Defining Schizophrenia: A Testable Model for Schizophrenia Incorporating Homogeneous Subtypes

Rick postulated a highly interesting point that the subclasses of schizophrenia were based primarily on the notion that people with schizophrenia were more susceptible to other mental disorders--that a person who is classified with paranoid schizophrenia may in fact be a person with schizophrenia while at the same time affected by paranoia. He also claimed that the other mental disorders such as paranoia, when combined with schizophrenia, were intensified to the point that it seemed like a subtype or symptom of schizophrenia, whereas it is not a subtype at all. This is quite a novel idea in the area of classifying schizophrenia and its subtypes, one that should probably be the point of further study.

Rick made a number of interesting points and suggested many new ideas with regards to the classification of schizophrenia. One of the biggest problems inherent with classifying schizophrenia, however, was not discussed--namely, the fact that for a long time schizophrenia has been used as a blanket diagnosis for people who are "crazy." Anyone who obviously had a mental disorder and did not fit into any other category got lumped into the realm of schizophrenia. If need be, new symptoms or even new subclasses were added to make this new case “fit.”

The paper touched upon the fact that the requirements for being classified as schizophrenic are vague at best. It also mentioned the fact that the differences among the subtypes are so minor that one psychologist could classify a person into a certain subclass, whereas another could classify the same person into a different subclass.

In my opinion, the mental disorder known as schizophrenia should not be reworked, nor should it be fixed. Instead it should be completely erased of all notions affiliated with schizophrenia, and researchers should start over from scratch. We need to come up with a better way of diagnosing people with this disorder. The old "wastebasket" diagnosis of schizophrenia is so fundamentally flawed that attempting to repair it or theorize upon it is a lesson in futility.

The traditional classification of schizophrenia is a categorical model that splits the disorder into a variety of subtypes. The basis for a categorical model is a set of discrete categories in which all patients can fit into one and only one category. Rick stated what is, in my opinion, the largest flaw in a categorical model of classification. This is that when one is dealing with a disorder such as schizophrenia, one will always be able to find cases that do not clearly fit into any of the defined categories. Rick also stated that although at one point in time a patient may fit into one category, the patient can later be diagnosed to fit into a different category. It seems to me that this is an example of researchers forcing a disorder to fit within a given model, when in fact the model should evolve to fit the disorder.

The concept of one patient fitting into more than one of the established subtypes during different points in time also lent support to Rick's next conclusions. Rick looked at schizophrenia as a lifetime illness and considered more than just the symptoms that are visible during a schizophrenic episode. This is important because it forces attention onto the constant elements of the disorder rather than the shifting visible symptoms. Focusing on these more stable disorder elements will bring researchers closer to a true understanding of the disorder, and it is only through a true understanding of the disorder that a valid model can be created.

The model that Rick proposed is very interesting. It divided the disorder into three subtypes, but the subtypes were not based on symptoms. Instead they were based on brain anomalies and malfunctions that are the sources of the symptoms. I believe that this model got closer to what was really behind schizophrenia than simply categorizing the symptoms, with no real thought as to what caused people to display the symptoms.

The theory presented in this paper shed light on the weaknesses of the current model of classification. The alternative model suggested has great possibilities and should definitely be further explored. As a whole, I think that the model suggested could very possibly replace the model used today and eventually could lead to a much clearer understanding of schizophrenia as disorder, its causes and symptoms.

On the whole I felt that Rick did a very good job of summarizing the problem he was addressing and that he developed a fairly accurate and understandable theory for identifying and diagnosing schizophrenia. The description gave good background, outlining the problems with the existing methods as well as providing good corroborating evidence for his theory by describing the different types and subtypes that can be used to identify different manifestations of the disorder. Lastly, the final section in which Rick detailed further studies and tests that need to be performed also rounded out his presentation of the possible implications and further gains to which this theory could give rise.

I felt that there was one other major implication from Rick's theory, which was sparked by his statement "...schizophrenia is a lifetime illness, whether or not the individual ever expresses schizophrenic symptoms.” Assuming this can be held as a truth, it could be assumed that a test could be developed to detect the physical brain defect and at the very least let the person would know he or she is at risk for developing the disorder; a treatment for the disorder could even potentially be developed that would not rely on a lifelong drug regimen. Of course, this would really only be of benefit if the physical defect was easily identifiable as well as treatable.

By tying the physiological explanation to psychological factors, including comorbidity with other disorders, Rick gave a viable path to incorporate possible correlations with other non-physiologically based theories. I felt that this was a very smart move, because it can be used as a way to explain away a lot of possible problems with his theory. Unfortunately, it also came with the negative implication that it could be used merely to explain away these criticisms without a valid reason.

