schizophrenia

Question 1

Prevelance:

Answer 1

serious mental disorder affecting 1% of the population
more common in males, city dwellers and low socio-economic groups.

Question 2

diagnosis:

Answer 2

diagnosis and classification and interlinked. to diagnose a specific disorder, we need to be able to distinguish one disorder from another

classification - identify symptoms that go together = a disorder

diagnosis - identify symptoms and use classification system to identify the disorder.

Question 3

What are DSM - 5 and ICD - 10?

Answer 3

there are two main classification systems in use:

DSM 5 - one positive symptom must be present (delusions, hallucinations or speech disorganization)

ICD - 10 - two or more negative symptoms are sufficient for diagnosis (speech poverty and avolition).

Question 4

what are positive symptoms of schizo?

Answer 4

• additional symptoms beyond those of ordinary existence

1) hallucinations - unusual sensory experiences that have no basis in reality or distorted perceptions of real things. experienced in relation to any sense e.g hearing voices

2) delusions - beliefs that have no basis in reality - make a person with schizo behave in ways that make sense to them but are bizarre to others e.g the victim of a conspiracy.

Question 5

What are the negative symptoms of schizophrenia?

Answer 5

• loss of usual abilities and experiences

1) speech poverty - a reduction in the amount and quality of speech. may include a delay in verbal responses during conversation.
DSM emphasizes speech disorganisation and incoherence as a positive symptom

2) avolition - severe loss od motivation to carry out everyday tasks e.g hobbies
results in lowered activity levels and unwillingness to carry out goal directed behaviors.

Question 6

one strength of diagnosis of schizophrenia

Answer 6

good reliability = a reliable diagnosis is consistent between clinicians (inter-rater)and between occasions (test-retest)

Osorio et al report excellent reliability for schizo diagnosis using the DSM. Pairs of interviewers achieved inter-rater reliability of +.97 and test - retest reliability of +.92

this means that we can be reasonably sure that the diagnosis of schizophrenia is consistently applied.

Question 7

one limitation is comorbidity with other conditions

Answer 7

if conditions often co-occur then they might be a single condition. schizophrenia is commonly diagnoses with other conditions

for example, Buckley et al concluded that schizophrenia is co morbid with depression (50% of cases), substance abuse (47%) or OCD 23%)

this suggests that schizophrenia may not exist as a distinct condition.

Question 8

another limitation is gender bias

Answer 8

Since the 1980s men have been diagnosed with schizophrenia more often than women, in a ratio of 1.4:1 (Fischer and Buchanan)

this could be because men are more genetically vulnerable, or women have better social support, masking symptoms

this means that some women with schizo are not diagnosed so miss out on helpful treatment.

Question 9

another limitation is culture bias

Answer 9

some symptoms of schizo e.g hearing voices are accepted in some cultures e.g Afro Caribbean societies ‘hear voices’ from ancestors

afro carribean men are up to ten times as likely to receive a diagnosis as white british men, probably due to overinterpretation of symptoms by UK psychiatrists

this means that afro carribean men living in the UK appear to be discriminated against by a culturally biased diagnostic system.

Question 10

another limitation is system overlap

Answer 10

there is an overlap between the symptoms of schizo and other conditions e.g both schizo and bipolar disorder involve delusions and avolition

In terms of classification, this suggests that schizo and bipolar may not be two different conditions but variations of a single condition. in terms of diagnosis, this means that schizo might be hard to distinguish from bipolar

this means that schizo may not exist as a condition, and, if it does, it is hard to diagnose. So both its diagnosis and classification systems are flawed.

Question 11

biological explanations for schizo

Answer 11

.

Question 12

the genetic basis: family studies

Answer 12

strong relationship between the degree of genetic similarity and shared risk of schizo

Gottesmans large scale study found for example someone with an aunt with schizo has a 2% chance of developing it, 9% for a sibling and 48% for an identical twin

family members also share environment but still indicates support for a genetic view.

