Schizophrenia

Question 1

Schizophrenia

Answer 1

A severe mental illness where contact with reality and insight are impaired, an example of psychosis. The term comes from two Greek words: ‘schizo’, meaning ‘split’, and ‘phrena’ meaning ‘mind’. The ‘split’ in schizophrenia occurs between a person’s thought processes and reality.

Question 2

Psychosis

Answer 2

Psychosis is a term used to describe a severe mental health problem where the individual loses contact with reality.

Question 3

‘recovery’

Answer 3

Before the 1950s, many people with schizophrenia spent most of their lives in psychiatric hospitals. This is known as institutionalisation. New treatment methods have changed this. About 25% of sufferers will get better after only one episode of the illness; 50-65 % will improve, but continue to have bouts of the illness. The remainder will have persistent difficulties (Stirling and Hellewell, 1999).

Question 4

Classification

Answer 4

There are a number of systems by which we can classify abnormal patterns of thinking, behaviour and emotion into mental disorders. These systems not only classify abnormality, but give guidance on how to diagnose them. The two most widely used systems of classification and diagnosis are ICD and DSM.

Question 5

Disorganised/ Hebephrenic Schizophrenia

Answer 5

> disorganised speech, disorganised behaviour, flat or inappropriate affect and does not meet the criteria for Catatonic Type.
The person’s behaviour is generally disorganised and not goal-directed.
Symptoms include thought disturbances (including delusions and hallucinations), absence of expressed emotion, incoherent speech, large mood swings and a loss of interest in life – social withdrawal. It is usually diagnosed in adolescence/young adulthood.

Question 6

Catatonic Schizophrenia

Answer 6

> Immobility or stupor excessive motor activity that is apparently purposeless, extreme negativity, strange voluntary movements as evidenced by posturing, stereotyped movements, prominent mannerisms or prominent grimacing.
This is diagnosed if the patient has severe motor abnormalities such as unusual gestures or use of body language. >Sometimes patients gesture repeatedly, using complex sequences of finger, hand and arm movements, which appear to have some meaning for them.
This type often involves doing opposite to what is being asked or repeating everything that is said.
The main feature is almost total immobility for hours at a time, with the patient simply staring blankly.

Question 7

Paranoid schizophrenia

Answer 7

> Preoccupation with one or more delusions or frequent auditory hallucinations. No disorganised speech, disorganised or catatonic behaviour or flat or inappropriate affect.
This type involves delusions of various kinds (persecution and grandeur); however, the patient remains emotionally responsive. They are more alert than patients with other types of schizophrenia.
Paranoid schizophrenics tend to be argumentative. In some ways this is the least serious - but the most well-known. This often has a later onset than other types.

Question 8

Undifferentiated schizophrenia

Answer 8

> Variation between symptoms not fitting into a particular type.
This is a broad, ‘catch-all’ category which includes patients who do not clearly belong within any other category. They show symptoms of schizophrenia but do not fit into the other types.

Question 9

Residual schizophrenia

Answer 9

> Absence of prominent delusions, hallucinations, disorganised speech and grossly disorganised or catatonic behaviour. A presence of negative symptoms.
This is the category that describes people who, although they have had an episode of schizophrenia during the past 6 months and still exhibit some symptoms, these are not strong enough to merit putting them in the other categories.
This type consists of patients who are experiencing mild symptoms.

Question 10

Symptoms

Answer 10

> Positive symptoms - Exeriences in addition to normal experiences. (Hallucinations and delusions)
Negative symptoms - Loss of normal experience or abilities. (Avolition and speech poverty)

Question 11

Diagnosis

Answer 11

> In the DSM-5 system one of the so-called positive symptoms (delusions, hallucinations or speech disorganisation) must be present for diagnosis.
Under ICD, two or more positive symptoms must be present for a diagnosis to be made - only one symptom is needed if the delusions are bizarre, or if the hallucinations consist of a voice commenting on the individual’s behaviour.

Question 12

The Prodromal Phase

Answer 12

The individual becomes withdrawn and lose interest in work, school and leisure activities.

Question 13

The Active Phase

Answer 13

More obvious symptoms begin to occur: the duration of this phase can vary; for some people it will last a few months, whereas others remain in the active phase.

