Schitzophrenia

Question 1

Classification of schizophrenia

Answer 1

• DSM 5 = one positive and at two negative symptoms of schizophrenia
• ICD-10= Two or more negative symptoms of schizophrenia

Question 2

Positive symptoms

Answer 2

additional experiences beyond those ordinary existence
- hallucinations= either have no basis in reality or distorted perceptions of things that are not there
- delusions= have no basis in reality
- grandeur= believe they are an important historical figure e.g. Jesus
- persecution= e.g. the government
-of the body= suffered may feel there body is under external control
- of thoughts

• speech disorganisation= speech is incoherent or speaker changes topic mid sentence

Question 3

Negative symptoms

Answer 3

Loss of usual abilities and experience s

-avolition= finding it difficult to begin or keep up with either goal- directed activity due to lack of motivation. E.g. poor hygiene, work/education

-speech poverty= reduction is the amount of speech. Often accompanied by a delay in the suffers verbal response during a conversation.

Question 4

Evaluation of schizophrenia to do with reliability

Answer 4

-low-inter reliability= the extent to which two or more mental health professionals arrive at the same diagnosis for the same patient. Cheniaux et al (2009) has two psychiatrist diagnose 100 patients using both DSM and ICD criteria. One psychiatrist diagnosing 26 with schizophrenia according to DSM and 44 according to ICD, the other 13 according to DSM and 24 according to ICD.

ALSO has poor validity= different assessment systems arrive at the same diagnosis. Using cheniaux et al study is seen schizophrenia is more likely to be diagnosed using the ICD than DSM. So may be over-diagnosed in ICD or under-diagnosed in DSM.

Question 5

Biological explanations for schizophrenia ( the genetic bias)

Answer 5

Gottesman (1991) found that as genetic similarity increases so does the probability of sharing schizophrenia. E.g. first cousins has a 2%, DZ 17% chance whereas identical twins have 48%.

-schizophrenia is found to be polygenic because different studies have identified different candidate genes.

• Stephen Ripke et al (2014) carried out a study combining all previous data from genome-wide studies of schizophrenia. The genetic makeup of 370000 patients was compared to that of 113000 controls, 108 separate genetic variation were associated with risk of schizophrenia which included those coding for the functioning of a number of neurotransmitters including dopamine .

Question 6

Evidence for the biological explanation of schizophrenia ( genetic bias)

Answer 6

-gottesman (1991) shows how genetic similarity and shared rush of schizophrenia are closely related.

-Tiernari et al (2004) adoption study shows that children of schizophrenia suffered are still at heightened risk of schizophrenia if adopted into families with no history of schizophrenia.

-Ripke et al (2014) found that particular genetic variations significantly increases the risk of developing schizophrenia.

Question 7

psychological explanations-schizophrenic mother

Answer 7

–Fromm-reichm noted that many of her patients spoke of a particular type of parent in which she called the schizophrenic mother which is cold,rejecting and controlling and tend to create a family climate characterized by tension and secrecy. this tend to leads to distrust that later develops into paranoid delusions, and ultimately schizophrenia

Question 8

psychological explanations- cognitive explanations

Answer 8

• Frith et al identified two types of dysfunctional thought processing that could underlie symptoms

-metarepresentation= leads to the inability to recognize our own actions and thoughts as
being carried out by ourselves rather than someone else. this would explain hallucinations of voices and delusions

-central control= the cognitive ability to suppress automatic responses while we perform deliberate actions. the inability could result in disorganised speech and though disorder.,g, schizophrenic suffers tend to experience derailment of thoughts and spoken sentences each word triggers a new associations, and patient cannot suppress automatic responses to theses

Question 9

evaluation of psychological explanations to do with evidence

Answer 9

there is a lot of evidence:
-Read et al reviewed fourty six studies of child abuse and schizophrenia and concluded that 69% of adult women with a diagnosis experience abuse being physical,sexual or both in childhood. men had 59%/

-adults with an insecure attachment were also more likely to develop schizophrenia.

