schizophrenia

Question 1

what is schizophrenia?

Answer 1

a severe psychotic disorder where contact with reality and insight are impaired.

Question 2

two major classification systems for disorders

Answer 2

1. The International Classification of Diseases 10 (ICD-10)
2. The Diagnostic and Statistical Manual 5 (DSM-5)

The definitions in these manuals differ. This can lead to inconsistency and therefore unreliability however it can also be good since there is competition to be the “best most accurate manual”.

Question 3

ICD classification of Schizophrenia

Answer 3

• recognises sub-types
• having a positive symptom is not necessary

Question 4

DSM classification of Schizophrenia

Answer 4

• does not recognise sub-types
• one positive symptom must be present at the time of diagnosis

Question 5

what are positive symptoms (give examples within schizophrenia)?

Answer 5

• additional experiences to normal functioning
  eg. hallucinations
  eg. delusions aka paranoia

Question 6

what are hallucinations?

Answer 6

• unusual sensory experiences
• can both be related and irrelated to the environment
• such as voices (often critical) talking to or commenting on the sufferer
• can be experienced in relation to any sense eg. distorted faces or people/animals that aren’t actually there

Question 7

what are delusions?

Answer 7

• irrational beliefs either of persecution (such as people following you) or of grandeur (such as believing you are a political figure)
• mostly not aggressive and sufferers are more likely to be the victims than aggressors

Question 8

what are negative symptoms (give an example from schizophrenia)?

Answer 8

• the loss of usual functioning/experiences
  eg. avolition aka apathy

Question 9

what is avolition (apathy)?

Answer 9

• finding it difficult to begin or keep up with goal-directed activity, sharply reduced motivation
  > Andreason (1982) identified 3 identifying signs of avolition: poor hygiene and grooming, lack of persistence in work/education, lack of energy

Question 10

what is speech poverty (compare ICD and DSM)?

Answer 10

In the ICD-10, speech poverty is considered a negative symptom of schizophrenia characterised by:
- changes in patterns of speech
- reduction in the amount and quality of speech
- sometimes accompanied by a delay in verbal responses during conversation

The DSM 5 places emphasis more on speech disorganisation in which the speech becomes incoherent or involves mid-sentence topic changes, this is classified as a positive symptom.

Question 11

what were the subtypes of Schizophrenia?

Answer 11

Paranoid Schizophrenia - powerful delusions but relatively few other symptoms
Hebephrenic Schizophrenia - primarily negative symptoms present (also called disorganised)
Catatonic Schizophrenia - disturbance to movement leaving the sufferer immobile

Question 12

what is classification?

Answer 12

the process of organising symptoms into categories based on which symptoms cluster together in sufferers. Psychologists use the DSM and ICD to diagnose patients with Schizophrenia

Question 13

what is diagnosis?

Answer 13

the assigning of a label to a patient

Question 14

reliability issues in the diagnosis/classification of schizophrenia

Answer 14

• level of agreement on a diagnosis by different psychiatrists (inter-rater reliability)
• stability of diagnosis overtime (when symptoms remain unchanged)

Question 15

validity issues in the diagnosis/classification of schizophrenia

Answer 15

• symptom overlap (especially with bipolar)
• gender bias
• culture bias
• comorbidity (especially with depression, substance abuse, and PTSD)
• criterion validity (both assessment systems arrive at the same diagnosis for the same patient)

Question 16

Cheniauz et al. (2009) - schizophrenia diagnosis has low criterion and inter-rater reliability

Answer 16

• two psychiatrists independently diagnose 100 patients using both DSM and ICD criteria.
• one psychiatrist diagnosed 26 according to the DSM and 44 according to the ICD and the other diagnosing 13 according to the DSM and 24 according to the ICD - LOW INTER-RATER

> some patients may not receive a diagnosis when it is needed, inhibiting their ability to obtain treatment
low criterion validity (either over- or under- diagnosed using the ICD or DSM), may receive a diagnosis when they shouldn’t, perhaps leading to the use of unsuitable medications

Question 17

Buckley et al. (2009) - comorbidity of Schizophrenia

Answer 17

• 50% of patients with Schizophrenia are also diagnosed with depression, 47% are also diagnosed with substance abuse, 29% with PTSD, and 23% with OCD.
  > could be that practitioners are poor at telling the difference between conditions like depression and schizophrenia
  > if someone is incorrectly diagnosed with schizophrenia, this is difficult to change later and could result in the use of ineffective/inappropriate treatments which could worsen symptoms

