Schizophrenia

What are the two major classification systems used to diagnose schizophrenia?

What are the two major classification systems used to diagnose schizophrenia?

ICD 10 and DSM 5

What is the main difference between them?

DSM 5 - positive symptoms must be present, ICD 10 - two or more negative symptoms are sufficient for the ICD

What problems would this cause?

If a patient with negative symptoms goes to a psychiatrist who uses the ICD 10 they would likely get a schizophrenia diagnosis but if they went to someone who uses DSM 5 they would likely not.

What are positive symptoms of schizophrenia?

Can be described as ‘pathological excess’. Most commonly associated with type 1

What are negative symptoms of schizophrenia?

Can be described as ‘pathological deficit’. More commonly associated with type 2.

What are some positive symptoms of schizophrenia?

Delusions of grandeur, control and persecution, hallucinations, heightened perceptions, disorganised thinking and speech.

What are some negative symptoms of schizophrenia?

Anhedonia, restricted affect, social withdrawal, alogia, and avolition.

What are 4 issues with the diagnosis and classification of schizophrenia?

Reliability, Validity, Co-Morbidity, and System Overlap.

What does reliability mean and how is it an issue of the classification and diagnosis of schizophrenia?

Reliability means consistency and is the level of agreement on the diagnosis by different psychiatrists across time and cultures.

What does validity mean and how is it an issue of the classification and diagnosis of schizophrenia?

Validity is the extent to which you measure what you intend to measure and is the extent to which schizophrenia is a unique syndrome with characteristics, signs and symptoms. all assessment systems arrive at the same diagnosis every time.

What does co-morbidity mean and how is it an issue of the classification and diagnosis of schizophrenia?

Co-morbidity is when two or more conditions occur together in the same person at the same time. e.g type 2 diabetes is often co morbid with heart disease. If conditions are often co morbid then it questions the validity of the diagnosis as it may suggest that it is one incorrectly diagnosed condition.

What is symptom overlap and how is it an issue of the classification and diagnosis of schizophrenia?

Symptom overlap is the extent to which the symptoms of one disorder are also present in a different disorder e.g bipolar also involves positive and negative symptoms. which causes issues for diagnosis and classification. Patient may get schizophrenia diagnosis using ICD but bipolar using DSM.

How is gender an issue of the diagnosis and classification of schizophrenia?

Men are more likely to be diagnosed possibly due to women being better at managing symptoms. Also, clinicians fail to consider that males tend to suffer more negative symptoms than women and have higher levels of substance abuse.

How is culture an issue in the classification and diagnosis of schizophrenia?

People from African American/ Afro Caribbean origin are more likely to be diagnosed due to bias from the psychiatrist.

What is a limitation of issues in classifying and diagnosing schizophrenia? (reliability and validity)

• Evidence for the issues of reliability and validity can be seen in research from Cheniaux et al

• 2 psychiatrists diagnose 100 people using the DSM or ICD. Number - 1 diagnosed 26 people with sz using DSM and 44 with sz using ICD. Number 2 - diagnosed 13 people with sz using DSM and 24 with sz using ICD

• shows that not only do psychiatrists not agree on a diagnosis but the multiple assessment systems used are not measuring same thing

• this is a limitation as it shows poor inter-rater reliability and poor criterion validity.

• however, ICD and DSM do offer recommended treatment plans and help patients recover.

What is a limitation of issues in classifying and diagnosing schizophrenia? (comorbidity)

• Evidence for the issue of co morbidity comes from Buckley et al

• sz is highly comorbid with depression- 50%, PTSD-29%, and OCD- 23%

• research from ketter also suggests bipolar has symptom overlap with sz which may lead to misdiagnosis.

• therefore, this suggests individuals with multiple diagnoses may have one incorrectly diagnosed disorder and many patients with sz may get a wrong diagnosis of bipolar, so validity of diagnosis is questioned

• however, serper et al found it is possible to distinguish between symptoms of multiple disorders e.g sz + cocaine abuse and comorbidity doesnt impact validity of diagnosis.

What is a limitation of issues in classifying and diagnosing schizophrenia? (gender + culture)

• Evidence for the issue of gender bias comes from Loring and Powell

• 290 randomly selected male and female psychiatrists asked to read two articles of patients behaviour and asked them t offer judgement using standard diagnostic criteria. 56% of patients described as “male” or no info given about gender diagnosed with sz, 20% of “female” patients diagnosed with sz

• research from Harrison et al suggests those of west indian origin were over diagnosed with sz by white doctors from bristol because of ethnic background.

