Schizophrenia Flashcards
(138 cards)
1
Q
Background Information - 4 Points
A
- Affects 1% of the population
- More commonly diagnosed in men than women
- More commonly diagnosed in cities than in the countryside
- More commonly diagnosed in working class than middle class people
2
Q
Definition of Schizophrenia
A
A severe mental illness where contact with reality and insight are impaired - an example of psychosis
3
Q
Definition of Classification of a Mental Disorder
A
The process of organising symptoms into categories based on which symptoms cluster together in sufferers
4
Q
Definition of Positive Symptoms
A
Atypical symptoms experienced in addition to normal experiences
5
Q
Definition of Negative Symptoms
A
Atypical symptoms representing the loss of a regular experience
6
Q
What are the Two Main Systems for Classifying Mental Disorders?
A
WHO’s ICD-10 and the American Psychiatric Association’s DSM-5
7
Q
What does ICD-10 Stand For?
A
International Classification of Disease - Edition 10
8
Q
What Does DSM-5 Stand For?
A
Diagnostic and Statistical Manual - Edition 5
9
Q
How Does the DSM-5 Classify Schizophrenia?
A
Criterion A, B and C
10
Q
Criterion A of the DSM-5 Classification System
A
Need two or more symptoms but only need one symptom if delusions are bizarre or hallucinations consist of a voice running commentary on behaviour or two voices conversing
11
Q
5 Symptoms of DSM-5 Criterion A
A
- Delusions
- Hallucinations
- Disorganised speech, such as frequent derailment or incoherence
- Grossly disorganised or catatonic behaviour
- Negative symptoms, such as affective flattening, logia, or avolition
12
Q
Criterion B of the DSM-5 Classification System
A
For a significant portion of the time since onset, one or more major ares of functioning such as work, interpersonal relationships or self-care are markedly below the level achieved prior to onset
13
Q
Criterion C of the DSM-5 Classification System
A
- Continuous signs of disturbance persist for at least 6 months
- 6 month period must include at least 1 months of symptoms that meet Criterion A
- During non-active periods, disturbance may be limited to negative symptoms or two or more symptoms in Criterion A in attenuated form, such as odd beliefs or unusual perceptual experiences
14
Q
3 Subtypes of Schizophrenia Recognised by the ICD - 10
A
- Paranoid schizophrenia
- Hebephrenic schizophrenia
- Catatonic schizophrenia
15
Q
Paranoid Schizophrenia
A
Powerful hallucinations and delusions with relatively few other symptoms
16
Q
Hebephrenic Schizophrenia
A
Primarily negative symptoms
17
Q
Catatonic Schizophrenia
A
Disturbance to movement or immobile or inactive
18
Q
2 Types of Symptoms
A
- Positive symptoms
- Negative symptoms
19
Q
3 Positive Symptoms
A
- Hallucinations
- Delusions
- Affective flattening
20
Q
3 Negative Symptoms
A
- Avolition
- Speech poverty
- Anhedonia
21
Q
Hallucinations - 4 Points
A
- Unusual sensory experiences
- Some related to events in the environment (distorted representations) and some bear no relationship to the environment
- Can include voices heard talking to/commenting on the sufferer and are often critical
- Hallucinations can be experienced in relation to any sense
22
Q
Delusions - 5 Points
A
- Irrational beliefs and a strong crossover with paranoia
- Come in a range of forms, such as delusions of grandeur and delusions of persecution
- May involve thinking part of the body is under external control
- Makes a sufferer behave in ways that seem sensible to them but bizarre to others
- Most sufferers are not aggressive and are more likely to be victims of violence, but some delusions can lead to aggression
23
Q
Definition of Delusions of Grandeur
A
Thinking you have more importance than you do
24
Q
Definition of Delusions of Persecution
A
Believing you are being mistreated
25
Avolition - 4 Points
- Sometimes called apathy
- Finding it hard to begin or keep up with goal-directed activity
- Sharply reduced motivation to carry out activities
- Andreason put forward the 3 signs of avolition
26
3 Signs of Avolition
- Poor hygiene and grooming
- Lack of persistence in work or education
- Lack of energy
27
Speech Poverty - 5 Points
- Changes in patterns of speech
- ICD-10 says this is a negative symptom due to reduction in the amount/quality of speech
- Sometimes comes with delays in verbal responses during conservations
- DSM-5 now puts emphasis on speech disorganisation - speech becomes incoherent or topic changes mid sentence
- DSM-5 now says this is a positive symptom whilst speech poverty is a negative symptom
28
Affective Flattening
Reduction in the range and intensity of emotional expression, voice tone, eye contact and body language
29
Anhedonia - 2 Points
- Loss of interest or pleasure in all or almost all activity, or lack of reactivity to normally pleasurable stimuli
- Can experience physical or social anhedonia
30
Schizophrenia Classification and Diagnosis A03 - Reliability - 4 Points
- Inter-rater reliability in relation to schizophrenia involves whether two or more mental health professionals come to the same diagnosis for the patient
- Cheniaux et al - had 2 psychiatrists independently diagnose 100 patients using DSM and ICD criteria and found poor inter-rater reliability
- One psychiatrist diagnosed 26 with Sz using DSM and 44 using ICD
- Other psychiatrist diagnosed 13 using DSM and 24 using ICD
31
Schizophrenia Classification and Diagnosis A03 - Validity - 4 Points
- For mental disorders, there are many validity issues to be considered
- A standard way to assess the validity of diagnosis is criterion validity - do different assessment systems arrive at the same diagnosis for a patient
- From the Cheniaux study, we can see a patient with Sz is much more likely to be diagnosed using ICD than using DSM
