Schizophrenia

Question 1

Classification of mental disorder

Answer 1

The process of organising symptoms into categories basemen which symptoms frequently cluster together.

Question 2

Schizophrenia

Answer 2

A severe mental disorder where contact with reality and insight are impaired, an example of psychosis.

Question 3

Positive symptoms of schizophrenia

Answer 3

Atypical symptoms experienced in addition to normal experiences. They include hallucinations and delusions.

Question 4

Hallucinations

Answer 4

A positive symptom of schizophrenia. They are sensory experiences that have either no basis in reality or are distorted perceptions of things that are there.

Question 5

Delusions

Answer 5

A positive symptom of schizophrenia. They involve beliefs that have no basis in reality, e.g. a person believes that they are someone else or that they are the victim of a conspiracy.

Question 6

Negative symptoms of schizophrenia

Answer 6

Atypical experiences that represent the loss of a usual experience such as loss of clear thinking or a loss of motivation.

Question 7

Speech poverty

Answer 7

A negative symptom of schizophrenia. It involves reduced frequency and quality of speech.

Question 8

Avolition

Answer 8

A negative symptom of schizophrenia. It involves loss of motivation to carry out tasks and results in lowered activity levels.

Question 9

Co-morbidity

Answer 9

The occurrence of 2 disorders or conditions together, e.g. a person has both schizophrenia and a personality disorder. Where 2 conditions are frequently diagnosed together it calls into question the validity of classifying the 2 disorders separately.

Question 10

Symptom overlap

Answer 10

Occurs when 2 or more conditions share symptoms. Where conditions share many symptoms this calls into question the validity of classifying the 2 disorders separately.

Question 11

One strength of the diagnosis of schizophrenia is its reliability.

Answer 11

A psychiatric diagnosis is said to be reliable when different diagnosing clinicians reach the same diagnosis for the same individual (inter-rater reliability) and when the same clinician reaches the same diagnosis for the same individual on 2 occasions (test-retest reliability).
- Osório et al. (2019) report excellent reliability for the diagnosis of schizophrenia in 180 individuals using the DSM-5. Pairs of interviewers achieved inter-rater reliability of +.97 and test-retest reliability of +.92.
- We can be reasonably sure that the diagnosis of schizophrenia is consistently applied.

Question 12

One limitation of the diagnosis os schizophrenia is its validity.

Answer 12

One way to assess validity of a psychiatric diagnosis is criterion validity. Cheniaux et al. (2009) had 2 psychiatrists independently assess the same 100 clients using ICD-10 and DSM-IV criteria and found that 68 were diagnosed with schizophrenia under ICD system and 39 under DSM.
- This suggests that schizophrenia is other over - or under diagnosed according to the diagnostic system. Either way this suggests that criterion validity is low.

Question 13

Another limitation of schizophrenia diagnosis is its comorbidity with other conditions.

Answer 13

If conditions occur together a lot of the time when this calls into question the validity of their diagnosis and classification because they might actually be a single condition.
Schizophrenia is commonly diagnosed with other conditions. E.g. one review found that about half of those diagnosed with schizophrenia also had a diagnosis of depression or substance abuse.
- This is a problem for classification because it means schizophrenia may not exist as a distinct condition, and is a problem for diagnosis as at least some people diagnosed with schizophrenia may have unusual cases of conditions like depression

Question 14

A further limitation of schizophrenia diagnosis is the existence of gender bias.

Answer 14

Since 1980s men have been diagnosed with schizophrenia more commonly than women. One possible explanation for this is that women are less vulnerable than men, perhaps because of genetic factors. However it seems more likely that women are under diagnosed because they have closer relationships and hence get support. This leads to women with schizophrenia often functioning better than men.
- This under diagnosis is a gender bias and means women may not therefore be receiving treatment and services that might benefit them.

Question 15

A further limitation of schizophrenia diagnosis is the existence of culture bias.

