Schizophrenia Flashcards
Positive Symptoms
Excess or distortion of normal functions
Negative Symptoms
Normal functions are limited, including speech poverty and avolition
Examples of Positive symptoms of SZ
Psychomotor disturbances
Catationia
Hallucination, Delusions, Though disturbances
Psychomotor Disturbances
Stereotypical, rocking, twitches, repetitive behaviours
Catatonia
Staying in position for hours/days on end
Negative Symptoms examples
Speech Poverty
Avolition
Thought Disorder
Broadcasting
Thought disorder
Breaks in the train of thought and one person appears to make illogical jumps from one topic to another
Words and sentences may become incoherent
Broadcasting
A thought disorder whereby a person believes their thoughts are being broadcasted to others
What did Slater and Roth suggest about hallucinations as a symptom of SZ?
They are the least important of symptoms as they are not exclusive to SZ
What did Scheff Suggest about the effects of the diagnosis classification of SZ?
It labels the individual, causing many adverse effects, such as a self-fulfilling prophecy and lower self-esteem
What is the advantage of diagnosis and classification of SZ?
Allows doctors to communicate effectively about a patient and use similar terminology when discussing them
Reliability of SZ Classification
For the classification system to be reliable, different clinicians should arrive at the same diagnosis for one individual
Stability of diagnosis over time given no change in symptoms
Why is diagnosis of SZ difficult?
The practitioner has no physical signs and only symptoms, reported by the patient, to make a decision on
Comorbidity
A person who suffers from multiple mental disorders, which occurs due to symptoms of different disorders overlapping
Jacobson - Reliability of ICD-10 in diagnosing SZ
100 Danish patients with a history of psychosis were assessed using the opertaional criteria
98% Concordance rate - demonstrating the high reliability of the clinical diagnosis of SZ using up-to-date classification
SZ Gender bias - Loring + Powell
Some behaviour regarded as psychotic in males was not regarded as psychotic in females
Validity of SZ
The extent to which SZ is a unique syndrome, with characteristics, signs and symptoms.
For the classification system to be valid, it should be meaningful and classify a real pattern of symptoms which result from an underlying cause
SZ - Predictive Validity
If a diagnosis leads to successful treatment, the diagnosis can be seen as valid.
However, some schizophrenics are treated successfully, whereas others are not
SZ - Aetiological Validity
In order for the diagnosis to be valid, all patients diagnosed as schizophrenic should have the same cause for their disorder
This is often not the case, as the causes of SZ may be one of biological, psychological, or both
What are the issues of the validity of SZ as a diagnosis?
There is no such thing as a ‘normal’ schizophrenic demonstrating typical symptoms
Unsuitable treatments may be administered, even on an involuntary basis, raising ethical and practical issues
Validity of SZ - Cultural Bias - US vs london
USA - 20% diagnosed in 1930s vs 80% in the 1950s
London - rate remained at 20%
This suggests that neither group had a valid definition of schizophrenia
Validity of SZ - David Rosenham ‘pseudopatients’
Experiment involving pseudo patients led to 8 ‘normal’ people being kept in hospital, despite behaving normally
This suggests that doctors have no valid method for detecting SZ
In a follow up study, they rejected genuine patients whom they assumed were a part of the deception
Validity of SZ - Issue of Culture (Asian vs Arabic)
Some Asian countries are not encouraged to show emotional expression
Some Arabic cultures, public emotion is encouraged and understood
Without this knowledge, a person displaying overt emotional behaviour in a western culture may be regarded as abnormal
Validity of SZ - Cochrane - Culture
Those of Afro-Carribean heritage are 7x as likely to be diagnosed as having SZ when living in the UK
Gottesman Concordance Rates MZ & DZ twins + Siblings for SZ
MZ - 48%
DZ - 17%
Siblings - 9%
Tienari - SZ adoption study
Adopted children of biological mothers with schizophrenia were more likely to develop the disorder themselves than adopted children of mothers without schizophrenia, supporting the genetic link
Hyperdopaminergia
Abnormally high levels of dopamine in the subcortex
Linked with positive Symptoms, such as hallucinations
There may be a higher number of dopamine receptors, causing over-activity of dopamine, causing sensory hallucinations
Hypodopaminergia
Low levels of dopamine in the subcortex
Less dopamine transmitted across the subcortex
Linked with negative symptoms
Curran - Hypodopaminergia
Dopamine agonist produce SZ-type symptoms in patients, supporting the hypodopaminergia aspect of the dopamine hypothesis
Tauscher - hyperdopaminergia
Antipsychotics, which lower dopamine levels, reduced the occurrence of positive symptoms, supporting the hyperdopaminergia aspect of the dopamine hypothesis
What did Noll find about antipsychotics?
