Schizo L4-6 Flashcards
(35 cards)
1
Q
Biological therapies for SZ
A
- most common treatment for SZ is drugs
- specifically antipsychotic drugs
- drugs can be taken in the form of tablets or syrup or even injections
- injections tend to be given to those patients who are at risk of not taking their medication or don’t take it properly, would be given every 2 – 4 weeks
- to control symptoms of SZ, nearly all patients are first given antipsychotic drugs either for a short or long period depending on the control of their symptoms
- some patients may have the drugs for a short period and be completely cured whereas others may need to take these drugs for a long period or even forever
- sometimes, once the patient is stable, they may be given psychological therapies as well such as family therapy or CBT
2
Q
2 main types of antipsychotic drug
A
- typical (traditional or first generation) antipsychotics
- atypical (second generation) antipsychotics
3
Q
typical antipsychotics
A
- have a strong link to the dopamine hypothesis explanation of SZ
- hypothesis suggests that SZ symptoms are due to high levels of dopamine
- these drugs are dopamine antagonists
- work by reducing the effects of dopamine and thus reduce the symptoms of SZ
- these drugs bind to but do not stimulate dopamine receptors
- so blocks their action
- they block the dopamine receptors in the synapses in the brain reducing the actions of dopamine
- this will reduce the positive symptoms of SZ
4
Q
typical antipsychotic example
A
Chlorpromazine
- drugs can be taken as a tablet, syrup or injection
- also an effective sedative and was used to calm patients not only with SZ but also other conditions
- faster absorbed in syrup form rather than tablet – hence it being an effective sedative
- when patient first take Chlorpromazine, dopamine levels would build up
- but then the production of dopamine would reduce
- manages dopamine production and transmission
- works mainly as a dopamine antagonist, reducing dopamine levels
- helps reduce positive symptoms like hallucinations
5
Q
atypical antipsychotics
A
- drugs emerged in the 1970s and used to improve the effectiveness of typical antipsychotics
- and minimise the side effects that were occurring when patients were given typical antipsychotics
- also have a beneficial effect on negative symptoms and cognitive impairment
- work like typical antipsychotics by blocking D2 receptors
- but only temporarily occupy the D2 receptors
- then rapidly dissociate to allow normal dopamine transmission
- it is this rapid dissociation that is thought to be responsible for the lower levels of side effects
- some of the atypical antipsychotics include: clozapine and risperidone
6
Q
atypical antipsychotic example
A
clozapine
- used as alternative drug if typical antipsychotic failed to work
- available as syrup, tablet
- it had a fatal blood condition side effect so now when it is used, patients must regularly take blood tests to ensure they don’t have this condition.
- it has max dosage of 300-450mg
- works by binding to dopamine receptors but also acts on serotonin and glutamate receptors
- by working on other neurotransmitters too, it can reduce depression and anxiety alongside SZ symptoms
- treats positive and negative symptoms
7
Q
drug therapy +ve
A
- Studies compared effectiveness between 2 atypical drugs, clozapine and risperidone, the results were inclusive
- this shows that some patients responded better to one drug than the other which supports idea of SZ being a complex disorder
= research to support fact that antipsychotics reduce relapse rate
= Leucht did a meta analysis of 65 studies with 6000 patients
= some patients were taken off their antipsychotic meds and given placebos
= in a year, 64% of placebo patients had relapsed whilst only 27% relapsed on actual meds, shows the effectiveness of drug therapy - research evidence to support effectiveness of typical antipsychotic drugs in treating SZ
- Thornley et al compared the use of chlorpromazine, typical antipsychotics, with a placebo
- data from trials with many pps showed that chlorpromazine was associated with reduced symptoms and better overall functioning
- also data from other trials with about 500 pps showed that relapse rate was also lower when chlorpromazine was taken
- study this shows that typical antipsychotics were effective in reducing the symptoms of SZ compared to a placebo showing that drug therapy is appropriate in treating SZ
8
Q
drug therapy -ve
A
- side effects like typical drugs consist of dizziness, agitation, sleepiness, tardiness, weight gain
