Evaluation Points Flashcards
(62 cards)
1
Q
Classification systems for Sz ?
A
DSM (diagnostic and statistical manual)- US
ICD (internal classification of disease) - Europe
2
Q
Who produced the DSM 5 ?
A
American psychiatric association
3
Q
Who produces the ICD?
A
WHO
4
Q
What symptoms are required in the DSM 5 for diagnosis of SZ?
And how long must they be present ?
A
Delusions
Hallucinations
Disorganised speech and behaviour
Must be present for 6 months with 2 active symptoms
5
Q
How many symptoms are required for the ICD?
A
1 symptoms
6
Q
Positive symptoms of SZ ?
A
Delusions e.grandiose beliefs
Hallucinating (visual, tactile and auditory)
Disorganised speech
Catatonic behaviour
7
Q
Negative symptoms?
A
Loss of severe reduction of normal functioning
- speech poverty (limited speech output)
- avolition (no goal directed behaviour)
- affective flattening (reduction in range and intensity of emotional expression)
8
Q
Prevalence of Sz?
A
1% risk in general population
9
Q
Most of Sz?
A
For most is a gradual descent over 6 months with odd idea and psychotic episodes
10
Q
Risk factors that trigger genetic vulnerability ?
A
- low socio economic status
- urban residence
- minority ethnicity
11
Q
Why do we use classification systems ?
A
Makes it easier to identify and breakdown and treat disorders
- increases reliability of diagnosis (doctors more likely to arrive at same diagnosis when using classification systems
12
Q
What is reliability in diagnosis ?
A
= consistency
- for diagnosis to be replicable it must be repeatable
Aka test retest reliability
13
Q
How can we test diagnosis in Sz?
A
Inter inter-rate agreement
- 2 clinicians must reach same conclusion about a patient
- agreement should be same over time and cultures
14
Q
How is the inter eater reliability between the DSM and ICD?
A
Poor
- Cheniaux,2 psychiatrists independently diagnose 100 patients using ICD and DSM
Findings
- both diagnosed twice as many with SZ when using ICD over DSM
- one psychiatrist diagnosed twice as many as the other
15
Q
Why is the inter-rated reliability between ICD and DSM so poor ?
A
- some clinical characteristic are open to interpretation such as eccentric and delusional
- symptom threshold for diagnosis is higher in DSM, 2 vs 1
- cultural differences, in US and UK more African Americans are diagnosed with SZ due to lack of cultural awareness e.g hearing voices is more acceptable in African cultures as you believe u can communicate with ancestors = less bizar behaviour, this leads to clinicians having to take extra care in assembler for people from different ethnic groups
16
Q
What is validity in diagnosis of SZ ?
A
Extent to which Sz is a unique syndrome with a shared set of characteristic, distinct from other disorders = extent to which different classification systems measure what they claim
to measure
17
Q
Why are validity and diagnosis linked ?
A
Because a diagnosis isn’t valid if it’s not reliable
18
Q
Why is diagnosis in validity of Sz problematic ?
A
Symptoms and development of disorder varies enormously so it’s not really a unique condition syndrome with shared set of characteristics
Difficult to define boundaries between Sz and other disorders
19
Q
3 areas In validity for Sz ?
A
Gender bias
Symptom overlap
Co-morbidity
20
Q
Gender bias ? In diagnosis, studies
A
- extent to which diagnosis is dependent on gender of a person
(Longnecker et al found since 1980’s) mehave been diagnosed more than women
Is this gender bias or genetic vulnerability
- Loring and Powell
Randomly selected 290 female psychiatrists
- 2 case studies were read
- 56% diagnosed when patient was male
- 20% diagnosed when patient said to be female
- gender bias is less evident in female psychiatrists suggesting gender bias is also effected by gender of clinician
21
Q
Reason for gender bias in diagnosis?
A
- female patients usually function better than men and more likely to have better relationships with family which may cause under diagnosis as Symptoms may be masked as higher functioning
22
Q
What is symptoms over lap in areas in validity?
A
- many pos and beg symptoms found in Sz and no polar disorder e.g delusions and hallucinations seen in both
- class into questions validity and diagnosis of Sz = extent to which Sz is a unique disorder
23
Q
Co-morbidity In validity of Sz?
