A2 - schizophrenia Flashcards
what is schizophrenia?
a psychotic disorder where people interpret reality abnormally. It is marked by severely impaired thinking, emotions, and behaviour
what are positive symptoms?
symptoms which are an excess or a distortion of normal functions. In addition to normal experience
what is a negative symptom?
a diminution or loss of normal symptoms
1/3 of patients suffer from significant negative symptoms
what are examples of positive symptoms?
delusions
hallucinations
catatonic or disorganised behaviour
what are examples of negative symptoms?
affective flattening
alogia
avolition
anhedonia
what are delusions and outline 3 types
set of beliefs with no basis in reality e.g. paranoia that they are being stalked
- persecutory
- gandeur
- reference
what are hallucinations and different types?
distorted view/ perception of stimuli
can be auditory, visual, tactile
what is psychomotor behaviour?
stereotypical rocking back and forth, twitches and/or repetitive behaviours
what is disorganised speech?
rapid, loss of focus ‘word salad’ incoherent sentences ‘derailment’
what is affective flattening?
lack of showing emotion, characterised by an unchanging facial expression and little to no change in tone, strength, pitch
what is alogia?
abnormally low level of the frequency and quality of speech
what is avolition?
lack of motivation - inability to cope with the normal pressures and motivations associated with everyday tasks
what is anhedonia?
loss of pleasure - not finding joy in anything
what are the 2 main diagnostic tools for schizophrenia?
DSM-V
ICD-11
what is the criteria on the DSM-V for schizophrenia
symptoms for at least 1 month - requires at least 2 or more of: delusions, hallucinations, disorganised speech, and catatonic behaviour
what is the criteria on the ICD-11 for schizophrenia?
1 month + symptoms - the clinical picture is dominated by relatively stable, often paranoid delusions, usually accompanied by hallucinations
what is reliability?
the extent to which a finding can be consistent
what are the 2 ways reliability can be tested
- test-retest
- inter-rater reliability
what is schizophrenia’s KAPA score?
0.46
what was found about cultural differences in diagnosis?
Copeland et at gave a description of the same patients to 134 US and 194 UK psychiatrists and
69% of US diagnosed them but only 2% of the UK did
what was found about the different variations of ‘hearing voices’ by Luhrman et al
He interviewed 60 adults, 20 from Ghana, India, and US each. The Indians and Ghanaians said they heard playful, advice diving voices. Whereas the Americans reported voices as being violent and hateful. Indicative of being ‘sick’
Evidence that DSM-V shows low reliability AO3
P - despite claims of better reliability as the DSM has been regularly updated since the DSM-III, 30 years ago, there is still little evidence that DSM-V is used reliably by clinicians
E - Whaley found inter-rater reliability correlations in diagnosis as low as 0.11/ For results to be reliable, there must be a 0.7 KAPA score, or a 0.8 inter-rater reliability.
E - these findings suggest, with the lack of objective measures used by other branches of medicine, there continues to be low reliability in the diagnosis of SZ
define validity
the extent to which we are measuring what we are intending to measure
how does Rosenhan’s research demonstrate a lack of validity in the diagnosis of schizophrenia?
Pseudo patients reported hearing voices saying ‘hollow, empty, thud’ at several US psych hospitals.
11/12 times fake patients were diagnosed as insane, showing a lack of validity as they were all fave patients and none had SZ
how does gender bias affect the validity of diagnosis for schizophrenia
critics of the DSM diagnostic criteria argue that some diagnostic categories are biased towards diagnosing one gender rather than the other, therefore lack validity
supporting evidence for how gender bias affects the validity of diagnosis for schizophrenia AO3
E - Loring and Powell randomly selected 290 male and female psychiatrists to read patiend behaviour. Then, were asked to give their diagnosis using a standard criteria.
E - when said to be male or no gender, 56% were diagnosed with SZ
when they were said to be female, only 20% were diagnosed
E - this gender bias did not appear to be evident amongst the female psychiatrists. This suggests that diagnosis is influenced not only by the gender of the patient but the gender of the clinician. It may be that men are more likely to be diagnosed due to gender bias with women’s issues not being taken seriously
what is symptom overlap?
the extent to which symptoms of schizophrenia are also found in other disorders e.g. old, depression, bipolar disorder
AO3 of how symptom overlap can cause problems with making a valid diagnosis of SZ
P - symptom overlap can cause problems with making a valid diagnosis of SZ
E - this suggests that many people diagnosed with sz have enough symptoms of other disorders that they could receive an incorrect diagnosis
E - Ketter identified that misdiagnosis due to symptom overlap can lead to years of delay in receiving correct treatment, during which time further suffering can occur.
