RUNNING HEAD: Discussing benefits and harms of schizophrenias formal diagnosis

Discussing Potentials in Dimensional and Clinical Staging Models of Schizophrenia

Diagnosis and How They Relate to the Problem of Stigma
George Steven Baker/539340
PSYC30014 The Psychopathology of Everyday Life
Practical 15: Friday 3:15 p.m.
2726 words

Discussing benefits and harms of schizophrenias formal diagnosis

There is no objective test to determine whether formal diagnosis of schizophrenia

results in more harm than good. Nonetheless, this essay discusses both beneficial and harmful
consequences of formally diagnosing this clinically confounding and debilitating syndrome
with still no known cure (Van Os & Kapur, 2009). Three focal topics loosely form the essays
structure, two of which include the continually emerging research areas of the dimensional
model and clinical staging model of diagnosis. These models proponents suggest they
increase validity and reliability of diagnosis relative to the current categorical model of
diagnostic criteria in the DSM-5 and ICD-10. However, as the third focal topic will discuss,
public and self-stigma caused by diagnosis of schizophrenia is a major dilemma, and the
deleterious implications of stigma may be the most harmful and hindering impact on research
and those formally diagnosed.
A benefit of a formal diagnosis of schizophrenia includes the recognition that the
disorder is a deviation from health, and so can help explain and treat symptoms of a
presenting patient (Allardyce, Gaebel, Ziealsek, & Van Os, 2007). Symptoms of
schizophrenia broadly include positive symptoms such as delusions, hallucinations,
disorganised speech, and grossly disorganised or catatonic behaviour; negative symptoms
include avolition, and diminished emotional expression (American Psychiatric Association
[APA], 2013). Validity and reliability are salient necessities for diagnosis, validity defined as
whether research and tests truly measure what they intend to measure, and reliability as
whether repeated tests will produce consistent results (Golafshani, 2003).
Psychotic disorders have historically been considered on a Kraepelinian dichotomy
that considers schizophrenia and the bipolar disorders as discontinuous diagnoses (Fischer,
2009). Studies have shown that patients can neatly classify into one or the other disorder
(Keshavan et al., 2011). However, patients have also presented with symptoms from both
categories, and thus the boundaries between both ends of the dichotomy become unclear

Discussing benefits and harms of schizophrenias formal diagnosis

(Keshavan et al., 2011). This presents a problem for formal diagnoses that continue to consist
of categorical criteria.
The American Psychiatric Association (APA) publishes one of the two most widely
used mental disorder diagnostic systems (Mezzich, 2002), The Diagnostic and Statistical
Manual of Mental Disorders (DSM). The APA are not strangers to the dimensional model of
nosology; the introduction of DSM-IV (1994) credited the dimensional diagnosis system as
having more reliability and an enhanced ability of communicating clinical information.
Although the DSM-5 maintains categorical diagnostic criteria, dimensional approaches to
diagnosis appear to be incorporating progressively into formal diagnoses.
In the DSM-5, the APA still expressed it would be scientifically premature to propose
alternative definitions for most disorders (APA, 2013). By the same token, the APA seem
motivated to embrace the dynamics of modern technology in regularly revising diagnoses as
discoveries in neurobiology, genetics, and epidemiology are made and replicated (APA,
2013). These research fields would hopefully contain indicators of the more proximal
underlying aetiologies of schizophrenia and thus improve the validity of diagnosis.
The aim of diagnosis refinement should be to improve validity and reliability, thus
reducing the prevalence of false positive and false negative diagnoses, and providing more
precise treatment and prognosis (McGorry, Hickie, Yung, Pantelis, & Jackson, 2006). Initial
field trials of the DSM-5 found good interrater reliability in schizophrenia with a kappa score
of 0.46 (Freedman et al., 2013). However, this was a relatively mid-range score in the field
trial, so improvement is required to reflect a proper understanding of the aetiology and signs
of schizophrenia. The diagnosis of schizophrenia does not yet have an objective test due to no
confirmed biological explanation of cause (Van Os & Kapur, 2009).
Arrival at a categorical diagnosis of a disorder in the DSM-5 involves the use of
assessment measures rated by the patient and also the clinician (APA, 2013). The APA

