schizophrenia

• Family dysfunction


  Refers to processes within a family such as poor family communication, cold parenting and high levels of expressed emotion. These may be risk factors for both the development and maintenance of schizophrenia
• Schizophrenogenic mother


  Fromm-Reichmann (1848) proposed a psychodynamic explanation for schizophrenia based on accounts she had heard from her patients about their childhoods. She noted many patients spoke of a particular type of parent - the schizophrenogenic mother, who is cold, rejecting, & controlling and tends to create a family climate characterised by tension & secrecy. This leads to distrust that later develops into paranoid delusions and ultimately schizophrenia.
• Double-bind theory


  Bateson et al 1972 agreed that family climate is important in the development of schizophrenia but emphasised the role of communication style within a family. The developing child regularly finds themselves trapped in situations where they fear doing the wrong thing, but receive mixed messages about what it is and feel unable to comment on the unfairness of this situation or seek clarification. When they get it wrong (often happens) the child is punished by withdrawal of love. This leaves them with an understanding of the world as confusing and dangerous - reflected in symptoms - disorganised thinking & paranoid delusions.
• Expressed emotion (EE)


  The level of emotion (particularly negative emotion), expressed towards a person with schizophrenia by their carers who are often family members. EE contains several elements: Verbal criticism of the person, occasionally accompanied by violence, Hostility towards the person, including anger & rejection, Emotional overinvolvement in the life of the person, including needless self-sacrifice. High levels of EE directed at the individual = serious source of stress for them.
• High levels of EE directed at the individual


  Serious source of stress for them
• High levels of EE


  May trigger the onset of schizophrenia in someone who is already vulnerable e.g. due to their genetic make up (diathesis-stress model)
• Cognitive explanations


  Explanations that focus on mental processes such as thinking, language and attention
• Dysfunctional thought processing


  Information processing that does not represent reality accurately and produces undesirable consequences
• Dysfunctional thought processing in schizophrenia


  • Reduced thought processing in the ventral striatum associated with negative symptoms
  • Reduced processing of info in temporal and cingulate gyri associated with hallucinations
• Metarepresentation dysfunction


  Cognitive ability to reflect on thoughts and behaviour. Dysfunction in metarepresentation would disrupt our ability to recognise our own actions and thoughts are being carried out by ourselves rather than someone else. This would explain hallucinations of hearing voices and delusions like thought insertion.
• Central control dysfunction


  Cognitive ability to suppress automatic responses while we perform deliberate actions. Speech poverty & thought disorder could result from the inability to suppress automatic thoughts and speech triggered by other thoughts.
• Cognitive explanations only explain the proximal origins of symptoms, not the distal explanations like genetic and family dysfunction
• Abnormal cognition associated with schizophrenia

  Partly genetic in origin and the result of abnormal brain development
• Interactionist approach


  A way to explain the development of behaviour in terms of a range of factors, including both biological and psychological ones. Most importantly such factors don't simply add together but combine in a way that can't be predicted by each one separately i.e. they interact
• Diathesis-stress model


  An interactionist approach to explaining behaviour. For example, schizophrenia is explained as a result of both an underlying vulnerability (diathesis) and a trigger (stressor), both of which are necessary for the onset of schizophrenia. In early versions of the diathesis-stress model, vulnerability was genetic and triggers were psychological. Nowadays both genes and trauma are seen as diatheses and stress can be psychological or biological in nature.
• Factors in the development of schizophrenia (interactionist approach)


  • Biological factors
  • Psychological factors
  • Social factors
• The interactionist approach (biosocial approach) acknowledges that there are 3 factors in the development of schizophrenia: biological factors, psychological factors, and social factors
• Stress


  Negative psychological experiences
• The diathesis-stress model states that both a vulnerability and a stress trigger are needed to develop schizophrenia
• Meehl's diathesis-stress model


  In the original model, diathesis was entirely the result of a single 'schizogene'. This led to the idea of a biologically based schizotypic personality, one characteristic of which is sensitivity to stress. Meehl argued that without this gene a person should never develop schizophrenia no matter how much stress they were exposed to, but a person who does have this gene is vulnerable to the effects of chronic stress (e.g., a schizophrenogenic mother), which could result in the development of the disorder.
• One way our understanding of diathesis has changed is that it is now believed diathesis is not due to a single 'schizogene', but instead many genes increase vulnerability. Diathesis does not have to be genetic, it could be early psychological trauma affecting brain development.
• A modern definition of stress (in relation to diathesis-stress) includes anything that risks triggering schizophrenia, including psychological stress and biological factors like cannabis use.
• Treatment according to the Interactionist approach