Question 14

The Residual Phase

Answer 14

The obvious symptoms begin to subside, e.g. when treatment is given.

Question 15

Onset of Schizophrenia

Answer 15

> Schizophrenia rarely starts before the age of 15, and although it affects men and women equally, there are differences in the age of onset.
Men usually notice the symptoms in their late teens. Women are affected later, in their twenties and thirties.

Question 16

Mental Health Act and Schizophrenia

Answer 16

> Someone with schizophrenia may not realise they are ill and can refuse treatment when they need It.
As a result they can be admitted to hospital against their will and given treatment without their consent under the Mental health Act.
This should only happen if their health is at risk, if they are a danger to themselves, or if they may be a danger to others.

Question 17

Evaluation - Reliability and Consistency of Diagnosis -

Answer 17

> An important measure of reliability is inter-rater reliability In relation to diagnosis, this means that different clinicians make identical, independent diagnosis of the same patient.
Cheniaux et al (2009)had two psychiatrists independently diagnose 100 patients using both DSM and ICD criteria. This poor reliability is a weakness of diagnosis of schizophrenia.

Question 18

Evaluation - Reliability and Consistency of Diagnosis +

Answer 18

> Even if reliability of diagnosis based on classification systems is not perfect, they do provide practitioners with a common language, permitting communication of research ideas and findings, which may ultimately lead to a better understanding of the disorder and the development of better treatments.
Evidence does generally suggest that reliability of diagnoses has improved as classifications systems have been updated.

Question 19

Evaluation - Validity and Accuracy of Diagnosis

Answer 19

> An important measure of validity is criterion validity: do different assessment systems arrive at the same diagnosis for the same patient?
Evidence from the Cheniaux et al (2009) study suggests that it is much more likely to be diagnosed using ICD rather than DSM
This suggests that schizophrenia is either over-diagnosed in ICD or under diagnosed in DSM >Either way, this is poor validity - a weakness of diagnosis of schizophrenia.

Question 20

Schizophrenia case study 1

Answer 20

> DD, an economics graduate, frequently heard a voice (auditory hallucinations) she believed to be the devil. >The devil was using DD’s telepathic powers to control the Prime Minister, making him do things that would destroy the British economy (delusion of grandeur).
DD tried to resist the voice every time she heard it, by saying the opposite of what the voice commanded but would always eventually give in to the voice.
She monitored the economic news carefully, and always felt very guilty when the economy took a turn for the worse (Chadwick and Birchwood 1996).

Question 21

Schizophrenia case study 2

Answer 21

A patient complained that communists were flying over his house in planes, shooting him with invisible rays (visual hallucinations) that caused abdominal churning, tension and heart palpitations (Turkington and Kingdon 1996).

Question 22

Gender bias in diagnosis

Answer 22

> Underdiagnosis or women may be due to a gender bias with women’s issues not being taken seriously.
Cotton - Women may have better coping mechanisms and therefore not seek help

Question 23

Cultural bias in diagnosis

Answer 23

> African Americans and English people of Afro-Caribbean origin are several times more likely than white people to be diagnosed with schizophrenia.
This suggests that the validity of the diagnosis is poor because either it is confounded by cultural beliefs and behaviours in patients, or by racist distrust of black patients on the part of mental health practitioners.

Question 24

Co-morbidity

Answer 24

Often diagnosed with other disorders; depression 50%, drug abuse 47%, PTSD 29%, OCD 23% (Buckley 2009).
>Could lead to innacurate diagnosis of schizophrenia or as these diagnoses often occur together maybe they are not separate disorders

Question 25

Symptom overlap

Answer 25

Bipolar disorder also has hallucinations and delusions as a positive symptom. If the two disorders are similar, they may not be different

Question 26

Biological explanation: Genetics

Answer 26

> If schizophrenia is biological in nature then the more closely related two people are the more likely the other person is to have it.
Family studies: siblings more likely to both have it than cousins (shared environment)
Twin studies: MZ and DZ twins share environments so higher concordance rate is likely to be due to genetics

Question 27

Twin Studies - Gottesman (1991)

Answer 27

Reviewed cases of schizophrenia and found a concordance rate of 48% for MZ twins and 17% for DZ twins. This compares to 1% general population rate. This suggests that the more genetically related two people are, the higher the rate of schizophrenia indicating a genetic link. Both siblings and DZ twins share 50% of DNA but siblings are significantly lower risk. Although, if it was entirely genetic it would be 100% for MZ twins.