-HOWEVER, most of this evidence was gathered after the patient already showed symptoms of schizophrenia so recall of their childhood may have been distorted lowering the validly. Tienari et al followed up children following childhood experiences to see if they predicted any adult characteristics. There is prospective evidence linking family dysfunction to schizophrenia but not a huge amount

Question 10

biological therapies for treating schizophrenia=drug therapies

Answer 10

• chlorpromazine= 50s. initally dosages are smaller for most patients but it gradually builds upulot by binding to blocking dopamine receptors in the synapse of the brain, reducing the action of dopamine which in tern normalizes transmission in key areas of the brain, reducing symptoms like schizophrenia

Typical( first generation)

-clozapine=60s.used when other treatments failed and patients have to take regular blood test to ensure they are not developing agranulocytosis.. Binds to receptors in the same way as chlorpromazine but alos serotonin and glutamate receptors. the action helps improve mood and reduce depression and anxiety in patients and may improve cognitive functioning. it is sometimes prescribed to patients at risk of suicide which is common in people suffering.

-risperidone= 90s. binds to dopamine and serotonin receptors but binds more strongly to dopamine receptors than clozapine so is therefore effective in smaller doses. there is some evidence to suggest that this leads to fewer side effects.

ATYPICAL (after typical drugs), 50s)

Question 11

Evaluation of biological therapies( drug therapies) evidence,side effects

Answer 11

-lots of evidence to support effectiveness for atypical and typical antipsychotics.
-Thornley et al (2003) reviewed studies comparing the effects of chlorpromazine to control conditions in which patients received a placebo.
Typical =Data from 13 trials with a total of 1121 participants showed that chlorpromazine was associated with overall better functioning and reduced symptoms of severity. Data from 3 trials with a total of 512 participants showed that relapse rate was also lower when chlorpromazine was taken.
Atypical = Melzer (2012) concluded that clozapine is more effective than typical antipsychotics and other atypical antipsychotics and in 30-50% of treatment-resistant cases where typical antipsychotics failed.
- despite evidence , Healy(2012) has suggested that some successful trials have had their data published multiple times, exaggerating the evidence for positive effects. Also because they have a calming effect, it is easy to that they have some positive effect on patients which is not the same as saying they reduce severity of psychosis. AND most published studies access short-term benefits and not long term.

• serious side effects. Typical antipsychotics= dizziness,agitation,sleepiness,stiff jaw,weight gain and itchy skin. Long term use can result in tardive dyskinesia which is caused by dopamine hypersensitivity manifesting in involuntary face movements such as blinking or lip smacking. Neuroleptic malignant syndrome (NMS) is the most serious side effect. Caused by the drug blocking dopamine action in the hypothalamus. This results in high temperature, delirium and coma which can be fatal.
• although Atypical drug were developed to reduce side effects they still exist. E.g. patients taking clozapine have regular blood tests
• depend if the dopamine hypothesis= evidence shows that the the original dopamine hypothesis such as…. Is not a complete explanation of schizophrenia and dopamine levels are in other parts of the brain are too low rather than too high. If true then it’s not clear how antipsychotic, which are dopamine antagonists can help with schizophrenia when they reduce dopamine activity. Modern understanding suggests antipsychotic shouldn’t work therefore this has undermined the faith of some people that they do work

Question 12

Psychological therapies

Answer 12

• CBT =aim involves helping patients identify irrational thoughts and trying to change them.
  -usually takes place between 5 and twenty sessions.
  -may involve arguments or a discussion of how likely the patients beliefs are to be true, and a consideration of other less threatening possibilities. can help patients be able to cope with symptoms better

-family therapy=aims to improve the quality of communication and interaction between family members. Nowdays most family therapy are more concerned with reducing stress within the family that might contribute to the patients risk of relapse.
-pharoah et al (two thousand and ten) identified a range of stratergies by which work by reducing levels of stress and expressed emotion whilst increasing the chances increasing the chance of patients complying with their medication.combination of benefits result in the reduced likelihood of relapse and re admission to hospitals

-token economies= reward systems used to manage the behavior of patients with schizophrenia, in particular those who have developed maladaptive behavior through being institutionalised in psychiatric hospitals. patients under these condition tend to develop bad habits such as bad hygeine so modifying theses bad habitats may improve the patients quality of life and make it more likely they can live outside a hospital setting. Tokens are given to patients once they perform a desirable behaviour such as getting dressed or making the bed as reinforcement.
- although the tokens have no value itself they can be swapped later for more tangible rewards e.g. sweets, cigarettes etc..
- based on operant conditioning in which the tokens are secondary reinforcers as they only have value once the patient has learned they can obtain a reward.

