Schizophrenia

Question 1

Facts on SZ (A02)

Answer 1

• schizophrenia - a severe mental disorder where contact with reality and insights are impaired e.g psychosis
• Experienced about 1% of the world’s population
• commonly diagnosed in men, city dwellers and lower socio-economic groups
• the symptoms of schizophrenia can interfere severely with everyday tasks, so many people with schizophrenia end up homeless or hospitalised.
• Each patient has different symptoms
• 15-35
• people with a family x10 more likely to get SZ (genetic)
• Drugs, the environment may increase the development if they’re vulnerable to developing it (nurture)

antipsychotic drugs target neurotransmitters
- most effective when combined with CBT + EBT

Question 2

Classification of SZ
DSM

Answer 2

one positive symptom must be present for a diagnosis of SZ.
No subtypes

Question 3

Classification of SZ

Answer 3

2 or more negative symptoms of SZ
7 subtypes

Question 4

Positive symptoms
- symptoms which have been added due to SP, that the general population don’t have
symptoms shouldn’t be there

Answer 4

Hallucinations - unusual sensory experiences.
Some hallucinations are related to events in the environment whereas others bear no relationship to what the senses are picking up from the environment. e.g. voices heard either talking to or commenting on a person often criticising them. They may see distorted facial expressions, people or animals that aren’t there.

Delusions - are irrational beliefs. They involve beliefs that have no basis in reality. e.g a person believes that they are someone else or that they are the victim of a conspiracy. A person may believe that they are under external control. Delusions can make a person behave in ways that make sense to them but bizarre to others.

• coherent/irrelevant speech

Question 5

Negative symptoms

symptoms which have been removed due to SP, that the population have. Symptoms that should be there that aren’t (missing)

Answer 5

• Anhedonia
• Flatness of effect
  Speech poverty is seen as a negative symptom because the emphasis is on the reduction in the amount quality of speech in schizophrenia. This is sometimes accompanied by a delay in the person’s verbal responses during a conversation.

Speech disorganization - speech becomes incoherent or the speaker changes topic mid-sentence. This classified in DSM-5 as a positive symptom in SZ.

Avolitation- finding it difficult t begin or keep up with goal-directed activity. People with SZ often have sharply reduced motivation to carry out a range of activities.
Nancy Andersen 1982 - identified 3 signs of abolition : poor hygiene and grooming/ lack of persistence in work or education and lack of energy

Question 6

Classification of SZ - ICD 10 subtypes of SZ

Answer 6

1. Paranoid Schizophrenia - Delusions and hallucinations. Do not usually have an absence of feelings and emotions of disorganised speech.
2. Hebephrenic Schizophrenia (called disorganised SZ in DSM-IV) - often begins early age, with incoherent and disorganised speech, and lack of feelings or emotion (known as the flat affect). Sometimes hallucinations and delusions.
3. Catatonic schizophrenia - Unusual motor activity (either agitation or immobility) often extreme negativism and strange posturing - very rare disorder
4. Undifferentiated schizophrenia - Diagnosed when showing clear schizophrenic symptoms that do not fit into the other categories.
5. Post-schizophrenic depression (not in the DSM-IV) - Criteria for schizophrenia have not been met for 12 months but are currently present. Depressive symptoms are prolonged and severe.
6. Residual schizophrenia - At least one episode of SZ but no longer showing obvious signs of the disorder.
7. Simple schizophrenia (not in DSM-IV) Slow but progressive development of social withdrawal, apathy, poverty of speech, and decline in scholastic or occupational performance.

Question 7

Copeland et al 1971

Answer 7

described a patient to 134 US psychiatrists and 194 British psychiatrists. 69% of US psychiatrists diagnosed SZ, but only 2% of British psychiatrists gave the same diagnosis.

Question 8

Issues with diagnosis and classification of SZ
Validity

Answer 8

A pathognomic symptom - unique to a particular disorder.
There are no pathognomic symptoms for SZ.
Brain tumours can also produce schizophrenic-like symptoms.
Rosenhan - symptoms can be faked
Blever’s - No predictive validity
This proves how schizophrenia develops cannot be predicted as the figures are not accurate - which is difficult to predict.
33-37% of people don’t respond to treatment.

