Schizophrenia Spectrum and Other Psychotic disorders

Schizophrenia is not categorized in the DSM or ICD manuals as a dissociative disorder, or a trauma-stressor disorder, but is included here because it is a common misdiagnosis of Dissociative Identity Disorder.^[1] Schizophrenia is one of a number of schizophrenia spectrum and psychotic disorders. Note that, since this website is about trauma and dissociative disorders, it is not centered on Schizophrenia, it's causes and the possible courses of treatments, but interested in the differences between schizophrenia and Dissociative Identity Disorder, especially when it comes to symptoms and experiences.

About Schizophrenia

Schizophrenia was previously known as "dementia praecox" and has been considered a unique condition for over 100 years,^[3] it is often referred to as a "brain disease"^[2]. It's clinical manifestations are very diverse, which has led to significant revisions in clinical descriptions of schizophrenia over time.^[3] Definitions and definitions of schizophrenia come from three major roots:

• the Kraepelinian emphasis on avolition (lack of will, eg, leading to poor grooming, apathyDulled emotional tone associated with detachment or indifference; observed in certain types of schizophrenia and depression." {{Rp|22}}), chronicity and poor outcome (Kraepelin, 1971),^[3] this very pessimistic view came before major advances in treatment and understanding
• Eugene Bleuler's view that dissociative pathology is primary and fundamental, and emphasizing the lack of abilities such as a limited emotional range, social difficulties and low energy (known as negative symptomsRefers to the loss of an important, previous ability. "In schizophrenia - flat affect, alogia, abulia, and apathy". {{Rp|29}}) (Eugene Bleuler, 1950)^[3]
• Kurt Schneider's views emphasize "reality distortion",^[3] in 1959 he developed a list of symptoms which he believed categorized schizophrenia, which later become known as "Schneiderian first-rank” symptoms^[4]

Schneiderian First-rank symptoms

Schneiderian First-rank symptoms (FRS) were devised by Kurt Schneider in 1959 in an attempt to list the most important indicators of schizophrenia^[5], but they have been found to exist in disorders not related to schizophrenia, for example Bipolar disorder^[4] and dissociative identity disorder^[6][7]. Dr Colin Ross, a psychiatrist specializing in dissociative identity disorder, included Schneiderian first-rank symptoms in the Dissociative Disorders Interview Schedule diagnostic test in order to aid differentiation between dissociative disorders and schizophrenia,^[8] as well as aiding diagnosis when both conditions occur. Ross (1988) found that greater numbers of FRS increased the change of patients with dissociative identity disorder without comorbid schizophrenia being diagnosed with schizophrenia alone.

Ross (1988)^:41 describes the eleven Schneiderian First-rank are:

• Voices arguingTwo or more voices conversing, they may be arguing. Common in both schizophrenia and dissociative identity disorder. This is a type of auditory hallucination. {{Rp|45}} In dissociative identity disorder the voices belong to alter identities and this may extend to alters who are contending for physical control, for example involving the person feeling a force or an "other" that ties to control or change the person's actions, or feeling or hearing an angry other that tries to control the person.{{Rp|230}}
• Voices commentingRefers to voices commenting (in the form of a running commentary) on the person's behavior or thoughts. Common in both schizophrenia and dissociative identity disorder. This is a type of auditory hallucination. {{Rp|45}}{{Rp|230}}
• DelusionsA delusion is a "false belief, based on incorrect inference about external reality, that is firmly held despite objective and obvious contradictory proof or evidence and despite the fact that other members of the culture do not share the belief." {{Rp|24}}Delusional perception is a "perception that has a unique and idiosyncratic meaning for a person, which leads to an immediate delusional interpretation". A Schniederian first-rank symptom often associated with schizophrenia {{Rp|1434}} but not associated with dissociative identity disorder. {{Rp|391}}
• Made acts'Made' or intrusive actions are also called 'made volitional acts'; a person's actions are "from and are controlled by an external agent; the person is a passive participant in the action". {{Rp|1434}} A Schnieder first-rank symptom often present in schizophrenia, but common in DID.In dissociative identity disorder the behavior does not feel like it belongs to the person, they make be unaware of the actions or may "see" another part take control of the body. In dissociative identity disorder there are three types of experience of made actions:
  1. Depersonalized stance - inside or outside of the body just passively watching or observing your actions
  2. feeling as if you are being suddenly being "overpowered, taken over, controlled, or even possessed"
  3. observing a part of your body which suddenly seems to have a mind of its own, and performs an unintended action.{{Rp|230}}
• Audible thoughtsA person's thoughts being spoken aloud. A Schniederian first-rank symptom often associated with schizophrenia.{{Rp|1434}} but not associated with DID.{{Rp|391}}
• External influencesSomatic passivity is also referred to as "influences on the body". These are tactile or visceral hallucinations that are imposed by some external agent (can be combinations of different somatic hallucinations). Common in Schizophrenia in Dissociative Identity Disorder. {{Rp|1434}} {{Rp|6}}
• Made impulsesThese impulses for action are imposed on the person and do not feel like they belong to the person, who feels like the impulses are "coming from somewhere else or someone else". In dissociative disorders this can some other part is trying to overrule the host/apparently normal part of the personality. A Schnieder first-rank symptom often present in schizophrenia but common in DID.{{Rp|231}}In schizophrenia or psychosis the impulses may be given a delusional explanation, for example naming a person or object who the impulses appear the be coming from.
• 'Made' feelings'Made' or intrusive feelings and emotions are unexpected surges of feeling-pain, hurt, anger, fear, shame, and so on. Often these surges of feeling are inexplicable and frankly puzzling". A Schnieder first-rank symptom often present in schizophrenia. These tend to be partially dissociated intrusions from another self-state, fairly common in "PTSD, borderline personality disorder, bipolar disorder, panic disorder and ADHD."{{Rp|231}}
• Thoughts ascribed to others (sometimes called Thought Insertion)
• Thought withdrawalThe person believes thoughts have been taken away from his/her mind. This is a symptom of schizophrenia,{{Rp|45}} but either thought withdrawal and thought insertion are also very common in people with Dissociative Identity Disorder. {{Rp|527}}
• Thought broadcastingThe belief that "a person's thoughts are experienced as real phenomena by others - the thoughts are made audible or heard through telepathy". A Schnieder first-rank symptom often associated with schizophrenia {{Rp|1434}} but not associated with DID.{{Rp|391}} {{See also| Schizophrenia}}

