schizophrenia

• schizophrenia: a severe mental illness, where contact with reality and insight are impaired - it is an example of psychosis

  • a psychotic disorder marked by severely impaired thinking, emotions and behaviours
  • patients are unable to filter sensory stimuli & may have enhanced perceptions of sounds, colours and other features of their environment
• classification of schizophrenia

  + listing an agreed set of symptoms in one place increases the reliability of diagnosis and reduces any chance of the psychiatrist being subjective

  • DSMV - 1 of the positive symptoms must be present for diagnosis
  • ICD - 2 or more negative symptoms must be present for diagnosis
• positive symptoms: symptoms the person did not have before the illness

  • delusions
  • hallucinations
• negative symptoms: symptoms which have made the patient lose something that they had before the illness set in

  • alogia
  • avolition
  • anhedonia
  • emotional blunting/flat effect
• + symptom

  delusions: believing something that is not true

  • grandeur
  • persecution
  • reference
  • nihilism
  • control, influence & passivity
• + symptom

  hallucination: sensing something that is not there; distorted perception of a real stimuli or perceptions of stimuli that no basis in reality

  • auditory
  • visual
  • somatosensory
• -- symptom

  alogia - speech poverty: when speech becomes less fluent and elaborative -> the person demonstrates short replies to questions lacking in depth, in response to slowing or blocked thoughts
• -- symptom

  avolition - apathy: a lack of motivation and drive

  • losing enjoyment in activities that used to be pleasurable
  • inability to cope with the normal pressures and motivations of everyday living and daily tasks
• -- symptom

  anhedonia: inability to feel pleasure in normally pleasurable activities
• emotional blunting/flat effect: not responding to stimuli that would produce an emotional reaction
• DSM V diagnosing schizophrenia

  1. do they have the symptoms?
  2. do their symptoms have a negative effect on the life of the patient?
  3. how long have the symptoms lasted for?
  4. rule out other disorders
  5. rule out known causes
• Stage 1: do have the symptoms?

  2 or more of the following, with at least one of 1-3

  1. delusions
  2. hallucinations
  3. disorganised speech e.g. loose associations; word salad
  4. grossly disorganised or catatonic behaviour e.g. catatonia; stereotypy
  5. negative symptoms
• Stage 2: do the symptoms have a negative effect on the life of the patient?

  patient must experience lower levels of achievement as a result of the illness in 1 or more areas:

  • work
  • relationships
  • self-care
• Stage 3: How long have the symptoms lasted for?

  the patient must have shown continuous signs of disturbance for at least 6 months, with at least one month of continuous symptoms
• Stage 4: rule out other disorders

  there are similar psychotic disorders, such as schizoaffective disorder and mood disorder with psychotic features - these need to be ruled out before a diagnosis of SZ can be made
• Stage 5: Rule out known causes

  A person will not be diagnosed if their symptoms are due to current drug use or a separate medical condition
• diagnosis of subtypes of schizophrenia - categorised depending on the dominant symptom

  • paranoid
  • disorganised/hebephrenic
  • catatonic
  • undifferentiated
  • residual
• paranoid schizophrenia

  • delusions
  • auditory hallucinations
• hebephrenic/disorganised schizophrenia

  • disorganised speech and behaviour
  • flattened or inappropriate affect
  • absence of expressed emotion
  • incoherent speech
  • mood swings
  • social withdrawal
• catatonic schizophrenia: loss of voluntary movements

  • motor disturbances - repetitive movements, prominent mannerisms, total immobility
  • echolalia: involuntary parrot-like repetition of a word/phrase
  • echopraxia: involuntary imitation or repetition of body movements of another person
• undifferentiated schizophrenia: where the symptoms do not fit into the previous 3
• reliability when diagnosing schizophrenia

  • consistency over time: will the same doctor make the same diagnosis a second time, with the same symptoms presented?
  • consistency between doctors: will different doctors agree on the diagnosis of schizophrenia?
• Kleitman identified 3 factors that make the diagnosis of Sz unreliable:

  • differences between clinicians
  • differences between patients
  • differences in the procedures used to assess the patients
• differences between clinicians

  • classification systems make diagnosis clearer, but it can still be interpreted differently by different psychiatrists
  • they may be used to seeing symptoms manifest themselves in different ways if they come from different cultures
  • can cause disagreement in diagnosis -> low reliability
• differences between patients

  role of culture: cultural differences between the patient and doctor affect reliability

  • they may misinterpret behaviour of a patients from a different culture to themselves -> gives a different diagnosis to a psychiatrist that's from the same culture as the patient

  symptom of the day: symptoms displayed on the day of diagnosis can be clear or subtle

  • patient may show clear signs one day and not the next
• differences in procedures used to assess the patient