And studies ?
A
Extent to which two or more conditions occur together
- if two or more conditions occur together a lot it calls into question validity of diagnosis and classification of Sz as may just be a single condition
- Buckley concluded patients with Sz have following comorbid conditions
- 50% have depression
- 47% substance abuse
- 23% OCD
In terms of diagnosis- If half are diagnosed with depression maybe were bad at telling difference between the 2
In terms of classification- maybe severe depression looks a lot like Sz and visa Versa, maybe they should be a single conditions
24
Q
Ethical issues with labelling ?
A
- label in of Sz strays on medical record forever
- can hamper recover as becomes self fulfilling prophesy
- people suspicious of such labels
25
Biological explanations of Sz?
Set out genetic factors
Strong biological basis
Environmental stressors
Genetic hypothesis
Evaluating of genetic factors
26
Biological explanations of Sz
Set out, role of neurotransmitters ?
Original D hypothesis
Support for D hypothesis
Problems with D hypothesis
Revised D hypothesis
Support for RD hypothesis
Glutamate theory and support
Overall evaluation
27
Bio explanations for Sz ?
Genetic basis ?
- genetic predisposition
- genes in brain set up badly
- found across all cultures
- early life factors also play a role e.g malnutrition In 2nd trimester
28
Bio explanations of Sz
Environmental stressors ?
Drug use may trigger
29
Bio explanations for Sz ?
Genetic hypothesis ?
More closely related a family member greater the chance of them developing disorder
30
Bio explanation for Sz
Evaluation pints for genetic factors ?
- strong research evidence from adoption studies
- not 100 concordance rates
- 2/3 Sz have no Sz relative ( must be other explanations)
- close to identifying genes involved in Sz ( same cluster in bipolar disorder )
- genetic factors may influence genetic hardware of brain E.g problems with brain structures such as large ventricles
31
Role of neurotransmitters?
Original D hypothesis
Original d hypothesis
- D guides attention (disturbances here affect attention and thought)
- excess dopamine = positive symptoms such as delusions and hallucinations
- Sz have high numbers of D2 receptors on receiving neurons = more dopamine binding and more neurons firing
32
Bio explanations?
Support for D hypothesis ?
Amphetamines increase D levels = delusions and hallucinations whiz disappears with absistence from drug
Parkinson’s disease = v low depression
- when given L dips which raised D levels = schizophrenia symptoms
Antipsychotic drugs
- block many D receptor sites and + reduce many positive symptoms
33
Bio explanations
Problems with D hypothesis ?
Genome wide studies suggest other Neurotransmitters play a bigger role in Sz
Clozapine
Blocks D and works better may be cause it also effects serotonin
Glutamate
Much research attention shifters to this
34
Bio explanations
| What is the revised D hypothesis ?
Proposed by Davis and Khan
Positive symptoms = excess of D in subcortical areas, particularly mesolbic pathway
Negative symptoms = D deficit in prefrontal cortex (mesocortical pathways)
35
Bio explanations support for RD hypothesis ?
Patel neural imaging
- PET scans
Lower levels of D found in prefrontal cortex fo Sz patients compared to controls
Want and Deutch
- creates D depletion in PFC of rats
=Cognitive impairment of rats
= reverses effect by giving antipsychotic drugs working on neg symptoms in humans
36
Bio explanations ?
Glutamate theory ?
Focuses on under activity of G receptors
- causes abnormal levels of D involved in P symptoms
- effects other neural circuits involved in p symptoms)
37
Bio explanations ?
Supper for D hypothesis ?
Support
- newer drugs e.g clozapine world of D and G receptors = sormecfects in negative symptoms
- drugs targeting G receptors effect negative symptoms as as good as antipsychotics on p symptoms and reduces side effects
38
Bio explanations of Sz
New URL’s correlates examples ? And support and problems
MRI show definite structural abnormalities in Sz
Enlarged ventricles associated with negative symptoms
Support
- Adreasen, CAT scan studies = significant enlargement of ventricles of Sz compared to control
Problems
- enlarged ventricles found in non Sz aswell
- MRI done on people already diagnosed = cause and effect not clear
39
Treatments of Sz ?
| Historical treatment
Psychosurgery
- remove/ reduce symptoms, thousands of frontal lobotomies undertaken
= many died and caused irreversible brain damage practise abandoned after 1950s arrival of drug treatment
40
Medication types in treating Sz?
