Paper 3 - Schizophrenia

Question 1

Define Positive symptoms of Sz

Answer 1

Positive symptoms: these are additional to normal life experiences and concern losing touch with reality (e.g. Hallucinations and Delusions)

Question 2

Define Negative symptoms of Sz

Answer 2

Negative symptoms: Loss of usual abilities and experiences, loss of pleasure in life,
inappropriate emotional responses to situations and thought processes. (e.g. Alogia and Avolition)

Question 3

4 symptoms of Sz

Answer 3

Hallucinations
Delusions
Alogia (speech poverty)
Avolition

Question 4

Explain hallucinations as a symptom of Sz

Answer 4

Hallucinations: Auditory/Visual-
Usually take the form of hearing voices that are not there. These voices are normally critical and unfriendly. Additionally, some people with schizophrenia may also see,
smell, taste and feel things that are not there.

Question 5

Explain delusions as symptoms of Sz

Answer 5

Delusions: An unshakable belief in something that is very unlikely, bizarre or obviously untrue. One of the delusions experienced in schizophrenia is paranoid delusions, where an individual believes that something, or someone, is deliberately trying to mislead, manipulate, hurt or, in some cases, even kill them. Another common delusion is the delusion of grandeur. An individual believes that they have some imaginary power or authority, such as thinking that they are on a mission from God or that they are a secret agent.

Question 6

Explain alogia/speech poverty as a symptom of Sz

Answer 6

Alogia (Speech Poverty): When a person loses their ability to speak fluently
(reduction in the amount of quality speech).
There can also be a noticeable delay in verbal responses
during conversation. Poor amount of coherent speech.

Question 7

Explain avolition as a symptom of Sz

Answer 7

Avolition: Apathy, where people with schizophrenia have a lack of
motivation.
Results in low activity levels therefore do not to follow through
any plans/goals and neglect household chores, such as
washing the dishes or cleaning their clothes, or maintaining
personal hygiene. Loss of persistence in work/education.

Question 8

Difference between positive and negative

Answer 8

Positive symptoms are feelings or behaviours that are not usually present and include:
+ Delusions
+ Hallucinations
+ Catatonic or Disorganised Behaviour
+ Disorganised Speech (word salad)
Negative symptoms on the other hand refer to abilities that the patient has lost or can no longer perform and include:
- Affective Flattening
- Anhedonia
- Avolition
- Alogia (speech poverty)

More symptoms on docs (diagnosis of Schizophrenia)

Question 9

Difference between classification and diagnosis

Answer 9

Classification is the systems used to list symptoms.Symptoms are grouped accordingly to mental disorders.Schizophrenia should have a distinct set of symptoms from other disorders.
Diagnosis is giving a person the label ‘schizophrenia.’ Generally need 2+ symptoms for ONE month or more
Important to get the labels right because of issues with stigmas and getting the right
treatment.

Question 10

Classification : Rosenhan (being sane in insane places) - aim procedure findings conclusion

Answer 10

Aim : To investigate whether psychiatric labels would be used in situations where they weren’t appropriate. To investigate the experience of being hospitalised in a psychiatric ward.
Procedure : Rosenhan used 8 students as his ppts. These ppts were told to fake a singular symptom (hearing voices saying hollow, empty, thud). These were then admitted to 12 psychiatric hospitals in 8 states. Once admitted they stopped faking symptoms (act ‘normal’) and acted to be released because they felt fine.
Findings : 11/12 diagnosed as schizophrenia in remission (meaning they are recovering from Sz). None were ever detected as being pseudo patients (fakers) and the longest stay was two months.
Conclusion : Psychiatric labels were used in situations where they weren’t appropriate. Diagnosis isn’t reliable/accurate or consistent.

Question 11

Classification : DSM-V

Answer 11

⦿ The Diagnostic and Statistical Manual of Mental Disorder (Edition 5), was last published in 2013.
⦿ The DSM is produced by the American Psychiatric Association.
⦿ It is the most widely used diagnostic tool in psychiatric institutions throughout America and some parts of Europe.

One positive symptom
Continuous sign of disturbance for six months with symptoms present for at least one month
Focuses on Sz as a spectrum disorder (as it features a range of symptoms that may change over time).

Question 12

Classification : ICD-10

Answer 12

⦿ International Statistical Classification of Diseases (known as ICD)- produced in Europe by the World Health Organisation (WHO) Currently in it’s 11th edition.
⦿ Used in the UK and many other European countries
Currently refer to ICD-10 due to 11 not being used for diagnosis until 2022 (ICD - 10 used on spec)

Two or more negative symptoms
Symptoms present for one month
Recognises seven sub-types of Sz

Question 13

Classification : A03 : Good Reliability

Answer 13

Strength
Good Reliability - A reliable diagnosis is consistent between clinicians (inter-rater) and between occasions (test-retest).
Osorio et al (2019) report excellent reliability for Sz diagnosis (DSM-5) – inter-rater agreement of +.97 and test-retest reliability of +.92. This means that the diagnosis of Sz is consistently applied.

