Lesson 1 Schizophrenia

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 perception, emotions and even their sense of self. It is suffered by approximately 1% of the population. The onset of the disorder is between 15 and 45 years of age.

Schizophrenia is a psychotic rather than neurotic disorder – the term psychotic refers to serious mental issues causing abnormal thinking and perceptions and also the fact that people lose touch with reality and even their sense of self. Many people who suffer from schizophrenia end up homeless or hospitalised. It is not uncommon for a person
suffering with SZ to commit or attempt suicide.

Question 2

What is schizophrenia most commonly diagnosed in

Answer 2

Men more than women
Cities rather than the countryside
Working clans than middle class people

Question 3

Diagnosing schizophrenia

Answer 3

Two classification systems are used to diagnose schizophrenia.
1. The DSM 5(The Diagnostic and Statistical Manual of Psychiatric Disorders) – devised by the American Psychological Association (APA) – the DSM is currently now in its 5th edition.
2. The ICD 11 (The International Classification of Diseases) – devised by the World Health Organisation (WHO) - the ICD is currently in its 11th edition.

Question 4

How does DSM 5 diagnose schizophrenia

Answer 4

DSM 5 states that you need to show at least two or more positive symptoms such as hallucinations or delusions for a period of a month

Question 5

How does ICD 11 diagnose schizophrenia

Answer 5

The ICD 11 states you need to show one positive and one negative symptom (or two negative symptoms) for at least one month to be diagnosed with schizophrenia.

Question 6

Subtypes or schizophrenia

Answer 6

Also both the ICD and DSM recognises that there are subtypes of schizophrenia (such as Catatonic Schizophrenia, Paranoid Schizophrenia) but both manuals have deleted these subtypes of schizophrenia as it made diagnosis more complex and had little effect on the treatments.

Question 7

Different types of schizophrenia

Answer 7

Type 1
Type 2

Question 8

Type 1 schizophrenia

Answer 8

Type 1: characterised more by positive symptoms (those which are an addition to an individual’s behaviour) e.g. visual or auditory hallucinations or delusions of grandeur. Generally with this type of SZ, there are better prospects for recovery.

Question 9

Type 2 schizophrenia

Answer 9

Type 2: characterised more by negative symptoms e.g. loss of appropriate emotion of poverty of speech. Generally with this type of SZ, there are poorer prospects for recovery.

Question 10

Symptoms of schizophrenia

Answer 10

Symptoms of SZ are typically divided into positive and negative symptoms. Positive symptoms are those that appear to reflect an excess or distortion of normal functions. Negative symptoms of SZ are those that appear to reflect a reduction or loss of normal functions which often persist even during periods of low (or absent) positive symptoms.

Question 11

Positive symptoms

Answer 11

Hallucinations
Delusions
Disorganised speech
Grossly disorganised or catatonic behaviour

Question 12

Hallucinations

Answer 12

Hallucinations – 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

Delusions – 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 or Napoleon. 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

Disorganised speech – this is the result of abnormal thought processes, where the individual has problems organising his or her thoughts and this shows up in their speech. They 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 like complete gibberish – this is often referred to as ‘word salad’. (this symptom is diagnosed in the DSM but not ICD – extra symptom)

Question 15

Grossly disorganised or catatonic behaviour

Answer 15

Grossly disorganised or catatonic behaviour – 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 – extra symptom)

Question 16

Grossly disorganised or catatonic behaviour

Answer 16

Grossly disorganised or catatonic behaviour – 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 – extra symptom)

Question 17

Negative symptoms of schizophrenia

Answer 17

Speech poverty
Avolition
Affective flattening
Anhedonia

Question 18

Speech poverty

Answer 18

Speech Poverty (Alogia): 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 19

Avolition

Answer 19

Avolition: 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 20

Affective floating

Answer 20

Affective flattening: a 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 (extra symptom)

Question 21

Anhedonia

Answer 21

Anhedonia – 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 (extra symptom)

Question 22

Issues associated with the classification and diagnosis of schizophrenia

Answer 22

There are several issues associated with the classification and diagnosis of SZ such as
1) reliability; 2) validity; 3) co-morbidity; 4) symptom overlap; 5) gender bias and 6)
cultural bias and..

It is worth noting that co-morbidity, symptom overlap, gender and culture bias have a
negative effect on the reliability and validity in the classification and diagnosis of SZ.

Question 23

Reliability

Answer 23

Reliability – consistency of a measuring instrument (e.g. the DSM or ICD). An example of reliability is inter-rater reliability – this is when two or more diagnosticians agree with the same diagnosis for the same individual. The diagnosis would be done separately. Whaley (2001) found the inter-rater reliability between diagnosticians as low as +0.11 (using the DSM). Another more recent study that also showed low inter rater 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-rater reliability was poor with one psychiatrist 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.

Furthermore reliability of SZ diagnosis can also be shown through test-retest reliability – which is when a clinician makes the same diagnosis on separate occasions from the same information. Read et al (2004) reported test-retest reliability of SZ diagnosis to have only a 37% concordance rate, and noted a 1970 study in which 194 British and 134 US psychiatrists provided a diagnosis on the basis of a case description – 69% of the Americans diagnosed SZ but only 2% of the British did so. This suggests that the diagnosis of SZ has never been fully reliable.

Question 24

Validity

Answer 24

Validity – the extent to which we are measuring what we intend to measure. In other words, are we diagnosing schizophrenia correctly based on the symptoms used in the manuals. This 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. Either way, this problem is a sign of poor validity.

One reason why the validity is low 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 the 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 findings of this study were really shocking. 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. This finding was even more shocking since during the subsequent three month period, 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.

However in a more recent study, 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.

Another problem is that patients are more likely to be diagnosed when using ICD rather than DSM as shown in Cheniaux’s study. This shows that the classification systems lack validity and reliability.

Question 25

Co-morbidity

Answer 25

Co-morbidity – the idea that two or more mental disorders (or conditions) 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. Infact, schizophrenia 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.

This 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.

Co-morbidity is therefore a weakness of diagnosis and classification of SZ.

Question 26

Symptom overlap

Answer 26

Symptom overlap – this means that 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 symptom will also be in another disorder. For example, Ellason and Ross (1995) point out that people with DID (Dissociative Identity Disorder) actually having 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. For example, 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 27

Gender bias in diagnosis

Answer 27

Gender Bias in diagnosis – is there a gender bias in the diagnosis of SZ? In other words, does one gender get diagnosed more/less than the other gender and if so why? 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 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 than females.

Question 28

Cultural bias in diagnosis

Answer 28

Cultural Bias in Diagnosis – Is there a cultural bias in the diagnosis of SZ? In other words, does one particular culture get more or less diagnosed than another culture? African American and English people of Afro Caribbean origin are nine times more likely to be diagnosed with SZ. (Pinto and Jones, 2008) Why? 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 29

Advantages of classification and diagnosis

Answer 29

• 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.