Question 13

candidate genes:

Answer 13

early research looked unsuccessfully for a single genetic variation to explain schizo

schizo is polygenic - requires several genes

it is also aetiologically heterogeneous i.e risk is affected by different combinations

Ripke et al combined all previous data from genome wide studies. found 108 separate genes associated with slightly increased risk of schizo.

Question 14

mutation:

Answer 14

Schizo can also have a genetic origin in the absence of family history because of mutation in parental DNA

evidence comes from the correlation between parental age (associated with increased risk of sperm mutation) and increased risk of schizo.

Question 15

neural correlates of schizo: role of dopamine

Answer 15

dopamine is widely believed to be involved in schizo because it is featured in the functioning of brain systems related to the symptoms of schizo.

Question 16

Original DA hypothesis
hyperdopaminergia linked to subcortex:

Answer 16

Linked schizophrenia to high levels of dopamine (hyperdopaminergia) in subcortical areas of the brain. For example, an excess of DA receptors in pathways linking from subcortex to brocas area may explain specific symptoms e.g poverty of speech and auditory hallucinations.

Question 17

updated version
hypodopaminergia linked to prefrontal cortex:

Answer 17

updated hypothesis has added low levels of DA in the prefrontal cortex (responsible for thinking), could explain negative symptoms

explains origins of abnormal DA - genetic variations and early experiences of stress make some people more sensitive to cortical hypodopaminergia and hence subcortical hyperdopaminergia.

Question 18

one strength for the genetic basis of schizo is the strong evidence base

Answer 18

family studies show risk increases with genetic similarity. twin study (hilker et al) found 33% of concordance for MZ twins and 7% for DZ twins

adoption studies show that biological children of parents with schizo are at greater risk even if they grow up in an adoptive family

this shows that some people are more vulnerable to schizo because of their genes.

Question 19

one limitation is evidence for environmental risk factors

Answer 19

biological factors include birth complications and smoking THC rich cannabis in teenage years

psychological risk factors include childhood trauma e.g researchers found that 67% of people with schizo (38% matched controls) reported at least one childhood trauma

this means that genes alone cannot provide a complete explanation for schizo.

Question 20

one strength of neural correlates of schizo is support for dopamine in the symptoms of schizo:

Answer 20

amphetamines (increase DA) worsen symptoms. antipsychotic (reduce DA) drugs reduce the intensity of symptoms

candidate genes act on the production of DA or DA receptors

this strongly suggests that dopamine is involved in the symptoms of schizo.

Question 21

one limitation is evidence for a central role for glutamate

Answer 21

post mortem scanning studies found raised glutamate in people with schizo

also, several candidate genes for schizo are believed to be involved in glutamate production or proccessing

this means that a strong case can be made for a role for other neurotransmitters in schizo, not just DA.

Question 22

biological explanations for schizo: family dysfunction

Answer 22

.

Question 23

schizophrenogenic mothers:

Answer 23

Reichmanns proposed a psychodynamic explanation for schizo by coining the term schizophrenogenic mothers (mothers who cause schizophrenia)

these mothers are cold, rejecting and controlling, and create a family climate of tension and secrecy. this leads to distrust and paranoid delusions and schizo.

Question 24

what is the Double Bind Theory

Answer 24

Bateson et al described how a child may be regularly trapped in situations where they fear doing the wrong thing, but receive conflicting messages about what counts as wrong. they cannot express their feelings about the unfairness of the situation

when they ‘get it wrong’ (often) the child is punished by withdrawal of love - they learn the world is confusing and dangerous, leading to disorganised thinking and delusions.

Question 25

what is expressed emotion?

Answer 25

The level of emotion, in particular negative emotion, expressed towards patients including - verbal criticism of the person with schizo - hostility towards them - emotional over-involvement in their life high levels of EE cause stress in the person, may trigger onset of schizo or relapse.