Opposing evidence of the dopamine hypothesis
They do not work in 1/3 of patients
Some patients still experience hallucinations despite dopamine levels being normal
Role of Vental Striatum in SZ
Vental Striatum involved in reward anticipation
SZ patients have less activity in this region
The lower the activity, the more severe the negative symptoms, which could explain avolition
Allen - What parts of the brain had lower activity levels of those experiencing hallucination?
Superior temporal gyrus
Anterior Cingulate Gyrus
Typical Antipsychotic
Chlorpromazine
Chlorpromazine - How does it work?
Antagonist in the dopamine system
Blocks dopamine receptors to reduce action
Binds to receptors in the mesolimbic dopamine pathway
Normalizes neurotransmission
Reduces positive symptoms
Chlorpromazine side effects
Extrapyramidal effect
Shuffling of feet, moving slowly
Restlessness and limb discomfort
Tardive Dyskinesia
Tardive Dyskinesia
Jerky movements of the face, tongue and whole body, sucking and smacking of lips
What % of patients receiving chlorpromazine develop tardive dyskinesia?
Up to 30%
After 25 years on chlorpromazine, what % of patients develop tardive dyskinesia?
up to 68%
Atypical antipsychotics
Clozapine
Risperidone
When were atypical antipsychotics developed?
1970s
What is different about atypical antipsychotics compared to typical?
Suppress symptoms and minimize effects
Suitable for treatment resistant patients
Block dopamine AND serotonin receptors
What dosage of clozapine are patients given?
300-450mg daily
How does Clozapine work?
Temporarily binds to D2 receptors and acts on serotonin and glutamate receptors
What patients is Clozapine suitable for?
Suicidal patients - improves mood
A strength of Clozapine compared to other antipsychotics?
Does not cause motor problems
Risperidone Dosage
4-12mg daily through tablet, syrup or injection
How does Risperidone work?
Binds to dopamine and serotonin receptors but more strongly to dopamine
Side effect of Risperidone
No side effects at a normal dosage, other than occasionally akathasia
Akathasia
Restlessness and agitation
Davis - meta analysis on the effectiveness of antipsychotics compared with placebos
Antipsychotics more effective than placebos in 70% of patients, seeing improvements after 6 weeks
Less than 25% reported improvements with placebos
Vaughn & Leff - Review of Davis meta analysis of antipsychotics
Antipsychotics only made a difference for those living with hostility and criticism in their home environment
Vaughn & Leff - relapse rate for those on antipsychotics vs placebos
Antipsychotics - 53%
Placebo - 92%
Antipsychotics vs placebos for those with a supportive home environment
12% - placebo
15% - antipsychotic
What did Marder suggest about atypical antipsychotics vs typical?
Atypical antipsychotics are just as effective as typical
What % of patients who resisted typical antipsychotics responded to atypical antipsychotics?
30-61%
Benefit of atypical antipsychotics
Fewer side effects, meaning patients are more likely to continue treatment, resulting in improved symptoms
Atypical antipsychotics side effects
Reduction in WBC count - regular blood tests required
Health risks: weight loss, stroke, cardiac arrest, diabetes
Tardive Dyskinesia sufferer in US
Won a large out-of-court settlement due to drug breaching the human rights act 1988
Appropriateness of antipsychotics
Cheap and easy to administer - advantageous from an economical viewpoint
Help those who struggle to talk about their mental health problems
Positive effect on many sufferers, allowing them to live a relatively normal life
Criticisms of antipsychotics
Not effective in treating the underlying cause - only provide relief of symptoms
High relapse rate
Not an effective long-term solution
Relapse rate of those on antipsychotics within first year and in later years
First year - 40%
Later years - 15%
Ross + Read - criticism of antipsychotics
Prescribing medication reinforces the idea that there is ‘something wrong with you’
Prevents the individual to think about possible stressors triggering their condition
Haslam - surveyed people on the causes of schizophrenia - results
People less inclined to confront environmental factors such as poverty or childhood trauma if they were simply given drugs to manage their condition
Drug therapies may be inappropriate as a first point of call
3 types of family dysfunction
Schizophrenogenic mother
Double-bind theory
Expressed emotion
Schizophrenogenic mother
Cold, rejecting, controlling
Leads to Distrust and paranoid delusions
Double-bind theory
Conflicting messages
Expressed emotion
Verbal criticism of the patient, violence
Hostility towards patient, anger and rejection
Emotional over-involvement in the life of a patient
How does expressed emotion link to schizophrenia?