Question 14

Classification : A03 : Low Validity

Answer 14

Weakness
Low validity - Criterion validity involves seeing whether different procedures used to assess the same individuals arrive at the same diagnosis.
Cheniaux et al. (2009) had two psychiatrists independently assess the same 100
clients. 68 were diagnosed with Sz using ICD and 39 using DSM. This means that Sz is either over- or under-diagnosed, suggesting that criterion validity is low.
However, Osiorio found excellent agreement between clinicians using different
procedures both derived from the DSM system – this means that criterion validity
for Sz is good provided it takes place within a single diagnostic system.

Question 15

Classification : A03 : Co morbidity

Answer 15

Weakness
Co-morbidity - If conditions often co-occur then they might be a single condition. Sz is commonly diagnosed with other conditions. For example, Buckley et al (2009) concluded that Sz is co-morbid with depression (50% of cases), substance abuse (47%) or OCD (23%). This suggests that Sz may not exist as a distinct condition.

Question 16

Classification : A03 : Symptom Overlap

Answer 16

Weakness
Symptom overlap - There is an overlap between the symptoms of Sz and other conditions e.g. both Sz and bipolar disorder involve delusions and avolition. Sz and bipolar disorder may be the same condition (a classification issue). Sz is hard to distinguish from bipolar disorder (a diagnosis issue). This means that Sz may not exist as a condition and, if it does, it is hard to diagnose.

Question 17

Classification : A03 : Gender Bias

Answer 17

Weakness
Gender bias - Men are diagnosed with Sz more often than women in a ratio of 1.4:1
(Fischer and Buchanan 2017). This could be because men are more genetically vulnerable, or women have better social support, masking symptoms. This means that some women with Sz are not diagnosed so miss out on helpful treatment.

Question 18

Classification : A03 : Cultural Bias

Answer 18

Weakness
Culture bias - Some symptoms e.g. hearing voices, are accepted in some cultures, e.g. Afro-Caribbean societies ‘hear voices’ from ancestors. Afro-Caribbean British men are up to ten times more likely to receive a diagnosis as white British men, probably due to over interpretation of symptoms by UK psychiatrists. This means that Afro-Caribbean men living in the UK appear to be discriminated against by a culturally-biased diagnostic system.

Question 19

Define comorbidity and symptom overlap

Answer 19

Co-morbidity : Two or more different disorders at the same time.
Symptom Overlap : Symptoms of one disorder are also symptoms of another disorder making it difficult to diagnose.

Question 20

Biological Explanation : Genetic Basis : Gottesman (1991) twin study & conclusion

Answer 20

Twin: Gottesman (1991) MZ twins 48%, DZ 17% - shows a genetic element.
Conclusion = There is a genetic element to developing schizophrenia as identical twins (Mz with 100% same genes) have a concordance rate of 48% whereas fraternal twins (Dz with 50% same genes) have a concordance rate of 17%. However if it was only based on genes, identical twins (Mz) would have a 100% concordance rate, not 48%.

Question 21

Biological Explanation : Genetic Basis : genetic explanation

Answer 21

Genetic explanation - trying to find a gene responsible for causing schizophrenia (if found it could lead to early detection and prevention of schizophrenia)

Question 22

Biological Explanation : Genetic Basis : Adoption (Tienari 2004)

Answer 22

Adoption: Separates genetics from environment, Tienari (2004), found 6.7% of adoptees with a biological mother with schizophrenia. This suggests that it’s still based on genetic as 6.7% is higher then 1% chance which is the rate for general population.

Question 23

Biological Explanation : Genetic Basis : candidate gene

Answer 23

Candidate Gene: There is NOT a ‘schizophrenia gene’ but SEVERAL genes are
involved (CANDIDATE GENES). Schizophrenia is polygenic and aetiologically heterogeneous. Ripke et al (2014) conducted a HUGE study using previous data
comparing 37,000 patients data with 113,000 controls and 108 genetic variations associated with increased risk of developing schizophrenia were identified. Many coded for the dopamine neurotransmitter.

Question 24

Biological Explanation : Genetic Basis : Mutation

Answer 24

Mutation: Sz can have a genetic origin without a family history due to a mutation in parental DNA. Evidence comes from Brown et al (2002) who found a correlation between paternal age (associated with increased risk of sperm mutation) and risk of Sz.

