schizophrenia Flashcards
what is schizophrenia
a type of psychosis characterised by profound disruption of cognitive and emotion. This affects a person’s language, thought perception, emotion and sense of self and affects around 4 in 1000 at some point of their live (Saha)
define positive symptoms
appear to reflect an excess or distortion of normal functioning
hallucinations
POSITIVE SYMPTOM
bizarre unreal perception of environment
-auditory = hearing voices other people can’t hear such as (several) voices telling them to do something eg harm themselve or commenting on their behaviour
-visual = seeing lights objects or faces others can’t see
-olfactory = smelling things other people can’t smell
-tactile = eg feeling bugs crawling under the skin
delusions
POSITIVE SYMPTOMS
-firmly held erroneous beliefs that are caused by distortions of reasoning or misinterpretations of perceptions or experiences
-either persecutory in nature the belief that the person is being followed or spied eg phone is tapped
-or inflated beliefs about ones power or importance (delusions of grandeur) eg believe they are famous and personal messages are being communicated through TV
disorganised speech
POSITIVE
-result of abnormal thought processes where an individual has problems organising thoughts in their speech
-may slip from topic to topic (derailment)
-in extreme cases talk complete gibberish known as ‘word salad’
grossly disorganised or catatonic behaviour
POSITIVE
-inability or motivation to initiate a task
-leads to difficulty in daily living and decreased interest in hygiene one might wear heavy clothes in summer
=catatonic behaviour reduced reaction to immediate environment rigid posture or aimless motor activity
define negative symptoms
-appear to reflect a diminution or loss of normal functioning 1 in 3 schizophrenic patients suffer from significant negative symptoms
speech poverty (alogia)
NEGATIVE
-characterised by Lessing of speech fluency and productivity which reflects slowing or blocked thoughts
-eg produces fewer words in a given minute
-less complex syntax fewer clauses, shorter utterances etc
avolition
NEGATIVE
-the reduction, difficulty or inability to initiate and persist in goal-directed behaviour often mistaken for disinterest
-eg sitting in the house for hours everyday doing nothing
-may not have no social contact with family or friends
affective flattening
NEGATIVE
a reduction in the range and intensity of emotional expression eg facial expression, voice tine and body language and less co-verbal movement eg hand movements
anhedonia
NEGATIVE
loss of interest or pleasure in almost all activities lack of reactivity to normally pleasurable stimuli. Physical anhedonia inability to experience physical pleasures such as food. social anhedonia is inability th experience pleasure from interpersonal relationships
reliability of schizophrenia
means the consistency we expect any measurement to produce same data on successive occasions must be repeatable
cultural differences in diagnosis key study
-copeland
-134 US and 194 UK psychiatrists description of patient
-US 69% diagnosis vs 2% uk on same diagnosis
-
-luhrmann et al
-interviewed 60 disgnisied with sz
-20 each in ghana indian and the US
-african and indian patients hearing voices were playful and offered advice VS US violent and hateful
-harsh violent voices may not be an inevitable feature of schizophrenia
validity
refers to whether an observed effect in a genuine one. the extent to which s diagnosis represents something that is real and distinct from other disorders in a classification system
gender bias in schizophrenia
the tendency to describe to describe the behaviour of men and women in research that may not represent accuracy of characteristic in either gender this may be due to stereotypical beliefs about gender
broverman et al
critic of the DSM found that biased towards healthy ‘adult’ behaviour was equated to mentally healthy ‘male behaviour’
symptom overlap
relates to whether a disorder can be clearly distinguished from other disorders symptoms shouldn’t overlap with that of another disorder systems of schizophrenia are found in other disorders for example bipolar and sz both has aggression and mood swings
comorbidity
the extent to which two or more conditions co-occur if a person has multiple disorders it may make accurate diagnosis more difficult to determine which symptoms reflect which disorder also know as dual diagnosis eg weather a symptom may be anxiety which could either be from sz hearing voices or substance misuse increase in heart rate etc
why do researchers believe there is a biological component to sz
-higher incidence of sz genetic in relatives
-people misuse amphetamines (increase dopamine) experience similar symptoms to sz eg hallucinations
-people treated for Parkinson’s with l-dopa (increase dopamine) can experience symptom similar to sz
-people treated with antipsychotics (block dopamine transmission ) = reduction in sz symptoms
evaluate reliability and validity of diagnosis
+ Whaley found inter-rater scores in diagnosis of sz as low as 0.11 (11%) he also found 50 US senior psychiatrists when asked to differentiate between ‘bizarre’ vs -non-bizarre’ delusions showed correlation of 0.4 TMB below 70% kappa score only 11% and 40 % agreed lack of consistency in diagnosis
+loring and Powell gender bias influences diagnosis of sz if described as male 56% diagnosis vs female 20% female psychiatrists showed less gender Bias TMB entrenched stereotypes play a role in misdiagnosis
- cultural variation in interpreting symptoms of sz and its prognosis eg gelfand = hallucinations real by spirts + jablensky not rejected by society increased recovery rates
