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Schizophrenia: issues surrounding diagnosis

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.

The Diagnostic and Statistical Manual of Mental Disorder (DSM)(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 around the world.

ICD - 10
There is also the International Statistical Classification of Diseases (known as ICD). It is produced by the World Health Organisation (WHO) and is currently in its 10th edition.

Reliability and validity of DSM-IV and ICD-10

Diagnosing a mental disorder is almost always done using the DSM-IV and the ICD-10; although it could be argued that the DSM is the most commonly used. The main issues surrounding the diagnosis of mental disorders such as Schizophrenia centre on the reliability and validity of the diagnoses.

Reliability of Diagnosis
Reliability: Q. Can psychiatrists agree on the diagnosis? A. Generally = NO! Validity: Q. How accurate and meaningful is the research? A. Not very!

Reliability of Diagnosis
Reliability refers to the consistency of measurement in relation to the classification and diagnosis of Schizophrenia in two ways:

Test-retest reliability: occurs when a practitioner makes the same consistent diagnosis on separate occasions from the same information. Inter-rater reliability: occurs when several practitioners make identical, independent diagnosis of the same patient.

Test-retest reliability: Can psychiatrists agree on diagnosis?

Read et al (2004) Reported test-retest reliability of schizophrenia diagnosis to have just 37% concordance rate. They also noted Copeland et als (1974) study where 134 American and British Psychiatrists were asked to diagnose a patient based on a case description.

Test-retest reliability: Can psychiatrists agree on diagnosis?

69% of American psychiatrists diagnosed Schizophrenia v just 2% of British. This suggests that the diagnosis of Sz has never been reliable.

Inter-rater reliability do psychiatrists agree? I wonder what

Beck et al (1961) looked at the inter-rater reliability between 2 psychiatrists when considering the cases of 154 patients. The concordance rate (reliability)was only 54% - meaning they only agreed on a diagnoses for 54% of the 154 patients!
the other bloke thinks?

Soderberg et al (2005) Reported a concordance rate of 81% using the latest version of the DSM, (IV). Q. What does this suggest? Though efforts have been made to bring the two classification systems into line to increase reliability Nilsson et al (2000)found only a 60% concordance rate between practitioners using just the ICD classification system, suggesting that the DSM IV is more reliable.
I wonder what the other bloke thinks?

Contradictory evidence?
Though these findings were contradicted by Jakobsen et al (2005). When testing the reliability of the ICD-10 classification system in Denmark, a concordance rate of 98% was attained. Q. What does this demonstrate?

Alternative Tools
Though attempts have been made to bring these diagnostic tools in line with each other; the differences are still causing problems this led to the development of several other diagnostic tools e.g. St Louis Criteria and PSE. This means that different clinicians using the same criteria arrive at the same diagnosis.

Excellent news!?
Not really. The problem is that as different criteria are still being used to diagnose Sz, it is difficult to research studies.

In studies of treatment outcome e.g. it is difficult to compare data based on individuals who have been diagnosed with Sz based on different criteria.

Excellent news!?
It also highlights the difficulties clinicians have when deciding exactly what they mean by the diagnosis of Sz.

If the categories are poorly designed and arbitrary, consistent (reliable) diagnosis is likely to be low.

As all criteria are fairly arbitrary, often modified and superceded even the updated versions are likely to be low in validity even if more reliable than before.

As a result..
Seto (2004) reports that in Japan, the term Sz has been replaced by ntegration disorder due to the difficulty of attaining reliable diagnosis. Q. What does this suggest?

Totally Useless?
Kendell & Jablensky (2007) In response to the argument that Sz should be abolished as a concept because it is scientifically meaningless, state that diagnostic categories are justifiable concepts, as they provide a useful framework for organising and explaining the complexity of clinical experience, allowing us to derive inferences about outcome and to guide decisions about treatment.

Inter-rater reliability do psychiatrists agree?

I really hope I agree with that other bloke!

Even with physical medical disorders, diagnosis are not always reliable and making reliable diagnosis of Sz is even more problematic as a practitioner has no physical signs only symptoms (what the patient reports) to base their diagnosis on.

Inter-rater reliability do psychiatrists agree?

I really hope I agree with that other bloke!

A true diagnosis cannot be made until a patient is clinically interviewed. Psychiatrists are relying on retrospective data, given by a person whose ability to recall much relevant information is unpredictable. Q. Why? Some may be exaggerating the truth or blatantly lying!

Reliability of DSM and ICD

It was originally hoped that the use of diagnostic tools could provide a standardised method of recognising mental disorders. However clear the diagnostic tool, the behaviour of an individual is always open to some interpretation. The process is subjective. The most famous study testing the subjectivity, reliability and validity of diagnostic tools was Rosenhan et al (1972).

On Being Sane in Insane Places

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.

On being sane follow up

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 send no-one at all! All were genuine patients, suggesting the reliability of SZ diagnosis to be poor.

A good film to watch: One Flew Over the Cuckoos Nest (is Jack Nicholsons character mentally ill? Is he mad, bad or sad? You decide!