L - focussing on resolving this could save money for the NHS and lives of patients
what is co-morbidity?
the extent that 2 or more conditions can occur at the same time
example (Buckley) of co-morbidity
suggested co-morbid depression occurs in 50% of patients with SZ and 47% experience substance abuse
what is likely to contribute to the risk of developing schizophrenia?
variations in candidate genes
what were the findings of concordance rates in family studies for
spouse
child
DZ twins
MZ twins
spouse - 1%
child - 13%
DZ twins - 17%
MZ twins - 48%
AO3 flaw in the argument that MZ and DZ share equally similar environments
Joseph pointed out that MZ twins are treated more similarly, encounter more similar environments and experience more ‘identity confusion’ being treated as ‘the twins’ rather than 2 individuals
what was an adoption study on schizophrenia?
Tienari et al
used two groups, one of 164 adoptees whose mother did have SZ (11 of these also received a diagnosis)
- control group of 197 non sz mothered children (only 4 were later diagnosed)
shows that the genetic liability to schizophrenia had been ‘decisively confirmed’
what is the dopamine hypothesis?
suggests that hyperdopaminergia (high dopamine levels) in the sub-cortex is responsible for schizophrenia
abnormally high numbers of dopamine receptors (D2) on some receiving neurones leads to greater neuronal activity
what is the revised dopamine hypothesis?
hyper and hypo dopaminergia is different areas of the brain contribute to development of sz
what may be responsible for the positive symptom of auditory
hallucinations?
Hyperdopaminergia in the mesolimbic area and Broca’s area
due to the overactivity of neurotransmission
in the auditory areas.
what may be responsible for negative symptoms of sz, such as speech poverty and avolition.
And why
hypodopaminergia in the prefrontal cortex
The prefrontal cortex is associated with logical thinking, so abnormally low dopamine levels in this area may impair the ability to construct sentences (speech poverty) or to make decisions about how to function in day to day
living (avolition).
what are agonist drugs and what effect do they have on the symptoms of schizophrenia?
drugs that increase dopamine activity such as amphetamines or parkinsons drugs can lead to a development of positive SZ symptoms
what are antagonist drugs and what effect do they have on the symptoms of schizophrenia?
decrease dopamine activity by blocking pathways, lead to a reduction in symptoms such as hallucinations and delusions
support evidence for the idea that dopamine impacts SZ symptoms AO3
P - most supporting evidence arises from the results from drug treatments. Medication attempts to alter the activity of dopamine in the brain. Antipsychotic drugs are successful as they reduce symptoms.
E - a meta-analysis carried out by Leucht et al involved the analysis of 212 studies. A comparison of antipsychotic drugs with placebo found all drugs tested were more
effective than the placebo in treating positive and negative symptoms of Sz.
E - this demonstrates effectiveness of antipsychotic drugs in the treatment of schizophrenia
evidence against the dopamine hypothesis AO3
P - however, there is evidence against the dopamine hypothesis
E - Noll found that antipsychotic drugs only reduced all of the symptoms in 20% of patients.
E - this suggests the dopamine activity is not the sole cause of positive symptoms, and other factors may play a role
what is the explanation of abnormal brain structure to explain schizophrenia?
Johnstone et al found that people with sz have larger than average ventricles in the brain. This may be due to areas of the brain dying and ventricles enlarging to take up the extra space
what is found about white matter in the brains of sz patients?
found to be reduced in the brain, particularly in the neural pathways between the prefrontal cortex and the hippocampus
what is a catch-22?
a situation that has no resolution due to mutually conflicting conditions on both sides of the situation
who came up with the double bind theory?
Gregory Bateson
what is the double bind theory as a psychological explanation for Sz
dilemma in communication when an individual receives one or more conflicting message, in which one is negative and the other is positive
what situation does a double bind give?
gives a situation in which the successful response to one message results in a failed response to the other message
what is the outcome of the double bind theory?
failure to confront dilemma
what are conflicting verbal and/or non-verbal messages
when a child receives 2 conflicting messages about their relationship - one of verbal affection and one of non-verbal hostility or vice versa
support for the double bind theory AO3
P - Berger found that sz individuals recalled more double bind statements from their mothers than non sz individuals
H - however, Liem measured patterns of parental communication in families with a sz child and found no difference when compared to normal families
E - although, the real value of the double bind theory is that it led to the development of family therapy
what is expressed emotion?
qualitative measure of the amount of emotion displayed within the family setting usually by members or care takers
how can express emotion be measured? 2 ways
a. Camberwell family interview
b. Five minute speech sample
what is suggested that high levels of expressed emotion can do?
