Schizophrenia

Classification of schizophrenia

Types of schizophrenia

DSM-4

• Paranoid- auditory and visual hallucinations, delusions, disorganised speech, trouble concentrating, behavioural impairment
• Catatonic- either increased (catatonic excitement) or decreased (catatonic stupor) movement, less reaction to stimuli, strange body positions, odd movements, extreme limb rigidity, inability to speak
• Disorganised- disorganised speech and thoughts, flat affect, inappropriate emotional and facial reactions, difficulty with daily activities
• Residual- no longer experience prominent symptoms like delusions and hallucinations, but still experience flat affect, psychomotor difficulties and disturbed speech
  • Experts now know many people with schizophrenia experience periods of fewer symptoms
• Undifferentiated- fit into multiple categories

DSM-5

• Type I- acute, more positive symptoms, responds better to treatment
• Type 2- chronic, more negative symptoms, less responsive to treatment
  • Affects mood, thought processes and ability to determine what is real

Symptoms

• Positive symptoms- add to normal life experiences, involve losing touch with reality
• Negative symptoms- detract from normal life experiences
  • Anhedonia- loss of pleasure in life
  • Disturbances of affect- inappropriate emotional responses
  • Thought process disorders
  • Psychomotor disturbances

Positive symptoms

• Perpetual disturbances
  • Hallucinations- auditory and/or visual, voices are typically abusive or critical
• Cognitive symptoms
  • Delusions- false beliefs that defy logic
  • Delusions of grandeur- believing they are someone famous or important
  • Paranoia- belief they are being persecuted or followed
  • Delusions of control- thinking other people are controlling part of all of their body

Negative symptoms

• Social symptoms
  • Withdrawal from social contact
• Cognitive symptoms
  • Language impairments
  • Alogia- brief replies
  • Echolalia- copying sounds
  • Jumbled, incoherent speech
  • Difficulty in maintaining a train of thought
• Affective symptoms
  • Avolition- lack of motivation and ability to look after themselves
  • Lack of emotion or inappropriate emotional responses, e.g. laughing at a funeral
• Behavioural disturbances
  • Stereotyped behaviours- moving oddly with no obvious purpose
  • Psychomotor disturbance- not having control over muscles or staying in one position for a long time (catatonia)

Clinical interview

• To get a diagnosis, client would usually self-report symptoms with a psychiatrist
  • Also takes into account observations of friend or family member
• Questions would be about everyday life, early life and childhood
• Usually several months before an observation can be made
• If onset is sudden and severe, client may be admitted to a mental hospital or sectioned for their own safety
• Criteria for diagnosis, 2 of these symptoms must be present for at least a month- delusions, hallucinations, disorganised speech, disorganised/catatonic behaviour, negative symptoms like alogia or avolition

Reliability of diagnosis

Types of reliability

• Test-retest reliability- on separate visits, when reliability stays the same
• Inter-rater reliability- two or more different clinicians make the same diagnosis of the patient independently of each other
• Studies have found concordance rates of 98% and 81% (2005)

Causes of unreliability of diagnosis

Client/patient factors

• Client may not be able to speak clearly, may feel ashamed or leave out info
• Person speaking on client’s behalf may have a vested interest in the diagnosis being made and may minimise or exaggerate the severity
• Atypical presentations mean not all clients present textbook symptoms, so may not exactly fit DSM criteria

Clinician factors

• How well the clinical interview is conducted depends on the clinician
• How well and where they were trained
• What approach in psychology they follow
• How much they rely on observation or tests

Classification factors

• Differences between DSM and ICD
• Private medical bills, use of DSM may lead to bias

:) Using a classification system improves diagnosis, has become more refined over time as DSM and ICD have been updated

:) Means clients get the help they need through the correct treatment programme

:( Getting the wrong label could be devastating for the patient, as a diagnosis of schizophrenia is often misunderstood and could affect employment opportunities

Validity of diagnosis

• Predictive validity- will correctly predict the prognosis of the illness
• Descriptive validity- symptoms of an illness being unique and distinct from other illnesses
• Aetiological validity- all people with an illness appearing to experience it in a similar way

Rosenhan study

• Rosenhan believed the DSM-II was not a valid measure for diagnosing schizophrenia
• 8 pseudo-patients presented at mental hospitals in USA, claimed to hear voices saying “empty”, “hollow” and “thud”
• Once admitted, they acted normally
• Admitted for between 7 and 52 days, released diagnosed with schizophrenia in remission
• Normal behaviour on the ward was seen as part of the illness
• 35/118 real patients suspected that the pseudo-patients were sane
• Second study, hospital was told they would have to identify how many pseudo-patients were sent into the hospital
  • None were sent in but the hospital identified 83/193 real patients as fake
• Treatment of patients reflected depersonalisation, label given at the start stuck despite being wrong

