1. Specification details
Schizophrenia Link to spec
Pages 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.

2. 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.

3. 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

4. Schizophrenia onset
Source: CIHI (2001)

5. 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

6. Introduction to schizophrenia task

7. 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.

8. 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

9. 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.

10. Specification details
Schizophrenia – symptoms and diagnosis
Pages 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.

11. 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.

12. 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

13. 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

14. 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.

15. 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

16. 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.

17. 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.

18. The Signs of Schizophrenia
Complete worksheet 8.2 in your workpack.

19. 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)

20. 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

21. 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

22. Mix and match task

23. Diagnosing Schizophrenia
Worksheet 8.3

24. Specification details
Living with Schizophrenia
Pages 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.

25. 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

26. 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

27. 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

28. Case studies – Group Task
Work in pairs. Discuss each of the schizophrenia case studies.
Share your ideas with another group. Are there any differences in your answers?
Why might this be?

29. Living with Schizophrenia https://www. ted

30. Prep
Revisit the Rosenhan Study ahead of next lesson

31. Tuesday 6th February 9am in the Old Ref.

32. Specification details
Schizophrenia –Reliability and validity
Pages 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.

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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Prep Complete the PHG worksheet 8.4
Look at the Rosenhan study summary template
Check out the tutor2u study notes on schizophrenia

40. Specification details
Schizophrenia –Reliability and validity
Pages 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.

41. 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

42. 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

43. 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

44. 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

45. Complete the final sections Q5-6 on the tutor2u worksheet

46. Timed Essay question
Discuss reliability and/or validity in relation to the diagnosis and classification of schizophrenia.
[8 marks]

47. 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