Schizophrenia

• Classification of schnizophrenia


  Classification is the process of organising symptoms into categories based on which symptoms cluster together in sufferers. Psychologists use the DSM and ICD to diagnose a patient with schizophrenia.
• Positive symptoms


  Hallucinations are usually auditory or visual perceptions of things that are not present. Imagined stimuli could involve any of the senses. Voices are usually heard coming from outside the person's head giving instructions on how to behave.

  • Delusions are false beliefs. Usually the person has convinced themself they are someone powerful or important, such as Jesus Christ, the Queen (e.g. Delusions of Grandeur). There are also delusions of being paranoid, worrying that people are out to get them.
• Negative symptoms


  Negative symptoms are a diminution or loss of normal functions such as psychomotor disturbances, avolition (the reduction of goal-directed behavior), disturbances of mood and thought disorders.

  
  

  • Thought disorder

  • Avolition
• Evaluation of classification


  Classification and diagnosis does have advantages as it allows doctors to communicate more effectively about a patient and use similar terminology when discussing them. In addition, they can then predict the outcome of the disorder and suggest related treatment to help the patient.

  Scheff (1966) points out that diagnosis classification labels the individual, and this can have many adverse effects, such as a self-fulfilling prophecy (patients may begin to act how they are expected to act), and lower self-esteem.
• Reliability in Diagnosis and Classification of Schizophrenia


  For the classification system to be reliable, differfent clinicians using the same system (e.g. DSM) should arrive at the same diagnosis for the same individual.

  Reliability is the level of agreement on the diagnosis by different psychiatrists across time and cultures; stability of diagnosis over time given no change in symptoms.
• Evaluation: Reliability


  Jakobsen et al. (2005) tested the reliability of the ICD-10 classification system in diagnosing schizophrenia. A hundred Danish patients with a history of psychosis were assessed using operational criteria, and a concordance rate of 98% was obtained. This demonstrates the high reliability of the clinical diagnosis of schizophrenia using up-to-date classification.
• Validity in diagnosis and classification of schizophrenia

  Validity - the extent to which schizophrenia is a unique syndrome with characteristics, signs and symptoms. For the classification system to be valid it should be meaningful and classify a real pattern of symptoms, which result from a real underlying cause.
• Evaluation: Validity


  Problems of validity: Are we really testing what we think we are testing? In the USA only 20% of psychiatric patients were classed as having schizophrenia in the 1930s but this rose to 80% in the 1950s . In London the rate remained at 20%, suggesting neither group had a valid definition of schizophrenia.
• Biological Explanations for Schizophrenia

  • Family studies find individuals who have schizophrenia and determine whether their biological relatives are similarly affected more often than non-biological relatives.

  Gottesman (1991) found that MZ twins have a 48% risk of getting schizophrenia whereas DZ twins have a 17% risk rate. This is evidence that the higher the degree of genetic relativeness, the higher the risk of getting schizophrenia.
• Evaluation of biological explanations for schizophrenia


  One weakness of the genetic explanation of schizophrenia is that there are methodological problems. Family, twin and adoption studies must be considered cautiously because they are retrospective, and diagnosis may be biased by knowledge that other family members who may have been diagnosed. This suggests that there may be problems of demand characteristics.
• The dopamine hypothesis


  • Dopamine is a neurotransmitter. It is one of the chemicals in the brain which causes neurons to fire. The original dopamine hypothesis stated that schizophrenia suffered from an excessive amount of dopamine. This causes the neurons that use dopamine to fire too often and transmit too many messages.

  • High dopamine activity leads to acute episodes, and positive symptoms which include: delusions, hallucinations, confused thinking.

  • Evidence for this comes from that fact that amphetamines increase the amounts of dopamine. Large doses of amphetamine given to people with no history of psychological disorders produce behavior which is very similar to paranoid schizophrenia. Small doses given to people already suffering from schizophrenia tend to worsen their symptoms.
• Evaluation: dopamine hypotheis


  One criticism of the dopamine hypothesis is there is a problem with the chicken and egg. Is the raised dopamine levels the cause of the schizophrenia, or is it the raised dopamine level the result of schizophrenia? It is not clear which comes first. This suggests that one needs to be careful when establishing cause and effect relationships in schizophrenic patients.

