Schizophrenia: Paper 3 Flashcards

Question

Contradictory research support for inter-rater reliability A03: Classification and/or diagnosis of schizophrenia

Answer 1

Cheniaux et al (2009) found that inter-rater reliability amongst two psychiatrists was low. One diagnosed 26 out of 100 patients with schizophrenia using the DSM, and 44 out of 100 using the ICD. The other diagnosed 13 using the DSM and 24 using the ICD.

Answer 2

Research support from Buckley found that 50% of the patients diagnosed with schizophrenia also were diagnosed with depression. This is a limitation because it undermines the usefulness of diagnosis and classification systems of schizophrenia. This is because if half as many patients with schizophrenia also have severe depression it suggests that schizophrenia could be one single condition, affecting the validity of diagnosing schizophrenia.

Answer 3

Loring and Powell sent 290 psychiatrists two identical case studies, the psychiatrists changed the gender and race of the case studies to different genders and races and a control situation in which no gender or race is disclosed. The researchers found an over diagnosis of black case studies and under-diagnosis of female case studies. When the race and gender of the psychiatrist was the same, an accurate diagnosis was achieved. This suggests the existence of both gender and cultural bias in psychiatrists diagnosis of schizophrenia.

Answer 4

One biological explanation is that schizophrenia is inherited/passed on through twin studies. By comparing the concordance rates between MZ and DZ twins we can determine the likelihood of genetic inheritance of schizophrenia. If MZ twins have a higher concordance rate than DZ twins, we can determine that schizophrenia was inherited.

Answer 5

The Dopamine Hypothesis theory suggests that symptoms of schizophrenia are associated with an imbalance of the dopamine neurotransmitter across the brain.

Answer 6

Excessive amounts of dopamine (this is called hyperdopaminergia) in speech areas such as the Broca's area could lead to positive symptoms such as auditory hallucinations. WHEREAS... Lower levels of dopamine (this is called hypodopaminergia) in areas like the frontal cortex lead to negative symptoms such as avolition or speech poverty.

Answer 7

Amphetamines increases dopaminergic activity by stimulating nerve cells containing dopamine, flooding the synapse. It has been found that giving normal individuals large doses of dopamine releasing drugs such as amphetamines leads to schizophrenic symptoms such as hallucinations and delusions. Thus, amphetamines have been used to treat schizophrenics suffering from negative symptoms.

Answer 8

Antipsychotics decreases dopaminergic activity. By reducing the activity in the neural pathways of the brain that use dopamine as the neurotransmitter, this leads to the elimination of these positive schizophrenic symptoms such as hallucinations.

Answer 9

A biological approach to explaining schizophrenia, such as a genetic basis assumes that schizophrenia is inevitable, or biologically determined. Potentially making sufferers feel disempowered when diagnosed. Other more psychological approaches such as the cognitive approach has a soft determinist perspective suggesting that mental processes can be altered or managed via free will to control the disorer.

Answer 10

This has positive implications for the economy because it means patients can return to their homes, saving the NHS money on hospitalisations for schizophrenia, reducing the burden on the NHS (with already very long waiting times). It also allows patients to go back to work and contribute to the economy.

Answer 11

Explaining schizophrenia at the basic cellular and chemical level has the advantage of the scientific principle of parsimony. This has allowed for the development of antipsychotic drugs, which are the primary course of treatment for this condition. These drugs are indispensable treatment for schizophrenia and the fact that they have dramatically improved the lives of schizophrenic sufferers and their families is a real strength of the dopamine hypothesis.

Answer 12

Barlow & Durand (1995) report that chlorpromazine is effective in reducing schizophrenic symptoms in about 60% of cases. The drug blocks dopaminergic activity receptors and reduces its levels. Clearly shows that dopaminergic activity is implicated in schizophrenia because the study demonstrates that using a dopaminergic activity blocking drug like chlorpromazine is effective in treating schizophrenia in many cases.

