The Schizophrenia Spectrum E-Book

William D. Spaulding

• Herausgeber: Hogrefe Publishing
• Kategorie: Geisteswissenschaft
• Serie: Advances in Psychotherapy - Evidence-Based Practice
• Sprache: Englisch

Seitenzahl: 233

Veröffentlichungsjahr: 2018

Beschreibung

An essential reference for assessing and treating people with schizophrenia spectrum disorders – now updated and even more comprehensive. The new edition of this highly acclaimed volume provides a fully updated and comprehensive account of the psychopathology, clinical assessment, and treatment of schizophrenia spectrum disorders. It emphasizes functional assessment and modern psychological treatment and rehabilitation methods, which continue to be under-used despite overwhelming evidence that they improve outcomes. The compact and easy-to-read text provides both experienced practitioners and students with an evidencebased guide incorporating the major developments of the last decade: the new diagnostic criteria of the DSM-5, introducing the schizophrenia spectrum and neurodevelopmental disorders, the further evolution of recovery as central to treatment and rehabilitation, advances in understanding the psychopathology of schizophrenia, and the proliferation of psychological and psychosocial modalities for treatment and rehabilitation.

Leseprobe

The Schizophrenia Spectrum

2nd edition

William D. Spaulding

University of Nebraska-Lincoln, Lincoln, NE

Steven M. Silverstein

Rutgers University Behavioral Health Care (UBHC), Robert Wood Johnson Medical School, Piscataway Township, NJ

Anthony A. Menditto

Fulton State Hospital, Fulton, MO

About the Authors

Will D. Spaulding, PhD, is a professor of psychology in the doctoral clinical psychology program of the University of Nebraska - Lincoln. His entire career has been devoted to understanding and treating serious mental illness, from psychopathology to treatment outcome to mental health services policy and administration. For over 20 years he was the senior psychologist in a state hospital-based psychiatric rehabilitation program in Nebraska, and has consulted nationally and internationally on development of services for people with schizophrenia spectrum disorders.

Steven M. Silverstein, PhD, is Director of Research, and Director of the Division of Schizophrenia Research at Rutgers University Behavioral Health Care (UBHC), and Professor of Psychiatry at Rutgers - Robert Wood Johnson Medical School. He is the former Chair of the American Psychological Association’s Task Force on Serious Mental Illness, and the 2017 President of the Society for Research in Psychopathology. He has over 25 years of experience in treating people with serious mental illness, and has directed inpatient units and outpatient programs for this population. This includes work with both chronically ill and first episode patients. Dr. Silverstein’s research interests are in the development of schizophrenia, perceptual and cognitive changes found in schizophrenia, and prediction of treatment response and relapse. He has over 190 publications related to schizophrenia and is currently Principal Investigator (PI) on multiple NIMH or foundation grants involving assessment and treatment. Dr. Silverstein is the recipient of many national and state awards, including the New Jersey Psychological Association’s Distinguished Researcher Award in 2009, the American Psychological Foundation Alexander Gralnick Research Award in 2010, and the Trailblazer Award from the Schizophrenia Special Interest Group of the Association for the Advancement of Behavioral and Cognitive Therapy in 2016.

Anthony A. Menditto, PhD, is the Director of Treatment Services at Fulton State Hospital in Missouri. He has spent the past 30 years as a clinician, administrator, researcher, and consultant dedicated to improving our understanding of serious mental disorders. His work has focused on the implementation and evaluation of evidence-based approaches to assessment and treatment for individuals with serious mental disorders.

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, School of Medicine, American University of Antigua, St. Georges, Antigua

Associate Editors

Larry Beutler, PhD, Professor, Palo Alto University / Pacific Graduate School of Psychology, Palo Alto, CA

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

David A. Wolfe, PhD, RBC Chair in Children’s Mental Health, Centre for Addiction and Mental Health, University of Toronto, ON

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a reader-friendly manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work and an ideal educational resource for students as well as for practice-oriented continuing education.

The most important feature of the books is that they are practical and easy to use: All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Library of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2016956064

Library and Archives Canada Cataloguing in Publication

Silverstein, Steven M.

[Schizophrenia]

The schizophrenia spectrum / William D. Spaulding (University of Nebraska-Lincoln, Lincoln, NE), Steven M. Silverstein (Rutgers University Behavioral Health Care (UBHC), Robert Wood Johnson (Medical School, Piscataway Township, NJ), Anthony A. Menditto (Fulton State Hospital, Fulton, MO). -- 2nd edition.

