Clinical Psychology Flashcards
ICD-11 diagnostic criteria for schizophrenia
Positive Symptoms (CORE symptoms) - an addition to/distortion of normal experience:
- Persistent delusions - convinced beliefs that a patient holds, which are not based in reality. e.g. falsely believing that someone is out to harm you.
- Persistent hallucinations - sensory experiences e.g. auditory hallucinations (hearing voices) or visual hallucinations (seeing a dead relative, etc).
- Thought disorder - an inability to think and speak in an organized manner.
- Experience of influence, passivity or control - the belief that your thoughts or actions are influenced or controlled by someone or someone else.
Negative Symptoms (further diagnosis) - level of functioning is being taken away:
- Avolition - lack of motivation
- Flattened affect (blunted emotional expression)
- Impaired cognitive function (reduced memory or attention)
- Catatonia (lack of movement or speech)
Age of onset
Early onset:
- Males - early to mid-20s
- Females - late 20s
Late onset:
- Females, more commonly - 40s
Prevalence between genders is closely similar - about 0.3-0.7% = not a significant gender difference
Types of Delusions
- Persecutory: a strongly held beliefs that you are in danger or are being conspired against, and being pursued by others intending to harm you.
- Grandeur: a strongly held belief that you are someone with special abilities or special powers, e.g. that you are a superhero
- Delusions of reference: a strong held belief that events in the environment are related to you and have significant meaning. Things are a sign of prophecy or what to expect of the future, e.g. the belief that a TV programme is talking about you.
Aneja et. al (2018) - the study
Aneja et al (2018): carried out 3 case studies on early-onset schizophrenia before the age of 18 years.
Background:
- A boy from a troubled home with an aggressive father, began to show a decline in his academic studies and general behavior at 10 years old after parents’ divorce. Thus, he and his mother moved in with his grandparents and changed schools
- At 12 years old, he heard voices and over time, he believed his mother and other people were communicating with the voices.
- His behavior grew more erratic: muttering to himself and shouting at people who were not there.
- His schoolwork suffered and by 12 yrs, he stopped attending school at all. He was irritable, sad and often got into trouble for fighting.
- He barely slept and his level of self-care declined dramatically
- He was admitted to hospital several times and given a range of medications to attempt to control his worsening symptoms.
- The boy was diagnosed with early-onset schizophrenia and was released from hospital, on medication that kept his aggressive behaviors under control.
- He still suffered from negative symptoms e.g. apathy, social withdrawal and a resistance to going to school.
Symptoms:
- Spoke very little
- Poor sleep and self-care
- Preferred to be alone, away from other people
- Lack of insight into his condition
- Hearing voices that teased him
- Suspicious of his mother
- Muttered, laughed, and shouted at unseen others
Treatment:
- Sodium valproate (drug often treating BPD)
- His mood and behavior improved for a while but later became worse again
- Diagnosed with very-early-onset schizophrenia (VEOS).
- His aggressive and violent outbursts increased, and often admitted to hospital for his safety.
Methodological strengths and weaknesses
- STRENGTH: It has a detailed case history. The amount of detail highlighted that the boy had exhibited prodromal symptoms. This increases the validity of the schizophrenia diagnosis.
- WEAKNESS: the case study is limited to 1 child and does not represent other cultures. India has stigma around people with mental disorders (Thomas, 2018). This means there were little community support and could have worsened symptoms due to family stress. This does not represent other VEOS in other cultures.
Aneja et. al (2018) - I&D
Application to real life
- it is difficult to use the ICD-11 diagnosis due to symptom overlap, e.g. catatonia and hallucinations can be experienced by ppl w/ depression or be caused by drug withdrawal, stress and sleep deprivation.
- So, different clinicians give different diagnoses, which decreases the reliability of the schizophrenia diagnosis.
- however, ICD-11 only requires to display symptoms for 1 month while DSM-5 requires 6 months, which means people could access treatment early.
- early treatment correlate with positive outcomes (Patel, 2014).
- ICD-11 removes a set of subtypes to classify schizophrenia e.g. catatonic, hebephrenic. The subtypes were primary symptoms a person displayed but symptoms often change.
- so, ICD-11 replaces the subtypes with dimensional descriptors and doctors rate each category of symptoms based on severity.
- this help access more treatment.
Use of children in psychological research
- the boy is 14 yrs old and so, he cannot give his informed consent.
