schizophrenia Flashcards
what is the nature of schizophrenia
psychosis- sufferer has no concept of reality
individuals thoughts, emotions and senses are impaired
15-35 years old ( peak onset is at 25- 30 and cases prior to adolescence are rare )
effects men and women equally ( men are diagnosed earlier)
what are positive symptoms
those that appear to reflect an excess or distortion of normal function
what is the definition of negative symptoms of diagnosing schizophrenia
those that appear to reflect a loss or decline of normal function
what are delusions
positive
false beliefs that are held despite being completely illogical or no evidence
what are the common types of delusions of schizophrenia
delusions of persecution - belief that others want to harm, threaten or manipulate you
delusions of grandeur- idea that you are an important individual, even god like , most frequent Jesus Christ
delusions of control- may believe under control of alien forces that has invaded their mind and body
what are the symptoms of SZ
delusions
hallucination
speech pov
avolition
affective flattening
anhedonia
what are hallucinations
Distortion or exaggeration of perception of any of the senses
EG auditory hearing voices visual seeing things
what are examples of positive symptoms
Delusions and hallucinations
What is speech poverty
less of speech fluency and productivity
Thought to reflect slow or blocked thoughts
what is avolition
Inability to initiate and persist in gold directed behaviour- severe loss of motivation
For example no longer being interested in going out and meeting with friends
what is affective flattening
A reduction in the range and intensity of emotional expressions
What is anhedonia
The loss of interest or pleasure in all or almost all activities
What are examples of negative symptoms
speech poverty , avolition, affective flattening anhedonia
what are the two different diagnostic criteria for SZ
DSM- one of positive symptoms
ICD - two or more negative symptoms
what is reliability
How repeatable something is- consistency- in SZ reliability means diagnosis can be repeated
What is test retest reliability
repeating a test how similar are the results- a clinician must be able to reach the same results twice
What is interrater reliability
two different psychologists must be able to reach the same conclusion- Kappa score
what is cultural differences or cultural bias
The tendency to judge people in terms of one’s own culture assumptions
What is validity
Does it measure what it intended to measure
What is gender bias
The differential treatment of men and women based off of stereotypes not real differences
What is symptom overlap
Symptoms may not be unique to that wonder disorder but may also be found in other disorders making accurate diagnosis difficult
what is co morbidity
The extent to which two or more conditions occur simultaneously in a patient
why is reliability an issue and what is the evidence/ case studies
what impact does it have ?
inter rater reliability- different clinicians must be able to reach the same conclusion. inter rater reliability is measured by a statistic called kappa score . kappa score of 7 or above considered good
whaley- found inter rarer reliability as low as 0.11
later found a kappa score of only .46
recently- seen to have an excellent reliability of .97
may miss out on diagnosis or be wrongly diagnosed
why is cultural bias an issue?
what is the evidence?
how does it effect the diagnosis?
cultural bias is the tendency to judge people in terms of one’s own cultural assumptions
Evidence of this - Escobar saw that African Americans are several times more likely than white people to be diagnosed with schizophrenia. this is not due to genetic vulnerability but due to cultural bias. One issue is that auditory hallucinations is more acceptable within African cultures because of their beliefs in communication with ancestors.
this causes the overdiagnosis of ethnic minority groups and leads to them being treated different differently because they are seen as different or excluded
what is the problem with validity?
What is the evidence/case studies to prove this ?
What impact does this have on diagnosing ?
Leeds to the differential treatment of males and females based on stereotypes not real differences
loring + powell- randomly selected 290 male and female psychiatrist to read two case studies of patient behaviour. Then asked to offer their judgement on individuals using the standard diagnostic criteria- when patients were described as males or no information about gender 56% of psychiatrists gave the diagnosis
When patients were described as female, only 20% were given diagnosis
This shows pronoun effects whether they are diagnosed which decreases validity
“she” - diagnosis missed can’t get access to treatment impacts functioning wrongly diagnosed impact on economy
“he “- overdiagnosed negative stereotypes e.g. violent
Self fulfilling prophecy
what is the issue of comorbidity
What is the evidence to prove this ?
