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Recent developments

2004 Japanese psychiatric assoc changed term for schizo from
Swishing bunretsu boy .....mind split disease
To Togo schicho sho ....integration disorder
2006 campaign for the abolition of the schizophrenic label CASL


DSM IV TR (APA 2000)

Disorganised speech
Catatonic behaviour
Negative symptoms e.g. Flattened mood

2 or more of these but only one symptom reqd if delusions bizarre or hallucinations involve voice providing commentary or 2 voices conversing
Decline in social. And occupational functioning
6 months+
Exclusion if schizoaffective disorder or mood disorder with psychotic features.
Exclusion if substance abuse


Related diagnoses

Delusional disorder
Schizoaffective disorder


DSM5(APA 2013)

Paranoid disorganised catatonic undifferentiated,and residual sub types removed
2criterion A symptoms required for a schizophrenia diagnosis

Must have at least one of 3 positive symptoms of schizo
Disorganised speech
the APA believe this will increase the reliability of schizo diagnoses


ICD 10 (WHO 1994)


Schizo disorders characterised in general by fundamental and characteristic distortions of thinking and perception and affects that are inappropriate or blunted.
clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve over course of time



Mental condition when someone is unable to distinguish between reality and their imagination

Presents in schizophrenia and bi polar disorder
Drug or alcohol induced


Psychosis versus psychopath

Psychosis... An acute condition that his treated can lead to a full recovery

Psychopath ...incurable anti social personality disorder lack of capacity for empathy behave in a manipulative fashion and often have total disregard for consequences of their actions



Positive Negative
Hallucinations. Social withdrawal
Often auditory

Delusions of grandeur/persecution. Flat affect,blunted emotions

Disorders thought processes. Anhedonia ...loss of pleasure

Bizarre behaviours. Reduced motivation
Alogia ,Catatonia


Hallucinations and delusions


False perception of something not rely there sight sounds smell touch taste (excludes dreams and illusions


Unshakeable belief ,convictions outside normal cultural and personal experience


Hearing voices

Auditory hallucinations, major symptom
Rome and Escher 1989
1.25 people may hear voices but not mentally ill
70% people. Who hear voices identify a traumatic event that triggered the Voices
Johns 2001
Continuity of psychotic experiences in general populations



In unshakeable belief in something implausible,bizarre or untrue
2 ,common types
Paranoid delusion
Believes an organisation or person making plans to kill them leads to unusual behaviour
Delusions of grandeur
Believe they have some imaginary power or authority


Confusion of thought

People have disturbed confused and disrupted patterns of thought
Speech may be rapid and constant

Content of speech appears random,topic switching mid sentence
Train of thought suddenly stops causing abrupt pauses


Lack of insight

People experiencing a psychotic episode may be unaware..
Their behaviour is strange
Delusions or hallucinations could be imaginary
May be capable of recog delusional or bizarre behaviour in others. But lack self awareness to cog in themselves.
Often complain that all their .f,elbow patients are ill but not them


Biological perspective on aetiology

Genes scattered all but 8. Chromosomes have been implicated
Indicates a poly genetic vulnerability to schizo
Genetic factors,family,twin and adoption methods indicate genetic predisposition and transmission.
Diasthesis model

Ventricles enlarged...not limited to schizo
Impaired psychological performance
Loss of grey matter in adolescence
Possible causes... Viral infection influenza and neonates
Pregnancy and delivery complications
Substance abuse cannabis


Dopamine hypothesis

Theory revised excess numbers of dopamine receptors or


What is Schiophrenia

Kraepelin 1883 dementia praetor, progressive deterioration in mental functioning

bleuler 1908 schizophrenias ...split minds recog multifaceted symptoms dissociative thinking,delusions,hallucinations,affective disturbance autism
controversy over diagonis continues


Dopamine hypothesis

`Excessive quantity of dopamine

Theory revised:
Excess numbers of dopamine receptors or oversensitive dopamine receptors
Dopamine abnormalities mainly related
to positive symptoms
Dopamine theory doesn’t completely explain disorder
Antipsychotics block dopamine rapidly but symptom relief takes several weeks
To be effective, antipsychotics must reduce dopamine activity to below normal levels

Other neurotransmitters involved:


Environmental factors

Psychosocial factors.
Adoptees with parents with high communication deviance showed elevated thought disorder.

Pregnancy and delivery complications
Pre-eclampsia leading to foetal hypoxia
Low birth weight

Viral infections in neonate
(Tsuang, 2001)


NICE Clinical Guideline (CG82)

Schizophrenia guideline updated March, 2009

Psychological interventions
CBT during acute phase or later; 16+ sessions
Family intervention for those in close contact with families, during acute phase or later
Arts therapies for negative symptoms
NB social skills training not recommended

Pharmacological interventions
Oral anti-psychotics
If first 2 unhelpful consider clozapine
Depot injections


NB Care programme approach (CPA)

Early intervention services should aim to provide a full range of relevant pharmacological, psychological, social, occupational and educational interventions for people with psychosis, consistent with this guideline’.