- worsen prognosis in patients
- increase likelihood of relapse and hospital readmission
what 3 things is a high expressed emotion household made up of?
- verbal criticism
- hostility towards patient
- emotional over-involvement in life of patient
what is the 5 minute speech sample?
requires parents to talk about their child and their relationship for 5 minutes
- speech is transcribed, and coded using different protocols to calculate level of expressed emotion or narrative coherence in speech
High EE affects relapse rates. How has this been demonstrated?
an increase in symptoms
Why does negative emotional climate trigger Sz episodes?
Arouses the patient and
causes stress levels too great for the patient to cope with.
What contrasting effect results from a positive, supportive emotional climate?
The lower levels
of stress experienced can help a patient reduce relapse.
AO3 - individual differences in vulnerability to expressed emotion
P - not all patients who live in high EE families relapse, and not all who live in low EE homes avoid relapse
E - Alforter et al found 1/4 of patients showed no physiological response to stressful comments from relatives
The perception of emotions, by the patient with SZ is likely to be an important factor. If expressed emotion is not seen as negative or hostile. the outcome is more positive
L - therefore the subjective experience of the individual is an important factor.
what are 3 factors that may be related to some of the symptoms of sz?
- attention deficit disorder
- attention bias
- lack of schema
what is attention deficit disorder?
an impairment in perception, memory, and attention. Poor ‘central control’. Cognitive ability to suppress/ control automatic responses while performing deliberate actions
what symptoms does attention deficit disorder account for?
disorganised speech and disorganised thinking
what is attention bias?
Bentall - bias towards stimuli of a threatening and emotional nature such as violence, pain etc.
what symptoms does attention bias account for?
delusions - other people trying to kill them
hallucinations - biased attention on auditory stimuli of a threat
what is a lack of schema?
cant predict what will happen next and an overload of information
what symptoms does a lack of schema account for?
attend to unimportant and irrelevant emotions
Support for the psychological explanation of schizophrenia
P - the success of CBTp supports dysfunctional thought processes in the role of schizophrenia
E - In CBT, patients are encouraged to evaluate the content of their delusions to consider ways they may test their faulty beliefs.
A national review (NICE) of sz treatment found consistent evidence that, when compared with antipsychotic medication treatment, CBT was more effective in reducing symptom severity and improving levels of social functioning
What is a limitation of the cognitive explanation for explaining sz
P - a limitation of the cognitive explanation for schizophrenia, is the failure to incorporate other explanations.
E - the approach does not consider other explanations such as biological: the role of genes, brain structure, and neurotransmitters. It could be that biological problems creates the cognitive deficit. Suggesting the cognitive approach is over simplified when considering the explanation of schizophrenia
E - this highlights the need for a model that integrates other explanations
what are typical antipsychotics?
dopamine antagonists
- 60-75% of D2 receptors must be blocked to be effective
how long does it take for hallucinations to be reduced/ stopped compared to other symptoms?
hallucinations - within a few days
other symptoms - within a few weeks
what is the affinity and dissociate features of typical antipsychotics like?
strong affinity and hard to dissociate from D2 receptors
what type of symptoms do typical antipsychotics treat?
positive
what are atypical antipsychotics?
antagonists
what is the difference between association and affinity between typical antipsychotics and atypical?
atypical dissociate quicker and do not block for so long
they have a stronger afinity for serotonin receptors
what is the proven and claimed effect for atypical antipsychotics
proven - positive symptoms
claimed - negative symptoms and cognitive impairment
what is an example of a typical antipsychotic?
haloperdiol
how does a haloperidol work?
blocks post-synaptic D2 receptors
what are side effects of haloperidol?
dizziness, dry mouth, Parkinsonism, sleepy, insomnia
what is the risk of relapse from haloperidol?
59%
what is an example of an atypical antipsychotic?
clozapine
how does clozapine work?
balances the levels of dopamine and serotonin in the brain
what are the side effects of clozapine?
blurred vision, confusion, constipation, shakiness
less than typical
what is the risk of relapse from clozapine?
34%
AO3 of drug therapies - effectiveness
P - support for the use of anti-psychotics comes from research into relapse rates
E - Leicht et al (2012) conducted a meta-analysis of research published from 1959-2011, involving almost 6000 patients that compared relapse rates. All patients positive symptoms had been stabilised with either typical or atypical antipsychotics. Some were taken off medication and given placebo and some remained on medication
F - within 12 months, 64% on placebo relapsed compared to 27% who remained on their drugs
E - research on a large scale, and over an extended period of time is valid evidence.
