Diagnosis of schizophrenia

Schizophrenia is a mental disorder that occurs with a lifetime risk of approximately 1 % worldwide. The disease has a variable course and begins in the majority of patients before the age of 35. The cause of the disease is unknown. The appearance of schizophrenia is characterized by positive and negative symptoms that manifest themselves differently in different disease stages. This article gives an overview of the forms of the illness experience and behavior of patients with schizophrenia (symptoms), and the procedures of correct identification of the disease ( diagnosis).

3.2.1 Experience manner and expression

4.1 operationalized diagnostic
4.2 comorbidity
4.3 Multiaxial diagnostics

5.1 Differential diagnosis against somatic and substance-induced disorders
5.2 Differential typology against other mental disorders 5.2.1 Digression: classification of so-called Schizoaffective Disorder

Introduction

Due to the diversity of schizophrenia as a group of diseases ( Bleuler ) a uniform description of symptoms is not possible. There is also no cardinal symptoms of schizophrenia in the strict sense, because the cause of the disease is unknown. Over time, different disease concepts of schizophrenia have been developed, each with its own value placed on certain symptoms.

Basics

The Basics of a psychiatric diagnostic process can be summarized under the general phrases of the psychiatric examination and diagnostic assessment and psychiatric diagnosis and classification. The psychiatric examination includes conversation, diagnostic assessment, and various levels of analysis. In order to structure this wide variety of data collection instruments were developed. Here is mainly the AMPD system for the German-speaking countries: Mentioned ( AMPD in Psychiatry Association of Methodology and Documentation ). The psychiatric classification known today two classification systems, the ICD of the World Health Organization (WHO ) and the DSM -IV of the American Psychiatric Association (APA). For diagnostic classificatory special survey instruments were developed. The so-called structured clinical interview for DSM -IV (SCID ) is used for classification according to the DSM and the International Diagnostic Checklist ( IDCL ) serves as a checklist for a classification according to the ICD system. There are also a number of survey instruments that are suitable for both classification systems (DIA -X).

Symptoms and signs of schizophrenia

The pathological mode of experience of patients with schizophrenia is very diverse. We distinguish non-specific symptoms and characteristic symptoms. Non-specific symptoms occur not only in schizophrenia, therefore it does not help in detecting the disease. But you can be a measure of the severity of the disease. Characteristic symptoms are those that are frequently found in schizophrenia. A distinction is characteristic symptoms for the different phases of the disease and symptoms characteristic of various disease types of schizophrenia.

In the characteristic symptoms in the course of disease, a distinction is mainly positive or positive symptoms of the features of the negative or negative symptoms, which may be predominantly in the entire course of the disease acute phase of schizophrenia.

The predominant symptoms of the subtypes of schizophrenia can be under the key words for delusional paranoid schizophrenia, summarize affective changes and disorganization of thought for the hebephrenic schizophrenia and psychomotor disturbances for catatonic schizophrenia.

Finally, one can still distinguish disease characteristics that can be tapped only or mainly by the patient's report ( hearing voices ), and those that can be tapped only or primarily through observation ( rigid motion ). Following the proposal Kurt Schneider distinguishes Gerd Huber in his textbook experience abnormal manner and abnormal expression. This distinction reflects the conceptual difference of clinical symptoms ( patient complaints ) and clinical evidence ( finding a physical examination ).

Nonspecific psychological symptoms

There are a number of non-specific symptoms in schizophrenia. Such symptoms do not allow the diagnosis of the disease. They also occur in other diseases and the fact that a man has such complaints, does not say that he is suffering from schizophrenia. But many patients with schizophrenia show in addition to the characteristic symptoms of the disease non-specific symptoms. A classification of non-specific symptoms of the disease can occur in different ways.

