How is Schizophrenia Diagnosed?
What does a diagnosis of schizophrenia mean?
For some a diagnosis of schizophrenia is an emotional body blow and seems to represent the beginning of a lifetime of low achievement and stigma. But for others it represents a breakthrough and the starting point of their recovery and is met with a great sense of relief. At last they are able to explain in a simple way all of the bizarre and distressing experiences that they have been having over many months of disturbed thinking and behaviour.1
Some see the process of diagnosis as simply a convenient method of labelling different behaviour so that it can be controlled. In fact, the diagnosis process is not approached lightly by the mental health professionals and the diagnosis is based not simply on the professional judgement of the doctors but on the long experience we have of treating schizophrenia over many decades and in many countries.
Getting a correct diagnosis of your problems has a number of major advantages1:
· It will help you to understand the problems that you have been having.
· It will give you access to the right methods of treatment
· It will be the starting point of your recovery journey
· It will help the people around you to understand more about your struggle
· It will give you access to the right benefits
· It will give you access to other kinds of support such as help with housing and debt
How is a diagnosis of schizophrenia made?
There is no simple scan or blood test that will enable a diagnosis of schizophrenia to be made. Instead the diagnosis will be made on the basis of a diagnostic interview conducted between the patient and the doctor. In this case the doctor is usually a consultant psychiatrist as it is rare for a GP to have the time or the expertise to carry this out themselves.
For many years the criteria on which diagnosis of schizophrenia was made were very fluid and this led to many misdiagnoses. However over the last 20 years or so very precise diagnostic tools have been developed which have reduced the incidence of misdiagnosis although these still do occur in, it is thought, up to about 10% of cases.
In addition to asking a structured series of questions aimed at finding out how the patient is thinking, the doctor will also take into account other background information for instance from the patient’s relatives. The interview may be quite lengthy lasting two hours or more and may take place at the patient’s home, in hospital or at an outpatient clinic.
If the patient is in crisis and the doctor is considering sectioning them under the Mental Health Act then other professionals will be present including another doctor (usually the GP), and an approved social worker.
In an ideal world the patient would be interviewed by the doctor and would describe their experiences fully and in detail and the doctor would be able to make a diagnosis there and then. However, reality is often very different. Sometimes if the patient is suffering from paranoid thoughts they may be suspicious of the doctor or they may be under great pressure from their psychotic thoughts to cover things up rather than tell the doctor everything. This is not their fault it is simply another cruel feature of this illness.
In her book Serious Mental Illness a Family Affair, Gwen Howe describes the all too common experience of a seriously deranged person driving their family to absolute distraction over many months of bizarre and disturbed behaviour only then to put on an Oscar-winning performance of calm and serenity when their family finally manage to persuade the doctors to carry out an assessment.
At other times the patient may find it difficult to describe very bizarre thoughts and feelings or may be embarrassed by them and not want to reveal them. Psychotic thinking can be very complex and difficult to explain to a person who has not experienced it themselves.
The two principal diagnostic methods used by doctors today in the diagnosis of schizophrenia are the Diagnostic and Statistical Manual ( known as DSM IV) which is used mainly in the USA and the International Classification of Diseases (ICD), 10th revision, which is used commonly in the UK and Europe.2
The diagnosis will take into account four main types of symptoms: delusions, hallucinations, thought disorders and negative symptoms such as apathy or withdrawal.
Because disorders of the mind can be very complex (after all the brain is the most complex organ in the human body), the doctor may make an initial diagnosis, called a working diagnosis, which may later be changed when the doctor has had more experience of the patient.
Schizophrenia and schizo-affective disorder: what is the difference?
There are two psychotic illnesses, schizophrenia and bipolar disorder (previously called manic depression). Some doctors will also give a diagnosis of schizo-affective disorder to describe a condition that falls between the two classifications. It is quite common for a patient to be given a working diagnosis of schizo-affective disorder at first only for it to be changed to schizophrenia (or the other way around) later. A diagnosis of schizo-affective disorder will be made if the symptoms of schizophrenia are present alongside disturbances of mood such as depression or manic moods.3
Are there different kinds of schizophrenia?
The ICD method of classification also describes six sub-types of schizophrenia such as paranoid schizophrenia or simple schizophrenia which the doctor will use in making their diagnosis.4
When should a diagnosis be made?
