Schizophrenia

What are positive symptoms?

Additional experience beyond ordinary schizophrenia experience.

• Hallucinations= unusual sensory experiences- hearing voices commenting on others in a critical way or seeing people/ animals that are not there.

• Delusions= irrational beliefs- the mafia is after them. Other delusions concern the body where they behave in a way that makes sense to them but bizarre to others.

What are negative symptoms?

Loss of usual abilities and experiences

• Apathy (avolition)= loss of motivation and difficulty keeping up and achieving goals- poor hygiene, lack of persistence and lack of energy.

• Speech poverty= change in speech pattern, accompanied by delaying the verbal responses- speech disorganisation (changing topic and becomes incoherent)

What is Co-morbidity?

Occurrence of two disorders together- 50% of schizophrenics also have depression.

What is Symptom overlap?

Occurs when 2 or more disorders share symptoms. Calls into question whether 2 disorders are really separate. Depression includes avolition and Bipolar includes delusions.

What is a strength of the classification of schizophrenia?

P= High reliability

E= Prior to the DSM-5, reliability for SCZ diagnosis was low, but this has now improved. Osorio et al (2019) reported 180 individuals being diagnosed using the DSM-5. Pairs of interviewers achieved inter-rater reliability of +.97 and test-retest of +.92.

L= Diagnosis can be consistently applied when using the DSM.

What are the weaknesses of the classification of schizophrenia?

P= Diagnosis has low criteria validity

E= Cheniaux et al (2009) had 2 psychiatrists, one using DSM and one using ICD, assess 100 patients. 39 were diagnosed with schizophrenia under DSM criteria, 68 under ICD.

L= Schizophrenia is over and under diagnosed. Under: people aren’t receiving treatment- dangerous to themselves and others. Over: harmful side effects and waste of treatment.

P= Gender biased

E= Men are more likely to be diagnosed with SCZ by a ratio of 1.4:1. Women may be underdiagnosed due to the higher likelihood of support networks to help manage stress

L=Viewed in 2 ways- either men lack support networks, making SCZ more damaging for men, or that women are underdiagnosed, meaning they don’t receive specialist treatment.

What is inter-rater reliability?

Different clinicians make identical independent diagnosis of the same patient

What is test-retest reliability?

The same or different clinicians make same diagnosis on separate occasions.

What is predictive validity?

If treatment given is successful then diagnosis is valid- e.g. anti-psychotic medication reduces psychosis.

What is descriptive validity?

If patients who have schizophrenia have similar symptoms and these are different from other disorders than diagnosis is valid.

What is Criterion Validity?

If different systems (ICD AND DSM) arrive at the same diagnosis then it is valid.

What is the genetic basis of SCZ?

Family studies- risk of SCZ increases if there is genetic similarity.

What did Gottesman twin study meta-analysis show for genetic susceptibility?

• More related (genetically similar) you are with the SCZ person, more likely you are going to have it.

• Must be environmental factor because it would be 100% for identical twins, not 48%.

• Clear genetic basis for SCZ

What are the candidate genes in SCZ?

Increases vulnerability and is polygenic- Ripke et al found 108 separate genetic variations in 37,000 SCZs compared to a control group of 113,000- associated with production of dopamine. Becoming aetiologically heterogenous.

What is aetiologically heterogenous?

Different combinations of candidate genes lead to different lustres (set) of symptoms.

What is the role of mutation in SCZ?

Mutation in parental DNA (by radiation, poison or viral infection) Risk increases from 0.7% with fathers from under 25 to 2% in father over 50.

Explain the concept of genetic vulnerability?

Genetic vulnerability refers to the inherited characteristics passed from parents to offspring, making it more likely that the offspring are at risk of disease.

What are the strengths and weaknesses for the genetic basis of SCZ?

S P= Strong evidence base

E= Gottesman showed that risk increases with genetic similarity to a family member. Adoption studies  show that biological children of parents with SCZ still have a high risk of developing SCZ even when raised in an adoptive family. A concordance rate of 33% for identical twins and 7% for non-identical.

L=Even when the environment of SCZ is removed (via adoption), likelihood of getting SCZ still increases.

