Schizophrenia

Question 1

definition of schizophrenia

Answer 1

A mental disorder that is characterised by the disruption of cognitive and emotional functioning.

It effects language, thoughts, perceptions, emotions and sense of self.

The person hears voices and sees visions.

Question 2

Causes of schizophrenia

Answer 2

• biochemistry in the brain (high dopamine)
• structural damage
• abnormal birth
• bacteria in the brain
• family dysfunction

Question 3

An Introduction to Schizophrenia

Answer 3

1911 - Bleuler came up with the term schizophrenia which means split mind

The illness has a 1% prevalence rate

age of onset 15-45

equal chances of men and women getting the illness

Question 4

Type I Acute schizophrenia:

Answer 4

Obvious positive symptoms appear suddenly - usually after stressful events.

Question 5

Type II Chronic schizophrenia:

Answer 5

The illness takes many years to form and gradual change of increased disturbance and withdrawal occur.

Characterised by negative symptoms.

Question 6

The types of schizophrenia according to ICD-11

Answer 6

1) disorganised – hallucinations, incoherent speech, mood swings

2) catatonic – immobility

3) paranoid -delusions

4) undifferentiated – do not fit in with other categories

5) residual – had schizophrenia in the past but do not have enough of the symptoms now to be classified as schizophrenic

6) simple schizophrenic – no delusions but negative symptoms of psychosis might be present

7) post schizophrenia depression – has a schizophrenic episode followed by long term depression

Question 7

Classifying schizophrenia: International Classification of Diseases tenth edition (ICD-11)

Answer 7

Produced by the World Health Organisation and is updated every few years

Focuses on clusters of symptoms needed to classify a psychiatric illness

For schizophrenia, the ICD-11 focuses on subtypes of schizophrenia, whereas DSM-V does not do this anymore.

Question 8

The Diagnostic Statistical Manual fifth edition (DSM-V):

Answer 8

Classification and description of 200 mental disorders which are grouped together in terms of features

Produced in the USA

Updated every few years

DSM-IV used to have subtypes of schizophrenia that existed, however when DSM-V was introduced, the subtypes were removed.

Question 9

DSM-V criteria for schizophrenia:

Answer 9

Criterion A:
2 or more of the following criteria must be present, OR only one of the criteria must be present if the delusion is bizarre or hallucinations consist of a running commentary of the person’s behaviour or thoughts:
A) Delusions
B) Hallucinations
C) Disorganised speech
D) Grossly disorganised/catatonic behaviour
E) Negative symptoms such as flattening/avolition

Criterion B: Social/occupational dysfunction:
Since the onset of schizophrenia, one or more areas of functioning will be negatively affected e.g. work/interpersonal/self-care.

Criterion C: Duration
Continuous signs of disturbance will be present for 6 months or more.
Symptoms from criterion A must be present for one month.
During non-active periods, disturbance might be limited to negative symptoms only, or two or more symptoms from criterion A.

Question 10

The positive symptoms of schizophrenia:

Answer 10

Symptoms that have been added to the patients personality as they now have schizophrenia
These symptoms were not present when the person was healthy

EXAMPLES:
Hallucinations
Delusions
Disorganised speech
Grossly disorganised/catatonic behaviour

Question 11

The negative symptoms of schizophrenia:

Answer 11

The reduction or loss of functioning.

The person will have a weakened ability to cope and manage in every day life.

The person loses their ability to do certain things because of their illness

Examples:
Deficit syndrome
Speech poverty
Avolition/apathy
affective flattening/blunting
Anhedonia

Question 12

Hallucinations

Question 13

Delusions

Question 14

Disorganised speech

Question 15

Grossly disorganised/catatonic behaviour:

Question 16

Speech disorganisation

Answer 16

Avolition/apathy

Question 17

Affective flattening/Blunting

Question 18

Anhedonia

Question 19

Reliability: AO1:

Answer 19

The ICD and DSM-V should be reliable.

There should be a good consistency of diagnosis of schizophrenia over a period of time and between different psychologists.

Inter-rater reliability means that 2 different psychologists would agree and both diagnose the illness of schizophrenia

Question 20

Validity: AO1:

Answer 20

A diagnostic system assesses what it claims to be assessing (schizophrenia).

If the DSM and ICD are valid that we can be confident in saying that people who have been diagnosed with schizophrenia do actually have that disorder and not another.

Content validity -when you look at the content of a test and it should be measuring all the content of schizophrenia as an illness

Concurrent validity

Face validity

Ecological validity

Predictive validity – looking at a test and predicting how severe the symptoms might get or what the symptoms might lead to.

Question 21

Co-morbidity (AO1) (Validity issue)

Answer 21

Refers to the extent that two or more illnesses occur simultaneously in a patient e.g. schizophrenia and depression.

This is an important issue when considering the validity in diagnosing and classifying schizophrenia.

Swets stated that 1% of the population will suffer from schizophrenia and 2.5% from OCD. However, 12% of schizophrenic patients meet the diagnostic criteria to also be suffering from OCD. This causes the problem of classifying the illness as schizophrenia, and not OCD.

The boundaries between schizophrenia and mood disorders are blurred, and both types of illnesses share many symptoms. E.g depression is co-morbid with schizophrenia.

Therefore a psychologist must use their professional judgement to try to categorise a patient as either being possibly depressed or having schizophrenia.

This means that full consultation using the DSM and ICD must be used in order to get the correct and valid diagnosis of the illness.

Question 22

Evaluation of co-morbidity (AO3)

Answer 22

Disadvantages:

1) The DSM and ICD can be viewed as lacking validity. There is too much of an overlap between schizophrenia, mood disorders and OCD. Clinicians need to be certain that the patient really has schizophrenia and not another illness. Sometimes clinicians might classify the patient as having both schizophrenia and depression as a way to get round the problem of making a judgement between schizophrenia and depression. Sometimes a second opinion from another clinician might be required in order to make an accurate and valid diagnosis.

2) Research conducted by Sim found that the diagnosis of schizophrenia can be invalid and unreliable because of the issues surrounding co-morbidity. He found that 32% of 142 hospitalised schizophrenic patients had additional mental disorders which is a problem when diagnosing and classifying the illness.

