Download Schizophrenia - issues surrounding diagnosis L1

The clinical characteristics of
Schizophrenia
What is it?
 Schizophrenia is one of the most chronic and disabling of the major mental
illnesses affecting thought processes
 Schizophrenia has been variously described as a disintegration of the
personality. A main feature is a split between thinking and emotion, but is NOT
a split personality
 It involves a range of psychotic symptoms (where there is a break from reality)
 Generally, schizophrenic patients lack insight into their condition, i.e. they do
not realise that they are ill.
 In order for a diagnosis to be made, two or more of the symptoms must be
present for more than one month along with reduced social functioning
 The symptoms are separated into two categories; positive and negative.
Positive symptoms are an excess or distortion of normal functions and
negative symptoms are an diminution or loss of normal functions.
 Age of onset; males late teens, early twenties. Females late 20’s
Symptoms
A distinction has been made between type 1 and type 2 schizophrenia. Whilst
positive symptoms reflects an excess or distortion of behaviour, negative
reflects a diminution or loss of normal functions.
Positive
Negative
 Delusions – paranoia, grandiosity
 Reduction in range and intensity of
emotional expression, including facial
 Experiences of control – believe under
expression, tone of voice etc
control of alien force (smiling after
bad news).
 Alogia – lessening speech fluency
 Auditory hallucinations – bizarre,
 Avolition – reduction or inability to
unreal perceptions, usually auditory.
take part in goal directed behaviour.
 Thought disturbance and disordered
 Reactivity is not expected
thinking – thoughts have been
 Thought blocking
inserted or withdrawn from the mind.  Asocial behaviour
 Language impairments
 Emotional blunting
 Disorganised behaviour
 Reflects a loss of normal functions
 catatonia – immobility – echopraxia,
 Psychomotor – catatonia – immobility
echolalia
and frenetic activity
Negative symptoms
Keyword
Symptom
Avolition
Poverty of speech, reflecting lack of or
blocked thought process
Affective flattening
Alogia
The reduction and inability to initiate in
goal directed behaviour. Ie Sitting in
the house for hours doing nothing.
Reduction in the range or intensity of
emotional expression. Limited tone of
voice and facial expression
Assumptions:
• People often associated schizophrenics with violence. Only 8% of
schizophrenics commit a violent act in a year- which although is
below the rate of those with other mental disorders (ie depression) it
is below the average of those without any disorder.
• The TV and media represent schizophrenics to be violent.
• The Diagnostic and Statistical Manual of Mental Disorders (DSM)
states a person needs to be suffering from two or more positive
symptoms or one which is reoccurring for at least one month.
Validity of the manual has been questioned.
The subtypes of Schizophrenia
Paranoid Type – 35-40% (less
severe)
Preoccupation with one or more
delusions or frequent auditory
hallucinations. No disorganized
speech, disorganized or catatonic
behaviour, or flat or
inappropriate affect.
Catatonic Type – 10%
immobility or stupor excessive
motor activity that is apparently
purposeless, extreme negativism,
strange voluntary movement as
evidenced by posturing,
stereotyped movements, prominent
mannerisms, or prominent
grimacing.
Residual Type – 20%
Absence of prominent delusions,
hallucinations, disorganized
speech, and grossly disorganized
or catatonic
behaviour. Plus presence of
negative symptoms or two or more
symptoms listed in Criterion A for
Schizophrenia
Disorganized Type – 10%
Undifferentiated Type – 20%
Variation between symptoms,
not fitting into a particular type
Must have all; disorganized
speech, disorganized
behaviour, flat or
inappropriate affect and not
meet the criteria for Catatonic
Type.
Schizophrenia: issues surrounding
diagnosis
• There are several issues surrounding the
diagnosis of Schizophrenia that need to be
assessed.
• These include addressing issues
surrounding the reliability and validity of
diagnosis.
DSM- IV
• The Diagnostic and
Statistical Manual of
Mental Disorder (Edition
4), was last published in
1994.
• The DSM is produced by
the American Psychiatric
Association.
• It is the most widely used
diagnostic tool in
psychiatric institutions
around the world.
ICD - 10
• There is also the
International
Statistical
Classification of
Diseases (known as
ICD).
• It is produced by the
World Health
Organisation (WHO)
and is currently in it’s
10th edition.
Reliability and validity of DSM-IV
and ICD-10
• Diagnosing a mental disorder is almost always
done using the DSM-IV and the ICD-10.
• However, there is a risk of using this professional
jargon. (Wording in the manuals is written for
specialists to understand, not laymen).
• The main issues surrounding the diagnosis of
mental disorders centre on the reliability and
validity of the diagnoses.
Inter-rater reliability – do
psychiatrists agree? I wonder what
• Beck et al (1961)
looked at the inter-rater
reliability between 2
psychiatrists when
considering the cases
of 154 patients.
• The reliability was
only 54% - meaning
they only agreed on a
diagnoses for 54% of
the 154 patients!
the other bloke
thinks?
