sz AO3

Classification and diagnosis

There are issues with inter-rater reliability when diagnosing sz

Cheniaux et al (2009) had 2 psychiatrists independently diagnose 100 patients using both psychiatric manuals. Found that one psychiatrist diagnosed 26 using the DSM and 44 using the ICD whereas the other psychiatrist diagnosed 13 using the DSM and 33 using the ICD. The difference in diagnosis suggests there’s a disagreement between psychiatrists, making diagnosis subjective rather than objective, therefore leading to many people being potentially wrongfully diagnosed/undiagnosed.

Classification and diagnosis

There are issues with criterion validity when diagnosing sz

In the Cheniaux study both psychiatrists reached diagnoses of sz more frequently when using ICD compared to DSM. This means that at least one of the manuals must be incorrect - either ICD is over diagnosing or DSM is under diagnosing. Therefore accurate measurement of the condition is not occurring, as different countries use different manuals, again leading to a large number of patients who could be potentially inaccurately diagnosed.

Classification and diagnosis

High co-morbidity rates in sz suggest a lack of understanding about the illness

If conditions commonly occur together, the validity of the diagnosis is questioned as this could mean a different condition altogether, combining symptoms. Buckley et al (2009) reviewed diagnoses of sz and found that 50% of sz patients were diagnosed with depression, 47% substance abuse, 29% PTSD and 23% OCD. This would suggest that there may be an issue where psychiatrists are unable to tell the differnce between two disorders or that when two disorders appear in tandom, it may be a completely different, singular disorder. Therefore we still do not fully know the illness or the symptoms that accompany it.

Classification and diagnosis

There is an issue when diagnosing due to the degree of similarly between sz and other disorders

The symptoms of sz overlap with many disorders - such as bipolar which involves positive symptoms such as delusion are thinking and negative symptoms such as avolition. This not only makes it difficult to distinguish between disorders but also brings to question whether these two disorders are the same.

Classification and diagnosis

There is cultural bias diagnosing sz which is evident by higher rates of diagnosis in African-american and afro-carribeans

Pinto and Jones (2008) found that british people of afro-caribbean origin are 9 times more likely to be diagnosed with sz than white british people. Yet this is not the case in afro-caribbean countries - since this is not due to genetic vulnerability, there may be an issue with cultural bias when diagnosing. A case of western doctors diagnosing cases that are misinterpreted.

Classification and diagnosis

Much of the research conducted is based on gender stereotypes

Men are more likely to be diagnosed with sz compared to women on a ratio of 1.4:1. Cotton et al (2009) suggests that this is because women have closer relationships and have greater emotional support. This strong interpersonal functioning could mask the fact that they have sz/ severity of their sz. This questions how valid the procedure of diagnosis is, if it doesn’t work equally well on both genders.

Biological explanations

Although Gottesmans study provides overwhelming support for hereditary in the risk of developing sz, some findings detract from the role of genes

For example it states that identical twins only have a 48% risk despite the fact that 100% of genes are shared. This suggests that the role of genes is not a full explanation for sz, if it was, identical twins would possess 100% risk. Therefore other factors such as environment also play a role in the development of sz

Biological explanantion

Tienari study acts as research support for a genetic explanation

She found that 155 adopted children born to sz mothers had a concordance rate of 10%, compared to 1% in adopted children without sz mothers. This shows that despite removing the sz environment, the risk was still greater for those with a genetic dispotion. This study also shows that adoption is not a risk factor itself since the control group rates remained 1%. Not only does this add support for the genetic vulnerability for the illness, but also gives suggestions on how to improve the risk for those who are genetically vulnerable - placing them in a non-sz environment/home.

Biological explanation

Evidence from therapeutics to show the dopamine hypothesis

1. +DA through drugs

2. +DA in Broca’s area

3. Antipsychotics effect on DA

4. -DA in prefrontal cortex

Drugs that increase levels of dopamine (eg. amphetamines) produce psychotic symptoms - dopamine is therefore implicated in the symptoms of sz, supports hyperdopaminergia

Excess number of dopamine receptors found in Broca’s area - linked to speech production, helps explain disorganised speech and auditory hallucinations, as dopamine causes overactivity in Broca’s area

Antipsychotics that reduce sz symptoms do so by blocking the neurotransmitter for it - thereby reducing dopamine, further support for existence of hyperdopaminergia as a explanation for sz as it suggests that reduced dopamine reduces symptoms

Low levels of dopamine have been linked to negative symptoms of sz - supporting the hypodopaminergia hypothesis, symptoms such as avolition are said to be the cause of low dopamine activity in the prefrontal cortex

Biological explanation

However there are some issues associated with evidencing the causal influence of dopamine

High levels of dopamine could actually be a symptom of sz rather than a cause, suggesting an unknown third factor could be causing sz. Clozapine is the most effective drug at reducing sz symptoms - works because it acts on seratonin, meaning that it must also be involved in sz. Therefore dopamine hypothesis is not a complete explanation. Inconsistencies in evidence means that our understanding of the role of dopamine in development is inconclusive, difficult to accept this as a sole explantion, better to take a interactionist approach and consider all factors.

