Schizophrenia

• What is schizophrenia?


  • a severe mental disorder where reality and insight are impaired
  • leads to a change in emotions and behaviour
  • 1% of the world population
  • common in males
  • common in lower social backgrounds
• How is SZ diagnosed and classified?


  • DSM-5 - one positive symptom
  • ICD-10 - two or more negative symptoms
• What are positive symptoms?


  • additional experiences beyond those of ordinary existence/normal experiences
• What are hallucinations?


  • unusual sensory experiences and some are related to events in the environment and some are not ( hearing voices, seeing a person)
• What are delusions?


  • irrational beliefs/paranoia which commonly involve important figures or being prosecuted by aliens/gov
  • Body control - may believe they are under external control, makes sense to them but not others
• What are negative symptoms of SZ?


  • atypical experiences that involve the loss of usual experiences such as speech poverty and avoltion.
• What is speech poverty?


  • changes in the patterns of speech and has a reduction in the amount/quality of speech
  • Also speech disorganisation - changes in topic mid sentence (positive symptom for DSM-5)
• What is avolition?


  • lack of motivation to persist in everyday or goal directed activity
  • Andreasan - 3 signs - poor hygiene, lack of persistence in work/education and a lack of energy
• Evaluation of diagnosis of SZ -


  • GOOD RELIABILITY - Osorio et al measured diagnosis in 180 individuals using DSM-5 and found a pair of interviewers achieved an inter-rater reliability of +.97 and a test-retest of +.92
  • LOW VALIDITY - lacks criterion validity as psychiatrists independently assessed 100 SZ patients and found 68 were diagnosed using ICD and 39 using DSM. Could suggest under/over diagnosis
  • LIMITATION - co-morbidity with its other conditions as if conditions occur together, it questions the validity of the diagnosis as it may be a single condition
• Evaluation of diagnosis -

  • GENDER BIAS - men are diagnosed more with SZ as it is suggested that women can control their SZ or can get support better. This means there is a lack of treatment available for women since men are treated more
  • CULTURE BIAS - in AC cultures, hearing voices (delusions) are part of their culture as compared to british culture. This means AC may be discriminated against and a lack of generalisability to all cultures
• What is the biological explanation of SZ?


  • Genetic basis - family studies have confirmed the risk of SZ increases in line with genetic similarity to a relative with the condition. Gottesman et al found that identical twins have a 48% risk of developing SZ as compared to 17% of dyzogotic twins
  • Candidate genes - SZ is polygenic (number of diff genes involved) and these genes likely code for dopamine. Ripke et al found that there were 108 separate genetic variations that increased the risk of SZ (aetiologically heterogenous)
• How does the role of mutation explain SZ?


  • Mutation - parental DNA can be mutated and can develop a risk of SZ. Positive correlation between paternal age (sperm mutation risk) and risk of SZ. 0.7% in fathers under 25 and 2% in fathers over 50
• What is the original dopamine hypothesis?


  • SZ may be a result of high levels of dopamine (hyperdopaminergia) in subcortical areas of the brain (Broca) and may explain speech poverty and auditory hallucinations
• What is the updated dopamine hypothesis?


  • Davis et al proposed the addition of cortical hypodopaminergia which is low dopamine in brain's prefrontal cortex. Low dopamine could explain cognitive problems and negative symptoms
• What are the neural correlates of negative symptoms?


  • The ventral striatum is involved with the anticipation of a reward (motivation). Abnormality in the ventral striatum may be involved in the development of avolition
  • Juckel et al - measured activity levels in the ventral striatum in patients with SZ and found lower activity levels than control group
• What are the neural correlates for negative symptoms?


  • Allen et al scanned the brains of patients experiencing auditory hallucinations and compared them to a control group
  • Found lower activation levels in the superior temporal gyrus and anterior cingulate gyrus in hallucination group
• Evaluation for biological explanation -

  • RESEARCH SUPPORT - Gottesman et al.
  • LIMITATION - Ignores the role of environmental factors. Psychologists found that 67% of SZ patients tend to report at least one account of family trauma
  • DOPAMINE EVIDENCE - Amphetamines that increase dopamine tend to worsen symptoms and antipsychotic drugs that reduce dopamine tend to relieve symptoms
• Evaluation for biological explanation -

  • LIMITATION - post mortems and live scanning studies have shown persistent increased glutamate levels in several regions of the brain of people with SZ
  • Tenn et al induced SZ symptoms in rats and relieved them with drugs that reduce dopamine activity
• What are antipsychotics?


  • reduce the severity of symptoms of mental disorders (SZ)
  • may be required to be taken short or long term
• What is chlorpromazine?


  • can be taken as a syrup, tablets or injection
  • orally taken
  • administered daily up to a maximum of 1000 mg
  • gradually increased dosage from 400-800 mg
• How does chlorpromazine work?


  • dopamine antagonists work by blocking dopamine receptors in synapses, reducing dopamine. The dopamine-antagonist effect also normalises neurotransmission, reducing symptoms like hallucinations
  • can also work as a sedative as it calms individuals when coming to hospital. Syrup absorbs faster than tablets
• What is clozapine?


  • people taking it have regular blood tests to ensure they do not develop agranulocytosis
  • not an injection because of the side effects
  • dosage is 300-450 mg
• How does clozapine work?


  • clozapine binds to dopamine, serotonin and glutamate receptors. This helps reduce mood and reduce depression and anxiety; improves cognitive functioning
  • prescribed if patients are suicidal (30-50% of SZ patients)
• What is risperidone?


  • can be taken in the form of tablet, injection or syrup
  • small dosage - 4-8 mg but max is 12 mg
• How does risperidone work?