3) Co-morbidity can be a problem when diagnosing schizophrenia. It has been found from research that schizophrenic patients have used alcohol and suffer from substance abuse before they were diagnosed with the illness (as well as during their illness). This makes it incredibly difficult to give a reliable and valid diagnosis of schizophrenia, because some of the symptoms of the illness are the same as those who use drugs and alcohol

4) Jeste conducted research and identified problems that would lead to low levels of validity. He found that schizophrenic patients with co-morbid illnesses were often excluded from research, but the majority of schizophrenic patients do actually suffer from other psychological illnesses. Research findings from schizophrenia patients cannot be generalized to all patients and might be invalid overall.

Question 23

Culture bias: (AO1) Reliability & validity issue

Answer 23

Culture has an influence on the diagnosis and classification of schizophrenia.

E.g Auditory hallucinations can be influenced by culture.

Luhrmann interviewed 60 adults with schizophrenia, (20 from Ghana, 20 from India and 20 from USA), all of the patients reported that they heard voices, but the patients from the USA reported the most negative experiences associated with the voices, e.g. the voices were violent and hateful. Therefore culture has an influence on the reliability of diagnosing schizophrenia.

Davison and Neale explain that in Asian cultures, some people are praised if they do not show that they are suffering from an emotional/psychological problem, so people from Asian cultures might be unlikely to seek psychological help if they have schizophrenia and will therefore not appear in any stats.

In Arabic cultures, people are encouraged to show emotions, and therefore this culture might be more likely to seek help for schizophrenia if they have it and there might be more stats and data available for this group.

Therefore there is a cultural bias when examining the number of people from different cultures that suffer from schizophrenia.

Question 24

Evaluation of culture bias (AO3)

Answer 24

ADVANTAGES:
1) Research evidence has found support for cultural relativism. Afro-Caribbean people have little immunity to flu, and children born to mothers who had flu when they were pregnant in their second trimester, have an 88% increased chance of developing schizophrenia. Therefore there might be a cultural vulnerability which means Afro-Caribbean’s might be more at risk from developing schizophrenia than the white population

2) Barnes suggested there is supporting research evidence for cultural differences when diagnosing and classifying schizophrenia. The Ethnic Culture hypothesis predicts that ethnic minorities experience less distress if they suffer with schizophrenia, as they have protective characteristics and social structures that exist in their culture. 184 individuals with schizophrenia were investigated from African American, Latino or White American cultures. It was found that Americans had more symptoms than the other 2 cultures because they had less protective and supportive features in their culture (social support)

DISADVANTAGES:
1) A negative point about diagnosing and classifying schizophrenia is cultural relativism. The psychologist might not be able to understand the patient’s symptoms correctly due to not fully understanding the patient’s cultural background, and might misdiagnose schizophrenia. The psychologist might also wrongly label the patient as schizophrenic if they make incorrect judgements about the patient in terms of their cultural background. Also some people from an African background might be wrongly diagnosed with schizophrenia due to the fact that they might claim that they can hear the voice of God (due to religion). In the African culture, these people would be seen as gifted; however in the western world this could be interpreted as a hallucination (auditory), and could be judged as being a symptom of schizophrenia, which could lead to an incorrect and invalid diagnosis.

Question 25

Gender bias (AO1) Validity issue:

Answer 25

The accuracy of diagnosing schizophrenia can be dependent on the gender of the patient which leads to a gender bias occurring.

Male sufferers of schizophrenia tend to show more negative symptoms than women, and also seem to suffer from more substance abuse.

Males have an earlier onset (aged 18-25 years) of schizophrenia than females (25-35 years).

There seems to be great disagreement amongst clinicians when diagnosing schizophrenia, especially when the factor of gender is taken into account.

The accuracy of diagnosis can vary due to clinicians having stereotypical beliefs about gender. Critics of the DSM argue that healthy adult behaviour is linked more to healthy males rather than healthy females. Therefore the DSM could be viewed as being gender biased, especially when trying to classify and diagnose the symptoms of schizophrenia, which might be invalid.

Question 26

Evaluation (AO3)

Answer 26

DISADVANTAGES:
1) There is a problem of gender bias occurring when diagnosing schizophrenia and research support comes from Loring. He gave 290 male and female psychologists case studies of patients to read (one male and one female). Psychologists had to judge the patients using diagnostic criteria. When the patient was described as male, or no information was given about gender, 56% of psychologists diagnosed the patient as schizophrenic. When the patient was described as female, 20% of the psychologists diagnosed schizophrenia. Therefore there is a gender bias when diagnosing schizophrenia, and this was especially prominent when the psychologist was male.

2) The validity of the diagnosis of schizophrenia can be questioned, especially as it seems that females develop schizophrenia 4-10 years later than males do. There are different types of schizophrenia that males and females are vulnerable to, so this must be taken into account when diagnosing and classifying the illness.

ADVANTAGES:
1) Research evidence by Kulkarni has found supporting data to suggest that females might be less vulnerable than males to schizophrenia. He found the female sex hormone estradiol can help treat schizophrenia in females, especially when added to anti-psychotic drugs. It seems that estradiol might be a protective factor present in females that might lower their chances of getting schizophrenia compared to males. Clinicians must take this into account when diagnosing schizophrenia, especially in females, in order to ensure the diagnosis is valid.

Question 27

Symptom Overlap: (AO1): Validity:

Answer 27

The positive and negative symptoms of schizophrenia are a valid diagnosis of schizophrenia, however some of the symptoms of schizophrenia can also be found in the other disorders such as depression and bipolar disorder, and this can affect the validity of diagnosis.

Ross found that patients who had Dissociative Identity Disorder had many symptoms which overlapped with schizophrenia, so much so, that they could have been diagnosed with schizophrenia

Other illnesses that seem to show symptom overlap with schizophrenia include:
* Bipolar depression (depressed mood, episodes of mania/energy, unpredictable, hallucinations delusions)
* Depression (hallucinations)
* Cocaine intoxication (paranoia, disorganized speech, delusions)
* Schizotypal personality disorder (similar symptoms of schizophrenia, but milder)

Clinicians must be very careful when diagnosing schizophrenia to ensure that they have identified the correct and valid diagnosis.

