- Hallucinations – perceptions that occur without stimuli from the external world.
- Can be auditory, somatic or visual, but usually auditory.
- Voices heard by the schizophrenic are usually persecuting, critical or threatening.
- Delusions – ideas, beliefs or values that the schizophrenic thinks are true, but are impossible or highly unlikely to be so.
- Common types are; persecution, grandeur and control.
- Thought and speech disturbances – illogical thinking and speech. It is confused or difficult to understand.
- It is unconnected and incoherent – hard to make sense of the train of thought.
- Incoherent word salad.
- The person may feel that their thoughts have been inserted/withdrawn from their mind.
- Disorganised behaviour – unpredictible, sudden and unexpected.
- This is the symptom most likely to elicit fear from others.
- Also includes issues such as organising the basics of daily life.
- Excited/wild behaviour = catatonic excitement.
- Avolition/apathy – general loss of energy resulting in a lack of goal-directed behaviour, an inability to complete tasks and a general loss of interest in life.
- Affective flattening – almost total absence of emotional responses which would be considered normal or appropriate.
- Sufferer may not not make eye contact whilst speaking and has an emotionless, monotonous voice.
- Absence of social functions – poor social skills and interactions with others.
- Alogia can occur (speech dramatically reduced in content)
- May be unable to hold down a job, keep friends and maintain intimate relationships.
- Can become isolated as a consequence.
- Wing distinguishes between secondary symptoms and primary as – primary symptoms being part of the disorder, and secondary as resulting from these primary impairments.
- Most common; depression, anxiety, alcohol and substance abuse, and social isolation.
- Sufferers are also more likely to be unemployed due to unreliability or inappropriate behaviour.
Diagnosis of schizophrenia
- Schizophrenia in the 1950s and 60s was diagnosed more frequently than it is today.
- The diagnostic and statistical manual (DSM) is used in the USA.
- The international classification of diseases (ICD) is used in the UK.
- These have much more stringent criteria for a diagnosis of schizophrenia.
- Current diagnostic criteria currently set out in the DSM-IVR:
- A- 2 or more of the following characteristic symptoms, each present for a 1 month period – delusions, hallucinations, disorganised speech, grossly disorganised/catatonic behaviour, negative symptoms.
- B- For a significant period of time since onset, 1 or more major areas of social functioning such as work, interpersonal relations or self care are markedly below the level achieved prior to onset.
- B- Continuous signs of disturbance persist for at least sixth months and must include at least one month of symptoms (or less in successfully treated) that meet criterion A.
Subtypes of schizophrenia
- Type I – pos. symptoms – patient behaves normally, but has hallucinations, delusions, though and speech disturbances and disorganised behaviour.
- Type II neg. symptoms – loss or deficit of normal behavioural patterns.
- Prognosis for type II is lower, so it is therefore, more difficult to treat.
- Most patients have a mixture of positive and negative symptoms, but the prognosis is better for those who have mainly positive symptoms.
- So, Type I sufferers are more responsive to drug treatment and have limbic system abnormalities.
- Type II sufferers suffer from low activity in the frontal lobes (the area responsible for planning, reasoning and decision making) and enlarged ventricles (meaning that there is a deficit in brain tissue).
Types of schizophrenia that appear in the DSM
- Paranoid – preoccupation with delusions/frequent auditory hallucinations.
- Catatonic – At least two of the following present: immobility (including waxy flexibility, which is a decreased response to stimuli and a tendency to remain in an immobile posture) or stupor (a motionless, apathetic state where there is no reaction to external stimuli), excessive motor activity, extreme negativism or mutism, posturing, stereotyped movements, prominent mannerisms/ grimacing, echoalia (repetition of a word or phrase) or echopraxia (repetition of gestures made by others).
- Disorganised – All of the following are prominent: disorganised speech, disorganised behaviour, flat effect.
- Undifferentiated – aforementioned criterion A symptoms are present, but the criteria are not met for disorganised/catatonic.
- Residual – Absence of prominent delusions, hallucinations, disorganised speech, catatonic behaviour. There are neg. symptoms, or 2 or more symptoms listed in criterion in an attenuated form.
Problems/challenges in diagnosis
- Validity – there is some overlap between schizophrenia and other disorders, such as bipolar depression and dissociative identity disorder, making accurate diagnosis very difficult. There is also considerable overlap between different types of schizophrenia in terms of symptoms, such as paranoid and type one. All this considered, these factors may impact on whether a patient receives the correct treatment, which is integral to their recovery.
- Reliability – the criteria for diagnosis doesn’t specify a precise set of symptoms, but say that some from each category need to be present. Lack of precision means that misdiagnosis can occur.
- Rosenhan’s Sane in insane places study demonstrates the unreliability of diagnosis, as there is evidence to suggest that the inter-rater reliability of two psychiatrists diagnosing schizophrenia is exceptionally low (Ie. less than 50%).
- Cultural differences in diagnosis – there is a huge variation between countries – Copeland et al gave a description of a patient to over 100 US and British psychiatrists. 69% of the US psychiatrists diagnosed schizophrenia, but only 2% of the British psychiatrists gave the same diagnosis.
How schizophrenia develops
- Prodomol phase – the sufferer can go to work and engage in leisure activities, as positive symptoms are mild.
- Active phase – there is a range of strong positive symptoms. This phase can last for months, or if untreated, even years.
- Residual phase – the highly obvious and active positive symptoms subside with a return to what seems like the prodomol phase. Negative symptoms persist though, and so the person cannot function adequately socially/at work.
- So, schizophrenia is only clearly diagnosed when it is in the active phase and symptoms are full-blown. Each phase may last for months, or even years. Most sufferers show a degree of residual impairment for many years, if not the rest of their lives after the active phase.
- Some people stay in the active phase for many years and in such cases, the positive symptoms in the early years are replaced by negative symptoms in later years.