Meet any two people with Schizophrenia and you will be confronted by an interesting and somewhat puzzling scenario. For a start they will relate entirely different experiences about their condition and most likely will respond entirely differently to their medication - if indeed they respond at all. The course and treatment of schizophrenia varies so markedly that one commentator (R.P. Bentall) described schizophrenia as, "a disease which has no particular symptoms, which has no particular course, and which responds to no particular treatment." If this is really the case shouldn't we give up on the concept of schizophrenia altogether?
To explore the question we need to take a step back to where a diagnosis of schizophrenia is first made. According to the Diagnostic & Statistics Manual DSM-IV-TR (APA 2000) two or more of the following symptoms need to be present for a good proportion of time during a one month period:
- Disorganized speech: frequent derailment or incoherence
- Grossly disorganized or catatonic behavior
- Negative symptoms: flattened mood, alogia or avolition
Actually, only one of these is required if hallucinations involve a running commentary involving two or more voices, or a single voice comments regularly on the person's behavior, or delusions are bizarre.
A second criterion is that symptoms should result in significant impairment. Thereafter, a diagnosis can be made on the basis of which particular set of symptoms predominate, the result of which will place the individual into one of four sub-types, namely a ‘disorganized', ‘paranoid', ‘catatonic' or ‘residual' schizophrenic.
So far so good, until you realise that this is only one way of looking at things. Another way (proposed by Liddle et al. 1994) is to consider how symptoms cluster together and to look at the reasons why. If we adopt this approach the sub-types of schizophrenia fall into three clusters. First, a ‘disorganized' cluster which is characterized by disorganized speech, behaviour and mood. Secondly, a ‘positive' cluster which includes hallucinations and delusions. Thirdly, a ‘negative symptoms' cluster, which includes apathy and low motivation.
The very difficulty in explaining schizophrenia is typified by the attempts made to diagnose it. As each version of the DSM is published the criteria for a diagnosis of schizophrenia changes. Schizophrenia is a slippery customer and this is one of the reasons that some observers question whether it even really exists.
Critics make the point that ‘normal' people also have delusions and sometimes even hallucinations. Such people may never come to the attention of psychiatric services so the question is what separates them from the people who do? One answer seems to be that they can cope with their situation.
Perhaps there is a case here for focussing our attention on ways to explain the very specific experiences of people with schizophrenia. Instead of looking for ways in which signs and symptoms can be clustered, grouped or classified, maybe our attention should focus on each specific symptom as a unique feature with its own underlying cause, or causes, that need to be treated in a specific way, a feature of which might be the use of positive coping strategies?
Bennett, P. (2003) Abnormal and Clinical Psychology. Open University Press
Liddle, P., Carpenter, W.T and Crow, T. (1994) Syndromes of Schizophrenia: classic literature. British Journal of Psychiatry, 165: 721-7