Nordgaard (2008) found that both the DSM-IV and ICD-10 diagnostic manuals emphasized FRS to "a degree not supported by empirical evidence", and their study of existing literature showed that most studies found FRS are not specific to schizophrenia. They also showed that FRS are not described precisely, leading to differing interpretations. Nordgaard (2008) stated:

Thus, in order to assess, eg, a presence of thought insertionThe person believes that thoughts that are not his/her own thoughts have been inserted into his/her mind. {{Rp|45}}This is a symptom of schizophrenia, but either thought withdrawal and thought insertion are also very common in people with Dissociative Identity Disorder. {{Rp|527}} and its diagnostic significance, one has to obtain a comprehensive picture of the patient's subjective world, a requirement that goes beyond the apparent validity provided by a “yes-no answer” (or any other single, underdetermined proposition) uttered by a patient in response to a question. (Mellor 1982)"

Schizophrenia Spectrum and Other PsychoticA person experiencing psychosis, or a characteristic of psychosis. {{Rp|24}} disorders

The DSM-5 recognizes the following:

• Schizotypal (Personality) Disorder
• Delusional Disorder
• Brief Psychotic Disorder
• Schizophreniform Disorder
• Schizophrenia
• Schizoaffective Disorder, Bipolar type
• Schizoaffective Disorder, Depressive type
• Substance/Medication-induced psychotic type (not coded)
• Psychotic disorder due to another medical condition (specify if Delusions or HallucinationsThe DSM-IV-TR psychiatric manual defined hallucinations as a "sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Auditory hallucinations are common both in schizophrenia and dissociative identity disorder. {{Rp|525}}Hallucinations can be auditory (voices, noises or other sounds), voices commenting on the person's behavior or thoughts, voices conversing, somatic or tactile (peculiar physical sensations), olfactory (unusual smells), visual (shapes or people that are not present). {{Rp|45}}Visual hallucinations are the most common type of hallucination and are often in geometric forms and figures {{Rp|127}} Illusions are similar to visual hallucinations but are based on real images or sensations.)
• Catatonia associated with another mental disorder
• Catatonia associated with another medical condition
• Other Specified Schizophrenia Spectrum and Other Psychotic disorder
• Unspecified Schizophrenia Spectrum and Other Psychotic disorder^{[9]: 21}

  Overview

Schizotypal is described within the personality disorders section. Delusional Disorder does not involve impaired functioning and shared delusionA delusion is a "false belief, based on incorrect inference about external reality, that is firmly held despite objective and obvious contradictory proof or evidence and despite the fact that other members of the culture do not share the belief." {{Rp|24}}Delusional perception is a "perception that has a unique and idiosyncratic meaning for a person, which leads to an immediate delusional interpretation". A Schniederian first-rank symptom often associated with schizophrenia {{Rp|1434}} but not associated with dissociative identity disorder. {{Rp|391}} disorder has been removed. Brief Psychotic Disorder lasts less than a month, if it lasts more then Schizophreniform Disorder should be considered or Delusional Disorder. Schizoaffective Disorder states that a mood"Pervasive and sustained emotion" which affects a person's perception of the world.{{Rp|6}} disorder must be present most of the time for this to be diagnosed. ^{[9]: 22-24}

Schizophrenia in the DSM-5

Schizophrenia has a wide variety of different symptoms, not all of which are needed for diagnosis.^[10][11] Bizarre delusionsA delusion is a "false belief, based on incorrect inference about external reality, that is firmly held despite objective and obvious contradictory proof or evidence and despite the fact that other members of the culture do not share the belief." {{Rp|24}}Delusional perception is a "perception that has a unique and idiosyncratic meaning for a person, which leads to an immediate delusional interpretation". A Schniederian first-rank symptom often associated with schizophrenia {{Rp|1434}} but not associated with dissociative identity disorder. {{Rp|391}} and Audible hallucinations were removed from criteria A in the DSM-5 and the subtypes of schizophrenia were removed.^{[9]: 22}

Symptoms of schizophrenia are two or more of the following for at least a month^[12]