Answer 15

Some symptoms of schizophrenia, e.g. hearing voices, have different meanings in different cultures. E.g. in Haiti some people believe that voices actually are communications from ancestors. British people of African-Caribbean origin are up to 9 times 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 differential cultural background. This appears to lead to an over interpretation of symptoms in black British people.
- This means that British African-Caribbean people may be discriminated against by a culturally biased diagnostic system.

Question 16

A further limitation of schizophrenia diagnosis is symptom overlap with other conditions.

Answer 16

There is considerable overlap between the symptoms of schizophrenia and the symptoms of other conditions. E.g. both schizophrenia and bipolar disorder involve positive symptoms and negative symptoms. In terms of classification this suggests that schizophrenia and bipolar disorder may not be 2 different conditions but variations of a single condition.
- Symptom overlap means that schizophrenia may not exist as a distinct condition and that even if it does it is hard to diagnose. So both its classification and diagnosis are flawed.

Question 17

Genetics

Answer 17

Genes consist of DNA strands. DNA produces ‘instructions’ for general physical features of an organism (eye colour, height) and also specific physical features (neurotransmitter levels and size of brain structures).
- These may impact on psychological features (such as intelligence and mental disorder). Genes are transmitted from parents to offspring, i.e. inherited.

Question 18

Neural correlates

Answer 18

Patterns of structure or activity in the brain that occur in conjunction with an experience and may be implicated in the origins of that experience.

Question 19

Dopamine

Answer 19

A neurotransmitter that generally has an excitatory effect and is linked to the sensation of pleasure. Unusually high levels are associated with schizophrenia and unusually low levels are associated with Parkinson’s disease.

Question 20

Neural correlates (brain structure or function) of schizophrenia

Answer 20

Dopamine -> important in the functioning of several brain systems related to the symptoms of schizophrenia.

Question 21

The original dopamine hypothesis

Answer 21

based on the discovery that antipsychotics caused symptoms similar to those people with Parkinson’s disease, a condition associated with low DA levels. Therefore, schizophrenia may be as result of high levels of DA in subcortical areas of the brain.
- E.g. an excess of DA receptors in pathways from the sub cortex to Broca’s area may explain specific symptoms of schizophrenia such as poverty of speech and/or auditory hallucinations.

Question 22

One strength of the genetic explanation for schizophrenia is the strong evidence base

Answer 22

Family studies (Gottesman) show that risk increases with genetic similarity to a family member with schizophrenia.
Adoption studies such as Tiernari et al. (2004) show that biological children of parents with schizophrenia are at heightened risk even if they grow up in an adoptive family.
A recent twin study by Hilker et al. (2018) showed a concordance rate of 33% for identical twins and 7% for non-identical twins.
- Shows that some people are more vulnerable to schizophrenia as a results of genetic makeup.

Question 23

One strength is support for the idea that dopamine is involved in schizophrenia.

Answer 23

• Amphetamines increase DA and worsen symptoms in people with schizophrenia and induce symptoms in people without.
• Antipsychotic drugs reduce DA activity and also reduce the intensity os symptoms.
• Some Candidate genes act on the production of DA or DA receptors.

Question 24

Family dysfunction.

Answer 24

Refers to processes within a family such as poor family communication, cold parenting and high levels of expressed emotion. These may be risk factors for both the development and maintenance of schizophrenia.

Question 25

Cognitive explanations

Answer 25

Explanations that focus on mental processes such as thinking, language and attention.

Question 26

Dysfunctional thought processing

Answer 26

Information processing that does not represent reality accurately and produces undesirable consequences.

Question 27

The schizophrenogenic mother

Answer 27

Fromm-Reichman (1948) proposed a psychodynamic explanations for schizophrenia based on the accounts she heard from her patients about their childhoods. She noted that many of her patients spoke of a particular parent, which she called the schizophrenogenic mother = schizophrenia causing. The schizophrenogenic mother is cold, rejecting and controlling, and tends to create a family climate characterised by tension and secrecy. This leads to distrust that later develops into paranoid delusion (schizophrenia).