Question 25

Biological Explanation : Explain Neural correlates

Answer 25

Structural and functional brain abnormalities. Neural correlates are measurements of the structure or function of the brain that correlate with the positive or negative symptoms of schizophrenia.

Question 26

Biological Explanation : Neural Correlates : Hyperdopaminergia

Answer 26

The dopamine hypothesis
Hyperdopaminergia - original view = too much dopamine in the subcortex! Central areas of the brain including Broca’s area (responsible for speech production) – associated with positive symptoms such as hallucinations & delusions BUT also speech poverty.

Question 27

Biological Explanation : Neural Correlates : Hypodopaminergia

Answer 27

Hypodopaminergia - recent view = too little dopamine in the cortex! The prefrontal cortex (responsible for thinking & decision making) – associated with negative symptoms such as avolition.
They both have worth and could both be correct BUT antipsychotics support the original view by reducing dopamine activity by blocking receptors (Tauscher et al, 2014)!

Question 28

Biological Explanation : Neural Correlates : Parkinson’s Disease

Answer 28

Dopamine levels in a Parkinson’s sufferer is low. L-dopa raises DA activity
People with Parkinson’s develop schizophrenic symptoms if they take too much L-dopa.
Chlorpromazine (given to schizophrenics) reduces the symptoms by blocking D2 receptors.

Question 29

Biological Explanation: Genetic strength

Answer 29

Strong evidence base
▪ Gottesman (1991) family study shows how genetic similarity and shared risk of schizophrenia are closely related.
▪ Adoption studies Tienari (2004), show biological children of people with schizophrenia are still at heightened risk of schizophrenia even if adopted into a family without a history of schizophrenia.
▪ Hiker et al (2018) – 33% concordance for Mz and 7% for Dz twins
▪ This shows that some people are more vulnerable to sz because of their genes

Question 30

Biological Explanation: Genetic weakness

Answer 30

Evidence for environmental risk factors
▪ Biological risk factors include birth complications (Morgan et al 2017) and smoking THC-rich cannabis in teenage years (Di Forti et al 2015)
▪ Psychological risk factors include childhood trauma e.g. 67% with Sz (38% matched controls) reported at least one childhood trauma (Morkved et al 2017)
▪ This means that genes alone cannot provide a complete explanation for Sz

Question 31

Biological Explanation: Neural strength

Answer 31

Support for dopamine
▪ Tauscher et al (2014) also showed antipsychotics that reduce DA also reduce intensity of symptoms
▪ Amphetamines increase DA and mimic Sz symptoms (Curran et al 2004)
▪ This strongly suggests that dopamine is involved in the symptoms of Sz

Question 32

Biological Explanation: Neural weakness

Answer 32

Evidence for a central role of glutamate
▪ Post-mortem and live scanning studied have consistently found raised levels of the neurotransmitter glutamate in several brain regions (McCutheon et al. 2020)
▪ Several candidate genes are believed to be involved in glutamate production or processing
▪ Therefore there is evidence of other neurotransmitter being involved and not just dopamine

Question 33

Biological Explanation : General Weakness

Answer 33

This explanation is reductionist as it reduces a complex disorder like schizophrenia to a basic cellular and chemical level which therefore does not recognise the gender and culturally differences that occur.
▪ If it was purely genetic, MZ concordance should be 100%. However MZ twins are usually reared in the same environments, therefore treated the same compared to DZ, so it may be social learning theory (imitation through observation) that causes
schizophrenia. Therefore we cannot disentangle the environmental influences from biological causes.

Question 34

Biological treatment : Typical Antipsychotics (chlorpromazine)

Answer 34

Typical Antipsychotics (1950s)
▪ Chlorpromazine combat the positive symptoms of schizophrenia. They are dopamine antagonists; they bind to dopamine receptors, without stimulating them, blocking the action of dopamine receptors in the synapse. This reduces the action of dopamine.
▪ Hallucinations and delusions diminish within a few days.
▪ Chlorpromazine also has an effect on histamine receptors which lead to a sedation effect – used to calm anxious patients when they are first admitted to hospital.

Question 35

Biological treatment : Typical Antipsychotics (pimozide)

Answer 35

▪ Pimozide is another typical antipsychotic that works by decreasing the activity of dopamine in the brain

Question 36

Biological treatment : Atypical Antipsychotics (explain the aim)

Answer 36

▪ The aim of these is to supress psychosis and also minimise the side effects.
▪ They target dopamine and serotonin.

