When are diagnoses used?
As mentioned previously in this course, there is a spectrum of unusual experiences that ranges from those that are more prevalent in the population to those that are less prevalent e.g. many people will experience hearing voices at some time in their lives and some people will experience hearing voices on a more regular basis.
Mental health diagnoses associated with unusual experiences are not used for every incidence of them, the majority of people who have these experiences do not have a diagnosis.
For a diagnosis related to unusual experiences to be used they are likely to be highly distressing and significantly impact on daily functioning.
Diagnoses that are more likely to be used related to unusual experiences are referred to within the medical perspective using the term ‘psychosis’. Not all diagnoses directly relate to psychosis, for example a person diagnosed with personality disorder may have experiences of psychosis. Not all unusual experiences are considered to be related to psychosis but all experiences of psychosis are related to unusual experiences.
The rest of this course will look at aspects of unusual experiences that are widely thought of as psychosis including associated diagnoses, models explaining the stages or progression and treatments aimed towards it. For this reason, the term psychosis will be used rather than unusual experiences.
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Three factors that can influence whether experiences reach the diagnostic threshold include cultural acceptability, frequency and level of associated distress.
- Cultural acceptability refers to how the experiences are viewed within societal norms. Depending on where you live and the people around you will influence how the experiences are perceived, for example paranormal beliefs are more accepted in some cultures than others.
- Frequency refers to how often the experiences are happening and will vary depending on the type of experience.
- Level of associated distress refers to how upsetting or troubling the experiences are. This can relate to how the person is feeling, the impact that it is having on their ability to get on with their daily life and whether it is affecting their relationships and their health.
Diagnostic significance
No diagnostic significance:
- Frequency: infrequent, perhaps only once or twice.
- Distress: not distressing.
- Cultural acceptability: appropriate to cultural norms.
Slightly atypical experience:
- Frequency: infrequent, less than monthly.
- Distress: low levels of distress, easily brushed off.
- Cultural acceptability: within cultural norms but slightly unusual.
Borderline diagnostic significance:
- Frequency: common, perhaps weekly or more.
- Distress: moderate distress, not easy to brush off.
- Cultural acceptability: unusual within cultural norms.
Diagnostically significant:
- Frequency: common, perhaps daily or more.
- Distress: highly distressing, consumes life.
- Cultural acceptability: not culturally acceptable.
What are the diagnoses?
Although when people think about experiences associated with psychosis they often think of the diagnosis Schizophrenia but there are a number of other diagnoses related to experiences of psychosis. These are known as ‘primary psychotic disorders’ such that the manifestation of the disorder stems primarily from experiences of psychosis.
In the ICD 11 there are five disorders listed under the ‘Schizophrenia and primary psychotic disorders’ category. These are schizophrenia, schizoaffective disorder, delusional disorder, schizotypal disorder and acute and transient psychotic disorder.
Schizophrenia: This is the most widely known diagnosis related to psychosis. To meet the criteria for this diagnosis the person must have had difficulties for a period of at least one month. Core experiences include; persistent delusions and hallucinations, disorganised thinking and in particular experiences of influence, passivity or control.
Schizoaffective Disorder: This diagnosis is a combination of schizophrenia and a mood disorder. To meet the criteria for this diagnosis the person must have had difficulties for at least one month. Core experiences include; meeting the criteria for schizophrenia and a mood disorder (depression, mania or a mixed episode) either simultaneously or within a few days of each other.
Delusional Disorder: This diagnosis is predominantly to do with delusional thinking and for a person to meet the criteria difficulties must persist for at least three months. This must occur in the absence of a mood episode (depression, mania or a mixed episode) and the person must not meet the core criteria for schizophrenia.
Core experiences include; either one or a set of related delusions are the prominent issue. If hallucinations are present they are thematically related to the delusional thoughts. Affect, speech and behaviour are not affected aside from where they are related directly to the delusional thoughts.
Schizotypal Disorder: To meet the criteria for this diagnosis the person must, over a period of at least several years, have a pattern of eccentricities in behavior, appearance and speech as well as cognitive and perceptual distortions, unusual beliefs, and discomfort with, and often reduced capacity for, interpersonal relationships.
Core experiences include; constricted or inappropriate affect and anhedonia (negative schizotypy), paranoid ideas, ideas of reference, or other psychotic symptoms, including hallucinations in any modality, may occur (positive schizotypy). However, these are not of sufficient intensity or duration to meet the diagnostic requirements of schizophrenia, schizoaffective disorder, or delusional disorder.
Acute and Transient Psychotic Disorder: This diagnosis is indicative of a short lasting episode of psychosis that typically lasts a few days to one month and must not exceed 3 months. Unlike other related diagnoses there is no prodrome and difficulties reach a peak within 2 weeks.
Core experiences include; delusions, hallucinations, disorganised thinking, perplexity or confusion, and changes in affect and mood. These typically change rapidly, both in nature and intensity, from day to day, or even within a single day.
(adapted from ICD-11(opens in a new tab) by WHO, CC BY-NC 3.0 IGO(opens in a new tab))
Psychosis is not unique to the diagnoses described above, individuals with other diagnoses may also have experiences of psychosis. Additionally, an individual may have more than one diagnosis, including one of those described above, this is known as co-morbidity.
Having a diagnosis can bring advantages and disadvantages, the table below looks at some of the reasons this might be the case.
Advantages and disadvantages of a diagnosis
Advantages of a diagnosis
- Some support avenues are only available if you have a diagnosis. Having a diagnosis can provide access to a range of services that you may not have had access to before.
- Having a diagnosis can help you to feel less alone.
- It can help you to understand some of the patterns in the experiences you are having.
Disadvantages of a diagnosis
- Some people find having a diagnosis restricting and pessimistic.
- Many individuals feel that having a diagnosis of a mental health condition is not useful and prefer to focus on the reasons behind their diagnosis.
- Individuals can be labelled negatively by other people based on their diagnosis or experience stereotypes from others, for example stigma.
The ICD-11
The ICD-11 defines and categorises diagnoses related to psychosis but does not speculate about their aetiology (cause). This system can be helpful but it does not answer what underlies peoples’ experiences and naming and categorising something doesn’t always give it more meaning. Within this society there is a need for a system like this at the present time to decide between likely effective interventions and to determine how to best allocate resources, within services and other systems like the benefit system. There is no one definitive explanation as to what causes experiences associated with psychosis, to find out more about this go to our Explaining Unusual Experiences course which you can access via the main courses page.
Consider more:
- What do you think about the threshold for diagnosis?
- Were you aware of the range of diagnoses associated with psychosis?
- Can you think of any other advantages or disadvantages of diagnosis?