Question 28

Adoption Studies

Answer 28

These are studies of genetically related individuals who have been reared apart due to being adopted. Tienari (2000), found that of the 164 adoptees whose biological mothers had been diagnosed with schizophrenia , 6.7% also received a diagnosis of schizophrenia, compared to just 2% of the 197 control adoptees. Although only a small percentage, it still suggests that genes must play a role within schizophrenia. Tienari conducted his study within Finland, therefore we are not able to generalise this study to the rest of the world.

Question 29

Dopamine Hypothesis

Answer 29

Symptoms of schizophrenia are associated with too much or an imbalance of the dopamine neurotransmitter in the brain. The theory originated from observations that dopamine-releasing drugs such as L-dopa can produce schizophrenia-like symptoms in healthy patients

Question 30

Dopamine Hypothesis - Hyperdopaminergia

Answer 30

Hyperdopaminergia = Excessive levels of dopamine in the Subcortex and Broca’s Area

Question 31

Dopamine Hypothesis - Hypodopaminergia

Answer 31

Hypodopaminergia = Low levels of dopamine in the prefrontal cortex.

Question 32

Dopamine Hypothesis - Evaluation

Answer 32

Leucht et al (2013) reviewed 212 studies in a meta-analysis on the effectiveness of biological anti-psychotic drug treatments that work via normalising levels of dopamine. Treatment of symptoms with the drug were found to be more effective than a placebo

Question 33

Neural Correlates - Negative correlation

Answer 33

Negative correlation between activity levels and severity of avolition. As activity levels increase, avolition decreases. As activity decreases, avolition increases. Ventalstriate is a neural correlate of= negative symptoms.

Question 34

Neural Correlates - Positive symptoms

Answer 34

Positive symptoms also have neural correlates. Allen et al (2007) scanned patients with auditory hallucinations, compared to a control. Lower activation levels were found in superior temporal gyrus and anterior cingulate gyrus of hallucination group. Reduced activity in these parts of the brain is a neural correlate for auditory hallucinations.

Question 35

Neural Correlates - Evaluation 1

Answer 35

There are a number of neural correlates of schizophrenia symptoms, including both positive and negative symptoms. Although studies like those on the facing page are useful in flagging up particular brain systems that may not be working normally, this kind of evidence leaves some Important questions unanswered. Most importantly, does the unusual activity in a region of the brain cause the symptom? Logically there are other possible explanations for the correlation.

Question 36

Neural Correlates - Evaluation 2

Answer 36

Take, for example, the correlation between levels of activity in the ventral striatum and negative symptoms of schizophrenia. It may be that something wrong in the striatum is causing negative symptoms. However, it is lust as possible that the negative symptoms themselves mean that less information passes through the striatum. resulting in the reduced activity. A third possibility is that another factor influences both the negative symptoms and the ventral striatum adivity. The existence of neural correlates in schizophrenia therefore tells us relatively little in itself.

Question 37

Mutation in parental DNA

Answer 37

Schizophrenia can take place in the absence of a family history of the disorder. One explanation for this is mutation in parental DNA, for example. in paternal sperm cells. This can be caused by radiation, Poison or viral infection. Evidence for the role of mutation comes from a study shoving a positive correlation between paternal age (associated with increased risk of sperm mutation) and risk of schizophrenia, increasing from around 0.7% with fathers under 25 to over 2% in fathers over 50 (Brown et al. 2002).

Question 38

Support for biological factors

Answer 38

The evidence supporting the role of biological factors in schizophrenia is overwhelming. However, there is also evidence to suggest an important role for environmental factors. including psychological ones such as family functioning during childhood. After all, the probability of developing schizophrenia even if your Identical twin has it is less than 50%

Question 39

Family Dysfunction

Answer 39

Abnormal processes within a family such as poor family communication, cold parenting and high levels of expressed emotion. These may be risk factors for both the development and maintenance of schizophrenia

Question 40

Family Dysfunction - Evaluation 1

Answer 40

Support for family dysfunction as a risk factor - There is evidence to suggest that difficult family relationships in childhood are associated with increased risk of schizophrenia in adulthood. For example, Read et at (2005) reviewed 46 studies of child abuse and schizophrenia and concluded that 69% of adult women in-patients with a diagnosis of schizophrenia had a history of physical abuse, sexual abuse or both in childhood. For men the figure was 59%. Adults with insecure attachments to their primary carer are also more likely to have schizophrenia (Berry et al. 2008).