Question 37

Biological treatment : Atypical Antipsychotics (clozapine)

Answer 37

▪ Clozapine binds to dopamine receptors BUT ALSO acts on serotonin and glutamate receptors.
▪ This drug was more effective than typical anti-psychotics – clozapine reduce depression and anxiety as well as improves cognitive function.
▪ They also improves mood, which is important as up to 50% of people suffering from schizophrenia attempt suicide

Question 38

Biological treatment : Atypical Antipsychotics (risperidone)

Answer 38

▪ Risperidone: this developed due to clozapine being involved in
the deaths of some patients from a blood condition.
▪ This binds to dopamine and serotonin BUT risperidone binds
more strongly to dopamine receptors and is therefore more
effective in smaller doses than most antipsychotics and has
fewer side effects.

Question 39

A03 : biological treatment : anti-psychotic vs placebo

Answer 39

Strength
Anti-psychotic vs placebo: a meta-analysis of 65 studies including 6,000 patients concluded that 64% of patients taken off antipsychotics and given a placebo relapsed within 12 months, compared to 27% of those who stayed on antipsychotics.

Question 40

A03 : biological treatment : Thornley et al

Answer 40

Strength
Thornley et al (2003) reviewed data from 13 trials (1121 participants) and found the chlorpromazine was associated with better functioning and reduced symptom severity compare with a placebo

Question 41

A03 : biological treatment : Meltzer

Answer 41

Strength
Meltzer (2012) concluded that clozapine is more effective than typical antipsychotics - it is effective in 30-50% of treatment-resistant cases
▪ This shows the effectiveness of antipsychotics treatments.

Question 42

A03 : biological treatment : side effects

Answer 42

Weakness
Side Effects: typical antipsychotics are associated with dizziness, agitation, sleepiness, weight gain and in the long term lip smacking, grimacing.
An extreme side effect is neuroleptic malignant syndrome, caused by blocking dopamine action in the hypothalamus. Atypical anti-psychotics were developed to
reduce side effects BUT some still exist. Therefore patients won’t take the drug which can therefore make their symptoms worse again.

Question 43

A03 : biological treatment : Healy

Answer 43

Weakness
Healy (2002) suggests that data from some successful trials have been published multiple times, exaggerating the positive effects. Also most studies only review short term effects, furthermore they have a powerful calming effect which demonstrates that they have a positive effect on patients despite the fact that they may not be effective in treating psychosis. This means the effectiveness of drug therapy may have been overestimated.

Question 44

A03 : biological treatment : motivational deficits

Answer 44

Weakness
Motivational Deficits: Ross and Read (04) Claim that prescribing medication reinforces a biological explanation of schizophrenia, so people aren’t motivated to look for solutions to social or cognitive factors which may be contributing to their suffering. – REDUCTIONIST. Antipsychotics may have been used in hospitals to calm patients and make them easier to work with, rather than to benefit the patients. This practice is seen by some, as a human rights abuse. This raise ethical issues in the use of antipsychotic drugs with schizophrenia patients.

Question 45

Psychological Explanation : Family Disfunction : Schizophrenogenic Mother

Answer 45

Fromm-Reichmann (48) noted that many of her patients spoke of a particular type of parent - SCHIZOPHRENOGENIC MOTHER which literally means ‘schizophrenia-causing mothers are cold, rejecting and controlling and create a family climate of tension and secrecy.
This leads to distrust which develops into paranoid delusions and ultimately schizophrenia.

Question 46

Psychological Explanation : Family Disfunction : Double Bind Theory

Answer 46

Bateson et al (1972) described how a child may be regularly trapped in situations where they fear doing the wrong thing but receive conflicting,messages about what counts as wrong
It is not an innate mental disorder but instead is a learned confusion in thinking.
When the child gets it wrong, the child is punished by withdrawal of love – they learn that the world is confusing and dangerous.

Question 47

Psychological Explanation : Family Disfunction : Causes of Double Bind

Answer 47

This leads to disorganised thinking and delusions
Leads to difficulties in communication, high levels of interpersonal conflict
The child doesn’t know how to respond to the conflict between the words and the body language
They cannot express their feelings about the unfairness of the situation
If the child cannot resolve the confusion, then he/she is in a double bind situation. This causes confusion and leads to a state of internal conflict.
Prolonged exposure to such interactions prevents the development of an internally coherent construction of reality.

Question 48

Psychological Explanation : Family Disfunction : Expressed Emotion

Answer 48

Links more to why they may relapse.
This is the level of emotion expressed toward the schizophrenic patient, it includes: verbal criticism of the patient, hostility toward them, emotional over-involvement in their life.
High EE families talk more listen less in a critical or hostile manner
Links to verbal criticism, hostility, emotional over involvement
The theory proposes that a high level of EE within the home of the schizophrenic can: Worsen the prognosis (the outcome, could be that more likely to relapse) in patients with schizophrenia, Increase the likelihood of relapse and readmission into hospital for the patient.