- serious side effect in typical drugs is neurological malignant syndrome (NMS)
- causes high temperature, delirium, coma, death
- atypical drugs worked past these side effects but also have their own like the fatal blood condition in clozapine
= ethical issues
= SZ is a psychotic disorder hence patients may not be in the right frame of mind to consent for such strong drugs with severe side effects - antipsychotics may not be suitable for all schizophrenic patients which questions whether all patients should be given them
- understanding of how antipsychotic drugs work is strongly tied with hyperdopaminergia explanation that high dopamine levels in the subcortex of the brain are responsible for symptoms of SZ
- but the use of antipsychotics do not explain the hypodopaminergia explanation of SZ, that is low levels of dopamine
- if this is the case then antipsychotics should not work as they are antagonists, blocking dopamine
9
Q
psych therapies for SZ
A
- CBT
- family therapy
- token economies
10
Q
CBT, P
A
- main psychological treatment used with SZ
- idea is that beliefs of self, surroundings and personal problems
- affect how individuals perceive themselves, others, problems approach, and how successful people are in coping and reaching goals
- period of 5 – 20 sessions groups or individually
- antipsychotic drugs given first to reduce thought process, so that CBT can be more effective
- CBT is then done around once every 10 days for about 12 sessions to identify and alter irrational thinking
- drawings are often used to display links between sufferers’ thoughts, actions and emotions
- understanding where symptoms originate from can be useful in reducing sufferers’ anxiety levels
11
Q
CBT approach, PT
A
- personal therapy
- involves detailed evaluation of problems, experiences, their triggers, consequences, and strategies being used to cope
- also used to tackle problems faced by schizophrenics discharged from hospital
- takes place in small groups or as one-to-one therapy
- patients are taught to recognise small signs of relapse, which can build up to produce cognitive distortions and unsuitable social behaviour
12
Q
cognitive techniques, CBT
A
- helping understand and make sense of how their irrational cognitions impact on their feelings and behaviour
- distractions from intrusive thoughts, tell them to perhaps put the volume of the TV up when this happens
- challenging the meaning of intrusive thoughts, can be done through reality testing
- increasing/decreasing social activity to distract from low mood
- normalisation – conveying to patients that many people have unusual experiences so patient feels less alienated
- using relaxation techniques
- positive self-talk
13
Q
CBT +ve
A
- evidence to support that it is effective in treating SZ
- Jauhar et al reviewed 34 studies of using CBT with SZ and found that there is clear evidence for small but significant effects on both positive and negative symptoms
- other studies have focussed on symptoms
- Pontillo et al found reductions in frequency and severity of auditory hallucinations
= clinical advice from NICE recommends CBT for SZ
= means that both research and clinical experience support the benefits of CBT - effectiveness of CBT is dependent on the stage of the disorder
- CBT more effective when made available at certain stages of the disorder and when the delivery of CBT is adjusted to the stage currently at
- Addington and Addington claim that, in the initial acute phases of SZ, self reflection is not particularly appropriate
- but after stabilisation of the psychotic symptoms with medication, patients can benefit from group based CBT
- can normalise their experience by meeting similar individuals
- research shows that individuals with more experience of the SZ and more aware of their problems are most likely to benefit from CBT
14
Q
CBT -ve
A
- lack of availability of CBT and patients refusal to attend sessions
- despite being recommended by NICE, is estimated that in the UK only one in ten individuals with SZ have access to CBT
- figure is even lower in some areas of the UK
- survey by Haddock et al found that in the North West of England only 7% had been offered CBT
- but of those who are offered CBT as a treatment for SZ, a significant number either refuse or fail to attend the therapy sessions
- this limits its effectiveness even more
= wide range of techniques and symptoms included in the studies
= SZ symptoms and CBT techniques vary widely from one case to another
= Thomas points out that different studies have involved the use of different CBT techniques and people with different combinations of positive and negative symptoms