Question 18

Longenecker et al. (2010) - prevalence in men vs women

Answer 18

• reviewed studies on the prevalence of Schizophrenia and found that (since the 1980s) men have been diagnosed with schizophrenia more frequently than women.
  > could reflect genuine differences in prevalence or reflect the gender bias in the classification/diagnosis of Schizophrenia
  > lack of faith in the mental health field due to failure to diagnose when women seek out help

Question 19

Cotton et al (2010) - characterisation in men vs women

Answer 19

found that female patients typically function better than men, being more likely to work and have good family relationships.
> so may go undiagnosed

Question 20

Harrison et al. - culture bias

Answer 20

• found that African Americans and English people of Afro-Caribbean origin are 8 times more likely to be diagnosed with schizophrenia than white people.
  > Escobar (2012) explained this by pointing out that psychiatrists (often white) tend to over-interpret symptoms and distrust the honesty of black people during diagnosis
  > some African cultures find hearing voices more acceptable due to cultural beliefs in talking to ancestors, this could mean that they are more likely to acknowledge and report these experiences

Question 21

writing about issues with classification/diagnosis of schizophrenia

Answer 21

• no AO1 paragraph at the start
• in a 16 marker, at least 4 PEECs describing and evaluating each issue
• in an 8 marker, at least 2, ideally 3 PEECs
• for each paragraph:
  
  1. state the issue
  2. explain what the issue is
  3. bring in evidence of this issue
  4. explain why this is a problem
  5. detailed consequence of this issue

Question 22

Rosenhan’s study: ‘On Being Sane in Insane Places’ (1973)

Answer 22

> testing stability of diagnosis over time (when symptoms change)
- 8 pseudopatients at different hospitals claimed to hear unfamiliar voices of the same sex as the pseudopatient saying ‘empty’, ‘hollow’, and ‘thud’
- 7 were diagnosed with schizophrenia and 1 with manic depression
- once admitted, they behaved normally and wrote down their observations of the institution
- staff never detected that they were ‘sane’ and interpreted ‘normal’ behaviours as abnormal eg. pathological writing

Question 23

conclusions based on Rosenhan’s research

Answer 23

• so their symptoms changed but the diagnosis didn’t, suggesting that the diagnosis was not reliable over time
  > since then, the system has changed significantly and the study is also over forty years old

It is also very difficult to get a diagnosis removed, especially if it is one that invalidates your view of reality.

Question 24

what are the biological explanations for schizophrenia?

Answer 24

genetics and neural correlates

Question 25

genetic explanations for schizophrenia

Answer 25

• investigated using family, adoption, and twin studies
• schizophrenia has been found to run in families
• a positive correlation has been found between genetic similarity and shared risk of developing schizophrenia
• concordance rates are used to demonstrate the percentage risk of developing schizophrenia, eg. Gottesman (1991)
• Schizophrenia is polygenic and aetiologically heterogeneous
• 108 candidate genes for schizophrenia

Question 26

what are candidate genes?

Answer 26

• individual genes believed to have an association with risk of inheritance, Schizophrenia appears to have a number of candidate genes so is polygenic

Question 27

candidate genes in Schizophrenia

Answer 27

• according to Ripke et al. (2014), Schizophrenia has been associated with 108 separate genetic variations
• since it appears to have a number of genes that give an increased risk, it is considered polygenic (requires a number of factors to work in combination)

Question 28

what does aetiologically heterogeneous mean?

Answer 28

• different combinations of factors can lead to the condition

Question 29

evaluation of the genetic explanation

Answer 29

+ Gottesman as supporting the genetic explanation, as genetic similarity increased, so did concordance
- MZ twins do not have 100% concordance rate so there must also be environmental factors, siblings and DZ twins have different concordance rates but the same genetic similarity
- not useful, not direct causation from the 108 candidate genes
- diathesis stress model/interactionist approach may be a better alternative to genetics as a sole explanation
- dangerous to link genetics to characteristics/disorders, eg. eugenics policies

Question 30

what are neurotransmitters?

Answer 30

• endogenous (internal) chemicals that enable neurotransmission
• a type of chemical messenger which transmits signals across a chemical synapse
• carry, boost, and balance signals between neurons, or nerve cells, and other cells in the body.
• sent over synapses whereas hormones travel through the bloodstream.