Joseph et al
pooled data for all schizophrenia twin studies prior to 2001 shows 40.4% concordance for MZ twins and 7.4% for DZ twins
tienari et al
-164 adoptees whose biological mother had been diagnosed with sz 11 (6.7%) received a diagnosis
-197 control adoptees (non sz parents ) 4 (2%) received diagnosis
gottesman
-children with 2 schizophrenic parents 46% concordance
-children if one schizophrenic parent = 13 %
-sibling 9%
dopamine hypothesis
excess of the nuerotransmittor dopamine in certain regions of the brain can be asscociate with positive symptoms the abnormal levels of the D2 receptor resulting in more nuerons firing and binding leading to hallucinations and delusions
drugs that increase dopaminergic activity
-amphetamine is a dopamine agonist stimulates releases large dose of dopamine. people who suffer from Parkinson’s disease (low dopamine nuerodegenerative disease take Ldopa (to increase dopamine ) develop schizophrenic type symptoms
drugs that decrease dopaminergic activity
block activity of dopamine in the brain known as a dopamine antagonist alleviated symptoms of sz such as delusions and hallucinations strengthening case for importance of dopamine
revised dopamine hypothesis
davis and kahn postive symptoms of sz caused by excess dopamine in subcortical areas of brain particularly the mesolimbic pathway
-negative symptoms from a deficit of dopamine in areas of pre-frontal cortex (mesocortical pathway)
evaluate biology explanations of sz
+patel used PET scans found lower levels of dopamine in the dorsolateral prefrontal cortex of sz patients compared to control TMB importance dopamine
+leucht meta analysis of 212 studies effectiveness of different antipsychotic compared to placebo drugs better at alleviating symptoms of sz TMB achieved normalisation of dopamine
-Noll challenges dopamine hypothesis arguing that antipsychotics only alleviate 1/3 of hallucination and delusions + people experience these symptoms with normal levels of dopamine TMB sz caused by array of genes blocking d2 receptors doesn’t stop other nuerotransmitters
cognitive explanations of delusions
-formed through inadequate information processing
-thought to have an egocentric bias
-which is the extent to which can individual seems themselves to be the central component to events therefore may interpret irrelevant events eg news from radio as being related to them eg communicating specifically to them
cognitive explanations of hallucinations
due to autonomic agnosia known as ‘the inability to identify self-generated mental events’ therefore finding it difficult to maintain distinction internal and external sources so not able to recognise a thought that has come from their own mind instead misattributes it to external sources
evaluate cognitive explanations
+ supporting evidence sarin and Wallin delusional patients showed various biases for information processing as they had impaired self monitoring and had dysfunctional thought systems have low expectations for pleasure and success
+support in terms of cognitive therapies NICE review cognitive behaviour therapy more effective than antipsychotics as it allows for evaluation of validity of faulty beliefs TMB aspects must correct as improvement of quality of life
-interactionist model fails to consider a holistic approach doesn’t equate for biological factors dopamine activity results in trigger to stresses
expressed emotion WHAT IS IT
the extent to which family environment creates a negative emotional climate
-in terms of negative communication - criticism, hostility and emotional over-involvement or over concern
-often talk more and listen less
-high levels of EE likely to increase RELAPSE RATE (not a cause)
expressed emotion what impact can it have on people with sz
-lower tolerance for intense environmental stimuli particularly emotional comments and interactions with family
-leads to stress beyond a patients already impaird coping mechanisms which could trigger an episode of sz
double blind
-Gregory Bateson
-children receive conflicting messages from parents more likely to develop sz eg mother I love you but turns head away in disgust
-child receives 2 conflicting messages verbal= affectionate non-verbal = critical
-incapacitated by conflicting messages fails to develop a coherent sense of reality and self
evaluate family dysfunction
+support for family relationships eg tienari studied people different levels of genetic vunerality to sz and measured there chances of developing sz via an OPAS scale (conflict, lack of empathy and insecurity) adoptees with genetic vunerality and high OPAS most likely TMB environmental conditions
+support berger found sz patients reported higher recall of double blind statements be their mother than no -schizophrenixc results may be effected by their condition liem found no difference in communication style with sz child
- individual differences in vulnerability to EE lebell suggests how patients appraise me behaviour of their relatives is important where high levels of EE behaviours are not perceived as being very stressful and don’t replace TMB not all equally vulnerable to high EE
Typical antipsychotics
reduce the effects of dopamine. They are used primarily to treat the positive symptoms of Sz (e.g. chlorpromazine (Largactil)). These drugs contain phenothiazine, which has been found to act on dopamine receptors and is therefore a dopamine antagonist. They bind to dopamine receptor sites (particularly D2 receptors in the mesolimbic dopamine pathway) , but do not stimulate them and consequently block their action.
