Schizophrenia left side of page

Question 1

symptoms of schizophrenia

Answer 1

Positive
what are positive symptoms
- These are those that appear to reflect an excess or distortion of normal functions
- Hallucinations
- These are unreal perceptions of the environment that are usually auditory – hearing voices – but may be visual – seeing things that other people see – olfactory – smelling things that other people cannot smell – or tactile.
- Many report hearing voices or several voices telling them to do something like harm themselves or someone or commenting on their behaviour

• delusions
• Bizarre beliefs that seem real to the person, they are often not real
• They can be paranoid in nature, this involves the belief that they are being followed or spied upon
• Or they can be inflated beliefs about the persons power and importance
• Delusions of reference when events in the environment appear to be directly related to them for example special personal messages are being communicated through the TV or radio
• disorganized speech
• This is the result of abnormal thought processes where the individual has problems organising his or her throughs and this shows up in their speech
• Can slip from one topic to the next
• Or sound like gibberish
• grossly disorganized or catatonic behavior
• Inability or motivation to initiate a task once it has finished this leads to difficulties in daily living
• Decreased interest in personal hygiene or dressing and acting in ways that can appear bizarre
• They have a reduced reaction to the immediate environment

Negative
what are the negative symptoms
- These are those that appear to reflect a reduction or loss of normal functions which often persist even during periods of low positive symptoms
- Speech poverty
- This is lessening of speech fluency and productivity, this reflects a slowing or blocking of thoughts
- They may produce fewer words in a given time on a task of verbal fluency such as name as many fruit in a minute, not the fact that they do not know them but more the idea that they cannot produce them
- Reflected in less complex syntax such as fewer clauses and shorter utterances

• Avolition
• A reduction in interests and desires as well as reducing goal directed behaviour
• Poor social function or disinterest this can be result of other circumstances for example having no social contact with family or friends
• affective flattening
• Reduction in the range and intensity of emotional expression including facial expression, voice tone, eye contact, and body language
• Compared to this control without this symptom individuals show fewer body and facial movements and smiles and less co-verbal behaviour
• Anhedonia
• Loss of interest or pleasure in almost all activities or a lack of reactivity to normal pleasurable stimuli
• Physical anhedonia is the inability to experience physical pleasures such as the pleasure from food and bodily contact and so on
• Social anhedonia is the inability to experience pleasure from interpersonal situations such as interacting with other people
  Social anhedonia overlaps with other disorders such as depression therefore physical anhedonia does not so is more of a reliable symptoms of schizophrenia

Question 2

describe reliability and validity

Answer 2

reliability

• Diagnostic reliability means that a diagnosis of schizophrenia must be repeatable, clinicians must be able to reach the same conclusion at two different points in time or same clinicians must reach the same conclusion.
• Inter-reliability is measured by a statistic called Kappa score, score of 1 is the perfect inter-rater agreement, 0 is zero agreement, 0.7 is considered good.

Cultural differences in diagnosis

• Significant variation between countries when it comes to diagnosing schizophrenia
• Copeland 1971 – gave 134 US and 194 British psychologists a description of a patient 69% of the US psychiatrists diagnosed schizophrenia but only 2% of the British psychiatrists diagnosed them as schizophrenic
• Luhrman et al 2015 interviewed 60 adults diagnosed with schizophrenia, 20 each in Ghana, India and the US each were asked about the voices they heard. While many of the African and Indian subjects reported positive experiences with the voices who often offered them help the US subjects were more likely to describe the voices as violent and hateful

describe validity

1. Gender bias in diagnosis
   - Gender bias occurs when the accuracy of diagnosis is dependent on the gender of an individual
   - Clinicians could have gender based and stereotypical beliefs held about gender
   - DSM criteria argues that some diagnostic cater goes are biased towards pathologising one gender rather than the other
   - Broverman et al – found that clinicians in the US equated mentally healthy adult behaviour with mentally healthy male behaviour therefore there is a tendency to show that women are less mentally healthy
2. symptom overlap
   - Many of symptoms are also found in other disorders such as depression and bipolar, this is referred to as symptom overlap
   - Elllason and Ross 1995 pointed out that people with dissociative identity disorder have more schizophrenic symptoms that people diagnosed with schizophrenia
   - They usually have sufficient symptoms of other disorders that they have at least one other diagnosis
3. Co-morbidity
   - Refers to the extent that two or more issues can occur
   - Buckley et al estimated that co-morbid depression occurs in 50% of patients and 47% of patients also have a lifetime diagnosis of co-morbid substance abuse
   - OCD and Schizophrenia appear together more often than chance would suggest, meta-analysis by Swets et al found that at least 12% of patients with schizophrenia also fulfilled the diagnostic criteria for OCD and about 25% displayed OCD symptoms

