morning Flashcards
(7 cards)
Diagnosis and classification
-World health organisations ICD-10, American psychiatric associations DSM-5.
-DSM-5=one positive symptoms, at least 2 symptoms overall ICD-10+two or more negative symptoms sufficient
-previous editions had subtypes eg paranoid schizophrenia-powerful hallucinations and delusions-dropped because inconsistent-may not show same symptoms few years later
-hallucinations, delusions
-speech poverty(speech disorganisation seen as a positive symptom), avolition(sometimes called apathy, poor hygiene and grooming, lack of persistence in work/education,lack of energy
-Osorio et al report excellent relaibility for diagnosis of schizophrenia in 180 individuals using DSM-5. Inter rate +97, test retest +92
-Criterion validity-Cheneaux et al had to psychiatrists independently assess same 100 clients using DSM-5 and ICD-10. 68 diagnoses under ICD and 39 under DSM
-C-In Osorio study-good agreement between clinicians when they used two measures to diagnose schizophrenia both derived from DSM system.
-gender bias 1.4:1
-Haiti-some believe hearing voices are communication from ancestors.British people of African Caribbean origin 9x as likely to be diagnosed as white British.People living in Afro Caribbean countries are not.
Biological explanations for schizophrenia
-Gottesman large scale family study-aunt 2%,sibling 9%,identical twin 48%
-Ripke-combined all genome(looking at whole genome not particular gene) wide studies of schizophrenia,genetic makeup of 37000 people with schizophrenia diagnosis compared to 113000 controls, 108 separate genetic variations associated with slightly increased risk of schizophrenia. Aetiologically heterogenous.
-mutation-0.7% with fathers under 25 to over 2% for fathers above 50.
-neural correlates-ie brain structure or function, neurotransmitter dopamine
-High levels of DA in subcortical areas of brain eg excess of DA receptors in pathway from sub cortex to brocas area may explain symptoms eg speech poverty and auditory hallucinations.
-Davis proposed addition of cortical hypodopaminergia-low levels of DA in cortex. eg low levels of DA in prefrontal cortex(responsible for thinking) could explain cognitive problems eg negative symptoms of schizophrenia.Cortical hypodopaminergia leads to subcortical hyperdopaminergia.
-current versions also try explain origins-gentic variations and early experiences of stress make some people more sensitive to cortical hypodopaminergia
-Hilker-concordance rate of 33% for identical twins and 7% for non-identical.
-birth complications and smoking cannabis during teenage years , childhood trauma.67% ppl reported at least one childhood trauma-38% of a matched group with non-psychotic mental health issues.
-amphetamines increase DA and worsen symptoms in ppl with schizophrenia and induce symptoms in people without. Antipsychotic drugs reduce DA-reduce intensity of symptoms.Some candidate genes act on production of DA or DA receptors.
-Glutamate-post mortem and live scanning studies, candidate genes
psychological explanations for schizophrenia
-Frieda Fromm-Reichmann-schizophregenic mother-psychodynamic explanation-based on accounts she heard from patients about childhood. Cold,rejecting, controlling, creates family environment characterised by tension and secrecy-leads to distrust which later develops to paranoid delusions.
-Bateson-Double bind theory-fear doing wrong thing, get mixed messages about what it is-cant comment on unfairness of situation or seek clarification,punished by withdrawal of love.understanding of the world as confusing and dangerous-reflected in symptoms like disorganised thinking and paranoid delusions.
-EE-verbal criticism of person occasionally coupled by violence, hostility towards person including anger and rejection,emotional over involvement in life of person eg needless self sacrifice
-reduced thought processing in ventral striatum associated with negative symptoms , reduced processing of information in temporal and cingulate gyri associated with hallucinations
-Frith identified two kinds of dysfunction thought processes-metarepresentation dysfunction,central control dysfunction
-s-review by Read-adults with schizophrenia disproportionately likely to have insecure attachment particularly c or d. 69% women and 59% men have history of sexual abuse
-both double bind and schizophrenia mother based on clinical observation of people and informal assessment of mothers personalities, not clinical evidence.
-Stirling-compared performance on range of cognitive tasks in 30 ppl with schizophrenia and 30 ppl without, eg stroop task where they name font colours of coloured words-people with schizophrenia took twice as long to name font colours.
-proximal explanations-only explain what’s happening now to produce symptoms, distal explanations focus on what initially caused condition.
biological therapy for schizophrenia
-Antipsychotic refers to psychosis
-typical-been around since 1950s-chlorpromazine,taken as tablets, syrup,injection.max 1000mg if taken orally, most people dosage gradually increased to max on 400-800mg. Typical prescribed doses declined over last 50 years.
-act as antagonists in dopamine system,chemicals which reduce action of neurotransmitter-block dopamine receptors
-sedative effect-histamine receptors.syrup faster absorbed than tablets so given when used as sedative.
atypical-used since 1970s.
-clozapine-devloped 1960s used 1970s,withdrawn in 1970s following deaths of some patients developing agranulocytosis,1980s then remarketed as treatment when others failed-regular blood tests-not available as infection-300 to 450 mg dose a day. acts on serotonin and glutamate receptors-improve mood and reduce anxiety-may improve cognitive functioning-when high risk of suicide-30-50% of ppl attempt
-risperidone-1990s,tablets,syrup,injection that lasts two weeks, small dose initially given, can build up to 4-8mg a day.max of 12 mg.dopamine and serotonin receptors. binds more strongly than clozapine-lower dose.
