Descriptive Psychopathology: The Signs and Symptoms of ...

384 Section 4: Evidence-based classificationas “grossly disorganized” and “bizarre” behavior are vague and over-inclusive,assuring false positive conclusions. The use of catatonia as a criterion disregardsthe extensive literature on catatonia as a distinct syndrome. From a scientificperspective, catatonia’s continued presence in the schizophrenia criteria isunsupportable.The evidence for schizoaffective disorder as a separate illness from mooddisorder with psychosis is unimpressive and the syndrome is best placed in themood disorders category. There is a clinical adage “If the diagnosis is uncertainand no harm is likely, make the choice with the best prognosis and for whichthere are better treatments.” From this perspective, patients who meet criteria forschizoaffective disorder would best be served if considered a psychotic form ofmanic-depressive illness rather than a form of schizophrenia with mood features.Shared psychotic disorder has little validation and should be eliminated.SchizophreniaThe DSM/ICD image of schizophrenia is limited to a few cross-sectional featuresthat can be distorted by idiosyncratic usage of criterion A. Persons who experienceonly complete auditory hallucinations, or delusions of alienation or control,or catatonic features with any hallucination or delusion meet the criterion. Butmany other conditions are associated with these features. The division of thesyndrome into paranoid, catatonic, disorganized, undifferentiated and residualforms has neither clinical nor research utility.Identifying schizophrenia by the presence of emotional blunting, however, hasrepeatedly shown the negative or deficit syndrome to be reliably assessed andstable over time. Patients with these features are likely to have a chronic course,sustained cognitive impairment, and a family history of psychosis. 98 Negativesymptoms are the best variable discriminating ICD-10 defined schizophrenicsfrom patients with other psychotic syndromes. 99 Schizophrenic patients, however,cannot be clearly divided into positive and negative symptom subgroups, asmost exhibit both types of features. 100Research over the past 40 years has also demonstrated that schizophrenia isnot merely the summation of psychotic episodes. The model of a developmentaldisorder as the basis for schizophrenia best fits the data showing sufferers to haveemotional, social, cognitive, and neuromotor problems beginning in childhood.Substantial genetic and intrauterine factors contribute to the condition. 101The psychosis of schizophrenia can be defined in cross-section by the presenceof emotional blunting and hallucinations or delusions and longitudinally bythe presence of childhood pre-psychotic features. To fit the data, criterionA should be modified to resemble Table 16.2. Each feature should also beoperationally defined. 102