Atypical and typical
41
Typical antipsychotics
Chlorpromazine (dopamine agonist)
- work on positive symptoms
- bind to D2 receptors On PS neurone which then isn’t stimulated to fire = eliminated hallucinations-and delusions
Effectiveness
- small effect on negative symptoms
- 60% of the time p symptoms are reduced, relapse occurs if stopped medication
Side effects
- 25% cases = traduce dyskinesia
- constipation
Support
- Davis and Khan
55% placebo group patients relapsed
- 19% treatment group relapsed
Vaughn and left
- alternative explanation
42
Bio treatment
Atypical?
Clozapine
- works on some negative and positive symptoms
- fewer side effects
Temporarily blocks D2 receptors allowing normal D transmission
- also works of serotonin and glutamate
Effective ?
- marginally more effective than typical ones
- reduces neg symptoms
- NICE recommends over typical
Side effects
- 5% tardive dyskinesia
- weight gain
- reduces WBC= damage immune system
43
Why must environmental factors play a role In Sz ?
Mz studies don’t show 100% conv rates
44
What is family dysfunction ?
Idea Sz is caused by abnormal communication patterns in fam
There are two theories
- state that one person behaving abnormally in a system may be reflective of problems in wider family system
2 theories
- double bind
- Expressed emotion
45
Cognitive explanations of Sz
Double bind theory ?
Bateson
- parents predispose children through contradictory comments e.g I love u- leave me alone
- contradicting comments = child understands world as confusing and dangerous
Berger
- found Sz patients recorded higher numbers of double bind statements from mothers than control
Liem
- found no evidence
46
Cognitive explanations of Sz?
Expressed emotion
Expressed emotion
- communication style in family talks of patient in more hostile way suggesting emotional over involvement
- makes someone 4x more likely to relapse
Why cause relapse ?
- causes stress beyond patients coping capability
47
How is expressed emotion measured ?
Plus studies
Counting numbers of critical comments made by relatives and statements reflective over involvement
- Vaughn and leff
- 129 patients after return from hospitalisation
- families rated for levels of EE
Low EE fam relapse rates are 12% in medication, 15% if not)
High EE fams 53% is in medication and 92% if not
48
AO3? For cognitive explanations
Isreali study found no Sz in high risk children who had good parenting
Shit communication patterns doesn cause Sz alone but may trigger it
Not all fams will necessarily benefit from family therapy as not all patients are equally vulnerable to high levels of EE
Lead to effective form of family therapy- significantly reduced relapse rates which suggests high EE plays important role in triggering Sz
High EE is less common in first episode of Sz suggesting High Er may be an effect of Sz
49
Cognitive explanations of Sz?
Set out
Attentional impairment
Friths 2 kinds of dysfunctional thought processing
Evaluation
50
Attentional impairment ?
Filtering + processing systems are faulty in Sz brains
- too much irrelevant info let it which can’t be processed = confusion, difficulty on focusing on one thing at a time and turning insignificant stimuli into highly meaningful stimuli
Evidence
- supported by evidence where the Sz performs badly in visual tracking tasks
51
Friths two kinds of dysfunctional thought processing in Sz ?
1) deficits in meta- representation
- allows insight into our own intentions
- allows interpretation of others
- dysfunction in this area (inability to recognise own actions and thoughts as our own)
- explains delusions such as thought insertion
Evidence
- Sz perform badly in theory of mind tasks suggesting problem here, theory of mind tasks test understanding that people see the world from different POV
2) central control and dysfunction
- struggle suppressing automatic responses while performing deliberate actions
- speech becomes disorganised
Evidence
- Stirling stroop rest
- Sz took twice as long (just tell colour not word)
52
Evaluating cognitive explanations ?
Doesn’t explains cause of faulty thought processing
- maybe has biological basis
- salience theory may be better( salience = important to which we attach stimuli, dopamine tells us something is salient, excess of D = extra salience and attaching inappropriate importance to stimuli
- supported by success do CBTp
- NICE found CBTp more effective in reducing
symptoms severity than antipsychotics
- CBTp changes faulty cognition a not biochemistry suggesting faulty cognition play a clear role in Sz
- conc rates higher for Mz than Dz in role of developing Sz this theory can’t be well developed then
53
CBT as part of psychological therapy??