results of typical antipsychotics
Hallucinations and delusions usually diminish within a few days of beginning medication, whereas other symptoms may take several weeks to show improvement. Kapur et al (2000) estimate that between 60%-70% of D2 receptors in the mesolimbic dopamine pathway must be blocked for these drugs to work. However, the D2 receptors in other areas of the brain are also blocked, leading to side effects.
atypical antipsychotics
Atypical antipsychotics are the second-generation antipsychotics and differ from typical antipsychotics in three main ways: they carry a lower risk of extrapyramidal side effects; they also target negative symptoms and they are suitable for treatment resistant patients.
In contrast to typical antpsychotics, atypicals only temporarily occupy D2 receptors, then rapidly dissociate to allow normal dopamine transmission. Therefore, they reduce dopamine absorption, but do not completely block it.
One example of an atypical antipsychotic drug is clozapine
evaluate drug therapy
+antipsychotics versus placebo leucht carried out meta analysis of 65 studies involving schizophrenic 6000 patients all been stabilised by being given either atypical or typical antipsychotics some given placebo after 64% chance of relapse compared to 27% continuation
-extrapyramidal side effects can produce movement problems most common being Parkinson’s disease more than half taking typical experience symptoms in atypical tar dive dyskinesia involuntary movement of tongue jaw mouth
-ethical problem with typical antipsychotics critics argue if a cost -benefit analysis considered side effects and psychological consequences large court case won from tardive dyskinesia on the basis of human rights act 1988 which states no human shall be subject to degrading treatment
overview of CBTq
NICE (national institute for health and care excellence) recommend that all people of sz should be offered over at least 16 sessions Basic assumption is distorted beliefs delusions from faulty interpretations eg people are trying to kill me
assessment
-trace back to the origins of the symptoms such as people want to kill me to understand how they developed eg life events being abused/bullied during this stage the therapist focusses on engagement trusting non-judgmental relationship
ABC model
used to assess the activating events which trigger symptoms such as delusional beliefs eg being around strangers and to understand how the person feels and behaves in response to consequences eg refusing to go out
normalisation
-informatiom that many people have unusual experiences such as delusions and hallucinations under stress often alleviates anxiety and correct misinterpretation
critical collaborative analysis
-the therapist will sensitively aim to help the individual evaluate the content of delusions-voices by testing the validity of faulty beliefs eg if your voice is real why can’t other people hear it
developing alternative explanations
-the aim is to develop more realistic alternative beliefs eg I feel wary of other people but there isn’t evidence that they want to hurt me the healthier explanation weakens dysfunctional thinking patterns
evaluation for CBTq
+advantages of CBTq over standard care NICE found consistent evidence when compared to antipsychotic medication alone CBTq was much more effective in reducing rehospitalisation rates up to 18 months additionally in severity
-lack of availability of CBTq it is estimated that only 1 in 10 get access to therapy this figure in even lower in north west of England which found that 187 randomly selected patients only 13 (6.9%) offered CBTq as a treatment Haddock et al
-problem with meta-analysis unreliable conclusions as some studies fail to randomly allocate the associated methodological issues translate into biased finding of the effectiveness of CBTq
overview of family therapy
NICE recommends family therapy should be offered to all people diagnosed with sz who are in contact or live with their family especially if they are at high risk of relapse
-over period of 3-12 months at least 10 sessions to reduced expressed emotion
education
about the nature of the disorder and provide information to the family about the symptoms possible cause etc
encagement
important to build an alliance with the family to develop trust between them and the therapist
reduce
aim to reduce the expressions of anger, guilt and frustration by working on communication in a more constructive polite and calm manner
enhance problem-solving skills
-learn to anticipate problems and crises and ideas for managing them
-eg ways to calm the person recognising triggers
maintain reasonable expectations
