BMJ：精神分裂症真的并不存在？

#BMJ#

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#精神分裂#

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Richard Saville-Smith的评价：

I'm familiar with Jim van Os' work and find it of value in its contributions to questions beyond the day to day clinical issues which routinely dominate psychiatrists. For example, I find the arguments advanced by Burns, Crow, Horrobin and Nichols about the evolutionary basis of schizophrenia both fascinating and frustrating.

Fascinating in their inevitable conclusion that the schizophrenic are part of the neurodiversity (or whole body diversity as Horrobin would have it) of being human, frustrating because it is patently obvious that schizophrenia is an anachronistic concept when applied to pre-sub-Saharan diaspora of Homo Erectus/Sapiens. Schizophrenia didn't exist before Bleuler. The result is that as the scholars mentioned have overly privileged schizophrenia, the wider evolutionary contribution of the genetic propensity for psychosis is squeezed out of the discussion.

Jim van Os' approach provides a bigger, richer fuller idea of madness with a contribution to human development which is multi-dimensional not just 'bad'. This not only deconstructs the urge to pathologize madness (the inevitable consequence of focusing on the negatives and casting them in terms of mental illness) but loosen up the nosological propensity to confuse naming with understanding.

In an evolutionary context where madness is not mental illness and we are not always driven by the relentless negativity conjured by schizophrenia, the evolutionary advantages of psychosis to the human population can be considered in ways which are less bleak and more fecund .

Thanks Jim!

Burns, Jonathan Kenneth. "An Evolutionary Theory of Schizophrenia: Cortical Connectivity, Metarepresentation, and the Social Brain." Behavioral and Brain Sciences 27, no. 6 (2004): 831-55.

Crow, Timothy. "Aetiology of Schizophrenia", Current Opinion in Psychiatry 7, no. 1 (1994): 39-42. (and similar)

Horrobin, David F. The Madness of Adam and Eve : How Schizophrenia Shaped Humanity. London: Corgi, 2002.

Nichols, Catherine. "Is There an Evolutionary Advantage of Schizophrenia?" Personality and Individual Differences 46, no. 8 (2009): 832-38.

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Stephen M Lawrie的评价：

Re: “Schizophrenia” does not exist
To state that schizophrenia does not exist is a trite assertion with no more meaning than saying, for example, that migraine does not exist. It would be equally meaningless to suggest that any abstract noun or concept does or does not exist. The key question is whether it is a useful concept, and even this may have to be asked within a defined context. (1)

The use of the term schizophrenia has allowed us to identify genes that increase risk, reproducible biological concomitants and, most importantly, treatments that are known to work from the results of clinical trials. (2-4) While schizophrenia has often been misrepresented, there is no strong evidence that doing away with the term is the solution. The ideas that schizophrenia always has a poor outcome and for which treatment at best ameliorative are just plain wrong. (5) Equally, however, we have to accept that about one-third of people with schizophrenia have a poor outcome. Changing the name of their condition won’t do anything to help those people. And to move towards having different terms around the world would be a retrograde step. It would be much preferable and more achievable to communicate more accurately about schizophrenia.

It would also be wrong to think no useful research is done on other psychosis categories. We know, for example, that most people with a brief psychotic disorder do not need ongoing treatment, (6,7) and that patients with bipolar disorder tend to respond to lithium, whereas those with schizophrenia do not. (8,9) Doing away with these diagnostic terms would simultaneously dispense with decades of clinical experience and research endeavour.(8) And for what? Because one of a number of vague alternatives may have a chance of reducing stigma? And what about the potential harms of such a conceptual change? To move to the less well defined runs the risk of increasing mis-diagnosis and losing what we already know about how to help patients in clinical settings.

The correct response to the heterogeneity of schizophrenia and the even greater heterogeneity of ‘psychosis’ is to study and to seek to progressively sub-group, building on accumulated wisdom. (9) This demands painstaking research. Just because a word like schizophrenia is mis-used does not mean it should be abandoned; and replacing it with something else of unproven value is likely to do more harm than good.

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Iris E Sommer的评价：
Schizophrenia: Change the Name and Broaden the Concept?
In his opinion paper, van Os posits that:
1. Schizophrenia is a heterogeneous syndrome, not a specific disease;
2. Expert opinions, diagnostic manuals, and clinicians cause patients to wrongly believe they have a devastating genetic illness;
3. Forming a single category “Psychosis Susceptibility Syndrome” including schizophrenia with a number of other psychosis categories will increase knowledge of understudied categories, while providing better information for persons with psychotic disorders.
4. Removing the term “schizophrenia” would reduce the effect of stigma.

We respond to his opinion on these four points below.

