4.3.5 - Schizophrenia

Question 1

What is schizophrenia?

Answer 1

A severe mental disorder where contact with reality and insight are impaired, an example of psychosis.

Question 2

What is the DSM-V?

Answer 2

The Diagnostic and Statistical Manual of Mental Disorder (edition 5)

• Was last published in 2013 and is produced by the American Psychiatric Association.
• Used in psychiatric institutions throughout America and some parts on Europe.

Question 3

What is the ICD-10?

Answer 3

Health Organisations International Classification of Disease

Question 4

What are positive symptoms?

Answer 4

Additional experiences beyond those of ordinary existence, examples are hallucinations and delusions.

Question 5

What are hallucinations?

Answer 5

These are unusual sensory experiences. Some hallucinations are related to events in the environment whereas others bear no relationship to what senses are picking up from the environment.

Question 6

What are examples of hallucinations?

Answer 6

Hearing voices, seeing distorted facial expressions, seeing people or animals which aren’t there

Question 7

What are delusions?

Answer 7

Also known as paranoia, delusions are irrational beliefs. Delusions can make a person behave in a way that makes sense to them but seem bizarre to others.

Question 8

What are examples of delusions?

Answer 8

-Common delusions involve being an important, historical figure, like Jesus.
-Some involve being persecuted, perhaps by government or aliens.
-They may believe they are under external control
-Some delusions can turn aggressive

Question 9

What are negative symptoms?

Answer 9

Loss of usual abilities

Question 10

What are examples of negative symptoms?

Answer 10

Speech Poverty and Avolition

Question 11

What is speech poverty?

Answer 11

Changes in patterns of speech. Speech poverty is the reduction in the amount of quality speech, it can also be accompanied by a delay in the persons verbal responses during conversation

Question 12

What is avolition?

Answer 12

Involves loss of motivation to carry out tasks and results in lowered activity levels.

Question 13

What did Nancy Andreasen (1982) say the 3 signs of avolition are?

Answer 13

1. Poor hygiene and grooming
2. Lack of persistence in work or education
3. Lack of energy

Question 14

What are the strengths of diagnosis and classification?

Answer 14

-Good reliability: A psychiatric diagnosis is said to be reliable
when different diagnosing clinicians reach the same diagnosis for the same individual (inter-rater reliability) and test-retest reliability. Flavia Osorio et al 2019, reported excellent reliability for the diagnosis of SZ in 180 using DSM-5. Pairs of interviewers achieved inter-rather reliability of +.97 and test-retest reliability of +.92

Question 15

Why is low validity a limitation of diagnosis and classification?

Answer 15

SZ is either over or under diagnosed.

One way to assess validity of a psychiatric diagnosis is criterion validity. Elise Cheniaux 2009, had two psychiatrists independently assess the same 100 clients using ICD-10 and DSM-5 criteria and found that 68 were diagnosed with SZ under the ICD system and 39 under the DSM. Criterion validity between these is low.

Question 16

Why is co-morbidity a limitation of diagnosis and classification?

Answer 16

It has co-morbidity with other conditions e.g. bipolar, depression
If conditions occur together a lot of the time then this calls into question the validity of their diagnosis and classification because they might actually be a single condition.
Buckley et al found that about half of those diagnosed with SZ also had depression or substance abuse. This is a problem for classification because it means that SZ may not exist as a distinct condition.

Question 17

Why is gender bias a limitation of diagnosis and classification?

Answer 17

Since the 1980s men have been diagnosed with schizophrenia more than women. One possible explanation for this is that women are less vulnerable than men, perhaps because of genetic factors. However it seems that women are underdiagnosed because they have closer relationships and hence get more support (Cotton et al 2009). This leads to women with schizophrenia functioning better than a men.

Question 18

Why is culture bias in diagnosis a limitation?

Answer 18

Some symptoms of SZ, specifically hearing voices, have different meanings in different cultures. Eg in some Afro-Caribbean societies voices may be attributed to communication from ancestors.
Afro-Caribbean’s living in the UK are up to ten times more likely to receive diagnosis than white British people.
The most likely explanation for this is culture bias in diagnosis of clients by psychiatrists from a different cultural background.

Question 19

Why is symptom overlap a limitation for diagnosis and classification?

Answer 19

An example is both SZ and bipolar involve positive symptoms and negative symptoms. In terms of classification this suggests that SZ and BPD may not be two different conditions but variations of a single condition. Both diagnosis and classification are flawed.

Question 20

what is the biological explanation for SZ in families?