• therefore, suggests that diagnosis is influenced by not only gender of patient but also their culture, people like men or someone from different culture may be more likely to be misdiagnosed due to gender or culture.

what is the main assumption of the genetic explanation of schizophrenia?

schizophrenia is inherited - passed on in your genes

what did Gottesman find about genes and schizophrenia?

• mz (identical) twins have a 48% risk of developing sz because they share 100% of their genes.

• dz (non identical) twins have a 17% risk of developing sz because they share 50% of their genes

• siblings have 9% risk of developing sz because they share 50% of their genes

• parents have 6% risk of developing sz because they share 50% of their genes

• general population have 1% risk of developing sz

what are candidate genes and how do they link to schizophrenia?

candidate genes is a gene that is believed to be related to a particular trait e.g sz

what does polygenic mean?

it means it requires a number of factors to work in combination

what does aetiologically heterogenous mean?

it means caused by many different genes

how many genetic variations are involved with sz?

108 genetic variations

What is a strength of the genetic explanation for schizophrenia?

• research support for the genetic basis of sz from Gottesman

• he found that increased genetic familiarity leads to a greater risk of developing

• for example, general population have 1% risk of schizophrenia, DZ twins have 17% risk of developing sz, MZ twins have 48% risk of developing sz

• this is a strength as it shows that as % of shared DNA increases, so does risk of developing sz, increasing validity of explanation

• however, if sz was purely genetic, concordance rates for MZ twins should be 100%, mean some other factor must play a role, e.g environment, therefore genetic explanation is biologically deterministic

What is a limitation of the genetic explanation for schizophrenia?

• cannot separate the effects of nature and nurture

• family and twin studies look at families who share genetics, but also share same home environment

• could be argued that high concordance rates in MZ twins due to them being treated similarly and experiencing the same things at the same time

• therefore, this is a limitation of genetic explanation as environment acts as a confounding variable and reduces validity of explanation

• furthermore, family + twin studies often rely on retrospective studies which are methodologically flawed as there are often inaccuracies and omissions in peoples memories.

What is a limitation of the genetic explanation for scizophrenia?

• research suggests a genetic cause can be triggered by mutations

• this mutation can occur in parental DNA e.g in parental sperm cells. this can be caused by radiation, poison or viral infection

• evidence for role of mutation comes from Malaspina et al which shows positive correlation between paternal age and risk of sz, increasing from 0.7% with fathers under 25 to over 20% in father over 50

• however, two thirds of people with sz have no relative with a diagnosis therefore , there is no genetic basis.

What is dopamine and what does it regulate?

dopamine is a neurotransmitter that helps control pleasure, motivation and satisfaction. Dopamine also helps regulate movement and emotional responses, and it enables us to not only see rewards but to take action to move toward them.

what is hyperdopaminergia and how is it related to schizophrenia?

it is when there is an excess amount of dopamine in the subcortex. and in relation to sz, an excess of dopamine in Broca’s area may linked to disorganised speech or poverty of speech.

what is hypodopaminergia and how it is related to schizophrenia?

it is when there are low or abnormal dopamine levels in the cortex. and in relation to sz, the prefrontal cortex is responsible for decision making and thinking, and low levels may lead to disorganised thoughts or avoltion.

What is a strength of the dopamine hypothesis?

• the effectiveness of typical antipsychotics

• typical antipsychotics such as chlopromazine work by blocking the amount of dopamine the post synaptic cell receives

• this reduction in dopamine works to reduce symptoms of sz and helps patients recover

• this strength for the dopamine hypothesis as the effectiveness of the treatment gives credit tot he proposed cause, increasing validity

• however, atypical antipsychotics such clozapine are the most effective treatment for sz and work on multiple neurotransmitters like dopamine, serotonin and glutamate. this suggests multiple neurotransmitters are involved in the development of sz and the dopamine hypothesis is a reductionist explanation

What is a limitation of the dopamine hypothesis?

• high levels of dopamine could actually be a symptom of sz

• Lloyd et al believed that if dopamine is a causative factor, it may be an indirect one, mediated through environmental factors.

• this is because abnormal family circumstances can lead to high levels of dopamine, ehich in turn triggers sz symptoms

• this suggests that its best to be careful when establishing cause and effect relationships in schizophrenic patients

• furthermore, the differences in the biochemistry of schizophrenics could just as easily be an effect rather than a cause of the disorder

What is another strength of the dopamine hypothesis?

• schizophrenia sufferers have more dopamine receptors

• having more receptors may lead to more neural firing and therefore an over production of messages

• research from Owen et al has shown that autopsies have found that there are generally a larger number of dopamine receptors in schizophrenics.

