Randall D. Ordovich Clarkson, MD
May 6, 2022
Our ability to interface with the realities of the world is paramount to our survival as both individuals as well as a species. In that, pathologies of #perception can greatly impact such abilities to the point of complete debilitation. That is why conditions such as #schizophrenia can be so incredibly devastating. As Picchioni & Murray (2007) succinctly state, “Schizophrenia is one of the most serious and frightening of all mental illnesses. No other disorder arouses as much anxiety in the general public, the media, and doctors.”
For over a century, Schizophrenia—formerly referred to as dementia praecox in 1887 by Dr. Emile Kraepelin—has been the inspiration for vast bodies of creative works from the music of Pink Floyd to books such as Ken Kesey’s One Flew Over the Cuckoo’s Nest (Kraepelin & Barclay, 1919). During the peak of interest in psychedelic drugs, authors and clinical researchers were heavily interested in the potential to develop a deeper understanding of such alterations of perception. Aldous Huxley in the Doors of Perception wrote how certain #psychedelic drugs can similarly mimic the schizophrenic state in the following passage:
"The schizophrenic is like a man permanently under the influence of #mescaline, and therefore unable to shut off the experience of a reality which he is not wholly enough to live with, which he cannot explain away because it is the most stubborn of primary facts, and which, because it never permits him to look at the world with merely human eyes, scares him into interpreting its unremitting strangeness, its burning intensity of significance, as the manifestations of human or even cosmic malevolence, calling for the most desperate countermeasures, from murderous violence at one end of the scale to catatonia, or psychological suicide, at the other." (Huxley, 1970, p. 56-57)
One of the most devastating aspects of schizophrenia is its chronic nature. Although the condition has a low incidence of 15.2 per 100,000, the overall prevalence is 7.2 of 1,000 due to the fact that most individuals are diagnosed in their 20s and remain symptomatic for their entire lifetime (Picchioni & Murray, 2007). In terms of symptomatology, schizophrenia is characterized by both positive and negative symptoms; meaning that symptoms are present verses absent respectively.
According to Picchioni & Murray (2007), positive symptoms may include lack of insight, hallucinations, delusions, and thought disorder manifested as distorted or illogical speech while negative symptoms may include, “withdrawal, self neglect, loss of motivation and initiative, emotional blunting, and paucity of speech.”
In terms of disease course and prognosis, schizophrenia generally follows the rule of thirds, whereby 1/3rd of patients have one #psychotic episode and recover, 1/3rd of patients show some improvement, and 1/3rd of patients remain unchanged or decompensate into worse states (Harding et al., 1987). Some of these trends may follow the biopsychosocial theory of mental health proposed by Engel (1981) whereby patients with adequate social support systems may be able to improve their overall health despite their genetically biological and psychological states of being.
With that being considered, the fact that 2/3rds of patients diagnosed with schizophrenia ultimately remain schizophrenic is tragic, especially considering the overall impact on their quality of life. Thus, it is critical for any clinician working in the field of mental health to be able to adequately diagnose and treat patients presenting with symptoms of schizophrenia. In this article, schizophrenia will be used as an example of how adequate psychological testing, assessments, and other diagnostic considerations can be applied in guiding effective clinical treatment strategies.
For over a century, Schizophrenia—formerly referred to as dementia praecox in 1887 by Dr. Emile Kraepelin—has been the inspiration for vast bodies of creative works from the music of Pink Floyd to books such as Ken Kesey’s One Flew Over the Cuckoo’s Nest
Diagnostic Approaches: Tests and Assessment Tools
In behavioral health, one would be remiss to overlook the importance of the Diagnostic and Statistical Manual of Mental Disorders (#DSM). Originally published in 1952 and modified over the years to it’s current fifth iteration, the DSM is effectively the principal canon for the entire field of behavioral health insofar as it provides the diagnostic criteria for all mental disorders (Cohen & Swerdlik, 2018). Such criteria make up the framework for diagnosis; though, its clinical application is heavily reliant on the behavioral health professional’s skill sets. As Cohen & Swerdlik (2018) explain, the DSM is unlike other assessment tools insofar as it requires clinical skill and knowledge—in other words, diagnostic inter-rater reliability.
