clinical

• Diagnosis


  A clinical assessing a patient, deciding whether they show evidence of a mental disorder
• The 4 D's of diagnosis

  • Deviance (behaviours unusual in society)
  • Distress (find their behaviours upsetting)
  • Dysfunction (interferes with day to day life)
  • Danger (harm themselves or others)
• strengths of the 4 D's of diagnosis

  • Useful as they have practical applications in helping professionals decide whether a patient's symptoms needs a diagnosis
  • Provide a holistic way to assess someone's mental health
  • Davis argues a fifth D should be added (duration)
• weaknesses of the 4 D's of diagnosis

  • Subjectivity in the application of the four D's
  • Distress is subjective and difficult to measure
  • Because of subjectivity, four D's may lack validity
  • Subjectivity reduces reliability, overall reducing scientific status of diagnosis
  • Issue of social control
• Classification systems


  Used by practitioners to help make diagnoses and establish appropriate treatment. Their aim is to provide clear and measurable criteria which can increase reliability
• Types of classification systems

  • The international standard classification of diseases (ICD-10)
  • The diagnostic and statistical manual of mental disorders (DSM 5)
• Medical model of abnormality

  A biological approach which assumes the major source of 'disturbed' and 'abnormal' behaviour is some form of medical illness. Supporters believe psychological symptoms are outward signs of the inner physical disorder
• Problems with using the medical model for diagnosis of mental disorders

  • Mental illness symptoms are much more subjective than measuring physical symptoms
  • The causes of mental illness are largely unknown, so treatments only focus on symptoms not causes
  • Criticised by the anti-psychiatry movement who argue symptoms may be an understandable reaction to coping with a sick society
• Similarities between ICD-10 and DSM-5


  • Both are diagnostic tools
  • Both regularly updated to account for new research
  • Attempt to improve psychiatric diagnosis across cultures
  • Includes categories of mental disorders based on symptoms
  • Both rely on checklists for behaviour
• Differences between ICD-10 and DSM-5


  • ICD does not look at other aspects that could influence diagnosis but DSM takes into account psychosocial factors
  • ICD is more reductionist than DSM
  • DSM is only used for mental disorders but ICD diagnoses physical disorders too
  • ICD is an open and free resource
  • DSM is more holistic
• Evidence for the reliability of diagnosis

  • Spitzer and Williams: Early versions of DSM were low in reliability, experienced psychiatrists only agree on diagnosis about 50% of the time
  • Ward: Studied 2 psychiatrists diagnosing the same patient, 62.5% of disagreements occurred due to inadequacy of the classification system
  • Brown: Tested the reliability and validity of DSM 5 diagnoses for anxiety and mood disorders and found them to be good to excellent
  • Pederson: 71% of psychiatrists agreed with the ICD-10 definition of depression when assessing 116 patients
• Factors that impact the reliability of diagnosis


  • Patient factors: May give different psychiatrists different information, lack of standardisation for interviews
  • Clinician factors: Practitioners are not completely objective, may gather insufficient information
  • Classification systems: DSM has a clear set of criteria which increases reliability
• Factors that could impact the validity of diagnosis


  • Patient factors: May not disclose all relevant information, may be embarrassed, ashamed or don't remember
  • Clinician factors: Implicit bias in clinical reduces validity
  • Classification systems: Cochrane et al argues classification systems lead practitioners to take on a Eurocentric bias, they cannot take into account normal behaviour of other cultures
• Symptoms of schizophrenia


  • Positive symptoms - strange and bizarre additions to behaviour
  • Negative symptoms - loss or absence of normal characters
  • Cognitive symptoms - issues to do with information processing
• Positive symptoms of schizophrenia

  • Delusions - false or bizarre beliefs

  Hallucinations - perception of stimuli that is not present

  Disorganised thinking/speech - jumbled speech, loose associations of thoughts, jump from topic to topic, invention of new words

  Abnormal motor behaviour - agitated movement, catatonia (not moving or responding to others)
• Negative symptoms of schizophrenia


  • Lack of energy and motivation

  Social withdrawal

  Flatness of emotion

  Not looking after appearance and self

  Lack of pleasure in everyday things

  Speaking little
• Cognitive symptoms of schizophrenia

  • Difficulties in concentrating and paying attention

  Problems with working memory

  Difficulties with executive functioning
• Features of schizophrenia

  • Onset: Late teens and mid-30's, may be triggered by some aspect of development, males peak onset in early to mid twenties, female peak onset is late twenties
  • Prevalence: Likelihood of developing schizophrenia is 0.7-1%, people who experience social problems such as poverty and unemployment are more likely to develop schizophrenia
  • Prognosis: 25% who have an episode recover and do not have another, 50% have recurrent episodes, 25% have symptoms continually, life expectancy is 10 years younger than average population, males show more negative symptoms than females
• Aspects of neurotransmitters being an explanation of schizophrenia

  • Dopamine hypothesis: Excess dopamine (hyperdopaminergia) - positive symptoms, Dopamine Deficiency (hypodopaminergia) - negative symptoms
• Evidence of genetics being an explanation of schizophrenia

  • Hilker: 79% heritability rate for schizophrenia, 25% of people with DiGeorge syndrome (deletion of 30-40 genes) develop schizophrenia

  Wright: As many as 700 genes have been linked to schizophrenia, such as the COMT Gene (deletion of the comt gene which regulates dopamine levels) and the DISC1 Gene (people with an abnormality in the DISC1 gene are 1.4 times more likely to develop schizophrenia)
• Types of research that have investigated the role of genetics in schizophrenia

