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.
Thank you Giovanni! The social context and social determinants are of course very important in terms of clinical care and clinical outcomes. Their relationship to classification is a bit more complicated, as they don’t directly address the question of optimal classification. They are certainly an essential part of any good clinical formulation and if we want a dimensional characterization to incorporate this information, then having a dimension for social and contextual factors makes sense. I am also mindful that the future DSM is planning to have a contextual factors and social determinants of health domain in the DSM organization independent of the diagnosis domain.
I agree with Giovanni that social context should be considered within the classification system itself because it is so central to the “disease” course and the meaning and expression of symptoms. When you include Treatment Response as a dimension but “Responsive/resistant to standard antipsychotics, clozapine-responsive/ultra-resistant” are the only options, the diagnostic system then implies that the most important treatments are the antipsychotics. This is misleading. The social dimension and meaning-context is of equal importance in the classification and prognosis.
I hear you but I am not so sure I agree. Why would it be more complicated? I am at 35,000 ft flying to Europe so I can't answer in detail but I am not sure I agree with you. Why can't social determinants become a classification criteria? It will take some phenomenological description but I believe they could be part of an axis of classification. Once I get to my destination I'll try to show you some examples of what I mean.
Anyway thank you for engaging and keep up the good work. It's really a joy to read your writings. Ciao
Look forward to your examples! I’m also curious to know whether you think this applies to epilepsy too (and other medical classifications), that they too should include social context within the classifications.
Awais, I've landed, so as promised, here are my examples.
Take paranoid schizophrenia. I propose that the social determinants are the ecosystem in which the paranoia came to a brew, and that different ecosystems produce clinically distinct forms of the illness. Consider an African American man who grew up through discrimination, poverty, and deprivation of nearly everything. His paranoia grew inside a world that gave him repeated, concrete reasons for vigilance. Now consider the 23-year-old white male who had his first break in college, with no comparable history of threat. Both meet criteria for paranoid schizophrenia, yet I have seen in practice that they may respond to different medications and, without question, to different social interventions. If two presentations of the "same" illness diverge in treatment response, then IMHO the dimension along which they diverge belongs in the classification.
The same logic applies to depression. A depressed immigrant fighting to make his/her way through this country may carry the same chemical imbalances that predispose anyone to depression, but his/her response to an antidepressant may differ, because the antidepressant does not act on a neutral substrate. It acts on a brain embedded in a life. The well-integrated 30-year-old American is suffering too, but his response profile and the social interventions he requires may look entirely different. The classification becomes the phenomenological expression of one type of illness, with a consequence: a different treatment. We classify in order to match treatment to patient, exactly as oncology learned to do. If the biological determinant is the sole cause of the illness, then social classification has no merit. I refuse to believe that, and I suspect you do too.
On epilepsy: my criterion is pragmatic. A dimension earns a place in classification when it changes treatment response or predicts course. In epilepsy, the choice of anticonvulsant tracks the seizure type, and the patient's social world does not alter which molecule controls the seizures. In psychiatry it passes the test, and that asymmetry tells us something honest about our field: the illness is constituted, in part, in the space between the person and their world.
As for the DSM's plan to keep social determinants independent of diagnosis, I worry that independence is the problem. Kept outside, the social becomes an appendix clinicians document and ignore, the way Axis IV lived and died. Brought inside as a coordinate, it shapes the treatment decision itself.
Grazie for engaging. Your framework is strong enough to carry the extra axis, which is exactly why I keep pushing. :-) (I used AI to help me make this comment more structured).
This is good, Giovanni. Here's how I think of this.
Nosology characterizes a pathological condition into types or kinds or relevant constitutive clinical dimensions. The Robins-Guze tradition and its descendants distinguish between the features that define a class and the external validators we use to judge whether the class is any good as well as contextual factors that don't define a class but modify its course or outcomes. The operative principle "a dimension earns a place when it changes treatment response or predicts course" you suggest promotes validators and contextual factors into classifiers. But those are the criteria for evaluating a taxonomy or characterizing the modification of expression. If everything that predicts course or moderates treatment response were thereby a classificatory axis, the diagnosis would swell to include age, gender, personality, marital status... every clinically consequential variable.
The second problem is specificity. A classifier has to differentiate. Social determinants are the great transdiagnostic amplifiers. Poverty, discrimination, dislocation, and deprivation raise risk and worsen course across psychosis, depression, PTSD, and substance use. A factor that pushes on nearly every condition is, almost by definition, a poor instrument for telling conditions apart.