(Advances in psychotherapy--evidence-based practice ; v. 5 )

Revision of: Schizophrenia / Steven M. Silverstein, William D. Spaulding, and Anthony A. Menditto. -- Cambridge, MA ; Toronto : Hogrefe & Huber, ©2006.

Includes bibliographical references.

Issued in print and electronic formats.

ISBN 978-0-88937-504-8 (paperback).--ISBN 978-1-61676-504-0 (pdf).--ISBN 978-1-61334-504-7 (epub)

1. Schizophrenia--Treatment. 2. Schizophrenia. I. Spaulding, William D. (William Delbert), 1950-, author II. Menditto, Anthony A., author III. Title. IV. Title: Schizophrenia V. Series: Advances in psychotherapy--evidence-based practice ; v. 5

RC514.S544 2016

616.89’8

C2016-906774-2

C2016-906775-0

Cover image © Olivier Tabary/fotolia.com

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|v|Preface to the Second Edition

The intent of this book is to provide an overview of current conceptualizations of, and treatments for, schizophrenia spectrum disorders. There is an emphasis on psychological treatments. These interventions are usually neglected in graduate and medical training about schizophrenia, even though the evidence for their effectiveness is comparable to that of pharmacologic treatment, with the combination of the two typically producing the best treatment outcomes. However, schizophrenia spectrum disorders are complex conditions with expressions at all levels of a person’s biological, psychological, and social functioning. Modern treatment incorporates, integrates, and coordinates modalities that operate at all those levels. Pharmacological treatment addresses the neurophysiological level of the disorders and some of the direct cognitive and behavioral consequences, but this is just one part of the picture. We hope to provide the reader a reasonably complete overall picture of assessment, treatment, and rehabilitation.

Since the first edition, the major developments that required the most attention for the second are:

Publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The fifth edition introduces the schizophrenia spectrum and neurodevelopmental disorders, reflecting advances in our scientific understanding of mental illness in general and schizophrenia in particular;

Evolution of the idea of recovery as central to treatment and rehabilitation, and to the subjective experience of the person affected;

Advances in the psychopathology of schizophrenia and other disorders that transform our basic understanding of mental illness as non-categorical, multidimensional processes with indistinct boundaries and multiple interacting etiological factors that are inseparable from the process of human development;

A proliferation of psychological and psychosocial modalities for treatment and rehabilitation and their subsequent consolidation into the integrated multimodal arrays and organizational models that characterize modern psychiatric rehabilitation;

The continuing failure to disseminate, implement, and effectively regulate modern treatment and rehabilitation methods in our mental health service systems, despite overwhelming evidence for improving outcomes.

We hope this book is useful to a wide range of people, from students first learning about the schizophrenia spectrum to advanced clinicians and researchers looking for a compact review of current conceptualizations and clinical tools. The schizophrenia spectrum represents one of the greatest scientific challenges of our time and also one of the most disenfranchised, undertreated populations in our society. Our hope is that this book will inspire all readers to address the social, political, and humanitarian issues as well as the scientific ones.

|vi|Acknowledgments

The authors would like to thank Danny Wedding for providing the opportunity to write this book and for his guidance during the writing process. Will Spaulding would like to thank Rue Cromwell and the late Gordon Paul for guiding his early work in schizophrenia and all the teachers and mentors named by this volume’s co-authors, and Mary Sullivan for ongoing love, support, and teamwork. Steve Silverstein would like to thank his mentors and teachers who taught him about schizophrenia and its treatment, including Ray Knight, Michael Raulin, Frank Miller, Jim Bowman, Robert Liberman, Chuck Wallace, and Rich Hunter. He would also like to thank his parents and Judy Thompson for their love and support. Anthony Menditto adds his thanks to Gordon Paul for his pioneering work that laid the groundwork for applying rigorous standards of practice to developing services and properly evaluating them for individuals with severe mental disorders, and for the personal support and guidance he has provided to each of us over the years. He would also like to thank Lynn Geeson and Theresa Menditto for their love and support. All the authors wish to thank all the students from whom we have learned, and, most especially, the people we’ve been privileged to accompany on their journeys of recovery. We also thank the Hogrefe editorial and production staff for their helpful and professional collaboration and assistance.

