Schizophrenia

Question 1

What is schizophrenia?

Answer 1

• it’s a type of psychosis, a severe mental disorder in which thoughts & emotions are so impaired that contact is lost with external reality.
• most likely to be diagnosed between ages of 15-35, men and women being equally effected

Question 2

How is schizophrenia diagnosed (& using what)?

Answer 2

• diagnosed using the DSM (diagnostic and statistical manual, must meet a criteria of positive and negative symptoms.

Question 3

What does positive symptoms of schizophrenia mean and what are they?

Answer 3

positive symptoms- adding on to patients everyday life.

Hallucinations- bizarre and unreal perceptions of the environment. Auditory (hearing voices), Visual (seeing things), Olfactory (smelling things), Tactile (feeling things)

Delusions- Bizarre beliefs that seem real to the person. Can be persecutory (believing there being followed or spied on). Can involve beliefs about being famous (delusions of grandeur)
more about believing something is happening to themselves as individuals.

Question 4

What does negative symptoms of schizophrenia mean and what are they?

Answer 4

negative symptoms- taking away from the patients everyday life.

Speech poverty- decreased speech fluency (reflective of slow/blocked thoughts), produce fewer words in a given time, less complex syntax

Avolition- reduction of interests and desires, unable to persist with goal-directed behaviour, self-initiated activities are available patient but will not partake due to mental distress.

Question 5

What are the criteria’s that a patient must fullfil in order to be diagnosed with schizophrenia?

Answer 5

Criteria A; must have two symptoms from- delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour (neg symptoms)

Criteria B; significant amount of time since the start of one or more major areas of functioning decrease below the level achieved prior the onset.

Criteria C; continuous signs of disturbance persist for at least 6 months - must include at least 1 month of symptoms from Criteria A.

Question 6

What is diagnostic reliability?

Answer 6

must be repeatable (clinicians must be able to reach the same conclusion about patients conditions at two different points in time, test-re-test reliability & inter-rater reliability)

Question 7

Discuss interrater reliability for classification of schizophrenia. (Kappa scores)

Answer 7

• measured by a scale found on a Kappa score- 0.7/0.8 or above is considered good reliability
• 1 indicates a perfect agreement

Question 8

Discuss cultural differences in the classification of schizophrenia.

Answer 8

culture DOES HAVE an influence of the diagnosis of schiz.

COPELAND (1971)
- US & British psychiatrists given description of a patient
- 69% of US diagnosed patient with schiz
- 2% of British diagnosed patient with schiz

LUHRMAN (2015)
- interviewed 60 adults who ‘heard voices’
- 20 Ghanaians, 20 Indian, 20 American.
- African & Indian reported having pos experience with their voices (playful & offering advice)
- US said voices violent & hurtful

Question 9

What is meant by validity of the classification system of schhizophrenia?

Answer 9

refers to the extent that classification systems (DSM) measure what they claim to.

Question 10

What is gender bias in diagnosis?

Answer 10

• occurs when accuracy of diagnosis is dependent on the gender of patient, judgements can vary. Can be based on stereotypical beliefs held about gender.

Question 11

What is symptom overlap?

Answer 11

• considerable overlap between symptoms of schiz and another disorder, for example bipolar and schiz.
  Makes DSM less valid as patients could be diagnosed incorrectly.

Ellason & Ross (1955)
people with DID have more schizophrenic symptoms (suggested by DSM) than schiz individuals do.

Question 12

Evaluate the reliability & validity in diagnosis & classification of schizophrenia.