Why does this have an impact
Comorbidity is the extent that two or more conditions or diseases occur simultaneously in a patient
buckley et al- schizophrenia was also diagnosed with depression 50% of the time substance abuse 47% of the time PTSD 29% of the time
Issue different conditions have different treatments - may not know which ones to treat and maybe more complex to treat- costing more money and taking longer
What is an example of a neural correlate
The dopamine hypothesis
what was the dopamine hypothesis
claims that an excess of the neurotransmitter dopamine in certain regions is associated with positive symptoms of SZ
To have abnormally high numbers of D2 receptors resulting in more dopamine
what was the drug evidence to support the dopamine hypothesis
Amphetamine- dopamine agonist- normal individuals exposed to large doses of dopamine releasing drugs can develop characteristic symptoms of SZ. EG hallucinations and delusions
Antipsychotic drugs - dopamine antagonist- block the activity of dopamine in the brain, alleviate symptoms of such as hallucinations and delusions
what is the revised dopamine hypothesis
Davis and kahn-
- positive symptoms are caused by an excess of dopamine in subcortical areas of the brain
- Negative symptoms of schizophrenia to arise from deficit of dopamine in prefrontal cortex
hyperdopaminergia- excess
hypodopaminergia- low levels of
Other than drugs what is the other evidence to support dopamine hypothesis
PET scans assess dopamine levels in schizophrenic and normal individuals and found lower levels of dopamine in prefrontal cortex of SZ patients
What are neural correlates
Patterns of structure and function in the brain that correlates with schizophrenic experience
what are the strengths of the dopamine hypothesis
Supporting evidence of successful drug therapy-
Found that antipsychotic drugs were significantly more effective than the placebo in the treatment of positive and negative symptoms
strength of neural correlates comes from support of influence of Gray matter deficit
Patient with SZ - higher reduction in cortical grey matter volume over time
What is a weakness of the dopamine hypothesis
evidence for the dopamine hypothesis has been challenged claims that there is evidence against effectiveness of drugs
Antipsychotic drugs do not alleviate hallucinations and illusions in one third of people - these are present despite levels of dopamine being normal
Suggest that dopamine may not be the sole cause of positive symptoms
maybe other explanations
what are the genetic factors in the biological explanation of SZ( + evidence)
Tends to run in families but only among individuals who are genetically related
The risk of developing the disorder among individuals who have family members with SZ is higher than it is for those who do not
No one gene is responsible for this disorder - polygenic condition
Gottesman- Large scale family study
Found that strong relationship between the degree of genetic similarity and the risk of sz
Identical twins 48%
Fraternal twins 17%
Siblings 9%
what is the diathesis stress model
It is an interaction approach to explaining behaviour
Conditions are explained as a result of both an underlying vulnerability (diathesis) and a trigger
What is a strength of the genetic evidence of SZ
there is support from other twin studies- another study calculated that concordance rates for MZ twins were 40%- and for DZ twins 7%
What are the weaknesses of the genetic basis of SZ
does not take into account environmental factors
SZ may be more to do with child rearing patterns - maybe due to expressed emotion in the family when families communicate in a hostile manner (critical and overconcerned) - siblings are exposed to the same environment so maybe due to family dysfunction rather than genetics
Mz twins encounter more similar environments than DZ twins - MZ have a greater environmental similarity because they are more likely to do things together- same school same clothes- suffer from identity confusion
Often treated as twins rather than two distinct individuals
Concordance rates may reflect nothing more than situational factors
What are antipsychotic drugs
Antipsychotic drugs work by reducing the action of the neurotransmitter dopamine in areas associated with the symptoms of SZ
What are the two different types of antipsychotics
typical and atypical
Typical are the first generation ones
when were typical antipsychotics first introduced
In the 1950s
Traditional antipsychotics
Prescribed dose has declined
what is an example of a typical antipsychotic
Chlorpromazine- it can be taken as tablets syrup or injection
Administered daily initially doses are smaller and gradually to a max of 400 to 800 MG
Prescribed doses have declined over the last 50 years
How do typical antipsychotics work in the brain
they bind but do not stimulate dopamine receptors thus blocking their action
By reducing the action of dopamine it alleviates positive symptoms
They have a sedative effect
However blocking dopamine receptors can be harmful for the person as negative symptoms may get worse
what are the side effects of typical antipsychotics
There are lots of side-effects
Loss of muscle movement in face - involuntary movements( tardive dyskinesia) found in 68% of patience and it is irreversible( significant ethical issues as didn’t know would end up with an irreversible side-effect)
Normally the side effects lead to people stopping taking the drug which leads to relapse so symptoms come back
what is information on the effectiveness and appropriateness of typical antipsychotics
Issues with informed consent- patience have no perception of reality
Treats symptoms not cause -passive- can cause relapse
Unclear on how they work - work better alongside therapy interactionist approach
Chemical cosh- in hospital situations it is believed that people are to make them easier to work with rather than to make the patient better
