4.3.5 SCHIZOPRENIA

What is schizophrenia (SZ)?

A long-term mental disorder involving a breakdown in the relationship between thought, emotion and behaviour, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation.

What does SZ do to your mental state?

SZ changes the way you think, feel and act - it differs from person to person and symptoms can come and go.

When do schizophrenic symptoms typically begin? What is the first stage?

Between 16 and 30, with men developing them (on average) earlier than women. The gradual change in a person before symptoms start is called the prodome phase.

What are the two types of SZ symptoms?

• Positive

• Negative

What is a positive symptom?

Highly exaggerated ideas, perceptions or actions that show the person can’t perceive reality from what isn’t. Positive means the presence of symptoms.

What are the 5 positive SZ symptoms?

1. Hallucinations

2. Delusions

3. Confused thoughts and disorganised speech

4. Trouble concentrating

5. Movement disorders

What are the 4 types of hallucinations a SZ patient may experience? Briefly explain them.

• Auditory (voices in their head)

• Visual (seeing things that aren’t there)

• Olfactory and gustatory (smells and taste)

• Tactile (feelings of things moving on your body)

What are negative SZ symptoms?

An absence or lack of normal mental functioning involving thinking, behaviour and perception.

What are the 6 negative SZ symptoms?

• Lack of pleasure/anhedonia

• Alogia/Trouble with speech

• Flattening

• Withdrawal/apathy

• Struggling with daily basics of life

• Avolition

What is the DSM? How does it relate to SZ?

The Diagnostic and Statistical Manual of Mental Disorders, used by mental health professionals to diagnose a patient. A SZ patient must display at least 2 positive symptoms of SZ for at least a month to be diagnosed.

What is the ICD?

The International Statistical Classification of Diseases, produced by WHO.

What was Rosenhan’s 1973 study called? What did it aimed to emphasize/show?

‘Being sane in insane places’ where the unreliability of diagnosis was highlighted.

What was Rosenhan’s procedure?

Asked his friends and colleagues (‘normal’ people) to go to psychiatric hospitals in the US and say they heard voices saying ‘thud’, ‘empty’ and ‘hollow’.

They didn’t shave or shower for 5 days previous to presenting themselves.

Before they went in they were taught how not to swallow the medication.

They were truthful about the rest of their life.

What happened in the psychiatric hospitals respond to Rosenhan’s patients?

After all participants were diagnosed and admitted, they reverted back to acting ‘normal’. They would tell hospital staff they felt fine and had stopped experiencing any previously stated symptoms.

How long did it take for the majority to be released from the psychiatric hospitals? What happened for them to be discharged?

2 months after telling staff it was a study.

What are the 2 main issues surrounding diagnoses? Why?

• reliability (consistency)

• Validity (accuracy)

Due to the differences between the ICD and the DSMV.

What does culture bias have to do with SZ?

Culture bias concerns the tendency to over diagnose members of other cultures as suffering from SZ.

What culture is 6-8X more likely to be diagnosed with SZ than any white culture? Why?

Afro-Caribbean, statistical patterns suggest that they are more likely to live in a deprived area and experience material deprivation. This may lead to less educational achievement meaning that stress is increased.

What specific evidence is there to support the increase of SZ for Afro-Caribbean diagnoses?

Cochrane 1977 found that the occurrence of SZ was 1% in both the West Indies and the Uk but that people of Afro-Caribbean decent were 7X more likely to be diagnosed with SZ when living in Britain.

What is symptom overlap? What does it effect?

When two or more conditions shares symptoms. This calls into question the validity of classifying the 2 disorders separately.

What does SZ have symptom overlap with?

Bipolar disorder.

What is co-morbidity? Why is it an issue for SZ?

When 2 conditions co-exist in the same individual at the same time.

It impacts the validity of SZ diagnosis because a person can’t be diagnosed with SZ when they have been diagnosed with a mood disorder.

What did Buckley find about co-morbidity?

That depression occurs in 50% of SZ patients and 47% of SZ patients also have a lifetime diagnosis of co-morbid substance abuse.

How does gender bias affect SZ diagnosis?

• more research based on men: medication is more suited to men

• female and male differences in reactions to stress (men don’t deal as well)

What do the biological explanationsbelieve about SZ?

This approach sees mental disorders as physical causes.

What are the 4 biological explanations of SZ?

1. Genetic vulnerability

2. Candidate genes

3. The dopamine hypothesis

4. Neural correlates

What does genetic vulnerability propose?