Question 3

Biological explanations of schizophrenia

Answer 3

• May be hereditary as tends to run in the family
• Higher chance of getting it if you have family members who have it
• No single gene is responsible for it but a mixture or different combinations of genes make individuals more vulnerable

Biological explanations for schizophrenia: Family studies

• Gottesman 1991 – found that individuals who have schizophrenia and determine whether their biological relatives are similarly affected more often than non-biological relatives
• The c loser the degree of relatives of a person with schizophrenia the greater the risk for example children with two schizophrenic parents had a concordance rate of 46% whereas those with one schizophrenic parent had a concordant rate of 13% and those with a brother or sister had a rating of 9%

Biological explanations for schizophrenia: Twin studies

• Joseph 2004 calculated that the pooled data for all schizophrenic twin studies carried out prior to 2001 showed a concordance rate for MZ twins of 40.4% and 7.4% for DZ twins
• More recent studies where it is blind and the researcher does not know if the twin is MZ or DZ has shown a lower concordance rate for MZ twins, but they still support a genetic position as they are still much higher than non-twins

Biological explanations for schizophrenia: Adoption studies

• Studies of genetically related individuals who have been reared apart are used to show how the environment can affect the illness
• Tienari et al 2000 in Finland, of the 164 adoptees whose biological mothers had been diagnosed with schizophrenia 11 of them received a diagnosis compared to just 4 of the 197 control adoptees therefore this shows the genetic link

Neuronal explanations
Biological explanations for schizophrenia: Neural correlates, the dopamine hypothesis
- The dopamine hypothesis claims that an excess of the neurotransmitter dopamine in certain regions of the brain is associated with the positive symptoms, messages fire to easily and often this leads to delusions and hallucinations
- They have abnormally higher numbers of D2 receptors on receiving neurons this results in more dopamine binding and more neurons firing

Biological explanations for schizophrenia: Drugs that increase dopaminergic activity

• Amphetamine is a dopamine agonist this means it stimulates nerve cells containing dopamine which causes the synapses to be flooded with this neurotransmitter
• Normal individuals who are exposed to large doses of dopamine relating drugs can develop hallucinations and delusions like a schizophrenic episode, this disappears when the drugs wear off
• People who suffer from Parkinson’s disease which is caused by low levels of dopamine and take the drug L-dopa in order to raise dopamine levels develop schizophrenic like symptoms

Biological explanations for schizophrenia: Drugs that decrease dopaminergic activity

• Although there are many different types of antipsychotic drugs they all have one thing in common this is the blocking of the activity of dopamine in the brain
• By reducing the neural pathways of the brain they eliminate symptoms such as hallucinations
• This increased the case for dopamine as a factor that causes schizophrenia

revised Dopamine hypothesis

• Davis and Kahn 1991 proposed that the positive symptoms of schizophrenia are caused by an excess of dopamine in subcortical areas of the brain, particularly the mesolimbic pathway
• The negative and cognitive symptoms of schizophrenia are thought to arise from a deficit of dopamine in areas of the prefrontal cortex
• Neural imaging – Patel et al – used PET scans to assess dopamine levels in schizophrenic and normal individuals, found lower levels of dopamine in the dorsolateral prefrontal cortex of schizophrenic patients compared to normal controls
• Animal studies – Wang and Deutch 2008, induced dopamine depletion in the prefrontal cortex in rats, this resulted in cognitive impairment and the researcher were able to reverse this using olanzapine as an atypical antipsychotic drug which has beneficial effects of negative symptoms in humans

Question 4

Psychological explanations

Answer 4

double bind theory

• Gregory Bateson et al suggested that children who frequently receive contradictory messages from their parents are more likely to develop schizophrenia
• For example a mother who tells her son that she loves him yet turns her head in disgust at the same time, therefore the child receives two different conflicting views on their relationship
• Child can no longer respond to the mother due to these contradictions and these prevent the development of internally coherent construction of reality and can cause schizophrenic symptoms

expressed emotion

• Negative emotional climate or a high degree of expressed emotions can cause schizophrenic symptoms
• Expressed emotion is a family communication style in which members of the family talk about that patient in a critical or hostile manner or in a way that indicates emotional over involvement or over concern for the patient
• Kuipers et al found that high EE relative talk more and listen less and they are most likely to influence relapse rates, 4 times more likely to relapse
• People with schizophrenia have a low tolerance for intense environmental stimuli and intense emotional comments and interactions with family members
• Leads to stress beyond there coping mechanisms causing an episode
• Supportive and undemanding may help reduce dependence of antipsychotic medication and reduce chance of relapse