Question 26

biological explanations for schizo: cognitive explanations

Answer 26

.

Question 27

what is dysfunctional thought processing?

Answer 27

lower levels of information processing in some areas of the brain suggest cognition is impaired for example, reduced processing in the ventral striatum is associated with negative symptoms.

Question 28

metarepresentation leads to hallucinations:

Answer 28

metarepresentation is the cognitive ability to reflect on thoughts and behaviours this dysfunction disrupts our ability to recognise our thoughts as our own - could lead to the sensation of hearing voices (hallucination) and experience of having thoughts placed in the mind by others (thought insertion, a delusion).

Question 29

central control dysfunction leads to speech poverty:

Answer 29

Frith et al also identified dysfunction of central control as a way to explain speech poverty - central control being the cognitive ability to suppress automatic responses while performing deliberate actions people with schizo experience derailment of thoughts because each word triggers automatic associations that they cannot suppress.

Question 30

one strength of family dysfunction explanation is evidence linking family dysfunction to schizo

Answer 30

indicators of family dysfunction include insecure attachment and exposure to childhood trauma. a review by Read et al reported that adults with schizo are disproportionately likely to have insecure attachment also 69% of women and 59% of men with schizo have a history of physical abuse and/or sexual abuse this strongly suggests that family dysfunction does make people more vulnerable to schizo.

Question 31

one limitation of family dysfunction is the poor evidence base for any of the explanations

Answer 31

there is almost no evidence to support the important of traditional family based theories e.g schizo mother and double bind both theories are based on the clinical observation of patients and informal assessment of the personality of the mothers of patients, but no systematic evidence this means that family explanations have not been able to explain the link between childhood trauma and schizo.

Question 32

one strength of cognitive explanations is evidence for dysfunctional thought processing

Answer 32

Stirling et al compared performance on a range of cognitive tasks e.g Stroop task in people with and without schizo as predicted by central control theory, people with schizo took over twice as long on average to name the font colours this supports the view that the cognitive processes of people with schizo are impaired.

Question 33

one limitation of cognitive explanations is that biological explanations may be a better alternative

Answer 33

the cognitive approach provides an excellent explanation for the symptoms of schizo, suggesting it is a psychological condition however, abnormal cognition is probably partly genetic in origin and the result of abnormal brain development this means that although it has psychological symptoms, schizo is perhaps best seen as a biological condition.

Question 34

biological therapy for schizo

Answer 34

.

Question 35

typical antipsychotics: dopamine antagonists

Answer 35

- Typical antipsychotic drugs (e.g. chlorpromazine) have been around since the 1950s, which can be taken as tablets, syrup or injection - if it is taken orally it is admististered daily up to a maximum of 1000mg - They work by acting as antagonists in the dopamine system and aim to reduce the action of dopamine, they are strongly associated with the dopamine hypothesis.

Question 36

typical antipsychotics: block dopamine receptors in the synapses:

Answer 36

typical antipsychotics like chlorpromazine work as antagonists by blocking dopamine receptors in the synapses in the brain, reducing the action of dopamine initially, dopamine levels build up after taking chlorpromazine, but then production is reduced this normalises neurotransmission in key areas of the brain, which in turn reduced symptoms like hallucinations.

Question 37

typical antipsychotics: chlorpromazine also has a sedation effect

Answer 37

chlorpromazine also has an effect on histamine receptors which appears to lead to a sedation effect it is also used generally to calm anxious patients when they are first admitted to hospital.

Question 38

atypical antipsychotics: newer drugs

Answer 38

- the aim of developing newer antipsychotics was to maintain or improve upon the effectiveness of drugs in suppressing the symptoms of psychosis and also to minimise the side effects of the drugs used.

Question 39

atypical antipsychotics: clozapine acts on dopamine, glutamate and serotonin to improve mood

Answer 39

clozapine binds to dopamine receptors as chlorpromazine does but also acts on serotonin and glutamate receptors - daily dosage 300-450mg per day the drug was more effective than typical antipsychotics - clozapine reduces depression and anxiety as well as improving cognitive functioning it also improves mood, which is important as up to 50% of people with schizo attempt suicide.