L - reducing relapse rates of symptoms supports high efficacy and the usefulness of anti-psychotic drugs to treat schizophrenia
AO3 of using drugs to treat sz - side effects
P - a problem with drug therapy for schizophrenia is the distressing side effects
E - More than half the patients taking typical antipsychotics experience extrapyramidal effects such as Parkinsonian symptoms. These include impaired motor control. In addition, after an extended period of time, more distressing effects may develop such as tardive dyskenesia,
with involuntary facial muscle movement.
E - These side effects can be so distressing that patients can stop using antipsychotics.
L - This is an important issue and other therapies and support may be more appropriate.
what is the general process of CBTp?
- patients trace back the origins of their symptoms
- are taught to recognise their own examples of delusions
- are challenged in their interpretation of events
- are asked for evidence of their delusions
- are encouraged to suggest their own coping strategies
what are the time frames for CBTp?
8 to 20 sessions
6 to 12 months
1 hour each
what happens in the initial assessment of CBTp?
patients express his or her thoughts about their experience and goals are discussed
what is the engagement stage in CBTp?
therapist emphasises with the patient’s perspective and their feelings can be developed together
what is the ABC identified stage in CBTp?
patient gives their explanation of activating event, belief and consequence. These are challenged, disputed and changed
what is the normalising the condition stage in CBTp?
therapist explains that symptoms such as hallucinations are quite common and this reduces anxiety and the sense of isolation
what is the critical, collaborative analysis aspect of CBTp?
identify illogical thoughts by asking for evidence, therapists use gentle questioning to help patients understand illogical thinking
what is the developing alternative explanations aspect of CBTp?
patient creates healthier explanations which might have been temporarily weakened by dysfunctional thinking patterns
replaces negative explanations with positive ones
what are some general discussion points for CBP?
- requires self awareness and willingness to engage
- practical issues
- more expensive than drug therapies
Advantage of CBTp over standard care AO3
P - A recent NICE review of treatments for schizophrenia found consistent evidence that CBTp was an effective form of therapy
E - CBTp was shown to be effective in reducing symptom severity and when compared with patients at the same time receiving standard care (meds), there was some evidence for improvements in social functioning
E - However, most studies have included patients who were taking antipsychotics at the same time as undergoing CBTp, making it hard to assess effectiveness
Lack of availability of CBTp AO3 point
P - Despite being recommended by NICE as a treatment for schizophrenia, not all patients have access to this form of therapy
E - this figure is even lower in some areas of the country. A survey in the North West of England by Haddock et al found that out of 187 randomly selected patients with sz, only 13 had been offered CBTp
E - effectiveness of the therapy is further reduced due to a significant number of people either refusing or failing to attend therapy sessions
what are the aims of family therapy?
reduce expressed emotion, therefore reducing stress and the risk of relapse
what does NICE recommend about family therapy time sessions?
10 sessions, between 3-12 months
what did Garety et al estimate about relapse rates?
relapse rates for those who receive family therapy are 25% compared to 50% for those who just receive standard care
what are the 6 things suggested in family therapy?
- education to family
- building trust
- improving communication
- recognising early signs of relapse
- building a supportive family environment
- empathy towards sz individuals
what is family therapy for schizophrenia?
reduces levels of expressed emotions and stress, by increasing the capacity of related problems, family therapy attempts to reduce the incidence of relapse rates
what were the aims of Pharoah et al’s study?
investigate the effectiveness of family intervention
what was the procedure of Pharoah et al’s study?
meta analysis reviewing 53 studies published between 2002 and 2010
- conducted in Europe, Asia, North America
- compared the outcomes of family therapy to ‘standard care’
AO3 of how family therapy is effective - Pharaoh et al
Compliance with medication, family therapy increases patients’ likelihood to take antipsychotics.
Reduction in relapse rates and readmission during therapy and the 24 months after suggests that FT is successful in reducing the symptoms of schizophrenia
However, some of the improvements identified in research carried out by Pharaoh et al may not be due to family therapy… AO3
The reduction in relapse and admission rates may be indirectly due to the compliance of taking medication, rather than the therapy itself, making it more of a ‘knock on effect’ than direct cause
Furthermore, Pharoah’s meta analysis is flawed due to a lack of blinding of the condition to which the participants were allocated… AO3
10/53 did not use any form of blindings i.e. raters were aware of the type of treatment a patients received. A further 16 did not mention whether the blinding had been used. This is problematic in studies where pp’s tend to unintentionally reveal the type of therapy they received, leading to researcher bias.
what is a token economy?
