26/02/2020 Outline • schizophrenia • history Diagnosis and Classification • international variation Michael Shaw • modern classification Consultant Psychiatrist • schizoaffective disorder MRCPsych course year 1 • acute psychotic disorders Psychotic disorders module • Other chronic psychotic disorders Schizophrenia: Kraepelin • Emil Kraepelin (1856 - 1926) • Founder of modern scientific psychiatry • Unitary concept of psychosis: • dementia praecox (1887) • catatonia, hebephrenia, paranoia • brain disease with progressive deterioration • vs • manic-depressive insanity by prognosis (now seen as mood disorders) • 13% recovered • Symptoms can be in either category • but diagnosis about specific pattern of symptoms Schizophrenia: Bleuler • Eugen Bleuler (1911 - 1939) • Gave name : Schizophrenia (1908) • psychological disorder: splitting of mind (emotional vs intellectual) • Believed condition was not a dementia – seen recovery • Deteriorating attacks, rather than recurrence – no cure • First to identify positive & negative symptoms • fundamental symptoms • loosening of associations, affective blunting, autism, ambivalence (‘four As’) • accessory symptoms • hallucinations, delusions, catatonia • simple schizophrenia 1 26/02/2020 Schizophrenia: Schneider • Kurt Schneider (1887 - 1967) • attention on early acute phase of illness • ‘symptoms of first rank’ (1938) • pathognomonic of schizophrenia in absence of organic brain disease • ‘loss of ego boundaries’ • form basis of ICD-10, DSM-IV core criteria • ‘symptoms of second rank’ • perplexity, blunting, hallucinations, delusions First rank symptoms US traditions • auditory hallucinations • influenced by Freud & Bleuler • thought echo • diagnosis based on ‘four As’ • 3rd person voices • autism, inappropriate affect, ambivalance, loose • commentary voices associations • thought insertion or withdrawal • Meyer • thought broadcasting • psychobiology: illness as adaptation to changing environment • US/UK diagnostic project • passivity feelings / delusions of control • narrowing definition of schizophrenia • somatic hallucinations • Neo-Kraepelinians • delusional perception • critical of psychodynamic view • diagnostic criteria US / UK diagnostic project : UK / German traditions 1971 • Kraepelinian paradigm • Cooper JE et al. (1972) Psychiatric Diagnosis in New York and London. Maudsley • narrow concept of schizophrenia Monograph 20. Oxford: OUP. • strongly influenced by Schneider’s first rank • Far higher rates of schizophrenia in US than UK (ICD 9) symptoms • Far lower rates of mania in US than UK (0.5% vs. 6.9% of hospital discharge diagnoses) • Looser diagnostic criteria for schizophrenia used in US (DSM- • SOVIET UNION II) • Rosenhans 1972 study “Being Sane in Insane Places” • Use for political purposes, to discredit political concluded diagnosis of schizophrenia in US often is subjective dissidents @ trial – Been condemned and unreliable. 2 26/02/2020 Japan: Renaming Schizophrenia 2004 Seishin Bunretsu Byo (“mind-split-disease”) Scandinavian traditions • Schizophrenia was inaccurate • narrow concept of schizophrenia • Negative image & legacy of inhumane • schizophreniform psychosis treatment • Langfeldt • psychosis with better prognosis • ‘Integration Disorder’ Togo Shitcho Sho • psychogenic psychoses • Away from Kraepelinian disease concept to • Wimmer (1916), Stromgren Stress Vulnerability model (to reflect outcomes) • predisposed individuals • Reduce stigma • multi-dimensional classification • Improve communication of diagnosis • Sjobring (1919) Anti – Psychiatry French traditions Movement • Morel (1857) • Challenged the medical concept • theory of degeneration • Magnan (1895) • Emphasised social context • psychoses in normals / degenerates • Prominent thinkers include R.D Laing/ • transitory delusional states David Cooper • bouffee delirante (acute nonaffective/ non schizophrenia • Schizophrenia: an understandable reaction to psychotic state (ICD 10 = Acute polymorphic psychotic conflicts between family & self, or through trauma. disorder)) • Believe represents a problem, many humans have. • non-schizophrenic chronic delusional states: • Schizophrenia is a disease vs impact of • no FTD/ IQ impairment environmental factors (the social cradle) • chronic interpretative psychosis ≈ delusional disorder • chronic hallucinatory psychosis ≈ paraphrenia • Intelligent/ sensitive beings confronted by a ‘Mad • chronic imaginative psychosis World’ Classifying psychotic states Classifying psychotic states • List the disorders in which psychotic symptoms • List the disorders in which psychotic symptoms can occur can occur • Non-affective psychotic disorders • schizophrenia • schizophreniform disorder • schizoaffective disorder • delusional disorder • Affective psychoses • bipolar