Today we speak again with Professor Josef Parnas, Professor of Psychiatry at the University of Copenhagen and a co-founder and Senior Researcher at the Danish National Research Foundation: Center for Subjectivity Research.
For some 40 years, Professor Parnas has worked as a clinician and conducted research into the schizophrenia spectrum with an emphasis on the phenomenology of schizophrenia. In our first conversation we discussed the implications of taking the phenomenology of schizophrenia seriously, and covered topics such as importance of clinical experience, and adequacy of current systems to classify psychopathology.
But after the interview I realised that we didn’t really discuss the phenomenology of schizophrenia itself and felt that I had missed an opportunity to learn from someone with so much experience. So in this episode, I ask of a lot of basic questions to better understand what schizophrenia is and what life is like for those with it.
Show Notes
1:20 – On the prototypical case of schizophrenia.
26:15 – On psychosis and it’s relationship to schizophrenia
32:10 – On psychosis in schizophrenia vs. psychosis in other conditions.
38:00 – What catalyses psychotic episodes?
44:30 – Is psychosis itself adaptive?
49:00 – On the marked difference in quality of life outcomes between different cultures.
55:00 – On the link between Autism and Schizophrenia
1:20 – On the prototypical case of schizophrenia.
One interesting point about schizophrenia is that it can be difficult to date its onset. Although onset of flamboyant psychotic symptoms and diagnosis with schizophrenia typically occurs somewhere around the early 20s, and there is often a prior history of contact with psychological/psychiatric services and differences in behaviour and the person’s experience that occur well before diagnosis. These differences and difficulties are related to being a subject in the world. For example, even as a, say 11 or 13 year old, the person would often feel profoundly different and cut-off from others, even if they don’t display conspicuous behavioural differences. Interestingly people with schizophrenia may find it difficult to verbalise in what sense they are profoundly and fundamentally different. This feeling of a lack of naturalness in and attunement to the world is reflected in the person being perceived as peculiar or eccentric, and sometimes leads to a interest in metaphysical or philosophical issues.
The onset of psychosis itself, is linked to an increasing sense of self-alienation. For example, the patient starts to experience their thoughts as being ‘at a distance from themselves’ and eventually as not belonging to themselves. This may lead to a sense of revelation that they are in contact with another dimension of reality that is not accessible to other people (and such a sense is often experienced by those with schizotypal traits without psychosis). Other schizophrenic symptoms such as the sense of have thoughts inserted into their head, and of one’s thoughts/actions being controlled (ie. passivity phenomena) is also related to this increasing sense of self-alienation. Delusions are also related to the growing sense of self-alienation, and are often developed while the person realises that something is happening, but doesn’t understand what is happening.
For most patients, schizophrenia is a fluctuating condition (with or without medication). Only a minority of people deteriorate into a chronic debilitated state.
26:15 – On psychosis and it’s relationship to schizophrenia
Psychosis is nearly impossible to define satisfactorily. People may have the auditory hallucinations characteristic of psychosis, but should not be considered psychotic if they recognise them as such and are able to function in the world. Only when such private experiences are taken to be the objective, shared world and are then acted upon is there a clear case of psychosis. And indeed, many people who are discharged as non-psychotic will continue to have unusual experiences but are able to separate their own experiences from those of the socially shared reality.
32:10 – On psychosis in schizophrenia vs. psychosis in other conditions.
The experience of psychosis itself is similar between its occurrence in schizophrenia and in other conditions. However, you might say that before psychosis, the experience of the person with schizophrenia is closer to the psychotic state than that of non-schizophrenic people.
38:00 – What catalyses psychotic episodes?
Drug abuse can precipitate schizophrenia, but often there are questions about the direction of causality. Self-medication through dug abuse is common amongst people with schizophrenia. Additionally trauma, emotional deprivation (as was more common in the foster homes of past generations) or the loss of another person on whom the person is in some way dependent, is often a catalyst.
44:30 – Is psychosis itself adaptive?
I asked this question after coming across this paper: https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00237/full
In contrast, Josef doesn’t consider there to be any real adaptiveness to psychosis itself.
49:00 – On the marked difference in quality of life outcomes between different cultures.
Research almost 30 years ago by the WHO suggested that people in less developed countries had a better prognosis than people in more developed countries. However, such studies are extremely complicated. But the social environment is certainly important for life outcomes for those with schizophrenia. People with schizophrenia will do better in more tolerant social environment than a rigid and hostile one. So we could expect a more productivity-focused social environment to lead to worse outcomes for people with schizophrenia.