based on a rewards system that helps manage behaviour in long stay hospitals by improving quality of life and coping strategies
what theory is the token system based off?
operant conditioning and rewards systems
which symptoms is token economies aimed at for improvement?
avolition and withdrawal
what are the two types of reinforcers and explain them
primary - anything that gives pleasure or removes unpleasant states
secondary - initially have no value, but can be paired with primary enforcers
what are examples of desirable behaviours in order to gain tokens?
making bed, carrying out domestic tasks
what example of primary reinfocement was given in Ayllon and Azrin?s
being able to watch a movie
Why should tokens be given directly after the behaviour is carried out?
so the patient knows exactly what they’re being rewarded for
what is the relevance of operant and classical conditioning in the process of a token economy
operant conditioning using positive reinforcement
classical - associates behaviour with reward
what effect does it have if the time period between award of token and reward is too long?
negative emotions performed in between e.g. arguing, may be reinforced and become more frequent
strength of token economies - success
P - dickerson et al’s review of 13 studies of the use of token economies found that 11 of these studies reported beneficial effects that were directly attributed to the reinforcement of desired behaviour
H - however, many of the studies in Dickerson’s review had significant methodological shortcomings that limited the impact of their overall assessment of token economy systems in the treatment of SZ
limitation of token economies - uncontrolled
P - when trying to determine the effectiveness of token economy systems, Comer suggests a major problem is that the use of such systems tend to be uncontrolled
E - Token economy programmes are usually used for all suitable patients on a psychiatric ward, therefore there is no control group (no TE) to compare to the experimental group (TE).
E - Evidence of patient improvement has to be drawn from past behaviours. This can be
misleading because patient improvement may arise from the additional staff attention
given to the patients.
Ethical concerns with token economies AO3
For example, in order to make reinforcement effective, clinicians may excercise control over important primary reinforcers such as food or access to activities.
Patients may then exchange tokens if they display behaviours
However, it is generally accepted that all humans have certain basic rights that can’t be violated regardless of the positive consequences that might be achieved via token manipulation
what is the diathesis strrss model of sz? Meehl
the diathesis-stress model links biological vulnerability to environmental stressors. It suggests that certain individuals are pre-disposed to develop schizophrenia, but only develop the disorder if exposed to certain environmental factors
what are examples of diathesis
genetics, brain structure, birth complications, exposure to certain viruses
what are examples of stressors
family disfunction, traumatic events, living environment, exposure to cannabis
what were the aims of Tienari et al’s key study on diathesis-stress model?
to investigate whether genetic factors affect susceptibility to environmental risks associated with adoptive
family functioning.
what was the procedure of Tienari et al’s key study on diathesis-stress model?
Hospital records of 20,000 women from Finnish psychiatric hospitals between 1960 and 1979 were
used. Some were identified who’d been diagnosed at least once with schizophrenic or paranoid psychosis and had at least one child adopted.
These 145 adoptees were the ‘high risk’ group and were matched with a sample of 158 adoptees, without this
genetic risk ‘low risk’
Both groups were interviewed and assessed after 12 years and followed up after 21 years.
Family functioning was also assessed using the OPAS scale, to determine features of the family such as conflict
and insecurity. The interviews were conducted blind.
what were the findings of Tienari et al’s key study on diathesis-stress model?
Out of the 303 adoptees, 14 had developed SZ. 11 of these were from the high risk group and 3 were
from the low risk group.
Being reared in a ‘healthy’ adoptive family (low OPAS score) appeared to have a protective effect. High risk, low
OPAS score individuals were significantly
what was the conclusions of Tienari et al’s key study on diathesis-stress model?
Stress was identified as a significant predictor for high genetic risk adoptees for the development of
SZ.
limitation of Tienari et al’s explanation
P - Although the results from Tienari et al provide support for the interaction between a
genetic vulnerability and exposure to stressors, there are limitations.
E - For example, the use of the OPAS scale to assess adoptive family environment, was only at one
point. This doesn’t reflect changes in family functioning over time.
E - This study can’t identify if the stressful family environment contributes to the outcomes for the
patient or whether the behaviour of the adoptee causes the stressful environment within the
family.
what is the interactionalist model to treat schizophrenia?
CBT + medication
or
Family therapy + medication
AO3 limitation of diathesis stress model - urban areas are not necessarily stressful
P - Vassos suggested that living in a densely populated area was a significant factor for schizophrenia
E - However, Romans-Clarkson found no urban-rural difference in mental health among women in NZ. Other studies showed these differences disappeared after adjusting for the socio-economic differences
E - suggesting although social adversity may be a significant trigger, it may not be synonymous with urbanisation.