Outpost symptoms of schizophrenia

One way to classify the non-specific symptoms of schizophrenia, is to identify the picket symptoms of the disease. These outposts are frequent symptoms or early signs of the disease have been identified in studies of the onset and early course of schizophrenia. The most common symptoms in the early course of schizophrenia are: agitation, depression, anxiety, thinking and concentration problems and worries. Other investigators have as a common early warning signs in 72% of affected restlessness, insomnia in 64%, 62% anxiety, 60% difficulties at work and 56% feel they are not understood found.

Common general symptoms in schizophrenics

Another way to classify the non-specific symptoms of schizophrenia, is realized in the scale for detecting the psychopathological findings. A frequently used scale is the Positive and Negative Syndrome Scale ( PANSS ). Next seven positive and seven negative symptoms It also contains a list of sixteen non-specific symptoms such as anxiety, guilt, concern for physical integrity or disturbance of the will.

Characteristic features of mental illness

There are different ways to classify the characteristic features of the mental illness schizophrenia: after positive-negative approach, according to the symptoms of acute and chronic schizophrenia, according to commonly occurring symptoms or in the sense of Erstrangsymptome by Kurt Schneider.

The symptoms of schizophrenia can be categorized into two groups of positive and negative symptoms. The Positive symptoms are those that were observed particularly clearly in an acute attack of the disease and the negative symptoms such that often appear as a temporally enduring feature of the disease. As negative symptoms, the so-called " six a 'level by Andreasen: affective flattening, alogia ( paucity of speech ), aboulia / apathy ( lack of will ), anhedonia (inability to feel positive feelings), attention disorders and antisocial behavior ( disruption of interpersonal skills ). The most common positive symptoms are delusions, hallucinations, thought disorder, and I experience problems. Although the dichotomous model of schizophrenia, the Nancy Andreasen presented in this paper, a critical review was not held, the introduction of the positive-negative - concept in schizophrenia research has been very successful.

When divided Schizophrenia in type I and type II schizophrenia according to Tim Crow, then an order of symptoms results according to whether they occur mainly in the acute or in the chronic phase. The most common symptoms of the acute phase are not limited to: lack of insight into illness, auditory hallucinations and delusions. The most common symptoms of the chronic phase are, inter alia: social withdrawal, apathy and paucity of speech. However, this classification of schizophrenia could not be replicated in subsequent empirical studies.

The Erstrangsymptome of schizophrenia by Kurt Schneider are:

Delusional perception
The dialogic and commenting auditory hallucinations
Thought insertion, thought withdrawal, thought broadcasting, and will influence
Other influencing experiences with the character of externally -made ( eg, physical experiences influence )

The empirically most common symptoms of schizophrenia include disturbances of thought and language ( especially the thought disorganization ), disturbances of affect ( affective flattening and depression ), hallucinations ( dialogical and commenting voices ), delusions (eg, paranoia ) and I - disorders ( the so-called disorders of Meinhaftigkeit of experience ).

Through the study of symptom groups different investigators have suggested hypotheses for a subclassification of schizophrenia after Kraepelin ( paranoid, hebephrenic, catatonic ) the old classification system was intended to replace. Surprisingly, almost all of these tests have proved ineffective, clinically subdivide schizophrenia into subtypes. The concept of syndrome clusters according to Liddle ( reality distortion, psychomotor poverty and disorganization ) appears different authors as promising as it supports the empirical evidence and clinical observation, can show symptoms of various subtypes in changing the schizophrenic patients in the course of their disease.

