Schizophrenia Flashcards
1
Q
Facts on SZ
(AO2)
A
- mostly for ages 15-35
- affects 1% population
- ppl with family x10 more likely
2
Q
classification of SZ ?
(categorising)
A
- DSM - 5
- ICD - 11
3
Q
diagnosis of SZ with
DSM-5 v ICD-11
A
- DSM - 5
- 2 positive symptom must be present for diagnosis of SZ
- No sub-types - ICD - 11
- 2 or more negative symptoms must be present for diagnosis of SZ
- 7 sub-types
4
Q
positive symptoms of SZ?
EG?
A
+ symptoms = additional experiences that the general population don’t experience
- Hallucinations - unusual sensory experiences
- Delusions - irrational beliefs
- Jumbled speech
5
Q
Negative symptoms of SZ
A
- = the loss of usual abilities + experiences
- abilities which have been removed due to SZ that the general population have
-
Speech poverty - changes in patterns in speech
reduction in quality + amount of speech - Avolition - reduced motivation to begin / keep up with goal-directed activity, becoming disinterested
- Anhedonia - loss of ability to feel pleasure
- lack of emotion
6
Q
reliability AO3:
Validity AO3:
A
- low reliability of classification - DSM5 + ICD11 not consistent
- low reliability of diagnosis - low inter-rater reliability
- may be explained by low resources + time
. - low validity = high co-mobility overlap of symptoms
- culture bias
- gender bias
7
Q
Issues with Reliability of CLASSIFICATION of SZ
A
- classification of SZ is not reliable as the classification in DSM-5 + ICD-11 are not consistent.
- This is because the DSM-5 diagnoses SZ if 2 positive symptom is present and has no sub-types
- whereas the ICD-11 diagnosis SZ if 2 or more negative symptoms are present and it also has 7 sub-types of SZ
- Showing there is no consistency in the classification in SZ
8
Q
1
Issues with Reliability of DIAGNOSIS of SZ
A
- Evidence which shows that the diagnosis of SZ is not reliable.
- Cheniaux et al had 2 psychiatrists independently diagnose 100 ps using DSM + ICD
- one diagnosed 2ps according to DSM + 44 according to ICD
- the other diagnosed DSM: 13 + ICD: 24
- = more SZ likely to be diagnosed under ICD than DSM and SZ is either over diagnosed with ICD or under diagnosed with DSM.
- Beck et al looked at inter-rater reliability between 2 psychiatrists when considering 154 ps
- the reliability was only 54% = only agreed on a diagnosis for 54% of the 154 ps.
9
Q
Low inter-rater reliability may be explained..
A
- Different hospital have different resources + demand for number of patients = time availability differs
= could explain low inter-rater reliability, as these factors could explain differences in diagnosis by different psychiatrists
- As diagnosis made may not reflect true diagnosis of symptoms but rather may be as a result of it being rushed due to high demand for professionals as they have less time available
10
Q
2
symptom overlap
- validity
(comorbidity = 2 conditions present at same time)
A
- SZ + bipolar disorder both share positive symptoms (e.g. delusions) + negative symptoms (e.g. avolition) = there’s symptom overlap
- depression + schizophrenia both involve very low levels of motivation = creates problems of reliability = Does low motivation reflect depression or schizophrenia / both?
- Using ICD, 1 patient might be diagnosed with SCZ but using DSM, would receive diagnosis of bipolar disorder = questions the validity of the classification of SZ
- Lack of distinction questions the validity of both classification/diagnosis of SZ
- = difficult to choose suitable diagnosis + treatment
- misdiagnosis due to symptom overlap = years of delay in receiving relevant treatment= suffering + high suicide levels can occur
- Symptom overlap can have serious consequences - focusing on fixing this issue could save money/lives = focus should not heavily be about the name of the disorder but rather the success of the relevant treatment they should receive
11
Q
3
Culture bias (validity)
A
-further limitation of schizophrenia diagnosis is the existence of culture bias.
- Some symptoms of schizophrenia (auditory hallucination - hearing voices) have different meanings in different cultures.
- For example in some cultures some people believe that voices actually are communications from ancestors.
- British people of African-Caribbean origin are 9x as likely to receive a diagnosis as white British people, although people living in African- Caribbean countries are not = ruling out a genetic vulnerability.
- The most likely explanation for this is culture bias in diagnosis of clients by psychiatrists from a different cultural background.