To make it a coordinate within the psychosis classification space (beyond having a contextual factors domain), we'd need to show it carves psychosis-internal distinctions, not merely that adverse contexts produce worse outcomes, which we already know and which holds everywhere. We cannot subtype by social context unless social context produces discernible differences in symptomatology, biology, or psychology that can be subtyped.
Medicine does incorporate social and environmental causes into nosology, but almost always where the cause is a specific, mechanistic, proximate exposure rather than a diffuse determinant. Consider occupational exposures, e.g. asbestosis or silicosis, or coal miner's disease, or nutritional deficiencies. But we don't subtype tuberculosis based on social determinants, even though social determinants play a very recognizable part in risk and prognosis.
Social and contextual factors absolutely belong in a diagnostic framework, which is why the future DSM is moving in that direction too, and I agree that it makes sense to include them in my list of clinical characterization of psychosis. At the same time, we shouldn't lose sight of the differences between features that define and constitute a clinical phenomenon, external validators, and contextual factors.
Awais, you made me think, which is the best thing anyone can do. Grazie!
You're right and I was wrong. My criterion was bad. If a dimension earns classifier status just by predicting course or moderating treatment, then age and marital status walk right in behind it and the category means nothing. And the specificity objection was right on. A classifier has to differentiate, poverty pushes on nearly everything in the book, and in my clumsy comment I never showed that social context carves psychosis from the inside. I said my two patients might respond to different medications. I don't have that evidence. I have clinical impression, which is exactly what our field has been fooled by for a century. My wife has been telling me for years that I argue with great confidence in areas where I should be asking questions instead, and she's usually right, and now you've joined her side of the argument. :-(
Some context for why I'm clinically rusty. I rejoined the APA after about thirty years away, and I got my license back two years ago. For three decades I was starting companies, more by destiny than by choice, which is a story for a different thread. So I come at this from the reimbursement end, and you can probably tell.
So I give up the coordinate. Here's what I still believe, and I think this is where the DSM is heading anyway, and I suspect you and I agree more than we disagree. Let me lay it out.
Social context as a required, coded domain. Not a classifier. Mandatory characterization. Your tuberculosis example is what convinced me this still matters, because I think it cuts my way. We don't subtype TB socially, agreed, but look at what medicine built around TB anyway. Directly observed therapy, housing, nutrition, contact tracing, a whole public health apparatus funded on the understanding that the pathogen is half the problem at best. The social lives outside the taxonomy there because there is an outside for it to live in. Psychiatry has no outside. Nothing is waiting to catch it. So when we leave it out of the framework, we're not filing it elsewhere, we're dropping it. Axis IV didn't die of conceptual confusion. It died because nothing was attached to it. The Z-codes are dying the same death right now, sitting there optional and unused.
And here's the argument I should have led with instead of my two patients. The social is already inside our diagnoses, it's just running unmeasured. Black American men get diagnosed with schizophrenia at several times the rate of white men presenting the same way, and they get more antipsychotic, more depot, more coercion. That's social context operating as a de facto classifier in every clinic in the country. Nobody coded it, which is exactly why it gets away with it. Coding it is how you drag it into the light where someone can audit it. Leaving it out isn't neutrality, it's the version where the bias never has to show its work.
That's where the mind stops being only a medical object for me. A framework that records hallucinations with great precision and treats homelessness as context is describing the part of the illness we know how to bill for. Medicine keeps what it can bill for. That's my obsession, and it's probably why I commented on your taxonomy uninvited.
Last thing. You let social causes into nosology when they're specific, mechanistic, proximate. Asbestos, silica, thiamine. If psychosis has a candidate of that shape, it's migration and urbanicity. Big effects, dose-response, second generation higher than first, and a mechanism people are actually chasing. I'm not claiming it's proven. I'm saying that's the asbestos-shaped hole, and it's your own criterion telling me to go look there.
Grazie for taking this apart so carefully. Tell me where I'm still wrong.
Thank you. A lot of worthwhile observations that bear thought. Here are two reactions, brief.
1. Many of the ‘symptoms’ of SCZ are essentially first-personal in nature. Real progress dealing with SCZ (or better, whatever classifications succeed it) will need to involve a serious attempt to investigate the phenomenology of the symptoms. (Some attempts exist. Not nearly enough, and many of them are methodologically suspect IMO.) For example, ‘hallucination’ is not just one thing. I think that right now nobody really knows how best to characterize the relevant types of hallucination. Same for delusion. Until we have a better handle on the phenomenology of these things, we don’t really even know what we’re talking about.
