Swings of Fashion in Schizophrenia

1. Swings of Fashion in Schizophrenia The Kraepelinian Disease Model 1896-1940 Psychoanalytical Model 1940-1976

2. Psychotic people are not categorically different • The experience and behaviour of people with schizophrenia is “much more socially intelligible than has come to be supposed by most psychiatrists” • Psychiatry is often a coercive agent for social control • Parents cause schizophrenia

3. The man who changed the face of schizophrenia research

4. Swings of Fashion in Schizophrenia The Kraepelinian Disease Model 1896-1940 Psychoanalytical Model 1940-1976 Genetic-Brain Disease Model 1976-2000

5. The Diagnosis of Schizophrenia is a Contentious Issue for Many Patients You are a Schizophrenic!

6. The Years of Warring Factions • Kraepelinians maintained that schizophrenia was just a simple brain disease while antipsychiatrists claimed that psychotic people were saner than those who treated them. • Geneticists boasted there was no role for environment while psychologists called geneticists fascists; and charities hated each other even more than they hated psychiatrists. • These disputes brought disrepute on the mental health services and allowed politicians to ignore the needs of the mentally ill

7. Swings of Fashion in Schizophrenia The Kraepelinian Disease Model 1896-1940 Psychoanalytical Model 1940-1976 Genetic-Brain Disease Model 1976-2000 Increasing Emphasis on Social Factors 2000-2006

8. Alternative Models in 2008 Persist with the Neurodevelopmental Model ? Welcome the Kraepelinians back ? Switch to a Cognitive or Social Model ?

9. Integrated Model

10. The Critics “It is now almost a hundred years since Kraepelin introduced his concept of dementia praecox, the direct forerunner of ……the modern concepts of schizophrenia. Criticising these concepts has been a popular sport

11. Is 112 years of schizophrenia enough? • Overlap with schizotypy and into minor psychotic symptoms in the normal population • Overlap with affective psychosis • Are dimensions better than categorical diagnosis?

12. The Mad The Sane 12

13. Only psychiatrists believe there is a categorical distinction between sanity and insanity “No excellent soul is exempt from a mixture of madness”  Aristotle “Sanity is very rare: every man almost, and every woman, has a dash of madness” Ralph Waldo Emerson “Insanity in individuals is something rare – but in groups, parties, nations and epochs, it is the rule” Friedrich Nietzsche “The statistics on insanity are that 1 out of every 4 Americans is suffering from mental illness. Think of your three best friends. If they are okay then it’s you” Rita Mae Brown

14. Are minor psychotic symptoms in the general population of relevance to schizophrenia? • 8580 individuals aged 16-74 were interviewed as part of a large survey of mental health in the UK population • The Psychosis Screening Questionnaire of Bebbington et al (1995) was used to identify those with psychotic symptoms • We examined the correlates of these symptoms Johns L et al. Br J Psych. 2004;185:298-305.

15. Correlates of Minor Psychotic Symptoms in the General Population • Low verbal IQ • Low education • Living in cities • Cannabis dependence • Life events/victimisation • Neurotic symptoms • Ethnic minorities Minor psychotic symptoms in the general population are related to the same variables as is schizophrenia. Psychosis is at one extreme of a distribution of psychotic symptoms

16. Diastolic blood pressure of 85 mmHg Continua in Medical Disorders • Many medical disorders are considered to be at the extreme end of a continuum (eg, obesity, hypertension, diabetes, anemia) • A categorical division is imposed at the point at which it seems useful to initiate treatment HEALTHY ill • Psychotic illness is at the extreme of a dimension upon which we impose a categorical distinction at the point at which it seems useful to initiate treatment

17. Know Your Own Psychosis Levels • Do you ever feel that others are against you? • Do you believe that others are influencing your mind? • Do you believe that other people talk about you? • Can you communicate with animals? Do you ever feel that your manager/professor is against you? Do you believe that drug companies are influencing your mind? Do members of your clinical/research team gossip about you? If you have a pet, can you tell what it is thinking?

18. The Traditional Kraepelinian Dichotomy True schizophrenia True bipolar disorder After Pak Sham.

19. Misdiagnosis Clinicalschizophrenia Clinicalbipolar disorder Schizoaffective disorder Traditional Kraepelinian Dichotomy (in real life) True schizophrenia True bipolar disorder

20. Motor and Language Developmentin Pre-symptomatic Children Pre-schizophreniform 0.2 0.1 0.0 Co-efficient -0.1 -0.2 -0.3 -0.4 IQ Receptive language Expressive language Motor development Cannon M et al. Arch Gen Psychiatry. 2002;59:449-456.

21. Motor and Language Developmentin Pre-symptomatic Children Pre-schizophreniform Pre-manic 0.4 0.3 Co-efficient 0.2 0.2 0.1 0.1 0.0 0.0 IQ Co-efficient -0.1 Receptive language Expressive language Motor development -0.2 -0.3 -0.4 IQ Receptive language Expressive language Motor development Cannon M et al. Arch Gen Psychiatry. 2002;59:449-456.

22. The genetic relationship between schizophrenia and bipolar disorder A Additive genetic Schizophrenia Schizoaffectivedisorder Bipolar disorder Cardno et al 2002

23. A1 E1 The genetic relationship between schizophrenia and bipolar disorder A Additive genetic Developmentalimpairment Schizoaffectivedisorder Bipolar disorder Cardno et al 2002

24. Neuregulin Dysbindin DISC1 COMT ETC, ETC Genes for psychosis exist

25. The Implications of the Findings • Schizophrenia is subject to genetic influence! • But it is equally clear that geneticists exaggerated the influence! • The genes are multiple, of small effect, and to interact with each other and with environmental factors • The genes are distributed through the normal population • People with schizophrenia are not categorically different

26. Dopamine as the “Wind of Psychotic Fire” • When individuals are acutely psychotic, they show an excessive release of dopamine (Laruelle et al 1996) • Dopamine normally mediates the attachment of salience to ideas and objects (Berridge and Robinson, 1998) • Heightened DA transmission leads to aberrant assignment of salience to external and internal stimuli (Kapur, 2003). • Delusions arise from attempts to explain this abnormal salience (Maher, 1983)

27. Dimensional view: grouping of symptoms negative manic positive depressed disorganisation

28. Dimensions or Diagnosis? • Dimensions are marginally better than categorical diagnoses • However, using both provides more clinical information than either alone • DSM V and ICD 11 should use both

29. Towards DSMVI and ICD12 • The term psychosis will have been replaced by the term Dopamine Sensitisation Disorder of the Associative Striatum (DSDAS) • This will be routinely diagnosed by neurochemical imaging • Different genes and different environmental factors will have been mapped onto the 5 symptom factors and the developmental dimension of DSDAS