A Level Psychology, 4.3.5 - Schizophrenia

• Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity, culture and gender bias and symptom overlap. • Biological explanations for schizophrenia: genetics and neural correlates, including the dopamine hypothesis. • Psychological explanations for schizophrenia: family dysfunction and cognitive explanations, including dysfunctional thought processing. • Drug therapy: typical and atypical antipsychotics. • Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia. Token economies as used in the management of schizophrenia. • The importance of an interactionist approach in explaining and treating schizophrenia; the diathesis-stress model. (AQA)

Classification - DSM5 (AO1)

• Only one positive symptom (delusions, hallucinations) needed to be present for diagnosis.

• Places emphasis on ______________________ (classified as a _______________ symptom), rather than ___________________. Speech can often become incoherent if the speaker changed topic mid-sentence.

• ______________ omitted from current DSM edition, even though they were present in previous editions.

Classification - DSM5 (AO1)

• Only one positive symptom (delusions, hallucinations) needed to be present for diagnosis.

• Places emphasis on ______________________ (classified as a _______________ symptom), rather than ___________________. Speech can often become incoherent if the speaker changed topic mid-sentence.

• ______________ omitted from current DSM edition, even though they were present in previous editions.

speech disorganisation / positive / speech poverty / subtypes

What are the characteristics of paranoid schizophrenia?

powerful delusions & hallucinations but few other symptoms

What are the characteristics of hebephrenic schizophrenia?

mainly negative symptoms

What are the characteristics of catatonic schizophrenia?

movement disturbance leaving sufferer immobile or inactive

Classification - ICD10 (AO1)

• Needs ____________________________.

• Recognises sub-types of schizophrenia (_______________________________).

• Categorises ___________________ as a ____________ symptom because of the reduction in the amount and quality of speech, as well as a delay in verbal response during conversations.

2+ negative symptoms / paranoid, hebephrenic & catatonic / speech poverty / negative

Classification - Positive Symptoms (AO1)

• Those that are not present in non-schizophrenic individuals - include hallucinations and delusions.

• Hallucinations are ________________________, such as hearing voices, that are not present in the environment. These voices can be very critical.

• Hallucinations can also be visual, such as seeing people who aren’t there.

• Delusions are _____________________ that can take many forms, such as believing you are a famous historical figure or under surveillance by the government.

unusual sensory experiences / irrational beliefs

Classification - Negative Symptoms (AO1)

• Involve the loss of usual abilities and experiences. Symptoms include avolition (or apathy) and speech poverty.

  • Avolition includes _______________________, such as personal hygiene, lack of persistence and lack of energy.

  • Speech poverty involves ____________________________.

goal directed behaviour difficulty / speech pattern changes

Classification - Reliability & Validity (AO1/3)

• ____________________: measures if two observers agree.

• _______________________: the same doctor giving the same diagnosis over time with the same symptoms

• In the context of schizophrenia, validity questions if a person has the disorder when diagnosed, or if schizophrenia is a real disorder with clear and unique symptoms.

  • 3 supporting researches?

• Comorbidity: schizophrenia is often diagnosed with other disorders. This could lead to an inaccurate diagnosis of Schizophrenia when it could be a severe case of depression.

• Symptom overlap: ____________ disorder also has hallucinations and delusions as a symptom (positive). If the two disorders are so similar, they may not be distinct and should be redefined.

  • Supporting research?

inter-rater reliability / test-retest reliability / Beck, Cheniaux & Rosenhan / bipolar / Buckley

Classification - Reliability & Validity: ________ (1963) (AO3)

• Found _____ patients diagnosed by multiple doctors had only a ______ concordance rate between the doctor's X assessments.

• Lack of agreement suggests there is low ___________________ in diagnosing Schizophrenia.

• Also suggests many people are diagnosed incorrectly (low validity), potentially receiving inappropriate treatments.

Beck / 153 / 54% / inter-rater reliability

Classification - Reliability & Validity: ____________ et al. (2009) (AO3)

• Investigated the reliability of schizophrenia diagnosis.

• _______ patients were diagnosed by different psychiatrists using both ICD and DSM criteria.

• Results showed poor reliability.