  • ICD 10, DSM V, CCMD 3
  • they do not all list the same mental illness and the same characteristics for each mental illness
  • this lowers reliability in diagnosis as if different doctors are using different systems, they may end up with different diagnoses
• research to support low reliability in the diagnosis

  • role of culture
  • role of the classification system
  • role of the clinician - subjectivity
• role of culture: a limitation of SZ diagnosis is culture bias

  • symptoms have different meanings in different cultures - Afro-Caribbeans see hearing voices as communication from ancestors - 'hallucinations' -> they are 10x more likely to receive a diagnosis than their white counterparts in the UK, but not in their home country (rules out genetic vulnerability)
  • Escobar: overinterpretation of symptoms of Black british people
  • this means that afro-caribbean people may be discriminated against by a culturally-biased diagnosis system
• role of culture: a limitation of SZ diagnosis is culture bias

  Copeland et al

  • 134 US & 194 UK psychiatrists were given a description of a patient and asked to diagnose the patient using the same classification system
  • 69% of US psychiatrists gave a diagnosis
  • 2% of UK psychiatrists gave a diagnosis
  • supports the idea that the culture of the psychiatrist can be a factor in lowering the reliability of diagnosis
• role of the classification system

  Stephens et al investigates the inter-rater reliability of 9 different classification systems

  • looked to see whether each system would give 283 patients the correct diagnosis
  • found that agreement between the classification systems were poor - the same patient was not given the same diagnosis by each system
  • supports the idea that there's low reliability between different classification systems
• role of the clinician: subjectivity

  Mojtabi & Nicholson investigates how the subjective interpretation of psychiatrists might lead to differences in diagnosis

  • based their study on the idea that clinical characteristics of SZ are verbal descriptions -> open to interpretation
  • gave 50 psychiatrists of delusions and they had to sort them into bizarre and non-bizarre
  • they only had a 40% agreement, supporting the idea that the subjectivity of the psychiatrist can lower the reliability
• validity when diagnosing SZ

  validity refers to whether a psychiatrist is correct in their diagnosis

  • does schizophrenia actually exist as a unitary disorder, where all the sufferers have the same disorder?
  • is diagnosis accurate?
• 3 factors that casts doubts on the validity of diagnosis:

  1. the wide range of experiences
  2. symptom overlap/the similarities with other mental illnesses
  3. co-morbidity
• wide range of experiences

  • a person only needs 2 symptoms to be diagnosed, which means that one sufferer's experience is vastly different to the next person's experience
  • these 2 people may not have a single symptom in common
  • is it fair to say that they have the same illness?
• symptom overlap

  • SZ doesn't have any pathognomic symptoms - symptoms that are exclusive to the disorder
  • this means that all of the symptoms of SZ are also symptoms of other mental illnesses
  • the potential to lower validity as the person could be diagnosed with SZ, when it could be another mental illness
• co-morbidity: when a person suffers with more than 1 mental illness at a time

  • depression, OCD, PTSD and substance abuse are all common in people who are diagnosed with SZ
  • Buckley: SZ patients also have a diagnosis of depression (50%), OCD (23%), PTSD (29%), substance abuse (47%)
  • this makes it hard to see where schizophrenia ends and where other mental illness like depression begins
  • behaviours that are caused by depression might be mistakenly attributed to schizophrenia
• validity concerns whether the psychiatrists are correct in their diagnosis, while reliability concerns whether there is an agreement on diagnosis. 2 or more psychiatrists can all diagnosis a patient consistently with SZ (high reliability), but this diagnosis may actually be incorrect (low validity)
• importance of validity

  • make sure a diagnosis is accurate so that the patient is given the appropriate treatment
  • avoids labelling a person as 'schizophrenic' if there's a chance that they do not have SZ
  • this is because it's a misunderstood condition with a huge negative stigma
  • Thornicroft el al found that since their diagnosis: 47% found it hard to maintain friendships; 43% suffered discrimination from family; 29% found it hard to keep a job
• Rosenhan: research to support low validity in diagnosis

  Him + 8 mentally healthy pseudo-patients went to different psychiatric institutions - they heard 'thud' 'empty' 'hollow. All but 1 were admitted with SZ & the other manic depressive psychosis. Average: 3 weeks, 6 minutes with doctors a day. They told the doctors they felt fine but this was seen as insanity - normal behaviours were deemed insane allowing them to get away with writing notes. Staff were physically and mentally abusive - real patients copied pseudo-patients behaviours allowing them their symptoms to be reduced
• Rosenhan's study

  + supports the argument that there's low validity in diagnosis

  -- caused great controversy

  • •The conclusion seems that Sz is not a valid concept if it can be diagnosed inaccurately HOWEVER, the 9 pseudo-patients did initially say they heard voices -> this study therefore tested the doctor’s ability to detect a lie, rather than their ability to diagnose