Discussing benefits and harms of schizophrenias formal diagnosis

advises that the broader Cross-Cutting Symptom Measures should be used frequently from
the initial interview onwards to ascertain the severity of self-rated symptoms across a range
of 13 psychiatric domains (APA 2013; King, 2014). The measures purpose may be
considered as a lens that focuses onto the relevant and most urgent domains to assess.
Responses that exceed a threshold on the Level 1 measure suggest detailed clinical inquiry is
necessary in these areas, and further details will be obtained in the Level 2 measure of the
measures of interest (APA, 2013). These inquiries directing diagnosis are captured on a 5point scale with dimensions such as none, slight, mild, moderate, and severe.
As psychotic disorders (including schizophrenia) are heterogeneous with different
illness aspects depending on presenting symptoms, it should be useful to have the more
specific Clinician-Rated Dimensions of Psychosis Symptom Severity scale as a tool for
diagnosis (APA, 2013). Its function is similar to the cross-cutting measure, but the scale is
completed by the clinician from observation and provided information. The 5-point scale
enables symptom severity to be rated, guiding diagnosis, planning treatment, deciding on
prognosis, and tracking progress over time (APA, 2013).
Therefore, though the DSM-5 continues to use the categorical model for diagnostic
criteria, it has also introduced supplementary dimensional assessment measures. With
increased research on the efficacy of a dimensional model of diagnosis, formal diagnoses
would most probably follow this model, as long as they provided more validity and reliability
than the categorical model.
A benefit of dimensional assessment measures could be the idea that they help
standardise clinical observation, which could be prone to rater subjectivity. Due to there not
yet being any tests that can directly measure the causes of schizophrenia, there is an amplified
need for clinical observation and judgement to be as accurate as possible to avoid harmful
consequences of formal diagnosis. Comparison of clinicians ratings on the DSM-5s

Discussing benefits and harms of schizophrenias formal diagnosis

Psychosis Symptom Severity Scale, for example, could improve inter-rater reliability by
drawing attention to discrepant ratings, and enabling discussion regarding those
discrepancies.
Resolution of differently scored ratings between clinicians could work towards a
more objective empirical evaluation of symptoms, and thus could result in a more valid
diagnosis of a patient. There may be limitations to this proposition in that patients may not
normally get consulted by multiple clinicians, and discussions about a patient with multiple
clinicians superficially could increase time and cost of diagnostic consultation. However,
more rigorous diagnostic practices could effectively lower the financial costs of
schizophrenia. Lowered financial burden to the taxpayer would be a good consequence of the
formal diagnosis of schizophrenia.
Schizophrenias financial cost is an immense figure in Australia, with an estimated
direct cost of over $650 million dollars to the health system, and over $1 billion of indirect
costs for the year 2001 (Access Economics, 2002). This rather dated report for SANE
Australia had already identified findings describing the probable benefits that come with
implementing clinical staging models into mental disorder diagnoses. It reported data from
the Early Psychosis Prevention and Intervention Centre (EPPIC) that showed patients treated
on their early intervention and care model had better health outcomes and resulted in costing
70% as much as general patients (Access Economics, 2002). EPPICs achievement was in
providing better treatment for a lower cost, and one of the centres pioneers, Professor Patrick
McGorry, has continued advocating clinical staging models of schizophrenia as an expansion
and benefit to the disorders categorical formal diagnosis.
Formal diagnosis of schizophrenia is beneficial in that epidemiology is developed
from collection and analysis of data. Epidemiologic reviews have found groups with higher
incidence and prevalence rates of schizophrenia, such as men, migrants, and those residing in

