Schizophrenia Diagnosis and Classification - PowerPoint Presentation

1. SchizophreniaDiagnosis and Classification

2. Starter Activity: General DiscussionDid you have any misconceptions about schizophrenia before you studied it for homework?Had you heard of any of the symptoms before?Were there any symptoms that you were surprised were associated with schizophrenia?

3. Classification of Schizophrenia: Matching ActivityComplete the activities in pairs, without using your notes:Using the worksheet, match the terms in the left-hand column of the worksheet with the definitions on the right-hand columnCan you define what a positive symptom is and what a negative symptom is? (write on the back of your sheet)From the front of the sheet, highlight two positive characteristics in one colour, and two negative characteristics in anotherThe characteristics that you must learn for the exam are: Hallucinations, delusions, speech poverty and avolition. The rest are optional

4. You are going to watch a video clip featuring four schizophrenic patients. In your groups, get four MWBs and, write down a different name at the top of each board:ColinJackAnnieJohnClassification of Schizophrenia: Video Case StudiesTASK: As they are speaking, write down under their name the symptoms you think they are displaying, and give examples from their behaviour that has led you to believe they are experiencing that particular symptom. Use the symptoms matching worksheet to help you

5. You will now have a few minutes to discuss each case in your groups, and add to your boards, before you feed back on each oneClassification of Schizophrenia: Video Case Studies FeedbackWhat did you have for Colin?

6. You will now have a few minutes to discuss each case in your groups, and add to your boards, before you feed back on each oneClassification of Schizophrenia: Video Case Studies FeedbackWhat did you have for Jack?

7. You will now have a few minutes to discuss each case in your groups, and add to your boards, before you feed back on each oneClassification of Schizophrenia: Video Case Studies FeedbackWhat did you have for Annie?

8. You will now have a few minutes to discuss each case in your groups, and add to your boards, before you feed back on each oneClassification of Schizophrenia: Video Case Studies FeedbackWhat did you have for John?

9. Complete the following question individually without notes:Janelle has been diagnosed as suffering from schizophrenia. It began when she started hearing voices in her head criticising her behaviour and she became convinced that she’d been chosen by alien beings for a special purpose. Friends noticed that it became increasingly difficult to make sense of Janelle’s speech and she would give only brief answers to their questions. She also became untidy and unenthusiastic about life in general, spending hours pacing up and down her roomDescribe one positive and one negative symptom of schizophrenia. Make reference to Janelle in your answer (4 marks)Now swap your answer with the person sitting next to you and award a mark out of 4 using the guidance on the next slideClassification of Schizophrenia: Exam Practice

10. Positive symptoms:One positive symptom of schizophrenia is hallucinations, which are unreal perceptions of external stimuli and may be auditory, visual, olfactory or tactile (1 mark). Janelle is experiencing auditory hallucinations as she is hearing voices in her head criticising her (1 mark)OrOne positive symptom of schizophrenia is delusions, which are false beliefs that the individual has about themselves or the world (1 mark). Janelle is experiencing delusions because she believes that she has been chosen by aliens for a special purpose (1 mark)Exam Practice: Mark Scheme

11. Negative symptoms:One negative symptom of schizophrenia is Alogia (speech poverty), which is where there is a lessening of speech fluency and productivity (1 mark). Janelle is experiencing Alogia, as she is only giving brief answers to her friends’ questions (1 mark) OrOne negative symptom of schizophrenia is avolition, where there is a reduction of, or inability to engage in goal-directed behaviour (1 mark). Janelle is experiencing avolition as she is unable to tidy up and does not feel enthusiastic about life (1 mark)Exam Practice: Mark Scheme

12. Reliability & Validity in Diagnosis & ClassificationAnswer the following questions in pairs:How do clinicians make a diagnosis of schizophrenia? Clinicians (doctors) use the ICD (Europe) and the DSM (USA) to diagnose schizophreniaUsing what you remember from your preparation homework, list the reasons why diagnosis and classification of schizophrenia is difficultDid you have: Overlap of symptoms; co-morbidity; gender bias; culture bias

13. Rosenhan’s (1973) study being sane in insane places was one of the first to recognise that psychiatrists and their diagnoses might not be perfectReliability & Validity in Diagnosis & Classification: Rosenhan’s studyWatch the clip of Rosenhan’s study. You will be asked some questions about what you seeNow discuss and answer the following questions in pairs on MWBs:What type of observational technique was used in this study?What evidence was there that the diagnosis of schizophrenia lacks validity What evidence was there that the diagnosis of schizophrenia lacks reliability?