• Delusions - false beliefs strongly held in spite of invalidating evidence, paranoid delusions/delusions of persecution, believing special personal messages are being communicated to you through the TV, radio, or other media, false beliefs about your body (which are unrelated to OCD or body dysmorphia), delusions of grandeur.^[12]
• Hallucinations - visual (seeing things that are not there or that other people cannot see), auditory (e.g. hearing voices), tactile (e.g. feeling something touching your skin that isn't there), olfactory (smelling things that other people cannot smell) and gustatory experiences (tasting things that aren't there)^[12]
• Disorganized speech - sometimes called "word salads". ^[12]
• Grossly disorganized^[12] or catatonic behavior (e.g. stupor/inactivity, mania, and either rigidity or extreme flexibility of the limbs).
• Negative symptomsRefers to the loss of an important, previous ability. "In schizophrenia - flat affect, alogia, abulia, and apathy". {{Rp|29}} which cause social or occupational dysfunction^[12]

The "negative" symptoms mean a lack of important abilities, e.g., social isolation, inappropriate social behavior, flat or blunted affect i.e., bluntedBlunted affect - "Disturbance in affect manifested by a severe reduction in the intensity of externalized feeling tone" {{Rp| 22}} emotions, poverty of speech, low energy with sleepiness.^[13] Positive symptoms"In schizophrenia - hallucinations, delusions, and thought disorder" {{Rp|29}} are symptoms which are an addition rather than a lack of function, for example hallucinations and delusions.^[14]:44-45

In addition, there must be significant social or occupational dysfunction, a minimum duration of symptoms and no other medical condition or substance use accounting for the symptoms. Schizoaffective disorder is also an exclusion; this is a mood disorder which includes symptoms of schizophrenia as well.^[13]

Schizophrenia is actually a group of disorders, which were first studied in the early 20th century by Bleuler and Kraepelin, among others. Kraepelin referred to schizophrenia as dementia precox but it was Bleuler who realized that some patients improved.^[14]:156 Bleuler introduced the name schizophrenia to represent "schisms between thought, emotion and behavior in patients".^[14]:156 The average prevalence for schizophrenia is often reported to be 1% of the general population^[15], presumably referring to the lifetime risk, a more recent analysis of a collection of research reports give the lifetime risk as "about seven individuals per 1,000 will be affected" (0.72%).^[16] This shows that schizophrenia is slightly less common than Dissociative Identity Disorder from the viewpoint of medical statistics. ^[17] Because some symptoms reported by people suffering from Schizophrenia and Dissociative Identity Disorder are similar, misdiagnosis is common.^[1][18] leading to potentially inefficient treatment which may be harmful when prolonged in time.

Etiology (causes)

Strong evidence shows that the development of schizophrenia in a person is related to both biological, genetic and environmental factors ^[19][20].

Genetic risk factors in schizophrenia

Twin and adoption studies have shown a substantial genetic risk factor in schizophrenia^[20]. Schizophrenia affects about 1% of the general population, but relatives of those with schizophrenia have a higher risk, siblings and non-identical twins of someone with schizophrenia have a risk of 9%, rising to 50% for identical twins,^[20] although environmental factors including early trauma may contribute. ^[21] Finnish studies using the Thought Disorder Index have shown children of mothers with schizophrenia are more likely to show symptoms of a thought disorder if raised by adoptive mothers with 'communication deviance'. Thought disorder is a cognitive symptom associated with schizophrenia but not with trauma or dissociative disorders. Diathesis refers to a genetic predeposition to developing the condition.

The Trauma-Psychosis"Mental disorder in which thoughts, affective response, ability to recognize reality, and the ability to communicate and relate to others are sufficiently impaired to interfere grossly with the capacity to deal with reality." Impaired reality testing, hallucinations, delusions, and illusions are classic characteristics. {{Rp|24}} Link

Shevlin et al. (2008) used The National ComorbidityComorbid means the the presence of more than one psychiatric diagnosis at once, with substance use this is often referred to as "dual diagnosis" Also see [[Cormobid]]. Survey data from the United States and The British Psychiatric Morbidity Survey to estimate the effect of cumulative traumatic experiences on psychosis"Mental disorder in which thoughts, affective response, ability to recognize reality, and the ability to communicate and relate to others are sufficiently impaired to interfere grossly with the capacity to deal with reality." Impaired reality testing, hallucinations, delusions, and illusions are classic characteristics. {{Rp|24}}"Mental disorder in which thoughts, affective response, ability to recognize reality, and the ability to communicate and relate to others are sufficiently impaired to interfere grossly with the capacity to deal with reality." Impaired reality testing, hallucinations, delusions, and illusions are classic characteristics. {{Rp|24}}; traumatic life events were previously known to be associated with a diagnosis of psychosis. Shevlin et al. (2008) concluded that experiencing two or more trauma types "significantly predicted psychosis" and that the risk of psychosis continued to increase with additional trauma.^[22] In the US data the study found sexual and physical abuse were significant predictors of psychosis; the British data gave serious injury or assault/violence in the home as significant predictors. Multiple traumatic events are not rare, and are associated with poorer mental and physical health. However, trauma was shown not to be the sole cause of psychosis; 14-20% of people with psychosis had experienced no traumatic experiences and a single type of traumatic experience was not associated with an increased risk of psychosis.^[22]

Janssen et al. (2004) found that the greater child abuse experienced the greater psychotic symptoms were reported in adulthood, and Whitfield (2005) found with a direct correlation shown between hallucinations childhood trauma. High rates of child sexual abuse has been reported by people with psychotic disorders by a number of different researchers.