- Either DSM under-diagnoses or ICD over-diagnoses
32
Schizophrenia Classification and Diagnosis A03 - Symptom Overlap - 5 Points
- Considerable overlap between symptoms of Sz and bipolar disorder
- Both Sz and BPD involve positive symptoms like delusions and negative symptoms like avolition
- Leads to the question over validity of classification/diagnosis
- Under ICD, a patient may be diagnosed with Sz, but with same symptoms, some patients could be diagnosed with BPD according to DSM
- Could suggest that Sz and BPD could be one condition not two
33
Schizophrenia Classification and Diagnosis A03 - Co-Morbidity - 6 Points
- If 2 conditions occur together a lot of the time, we must question validity of diagnosis and classification, as it could be just one condition
- E.g. 1% of population experience Sz and 2-3% OCD, so we would expect only a few to have both
- Swets et al - meta analysis found at least 12% of patients with Sz fulfilled diagnostic criteria for OCD and about 25% displayed significant obsessive compulsive symptoms
- Buckley et al - found 50% with a diagnosis of Sz also have a diagnosis of depression, 47% substance abuse, 29% PTSD, and 23% OCD
- If 50% have depression as well, maybe we are just bad at telling the difference between the two conditions
- For classification , if severe depression looks a lot like Sz and vice versa, might it be better to see them as one condition
34
Definition of Co-Morbidity
Two or more conditions occur together
35
Schizophrenia Classification and Diagnosis A03 - Gender Bias in Diagnosis - 5 Points
- Longenecker et al - reviewed studies since the 80s, finding men have been diagnosed with Sz more often than women
- Men may be more genetically vulnerable, but a more plausible explanation is gender bias
- Cotton et al - female patients typically function better than male
- Might explain why some women have not been diagnosed where men with similar symptoms have been, as they are better at interpersonal functioning which may bias practitioners to under-diagnose Sz
- Women are generally better at masking symptoms
36
Schizophrenia Classification and Diagnosis A03 - Culture Bias in Diagnosis - 6 Points
- African Americans and English people of Afro-carribean origin are several times more likely than white people to be diagnosed with Sz
- Rates in Africa and West Indies are not particularly high so very unlikely to be genetically vulnerable but instead is the result of culture bias
- Positive symptoms like hearing voices may be more acceptable in African cultures
- Cultural beliefs in the communication with ancestors means they are more likely to acknowledge such experiences
- When reporting these symptoms to psychiatrists from different cultural traditions they can take a very ethnocentric approach
- Escobar - Many (white) psychiatrists over-interpret symptoms and distrust honesty of black people during diagnosis
37
Definition of Dopamine
A neurotransmitter which usually has an excitatory effect and is associated with the sensation of pleasure
38
Definition of Neural Correlates
Patterns of structure or activity in the brain that occur alongside an experience and may be implicated in the origins of it
39
Genetic Basis of Schizophrenia - Runs in Families? - 4 Points
- Noted for many years that schizophrenia is said to run in families
- Weak evidence for genetic basis to schizophrenia as families tend to share aspects of their environment too
- There have been systematic investigations of the extent to which greater genetic similarity is associated with concordance of schizophrenia
- These investigations, like Gottesman's, suggest a strong relationship between the degree of genetic similarity and shared risk of schizophrenia
40
Genetic Basis of Schizophrenia - Candidate Genes - 6 Points
- Individuals are believed to be associated with a risk of inheritance
- Lots of different genes involved in increased risk (polygenic)
- Different studies have identified different candidate genes which suggests schizophrenia is aetiologically heterogenous
- Ripke et al - Combined previous data of genome-wide studies of schizophrenia
- Genetic make-up of 37,000 participants was compared to 113,000 controls
- 108 separate genetic variations associated with increased risk of schizophrenia
41
Definition of Aetiologically Heterogenous
Different combinations of factors can lead to same condition
42
Dopamine Hypothesis - 6 Points
- Can be seen as a neural correlate
- Neurotransmitters seem to work differently in the brain of a schizophrenia patient
- Dopamine (DA) thought to be involved
- DA important in functioning of many brain systems implicated in the symptoms of schizophrenia
- 2 parts involved - hyperdominergia in the sub cortex and hypdominergia in the cortex
43
Hyperdopaminergia in the Sub Cortex - 3 Points
- Original version of the DA hypothesis focused on the high levels/activity of DA in the sub cortex
- Sub cortex is a central area in the brain
- Excess of dopamine receptors in Broca's areas could be associated with speech poverty and/or experience of auditory hallucinations
44
Hypodopaminergia in the Sub Cortex - 2 Points
- More recent version of DA hypothesis have focused on abnormal DA systems in the cortex
- Goldman-Rakic et al - identified role for low levels of DA in the pre-frontal cortex (responsible for thinking and decision making) in the negative symptoms of schizophrenia
45
Neural Correlates of Negative Symptoms - 5 Points
- Avolition involves loss of motivation and the anticipation of a reward
- Certain brain regions, like this one, are involved in this anticipation
- Abnormality of areas like this may be involved in the development of avolition
- Juckel et al - measured activity levels in ventral striatum in schizophrenia patients and found lower levels of activity than in control group