- The DSM classification system is often regarded as more

reliable than ICD due to degree of specificity in the symptoms outlined for each category. However, evidence suggests that both are unreliable tools. + Even if reliability of diagnosis based on classification systems is poor, they do at least allow practitioners to have a common language, permitting communication of research ideas and findings, which may ultimately lead to a better understanding of the disorder, and effective treatments. + Evidence generally suggests that the reliability of diagnosis has improved as classification systems have been updated.

Now you have an idea of just how unreliable the diagnosis is how can we treat that which we do not understand? Take a second to think about those being treated with medication for Sz. Q. how can we be sure they have been correctly diagnosed? What about those being denied treatment that they need in order to maintain some Kind of normality in their lives?

Validity of Diagnosis
Soif we cannot agree on what Sz is = point e.g. inconsistent diagnosis How do we treat it = issue e.g. labelling/social stigma

What psychiatrists dont understand

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 which could then become a selffulfilling prophecy(Scheff, 1966). Sometimes a disorder must reach a particular level of severity before it can be recognised with confidence as a mental health issue. It is vital we get this right as labels tend to stick

Validity of Diagnosis
For diagnosis to be valid.. Aetiological Validity: all patients diagnosed as Sz should have the same cause for their disorder. Descriptive Validity: patients diagnosed with different disorders should actually differ from each other. Reduced by comorbidity (two or more disorders simultaneously) suggesting they are not discreet. Predictive Validity: it should lead to successful treatment.

Does the system of classification and diagnosis reflect the true nature of the problems the patient is suffering; the prognosis (the course that the disorder is expected to take); and how great a positive effect the proposed treatment will actually have. Many individuals do not neatly fit into categories that have been created. Instead of acknowledging this, clinicians tend to diagnose 2 separate disorders.

Aetiological Validity
Heather (1976): Argues that only very few causes of mental disorders are known and there is a 50% chance of predicting what treatment a patient will receive based on diagnosis, suggesting that diagnosis of Sz has low validity.

Indeed, in this course we will be covering two causes: Biological and Psychological. Bentall (2003): says the diagnosis of Sz tells us nothing about the cause of the disorder, impying diagnosis to be therefore invalid.

Cultural Relativism
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 abnormal, when it fact it is not.

Cultural Bias?
Whaley (2004): believes that cultural bias is the main reason that the incidence of Sz is greater among black Americans than white Americans, as ethnic differences in symptom expression are overlooked or misinterpreted by practitioners. This suggests a lack of validity in diagnosing Sz cross-culturally Cochrane (1977): Afro-Caribbean people living in UK 7 X more likely to be diagnosed with Sz. Q. why?

Language difficulties
The clinician might not speak the same language as the person they are attempting to diagnose. Certain things can be lost in translation Due to misinterpretation, this could lead to inappropriate treatment or no treatment at all.

Predictive Validity
There is a marked variability in response to treatment (and symptoms) which has led to the development of subtypes of Sz. However, subtypes have been questioned in terms of validity e.g. how many when diagnosed with undifferentiated Sz will be recategorised later when new symptoms appear? Kraeplin (1998): Saw SZ as a chronic deteriorating condition in all cases. This is not true, with many outcomes possible, from complete recovery to chronic suffering, again suggesting diagnosis to be low in validity.

Schneider (1959)
Proposed a different approach to the diagnosis of Sz. He argued that the nature of the symptom that would determine whether a person was schizophrenic. He arrived at a number of first rank symptoms, these included thought insertion and thought broadcast, hearing voices and delusional perceptions. This approach as been criticised as too stringent and did little to improve the predictive validity of Sz.

Descriptive Validity
Allardyce et al (2006): report that the symptoms used to characterize Sz do not define a specific syndrome rather, a number of different combinations and permutations of the defining symptoms are possible, suggesting that Sz is not a separate disorder and that therefore diagnosis of the disorder is invalid. In clinical practice it is often difficult to determine the boundaries between Sz and other disorders e.g. mood disorder, personality disorders and other developmental disorders such as Autism.

Descriptive Validity
It is sometimes possible to use additional tests to make the distinction; however, this is extremely difficult as e.g. depression is comorbid with Sz. The ICD and DSM have tried to address the problem of symptom overlap by proposing mixed disorder categorys e.g. schizo-affective disorder but the validity has been questioned!

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 it sticks! Schizophrenics risk carrying the stigma of their condition for the rest of their lives. YET such diagnosis maybe made with very little evidence of validity in terms of the conditioning existing as a separate one.

How to revise this topic:

DSM IV written by APA last published in 1994. ICD 10 written by WHO. Reliability Beck (1961) 54% agreement Rosenhan study subjectivity Issues with severity unnecessary labelling. Validity ps dont fit into categories Labelling/Stigma Cultural relativism Davison & Neale (1994) Schneider (1959) 1st rank symptoms (too stringent). Other things can produce schizophrenic-like symptoms.