Schizophrenia

Diagnosis & Classification AO1 - Systems

Psychotic disorder, where individual loses contact with reality.

Onset: 1% Population, Rarely starts <15, equally affects men and women, but different onset age (men=late teens, women=20s/30s).

Diagnosis in ICD - 2 neg (UK) and DSM - 1 pos, 2 overall (USA). Give guidance on classification (clustering symptoms to identify & distinguish disorders), and diagnosis (identifies disorders in individuals w/ specific symptoms). Only PHD/Med degree can diagnose.

= Classification of abnormal patterns of thinking, behaviour and emotion into mental disorders.

Diagnosis & Classification AO1 - Positive Symptoms

Rarer, more dramatic, shorter, easier treatable. Excess/distortion of normal function, e.g.

Hallucinations (unusual sensory experience), Paranoid Delusions (irrational beliefs).

Diagnosis & Classification AO1 - Negative Symptoms

Common, less dramatic, longer, harder to treat. Subtracts from life aspects, e.g.

Avolition (lack of motivation), Speech Poverty (difficulty formulating words and thoughts), Blank Affect (lack of emotional expression).

Diagnosis & Classification AO3 - High Reliability (STR)

Classification systems provide practitioners with common language, comm of research ideas & finding.

Led to better understanding, development of better treatment.

Improved classifications = more consistent diagnosis.

Diagnosis & Classification AO3 - Low Criterion Validity (LIM)

Different assesment systems arrive at different diagnoses.

Cheniax et al (2009): 2 idp psychiatrists assess same 100 patienbts with ICD/DSM. More likely diagnosis with ICD (68) and less likely diagnosis with DSM (39).

Suggests over/under diagnosis.

Diagnosis & Classification AO3 - Co-morbidity (LIM)

People rarely diagnosed with single problem.

Buckley et al (2009) found schizophrenia diagnosed with depression (50%), substance abuse (47%), PTSD, OCD.

Questions validity of schizophrenia’s existence as a distinct conditon.

Diagnosis & Classification AO3 - Symptom Overlap (LIM)

Schizophrenia shares symptoms with other conditions e.g.

Bipolar shares positive symptoms (delusions) and negative symptoms (avolition). May not be 2 conditions, but variations of same condition. Questions validity of diagnosis esp when using different symptom criterion.

Diagnosis & Classification AO3 - Diagnosis Gender Bias (LIM)

Fischer and Buchanan (2017): Men diagnosed more than women in ratio of 1.4:1

Could be explained by greater male genetic vulnerability, but Cotton et al (2009) found female patients typically function better than men, may explain under/later diagnosis, due to better interpersonal functioning.

Man and Woman with same symptoms may have different diagnosis reduces reliability.

Diagnosis & Classification AO3 - Diagnosis Culture Bias (LIM)

Hearing voices more normal in some cultures, e.g. in Haiti (voices of ancestors).

Pinto and Jones (2008) - British African-Caribbean people 9x more likely diagnosis than white British, though not so high in those countries, ruling out genetic vulnerability.

Leads to overinterpretation of symptoms in Black British people (Escobar 2012), resulting in discrimination (culturally biased diagnostic system).

Biological (genetic) Explanations AO1 - Family Studies

Family studies have confirmed schizophrenia risk inc. in line with genetic similarity with relative.

Gottesman (1991) : Person-Schizophrenic Aunt = 2%, Person-Schizophrenic Sibling = 9%, Person-Identical Twin = 48%.

Correlation represents nature & nurture but still shows genetic significance.

Biological (genetic) Explanations AO1 - Candidate Genes

Polygenic condition, candidate genes that code ntm including dopamine.

Ripke et al (2014): All data from previous genome-wide studies combined, found genetic makeup of 37000 people with diagnosis of schizophrenia compared to 113000 controls, 108 separate variations associated with slightly inc. risk.

As different studies have identified different candidate genes = aetiologically heterogeneous.

Biological (genetic) Explanations AO1 - Mutation

Mutation in parental DNA can lead to disorder, caused by radiation, poison, viral infection.