• One psychiatrist diagnosed ____ patients according to DSM and _____ according to ICD, while another psychiatrist diagnosed ___ (DSM) and ___ (ICD).

Cheniaux / 100 / 26 / 44 / 13 / 24

Classification - Reliability & Validity: Rosenhan (1973) (AO3)

• The main study is an example of a field experiment. The manipulation (independent variable) was the made-up symptoms of the 8 pseudo (fake) patients, and the dependent variable was the psychiatrists' admission and diagnostic label of the pseudo patient.

• The study also involved participant observation, since, once admitted, the pseudo-patients kept written records of how the ward operated, as well as how they personally were treated. They telephoned hospitals for appointments and all reported the same symptom, ‘I hear a voice saying thud, empty or hollow’.

• All were admitted and all except one given a diagnosis of schizophrenia. They remained in hospital for 7 to 52 days (average 19 days). Visitors to the pseudo patients observed “no serious behavioural consequences”. Although they were not detected by the staff, many of the other patients suspected their sanity (35 out of the 118 patients voiced their suspicions).

• Some patients voiced their suspicions very vigorously for example ‘You’re not crazy. You’re a journalist, or a professor. You’re checking up on the hospital’.

• The study demonstrates both the limitations of classification and, importantly, the appalling conditions in many psychiatric hospitals. This has stimulated much further research and has led to many institutions improving their philosophy of care.

What did Buckley (2009) find? What were these?

comorbidity rates / depression 50% / drug abuse 47% / PTSD 29% / OCD 23%

Classification - Reliability & Validity (AO1/3)

• Gender bias: Cotton argues women's experience of Schizophrenia is taken less seriously and underdiagnosed compared to men due to women's better _______________________ leading to being less likely to seek treatment. This better interpersonal functioning might lead to practitioners under-diagnosing schizophrenia in women.

• Culture Bias: People with Afro-Caribbean heritage in the UK are up to nine times more likely to be diagnosed with Schizophrenia. Fernando argues this is due to "___________________" when Western definitions of mental illness are applied to people from non-western cultures.

  • 3 supporting researches?

• 2 overall supporting researches?

social coping strategies / category failure / Escobar, Pinto & Taitimu / Loring + Powell & Copeland

Classification - Reliability & Validity: ______________ (1988) (AO3)

• Sent ________ psychiatrists 2 identical case studies (altering ethnicity and gender).

• Findings: overdiagnosis if the case study claimed to be of a ________ client and underdiagnosis if the case study claimed it was of a __________ client. The most accurate diagnosis was when the __________________________ were the same as in the case study.

• Suggestions: existence of gender and cultural bias in psychiatrists’ diagnoses of Schizophrenia.

Loring + Powell / 290 / black / female / psych’s gender & race

Classification - Reliability & Validity: ____________ (2012) (AO3)

Suggested that, because the psychiatric profession is dominated by white people, psychiatrists might be _________________ symptoms and _______________ the honesty of black people during diagnosis.

Escobar / over-interpreting / distrusting

Classification - Reliability & Validity: _________ (2008) (AO3)

• Some symptoms of schizophrenia seen as acceptable in some cultures would be seen as atypical in others.

• For example, a study of ________________ showed that they deemed hearing voices to be completely normal.

Taitimu / 80 Maori people

Classification - Reliability & Validity: _________ (2017) (AO3)

• Meta-analysis of databases from ____________, studying schizophrenia and other psychotic disorders in Caribbean-born migrants and their descendants in England to investigate the increased risk of schizophrenia in Black Caribbean people and their descendants.

• FIndings: statistically significant elevated incidence rates in the Black Caribbean group were found, present across all major psychotic disorders, including schizophrenia and bipolar disorder.

• Suggestions: in the UK, Black Caribbean’s are more likely to be diagnosed with mental illness than their white counterparts.

Pinto / 1950-2013

Classification - Reliability & Validity: ______________ (1971) (AO3)

• Studied American psychiatrist diagnoses vs British to investigate cultural variations in the diagnosis of schizophrenia.

• Have ____ US and ____ British psychiatrists a description of a patient.

• _____ of the US psychiatrists diagnosed schizophrenia, but only _____ of the British ones gave the same diagnosis.

