“Semantic void” of some of psychiatric terms used in the diagnosis of schizophrenia

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Diagnosing mental disorders, particularly schizophrenia, is a complex process that requires the doctor not only to conduct a clinical interview and master the art of interpretation and evidence but also to be able to use psychiatric terminology. Critics point out the high level of subjectivity and the lack of reasoned nature of the evidence for diagnostic results based on ambiguous terminology. This is probably why overdiagnosing schizophrenia is a relatively common phenomenon in Russian psychiatric practice [1], manifesting itself most clearly in the widespread and unfounded diagnosis of “schizotypal disorder.” At the same time, psychiatrists acknowledge the absence of pathognomonic psychopathological symptoms in schizophrenia but continue to use ambiguous terms in diagnostic substantiation, where unconditional attribution to schizophrenia requires context rather than a statement of their presence.

Furthermore, it is debatable whether these terms reflect the presence of psychopathological symptoms or the detection of signs that do not correspond to the characteristics of the symptoms. Such ambiguous phenomena/symptoms/signs in schizophrenia spectrum disorders include amorphous and diverse thinking, derailment and tangentiality, pretentiousness and absurdity of actions and hobbies, exhaustion of emotions, ambivalence, and ambitendency [2].

Terms used in psychiatry in the 19th century now sound anachronisms, not only because there is no clear and convincing psychiatric definition for them but also because many of them have acquired different connotations in modern language, and the development of psychiatric terminology is subject to objective laws of language and vocabulary development [3]. Additionally, there has been a tendency in recent decades for English-language terms to penetrate Russian-language psychiatry [4], complicating the process of proving diagnostic accuracy.

There is no doubt that specialists must rely on standardized clinical descriptions in the diagnostic lists of the International Classification of Mental and Behavioral Disorders (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) when determining the presence of specific psychopathological symptoms and substantiating the diagnosis.

The analysis reveals that many of the symptoms listed above are missing from the ICD and DSM corresponding categories. Thus, the terms “diverseness of thinking,” “ambivalence,” “tangentiality,” “pretentiousness,” and “exhaustion” are not included at all in ICD-10 section F2 (schizophrenia, schizotypal and delusional disorders) [2, 5–8]. The term “amorphous thinking,” which appears in the section “schizotypal disorder,” is an exception; it is ironic that in the actual activities of Russian psychiatrists, these symptoms, which are lacking in the ICD, are emphasized when diagnosing schizophrenia spectrum disorders. In this regard, a natural question arises as to why these psychopathological symptoms were not included by the developers in the ICD diagnostic rubrics and whether it is worthwhile to preserve them when selecting grounds for making an accurate diagnosis of a mental disorder.

In psychiatry, unlike other medical disciplines, the diagnostic problem identifies a phenomenon as a symptom and distinguishes it from normative, nonmorbid aspects of behavior, experiences, and statements [2]. Symptom assessment is clear and traditionally focused on identifying unambiguous clinical signs in other medical specialties. A therapist, for example, determines a cough or dyspnea symptom solely based on what the diagnostician sees and hears, who can identify a dry cough from a wet cough, a hacking cough from a heavy cough, and inspiratory dyspnea from expiratory dyspnea. Assessing a clinical symptom is not contentious, and doctors have a clear consensus and consistency in understanding what kind of symptom they are dealing with. Cough or dyspnea is assessed consistently by diagnosticians–therapists.

Unlike internists, disagreements and misunderstandings among mental health professionals often arise when assessing psychopathological symptoms. Psychopathological symptoms observed in a particular patient can be interpreted differently by doctors and labeled with various terms attributed to separate areas of the “norm-pathology” and “health-disease” spectrums. However, tangentiality is not demagoguism, ambivalence is not indecisiveness, and autism is not unsociability [2]. They are often confused; however, the same term is used throughout the diagnostic process.

Thus, it refers to the lack of a single, unified, consistent understanding of specific clinical phenomena in the psychiatric community. To be fair, it should be noted that for most psychopathological symptoms, professional opinions remain consistent, with only a few cases displaying apparent opposition across diagnosticians. Professionals agree on the former (their assessment and definitions are unambiguous), which include mnestic disorders (amnesia and paramnesia), perception disorders (illusions, hallucinations, and derealization), affective phenomena (mania, depression, dysphoria, and apathy), motor-volitional disorders (echolalia, echopraxia, and catatonia), and cognitive decline. The latter group should include cognitive disorders, particularly qualitative ones that lack clinical qualifications.

The philological concepts of “semantic completeness/emptiness and certainty/uncertainty,” polysemanticity/eurysemy/unambiguousness of verbal expressions, and vagueness or clarity of definitions can be used to analyze the phenomenon of consistency or inconsistency of psychiatrists’ diagnostic conclusions regarding individual symptoms [9, 10]. From this perspective, most psychopathological disorders are still “semantically complete” and unambiguous, whereas others are “semantically vague and empty,” that is, ambiguous. The problem consists of semantically empty symptoms that, in many cases, determine the diagnosis of schizophrenia, which greatly stigmatizes patients and requires special scrupulousness and reasoning when making a diagnosis.

Such phenomena are used more often than others in diagnosing schizotypal disorder, which many Russian psychiatrists continue to identify with the concept of “sluggish schizophrenia” [11–13]. However, in recent years, many of the so-called typically schizophrenic symptoms have been revised scientifically. For example, studies on ambivalence, which refers to having conflicting feelings about something, indicate a weak association between ambivalence and schizophrenia, and some evidence shows that ambivalence may be a more common symptom of affective disorders [14, 15].