55:00 – On the link between Autism and Schizophrenia
Josef does not think there is a link between the two conditions. This is not surprising given Josef’s emphasis on anomalous self-experiences – a recent paper has pointed to very different self-experiences in ASD and schizophrenia (https://academic.oup.com/schizophreniabulletin/article/46/1/121/5485220). He is also sceptical about the dramatic increase in prevalence of ASD in recent years, mentioning the work of Ian Hacking (for example, https://www.lrb.co.uk/the-paper/v28/n16/ian-hacking/making-up-people)
Today we speak with Professor Josef Parnas, Professor of Psychiatry at the University of Copenhagen and a co-founder and Senior Researcher at the Danish National Research Foundation: Center for Subjectivity Research. Professor Parnas has been involved in research into the schizophrenia spectrum for about 40 years, and by using a phenomenological approach, has come to focus on the anomalous self-experiences associated with the schizophrenia spectrum.
In this conversation we discuss how we should think about schizophrenia, phenomenology and the importance of clinical experience, and systems to classify psychopathology.
Show Notes
0:00 – On Josef’s background.
3:25 – Josef’s overview of what we know about schizophrenia.
10:30 – Contrasting the core of schizophrenia from the symptoms.
21:45 – On the compatibility of predictive Bayesian computation accounts and phenomenological accounts of schizophrenia.
36:50 – Does Josef find the research on meditation or psychedelics interesting, given his interest in alterations of self-experience?
38:20 – Why Josef is not hopeful that dimensional classification systems for psychopathology?
50:15 – Alternatives for students or researcher who do not have the option of gaining direct experience with schizophrenic populations.
52:00 – On what historical European psychiatry has to offer contemporary psychiatry.
0:00 – On Josef’s background.
Josef was trained as a medical doctor at the University of Copenhagen, and then completed his internship at a hospital running important studies that showed that schizophrenia has an important genetic basis. He has worked simultaneously in clinical and research capacities throughout his career.
He arrived at his interest in phenomenology because of his interest in psychopathology. The phenomenological perspective was the most mature account of psychopathology, and was very much mainstream until DSM-3.
3:25 – Josef’s overview of what we know about schizophrenia.
Thinks that schizophrenia is not well represented by the current medical model, which emphasises chronic psychotic symptoms, such as hallucinations and delusions. This is likely due to the desire of recent DSM efforts for reliability of diagnoses. The core features of the schizophrenia spectrum, which include distortion of subjective life and disorders or expressivity, are relatively neglected perhaps because they tend to require clinical experience to reliably identify.
Schizophrenia is more than just the chronic condition identified by the DSM. One piece of evidence that suggests schizophrenia is a spectrum rather than just the severe diagnosable condition is that only a minority of patients with diagnosable schizophrenia experience a deteriorating chronic course, many experience a remitting course and a significant proportion (20-25%) of those that would qualify for a diagnosis are never treated or seek medical help at all. Then there are milder parts of the spectrum that wouldn’t qualify for a schizophrenia diagnosis, which again, do not typically seek psychiatric help. Also, there are links between vulnerability to schizophrenia and creativity.
10:30 – Contrasting the core of schizophrenia from the symptoms.
There is something qualitative about the symptoms of schizophrenia. A schizophrenic delusion or hallucination is easily distinguished by the experienced clinician from the delusions or hallucinations symptomatic of other conditions. Josef considers the nature of these symptoms to be reflective of differences in the subjective experience, which he considers the core of schizophrenia colouring the manifest symptoms. Said differently, it is not the case that the symptoms in schizophrenia are not simply occurring to a person that otherwise experiences life as a neurotypical person does. The differences occur right down to a fundamental level of the person’s subjective experience, and these differences pre-date and may give rise to the more obvious clinical symptoms.
Josef tells a story of a client of his that was surprised to learn that most people experience thoughts as their own, as opposed to existing in some sort or collective space as experienced by the client.
Therefore, to understand schizophrenia, we need to be thinking in terms that are pervasive and fundamental, rather than modular.
21:45 – On the compatibility of predictive Bayesian computation accounts and phenomenological accounts of schizophrenia.
Intuitively, Josef is attracted to such accounts.
26:10 – Are schizotypal traits adaptive?
