In this article we will examine why clinicians diagnose serious mental illnesses and why misdiagnosis is a common factor in the process. Looking at the definitions of schizophrenia and labelling as an incidence of laziness, misunderstanding, poor training and guidance from the psycho-pharmaceutical industry to sell powerful money making drugs for life. To remind ourselves as clinicians that mental illness labels are not real, but a cluster of symptoms, that describe a persons perception of reality to enable directed treatment and internal psychiatric discussion with familiar terms that mean something to the treating doctors.
Schizophrenia like many other mental illness labels describe a cluster of symptoms that can explain the mental state of the person presenting to a mental health profession such as a psychiatrist, clinical psychologist and psychiatric nursing. When a potential patient arrives at the hospital for initial consultation some predisposing information arrives with them. These can be the family story, (what has been happening) the police story, (why they were detained), the social worker story, (their history of social breakdown) and in all these stories is the bias of the referring agency, as they have to justify the reasons they are asking the mental health professional to see the person in the first place. Armed with this background the mental health professional will begin the process of trying to identify from reported behaviour what label is appropriate for this individual from the DSM V manual of mental health statistical classification. (1. ICD 9 in the EU) This book of coding labels as numbers is meant to help mental health professionals to claim insurance payments and give a convenient depersonalising number to a mental health disease so that professionals can agree on a method of treatment, usually a chemical straight jacket in the form of several psychiatric drugs, confinement and even surgery. (ECT and Lobotomy).
To understand what exactly schizophrenia actually is in terms of everyday language we can consider the following extract – is a severe form of psychopathology in which a personality seems to disintegrate, in thought and perception which are distorted and emotions are blunted (2. 2010, Psychology of Life). This catch-all statement is the common idea of being insane or madness in which a persons reality is distorted by delusions that corrupt their everyday concepts of normality.
In order to understand this process we need to know more about Schizophrenia in the first instance. According to the DSM manual (constantly being revised by psychiatry to include more definitions) there are several subtypes of the condition. The number is 295 plus an additional number to identify type. So 295.30 is paranoid schizophrenia, 295.10 is disorganised, 295.20 is catatonic, 295.90 is undifferentiated, 295.60 residual type, then additional numbers can identify particular presenting problems such as 295.40 schizophreniform disorder, 295.70, schizoaffective, 297.1 delusional, 298.8 brief psychotic, 297.3 shared psychotic, 293.81 with delusions, 293.82 with hallucinations with an additional idea of substance induced psychotic disorder, finally, 298.9 psychotic disorders NOS (no obvious reasons). (1. 1994 – DSM IV Classifications)
With all these sub-types of the labelling of schizophrenia the clinician has to research with the patient the length and severity of the symptoms being expressed. This is usually a self report from and initial interview with the patient about their experience of their own behaviour. This can be very subjective as the patient is suffering from confusion and may not have a clear idea of their own mental state. Let alone know the common word parlance of mental illnesses to explain their situation. Time as a factor so is specified as suffering for two months or more from delusions., hallucinations, disorganised speech, gross disorganisation or catatonic behaviour (turned to stone) negative symptoms such as affective flattening ( dead like response) alogia (without speech) or avolition (failure to engage). These basic requirements can be a mixed bag not requiring all states in order to label the person schizophrenic. The diagnosing mental professional will through experience judge the severity of the case by the amount of symptoms being expressed or reported. In order to extend the label to the other subcategories, for example, paranoid there would have to be additional evidence to support the patient being diagnosed as such by statements that indicate a paranoid belief in that their delusions include persecution from imaginary third parties. Along with schizophrenia may be episodes of depression, anxiety or bipolar (mood swings between both states), this leading to additional diagnosis of schizoaffective disorder for example.
As you can see the process of identifying exactly what the diagnosis should be is quite complex and needs sufficient time in order to be sure of the exact condition of the patients mind. In this case the law takes over giving the psychiatrist considerable power over individuals under the guise of care, such as, is the person considered a danger to themselves or others, as a catch all for confinement over a 24 to 78 hour period with no representation of a third party. In other words the power to arrest and detain a person with out trial, legal protection or any form of protest. In place are panels to review that decision after the initial period of observation but rarely go against the psychiatrists recommendation and so uphold any confinement decisions.
