The February edition of the British Journal of Psychiatry has a thought-provoking editorial by psychiatrist Jim van Os, arguing that we should reject the diagnosis of schizophrenia owing to its lack of validity and replace it with a concept of a ‘salience dysregulation syndrome’.
If you’re not familiar with the use of the term salience, it is used widely in cognitive science to describe the attention grabbing quality of things and psychosis is widely thought to involve, at least in part, a problem with the regulation of salience so normally unremarkable things seem important or alarming.
Although this idea has been kicked around for many years, it was popularised in recent years by an influential article by psychiatrist Shitij Kapur called ‘Psychosis as a state of aberrant salience’, as differences in dopamine function are regularly found in studies on delusions and hallucinations.
Importantly, disturbance in dopamine-regulated salience does not seem specific to schizophrenia, but is common across all psychotic disorders.
Consequently, van Os reviews the scientific literature that has repeatedly found that the diagnosis of schizophrenia does not seem to be a cut-and-dry category and that psychosis appears in various forms to differing degrees throughout the population.
He particularly argues for the importance of explicitly naming the problem as a ‘syndrome’, as despite that fact that most people accept that it is not a single disorder, it can get treated as such simply out of habit:
First, although criticisms about the diagnostic construct of schizophrenia may be deflected with the argument that it is merely a syndrome (the association of several clinically recognisable features that often occur together for which a specific disorder may or may not be identified as the underlying cause), the problem is that its very name and the way mental health professionals use and communicate about the term results in medical reification and validation through professional behaviour rather than scientific data, exposing psychiatry to ridicule and hampering scientific progress. It may be argued, therefore, that if it is a syndrome, calling it as such may serve to remind professionals (and downstream of these, the rest of the world) of the relatively agnostic state of science in this regard.
Second, given the fact that maximum utility in terms of conveying clinical information may be obtained by combining categorical with dimensional representations of psychopathology, DSM‚ÄìV and ICD‚Äì11 may be best served by creating separate categorical and dimensional axes of the psychopathology of psychotic disorders.