Schizophrenia

Question 1

Define diagnosis

Answer 1

The identification of the nature of an illness or other problem by examination of the symptoms i.e. someone reporting hearing voices

Question 2

define classification

Answer 2

The action or process of classifying something: the classification of disease according to symptoms. i.e a symptom of SZ is hallucinations

Question 3

What is reliability in diagnosis and classification of SZ

Answer 3

• refers to consistency
• refers to whether we can gain consistent results when classifying and diagnosing Sz.
• extent to which different classification systems agree upon how schizophrenia should be classified
• extent to which two or more health professionals would agree on the same diagnosis, regardless of time period or culture, measured by inter-rater reliability

Question 4

What is validity in diagnosis and classification of SZ

Answer 4

-refers to accuracy
- the extent to which we are measuring what we intend to measure (schizophrenia).
-For example, are the classification systems accurately outlining the signs and symptoms of schizophrenia and are health professionals’ accurately diagnosing schizophrenia?

Question 5

Research into reliability and validity in diagnosis and classification of SZ

Answer 5

1) Cheniaux (2009) asked two psychiatrists to diagnose the same 100 patients using the DSM and ICD.
2) One psychiatrist diagnosed 26 according to DSM and 44 according to ICD.
3) The other diagnosed 13 according to DSM and 24 according to ICD.
- This shows poor inter-rater reliability as one psychiatrist
diagnosed almost double the amount than the other psychiatrist.
- Moreover, it demonstrates poor reliability in the classification of schizophrenia as both psychiatrists diagnosed almost double the
amount of patients using the ICD than the DSM, which also calls in to question the validity of the diagnosis.

Question 6

define symptom overlap

Answer 6

-This is where two or more conditions share similar symptoms.
-For example, both schizophrenia and depression involve negative symptoms such as avolition.

Question 7

Co-morbidity

Answer 7

• This is where two illnesses/conditions occur at the same time.
• Schizophrenia is commonly diagnosed with other conditions such as depression and/or OCD.

Question 8

Gender bias

Answer 8

• Since the 1980s men have been diagnosed with schizophrenia more often than women.
• may be men are more genetically vulnerable to developing schizophrenia than women.
• However, it could be because females with schizophrenia typically function better than men, being more likely to work and have good family relationships

Question 9

Culture bias

Answer 9

• English people of African origin are much more likely to be diagnosed with schizophrenia in the UK
• Higher diagnosis rates in the UK may be because some behaviors classed as positive symptoms of schizophrenia are normal in African cultures

Question 10

AO3 for reliability and validity of diagnosis and classification

Answer 10

One problem of reliability and validity is that there is often ‘Symptom overlap’. This is where two or more conditions share similar symptoms. For example, both schizophrenia and depression involve negative symptoms such as avolition. This questions the validity and reliability of the classification and diagnosis of schizophrenia because an individual may be diagnosed with the wrong disorder. This is an issue as doctors may not be diagnosing schizophrenia correctly, and therefore individuals may not receive appropriate treatment. this weakens the validity and reliability in the classification and diagnosis of schizophrenia as it negatively affects its accuracy and consistency.

A further problem with the reliability and validity of the diagnosis and classification of schizophrenia is ‘Co-morbidity’. This is where two illnesses/conditions occur at the same time. For example, Buckley et al (2009) concluded that 50% of patients diagnosed with schizophrenia also
have a diagnosis of depression and 23% of patients diagnosed with schizophrenia are diagnosed with OCD. This questions the validity and reliability of classification and diagnosis of schizophrenia, because they may be better seen as one condition and doctors may diagnose the wrong condition.

Moreover, another issue with the validity of the diagnosis and classification of schizophrenia is Gender bias in diagnosis. Since the 1980s men have been diagnosed with schizophrenia more often than women. This may be because men are more genetically vulnerable to developing
schizophrenia than women. However, it could be because females with schizophrenia typically function better than men, being more likely to work and have good family relationships therefore their symptoms may be masked by good interpersonal skills (Cotton et al). This questions the
validity and reliability of the classification and diagnosis of schizophrenia as women who share similar symptoms as men may not receive the same diagnosis as their symptoms seem mild.

