SPECIFICATION

The Reliability and Validity in the Diagnosis and Classification of Schizophrenia.

Including Reference to:

• Co-Morbidity,

• Culture and Gender bias

• Symptom overlap

The specification roughly translates to the following questions:

1. Is schizophrenia a valid classification, e.g., is it a disorder or a social construct?

2. Is schizophrenia a reliable classification, e.g., has the classification of schizophrenia remained stable over time?

3. Is a diagnosis of schizophrenia valid and reliable, e.g., will other doctors diagnose schizophrenia too?

4. Do factors such as co-morbidity, culture and gender bias, and symptom overlap compromise the validity and reliability of schizophrenia? Please refer to them when answering questions 1-3.

INTRODUCTION

Is schizophrenia a chronic and severe disabling brain disease? John Read (2004) argues that the classification of schizophrenia is not based on solid science and believes that it's not useful or relevant as a label. Essentially, Read questions whether schizophrenia is a specific brain disease, suggesting that classification might need to change.

Since 1911, when the illness was first described as Dementia Praecox, there has been great controversy concerning what symptoms should be used to define it, in other words, to gain a valid definition.

Psychologists, including Crow, challenge the broad categorization of schizophrenia, arguing that it potentially merges at least two fundamentally different disorders. Crow suggests a division where individuals displaying positive symptoms with a sudden onset are categorized as "Type One" schizophrenics. In contrast, those showing negative symptoms with a gradual onset are considered "Type Two.

Consequently, research grounded in the early 20th-century definitions of mental illnesses, such as the meta-analysis conducted by Gottesman and Shields, may become outdated. This is due to the continuous evolution in understanding these disorders, suggesting that historical research might not align with current conceptualizations and insights into this condition.

The characteristics that once defined schizophrenia in the DSM-III era are notably different from those outlined in the DSM-V. Recent years have marked a significant phase in the development of schizophrenia's understanding, as the criteria for diagnosing the condition have seen considerable shifts. This evolution underscores a transformative period in psychiatric diagnosis, highlighting how perceptions of schizophrenia have changed over time.

If the definition of schizophrenia is considered invalid or continues to evolve, it poses a significant challenge for doctors and psychiatrists attempting to diagnose the disorder. Diagnosing a condition requires a stable, reliable set of criteria distinguishing the disorder from other conditions. When the definition is in flux or deemed unreliable, it undermines the diagnostic process, making it difficult for psychiatrists to identify and categorize the disorder in patients confidently. This uncertainty has profound implications for diagnosis, treatment, and research.

Incorrect diagnoses can lead to significant treatment mismatches, where individuals might undergo therapies that do not suit their condition, facing unnecessary side effects, especially from treatments like antipsychotics. Conversely, some patients might not receive any therapy, having been overlooked by the diagnostic process. This mismatch between diagnosis and actual condition can severely distort research outcomes, making statistics on treatment efficacy unreliable. The data derived under these circumstances would reflect an inaccurate picture of success or failure rates, as the participant samples wouldn't accurately represent those genuinely affected by the condition under study. Such inaccuracies can significantly impede the progress in pinpointing schizophrenia's causes and formulating effective treatments.

The shifting criteria for diagnosing schizophrenia can lead to the selection of inappropriate participants for studies aimed at uncovering the disorder's roots. This inconsistency might result in research and treatment programs including individuals who either don't have the illness or have other conditions that haven't been identified.

The argument for classifying schizophrenia into distinct categories, rather than viewing it as a monolithic condition, gains support from research demonstrating that individuals with different types of schizophrenia, e.g., Type 1 compared to Type 2, show varied responses to treatments. Studies have found that typical antipsychotics and Cognitive Behavioral Therapy (CBT) are more effective in managing the positive symptoms seen in certain forms of schizophrenia. Despite this evidence, it remains common for doctors to diagnose schizophrenia without making distinctions based on positive or negative symptoms or identifying specific subtypes. This generalized approach to diagnosis may result in suboptimal treatment plans, as what works well for one subtype might not be effective for another. Consequently, the inability to accurately identify and differentiate between forms of schizophrenia can adversely affect the quality of treatment and outcomes for patients.