Question 41

Family Dysfunction - Evaluation 2

Answer 41

There is thus a large body of evidence linking family dysfunction to schizophrenia. However, most of this evidence shares a weakness. Information about childhood experiences was gathered after the development of symptoms, and the schizophrenia may have distorted patients’ recall of childhood experiences. This creates a serious problem of validity. A much smaller number of studies (e.g. Tienari et al) have been carried out prospectively, i.e. they followed up children following childhood experiences to see if the childhood experience predicted any adult characteristics. There prospective evidence linking family dysfunction to schizophrenia but not a huge amount and results have been inconsistent.

Question 42

The schizophrenogenic mother

Answer 42

Frieda Fromm-Reichmann (1948) proposed a psychodynamic explanation for schizophrenia based on the accounts she heard from her patients about their childhoods. Fromm-Reichmann noted that many of her patients spoke of a particular type of parent, which she called the schizophrenogenic mother. ‘Schizophrenogenic’ literally means ‘schizophrenia-causing’. According to Fromm-Reichmann the schizophrenogenic mother is cold, rejecting and controlling, and tends to create a family climate characterised by tension and secrecy. This leads to distrust that later develops into paranoid delusions (i.e. the belief that one is being persecuted by another person), and ultimately schizophrenia.

Question 43

Family Dysfunction - Evaluation 3

Answer 43

Although there is plenty of evidence supporting the broad principle that poor childhood experiences in the family are associated with adult schizophrenia, there is almost none to support the importance of the schizophrenogenic mother or double bind. Both these theories are based on clinical observation of patients, and early evidence involved assessing the personality of the mothers of patients for ‘crazy-making characteristics’ — an approach that makes many modern psychiatrists wince (Harrington 2012).

Question 44

Family Dysfunction - Evaluation 4

Answer 44

Another problem with dysfunctional family explanations for schizophrenia is that they have led historically to parent-blaming. Parents, who have already suffered at seeing their child’s descent into schizophrenia and who are likely to bear lifelong responsibility for their care, underwent further trauma by receiving the blame for the condition. This is literally adding insult to injury. In fact the shift in the 1980s from hospital to community care, often involving parental care, may be one of the factors leading to the decline of the schizophrenogenic mother and double bind theories — parents no longer tolerated them.

Question 45

Double-bind theory

Answer 45

Gregory Bateson et al. (1972) agreed that family climate is important in the development of schizophrenia but emphasised the role of communication style within a family. The developing child regularly finds themselves trapped in situations where they fear doing the wrong thing, but receive mixed messages about what this is, and feel unable to comment on the unfairness of this situation or seek clarification. When they ‘get it wrong’ (which is often) the child is punished by withdrawal of love. This leaves them with an understanding of the world as confusing and dangerous. and this is reflected in symptoms like disorganised thinking and paranoid delusions. Bateson was clear that this was neither the main type of communication in the family of schizophrenia-sufferers nor the only factor in developing schizophrenia, just a risk factor.

Question 46

Expressed emotion and schizophrenia

Answer 46

Expressed emotion (or EE) is the level of emotion, in particular negative emotion, expressed towards a patient by their carers. EE contains several elements: 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, induding needless self-sacrifice. These high levels of expressed emotion in carers directed towards the patient are a serious source of stress for the patient. This is primarily an explanation for relapse in patients with schizophrenia. However, it has also been suggested that it may be a source of stress that can trigger the onset of schizophrenia in a person who is already vulnerable, for example, due to their genetic make-up.

Question 47

Cognitive explanations

Answer 47

A cognitive explanation for any phenomenon is one which focuses on the role of mental processes. Schizophrenia is associated with several types of abnormal information processing, and these can provide possible explanations for schizophrenia as a whole. Schizophrenia is characterised by disruption to normal thought processing. We can see this in many of its symptoms. We have already seen that reduced processing in the ventral striatum is associated with negative symptoms, whilst reduced processing of information in the temporal and cingulate gyri are associated with hallucinations (see page 202). This lower than usual level of information processing suggests that cognition is likely to be impaired.