:( Showing up at the mental hospital pretending to be ill created an expectancy effect among the staff, because nobody would normally want to be admitted

:( Unethical- in the second study, genuinely ill people were doubted or turned away because they were believed to be pseudo-patients

:) Study- followed 99 patients over 13 years to see if predictive validity of main classification system worked, found if symptoms were present over 6 months then there was good predictive validity

Co-morbidity

• When someone has two separate conditions at the same time
  • Complicates diagnosis and means they may need two treatment programmes

OCD

• Common for someone with schizophrenia to also experience symptoms of OCD
• 1% of population has schizophrenia, 3% for OCD
  • 10-52% of schizophrenic population shows OCD symptoms
• Suggests a recognisable sub-group called schizo-obsessive disorder
• 12.1% of general pop show OCD symptoms, 17.1% of people who have experienced a schizophrenic episode show OCD symptoms, 25% of people with full schizophrenia show OCD symptoms

Depression

• Symptom overlap
  • Someone with major depression or bipolar disorder may experience psychosis
• Can affect predictive validity- primary diagnosis could be wrong
• 50% of people with schizophrenia have depression, 15% have co-morbid panic disorder and 29% have co-morbid post-traumatic stress disorder
  • 47% have substance misuse problems

:( Most schizophrenic clients have co-morbid symptoms yet are left out of studies to try and control the sample, decreases generalisability of studies

:( High levels of co-morbid symptoms suggest schizophrenia is not a clearly defined illness

:( Biggest challenge in diagnosis is differentiating from bipolar disorder, DSM-5 has moved to make it a spectrum disorder like autism and tried to remove subtypes, which it suggests had become unhelpful

:( Confusion in diagnosis is compounded when clients overuse alcohol or cannabis, which lower functioning levels

Cultural bias

• Tendency to over-diagnose members of other ethnic groups because their typical behaviours may be seen as abnormal by clinicians
• Could be communication issues because of how the client describes their symptoms and lifestyle
• In the UK, people of Afro-Caribbean descent are more likely to be diagnosed with schizophrenia
  • First generation- 8.9% Afro-Carribean, 8.4% white
  • Siblings born later- 15.9% Afro-Carribean, 1.8% white
  • Next generation siblings- 27.3% Afro-Carribean, 1.8% white
• Suggests schizophrenia is no less genetic for Afro-Carribean people, but increased frequency is either due to environmental stress factors or cultural bias

:) DSM-5 has a section that acknowledges that there has been cultural bias in the past and encourages the clinician to understand that different cultures may describe their illnesses in different ways

:) In many Eastern cultures, hearing voices or seeing people who have recently died is seen as positive, while in the West this behaviour is more likely to be seen as psychotic

:( Racism and social deprivation suffered by immigrants are likely to affect mental health but clinicians wrongly attribute this to their ethnicity

Gender bias

• Schizophrenia was originally believed to have equal incidence in males and females
• Gender bias may have masked the fact that it is a very different experience depending on gender
• Male- more severe, earlier onset, typical features, negative symptoms, chronic
• Female- less severe, late onset, atypical features, depressive symptoms, favourable prognosis
• Incidence
  • Half as many females are diagnosed with schizophrenia than male
  • If clearer criteria was used, fewer females were diagnosed, suggesting bias
• Age of onset
  • Males typically show symptoms in late teens
  • Females in mid to late 20s
• Hormones
  • Late onset schizophrenia in females is likely to be chronic, could be linked to menopause
  • Oestrogen may protect women until the levels drop at menopause
  • Oestradiol (from oestrogen) added to antipsychotic medication helped women more

:) Meta-analysis- 50 studies, found women had fewer re-hospitalisations, fewer admissions and shorter hospital stays

:) Study- reviewed early-1980s writing on gender differences in social outcome of schizophrenia, concluded that overall, women with schizophrenia live better lives than men

:( Some researchers have argued that women experience ‘affective psychosis’ and not schizophrenia due to differences in age of onset and experience

Symptom overlap

• When the symptoms of two mental illnesses are similar, problematic with schizophrenia and bipolar disorder, major depression, drug intoxication and some developmental conditions like autism

