Schizophrenia Flashcards
Schizophrenia
Psychosis in the form of profound disruption to ones cognition and emotion, affecting language, thought, perception, emotions and sense of self.
Positive Symptoms
An excess or distortion of normal functions. This includes hallucinations, delusions, disorganised speech, and disorganised of catatonic behaviour.
Disorganised speech
Thoughts interrupt speech/ derail topics. Echolalia- rhyming words, Neologism- making up words.
Catatonic behaviour
Inability to motivate or initiate a task, rigid postures or aimless motor activity.
Negative Symptoms
Symptoms that reflect a reduction/ loss of normal function. This includes alogia, avolition, anhedonia and affective flattening.
Alogia
Lessening of speech fluency and productivity.
Avolition
Reduction of interest and desires.
Affective Flattening
Reduction in the range and intensity of emotions.
Anhedonia
Loss of interest in pleasurable activities.
Milev et al 2005- defecit syndrome/ symptoms
Deficit syndrome = more than 2 negative symptoms for 12 months or longer. Those with deficit syndrome have more pronounced cognitive deficits and poorer outcomes.
Makinen et al 2008- negative symptoms ratio
1 in 3 schizophrenics suffer with negative symptoms.
Schizophrenia Diagnosis Kappa Score
According to Regier et al 2013 the diagnosis had a kappa score of 0.46.
Reliability Cultural Differences
- Significant variations between countries when it comes to a SZ diagnosis.
- Copeland 1971- 134 US and 194 British psychiatrists a description of patients: 69% of the US ones diagnosed SZ, whereas only 2% of the British did.
- Luhrman et al 2015- interviewed 60 adults, 20 from each of Ghana, India and the US,. Those from Africa and India had positive experiences with their voices, where the American ones were violent and hateful- no consistent characteristics.
Reliability- inter-rater
Whaley 2001- inter-rater reliability correlations in the diagnosis of SZ as low as 0.11 (kappa score).
Reliability- unreliable symptoms
Mojtabi and Nicholson 1995- 50 senior psychiatrists differentiated between bizarre and non bizarre delusions, producing an inter-rater reliability of 0.4- subjective.
Rosenhan et al 1972
Sent pseudo-patients to 12 different hospitals. They phoned the hospital for an appointment, stating that they had voices in their head that were ‘empty’, ‘hollow’ and ‘thud’. After they were admitted, they stopped stimulating symptoms and told staff that they were better. They remained in the hospital between 7 and 52 days (average of 19).
Validity- gender bias
- Some diagnostic categories in the DSM may be more biased toward pathologising one gender due to research being more focused on one.
- Broverman et al 1970- clinicians in the US equated a mentally healthy adult behaviour with a male.
- Longenecker et al 2010- men have been diangosed with schizophrenia more often than women since the 1980s.
- Cotton et al 2009- female schizophrenics tend to function better than males.
- Loring and Powell 1988- 290 male and female psychiatrists read patients behaviour: when described as male or unspecified, 56% gave diagnosis, when described as female, 20% gave diagnosis.
Validity- symptom overlap
- Many symptoms of schizophrenia are also prevalent in depression and bipolar disorder.
- Ellason and Ross 1995- pointed out that people with dissociative identity disorder have more schizophrenic symptoms than most diagnosed schizophrenics.
- Read 2004- most schizophrenics could also have at least one other diagnosis.
Validity- co-morbidity
- Multiple disorders can occur at once in schizophrenics.
- Buckley et al 2009- estimate that co-morbid depression occurs in 50% of patients and substance abuse in 47%.
- Swets et al 2014- meta analysis showed that at least 12% of schizophrenics had OCD, 25% displayed symptoms.
- Calls into question whether it is a single condition.
- Weber et al 2009- analysed 6 million hospital discharge records and found thjat 45% had evidence of other disoders, but also found evidence of other non-psychiatric disorders like asthma or diabetes.
Validity- prognosis
The prognosis varies with 20% recovering to their previous functioning, 30% showing improvement with some relapses and 10% achieving long lasting progress/ improvement. Diagnosis has little predictive value.