• these studies indicate that there is evidence of dopamine abnormalities in the brains of people who suffer from sz.

What does the neural correlates explanation suggest about schizophrenia?

it suggests that certain brain structures show abnormalities in schizophrenic patients and may be linked to specific symptoms of schizophrenia

What are the Anterior Cingulate Gyrus and Superior Temporal Gyrus linked to?

They are linked to auditory associations and recognition of abnormal behaviour.

What are low levels of activity in the Anterior Cingulate Gyrus and Superior temporal Gyrus linked to?

Hallucinations - there is a negative correlation between activity in the ACG and positive symptoms

What is the Ventral Striatum linked to?

anticipation there is a negative correlation between activity in the ventral striatum and negative symptoms

What are low levels of activity in the Ventral Striatum linked to?

Avolition

what is a limitation of the nerual correlates theory?

• we cannot be sure whether the brain regions functioning inadequately causes sz or if they are functioning inadequately due to the sz

• therefore, the neural correlation theory has a correlation - causation problem.

What is a limitation of the neural correlates theory?

• inconclusive research

• Weyandt reported that enlarged ventricles are linked with negative symptoms only

• similarly, many patients with sz do not have structural abnormalities and some people without sz do have structural abnormalities

• this is a limitation because it does not consider positive symptoms and this explanation cannot explain all symptoms and types of the illness which reduces reliability

What is a strength of the neural correlates theory?

• research support

• Ho et al performed MRI scans on recent onset sz and then re scanned them 3 years later

• they found evidence of brain damage in the recent onset patients, which worsened over time even thought they were on medication

• this suggests brain damage does increase in schizophrenics over time, for example as the persons sz continues their brain structure continues to change for the worse.

How did we use to treat psychological disorders?

trepanning, bloodletting, mental asylums, electroconvulsive therapy and drugs

What is the most common treatment for schizophrenia and how is it taken?

Antipsychotics, and they can be taken as a tablet or as a syrup, they can also be given as an injection every 2-4 weeks.

What can antipsychotics be divided into?

Typical antipsychotics or Atypical antipsychotics

What type of antipsychotic is Chlorpromazine?

Chlropromazine is a typical antipsychotic

How does Chlorpromazine work?

It works through dopamine agonists, which block dopamine receptors in the brain reducing the amount of dopamine the post synaptic cell receives.

What are the side effects of Chlorpromazine?

A 30% chance of Dyskinesia which are uncontrollable movements of the jaw, lips and tongue. Some side effects also include sedation, akathisia and a dry mouth.

Which symptoms do Chlorpromazine target?

It targets positive symptoms like hallucinations.

Which type of antipsychotic are Clozapine and Risperidone?

They are atypical antipsychotics.

How does Clozapine and Risperidone work?

They work on multiple neurotransmitters such as dopamine, serotonin, and glutamate. They temporarily bind to dopamine receptors and then dislocate allowing some dopamine to pass.

What are the side effects of Clozapine and Risperidone?

A 5% chance of Dyskinesia. Akathisia, sedation, weight gain, and a dry mouth.

What symptoms do Clozapine and Risperidone target?

They target negative symptoms like avolition and are better for combination symptoms.

What is a strength of drug therapy? (treatments for schizophrenia)

• it is effective at reducing symptoms of sz

• individuals who take antipsychotics experience a reduction in their symptoms in particular positive symptoms

• the use of antipsychotics allows many individuals to live relatively normal lives, outside of institutions. it is estimated that less than 3% of people with sz in the UK live in a hospital permanently

• this is a strength for drug therapies as it shows that they work to reduce symptoms and improve quality of life for the vast majority of individuals who take them making them a liable treatment.

• however, many argue that drugs are only palliative meaning that they treat the symptom and not the cause, so when individuals stop taking them their symptoms return.

What is a strength for drug therapies? (treatments for schizophrenia)

• antipsychotics are more effective than placebos

• research indicates that patients are less likely to relapse on antipsychotics than when on placebos

• for example, Lecht et al found patients were 27% likely to relapse on antipsychotics but 64% likely in placebos

• this is a strength as it shows that the antipsychotics do work to improve symptoms and reduce relapse rates and the effects are not purely placeboic.

• furthermore, they found that many individuals do not relapse after taking antipsychotics the 73% in Lecht’s study may indicate that drugs do help to treat the proposed cause.