Question 13

evaluation of pyschological therapies

Answer 13

• Limitation is there is only modest support for the effectiveness of psychological treatments,
  -jauahr et al (Fourteen) reviewed the result of CBT for schizophrenia. they concluded that CBT has a significant but fairly small effect on both positive and negative symptoms.

Pharoah et al. reviewed the evidence for the effectiveness of family therapy for families of schizophrenia sufferers. They concluded that there is moderate evidence to show that family therapy significantly reduces hospital readmission over the course of a year and improves quality of life for patients and their families. However, they also noted that results of different studies were inconsistent and that there were problems with the quality of some evidence. Overall then the evidence base for family therapy is fairly weak. - - - (McMonagle and Sultana 2009) who studied evidence for Token economy found only three studies where patients had been randomly allocated to conditions, with a total of only 110 patients. Random allocation is important in matching patients to treatment and control groups. Only one of the three studies showed improvement in symptoms and none yielded useful information about behaviour change.

• All the psychological treatments for schizophrenia aim to make schizophrenia more manageable and in some way improve patients’ quality of life. CBT helps by allowing patients to make sense of and in some cases challenge some of their symptoms. Family therapy helps by reducing the stress of living with schizophrenia in a family, both for the patient themselves and other family members. Token economies help by making patients’ behaviour more socially acceptable so that they can better re-integrate into society. These things are all worth doing, but should not be confused with curing schizophrenia. Of course biological treatments do not cure schizophrenia either but they do reduce the severity of some symptoms.
  This failure to cure schizophrenia is a weakness of psychological treatments.
• • Talk about maybe drug therapies therefore being more effective and a study that shows this*

Although psychological treatments for schizophrenia do not have the serious side effects or medical risks of drug treatments, they can raise ethical issues. In particular token economy systems have proved controversial. The major issue is that privileges, services, etc., become more available to patients with mild symptoms and less so for those with more severe symptoms of schizophrenia that prevent them complying with desirable behaviours.
This means that the most severely ill patients suffer discrimination in addition to other symptoms, and some families of patients have challenged the legality of this. This has in turn reduced the use of token economies in the psychiatric system.
Other psychological therapies can raise additional issues. CBT may involve, for example, challenging a person’s paranoia, but at what point does this interfere with an individual’s freedom of thought? If, for example, CBT challenged a patient’s beliefs in a highly controlling government, this can easily stray into modifying their politics.
Ethical issues like this are a weakness of psychological treatments for schizophrenia.

• link to issues and debates free will
• also There are other psychological therapies that can be helpful for some people with schizophrenia that are less well-known and less likely to be available to patients.
  For example, the National Institute for Health and Clinical Excellence (NICE) recommends art therapy, provided a qualified art therapist with experience of working with schizophrenia sufferers is available. May have less ethical issues

Question 14

The interactionist approach - original diathesis- stress model

Answer 14

The diathesis-stress model says that both a vulnerability to schizophrenia and a stress-trigger are necessary in order to develop the condition
- In the original diathesis-stress model (Meehl 1962) diathesis (vulnerability) was entirely genetic, the result of a single ‘schizogene’. This led to the development of a biologically based schizotypic personality. According to Paul Meehl, if a person does not have the schizogene then no amount of stress would lead to schizophrenia. However, in carriers of the gene, chronic stress through childhood and adolescence, in particular the presence of a schizophrenogenic mother could result in the development of the condition.

Question 15

Evidence of the interactionist approach

Answer 15

• there is evidence to support the dual role of vulnerability and stress in the development of schizophrenia.Tienari et al. (2004) investigated the combination of genetic vulnerability and parenting style (the trigger). Children adopted from 19,000 Finnish mothers with schizophrenia between 1960 and 1979 were followed up. Their adoptive parents were assessed for child-rearing style, and the rates of schizophrenia were compared to those in a control group of adoptees without any genetic risk. A child-rearing style characterised by high levels of criticism and conflict and low levels of empathy was implicated in the development of schizophrenia but only for the children with high genetic risk but not in the control group. This suggests that both genetic vulnerability and family-related stress are important in the development of schizophrenia. Which supports the model

Question 16

Evaluation of classification of schizophrenia to do with co- morbidity’s and symptom overlap

Answer 16

• co-morbidity’s= if conditions occur together a lot of the time calls in to question the validity as it may be a single condition.
  Peter Buckley et al(2009) concluded 50% of people diagnosed with schizophrenia have depression, 47% abuse substance. It may be the case that we are bad at telling the difference between the two and severe cases of depression looks a lot like schizophrenia so may be a single condition.