Discussing benefits and harms of schizophrenias formal diagnosis

the inner city (McGrath, Saha, Chant, & Welham, 2008). Therefore, inner urban dwelling
male migrants could immediately be identified as possibly being at a higher risk than the
general population for developing schizophrenia.
Mortality is also of urgent concern regarding patients with schizophrenia in that the
rate of natural cause mortality appears to be two to three times higher than the normal
population (Brown, Kim, Mitchell, & Inskip, 2010). An alarming finding is that the
differential mortality gap has widened over recent decades as the general population health
outcomes have improved, but patients with schizophrenia have not experienced the same
benefits (McGrath et al., 2008). Explanation may be that the second generation, atypical
antipsychotic medications have contributed to increased mortality due to their negative
physical health side effects, and may continue to into the future (Saha, Chant, & McGrath,
2007). These findings based in epidemiology prompt the need to prevent the onset of
schizophrenia.
The categorical model of diagnosis has a concerning limitation in that its descriptions
of diagnosis may focus too closely on the chronic and later stages of a disorder (McGorry et
al., 2006). This is apparent in the DSM-5s diagnostic criteria of schizophrenia, which
includes course specifiers of the disorder that can only be used after a patient has been
diagnosed for a year (APA, 2013). Diagnosis and subsequent specification of schizophrenia
therefore may create the impression that the disorder is longstanding, stable, and nominally
unable to be cured (McGorry et al., 2006; McGorry, Nelson, Goldstone, & Yung, 2010).
Professor McGorry and colleagues have worked to introduce clinical staging into
psychiatric disorders including schizophrenia. They ostensibly challenge ideas that
schizophrenia, and other mental disorders, are unpreventable and incurable. The proposed
framework of the clinical staging model for psychotic and severe mood disorders describes
clinical stages as a continuum including no symptom presentation, subthreshold levels, first

Discussing benefits and harms of schizophrenias formal diagnosis

episode, relapse, and severe illness (McGorry et al., 2006). The male urban dwelling migrant
example mentioned earlier would probably be captured by this framework at the Clinical
Stage 0 where there are no current symptoms, but the subject has an increased risk of a severe
mood or psychotic disorder (McGorry et al., 2006).
McGorry and colleagues from Australia and Europe have also developed a staging
model specifically for schizophrenia (Agius, Goh, Ulhaq, & McGorry, 2010). The model
proposes three stages of schizophrenia being prodromal, first episode, and long term chronic
phase, which is based on the Nottingham Onset Schedule (NOS) (Singh et al., 2005). Each
stage has its own schedule of treatment methods, each with different evidence bases and
different expected treatment outcome (Agius et al., 2010). This staging of schizophrenia is
clearly distinct from the categorical diagnoses in the DSM and ICD-10.
In research settings, an early intervention-geared clinical staging model of diagnosis
may present as a worthy candidate to elaborate on existing formal diagnoses. However, its
external validity may be questioned when considering possible harmful consequences of
practising it. The harm would come in the form of stigmas surrounding mental disorder
diagnosis. More people would be diagnosed in a clinical staging model relative to the
categorical model, so more people could be subjected to stigma. Two broad classes of stigma
include public stigma and self-stigma. These stigmas respectively involve stereotypes,
prejudices and discrimination in the form of public and self-constructed beliefs, and
consequent behaviours (Corrigan & Watson, 2002).
Research has shown that the general public are prone to stigmatise people with
schizophrenia as more violent and disorderly than people without schizophrenia. Findings
have consistently shown that relatively more violence is committed by people with
schizophrenia compared with the general population (Link, Phelan, Bresnahan, Stueve, &
Pescosolido, 1999; Hodgins, 2008). However, there have been suggestions that the vast

Discussing benefits and harms of schizophrenias formal diagnosis

majority of violence is perpetrated by those without a diagnosed mental illness (Varshney,