Psychological explanation

Supporting res reach for the importance of family dysfunction in development of sz

Read et al (2005) - 69% of women and 59% of men with sz had a history of physical/sexual abuse. Additionally resreach by Berry et al (2008) showed that adults with insecure attachments are more likely to have sz. This shows that unhealthy family dynamics, early trauma and poor r/s with pcg may mean a higher risk of developing sz.

Psychological explanation

Further support specifically for double bind communication comes from Berger (1965)

Found that sz patients reported a higher recall of double bind statements by their mothers than non-sz. Although this shows support for role of family dysfunctions, we have to be careful when interpreting such findings as data from this study was collected retrospectively and caution should be exercised as the recall of sz patients may be unreliable. Looking at prospective studies such as Tienaris, only a weak link between sz and fd has been identified. Therefore as findings are somewhat inconsistent, it is difficult to pinpoint exactly what role of family is in development of sz, may be more contributory rather than causal.

Psychological explanations

The cognitive explanation allows for more clinical experimentation than the family explanation and so there is a wealth of evidence illustrating cognitive dysfunction in sz sufferers

For example Stirling et al (2006) found pps with Sz took over twice as long to complete the stroop task than controls. This is because they struggled with “Central Control” i.e the ability to suppress automatic response as they were unable to suppress the impulse to read the word rather than the ink colour. Additionally, Meyer-Linderberg (2002) found reduced activity in the prefrontal cortex of Szs when they did a task involving the Wisconsin Card Sorting Test. Due to deficits in working memory consistent with cognitive dysfunction. These highly controlled lab studies provide empirical support for the CD explanation making it a credible explanation.

Psychological explanation

Some theorists believe the Cognitive Dysfunction explanation offers a more complete account of Sz compared to Family Dysfunction

This is because it is highly probable that sz has some basis in biology and CD can be traced back to neurological abnormalities in the brain (likely to be inherited trait or chemical). Additionally CD can account for both positive and negative symptoms whereas FD only accounts for positive.Therefore when considering the best explanation, an interaction between faulty cognition and faulty biology seems to make more sense and explain more aspects of the behaviours and symptoms experienced with Sz

Biological therapy

There is empirical evidence to show the effectiveness of Chlorpromazine

For example, Thornley et al (2003) reviewed 1121 cases from 13 drug trials and found that Chlorpromazine was associated with greater functioning when compared with a placebo. Additionally they found chlorpromazine reduced the risk of relapse compared with no treatment. Suggesting Chlorpromazine clearly works at reducing the symptoms of schizophrenia in the short term and over time

Biological therapies

There is evidence from Meltzer (2012) which supports the effectiveness of clozapine

He found that not only was clozapine more effective than other atypical antipsychotics but also particularly effective in treatment-resistant cases. In 30-50% of such cases patients were able to improve functioning despite have little to no success with typical drugs. This shows that Clozapine is a powerful drug and can be useful in cases where there seems little hope left

Biological therapies

There are quite a number of side effects associated with typical antipsychotics which range from mild to fatal

Users can experience mild side effects including sleepiness and weight gain. More seriously users often experience tardive dyskinesia - a disorder which causes involuntary facial movements such as grimacing, lip-smacking and blinking. However, the most serious of all is NMS where blocking dopamine in the hypothalamus can lead to coma or even death. This suggests that the side effects involved in typical antipsychotics may, at worst, outweigh the advantages gained from using them and, at best, affect compliance rates

Biological therapies

There are limited side effects associated with atypical antipsychotics as they were developed specifically to address this issue

However there is still one major side effect which is arangulocytosis - dangerous blood disorder which affects immune system functioning. For this reason this drug cannot be given in injection and users must have regular blood checks. This may affect the sustainability as patients may be more reluctant to use it.

Biological therapies

Some have circuses the use of drugs, particularly atypical, for the calming effect they have on patients

It is thought that this effect, while beneficial to hospital staff, is only acting as a chemical striatjacket for the patient. However such effects might be considered necessary to keep the patient from harming themselves or others in order to allow therapy to have an opportunity to work. Therefore important that the practioner weighs up benefits and costs.

Biological therapies

There are multiple issues with may of the studies used to support the effectiveness of drug treatments

Firstly, when under the placebo condition, Ross and Read point out the patient is usually in a withdrawal state as they’ve had their antipsychotic replaced with an inert substance. This means their dopamine receptors are suddenly flooded with dopamine. at much greater levels that they would usually experience. Secondly, according to Healy (2012) some of the successful trials showing the effectiveness of drug therapy have been published multiple times, inflating their success. Studies also ignore the success of placebos - while the antipsychotic may have a greater effectiveness, the placebo condition often show some degree of effectiveness too, highlighting the importance of the patients psychology in their recovery. All of this indicates that we should be wary when making direct comparisons in drug treatments and to consider who funds these trails - drug companies may often benefit from the positive outcomes.