Levels of EE by carers can be a serious source of stress, causing high relapse rates in schizophrenia patients
However, the source of stress may trigger the inset of symptoms in a person who is already vulnerable
What did Bateson suggest about double-bind theory as a caise of schizophrenia
Communication style within a family leads to development of schizophrenia
Children are ‘trapped’ in situations where they fear what they are doing wrong
Punished by ‘withdrawal of love’ Receive mixed messages and see the world as dangerous and confusing which is reflected in symptoms such as disorganised thinking and paranoid delusions
What was emphasised about double-bind theory contributing to schizophrenia?
Neither the main type of communication or only factor in the development of schizophrenia
Read - what type of attachment do those with schizophrenia typically have?
Insecure
What % of men and women with SZ have a history of physical and/or sexual abuse?
Women - 69%
Men - 59%
how do family dysfunction explanations of schizophrenia lack support?
poor evidence based for any of the explanations
Although there is plenty of evidence supporting the idea that family-based stress is associated with adult SZ, there is almost none to support the schizophrenogenic mother and double-bind
What is research around double-bind and schizophrenogenic mother based on?
Clinical observation and informal assessment
Cognitive explanation of Schiozophrenia
SZ is caused by abnormal information processing and disruption to normal thought processes
Lower level of information processing suggests that cognition is likely impaired
What 2 kinds of dysfunctional thought processing did Frith identify which may underlie some symptoms of Schiozophrenia?
Meta-representation
Central Control
Meta-representation
Cognitive ability to reflect on thoughts and behaviours
allow us insight into our own intentions and goals
interpretations of the intentions of others
Meta-representation linked to Schiozophrenia
inability to recognize our own actions and thoughts are carried out by ourselves rather than by anyone else
Hallucination of vouces and delusions such as thought insertion
Central Control
Cognitive ability to suppress automatic responses while we perform deliberate actions
Central Control linked to Schiozophrenia
Disorganised speech and thought disorder could result from the inability of Central Control and speech triggered by other thoughts
Cognitive explanation of Schiozophrenia - Stirling - Ink colours
30 SZ vs 18 non-SZ
Patients took 2x as long to name the ink colours compared to the control group
CBT on Schiozophrenia patients effectiveness
CBT is effective, suggesting there is a cognitive aspect
Normalisation of Schiozophrenia symptoms
Placing psychotic experiences on a continuum of normal experiences means the patient feels less alienated and stigmatised
Critical Collaborative Analysis
Critical questioning to understand illogical deductions and conclusions
Developing Alternative Explanations
Patient develops their own alternative explanations for their previously unhealthy assumptions
Basic assumption of CBT
People have distorted beliefs which influence their behaviour in maladaptive ways
What are Schiozophrenia patients encouraged to do in CBT?
Trace back the origin of their symptoms in order to get a better idea of how the symptoms may have developed.
They are also encouraged to evaluate the content of their delusions and auditory hallucinations and consider ways in which they might test the validity of their faulty belief
Jauhar et Al - evaluation of CBT on Schiozophrenia patients
Meta-analysis - found that CBT had an effect on positive and negative symptoms
This effect was significant but quite small, suggesting moderate support for the effectiveness of CBT in treating schizophrenia
How does CBT have potential ethical issues when treating Schiozophrenia patients?
Challenging the validity of beliefs may interfere with the freeddom of thought
Why is CBT not effective by itself as a treatment for Schiozophrenia?
If the dysfunctional thoughts have a biological basis, disputing may not be enough to change them
CBT is rarely used without drug therapy
CBTp techniques
Critical Collaborative Analysis
Normalisation
ABC
The nature of family therapy
3-12 months
10+ sessions
Reducing levels of expressed emotion
Schiozophrenia relapse with rate with and without family therapy
With - 25%
Without - 50%
Family Therapy Study - Pharoah
Moderate evidence to show that family therapy reduces relapse rates and hospital readmissions in Schiozophrenia patients
There were variances in the quality of research studies used. therefore, there is weak research support family therapy
Why does family therapy not actually treat SZ?
