Schizophrenia

• Introduction to Schizophrenia: Identification and Classification

  There are two major systems for classification of mental disorder:

  • ICD-10 (founded by World Health Organisation) - two to more negative symptoms are a diagnosis for schizophrenia
  • DSM-5 (founded by American Psychiatric Association) - one positive symptom is a diagnosis for schizophrenia
  • Strength: reliable, Osório diagnosed 180 patients, achieved +97 inter-rater reliability, +92 test-retest reliability
  • Limitations: valid, Cheniaux, two psychiatrists independently diagnosed 68/100 for ICD-10 and 39/100 for DSM-5/
• Introduction to Schizophrenia: Symptoms of Schizophrenia

  positive - atypical symptoms experienced additionally

  • hallucinations (auditory hallucinations, distorted facial expressions, seeing things that aren't there)
  • delusions (being an important figure, believes they're being persecuted, super powers, aliens)

  negative - atypical symptoms experienced as a loss of ability

  • speech poverty (reduction of quality of speech, delayed responses, disorganised speech)
  • avolition (difficulty starting or keeping up a goal, lack motivation and energy)
• Evaluation of Symptoms of Schizophrenia:

  • co-morbidity, Buckley: found schizophrenia is often diagnosed with other disorders, may no be one condition
  • gender bias, Cotton: said women are underdiagnosed because they deal with it better than men
  • culture bias, Pinto & Jones: said some cultures believe in communication with ancestors, therefore auditory hallucinations may not be classed a symptom of schizophrenia in some cultures
  • symptom overlap, disorders have similar symptoms so can be hard to diagnose
• Biological explanations for Schizophrenia: Family Studies

  Family Studies:

  • Gottesman: found someone with a schizophrenic aunt has 2% chance of getting it, but 7% for siblings and 48% for identical twins
  • confirms the genetic risk of schizophrenia
• Biological explanations for Schizophrenia: Candidate Genes

  Candidate Genes:

  • Ripke: examined the genetic makeup of 37,000 people with schizophrenia and 113,000 without, found 108 genetic variations linked to increased susceptibility to schizophrenia
  • suggests schizophrenia is aetiologically heterogenous
• Biological explanations for Schizophrenia: The Role of Mutations

  The Role of Mutations:

  • Brown: found evidence for mutation through positive correlations between parental age and risk of schizophrenia
  • mutation in parental DNA caused by radiation, poison or viral infection
• Evaluation for Biological explanation for Schizophrenia:

  Strength: Tienara: biological children of parents with schizophrenia are still at risk if living in an adoptive family

  Strength: Hilker: concordance rates were 33% for identical twins and 7% for non-identical twins, shows genetics are a risk factor

  Limitation: Mørkved: found 67% schizophrenics had childhood trauma and 38% had no trauma, therefore may suggest environmental factors may also be a risk factor
• Biological explanations for Schizophrenia: Neural Correlations

  The Original Dopamine hypothesis:

  • based on the discovery of drugs for treatment
  • schizophrenia may be a result of a high dopamine or an excess of dopamine receptors in pathways to Broca's area (speech production) causing speech poverty
• Evaluation for Neural Correlations:

  Strength: Tausher: antipsychotic drugs reduce dopamine activity and reduce intensity of symptoms, suggesting dopamine is involved

  Limitation: post-mortem and live scanning studies have found raised levels of the neurotransmitter glutamate in several regions of the brains of people with schizophrenia, equally important for other neurotransmitters
• Psychological Explanations for Schizophrenia: Family Dysfunction

  The Schizophrenogenic Mother: means "schizophrenia-causing"

  • Fromm-Reichmann: the schizophrenogenic mother is cold, rejecting and controlling which creates a family of tension and secrecy

  Double Bind Theory: children receive mixed messages

  • Bateson: the developing child fears doing the wrong thing and is punished with a withdrawal of love

  Expressed Emotion: intensity of emotions in a family

  • verbal criticism, hostility and emotional overinvolvement create a stressful environment which can cause relapse or onset schizophrenia
• Evaluating Psychological Explanations for schizophrenia: Family Dysfunction

  Strength: Read: reported 69% of women and 59% of men with schizophrenia have a history of physical and sexual abuse

  Strength: Mørkved: found 67% had childhood trauma

  Limitation: no research support for the schizophrenogenic mother or double bind which are based off observing people with schizophrenia and tier mothers personalities

  Limitation: parent-blaming, parents have to watch the symptoms and take responsibility
• Psychological Explanations for Schizophrenia: Cognitive Explanations

  Dysfunctional Thinking:

  • reduced processing in ventral straitum associated with negative symptoms and in temporal and cingulate gyri causes hallucinations
  • reduced processing suggests cognition is impaired

  Metarepresentation Dysfunction:

  • metarepresentation is the cognitive ability to reflect on thoughts and behaviour
  • dysfunction in metarepresentation disrupts that ability

  Central Control Dysfunction:

  • speech poverty and thought disorder could result form the inability to suppress automatic thoughts and speech
• Evaluating Psychological Explanations for Schizophrenia: Cognitive Explanations

  Strength: Stirling: conducted a study with 30 people with schizophrenia and a control group of 30 without, did the Stroop Task, found people with schizophrenia took longer which suggests their cognitive processes are impaired