Psychological therapies

There is mixed research looking at the effectiveness of these psychological therapies

Jauhar et al (2014) reviews the results of 34 studies of CBT in treating sz. They concluded that it had a significant but fairly small effect on positive and negative symptoms. Pharoah et al (2010) reviewed evidence on the effectiveness of family therapy on sz sufferers. They concluded that although there was moderate evidence to show that it reduces hospital admissions and improve quality of life for both patients and families, there was inconsistencies in findings. MC Monagle and Sultana (2009) reviewed evidence for token economy and found only 3 studies which used random allocation to assign patients to a condition - of these only one found an improvement in improvement of symptoms and none found evidence of behaviour change. Overall, there is only modest support for effectiveness of psychological therapies and sz remains one of the harder mental health problems to treat. Making this a limitation of psychological treatments.

Psychological treatments

However the research into effective on life quality is more positive

CBT allows patients to make sense of and challenge some of their symptoms. Family therapy helps to reduce the stress of living with a family member who has sz, both for the patient and other family members. Token economy works by making the patients behaviour more socially acceptable so that they can better reintregrate into society. All of these therapies will in some way improve life quality of the patients and help them understand their symptoms. Additionally they will allow the pateint to return to a more positive family environment, and become better suited to society reducing chances of relapse.

Psychological therapies

In general much more ethically sound than biological therapies

CBT: Although generally considered to be ethically sound, when challenging a patient’s paranoia, CB therapists may be accused of interfering with their freedom of thought. E.g. when challenging a belief about a controlling government, this maybe considered an attempt to modify their political views

Family Therapy: Risk of social coercion - family members may not wish to participate in the the therapy but feel obliged to. Also the therapist will have to work hard to remain neutral and avoid taking sides

Token Economy: Rewards become more available to those with milder symptoms as they are more able to engage in positive behaviours. This leads to discrimination of those who are severely affected

Overall, although there are a number of ethical issues associated with treatments for sz, in comparison with drug treatment they are considered less concerning and therefore looked upon more favourably.However, issues such as victimisation and social control are potentially possible meaning that all psychological treatments must be conducted with the utmost care and diligence.

Interactionist approach

Support for the diathesis stress model comes from Tienari (2004) in her investigation into genetic vulnerability

and parenting style (trigger)

E: She studied 19,000 children who were born to mothers of sz in Finland from 1960-1979 and adopted into

non-sz families

E: She assessed the adoptive parents on child-rearing styles and compared the children with a control group with

no genetic risk.

E: She found child rearing styles associated with high levels of criticism and conflict and low levels of empathy

was implicated in the development of sz but only in those from the experimental group where there was a genetic

risk

L: This is clearly strong support for the model but also it reduces the blame directed onto the parents that

parenting style is a causal factor

Interactionist approach

Interactionist treatments are considered to be superior to any other form of treatment

E: Tarrier (2004) showed this in his study of 315 patients who were randomly allocated to either a medication +

CBT condition, medication + supportive counselling condition or a control group of medication only

E: He found those patients who engaged in a combination therapy had a greater reduction in severity of

symptoms than those treated only with drugs

L: This clearly shows the advantage of an interactionist approach to treatment rather than solely psychological or

biological treatments

Interactionist approach

We should be careful not to fall victim to treatment-causation fallacy when looking at solely

biological/psychological approaches

E: This is the assumption that because the treatment works that the cause must be whatever the treatment

treats....e.g. assuming that if drugs work that Sz is caused by excess dopamine or because CBT works that Sz is

the result of faulty cognitions

E: This is dangerous as often therapies treat the symptoms not the underlying cause meaning the real cause of sz

may just be suppressed by drug treatment or family therapy and as soon as therapy stops the symptoms return

L: Diathesis-Stress avoids this as a combination of treatments allows both the symptoms and the causes to be

addressed in tandem and therefore likely to have a greater impact

Interactionist approach

It is hard to argue with an interactionist approach based on research support and how it addresses the flaws of

other explanations

E: Biological approaches and psychological approaches have come in and out of favour over the

years—psychological explanations fell by the wayside when it was realised how important genes were. But

nowadays there is a greater significance placed on psychological triggers such as stress.

E: Twin studies are the perfect example of how interactionism is important in the onset of Sz as because, whilst

both twins will have inherited the same genes, they may experience different interactions within the family,

different stressful life events, or a different pre-natal environment in terms of placenta size and nutrition.

Therefore, the diathesis may be triggered in one twin but not the other.

L: It seems adopting either of the extremes on the heredity/environment debate is a mistake. Most theories have

now abandoned extreme positions and research is now pursuing the acknowledgment and influences of both

environmental and biological factors and trying to figure out exactly in which ways they interact to lead to the

development of schizophrenia