Question 28

Double-bind theory

Answer 28

Bateson et al. (1972) agreed that family climate is important in the development of schizophrenia but emphasised the role of communication style within a family.
- The developing child regularly finds themselves trapped in situations where they fear doing the wrong thing, but receive mixed messages about what this is, and feel unable to comment on the unfairness of this situation or seek classification.
- When they ‘get it wrong’ the child is punished by withdrawal of love, leaving them a confusing understanding the world.
RISK FACTOR

Question 29

Expressed emotion

Answer 29

level of emotion, particularly negative emotion, expressed towards a person with schizophrenia by their carers (often family members).

Question 30

Expressed emotion contains several elements:

Answer 30

• verbal criticism of the person, occasionally accompanied by violence.
• hostility towards the person, including anger and rejection.
• emotional over involvement in the person’s life including self-sacrifice.

Question 31

These high levels of expressed emotion directed towards the individual are a serious source of stress.

Answer 31

This is primarily an explanation for relapse in people with schizophrenia.

Question 32

Diathesis-stress model

Answer 32

It has also been suggested that it may be a source of stress that can trigger the onset of schizophrenia in a person who is already vulnerable, e.g. due to genetic makeup.

Question 33

Schizophrenia is characterised by disruption to normal thought processing. We can see this in many of its symptoms.

Answer 33

• Reduced thought processing in the ventral striatum is associated with negative symptoms.
• Reduced processing of information in the temporal and cingulate gyri is associated with hallucinations.
• This lower than usual level of information processing suggests that cognition is likely to be impaired.

Question 34

Metarepresentation dysfunction (identified by Frith et al. 1992)

Answer 34

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.

Question 35

Dysfunction in metarepresentation would…

Answer 35

disrupt our ability to recognise our own actions and thoughts as being carried out by ourselves rather than someone else. This would explain hallucinations of hearing voices and delusions like thought insertion.

Question 36

Frith also identified issues with the cognitive ability to suppress automatic responses while we perform deliberate actions.

Answer 36

Speech poverty and thought disorder could result from the inability to suppress automatic thoughts and speech triggered by other thoughts. E.g. people with schizophrenia tend to experience derailment of thoughts because each word triggers associations, and the person can’t suppress automatic responses to these.

Question 37

One strength of these explanations is evidence linking family dysfunction to schizophrenia.

Answer 37

Indicators of family dysfunction include insecure attachment and exposure to childhood trauma, especially abuse. Read et al. (2005) -> adults with schizophrenia are disproportionally likely to have insecure attachment. Read also reported that 69% of women and 59% of men with schizophrenia have a history of physical and/or sexual abuse.
- Mørkved et al. (2017) - most adults with schizophrenia reported at least one childhood trauma, mostly abuse.
- Strongly suggests that family dysfunction makes people more vulnerable to schizophrenia.

Question 38

One limitation of family explanations is the poor evidence base for any of the explanations.

Answer 38

There is almost none to support the importance of traditional family-based theories such as the schizophrenogenic mother and double bind.
- Both theories are based on clinical observation of people with schizophrenia and also informal assessment of their mothers’ personalities, but not systematic evidence.
- Family explanations haven’t been able to account for the link between childhood trauma and schizophrenia.

Question 39

One strength of cognitive explanations is evidence for dysfunctional thought processing.

Answer 39

Sterling et al. (2006) compared performance on a range of cognitive tasks in 30 people with schizophrenia and a control group of 30 people without schizophrenia.
- Tasks included the Stroop task (name font-colours of colour-words).
- As predicted by Frith’s central control theory, people with schizophrenia took longer to name for colours.
- cognitive processes of people with schizophrenia are impaired.

Question 40

One limitation of cognitive explanations is that they only explain the proximal origins of symptoms.