Answer 13

This is because it is possible for people to develop schizophrenia even in the absence of a family history of the disorder. This could be through mutation in the paternal DNA in the sperm because of mutagenic agents. Brown et al found a relationship between paternal age (which is linked with an increased risk of mutation) and the risk of developing schizophrenia. He found that in men under 25 the risk was 0.7% and men over 50 was 2%. Therefore, the older the father, the higher the risk that the child develops schizophrenia, supporting the theory of the genetic explanation

Answer 14

The fact that the concordance rates are not 100% means that schizophrenia cannot be solely explained by genes and therefore the environment could have also played a role in the development of schizophrenia. This means that the biological explanation of schizophrenia does not give a full explanation of the schizophrenia disorder.

Answer 15

Alternatively, the diathesis stress model may be a more suitable explanation to explain schizophrenia as it combines both biological and psychological factors in the development of schizophrenia, providing a more holistic approach to explaining schizophrenia. This is because this explanation considers not only the development of schizophrenia determined by a biological predisposition but also the environmental stressors within an individual's lives that trigger this vulnerability, causing schizophrenia.

Answer 16

Gottesman reviewed cases of schizophrenia and found a concordance rate of 48% for MZ twins and 17% for DZ twins. This suggests that schizophrenia has a genetic aspect because MZ twins had a significantly higher concordance rate than DZ twins.

Answer 17

Leucht et al carried out a meta-analysis of 212 studies which analysed the effectiveness of different antipsychotic drugs compared with a placebo. They found all drugs tested were significantly more effective than the placebo in the treatment of positive and negative symptoms. The effectiveness suggests that dopamine does play an important role in the development of schizophrenia.

Answer 18

Kesler et al (2000) used MRI and PET scans to compare schizophrenic and non-schizophrenic participants. They found differences in dopamine levels suggesting that dopamine is an important factor in the onset of schizophrenia. This study supports the dopamine strand as the finding shows that dopamine levels are different in non-schizophrenics and schizophrenics.

Answer 19

Neural correlates are patterns of structure or activity in the brain that occur in conjunction with schizophrenia

Answer 20

Ventricles are fluid filled cavities (i.e. holes) in the brain that supply nutrients and remove waste. It has been found that the ventricles of a person with schizophrenia are on average about 15% bigger than normal (Torrey, 2002). Researchers have also found that many people with schizophrenia, particularly those displaying negative symptoms have enlarged ventricles.

Answer 21

Excessive amounts of dopamine (this is called hyperdopaminergia) in speech areas such as the Broca's area could lead to positive symptoms such as auditory hallucinations. WHEREAS... Lower levels of dopamine (this is called hypodopaminergia) in areas like the frontal cortex lead to negative symptoms such as avolition or speech poverty. Current understanding of the role of dopamine in schizophrenia is that both hyperdopaminergia and hypodopaminergia may be at work in different brain areas to produce schizophrenia

Answer 22

A neural correlates explanation of schizophrenia is an example of biological determinism as it assumes that specific brain structures and/or dopaminergic activity in the brain play a key role in the onset of schizophrenia This suggests that the dopamine hypothesis does not account for freewill and could potentially make sufferers feel disempowered when diagnosed as they feel that they cannot do anything about their illness.

Answer 23

The research evidence for neural correlates takes (as the name suggests) a correlational approach to mapping brain regions to schizophrenia which means that it lacks a cause-effect explanation There is no acknowledgement of the role of the environment to a neural correlates-based explanation of schizophrenia which means that it lacks external validity

Answer 24

One strength is that the biological explanation of schizophrenia using neural corelates uses highly scientific procedures and standardised procedures. These machines take accurate readings of brain regions such as the frontal and pre-frontal cortex, the basil ganglia, the hippocampus and the amygdale. This suggests that if this research was tested and re-tested the same results would be achieved, high test-retest reliability

Answer 25

Supporting evidence for the brain structure explanation comes from further empirical support from Suddath et al. (1990). He used MRI (magnetic resonance imaging) to obtain pictures of the brain structure of MZ twins in which one twin was schizophrenic. The schizophrenic twin generally had more enlarged ventricles and a reduced anterior hypothalamus. The differences were so large the schizophrenic twins could be easily identified from the brain images in 12 out of 15 pairs. This suggests that there is wider academic credibility for enlarged ventricles determining the likelihood of schizophrenia developing.

