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Bölte, Sven

 44 
 
Scandinavian Journal of Child and Adolescent Psychiatry and Psychology 
Vol. 4(2):44-45 (2016)  
 
 
Editorial                                                                                                                                                     Open Access 
 
 
 
 
The Swedish Patient 
 
Sven Bölte 
 
 
 
 
There is a ghost in the house of academic child and 
adolescent psychiatry in Sweden that harbors an 
inconvenient truth that has been ignored for far too 
long: there is currently a dramatic shortage of 
domestic child and adolescent psychiatrists who are 
qualified for university professorships, and there is a 
serious risk for the extinction of several chairs in this 
field. About 450 child and adolescent psychiatrists 
are registered in Sweden; 150 of these are in 
Stockholm County alone, which represents one of 
the highest—if not the highest—density of 
practitioners of this profession in the world. Child 
and Adolescent Psychiatry Stockholm has 900 
employees and serves an area with a population of 
2.2 million, which makes it one of the largest single 
child and adolescent psychiatry organizations 
worldwide. Nevertheless, among all child and 
adolescent psychiatrists in Sweden, the proportion 
with PhDs is low, and the number of senior 
researchers with track records that make them 
eligible for professorships and that demonstrate 
international competitiveness is humble.  
In Sweden, there are six university child and 
adolescent psychiatry departments: Lund, 
Gothenburg, Linköping, Stockholm, Uppsala, and 
Umeå. In Uppsala and Umeå, the chairs have been 
formally vacant for several years, having only been 
kept alive by the former and now retired chairs taking 
continuous responsibility. Fortunately, in Uppsala, it 
seems that a valuable new recruit is within reach. 
Lund, Gothenburg, and Linköping are facing the 
emeritus statuses of their chairs in the not too distant 
future. In Stockholm, the traditional child and 
adolescent psychiatry chair has not been continued, 
and it is likely to be terminated completely after the 
current senior professor’s final retirement. Instead, 
two new professors have been recruited for the area 
of child and adolescent psychiatric science, 
particularly to address neurodevelopmental disorders 
as well as obsessive-compulsive disorders and related 
conditions. However, these individuals are clinical 
psychologists rather than child and adolescent 
psychiatrists. It may be considered a positive move 
that academia and child and adolescent psychiatry 
have opened themselves up to psychologists and 
acknowledged their pivotal role in clinical child and 
adolescent psychiatry and that the field is prioritizing 
scientific excellence, irrespective of profession. Still, 
one of the major reasons that child and adolescent 
psychiatrists were not recruited for these positions 
was simply the lack of availability. For example, for 
the professorship on neurodevelopmental disorders, 
Karolinska Institutet and Child and Adolescent 
Psychiatry Stockholm had searched Sweden for 
eligible candidates who were child and adolescent 
psychiatrists for several years, without success. It is 
also worth noting that the two psychologists 
recruited for the chairs came from abroad. Although 
it is vital for Swedish psychiatry to diversify by 
incorporating international perspectives, the inability 
to employ domestic experts raises additional 
questions about the availability of sufficiently 
academically qualified senior researchers in this field 
in Sweden as a whole.  
What are the reasons for this problematic situation, 
and what can be done to improve it? Most of my 
academic and clinical colleagues in Sweden agree that 
the negative developments in this area began during 
the 1980s as a result of the politics associated with 
the decisions made in many counties to separate the 
academics and clinical practice of child and 
adolescent psychiatry as much as possible. This 
generated gaps between research, education, and 
practice, and it made it hard for clinicians to combine 
their clinical and scientific work. It diminished the 
inclusion of research and education as natural parts 
of an active clinician’s working life, and it excluded 
the use of any clinical resources for research, 
development, and education. Consequently, 
academic skills were no longer considered necessary 
or beneficial to standard child and adolescent 
services. In many of today’s child and adolescent 
 45 
 