Answer 12

limitation; research suggests that there is gender bias in diagnosis. Loving & Powell (1988) found a case described as ‘male’ was more likely to be diagnosed with schiz than the same case labelled as ‘female’. TMB shows that diagnosis of schiz is not applied to everyone in the same way, this could lead to missed diagnoses or incorrect diagnosis. Lacks validity.

limitation; co-morbidity can have negative consequences on patients diagnosed. Webber (2009) found schiz was co-morbid with medical problems such as hypertension (high blood pressure). Also found that co-morbidity was associated with a lower standard of medical care. TMB patients will face poorer care due to being diagnosed, this could have a negative effect on physical health as well as mental. Lacks validity.

limitation; lack of interrater reliability. Whaley (2001) found kappa score to be as low as 0.11 in diagnosis of schiz. TMB shows DSM is inconsistent as score is below 0.7, in order to have high reliability score needs to be >0.7. Diagnosis of schiz is unreliable.

limitation; lack of agreement on symptoms. Mojtabi & Nicholson (1955) found that psychiatrists produced an interrater reliability score of 0.4 when deciding what was considered as ‘bizarre’ & ‘non-bizarre’ delusions. TMB psychiatrists cannot distinguish between two important factors which are crucial in diagnosis of schiz. Kappa score of 0.7 required to be considered reliable. Hard to diagnose schiz & simply based off of the opinion of a Dr. not clear, objective rules. Unreliable.

Question 13

What is co-morbidity?

Answer 13

when two or more conditions occur together, common among patients with Schiz (substance abuse, anxiety, depression)

Buckley (2009)
estimated that co-morbid depression occurs in 50% of patients.

Question 14

Biological explanations for schiz- Genetic factors (family, twin & adoption studies)

Answer 14

genetic factors- can be genetically passed on, higher chance of getting schiz if a blood member has it.

FAMILY STUDIES
- established that schiz is more common among biological relatives
STUDY- Gottesman
children w/ 2 schiz parents- concordance rate= 46%
children w/ 1 schiz parent- 13%
siblings who both have schiz= 9%

TWIN STUDIES
MZ twins more likely to develop schiz
STUDY (2004)
pooled data for all schiz twin studies
MZ- 40.4%
DZ- 7.4%
because concordance rate not 100%, even for MZ twins, schiz is not predisposed, other factors contribute.

ADOPTION STUDIES
TINERARI (2004)
- found that adopted children with a bio schiz mother were MORE likely to develop schiz than adopted children of mothers without schiz- Supports genetic link.

Question 15

Biological explanations for schiz- The dopamine hypothesis (increasing/decreasing dopaminergic activity & revised dopamine hypothesis)

Answer 15

neurotransmitter dopamine- high levels of this are a cause of positive symptoms of schiz.

INCREASING DOPAMINIERGIC ACTIVITY
Amphetamine- stimulates nerve cells containing dopamine- causes a normal individual to have symptoms of a schiz episode, disappear with removal of drug
*hyperdopaminergic- high levels of dopamine in subcortex = pos symptoms

DECREASING DOPAMINIERGIC ACTIVITY
Dopamine antagonists- reduce activity in neural pathways of the brain- eliminate symptoms of such as hallucinations & delusions
*hypodopaminergic- lower levels of dopamine in cortex, linked with neg symptoms.

REVISED DOPAMINE HYPOTHESIS
- pos symptoms caused by excess of dopamine in subcortical areas
- neg & cog symptoms caused by deficit of dopamine.

Question 16

Biological explanations for schiz- Neural correlates (prefrontal cortex, hippocampus, grey matter & white matter)

Answer 16

• schiz is down to abnormalities in the brain; structure & functioning of brain is correlated with pos + neg symptoms.

PREFRONTAL CORTEX
- PFC; executive control (planning, reasoning & judgement)
- PFC impaired for schiz patients
- cog symptoms result of deficit in PFC & it’s connections with areas (hippocampus)

HIPPOCAMPUS
- anatomical changes in schiz patients
- deficits in nerve connections between hippocampus & PFC
- working memory impairments (cog symptoms)
- dysfunction in hippocampus can influence production of dopamine release in basal ganglia- affecting processing of info in PFC

GREY MATTER
- less of it in schiz patients
- enlarged ventricles = neg symptoms
CANNON (2014)
- found ppl at high risk of schiz have less grey matter & enlarged ventricles

WHITE MATTER
- in brain & spinal cord- made of nerve fibres & myelin
- reduced myelination in schiz patients compared to normal

Question 17

Evaluation of biological explanations for schizophrenia.