what is information on the effectiveness and appropriateness of typical antipsychotics
Issues with informed consent- patience have no perception of reality
Treats symptoms not cause -passive- can cause relapse
Unclear on how they work - work better alongside therapy interactionist approach
Chemical cosh- in hospital situations it is believed that people are to make them easier to work with rather than to make the patient better
When were atypical antipsychotics introduced
The 1970s
To maintain an improve effectiveness of drugs in suppressing symptoms and minimising side effects
what is an example of an atypical antipsychotic
clozapine
Helps negative symptoms and regulate cognitive function
Withdrawn for a while due to the death of some patients
Discovered to be more effective than typical
Tablet form and lower dose
how do atypical antipsychotics work in the brain
These drugs temporarily blocked dopamine receptors then rapidly dissociate to allow normal dopamine transmission
Also act on other neurotransmitters e.g. serotonin which also addresses negative symptoms
What are the side effects of atypical antipsychotics
few side effects and typical and less serious so there’s a reduced risk
Blood condition -people on this drug have to take regular blood tests
If it has side-effects people stop taking the drug and it causes relapse
What is the effectiveness and appropriateness of atypical antipsychotics
issues with ethical issues no informed consent as they have no perception of reality
Treat the symptoms not the cause means that patients don’t look at the root
Don’t know why they work and only work in 75% of cases alongside other therapy
Chemical cosh- hospitals may be given drugs to make them easier to work with rather than to make them better human rights abuse
what are the two psychological explanations
family dysfunction
cognitive explanations
what is family dysfunction
abnormal patterns of communication within the family
risk factor in the development of sz and relapsing
3 categories- double bind, sz mother, expressed emotion
what is double bind theory
when an individual receives two or more conflicting message- one contradicts other- one on verbal ( affection) level one on non verbal level ( mother is angry or hostile )
how did double bind cause sz
children who frequently receive contradictory messages from parents are more likely to develop sz
prevents child from developing a construction of reality so manifests itself as sz- delusions
affective flattening- don’t know how to show emotions
what is schizophrenogenic
sz cause
what are the characteristics of a schizophrenic mother
reichmann- proposed psychodynamic based explanation
sz mother is cold, rejecting and controlling and climate is characterised by tensions anxiety and secrecy
by contrast father is passive - not involved
leads to distrust - paranoid delusions
what is expressed emotion and how does it effect sz
a family communication style in which members of family talk about patient in
•critical or hostile manner verbal criticism
•way that indicates emotional over involvement
• high levels of EE influence relapse rates
• 4x more likely to relapse in high EE
what does cognitive explanation say sz is a result of
dysfunctional thought processing
does not reflect reality
evident in those who display delusions
what are the cognitive explanations for delusions
relate irrelevant events to themselves and arrive at false conclusions
unable to consider they may be wrong and can not substitute more realistic explanations
what is the cognitive explanation for hallucinations
metarepresentation- cognitive ability to reflect on behaviour and thoughts
metarepresentation dysfunction- disrupts ability to reflect - misunderstand the source of a self generated auditory experience with an external force
can’t recognise as own thoughts
what is the strength for family dysfunction
research support
- indicators of family dysfunction include insecure attachment and exposure to childhood trauma
- John read- adults with sz are more likely to have insecure attachment
- reported that 69% of women and 59% of men with sz have history of physical and or sexual abuse
- strongly suggests FD makes more vulnerable to sz
HOWEVER- poor evidence base for theories-sz mother and double bind
what are the weaknesses for family dysfunction
can be criticised for being retrospective-
- evidence high but most of it based on info about childhood experiences gathered after diagnosis
- symptoms may have distorted patients recall of child experiences
-creates a problem with valadity
socially sensitive -
-blames the mother for child getting sz mother but not father also shows the traditional view of stay at home mother
- research support into the studies needed and useful but socially sensitive
- for parents already having to watch child suffer and then take responsibility and blame for causing it- psychological harm
what are the strengths for cognitive explanations
supporting evidence for cog model-
-stirling compared 30 patients with sz with 18 control group on cog task (naming ink colour of words)
- patients took over 2x as long as control to suppress the impulse of reading word not colour
-supports theory of central control dysfunction
-shows processing differs
- however issues with cause and effect
support of the success of cog behaviour therapy and success of family therapy
what is the weakness of cognitive explanations
fault to consider the biological approach-
- only looks at one apperoach (reductionist)
- if bio are valid, how do they fit with psychological
- both bio and psych can seperately product same symptoms
- raises question of whether both outcomes are really sz
- diathesis stress model
what is the explanation of CBTp
Cognitive exp = Delusions result from faulty
interpretations of events. CBTp is therefore used to help
the patient identify and correct/change these faulty
interpretations.