Environmental risk factors in Schizophrenia and Psychosis

In a 2012 study, the researchers concluded that "dissociative symptoms in patients with Schizophrenia Spectrum disorders are related to childhood trauma. Dissociation seems to be state dependent in this diagnostic group. Moreover, diagnostic interviews, in addition to the Dissociative Experiences Scale, should be considered to avoid measurement artefacts." ^[23]

It has been suggested that the medical model and funding by pharmaceutical companies has encouraged more research into biological/genetic causes of schizophrenia rather than the environmental causes. Those with no family history of psychotic conditions have a seven times greater risk of schizophrenia if they grow up in deprived economic conditions, and the risk of becoming psychotic is nine times greater in abused people. ^[19] Delusions and hallucinations are significantly more common in survivors of child sexual or physical Abuse.^[19]

The diathesis-stress model, more commonly known as the stress-vulnerability model proposes a mixture of genetic and environmental causes lead to schizophrenia; this refers to persistent stress rather than everyday stress. For example factors may include birth trauma, early exposure to a virus of chemical. In addition events caused by interpersonal interactions ^[24] or a failure to protect someone with a generic predisposition to schizophrenia from normal degrees of stress. ^[24] Being exposed to traumatic events alone is not sufficient to cause schizophrenia, ^[19] although the trauma can cause other psychiatric conditions, including PTSD.

Substance abuse as an environmental risk factor

Substance abuse can cause temporary symptoms such as delusions and hallucinations, mimicking schizophrenia. On rare occasions LCD use had led to schizophrenic symptoms which have become permanent, although this is believed to be due to an existing genetic predeposition or after experiencing intermittent symptoms beforehand.^[19] Prolonged use of cocaine, amphetamines and cannabis (marijuana) have also been linked to delusions and sometimes hallucinations. Marijuana users have a two^[25] to four fold chance of developing schizophrenia compared to those who do not use it.^[19]

Symptoms

Hallucinations

For a long time, it was assumed "all hallucinations are Schizophrenia",^[26] but more recently the DSM-IV-TR psychiatric manual listed illusionsIllusions are distortions of real images or sensations, however hallucinations are not based on things which are not real. Illusions have many different causes include being substance related, or caused by a disorder such as Schizophrenia or PTSD (reexperiencing the truma). {{Rp|168,260}} and hallucinations as trauma symptoms, along with dissociative flashback episodes.^[27]:468 In Schizophrenia tactileTactile refers to the sense of being touched. Tactile hallucinations primarily involve the sense of touch and can occur in mental disorders or by caused by substance use or another medical condition. The sensation of bugs crawling just beneath the skin (formication) is one type of tactile hallucination which is particularly associated with cocaine and amphetamine use. {{Rp|31,67}}, olfactory, and gustatory hallucinationsGustatory hallucinations involved an altered sense of taste. These are rare in Schizophrenia but often present in temporaral lope epilepsy and PTSD (in the form of flashbacks).{{Rp|27}} are unusual.^[28]:168 Shevlin et al. (2007) found that a history of childhood rape and molestation were significantly associated with visual, auditory (sounds, voices) and tactile (touch-based) hallucinations. Neglect was also associated with visual hallucinations, and physical abuse was associated with tactile hallucinationsTactile refers to the sense of being touched. Tactile hallucinations primarily involve the sense of touch and can occur in mental disorders or by caused by substance use or another medical condition. The sensation of bugs crawling just beneath the skin (formication) is one type of tactile hallucination which is particularly associated with cocaine and amphetamine use. {{Rp|31,67}}. Experiencing multiple types of trauma was associated with increases in the likelihood of reporting each of the three types of hallucinations. The same researched considered hallucinatory experiences to be possible indicators of a early childhood trauma.

Confusion with Flashbacks

Flashbacks are traumatic intrusions occur as a result of unprocessed memories of trauma. Flashbacks may take many forms, including visual, auditory and tactile hallucinations; flashbacks are a common symptom of Dissociative Identity Disorder, Other Specified Dissociative Disorder, PTSD and other trauma-based disorders.

The DSM-IV-TR psychiatic manual stated the importance of distinguishing between flashbacks and hallucinations of a psychotic nature in diagnosis:

"Flashbacks in Posttraumatic Stress Disorder (PTSD) must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in Schizophrenia, other Psychotic Disorders, Mood"Pervasive and sustained emotion" which affects a person's perception of the world.{{Rp|6}} Disorder with Psychotic features, a delirium, Substance-Induced Disorders, and Psychotic Disorders Due to a General Medical Condition."^[27]:467

Hearing Voices

Are they an indicator that mental illness is present?

The lifetime prevalence of voice hearing in the general population is estimated to vary from 1-16% of adult nonclinical populations, and 2-41% in healthy adolescent samples.^[29] Hearing voices is particularly common among people with schizophrenia or a psychotic disorder, dissociative identity disorder and has been reported within PTSD^{[14]:243, 260-261}, but in the absence of other symptoms a mental health disorder would not be diagnosed.^[11]

Voice hearing is characterized by hearing voices which have no external (physical) cause. However, this does not mean they have no causes at all. TraumaThe most fundamental effect of trauma is dissociation, so we define trauma as the event(s) that cause dissociation. {{Rp|75}} The original trauma in those with dissociative identity disorder was failure of secure attachment with a primary attachment figure in early childhood. {{Rp|83}}, in particular child sexual abuse, have associated with hearing voices.^[29] Hearing voices is also known as "auditory verbal hallucinations",^[30] other forms of auditory hallucinations include hearing sounds that aren't physically present. Hearing sounds or voices which are not present can also be a form of flashback.