The DSM-V's choice to remove subtypes of schizophrenia stemmed from the realisation that many patients' symptoms did not align clearly with the previously established categories, prompting a shift to a more generalized diagnosis of schizophrenia without subtypes. However, this broad categorization may overlook the needs of specific groups. For instance, families of individuals with Paranoid schizophrenia might find themselves without the tailored support they need, such as specialised training to manage Expressed Emotions (EE). This kind of nuanced support can be crucial for navigating the challenges associated with particular subtypes of schizophrenia, suggesting that a one-size-fits-all approach to diagnosis may not serve all patients and their families equally. Research indicates that families often perceive negative symptoms, such as lack of motivation (avolition) or apathy, as behaviours within the person's control, leading to more hostile and critical attitudes towards the affected family member. On the other hand, positive symptoms, which include hallucinations and delusions, are frequently recognized as inherent aspects of the illness, possibly due to their overtly "bizarre" nature. Consequently, families dealing with members who exhibit positive symptoms tend to have lower levels of Expressed Emotion. This disparity highlights the importance of nuanced understanding and classification of schizophrenia, suggesting that a one-size-fits-all diagnosis may overlook the specific needs and challenges faced by patients and their families.

The lack of homogeneity (consistency) in schizophrenic symptoms

A pathognomic symptom is unique to a disorder and is not present in any other. However, there are none of these for schizophrenia, so making a valid diagnosis can be problematic. For example, only 75% of schizophrenic patients suffer from hallucinations and delusions so it's impossible to diagnose schizophrenia based on someone having or not having these symptoms. Plus, these symptoms are also a result of other disorders such as alcohol/drug dependency and bipolar depression.

Very different problems can be presented by different patients diagnosed with schizophrenia, and per ICD and DSM, only two potentially quite different symptoms need to be present to diagnose schizophrenia. For example, it’s possible to give individuals with totally different behaviours the same diagnosis of schizophrenia.

 This suggests that there is no single underlying causal factor - a further reason to question the validity of schizophrenia as a diagnosis. Critics argue that a diagnosis of schizophrenia is too longwinded to be useful as a diagnostic category.

The lack of Objective tests for Schizophrenia

There is no objective biological test for determining whether a person has Schizophrenia. Assessment must be done by clinical interview. This has led to major problems and has led some critics to argue that if Schizophrenia cannot be diagnosed physically, then it may not be a disorder at all.

The difficulty of being able to predict outcome or response to treatment.

Predictive validity refers to the classification system's ability to predict the disorder's course and the response to treatment. However, it has proved to be very difficult to predict accurately the ICD and DSM validity, and there are wide individual variations. About one-third of patients have one episode or a few brief episodes of schizophrenia and then fully recover. Another one-third, throughout their lives, has occasional episodes and functions reasonably effectively between episodes. The remaining patients deteriorate over a series of increasingly incapacitating episodes. Between 10-15% of people with schizophrenia commit suicide. This proves that how schizophrenia develops cannot be predicted as the figures are not that accurate. It becomes more like a 'lottery' which is difficult to predict

Counter arguments to the above three points (e.g., the lack of homogeneity (consistency) in schizophrenic symptoms, the lack of objective tests for Schizophrenia, and the difficulty of being able to predict outcome or response to treatment would point out that DSM V now believes that Schizophrenia is an aetiologically heterogeneous disorder and has thus renamed it a “spectrum” disorder (a bit like the new labelling of Autism).

In other words, schizophrenia is a disorder that has not only a multitude of different things that can cause it, but it is also a disorder with no defining features. The addition of the term “spectrum” and the less stringent guidelines show that the DSM 5 is acknowledging that it sees Schizophrenia as an umbrella term.

DSM V acknowledges that any risk factor for developing Schizophrenia will combine biology and the environment. Therefore, the aetiology is no longer a fight between nature and nurture. A mixed explanation like this is known as a diathesis-stress model (DS).

In short, the DS sees Schizophrenia as a form of brain damage to various regions in the brain that are concerned with language and thought. For example, areas in the brain occupied by Dopamine D2 receptors are hypo and hyper-presented in Broca’s area. This may account for the differences found in language between patients with positive and negative symptoms. The DS sees the causes of Schizophrenic brain damage as a varying combination of genes, pathogens, viruses, difficult birth, etc., that interact with environmental stressors (abuse, bullying, marital schism, etc.).