Question 49

Psychological Explanation : Family Disfunction : Expressed Emotion (verbal criticism)

Answer 49

Critical attitudes are combinations of hostile and emotional over-involvement. It shows an
openness that the disorder is not entirely in the patients control but there is still negative
criticism.

Question 50

Psychological Explanation : Family Disfunction : Expressed Emotion (hostility)

Answer 50

Hostility is a negative attitude directed at the patient because the family feels that the
disorder is controllable and that the patient is choosing not to get better. Problems in the
family are often blamed on the patient.

Question 51

Psychological Explanation : Family Disfunction : Expressed Emotion (emotional over involvement)

Answer 51

The family member shows a lot of concern for the patient and the disorder. This is the
opposite of a hostile attitude, but still has the same negative effect on the patient as it makes
the patient feel guilty. The pity from the relative causes too much stress and the patient
relapses to cope with the pity.

Question 52

A03 : Psychological Explanation : Family Disfunction : evidence to link

Answer 52

+ There is evidence linking family dysfunction to schizophrenia
Read et al (2005) reported adults with schizophrenia are disproportionately likely to have insecure attachment (Type C or D). 69% of women and 59% of men with schizophrenia have a history of physical and/or sexual abuse. This suggests that family disfunction can make people more vulnerable to Sz.

Question 53

A03 : Psychological Explanation : Family Disfunction : no evidence for importance

Answer 53

• There is almost no evidence to support the importance of traditional family-based theories
  e.g. schizophrenogenic mother and double bind. Both theories are based on clinical observation of patients and informal assessment of the personality of the mothers patients. This means that family disfunction explanations cannot explain the link between childhood trauma and Sz.

Question 54

Psychological Explanation : Cognitive Explanations

Answer 54

The cognitive explanation of schizophrenia is based around the idea of faulty information processing and faulty thinking. In non-schizophrenic brains, we are able to filter incoming stimuli and process them to extract meaning. It is thought that these filtering mechanisms and processing systems are defective in the brains of schizophrenics.

Question 55

Psychological Explanation : Cognitive Explanations : Dysfunctional Thought Process

Answer 55

Lower levels of information in some areas of the brain suggests cognition is impaired – reduced processing within the ventral striatum is associated with negative symptoms.
Also explain metacognitions where a schizophrenic is not aware of their thoughts or what they are feeling (explains positive symptoms were they lose touch with reality).

Question 56

Psychological Explanation : Cognitive Explanations : Dysfunctional Thought Process : Metarepresentation

Answer 56

Metarepresentation =Hallucinations
Metarepresentation is the cognitive ability to reflect on thoughts and behaviours.
Frith et al (1992) Hypervigilance leads to excessive attention on auditory stimuli and difficulty to distinguish between imaginary and sensory-based perception.
This dysfunction disrupts our ability to recognise our thoughts as our own leads to the sensation of hearing voices and having thoughts placed in the mind by others.

Question 57

Psychological Explanation : Cognitive Explanations : Dysfunctional of central control

Answer 57

Frith et al (1992) also identified dysfunction of central control as a way to explain speech poverty – central control being the cognitive ability to suppress automatic responses while performing deliberate actions.
People with schizophrenia experience derailment of thoughts and spoken sentences because each word triggers automatic associations that they cannot suppress.

Question 58

A03 : Psychological Explanation : Cognitive Explanations : Evidence for dysfunctional thought processing

Answer 58

+ There is evidence for dysfunctional thought processing
Stirling et al (06) compared 30 patients with schizophrenia with 18 non-patients on cognitive tasks (stroop test = have to read the colour of the font of the colours, e.g. word black in red font = say red). Schizophrenic patients took twice as long as the control group to supress the impulse to read the word and name the ink colour. This shows that the cognitive processes of people with sz are impaired.

Question 59

A03 : Psychological Explanation : Cognitive Explanations : only proximal origins explained

Answer 59

• Only proximal origins of symptoms explained
  Cognitive explanations are proximal (now in the moment) because they explain what is happening now to produce symptoms (distal explanations focus on what initially caused the condition e.g.genetic, family dysfunction) (distal = things in the past). It is unclear how genetic variation or childhood trauma might lead to problems with metarepresentation or central control. This means that cognitive theories on their own only provide partial explanations for schizophrenia.

