Recognition

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The Perspectives section has tried to explain that there are many ways in which we can understand the causes of an individual's mental distress, and these ways, or 'models' of understanding can lead to sometimes different or contradictory explanations.

What is important to an individual's recovery is that they are helped to come to their own understanding about the causes and maintaining factors associated with their experiences. It is not the role of mental health workers to try to convince them of the rights or wrongs of any one perspective, rather to work with an individuals own beliefs in helping them discover what their experiences mean for them, and how best to minimise any distress arising from them.

For some individuals, a belief in a biological cause and taking medication will be the key to their recovery. For others, an understanding of how their beliefs about themselves and their world lead them to being vulnerable to certain styles of thinking may be central to their recovery.

This section of the NICE Implemetation Resource Tool helps to explain some of the ways in which mental health workers recognise and understand psychosis and schizophrenia. The practice of diagnosing mental illness will be introduced, along with some guidance on where to access further information.

An Introduction

According to the World Health Organization's (WHO) International Classification of Diseases (ICD)-10th Edition, the signs and symptoms for this diagnosis must be present for most of the time during an episode which lasts at least one month.

The most important symptoms and signs include:

• Hallucinations (i.e. seeing, hearing, smelling, sensing, or tasting things that other people do not see, hear, smell, sense, or taste; for example, the person may hear voices which command him or her to behave in certain ways).
• Delusions (i.e. false beliefs that are firmly held despite objective and contradictory evidence, and despite the fact that other members of the culture do not share the same beliefs, for example, the person may believe that he or she is Jesus Christ, or that he or she is being followed, poisoned, or experimented upon).
• Thought disturbances in which the person believes that thoughts are being inserted into or withdrawn from the mind; are being broadcast to others; or are being echoed in the mind.
• Disordered thinking which results in incoherent or irrelevant speech.
• Negative symptoms such as extreme apathy, lack of spontaneous speech, and blunted or inappropriate affect, leading to disturbances in social or occupational functioning (or, if onset is in childhood or adolescence, a failure to reach expected academic, occupational or interpersonal achievement).

There is no single specific symptom that is required for a diagnosis of schizophrenia. In other words, the symptoms experienced by one person may not be exactly the same as the symptoms experienced by another person. However, as a group, people with schizophrenia display an identifiable set of symptoms. If someone exhibits one or more of these symptoms for a specified length of time, he or she may then be regarded as having a diagnosis of schizophrenia.

The American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) [18] is the alternative major diagnostic classificatory system to ICD-10. In DSM-IV, the diagnostic criteria for schizophrenia differ slightly from ICD-10 in relation to the duration of time for which symptoms are required to have been present prior to diagnosis. DSM-IV requires a minimum duration of six months, including a prodromal or residual phase, while ICD-10 requires the persistence of symptoms for only one month. Although acknowledging the existence of a prodromal phase to the disorder, ICD-10 states that the symptoms of the prodrome are not specific to schizophrenia, and hence the inclusion of a prodrome as part of the diagnosis is not justified.

Both DSM-IV and ICD-10 allow the diagnosis to be broken down into the pattern of course of the illness (e.g., chronic or continuous, episodic or with acute exacerbation, in remission, etc.). This breakdown may add further depth to the clinical picture. Individuals wishing to know more about the classification of the course of the illness are advised to consult ICD-10 or DSM-IV.

Subtypes of Schizophrenia

Many attempts have been made to classify schizophrenia into various subtypes although to date there is no consensus about the best system for subtyping schizophrenia. The most widely accepted form of subtyping is that used in both ICD-10 and DSM-IV. The subtypes describe a number of symptom patterns that are, or have been, commonly observed (e.g., paranoia, catatonia, hebephrenia, undifferentiated symptoms, etc.). See ICD-10 or DSM-IV for further details about these subtypes.

Differential Diagnosis

The diagnosis of schizophrenia can only be made when there is no evidence that an organic factor initiated and maintained the disturbance. A neurobiological assessment is usually considered for individuals who are experiencing their first episode of schizophrenia. This assessment will help rule out the possibility of an organic mental disorder.

