Classification and diagnosis of schizophrenia

Homework: 12th November Research methods booklet 2 weeks to complete

Revision sessions Up to Christmas: After Christmas: Friday: Research methods After Christmas: Wednesday: other topics

Diagnosis and classification of SZ

Task In your groups, outline on a sheet of paper, the advantages and disadvantages of using classification systems like the ICD and DSM

Advantages of using classification systems Leads to effective treatment programmes and support which would, otherwise, not be offered Common language among practioners. Facilitates communication and research DSM incorporates a great deal of practical knowledge in a convenient and useful format. It does its job reasonably well when it is applied properly and when its limitations are understood

Problems associated with classification and diagnosis. Diagnosis might lead to labelling and stigmatisation (Scheff 1966) causing long-term problems of getting / keeping employment/relationships. Lead to a self-fulfilling prophecy. The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the changes enhanced pharma profits by adding to an ‘already existing societal overdose of carelessly prescribed psychiatric medicine’. Criticisms of the DSM-5, such as the issue of medicalising mental wellbeing, are legitimate areas of debate. This debate is to be welcomed if doctors are to appreciate the scale of the challenges of better diagnosing, treating and caring for people with mental health conditions.

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. Task…. What is meant by reliability What is meant by Validity Discuss in pairs the difference between the two.

RELIABILITY OF CLASSIFICATION SYSTEMS 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. Level of agreement on the diagnosis by different psychiatrists across time and cultures; stability of diagnosis over time given no change in symptoms Reliability of such questionnaires or scales can be measured in terms of: whether 2 independent assessors give similar diagnosis (inter-rater reliability) whether tests used to deliver these diagnoses are consistent over time (test-retest reliability)

Validity Define the following terms…. Predictive validity Descriptive validity Aetiological validity Criterion validity

Validity In relation to schizophrenia validity refers to the extent to which the classification systems are accurately diagnosing schizophrenia. Reliability – a valid diagnosis has to first be reliable, though this is no guarantee of validity. Predictive Validity – if diagnosis leads to effective treatment, the diagnosis can be seen as valid. Descriptive Validity – to be valid, patients diagnosed with different disorders should differ from each other. (e.g. The description of schizophrenia should match the symptoms shown in individuals). Aetiological Validity – to be valid, all patients with the same disorder should have the same cause. Criterion validity: - to be valid, different assessment criterions should arrive at the same diagnosis

Rosenhan: Being Sane in insane places https://www.youtube.com/watch?v=D8OxdGV_7lo 1960’s anti psychiatry movement https://www.livingwithschizophreniauk.org/information- sheets/the-anti-psychiatry-movement/ Psychiatric classification is unreliable Rosenhan’s 1973 study aimed to investigate the reliability of staff in psychiatric hospitals to identify the sane from the insane. He wanted to see if people who posed as mentally ill would be identified by staff in psychiatric hospitals as sane rather than insane. The participants he used had never been diagnosed with a mental illness.

Rosenhan asked eight ‘sane’ people to telephone psychiatric hospitals for urgent appointments, complaining of hearing unclear voices saying ‘thud, hollow, empty’. All eight were admitted to hospital and all but one was diagnosed with schizophrenia, the other with manic-depressive psychosis. Upon admission, all pseudo-patients stopped showing any symptoms and took part in ward activities. The average length of stay was 19 days. All participants had agreed to stay until they had convinced staff they were no longer ill. On release, the pseudo-patients were given the diagnosis of schizophrenia ‘in remission’. In a second follow up study one hospital was told that sometime over the next three months, one or more pseudo-patients would try to be admitted, and hospital staff were asked to rate the patients who presented themselves on a scale of 1-10 on the likelihood of them being a pseudo-patient. 44% were judged by at least one member of staff to be a pseudo patient. Rosenhan concluded that we cannot reliably distinguish the sane from the insane, and that hospitalisation and labelling can lead to depersonalisation, powerlessness and segregation which are counter- therapeutic.

Research into Reliability/validity of Schizophrenia Diagnosis Task Read pages 12-15, complete the activities and complete the summary box below Research into Reliability/validity of Schizophrenia Diagnosis Researchers What they did / found.......... Reliability/ Validity and WHY Cheniaux % concordance rate between..... Jakobson Rosenhan Birchwood and Iqbal

Rosenhan 1973/77 This study 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. Rosenhan refers to mental health diagnoses as "labels" which are attached to patients. His study shows that these labels are often attached wrongly. He also claims that these labels, once attached, are very hard to change or remove.

However… Seymour Ketty (1974) criticised Rosenhan, saying that, because the pseudopatients were faking an unreal mental condition, it doesn't tell us anything about how people with genuine mental conditions are diagnosed. Kety’s point is that psychiatrist don't expect someone to carry out deception in order to be admitted to a psychiatric hospital. In other words, the study lacked ecological validity.

Discuss reliability and/or validity in relation to the diagnosis and classification of schizophrenia. (Total 8 marks) In pairs, person A: reliability. Person B: validity

Discuss reliability and/or validity in relation to the diagnosis and classification of schizophrenia. (Total 8 marks) Possible Content: Definitions of reliability in relation to diagnosis and classification – level of agreement on the diagnosis by different psychiatrists across time and cultures; stability of diagnosis over time given no change in symptoms Definitions of validity – the extent to which schizophrenia is a unique syndrome with characteristics, signs and symptoms Possible discussion points: Use of evidence on the reliability of major classification systems Use of evidence on reliability of diagnosis between different clinicians and across different cultures Range of different symptoms in different patients – positive and negative symptoms Factors affecting reliability and validity of diagnosis Wider implications of reliability and validity of diagnosis eg labelling

Extra reading Issues with diagnosing and classifying schizophrenia using the DSM/ICD https://www.psychologytoday.com/gb/blog/ds m5-in-distress/201212/dsm-5-is-guide-not-bible- ignore-its-ten-worst-changes https://www.nhs.uk/news/mental-health/news- analysis-controversial-mental-health-guide-dsm- 5/#in-defence-of-the-dsm-5

Store the research Create your own poster/method/revision activity of the research for schizophrenia *We are going to add o this every lesson