Schizophrenia

Question 1

Schizophrenia definition and what is it characterised by

Answer 1

• Schizophrenia is a severe mental illness where contact with reality and insight are impaired- an example of psychosis
• It is characterised by incoherent or illogical thoughts, bizarre behaviour and speech, delusions or hallucinations

Question 2

What is psychosis

Answer 2

Psychosis is a term used to describe a severe mental health problem where the individual loses contact with reality (unlike neurosis where the individual is aware that they have problems)

Question 3

What are the clinical characteristics of Scjizophrenia

Answer 3

• Schizophrenia can be described as a disintegration of personality
• A main feature is a split between thinking and emotion
• Involves a range of psychotic symptoms (a break from reality)
• Schizophrenic patients lack insight into their condition, i.e they do not realise they are ill

Question 4

What is the prevalence of schizophrenia

Answer 4

• affects 1% of the population
• men are more likely to suffer than women
• the onset is typically in late adolescence and early adulthood
• commonly diagnosed in cities and the working class

Question 5

Def of positive vs negative symptoms of schizophrenia

Answer 5

Positive Symptoms= symptoms that appear to reflect an excess or distortion of normal functions

Negative Symptoms= symptoms that appear to reflect a loss of normal functions

Question 6

What are the positive symptoms of Schizophrenia

Answer 6

Delusions and Hallucinations

Question 7

What are delusions (positive symptom) associated with schizophrenia

Answer 7

DELUSIONS
- delusions are irrational beliefs
- delusions of grandeur involve being important historical/political/religious figures such as Jesus
- Delusions can also involve being persecuted by government/aliens/superpowers
- can concern the body - they may believe a part of them is under external control
- some delusions can lead to violence

Question 8

What are hallucinations (positive symptom) associated with schizophrenia

Answer 8

Question 9

What are the negative symptoms of Schizophrenia

Answer 9

Avolition and Speech poverty

Question 10

What is avolition (negative symptom) associated with schizophrenia

Answer 10

Question 11

What is speech poverty (negative symptom) associated with schizophrenia

Answer 11

Question 12

How is Schizophrenia diagnosed

Answer 12

• there are a number of systems by which we can classify abnormal patterns of thinking, behaviour and emotion into mental disorders. These systems not only classify abnormality, but give guidance on how to diagnose them

ICD - uses subtypes
(2 or more negative symptoms needed for diagnosis)

DSM 5 - this system does not use subtypes

(At least one positive symptom needed for diagnosis)

Question 13

Evaluation for diagnosing schizophrenia

Answer 13

Question 14

Describe the reliability in the diagnosis of schizophrenia

Answer 14

• diagnosis is difficult because the practitioner has no physical signs, but only symptoms (what the patient reports) to make a decision on.
• Jacobsen et al tested the reliability of the ICD-10 classification system in diagnosing schizophrenia:

100 Danish Patients with a history of psychosis were assessed using operational criteria, and a concordance rate of 98% was obtained.
This demonstrates the high reliability of the clinical diagnosis of schizophrenia using up-to-date classification

Question 15

Describe the validity in diagnosing schizophrenia

Answer 15

• the validity of a single schizophrenic disorder is critiqued as there is no such thing as a ‘normal’ schizophrenic.
• Problems with the validity of diagnosis result in unsuitable treatment, sometimes on an involuntary basis. This raises practical and ethical issues.

-CHENIAUX ET AL:
Two psychologists assessed the same 100 Dutch patients as Jakobson et al.
68 were diagnosed using the ICD-10 and 39 were diagnosed using the DSM-5
This demonstrates that schizophrenia is either under diagnosed or over diagnoses as there is low criterion validity.

Question 16

What should schizophrenic diagnosis be like is it is fully reliable?

Answer 16

Different clinicians using the same system (e.g DSM) should arrive at the same diagnosis for the same individual (inter observer reliability)

Question 17

What should schizophrenic diagnosis be like is it is fully valid?