Causes of Schizophrenia:
The problem with causes is that at the moment in psychological science there is a lot of ideas, conjecture and discussion but no clear answer. Biologically, some patients will clearly have brain damage, brain dysfunction i.e. the process of neurological communication or neurotransmitters maybe dysfunctional or low in production, such as serotonin (linked to mood) etcetera. However cause and effect in any correlation means which causes what? Does brain damage occur because you are delusional or are you delusional because your brain is damaged? The only evidence is xrays from differing processes and post-mortum examination of someone diagnosed in their lifetime. Both clearly not definitive in providing real evidence that have many scientific validity problems. The second is twin studies or family studies both with huge validity problems as most evidence is from meta analysis (this means many small studies to combine into one big study) again modelling may explain much of this evidence – if a child witnesses a family member or their twin behaving oddly they will think this is actually normal and so model that behaviour as sound, to be learned from, so a new schizophrenic is developed from the existing schizophrenia within the family or from a twin / sibling. This is not a big surprise to many as we often see similar traits in family members even if they have lived apart for long periods of time. Any clinical psychologist can tell you when treating family issues that often the new mother has revelations about becoming just like her mother in her raising of her subsequent children. As one mother said, “I looked in the mirror and saw my mother staring back at me” What she is expressing is not looking like her mother but in fact acting like her and talking like her as an adult. (Research, Transactional Analysis functional PAC model). So even if there is lots of statistical evidence that schizophrenia runs in families this has no effect on why the disease develops in the first place. Modern genetics again tries to answer the problem by saying it is inherited, however despite mapping the genetics of humans and other species we know very little about how genes actually express themselves and only have a broad ideology that informs us that genes can express themselves in many forms later in life according the to the environment they are exposed to from every day events. Our genetics are like a time bomb that given the right stimulus will create a response in our behaviour, developing disease and longevity of life in general. In other words nothing is specific and nothing is for sure. So as in schizophrenia the biological, genetic and family approach are still full of validity problems from the type of research conducted and are full of bias’s from the very science that seeks the answers they wish they could have. The most likely cause of schizophrenia is still stress and the problem of living in a complex world full of conflicting ideology and purpose, where the disease can be seen as a form of mental escapism from the pressures of life. Better to live deluded than have to deal with the reality of failure, disappointment, lost expectations plus a lack of real love and affection from others. (4. 2011 Abnormal Psychology Core Concepts)
The most controversial part of any mental illness is being labelled with schizophrenia or any other mental problem and have no power over that decision. A very famous study by Rosenhan (1973) showed that students who were asked to present themselves as hearing voices (auditory hallucinations) could after a few minutes be admitted to a psychiatric ward and be kept for sometimes days and weeks as patients, when reporting soon after arrival, that they no longer hear the voices and felt well – they were still seen as having schizophrenia in remission, when in fact all were perfectly well. Could this still happen today after 40 years – the answer is yes and even more frightening as we never learned anything from the study about the fact psychiatrists are easy to fool! (3. 1973 Rosenhan) A true modern case is given below:
A young woman wanted a medical sick certificate to have some time off work. She was exhausted by her life in general but other than that was not depressed or anxious about everyday life. Her brother suffered from a mental disorder mainly around being dysfunctional, backward and idle. He was on medication for schizophrenia. The girls father took her to the mental hospital where her brother attended and informed the doctor of the family history and his girls exhaustion. The psychiatrist within five minutes of the consultation labelled her as schizophrenic. The psychiatrist went on to register as an out-patient, gave her several types of psychotic drugs, and her sick certificate for work. The young women having left the hospital became extremely anxious about showing the sick certificate to her employer as this might lead to her losing her employment. On a friends advice she sought a second opinion from a clinical psychologist. The psychologist was amazed at the diagnosis but never the less completed a thorough examination of the patient. After an hour his diagnosis was perhaps mild reactive anxiety brought on most probably by the misdiagnosis of the psychiatric doctor.
To understand what happened the psychologist interviewed the young woman, the father and observed the brother. It was clear that the diagnosis was heavily influenced by circumstances, family and by the time element in making a decision about her condition. It would be nice to imagine this as an isolated case but in fact this is the norm. Quick diagnosis based on very little evidence. None of the criteria for schizophrenia existed, she had no delusions, she was not disorganised, she did not report any bizarre affect, she was coherent in speech and manner. So how did such a clear misdiagnosis be allowed to happen? Luckily with budget cuts in mental health and lack of facilities the young woman was not severe enough to be confined to a mental ward. She discarded the medication and sought out a general practitioner who having re-assessed her gave her a sick certificate for exhaustion and no medication was needed. (4. Myler 2016)
The above case is only one example of how misdiagnosis can happen, so what are the main elements that lead to such a dangerous practice by psychiatrists in general.
- Time – less than 10 minutes average time to make a diagnosis.
- Depending too much on third party reports – police, social workers, family.
- Lack of resources – such as second opinions, team lead discussion, clinical psychologists (who have more training in mental health than any psychiatrist).
- Lack of training – most have less than 18 months after graduation from medical school and most of this is spent on drug therapy.
- DSM V and preceding publications that promote mental illness instead of mental health.
- Depersonalisation of medical practitioners by their very training regimes at University.
- Time – constraints via patient over-load and lack of administrative support.
- Lack of knowledge about other professionals in the field, such as clinical psychology and counselling therapists.
- Arrogance – pure and simple – the I know best syndrome – grandiosity (a form of schizophrenia in itself ironically).
- Governments around the world who think mental health is a low priority to health budgets that in the same time have enormous hidden costs to the global economy.
- Tendency of the patient to over exaggerated symptoms in order to receive a diagnosis.
- Other professionals trying to remove responsibility for care.
- Family seeking to distance themselves from troubled family members.
The misdiagnosis of schizophrenia and other mental illness problems in the general population cause major distress and depression to millions of people around the world. While there are clearly many genuine cases of schizophrenia, that may benefit from the help and support of the community, in the form of hospitalization and confinement this is clearly not the case for the majority of patients who after five minutes and other peoples reports find their world turned upside down forever. Once labelled, the stigma of being a mental health patients can last for life and push the patient into acting out an illness they do not actually have. You label someone something and their instinct is to become the very label you gave them and so a self fulfilling prophecy is enacted and they can all pat themselves on the back and say – see I told you so!
- 1994 – DSM IV American Psychiatric Association publication.
- 2010 – Gerrig, Zimbardo – Psychology and Life, pg. 465 – Pearson Publications.
- 1973 – Rosenhan – On being sane in insane places – pg179 Science Publications
- 2011 – Butcher, Mineka, Hooley – Abnormal Psychology Core Concepts 2nd Ed. – Pearson Publications. General background information on schizophrenia.
- 2016 – Myler – Case Notes – unpublished