Schizophrenia

Question 1

Describe schizophrenia

Answer 1

Schizophrenia is a severe mental illness where contact with reality and insight are impaired, an example of psychosis.

• Main feature is a split between thinking and emotion. Schizophrenia patients lack insight into their condition, i.e. they do not realise that they are ill.

Question 2

What are the positive symptoms of schizophrenia?

Answer 2

An excess or distortion of normal functions which is in addition to normal behaviour.

• Delusions
• Hallucinations
• Catatonic or disorganised behaviour
• Disorganised speech

Question 3

Describe the symptom - Delusions (positive)

Answer 3

An unshakable belief in something that is very bizarre.
• Paranoid - eg. someone is trying to kill them.
• Delusion of grandeur - eg. believes that they have some imaginary power/authority.

Question 4

Describe the symptom - hallucinations (positive)

Answer 4

Sensory experiences of stimuli that have no basis in reality/are distorted perceptions of thing that are there.

• Auditory/Visual - usually take the form of hearing voices that are not there. These voices are normally critical and unfriendly.

Question 5

Describe the symptom - Catatonic or disorganised behaviour (positive)

Answer 5

Where an individual behaves in ways that seem inappropriate or strange to to the norms of society.

Question 6

Describe the symptom - Disorganised speech (positive)

Answer 6

When an individual speaks in ways that are incomprehensible. Reduced frequency and quality of speech (-speech poverty).

Question 7

What are the negative symptoms of schizophrenia?

Answer 7

A diminution or loss of normal functions to include:

• A lack, or ‘flattening’ of emotions - a persons voice becomes dull and a constant black appearance.
• An inability to enjoy things that they used to enjoy.
• Apathy/Avolition - lack of motivation to follow through any plans, eg. neglect household chores.
• Social withdrawal - where they find it hard/become reluctant to speak to people.

Question 8

Outline how schizophrenia is diagnosed/classified

Answer 8

Schizophrenia doesn’t have a single defining characteristic - it is a cluster of symptoms.

2 major systems for classification:
• ICD-10 (two or more negative symptoms present, recognises subtypes of schizophrenia)
• DSM-5 (one positive symptom present)

Question 9

Evaluate the diagnosis/classification of schizophrenia

Answer 9

• Lacks reliability (inter-rater) - Cheniaux et al showed inconsistency.
• Co-morbidity therefore lacks validity- Buckley et al shows a weakness.
• Symptom overlap therefore lacks validity. Eg. Schizophrenia and bipolar disorder share positive symptoms so diagnosis can be incorrect.
• Cultural bias in diagnosis, eg. In Africa hearing voices is considered normal as it is a way of communication with ancestors.

Question 10

Develop Cheniaux et al (2009)

Answer 10

Classification/diagnosis, reliability

Had two psychiatrist independently diagnose 100 patients using both DSM and ICD. Inter-rater reliability was poor, one psychiatrist diagnosed 26 patients according to DSM and a further 44 with ICD. The other diagnosed 13 with DSM and a further 24 with ICD.

Question 11

Develop Buckley et al (2009)

Answer 11

Diagnosis/classification, co-morbidity

Concluded that patients with schizophrenia also suffer from depression (50%) or substance abuse (47%). PTSD has also occurred in 29% of cases and OCD in 23%.

Question 12

What are the 2 psychological explanations for schizophrenia?

Answer 12

Family dysfunction - source of stress that can trigger the onset of schizophrenia.
• Schizophrenogenic mother, Double - bind theory and Expressed emotion

Cognitive explanations
• Metarepresentation and Central control

Question 13

Describe Schizophrenogenic mother

Answer 13

Frieda Fromm-Reichmann (1948) proposed this based on accounts from her patients about their childhoods.

• Many of her patients talked about a parent which is described as cold, rejecting and controlling, tends to create a family solution characterised by tension/secrecy.
• This leads to distrust that later develops into paranoid delusions and ultimately schizophrenia.

Question 14

Describe Double-bind theory

Answer 14

Bateson et al (1972) emphasised the communication style within a family.

• Developing child finds themselves in unknown situations (feat doing the ‘wrong’ thing) and receive mixed messages, therefore are unable to seek clarification.
Child is punished when they get it wrong, begin to understand the world as dangerous/confusing, can lead to paranoid delusions/disorganised thinking.