Question 60

Psychological Treatment : CBT

Answer 60

NICE recommends everyone with schizophrenia should be offered CBT to help patients deal with residual symptoms which persist despite antipsychotic drugs.
Distorted beliefs negatively influence feelings and behaviour. Delusions results from faulty interpretations of events.
Between 5-20 sessions total, one-to-one or group.
Patients are encouraged to evaluate content of their delusions/voices to test validity of beliefs, THEN change them.
Patients helped to make sense of how their delusions/hallucinations impact on their feelings and behaviour.
Distorted thinking and maladaptive beliefs are identified with the help of the therapists, looking for alternative explanations and coping strategies.

Question 61

Psychological Treatment : Features of CBT

Answer 61

Assessment: patient expresses their thoughts/goals using their distress as motivation for change.
Engagement: the therapist empathises with the patient’s perspective and distress.
The ABC model: activating events (voices), Beliefs (voices are mean and hostile) and emotional Consequences (sorrow, depression) are discussed. Irrational beliefs are,disputed (challenged).
Normalisation: patients are reassured that many people have hallucinations and
delusions when they are stressed. This help patients to feel less anxious about their
symptoms, and to believe in the possibility of recovery.
Critical Collaborative Analysis: the therapist uses gentle questioning to challenge
the patients beliefs, in an atmosphere of trust and non-judgemental acceptance.
Developing Alternative Explanations: the patient develops their own alternative
explanations for previously unhealthy assumptions, with the support of the therapist.

Question 62

Psychological treatment: Turkington et al

Answer 62

Turkington et al (2004)
▪ Treated a paranoid client who believed the Mafia were plotting to kill him
▪ The therapist acknowledged the client’s anxiety, and explained that there were other, less frightening possibilities and gently challenged the client’s evidence for his belief in the Mafia explanation

Question 63

A03 : Psychological Treatment : Lack of availability of CBT

Answer 63

• Lack of availability of CBT: only 1 in 10 patients who could benefit are able to access CBTp
  in the UK BUT some refuse treatment or fail to attend

Question 64

A03 : Psychological Treatment : evidence for effectiveness of CBT

Answer 64

+ There is evidence for the effectiveness of CBT
▪ Jauhar et al (2014): reviewed 34 studies of CBT for Sz and found CBT had a significant but small effect on positive and negative symptoms.
▪ Pontillo et al (2016): found reductions in auditory hallucinations
▪ NICE (2019) recommends CBT for people with Sz
This means that research and clinical experience suggest CBT is seen to reduce the symptoms of Sz whilst reducing side effects (antipsychotics have worse side effects).

Question 65

A03 : Psychological treatment: the quality of the evidence

Answer 65

• The quality of the evidence
  ▪ Thomas (2015): different studies have focused on different CBT techniques and people with different symptoms
  ▪ Modest benefits of CBT for Sz may conceal a range of effects of different techniques on different symptoms
  ▪ Some studies fail to randomly allocate patients to conditions, others fail to mask conditions for assessors. This weakens the validity of conclusions of meta-analyses.
  This means it will be hard to say that CBT can be effect for all people with Sz.

Question 66

Psychological treatment: family therapy

Answer 66

Family therapy attempts to help the family find more positive ways of dealing with the stress of life with a family member with schizophrenia.
This should reduce relapse rate, as it has been found that those withhigh EE families have a high risk of relapse.
In particular it aims to reduce levels of expressed emotion.
Around 10 sessions over 3-12 months are offered aiming to reduce EE and stress in a family

Question 67

Psychological treatment: family therapy (4 points on how it works - Pharoah 2010)

Answer 67

Reduces the emotional climate in the family
Reducing expressions of anger and guilt by family members
Gets everyone’s voice heard to reduce tensions
Gives everyone in the family all the information they need to understand the illness.

Question 68

Psychological treatment : family therapy - Burbach’s Model

Answer 68

Burbach’s (2018) Model
▪ Phases 1 and 2 – share information and identify resources family can offer
▪ Phases 3 and 4 – learn mutual understanding, and look at unhelpful patterns of interaction
▪ Phases 5, 6 and 7 – skills training (e.g. stress management techniques), relapse prevention and maintenance

Question 69

A03 : Psychological Treatment : Evidence for effectiveness of family therapy

Answer 69

+ There is evidence for the effectiveness of family therapy
▪ McFarlane (2016): concluded family therapy is effective for Sz, relapse rates were reduced by 50-60%
▪ Family therapy is particularly promising during time when mental health initially starts to decline
▪ NICE recommends family therapy
This means it’s good for people with early and full Sz, (good at any stage)

Question 70

A03 : Psychological Treatment : family therapy beneficial for whole family

Answer 70

+ Family therapy is beneficial for the whole family
▪ Lobban and Barrowclough: therapy is not just for the benefit of the patient but also the families that provide the majority of the care for the person with Sz
▪ Family therapy lessens the negative impact of Sz on the family,and strengthens the ability of the family to give appropriate support
This means has wider benefits beyond treating just the patient

Question 71

A03 : Psychological treatment: family therapy: Pharoah

Answer 71

+ Pharoah (10) Compared outcomes from family therapy to treatment to treatment involving medication alone. There were MIXED RESULTS in mental state of the patients. Increased compliance with medication. Some improvements in general functioning, but no effect,on independent living or employment. Reduction in the risk of,relapse and hospital admission during family therapy and for 24,months after. This supports the view that treating the whole family is beneficial.