Answer 26

Explanations based on family dysfunction claim that schizophrenia is caused by abnormal patterns of communication within the family. It is argued that poor relationships and communication in families increase the risk of developing schizophrenia.

Answer 27

Parent gives contradictory messages by verbally communicating a message but non-verbally rejecting another message. When the child ‘disobeys’, the parent punishes the child by withdrawing their love. As a result of these mixed messages from parents, the child fears voicing objections about their unfair treatment and becomes confused and doubtful.

Answer 28

An example of mixed messages would be telling a child that they need to be more independent and then the parent becomes overprotective and critical of their child’s attempts to be independent. Bateson suggested that this upbringing affects the child’s internal reality resulting in disorganised thinking and paranoia.

Answer 29

Expressed emotion refers to communication patterns which involve high levels of negative emotion expressed to the schizophrenic patient from their carers, which contribute to schizophrenia.

Answer 30

Examples of behaviours shown by families with high expressed emotions can be: - Exaggerated involvement. This is when families indicate that the sufferer is a burden through self-sacrifice such as by reminding the sufferer what an inconvenience they are all the time. - Over-involvement in a patients life. This lack of freedom could lead to the development of positive symptoms such as hallucinations and is a major cause of relapse. Research support for Hooley found that 705 of schizophrenic sufferers from families with expressed emotion relapse while only 30% with low expressed emotions relapse when the patient returns after being hospitalised.

Answer 31

One strength of the research into expressed emotion is that it has practical applications. Family therapy has been demonstrated to reduce expressed emotion in families and to be an effective intervention for reducing relapse rates The fact that family therapy for psychosis is effective shows that psychological factors are involved in schizophrenia thus supporting the argument that family dysfunction causes schizophrenia.

Answer 32

However one limitation is that not all patients who live in high expressed emotion families relapse, and not all patients who live in low expressed emotion homes avoid relapse. Research has shown individual differences in stress response to high expressed emotional behaviour. For example, vulnerability may be physiological as one quarter of patient studies showed no physiological responses to stressful comments made by their relatives. This is a limitation because it shows that not all patients are equally vulnerable to high levels of expressed emotion within the family.

Answer 33

The family explanation for schizophrenic only deals with one aspect of the disorder (faulty communication) and in doing so it ignores the compelling evidence for the role of biology in the onset of the disorder. {insert Gottesman and Shield study as supporting evidence) This is a weakness as it fails to provide a complete explanation for schizophrenia and over emphasises the role of nurture at the expense of nature.

Answer 34

Alternatively, the diathesis stress model may be a more suitable explanation to explain schizophrenia as it combines both biological and psychological factors in the development of schizophrenia, providing a more holistic approach to explaining schizophrenia. This is because this explanation considers not only the development of schizophrenia determined by a biological predisposition but also the environmental stressors such as expressed emotion and mixed messages within an individual’s lives that trigger this vulnerability, causing schizophrenia.

Answer 35

Tienari who studied the biological children of schizophrenic mothers who had been adopted. It was found that 5.8% of those adopted into psychologically healthy families developed schizophrenia, compared to 36.8% of children raised in dysfunctional families. This suggests that the interpersonal family environment has a significant impact on the development of schizophrenia is genetically vulnerable people.

Answer 36

Butzlaff and Hooley showed using a meta-analysis of 27 studies that relapse into schizophrenia is significantly more likely in families that have issues with expressed emotion.

Answer 37

It is socially sensitive to suggest that schizophrenia is caused by the family, parents are already dealing with the difficulty of their relatives behaviour. Theorists may be adding additional stress and anxiety by making the family think they are responsible.

Answer 38

It could be that schizophrenia of the child and the associated behaviour is the cause of the family dysfunction.

Answer 39

For example, research from Ringuette and Kennedy contradicts the importance of double bind. A content analysis of letters sent to psychiatric patients from mothers had found no difference in the number of double bind communications in patients with schizophrenia compared to patients with other psychiatric conditions. Therefore, it was concluded that double bind led to poor mental health not schizophrenia and thus limits the importance of double bind communication in the development of schizophrenia opposing the argument that family dysfunction causes schizophrenia.

