A Disappearing Heritage

The Clinical Core of Schizophrenia

Josef Parnas

Disclosures

Schizophr Bull. 2011;37(6):1121-1130. 

In This Article

Conclusions and Implications

There was a consensus among schizophrenia researchers in the European tradition that the specificity of schizophrenia was not to be found in the positive psychotic symptoms. Even Kurt Schneider, while cherishing his diagnostic notion of first rank symptoms, referred to a larger Gestalt and to the disorders of subjectivity structure (self-disorders) as a condition for the emergence of certain psychotic phenomena. When confronting schizophrenia, we say, paraphrasing Jaspers and others, "ununderstandable," "impenetrable," or "bizarre," we express a sense of confronting a condition not only marked by circumscribed abnormal mental contents but also, rather, a structural change of subjectivity (mentality, consciousness). The clinical core manifests itself, and is graspable, as a larger whole, a Gestalt emerging across a manifold of symptoms and signs. These single features may occur in all domains of mental life: affect-expression, motivation, mood, cognition, willing, and action Table 1.

This core disorder was believed to possess a generative status, making the clinical picture less enigmatic and endowed with certain coherence between its elements (vide supra, the "social phobia").[22,36] A subtler articulation of such core marked the extension of the schizophrenia spectrum disorders. Needless to say, it was the core that was considered as etiologically significant. Minkowski[20] was among the first to propose a diathesis-stress model of the etiology of schizophrenia:

The notion of schizophrenia as a mental illness can be decomposed into two factors, of different order. First, the schizoidia [the clinical core], which is a constitutional, highly specific and temporally enduring factor, and, second, a noxious nonspecific factor of [environmental] evolutive nature. This noxious factor, acting upon the [vulnerability of] schizoidia, transforms the latter into schizophrenia,[20,p50–51] my translation and insertion in square brackets).

This presentation of schizophrenia paints a picture that is rather different from the corresponding concepts of the DSM-IV and ICD-10. The operational definitions only capture a fragment of the clinical core. Both the negative and disorganized symptoms are, because of reliability concerns, stipulated on a very high severity level, effectively precluding a diagnosis of many nonparanoid cases. More importantly, the negative symptoms are conceived of as quantitative deficits, fall-outs of normal functions (too little), which are signaled by the deprivative alpha: a-logia, a-volition, an-ergia, etc. This deficit view, however, has a limited resemblance to the clinical core of schizophrenia.[15] Blankenburg[25] evoked here an insightful and useful dictum: "the Minus (the deficit) in schizophrenia is caused by the Aliter (the different [strange]), whereas the reverse is true for the organic dementia." Psychiatrists, trained today, have difficulty in indentifying and describing clinically significant formal thought disorder, disordered discourse, and varieties of disintegrated expressivity. Most importantly, however, the sense of the fundamental Gestalt or prototype has vanished. Clinicians are not taught and therefore not aware of the characteristic Gestalt of schizophrenia, of its "whatness". This prototype, especially salient in hebephrenia, eludes the diagnostic radar. These patients become frequently diagnosed as borderline personality disorder, social phobia, anxiety disorders, obsessive-compulsive disorder (OCD), and affective disorder. We know from the statistics of the Danish National Psychiatric Register that since the introduction of the ICD-10, the "borderline" diagnosis has exploded while hebephrenia diagnosis now only accounts for 1% of all first diagnosed cases of schizophrenia (there is no reason to believe that the situation is dramatically different with DSM-IV). The polydiagnostic studies indicate that DSM-IV/ICD-10 schizophrenia definition reliably captures a chronic paranoid-hallucinatory subset of schizophrenia patients. Chronicity is here inbuilt, partly by the duration criteria, but mainly because the disorganized and negative symptoms are defined on a very high severity level, the number of original Schneiderian criteria is reduced, and many of those retained have been transformed from anomalous experiences to delusions (taking time to become articulated).

Viewed through the lens of the continental concept, many of the currently "easy" psychopathological issues (considered as merely technical psychometric problems) would reacquire important conceptual dimensions (eg, chronicity, onset, datability of onset, the concept of psychosis, and the issue of early detection).

It is beyond our scope to assess the consequences of the phenomenological and epistemological discontinuity between the classic European and the current operational versions of the schizophrenia concept. The change in the concept of schizophrenia is, at least in part, a reflection of a more overarching epistemological change, concerning the status of "psychiatric object" (the reasons why a patient sees a psychiatrist). This change may be viewed, depending on perspective, positively, as a sign of progress, or negatively, as a sign of regression (or as a mixture of both). It would require another study to articulate the contents and processes of that change.

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