Question 28

Evaluation (AO3):

Answer 28

ADVANTAGES:

1) In order to correctly diagnose schizophrenia in a valid way, clinicians should conduct a brain scan or EEG. This can examine the brain in detail and especially check the grey matter in the brain (where intelligence is held). Schizophrenic patients tend to suffer from a deterioration of grey matter, and this can be checked by conducting a brain scan to make sure the correct illness has been diagnosed. Patients who have bipolar depression do not have a reduction in grey matter.

DISADVANATGES:
1) A problem of symptom overlap is that it can cause misdiagnosis of schizophrenia. Ketter found evidence of schizophrenia being misdiagnosed as another illness, because of symptom overlap. This causes years of delays, whereby schizophrenia patients do not receive the necessary treatment that they actually need, and their illness gets worse. This can increase rates of suicide and deterioration. Therefore it is important than patients get a valid and accurate diagnosis in the first place.

2) Research evidence has supported the idea that inter-rater reliability is actually quite low, especially when asking psychologists to agree on diagnosing schizophrenia and not another illness. Beck studied 154 patients who met with two different psychiatrists. It was found that inter-rater reliability was 54%, which means that there was 54% agreement between the two psychiatrists in terms of diagnosis of the illness schizophrenia. This therefore suggests that different psychiatrists might give different diagnosis to the same patient who display the same symptoms of schizophrenia

Question 29

Genetic causes of schizophrenia: AO1:

Answer 29

Schizophrenia arises due to a combination of many factors, but it seems that biological factors such as genetics might play an important role in the development of the illness.

Question 30

A study by Ripke et al (2014): AO1

Answer 30

• Ripke suggested that schizophrenia might be polygenic (a number of candidate genes might be responsible for schizophrenia)
• He did a meta-analysis of studies that looked at candidate genes and schizophrenia sufferers.
• 37,000 schizophrenia sufferers were investigated compared to 11,000 controls
• He found that 108 separate genetic variations were associated with increased risk of getting schizophrenia.
• These genes seemed to code for the functioning of dopamine. High levels of dopamine can cause schizophrenia

Question 31

An Evaluation of the study by Ripke: (AO3):

Answer 31

ADVANTAGES:
1) There is a great amount of research support from many psychologists e.g Gottesman and Kety that schizophrenia does seem to be caused by genetics, which makes the evidence robust and strong. Therefore genetics cannot be ignored as a major cause for schizophrenia

2) The research conducted by Ripke can by supported by the dopamine hypothesis which states that high levels of dopamine in the D1 and D2 receptors in the brain can cause schizophrenia. Ripke’s work can be praised for linking together two biological mechanisms that could cause schizophrenia: genetics and the link to high dopamine production.

DISADVANTAGES:

1) Although genetics has a great deal of support, we must be cautious when looking at genetics alone as a cause for schizophrenia. Other approaches need to be examined in terms of what could cause schizophrenia. E,g the behavioural model might suggest that children can learn abnormal behaviours via the environment (conditioning and social learning theory), and this could help develop schizophrenia rather than genetics.

2) Genetics doesn’t offer a full explanation as to how schizophrenia is transmitted. Just because someone has the gene for schizophrenia, it does not automatically mean that they will get the illness (due to the gene possibly being recessive). The DSM would advocate the idea that a person is more likely to get schizophrenia if they have the gene for the illness, and then a factor in the environment will trigger the illness (e.g stress). Therefore the DSM highlights the importance of genetics, but also includes an environmental factor that helps trigger the illness

3) To contradict the research conducted by Ripke, sometimes schizophrenia can occur in the absence of genetics or family history. There could be a mutation in parental DNA that causes schizophrenia in their future offspring, (such as a sperm cell might be damaged by radiation or a viral infection). There is a positive correlation between the paternal age of fathers and the risks of having a schizophrenic child. 0.7% if the father is under 25, which increases to 2% if the father is over 50.

Question 32

A study by Gottesman and Shields on twins and schizophrenia: (AO1)

Answer 32

-They investigated 224 sets of twins from 1948-1993 who appeared on the Maudsley twin register (106 sets of twins were MZ and 118 were DZ).

• 120 males and 104 females took part in the study.
• The average age of the participants’ was 46 years of age, and the participants came from different ethnic backgrounds.
• The study was conducted in a London hospital and was a longitudinal study over a period of 25 years.
• The study relied on the fact that one twin already had the illness of schizophrenia, and concordance rates were investigated. examining the likelihood or the chances of the healthy twin becoming schizophrenic over time
• The methods used to diagnose schizophrenia included:
• In depth interviews
• Doctors case notes
• The DSM

The result found that:
48% of MZ twins were both concordant for schizophrenia by the end of the study

17% of DZ twins were both concordant for schizophrenia by the end of the study

This indicates that schizophrenia does have a genetic basis to some extent, especially for MZ twins.

For DZ twins, genetics seems less prominent as a cause for schizophrenia (but the risk is still greater than for the general population which is 1%)

Question 33

A study by Gottesman and Shields on twins and schizophrenia AO3

Answer 33

ADVANTAGES:

1) A strength of Gottesman and Shields study is that it was longitudinal, meaning that the schizophrenic patients could be tracked over long periods of time in order to monitor the development of the illness schizophrenia.

2) The research by Gottesman and Shields has the advantage of being both reliable and valid when investigating the genetic cause for schizophrenia. The research diagnosed schizophrenia using in depth interviews, doctor case notes and the DSM. There were three different methods that were used to diagnose the illness which means that there would have been more chance of inter-rater reliability and higher validity

DISADVANTAGES:

1) The research by Gottesman and Shields ignores the behavioural approach when examining the causes of schizophrenia. Identical twins often copy and model each other’s behaviour, so it could be that the healthy twin has modelled or copied schizophrenic behaviour rather than getting the illness via genetics.

2) The research conducted by Gottesman and Shields could be criticised because it relied on interviews with patients. Schizophrenia patients often have difficulty with their speech and communication and so some patients might have found it difficult to communicate their symptoms effectively to the psychologist. Therefore this issue could have had a negative effect on the diagnosis and classification of schizophrenia.