- This meant that his mother had to give his consent on his behalf to participate in Aneja’s study and for him to write up a published case study.
- however, children would have been asked for their consent typically, and the study wouldn’t have proceeded without his cooperation.
- researcher must’ve found ways to make the study more accessible for the boy to know his rights to withdraw and how he would his data to be used.
Freeman’s Aim
- To investigate whether participants without a history of mental illness have thoughts of a persecutory nature in VR
- To investigate whether there are cognitive or emotional factors that predicted the likelihood of persecutory ideation being shown in VR
Freeman’s sample
- 12 males and 12 females, all students/admin staff from UCL
- mean age: 26 years
- no history of mental illness
- recruited via volunteer sampling: responded to ad within UCL
Freeman’s hypothesis
a small number of people will have thoughts of a persecutory nature in VR,
and these people will have higher levels of emotional distress and paranoia
Freeman’s research method
lab experiment: participants were trained on how to use the VR equipment, and entered a virtual environment (a library space) for 5 minutes
Freeman’s procedure
- Participants trained in how to use VR equipment, including:
* Lightweight headgear to track head position
* Handheld joystick to allow participant to move around the virtual space - Half the participants completed the:
* BSI (53-item questionnaire) to assess mood, anxiety and psychotic symptoms in the last 7 days
* Two 20-item self reports (Spielberger State Anxiety Questionnaire & Paranoia Scale), to measure ideas of persecution and reference - All participants completed the VR task: exploring a virtual library, where 5 avatars sat in 2 small groups (a three and a pair), occasionally smiling, looking over and talking to one another
- Participants were asked to “Explore the room and try to form some impression of what you think about the people in the room, and what they think about you”
- 5 mins after, all participants ‘exited the room’ and completed the questionnaires outlined above (half of them for the 2nd time)
- Participants were interviewed about their experiences, including any feelings of distress
- A clinical psychologist watched the videotaped interviews, rated them out of 6 for indications of persecutory ideation
Examples of items in Paranoia questionnaire:
* They were hostile towards me.
* They were laughing at me.
* They were watching me.
Freeman’s findings
- Mean paranoia score: 31.8 (minimum: 20, maximum: 100)
- no significant difference in paranoia scales between males and females
- positive correlation between persecutory thoughts in questionnaires & the interviews
- Most people had positive beliefs about the avatars, but some had more negative beliefs
- VR persecutory ideation was positively
correlated with paranoia, interpersonal sensitivity and
anxiety,
Freeman conclusion
- Emotional processes linked to anxiety and interpersonal sensitivity directly contribute directly to development of perseuctory ideation,
- Showing that VR holds ‘great promise’ not only as a tool for enhancing theoretical understanding, but also to help individuals evaluate and reduce persecutory ideation
Psychological explanation of schizophrenia
a. Frith noted that schizophrenic people might have a deficient ‘metarepresentation system’ (system that makes people able to reflect on thoughts, emotions and behaviors).
* Could also be linked to theory of mind, as it controls self-awareness and how we interpret actions of others
* Those showing more negative symptoms might have a dysfunctional supervisory attention system (responsible for generating self-initiated actions)
* In a study, when ppts were asked to do things, such as name as many different fruits as possible, those with schizophrenia (with negative symptoms predominant) had great difficulty managing this
b. Frith noticed that in some people with schizophrenia, inner speech may not be recognised as being self-generated
* Therefore, when they hear ‘voices’, it’s their inner voice, but they’re unaware it’s themselves producing inner speech and believe it’s someone else
* Johnson et al. tested cognitive abilities of 99 people with schizophrenia, and 77 healthy controls
* Seen that people with schizophrenia performed worse across all cognitive tests, including those for working memory (involves tasks like dealing with inner speech)
* This might be the core determinant of overall cognitive impairment in schizophrenic people
Psychological treatments of schizophrenia
Cognitive behavioral therapy (CBT): aims to change or modify people’s thougths and beliefs, and also change the way they process information
Intention of CBT for schizophrenia: to help patients make sense of the psychotic experiences, and reduce the negative effects of the conditions, and any distress they may be feeling
- Patients may be given help to understand that their thoughts and views aren’t facts, then given help with assessing them
Sensky et al. (CBT)