Mode of experience and expression

Based on Schneider G. Huber distinguishes the abnormal way of experiencing the abnormal expression. Abnormal experience, the schizophrenic then, primarily the symptoms of the first rank according to Schneider, who can also be a symptom group 1-4 in the ICD 10 apply. The table gives an overview modified by Huber:

Auditory hallucinations
Body hallucinations
Other hallucinations
I Schizophrenic Disorders
Delusion

Dialogical voices, voices commenting end, thought echo
Influencing bodily experiences
Thought insertion, thought withdrawal. Thought broadcasting, will influence
Delusional perception

Other auditory hallucinations
Zönästhesien in the strict sense
Optical hallucinations, olfactory hallucinations, taste hallucinations
Simple self-reference, delusions incidence

Formal thought disorder ( incoherence of thought and thoughts Cancel ).
Catatonic disorders
Affective disorders and Contact
Expression disturbances in the narrow sense

Psychomotor: " loss of grace "
Facial expressions: " Paramimie "
Verbal expression: neologisms, Flick words, Quirky language
Holistic term distortions: distance loose or bizarre behavior

Physical symptoms and signs

Patients with schizophrenia have sometimes certain physical symptoms, so-called " neurological soft signs" ( nichtlokalisatorische neurological signs ). They include abnormal involuntary movements, intermittent saccades and reduced p300 amplitude. In addition, we find in schizophrenics a variety of autonomic disturbances.

The assessment of such phenomena as the disturbed pursuit eye movement in schizophrenic patients and their next of kin is controversial. Some authors have suggested that it was a so-called intermediate endophenotype, a disorder that is genetic and is closely linked with the physiological cause of schizophrenia. This hypothesis is controversial, although the concept of endophenotypes is very popular in the context of a neurobiological cause for schizophrenia research.

Technical examination findings

Main article: Neurobiological schizophrenia concepts

In general, patients with schizophrenia show for technical investigations no abnormalities. The physical health is yes according to the diagnostic criteria of the ICD as a prerequisite for the diagnosis of schizophrenia can be made. The exceptions to this rule are discussed in detail in the main article above. Regardless of are found in patients who are ill for some time and a chronic form of the disease does not show due to concomitant diseases rare blood disorders. Thus neuroleptics can cause slight increases in liver function tests. Some patients show behavioral anomalies (eg, a delusional induced polydipsia ), which then present themselves in changes in laboratory values ( in the case of polydipsia a lowering of serum sodium values).

The operationalized diagnosis of schizophrenia

To understand the principles of diagnosis for schizophrenia ( as for all mental illnesses ) after the ICD or DSM -IV - catalogs you need the hallmarks of current classification systems in psychiatry.

It is the following:

The concept of operationalized diagnostic
The phenomenon of comorbidity
The principle of multi-axial diagnosis

Operationalized diagnostic

To make an operationalized diagnosis of a disease you need two things: first, diagnostic criteria, ie symptoms, signs, findings, time and historical criteria in the sense of inclusion and exclusion criteria; Second, decision-making and linking rules for these criteria.

The symptom criteria are described in textbooks of psychopathology or in handbooks and manuals with psychiatric scales accurately and are often different from the everyday use of language. The use terms such as " episode" or " disorder " are also subject to precise definitions and should not be confused with everyday concepts. The operationalization is done differently strictly for research purposes about stricter criteria are applied.

For the schizophrenia of ICD- catalog distinguishes general diagnostic criteria for schizophrenia and an exclusion of title. Then diagnostic criteria for subtypes of the disease are ( paranoid, hebephrenic, catatonic, and undifferentiated) prescribed, and for the postschizophrene depression, schizophrenic residuum and the simple schizophrenia. In addition, rules for course pictures are given.

The diagnostic algorithm for schizophrenia according to ICD-10 provides the following. There is first a time criterion defined: the symptoms must be present at least one months continuously. Then identifies two sets of symptom clusters. The first row includes the symptom groups 1-4 The second series includes the symptom groups 5-9. The symptom group 1-4 is true after the ICD 10 match most of the substance with the Erstrangsymptomen by Kurt Schneider.