Trained clinicians, weather it be #psychiatrists, #psychologists, or other forms of behavioral professionals must be able to identify different risk factors in order to adequately and accurately assess patients in a clinical setting. Otherwise clinical outcomes may be at best ineffective or at worse damaging to the patient’s overall state-of-being. Despite this challenge, the DSM is the gold-standard for both diagnosis as well as the coding of mental health disorders. Then after proper diagnosis, the most appropriate treatment protocol can be prescribed.
Let us take the assessment and diagnosis of schizophrenia as an example of DSM’s utility. In assessing various types of schizophrenia spectrum and other psychotic disorders, the DSM-V maintains a rigorous diagnostic criteria ranging from time frame and duration to overall symptomology to be able to officially diagnose the patient (American Psychiatric Association [DSM-V], 2013). In order to arrive at a diagnosis of schizophrenia, the DSM-V (2013) requires that patients meet criteria listed A through F. In criteria A, the patient must have either (1) delusions, (2) hallucinations, or (3) disorganized speech along with either (4) grossly disorganized/catatonic behavior or (5) negative symptoms such as avolition or diminished emotional expression (DSM-V, 2013). Either of the items listed from 1-3 must be present in combination with either of the items listed as 4-5. Under criteria B, the patient must have clinically significant impairment such as that affecting work, self-care, and inter-personal relations (DSM-V, 2013). For criterion C, the patient must have experienced the symptoms for a duration lasting longer than 6 months, 1 month of which must be characterized by active clinical disturbances (DSM-V, 2013). Criteria D is effectively in place to exclude the diagnosis of Schizoaffective Disorder (either depressive or bi-polar subtype). The DSM-V (2013) states that, “1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness” (p. 99). Criteria E is designed to exclude the effects of substance abuse or other medical conditions that could result in psychosis and criteria F discusses the qualifiers of individuals with prior diagnosis of autism.
Further specifications are also noted in the DSM-V (2013) including whether or not the psychotic event is the patient’s first episode, whether they are currently in an acute phase of symptoms, whether the patient is in remission, whether or not the patient has had multiple episodes, whether they are in continuous states of psychosis, the severity of symptoms (i.e. delusions, hallucinations, disorganized speech, etc.), and whether the symptoms include catatonia.
With neuromuscular #extrapyramidal reactions to anti-psychotic medications such as the “Thorazine Shuffle” or tardive dyskinsesia along with other adverse effects including dystonias, motor restlessness, pseudo-parkinsonism, particularly associated with conventional anti-psychotics, it is no wonder why schizophrenia is such a terrifying condition.
Other diagnostic tools that clinicians may consider include the Positive and Negative Syndrome Scale (PANSS), the Brief Psychiatric Rating Scale (BPRS), the Clinical Global Impression-Schizophrenia (CGI-SCH), and the Calgary Depression Scale for Schizophrenia (Willaims, 2018). According to Willaims, the PANSS is one of the gold standard treatments that assesses factors such as severity as well as ability to reason through problems. In testing severity, clinicians may ask questions such as “How do you compare to the average person?” or “Do you have special or unusual powers?” Then in order to assess reasoning skills, clinicians may as questions such as “How are a train and bus alike?” (Willaims, 2018).
When complete, the PANSS gives a score ranging between 30 to 210, with 30 representing no symptoms and 210 being on the extreme end of schizophrenia. In terms of its reliability and validity, Yehya et al. (2016) states that, “the PANSS showed good interrater reliability and test-retest reliability (0.92 and 0.75, respectively). In comparison with the MINI-6, the PANSS showed good sensitivity and specificity, which implies good construct validity of this version.” In terms of cost, the 30-40 minute PANSS developed by Kay et al. (2012) is a cost-effective assessment currently offered by Pearson Clinical Assessment at $80.
