Vol 3 n° 2 - Schizophrenia: Specific Topics
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Even though schizophrenia is a clear psychiatric entity, the diagnostic boundaries of the illness are indistinct and the exact nature of the core diagnosis is often debated. In practice, overlapping characteristics common to many chronic psychotic illnesses can confuse an exact diag- nostic delineation. This is due, in part, to the fact that we only have clinical signs and symptoms to use for making diagnostic decisions. It would be analogous to trying to delineate a diagnosis of anemia or congestive heart fail- ure based on “fatigue” as a symptom. This problem is especially acute in childhood psychotic disorders. Moreover, because the focus on controlled drug trials in children and adolescents is only recent, few solid treatment data exist from this target population. Helen Courvoisie, Michael J. Labellarte, and Mark A. Rid- dle discuss these issues and review existing evidence in this issue in their State-of-the-art article (page 79). The issue of diagnosis is now seen to be confusing the genetic characterization of schizophrenia as well. Marion Leboyer is certain that existing data support a multigenic basis of the illness, with many suggested, but no firm genetic linkages (see her Pharmacological aspects arti- cle on page 99). Instead of a strict genetic basis for the entire diagnostic spectrum, she proposes a “candidate symptom” approach and an “endophenotype” strategy to enable progress in the genetics of schizophrenia. Diagnosis is particularly obscure and problematic in the late adolescent stage involving the time of disease onset. In the Basic research article, Barbara Cornblatt describes a current trend toward early treatment, indeed treatment during the “prodrome” period (page 93). But she warns about the inherent difficulties with early diagnosis and valid case identification. Even when diagnosis is no longer a major issue, treat- ment issues can be problematic. Robert R. Conley and Deanna L. Kelly detail treatment problems inherent in the “special”  patient,  the  very  old,  the  very  young,  the comorbid drug user, and the nonresponder (see their Clinical research article on page 123). Moreover, they make recommendations about the advantages of the new antipsychotic agents in these categories of illness. Putting these Western experiences in perspective is the Clinical research  paper by Michael R. Phillips (page 109), detailing diagnostic and treatment issues in China. His comprehensive presentation of the psychosocial, eco- nomic, and therapeutic conditions of schizophrenia in China suggests fascinating comparisons with Western- based schizophrenia material contained in this and in the previous issue on schizophrenia (Dialogues in Clinical Neuroscience, 2000, Volume 2, No. 4). That schizophre- nia is considerably more prevalent in China in urban than rural areas and in women than men raises new aspects of the illness to consider. The diagnosis of schizophrenia, while currently based only on clinical signs and symptoms, is moving toward another more solid phase, where genetic, physiological, and pharmacologic criteria will become integrated into critical criteria for diagnosis, as they are in all other med- ical diagnoses. Carol A. Tamminga, MD 7 7 I n   t h i s   i s s u e . . .