Contents

Preface to the Second Edition

Acknowledgments

1 Description

1.1 Terminology

1.1.1 Schizophrenia as a Mental Health Policy Construct

1.1.2 Schizophrenia as a Psychiatric Diagnosis

1.1.3 Dimensions of the Schizophrenia Spectrum

1.1.4 The Medical Model

1.1.5 Psychiatric Rehabilitation

1.1.6 Recovery

1.1.7 Evidence-Based Practice

1.2 Definition

1.3 Epidemiology

1.4 Course and Prognosis

1.4.1 Short-Term Outcomes

1.4.2 Long-Term Outcomes

1.5 Differential Diagnosis

1.6 Co-Occurring Conditions

1.6.1 Psychiatric Conditions

1.6.2 Medical Conditions

1.7 Diagnostic and Other Assessment Procedures

2 Theories and Models of the Schizophrenia Spectrum

2.1 The Concept of Vulnerability

2.2 Genetics

2.3 Theories Involving Viruses or Immunopathology

2.4 Birth Complications

2.5 Neuroanatomy

2.6 Neurophysiology

2.7 Neurodevelopmental Factors

2.8 Cognitive Factors

2.9 Social Learning Theory

2.10 Environmental Factors

3 Diagnosis and Treatment Indications

3.1 Assessment

3.1.1 Neurophysiological and Symptom Assessment

3.1.2 Cognitive Assessment

3.1.3 Dynamic Assessment

3.1.4 Functional Assessment

3.2 Treatment Planning

3.2.1 Problem-Oriented Treatment Planning

3.2.2 The Multimodal Functional Model

4 Treatment

4.1 Descriptions of Treatment Modalities

4.1.1 Rehabilitation Counseling and Related Modalities

4.1.2 Collaborative Psychopharmacotherapy

4.1.3 Neurocognitive Therapy

4.1.4 Contingency Management

4.1.5 Individual Psychotherapy

4.1.6 Social Skills Training

4.1.7 Problem Solving Skills Training

4.1.8 Illness/Wellness Management Skills Training

4.1.9 Independent Living Skills Training

4.1.10 Specialized Integrated Treatment for Co-Occurring Substance Abuse

4.1.11 Supported Employment and Occupational Skills Training

4.1.12 Family Therapy

4.1.13 Peer Support and Self-Help Groups

4.1.14 Acute Treatment, Crisis Intervention, and Related Services

4.1.15 Specialized Models for Service Integration and Provision

4.1.16 Supported Housing

4.2 Mechanisms of Action

4.2.1 Recovery-Oriented Perspectives

4.3 Efficacy and Effectiveness

4.4 Variations and Combinations of Methods

4.5 Problems in Carrying Out the Treatment

4.5.1 The Domain of Research Review and Meta-Analysis

4.5.2 Mental Health Policy, Funding, and Regulation

4.5.3 Education and Training of Practitioners

4.5.4 The Economics of the Mental Health Provider Industry

4.6 Multicultural Issues

5 Case Vignettes

6 Further Reading

7 References

8 Appendix: Tools and Resources

I. Government Agencies

National Institute of Mental Health

The SAMHSA Store: Publications ordering

II. Professional Organizations

American Psychological Association: Schizophrenia

American Psychological Association: Catalog of Clinical Training Opportunities: Best Practices for Recovery and Improved Outcomes for People with Serious Mental Illness

American Psychiatric Association: Help With Schizophrenia

III. Academic Institutions

Boston University: Center for Psychiatric Rehabilitation

Dartmouth University: Dartmouth Psychiatric Research Center

UCLA: UCLA Center for Neurocognition and Emotion in Schizophrenia

University of Illinois at Chicago : National Recovery and Training Center on Psychiatric Disability

University of Maryland: Maryland Psychiatric Research Center

IV. Advocacy and Interest Organizations

Schizophrenia.com

Mental Health America

National Alliance for the Mentally Ill (NAMI)

Schizophrenia Research Forum (SRF)

V. Foundations, Providers, and Consulting Organizations

Psychiatric Rehabilitation Consultants

Brain & Behavior Research Foundation

Thresholds

CET Training, LLC

|1|1Description

1.1 Terminology

1.1.1 Schizophrenia as a Mental Health Policy Construct

Schizophrenia refers to a type of severe and disabling mental illness that affects between .5% and 1.5% of the population worldwide, with a current global prevalence calculated at over 20 million people. It is typically first recognized in late adolescence or early adulthood, and is often associated with lifelong disability, especially when appropriate services are not provided. It has been estimated that as many as ten percent of all disabled persons in the US are diagnosed with schizophrenia.