14. ValidityThe mental health professionals failed to distinguish between ‘real’ and ‘fake’ patients.‘Normal’ behaviour was misinterpreted as ‘abnormal’ to support their idea that pseudo patients had a mental illness (researcher bias) In the follow up study - 44% were judged by at least one member of staff to be a pseudo patient but Rosenhan did not send any pseudo-patients Reliability & Validity in Diagnosis & Classification: Rosenhan’s StudyReliability7 of the pseudo-patients were diagnosed with schizophrenia but 1 was diagnosed with manic-depression, even though they all displayed the same symptom

15. Answer the following questions in pairs:Reliability & Validity in Diagnosis & Classification: Key TermsWhat does the term reliability mean in the context of schizophrenia diagnosis?It refers to the consistency of the diagnosisHow might the consistency of the diagnosis be measured?Through inter-rater reliability, i.e. the extent to which two clinicians would be consistent in their diagnosis of the same patientWhat does the term validity refer to in the context of the schizophrenia diagnosis?It refers to how accurate the diagnosis isHow might we measure the accuracy of the diagnosis?Through concurrent validity: The two systems should be coming up with the same diagnosis for the same patientThrough predictive validity: For the diagnosis to be a useful tool, we should be able to predict the course of the illness and treatment outcomes

16. Cheniaux et al (2009) had two psychiatrists independently diagnose 100 patients using both DSM and ICD criteriaReliability & Validity in Diagnosis & Classification: Research Evidence Psychiatrist 1Psychiatrist 2DSM2613ICD4424Comment on what the results in the table suggest about the validity and reliability of the diagnosis (use what you have learned about assessing the validity and reliability of a test)The systems have low concurrent validity. Diagnosis is more likely with ICD than with DSMThere is low inter-rater reliability for both systems, but it is slightly poorer with ICD (50%) than DSM (54%)

17. Research into inter-rater reliabilitySoderberg et al. (2005) reported a concordance rate of 81% using the DSM classification system Nilsson et al (2000) found a 60% concordance rate between practitioners using the ICD classification systemReliability & Validity in Diagnosis & Classification: Research EvidenceWhat do these results tell us about the inter-rater reliability of the two systems?DSM appears to be more reliable than ICD

18. Birchwood and Jackson (2001) argue that 20% of schizophrenics recover and never have another episode but 10% are so affected they commit suicideReliability & Validity in Diagnosis & Classification: Research EvidenceInterpret these results. Do they relate to reliability or validity? Explain your answer

19. One of the issues with diagnosing schizophrenia accurately, is that it has symptoms in common with lots of other disorders. This can make it difficult to decide whether the person is suffering from schizophrenia, or another illnessIn your groups, draw out the Venn Diagram on BWBs and see if you can place the number of each symptom provided in the right place on the diagramReliability & Validity in Diagnosis & Classification: Symptom OverlapDepressed mood most of the dayAffective flatteningAlogia (speech poverty)Period of mania (elevated mood)Psychomotor disturbancesInsomnia/ hypersomniaSubjective experience that thoughts are racingInflated self-esteem and feelings of grandiosityDelusionsInability to do everyday tasksDifficulty concentratingFeelings of worthlessnessExcessive involvement in pleasurable activitiesHallucinationSignificant weight loss or weight gainRecurrent thoughts of suicide

20. Reliability & Validity in Diagnosis & Classification: Symptom Overlap AnswersSchziophrenia onlySchiz and bipolarBipolar onlyBipolar + depressionDepression onlyDepression, schiz, bipolar2 Affective flattening9 Delusions4 Periods of mania1 Depressed mood most of the day1 Depressed mood most of the day, no mania10 Inability to do everyday tasks3 Poverty of speech14 Hallucinations13 Excessive involvement in pleasurable activities15 Significant weight loss/gain11 Difficult concentrating5 Psychomotor disturbance6 Insomnia/hypersomnia7 Subjective experience- thoughts racing12 Feelings of worthlessness8 Inflated self esteem16 Recurrent thoughts of suicide

21. So what we have learned is that many symptoms of schizophrenia are also found with other disorders such as bipolar disorderThis would affect the validity of diagnosis, but why and how?Different diagnoses could be given to those with the same symptoms. In one instance, they could be diagnosed with schizophrenia, and in another they could be diagnosed with bipolar disorderHow might this impact on the patient?The diagnosis will have an effect on the treatments offered, therefore a misdiagnosis would result in inappropriate treatment, which would be ineffective and in some cases could have very serious consequencesReliability & Validity in Diagnosis & Classification: Symptom Overlap

