Schizophrenia

Types of Schizophrenia

• Catatonic schizophrenia = the main feature is almost total immobility for hours at a time, with the patient simple staring blackly into space

• Paranoid schizophrenia = this type involves delusions of persecution

• Hebephrenic schizophrenia = this type involves great disorganisation of behaviour including delusions, hallucinations, incoherent speech and large mood swings

Diagnosing and Classification of Schizophrenia

• Diagnosis and classification is interlinked

• Classification = identify symptoms that go together, cause a disorder

• Diagnosis = identify symptoms and use classification system to identify the disorder

• There are 2 classification systems used

  • DSM 5 - one positive symptoms must be present

  • ICD 10 – two or more negative symptoms are sufficient fort diagnosis

Issues with Diagnosis and Classification

• co-morbidity = where two conditions co exist in the same individual at the same time eg. schizophrenia and depression

• symptom overlap = occurs when two or more conditions share symptoms

• validity = the extent to which schizophrenia is a unique syndrome with characteristic, signs and symptoms

• reliability = the level of agreement on the diagnosis by different psychiatrists across time and cultures

Types of Symptoms

• positive symptoms = atypical symptoms experiences in addition to normal experiences

• negative symptoms = atypical that represent the loss of a usual experiences

Identifying Positive Symptoms

• Hallucinations = sensory experiences that have either no basis in reality or are distorted perceptions of things that are there

• Delusions = they involve beliefs that have no basis in reality

Identifying Negative Symptoms

• speech poverty = involves reduced frequency and quality of speech

• avolition = it is a loss of motivation to carry out tasks and results in loss of activity levels

  • Andreasen (1982) identified 3 signs of avolition: poor hygiene ad grooming, lack of persistence in work of education, and lack of energy

Rosenhan’s Study

Elizabeth Cochrane assumed a false identity and acted in a strange manner in a boarding house, she was out into an insane asylum – she inspired Rosenhan

• 7 participants (4 male and 3 female students)

• They visited 12 different hospitals in 5 different states the pseudo patients had to state they were hearing a voice saying ‘empty, hollow, thud’

• Once they had gained admission, they acted normal and said the symptoms had gone away

• 2 aims of the study

  • 1 = to investigate whether psychiatric labels would be used in situations where they weren’t appropriate

  • 2 = to investigate the experience of being hospitalised in a psychiatric ward

• Findings = none were ever detected as being pseudo patients (fakers) and the longest stay was 2 months

Classification and Diagnosis of Schizophrenia AO3

• a strength of diagnosis is good reliability

• a weakness is symptom overlap

• a weakness is that classification and diagnosis are culturally biased

Classification and Diagnosis of Schizophrenia (AO3): a strength of diagnosis is good reliability

• Evidence = Osorio (2019) reported excellent reliability for schizophrenia diagnosis - inter rater agreement of +.97 and test retest reliability of +.92

• Explain = this is a strength as it demonstrates the consistency in diagnosis for schizophrenia

• this means we can be more confident in diagnosis drawn from cause and effect

• Link = therefore, this increases the reliability

Classification and Diagnosis of Schizophrenia (AO3): a weakness is symptom overlap

• Evidence = for example, there are classification issues with schizophrenia and bipolar disorder as they are hard to distinguish from each other

• Explain = this is a weakness as overlaps can lead to misdiagnosis, reducing the chances of receiving proper treatment

• this puts into question the validity of diagnosis methods that may cause further harm to patients

• Link = therefore, this reduces the internal validity

Classification and Diagnosis of Schizophrenia (AO3): a weakness is that classification and diagnosis are culturally biased

• Evidence = for example, Afro-Caribbean British men are up to 10x more likely to receive a diagnosis as white British men, probably due to over interpretation of symptoms

• some symptoms such as hearing voices are accepted in some cultures eg. Afro-Caribbean cultures

• Explain = this is an issues as it means individuals from minority backgrounds are more likely to be misdiagnosed as clinicians may judge through their own cultural norms

• this leads to inappropriate treatment, limiting the applicability of diagnosis methods across cultures

• Link = therefore, this reduces the validity

Biological Explanations of Schizophrenia

• genetic basis

  • family studies

  • candidate gene

  • role of mutation

• neural correlates of schizophrenia

Genetic Basis: Family Studies

• the risk of schizophrenia increases in line with genetic similarity to a relative with the disorder

• Gottesman’s (1991) large scale family study

  • IV = parents mental illness – schizophrenia

    • Operationalised as parents receiving diagnosise from world health organisation’s system for classification

