“What is Schizophrenia?”

Someone asked me this at a party recently. It’s a difficult question to answer in a single sentence.

For a start, schizophrenia is not a single disorder. According to the ICD-10 it is a group of disorders, classified under F20 in a chapter called ‘Schizophrenia, schizotypal and delusional disorders’.

F20 is split into the following sub-classifications:

F20.0 Paranoid schizophrenia

F20.1 Hebephrenic schizophrenic schizophrenia

F20.2 Catatonic schizophrenic schizophrenia

F20.3 Undifferentiated schizophrenia

F20.4 Post-schizophrenia depression

F20.5 Residual schizophrenia

F20.6 Simple schizophrenia

F20.8 Other schizophrenia

F20.9 Schizophrenia, unspecified

(I can’t immediately find out what happened to F20.7 – maybe it suffered the same fate as floor number 13 in New York skyscrapers)

The aetiology of schizophrenia is unknown; as this is the case we are forced to define schizophrenia on the basis of a number of symptoms which appear together sufficiently frequently to merit a grouping. In this way schizophrenia is a syndrome rather than a disease. A disease is a disorder with a specific cause and recognizable signs and symptoms whereas a syndrome is combination of signs and/or symptoms that form a distinct clinical picture. The ICD-10 classification system deliberately avoids including aetiology in its definition.

Schizophrenia is a disorder which covers a wide range of cognitive, emotional and behavioural disturbances; there is disintegration in the process of thinking, of contact with reality and a pattern of emotional unresponsiveness.

ICD-10 puts it nicely:

The schizophrenia disorders are characterized in general by fundamental and characteristic distortions of thinking and perception and by inappropriate or blunted affect.

There is no one sign that ‘guarantees’ a diagnosis of schizophrenia. For instance many of the characteristic symptoms of schizophrenia can occur during a manic phase of bipolar disorder or during psychotic depression. However the following ‘fundamental and characteristic disorders of thinking and perception’ are considered to have special importance in the diagnosis of schizophrenia. They are based on Schneider’s first rank symptoms, proposed in 1959 and are:

a) thought echo, thought insertion or withdrawal, and thought broadcasting;

(b) delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;

(c) hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;

(d) persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.g. being able to control the weather, or being in communication with aliens from another world);

(e) persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end;

(f) breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms;

(g) catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor;

(h) “negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to neuroleptic medication;

(i) a significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

(Source of (a)-(i) ICD-10)

The final thing to say is that the conception of schizophrenia is to a certain extent historical and many textbooks choose to explain schizophrenia as a disorder with reference to the history of its classification. The term itself was Bleuler introduced the term in his 1911 book ‘Dementia praecox or the group of schizophrenias’

I’m doing some more nights shifts at the moment.  As regular readers of this blog will know, for me this involves a lot of grumbling, but it also involves seeing a lot of patients who are having problems with their mental health at times when most people are asleep.

Whenever I see a patient for the first time I interview them and ask a set of particular questions.  These questions add up to a ‘psychiatric history’.  The aim of the psychiatric history is to establish in a systematic way the problems that the patient is having, their chronicity, i.e. how long these problems have been going on, and any other influencing factors. 

If you ever fancy taking a psychiatric history from one of your friends then here’s how to go about it. 

Write the date and time a the top of the page and say who you are.  In my case ‘Psychiaty doctor on call’.  In general try and write down everything that you think is important.  This not just for when others may be reading the notes later, but also from a legal standpoint if there is no record in the notes then something will be considered not to have happened. 

The first part of the history is called the history of the presenting complaint (HPC).  It involves recent events which have lead to this particular visit to hospital.  These events could be over a few weeks or months or over a few days or hours. With a cooperative patient I often start with a list of the things that are bothering them.  This can be very illuminating and provide a guide as to the help the patient would like to receive.  I also find that this is a useful way of not medicalising a patient’s problems.  It is not unusual for a patient to be referred to me for depression, but to say to me that their problems are housing related, and that their husband keeps hitting them and to not mention any psychiatric symptoms at all.

An important thing to establish here is what brought the patient to hospital.  They may have been sent by their GP, or have been brought in by a family member, or have come in of their own volition.  They may also have been brought in by the police or an ambulance.  Although your patient is your primary ‘witness’ so to speak, don’t be shy of asking other people details like this.  This called taking a ‘collateral history’. 

The next section to cover is the past psychiatric history.  Here we must establish for how long the patient has had problems with their mental health.  This usually covers doctors seen, medications taken and admissions to hospital. 

Mental illness often runs in families, and it is important to probe about this.  This is called the family psychiatric history. If we know that there is mental illness already in someone’s family then this may lend weight to any diagnosis we may make, but it will also give us information about a patient’s background.  For instance if an adolescent is living with a depressed parent then this will make a big difference to their home environment. 

Some psychiatric problems may be caused by or interact with physical problems.  So the next section concerns medical history.  I usually split this up into family medical history and patient’s medical history.  It is far from unheard of for a psychiatric problem to actually be the result of an undiagnosed physical problem so psychiatrists have to be awake to this possibility.

One of the reasons that working in mental health is so interesting is that someone’s mental health is often very tied up with their social situation and the experiences they have had up to the point of presenting.  This is why a personal history is taken.  This will include details of childhood, with important questions about developmental delay, schooling, employment and relationships.  If time is short this is part of the history that can be left to a later time.

Drug use and particularly alcoholism is rife in our society and a careful drug and alcohol history is important.  I’m always amazed by how reluctant people are to tell me how much they drink.  The usual conversation: Me: how much alcohol do you drink?  Patient: not much.  Me: how much is not much?  Patient: much less than I used to.  Me: how much is that? Patient: one or two. Me: one or two what? Patient: well I don’t drink every night of the week…..  Cannabis use is also linked to the development of psychotic illness.

If writer’s cramp is holding off, then a forensic history, detailing brushes with the law and time spent in prison can be taken, and it is also useful to ask about premorbid personality whereby the patient or their relatives tell you how they used to be can give an idea as to how out of character a patients actions are and how sick they may be.

There are quite thick books written on the subject of the psychiatric interview and so I can’t hope but provide anything but a taster here.  Sometimes the patient is able to give you all the information you might need.  Sometimes they might be so disturbed that the entire history is from a a collateral source.  Often psychiatrists need to talk to several people.  At the same time as the history is being taken information for the mental state examination is also being noted - this is a posting for another day.

PS I have a theory that if someone without the appropriate qualifications, but with a bit of guile and a crash course in the right things to say, decided to pose as a psychiatrist then it would be quite some time before they were found out.  If anyone is interested in giving this a go, then take careful note, as the ability to take a ’psychiatric history’ will be an important part of your subterfuge