ALSO, there are symptom overlaps.e.g. Both schizophrenia and bipolar disorder involve positive symptoms like delusion and negative symptoms like avoliton. Calls into question both the classification and diagnosis of schizophrenia. Under ICD a patient may be diagnosed as a schizophrenic, however the same patient would receive bipolar disorder according the DSM. Both condition may not also be two separate but single.

Question 17

Evaluation of classification of schizophrenia to do with bias

Answer 17

–studies found in the 1980s men are more likely to be diagnosed with schizophrenia rather more often than women. May be because men are genetically vulnerable than women or may be a result of gender bias. Females typically function better than men, being more likely to work and have good family relationships. May lead to under diagnosis

ALSO
- African Americans and English people of Afro-Caribbean are more likely to be diagnosed than white people. Give. The rates are not particularly high in Africa and the West Indies this is not due to genetically vulnerability. Therefore may be issues of culture bias. Positive symptoms such as hearing voices may be more acceptable in African cultures but seem as irrational in other cultures. Escobar (2012) pointed out that white psychiatrist may tend to over-interpret symptoms and distrust the honestly of black people during diagnoses

Question 18

Biological explanation for schizophrenia (the dopamine hypothesis)

Answer 18

– hyperdopaminergia in the subcortex= high levels/activity of dopamine in the subcortex e.g. an excess of dopamine receptors in Broca’s area( associated with speech production) may be associated with poverty of speech and the experience of auditory hallucinations
- hypodopaminergia in the cortex= Low levels in the prefrontal cortex ( thinking and decision making) has a role in negative symptoms of schizophrenia such as avolution.

Question 19

Biological explanation for schizophrenia (neural correlates)

Answer 19

– neural correlates of negative symptom avolution= activity of ventral striatum which is believed to be involved in creating anticipation of a reward which creates motivation. Jucket et al (2006) found lower levels of activity in the ventral striatum than those observed in controls. They observed a negative correlation between activity levels in the ventral striatum and the severity of overall symptoms.

Neural correlate of positive symptoms= Allen et al (2007) scanned brains of patients experiencing auditory hallucinations and compared to a control group whilst they identified pre-recorded speech as their own or others. Lower activity in the superior temporal gurus and anterior cingulate gyrus were found in the hallucination group, who also made more errors than the control group. Therefore reduced activity in the two areas of the brain is a neural correlate of auditory hallucinations

Question 20

Psychological explanation- double blind theory

Answer 20

-bateson et al emphasised the role of communication style within a family. the developing child finds themselves trapped in situations where they fear doing the wrong thing, but received mixed feelings about what this is. when they get it wrong the child is often punishment by withdrawal of love therefore they are unable to seek clarification. This leaves them with understanding the world as confusing and dangerous, and is reflected in symptoms like disorganised thinking and paranoid delusions.

Question 21

Psychological explanation- expressed emotion

Answer 21

the level of negative emotion expressed towards a patient by their carers
contains several elements:
-verbal criticism of the patient,occasionally accompanied by violence
-Hostility towards the patient
-emotional over-involvement in the life of the patient

• this is a source of stress in the patient and believed to be the primary explanation for relapses and can trigger the onset of schizophrenia in a person who is already vulnerable.

Question 22

Evaluation of psychological explanations of schizophrenia- to do with the schizogenic mother and expressed emotion

Answer 22

-Although there is a broad amount of evidence that childhood experiences lead to schizophrenia there is none amount the schizophrenic mother and the double-blind theory. Both based on clinical observations of patients, and early evidence involved assessing the personality of mothers of patients for ‘crazy-making characteristics’ in which psychologist are reluctant to do.

