Delusional Disorder

Question 1

Definition of delusional disorder

Answer 1

Characterised by persistent delusions, but people suffering from it otherwise have quite normal behaviour, unlike those with classic schizophrenia.

Exclude those suffering from other psychotic symptoms: hallucinations to negative symptoms

Question 2

Bizarre content

Answer 2

May believe one’s internal organs had been removed and replaced with those of another, without leaving any wounds or scars

Delusions may be logically impossible or difficult to understand

Question 3

Non-bizarre content

Answer 3

Belief that one’s partner is cheating on them, or that their boss wants to fire them

Delusions could be true or possible but unlikely

Question 4

Types of delusional disorder

Answer 4

Erotomanic
Belief that another person is in love with them

Grandiose
Convinced they have a great unrecognised skill or status

Jealous
Belief that a partner is being unfaithful

Prosecutory
Belief that the person is being conspired against or pursued by others who intend to harm them

Question 5

How to diagnose

Answer 5

Individual must have experiencing symptoms for one month or longer

DSM-5 states that symptoms should be unrelated to psychological effects of substance use, not better explained by another psychological or medical disorder

Question 6

Symptoms assessment using VR - Freeman

Answer 6

1. A powerful tool to make learning for the benefit of their psychological well being
2. Immersive VR creates interactive computer generated worlds, substitute real-world sensory perceptions with digitally generated ones, producing the sensation of actually being in life-sized new environments
3. Key element: perception through natural movement
4. Current excitement relates to Head mounted display (HMD)
   A. displays images, one for each eye, forming an overall stereo scene
   B. Typically tracked, with continuous capturing the position and orientation of the participant’s head and therefore head-based gaze direction
   C. As participants turn or move their head to look around, the computer updates at a very high frame rate (60 frames per second), the images displayed
   D. Participants see a surrounding 3D stereo scene that can change dynamically.
5. VR in Freeman’s research involved a specifically designed library or underground train scene where the user takes a walk or ride in the presences of other neutral avatars wearing VR headgear.
   A. Participants: 200 students, non-clinical population.
   B. Prior to the virtual reality test, validated measurement tools were used to profile each individual’s levels of paranoid thinking, emotional distress and other social and cognitive traits, such as the 16 item Green et al. Paranoid Thoughts Scale (CPTS) Part B.
   C. Measures of persecutory thinking were taken after being in the virtual environment, along with visual analogue rating scales, and an assessment of their degree of immersion in the virtual environment.
   - More likely to make comments such as ‘Lady sitting down next to me laughed at me when I walked past’, rather than positive or neutral comments such as ‘Getting on with my own business’.
   - Persecutory ideation is the process of forming an idea that one is at risk of being ill-treated or harmed by others.
   D. Freeman reports that individuals who experience auditory hallucinations in the real world also experienced them in the VR environment.

Question 7

First possible cause of schizophrenia

Answer 7

Genetics

1. Genes or particular combinations of genes are passed onto offspring which may cause the disorder to develop.
2. General symptoms includes features such as psychosis.
   a) It is a specific aspect of these disorders when the individual loses contact with reality in key ways.
   b) Experience of psychosis consists of a series of abnormalities of function, such as sensory dysfunction and working memory impairment.
   c) These specific difficulties have known genetic origins and are otherwise known as ‘endophenotypes’.
   d) Thus, schizophrenic symptoms are believed to have identifiable genetic markers which may be inherited.

Question 8

A way to study genetic causes of schizophrenia

Answer 8

Pedigree

1. Research have shown that schizophrenia is more common in people who have schizo 1st degree relatives.
2. Best relative is twins.
   - highly useful
   - allow researchers to establish the relative influences of nature and nurture
   - their DNA are shared
   • Identical or monozygotic (MZ) twins share their entire DNA
   • Non-identical or dizygotic (DZ) twins only share around 50% of their DNA
3. There is little genetic concordance if the occurrence of the disorder is no higher in MZ twins than DZ twins.
   > Genetic concordance is the presence of a particular observable trait or disorder in both individuals within a set of twins.

