4.3.5 - Schizophrenia (NEW)

• 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.
• Key facts 

  •It affects 1% of the population

  •More commonly diagnosed in men than women

  •The onset is typically in late adolescence and early adulthood

  •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:  An excess or distortion of normal functions (additional experience beyond those of ordinary existence)


  •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:
• Negative Symptoms: - loss of usual abilities and experiences


  •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
• Classification of Schizophrenia

  Classification: 

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

  • Schizophrenia does not have a single defining characteristic but has many different symptoms.

  • Classification refers to identifying  symptoms which occur together in a disorder  whereas diagnosis is the process of identifying and applying the label of the disorder to a patient using the classification 
• Classification of Schizophrenia:

  DSM-V by the  American Psychiatric Association (APA)


  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
• Classification of Schizophrenia:

  ICD-11 by the World Health Organisation (WHO)


  At least 2 out of 7 symptoms, including at least one core symptom 

  Core symptoms: 

  • Delusions, 

  • Hallucinations

  • Thought insertion/thought withdrawal, 

  • Thought disorder (any disturbance of thinking that affects language, communication, or thought content)
• Reliability and Validity 

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

  • 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.
• Reliability and Validity 

  Validity concerns how accurate diagnosis is (that we are measuring what we intend to measure-SZ).

  • 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 
• Reliability and Validity 

  Co-morbidity: 

  This is 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:

  Longenecker et al. (2010) 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. 
• STUDY - Rosenhan (1973): Being sane in insane places 


  Summary

  • 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 behavioursuch as note-taking was interpreted as pathological (caused by a physical or mental disease)

  The diagnosis lacks validity as psychiatrists cannot distinguish between real and pseudo-patients
• Reliability and Validity AO3 

  -Poor inter-rater reliability for both ICD and DSM à

   Cheniaux et al. (2009) 

  
• Reliability and Validity AO3 

  + Good reliability.

   Osario et al (2019  found high inter-rater (+.97)and test-retest reliability for DSM +.92. (newer research and version of DSM)
• Reliability and Validity AO3 

  -Low criterion validity (agreement between ICD and DSM) 

  Cheniaux et al (2009) 100 clients, 68 were diagnosed with schizophrenia with the ICD and 39 with the DSM
• Reliability and Validity AO3 

  -Comorbidity . 

  Buckley et al (2009) concluded that around half of people with a diagnosis of schizophrenia also have a diagnosis of depression (50%) or substance abuse (47%) severe depression and SZ might actually be a single condition.
• Reliability and Validity AO3 

  -Symptom overlap

   e.g. bipolar disorder involves positive symptoms like delusions and negative symptoms such as avolition
• Reliability and Validity AO3 

  -Gender bias,

   Longnecker et al. This could be because females display better interpersonal functioning (which may mask symptoms).
• Reliability and Validity AO3 

  - Culture bias Escobar (2012),

  psychiatrists (overwhelmingly white) distrust the honesty of black patients. DSM is ethnocentric, in Western cultures hearing voices is classified as a symptom of a mental health problem. 
• Biological explanations - Genetics:

   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 (e.g. DRD2 gene) and glutamate (e.g. GRM3 gene).

  Showing that SZ is polygenic
• Biological explanations - Neural correlates: 

  Dopamine Hypothesis

  • Hyperdopaminergia = excessive dopamine levels/activity dopamine e.g. in the Broca’s area linked to speech poverty and /or auditory  hallucinations. 
  • Hypodopaminergia = Lowlevels of dopamine in the prefrontal cortex (responsible for thinking and decision making) linked to negative symptoms

  Enlarged Ventricles: ,

  associated with damage to central brain areas and the pre-frontal cortex .