However, schizophrenia overlaps with bipolar disorder. Depending on your mood and what’s going on in your life when you speak to a mental health professional. They might find it difficult to understand which diagnosis best fits their experiences.

Limited time and resources may explain low inter-rater reliability in the diagnosis of SZ. Diagnosis can be made by professionals, that are rushed and preoccupied with only admitting the most serious case in order to safeguard the resources of the institutions.
Co-mobility symptoms of different disorders overlap. High co-mobility rates question the validity and reliability of diagnosis and classification diagnosis - a single condition.

Question 9

Reliability
Issues with diagnosis and classification of SZ

Answer 9

2 diagnostic manuals
No biological/diagnostic test
Co - mobility - the overlap of symptoms
Low - interrater - reliability
Wider applications - labelling, economic applications

Question 10

Issues with diagnosis and classification of SZ
Gender bias

Answer 10

Fischer and Buchanan 2017 - Since the 1980s men have been diagnosed with schizophrenia more commonly than women (1.4:1)

Question 11

Issues with diagnosis and classification of SZ
Cultural bias

Answer 11

In Haiti, Some people believe that voices actually are communications from ancestors.
Pinto and Jones 2008, African Caribbean origin are 9x likely to receive a diagnosis as white British people.

Question 12

Biological explanation of Schizophrenia - The genetic hypothesis
Twin studies

Answer 12

Cardno et al - 40% concordance rate in MZ twins, compared with 5.3% in DZ twins

candidate may be inherited
SZ is polygenic
SZ is aetiologically heterogeneous - different combinations of the factor s may lead to SZ
There is no schizophrenic gene
Ripkeet al - 108 separate genetic variations

Rosenthal 1963 studied quadruplets in which all 4 girls were identical to each other. All 4 of them developed SZ, although they did differ in age of onset and the precise symptoms. It is worth noting that they had a dreadful and aberrant childhood, so the conclusion of this investigation is not clear out.

Question 13

Biological explanation of Schizophrenia - The genetic hypothesis

Family studies

Answer 13

The general population have a 1% risk of getting schizophrenia
1st degree relative - 50%
2nd degree - 25%
3rd degree - 12.5%

Gottesman - the more genes you have with someone with schizophrenia the risk increases.
1st degree - 6-9%
2nd degree - 2-4%
3rd degree - 2%

Question 14

Biological explanation of Schizophrenia - The genetic hypothesis

adoption studies

Answer 14

Tienari et al 2004 - children of SZ parents have a heightened risk of developing SZ even if the adopted family has no history of SZ.

genes associated with increased risk include those coding the functioning of a number of neurotransmitters including dopamine.

Question 15

Biological explanation of Schizophrenia - Dopamine hypothesis

Answer 15

Hyperdopaminegia in the subcortex
SZ patients have excessive amounts/levels/activity of dopamine in the subcortex (central area of the brain)
What symptoms would be present if there is excessive dopamine in a broca area?
- Positive symptoms
- Poverty of speech
- Auditory hallucinations

Hypodopaminergia in the cortex
Low levels of dopamine in the prefrontal cortex (Goldman-Rakic et al 2004)
Prefrontal cortex - Thinking and decision making
What symptoms of SZ would be present ?
Negative symptoms

Both hyper and hypodopaminergia are correct explanations - both involved in the onset of SZ

Supporting evidence
1. the use of antipsychotic drugs

Question 16

Supporting evidence Dopamine hypothesis
Drug therapy (practical application)

Answer 16

SZ is usually treated with chlorpromazine. Chlorpromazine is a drug that binds to dopamine (DA)
receptors without stimulating them, rendering them unavailable for activation by DA.
Barlow & Durand 1995 report that chlorpromazine is effective in reducing schizophrenic symptoms in about 60% of cases. It appears to have the most impact on the positive symptoms (hallucinations,delusions) and treated patients may still suffer from severe negative symptoms.