There is a genetic component which predisposes some individuals to the illness. The fact that schizophrenia tends to run in families leads to the conclusion that it has a genetic basis and the more closely related a family member is with the sufferer, the more likely they are to suffer as well.

What are the three types of studies used to study genetics?

• family

• adoption

• twin

What are the two types of twins and what % of genes do they share?

Dizygotic - 50%

Monozygotic - 100%

What did Kendler find about SZ in family studies?

Kendler found that 1st degree relatives of those suffering were 18X more at risk of developing the disorder.

Give 3 concordance rates about schizophrenia in genetics?

1. Siblings = 9%

2. monozygotic twins = 48%

3. Dizygotic twins = 17%

What do twin studies help to distinguish?

Whether nature or nurture has the greater influence.

Give 2 specific pieces of evidence that schizophrenia is inherited through genes.

Gottesman and Shields — concordance rates of 48% MZ and 17% DZ.

Joseph — concordance rates of 40.4% MZ and 7.4% DZ.

Give the 3 strengths for twin studies.

• Indicates there's a strong genetic component to the disorder.

• Can help identify whether SZ is nature/nurture

• Evidence to support the genetic explanations

Give the 6 limitations of twin studies.

• Concordance rates aren’t 100%, so there must be an environmental element

• small sample sizes - lack of pop. validity and difficult to generalise

• the (higher) MZ concordance rate could be due to MZ twins eliciting more similar treatment than DZ twins

• No single gene has been identified for SZ - validity of the explanation

• Temporal validity

What do researchers think about family studies?

SZ concordance rates in families may be more to do with rearing patterns/environmental factors rather than hereditary.

What do adoption studies help identify?

Allow researchers to overcome the problem of disentangling genetic and environmental influences.

What was Heston’s adoption study?

Compared 47 adopted children (whose biological mother had SZ) with a control group of adopted children without a history of SZ.

What did Heston’s adoption study find?

None of the control group was diagnosed with SZ, but 16% of the children whose mother suffered were diagnosed with it.

What was Tienara’s adoption study?

Of the 155 adoptees whose biological mothers had a SZ diagnosis, 10% were diagnosed, compared to 1% of the 185 adoptee control group.

Give 3 strengths for adoption studies.

• Research supporting

• Scientific evidence (percentages)

• Research shows a connection between genes and diagnosis.

Give 2 limitations of adoption studies.

• Tienara’s study was conducted in Finland, so it’s difficult to generalise to a wider pop.

• Both supporting studies lack temporal validity

• Still not 100% - other factors influencing

What are candidate genes?

Any gene thought likely to cause a disease. It may be because it’s located in a particular chromosome region suspected of being involved in the disease/its protein product may suggest it could be the disease gene.

How do candidate genes explain SZ?

SZ is thought to be polygenic (as many as 108 genes) meaning the explanation has little predictive power. Genes associated with the increased risk included those coding for the functioning of a number of neurotransmitters.

What is the dopamine hypothesis?

The brain of a schizophrenic produces more dopamine than a ‘normal’ person and has more D2 receptors than the average person, which has been shown to increase symptoms of SZ.

What system in the brain does dopamine belong to and what does it govern?

Dopamine is active in the limbic system, responsible for governing emotion and regulating attention.

What does the dopamine hypothesis say about neurons?

That neurons which transmit dopamine fire too often/easily and that the increase of D2 receptors results in more dopamine binding and therefore more neurons firing.

What 3 types of drugs affect SZ?

• Amphetamines

• Cocaine

• Anti-psychotic drugs

How do Amphetamines affect SZ?

As a dopamine agonist, this stimulates nerve cells containing dopamine, causing the synapse to become over-flooded, leading to the development of SZ symtpoms.

How does cocaine affect SZ?

Increases levels of dopamine, causing/exaggerating symptoms of SZ.

How do anti-psychotic drugs affect SZ?

As dopamine antagonists, they block the activity of dopamine in the brain, which reduces hallucinations/delusions.

What are the 2 strengths of the dopamine hypothesis? Give specifics.

1. Supporting evidence: L-Dopa (drug for Parkinson’s) increases dopamine and can produce symptoms similar to SZ.

2. Scientific evidence: Post-postmortems of SZs show an increase of dopamine/D2 receptors in parts of the brain. PET scans have found similar results.

What are the 2 limitations of the dopamine hypothesis?

1. Cause-and-effect cannot be established

2. Biological reductionism; there are many neurotransmitters involved, not just dopamine

What is the neural correlates explanation of SZ?

