Many of the clinical concepts of schizophrenia summarized so far, selected from a range that could be broadened to include dozens more authors, have been unsatisfactory in several ways:
• their symptomatic and syndromic components overlap but are not identical;
• they cannot be stated in precisely reproducible terms;
• the weights given to individual symptoms when formulating a diagnosis are not specified but left to clinical interpretation;
• other criteria, such as course, are of uncertain value for classification; and
• until recently there has been little convincing evidence for specific pathologies or physical causes in the large majority of cases.
Testing clinical concepts
New syndromes can be derived from symptom lists by the application of statistical techniques. There is a long line of such studies, many of them initiated in the 1950s and 1960s in order to overcome the unreliability then being demonstrated in day-to-day clinical diagnosis (e.g. Lorr 1966). They were successful in achieving reasonable reliability, but the usefulness of the statistical syndromes was not demonstrated, except in the sense that the factors often looked very similar to the diagnoses they tried to leave behind.
Kendell (1989) addressed the problem in a more practical way. He suggested utilizing statistical methods to refine syndromes, which could then be tested against outcome and used to generate or test biological hypotheses. His own studies (Kendell & Brockington 1980) did not demonstrate a point of statistical discontinuity between schizophrenic and affective psychoses.
This could be due in part to fluctuation over time; cross-sections cannot display the clinical picture that eventually emerges. In addition, the hierarchies that run through psychiatric classification ensuring that disorders higher up, such as dementia, schizophrenia and bipolar disorder, which tend to be co-morbid with symptoms of disorders lower down, must also be considered.
A high proportion of people with schizophrenia in the International Pilot Study of Schizophrenia (WHO 1973) would have been classified by the PSE computer program known as CATEGO as having affective disorders if symptoms discriminating for schizophrenia had been left out (Wing et al. 1974).
Moreover, some at least of the affective symptoms so common in acute schizophrenia must be reactive to the stress of the primary experiences.
From concepts to classification
The clinical concepts, especially those of Kraepelin and Bleuler, can be recognized as early attempts to classify schizophrenia, but there were differences in their approach to defining schizophrenia as an entity. While Kraepelin emphasized the value of onset and course as well as descriptions in diagnosis and classification of schizophrenia, Bleuler and Schneider preferred a crosssectional approach based on patients’ current mental state, emphasizing fundamental and characteristic distinguishing symptoms. Recent recognizable international classification systems such as DSM and ICD have attempted syntheses of these concepts to foster international consensus.
Early DSM and ICD classifications (such as DSM-II and ICD-8) included a very broad definition of psychosis based on severity of social and personal dysfunction, thereby allowing for considerable overlap with personality disorders. This, in addition to the prevalent influence of the psychoanalytic movement in the USA, led to significant differences in the interpretation of diagnostic guidelines and definitions of concepts of psychosis and schizophrenia. These differences were clearly reflected in studies such as the US–UK study (Kendell et al. 1971), which displayed the range of concepts of schizophrenia from a broad one in the USA to a very narrow one in Europe.
One obvious line of development, therefore, has been to try to provide comprehensive, accurate and technically specifiable means of describing and classifying the component concepts (phenomena) in order to allow more meaningful comparisons between clinicians, academic schools, research laboratories and public health statistics.
Standards for symptom definition and combination
In the case of schizophrenia, the first essential is to provide differential definitions of the symptoms and signs, based as far as possible on deviations from normal psychological functioning.
The descriptions of Jaspers and Kurt Schneider are well suited to such an exercise. These descriptions influenced attempts of clinical standardization in the form of development of definitions and structured interviews and diagnostic criteria such as the PSE (Wing & Brown 1970), Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott & Spitzer 1978) and Research Diagnostic Criteria (RDC) (Spitzer et al. 1975). The 10th edition of PSE (now with other materials called Schedule for Clinical Assessment in Neuropsychiatry (SCAN); Wing et al.
1998, WHO 1999) is a more recent attempt of clinical standardization, as is the Diagnostic Interview for Social and Communication Disorders (DISCO) for social and communication disorders (Leekam et al. 2002; Wing et al. 2002). The definitions of symptoms and the algorithms for standardized diagnosis they provide make it possible to undertake more reliable and comparable clinical studies and more specific tests of biological functioning. These developments influenced further revisions of ICD and DSM concepts and classifications of schizophrenia. The American diagnostic classification (DSM) in the next revision of DSM-III and -IIIR made the concept of schizophrenia one of the narrowest, whereas the concept in ICD-9 remained very broad.