Question 72

Management of Sz : What is token economy + what does it link too?

Answer 72

A form of therapy where desirable behaviours are encouraged by the use of selective reinforcements. Behaviour can be shaped by the use of positive and negative reinforces (Operant Conditioning).
They are used on those who have developed patterns of maladaptive behaviour through spending long periods of time in psychiatric hospitals (institutionalised) - common to develop bad hygiene habits.
It WILL NOT CURE schizophrenia but it improves the quality of life!

Question 73

Management of Sz : Development of Token Economies

Answer 73

Ayllon and Azrin (1968) used a token economy in a Sz ward
▪ A gift token was given for every tidying act - later swapped for privileges e.g. films
▪ Token economies were used extensively during the 1960s and 70s but then declined in the UK due to a shift towards care in the community
▪ Token economies remain a standard approach to managing Sz in many parts of the world

Question 74

Management of Sz : Rationale for Token Economies

Answer 74

Institutionalisation occurs in long-term hospital treatment
Matson et al (2016) identified three categories of institutional behaviour that can be tackled
▪ Personal care
▪ Condition-related behaviours e.g. apathy
▪ Social behaviour
Modifying these behaviours does not cure but does have benefits
▪ Improved quality of life
▪ ‘Normalises’ behaviour

Question 75

Management of Sz : Token Economy (link to primary and secondary _)

Answer 75

Tokens (coloured discs) are given immediately after a desirable behaviour - target behaviours are decided individually based on the knowledge of the person (Cooper et al 2007). Token given immediately because delayed rewards are less effective.
Negative symptoms of schizophrenia (social withdrawal) means the patient may neglect self-care (washing). Token economy can be used to encourage positive behaviours using operant conditioning.
Primary reinforcers – anything that gives pleasure and is directly rewarding (food/TV time)
Secondary/Generalised reinforcers – no value, but can be swapped a range of different primary reinforcers (these have a more powerful effect)

Photo on docs

Question 76

A03 : Management of Sz : Evidence of effectiveness

Answer 76

+ Glowacki et al (2016) identified seven high quality studies published between 1999 and 2013 on the effectiveness of token economies in a hospital setting. All the studies showed a reduction in negative symptoms and a decline in frequency of unwanted behaviours. This supports the value of token economies.
However seven studies is quite a small evidence base. One issue with such a small number of studies is the file drawer problem (bias towards publishing positive findings). This means that there is a serious question over the effectiveness of token economies.

Question 77

A03 : Management of Sz : Ethical issues

Answer 77

• Professionals have the power to control people’s behaviour and this means imposing one person’s norm on the others (e.g. a patient may like to look scruffy). Also restricting the availability of pleasures to people who don’t behave as desired means that very ill people, already experiencing distressing symptoms, have an even worse time. This means that benefits of token economies may be outweighed by the impact on freedom and short term reduction in quality of life.

Question 78

A03 : Management of Sz : More pleasant and ethical alternatives exist (Chiang et al 2019)

Answer 78

• Other approaches do not raise ethical issues (e.g. art therapy is a high gain low risk approach to magazine Sz (Chiang et al). Even if the benefits of art therapy are modest, this is true for all approaches to treatment and management of Sz and art therapy is a pleasant experience. This means that art therapy might be a good alternative to token economies (no side effects or ethical abuses).

Question 79

A03 : Management of Sz : Extra Evaluation

Answer 79

+Token economies help to make patients behaviour more socially acceptable, HOWEVER they do not cure schizophrenia
-Problems may arise that once the tokens stop, then desirable behaviour may stop.
- Patients may only be presenting desirable behaviour to get a reward and not understand WHY they are doing the behaviour.

Question 80

Interactionist Approach : The Diathesis-Stress Model

Answer 80

▪ The interactionist also is also known as the biosocial approach.
▪ Explains mental disorders as the result of an interaction between biological (diathesis) and psychological (stressors) factors
▪ The diathesis-stress model says that both vulnerability to schizophrenia and a stress-trigger are necessary to develop the condition.