Question 31

the dopamine hypothesis

Answer 31

• the neurotransmitters of a schizophrenic patient seem to work differently to a non-schizophrenic individual (although the differences are not the same across all patients)
• in particular, dopamine is believed to be involved in the disorder with excess or lack of the neurotransmitter in specific areas of the brain
• dopamine is important in the functioning of several brain symptoms that may be implicated in the symptoms of schizophrenia
• two types: hyperdopaminergia and hypodopaminergia

Question 32

hyperdopaminergia

Answer 32

• the original dopamine hypothesis
• high levels of dopamine in the subcortex (just below the outer edge of the forefront of the brain)
• could be that messages from neurons fire too easily or too often leading to hallucinations and delusions, also individuals with schizophrenia are thought to have abnormally high numbers of D2 receptors on post-synaptic neurons, resulting in more dopamine binding and therefore more neurons firing

Question 33

example for hyperdopaminergia

Answer 33

• eg. an excess of dopamine receptors in Broca’s area (responsible for speech production) may be association with poverty of speech in schizophrenics

Question 34

amphetamines evidence for hyperdopaminergia

Answer 34

• amphetamine stimulates nerve cells containing dopamine causing the synapse to be flooded with dopamine, typically individuals exposed to large doses develop characteristic hallucinations and delusions of a schizophrenic episode, this generally disappears with abstinence from the drug
• people who suffer from Parkinson’s who take the drug L-dopa to raise the levels of dopamine have also displayed schizophrenic symptoms

Question 35

Hypodopaminergia and example

Answer 35

• the more recent version of the hypothesis
• abnormal dopamine systems in the brain’s cortex
• eg. Goldman-Rakic et al. (2004) have identified a role for low levels of dopamine in the prefrontal cortex (responsible for thinking and decision making) in the negative symptoms of schizophrenia eg. disordered thinking and avolition

Question 36

ventral striatum and schizophrenia (neural correlates)

Answer 36

• responsible for motivation and the anticipation of reward > avolition
• eg. Juckel et al. (2006) measured activity levels in the ventral striatum of people with schizophrenia and found much lower activity than in control groups
• They also observed a negative correlation between activity levels in the ventral striatum and severity of negative symptoms

Question 37

superior temporal gyrus and anterior cingulate gyrus

Answer 37

eg. Allen et al. scanned the brains of patients experiencing auditory hallucinations and a control group whilst they identified pre-recorded speech as theirs or others, low activation levels in these areas were found in the hallucination group, they also made more errors

Question 38

evaluation of the dopamine hypothesis

Answer 38

+ amphetamine research
+ practical applications for helping people with schizophrenia (drug therapies to change the dopamine levels)
- correlation not causation - it may be that the symptoms are altering brain chemistry, so avolition leading to low levels of dopamine in the prefrontal cortex
- neglects environmental factors, too simplistic (eg. diathesis stress model)

Question 39

two types of drug given to treat schizophrenia

Answer 39

1. Typical antipsychotics - 1st generation, developed in the 1950s, primarily used to combat the positive symptoms of schizophrenia
2. Atypical antipsychotics - 2nd generation, combat positive symptoms but also have some benefit on negative symptoms

Question 40

typical antipsychotics

Answer 40

• aim to reduce the effect of dopamine and so reduce the symptoms of schizophrenia
• work by acting as antagonists in the dopamine system (bind to but do not stimulate dopamine receptors in the synapses of the brain therefore blocking their action and thus reducing the action of dopamine)
• this dopamine antagonist effect normalises neurotransmission in key areas of the brain, reducing symptoms of hallucinations and delusions
  eg. Chlorpromazine (1950s)

Question 41

atypical antipsychotics

Answer 41

• called ‘second generation’ because of their three main differences to typical antipsychotics:
  
  1. they carry a lower risk of extrapyramidal side effects (related to movement)
  2. have a beneficial effect on negative symptoms and cognitive impairment
  3. suitable for treatment-resistant patients
• these drugs also act on the dopamine system but by temporarily blocking D2 receptors but then rapidly dissociate to allow normal dopamine transmission

Question 42

clozapine

Answer 42

(1970s - atypical antipsychotic) binds to dopamine receptors but it also acts as an agonist (increase) on serotonin and glutamate receptors believed to help improve mood and reduce depression, due to this, clozapine is sometimes prescribed when a patient is at particular risk of suicide

Question 43

risperidone

Answer 43

(1990s- atypitcal antipsychotic)
- an attempt to produce a drug as effective as Clozapine but without the serious side effects
- believed to bind to dopamine and serotonin receptors but binds to dopamine receptors much more strongly than Clozapine so it is effective in much smaller doses
- it is believed that because of this it produces less side effects.

