Schizohrenia A03 Flashcards
Reliability and validity of the classification of Sz
Criticism poor inter-rater reliability
- Ev - In Rosenhan study there was inconsistency in diagnosing sanity as it took between 7-52 days for pseudopatients to be released when showing no symptoms.
- Ex - Q’s whether psychiatrists can reliably classify people consistently when they have the same symptoms. If it was reliable then all psychiatrists would have released the 7 pseudopatients after 2 days. This did not happen. Also, another study found a very weak 0.11 correlation for inter-rater reliability amongst psychiatrists when diagnosing Sz.
- L - : However, Rosenhan did show good inter-rater reliability in diagnosing Szas all 7/8 pseudopatients were diagnosed. However, this diagnosis was invalid as all pseudopatients did not show any genuine symptoms for Sz and hence should not have received a diagnosis.
Criticism of validity - Co-morbidity & symptom overlap
- Ev - When two or more disorders are diagnosed together, e.g., 50% diagnosed with depression & Sz. There is also an overlap of symptoms with other disorders, e.g., anxiety & bipolar depression both have hallucinations & avolition
- Ex - Q’s validity of classification & diagnosis as many are too similar and hence really one diagnosis. Maybe the symptoms are more related to a different mood disorder, rather than another stand-alone disorder as Sz. The DSM-V has removed some of the categories of Sz due to the overlap of symptoms amongst the different types of Sz and psychiatrists’ difficulty in classifying them under just one type.
- L - : So, we need to be very careful in giving a diagnosis for Sz due to the impact that this can have on the person concerned. Furthermore, if someone is not able to be ‘cured’ but only classed as having Sz in remission, this is dangerous as it means that someone then has a label for life
Criticism – Culture & Gender Bias
- Ev - There is a higher % of males (56%) diagnosed with Sz than females (20%). Also depended on the gender of the psychiatrist. Furthermore, there is a greater chance of being diagnosed with Sz as a black ethnicity than a white ethnicity living in the UK, due to cultural differences.
- Ex - Q’s the reliability & validity of the diagnosis. Sz as a psychosis is seen as more severe than a mood disorder (depression); hence males emotionally struggling may be perceived more severe than females. Also, it depends on who is diagnosing and from which culture, as psychiatrists are predominantly male, western and white ethnicity. Therefore, there is bias in the interpretation of people’s culture too, e.g., assuming delusions of grandeur when it is more of a cultural or religious aspect.
- L - In summary, the classification and diagnosis of Sz can be considered both lacking in validity and reliability. It calls into Q whether mental health can be objectively assessed, as the DSM-VC attempts to, or whether we have to accept that mental health will also be subjective and open to confirmation biases; because unlike physical health, the internal mental processes of people cannot be empirically observed as easily.
biological explanation of Sz: genetic
Research support from a family
study/twin study
- Ev - Gottesman (48%/17%), 16% CR with their children, compared to 2% with aunts/uncles.
- Ex - More similar genetically the more likely to have Sz. Therefore, suggesting that Sz is genetic.
- L - However, they share the same env and may see their parents as role models (SLT) hence is it biological or due to imitation of behaviour or family dysfunction.
Research support from adoption
study
- Ev - 30 Sz mothers had children removed at birth and adopted were compared to 33 non-
Sz who were adopted. Found:
Sz mothers = 16.67% concordance with their adoptive child
NSz mothers = 0% concordance
- Ex - Therefore, no shared env and higher correlation with bio mother when Sz suggests that it is genetic.
- L - However, the trauma of the adoption could account, it is a low CR (16.67%). Cannot account of possibly of contact with bio parent and adoptive parent could demonstrate family dysfunction.
However, more likely to be an
interaction of genetics and env
- Ev - 48% genetic therefore 52% environment?
-
Ex - DSM – genetic predisposition, triggers but stress from the environment (e.g., family
dysfunction) -
L - However, maybe more a modern DSM, the env, e.g., virus in the womb could cause fault in the genes – epigenetics, this can
imbalance dopamine within the mesocortical and mesolimbic system, this can create more
family dysfunction/stress and so on. Therefore, not possible to separate the env or genetics as cause of Sz
biological explanations of Sz: neural correlates and dopamine hypothesis.