Point 1: We agree that schizophrenia (and most other psychotic disorders) are heterogeneous clinical syndromes but disagree on aspects of his critique and proposed solution. In order to come to individualized treatment, it will be key to explore underlying factors. In this way, the DSM-5 category is a starting point, not an endpoint.

Point 2: Van Os believes that diagnostic manuals such as DSM-5 reinforce a false view of schizophrenia as a devastating genetic disorder. We share the concern that professional and public perception often ignores the extensive data documenting a wide variety of courses including very good outcome in perhaps 20% of persons with schizophrenia. However, it should be noted that DSM-5 gives very specific emphasis to the syndromal status of psychotic disorders, provides symptom dimensions giving emphasis on what doctors need to know about patients, and that therapeutic targets lie beyond diagnostic categories.

Doctors and patients need to develop a shared view of illness and psychosis is no exception. Physicians are not entitled to withhold relevant information from patients. To inform a person with schizophrenia that they have a devastating genetic disorder would be harmful and misinformed. To withhold information on the chance for poor outcome would also be unethical. To explain to a person that many genes make small contributions to risk and that some 60-70% of variance is at the genetic level, but that these genes are also common in the population, provides a basis for discussion, not a pronouncement about the individual’s future.

The prognosis of schizophrenia can be devastating, but can also be rather good, as witnessed in many longitudinal course studies. Clinicians tend to see the latter group much less frequently than the first and may be inclined to give a too gloomy picture of expected outcome. Although Kraepelin’s original formulation viewed poor prognosis as central to dementia praecox, long-term follow-up studies have always demonstrated heterogeneity of course including good outcome. A very early example is the 40 years follow-up study that Manfred Bleuler performed of his father’s (Eugen Bleuler) patients. Registry and cohort studies show unbiased information about long-term mortality, employment rates and generally replicate good prognosis of a small, but significant, group across the globe (Holla et al. 2015; Yuen et al. 2014, Davidson et al. 2015). Most experts are well aware of these studies and report correctly on their findings to colleagues and patients. Perhaps some clinicians and the general public need to be better informed by these data and this is a challenge for public and professional education. More emphasis on remission and recovery may be needed, but it is certainly not established that clinicians routinely over-emphasize potential dire consequences of schizophrenia. In any case, prognosis assessment approaches have been available for over 60 years to assist clinicians and to inform patients that diagnosis is not fate.

Point 3. van Os’ suggestion that different categories of psychotic disorders, regardless of name, should be removed in favor of a single category comprising multiple psychoses diagnoses raises important problems. “Psychosis susceptibility syndrome” would increase the number of cases three to four fold resulting in between patient variability and within category heterogeneity that would challenge application of existing knowledge and confound future research with the problem already undermining less heterogeneous categories. In addition, there is meaningful validity to the current diagnostic categories. For example, lithium can be particularly beneficial in bipolar disorder, antipsychotic medication reduces relapse rates for most persons with schizophrenia, a schizoaffective disorder calls for explicit attention to mood disturbance as well as to psychotic symptoms, and brief psychotic disorders identify patients where long-term antipsychotic drug therapy is not indicated. To combine these various disorders in one group of “psychosis susceptibility disorder” will very substantially increases heterogeneity and confound interpretation of science at the level of clinical application.

Point 4. We agree that the proposed new name “psychosis susceptibility syndrome” has a more pleasant ring than current diagnostic terms. Changing the name is quite a rigorous way to improve the public’s and clinicians ideas about a disorder. A serious consideration of name change should be done with care, and not ad hoc. Preferably by the WHO, which can convene relevant experts and stakeholders and make a single decision with international implications rather than each country having their own nosology or name. Changing the word “schizophrenia” for a new term could be done without losing accumulated knowledge or changing future directions of clinical care or research. However, we do not know whether this would decrease stigma or make communication about the diagnostic category more informative. In Japan the translation of schizophrenia resulted in a very negative term and it was hoped that the name change would result in a more benign public perception. However, a recent report suggests that changing the new name in Japan has not appreciably changed public perception as represented in the media (Koike et al. 2015). The process of change has started at the single nation level and we believe it should quickly be addressed as an international issue. Yet the question here remains: will renaming be helpful?

To conclude: heterogeneity amongst people diagnosed with schizophrenia-related syndromes is high and this complicates individual treatment and research into new treatment strategies. The suggested even broader term “psychosis susceptibility syndrome” will make this problem even worse. If clinicians are insufficiently aware of this heterogeneity and if they provide too gloomy prognostic information, education is needed. However, it should first be investigated if this is indeed the case. Finally, whether a name change will improve stigma is not known.

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