Question 15

Describe Expressed emotion

Answer 15

Usually negative emotion expressed toward a patient from their carer. This stress can trigger the onset of schizophrenia in vulnerable individuals.

• Verbal criticism of patient usually accompanied by violence.
• Hostility towards patient, includes anger and rejection.
• Emotional over-involvement in the life of patient.

Question 16

Describe metarepresentation

Answer 16

The cognitive ability to reflect on thoughts/behaviour which allows insight into personal intentions and to interpret the actions of others.

• Dysfunction in this would disrupt ability to recognise actions as our own instead of someone else’s.
• This explains hallucinations of voices and delusions like thought insertion.

Question 17

Describe central control

Answer 17

The cognitive ability to suppress automatic responses while we perform deliberate actions.

• Dysfunction in this results in disorganised speech and thought disorder as there is an inability to suppress automatic thoughts.

Question 18

Evaluate the psychological explanations for schizophrenia

Answer 18

• Evidence supporting family dysfunction is associated with the condition - Read et al.
• Correlation not a cause - remains unclear what causes the condition. Eg. are cognitive factors a cause or a result, questions validity.
• Evidence supporting dysfunctional info processing - Stirling et al. Can explain faulty cognition.

Question 19

Develop Read et al (2005)

Answer 19

Psychological causes of schizophrenia.

Reviewed 46 studies of child abuse and schizophrenia. Concluded that 69% of adult woman in-patients with a diagnosis had a history of physical abuse, sexual abuse, or both in childhood. For men it was 59%.

Question 20

Develop Stirling et al (2006)

Answer 20

Psychological causes of schizophrenia, Central control.

Information is processed differently in the mind of the schizophrenias sufferer. 30 patients were compared to 18 non-patient controls on a range of cognitive tasks, including the Stroop test. Patience took over twice as long to name the ink colours compared to control group.

Question 21

What are the 3 biological explanations for schizophrenia?

Answer 21

• Genetics
• Neurochemical imbalances (dopamine hypothesis)
• Brain structure (neural correlates)

Question 22

Describe genetics (as a biological explanation)

Answer 22

• Schizophrenia tends to run in families (however nurture also comes into play as family also share the same environment).
• Strong relationship between the degree of genetic similarity and shared risk of schizophrenia - Gottesman (1991).
• Candidate genes - associated with risk of inheritance. Schizophrenia is polygenic and aetiologically heterogenous (different combinations of factors can present risk).
• Ripke et al (2014) found 108 separate genetic variations associated with increased risk of schizophrenia.

Question 23

Describe the dopamine hypothesis

Answer 23

• Neurotransmitter such as dopamine appear to work differently in a schizophrenia patient.
• High levels/activity of dopamine in the sub-cortex (Hyperdopaminergia). Eg. excess dopamine receptors in the Broca’s area (responsible for speech production) associated with speech poverty.
• Low levels/activity of dopamine in the prefrontal cortex (hypodopaminergia). Prefrontal cortex is responsible for thinking/decision making, low levels can be associated with negative symptoms.

Question 24

Describe neural correlates

Answer 24

• Structures in the brain that occur in conjunction with a symptom of schizophrenia.
• Neural correlates of -ve symptoms: eg. avolition involves the ventral striatum. Abnormality of this structure may then be involved in the development of avolition. Juckel et al (2006) found lower activity levels in the ventral striatum of schizophrenia patients.
• Neural correlates of +ve symptoms. Allen et al (2007) scanned brains of patients experiencing auditory hallucinations. When compared to a control group and asked to identify if pre-recorded speech was their own, the hallucination group made more errors. Lower activation levels in superior temporal gyrus and anterior cingulate gyrus were also found in correlation.

Question 25

Evaluate the biological explanation for schizophrenia

Answer 25

• Evidence supporting genetic vulnerability - Gottesman’s (1991) study, Tienari et al (2004) and Ripke et al (2014).
• Mixed support for abnormal dopamine functioning in schizophrenia patients - Curran et al (2004), Tauscher et al (2014). Ripke et al - several genes found code for the production of other neurotransmitters, which may be other factors in development of schizophrenia.
• Evidence of several neural correlates of schizophrenia symptoms. However correlation is not a cause, this tells us relatively little.

