Schizo

Question 1

What is schizo

Answer 1

A severe mental illness where contact with reality and insight are impaired

Suffered by about 1% of the world population

More commonly diagnosed in men than in women

Commonly diagnosed in cities than the countryside

Question 2

Classification of schizophrenia

Answer 2

There are 2 types of classification for mental disorders

1. The diagnostic and statistical manual (DSM-V) - American psychiatric Association
2. International classification disease (ICD-10) - from WHO

These differ sightly in their classification of schizophrenia. E.g
In the DSM-5 system one of the positive symptoms MUST be present for diagnosis where a 2 or more negative symptoms are sufficient under ICD

Also ICD recognizes a range of subtypes of schizophrenia
Such as paranoid schizophrenia is characterized by powerful delusion and hallucinations but relatively few other symptoms.
Also hebephrenic schizophrenia involves primarily negative symptoms
Previous editions of the DSM system also recognized subtypes but has been dropped in DSM- 5

So the main difference is what organization produces them, the number of symptoms and the recognition of different subtypes if schizophrenia

Question 3

Positive symptoms of schizophrenia

Answer 3

Sufferers may experience negative or positive e schizophrenia

Positive symptoms of Schizophrenia atypical symptoms experienced in addition to normal experiences

1. Hallucinations- are positive symptoms of schizophrenia- are sensory experiences of stimuli they have no basis of reality or distorts perception of things that are
   there
   Such as sufferer may see distorted facial expression, people or animals that are not there. Also hearing voices commenting on the sufferer
2. Delusions- irrational beliefs- belief that have no basis of reality
   Types of delusions
   - delusions of grandeur- belief that they are impotant historical, political, religious figures like Jesus
   Delusions of persecution such as Gov.
   Delusions of control- think their actions are being under external control

Question 4

Classification of schizophrenia

Negative symptoms

Answer 4

Are Atypical experiences that involves the loss of usual abilities and experience

1. Avolition- a negative symptom of schizophrenia- involves loss of motivation to carry out task and results in lower activity levels
   Andreason identified 3 signs of avolition: poor hygiene and grooming, lack of persistence in work or education and lack of energy

2.Speech poverty- involves reduced frequency and quality of speech in schizophrenia
Such as delay in response, or uses few words as possible

Question 5

Evaluations of classification of schizo

Answer 5

1. Lacks reliability
   An important measure of reliability is inter rate relliability- in case of diagnosis it is the extent to which 2 or more mental health professionals arrive at the same diagnosis for the same patient
   Cheniaux et al- had 2 psychiatrists independently diagnosed 100 patients using both DSM and ICD criteria = inter rater reliability was poor= with 1 psychiatrists diagnosing 26 with schizo according to DSM 5 and 44 according to ICD

2 . Poor validity
One standard way to assess validity of a diagnosis is criterion validity= do different assessment systems arrive at the same diagnosis for the same patient
Looking at the figures in Cheniaux et al study we see that schizo is much more likely to be diagnosed using ICD than DSM= suggest that schizophrenia is either over diagnosed in ICD
Or under diagnosed in DSM

3.Gender bias
longenecker et al reviewed studies of the prevalence of schizo and concluded that since the 1980 men have been diagnosed with schizo more often than women
This may be due to gender bias- it appears female patient typically function better than men = bring more likely to work and have good family relationships
This means that their interpersonal functioning may bias practitioners to under diagnose schizo
This means that the current system of the diagnosis of SZ does not account for these biases in functioning between men and women= increasing likelihood of inaccurate diagnosis

Cultural bias in diagnosis
- African American and English people of Afro Caribbean are several times more likely than white people to be diagnosed with schizophrenia
- the diagnosis may be due to the issue of culture bias— positive symptoms such as hearing voices may be more acceptable in African cultures due to the culture belief in communication with ancestors
When reported to psychiatrists from a different culture = these experiences are likely to be seen as bizarre and irrational
In addition = Escobar pointed out psychiatrists may tend to over interpret symptoms and distrust the honesty of black people during diagnosis
- diagnosis lacks validity

Question 6

What are the definition of genetics and dopamine

Answer 6

Genetics are genes that consist of DNA strands
These may impact on psychological features such as mental disorders= genes are transmitted from parent to offspring

Dopamine is a neurotransmitter that genetically has excitatory effect and is associated with sensation of pleasure = unusual high level of schizo

Question 7

What is the genetic basis of schizophrenia

Answer 7

• there’s evidence that schizo runs in families and so appears to have a genetic basis

Gottesman demonstrated a positive correlation between increasing genetic similarity of family members and their increased risk of developing SZ