-s-thornley reviewed studies comparing effect of chlorpromazine to control, 13 trials 1121 patients, better overall functioning and reduced symptom severity.
-Meltzer concluded clozapine more effective than typical anti and atypical, effective in 30-50% treatment resistant cases where anti hasn’t worked
-c-healy has suggested serious flaws with evidence for effectiveness. most studies short term effects only-some successful trials had data published multiple times. calming effect so easy to show positive effects
-L-side effects typical-dizziness,agitation,sleepiness,stiff jaw, weight gain, itchy skin.LT tardive dyskinesia, caused by dopamine superdensitivity and causes involuntary facial movements eg grimacing, blinking,lip smacking.
-neuroleptic malignant syndrome-when drug blocks dopamine action in hypothalamus-results in high temp, delirium and coma, can be fatal 0.1% to 2% frequency
Psychological therapies
-CBT-5 to 20 sessions,groups or individual basis, aims to deal with thoughts (cognitions) and behaviour.
-people hearing voices can be taught that voice hearing is extension of ordinary experience of thinking in words-called normalisation.
-Turkington,’The mafia are observing me to decide how to kill me’‘you are obviously very frightened…there must be a good reason for this’‘do you think its the mafia’‘Its a possibility,but there could be another explanation.How do you know that its the mafia?’
-family and identified patient-improve quality of communication and interaction between family members.Range of approaches to family therapy for schizophrenia, in keeping with psychological theories like schizophrenia mother, double bind
-Pharoah-reduce negative emotions, improve families ability to help(form therapeutic alliance, all agree on aims of therapy, improve families beliefs about and behaviour towards schizophrenia-achieve balance between caring and maintaining own lives.
-Burbach-model
1)sharing basic information and offering emotional and practical support
2)Identifying resources including what family members can and cannot offer
3)encourage mutual understanding,creating a safe space for families to express their feelings
4)identify unhelpful patterns of interaction
5)skills training such as stress management techniques
6)relapse prevention planning
7)maintenance for future
-s-CBT-Jahaur-reviewed 34 studies using CBT-small but significant effects on positive and negative symptoms
-Pontillo found reductions in frequency and severity of auditory hallucinations, clinical advice from NICE recommends CBT for schizophrenia.
-C-Thomas points out that different studies have involved use of different CBT techniques and people with different combos of positive and negative symptoms.
-s-review of studies by McFarlane concluded that family therapy consistently most effective treatment. relapse rates found to reduce by 50-60%,using family therapy as mental health starts declining is particularly promising.Clinical advice from NICE recommends family therapy for ppl with schizophrenia.
-review of evidence by Lobban and Barrowclough concluded these effects important because families provide bulk of care
token economy
-classic demonstration of a token economy carried out by Ayllon and Azrin-trialled a system with in ward of women with schizophrenia,every time ppts carried out task eg making bed or cleaning up they were given plastic token embossed with words ‘one gift’.swapped for rewards-number of tasks carried out increased significantly.
-used extensively in 60s and 70s when norm of treating schizophrenia was long term hospitalisation.
-Matson identified three categories of institutional behaviour commonly tackled by means of token economies- personal care, condition related behaviours eg apathy and social behaviours
-example of behavioural modification-behavioural therapy based on operant conditioning
-tokens are secondary reinforcers-only have value when person receiving understands they can be exchanged, meaningful rewards are primary reinforcers.tokens that can be exchanged for a range of different primary reinforcers are particularly powerful secondary reinforcers-generalised reinforcers. Administered together at start so tokens can become secondary reinforcers
-Glowacki-identified 7 high quality studies published between 1999 and 2013-examined effectiveness of token economies for people with chronic mental health issues-reduced negative symptoms and decline in frequency of unwanted behaviours.
-c-file drawer problem
-review by Mathew Chiang concluded art therapy might be a good alternative-evidence base regularly small and has some methodological limitations-art therapy is high reward low risk.
interactionist approach
-biological,psychological and social factors in development of disorder. social factors eg poor quality interactions in family
-diathesis means vulnerability and stress means negative experience.
-Meehls model-originally single schizogene-led to idea of biologically based schizotypic personality, one characteristic of which is sensitivity to stress
-modern views show psychological trauma as the diathesis, read proposed a neurodevelopment model where early trauma alters developing brain eg hypothalamic pituitary adrenal system can become overactive, making a person more vulnerable to later stress.
-cannabis-stressor-increases risk by 7 times-interferes with dopamine system.
-Turkington point out that its perfectly possible to believe in biological causes of schizophrenia and still practice CBT to relieve psychological symptoms-requires adopting an interactionist model.
-tienari et al,19000 Finnish children, adoptive parents assessed for child rearing style, high levels of criticism,hostility and low levels of empathy strongly associated with development of schizophrenia.
-Tarrier-randomly allocated 315 ppts to medication+cbt,mediaction+counselling, mediation only, lower symptoms in combinations.
-treatment causation fallacy