- This appears to lead to an over interpretation of symptoms in black British people = British African - Caribbean people may be discriminated against by a culturally-biased diagnostic system
= Diagnosis is taking an ethnocentric approach, lowering the validity of the diagnosis of SZ.
12
Q
4
Gender bias (validity)
A
- further limitation of schizophrenia diagnosis is the existence of gender bias.
- men are diagnosed with SZ more than women (ratio of 1.4 : 1 Fischer + Buchanan)
- A possible explanation for this is that women are less vulnerable than men, perhaps because of genetic factors.
- some behavior which was regarded as psychotic in males was not regarded as psychotic in females
- However it seems more likely that women are under diagnosed because they have closer relationships + hence get support (Cotton et al ). = so better able to manage symptoms = less severe = less diagnosed
- This leads to women with SZ often functioning better than men.
-This under diagnosis is a gender bias = lower validity + means women may not therefore be receiving treatment + services that might benefit them.
13
Q
symptoms easily fakes + no predictive validity
A
- no predictive validity as there are no pathognomic symptoms
14
Q
Biological explanations for SZ ?
A
- Genetic hypothesis
- Dopamine hypothesis
- Neural correlates
15
Q
Genetic hypothesis:
A
- There is no SZ gene
- candidate genes associated with risk of inheritance
- SZ is polygenic
= different combinations of genes make individuals more vulnerable to SZ
16
Q
Twin studies:
A
Cardno et al:
- found 40% concordance rate in MZ twins
- 5.3% in DZ twins
17
Q
Family studies:
A
- General population 1% risk
Gottesman :
- the more genetically related a person to someone who has SZ = the higher risk they have
1st degree relatives: 6-9%
2nd degree relatives: 2-4%
3rd degree relatives: 2%
Kendler et al: 1st degree relatives 18x more at risk than general population
18
Q
Adoption studies:
A
Tienari et al :
- children of SZ parents have higher risk of developing SZ even if adopted family have no history of SZ
19
Q
AO3 genetic hypothesis:
A
- supporting evidence
- Nurture elements ignored
- reductionism
20
Q
- Supporting evidence
A
- Supporting evidence : Tienari et al (adoption studies) + Gottesman (family studies) + Cardno et al (Twin studies)
= these show that some people are more vulnerable to SZ due to genetic makeup.
21
Q
- Nurture elements
A
- Nurture (Environmental) factors have not been considered.
- As MZ twins share 100% genes, it would be expected that concordance rate would also be 100% if it was purely genetic
- As it’s only 40% - it suggests other influences (environment) are playing a part
- Also limitation of Gottesman study, is that the high concordance rate may be due to increased chance of sharing the same environment.
- EG 1st degree relatives may share exact same environment, whereas 2nd degree would not
= cannot be concluded that genetic has caused SZ.
22
Q
- Reductionist
A
- The genetic explanation for SZ is reductionist.
- It has reduced SZ, which is a complex + serious psychologoical disorder to genetics.
- This allows researchers to investigate the genetic link for SZ in great detail + makes it more scientific.
- However, reductionism is negative as it oversimplifies serious behaviour into small simple components, making SZ seem very simple whilst realistically it is very complex and large.
23
Q
Dopamine hypothesis
A
Dopamine neurotransmitters linked with SZ
- Both hyper + hypo are involved in onset of SZ
- hyperdopaminergia in subcortex :
- excessive levels of dopamine in subcortex
= positive symptoms
(Jumbled speech + auditory hallucinations) - hypodopaminergia in pre-frontal cortex :
- Low levels of dopamine in pre-frontal cortex
= negative symptoms
(to do with thinking + decision making as pre-frontal cortex responsible for that)
24
Q
AO3 Dopamine hypothesis:
A
- Use of anti psychotic drugs for treating SZ
- opposing evidence
- Supporting evidence from PET scans + post postmortems
25
1. Supporting evidence : Drug therapy
use of anti psychotic drugs for treating SZ
- Barlow + Durand report that chlorpromazine is effective in reducing SZ symptoms in about 60% cases
= the effectiveness of drug therapy by recovering dopamine levels supports the dopamine hypothesis as it shows SZ was caused by the original excessive / limited amount of dopamine.
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2. opposing evidence
Kasper et al :
- found anti psychotic drugs effective only for positive symptoms = therefore excessive dopamine can at best explain only some types of SZ
- newer atypical anti psychotic drugs have proved more effective than traditional ones
27
3. Supporting evidence from PET scans + post postmortems
Wise + Stein found that SZ pts who died in brain accidents showed abnormally low levels of dopamine hydroxylase (DBH) in brain fluid
(DBH is enzyme which breaks down dopamine after release)
- correlation not causation ?