Bipolar disorder

• Shared genetic determinants
• Symptom overlap between positive symptoms of schizophrenia and the manic phase of a bipolar cycle
  • Psychotic symptoms, chronic course, cognitive deficits
• Study- 50,000 patients’ genetic material, 3/7 genes associated with schizophrenia were also associated with bipolar disorder

Autism

• Overlap between negative symptoms of schizophrenia and the social/communicative deficits of autism
• Do not share positive symptoms of schizophrenia and other autism symptoms like repetitive behaviours
• Study- 14 schizophrenic patients and 14 autistic patients, 7 of the autistic patients showed symptoms of schizophrenia

:) Distinctive positive characteristics of each condition help clinicians distinguish people who need a single or dual diagnosis

:) Neuroscience is showing clear differences in brains between people with schizophrenia and people with other conditions, possible that this could help in diagnosis

:( Misdiagnosis due to symptom overlap could lead to wrong treatment and needless suffering

:( Negative associations with a schizophrenia diagnosis may make clinicians especially cautious

Genetic explanation

• Says schizophrenia can be passed down genetically
• Risk for general population is 1%, if a close relative has it then risk is 6-17%, if an identical twin has it then risk is 48%

Gottesman and Shields

• Meta-analysis of studies across 10 years
  • Adoption studies- 711 participants
  • Twin studies- 210 MZ, 319 DZ
• Increased incidence of schizophrenia in adoptees with a biological parent with it
• Siblings of children with schizophrenia showed a much higher percentage
• All twin studies found a higher concordance rate for schizophrenia in MZ than DZ
  • In Gottesman and Shields’ own study, rate was 58% for MZ and 12% for DZ
• Concluded that there is a strong genetic input into onset
  • Concordance rates under 100% show there must be some environmental factors

:) Study- concordance rate of 35% in first-degree relatives

:) Study- analysed DNA of 36,989 people with schizophrenia and 113,075 controls. Identified 128 genetic variations on the chromosomes implicated in schizophrenia, associations were higher where genes had a role in immunity- supports biological cause and suggests a link to immune system

:( If genes were the sole cause, concordance rates would be 100%- other influences involved

:( Twin studies- cannot be certain that environment is not playing a part

The dopamine hypothesis

• Dopamine works in the brain to stimulate neurons at the synapse
• Some researchers believe that too much dopamine causes the onset of schizophrenia
• Antipsychotics that block dopamine via D2 receptors are effective in reducing positive symptoms
• L-dopa (drug that converts to dopamine, given to people with Parkinson’s) creates similar symptoms to schizophrenia
• Hallucinogenic drugs like LSD work on dopamine circuit and cause similar symptoms
• Dopamine mechanism- brain’s pleasure pathway, dopamine is released whenever we do anything that makes us feel good

:) Has generated lots of research and driven drug treatments that have helped some patients

:( Clozapine, an antipsychotic that is effective in treating schizophrenia, does not block much dopamine activity

:( Criticised as over-simplistic and inconclusive- more than just dopamine is involved, does not explain negative symptoms

:( Some researchers have suggested that drug companies have a vested interest in promoting the dopamine hypothesis because they can make profits from selling antipsychotics

Neural correlates

• New scanning technology has allowed schizophrenic patients’ brains to be scanned and certain differences have been found between their brains and the brains of healthy people
• Correlational data- no cause-and-effect relationship

Ventricles

• Post-mortems have found larger ventricles in the brains of people with schizophrenia
• Suggests damage to central brain areas and prefrontal cortex- could account for negative symptoms

Wernicke’s area

• Wernicke’s area is part of a loop involved in auditory hallucinations
• Excessive activity could cause an overabundance of language representations and make them hear voices

Amygdala

• Bilateral amygdala is less active in schizophrenic patients
• Used for processing faces, could explain difficulty

Grey matter

• Differences found in schizophrenic patients over time
• Gradual diminishing of cortical activity as the patient experiences negative symptoms and often becomes less active
  • Early medication can slow this as the patient maintains a more active lifestyle

Family dysfunction explanation

• Diathesis-stress model- sources of stress can cause problems with people who have a genetic predisposition to schizophrenia
  • Family can be a source
  • Having someone with schizophrenia in the family can be upsetting- hard to determine which comes first
• Stress releases cortisol, if there is long-term stress then this can be harmful physically and mentally and may cause schizophrenia
• Study found family dysfunction when at least 3 were reported:
  • Poor relationship between adults
  • Lack of warmth between parents and child
  • Overt disturbance of father-child relationship
  • Overt disturbance of mother-child relationship
  • Overt disturbance of sibling-child relationship
  • Parental overprotection
  • Child abuse
• Double-bind hypothesis- a set of contradictory positions, both of which have a negative consequence
  • For example, a mother tells her child she loves them while turning away in disgust, words conflict body language and child does not know how to respond
• Expressed emotions (EE)- communication style that involves criticism, hostility and emotional over-involvement
  • Patient returning to a high EE family is 4x more likely to relapse