Answer 20

Family studies have confirmed that risk of SZ increases in line with genetic similarity to a relative with the condition, Irving Gottesman’s large-scale family study.

Question 21

What are candidate genes?

Answer 21

Candidate genes are believed to be faulty genes which could explain schizophrenia, polygenic. The most likely genes would be those coding for neurotransmitters, including dopamine.

Question 22

What is Stephen Ripke et al 2014 study?

Answer 22

He combined all previous studies looking at the whole human genome as opposed to particular genes for SZ. The genetic makeup of 37,000 people with a diagnosis of SZ was compared to that of 113,000 controls, 108 separate genetic variations were associated with slightly increases risk of schizophrenia.

Question 23

Why is SZ aetiologically heterogenous?

Answer 23

Because different candidate genes have been identified

Question 24

What is the role of mutation in schizophrenia?

Answer 24

SZ can also have a genetic origin in the absence of a family history of the disorder. One explanation for this is mutation in parental DNA which can be caused by radiation, poison or viral infection. Evidence for mutation comes from positive correlations between paternal age and risk of SZ, increasing from around 0.7% with fathers under 25 to over 2% in fathers over 50 (Brown et al)

Question 25

What are neural correlates?

Answer 25

Patterns of structure or activity in the brain that occur in conjunction with an experience (and may have caused the experience) e.g. People with schizophrenia have abnormally large ventricles in the brain.

The best known neural correlate is dopamine.

Question 26

What is the original dopamine hypothesis?

Answer 26

It was based on the discovery that drugs used to treat SZ caused symptoms similar to those with Parkinson’s disease, a condition associated with low DA levels (Seeman 1987). Therefore SZ might be the result of high levels of DA in subcortical areas of the brain. For example, the excess of DA receptors in pathway from the sub cortex to Broca’s area may explain symptoms of SZ like speech poverty or auditory hallucinations.

Question 27

What is hyperdopaminergia ?

Answer 27

Too much dopamine

Question 28

What is hypodopaminergia?

Answer 28

Not enough dopamine

Question 29

What are the updated versions of the dopamine hypothesis?

Answer 29

Kenneth Davis et al 1991 proposed the addition of cortical hypodopaminergia. This too can explain symptoms of SZ. Eg. low DA in the prefrontal cortex can explain cognitive symptoms (negative symptoms).

Question 30

What did Howes et al 2017 conclude about the dopamine hypothesis?

Answer 30

Both genetic variations and early experiences of stress, both psychological and physical, make some people more sensitive to cortical hypodopaminergia and hyperdopaminergia.

Question 31

Evaluation of the genetic basis of SZ

Answer 31

:) Research Support: Family studies show that risk increases with genetic similarity to a family member with SZ. Pekka Tienari et al shows that adopted children with parents who suffer with SZ still have a heightened risk even if they grow up with the adoptive family.
:( Environmental factors: There is clear evidence to show that environmental factors also increases the risk of developing SZ. These factors include both biological and psychological. Di Forti et al 2015, smoking THC-rich cannabis in teenage years. Psychological include childhood trauma, Nina Morkved et al 2017.

Question 32

Evaluation of the dopamine hypothesis

Answer 32

:) - Evidence for dopamine: Amphetamines increase DA and worsen symptoms in people with SZ and induce symptoms in people without (Curran et al 2004). Second, antipsychotic drugs reduce DA activity and also reduce the intensity of symptoms (Tauscher et al 2014). Some candidate genes act on the production of DA or DA receptors.
:( - Glutamate: Post-mortem and live scanning studies have consistently found raised levels of the neurotransmitter glutamate in several brain regions of people with SZ (McCutcheon et al 2020). Several candidate genes are believed to be involved in glutamate production or processing.

Question 33

What is family dysfunction as a psychological explanation for schizophrenia?

Answer 33

Psychologists have attempted to link schizophrenia to childhood and adult experiences of living in a dysfunctional family

Question 34

Who proposed the schizophrenogenic mother theory?

Answer 34

Frieda Fromm-Reichmann (1989) proposed a psychodynamic explanation for schizophrenia based on the accounts she heard from her patients about their childhood.

Question 35

What is the schizophrenogenic mother?

Answer 35

‘Schizophrenogenic’ literally means ‘schizophrenia-causing’. According to Fromm-Reichmann, a this type of mother is cold, rejecting and controlling. They tend to create a family climate characterised by tension and secrecy. This leads to distrust that later develops into paranoid delusions.