22. Based on what you remember from the preparation work, complete the following quiz in pairs on MWBs:1. With reference to schizophrenia, explain what is meant by co-morbidity (1 mark) Co-morbidity is where 2 or more conditions occur together2. According to Buckley, what percentage of people with schizophrenia are also diagnosed with: Depression, substance abuse, PTSD and OCD? (4 marks) 50%, 47%, 29%, 23%3. how many people from a sample of 2000 patients with a diagnosis of schizophrenia also have OCD (2 marks) 2000/100 x 23 = 460 patients4. What is the ratio of patients with co-morbid OCD to those with co-morbid substance abuse (2 marks) 2000/100 x 47= 940 patients 940:460, 47:235. What does this suggest about schizophrenia? (1 mark) That it may not be a stand alone, separate disorderReliability & Validity in Diagnosis & Classification: Co-Morbidity

23. In pairs on MWBs, list all the reasons you can think of that would possibly explain co-morbidity in people with schizophreniaThe strain of living with schizophrenia makes the person more vulnerable to other disorders (e.g. depression)Because of the issue of symptom overlap, doctors find it difficult to tell the difference between the disorders, and therefore the patient ends up being diagnosed with bothThe high rate of co-morbidity may suggest that schizophrenia is not a separate disorder, but part of another condition, which would mean that the DSM and ICD need to change Reliability & Validity in Diagnosis & Classification: Co-Morbidity

24. Read the following information:Cochrane (1977) reported the incidence of schizophrenia in the West Indies and Britain to be similar, at around 1%, but that people of African-Caribbean origin are 7 times more likely to be diagnosed with schizophrenia when living in BritainThey are also more likely to be confined to a secure unit (There are very few recent studies looking at the prevalence of mental health conditions in the BAME population, but there is some evidence that rates of psychosis are still higher in British people from a BAME background than for white British people)Reliability & Validity in Diagnosis & Classification: Culture BiasDiscuss the following in your groups:Why does Cochrane’s research suggest that there is culture bias in the diagnosis, rather than people from a West Indian background being more susceptible to schizophrenia?Because if people of African-Caribbean descent were more susceptible to schizophrenia, we would expect to see a high rate in the population of the West Indies, which is not the caseTherefore, It must be down to the way clinicians are diagnosing this group of people, suggesting that the diagnosis lacks validity

25. In pairs, on MWBs, list all the reasons you can think of that would explain why black people are more likely to be diagnosed with schizophrenia, and more likely to be confined in a secure unitIt could be that heightened stress levels for black people living in Britain, due to being in a minority group, lead to higher incidence of schizophreniaMost doctors in Britain are white, and may perceive black schizophrenics to be more dangerous, due to underlying racism, and therefore are more likely to commit them to an institutionRack (1982) points out that in many cultures it is normal to see and hear recently deceased loved ones, but this may be considered part of a mental illness in BritainReliability & Validity in Diagnosis & Classification: Culture Bias2 & 3 would suggest a lack of validity in the diagnosis due to bias on the part of the clinician (2) or society (3). 1 would suggest that the diagnosis is correct, but that there is a problem in society, that needs addressing, that is leading to a higher rate of mental illness in the black populationDiscuss in pairs: Which of the above points would suggest that there is a problem with the validity of the diagnosis?

26. Reliability & Validity in Diagnosis & Classification : Exam PracticeIn pairs, write a snap plan for the following essay:Discuss reliability and/or validity in relation to the diagnosis and classification of schizophrenia.(Total 8 marks)

27. Mark scheme suggestions:AO1: 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 symptomsDefinitions of validity – the extent to which schizophrenia is a unique syndrome with characteristics, signs and symptomsIdentification of issues such as range of symptoms across individuals, comorbidity and symptom overlapReliability & Validity in Diagnosis & Classification : Exam PracticeAO3: Possible discussion points:     Use of evidence on the reliability of major classification systems (ICD IV, DSM IV or V)Use of evidence on reliability of diagnosis between different clinicians and across different culturesRange of different symptoms in different patients – positive and negative symptomsEvidence on comorbidity with eg depression, mixed syndromes eg schizo-affective disorder, symptom overlap eg bipolar disorderFactors affecting reliability and validity of diagnosisWider implications of reliability and validity of diagnosis eg labelling, cultural bias

28. In pairs, on MWBs, write a definition of the following terms:Gender biasThe differential treatment and/or representation of males and females based on stereotypesAlpha biasAn exaggeration of the differences (between the sexes)Beta biasA minimisation of the differences (between the sexes)AndrocentrismA focus on the male viewpoint, for example, only studying malesReliability & Validity in Diagnosis & Classification: Gender Bias

29. Watch the clip relating to issues with female diagnosis of schizophreniaNow answer the following questions, in pairs, on MWBsWhat was the figure for differences in males and females having schizophrenia?Do you think that this means more males have schizophrenia? (give a reason for your answer)How could what you have seen in this clip explain why males are diagnosed more than females?Reliability & Validity in Diagnosis & Classification: Gender BiasFemales may have better social functioning, they are less likely to engage in anti-social behaviour and substance misuse, they are less affected by lack of expressing emotionsMales are 1.4 times more likely to be diagnosed