28
neural correlates hypothesis
- certain structures + functions of the brain correlates with displaying symptoms of SZ
1. positive symptoms: Allen et al found ps experiencing auditory hallucinations recorded lower activation levels in superior temporal gyrus + anterior cingulate gyrus, + made more errors, compared to a control group.
2. Negative symptoms: loss of motivation (Avolition)
- ventral striatum is involved in this
- abnormality in this area may be involved in development of Avolition
- Juckel et al measured activity of ventral stratum in SZ ps
= found lower activity levels than control
29
Neural correlates AO3
1. supporting evidence: Suddath et al
2. Methodological strength of supporting evidence
3. Correlation / causation issue
30
1. supporting evidence
- Evidence which supports the neural correlates hypothesis comes from Suddath et al.
- Suddath et al used MRI on MZ twins where one was SZ and found large differences:
- the SZ twin had more enlarged ventricles and reduced anterior hypothalamus.
= supporting the hypothesis that there's a correlation between brain structures and the display of SZ symptoms.
= therefore validating the neural correlates hypothesis
31
2. Methodological strength of supporting evidence
- Research is carried out in highly controlled environments, with specialist high tech equipment such as MRI (Suddath et al)
- MRI take accurate readings on the different regions of the brain such as the hippocampus
- If this research was replicates and re-tested, the same results would be achieved due to its scientific nature.
- This increases the validity of the findings from the supporting evidence and in return adds credibility to the neural correlates hypothesis
32
# 3
causation / correlation
- difficult to establish cause + effect
- Do abnormalities in the brain cause SZ symptoms, or are the SZ symptoms affecting brain structures after SZ is developed
- Therefore neural correlates limited explanation as does not tell us much more / further our understanding as we are unable to accurately conclude that brain structures are the onset of SZ
33
Essay on biological explanations of SZ:
AO1 + AO2
AO1: Genetic hypothesis: SZ is polygenic as different combinations of genes make individuals more vulnerable to SZ.
AO2: Family studies such as Gottesman found the more genetically related a person to someone who has SZ = the greater the risk
AO2: Twin studies (Cardno et al) found that MZ twins are more concordant than DZ = suggests the greater similarity is due to genetic factors.
AO2: Tienari et al: children of SZ parents have higher risk of developing SZ even if adopted family have no history of SZ
AO1: Dopamine hypothesis: Dopamine neurotransmitters linked with SZ.
- Hyperdopaminergia - excessive levels of dopamine in subcortex = positive symptoms
- hypodopaminergia - Low levels of dopamine in pre-frontal cortex = negative symptoms
AO1: neural correlates: certain structures + functions of the brain correlates with displaying symptoms of SZ
AO2: Allen et al found ps experiencing auditory hallucinations recorded lower activation levels in certain parts of their gyrus brain region
34
AO3 Evaluation for biological explanations of SZ:
1. supporting evidence
2. causation - correlation problem
3. biologically reductionist
35
1. supporting evidence
(or SE from genetic hypothesis)
Support for the dopamine hypothesis comes from drug therapy for SZ.
The mechanism of antipsychotic drugs is to reduce the effects of dopamine = reduce the symptoms of SZ.
- Barlow + Durand report that chlorpromazine is effective in reducing SZ symptoms in about 60% cases
= This therefore, shows that the use of antipsychotic drugs is proven to be more effective in the treatment of positive + negative symptoms which is achieved through the normalisation of dopamine
= The effectiveness of drug therapy by recovering dopamine levels supports the dopamine hypothesis as it shows SZ was caused by the original excessive / limited amount of dopamine.
36
2. causation - correlation problem
- There's a causation-correlation
- Does the unusual activity in the brain cause the symptoms or are other possible explanations for the correlation.
-Neural correlates hypothesis may suggest that low activity in the striatum causes avolition,
but it could be that avolition means that less information passes through the striatum resulting in the low activity
= Therefore, although neural correlates exist, its limited as it does not further out understanding on the onset of SZ, but instead leaves us confused on whether its correlation or causation.
37
3. Biological reductionist
-Biological for explanations for SZ or biologically reductionist.