However, in their most recent revisions, DSM-IV and ICD-10 have tried to bridge these differences by bringing the criteria closer.
J.K. Wing and N. Agrawal
Steven R. Hirsch
MD FRCP FRCPsych
Professor of Psychiatry Emeritus, Division of Neuroscience and Psychological Medicine Imperial College Faculty of Medicine and Director of Teaching Governance, West London Mental Health NHS Trust
Daniel R. Weinberger MD
Chief, Clinical Brain Disorders Branch
Intramural Research Program
National Institute of Mental Health
MD 20982, USA
- American Psychiatric Association (1993) Diagnostic and Statistical Manual of Mental Disorders, 4th edn. APA, Washington, DC.
- Andreasen, N.C. & Carpenter, W.T. (1993) Diagnosis and classification of schizophrenia. Schizophrenia Bulletin 19, 199 - 211.
- Asperger, H. (1944/1991) Autistic psychopathy in childhood. In: Autism and Asperger Syndrome. Cambridge University Press, Cambridge. Translated and annotated by U. Frith, from: Die 'Autistischen Psychopathen' im Kindesalter. Archiv fur Psychiatrie und Nervenkrankheiten 117, 76 - 136.
- Bentall, R.P., Jackson, H.F. & Pilgrim, D. (1988) Abandoning the concept of schizophrenia. British Journal of Psychology 27, 303 - 324.
- Berrios, G.E. & Hauser, R. (1988) The early development of Kraepelin's ideas on classification: a conceptual history. Psychological Medicine 18, 813 - 821.
- Berze, J. (1914/1987) Primary insufficiency of mental activity. In: The Clinical Roots of the Schizophrenia Concept (eds J. Cutting & M. Shepherd), pp. 51 - 58. Translated from Chapter 4 of Die primare Insuffizienz der psychischen Aktivitat. Deuticke, Leipzig.
- Bleuler, E. (1911/1950) Dementia praecox or the group of schizophrenias. New York: International Universities Press. Translated by J.Zinkin from Dementia Praecox oder der Gruppe der Schizophrenien. In: Handbuch der Geisteskrankheiten (ed. G. Aschaffenburg). Deuticke, Leipzig.
- Bleuler, E. (1919) Das Autistisch-Indisziplinierte Denken in der Medizin und Seine Uberwindung. Springer, Berlin.
- Bush, G., Fink, M., Petrides, G. et al. (1996) Catatonia. I. Rating scale and standardised examination. Acta Psychiatrica Scandinavica 93, 129 - 136.
- Cohen, H. (1961) The evolution of the concept of disease. In: Concepts of Medicine (ed. B. Lush), pp. 159 - 169. Pergamon, Oxford.
- Creer, C. & Wing, J.K. (1974) Schizophrenia at Home. National Schizophrenia Fellowship, London. [Reprinted with a new preface, 1988.]
- Crow, T.J. (1985) The two syndrome concept: origns and current status. Schizophrenia Bulletin 11, 471 - 486.
- Crow, T.J. (1998) Nuclear schizophrenic symptoms as a window on the relationship between thought and speech. Schizophrenia Research 28, 127 - 141.
- Diem, O. (1903/1987) The simple dementing form of dementia praecox. In: The Clinical Roots of the Schizophrenia Concept (eds J. Cutting & M. Shepherd), pp. 25 - 34. Translated from Die einfach demente Form der Dementia Praecox. Archiv fur Psychiatrie und Nervenkrankheiten 37, 81 - 87.
- Endicott, J. & Spitzer, R.L. (1978) A diagnostic interview: the Schedule for Affective Disorders and Schizophrenia. Archives of General Psychiatry 35, 837 - 844.
- Falret, J. (1854) Lecons Cliniques de Medicine Mentale. Bailliere, Paris.
- Fish, F.J. (1958) Leonhard's classification of schizophrenia. Journal of Mental Science 104, 103.
- Fisher, C.M. (1983) Abulia minor versus agitated behavior. Clinical Neurosurgery 31, 9 - 31.
- Flaum, M. & Andreason, N.C. (1991) Diagnostic criteria for schizophrenia and related disorders: options for DSM-IV. Schizophrenia Bulletin 17, 143 - 156.
- Foucault, M. (1967) Madness and Civilisation. Tavistock, London.
- Foulds, G.A. (1965) Personality and Personal Illness. Tavistock, London.