Answer 40

Cognitive explanations for schizophrenia are proximal explanations because they explain what is happening now to produce symptoms - distal explanations focus on what initially caused the condition (genetic and family dysfunction).
- What is currently unclear and not well-addressed is how genetic variation or childhood trauma might lead to problems with metarepresentation or central control.
- Cognitive theories on their own provide partial explanations for schizophrenia.

Question 41

Antipsychotics

Answer 41

Drugs used to reduce the intensity of symptoms, particularly positive symptoms, of psychotic disorders like schizophrenia.

Question 42

Typical antipsychotics

Answer 42

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

Question 43

Atypical antipsychotics

Answer 43

Drugs for schizophrenia developed after typical antipsychotics. They typically target a range of neurotransmitters such as dopamine and serotonin. Examples include clozapine and risperidone.

Question 44

Dopamine antagonist

Answer 44

There is a strong association between the use of typical antipsychotics like chlorpromazine and the dopamine hypothesis. Typical antipsychotics like chlorpromazine work by acting as antagonists in dopamine system (block dopamine receptors in synapses of brain, reducing action of dopamine).
- Dopamine-antagonist effect normalises neurotransmission in key areas of the brain, reducing symptoms like hallucinations.

Question 45

Sedative effect

Answer 45

Related to its effect on histamine receptors but not fully understood how this leads to sedation.
- Chlorpromazine is often used to calm individuals not only with schizophrenia but also with other conditions.

Question 46

Clozapine

Answer 46

Binds to dopamine receptors in the same way that chlorpromazine does, but in addition it acts on serotonin and glutamate receptors = improve mood and reduce depression and anxiety in patients, may improve cognitive functioning.
- Mood enhancing effects of clozapine mean that it is sometimes prescribed when an individual is considered at high risk of suicide. (30-50% of people with schizophrenia attempt suicide)

Question 47

Risperidone

Answer 47

Binds to dopamine and serotonin receptors - bind more strongly to dopamine receptors than clozapine and is therefore effective in smaller doses than most antipsychotics = fewer side effects??

Question 48

One strength of antipsychotics is evidence to support their effectiveness.

Answer 48

Thornley et al. (2003) reviewed studies comparing the effects of chlorpromazine to control conditions. Data from 13 trials with a total of 1121 ppts showed that chlorpromazine was associated with better overall functioning and reduced symptom severity as compared to placebo.
- Meltzer (2012) concluded that clozapine is more effective than typical antipsychotics and other atypical antipsychotics - effective in 30-50% of treatment-resistant cases where typical antipsychotics have failed.

Question 49

Healy (2012) suggested serious flaws with evidence for effectiveness.

Answer 49

Most studies are of short term effects only and some successful trials have had their data published multiple times, exaggerating the size of the evidence base for positive effects.
- evidence base for antipsychotic effectiveness may be misleading.

Question 50

One limitation of antipsychotic drugs is the likelihood of side effects

Answer 50

Typical antipsychotics are associated with a range of side effects including dizziness, agitation, sleepiness, stiff jaw, weight gain and itchy skin.
- Long term use can result in thrive dyskinesia - caused by dopamine supersensitivity and causes involuntary facial movements.
- The most serious side effect is neuroleptic malignant syndrome (caused when the drug blocks dopamine action in hypothalamus).
- Antipsychotics can do harm as well as good and individuals who experience these may avoid treatments (ineffective).

Question 51

Cognitive Behaviour Therapy

Answer 51

A method for treating mental disorders based on both cognitive and behavioural techniques. From cognitive viewpoint the therapy aims to deal with thinking, such as challenging negative thoughts. The therapy includes behavioural techniques.

Question 52

Family therapy

Answer 52

A psychological therapy carried out with all or some members of a family with the aim of improving the communications within the family and reducing the stress living as a family.