Question 9

Genetic concordance definition

Answer 9

The presence of a particular observable trait or disorder in both individuals within a set of twins.

Question 10

Genetic link in twin research (Gottesman & Shields)

Answer 10

Aims:
1. To investigate the relative importance of genetic and environmental influence on schizophrenia by comparing MZ and DZ twins.
2. To know the extent to which schizophrenia was genetic.
3. To replicate other studies that had found a genetic link with schizophrenia.

Sample:
1. From 467 twins, 57 twin pairs were selected aged between 19 to 64 years.
2. Average age of 37.
3. At least one of the twins was on the register of the hospital as sufferings schizophrenia.
4. 5 pairs were both on the register.

Procedures:
1. Twins are identified as MZ and DZ using blood group and fingerprint analysis.
2. Collect secondary data from hospital records of twins from the Maudsley and Bethlem Royal Joint Hospital (London).
3. Collect primary data by interviewing and giving personality (psychometric) tests.
4. Participants undertook cognitive tests such as object sorting to ensure the validity of diagnosis.
5. Case summaries of each participant were independently evaluated by judges external to the research.

Information collected:
1. Case histories based on self-report questionnaire and interview with the twins and their parents to provide a record of verbal behaviour.
2. A personality test.
3. A test used to measure disordered thinking conducted on twins and parents.

Results:
1. 50% of MZ twins had a shared schizophrenia status, but that concordance was much lower in DZ twins, around 9%.
2. MZ twins were more likely to be schizophrenic if the illness of their twins were severe. For example, if one twin had been hospitalised within the last six months or had catatonic symptoms, this was classified as severe. There was then a high likelihood their co-twin also showed some schizophrenic symptoms.
3. In MZ twins, the above findings do not apply if the schizophrenia symptoms are mild.

Data analysis:
1. Looked for similarities between each patient and their twin.
2. Concordance was assessed in three different ways:
a) Grade 1 - Both the patient and co-twin had been hospitalised and diagnosed with schizophrenia.
b) Grade 2 - Both patient and co-twin have had psychiatric hospitalisation but the co-twin has a different diagnosis.
c) Grade 3 - The co-twin has some psychiatric abnormality, examples, out-patient care, GP care, neurotic or psychotic personality profile or being abnormal on interview.

Conclusions:
1. Genes play an important role in schizophrenia because the concordance rate is higher in MZ twins than DZ twins.
a) MZ twins are at least 48 times more likely to have schizophrenia than someone in the general population.
b) There is some evidence to suggest that there is a set of genes responsible but not one in particular.
2. The Diathesis-stress model suggests that individuals have a genetic predisposition for schizophrenia which is in part triggered from the environment.
3. Gottesman went on to investigate the influence of genes by combining the results of 40 investigations spanning over 60 years.
a) The concordance rate for schizophrenia was 48% for MZ and 17% for DZ twins.

Question 11

Two types of presence using VR

Answer 11

The subjective experience delivered is termed ‘presence’.

Place illusion (PI)
- The sense of being in a virtual place.
- If what we see matches our movements, then the brain’s conclusion is that these are our surroundings.

Plausibility illusion (Psi)
- The Psi is the sense that the events experienced in VR are happening, examples, that there are people walking about, that a ball is flying through the air.
- Even though individuals consciously know that these are not real.
- Psi requires that the virtual environment responds to actions of the participants, generates spontaneous actions towards them, and is ecologically valid when real-life events are depicted.
- When the environment includes virtual human characters, these avatars should respond to the presence of the participants, for example, by gaze and maintaining appropriate interpersonal distances.

When both PI and Psi operate, participants will be likely to behave realistically in VR.

Question 12

Symptoms of schizophrenia which are targeted by virtual reality

Answer 12

Misinterpretation of other people’s behaviour is a key feature of persecutory ideation. The occurrence and intensity of hallucinations is affected by the social context.

Negative symptoms such as anhedonia, asociality, and blunted affect, reflect difficulties in social interactions.

Withdrawal and avoidance of other people is frequent in schizophrenia, leading to isolation and rumination.