People with schizotypal traits often don’t share the naturalness with which neurotypical people relate to the world. And if you don’t take the obvious for granted, this may facilitate a curiousity about the world and lead to greater creativity. And indeed, there is a documented link between schizophrenia (and relatives of those with schizophrenia) and creativity.
Here is a link to the study Josef mentioned on the prevalence of schizophrenia in the relatives of university scientists.
Robert Sapolsky’s lecture on schizophrenia: https://www.robertsapolskyrocks.com/schizophrenia.html
Josef’s translation of Hans Gruhle’s 1929 work, ‘The schizophrenic basic mood (self-disorder)’.
33:25 – On the disorder of self in schizophrenia.
Josef thinks that the disorders of self-experience in schizophrenia, are coming to be increasingly recognised. In fact, disorders of self-experience will be mentioned in the new ICD-11.
38:20 – Why Josef is not hopeful that dimensional classification systems for psychopathology?
Clinicians say that they only need ~25 diagnostic categories, not the ~400 in DSM-5. The reliance on well defined diagnostic criteria (in the DSM and ICD) and the discarding of phenotypic/prototypic descriptions, has resulted in an unending proliferation of diagnoses. Josef is also sceptical that a dimensional approach will be adopted by clinicians – “clinicians like categories”.
Instead, Josef thinks the best solution might be to have different classification systems depending on the context/purpose.
50:15 – Alternatives for students or researcher who do not have the option of gaining direct experience with schizophrenic populations.
Josef recommends a number of books to gain insight into the phenomenology of schizophrenia, including;
Today we speak with Professor Robert Krueger, Distinguished McKnight University Professor, Hathaway Distinguished Professor, and the Director of Clinical Training in the Department of Psychology at the University of Minnesota. Professor Krueger’s work spans the fields of personality and personality disorders, psychometrics, and genetics, and is centred on developing an empirically-based system of grouping and delineating psychopathology.
This is a topic that I think is important to the way we think about mental health and conduct research into it. And I couldn’t hope to have to have a more qualified guest to discuss the topic with. Professor Krueger was a member of the DSM-5 Personality and Personality Disorders Work group, and is an architect of the Hierarchical Taxonomy of Psychopathology a new, dimensional classification system of psychiatric problems.
Show Notes
1:20 – On Robert’s background
2:55 – On the problems associated with the DSM diagnostic procedure
5:05 – How did we end up with the DSM given how readily the associated problems are observed, and given the transdiagnostic approach of early psychotherapists?
8:20 – On the pendulum swinging back the other way now.
11:50 – An outline of the HiTOP (Hierarchical Taxonomy Of Psychopathology) approach to diagnosis and categorisation.
17:20 – On why traditional categorical diagnoses appear in the HiTOP?
22:25 – On the similarities and differences of Research Domain Criteria (RDoC)
26:40 – On other approaches to deriving an empirically derived nosology, apart from HiTOP and RDoC.
28:55 – Will the shift to an empirically derived nosology be a big change for clinicians?
33:20 – Thinking about an example involving multiple diagnoses, from a HiTOP perspective.
37:15 – Does the move toward an empirically derived nosology have any implications for debates around the over-pathologising of normal human experience?
41:00 – What advice does he have for students?
2:00 – On Robert’s background
Robert was trained as a clinical psychologist, obtaining a PhD in clinical psychology. His interest in diagnosis and categorisation goes back to early experiences struggling to apply the standard diagnoses to his clients.
2:55 – On the problems associated with the DSM diagnostic procedure
Under the DSM, diagnoses are made when someone meets a certain threshold of diagnostic criteria from a list of diagnostic criteria. Under this system there can be considerable heterogeneity within categories (people with different symptoms receiving the same diagnosis). Similarly, people tend to meet the criteria for more than just a single diagnoses. This is known as the co-morbidity problem, and limits the usefulness of a diagnosis for planning appropriate treatments.
5:05 – How did we end up with the DSM given how readily the associated problems are observed, and given the transdiagnostic approach of early psychotherapists?
DSM-3, published in 1980, was a significant turning point. Earlier editions of the DSM had only descriptive paragraphs instead of well delineated criteria sets (which was also problematic). It is only by doing research with such criteria sets that their problems clearly emerge.
8:20 – On the pendulum swinging back the other way now.
Robert identifies the main reasons why people in the research community are supportive of a move to a more empirical diagnostic system as due to the disappointing search for biomarkers of psychiatric conditions. For clinicians, it is the lack of informativeness of a diagnosis for planning appropriate treatments.