In his large scale family study- The concordance rates are as follows= Mz twins (48%) whereas DZ twins (17%)
Siblings (9%)
Parents (6%)
This is due to MZ twins sharing 100% of their genes = suggest there’s a genetic basis

Schizo is polygenic - there’s number of genes each appear to confer a small increase risk of schizo
Different studies have identified different candidate genes such as Ripke et al carried out a huge study combining all previous data from genome wide studies of schizo
The genetic makeup of 37, 000 patients was compared to that of 113,000 controls

Found that 108 separate genetic variation were associated with increased risk of schizo
Genes associated with and increase risk of developing schizo included those responsible for coding of the function of the neurotransmitter dopamine

Question 8

Biological explanations

The dopamine hypothesis

Answer 8

The brain chemical messenger appears to work differently in the brain of patient with schizophrenia in particular dopamine

Hyperdopaminergia in the sub cortex— the original version of the dopamine hypothesis focused on the possible role of high levels of dopamine in the sub cortex such as the central areas of the brain
For example an excess of dopamine receptors in Broca area may be associated with poverty of speech and/or the experience of auditory hallucinations

Hypodopaminergia- more recent version of the dopamine hypothesis have focused instead on abnormal dopamine systems in the brain cortex
Goldman Rakic et al have identified a role for low levels of dopamine in the prefrontal cortex in the negative symptoms of schizophrenia
It may be that both hyper and hypodopaminergia are correct explanation - both high and low levels of dopamine in different brain regions are in schizophrenia

Question 9

Biological explanations of schizophrenia
Neural correlates of schizophrenia

Answer 9

Neural correlates are measurements of the structure of the brain that correlates with an experience in this case schizo
Both police and negative symptoms have neural correlates

Neural correlates of negative symptoms - one negative symptom is avolition = involve loss of motivation
Motivation involves the anticipation of a reward and certain region such as VENTRAL STAITUM believed to be involved in this anticipation
Therefore abnormality of area like the VS= involved in development of avolition
Juckel et al found low level of activity in VS than those observed in control
Also found a negative correlation between activity levels in the VS and the severity of overall negative symptoms

Positive symptoms also have neural correlates-
Allen et al scanned the brain of patients experiencing auditory hallucinations and compared them to a control group while they identified a pre recorded speech as theirs or others
Lower activation level in the superior temporal gyrus and anterior cingulate gyrus were found in the hallucination group who also made more errors than the control group
We can say that reduce activity in these 2 areas of brain is a neural correlate of auditory hallucination

Question 10

Biological explanations of schizo - evaluations

Answer 10

1. The evidence for the dopamine hypothesis can be described as mixed
   On one hand support from Tauscher et al who found that antipsychotics = which acts as a dopamine antagonist = reduced dopamine activity = alleviated the symptoms of SZ= suggesting that dopamine has a key role in its development
   On the other hand some researcher such as Moghaddam and Javitt have criticized the dopamine hypothesis and biological explanations of SZ as emphasizing the role of dopamine too far.
   E.g. the neurotransmitter glutamate and serotonin may also play key role = evidenced by the antipsychotic Clozapine acting upon both of these substances and being more effective
   Suggest that dopamine does not provide a complete explanation of schizo
2. There are other possible explanations for the correlation
   Such as the correlation between level of activity in the central striatum and negative symptoms of schizo
   It just as possible they the negative symptoms themselves mean less info passed through the striatum = resulting reduced activity
   Also another factor can influence both negative symptoms and ventral striatum activity
   Therefore demonstrates that correlational research cannot be used to reliably demonstrate a cause and effect relationship between 2 variables

Question 11

Psychological explanations for schizophrenia

Family dysfunction

Answer 11

The schizophrenogenic mother:

Fromm- Reichmann noted that many of her patient spoke of a particular type of parent which is called the schizophrenogenic mother
Found that schizophrenogenic mother is cold, rejecting and controlling = tend to create family climate characterized u tension and secrecy= leads to distrust= later develops into paranoid delusions and ultimately schizophrenia

Double blind theory
Baterson- emphasizes the role of communication style within family= suggest that within family, child receive mixed messages from both parents about what is right or wrong
The tense atmosphere or controlling parenting style = the child is unable to clarify these messages and voice their opinions about unfairness of conflicting messages
- when a child makes a mistake= they are punished through a withdrawal of love= means the child will see the world as confusing and dangerous = is reflected in symptoms like disorganized thinking and paranoid delusion
- this is just a risk factor

Question 12

Family dysfunction
- expressed emotion

Answer 12

Expressed emotion is the level of emotion in particular negative emotion towards a patient by their carers