Question 34

An Adoption study by Kety et al (1994) The Copenhagen High Risk Study: (AO1)

Answer 34

• Prospective longitudinal study carried out in Denmark and began in 1972. Follow up studies occurred in 1974 and 1989
• 207 adopted children were studied - their biological mothers had been diagnosed with schizophrenia (high risk group).
• Matched control group of 104 adopted children who had healthy biological mothers (who did not have schizophrenia), they were labelled low risk group

-Children aged 10-18 at the start of the study and both groups were matched in terms of age, gender and parental socio-economic status.

RESULTS:
- Results showed there was a strong genetic basis for mental disorders (not just schizophrenia)

-16.2% of the high risk group were diagnosed with schizophrenia, compared to 1.9% from the low risk group

• Schizotypal personality disorder was diagnosed in 18.8% of the high risk group and 5% in the low risk group (milder schizophrenia symptoms)
• The high risk group had a total of 35% that experienced a mental disorder, compared to 6.9% of the low risk group.

Question 35

An evaluation of the study by Kety: (AO3)

Answer 35

ADVANTAGES:

1) Erlenmeyer-Kimling conducted study known as the “New York High Risk Project.” which supports the research by Kety. His study was a longitudinal piece of research that lasted 25 years and found similar results to Kety. This further supports the idea that biological causes are a strong factor that can cause schizophrenia.

2) Kety conducted a prospective longitudinal study which has many advantages. This method looks at children before they show any symptoms of schizophrenia and does not rely on retrospective data (whereby the patient already has schizophrenia and would need to remember when they got the symptoms, which could be quite unreliable). Kety was able to follow the participants accurately

3) An advantage of Kety’s research is that all of the children in the study were carefully matched on relevant variables such as age, gender and socio economic status. This makes the study very fair and controlled and also helps to eliminate confounding variables that could effect the diagnosis of schizophrenia

DISADVANTAGES:

1) One problem with the study conducted by Kety is that we cannot separate genes from the environment. The children who were born to schizophrenic mothers still would have shared the same environment as their mothers for a short time before being adopted. Therefore it is very hard to separate the genetics element from the environment completely and this needs to be considered when interpreting the results

2) The reliability of diagnosing schizophrenia in this study can be problematic. The mothers had been diagnosed with schizophrenia before the introduction of diagnostic systems e.g. DSM. There have been criticisms from other psychologists that maybe the mothers did not have schizophrenia at all, but might have had a very similar illness called, “schizotypal personality disorder”.

Question 36

Assumptions of the Dopamine Hypothesis: AO1

Answer 36

1) Schizophrenia sufferers have more dopamine receptors in the brain and this causes an increase in dopamine

2) Winterer investigated dopamine receptors D1 and D2 and found that schizophrenia sufferers had Hugh ratios of dopamine

3) Anti-psychotic drugs such as phenothiazines can block activity in dopamine receptors in the brain. These minimise positive symptoms

4) L-Dopa increases dopamine levels for people who have low levels of dopamine. The side effects of L-Dopa is that it can cause schizophrenic symptoms

Question 37

The Dopamine Hypothesis by Davis and Neale (AO1):

Answer 37

Schizophrenic patients’ tend to have high levels of the neurotransmitter dopamine in their brain which increases the firing of neurons. When drugs such as phenothiazine’s (dopamine antagonist) are given to patients’ that block dopamine at synapses in the brain; the positive symptoms of schizophrenia seem to reduce (hallucinations and delusions). However, negative symptoms of schizophrenia seem to remain, and these symptoms are not decreased.

A drug called L-Dopa increases dopamine levels in the brain. This drug can induce symptoms of schizophrenia, and it has been tested on healthy non psychotic people. Drugs such as LSD and amphetamines (dopamine agonist) also increase dopamine levels in the brain and can induce schizophrenic symptoms. Davis and Neale based the dopamine hypothesis on the following facts:
• Post mortem studies have found that schizophrenic patients’ have an increased amount of dopamine receptors and dopamine in the left amygdala of the brain.

• Dopamine metabolism in schizophrenic patients’ seems to be abnormal, and this can be monitored by PET scanning (Positron Emission Tomography) which looks at brain activity and imaging.

• The dopamine hypothesis might be linked to a fault in genes which causes dopamine levels to increase dramatically.

Question 38

Evaluation of the Dopamine Hypothesis: (AO3)

Answer 38

1) There is a great deal of research to support the hypothesis that schizophrenic patients have a high level of dopamine in their brain. For instance research by Davidson found that when schizophrenic patients were given the drug L-Dopa their schizophrenic symptoms got worse and intensified. (+)

2) A problem with this theory is that cause and effect is not clear. Could it be that an increase in dopamine causes schizophrenia to develop; or could it be that the illness develops first (due to another cause) and then this causes dopamine levels to increase? PET scanning might be able to answer some of these questions (-)

3) A problem with the neurotransmitter dopamine is that it is not only associated with the illness of schizophrenia. Dopamine has also been associated with mania (bipolar depression), and this illness is not alleviated by phenothiazine drugs. Therefore is seems that dopamine has a complex role in the brain and might be associated with many psychological illnesses and not schizophrenia alone. (-)

4) A disadvantage of this theory is that the dopamine hypothesis could be viewed as being reductionist. It looks at the complicated phenomenon of the causes of schizophrenia and reduces it down to the component of dopamine alone. There might be other factors or causes of schizophrenia that have been ignored e.g. neuroanatomy of the brain. (-)

5) An advantage of this theory is that there is a great deal of scientific evidence and support for the dopamine hypothesis as a cause of schizophrenia. Most of the research has used evidence that have come from brain scans (PET and fMRI) which is highly valid and reliable information. (+)

Question 39

Neural correlates: A study by Swayze: (AO1)

