Schizophrenia

Question 1

Diagnostic criteria for schizophrenia (RELIABILITY)

Answer 1

A;
Two or more must be present for a significant portion of time within a month:
- Delusions
-Hallucinations
-Disorganised Speech
-Completely disorganised or catatonic behaviour
-Negative symptoms (avolition)

B;
For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas such as, work, interpersonal relations or self care is markedly below the level achieved prior to the onset

C;
Continuous signs of the disturbance persist for at least 6 months. This 6 month period must include at least one month of symptoms that meet criteria A and may include periods of prodromal or residual symptoms. During these prodomal or residual periods the signs of the disturbance may be manifested only by negative symptoms or by two or more symptoms in criteria A present in attenuated form

Question 2

Positive symptoms

Answer 2

• Hallucinations - distortions or exaggerations of perception in any of the senses, most notably auditory hallucinations
  Auditory (hearing voices)
  Visual (seeing things that aren’t there)
  Olfactory (smelling things that others can’t)
  Tactile (feeling things people don’t)
• Delusions - Bizzare beliefs that seem real to the person but are not real. Delusions can be paranoid (eg - being watched when your not) They may also involve inflated beliefs like that person is famous or has a lot of power
• Disorganised Speech - the result of abnormal thought processes. May slip from one topic to another even in mid sentence
• Disorganised/Catatonic Behaviour - includes the inability or motivation to initiate a task or to complete it once its started
  May result in decreased interest in personal hygiene
  Person may dress weirdly - like wearing heavy clothes on a hot day
  Catatonic behaviours are characterised by a reduced reaction to the immediate environment

Question 3

Negative symptoms

Answer 3

• Alogia (Speech Poverty) - The lessening of speech fluency and productivity which reflects slowing or blocked thoughts
  May display a number of characteristic signs
  They may produce fewer words within a time period
  May also be displayed through less complex syntax - this is associated with long illness and earlier onset of the illness
• Avolition - reduction of interests and desires as well as an inability to intiate and persist in goal directed behaviour
  Its distinct from poor social function or disinterest which results in other circumstances like:
  The person may have no social contact with friends or family
• Affective Flattening - a reduction in the range and intensity of emotional expression including facial expression, voice tone, eye contact etc.
  Individuals show less body and facial movements and smiles and less co-behaviour
• Anhedonia - a loss of interest or pleasure in all or almost all activities or a lack of reactivity to normal pleasurable stimuli
  May be pervasive or confined to a certain aspect of experience
  Physical anhedonia - the inability to experience physical pleasures
  Social anhedonia - inability to experience pleasure from interpersonal situations like interacting with other people

Question 4

Diagnostic reliability definition….

Answer 4

Diagnostic reliability means that a diagnosis of schizophrenia must be repeatable

Question 5

Research….

Answer 5

• Research suggests there is a significant difference between countries when it comes to diagnosing schizophrenia - researcher gave 134US and 194 British psychiatrists a description of a patient - 69% US diagnosed them with schizophrenia whereas 2% British diagnosed with schizophrenia
• Hearing voices also appears to be influenced by a cultural enviroment - 60 adults with schizophrenia interviewed
• 20 from Ghana, US and India
• Many of the African and Indian people reported positive experiences with their voices no one from the US did

Question 6

Reliability - AO3

Answer 6

• Lacks inter rater reliability - despite claims for increased reliability in DSM-III over 30 years later there is still little evidence that DSM is routinely used with high reliability by clinicians - example - researcher found inter rater reliability correlations in the diagnosis as low as 0.11 - suggests that because psychiatric diagnosis lacks some of the more objective measures enjoyed by other branches of medicine it inevitably faces additional challenges with inter rater reliability
• Unreliable symptoms - diagnosis of schizophrenia only one of the characteristic symptoms is required if delusions are bizarre - BUT - creates problems for reliability of diagnosis - 50 senior psychiatrists in the US were asked to differentiate between bizarre and non bizarre delusions they produced inter rater reliability correlations of only 0.40 - concluded that even this central diagnostic requirement lacks sufficient reliability for it to be a reliable method of distinguishing between schizophrenic and non schizophrenic patients
• Cultural bias - ethnic culture hypothesis predicts that ethnic minority groups experience less distress associated with mental disorders because of the protective characteristics and social structures that exist in these cultures - researchers - found evidence to support this hypothesis in a study of 184 people diagnosed or with a spectrum disorder - drawn from two non white minority groups and a majority