Brown et al (2002): Positive correlation between paternal age (assc. inc. risk of sperm mutation) & risk of schizophrenia. Fathers under 25=0.7%, over 50=2%.

Biological (genetic) Explanations AO3 - Research Support (STR)

Strong evidence base from:

Family studies e.g. Gottesman.

Adoption studies e.g. Tienari et al (2004) [children with schizophrenic biological parents at heightened risk even if grown up in adoptive family].

Twin studies e.g. Hilker et al (2018) [concordance rate of schizophrenia = 33%MZ vs 7%DZ].

Evidence for genetic vulnerability.

Biological (genetic) Explanations AO3 - Environmental Factors (LIM)

Evidence for significant impact of biological/psychological external factors.

Biological = birth complications (Morgan et al 2017), Smoking THC-rich cannabis in teenage years (Di Forti et al 2015).

Psychological = 67% of schizophrenic/related ptcps report at least 1 childhood trauma opposed to 38% of non-psychotic matched group (Mørkved et al 2017).

Genetic factors alone = incomplete explanation.

Biological (neural) Explanations AO1 - Neural Correlates

Neural correlates of Schizophrenia = pattern of structure/activity in brain that occurs in conjunction with an experience, may be implicated in origin of experience.

Best known is dopamine.

Another is the ventral striatum, largest structure of basil ganglia, associated with avolition. VS is part of limbic system assc w/ anticipation of reward.

Biological (neural) Explanations AO1 - Original Dopamine Hypothesis

Seeman (1987): Antipsychotics reduce DA caused symptoms similar to Parkinson’s (assc. with low DA levels).

Therefore, schizophrenia = result of hyperdopaminergia (HPDM) in subcortical regions, for instance excess of DA receptors in pathways from subcortex to Broca’s area may explain symptoms e.g. speech poverty, auditory hallucinations.

Biological (neural) Explanations AO1 - Updated Dopamine Hypothesis

Davis et al (1991): Hypodopaminergia (HODM) may also be implicated.
E.g. low DA in prefrontal cortex may explain cognitive issues (negative symptoms). Also suggested cortical HODM leads to subcortical HPDM (updated system includes high/low levels of DA in different regions of brain).

Howes et al (2017): Genetic variations and early experiences of physical/psychological stress = greater sensitivity to cortical HODM and therefore subcortical HPDM.

Biological (neural) Explanations AO3 - Research Support

Curran et al (2004): Amphetamines inc. DA, worsens symptoms in schizophrenic individuals, induces symptoms in those without it.

Tauscher et al (2014): Antipsychotics reduce DA activity, reduce symptom intensity.

Some candidate genes act on DA production/receptors e.g. DRD2.
Strongly suggests role of dopamine.

Biological (neural) Explanations AO3 - Central Role of Glutamate

McCutcheon et al (2020): Postmortem & Live scanning studies found raised level of NTM glutamate in several brain regions of those with schizophrenia.

Several candidate genes for schizophrenia believed to be involved in glutamate production/processing e.g. GRIN2A.

Equally strong case for another ntm.

Psychological Explanations (family dysfunction) AO1 - Schizophrenogenic Mother

Influenced by Freud.
Schizophrenic-causing mother is: cold, dominant, creates conflict, is rejecting, overprotective, self-sacrificing, moralistic about sex, fear of intimacy.

Causes distrust, resentfulness, instability → induces paranoid delusions (+ symptom).

Psychological Explanations (family dysfunction) AO1 - Double Bind theory

Children punished for doing as asked, punished again when parent gives no reason for this (inconsistent parenting).

Children confused, lose grip on reality. Appropriate logical response = social withdrawal and a flat affect (- symptoms)

Bateson - Children recieve these mixed messages = cannot trust messages they recieve from others. Therefore, do not trust own feelings, perceptions, reflected in paranoid delusions, disorganised thinking (+ symptoms).