  One of the biggest criticisms of the dopamine hypothesis came when Farde et al found no difference between schizophrenics' levels of dopamine compared with 'healthy' individuals in 1990.
• Neural correlates


  • Neural correlates are patterns of structure or activity in the brain that occur in conjunction with schizophrenia

  • People with schizophrenia have abnormally large ventricles in the brain. Ventricles are fluid filled cavities (i.e. holes) in the brain that supply nutrients and remove waste. This means that the brains of schizophrenics are lighter than normal. The ventricles of a person with schizophrenia are on average about 15% bigger than normal (Torrey, 2002).
• Evaluation: neural correlates


  A strength is that the research into enlarged ventricles and neurotransmitter levels have high reliability. The reason for this is because the research is carried out in highly controlled environments, which specialist, high tech equipment such as MRI and PET scans. These machines take accurate readings of brain regions such as the frontal and pre-frontal cortex, the basil ganglia, the hippocampus and the amygdale. This suggests that if this research was tested and re-tested the same results would be achieved.
• Psychological explanations for schizophrenia

  Family Dysfunction refers to any forms of abnormal processes within a family such as conflict, communication problems, cold parenting, criticism, control and high levels of expressed emotions.
• Evaluation: Psychological explanations for schizophrenia

  One strength of the double bind explanation comes from further empirical support provided by Berger (1965). They found that schizophrenics reported a higher recall of double bind statements by their mothers than non-schizophrenics. However, evidence may not be reliable as patient's recall may be affected by their schizophrenia. This suggests that there is wider academic credibility for the idea of contradictory messages causing schizophrenia.
• Cognitive explanations


  Cognitive approaches examine how people think, how they process information. Researchers have focused on two factors which appear to be related to some of the experiences and behaviors of people diagnosed with schizophrenia.

  First, cognitive deficits which are impairments in thought processes such as perception, memory and attention. Second, cognitive biases are present when people notice, pay attention to, or remember certain types of information better than other.
• Cognitive Deficits


  • There is evidence that people diagnosed as schizophrenic have difficulties in processing various types of information, for example visual and auditory information. Research indicates their attention skills may be deficient - they often appear easily distracted.

  • A number of researchers have suggested that difficulties in understanding other people's behavior might explain some of the experiences of those diagnosed as schizophrenic. Social behavior depends, in part, on using other people's actions as clues for understanding what they might be thinking. Some people who have been diagnosed as schizophrenic appear to have difficulties with this skill.

  • Cognitive deficits have been suggested as possible explanations for a range of behaviors associated with schizophrenia. These include reduced levels of emotional expression, disorganised speech and delusions.
• Cognitive Biases


  • Cognitive biases refer to selective attention. The idea of cognitive biases has been used to explain some of the behaviors which have been traditionally regarded as 'symptoms' of 'schizophrenia'.

  • - Delusions: The most common delusion that people diagnosed with schizophrenia report is that others are trying to harm or kill them - delusions of persecution. Research suggests that these delusions are associated with specific biases in reasoning about and explaining social situations. Many people who experience feelings of persecution have a general tendency to assume that other people cause the things that go wrong with their lives.
• Evaluation: cognitive explanation


  A strength of the cognitive explanation is that it has practical applications. Yellowless et al. (2002) developed a machine that produced virtual hallucinations, such as hearing the television telling you to kill yourself or one person's face morphing into another's. The intention is to show schizophrenics that their hallucinations are not real. This suggests that understanding the effects of cognitive deficits allows psychologists to create new initiatives for schizophrenics and improve the quality of their lives.