It is important to keep in mind that although schizophrenia may have effects on a patient’s personality, personality assessments per se would have little to no benefit in addressing the needs of schizophrenic patients. Such tests are designed to assess aspects of depressiveness, introversion, intuitiveness, thinking/contemplative, etc. (Cohen & Swerdlik, 2018). Furthermore, tests such as John Holland’s Self-Directed Search test that categorizes individuals as Artistic, Enterprising, Investigative, Social, Realistic, or Conventional as well as D. W. Fiske’s Big 5 Personality Traits including extraversion, agreeableness, openness, conscientiousness, and neuroticism are more geared towards identifying traits suited for either self-development or career paths—thus, doing little to help patients suffering from conditions such as schizophrenia (Cohen & Swerdlik, 2018; Hurtz & Donovan, 2000).
Conclusion on Schizophrenia Diagnosis and Treatment
In his book Hidden Valley Road about a family famously plagued by schizophrenia, Kolker (2020) states that, “One of the consequences of surviving schizophrenia for fifty years is that sooner or later, the cure becomes as damaging as the disease.” With neuromuscular extrapyramidal reactions to anti-psychotic medications such as the “Thorazine Shuffle” or tardive #dyskinsesia along with other adverse effects including #dystonias, motor restlessness, pseudo-parkinsonism, particularly associated with conventional anti-psychotics, it is no wonder why schizophrenia is such a terrifying condition (Pierre, 2005). Not only is the disorder debilitating, but in many cases, the treatment can be debilitating as well. Despite this, it is still important for clinicians to be able to adequate assess, test for, and diagnose schizophrenia as it is the first step in what may be a long road towards treatment and recovery.
References
American Psychiatric Association [DSM-V]. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Publisher.
Cohen, R. J., & Swerdlik, M. E. (2018). Psychological testing and assessment : an introduction to tests and measurement. Mcgraw-Hill Education. ISBN-13: 9781259870507
Engel, G. L. (1981, January). The clinical application of the biopsychosocial model. In The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine(Vol. 6, No. 2, pp. 101-124). Oxford University Press.
Harding, C. M., Brooks, G. W., Ashikaga, T., Strauss, J. S., & Breier, A. (1987). The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American journal of Psychiatry, 144(6), 727-735.
Hurtz, G. M., & Donovan, J. J. (2000). Personality and job performance: the Big Five revisited. Journal of applied psychology, 85(6), 869.
Huxley, A. (1970). The doors of perception. Perennial Library.
Kay, S. R., Fiszbein, A., & Opler, L. A. (2012). Positive and negative syndrome scale (PANSS). MHS.
Kolker, R. (2020). Hidden Valley Road : inside the mind of an American family. Doubleday.
Kraepelin, E., & Barclay, R. M. (1919). Dementia praecox. Cutting and Shepherd, 13-24.
Picchioni, M. M., & Murray, R. M. (2007). Schizophrenia. BMJ (Clinical research ed.), 335(7610), 91–95. https://doi.org/10.1136/bmj.39227.616447.BE
Pierre, J. M. (2005). Extrapyramidal symptoms with atypical antipsychotics. Drug safety, 28(3), 191-208.
Willaims, S. (2018, October 23). Diagnostic Tests for Schizophrenia. WebMD; WebMD. https://www.webmd.com/schizophrenia/diagnostic-tests-schizophrenia
Yehya, A., Ghuloum, S., Mahfoud, Z., Opler, M., Khan, A., Hammoudeh, S., Abdulhakam, A., Al-Mujalli, A., Hani, Y., Elsherbiny, R., & Al-Amin, H. (2016). Validity and Reliability of the Arabic Version of the Positive and Negative Syndrome Scale. Psychopathology, 49(3), 181–187. https://doi.org/10.1159/000447328
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