A final problem with the classification and diagnosis of schizophrenia is cultural bias. English people of African origin are much more likely to be diagnosed with schizophrenia in the UK (rates in the West Indies and Africa are not high so this cannot be due to generic vulnerability). Higher
diagnosis rates in the UK may be because some behaviors classed as positive symptoms of schizophrenia are normal in African cultures (e.g. hearing voices as part of ancestor communication). This is an issue with the validity of classification and diagnosis because it suggests
that some individuals from some cultural backgrounds are more likely to be diagnosed than others due to bias.

Question 11

what are the two types of drug therapies

Answer 11

typical (Chlorpromazine) and atypical antipsychotics (clozapine)

Question 12

Typical antipsychotics e.g. Chlorpromazine

Answer 12

• First generation antipsychotics such as Chlorpromazine are dopamine antagonists
• they reduce levels of dopamine activity in the brain
• Chlorpromazine works by binding to the D2 receptors on post synaptic neurons in the brain, reducing the action of dopamine.
  -This reduces dopamine activity levels and results in a reduction of positive symptoms of schizophrenia, such as hallucinations.
• They are also used as a sedative and can be used to
  calm patients.

Question 13

Atypical antipsychotics e.g. Clozapine

Answer 13

• Second generation/atypical antipsychotics act upon neurotransmitters dopamine AND serotonin.
• Clozapine also binds to D2 dopamine receptor sites on the post synaptic
  neuron, reducing positive symptoms such as hallucinations.
• They also act as agonists upon serotonin receptor sites (2A and 2C), it is believed that this action reduces negative symptoms of schizophrenia such as a lack of emotions as it helps improve mood and
  reduce depression and anxiety in patients.

Question 14

which drug has fewer side effects

Answer 14

• Atypical antipsychotics (clozapine) have fewer side effects than typical antipsychotics (chlorpromazine) - as they have less action on the dopamine system.
• Atypical antipsychotics (clozapine) can be used to treat both positive and negative symptoms of schizophrenia as they act upon both dopamine and serotonin where as typical antipsychotics (chlorpromazine) only treat the positive symptoms as they only act upon dopamine.

Question 15

AO3 for drug therapy

Answer 15

A strength of antipsychotics as a treatment for schizophrenia is that there is evidence to support their effectiveness. There is a large body of research to support the effectiveness of typical and atypical antipsychotics. Thornley et al (2003) found that a meta-analysis of 13 studies with a total of 1121 participants investigating chlorpromazine against a placebo, that the typical antipsychotic was associated with better overall functioning and reduced symptom severity. Furthermore, Meltzer concluded that clozapine (atypical) was more effective than typical antipsychotics and is effective in 30 - 50% of treatment resistant cases. therefore supporting that antipsychotics are an effective treatment for positive and negative symptoms of schizophrenia.

Moreover, a strength of drug therapy, is that typical and atypical antipsychotics require little motivation from the patient. This is because the patient only has to take a tablet in order to reduce the symptoms of schizophrenia. This is unlike Cognitive Behavior Therapy which requires
motivation from patients as they have to attend session and engage in them in order to identify and challenge irrational thoughts such as delusions. this may be difficult for a person with schizophrenia as they may not have an accurate perception of reality. further to this, it is very beneficial for those with negative symptoms such as avolition who struggle with keeping up with everyday tasks as they receive immediate positive effects on their symptoms. Therefore drug therapy may be more appropriate than CBT in treating schizophrenia.

A weakness of antipsychotics as a treatment for schizophrenia is that they impose the chemical straightjacket as the drugs may control an individual’s mind and body by controlling levels of
dopamine. This is unlike cognitive behaviour therapy, which encourages individuals to challenge their delusional thoughts independently, so they are in control of their own behaviour. Therefore, antipsychotics may not be an appropriate treatment for schizophrenia compared to CBT due to the dependence they may cause.

Moreover, Another weakness of using drug therapy to treat Schizophrenia is that they can cause negative side effects. Typical antipsychotics such as chlorpromazine can produce movement side effects such as parkinsonism., moreover atypical antipsychotics carry the risk of a life-threatening illness, agranulocytosis (reduced white blood cell count. Unlike CBT, as this just involves a person identifying and challenging
their irrational thoughts, without the use of drugs so there are no negative side effects. Therefore drug therapy may not be appropriate for all patients, this may also reduce the effectiveness of drug therapy as a treatment of schizophrenia as some people may stop taking them resulting in relapse of symptoms.

Question 16

Cognitive behaviour therapy to treat SZ AO1

Answer 16

Aim: The aim of CBT is to help patients identify irrational/delusional thoughts and change them.