As a symptom of a mental health condition

In schizophrenia, voices are said to be "positive" symptoms, that is, they are an experience normally not present in people not suffering from a psychotic disorder, however, they are one of the major criteria for diagnosis.

Voices in dissociative identity disorder are very common^[18], and are manifestations of other parts of the personality, often known as alter personalities or alters which occur when a person is co-conscious with other identities. Child voices are particularly common in dissociative identity disorder.^[31] There has been some discussion over whether voices in schizophrenia or psychotic conditions should be considered "psychotic", with those in DID and OSDD being considered "dissociative voices". There does not yet appear to be general agreement on this.^[30][32][29]

Longden (2012) comprehensively reviewed and integrated "historical, clinical, epidemiological, and phenomenological evidence" of voice hearing, and demonstrated that voice location (inside the head as "thoughts" or outside as auditory experiences), content, and frequency limited its usefulness in both diagnosis and differentiating between psychotic disorders such as schizophrenia from trauma-spectrum and nonclinical populations. This wide-ranging and historical review argued that voice hearing experiences "including those in the context of psychotic disorders, can be most appropriately understood as dissociated or disowned components of the self (or self–other relationships) that result from trauma, loss, or other interpersonal stressors" and may be "more appropriately understood as a dissociative rather than a psychotic phenomenon", providing a rationale for the use of psychotherapy to help those experiencing distressing voices.

However, some differences have been suggested between hearing voices in DID and in schizophrenia.^[31] These include people with DID being more likely to hear voices before age 18, being more likely to hear more than two voices and to have both child and adult voices, and to experience tactile and visual hallucinations. They also found that those with schizophrenia were also more likely to hear internal than external voices, and that voices content did not depend on a person's mood. Regardless of diagnosis, pathological dissociation predicted several aspects of voice hearing in those with a history of childhood maltreatment, regardless of diagnosis.^[31] However, even within this relatively small study, there was no completely definite way to determine differences by either diagnosis or a person's childhood history.

Delusions: Fears and beliefs deemed irrational

DelusionA delusion is a "false belief, based on incorrect inference about external reality, that is firmly held despite objective and obvious contradictory proof or evidence and despite the fact that other members of the culture do not share the belief." {{Rp|24}}Delusional perception is a "perception that has a unique and idiosyncratic meaning for a person, which leads to an immediate delusional interpretation". A Schniederian first-rank symptom often associated with schizophrenia {{Rp|1434}} but not associated with dissociative identity disorder. {{Rp|391}} is a false belief that is fixed and firmly held by the patients despite explicit contradictory evidence. ^[33]

Common delusions include:

• delusion of reference
• delusion of control
• delusion of granduer
• delusion of infidelity (pathological jealousy)
• delusion of persecution
• delusion of poverty
• delusion of reference
• delusion of self-accusation^[14]:27

Examples of delusional beliefs common in schizophrenia include believing that:

1. Thoughts, feelings, or actions are being controlled by external forces or agents (alien control)
2. Private thoughts are being broadcast (thought insertion)
3. That thoughts are take away by some external forces or agents (thought withdrawalThe person believes thoughts have been taken away from his/her mind. This is a symptom of schizophrenia,{{Rp|45}} but either thought withdrawal and thought insertion are also very common in people with Dissociative Identity Disorder. {{Rp|527}})^[33]

They may also believe that they are very famous or important people (e.g. Jesus Christ, a delusion of grandeur), that people are plotting against them (persecution), or that television programs bear special significant meanings for them (delusion of reference). ^[33]

Common cognitive distortions within Dissociative Identity Disorder may be mistaken for delusions, for example delusional of separateness; "some alternate identities may insist that they do not inhabit the same body as the others or that suicide or self-injurySelf-injury (direct self-harm) with non-suicidal intent. would have no effect on them; they may even be invested in killing off the “others.”" This should be treated with psychotherapy. Serious safety problems can result from this issue, and it is important to directly challenge this extreme form of dissociative denial. ^{[1]: 140}

In schizophrenia people may manifest unusual beliefs in spite of evidence that these beliefs are not true (delusions),^[11] these delusions are often not held before the onset of the illness. Dissociative Identity Disorder and schizophrenia are rare as comorbidities, but the presence of one condition does exclude the other. ^[34]

In Dissociative Identity Disorder, these fears and beliefs result from traumatic experiences in the past, which are typically more severe than in schizophrenia.^[6] People with complex dissociative disorders may be unaware have isolated the traumatic experience from their consciousness, and are thus unaware of it initially due to the amnesia between their alters. Amnesia is a requirement for diagnosing dissociative identity disorder, but not a psychotic condition.^[11]