  • DV = a diagnosis of any mental illness in offspring

    • Operationalised as receiving diagnosis of any mental illness according to the international classification for disease

• Sample

  • Danish sample of approx 2.7 million, aged 10 to 52 years old

  • 196 couples both with schizophrenia and their 270 children

• Findings

  • both parents with schizophrenia = 27.3% admission in offspring

  • one parent with schizophrenia = 7% admission in offspring

  • neither parent ever admitted = 0.86% admission in offspring

  • general population = 1.12% admission in offspring

Genetic Basis: Candidate Gene

• early research in this area unsuccessfully found a single genetic variation to explain schizophrenia - it is polygenic

• Ripke (2014) combined all previous data from genome wide studies

  • found 108 seperate genes associated with slightky increased risk of schizophrenia

• because different studies have identified different candidate genes it also appears that schizophrenia is aetiologically heterogeneous

Genetic Basis: Role of Mutation

A mutation in parental DNA which can be caused by radiation, poison or viral infection

• evidence (Brown 2002) for mutation comes from positive correlations between parental age (associated with increased risk of sperm mutation) and risk of schizophrenia, increasing from around

  • 0.7% with fathers under 25

  • over 2% in fathers over 50

Neural Correlates of Schizophrenia

Dopamine (DA) is believed to be involved in because it is featured in the functioning of brain systems related to symptoms of schizophrenia

• dopamine = a neurotransmitter and hormone that plays a role in brains reward system, influencing mood, motivation, pleasure and attention

• original DA hypothesis

  • high dopamine in subcortex associated with hallucinations and poverty of speech

• updated version of DA hypothesis

  • low levels of DA in the prefrontal cortex could explain negative symptoms

• origins of abnormal DA

  • genetic variations and early experiences of stress make some people more sensitive to cortical hypodopaminergia and hence subcortical hypodopaminergia

Biological Explanations of Schizophrenia AO3

• a strength is the supporting research for genetic explanations of schizophrenia

• a weakness is the evidence for environmental risk factors

• a weakness is the evidence for a central role of glutamate

Biological Explanations of Schizophrenia (AO3): a strength is the supporting evidence

• Evidence = Tauscher 2014 found that antipsychotic drugs reduce DA activity and also reduce the intensity of symptoms

• Explain = this is a strength as it supports the rile of dopamine in symptoms of schizophrenia

• this means we can be more confident making diagnosis from the claims about the cause and effect of dopamine

• Link = therefore, this increases the reliability

Biological Explanations of Schizophrenia (AO3): a weakness is the evidence for psychological risk factors

• Evidence = psychological risk factors may include childhood trauma - Morkved 2017 found 67% of those with schizophrenia reported at least 1 instance of childhood trauma

• Explain = this is a weakness as this biologically reductionist viewpoint alone cannot provide a complete explanation for schizophrenia

• this limits the applicability of the explanation to a wide variety of patients

• Link = therefore, reducing the generalisability

Biological Explanations of Schizophrenia (AO3): a weakness is the evidence for a central role of glutamate

• Evidence = post mortem and live scanning studies have consistently found raised levels of the neurotransmitter glutamine in several brain regions of people with schizophrenia (McCutcheon 2020)

• Explain = this is a weakness as it suggests that dopamine alone cannot provide a full explanation for schizophrenia

• this limits the explanatory power of these explanations

• Link = this reduces the internal validity

Psychological Explanations for Schizophrenia

• Family Dysfunction

• Cognitive Explanations

Family Dysfunction

• the notion that hostility and difficulties in family communication cause stress and tension which leads the child to develop schizophrenia

  • schizophrenogenic mother

  • double bind theory

  • expressed emotion

Schizophrenogenic Mother

• Fromm Reichmann (1948) proposed a psychodynamic explanation for schizophrenia called the schizophrenogenic mother

• This is characterised by a mother being cold, rejecting and controlling

• This tends to create a family environment that is tense snd untrusting

• This leads to distrusts which later develops into paranoid delusions and ultimately schizophrenia

Double Bind Theory

• Bateson (1972) emphasised the role or communication style within the family

• The developing child fears doing the wrong thing and receive mixed messages about situations

• They feel unable to comment on situations and constantly seek clarification

• Punishment is done in the form of withdrawal of love

• This leaves them with an understanding of the world as confusing and dangerous – disorganised thinking and paranoid delusions

• This is just a risk factor

Expressed Emotion

• The level of negative emotion, expressed towards a person with schizophrenia by carers or family members

• Can be in the form of verbal criticism, hostility, and emotional over involvement