• Diagnosis of schizophrenia is not very reliable between cultures.

• Shows that mental illness can be a __________________.

• Lacks ecological validity - giving a diagnosis from a description is different to seeing a patient in real life.

Copeland / 134 / 194 / 69% / 2% / cultural construct

Psychological Explanation - Family-Based (AO1)

• Family dysfunction: schizophrenia symptoms are due to the interpersonal relationships within the family.

• ____________________ (_________________________): a psychodynamic theory, paranoid delusions result from the influence of a cold, rejecting and controlling mother & a passive father.

  • An atmosphere of stress & secrecy triggers _______________________.

• Double Bind Theory (______________): due to mixed messages, feels unable to do the correct thing.

  • Results in ___________________________.

• Theory of Expressed Emotion: Verbal interactions, _______________________, indicating the sufferer is a burden via self-sacrifice.

  • Criticism & control of the sufferers behaviour.

  • Physical & verbal emotional hostility towards the sufferer = rejection.

schizophrenogenic mother / Fromm-Reichmann / psychotic thinking / Bateson / disorganised thinking & paranoia / exaggerated involvement

Psychological Explanation - Cognitive (AO1)

• _________’s Theory of Mind (1992) identified two kinds of dysfunctional thought processing that could underlie some symptoms:

  • ________________

  • ______________________

Frith / central control / meta-representation

Psychological Explanation - Cognitive: Central Control (AO1)

• Refers to the ability to ____________________ while performing deliberate actions.

• Malfunction could explain ___________________.

suppress automatic responses / disorganised speech & thought

Psychological Explanation - Cognitive: Meta-Representation (AO1)

• Refers to the cognitive ability to reflect on thoughts and behaviours - gives individuals insight into their own _________________, as well as the ability to __________________________.

• Dysfunction would disrupt our ability to recognise our own actions and thoughts as being carried out by ourselves rather than somebody else.

  • Would explain ___________________, such as hearing voices and delusions, as internal thoughts believed to have originated in the environment.

  • Would also explain other symptoms, such as ______________________, where patients believe that others have projected thoughts into their mind.

intentions & goals / interpret others’ reactions / hallucinations / thought insertion

Psychological Explanation (AO3)

• _______________________ to suggest that the family causes Schizophrenia, as this is likely to cause additional stress and anxiety.

• Research evidence that Schizophrenia has a biological cause such as genetics (________________) and neurotransmitters (__________).

• Evidence is _____________________, and it could be that having a schizophrenic child is the cause of family dysfunction.

socially sensitive / Gottesman / Leucht / correlational

Psychological Explanation - Cognitive: _______________ (2006) (AO3)

• Compared 30 patients with a diagnosis of schizophrenia with 18 non-patient controls on a range of cognitive tasks, like the ______________.

  • In this, participants are asked to name the colour of the ink that a word (naming a different colour) is written in. Participants need to ___________________ to read the word to complete the task.

• Findings: Patients took _________________ to name the ink colour as the control group.

• Suggestions: supports the ___________________________.

Stirling / Stroop test / impulse suppress / over twice as long / central control theory

Psychological Explanation - Cognitive: _____________ (2004) (AO3)

• Studied children adopted from _____________________ with schizophrenia between 1960 and 1979. Adoptive parents assessed for child rearing style.

  • Found that the child rearing style characterised by high levels of ____________________ and lower levels of _____________ was implicated in the development of schizophrenia.

  • This was only true of children with high _______________ and not for children in the control group.

• Only _______ of biological children of schizophrenic mothers adopted into psychologically healthy families developed schizophrenia, compared to ________ of children adopted into dysfunctional families.

Tienari / 19000 Finnish mothers / criticism & conflict / empathy / genetic risk / 5.8% / 36.8%

Psychological Explanation - Cognitive: _____________ (1978) (AO3)

• Compared paranoid & nonparanoid schizophrenics to normal controls on a ______________________ - permitted separation of times taken.

• Findings: both groups of schizophrenics took the same amount of time as the normal controls for __________________________. However, both took longer for ____________________________.

• Suggestions: the cognitive deficits were in the short term & ____________________ of the schizophrenics.