- This is scientific as by breaking complex behaviours such as SZ into smaller parts
= makes it easier to investigate
= allowing researchers to focus on specific causes of SZ in more detail
= giving more valid in depth findings
- Biological reductionist can be criticised as it oversimplifies SZ to just genes + neurotransmitters, + the social context which it develops in is not considered.
- It's said that although biological factors predispose someone to SZ, this has to be triggered by some sort of experience / stressor for symptoms to be displayed.
= Therefore in order to explain SZ effectively, it would be better to take an interactionist approach such as the diaphrases stress model.
38
Biological therapies for SZ : drug therapies
What are the 2 types of antipsychotic drugs?
1. Typical antipsychotic (1st generation) drugs
2. Atypical antipsychotic (2nd generation) drugs
39
Typical antipsychotic drugs
(1st generation drug)
- work as dopamine antagonist
- block dopamine receptors in the synapses of the brain = reducing the action of dopamine.
- also an effective sedative due to its effect on histamine receptors (reduces anxiety + calms down)
- have more side effects
40
Example of typical antipsychotic drug
chlorpromazine
- act as dopamine antagonists in the dopamine system
- reduce the action of dopamine.
- Dopamine antagonists block dopamine receptors in the synapses of the brain = reducing the action of dopamine = reduces positive symptoms of SZ
41
Atypical antipsychotic drug
(2nd generation drug)
- target a range of neurotransmitters such as dopamine and serotonin.
- improve the effectiveness of drugs in suppressing negative symptoms + minimise side effects
42
Example of atypical antipsychotic drug
Clozapine
- binds to dopamine receptors + also acts on serotonin + glutamate receptors.
-It is believed that this improves mood + reduces depression + anxiety in patients = may improve cognitive functioning.
- important, as 30-50% SZ ps attempt suicide at some point
43
AO3 evaluation of use of antipsychotic drugs
1. Effective?
2. Appropriate?
3. Ethical?
44
Is effective:
- Evidence supports effectiveness of typical + atypical antipsychotics in treating symptoms of SZ.
- Thornley et al found that when compared to a control group Ps who were treated with chlorpromazine (typical) had a reduce rate of severe symptoms + less likely to relapse
- Meltzer concluded that clozapine is more effective than typical antipsychotic- it is effective in 30-50% of treatment resistant cases where typical have failed
- The evidence above suggests that antipsychotics are reasonably effective, is increases our confidence in their use.
- Therefore, some Ps can confidently rely on the use of antipsychotic drugs to reduce the symptoms they are experiencing as part of their condition which could help them feel more stable + possibly improve their life chances/ opportunities including possible employment, formation + maintenance of relaitonships + improved family ties
45
Ineffective:
- Issue with using antipsychotic drugs to treat (some of the) symptoms of SZ is the side effects, which range from mild to serious + fatal including ( involuntary facial movements)
- Although atypical antipsychotics were developed to reduce the frequency of side effects + generally this has succeeded, side effects still exist.
- ps who take clozapine have to have regular blood tests to detect early signs of agranulocytosis, a blood condition which could be fatal.
- Therefore we conclude that side effects of antipsychotic drugs are a significant limitation + question the overall effectiveness of drug therapy
- However, it is important to note that despite this 1/3 of patients respond well to antipsychotic drugs.
46
Appropriate?
Drug therapy is appropriate for most Ps.
- Antipsychotics drugs can be administered in Tablet; Syrup + Depot injection.
- Depot injection is more appropriate if you have difficulty swallowing medication, have difficulty remembering to take medication regularly, prefer not to have to think about taking medication every day
- You may also be given a depot if your doctors agree that you need the drug but feel that you will not take it regularly as prescribed
- This allows drug therapy to be accessible for most Ps + are usually recommended as the first treatment for psychosis
- However it is often combined with other forms of treatment including psychological therapies + social support as some Ps are resistant to treatment unsuitable for drug therapy due to pre-existing medical conditions such as cardiovascular disease
47
Ethical?