Psychological Explanations (family dysfunction) AO1 - Expressed Emotion

High EE = family communication style, involving: Critical comments (tone, content) occasionaly accompanied with violence, hostility (anger and rejection), emotional over-involvment, needless self-sacrifice leading to resentment and guilt.
High level = higher relapse rates

Psychological Explanations (family dysfunction) AO3 - Support for risk of family dysfunction (STR)

Evidence suggests difficult childhood family relationships assc. inc. risk of SZ.

Read (2005): Reviewed 46 studies of child abuse/adult SZ, found 69% of adult inpatients had history of child abuse.

Adults with insecure attatchments to primary carer implicated in SZ.

Psychological Explanations (family dysfunction) AO3 - Poor Validity of explanations (LIM)

Info abpout childhood experiences is gathered after symptoms develop, may distort patients’ recall - serious issue of validity.

Can lead to unjust parent-blaming. Parents have already suffered seeing child in pain undergo further trauma through blame.

Led to shift away from hospital care, towards community care. Added to decline of schizophrenogenic mother/ double bind.

Psychological Explanations (family dysfunction) AO3 - Negative connotations of family dysfunction (LIM)

Psychological Explanations (cognitive) AO1 - Dysfunctional Thinking

SZP characterised by disturbance in language, attention, thought, perception.

Cog psychologists explain disorder as a result of dysfunctional thought processing.

Reduced thought processing = biological, suggest impaired cognition.

Psychological Explanations (cognitive) AO1 - Metarepresentation Dysfunction

Frith (1992): SZP patients fail to monitor own thoughts correctly, misattributing them to the outside world.

Someone hearing voices = misinterpretation of own inner speech as something in external world communicating with them. Sometimes called alien control symptoms, SZP feeling like they have no personal control.

Psychological Explanations (cognitive) AO1 - Central Control Dysfunction

Auditory Selective Attention - Process by which the brain selects what sounds to respond to/ignore. Selectiveness helps our limited processign ability when bombarded with external info.

SZP negative symptoms = result of ASA impairment, result of cog strategies from SZP patient to keep mental stimulation manageable when overwhelmed and cannot distinguish from internal/external info.

Pickering (1981): Catatonic SZP caused by ASA breakdown, making social interaction inc. difficult. Individual overloaded with auditory info. CSZP have no choice but to withdraw from world to manage sensory stimulation.

Psychological Explanations (cognitive) AO3 - Research Support (STR)

Stirling et al (2006) compated 30 SZP with 30 nSZP on various tasks, including:

Stroop task. SZP took 2x as long to name font colours.
Drawing with hand hidden. SZP unable to recognise their drawing.

Evidences impairment of SZP cog processes.

Psychological Explanations (cognitive) AO3 - Limited explanatory power (LIM)

Only explains proximal origins of symptoms. Focus on what is happening in the moment to cause a symptom, different from distal explanations that focus on initial cause of condition, e.g. genetic/family dysfunction.

Cognitive explanation only partial.

Biological Therapy AO1 - Antipsychotics

Most common treatment for SZ. Taken as tablets/syrups/injections (injections every 2-4 weeks for unreliable patients). Can be both short term and long term.

Biological Therapy AO1 - Typical/Atypical Distinction

Typical: Older, target positive, more side effects, cheaper.

Atypical: Newer, target positive and negative, less side effects, expensive.

Biological Therapy AO1 - (Typical) Chloropromazine

Used since 1950. Works as dopamine antagonist, blocking receptor sites in synapses. Reduces action of dopamine treats positive symptoms e.g. hallucinations.

Initially, dopamine levels build up, but then production is reduced. Normalises neurotransmission in key areas of brain.

Biological Therapy AO1 - (Typical) Sedation effect

Also has (unreasoned) sedation effect. Drug affects histamine receptors, implicated in this. Used to calm erratic patients when they first come to hospital. Uses syrup as fastest acting.

Biological Therapy AO1 - (Atypical) Clozapine

Acts on dopamine, serotonin, glutamate. Binds to receptors of these NTMs. More effective than typical AP, reducing positive symtoms as well as depression, anixety and improving cog. functioning. Improves patient mood, important as 50% of SZ attempt suicide at least once.