W P=Clear evidence of environmental factors increasing the risk of SCZ

E= Morkved et al- 67% of those with SCZ experienced childhood trauma vs 38% of a control group with non-psychotic related mental health problems.

L= Biological reductionist- shows that childhood trauma has a significant impact on risk of SCZ.

What is the original dopamine hypothesis?

Discovery that antipsychotics reduce dopamine therefore SCZ result in hyperdopaminergia in subcortical areas. Excess of dopamine receptors in pathways to Broca’s area (speech production) explain speech poverty or auditory hallucinations.

What is the evidence for the biochemical explanation of SCZ?

Randrup and Munkvad (1966)- see whether schizophrenic symptoms could be induced in animals by giving them amphetamines (dopamine agonists which worsen SCZ symptoms by release dopamine at central synapse). Injecting rats with doses of 1-20mg/kg of amphetamines. Concluded that experiments with a number of different animals (chickens, pigeons, cats, dogs and squirrels) showed stereotyped SCZ activity can be produced by amphetamines. 

What is the updated dopamine hypothesis?

David- cortical hypodopaminergia explains cognitive problems in prefrontal cortex (responsible thinking). Cortical hypodopaminergia leads to subcortical hyperdopaminergia (both high and low dopamine levels). The hypothesis argues this occurs due to genetic variations, early experiences of stress (physical and psychological)

What are the strengths and weaknesses for the neural basis of SCZ?

S P= Research support role of dopamine

E= Curran et al (2004)- amphetamines increase dopamine and worsen symptoms for those with SCZ and induce SCZ symptoms for people without SCZ. Tauscher et al (2014)- Antipsychotic drugs reduce dopamine and reduce SCZ symptoms. Thirdly candidate genes act on the production of dopamine.

L= All 3 of these factors support the role of dopamine in SCZ

W P= Evidence for the role of the neurotransmitter glutamate

E= Post mortem and live scanning studies have found high levels of glutamate in several regions of a SCZ’s brain.

L= This suggests that the dopamine hypothesis may be an incomplete neural explanation for SCZ.

What is a Typical Antipsychotics?

Traditions drugs around 1950s, like chlorpromazine (dopamine antagonists). Max 1000mg, although initial doses are much smaller.

What are Dopamine Antagonists?

Reduce the action of a neurotransmitter and block dopamine receptors in the synapse of a brain- reducing dopamine. Initially dopamine levels build up and then production and symptoms are reduced. Normalises neurotransmission in key areas of the brains

What is Chlorpromazine?

Dopamine antagonist and has sedative effects- due to histamine receptors yet it is not understood how it creates sedation. Used to calm anxious patients and people with SCZ. Better at treating + symptoms than -

Side effects= hallucinations and movement related.

What are Atypical Antipsychotics?

Newer drugs to maintain or improve effectiveness in suppressing symptoms of psychosis and minimise side effects.

What is Clozapine?

Binds to dopamine receptors and also acts on serotonin and glutamate receptors, improving mood and reduce depression and anxiety. Work against positive and negative symptoms.

Side effects= Suicidal thoughts and blood clots (animal study)

What is Risperidone?

Binds to dopamine and serotonin receptors and binds more strongly to dopamine than clozapine, effective in smaller doses- fewer side effects. Work against both symptoms.

What is the aim of Bagnall’s study?

To compare effectiveness, safety and cost of typical and atypical antipsychotic drugs for SCZ. Compare effectiveness for “resistant“ SCZ, as well as those just diagnosed.

What was the procedure of Bagnall’s study?

171 randomly controlled trials, and 52 non-randomised trials. Data was also taken from 31 economic evaluations of antipsychotics treatments. Data was analysed by 2 independent researchers.

What were the findings for Bagnall’s study?

Atypical drugs were all more effective in reducing symptoms, with the exception of 2 (Quetiapine and Sertindole).

Clozapine was more effective than other typical antipsychotic drugs in improving negative symptoms.

There was no real difference in the drugs when treating first onset SCZ.

No clear difference in the drugs when patients also had substance abuse problems, or other issues such as depression.

Fewer patients taking atypical drugs dropped out of the study.

Atypical drugs caused fewer movement side effects.