- Frith, C.D. & Frith, U. (1991) Elective affinities in schizophrenia and childhood autism. In: Social Psychiatry. Theory, Methodology and Practice (ed. P.E. Bebbington), pp. 65 - 88. Transaction, New Brunswick.
- Frith, U. (1989) Autism: Explaining the Enigma. Blackwell, Oxford.
- Frith, U. & Happe, F. (1994) Autism: beyond theory of mind. Cognition 50, 115 - 132.
- Gillberg, C. (2002) A Guide to Asperger Syndrome. Cambridge University Press, Cambridge.
- Goffman, E. (1961) Asylums. Essays on the Social Situation of Mental Patients and Other Inmates. Penguin, Harmonsworth.
- Griesinger, W. (1861) Die Pathologie und Therapie der Psychischen Krankheiten. Krabbe, Stuttgart.
- Gruhle, H.W. (1929) Psychologie der Schizophrenie. In: Psychologie der Schizophrenie (eds J. Berze & H.W. Gruhle). Springer, Berlin.
- Jackson, J.H. (1869/1932) Certain points in the study and classification of diseases of the nervous system. Reprinted in: Selected Writings of
- John Hughlings Jackson, Vol. 2. (ed. J. Taylor). Hodder and Stoughton, London.
- Janzarik, W. (1984) Jaspers, Kurt Schneider und die Heidelberger Psychopathologie. Nervenarzt 55, 18 - 24.
- Janzarik, W. (1987) The concept of schizophrenia: history and problems. In: Search for the Causes of Schizophrenia (eds H. Hafner, W.F. Gattaz & W. Janzarik). Springer-Verlag, Heidelberg.
- Jaspers, K. (1946/1963) General Psychopathology. Manchester University Press, Manchester. Translated by J. Hoenig & M. Hamilton from Allgemeine Psychopathologie. Springer Verlag, Heidelberg.
- Joseph, A.B. (1992) Catatonia. In: Movement Disorders in Neurology and Neuropsychiatry (eds A.B. Joseph & R.R. Young), pp. 335 - 342. Blackwell Scientific, Boston.
- Kahlbaum, K. (1874/1973) Catatonia. Johns Hopkins University Press, Baltimore. Translated by Y. Levij & T. Priden from Die Katatonie oder das Spannungs-Irresein. Hirschwald, Berlin.
- Kanner, L. (1943) Autistic disturbances of affective contact. Nervous Child 2, 217 - 250.
- Kendell, R.E. (1987) Diagnosis and classification of functional psychoses. British Medical Bulletin 43, 499 - 513.
- Kendell, R.E. (1989) Clinical validity. Psychological Medicine 19, 45 - 55.
- Kendell, R.E. & Brockington, I.F. (1980) The identification of disease entities and the relationship between schizophrenic and affective psychoses. British Journal of Psychiatry 137, 324 - 331.
- Kendell, R.E., Cooper, J.E., Gourlay, A.J. et al. (1971) Diagnostic criteria of American and British psychiatrists. Archives of General Psychiatry 25 (2), 123 - 130.
- Kendler, K.S. (1985) Diagnostic approaches to schizotypal personality disorder: a historical perspective. Schizophrenia Bulletin 11, 538 - 553.
- Kleist, K. (1960) Schizophrenic symptoms and cerebral pathology.Journal of Mental Science 106, 246 - 255.
- Kraepelin, E. (1896/1987) Dementia praecox. In: The Clinical Roots of the Schizophrenia Syndrome (eds J. Cutting & M. Shepherd), pp. 15 - 24. Cambridge University Press, Cambridge. Translated from Lehrbuch der Psychiatrie, 5th edn, pp. 426 - 441. Barth, Leipzig.
- Kraepelin, E. (1920) Die Erscheinungsformen des Irreseins. Zeitschrift fur Neurologie und Psychiatrie 62, 1 - 29.
- Kretschmer, E. (1966/1974) The sensitive delusion of reference. In: Themes and Variations in European Psychiatry (eds S.R. Hirsch & M.Shepherd). Wright, Bristol. Translated from Der sensitiver Beziehungswahn. Springer, Heidelberg.
- Laing, R.D. & Esterson, A. (1964) Sanity: Madness and the Family. Tavistock, London.
- Leekam, S.R., Libby, S.J., Wing, L. et al. (2002) The diagnostic interview for social and communication disorders. Algorithms for ICD 10 childhood autism and autistic spectrum disorders. Journal of Child Psychology and Psychiatry 43, 325 - 327.