Biological Therapy AO1 - (Atypical) Clozapine History

Made in 1970, but withdrawn due to death of some patients from Agranulocytosis (lowers white cell count, immune suppresion). Later remarketed as SZ treatment.

People taking clozapine must have regular blood tests to ensure they don’t develop this condition.

Biological Therapy AO1 - (Atypical) Risperidone

Developed following 1970 Clozapine withdrawal. Bind to dopamine, serotonin receptors.
Binds more strongly to receptor sites = more effective in smaller doses. Fewer side effects.

Biological Therapy AO3 - Practical Applications (STR)

Used for patients ; psychological therapies won’t suffice. Regulates patient’s symptoms allowing energy and cognition to engage in therapy.

More convenient as faster acting, cheaper, less time consuming.

Aligns with chloropromazine studies showing greater improvement in cog functioning than placebo. (Thornley et al analysis of 13 trials, 1121 ptcps).

Biological Therapy AO3 - Side Effects (LIM)

Typical side effects include diziness, sleepiness, weight gain, stiff-jaw, itchy skin, tremors.

Prolonged use = Tardive Dyskinesia → Dopamine supersensitivity causes involuntary face movements (grimacing, blinking, lip smacking).

Neuroleptic Malignant Syndrome (0.1% - 2%) caused when drug blocks hypothalamus dopamine action, causing high temperature, delirium, coma, death.

Antipsychotics unreliable treatmnent, can cause harm which may lead to patients avoiding it.

Biological Therapy AO3 - Ethical Issues (LIM)

Anti psychotics used in hospitals to calm patients, make them easier to work with rather than benefiting them.

Using antipsychotics to sedate interpreted as human rights abuse.

Can make sedative antipsychotics redundant therefore useless.

Biological Therapy AO3 - Dopamine Hypothesis (LIM)

Drug therapy based on potentially dangerous inaccurate theory.

Antipsychotics tied to idea that SZ = high dopamine in sub cortex. New evidence shows dopamine levels in other parts of brain may be too low instead (antipsychotics may not be fully effective).

Undermines faith that positive results is pharmacological effect. Instead may be a placebo.

Psychological Therapy (CBT) AO1 - Basis and Explanation

5-20 sessions, longer than CBT for other conditions (3-12).

Aims to help client understand how irrational cognitions impact their feelings, behaviours.

E.g auditory hallucinations can represent demonic forces, understandable fear. Therapist can convince client it comes from malfunctioning speech centre in brain, voice isn’t real = less frightening, debilitating.

Doesn’t eliminate symptoms, but helps clients cope, reduces distress, improves functioning.

Psychological Therapy (CBT) AO1 - Explanation cont.

Normalisation: Explain auditory hallucinations = extension of normal functioning (thinking in words).

Reality testing: Client and therapist examine likelihood of client’s delusions’ truth. Sometimes client resistent to this, CBT still useful for helping with anxiety, depression.

Psychological Therapy (CBT) AO1 - Research support

Turkington et al (2004): Assessed CBT as SZ treatment. Observed one client as example:

Client: “The Mafia has my house under surveillance!”

Therapist: “Well, that is possible…. But why do you think it is the Mafia? Could it be some other organization? Or is something else happening altogether? How could we find out?”

Goes into specific experience of client. Does not collude with delusion, does not deny it either. Works toward mutually agreeable explanation. Helps reduce positive symptoms.

Psychological Therapy (CBT) AO3 - Research Support (STR)

Jahuar et al (2014): Meta analysis, 34 studies assessing CBT effectiveness. Clear evidence of small, significant effects on pos/neg symptoms compared to control group.

Pontillo et al (2016): CBT can lead to reduction in frequency/severity of auditory hallucinations.

Psychological Therapy (CBT) AO3 - Limited Application (LIM)

SZ varies significantly between clients, can never apply uniform approach like CBT. Effectiveness of treatment depends on severity of symptoms (pos/neg too severe = client unable to engage, CBT has no effect).

Difficult to determine whether CBT will be effective for particular SZ client.