Answer 17

It should be meaningful and classify a real pattern of symptoms, which results from a real underlying cause

Question 18

What is co-morbidity and it’s relation to schizophrenia

Answer 18

Co-morbidity describes people who suffer from two or more mental disorders.
For example, schizophrenia and depression are often found together as symptoms overlap (e.g both involve very low levels of motivation)

• this makes it more difficult to confidently and reliably diagnose schizophrenia
• it also calls into question the validity of schizophrenia as an actual condition

Question 19

What is the evidence for co-morbidity

Answer 19

• A US study looked at nearly 6million hospital discharge records to calculate co-morbidity rates
• They found co-morbidity of other psychiatric disorders with schizophrenia (45%)
• Schizophrenia is co-morbid with depression in 50% of cases and OCD in 23% of cases
• They found co-morbid, non-psychiatric disorders such as asthma, hypertension and type 2 diabetes

Question 20

Describe the gender bias in schizophrenia diagnosis

Answer 20

Question 21

Describe the culture bias in schizophrenia diagnosis

Answer 21

Question 22

Describe David Rosenhan’s famous experiment on schizophrenia

Answer 22

Question 23

Describe the reason why schizophrenia as a condition is criticised

Answer 23

Question 24

Describe the biological explanation of schizophrenia (GENETICS)

Answer 24

• Genes consist of DNA that are involved in producing instruction - this may impact psychological features such as intelligence or mental disorders and, hence, schizophrenia may be affected.
• Genes are inherited
• Research into this area focuses on looking into pin-pointing a single genetic variation responsible for SZ. In reality, SZ is polygenic. Genes coding for neurotransmitters, including dopamine, are involved.

FAMILY STUDIES:
- Gottesman 1991 suggests schizophrenia is inherited through genes.
- He conducted a large-scale family study showing that the risk of schizophrenia increases in line with genetic similarity to a relative.
- For example, a 2% change of developing schizophrenia if you have a first cousin who is diagnosed, 9% chance if you have a sibling with SZ and a 48% chance is you have an identical twin who has SZ

CANDIDATE GENE EVIDENCE:
- A genetic makeup of 37,000 individuals with SZ were compared to 113,000 controls. 108 genetic variations were associated with a slightly increased risk of schizophrenia
- Different studies have found different candidate genes, leading to the conclusion that schizophrenia is aetiologically heterogeneous (meaning that a different combination of factors, including genetic variations, can lead to the condition)
- This suggests that there is weak evidence for a specific candidate gene and genetics being the only explanation for schizophrenia

MUTATION:
- Schizophrenia can also have a genetic origin in the absence of family history.
- This may be as a result of inheriting mutated DNA from parents, caused by radiation, poison or viral infections
- Brown et al (2002) - Evidence for mutation comes from positive correlations between paternal age (with an increased risk of sperm mutation) and schizophrenia: 0.7% risk for fathers under the age of 25, increasing to a 2% risk for fathers aged over 50.

Question 25

Evaluate twin studies in schizophrenia

Answer 25

• Correlational research - no definitive answer on cause and effect. Findings may be a result of closer family members sharing the same environment, so therefore there may be an element of learning involved.
• The fact that the concordance rate for twins is not 100% means that schizophrenia cannot be accounted for by genetics alone.
• The sample size of such twin studies is always going to be very small, therefore there are issues with generalisability

Question 26

Evaluate the genetic explanation for schizophrenia

Answer 26

Strength:
- Adoption studies: Tinari et al (2004). Children growing up in an adoptive family, away from biological families, we’re at heightened risk of schizophrenia if their parents had it.

Weaknesses:
- Environmental factors also increase the risk of Schizophrenia. E.g birth complications caused my the mother smoking cannabis in teenage years and childhood trauma. I one study, 67% of individuals with SZ or other psychotic disorders reported at least one childhood trauma, in comparison to 37% of a matched group with non-psychotic disorders.