- Not only are there side effects of antipsychotic drugs which reduce the effectiveness of drug therapy, there are also ethical issues to consider
- Antipsychotics have been used in hospitals to calm patients + make them easier for staff to work with rather than for the patients’ benefit
- Can lead to the abuse of the Human Rights Act = states that ‘no one shall be subjected to inhuman or degrading treatment or punishment'
- highlights wider social issues with drug therapy + questions whether it should be commonly available if patients human rights are being breached = questions whether drug therapy is an appropriate treatment for all patients
- Ps also have to be fully infromed about all potential side effects + give full consent before receiving anythimg
48
Psychological explanations for SZ
1. Family dysfunction
2. Cognitive explanations
49
1. Family dysfunction
The Schizophrenogenic mother
(psychodynamic explanation)
- a "SZ causing mother"
- cold, rejecting, controlling + secrecy + creates tension in family
= leads to distrust + later develops into paranoid delusions + ultimately SZ
50
Double - blind theory
- child fears that they're doing something wrong but are unclear what
- They receive mixed signals about this so don't know how to react
- when they 'get it wrong' are punished through withdrawal of love
= leaves them with understanding of the world as confusing + dangerous
= reflected in symptoms (disorganised thinking + paranoid delusions)
= risk factor for SZ
51
Expressed emotions
(negative)
carers expressing EE:
- verbal criticism of a person ( occasionally accompanied by violence)
- Hostility (anger + rejection)
- Emotional overinvolvement in their life
- high levels of EE are a serious source of stress
= triggers onset of SZ to someone who's already vulnerable (eg from genes)
52
AO3 of psychological explanations for SZ
(family dysfunction)
1. strength - supporting evidence
2. Ignores biological explanation
3. ethical issues
53
1. supporting evidence
- One strength of these explanations is evidence linking family dysfunction to SZ.
- Indicators of family dysfunction include insecure attachment + exposure to childhood trauma, especially abuse.
- According to a review by John Read et al adults with SZ are more likely to have insecure attachment
- Read et al. also reported that 69% of women + 59% of men with SZ have a history of physical and/or sexual abuse.
- Other studies also found that most adults with SZ reported at least 1 childhood trauma, mostly abuse.
- This strongly suggests that family dysfunction makes people more vulnerable to schizophrenia.
54
2.Ignores biological explanation
- fail to explain why some children in such dysfunctional families often do not go on to develop SZ
- If family dynamics were the sole cause of SZ, then all children raised in similar environments should be schizophrenic.
- This is not the case = family dysfunctions cannot be the sole cause of the illness. (nature / nurture)
- It is more likely that the SZ has a biological predisposition to the disorder + that the unhealthy family environment combines with the biological vulnerability to cause the illness, like the diathesis-stress model proposes.
- One element of nurture is most probably not enough alone to cause the illness + nature needs to be considered as well.
55
3.ethical issues
- There are ethical issues with the psychological explanation
Research linking family dysfunction to sz is highly socially sensitive because it can lead to parent-blaming, as mothers seem to be pariculay blaimed
- There are serious ethical concens in blaming the family, particularly as there's evidence upon which to base this.
- The schizophrenogenic mother theory clearly shows alpha gender bias as it suggests that women/mothers play a key, destructive role in the onset of schizophrenia in a child, when this will not always be the case.
- Therefore, a mother taking care of her child with symptems of SZ may be blamed, which can affect her self-esteem and this research does not protect individuals from these negative harm + effects of the theory.
56
Psychological therapy for SZ
1. Family therapies for SZ
- involves the family members of the person with schizophrenia
- to improve communication within family + reducing stress of SZ for all involved
**Pharoah et al** identified most important goals of family therapy:
```
1. reduce negative destructive emotions = reduce levels of EE + reduce stress = to reduce relapse
2. Educate family member + improve their beliefs + behaviour towards SZ
3. Enable the family to work as a team + improve their ability to help
```
57
AO3 Family therapy
1. effective
2. not appropriate for all SZ
3. Ethical
58
# 1.
effective
- evidence that supports the effectiveness of family therapy for schizophrenia.
- Pharaoh at al did meta-analysis on 53 studies on effectiveness of family therapy comparing it to antipsychotic drug therapy.
- found that there was a reduction in Relapse during treatment + 24 months after = therefore improves quality of life For Ps + family + increases compliance to medication
- shows that family therapy is more effective as it benefits both the individual + their family ultimately leading to better quality of life
- Adds credibility to this treatment suggests it should be more widely available for individuals who are in contact or live with their family
59
# 2.
not appropriate for all SZ ps
- therapy may not be appropriate for all schizophrenia patients
- Some patients don’t live with their family or not in Close contact with them = family therapy is not very appropriate for them
- Also family therapy takes a lot of time + effort for around 6 months + 10 different sessions + family visits may be needed during times where they normally work
= so it may not be appropriate for all patients + their family’s schedules.