Atypical and typical drugs both induced similar levels of nausea and vomiting.

Atypical drugs are more expensive overall than typical ones.

What was the conclusion of Bagnall’s study?

Atypical drugs are more effective overall, although no one drug can be seen as superior in all treatment cases. All have their issues and must be suited to the patient. Sertindole was removed as a prescription drug in 1999 as it was linked to heart failure.

What are the strengths of anti-psychotic drugs?

P= Thornley et al (2003) found that chlorpromazine was effective.

E= Increase confidence in clinicians in administrating the drugs and patients taking the drugs- increase the validity of the treatment.

CP= Meltzer (2012) found that atypical anti-psychotics were more effective

P= Patients often welcome drug therapy as it is quicker, easier and less threatening than “talking therapies“

E=Symptoms, like avolitation, speech poverty, hallucinations prevent effective “talking therapies“ difficult to communicate their feelings and leave the house- easier to take drugs

CP= Drugs may only be used as a “chemical cosh“.

What are the weaknesses of anti-psychotic drugs?

P= Serious side effects such as uncontrollable limb and facial movements.

E= Impact- serious side effects leads them not to take the drugs, decreasing the chance of improvements.

CP= Atypical anti-psychotics were produced to reduce side effects.

P=Much of the original research into antipsychotics was completed using animals

E= Difficult to generalise- Chlorpromazine creates blood clots leading to death but they didn’t know as they tested animals. Different mental processes and structures.

CP= we are unable to test them on humans

What is a strength of drug therapy?

P= Supportive evidence for both typical and atypical in reducing SCZ symptoms

E= Thronley et al reviewed studies comparing the effects of chlorpromazine to control conditions (placebo). Data with 1121 ppts showed chlorpromazine was associated with better overall functioning and reduced symptoms. Meltzer found clozapine is more effective than typical and other atypical anti-Ps and effective in 50% treatment resistance cases where typical anti-Ps have failed.

L= Cheap and effective, helping people return to a normal life- better than CBT, links to paranoid delusions

What are weaknesses in drug therapy?

P= Side effects

E= E.g- dizziness, agitation, sleepiness, weight gain and itchy skin. Long term- tardive dyskinesia, dopamine super sensitivity and causes involuntary facial movements (blinking and lip smacking). Severe Typical AP side effect- neuroleptic malignant syndrome, blocking dopamine actions in the hypothalamus which regulates body systems. Results in high temp, coma and can be fatal- 2% effected.

L= APs can do harm as well as good. Side effects may lead to people stopping medication- symptoms worsen.

P= Chemical cosh

E= APs, particularly chlorpromazine are potentially used to calm people with SCZ to make it easier for staff to work with them rather than actually benefitting those with the disorder.

L= Numbs someone than treating them- questions how ethical it is.

What is the schizophrenogenic mother?

Psychodynamic explanation by Reichman (1948) heard accounts of her SCZ patient’s childhood. Many spoke about a particular type of parent- mother is cold, rejecting and controlling, creating a family climate characterised by tension and secrecy. Develops distrust and paranoid delusions.

What is the double bind theory?

Bateson- Communication style within a family- child fear they are doing the wrong thing but get mixed messages. When they get it wrong, they are punished by withdrawal of love- world understanding of confusion and danger (reflects disorganised thinking and paranoid delusions). Only a risk factor and not the case for all SCZs and not the only cause.

What is expressed emotion?

Negative emotions expressed towards someone with SCZ by a carer who is often a family member. Includes:

• Verbal criticism accompanied with violence.

• Hostility (anger)

• Rejection and emotional overinvolvement- unnecessary self-sacrifice from family.

Triggers stress which can explain relapse and develops onset of SCZ for someone who is vulnerable due to their genetic makeup (Diathesis stress model).

What is a strength for family dysfunction explanations?

P= Research support of family dysfunction and SCZ.

E= Dysfunction can include insecure attachments, trauma and abuse. Read et al found most SCZ adults had and insecure attachments with 69% of SCZ women and 59% of men had a history of abuse either physical or sexual.

L=Family dysfunction creates vulnerability to SCZ.

CP= Correlational doesn’t equal causation- only correlation where genetics may cause behaviour difficulties- SCZ children may be more vulnerable.

