This document discusses the debate around schizophrenia diagnoses and proposes an alternative psychosis spectrum syndrome approach. It summarizes that the debate is about clinical diagnosis, not research criteria. It also notes that around 3.5% of people experience some form of psychosis, but the current system publishes overwhelmingly on only one category, schizophrenia. The document advocates for recognizing a spectrum approach and dimensional personal diagnoses within a categorical psychosis spectrum to better reflect individuals' experiences and needs.

1. IIs Schizophrenia Dead Yet?
Jim van Os & Sinan Guloksuz,
Utrecht University Medical Centre, Utrecht, The Netherlands

2. The Psychosis Spectrum Syndrome

3. Debate is about Clinical Diagnosis, not About:
Research – researchers can choose their own
sample inclusion criteria, eg DSM schizophrenia,
ICD schizophrenia, or ‘Deficit syndrome’
Subclinical psychotic experiences – part of
phenotype but not of ‘diagnosable’ clinical
syndrome
Semantics: ‘psychosis’ here refers to the
multidimensional syndrome, not merely positive
symptoms

4. “Who gets to define value in
health systems? The notion that it
should be the people who use
their services, rather than those
who provide them, is gaining
momentum.” (Richards, 2017).
Who gets to define value?

5. Medicine and Health Care Moving into the 3rd Era
JAMA, 2016
Era 1: Professional dominance
Era 2: Accountability and market theory
Era 3: The moral era

6. Two Discourses – 1 Dominant
BMC Psychiatry, 2015
“Two discourses exist in mental health research
and practice. The first focuses on the limitations
associated with disability arising from mental
disorder. The second focuses on the possibilities
for living well with mental health problems”

7. Health is
absence of
disease and
complete
wellbeing
WHO 1947
Health is the ability
to adapt and
selfmanage, given
physical, mental &
social challenges
Huber, 2011
Two
Definitions
of ‘Health’

8. Two Discourses and two Types of Care
SICK
CARE
HEALTH
CARE

9. We revealed a dysfunctional
system that does not deliver
the quality of treatment needed
for recovery. Is this tolerable in
the 21st century?
(Evaluation Sick Care Model)

10. Values According to Users: CHIME-D
……..point to the need for a greater emphasis on
assessment of strengths and support for self-narrative
development, promoting the role of mental health
systems in developing inclusive communities enabling
access to peer support as well as providing retreats,
and clinical interaction styles which promote
empowerment and self-management.
CONNECTEDNESS; HOPE AND OPTIMISM;
IDENTITY; MEANING IN LIFE; EMPOWERMENT
Leamey et al, 2011; Stuart et al, 2016
Difficulties

11. Narrative development & Hope?
“Schizophrenia is a
devastating, highly
heritable brain disorder”
Science, 2009

12. Genetic Brain Test for “Disorder”?
Diagnosis Mental Disorder
Diagnostic Brain Test
Kapur, Philips & Insel, Mol Psychiatry 2012

13. Useful for Patient?
Weak relationship between
diagnosis and symptoms
Weak relationship between
diagnosis and needs
Weak relationship between
diagnosis and prognosis

14. Academic Abstractions Sell Poorly
Because they Disempower
Are being caused by:
Hearing voices
(plus some secondary delusional ideation)
Schizophrenia
Allen Frances, 2012

15. DSM5: Introducing Human Variation Perspective
❖ Autism spectrum
❖ Addiction spectrum
Multi-dimensional

16. Disorder Prevalence
Schizophrenia 1.00%
Schizoaffective 0.32%
Schizophreniform 0.07%
Delusional disorder 0.18%
Brief psychotic disorder 0.05%
Psychotic disorder NOS 0.45%
Affective (Bip + Dep) 0.62%
Substance use 0.43
Gen. Med. Condition 0.22%
Perala et al, 2007
3.5%

17. Schizoaffective
Schizophreniform
Delusional disorder
Psychotic depression
Psychotic bipolar disorder
Brief psychotic disorder
Substance-induced psy. dis.
Psy. disorder medical cond.
Psychotic disorder NOS
Hidden Syndrome: Prognostication Bias
Schizophrenia
PSYCHOSIS
MORBIDITY
70%
30%
PUBLICATIONS
95%
5%

18. “Belief-based” Psychiatric Dichotomy
Woo-kyoung Ahn, 2009
Extremely serious
Biological
“Physical”
treatment
Mild
Psychosocial
“Psychological”
treatment

19. What is Science?
The important thing in science
is not so much to obtain new
facts as to discover new ways
of thinking about them.
(William Lawrence Bragg)

20. Hallucinations
& delusions
Cognitive
alterations
Affective
dysregulationSform
SA
Sz
BP
Psychosis Spectrum Syndrome
3.5%
Van Os & Reininghaus, World Psychiatry, 2016

21. Adverserial Collaboration: Personal Dimensional Diagnosis Within
Categorical Psychosis Spectrum Syndrome
3.5%

22. Fin

23. Guérir parfois, Soulager toujours
“Better false hope
than
false hopelessness”
Daniel Fisher

24. Not Knowing is also
a form of Knowledge
Users Reminding Us:
Wouter Kusters, 2015

25. Resistance to Change: “Organisational Readiness”
Lancet, 2013, Plos One, 2014