Is schizophrenia disappearing?
Psychosis is a mental state with grossly impaired reality testing, manifesting as different mixtures of delusions, hallucinations, deviant thinking and abnormal motor behaviour – so-called positive symptoms. Negative symptoms – reduced emotions, interests, will and social participation – are also common, as is disturbed mood/affect and energy. When no detectable organic cause is present, psychoses have been denoted functional from the 1800s. Until then the conceptions of mania and melancholia (abnormally elevated or reduced mood and energy, respectively) from the Greek antiquity had included largely all these conditions.
The category diagnosis of functional psychoses builds on the views of influential professionals, as no biological test exist. A common pathology was assumed until the first half of the 1800s, and the idea of “unitary psychosis” prevailed. In the second half of the 1800s some influential European psychiatrists argued for several other psychoses in addition to mania, melancholia and mixtures of these. At the turn of the century the German psychiatrist Emil Kraepelin dichotomized functional psychoses into a broad concept of manic-depressive insanity, and a narrow one of dementia praecox. In the minds of many professionals this dichotomy established a “firewall” between the two groups. In 1911 another German psychiatrist, Paul Eugen Bleuler, introduced the term schizophrenia to replace dementia praecox. He markedly broadened the concept by claiming features resembling negative symptoms to be basic, the positive ones being accessory.
Later, two groups of psychoses between mood/affective disorders and schizophrenia were described, one including overlapping syndromes named schizoaffective, cycloid, reactive and polymorphic psychosis, the other denoted delusional or paranoid psychosis. These groups and schizophrenia are included in the main group of psychotic disorders, the other main group being mood/affective disorders with psychosis. However, the differentiation between these two main groups has varied with time and place, and continues to vary depending on professionals’ views and education. Thus, in 1990 Der, Gupta and Murray (UK) published the article “Is schizophrenia disappearing?” because the frequency of psychotic disorders in England and Wales had decreased about 50% from the mid-1960s to the 80s. Later, Lake and Hurwitz (USA) outlined that most psychotic patients were diagnosed with schizophrenia from the 1930s to 60s, followed by a gradual shift towards schizoaffective and then affective psychoses. Genetic and brain studies suggests a continuum between the two main groups. Studies relating symptoms, psychology, biology, course and treatment effects may be more fruitful than studies depending on predefined categories, which may have contributed to lack of progress.
Lake (USA) recently argued that schizophrenia is a misdiagnosis. Time may be in for replacement of the term, which is stigmatizing and leads the thought away from treatment of mood disturbance, which may be masked by psychotic symptoms. Pathological depression is not common sadness, but mental pain that cannot be fully defined. Berrios (UK) has in “The history of mental symptoms” (1996) pointed out that “the clinical disorders of affect struggled for recognition”, and that those afflicted are often “unable to behave as a rational observer.” The patient may deny depression and the clinician wrongly characterize the patient’s mood as “neutral” or “flat.” Depression may become more obvious when psychotic symptoms diminish, but may then be explained away as post-psychotic depression. Thoughts and emotions are always intermingled, and being psychotic with “neutral” mood seems anti-intuitive.
Chronic, often sub-optimally treated, severe mood disorders may appear as psychotic disorders. They often represent end-stages, like heart failure after different heart diseases. All available treatments must be tried to stop such a development. This strengthens the importance of optimal treatment of mood disorders, which may be the most important cause of schizophrenia and other functional psychoses.
Department of Psychiatry, District General Hospital of Førde, Norway
Is schizophrenia disappearing? The rise and fall of the diagnosis of functional psychoses: an essay.
BMC Psychiatry. 2016 Nov 9