Schizophrenia is a specific psychiatric diagnosis, but for the purposes of social policy and healthcare administration it is often grouped together with schizoaffective disorder, bipolar disorder, severe chronic depression, and sometimes other conditions. Such grouping is convenient because treatment and service needs are similar within the group. The diagnoses usually grouped with schizophrenia have in common an onset in late adolescence or adulthood, an episodic course (periods of better and poorer functioning), a high risk of severe disability, and in most cases (traditionally) a lifelong need for treatment and support services.

Psychiatric Disability

Psychiatric disability resulting from schizophrenia extends to multiple domains of personal and social functioning. People with the diagnosis are vulnerable to institutionalization, to being found legally incompetent and requiring a guardian, and to needing assisted living situations. As a group they have very high unemployment and poor quality of life. The economic costs of schizophrenia, including direct treatment costs and lost productivity, are enormous (Insel, 2008), among the highest of all health conditions, ranking with cancer and heart disease. The diagnosis accounts for 75% of all mental health expenditures and approximately 40% of all Medicaid reimbursements, although the greatest part of the economic burden comes not from treatment but from the disability, i.e., from the lost productivity of those affected (Insel, 2008).

Serious Mental Illness

The term serious mental illness (SMI) has been in use for several decades, especially in federal mental health policy, to refer to schizophrenia and the other diagnoses with which it is usually grouped. However, in recent years the |2|meaning of SMI has generalized to include less disabling conditions, sometimes virtually any psychiatric diagnosis (Satel & Torrey, 2016). This would not be a problem if the criteria were sensitive to the actual, measurable degree of disability, but in practice expansion of the meaning of SMI directs resources away from those in most need. This issue is related to the so-called practice of “cherry picking,” strategically selecting healthcare clients to optimize corporate or individual profits. It is a matter of ongoing concern and debate in the healthcare industry and the mental health policy communities.

The Schizophrenia Spectrum

Schizophrenia spectrum is also used as a group term, although its specific meaning is variable. In the recently issued fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (American Psychiatric Association, 2013), “Schizophrenia Spectrum,” is a sub-family that includes schizophrenia and related diagnoses under the major heading “Schizophrenia Spectrum and Other Psychotic Disorders.” DSM-5 also includes schizotypal personality disorder in its definition of the schizophrenia spectrum, even though it is placed under the major heading “Personality Disorders.” In the scientific literature, “schizophrenia spectrum” is used more broadly, in recognition of the indistinct boundaries of “schizophrenia” as a diagnostic category, the multiple causes and expressions of psychopathology related by common genes, symptoms and other features, and commonalities in treatment. Schizotypal traits and other developmental vulnerabilities are considered part of the schizophrenia spectrum whether or not they meet diagnostic criteria for any disorder. For the purposes of this book, the scientific usage of “schizophrenia spectrum” provides a better reflection of its meaning than the DSM usage.

Psychosis

Psychosis is a clinical term that has significant policy implications as well. It is not a diagnosis, but is closely associated with schizophrenia and related diagnoses, sometimes collectively termed psychotic disorders. Psychosis is a state often loosely described as detachment from reality, expressed as specific psychiatric symptoms including hallucinations, delusions (expression of unrealistic or bizarre beliefs), disruption of coherent thought and language, and affect inappropriate to the situation (e.g., euphoria in the face of deteriorating personal circumstances, extreme anger without a discernable cause). Sometimes affective symptoms may have associated psychotic features, e.g., if depressed mood is accompanied by delusions of guilt. In such cases the psychotic features are said to be mood-congruent. Psychosis may be continuous or episodic and is highly variable in quality and severity across individuals and within individuals over time. The presence of psychosis in any clinical picture is indicative of increased morbidity, risk, and disability. Even in the general population, the presence of psychotic symptoms is associated with greater social disability (Rossler et al., 2015) and an increased risk for violent behavior (Silverstein, Del Pozzo, Roché, Boyle, & Miskimen, 2015). Unfortunately, mental health policies, regulations, and practices often fail to recognize and manage the highly variable and episodic nature of psychosis and the individual differences this creates.

|3|Treatment Refractory Schizophrenia

It may seem curious that the term treatment refractory appears in a discussion of policy terminology. In fact, the concept behind the term has a pervasive influence on policy and in organization and administration of mental health services. Applied in mental health in the context of severe, disabling disorders, treatment refractory means refractory to drug treatment, specifically to treatment with first-generation antipsychotic drugs (see Section 4.1.2). There is no scientific rationale for distinguishing a group based on response to drugs, much less on response to a specific sub-family of drugs. There are, however, commercial and economic reasons to make the distinction, but these are not typically reasons that serve the best interests of consumers. For example, this distinction is often used to support the use of cheaper post-patent medications, to promote prescription of newer, more profitable drugs, or to promote the interests of the medical services industry.