- Found negative correlation between activity levels in ventral striatum and severity of negative symptoms
46
Neural Correlates of Positive Symptoms- 3 Points
- Allen et al - scanned brain of those experiencing auditory hallucinations and compared them to control groups whilst identifying pre-recorded messages as their own or other's speech
- Lower activation levels were found in sub cortex and VS in the hallucination groups
- They also made more errors than the control group
47
Biological Explanations for Schizophrenia A03 - Research Support for Genetic Vulnerability - 4 Points
- Very strong evidence from many sources, including Gottesman
- Tienari et al - adoption study of children of Sz sufferers still at heightened risk of Sz even if adopted into families with no history of Sz
- Also evidence at molecular level to show particular genetic variations significantly increase the risk of Sz, e.g. Ripke
- Overwhelming evidence that genetic factors have a big impact on vulnerability, even if not 100% responsible
48
Biological Explanations for Schizophrenia A03 - Mixed Evidence for DA Hypothesis - 7 Points
- Support from many sources for abnormal DA functioning in Sz
- Curran et al - DA agonists like amphetamines (increase in DA levels) make Sz worse and can produce Sz-like symptoms in non-sufferers
- On the other hand, antipsychotic drugs work by reducing DA activity
- Both kinds of study suggest an important role for DA in Sz
- Lindstroem et al - radioactive labelling studies have found chemicals needed to produce DA are taken up faster in brain of Sz patients than controls, which suggests they produce more DA
- Also evidence that DA cannot be a complete explanation - some genes identified in Ripke's research code for production of other neurotransmitters, which means it seems likely DA is important but other neurotransmitters are likely to be important
- Lots of attention recently has shifted to another neurotransmitter called glutamate
49
Biological Explanations for Schizophrenia A03 - Correlation Causation Problem - 4 Points
- There are many neural correlates of Sz symptoms, both positive and negative
- Although studies can flag up brain systems that may not operate normally, there are still unanswered questions
- Does the unusual activity cause the symptoms or do the symptoms cause the unusual activity?
- Could another factor draw them together?
50
Biological Explanations for Schizophrenia A03 - The Role of Mutation - 4 Points
- Sz can take place even when there is no family history of the disorder
- One explanation for this is mutation in parental DNA
- Brown et al - demonstrated a positive correlation between parental age, which is associated with increase risk of sperm mutation, and risk of Sz
- Increase from 0.7% with fathers under 25 y/o to 2+% in under 50 y/o
51
Biological Explanations for Schizophrenia A03 - Role of Psychological Environment is Important but Unclear
Evidence supporting the role of biology in Sz is overwhelming but there is also evidence for an important role of environmental factors, including psychological ones like family functioning during childhood
52
Biological Treatments for Sz - Drug Therapies - 5 Points
- The most common Sz treatment involves the use of antipsychotic
- Antipsychotics can be taken in tablet, syrup form, or even as 2-4 weekly injections for those at risk of failing to take regular medication
- Can be required for short or long term
- Some may take them for a short course then stop use, and their symptoms never return
- Others may require them for life or face the likelihood that their Sz will recur
53
Definition of Antipsychotics
Drugs to reduce the intensity of symptoms, especially the positive symptoms of psychotic conditions
54
Definition of Typical Antipsychotics
The first generation of antipsychotic drugs used since the 50s, and they work as dopamine antagonists
55
Definition of Atypical Antipsychotics
Drugs for Sz developed after typical antipsychotics, and they target a range of neurotransmitters including dopamine and serotonin
56
3 Drugs used to Treat Schizophrenia
- Chlorpromazine
- Clozapine
- Risperidone
57
Typical Antipsychotic for Schizophrenia
Chlorpromazine
58
2 Atypical Antipsychotics
- Clozapine
- Risperidone
59
Chlorpromazine - Background Information - 4 Points
- Taken as tablets, syrup or injection
- If taken orally, it is given daily up to a maximum of 1000 mg
- Does usually much smaller initially
- Liu and de Haan - typical prescribed doses have declined over the last 50 years
60
Chlorpromazine - How it Works - 8 Points
- Strong association between typical antipsychotics and the DA hypothesis
- Typical antipsychotics work by acting as antagonists in the DA system to reduce the action of the neurotransmitter
- Dopamine antagonists block dopamine receptors in the synapses of the brain to reduce the action of dopamine
- Initially, when a patient takes this drug, DA levels build up but then production is reduced
- According to DA hypothesis, dopamine-antagonist effect normalises neurotransmission in key areas of the brain to reduce symptoms like hallucinations
- Is also an effective sedative, believed to be due to its effect on histamine receptors
- Not fully understood how this leads to sedation, but is often used to calm patients with conditions beyond just schizophrenia
- Syrup absorbed faster than tablets, so often used when for sedative properties
60
Clozapine - Background Information - 6 Points
- Developed in 60s and trialed in early 70s
- Withdrawn for a period in 70s following deaths of some patients from a blood condition (agranulocytosis) but re-introduced in 80s when it was found to be more effective than typical antipsychotics
