1 Discuss the reliability and validity of the classification and diagnosis of Schizophrenia Reliability Reliability means that each

time the classification systems are used (such as the International Classification System for Diseases (ICD) and the Diagnostic and Statistical Manual of Mental disorders (DSM)) they should produce and provide the same outcome. You can measure the reliability of classification and diagnosis of schizophrenia in two ways: Test-retest reliability (practitioner making same consistent diagnosis on separate occasions from the same information) and Inter-rater reliability (several practitioners make identical, independent diagnoses of the same patient). The reliability of the early editions of these two classifications was marked as inconsistent and the vagueness of the DSM led to very low reliability in diagnosis. They do at least allow practitioners to have a common language, permitting communication of research ideas and findings, which may ultimately lead to a better understanding of the disorder and effective treatments. Schizophrenia was more commonly diagnosed in the USA (80% of patients during the 1950s) than compared to England (at the same period 20%), because earlier versions of DSM contained very broad diagnostic criteria. As a consequence this hampered research into the underlying causes of schizophrenia and into effective treatments for the disorder. However, Beck et al. (1962) reported 54% concordance rate between experienced practitioners diagnoses when assessing 153 patients, while Soderberg et al. (2005) reported a concordance rate of 81% using DSM-IV-TR. This is suggesting classification systems have become more reliable over time. There is no universally agreed definition of schizophrenia, the lack of agreement to define schizophrenia points that definitions of mental disorders are fairly arbitrary and liable to change according to prevailing influences. There is a possibility that a person is wrongly diagnosed with schizophrenia. For example, a New Zealand poet, Janet Frame, spent eight years in an institution because she did not fit into her rural New Zealand background, and increasingly alienated herself into her world of fantasy. She only just managed to leave before being subjected to psychosurgery. Eventually, she was able to travel and became a full-time writer, as she had always wished to do. Recently, ICD-10 and DSM-IV-TR have now become very similar, although there are two important differences between the classifications: the DSM requires symptoms to have been in evidence for a period of six months whilst ICD requires only one month. Secondly, the DSM is multi-axial, which means that various

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2 factors are taken into account before a diagnosis is made. ICD places more emphasis on the first-rank symptoms whereas DSM emphasizes the course of the disorder and the accompanying functional impairment. DSM is multi-axial, which means that various factors are taken into consideration before a diagnosis is made. The ICD lists two types of schizophrenia that is not listed as schizophrenia in the DSM (post-schizophrenic depression and simple schizophrenia). Jakobsen et al. tested reliability of ICD-10 classification system in diagnosing schizophrenia. A hundred Danish patients with a history of psychosis were assessed using operational criteria, and a concordance rate of 98% was attained, shows high reliability of the clinical diagnosis of schizophrenia using up-to-date classifications. However, Nilsson et al. found a 60% concordance rate between practitioners using the ICD classification system, implying that the DSM system is more reliable. Although most researchers agree that DSM-IV-TR has improved reliability; Eysenks argues that the approaches to diagnosing schizophrenia have proved to be reasonably reliable. However his argument is that the reliability of the DSM in everyday usage may be lower than seen in research studies meaning that only research studies are recorded with high reliability and non-research studies may have lower reliability. Read et al. found test-retest reliability of schizophrenia diagnosis to have only a 37% concordance rate; 194 British and 134 American psychiatrists were asked to provide a diagnosis on the basis of a case description: 69% of the Americans diagnosed the disorder as schizophrenia, but only 2% of the British did. Diagnosis of schizophrenia has never been reliable. Others like Seto reported that the term schizophrenia had been replaced by integration disorder in Japan due to the difficulty of attaining reliable diagnosis suggesting that schizophrenia, as a separate, identifiable disorder, does not exist. The success of the system relies on how well they are interpreted by the person making the diagnosis. A solution to solve the reliability problem is changing the concept of schizophrenia into one of the schizophrenic spectrum, turning schizophrenia from a categorical disorder to a dimensional one. Validity Validity is regarded whether a diagnostic system assesses what it claims to be assessing. However, the boundaries between schizophrenia and other disorders can often be difficult to define, such as, mood disorders and development disorders such as autism. Heather argues that very few causes of mental disorders are known and there is only a 50% chance of predicting what treatment a patient will receive based on diagnosis, suggesting diagnosis of schizophrenia has low validity. Although, different problems can be presented by different patients diagnosed with schizophrenia.

