L1 - Classification Of Schizophrenia

Question 1

What is schizophrenia?

Answer 1

A serious mental psychotic disorder characterised by a profound disruption of cognition and emotion.

It affects language, thought, perception, emotions, and sense of self.

Question 2

What percentage of the population suffers from schizophrenia?

Answer 2

Approximately 1% of the population.

Question 3

What is the typical onset age range for schizophrenia?

Answer 3

Between 15 and 45 years of age.

Question 4

Who is more commonly diagnosed with schizophrenia

Answer 4

• Men more than women
• In cities rather than the countryside
• Working class more than middle class people

Question 5

2 ways of diagnosing schizophrenia

Answer 5

• Diagnostic statistical manual (DSM 5) - used in America
• International classification of diseases (ICD 11) - used in Europe and the rest of the world
• both recognise there are subtypes of SZ (e.g. catatonic SZ, paranoid SZ) but both have deleted this - makes diagnosis complicated & has little effect on treatment

Question 6

DSM diagnosis

Answer 6

• at least 2 or more +ve symptoms or one positive & negative for a period of 1 month
• also have to show extreme social withdrawal for 6 months

Question 7

ICD diagnosis

Answer 7

• need to show 1 positive & negative symptom (or two negative symptoms) for at least one month to be diagnosed with SZ

Question 8

Types of SZ

Answer 8

• crow (1980) distinguished between two types of SZ:
• Type 1 - characterised by +ve symptoms (addition to behaviour), generally with this type there are better prospects for recovery - known as acute SZ
• Type 2 - characterised by -ve symptoms (loss to behaviour), generally with this food fhsfe are poorer prospects for recovery - known as chronic SZ

Question 9

Types of symptoms of SZ

Answer 9

• positive symptoms - appear to reflect an excess/distortion of normal functions - seen as an addition to normal behaviour
• negative symptoms - appear to reflect a reduction/loss of normal functions which often persist even during periods of low (or absent) positive symptoms

Question 10

Positive symptoms of SZ

Answer 10

• hallucinations
• delusions
• disorganised speech (optional)
• grossly disorganised or catatonic behaviour (optional)

Question 11

Negative symptoms of SZ

Answer 11

• speech poverty (alogia)
• avolition
• affecting flattening (optional)
• anhedonia (optional)

Question 12

Hallucinations

Answer 12

• these are sensory experiences of stimuli that have either no basis in reality or are distorted perceptions of things that are there
  Auditory (hearing) hallucinations - this is when the person will experience hearing voices making comments or talking to them in their head normally criticising them.
  Visual (seeing) hallucinations seeing things which are not real e.g. distorted facial expressions on animals or people
  Olfactory (Smelling) hallucinations smelling things which are not real e.g. a person could be smelling disinfectant which is not real
  Tactile (touching and feeling) hallucinations touching things which are not there for example, bugs are crawling on your skin

Question 13

Delusions

Answer 13

• also known as paranoia – these are irrational, bizzare beliefs that seem real to the person with SZ. These can take a range of forms.
• Common delusions involve being an important historical, religious or political figure such as Jesus
• Delusions also may involve being persecuted perhaps by government, aliens or even superpowers.
• Delusions may involve the body – sufferers may believe that they or part of them is under external control.
• Some delusions can lead to aggression but this is not often.

Question 14

Disorganised speech

Answer 14

• this is the result of abnormal thought processes, where an individual has problems organising his or her thoughts and this shows up in their speech.
• may slip from one topic to another (derailment), even in mid- sentence, and in extreme cases their speech may be so incoherent that it sounds complete gibberish – this is often referred to as ‘word salad’. (this symptom is diagnosed in the DSM but not ICD)

Question 15

Grossly disorganised or catatonic behaviour

Answer 15

• includes the inability or motivation to initiate or even complete a task – this can lead to problems of personal hygiene or the person could be over active and doing loads of different activities simultaneously.
• The person may dress in a bizarre way such as wearing warm clothes on a hot summer’s day.
• Catatonia refers to adopting rigid postures or aimless repetition of the same behaviour. (this symptom is diagnosed in the DSM but not ICD)

Question 16

Speech poverty (alogia)

Answer 16

• SZ is characterised by changes in patterns of speech – meaning the emphasis is on the reduction in the amount and quality of speech.
• This is sometimes accompanied by a delay in the sufferer’s verbal responses during conversation.
• Speech poverty may also be reflected in less complex syntax, e.g. fewer clauses, shorter utterances, etc.
• This type of speech appears to be associated with long illness and earlier onset of the illness.