Question 27

Describe the biological explanation of schizophrenia (NEURAL)

Answer 27

Question 28

Evaluate the neural explanation of schizophrenia

Answer 28

Question 29

Describe the psychological explanation of schizophrenia (FAMILY DYSFUNCTION)

Answer 29

FAMILY DYSFUNCTION:
- Refers to any abnormal processes within a family such as conflict, communication problems, cold parenting, criticism, control and high levels of expressed emotions.
- These may be risk factors for the development of schizophrenia.
- Laing and others rejected the biological explanation for mental disorders and believed schizophrenia was a result of social pressures in life.
- Bateson et al (1956) suggested the double blind theory, which suggests that children who frequently experience contradictory messages from their parents are more likely to develop schizophrenia.
- Another family variable associated with schizophrenia is a negative emotional climate ( a high degree of expressed emotion - EE)
- EE is a family communication style that involves criticism, hostility and emotional over-involvement.
- Brown et al found that this is more important in maintaining schizophrenia than causing it in the first place. Schizophrenics returning to such a family are more likely to relapse into the disorder.
- SZ patients in research often spoke of a schizophrenogenic mother who is cold,rejecting and controlling and tends to create a family climate characterised by tension and secrecy.This leads to distrust ,paranoid delusions and ultimately schizophrenia.

Question 30

Evaluate the family dysfunction explanation for schizophrenia

Answer 30

• Strength: Research into expressed emotions has practical applications. For example, Hogarty (1991) produced a type of therapy session which reduced social conflicts between parents and their children which reduced EE and therefore relapse rates
• Strength: Read et al (2005) reviewed 46 studies of child abuse and schizophrenia and concluded: 69% of adult women in-patients with a diagnosis of schizophrenia had a history of physical or sexual abuse, or both, in childhood. For men the figure was 59%
• Weakness: Individual differences: EE is associated with relapse but not all patients who live in high EE families relapse and not all patients in low EE families avoid relapse.
• Weakness: Cause and effect: Mischler & Waxler (1968) found significant differences in the way mothers spoke to their schizophrenic daughters compared to their normal daughters, which suggests that dysfunctional communication may be a result of living with the schizophrenic, rather than the cause of the disorder.
• Weakness: Ethical issues of double bind theory. There are ethical concerns in blaming the family, particularly as there is little evidence upon which to base this on.
• Weakness: Gender bias: the mother tends to be blamed the most, which means such research is highly socially sensitive. This suggests that the research does not protect individuals from harm

Question 31

Describe the psychological explanation for schizophrenia (COGNITIVE)

Answer 31

• emphasis on the role of dysfunctional thought processing, particularly evident in those who display positive symptoms of schizophrenia (delusions and hallucinations)
• Reduced processing in the ventral striatum is associated with negative symptoms such as avolition.
• Reduced processing of information in the temporal and cingulate gyri are associated with hallucinations

COGNITIVE EXPLANATIONS OF DELUSIONS
- A critical characteristic of delusional thinking is the degree to which the individual perceives him or herself as the central component in events (egocentric bias) and so jumps to conclusions about external events.
- This is manifested in the patient’s tendency to relate irrelevant events to themselves and consequently arrive at false conclusions.
- Delusions in schizophrenia are relatively impervious to reality testing, in that patients are unwilling/unable to consider that they are wrong (Beck and Rector, 2005).

COGNITIVE EXPLANATIONS FOR HALLUCINATIONS
- Hallucinating individuals focus excessive attention on auditory stimuli (hyper-vigilance) and so have a higher expectancy for the occurrence of a voice than normal individuals.
- Aleman (2001) suggests hallucination-prone individuals find it difficult to distinguish between imagery and sensory-based perception. For these individuals, the inner representation of an idea (e.g what other people think of me) can override the actual sensory stimulus and produce an auditory image (‘he is not a good person’) that is just as real as the transmission of actual sounds.
- Hallucinating patients with schizophrenia are much more likely to misattribute the source of self-generated auditory experience to an external source than non-hallucinating schizophrenics.

