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Going Beyond Classic Descriptions to Future

Phenomenology of Schizophrenia Next Step for
Psychopathology in Schizophrenia Research We
already have 2 classification systems for schi...
Article in JAMA Psychiatry October 2016

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Opinion

EDITORIAL

Going Beyond Classic Descriptions to Future Phenomenology

of Schizophrenia
Manuel J. Cuesta, MD, PhD; Victor Peralta, MD, PhD

The symptoms of schizophrenia span a wide range of psychopathology and display an extraordinary amount of interindividual and temporal variability. Over time, authors have invested different diagnostic
value to symptoms, dependRelated article
ing on their theoretical point
of view. For Emil Kraepelin, dementia praecox was a nosological entity and the negative symptomsVerbldungwere characteristic; for Eugen Bleuler, schizophrenia was a heterogeneous syndrome and thought disorders were the distinctive
feature; and for Kurt Schneider, schizophrenia was a diagnostic convention and certain disturbances of the experiencethe
so-called first-rank symptomswere the defining features.
With the publication of the Feighner criteria in 1972, a number of operational diagnostic systems were developed on either
statistical or theoretical grounds. This led to a Babel of diagnostic formulations and then consensus diagnostic systems, best exemplified by the DSM and International Classification of Diseases criteria. The schizophrenia construct of the
DSM editions (particularly DSM-III) has been the most influential, both in clinical practice and in research. The main purpose of the DSM system is to achieve greater diagnostic reliability. This objective has been largely met, but reliability does
not ensure validity. The DSM schizophrenia concept represents an oversimplified and incomplete view of the clinical picture leading to the (wrong) assumption that we are confronted with a simple, clear, and discrete disorder. Indeed, the
putative atheoretical and pragmatic approach of the DSM classification has provided us with a mixture of arbitrary inclusion, exclusion, and duration criteria of clinical phenomena.1
The article in this issue of JAMA Psychiatry by Kendler2 presents renewed bibliographic research attempting to clarify the
most constant and relevant signs and symptoms of schizophrenia. Kendler2 took an original and straightforward methodological approach to examine the degree to which modern diagnostic criteria reflect the main clinical features of the disorder
as described historically by diagnostic experts. Indeed, it has
been noted that there is not a linear progression from classic
descriptions to current diagnostic criteria of schizophrenia but
a patchwork made out of clinical features plucked from different definitions3; thus, the study by Kendler2 contributes
meaningfully to fill this gap. The study brings forward 3 related main findings: (1) modern criteria do not describe all the
symptoms and signs considered relevant by classic authors; (2)
modern criteria underemphasize signs compared with symptoms; and (3) the underemphasized signs mainly correspond
to the psychomotor domain. These findings are of practical and
jamapsychiatry.com

research importance because signs are more easily and reliably elicited than subjective experiences and are closer to the
hypothesized neurobiological substrate of the disorder.
Kendler2 restricted his search to those classic descriptions that adopt a broadly Kraepelinian or Bleulerian perspective on dementia praecox or [schizophrenia] and therefore left
out important classic concepts and descriptions such as those
by Kurt Schneider and Karl Leonhard. Taking a Kraepelinian
or Bleulerian perspective implies that 2 rather different conceptualizations of the disorder are mixed together, concealing
the original ones. Historical definitions of schizophrenia continue to be the basis for powerful hypotheses about the nature
of the disorder that deserve to be tested on their own against
external validators. Of particular concern is the neglect of
Leonhards work,4 because in our view, it is one of the major
historical contributions of European psychiatry to the description and classification of psychotic disorders. This classification is arguably the most detailed and comprehensive system
produced in the realm of psychotic disorders. Taking a bottom-up approach, he described the clinical features of psychotic disorders which group together into subtypes, which
in turn form the main types, namely, phasic (affective) psychoses, cycloid psychoses, unsystematic schizophrenias, and
systematic schizophrenias, for which clinical homogeneity and
distinct disease status were claimed on the basis of their differential psychopathology, course/outcome, and risk factors.
Without doubt, this is the most comprehensive and detailed
description of the phenomenology of psychotic disorders, both
during the acute exacerbation and final states. Leonhards
system4 emphasizes behavioral symptoms and signs over subjective experiences, thus maximizing the unbiased assessment of psychopathology and diagnosis. More specifically,
Leonhard4 puts special emphasis on the description of a broad
range of behavioral phenomenaincluding speech, affect, and
motilitydescribing their differential phenomenology according to psychosis type. Because modern diagnostic criteria
neglect the value of these signs, revisiting Leonhards differential psychopathology4 is of great value for a more comprehensive view of the phenomenology of schizophrenia. In fact,
Leonhards classification4 has proved to be more valid than
DSM and International Classification of Diseases classifications in predicting familial aggregation of psychotic disorders and particularly systematic schizophrenia.5

Next Step for Psychopathology in Schizophrenia Research

We already have 2 classification systems for schizophrenia
(DSM and International Classification of Diseases) and now also
(Reprinted) JAMA Psychiatry Published online September 14, 2016

