Schizophrenia: treatment of Sz

Question 1

What is the aim of anti-psychotics?

Answer 1

To reduce, modulate or stabilise the balance of dopamine in 4 key dopamine pathway, and alleviate some of the symptoms of schiz

Question 2

Describe anti-psychotics as a treatment for schiz

Answer 2

Aim: To reduce, modulate or stabilise the balance of dopamine in 4 key dopamine pathway, and alleviate some of the symptoms of schiz

1. Typical
2. Atypial

Medication must be taken on a regular basis to keep symptoms under control. It takes about 7 days before the drug starts to show an effect and symptoms reduce. Initially, positive symptoms are dramatically reduced and slowly some negative symptoms subside.

Question 3

Describe an example of a typical antipsychotic

Answer 3

Name: chlorpromazine, Haloperidol

AIM: to antagonise (reduce) levels of dopamine in the brain
ACTION :
By binding to D2 receptor sites, this lowers dopamine transmission and reduces some positive symptoms
Kapur (2000) approx 60-75% of D2 receptors blocked in mesolimbic pathway

Potential problems:
As the 60-75% D2 receptor sites were (permanently) blocked, dopamine levels become too low
This can aggravates negative motor symptoms

Question 4

Describe examples of atypical antipsychotics

Answer 4

Name: CLOZAPINE, OLANZAPINE, SEROQUEL (QUETIAPINE);

AIM: to modulate levels of dopamine and serotonin in key dopamine pathways in the brain
ACTION :
to regulate functioning of dopamine and serotonin in several areas
To attach to dopamine receptors and then quickly dissociate themselves (hit and run)

Two key pathways are :
MESOLIMBIC PATHWAY
NIGROSTRIATAL PATHWAY
Too much for A level but…

Question 5

Describe action in the mesolimbic dopamine pathway - the hit and run

Answer 5

This sensory pathway is involved with emotions and sensations of pleasure. Reducing the hyperactivity of dopamine here should reduce positive symptoms like delusions

By using a hit and run action (rapid dissociation) AP have their effect on dopamine receptors and then quickly leave the receptor site. This type of action allows AP to have an effect, but then receptors quickly become available for naturally occurring dopamine before the next dose. This action helps avoid some motor side effects

Question 6

Describe action in the nigrostriatal dopamine pathway

Answer 6

This sensory pathway has a role in controlling movement, and as such involves dopamine and serotonin . The blocking /reducing of dopamine receptor sites here can lead to motor side effects.

Serotonins presence in this pathway inhibits (reduces) dopamine, so the AP’s action is to block serotonin receptors to actually increase levels of natural dopamine. Hence, natural dopamine fills receptor sites and prevents blockade from AP’s in this area. This helps tackle negative symptoms and reduces motor side effects

Question 7

What are 3 types of psychological treatments

Answer 7

1- CBT
2- family therapy
3- token economy

Question 8

What is the aim and types of CBT?

Answer 8

CBT aims to change the maladaptive thinking of schizophrenic individuals.
Two main techniques used in CBT include:
Integrated Psychological Therapy (IPT)
Coping Strategy Enhancement (CSE)

Question 9

Describe integrated psychological therapy

Strongest one! (incorporate reality tests)

Answer 9

• ## to improve attention and refine concept formation, this technique tried to identify specific cognitive deficits and remedy them in a non-confrontational way

Question 10

Describe coping strategy enhancement (Tarrier, 1987)

Answer 10

-This technique tries to teach patients with schiz better ways to manage the severity and frequency of their psychotic symptoms to reduce distress and their impact day to day functioning

Question 11

What behavioural techniques could drown out hallucinations?

Answer 11

Relaxation techniques
Listening to music
Humming or singing a song several times
Reading (forwards and backwards)

Question 12

Effectiveness of CBT

Evaluation of psychological treatments for schiz: Startup et al 2004

Answer 12

There is research support for the effectiveness of CBT in treating schizophrenia.
Startup et al. (2004) investigated the effectiveness of CBT on 90 patients who had been admitted to hospital with an schizophrenic acute episode. 43 were given standard care (i.e., antipsychotics and nursing care), whilst the other 47 were given standard care plus up to 25 90 minute sessions of CBT.
60% of CBT group showed improvement, compared to 40% of the control group. More importantly, these benefits stood the test of time and remained at 6 and 12 month follow ups, compared to just 17% of the control group.
This implies… CBT is an effective treatment option for schizophrenia and can drastically improve the quality of life of patients by reducing their symptoms.

Question 13

Evaluation of psychological treatments for schiz: Garrett 2008

Answer 13

In addition, Garrett (2008) argued that CBT is an appropriate mechanism to encourage schizophrenic patients to take their antipsychotic medication.
Garrett described successfully using CBT to change a patient’s mind about taking the antipsychotic drugs she was prescribed and therefore reducing her schizophrenic symptoms in that way.
This implies… CBT can have peripheral benefits alongside biological treatments, and is therefore appropriate for schizophrenic patients.

Question 14

Are they appropriate for spme more than others?