Diathesis = a predisposition to develop a medical condition
Stress = any environmental factor that could trigger the disorder

Question 81

Interactionist : 1st thinking : Gene + stress

Answer 81

1st thinking: Gene + Stress = Schizophrenia
▪ Meehls model was entirely genetic, due to a single schizogene..
▪ Meehl (62) argues that someone without schizogene should never develop schizophrenia, no matter how much stress they were exposed to.
▪ But a person who does have the gene is vulnerable to the effects of chronic stress (schizophrenogenic mother).

Question 82

Interactionist : modern understanding

Answer 82

Modern Understanding of Diathesis
▪ Schizophrenia has a genetic component. MZ twins of schizophrenic parents are at greater risk of developing it than siblings or DZs. However the concordance rate for MZs is only 50%, showing environmental factors must play a part.
▪ Now it is believed many genes increase vulnerability.
▪ Diathesis does NOT have to be genetic, it can be early psychological trauma (affects brain development).
▪ Child abuse affects the HPA system (hypothalamic- pituitary-adrenal) – makes child vulnerable to stress.
▪Anything that risks triggering schizophrenia, this includes psychological stress.
▪A lot of research looks at cannabis usage, cannabis is a stressor because it increase that risk of schizophrenia by up to 7 times.
▪This is due to the fact that cannabis interferes with the dopamine system.
▪That said not everyone that uses cannabis develops schizophrenia, so it seems there must be more vulnerability factors.
▪Further findings suggest living in densely populated areas increase the risk of developing schizophrenia.
▪ Vassos (12) risk of schizophrenia in densely populated urban areas were 2.37 times higher than rural

Question 83

Interactionist : treatment

Answer 83

▪Turkington (06) suggests it is not possible to adopt an entirely biological approach, tell patients their condition is entirely biological then treat them with CBT
▪We cannot adopt a purely biological approach and say the cause is due to chemical imbalances then treat with CBT, the two must interact.
▪ Furthermore the idea that combining two treatments can highly improve the effectiveness of the treatments in reducing the symptoms of schizophrenia.
Anti-psychotics + Anti-depressants = to treat negative symptoms
Anti-psychotics + assertive community therapy = gets patients back to work in the community
Anti-psychotics + CBT = to treat positive and negative symptoms
Anti-psychotics + Family therapy = cures dysfunctional family problems
Anti-psychotics + Mindfulness = treats positive symptoms.
▪ Drugs are used to stabilise the patient and the other methods are useful in order to try to treat the disorder.
▪In the UK it is standard practice to treat patients with a combination of drugs and CBT
▪In the US there is more conflict between biological and psychological approaches – slower adoption of the interactionist approach as a result

Question 84

Interactionist : Key Research : Tienari et al

Answer 84

Tienari et al. (2004) carried out a prospective study of 19 000 Finnish children adopted away from their biological family who had mothers diagnosed with Sz. They also assessed the rearing style of the adoptive family. They compared this group with a group of children with no parent diagnosed with Sz. After 21 years they found that in adoptees at high genetic risk of Sz, but not in those at low genetic risk, an adoptive-family with a high level of criticism and conflict was a significant predictor of schizophrenia. This suggests that either factor on its own does not cause Sz but when combine they increase the risk of developing the disorder.

Question 85

A03 : Interactionist : Tienerai et al

Answer 85

+ Tienerai et al (2004) show that combination of genetic vulnerability and family stress leads to an increased risk of Sz. Also show there is a clear practical advantage to adoption an interactionist approach in the form of superior treatment outcomes (refer to revision guide p.137 or digital textbook p. 215)

Question 86

A03 : Interactionist : Hogarty

Answer 86

+ Hogarty (86) looked at relapse rates of schizophrenia patients: drug therapy alone had a relapse rate of 41% but combined with family therapy relapse rates decreased to 19% and with social support therapy 20%. Cheaper in the long run as it reduces hospitalisation.

Question 87

A03 : Interactionist: genetic influences cause

Answer 87

• Most Diathesis-stress models assume that genetic influences cause neurochemical abnormalities, which result in increased risk of schizophrenia. However brain damage, caused by oxygen deprivation during birth, increases the chance of having schizophrenia by 4 times (not biological).

Question 88

A03 : Interactionist: multiple genes increase vulnerability

Answer 88

• Multiple genes increase vulnerability, each with a small effect on its own, there is NO schizogene. Stress comes in many forms, Houston (08) found childhood sexual trauma was a diathesis and cannabis use a trigger. This demonstrates the original diathesis-stress model is too simplistic.

Question 89

A03 : Interactionist: strong evidence

Answer 89

• There is strong evidence to suggest that some sort of underlying vulnerability coupled with stress can lead to schizophrenia. But we don’t understand the mechanisms by which symptoms of schizophrenia appear and how both vulnerability and stress produce them.