Question 40

risperidone is as effective as clozapine but safer

Answer 40

risperidone is a more recently developed atypical antipsychotic. it was developed around the 1990s as clozapine was involved in the deaths of some people from a blood condition called agranulocytosis - typical daily dose of 4-8mg and a maximum of 12mg risperidone like clozapine binds to dopamine and serotonin receptors but risperidone binds more strongly to dopamine receptors and is therefore more effective in smaller doses than most antipsychotics and has fewer side effects.

Question 41

one strength of antipsychotics + CP

Answer 41

- evidence of their effectiveness Thomley et al reviewed data from 113 trials and found that chlorpromazine was associated with better functioning and reduced symptom severity compared with placebo there is also support for the benefits of atypical antipsychotics. Meltzer concluded that clozapine is more effective than typical antipsychotics and that it is effective in 30-50% of treatment-resistant cases this means that, as far as we can tell, antipsychotics work CP: most studies are of short term effects only and some data sets have been published several times, exaggerating the size of the evidence base. also benefits may be due to calming effects of drugs rather than real effects on symptoms this means the evidence of effectiveness is less impressive than it seems.

Question 42

one limitation of antipsychotic drugs is the likelihood of side effects:

Answer 42

typical antipsychotics are associated with dizziness, sleepiness, weight gain etc. long term use can lead to lip smacking and grimacing due to dopamine super sensitivity the most serous side effect is neuroleptic malignant syndrome caused by blocking dopamine action in the hypothalamus (can be fatal due to disrupted regulation of several body symptoms) this means that antipsychotics can do harm as well as good and individuals may avoid them (reducing effectiveness).

Question 43

another limitation of antipsychotics is that we do not know why they work

Answer 43

the use of most of these drugs is strongly tied up with the dopamine hypothesis and the idea that there are higher than usual levels of dopamine in the subcortex of people with schizo but there is evidence that this may not be correct and that dopamine levels in other parts of the brain are too low rather than too high. if so, most antipsychotics shouldn't work this means that antipsychotics may not be the best treatment to opt for - perhaps some other factor is involved in their apparent success.

Question 44

psychological therapy for schizo

Answer 44

.

Question 45

CBT- identify and change irrational thoughts

Answer 45

the aims of CBT in general are to help clients identify irrational thoughts e.g delusions and try to change them 5-20 sessions, individually or in a group.

Question 46

CBT - helps clients to understand their symptoms

Answer 46

clients are helped to make sense of how their delusions and hallucinations impact on their feelings and behaviour for example, a client may hear voices and believe they are demons so they will be afraid. therapist may explain that this voice actually comes from the malfunctioning speech centre in their own brain and that it cannot hurt them. this will not eliminate their symptoms of schizo but it can help them better abe to cope with them normalisation involves explaining to the client that hearing voices is just an extension of the ordinary experience of thinking in words.

Question 47

CBT - case example

Answer 47

- Turkington et al (2004) treated a paranoid client who believed the Mafia were plotting to kill him - The therapist acknowledged the client's anxiety and explained that there were other, less frightening possibilities, and gently challenged the client's evidence for his belief in the Mafia explanation.

Question 48

family therapy - reduce negative emotions

Answer 48

family therapy aims to reduce levels of expressed emotion, especially negative emotions such as anger and guilt which create stress reducing stress is important to reduce the likelihood of relapse.

Question 49

family therapy - improve family ability to help

Answer 49

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 and behaviour towards schizo a further aim is to ensure that family members achieve a balance between caring for the individual with schizo and maintaining their own lives.