Once the irrational thoughts have been identified, for example a paranoid delusion that they were being controlled by aliens, the psychiatrist would challenge the patients irrational thoughts in order to encourage patients to come up with a more plausible/less threatening explanation

Empirical disputing – Asking the patient where is the evidence? For example ‘Where is the evidence that aliens exist? Has anybody else seen these aliens? Do you have a photograph of them?’

This disputing helps patients to make sense of how their delusions and hallucinations impact on their feelings and behaviour. For example a patient may hear voices and believe that they are demons and be very afraid. Offering plausible explanations for these symptoms can reduce anxiety/distress and helps the patient realise their beliefs (e.g. delusions) are not based in reality.

Positive self talk can also be used, for example, if an individual hears negative voices, they can say positive statements that challenge the auditory hallucinations.

Therapist would also teach self distraction strategies for example listening to music to drown out voices.

Question 17

AO3 for cognitive behaviour therapy

Answer 17

Research into the effectiveness of CBT was carried out by Jauhar et al. They reviewed the results of 34 studies of CBT as a treatment for schizophrenia. They concluded that CBT has a significant but small effect on both positive and negative symptoms. Demonstrating that CBT is fairly effective in treating schizophrenia and that by challenging patients irrational thoughts it can reduce symptoms of schizophrenia. however, it is worth noting that out of 34 studies, CBT only had small impact on SZ symptoms. therefore placing doubt on the effectiveness of CBT as a treatment of SZ.

A limitation of CBT as a treatment for schizophrenia is that it requires motivation and commitment from patients to attend sessions, this is something that individuals suffering from negative symptoms of schizophrenia, such as avolition, often lack. THINK FURTHER… CBT also
requires a patient to engage with the therapy, however, somebody with positive symptoms of schizophrenia (delusions) may have a lack of awareness. Therefore in some cases of schizophrenia, CBT is only effective when combined with antipsychotics. This is because the drugs help the
patient to motivate themselves to attend the sessions/increase the patients awareness. Therefore, CBT alone may not be an effective treatment for all cases of schizophrenia

Moreover, another limitation of CBT as a treatment of schizophrenia is that is it very time-consuming as it requires the patient to attend weeks/months of sessions before the therapy effectively treats their schizophrenia. Unlike biological treatments such as antipsychotics which are effective in the short term as they are quick at reducing patients positive symptoms such as delusions and hallucinations in a couple of weeks. Therefore, CBT may not be an appropriate cognitive treatment for all patients with schizophrenia as patients may drop out of therapy, this will also reduce the effectiveness of the therapy.

Question 18

Family Therapy – AO1

Answer 18

• altering relationship and communication patterns within
  dysfunctional families should help schizophrenics to recover.
• It also works by reducing Expressed emotion and stress levels within the family which may contribute to a patient’s risk of relapse.
  The main aim of family therapy is to reduce levels of expressed emotions/stress by:
  1) Improving families’ beliefs about and behaviour towards schizophrenia
  2) Reducing the stress of caring for a relative with schizophrenia
  3) Decreasing feelings of guilt and anger in family members.
  4) Helping family members achieve a balance between caring for the individual with schizophrenia and maintaining their own lives.
  Therapists meet regularly with patients and family members, over the course of around 9 months to a year, and are encouraged to be open and talk about the patient’s symptoms, behaviour and progress.

Question 19

Family Therapy AO3

Answer 19

Research to support Family therapy as a treatment for schizophrenia was conducted by, Leff et al (1985) compared family therapy with routine outpatient care for schizophrenics and found that in the first 9 months of treatment 50% of those receiving routine care relapsed, compared
with only 8% of those receiving family therapy. This suggests that family therapy is an effective therapy for treating schizophrenics.

A limitation of family therapy as a treatment of schizophrenia is that it does not get to the root cause (aetiology) of schizophrenia. It works by helping to reduce the stress of living with schizophrenia in a family, for both the patient and family members, this does not eliminate the symptoms completely. This questions the appropriateness and effectiveness of the therapy as when the therapy stops patients could relapse, which is what Hogarty et al (1986) found in a follow up study of patients who had received family therapy.

Moreover, In family therapy emphasis is placed on ‘openness’, this can sometimes be an issue as it may cause or reopen family tensions. Some family members may also be reluctant to talk about, or even admit, their problems, lowering the effectiveness of family therapy as a treatment for schizophrenia.