CBT
Aims to identify + correct faulty interpretations + improve patients general functioning
How it works
- patients asked to track back when Sz developed
- patients asked for evidence of irrational beliefs and way to test them
- behaviour assignments given to improve level of functioning
- explore alternative beliefs
- help patient understand problem and reduce stress which improves functioning
54
Effectiveness of CBT ?
Gould meta analysis
- 7 studies all showed significant reductions in p symptoms after CBT
NICE
- found drug and CBT group improved more significantly than just drug group
Better long term effects
- Mike Startup
- 90 patients with half given drugs and half given CBT and drugs, 2 years later CBT and drug group still had less negative symptoms than just drug, cost of CBT is compensated by lack
Of hospitalisation
55
Family therapy as psychological therapy?
Families play important role in affecting course of Sz
Works by improving communications in fams and reducing levels of high EE and stress
- NICE recommends to all in contact with their fam
Focuses
- increase understanding of disorder
- provide fam with coping skills
- learn more constructive ways of communicating
- how to handle embarrassment
56
How effective is family therapy ?
Garety
- Sz with fam theory half hose on standard care
- pharaohs meta analysis of 53 studies shows family therapy increases medications compliance (may be improvement due to increased compliance/ medication)
- NICE says it saves huge amounts of money
- methodological issues e.g over 20% all studies fail to use observers blind (observer bias risk) so drawing conclusions about family therapy effectiveness is difficult
57
Token economy as a psychological therapy ?
Used to improve patients involvement in daily activities e.g basic hygiene
How it works
- based on principles of operant conditioning (learning though reward)
- things that give the patient pleasure are primary reinforcers
- token given when patient does desirable behaviour e.g shower
- token used to buy primary reinforcer
- token become paired with primary reinforcers and become secondary reinforcers
- early stages of token economy primary reinforcement must happens fast or Sz may not make association
58
Evaluate token economy ?
Dickerson
Reviewed 13 studies using TE
- 11 found beneficial effect in reducing negative symptoms (not all studies conducted with same methodological rigour)
- lack of control group
Unethical to use control groups so makes it hard assess the success of TE, patient improvement therefore can only be compared to last behaviour but other extraneous variable such as increased staff attention may have caused this
May only be effective In institutions
- SZ I’m institutions receive 24 hour care, outpatients in community only seen few hours. A day so can’t be given necessary reinforcement at right time
Unethical
- clinicians use food as reinforcement = basic human rights withheld in attempt to change behaviour
59
Interactions approach in Sz ?
Acknowledges biological, psychological and societal factors in development of Sz
Diathesis stress
Proposes Sz is result of interaction between biological and environmental influences
- explains why not all with genetic vulnerability develop disorder
- problem differ in amount of cubed ability and stress they exp
- people with fam history of Sz have high vulnerability, tressors such as living in city and childhood trauma are triggers
60
Evidence for interventionist approach ?
Evidence for childhood trauma
- children who exp severe trauma a before 16 are three times more
Likely to develop Sz than general pop
Vassos
- risk of Sz 2 x higher than in urban areas
Tienari
- children born to Sz mothers and adopted
- significantly more likely to develop Sz if raised in healthy adoptive fam than in a high stress fam
- children born to non Sz mothers then adopted didn’t make a difference how their adoptive family was which shows the interaction between diathesis stress
61
Additive nature of diathesis stress ?
Multiple genes increase vulnerability to Sz, more genes u have the higher the vulnerability
Models assumes diathesis and stress add together in a way to cause Sz
62
More evaluation for interactionist approach ?
Romans Clarkson found no difference in mental health between rural and urban areas
Lead to most theories now abandoning either extreme of nature nurture debate and taking more interactions it approach in treating Sz
Implications for treatment
- acknowledges bio and environmental factors in Sz so compatible with not treatment types as pps who are offered both have greater reduction in symptoms
Genetic vulnerability isn’t the only diathesis that increases risk of developing Sz
- birth complications also associated with increased risk of Sz Verdoux says 4 x more likely for those who exp both complications
