How to Ace Your Next Schizophrenia Test
first in a short series on psychiatric scales
This post is the first in a series of posts about some of the (many!) existing ‘scales’ that are used to ‘measure’ the presence, and (if present) severity, of schizophrenia. Future posts will consider some specific scales (BPRS, PANSS, maybe some others). The scales that we will consider are not all aimed only at assessing schizophrenia, but they are frequently used for that purpose.
If you don’t already know, and you’d like to see what the scales look like in at least a sketchy form, search for something like “PANSS online” and you will find ‘online tests’, where you answer a couple of dozen questions or so, and then it pops up your ‘grade’, something like “moderately ill,” or, if you study well and apply what you learn from this post, “not ill.” (The sites generally warn that ‘this result is not a diagnosis’, which is of course disingenuous, inasmuch as, yes, it actually is a diagnosis, just not one that anybody should trust.)
Stories are nice, so let’s continue with a story. A couple of years ago, after a longish bout of some disturbing experiences and a general feeling of not fitting into the world that became increasingly extreme, I sought psychiatric treatment. That story was the first post on this substack, which ended as the protagonist (i.e., me) was walking into the psychiatrist’s office. (For context: This appointment was very far—as in 30 years far—from my first encounter with the psychiatric system; I had a pretty good idea of what to expect.)
After 2 minutes of friendly introduction, she asked about physical health. It’s decent in general (if you don’t count all of the bits of metal, and somebody else’s ACL, that are holding various bones together), except there has been an ongoing, undiagnosed, stomach pain. It was quite irksome on that day, and I was initially inclined to dwell on it. The right shoulder had recently been bothersome as well, and also got some airtime. (It’s one of those joints with metal plates, Kevlar, screws, and who knows what else, holding it together.) Then she pressed on this point, and it suddenly became apparent that she was scoring for ‘somatic concern’, the first item on the BPRS (Brief Psychiatric Rating Scale).
(“Somatic Concern. Degree of concern over present bodily health. Rate the degree to which physical health is perceived as a problem by the patient, whether complaints have a realistic basis or not” (Overall and Gorham 1962)—that language is unchanged in current versions.)
Oh no! I’m going to flunk this test. Time to change my tune: “Well, the stomach isn’t that bad, and I’m sure my shoulder will feel better tomorrow.” Whew! Maybe that last-minute clutch move shaved off a point. (As in golf, lower is better; higher is sicker.) She moved on to ‘anxiety’, and so on through the list (not quite in the canonical order for BPRS, but fortunately I had the presence of mind not to point this fact out.)
Now is the time to alert you that I have spent far too much time reading textbooks and scholarly papers in psychiatry, especially concerning schizophrenia. I’m not inclined to just trust what somebody else says, even if they happen to have a fancy degree. (Danggit, that might be a point gained for ‘uncooperativeness’.) I know too many people with PhDs (myself included) to think that a PhD makes you smart, or even that it makes you an expert in your field. (Am I revealing a dirty secret of academia when I say that sometimes PhDs are granted as an act of mercy, or to get rid of somebody?) MDs do not seem to be all that different. You probably know the joke about what we call people who barely graduated from medical school. (‘Doctor’.)
So naturally, when doctors say things like “you have schizophrenia,” or “your symptoms are improving/getting worse/staying the same” one wants to know more. What do you really mean, doctor? And on what grounds are these judgments being made? All we did was talk. There was no brain scan, blood test, or whatever. (No reliable tests exist.) What’s your evidence? Define your terms.
Reading is one way to try to answer these questions, especially when doctors are reluctant (as they often are) to answer them directly and fully. (In fairness to doctors, they are pressed for time, and they might suspect (correctly, in my case) that every detailed answer is likely to elicit another two questions. Philosophers probably don’t make the most convenient patients.) So I read. A lot. And I know these tests quite well, not only the items on the test, but also the instructions and training that go with them (as far as these things can be gleaned from written sources plus one’s experience of undergoing assessment).
It appears that the tests are used more in academia (for example to compare the effectiveness of different treatments) than in clinics (to assess or diagnose patients), but they are sometimes used in clinics, and in this brief psychiatric interview it was not difficult to detect the use of BPRS, including the commonly suggested questions and techniques for eliciting information. By the end it was even apparent that she had in mind BPRS-18, not 16 or 24 (with 2 fewer, and 6 more, items, respectively). Yes, I was counting. She did ask about ‘suicidality’ (because all doctors do), which initially suggested BPRS-24 because that item is not on BPRS-18, but she didn’t seem to be concerned with the five other additional items from BPRS-24, and she hit every one of the 18.
