(OLD) 4.3.5 - Schizophrenia

• Psychological explanations for schizophrenia


  Family dysfunction and cognitive explanations, including dysfunctional thought processing
• Drug therapy


  Typical and atypical antipsychotics
• Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia


  1. Aims to improve the quality of communication and interaction between family members

  2. By reducing instances of double bind and expressed emotion (e.g. anger, criticism, hostility)
• Interactionist approach in explaining and treating schizophrenia

  Diathesis-stress model
• Schizophrenia is a severe mental illness where contact with reality and insight are impaired, an example of psychosis
• It is characterised by incoherent or illogical thoughts, bizarre behaviour and speech, and delusions or hallucinations
• Schizophrenia

  • Affects 1% of the population
  • More commonly diagnosed in men than women
  • Onset is typically in late adolescence and early adulthood
  • More commonly diagnosed in cities and the working class, than in the countryside and the middle class
  • British people of Caribbean and African origin are more likely to be diagnosed with SZ than white people. People of Asian origin have lower than average rates of diagnosis
• Positive Symptoms


  • Hallucinations: sensory experiences which have no basis in reality or distorted perceptions of things that are there
  • Delusions: irrational beliefs that have no basis in reality. E.g. delusions of grandeur, persecution, of the body and thought insertion and thought broadcasting
  • Disorganised speech: speech that does not make sense including jumping from topics and repetition
• Negative Symptoms

  • Avolition (sometimes called 'apathy'): severe loss of motivation to carry out everyday tasks (e.g. work, hobbies and personal care) and results in lower activity levels
  • Speech poverty: A reduction in the amount and quality of speech. May include a delay in verbal responses
  • Flat affect: a severe reduction in emotional expression e.g. monotone voice or lack of expression in the face
• DSM-V criteria for schizophrenia

  • Two (or more) should be present
  • At least one of these must be 1, 2, or 3: Delusions, Hallucinations, Disorganised speech (e.g., frequent derailment or incoherence), grossly disorganized or catatonic behaviour, Negative symptoms
• ICD-11 criteria for schizophrenia

  • At least 2 out of 7 symptoms, including at least one core symptom: Delusions, Hallucinations, Thought insertion/thought withdrawal, Thought disorder (any disturbance of thinking that affects language, communication, or thought content)
• Classification of schizophrenia

  The process of organising symptoms into categories based on which symptoms cluster together in sufferers of a condition
• Reliability


  The extent to which the diagnosis of schizophrenia is consistent, i.e. over time and/or between clinicians
• Types of reliability

  • Test-retest reliability: occurs when the same clinician makes the same diagnosis on two separate occasions from the same information
  • Inter-rater reliability: occurs when different clinicians make identical, independent diagnoses of the same patient
• Validity

  Concerns how accurate diagnosis is (that we are measuring what we intend to measure-SZ)
• Types of validity

  • Criterion validity: When different classification systems arrive at the same diagnosis for the same patient
  • Predictive validity: if diagnosis leads to effective treatment, the diagnosis can be classed as valid
  • Aetiological validity: All sufferers of SZ should have the same causal factors
• Co-morbidity


  The phenomenon when 2 or more conditions occur together
• Common co-morbidity with schizophrenia: depression, substance abuse, PTSD and OCD
• Symptom overlap

  When two or more conditions share symptoms
• Gender bias: Men have been diagnosed with SZ more often than women
• Cultural bias: African Americans and English people of Afro-Caribbean origin are much more likely to be diagnosed as schizophrenic than white people
• Rosenhan (1973): Being sane in insane places - 8 pseudopatients (including Rosenhan) went to 12 different psychiatric hospitals stating they were hearing voices. Once they had been admitted they acted 'normally'. All but one was diagnosed with SZ (the other bipolar depression). Average stay was 19 days and normal behaviour such as note-taking was interpreted as pathological
• The diagnosis lacks validity as psychiatrists cannot distinguish between real and pseudo-patients
• Reliability and Validity issues

