THE CLINICAL APPROACH - SCHIZOPHRENIA

Question 1

What are some key points about schizophrenia?

Answer 1

Around 1% of the population suffer from schizophrenia
Individuals who develop the symptoms tend to be 16-25
It’s equally prevalent in men and women, although onset is later in women
The peak of onset for men is 16-25 and for women it tends to be 10 years later
Men tend to have a worse prognosis than women
About ⅓ will have repeated episodes, ⅓ will make a full recovery and ⅓ will be untreatable

Question 2

What did Goldstein find?

Answer 2

that male schizophrenia had twice as many admissions and spent twice as long in hospital than female schizophrenics

Question 3

What does the DSM V require in order to diagnose schizophrenia?

Answer 3

Two more positive or negative symptoms prevalent for a month or more
General disturbance of 6 months
Cannot be a product of an organic disorder (eg brain tumour) or be on drugs/alcohol
Absence of a mood disorder

Question 4

What are positive symptoms?

Answer 4

symptoms that one gains in addition to normal functioning
Eg hallucinations, delusions, racing thoughts, paranoid thinking

Question 5

What are negative symptoms?

Answer 5

symptoms that result in the loss of normal functioning
Eg low motivation, emotional flatness, decreased speech, loss of interest in life (apathy), social withdrawal, decreased sense of purpose

Question 6

What are cognitive symptoms?

Answer 6

how well the brain uses/stores/learns information
Eg disorganised thinking, slow thinking, poor executive function, difficulty understanding, trouble focusing, anosognosia

Question 7

What are the key points of the dopamine hypothesis?

Answer 7

Positive schizophrenic symptoms are linked to high levels of dopamine (hyperdopaminergia) in the region called the mesolimbic pathway
Negative schizophrenic symptoms are linked to low levels of dopamine (hypodopaminergia) in the mesocortical pathway
Research by Carlsson et al adds more detail to the hypothesis

Question 8

What is L-DOPA?

Answer 8

used to treat people with Parkinson’s disease, until the levels of the administered drug are properly established the side effects can produce schizophrenic symptoms as it increases dopamine levels

Question 9

What did Randrupp and Munkvad do?

Answer 9

Injected laboratory rats with doses of between 1-20mg of amphetamines
Noted that the rats exhibited behaviours associated with schizophrenia, such as aggression, social isolation and stereotypical activity
Repeated the procedure on different species, including chickens, pigeons, cats, dogs, and squires and found similar results
Concluded that some forms of schizophrenic behaviour can be induced by amphetamines as they increase dopamine levels in the brain

Question 10

What are strengths of the dopamine hypothesis and what are the key names?

Answer 10

Explains both positive and negative symptoms of schizophrenia which gives it explanatory power
Another neurotransmitter - glutamate - is also thought to cause psychotic symptoms if its production is blocked, supporting the role played by neurotransmitters in schizophrenia but rejecting a specifically dopamine explanation
Lieberman et al, Johnstone et al, Lindstroem et al

Question 11

What did Lieberman et al find?

Answer 11

that 75% of schizophrenic patients show new symptoms or an increase in symptoms when using amphetamines and methylphenidate (drugs that mimic the action of dopamine)

Question 12

What did Johnstone et al find?

Answer 12

that there are drugs that are effective for treating schizophrenia that are dopamine antagonists

Question 13

What did Lindstroem find?

Answer 13

performed a PET scan study on 10 untreated patients with schizophrenia and 10 health controls, injected L-DOPA and saw that it was taken up more quickly in the patients with schizophrenia suggesting more dopamine was produced

Question 14

What are weaknesses of the dopamine hypothesis?

Answer 14

Alpert and Friedhoff found that some patients show no improvement after taking dopamine antagonists
There is no evidence to suggest that clozapine actually increases levels of dopamine in some parts of the brain, presumably as the brain adapts to the antagonist effects of the drug - this contradicting the dopamine hypothesis
Depatie and lal showed that a drug called apomorphine, which acts as a dopamine antagonist (increases the effect) does not induce schizophrenia
Ethical issues in directly testing the dopamine hypothesis as it would involve extracting dopamine from live brains

Question 15

What is the genetic explanation of schizophrenia?

Answer 15

studied MZ twins and schizophrenia and discovered that MZ twins have a concordance rate of 48% and for DZ twins it was 17% (suggests that genetic factors are strongly implicated in schizophrenia yet not entirely)
Also found that the stronger the genetic connection to a schizophrenic relative, the greater the risk of developing the condition
If both parents have it - 46%, if grandparent has it - 5%

Question 16

What did Rosenthal find in relation to the genetic explanation of schizophrenia?