cognitive explanations
- Levels of dysfunctional thought processing in people with schizophrenia this is shown in positive symptoms which are displayed
cognitive explanations of delusions
- During formation of delusions the patients interpretations of their experiences are controlled by inadequate information processing
- Characteristic of delusional thinking is the degree to which the individual sees him or herself as the central component in events so jumps to conclusions about external events
- Patients tendency to relate irrelevant events to themselves and arrive at false conclusions
- Muffled voices are interpreted as people criticising them and flashes of light are a signal from God
- Unwilling to recognise that they are wrong

cognitive explanations of hallucinations

• Aleman 2001 suggest that hallucination prone individuals find it difficult to distinguish between imagery and sensory based perception
• The inner representation of an idea can override the actual sensory stimulus and produce an auditory image
• They do not go through the same process of reality testing.

Question 5

Drug therapy

Answer 5

Antipsychotics

• Treat the most disturbing forms of psychotic illnesses,
• Helps person function with there life
• Tend to use a combination of medicine to treat it, they all work by reducing the dopaminergic transmission
• Typical antipsychotic – are used primarily to combat the positive symptoms of schizophrenia such as hallucinations and thought disturbances
• Atypical antipsychotic – combat positive symptoms but in addition there are claims that they have some beneficial effects on negative symptoms as well

typical antipsychotics
- Developed in 1950s
- They reduce the effects od dopamine and reduce the symptoms of schizophrenia, typical antipsychotics are dopamine antagonists in that they bind to but do not stimulate dopamine receptors and block their action
- Therefore drugs such as chlorpromazine eliminates the
hallucinations and delusions experienced by people with schizophrenia
- Hallucinations and delusions diminish within a few days of the medication
- Kapur et al 2000, estimate that between 60% and 75% of D2 receptors in the mesolimbic dopamine pathway must be blocked for these drugs to be effective, in order to do this a similar number of D2 receptors in other areas of the brain must also be blocked leading to side effects
- High cost

atypical antipsychotics

• They have three main differences to the first generation typical antipsychotics, they have a low risk of extrapyramidal side effects and have a beneficial effect on negative symptoms and cognitive impairment therefore they are suitable for treatment resistant patients
• Drugs also act on dopamine systems and block D2 receptors and rapidly dissociate to allow normal dopamine transmission
• Drugs such as clozapine have little effect on the dopamine systems that control movement and do cause the movement problems.
• Rapid dissociation is one feature of atypical antipsychotics that distinguish them from typical antipsychotics,
• Typical only block D2 receptors, however atypical have a stronger affinity for serotonin receptors and a lower affinity for D2 receptors

Question 6

cognitive behavioural therapy

Answer 6

What is cognitive behavioural therapy
- this is a combination of cognitive therapy (a way of changing maladaptive thoughts and beliefs) and behaviuoral therapy ( a way of changing behaviour in response to these thoughts and beliefs)

describe CBTp

• Basic assumption is that people often have distorted beliefs which influence feeling and behaviours
• For example someone with schizophrenia may believe that their behaviour is being controlled by someone or something else and delusions are the result from faulty interpretations of events.
• CBTp is used to help the patient identify and correct these faulty interpretations -
• Can be delivered in groups but it is usually delivered on a one to one basis
• NICE recommend at least 16 sessions when used in treatment of schizophrenia
• Aim is to establish links between their thoughts, feeling or actions and their symptoms as well as their general level of functioning by monitoring they are able to consider alternative ways of explaining why they feel and behave the way that they do reducing distress and improving functioning

How does CBTp work

• Patients are encouraged to trace back the origins of their symptoms in order to get an idea of how they developed, they also evaluate the content of their delusions or of any voices which allows them to test the validity of their faulty beliefs
• May be set behavioural assignments to improve functioning
• During CBTp the therapist lets the patient develop their own alternatives to these previous maladaptive beliefs and look for alternative explanations and coping strategies that are present in the patients mind.