Neural correlates are measurements of the structure/function of the brain that occurs in conjunction with an experience (they correlate with experience). Both positive and negative symptoms have correlates and there’s growing evidence that SZ is down to structural abnormalities in the brain.

What are the neural correlates to the positive symptoms of SZ?

Reduced activity in the superior temporal gyrus and anterior cingulate gyrus has been linked with the development of auditory hallucinations. There are lower activation levels in these areas than controls for people experiencing SZ.

What are the neural correlates to the negative symptoms of SZ?

Activity in the ventral striatum has been linked to the development of avolition. The ventral striatum are thought to be involved in the anticipation of a reward for certain actions, so abnormality in this area would lead to avolition.

What neural correlate is there for SZ in general?

People with SZ have abnormally large ventricles (fluid filled cavities), meaning the brains of SZs are lighter than normal.

What are the first 3 neural mechanisms which may have neural correlates with SZ? What affect do they have on those suffering with SZ?

• Lower activity in the prefrontal cortex, where thoughts are rationalised/organised (linked to delusions+disorganised thoughts)

• Same activity in the visual and auditory cortex’s (where info. from the eyes and ears are processed) as people genuinely having visual/auditory experiences.

• A larger basal ganglia (affects movement+thinking skills) could cause motor dysfunction.

What are the last 2 neural mechanisms which may have neural correlates with SZ? What affect do they have on those suffering with SZ?

• smaller amygdala (responsible for basic feelings) which can lead to flattening

• Could either be low levels (neg. symptoms) or higher levels (pos. symptoms) as it’s responsible for pleasure.

What are the 2 strengths of neural correlates?

1. Scientific methods - MRI scans = an advance on simply relying on postmortems

2. more holistic than the other biological explanations

What are the 2 limitations of neural correlates?

• inconsistent findings, so therefore inconclusive

• issues of casuality (cause-and-effect cannot be established with brain abnormalities) - it’s still uncertain whether structural abnormalities predispose to SZ or whether SZ causes these changes

Overall, what are the 3 strengths of the biological explanations for SZ?

• Supporting evidence

• Scientific evidence (PETs)

• Real life application (drug therapies)

What are the 4 limitations of the biological explanations?

• no conclusive explanation as evidence has contradictory findings

• difficult to establish cause and affect

• enlarged ventricles may be the result of the medication

• reductionist methods/explanations

• deterministic in the assumption that SZ can be inherited and unavoidable.

• evidence for the diathesis-stress model

What is the most common therapy for SZ?

Drug therapies.

What are the two types of drugs for SZ?

There are two types of anti-psychotics:

• Typical

• Atypical

What is the most common type of the typical drug? Briefly give a description for it.

Chlorpromazine - can be administered by injects, tablets or syrup.

Tablets are taken daily, up to 100mg.

It’s also used as a sedative in a medical situation.

Which biological explanation does Chlorpromazine support? Why?

As an antagonist, Chlorpromazine blocks D2 receptors from binding, linking heavily to the dopamine hypothesis.

What is the difference between typical and atypical drugs?

Atypical is a newer form of drugs created to try and alleviate side effects such as dizziness, agitation, sleeplessness, weight gain etc.

What are the two types of atypical drug?

• Clozapine

• Rispendone

What is clozapine and what does it do? When is it used?

Taken in tablet form (300-450mg) each day, clozapine is used when other drugs are ineffective, or if risk of suicide is high. Binding to D2 receptors, it acts on serotonin and glutamate receptors (making depression symptoms less likely).

What are the positives and negatives of Clozapine?

POS- improved mood, reduced depression, may improve cognitive functioning.

NEG- can cause blood issues (risk of death), so blood tests needed.

What is Risperidone? Why is it considered good?

It’s the most recently developed medication for SZ (1990s). Risperidone binds to dopamine and serotonin receptors (stronger than clozapine).

POS- reduced side effects.

What are the 2 strengths of drug treatments?

• Typical and Atypical are known to be effective

• Supporting evidence - Thorny et al reviewed studies comparing chlorpromazine to control conditions (placebo). Chlorpromazine had better overall functioning and reduced severity of SZ and had a lower relapse rate.

What are the 3 limitations of drug treatments?

• drug treatments (especially typical) problems with side effects

• dopamine hypothesis isn’t a full explanation/ reductionist

• Abuse of human rights to give sedative as a medication

What are the three psychological explanations to SZ?

• Family dysfunction - the SZ mother

• Family dysfunction - Double-bind theory

• Family dysfunction - Expressed Emotion

Who was the SZ Mother theory proposed by? What approach does that come from?