Answer 16

Reported on the Genain Girls (quadruplets who all developed schizophrenia but at differing ages and different forms)
They all inherited a predisposition to the disorder, but seemingly had sufficiently different environmental experiences within the family which altered the onset and outcome of the disorder

Question 17

What are strengths of the genetic explanation of schizophrenia?

Answer 17

Heston studied 47 adults, adopted at birth because their mothers were schizophrenic and compared them to 47 adoptees whose mothers weren’t schizophrenic
10% of adults with schizophrenic adults went on to develop schizophrenia compared to none of the control group
Study by the International schizophrenic consortium 2008 found that schizophrenics are more likely to have structural changes to their genes
Crepsi, Summers and Dorus did a DNA analysis and found 28 separate genes linked to schizophrenia, which provided or conferred linguistic skills and creativity, but most or all of these genes tended to lead to serious mental illnesses

Question 18

What are weaknesses of the genetic explanation of schizophrenia?

Answer 18

Concordance isn’t 100% so genes cannot be the entire explanation
Around ⅔ of schizophrenics have no schizophrenic relative
Research has failed to isolate a single recessive or dominant gene for schizophrenia (more complex than one gene)
Kelly and Murray argue that there are only weak correlations between variations in particular genes of schizophrenics and non-schizophrenics which suggests that there are actually a number of genes involved in the development of schizophrenia
Genes may simply give someone a predisposition to schizophrenia but not an inevitability
There are alternative explanations - eg neurological, neurochemical, psychodynamic, cognitive, social etc

Question 19

What is the social explanation of schizophrenia?

Answer 19

Argues that the human world acts as a major cause of schizophrenia or at least precipitates relapse in those who are already diagnosed
Fits with the diathesis stress model of mental illnesses, as it argues that it is a combination of biological and environmental factors that causes mental health disorders
Urbanicity, social drift, socio-economic status, immigration and minority status,

Question 20

How can urbanicity lead to schizophrenia?

Answer 20

Living in an urban, densely populated, working class area can be stressful and this stress itself may be the cause of schizophrenia
Urban living is often associated with social deprivation, high unemployment and poverty, poor housing, social isolation, high rates of crime and drug use, separation from parents and hold a low status
This factors all contribute to a high level of psychological distress, leading to a schizophrenic breakdown in people who are vulnerable
Eaton found that living in a city exposed people to more long term stress such as exposure to noise, light pollution, criminality, faster pace of living and greater anonymity
Life can be more competitive in a densely populated city, this can increase the feeling of social defeat which is a stressor that can lead to schizophrenic symptoms

Question 21

How can social drift lead to schizophrenia?

Answer 21

Individuals struggling with stress are more likely to withdraw fro society
Less likely than other people to spot their unusual thinking and behaviour
This allows space for abnormal thinking to develop and therefore they begin to behave strangely
People with schizophrenia may find it difficult to maintain high powered jobs and dynamic lifestyles and so drift down the socio-economic scale
Schwartz found that schizophrenics were downwardly mobile, supporting the social drift theory

Question 22

How does socio-economic status lead to schizophrenia?

Answer 22

Some children grow up in environments that are less favourable than others where their needs aren’t met and this can make them more vulnerable to mental health disorders
For example, families affected by unemployment, poverty, and a poorer standard of living may be exposed to considerable more stress
Cooper using five categories of social class found that for single men, the rate of schizophrenia in social class 5 (unskilled labourers) was 4.1x higher than those in class 1

Question 23

How can immigration and minority status lead to schizophrenia?

Answer 23

There are higher rates of schizophrenia in the 1st and 2ns generation immigrants than there are in indigenous populations (higher in 2nd generation)
Although it appears that minority or out group status is the key, the marginalisation of people leaves them vulnerable to schizophrenia
The higher rates in the 2nd generation can be explained by them developing a weaker ethnic identity than their parent as they have learnt more than their parents of the culture they live in so fit into the norms of society (identification with their family is at odds and can create stress)
Immigration populations tend to be disadvantaged with regard to educational attainment, social class, standard of housing and discrimination and also tend to live in over crowded conditions
White people from lower SES groups don’t have the same increased risk as black immigrants, suggesting it is more than simply social diversity and lower SES that causes schizophrenia, it is also experiencing discrimination
Brown found than when immigrants lived in neighbourhoods where their own ethnic group did not predominate there was a higher rate of psychotic disorders compared to neighbourhoods where they did

Question 24

What are strengths of the social explanation of schizophrenia and what are the key names?

