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A salience dysregulation syndrome

  • Jim van Os (a1)


Revisions of DSM and ICD are forthcoming. Should the old categories of psychotic disorder, in particular the construct of schizophrenia, be retained or is a new system of representation of psychosis in order? It is argued that both scientific and societal developments point to a system of classification combining categorical and dimensional representations of psychosis in DSM and ICD. Furthermore, it is proposed to introduce, analogous to the functional descriptive term ‘metabolic syndrome’, the diagnosis of salience dysregulation syndrome. Within this syndrome, three sub-categories may be identified, based on scientific evidence of relatively valid and specific contrasts: with affective expression; with developmental expression; and not otherwise specified.

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A salience dysregulation syndrome

  • Jim van Os (a1)


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A salience dysregulation syndrome

  • Jim van Os (a1)
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Re: Time to change concepts and terminology

Jim van Os, Professor of Psychiatry
19 March 2009

I thank David Kingdon and colleagues for their comment. In an attemptto come up with new terminology, I sought to combine scientific evidence for valid contrasts with scientific evidence for a mechanism (aberrant assignment of salience) that refers to a psychological process that the general public can recognize and relate to, although a considerable amountof explanation may be necessary (see reply to Bill George). Kingdon and colleagues propose a different approach: they select possible risk factorsand mechanisms associated with schizophrenia and investigate whether aetiological diagnostic constructs based on these are acceptable to patients. To the degree that their method included an analysis of acceptability to patients (Kingdon et al, 2008), their proposal is certainly superior to mine. A weakness of the method may be that there is little evidence that, for example, trauma and drug use underlie discrete effects that can be separated diagnostically. If anything, research suggests that they may be interacting causes impacting on the same final common pathway (Cougnard et al, 2007; Houston et al, 2008). Although it could certainly be argued that as long as they are established risk factors (although doubts exist (Macleod et al, 2007; Morgan & Fisher, 2007)) and the terminology is acceptable to patients, this should not prevent their use as aetiological diagnostic constructs, a major problem would remain acceptability to mental health professionals. How likely is it that these constructs would be accepted by the DSM and ICD committees currently revising diagnostic criteria? In my view, if we really want to abandon the stigmatizing term of “mind-split disease”, it is important to come up with an alternative that is not only acceptable to patients, but also to mental health professionals. The reason for this is that DSM and ICD terminology is by far the most influential in how the general public attempts to understand madness. Therefore, unless DSM and ICD terminology is changed, the part of the stigma that is induced by confusing and mystifying terminology will not change. Also, the continued use of the term “psychosis” proposed by Kingdon and colleagues may perpetuate the mystification of the experiences of patients, as the public cannot understand this term to make a connection to their own psychological experiences.

The most important issue, however, is how many patients, professionals and other stakeholders want the name to change. It certainlyseems that many are of the opinion that a confusing and mystifying 19th century term should not be used to diagnose patients in the 21st century. Maybe the time has come for the DSM and ICD committees to make a decision on this topic and, in the case a name change is favoured, to develop a process through which a change that is acceptable to as many stakeholders as possible is achieved. The methodology of consulting patients developed by Kingdon and colleagues should figure prominently in this endeavour.

Cougnard, A., Marcelis, M., Myin-Germeys, I., et al (2007) Does normal developmental expression of psychosis combine with environmental risk to cause persistence of psychosis? A psychosis proneness-persistence model. Psychological Medicine, 37, 513-527.

Houston, J. E., Murphy, J., Adamson, G., et al (2008) Childhood sexual abuse, early cannabis use, and psychosis: testing an interaction model based on the National Comorbidity Survey. Schizophrenia Bulletin, 34, 580-585.

Kingdon, D., Gibson, A., Kinoshita, Y., et al (2008) Acceptable terminology and subgroups in schizophrenia: an exploratory study. Social Psychiatry and Psychiatric Epidemiology, 43, 239-243.

Macleod, J., Davey Smith, G., Hickman, M., et al (2007) Cannabis and psychosis. Lancet, 370, 1539; author reply 1539-1540.

Morgan, C. & Fisher, H. (2007) Environment and schizophrenia: environmental factors in schizophrenia: childhood trauma--a critical review. Schizophrenia Bulletin, 33, 3-10.
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Conflict of interest: None Declared

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Time to change concepts and terminology

David Kingdon, Professor
19 February 2009

The proposal by Van Os to introduce ‘salience dysregulation syndrome’1 to describe the psychosis spectrum, replacing schizophrenia andbipolar disorder, represents an acceptance that such terms have outlived their usefulness. But by introducing three sub-categories, ‘with affective expression’, ‘with developmental expression’ and not otherwise specified, he simply replaces outdated terms but retains the invalid and unreliable concepts – schizophrenia and bipolar disorder re-emerge with different names.

The evidence for a psychosis spectrum, as he describes, now seems irrefutable. At one end, manic symptoms ‘represent the greatest diagnosticvalue’ and this end of the continuum seems relatively recognisable and clinically relevant. Moving toward the other end takes us into Bleuler’s schizophrenias and the more recently emerged area of drug-related psychosis. We have argued the case that rather than simply continuing to try to homogenise the schizophrenias, we should listen to what patients tell us led to their first episodes. Dudley2 has recently used Q sort methodology to elicit this and found similarities to concepts developed empirically from clinical practice3. We have used these concepts drug-related, traumatic, stress-sensitivity [early onset] and anxiety [late onset] psychoses successfully with patients4 and also found them to be destigmatising5. They are derived from work which Van Os himself has beenpre-eminent in developing and we suggest to him that he has the courage ofhis convictions and use aetiological concepts rather than nebulous descriptive ones.

1 van Os J. A salience dysregulation syndrome. The British Journal of Psychiatry 2009; 194:101-103.

2 Dudley R, Siitarinen J, James I, Dodgson G. What Do People with Psychosis Think Caused their Psychosis? A Q Methodology Study. Behaviouraland Cognitive Psychotherapy 2009; 371:11-24.

3 Kingdon DG, Turkington D. Cognitive therapy of schizophrenia. New York: Guilford; 2005.

4 Kingdon D, Gibson A, Kinoshita Y, Turkington D, Rathod S, MorrisonA. Acceptable terminology and subgroups in schizophrenia. Social Psychiatry and Psychiatric Epidemiology 2008; 433:239-243.

5 Kingdon D, Vincent S, Selvaraj S, Kinoshita Y, Turkington D. Destigmatising schizophrenia: changing terminology reduces negative attitudes. Psychiatric Bulletin 2008; 32: 419-422.
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