What are the weaknesses of family dysfunction explanations?

P= No evidence base for schizophrenogenic mother and double bind theory.

E=Theories are based on clinical observations of people with SCZ and informal assessments of mother’s personality which is not systematic evidence.

L= These theories therefore do not need the scientific standards needed to define a theory as valid.

P= Socially sensitive as it can lead to parent blaming 

E= Mothers seems to be particularly blamed. For parents who already watch their child go through this, take on care and then to be blamed is highly problematic.

L= Even lead to mental health problems for the mother- child’s care could worsen and SCZ would become more severe as a result.

What is dysfunctional thinking?

Disruption to normal thought processing in the ventral striatum (associated with negative symptoms- speech poverty and apathy). Reduced information processing in temporal and cingulate gyri (positive symptoms- hallucinations)

What is meta-representation dysfunction?

Disrupt our ability to recognise our own actions and thoughts as being carried by ourselves rather than someone else- explains hallucinations of hearing voices or delusion.

What is central control dysfunction?

Inability to suppress automatic thought and speech triggered by other thoughts- derailment of thought because each word triggers associations which they cannot suppress.

What is a strength for cognitive explanation of SCZ?

P= Evidence for dysfunctional thought processing

E= 30 with SCZ and 30 without (CG) completed the Stroop test (name font colours of colour words), meaning they have to supress the tendency to read the words aloud. SCZs took twice as long.

L= Shows cognitive processes are impaired particularly their central control function.

What is a weakness for cognitive explanation of SCZ?

P= Cognitive explanation can only explain proximal origins of symptoms- explaining what is happening now to produce symptoms rather than what caused the condition.

E= This causes could be genetic or family dysfunction, not addressing how genetic variation or childhood trauma might lead to cognitive problems.

L= Partial explanation- meaning method for treating cognitive dysfunction is not clear.

How does CBT (cognitive behavioural therapy) treat for SCZ?

Helps people make sense of and manage their hallucinations or delusions. E.g. understanding that voices are not coming from the devil, but instead from a malfunctioning Broca’s area.

Work with the patient to examine the likelihood that their delusions are true- e.g. the likelihood that the Mafia is after you. Plus, normalising voices as an extension of their own thinking can help to cope with anxiety. 

What is a strength of CBT for SCZ?

P= Research support

E= Juahar (2014) meta analysis of 24 studies using CBT for SCZ- found small but significant reduction in positive and negative symptoms.

L=Meta-analysis provides a large evidence base for the effectiveness of CBT.

CP= Small reduction in symptoms- costly treatment but not that effective.

What is a weakness of CBT for SCZ?

P= Poor quality of evidence

E= Wide range of techniques and symptoms used- different number of sessions. Different symptoms, e.g. dealing with anxiety vs challenging delusions.

L= Means it is hard to know which types of CBT are effective, and which symptoms are improved.

What is family therapy?

Aims to:

• reduce negative emotions- reduces stress. Reducing anger and guilt being expressed by the family towards patient- reduce symptoms.

• Improves the family ability to cope- family educated on SCZ and best forms of support and a balance between care and maintaining their own lives is formed.

• Further model- aims to identify what support each family member can (and cannot) offer, aims to develop specific techniques to manage stress, relapse prevention and finally planning for the future.

What are the strengths for family therapy?

P= Research support

E= Meta-analysis by McFarlane (2016) found that family therapy reduced relapse by 50-60%. Family therapy also found to be effective for people in early and more advanced stages of SCZ

L= meta- analysis provides a large evidence base for the effectiveness of family therapy

P= Wide benefit

E= Research has found that family therapy reduces the burden of schizophrenia on the rest of the family who provide the bulk of the care. This shows the wider benefit of family therapy.

L= Family therapy can give family tools to support the schizophrenic family member and improve their own lives

What is the weakness of family therapy?

P= Not cost effective

E= Combined therapies of both drug treatments and family therapy cannot be offered as it is very expensive, decreasing the accessibility for range of patients.

L=Less patients can access treatment from different socio-economic backgrounds, increasing symptoms and waiting lists.

What is token economies for SCZ?

Reward systems used to manage behaviour and can be used for people with SCZ.