• This can be a serious source of stress for the individual

• This can trigger onset schizophrenia in a person who is already vulnerable eg. Due to their genetic makeup

Cognitive Explanation

• impaired cognitive processing leading to inability to distinguish between own thoughts and external events

  • dysfunctional thinking

  • meta-representation dysfunction

  • central control dysfunction

Dysfunctional Thinking

• This focuses on the role of mental processes

• This is characterised by disruption to normal though processing

• Reduced though processing in the ventral striatum is associated with negative symptoms

• Reduced processing of information in the temporal and cingulate gyri is associated with hallucinations

• This suggests that cognition is likely to be impaired

Meta-Representation Dysfunction

• Frith (1992) identified 2 kinds of dysfunctional thought processes

  • Metarepresentation = the cognitive ability to reflect on thoughts and behaviour

    • This allows us insight into our own intentions and goals

    • It allows us to interpret the actions of others

    • Dysfunction here could disrupt our ability to recognise our own actions and thoughts as being carried out by ourselves rather than someone else

    • This would explain hallucinations of hearing voices and delusions

Central Control Dysfunction

• Firth (1992) identified issues with the cognitive ability to suppress automatic responses while we perform deliberate actions

• Speech poverty and thought disorder could result from the inability to suppress automatic thoughts and speech triggered by other thoughts

Psychological Explanations of Schizophrenia AO3

• a strength is the research support for family dysfunction

• a weakness is that it is socially sensitive

• a strength is the research support for dysfunctional thought processing

Psychological Explanations of Schizophrenia (AO3): a strength is the research support for family dysfunction

• Evidence = Read 2005 found that adults with schizophrenia are disproportionately likely to have insecure attachment, Type C or D

• Explain = this is a strength as it supports explanations that family dysfunction makes people more vulnerable to schizophrenia

• this increases the applicability of the explanation to different patients and increases the likelihood for treatments being developed

• Link = therefore this increases the inter-rater reliability as the explanations are consistent across studies

Psychological Explanations of Schizophrenia (AO3): a weakness is that it is socially sensitive

• Evidence = family dysfunctions explanations particularly focus on the mother and the effect of dysfunctional raising from the mother

• Explain = this is a weakness these explanations are socially sensitive so they can lead to parent blaming

• this can cause undue stress and psychological issues for mothers who may feel inferior or overwhelmed because they are not doing enough, violating ethical guidelines of protection from harm

• Link = therefore this reduces the validity of

• Counter = however, the research in this area may be useful in helping parents adjust their behaviour to help children

Psychological Explanations of Schizophrenia (AO3): a strength is the research support for dysfunctional thought processing

• Evidence = Stirling 2006 compared performance on a range of cognitive tasks in people with schizophrenia and a control group without - fond that people with schizophrenia took long to name font colours

• Explain = this is a strength as it supports explanations that the cognitive process of people with schizophrenia are impaired

• this increases the applicability of the explanation to different patients and increases the likelihood for treatments being developed

• Link = this increases the inter-rater reliability

Biological Therapy for Schizophrenia

drug therapy

Drug Therapy

• typical antipsychotic

• atypical antipsychotics

Typical Antipsychotic

• are dopamine antagonists reducing dopamine activity by blocking dopamine receptors at the synapse

• this reduces positive symptoms such as hallucinations and has a sedative effect

Dopamine Antagonist

• antagonists are chemicals which reduced the action of a neurotransmitter

• dopamine antagonist eg. chlorpromazine block dopamine receptors in the synapses of the brain reducing action of dopamine

• can reduced symptoms like hallucinations

• has a sedative effect

Atypical Antipsychotics

• block dopamine receptors and also act on other neurotransmitters

• this reduces negative symptoms such as avolition

  • clozapine

  • risperidone

Clozapine

• binds to dopamine receptors in the same was as chlorpromazine does but also acrs in serotonin and glutamate receptors

• this can help improve mood, reduce depression and anxiety

• can be prescribed when someone is high risk suicide - 30-50% attempt

Risperidone

• just as effective as clozapine but without its serious side effects

  • believed to bind more strongly to dopamine and serotonin receptors

  • therefore more effective in smaller doses

Biological Therapy AO3

• a strength is the evidence of antipsychotics effectiveness

• a weakness is the serious side effects

• a weakness is limited understanding over mechanism

Biological Therapy (AO3): a strength is the evidence of antipsychotics effectiveness

• Evidence = Thornley 2003 collected data from 1 trials which showed that chlorpromazine was associated with better overall functioning and reduced symptom severity

• Explain = this is a strength as it shows antipsychotics work to reduce the symptoms of schizophrenia

• this means those with schizophrenia may have better quality of life and may not have to spend money on expensive therapies

• Link = this increases the inter-rater reliability as

• Counter = Healy suggests that most studies are of short term effects only and successful trial have been published multiple times

• this exaggerates the effectiveness of the drug therapies and fails to consider long term effects, perhaps reducing the validity

Biological Therapy (AO3): a weakness is the serious side effects

• Evidence = typical antipsychotics are associated with a range of side effects including dizziness, agitation, sleepiness, stiff jaw etc.

