2. In relation to Information to know
their chosen Clinical characteristics of Sz
disorder:
schizophrenia Issues surrounding the classification and diagnosis of including reliability and
validity
Biological explanations of Sz, for example, genetics,
biochemistry
Psychological explanations of Sz; behavioural, cognitive, psychodynamic and
socio-cultural
Biological therapies for their chosen disorder, including their evaluation
in terms of appropriateness and effectiveness
Psychological therapies for Sz, for example, behavioural, psychodynamic and
cognitive-behavioural, including their evaluation in terms of appropriateness
and effectiveness
3. a) Outline clinical characteristics of
schizophrenia. (4 marks)
b) Explain issues of reliability and validity
associated with the classification and
diagnosis of schizophrenia. (4+ 16 marks)
4. Schizophrenia has been variously described as a
disintegration of the personality
A main feature is a split between thinking and
emotion.
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.
They must follow the pattern of symptoms (see
next slide)
5. Positive symptoms are an
excess or distortion of normal
functions which represent a
change in behaviour or
thoughts, to include:
6. An unshakable belief in something that is
very unlikely, bizarre or obviously untrue.
One of the delusions experienced in
schizophrenia is paranoid delusions, where
an individual believes that something, or
someone, is deliberately trying to mislead,
manipulate, hurt or, in some cases, even kill
them.
Another common delusion is the delusion of
grandeur, which is where an individual
believes that they have some imaginary
power or authority, such as thinking that
they are on a mission from God or that
they are a secret agent.
7. Auditary/Visual- usually take the form of
hearing voices that are not there. These voices
are normally critical and unfriendly.
Additionally, some people with schizophrenia
may also see, smell, taste and feel things that
are not there.
8. where an individual behaves in ways that seem
inappropriate or strange to the norms of
society.
9. often known as a „word salad‟, where an
individual speaks in ways that are completely
incomprehensible. For instance, sentences
might not make sense, or topic of conversation
changes with little or no connection between
sentences.
10. are a diminution or loss of normal functions
to include:
A lack, or 'flattening', of emotions, where a
person‟s voice becomes dull and monotonous
and their face takes on a constant blank
appearance.
An inability to enjoy things that they used to
enjoy.
Apathy, where they have a lack of motivation
to follow through any plans and neglect
household chores, such as washing the dishes
or cleaning their clothes.
Social withdrawal, where they find it hard or
become reluctant to speak to people.
12. Explain issues of reliability
and validity associated with
the classification and
diagnosis of schizophrenia.
(8+ 16 marks)
13. 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.
14. Reliability refers to the consistency of a
measuring instrument, such as a
questionnaire or scale, to assess for
example, the severity of the schizophrenic
symptoms.
Reliability of such questionnaires or scales
can be measured in terms of whether 2
independent assessors give similar diagnosis
(inter-rater reliability) or whether tests
used to deliver these diagnoses are
consistent over time (test-retest reliability)
15. The two most widely used
classifications systems for
diagnosis of schizophrenia are:
16. 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
throughout America and
some parts of Europe.
17. International Statistical
Classification of Diseases
(known as ICD)- produced
in Europe by the World
Health Organisation (WHO)
and is currently in it’s 10th
edition.
Used in the UK and many
other European countries
18. DSM IV versus ICD 10
all people diagnosed as suffering from
schizophrenia must have one or more of the
clinical characteristics outlined above
present for at least 6 months
ICD requires the signs to be apparent for one
month.
What are the implications?
19. The ICD classification system appears to
offer some advantage over the DSM
classification:
1. Firstly, with the symptoms only needing to
be present for one month as opposed to six
with the DSM, sufferers do not have so
much time in which they may be at risk to
themselves and others.
2. They also only have to live without help for
one month before receiving diagnosis and
therefore appropriate treatment.
20. DSM – multi-axial ICD-
various factors emphasis on first
considered (bio, rank symptoms-
psychological, social)- ignores the social
takes account the functioning/contex
individual and the
situation rather than t of individual
merely the symptoms
as it assesses the
sufferer‟s social
functioning such as
poverty and
physiological state of
health-therefore- more
informed decision,p303
21. ICD and the DSM do not entirely agree on the
number of subtypes of schizophrenia, with
the ICD suggest seven different subtypes and
the DSM five.
(AO2)The reliability here is questioned as a
sufferer could be diagnosed as one type of
schizophrenic according to the DSM and a
different type according to the ICD.
Implications: incorrect treatment
22. Culturally- biased - created by Americans for
Americans.
Problem- as behaviour in one culture may not
be regarded as a symptom of schizophrenia but
according to the DSM it is. For instance,
hearing voices in some cultures is considered
to be a message and is regarded as an honour-
not a symptom of a mental disorder.
