Diagnosing Schizophrenia

April 29, 2009 12:25 PM

Is there any good data on the sensitivity and specificity of symptoms of schizophrenia in its diagnosis?

How often are symptoms like relatively general but nevertheless involved and paranoid delusions, or hearing voices, not symptoms of schizophrenia and/or an 'early-stage' psychotic state?

The delusion that has me concerned in this case centers around the total control of the media by a few very wealthy families whose goal is world domination--it actually has some basis in fact, but comes along with lots of false, paranoid elaborations about how the families installed President Bush into office and have 'armies of people with IQs over 200' who are working to keep the public oblivious of their control. I've seen violently debilitating paranoias in schizophrenia before and this is clearly not that, but in conjunction with hearing voices it has me worried about this person (who is a college-aged male).

posted by anonymous to health & fitness (12 comments total)

Well, I am definitely NOT a psychologist. But it does sound like your friend needs professional medical help ASAP, so you should strongly consider alerting his family and/or a doctor.

One important aspect of the clinical definition of a delusion involves the fact that it is entirely irrational and cannot be reasoned with. If you can talk with this friend and get him to concede that his theory sounds overblown, highly illogical, un-realistic, etc., then that is a good sign. If he is adamant that this is a true and valid theory, less of a good sign.

The fact that he is hearing voices concerns me even more. Delusions (I think) can come in all shapes in forms and can be stronger or weaker than others. But hallucinations in and of themselves are a clear warning sign for mental illness. I would also like to point out Schizophrenia in males typically onsets in the early to mid-twenties, and your friend falls in this category.
posted by HabeasCorpus at 1:37 PM on April 29

Disclaimer: I am a neurobiology undergraduate student. Consult people who have more expertise than me on this.

Schizophrenia crops up mostly when patients are young adults; I don't know if that has much bearing on your suspicion.

Its main hallmarks, from reading my psychology textbook (published last year), are 'disordered thought, odd communication, inappropriate emotion, abnormal motor behavior, and social withdrawal', 'hallucinations, delusions', 'flat affect', 'difficulty sustaining attention, holding information in memory, and inability to interpret information and make decisions '. Some or all of these may occur in schizophrenia cases.

This friend of yours is at the very least paranoid; whether that is connected with schizophrenia is for a professional to determine.

Is there a reason you're asking this?
posted by kldickson at 1:40 PM on April 29

It might help to convince his family he needs help if you document these outbursts.
posted by kldickson at 1:42 PM on April 29

I am not really sure what your are asking. From a clinical perspective it is not as important what you call it as whether it significantly interferes with the person's ability to function in the full complement of life roles--if it substantially interferes then it is a problem. Schizophrenia comes in 36 flavors and is diagnosed based on history and clinical manifestations such as cognitive changes, hallucinations, delusions, social impairment, etc. It is also used after other diagnoses are eliminated. As a practical matter, the things I would look for include the rigidity/inflexibility of the belief, the extent the belief permeates/interferes with other parts of the persons life, departure of the belief from generally held cultural beliefs/norms, etc. Speaking and hearing (G)od may or may not be a delusion based on the cultural context, frequency, rigidity and associated hallucinations. If i understand the question--if these belief are accompanied by related or unrelated hallucinations I would be concerned about some psychotic process. The best test, n my book, is whether or not the person ( if they are willing) experiences personal relief, increased behavioral/cognitive flexibility with appropriate medication. My guess is the person states these are not delusions and is unwilling to try medication--the presence of hallucinations may be a future impetus to seek treatment.
posted by rmhsinc at 1:57 PM on April 29 [1 favorite]

I am a clinical psychology graduate student, and those delusions and hallucinations sound very much like schizophrenia. In fact, psychosis is defined as presence of delusions or hallucinations - it's not a separate state that happens to occasionally be characterized by D&H. So are there other psychotic conditions that could explain it? Possibly, depending on the specifics, on drug use, on medical conditions, etc. But it certainly sounds like a schizophrenic onset...
posted by namesarehard at 2:48 PM on April 29

I understand that you're freaked out, and I think you're right to be -- the '200 IQ detail' is the one I think you rightly picked out as a specific detail.

But nobody knows the context, and I know you're just asking a simple question, but without any more info I don't think anyone can come up w/any study that's going to say, yes, the hypothetical person in your example has schizophrenia. It's not like being pregnant. And, what you'd actually do if the person seemed to have schizophrenia is a whole host of other questions. So I think the best you can get is, you're right to be concerned, but no one can know for sure.
posted by A Terrible Llama at 3:19 PM on April 29

Get your friend to a doctor if at all possible. Your friend sounds like he is experiencing active delusions and paranoia rather than less-specific prodromal symptoms. Serious illness can't be diagnosed via an Internet description.