The problem of co-morbidity with depression

Critics argue about the importance of the clinical practice of psychiatry in recognising and assessing symptoms and syndromes that, even though not directly related to the “core” clinical features of schizophrenia, may complicate the course and the long-term management of the disease. Disorders that are comorbid with Schizophrenia are obsessive-compulsive disorder, panic disorder, depression/suicide risk, and drug dependency.

Buckley et al. (2009) estimate that comorbid depression occurs in 50% of patients, and 47% of patients also have a lifetime diagnosis of comorbid substance abuse. Such comorbidity creates difficulties in diagnosing a disorder (as well as treatment).

Recognising that Schizophrenia is a comorbid condition defies the view of schizophrenia as a standardised and single category and proposes a more reliable approach to the disease’s diagnosis and treatment.

Most importantly, though, recognising that Schizophrenia is comorbid means again that patients who, for example, may be at risk of committing suicide receive appropriate treatment for this as well as their Schizophrenia. It also begs the question of why so many Schizophrenics are depressed. Is Schizophrenia that is comorbid with depression another disorder? Or is it a product of being mentally ill? Either way, it needs to be qualitatively treated differently, say Schizophrenics who present with drug abuse.

The question of whether schizophrenia is a mental disorder at all or a form of political control (Szasz)

The label schizophrenia is extremely damaging to those to whom it is applied.

Many psychologists believe that Schizophrenia is a term that can be viewed as a social construction. Szasz has argued that psychiatric diagnoses are nothing but language constructs. He has criticised the DSM’s poor validity and reliability and hypothesised that terms like 'schizophrenia' and 'mental illness' only exist by agreement and persevere by convention.

Szasz’s main arguments can be summarised as follows:

The myth of mental illness: "Mental illness" is an expression, a symbol that describes offending, disturbing, shocking, or vexing conduct, action, or pattern of behaviour, such as schizophrenia, as an "illness" or "disease". Szasz wrote: "If you talk to God, you are praying; if God talks to you, you have schizophrenia. If the dead talk to you, you are a spiritualist; if you talk to the dead, you are a schizophrenic."

While people behave and think in disturbing ways, which may resemble a disease process (pain, deterioration, response to various interventions), this does not mean they have a disease. To Szasz, the disease can only mean something people "have," while the behaviour is what people "do". Diseases are "breakdowns of the human body, of the heart, the liver, the kidney, the brain" while "no behaviour or misbehaviour is a disease or can be a disease.

The idea that schizophrenia can be viewed as a specific, genetically determined, biologically driven brain disease has been based on bad science and social control since its inception.

A wide range of individuals and organisations have argued that the DSM-5 is in danger of "medicalising normal reactions and behaviours". The argument expressed is that grief is a normal, if upsetting, human process that should not require treatment with drugs such as antidepressants.

“The DSM-5, to be published in May, defines shyness in children and uncertainty over gender as mental disorders. Loneliness could be diagnosed as chronic depressive disorder, as well as unhappiness after bereavement. Under the new edition, a rapist could be classified as mentally ill and could be diagnosed with paraphilic coercive disorder. The DSM-4 – last revised 12 years ago – classifies children who argue and disobey their parents as having oppositional defiance disorder.”

Professor Nick Craddock, a consultant psychiatrist in Cardiff and director of Wales' National Centre for Mental Health, said: “Somebody who is bereaved might need help and even counselling, but they did not need a label saying they had a mental illness. I believe that a large proportion of psychiatrists in the UK and Europe are sceptical about DSM-5.” The American Psychiatric Association has defended the DSM-5. The vice-chair of the DSM-5 task force wrote: “While we agree that human feelings and behaviours exist on a spectrum that contains some overlap of normal reactions to disease states, psychiatry also recognizes that there are real and discrete disorders of the brain that cause mental disorders and that can benefit from treatment.”

~ Guardian, Feb 9; BMJ, Feb 10

 “The maverick psychiatrist RD Laing once described insanity as "a perfectly rational response to an insane world". In 1965, having served as a doctor in the British army and then trained in psychotherapy at the Tavistock Clinic in London, Laing formed the Philadelphia Association with a group of like-minded colleagues. They aimed to bring about a revolution in the diagnosis and treatment of mental illness.”

