sz - treatment

Question 1

outline drug therapy for sz?

Answer 1

The introduction of anti-psychotic drugs (also known as neuroleptics) has revolutionised the treatment of schizophrenia. They work by reducing the action of the neurotransmitter dopamine in areas of the brain associated with SZ. These reduce symptoms to allow for some degree of functioning to become possible, but they do not offer a cure. There are two types:

Typical anti-psychotics (e.g. Chlorpromazine): stops dopamine production by blocking receptors in synapses. They are dopamine antagonists; in that they bind to but do not stimulate dopamine receptors (particularly the D₂ receptors in the mesolimbic dopamine pathway). This reduces positive symptoms, such as auditory hallucinations.

Atypical anti-psychotics (e.g. Clozapine): act on serotonin and dopamine production systems, and affect negative symptoms, such as reduced emotional expression. They have some side effects such as weight gain, but a lower risk of the extrapyramidal side effects, due to the fact that they only temporarily occupy the D₂ receptors, and then rapidly dissociate to allow normal dopamine transmission.

Atypical has less side effects
Atypical produces negative effects whereas typical is more positive
Typical only acts on dopamine, Atypical acts on serotonin and dopamine

Question 2

explain research into anti-psychotics

Answer 2

Leucht et al. (2012) carried out a meta analyses involving nearly 6000 patients who had been stabilised on antipsychotics. Some were taken off the drugs and given a placebo instead. Within 12 months, 64% of the patients given the placebo had relapsed, compared with 27% who had stayed on the drug.

This suggests that the drug is effective, as the placebo has a higher relapse rate than people who stayed on the drug, therefore it must be an effective treatment

However there was still 27% relapse so there is likely to be another variable effecting schizophrenia
Even on a placebo, some people did not relapse, therefore some of the recovery must be partly psychosomatic

Question 3

explain research into the side effects of anti-pscyhotics

Answer 3

Kapur et al. (2000) estimated that between 60%- 75% of D₂ receptors in the mesolimbic dopamine pathway must be blocked in order for these drugs to be effective in reducing symptoms. However in order to do this, a similar number of D₂ receptors in other areas of the brain must also be blocked leading to undesirable side effects
Extrapyramidial side effects:

Parkinson related symptoms
Tardive dyskinesia – involuntary movement of face/tongue/jaw
May make them stop taking the drugs
Also neuroleptic malignant syndrome – high temp, delerium and coma, can cause death

Question 4

study into effectiveness of typical and atypical anti-psychotic drugs

Answer 4

Scholer et al (2005) Compared the effectiveness of typical and atypical anti-psychotic drugs
They found that 75% of patients experienced at least 20% reduction in their symptoms, when taking atypical drugs, 55% of patients on typical relapsed compared to 42% on atypical, Side effects were fewer with atypical

Reduction in symptoms of ¾ of patients
Atypical less side effects
Atypical seems more effective
Atypical lower relapse rate

Question 5

study to evaluate effectiveness of typical and atypical anti-pscyhotics

Answer 5

However - Other studies have found conflicting results, e.g. Kahn (2008) found that atypical anti-psychotics were not more effective than typical anti-psychotic drugs.

However the results we see might be because people continue to take the atypical due to less side effects
This makes it appear as if the drug is more effective when actually it is not

Question 6

explain ethical issues of drug treatments?

Answer 6

In US a large out of court settlement was awarded to a Tardive Dyskinesia sufferer based on Human Rights Act 1988 ‘noone shall be subjected to inhuman or degrading treatment or punishment’

Comment on the cost-benefit analysis of typical antipsychotics

More people will be able to function better and work if they can lower delusions – benefit
Lots of risks and side-effects - cost

Issue of consent- can patients with delusions give consent

Question 7

explain motivational deficits of drug treatment?

Answer 7

Ross and Read (2004). Drugs reduce the effects but not the cause, and therefore they decrease the motivation of the patient to find their cause of schizophrenia

Problem – if you keep on giving a patient drugs they become less motivated to find the root cause of the SZ and therefore recovery might be less good

Question 8

Comment on the issue of drug producing companies.