Genetic Explanation
Schizophrenia tends to run in families, but only among individuals who are genetically related. It is thought that it is a combination of genes that make a person more vulnerable to developing schizophrenia.
Family Studies (Gottesman and Shields 1991)
Children with two schizophrenic parents had a concordance rate of 46%, with one parent had a rate of 13% and with a sibling 9%.
Twin Studies (Joseph 2004)
Calculated from a poll of all twin studies that MZ twins had a concordance rate of 40.4%, while DZ twins had a rate of 7.4%. More recent blind studies (researchers don’t know if they are MZ or DZ twins, concordance rates have been lower for MZ twins.
Adoption Studies (Tienari et al 2000)
164 adoptees (biological mother had schizophrenia) 11 (6.7%) received a diagnosis compared to 4 (2%) of 197 control adoptees.
The Dopamine Hypothesis
An excess of dopamine is associated with positive symptoms of schizophrenia. Schizophrenics are thought to have excess D2 receptors, resulting in messages from neurones associated with dopamine to fire too easily or too often. The revised hypothesis by Davis and Kahn in 1991 suggests that excess dopamine in the mesolimbic pathway causes positive symptoms, while a deficit in the mesocortical pathway causes negative symptoms.
Drugs that increase dopaminergic activity
Amphetamines trigger dopamine-like symptoms in non-schizophrenics. These cause nerve cells to flood the synapse with dopamine, revealing that excess dopamine can cause positve symptoms.
Antipsychotics
They block the activity of dopamine in the brain eliminating symptoms.
Neural Imaging (Patel et al 2010)
Used PET scans to assess dopamine levels in schizophrenic and normal individuals and found lower levels in the dorsolateral prefrontal cortex of schizophrenics.
Animal Studies (Wang and Deutch 2008)
Induced dopamine depletion in the prefrontal cortex of rats, resulting in cognitive impairment that could be reversed with atypical antipsychotics.
Genetic Evaluation
+ Strong evidence to support it- Gottesman, Tienari, Joseph
- Common rearing patterns may explain family similarities
- MZ twins encounter similar environments/ treatment
- Adoptees may be selectively placed.
- Adoptees may be treated differently/ smothered by parents.
Dopamine Hypothesis Evaluation
+ Strong evidence from treatment- Leucht et al (2013) carried out a meta-analysis of 212 studies finding that the drugs were more effective than placebos.
- Inconclusive supporting evidence- Moncrieff (2009) claims that evidence is far from conclusive- drugs affect multiple neurotransmitters and dopamine has not been found in post mortem examinations. Smoking or stress also increases the release of dopamine.
- Challenges to the dopamine hypothesis- Noll (2009) claims there is evidence against both hypothesise as drugs do not alleviate symptoms in 1/3 of patients. Some people also experience symptoms but have normal levels of dopamine.
Family Dysfunction - Double Bind Theory - Bateson et al 1956
Children who receive contradictory messages from parents are likely to develop schizophrenia. They find themselves trapped in situations where they fear doing the wrong thing but don’t know what they are doing wrong. They are punished with a withdrawal of love. Bateson said that this was a risk factor.
Family Dysfunction - Expressed Emotion
Primary an explanation for relapse. Source of stress can trigger the onset of schizophrenia in those who are already vulnerable. A patient is treated in a hostile manner or talked about by family members. Or, family members may be over involved with the patients behaviour and listen to them less.
Linszen et al 1997- EE
A patient returning to a family with high EE is four times more likely to relapse.
Cognitive Explanations of Delusion
A critical characteristic is the degree to which the individual perceives him or herself as the central component in events (egocentric bias) and so jumps to conclusions.
Beck and Rector 2005- cognitive delusions
Patients are unwilling or unable to consider they might be wrong.
Cognitive Explanations of Hallucinations - Frith et al 1992
- Metarepresentation is the ability to reflect on thoughts and behaviour. This allows us insight into our own intentions and goals. Dysfunction would disrupt our ability to recognise our own actions and thoughts as being carried out by ourselves.