The description and identification of the verschroben phenomenon, attributed by many Russian authors to manifestations of an “endogenous process,” typical signs of schizophrenia spectrum disorders, indicate incorrect use of some terms as characteristic of the schizophrenia spectrum of disorders [11, 12, 16].

Notably, this phenomenon is absent in psychiatric classifications, such as the ICD, in recent international scientific publications. All articles with the keyword verschroben in the PubMed library are by Russian authors and have only appeared in one publication, the S.S. Korsakov Journal of Neurology and Psychiatry [17]. Its fundamental diagnostic criteria are oddity, eccentricity, strangeness of a person’s appearance, speech, behavior in everyday life, and the entire lifestyle pattern that does not correspond to conventional norms and cultural stereotypes, does not fit into the situational context, and dystonic of interpersonal communications, namely, lack of nuances and adequate assessment of established relationships with others with a loss of sense of delicacy and distance, straightforwardness, and pathological nakedness reaching a degree of regressive syntonic, as well as emotional coldness, exhaustion, and paradoxical feelings [11, 12]. These psychopathological signs/symptoms often support diagnosing “symptom-poor (‘sluggish’) schizophrenia.”

Symptoms used to diagnose schizophrenia spectrum disorders can be classified as semantically unambiguous, ambiguous, and conditionally ambiguous. The first group of symptoms includes “hyper-detailed,” circumstantial, or fragmented thinking; the second group of symptoms includes pretentiousness, paradoxicality, emotional exhaustion, eccentric behavior, and ambivalence; and the third group of symptoms includes amorphousness, diversity, tangentiality, and thinking derailment.

In psychiatry, amorphous thinking is defined as a “confused, unclear, inconsistent, and shallow pool mind, characterized by (a) loss or absence of a specific strand of thought, (b) frequent transitions of mental activity from one logical plane to another, (c) absence of a specific result of mental activity (conclusion, decision), and (d) loss of patients’ ability to control their thoughts” [6].

Some authors consider amorphous thinking and derailment to be an early version of discontinuous thinking and schizophasia, signs of schizophrenic disorder of mental activity. Diversity of thinking is defined as “a constant unmotivated change in the basis for logical ordering of associations, derailment into a different semantic field, as a result of which incompatible or even mutually exclusive ideas and concepts start to be combined in thoughts” [18].

The pretentiousness of behavior is defined as deliberate complexity, intricacy, and unnaturalness, whereas oddity is a tendency to act and act strangely for others; eccentricity is a tendency to demonstrate excessive originality, unusualness to the extent of strangeness; and emotional exhaustion implies an impoverishment of the repertoire of experiences, a lack of liveliness, adequate brightness and variability, emptiness, and inexpressiveness.

The description of these phenomena in Russian psychiatry is imprecise and does not enable us to assert that these terms represent diagnostic units, which are specific psychopathological symptoms. The references in definitions to “excessiveness,” “strangeness,” and “unusualness of something” do not permit recognition of their objective diagnostic significance. What one individual considers strange or excessive may be regarded quantitatively and qualitatively appropriate to the context by another.

A significant theoretical basis for analyzing the examined symptoms, which is considered one of the most important criteria for diagnosing schizophrenia spectrum disorders, is the classification of disease-related (abnormal) phenomena into symptoms and signs [19]. In modern semiotics, no signs may become a symptom, a tool in medical diagnostics, unless it is understood, approved by medical science, tested by medical practice, and met a particular set of criteria.

According to Volkova and Volkov [19], a symptom is a phenomenon that denotes either the risk of unhealthiness or unhealthiness itself, and it carries a particular amount of information. If a phenomenon called a symptom does not constantly or entirely represent unhealthiness, it loses its essence; that is it is not a sign and, as a result, should not be recognized as a medical symptom. In this regard, psychopathological symptoms (pretentiousness, exhaustion, ambivalence, oddity, and eccentricity) cannot be called symptoms because they lack essence and represent schizophrenia as a disease optionally rather than obligately.

Thus, an analysis of the semantic content of several psychiatric terms used in the diagnosis of schizophrenia spectrum disorders leads us to the conclusion that the terms used to designate typical schizotypal disorders, as well as latent forms of schizophrenia, should be revised, except those that are vague and ambiguous in nature, are not included in international diagnostic systems, and are considered archaic.

In this regard, we can quote the words of Gustave Le Bon that “certain words at some point attract certain images: a word is nothing more than a call button that makes them appear” [20]. Precisely, the clarity of the terms used can objectify the diagnostic process in psychiatry and prevent diagnostic errors.

ДОПОЛНИТЕЛЬНО

Финансирование. Исследование не имело спонсорской поддержки.

Конфликт интересов. Автор заявляет об отсутствии конфликта интересов.

Funding. This publication was not supported by any external sources of funding.

Conflict of interests. The author declare no conflicts of interests.

About the authors

Vladimir D. Mendelevich

Author for correspondence.
Email: mendelevich_vl@mail.ru
ORCID iD: 0000-0002-8476-6083
SPIN-code: 2302-2590
Scopus Author ID: 6602765981
https://kazangmu.ru/psychiatry/sotrudniki-kafedry

M.D., D. Sci. (Med.), Prof., Head of the Depart., Depart. of Psychiatry and Medical Psychology

References

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