Question 17

Supporting evidence for dopamine hypothesis
Post Mortems and PET scans

Answer 17

Wise & Stein 1973 found that schizophrenia patients who died in accidents showed abnormally low levels of Dopamine Beta Hydroxylase (DBH) in the brain fluid. DBH is an enzyme whose function is to break down the neurotransmitter Dopamine after release.

Autopsies have found that there are generally a large number of dopamine receptors (Owen et al 1987) and there was an increase in the amount of dopamine in the left amygdale (falkai et al 1988) and increased dopamine in the caudate nucleus and putamen (Owen et al, 1978).

Question 18

Opposing evidence for Dopamine hypothesis

Answer 18

Kasper et al 1999
- Antipsychotic drugs are effective for only positive symptoms. Therefore, excessive dopamine can at best explain only some types of schizophrenia.

Newer atypical antipsychotic drugs e.g. clozapine have proved more effective than traditional ones in successfully treating the symptoms of schizophrenia despite blocking fewer dopamine receptors.

Question 19

Biological explanation of Schizophrenia - Neural correlates
Certain structures and functions of brain structures with displaying symptoms of SZ :

Answer 19

Positive symptoms - Allen et al 2007 found that patients experiencing auditory hallucinations recorded lower activation levels in the superior temporal gyrus and anterior cingulate gyrus.

Negative symptoms
- loss of motivation (anoiton)
- verbal stratum is involved in this abnormality in this area and may be involved in the development (avolition)

Jackel et al measured the activity of verbal stratum in SZ participants.
- lower levels of activity than control groups
- they also observed a negative correlation between activity levels in the verbal stratum and the severity of overall negative symptoms.

Question 20

Neural correlates are…

Both positive and negative symptoms have…

Answer 20

Measurements of the structure or function of the brain that correlate with an experience.
Neural correlates

Question 21

A03 - Neural Correlates
Supporting evidence

Answer 21

Buchsbaum 1990 - abnormalities in the frontal and pre-frontal cortex, the basil ganglia, the hippocampus and amygdale

Torrey 2002 - The ventricles (cavities in the brain) that supply nutrients and remove the waste of joy in a person with schizophrenia are on average about 15% bigger than normal.

Suddath et al 1990 - He used MRI (magnetic resonance imaging) to obtain pictures of the brain structure of MZ twins in which one twin was schizophrenic. The schizophrenic twin generally had more enlarged ventricles and a reduced anterior hypothalamus. The differences were so large the schizophrenic twin could be easily identified from the brain images in 12 out of 15 pairs.

Methodological ‘issues’ of supporting evidence
Research is carried out in highly controlled environments, with specialist, high-tech equipment such as MRI and PET scans. These machines take accurate readings of brain regions such as the frontal and pre-frontal cortex, the basil ganglia, the hippocampus and the amygdale. This suggests that if this research was tested and retested the same results would be achieved.

Question 22

Biological therapies for schizophrenia: Drug therapy

Typical antipsychotic drugs

Answer 22

It can be in the form of Tablet, Syrup and Injection
Chlorpromazine (antagonists)- linked with the dopamine hypothesis.
It reduces the action of dopamine by blocking the dopamine receptors. This reduces symptoms like hallucinations.

Typical antipsychotics - The first generation of drugs for schizophrenia and other psychotic disorders having been used since the 1950s. They work as dopamine antagonists and include chlorpromazine.

Question 23

Dopamine antagonists

Answer 23

Antagonists are chemicals which reduce the action of the neurotransmitter. Dopamine antagonists work by blocking dopamine receptors in the synapses of the brain, reducing the action of dopamine. This dopamine antagonist effect normalises neurotransmission in key areas of the brain, reducing symptoms like hallucinations.

Sedation effect - chlorpromazine is also an effective sedative. Chlorpromazine is often used to calm individuals not only those with schizophrenia but also with other conditions. Syrup is absorbed faster than tablets so it tends to be given when chlorpromazine is used for its sedative properties.