Frieda Fromm-Reichmann (1948) proposed a psychodynamic explanation for SZ.

What does the SZ mother explanation believe?

That SZ is borne from childhood experiences.

SZ patients spoke about a cold, rejecting and controlling mother. This leads to distrust which later resulted in paranoid delusions and SZ.

What is the double-bind theory about?

Lack of clear communication can lead to SZ:

• mixed messages are given to the child, which confuses them.

(i.e “I hate you” whilst hugging)

What is Expressed Emotion about?

The emotions expressed (like verbal aggression, or over-involvement) towards the child creates stress for the patient which can cause a genetically vulnerable person to be triggered or relapse.

What do the cognitive explanations of SZ believe is disrupted?

• Disruption to normal thought processing

• Disruption in the ventral striatum is associated with negative symptoms (neural correlate).

• Disruption to the temporal lobes and cingulate gyri are associated with hallucinations.

What were the two kinds of dysfunctional thought processing which could underlie some symptoms proposed by Frith?

• Metarepresentation

• Central control

What is metarepresenation and central control?

Metarepresenation - Being able to control and be more logical in their thinking patterns. Having self-awareness in how to communicate and reflect - everyone should have it.

Central control - controlling thoughts/thinking patterns.

How does SZ affect metarepresenation and central control?

They are disrupted, so they lack control and reflectiveness, whilst being unable to control feelings/thoughts.

Give the strength for the double bind theory.

Evidence

Berger (1965) - Szs reported higher recall of double bind statements said by their mothers than non-szs.

Give the limitation for expressed emotion.

Individual differences

Altorfer (1998) - ¼ patients had no physiological responses to stressful comments.

Give the strength for the cognitive model of SZ.

Supporting research

Sarin and Wallin (2014) - pos. symptoms of SZ originate in faulty cognition, such as jumping to conclusions.

What do CBT therapists believe SZ causes?

Abnormal behaviour is the consequence of distorted and irrational thoughts.

What are the roles of CBT in SZ?

To help the patient identify and correct these beliefs by changing their thinking patterns by learning new behaviours and approaches.

What are the 5 steps of CBT?

1. Establish a therapeutic alliance

2. Psychoeducation

3. Normalise the symptoms

4. Cognitive and behavioral interventions (i.e. stress management techniques)

5. Reduce relapse by planning ahead.

What is the aim of family therapies?

To improve communication and interaction between family members. The therapists sees the family as the root cause of SZ.

What does family therapy do?

Reduces stress of the family and reduce levels of expressed emotion.

What are the 6 steps of family therapy?

1. Form a therapeutic alliance

2. Reduce stress of caring for a relative

3. Improve family’s ability to anticipate problems

4. reduce anger/guilt felt by family

5. Achieve balance between caring for sufferer and own lives

6. Improve families beliefs about SZ

What does Pharoah et al say about family therapies?

The aim to reduce expressed emotion increases a patients chance of complying with medication and has an overall reduced likelihood of relapse.

Give a strength for CBT in helping SZ. What’s the counter?

CBT is more effective in reducing rehospitalisation rates over standard care.

• NICE’s (2014) review supported this for up to 18 months after the conclusion of the patients treatment

• Patients of CBT were also found to show improvements in social functioning over patients receiving standard care

COUNTER: patients take medication alongside CBT, so difficult to determine the effectiveness of CBT alone.

What is the limitation of CBT?

Benefits of CBT may have been overstated.

• Jauhar et al’s (2014) meta analysis revealed only a ‘small’ therapeutic effect on key symptoms

What is the strength of family therapies?

Economic benefits due to a reduction in costs of hospitalisation (NICE review in 2009).

What is a limitation of family therapies?

Lack of blinding leads to an unintentional revealation of the therapy the participants received.(Pharoah et al meta-analysis, 10 of 53 didn’t use blinding techniques).

What is the aim of a token economy for helping those suffering from SZ?

To help manage those who have developed maladaptive behaviours. Token economy is a form of treatment/modification to manage or control this behaviour.

Give 4 examples of maladaptive behaviours and how they could be resolved using a token economy.

• Poor hygiene (i.e. a token for brushing teeth)

• Stopped socializing (3 tokens for interacting with other patients/staff)

• Lack of effective communication (i.e. 5 tokens for saying how they feel)

• Lashing out with hallucinations (10 tokens for acknowledging, not acting)

What is token economy based on? How?

Operant conditioning.

Rewards from tokens = primary reinforcers

Tokens = secondary reinforcers