  • Torrey et al (2002) found that ventricles of people with schizophrenia are 15% larger than those of non-sufferers
• Biological explanations - AO3

  + Research support,

   Tienari et al (2004) Finnish Adoption Study, adopted-away offspring of biological mothers with SZ were still at heightened risk of developing SZ
• Biological explanations - AO3

  -Issues with supporting research, 

  Gottesman’s study, concordance rates were not 100%, and may have been due to a more shared environment 
• Biological explanations - AO3

  -Neural correlates cannot establish cause and effect 
• Biological explanations - AO3

  -Reductionism,

  fails to consider family dysfunction.

  -Determinism, 

  suggests that if a person possesses the specific candidate gene then SZ is inevitable, evidence from twin/ family studies suggests that this is not the case.
• Drug therapy - Typical anti-psychotics:

   first generation 

  e.g chlorpromazine

  • 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 used to calm anxious patients when they are first admitted to hospital
• Drug therapy - Atypical anti-psychotics:


  second generation

  e.g clozapine and risperidone 

  • Block dopamine receptors and also act on other neurotransmitters eg glutamate and serotonin; also address the negative symptoms such as avolition.-more effective, less side effects
  • Clozapine improves mood, reduces anxiety and depression & improves cognitive function
  • Risperidone binds to dopamine and serotonin receptors but binds more strongly to dopamine receptors-effective in lower doses
• Drug therapy: typical and atypical - AO3

  + Effectiveness,

  • Thornley et al. (2003) data from 13 trials (1121 bpps) found that chlorpromazine was associated with better functioning and reduced symptom severity compared to placebo 
  • Meltzer (2012) clozapine is more effective than typical anti-psychotics, and that it is effective in 30-50% of treatment-resistant cases
• Drug therapy: typical and atypical - AO3

  -Side effects,

  for typical anti-psychotics 

  • e.g. dizziness, agitation, sleepiness, weight gain, 
  • Tardive dyskinesia (irregular movements which you cannot control).
  • Most serious - Neuroleptic malignant syndrome (NMS) caused by blocking dopamine action in the hypothalamus
• Drug therapy: typical and atypical - AO3

  -Chemical cosh,

  used to calm patients and make them easier for staff to deal with -> human rights abuse 
• Drug therapy: typical and atypical - AO3


  +/- Comparison to CBT
• Family dysfunction - 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. 
  • passive father who failed to counteract the mother
• Family dysfunction - 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. 
  • Negative symptoms to escape double bind situation 
• Family dysfunction - Expressed Emotion:

   negative feelings

  • e.g. anger conveyed to a patient with schizophrenia by carer, verbal criticism of patient,
  • occasionally accompanied by violence, hostility towards them,
  • including anger and rejection, emotional over-involvement,
  • including needless sacrifice- leading to relapse
• Family dysfunction - AO3

  + Applications to family therapy

  to improve communication, reduce stress and educate families about SZ
• Family dysfunction - AO3

  -Ethics/socially sensitive

  parents feel responsible for their child’s illness causing even greater stress and anxiety. Particularly mothers -> gender bias/sexism -> stigma
• Family dysfunction - AO3

  -SZ mother based retrospective accounts, 

  symptoms of SZ have also distorted their recollection -> validity?
• Family dysfunction - AO3

  -Reductionist,

  focusing on family environment, a more holistic approach would be the diathesis-stress model (which EE recognises)
• Family therapy - AO1

  
  

  • Aims to improve the quality of communication and interaction between family members - by reducing instances of double bind and EE (e.g. anger and guilt) 
  • To educate the family about schizophrenia, to help the them better understand and deal with the illness (developing skills to be used after therapy has ended)
• Family therapy - AO1


  • Reducing stress in families helps to improve a patient’s quality of life at home and reduce their likelihood of relapse and re-admission to hospital.
  • The therapist meets regularly with the patient and family who are encouraged to talk about the patient’s symptoms, behaviour, progress with treatment and how patient’s illness affects them
• STUDY - Family therapy

  Pharaoh et al (2010)

  • strategies include: helping family members achieve a balance between caring for the individual and maintaining their own lives and improving the ability of the family to anticipate and solve problems