Specification details Schizophrenia Link to spec 4.3.5 https://www.youtube.com/watch?v=iasrGrbylIM Pages 200-203 of Year 2 PHG Specification details Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity, culture and gender bias and symptom overlap.

What is it? The term comes from two Greek words: ‘schizo’, meaning ‘split’, and ‘phrena’ meaning ‘mind’ The ‘split’ in schizophrenia occurs between a person’s thought processes and reality.

Schizophrenia Prevalence 1% lifetime risk in general population Holds true for most geographical areas although rates do vary Abnormally high in Southern Ireland, Croatia; significantly lower rates in Italy, Spain (Torrey, 2002) Risk factors include minority ethnicity, urban residence

Schizophrenia onset Source: CIHI (2001)

Prognosis ‘Rule of the thirds’ (rule of thumb): 1/3 recover more or less completely 1/3 episodic impairment 1/3 chronic decline With treatment about 60% of patients manage a relatively normal life Prognosis better in non-industrialised societies

Introduction to schizophrenia task

Classification There are a number of systems by which we can classify abnormal patterns of thinking, behaviour and emotion into mental disorders. These systems not only classify abnormality, but give guidance on how to diagnose them The two most widely used systems of classification and diagnosis are ICD and DSM ICD: International Classification of the Causes of Disease and Death (World Health Organisation) – recognises a range of subtype DSM: Diagnostic and Statistical Manual of Mental Disorder (American Psychiatric Association) – used to also recognize the subtypes but the most recent DSM-5 have dropped these.

Classification Schizophrenia does not have a single defining characteristic. It is a cluster of symptoms some of which appear to be unrelated According to ICD 10, there are five main sub-types of schizophrenia disorder: Disorganised/ Hebephrenic Schizophrenia Catatonic Schizophrenia Paranoid schizophrenia Undifferentiated schizophrenia Residual schizophrenia

Task Using the DSM V and ICD 11, look up the key sub types of schizophrenia and make brief notes on the symptom clusters for each.

Specification details Schizophrenia – symptoms and diagnosis https://www.ted.com/talks/elyn_saks_seeing_mental_illness Pages 186-197 of Year 2 white maskbook Specification details Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity, culture and gender bias and symptom overlap.

Diagnosis – Homework recap In the DSM-5 system one of the so-called positive symptoms (delusions, hallucinations or speech disorganisation) must be present for diagnosis Under ICD, two or more positive symptoms must be present for a diagnosis to be made - only one symptom is needed if the delusions are bizarre, or if the hallucinations consist of a voice commenting on the individual’s behaviour.  

Subtypes of Schizophrenia Paranoid Type Preoccupation with one or more delusions or frequent auditory hallucinations. No disorganised speech, disorganised or catatonic behaviour, or flat or inappropriate affect. Catatonic Type Immobility or stupor excessive motor activity that is apparently purposeless, extreme negativity, strange voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing. Disorganised (hebephrenic) Type Must have all; disorganised speech, disorganised behaviour, flat or inappropriate affect and does not meet the criteria for Catatonic Type. Undifferentiated Type Variation between symptoms, not fitting into a particular type Residual Type Absence of prominent delusions, hallucinations, disorganised speech, and grossly disorganised or catatonic behaviour. A presence of negative symptoms

Disorganised Schizophrenia The person’s behaviour is generally disorganised and not goal directed. Symptoms include thought disturbances (including delusions and hallucinations), an absence of expressed emotion, incoherent speech, large mood swings and a loss of interest in life – social withdrawal. It is usually diagnosed in adolescence/young adulthood

Catatonic Schizophrenia This is diagnosed if the patient has severe motor abnormalities such as unusual gestures or use of body language. Sometimes patients gesture repeatedly, using complex sequences of finger, hand and arm movements, which appear to have some meaning for them. This type often involves doing opposite to what is being asked or repeating everything that is said. The main feature is almost total immobility for hours at a time, with the patient simply staring blankly. Echolalia: The involuntary parrot-like repetition (echoing) of a word or phrase just spoken by another person Echopraxia: The involuntary imitation or repetition of the body movements of another person, sometimes practiced by catatonic schizophrenic patients.