Question 36

Who proposed the double-bind theory?

Answer 36

Gregory Bateson et al (1972) emphasised the role of communication style within a family, just a risk factor.

Question 37

What is the double-bind theory?

Answer 37

The child has a fear doing the wrong thing, but receive mixed messages about what this is, and feel unable to comment on the unfairness of the situation or seek clarification.
When they get it wrong, they are punished by withdrawal of love.
They then think the world is confusing and dangerous which leads to disorganised thinking and paranoid delusions.

Question 38

What is expressed emotion (EE)?

Answer 38

It is the level of emotion, in particular negative emotion, expressed towards a patient by their carers who are often family members:

-Verbal criticism of the patient, occasionally accompanied by violence
-Hostility towards the patient, including anger and rejection
-Emotional overinvolvement in the life of the patient, including needless self-sacrifice.

It can be used as an explanation for the relapse of SZ or even a trigger of someone already vulnerable.

Question 39

What are the three cognitive explanations?

Answer 39

-Dysfunctional thinking
-Metarepresentation dysfunction
-Central control dysfunction

Question 40

What is dysfunctional thinking?

Answer 40

SZ is characterised by disruption to normal thought processing. Reduced thought processing in the ventral striatum is associated with negative symptoms, whilst reduced processing of info in the temporal and cingulate gyri are associated with hallucinations (Simon et al 2015)

Question 41

What is metarepresentation?

Answer 41

When someone can not cognitively reflect on thoughts and behaviour. This means an individual cannot recognise their own actions and thoughts as being carried out by themselves not someone else.
This explains hallucinations and delusions.
(Proposed by Christopher Frith et al 1992)

Question 42

What is central control dysfunction?

Answer 42

This is when there is an issue with the cognitive ability to suppress responses while we perform deliberate actions. Speech poverty and thought disorder could result from the inability to supress automatic thoughts and speech triggered by other thoughts.

Question 43

Evaluation of psychological explanations:

Answer 43

:) - Research support: John Read et al 2005, adults with SZ are disproportionately likely to have insecure attachment. 69% of women and 59% of men with SZ have history of physical and/or sexual abuse. Morkved reported most adults with SZ suffered childhood trauma, usually abuse.
:( - Explanations lack support: Almost no research to support Sz mother & double-bind, based off clinical observations of patients, and informal assessment of the personality of mothers of patients but no systematic evidence.
:( - Parent blaming

Question 44

Evaluation of cognitive explanations:

Answer 44

:) - Research support: John Stirling et al 2006, compared performance on a range of cognitive tasks in 30 people with SZ and a control group of 30 people without SZ. Tasks include stroop test, people with SZ took longer. Those with SZ are cognitively impaired.
:( - Proximal explanation: They explain what is happening now to produce symptoms, as distinct from distal explanations which focus on what initially caused SZ.

Question 45

What are antipsychotics?

Answer 45

Drugs used to reduce the intensity of symptoms, in particular the positive symptoms.

Question 46

What are typical antipsychotics?

Answer 46

The first generation of drugs for SZ, have been used since 1950s. They work as dopamine antagonists and include chlorpromazine.

Question 47

What are dopamine antagonists?

Answer 47

Antagonists are chemicals which reduce the action of a neurotransmitter. Dopamine antagonists work by blocking dopamine receptors in the synapses of the brain, reducing the action of dopamine.

Question 48

What is meant by sedation effects of typical antipsychotics?

Answer 48

It is often used to calm individuals not only with SZ but also with other conditions.
This has often been done when patients are first admitted to hospitals and are very anxious.
Syrup is absorbed faster than tablets.

Question 49

What are atypical antipsychotics?

Answer 49

Drugs for SZ developed after typical antipsychotics. They typically target a range of neurotransmitters such as dopamine and serotonin. Examples include clozapine and risperidone.

Question 50

What is the history of clozapine?

Answer 50

-Developed in the 1960s.
-It was withdrawn in the 1970s due to deaths from a blood condition called agranulocytosis.
-In the 1980s it was discovered to be more effective than other typical antipsychotics.
-It was remarked as a treatment for SZ
-It is taken with regular blood tests
-Not available as injection

Question 51

How does clozapine work?

Answer 51

It binds to dopamine receptors in the same way that chlorpromazine does, but in addition it acts on serotonin and glutamate receptors.
It improves mood and reduces depression and anxiety. Important as 30 to 50% of people with SZ attempt suicide at some point.

Question 52

What is the history of Risperidone?

