Schizophrenia

• Define schizophrenia

  A psychotic disorder characterised by major disturbances in thought, emotion and behaviour. It involves disordered thinking, where ideas are not logically related. Patients withdraw from people and reality into a fantasy life of delusions and hallucinations
• Define positive symptoms

  Atypical symptoms in addition to normal experiences. Include hallucinations and delusions displaying a loss of touch with reality
• Define negative symptoms


  Atypical experiences representing a loss of the usual experience such as emotions, actions or normal motivation levels
• Give three examples of positive symptoms

  • Disorganised thought and speech
  • Hallucinations
  • Delusions
• Give three examples of negative symptoms

  • Avolition
  • Affective flattening
  • Alogia
• Describe the current DSM criteria for schizophrenia


  The current version is DSM-5. The individual must be experiencing at least two of the following:

  • Delusions
  • Hallucinations
  • Disorganised speech
  • Grossly disorganised behaviour
  • Negative symptoms

  At least one of the symptoms must be from the top 3 and must have been present for at least one month but there must also have been a continuous disturbance in functioning for 6 months
• Describe what reliability refers to and in context to schizophrenia

  • How consistent the measurement tool is
  • A reliable classsification should produce the same diagmosis over time and between different professionals
  • Clinicians only agree on diagnosis 11% of the time (Whaley 2001)
• Give AO1 and AO3 descriptions for culture bias in schizophrenia

  AO1: Clinicians from different cultural backgrounds often disagree on whether it should be diagnosed. The ethnicity of patient can affect likelihood of getting the diagnosis

  AO3: A negative implication is that clinicans are sometimes culturally biased when diagnosed schizophrenia. They may be looking at behaviour that is typical in some African cultures and mistaking them for the symptoms of schizophrenia
• Give research evidence for culture bias in schizophrenia

  • Copeland gave a description of a patient to 134 clinicians, half from the US nd half from the UK. 69% of the US clinicians diagnosed schizophrenia and only 2% of the UK clinicians did so
  • Blake found clinicians more likely to diagnose a patient with schizophrenia if the description referred to them as African American compared to White
• Describe what validity refers to and in context to schizophrenia

  • How accurate and meaningful the measurement tool is
  • A valid classification should refer to a pattern of symptoms which as a single aetiology, treatment and prognosis and is the correct diagnosis for schizophrenia
• Give AO1 and AO3 descriptions for gender bias

  AO1: Since the 1980s, men have been diagnosed with schizophrenia more than women, reflecting stereotyped beliefs help by clinicians or parents

  AO3: Clinicians mat be underdiagnosing women due to female patients having good interpersonal functioning so their symptoms are masked or appear to mild to warrant diagnosis
• Give research evidence for gender bias in schizophrenia

  Loring and Powell (1988) gave psychiatrists patient case stories and asked for their judgement requiring diagnosis using standard criteria. When the patient was describe as male, 56% gave a schizophrenic diagnosis, compared to only 20% when the description was female

  This suggests diagnosis is influenced by the gender of patients and of the psychiatrist
• Give AO1 and AO3 descriptions for co-morbidity

  AO1: Schizophrenic patients are often diagnosed with other disorders such as depression, anxiety or OCD. Such cases are complex as clinicians have to diagnose each condition separately

  AO3: Co-morbid patients are difficult to treat effectively as each diagnosed disorder needs to be addressed in the treatment programme and so patients may be prescribed numerous drugs which increases side effects and non-compliance
• Give research evidence for co-morbidity in schizophrenia

  Buckley et al (2009) identified that 50% of schizophrenic patients also had depression, 29% had PTSD and 23% had OCD
• Give AO1 and AO3 descriptions of symptom overlap

  AO1: Conditions have very similar symptoms to schizophrenia as it doesn't have pathognomic symptoms so it can be hard for clinicians to tell it apart from similar conditions

  AO3: DSM has built in 'exclusion criteria' so clinicians have to rule out certain disorders before diagnosing schizophrenia, making it more likely the diagnosis when given is valid
• Give research evidence for symptom overlap in schizophrenia

  Eliason and Ross point out that that people with DID have more 'schizophrenic' symptoms than those actually diagnosed with schizophrenia

  Schneider (1959) listed symptoms he believed distinguised schizophrenia from others and referred to them as first rank. These form the basis of the current diagnosis in ICD-10. Using these symptoms make the diagnosis more valid
• Describe human genome studies as a biological explanation

  Ripke et al (2014) combined data looking at the genetic makeup of 37000 individuals with schizophrenia compared to unaffected individuals.