Psychosis resulting from psychoactive substance abuse (e.g., LSD, cocaine, amphetamines, alcohol, L-dopa, etc.) shares many of the symptoms of schizophrenia, such as hallucinations, delusions, and abnormal speech. Before a provisional diagnosis of schizophrenia can be made, it is best if the individual is free from the effects of drug or alcohol intoxication or withdrawal. Urine sample will detect amphetamines as individuals will not always admit to drug use. Particular attention needs to be given to young people who have a psychosis of sudden onset with no evidence of the usual prodromal symptoms. Psychotic phenomena such as delusions and hallucinations may be present in severe (psychotic) depression and in mania, thus causing diagnostic confusion. Schizophrenia should not be diagnosed if psychotic and affective symptoms are present simultaneously unless it is clear that the symptoms of schizophrenia occurred before the affective symptoms. A manic episode can be differentiated according to the presence of elevated mood and the absence of a gradual accumulation of residual symptoms. In addition, psychotic experiences in the affective disorders are usually consistent with the underlying mood (e.g., delusions that one does not exist in depression and delusions related to self-importance in mania).

Related Disorders

Following are a number of diagnostic categories which may be confused with schizophrenia. Schizoaffective disorder is diagnosed when schizophrenic and affective symptoms (depressive or manic) are both prominent in the same episode of illness, usually simultaneously, but at least within a few days of each other. A diagnosis of schizophrenia alone is not appropriate here (even though criteria for schizophrenia are met) since the diagnosis of schizophrenia would not give a complete picture of the disorder.

Acute and transient psychotic disorder is the appropriate diagnosis when psychotic symptoms are present for less than one month. The onset of symptoms is usually associated with acute psychological stress and occurs over a matter of days (one to two weeks at most), resolving within two to three weeks.

Schizotypal personality disorder and other personality disorders need to be differentiated from schizophrenia. A schizotypal personality disorder should not be diagnosed if the criteria for schizophrenia are met. Schizotypal disorder is characterised by a chronic disturbance (at least two years duration) which includes eccentric behaviour or appearance, odd beliefs and `magical' thinking, cold and aloof affect, social withdrawal, and unusual speech (e.g., vague, digressive, or impoverished). Although transient psychotic symptoms may be present, these symptoms usually disappear within hours or days.

Schizophrenia may be confused with persistent delusional disorder in which a single delusion or set of related delusions is the only, or most conspicuous, characteristic. The content may be persecutory, hypochondriacal , grandiose, or may concern litigation or jealousy. Hallucinations are not typical symptoms of persistent delusional disorder, and there are usually no disturbances in affect, speech, or behaviour.

Problems with 'diagnosis' in mental health

Experiences such as hearing voices , holding unusual beliefs and experiencing marked mood swings are usually thought of as symptoms of mental illnesses and are described using terms from psychiatry - hallucinations , delusions and mania.

The most commonly used diagnoses are schizophrenia and bipolar disorder (manic depression). Psychiatric diagnoses are labels that describe certain types of behaviour and assign them to different categories. They do not tell you anything about nature or causes of the experiences. If care is not taken it may be assumed that diagnostic categories offer an explanation for unusual experiences, rather than merely a short-hand description.

If diagnoses are 'valid', the symptoms should cluster together in a meaningful fashion. However this is not always the case. Many people who hear voices have no other symptoms of 'schizophrenia'. Many people have particular psychotic experiences once but never again, casting doubt on the usefulness of a diagnosis to predict a person's future mental health. Moreover, it does not always follow from a particular diagnosis which medication will be helpful for each individual.

Symptoms  

In psychiatric terms, hearing voices, holding unusual beliefs and experiencing marked mood swings are seen as 'symptoms' of underlying 'mental illnesses'. Therefore, the experiences themselves (hearing voices, holding unusual beliefs or experiencing marked mood swings) are thought of as symptoms, and referred to as hallucinations, delusions and mania respectively. These terms are useful to the extent that different professionals and members of the general public can communicate clearly. However, there are a number of problems with the diagnostic approach. These problems are described in this section

Diagnoses

Again in traditional psychiatric terms, these 'symptoms' are thought of as manifestations of underlying mental illnesses. The most common diagnostic categories used to classify psychotic experiences are schizophrenia, schizo-affective disorder and bipolar disorder or manic-depression.