  
  

  One weakness of the cognitive explanation is that there are problems with cause and effect. Cognitive approaches do not explain the causes of cognitive deficits - where they come from in the first place. Is it the cognitive deficits which causes the schizophrenic behavior or is the schizophrenia that causes the cognitive deficits? This suggests that there are problems with the chicken and egg problem.
• Drug Therapy: typical and atypical antipsychotics

  Drug therapy is a biological treatment for schizophrenia. Antipsychotic drugs are used to reduce the intensity of symptoms (particularly positive symptoms).
• Typical Antipsychotics


  • First generation Antipsychotics are called "Typical Antipsychotics" Eg. Chlorpromazine and Haloperidol.

  • Typical antipsychotic drugs are used to reduce the intensity of positive symptoms, blocking dopamine receptors in the synapses of the brain and thus reducing the action of dopamine.

  • They arrest dopamine production by blocking the D2 receptors in synapses that absorb dopamine, in the mesolimbic pathway thus reducing positive symptoms, such as auditory hallucinations.

  • But they tended to block ALL types of dopamine activity, (in other parts of the brain as well) and this caused side effects and may have been harmful.
• Atypical antipsychotics


  • Newer drugs, called "atypical antipsychotics" attempt to target D2 dopamine activity in the limbic system but not D3 receptors in other parts of the brain.

  •Atypical antipsychotics such as Clozapine bind to dopamine, serotonin and glutamate receptors.

  • Atypical antipsychotic drugs work on negative symptoms, improving mood, cognitive functions and reducing depression and anxiety.

  • They also have some effect on other neurotransmitters such as serotonin. They generally have fewer side effects eg. less effect on movement Eg. Clozapine, Olazapine and Risperidone.
• Evaluation: Drug therapy


  Antipsychotic drugs are highly effective as they are relatively cheap to produce, easy to administer and have a positive effect on many sufferers. However they do not "cure" schizophrenia, rather they dampen symptoms down so that patients can live fairly normal lives in the community.

  
  

  Severe side effects - Long term use can result in tardive dyskinesia which manifests as involuntary facial movements such as blinking and lip smacking - While they may be effective, the severity of the side effects mean the costs outweigh the benefits therefore they are not an appropriate treatment.
• Family therapy


  Family therapy is a form of therapy carried out with members of the family with the aim of improving their communication and reducing the stress of living as a family.

  Family Therapy aims to reduce levels of expressed emotion, and reduced the likelihood of relapse.
• Aims of Family Therapy

  • To educate relatives about schizophrenia.

  • To stabilize the social authority of the doctor and the family.

  • To improve how the family communicated and handled the situation.

  • To teach patients and carers more effective stress management techniques.
• Methods used in Family Therapy

  • Pharoah identified examples of how family therapy works: It helps family members achieve a balance between caring for the individual and maintaining their own lives, it reduces anger and guilt, it improves their ability to anticipate and solve problems and forms a therapeutic alliance.

  • Families taught to have weekly family meetings solving problems on family and individual goals, resolve conflict between members, and pinpoint stressors.

  • Preliminary analysis: Through interviews and observation the therapist identifies strengths and weaknesses of family members and identifies problem behaviors.

  • Information transfer - teaching the patient and the family the actual facts about the illness, it's causes, the influence of drug abuse, and the effect of stress and guilt.

  • Communication skills training - teach family to listen, to express emotions and to discuss things. Additional communication skills are taught, such as "compromise and negotiation," and "requesting a time out" . This is mainly aimed at lowering expressed emotion.
• Evaluation of family therapy


  Economic Benefits: Family therapy is highly cost effective because it reduces relapse rates, so the patients are less likely to take up hospital beds and resources. The NICE review of family therapy studies demonstrated that it was associated with significant cost savings when offered to patients alongside the standard care - Relapse rates are also lower which suggests the savings could be even higher.

  Lobban (2013) reports that other family members felt they were able to cope better thanks to family therapy. In more extreme cases the patient might be unable to cope with the pressures of having to discuss their ideas and feelings and could become stressed by the therapy, or over-fixated with the details of their illness.
• Token economy


  • Token economies aim to manage schizophrenia rather than treat it.