= so it becomes difficult to assess what technique works best for what symptom
= makes it hard to see how effective CBT will be for a person with SZ
15
Q
FT, P
A
- takes place with families as well as the identified patient
- like CBT it is given a set amount of time, usually between nine months and a year
- there is a range of approaches to family therapy for SZ
- these consider psychological theories like the double-bind and the schizophrenogenic mother
16
Q
FT aims, P
A
- improve the quality of communication and interaction between family members
- increase tolerance levels and decreases criticism levels between family members and reduce levels of expressed emotion
- decrease feelings of guilt and responsibility for causing the illness among family members
17
Q
Strategies of FT, P
A
1, reduces negative emotions
- FT aims to reduce levels of expressed emotions
- especially the negative emotions such as anger and guilt which create stress
- reducing stress is important to reduce the likelihood of relapse
2, improves the family’s ability to help – the therapist encourages family members to form a therapeutic alliance whereby they all agree on the aims of therapy
- the therapist also tries to improve families’ beliefs about behaviour towards SZ
- further aim is to ensure that family members achieve a balance between caring for the individual and having their own lives too
18
Q
Burbach model for working with families dealing with SZ, opt
A
phase 1- sharing basic information and providing emotional and practical support
phase 2 - involves identifying resources including what different family members can and cannot offer
- e.g. one family member may be able to offer emotional support whereas another may be able to help make the schizophrenic more independent
phase 3 – this aims to encourage mutual understanding, creating a safe place for all family members to express their feelings
phase 4 – involves identifying unhelpful patterns of interaction such as the negative emotions like anger which could make things difficult for everyone in the family
phase 5 - is about skills training such as learning stress management techniques
phase 6 – focuses on relapse prevention
phase 7 – is about maintenance for the future
19
Q
FT +ve
A
- benefits for all family members
- therapy is not just for the patient but also for the families that provide the bulk of the care
- review of evidence concluded that these effects are important because the family provide most of the care for the person with SZ
- by strengthening the functioning of a whole family, FT lessens the negative impact on other family members and strengthens the ability of the family to support the person with SZ
- means that FT has wider benefits beyond the obvious positive impact on the identified patient
= effectiveness
= review of studies concluded that FT was one of the most consistently effective treatments available for SZ
= relapse rates were found to be reduced by about 50-60%
= also concluded that using family therapy as mental health initially starts to decline is particularly promising
= clinical advice from NICE recommends family therapy for everyone with a diagnosis of SZ
= means that FT is beneficial to people who have just started having symptoms of SZ to those who have developed full blown SZ - economical benefits to family therapy
- NICE review of family therapy studies demonstrated that family therapy is associated with significant cost savings when offered to people with SZ in addition to standard care
- extra cost of family therapy results in a reduction in costs of hospitalisation as the lower relapse rates associated
- also evidence that family therapy reduces relapse rates for a significant period after completion
- means that the cost savings associated with family therapy would be even higher as less chance of rehospitalisation
20
Q
FT -ve
A
- is a management strategy rather than a cure
- family therapy can reduce symptoms and prevent relapse but it does not treat the root cause of schizophrenia
= is time-consuming and requires willing and engaged family members
= may not always be possible, especially in dysfunctional or distant families
20
Q
Token economy, P
A
- reward systems used to manage not treat the behaviour of patients with schizophrenia in hospital settings
- in particular to those who have developed maladaptive behaviours through spending too long in hospital
- is common for patients who are institutionalised to develop bad hygiene or perhaps remain in pyjamas all day