• EE contains several element:
  Verbal criticism of the patient ,occasionally accompanied by violence
  Hostility towards the patient, including anger and rejection
  Emotional over involvement in the life of the patient, including needles self sacrifice

These high level of EE = serious source of stress for the patient
Primarily an explanation for relapse in patient with schizo
Also suggest that the source of stress can trigger the onset of schizo in a person who is already vulnerable such as due to their genetic makeup

Question 13

Psychological explanations for schizophrenia

Cognitive explanation

Answer 13

Cognitive explanation for any phenomenon is one which focuses on the role of mental processes

The explanation sees abnormal info processing and family thinking as the cause of schizo

We can see that reduced processing in the VS is associated with negative symptoms, whilst reduced processing of info in the temporal and cingulate gyri are associated with hallucinations

This lower level of information processing suggest effects that cognition likely to be impaired

Question 14

Cognitive explanations

Dysfunctional though processing

Answer 14

Dysfunctional thought processing - info processing that not functioning normally and produces undesirable consequences

Frith et al identified 2 kinds of dysfunctional thought processing:

• metarepresentation - id the cognitive ability to reflect on thoughts and behaviour
  Allows us insight into our own intentions and goals and interpret actions of others
  Dysfunction in M would distrupt our own ability to recognize our own actions/ thought as being carried out by ourselves rather than someone else
  This would explain hallucination of voices and delusions like thought insertion

Central control- is the cognitive ability to suppress automatic responses while we perform deliberate actions instead
Disorganized speech and thought disorders could result from inability to suppress automatic thoughts and speech triggered by other thoughts

Question 15

Psychological explan for schizo

Evaluation

Answer 15

1. Support for family dysfunction as a risk factor
   - Read et al reviewed 46 studies of child abuse and schizo and concluded that 69% of adult women with diagnosed of SZ had history of physical abuse, sexual abuse or both in childhood
   For men -95%
   Berry- adults with insecure attachment to their primary carer= more likely to have schizo
   - therefore there’s a large body of evidence linking family dysfunction to schizo

2.problem with dysfunctional family explanations is that they let historically to parent blaming
- parents who have already suffered at seeing their child descent into schizo and who are likely to bear lifelong responsibility for their care= underwent further trauma by recurving blame for the condition
= this may explain the sudden popularity of community care in 1980s= which could have marked parent refusing to take responsibility for their child condition = seeing they are so dedicated to their care
- lack support of schizophrenogenic mother and double blind theories as parents no longer tolerated them

Cause and effect – It remains unclear whether cognitive factors cause schizophrenia or if schizophrenia causes these cognitions – Family dysfunction may not be a valid explanation for schizophrenia.

4. Evidence for biological factors is not adequately considered
   - since such biological factors can explain the distal origins of schizo such as dopamine levels in brain, candidate genes
   This suggest that psychological explanations would best be reserved for the proximal causes of SZ, as these causes are more likely to be most affected by psychological factors

Question 16

Biological treatment for schizo: drug therapy
Typical antipsychotic

Answer 16

First generation of antipsychotics drugs- have been used since the 1950’s

Typical antipsychotic like Chlorpromazine work by acting as an antagonist in the dopamine system
Dopamine antagonist work by blocking dopamine receptors in the synapses of the brain= reducing the action of dopamine
This dopamine antagonist effect normalizes neurotransmission in key areas of the brain= reducing symptoms like hallucinations

Chlopromazine is also an effective sedative- due to acting upon histamine receptors
Is often used to calm patients with schizo also other conditions

Can be taken as tablets, syrup or injection

Question 17

Atypical antipsychotic

Answer 17

Drugs for schizo used since 1970, developed after typical antipsychotic
The aim : was to maintain or improve upon the effectiveness of drugs in suppressing the symptoms of psychosis and also minimize the side effects

Examples as clozapine and Risoeridone

Clozapine binds to dopamine receptors but in addition it acts on serotonin and glutamate receptors
Believed that this action helps improve mood and reduce depression/ anxiety in patients, and that it may improve cognitive functioning
- the mood enhancing effect of clozapine= sometime prescribe when a patient is considered at high risk of suicide
Important as 30-50 percent of people suffering from schizo attempt suicide at some point
-is remarked as a treatment for schizophrenia or I be used when other treatment failed

Question 18

Atypical antipsychotic- risperidone

Answer 18

• is a more recently developed atypical antipsychotic- around since 1990

Developed in attempt to produce a drug as effective as Clozapine but without serious side effects like Chlorpromazine