Stigma

“Alternative Perception” is one of several names suggested by the schizophrenic user movement to replace the term schizophrenia, which is on a spectrum of psychotic disorders and is considered to be outmoded by many consumers of services. Several academic authorities, notably Professor Marius Romme, founder and principal theorist for the Hearing Voices Movement, provide a rationale for the abandonment of the Schizophrenic label. A convention of some of the leading notions in this field from consumers of services and academics concluded:

“We are calling for the label of schizophrenia to be abolished as a concept because it is unscientific, stigmatising, and does not address the root causes of serious mental distress. Two central factors drive the CASL campaign. The concept of schizophrenia is unscientific and has outlived any usefulness it may once have claimed. The label schizophrenia is extremely damaging to those to whom it is applied.”

To be labelled a schizophrenic’ is one of the most devastating things that can happen to anyone. This label implies dangerousness, unpredictability, chronic illness, inability to work or function at any level and a lifelong need for medication that will often be ineffective (Whitaker 2005) but will usually cause unpleasant side effects. To champion the idea that schizophrenia is an illness just like any other (sometimes referred to as mental health literacy) makes the situation worse in that it has been shown to increase, amongst other things, mistrust and a desire for social distance.

Anti-psychiatrists desire to place the label ‘schizophrenia’ into the diagnostic dustbin, to which they believe it most certainly belongs. They think it is not based solely on the poor science surrounding it but also on the immense damage this label can bring about.

A single word can ruin life as surely as any bullet, and schizophrenia is just such a bullet.

Stigmas can reduce the validity. 

A system for diagnosing schizophrenia cannot be considered accurate if many cases go undiagnosed. This may be because there are certain social stigmas and repercussions attached to diagnosing someone with schizophrenia, so some clinicians may be reluctant to do so. Although this can occur all over the world, it is more likely in a country such as Japan, as schizophrenia translates to 'disease of the disorganised mind.' Kim and Berrios (2001) researched this and found that in Japan, the idea of a 'disorganised mind' is so stigmatised that psychiatrists are reluctant to tell patients of their condition. This means that only 20% of those with schizophrenia are aware of it.

RELIABILITY

The reliability of the major classification systems (ICD and DSM)

Perhaps the most important issue concerning the validity and reliability of Schizophrenia is the differences between the two classification systems: ICD and DSM. 

The term reliability means that each time the two main classification systems (the International Classification System for Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM)) are used, they should produce and provide the same classification and diagnosis. Reliability will be hard to attain if validity is not certain.

The DSM-IV-TR contains five sub-classifications of schizophrenia (paranoid, Disorganised, Catatonic, Undifferentiated and Residual), Whereas the ICD recognises seven subtypes.

DSM is multi-axial, meaning various factors are considered before making a diagnosis.  ICD is not multiaxial.

Lastly, the duration criteria differ markedly: ICD-10 requires at least one month, whereas DSM-IV requires continuous disturbance for at least six months. This has not changed with DSM V.

If the two major classification systems cannot agree, then issues of Schizophrenia being viewed as a valid scientific term remain questionable.

Many researchers believe that DSM-IV-TR has improved reliability; however, the reliability of the DSM in everyday usage may be lower than seen in research studies - meaning that only research studies are recorded with high reliability, and non-research studies may have lower reliability.

Moreover, despite claims for increased reliability in DSM-III and later versions, 30 years later, many still feel there is little evidence that DSM is routinely used with high reliability by mental health clinicians.

Reliability of diagnosis between doctors

Reliability refers to the consistency of a measuring instrument (e.g. a questionnaire or scale) to assess and diagnose schizophrenia. The reliability of such questionnaires or scales can be measured in terms of 
Inter-rater reliability, which is whether two independent assessors give similar diagnoses
Test-retest reliability is whether tests used to deliver these diagnoses are consistent over time.

Early versions of the classification manuals were unreliable or valid –symptoms weren’t clearly defined and were vague and inconsistent. For a diagnosis to have any clinical utility, it must be reliable. That is to say, there must be consistency in how individuals are diagnosed. There is no evidence that this has ever been the case with schizophrenia.

Beck 1962, says clinicians and doctors use very different interview techniques when assessing patients, leading to very low reliability in diagnosis.

Read (2004) has illustrated how it is possible for 15 individuals with nothing in common to be gathered together in one room and all be diagnosed with schizophrenia.