Psychological Therapy (Family Therapy) AO1 - Basis

Takes place with family and identified patient (member of dysfunctional family who expresses conflicts).

Aims to improve quality of communication/interaction between members.

Psychological Therapy (Family Therapy) AO1 - Effects

Pharoah et al (2010): Identified possible strategies to improve functioning of family with SZ member.

Reduce Negative Emotions → Reduce levels of EE, esp. negative emotions (anger, guilt) that contribute to stress. Important to reduce likelihood of relapse.

Improve Family’s Capability To Help → Therapist encourages family members to all agree on aims of therapy. TRP tries to improve beliefs/behaviour towards SZ. TRP tries to ensure family member balance between care for SZ member and maintaining own lives.

Psychological Therapy (Family Therapy) AO1 - In Practice (Phases 1-3)

Burbach (2018): Proposed model for working with families dealing with SZ.

Phase 1: Sharing basic info, providing emotional/practical support.

Phase 2: Identiying what resources family members can/can’t offer.

Phase 3: Encourage mutual understanding, create safe space for family members to express feelings.

Psychological Therapy (Family Therapy) AO1 - In Practice (Phases 4-7)

Phase 4: Identifying unhelpful patterns of interaction.

Phase 5: Skills training e.g. learning stress management techniques.

Phase 6: Relapse prevention.

Phase 7: Maintenance for future.

Psychological Therapy (Family Therapy) AO3 - Research Support (STR)

McFarlane (2016): Family therapy one of most consistently effective treatments, relapse rates reduced by 50-60%. Esp. helpful when mental health initially begins to decline.

Benifits wide range of SZ cases.

Psychological Therapy (Family Therapy) AO3 - Whole Family Benifit (STR)

Therapy targets client and their surroundings (family who provides most care).

Lobban & Barrowclough (2016): Review of family therapy studies. Found that strenghthening function of whole family = lesser negative impact of SZ on other family members, strengthens capability to support SZ member.

Family therapy has wider benifits beyond treating identified patient.

Managing Schizophrenia through Token Economy AO1 - Basis

Currency in institutions rewarding positive behaviours, can later be exchanged for desirable rewards.

Ayllon & Azrin (1968): Trialed token economy in SZ women ward. Found significant increase in completion of tasks.

Managing Schizophrenia through Token Economy AO1 - Rationale

Prolonged hospitalisation can lead to bad habits e.g. poor hygiene, infrequent socialisation.

Matson et al (2016): 3 categories of institutional behaviour tackled by TE.

1) Personal Care
2) Condition-Related behaviours
3) Social Behaviour

Helps improve quality of life, and normalises behaviours to make it easier to readjust into normal life.

Managing Schizophrenia through Token Economy AO1 - In Practice

Patient and staff decide target behaviours. Token given immediately to avoid delayed gratification (longer delay = less effective). Exhangeable rewards may be: More TV time, sweets, cigarettes, outdoor time, etc.

Managing Schizophrenia through Token Economy AO1 - Theory

TE = behaviourist therapy, attempting behaviour modification.

Token = secondary (generalised) reinforcer, Exhangeable reward = primary reinforcer (has specific meaning to patient).

Managing Schizophrenia through Token Economy AO3 - Research Support (STR)

Glowacki et al (2016): Analysis of 7 studies from 1999-2013 looking at TE effectiveness in hospital setting.

All showed sig. reduction in negative symptoms, decline in frequency of unwanted behaviours.

Managing Schizophrenia through Token Economy AO3 - Ethical Issues (LIM)

Gives staff power over patients, imposing the institution’s / staff’s norms onto others. Sig. issue if target behaviours not identified sensitively.

E.g. restricting availability of rewards to patients can worsen their experience.

Legal actions from families with affected patient led to decline of token economy use for SZ.

Interactionist Approach AO1 - Definition & Factors

SZ accumulation of biological, psychological, social factors.
Bio: Genetic Vuln, neurochemical/neurological abnormality.
Psycho: Stress (from life events/daily hassles)
Soc: Poor quality family interaction