Question 48

Two types of dysfunctional thought processing - Metarepresentation

Answer 48

Christopher Frith et al. (1992)
Identified two kinds of dysfunctional thought processing
Metarepresentation is the cognitive ability to reflect on thoughts and behaviour. This allows us insight into our own intentions and goals. It also allows us to interpret the actions of others. Dysfunction in metarepresentation would disrupt our ability to recognise our own actions and thoughts as being carried out by ourselves rather than someone else. This would explain hallucinations of voices and delusions like thought insertion (the experience of having thoughts projected into the mind by others).

Question 49

Two types of dysfunctional thought processing - Central control

Answer 49

Christopher Frith et al. (1992)
Identified two kinds of dysfunctional thought processing
Central control is the cognitive ability to suppress automatic responses while we perform deliberate actions instead. Disorganised speech and thought disorder could result from the inability to suppress automatic thoughts and speech triggered by other thoughts. For example, sufferers with schizophrenia tend to experience derailment of thoughts and spoken sentences because each word triggers associations, and the patient cannot suppress automatic responses to these.

Question 50

Auditory selective attention

Answer 50

The process by which the brain selects which sounds to respond to. Our brain selects information to pay attention to and ignores the rest – we are bombarded with information from the outside world yet our processing abilities are limited.The negative symptoms of schizophrenia may be the result of cognitive strategies used by the individual to keep mental stimulation to a manageable level. This happens when people experience potentially overwhelming levels of information from the external world and their inner world. This may be due to auditory selective attention impairment.

Question 51

Pickering (1981)

Answer 51

Pickering proposed that catatonic schizophrenia may be caused by a breakdown in auditory selective attention; this would make social interaction increasingly difficult, as the individual is overloaded with auditory information. Pickering believes that catatonic schizophrenics have no choice but to withdraw from the world and this way they can keep sensory stimulation at a manageable level.

Question 52

Antipsychotics

Answer 52

> Drugs used to reduce the intensity of symptoms, in particular the positive symptoms, of psychotic conditions like schizophrenia.
The most common treatment for schizophrenia involves the use of antipsychotic drugs. Antipsychotics can be taken as tablets or in the form of syrup. For those particularly at risk of failing to take their medication regularly one antipsychotic are available a injections given every 2 weeks.
Antipsychotics can be divided into typical (traditional, and newer atypical or second-generation drugs.

Question 53

Typical antipsychotics

Answer 53

> The first generation of antipsychotic drugs, having been used since the 1950s. They work as dopamine antagonists and include Chlorpromazine.
There is a strong association between the use of typical antipsychotics like Chlorpromazine and the dopamine hypothesis.

Question 54

Atypical antipsychotics

Answer 54

Drugs for schizophrenia (a psychotic disorder) developed after typical antipsychotics. They typically target a range of neurotransmitters such as dopamine and serotonin. Examples include Clozapine and Risperidone
>These drugs have been used since the 1970s. The aim in developing newer antipsychotics was to maintain or improve upon the effectiveness of drugs in suppressing the symptoms of psychosis and also minimise the side effects.

Question 55

Typical antipsychotics and dopamine hypothesis

Answer 55

> Typical antipsychotics like Chlorpromazine work by acting as antagonists in the dopamine system. Antagonists are chemicals which reduce the action of a neurotransmitter. Dopamine antagonist work by blocking dopamine receptors in the synapses of the brain. reducing the action of dopamine. Initially when a patient begins taking chlorpromazine dopamine levels build up, but then its production is reduced. According to the dopamine hypothesis of schizophrenia this dopamine-antagonist effect normalises neurotransmision in key areas of the brain, reducing Symptoms like hallucinations.

Question 56

Atypical antipsychotics and dopamine hypothesis

Answer 56

Clozapine binds to dopamine receptors in the same way that Chlorpromazine does, but in addition it acts on serotonin and glutamate receptors. It is believed that this action helps improve mood and reduce depression and anxiety in patients, and that it may improve cognitive functioning. The mood-enhancing effects of Clozapine mean that it is sometimes prescribed when a patient is considered at high risk of suicide. This is important as 30 to 50% of people suffering from schizophrenia attempt suicide at some point.