Benefits of diagnosis

Many people think that diagnoses serve some very useful purposes, including simplifying communication and permitting a relatively brief and straightforward means of describing complex difficulties. Diagnoses are also used by medically trained doctors as a means of deciding upon appropriate treatment. Some people find having a diagnosis reassuring, because it implies that they are not alone in having the experiences, and gives hope that professionals will be able to help.

Problems with diagnosis

The symptom-diagnosis approach to thinking about psychotic behaviour and experiences is well established. Psychiatric diagnoses are labels which describe certain types of behaviour, they do not tell us anything about nature or causes of the experiences. If care is not taken it may be assumed that diagnostic categories offer an explanation for unusual experiences, rather than merely a short-hand description.

The diagnostic approach has not been as useful as was hoped and has been the subject of much scrutiny and debate. In order to understand why, it is helpful to look at the validity of the assumptions underlying the idea and practice of diagnosis.

(un) reliability of diagnosis

The use of diagnostic categories involves two basic assumptions about consistency and usefulness. It is assumed, first , that people can be reliably assigned to a particular category - that two clinicians can agree on which category to use. Early research , however, showed that clinicians often disagreed about psychiatric diagnosis and that diagnostic practices differed from country to country. Clinicians have put a great deal of effort into improving the consistency of diagnosis, most notably through the publication of specific manuals which specify which symptoms an individual must have for a specific diagnosis to be made. The best-known example is the Fourth Edition of the Diagnostic and Statistical Manual of the American Psychiatric Association ,( D S M - I V1 994 ) . However, these efforts have had only limited success in normal clinical practice.

(in) validity of diagnosis

A second set of assumptions about diagnostic categories involves their validity - whether they can be said to be scientifically meaningful and useful. We can look at this issue in several way s .Ideally, the usefulness of a diagnostic category is shown by its ability to predict new observations that cast light on the causes of a person's symptoms. For example, a diagnosis of 'malaria' would suggest that the individual has suffered a viral infection , and even that the person has recently traveled to tropical countries. It also tells you which treatment is likely to help and what the prognosis is. Similar predictions have never been successfully made from any of the psychosis categories.

If a diagnosis is valid, it should predict prognosis. However, as explained above, the outcome for people with a diagnosis of schizophrenia is extremely variable and attempts to define a diagnostic group with a more uniform outcome have not been very successful.

Diagnoses should also indicate what treatments will be effective. However, responses to medication for 'schizophrenia' and 'bipolar disorder' are also variable. For example, drugs such as Largactil (known as 'neuroleptics' or 'antipsychotics') are often thought of as specific treatments for schizophrenia. But not all people with this diagnosis appear to benefit significantly while some people with a diagnosis of affective disorder (traditionally thought of as unrelated to 'schizophrenia') do benefit.

The effectiveness of lithium, a drug traditionally used with people diagnosed as suffering from bipolar disorder, is similarly variable and non-specific. In one study, people were randomly assigned to either a neuroleptic , lithium, both or neither. It was found that drug response was related to specific problems but not diagnoses: delusions and hallucinations responded to the neuroleptic and mood swings responded to the lithium, irrespective of diagnosis. Diagnostic categories are therefore of very limited use in predicting course or outcome.

Another way of examining the validity of diagnostic categories involves using statistical techniques to investigate whether people's psychotic experiences actually do cluster together in the way predicted by the diagnostic approach. The results of this research have not generally supported the validity of distinct diagnostic categories. For example the correlation amongst psychotic symptoms has been found to be no greater than if the symptoms are put together randomly. Similarly, cluster analysis - a statistical technique for assigning people to groups according to particular characteristics - has shown that the majority of psychiatric patients would not be assigned to any recognisable diagnostic group.

Statistical techniques have also highlighted the extensive overlap between those diagnosed with schizophrenia and those diagnosed as having major affective disorder. The central issue in diagnosis is one of classification - the idea that particular psychological problems cluster together and can therefore be considered together. This has been termed 'carving nature at the joints'. This means that it is assumed that the problems called 'schizophrenia' are different from the problems called 'bipolar disorder' in the same way that birds are different from reptiles. On the basis of the evidence reviewed above, many psychologists believe that these distinctions are invalid, that diagnostic approaches to psychological problems do not reflect real 'joints' in nature. [3]