- changing these bad habits does not cure SZ but it improves the patient’s quality of life
- and makes it more likely that they can live outside a hospital setting
21
Q
3 categories of institutional behaviour tackled by TE, P
A
- personal care
- condition related behaviours
- social behaviour
22
Q
Tokens, TE, P
A
- tokens, coloured discs, given immediately to patients when they have carried out a desirable behaviour that has been targeted for reinforcement
- e.g. made their bed, combed their hair, had a shower etc
- each individual patient will be assessed and given token for them showing certain behaviours depending on the behaviours that need work on
- tokens given immediately so that the patient can associate that positive behaviour with a reward as opposed to delayed rewards
- tokens have no value in themselves they can be swapped later for more tangible rewards
- they are secondary reinforcers because they only have value once the patient has learned that they can be used to obtain rewards
23
Q
Rewards, TE, P
A
- tokens have no value in themselves they can be swapped later for more tangible rewards
- are secondary reinforcers because they only have value once the patient has learned that they can be used to obtain rewards
- rewards in a hospital setting might include objects like sweets and magazines
- or access to activities like a film or a walk outside
- or perhaps an appointment with a social worker to plan for life after hospitalisation
24
Theoretical understanding TE
- TE are an example of behaviour modification
- a behavioural therapy based on operant conditioning
- tokens are secondary reinforcers because they only have value once the person receiving them has learned that they can be used to obtain meaningful rewards
- meaningful rewards are primary reinforcers
- tokens that can be exchanged for a range of different primary reinforcers are particularly powerful secondary reinforcers
- such secondary reinforcers are called generalised reinforcers
- for the tokens to become secondary reinforcers they are paired with primary reinforcers
- so at the start of a TE programme token and primary reinforcers are administered together to build association
- e.g. the token and a packet of sweets will be given together for the patient to understand the connection
25
TE +ve
- evidence for their effectiveness
- researcher identified several high quality studies that examined the effectiveness of token economies for people with chronic mental health issues like SZ and involved patients living in a hospital setting
- all the studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours
- supports the value of token economies
= further research support for token economies
= 13 studies reviewed which used token economies to work with SZ
= 11 of these reported beneficial effects that were directly attributable to the use of token economies
= concluded that these studies provide evidence of the token economy’s effectiveness in increasing the adaptive behaviours of patients with SZ
= but caution that many of these studies had methodological issues which could have then affected the overall impact of token economies i.e. whether they were indeed successful
26
TE -ve
- ethical concerns with the use of token economy programmes in psychiatric settings
- e.g. in order to make reinforcement effective, clinicians may exercise control over important primary reinforcers such as food, privacy or access to activities that stop patients from being bored
- patients may exchange tokens if they display the target behaviours
- but all human beings have certain basic rights that should not be violated
- regardless of the positive consequences that might be achieved through the token economy programme
= lack ecological validity
= has been shown to be effective in reducing negative symptoms for people with SZ but only in a hospital setting
= suggested that there are problems administrating the token economy method with outpatients who live in the community
= patients receive 24 hour care and can be given tokens straight away in hospital
= but irl when people with SZ are living in the community, who will give them the tokens straightaway and how will they exchange them for a tangible item
= so token economies lack ecological validity because they cannot be used in the real world community
- existence of more pleasant and ethical alternatives
- art therapy might be a good alternative
- appears that art therapy is a high-gain low-risk approach to managing SZ
- NICE recommends art therapy for SZ
- means that art therapy may be a good alternative to token economies.