  • A number of genes seem to increase schizophrenia risk but only by a small amount individually
  • 108 separate genetic variations associated with schizophrenia
  • Suggests schizophrenia is polygenic: requires a number of factors to work in combination
• Describe research on the role of the C4 gene

  Linked to the immune system - helps to control infection, it is a clear risk factor for schizophrenia and is expressed by human neurons and found at synapses, and it mediates the pruning of synapses that normally takes place in development. It goes into overdrive and eliminates too many symptoms

  It will allow treatments to focus on cognitive and emotional symptoms
• Describe family studies as a biological explanation

  Gottesman (1991) looked at the likelihood of developing schizophrenia depending on whether different biological relatives suffered from the disorder.

  • Schizophrenia among general population = 1% risk
  • Schizophrenic half sibling = 6% risk
  • Schizophrenic parent = 6% risk
  • Schizophrenic sibling = 9% risk
• Describe twin studies as a biological explanation

  Involve comparing condordance rates in identical twins who share 100% genetic similarity to non-identical twins who share 50% genetic similarity. If the concordance rates are higher in MZ, it indicates schizophrenia has a genetic component

  Gottesman (1991) found concordance rates:

  • 48% in MZ
  • 17% in DZ

  Joseph (2004) pooled data prior to 2001 and found concordance rates:

  • 40% in MZ
  • 7% in DZ
• Describe neural correlates as a biological explanation

  Measurements of structure/function of the brain that correlates to schizophrenia

  • The frontal lobes are smaller and have reduced activity which could explain positive symptoms such as disorganised speech
  • Ventricles are 15% larger linked to type 2 schizophrenia, involving negative symptoms
  • An abnormality in the ventral striatum has been linked to negative symptoms such as avolition as it is involved with anticipation of reward and motivation
• Describe the dopamine hypothesis

  Dopamine overactivity could be caused by:

  • High levels of dopamine being released into the synapse by the presynaptic neuron
  • High numbers of dopamine receptors on the postsynaptic dendrites
  • Oversensitivity of dopamine receptors on the postsynaptic dendrites

  Excess levels in the sub cortex areas of the brain that make up the mesolimbic pathway is known as hyperdopaminergia and could explain disturbances in speech functions

  Dopamine is an excitatory neurotransmitter so these factors increase the amount of neurons that fire
• Describe the revised dopamine hypothesis

  While dopamine overactivity causes positive symptoms, low dopamine activity in the mesocortical pathway in the prefrontal cortex may cause negative symptoms

  Low activity in the subcortex areas of the brain is known as hypodopaminergia

  The prefrontal cortex is responsible for planning and decision making so a deficit of dopamine could explain negative symptoms such as avolition
• Describe dysfunctional thought processes as a psychological explanation

  • Schizophrenics process information in a different way to non-sufferers
  • They make irrelevant connections between pieces of information and don't understand the true sources

  The Stroop effect: Schizophrenics typically take twice as long to name the ink colour the word is written in for the Stroop effect test (Stirling et al 2000)

  It is difficuly for schizophrenics to suppress the automatic impulse to read the word as they can't filter out incoming sensory information
• Describe the dysfunctional processes

  Frith et al (1992)

  Metarepresentation - dysfunction impairs the ability to recognise thoughts as coming from oneself - related to delusions and auditory hallucinations

  Central control - dysfunction impairs ability to supress automatic thoughts and speech - related to disorganised thought and speech

  Supervisory attention system - dysfunction impairs ability to initiate goal-directed action - related to avolition
• Describe family dysfunction as a psychological explanation

  Family dysfunction models are based on psychodynamic principles that suggest early childhood experiences influence adult abnormality in adulthood

  A family can be seen as a set of entities, the behaviour of each can be understood by looking at its relationship with others; if one starts to behave abnormally, it may be a manifestation of a problem occurring within the family system.
• Describe the schizophrenogenic mother

  It is a psychodynamic explanation based on accounts from schizophrenic patients about their childhood. The schizophrenogenic mother is cold, rejecting and controlling. She creates a family environment characterised by tension and secrecy. The child feels distrusting which leads to symptoms such as paranoid delusions.
• Describe the double-bind theory

  The term was used by Bateson et al to describe a communication style in a family. The child receives conflicting messages from parents, where the verbal may be affectionate but the non-verbal is hostile. Children receiving these prevent them from developing a healthy construction of reality. This manifests in symptoms such as paranoid delusions and social withdrawal.
• Describe expressed emotion