Answer 40

Firth’s (1979) “Attention-deficit theory” suggests that schizophrenia is due to a faulty attention system unable to filter preconscious thoughts and gives too much significance to information that would usually be filtered out, thus overloading the mind. This accounts for positive symptoms such as hallucinations and delusions.

Answer 41

Meta representation is the cognitive ability to reflect on thoughts and behaviour. This allows us insight into our own intentions and goals and interpret the actions of others. Dysfunction in meta representation would disrupt our ability to recognise our own actions and thoughts as being carried out by ourselves rather than someone else. This would explain hallucinations of voices and delusions like thought insertion (the experience of having thoughts projecting into the mind by others)

Answer 42

Central control = cognitive ability to suppress automatic responses while performing deliberate actions instead. Disorganised speech and thought disorders could result from the inability to suppress automatic thoughts and speech triggered by thoughts (faulty central control) For example, sufferers with schizophrenia tend to experience derailment of thoughts and spoken sentence because each word triggers associations and the patient cannot suppress automatic responses to these

Answer 43

Sarin and Wallin (2014) reviewed recent research relating to the role of cognitive biases and found supporting evidence for the claim that the positive symptoms of schizophrenia have their origin in faulty cognition. They found that patients with hallucinations were found to have impaired self-monitoring and tended to experience their own thoughts as voices. This research illustrates that schizophrenia sufferers have cognitive biases not present in normal controls.

Answer 44

There is a problem of causality with the cognitive approach because the approach assumes that cognitive dysfunction is the cause of schizophrenia, when it may be that schizophrenia causes the cognitive dysfunction. Therefore it is impossible to claim that the cognitive explanation is valid as we cannot establish a casual relationship because we cannot identify whether cognitive dysfunction is a cause or symptom of schizophrenia.

Answer 45

Stirling et al (2006) conducted the Stroop test on 30 patients with schizophrenia and 18 control patients. The task involved naming the ink colours without saying the word. This is difficult as there is desire to say the words that needs to be controlled. Stirling found that patients with schizophrenia took twice as long to name the colours as controls. This shows that patients with schizophrenia do have dysfunctional thought processing such as deficits in Central control tasks, supporting Firth’s ideas

Answer 46

Firth (1992) supported these ideas with biological/cognitive neuroscience studies. 30 schizophrenic patients with various symptoms had PET scans. The scans indicated a reduction in the blood flow in the frontal cortex of patients with negative symptoms like Avolition and inability to suppress automatic thoughts. Scans also showed increased activity in an area of the temporal lobe responsible for the retrieval of memories (Para hippocampal) with patients with reality distortion This suggests that there are biological differences in schizophrenics brain regions associated with theorised cognitive processes.

Answer 47

Yellowless et al. (2002) developed a machine that produced virtual hallucinations, such as hearing the television telling you to kill yourself or one person’s face morphing into another’s. The intention is to show schizophrenics that their hallucinations are not real. This suggests that understanding the effects of cognitive deficits allows psychologists to create new initiatives for schizophrenics and improve the quality of their lives.

Answer 48

As cognitive behavioural therapy can be an effective treatment this indicates that cognitive factors are involved in the disorder. The effectiveness of cognitive behavioural therapy for psychosis (CBTp) was demonstrated in the National Institute for Health and Care Excellence review of treatments for schizophrenia. This review found consistent evidence that, when compared with treatment by antipsychotic medication, CBTp was more efficient in reducing symptom severity and improving levels of social functioning. This supports the view that faulty cognition has an important causal influence in the development of schizophrenia.

Answer 49

One weakness of the cognitive model is that it is reductionist. The reason for this is because the approach does not consider other factors such as genes. It could be that the problems caused by low neurotransmitters creates the cognitive deficits. This suggests that the cognitive approach is oversimplistic when considering the explanation of schizophrenia and is not addressing the root cause (imbalance in neurotransmitters) according to the biological explanation of schizophrenia.