Question 26

Develop Gottesman et al (1991)

Answer 26

Biological causes, genetics

Gottesman’s large-scale family study.
We share 100% of our genes with identical twin, 50% with sibling/parents, etc.

Question 27

Describe the biological therapy - typical antipsychotics

Answer 27

• Have been around since 1950s, eg. CHLORPROMAZINE - can be taken as tablets, syrup or injection.
• Works by acting as an antagonist in the dopamine system. Blocks dopamine receptors which normalises neurotransmission, reducing symptoms like hallucinations.
• Also an effective sedative, often used to calm patients (especially when first admitted/anxious).

Question 28

Describe the biological therapy - Atypical antipsychotics

Answer 28

• Used since the 1970s, eg. CLOZAPINE and RISPERIDONE. Both suppress the symptoms of psychosis and minimise side effects.
• CLOZAPINE: works in the same way chlorpromazine does, but also acts on serotonin and glutamate receptors. Mood-enhancer as it reduces depression/anxiety which improves cognitive function.
• RISPERIDONE: binds to dopamine and serotonin receptors, but at much smaller doses therefore fewer side effects.

Question 29

Evaluate biological therapy

Answer 29

• Research support for the effectiveness of antipsychotics - Thornley et al (2003).
• Chemical cosh, antipsychotics have been used to benefit staff instead of patients - Moncrieff (2013).
• Problems with the evidence for effectiveness - Healy (2012). Shows unreliability.
• Use of antipsychotics depends on dopamine hypothesis, which is not a complete explanation. Eg. In cases of hypodopaminergia, antipsychotics will further reduce dopamine activity which contradicts its effectiveness.

Question 30

Develop Thornley et al (2003)

Answer 30

Evidence for effectiveness of biological therapies.

Thornley et al reviewed studies comparing effect of chlorpromazine to control conductive in which placebo was given. Data from 13 trials with 1121 participants showed that chlorpromazine was associated with better overall functioning and reduced symptom severity.

Question 31

Develop Moncrieff (2013)

Answer 31

Biological therapies, chemical cosh

Although short term use of antipsychotics to calm agitated patients is recommended by NICE, this practice is seen by some as a human rights abuse (Moncrieff).

Question 32

Develop Healy (2012)

Answer 32

Problems with the evidence for effectiveness of biological therapies.

Healy suggested that some successful trials have had their data published multiple times, exaggerating positive effects. Antipsychotics naturally have a calming effect, so is easy to demonstrate a positive effect on a patients. Do they really reduce the severity of psychosis?

Question 33

What are the 3 psychological therapies for schizophrenia?

Answer 33

Cognitive behaviour therapy (CBT) and family therapy are used in the treatment of schizophrenia.
Token economies are used in the management of schizophrenia.

Question 34

Describe CBT (in relation to schizophrenia)

Answer 34

• Patients can be helped to make sense of how their delusions/hallucinations impact their feelings/behaviours.
• Understanding where symptoms come from can be helpful, offering psychological explanations also can help reduce anxiety.
• Delusions can also be challenged so that a patient can understand their beliefs are not based on reality.

Question 35

Describe family therapy

Answer 35

• A psychological therapy carried out with members of a family, with the aim of improving their communication and reducing stress.
• Pharoah et al (2010) identified a range of strategies which aim to improve family function:
- forming a therapeutic alliance with all family members.
- reducing the stress of caring for a relative with schizophrenia.
- improving the ability of the family to anticipate and solve problems.
- reduction of anger and guilt in family members.
- helping family members achieve a balance between caring for the individual and maintaining their own lives.
- improving families’ beliefs about and behaviour towards schizophrenia.

Question 36

Describe token economies

Answer 36

• A form of behavioural therapy where desirable behaviours are encouraged by the use of selective reinforcement.
• Useful for schizophrenia patients who have developed patterns of maladaptive behaviour through being institutionalised for a long time. Improves quality of life.
• Tokens, eg. coloured discs are given to patients when they carry out desirable behaviour which has been targeted for reinforcement. Such as getting dressed or making a bed. Based on operant conditioning.