Supporting evidence comes from drug treatments that attempt to change the level of dopamine in the brain
- Ev - Leucht et al, carried out a meta-analysis of 212 studies and found that all antipsychotic drugs were signif more effective than a placebo in treating the positive and
neg symptoms of Sz.
-
Ex - suggests dopamine is specifically responsible for pos and neg symptoms of Sz, and does not matter whether the antipsychotics are typical (blocking D2 receptors in the mesolimbic system) or atypical (temporary blocking of D2
receptors). Therefore, it challenges the need for difference classifications of treatments. -
L - But, the bio explanation is also reductionist and deterministic. Means the only form of treatment is through making changes to brain structure and dopamine levels, and that the person is not in control of their own
disorder and ‘curing’ themselves and improving their lives.
This ignores the role of family dysfunction and impairment
in cognitive functioning from their past environmental experiences.
However, there is strong evidence against the dopamine hypothesis &/neural correlates
- Ev - Not all antipsychotic medication alleviates hallucinations
and delusions (only in 1/3 of ppl). Furthermore, some ppl have these symptoms even when levels of dopamine are normal.
-
Ex - suggests that rather than dopamine being sole cause of + symptoms of Sz, maybe there
are other neurotransmitters or neural correlates outside of
the dopaminergic system that also produce the + symptoms of Sz. -
L - But raises importance of early intervention to prevent later stages of the disorder. This
was shown in the North American Prodrome Longitudinal study which uses several diff assessments, including neuroimaging to predict who will develop psychoses such as
Sz. From the neuroimaging, early
treatments in the form of anti-psychotic medication can be
used early with at-risk patients before psychosis develops.
So, the bio explanation is useful in preventing Sz, not just in treating those who have it already.
The theory on neural correlates
explaining Sz is supported by a meta-analysis
- Ev - They analysed results of 19 studies and found that patients with Sz showed a higher reduction in cortical grey matter than healthy controls. This was specific to the frontal, temporal and parietal lobes.
- Ex - implies that Sz = bio disorder that is due to the degeneration of the neurons in the brain. This is particularly evident in the early onset of Sz when people are in the first stages of the disease.
- L -But, meta-analysis, using secondary sources with different methodological approaches, and each patient would show unique Sz symptoms. So, not possible to say that the reduction of grey matter causes Sz, or whether it’s responsible for only pos or neg symptoms.
Psychological explanations of Sz - family dysfunction.
research support for family dysfunction
- Ev - Sz patients in HEE families were 4x more likely to relapse than those in LEE families. Sz mothers were more likely to give double bind statements than non-Sz controls. They were more aloof and unresponsive with Sz daughters (Schizophrenogenic mother)
- Ex - So family dysfunction is a cause of Sz, otherwise HEE would not be responsible for creating higher relapse. Moreover, studies would not support there being differences in mothers with Sz children, and the differences in the way mothers paralinguistically communicate.
- L - However, there are methodological issues with the studies. Self-report, retrospective and open to social desirability. However this is controlled by some studies using triangulation, e.g. controlled observations and interviews.
But there are individual differences in how stressful Sz find family dysfunction
- Ev - 25% of Sz’s didn’t have a physiological arousal response to critical comments from their parents/relatives.
- Ex - So CC weren’t a stressor that person needs to escape from through loss of touch with reality. More of a judgement from those outside family on how communication may be perceived.
- L - could be argued theory of family dysfunction causes Sz = socially sensitive. Blamed mothers for causing Sz. Further increases stigma of Sz within societies not just to person with Sz but to whole family as it judges parenting negatively. So, driving the disorder underground and making it harder for the family to admit needing and seeking help.
but correlation between mother and Sz child could be biological -genetics
- Ev - a study found no difference between Sz and their families parental communication.
- Ex - Adoption studies have shows that children with bio parents with Sz = more likely to develop Sz. So maybe family dysfunction = just measuring mothers own symptoms of Sz and hence is inherited, not env caused. Schizophrenogenic mothers being cold and aloof is system of Sz (avolition)
- L - But adoption study also found when adoptive parents had HEE, the likelihood of child developing Sz increased. So more likely to be an interaction of genetic predisposition brought on through env stressors such as family dysfunction.