- Used as a back-up for when other treatments failed, and still used in this way today
- People taking Clozapine have regular blood tests to ensure they're not developing agranulocytosis
- Due to potentially fatal side effects, not available as an injection
- Daily dosage lower than for chlorpromazine 300 - 450 mg a day
61
Clozapine - How it Works - 4 Points
- Binds to dopamine receptors in the same way chlorpromazine does but also acts on serotonin and glutamate receptors
- Believed this action helps improve mood and reduce depression and anxiety in patients, and that it may improve cognitive functioning
- Mood-enhancing effect means it is sometimes prescribed when a patient is considered a suicide risk
- 30 - 50% of people suffering with schizophrenia attempt suicide at some point
62
Risperidone - Background Information - 5 Points
- More recently developed - been around since the 90s
- Developed as an attempt to produce drug as effect as clozapine, but without the serious side effects
- Can be taken in form of tablets, syrup, or injection that lasts for around 2 weeks
- Small dose given initially, building up to a typical dose of 4 - 8 mg and a maximum of 12 mg
- Some evidence suggests it leads to fewer side effects than is typical for antipsychotics
63
Risperidone - How it Works - 2 Points
- Believed to bind to dopamine receptors and effect serotonin receptors
- Binds more strongly to dopamine receptors than clozapine, so its effective in much smaller doses than most antipsychotics
64
Definition of Family Dysfunction
Abnormal processes within a family
65
3 Examples of Family Dysfunction
- Poor family communication
- Cold parenting
- High levels of expressed emotion
66
3 Family Dysfunction Explanations
- Schizophrenogenic mother
- Double-bind theory
- Expressed emotion
67
Family Dysfunction - The Schizophrenogenic Mother - 4 Points
- Fromm-Reichmann - psychodynamic explanation based on accounts from her patients about their childhoods
- Schizophrenic Mother (SM) - means schizophrenia causing
- SM is cold, controlling and rejecting, and tends to create a family climate caused by tension and secrecy
- This environment creates distrust that develops into paranoid delusions and ultimately schizophrenia
68
Family Dysfunction - Double-Bind Theory - 6 Points
- Bateson et al - agreed family climate is important but emphasised the role of communication style within a family
- The developing child often finds themselves trapped in situations where they fear doing the wrong thing
- Receive mixed messages about what this is and feel unable to comment on the unfairness of the situation or seek clarification
- When they 'get it wrong', the child is punished by withdrawal of love
- Leaves them with an understanding of the world as confusing and dangerous - reflected in symptoms like disorganised thinking and paranoid delusions
- Bateson was clear that this was just a risk factor
69
Family Dysfunction - Expressed Emotion - 5 Points
- Expressed emotion (EE) is the level of emotion, especially negative, expressed towards a sufferer by their parents/carers
- EE contains many elements
- These high levels of EE come from parents/carers directed towards the sufferer cause high levels of stress for them
- This is an explanation for relapse in patients with Sz
- However, it has been suggested that it could trigger the onset of Sz in someone who is vulnerable to developing Sz
70
3 Elements of Expressed Emotion
- Verbal criticism of the sufferer, often with violence
- Hostility towards the sufferer, including anger and rejection
- Emotional over-involvement in the life of the sufferer
71
Cognitive Explanations - 6 Points
- Cognitive explanations focus on mental processes like thinking, language and attention
- Sz associated with several types of abnormal information processing
- Sz characterised by disruption to normal thought processing
- Reduced processing in ventral striatum associated with negative symptoms and reduced processing in temporal and cingulate gyri associated with hallucinations
- Therefore, lower than usual levels of information processing suggest condition is likely to be impaired
- Frith et al - identified 2 kinds of dysfunctional through processing which could underlie some symptoms
72
Definition of Dysfunctional Thought Processing
General term to describe information processing that does not function normally and produces undesirable consequences
73
2 Types of Dysfunctional Thought Processing
- Metarepresentation
- Central control
74
Definition of Metarepresentation
Cognitive inability to reflect on thoughts and behaviour
75
Definition of Central Control
Cognitive inability to suppress automatic responses whilst performing deliberate actions instead
76
Dysfunctional Thought Processing - Metarepresentation - 4 Points
- Allows insight into our intentions and foals
- Allows us to interpret the actions of others
- Dysfunction - disturbed ability to recognise own actions and thoughts as being carried out by ourselves rather than someone else
- Could explain hallucinations of voices and delusions like thought insertion - experience of having thoughts projected into mind by others
77
Dysfunctional Thought Processing - Central Control - 2 Points
- Dysfunction - disorganised speech and thought from inability to suppress automatic thoughts and speech triggered by other thoughts
- Sufferers often experience derailment of thoughts and spoken sentences as each word triggers associations which the patient cannot suppress automatic responses to
78
Biological Treatments A03 - Evidence for Effectiveness - 5 Points
- Thornley et al - reviewed studies comparing chlorpromazine to control conditions where patients received a placebo
- Data from 13 trials with a total of 1121 patients showed chlorpromazine was associated with better overall functioning and reduced symptom severity