2. Most attempts to understand the ‘symptoms’ of SCZ begin with diagnosed patients. That seems totally fine until we remember that (as you say) diagnosis is currently a mess. For example, diagnosis requires substantial dysfunction. That makes sense for clinical reasons—we don’t need to be treating people who don’t need treatment—but for understanding the nature of the symptoms, restricting attention to the cases where ‘symptoms’ are associated with dysfunction could be blinding us to a lot of evidence. What might we learn, for example, from people involved in the Hearing Voices Network, many of whom hallucinate frequently but do not report clinically significant dysfunction? If we already knew that DSM-styled SCZ is a thing, a natural kind, then it would make sense to set aside persons who are not diagnosed. But (as you also say) we don’t know this. And yet, study after study after study begins by selecting only DSM-diagnosed persons as the subjects.
I like this idea. Its something I've been thinking a lot about lately. Setting Robert Post amd Geschwind aside, is there something to be learnt from the classificatory system of epilepsy? I think the answer is yes. It even allows for the separation of different kinds of psychosis just as there are different forms of seizure.
The only issue that I see is psychopathology itself. Would something be lost?
My idea is that at this point in time what is needed are multiple competing classificatory systems. Ideally they should be robust, defensible and widely used. Having a number of high quality methods for coding, annotating and classifying phenomenon allows for a good visualisation of the data helping to surface patterns.
A single dominant system like the DSM surfaces only a narrow slice of the data. Flexibility is needed. We went down the wrong road trying to standardise things too much.
The competitors that have gained popularity are more ancillary psychological and social explanations. That is fine but we need competitors that are based on biology to create an even playing field.
Allowing people to "play" around with different classificatory systems is my mind an excellent idea, particularly if the systems are of a high quality.
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! :)
Thank you Mel! Much appreciate the compliments ☺️ It is great to see you notice the form as well as the humor! Usually goes by unremarked, so thank you. Very true about our big feelings and special attachments. The human side of nosology 😊
It depends on the case - eg is it drug induced or as part of severe mood disorder or better conceptualised as the extended psychosis phenotype. SCZ is best reserved for those with negative and/ or cognitive impairment or disorders of self.
I attacked or rather criticized the central idea of this thread, Aftab intiially was posing the epilepsy classification as a possible jumping off point for a new psychosis classification.
But we share the central concerns. There is a problem with our psychosis classification in the DSM. When I was a resident I fatuously accepted or at least memorized for regurgitation on exams, every concept promoted by the DSM. Twenty-five years on when I have seen the most psychiatrically extreme patients from every category of disorder no exception, at every phase of the life cycle, across psychiatry, neuropsychiatry, and sleep medicine, and I have become cynical when the DSM didn't deliver what it promised.
The "diagnosis I love to hate" is Intermittant Explosive Disorder. This is arguably in the realm of the psychotic disorders, but whether you see its proximity, it's unimportant. I have found it to be an invalid diagnosis by every measure I can imagine. I have found it unuseful. Schizoaffective Disorder is similarly problematic. I ignore the substantial part of the DSM that I don't find useful. I doubt others, particularly those closer to training, can do that.
I find the DSM useful in ways I doubt other people do, I appreciate its categories. Even though the exact place of many disorders is unclear, the efffort to categorize mental illnesses, is a useful exercise and good idea to my mind.
I PERSONALLY feel that if a diagnosis doesn't guide me in treatment, it shouldn't exist, or at least I shouldn't consider it in my already crowded brain. And I write very few diagnoses doen in my chart. I am eternally skeptical.
So by all means, tear down the DSM and find an alternative.
If this is your strategy, that it's unprovoked seizure activity without final cause, it is inevitable that you will run into Gecshwind syndrome. And when you do, you'll be forced to reconcile with why that population - but not schizophrenia - intentionally and habitually engages in behaviors that re-provoke the mystical experiences that emerge from extreme TL dynamics, which get sustained with hypergraphia. Embedded in their is a final cause.
Why bother is good enough for me for now. Thank you for the read ! Can I ask if you chose not to include family history in your own view of the concept ?
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?
Well it solves one problem: it corresponds to the phenotypes we see in clinical practice, so at least we can imagine that our understanding might catch up to the nosology. The DSM never did that, it was always too schematic, with too much deference to Kraepelin.
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.
