It seemed appropriate that I recently attended a DSM 5 seminar entitled Schizophrenia Spectrum and Other Psychotic Disorders, given that the recent World Mental Health Day centred on the theme ‘Living with Schizophrenia’.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook developed by the American Psychiatric Association (APA) and is used by psychiatrists and other health care professionals as a diagnostic tool for the management of people with mental disorders. It was first devised in 1952, (and merely as an aside, it classified homosexuality as a mental disorder until 1974). It is currently in its 5th iteration (released in May 2013) hence the term DSM 5 guidelines. However, it is worth noting that ICD-10, which uses the WHO criteria, is used more frequently in the UK.
The psychotic disorders in DSM-5 are:
- Schizoaffective Disorder;
- Delusional Disorder;
- Brief Psychotic Disorder;
Each person with psychosis will have different problems and the symptoms may include hallucinations, delusions, thought disorder and lack of insight. People can often believe they are going mad when they suffering from stress. However, ‘Psychosis’ is when your thoughts are so disturbed that you lose touch with reality. When this happens, this type of problem can be severe and distressing and can potentially be life limiting.
DSM 5 has removed the following schizophrenia subtypes: paranoid, disorganized, catatonic, undifferentiated, and residual type because of their “limited diagnostic stability, low reliability, and poor validity,” according to the APA.
What is new in DSM 5? Two Criterion A symptoms are now required for any diagnosis of schizophrenia. The second change was the requirement for a person to now have at least one of three “positive” symptoms of schizophrenia: Hallucinations, Delusions, Disorganized speech. The APA believes that this helps increase the reliability of a schizophrenia diagnosis.
The incidence of schizophrenia occurs in males and females but typically appears earlier in men with peak onset between the ages of 20-28 for men and 26-32 for women. The lifetime prevalence is 1%. The prevalence of schizophrenia varies around the world.
Causes – Genetics
Twin studies have shown that if one identical twin has schizophrenia, their twin has roughly a 40 to 65 % chance of developing the disorder. It is unlikely that there is one exclusive gene for schizophrenia, there are probably a number of genes for a variety of characteristics (e.g. schizotypal personality, enlarged ventricles, childhood neuroticism etc.) which increase the risk of schizophrenia.
One in ten people with schizophrenia have a parent with the illness. However, “Genome scans”, are unlikely to offer a comprehensive assessment of a person’s risk for developing a mental disorder like schizophrenia.
Psychiatric academics seem to agree that whether or not schizophrenia manifests itself depends on the result of a conglomeration of these factors, both genetic and environmental in origin (Sullivan et al., 2003).
Causes – Environment
The debate about the causes of schizophrenia have progressed since the 1960s when schizophrenogenic parents were viewed as the cause of the illness in their children. That does not mean that early environment is not still important. Indeed, according to scientists, the risk for schizophrenia appears to begin as early as the first trimester in pregnancy. This can emanate from exposure to influenza associated with increased risk of later developing schizophrenia (Brown et al., 2004). There are other prenatal factors in the second and third trimesters which include respiratory infections, maternal rubella, low socioeconomic status, maternal deprivation resulting from war or famine, being born in an urban setting and obstetric complications. Also, those born in Winter/early Spring (in Northern Hemisphere) appear to have an increased risk compared to those born in the Autumn.
Children of migrants appear to have an increased risk of psychosis, however the increased risk is not shared in the population of origin.
References: (Dohrenwend et al., 1992; Lewis and Murray, 1987; Marcelis et al., 1999; Susser et al., 1996; Torrey et al., 1997).
Causes – Neurobiology
Scientists have speculated that an imbalance in chemical reactions of the brain involving the neurotransmitters dopamine, glutamate and serotonin, and possibly others, play a role in the development of schizophrenia. They are unsure why this should be the case and more research is needed to help explain how it develops.
Causes – Substance abuse
It is difficult to find research that states that substance abuse causes schizophrenia. However, people who have schizophrenia often abuse alcohol or drugs. Indeed, they may have particularly bad reactions to certain drugs.
Heavy cannabis intake at 18 years of age is associated with increased risk of later psychosis. There also appears to be a dose dependent relationship as well as a connection between the use of cannabis and relapse. It may be fair to state that substance abuse can be a trigger to the onset of the illness, as is stress, for those that are susceptible to the condition.
Psychological Treatment for Schizophrenia
Perhaps the greatest block to care is the stigma of mental health diagnosis and then the barriers to care in the system, once they are diagnosed. It will perhaps take more than a party conference speech by Nick Clegg MP to address these issues. NICE guidelines suggest a course of CBT for both first episode and relapse prevention. I was wondering about the transpersonal aspects of schizophrenia: might patients be wrongly diagnosed if undergoing a spiritual emergency? Professor Grof, a transpersonal proponent, has stated in the past that some form of transpersonal experiences can seem like psychotic episodes, such as undergoing a spiritual emergency. However, he also states clearly that psychosis is still quite pathological especially when the subject of psychosis loses all objectivity and becomes truly paranoid.
I learned a lot on the course. It is estimated that GPs see 95% of mental health problems in the UK, as GPs are the gatekeepers to the secondary care services. The most frequent psychiatric disorders in general practice are depression, anxiety and somatoform disorders. I was left wondering about the powerful impact of psychiatrists who falsely diagnose schizophrenia because of their racist beliefs or because they simply fail to account for cultural norms and values. Perhaps we need to rethink our whole attitude to mental health care service provision and this will entail a significant political shift so that mental health care provision starts to receive greater funding in the healthcare system.
Key facts about Schizophrenia
Support for those living with Schizophrenia
The National Spirituality and mental health Forum