  Limitation: cognitive theories only provide partial explanation as it only explains proximal symptoms rather that what initially caused it, therefore unclear how childhood trauma leads to metarepresentation dysfunction
• Biological Therapy for Schizophrenia: Typical Antipsychotics

  Typical Antipsychotic: 1st generation of drugs for mental disorder

  (1) Dopamine Antagonists:

  • strong association between antipsychotic drug chlorpromazine and the dopamine hypothesis
  • Chlorpromazine acts as a dopamine antagonist by blocking dopamine receptors at the postsynaptic neuron which reduces hallucinations

  (2) Sedation Effect:

  • chlorpromazine is often used to calm people with schizophrenia
• Biological Therapy for Schizophrenia: Atypical Antipsychotics

  Atypical Antipsychotic:

  (1) Clozapine:

  • caused some deaths of patients with blood conditions
  • clozapine binds to dopamine receptors but acts on serotonin and glutamate receptors
  • believed to help with depression, often meaning its prescribed if a patient is at risk of suicide (30-50% of people with schizophrenia attempt to take their life at least once)

  (2) Risperidone:

  • attempts to be as effective as clozapine but with less side effects
  • binds to dopamine and serotonin receptors
• Evaluating Biological Therapy for Schizophrenia:

  Strength: Thornley: reviewed studies comparing the effects of chlorpromazine to control conditions, data from 13 trials with 1121 patients found chlorpromazine reduced symptoms compared to placebo

  Limitation: Healey: because antipsychotic drugs have powerful calming effects which have a positive effect in people, doesn't mean there is a reduction in the severity of psychosis

  Limitation: typical antipsychotics are associated with a range of side effects such as dizziness, agitation and weight gain
• Psychological Therapy for Schizophrenia: CBT

  CBT:

  • therapists help client understand auditory hallucinations are from a malfunctioning speech centre in their brain and not demonic forces+
  • reducing stress will help clients function adequately
  • doesn't eliminate symptoms of schizophrenia but helps people cope
• Evaluating Psychological Therapy for Schizophrenia: CBT

  Strength: Jahaur: revised 34 studies of CBT for schizophrenia and found small but significant effects on positive and negative symptoms

  Strength: Pontillo: found reductions in frequency and severity of auditory hallucinations

  Limitation: Thomas: says studies have used different CBT techniques on people with different combinations of positive and negative symptoms which makes it harder to see effects
• Psychological Therapy for Schizophrenia: Family Therapy

  Pharoah's Family Therapy: reduce expressed emotions and relapse

  • therapist encourages a therapeutic alliance with balanced care

  Burbach's Model of Practise:

  Phase 1 - share basic info and provide emotional and practical support

  Phase 2 - identify what different members can offer

  Phase 3 - mutual understanding, creating a safe space for expression

  Phase 4 - identify helpful patterns of interaction

  Phase 5 - skills training learning stress management

  Phase 6 - relapse prevention

  Phase 7 - maintenance for the future
• Evaluating Psychological Therapy for Schizophrenia: Family Therapy

  Strength: McFarlane: concluded family therapy was consistently very effective in reducing relapse rates by 50-60%

  Strength: Barrowclough: concluded these effects are important as by strengthening the whole family and their ability to support the person with schizophrenia
• Management of Schizophrenia: 


  Developing Token Economies:

  • Azrin: used token economies on a ward of women, every time they completed a task (made bed) they could swap token for a reward

  Rationale for Token Economies:

  • Matson: token economies helped personal care, condition-related behaviour and social behaviour in institutions

  Theoretical Understanding of Token Economies:

  • behaviour modification through operant conditioning
  • primary reinforcer = reward
  • secondary reinforce = tokens
• Evaluating Management of Schizophrenia:

  Strength: Glowacki: identified 7 studies that examined the effectiveness of token economies for schizophrenia and found a reduction of negative symptoms and unwanted behaviours

  Limitation: ethical issues of token economies gives professionals power to control patients freedom

  Limitation: Chiang: suggests art therapy is a good alternative as it is a high-gain low-risk approach

  Limitation: difficult to continue outside the hospital setting
• The Interactionist Approach to Schizophrenia:

  The Diathesis-stress model: 'diathesis' = vulnerability, 'stress' = trauma

  • model states both is needed to develop schizophrenia

  Meehl's model:

  • 'diathesis' is genetic as a result of the schizogene, creates the schizptypic personality
  • argues there is no level of stress without the schizogene that could cause schizophrenia
• The Interactionist Approach to Schizophrenia:

  Modern Understanding:

  • Read: early trauma alters the developing brain
  • recent research suggests cannabis can cause schizophrenic episodes as it interferes with dopamine

  Treatment:

  • Turkington: caused by biological and psychological so combination of CBT and antipsychotics is most effective
• Evaluating the Interactionist Approach to Schizophrenia:

  Strength: Tienara: investigated genetic vulnerability and psychological trigger in 19,000 Finnish children with schizophrenic mother, found adopted children in hostile environment also at risk (gene+stress)

  Strength: Tarrier: participants with combination of treatment had lower symptoms (medication + CBT, medication + counselling)

  Limitation: many forms of diathesis and stress can create over simplicity, Houston: sexual abuse may be diathesis and cannabis is the stress trigger