Risperidone can be taken in form of tablet, syrup or injection

Believed to bind to dopamine and serotonin receptors
It binds more strongly to dopamine receptors than clozapine and is therefore effective in much smaller doses than most antipsychotics
There is some evident or suggest this leads to fewer side effects than is typical for antipsychotics

Question 19

What are antipsychotic

Answer 19

• drugs used to reduce the intensity of symptoms in particular positive symptoms

Question 20

Biological therapies for schizophrenia: drug therapy- evaluation

Answer 20

1. Evidence for effectiveness
   Thornley et al found in a Mets analysis that Chlorpomazine was associated with better functioning and reduced symptoms severity than placebo, supporting that the drug does have a positive effect on schizophrenia patients
   ALSO there’s support for the benefits of atypical antipsychotic- Melzer concluded that Clozapine is effective in 30-50% of cases where typical drugs have failed, supporting its use in schizo treatment
2. serious side effects
   Typical antipsychotic associated with dizziness, agitation, sleepiness, stiff jaw, weight gain and itchy skin
   Long term use can result in tardive dyskinesia = is caused by dopamine super sensitivity
   More serious side effect is neuroleptic malignant syndrome= result in high temperature, coma, and can be fatal
   - atypical antipsychotic were developed to reduce frequency of side effect and has succeeded but side effects still exist= patient taking clozapine have to have regular blood test to alert doctors to early signs of agranulocytosis
3. The chemical cosh argument
   Widely believed antipsychotic have been used in hospital situations to calm patients and make them easier for staff to work with, rather than for the benefit to the patient themselves
   Although short term use of antipsychotic to calm agitated patient is recommended by NICE, this practice is seen by some as a human right abuse
   - serious ethical issue

Problems with the evidence for effectiveness
- Healy suggest that because antipsychotics have powerful calming effects, it is easy to demonstrate that they have some positive effect on patient but it’s not the same as saying they really reduce the severity of psychosis
Secondly, drug companies are selective about what type is info they publish- may focus on short term benefits than long term risk,
and use inappropriate control group, such as patient suffering from withdrawal symptoms as they have stopped taking their medication
- this distorted focus brings into question the validity of research into effectiveness of antipsychotic

Question 21

Psychological therapies for schizophrenia

CBT

Answer 21

Is a method for treating mental disorders based on both cognitive and behavioral techniques

Now commonly used to treat patients with schizophrenia

The aim of Cabal involves helping patient identify irrational thought and trying to change them

This may involve discussion of how likely the patient beliefs are to be true

How CBT helps— just understanding where symptoms such as hallucinations and delusion comes from can be hugely helpful for some Ps - can help reduce anxiety

Delusions can also be challenged so that a patient can come to learn that their belief are not based on reality

Turkington et al who found they CBT could be used to challenge a patient belief about being targeted by the mafia as the therapist was questioning the reality of patient belief and considering other reasonable alternatives

Question 22

Psychological therapies for schizophrenia Family therapy

Answer 22

Is a psychological therapy which takes place with family rather than individual patient l, aiming to improve the quality of communication between family members

Most family therapist are concerned with reducing stress of living together as a family, with a schizophrenic mother. In particular l, family therapy aims to reduce levels of EE

How FT helps— Pharoah et al identify range of strategies by which family therapist aim to improve functioning of a family with a member suffering from schizophrenia:

-forming a therapeutic alliance with all family members
- improving ability of family to solve problems
- reduction of anger and guilt in family members
- helping family achieving a balance between caring for individual with schizo and maintaining their own lives
-Improving family beliefs towards schizo

Question 23

Psychological therapies for schizophrenia
Token economies

Answer 23

• a form of behavioral therapy based on operant conditioning
  They are reward system used to manage the behavior of patients with schizophrenia

-tokens are given immediately to patients when they have carried out a desirable behaviour tolhas had been targeted for reinforcement
This may be getting dressed in the morning or making a bed
According to the patient individual behaviour issue
This immediacy of reward is important as it prevents delay discounting, the reduce effect of a delayed reward

Rewards- tokens can be swapped with Lee tangible rewards.

Tokens are secondary reinforcers as they only have value once the patient has learned they can be used to obtained rewards
These rewards might be in form of rewards such as sweets, cigarettes or in form of service such as having the privileges of o walk outside the hospital

Question 24

Evaluation of psychological therapies for schizophrenia

Answer 24

Evidence for effectiveness-
Sameer Jauhar et al (2014) reviewed the results of 34 studies of CBT for schizophrenia.They concluded that CBT has a significant but small effect on both positive and negative symptoms.Pharoah et al reviewed evidence for family therapy and concluded that there is moderate evidence to show that family therapy reduces hospital readmission and improves the quality of life for the patient and their families.They noted that different studies had inconsistent findings so the evidence overall for family therapy is weak.