  • binds to both dopamine and serotonin receptors. Binds more strongly to dopamine than clozapine; so more effective in smaller dosages and fewer side effects
• Evaluation of drug therapy -

  • research support - Thornley et al reviewed studies comparing chloropromazine to placebos. Data from 113 studies with 1121 patients and showed chloropromazine was associated with overall better functioning and reduced severity of symptoms as compared to placebos
  • research support - Meltzer concluded that clozapine is more effective than typical and atypical drugs. It is effective in 30-50% of the treatment
• Evaluation of drug therapy -


  • Limitation - there are side effects to the drugs. Typical ones produce dizziness, sleepiness and jaw and weight gain. Long term effects can be tardive dyskinesia. Atypical can result in NMS which can lead to a coma
  • Strength - chloropromazine is useful in calming patients for CBT and social work
  • limitation - Used to help hospital staff control patients rather than treating symptoms
• How does family dysfunction explain SZ?


  1. The Schizophrenogenic mother - literally means SZ causing. This mother is cold, rejecting and controlling and tends to create a family environment characterised by tension and secrecy. Can lead to delusions and paranoia
  2. Double-bind theory - the developing child is trapped in situations where they fear doing the wrong thing. They receive mixed messages about what that is and child is punished by a withdrawal of love which leaves them with a confusing idea of the world which is reflected in disorganised thinking and delusion
• How does family dysfunction explain SZ?


  • expressed emotions - the levels of emotion expressed towards a person with SZ by family members
  • Verbal criticism, accompanied by violence
  • Hostility towards a person, including anger and rejection
  • Emotional overinvolvement, including needless self sacrifice
  • These are a serious source of stress and can trigger SZ or a relapse of SZ
• What are the cognitive explanations of SZ?


  • dysfunctional thinking - SZ is characterised by disruption to normal thought processing. Reduced thought processing in the ventral striatum is associated with negative symptoms, whilst reduced processing of info in cingulate and temporal gyrus are associated with hallucinations (positive symptoms)
• What are the cognitive explanations of SZ?


  • Metarepresentation dysfunction - reflecting on our own thoughts and behaviour which allows us to interpret the actions of others. Dysfunction in metarepresentation would disrupt our ability to recognise our own thoughts and actions being carried out by ourselves (explains delusions and hearing voices)
  • Central Control Dysfunction - issues with the cognitive ability to surpress automatic responses while performing actions. Speech poverty could result from the inability to surpress automatic thoughts and speech triggered by other thoughts
• Evaluation of family dysfunction -

  • RESEARCH SUPPORT - Read et al reported that 69% of SZ women and 59% men had experienced physical or sexual abuse. Another psychologist found adults with SZ reported at least one case of trauma
  • SUPPORT - Genain sisters
  • Explanations lack support - lack of systematic evidence for SZ mother and double-bind theory as it based on clinical observations and reports from SZ patients
  • Limitation - blames the parent even if they are dedicating life to look after their child
• Evaluation of cognitive explanations -

  • SUPPORT - Stirling et al compared performances on the Stroop task with 30 SZ people and a control group. Found the SZ took twice as longer to do the task because of the inability to suppress thoughts
  • limitation - Cognitive explanations lack cause effect conclusions: does schizophrenia cause dysfunctional thought processing or is that dysfunctional thought processing leads to schizophrenia symptoms?  
• Evaluation of cognitive explanations -

  • Limitation - There may be issues with the validity of cognitive explanations, for example a person’s thought processing is likely to be highly subjective, regardless of whether they have schizophrenia or not, so it is difficult to know how to judge.
  • Limitation - biological explanation may be a better explanation as abnormal brain development is likely genetic.
• What are the psychological therapies used to treat SZ?


  1. CBT
  2. Family Therapy
• How does CBT treat SZ?


  • usually takes place over a period of 5-20 sessions and is in group or individual basis
  • CBT helps a client make sense of how their irrational cognitions (delusions/hallucinations) impact on their feelings and behaviour
  • Just understanding where these symptoms can be extremely helpful. This is much less frightening for patient
  • This will not eliminate the symptoms of SZ but can make it better to cope with them and reduce stress
  • People hearing voices can be taught as an extension of ordinary experiences (normalisation)
• How does family therapy treat SZ?


  • takes place with families as well as the identified patient and aims to improve the communication and interactions between family
  • reduces negative emotions - aims to reduce the levels of expressed emotions such as anger and guilt which create stress
  • improves family ability to help - encourages family members to form a therapeutic alliance whereby they all agree on the aims of therapy. Also tries to improve families beliefs towards SZ and to ensure their is a balance between taking care of patient and balancing their own life
• Evaluation of CBT -


  • SUPPORT - Jauhar et al reviewed 34 studies of CBT with SZ and found that there was a clear reduction in both positive and negative symptoms. Pontillio et al found reductions in frequency and severity of auditory hallucinations. Clinical advice from NICE recommends CBT for SZ
  • LIMITATION - CBT techniques vary from one case to another as patients have different symptoms. This means that there is a lack of standardised procedure for CBT
  • LIMITATION - CBT does not actually cure, but improves ability to live with SZ
• Evaluation of family therapy -

  • EVIDENCE - Psychologist concluded that family therapy was one of the most consistently effective treatments. Relapse rates were found to be reduced to 60% and also concluded that family therapy also reduces mental health
  • STRENGTH - benefits all the family members as it strengthens the functions of the whole family and lessens the negative impact of SZ and benefits the family support. This means that family therapy has wider benefits beyond the impact of identified patient
  • Psych and the economy - allows SZ patients to cope and less likely to be instituionalised
• What are token economies?


  • reward systems used to manage the behaviours of people with SZ
  • Those who have developed maladaptive behaviour through institutionalisation