At the end of the exclusion of title is defined. A schizophrenia should not be diagnosed when the constellation of symptoms suggests rather pronounced manic or depressive states. ( Differential diagnosis, respectively. Differential typology K. Schneider against other " endogenous psychoses " ) or when a somatic brain disease is present (tumor) or when there is evidence of intoxication or substance withdrawal as a cause of the symptoms are present ( differential diagnosis against physically related disorders = " organic psychoses " )

The algorithm is then: if a clear symptom of the symptom group 1-4 or two clear symptoms of the symptom groups 5-9 are present at least one month continuously and there are no exclusion criteria, the diagnosis of schizophrenia can be made.

The disease is then used for schizophrenia yet assigned subtypes according to the ICD and classifies the course of image using eight different rules. A operationalized ICD diagnosis of schizophrenia may look like this:

If a patient has at least one month a culturally inappropriate delusion shows ( symptom of the symptom group 1-4)
If symptoms of other subtypes standing in the background (eg, catatonic symptoms ),
When the exclusion criteria are met,
When the symptoms have occurred relapsing repeatedly over several years and
When the patient is between the acute phases of the disease was free of symptoms or few symptoms, the diagnosis is:
Paranoid schizophrenia (subtype No. 1) F 20.0
Episodic remitting ( course criterion No. 3). x3.

The full notation is, then: Paranoid schizophrenia, episodic remitting (ICD 10 F 20:03 )

Comorbidity

With the concept of comorbidity is meant the common occurrence of various diseases. The diagnostic rules of the ICD-10 require that one embezzles not a symptom, because it does not fit to a diagnosis, but as many diagnoses is as necessary for the illustration of all symptoms found. This procedure is not self-evident, what is clear only in comparison with historical concepts, such as Karl Jaspers layers rules.

In the modern diagnostic systems you go on such, although obvious, yet empirically unverifiable assumptions. The reasons for this are many:

Patients with multiple diseases are severe ill and their prognosis is less favorable.
The comorbidity may provide clues to the etiology of a disease.
If you leave the layers rule, the prevalence rates vary: some diagnoses occur more frequently then.

The introduction of the concept of comorbidity has revealed that certain diseases (eg, addiction or personality disorders ) often occur in combination. This phenomenon is explained differently, something like that comorbid disorders are a consequence of some other disease (example: addiction as a result of fear) that the co-morbidity common causes of various diseases indicates (for example, anxiety and depression ) or that the comorbidity an artifact blurred due to diagnostic criteria or erroneous diagnosis algorithms is (example: dependent personality and social phobia).

Multiaxial diagnostics

The basic idea of the multi-axial diagnosis in psychiatry is the consideration of all the circumstances that contribute to the disease process, represent formalized. The fact that such circumstances are of great importance, has already Kraepelin worn with his concept of " pathoplastischen " Conditions. In modern multiaxial approaches this is done systematically.

Historically, there are three precursors of multiaxial diagnosis:

Kretschmer considerations for multidimensional diagnosis,
The two-axis system (symptom and etiology ) of Essen- Müller and Welfare 1949,
The multi-axis system of Rutter from the year 1969.

There are many approaches to the diagnosis and multiaxial no match, the axes are required. For this reason, here only the multiaxial approach according to ICD 10 is to be displayed. There are 10 in the ICD for mental disorders three axes. Axis I describes the clinical diagnoses, Axis II, the so-called psychosocial functional limitations and Axis III problems of living and coping with life. The DSM has five axes. Axis I-III corresponds to the clinical diagnoses of the ICD -10, V axis captures the social functioning level and Axis IV psychosocial and enviromental issues. The following table shows the axes of ICD and DSM are compared.

Axis I: Clinical diagnosis of mental disorders.
Axis I: clinical diagnosis personality disorders and mental retardation.
Axis I: Clinical diagnosis of physical disease.
Axis II: degree of social adjustment or disability. (WHO DAS- S)
Axis III: psychosocial and environmental factors. ( according to ICD -10 Z)

Axis I: clinical disorders. xxx Axis II: Personality disorders and mental retardation. Axis III: medical illness factors. Axis V: Evaluation of the functioning level (GAF ) Axis IV: Psychosocial and enviromental issues.

