P3 - Schizophrenia

definition of schizophrenia

a mental disorder categorised by withdrawal from reality

Type I schizophrenia

mainly positive symptoms(pathological excess) which are intense but short term(acute)

Type II schizophrenia

mainly negative symptoms(pathological deficits)

Positive symptoms of schizophrenia

• Delusions

• Experience of control

• Hallucinations

• Disordered thinking

+symptoms - delusions

firm, unshakable beliefs that the individual feels

+symptoms - experience of control

not accountable for their actions, someone is controlling them

+symptoms - hallucinations

distorted perception of the environment, linked to all senses but most commonly auditory or visual

+symptoms - disordered thinking

feeling of someone or something taking away your thoughts and speech, non-coherent speaking

Negative symptoms of schizophrenia

• affective flattening

• alogia

• avolition

• psychomotor disturbances

-symptoms - affective flattening

communication and facial expressions reduced, mono-tonal

-symptoms - alogia

reduction of speech productivity and fluidity(speech poverty)

-symptoms - avolition

lack of motivation and ability to make decisions, no enthusiasm, energy, or sociability

-symptoms - psychomotor disturbances

sufferers adopt frozen, statue like poses, exhibit twitches and repetitive behaviours; e.g. pacing up and down

Diagnosis of schizophrenia

DSM-5, at least two of the following symptoms must be shown continuously for more than a month for schizophrenia to be diagnosed

• hallucinations

• delusions

• disorganised speech

• disorganised or catatonic behaviour

• negative symptoms

+social and occupational dysfunction (work, relationships, self-care)

reliability in schizophrenia

concerns the consistency of symptom measurement and diagnosis

• test retest - same diagnosis on separate occasions from same information

• inter-rater reliability - different clinicians make identical, independent diagnoses of the same patient

• different tool, same result - clinicians make same diagnosis using different diagnostic systems or methods

reliability - general AO3 research

• Klosterkotter argued Sz to broad a category for it to be a useful diagnosis, 2 patients could have completely different symptoms but same diagnosis

• Seto relabelled Sz to ‘integration disorder’ in Japan due to difficultly attaining reliable diagnosis

reliability - research for consistency of a measure

• Beck found 54% concordance rate between diagnosis of 153 patients using DSM-II

• Soderberg found 81% concordance rate using DSM-IV-TR, more reliable over time → not 100% though

• DSM-V removed subtypes of Sz as found not useful for diagnosis or treatment plans

reliability - research for different tool

• Nilsson found 60% concordance rate for ICD rather than 81% for DSM-IV, DSM more reliable

• Jakobsen tested reliability of ICD-10 on 100 Danish patients, found 99% concordance rate, high reliability when using up-to-date

reliability - research for test-retest

Read found test-retest reliability of schizophrenia diagnosis to have only 37% concordance rate

reliability - research for interrater reliability

Copeland

• description given to 194 UK and 134 US psychiatrists

• 69% of US psychiatrists diagnosed patient with Sz

• 2% of UK psychiatrists

diagnosis never been fully reliable, cultural and social differences in each country that would effect motive

Validity in schizophrenia

concerns how accurate, meaningful and useful a diagnosis is

• reliability - minimum requirement

• predictive validity - if diagnosis=successful treatment

• descriptive validity - diagnosis of different disorders need to differ(lack symptom overlap)

• aetiological validity - all patients with same disorder should have the same cause

Validity - research for predictive

• Mason tested ability of 4 different classification systems to predict outcome of disorder over 13yr period on 99Sz, more modern ones have higher predictive

• Birchwood - 20% of Sz’s recover and never have another episode, 10% recover to achieve lasting improvements, 30% some improvement with relapses, 30% never improved(10% of which commit suicide) TOO MUCH VARIETY

Validity - research for descriptive

Jager found it was possible to use the ICD-10 to distinguish 951 cases of Sz from:

• 51 persistent delusional disorders

• 116 acute and transient psychotic disorders

• 354 schizoaffective disorders (more negative and lower level functioning)

• HIGH DESCRIPTIVE

validity - research for aetiological

Baillie surveyed 154 UK psychiatrists and found that other than agreement on influence of genetics, biochem abnormalities, substance abuse; differing views on causes of schizophrenia - LOW AV

Bentall, diagnosis says nothing about cause, does not indicate prevalence rates in different groups and areas