CBTp patients are encouraged to trace back the origins
of their symptoms to understand how they developed.
Reality testing: patients are encouraged to evaluate
their own thoughts/beliefs against real-life to reduce
distress.
NICE recommend at least 16 sessions (usually 1-1 but
can be delivered in a small group).
CBTp is often used alongside drug therapy.
how does CBTp work
ABC framework: the patient gives their explanation of the
activating events (A) that appear to cause their
dysfunctional beliefs (B). The patients beliefs are then
Disputed/Challenged for more positive/rational
explanations.
Normalisation: Sz is ‘normalised’ to the patient – they
are given information that many people have unusual
experiences such as hallucinations and delusions under
different circumstances (e.g. in situations of extreme stress)
this reduces patients anxiety and the sense of isolation. If
they feel less alienated and stigmatised, relapse will be
more likely.
Critical collaborative analysis The therapist uses gentle
questioning to help the patient understand illogical
thoughts
Developing alternative explanations The patient develops
their own alternative explanations for their previously
unhealthy assumptions in cooperation with the therapist.
what is the explanation of family therapy
Family intervention usually aimed at parents, siblings
and partners of Sz sufferer to reduce relapse (due to
research into high EE)
Garety et al. (2008): relapse rate for individuals who receive
family therapy was 25% compared to 50% for those who
receive standard care alone.
Family therapy aims to reduce EE - expressions of anger
and guilt.
Provides family members with information about Sz,
finding ways of supporting an individual with Sz and
resolving practical problems.
Family therapy improves relationships because the therapist
encourages family members (including the person with
schizophrenia) to listen to each other and work towards
solutions.
Typically offered for 3-12months with atleast 10 sessions
– also often used in conjunction with drug therapy.
how does family therapy work
Family therapy uses a number of strategies:
Psychoeducation: educating the Sz patient and family
members on the disorder so they can deal with it better
- this reduces stress for family members and also reduces
the Sz sufferers’ suspicions of their treatment.
Reducing the emotional climate: reducing anger/over
involvement in the home and having reasonable
expectations of Sz sufferer.
Helping family members achieve a balance between
caring for the Sz patient and maintaining their own life.
what is the explanation of token economy
A form of behavioural therapy where clinicians set target
behaviours that will improve the patients engagement in
daily activities.
Tokens are rewarded whenever the patient engaged in
one of their target behaviours (e.g. plastic token
rewarded for domestic chores = movie)
Ayllon and Azrin (1968) gave Sz patients plastic tokens
for behaviours such as carrying out domestic chores.
These tokens were then exchanged for privileges such as
being able to watch a movie. This procedure was
effective in maintaining patients’ adaptive behaviours.
how does token economy work
CC: the ‘neutral’ token must be presented alongside (associated with) or
immediately before the reinforcing stimulus e.g. treat food or movie.
By pairing the neutral token with the reinforcing stimulus the token will
eventually acquire the reinforcing principles on its own.