It is not aimed at the patient
Token Economy Systems
A form of psychological therapy based on operant conditioning, which uses a reward system to manage maladaptive behaviours
Primary and Secondary reinforcers in Token Economy
Primary - reward
Secondary - token
Wolfe - Chimpanzees TE
Investigated the effectiveness of token rewards for chimpanzees, where chimpanzees could discriminate tokens and their associations with prizes such as food
Other systems then adopted TES, as the focus on behavioural alteration and maintenance gained traction
TE - 1960s
TE was a widely used therapy in the 1960s because many patients were institutionalized in hospital settings
Who were some of the first people to explore TES as a form of motivational therapy and rehabilitation?
Allyson and Azrin
Allyson and Azrin - TES study
45 Female SZ patients in a psychiatric ward showed significant improvements in their symptoms and behaviours after the introduction of TES
What did Allyon and Azrin demonstrate about TES?
TES can help control and treat symptoms and behaviours associated with SZ
Glowacki - TE meta-analysis
7 hight quality studies of the effectiveness of TES in hospitals
Decreased negative symptoms
Decrease in frequency of undesirable behaviours
Concluded the use of TES in psychiatric settings should be considered. However, the study included only a small evidence based to support it
McMonagle and Sultana - Review of TES over multiple studies
Found TES reduced negative symptoms by acting as a motivational tool
However, it was unclear whether the patients maintained these behaviours after the treatment programme
Results may not be reproducible, so clinical validity os questionned
Dickerson - TES review
13 controlled TES studies
TES effectively increased adaptive behaviours and decreased maladaptive behaviours
However, the historical context and methodological issues limit the studies
Ethical issues with TES
Gives professionals significant power of control over the behaviour of a patient
It imposes a ‘norm’ that, whilst it may be appropriate in societal settings, it is not fair to expect this perfection off of patients. this is a restriction of personal freedom, and it is unethical to deprive people of their rights
Milby - TES studies review
Whilst TES is effective in hospital work, upon review, the studies were found to be both poorly designed and lacking sufficient follow-up data
General Issue of TES
It may aggravate more distressing symptoms by removing pleasurable activities from the patient
It is normal to have off days. it would be unfair to deprive you of your favourite things because you were having a bad day. this has led to legal action In the past, as families are not okay with personal liberties being taken away from the patient
Kadzin - Effect of TES after discharge
Changes that were developed during a patients time in the hospital using TES did not remain once they were discharged, suggesting issues with maintenance that TES suggests it excels at
Meehl’s Model
Diathesis was entirely genetic and the result of a single schizogene
Development of a biologically based schizotype personality
What did Paul Meehl say about the schizogene?
If a person does not have the schizogene then no amount of stress would lead to SZ
However, in carriers of the gene, chronic stress through childhood and adolescence could result in the development of SZ
Modern Understanding of diathesis
Many genes increase genetic vulnerability and there is no single schizogene
Range of factors beyond genes, such as psychological trauma - where trauma acts as the diathesis rather than the stressor
Who proposed a neurodevelopmental model?
Read et al
Read et al - neurodevelopmental model
Early trauma affects the developing brain
Such as the HPA system becoming overactive, making the person much more vulnerable to later stress
The Modern understanding of stress
In the original model, stress was seen as psychological in nature
The Modern definition includes anything that risks triggering SZ
Effect of Cannabis on SZ
Cannabis can trigger an episode of SZ as it is seen as a stressor which interferes with the dopamine system
7x increased risk
Howevere, most people do not develop SZ after smoking cannabis, so there may be multiple vulnerability factors
Treatment of SZ according to the interactionist approach
Antipsychotic medication combined with CBT
Turkington - interactionsit approach to treating SZ
It is possible to believe in biological causes of SZ and still practice CBT to relieve psychological symptoms
However, it is not possible to adopt a purely biological approach and to simultaneously treat them with CBT
Tarrier - support for the effectiveness of combination of treatments
Randomly allocated 315 patients to a medication and CBT group; medication and supportive counselling; control group (only meds)
2 Combination groups showed lower symptom levels than those in control group
No difference in rates of hospital readmission
Tienari - role of vulnerability and triggers
Child-rearing style characterised by high levels of criticism and low levels of empathy was implicated in the development of SZ but only for adopted children who had a high genetic risk and were adopted by Finnish mothers with SZ but not in the adopted control group with no genetic risk
