\\\\\\\\\\\\\\\\\\

IIs Schizophrenia Dead Yet?

Jim van Os & Sinan Guloksuz, Utrecht University Medical Centre, Utrecht, The Netherlands

The Psychosis Spectrum Syndrome

Debate is about Clinical Diagnosis, not About:

Research – researchers can choose their own

sample inclusion criteria, eg DSM schizophrenia,

ICD schizophrenia, or ‘Deficit syndrome’

Subclinical psychotic experiences – part of

phenotype but not of ‘diagnosable’ clinical

syndrome

Semantics: ‘psychosis’ here refers to the

multidimensional syndrome, not merely positive

symptoms

“Who gets to define value in

health systems? The notion that it

should be the people who use

their services, rather than those

who provide them, is gaining

momentum.” (Richards, 2017).

Who gets to define value?

Medicine and Health Care Moving into the 3rd Era

JAMA, 2016

Era 1: Professional dominance

Era 2: Accountability and market theory

Era 3: The moral era

Two Discourses – 1 Dominant

BMC Psychiatry, 2015

“Two discourses exist in mental health research

and practice. The first focuses on the limitations

associated with disability arising from mental

disorder. The second focuses on the possibilities

for living well with mental health problems”

Health is

absence of

disease and

complete

wellbeing

WHO 1947

Health is the ability

to adapt and

selfmanage, given

physical, mental &

social challenges

Huber, 2011

Two

Definitions

of ‘Health’

Two Discourses and two Types of Care

SICK

CARE

HEALTH

CARE

We revealed a dysfunctional system that does not deliver

the quality of treatment needed for recovery. Is this tolerable in

the 21st century?

(Evaluation Sick Care Model)

Values According to Users: CHIME-D

……..point to the need for a greater emphasis on

assessment of strengths and support for self-narrative

development, promoting the role of mental health

systems in developing inclusive communities enabling

access to peer support as well as providing retreats,

and clinical interaction styles which promote

empowerment and self-management.

CONNECTEDNESS; HOPE AND OPTIMISM;

IDENTITY; MEANING IN LIFE; EMPOWERMENT

Leamey et al, 2011; Stuart et al, 2016

Difficulties

Narrative development & Hope?

“Schizophrenia is a

devastating, highly

heritable brain disorder”

Science, 2009

Genetic Brain Test for “Disorder”?

Diagnosis Mental Disorder

Diagnostic Brain TestKapur, Philips & Insel, Mol Psychiatry 2012

Useful for Patient?

Weak relationship between

diagnosis and symptoms

Weak relationship between

diagnosis and needs

Weak relationship between

diagnosis and prognosis

Academic Abstractions Sell PoorlyBecause they Disempower

Are being caused by:

Hearing voices(plus some secondary delusional ideation)

Schizophrenia

Allen Frances, 2012

DSM5: Introducing Human Variation Perspective

❖ Autism spectrum

❖ Addiction spectrum

Multi-dimensional

Disorder Prevalence

Schizophrenia 1.00%

Schizoaffective 0.32%

Schizophreniform 0.07%

Delusional disorder 0.18%

Brief psychotic disorder 0.05%

Psychotic disorder NOS 0.45%

Affective (Bip + Dep) 0.62%

Substance use 0.43

Gen. Med. Condition 0.22%

Perala et al, 2007

3.5%

SchizoaffectiveSchizophreniformDelusional disorderPsychotic depressionPsychotic bipolar disorderBrief psychotic disorderSubstance-induced psy. dis.Psy. disorder medical cond.Psychotic disorder NOS

Hidden Syndrome: Prognostication Bias

Schizophrenia

PSYCHOSIS

MORBIDITY

70%

30%

PUBLICATIONS

95%

5%

“Belief-based” Psychiatric Dichotomy

Woo-kyoung Ahn, 2009

Extremely serious

Biological

“Physical”

treatment

Mild

Psychosocial

“Psychological”

treatment

What is Science?

The important thing in science

is not so much to obtain new

facts as to discover new ways

of thinking about them.

(William Lawrence Bragg)

Hallucinations

& delusions

Cognitive

alterations

Affective

dysregulationSform

SASz

BP

Psychosis Spectrum Syndrome

3.5%

Van Os & Reininghaus, World Psychiatry, 2016

Adverserial Collaboration: Personal Dimensional Diagnosis Within

Categorical Psychosis Spectrum Syndrome

3.5%

Fin

Guérir parfois, Soulager toujours

“Better false hope

than

false hopelessness”

Daniel Fisher

Not Knowing is also

a form of Knowledge

Users Reminding Us:

Wouter Kusters, 2015

Resistance to Change: “Organisational Readiness”

Lancet, 2013, Plos One, 2014