Ritual Trauma - Misinterpreted as Delusions

Ritual abuse, also known as ritual trauma, which begins at a very young age is a known cause of Dissociative Identity Disorder. Mangen found that patients with a ritual trauma history tended to provide images that were perceptually accurate (largely consistent with shapes in the inkblot, for example recognizing the shape could be a person) but those with schizophrenia often had poor perceptual accuracy, a sign of more impaired perceptual and thought processes. However, the patients with ritual abuseTypically involves a combination of extreme abuses, including sexual, physical, emotional, psychological and spiritual abuse and is usually carried out by groups rather than lone individuals. May include murder and torture, often to near death. Torture may be used along side mind control and brainwashing techniques; combined these can be used to further control a person who has developed dissociative parts or identities in order to cope with the abuse. Survivors of ritual abuse report that most groups force them to commit horrific acts including harming others, including other children, vulnerable adults or pets, and being drugged. Miller (2012){{Rp|12}} Types of abuse used have been compared to the torture and brainwashing techniques used on political prisoners. (Matthew (2001)) histories would describe "seemingly bizarre associations" in the Rorschach, if not for an understanding of the underlying ritual trauma;^[35]. For instance, a shape similar to a person would be described carrying out seemingly "bizarre" and traumatic/violent acts. This could lead clinicians to incorrectly interpret traumatic associations and traumatic imagery as "delusions". Mangen observed that "many responses given by these patients sound blatantly psychotic"^[35]:154 but closer scrutiny revealed that these were derived from the ritual abuse and the traumatized level of functioning.

Leavitt and Labott (1998a)^[36] showed Rorschach results of patients reporting child sexual abuse within Satanic cults and histories of amnesia for their sexual trauma gave significantly more Rorschach responses with Satanic content than patients reporting child sexual abuse without ritual abuse or non-abused patients. A second study revealed more Satanic content in patients reporting ritual abuse if the degree of media and hospital milieu exposure to the subject of Satanic ritual abuse was less. ^[36]

In an earlier study, Leavitt and Labott (1998a) found that patients reporting Satanic ritual abuse provided more Satanic-content responses in a word association test than patients reporting non-ritual sexual abuse. They also provided fewer normative responses, understandable given the pervasive nature of ritual trauma and the paucity of normal childhood experience for so many of these victims.

Decreased social sensitivity and Impulsive behavior

Impulsive behavior can occur in Schizophrenia, and may be combined with a decreased social sensitivity, for example a patient grabbing another patient's cigarettes. ^[28]:169

Homicide and Suicide rates in people with Schizophrenia

People with Schizophrenia no more likely to commit homicide than general population; indicators of a greater risk of homicide within people with Schizophrenia include a previous history of violence and dangerous behavior when hospitalized.^[28]:169

Suicide leading cause of premature death in people with Schizophrenia, with 20-50% attempting suicide. Around 10-13% of people with Schizophrenia die by suicide, a rate 20 times higher than the general populations. ^[28]:169

Similarities between Schizophrenia/psychotic disorders and Dissociative Identity Disorder

Kluft (1987) studied a group of 30 people diagnosed with DID and found they had a mean average of 3.6 Schneiderian first-rank symptoms, with the number varying from 1 to 8 symptoms per patient, where as Ross' Dissociative Disorders Inteview Schedule research found an average of 6.5 first-rank symptoms using 166 patients.^[8] Ross (1988) analyzed symptoms of 236 patients diagnosed with dissociative identity disorder (then known as multiple personality disorder Of these, over 40% had a prior of schizophrenia, and these patients were found to be generally more self-destructive, had spent longer in the mental health system prior to diagnosis of DID, and during this period had received more alternative psychiatric diagnoses. This analysis intentionally excluded patients with particularly large number of personalities (polyfragmented DID), which is commonly believed to be caused by ritual trauma/ritual abuse. Dr Ross found the most common Schniederian first-rankSchniederian first-rank symptoms are a list of 11 symptoms often associated with schizophrenia which were devised by Kurt Schieder. {{Rp|1434}} Eight of these symptoms are also experienced in dissociative disorders like DID and other specified dissociative disorder. The symptoms are: audible thoughts, voices arguing or discussing, voices commenting on patient's actions, somatic passivity (tactile or visceral hallucinations that are imposed by some external agent; can be combinations of different somatic hallucinations), thought withdrawal, thought insertion, thought broadcasting, made feelings, made actions (made volitional acts), made impulses or drives, and delusional perception.{{Rp|1434}} These symptoms alone are not sufficient to make the diagnosis of schizophrenia. The three Schniederian first-rank symptoms not associated with DID are audible thoughts, broadcasting.{{Rp|391}} {{See also| Dissociative symptoms}} symptoms were:

First-rank symptom	DID patients with previous schizophrenia diagnosis	DID patients without previous schizophrenia diagnosis
Voices arguing	80.2%	70.2%
Delusions	63.0%	37.2%
Made acts	57.1%	37.6%
Audible thoughts	56.2%	38.0%
External influences	55.4%	40.9%
Made impulses	54.9%	41.9%
Made feelings'Made' or intrusive feelings and emotions are unexpected surges of feeling-pain, hurt, anger, fear, shame, and so on. Often these surges of feeling are inexplicable and frankly puzzling". A Schnieder first-rank symptom often present in schizophrenia. These tend to be partially dissociated intrusions from another self-state, fairly common in "PTSD, borderline personality disorder, bipolar disorder, panic disorder and ADHD."{{Rp|231}}	47.8%	29.0%
Thoughts ascribed to others	43.8%	34.4%
Thought withdrawal	40.5%	22.6%
Thought broadcasting	20.0%	10.6%

This clearly shows that hearing voices (auditory hallucinations) are very common in DID but aren't associated with a misdiagnosis of schizophrenia. However, delusions, passivity experiences, thought broadcastingThe belief that "a person's thoughts are experienced as real phenomena by others - the thoughts are made audible or heard through telepathy". A Schnieder first-rank symptom often associated with schizophrenia {{Rp|1434}} but not associated with DID.{{Rp|391}} {{See also| Schizophrenia}}, and thought withdrawal distinguish DID patients who had been misdiagnosed with schizophrenia. This information dates from 1988,^[18] significant improvements in the research, awareness and particularly clinical diagnosis of dissociative disorders in recent decades would likely mean results would be very different today, with misdiagnosis expected to be significantly less common.