Question 24

Windgassen 1992 Findings =

Answer 24

• about half of SZ patients taking neuroleptics (conventional drugs) reported grogginess or sedation
• 18% reported problems with concentration
• 16% had problems with salivation
• 16% had blurred vision
• 20% who had taken the drug for over a year developed the symptoms of tardive dyskinesia - these symptoms include voluntary sucking and chewing, jerky movements of the limbs and writhing movements of the mouth or face and the effects can be permanent.

Question 25

Biological therapies for schizophrenia: Drug therapy

Atypical antipsychotic drugs
since the 1970s

Answer 25

They typically target a range of neurotransmitters such as dopamine and serotonin. Eg. clozapine and risperidone. The aim of developing newer antipsychotics was to improve the effectiveness of drugs in suppressing the symptoms of psychosis and also minimise the side effects of the drug used.

Question 26

Atypical antipsychotic drugs
Clozapine

Answer 26

developed in the 1960s, first trailled in the early 1970s. It was withdrawn for a while in the 1970s following the deaths of some patients from a blood condition called agranulocytosis.

People taking it have regular blood tests to ensure they are not developing agranulocytosis. Because of its fatal side effects, clozapine is not available as an injection. Daily dosage is a little lower than chlorpromazine, typically 300 to 450 mg a day.

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

Question 27

Atypical antipsychotic drugs
Risperidone

Answer 27

• recent atypical antipsychotic since the 1990s.
  Form of tablets, syrup or injection that lasts 2 weeks. In common with other antipsychotics, a small dose is initially given and this is built up to a typical daily dose of 4-8mg and a maximum of 12mg.
  Risperidone binds more strongly to dopamine receptors than clozapine and is therefore effective in much smaller doses than most antipsychtoics.

Question 28

Psychological explanation for schizophrenia - Family dysfunction

The schizophrenogenic family/mother

Answer 28

Fromm Reichmann notes that many of the patients spoke of a particular type of parent, which she called the schizophrenogenic mother. “Schizophrenogenic” means “schizophrenia-causing”. The schizophrenogenic mother is cold, rejecting and controlling, and tends to create a family climate characterised by tension and secrecy. This leads to distrust that later develops into paranoid delusions and ultimately schizophrenia.

Question 29

Psychological explanation for schizophrenia - Family dysfunction
Double-blind theory

Answer 29

Bateson et al 1972, agreed the family climate is important in the development of schizophrenia but emphasised the role of communication style within the family. The developing child regularly finds themselves trapped in situations where they fear doing the wrong thing, but receive mixed messages about what this is, and feel unable to comment on the unfairness of this situation or seek clarification. When they get it “wrong” the child is punished by withdrawal of love. This leaves them with an understanding of the world as confusing and dangerous, and this is reflected in symptoms like diagnosed thinking and paranoid delusions.

Question 30

Psychological explanation for schizophrenia - Family dysfunction
Expressed emotion

Answer 30

EE is a negative emotion expressed towards a person with schizophrenia by their carers who are often family members.
EE contains several elements -
- Verbal criticism of the person, sometimes accompanied by violence
- Hostility towards a person, including anger and rejection
- Emotional overinvolvement in the life of the person, including needless self-sacrifice

These high levels of expressed emotion directed towards the individual are a serious source of stress for them. This is primarily an explanation for relapse in people with schizophrenia. However, it has been suggested that it may be a source of stress that can trigger the onset of schizophrenia in a person who is already vulnerable, due to their genetic makeup (the diathesis-stress model )

Question 31

Mednick 1984 - Family dysfunction

Answer 31

Identified 207 children they considered to be at a high risk of developing schizophrenia because of being reared in dysfunctional families. More specifically mothers who were temperamental, cold, rejecting and emotionally aggressive.
They were compared to a group of 107 people.

Findings =
None of the participants or their mothers had schizophrenia at the beginning of the study, within 10 years 17 of the high-risk group were diagnosed with schizophrenia, whereas only 1 in the control group.

Question 32

Psychological Therapies for schizophrenia - Family therapy

Answer 32

Family therapy takes place with families as well as the identified patient. The therapy aims to improve the quality of communication and interaction between family members.

