DSM-IV and the founding prototype of schizophrenia: are we regressing to a pre-Kraepelinian nosology?

Josef Parnas

in Philosophical Issues in Psychiatry II

Published on behalf of Oxford University Press

Published in print April 2012 | ISBN: 9780199642205
Published online February 2013 | e-ISBN: 9780191754777 | DOI:

Series: International Perspectives in Philosophy & Psychiatry

DSM-IV and the founding prototype of schizophrenia: are we regressing to a pre-Kraepelinian nosology?

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This contribution will be both anachronistic and anarchic. Anachronistic, because it will seriously take up Bolton's (Chapter 1, this volume) emphasis on the constitutive dimension of distress for psychiatric classification, and the equally fundamental remark of Berrios (Chapter 6, this volume), that the conceptualization of the “psychiatric object” (symptoms and signs) remains today the most challenging task confronting psychiatric nosology. The anachronistic element will be visible through an appeal to a phenomenological perspective as the most adequate for addressing the concerns of Bolton, Berrios and others. It is a perspective where a psychiatrist, through a conversation with her patient, explores, conceptualizes and grasps the patient's experience (“inner life”), not only in its content but its structure as well (Parnas and Zahavi 2002). This (mainly) European perspective is now almost forgotten in the Anglophone world (if it had ever been voiced), and if occasionally remembered, then either as a superfluous or no longer necessary detour on psychiatry's path to scientific fulfillment. It is also an anarchic essay, not only because of its unorthodox appeal to phenomenology, but also due to a rather skeptical view of a widespread, mainstream representation of a formidable progress of psychiatric nosology over the last 30 years, and equally critical of the mainstream epistemology.

This essay compares the concept of schizophrenia described in the DSM-IV-TR (APA 2000) with the continental European concept from 1974—described in the glossary of ICD-8 (which later served as a template for the DSM-III) (WHO 1974). This prototype may be seen as a zenith achievement of psychopathologic research in Europe, providing the basis for the first major scientific achievements in the study of schizophrenia, e.g., the foundational Scandinavian epidemiological studies, the US-DK Adoption studies, the US-DK High-Risk studies, and the WHO's International Pilot Studies of Schizophrenia (Bøjholm and Strömgren 1989; Jablensky and Sartorius 2008; Kety 1988; Mednick et al. 1987).

The transition to DSM-IV entailed important modifications. First, it reduced its utility for diagnosing non-paranoid schizophrenia (hebephrenia). Second, in the process of operational transformation, the very gestalt or prototype of what schizophrenia is, has vanished, suffering from a progressive oblivion.

We will first deal with the question of DSM-IV's affinity to the Schneiderian concept of schizophrenia. This issue will be examined in some detail, especially the phenomenological features which are omitted in the DSM. This will be followed by presenting the phenomenology of the core gestalt of schizophrenia, as it was conceived of in the European prototype, and its prime embodiment in the form of hebephrenia (non-paranoid schizophrenia). I will end by briefly addressing the epistemological/metaphysical underpinning of the “operational revolution,” an aspect which is necessary to illuminate in order to assess the potential nosological gains brought forth by the contemporary diagnostic systems. These crucial clinical and conceptual issues are unaddressed in the recent reviews (Tandon et al. 2009; Van Os 2010).1

Chapter.  10622 words.  Illustrated.

Subjects: Psychiatry

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