Question 7

Family therapy

Answer 7

What is family therapy
- This is the name given to a range of interventions aimed at the family of someone with schizophrenia in their guidance and treatment of it

describe family therapy

• Offered between a period of 3 to 12 months and at least 10 sessions, reduces the levels of expressed emotion within the family as this could increase the chance of relapse
• Garety et al estimated the relapse rate for individuals who receive family therapy at 25% compared to 50% of those who receive standard care alone
• Provides family members with information about schizophrenia and finds ways to support the individual and resolve any practical problems
• Should involve the individual as well as the family as they are often paranoid about their treatment so when they are there it reduces the paranoia

describe pharoah et al

• Reviewed 53 studies published between 2002 and 210 to investigate the effectiveness of family intervention, they were conducted in Europe, Asia and North America
• Compared outcomes from family therapy to standard care and they concentrated on randomised studies

what were the results of pharoah et al

• Mental state – overall impression was mixed, some reported an improvement in the overall mental state whereas others did not
• Compliance with medication – use of family intervention increased patients compliance with medication
• Social functioning – although appearing to show some improvement on general functioning it did not have an impact on concrete outcomes such as living independently
• Reduction in relapse and readmission – reduction in the risk of relapse and reduction in hospital admission during treatment and in 24 months after

Question 8

Token economy

Answer 8

What is token economy
- It is a form of behavioural therapy where clinicians set target behaviours that they believe will improve the patients engagement in daily activities, may be something as simple as the patient brushing their hair or dressing themselves or helping another patient

How does token economy work

• Tokens are awarded when they engage in the activity, they can be exchanged for rewards and privileges, therefore they associate this behaviour with rewards
• Ayllon and Azrin used a token economy on a ward of female schizophrenic patients who had been hospitalised for years, they were given plastic tokens each embossed with the words one gift for there behaviour they were then exchanged for things like getting to watch a movie, this dramatically increased the number of desirable behaviours that they carried out

What are the important parts of token economy

• Assigning value to the tokens
• reinforcing target behaviours
• the trade

describe assigning value to the tokens

• The behaviour needs to be repeated and presented alongside or immediately before the reinforcing stimulus which may be a reward such as food or privileges, by pairing they require the same reinforcing properties
• Classical conditioning

describe reinforcing behaviours

• When a token it exchanged for a variety of different privileges and rewards it is referred to as generalised reinforcer, they are more powerful when they can get multiple items on the token
• Sran and Borrero 2010 – compared behaviours reinforced by tokens that could be exchanged for one single highly preferred edible item with tokens that could be exchanged for a variety, all participants had higher rates of responding in those sessions where tokens could be exchanged for a variety of items.

describe the trade

• Important is the exchange of tokens for backup rewards chose by the clinician such as being able to watch a movie
• During early stages frequent exchange periods mean that the patients can be quickly reinforced and target behaviours can then increase in frequency
• Effectiveness of the token economy may decrease if more time passes between presentation of the token and reward

Question 9

interactionist approach

Answer 9

what is the interactionist approach
this explains mental disorders as the result of an interaction between biological and environmental influences

describe the diathesis stress model
Diathesis
- Schizophrenia has a genetic component in terms of vulnerability
- Shown in identical twin studies
- Adoptive relatives do not share the increased risk of biological relatives therefore showing environmental factors are also at play
Stress
- Stress can be from childhood trauma to living in urbanised spaces
- Varese et al found that children who experience sever trauma before the age of 16 were three times likely to develop schizophrenia than in their others general lifetime
- Relationship between the level of trauma and the likelihood of developing schizophrenia
- Research shown that high level of urbanisation is linked with developing a range of psychosis
- Meta- analysis study Vassos et al found that the risk for schizophrenia is in the most urban environments is 2.37 times higher than in most rural environments
- More adverse living conditions of densely populated environments contribute but only a tiny amount develop schizophrenia
The additive nature of diathesis and stress
- Minor stressors may lead to the onset of the disorder for an individual who is highly vulnerable or major stressful event may cause it in someone who is low in vulnerability
- Both together help develop the disorder

describe tinari et al

• Hospital records were reviewed for nearly 20,000 women admitted to Finnish psychiatric hospitals between 1960 and 1979
• Those who had been diagnosed at least once with schizophrenia or psychosis
• The list was checked to find mothers who had one or more of their offspring adopted away
• Resulting sample of 145 adopted away offspring was then matched with a sample of 158 adoptees without the genetic risk
• Both groups were assessed independently after a median interval of 12 years and a follow up of 21 years
• They assessed family functioning using the OPAS, measures family using lack of empathy and insecurity

describe findings

• Of the 202 adoptees 14 had developed schizophrenia, and 11 of these were from the high risk group with mothers who had previously had schizophrenia
• Healthy adoptive families lowered the risk for even those with high risk while high OAPS rating increased the risk
• Adoptive family stress was a significant predictor of the development of schizophrenia