11:50 – An outline of the HiTOP (Hierarchical Taxonomy Of Psychopathology) approach to diagnosis and categorisation.
HiTOP is an effort to follow the evidence of how the symptoms associated with psychiatric conditions are organised. The resulting view is one where people’s experience is seen to fall along different dimensions, rather than in clearly different categories. The dimensions are considered to be organised hierarchies from signs and symptoms at the lowest level to a general psychopathology factor at the highest level.
17:20 – On why traditional categorical diagnoses appear in the HiTOP?
The presence of traditional categorical diagnoses in HiTOP, such as Major Depressive Disorder and Bipolar Disorder, partially reflects that fact that most research has been done along the line of such categories. However they are also intended to help with the transition from the current approach to an empirical approach.
In time, the use of such diagnoses may fall away if such a change was supported by the evidence.
22:25 – On the similarities and differences of Research Domain Criteria (RDoC)
The RDoC project is an initiative being developed by US National Institute of Mental Health. It was initiated in response to the same dissatisfactions with the DSM criteria that motivated HiTOP. However, in comparison with HiTOP, RDoC is more focused on biological mechanisms and makes less concessions to ensure continuity and an easy transition from the current approach.
RDoC and HiTOP should be seen less as competing approaches, and more as complementary approaches that will dialogue and converge on a consensus conception of psychopathology.
26:40 – On other approaches to deriving an empirically derived nosology, apart from HiTOP and RDoC.
There are a variety of approaches currently being explored with the hope of deriving an empirically derived nosology. Network approaches focus on the relationship between different symptoms. A key difference between network approaches and HiTOP is that network approaches don’t give much focus to higher levels of the hierarchy proposed by HiTOP.
28:55 – Will the shift to an empirically derived nosology be a big change for clinicians?
In some ways, especially around record-keeping and insurance, the move to a HiTOP-type system may require significant changed. But in terms of how they think about and approach treatment, clinicians may already operate in a way that is consistent with a HiTOP-type system. For example, they may often forego a formal diagnostic assessment as they consider it to have little clinical utility. Instead, they may think about their client’s difficulties in broader terms than DSM-5 labels, something like the HiTOP spectra (internalising, externalising and thought disorders).
33:20 – Thinking about an example involving multiple diagnoses, from a HiTOP perspective.
The example involved a case where a person presents with symptoms of anxiety, depression and substance-use disorder. There is little difference in the way one would approach treatment (again, testament to the fact that most clinicians don’t use DSM-5 diagnoses to guide treatment). However, a notable opportunity that comes from thinking in a HiTOP-consistent way, is to identify processes that are relevant to a number of diagnostic categories.
37:15 – Does the move toward an empirically derived nosology have any implications for debates around the over-pathologising of normal human experience?
For one thing, efforts to derive an empirically derived nosology have highlighted that there is no bright line between psychopathology and normal variation. This spectrum-based thinking, instead of categorical thinking, highlights that it is convention that dictates when to intervene, rather than a simple case a disease is present and therefore an intervention is warranted/necessary.
41:00 – What advice does he have for students?
Pursue your passion. This might seem cliche, but for Robert, doing something meaningful and interesting makes it easier to persist through the difficult times.
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Announcements
There is currently an opportunity to volunteer as a research assistant with the Black Dog Institute. They are particularly after volunteers who can visit Walcha and/or Glen Innes (travel costs reimbursed), though opportunities exist in other areas of New South Wales too. The positions will support The Future Proofing Study, which is the largest mental health prevention study ever undertaken in Australia. I spoke with the Chief Investigator of The Future Proofing Study in Episode 10 (https://www.mindstewpodcast.com/e010/). Details of the position can be found here.
Today we speak with Dr. Maria Kangas, Associate Professor of Macquarie University’s Centre for Emotional Health.
Maria is a registered psychologist with dual endorsements from the Psychology Board of Australia in Clinical and Counselling Psychology. Maria is also Director of the Clinical Psychology program at Macquarie University. Her research has focussed on coping strategies and emotional regulation relating to stress/PTSD, anxiety and mood disturbances in trauma and medical (e.g., cancer) populations, across the lifespan.
*Please accept my apologies for the recording quality. There are a number of moments where a faulty internet connection has undermined our VOIP program and resulted in a recording that was clipped in a few places.
Today we speak again with Professor Josef Parnas, Professor of Psychiatry at the University of Copenhagen and a co-founder and Senior Researcher at the Danish National Research Foundation: Center for Subjectivity Research.