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3 According to ICD and DSM, only two potentially quite different, symptoms need to be present in order to diagnose schizophrenia. This suggests that there is no single underlying causal factor a further reason to question the validity of schizophrenia as a diagnosis. Bottas reports that the incidence of schizophrenia with OCD is much higher than probability would suggest. Genetic and neurobiological evidence now suggests that separate types of schizophrenia may indeed exist. The term predictive validity refers to the ability of the classification system to predict the course of the disorder and the response to treatment. However, it is proved to be very difficult to predict accurately the ICD and DSM validity and there are wide individual variations. About one-third of patients have one episode or a few brief episodes of schizophrenia then fully recovering. Another onethird, throughout their lives has occasional episodes and function reasonably effectively between episodes. The remaining patients deteriorate over a series of increasingly incapacitating episodes. Between 10-15% of people with schizophrenia commit suicide. This has led some people to suggest that schizophrenia is not an all-ornothing condition as suggested by the categorical diagnostic systems. Richard Bentall believed the problems with schizophrenia as a diagnostic category does not provide enough evidence for the disorder, unless it is broken down into smaller diagnoses with each symptom becoming a separate disorder. Jansson and Parnas reviewed 92 polydiagnostic studies, which apply different definitions of the disorder to the same patient samples, to assess the reliability and validity of schizophrenia diagnoses. Both ICD-10 and DSM-IV showed moderate reliability, but both were weak on all measures of validity, again casting doubt on whether the disorder exists as a separate condition. In contrast, Hollis applied DSM classification diagnoses retrospectively to 93 cases of early onset schizophrenia and findings indicated that the diagnosis of schizophrenia had a high level of stability, suggesting such diagnoses are to an extent valid. Dimensional disorder is a classification that relates to the degree to which problems are experienced, not simply the presence or absence of such problems. Some psychologists believe that schizophrenia should be seen as a dimensional disorder. For example, it has been found that people who have not been diagnosed wit schizophrenia can nevertheless experience one of its main symptoms, but they have strategies to cope with them and they do not feel disabled by them (Romme and Escher). Some people would prefer the classification systems to be dimensional rather than categorical. Co-morbidity is described as a patient who suffers from two or more mental disorders at the same time. Sim et al. (2006) studied 142

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4 hospitalised schizophrenic patients in which 32% of that had an additional mental disorder. Co-morbidity occurs in part because the symptoms of different mental disorders often overlap with each other. An example of this might be, schizophrenia and major depressive disorder both involve very low levels of motivation. This creates a problem of reliability, whether the low motivation reflects the existence of depression or schizophrenia, or both. There is a growing trend to diagnose patients as suffering from co-morbidity disorder. This may be because many individuals do not neatly fit into a category that has been created. Instead of acknowledging that the methods by which diagnostic decisions are arrived at are lacking validity, clinicians diagnose two separate disorders. One way cultural biases can affect the diagnosis of schizophrenia is by causing clinicians to over/underestimate psychological problems in members of other cultures. Although across all cultures, schizophrenia can occur, there is a more consistent finding in the USA and the UK that schizophrenia is diagnosed more frequently to those who are African-American and African-Caribbean than in other groups. 2.1% of African-American are diagnosed with schizophrenia, compared with 1.4% of white Americans (Keith et al. 1991). There are three possible reasons for the difference in the rates of diagnosis genetic vulnerability, psychosocial factors associated with being part of a minority group (e.g. racism) or misdiagnosis. It could be the case that clinicians from the majority population misinterpret cultural differences in behaviour and expression as symptoms of schizophrenia. Davison et al. (2004) found that clinicians were more likely to diagnose a patient as having schizophrenia if the case summer referred to the person as AfricanAmerican than if she/he was described as white. However, the DSM-IV-TR attempts to improve cultural sensitivity by providing a general framework for evaluating the role of culture and ethnicity, compared to the early editions of DSM which were criticised for the lack of attention to cultural and ethnic variations in psychopathology. Cochrane reported that the incidence of schizophrenia in the West Indies and Great Britain is the same, at around 1%, but that people of Afro-Caribbean origin are seven times more likely to be diagnosed as schizophrenic when living in Great Britain. This suggests either that Afro-Caribbean people livening in Great Britain experience more stressors leading to schizophrenia, or that invalid diagnoses are being made due to cultural bias. There are some issues with patient being labelled, this is demonstrated in Rosenhans On being sane in insane places study. Rosenhan and some pseudopatients went to a psychiatric hospitals saying they could hear voices saying empty, hollow and thud. They were admitted with a diagnosis of schizophrenia. Afterwards, Rosenhan and the pseudopatients behaved normally.

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5 Patients being diagnosed with schizophrenia can have many negative effects on them. A person diagnosed with schizophrenia might become fearful of another episode, or unable to deal with new challenges as they have lost confidence to use this ability. Critics argue that placing a person in a diagnostic category distracts from understand the person as a unique human being, but that instead the label can be used to describe the person instead of the disorder. This can lead to prejudice towards the individual with schizophrenia e.g. dangerous, unpredictable or unemployable. Once labelled with schizophrenia, it is extremely difficult to remove whether they suffered one episode of schizophrenia or lots and recovered, they may still always be labelled schizophrenic. This had led psychiatrists to refine the diagnostic process, to include longerlasting symptoms. Although it may be argued that responsible psychiatrists would not expect healthy people to invent psychiatric symptoms and risk hospital admission; nor would they turn away someone apparently in need. Kendell and Jablensky suggested that schizophrenia should be abolished as a concept because it is scientifically meaningless, state that diagnostic categories are justifiable concepts, as they provide a useful framework for organising and explaining the complexity of clinical experience, allowing us to derive inferences about outcome and to guide decisions about treatment. Although there are serious issues to do with classification, there are arguments for why classification is used in psychopathology to make communication between professionals easier; to predict the outcome of the disorder and to choose appropriate treatment and to understand more about the possible causes of mental disorder, are only a few to name.

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