  • Poor inter-rater reliability for both ICD and DSM
  • Good reliability in newer research and versions of DSM
  • Low criterion validity (agreement between ICD and DSM)
  • High comorbidity, e.g. around half of people with a diagnosis of schizophrenia also have a diagnosis of depression or substance abuse
  • Symptom overlap with other disorders like bipolar disorder
  • Gender bias, e.g. females display better interpersonal functioning which may mask symptoms
  • Cultural bias, e.g. psychiatrists (overwhelmingly white) distrust the honesty of black patients, DSM is ethnocentric
• Genetics of schizophrenia

  SZ is inherited and is polygenic, several candidate genes are involved
• Gottesman (1991) family study found concordance rates of 48% MZ and 17% in DZ twins
• Ripke et al. (2014) found 108 separate genetic variations associated with increased risk of SZ, many coded for neurotransmitters such as dopamine and glutamate
• Dopamine Hypothesis


  • Hyperdopaminergia = excessive dopamine levels/activity, linked to positive symptoms like speech poverty and auditory hallucinations
  • Hypodopaminergia = Low levels of dopamine in the prefrontal cortex, linked to negative symptoms
• Torrey et al (2002) found that ventricles of people with schizophrenia are 15% larger than those of non-sufferers
• Biological explanations - Strengths and Weaknesses

  • Research support, e.g. Finnish Adoption Study found adopted-away offspring of biological mothers with SZ were still at heightened risk
  • Issues with supporting research, e.g. Gottesman's study had concordance rates less than 100%
  • Neural correlates cannot establish cause and effect
  • Reductionism, fails to consider family dysfunction
  • Determinism, suggests that if a person possesses the specific candidate gene then SZ is inevitable
• Typical antipsychotics (first generation)


  Dopamine antagonists, reducing dopamine activity by blocking dopamine receptors at the synapse. This reduces positive symptoms such as hallucinations and has a calming/sedative effect
• Atypical antipsychotics (second generation)


  Block dopamine receptors and also act on other neurotransmitters like glutamate and serotonin; also address the negative symptoms such as avolition. More effective, less side effects
• Thornley et al. (2003) found that chlorpromazine was associated with better functioning and reduced symptom severity compared to placebo
• Meltzer (2012) found that clozapine is more effective than typical anti-psychotics, and that it is effective in 30-50% of treatment-resistant cases
• Side effects of typical antipsychotics

  • Dizziness, agitation, sleepiness, weight gain, Tardive dyskinesia (irregular movements which you cannot control), Neuroleptic malignant syndrome (NMS) caused by blocking dopamine action in the hypothalamus
• The Schizophrenogenic mother

  The 'schizophrenia causing' mother is cold, rejecting and controlling, leading to a family of secrecy and tension; this distrust leads to paranoid delusions and ultimately schizophrenia
• Double-bind Theory


  Conflicting family communication- they may express care but are also critical. When they get it wrong, they are punished with a withdrawal of love. They learn the world is confusing and dangerous, leading to disorganised thinking and paranoid delusions
• Expressed Emotion

  Negative feelings e.g. anger conveyed to a patient with schizophrenia by carer, verbal criticism of patient, hostility towards them, including anger and rejection, emotional over-involvement, including needless sacrifice- leading to relapse
• Strengths and Weaknesses of Family Dysfunction Explanations

  • Applications to family therapy to improve communication, reduce stress and educate families about SZ
  • Ethics/socially sensitive- parents feel responsible for their child's illness causing even greater stress and anxiety. Particularly mothers gender bias/sexism stigma
  • Symptoms of SZ have also distorted their recollection, validity?
  • Reductionist, focusing on family environment, a more holistic approach would be the diathesis-stress model (which EE recognises)
• Family therapy

  1. Aims to improve the quality of communication and interaction between family members

  2. By reducing instances of double bind and expressed emotion (e.g. anger, criticism, hostility)