Question 53

How cognitive behaviour therapy helps

Answer 53

• make sense of how their irrational conditions impact on their feelings and behaviour. Understanding where symptoms come from can help with auditory hallucinations for example.
• Teach them that voice-hearing is an extension of the ordinary experience of thinking in words = normalisation.
• challenge delusions -> reality testing.

Question 54

How family therapy helps (strategies identified by Pharaoh 2010)

Answer 54

• reduces negative emotions (expressed emotion), reducing stress.
• improve family’s ability to help -> beliefs and behaviour towards schizophrenia, create balance between caring for individual and maintaining own lives.

Question 55

One strength of CBT for schizophrenia is the evidence for its effectiveness

Answer 55

Jauher et al. (2014) revised 34 studies of using CBT with schizophrenia, concluding evidence for small but significant effects on both positive and negative symptoms.

Question 56

One limitation of CBT for schizophrenia is the wide range of techniques and symptoms included in studies

Answer 56

CBT techniques and schizophrenia symptoms vary widely.
- Thomas (2015) point out that different studies have involved the use of different CBT techniques and people with different combinations of positive and negative symptoms. The overall modest benefits of CBT for schizophrenia probably conceal a wide variety of effects of different CBT techniques on different symptoms.
- Makes it hard to say how effective CBT will be for a particular person with schizophrenia.

Question 57

One strength of family therapy for schizophrenia is evidence of its effectiveness.

Answer 57

McFarlane (2016) concluded that family therapy was one of the most consistently effective treatments available for schizophrenia.
- Relapse rates were found to be reduced, typically by 50-60%.
- McFarlane also concluded that using family therapy as mental health initially starts to decline is promising. Clinical advice from NICE recommends family therapy for everyone with diagnosis of schizophrenia.
- Family therapy is likely to be of benefit to people with both early and ‘full-blown’ schizophrenia.

Question 58

A further strength of family therapy is the benefits for all family members.

Answer 58

Lobban and Barrowclough (2016) concluded that these effects are important because families provide the bulk of care for people with schizophrenia. By strengthening the functioning of a whole family, family therapy lessens the negative impact of schizophrenia on other family emerges and strengthens ability to support person.
- wider benefits beyond obvious positive impact on identified patient.

Question 59

Token economies

Answer 59

A form of behavioural modification, where desirable behaviours are encouraged by the use of selective reinforcement. E.g. people are given rewards (tokens) when they engage in socially desirable behaviours. The tokens are secondary reinforcers and can then be exchanged for primary reinforcers - food or privileges.

Question 60

The classical demonstration of a token economy was carried out by Ayllon and Adrian (1968).

Answer 60

They trailed a token economy system in a ward of women with a diagnosis of schizophrenia.
Every time the ppts carried out a task such as making their bed or cleaning up they were given a plastic token embosses with the words ‘one gift’. These tokens can be swapped for ward privileges (watch a film). The number of tasks carried out increased significantly.

Question 61

Johnny Matson et al. (2016) identify 3 categories of institutional behaviour commonly tackled by means of token economies:

Answer 61

personal care, conditions-related behaviours (apathy), and social behaviour.

Question 62

Modifyin these behaviours doesn’t cure schizophrenia but it has 2 major benefits:

Answer 62

1. improves the persons quality of life within the hospital setting
2. ‘Normalises’ behaviour and this makes it easier for people who have spent a time in hospital to adapt back into life in the community.

Question 63

Token economies are an example of behaviour modification -

Answer 63

a behavioural therapy based on operant conditioning.
- Tokens are secondary reinforcers because they only have value once the person receiving them has learned that they can be used to obtain meaningful rewards, which are primary reinforcers.

Question 64

One strength of token economies for the management of schizophrenia is evidence for their effectiveness. (Glowacki et al. 2016)

Answer 64

Glowacki identified 7 high quality studies published between 1999 and 2013 that examined the effectiveness of token economies for people with chronic mental health issues such as schizophrenia and involved patients living in a hospital setting.
All studies showed reduction in negative symptoms and a decline in the frequency on unwanted behaviours -> value.