:) Study- 37% of high-risk genetic adoptees in a dysfunctional family environment developed a schizophrenia-spectrum disorder, only 5.3% in a healthy family environment

:) Family therapy has been shown to be effective in treating schizophrenia

:( Having someone with schizophrenia in the family is stressful and can cause high emotions and conflicts, difficult to establish which comes first

Cognitive explanations

• Cognitive deficits are caused by faulty thinking by the patients, which could have an underlying biological cause
  • Voices are seen as misperceptions instead of inner speech
  • Hallucinations are seen as biased information processing
  • Negative symptoms are seen as control strategies to manage high levels of mental stimulation
• Proposed cognitive model- interaction of environmental, neurobiological, behavioural and cognitive factors that lead to cognitive deficits
• Mainly affect attention, working memory, verbal learning and executive function
• Impairments were present before the condition developed
• Study- got people with and without schizophrenia to listen to tones and try to tell them apart, schizophrenics struggled to do this- could be due to difficulty in rapidly encoding new info or selectively attend to info

:) Can explain both positive and negative symptoms

:) Treatment of cognitive dysfunction may have an important role in increasing effective treatment, new drugs could be found that improve cognitive functioning

:( Does not explain the cause of schizophrenia or the deficits

:( If this is true, it should be easy to persuade someone with schizophrenia of reality, but this is extremely difficult

Dysfunctional thought processing

• Healthy people are able to use metacognition (awareness of how they are thinking and feeling and knowledge of when they have made an error) to guide thinking and problem solving
  • Schizophrenic people lose this awareness, resulting in cognitive dysfunction
  • Especially in positive symptoms, where they lose touch with reality

Hayling sentence completion task

• Participant has to provide the final word of a sentence as fast as they can
  • For example, “He sent the letter without a…” “stamp.”
• Then participant has to generate a word that is inappropriate and unrelated
  • For example, “The captain wanted to stay with the sinking…” “banana.”
  • Participants have to suppress/inhibit a strongly activated response (ship) before they could generate a new one (banana)
• Conducted on people with schizophrenia, people with bipolar disorder, and healthy controls
  • People with schizophrenia were slower to respond and slower in suppressing inappropriate responses than controls, and made more errors
  • Associated with higher levels of cognitive disorganisation
  • People with bipolar disorder did not differ compared to the controls
  • Performance was not related to age, gender, IQ, etc.

BADS

• Behavioural Assessment of the Dysexecutive Syndrome
• Set of tasks that assess the skills and demands involved in everyday life
  • Shows difficulties with frontal lobe damage
• BADS, IQ tests and memory tests were conducted on schizophrenic, brain-injured and healthy participants
  • Schizophrenic and brain-damaged participants had impaired executive functioning
  • Schizophrenic participants also showed memory problems

:) Meta-analysis of 20 years of research supported the idea that schizophrenia impairs metacognition and leaves patients with impairments in social functioning, self-reflection and empathy

:) If a clear idea of problems with metacognition can be established, then patients can be treated and helped to overcome these deficits

:( Metacognition is not visible and is investigated with ratings on tests, which could be invalid and unreliable

Drug therapy

• People with schizophrenia are usually offered antipsychotics, which helps with positive symptoms
• Typical antipsychotics- developed in 1950s, first generation
• Atypical antipsychotics- developed since 1990s, second generation

• Can reduce positive symptoms in 8-15 days but often fail to significantly improve negative symptoms and cognitive dysfunction
• Which drug to use on a specific patient is based on benefits, risks and costs
• Typical and atypical have similar effectiveness and relapse rates
  • Good response in 40-50%
  • Partial response in 30-40%
  • Treatment resistance in 20% (failure to respond after 6 weeks of 2-3 different antipsychotics)

:) Study- meta-analysis of over 100 studies, found antipsychotics were 75% effective and placebos were 25% effective

:) Study- clozapine helped 30-61% of patients who were resistant to typical antipsychotics

:( Side effects can be serious and lead to significant decrease in quality of life

:( Socially sensitive- some argue drugs are used to sedate people to make them easier to manage and deprive them of free will

Cognitive behavioural therapy

• Cognitive explanation says it should be possible to help people logically deal with hallucinations and delusions