Ethical issues
Token economy system proven controversial= major issues is that privileges, services become more available to patient with mild symptoms and less so for those with more severe symptoms of schizo that prevent them complying with desirable behavior
- means that most severely ill patient suffer discrimination in passion or I other symptoms = this reduce use of token economies in psychiatric systems
CBT may involve challenging a person paranoia =but this could interfere with person freedom of thought
- shows ethical issues are a weakness of psychological treatment for schizophrenia

Treatment improve quality of life but do not cure
CBT helps allow patient to make sense of and challenge some of their symptoms
FT helps reduce stress of living with schizo in family
TE help make patient behaviour more socially acceptable
But these don’t cure schizo, biological treatment also don’t cure schizo but does reduce severity of some symptoms
= weakness

• they are alternative psychological therapies which may address the ethical issues
  such as the use of art therapy, as suggested by the National Institute for Health and Clinical Excellence.
  This provides the patients with a creative outlet which reduces stress fut does not require changing the patients beliefs (as is the case with CBT) or discriminate against severely ill patients (as is the case with token economies).
  Thus, this all suggests that psychological therapies are not appropriate for all patients, but must be selected according to the type and severity of the patient’s symptoms.

Question 25

Integrationist approach

Answer 25

Put simply the interactionist approach
is an approach that acknowledges that there are biological, psychological and societal factors in the development of schizophrenia. Biological factors include genetic vulnerability and neurochemical and neurological abnormality. Psychological factors include stress, for example, resulting from life events and daily hassles, including poor quality interactions in the family.

Meehl’s model 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, one characteristic of which is sensitivity to stress. 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 (see page 208), could result in the development of the condition.

• The renewed, modern understanding of stress is that it need not be biological in origin but could also be psychological, such as in the form of childhood trauma, as suggested by Ingram and Luxton
(2005). The idea of a single schizogene has also been refuted by Ripke’s finding of over 108 candidate genes, whilst early childhood trauma causes dysfunction in the functioning of the HPA system (hypothalamic-pituitary-adrenal system), leading to a greater sensitivity to stressors in the future, and thus increasing the likelihood of developing SZ according to the diathesis-stress model.

• modern definition of streee includes anything that risk triggering schizo as according to Houston et al (2008). For example, cannabis use may be considered a lifestyle stress which, when companied with childhood trauma, a biological predisposition or chronic stress, increases the risk of developing SZ by 7-fold.

• If, according to the diathesis-stress model, both psychological and biological explanations apply to SZ, then it also follows that the same approach should be used in SZ treatment. This is particularly the case as biological treatments appear to address the (direct) distal causes of SZ, whilst psychological treatments appear to be more well-suited in treating the (indirect) proximal causes, as suggested by Turkington et al (2006). Such an approach is likely to be reflected in the use of antipsychotic medication with CBT, but less frequently used in the USA where there is still little overlap between biological and psychological approaches towards explaining and treating SZ.

Question 26

Evaluation

Answer 26

explaining SZ comes from Tienari et al’s 2004 adoption study. The researchers used data from 19,000 Finnish mothers and adoptees who suffered from SZ and compared these findings to a neurotypical group of children adopted across the same period
The researchers found that “in adoptees at high genetic risk of schizophrenia, but not in those at low genetic risk, adoptive-family ratings were a significant predictor of schizophrenia-spectrum disorders in adoptees at long-term follow-up”. Therefore, this provides strong support for the diathesis-stress model because the findings demonstrate that a single diathesis or stressor is not enough to trigger the development of SZ, but rather a combination of the two is required.

— The original diathesis-stress model can be considered as an over-simplified explanation of SZ and a reflection of the outdated understanding of that disorder in the mid-twentieth century. For example, Ripke et al (2014) demonstrated that there are over 108 candidate genes, each slightly increasing the risk of SZ, and so there is no single ‘schizogene’. Stress can come in many forms apart from the schizophrenogenic mother, such as high levels of expressed emotion, childhood trauma (Read et al,
2001) and the excessive use of cannabis (Houston et al, 2008). Therefore, the diathesis is not exclusively biological, nor is the stressor exclusively psychological. Hence, this may also be considered a strength in the sense that our current understanding of SZ is far more accurate than the orginal perspective.

There is strong evidence to suggest that some sort of underlying vulnerability coupled with stress can lead to schizophrenia. We also have well-informed suggestions for how vulnerabilities and stress might lead to symptoms. However, we do not yet fully understand the mechanisms by which the symptoms of schizophrenia appear and how both vulnerability and stress produce them.