Answer 39

Swayze reviewed 50 studies of schizophrenic patients and examined their brain imaging using MRI (Magnetic Resonance Imaging). From these brain images, the structure of the brain could be examined and it was found that schizophrenic patients’ have structural abnormalities in their brain including:
• A decrease in brain weight
• Enlarged ventricles (that are filled with water)
• A smaller hypothalamus
• Less grey matter (this is where the intelligence is held and it seems to deteriorate)
• Structural abnormalities in the pre frontal cortex (where the personality is held)

Question 40

Neural correlates evaluation (AO3):

Answer 40

1) Andreason (1982) has criticised the neural correlates explanation for schizophrenia. He found that the extent to which the ventricles in the brain are enlarged in schizophrenic patients is not significant; and therefore there is actually very little difference between the neural correlates of schizophrenic patients’ and normal people. (-)

2) A problem with this theory is that cause and effect needs to be established. Is it the fact that abnormal neural correlates actually causes schizophrenia to occur, or does schizophrenia occur first (due to other factors) and then cause the brain structure/neural correlates to alter? (-)

3) There is a strong amount of supporting psychological evidence to state that schizophrenia is caused by neural correlates changing in the brain that occur during pre natal development in the womb. However, this does not explain why schizophrenia occurs in early adulthood (and not straight away during infancy). Weinberger (1987) has stated that the pre frontal cortex (an area effected by schizophrenia) develops during adolescence and therefore damage to this part of the brain would only be noticed during adolescence and adulthood (when the symptoms of schizophrenia become apparent) (+)/ (-)

4) Davison and Neale (2001) have found contradictory evidence to suggest that enlarged brain ventricles are not only found in schizophrenia patients, but that sufferers of mania also have enlarged ventricles. Therefore enlarged ventricles alone cannot cause schizophrenia, but it could be a vulnerability factor that increases the risk of getting the illness (damage to the brain structure). Diathesis stress model? (-)

5) There is a great deal of supporting evidence to suggest that neural correlates do seem to be an important factor when looking at the cause of schizophrenia e.g. research by Swayze and Juckel have all pointed out that there are problems in brain functioning/structure that could have contributed to causing the illness. (+)

Question 41

Psychological explanations for schizophrenia – Family dysfunction:

“The double bind theory of communication” by Bateson: AO1:

Answer 41

Bateson has proposed that disturbed patterns of communication and family dysfunction, might be a risk factor that can help cause the illness of schizophrenia. The double bind hypothesis specifically refers to the fact that children are given conflicting messages from parents. For instance parents might be caring some of the time and then critical at other times, or they might say positive comments in a cruel way, e.g. “I love you” might be said in a very negative way. This can create confusion, withdrawal and self doubt in children, and they cannot construct an internally coherent sense of reality. The child becomes trapped in situations whereby they fear doing the wrong thing and get mixed messages from parents. If they do something wrong parents might punish them by withdrawing their love. Children see the world as confusing and dangerous. They might start to develop some schizophrenic symptoms such as withdrawal, disorganized thinking and delusions.
A marital schism can also help explain how family dysfunction can induce strange behaviour in their children. A marital schism is when parents may argue in front of their children and they might involve children into their argument. This can cause distress and confusion for children and they might then start developing some symptoms of schizophrenia.

Question 42

An evaluation of the double bind theory of communication (family dysfunction) AO3:

Answer 42

1) The double bind theory can be criticised because Bateson investigated his theory studying families retrospectively. This meant that families had to think back over a long period of time and identify traits of the double bind theory. Participants had to rely on their memories which could have been faulty and inaccurate. (-)

2) Bateson’s ideas can be criticised because he needs to investigate the element of cause and effect. Does family dysfunction cause schizophrenia to occur, or could it be that schizophrenia is caused by other factors which then cause the development of double bind? (-)

3) Research conducted by Berger (1965) would support the double bind theory of schizophrenia. Berger found that schizophrenic patients reported a higher recall of double bind statements by their mothers, than did non schizophrenic people. (+)

4) Ethical issues need to be taken into account when studying dysfunction in the family, and the research can be criticised for being unethical. It can cause a great deal of psychological harm if a family is told that their negative communication patterns have helped cause schizophrenia in a family member. Psychologists must also be aware of invading the family’s privacy, and they should also keep results confidential and anonymous (-)

5) Research evidence from the psychologist Read (2005) would support the double bind theory. He found that people who had difficult families in childhood had an increased risk of developing schizophrenia in adulthood. From studies of child abuse and schizophrenia it was found that 69% of females and 59% of adult male schizophrenia patients had a history of physical or sexual abuse in childhood (+)

Question 43

Expressed Emotion (EE): by Kavanagh (1992) AO1:

Answer 43

Negative emotional interactions/climate in families might play a key role in helping to cause and maintain the symptoms of schizophrenia Expressed emotion can be regarded as a set of traits whereby family members talk about/to the schizophrenia patient in a critical and hostile manner. This might aid a relapse in a person who once had schizophrenia, but is now getting better.

Such traits include:
Criticism, hostility and emotional over involvement

• Families with high EE talk more than they listened, causing the schizophrenia patient to have a low tolerance for emotional stimuli such as intense emotional comments and interactions in the family. This causes stress.
• There is evidence that schizophrenics living in families with high expressed emotion are X4 more likely to relapse than those families with low expressed emotion.
• Hooley (1998) found evidence to suggest that high EE families can help predict the relapse of not just schizophrenia, but other mental disorders such as depression and eating disorders.
• EE seems to be more typical in developed countries rather than developing ones, (even though developed countries have more access to resources and treatments).