Answer 50

Much of the research into cognitive explanations is scientific and replicable. For example, McGuigan (1966) found that the vocal cords of patients with schizophrenia were tense during the time they experienced auditory hallucinations. This suggests that they were mistaking their own inner speech for someone else's voice. Thus supporting cognitive explanations of schizophrenia as they are high in internal validity.

Answer 51

The cognitive approach is limited because it can only explain the positive symptoms experienced by schizophrenics, but offers no explanation for negative symptoms, such as avolition. Therefore, it is likely that there are other factors that play a role in causing schizophrenia that account for the presence of the negative symptoms.

Answer 52

The interactionist approach to schizophrenia is the idea that the interaction of multiple factors cause schizophrenia. An interactionist model for schizophrenia is the diathesis stress model. The diathesis-stress model is the psychological concept that a disorder is due to the interaction between predisposed vulnerability (this is the diathesis) and an environmental trigger later in life such as stress.

Answer 53

Diathesis in schizophrenia is often considered to be a genetic vulnerability, which leads to dopamine imbalance. However, recent research now takes into consideration non genetic diathesis such as psychological trauma such as child abuse. This is thought to also influence brain development, creating a diathesis.

Answer 54

A stressor in schizophrenia refers to later negative environmental experiences such as high levels of stress. This emotional event triggers schizophrenia along with having a diathesis.

Answer 55

Combinations of CBT and drug therapies are seen as a particularly effective interactionist treatment for schizophrenia as they address both the diathesis and the trigger for the condition. Biological therapies such as drugs allow patients to reduce their symptoms so that they can engage in psychological therapies that give them skills to change their underlying faulty cognitions.

Answer 56

Gottesman found a concordance rate of 48% for MZ twins and 17% for DZ twins. This suggests a role for both biological genetic factors as the MZ twins have a higher concordance rate than DZ twins, But as the concordance rates is far les than 100% for MZ twins, this suggests that there must be some psychological experience triggered in one twin but not the other, supporting the interactionist approach.

Answer 57

Studied the biological children of schizophrenic mothers who had been adopted. It was found that 5.8% of children adopted in psychologically healthy families developed schizophrenia compared to 36.8% of children raised in dysfunctional families. This research supports the influence of biological factors, due to high rate even in psychologically healthy families, but the even higher figure for dysfunctional families suggests a psychological trigger is needed.

Answer 58

Both meta-analysis by Pharoah, and Jauhar showed that patients responded better to combination therapy (CBTp with Family Therapy) than with just antipsychotics alone. They found that these patients had lower relapse rates and less rehospitalisation in dealing with their schizophrenia. Jauhar had also found that combination therapy reduced both negative and positive symptoms. This relative success of combination therapy compared to antipsychotics alone suggests combination therapy is more effective, supporting the interactionist approach.

Answer 59

Tarrier et al had 315 patients randomly allocated to either: - Combination of drugs and CBT - Combination of drugs and supportive counselling - Control of drugs only He found patients in the two combination groups show lower symptom levels. This is a strength because it helps highlight the clear practical advantage to adopting an interactionist approach to treatment in form of superior treatment outcomes and therefore demonstrates the importance of taking an interactionist role.

Answer 60

One strength is that this approach is holistic as it recognises the compelx nature of the disorder. This is a strength because it identifies that schizophrenic patients have different triggers such as genes and therefore avoids being reductionist by not reducing complex mental disorder to a single causal factor. This means that schizophrenic patients can receive different and individualised treatments for their schizophrenia which will be more effective, because it targets the specific problem that each person with schizophrenic has and how to effectively treat it.

Answer 61

Moreover, holistic explanations appear to be impractical as they tend not to lend themselves to rigorous scientific testing and become vague and speculative as they become more complex. For example, if we accept there are many factors contributing to schizophrenia, it is difficult to establish which is most influential and which to use as a basis for therapy. Therefore, in practical terms, this complexity suggests that lower-level explanations may be more applicable when seeking solutions for real-world problems, as they allow for a more focused and measurable approach.