30. Research evidence:Long & Powell (1988) randomly selected 290 male and female psychiatrists to read two cases of ‘a patient’s behaviour’When the patient was described as male, (or no gender), 56% gave a schizophrenia diagnosisWhen the patient was described as female, 20% gave a diagnosisInterestingly, this gender bias was not evident among the female psychiatristsReliability & Validity in Diagnosis & Classification: Gender BiasHow does this finding link to the validity of the diagnosis? Write a statement, in pairs, on MWBs

31. Research evidence:Clinicians often fail to consider that males tend to suffer more negative symptoms than women (Galderisi et al, 2012) and women typically function better than men (Cotton et al, 2009)Reliability & Validity in Diagnosis & Classification: Gender BiasOn MWBs: What does the research suggest is the cause of differences in diagnosis between males and females? How does it link to the concepts of androcentrism and beta bias? What are the possible consequences for females?It explains why women may not get diagnosed, but it suggests that there may not be an actual difference in prevalence of schizophrenia between the sexes, just in the rate of diagnosisThe classification of schizophrenia may be considered to be androcentric because it is based on the way it manifests itself in males (androcentrism), and the differences in how it manifests itself in females is ignored (beta bias)This could lead to a serious disadvantage for females, because they will not receive appropriate treatment for their symptoms

32. Read through the model essay and highlight what you consider to be the AO1 contentNow check against the highlighted model. Did you get it right?Reliability & Validity in Diagnosis & Classification : Model EssayModel Essay

33. In your groups: State whether you think each of these items relates to the validity (predictive or concurrent?) or Reliability (test-retest or inter-rater?) and whether it is a  or Reliability & Validity in Diagnosis & Classification: A quick quizDerek has been to see Dr Padawi who diagnoses schizophrenia; Dr Padawi asks Dr Ahmed to also see Derek to see what she thinks; she also diagnoses schizophrenia Inter-rater reliability 

34. In your groups: State whether you think each of these items relates to the validity (predictive or concurrent?) or Reliability (test-retest or inter-rater?) and whether it is a  or Reliability & Validity in Diagnosis & Classification: A quick quizMary is referred to Dr O’Leary who diagnoses schizophrenia; she asks to see her in eight weeks time and re-assess Mary; Mary still appears to have schizophreniaTest-retest reliability 

35. In your groups: State whether you think each of these items relates to the validity (predictive or concurrent?) or Reliability (test-retest or inter-rater?) and whether it is a  or Reliability & Validity in Diagnosis & Classification: A quick quizMaureen sees three doctors as she has a complex variety of symptoms; none of them can agree; one thinks she has bipolar disorder, another says she has PTSD and another says she has schizophreniaInter-rater reliability 

36. In your groups: State whether you think each of these items relates to the validity (predictive or concurrent?) or Reliability (test-retest or inter-rater?) and whether it is a  or Reliability & Validity in Diagnosis & Classification: A quick quizDr Foster diagnoses Mervyn with schizophrenia and prescribes a course of anti-psychotics; Mervyn returns for a check-up six weeks later; Dr Foster is pleased with Mervyns progress as his delusions have much reducedPredictive validity 

37. In your groups: State whether you think each of these items relates to the validity (predictive or concurrent?) or Reliability (test-retest or inter-rater?) and whether it is a  or Reliability & Validity in Diagnosis & Classification: A quick quizDr Goldacre has prescribed anti-psychotics as he believes Dervla has schizophrenia; eight weeks later Derval seems no better, in fact her schizophrenia is getting worsePredictive validity 

38. In your groups: State whether you think each of these items relates to the validity (predictive or concurrent?) or Reliability (test-retest or inter-rater?) and whether it is a  or Reliability & Validity in Diagnosis & Classification: A quick quizDoris has been diagnosed with schizophrenia on the basis of a structured interview using the DSM; her doctor also spoke to her family about her behaviour at home and many of the behaviours they mentioned were in line with the diagnosisConcurrent validity 

39. In your groups: State whether you think each of these items relates to the validity (predictive or concurrent?) or Reliability (test-retest or inter-rater?) and whether it is a  or Reliability & Validity in Diagnosis & Classification: A quick quizJosephine’s tells her doctor she has no motivation and isn’t experiencing the same range of emotions as other people; her doctors thinks she might have schizophrenia and uses a DSM checklist with her; he decides she does not have schizophrenia; however three weeks later Josephine comes back with her Mum who talks a lot more about her daughter; the doctor uses the ICD checklist which reveals that Josephine may have schizophrenia after allConcurrent validity 