Paranoid schizophrenia This type involves delusions of various kinds (persecution and grandeur); however, the patient remains emotionally responsive. They are more alert than patients with other types of schizophrenia. Paranoid schizophrenics tend to be argumentative. In some ways this is the least serious - but the most well-known. This often has a later onset than other types

Undifferentiated schizophrenia This is a broad, ‘catch-all’ category which includes patients who do not clearly belong within any other category. They show symptoms of schizophrenia but do not fit into the other types.

Residual schizophrenia This is the category that describes people who, although they have had an episode of schizophrenia during the past 6 months and still exhibit some symptoms, these are not strong enough to merit putting them in the other categories. This type consists of patients who are experiencing mild symptoms.

The Signs of Schizophrenia Complete worksheet 8.2 in your workpack.

Symptoms and diagnosis The symptoms of schizophrenia are typically divided into positive and negative Some symptoms are rare in normal, everyday experiences; these are known as positive symptoms (type I). Positive symptoms appear to reflect an excess or distortion of normal function (i.e. delusions and hallucinations) Other symptoms are much less dramatic and can be experienced in everyday life (i.e. loss of energy, reduced personal hygiene); these are known as negative symptoms (type II). While the negative symptoms are less dramatic, they tend to last for longer than the positive symptoms A person may also be affected by secondary impairments such as depression, as a result of the difficulties of living with the disorder (Davison and Neale, 2001)

The positive, negative and secondary symptoms of schizophrenia Hallucinations Delusions Thought disturbances Avolition Speech poverty Lack of expressed emotion Depression Loss of employment Breakdown of relationships While the negative symptoms are much less dramatic, they tend to last for longer than the positive symptoms

EVALUATION Positive symptoms Negative symptoms Can be affected by cultural differences Tend to have greater weight when diagnosing Hard to measure objectively Negative symptoms Start before positive ones Sometimes start years before diagnosis Less affected by cultural factors More objectively measured

Mix and match task

Diagnosing Schizophrenia Worksheet 8.3

The illness usually occurs gradually and has three phases: The prodomal (first) phase The individual becomes withdrawn and lose interest in work, school and leisure activities The active phase More obvious symptoms begin to occur: the duration of this phase can vary; for some people it will last a few months, whereas others remain in the active phase The residual phase The obvious symptoms begin to subside, e.g. when treatment is given One third of schizophrenics regain the ability to function normally, a third are permanently in the active phase, while a third move between the active and the residual phase

Mental Health Act Someone with schizophrenia may not realise they are ill and can refuse treatment when they need it. As a result they can be admitted to hospital against their will and given treatment without their consent under the Mental health Act. This should only happen if their health is at risk, if they are a danger to themselves, or if they may be a danger to others

Specification details Schizophrenia – symptoms and diagnosis https://www.ted.com/talks/elyn_saks_seeing_mental_illness Pages 186-197 of Year 2 white maskbook Specification details Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity, culture and gender bias and symptom overlap.

Recap Case studies Task Work in pairs. Discuss the schizophrenia case studies that you completed last lesson. Are there any differences in your answers? Why might this be?

What is like to live with schizophrenia? Watch this video clip carefully What type of schizophrenia is the man suffering from? What symptoms does he show? Look out for how he perceives his environment Living with schizophrenia

Specification details Schizophrenia –Reliability and validity https://www.youtube.com/watch?v=T0OVhTpNjb4 Pages 186-197 of Year 2 white maskbook Specification details Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity, culture and gender bias and symptom overlap.