- Data from 3 trials with 512 patients also showed relapse rate was lower when chlorpromazine was taken
- Meltzer - concluded clozapine is more effective than typical antipsychotics, and is effective in 30-50% of treatment-resistant cases where typical antipsychotics have failed
- Many studies compared the effectiveness of clozapine and risperidone but results have been inconclusive, suggesting that some patients may respond better to one drug or the other
79
Biological Treatments A03 - Problems with Evidence for Effectiveness - 4 Points
- Healy - said some successful trials have had their data published many times, which exaggerates their positive effects
- Also suggests that because of their powerful sedative effects, it is easy to demonstrate some positive effects on patients
- Not the same as saying they reduce the severity of psychosis
- Most studies assess short-term benefits rather than long-term benefits and compare patients who keep taking antipsychotics with those suffering withdrawal
80
Biological Treatments A03 - Use of Antipsychotics Depends on the DA Hypothesis - 4 Points
- Original form of DA hypothesis is the idea that there are higher than usual levels of dopamine activity in the sub cortex of the brain
- However, there is evidence that this is not a complete explanation, and outside of the sub cortex, the dopamine levels are too low
- Unclear how antipsychotics can help with schizophrenia when they reduce DA activity
- Modern understanding of the relationship between dopamine and psychosis suggests antipsychotics shouldn't work, which undermines people's faith in them
81
Biological Treatments A03 - Chemical Cosh Argument - 2 Points
- Widely believed antipsychotics have been used in hospital situations to calm patients and make then easier for staff to work with, rather than for the benefits of the patients themselves
- Although short-term use of antipsychotics to calm agitated patients is recommended by National Institute for Health and Clinical Excellence (NICE), this practice is seen by some as a human rights abuse
82
Biological Treatments A03 - Serious Side Effects - 7 Points
- Antipsychotic drugs come with likely side effects ranging from mild to sever, and sometimes even fatal
- Typical antipsychotics associated with range of side-effects, and long term use can result in tardive dyskinesia
- Caused by dopamine super sensitivity and manifests as involuntary facial movement like grimacing, blinking and lip smacking
- Most serious side effect of typical antipsychotics is neuroleptic malignant syndrome (NMS), which is believed to be caused because the drug blocks dopamine action in the hypothalamus
- NMS results in high temperature, delirium and coma, and can sometimes be fatal
- Atypical antipsychotics were developed to reduced to the frequency of side effects and generally gave worked
- Side effects still exist and patients taking clozapine have to have regular blood tests to alert doctors early signs of agranulocytosis
83
6 General Side Effects of Typical Antipsychotics
- Dizziness
- Agitation
- Sleepiness
- Stiff jaw
- Weight gain
- Itchy skin
84
5 Side Effects of Chlorpromazine
- Constipation
- Dry mouth
- Seizures
- Irregular periods
- Confusion
85
6 Side Effects of Clozapine
- Dizziness
- Irregular heart beat
- Shakiness
- Swelling of heart muscles
- Yellow eyes
- Agranulocytosis
86
2 Side Effects of Risperidone
- Weight gain
- Blood clots
87
Psychological Explanations for Schizophrenia A03 - Support for Family Dysfunction as a Risk Factor - 5 Points
- Evidence suggests difficult family relationships in childhood are a risk factor for Sz
- Read et al - reviewed 46 studies of child abuse and SZ
- Concluded 69% of adult female in-patients with a diagnosis of Sz had a history of physical abuse, sexual abuse or both in childhood
- For male in-patients, it was 59%
- Berry et al - adults with insecure attachments to their primary carer were also at higher risk of Sz
88
Psychological Explanations for Schizophrenia A03 - Counterpoint for Support for Family Dysfunction as a Risk Factor - 3 Points
- Information about childhood experiences was gathered following the development of symptoms, and the Sz may have distorted patients' ability to recall these experiences
- Only a small number of studies have been carried out prospectively, where data was collected on patients during childhood, and they were later assessed as adults to see if childhood experiences predicted adult characteristics
- From this prospective evidence, there is some evidence linking family dysfunction to Sz, but results have been inconsistent
89
Psychological Explanations for Schizophrenia A03 - Directions of Causality - 4 Points
- We have a lot of information about abnormal cognitions and a lot of information about abnormal biology in Sz
- It is still unclear what causes what, including whether cognitive factors are a cause or result of neural correlates and abnormal transmitter levels seen in Sz
- If it is the case that abnormal cognition is simply the result of neural correlates
- Massively weakens the validity of cognitive explanations of Sz
90
Psychological Explanations for Schizophrenia A03 - Strong Evidence for Dysfunctional Information Processing - 5 Points
- Stirling et al - compared 30 patients with Sz against 18 non-patient controls on many cognitive tasks, including the Stroop Test
- Patients took over twice as long to complete this task compared to controls
- However, cognitive explanations still preset problems
- Links between symptom and faulty cognition are clear but this does not tell us anything about the origins of these cognitions or of Sz
- Cognitive theories can explain proximal causes of Sz but not the distal causes
91
What is the Stroop Test?