Question 7

Validity……

Answer 7

• Gender bias in diagnosis - said to occur when the accuracy of diagnosis is dependant on the individual
• Accuracy of diagnostic judgements can vary for a number of reasons including gender based diagnostic criteria or clinicians based on their judgements on stereotypical beliefs held about gender
• Symptoms of schizophrenia are also found in other psychiatric disorder such as depression and bipolar disorder - called a symptom overlap
• Co-morbidity - refers to the extent that two or more conditions co occur

Question 8

Validity - AO3/ww333354rc

Answer 8

• Evidence of gender bias among psychiatrists in diagnosis - randomly selected 290 male and female psychiatrists to read two case vignettes of patients behaviour and were asked to offer their judgement using standard diagnostic criteria - males = 56% were diagnosed and females = 20%
• Small sample sizes - researcher looked at 9 million hospital discharge records fining many co morbid and non psychiatric diagnoses - many patients with a primary diagnosis of schizophrenia were also diagnosed with medical problems like asthma and type 2 diabetes - concluded the very nature of a diagnosis of a psychiatric disorder is patients tend to receive a lower standard of medical care which in turn adversely affects the prognosis for patients with schizo
• Diagnosed as schizophrenic rarely share the same symptoms so there is no evidence they share same outcomes - varies with 20& recovering their previous level of functioning 10 achieving significant and lasting improvement and 30% showing improvement with relapses - diagnosis of schizophrenia has therefore little predictive validity

Question 9

Biological explanations - GENETIC FACTORS

Answer 9

Family studies;

• closer the degree of genetic relatedness the greater the risk
• researchers study - two schizophrenic parents had a concordance rate of 46% - one schizophrenic parent a rate of 13% and siblings a concordance rate of 9%

Adoption studies;

• studies of genetically related individuals who had been reared apart are used
• Finland - 164 adoptees whose biological mothers had been diagnosed with schizophrenia - 11 received a diagnosis

Twin studies;
- concordance rate for MZ twins of 40.4% and 7.4% for DZ

Question 10

Biological explanations - DOPAMINE HYPOTHESIS

Answer 10

• claims that an excess of the neurotransmitter dopamine in certain regions of the brain is associated with positive symptoms of schizophrenia
• drug that increase dopamine activity - Amphetamine - stimulates the nerves cells containing dopamine - can develop the characteristic hallucinations and delusions of a schizophrenic episode
• drug that decreases dopamine activity - different types of antipsychotic drugs - block the activity of dopamine in the brain - eliminate symptoms such as delusions and hallucinations
• hypothesis - positive symptoms of schizophrenia are caused by an excess of dopamine in subcortical areas of the brain - negative and cognitive symptoms of schizophrenia are thought to arise from a deficit of dopamine in areas of the prefrontal cortex

Question 11

Biological explanations - NEURAL CORRELATES

Answer 11

• scans show MZ twins where only one twin had schizophrenia, the schizophrenic twin had more enlarged ventricles and reduced anterior hypothalamus
• reductionist as it ignores the contributions that other factors and causation cannot be inferred
• ventricles in brain of a person with schizophrenia are on average about 15% bigger than normal

Question 12

Biological explanations - GENETICS - AO3

Answer 12

• MZ have more similar environments - assumed greater the concordance for schizophrenia between MZ twins is a product of genetic similarity rather than environmental similarity - researcher it is widely accepted that MZ twins are treated more similarly, encounter more similar environments and experience more identity confusion
• Adoptees may be selectively placed - researcher claims that adoptees are unlikely to be selectively placed, particularly in early studies - countries like Denmark and the US, potential adoptive parents would have been informed of the genetic background of the children prior to selection for adoption