Validity - Rosenhan’s study

uses DSM-II classification, psychiatrists could not distinguish between sanity and insanity in real and pseudo-patients

• 8 volunteer pseudo, ‘heard voices’ for admittance then acted normal

• 7-52 days to be released, normal behaviour interpreted as Sz

• 35/118 actual patients suspected that volunteers were sane

• 193 patients admitted - when told of pseudo 83 aroused suspicion

Bias in schizophrenia

lack of objectivity or an inclination to favour one thing or person over another, often unconsciously

• co-morbidity - 1 or more additional disorders occurring with schizophrenia

• cultural bias - tendency to over-diagnose members of other cultures

• gender bias- tendency for diagnostic criteria to be applied differently to males and females

• symptom overlap - perception that symptoms of schizophrenia are also symptoms of other mental disorders

Bias - research for co-morbidity

• Sim reported that 32% of 142 hospitalised Szs had an additional mental disorder

• Buckley - estimated 50% of Szs had comorbid depression, 15% panic disorder, 29% PTSD, 23% OCD, 47% substance abuse → Prevalent issue

Bias - research for culture

Cochrane - Sz in the West Indies and Britain is around 1%, people in Afro-Caribbean origin are 7x more likely yo be diagnosed with Sz when living in Britain; more stressors or invalid diagnosis

Whaley - reason for higher incidence in black Americans than in white is due to ethnic differences in symptom expression that are overlooked or misinterpreted

Bias - research for gender

• Lewin found that if clearer diagnostic criteria applied, number of female sufferers decreases

• Kalkarni found female sex hormone effective in treating Sz in women in addition to antipsychotic therapy, different protective and predisposing factors in male and female vulnerability that clinicians ignore

bias - research for symptom overlap

• Serper assessed patients with comorbid cocaine abuse, abuse on its own and sz on its own; found that although there was considerable symptom overlap, it was possible to make accurate diagnoses

• Ophoff assessed genetic material from 50,000 participants and found that of 7 gene locations on the genome associated with Sz, 3 were also associated with bipolar disorder

Explanations of schizophrenia

• psychological

• cognitive

• biological

Psychological explanations of schizophrenia

• Psychodynamic

• Family dysfunction

  • double-bind theory

  • expressed emotion

Psychodynamic explanation for schizophrenia

Freud believed most behaviour driven by unconscious motives

• childhood critical, mental disorders arise from unresolved, unconscious conflicts

• resolution occurs through accessing and coming to terms with repressed ideas and conflicts

psychodynamic - psychological disorders through manifestation of…

• imbalance between id, ego, and superego

• fixation and regression to primary narcissism(pre-ego so id takes over)

  • no distinction between reality and fantasy, self and others

  • inability to function, delay gratification

• attempts to deal with repressed material (through re-establishing ego control)

psychodynamic - schizophrenia seen by Freud as…

an infantile state, some symptoms(delusions of grandeur) reflecting primitive condition and other symptoms(auditory hallucinations) reflecting attempts to re-establish ego control

• assume to be due to maternal behaviour - schizophrenogenic mother

psychodynamic - characteristics of a schizophrenogenic mother

Fromm-Richmann

• rejecting

• overprotective

• dominant

• moralistic

• cold

• conflict inducing

support from Bowlby FR agreed with Freud that disordered family patterns are the cause of this disorde

psychodynamic - research

Oltmanns studies found PARENTS of Sz patients act differently, particularly in presence of disturbed child

Ricks - mothers tend to be anxious, shy, withdrawn, and incoherent; argued no difference between Sz and no Sz so lack of causation

Family dysfunction

Sees maladaptive relationships and patterns of communication within families as sources of stress = development of Sz

Family dysfunction - parental characteristics

• high levels of interpersonal conflict(arguments)

• difficulty communicating with each other

• being excessively critical and controlling of their children

Family dysfunction - double bind theory

Bateson suggests that children who frequently receive contradictory messages from their parents are more likely to develop schizophrenia

prevent development of an internally coherent construction of reality, in the long term manifests as schizophrenia symptoms e.g. affective flattening

Family dysfunction - expressed emotion

negative emotional climate or high degree of expressed emotion

family communication system involves criticism, hostility and emotional over-involvement

high levels of EE=4x more likely to relapse → Linszen