Answer 17

strength; evidence from treatment for dopamine hypothesis. Leucht’s meta-analysis found that all antipsychotics are more effective than the placebo in reducing schiz symptoms. TMB highlights importance of drug therapy to alleviate symptoms and symptoms are actually a result of a neurochemistry issue. Supporting dopamine hypothesis as an explanation of schiz.

strength; research support for significance of grey matter deficits. Vita (2012), schiz patients had less grey matter in parietal, temporal & frontal lobes. TMB evidences the link between less grey matter and schiz symptoms, this could be recognised during brain scans and early intervention can be made. Thus supporting neural correlates as an explanation of schiz.

limitation; influence of environmental factors in family studies. Findings from family studies are limited by the fact that family’s typically share the same env as well as genes (cannot be separated). TMB suggests that differences in concordance rates between MZ & DZ twins reflect nothing more than env differences. Limiting use of family studies to study biological explanations for schiz.

limitation; twin studies- higher concordance rates in MZ twins may be due to env rather than genes. Studies assume that DZ 7 MZ twins studies are equivocal however MZ twins are often treated as ‘the twins’ not two separate individual where as DZ twins are. TMB suggests that differences in findings reflect nothing more than env differences. Limiting role of twin studies to look at bio explanations for schiz.

Question 18

Psychological explanations for schiz- Family dysfunction (double bind), expressed emotion.

Answer 18

FAMILY DYSFUNCTION
claims that schiz is caused by abnormal patterns of communication in families.

BATESON (1956)- DOUBLE BIND
- children who receive contradictory messages from their parents are more likely to develop schiz. (mum tells son ‘love you’ but turns head in disgusting)
- child receive contradictory messages on two different communication levels.
- child’s response is incapacitated- one message invalidates the other
- prevents the development of internally coherent construction of reality- manifests itself as schiz symptoms

EXPRESSED EMOTION
- known as a communication style
- env with high degree of EE (hostility & criticism), causes stress
- EE primarily associated with relapse of schiz - patients returning to a env with high EE are x4 more likely to relapse than those without.
- suggests people with schiz have less tolerance for an intense stimuli (env)

Question 19

Psychological explanations for schiz- cognitive explanations (for delusions, for hallucinations)

Answer 19

COGNITIVE EXPLANATIONS
- dysfunctional thought processing- inability to reflect on ones own thoughts/emotions = pos symptoms

COG DELUSIONS- delusions are patients interpretations of their experiences
- voices interpreted as people criticising them, flashes of light usually a signal from God. Patients not willing to consider they may be wrong.
Central control- inner voice- cannot supress, can be triggered by other thoughts

COG HALLUCINATIONS
ALEMAN (2001)
- hallucination prone patients have difficulty distinguishing imagery & sensory based perception.
- inner representation of an idea can override actual sensory stimulus- manifests itself as real to the individual.
- not corrected by disconfirming evidence because of poor cognitive processing

Question 20

Evaluation of psychological explanations of schizophrenia.

Answer 20

strength; family dysfunction has research support. Tienari (1994) found adopted kids with bio schiz parents more likely to get it but only if adopted family was rated as disturbed. TMB suggests that schiz only manifests itself under appropriate env conditions & genetic info alone is not sufficient enough for schiz. Validity.

strength; real- world applications- development of family therapy. Gibrey (2006) suggested that if family interactions can be problematic then they can be constructed to become useful and health producing. TMB helps schiz patients with family issues resolve issues, meaning less likely to relapse. Validity.

limitation; individual differences in schiz patients vulnerability to EE. Aluffer (1998) found 25% of schiz patients showed no psychological response to stressful comments from relatives. TMB suggests that not all sufferers are affected by same triggers, challenges the comments that relapse is caused by EE therefore may be alternative explanations for relapse. Limiting use of EE in psychological explanations of schiz.

limitation; little evidence for double-bind theory. Berger (1965), schiz patients reported a high number of double-bind statements from their mothers than non-schiz parents. TMB schiz patients are often a lot more sensitive, this means they may have perceived their mothers comments in a neg way. comparing statements from schiz & non-schiz patients is not valid, more measuring of how it’s perceived. Limits research for schiz.