What is a limitation of drug therapies? (treatments for schizophrenia ethical issues)

• ethical issues

• if side effects, death and social consequences are taken into account, a cost-benefit approach wold most probably be negative

• In the USA a large out of court settlement was awarded to a tardive dyskinesia sufferer by the Human Rights Act 1988

• also, many within the psychiatric community see the widespread use of antipsychotics as being filled by the powerful influence of drug producing potential negatives outweigh the positives and suggest there is no need to use them at all

• other therapies such as CBT are also effective at treating sz, suggesting no need for the drugs.

What are the characteristics of a Schizophrenogenic Mother?

• Overprotective but rejecting

• cold + dominant

• Appears self-sacrificing but uses the child to satisfy her own emotional needs

• Ineffectual, passive husband - results in negative skew, when one spouse denies negative qualities of the other spouse

How does the Schizophrenogenic Mother link to sz?

• Individuals brought up with this mothering style develop sz as they are confused by their mothers overprotective but rejection nature.

What did Bateson suggest about Double Bind Theory?

Bateson et al agreed that family climate is important in the development of sz but emphasised the role of communication style within the family.

Where does the developing child find themselves?

Trapped in situations where they fear doing something wrong but receive mixed messages about what this is, and feel unable to comment on the unfairness or seek clarification.

How is the child punished when they ‘get it wrong’?

With withdrawal of love.

How does withdrawal of love leave the child feeling?

This leaves them understanding that the world is confusing and dangerous, and is reflected in symptoms like disorganised thinking and paranoid delusions.

What does prolonged exposure to double bind theory prevent the child from doing?

It prevents the development of an internally coherent construction of reality.

What is Expressed Emotion?

The level of emotion, in particular negative emotion, expressed towards a patient by their carer.

What are the characteristics of high Expressed Emotion?

• verbal criticism of the patient, occasionally accompanied by violence

• hostility towards the patient, including anger + rejection

• emotional over-involvement in the life of the patient

How does EE make the individual feel?

These high levels of emotions by the carer to the patient are a serious cause of stress for the patient

Causal factor or relapse?

Primarily explains relapse in patients with sz - the researchers stated that this is more important in maintaining sz than in causing it in the first place.

What is a limitation for Double Bind Theory?

• little research support

• there is a lack of any supporting evidence for DB theory, but where it does exist it is weak

• for example, Bateson recalled a case study where a sz patient was hugged by his mother, she stiffened when he hugged her, he withdrew and asked ‘dont you love me?’

• this singular example of DB statements in one individual is not enough to make reliable conclusions about the theory and highlights the lack of research support

• however, Berger states that sz’s do recall a higher proportion of DB statements from their mothers

What is a strength of Expressed Emotion?

• research support

• Kavanagh conducted a meta-analysis of sz patients returning home after a hospital admission

• 48% of those returning to high EE families relapsed but only 21% of those returning to non EE families relapsed

• this is a strength as it suggests high EE is a causal factor in increased relapse rates increasing validity of the explanation

• however, not all patients who live in high EE families relapse and not all patients who live in low EE families avoid relapse

What is a limitation of family dysfunction?

• don’t consider that having sz may be the cause of the family dysfunction

• living with a family member who has sz can be very challenging and disruptive for a family

• many have argued that this disruption is a consequence of having a family member with sz, rather than the cause of sz

• therefore this is a limitation as they may not be considering the true cause of the illness reducing the validity

• furthermore, not all individuals with sz come from dysfunctional families and not all dysfunctional families have sz members therefore other factors must play a role and family dysfunction is overly deterministic

What did Frith et al identify?

2 kinds of dysfunctional thought processing

What is the first type of dysfunctional thought processing?

Metarepresentation

What is Metarepresentation?

The ability to reflect on thoughts and behaviour - it allows insight into our own intentions and goals and interpret the actions of others.

How does Metarepresentation link to sz?

Not being able to recognise our own actions and thoughts as being carried out by ourselves rather than someone else. this may result in us interpreting our own thoughts as external voices (auditory hallucinations)

What is the second type of dysfunctional thought proccessing?

Central Control

What is Central Control?

The cognitive ability to suppress automatic responses while we perform deliberate actions instead. Word association may trigger an automatic response.

What link does Central Control have to sz?

Dysfunction here could lead to disorganised thoughts + speech as individuals lose the ability to stop automatic responses.

What is Bias?

Preference or favouring one thing/idea

What is Selective Attention?

Only focusing on certain things, cognitively.

Delusions? (Cognitive Biases + Selective Attention)

Others are trying to harm or kill them (persecutory delusions)

What are Delusions linked to?

Biases in reasoning. Others people cause things to go wrong with their lives.

Auditory Hallucinations? (Cognitive Biases + Selective Attention)

People see themselves in terms of their social relationships. Some people see themselves as powerless compared to other, more powerful people around them.

