Issues in the diagnosis of schizophrenia

Question 1

What are the issues in the diagnosis of schizophrenia?

Answer 1

• Reliability and validity
• Comorbidity
• Overlapping symptoms
• Gender and cultural bias

Question 2

What are the types of reliability?

Answer 2

1. Inter-rater reliability
2. Test-restest reliability

Question 3

What is inter-rater reliability?

Answer 3

Occurs when clinicians make identical, independent diagnosis of the same patient

Question 4

What are the pieces of research for inter-rater reliability?

Answer 4

1. Beck et al found that when a group of 153 patients with schizophrenia were each assessed by 2 different psychiatrists, the diagnosis agreement rate was only 54%
2. Copeland gave a description of a patient to 134 US and 194 British psychiatrists and found that 69% of the US psychiatrists diagnosed the patient with schizophrenia, whereas only 21% of British psychiatrists gave the same diagnosis.

Question 5

What is test-retest reliability?

Answer 5

Occurs when clinicians make the same schizophrenia diagnosis of the patient on separate occasions from the same information.

Although clinicians have detailed manuals to use we must accept that patients with schizophrenia, and their symptoms change with time.

Question 6

If the point is:

A weakness of the reliability of diagnosis is that there is research which reveals the problems with inter-rater reliability of the diagnosis of schizophrenia.

What is the evidence and link?

Answer 6

Evidence- For example, the Copeland study. Copeland gave a description of a patient to 134 US and 194 British psychiatrists and found that 69% of the US psychiatrists diagnosed the patient with schizophrenia whereas only 21% of British psychiatrists gave the same diagnosis.

Link- This shows that American clinicians are far more likely to diagnose schizophrenia than their UK counterparts.

Question 7

If the point is:

A weakness of the reliability of diagnosis is that Read reported that test-retest analysis is as low as 37% for schizophrenia which is extremely concerning, especially when we consider the potential false positives and false negatives this could create.

What is the evidence and link?

Answer 7

Evidence- For example, not making a diagnosis when a person has schizophrenia, leading to them receiving no treatment.

Link- This could imply that this type of reliability is not actually that reliable and should be very careful when it is being used.

Question 8

If the point is:

A strength of the reliability of diagnosis is that a way to improve it has been highlighted by Farmer.

What is the evidence and link?

Answer 8

Evidence- Farmer found that a standardised interview technique, known as the present state examination, increases the reliability of diagnosing schizophrenia. This is because it focuses on the frequency and severity of symptoms, meaning all patients are asked these things.

Link- This suggests that reliability of diagnosis may have some credibility.

Question 9

If the point is:

A strength of the reliability of diagnosis is that the DSM has improved it through revising the criteria.

What is the evidence and link?

Answer 9

Evidence- The DSM has now stripped the criteria from the diagnostic guide, as it was difficult to differentiate between bizarre delusion and non bizarre delusions. For example, within religion.

Link- This supports the notion that the DSM has helped to increase the reliability of diagnosis by adapting and changing certain specific criteria to make diagnosis more consistent.

Question 10

What are the evaluation points for the reliability of diagnosis?

Answer 10

— A study to highlight the problems with inter-rater reliability of the diagnosis of schizophrenia was conducted by Copeland and illustrates how the culture of the clinician can damage inter-rater reliability.

— Read reported that test-retest analysis is as low as 37% for schizophrenia, which is extremely concerning, especially when we consider the potential false positives and false negatives this could create.

+ A way to improve reliability for diagnosing schizophrenia has been highlighted by Farmer.

+ The DSM has improved the reliability of diagnosis through revising the criteria.

Question 11

What can the validity of diagnosis be affected by?

Answer 11

1. Comorbidity
2. Overlapping symptoms

Question 12

What is comorbidity?

Answer 12

• When more than 1 disorder or disease exists alongside a primary diagnosis
• Where 2 conditions are frequently diagnosed together it calls into question the validity of the classification of both illnesses and perhaps the combination of schizophrenia and personality disorder.

(Validity)

Question 13

What are overlapping symptoms?

Answer 13

• None of the symptoms of schizophrenia are exclusive to the disorder, making a valid diagnosis difficult to achieve.
• Bipolar disorder, OCD and autism are amongst many disorders that have overlapping, typical symptoms with schizophrenia.
• It’s estimated that about 13% of the population hear voices but only 1% are diagnosed with schizophrenia.

(Validity)

Question 14

If the point is:

A weakness of validity of diagnosis is that comorbidity reduces the validity of diagnosis, as a clinician could make an inaccurate diagnosis due to the additional disorder.

What is the evidence and link?

Answer 14

Evidence- Buckley et al identified the following comorbid conditions with schizophrenia and argues they could be subtypes of schizophrenia. The following were reported with schizophrenia: 29% PTSD, 50% depression and 47% substance abuse. The prevalence of depression with schizophrenia is widely acknowledged yet poorly understood.

Link- This suggests that close attention should be paid to each behaviour of the individual.

