The Carpenter-Strauss quest to save schizophrenia: How DSM shifted the construct from its historical core

Abstract

During the 1960 s and 1970 s, questions about the validity of psychiatric diagnoses challenged psychiatry's respectability. Robert Spitzer and the DSM-III project hoped to rescue psychiatry by fixing its diagnoses. However, their choices regarding the schizophrenia diagnosis perhaps hampered psychosis research for 40 years. The defining characteristics of psychosis are perceptions, thoughts, and actions that do not comport with socially shared experience. For Kraepelin and Bleuler, the core features of a schizophrenia-like psychosis syndrome were disturbances of affect, self, and volition. John Wing and the International Pilot Study of Schizophrenia (IPSS) favored the theory of Kurt Schneider and his symptoms of first-rank importance for diagnosing schizophrenia. They reconceptualized schizophrenia as a reality distortion diagnosis. Will Carpenter and John Strauss, using IPSS data, showed that schizophrenia was most like an affect-self-volition disturbance syndrome and that depending on reality distortions for a schizophrenia diagnosis was incompatible with the evidence. Nevertheless, schizophrenia in DSM-III and DSM-IV was championed by John Wing and embraced by the DSM framers. Outcomes from the Bipolar-Schizophrenia Network for Intermediate Phenotypes (B-SNIP) are consistent with Carpenter and Strauss's concern that switching from a Kraepelin-Bleuler core to reality distortion was an error. B-SNIP found, replicated, cross- and externally validated neurobiologically distinctive subgroups called psychosis Biotypes. The main clinical characteristics differentiating the Biotypes are thought disturbances, lack of spontaneous speech, and low involvement in social and occupational activities. Psychosis research and clinical care might be different today if Spitzer and the DSM-III framers had made a different choice and listened to Carpenter and Strauss.