Participants have to state the colour of the words, suppressing the automatic urge to read the word aloud
92
Psychological Explanations for Schizophrenia A03 - Weak Evidence for Family-Based Experiences - 3 Points
- Almost no evidence to support the importance of the schizophrenogenic mother or for double bind theory
- Both theories are based on clinical observation of patients only, and early evidence involved in assessing the personality of mothers of patients for "crazy-making characteristics"
- Also often leads to parent blaming
93
Psychological Explanations for Schizophrenia A03 - Evidence for Biological Factors are Not Adequately Considered - 3 Points
- In their pure form, psychological explanations can be hard to reconcile with biological explanations
- Could be that both biological and psychological factors can separately produce the same symptoms, which raises the question of whether not outcomes are really Sz
- Could view this in the context of the diathesis-stress model - diathesis could be either, whilst the stress is the opposite
94
2 Psychological Treatments of Sz
- CBTp
- Family Therapy
95
What Does CBTp Stand For?
Cognitive Behavioural Therapy for Psychosis
96
Definition of Cognitive Behavioural Therapy
A method to treat mental disorders focussing on cognitive and behavioural techniques
97
CBTp - Background Information - 2 Points
- Common treatment usually over the course of 5 - 20 sessions
- Can be done as a group or Individually
98
CBTp - 6 Stages of How it Works
- Assessment
- Engagement
- ABC model
- Normalisation
- Critical collaborative analysis
- Developing alternative explanations
99
CBTp - 6 Stages of How it Works
- Assessment
- Engagement
- ABC model
- Normalisation
- Critical collaborative analysis
- Developing alternative explanations
100
CBTp - Assessment Stage - 2 Points
- Patient expresses their thoughts about their experiences to the therapist
- Realistic goals for therapy are discussed, using the patients current distress as motivation for change
101
CBTp - Engagement Stage - 2 Points
- Therapist emphasises with the patients' perspective and their feelings of distress
- Stresses that explanations for distress can be developed together
102
CBTp - ABC Model - 2 Points
- Patient gives their explanation of the activating events that appear to cause their emotions and beliefs, which lead to consequences
- The patient's own beliefs can be rationalised, disputed and changed
103
CBTp - Normalisation - 2 Points
- Give information that many people have unusual experiences, such as hallucinations and delusions, under many different circumstances
- Reduces anxiety and sense of isolation
104
CBTp - Critical Collaborative Analysis - 2 Points
- Therapist uses gentle questioning to help the patient understand illogical deductions and conclusions
- Questioning can be carried out without causing distress, provided there is an atmosphere of trust between the patient and the therapist
105
CBTp - Developing Alternative Explanations
Patient develops their own alternative explanation for their previously unhealthy assumptions
106
CBTp - How it Helps - 4 Points
- Makes sense of how their irrational cognitions impact their feelings and behaviour
- May make people feel able to cope which reduces their stress and improves their ability to function
adequately
- Delusions can be challenged by reality testing - patient and therapist jointly examine the likelihood of their beliefs being true
- Even when delusions are resistant to reality testing, CBT can still be used to tackle the anxiety and depression that result from living with Sz
107
CBTp - Case Example from Turkington et al - 4 Points
- Client: The Mafia are observing me to decide how to kill me.
- Therapist: You are obviously very frightened, there must be a good reason for this.
- Client: Do you think its the Mafia?
- Therapist: Its a possibility but there are other explanations. How do you know that its the Mafia?