Key stages of CBT include
Developing a therapeutic alliance based on the patient’s perspective,
Developing alternative explanations
of schizophrenia symptoms,
3) Reducing the impact of positive and negative symptoms
4) Offering alternatives to the medical model to address medication adherence
(Turkington, 2006)


Enhancements to CBT Treatment for Psychosis

Virtual reality with paranoia (Freeman, 2008)

Advantages include the fact that paranoid thoughts cannot be based in reality and that the person cannot respond to a live human trigger

Can be used to identify causal roles

3 treatment purposes;
Exposure to persecutory fears
Develop coping strategies
Educational function


the work of Daniel Freeman

Also see website

10-15% general population experience paranoid ideation (Freeman, 2007)
Media portrayal of events and risks has the capacity to increase paranoid thinking (Freeman & Freeman, 2009)


Family intervention should: (NICE, 2009)

include the person with schizophrenia if practical

be carried out for between 3 months and 1 year

include at least 10 planned sessions

take account of the whole family's preference for either single-family intervention or multi-family group intervention

take account of the relationship between the main carer and the person with schizophrenia

have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work.


Further Guidance from CG82(NICE, 2009)

Family intervention may be particularly useful for families of people with schizophrenia who have:

recently relapsed or are at risk of relapse

persisting symptoms.


Why Family Interventions?

Double-bind theory (Bateson et al., 1956)

Communication deviance (Wahlberg et al., 2001)
Odd use of language

Expressed emotion (EE) (Brown et al., 1958; Leff & Vaughn, 1985)
Emotional over-involvement
(see activity box 7.1, p234 of Davey, 2008)


Why focus on EE?

Risk of those diagnosed with schizophrenia relapsing after returning to high EE environment after inpatient treatment is 3-4 fold, compared to those in low EE environments (Kavanagh, 1992)

Staff may have similar attitudes (Kuipers, 2006)

Burden on carers

What types of burden can you identify?

High EE correlates with high subjective burden (Raune et al., 2004, cited in Kuipers, 2006)


Measuring EE

Camberwell Family Interview (CFI) (Vaughn & Leff, 1976)

Done individually with each relative
Takes 4 hours per person
Good predictor of relapse

Family Questionnaire (Wiedemann et al., 2002)
Briefer assessment of level of EE


What Causes High EE?

Harrison et al. (1998) proposed that 3 variables might be associated with higher levels of criticism among caregivers:

Patients’ greater proportion of negative symptoms (as opposed to positive symptoms)

Caregiver’s low level of knowledge of the illness

Caregiver’s tendency to attribute negative symptoms to the patient (internal causal attributions) rather than to the illness (external causal attributions).

Support gained for lower 2 hypotheses


Common Characteristics of Effective Family Intervention Programmes in Schizophrenia

Show concern, sympathy, and empathy to all family members
who are coping with mental illness
Provide information about the illness
Avoid blaming the family or pathologizing their efforts to cope
Foster the development of all family members
Enhance adherence to medication and decrease substance abuse and stress
Provide treatment that is flexible and tailored to the individual needs of families
Encourage family members to develop social supports outside
their family network
Instil hope for the future
Take a long-term perspective
Strengthen communication and problem-solving

(Glynn et al., 2006)


Two Types of Family Intervention

Supportive Family Management

Focus on social support & reassurance

Applied Family Management

Also includes behavioural training
Coping skills
Problem solving
Communication skills

(Davey, 2008)

In both emotion central
10-20 sessions


FI Manuals

Falloon et al. (1993)
Barrowclough & Tarrier (1992)
Kuipers et al. (2002)


What are the advantages and disadvantages of manualised treatments?

Sellwood et al. (2007) demonstrated that a manualised FI reduced relapse at 12 mths, and that this advantage was maintained at 5 yrs, when compared to treatment as usual.

However number of re-admissions was not significantly different and no significant difference to time spent in hospital.

Benefit related to relapses occurring in the community


Comparing CBT and FI

‘Generic CBT for psychosis is not indicated for routine relapse prevention in people recovering from a recent relapse of psychosis and should currently be reserved for those with distressing medication-unresponsive positive symptoms. Any CBT targeted at this acute population requires development. The lack of effect of family intervention on relapse may be attributable to the low overall relapse rate in those with carers.’

(Garety et al., 2008)


Drugs used to treat Schizophrenia Drug side effects

Side effects of typical antipsychotics include:
muscle twitches, and

Side effects of both typical and atypical antipsychotics include:
weight gain,
blurred vision,
lack of sex drive, and
dry mouth.