Answer 8

In 2011, 3.1 million Americans were prescribed antipsychotics, generating $18.2 billion in profits. Prescriptions for atypical antipsychotics increased by 93% between 2001 and 2011, though the incidence rate of SZ and depression remained approximately the same. Comment on the issue of drug producing companies.

Only controlling symptoms
Drug companies sponsor people to research the effectiveness of their drugs
File draw effect – headline stats we see might not be the actual ones

Question 9

Theoretic issue with dopamine hypothesis?

Answer 9

Treatment causation fallacy
Theory of hyperdopaminergia as a theory was made after the treatment found
This is a potential evaluation issue as the causes of schizophrenia have been assumed

Question 10

what are the strengths of drugs as a treatment?

Answer 10

Economically better to have people living outside and working with less symptoms

Question 11

Apart from effectiveness, briefly explain one limitation of drug therapy for schizophrenia. (Total 2 marks)

Answer 11

One limitation of drug therapy is that it only treats the symptoms of SZ and not the actual root cause, this creates a sense of dependency and patients are less likely to be motivated to find the root cause. Without finding the root cause, participants are more liekly to relapse.

Question 12

outline the Psychological Therapies?

Answer 12

CBT is the main psychological treatment for schizophrenia. However, antipsychotics are often used before or alongside CBT to reduce psychotic thought processes, ensuring CBT is most effective, and to reduce patient dropout rate (Kuipers et al, 1997). CBT is then take undertaken around once every 10 days for about 12 sessions.

CBT aims to identify and alter irrational thinking. Drawings are employed to display links between sufferers’ thoughts, actions (behavioura) and emotions; comprehension of the origins of their symptoms is useful in reducing sufferers’ anxiety levels.

Research on expressed emotion has shown that certain aspects of family life can affect the course of schizophrenia. This has led to the development of various family intervention programmes. Central to these programmes is the emphasis on inclusion and sharing information. The treatment involves the whole family, not just the member with SZ, with the family becoming the patient’s support network. It is usually between 9 months and a year, allowing family to develop skills that can be continued afterwards.

Aims:
Improve positive and decrease negative forms of communication
Increase tolerance levels and decrease criticism
Decrease feelings of guilt and responsibility for causing the illness amongst family member

Question 13

outline the aims of CBT?

Answer 13

cognitive restructuring via ABCDE framework. Identifying activating event (A), exploring beliefs (B), recognising consequences (C), disputing irrational beliefs (D), restructured belief (E).

To discover that we all have inherent tendencies to certain negative thoughts that evoke unhappiness and disturbance - especially in response to particular trigger situations.

To help the patient to identify delusions.

To challenge and modify delusory beliefs (make irrational thoughts rational). To challenge those delusions by looking at evidence. To help the patient to begin to test the reality of the evidence.

Recognise negative thoughts. Once patients accept that fact, they can learn to spot these negative thoughts as they arise, and then challenge and re-think them. To trace back the symptoms to get a better idea of how they developed

Evaluate the context of the patients delusions and hallucinations by considering ways to test the validity of their faulty beliefs

Set behavioural assignments to improve general levels of functioning (e.g increasing social activity)

Let the patient develop their own alternatives to their previous maladaptive behaviour by looking at coping strategies and alternative explanations.

Question 14

explain a study to support CBT?

Answer 14

Zimmerman (2005) performed a meta analyses of 14 studies on CBT from 1990 to 2004 and found CBT significantly reduced positive symptoms and that treatment was especially beneficial to those suffering short term acute schizophrenic episode

Question 15

outline family relationship therapy?

Answer 15

Research on expressed emotion has shown that certain aspects of family life can affect the course of schizophrenia. This has led to the development of various family intervention programmes. Central to these programmes is the emphasis on inclusion and sharing information. The treatment involves the whole family, not just the member with SZ, with the family becoming the patient’s support network. It is usually between 9 months and a year, allowing family to develop skills that can be continued afterwards.

Aims:
Improve positive and decrease negative forms of communication
Increase tolerance levels and decrease criticism
Decrease feelings of guilt and responsibility for causing the illness amongst family member

Question 16

study to support family therapy?