Psychological explanations of Sz: cognitive explanations.
Research support for validity of cognitive explanation for Sz
- Ev - Delusional patients found to show various biases
in their info processing, e.g., jumping to conclusions and lack of reality testing.
Patients with hallucinations had more impaired self-monitoring that
tended to experience their own thoughts as voices.
Furthermore, CBTp found to be more effective in a NICE review than anti-psychotic drugs + improved social functioning + reduced symptom severity.
-
Ex - Sz tend to have more issues with meta- representation, egocentric bias and hypervigilance which causes some positive symptoms of Sz.
Moreover, the fact that CBTp reduces these cognitive biases and reduces positive symptom severity more than drugs shows that Sz is more a cognitive cause rather than biologically created. -
L - does not support explanation of negative Sz symptoms and it does not ‘cure’ Sz by removing symptoms completely. So, an interactionist approach
to explaining Sz = needed, as argument is where did the cognitive biases originate from, and that is likely to be a genetic and neurological explanation (cognitive
neuroscience).
_Research support for central control dysfunction _
- Ev -30 patients with Sz and 18 without Sz completed a Stroop test. Sz took 2 x longer to complete the Stroop test that non-Sz.
-
Ex - Sz have difficulty suppressing their cognitive automatic thoughts, and when trying to attend to the colour that the word is written in, the word
itself is more a distractor, as it would be automatically thought about.
explains why Sz have disorganised
speech (word salad) as they cannot suppress the thoughts that automatically are produced from previous thoughts.
Therefore, they are unable to selectively attend to the point of the conversations made. -
L - study = making inferences about the internal mental process deficit that is occurring, from a reaction time in a Stroop test. We cannot be certain of what
the internal process is in reality, and neither can the Sz patient report it (as it happens automatically, and they have less insight into their mental processes as a result of the
Sz).
_ However, Cognitive explanation is reductionist_
- Ev - ignores other aspects that can account for Sz, e.g., social adversity, family dysfunction or
genetics. It assumes that cognitive is the cause but does not explain how the thought processes become
dysfunctional.
-
Ex - maybe cognitive explanation is more a symptom of other underlying causes. may be better explained through an integrated model. E.g., early
vulnerability, such as genetics or birth complications, together with exposure to significant social stressors, sensitivity to dopamine and cognitive processing difficulties.
These combined could result in both the positive and negative symptoms of Sz. - L -So, we should use a more interactionist explanation to fully explain Sz. This is how in modern times Sz is viewed (i.e., cognitive neuroscience).
Drug therapy
Research support for effectiveness of typical anti psychotics
- Ev - Chlorpromazine is 70% effective in reducing positive
symptoms and another study found 1121 people had better quality of life/functioning.
-
Ex - typical anti-psychotics can be considered most effective in dealing with the most challenging
positive symptoms of Sz (hallucinations & delusions),
compared to atypicals like Clozapine where it is most effective in treatment resistance cases and only has a 30- 50% effectiveness or Risperidone which is more effective
(81%) for negative symptoms of Sz, thereby having less impact on the Sz quality of life than typicals. -
L - but both typical and atypical antipsychotics have a high relapse rate of around 45-41% from 6 months onwards after not taking them, except for Clozapine which
is the lowest (9%) but is rarely prescribed due to a lack of
effectiveness.
However, even though typical anti-psychotics seem to be highly effectiveness in dealing with the most challenging symptoms of Sz, there is still 30% of people
that it does not work for. so, maybe dopamine hypothesis does not account solely for the cause of Sz and hence the treatments are not 100% effective.
serious side effects to taking
drug therapies for Sz
- Ev - Typical antipsychotics, Chlorprozamine have serious side
effects of Tardive Dyskinesia. This is like Parkinson’s disease as it
disrupts motor movement. The person with Sz displays automatic
repetitive motor movements of the mouth, tongue, hands, arms
and legs. It can give them unusual gait.