Question 21

Drug therapy for schizophrenia. (antipsychotics)

Answer 21

ANTIPSYHCOTICS
- treat psychotic illnesses
- helps individual return to normal functioning by decreasing symptoms
- reduces dopaminergic transmission

TYPICAL ANTIPSYCHOTICS
CHLORPROMAZINE
- treats pos symptoms only (hallucinations & thought disturbances)
- dopamine antagonists; bind to D2 receptors in mesolimbic pathway (less dopamine, less hallucinations)
- has side effects
KAPUR (2000)
- 60%-75% of receptors need to be blocked in order for it to be effective.

ATYPICAL ANTIPSYCHOTICS
RISPIDRONE/ CLOZAPINE
- treats neg and pos symptoms
- carry lower risk of extrapyramidal side effects
- block D2 receptors but disassociate quickly after to allow normal dopamine transmission
- lower affinity for dopamine and higher for serotonin

Question 22

What are the side effects of drug therapy?

Answer 22

Tardive dyskinesia- excessive involuntary movements of the mouth, tongue and jaw.

Agranulocytosis (atypical ONLY)- mouth, tongue and jaw movement with rashes and itchiness.

Question 23

Evaluation of drug therapy.

Answer 23

strength; supporting evidence, Leutch’s meta-analysis, 64% of ptps relapsed after 12 months compared to 27% who relapsed after staying on meds. TMB shows drugs are affective in controlling schiz as they decrease dopamine levels . giving the placebo is shown to cause relapse which evidences that schiz is actually a result of a neurochemical imbalance not just psychological. Beneficial to suffers life- return to normal functioning supporting use of drug therapy to control schiz.

strength; cost-effective. Cheap to administer, and has a pos effect for schiz patients allowing them to live normal lives outside of institutions. TMB allows majority of individuals suffering to seek help regardless of financial status, shows drug therapy affective in alleviating symptoms also decreasing chance of relapse and rehospitalization.

limitation; has negative side effects. prolonged use of antipsychotics can cause involuntary movement of the mouth, tongue and jaw, 20-25% of patients will suffer from distorted movements. TMB shows that although they are useful in removing symptoms, not always appropriate and can provide no help to those suffering from schiz as the side effects increase the chance of stopping using the medication increasing chance of relapse. Limiting use of drug therapy as a way of controlling schiz.

limitation; biologically reductionist. Ross & Reed (2004) stated that receiving medication re-enforces the idea that there is something with the patients, prevents them from thinking about other possible stressors. TMB it can have a negative psychological impact which drug therapy doesn’t account for as it only deals with chemical imbalances but doesn’t deal with other factors like environmental ones. Limiting use of drug therapy to control schiz.

Question 24

Psychological treatments for schizophrenia. - CBTp

Answer 24

REBT- CBT MODEL
A- activating event- triggers schiz
B- beliefs which are irrational
C- consequences (schiz symptoms)
D- dispute- challenge irrational thought

CBTp
- NICE recommended all people with schiz should be offered CBTp
- used for those who don’t take drugs or do but are still experiencing symptoms
- patients encouraged to trace back to origin of symptoms, evaluate hallucinations & delusions
- therapist may use collaborative analysis; logical, empirical, disputing techniques.
- may be set home assignments
- recommended 16 sessions

HOW IT WORKS
1. assessment
2. engagement
3. ABC model
4. Normalisation
5. critical collaborative analysis
6. developing alternative explanations

Question 25

Evaluation of CBTp.