  • Family studies: Whether close biological relatives also have schizophrenia

  Adoption studies: Genetic factor can be looked for in adopted children who are 'reared apart' from biological parents

  Twin studies: Schizophrenia in monozygotic and dizygotic twins can be compared
• Social causation hypothesis


  It suggests that schizophrenia may be caused by factors within the environment
• Environmental risk factors for schizophrenia

  • Social adversity: If a child grows up in an environment where their needs are not met, may be more likely to develop mental health issues

  Urbanicity: Schizophrenia is more associated with living in cities than rural, city life is more stressful and long term exposure to stressors can trigger schizophrenia

  Social isolation: Faris suggested cultural isolation may lead to symptoms, people don't get any feedback on their behaviour

  Immigration and minority status: Immigrants are at greater risk of developing schizophrenia, may be due to stress due to discrimination and poorer living conditions

  Family dysfunction + childhood trauma: Popovich suggests childhood trauma may interact with other pre-existing risk factors to trigger schizophrenia in vulnerable individuals
• Treatments for schizophrenia


  • Drug treatment

  Cognitive treatment
• Why drug treatment is used for schizophrenia


  Based on the medical model, if schizophrenia is due to a biological basis such as genes or neurotransmitters, treatment should also have a biological basis
• How drug treatment works for schizophrenia

  Typical drugs block the receptor site for the neurotransmitter dopamine so the effects of dopamine are not picked up by the brain, more recent drugs block serotonin receptors and have fewer side effects
• Seven standards HCPC set out for clinical practitioners

  • Character
  • Health
  • Standards of proficiency
  • Standards of conduct, performance and ethics
  • Standards of continuing personal development
  • Standards of education and training
  • Standards for prescribing
• Two treatments for schizophrenia

  • Drug treatment
  • Cognitive treatment
• Why drug treatment is used for schizophrenia

  Based on the medical model - if schizophrenia is due to a biological basis such as genes or neurotransmitters, treatment should also have a biological basis
• How drug treatment works for schizophrenia

  • Typical drugs block the receptor site for the neurotransmitter dopamine so the effects of dopamine are not picked up by the brain
  • More recent drugs block serotonin receptors and have fewer side effects
• Strengths of drug therapy for schizophrenia

  • Drug treatment has been effective in reducing symptoms
  • More effective than other forms of therapy as it reduces symptoms more quickly
  • Useful to help people manage symptoms and hopefully avoid hospitals
  • Helped patients live relatively normal lives (not have to live in hospitals)
  • Appropriate due to it being a biological basis for a genetic condition
• Weaknesses of drug therapy for schizophrenia

  • Reductionist as it ignores all psychological or social factors
  • Effectiveness is questionable as it surpasses systems without addressing the cause
  • Relapse is an issue so drugs are not a long term cure
  • Ethical issues as drugs often have unpleasant side effects
  • Patients are often reluctant to take drugs
  • Not effective in treating negative symptoms
• Cognitive Behavioural Therapy (CBT)


  Assumes patients have irrational thoughts and beliefs, CBT helps to challenge these thoughts and therefore change a patients behaviour
• How CBT is used to treat schizophrenia

  • It can help target cognitive symptoms as well as delusions and hallucinations
  • Aim to help reduce the stress felt by the patient and help them manage and understand their symptoms
  • Techniques include belief modification, focusing and reattribution, and normalising the experience of the person
• Strengths of CBT as a treatment for schizophrenia

  • Research shows CBT can be helpful in treating schizophrenia
  • CBT can work well for those who did not respond to medication
  • CBT is the most ethical treatment (empowers patients, self help strategies they can use on their own and become independent)
• Weaknesses of CBT as a treatment for schizophrenia

  • Reductionist as it focuses on thought processes but does not address underlying cause
  • Effectiveness may be limited as patients need good insight into their condition and have good problem solving skills
  • Effectiveness is hard to judge as most studies compare CBT to a control treatment, CBT may not be superior rather than control treatment is inadequate
• Aims of Carlson's study

  • To investigate the role of glutamate in the causation of schizophrenia
  • To investigate whether any other neurotransmitters besides dopamine play a role in schizophrenia
• Type of study Carlson's research was

  Literature review - studies using rodents, studies on people with acute schizophrenia, studies on people with schizophrenia in remission, studies on people with Parkinson's, studies on people with Huntington's
• Key findings from Carlsson's research

  • PET scans showed high levels of dopamine are related to psychosis and changes in dopamine may be a result of other changes in neurotransmitters like noradrenaline and glutamate
  • Low levels of glutamate play a role in schizophrenia - glutamatergic failure in the cerebral cortex leads to negative symptoms whilst failure in the basal ganglia leads to positive symptoms
  • Reduced levels of glutamate are associated with increased dopamine release
  • The thalamus plays a role in schizophrenia - the thalamic filter, the thalamus filters off neurotransmitters to stop the cerebral cortex from overloading, abnormal levels in the indirect and direct pathways cause positive and negative symptoms
• Conclusions from Carlsson's research

  • There are different subpopulations of those with schizophrenia due to many neurotransmitters being involved
  • Glutamate deficiency should be studied to explain schizophrenia
  • Glutamate deficiency may explain increased dopamine responsiveness
  • Increased serotonin levels are found in people with schizophrenia
  • More focus on other neurotransmitters in schizophrenia is needed