Arguably “treatment refractory schizophrenia” is a terminological relic of the deinstitionalization era, the 1970s and 1980s, when the population of psychiatric institutions was dramatically reduced. Policy during that era showed a naïve (in retrospect) expectation that antipsychotic drugs would enable people discharged from the psychiatric institutions to function normally in their communities. Being “refractory” in this context could render the community inaccessible to the person so labeled.

Most people with schizophrenia spectrum disorders are “refractory” to some degree, in the sense that very few people experience complete remission of all aspects of the disorder from drug treatment alone. Most people who are “refractory” to first-generation antipsychotics are responsive to a range of psychological treatments and social interventions, some to a very extensive degree (Newbill, Paul, Menditto, Springer, & Mehta, 2011; Paul & Lentz, 1977; Silverstein et al., 2006; Spaulding, Johnson, Nolting, & Collins, 2012).

1.1.2 Schizophrenia as a Psychiatric Diagnosis

The modern diagnosis of schizophrenia has its origins in the work of Emil Kraepelin, who named it dementia praecox, “early dementia.” In the early 20th century the Swiss psychiatrist Eugen Bleuler introduced the term “schizophrenia” as he challenged the presumptions underlying Kraepelin’s “dementia praecox.” “Dementia” is inappropriate, Bleuler argued, because many people recover in ways inconsistent with an irreversible progressive brain disease. Bleuler also argued that the extensive individual differences between people with the same diagnosis suggest that it is not a single disorder, but a group of similar but distinct disorders. He argued that the most important characteristic of the disorder is not its onset or course, but the nature of its expression, particularly in the domain of human functioning we recognize today as cognition. He therefore proposed “schizophrenia,” derived from Greek for “severed mind” (skhizein, σχίζειν, “to split;” phren, φρήν, “mind”) to reflect a fragmentation of mental functioning, including a split between thinking and feeling. Later, misunderstanding of “schiz-” led to the unfortunate and totally erroneous confusion of schizophrenia with “split personality” in popular culture.

|4|Later in the 20th century Bleuler’s “schizophrenia” became the accepted diagnostic term in psychiatry, but the key clinical features that comprise the criteria for making the diagnosis were mostly those described by Kraepelin. Scientific debate continued throughout the century about which symptoms are most essential and whether there are subcategories of symptoms reflecting subtypes of schizophrenia. Kraepelin’s original subgroups of symptoms gradually evolved into the diagnostic subcategories familiar today: paranoid, hebephrenic, catatonic, and undifferentiated. Two of the original subgroups became schizoaffective disorder and catatonia, today considered separate diagnoses, not subtypes, but still within the schizophrenia spectrum if not caused by other medical conditions or substance abuse.

In the 1970s a group of academic psychiatrists who became known as “neo-Kraepelinians” gained control of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (Kutchins & Kirk, 1997). The neo-Kraepelinian agenda was, among other things, to eliminate the influence of psychoanalysis in psychiatry and replace it with an understanding of mental illness as the expression of distinct medical conditions comparable to infectious diseases. Mental illness was reduced to a “broken brain” (Andreasen, 1984). Treatment was not treatment unless it was medical, i.e., pharmacological (Klein, 1980). In 1980 the neo-Kraepelinians issued the 3rd edition of the DSM, which asserted this perspective. “Correct” diagnosis of specific psychiatric diseases, based on observation and patient report of specific symptoms, became a keystone of both research and clinical practice.

The neo-Kraepelinians dominated two editions of DSM, the third (including a revision in 1987) and the fourth, in 1994. By the turn of the 21st century, however, the flaws in such a reductionist approach were no longer manageable. Psychopharmacology contributed importantly to illumination of the flaws, ironically so, because the neo-Kraepelinians expected that drug effects would play a major role in validating their diagnostic system. In fact, the expected correspondence of drug families to diagnostic groups did not develop. By the 21st century, antipsychotic drugs were being used to treat affective and personality disorders, antidepressants were being used to treat anxiety disorders, and mood stabilizers were being used to treat psychosis. Similarly, as behavioral neuroscience matured, the hypothesis that psychiatric disorders are separate diseases caused by distinct genes or pathogens following simple etiological pathways became untenable. It became clear that the population of “people with schizophrenia,” as rigorously diagnosed with neo-Kraepelinian criteria, is immensely heterogeneous, as is their response to drugs. The irony is compounded by recent historical scholarship that indicates that by the end of his life Kraepelin himself had come to doubt the validity of his system, in ways that eerily anticipate developments in psychopathology and neuroscience nearly a century later (Engstrom & Kendler, 2015). Had he lived until 1975, Kraepelin probably would not have been a neo-Kraepelinian.