Question 17

Avolition

Answer 17

• this can sometimes be called apathy – and can be described as finding it difficult to begin or keep up with goal-directed activity, i.e. actions performed in order to achieve a result.
• Sufferers of SZ often have sharply reduced motivation to carry out a range of activities.
• Andreason (1982) identified these signs of avolition; poor hygiene and grooming, lack of persistence in work or education and lack of energy

Question 18

Affective flattening

Answer 18

• reduction in the range and intensity of emotional expression, including facial expression, voice tone, eye contact and body language.
• Individuals who are schizophrenic have fewer body and facial movements and smiles, and less co-verbal behaviour.
• When speaking, patients may also show a deficit in prosody (e.g. intonation, tempo, loudness and pausing) which gives cues to the emotional content of the conversation

Question 19

Anhedonia

Answer 19

• a loss of interest or pleasure in all or most activities, or a lack of reactivity to normally pleasurable stimuli.
• Physical anhedonia is the inability to experience physical pleasures such as pleasure from food, bodily contact etc.
• Social anhedonia is the inability to experience pleasure from interpersonal situations such as interacting with other people

Question 20

Issues associated with the classification & diagnosis of SZ

Answer 20

1) reliability
2) validity
3) co-morbidity
4) symptom overlap
5) gender bias
6) culture bias
- the last four symptoms have a negative affect/causes low reliability & validity

Question 21

Reliability

Answer 21

• consistency of measuring instrument e.g. ICD/DSM or diagnosis
• inter-rater reliability- when 2+ people agree on diagnosis for same person when done individually
• reliability of SZ can also be shown through test-retest reliability - when a clinician makes the same diagnosis on separate occasions from the same information

Question 22

Inter-rater reliability

Answer 22

• Whaley (2001) found it to be as low as +0.11 using DSM
• A more recent study by Cheniaux et al. (2009) used 2 people to diagnose 100 ppt independently
• 1 diagnosed 26 with DSM & 44 with ICD with SZ
• other diagnosed 13 with DSM & 24 with ICD with SZ
• poor reliability is weakness of diagnosis of SZ

Question 23

Test-retest reliability

Answer 23

• Read et al. (2004) reported test retest reliability of SZ diagnosis to have only a 37% concordance rate
• noted a 1970 study where 194 British & 134 US psychiatrists provided a diagnosis on the basis of a case description
• 69% of Americans diagnosed SZ but only 2% of British did
• suggests the diagnosis of SZ has never been fully reliable
• also for different studio different editions of DSM/ICD used - depends whatever is the latest version

Question 24

Counter for reliability

Answer 24

• recent study diagnosing using DSM 5 was very high
• flavia osario et al. (2019) reported inter-rated reliability between pairs of psychiatrists was +0.97
• test-retest reliability was +0.92
• both suggest most recent diagnosis of SZ using DSM is very good & reliable
• as new editions come out they are improved, so better diagnoses

Question 25

Validity

Answer 25

• extent to which we are measuring what we intend to measure, so are we diagnosing schizophrenia correctly based on the symptoms used in the manuals.
• can be assessed using criterion validity which is when different assessment systems arrive at the same diagnosis for the same patient (e.g. both using ICD and DSM – the patient is seen as schizophrenic).
• According to Cheniaux’s study we can see the SZ is much more likely to be diagnosed using ICD than DSM suggesting that SZ is either over diagnosed in ICD and under diagnosed in DSM, this problem is a sign of poor validity.

Question 26

Validity research

Answer 26

• low validity can be explained through a classic piece of research carried out by Rosenhan (1973) – his research is known as ‘on being sane in insane places’.
• Rosenhan aimed to test the validity of SZ diagnosis using DSM (at that time it was in its second version) classification.
  -Eight volunteers who did not suffer with mental illness presented themselves to different mental hospitals, claiming that they could hear voices such as, ‘hollow, empty, thud’.
• All were admitted and acted normally. Time taken to be released and reactions to them were recorded.
• The eight volunteers took between 7 and 52 days to be released, diagnosed as schizophrenics in remission.
• Normal behaviours were interpreted as symptoms of SZ. However, 35 out of 118 actual patients suspected that the volunteers were sane!
• Later a hospital was informed that an unspecified number of pseudo-patients would attempt entry over a three month period.
• The number of suspected imposters were recorded. 193 patients were admitted, of whom 83
  aroused suspicions of being false patients. No actual pseudo-patient attempted admission.
• Rosenhan’s study highlights the reason for why the diagnosis of SZ lacks validity, psychiatrists are unable to distinguish between real and pseudo-patients.
• unethical study, deception, no right to withdraw also un generalisable as only went to 1 state

