June 10 – unit 4 – Schizophrenia
‘In an important and influential criticism of the diagnosis of mental illness, Rosenhan (1973)
showed that healthy ‘pseudopatients’could gain admission to psychiatric hospitals by
pretending to have auditory hallucinations. Although systems of classification and diagnosis
have changed considerably since the 1970’s, many people still have concerns about their
accuracy and approriatness.’
Discuss issues surrounding the classification and diagnosis of schizophrenia.
(9 + 16)
Schizophrenia has become a label for a severe mental illness often involving a loss of contact
with reality. In addition, it is a highly complex disorder covering a wide variety of symptoms
and types e.g. catatonic, paranoid and disorganised, meaning that classification and diagnosis
is often difficult. Nevertheless, the risk is around 19%and there are no cultural or gender
differences, although onset may occur later in females due to oestrogen which may slow
down brain degeneration, nevertheless this hormone is said to decrease with age.
In terms of symptoms which are used in diagnosis and classification, there are the positive
symptoms which reflect an excess or distortion of normal functions, - hallucinations,
delusions, experiences of control and disorganised thinking. Furthermore, there are also
negative symptoms which in fact reflect a loss or reduction in normal functions e.g. alogia
(the loss of fluent speech) avolition (the loss of motivation) and accecore flattening (a
reduction in the range of emotional intensity).
According to the DSM-IV-TR there are 5 distinct points which must be met for diagnosis to be
made. Firstly, the patient must have been experiencing at least 2 symptoms for 1 month
(N.B. if delusions bizarre one is enough), occupational/social dysfunction , continuous
disturbance over 6 months with one month of symptoms, no other sign of mental illness and
no other known organic cause e.g. drug abuse or brain tumour.
However, issues of classification and diagnosis involve looking at possible problems of
reliability and validity.
In terms of the issues with reliability it is often found that inter-rater reliability is low,
meaning that psychiatrists often have difficulty agreeing on diagnosis. Pre 1970’s a lot more
people were diagnosed in the USA than in the UK, highlighting that classification may not be
reliable. Nevertheless, improvements of the DSM in 1991 led to improvements, but some
reviews of schizophrenia classification has still highlighted the issue of low inter-rater
reliability, however, psychologists now have other diagnostic tools to help improve reliability
of classification and diagnosis e.g. standardised interviewing techniques and computer
software.
Additionally, concerns have been raised about the reliability of symptoms to be used in
classification. Research by Klostercater found that out of 489 admissions to a German unit,
positive symptoms were deemed to be more reliable however, others would argue that
symptoms are too varied and it is too difficult to gain objective information to ever give an
accurate diagnosis. Additionally , further issues of reliability of classification and diagnosis
came from a study which found that even 50 US surgeons could not agree what is in fact
meant by ‘bizarre’ which would again highlight possible problems of reliability.
In addition, research from Rosenhan also highlights the lack of scientific evidence on which
diagnosis is made. He discovered that out of 8 psuedopatients sent to 12 hospitals, 7 were
admitted and it did in fact take an average of 19 days to be discharged, even when they
explained that the symptom of hearing voices saying ‘empty’, and ‘thud’ had gone. As well as
highlighting problems of reliability in diagnosis, this research did in fact also pose ethical
issues as the hospital staff were deliberately deceived. Nevertheless Rosenhan defended
himself, suggesting that a more open study wouldn’t have revealed such striking results.
Lastly problems of reliability were also highlighted in cross cultural research by Coper and
Keno found that when gave the same patient descriptions to 134 USA doctors and 194 UK
doctors, 69% of US doctors diagnosed schizophrenia, compared to only 29% of UK doctors,
highlighting the possible issue of reliability surrounding classification and diagnosis of
schizophrenia.
Additionally, the validity of classification becomes meaningless if deciding who has got it in
the first place is unsure. For example, a review of symptoms, treatments and outcomes
concluded that schizophrenia was not a ‘useful’ category.
In terms of symptoms, validity of diagnosis and classification can be decreased. Schneider
attempted to overcome this issue by producing a list of 1st rank symptoms e.g. hallucinations
and delusions which should be unique to schizophrenia. However, others have criticised this
attempt as symptoms are actually too varied and may actually appear in other illnesses e.g.
bipolar, to be valid in diagnosis.
Additionally there is little evidence to suggest that diagnosis will show the same outcome
(prognosis). For example, around 20% of patients recover, 10% improve, yet some never
make any substantial changes, highlighting that diagnosis and classification has little
predictive validity. Furthermore, there are so many other causes which may influence
recovery e.g. family support, socio-economic status and even age.
To conclude, it is evident that schizophrenia is a highly complex mental disorder, of which
diagnosis and classification are often compromised by the issues of reliability (inter-rater and
symptoms) and validity (symptoms and prognosis). However, it cannot be denied that
diagnosis and classification has improved greatly since the 1970’s.
AO1 – 6
AO2 - 9