Answer 24

Can help deal with schizophrenia by drawing attention to factors which affect mental health at the community level
Housing projects which reduce overcrowding and encourage neighbourhood cohesion and celebrate cultural diversity should foster the courage, fortitude and resilience which will help communities arm themselves against mental breakdown
Evangelos Vassos et al, Veling et al

Question 25

What did Evangelos Vassos et al find?

Answer 25

performed a meta-analysis of data from four studies conducted in Sweden, The Netherlands and Denmark including nearly 24,000 cases of schizophrenia
They correlated location (urban to rural) with schizophrenia risk and found a link
At the extremes, they found that the risk was 2.37x higher for people living in the most urban environments compared to the most rural
However, this correlation doesn’t mean there is a causal relationship

Question 26

What did Veling et al find?

Answer 26

Did a complex analysis of self reported questionnaire data
Found that people classed as marginalised (weak national and ethnic identity) and assimilated (strong national but weak ethnic identity) were at greater risk of schizophrenia than people classed as integrated (strong national and ethnic identity) or separate (weak national but strong ethnic identity)
This suggests that a strong ethnic identity may be a protective factor against schizophrenia

Question 27

What are weaknesses of the social explanation of schizophrenia?

Answer 27

It is not a complete explanation of schizophrenia as we know there is some genetic contribution to the development of it, which it fails to explain
The research that supports it is correlational so it isn’t possible to say that schizophrenia is caused by urbanicity or adversity
In fact, the social drift hypothesis suggests that people with schizophrenia find it hard to hold down a job, leading them to ‘drift’ into a lower social class (this is what schizophrenia causes not what causes schizophrenia)

Question 28

What is the biological treatment of schizophrenia?

Answer 28

The most common treatment for schizophrenia involves the use of antipsychotic drugs, which can be taken as tablets or as a syrup, but can also be injections if risk of failing to take it
They can be taken for a short amount of time, or others require them for life
There are typical antipsychotics (chlorpromazine) which have been around since the 1950s and are called first generation antipsychotics
Also, atypical antipsychotics (clozapine and risperidone) which have been used since the 1970s and are known as second generation antipsychotics

Question 29

What is chlorpromazine?

Answer 29

Typical antipsychotic that works by acting as antagonists in the dopaminergic system in the brain, and are chemicals which reduce the action of neurotransmitters
The dopamine antagonists bind to the D2 receptors in the synapse and depolarise them, which stops the dopamine from binding and causing a signal to the post-synaptic neuron therefore the message to the cells doesn’t get passed on and prevents symptoms
Only works to treat positive symptoms (eg hallucinations, delusions)
Chlorpromazine has been shown to be 70% effective in reducing positive symptoms
However they have a huge amount of side effects which can compliance more difficult
Example are dizziness, restlessness, agitation, nervousness, increased appetite and weight gain, missed menstrual periods, decreased sexual ability and dry mouth

Question 30

What is clozapine?

Answer 30

Atypical antipsychotic that was developed in the 1960s and first trialled in the 1970s, yet was withdrawn in the 70s following the deaths of some patients from a blood condition called agranulocytosis
It was remarketed as was more effective than typical antipsychotics but requires regular blood tests to prevent fatal side effects
It binds to dopamine receptors like chlorpromazine, but also acts on serotonin an glutamate receptors to help improve mood and reduce depression and anxiety
The mood enhancing effect means it is prescribed when a patient is considered at a high risk of suicide (30-50% of people with schizophrenia attempt suicide)
Possible side effects include blurred vision, confusion, nausea, fever or tiredness

Question 31

What is risperidone?

Answer 31

A more recently developed atypical antipsychotic (1990s)
It was developed in an attempt to produce a drug as effective as clozapine but without the serious side effects
Can be taken as tablets, syrup or injection
Believed to bind to dopamine and serotonin receptors, but binds more strongly to dopamine receptors than clozapine and is therefore effective in smaller doses
There is also some evidence to suggest that this leads to fewer side effects than is typical for antipsychotics
Effective in 81% of patients for both positive and negative symptoms, and seems to work regardless of how severe it is
Potential side effects include feeling sleepy, headaches, nausea or constipation/diarrhoea

Question 32

What are the strengths of biological treatments of schizophrenia?

Answer 32

Modern drugs (clozapine and risperidone) have fewer side effects and also make it possible for patients to engage in other forms of therapy and avoid hospitalisation
McEvoy et al showed that clozapine was effective, partly because patients continued taking this drug for longer due to less side effects so were able to get more benefits from drug therapy
Pickar et al found that clozapine was very effective in treating schizophrenia, even in patients previously unresponsive to drug intervention
Emsley found that risperidone lowered relapse rates significantly, especially if used in the course of the disorder
In 84% of patients there was at least a 50% reduction in positive and negative symptoms, and over 2 years 64% of patients went into remission
Drugs allow them to function normally in everyday life, whilst being able to access other therapies that help the patient come to terms with their condition and improve their long term quality of life

Question 33

What are the weaknesses of biological treatments of schizophrenia?