Answer 25

strength (counter); research support. NICE (2014) found it was effective in reducing hospitalization, suggests there are alternative ways of dealing with schiz. However, most studies looking at effectiveness of CBTp have been done in conjunction with drugs. It is difficult to assess what is actually having the impact, weather CBTp is working independently. Thus limiting the effectiveness of CBTp to treat schiz.

limitation; not always appropriate. Appears to be more effective at certain stages of schiz and when the therapy is adjusted to the individual. Although beneficial for some schiz patients, its not for everyone, meaning it cannot be generalised to all patients to have the same effect. limiting it’s effectiveness

limitation; lacks accessibility. Haddock (2013)- 187 patients, only 13% had access to CBTp. TMB not everyone suffering are able to benefit from it due to lack of access, they will continue to struggle and not be able to be treated. limiting CBTp as a way of treating schiz.

limitation; benefits of it may be overstated. Jaunar (2014), only small therapeutic on symptoms like hallucinations and delusions- this has lead to conflicting recommendations form psychologists- even in the UK. TMB isn’t a definitive set of instructions- psychologists are left to their own devices on how to help patients, which may not always be the correct decision, not actually helping them. limiting use.

Question 26

Describe family therapy as a way of treating schizophrenia.

Answer 26

FAMILY THERAPY; provides support for carers in an attempt to make life less stressful, reduces neg emotions and increases families ability to help.

• 3-12 months recommended
• schiz individual encouraged to be there as much as possible but sessions can take place without them

REDUCES NEGATIVE EMOTIONS
- like anger and guilt, removing these reduces chances of relapse

IMPROVES FAMILIES ABILITIES TO HELP
- encourages family to form a therapeutic alliance, therapist tries to improve families beliefs about schiz.
- try to help achieve a balance between maintaining own life and helping the person with schiz.

Question 27

Pharoah’s et al (2010), study of techniques of family therapy.

Answer 27

1. sharing basic info & providing practical and emotional support
2. identifying resources
3. aims to encourage a mutual understanding, safe space for all members to express
4. identifying unhelpful patterns of interactions
5. learning stress management techniques
6. relapse prevention planning
7. maintenance for the future

Question 28

Evaluation of family therapy.

Answer 28

strength; economic benefits, NCCMH (2009) found significant cost savings when family therapy was combined with antipsychotics. Originally adds to expenses, but in long run it reduces rehospitalization and relapse rates, reduces cost for care providers. Supporting family therapy.

limitation; limited effect of family therapy when combined with drugs. Pharoah (2010) found that family functioning only had a little effect on relapse rates, instead it encouraged patients to take their medication. TMB shows that antipsychotics are actually the reason to the decrease of symptoms and relapse. Thus limiting use of family therapy.

limitation; only helps manage symptoms not cure them. Family therapy only helps subside symptoms but does not get rid of them. FT alone cannot be used to treat schiz and it requires something alongside it. Limiting use.

limitation; Reductionist. Based on premise that schiz is result of nurture. Biological basis in schiz is not addressed in FT. TMB there is evidence to show that schiz symptoms are a result of chemical imbalances, ignoring this, symptoms are not being cured, patient does not benefit as much as if FT was used in conjunction with drug therapy. Limiting effectiveness.

Question 29

Describe token economy as a way of managing schizophrenia. (what it is and how it works)

Answer 29

TOKEN ECONOMIES
- behaviourist approach to management of schiz
- aimed at targeting neg symptoms
- used for long-term hospitalized patients.

HOW IT WORKS
- clinicians set target behaviours that improves social functioning in everyday life
- tokens awarded for each desirable behaviour displayed (can be exchanged later for rewards)
- tokens act as a neutral stimulus (to give it value, reward must be presented alongside/ immediately after token) - reinforcing value
- as a result of this classical conditioning, tokens become secondary reinforcers- can be used to manage schiz behaviours
(effectiveness of TE may decrease if more time passes between the presentation of token and exchange for reward)

Question 30

Evaluation of Token Economy as a way of managing schizophrenia.