Question 13

Application of VR

Answer 13

1.
Application of VR to psychiatric problems has been for the treatment of height phobia.

For example, in Emmelkamp et al., 33 participants with acrophobia to 3 sessions of exposure to heights in vivo or in VR.

Both forms of exposure were equally effective.

Even though the patients knew the VR heights were not real, anxious responses were still triggered. The patients’ responses to real or VR environments were equivalent.

2.
VR has also been applied to the treatment of other anxiety conditions such as post-traumatic stress disorder (PTSD) and flying phobia.

Question 14

Strengths of using VR to treat schizophrenia

Answer 14

Controls the environment allowing a range of situations and settings to be investigated.

Ensure patients with psychosis are not making up situations and symptoms.

Treatment can be concluded in a safe environment for both patient (and public).

Has many uses.
Freeman lists 7 uses: symptoms assessment, identification of symptoms markers, establishment of predictive factors, tests of putative causal factors, investigation of the differential prediction of symptoms, determination of toxic elements in the environment, and development of treatment.

Question 15

Weaknesses of using VR to treat schizophrenia

Answer 15

May have side effects such as simulator sickness.
Dizziness, nausea, headache, and eyestrain.

VR cannot establish the truth of claims underlying suspicious thought, but neither can any method.

VR is only good as the programmers ability to write an appropriate programme.
A programme may only apply generally and not be tailor-made for the needs of specific individuals.

Question 16

Evaluation of VR Freeman study

Answer 16

Used a fairly large sample. However, it did not represent a clinical population.

Specially designed VR programme adopts a standardised approach to assessment. Increases the reliability of measurement.

Compromises the ecological validity of the assessment, as it involves a simulated environment quite different from what one would typically experience.

Continues to rely on self-report in that users of VR are asked to make comments about their experiences. May lead to response bias.

The use of VR - interactive immersive computer environments - allows one of the key variables in understanding psychosis, social environments, to be controlled.

Question 17

Issues and debate for VR Freeman

Answer 17

1. Application to everyday life
   - Can be used to assess patient symptoms, as well as potentially identify causal factors and treatment strategies.
   - However, the method has not been used extensively in clinical populations at the time of Freeman’s writing, meaning it is yet to be determined whether it can replace conventional clinical interviews and questionnaires in diagnosing schizophrenia.
2. Cultural bias
   - The diagnosis of schizophrenia and other psychotic disorders is particularly open to criticism because it relies on culturally based expectations of what constitutes normal social behaviour.
   - This is important, because some cultures are more tolerant than others in what is considered normal with regard to hearing voices.
   - There are also social norms around interacting in public, levels of eye contact and personal space which vary among cultures.
   - Use of VR in diagnosing symptoms would need to take such factors into consideration to avoid creating biassed interpretations of individuals’ behaviour and comments.

Question 18

Second possible cause of schizophrenia

Answer 18

Biochemical (dopamine hypothesis) by Lindström et al

1. Dopamine is a neurotransmitter, meaning it is a chemical substance which enables communication between two neurons.
   - to allow the nerve impulse to pass between two cells, it moves across a small junction known as ‘synapse’
2. Dopamine hypothesis states that the brain of schizophrenic patients produces more dopamine than normal brains.
   - the dopamine hypothesis identifies a link between excessive amounts of dopamine or dopamine receptors and positive symptoms of schizophrenia and related disorders
3. Neurons that use the transmitter dopamine are thought either to fire too often, or to send too much information.
   - it is thought that an excess of dopamine in particular brain regions can be related to certain symptoms
   - for example, such an increase in the Broca’s region which is responsible for formation of language, can impair logical speech, which is a classic symptom of schizophrenia
4. Evidences to support this theory
   A. Drug trials
   - involving those with and without schizophrenia
   - amphetamines and cocaine are drugs that increase the level of dopamine in the brain of non-clinical individuals
   > large increase in dopamine production are correlated with an increase in the reporting of hallucinations and delusions
   > when people experience amphetamine psychosis, it resembles certain types of schizophrenia
   > this is caused by an excess of dopamine
   - same drugs administered to clinical populations worsen positive schizophrenia symptoms greatly
   - Parkinson’s disease is often treated with a synthetic form of dopamine (L-dopa)
   > if their dosage is too high, it also creates symptoms in these individuals identical to those in people with schizophrenia, such as hallucinations
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   B. Autopsies
   - performed on schizophrenia patients and found a greatly increased amount of dopamine receptors with the brain
   - Wise et al found that brain fluid from deceased patients had abnormally low levels of enzyme which breaks down dopamine, suggesting it may have been present in excessive quantities
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   C. Positron emission tomography (PET)
   - PET scan analysis of dopamine usage indicates a greater number of receptors in the striatum, limbic system and cortex of the brain in those with schizophrenia than in those without
   - excessive dopamine activity in these areas may be linked to positive symptoms
   - Nesler hypothesised in contrast that decreased dopamine in the prefrontal cortex leads to negative symptoms such as flat affect.