If you are a carer or relative who is concerned about a loved one your first approach may be to go and see your GP. Unfortunately as many carers and relatives of people with schizophrenia have discovered to their cost, getting help for their loved one at the beginning of the first psychotic episode can be more difficult than it should be. Unfortunately some psychiatrists still like to take a wait and see approach to the diagnosis especially on the first episode and will not intervene until the crisis has peaked. You may find that you will need to start to pestering the professionals to help your loved one.1,5
There are also sadly many professionals who see a diagnosis of schizophrenia as “labelling” the patient and perceive, erroneously, that attaching such a label may, in the long run, cause the patient more harm than the illness itself. If only these professionals had had to endure the suffering caused by psychotic illness for one day they would understand just how misguided such a policy is.1
It is important for professionals to appreciate that there is a huge difference between attaching a label to the patient and attaching a label to the patient’s problems, which is entirely constructive and can be the starting point of the patient’s recovery.
In addition there is ample research evidence to show that early intervention with antipsychotic medication in schizophrenia will improve the outcome of the first episode and reduce the likelihood of further relapses.6
It is important to remember that your GP will almost certainly not be able to carry out a diagnostic interview themselves but will want to refer the case to a consultant psychiatrist. Even if your GP agrees to this, (and some will not) there may be a delay of several weeks whilst an appointment is made.
If you believe that your loved one is in danger of harming themselves or others then you should try to take them to the Accident and Emergency Department at the local hospital and ask to see the duty psychiatrist. If your loved one will not agree to this then you should call the local duty social worker. If you believe that the danger is immediate, you should call the police.
What information does the doctor need?
If you are concerned about a loved one and want to try to arrange for medical help for them you will need to be able to give the doctor as full and precise information as you can about the various ways in which they have changed. It is a very good idea to start writing these observations down. The following are all features that the doctor will be interested in7:
Withdrawal: has the person become withdrawn from friends and family? Do they spend all day in their room and refuse to spend time with the family?
Strange ideas: has the person expressed strange ideas about being spied on or persecuted or strange religious ideas or ideas about aliens? Do they relate things that happen in the world news to themselves?
Risky behaviours: has the person started to drive dangerously or started to harm themselves? Have they become sexually disinhibited? Have they been getting in trouble with the police?
Emotional Responses: Does the person appear afraid or agitated for no reason? Do their responses appear blunted emotionally or do they make paradoxical responses, appearing happy when something bad happens and sad when something good happens?
Changes in activity: Has the person given up studying or work for no apparent reason? Do they stay up at night and then sleep during the day? Have they started to attend church frequently or spend lots of time shopping? Have they been spending lots of money on things they do not need?
Performance: has the persons performance at work or college suddenly fallen off? Have they become lax with personal hygiene or obsessive about it? Have they become very forgetful? Do they forget about appointments and arrangements they have made?
These are just some examples. There are many features of psychotic illness that people exhibit when they become ill and it is necessary for you to observe the specific ways in which your loved one’s life has changed. The more evidence you are able to give the doctors the more likely they will be to intervene.
What are the diagnostic criteria for schizophrenia?
There are four conditions that must be met for a diagnosis of schizophrenia to be made8:
1. The person must have at least one clear symptom that is characteristic of schizophrenia such as hearing voices.
2. The symptom must have been present for at least one month and the disturbances to their life must have been evident for at least six months.
3. The symptoms must be impacting on the person’s social functioning or their occupation such as employment or studying.
4. Other conditions that may cause the symptom such as use of street drugs must have been ruled out.
Change: the key to successful diagnosis
If there is one word that is key to the diagnosis process it is “change”. It is vital that the doctors should be told how the patient has changed since they started to become unwell. After all, going to church frequently is not necessarily a symptom of serious mental illness nor is getting into trouble with the police but if someone suddenly starts to frequent churches or gets into trouble when they have previously been very law abiding then these changes in their behaviour should start to ring alarm bells.
Whether you are a patient or a relative of someone who is experiencing mental health problems the issue of the diagnosis will be one of the biggest challenges you will face. Getting your problems correctly diagnosed can open up the path to a true and lasting recovery and enable you to be able to eventually put all of your distressing experiences behind you. It is true to say that for most people a diagnosis of schizophrenia will be one of the most significant things that will ever happen to them but remember that a correct diagnosis is vital to successful recovery.
1. Author’s personal experiences.
2. Jones S and Hayward P, 2004, Coping with Schizophrenia, One World, p19.
3. Jones S and Hayward P, 2004, Coping with Schizophrenia, One World, p29.
4. Jones S and Hayward P, 2004, Coping with Schizophrenia, One World, p28.
5. Howe G, 1997, Serious Mental Illness a Family Affair, Sheldon Press, p11.
6. Fuller Torrey E, 2001, Surviving Schizophrenia, Quill, p218.
7. Lintner B, 1989, Living with Schizophrenia, Vermilion
8. Burton N, 2012, Living with Schizophrenia, Acheron Press, p35.