Question 13

Biological explanations - DOPAMINE HYPOTHESIS - AO3

Answer 13

• Evidence from treatment - meta-analysis of 212 studies that had analysed the effectiveness of different antipsychotic drugs compared with a placebo - found that all the drugs tested were significantly more effective than placebo in the treatment of positive and negative symptoms - suggests the dopamine hypothesis can help explain schizophrenia
• Challenges towards the hypothesis - researcher claims there is strong evidence against both the original and revised dopamine hypothesis - argues that antipsychotic drugs do not alleviate hallucinations and delusions in about 1/3rd of people - suggests that rather than dopamine being the sole cause of positive symptoms other neurotransmitter systems, acting independently are also involved

Question 14

Biological explanations - NEURAL CORRELATES - AO3

Answer 14

• Research support for the influence of grey-matter deficits in schizophrenia - found that sz patients do have larger ventricles and reduced grey matter which can be the cause of sz and or the development of it - high reliability as it uses high technical and scientific equipment

Question 15

Psychological explanations - Family dysfunction

Answer 15

• presence of problems within a family that contribute to relapse rates in recovering schizophrenics, including lack of warmth between parents and child, dysfunctional communication patterns and parental over protection
• Double Bind Theory - Bateson suggests that children who frequently receive contradictory messages from their parents are more likely to develop schizophrenia
• Expressed Emotion - Another family variable associated with schizophrenia is a negative emotional climate or, more generally, a high degree of expressed emotions

Question 16

Psychological explanations - Cognitive explanations

Answer 16

• Cognitive explanations of mental disorders propose that abnormalities in cognitive function are a key component of schizophrenia
• Cognitive explanations of DELUSIONS - During the formation of delusions, the patients’ interpretations of their experience are controlled by inadequate information processing - critical characteristic of delusion thinking is the degree to which the individual perceives him or herself as the central competing in events (egocentric bias) and so jumps to conclusions about external events
• Cognitive explanations of HALLUCINATIONS - Aleman suggests that hallucination prone individuals find it difficult to distinguish between imagery and sensory based perception. For these individuals the inner representation of an idea can override the actual sensory stimulus and produce an auditory image. Hallucinating patients are more likely to miss attribute the source of a self generated auditory experience to an external source than are non hallucinating patients with schizophrenia

Question 17

Psychological explanations - Family dysfunction - AO3

Answer 17

• Importance of family relationships in the development of schizophrenia can be seen in Tienari’s adoption study - adoption study which found that adopted children who had schizophrenic parents were more likley to become ill themselves - difference only emerged in situations where adopted family were rated as distubured in other words illness only manifested itself under appropriate environmental conditions - Genetic vulnerability alone was not sufficient
• Double bind theory - some evidence to support this particular account of how family relationships may lead to schizophrenia - researcher found that schizophrenics reported a higher recall of double blind statements by their mothers than non schizophrenic - may not be reliable as patients recall may be affected by their schizophrenia

Question 18

Psychological explanations - Cognitive explanations - AO3

Answer 18

• Supporting evidence for the cognitive model of schizophrenia - 2 researchers found supporting evidence for the claim that the positive symptoms of schizophrenia have their origins in faulty cognition - delusional patients were found to show various biases in their information processing, such as jumping to conclusions and lack of reality testing - means that the cognitive explanation of schizophrenia can be used to explain some aspects of the disorder
• Support from the success of cognitive therapies - claim that the symptoms of schizophrenia have their origin of faulty cognition is reinforced by the success of CBT for schizophrenia - effectiveness of this approach was demonstrated in the NICE review that found consistent evidence - suggests that CBT is effective in reducing symptom severity and improving levels of social functioning

Question 19

Biological therapies - typical antipsychotics

Answer 19

• reduces effects of dopamine and symptoms of schizo
• by reducing the stimulation of dopamine system in the mesolimbic pathways drugs eliminate the hallucinations and delusions
• other symptoms may take several weeks before improvement becomes evident - effectiveness of dopamine antagonists led to development of dopamine hypothesis