psychiatry departments, even the leaders lack 
scientific qualification. For child and adolescent 
psychiatrists who may wish to start scientific careers, 
a particular challenge related to the dissociation of 
academia from practice is compensation. Salaries for 
physicians are high as compared with other 
professions in clinical psychiatry; such salaries are 
very unusual for junior researchers or simply 
impossible for universities to afford. Most 
physicians, for understandable reasons, do not feel 
that they can tolerate large salary cuts to conduct 
science. In addition, for some areas of psychiatric 
research, medical expertise is not mandatory, so 
employing young gifted researchers from other 
professions can be equally meaningful. As compared 
with the examinations that must be passed in the field 
of psychology, an explicit scientific education in 
medicine is limited, which is another disadvantage 
for physicians who may want to begin performing 
research. 
Are there other explanations for the shortage of 
highly merited academic senior child and adolescent 
psychiatrists? I am afraid that there are at least two 
additional aspects of significance. First, research is 
still not valued highly enough in the field of clinical 
child and adolescent psychiatry in Sweden, and 
evidence-based clinical practice is a goal that is far 
from being achieved. There are still many anti-
scientific practices and traditions that are tolerated by 
health care authorities and influential in many clinical 
organizations. There is also a widespread, 
subliminally shared belief that research does not 
really contribute to clinical practice and thus that 
practice can do well without science. Guidelines for 
the diagnosis and treatment of mental disorders do 
not exist, are not evidence based, or are not 
sufficiently followed. Regrettably, these circum-
stances—which contribute to academic child and 
adolescent psychiatry being threatened with 
extinction—are not taken very seriously or are not 
even recognized by many. Second, despite the bad 
odds described previously, academic child and 
adolescent psychiatry frankly must blame itself for 
not having made a better effort to bring up the next 
generation of senior child and adolescent 
psychiatrists to lead the profession in this country’s 
universities. 
Although the situation appears to be critical, there 
are also some positive developments to report. In 
2004, the Swedish Association for Child and 
Adolescent Psychiatry started a child and adolescent 
psychiatry academy with the objective of connecting 
all academic child and adolescent psychiatry chairs 
and senior researchers to coordinate and strengthen 
                                                     
1www.bup.se/sv/Om-BUP/Forskning/Barn--och-
ungdomspsykiatriskt--forskningscentrum/ 
the field and to develop an adequate academic 
curriculum. The Child and Adolescent Psychiatry 
Research Center in Stockholm1 (Karolinska Institutet 
& Stockholm County Council) was also established 
to unite three strong clinical research centers (Center 
of Neurodevelopmental Disorders at Karolinska 
Institutet [KIND]2, Child and Adolescent Psychiatry 
Stockholm (BUP) Obsessive Compulsive Disorders 
and related disorders [BUP OCD], and BUP Center 
for Psychiatry Research [BUP-CPF] at one location, 
thereby integrating clinical services, education, and 
research and development. I am keeping my fingers 
crossed for more such developments, and I sincerely 
promise to increase my own engagement with these 
issues so that the Swedish patient can recover.  
The Scandinavian Journal of Child and Adolescent 
Psychiatry and Psychology assists in addressing these 
matters by offering timely and high-quality reviews to 
child and adolescent psychiatrists at all stages of their 
careers and by providing open access to its findings 
to the scientific community at large. 
 
Conflicts of interest 
Sven Bölte does not report any direct conflicts of interest 
related to this article. Bölte discloses that he has in the last 
five years acted as an author, consultant or lecturer for 
Shire, Medici, Roche, Eli Lilly, Prima Psychiatry, 
GLGroup, System Analytic, Kompetento, Expo Medica, 
and Prophase. He receives royalties for text books and 
diagnostic tools from Hyper/Hogrefe, Kohlhammer and 
UTB. 
 
Sven Bölte, Editor in Chief, Scandinavian Journal of Child 
and Adolescent Psychiatry and Psychology, Karolinska Institutet 
& Stockholm County Council 
 
 
 
 
2www.ki.se/kind  


The Swedish Patient

Nordgaard, Julie

Henriksen, Mads Gram

12 
 
Scandinavian Journal of Child and Adolescent Psychiatry and Psychology 
Vol. 4(1):12-13 (2016) – Special Issue 
 
 
Commentary                                                                                                                                             Open Access 
 
 
 
Self-disorders: A promising Candidate for Early Detection 
 
Julie Nordgaard1* & Mads Gram Henriksen2,3 
 
1Psychiatric Research Unit, Region Zealand, University Hospital, Copenhagen, Denmark 
2Center for Subjectivity Research, University of Copenhagen, Denmark 
3Psychiatric Center Hvidovre, University Hospital, Copenhagen, Denmark 
 
 
 
*Corresponding author: juef@regionsjaelland.dk 
 
 
 