Implication: Incorrect diagnosis- incorrect
treatment (drugs- side effects)
23. Reliabilityof diagnosis in schizophrenia is
further challenged by the finding that there
is massive variation between countries.
24. less
culturally biased - can be applied to
more diverse cultures as the World Health
Organisation (creators of the ICD) are made
up of representatives from 193 countries and
therefore various cultures are represented.
25. Prior to 1970‟s – sig. diff. in prevalence rates of Sz in diff
countries.
In America- DSM –too vague/contained broad diagnostic
criteria. Hampered research into causes and treatments.
In US patients diagnosed with Sz rose from 20% in 1930‟s
to 80% in 1950‟s. In London, diagnosis rate remained
constant throughout same period (Cooper et al 1972)
Copeland (1971) gave 124 US and 194 British psychiatrists
a description of a patient.
- 69% of the US psychiatrists diagnosed schizophrenia
- only 2% of British psychiatrists diagnosed schizophrenia
To eliminate diagnostic diffs, attempts were made to
bring the major systems (ICD-10 and DSM-TR-IV) into line
with one another –became similar- not identical
26. Despite claims for increased reliability in
DSM-III and later versions, 30 years later
there is still little evidence that DSM is
routinely used with high reliability by mental
health clinicians.
27. The problems with the medical classification
were highlighted in the most famous
investigation on hospital practices. “On Being
Sane in Insane Places”, Rosenhan (1973):
An all-time classic study in psychology that
breaks some of the unwritten rules in that
the real participants are the psychiatric
establishment!
Rosenhan (1973) aimed to test the hypothesis
that psychiatrists cannot reliably tell the
difference between people who are sane and
those who are insane
28. 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.
29. 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 sent 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!
31. Thisstudy highlighted the unreliability of
diagnosis. However, this study was conducted
over 30 years ago. Since then manuals have
been improved and diagnostic practise is
very different. For example, categories and
definitions are more detailed and
operationalised and psychiatrists now use
standardised interview schedules when
assessing patients. Also the ICD and DSM have
been bought in line with one another so they
are now very similar.
32. Kurt Schneider (1959)- tried to make the
diagnosis of Sz more reliable:
He identified a group of symptoms
characteristic of S but rarely found in other
mental disorders.
These „first-rank‟ symptoms-useful in helping
clinicians determine the diagnosis of S-
formed the basis of the current ICD-10
classification.
33. Along with the ICD and DSM clinicians use other
diagnostic tools to help diagnose schizophrenia
(e.g. St. Louis Criteria, Schneider
Criteria, Research Diagnostic Criteria). The
fact that other criteria have been developed
makes research comparisons difficult. It also
highlights the difficultly clinicians have when
deciding what exactly they mean by the
diagnosis of schizophrenia. If the categories are
poorly defined and arbitrary, consistent diagnosis
(reliable diagnosis) is likely to be low.
(see Janet Frame p309; Rosenhan -1973)
34. The inter-rater reliability of
two psychiatrists diagnosing
Schizophrenia is exceptionally
low, e.g. less then 50%-suggests
that psychiatrists do not know
what they are doing. Thus
people who do not have
Schizophrenia may be included
in research -may result in
invalid conclusions about the
cause of the „illness‟ and/or
treatment.
35. Beck et al (1961) Found that agreement on
diagnosis for 153 patients (where each was
assessed by two psychiatrists from a group of
four) was only 54%. This was often due to
vague criteria for diagnosis and
inconsistencies in techniques to gather data.
– Inter rater reliability.
Whaley (2001) found inter-rater reliability
correlations in the diagnosis of schizophrenia
as low as 0.11
Incorrect diagnosis -the result of problems
with defining Schizophrenia, e.g. if you
cannot classify Schizophrenia how can you
diagnose it?
36. A true diagnosis cannot be
I really hope made until a patient is
I agree with
that other clinically interviewed.
bloke! 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!
37. 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.
38. Crow (1985) believes that Sz is too broad a term because at least
two very different conditions exist.
Type I syndrome- acute disorder characterised by positive
symptoms ( exaggerations of normal beh.)
Type II syndrome- chronic disorder- negative symptoms such as
flattening of affect, apathy and poverty of speech.
Further evidence for this view comes from research that shows
that Type 1 and Type 2 Schizophrenics do respond very
differently to psychological and biological treatments, e.g.
Typical and Atypical Phenothiazines have more success with
relieving positive symptoms as does CBT.
Problems with above division- people do not fit neatly into
one or other category.