Question 44

Evaluation of Expressed Emotion: AO3:

Answer 44

1) Brown conducted research into expressed emotion and found results that agree and support that of Kavanagh, in terms of high EE causing schizophrenia/relapse. (+)

2) Support for expressed emotion was apparent in the 1990’s and became a well established maintenance model of schizophrenia. There was a large amount of evidence to suggest that EE can cause relapse in schizophrenia patients; this is true in many different cultures. This idea is so strong that families who show high EE are encouraged to undergo education and training to help reduce the amount of EE in the family. (+)

3) Critics of the EE model would state that schizophrenic patients have minimal contact with their families, possibly because the patient is institutionalised and the amount of familial contact is controlled, or because the family withdraw themselves. Therefore critics have argued that there is a minimal chance of expressed emotion being a causal factor for schizophrenia. (-)

4) Cause and effect needs to be established and is a major criticism of the EE model. Could it be that high EE can cause schizophrenia, or could it be that that the schizophrenia itself can cause the family members to have high EE? (-)

5) EE can be criticised because it ignores biological factors that might cause schizophrenia. When examining schizophrenia, we must remember that the main causes of the illness tend to be biological e.g. genetics, dopamine. (-)

Question 45

Cognitive causes

Question 46

Cognitive causes

Question 47

Cognitive causes

Question 48

Cognitive causes

Question 49

Cognitive causes

Question 50

Cognitive causes

Question 51

Typical Anti-Psychotic drugs: (AO1): 1950’s

Answer 51

• Common examples of these drugs include: Chlorpromazine, Phenothiazines and Thorazine,
• These drugs are available as a tablet, syrup or injection.
• Chlorpromazine is a popular typical anti-psychotic drug and acts as an effective sedative.
• Typical drugs are less popular than atypical drugs (see later on)
• Typical drugs aim to reduce the positive symptoms of schizophrenia such as delusions and hallucinations that have been caused by high dopamine levels.
• These drugs reduce dopamine levels in the brain and act as dopamine antagonists. The drugs bind to dopamine receptors (D2) in the mesolimbic dopamine pathway in the brain and reduce the positive symptoms of schizophrenia such as delusions and hallucinations.
• The drugs must bind to 60-75% of the D2 receptors and block their activity in order to be effective

Question 52

Evaluation of typical anti-psychotic drugs: AO3

Answer 52

1) There is supporting evidence from Thornley (2003) that typical anti-psychotic drugs are effective in tackling symptoms of schizophrenia. He compared Chlorpromazine to a placebo and found that schizophrenia patients had better functioning and reduced severity of symptoms when they took Chlorpromazine compared to a placebo, and the relapse rate was lower. (+)

2) A negative point about typical drugs is that they have terrible side effects which include dizziness, agitation, sleepiness, stiff jaw, weight gain, itchy skin and in the long term patients might develop, “tardive dyskinesia” (can be caused by dopamine super sensitivity) whereby mouth muscles and their chin make involuntary strange movement. (-)

3) A problem with typical anti-psychotic drugs has found that problems can occur when patients take the drug long term, for instance, 2% of schizophrenic patients’ develop the side effect of, “Neuroleptic malignant syndrome” which involves muscle rigidity, high temperature, delirium, altered consciousness, fever and a coma that can be fatal. (-)

4) A strength of Typical anti-psychotic drugs is that they are effective in minimising symptoms of schizophrenia, they are cheap to produce and administer and help patients lead a relatively normal life outside of an institution. Around 97% of schizophrenia patients live at home, and this is because of the use of drug therapy (+)

5) Supporting research from Marder (1996) has found that typical anti-psychotic drugs are good at reducing the positive symptoms of schizophrenia such as delusions and hallucinations. However they do not have any effect on the negative symptoms of schizophrenia such as apathy and speech poverty. (+) (-)

6) A negative point about typical drugs is that they can produce terrible side effects called, “extra pyramidal side effects” whereby dysfunction occurs in the nerve tracts from the brain and the spinal motor neurons. The schizophrenia patient might develop side effects that resemble Parkinson’s disease such as tremors in the fingers, drooling and muscular rigidity. (-)

Question 53

Atypical Antipsychotic drugs: (AO1) 1980’s

Answer 53

• There are alternative drugs available that seem to be better than neuroleptic drugs. Some examples of atypical anti psychotic drugs include Risperidone and Clozapine
• These drugs block the activity of dopamine within the brain by acting on the D2 receptors (reduce dopamine). The drugs temporarily occupy the D2 receptors and then allow normal dopamine transmission.
• Atypical drugs also increase serotonin activity in the brain and bind to serotonin receptors (5-HT 2A) in order to improve mood
• These drugs have fewer side effects than typical drugs
• Atypical drugs also seem to be able to reduce both the positive and negative symptoms of schizophrenia, which is an improvement when comparing them to typical drugs

Clozapine: Atypical drug (AO1)
• It is given when there is a high risk that the schizophrenic patient might commit suicide
• Clozapine binds to dopamine receptor cells but also acts on serotonin and glutamate receptors too. This has the following effects on the schizophrenic patient:
• Improvement of mood
• Reduction of anxiety and depression
• Can improve cognitive functioning

Risperidone: Atypical drug (AO1)
• Risperidone is as effective as Clozapine but with less side effects
• Can be taken in tablet or syrup form
• Small doses are given to start with
• Risperidone binds more strongly to dopamine receptors than clozapine

Question 54

Evaluation of Atypical drugs: (AO3)

Answer 54

1) Typical and atypical drugs have their strengths in that they have been proven to be the most effective treatment when compared to any other form of therapy available for treating schizophrenia (biological or psychological) (+)

2) Drug therapy has the disadvantage that it treats the symptoms of schizophrenia, but not the cause of it. Symptoms might return if the patient stops taking the drugs and this leads to the, “Revolving door phenomenon” whereby patients leave hospital and then return because the drugs have failed to work (and this is a cycle). (-)

3) A problem with atypical drugs (and drugs in general), is that some schizophrenia patients are resistant to Clozapine and/or Risperidone as results from trials can sometimes be inconclusive about how effective they are. Some drugs will not be effective on some schizophrenic sufferers due to individual differences. (-)

4) Meltzer (2012) conducted research to support the idea that Clozapine is a more effective drug for treating schizophrenia than typical anti-psychotic drugs and alternative drugs. Clozapine was found to be 30-50% more effective in minimising schizophrenia symptoms compared to typical drugs. (+)

5) A problem with drug therapy in general is that there are ethical issues that can be raised. Drugs have been referred to as being, “A chemical strait jacket” whereby they do not help the schizophrenic patient, but just aims to control them, sedate them and make them easier to manage. (-)

6) Atypical drugs such as Clozapine have serious side effects, one of them is called, “Agranulocytosis” which is a blood condition whereby the bone marrow is affected and less white blood cells are produced, which can affect immunity to illness. (-)