So yes, I know ‘the test’, and often, consistent with being honest, I have used that knowledge to lower my score. I know that dwelling on one’s stomach pain increases one’s score, and that even if I think about it 20 times a day, I might be better off saying “it’s no big deal”. (This statement isn’t necessarily a lie—one can both think about it 20 times a day and believe that it is no big deal; the question is: Which aspect of my experience am I going to emphasize in this interview?) Failing to smile and cooperate might also earn you a point or two (especially if the doctor or nurse is in a bad mood). If you happen to hallucinate while in the doctor’s office, by no means pay the hallucination any attention. And when the doctor or nurse asks “Do you have a special relationship with God?” the answer is ‘no’, regardless of your religious convictions. (I have been asked this precise question many times. I’m not sure why, because I’m never the one to bring up God. I usually say something like “God probably has a special relationship with everybody.” I now find myself wondering whether my score gets popped for that answer.)
Doctors are aware, of course, that some patients will make a run at a low score. Indeed, they are given standard (and in general sound) advice about what to do when they suspect that a patient is being evasive, or just outright lying. But that advice can take one only so far. It isn’t merely that evasion and lying are sometimes very easy to do and very difficult to detect (though it seems that some doctors prefer not to acknowledge this fact). The more general and more important point—the point that will be explored further in the next post, or two or three—is that, in general, psychiatric diagnosis is basically meaningless without the real cooperation of the patient.
For now, to illustrate some of the ideas in play, here, I’ll share my own somewhat recent, ongoing (and very embarrassing) delusion-like experience. (It isn’t quite a delusion, but is, I suspect, something that many doctors would characterize as ‘nearby’ to delusion.) For reasons that I cannot quite pinpoint, over the last year or so I have come to perceive getting a haircut as inherently dangerous. I understand that people in general do not consider haircuts to be dangerous, and I also used to feel that way. Something has changed. It has to do with sharp metal objects, casually slung about by a (not very well paid) stranger, very close to biologically important bits of one’s body. What’s not to fear?
This feeling was a problem for a while, but the problem has been sorted by a frank conversation with a particular barber (thanks, Zach). He now understands the fear, and treats me kindly. He cuts my hair in a manner that I can tolerate, and gets tipped very handsomely. (The mere fact that we talked openly about it is really most of the solution.) Maybe he also now has a funny story for his wife and friends. Happy to oblige.
This situation has not been revealed to a doctor, and it is not likely to be. There are really two points, here. First, no doctor is going to ask “how do you feel about haircuts?” or “how have your haircuts been going?” and the information is not likely to be volunteered—there’s really no need for evasiveness, because it won’t come up in the first place. Second, from my point of view, the problem has been resolved. Am I still terrified of haircuts? In general, yes. (Even with Zach I’m pretty nervous the whole time—but I sit still!) But it isn’t causing any serious ‘problem of living’. I do procrastinate with the haircuts sometimes, but procrastinating a haircut is no big deal—my hair will be fine. And if a doctor asks (as they do) “are there any other problems that you’d like to share with me” the answer is (truthfully) ‘no’ (both because I don’t really see it as a problem any more, and because I don’t wish to share it for fear that the doctor will see it as a problem).
But if that information were to be shared, what would the doctor make of it? Maybe nothing? Or maybe it increases the ‘anxiety’ score? Or maybe ‘unusual thought content’, or ‘bizarre behavior’? All three? (Before I sorted out the issue, I did once enter a barber shop and request a haircut “without the need for police involvement.” Maybe that’s ‘bizarre behavior’? But all I really meant was “please don’t jab me with your sharp things.” Is it really so crazy to wish not to be jabbed with scissors?)
The issue, more generally, is that these scores depend on the extent to which the doctor or nurse characterizes the patient’s thinking or behavior as ‘abnormal’. Terms like “odd”, “unusual”, “strange”, and so on, are used in the training manuals (see, e.g., Lukoff et al. 1986), but what do these words mean? What is ‘normal’ or ‘usual’? Who gets to decide? On what grounds? And even if the issue of normality is settled, who decides when (or why) ‘abnormal’ is ‘in need of repair’?
Using these scales requires having answers to these questions (whether explicitly acknowledged or not). The next post, or two or three, will look further into that point, with more specific reference to some psychiatric ‘scales of assessment’ that are commonly associated with schizophrenia.
References
Overall, J. and D. Gorham (1962) “The Brief Psychiatric Rating Scale,” Psychological Reports 10:799–812.
Lukoff, D., K. Nuechterlein, and J. Ventura, (1986) “Manual for the Expanded Brief Psychiatric Rating Scale,” Schizophrenia Bulletin 12:594–602.