Conceptual and Ethical Issues in early Diagnosis and Treatment

THE PROS AND CONS OF ASSESSING INFORMED CONSENT IN EARLY PSYCHOSIS : THE MacCAT-CR OPTION

K.F. Schaffner

George Washington University, Washington, DC, USA

Research in early detection and intervention in psychosis can raise ethical issues regarding safety, efficacy, informed consent, and stigma. One way to progress is to insure that adequate informed consent from subjects is obtained. A specific, well-tested, easy-to-administer, and reliable instrument (the MacCAT-CR) that empirically assesses informed consent is available to use in such programs. Three versions of the instrument have very recently been produced for use at three sites (Melbourne, Yale, Amsterdam) and exploratory discussions have been held with site leaders. So far, however, no trials of the MacCATCR have yet been conducted. It has turned out that there are trade-offs in such research, including concerns about the possible need to change original consent forms, and inappropriately alarming patients by using the MacCAT-CR. A deeper but closely related issue is differing conceptions of psychosis and prognosis at different sites. One MacCAT-CR trial at the University of Amsterdam is nearing approval, which will be described in detail, and which may suggest ways of resolving these concerns. The hope is that only one reasonably uniform instrument may be employed internationally so as to increase the power, significance, and utility of this research.

EVALUATIVE CONSIDERATIONS IN THE EARLY DIAGNOSIS AND TREATMENT OF SCHIZOPHRENIA

C. Pouncey

Department of Psychiatry, Presbyterian Hospital, New York, NY USA

Although ethics and epistemology are often treated separately in philosophy, the prospect of early diagnosis and treatment of schizophrenia makes apparent the intimate relationship between them. In this presentation, I review how moral concerns about socially stigmatizing diagnoses – especially schizophrenia – influenced early epistemological discussions about psychiatric classification. I provide my own account of how nosologic changes are made and diagnostic criteria modified. This account emphasizes a common confusion in philosophy of psychiatry between methodology and epistemology. Finally, I consider where ethical and epistemic values may direct decisions about whether to include new diagnostic techniques in the diagnostic criteria for schizophrenia. I conclude that considering ethical and epistemological questions together provides a richer understanding of how social expectations might influence psychiatric science.

SPIRITUAL EXPERIENCE AND PSYCHOSIS : A TEST CASE FOR EARLY DIAGNOSIS OF SCHIZOPHRENIA KWM.

Fulford (1), J.Z. Sadler (2)

(1) University of Warwick and Oxford, UK, (2) Department of Psychiatry, UTSouthwestern, Dallas, TX, USA

The distinction between spiritual experience and psychotic illness remains controversial. In the DSM, criterion B (of ‘social/occupational dysfunction’) is helpful in distinguishing adaptive from maladaptive forms of psychotic experience. Assessment under this criterion may also be helpful as the basis of cognitive-behavioural approaches to management. However, current scales for operationalising criterion B are unsatisfactory. Combined with the ambiguity of other key concepts in psychiatric diagnosis (for example the concept of ‘clinically significant’ as used in DSM), this raises particular difficulties for differential diagnosis at the early stages of a possible psychotic illness. A possible contribution to improved diagnostic methods in this context will be described arising from recent international work on the role of value judgements in psychiatric diagnosis.

CONCEPTUAL ISSUES IN THE PRODROME OF PSYCHOSIS

M.R. Broome

Institute of Psychiatry, London, UK

The phase prior to transition to first episode of psychosis is increasingly becoming of interest to schizophrenia researchers and clinicians. This talk will review historical conceptions of the prodrome before discussing current conceptualisations and methods of assessment. Transition rates based upon these various measures will be reviewed and our own clinical cohort in South London described. In particular, the nature of their psychopathology and the prominent comorbidity. The talk will conclude with how studying the prodromal phase of psychosis helps us, if at all, to understand schizophrenia and :he ethical concerns that have been raised regarding intervention in this group.