1. Assessment- patient expresses thoughts about experiences while therapist listens actively, use of rating scales is encouraged to monitor progress
2. Engagement- use of Socratic questioning (drawing out understanding) and empathy creates a therapeutic relationship
3. ABC model- (originally made for people with depression but can be applied to schizophrenia) helps patient organise thoughts and feelings

1. Activating event- voices
2. Beliefs- voices are constantly mean, you will never believe me, I will never be able to do what I want again
3. Consequence- emotions, depression, loneliness, isolation
   4. Goal-setting- realistic goals for therapy are discussed with patient, using distressing consequences as motivation for change. Therapist is supposed to make sure goals are measurable, realistic and achievable. Revisited during and at the end of treatment
   5. Normalising- de-catastrophising psychotic experiences, placed on a continuum with normal experiences to make the possibility of recovery seem less distant
   6. Critical collaborative analysis- once trust is formed, gentle questioning is used to help the patient realise maladaptive beliefs
   7. Developing alternative assumptions- patient develops alternatives to maladaptive beliefs, preferably by looking for alternative explanations and coping strategies already present in their mind

Sensky study

• 97 UK patients who were unresponsive to medication, received around 19 sessions over 9 months
• CBT group experienced the 7 stages
• Befriending group had a therapist who was empathetic but did not try to treat them
  • Talked about daily activities and hobbies
• Patients assessed by blind raters at the beginning, at the end of the 9 months, and 9 months after that
• Both groups equally improved in positive and negative symptoms at the end of treatment, but 9 months later, the CBT group showed improvement while the befriending group showed losses

:) Works in combination with drug therapy, more effective than just drug treatment

:( Not suitable for everyone, extremely agitated patients will be unable to rationalise or empathise with a therapist

:( Suggested that it provides strategies to cope rather than dealing with symptoms

Family therapy

• Attempts to combat family dysfunction and help the family find more positive ways of dealing with the stress of living with someone with schizophrenia
• Goals of family therapy
  • Give the family all the info they need to understand the condition
  • Help the family understand they are not to blame
  • Help the family come to terms with the patient’s behaviour, which may be frustrating or frightening
  • Make sure everyone is heard to reduce tension
  • Help the patient move forward and cope
  • Encourage discussion about what it is like to live with the patient
• Takes place over many sessions, usually in patient’s home

:) Causes fewest relapses and hospital admissions and best compliance with medication

:( Expensive and time-consuming

Token economies

• Based on operant conditioning
  • Says behaviour can be shaped with positive and negative reinforcement
• Used in hospitals to help institutionalised people with schizophrenia gain more control over their daily lives and increase positive behaviours

Meadowview Unit in Clinton Valley Center, Michigan (1988-91)

• Token economy provided a structured programme that reinforced positive behaviour
• Primary focus was to observe and reinforce desired behaviour
• Patient participation was voluntary
• Points were only given, never taken away, and participants were never threatened with losing points
• Rewards for specific criteria were given only when met
  • Included verbal praise, points and backup reinforcers from the token store
• Behaviours included maintaining hygiene, getting up on time, etc.
• Rewards included snacks, puzzles, clothing, etc.

:) Provides a positive means for motivating and promoting desired behaviours, and monitoring patients’ progress

:) Tokens can be awarded by all staff, no need for specialist training

:( Requires continuous dedication from all staff, can be difficult to maintain

:( Can be seen as demeaning, risk of power abuse such as withholding basic needs

Interactionist approach

• Explains schizophrenia through a combination of factors
  • Psychological, biological and social
• Combines therapies
• Normally referred to as the biopsychosocial perspective
• Diathesis-stress model- people are born with genetic predispositions to schizophrenia and factors in the environment act as stressors that cause symptoms
• Childhood
  • Pre-natal and post-natal risk factors
  • Genetics
  • Predisposing neural correlates
• Early adolescence
  • Social adversity (environmental stressor) leading to social withdrawal, anxiety, depressive symptoms
• Early adulthood
  • Prodromal stage (developing schizophrenia) and development of full psychosis
• Interactionist treatments
  • Anti-depressants for treating negative symptoms while another therapy treats positive symptoms (combination therapy)
  • Assertive community therapy for getting patients back into work and community
  • CBT for treating positive and negative symptoms
  • Family therapy for those with dysfunctional families
  • Mindfulness for treating positive symptoms

:) Study- found support for diathesis-stress model, diathesis was genetic inheritance and stress was dysfunctional family

:) Relapse rate with just drug therapy was 41%, reduced to 19% when combined with family therapy

:) Compliance with antipsychotic medication improved when also given CBT