The results of the assessment may on the one hand axis are represented as ICD diagnoses and on the other hand specified as numeric values based on scales.

Axis I: ICD-10 F 20.00 ( paranoid schizophrenia, continuous)
Axis II: Global Assessment of Functioning Scale of 50, analogous values for the WHO Disability Diagnostic Scale.
Axis III: ICD-10 Z56.0 (unemployment); ICD-10 Z60.2 ( person living alone ); ICD-10 Z 59.6 ( low income )

In this way it is possible to systematically record important circumstances that show the severity of a disease. In addition, it is possible through the formalization, computer-aided evaluate the collected data and to compare studies. The Mental Health Research multiaxial approaches are indispensable today.

The main problem of multiaxial diagnosis is the diversity of systems and the lack of consensus on the use of different types. This limits the value of the method, namely the comparability of scientific studies, a. In addition, some axes show content overlap, ie they are not independent.

Differential Diagnosis

The differential diagnosis of schizophrenia is diverse. Generally, it is assumed here following presupposition: Schizophrenia is always a psychosis, but not all psychoses are schizophrenia. The core question can then formulate, in which disease the most common positive symptoms of schizophrenia can ( delusions and hallucinations) also occur and how to defining such disorders of schizophrenia. This is the substance-induced psychosis schizophrenia against, somatic disorders and other mental disorders are deferred.

Differential diagnosis against somatic and substance-induced disorders

The ICD- catalog defined in this sense that schizophrenia should not be diagnosed if the psychotic symptoms as a result of intoxication or withdrawal occurs ( alcohol, drugs, medications ) or appears, accompanied by the brain of a physical illness (epilepsy, brain tumor, craniocerebral trauma, infection of the central nervous system, etc. ). Here, the differential diagnosis is made by exclusion of a physical illness. The Guideline of the differential diagnosis is, therefore, that a diagnosis of schizophrenia to be made only if the patient in question is physically healthy and takes no psychotropic substances.

Differential typology against other mental disorders

Then follows the definition of schizophrenia against other mental disorders. Differentiation from other psychoses, especially towards the affective disorders are referred to by K. Schneider not as a differential diagnosis but as a differential typology, because the cause of schizophrenia is unknown. Here come first in the question:

Persistent delusional disorder ( F 22 )
Acute psychosis ( F23 )
Schizoaffective disorder (F25 )

As well as the affective psychoses:

Depression with psychotic symptoms ( F32/33 )
Mania or bipolar disorder with psychotic symptoms ( F30/31 )

Usually, the distinction is made by bringing two criteria to stop, that the course and the absence or predominance of symptom group 1-4 after the ICD or the Erstrangsymptome according to Schneider. If the psychosis occurs in the course of the disease quickly remitted quickly and completely, and then no further psychotic symptoms recur, the diagnosis of acute psychosis is to be made ( F23 ). If schizophrenic symptoms and depressive or manic symptoms are present in the patients of the same intensity, the diagnosis of schizoaffective disorder should be provided (F25 ). In the event, the only mania symptoms in the patients and they continue for a long time the diagnosis of persistent delusional disorder is to be made . If the delusion briefly and temporarily, the diagnosis of acute delusional psychotic disorder is made ( or F22 F23.3 ). If a patient experiences psychotic and affective symptoms, but which outweigh the symptoms from among the affective disorders, the diagnosis of an affective disorder is provided ( F3x ). The occurrence of isolated symptoms, such as hallucinations or delusions of a culturally appropriate is not groundbreaking for schizophrenia and is convinced that different authors are not always as signs of disease.

Digression: classification of so-called Schizoaffective Disorder

Janzarik described with the term " psychosis of the schizoaffective intermediate region " a condition in which there is a simultaneous occurrence of schizophrenia and manic or depressive symptoms. This disease is called, the ICD treated with the term " schizoaffective disorder " under F25.