  The term was used by Brown to describe a negative emotional climate within the family. It is an explanation for relapse. Its 3 main elements are criticism, hostility and emotional over involvement. This causes significant stress for the patient and trigger relapse or onset of schizophrenia.
• Describe antipsychotics

  Drug therapy replaced electroshock, insulin shock and lobotomies as treatment for schizophrenia as these treatments only led to about 20% of patients showing long-term improvements. Antipsychotics alter the levels of neurotransmitters in patients. There are two types:

  • Typical such as chlorpromazine
  • Atypical such as clozapine
• Describe how typical antipsychotics work

  • Drugs bind to dopamine receptors called D2 receptors without stimualting them
  • These include chlorpromazine and act as dopamine antagonists
  • The drug blocks the receptor sites so the post synaptic neuron cannot be activated by dopamine
  • This reduces dopamine activity in the brain, most importantly in the mesolimbic pathway
  • The effect is a reduction in positive symptoms within 48 hours of first dose
• Describe how atypical antipsychotics work

  Work the same as typical by binding to D2 receptors but rapidly dissociate from receptors to reduce extrapyrimidal side effects such as tardive dyskinesia

  Also :

  • Drugs have a greater effect on serotonin activity

  • They bind to a group of serotonin receptors called 5HT 2A
  • This helps improve mood and reduce depression and anxiety in symptoms
• Describe CBT as a psychological therapy

  Used to teach schizophrenics how to modify their beliefs in order to regulate emotions and behaviour and is based on the ideas proposed by Ellis' ABC model. It can lead to people having a lower relapse risk and they develop improved social skills.

  Therapist may:

  • Normalise auditory hallucinations
  • Introduce coping strategies
  • Cognitive restructuring

  Discussions may include:

  • Beliefs
  • Thought patterns
  • Avoidance behaviours
• What does ABCDE stand for in CBT

  A = activating event / adversity

  B = beliefs about event

  C = consequences

  D = disputations to challenge self defeating belief

  E = effect/consequence of challenging self defeating belief
• Describe techniques used in CBTp

  Critical collaborative analysis:

  • Therapist uses gentle questioning to help the patient recognise their illogical conclusions and come to dispute irrational beliefs. Questions must be empathetic and non-judgemental to avoid further distress

  Reality testing

  • Therapist designs practical ways to test reality of irrational beliefs and demonstrate they are not true

  Self-talk

  • Patient is encouraged to devise statements to avoid symptoms or cope with stressful situations. These can be instructions or positive affirmations.
• Describe family therapy as a psychological therapy

  Based on the idea that living with a family whose communication is dysfunctional can make a schizophrenia patient worse / cause a relapse

  It aims to change the way family members interact, specifically to reduce the level of expressed emotion

  High expressed emotion involves:

  • Hostility, criticism and emotional over involvement demonstrated by relatives towards the schizophrenic
  • Creates a stressful, living environment and leads to relapse
• Describe techniques used in family therapy

  • Patient and their family member attend formal group session
  • Before starting, family members attend a 'psycho-education' workshop where they are taught about the biological nature of schizophrenia and any negative / false beliefs are challenged
  • Around 10 formal sessions are required over 12 months
  • Some things discussed are the patients recent symptoms and behaviour and its impact on family members as well as any progress made

  Family members are taught:

  • coping strategies
  • how to help patient taking medication
  • to identify relapse signs
• Describe token economy as a psychological therapy

  Based on behavioural principles of operant conditioning

  • Positive reinforcement increases the frequency of that behaviour

  A 'token economy' is a system used in psychiatriac hopsitals with patients who may have developed patterns of maladaptive behaviour through spending a long time in this setting (institutionalised)
• Describe techniques used in token economy

  • Tokens are given to patients immediately after they perform one of the target behaviours. It is important that it is immediate as it will motivate them to repeat as they're seeing instant rewards
  • Tokens are secondary reinforcers, as they have no value in themselves but acquire reinforcing properties by being associated with genuine rewards
  • Tokens can then be exchanged for rewards / priveliges which are the primary reinforcers as they directly give pleasure
  • It is important the exchange periods are frequent to prevent a reduced effect of the reward
• Why are some tokens referred to as generalised reinforcers?

  They can be exchanged for a variety of different rewards and priveliges

  • The more things the token can be exchanged for, the more powerful the token becomes and the more target behaviours are likely to be repeated by patients

  They don't provide a cure for schizophrenia but do give the benefit of:

  • Improved quality of life
  • Make them live more independently