-
Ex - problematic - permanent. continues once drug has stopped being taken. Secondly the symptoms appear ‘odd’ to the observer and can cause reactions
amongst the general public. This can create further stigma of the person with Sz.
Can make it difficult for Sz person to continue with normal quality of life, gain employment, and increase their social functioning.
Which is better the Sz symptoms or the tardive dyskinesia, either
way the quality of life for the person is affected severely. -
L - antipsychotics with ‘lesser’ side effects - Clozapine. Side effect of agranulocytosis can
be managed to avoid ‘death’ from a blood disorder.
Person does not have permanent effects from taking the drugs.
However, if not well managed and person stops attending regular blood tests, can be potentially
very serious. Therefore, risperidone maybe the best option as there are no permanent side effects or risk of death. However, the seizures and unusual gait are debilitating. Again, calling into Q whether the drugs are replacing Sz symptoms with something equally as damaging for their quality of life.
issues with why the drugs are prescribed to Sz patients
- Ev - Chlorprozamine has sedative effects. This can make Sz
patiens appear to have improved in their positive symptoms.
However, in fact it is because of the sedative making the patients ‘calmer’ and more complaint. In fact,
it may not have reduced the severity of the symptoms. It is just masking them.
-
Ex - Within hospital env, is it that the drug is being given as a treatment for positive symptoms of Sz or to gain a more complaint patients, easier to manage by the hospital staff. This is the chemical COSH argument. NICE highlighted that using drug therapies to calm
patients is a human rights abuse. - L - most published studies have only assessed the short term impact, not the long term impact or the withdrawal effects from those that stop taking the medication. Cannot be certain drug therapies = effective in treating symptoms of Sz
CBT therapy
Research support for effectiveness
- Ev - NICE compared standard drug therapy to CBTp. Found CBTp is better at reducing hospitalisations and symptom severity for up to 18 months after treatment than antipsychotic medication alone.
-
Ex - So, CBTp effectively treats Sz longer term than drug therapy and there are no side effects unlike drugs (e.g., tardive dyskinesia) which are permanent. Hence, would also save taxpayers money long term as there is no
requirement to continually fund the treatment unlike drugs.
CBTp provides Sz patient with higher quality of life long-term, allowing them to gain future employment and bring money back into the economy. -
L - But CBTp is less effective with those Sz patients who have been recently diagnosed and in their initial acute phase of the disorder (more psychotic episodes). Harder for them to self-reflect and reality test. Hence CBTp not appropriate for all Sz patients. So, it may be
more appropriate to use an interactionist treatment model
of both drugs, CBTp and family therapy. The drug therapy
would lessen the acute phase and enable Sz patients to engage more in CBTp and family therapy. Studies have supported this that when this is done there is a 0% relapse
rate.
effectiveness of CBTp may be overstated
- Ev - Meta-analysis examined many CBTp programmes, found a small therapeutic effect. But, when
assessment of the CBTp sessions was double blind, there was no effect of CBTp on Sz.
-
Ex - Therefore, it was more an investigator bias as the
psychologists assessing the programmes had invested time
and effort into their own patients, producing a confirmation bias. -
L - But, meta-analysis may not have taken into account the methodologies used, e.g., the competence of the therapist, it was a double-blind study or if pps were
randomly allocated to the CBTp or control group.
However, there is a lack of
availability in the UK
- Ev - estimated 1/10 ppl with Sz can access CBTp in the UK. This is even lower in some counties, such as the North West only 7% of Sz
patients have been offered CBTp. Out of those a significant number refuse or fail to attend, thus
limiting the effectiveness even more.
-
Ex - important for the gov
to provide more funding for mental health services.
Without support from treatment programmes like CBTp, many people with Sz may end up homeless, self-medicating on illegal drugs and being victims of and/or committing crime to help fund their self-medication. - L - society has a duty of care to help those who are most vulnerable and unfortunately Sz is not seen by the majority in society as a disorder worthy of support.
Family therapy
Research support for Effectiveness
- Ev - NCCMH, 2009: meta-analysis of 32 studies, 2500 patients. Compared standard drug therapy to family therapy. Found lower relapse rate (26% family compared to 50% drug therapy), reduction in hospitalisation and lower severity of symptoms – up to 24 months.
