Diagnosing and defining schizophrenia

Bleuer  (1911) first used the term 'schizophrenia' to describe a general class of disorders that were characterised by:

• disorganised thought processes
• a split between interlect and emotion
• a split between external reality and interlect

• Auditory hallucinations
• Delusions
• Disordered thinking
• Control
• Emotion and volitional changes

The person 'hears' noises, usually voices in the person's mind, talking to each other or directly to the person.

There are false beliefs that can take many forms: for example, delusions of grandeur (thinking you are God) or delusions of persecution (a belief that others are trying to harm you).

The person feels that their thoughts have been inserted or withdrawn from their mind

The person experiences lack of self-control, although they are under the influence of an alien power

Emotions are 'flat' and the person has little initiative and no energy

Wing (1992) has argued for a distinction between primary impairments, which are intrinsic to the disorder and secondary impairments, which result from primary impairments.

Primary impairments

Hallucinations, delusions, thought disorders, apathy and emotional blunting

lead to -----> 

Secondary impairments

Secondary impairments can be subdivided into:

Social - unemployment, social drift, institutionalisation and rejection or prejudice

Psychological - Dependant, poor coping, loss of confidence and no motivation. 

• Two general patterns are found in schizophrenic symptoms; 'positive-syndrome schizophrenia' and 'negative-syndrome schizophrenia' (Andreasen et al, 1995.)
• Positive symptoms are those that add to normal behaviour or experiences, such as hallucination or delusions, whilst negative-syndrome schizophrenia shows a defiect in normal behaviour, such as lack of emotional expression or communication.
• Most patients exhibit both symptoms, yet it is much worse if they show negative, rather than positive symptoms.

Type I (Positive symptoms)

• Responsive to drug treatment
• Limbic system abnormalities

Type II (negative symptoms)

• Less responsive to drugs
• Abnormalities in the fronal lobes and enlarged ventricles

• There is no universal agreement about simple positive-negative distinction, and some researchers point to a third cluster of symptoms, unrelated to the other two, known as 'disorganised schizophrenia' and is largely associated with chaotic speech and behaviour.
• The distinction between positive and negative symptoms is not a dichotomy, but can be percieved as a continuum with positive and negative at opposite ends.
• The term 'schizophrenia' may be convenient but is also misleading. It is likely that there are severaly different types of servere mental disorder with only one aspect in common - a loss of contact with reality.

The diagnosis of schizophrenia is currently set to the DSM-IVR which refers to characteristic symptoms, social/ occupational dysfunction and the duration of the symptoms. 

The DSM-IVR is the diagnositic and statistical manual, and is widely used for the diagnosis of abnormalities.

Criteria A - Characteristic symptoms

Two (or more) of the following must be present for a one month period: delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, negative symptoms, eg, affective flattening or alogia (speech that is reduced in content).

Criteria B - Social/occupational dysfunction

For a significant portion of time since the onset, one or more major areas of functioning such as work, interpersonal relations, or self care are markedly below the level achieved prior to the onset

Criteria C - Duration

Continuous signs of the disturbance persist for at least six months. This six month period must include at least one month of symptoms (or less if sucessfully treated) that meet Criterion A.

• Paranoid
• Catatonic
• Disorganised
• Undifferentiated
• Residual

Paranoid

There is a preoccupation with one or more delusions or frequent auditory hallucinations. None of the follwing is prominent: disorganised speech, catatonic or disorganised behaviour, or flat or inappropriate affect. 

Catatonic

At least two of the following are present; immobility (ncluding waxy flexibility) or stupor, excessive motor activity, extreme negativism or mustism, posturing, stereotyped movements, prominent mannerisms/grimacing, echolia (repetition of word or phrase) or echopraxia (the repeating of gestures made by others.)

Disorganised

All of the following are prominent; disorganised speech, disorganised behaviour and flat affect

Undifferentiated

Criterion A symptoms are present, but the criteria are not met for the paranoid, disorganised or catatonic type

Residual

There is an absence of prominent delusions, hallucinations, disorganised speech, catatonic behaviour. There are negative symptoms, or two or more symptoms listed in Criterion A in an attenuated form.

• The main symptoms of schizophrenia include hallucinations, delusions, thought disorders and emotional flattening
• The primary impairments can lead to secondary impairments, both social ad psychological
• Subtypes of schizophrenia include Type I, linked to positive symptoms and Type II linked to negative ones.
• Diagnostic criteria for schizophrenia are outlined in the DSM-IVR and include characteristic symptoms, social dysfuntion and duration of the disturbance. Diagnosis leads to classification as a particular type of schizophrenia (eg, paranoid.)