Schizophrenia: AO1 Flashcards
Positive Symptoms and Examples
- symptoms that reflect an excess or distrotion of normal functions
- hallucinations: sensory experiences of stimuli that aren’t real or distorted perceptions of things which are real, people report hearing voices
- delusions: irrational beliefs that have no basis in reality, often people believe themselves to be historical or popular figures, paranoid delusions are beliefs that the person is being persecuted, people often believe themselves to be under external control
Negative Symptoms and Examples
- symptoms that reflect a loss or decrease of normal functions
- speech poverty: reduced frequency and quality of speech, disorganised speech: sentences which change subject half way through
- avolition: loss of motivation and low activity levels, difficulties with goal directed behaviour, commonly include poor personal hygiene, problems at work or school
Family Study of Genetic Explanation
Gottesman (1991):
- meta analysis of 40 studies investigating family history of SZ
- found closer degree of genetic relatedness, greater risk
- children with 2 SZ parents have concordance rate of 46%, children of one have 16% and siblings have 8%
Twin Study of Genetic Explanation
Gottesman & Shields (1966):
- 57 pairs of twins with at least one having SZ
- assessed using hospital notes, case histories, semi structured interviews with twins and parents
- concordance rate of 54% for MZ and 18% for DZ
Key Study: Tenari (1966)
Procedure: nationwide sample of adopted children, 1 group had bio mothers with SZ, matched control group who had bio mothers without, families assessed by interviews
Findings: 29% of children with bio mothers with SZ went on to develop symptoms compared to 16%, of 7 severe cases 6/7 were children of bio parent with SZ, across both groups level of symptoms strongly correlated with level of disturbance in adoptive family
Conclusion: diathesis stress model: genetic and environmental contribution
The Dopamine Hypothesis: Hyperdopaminergia
- excess of dopamine in subcortical regions particularly mesolimbic pathway associated with positive symptoms
- dopamine function elevated by brain producing abnormally high amount of dopamine and/or too many dopamine receptors on post synaptic neuron
The Dopamine Hypothesis: Hypodopaminergia
- too little neurotransmitter in the mesocortical pathway is associated with the negative symptoms
- modern refinement
Enlarged Ventricles
- Johnstone et al (1976) used CT scans to examine brains of 17 SZ patients and compared them to age matched non SZ patient
- found enlargement of ventricles common in people with SZ and the enlargement was most severe in those with most severe symptoms
Season of Birth Effect
- the idea that people born in the late winter and spring have a higher chance of getting schizophrenia due to their mothers being in their 2nd trimester during the winter when they are more likely to get a viral infection
- this infection may damage the brain of the unborn child directly or medicine taken by the mother could damage the unborn child
The Schizophrenogenic Mother
- Fromm-Reichmann (1948)
- noticed people with SZ often referred to mothers as cold, rejecting, controlling and domineering which leads to excessive stress
- SZ mothers create a family climate of tension and secrecy, leading to distrust and can later develop into paranoid delusions and psychotic thinking
- fathers often play passive role in such families
Double Bind Theory
- Bateson et al (1972)
- SZ caused by parents giving contradictory messages and child feeling like they can never do the right thing
- child receives verbal affection and non verbal animosity
- these interactions prevent construction of an internally coherent construction of reality resulting in disorganised thinking and paranoia
Expressed Emotion and Features
- defined as family relations characterised by hostility, criticism, over involvement and over concern
- hostility: the family feels that the disorder is controllable and that the patient is choosing not to get better, problems in the family are often blamed on the patient
- emotional over involvement: family behaviour often involving over protectiveness, self sacrifice and excessive use of praise or blame, intrusive and emotional behaviour towards the patient poor communication with the patient: much talking and little listening, over bearing behaviour
- critical comments: both hostile and emotional over involvement
Meta-representation
- the cognitive ability to reflect on thoughts and behaviour
- the ability to separate your thoughts and behaviours from those of others