-
Ex - So, family therapy is more effective than drug treatment. These reduction in relapse can even
be found after 8 years (67%) compared to 88% for drugs. This also means that family dysfunction is the main cause, and that high dopamine is just a symptoms possibly from the family dysfunction, hence why family therapy is important is stopping
relapse. - L - but meta-analysis, the methodology of the different studies would vary. Hence, it was not controlled as to whether they were also on drug treatment alongside the family therapy, which drug they were on and for how long. All of these variables could have an affect on the effectiveness and relapse rates, hence maybe nothing to do with family therapy.
Issues with comparing family therapy to standard therapy
- Ev - Most patients are undergoing standard drug treatment alongside family therapy, hence the comparison is not as valid. It would be more accurate
to compare family therapy without medication, with standard drug treatment.
-
Ex - cannot be certain if
it’s the drug combined with family therapy that is effective or whether it’s due solely to family therapy.
Could be that the medication is needed to enable the patient with Sz to partake in the family therapy.
The only way to eliminate this issue is to have a third group of family therapy only. This would allow more
conclusive support to be gathered. -
L - But, would be unethical
to deny drug treatment to patients that would benefit from it. It is therefore unlikely that such a
methodology could be conducted that would pass an ethics committee.
treatment is more helping the family to deal with a SZ child rather than treating cause of SZ
- Ev - Study of 103 Sz patients who lived in a high EE household. He found that 25% who had family
therapy relapsed after 2 years, compared to 62% on medication only.
-
Ex - So, family therapy helps reduce relapse rate of Sz. But, not treating the cause, otherwise the family would stop patients from
developing Sz in the first place, rather than measuring whether they get Sz symptoms back. -
L - could be more expensive to run family therapy than drug treatments. Family therapy is run over a significant time period and involves paying for the time of 2 family therapists. However, this is a short-term cost, as in the long run it would be cheaper as the patient is less likely to need hospitalisation and the higher costs that this type of
treatment would require.
token economy for management of Sz
Research support for usefulness of TES
- Ev - Meta-analysis of 13 studies and found 11/13 reported beneficial effects that were directly attributed to the TES.
- Ex - TES is useful in managing Sz as it increased the number of adaptive beh’s in patients with Sz.
-
L - But, methodological issues with study, as different studies implemented the TES in
different ways, to varying degrees of consistency.
Also, the studies lacked a control group, so unclear if it’s the hospital setting or the TES that is responsible for the change in behaviour.
There are issues with effectiveness in reducing negative symptoms long term
- Ev - TES only been shown to work in hospital settings, in reducing negative symptoms of Sz. The studies did not assess the effectiveness once out of the hospital and in a community setting.
-
Ex - difficult to implement a TES in the community, where there is not 24-hour supervision. Staff cannot monitor the patient’s beh and reward appropriately.
So, the TES in the community would be partially implemented. -
L - unlikely the TES makes a
permanent change in the beh of those with Sz but that they are changing beh for the extrinsic
reason of achieving the token whilst in the hospital.
So, it really is more a management of beh than a treatment of the negative symptoms of Sz.
Criticism – ethical concerns over the use of TES
- Ev - For a TES to work the clinicians have to have control over primary reinforcers such as food, or
access to social support or activities to relieve boredom. If beh is maladaptive the right to these things are taken away by removing tokens.
-
Ex - Humans have basic human right to food, hygiene
products, social support and stimulation.
people with Sz are being punished for demonstrating Sz symptoms that they are not in control of, which is
being classed as ‘bizarre behaviour’. This could just be increasing the stigma for the person with Sz, telling
them that they need to comply with what society deems as normal. -
L - So, given we accept that Sz has a biological component, should we be teaching compassion for the symptoms and an understanding of why they are
having the symptoms they are, and accepting themselves rather than being made to comply to rules
for extrinsic tokens.
Use of TES for the management of Sz has fallen out of use because of a
lack of clear efficacy, controlled studies and the ethical concerns surround it and its long term use.
Interactionist explanations of Sz
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Interactionist treatments of Sz
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