Evaluation of psychological treatments for schiz: Kingdon and Kischen 2006

Answer 14

Many clinicians have criticised the use of CBT with schizophrenic patients as they characteristically do not have coherent thinking and insight into their condition to actually gain therapeutic benefit.
For example, many delusionary patients may not accept they are ill and need help in the first place.
Kingdon & Kirschen (2006) found that clinicians significantly judged older schizophrenic patients as being far less suitable/appropriate than younger patients to benefit from CBT.
Therefore, CBT may not suitable for all patients – some may be too old to benefit from CBT as cognitions are set.

Question 15

Different symptoms, different help?

Evaluation of psychological treatments for schiz: Zimmerman et al 2005

Answer 15

Furthermore, the appropriateness of CBT is also called into question when considering patients may suffer from different schizophrenic symptoms.
Zimmerman et al. (2005) found that there does seem to be a place for CBT helping with the auditory and visual hallucinations that sufferers experience; and it particularly helps in reducing the distress and negative emotions experienced by individuals who suffer these hallucinations.
However, it may be less helpful in treating some of the negative symptoms of schizophrenia, like flat affect and avolition.
This could suggest… CBT is of limited usefulness as it can reduce the distress of schizophrenic patients who suffer more from hallucinations, but is less useful for those struggling with their negative symptoms.

Question 16

Outline family therapy

Answer 16

Family therapy is an attempt to fix the faulty and dysfunctional dynamic of a family that may have caused schizophrenia.
It tries to alter communication practices within a family and trains people to express emotion in a more beneficial way.

Question 17

What are the main aims of family therapy

Answer 17

The main aims of the therapy are:
Improve positive and decrease negative forms of communication
Increase tolerance levels and decrease criticism within the family dynamic
Decrease feelings of guilt and responsibility for causing the illness.

Therapists aim to hold an open forum about the effects the illness has had on the family.

Question 18

Outline 5 processes in family therapy

Answer 18

1) Co-operative and trusting relationships-
Both the patient and family meet in a supportive environment, where all family members are valued. This process usually lasts around 6 months, with a minimum of 10 sessions recommended to patients and families.

2) Educate-
Therapist educates the group about the symptoms, causes and prognosis of SZ whilst family members bring together their experiences of the disorder. E.g., the patients will be encouraged to open up to their family about what is helpful and what makes their symptoms worse.

3) Practical coping skills-
The patients and family are provided with a set of practical coping skills that enable then to manage the everyday difficulties involved with SZ. These are behavioural and cognitive techniques. E.g., setting targets so the patient isn’t dependent on their family (i.e., responsibility over household chores).

4) How to express concern without resorting to high EE-
It is accepted that the family may occasionally feel anger and impatience, but they are taught how to express concern without resorting to high EE. E.g., using relaxation techniques to calm yourself down before discussing concerns.

5) Recognising the early signs of potential relapse-
Learning how to detect the early signs of relapse means they can respond rapidly and reduce its severity. E.g., insomnia, social withdrawal, difficulty concentrating, loss of interest, increasing paranoia, and hallucinations.

Question 19

Evaluation for family therapy as a treatment for schiz: Leff et al 1982

Answer 19

There is evidence to support the effectiveness of family therapy with schizophrenia patients.

For example, Leff et al. (1982) used 24 participants in a programme that involved (i) educational sessions dealing with the nature of schizophrenia, its symptoms and the best way to deal with difficult behaviour. (ii) group meetings between families to discuss how they dealt with schizophrenic family members (iii ) family sessions where social workers and other professionals were present.

Leff found that families involved in the intervention showed a significant decrease in critical comments directed towards the patient and reduced over–involvement (characteristics of high EE). Plus, 78% of patients in control group were readmitted to hospital compared to only 14% of the experimental group with schizophrenia.

This implies that family intervention made a significant difference to the interactions within the families, and also helped to significantly reduce the chance of relapse.

Question 20

Evaluation for family therapy as a treatment for schiz: methodological flaws

Answer 20

However, research like Leff’s has many methodological flaws that limit the credibility of the support.
In Leff’s research investigating comparing the use of FT & APs against just taking APs, there are multiple extraneous variables that have not been controlled.
For instance, the schizophrenic patients may have had differing severity of symptoms to start with; they may be on different types of APs which all have different levels of effectiveness; some may not have been routinely taking their APs; also it is not reported why some relapsed (it may not be due to their schizophrenia and could be due to a different mental health problem).
This implies that family therapy lacks rigorous experimental support which questions how effective it really is for schizophrenia.

Question 21

Evaluation for family therapy as a treatment for schiz: Vaughn and leff 1976

Answer 21

Family therapy seems to be most effective when used in conjunction with powerful antipsychotics to treat schizophrenia.
Vaughn and Leff (1976) looked at schizophrenic patients returning to either high or low EE in the household.
The effect of no medication on low EE was insignificant.
In the high EE household, relapse of schizophrenic symptoms increased with more face-to face contact, and with no medication relapse rate rose to 92%, showing the importance of effective treatment.
This implies that focusing on both family dynamics and biochemistry is best for patients with schizophrenia and their families.

