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Diagnostic Validity of Schizophrenia

Dr. Rajdip Hazra

What is diagnostic validity?

How to establish validity in a

psychiatric diagnosis? Evolution of diagnosis of Schizophrenia. Application of validity principles in Schizophrenia.

What is diagnostic validity?

The term refers to what extent the test

(here diagnostic criteria) accurately measures what it purports to measure. Degree of achieving the objective' namely of answering the question which the physician asks.

In psychiatry there is a particular issue with

assessing the validity of the diagnostic categories themselves. In this context: content validity may refer to symptoms and diagnostic criteria; concurrent validity may be defined by various correlates or markers, and perhaps also treatment response; predictive validity may refer mainly to diagnostic stability over time; discriminant validity may involve delimitation from other disorders.

How to establish validity in a psychiatric diagnosis?

Distinct clinical description (including symptom

profiles, demographic characteristics, and typical precipitants) Laboratory studies (including psychological tests, radiology and postmortem findings) Delimitation from other disorders (by means of exclusion criteria) Follow-up studies showing a characteristic course (including evidence of diagnostic stability) Family studies showing familial clustering

Establishment Of Diagnostic Validity In Psychiatric Illness:its Application To

Evolution of diagnosis of Schizophrenia

BENEDICT AUGUSTE MOREL Coined the term 'dementia precoce Characteristics:

Observed in young

people Cognitive impairment Progressive degeneration

KARL KAHLBAUM Emphasized on using course of illness (as opposed to symptoms) to define discrete disorders. Argued that various kind of psychiatric disorders could be differentiated from one another based on changing pattern of symptoms & long term outcome.

Emil Kraeplin
Dementia praecox. An illness that tends

to develop at an early age. Have a relatively chronic course characterized by significant cognitive & social impairment. Negative symptoms & fragmenting of thought were two key feature of the disorder.

Eugen Bleuler
Coined the term

Schizophrenia. Basic or fundamental symptoms:

Loosening of

association Flattened affect Ambivalance Autism

Accessory symptoms:
Delusion and


Problems with Bleulerian concept

Symptoms were difficult to define and

rated reliably. They are often continuous with normality. There use in USA broadened the definition of Schizophrenia to an excessive degree.

Kurt Schneider
Beginning in late 1960s florid symptoms which

were Bleulers accessory symptoms were being given greater prominence. Since they were easy to recognize & not seen in normalcy they gave diagnostic precision. Schneider like Bleuler tried to identify fundamental symptoms and thus identified various first rank symptoms. Schneiders FRS satisfied the fundamental need to find an anchor in the perplexing flux of the phenomenology of Schizophrenia. It was included in PSE developed for

Feighner Criteria
First attempt to diagnostic classification

system. Developed by Washington University Diagnostic Research Group in St.Louis, Missouri. An emphasis on course of illness in addition to cross-sectional symptoms. 6 month duration criteria was introduced.

Research Diagnostic Criteria

Created in1978.
Duration of active symptoms criteria reduced

to 2 weeks from 1 month. Borrowed concept from Feighner criteria & Schneiderian criteria.

DSM III & after

DSM III was published in 1980.
Placed more emphasis on Schneiderian

concepts. Clear exclusion criteria were described Maximum age of onset of 45 was eliminated. Current systems (DSM IV TR & ICD 10) reflect a clear narrowing of diagnosis of Schizophrenia compared to previous diagnostic practices.

DSM III & after

Concept of negative symptoms was first given by

Crow. Though the concept was interesting ther was no method to measure negative & positive symptoms initially. The problem was solved in 1982 at University of Iowa by development of SAPS & SANS. Currently Schizophrenia is conceptualized as a psychotic disorder characterized by longer duration, bizarre delusion (FRS), negative symptoms & few affective symptoms.