27
Interactionist approach
- explains onset and treatment for SZ
- interactionist approach, aka biosocial approach, acknowledges that there are biological, psychological and societal factors in the development of SZ
- biological factors include genetic vulnerability and neurochemical (e.g. dopamine) and neurological (brain) abnormality
- psychological factors include stress resulting from life events
- such as losing a loved one, moving country etc
- and daily hassles (such as concern about weight, worried about appearance)
- and including poor quality interactions in the family
28
The diathesis-stress model, IA
- diathesis refers to vulnerability to SZ
- stress is a negative psychological experience that acts an external trigger
- says that both a vulnerability to SZ and a stress trigger are necessary for the condition to develop
29
Meehl's model, IA
- in original model diathesis was entirely genetic
- and the result of a single schizogene
- this led to the development of a biologically based schizotypic personality
- one characteristic is sensitivity to stress
- Paul Meehl said that if a person doesn’t have the schizogene then no amount of stress would lead to schizophrenia
- however, in carriers of the gene, chronic stress through childhood and adolescence such as a schizophrenogenic mother could result in the development of schizophrenia
30
Modern understanding of diathesis, IA
- is now believed that many genes increase genetic vulnerability and that there is no single schizogene
- include a range of factors beyond genes such as psychological trauma
- so trauma becomes the diathesis rather than the stressor
- neurodevelopmental model proposed in which early trauma affects the developing brain
- e.g the HPA system can become overactive, making the person much more vulnerable to later stress
31
Modern understanding of stress, IA
- in the original model stress was seen as psychological in nature e.g parenting
- the modern definition includes anything that risks triggering schizophrenia
- recent research has shown cannabis use can trigger an episode of schizophrenia
- as it is seen as a stressor as it interferes with the dopamine system
- and increases the risk of SZ by up to seven times
- but most people do not develop SZ after smoking cannabis so there may be one or more vulnerability factors
32
Treatment according to IA
- interactionist model of SZ acknowledges both biological and psychological factors in SZ
- is therefore compatible with both biological and psychological treatments
- model is associated with combining antipsychotic medication and
psychological therapies
- such as CBT
- in Britain it is increasingly standard practice to treat patients w combo of drugs and CBT
- unusual to treat SZ using
psychological therapies alone this is because SZ is a complex psychotic disorder
- drug therapy will be first given to control the symptoms of SZ
- the drug therapy will be used
in a hospital setting perhaps with token economy to manage the behaviour of patients with SZ
- then CBT and family therapy will precede this
33
IA +ve
- evidence for the role of vulnerability and triggers
- is research support for the
dual role for genetic vulnerability to SZ and stress triggers
- Tienari et al.studied children adopted away from schizophrenic mothers
- adoptive parents’ parenting styles were assessed and compared with a control group of adoptees with no genetic risk
- a child-rearing style with high levels of criticism and conflict and low levels of empathy was linked to development of SZ
- but only for children with a high genetic risk
- very strong direct support for the
interactionist approach
- genetic vulnerability and family-related stress combine in the development of SZ
= support for the effectiveness of combination of treatments, is a useful approach
= Tarrier et al. randomly allocated 315 patients to (1) medication and CBT group
= or (2) a medication and supportive counselling group
= or (3) a control group, med only
= patients in the two combo groups (groups 1 and 2) showed lower symptom levels than those in the
control group (medication only)
= but no difference in hospital readmission
= shows that there is a clear practical advantage to adopting an interactionist approach based treatment
34
IA -ve
- original diathesis-stress model is too simplistic
- multiple genes increase vulnerability
- each with a small effect on its own, there is no schizogene
- stress comes in many forms, including dysfunctional parenting
- researchers now believe
stress can also include biological factors
- Houston et al. found
childhood sexual trauma was a diathesis and cannabis use a trigger
- shows that the old idea of diathesis as biological and stress as psychological has turned out to be overly simple
= we don’t know exactly how diathesis stress work
= strong evidence to suggest that some sort of underlying vulnerability coupled with stress can lead to SZ
= but we don’t understand the mechanisms by which symptoms of schizophrenia appear
= and how both vulnerability and stress produce them
= does not undermine support for the approach
= but it does mean we have an
incomplete understanding of the actual medication
- treatment-causation fallacy
- Turkington et al. argue that combined biological and psychological therapies are more effective than either on their own does not necessarily mean the interactionist approach to SZ is correct
- similarly the fact that drugs help does not mean that SZ is biological in origin
- error of logic is called the treatment-causation fallacy
- means that the superior outcomes of combined therapies should not be over-interpreted in terms of evidence in support of the interactionist approach
- means that both the cause of SZ and how it is treated should be taken with caution and assumptions should not be made