Question 15

If the point is:

A weakness of validity of diagnosis is that we must really reconsider comorbid conditions and schizophrenia, as patients can actually suffer from 2 or more mental health states.

What is the evidence, explanation and link?

Answer 15

Evidence- For example, is it that they have 2 separate conditions, or that they actually have a completely different condition that combines their symptoms. For example, depression and schizophrenia are often comorbid (50%) with patients experiencing low mood alongside psychotic symptoms. However, are these patients just being misdiagnosed and actually have a different condition, such as type 1 bipolar, a mental health condition that incorporates depressive, manic and psychotic episodes.

Explanation- Surely that is a unique condition as opposed to 2 states that coexist and receive 2 separate diagnoses. This has been partly addressed in DSM V, but problems remain with comorbidity and schizophrenia.

Link- Therefore, the validity of diagnosis fir schizophrenia may actually be quite low.

Question 16

If the point is:

A weakness of validity of diagnosis is that overlapping symptoms can decrease the validity of diagnosis, as a clinician may identify symptoms which are common with other disorders.

What is the evidence and link?

Answer 16

Evidence- Konstantareas and Hewitt investigated the symptoms of autistic patients and patients of schizophrenia by comparing 14 male autistic patients with 14 male sufferers of schizophrenia. They found that none of the schizophrenic patients had symptoms of autism, but 50% of the autistic patients had symptoms of schizophrenia (particularly negative symptoms).

Link- This implies that there’s some support for the idea of symptom overlap with schizophrenia.

Question 17

If the point is:

A strength of validity of diagnosis is that classification systems such as the DSM can help to improve the validity of diagnosis due to having to meet more than 1 criteria.

What is the evidence and link?

Answer 17

Evidence- For example, having to have 2 symptoms for over a month and symptoms needing to be present for a certain time frame.

Link- Therefore, this helps to make accurate diagnoses for an area of medicine where the symptoms are not physical, as they are harder to objectively measure.

Question 18

What are the evaluation points for validity of diagnosis?

Answer 18

— Comorbidity reduces the validity of diagnosis as a clinician could make an inaccurate diagnosis due to the additional disorder.

— We must reconsider comorbid conditions and schizophrenia, as patients actually suffer from 2 or more mental health states.

— Overlapping symptoms can decrease the validity of diagnosis as a clinician may identify symptoms which are common with other disorders.

+ Classification systems such as the DSM can help improve the validity of diagnosis due to having to meet more than 1 criteria.

Question 19

What is the Rosenhan study?

Answer 19

1. Sent 8 pseudo patients, none of which had any mental disorders, to 12 psychiatric hospitals without revealing this to the staff
2. In all 12 instances, the patients were diagnosed and sent to hospital and no misdiagnosis was found during hospitalisation.
3. Some pseudo patients discovered significant deficits in patient-staff contact.
4. In a follow up study, professor Rosenhan asked staff to rate patients seeking admission on a 10 point scale (staff were aware of a previous study)- 41% scored 1 or 2 (extremely low) but no pseudo patients were sent in

Question 20

How can cultural interpretations of schizophrenia symptoms affect the diagnosis of the disorder?

Answer 20

Some research shows that religious and cultural groups can have a marked effect on perceptions of schizophrenia, and what can be seen as ‘insane’ in 1 culture may be highly desirable in another

Question 21

What are negative cultural attitudes to schizophrenia?

Answer 21

Psychological distress and mental health issues attract different levels of stigma in different cultures that will clearly affect the diagnosis of schizophrenia

Question 22

How can the culture/nationality of the clinician effect the diagnosis of schizophrenia?

Answer 22

• Can create reliability or validity issues when diagnosing schizophrenia
• Some nationalities diagnose schizophrenia in very different ways (e.g. the US is very likely to diagnose schizophrenia compared to other countries)

Question 23

How is race discrimination evident in diagnosing schizophrenia?

Answer 23

• Some nationalities or countries have considerably more or less cases of schizophrenia than others
• It is perceived that mental health professionals perceive diverse ethnic and cultural groups very differently, and hence discriminate
• To avoid misdiagnosis clinicians should be mindful of subtle prejudices

Question 24

If the point is:

A strength of cultural bias in the diagnosis of schizophrenia is that there is research into cultural differences.

What is the evidence and link?

Answer 24

Evidence- Malagdy’s research showed that different cultures interpret symptoms of mental disorders in very different ways. This research showed that, in traditional Costa Rican culture, hearing voices is interpreted as spirits talking to the individual, whereas in the USA the same phenomenon is interpreted as a core symptom of schizophrenia.

Link- This research implies that differences within cultures may influence diagnosis.

Question 25

If the point is:

A strength of cultural bias in the diagnosis of schizophrenia is that strong practical applications have come from research into it.

What is the explanation and link?

Answer 25

Explanation- Finding cultural biases allows for training psychologists into the differences in interpretation of symptoms in cultures.

Link- This implies that the research can be used effectively to limit cultural biases within the diagnosis of schizophrenia.

