Primary psychosis: more to know, much more to do

In this issue of the journal, Maj et al1 make clear the implications for a field that has turned slowly from concepts of various psychotic disorders as disease entities to recognition of the heterogeneity within each diagnostic group and the shared psychopathology across traditional diagnostic groups. The concept of “primary psychosis” brings clinical attention to a range of disorders where disorganization of thought and behavior and/or delusional thinking and/or hallucinatory phenomena are prominent, and cases are not easily distinguished by specific causation or mechanism of pathophysiology. With a focus on clinical intervention, the authors make clear the numerous therapeutic targets potentially present and the necessary evaluation of each case with the goal of comprehensive and personalized treatment. There is anticipated “payoff” in science as new concepts guide the effort to understand mechanisms for discreet aspects of psychopathology. The needs addressed by the authors provide many targets. I believe regulatory bodies concerned with drugs and devices are early in a shift from DSM/ICD diagnoses as guiding entities. This shift requires recognition of clinical syndromes with movement to more precise elements of psychopathology as a target for medication or device approval. Syndrome status was made explicit in the DSM-5 for schizophrenia spectrum disorders. The influence on clinical trials methodology will be profound. Many therapeutic and management approaches must be developed without commercial finance and it will be challenging for funders of public science to adequately address the need for knowledge acquisition in the range of psychopathology essential for broadly integrative care. This report would be valid if addressing schizophrenia rather than primary psychosis. The authors have given emphasis to transdiagnostic conceptualization of psychopathology related to psychosis. This advance has been unnecessarily slow. A personal milestone is our 1974 paper2 summarizing data that made clear, to us, that schizophrenia was a clinical syndrome rather than a disease entity. Six aspects of psychopathology were viewed as separate targets for discovery not unique to schizophrenia. However, in 1983, the DSM-III viewed schizophrenia as a disease based on the belief that heterogeneity would be addressed when clinicians used specified symptoms for the diagnosis and gave prominence to Schneiderian first-rank symptoms. It was three decades later that the DSM-5 made explicit the syndrome status and identified dimensions of psychopathology relevant for psychotic illnesses. A turn to transdiagnostic psychiatry is being supported by the US National Institute of Mental Health's Research Domain Criteria3. Very controversial at the outset, the view that dimensions of psychopathology can be investigated across diagnostic boundaries has taken hold. The comparison of schizophrenia patients versus non-ill controls is gradually giving ground to paradigms involving specific aspects of psychopathology with potential relevance across diagnostic boundaries. A nosology with specific diagnoses is necessary for many reasons, and schizophrenia is not an exception. The key is understanding the implications of the diagnosis and the need for a further clinical characterization in order to personalize management.