Differences between Schizophrenia and Dissociative Identity Disorder

Because Schizophrenia and Dissociative Identity Disorder (DID) have much similarity symptomatically, it was suggested historically believed that the two were the same, but further research has shown significant differences. Brand (2010) provides a clear summary of differences between symptoms of schizophrenia and dissociative identity disorder, many of which are briefly described below.

Amnesia

Amnesia is not a symptom of schizophrenia, but is a required symptom of dissociative identity disorder.^[11] Amnesia in the present is often described as "losing time" or "blackouts" by those with DID; this does not occur in schizophrenia except during periods of floridAn organization that has been voted down by other experts, because it mixes many disorders together. {{Rp|419}} psychosis^[6]. Amnesia for large periods of childhood are common in DID.

Dissociative symptoms

These are far more common in DID than schizophrenia, and can be assessed using a screening tool known as the DES, the Dissociative Experiences Scale. People with OSDD and DID score significantly higher that those with schizophrenia or another diagnosis without a comorbid dissociative disorder.

Trauma

People with DID typically report "early-onset, severe, chronic childhood trauma, and high level of traumatic intrusions on Rorschach"^[6] although it is possible for some or all identities to have total amnesia for childhood history, including trauma. People with schizophrenia are "less likely to have severe, chronic childhood trauma," and have "fewer traumatic intrusions than on Rorschach".^[6]

Negative symptoms

People with dissociative disorders typically lack the negative symptoms of schizophrenia,^[7] which can be helpful in diagnosis. This refers to a loss of ability to do basic things, for example grooming/personal hygiene and flat or blunted affect.

Physical health problems

Physical health problems, especially those with no known cause are far more common in DID.^[37] Especially common are headaches, fibromyalgia, gastrointestinal and gynecological problems.^[6]

Logical thinking and Organization

Thinking is less logical and organized in schizophrenia,^[6] in contrast DID patients typically have the skills to be self-reflective.^{[38]: 162}

Delusions

The DSM-IV describes this in the dissociative identity disorder section:

For example, the presence of more than one dissociated personality state may be mistaken for a delusion or the communication from one identity to another may be mistaken for an auditory hallucinationThe DSM-IV-TR psychiatric manual defined hallucinations as a "sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Auditory hallucinations are common both in schizophrenia and dissociative identity disorder. {{Rp|525}}Hallucinations can be auditory (voices, noises or other sounds), voices commenting on the person's behavior or thoughts, voices conversing, somatic or tactile (peculiar physical sensations), olfactory (unusual smells), visual (shapes or people that are not present). {{Rp|45}}Visual hallucinations are the most common type of hallucination and are often in geometric forms and figures {{Rp|127}} Illusions are similar to visual hallucinations but are based on real images or sensations., leading to confusion with the Psychotic Disorder."^{[15]: 529}

Hallucinations: hearing voices and flashbacks

While the reference to hallucinations was not included in the DSM-5,^[11] it was included as a PTSD symptom in the DSM-IV-TR.^[27]:467

Dissociative identity disorder is almost always comorbid with PTSD, but because of the amnesia which is a required symptom of DID, a flashback may occur in an identity with no memory of that specific trauma. This could lead to the flashback being mistaken for a hallucination without a trauma basis. Flashbacks are dissociated experiences and may take many forms: sights, sounds, body sensations, (for example sensation of touch or pain), or vehement emotions.^[38]:161

For example, "one time I turned around and saw a man with a raised knife. Imagine having a nightmare while you're awake."^[2] This could be a visual flashback from a previous traumatic experience of a person who was threatened with a knife, but in this case the speaker is describing it as a hallucination which is not a PTSD symptom. In cases like these further information about the context would be needed to understand whether this was a posttraumatic symptom or a psychotic symptom.^[38]:161Key differences

• A person with DID who is unaware of the source of a voice (or sound) they are hearing can recognize these experiences are not normal and will not attempt to explain them in a delusion way, in contrast a person experiencing psychosis is more likely to attach a delusion explanation.^[38]:6
• Voices which are seemingly bizarre are more likely to indicate schizophrenia^[38]
• People with DID are aware the voices aren't real; people with schizophrenia may be unaware of the hallucinogenic quality of the voices^[6]
• People with DID may have elaborate conversations and multiple conversations at the same time (which is uncommon in schizophrenia) or brief periods of "seeing" their identities ^[6]
• Parts which are psychotic can exist in DID, but do not mean the whole person is psychotic.^[38]:161-162

Identity alterationDefined as "objective behaviors that are manifestations of the assumption of different identities or ego states"{{Rp|14}} within DID, also known as "switching". The structured clinical interview for the dissociative disorders and other diagnostic tools assess identity alteration. {{See also| Identity alteration}} {{See also| Diagnosis}}

Alternation between different, distinct identities is a required criteria when diagnosing DID,^[11] but not all people with DID will be aware that this happens: it is often observed by others first so not all will admit to being aware of this. The diagnostic tests including the Dissociative experiences scale can be used to identify actions resulting from identity alterationDefined as "objective behaviors that are manifestations of the assumption of different identities or ego states"{{Rp|14}} within DID, also known as "switching". The structured clinical interview for the dissociative disorders and other diagnostic tools assess identity alteration. {{See also| Identity alteration}} {{See also| Diagnosis}} that the person is unaware of.