Early intervention for patients with psychosis has 
attracted an enormous amount of attention during 
recent decades. Research has shown that the duration 
of untreated psychosis has a significant effect on a 
patient’s long-term prognosis (1,2). Findings have 
also highlighted the importance of detecting 
individuals who are at high risk for the development 
of psychosis with the purpose of preventing the later 
transitioning of their conditions into psychosis or 
schizophrenia (3-6). The current approach that has 
been applied to detect these vulnerable individuals is 
the clinical high-risk (CHR) approach. The CHR 
approach includes the following: brief, limited, 
intermittent psychotic symptoms (BLIPS); 
attenuated psychotic symptoms (APS); genetic risk 
and functional deterioration (GRFD); and basic 
symptoms (BS). 
However, reliable identification of individuals who 
are at high risk for the development of psychosis has 
proved challenging. A recent meta-analysis of the 
prognostic accuracy of the CHR approach 
emphasized the need to further improve its 
predictive value (8). In brief, the prognostic value of 
the CHR approach seems to depend on the examined 
sample. For example, its utility for a non–help-
seeking sample was low, but it was excellent for a 
sample of help-seeking individuals who had been 
referred to specialized services (i.e., an enriched 
sample) (8). In our view, part of the problem is that 
both BLIPS and APS include near-psychotic or brief 
psychotic features, so the samples tend to center on 
individuals in the late prodromal pre-psychotic 
phase. This renders the CHR approach vulnerable to 
being criticized for being tautological: it is not 
surprising that milder psychosis predicts more severe 
psychosis. Furthermore, the meta-analysis demon-
strated that the excellent prognostic value of the 
CHR approach was mainly mediated by its ability to 
rule out psychosis (as compared with its ability to rule 
in psychosis) (8). 
A novel and highly promising candidate for 
improving the early identification of individuals with 
mental states that have the propensity to unfold into 
schizotypal disorders or schizophrenia is the concept 
of self-disorders (SDs). SDs are non-psychotic 
experiential phenomena. During the last two 
decades, an accumulating amount of empirical 
studies have shown that SDs constitute a specific 
experiential vulnerability phenotype of the 
schizophrenia spectrum (9,10). The idea that SDs 
form core features of schizophrenia is not new; 
explicit references to a variety of abnormal self-
experiences can be found in nearly all of the 
foundational texts that address schizophrenia (e.g., 
Kraepelin, Bleuler, Jaspers, Berze, Minkowski, 
Schneider). It is important to note, however, that 
SDs affect the “core” or “minimal” experiential self 
(11-13). The idea of the core self refers to a first-person 
articulation of experience that is typically thought of 
as ipseity, selfhood, or “mineness,” “myness,” or 
“for-me-ness” (14). It is a sense of self-presence and 
self-intimacy that implicitly or pre-reflectively 
permeates an individual’s consciousness across the 
flux of time and changing experiential modalities 
(e.g., perceiving, thinking, feeling). This sense of self-
presence may be described as a feeling of being a self-
coinciding subject of awareness and action. This self-
presence generally saturates our experiential life, and 
thus we never wonder if our thoughts, feelings, and 
bodily movements are in fact ours; the question 
simply does not arise. Among individuals with 
Self-disorders 
 
 
13 
 
schizophrenia spectrum disorders, however, this 
sense of self-presence is threatened and unstable, 
which allows a profound form of self-alienation to 
grow from within the disturbed subjectivity and 
result in a multiplicity of SDs. SDs include feelings 
of being ephemeral, of lacking an inner core or 
nucleus, of not feeling truly present or alive, of not 
being spontaneously immersed in the shared social 
world, of perplexity, and of thought pressure or 
block (15).  
Today, SDs are assessed with the Examination of 
Anomalous Self-Experience (EASE) scale (16). It is 
notable that certain SDs overlap with BSs; see 
Appendix C of the EASE scale for details. However, 
the definitions of the overlapping items are not 
completely identical. BSs are conceptualized as 
phenomena that first emerge during the stage that 
occurs before the onset of manifest illness (17). By 
contrast, SDs are considered mainly trait phenomena 
that typically have been present for years before the 
onset of psychosis and that tend to persist during 
remission after a frank psychotic episode. From 
patients’ self-reports, we have learned that SDs 
usually date back to childhood or early adolescence. 
Follow-up studies of help-seeking, prodromal, and 
first-admission patients have shown that the 
presence of SDs predicts a subsequent schizophrenia 
spectrum diagnosis (18,19). One study examined a 
non-clinical population at high risk for schizophrenia 
and found that premorbid SDs significantly 
predicted lifetime schizophrenia spectrum diagnoses 
(20). Another study examined 87 help-seeking, non-
psychotic adolescents between 14 and 18 years for 
SDs and prodromal symptoms; 22% of the 
participants reported the presence of SDs at clinically 
meaningful levels. This study lends preliminary 
support to SDs as relevant and clinically useful tools 
that can be used to supplement and refine the 
methods of early detection (21). In our view, SDs 
offer great promise for the identification of some of 
the most vulnerable adolescents years before the full 
and often disabling crystallization of the 
schizophrenia syndrome. Screening for SDs in help-
seeking individuals may contribute significantly to 
improving the early detection, diagnosis, and 
treatment of our younger patients. Therefore, we 
suggest including examination of SDs with the use of 
the EASE scale as a part of the psychopathological 
assessment of adolescent patients. 
 
Conflicts of interest 
The authors declare no conflicts of interest. 
 
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Self-disorders: A promising Candidate for Early Detection

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