60
# 3.
Ethical
- FT is ethical as long as patients have given informed consent + given the right to withdraw
- This consent will also ensure that they are complying in order to get the best outcome
- Although family therapy may make the individuals emotional, this is necessary + is part of the process
61
Psychological explanations
2.Cognitive explanations
- focuses on role of mental processes
- SZ is associated with several types of dysfunctional cognitive thought proccessing
- dysfunctional thought processing = info processing which does not represent reality accurately + produces undesirable consequences
62
Frith-dysfunctional thought process
Frith et al identified:
1. Dysfunction in meta- representation
2. Dysfunction in central control
63
Dysfunction in meta-representation
[frith et al]
Metarepresentation is our ability to reflect on thoughts + behaviour = allows us to identify our goals + intentions, as well as allowing us to interpret the actions of others.
- Dysfunction in this area would disturb out ability to recognise our own actions + thoughts as being ours + carried out by ourselves, rather than being carried out by someone else.
- This therefore can explain hallucinations as the inner voice is experienced as coming from an external source
64
Dysfunction in central control
[Frith et al]
- Central control is our ability to suppress automatic responses while we perform deliberate actions
- Having disorganised speech could be due to an inability to suppress automatic thoughts + speech triggered by other thoughts.
- Many schizophrenics experienced derailment of thoughts + spoken words/sentences because each word triggers an associations + the schizophrenic cannot stop the automatic responses to these associations
65
Ao3 of cognitive explanation for SZ
1. Supporting evidence
2. Issues with causation
3. Limited explanation only explains one aspect - biological?
4. Deterministic approach
66
# 1
Supporting evidence
- Stirling et al Found that SZ ps took twice as long as the control group to complete cognitive tasks
- This validates the cognitive explanation as it shows that information processing in SZ ps may not be functioning normally
= indicating that they were struggling to have central control + suppressnthe automatic associations
= which supports frith’s central control dysfunction + adds credibility to this explanation
67
# 2.
Issues with causation
- weakness of the cognitive explanation is that there are problems with cause + effect
- Cognitive approaches do not explain the causes of cognitive deficits i.e. where the dysfunction comes from in the first place
- Are the cognitive deficits causing the schizophrenic behaviour or is the schizophrenia the cause of the cognitive deficits?
- Links between symptoms + faulty cognitions are clear however, it is not possible to know the origin of those cognitions
= therefore it is not possible to be certain that cognitive dysfunctions are the cause of the illness + not just an effect
does schizophrenia cause dysfunctional thought processing or is that dysfunctional thought processing leads to schizophrenia symptoms?
68
# 3.
Limited explanation only explains one aspect
-biological?
- Although the cognitive approach provides an excellent explanation for the symptoms of schizophrenia = seeing SZ as a psychological condition
- On the other hand, it appears that the abnormal cognition associated with SZ is partly genetic in origin + the result of abnormal brain development
- This would suggest that SZ is a biological condition + this cognitive explanation does not account for biolgocal factors, making it limited
- An interactionist approach may be better to use to fully explain SZ
69
# 4.
Deterministic approach
- Takes the determinism side of the determinism/free will debate as it assumes that anyone with schizophrenia will think in a disordered way using attentional biases to interpret the world + eg be unable to repress automatic thoughts
- It does not account for individual differences within the array of experience of people with schizophrenia = lowers validity of this explaantion
- as assumes SZ is same for all = the way they think
70
3 types of Psychological therapies for SZ ?
1. CBT
2. Token economies
3. Family therapy
71
Psychological therapy for SZ:
2. CBTp ?
- focuses on identifying + altering their irrational + dysfunctional thoughts + behaviour, + avoiding acting on these thoughts
- won't get rid of symptoms , just helps them cope with them better
72
Stages of CBTp
1. Assessment
2. Engagement
3. The ABC model
4. Normalisation
5. Critical collaborative analysis
6. Developing alternative explanations
73
1. Assessment
Therapist encourages ps to explain concerns (eg describing delusions)
74
2. Engagement
Requires trust, honesty, patience
75
3. ABC model
Get ps to understand what's really happening
A- activating event
B- behaviour
c- Consequences
76
4. Normalisation
helps ps realise it's normal to have these negative thoughts in certain situations
= no need to feel ashamed / stressed about it
77
5. critical collaborative analysis
- carrying logical discussions until ps see why their ideas are wrong + why they developed
- develop ways to recognise negative thoughts + faulty beliefs + challenge them
78
6. Developing alternative explanations
- Helping ps find logical reasons for things which trouble them
79
AO3 for CBTp
1. Effective?
- evidence to support the benefits of CBTp on SZ
- Jauhar et al concluded that CBT has a significant but fairly small effect on both positive + negative symptoms.