Due to these weaknesses, an alternative therapy that may be useful in treating schizophrenia is art therapy. This is less well known and less likely to be available to patients. However art therapy takes place with a specially trained art teacher who has worked with patients with schizophrenia and allows patients to interpret their emotions and feelings, and express them without necessarily using words, in a safe environment. It also acts as a healthy form of distraction from various symptoms, such as disturbing thoughts, hearing voices, etc. Therefore art therapy may be more appropriate treatment than family therapy for schizophrenia.

Question 20

what does diathesis mean

Answer 20

vulnerability (at risk)

Question 21

what does stress mean

Answer 21

a negative psychological experience

Question 22

what is the interactionist approach

Answer 22

The Interactionist approach suggests that schizophrenia is developed due to a combination of biological, psychological and social factors. This is known as the diathesis-stress model

Question 23

How do we explain the diathesis stress model

Answer 23

• In Meehl’s original diathesis stress model, diathesis (vulnerability) was entirely genetic
• It was down to a single ‘schizogene’, which made somebody sensitive to stress
• Meehl suggested that if a person does not have this schizogene then no amount of stress would lead to schizophrenia.
• However, if you have the gene, stress through childhood, such as having a schizophrenogenic mother could lead to schizophrenia.
• However, it is now believed that there is no single schizogene, but that it is many genes that increase generic vulnerability to schizophrenia (polygenic).
• It is also believed that factors other than genes can be a diathesis such as psychological trauma. Early and severe enough trauma, such as child abuse can seriously affect aspects of brain development and can make a person more vulnerable to later stress.
• Moreover, a modern definition of stress (trigger) includes anything that risks triggering schizophrenia, not just parenting. Much of the recent research has concerned cannabis use.
• In terms of the diathesis-stress model cannabis is the stressor because it increases the risk of schizophrenia by up to seven times according to the dose. Probably due to its interference with the dopamine system. However, not everyone develops schizophrenia after smoking cannabis
  suggesting there must also be one or more vulnerability factors

Question 24

Treating schizophrenia: diathesis stress model AO1

Answer 24

• The interactionist model considers both biological and psychological factors in the development of schizophrenia and therefore is compatible with both biological and psychological treatments for schizophrenia.
• In particular, the combination of antipsychotic medication and psychological therapies, most commonly CBT.

-Turkington et al (2006) argue that it is possible to believe in biological causes of schizophrenia and still practice CBT to relieve psychological symptoms.
- However, this requires adopting an interactionist model. It is not possible to adopt a purely biological approach and tell the patient their condition is purely biological and that there is no psychological significance to symptoms, and then to treat them with CBT.

In the UK, treatments such as CBT, family therapy and drug therapy are often combined

Question 25

AO3 for interactionist approach

Answer 25

Research to support the interactionist approach in explaining schizophrenia comes from Tienari et al (2004). They followed up 19,000 adopted children in Finland whose mothers had schizophrenia and compared them to a control group of adopted children without any genetic risk. The child rearing styles of the adoptive parents were observed. Those children who were brought up in families with a lot of conflict and low empathy (family dysfunction) were much more likely to
develop schizophrenia but only in the children who had a genetic vulnerability, not the control group. This suggests that both genetic vulnerability and family related stress are important in the development of schizophrenia.

However, one limitation of the interactionist approach to explaining schizophrenia is that there are individual differences, for example two people may have the same vulnerability and stressor but one may not develop schizophrenia. This means that we do not have a full understanding of the interactionist approach to explaining schizophrenia and more research may need to be conducted.

Research to support the interactionist approach in treating schizophrenia was conducted by Tarrier et al (2004). 315 patients were randomly allocated to treatment conditions. They found that patients given a combined therapy of medication and CBT/counselling had lower symptom
levels than a control group with just one treatment (medication). This therefore suggests by adopting an interactionist approach and using both biological and psychological therapies, patient’s schizophrenic symptoms will be treated more effectively.

However, despite the research to support…The interactionist approach to treating schizophrenia may not be correct. Just because combining both biological and psychological treatments is more effective, does not necessarily mean the approach is right when explaining the development of schizophrenia. The fact that drugs help does not mean that schizophrenia is purely biological. This mistake is known as the ‘treatment-causation fallacy’ and is a limitation of the interactionist approach to explaining and treating schizophrenia.