Question 27

Predicative validity

Answer 27

• Birchwood and Jackson (2001) found about 20% of patients of schizophrenia show complete recovery and never have another schizophrenia episode, 10% show significant improvement, 30% show some improvement.
• 40% never really recover. Of the 40% that never recover, 10% are so affected that they commit suicide.
• This great variation in prognosis suggests very poor predictive validity.

Question 28

Validity counter

Answer 28

recent Osario (2019) study suggests that because the reliability is so high using the DSM, the validity would also be high using this single diagnostic system suggesting that the ICD perhaps need more revision.

Question 29

Co-morbidity

Answer 29

• idea that two or more mental disorders (or conditions) occur together at the same time with the same person.
• If so, then we can question the validity of diagnosis for schizophrenia, it is commonly diagnosed with other conditions.
• In one review Buckley et al. (2009) concluded that around half of the patients with SZ also have a diagnosis of depression (50%) or substance abuse (47%).
• Post- traumatic stress disorder also occurred in 29% of cases and OCD in 23% of cases.
• poses a challenge for both classification and diagnosis of SZ.
• In terms of diagnosis, if half the patients are diagnosed with both SZ and depression, this
  suggests that we are not able to distinguish between both disorders very well.
• In terms of classification, it may be that very severe depression looks like SZ or visa versa, that they may seen as a single condition.

Question 30

Symptoms overlap

Answer 30

• this means that there is considerable overlap between the symptoms of SZ and other conditions such as depression and bipolar disorders.
  E.g a person can show a symptom of SZ and this symptom will also be in another disorder.
  E.g. Ellason and Ross (1995) point out that people with DID (Dissociative Identity Disorder) actually having more schizophrenic symptoms than people diagnosed with SZ.
• most people diagnosed with SZ have sufficient symptoms of other disorders that they could also receive at least one other diagnosis (Read, 2004)
• overlap would question the validity of the classification and diagnosis of SZ.
  E.g under the ICD, a patient may be diagnosed with SZ but under the DSM the same person will be diagnosed with bipolar disorder – because of this overlap, this suggests that SZ and bipolar may not be two disorders but one

Question 31

Gender bias in diagnosis

Answer 31

• Since the 1980s men have been diagnosed with SZ more commonly than women (a ratio of 1.4:1 – Fischer and Buchanan (2017).
• One possible explanation for this is that women seem to function better than men having good family relationships & more likely to work (Cotton 2009).
• Therefore it is less likely to be diagnosed with SZ because women showing better interpersonal function than men.
• Thus, there seems to be a gender bias in diagnosis of SZ with more males getting diagnosed than females

Question 32

Culture bias in diagnosis

Answer 32

• African American and English people of Afro Caribbean origin are nine times more likely to be diagnosed with SZ. (Pinto and Jones, 2008)
• It may be because positive symptoms of SZ such as auditory hallucinations may be acceptable in Africa because of cultural beliefs in communication with ancestors (e.g. hearing their dead ancestors talking to them) which are acceptable and not warranted to a diagnosis in Africa (as SZ rates low in Africa).
• However in the UK, this is more likely to be seen as a positive symptom of SZ. Or, could it be that in Western cultures, we doubt the honesty of black people
  (Escobar, 2012).

Question 33

Advantages of classification & diagnosis

Answer 33

• Communication shorthand: a patient with a mental disorder often has numerous symptoms. It is simpler to incorporate these symptoms into a single diagnosis and this makes communication between mental health professionals much easier
• Treatment: treatments are often specific to certain disorders e.g. symptoms of schizophrenia respond well to certain anti-psychotic drugs but not anti-anxiety. A reliable diagnosis can point to a therapy that will alleviate symptoms.
• Although there is variation, there are many underlying biological abnormalities seen in people with schizophrenia. It is hoped that a greater understanding of these abnormalities will lead to even more effective treatment.