Question 20

Biological therapies - atypical antipsychotics

Answer 20

• to increase dopamine effects and symptoms of schizo

- role of 5HT receptors - have a stronger affinity for serotonin receptors and a lower affinity for d2 receptors

Question 21

Biological therapies (drug) - AO3

Answer 21

• Importance of antipyschotics compared to placebos - researcher carried out meta analysis of studies involving patients either taken off their meds and given a placebo or remaining on their meds - within 12 months - 64% on placebo had relapsed compared to 27% of other group
• Extrapyramidal side effects - most common are parkinsonian and related symptoms as they resemble the neurological disease - more than 1/2 patients taking typical antis experience these symptoms - therefore people may take other drugs as well to reduce the stress of these side effects
• Ethical issues with typical antis - in the US a large out of court settlement was awarded to a tardive dyskinesia sufferer on the basis of the human rights act which states noone should be subjected to inhumane treatment or punishment - suggests if side effects, deaths and psychological consequences taken into account cost benefit analysis would be negative

Question 22

Cognitive behavioural therapy - AO1

Answer 22

• Basic assumption - people often have distorted beliefs which influence their feelings and behaviour in maladaptive ways
• Delusions - result from faulty interpretations of events - CBT used to help person identify and and correct the faulty interpretations
• CBT aims to help people establish links between their thoughts feelings or actions and their symptoms and general level of functioning
• By monitoring thoughts - people are able to consider alternative ways of explaining why they feel and behave as they do
• People encouraged to trace back to where faulty thoughts came from and get a better idea of how they may have developed

Question 23

CBT - AO1 - How does it work?

Answer 23

6 stages;
- Assessment - person expresses their thoughts about experiences and goals are set out for therapy

• Engagement - therapist empathises with the persons perspective and feelings
• ABC model - patient gives their explanation of activating events, beliefs can be disputed and changed
• Normalisation - placing psychotic experiences on a continium with normal experiences the person feels less alienated
• Critical collaborative analysis - therapist uses gentle questioning to help person understand illogical deductions and conclusions
• Developing alternative explanations - person develops their own alternative explanations for their previously unhealthy assumptions in cooperation with therapist

Question 24

CBT - AO3

Answer 24

• Advantages of CBT over standard care - a review in 2014 found that compared to antipsychotics CBT was more effective in reducing rehospitilization - was also effective in reducing symptom severity - evidence of improvements in social functioning
• Effectiveness is dependent on the stage of disorder - appears more effective at specific stages of disorder - 2 researchers found intial phase of schizo self reflection not very effective - after a while on meds more effective - suggests people who have more experience with their schizo benefit more
• Benefits of CBT may have been overstated - more methodologically sound meta analyses of the effectiveness of CBT as a sole treatment suggest its effectiveness may be lower than originally thought - meta analysis in 2014 showed only a small therapeutic effect on the key symptoms of schizo like hallucinations

Question 25

Family therapy - AO1

Answer 25

• Schizos in families characterised by a lot of criticism have more frequent relapses than those in families less expressive of emotions
• family therapy aims to ; reduce expressions of anger and guilt by family and maintain reasonable expectations among family members for patient performance
• during therapy patient explains to family what support is helpful and what isn’t
• family interventions aim to reduce familys level of expressed emotion
• therapy also provides family with information about schizo

Question 26

Family therapy - AO1 - how does it work

Answer 26

• Psychoeducation - helping person and carers understand and be better able to deal with it
• Forming an alliance - who care for the person
• Reducing the emotional climate - within the family and burden of care for family members
• Enhancing relatives ability - to anticipate and solve problems
• Reducing expressed emotions - by family members
• Maintaining reasonable expectations - among family members for patient performance