Question 32

Evaluate cognitive explanations of schizophrenia

Answer 32

-A strength of the cognitive explanation is that it has practical applications. Yellowless et al. (2002) developed a machine that produced virtual hallucinations, such as hearing the television telling you to kill yourself or one person’s face morphing into another’s. The intention is to show schizophrenics that their hallucinations are not real. This suggests that understanding the effects of cognitive deficits allows psychologists to create new initiatives for schizophrenics and improve the quality of their lives.
- problems with cause and effect. Cognitive approaches do not explain the causes of cognitive deficits – where they come from in the first place.
- it is reductionist. The reason for this is because the approach does not consider other factors such as genes. It could be that the problems caused by low neurotransmitters creates the cognitive deficits. Is it the cognitive deficits which causes the schizophrenic behavior or is the schizophrenia that causes the cognitive deficits?

Question 33

What are antipsychotics

Answer 33

• a chemical treatment usually prescribed through tablets, intravenous means, or both
• the treatment is based on the dopamine hypothesis, which assumed dopamine activity is associated with schizophrenia
  -they do not cure the illness, they can only reduce the symptoms so that a degree of normal functioning can occur

Question 34

Describe typical and atypical antipsychotics

Answer 34

TYPICAL:
- used primarily to target positive symptoms of schizophrenia
- they are usually dopamine antagonists
- e.g chlorpormazine- reduces/blocks the effects/actions of dopamine and therefore reduces the effects of schizophrenia. It is an example of a dopamine antagonist as it binds to dopamine receptors, reducing their actions and not stimulating them. This reduces the stimulation of dopamine in the mesolimbic system in the brain

ATYPICAL:
- Combat both positive and negative symptoms of schizophrenia
- e.g clozapine - works on dopamine system but also blocks serotonin and glutamate receptors. Drugs like clozapine work by temporarily occupying the dopamine receptors and then rapidly disassociating them to allow normal dopamine distribution, as this means the receptions still receive dopamine but in smaller levels

Question 35

Evaluation of drug therapies

Answer 35

• effective at reducing the symptoms of schizophrenia, especially positive symptoms. They are also relatively cheap to produce, making them cost-effective, easy to administer and have positive effects on many sufferers, allowing them to live relatively normal outside of institutions. It is estimated that less than 3% of people with schizophrenia in the UK live permanently in hospital - largely due to medication.
• Drugs are more effective than placebos. Lecht et al (2012) found that patients that remained on their antipsychotic medication were only 27% likely to relapse compared to 64% for those given a placebo. This shows that drugs are effective in preventing relapse.
• Drugs are only palliative, meaning that they only treat the symptoms of schizophrenia and do not offer a cure. If a patient stops taking their medication, their schizophrenia symptoms return. Those from a psychodynamic perspective argue that drugs treat the symptoms of schizophrenia but not the cause. This leads to ‘revolving door phenomenon’, where patients are constantly being discharged and re-admitted to the hospital. They take their medication and therefore feel better; then they wrongly assume that they are cured and stop taking their drugs, only to get I’ll again and need to be hospitalised
• Ethical issues: if it’s side effects, death and social consequences are taken into account, a cost-benefit approach would most probably be negative. Also, many within the psychiatric community see the widespread use of antipsychotics as being fuelled by the powerful influence of drug-producing companies, which stand to make huge profits from their continued use

Question 36

Describe Christopher Frith’s cognitive explanations of schizophrenia

Answer 36

Christopher Frith (1991) identified 2 kinds of dysfunctional thought processing that could underlie some symptoms:

1. Meta representation:
   - the cognitive ability to reflect on thoughts and behaviour. This allows us insight into our own intentions and goals. It also allows us to interpret the actions of others. Dysfunction of this disrupt our ability to recognise our own actions and thought as being carried out by ourselves, rather than someone else. This explains hallucinations of voices and delusions like thought insertion (the experience of having thoughts projected into the mind by others).
2. Central Control:
   - the cognitive ability to suppress automatic responses while we perform deliberate actions instead. Disorganised speech and thought disorders could result from the inability to suppress automatic thought and speech triggered by other thoughts. For example, sufferers with schizophrenia tend to experience derailment of thoughts and spoken sentences because each word triggers associations and the patient cannot suppress automatic responses to these.