Another issue that affects the reliability of the diagnosis of schizophrenia is unreliable symptoms. In the DSM-IV, only one characteristic symptom was required for a diagnosis of schizophrenia if delusions were 'bizarre'. However, there seemed to be little agreement on what counted as a 'bizarre' symptom, therefore this may have also affected the inter-rater reliability of diagnosis.

klostercotter (1994) assessed 489 admissions to psychiatric wards. He found that positive symptoms were more useful for diagnosis than negative symptoms. This means that negative symptoms need to be better understood, and persons with Schizophrenia who present with very few positive symptoms, e.g., Hebephrenic Schizophrenia, may be much more poorly diagnosed than, say, persons with Paranoid Schizophrenia that has mainly positive symptoms.

When 50 senior psychiatrists in the US were asked to differentiate between ‘bizarre’ and ‘non-bizarre delusions, they produced inter-rater reliability correlations of 0.40. This finding forced researchers to conclude that even this central diagnostic requirement lacks sufficient reliability for it to be a reliable method of distinguishing between schizophrenic and non-schizophrenic patients.

Test-retest reliability: Measures of cognitive functioning are vital in diagnosing schizophrenia; therefore, they must have test-retest reliability to be useful in this role. This means practically that if a patient tests their cognitive functioning at various points in time, they should achieve the same score each time they are tested if their condition is stable.

Whaley (2001) found inter-rater reliability correlations in the diagnosis of schizophrenia as low as 0.11

Beck et al. (1962) Found that agreement on diagnosis for 153 patients (where two psychiatrists assessed each from a group of four—inter-rater reliability again!) was only 54%. This was often due to unclear diagnosis criteria and inconsistencies in data-gathering techniques.

Wilkes administered two alternate forms of cognitive screening tests to schizophrenic patients over intervals varying from 1 to 134 days. The test-retest reliability was 0.84. This demonstrates that the cognitive screening tests' test-retest reliability was relatively high, supporting the concept that the DSM has high test-retest reliability.

Prescott found strong evidence that the DSM has high test-retest reliability; they analysed the reliability of several measures of attention and information processing in 14 chronic Schizophrenics. Performances on these measures were stable over six months. Therefore, although the DSM may suffer from low inter-rater reliability, the cognitive screening tests seem to have high test-retest reliability.

DSM V has tried to overcome the problems with past editions. For example, it has deleted the classic subtypes and added dimensions to characterise the difference (heterogeneity) of Schizophrenic symptoms.

ICD-11 is expected to follow DSM by making similar changes, allowing supporters of the classification systems to argue that ICD and DSM will become more similar than ever. These modifications are hoped to lead to better diagnosis.

The current discrepancy in the duration criteria for schizophrenia between DSM and ICD (6 months vs. one month, respectively) will likely remain.

Symptom overlap and the inclusion of mixed disorder categories (schizoaffective disorder, Acute and Transient Psychosis, mania, depression) by classification systems

DSM recognises Schizoaffective disorder, acute & transient psychosis and Schizophreniform, delusional disorder as part of Schizophrenia, whilst ICD sees them as separate disorders (mood disorders).  Schizophrenia and bipolar disorder are generally considered to be distinct diagnoses, but people who show multiple symptoms of both disorders are often given the hybrid diagnosis of schizoaffective disorder. The boundaries between schizophrenia and other disorders can usually be difficult to define. Schizophrenia has similarities to many of the disorders listed below, making reliability and validity of diagnosis very difficult.

Schizophrenia is a Schizotypal disorder, Persistent delusional disorder, Acute and transient psychotic disorder, Schizophreniform Disorder, Schizoaffective disorder, Delusional disorder, Brief psychotic disorder, Substance-induced psychotic disorder and Delusional disorder.

Neither classification system recognises why symptom overlap happens (e.g., what is occurring environmentally or biologically to cause mania and positive systems? Why is it that some people suffer depression or mania and have Schizophrenic systems, and others do not? Why are mixed symptom disorders seen as mood disorders by ICD?

 Other diagnostic criteria for schizophrenia, e.g., Schneider criteria, are available!

Kurt Schneider (1887-1967). Schneider contributed a description of first-rank symptoms, which, he stressed, were not specific to schizophrenia and were not to be rigidly applied but helped make diagnoses. He emphasized that the disorder could be diagnosed exclusively based on second-rank symptoms and an otherwise typical clinical appearance in patients who showed no first-rank symptoms. Clinicians frequently ignore his warnings and sometimes see the absence of first-rank symptoms during a single interview as evidence that a person does not have schizophrenia.