Blurred distinction between some subtypes- some people
diagnosed in one category later develop symptoms from
another- weakens reliability
39. Moreover, Schizophrenia has many different
categories and symptoms, e.g. Paranoid,
Catatonic and Hebephrenic. Some of these
subtypes have very different qualities;
especially Catatonic Schizophrenia where the
person can lay motionless in rigid poses for
days.
40. Validity refers to the extent that a diagnosis
represents something that is real and distinct
from other disorders and the extent that a
classification system such as ICD or DSM
measure what it claims to measure.
Reliability and Validity are linked because if
scientists cannot agree who has Sz (low
reliability) then questions of what it actually
is (i.e. validity) become essentially
meaningless.
41. Schizophrenia-like disorders:
Some indivs show symptoms similar to S- but do
not meet criteria.
ICD/DSM- further set of disorders- linked to
above indivs- include- schizophreniform
psychosis, schizoaffective disorder, schizotypal
disorder, schizoid personality disorder- many
variations-difficult to diagnose indiv presenting
with S –type symptoms.
Doubt about the validity of some of these
classifications- boundary between them blurred.
42. some of the Sz symptoms are found in many
other disorders, such as depression and
bipolar disorder. Ellason and Ross point out
that people with dissociative identity
disorder have more Sz symptoms than people
diagnosed as being schizophrenic! This
affects the validity of the diagnosis.
43. Some psychologists believe that Sz- should be
seen as a dimensional disorder, i.e. Degree
to which problems are experienced, not
simply the presence or absence of such
problems.
E.g. People diagnosed with Sz can experience
one of its main symptoms ( Hearing voices) –
but have developed coping strategies.
44. Sz sufferers- can present with very different
problems.
ICD/DSM- only two very different symptoms need
to be present.
No single underlying cause as all people will
display same set of characteristics. Similarly, all
people do not respond in the same way to
treatments.
Some researchers question the validity of Sz as a
diagnosis- suggest abandoning the
term, (Bentall, 1993). Each of the symptoms
should be seen as a disorder in its own right with
its own cause/treatment
45. Difficultto define boundaries between S and
other disorders, e.g. Mood
disorders, personality and developmental
disorders such as autism. People with
temporal lobe epilepsy often show similar
symptoms to Sz.
Certain prescribed drugs- cause psychotic
behaviour- difficult to distinguish between
drug- induced psychosis and Sz.
Important for clinician – carry out thorough
physical exam and history - for accurate
diagnosis. Evidence that early diagnosis and
treatment- better long term outcome
46. Fairly common to show symptoms of two
mental disorders simultaneously (co-
morbidity). S – can be accompanied by
depression.
Clinicians make dual diagnosis- appropriate
treatment for both disorders
DSM- multi-axial classification system
encourages multiple diagnosis
47. A system for diagnosing schizophrenia cannot be
considered accurate if many cases go
undiagnosed- due to certain social stigmas and
repercussions attached to diagnosing someone
with Sz. Although this can occur all over the
world it is more likely in a country such as Japan
as schizophrenia literally translates to 'disease of
the disorganised mind.'
Kim and Berrios (2001) researched this and found
that in Japan the idea of a 'disorganised mind' is
so stigmatised that psychiatrists are reluctant to
tell patients of their condition. As a result only
20% of those with schizophrenia are actually
aware of it, while the other 80% are left
undiagnosed.
48. 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.
49. 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.
50. Although Sz occurs across cultures- finding in
USA/UK- more frequently among African
American and African- Caribbean pops
Not clear whether it reflects greater genetic
vulnerability, psychosocial factors , minority
groupings or misdiagnosis.
51. 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
abnormalit fact it is not.
52. Clinicianscould misinterpret cultural diffs in
behaviour and expression as symptoms.
Doctors don‟t understand Black cultures and
misdiagnose Schizophrenia, e.g. some
Caribbean cultures believe you should talk to
relatives/friends after they have died.
Psychiatrists in Pakistan, China and India-
think that the west place too much emphasis
on separation of mind and body.
53. 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.
54. Issue
State – Much of the research into the reliability and
validity of the classification systems has been using
ethnocentric samples.
Explain – Much of the research carried out on the DSM-
IV and the ICD-10 has investigated people diagnosed in
Western countries.
Apply – By only using Western samples you cannot get a
clear picture of the reliability and validity of the
classification systems. The reliability of DSM IV and ICD
10 may be much worse than has been found, which
would undermine the use of a classification system at all.
Stretch and Challenge – Psychologists should aim to
investigate the reliability of DSM IV (originally formulated
in the USA) in other non-Western countries to test the
usefulness of a classification system.