Thank you Giovanni! The social context and social determinants are of course very important in terms of clinical care and clinical outcomes. Their relationship to classification is a bit more complicated, as they don’t directly address the question of optimal classification. They are certainly an essential part of any good clinical formulation and if we want a dimensional characterization to incorporate this information, then having a dimension for social and contextual factors makes sense. I am also mindful that the future DSM is planning to have a contextual factors and social determinants of health domain in the DSM organization independent of the diagnosis domain.
I agree with Giovanni that social context should be considered within the classification system itself because it is so central to the “disease” course and the meaning and expression of symptoms. When you include Treatment Response as a dimension but “Responsive/resistant to standard antipsychotics, clozapine-responsive/ultra-resistant” are the only options, the diagnostic system then implies that the most important treatments are the antipsychotics. This is misleading. The social dimension and meaning-context is of equal importance in the classification and prognosis.
I hear you but I am not so sure I agree. Why would it be more complicated? I am at 35,000 ft flying to Europe so I can't answer in detail but I am not sure I agree with you. Why can't social determinants become a classification criteria? It will take some phenomenological description but I believe they could be part of an axis of classification. Once I get to my destination I'll try to show you some examples of what I mean.
Anyway thank you for engaging and keep up the good work. It's really a joy to read your writings. Ciao
Giovanni
Look forward to your examples! I’m also curious to know whether you think this applies to epilepsy too (and other medical classifications), that they too should include social context within the classifications.
Awais, I've landed, so as promised, here are my examples.
Take paranoid schizophrenia. I propose that the social determinants are the ecosystem in which the paranoia came to a brew, and that different ecosystems produce clinically distinct forms of the illness. Consider an African American man who grew up through discrimination, poverty, and deprivation of nearly everything. His paranoia grew inside a world that gave him repeated, concrete reasons for vigilance. Now consider the 23-year-old white male who had his first break in college, with no comparable history of threat. Both meet criteria for paranoid schizophrenia, yet I have seen in practice that they may respond to different medications and, without question, to different social interventions. If two presentations of the "same" illness diverge in treatment response, then IMHO the dimension along which they diverge belongs in the classification.
The same logic applies to depression. A depressed immigrant fighting to make his/her way through this country may carry the same chemical imbalances that predispose anyone to depression, but his/her response to an antidepressant may differ, because the antidepressant does not act on a neutral substrate. It acts on a brain embedded in a life. The well-integrated 30-year-old American is suffering too, but his response profile and the social interventions he requires may look entirely different. The classification becomes the phenomenological expression of one type of illness, with a consequence: a different treatment. We classify in order to match treatment to patient, exactly as oncology learned to do. If the biological determinant is the sole cause of the illness, then social classification has no merit. I refuse to believe that, and I suspect you do too.
On epilepsy: my criterion is pragmatic. A dimension earns a place in classification when it changes treatment response or predicts course. In epilepsy, the choice of anticonvulsant tracks the seizure type, and the patient's social world does not alter which molecule controls the seizures. In psychiatry it passes the test, and that asymmetry tells us something honest about our field: the illness is constituted, in part, in the space between the person and their world.
As for the DSM's plan to keep social determinants independent of diagnosis, I worry that independence is the problem. Kept outside, the social becomes an appendix clinicians document and ignore, the way Axis IV lived and died. Brought inside as a coordinate, it shapes the treatment decision itself.
Grazie for engaging. Your framework is strong enough to carry the extra axis, which is exactly why I keep pushing. :-) (I used AI to help me make this comment more structured).
This is good, Giovanni. Here's how I think of this.
Nosology characterizes a pathological condition into types or kinds or relevant constitutive clinical dimensions. The Robins-Guze tradition and its descendants distinguish between the features that define a class and the external validators we use to judge whether the class is any good as well as contextual factors that don't define a class but modify its course or outcomes. The operative principle "a dimension earns a place when it changes treatment response or predicts course" you suggest promotes validators and contextual factors into classifiers. But those are the criteria for evaluating a taxonomy or characterizing the modification of expression. If everything that predicts course or moderates treatment response were thereby a classificatory axis, the diagnosis would swell to include age, gender, personality, marital status... every clinically consequential variable.
The second problem is specificity. A classifier has to differentiate. Social determinants are the great transdiagnostic amplifiers. Poverty, discrimination, dislocation, and deprivation raise risk and worsen course across psychosis, depression, PTSD, and substance use. A factor that pushes on nearly every condition is, almost by definition, a poor instrument for telling conditions apart.