In 2013 the fifth edition of the DSM (DSM-5) was issued. Overall, the reductionist perspective of the previous editions was significantly moderated. Mental illnesses, including schizophrenia, were recognized to be not specific diseases or even distinct categories, but prototypes, “fuzzy sets” with indistinct boundaries and multiple etiologies. The subtypes of schizophrenia were elimi|5|nated, based on lack of scientific validation. These changes bring the diagnosis of schizophrenia into better congruence with science, but after decades of research based on neo-Kraepelinian assumptions there will inevitably need to be further changes in how we understand the relationship between science, diagnosis, and practice. Even the youngest readers of this book will see the lingering effects of the neo-Kraepelinian era and of biological reductionism in general in the foreseeable future. The most unfortunate part of this legacy may be expectations for outcome, because the neo-Kraepelinian perspective does tend to reduce schizophrenia to an incurable neurological disease.

Another significant change in the DSM-5 was introduction of the idea of neurodevelopmental disorders. As will be discussed in more detail in Chapter 2, the etiological processes associated with the schizophrenia spectrum have come to be recognized as essentially developmental. The DSM-5 defines a new family, “Neurodevelopmental Disorders,” that includes intellectual disability (formerly mental retardation), autism spectrum disorders, attention deficit hyperactivity disorder, and other congenital conditions. Schizophrenia was not placed in this family, arguably because disorders manifest at birth or in early childhood need their own category (in DSM’s III and IV there was literally a category of disorders usually diagnosed in infancy, childhood or adolescence). The schizophrenia spectrum has many premorbid manifestations, i.e., abnormalities present before all diagnostic criteria are met, that can be observed as early as infancy in some cases, but the modal window for onset, i.e., the point at which all diagnostic criteria are met, extends from late adolescence through the early 20s. In recognition of the onset difference, in DSM-5 schizophrenia spectrum disorders are placed just adjacent to the child onset family, in “Schizophrenia Spectrum and Other Psychotic Disorders.” Despite being in a separate DSM family, there is strong consensus across the scientific community that the schizophrenia spectrum has neurodevelopmental etiologies.

In a sense, identifying the onset of a neurodevelopmental disorder is inevitably arbitrary. Many people have serious impairments in their personal and social functioning long before they meet criteria for a schizophrenia spectrum disorder. For some, there is a sudden change of functioning and appearance of psychosis. For others, there is no distinct point of onset, and changes in functioning occur throughout adolescence. This is historically termed an insidious onset. The prodrome, or condition preceding the actual meeting of full diagnostic criteria, is sometimes so pronounced and protracted that a separate diagnosis for it has been proposed and included in DSM-5 as “attenuated psychosis syndrome,” not as a diagnosis but as a condition for further study. There is increasing interest in intervening upon detection of the earliest manifestations of abnormality. Waiting until the onset of psychosis to intervene has been likened to waiting until the patient has a heart attack before diagnosing heart disease.

Similarly, the idea of schizotypy has taken on additional meaning. In addition to representing a developmental vulnerability, schizotypal personality disorder is considered a separate diagnosis. This reflects recognition that some of the features of schizotypy, e.g., anhedonia (reduced ability to experience pleasure), magical thinking (illogical reasoning, odd beliefs), and social isolation, can have maladaptive impact independent of the vulnerability to psychosis.

|6|1.1.3 Dimensions of the Schizophrenia Spectrum

Symptom Categories

In contrast to the diagnostic subtypes of schizophrenia, some categorizations of specific clinical features have gained scientific validation and practical value. As long as we do not forget that schizophrenia itself is not really a valid category, other categorical and quantitative dimensions of severe psychopathology can have scientific and clinical utility. We can expect that these types of measures will play an important role in both research and practice in the foreseeable future.

An important example, derived from the work of the 19th century British neurologist John Hughlings-Jackson on neurologic disorders, is the distinction between positive, negative, and disorganized symptoms. Positive symptoms are behaviors or experiences not present in the normal population, e.g., the familiar psychiatric symptoms, hallucinations, and delusions. Negative symptoms are ones that represent an absence