  Combining antipsychotic medication and psychological therapies, most commonly CBT. It is possible to believe in biological causes of schizophrenia and still practice CBT to relieve psychological symptoms, but this requires adopting an interactionist model.
• In Britain it is increasingly standard practice to treat patients with a combination of CBT and antipsychotics, whereas in the US there is more of a conflict between psychological and biological models of schizophrenia and this may have led to a slower adoption of the interactionist approach.
• Strengths of the interactionist approach


  • Support for the dual role of vulnerability and stress
  • Usefulness of the interactionist approach in treatment
• Limitations of the interactionist approach


  • The original diathesis-stress model is too simplistic
  • We don't know exactly how diathesis and stress work
  • The treatment-causation fallacy
• Tienari et al 2004 found strong direct support for the interactionist approach - genetic vulnerability and family related stress combine in the development of schizophrenia.
• Tarrier et al 2004 found that patients receiving a combination of medication and CBT showed lower symptom levels than those receiving medication only, demonstrating the advantage of adopting an interactionist approach.
• The fact that combined biological and psychological therapies are most effective than either on their own does not necessarily mean the interactionist approach to schizophrenia is correct, as this would be a treatment-causation fallacy.
• Token economies


  A form of behavioural modification, where desirable behaviours are encouraged by the use of selective reinforcement. People are given rewards (tokens) when they engage in socially desirable behaviours. The tokens are secondary reinforcers and can then be exchanged for primary reinforcers – food or privileges.
• Token economies


  • Used to manage the behaviour of patients with schizophrenia who spend long periods in psychiatric hospitals
  • Tokens (e.g., coloured discs) are given to patients who carry out desirable behaviours (e.g., getting dressed, making their bed etc)
  • This reward reinforces the desirable behaviour and because it is given immediately prevents 'delay discounting' (reduced effect of a delayed reward)
• Token economies


  • The classic demonstration was carried out by Teodoro Ayllon and Nathan Azrin in 1968. They trialled a token economy system in a ward of women with a diagnosis of schizophrenia. Every time the participants carried out a task such as making their bed or cleaning up they were given a plastic token embossed with the words 'one gift'. These tokens could be swapped for ward privileges e.g. being able to watch a film.
• Token economies were extensively used in the 1960s and 70s when the form for treating schizophrenia was long term hospitalisation. Their use has no declined in the UK, partly because of the growth of community-based care and the closure of many psychiatric hospitals, but also because of the complex ethical issues raised by restricting rewards to people with mental disorders.
• Rationale for token economies

  Institutionalisation develops under circumstances of prolonged hospitalisation. One outcome is that people often develop bad habits e.g. cease to maintain personal hygiene or stop socialising with others. This is an understandable response to living without routine and small pleasures we experience in everyday life.
• Categories of institutional behaviour commonly tackled by means of token economies

  • Personal care
  • Condition-relates behaviours e.g. apathy
  • Social behaviour
• Benefits of modifying institutional behaviours with token economies

  • Improves the person's quality of life within the hospital setting
  • Normalises behaviour and makes it easier for people who have spent a time in hospital to adapt back into life in the community
• How token economies work

  1. Tokens e.g. in the form of coloured discs are given immediately to individuals when they have carried out a desirable behaviour

  2. Target behaviours are decided on an individual basis

  3. Tokens are swapped for more tangible rewards

  4. Immediate reward for target behaviour is important because delayed rewards are less effective

  5. Rewards in a hospital setting might include sweets/magazines/access to activities like a film or a walk outside
• Theoretical understanding of token economies

  • They are an example of behaviour modification, a behavioural therapy based on operant conditioning
  • Tokens are secondary reinforcers because they only have value once the person receiving them has learned that they can be used to obtain meaningful rewards (primary reinforcers)
  • Tokens that can be exchanged for a range of different primary reinforcers are particularly powerful secondary reinforcers (generalised reinforcers)
  • At the start of the token economy programme tokens and primary reinforcers are administered together
• Some people with schizophrenia may only get the chance to live outside the hospital if their personal care and social interaction can be improved, and perhaps using a token economy during hospital care is the best way to achieve this.