Aims: to compare the efficacy of one-to-one CBT and a befriending intervention for people with schizophrenia
Procedures:
a. Patients were recruited if they fitted the following criteria:
* Aged 16-60 years
* Had a diagnosis of schizophrenia according to DSM and ICD
* Symptoms persisting for at least 6 months
* Showed no improvement with medications
* Didn’t abuse alcohol or drugs
b. There were 90 qualifying participants, randomly assigned to one of two groups:
* A manualised CBT specifically designed for schizophrenia
* A ‘befriending’ intervention
c. All had been prescribed a daily dose of at least 300mg of chlorpromazine for at least 6 months, but still experienced positive symptoms
d. Treatment was delivered by 2 nurses who received regular supervision
e. They were assessed by ‘blind raters’ before the treatment started (to establish a baseline), post-treatment (up to 9 months later), and 9 months after treatment ended (follow-up)
f. CBT sessions: therapists worked collaboratively with the patients to understand the development of their positive and negative symptoms, and to reduce distress
g. Befriending: received same duration of interaction with a therapist. Therapists were empathic and non-directive. Talked about hobbies, sport and current affairs
Findings:
* Both interventions resulted in significant reduction in both negative and positive symptoms of schizophrenia, and depression scores on Comprehensive Psychiatric Rating Scale
* However, at the follow-up, those who had CBT continued to improve, whereas befriending group didn’t
Conclusions:
CBT is effective at reducing symptoms of schizophrenia in those previously resistent to antipsychotic medication
Biochemical explanations for schizophrenia: the dopamine hypothesis
Dopamine hypothesis
Dopamine excess as cause
- 1960s - Researchers proposed that schizophrenia was caused by an excess of the neurotransmitter dopamine - in the brain’s limbic system and mesolimbic pathways (Carlsson and Lindqvist, 1963).
- This excess can be caused by many factors, e.g. excess L-Dopa, the substance that dopamine is made from.
- Synapses using dopamine may also be overactive due to differences in the number of receptors on the postsynaptic cell.
- New evidence caused scientists to update this explanation. For example, many people who were taking dopamine antagonists e.g. chlorpromazine still suffered with -ve symptoms and some experienced no improvement.
Dopamine deficiency as cause
- 1990s - Researchers suggested that a lack of dopamine in the prefrontal cortex and mesocortical pathways may explain the negative and cognitive symptoms (Davis et al., 1991).
- Symptoms e.g. disorganised thinking and speech could certainly result from problems with dopamine regulation as this neurotransmitter is important for shifting and directing attention.
- However, new evidence revealed that the updated hypothesis was still over-simplified.
- Overactivity in the mesolimbic pathways was thought to result from excess D2 dopamine receptors and/or low levels of the enzyme beta-hydroxylase, which breaks down dopamine.
- However, in 2006, Arvid and Maria Carlsson proposed the dopamine deficiency hypothesis, suggesting that the brain compensates for low levels of dopamine by increasing the number of receptors on the postsynaptic cell.
- This process is known as upregulation.
Biochemical explanations for schizophrenia: genetic explanations
Genetic explanations
Classic family and twin studies
- there is a strong argument for the heritability of schizophrenia.
- the concordance rate (consistency) for monozygotic (MZ) twins is 42% but only 9% for dizygotic (DZ) twins (Gottesman and Shields, 1966).
- Since the siblings in MZ and DZ groups were raised in the same household, the higher concordance rate in MZ twins was thought to be due to the greater amount of shared DNA.
- Hilker et al 2017 carried out a twin study with over 30k twin pairs, using several Danish registers.
- They looked at related disorders and diagnosis of schizophrenia
- Hilker et al concluded that heritability of schizophrenia was 79%
Adoption studies
- Adoption studies separate influence of genetics and environment
- This is achieved by comparing a child raised by an adoptive family with their bio parent who they are not raised by
- Tienari et al 2000 found schizophrenia in 6.7% of adoptees w a bio mother w schizophrenia, compared to just 4% of a control group (adoptees born to mothers w/o schizophrenia)
- This suggests that there is a genetic influence in the dev of schizophrenia.
Describe the Biochemical Treatment of Schizophrenia
Typical Anti Psychotics
– Dopamine blockers that prevent dopamine from bonding to the receptor that thus reduces dopamine activity (called dopamine antagonists)
– This therefore reduces the positive symptoms of schizophrenia (hallucinations and delusions)
– The downside of typical antipsychotics is that there are many side effects.
Atypical antipsychotics:
– These block both dopamine and serotonin receptors
– The have a lower risk of side effects
– Shown to be more effective for ‘treatment-resistant’ patients