Question 55

Cognitive behavioural therapy an overview: AO1:

Answer 55

• Last between 5-20 therapy sessions
• Can be group or individual based
• The NICE (National Institute for Health Care Excellence) recommend that all schizophrenic patients have CBT. This is referred to as CBTp (Cognitive behavioural therapy for psychosis). Even if the schizophrenic patient is taking medication, they should have CBTp
• Can help the schizophrenic patient identify their irrational thoughts and change them
• Involves discussion between patient and therapist, about how likely the schizophrenic patients beliefs are true
• The patient is helped to make sense of delusions and hallucinations and the impact this has on their feelings and behaviour (where do the symptoms come from? E.g. hearing voices)
• CBT does not get rid of schizophrenia symptoms but allows the patient to cope more effectively
• CBT allows schizophrenic patients to evaluate the content of their delusions/hallucinations
• CBT involves the patient being set homework assignments in order to improve the functioning of the schizophrenic patient

Question 56

Cognitive Behavioural Therapy for Psychosis (CBTp) (AO1): The stages involved:

Answer 56

.

Question 57

Evaluation of Cognitive Behavioural therapy & (CBTp): AO3

Answer 57

1) CBT seems to be a very effective therapy when it is combined with drug therapy and it is better than using CBT alone. This supports the idea that combined therapy might be the best way to effectively treat schizophrenia (using biological and psychological therapies) (+)

2) Rathod (2005) has found that CBT clinicians tend to highly trained and effective. The most experienced, able and trained psychologists tend to deliver CBT and CBTp because they need to be able to show empathy, respect honesty and unconditional positive regards to their schizophrenic patents (+)

3) CBT and CBTp has the disadvantage of not being suitable for all schizophrenic patients, especially those that are too agitated, paranoid and disorientated. CBT seems to work best for schizophrenia patients who have refused to take drug treatment. However a further issue is that schizophrenic patients who refuse to take drug treatment are often extremely disturbed and might find that they cannot engage with CBT (+) (-)

4) A problem with CBT is that it is more expensive as a treatment for schizophrenia than drugs. Therefore in terms of money, the NHS might be more willing to issue medication to schizophrenia patients rather than CBT, because drugs are cheaper. (-)

5) CBT has the advantage that is has less ethical issues compared to drug treatment. For CBT, the schizophrenia patient might feel more in control of the treatment via the self-help element. With drugs, the patient might feel that they are not in control of the treatment and might feel that it is more of a, “chemical straight jacket”. CBT does not involve physical harm of the body (unlike drugs which have side effects and can have a negative effect on the body). CBT usually involves the schizophrenic patient having more free will. (+)

6) Research conducted by Haddock (2013) has shown that CBTp is usually not offered to schizophrenic patients in the UK, or if it is offered, many schizophrenic patients do not attend the therapy sessions. One in ten schizophrenic patients have access to CBTp in some parts of the UK. (-)

Question 58

CBT used as a treatment for schizophrenia:
National Institute for Health Care Excellence Research 2008: (AO1)

Answer 58

• Investigated schizophrenia patients that received CBT versus those that received standard care. Standard care refers to medication ……………………………………….
• CBT should be conducted one to one and involve 16 therapy sessions
• NICE carried out a review to identify the effectiveness of CBT in 39 randomised trials
• 2118 schizophrenia patients were studied in the UK (Leeds)
• NICE recommend CBT to schizophrenia patients in order to reduce the chance of Hospitalosation ………………………………… compared to standard care
• 910 schizophrenia patients received CBT treatment showed a reduction in Hospitalisation……………………….. rates (reduction by 24%) when followed up 18 months later
• Schizophrenic patients that receive CBT were less likely to leave…………………………. the study early compared to those patients that received standard care
• There was no difference between CBT patients and those that received standard care when examining rates of Suicide………………………………. and Relapse………………………………………
• The conclusion is that CBT should be added to standard care, and this can be useful to reduce total symptoms scores for schizophrenia and for Depression…………………………..

Question 59

Evaluation of the research: AO3

Answer 59

1) An advantage is that it raises an economical issue when treating schizophrenia. CBT can save the NHS money, because CBT reduces the chances of the schizophrenic patient being hospitalized (and using more resources). Therefore CBT is a cost effective treatment for schizophrenia compared to medication which has a higher relapse rate (+)

2) The research can be supported by the INTERACTIONIST ………………………………………… approach in psychology which would suggest that a combination of treatments is the best way forward for schizophrenia sufferers. The conclusion of the study was that CBT (psychological treatment) should be used alongside medication/drugs (biological treatment). Both of these treatments used together are more successful that if they used on their own. (+)

3) The study has been criticised by other psychologists because the Sample………………… is fairly small. Therefore the results of the study might not provide enough robust, objective and scientific evidence to fully support the idea that CBT can be an effective treatment for schizophrenia. (-)

4) CBT as a therapy does have its disadvantages. For instance, CBT is not always available for schizophrenia patients as it depends on NHS…….. funding and allocation of resources. Therefore, whilst some schizophrenic patients might benefit from CBT, it might not be available to them due to funding issues. (-)

Question 60

Family therapy (Family focused therapy) AO1:

Answer 60

• Family therapy is a form of psychotherapy which involves the whole family
• Lasts approximately 9 months to one year for roughly 10 sessions
• NICE recommend that family therapy is offered to all schizophrenic patients who are in direct contact or live with their family

• The therapist talks openly about symptoms, behaviour and treatment to all family members, (no details remain confidential, informed consent is important)
• It is based on the idea that family dysfunction can aid the development of schizophrenia in family members
• Family is encouraged to support each other
• Family therapy is usually used alongside anti-psychotic drugs

• Family therapy has the following aims:
• Lowers expressed emotions (EE)
• Decreases criticism and family guilt
• Reduces relapse rates
• Reduces symptoms of schizophrenia
• Improves positive communication between family members and increases the formation of alliances within the family

Question 61

Family therapy evaluation (AO3):

Answer 61

1) An advantage of family therapy is that it has economic benefits for schizophrenic patients. In 2009 NICE found that family therapy can save on costs if it is offered in addition to medication/drugs. This can help prevent relapse (+)