Question 57

> Evidence for effectiveness - antipsychotics 1 +

Answer 57

There is a large body of evidence to support the idea that both typical and atypical antipsychotics are at least moderately effective in tackling the symptoms of schizophrenia. Ben Thornley et al. (2003) reviewed studies comparing the effects of Chlorpromazine to control conditions in which patients received a placebo so their experiences were identical except for the presence of Chlorpromazine in their medication. Data from 13 trials with a total of 1121 participants showed that Chlorpromazine was associated with better overall functioning and reduced symptom severity. Data from three trials with a total of 512 participants showed that relapse rate was also lower when Chlorpromazine was taken.

Question 58

> Evidence for effectiveness - antipsychotics 2 +

Answer 58

In addition there is support for the benefits of atypical antipsychotics In a review Herbert Meltzer (2012) concluded that Clozapine is more effective than typical antipsychotics and other atypical psychotic, and that it is effective in 30-50% of treatment-resistant cases where typical antipsychotics have failed. A number of studies have compared the effectiveness of Clozapine and other atypical antipsychotics like Risperidone but results have been inconclusive, perhaps because some patients respond better to one drug or the other. It does seem though that antipsychotics in general are reasonably effective, and this is a strength.

Question 59

> Evidence for effectiveness - antipsychotics 1 -

Answer 59

A problem with antipsychotic drugs is the likelihood of side effects, ranging from the mild to the serious and even fatal. Typical antipsychotics are associated with a range of side effects including dizziness, agitation, sleepiness, stiff jaw, weight gain and itchy skin. Long-term use can result in tardive dyskinesia, which is caused by dopamine supersensitivity and manifests an involuntary facial movements such as grimacing, blinking and lip smacking.

Question 60

> Evidence for effectiveness - antipsychotics 2 -

Answer 60

The most serious side effect of typical antipsychotics is neuroleptic malignant syndrome (NMS). This is believed to be caused because the drug blocks dopamine action in the hypothalamus, an area of the brain associated with the regulation of a number of body systems. NMS results in high temperature, delirium and coma, and can be fatal. As typical do! of antipsychotics have declined NMS has become rarer. Estimates of its frequency range from less than 0.1% to just over 2%. Atypical antipsychotics were developed to reduce the frequency of side effects and genera this has succeeded (Meltzer 2012). However, side effects still exist and patients taking Clozapine have to have regular blood tests to alert doctors to early signs of agranulocytosis. Side effects are thus still a significant weakness of antipsychotic drugs.

Question 61

CBT and schizophrenia

Answer 61

Patients can be helped to make sense of how their delusions and hallucinations impact on their feelings and behaviour. Just understanding where symptoms come from can be hugely helpful for some patients. If, for example, a patient hears voices and believes the voices are demons, they will naturally be very afraid. Offering psychological explanations for the existence of hallucinations and delusions can help reduce this anxiety. Delusions can also be challenged so that a patient can come to learn that their beliefs are not based on reality

Question 62

CBT and schizophrenia - case study

Answer 62

A case example Turkington et al. (2004) describe an example of CBT used to challenge where a paranoid patient’s delusions come from: Paranoid patient: The Mafia are observing me to decide how to kill me. Therapist: You are obviously very frightened . . . there must be a good reason for this. Paranoid patient: On you think it’s the Mafia? Therapist: It’s a possibility, but there could be other explanations. How do you know that it’s the Mafia?

Question 63

CBT and schizophrenia - support

Answer 63

Sameer Jauhar et al. (2014) reviewed the results of 34 studies of CBT for schizophrenia. They concluded that CBT has a significant but fairly small effect on both positive and negative symptoms.

Question 64

Family therapy and schizophrenia

Answer 64

> A psychological therapy carried out with all or some members of a family with the aim of improving their communication and reducing the stress of living as a family.
Family therapy takes place with families rather than individual patients, aiming to improve the quality of communication and interaction between family members.
There is a range of approaches to family therapy for schizophrenia.
In keeping with psychological therapies like the double bind and the schizophrenogenic mother, some therapists see the family as the root cause of the condition.
Nowadays though, most family therapists are more concerned with reducing stress within the family that might contribute to a patient’s risk of relapse. In particular, family therapy aims to reduce levels of expressed emotion (EE).

