The facts of schizophrenia: A personal commentary

Abstract

A career in the field of schizophrenia research is a wonderful blessing. I am reminded of this as I recall Richard JedWyatt. Memories are sad and sweet. I had many years with him beginning as clinical associates together in the NIMH IRP in 1966. Visits with him before his death in 2002 were inspirational, and one aspect of his numerous contributions lives on in the series of “Facts” published in this journal from 2008–2011. Time pressures are intense in our field, and the opportunity to sit at length for an in-depth discussion of critical issues with a few colleagues of varied interest and experience is rare. Rajiv Tandon, John Greden, and Richard Wyatt initiated a series of two-day meetings at the University of Michigan where twelve to fifteen fortunate scientists talked at length about a few selected issues important to the schizophrenia field. It was my privilege to be included, and I am grateful to Rajiv for organizing this activity and using it to carry forward the attempt to advance knowledge by organizing what we know in the format created by Richard. Henry Nasrallah and Matcheri Keshavan, who co-authored the series with Rajiv, attended some of these meetings (e.g., Tandon, 1998, 1999). This booklet contains the substantive products resulting from these meetings and includes the material provided by Richard until death claimed this gifted person. This commentary provides an opportunity to express a few opinions related to the concept of “facts” and to offer a couple of “facts” from off the beaten path. First is the major conceptual problem of the schizophrenia construct. It is difficult to discuss information relevant to schizophrenia without presuming that it is a disease entity, as the authors noted in the first article of the series (Tandon et al., 2008a). But the schizophrenia construct is a clinical syndrome devoid of evidence that it is a single etiopathophysiological entity, as the authors conclude in their later papers in the series (Tandon et al., 2008b; Keshavan et al., 2008; Tandon et al., 2009, 2010). Persons with this diagnosis vary substantially in risk factors, developmental pattern, psychopathology manifestations, therapeutic response, illness course and functional outcomes. Any fact valid for some cases will not be relevant to others. Exceptions are mostly mundane. For example, delusions are ubiquitous in persons with a schizophrenia diagnosis, and are a pathological manifestation responsive to dopamine antagonist medication. But delusions are common in many disorders and are generally responsive to antipsychotic drugs. Delusions may be analogous to fever in infectious disease and antipsychotics to aspirin. Although DSM-IV allows a single bizarre delusion to fully meet the A criteria, delusions are certainly not a decisive core feature of schizophrenia. On this centennial celebration of the publication of Bleuler's treatise it is worth noting that he viewed reality distortion symptoms as secondary.