108
Definition of Family Therapy
A psychological therapy carried out with all or some members of a family, with the aim of improving family communication and reducing the stress living as a family
109
Family Therapy - Background Information - 2 Points
Therapy for the family and the identified patient
- Aims to improve communication quality and interaction between family members
110
Family Therapy - How it Helps - 5 Points
- Pharoah et al - identified aims and strategies of family therapy
- To reduce negative emotions - reduce levels of expressed emotion, especially negative to reduce stress of the patient and minimise the chance of relapse
- Improving the family's ability to help - encourages family members to form a therapeutic alliance where they all agree on the aims of therapy
- Also tries to improve families' beliefs about and behaviour towards Sz
- Further aim is to ensure family members achieve a healthy balance between caring for the individual with Sz and maintaining their own lives
111
Family Therapy - Model of Practice - 8 Points
- Burbach proposed a model for working with families dealing with Sz
- Phase 1 - sharing basic information and providing practical and emotional support
- Phase 2 - identifying resources, including what different family members can and can't offer
- Phase 3 - encourage mutual understanding which creates a safe space for all members of the family to express their feelings
Phase 4 - identifies unhelpful patterns of interaction
- Phase 5 - skills training
- Phase 6 - relapse prevention planning
- Phase 7 - maintenance for the future
112
Psychological Treatments of Schizophrenia A03 - Evidence for the Effectiveness of CBTp - 6 Points
- Jahur et al - reviewed 34 studies of CBTp with Sz patients and found a small but significant effect on positive and negative symptoms
- Pontillo et al - reductions in frequency and severity of auditory hallucinations
- NICE recommends CBT for Sz
- Studies often look at a wide range of symptoms and techniques
- Thomas - acknowledges different studies have used different CBT techniques and people with different studies have used different CBT techniques and people with different combinations of positive and negative symptoms
- The model benefits likely conceal a wide range of effects for different CBT techniques on different symptoms
113
Psychological Treatments of Schizophrenia A03 - Does CBTp Actually Cure - 3 Points
- CBTp may improve the quality of life but not 'cure' a patient
- Appears to be a largely biological condition, we would expect psychological therapies would only benefit people by improving their ability to live with Sz
- But studies report significant reductions in severity of positive and negative symptoms, so maybe it is doing more than enhancing coping
114
Psychological Treatments of Schizophrenia A03 - Evidence for the Effectiveness of Family Therapy - 4 Points
- McFarlane - reviewed studies and found family therapy was one of the most consistently effective treatments for Sz, especially for relapse
- Rates reduced by 50-60%
- Concluded using family therapy as mental health starts to decline is very promising
- Clinical advice from NICE recommends family there for everyone with a diagnosis of Sz
115
Psychological Treatments of Schizophrenia A03 - Benefits for the Whole Family - 3 Points
- Therapy not only benefits patients, but also their family
- Lobban and Barrowclough - review concluded these effects are important because families provide the bulk of care for people with Sz
- By strengthening functioning of family as a whole, it lessens the negative impact of Sz on other family members and strengthens their ability to support the person with Sz
116
Psychological Treatments of Schizophrenia A03 - Which Matters Most? - 2 Points
- Family therapy reduces relapse rates and makes families more able to provide care which has huge economic benefits as the state do not need to pay so much
- Alternatively, family theory has therapeutic benefits for the patient and their family
117
Definition of Token Economy
A form of behaviour modification where desirable behaviours are encouraged through the use of selective reinforcement, and rewards are given for socially desirable behaviours
118
One way to Manage Schizophrenia
Token Economy
119
Token Economies - Background Information - 6 Points
- Allyon and Azrin - trialled token economy system in ward of women with Sz diagnoses
- Given a token every time they showed a desirable behaviour
- Token could be swapped for privileges or gifts
- Significant increase in the amount of tasks being carried out
- Used extensively in the 60s and 70s due to long term hospitalisation
- Now less common in the UK due to a growth in community care and the closure of many psychiatric hospitals, and the ethical issues surrounding them
120
Token Economies - Rationale - 5 Points
- Institutionalisation develops under prolonged hospitalisation
- One outcome of this is reducing bad habits
- Matson et al - identified 3 categories of institutional behaviour commonly tackled by token economies: personal care, condition related behaviours, and social behaviour
- Modifying these behaviours doesn't cure Sz, but it does have benefits
- Improves quality of life and normalises behaviour making it easier to adapt back into the community
121
Token Economies - What's Involved? - 4 Points
- Given immediately for desirable behaviours
- Target behaviours are decided on an individual basis, so the patients must be well known
- Tokens have no value, but are associated with immediate rewards
- Rewards are objects or activities
122
Token Economies - Theory - 4 Points
- Behaviour modification is based on operant conditioning
- Tokens are secondary reinforcers because they only have value once the patient learns they can be swapped for more meaningful rewards
- Meaningful rewards are primary reinforcers
- For tokens to become secondary reinforcers, they must be paired with primary reinforcers at start of token economy program
123
Token Economies for Managing Schizophrenia A03 - Evidence for Effectiveness - 3 Points
- Glowacki et al - identified 7 high quality studies examining the effectiveness of token economies for people with chronic mental illnesses living in a hospital setting