• Also has led to historically parent blaming. parents arguably have already suffered at seeing their child’s descent into schizophrenia and likely have to bear the lifelong responsibly for caring for the child therefore they undergo further trauma by being blamed. adding insult to injury. parents no longer tolerate the blame which may have lead to the decline of theses theories

Question 23

Evaluation of psychological explanation to with cognitive explanations

Answer 23

-Stirling et al (06) compared thirty patients with schizophrenia to eighteen non-patients controls on a range of cognitive tasks including the strop test whereby participants have to name the ink colours of colour words, suppressing the impulse to read the words in order to do the task. i line with Friths central control theory central control dysfunction, patients took twice as long to name the ink colour as the control group. problem with cognitive explanations is that they do not tell us the origin of those cognition’s or of schizophrenia. they can explain the proximal causes of schizophrenia. e.g. what causes currents symptoms but not the distal causes

Question 24

The interactionist approach- modern day diathesis stress model

Answer 24

Modern day understanding of the stressor
-it is now clear that many genes each appear to increase genetic vulnerability slightly; there is no single ‘schizogene’ (Ripke et al. 2014). Modern views of diathesis also include a range of factors beyond the genetic, including psychological trauma - so trauma becomes the diathesis rather than the stressor. Read et al. (2001) proposed a neurodevelopmental model in which early trauma alters the developing brain. Early and severe enough trauma, such as child abuse, can seriously affect many aspects of brain development. For example the hypothalamic-pituitary-adrenal (HA) system can become over-active, making the person much more vulnerable to later stress.

Modern day understanding of the stress
- In the original diathesis-stress model of schizophrenia, stress was seen as psychological in nature, in particular related to parenting. a modern definition of stress (in relation to the diathesis-stress model) includes anything that risks triggering schizophrenia (Houston et al.
2008). Much of the recent research into factors triggering an episode of schizophrenia has concerned cannabis use. In terms of the diathesis-stress model cannabis is a stressor because it increases the risk of schizophrenia by up to seven times according to dose. This is probably because cannabis interferes with the dopamine system.
However, most people do not develop schizophrenia after smoking cannabis so it seems there must also be one or more vulnerability factors.

Question 25

The interactionist approach-treatment

Answer 25

–the interactionist approach compatible with both biological and psychological treatments. In particular the model is associated with combining antipsychotic medication and psychological therapies, most commonly CBT.

-In Britain it is increasingly standard practice to treat patients with a combination of antipsychotic drugs and CBT. However, in the USA there is more of a history of conflict between psychological and biological models of schizophrenia. Thus medication without an accompanying psychological treatment is more common than in the UK

Question 26

Evaluation of the interactionist approach to be with it being over simplified

Answer 26

• The classic model of a single schizogene and schizophrenic parenting style as the major source of stress is now known to be very over-simple. Multiple genes increase vulnerability to schizophrenia, each having a small effect on its own; there is no single schizogene. Also stress can come in many forms, including but not limited to dysfunctional parenting. Therefore vulnerability and stress do not have one single source.

In fact it is now believed that vulnerability can be the result of early trauma as well as genetic make-up, and that stress can come in many forms including biological. In one recent study by James Houston et al. (2008) childhood sexual trauma emerged as a vulnerability factor whilst cannabis use was a trigger. This shows that the old idea of diathesis as biological and stress as psychological has turned out to be overly simple. Supports the new model but is a limitation of the old model

Question 27

Evaluation of the interactionist approach to do with effectiveness

Answer 27

• There is support for the usefulness of adopting an interactionist approach from studies comparing the effectiveness of combinations of biological and psychological treatments for schizophrenia versus biological treatments alone. As Turkington et al.
  (2006) point out it is not really possible to use combination treatments without adopting an interactionist approach.
  Studies show an advantage to using combinations of treatments for schizophrenia.
  For example, in one study by Nicholas Tarrier et al. (2004) 315 patients were randomly allocated to a medication + CBT group, medication + supportive counselling or a control group. Patients in the two combination groups showed lower symptom levels than those in the control group (medication only) although there was no difference in rates of hospital readmission.
  Studies like this show that there is a clear practical advantage to adopting an interactionist approach in the form of superior treatment outcomes, and therefore highlight the importance of taking an interactionist approach.