Neufield / sentence verification task / response selection & execution / central scanning & comparison operations / working memory

Who’s research can be used to support the psychological cognitive explanation?

Neufield, Tienari, Stirling

Who’s research can be used to support the biological genetic explanation?

Tienari, Joseph

Biological Explanation - Genetic: ___________ et al (2000) (AO3)

• Findings: of the 164 adoptees whose biological mothers had been diagnosed with schizophrenia, _______ also received a diagnosis of schizophrenia, compared to just ____ of the 197 control adoptees (those born to non-schizophrenic mothers).

• Suggestions: the investigators concluded that these findings showed that the genetic liability to schizophrenia had been ‘decisively confirmed.’

Tienari / 6.7% / 2%

Biological Explanation - Genetic: ___________ (2004) (AO3)

• Calculated the pooled data for all schizophrenia twin studies carried out prior to ________.

• Findings: concordance rate for MZ twins of _______ and for DZ twins ________.

Joseph / 2001 / 40.4% / 7.4%

Biological Explanation - Dopamine Hypothesis: Drugs Increasing Dopaminergic Activity (AO1)

• ______________________ is a dopamine ____________ i.e. it stimulates nerve cells containing dopamine, causing the synapse to be flooded with this neurotransmitter.

• ‘Normal’ individuals who are exposed to large doses of dopamine-releasing drugs such as these can develop the characteristic hallucinations and delusions of a schizophrenic episode.

• This generally disappears with ________________ from the drug.

amphetamine / agonist / abstinence

Biological Explanation - Dopamine Hypothesis: Revision by ____________________ (1991) (AO1)

• Proposed that the positive symptoms of schizophrenia are caused by an excess of dopamine in _______________ areas of the brain, particularly in the ___________________ pathway.

• The negative and cognitive symptoms of schizophrenia are thought to arise from a deficit of dopamine in areas of the ______ (the _____________________). Evidence for this revised hypothesis comes from various sources.

Davis + Kahn / subcortical / mesolimbic / pfc / mesocortical pathway

Biological Explanation - Dopamine Hypothesis - __________ (2002) (AO3)

Some Parkinsonions, low levels of dopamine, who take the drug ___________ to raise their dopamine levels have been found to develop schizophrenia type symptoms.

Grilly / L dopa

Biological Explanation - Dopamine Hypothesis - __________ (2010)(AO3)

• Used _______________ to assess dopamine levels in schizophrenic and normal individuals.

• Found lower levels of dopamine in the __________________ of schizophrenic patients compared to their normal controls.

Patel / PET scans / dorsolateral pfc

Biological Explanation - Dopamine Hypothesis - ____________________ (2008)(AO3)

• Induced _________________________ in the prefrontal cortex in rats.

• Resulted in cognitive impairment (e.g. memory deficits) that the researchers were able to reverse using __________________, an ____________ antipsychotic drug thought to have beneficial effects on negative symptoms in humans.

Wang + Deutch / dopamine depletion / olanzapine / atypical

Who’s research can be used to support the biological dopamine hypothesis explanation?

Grilly, Patel, Wang + Deutch

Biological Treatment (AO1)

• ___________ antipsychotics (developed in 1950s).

  • Act as antagonists to the dopamine system (a collection of nerve cells in the brain), reducing the action of dopamine (a chemical messenger in the brain) by blocking dopamine receptors in the synapses.

  • Supports the dopamine hypothesis. The dopamine hypothesis says that the dopamine system of schizophrenia patients is overreactive.

• ______________ antipschotics: designed to improve the effectiveness of typical antipsychotics and reduce side-effects. Not always known how function.

typical / atypical

Biological Explanation - Genetic: _____________________ (AO3)

• Children with two schizophrenic parents had a concordance rate of _______.

• Children with one schizophrenic parent a rate of ______.

• Siblings (where a brother or sister had schizophrenia) a concordance rate of ____.

• Gottesman (1991): MZ twins ______ concordance rate; DZ _______

Gottesman + Shield / 46% / 13% / 9% / 48% / 17%

Biological Treatment - Typical: _________________ (AO1)

• One of the oldest drugs used in the treatment of schizophrenia. Administered as tablet, a syrup or through an injection (max dose _______ mg daily, increased gradually).