Question 37

Evaluate psychological therapies for schizophrenia

Answer 37

• There is some support for the benefits of psychological treatment - Jauher et al (2014).
• Psychological treatments (CBT, family therapy and token economies) improve quality of life, it is not a cure.
• Ethical issues can occur, eg. Privileges become more available to patients with mild symptoms. Discrimination inevitably occurs.

Question 38

Develop Jauher et al (2014)

Answer 38

Psychological treatments, supporting benefits.

Reviewed the results of 34 studies of CBT of schizophrenia. Concluded that CBT has a significant but fairly small effect on symptoms.

Pharoah et al found moderate evidence to show that family therapy significantly reduced hospital readmission over the course of a year.

Question 39

Briefly describe the interactionist approach to schizophrenia

Answer 39

Acknowledges that a range of factors (inc. biological, psychological and societal factors) are involved in the development of schizophrenia.

• Biological = genetic vulnerability, neurochemical/neurological abnormality.
• Psychological = stress, resulting from things such as poor quality interactions in the family.

Question 40

Explain the interactionist approach (diathesis - stress model)

Answer 40

• Meehl’s model (1962)
In the original diathesis-stress model, diathesis was entirely genetic - one ‘schizogene’. Therefore no amount of stress could lead to schizophrenia without this ‘schizogene’, only carriers who experience chronic stress through childhood, eg. Via the presence of a schizophrenogenic mother.

• The modern understanding of diathesis
Many genes appear to increase genetic vulnerability (Ripke et al). Diathesis is not just genetic, psychological trauma can become the diathesis rather than stressor. Read et al (2001) proposed a neurodevelopmental model in which early trauma alters the brain. Eg. Child abuse can cause the HPA system to become over-active, increasing vulnerability to later stress.
• The modern understanding of stress
In the original model, stress was psychological in nature but now also includes anything that increases risk of schizophrenia, eg. cannabis use. This increases risk up to seven times according to dose as it interfere with dopamine system.

Question 41

Outline treatment according to interactionist model

Answer 41

Acknowledges both biological and psychological factors in schizophrenia, therefore compatible with both biological and psychological treatments.
Eg. Combines antipsychotic medication with CBT.

Question 42

Evaluate the interactionist approach to schizophrenia

Answer 42

• Evidence to support the dual role of vulnerability and stress in development of schizophrenia - Tienari et al (2004).
• The original diathesis-stress model is oversimplified, hence why new models were created - Houston et al (2008).
• Support for the usefulness of adopting interactionist approach from studies comparing the effectiveness of combination treatment vs biological treatment alone - Tarrier et al (2004).
• Weakeness of this approach is the treatment-causation fallacy - Turkington et al. Cannot be a complete explanation.

Question 43

Develop Tienari et al (2004)

Answer 43

Supports diathesis-stress (interactionist approach).

Investigated the combination of genetic vulnerability and parenting (the trigger). Children adopted from 19,000 Finnish mothers with schizophrenia between 1960-1979 were followed up. Their adoptive parents were assessed for child-rearing style and compared to a control group of adoptees without genetic risk.
A child-rearing style characterised by high levels of criticism/conflict was implicated in the development of schizophrenia, but only for those with high genetic risk.

Question 44

Develop Houston et al (2008)

Answer 44

Oversimplification of original diathesis-stress model.

Childhood sexual trauma emerged as a vulnerability factor whilst cannabis use was a trigger. Shows that diathesis does not have to be biological and stress, psychological.

Question 45

Develop Tarrier et al (2004)

Answer 45

Usefulness of adopting an interactionist approach, combination treatment.

Some studies show an advantage to using combinations of treatments for schizophrenia. Eg. In Tarrier et al, 315 patients were randomly allocated to a medication + CBT group, medication + supportive counselling group, or a control group.
Patients in combination treatment showed lower symptom levels than those in the control group (medication only).

Question 46

Develop Turkington et al

Answer 46

Treatment-causation fallacy

The fact the combined treatments are more effective than either on their own does not necessarily mean the interactionist approach is correct. Similarly, the fact that drugs help does not mean that schizophrenia is biological in origin.