The special treatment of bizarre delusions and other Schneiderian first-rank symptoms in criterion an (active phase symptoms) has now been eliminated from DSM V because these symptoms are not specific to schizophrenia, and the distinction between bizarre versus non-bizarre delusions has been found to have poor reliability. These symptoms are now thought to lack any special significance in the context of schizophrenia. In DSM-5, “Schneiderian first-rank symptoms” are treated like any other positive symptom regarding their diagnostic implication. It is thought that ICD 11 will follow DSM in eliminating Schneiderian 1st rank symptoms.

 Schneider (1959) identified ‘first rank’ symptoms – that were designed to identify schizophrenia uniquely.

Ellison and Ross (1995) people with DID (dissociative identity disorder) have more first-rank symptoms than schizophrenics.

Cultural Differences in the reliability of diagnosis

The reliability of diagnosis in schizophrenia is further challenged by the finding that there is massive variation between cultures and within cultures.

Copeland et al. (1971) Describe a patient to 134 US and 194 British psychiatrists. Results: 69% of the US psychiatrists diagnosed with schizophrenia, 2% of the UK psychiatrists diagnosed with schizophrenia

Schizophrenia was more commonly diagnosed in the USA (80% of patients during the 1950s) than in England (during the same period - 20%).

The ethnicity of the patient may lead to misdiagnosis. Misdiagnosis may result from factors such as cultural differences in language and mannerisms and difficulties in relating between black patients and white clinicians. For example, if the patient has difficulty expressing themselves in English, their symptoms may be misunderstood. 
Harrison et al. (1997) supported the notion that the diagnostic criteria for schizophrenia may not be valid across cultures; they found that the incidence rate for schizophrenia was eight times higher for African-Caribbean groups (46.7 per 100,00) than for white groups (5.7 per 100,000). This suggests that language or cultural differences affect the validity of the diagnosis.

The reliability of diagnosis in schizophrenia is further challenged by the finding that there is massive variation between cultures and within cultures.

Copeland et al (1971)

Description of a patient to 134 US and 194 British psychiatrists

69% of the US psychiatrists diagnosed schizophrenia

2% of the UK psychiatrists diagnosed with schizophrenia

Afro-Caribbeans who live in the UK, USA, and other predominantly Caucasian societies are seven times more likely to be diagnosed as Schizophrenic than if living in a country that has predominantly black people. This again points to problems with the validity and reliability of diagnosis as the statistic would be similar in both types of culture if classification and diagnosis were correct. There are four theories for this occurrence.

Theory 1:

White societies are prejudiced. You are more likely to be socially and educationally disadvantaged if you are black, e.g. more likely to be stopped and searched by police, more likely to be expelled (even though white children may have done the same thing as their black classmate), worse job opportunities, poorer examination results. Afro Caribbean are also more likely to be the victim of more racially motivated attacks (Harralambous). Thus, the idea is that more black people get Schizophrenia than other ethnic groups because it is a reaction to racism/prejudice - being frustrated/depressed about living in an unjust society. Counter-arguments would indicate that East Asian people are equally marginalised in white society but do not suffer the same levels of Schizophrenia. Counter counter-arguments would retaliate by pointing out that East Asian communities are more likely to keep problems within the family and, therefore, not report mental health issues to the doctor because of fear of stigmatisation.

Theory 2:

Doctors don’t understand black cultures and misdiagnose Schizophrenia, e.g. some Caribbean cultures believe you should talk to relatives/friends after they have died. So, for instance, a grieving widow may tell a doctor she has been talking to her dead husband / or she may be observed talking to her dead husband. Either way, the idea is that many white UK doctors will not understand the norms of her culture and will diagnose Schizophrenia or another mental illness. Such doctors apparently will not be intelligent enough to ask the person further questions about why she is talking to her dead husband and make parallels with some of their own UK norms, such as how praying could be seen as bizarre if you did not understand or know about Christian beliefs, e.g. sitting at the end of your bed with your hands together, talking to an imaginary unproved entity might look pretty peculiar to somebody unfamiliar with the religious practices in the UK.