Question 65

Family threrapy - Pharoah et al - range of strategies

Answer 65

> Forming a therapeutic alliance with all family members.
Reducing the stress of caring for a relative with schizophrenia.
Improving the ability of the family to anticipate and solve problems.
Reduction of anger and guilt in family members.
Helping family members achieve a balance between caring for the individual with schizophrenia and maintaining their own lives.
Improving families’ beliefs about and behaviour towards schizophrenia.

Question 66

Family threrapy - Pharoah et al study

Answer 66

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.

Question 67

Token economies and schizophrenia

Answer 67

> A form of behavioural therapy, where desirable behaviours are encouraged by the use of selective reinforcement. For example, patients are given rewards (tokens) as secondary reinforcers when they engage in correct/socially desirable behaviours. The tokens can then be exchanged for primary reinforcers - favourite foods or privileges. Token economies are reward systems used to manage the behaviour of patients with schizophrenia, in particular those who have developed patterns of maladaptive behaviour through spending long periods in psychiatric hospitals (referred to as ‘institutionalised’).
Modifying these had habits does not cure schizophrenia but it improves the patient’s quality of life and makes it more likely that they can live outside a hospital setting.

Question 68

Ethical issues with psychological therapies - token economies

Answer 68

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.

Question 69

Ethical issues with psychological therapies - CBT

Answer 69

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.

Question 70

Interactionist approach

Answer 70

> A broad approach to explaining schizophrenia, which acknowledges that a range of factors, including biological and psychological factors, are involved in the development of schizophrenia.
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.

Question 71

The diathesis-stress mode

Answer 71

An interactionist approach to explaining behaviour. For example schizophrenia is explained as the result of both an underlying vulnerability (diathesis) and a trigger, both of which are necessary for the onset of schizophrenia. In early versions of the model, vulnerability was genetic and triggers were psychological. Nowadays both genes and trauma are seen as diathesis, and stress can be psychological or biological in nature.

Question 72

Meehl’s (1962) original diathesis-stress model

Answer 72

> Diathesis (vulnerability) is entirely genetic – the result of a single schizogene, which led to a biologically based schizotypic personality – extremely sensitive to stress. No amount of stress will lead to schizophrenia if the gene is not present. However chronic stress in someone with the gene could lead to the development of the disorder – nature and nurture interact.
As this model acknowledges an interaction of biological and psychological causes, it believes that a combination therapy should be employed between antipsychotic drugs and psychological therapies such as CBT. Turkington et al. – we can still believe that schizophrenia has a biological basis but use CBT to relieve the psychological symptoms.

Question 73

Interactionist approach - UK vs US conflict

Answer 73

UK – it is perfectly acceptable to use a combination of both CBT and drug therapies.
USA – conflict between biological and psychological therapies which has led to slower adoption of the interactionist model. Medication alone is more common here. Environmental stressors is the diathesis-stress model. This model explains that individuals will develop schizophrenia if they have a biological predisposition and if they are exposed to stressful situations.

Question 74

Modern understanding of diathesis

Answer 74

> One way in which our understanding of diathesis has changed is that 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 (Ingram and Luxton 2005)— 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 (HPA) system can become overactive, making the person much more vulnerable to later stress.

Question 75

The modern understanding of stress

Answer 75

> In the original diathesis-stress model of schizophrenia, stress was seen as psychological in nature, in particular related to parenting. Although psychological stress, including that resulting from parenting may still be considered important, a modern definition of stress (in relation to the diathesis-stress model) includes anything that risks triggering schizophrenia (Houston eta). 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 76

Treatment according to the interactionist model

Answer 76

> The interactionist model of schizophrenia acknowledges both biological and psychological factors in schizophrenia and is therefore compatible with both biological and psychological treatments.
In particular the model is associated with combining antipsychotic medication and psychological therapies, most commonly CBT.
Douglas Turkington et al. (2006) point out that it is perfectly possible to believe in biological causes of schizophrenia and still practise CBT to relieve psychological symptoms. However, this requires adopting an interactionist model: it is not possible to adopt a purely biological approach and tell patients that their condition is purely biological and that there is no psychological significance to symptoms, and to simultaneously treat them with CBT.