Answer 52

-More recently developed (1990s)
-It was developed in an attempt to produce a drug as effective as clozapine but without serious side effects.

Question 53

How does Risperidone work?

Answer 53

It can be taken in the form of a tablet, syrup or injection that lasts for around 2 weeks.
It is built up to a typical daily dose (4-8mg, max 12).
It binds to dopamine and serotonin receptors, it binds more strongly to dopamine receptors than clozapine and is therefore more effective in smaller doses.

Question 54

Strengths of drug therapy:

Answer 54

• Evidence to support their effectiveness:
  -Ben Thornley et al (2003) compared chlorpromazine to control conditions. Data from 13 trials with a total of 1121 participants showed that chlorpromazine was associated with better overall functioning and reduced symptom severity compared to the placebo.
  -Davis (1990)
• can allow individuals to carry out a ‘normal’ life
• can be used in conjunction with behavioural/cognitive therapy
• can reduce numbers in hospital
• more ethical than ECT (electric shock therapy)

Question 55

Limitations of drug therapy:

Answer 55

• Serious side effects e.g. weight gain, diabetes, sexual dysfunction, insomnia and muscle tremors → most worrying is tardive dyskenesia
• Could build up a tolerance
• Costly
• Pateint could become dependent on them/addicted
• Publication bias
• Depends on dopamine hypothesis - o.g. hypothesis is not a complete explanation as dopamine is sometimes too low, so the drugs cannot help with hypodopaminergia

Question 56

What is tardive dyskenesia?

Answer 56

Uncontrollable movement to the lips, tongue, face, hands and feet (about 30% of people taking antipsychotic medication develop this and it is irreversible in 75% of patients)

Question 57

What is cognitive behavioural therapy? (CBT)

Answer 57

A method for treating mental disorders based on both cognitive and behavioural techniques. From cognitive viewpoint therapy aims to deal with cognitive thinking, such as challenging negative thoughts. It takes place over a period of 5 - 20 sessions.

Question 58

How does CBT help treat SZ?

Answer 58

• It can make sense of their irrational cognitions (delusions or hallucinations).
• Understanding where they came from can be a huge help for clients.
  e.g. therapist can convince their client the auditory hallucinations are from the malfunctioning speech centre in their own brain and that it cannot hurt them if they ignore it. This reduces their distress and improves their ability to function adequately.
• This is called normalisation.
• Delusions can also be challenged by a process of reality testing, both joint examine the likelihood of it being true. ‘Patient as scientist’.

Question 59

What is family therapy?

Answer 59

A psychological therapy carried out with all or some members of a family with the aim of improving the communications within the family and reducing the stress of living as a family.

Question 60

How does family therapy help?

Answer 60

Fiona Pharoah et al (2010) identified a range of strategies that family therapists use.

-Reduces negative emotions: family therapy aims to reduce levels of expressed emotion (EE)

-Improves the families ability to help: The therapist encourages family members to form a therapeutic alliance whereby they all agree on the aims of therapy. The therapist tries to improve families’ beliefs about behaviour towards SZ. It is also to ensure that family members achieve a balance between caring for the individual with SZ and maintaining their own lives.

Question 61

What is the model of practice?

Answer 61

Frank Burbach (2018) proposed a model for working with families dealing with SZ.

phases:
-1 - Sharing basic information and providing emotional and practical support. Then it develops through progressively deeper levels.
- 2- Identifying resources including what different family members can offer.
- 3 - Encourage mutual understanding, creating safe space for all family members to express their feelings.
- 4 - Identifying unhelpful patterns of interaction.
- 5 - Skills training such as learning stress management techniques.
- 6 - Relapse prevention planning
- 7 - Maintenance for the future

Question 62

Evaluation of CBT

Answer 62

:) - Evidence of effectiveness: Sameer Jauhar et al (2014) reviewed 34 studies of using CBT with SZ and found clear evidence for small but significant effects on positive and negative symptoms.

:( - Quality of evidence: Wide range of techniques and symptoms included in studies. CBT techniques and vary widely from one case to another. Neil Thomas 2015, points out that different studies have involved the use of different CBT techniques and people with different combinations of positive and negative symptoms.
:( - May improve quality of life for people with SZ but not actually ‘cure’ them.

Question 63

Evaluation of family therapy:

Answer 63

:) - Evidence of effectiveness:
William McFarlane (2016) concluded that family therapy was one of the most consistently effective treatments available for SZ. In particular relapse rates were found to be reduced, typically 50-60%.

