Awais, I loved this essay. Seriously. I think this might be one of my more recent favorites of yours. I just always so appreciate your analysis and writing voice both, and how you seamlessly integrate your views in this, but without that taking over (or not being clear to your readers, either!). I feel that you are something of a "master of this form." Just in case you didn't already know that. :)
Sorry for the endless gushing, btw.
But anyway, with this one in particular, you having chosen to write about psychosis classification and its reductive mushy "schizophrenia" of the DSM popularized variation today, and simultaneously using this "epilepsy" diagnostics comparative angle -- plus, your very accurate "real talk" explanation of why/how things have stayed, and will likely continue to remain, in the ICD -- oh man, seriously, your language just on THAT made me laugh out loud, even though it's not, like, "funny," but I can't help but the see the dark humor in that.
Because oy, it's true, but what a mess, all these "compromises" we make for our chaos, and not to Hurt Anyone's Feelings, right? Right?!
Imagine a world in which no one felt any especial attachment to any particular diagnostic term, or its descriptors.
Like, imagine if we could just chill out on all of that.
Imagine that unrealistic utopian fantasy.
If we were better at psychosis, perhaps we could! :)
Awais, good work, I like how you keep the description observing separate from what clinically we "feel" about it. In psychiatry have needed this discipline for a long time, and the multi-spatial dimension you build around it is a good, stable reference that a clinician can actually use operationally, in a very different way from the way we are using it today. I like it, and I'm with you on the whole program. I also like the coordinated system because it anchors the field on the center of the fact that schizophrenia is a category, and you make a good case for that. Bravo!
Now allow me offer constructive feedback on a piece that I think is missing. I look at the six axes, and I see that five of them are entirely inside the person. The sixth, called Functional Impairment, is a deficit that the patient carries around, but not something that lives in the space that is in between the person and their social construct, their housing, their relationships, their work, their families, the people they love. There's no access for a social context anywhere in this system.
If with epilepsy all we envy about is the EEG the pull towards finding a physical correlate keeps bringing the social off the table. But I think you would agree that the social is where a lot of the outcome actually lives. We see it in the Trieste tradition, in the Clubhouse model, how they are able to move people towards real function, even though the biology is a mystery, and the social determinants literature is now pointing strongly the same way. In your axis the thing that predicts long-term function is staying outside this map.
Here's my ask: could you consider social context and social recovery as a dimension in its own right, putting it alongside symptoms and cognition instead of folding it into one category called Functional Impairment? If the psychosis lives in a multi-dimensional space, we're missing the coordinate of the person's world. Putting it back in the picture makes the whole model stronger and not softer. I would love to see you take that dimension as one axis further. To be fair, I know you're one of the few people in this debate who will give the social its due, and I think this is what the framework is asking for.
I find it amusing that Aftab uses epilepsy classifications as an example of a future direction of schizophrenia classification, for which he has to do various intellectual and sophistic somersaults, when he could make reference to....already constructed schizophrenia classifications. Bleuler and Kraepelin were not the first psychiatrists to describe schizophrenia, they were merely the ones reifide in American texts. And they weren't the last. Leonhard had his own system of classification based on the actual phenotypes he identified (and built on conceptions of Kleist and Wernike), and it is much more precise than any attempt the DSM ever made. Why don't we start there?
Sadly McGorry on classification is building castles in the air and confuses research utility for clinical utility.
The best compromise is to assign an appropriate diagnostic category then flesh out with symptom dimensions and course descriptors
Awais, I loved this essay. Seriously. I think this might be one of my more recent favorites of yours. I just always so appreciate your analysis and writing voice both, and how you seamlessly integrate your views in this, but without that taking over (or not being clear to your readers, either!). I feel that you are something of a "master of this form." Just in case you didn't already know that. :)
Sorry for the endless gushing, btw.
But anyway, with this one in particular, you having chosen to write about psychosis classification and its reductive mushy "schizophrenia" of the DSM popularized variation today, and simultaneously using this "epilepsy" diagnostics comparative angle -- plus, your very accurate "real talk" explanation of why/how things have stayed, and will likely continue to remain, in the ICD -- oh man, seriously, your language just on THAT made me laugh out loud, even though it's not, like, "funny," but I can't help but the see the dark humor in that.
Because oy, it's true, but what a mess, all these "compromises" we make for our chaos, and not to Hurt Anyone's Feelings, right? Right?!
Imagine a world in which no one felt any especial attachment to any particular diagnostic term, or its descriptors.
Like, imagine if we could just chill out on all of that.
Imagine that unrealistic utopian fantasy.
If we were better at psychosis, perhaps we could! :)
Thanks again for this one!
Awais, good work, I like how you keep the description observing separate from what clinically we "feel" about it. In psychiatry have needed this discipline for a long time, and the multi-spatial dimension you build around it is a good, stable reference that a clinician can actually use operationally, in a very different way from the way we are using it today. I like it, and I'm with you on the whole program. I also like the coordinated system because it anchors the field on the center of the fact that schizophrenia is a category, and you make a good case for that. Bravo!
Now allow me offer constructive feedback on a piece that I think is missing. I look at the six axes, and I see that five of them are entirely inside the person. The sixth, called Functional Impairment, is a deficit that the patient carries around, but not something that lives in the space that is in between the person and their social construct, their housing, their relationships, their work, their families, the people they love. There's no access for a social context anywhere in this system.
If with epilepsy all we envy about is the EEG the pull towards finding a physical correlate keeps bringing the social off the table. But I think you would agree that the social is where a lot of the outcome actually lives. We see it in the Trieste tradition, in the Clubhouse model, how they are able to move people towards real function, even though the biology is a mystery, and the social determinants literature is now pointing strongly the same way. In your axis the thing that predicts long-term function is staying outside this map.
Here's my ask: could you consider social context and social recovery as a dimension in its own right, putting it alongside symptoms and cognition instead of folding it into one category called Functional Impairment? If the psychosis lives in a multi-dimensional space, we're missing the coordinate of the person's world. Putting it back in the picture makes the whole model stronger and not softer. I would love to see you take that dimension as one axis further. To be fair, I know you're one of the few people in this debate who will give the social its due, and I think this is what the framework is asking for.
I find it amusing that Aftab uses epilepsy classifications as an example of a future direction of schizophrenia classification, for which he has to do various intellectual and sophistic somersaults, when he could make reference to....already constructed schizophrenia classifications. Bleuler and Kraepelin were not the first psychiatrists to describe schizophrenia, they were merely the ones reifide in American texts. And they weren't the last. Leonhard had his own system of classification based on the actual phenotypes he identified (and built on conceptions of Kleist and Wernike), and it is much more precise than any attempt the DSM ever made. Why don't we start there?
I’m familiar with Leonhard’s classification but I don’t see it as offering a promising path forward. It’s doesn’t solve any of the problems.