What are Auditory Hallucinations linked to?

Bias in self-perception. We think we are worthless.

What is a strength of Cognitive Explanations? (RS)

• Research Support from Sterling et al

• compared 30 patients with sz against 18 control ppts on a range of cognitive tasks including the stroop test

• they found that those with sz too 2x longer to complete the stroop test indicating they were struggling to process the information

• this is a strength as it suggests that there is impaired processing in sz increasing the validity of the explanation

• however research also indicates that biological factors e.g neurotransmitters are also involved in sz which are not considered in the explanation

What is a limitation of cognitive explanations for sz?

• Cause and Effect

• cognitive explanations for sz argue that cognitive deficits, biases and dysfunctional thought processing leads to sz symptoms

• however these explanations do not explain where the deficits and biases come from in the first place

• this is a limitation because we cannot be sure whether cognitive processes have caused sz or simply a symptom of the sz therefore this reduces the validity.

What is another strength of the cognitive explanation for sz?

• Practical Application

• yellowless et al developed a medicine that induced symptoms of sz e.g virtual hallucinations

• they intended to show patients that their hallucinations are not real and were successful at reducing symptoms

• therefore this is a strength as it suggests that understanding the effects of cognitive deficits allows psychologists to help patients and improve their quality of life, increasing the validity of the theory

• furthermore research from Sarin + Wallin reviewed research and found patients with the symptoms showed various biases in their information processing.

What is the aim of Cognitive Behavioural Therapy?

To identify irrational thoughts and try to change them.

What is the first step in CBT?

Identify irrational thoughts.

What is the second step in CBT?

Challenging beliefs and reality testing to reduce distress and provide less-threatening alternatives

What is the third step of CBT?

Use of positive self-talk and coping strategies that can help to target specific symptoms

What is the fourth step of CBT?

Cognitive restructuring through ABCDE framework

• Identifying activating event (A),

• exploring beliefs (B),

• recognising consequences (C),

• disputing irrational beliefs (D),

• restructured belief (E)

What is the aim of Family Therapy?

To improve the quality of communication and interactions between family members and to reduce the levels of expressed emotion.

How does Family Therapy work?

Pharaoh et al identified a range of strategies to improve the functioning of a family:

• Forming a therapeutic alliance with all family members

• Reducing stress of caring for a relative with sz

• Improving the ability of the family to anticipate and solve problems

• Reduction of anger and guilt of family members

What are Token Economies used for?

To manage behaviour of patients with sz in particular those who have developed patterns of maladaptive behaviour through spending long periods of time in psychiatric hospitals.

How do token economies work?

• Tokens are given immediately when a desirable behaviour is shown.

• Immediacy of rewards stops ‘delayed discounting’.

• Rewards given in exchange for tokens. Based on operant conditioning - Tokens become secondary reinforcers because people associate them with material things such as sweets, cigarettes, magazines etc.

What is a strength of the effectiveness of Family Therapy?

• Research support for the role of family therapy in treating sz

• Pharoah et al reviewed studies looking at family therapy in sz

• they found family therapy significantly reduces hospital readmissions and improves patient and family quality of life

• therefore the effectiveness of the therapy in the real world increases its validity

• however, there are inconsistencies in the quality of the evidence, reducing the reliability of the research

What is a limitation of the effectiveness of Token Economies?

• limited research support for the effectiveness of token economies

• McMonagle + Sultana found only 3 studies where patients had been allocated to treatment + control groups

• the studies consisted of a total of only 110 patients and only 1 in 3 showed any improvements in behaviour

• therefore, this is a limitation as the lack of research support and inconsistencies reduces the reliability of the treatment

• however, TE does help to improve quality of life for patients by promoting socially acceptable behaviour

Why are ethical issues a limitation in CBT?

• CBT does not allow patients to have freedom of thought - some have argued that challenging a patients paranoia is interfering with freedom of thought

• for example, if a patient had paranoid delusions about a controlling government, then challenging this may lead to modifying their political view

• this is a limitation because it questions the ethics of CBT and whether it is a suitable treatment at all

• however, some would argue that the benefit of the patient improving outweighs this issue

Why are ethical issues a limitation in Family Therapy?

• there are issues with confidentiality and family therapy. if a patient shares something in therapy, a family member may use that against them at a later date

• individuals may feel obligated to share something with their family that they did not want to

• therefore this is a limitation as it questions the ethics of family therapy and whether it is a suitable treatment for sz

• however, antipsychotics are the most widely used treatments for sz and have more serious ethical concerns.