- allows insight into own intentions and goals and interpret actions of others
- SZ patients have impaired MR: disrupts ability to recognise own actions as carried out by themselves
Central Control
- ability to suppress automatic responses while performing deliberate actions
- ability to concentrate
- SZ patients have impaired CC
Attentional Bias
- when people with SZ pay too much attention to irrelevant stimulus
- may result in delusions
Typical Antipsychotics
- discovered to be effective in 1950s and led to development of dopamine hypothesis
- block D2 dopamine receptors
- reduces positive symptoms such as hallucinations and delusions
- 70-90% receptors blocked
Atypical Antipsychotics
- became available in 1970s
- block D2 receptors
- rapidly dissociate to allow normal dopamine transmission
- block serotonin receptors
- fewer side effects
- reduce positive and negative symptoms
CBT
- basic assumption is that people with schizophrenia often have distorted beliefs which influence feelings and behaviours in maladaptive ways such as delusions about being watched and controlled
- aims to help people establish links between thoughts, feelings or actions and symptoms and general level of functioning
- sz patients encouraged to trace back origins of positive and negative symptoms to see how they developed, set behavioural assignments to improve level of functioning
CBT Phases
1) assessment: patient expresses thoughts about experiences, realistic goals discussed eg recognising delusions internal or finding coping mechanisms such as making appointments with voices
2) engagement: therapist emphasises with ps perspective and feelings of distress and stresses explanations can be developed together
3) ABC model: patient gives explanation of activating events that appear to cause emotional and behavioural consequences, beliefs then rationalised, disputed and changed to realise delusions are false
4) normalisation: info that many people experience symptoms helps patient feel less isolated as voice hearing is normal
5) critical collaborative analysis: therapist uses gentle questioning to help patient understand illogical deductions and conclusions eg asking for evidence for hallucinations and delusions
6) developing alternative explanations: patient develops own alternative explanations such as identifying adverse life events which could help reduce symptom severity particularly delusions
Family Therapy
- aim to make family life less stressful by reducing levels of EE and stress, increase capacity of relatives to solve problems related to the disorder and reduce the rate of re-hospitalisation
- aims to establish a collaborative relationship with all family members by forming alliance with all relevant parties
- reduce the emotional climate (feelings of anger or guilt) in the family and burden of care from family members.
- family and therapist work together to find coping strategies and practical solutions to day-to-day problems.
- the person who has had the psychotic episode is regarded as the main expert.
- therapy sessions involve all family members; enhancing the ability of family to anticipate and solve problems.
- emotive topics e.g., how to cope with a psychotic episode and the relatives’ own needs are kept for later sessions.
- an emphasis on communication strategies, acknowledging that the family atmosphere has been part of the problem, and working to find better ways of communicating, e.g., speaking clearly, not nagging, etc.
- everyone is taught to recognise early warning signs of problems.
- maintaining reasonable expectations among family members for patient behaviour.
- encourage relatives to set appropriate limits while maintaining some degree of separation when needed.
Token Economies
- form of behavioural therapy where desirable behaviours are encouraged by the use of selective reinforcement, it’s based on operant conditioning and is used for management not treatment of schizophrenia
- 3 steps: identifying the undesirable or maladaptive behaviour, identifying the reinforcers that maintain such behaviour, restructuring the environment so that the undesirable behaviour is no longer reinforced
- clients set target behaviours that they believe will improve the patients’ engagement with daily activities.
- used mainly in psychiatric hospitals, with patients in long term care, goal is to enable the patients to leave hospital and function independently.
- used to combat negative symptoms, the desired behaviours may be as simple as a patient brushing their own teeth or could be more socially oriented behaviour e.g. helping another patient, used to encourage patients to comply with drug regimes.