Usually, the earlier you can get him to seek help, the better his prognosis, but the nature of the illness can make this difficult. If you or he are in college, you should seek out the available mental health resources to ask for advice. Your next line would be to try as hard as possible to contact his family and close friends who may be able to help him. (If you already know his family, this may be your first line of action.)

Prodrome in schizophrenia refers to the "period of decreased functioning that is postulated to correlate with the onset of psychotic symptoms." In answer to your first question, there used to be available online in a few places a prodromal schizophrenia screening quiz developed by the PRIME Research Clinic at Yale University. It has been taken offline for now, possibly because they're making changes.
posted by jeeves at 3:33 PM on April 29

From the original poster:

Thanks for your answers and concern. This person is not a close friend so my options to act may be limited.

I meant sensitivity and specificity in the clinical sense--i.e., how many people who have schizophrenia exhibit these ('first-rank') symptoms, and how many people who don't have schizophrenia exhibit them: http://en.wikipedia.org/wiki/Sensitivity_and_specificity. I googled around but didn't find too much of great use and think this might be exactly the kind of topic an expert in the field would be well suited to answer because reading a single paper is not likely to do justice to the topic, which I think is somewhat debated and confusing.

I ask because I have read before of the importance of early intervention in these kinds of situations, but I have no clinical expertise and if it turns out that in large clinical investigations healthy people are sometimes rated as having moderately paranoid or delusional thoughts, or occasionally report hearing voices, then that would diminish my cause for alarm, as I think this individual is otherwise healthy and functionally unimpaired.

I have no evidence of some of the more dramatic symptoms of full-blown psychosis and paranoid schizophrenia, like delusions of reference, wild hallucinations, or patently distorted paranoid thoughts about close friends, relatives, doctors, etc.

posted by mathowie at 4:45 PM on April 29

Well, I doubt you're going to find numbers for sensitivity. That's because, as I understand it, there's no such thing as a "false negative" for schizophrenia. It's defined by its symptoms, and can't be diagnosed any other way — there's no blood test or whatever — so it just makes no sense to talk about the number of people who are schizophrenic but asymptomatic.
posted by nebulawindphone at 5:47 PM on April 29

Unfortunately your question is somewhat moot because the term "schizophrenia" as it is clinically used is not a pure disease state but really is a syndrome with many flavors defined by symptomatic criteria (see the DSM-IV). In clinical biostatistics, a test's sensitivity or specificity can really only be considered in the context of an alternative gold standard for the diagnosis in question. In this case the constellation of symptoms ARE the standard and no alternative test exists. In that context any one of the schizophrenia symptoms present but in isolation is neither sensitive nor specific at all.
posted by drpynchon at 6:00 PM on April 29

OP, it's because the topic is debated and confusing that it's probably not wise to rely on anyone here to tell you definitively what to do on the basis of a fairly vague long-distance description. You're still left with a bunch of signs and symptoms that could be suggestive of disorder in that they meet written clinical or subclinical thresholds, but as with autism and other behaviorally-diagnosed disorders, the know-it-when-I-see-it mojo of a clinician is critically important.

If nothing else, please seek advice yourself from a professional you can talk with directly. You don't have to name your friend to them, and they may be able to give you a better feel for what you can do, if indeed you need to do anything.

Knowing who's going to progress to psychosis is really tough even in an identified prodromal population — 12-month conversion rates in the literature run from 15% all the way up to 40, 50%, with the mode probably being in the 30% range right now. You or I as an armchair academic can't really tick a few boxes, and say "well, according to this one of six or ten different diagnostic instruments in use, Bartholomew has a 27% chance of converting to psychosis within the next 12 months, and I decided that I'd only say anything to him if he hit 31% or better."

I have collected some papers on this topic over time, so I'll offer a few references, some of which address sensitivity and specificity of particular clusters of symptoms as defined by one instrument or another. But as I said, if your alarm bells are going off it's a safer bet to keep a close eye on your friend, don't allow him to get socially isolated, and look into the available resources so that you can act concretely if you need to.

Moukas et al. (2009). Relationship of "prodromal" symptoms with severity and type of psychopathology in the active phase of schizophrenia. doi:10.1016/j.comppsych.2009.02.001

Woods et al. (2009). Validity of the Prodromal Risk Syndrome for First Psychosis: Findings From the North American Prodrome Longitudinal Study. doi:10.1093/schbul/sbp027

Miller et al. (1999). Symptom Assessment in Schizophrenic Prodromal States. doi:10.1023/A:1022034115078

Mason et al. (2004). Risk factors for transition to first episode psychosis among individuals with 'at-risk mental states'. doi:10.1016/j.schres.2004.04.006

The best to you and your friend.
posted by jeeves at 7:23 PM on April 29

From the original poster:

Thanks, jeeves, that's exactly the kind of information I was looking for.

posted by mathowie at 1:47 PM on April 30