Question 37

What are the three psychological therapies for schizophrenia

Answer 37

CBT, Family Therapy and Token Economies

Question 38

What are the three psychological therapies for schizophrenia

Answer 38

CBT, Family Therapy and Token Economies

Question 39

Describe CBT as a psychological therapy for schizophrenia

Answer 39

• based on the cognitive dysfunction explanation of schizophrenia (Metarepresentation and Central Control)
• CBT works over a period of 5-20 sessions
• CBT helps the patient identify faulty interpretations (I.e hallucinations and delusions)
• Behavioural assignments - homework is given

HOW IT WORKS:
3 ways to change irrational cognitions:
- Normalisation - their experiences are an extension of normal functioning
- Understanding where the delusions or hallucinations are coming from e.g malfunctioning speech centre in the brain and not demonic forces
- Reality testing - examining the likelihood that the beliefs are true

Question 40

Evaluate the CBT psychological treatment for schizophrenia

Answer 40

• STRENGTH: CBT is effective. Jaguar et al (2014) found small but significant effects on both positive and negative symptoms of schizophrenia, after a meta-analysis of 34 studies looking at SZ patients being treated with CBT.
• STRENGTH: CBT is the recommended treatment by the National Institute for Health and Care excellence (NICE)
• WEAKNESS: CBT does not cure schizophrenia, but improves the quality of life by helping to manage symptoms and Enhances coping mechanisms. BUT does result in a significant reduction in the severity of both positive and negative symptoms

Question 41

Describe Family therapy as a psychological therapy for schizophrenia

Answer 41

• Takes place with families as well as the identified patient
• Aims to improve the quality of communication and interaction between family members
• Based on the double bind theory, SZ mother and EE
• Often used together with drug treatment and outpatient clinical care

HOW DOES IT WORK?
(Pharaoh et al (2010) identified strategies):
- Reducing negative emotions - reducing levels of EE and stress. Reducing stress is important in reducing the likelihood of relapse
- Improving the family’s ability to help:
Psychoeducation: helping person and carers to understand and better able to deal with illness
Forming a therapeutic alliance with patient and carer with shared aims
Balance: between the care for the patient and maintaining their own lives

FRANK BURBACH (2018) MODEL FOR WORKING WITH FAMILIES:
- Sharing information and providing practical support
- Identifying resources and what family members can offer
- Encourages mutual understanding and safe space for expression of feelings
- Identify unhelpful patterns of interaction
- Skills training - e.g stress management techniques
- Relapse prevention planning
- Maintenance for the future

Question 42

Evaluate family therapy as a psychological treatment for schizophrenia

Answer 42

• STRENGTH: Macfarlane (2016) found family therapy to be consistently effective in the treatment of schizophrenia. Relapse rates were shown to reduce by 50 - 60%
• STRENGTH: NICE recommends family therapy for the treatment of SZ
• STRENGTH: Benefits are seen for the whole family, not just the identified patient. As family members provide the majority of the care, strengthening the functioning of the family lessens the negative impact of SZ on the family
• LIMITATION: Is family therapy for economic or therapeutic benefit? It could be argued that placing the responsibility of care on the family reduces the economic burden on the government. Improvements in clinical, social and family functioning would be expected to reduce the need for intensive medical and social care and thereby produce economical savings for services providers

Question 43

Describe the token economy as a psychological therapy for schizophrenia

Answer 43

• A form of behaviour therapy
• Clinicians set target behaviour that they believe will improve patient’s engagement in daily activities e.g. dressing themselves
• Tokens awarded when patient engages in target behaviour
• Tokens are later exchanged for various rewards and privileges. The more items or rewards the token can be exchanged, the more powerful the token become