disorder • major depressive disorder • Substance induced psychotic disorder • Psychotic disorder due to general medical condition 3 26/02/2020 Modern classification I Modern classification II • ICD-10 • DSM-IV • at least one of • positive symptoms for > one month, either • thought echo, thought insertion, thought withdrawal, • at least two of delusions, hallucinations, disorganised thought broadcasting, delusions of control, commentary speech, catatonic behaviour, negative symptoms voices, bizarre delusions • OR one of bizarre delusions, commentary or discussing • OR at least two of voices • hallucinations, thought disorder, catatonic behaviour, • markedly impaired functioning negative symptoms • continuous signs of disturbance for > 6m (positive or negative • present for > one month symptoms) • Certain exclusions Modern classification III DSM V • Criterion A: At least one of – delusions; hallucinations; • DSM V disorganised speech; plus another from these or one from negative symptoms; disorganised or catatonic • From 2013 behaviour • Elimination of special attribution to bizarre • Criterion B: Social/occupational/self care dysfunction delusions • Criterion C: Continuous signs for 6 months with 1 • Elimination of special attribution to Schneiderian month meeting Criterion A (less if treated) first-rank auditory hallucinations • Criterion D: Schizoaffective & Major Mood Exclusion • Requirement for at least one of 3 positive symptoms – hallucinations, delusions, disorganised • Criterion E :Substance/ general medical condition Ex speech. • Criterion F: ASD/communication disorder (childhood • Removal of subtypes onset) need prominent delusions or hallucinations along with other criteria ICD-11 6A2- Schizophrenia or other Differences between ICD-10 & primary psychotic disorders DSM-V schizophrenia • In release form for endorsement May 2019 and • ICD-10 has greater emphasis on first rank implementation January 2022 symptoms • Retains schizophrenia as a term • ICD-10 divides schizophrenia into subtypes • “significant impairments in reality testing” manifest as… • DSM-V requires longer duration of some • Deviate from cultural or subcultural norms symptoms • Do not arise from another disorder • DSM-V requires impairment of functioning • First, multiple and continuous episodes - no subtypes • Duration of symptoms of one month • Acute and transient psychosis – no prodrome, max severity 2 weeks, duration a few days to 3 months max 4 26/02/2020 OPCRIT Schizophrenia: reliability • Operational criteria checklist for psychotic and affective disorders • Jakobsen et al (2005) • Generates diagnoses according to 12 diagnostic • Evaluated patients with diagnosis of schizophrenia using systems (DSM, ICD etc) OPCRIT criteria • High PPV (0.87) for ICD-10 diagnosis • Initial 3 factor solution produced +ve/ -ve & • Near perfect agreement (kappa = 0.98) for DSM-IV diagnosis disorganisation factors. • Diagnosis of schizophrenia is highly reliable • Application suggested 5 factors to ensure good validity in diagnosis: Paranoia/ 1st rank delusions/ 1st rank hallucinations/ Disorganisation/ Negative sx. • Reliable, rapid & valid approach to polydiagnostic assessment Schizophrenia: Schizophrenia – polydiagnostic studies psychopathology • Jager et al (2003) Psychopathology • Jansson & Parnas (2006) • Clinical features of patients with diagnosis of psychotic • Review of 92 polydiagnostic studies disorders compared (n = 1476) • Insufficient validity to support any one definition over another • ICD-10 schizophrenia characterised by more negative • 1st rank symptoms not associated with family history or poor symptoms and lower global functioning prognosis • older than patients with ATPD (acute & transient psychotic disorder) • Long duration criteria and exclusion of affective states restricts • younger than patients with DD & SAD diagnosis to chronic stable patients • descriptive validity of schizophrenia supported • Patients meeting all definitions are a more severely ill group rather than a strongly valid subgroup • Conceptual and construct validity for schizophrenia remains under-researched Dimensions of major Schizophrenia - validity psychoses • Serretti & Olgiati (2004) • Allardyce et al (2007) Schizophrenia Bulletin • factor analysis of 1294 patients • clinical utility does not provide construct validity of • best fit with 5 factors schizophrenia • No clear distinction between normality & psychosis • positive symptoms • 18 month incidence of symptoms 4.4% of general • negative symptoms population in UK NPMS • disorganisation • alternative approaches to classification • mania • refine categories: new subtypes • depression • identify dimensions: 5 factor model • search for proximal indicators 5 26/02/2020 Diagnosis: Psychosis: a disorder of aberrant