• Explain = this is a weakness as it violates the ethical guidelines of protection from harm

• this may limit their applicability to a range of patients who may have other underlying medical issues or may further reduce their quality of life

• Link = therefore this may reduce the validity

Biological Therapy (AO3): a weakness is limited understanding over mechanism

• Evidence = our understanding of the mechanism by with antipsychotic drugs work is strongly tied up with the original dopamine hypothesis which we know is no a complete explanation

• Explain = this is a weakness as it may suggest that antipsychotics are not the best treatment to opt for - perhaps there is some other factor

• this means we cannot fully trust conclusions drawn from claims about cause and effect

• Link = this reduces the internal validity

Psychological Therapy

• CBT

  • Douglas (2004)

• Family Therapy

CBT

• aims to deal with both irrational thoughts and behaviour by challenging them

• helps make sense how irrational thoughts can impact thier feelings and bheaviour

• helps to convince that the voices are not real and cannot hurt, to make it less frightening

• does not eliminate symtpoms but helps to cope with them to improve ability to function adequately

• normalisation = people hearing voices can also be helped by explaining hearing voices is an ordinary experience

Douglas (2004)

• he treated a patient who belied that mafia were plotting to kill him

• the therapist acknowledged the anxiety

• explained that there were other less frightening possibilities

• then challenged the clients evidence

Family Therapy

• aim is to reduce anger, frustration and expressed emotion

• therapist meets family members and patient for open productive discussion

• educates family members about the disorder and what to expect

• encourages the family to develop problem solving and communication skills to support the patient

  • Pharaoh (2010) Range of Strategies

  • Burbach (2018) Model of Practise

Pharaoh (2010) Range of Strategies

• reduces negative emotions = family therapy aims to reduce levels of expressed emotion

• improve the family’s ability to help

  • encourages family to agree on the aims of therapy

  • improves their beliefs about and behaviour towards schizophrenia

  • achieve a balance between caring for the individual with schizophrenia and maintaining their own lives

Burbach (2018) Model of Practise

• phase 1 = sharing basic information and providing emotional practical support

• phase 2 = involves identifying resources including what different family members can and cannot offer

• phase 3 = aims to encourage mutual understanding, creating a safe space to express feelings

• phase 4 = involves identifying unhelpful patterns of interaction

• phase 5 = is about skills training such as learning stress management techniques

• phase 6 = looks at relapse prevention planning

• phase 7 = is maintenance for the future

Psychological Therapy AO3

• a strength is the evidence of effectiveness for family therapy

• a strength is the evidence of effectiveness for CBT

Psychological Therapy (AO3): a strength is the evidence of effectiveness for family therapy

• Evidence = McFarlance (2016) concluded that family therapy was one of the most effective treatments as relapse rates were typically reduced by 50-60%

• Explain = this is a strength as it means that family therpay is benefit to those with schizophrenic

• this means we can be more confident when using family therapy as a treatment , and help people become more functioning members of society

• Link = therefore this increase the reliabilty

Psychological Therapy (AO3): a strength is the evidence of effectiveness for CBT

• Evidence = Jauhar 2014 reviewed 34 studies of usng CBT and found there is clear evidence for small but significant effects on both positive and negaive symptoms

• Explain = this is a strength is it supports CBT as a treatment for schizophrenia

• this means….