Question 26

If the point is:

A strength of cultural bias in the diagnosis of schizophrenia is that there has been further support in research that the culture or nationality of the psychologist or clinician has shown to affect the rate of diagnosis.

What is the evidence and link?

Answer 26

Evidence- Copeland gave a description of a patient to 134 US and 194 British psychiatrists and found that 69% of the US psychiatrists diagnosed the patient with schizophrenia whereas only 21% of British psychiatrists gave the same diagnosis.

Link- This study suggests that American clinicians are far more likely to diagnose schizophrenia than their UK counterparts.

Question 27

If the point is:

A strength of cultural bias in the diagnosis of schizophrenia is that studying the culture allows us to come up with a ‘symptom pool’.

What is the explanation and link?

Answer 27

Explanation- This can be very beneficial for the validity of diagnosis of schizophrenia, as it allows for differences in symptoms in cultures and means that cultural norms can be taken into consideration when a diagnosis is made.

This could imply that studying cultures can provide a quicker and more reliable diagnosis of schizophrenia.

Question 28

What are the evaluation points for cultural bias in the diagnosis of schizophrenia?

Answer 28

+ There is research into cultural differences

+ There are strong practical applications that have come from research into cultural biases of the diagnosis of schizophrenia

+ There has been further support in research of the culture or nationality of the psychologist or clinician has shown to affect the rate of diagnosis

+ Studying culture allows us to come up with a ‘symptom pool’

Question 29

What are the gender biases on the diagnosis of schizophrenia?

Answer 29

1. Unreported facts when diagnosing schizophrenia in men and women
2. Biased research
3. Underdiagnosing of female patients suffering from schizophrenia

Question 30

What are unreported facts when diagnosing schizophrenia in men and women?

Answer 30

• Men suffer more severe negative symptoms than women as well as suffering more from substance related disorders
• Men are more likely to be involuntary committed to psychiatric wards than women

Question 31

What is the biased research into gender biases and the diagnosis of schizophrenia?

Answer 31

Some psychologists claim research into schizophrenia has neglected to use many female patients, questioning its usefulness and representativeness

Question 32

If the point is:

A weakness of gender bias in the diagnosis of schizophrenia is that Cotton’s research implies that women also seem to recover more and suffer less relapse than their male counterparts.

What is the explanation, evidence and link?

Answer 32

Explanation- Ignoring these facts would result in gender bias in clinicians not considering important factors in the diagnosis and recovery from schizophrenia.

Evidence- It could lead to misdiagnosing and the treatment for schizophrenia may not be applicable to treat females as well as males.

Link- This implies that gender bias can be problematic.

Question 33

If the point is:

A weakness of gender bias in the diagnosis of schizophrenia is that there is an issue with who the research has been focussed on.

What is the evidence and link?

Answer 33

Evidence- Nasser found that much of the early research into schizophrenia was conducted with men only. This means lots of research findings concerning treatments and explanations of the disorder may be inappropriate for women. When research focuses exclusively on men it can be accused of androcentrism and lacks generalisability to target populations.

Link- This suggests that early research into schizophrenia lacks reliability due to it not being generalisable and androcentric.

Question 34

If the point is:

A weakness of gender bias in the diagnosis of schizophrenia is that it may be due to the clinician’s preconceptions as to which gender the disorder is more prevalent in.

What is the evidence and link?

Answer 34

Evidence- Loring and Powell randomly selected 290 male and female psychiatrists to read 2 cases. They were then asked to offer their judgements on these individuals using standard diagnostic criteria. When the patients were described as ‘males’ or no information was given about their gender, 56% gave a diagnosis of schizophrenia. However, when the patients were described as ‘females’ only 20% were given a diagnosis of schizophrenia. This gender bias was less prominent with female psychiatrists.

Link- Therefore, far more attention should be paid to females awaiting a diagnosis in order to lead to a successful diagnosis.

Question 35

If the point is:

A strength of gender bias in the diagnosis of schizophrenia is that its research has good practical applications, as it reduces the possibility of diagnoses being made according to gender.

What is the explanation, evidence and link?

Answer 35

Explanation- Research can be used to help train psychologists to not misdiagnose females who have schizophrenia symptoms with other disorders associated with females. This should result in more women receiving the correct diagnosis of schizophrenia. It also means that male patients should not be over diagnosed and should not receive a diagnosis of schizophrenia that is incorrect.

Evidence- The findings from studies such as Loring and Powell can help to show there are biases when diagnoses are made and improve the validity of the process.

Therefore- These practical applications can improve the reliability of a schizophrenia diagnosis and reduce the gender bias.

Question 36

What are the evaluation points for gender bias in the diagnosis of schizophrenia?

Answer 36

— Cotton’s research implies women also seem to recover more and suffer less relapse than their male counterparts.

— There is an issue with who the research has been focussed on.

— There may be a gender bias in the diagnosis of schizophrenia due to clinician’s preconceptions as to which gender the disorder is more prevalent in.

+ Research into gender biases have good practical applications as it reduces the possibility of diagnoses being made according to gender.