I wholeheartedly support Rick's postulation as far as this theory is concerned, and I would very much like to see what further research based on this theory would uncover. I believe it has a very good base and could ultimately be a huge step towards developing a reliable testable model for schizophrenia. Consequently, I feel that care for the mentally ill inflicted with this disorder could greatly improve and that some so afflicted could be removed from permanent care facilities so they could, it is hoped, lead a full life.

My only problem with the paper is that it seemed to trail off near the end. Although Rick made several introductory statements that illustrated the aim of the paper and provided some evidence for specific points in the theory, it never felt like they were adequately tied together. Even though field research was probably not in question for a simple theory paper, it would help if Rick would provide a more coherent closing, stating how each of the sources he introduced tied together. Providing more specific information on his theory at the end, defining schizophrenia as it fits within his theory, and providing several examples of how specific cases might be defined under his diagnostic system would all improve this paper markedly.

There are also a few points earlier in the paper that could use some clarification or support. Rick claimed that schizophrenia diagnoses were based on the judgment of a clinician, which makes them inherently fallible. As I understand it, schizophrenia diagnoses are based on the DSM-IV, which is one of the systems least likely to allow for clinician bias. Illustrating the cases in which overlap occurs might be more effective than simply claiming bias. Without sufficient evidence for the fallibility of the old system, it is harder to accept the need for a new system.

Evidence for the theory could definitely use some shoring up. Aside from some interesting information from the Turetsky et al. (2002) study, there was little in the way of direct support for the theory. Again, this is partially explained by the fact that this is a theory Rick came up with himself, but it might be helpful to have more evidence supporting the compartmentalization of schizophrenia and the disorders he believes are comorbid with it that confound clinicians.

Were Rick to provide more extensive support and a clearer summation of his theory, this paper would be excellent. Though its present incarnation could use some work, the paper is very compelling.

A major problem with Rick's paper lay where he described the methodology of defining the disorder. Rick stated, "...the classifications are based on qualitative judgments." This is not true. Professionals, using rigid guidelines set forth by the Diagnostic and Statistical Manual of Mental Disorders (DSM), assess schizophrenia; it is not up to the practitioners' judgments. A major reason why the DSM was created was to solve this problem of bias on behalf of the practitioner.

A second concern for me was with the three different types of schizophrenia noted: cortical, subcortical, and composite subtypes. Limiting oneself to the cerebral and sub-cerebral cortex of the brain seems to me to be making the task of defining schizophrenia more challenging.

I understand the author's point of trying to focus more on the biological aspects in defining schizophrenia. When defining a disease such as A.I.D.S., in which biology is the only determining factor, this approach works. I personally do not think, however, that any distinguished professional working in the field of mental disorders would say that schizophrenia was purely biological.

Finally, Rick told readers that other mental disorders are comorbid with schizophrenia; I could not agree with him more. He went off track, however, in stating that, because of a study that found a correlation between post traumatic stress disorder (PTSD) and schizophrenia (Resnick, Bond, & Mueser, 2003), schizophrenia causes PTSD. I highly doubt that the authors of the study meant their audience to perceive this correlation as causation.

In summation, Rick made a weak argument that this new model should replace the DSM. I am intrigued with and appreciate the notion of having better diagnostic criteria for defining schizophrenia. This new model, however, is far too biological in nature for me to accept.

I would like to point out, however, that certain parts of this theory are generally supported by the psychological community or are major focuses of research. Discordant twin studies, as well as high risk studies, have shown that there is in all probability a biological component to schizophrenia (Byrne et al., 2003). MRI scanning and psychological tests can be used to demonstrate the three brain-structure related subtypes (Lenzenweger, Jensen, & Rubin, 2003). There is also evidence that many mental diseases increase in both frequency and intensity in the presence of schizophrenia (Barrowclough et al., 2003; Resnick, Bond, & Mueser, 2003).

The main purpose of this author response, however, is not only to suggest that I believe this theory to be sound--otherwise I would never have written the paper in the first place--but rather to appeal to those who would detract from its merit. I have one request of them: that they prove me wrong. Really, all I ask of them is that they run experiments. Attempt to determine the relation between those thought disturbances of high risk individuals and of schizophrenic individuals. Determine why there is a notable increase in frequency and severity of PTSD among schizophrenic persons (especially considering it is almost three times as high in frequency). All these things and more must be done before we finally put an end to this debilitating disorder.