Question 65

One limitation with the use of token economies to manage schizophrenia is the ethical issues raised.

Answer 65

It gives professionals considerable power to control behaviour of people in the role of patient. This involves imposing one person’s norms on to others, which is problematic if target behaviours aren’t identified sensitively.
E.g. someone who likes to look scruffy and get up late might have these personal freedoms curtailed. Perhaps more seriously, restricting the availability of pleasure to people who don’t behave as desired means that seriously ill people who are already experiencing distressing symptoms, have an even worse time.
- The benefits of token economies may be outweighed by their impact on personal freedom and short-term reduction of quality in life.

Question 66

A further limitation of token economies is the existence of more pleasant and ethical alternatives.

Answer 66

A review by Chiang et al. (2019) concluded that art ternary might be a good alternative. The evidence base is regularly small and has some methodological limitations, but it appears to who that art therapy is a high-gain low-risk approach to managing schizophrenia.
- Even if the benefits of art therapy are modest, this is generally true for all approaches to treatment and management of schizophrenia and, unlike alternatives, art therapy is a pleasant experiences without major risks of side effects or ethical abuse.
- Art therapy might be a good alternative to token economies.

Question 67

Interactionist approach

Answer 67

A way to explain the development of behaviour in terms of a range of factors, including both biological and psychological ones. Most importantly such factors don’t simply add together but combine in a way that can’t be predicted by each one separately i.e. they interact.

Question 68

Diathesis-stress model - an interactionist approach to explaining behaviour.

Answer 68

e.g. schizophrenia is explained as the result of both an underlying vulnerability (diathesis) and a trigger (stressor), both of which are necessary for the onset of schizophrenia.
- Both genes and trauma are seen as diatheses, and stress can be psychological or biological in nature.

Question 69

Biological factors include…

Answer 69

genetic vulnerability and neurochemical and neurological abnormality.

Question 70

Psychological factors include…

Answer 70

stress, e.g. from life events and daily hassles, including social factors such as poor quality interactions in the family.

Question 71

Treatment according to the interactionist model

Answer 71

Acknowledges both biological and psychological factors in schizophrenia and is therefore compatible with both biological and psychological treatments -> this model is associated with combining antipsychotic medication and psychological therapies (CBT).

Question 72

One strength of the interactionist approach to schizophrenia is evidence supporting the role of both vulnerability and triggers.

Answer 72

Tienari et al. (2004) investigated the impact of both genetic vulnerability and a psychological trigger. The study showed 19,000 Finnish children whose biological mothers had been diagnosed with schizophrenia. In adulthood this high genetic risk group were compared to a control group of adoptees without a family history.
- Adoptive parents had been assessed for child-rearing style and it was found that high levels of criticism, hostility and low levels of empathy were strongly associated with the development of schizophrenia, but only in high genetic risk group.

• Shows that combination of genetic vulnerability and family stress can lead to increased risk of schizophrenia.

Question 73

One limitation of the original diathesis-stress model is over simplicity.

Answer 73

Multiple genes in multiple combinations influences diathesis. Stress also comes in many forms, including dysfunctional parenting.
- Diathesis can also be influenced bye psychological factors and stress can be biological as well as psychological.
-> This was shown in a study by Houston et al. (2008), where childhood sexual abuse emerged as the major influence on underlying vulnerability to schizophrenia and cannabis use as the major trigger.
- This means there are multiple factors, both biological and psychological, affecting both diathesis and stress, supporting modern understanding of both diathesis and stress.

Question 74

A further strength of the interactionist approach is the combination of biological and psychological treatments.

Answer 74

Studies show that combining treatments enhances their effectiveness. Tarrier et al. (2004) randomly allocated 315 ppts to medication + CBT, medication + counselling, or control group (medication only). Ppts in the 2 combination groups showed lower symptoms following the trial than the control.
-> clear practical advantage to adopting an interactionist approach in terms of treatment outcomes.