- NICE, 2014, found that when compared with antipsychotic drugs, CBT was more effective in reducing symptom severity + improving levels of social functioning. CBTp is also effective in reducing rehospitalization rates up to 18 months following the end of treatment.
-This evidence increases our confidence in the use of CBT and we can conclude that overall it is somewhat effective.
-However, it is important to note that CBT is unlikely to be used as a sole treatment for SZ as it is one of the harder mental health problems to treat.
- It is also important to note that most studies into CBT have been conducted with patients treated at the same time with antipsychotic medication, therefore it is difficult to assess the effectiveness of CBT independent of drug therapy
80
2. Appropriate?
- CBT is more appropriate when it is made available at specific stages of the disorder + adjusted to the stage the individual is currently at.
- This is supported by Addington + Addington (2005) who claim that in the initial acute phase of Sz self-reflection is not appropriate; following stabilisation of the psychotic symptoms with medication, individuals can benefit from group CBT.
- The use of CBT at the appropriate stage of the disorder can allow patients to make sense of and in some ways challenge some of their symptoms.
- Whilst this does not cure SZ it can reduce the severity of symptoms + improve the quality of life for patients.
81
3. Ethical?
Although CBT doesn't have any serious side effects, it can still raise ethical issues as it involves challenging a persons paranoia which can interfere with a persons freedom of thought.
For example if CBT challenged a persons thoughts in a highly controlling government this can stray into modifying their politics.
This is a limitation of the use of CBT to treat SZ and must be used with care.
82
Psychological therapy for SZ
2.Token economies
- Based on operant conditioning
- reward system to manage behaviour of SZ ps (esp those who've been institutionalised for long time)
- Ps receive 'token' (which is then traded for a 'reward' they want) each time they carry out desired behaviour to reinforce it
Token : given immediately after desired behaviour is carried out (reinforcement)
Reward : Tokens swapped for tangible rewards (secondary reinforcement)
83
AO3 of token economy
1. Effective?
- There's supporting evidence for the effectiveness of token economies used to manage the behaviour of patients with SZ particularly those who have been institutionalised.
- Ayllon and Azrin (1968) found that the use of token economy increased the number of desirable behaviours that patients performed each day.
- However, it is important to note that the efficacy of token economies may be limited if there is a delay between the presentation of the token and the exchange for a reward, Kazdin (1977).
- Whilst token economies is not a cure for SZ it is an effective treatment which makes patients behaviour more socially acceptable so that they can re-integrate into society and have a better quality of life.
- The failure to cure SZ is a limitation of psychological treatments such as token economies, for this reason it is recommended that patients use a combination of biological + psychological treatments for increased efficacy.
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2. Appropriate?
- Its important to note that token economies are more appropriate in hospital setting (in-patients with mild symptoms) as SZ patients receive 24 hour care and staff monitor their behaviour more closely.
- Token economies is less useful and impractical to use for outpatients living in the community as they only receive day treatment for a few hours.
- Additionally, token economies is inappropriate to use with patients who have severe SZ symptoms, they are unlikely to engage with the reward system which will make modifying there behaviour more difficult.
- For this reason it is important to consider the use of token economies on an individual basis.
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3. Ethical?
- Although token economies, has no serious side effects it can still raise ethical issues as token economy systems have been proved controversial.
- The privileges/ services are mainly available to patients with mild symptoms and less so for those with severe symptoms = this leads to discrimination.
- Some families have challenged the legality of this.
- This has resulted in the reduced use of token economies in the psychiatric system.
86
The interactionist approach / biosocial approach to Schizophrenia
- looks at the interaction between biological, social + psychological factors in the development of SZ
87
Interactionist Approach to SZ :
1. Meehl’s model
(Original diathesis stress model)
Diathesis stress model :
1. **Diathesis** [**biological**]
- vulnerability (entirely genetic - ***schizogene***)
2. **Stress** [**psychological**]
- negative psychological experience
( If a person does not have the schizogene, no amount of stress would lead to SZ)
-child rearing practices eg (Tienari et al)
= Both necessary to develop SZ
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AO3 of Meehl's original diathesis stress model :
- Strength
- Supporting evidence for the dual role of vulnerability + stress in the development of SZ
- **Tienari** et al found that child-rearing style characterised by high levels of criticism + low levels of empathy was implicated in the development of SZ but only for the adopted children who had a high genetic risk + not in the adopted control group with no genetic risk.