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Opinion Editorial

new proposals from the Research Domain Criteria. Is there

room for yet another psychopathology?
A symptom approach avoids the complexity of syndromes
or dimensions and the controversy about the symptoms that
constitute them. When guided by strong hypotheses, this approach can explore symptoms, such as hallucinations or delusions, regardless of diagnostic categories.6
Traditionally, a syndrome-oriented approach, in a categorical sense, has been the hallmark in schizophrenia research.
However, factor analytic studies of schizophrenia symptoms
consistently demonstrate between 3 and 10 dimensions.7 This
dimensional approach allows the measurement of degrees of
severity of symptom clusters during the period considered. Several clinical dimensions of schizophrenia are common to all
studiesnamely, reality distortion, disorganization, and negative symptomsbut other dimensions comprising affective (mania and depression) symptoms, catatonia, and lack of insight
have also been recognized. Moreover, multidimensional models allow for the subdivision of the main dimensions into more
fine-grained dimensions within a hierarchical model of psychopathology from high-order dimensions (ie, positive, negative, and affective) to low-order dimensions (ie, lack of insight) close to a symptom level. 8 The multidimensional
approach also allows for determining the level at which dimensional syndromes can be converted into categorical diagnoses
to produce integrated hybrid models of psychopathology.9 Studies comparing categorical and dimensional approaches consistently report superior validity for psychopathological dimensions of schizophrenia and psychoses.10 Indeed, DSM-5
included the dimensional assessment of symptoms in the Clinician-Rated Dimensions of Psychosis Symptom Severity for
further research and clinical evaluation in schizophrenia.
The study of domains of psychopathology (or specific sign
and symptom complexes) in schizophrenia has enabled a paradigm shift toward recognizing the heterogeneity of schizophrenia not only at the clinical level, but even according to its
underlying pathophysiological processes and response to treatments. Domains are categorically defined and originally 5 domains for specific study were proposed: reality-distortion

ARTICLE INFORMATION
Author Affiliations: Department of Psychiatry,
Complejo Hospitalario of Navarra, Pamplona, Spain
(Cuesta); Instituto de Investigacin Sanitaria de
Navarra, Pamplona, Spain (Cuesta, Peralta);
Department of Mental Health, Servicio Navarro de
Salud, Pamplona, Spain (Peralta).
Corresponding Author: Manuel J. Cuesta, MD, PhD,
Department of Psychiatry, Complejo Hospitalario of
Navarra and Instituto de Investigacin Sanitaria de
Navarra, Irunlarrea 4, Pamplona, Navarra 31008,
Spain (mcuestaz@navarra.es).
Published Online: September 14, 2016.
doi:10.1001/jamapsychiatry.2016.2126
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by
grants 08/1026, 11/02831, and 14/01621 from the
Carlos III Health Institute (European Regional
Development Funds) of the Spanish Ministry of
Economic Affairs and Competitiveness.
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symptoms; cognitive impairment (both formal thought disorder and cognitive disturbances); deficit symptoms (primary and
enduring negative symptoms); dissociative affective processes; and neurological impairment.11 Until now, most research has been devoted to the deficit and cognitive domains
and the research on the 3 others, plus the psychomotor abnormalities domain (ie, catatonia), is open to future research.
Another level of research is the polydiagnostic approach,
which allows for comparing the validity of different schizophrenia definitions, which may help to resolve the many controversies regarding the schizophrenia concept and lead to the
resolution of many contradictions in the results of research to
date,12 including the finding that alternative definitions may
be validated by a different set of variables. The polynosological approach is the application of the same method to entire
nosological systems.5
Some authors have suggested that an ideal strategy for disentangling the clinical heterogeneity in common complex diseases, such as in the case of schizophrenia, and to study their
genetic underpinnings, is a clinical phenome-scanning
approach.13 This is an approach at entity level that may allow
for the testing of the comparative validity of available schizophrenia phenotypes, either dimensional or categorical ones.14
Phenomewide scanning in schizophrenia may allow the reversal of the design of genome-wide association studies by testing multiple phenotypes, instead of one single syndrome, with
1 or multiple genetic loci. Following this approach, Arnedo et
al15 identified several distinct categorical and dimensional clinical syndromes associated with different genotypic networks.

Conclusions
In current schizophrenia research, much effort and investment
are devoted to genetic and neurobiological research and very little
to psychopathology research. We need an integrated approach,
incorporating comprehensive fine-grained symptoms and signs,
dimensions, and domains of psychopathology, along with a
polydiagnostic/nosologic perspective. No doubt this is a complex task, but it is a necessary one to fill the gap between the different levels of schizophrenia manifestations and their causes.

Role of the Funder/Sponsor: The funder had no

role in the preparation, review, or approval of the
manuscript, or the decision to submit the
manuscript for publication.
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JAMA Psychiatry Published online September 14, 2016 (Reprinted)

Copyright 2016 American Medical Association. All rights reserved.

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jamapsychiatry.com

Editorial Opinion

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(Reprinted) JAMA Psychiatry Published online September 14, 2016

Copyright 2016 American Medical Association. All rights reserved.

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