Answer 16

Xiong et al. (1994) randomly allocated Chinese SZ into standard drug care or drug care plus family therapy. After 1 year 61% of standard drug care relapsed, compared to 33% of standard care plus family therapy patients.

Question 17

outline token economy?

Answer 17

Token economies are reward systems, used to manage the behavior in patients with SZ, in particular those who have picked up maladaptive patterns whilst living in an institution. In these circumstances it is common for patients to develop poor habits or perhaps to stay in pajamas all day. Modifying these does not cure SZ, but helps improve quality of life so they can live outside a hospital setting.

Tokens, for example in the form of coloured discs are given to patients immediately after a desirable behavior that has been targeted, for example, getting dressed in the morning.

Tokens can be swapped later for more tangible rewards. Token economy is based on operant conditioning. The tokens act as s________________ reinforcers, as they gain value once the patient has learnt that they can be used to obtain rewards, such as sweets or magazines.

Question 18

study to support token economy?

Answer 18

Dickerson et al. (2005) reviewed 13 studies of token economy to treat SZ. 11 reported beneficial effects in increasing adaptive behaviours of those with SZ. However they did comment that many studies had methodology issues.

Question 19

study to evaluate the effectiveness of token economy?

Answer 19

Comer (2013) argued that few studies use control groups (all patients in a psychiatric ward tend to be introduced to the treatment). As a result, patient’s improvements can only be compared with their previous behaviours. What other factors could impact patient improvement?

It may be due to the patients getting attention from staff that they improve rather than the actual token economy itself
Control group – group of schizophrenic in hospital receiving token economy / group of people out of hospital not receiving token economy – this is not often done – have to compare results to before

Question 20

explain individual differences as evaluation of therapy?

Answer 20

Individual differences - CBT is not, however, suitable for everyone – why?

CBT is not suitable for everyone because it requires interaction with a therapist and due to avolition SZs may struggle with committing to it (goal directed behavior)

Question 21

explain the practical issues of CBT/family therapy?

Answer 21

CBT requires co-operation over a long period of time - avolition

Family therapy – requires open talk – social anhedonia may prevent this (don’t like interacting with people)

Drop outs are a big problem
To combat this we can use drugs to lower the symptoms to hopefully lower dropout rates

Question 22

explain how family therapy is cost-effective?

Answer 22

The SZ Commission (2012) estimates family therapy is cheaper than standard care by £1004 a patient over 3 years, suggesting its relatively cost-effective. However, with an emphasis on ‘openness’ in family therapy – what issues do you foresee?

Often people with SZ will feel further friction about having to take time out with the family to attent therapy

Question 23

strength of token economy?

Answer 23

Strength – Token economy – tailored to meet the individual requirements of different patients

What behaviors you reward for – it doesn’t matter what the patients symptoms are, you can target behaviors with a different reward

Question 24

ethical issues of token economy?

Answer 24

Someone with mild SZ get more rewards than someone with worse SZ – therefore sometimes it is perceived as unfair as people with worse SZ do not get as many of the rewards

Question 25

There is only modest support for psychological therapies. They all make SZ more manageable but DO NOT CURE. State briefly how they make it more manageable referring to the 3 treatments.

Answer 25

CBT – try to reduce the faulty beliefs and therefore delusions as a main symptom
Family therapy – aims to reduce the friction caused from family environment, this is a trigger to SZ not cause
Token economy – aims to reduce the amount of symptoms through rewards

Question 26

Briefly outline how cognitive behaviour therapy (CBT) is used to treat schizophrenia and explain one limitation of using CBT to treat schizophrenia. (Total 4 marks)

Answer 26

CBT aims to identify and alter irrational thinking of SZ. Drawings are employed to display links between sufferers’ thoughts, actions and emotions caused by SZ and then correct the irrational thoughts such as delusions to attempt to treat SZ.

One limitation of CBT is that is requires co-operation over a long period of time. One symptom of SZ is social anhedonia which causes patients to not like social engagements, this will mean that they do not want to engage with the therapist and the CBT treatment will therefore be ineffective in treating SZ.