Allyon and Azrin (1968)= token economy on SCZs in a psychiatric facility- found giving token to exchange for rewards, increasing positive behaviours. H= token economies now in decline due to the ethical concerns and change from approach of long term hospitalisation.

What is rationale for token economies?

Long periods of institutionalisation lead to development of bad habits (bad hygiene or stopping socialising). Matson (2016) claimed TE can improve personal care, condition related behaviours (apathy), improve social behaviour.

What are the 2 major benefits of token economies?

• Improve quality of life within the hospital setting (e.g. increased social interaction)

• Normalises important behaviours in the outside world (e.g. getting dressed)

What is involved in token economies?

• Target behaviours are identified on an individual basis

• Tokens are given immediately following correct behaviour

• Tokens are exchanged for rewards such as a film or special food.

What is the theoretical understanding of token economies?

Behaviour modification uses operant conditioning.

• Token is secondary reinforcer (does not hold value, but linked to the reward)

• Reward (e.g. watching a film) is primary reinforcers- as this is the thing the person really wants.

What is a strength of token economies?

P= Research support for effectiveness

E= Glowacki et al (2016) identified seven high quality studies which looked at the use of token economies on people with chronic mental health issues in a hospital setting. All studies showed significant reduction in negative symptoms and decline in frequency of unwanted behaviour

L= Token economies can improve behaviour of those with SCZ.

What the weaknesses for token economies?

P= Ethical issues

E= Seriously ill people may be denied simple pleasures such as sweets- meaning their quality of life gest even worse. Legal action has even been taken in certain cases. Additionally, the hospital has ahigh degree of control over the “target behaviours“- if not identified sensitively, individuals can be harmed

L= Potential harmful effects of TE if not used appropriately.

P= Better alternatives

E= Art therapy has been identified as a “high gain, low risk“ alternative to token economies.

L= There is doubt about whether token economies are the best way of managing SCZ.

CP= There is, as of yet, limited research support for art therapy.

What is the diathesis stress model?

Diathesis means vulnerability (children trauma, candidate genes, neural factors, drug use). Stress means negative experience. Model says both vulnerability and stress is needed to develop SCZ. The onset of the disorders is therefore caused by stress (short-term- exams, arguments, relationships, trauma, abuse, drug use).

What is the original diathesis-stress model?

Meehl’s model- believed vulnerability was entirely due to a single “schizogene“. Without, no amount of stress could cause SCZ. This gene and chronic childhood stress (schizophrenogenic mother) would often lead to SCZ.

What is the modern understanding of diathesis?

Believed SCZ is polygenic which increases vulnerability. Plus childhood trauma now seen as part of the vulnerability (diathesis), altering developing child’s brain. Hypothalamic-pituitary-adrenal (HPA) system can become overactive, making a person much more vulnerable to later stress.

What is the modern understanding of stress?

Includes aspects of upbringing, such as neglect, a modern definition also includes anything that risks triggering SCZ.

E.g. Cannabis use has been found to increase risk of SCZ by up to 7X depending on dose- cannabis interferes with dopamine system.

What are the strengths for the interactionist approach?

P= Research support

E= Tienari et al (2004) investigated the combined impact of genetic vulnerability and environmental triggers in a large scale study of 19,000 finish children whose mothers had SCZ. High risk group was compared to similar group without family history (low genetic risk). Results showed child rearing with criticism, hostility and low levels of empathy was strongly linked to developed of SCZ but only in the group with genetic vulnerability.

L= Shows that combination of genetic vulnerability and family stress can lead to increased risk of SCZ.

P=Real world application- combination of treatments is effective.

E= Research showed lower symptoms in combined CBT and drug treatments group compared with drug only group. Therefore treatment outcomes are significantly improved using the interactionist approach.

L= Therefore treatment outcomes are significantly improved using the interactionist approach.

What is a weakness for the interactionist approach?

P= Diathesis-stress is complex.

E= Old understanding of a single gene is very outdated. Stress is also hard to understand with many risk factors often playing a part, and it is hard to understand what role each of them play.

L= Environmental factors such as abuse can also effect diathesis, so talking about stress and vulnerability as separate is overly simplistic.