Question 19

Evaluation for Gottesman and Shields

Answer 19

1. Used large sample of MZ and DZ twins
   - the results likely to be representative of twins with schizophrenia because of the sample size
   - findings may not be generalisable to non-twin individuals
2. Assessments were made in part by independent judges
   - reduce researchers bias
3. Collect qualitative data
   - through interviews which can gain in-depth data about participants, though may be subjective

Question 20

Third possible cause of schizophrenia

Answer 20

Cognitive explanations (Frith)

1. Cognitive approach to abnormality recognises that biological factors contribute in some way to the positive symptoms of schizophrenia.
   - Frith accepts the role of biochemical processes, brain structure and genetic influence on the disorder
   - however, since no one genetic, structural or biochemical cause has been identified, he sought to frame the signs and symptoms of schizophrenia in a cognitive manner
2. Cognitive explanation focuses on disorder as being a result of cognitive deficits.
3. Frith describes schizophrenia as an ‘abnormality of self-monitoring’
   - theorises that schizophrenia is explained by a mental impairment in failing to understand if stimuli is real or imagined, and internal or external
   - patients failed to recognise that their perceived hallucinations are in fact just inner speech (the kind of self-talk people normally experience)
   - leads them to attribute what they are hearing to someone else, example, a voice speaking to them from an external source
4. Frith examined a central monitoring system
   - allow us to understand and label actions that we do as being controlled by ourselves
   - he tested the idea with schizophrenia patients by asking them to decide whether items that had been read out loud were done so by themselves, an experimenter or a computer
   > schizophrenia patients with incoherent speech as a symptom performed worst at the task, which may be linked to memory and attention difficulties crucial for self-monitoring
   - he noticed that some schizophrenics may not recognise the inner speech as being self-generated
   - they are unaware that it is themselves producing inner speech and believe it is someone else
5. Frith believed that schizophrenia patients have problems with meta-representation which gives us the ability to reflect on own thoughts, behaviour and emotions
6. Frith suggest another major positive symptom - delusional thinking - may arise from a misinterpretation of perception
   - those experiencing delusions may be applying logical reasoning to their hallucinations
   - thoughts that are actually self-generated instead appear to be coming from an external source, and become incorporated in the individual’s set of beliefs
   - failures in monitoring can lead to delusions of alien control, auditory hallucinations and thought insertion.
7. Those with more negative symptoms might have a dysfunctional supervisory attentional system that is responsible for generating self-initiated response.
   - those experiencing negative symptoms such as a lack of action have difficulty generating spontaneous actions
   - this means that they are better at reacting to external stimuli to produce a response
   - this may arise in part due to impaired theory of mind, which creates problems in recognising the intentions of others and social cues, leading to delusions of paranoia and incoherence
   - a flattering of affect, lack of speech and social withdrawal all result from difficulties in monitoring their own mental states and the states of others.