I think this latter idea is quite patronising and insulting to black people. The vast majority of black people in the UK etc., are fourth and fifth-generation immigrants; some have been in the UK since Elizabethan times. Therefore, they are completely culturally assimilated into UK norms, customs, and values.  Furthermore, in the USA, everyone except native Indians is an immigrant, so cultural assimilation should not even be an issue for black people as they are as new as any other culture. Lastly, black people do not form one culture. They are from very diverse and different backgrounds: some are mixed-race with no cultural ties to anywhere, but their country of birth, some are from the many other islands in the Caribbean, some are from South America and some from Africa (which is a huge and dissimilar continent in terms of language, ethnicity, religion and culture) ……..So to assume that black people get diagnosed more frequently with Schizophrenia because doctors don’t understand they don’t come from a  “Only culture”, or they find it hard to understand black people is quite frankly ridiculous and offensive.

Theory 3: Doctors are racist and diagnose Schizophrenia as a form of social control.

Theory 4: Black people are more likely to get Schizophrenia in northern hemisphere countries because their skin makes Vitamin  D very slowly.  This is supposed to be because black people originate from equatorial countries with little variation in sunlight and seasons, and it is pretty hot and sunny all the time when it is daytime. As vitamin D is made on the skin and equatorial countries have abundant sunshine, it is hypothesised that black people have evolved to make vitamin D more slowly.  On the other hand, white northern Europeans live in countries with much lower levels of sunlight, and they experience minimal amounts of light during winter. It is hypothesised that they have evolved to cope with this by taking vitamin D on their skin very quickly. 

Vitamin D is vital for foetal brain development. Intense cortical development happens around the sixth month of pregnancy.  The idea is that black women* will be more likely to have children who develop Schizophrenia if they are six months pregnant during the late autumn/winter** months (low sunlight conditions) in northern hemisphere countries and do not have a diet rich in vitamin D. Their babies will not get sufficient vitamin D at a crucial time in brain development; they will then be vulnerable to developing Schizophrenia when they become teens.

Evidence for this theory comes from studies of weather conditions in Australia.  El Nino is a quasi-periodic climate pattern that occurs on average across the tropical Pacific Ocean every five years and is characterized by intense cloud coverage. This means that when El Nino occurs, there will be very little sunshine. Studies have shown that there are massive peaks in Schizophrenia fifteen years after El Nino occurs.

*This will not affect black fathers if their partner is a non-black or white mother of mixed-race children.

**Remember, Schizophrenics are far more likely to be born in winter.

Outline and evaluate issues surrounding the classification and diagnosis of Schizophrenia concerning reliability and validity

 Mark scheme:

Advice from the AQA mark scheme on this question

AO1 = six marks

AO1 credit is awarded for describing issues concerning the classification and diagnosis of schizophrenia, most of which are related in some way to reliability and validity. Some issues are specifically relevant to schizophrenia, e.g., the range of symptoms / sub-types of schizophrenia and the difficulty of distinguishing between them. Other issues surrounding the classification and diagnosis of mental disorders, in general, can receive credit if they are made relevant to schizophrenia.

For AO1 credit candidates, they need to identify some of these issues. For example:

1)    The reliability of the major classification systems (ICD and DSM)

2)   The lack of homogeneity (consistency) in schizophrenic symptoms

3)   The problem of co-morbidity with depression

4)   The availability of other diagnostic criteria for schizophrenia e.g. Schneider criteria

5)   Cultural differences in symptom presentation

6)   The lack of objective tests for schizophrenia

7)   The difficulty of being able to predict outcome or response to treatment

8)   The question of whether schizophrenia is a mental disorder at all or a form of political control (Szasz)

Examiners should be mindful of a depth/breadth trade-off – candidates can describe a few issues in detail or more issues in less detail. There is considerable overlap between the problems of classification and diagnosis, so partial performance criteria do not apply.

Candidates who offer lists of signs and symptoms of schizophrenia or who describe classification systems are not addressing the issues surrounding diagnosis and classification. Such material is rudimentary.

 AO2/AO3 = 10 marks

Candidates achieve AO3 credit by evaluating and offering commentary on the issues they have identified, for example, considering the consequences of the issue. They may discuss the advantages of using classification systems for effective treatment programmes and support and problems associated with classification and diagnosis. For example, the diagnosis might lead to labelling and stigmatisation (Scheff 1966), causing long-term problems in getting/keeping employment and leading to a self-fulfilling prophecy.