= very strong evidence supports the importance of adopting an interactionist approach to SZ, including the argument that poor parenting is a possible source of stress
= This could lead to practical + valuable advice given to families with a history of mental illness about the significance of their parenting style on their child's/ children’s mental health + where necessary offer additional support as a precautionary measure
89
- Limitation
- Meehl’s model original diathesis stress model is over-simple as multiple genes increase vulnerability to SZ = there is no single SZ gene
- diathesis can be caused by other non genetic factors such as physical + psychological trauma effecting brain development, and sexual trauma can cause vulnerability
- stress triggering SZ can also come in different forms, not limited to dysfunctional parenting - cannabis use increase the risk of developing schizophrenia by up to 7x
= suggests that vulnerability + stress does not have 1 source + limits the validity of the original diathesis stress model
[ also= might not fully be able to account for why some people develop mental illnesses and others don't despite having same vulnerability + stress]
90
Interactionist Approach to SZ:
2. The modern understanding of diathesis
1.Biological :
- Multiple genes increase vulnerability
[Ripke et al]
= No single schizogene
- Trauma (child abuse) effects the brain development = HPA system can become overactive = making the person more vulnerable to stress [ Read et al]
+
Psychological stressors
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Interactionist Approach to SZ :
3. The Modern understanding of stress
Biological vulnerability +
2. Psychological:
- Anything can be a stressor (risks triggering SZ)
- Cannabis use increases risk by x7
(interferes with dopamine systems = increases risk by x7)
- Houston et al (2008)
Most people do not develop SZ after smoking = must be 1 or more vulnerability factors
92
AO3 of the modern understanding of diathesis (vulnerability) AND stress
- Strength
- Brown + Birley found that
- approximately 50% of ppl experienced a major life event in the 3 weeks prior to a SZ episode
- whereas only 12% reported one in the 9 weeks prior to that.
= This supporting evidence increases the credibility of the modern understanding of diathesis + vulnerability
- It validates the claim that diathesis + stress does not come from one single source (poor parenting)
= This gives us a better insight into the onset of SZ + can be used to develop more effective combination treatments which not only improve the quality of life for patients but also the severity of their symptoms
93
- Limitation
- Despite the supporting evidence which gives us an insight into the role of vulnerability + stress in the onset of SZ, the interactions explanation does not fully explain the mechanisms of the SZ
- The theory fails to explain how symptoms appear/ are produced
= This incomplete understanding limits the validity of the diathesis stress model + suggests that further research into the mechanisms of SZ symptoms need to be investigated from an interactionist perspective
94
Interactionist treatment for SZ
- Biological + Psychological treatments
- Standard practice in UK to treat patients with combination of antipsychotic drugs + CBT
- Unusual to just use psychological treatments without medication
- In USA = there's more conflict between biological + psychological models of SZ
= More common to prescribe medication without accompanying psychological treatment
= economic implication as the American health system benefits from this = more purchases of medication
95
AO3 of Interactionist treatment for SZ
1. Effectiveness ?
- Supporting evidence for the usefulness of interactionist approach from studies comparing the effectiveness of combinations of biological + psychological treatments for SZ versus biological treatments alone.
= **Tarrier et al** randomly allocated 315 patients to 1 of 3 conditions:
1. Medication and CBT
2. Medication + supportive counselling
3. Control group (medication only)
Findings:
- Patients in condition 1 + 2 showed lower symptoms levels than condition 3 (control)
- No difference in rates of hospital readmissions
- This study shows that there is a clear practical advantage to adopting an interactionist approach in the form of superiors treatment outcomes + highlight the importance of taking an interactionist approach.
96
2. Ineffective
- We must be careful with causation fallacy.
- Turkington et al claims that the fact that combined biological + psychological treatments are more effective than either on its own does not mean the interactionist approach to SZ is correct.
= Therefore it's important to still consider alternative explanation for the onset of SZ as an interactions approach is limited in explaining how symptoms of SZ develop.
= Further research may need to be conducted to fully investigate cause of SZ.
97
3. Ethical
- ethical as long as ps aware of all side effects of drug therapy + psychological therapy
+ Informed consent / best interest of patient if they are unable to consent provided
98
4. Appropriate
Patient must comply with both medication + CBT for it to be effective = not for extreme ps who are unable to comply to this strict schedule of medication and CBT + balance them out