Application of validity principles in Schizophrenia

Clinical Description
Psychosis (delusion or hallucination) is not

exclusive to Schizophrenia which is found in a myriad of psychiatric disorder, not even the FRS which are used to diagnose Schizophrenia. A recent meta-analysis reported prevalence of psychotic experience is around 8% in the community, around 10 times greater than reported rates of psychotic disorder. Thus if psychotic experience are frequent, their diagnostic value in diagnosis of a rare disorder like Schizophrenia is low. FRS though more common in Schizophrenia has diagnostic likelihood ratio of <2 (LR>10 considered evidence of diagnostic value).

Clinical Description
Patients of Schizophrenia has more cognitive

impairment, but even it has a low diagnostic likelihood ratio. Primary negative symptoms when present with positive symptoms are consistent with diagnosis of Schizophrenia. But it is very difficult at this stage to differentiate between primary & secondary negative symptoms.

'Salience syndrome' replaces 'schizophrenia' in DSM-V and ICD-11: psychiatry's evidence-based entry into the 21st century? Van OS J. Acta

Delimitation from other disorders

Psychotic disorder associated with mood

disorder. Psychotic disorder associated with cannabis. Schizoaffective disorder. Cluster A Personality disorder
Symptoms are in continuum with typical

Schizophrenic symptoms. Prevalence is significantly higher in family of patients of Schizophrenia. ? Latent Schizophrenia.

Diagnostic stability over time

Over a 30- to 40-year period lifetime diagnosis,

based on blind diagnostic assessment, showed that 92.5% of the personally interviewed schizophrenics were given the follow-up diagnosis of schizophrenia, which was significantly higher than the 78.3% found in affective disorders.

Stability of Psychiatric Diagnosis Schizophrenia and Affective Disorders Followed Up Over a 30- to 40-Year Period . Ming T. Tsuang, MD, PhD; Robert F. Woolson, PhD; George Winokur, MD; Raymond R. Crowe, MD Arch Gen Psychiatry. 1981;38(5):535-539.

Diagnostic stability over time

A 13 year follow up study at Nottingham, UK

reported 100% stability of original diagnosis of Schizophrenia (n=86).* A 25 year follow up study at Cologne, Germany showed 90% of SZ at first episode retained the diagnosis at 25 years.**

* Harrison, Mason,Glazebrook, Medley,Croudace, & Docherty,1994; Mason, Harrison,Croudace, Glazebrook,& Medley,1997; Mason,Harrison, Glazebrook,Medley, & Croudace,1996; Mason, Harrison,Glazebrook, Medley,Dalkin, & Croudace,1995. ** Marneros, Deister, & Rohde, 1991, 1992

Familial aggregation
It was reported by Robin & Guze that most

mentally ill first degree relatives of patients of good prognosis Schizophrenia had a preponderance of another mental illness an affective disorder. Those of poor prognosis Schizophrenia had Schizophrenia. Recent genetic studies showed that most of the genetic liability between bipolar disorder & schizophrenia is shared.

The way ahead

a) choosing valid phenotype definitions increasingly

derived from translational neuroscience; b) addressing clinical heterogeneity by a crossdiagnostic dimensional and a staging approach to psychopathology; c) addressing pathophysiological heterogeneity by elucidating independent families of "extended" intermediate phenotypes and pathophysiological processes (e.g. altered excitatory/inhibitory, salience or executive circuitries, oxidative stress systems) that traverse structural, functional, neurochemical and molecular domains;
Schizophrenia, "Just the Facts" 6. Moving ahead with the schizophrenia concept: from the elephant to the mouse. Keshavan MS, Tandon R.Schiz Research.2011 Apr;127(1-3):3-13. Epub 2011 Feb 12

The way ahead

d) resolving etiologic heterogeneity by mapping

genomic and environmental factors and their interactions to syndromal and specific pathophysiological signatures; e) separating causal factors from consequences and compensatory phenomena; f) formulating or reformulating hypotheses that can be refuted/tested, perhaps in the mouse or other experimental models

The Future
Schizophrenia may be deconstructed and reconfigured into phenotypically overlapping, but etiopathologically unique and empirically testable component entities (similar to mental retardation, epilepsy or cancer syndromes).

Thank you