:) - Benefits to whole family:
Therapy is not just for the benefit of the identified patient but also for the families that provide the bulk of care. By strengthening the functioning of a whole family, family therapy lessens the negative impact of SZ on other family members and strengthens the ability of the family to support the person with SZ.

:( - Puts a lot of responsibility and burden back on the family - should it be the responsibility of the family? or should it be the responsibility of the mental health professionals?

Question 64

What are token economies?

Answer 64

A form of behavioural modification, where desirable behaviours are encouraged by the use of selective reinforcement (usually in psychiatric institutions).
For example, people are given rewards when they engage in socially desirable behaviours.
The tokens are secondary reinforcers and can then be exchanged for primary reinforcers - food or privileges.

Question 65

Subtypes of schizophrenia?

Answer 65

• Disorganised
• Catatonic
• Paranoid
• Undifferentiated
• Residual type

Question 66

Evaluation of token economies?

Answer 66

:) - Make behaviour more socially acceptable so patients can reintegrate with society.
:) - Breaks disruptive patterns of behaviour and increases likelihood of patients acting in accordance with hospital rules.
:( - Ethical issues - some of the ‘privileges’ that patients receive upon displaying desirable behaviours are actually rights e.g. calling home, exercising outside.
:( - Does not ‘cure’ SZ or treat patient (only treats proximal symptoms).

Question 67

What is the interactionist approach to schizophrenia?

Answer 67

Suggests that both biological and psychological explanations and therapies should be used in relation to SZ, to reflect both biological and psychological aspects (Turkington et al 2006).

Central to this interactionist perspective is the use of the diathesis-stress model.

Question 68

What is the original diathesis-stress model? (Meehl 1962)

Answer 68

Meehl proposed that the diathesis is biological in origin (e.g. single schizogene) which causes a schizotypic personality which in turn eventually manifests itself as schizophrenia.
This only occurs when the diathesis is accompanied by a purely psychological stressor (e.g. schizophrenogenic mother).

Question 69

What is a diathesis?

Answer 69

A factor that makes it more likely that an individual will develop a disorder.

Question 70

What is the modern understanding of diathesis?

Answer 70

-It is now clear that many genes increase the genetic vulnerability of schizophrenia (there is no single schizogene as Ripke found over 108 candidate genes).
-Modern views also include a range of factors beyond the genetic, including psychological trauma (trauma becomes the diathesis rather than the stressor).

Read (2001) proposed a neurodevelopmental model in which early trauma alters/causes dysfunction in the brain e.g. The hypothalamic-pituatry-adrenal system (HPA) becomes over-active and the person is vulnerable to later stress.

Question 71

What is the modern understanding of stress?

Answer 71

Originally stress was seen as psychological in nature, in particular related to parenting (e.g. schizophrenogenic mother).
Psychological stress is still seen as important - a modern definition of stress is anything that risks triggering SZ e.g cannabis.

Question 72

Why is cannabis a stressor of schizophrenia?

Answer 72

It increases the risk of SZ x7 as it interferes with the dopamine system.

However, most don’t develop SZ after smoking so there must be other vulnerability factors.

Question 73

How does the interactionist approach (diathesis-stress model) view treatment of SZ?

Answer 73

The same approach should be applied to SZ treatment.
The model combines antipsychotics with psychological therapies such as CBT.

In GB, it is standard practice to combine the two as biological treatments appear to address the (direct) distal causes of SZ, whilst psychological treatments appear to be more well-suited in treating the (indirect) proximal causes. (Turkington et al 2006).
This is less frequent in the USA where there is still little overlap between biological and psychological approaches.

Question 74

Evaluation of interactionist approach to explanation and treatment of SZ?

Answer 74

:) - Main evidence for explanation comes from Tienari et al’s 2004 adoption study- this provides strong support for the diathesis stress model because the findings demonstrate that a single diathesis or stressor is not enough to trigger SZ development.
:) - Real-world application
:) - Evidence supporting the use of a combination of treatments in treating SZ - Tarrier et al (2004) found that after an 18 month follow-up, there were significant advantages for CBT and supportive counselling over treatment as usual - shows adjunctive psychological treatments can have a beneficial long-term effect on reducing symptoms.
:( - Original diathesis-stress model is over-simplified - there is no single ‘schizogene’ and stress can come in many forms inc. expressed emotion and cannabis. Meehl doesn’t consider that the diathesis is not exclusively biological, nor is the stressor exclusively psychological.
:( - Treatment-causation fallacy - Just because treatment is successful does not mean explanation holds up.