- Central Control is the ability to suppress automatic responses while we perform deliberate actions instead. Dysfunction can be seen through disorganised speech in schizophrenics.
Aleman 2001 - Cognitive Hallucinations
Hallucination prone individuals find it difficult to distinguish between imagery and sensory based perception. Inner representation can override the actual sensory stimulus.
Baker and Morrison 1998- Cognitive Hallucinations
Hallucinators are significantly more likely to misattribute the source of self-generated auditory experience to an external source than are non-hallucinating patients.
Evaluation of Family Dysfunction
+ Support for family relationships
+ Double bind theory
- Evidence support weak
- Parent blaming
Tienari et al 1994 - adoption schizophrenia
Adopted children from schizophrenic parents and found them to be more likely to develop the illness than non-schizophrenic.
Berger 1965- double bind
Schizophrenics reported a higher recall of double mind statements by mothers than non-schizophrenics.
Liem 1974- double bind
Measured patterns of parental communications in families with a schizophrenic child and found no difference to normal families.
Read et al 2005- family dysfunction
Reviewed 46 studies of child abuse and schizophrenia and found that 69% of adult women in-patients with schizophrenia had a history of physical and/ or sexual abuse in childhood. For men the figure was 59%.
Berry et al 2008- family dysfunction
Adults with insecure attachments to their primary carer are more likely to develop schizophrenia.
Evaluation of Cognitive Explanations
+ Supporting evidence
+ CBT support
- Deals with only 1 aspect.
Sarin and Wallin 2014- cognitive explanations of schizophrenia support
Reviewed recent research evidence and found support for the claim that positive symptoms have their origins in faulty cognition. Delusional patients found to show various biases in their information processes, such as jumping to conclusions and lack of reality testing. Hallucinators were found to have impaired self-monitoring and tended to experience their toughts as voices. Those with negative symptoms displayed dysfunctional thought processes too.
NICE 2014- CBT
Consistent evidence finding that CBT highly effective when compared with drug treatments.
Howes and Murray 2014- integrated model of schizophrenia
Argue that early vulnerability factors together with exposure to significant stressors sensitises the dopamine system causing an increase, leading to paranoia and hallucinations.
Antipsychotics
Most effective in treating disturbing forms of psychotic illness like schizophrenia and depression. Helps people function in life.
Typical Antipsychotics (chorpromazine)
Used to combar positive symptoms- developed in the 1950s to reduce the effects of dopamine and reduce the symptoms. Dopamine antagonists that bind to but do not stimulate the dopamine receptors- especially those in the mesolimbic pathway- to eliminate hallucinations and delusions.
Atypical Antipsychotics (clozapine)
Three differences to typical antipsychotics- carry lower risk of extrapyramidal side effects, effect negative symptoms and are suitable for treatment resistant patients. Act on the dopamine receptors temporarily before allowing normal dopamine transmission, which is responsible for the reduction in side effects. They have more of an affinity to serotonin receptors than D2 receptors.
Side Effects of Typical Antipsychotics
Parkinsons disease, tardive dyskinesia (facial ticks/ uncontrollable sucking), low blood pressure, blurred vision, constipation
Side Effects of Atypical Antipsychotics
Agranulocytosis (blood condition that can cause death), heart disease, weight gain
Evaluation of Drug Therapy
+ More effective than placebo
- Extrapyramidal side effects
- No significant differences between them
- Causes motivational deficits due to believe there is something wrong
Leucht et al 2012- antipsychotics vs placebo
Carried out a meta-analysis of 65 studies involving nearly 6000 patients. All head been stabilised on either typical or atypical antipsychotics. Some taken off and given a placebo again. Within 12 months 64% of those given placebo had relapsed compared to 27% of those on antipsychotics.
Extrapyramidal side effects
Side effects affecting the extrapyramidal area of the brain involved in motor activity.