Question 33

Psychological Therapies for schizophrenia - How family therapy helps

Answer 33

Fiona Pharaoh et al 2010 identified a range of strategies that family therapists use to try to improve the functioning of a family that has a member with schizophrenia.

Reduces Negative emotions
Family therapy aims to reduce the levels of expressed emotion (EE) i.e reduce the level of emotion generally but especially negative emotions such as anger and guilt which creates stress. Reducing stress is important to reduce the likelihood of relapse.

Improves the family’s ability to help: The therapist encourages to formation a therapeutic alliance and improves the family’s beliefs about behaviour towards schizophrenia. A further aim is to ensure that family members achieve a balance between caring for the individual with schizophrenia and maintaining their own lives.

Question 34

Psychological explanation for schizophrenia - Cognitive explanation

Metarepresentation dysfunction

Answer 34

Frith et al 1992 identified 2 kinds of dysfunctional thought processes. The cognitive ability to reflect on thoughts and behaviour. This allows us insights into our intentions and goals and interprets the actions of others. Dysfunction in metarepresentation would disrupt our ability to recognise our own actions and thoughts as being carried out by ourselves rather than someone else. This would explain hallucinations of hearing voices and delusions like thought insertions (the experience of having thoughts projected in the mind of others

Question 35

Metarepresentation

Answer 35

The cognitive ability to reflect on thoughts and behaviours; insight into our goals and intentions; interpret actions of others

Question 36

Dysfunction in Metarepresentation

Answer 36

Disrupts the ability to recognise own actions and thoughts as being carried our by ourselves and not others. Hallucinations/delusions (thought insertions)

Question 37

Central Control

Answer 37

The cognitive ability to suppress automatic responses while we perform deliberate actions instead

Disorganised speech and thought disorder could result from an inability to suppress automatic thoughts and speech triggered by other thoughts.

Question 38

Central control dysfunction

Answer 38

Frith et al also identified issues with the cognitive ability to suppress automatic responses while we perform deliberate actions. Speech poverty and thought disorder could result from the inability to suppress automatic thoughts and speech triggered by other thoughts. For example, people with schizophrenia tend to experience derailment of thoughts because each word triggers associations, and the person cannot suppress automatic responses to these

Question 39

Psychological Therapies for treating SZ
- Token Economy

Answer 39

Based on operant conditioning

Reward systems to manage the behaviour of patients with SZ- especially those who have been institutionalised for a long period of time

Improves patient’s quality of life; does not cure SZ

Makes it more likely that they can live outside a hospital setting

Tokens- given immediately patient carries out desired behaviour (reinforcement

Rewards- tokens swapped for tangible rewards (secondary reinforce)

Question 40

Token Economy supporting evidence
Is it effective?

Answer 40

Ayllon and Azrin (1968)
Used a token economy on a ward of female Sz patients, many of whom had been hospitalised for many years. They were given plastic tokens, each embossed with the words ‘one gift’ for behaviours such as making their bed or carrying out domestic chores. Tokens are exchanged for privileges such as watching a movie

Findings:
The use of token economy increased the number of desirable behaviours that patients performed each day

McMongale and Sultana (2009)
1/ 3 studies (110 Ps), where patients were randomly allocated to conditions
Findings:
Only one study showed an improvement in patient’s symptoms
None yielded useful information about behavioural change

Kazdin (1977)
The effectiveness of the token economy may decrease if more time passes between the presentation of the token and the exchange for the backup reinforcers

Question 41

CBT- Is it effective?

Answer 41

NICE, 2014
When compared with antipsychotic drugs, CBT was more effective in reducing symptom severity and improving levels of social functioning
CBTp is also effective in reducing rehospitalisation rates up to 18 months following the end of treatment

Note:
Most studies into CBTp have been conducted with patients treated at the same time with antipsychotic medication
It is difficult to assess the effectiveness of CBTp independent of drug therapy

Jauhar et al (2014)
Reviewed results of 34 studies of CBT for SZ
Conclusion:
CBT has a significant but fairly small effect on both positive and negative symptoms