2) Family therapy has been praised because it helps improve the outcomes for schizophrenic patients, and it has a positive impact on family members. Lobban (2013) looked at 50 studies that focused on family therapy and 60% of these studies reported a significant positive impact of family therapy on coping and problem with a schizophrenic patient. (+)

3) Family therapy can be a very useful and successful treatment for schizophrenic patients who are young, or who live at home with their family. Patients that live at home with their family would benefit from family therapy as the whole family can be involved in aiding the patient to feel better and manage the illness. Family therapy is not so effective for older patients who live alone (+) (-)

4) Family therapy can be criticised because it requires the schizophrenic patient and family members to be open and honest. There might be an issue if the family are not willing to share sensitive information with the therapist. Also if there is family tension (high EE) then this could lower the effectiveness of family therapy (-)

5) A problem with family therapy is that due to restrictive NHS costs in the UK, family therapy might not be offered to all schizophrenic patients. Most schizophrenic patients are usually offered standard care (medication) and family therapy might be offered alongside drugs/medication. (-)

6) Family therapy has been criticised because it does not cure schizophrenia, or remove the symptoms. Family therapy is designed to help the patient and the family manage the patients’ symptoms, but it is not really a cure for schizophrenia and does not seem to get to get to the root cause of the illness. (-)

Question 62

Research on family therapy and schizophrenia by Pharoah (2010): AO1

Answer 62

• Reviewed 53 studies between 2002-2010 from Europe, Asia and North America
• Investigated outcomes for family therapy versus standard drug care for schizophrenia patients
• The results found similar outcomes for both therapies
• Patients who used family therapy increased their compliance to take medication successfully
• Family therapy did not have much effect on improving schizophrenic patients employability skills or for them to live more independently
• Family therapy does reduce relapse rates and reduces the chances of the schizophrenic patients being hospitalized in the next two years.

Question 63

Evaluation of the research by Pharoah: AO3

Answer 63

1) A strength of the research conducted by Pharoah is that family therapy seems to be effective in improving the mental state and social functioning of schizophrenic patients. However it has been questioned whether family therapy is only effective because it increases medication compliance for patients (it means they are more likely to take their medication). (+) (-)

2) The research by Pharoah has been criticised by Wu (2000) because of a lack of randomization when allocating schizophrenic patients to the family therapy condition or the drug condition. In the study it was noted that many patients came from China, and these patients were not randomly allocated to either of the two conditions. The research and its findings can be criticised as not being fair, objective or scientific (-)

3) A strength of the research conducted by Pharoah is that it compares a biological treatment for schizophrenia (drug care) with a psychological treatment (family therapy). This gains support from an interactionist approach whereby psychologists compare and contrast different therapies from different perspectives to see which ones are the most effective for treating the illness of schizophrenia. (+)

Question 64

Token economy: (AO1): 1950/1960’s

Answer 64

• Schizophrenia occurs via maladaptive learning, and the best treatment would involve a new form of learning by using reconditioning and operant conditioning
•
• Schizophrenia patients can change their unwanted behaviour into more desirable forms of behaviour
• Token economy is often with drug therapy
• Token economy only seems to be effective if used in an institution (hospital) rather than if used in the schizophrenic patients home.

Why might this be the case?
More controlled environment

• In the first stages of the treatment, schizophrenia patients would be rewarded for not displaying any strange or unusual behaviour. The tokens must be given immediately after the desired behaviour is displayed.
• Schizophrenic patients are given tokens or rewards for behaving in socially appropriate ways, such as making their bed or making a cup of tea.
• Tokens can later be exchanged for privileges such as outings or favourite foods.
• Token economy in not a treatment, but aims to manage the schizophrenic patients behavior

Question 65

The evaluation of token economy: (AO3)

Answer 65

1) Token economy might be seen as problematic when trying to apply it to the real world, especially if desired behaviours are performed but a token is no longer given afterwards (operant conditioning is removed). Patients might find it difficult to transfer their positive behaviour to the real world outside of a hospital setting. (-)

2) Token economy has its limitations because it only focuses on managing a few symptoms of schizophrenia, and tends to ignore other symptoms such as cognitive problems (hallucinations, delusions and disorganized speech). (-)

3) The ethics of token economy has been questioned. Patients who perform desirable behaviours are often rewarded with food, outings and free time. Token economy could be viewed as manipulating patients in order to change and manage their behaviour. Some patients cannot give their fully informed consent to take part in token economy (-)

4) Token economy can be criticised, because often it is not used on its own, but it is used alongside anti-psychotic drugs. How effective is token economy on its own? (-)

5) Token economy has the strength that it is a flexible treatment for managing schizophrenia. It can be easily tailored to meet the needs of the individual patient concerned to see if it suitable for them in their particular circumstances.

Question 66

Ayllon and Azrin (1968): AO1: Research on token economy:

Answer 66

• 45 female schizophrenic patients who had been hospitalized for 16 years (on average) were studied.
• They were rewarded with plastic tokens whenever they made their bed or combed their hair, or whenever they did not show any psychotic behaviour.
• The tokens were exchanged for pleasant activities such as watching films.
• It was found that token economy was very successful, as the number of chores the females performed every day increased from 5-40 throughout the course of the study, and their schizophrenic symptoms reduced.

Question 67

Evaluation: AO3

Answer 67

The results from the study on token economy can be criticised. Ayllon and Azrin only examined female schizophrenic patients and therefore the results cannot be generalized to male participants. (-)

2) Token economy has the advantage that it has no side effects compared to drug therapy. There is a great deal of evidence to suggest that anti-psychotic drugs have terrible side effects which means that schizophrenic patients must stop the treatment. However token economy has no side effects and very few ethical issues (+)

3) The research by Ayllon and Azrin has been supported by research conducted by Dickerson (2005), whereby he reviewed 13 studies that used token economy with schizophrenia sufferers. In 11 of the studies, token economy was very useful and increased adaptive behaviour in the patients. Beneficial and effective outcomes were noted, especially if token economy was combined with other psychosocial therapy or drug therapy. (+)

Question 68

Interactionist approach