To make it a coordinate within the psychosis classification space (beyond having a contextual factors domain), we'd need to show it carves psychosis-internal distinctions, not merely that adverse contexts produce worse outcomes, which we already know and which holds everywhere. We cannot subtype by social context unless social context produces discernible differences in symptomatology, biology, or psychology that can be subtyped.
Medicine does incorporate social and environmental causes into nosology, but almost always where the cause is a specific, mechanistic, proximate exposure rather than a diffuse determinant. Consider occupational exposures, e.g. asbestosis or silicosis, or coal miner's disease, or nutritional deficiencies. But we don't subtype tuberculosis based on social determinants, even though social determinants play a very recognizable part in risk and prognosis.
Social and contextual factors absolutely belong in a diagnostic framework, which is why the future DSM is moving in that direction too, and I agree that it makes sense to include them in my list of clinical characterization of psychosis. At the same time, we shouldn't lose sight of the differences between features that define and constitute a clinical phenomenon, external validators, and contextual factors.
Awais, you made me think, which is the best thing anyone can do. Grazie!
You're right and I was wrong. My criterion was bad. If a dimension earns classifier status just by predicting course or moderating treatment, then age and marital status walk right in behind it and the category means nothing. And the specificity objection was right on. A classifier has to differentiate, poverty pushes on nearly everything in the book, and in my clumsy comment I never showed that social context carves psychosis from the inside. I said my two patients might respond to different medications. I don't have that evidence. I have clinical impression, which is exactly what our field has been fooled by for a century. My wife has been telling me for years that I argue with great confidence in areas where I should be asking questions instead, and she's usually right, and now you've joined her side of the argument. :-(
Some context for why I'm clinically rusty. I rejoined the APA after about thirty years away, and I got my license back two years ago. For three decades I was starting companies, more by destiny than by choice, which is a story for a different thread. So I come at this from the reimbursement end, and you can probably tell.
So I give up the coordinate. Here's what I still believe, and I think this is where the DSM is heading anyway, and I suspect you and I agree more than we disagree. Let me lay it out.
Social context as a required, coded domain. Not a classifier. Mandatory characterization. Your tuberculosis example is what convinced me this still matters, because I think it cuts my way. We don't subtype TB socially, agreed, but look at what medicine built around TB anyway. Directly observed therapy, housing, nutrition, contact tracing, a whole public health apparatus funded on the understanding that the pathogen is half the problem at best. The social lives outside the taxonomy there because there is an outside for it to live in. Psychiatry has no outside. Nothing is waiting to catch it. So when we leave it out of the framework, we're not filing it elsewhere, we're dropping it. Axis IV didn't die of conceptual confusion. It died because nothing was attached to it. The Z-codes are dying the same death right now, sitting there optional and unused.
And here's the argument I should have led with instead of my two patients. The social is already inside our diagnoses, it's just running unmeasured. Black American men get diagnosed with schizophrenia at several times the rate of white men presenting the same way, and they get more antipsychotic, more depot, more coercion. That's social context operating as a de facto classifier in every clinic in the country. Nobody coded it, which is exactly why it gets away with it. Coding it is how you drag it into the light where someone can audit it. Leaving it out isn't neutrality, it's the version where the bias never has to show its work.
That's where the mind stops being only a medical object for me. A framework that records hallucinations with great precision and treats homelessness as context is describing the part of the illness we know how to bill for. Medicine keeps what it can bill for. That's my obsession, and it's probably why I commented on your taxonomy uninvited.
Last thing. You let social causes into nosology when they're specific, mechanistic, proximate. Asbestos, silica, thiamine. If psychosis has a candidate of that shape, it's migration and urbanicity. Big effects, dose-response, second generation higher than first, and a mechanism people are actually chasing. I'm not claiming it's proven. I'm saying that's the asbestos-shaped hole, and it's your own criterion telling me to go look there.
Grazie for taking this apart so carefully. Tell me where I'm still wrong.
Giovanni
(AI helped me structure this one too.)
Thank you. A lot of worthwhile observations that bear thought. Here are two reactions, brief.
1. Many of the ‘symptoms’ of SCZ are essentially first-personal in nature. Real progress dealing with SCZ (or better, whatever classifications succeed it) will need to involve a serious attempt to investigate the phenomenology of the symptoms. (Some attempts exist. Not nearly enough, and many of them are methodologically suspect IMO.) For example, ‘hallucination’ is not just one thing. I think that right now nobody really knows how best to characterize the relevant types of hallucination. Same for delusion. Until we have a better handle on the phenomenology of these things, we don’t really even know what we’re talking about.