- when desired behaviour is displayed tokens are given immediately as reinforcement, immediacy is important as it prevents delay discounting, the reduced effect of a delayed reward
- tokens (secondary reinforcers) can be exchanged for priviledges (primary reinforcers)
Interactionist Approach in terms of SZ
a broad approach to explaining SZ which acknowledges that both biological and psychological factors contribute to the disorder
Diathesis-Stress Model: Meehl’s Model
- diathesis entirely genetic, result of single ‘schizogene’
- if person doesn’t have schizogene no amount of stress would lead to SZ
- in carriers of the gene chronic stress through childhood and adolescence could result in development of SZ e.g. family dysfunction - schizophrenogenic mother
Diathesis-Stress Model: Contemporary Model
- many genes increase vulnerability - polygenic
- range of factors including psychological trauma which become diathesis
- definition of stress includes anything that risks triggerring SZ
Interactionist Treatment for SZ
- combines psychological treatments with biological treatments
- family therapy is interactionist: requires patients to continue taking medication
- token economies are also interactionist: require patients to comply with drug regimes
- requires adopting interactionist explanation as it is not possible to adopt a purely biological explanation, and tell patients their condition is biological (no psychological significance to their symptoms) and then treat them with CBTp
Inter-Rater Reliability
occurs when different clinicians make identical, independent diagnosis of the same
Test-Retest Reliability
occurs when a clinician makes the same diagnosis on separate occasions from the same information
Descriptive Validity
to be valid patients with SZ should differ in symptoms from patients with other disorders
Predictive Validity
if diagnosis leads to successful treatment than diagnosis is seen as valid
Criterion Validity
if different assessment systems arrive at the same diagnosis for the same patient then diagnosis is seen as valid
Inter-Rater Reliability Study
Cheniaux et al (2009)
- had 2 psychiatrists diagnose 100 patients using DSM and ICD
- inter-rater reliability poor
- one diagnosed 26 with DSM and 44 with ICD
- other 13 with DSM and 24 with ICD
Descriptive Validity Study
Jager et al (2003)
- found that it was possible to distinguish 951 cases of SZ from 51 persistent delusional disorders, 116 cases of acute and transient psychotic disorders and 354 schizoaffective disorderss with SZ patients having more pronounced negative symptoms and lower overall functioning
Predictive Validity Study
- in the same way people diagnosed with SZ rarely share the same symptoms there is no evidence they share the same outcomes
- prognosis for ps diagnosed with SZ varies with about 20% recovering to previous level of functioning, 10% achieving significant and lasting improvement, 30% showing some improvement with intermittent relapses
Criterion Validity Study
Cheniaux et al (2009)
- shows more likely to be diagnosed suing ICD
- either over diagnosed in ICD or under diagnosed in DSM
Gender Bias in SZ
the tendency for diagnostic criteria to be applied differently to males and females
Culture Bias in SZ
the tendency to over or under diagnose SZ in members of certain cultures
Co-Morbidity in SZ
- when one or more secondary disorders combine with the primary disorder
- people with schizophrenia often have other symptoms as well e.g. symptoms of depression, for example difficulty concentrating or anhedonia
- one view is that negative symptoms are a rational response to hallucinations and delusions
- SZ is often co-morbid with depression because those around people with SZ often don’t believe their delusions which leads them to feel lonely and have low moods
Symptom Overlap in SZ
- symptoms of schizophrenia are also symptoms of other mental disorders e.g. delusions - BPD, avolition - depression
- symptom overlap leads to problems in diagnosing for psychiatrists because a symptom such as delusions could be due to BPD or SZ
- due to the high symptom overlap between SZ and BPD it may be that they aren’t two separate entities
Culture Bias Studies
Cochrane (1977)
- in Britain, people of Afro-Caribbean origin are 7x more likely to be diagnosed with SZ than white British people
Whaley (2004)
- 2.1% of black Americans are diagnosed with SZ, compared to 1.4% of white Americans
Gender Bias Study
Longnecker et al (2010)
- reviewed studies of the prevalence of SZ, since the 1980s men have been more likely to be diagnosed with SZ than women