Question 27

Family therapy - Key study

Answer 27

• review of 53 studies to look into effectiveness of family therapy
• studies compared outcomes from family therapy to standard care alone
• researchers concentrated on studies that were randomised controlled trials
• Mental state - some studies reported an improvement in the overall mental state of patients compared to those receiving standard care whereas others did not
• Compliance with medication - use of family intervention increased patients compliance with meds
• Social functioning - family therapy did not appear to have much of an effect on concrete outcomes like living independently
• Reduction in relapse and readmission - there was a reduction in the risk of relapse and a reduction in hospital admission 24 months after

Question 28

Family therapy - AO3

Answer 28

• Economic benefits - associated with treatment - extra cost of family therapy is offset by a reduction in costs of hospitilization because of lower relapses - means that the cost savings are even higher
• Positive impact on family members - researcher analysed results of 50 studies that was an intervention to help parents - 60% reported a positive impact
• Improvements found in the study above may not have been a direct result of therapy - suggestions that the effectiveness has more to do with the fact it increases meds compliance - suggests main benefit is people are more compliant with meds

Question 29

Token economy and management of schizo - AO1

Answer 29

• Form of behavioural therapy where clinicians set target behaviours that will improve patients engagement in everyday life
• 2 researchers - gave schizo patients plastic tokens for behaviours like domestic chores and tokens exchanged for privelages
• To give tokens value its repeatedly presented alongside or immediately before the reinforcing stimulus
• Effectiveness may decrease if more time passes between presentation of token and exchange for backup reinforcers

Question 30

Token economy and management of schizo - how does it work

Answer 30

• operant conditioning

stage 1 - token paired with rewarding stimulus - secondary reinforces

stage 2 - patient engages in target behaviours

stage 3 - patient given tokens for engaging in these behaviours

stage 4 - patient trades tokens for a privelage

Question 31

Token economy and management of schizo - AO3

Answer 31

• Research support in psychiatric setting - researcher reviewed 13 studies of the use of token economy in treatment of schizo - 11 reported beneficial effects that were directly due to the use of token economies
• Less useful for people living in the community - only shown in a hospital - typically all patients are on the programme than having a control group and experimental group - therefore behaviours can only be compared to old behaviours - comparison may be misleading as other factors may be causing improvement
• Ethical concerns within psychiatric settings - staff may withhold primary reinforcers like food etc - patients gain access to these rewards by exchanging the tokens - however people have human rights and these can’t be violated even if it has a positive consequence by being manipulated into a token economy

Question 32

An interactionist approach - AO1

Answer 32

• Diathesis stress model - sees schizo as the interaction between genetic and environmental influences
• Diathesis - schizo has a genetic component in terms of vulnerability - eg - MZ twin of someone who has it is more likely to develop it than a fraternal twin or sibling
• Stress - stressful life events can trigger schizo - children who experience severe trauma before 16 3x likely to develop it

Question 33

An interactionist approach - Key study

Answer 33

• records for 20,000 women admitted to finnish hospitals were checked for those with schizo
• those who had one or more children adopted were chosen
• sample of 145 adopted kids were matched with 158 adoptees without the risk - both groups assessed 12 years later then 21 years later - assessors blind to whether mother had schizo or not
• of 303 adoptees 14 had developed schizo - 11 had a biological mother with schizo - high generic kids reared in healthy families were significantly less likely to have developed schizo

Question 34

An interactionist approach - AO3

Answer 34

• Difficulties in determing causal stress - possible that earlier in life can also influence how people respond to later stressful life events - maladaptive methods of coping with stress in childhood means the person fails to develop effective coping skills - compromises resilience and increases susceptibility
• Diathesis may not be entirely genetic - emphasises vulnerability due to genetic factors - this increased risk may also be due to brain injury caused at birth - researcher estimated the risk of developing schizo after complications is 4x more likely than those with no complications
• Implications for treatment - if the onset of schizo is a result of the additive effect of genetic vulnerability and environmental stress this has implications - researcher found women infected during pregnancy were more likley to have a child who developed schizo but only if they both carried a gene defect - suggests antiviral medicine during pregnancy prevents onset of schizo