-on the part of the family towards the patient
-eg understanding that the person is not deliberately acting this way
evaluate family therapy
+ supporting study eg pharaoh et al reviewed 53 studies between 2002-2010 conduced in: europe, Asia and North America compared outcome of family therapy vs standard care (antipsychotics alone)
-increased compliance to medication
-readuction in relapse and readmission 24 months after
-improvement in social function eg living independly and employment
-methodological limitations problem with random allocation wu found that Chinese studies involved in pharaoh weren’t randomly allocated + lack of blinding 10 no blinding 16 didn’t mentioned increases observer bias
+economic benefits NICE review suggests significant cost saving offset by reduction cost of rehospitialisation and lower relapse rate
what is token economy
-form of behaviour therapy
-set target behaviours are used to improve patients engagement with daily activities
-eg getting dressed brushing hair
-based on operant conditioning
-positive reinforcement
-tokens are secondary reinforcers as they show no value on their own
-being paired with primary reinforcer eg food, comfort removes unpleasant states eg boredom
how token economy works
-tokens need to assigned value presented alongside/immediately before the reinforcing stimulus eg watching a film by pairing the neutral token repeatedly with reinforcing stimulus eventually becomes reincofring itself
when patient performs target behaviour clinician awards token which can be exchanged for various rewards must be done immediately after target behaviour to be effective (generalised reinforcer) token exchanged for interim rewards eg sweets provide opportunities for frequent reinforcement to build on target behaviours
evaluate token economy
+Dickerson et al provided support for the effevtiveness of TE in a psychiatric setting. They reviewed 13 studies of the use of TE in the treatment of schizophrenia. 11/13 studies reported beneficial effects that were directly attributable to the use of token economies. Concluded that these studies provide evidence of the token economies effectiveness in increasing adaptive behaviours of patients with schizophrenia.
-Studies tend to be uncontrolled.
When a TE systems introduced into a psychiatric ward, typically all patients are brought into the programme rather than having an experimental group which goes through the TE programme and a control group that doesn’t. This means that patients improvements can only be compared to their past behaviours rather than the behaviour of a control group. This comparison may be misleading as other factors (such as an increase in staff attention) may be causing the patients improvements rather than the token economy.
-In order to make reinforcement effective, clinicians need to exercise control over important primary reinforces such as food or access to activities to alleviate boredom. However, it is generally accepted that all humans have certain basic rights (to food, privacy etc. ) that can’t be violated regardless of positive consequences that might be achieved by manipulating them in a token economy system.
In addition privileges become more available to patients with mild symptoms for those with severe that prevents them complying with desirable behaviours. This means that the most severely ill suffer discrimination.
Some families have challenged the legality of such a system which had led to a reduction in their use in the psychiatric system.
diathesis stress model
the interactionist approach proposes that schizophrenia is a result of a combination of biological,psychological and environmental factors
varying levels of biological vulnerability (diathesis) can be triggered by significant stressors in a persons ;life combined with biological vulnerability
diathesis
means vulnerability identical twins are more likely to both develop sz that non-identical twins Joseph 40.4% vs 7.4%
adoptees with a biological mother diagnosed with sz are more likely to develop the condition than without family history tierani 6.7% vs 2%
however the fact these studies never show 100% concordance implies environmental factors also play a part
stress 2 key studied hint V
means a stressful life event variety of forms eg early trauma or stressors associated in living in a highly urbanised environment varese et al children who experienced severe trauma before the age of 16 were 3 times as likely to develop sz later in life compared to general population Vassos sound sz in the most urban environments was estimated to be 2.37 times higher than rural environments
evaluated diathesis stress model to sz
