Academic journal article Hong Kong Journal of Psychiatry

Conceptual Issues in the Diagnosis of Schizophrenic Psychoses

Academic journal article Hong Kong Journal of Psychiatry

Conceptual Issues in the Diagnosis of Schizophrenic Psychoses

Article excerpt

SUMMARY

Some aspects of the current Anglo-American diagnostic concept of schizophrenic psychoses are examined from the viewpoint of classical and modern European psychiatry. Within this context three main areas are discussed: (1) the "neo-Kraepelinian" revival of the concept of schizophrenia in modem Anglo-Saxon psychiatry; (2) the diminishing role of the clinician-psychiatrist in the diagnostic process in current clinical practice and research, and (3) the role of clinical experience and the raecox-feeling" in the diagnosis of schizophrenia.

Key words: schizophrenia, diagnosis, psychopathology

INTRODUCTION

It was exactly 100 years ago that in the 5th edition of his textbook Emil Kraepelin first conceptualized dementia praecox, later renamed schizophrenia, as a putative disease entity (Kraepelin, 1896). Since then, the definition and diagnosis of schizophrenia has puzzled, and continues to p=le, generations of psychiatrists, clinicians as well as researchers. Comprehensive reviews on the topic are readily available so it would be an exercise in redundancy to produce another overview of the two, three, four or five factor component model of schizophrenia (e.g., Andreasen & Carpenter, 1993; Rey et al, 1994; Amdt et al, 1995). Instead, we have compiled a few critical comments on some aspects of the currently prevailing Anglo-American diagnostic concept of schizophrenia. Our vantage point is the classic and modem continental European psychiatry which usually escapes the attention of psychiatrists trained in the British or American schools of thought.

We shall touch upon the following loosely linked issues: (1) the "neo-Kraepelinian revival" of the concept of schizophrenia: (2) the diminishing role of the clinician in the diagnostic process and (3) the role of clinical experience and the "praecox-feeling".

THE NEO-KRAEPELINIAN REVIVAL OF SCHIZOPHRENIA

The past 25 years has been hailed as the co-Kraepelinian revival" (Klerman, 1978) or "neo-Kraepelinian revolution" (Compton & Guze, 1995) in Anglo-American psychiatry claiming that recent diagnostic practices as exemplified by the subsequent editions of DSM-III, DSM-III-R and DSM-IV represent a re-occurrence of descriptive psychiatry "in which careful observation of symptoms, signs and course of mental become the diagnostic criteria themselves" (Compton & Guze, 1995). We would like to question this widely accepted theoretical position using schizophrenia as an example. In agreement with a number of authorities (e.g. Berrios, 1994; Van Praag, 1992) we submit that modern diagnostic effort; only partly correspond to what classical descriptive psychiatry has achieved and current diagnostic criteria for schizophrenia are but a diluted and simplified version of views of Kraepelin and Bleuler, the two most oft-cited founders of the concept of schizophrenia. Limited space permits mentioning only a few aspects relevant to our thesis.

Kraepelin, Bieuler and their contemporaries based their schizophrenia concept on observable signs and symptoms embracing a significantly larger area of descriptive psychopathology than modem clinical practice and research operate. As two eminent European psychiatrists, Pamas and Bovet (1991) put it: if psychiatry remains stuck with the use of structured interviews solely compatible to pre-existing operational criteria, it %011 cut itself off from the major variable, namely psychopathology". The following examples will illustrate this point.

By a very conservative counting, we found 95 symptoms defining schizophrenia in Bleuler's textbook (Bleuler. 1911/1950) while Kraepelin (1913/1919) listed 65 symptoms of dementia praecox. ICD-10 (WHO, 1992) and DSM-IV (APA, 1994) considerably decreased the number of symptoms used as diagnostic criteria for schizophrenia to 38 and 30 respectively.

It is not only the sheer number of signs and symptoms what makes modern classification pale in comparison with classical accounts of schizophrenia but the omission of more complex psychopathological phenomena. …

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