Lesson 1: Issues Associated With The Classification And Diagnosis For SZ

Question 1

What is Schizophrenia?

Answer 1

Schizophrenia is a serious mental psychotic disorder characterised by a profound disruption of cognition and emotion. It is so severe, that it affects a person’s language, thought and perceptions, emotions and their sense of self. It is differed by approx. 1% of the population. The onset of the disorder is between 15 and 35 years of age.

Question 2

Diagnosing Schizophrenia

Answer 2

Two classification systems:
- DMS-5 (Diagnostic and Statistical Manual of Psychiatric Disorders) - used by America
- ICD-11 (International Classification of Diseases) - used by Europe and rest of the world
- DSM-5 states that you need to show at least two or more positive symptoms such as hallucinations or delusions (or one positive and one negative) for a period of 1 month (as well as extreme social withdrawal for at least 6 months) to be diagnosed by schizophrenia.
- ICD-11 states that you need to show one positive and one negative symptom (or two negative symptoms) for at least one month to he diagnosed with schizophrenia
Both ICD and DSM recognises that there are subtypes of schizophrenia by both manuals have deleted these untypes as it made diagnosis more complex

Question 3

Types of Schizophrenia

Answer 3

Crow (1980) made a distinction between two types of schizophrenia: type 1 and type 2
Type 1: characterised more by positive symptoms (addition to an individual’s behaviour) better prospects for recovery
Type 2: characterised by more negative symptoms (loss of aspects of individual’s behaviour e.g. loss of speech) poorer prospects of recovery

Question 4

Positive symptoms

Answer 4

1. Hallucinations - there are sensory experiences of stimuli that have either no basis in reality or are distorted perceptions of things that are there
2. Delusions - irrational, bizarre beliefs that seem real to the person with SZ
3. Disorganised speech - this is the result of abnormal thought processes, where the individual has problems organising his or her thoughts and this shows in their speech. They may slip from one topic to another (derailment), speech might even be incoherent.
   4 - Grossly disorganised/catatonic behaviour - includes the inability or motivation to initiate or complete a task, could lead to problems with personal hygiene or person could be overactive

Question 5

Types of hallucinations

Answer 5

Auditory - person experiences hearing voices making comments (usually criticising them)
Visual - seeing things which are not real
Olfactory - smelling things which are not real
Tactile - touching/feeling things which are not there

Question 6

Negative symptoms

Answer 6

1. Speech poverty (Alogia) - the reduction in the amount or quality of speech. This is sometimes accompanied by a delay in the sufferer’s verbal responses during conversation
2. Avolition - apathy, person finds it difficult to begin or keep up with a goal-directed activity. Sufferers of SZ often have sharply reduced motivation to carry out a range of activities
3. Affective flattening - a reduction in the range and intensity of emotional expression, including facial expression, voice tone, eye contact and body language
4. Anhedonia - a loss of interest or pleasure in all or most activities, or a lack of reactivity to normally pleasurable stimuli/ separated by physical and social

Question 7

Issues (Reliability)

Answer 7

• consistency of a measuring instrument
• e.g. inter-rate reliability - when two or more diagnosticians agree with the same diagnosis for the same individual - diagnosis would be done separately
• Whaley (2001) found the inter-rate reliability between diagnosticians was as low as 0.11+ (using the DSM)
  Another more recent study also showed low inter-rate reliability amongst diagnosticians was carried out by Cheniaux et al (2009). In this study, they had two psychiatrists independently diagnose 100 schizophrenic patients using both ICD and DSM criteria. Inter-rate reliability was poor with one psychiatric diagnosing 26 with SZ according to DSM and 44 according to ICD and the other psychiatrist diagnosing 13 according to DSM and 24 according to ICD. This poor reliability is a weakness of diagnosis of SZ.

*However, a recent study testing the reliability of diagnosis with the DSM found it was very high. For example, Flavia Osario et al (2019) reported that inter rate reliability between pairs of psychiatrists was +0.97 and test-retest reliability was +0.92. Both these figures suggest that the most recent diagnosis of SZ using the DSM was good and reliable.

Question 8

Issues (Validity)

Answer 8

• extent to which we are measuring what we intend to measure
• are we diagnosing schizophrenia correctly based on the symptoms used in the manuals - assessed using criterion validity which is when different assessment systems arrive at the same diagnosis for the same patient
• according to Cheniaux’s study, we can see that SZ is much more likely to be diagnosed using the ICD, suggesting that either SZ is over-diagnosed in ICD or under diagnosed in DSM. This is a sign of poor validity.
• Rosenhan’s study (1973) supports the idea that the validity in the diagnosis of SZ is low since 8 pseudo-patients were able to get themselves admitted into hospitals by using the symptom of hearing voices. During their stay all patients behaved normally and didn’t show signs of mental illness. It was found that all 8 patients stayed in for 7-52 days. All but one patient was discharged with SZ in remission. However, this is an old study suggesting the diagnosis was much poorer in the 1970s as the DSM was not reliable.

However, in a more recent study, Birchwood and Jackson (2001) found that about 20% of patients of SZ show complete recovery and never have another schizophrenia episode. 10% show significant improvement, 30% show some improvement, 40% never really recover. 10% of those 40% are so affected they commit crimes. This great variation in prognosis suggests very poor predictive validity. Although, Mason (1997) found that the use of newer classification systems has improved the predictive validity of diagnosis, particularly when the 6month criteria for diagnosis was used.

Question 9

Issues (Co-morbidity)

Answer 9

• idea that two or more mental disorders occur together at the same time with the same person. If this is the case, then we can question the validity of diagnosis for schizophrenia. In fact, schizophrenia is commonly diagnosed with other conditions.
• 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.
• This poses a challenge for both classification and diagnosis of SZ. In terms of diagnosis if half the patients are diagnosed with SZ and depression, this suggests we are unable to distinguish between both disorders very well.

Question 10

Issues (Symptom overlap)

Answer 10

• there is considerable overlap between the symptoms of SZ and other conditions such as depression and bipolar disorders. For example, a person can show a symptom of SZ and this symptoms will also be in another disorder.
• Ellason and Ross (1995) point out that people with DID actually have more schizophrenic symptoms than people diagnosed with SZ. In fact, most people diagnosed with SZ have sufficient symptoms of other disorders that they could also receive at least one other diagnosis (Read, 2004). This overlap would question the validity of the classification and diagnosis of SZ. E.g. under ICD, a patient might be diagnosed with SZ but under DSM, they are diagnosed with bipolar disorder.

Question 11

Issue (Gender Bias)

Answer 11

• Longenecker et al (2010) reviewed SZ studies since the 1980s and found men more likely to be diagnosed than women. There could be a gender bias in diagnosis as women seem to function better than men, having good family relationships and 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.

Question 12

Issues (Cultural bias)

Answer 12

• African American and English people of Afro Caribbean origin are nine times more likely to be diagnosed with SZ (Pinto Jones 2008). It may be becayse positive symptoms of SZ such as auditory hallucinations may be acceptable in Africa because of cultural beliefs in communication with ancestors 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.

Question 13

Advantages of classification and diagnosis

Answer 13

• 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.