- Leonhard, K. (1957) Aufteilung der Endogenen Psychosen. Akademie Verlag, Berlin.
- Locke, J. (1959) Essay Concerning Human Understanding, Vol. 1, 2nd edn (ed. A.C. Fraser ). Dover, New York.
- Lorr, M. (1966) Explorations in Typing Psychotics. Pergamon, London.
- McKenna, P.J., Lund, C.E., Mortimer, A.M. & Biggins, C.A. (1991)
- Motor, volitional and behavioural disorders in schizophrenia. II. The 'conflict of paradigms' hypothesis. British Journal of Psychiatry 158, 328 - 336.
- Magnan, V. (1893) Lecons Cliniques Sur les Maladies Mentales. Battaille, Paris.
- Robins, L.N., Wing, J., Wittchen, H.U. et al. (1988) The Composite International Diagnostic Interview: an epidemiological instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry 45, 1069 - 1077.
- Rogers, D. (1992) Motor Disorder in Psychiatry: Towards a Neurological Psychiatry. Wiley, New York.
- Scheff, T.J. (1966) Being Mentally Ill. Aldine, Chicago.
- Schneider, K. (1959) Clinical Psychopathology. Translated by M.W.Hamilton. Grune & Stratton, New York.
- Schneider, K. (1976) Klinische Psychopathologie, 11th edn. Thieme, Stuttgart.
- Spitzer, R.L., Endicott, J. & Robins, E. (1975) Research Diagnostic Criteria: Rationale and Reliability. Hodder and Stoughton, London.
- Sturt, E. (1981) Hierarchical patterns in the distribution of psychiatric symptoms. Psychological Medicine 11, 783 - 794.
- Szasz, T. (1971) The Manufacture of Madness. Routledge, London. Tantam, D. (1988) Asperger's syndrome. Journal of Child Psychology and Psychiatry 29, 245 - 255.
- Wing, J.K. (1961) A simple and reliable subclassification of chronic schizophrenia. Journal of Mental Science 107, 862 - 875.
- Wing, J.K., ed. (1975) Schizophrenia from Within. National Schizophrenia Fellowship, London.
- Wing, J.K. (1978) Reasoning About Madness. Oxford University Press, London.
- Wing, J.K. (1991) Social psychiatry. In: Social Psychiatry: Theory, Methodology and Practice (ed. P.E. Bebbington), pp. 3 - 22. Transaction, New Brunswick.
- Wing, J.K. & Brown, G.W. (1961) Social treatment of chronic schizophrenia: a comparative survey of three mental hospitals. Journal of Mental Science 107, 847 - 861.
- Wing, J.K. & Brown, G.W. (1970). Institutionalism and Schizophrenia.Cambridge University Press, London.
- Wing, J.K., Cooper, J.E. & Sartorius, N. (1974) The Description and Classification of Psychiatric Symptoms: an Instruction Manual for the PSE and CATEGO System. Cambridge University Press, London.
- Wing, J.K., Sartorius, N. & Ustun, T.B. (1998) Diagnosis and Clinical Measurement in Psychiatry: the SCAN System. Cambridge University Press, Cambridge.
- Wing, L. (1981) Asperger's syndrome. Psychological Medicine 11, 115 - 129.
- Wing, L. (1982) Development of concepts, classification and relationship to mental retardation. In: Psychoses of Uncertain Aetiology (eds
- J.K. Wing & L.G. Wing), pp. 185 - 190. Cambridge University Press, Cambridge.
- Wing, L. (2000) Past and future research on Asperger Syndrome. In: Asperger Syndrome (eds A. Klin, F. Volkmar & S. Sparrow). Guildford Press, New York.
- Wing, L. & Gould, J. (1979) Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification. Journal of Autism and Developmental Disorder 9, 11 - 29.
- Wing, L. & Shah, A. (2000) Catatonia in autistic spectrum disorders. British Journal of Psychiatry 176, 357 - 362.
- Wing, L., Leekam, S.R., Libby, S.J. et al. (2002) The diagnostic interview for social and communication disorders. Journal of Child Psychology and Psychiatry 43, 307 - 325.
- Wolff, S. (1995) Loners: The Life Path of Unusual Children. Routledge, London.
- World Health Organization (1973) The International Pilot Study of Schizophrenia. WHO, Geneva.
- World Health Organization (1993) The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. WHO, Geneva.
- World Health Organization (1999) Schedules for Clinical Assessment in Neuropsychiatry. World Health Organization, Geneva.
Provided by ArmMed Media