  • They are a form of behavioral therapy where desirable behaviors are encouraged by the use of selective reinforcement and is based on operant conditioning.

  • When desired behavior is displayed eg. Getting dressed, tokens (in the form of coloured discs) are given immediately as secondary reinforcers which can be exchanged for rewards eg. Sweets and cigarettes. • This manages schizophrenia because it maintains desirable behavior and no longer reinforces undesirable behavior.

  • The focus of a token economy is on shaping and positively reinforcing desired behaviors and NOT on punishing undesirable behaviors. The technique alleviates negative symptoms such as poor motivation, and nurses subsequently view patients more positively, which raises staff morale and has beneficial outcomes for patients.

  • It can also reduce positive symptoms by not rewarding them, but rewarding desirable behavior instead. Desirable behavior includes self-care, taking medication, work skills, and treatment participation.
• Evaluation: CBT


  CBT does seem to reduce relapses and readmissions to hospital (NICE 2014) However the fact that these people were on medication and having regular meetings with doctors would be expected to have that effect anyway.

  
  

  Requires self-awareness and willingness to engage - Held back by the symptoms schizophrenics encounter - It is an ineffective treatment likely to lead to disengagement.
• interactionist approach


  The Interactionist approach acknowledges that there are a range of factors (including biological and psychological) which are involved in the development of schizophrenia.
• Diathesis-stress model


  • The DSM model states that both a vulnerability to SZ and a stress trigger are necessary to develop the condition.

  • Zubin and Spring suggest that a person may be born with a predisposition towards schizophrenia which is then triggered by stress in everyday life. But if they have a supportive environment and/or good coping skills the illness may not develop.

  • Concordance rates are never 100% which suggests that environmental factors must also play a role in the development of SZ. MZ twins may have the same genetic vulnerability but can be triggered by different stressors.

  • Tienari Et. A. (2004): Adopted children from families with schizophrenia had more chance of developing the illness than children from normal families. This supports a genetic link. However, those children from families schizophrenia were less likely to develop the illness if placed in a "good" family with kind relationships, empathy, security, etc. So environment does play a part in triggering the illness.
• Evaluation: Interactionist approach


  Falloon et al (1996) stress - such as divorce or bereavement, causes the brain to be flooded with neurotransmitters which brings on the acute episode.

  
  

  Fox (1990): It is more likely that factors associated with living in poorer conditions (e.g. stress) may trigger the onset of schizophrenia, rather than individuals with schizophrenia moving down in social status.
• Comorbidity 


  When people suffer from two or more mental disorders. For example, schizophrenia and depression are often found together. This makes it more difficult to confidently diagnose schizophrenia. Comorbidity occurs because the symptoms of different disorders overlap.
• A problem of nature-v-Nurture with Biological explanation

  It is very difficult to separate out the influence of nature-v-nurture. The fact that the concordance rates are not 100% means that schizophrenia cannot wholly be explained by genes and it could be that the individual has a pre-disposition to schizophrenia
• A weakness of the family relationsships approach is that there is a problem of cause and effect. 


  Mischler & Waxler (1968) found significant differences in the way mothers spoke to their schizophrenic daughters compared to their normal daughters, which suggests that dysfunctional communication may be a result of living with the schizophrenic rather than the cause of the disorder.
• Svets (2014) found that 12% of schizophrenic patients fulfilled criteria for OCD
• Mis diagnosis- Rosenhann's research highlights issues with validity of diagnosis as 7 out of 8 of these pseudopatients were diagnosed with schizophrenia despite having only one smptom
• The interactionist approach can also be criticised for being too deterministic. If we accept that biological factors play an important role in causing schizophrenia then it seems unlikely that environmental factors alone will ever be able to prevent its occurrence. Therefore, the interactionist approach fails to offer any hope of finding a cure for schizophrenia.
• Double bind theory


  Bateson suggests that children who frequently receive contradictory messages from their parents are more likely to develop schizophrenia. For example parents who say they care whilst appearing critical or who express love whilst appearing angry. They believed that schizophrenia was a result of social pressures from life.