WE NEED TO ABANDON THE CURRENT SCHIZOPHRENIA CONSTRUCT
In this section
The debate at the 31st European Congress of Psychiatry in Paris, France addressed the question whether the current schizophrenia construct should be abandoned or not. On the pro side, Professor Silvana Galderisi from University of Campania Luigi Vanvitelli argued, while the con side was addressed by Professor Wolfgang Gaebel from Heinrich-Heine University Düsseldorf, Germany.
Pro
The current schizophrenia construct is detailed in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition1 as well as in the International Classification of Diseases 11th Revision.2
The strength of the current construct involves improved inter-rater and test-retest reliability when formulating the diagnosis, less ambiguous communication among clinicians and families, and usefulness in terms of education and training purposes.3,4
The main weaknesses on the other hand are that the present construct supports the belief that schizophrenia is a unitary disease entity, and the term is still often interpreted as “split personality”.3,4
The heterogeneity of schizophrenia has been recognized since Bleuler5 and there have been many attempts to bring this aspect back by defining subtypes such as deficit/non-deficit6 or negative/positive schizophrenia but the current construct fails to do so.7
Clinicians should be ready to acknowledge this heterogeneity and complement the ICD/DSM diagnosis with an in-depth characterization of the individual patient.3
Con
Clinicians should not abandon the current schizophrenia construct as it has been more useful than harmful in guiding the development of diagnostic, treatment, and care guidelines, but there are some important considerations.
There have been considerable changes in ICD-11 such as symptom- and course-profiles which should be implanted to everyday clinical practice.8
The dialogue between ICD-11 and DSM-5 should be more intensive as a harmonisation would be highly needed.9
Inclusion of the experience of people with schizophrenia in future research and on the construct would be appreciated.9
Instead of subtypes of schizophrenia, fluid neuro-mental constructs should be developed within the transdiagnostic concept.9
References
- American Psychiatric Association. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders Fifth Edition. Arlington (2013).
- World Health Organization. International Classification of Diseases Eleventh Revision (ICD-11). License: CC BY-ND 3.0 IGO vol. 11 (2022).
- Galderisi, S. & Giordano, G. M. We are not ready to abandon the current schizophrenia construct, but should be prepared to do so. Schizophr Res 242, (2022).
- Jablensky, A. The diagnostic concept of schizophrenia: its history, evolution, and future prospects. Dialogues Clin Neurosci 12, (2010).
- Bleuler, E. Dementia Praecox or the Group of Schizophrenias. Translated by Joseph Zinkin. International Universities Press (1950).
- Carpenter, W. T., Heinrichs, D. W. & Wagman, A. M. I. Deficit and nondeficit forms of schizophrenia: The concept. American Journal of Psychiatry 145, (1988).
- Andreasen, N. C. & Olsen, S. Negative v Positive Schizophrenia: Definition and Validation. Arch Gen Psychiatry 39, (1982).
- Reed, G. M. et al. Clinical utility of ICD-11 diagnostic guidelines for high-burden mental disorders: results from mental health settings in 13 countries. World Psychiatry 17, (2018).
- Tandon, R. & Maj, M. Nosological status and definition of schizophrenia: Some considerations for DSM-V and ICD-11. Asian Journal of Psychiatry vol. 1 Preprint at https://doi.org/10.1016/j.ajp.2008.10.002 (2008).