Question 50

a model of practice:

Answer 50

Burbach proposed a model of practice for working with families dealing with schizo - phases 1 and 2 - share information and identify resources family can offer - phases 3 and 4 - learn mutual understanding and look at unhelpful patterns of interaction - phases 5, 6 and 7 - skills training e.f stress management techniques, relapse prevention and maintenance.

Question 51

one strength of CBT is evidence for its effectiveness

Answer 51

Jauhar et al reviewed 34 studies of CBT for schizo, and concluded that there is evidence for significant effects on symptoms Pontillo et al found reductions in auditory hallucinations. Clinical advice from NICE recommends CBT for people with schizo this means both research and clinical experience support CBT for schizo.

Question 52

one limitation of CBT is the quality of evidence

Answer 52

CBT techniques and schizo symptoms vary widely from one case to another Thomas points out the different studies have focused on different CBT techniques and people with different symptoms The overall modest benefits of CBT for schizo may conceal a wide variety of effects of different techniques on different symptoms this means that it is hard to say how effective CBT will be for treating a particular person with schizo.

Question 53

one strength of family therapy is evidence of its effectiveness

Answer 53

McFarlanne concluded family therapy is one of the most consistently effective treatments for schizo. relapse rates were reduced by 50-60% He also concluded that using family therapy is particularly promising during time when mental health initially strats to decline. NICE recommends family therapy this means that family therapy is good for people with both early and 'full blown' schizo.

Question 54

another strength is the benefits for the whole family

Answer 54

therapy is not just just benefit of identified patient but also for the families that provide and take care of people with schizo family therapy lessens the negative impact of schizo on the family and strengthens the ability of the family to give support this means that family therapy has wider beenfits beyond the obvious positive impact on the identified patient.

Question 55

management of schizo: token economies

Answer 55

Systems of secondary reinforcement used to improve the behaviour of individuals by systematically rewarding desired behaviour.

Question 56

Development of token economies:

Answer 56

Ayllon et al used a token economy in a schizo ward. a gift token was given for every tidying act. tokens were later swapped for privilidges e.g films token economies were extensively used in the 1960s and 70s. decline in the UK due to a shift towards care in the community rather than hospitals and because of ethical concerns token economies still remain a standard approach to managing schizo in many parts of the world.

Question 57

rationale for token economies:

Answer 57

- Institutionalisation develops after periods of prolonged hospitalisation - Mateson identified categories of institutionalised behaviour tackled by token economies: personal care, condition-related behaviours and social behaviour - modifying these behaviours does not cure schizo but has two major benefits.

Question 58

what are two major benefits?

Answer 58

improves quality of life - within the hospital setting ''normalises behaviour' - encourages return to more normal behaviour, making it easier to adapt back into the community e.g making your bed.

Question 59

what is involved in a token economy?

Answer 59

- tokens are given immediately to a person who has demonstrated a desirable behaviour. - target behaviours are developed on an individual basis (Cooper 2007) - tokens have no value in themselves but can be swapped for rewards e.g magazines - tokens are rewarded immediately following target behaviours as delayed rewards are less effective.

Question 60

the theory behind token economies - operant conditioning:

Answer 60

token economies are an example of behaviour modification based on operant conditioning tokens are secondary reinforcers - exchanged for rewards (primary reinforcers which are direct awarded e.g food) tokens that can be exchanged for a range of different primary reinforcers are called generalised reinforcers. these have a more powerful effect.

Question 61

one strength of token economies + CP

Answer 61

- evidence of its effectiveness Glowacki et al identified seven high quality studies published between 1999 ad 2013 on the effectiveness of token economies in a hospital setting all the studies showed a reduction in negative symptoms and a decline in frequency of unwanted behavours this supports the value of token economies CP: seven studies is quite a small evidence base. one issue with such a small number of studies is the file drawer problem - a bias towards publishing positive findings this means that there is a serious question over the effectiveness of token economies.