Question 21

Issues and debates for schizophrenia and related disorders explanations

Answer 21

1. Nature

A. Genes
- genes or particular combinations of genes are passed onto offspring which may cause the disorder to develop
- experience of psychosis have specific difficulties that have known genetic origins and are otherwise known as ‘endophenotypes’
- this schizophrenic symptoms are believed to have identifiable genetic markers which may be inherited
- evidence: genetic link in twin research by Gottesman and Shields
> genes play an important role in schizophrenia because the concordance rate is higher in MZ twins than DZ twins
> MZ twins are at least 48 times more likely to have schizophrenia than someone in the general population

B. Biochemical
- dopamine hypothesis states that the brain of schizophrenic patients produces more dopamine than normal brains
- dopamine is a neurotransmitter which is a chemical substance which enables communication between two neurons
- evidently, Wise eat al found that brain fluid from deceased patients had abnormally low levels of enzyme which breaks down dopamine, suggesting it may have been present in excessive quantities

2. Nurture

A. Genetics
- environmental factors are also important
- the Diathesis-stress model suggests that individuals have a genetic predisposition for schizophrenia which is in part triggered from the environment

B. Biochemical
- drug trials
- amphetamine and cocaine drugs increase level of dopamine in the brain of non-clinical individuals
- same drugs administered to clinical populations worsen positive schizophrenia symptoms greatly

C. Cognitive explanations
- Frith examined a central monitoring system
> allow us to understand and label actions that we do as being controlled by ourselves
- Frith suggests that one of the major positive symptoms - delusional thinking - may arise from a misinterpretation of perception
- those experiencing delusions may be applying logical reasoning to their hallucinations

3. Nature VS Nurture
   - The twin study technique employed by Gottesman and Shields (1972) attempts to establish a causal link between genetics (nature) and mental disorder.
   - However, it is difficult to isolate nature from nurture.
   - It is likely that MZ twins are not only more genetically similar than DZ twins, but are more likely to be treated more similarly by others.
   > This is because they are always the same gender (unlike DZs), and may look much more alike.
   - DZ twins, although they are the same age and live in the same environment, may experience life more like ordinary non-twin siblings.
   - This means that not all differences between MZ and DZ twins can be simply attributed to genetics.
4. Longitudinal study
   - longitudinal twin study technique employed by Gottesman and Shields attempts to establish a causal link between genetics and mental disorder
5. Reductionist
   - biological and cognitive explanation seemed to be reductionist
   - Gottesman and Shields attribute the origin of schizophrenia to particular genes or gene combinations as the most simple biological explanation possible
   > however, they do acknowledge that environmental factors are important to the onset of the disorder
   - dopamine hypothesis indicates a specific biological origin, namely disruption to the normal uptake of a particular neurotransmitter
6. Holistic
   - cognitive theory put forward by Frith is more holistic as it takes into account mental processing as well as biological causes, but could still be said to ignore social and environmental causes for the disorder
7. Individual explanations, no situational explanations
   - however, psychologists from the social or psychodynamic traditions would look towards situational factors that contribute to the disorder, such as traumatic events or difficulty with forming early relationships

Question 22

First treatment for schizophrenia and delusional disorders

Answer 22

Biochemical (dopamine hypothesis) (Lindström et al.)

1. Using medications divided into antipsychotics and atypical antipsychotics
   - known as first generation and second generation
   - both types reduce the severity of psychotic symptoms in those suffering from schizophrenia and related disorders
2. Example and how it works
   - chloropromazine and other similar antipsychotics
   - block the dopamine and serotonin receptors in the cortical and limbic areas of the brain
   - affect different neurotransmitters such as serotonin and norepinephrine, depending on the individual antipsychotic
3. What happened after taking the drugs
   - after one week
   > patients may appear less hostile and agitated
   - after two or three weeks
   > may report diminished positive symptoms
4. Evidence for cure using drugs
   - use of antipsychotic drugs has been thoroughly researched using randomised control trials (RCT) which are often double-blind placebo controlled
   - 50% of those antipsychotic medications show significant improvement in their conditions after four to six weeks
   - 30-40% show partial improvement
   - remaining patients show little to no improvement in their functioning (‘treatment-resistant’ schizophrenia)
5. Relapse rate
   - quite high in using antipsychotics
   - because patients are supposed to continuously take the medications even after the acute psychotic episodes in a lower doses
6. Unpleasant side effects
   - weight gain
   - drowsiness
   - extrapyramidal symptoms (EPS)
   - tardive dyskinesia (TD)
   - EPS and TD are conditions which affect motor control, and can result in
   - involuntary spasms and
   - abnormal movements of the face and body
7. Why difficult to treat schizophrenia patients despite having medications? How to overcome it?
   - when an individual experiences a reduction in symptoms combined with unpleasant side effects, non-adherence to medication may be the result.
   - the side effects are too strong.
   - can be overcomes by combining with other treatment methods so that the patients do not have to take even little doses for life long fearing for relapse

