Gin S. Malhi: A critical analysis of concepts in psychiatry.

Gin S. Malhi and Erica Bell: Make News: Attenuated Psychosis Syndrome: A premature speculation?*

Edward Shorter’s comment

        “Schizophrenia” is already such a can of worms that devising schemes for diagnosing and treating a prodrome really seem perilous.  There are three problems:

1.  One is conceptual — the difficulty in defining just when a disorder begins.  Here references to the work of German psychiatrist Karl Jaspers might be useful, especially to his epochal 1913 book Allgemeine Psychopathologie that specified two different kinds of onset:  Those onsets understandable through Verstehen, a kind of empathic leap. These would be slow,  as opposed to those explicable through Erklären, behavior that is not understandable in its own terms but seems to come out of the blue: There is a puzzling kind of rapid onset that has no evident prodrome that one can grasp in psychotherapy or identify with at a human level.  (Unfortunately, both terms translate in English as the synonyms “understanding” or “explaining.”)

        Those disorders having a long, slow prodrome that can lead to an empathic reaching out in the doctor-patient relationship are classed as Verstehen.  But it is unclear what, in a possible prodrome, represents the vicissitudes of normal experience as opposed to the slow onset of frank disease.  Those seeming to burst out of nothing, like catatonia, defy any kind of intuitive reaching out and are subject to “erklären."  In schizophrenia, this would be the “praecox feeling.”  

        Unfortunately, defining schizophrenia as psychosis and searching for an Attenuated Psychosis Syndrome  confuses both kinds of onset.   Some will be apples and other oranges.  We need to distinguish between  these different onsets.  Fans of Jaspers are very aware of this but grosso modo, Jaspers failed to cross the Atlantic.

2. Schizophrenia does not reduce to psychosis.  What is meant by “schizophrenia” is often unclear. The term has staggered on for a hundred years without change.  Just imagine “consumption” staggering  on unchanged for a century in the field of respiratory disease.   The schizophrenia basin seems to have a number of distinct disorders in it.  Some of them involve early psychosis, others do not, still others are adolescent growth pains.  But there is wide agreement that the diagnosis of schizophrenia can be made in the absence of psychosis.  The core features would be emotional blunting (“emotional dementia”), executive dysfunction (the inability to get anything done) and thought disorder.  But a lot of the Attenuated Psychosis Syndrome discussion seems to focus around social withdrawal, which happens often enough in adolescents without being a prodrome of anything.  So, until we have a much clearer sense of what can go wrong in the community relations-department, we’ll be at a lost to define a “prodrome” for it.

3.  Attenuated Psychosis Syndrome is going to involve a huge number of false positives.  If we proactively put all the kids with the APS diagnosis on medication, we will end up overdosing the population on such a vast scale that adolescent  psychiatry will be forever discredited.  Malhi and Bell see the major downside of APS as unnecessary “stigmatization.”  But a torrent of false positives is the elephant in the room.

        I sympathize with Gin Malhi and Erica Bell’s desire to make sense of the DSM by trimming and adjusting here and there.  But DSM is so filled with false concepts that any effort to  trim and refine  “major depression” or “bipolar disorder” will inevitably run aground.  This is like making sense of the Tooth Fairy.  Bottom line: there must be no DSM-5-R.  Control must be wrested from the APA.

September 3, 2020