STUDY: Ayllon and Azrin- increased desirable behaviour:
- Must be repeatedly presented immediately - value. Delay may cause lack of effectiveness

TOKEN ECONOMY IS USED FOR 3 CATEGORIES OF INSTITUTIONAL BEHAVIOUR:
(Matson et al, 2016)
1) Personal Care
2) Apathy
3) Social behaviour

Token economy is not a cure, but it does:
- improve quality of life within the institution
- Normalises behaviour - helping them integrate back into the community setting

THEORETICAL BASIS OF TOKEN ECONOMY:
- Token economy is ‘Behaviour modification’
- Based on the principles of operant conditioning - rewards given for desirable behaviour = positive reinforcement
- Tokens are secondary reinforcers - they have no value but can be exchanged for primary reinforces - such as extended TV time.

Question 44

Evaluate token economies as a psychological therapy for schizophrenia

Answer 44

• STRENGTH: Glowacki et al (2016) analysed studies that looked at the effectiveness of token economy. Found that it was very effective in reducing negative symptoms.
• LIMITATION: Ethical issues - doctors/clinicians have power and control over the patient and this restricts their freedom. Token economy is usually used for children - this belittles patients and makes them feel inadequate. What happens when rewards are taken away? Can behaviour continue when integrated back into the community.

Question 45

Describe aalon and azwick’s psychological study on developing token economies for schizophrenia

Answer 45

Question 46

Describe the interactionist (biosocial) approach of schizophrenia

Answer 46

• Believes that biological, psychological and social factors are involved in the development of schizophrenia

DIATHESIS STRESS MODEL:
Diathesis - vulnerability
Stress - a stressor is a negative experience
- Both have to present for schizophrenia to occur
- Underlying factors make people more vulnerable to schizophrenia, but the disorder only occurs after a negative stressor

MEEHL’S (1962) ORIGINAL DIATHESIS-STRESS MODEL:
- Vulnerability is entirely genetic - a single schizogene leads to a biologically based schizotypic personality (extremely sensitive to stress)
- No amount of stress will lead to schizophrenia if the gene is not present
- Chronic stress in someone with the gene could lead to the development of the order - nature and nurture interact.

MODERN UNDERSTANDING OF DIATHESIS
- Multiple genes play a part in vulnerability
- Diathesis can be factors that aren’t genetic
- For example: Psychological trauma (trauma therefore becomes the Diathesis - not a stressor). For example, Chugani et al (PET scans of Romanian orphans showed they has smaller hypocampus + amygdala)
- Read et al (2001) proposed the ‘Neurodevelopmental model’ - early trauma can affect brain development which makes someone more vulnerable.
- e.g hypothalamic-pituitary gland (HPA) system becomes overactive - more sensitive to stress.
- The HPA is the main stress response system. It is the ‘neuroendocrine’ link between perceived stress and physiological reactions to stress

MODERN UNDERSTANDING OF STRESS
- Lack of 100% concordance rates for MZ twins - must be some sort of environmental factor too
- Anything that risks triggering schizophrenia - not just parenting
- Focus in recent research on cannabis use - increases risk of schizophrenia by up to 7 times
- Cannabis interferes with the dopamine system - this could be the stressor.

Question 47

How can schizophrenia be treated, according to interactionism

Answer 47

• Focus should be on combining biological and psychological treatments
• Antipsychotics and CBT are used
• The approach is more common in the UK than the US
• US has more disagreement between biological and psychological theories
• We can still believe in a biological basis but use CBT to relieve psychological symptoms
• BUT this relies on the interactionist view

Question 48

Evaluate the interactionist approach to schizophrenia

Answer 48

– The original model is too simplistic– Modern model is more valid and worthwhile - multiple things can be Diathesis and stress
– Real life application – making treatments worthwhile and predicting those who are more vulnerable
– something to consider is urbanisation – schizophrenia is more commonly diagnosed in urban areas
– The approach is holistic