2. Most attempts to understand the ‘symptoms’ of SCZ begin with diagnosed patients. That seems totally fine until we remember that (as you say) diagnosis is currently a mess. For example, diagnosis requires substantial dysfunction. That makes sense for clinical reasons—we don’t need to be treating people who don’t need treatment—but for understanding the nature of the symptoms, restricting attention to the cases where ‘symptoms’ are associated with dysfunction could be blinding us to a lot of evidence. What might we learn, for example, from people involved in the Hearing Voices Network, many of whom hallucinate frequently but do not report clinically significant dysfunction? If we already knew that DSM-styled SCZ is a thing, a natural kind, then it would make sense to set aside persons who are not diagnosed. But (as you also say) we don’t know this. And yet, study after study after study begins by selecting only DSM-diagnosed persons as the subjects.
Thanks again. Lots to consider, here.
Both excellent points Michael! Thank you. I agree
I like this idea. Its something I've been thinking a lot about lately. Setting Robert Post amd Geschwind aside, is there something to be learnt from the classificatory system of epilepsy? I think the answer is yes. It even allows for the separation of different kinds of psychosis just as there are different forms of seizure.
The only issue that I see is psychopathology itself. Would something be lost?
My idea is that at this point in time what is needed are multiple competing classificatory systems. Ideally they should be robust, defensible and widely used. Having a number of high quality methods for coding, annotating and classifying phenomenon allows for a good visualisation of the data helping to surface patterns.
A single dominant system like the DSM surfaces only a narrow slice of the data. Flexibility is needed. We went down the wrong road trying to standardise things too much.
The competitors that have gained popularity are more ancillary psychological and social explanations. That is fine but we need competitors that are based on biology to create an even playing field.
Allowing people to "play" around with different classificatory systems is my mind an excellent idea, particularly if the systems are of a high quality.
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!
Thank you Mel! Much appreciate the compliments ☺️ It is great to see you notice the form as well as the humor! Usually goes by unremarked, so thank you. Very true about our big feelings and special attachments. The human side of nosology 😊
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
What do you think is the appropriate diagnostic category?
It depends on the case - eg is it drug induced or as part of severe mood disorder or better conceptualised as the extended psychosis phenotype. SCZ is best reserved for those with negative and/ or cognitive impairment or disorders of self.
I attacked or rather criticized the central idea of this thread, Aftab intiially was posing the epilepsy classification as a possible jumping off point for a new psychosis classification.
But we share the central concerns. There is a problem with our psychosis classification in the DSM. When I was a resident I fatuously accepted or at least memorized for regurgitation on exams, every concept promoted by the DSM. Twenty-five years on when I have seen the most psychiatrically extreme patients from every category of disorder no exception, at every phase of the life cycle, across psychiatry, neuropsychiatry, and sleep medicine, and I have become cynical when the DSM didn't deliver what it promised.
The "diagnosis I love to hate" is Intermittant Explosive Disorder. This is arguably in the realm of the psychotic disorders, but whether you see its proximity, it's unimportant. I have found it to be an invalid diagnosis by every measure I can imagine. I have found it unuseful. Schizoaffective Disorder is similarly problematic. I ignore the substantial part of the DSM that I don't find useful. I doubt others, particularly those closer to training, can do that.
I find the DSM useful in ways I doubt other people do, I appreciate its categories. Even though the exact place of many disorders is unclear, the efffort to categorize mental illnesses, is a useful exercise and good idea to my mind.
I PERSONALLY feel that if a diagnosis doesn't guide me in treatment, it shouldn't exist, or at least I shouldn't consider it in my already crowded brain. And I write very few diagnoses doen in my chart. I am eternally skeptical.
So by all means, tear down the DSM and find an alternative.
If this is your strategy, that it's unprovoked seizure activity without final cause, it is inevitable that you will run into Gecshwind syndrome. And when you do, you'll be forced to reconcile with why that population - but not schizophrenia - intentionally and habitually engages in behaviors that re-provoke the mystical experiences that emerge from extreme TL dynamics, which get sustained with hypergraphia. Embedded in their is a final cause.
Why bother is good enough for me for now. Thank you for the read ! Can I ask if you chose not to include family history in your own view of the concept ?
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.
Well it solves one problem: it corresponds to the phenotypes we see in clinical practice, so at least we can imagine that our understanding might catch up to the nosology. The DSM never did that, it was always too schematic, with too much deference to Kraepelin.