Mahapatra, Krishnan, Gupta, & Deb, 2016), with a study finding 4% of violence could be
attributed to those with severe mental illness (Swanson, Holzer, Ganju, & Jono, 1990). An
association between violent behaviour and schizophrenia has been found in studies (Hodgins,
2008), but it seems this association is blown out of proportion by public stigmatisation of
those with schizophrenia (Link et al., 1999).
The consequences of stereotyping people with schizophrenia as vastly more likely to
be violent, disorderly, and unable to work or lead independent lives leads to negative
discrimination in family, social, and employment spheres (Lysaker, Tsai, Yanos, & Roe, 2007;
Thornicroft, Brohan, Rose, Sartorius, & Leese, 2009). Stigma is an inadvertent
embellishment of formal diagnosis of schizophrenia and all mental disorders, and may be the
most harmful aspect of the practise of diagnosis. Thornicroft and colleagues cross-sectional
study across 27 countries including over 700 people with schizophrenia found that roughly
half of the participants had experienced negative discrimination from friends and family
(Thornicroft et al., 2009). Furthermore, over a quarter had reported finding difficulty in
finding and keeping a job, and in intimate relationships due to negative discrimination.
Regarding self-stigma, around three quarters felt the need to hide their diagnosis, and around
half felt they would be unable to find and keep a job due to their diagnosis (Thornicroft et al.,
2009).
Thornicroft and colleagues findings indicate that both public and self-stigma is
consistently high in a large number of countries, and has a substantial presence on individual,
community, and global scales. Thornicroft has reported in a separate article (2007) that at
least two thirds of those suffering from mental illness do not receive treatment. A potential
reason for reluctance to receive treatment is that to identify oneself as someone with
schizophrenia is to categorise oneself into a group with negative stereotypes (Lysaker et al.,

Discussing benefits and harms of schizophrenias formal diagnosis

2007). As a member of this group, one would expect to be exposed to public stigmas, and
could subject oneself to self-stigma, thus causing oneself further pain due to lower selfesteem, and social avoidance. Therefore, denial of mental illness may be a strategy of selfprotection, but tragically is ostensibly unsustainable and ultimately an illogical effort.
Therefore, a drawback of formal diagnosis is the dilemma that to receive treatment and a
prognosis, you must be diagnosed, but a diagnosis will also heighten the risk of stigmatisation
in the community.
Having discussed three topics related to the formal diagnosis of schizophrenia,
including the emerging dimensional and clinical staging models of diagnosis, and the
stigmatisation of those with diagnoses, some points of concern and interest arise. McGorrys
clinical staging model would seemingly implicate a much larger pool of patients with the vast
clinical staging spectrum. For example, those with a heightened risk yet no presentation of
symptoms, such as the male urban dwelling migrant example, could be affected by the stigma
attached to a diagnosis of schizophrenia, even though they have no indication of meeting
traditional diagnostic criteria. This would be an occasion of when formal diagnosis could be
harmful.
Considering the dimensional and clinical staging models, and their contrasting
features from the categorical model, it seems implementing these models would involve a
sizable paradigm shift from the status quo. Future areas of research could investigate the
association of clinical staging diagnoses and stigmas associated with having been diagnosed
at the various stages of the continuum. The World Health Organisation has estimated that
mental disorders have a lifetime prevalence of up to 50% (Kessler, Berglund, & Demler,
2007), though schizophrenia is estimated to affect a minority of people with a systematic
review estimate of 0.4% of the population (Saha, Chant, Welham, & McGrath, 2005).

Discussing benefits and harms of schizophrenias formal diagnosis

Future research should focus on how changes to formal diagnoses can reduce the
stigma of having such a diagnosis. Placing the population on a continuum of risk of
developing schizophrenia could provide a perspective that those with schizophrenia and those
without it are in the same group, and can all be on different points of the continuum at any
time. Diagnosis should not be restricted to describing a stable, chronic condition, but also
must be cautious not to misdiagnose, not to marginalise certain populations by stating they
have proneness to a disorder that others dont, and not to pathologise what might be relatively
normal experience during adolescent development.
True effectiveness of dimensional and clinical staging models could be achieved with
the complement of objective neurobiological testing that indicate prodromal or chronic
course of schizophrenia. If we could establish the validity that schizophrenia is a
neurodevelopmental disorder that may result, for instance, from the combination of reduced
grey matter and aberrant connectivity in the prefrontal cortex (Pantelis et al., 2005), we could
emphasise that those found to display the target lesions have an objective risk to developing
the disorder.
With the increased reliability provided by more comprehensive and dynamic
diagnostic models, there is a chance that diagnosis of schizophrenia, and being scaled on any
stage of the model, could be considered a normal medical procedure tested for in adolescents,
young adults, and the wider population. Therefore, we could be quite confident of eliminating
stigma from the everyday perception of diagnosis of schizophrenia, and thus remove a major
harm of formal diagnosis.

Discussing benefits and harms of schizophrenias formal diagnosis

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