Crossley et al 2010- typical vs atypical
Carried out a meta analysis of 15 studies to examine the efficacy and side effects of typical vs atypical drugs. Found no significant difference in the effect on symptoms but found different side effects.
Ross and Read 2004- motivational deficits
When people are prescribed antipsychotics they think something is wrong with them, preventing them from thinking about possible stressors. Reduces motivation to search for solutions.
Read and Haslam 2004- schizophrenia surveys
Surveys found social factors like poverty and traumatic childhoods far more often cause schizophrenia that biology.
CBTp
Identify faulty dysfunctional thinking so wthat they can be corrected. Provide coping stratergies to deal with residual symptoms. 16+ sessions recommended. Patient expresses thought and realistic goals are set. Therapist empathises with the patient and feelings of distress- develop explanations for their stress.
Normalisation
Make them feel like their experience isn’t unusual or uncommon.
Critical Collaborative analysis
Gentle questioning to help the patient understand illogical deductions
CBT Evaluation
+ NICE found consistent evidence that when compared with medication CBTp was effective in reducing rehospitalisation up to 18 months.
- Most support studies conducted with drugs too.
- CBTp effective when made available at specific stages of disorder.
- Lack of availability
- Patient embarassed to talk about symptoms.
- Need to trust therapist.
- Disease comorbidity.
- May not be mentall well enough
- Negative symptoms may make consistency hard.
- Only managing symptoms.
- May have developed relationship with hallucinations.
Addington and Addington 2005- CBTp effectiveness
In the initial acute phase of schizophrenia self reflection is not appropriate. After symptom stabilisation people may benefit more.
Juni et al 2001- methodological weakness of CBTp trials
Problems associated with methodologically weak trials translated into biased findings about the effectiveness of CBTp.
Wykes et al 2008- weakness of CBTp trials
The more rigorous the study the weaker the effect of CBTp.
Jauhar et al 2014- CBT effectiveness
Meta analysis revealed only a small therapeutic effect on the key symptoms of schizophrenia. Small effects disappeared when symptoms assessed blind.
Family Therapy
Provide support for carers in an attempt to make family life less stressful and reduce rehospitalisation. Helps reduce levels of expressed emotion by increasing the capacity of relatives to solve problems. Commonly used in conjunction with drug therapies and CBT. Usually lasts between 3 and 12 months with at least 10 sessions.
Psychoeducation
Helping the person and their carers understand and better deal with the illness.
Garety et al 2008- family therapy
Relapse rate for individuals who receive family therapy is 25% compared to 50% who receive standard care.
Pharoah et al 2010- family therapy study
Reviewed 53 studies published between 2002 and 2010 to investigate the effectiveness of family intervention. Studies from Europe, Asia and North America. Compared outcomes of family therapy to standard car groups.
- Mental state- overall improvement was mixed
- Compliance with medication- increased compliance with medication
- Social functioning- didn’t have much of an effect on concrete aspects such as living independently or employment.
- Reduction in relapse- was a reduction in the risk of relapse during the treatment and 24 months after.
- 10 studies used no blinding, 16 didn’t mention it
Family Therapy Evaluation
+ Research support
- Only effective due to medication compliance.
- Methodological issues in studies- problem with random allocation, lack of blinding.
+ Economic benefits
+ Improve family members lives.
- Is expressed emotion high in a lot of families? Is it even worthwhile?
Wu et al 2006- Chinese family therapy
Many Chinese studies did not used random allocation even though stated otherwise.
Lobban et al 2013- family therapy impact
Analysed results of 50 family therapy studies. 60% reported positive impact on at least one category for relatives e.g. coping, problem solving, family functioning and relationship quality. Mentioned that methodological quality is poor.
Garety et al 2008- family therapy worth
Failed to show any better outcomes compared to those with no family therapy. Both groups had ow relapse rates compared to those without carers. Most carers displayed low expressed emotion- cultural changes. For many people family intervention may not improve outcomes further than standard treatment.