• Link = therefore this increases the reliability

• Counter = however CBT may improve quality of life but it does not actually cure them, meaning reducing its validity as a total treatment

Psychological Therapy (AO3):

Management of Schizophrenia

token economies

Token Economies

• a reward system used to manage the behaviour of people with schizophrenia

• tokens are given immediately when they have carried out desirable behaviour

• target behaviours are decided on a individual basis

• tokens are then swapped for tangible rewards eg. sweets

• delayed rewards are less effective

Developing Token Economies with Schizophrenia

• Ayllon and Azrin (1968) trialled a token economy system in a ward of women with a diagnosis of schizophrenia

• every time the participants carried out a task they were given a plastic token embossed with the words ‘one gift’

• they could be swapped for ward privileges eg. watching filsm

• the number of tasks increased significantly

Rational for Token Economies

• institutionalisation can increase the development of bad habits because they have lived without the kind of routine and small pleasures we experience everyday life

• Matson (2016) identified 3 categories of institutional behaviour tackled by token economies: personal care, conditioned related behaviours and social behaviour

• this doesn’t cure schizophrenia but has benefits:

  • improves a person’s quality of life within the hospital setting

  • normalises behaviour which makes it easier for people who have spent time in hospital to adapt back into the community

Theoretical Understanding of Token Economies

• token economies are an example of behaviour modification - a behavioural therapy based on operant conditioning

• tokens are secondary reinforcers because they only have value once the person receiving them has learned that they can be used to obtain meaningful rewards

• these meaningful rewards are primary reinforcers

• generalised reinforcers = tokens that can be exchanged for a range of different primary reinforcers

• for tokens to become secondary reinforcers they are paired with primary reinforcers, so at the start of a token economy programme tokens and primary reinforcers are administered together

Management of Schizophrenia AO3

• a strength is the evidence of effectiveness

• a weakness is the ethical issues

• a weakness is that there are better alternatives

Management of Schizophrenia (AO3): a strength is the evidence of effectiveness

• Evidence = Glowacki 2016 analysed various high quality studies and which all showed a reduction in negative symptoms and unwanted behaviours due to toke economies

• Explain = this is a strength as it supports the value of toke economies in treating schizophrenia

• …..

Management of Schizophrenia (AO3): a weakness is the ethical issues issues

• Evidence = gives professionals considerable power to control the behaviour of people in the role of patient which inevitably involves imposing one person’s norms on to others

• Explain = this is a weakness as the benefits of token economies ay be outweighed by their impact on personal freedom and short term reduction in quality of life

• this reduces the applicability of the treatment

• Link = ….

Management of Schizophrenia (AO3): a weakness is that there are better alternatives

• Evidence = Chiang 2019 concluded that art therapy might be a good alternative as it has a high gain low risk approach to managing schizophrenia

• Explain = this is a weakness as it means token economies as not be as effective

Interactionist Approach to Schizophrenia

considers the combined effects of biological, psychological and social factors on the development of schizophrenia

Diathesis Stress Model

• suggests that both a vulnerability to schizophrenia and a stress trigger are necessary in order to develop the disorder

  • Meehl’s model

  • modern understanding of diathesis

  • modern understanding of stress

Meehl’s Model

• if a person does not have the schizogene then no amount of stress would lead to schizophrenia

• in carriers of the gene, chronic stress through childhood and adolescence, in particular the presence of schizophrenogenic mother, could result in the development of the disoder

Modern Understanding of Diathesis

• we now understand that there is no single schizogene

• modern views of diathesis includes a range of factors beyond the genetic, including psychological trauma

• trauma becomes the diathesis rather than the stressor

• Read (20p1) proposed a neurodevelopmental model in which early trauma alters the developing brain

• early and severe trauma can seriously affect many aspects of brain development

Modern Understanding of Stress

• a modern definition of stress includes anything that risks triggering schizophrenia such as cannabis use

• cannabis is a stressor because it increases the risk of schizophrenia by up to 7x according to dose

• this may be because cannabis interferes with dopamine system

Treatment According to the Interactionist Model

• the interactionist model combines both biological and psychological treatments

• combining antipsychotic medication and psychological therapies eg. CBT

• Turkington (2006) advocated for the interactionist approach to treat biological causes and practise CBT

• in the UK this is standard practise

Interactionist Approach AO3

• a strength is the supporting evidence for vulnerability and triggers

• a weakness of the original diathesis stress model is over simplicity

• a strength is the real world applicability

Interactionist Approach (AO3): a strength is the supporting evidence for vulnerability and triggers

• Evidence = Tienari (2004) found that in the high genetic risk group, high levels of criticism, hostility and low levels of empathy were associated with the development of schizophrenia

Interactionist Approach (AO3): a weakness of the original diathesis stress model is over simplicity

• Evidence = the original model portrayed diathesis as a single schizogene when multiple genes influence diathesis and stress as schizophrenogenic parenting

• Explain = this means there are multiple factors

Interactionist Approach (AO3): a strength is the real world applicability

• Evidence = Tarrier 2004 found in a study that participants who had a combination medication and counselling showed lower symtoms compared to the medical only