Answer 30

strength; research support- Allyon & Azrin (1968)- female schiz patients using TE increased desirable behaviours each day. TMB it highlights that TE is effective, demonstrated by the association of reward and desirable behaviours, helps return to normal functioning. Strengthening use of TE as a way of managing schiz.

limitation; difficult to assess effectiveness of treatment. Comer (2013) found when TE was brought into the ward, all patients are introduced to it rather than having a control group who isn’t. TMB this would allow researchers to rule out alternative explanations for the behaviour and ensure the TE is responsible. Limiting use.

limitation; ethical issue concerns. To make reinforcement effective, researchers must exercise control over ‘human rights’ like privacy or food. TMB TE could be considered dehumanizing and may have negative effect on patient. Patient relatives may also dislike treatment so choose to withdraw them from it, increasing relapse rates. Limiting use.

limitation; may only be effective in a institutionalized setting. Patients receive 24hr care- monitored and rewarded appropriately. However, out patient schizophrenics are only see for a few hours a day. TMB outpatients will not have anyone to monitor them or reward them for their behaviour, this means that association is lost, TE looses effectiveness. Suggests TE lacks eco validity as not effective in real world (outside of institution). Limiting use.

Question 31

Explain the interactionist approach to explain schizophrenia. (diathesis-stress model)

Answer 31

DIATHESIS STRESS MODEL
- sees schiz as a result of interaction between biological (diathesis) & environmental (stress) influences.
- minor stressors may lead to onset of schiz for an individual who is highly vulnerable.

DIATHESIS (genes)
- family studies suggest that people have varying levels of inherited genetic vulnerability , childhood trauma can trigger schiz.
Reed- childhood trauma causes HPA to become overreactive- more vulnerable to stress.

STRESS (env)
- research shows children who experienced trauma before age 16 were vulnerable to schiz.
New diathesis stress model considers use of cannabis.

Question 32

Evaluation of interactionist approach to explain schizophrenia.

Answer 32

strength; research support- Barlow & Durana (2009), found that a family history (genetic link) combined with a dysfunctional family increased the risk of developing schiz. TMB it supports the diathesis-stress model as the increased risk was due to combination of genetic factors and env factors. Supporting interactionist approach to explaining schiz.

limitation; individual differences. Diathesis-stress model proposes that schiz is caused by a combo of biology & env. However, it is not known precisely how these contribute to the model. TMB suggests that the approach is limited as we do not fully understand the mechanism by which illness develops and how both vulnerability and stress produce it. Limiting explanation of interactionist approach.

limitation; too simplistic, unlikely that a single gene combined with a poor parenting style causes schiz. Multiple genes have been found to increase the risk of developing schiz, indicating there is no single ‘schizogene’ and stress is not limited to parenting style. TMB suggests that proposing vulnerability and stress have one single cause and each come in one form, like original model suggests, it is over simplistic and dated.

Question 33

Interactionist approach for treating schizophrenia.

Answer 33

GUO (2010)
- suggests combining bio + psych is more effective
- difficult to state which combo is more effective by each persons circumstances
(no point in combining drug therapy with family therapy if patient has no contact with relatives)

TURKINGTON (2006)
- psychological treatment never usually given on it’s own
- Britain offers drug therapy first- assesses the situation and later implements CBTp

Question 34

Evaluation of using the interactionist approach to treat schizophrenia.

Answer 34

strength; combining treatments is cost-effective. Schiz has bio + psych components, initial cost is more expensive- as effectiveness increases the likelihood of relapse and rehospitalization decreases making it more cost-effective. thus benefitting the patient and the economy due to expenses. Strengthening use of interactionist approach to treat schiz.

strength; research support- Guo (2010)- found patients who received combo treatment whilst in early stages of schiz had improved insight & social functioning, less likely to relapse. TMB shows value for patients of combining bio + psych treatments, by reducing cognitive symptoms and helping them to return to normal functioning. Validating interactionist approach.

limitation; combining treatments does not always have a pos impact. Patients receiving CBT can sometimes interpret antipsychotic side effects in a delusional manner. TMB can lead them to mistrusting & resisting any further treatment, making them vulnerable to relapse. Combining treatments can cause further issues, limiting use of interactionist approach to treat schiz.