Why Psychosis Is a Spectrum

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There is a lot of time spent delineating what makes up the definitions of “schizophrenia,” “schizoaffective disorder,” and “brief psychotic episode."

What distinguishes these disorders from each other is their relevance and symptom clusters over time.

Brief psychotic disorder is just that–it’s brief, for example, while the others tend to have more coinciding symptoms.

But for many, this culmination of DSM-5 definitions still doesn’t quite align with the exact nature of psychosis as it appears in “the wild”. What is a more accurate way to describe what is happening when we experience disorganized thinking, word salads, delusions, and hallucinations?

Some researchers are trying to do away with the term “schizophrenia”. In an article titled “The slow death of the concept of schizophrenia and the painful birth of the psychosis spectrum,” European scholars advocate for a gradient phenomenon similar to autism. They want to be rid of distinct categories of psychosis altogether.

The existing scientific literature on psychosis disproportionately boils down to schizophrenia. According to the researchers, schizophrenia covers only 30 percent of the full spectrum of psychotic experiences.

Many other disorders have benefitted from evolutions in diagnosis. Dissociative identity disorder, for one, was once referred to as "multiple personality disorder." Once thought to be a random mess of personalities, we now know that this disorder can be treated with therapy that targets trauma.

Schizophrenia, as a disorder, has not evolved in the same way. In fact, a whole century has gone by since psychiatrist Eugen Bleuler changed the original name, “dementia praecox,” proposed by Emil Kraeplin, to “schizophrenia”. Bleuler’s definitions were embraced until the third version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and even post DSM-III the definitions have become less encompassing.

A meta-analysis found that recovery and prognosis improve as a “function of diagnostic trends”. There was a two-fold increase in recovery after antipsychotics were introduced to patients in the 1950s and 60s. But this improvement was not sustained after the disorder had strictly enforced, more narrow, and specified diagnostic criteria, with the recovery rates dropping to 15 percent by 1990. The more stringent the definitions, the more narrow the pool of recovered subjects.

This might not be surprising, considering researchers might be looking at some of the worse cases. But by doing so, perhaps we leave out insights that can be derived from studying more simple versions of psychosis, in a similar way that we study mice to look for antidotes to human disease.

Studies that used categorical constructs like the word “schizophrenia” were affected by methodological problems that affected the external and internal validity of the studies. Simply put, these studies made it difficult to replicate findings.

Other research suggests that psychosis isn’t all-or-nothing. It’s not that people have it or they don’t. People can be on the "psychosis spectrum" just as someone can be on the autism spectrum. Psychotic experiences, as a whole, make up 75 percent of all reported psychotic reports and are transient, meaning they occur temporarily. The likelihood that a psychotic event evolves into a more serious disorder is due to the culmination of many symptoms all at once, which is what the diagnoses are defined by.

To qualify for a current diagnosis, a person must exhibit a minimum number of symptoms. This is essentially how any disorder is diagnosed. But if we take a moment to look at the experience as a broad spectrum, perhaps we can treat more people before they emerge as the stereotyped disorderly psychotic. If we had more insight into simple psychosis instead of studying the complexity of late-stage diagnosis, that could have significant effects on treatment.