Token Economy
Based on operant conditioning. Positive reinforcers- anything that gives pleasure or removes unpleasant states. Secondary reinforcers- have no initial value but gain reinforcing properties when paired with primary reinforcers. Reinforcer needs to be given immediately after the target behaviour.
Ayllon and Azrin 1968- schizophrenia token economy
Token economy on war of female patients who had been hospitalised for many years. Given plastic tokens saying ‘one gift’ in exchange for making their bed or carrying out domestic chores. Exchanged for privileges such as being able to watch a film. Increased the number of desirable behaviours.
Sran and Borrero 2010- token economy
Compared behaviours reinforced by tokens to be exchanged for one single highly preferred edible item with tokens to be exchanged for a variety of preferred items. Found more of a response to a variety of items.
Kazdin 1977- token economy trade
Effectiveness of the token economy may decrease if time passes between presentation of the token and exchange.
Token Economy Evaluation
+ Research support
- Studies uncontrolled
- Fallen out of use
- Unethical
+ No side effects
- Is the behaviour changed deeply?
- No one monitoring behaviour in life.
- Requires commitment.
Dickerson et al 2005- token economy support
Reviewed 13 studies. 11 had beneficial effects that were directly attributable to the use of token economies. Concluded that these studies provide evidence of the token economy’s effectiveness in increasing the adaptive behaviours of patients. However, many studies they reviewed had methodological shortcomings.
Comer 2013- token economy difficulties
A major problem in assessing effectiveness is that studies tend to be uncontrolled. All patients are typically brought into the economy instead of an experimental and control group.
McMonagle and Sultana 2000- token economy
Token economy may be still an important treatment if randomised trials could be carried out.
Interactionalist Approach
Interaction between biological (diathesis) and environmental (stress) influences. People’s genetic vulnerability vary and the environment can trigger a manifestation of the disorder.
Tienari et al 2004- record reviews schizophrenia
Hospital records for 20,000 women were reviewed from between 1960 and 1979. List checked to find those mothers who had one or more offspring adopted away. Resulting sample of 145 adopted away offspring (high risk group) compared with a sample of 158 (low risk group) adoptees without the genetic risk. Independently assessed at intervals of 13 years with a follow up after 31. Assessed family functioning using the Oulu Family Rating Scale, measuring parent-offspring conflict, lack of empathy and insecurity. Interviewing psychiatrists kept blind. Of the 303 adoptees, 14 developed schizophrenia, 11 being from the high risk group.
Varese et al 2012- children trauma
Children who experienced severe trauma before the age of 16 were 3 times as likely to develop schizophrenia in later life than general population.
Vassos et al 2012- meta analysis schizophrenia urban vs rural
Risk of schizophrenia in the most urban environments estimated to be 2.37x higher than rural areas.
Interactionist Approach Evaluation
- Diathesis not just genetic- increased risk could be caused by brain damage from environment.
- Urban environments not necessarily more stressful.
- Difficulties in determining casual stress
- Tienari study limited- OPAS scale was only at one point in time.
+ Combination of treatments more affective. - Treatment-causation fallacy- combined treatments doesn’t mean that the interactionalist approach is correct. Effective drug treatments doesn’t mean schizophrenia is biological in origin.
Verdoux et al 1998- obstetric complications
Risk of developing schizophrenia for individuals who experienced obstetric complicated at birth e.g. prolong labour which can cause oxygen deprivation, is four times more likely.
Romans-Clarkson et al 1990- rural-urban
Found no rural-urban differences in mental health among women in New Zealand.
Hammen 1992- maladaptive coping
Maladaptive methods of coping with stress in childhood and throughout development means the person fails to develop effective coping skills which in turn compromises their resilience and increases vulnerability.
Turkington et al 2006- combined treatment
Not possible to use a combined treatment strategy without the interactionalist approach.
Tarrier et al 2004- schizophrenia interactionalist treatment
Studied 315 patients randomly allocated to a medication + CBT group, medication + supportive counselling pr a control group. Patients in combination group showed lower symptom levels.