Question 23

Second treatment for schizophrenia and delusional

Answer 23

Electro-convulsive therapy

1. Small currents are used to stimulate certain parts of the brain during ECT
   - causes a brief and controlled seizure that may reduce symptoms related to depression or other mental health problems
2. How does ECT works?
   - causing changes to the chemistry and functioning of the brain
   - most often used when other treatments provide little or no relief from symptoms
   - other treatments often tried before ECT include medications and talk therapy
   - rarely used.
3. Experiment
   - physicians Ugo Cerletti and Lucio Bini has discovered the potential for electricity to be used to induce seizures and unconsciousness by observing the effect electric shocks had on cattle
4. Treatment sessions
   - ranging from 6 to 12 sessions
5. Potential risk
   - procedure affects the central nervous system and cardiovascular system, which can be dangerous for those with pre-existing medical conditions
6. Common side effect
   - memory loss (usually temporary)
7. Extremely rare side effects
   - lasting neurological damage
   - death
   - affect postsynaptic responses to central nervous system transmitters

Question 24

Third treatment for schizophrenia and delusional disorder

Answer 24

Token economy (behavioural treatment) (Paul & Lentz)

1. Method used for learning approach to improve behaviour
2. How does it work?
   - carried out with other treatments
   - patients are rewarded for performing socially desirable behaviour
   - patients will be willing to repeat these behaviours in order to gain more rewards
3. Paul and Lentz
   A. Token economy using operant conditioning
   B. Participants
   - patients were placed in 1 of 3 groups
   > traditional hospitalisation
   » no additional support
   » control group
   > traditional hospitalisation
   » with Milieu Therapy
   » Milieu Therapy is a treatment using a therapeutic community, where patients live together and look after both themselves and each other, promote social engagement, and build relationships
   > traditional hospitalisation
   » with Token economy
   - 84 patients chronically admitted to psychiatric institutions over 4 and 1/2 years
   C. Hypothesised that token economy patients
   - would see a reduction in symptoms
   - have more successful long-term outcomes as discharged patients
   D. Data collection
   - behaviour was monitored through various means, including time-stamped observations, standardised questionnaires, and individual interviews
   E. Results
   - patients in the token economy group showed the most improved results
   > both positive and negative symptoms were reduced
   > 97% of the token group lived independently after being discharged compared to 71% of the Milieu group and 45% of hospitalisation
   - very effective in treating catatonic behaviour and social withdrawal
   - less effective in treating hallucinations and delusional thinking
4. Wakefield (2008)
   - criticised research as not being generalisable outside of the clinical setting

Question 25

Evaluation of token economy (Paul and Lentz) - schizophrenia

Answer 25

1. High reliability
   - Paul and Lentz using token economy involved intensive staff training to ensure rewards were administered reliably
2. Increases standardisation
   - staff were monitored and issued with a manual to ensure procedures
3. Low ecological validity
   - such rigorous enforcement in other hospitals and indeed the outside world might not be possible
4. Ethical issues
   - denying privileges to patients who do not behave appropriately
   - may become demotivated and distressed by the therapy
5. Consistency
   - an easy-to-follow technique for patients
6. Application in everyday life
   - based on positive reinforcement
   - helps patients behave in appropriate ways in a care (and other) setting
   - not a treatment and will not cure schizophrenia
7. Generalisability
   - based on behaviourist principles and approach that can be generalised

Question 26

Issues and debates for token economy (Paula and Lentz)

Answer 26

1. Reductionist
   - behaviourist principles that are not humanist

Question 27

Fourth treatment for schizophrenia and delusional disorders

Answer 27

Cognitive behavioural therapy (Sensky et al.)