Question 22

Evaluation for family therapy as a treatment for schiz:cost effective

Answer 22

Despite the high costs of family therapy, many argue it can reduce the ‘revolving door syndrome’ often seen with schizophrenic patients.
A study by Anderson et al. (1991) found a relapse rate of almost 40% when patients had drugs only, compared to only 20% when Family Therapy was used and the relapse rate was less than 5% when both were used together with the medication.
With a drastically reduced relapse rate with FT, will reduce the amount of times patients are hospitalised and therefore reduce the cost to the NHS, and therefore the economy.
This could suggest that many psychologists would state that family therapy is a cost effective mechanism for dealing with schizophrenia.

Question 23

Outline token economies

Answer 23

Token economies aim to manage schizophrenia rather than treat it.

They are a form of behavioural therapy where desirable behaviours are encouraged by the use of selective reinforcement based upon the principles of operant conditioning.

It focuses on the negative symptoms of schizophrenia.

Question 24

Give examples of 3 negative symptoms and how a token economy may address this

Answer 24

Speech poverty (Alogia)
- Not replying when someone speaks to them
- Receiving a token for when they do give a reasonable length, coherent reply to someone

Flat affect
-Have dulled emotional expression
- A token is taken away

Avolition
- Not engaging in activities in the hospital like playing a sports activity
- Receiving a token when they do engage in activities

Question 25

Evaluation of token economies as a treatment for schiz: Allyon and Azrin 1968

Answer 25

There is evidence that token economies are very effective in the management of schizophrenia.
Allyon and Azrin (1968) studied 45 female chronic schizophrenic patients, with an average of 16 years of hospitalisation. They screamed for long periods, were mute, assaultive, many were incontinent, and they no longer ate with cutlery. Following a system of TE they were carefully reinforced with tokens for their ward work and self-care behaviours which were later exchanged for chosen privileges (e.g. listening to music, renting a private room, seeing a social worker). This regime led to a dramatic improvement in self-care behaviours (approx 45 self care behaviours per week), however, When the system was removed these behaviours disappeared.
This implies that TEs are a cost effective strategy to use with institutionalised patients suffering from schizophrenia.

Question 26

Evaluation of token economies as a treatment for schiz: institutionally bound

Answer 26

Many psychologists believe that token economies do nothing to attempt to cure schizophrenia and in fact provide nothing but ‘token learning’.
It is difficult to keep this treatment going once the patients are back at home in the community.
Kazdin et al. Found that changes in behavior achieved through token economies do not remain when tokens are withdrawn, suggesting that such treatments address effects of schizophrenia rather than causes. It is not a cure.
This could imply that the benefits of TEs for schizophrenia are institutionally bound and disappear when patients rejoin the real world.

Question 27

placebo used

Evaluation: Biological treatments for schiz. ( Davis, evidence)

Answer 27

There is evidence to support effectiveness of APs for removing schiz symptoms.
Davis et al analysed results of 29 studies (with 3519 patients) looking into the effectiveness of
antipsychotics. They found that relapse occurred in 55% in patients whose anti-psychotic drugs were replaced by a
placebo, compared to just just 19% relapsed when they were still taking their antipsychotic medication.
This suggests AP medication is a valuable tool in treating sz and reduces suffering for patients

Question 28

Evaluation: Biological treatments for schiz. (Ross and read counter evidence)

Answer 28

However there are significant problems with that evidence. Ross and Read (2004) point out that Davis’ figures could be misleading, as they also indicate that 45% of
those taking placebos did actually benefit from this. Likewise, of the 81% of those who benefitted from the drug, the
data suggests that a large number of these (i.e. 45%) would have also benefitted from a placebo.
This implies that more research is needed into the effect of placebo’s on patients with schiz

Question 29

Evaluation: Biological treatments for schiz. (elesser, not completely effective)

Answer 29

APs are not proven to be completely effective. In a longitudinal study design Elesser discovered
that anti-psychotics should not be thought of as
a cure, even though they can eliminate some
symptoms and make psychotic experiences less
intense and distressing.
They do not help everyone, and rarely remove
all symptoms. The more typical anti-psychotics
help about 65% of those treated whilst atypical
drugs help about 85% of patients.
This illustrates that alternative therapies like psychological treatments may also be helpful in treating schiz and that an interactionist approach could provide the best prognosis for patients

Question 30

Evaluation: Biological treatments for schiz. (too many side effects)

Answer 30

There is an argument that because APs have so many side effects, are they even appropriate for treating schiz?
Davison & Neale (1998) Are anti-psychotics
appropriate? Largely because of the side-effects produced by anti-
psychotics, around 50% stop taking these drugs after one year and up to 75% after two years.
Between 20-40% experience muscle tremors and rigidity, especially of their legs and feet;
Dsytonia – involves muscle contractions which produce uncontrollable movements of the face, neck and back;
Akathisia- is a psychomotor complaint involving restlessness, agitation , discomfort of limbs which causes you to constantly fidget
and pace up and down.
In addition, about 1% of users suffer from a life
threatening drop in white-blood cells.

This implies APs can cause as money problems as they solve