Role play – Reliability and Validity We need two volunteers Follow the instructions on the cards

Evaluation - Reliability Reliability – consistency of diagnosis Even if reliability of diagnosis based on classification systems is not perfect, they do provide practitioners with a common language, permitting communication of research ideas and findings, which may ultimately lead to a better understanding of the disorder and the development of better treatments Evidence does generally suggest that reliability of diagnoses has improved as classifications systems have been updated

Evaluation - Reliability Reliability – consistency of diagnosis can be tested in 2 ways First, an important measure of reliability is inter-rater reliability This means that different clinicians make identical, independent diagnosis of the same patient Cheniaux et al (2009)had two psychiatrists independently diagnose 100 patients using both DSM and ICD criteria DSM ICD Psychiatrist 1 26 44 Psychiatrist 2 13 24 Diagnosis of schizophrenia This poor reliability is a weakness of diagnosis of schizophrenia

Evaluation - Reliability Reliability – consistency of diagnosis A Test-retest occurs when a clinician makes the same diagnosis on separate occasion from the same information. Task – Work in pairs to design a piece of research that could test for reliability in the diagnosis of schizophrenia

Issues of validity https://www.youtube.com/watch?v=AVAbNL8mrgk There are several ways in which validity can be assessed. Watch the clip and think about the following: Reliability – a valid diagnosis must first be reliable, though reliability in itself does not guarantee validity will occur. Predictive validity – if diagnosis leads to successful treatment then diagnosis is seen as valid Descriptive validity – to be valid, participants with schizophrenia should differ in symptoms from patients with other disorders Aetiological validity –to be valid, all schizophrenics should have the same cause of the disorder

Evaluation Validity Validity – accuracy of diagnosis An important measure of validity is criterion validity: do different assessment systems arrive at the same diagnosis for the same patient? Compete the tutor2u worksheet Q1-4

Prep Check out the tutor2u study notes on schizophrenia http://www.tutor2u.net/psychology/collections/a-level-psychology-study-notes-schizophrenia

Specification details Schizophrenia –Reliability and validity https://www.youtube.com/watch?v=T0OVhTpNjb4 Pages 186-197 of Year 2 white mask book Prep Tasks Specification details Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity, culture and gender bias and symptom overlap.

Read evaluation extra on page 192 in white mask book Co-morbidity Morbidity refers to a medical condition or how common it is Co-morbidity is the occurrence of two illnesses or conditions together If conditions occur together a lot of the time then this calls into question the validity of their diagnosis and classification because they might actually be a single condition Often people in real life have complex problems and multiple problems rather single problems or problems one at a time like in a textbook Schizophrenia is commonly diagnosed with other conditions - Patients with schizophrenia may also have issues with substance abuse, PTSD or OCD. Mental health tends to be a complex area not a simple one. Read evaluation extra on page 192 in white mask book

Symptom overlap There is considerable overlap of symptoms of schizophrenia and other conditions Both schizophrenia and bipolar disorder for example involve positive symptoms like delusions and negative symptoms like avolition This calls into question, both the validity and the classification and the diagnosis of schizophrenia Under ICD a patient might receive a diagnosis of schizophrenia, however many of the same patients would receive a diagnosis of bipolar disorder under DSM criteria. Read the research and compare to the symptoms of bipolar disorder p 195

Gender bias in diagnosis The tendency for diagnostic criteria to be applied differently to males and females If women are under-diagnosed then this suggests that the validity of the diagnosis of schizophrenia is poor, because the procedures for diagnosis work well only on patients of one gender. Read evaluation extra on page194

Cultural bias in diagnosis The tendency to over-diagnose members of other cultures as suffering from schizophrenia African Americans and English people of Afro-Caribbean origin are several times more likely than white people to be diagnosed with schizophrenia This suggests that the validity of the diagnosis is poor because either it is confounded by cultural beliefs and behaviours in patients, or by a racist distrust of black patients on the part of mental health practitioners. Read and make notes on evaluation extra on page 193

Complete the final sections Q5-6 on the tutor2u worksheet

Timed Essay question Discuss reliability and/or validity in relation to the diagnosis and classification of schizophrenia. [8 marks] http://filestore.aqa.org.uk/resources/psychology/AQA-71823-SMS-2ND-SET.PDF

Complete the yellow box activities Half term Prep Complete the yellow box activities Also - Ensure you have written up your class notes to include the following: A definition of schizophrenia How schizophrenia is classified (ICD and DSM) An explanation of positive symptoms, including hallucinations and delusions. An explanation of negative symptoms, including avolition and speech poverty. Reliability and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity, culture and gender bias and symptom overlap. Read ahead – Biological explanations for schizophrenia