Question 62

one limitation is the ethical issues raised

Answer 62

professionals have the power to control peoples behaviour and this means imposing one persons norms on to others e.g a patient may like to look scruffy also restricting the availability of pleasures to people who dont dehave as desired means very ill people, already experiencing distressing symptoms, have an even worse time this means that benefits of token economies may be outweighed by the impact on freedom and short term reduction in quality of life.

Question 63

another limitation is the existence of more pleasant and ethical alternatives

Answer 63

other approaches do not raise ethical concerns e.g art therapy is a high gain low risk approach to managing schizo even if the benefits of art therapy are modest, this is true for all approaches to treatment and management of schizo and art therapy is a pleasant experience this means that art therapy might be a good alternative to token economies - no side effects or ethical abuses.

Question 64

the interactionist approach to schizo

Answer 64

.

Question 65

Diathesis-Stess Model: (vulnerability + trigger

Answer 65

schizo) = diathesis means vulnerability. stress in this context refers to negative experiences that trigger the vulnerability the diathesis stress model says both a vulnerability and a trigger are needed to develop schizo. individually may not create schizo - it is the interaction that is key.

Question 66

Meehl's model - diathesis is genetic

Answer 66

in the OG diathesis stress model, diathesis was entirely the result of a single 'schizogene' Meehl argued that someone without this gene should never develop schizo, no matter how much stress they were exposed to but a person who does have the gene is vulnerable to the effects of chronic stress (especially a schizophrenogenic mother) the schizogene is necessary but not sufficient for the development of schizo.

Question 67

Modern understanding of diathesis

Answer 67

-Now believed that diathesis is not due to a single 'schizogene'. Instead it is thought that many genes increase vulnerability. - Diathesis doesn't have to be genetic. Could be early psychological trauma affecting brain development. E.G. the hypothalamic pituitary adrenal system can become overactive, making a person more vulnerable to later stress.

Question 68

Modern understanding of stress

Answer 68

Modern definition of stress (in relation to diathesis stress) includes anything that risks triggering schizophrenia. can be psychological stress e,g parenting or biological e.g cannabis use cannabis use can increase the risk of schizo up to seven times depending on dose - probably because it interferes with the dopamine system.

Question 69

Treatment according to the interactionist model: antipsychotic medication and CBT

Answer 69

The model combines biological and psychological therapies, most commonly antipsychotic medication and CBT.

Question 70

Treatment according to the interactionist model: UK aopts more interactionist approach compared to US

Answer 70

in Britain it is an increasingly standard practice to treat patients with a combination of drugs and CBT in the US there is more of a conflict between psychological and biological models of schizo and this may have led to a slower adoption of the interactionist approach.

Question 71

one strength of the diathesis stress model is support for the dual role of vulnerability and stress

Answer 71

Tienari et al studied adopted children away from mothers diagnosed with schizo. the 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 implicated in the development of schizo but only for children with a high genetic risk this shows that a combination of genetic vulnerability and family stress leads to increased risk of schizo.

Question 72

one limiation of the OG diathesis stress modle is it is oversimplistic

Answer 72

multiple genes increase vulnerability, each with a small effect on its own - there is no one schizogene. stress comes in many forms, including dysfunctional parenting researchers now believe stress can also include biological factors. for example, Houston et al found childhood sexual trauma was a diathesis and cannabis use trigger this means that there are multiple factors, biological and psychological, affecting both diathesis and stress.

Question 73

one strength is real world application of interaction + CP

Answer 73

Tarrier et al randomly allocated 315 pts to a 1) medication + CBT group, or 2) medication + supportive counselling group, or 3) control group (medication only) pts in the two combination groups showed lower symptom levels than those in the control group - but no difference in hospital readmission this means that there is a clear practical advantage to adopting an interactionist approach in the form of superior treatment outcomes CP: Jarvis et al suggest this argument is the same as claiming that because alcohol reduces shyness, shyness is caused by a lack of alcohol, and treatment causation fallacy therefore we cannot automatically assume that the success of combined therapies means interactionist explanations are correct.