This disorder has been described by other authors with different terms. Schneider spoke of " intermediate cases " between the affective and schizophrenic psychoses, Kasanin spoke of " schizoaffective psychosis ", Leonhard von " unsystematic " or " cycloid psychosis " and the Scandinavian school (long- Feldt ) of " schizophreniform psychosis "

Karl Leonhard has distinguished six major groups of endogenous psychoses:

The three phasic psychoses (without the cycloid ): unipolar mania
Unipolar depression
Bipolar illness

The cycloid psychoses: anxiety-happiness psychosis, agitation - inhibited confusion psychosis, hyperkinetic - akinetic motility psychosis
The unsystematic schizophrenia: affective Full paraphrenia, periodic catatonia, etc.
The systematic schizophrenia: catatonic, Hebephrenien and paraphrenias.

The cycloid psychoses should have a good prognosis and " defect-free " heal.

On the question of diagnosis and prognosis of schizoaffective psychosis Huber and co-workers ' study Bonn " expressed in the. Here four types of schizoaffective psychosis intermediate region were found and their prognosis was generally significantly cheaper than in the total cohort of the Bonn schizophrenia study. Huber calls this type of disease as " schizoaffective psychosis " after Kasanin, Spitzer and anxiety or " cycloid psychosis " after Leonhard and Perris.

The conformity of " cycloid psychoses " and " schizioaffektiven disorder " has been made by other authors in question. Zaudig distinguishes two concepts of psychoses with good prognosis, the traditional concepts of " bouffée delirious ", the " cycloid psychosis " and " Schizoaffectiven " after Kasanin on one side and the " schizoaffective psychosis " according to the criteria of Kendell, Welner, DSM and ICD. It should consist According Zaudig no agreement between the two groups. Neure work of the group to Beckmann underscore the fact that not one of the mood disorders (bipolar disorder) are expected to be the so-called " cycloid psychosis ".

In the textbook by Mathias Berger is the " Schizoaffective disorder " described as a disease in which a risk of whether she was assigned to the affective or schizophrenic disorders. The concept of schizoaffective psychosis remains controversial. The Leohard classification with its concepts of cycloid psychosis and unsystematic schizophrenia try to remedy this uncertainty. We discuss different ways to classify the schizoaffective disorder is ..

In the ICD " cycloid psychosis " is not accepted as the " Schizoaffective Disorder " identical. It is classified (ICD 10 F 28 ) under "other non-organic psychotic disorders."

Thus, it must be noted that Leonhard four groups of psychoses differs: the affective, cycloid, the unsystematic and systematic psychosis. In German psychiatry Huber and Zaudig have the conformity of the cycloid psychoses with schizoaffective disorder of ICD seen and Beckmann and employees accepted the cycloid psychoses as a distinct group, regardless of the schizoaffective disorder and bipolar disorder.

Summary

When patients of hallucinations and delusions report, and who are anxious and troubled, the acute psychotic episode of schizophrenia can also be recognized by laymen. But these crises mark the life of a person with schizophrenia usually only for short periods. Regardless of the acute psychotic episodes the experience of the patient is usually marked by deficit experiences: depression, social disability and social stigma are just as much part of everyday life of the patient, such as hearing voices and delusional fears.

The assessment of the extent and the distinction of all associated symptoms requires not only experience and practice, but also an understanding of the investigator on common standards for the assessment of the various items. For this reason, survey instruments were developed, their application requires a special induction and training. The same applies to the operationalized diagnosis of diseases according to international classification systems. This is especially the coordination of survey instrument and classification system (eg, SCID and DSM ) is an advantage.

By using such standardized procedures comparability of data is achieved in scientific studies in psychiatry, which makes the study of large numbers of cases at all possible. The aim of this standardized method is the establishment of evidence-based medicine in the case of the treatment of schizophrenia.

Causes of schizophrenia Medical diagnosis Major depressive disorder Management of schizophrenia

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