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 Experiences of control – believe under control of alien force (smiling after bad news). Auditory hallucinations – bizarre, unreal perceptions, usually auditory. Thought disturbance and disordered thinking – thoughts have been inserted or withdrawn from the mind. Language impairments Disorganised behaviour catatonia – immobility – echopraxia, echolalia Reduction in range and intensity of emotional expression, including facial expression, tone of voice etc Alogia – lessening speech fluency Avolition – reduction or inability to take part in goal directed behaviour. Reactivity is not expected Thought blocking Asocial behaviour Emotional blunting Reflects a loss of normal functions Psychomotor – catatonia – immobility and frenetic activity

Negative symptoms Keyword Symptom Avolition Affective flattening Alogia Poverty of speech, reflecting lack of or blocked thought process 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% Must have all; disorganized speech, disorganized behaviour, flat or inappropriate affect and not meet the criteria for Catatonic Type. Undifferentiated Type – 20% Variation between symptoms, not fitting into a particular 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 the other bloke thinks? 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!

Inter-rater reliability – do psychiatrists agree? 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! I really hope I agree with that other bloke!

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: 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.