Question 44

evaluation of biological therapies for schizophrenia

Answer 44

+ supporting evidence eg. Thornley et al. compared the effects of chloropromazine to control conditions in which patients recieved a placebo, 1121 participants showed that the drug produced better overall functioning and reduced symptom severity, relapse rate was also lower
> David Healey suggested that studies are exaggerating the evidence for positive effects eg. powerful calming effects of antipsychotics may have been confused with positive results, the drug treatments are not actually reducing severity of psychosis, many studies also fail to assess long-term effects and significant withdrawal symptoms
> still improving quality of life?
- in response to criticisms around the severe side effects which raise ethical issues, eg. coma, death, tardive dyskenesia (involuntary facial movements), atypical antipsychotics have significantly reduced side effects in comparison to typical antipsychotics
- medication may not be an appropriate treatment for patients dealing with less severe hallucinations/questioning reality, they may refuse to take tablets so talking therapy may be more useful to deal with symptoms so that they will engage with medication, therapy is also useful for dealing with family dysfunction which can be an underlying cause

Question 45

psychological explanations of schizophrenia

Answer 45

1. family dysfunction (double bind theory, expressed emotion, schizophrenogenic mother)
2. cognitive explanations (for hallucinations and for delusions)

Question 46

double-bind theory

Answer 46

• Bateson’s (1956)
• suggests that the developing child regularly finds themselves in situations where they feel they are doing the wrong thing but they repeatedly receive mixed messages about what this is
• when the child ‘gets it wrong’ they are punished with withdrawal of love
• this leaves them with the belief that the world is confusing and dangerous, causing them to develop a false concept of reality and an inability to communicate effectively
• this is reflected in the symptoms of schizophrenia (disorganised thinking, paranoid delusions)
• Bateson was clear that his double-bind theory was a risk factor for developing schizophrenia not the only factor

Question 47

flow chart of the double-bind theory

Answer 47

child receives mixed messages about right and wrong —> gets it wrong —> withdrawal of love from parent –> false concept of reality and cannot communicate effectively —> disorganised thinking and paranoia

Question 48

expressed emotion

Answer 48

• originally based on work by Brown (1972) which suggested that patients with Schizophrenia are 4x more likely t o relapse if they returned to homes characterised by high levels of expressed emotions eg. hostility, criticism, and over-concern
• high levels of expressed emotion are a serious source of stress for the patient beyond their already impaired coping mechanisms thus triggering a schizophrenic episode

Question 49

how is expressed emotion measured?

Answer 49

measured by taping an interview with a relative of someone with schizophrenia and rating the following:
- hostility
- critical comments
- over-concern and over-involvement

Question 50

issues with the method of measuring expressed emotion

Answer 50

• subjective and open to bias
• only a snapshot in time, they may not act in the same way around the person - they are under a lot of stress and pressure (an opportunity to vent and be honest)
• social desirability bias
• hard to differentiate between categories (especially critical comments and hostility)
• given the situation, a loved one who has schizophrenia and may have put themselves in danger before, over-concern may not be unreasonable

Question 51

schizophrenogenic mother

Answer 51

(schizophrenia-causing)
- Fromm-Reichmann (1948) proposed a psychodynamic explanation for schizophrenia based on the accounts she heard from her patients about their childhoods
> retrospective studies like this are often inaccurate due to memory
> reality-distortion

Question 52

the schiziphrenogenic mother is… how does this lead to schizophrenia?

Answer 52

• cold
• rejecting
• controlling
• creates a family climate characterised by tension and secrecy
  These characteristics lead to distrust that then later develops into paranoid delusions and, ultimately, schizophrenia.

Question 53

evaluation of family dysfunction as an explanation of schizophrenia

Answer 53

+ Bateson recognises that DBT is a risk factor which allows for and encourages further research
- retrospective data-collection which is inaccurate (schizophrenogenic mother and double-bind)
- subjective methods of investigation
- ethical implications: could lead to blame (eg. “schizophrenogenic mother”) for families who are already likely to be struggling