- All studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours
- Still a small amount of evidence of the effectiveness of the technique
124
Token Economies for Managing Schizophrenia A03 - Ethical Issues - 4 Points
- Gives professionals considerable power to control the behaviour of patients
- Can be very problematic if target behaviours are not identified sensitively
- Restricting availability of pleasures to people who don't behave in a desirable way, means people who are seriously ill and already experiencing distressing symptoms, have an even worse time
- Legal action from families of patients has been a major factor in the decline of the use of token economies
125
Token Economies for Managing Schizophrenia A03 - Alternative Approaches - 4 Points
- More pleasant ethical alternatives exist with a comparable evidence base
- Chiang et al - concluded art therapy is likely to be a good alternative
- Whilst evidence is small and there are some methodological limitations, it shows art therapy is a high-gain low-risk approach to managing Sz
- NICE recommend art therapy for Sz
126
Token Economies for Managing Schizophrenia A03 - Long Term Effects - 3 Points
- Once outside the hospital setting, token economies are vey difficult to continue as target behaviours cannot be closely monitored, and tokens cannot be administered immediately
- Some people with Sz will only have the chance to live outside a hospital if their personal care and social interactions can be improved
- Use of a token economy may be and effective way for them to prove this, and thus able to achieve their goal of living outside the hospital setting
127
Definition of Interactionist Approach
A way to explain behaviour in terms of many factors, in a meaningful way
128
The Interactionist Approach - 5 Points
- Also referred to as the biosocial approach
- Acknowledges the interplay between psychological, biological and social factors in developing Sz
- Examples of biological factors are genetic vulnerability, and neurochemical and neurological abnormality
- An example of a psychological factor is stress
- An example of a social factor is poor quality interactions in the family
129
Diathesis Stress Model - Basic Information - 2 Points
- Diathesis is a vulnerability and stress is a negative experience
- Model says vulnerability and a stress trigger are needed to develop Sz
130
Diathesis Stress Model - Meehl's Model - 5 Points
- The original diathesis stress model
- Diathesis is seen as entirely genetic - the result of a schizogene
- Created the idea of a biologically based schizotypic personality - a characteristic of this being sensitivity to stress
- Meehl said if a person does not have the schizogene, no amount of stress would lead to Sz
- In gene carriers, chronic stress through childhood and adolescence could result in the development of Sz
131
Diathesis Stress Model - Modern Understanding of Diathesis - 3 Points
- Now clear many genes appear to increase genetic vulnerability of Sz
- Range of factors now included
- Read et al - proposed the neurodevelopmental model, where early trauma alters brain development
132
Diathesis Stress Model - Modern Understanding of Stress - 5 Points
- Original model saw stress as psychological and related to parenting
- Modern understanding includes anything that risks triggering Sz
- Recent research into factors triggering an episode of Sz have concerned cannabis use
- Considered a stressor and is 7 times more likely to increase the risk
- May be because it interferes with the DA system but more likely behaves as a stressor to a diathesis as most people who smoke cannabis do not develop Sz
133
Diathesis Stress Model - Treatment According to the Model - 3 Points
- Compatible with psychological and biological treatments
- Model often associated with combining antipsychotics and psychological therapies
- Turkington et al - possible to believe in biological causes of Sz but also practice CBTp to relieve psychological symptoms
134
Interactionist Approach A03 - Support for Vulnerability and Triggers - 6 Points
- Tienari et al - large scale study assessing impact of genetic vulnerability and psychological triggers
- Followed 19,000 Finnish children who had a biological mother with a Sz diagnosis
- As adults, this high risk genetic group were compared to control group of adoptees with no family history of Sz
- Adoptive parents assessed for child rearing practices
- Found high levels of criticism, hostility and low levels of empathy strongly associated with development of Sz, but only in high risk group
- Combination of genetic vulnerability and family stress leads to greatly increased risk of Sz
135
Interactionist Approach A03 - Diathesis and Stress are More Complex than the Model - 4 Points
- Original model is too simplistic, and showed diathesis as a single schizogene and stress as schizophrenogenic parenting
- Diathesis is polygenic and stress comes in many forms
- Diathesis can be influence by psychological factors and stress can be biological as well as psychological
- Houston et al - childhood sexual abuse emerged as a big influence on vulnerability, and cannabis use as the major trigger
136
Interactionist Approach A03 - Real World Application - 6 Points
- Helpful for combining biological and psychological treatments
- Evidence suggests combing treatments makes them more effective
- Tarrier et al - randomly allocated 315 participants to 1 of 3 conditions: medication and CBTp, medication and counselling, and medication only
- Participants in combination groups showed fewer symptoms following the trial than the control group, but there was no difference in hospital readmission
- Jarvis and Okani - point out potential treatment-causation fallacy that exists here
- Assumes a successful treatment for a mental disorder justifies a particular explanation
137
Interactionist Approach A03 - Effects of Urbanisation - 3 Points
- Sz more commonly diagnosed in urban rather than rural areas
- Often used to justify the interactions position because it assumes urban living is more stressful than rural, so city living acts as a trigger
- May simply be that Sz is more likely diagnosed in cities, or people with a diathesis for schizophrenia might be more likely to migrate to cities