• Initially after taking, dopamine levels typically rise before falling.

• Normalises neurotransmission in key brain areas, reducing symptoms such as hallucinations.

• Also useful as a sedative. Reasons unclear but relation to effect on ___________________.

• Most often used to calm patients upon arrival at hospital with increased feelings of anxiety

chlorpromazine / 100 / histamine receptors

Biological Treatment - Atypical: ____________ (AO1)

• First developed in 1960’s. First trialled in the 1970’s before being briefly withdrawn following the deaths of some patients from a blood condition called ________________________. Re-marketed because of its success in the treatment of resistant schizophrenia that hadn't responded to other treatments.

• Daily dosage: ________mg to _______mg.

• Binds to dopamine receptors. Unlike Chlorpromazine, it also acts on _________________________, which is thought to improve mood and reduce depression and anxiety.

• Because of its mood-enhancing properties, often used with patients at high risk of suicide (_____% to ____% schizophrenic sufferers attempt suicide).

clozapine / agranulocytosis / 300 / 450 / serotonin & glutamate receptors / 40 / 50

Biological Treatment - Atypical Antipsychotics: ______________ (AO1)

• Developed in the 1990’s. Less side-effects than clozapine.

• Administered in tablet, syrup and injection, with the injections lasting about two weeks (increasing doses up to max _____ mg).

• Thought to bind to _________________________, but binds more strongly to dopamine receptors than __________________. This makes it more effective in smaller doses.

risperidone / 12 / dopamine + serotonin receptors / Clozapine

Biological Treatment - Typical Antipsychotics: Side-Effects (AO3)

• Long-term can result in ____________________________, which is related to dopamine supersensitivity and leads to involuntary muscle movements such as grimacing and blinking.

• ___________________________ is a condition that leads to high temperature, delirium, coma and sometimes death.

  • Affects between ____% and _____% of those taking antipsychotics, although this has been reduced because of the lower dosage levels of newer drugs.

tardive dyskinesia / neuroleptic malignant syndrome / 0.1 / 2

Biological Treatment - Strengths (AO3)

• ___________ et al. (2003) conducted a review of studies (____ trials of _________ participants) comparing the effects of Chlorpromazine to controls who received a placebo.

  • Concluded that Chlorpromazine was associated with better overall functioning and the reduction of symptom severity.

  • Also found that in ____ trials of ___________ participants, Chlorpromazine __________________.

• __________ (2012) - typical antipsychotics have been found to be effective in _____% to ______% of treatment of resistant cases, that is, where other typical antipsychotics have failed.

Thornley / 13 / 1121 / 3 / 512 / reduced relapse incidences / Melzer / 30 / 50

Biological Treatment - _________ (1998) (AO3)

• Placed patients randomly into ____________________ (anti-psychotics), ________ or a _____________________________.

• FIndings: patients in the combined treatment significantly improved the severity and number of _____________________ as well as ______________________ in the X hospital receiving care.

• Suggestions: drug therapies are effective but better when combined with psychological therapies.

• Further conducted meta-analysis of _____ studies of CBT published between ________ & _______ involving ________ patients.

  • CBT significantly reduced positive symptoms and was especially beneficial to those suffering a short-term acute schizophrenic episode.

Tarrier / routine care / CBT / combined treatment / positive symptoms / fewer days / 14 / 1990 / 2004 / 1484

Psychological Treatment - CBT (AO1)

• Assumes that Schizophrenia results from dysfunctional thought processes.

• A primary aim of CBT is to help patients make sense of their delusions and hallucinations and the impact they have on their behaviour.

• ABC (DE) model by Ellis: The therapist's role is to identify and challenge irrational beliefs by logically disputing (D) the reality of the faulty cognitions (delusions), then ______________________________ those beliefs into alternatives (Effect E)

• ____________________: demonstrates that irrational thoughts (hallucinations & delusions) are not real (____________________). EG if they claim to see the future, test this.

cognitively restructuring / reality testing / symptom targeting

Psychological Treatment - CBT (AO3)

• May raise ethical concerns because it can be seen to be interfering with a person’s ____________________. If a patient is encouraged to challenge their ____________ of a controlling government, this might lead to change in their entire political outlook.