1. Definition
   - A talking therapy designed to help people change through recognising thoughts which underlie their behaviours.
2. Aims
   - Aims to change or modify people’s thought and beliefs
   - Aims to change the way that they process information
3. How it works?
   - A therapist will challenge irrational and faulty thoughts as well as behaviours that are not helping
4. Effectiveness
   - quite promising
   - helpful especially for those schizophrenia patients who do not agree to medications
5. Sensky et al. (2000)
   A. Background
   - research evidence supports the efficacy of cognitive-behavioural therapy in the treatment of drug-refractory positive symptoms of schizophrenia
   - although the cumulative evidence is strong, early controlled trials showed methodological limitations
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   B. Aims
   - looked at patients who did not respond to biochemical treatments and before going for ECT
   - randomised control trial (RCT) wanted to assess the effectiveness of CBT comparing it to ‘befriending group’
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   C. Conditions
   CBT
   - structured with specific stages:
   > engaging with patient
   > discussing emergence of the disorder
   > discussing current specific symptoms
   > possible treatment
   - patients keep voice diaries to record what they are hearing to be used to create coping strategies during treatment
   ——————-
   Befriending
   - simply a form of discussion that would typically occur between friends about various topics
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   D. Participants
   - 90 patients aged 16 to 60 were assigned to either CBT or befriending groups
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   E. Assessment
   - Comprehensive Psychiatric Rating Scale (CPRS)
   - Scale for the Assessment of Negative Symptoms (SANS)
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   F. Methods
6. A randomised controlled design was used to compare the efficacy of manualised cognitive behavioural therapy developed particularly for schizophrenia with that of a nonspecific befriending control intervention.
7. Both interventions were delivered by two experienced nurses who received regular supervision.
8. Patients were assessed by blind raters at baseline, after treatment (lasting up to 9 months), and at a 9 month follow up evaluation.
9. Patients continued to receive routine care throughout the study.
10. An assessor blind to the patients’ treatment groups rated the technical quality of audiotapes sessions chosen at random.
11. Analysis was by intention to treat.
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    G. Results
    - 90 patients received a mean of 19 individual treatment sessions over 9 months, with no significant between-group differences in treatment duration
    - both interventions resulted in significant reductions in positive and negative symptoms and depression
    - at the 9-month follow-up evaluation, patients who had received cognitive therapy continued to improve, while those in the befriending group did not
    - these results were not attributable to changes in prescribed medication
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    H. Conclusion
    - cognitive behavioural therapy is effective in treating negative and positive symptoms in schizophrenia resistant to standard antipsychotic drugs, with its efficacy over 9 months of follow-up

Question 28

Evaluation of Sensky et al. (Cognitive behavioural therapy)

Answer 28

1. Fairly representative
   - samples were from various clinics across the UK
2. Standardised approach to the CBT
   - nurses in both conditions were carefully trained and monitored
3. Increased validity
   - used an RCT design
   - assessor were blind to the treatment group they were assessing
   - removes any bias they might have felt for or against the treatment

Question 29

Issues and debates for treatment for schizophrenia and delusional disorder

Answer 29

1. Application to everyday life
   - Biochemical treatment in the form of antipsychotics is usually the primary treatment for the disorder, and has been shown to be effective in reducing the positive symptoms of schizophrenia in the majority of people.
   > This reduces hospitalisation and can improve quality of life.
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   - ECT, however, is far less effective and is likely only to be used in urgent, acute cases or those with primarily catatonic symptoms.
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   - The lasting impact of token economies on those with schizophrenia was evidenced in the study by Paul and Lentz (1977).
   - However, implementing the system requires specific conditions and rigorous training and enforcement by clinical staff.
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   - Other treatments include CBT as Sensky et al. (2000) have shown, the effectiveness of this treatment is fairly significant, and may offer hope to individuals who have not responded well to antipsychotic medication.