Inter-rater reliability – do
psychiatrists agree?
I really hope I
agree with that
other bloke!
• A true diagnosis cannot
be made until a patient is
clinically interviewed.
• Psychiatrists are relying
on retrospective data,
given by a person whose
ability to recall much
relevant information is
unpredictable.
• Some may be
exaggerating the truth –
or blatantly lying!
Reliability of DSM and ICD
• It was originally hoped that the use of diagnostic
tools could provide a standardised method of
recognising mental disorders.
• However clear the diagnostic tool, the behaviour of
an individual is always open to some
interpretation. The process is subjective.
• The most famous study testing the subjectivity,
reliability and validity of diagnostic tools was
Rosenhan et al (1972).
On Being Sane in Insane Places
• Rosenhan recruited 8 people (he worked with them or
knew him in some capacity).
• Each of the 8 people went to a psychiatric hospital
and reported only 1 symptom. That a voice said
only single words, like “thud”, “empty” or “hollow”.
• When admitted, they began to act “normally”. All
were diagnosed with suffering from schizophrenia
(apart from 1).
• The individuals stayed in the institutions for
between 7 to 52 days.
On being sane… follow up
• Rosenhan told the institutions about his results,
and warned the hospital that they could expect other
individuals to try & get themselves admitted.
• 41 patients were suspected of being fakes, and 19 of
these individuals had been diagnosed by 2
members of staff.
• In fact, Rosenhan send no-one at all!
• A good film to watch: One Flew Over the Cuckoo’s
Nest (is Jack Nicholson’s character mentally ill? Is
he mad, bad or sad? You decide!
What psychiatrists don’t understand
• It is tempting to label a person as a
sufferer of schizophrenia, without
really knowing the extent to which
they are suffering.
• The beliefs and biases of some
might mean the unnecessary
labelling of millions of people as
sufferers of a mental disorder.
• Sometimes a disorder must reach a
particular level of severity before it
can be recognised with confidence
as a mental health issue.
The NHS is a wonderful thing!
• There is limited time and resources available of many
professionals working in the National Health Service.
• Diagnoses can be made by professionals that are rushed,
and preoccupied with only admitting the most serious cases
in order to safeguard the resources of the institution they are
working for.
Meehl (1977)
• Suggests that mental health professionals
should be able to count on the diagnostic
tools if they:
– Paid close attention to medical records
– Were serious about the process of diagnosis
– Took account of the very thorough descriptions
presented by the major classificatory systems
– Considered all the evidence presented to them.
Validity of diagnosis
• Does the system of classification and diagnosis
reflect the true nature of the problems the patient is
suffering; the prognosis (the course that the
disorder is expected to take); and how great a
positive effect the proposed treatment will actually
have.
• Many individuals do not neatly fit into categories
that have been created. Instead of acknowledging
this, clinicians tend to diagnose 2 separate
disorders.
Labelling
• Someone who has suffered a
mental disorder has to disclose
that information in
situations such as job
interviews, or they could face
formal action.
• Unlike influenza, the label of
‘schizophrenic’ stay with a
person.
• Schizophrenics risk carrying
the stigma of their condition
for the rest of their lives.
Cultural Relativism
• Davison & Neale (1994) explain that in
Asian cultures, a person experiencing
some emotional turmoil is praised &
rewarded if they show no expression of
their emotions.
• In certain Arabic cultures however, the
outpouring of public emotion is
understood and often encouraged.
• Without this knowledge, an individual
displaying overt emotional behaviour
may be regarded as abnormal, when it
fact it is not.
Language difficulties
• The clinician might not speak the same language
as the person they are attempting to diagnose.
• Certain things can be ‘lost in translation’
• This could lead to inappropriate treatment or no
treatment at all.
Schneider (1959)
• Proposed a different approach to the diagnosis of
schizophrenia.
• He argued that the nature of the symptom that
would determine whether a person was
schizophrenic.
• He arrived at a number of “first rank symptoms”,
these included thought insertion and thought
broadcast, hearing voices and delusional
perceptions.
• This approach as been criticised as too stringent.
A final thought…
• A person cannot be diagnosed with the
condition if an existing mood disorder has been
diagnosed in the past or if the person is
suffering from this at present.
• It could also be the case that such symptoms are
brought about as a result of another medical
condition or the abuse of illegal drugs or other
medications.
• Organic problems such as brain tumours can
also produce schizophrenic-like symptoms
How to revise this topic:
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DSM IV – written by APA – last published in 1994.
ICD – 10 – written by WHO.
Reliability – Beck (1961) – 54% agreement
Rosenhan study – subjectivity
Issues with severity – unnecessary labelling.
Validity – p’s don’t fit into categories
Labelling/Stigma
Cultural relativism – Davison & Neale (1994)
Schneider (1959) – 1st rank symptoms (too
stringent).
• Other things can produce schizophrenic-like
symptoms.