• _____________ et al (2014) reviewed the results of _____ studies of CBT for schizophrenia and concluded a significant but fairly small effect on both positive and negative symptoms.

• ____________ et al’s meta-analysis (2005).

freedom of thought / paranoia / Jauhar / 34 / Tarrier

Psychological Treatment - Family Therapy (AO1)

• Involves both the patient and the patient’s family and aims to improve the __________________________ within the family.

• Some might see the family as the root cause of the condition (consistent with __________________________).

• Contemporary therapists are more likely to be concerned with reducing stress within the family than locating the causes of the condition within the family, particularly through reducing levels of _______________________.

communication quality / schizophrenogenic mother & double bind theories / expressed emotion

What are some of the strategies that Pharoah et al (2010) identified family therapists to use to try to improve the functioning of the family with a schizophrenia-suffering member?

therapeutic alliance with all / reducing caring stress / improving unresolved problem anticipation / reducing anger & guilt

Psychological Treatment - Token Economies (AO1)

• Based on the principle of operant conditioning.

• Usually operate via the use of ____________________ (tokens) that are given to patients immediately after they have carried out some positive or desirable behaviour, such as getting dressed or making their bed.

• _________________________ - tokens can then be exchanged for some tangible reward, expecting a progressive change in behaviour.

• Seen as _______________________ because they only have value once the patient has learned that they can be used to obtain rewards.

coloured discs / behaviour shaping / secondary reinforcers

Psychological Treatment - Token Economies (AO3)

• A major ethical consideration with is that privileges become more available to patients with less severe symptoms because compliance is lower amongst those with more severe symptoms. Results in __________________________________, leading to some families challenging the legality of the system.

• ___________________ (1968)

discrimination against very ill patients / Allyon + Azirin

Psychological Treatment - Token Economies: ________________ (1968) (AO3)

• Used a token economy on a ward of ____________ schizophrenic patients, many of whom had been hospitalised for many years. Given plastic tokens, each embossed with the words ‘____________’ for behaviours such as making their bed or carrying out domestic chores. These tokens were then exchanged for privileges such as being able to watch a movie.

• Findings: use of a token economy with these patients dramatically increased the number of desirable behaviours that the patients performed each day.

• Suggestions: token economy did increase the positive behaviour in patients but there was no evidence that it alleviated their symptoms of schizophrenia; it simply made their ________________________ more acceptable.

Ayllon + Azrin / female / one gift / social behaviours

Psychological Treatment - Quality of Evidence & Lack of Availability (AO3)

• Studies often lack _______________________ and participants are rarely _______________________ to conditions.

• These methodologically weak studies tend to be more optimistic in their results and conclusions than studies employing tighter controls.

• NICE recommends ________________, provided by a qualified professional with experience of working with schizophrenia sufferers, is made more widely available.

control group / randomly allocated / art therapy

Interactionist Approach - Diathesis-Stress Model: ___________ (1962) (AO1)

• In the original model, diathesis was entirely genetic. Diathesis was the result of a single ‘________________’, which led to the development of a biologically-based _________________ personality.

  • One characteristic of this was a sensitivity to ____________.

• According to this, people without diathesis will not develop schizophrenia, regardless of levels of ________.

• But the presence of a __________________________ could result in the development of the condition if diathesis was present.

• Modern interpretations realise schizophrenia to be polygenic and acknowledge a range of factors beyond genetics (such as _________________________) which are regarded as a diathesis rather than the stressor.

Meehl / schizogene / schizotypal / distress / stress / schizophrenogenic mother / psychological trauma

In 2008, who found childhood sexual trauma to be a vulnerability factor while cannabis use was a trigger?

Houston

Interactionist Approach - Triggers: __________ et al (2001) (AO1)

• Proposed a ______________________________ model, in which they propose that early trauma leads to changes in the developing brain.

• They suggest that early and significantly severe trauma (e.g. child abuse) can seriously affect many aspects of brain development.

• This can include over activation of the ___________________, which results in heightened susceptibility to __________.

Read / neurodevelopmental / HPA axis / stress

What is the treatment causation fallacy?

assumption that drug efficacy means cause is biological