OC:
Primary reinforcer = gives pleasure/comfort on its own (e.g. food/movie)
Secondary reinforcer = initially have no value but acquire their reinforcing
principles as they have been paired with the primary reinforcer.
what are the strengths of CBTp
NICE (2014): effectiveness of CBTp when used alongside medication (interactionist
approach) at reducing re-hospitalisation
-evidence for improvements in social functioning
-positive on economy long term less hospitalisation
what are the weaknesses of CBTp
does CBT actually ‘cure’?? – as SZ appears to be largely biological… CBT may
reduce severity of symptoms & enhance coping rather than ‘cure.
effectiveness depends on the stage of the disorder (if the patient is suffering from a
Sz episode, Hallucinations and delusions – can they engage with the treatment? Are
they able to reality test?)
- more likely to benefit after stabilisation of symptoms
-delusions- won’t trust
- avolition- no effort
-hallucinations- no concept of reality
what are the strengths of family therapy
PharoahFamily therapy improved patients mental state, led to increased compliance with medication and reduced relapse.
- leads to improvements to mental state and social functioning due to effectiveness of drugs
- less suspicious of family- med compliance
economy/cost effective (link to reduced relapse, reduction in hospitalisation costs
etc.
- extra cost of family therapy is offset by a reduction in cost of relapse
positive impact on all family members -
- 60% reported a significant positive impact on relatives
what are the weaknesses of family therapy
issues with Pharoah’s methodology could have compromised their findings (lack of
blinding – i.e. raters/researchers knew the therapy the patient received when rating
their success.
what is the strength of token economy
Dickerson: review of token economy studies reported beneficial effects (i.e.
increasing the adaptive behaviours of patients) Useful for reducing negative symptoms in psychiatric wards and hospital
settings
-13 studies, 11 showed beneficial effects
what are the weaknesses of token economy
less useful in a community setting for outpatients (without 24 hour and
monitoring the reward system isn’t appropriate).
- within a ward staff can monitor but can’t on the outside
- positive results may not be maintained out of ward
Ethical concerns – token economy requires clinicians control to reinforce
patients. (Primary reinforcer = food, privacy, activities, does this violate their
human rights?)
what is the diathesis stress model and how does it link to SZ
-considers combined effect of biological/ genetics vulnerability and the environment/ social factors
- sees SZ as a result of an interaction between biological and environmental influences
- whether or not the person develops SZ from inherited genetic vulnerability is partly determined by amount and level of stresses they experience in their life
what is meant by the term ‘diathesis’ and what is the evidence for the genetic component in terms of vulnerability to SZ
- genetic basis and vulnerability
- doesnt have to be genetic- could be early psychological that affected brain development
- eg child abuse affects HPA system making them vulnerable to stress
- polygenic and vulnerability increases the closer related you are to the individual with SZ
- identical twins with someone with SZ greater risk than a sibling with it
- however half of identical twins never get sz- shows can not be only factor
- gottersman study—–
what is meant by the term ‘ stress’ and what is the research to suggest that a stressful life could trigger SZ
- environmental, social and psychological factors
- trigger SZ
- family dysfunction- double bind, high EE, sz mother
- childhood trauma- those who experienced severe trauma before 16, 3x more likely to develop sz
- urbanisation - risk of sz in urban areas 2x higher
- cannabis incr risk of sz by up to 7x ( interferes with dopamine system)
what is the evaluation of the interactionist approach in explaining sz
EVIDENCE TO SUPPORT
- Tienari- investigated the combination of genetic vulnerability and parenting style
-found that a child rearing style of high criticism and conflict was associated with the development of sz but only for children with high genetic risk
- support for interactionist
TOO SIMPLISTIC
- oversimplifies the complexities
- taking a combined approach makes it difficult to understand how they work together
- inability to estabish causation- researchers do not know actual mechanisms involved
what does the interactionist approach to treating SZ state
- due to acknowledgements of both, both types of treatment
- combines antipsychotics with psych therapies
-standard practice in uk is to combine - evidence of the effectiveness of family therapy- halves relapse from 50- 25%
what is the evaluation for the interactionist approach to treating sz
PRACTICAL APP TO HEALTH SERVICES
- an abundance of research into effectiveness of using both
- mental health services adopt multi disciplinary approach- a range of professionals work together to treat
HOWEVER
- implications on economy- combined costs more
TREATMENT CAUSATION FALACY
- questions effectiveness of interactionist approach on treatment
- just because it works does not mean it was the original cause
-eg alcohol reduces shyness but shyness not caused by lack of alcohol
- does not provide causation explanation