Answer 33

The older forms of antipsychotic medication had severe side effects, which require other drugs or treatments to combat them
An example is clozapine can impaire the immune system, reduce white blood count and lead to agranulocytosis and therefore the patients need blood tests
Even when patients do comply with their medication regime, 50% of patients still experience distressing symptoms and some don’t respond to them at all
Non-compliance/partial compliance are major problems and it’s estimated that around 50% of patients discontinue their medication due to side effects or not remembering
Drug treatment is not a cure, patients have to continue their medication to maintain therapeutic effects and often drugs alone are not sufficient enough
Drug treatment does not take into account the patients’ environmental, social and family problems which might contribute to re-hospitalisation and relapse rates

Question 34

What is a non-biological treatment of schizophrenia?

Answer 34

CBT was developed by Ellis in 1962 and further developed by Beck in 1967 and is one commonly used to treat people with schizophrenia
It is a form of therapy that combines the cognitive approach and learning theory concepts which aim to change behaviour

Question 35

What is CBT and how is it used to treat schizophrenia?

Answer 35

Usually takes place in anywhere between 5-20 sessions, in groups or individually
It assumes that our beliefs about the world and ourselves affective how we feel about ourselves and how we see ourselves and the world, and as a result affects behaviour
Focuses on maladaptive cognitions (thinking that is not helpful or suitable in situations) - maintains emotional distress and behavioural problems
Beck claimed that maladaptive thinking comes from schemas and general beliefs about the world, oneself and the future (cognitive triad)
CBT acts to focus on these thoughts and schemas, to change them so that the emotions and behaviours that arise from these maladaptive thoughts also change
The therapist has to accept the patient’s perception of reality and then challenge these perceptions to allow the patient to see things more realistically
It doesn’t aim to cure schizophrenia, but rather allow the patient to function relatively normally, reduce the distressing experiences and developing coping mechanisms
CBT practitioners may set therapeutic ‘homework’ tasks so that the patients can practice their cognitive coping mechanisms and receive positive reinforcement

Question 36

What does CBT focus on when treating schizophrenia?

Answer 36

Irrational thoughts - involves helping clients to identify their irrational thoughts and try to challenge and change them, which helps reducing the stress experienced
Delusions - helped to make sense of how their delusions and hallucinations impact on their feelings and behaviour
Behavioural experiments - delusions and hallucinations may be combatted by verbally challenging the patients’ perceived reality
Behavioural activation - rewarding behaviour that goes against their schizophrenic symptoms (eg becoming more sociable, and expanding the range of pleasurable activities the person is involved in)

Question 37

What are strengths of CBT as a treatment of schizophrenia?

Answer 37

It doesn’t produce any side effects and gives the patient control over their condition and treatment, so they can tailor it to their specific needs
The therapist and patient work together collaboratively on issues to concern the patient, with a non-threatening and supportive relationship
Chadwick, Kingdon and Tuckington, NICE

Question 38

What did Chadwick find?

Answer 38

studied 22 schizophrenics who had auditory hallucination symptoms and found that after 8 hours of CBT, they all had reduced negative beliefs about how powerful and controlling the voices were

Question 39

What did Kingdon and Tuckington find?

Answer 39

found that 35/64 (54%) were free of symptoms after CBT in a 5 year follow up

Question 40

What did NICE say about CBT as a treatment of schizophrenia?

Answer 40

recommends CBT as an affective treatment for schizophrenia after doing a meta-analysis of high quality studied and finding it was effective in reducing rehospitalization rates for up to 18 months, and reduced the time spent in hospital

Question 41

What are weaknesses of CBT as a treatment of schizophrenia?

Answer 41

CBT can be distressing for the individual as they have to focus and confront their distressing symptoms, for example delusions and hallucinations
Patients may lack insight about their condition, making the analysis of their own thinking less difficult
Evidence from research into CBT tends to come from self-report data after therapy, without control groups and small sample sized which reduces scientific credibility
Yet drug trials involve randomised controls, double blind conditions and large sample sizes
Barraclough et al found no significant differences in schizophrenics between CBT and their usual treatment
McKenna and Kingdon compared CBT with routine treatment for a control non-biological intervention, and found that CBT was only superior in 2/9 methodologically rigorous trials, which suggests CBT is not as effective as the NICE report suggests