On Defining Schizophrenia

Josef Parnas1

Operational criteria were developed as a provisional and pragmatic tool, but are increasingly reified and gradually elevated to a status of unquestionable truth. A brief critical survey of the diagnostic criteria of schizophrenia (ICD-10, DSM-IV) is therefore due. It may be helpful to realize that these criteria represent a convention of unknown validity as compared to potential rival definitions. The first-rank symptoms (FRS) are assigned a strong prominence, due to their presumed simplicity and reliability, and their attractiveness as model medical symptoms. However, the reliability of FRS, though reasonable within one research group, is much weaker between the groups [1]. Schneider was quite laconic in the sole description available in the English translation. Consequently, what psychiatrists consider as representing a FRS varies in important respects [2]. This variation is, moreover, not only due to linguistic limitations. Today we know that FRS do not arise suddenly fully-fledged but are antedated by subtle, anomalous subjective experiences [3]. FRS are termini of progressive spatialization and externalization of these anomalous experiences, usually completed by a delusional elaboration. Reliability problems arise when investigators define a FRS using different cut-off points on these FRS continua [1, 2]. But even the patient himself, at the incipient illness stages, may vacillate in the felt concreteness of his inner change, and hence hesitate as to whether his verbalized explications are only metaphors or should be taken literally.

The pathognomonic status of delusions with ''impossible'' (bizarre) content was justified by an appeal to Jaspers' notion of ''incomprehensibility'' of

1University Department of Psychiatry, Hvidovre Hospital, 2650 Hvidovre, Denmark delusions in schizophrenia. However, this notion was embedded in a more overarching context of accessibility to empathic understanding. Impossibility of content is neither definitive nor exhaustive of ''incomprehensibility''. In fact, the diagnostic ineptitude of the sheer delusional content, commonly recognized in the German-speaking psychiatry already by 1930, stimulated interest in the form of experience in the arising delusion (e.g. delusional perception), in order to seize the experiential aspects suggestive of schizophrenia [4]. Recently, it has been proposed [5] that typicality of schizophrenic delusions lies partly in the fact that their content transpires a profoundly altered form of experiencing: blurred Self-world articulation, solipsistic access to the mind's own constituting activity and a mutation of the ontological axioms of experiencing. In conclusion, attributing to bizarre delusions a sufficient diagnostic efficacy is phenomenologically unfounded and historically inexact.

The second criterion of the ICD-10 (and its DSM-IV equivalents) is formulated on a severity level that fails to diagnose cases clinically considered as incipient disorganized and paranoid schizophrenia, with definite formal thought disorder and peculiarities of rapport, but below the stipulated severity level. In brief, the criteria work best with chronic patients, but definitely less so with first admission cases or cases identified in the population.

Defining schizophrenia equals specification of its validity criteria. No robust extraclinical marker is available and attempts to subtype have been dramatically unsuccessful. Factor analyses do not help because they rarely tell news. They aggregate intercorrelated items, entered in the first place, as reiterations of the clinically important aspects. Thus, the three-component structure was mathematically demonstrated already in 1948 [6].

It is logically impossible to assess the diagnostic import of a symptom, by looking at its distributions, if the symptom itself is a part of the very category definition. It does not make sense to claim that, say, thought insertion is more frequent in schizophrenia than in bipolar illness, if one believes, in the first place, that this symptom is highly diagnostic of schizophrenia. That is why many such studies are viciously circular or, at best, uninformative. An access is needed to the definition, which is independent of single symptoms. Given the lack of markers and singly typical course patterns, we can only turn to the original definition of what schizophrenia was considered to be. We need to distinguish criteria, defining the essence of schizophrenia, from symptoms, which may, but need not, be present. It was considered to be of essence of schizophrenia to persist, but persistence was conceived of as a persistence of trait phenomena (e.g. autistic tendencies) and thus not exhaustively reducible to chronicity of psychosis or debilitating course. This essence was perceived as a change at the very core of mental life and variously designated [7]. We can propose, more specifically, that the essence of schizophrenia, marking the extension of its spectrum concept, entails an alteration of the basic, pre-personal configuration of the Self and its intentional relation to the world. Modifications of the medical model are needed in order to investigate this hypothesis more closely. First, we must abandon the view that schizophrenia and its carrier can be separated in the way as one separates an infection from its victim, that is, that the subjectivity (Self) of the subject and his illness can be treated as independent regions. The second modification follows from the first: studying subjectivity calls for a suitable methodology, specifically developed to address first person data, namely phenomenology in its continental sense [5].

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