Brand (2010) states that people with schizophrenia "may admit to transformation in identity but with magical or delusional beliefs (eg, “I had to become the prophet David and then had to fight myself when I became the devil”)".

Co-morbidity with DID and PTSD

A person with DID may have parts (alters) who are psychotic, if this appears it is important to recognize that this is a part, not necessarily a breakdown of the whole person.^[38]:162 Schizophrenia and dissociative identity disorder are rarely comorbid (both occurring) but the presence of one condition does exclude the other. ^[34]

People with schizophrenia are more likely to have PTSD than those without, further artificially increasing the seeming similarity with dissociative identity disorder^[26] However, people with DID typically have more comorbid diagnosis, including with PTSD, mood disorders, anxiety disorders, mixed personality disorders and somatoform disorder.

Diagnostic tests

DES

The Dissociative experiences scale is a screening tool rather than a full diagnostic test. People will schizophrenia and no dissociative disorder typically score under 20. Those with Dissociative Identity Disorder score an average of 44.6, and may also self-harm to induce dissociation.^[6].

MID

The Multidimensional Inventory of Dissociation (MID) and SCID-D can be used to help determine accurate diagnosis. As many symptoms are superficially similar, it is likely that diagnostic instruments to measure Dissociative Identity Disorder (like the MID) will also give higher scores for schizophrenia.^[26]

Diagnostic testing and interviewing of 40 schizophrenia patients and 40 dissociative identity disorder patients using the MID; the Structured Clinical Interview for the DSM–IV Axis I Disorders was used for schizophrenia patients, and the Structured Clinical Interview for DSM–IV Dissociative Disorders–Revised for DID patients. The results showed that DID patients obtained significantly :

• higher dissociation scores;
• higher passive-influence scores (first-rank symptoms)
• higher scores on scales that measure child voices, angry voices, persecutory voices, voices arguing, and voices commentingRefers to voices commenting (in the form of a running commentary) on the person's behavior or thoughts. Common in both schizophrenia and dissociative identity disorder. This is a type of auditory hallucination. {{Rp|45}}{{Rp|230}}
• lower delusion scores.^[32]

Laddis (2012) also found that "the dissociation scores of patients with schizophrenia were unrelated to their reports of childhood maltreatment", and argued that "neither phenomenological definitions of dissociation nor the current generation of dissociation instruments can distinguish between the dissociative phenomena of DID and what we suspect are just the dissociation-like phenomena of schizophrenia".

SDQ-20The Somatoform disorders questionnaire in available in a 20 question or 5 question format and measures somatoform dissociation. {{See also | Somatoform Disorders}}

The 20-item Somatoform Dissociation Questionnaire (known as the SDQ-20) assesses somatoform symptoms (physical symptoms with no known physical cause) and is useful in differentiating between DID and schizophrenia when used along side other screening tools or diagnostic interviews. The degree of somatoform and psychological dissociation a person experiences is a correlated to the degree of trauma experienced,^[39] so indirectly it assess trauma which results in physically dissociatied symptoms. This is useful because those with complex dissociative disorders report more severe trauma histories than people with schizophrenia.^[6]

People with DID and OSDD have a greater number of somatoform symptoms than those with schizophrenia alone.^[37] People with a somatoform disorder alone would normally score closer to 30 although there may be some overlap between OSDD and somatoform disorders.^[40] Those with DID score consistently highest.^[40]

Dissociative Disorders Interview Scale

The DDIS is a structured clinical interview is designed to assess a variety of dissociative disorders and other conditions including schizophrenia, however it is based on the previous version of the DSM criteria.^[8] It also references schizophrenia's first-rank symptoms. ^[8] The DDIS states the average number of Schneiderian first-rank symptoms was 6.5 in research involving 166 patients, but uses substance abuse and somatic symptoms to differentiate between them.

SCID-D

The SCID-D screens for all dissociative disorders and can identify those which exist whether they occur alongside a psychotic disorder or not.

Treatment for schizophrenia

Schizophrenia is treated with anti-psychotic medication; individual psychotherapy has little positive effect although skills training may be useful, for example in developing social skills. ^[19] Dissociative Identity Disorder occurs due to severe trauma throughout early childhood in combination with disturbed caregiver interactions. ^[1] Anti-psychotic medication will not "remove" parts/alter personalities and usually has little or no effect on DID. In common with PTSD some medications can be helpful, including anti-depressants, anti-anxiety medication and medication to reduce insomnia. The recommended treatment is individual psychotherapy, in order to resolve the trauma and learn how to develop healthier relationships and attachments. ^[1]

Stigma

Even with all that — excellent treatment, wonderful family and friends, supportive work environment — I did not make my illness public until relatively late in life, and that's because the stigma against mental illness is so powerful that I didn't feel safe with people knowing.

If you hear nothing else today, please hear this: There are not "schizophrenics." There are people with schizophrenia, and these people may be your spouse, they may be your child, they may be your neighbor, they may be your friend, they may be your coworker."

Dr Elyn Saks, diagnosed with chronic schizophrenia as a young woman, now a chaired Professor of Law, Psychology and Psychiatry at the USC Gould School of Law^[2]

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