Answer 62

The fundamental mechanism by which a negative psychological event actually triggers a complex biological response resulting in symptoms is still uncertain. This reduces validity in the interactionalist approach as a full explanation for schizophrenia.

Answer 63

The interactionist approach may not suit all patients: some patients may have difficulty understanding or interpreting the side-effects of their drugs which CBT sessions could actually make worse with the emphasis they place on challenging dysfunctional thought processes i.e. the effects of the drug are exacerbated by the effects of the CBT

Answer 64

Using the interactionist approach may prove to be cost-effective (i.e. good for the economy) if it is more successful than other treatments as the patient will improve more quickly and is less likely to relapse, saving money on health services and getting the patient back into the workplace more quickly

Answer 65

Antipsychotic drugs also known as neuroleptics are used to control psychosis, such as hallucinations and delusions. They are taken in pill form or injected. There are two types of antipsychotics used to treat schizophrenia, typical antipsychotics (first generation), and atypical antipsychotics

Answer 66

Typical anti-psychotics (1st Gen) are drug therapies that have been used since the 1950s that have become less popular due to its severe side effects and only treating positive symptoms. Example: One example is the drug Chlorpromazine. The drugs work as dopamine antagonists, which reduce dopamine activity by blocking dopamine receptors at the synapse. This calms the dopamine system in the brain, which reduces positive symptoms such as hallucinations and delusions in schizophrenic patients.

Answer 67

Side effects: - It has a sedative effect (feelings of sleepiness) - As these drugs affect all dopamine receptors in the brain equally, they produce side effects such as dry mouth, constipation, lethargy, confusion, involuntary muscle movements

Answer 68

Atypical anti-psychotics (2nd Gen) are a drug therapy that started to be used in 1970's to avoid the more severe side effects of typical anti-psychotics. Example: Block dopamine receptors but also act on other neurotransmitters such as glutamate and serotonin. This means that antipsychotics also reduce the negative symptoms such as avolition, alongside positive symptoms.

Answer 69

Side effects of atypical antipsychotics - Weight gain, cardiovascular problems etc. - However, they are less likely to cause involuntary movements as a side-effect.

Answer 70

Leucht (2013) reviewed 212 studies in a meta-analysis on the effectiveness of biological antipsychotic drug treatments that work via normalising levels of dopamine. Treatment of symptoms with drugs was found to be much more effective than a placebo. This suggests that the effectiveness of these treatments is due to dopamine being involved in the underlying mechanisms/causes of schizophrenia, and also generally shows that these drugs are able to treat schizophrenia.

Answer 71

Bagnall (2003) meta-analysed 232 studies to compare the effectiveness of a range of atypical drugs to each other and to typical antipsychotic drugs. Bagnall found that atypical drugs were more effective than typical in treating overall symptoms, had fewer movement disorder side effects, and fewer people left the drug treatment early, suggesting that its side effects were more tolerable. However, clozapine was found to be the most effective in reducing negative symptoms and treating people who were resistant to other drugs. This suggests that atypical antipsychotics have improved treatment of people with schizophrenia.

Answer 72

Tarrier placed patients randomly into routine care (anti-psychotics) or routine care and CBT. Patients in the combined treatment had a significant improvement in the severity and number of positive symptoms as well as fewer days in hospital receiving care. This suggests that drug therapy alone is not the most effective treatment plan and an interactionalist approach to treating schizophrenia along side CBT is a better option.

Answer 73

This has positive implications for the economy because it means patients can return to their homes, saving the NHS money on hospitalisations, reducing the burden on the NHS (with already very long waiting times). It also allows patients to go back to work and contribute to the economy.

Answer 74

The use of drug treatments has resulted in the end of long-term institutionalisation in mental hospitals for those with schizophrenia. Now people can be treated at home and perhaps have enhanced quality of life as they have additional independence.

Answer 75

Drug therapies are often cheaper to prescribe than providing hospital treatment or psychological therapies such as CBT and family therapy. This means that more people can be treated with the same amount of money.

Answer 76

Drug therapies may only be suppressing symptoms and not treating the underlying problem, as symptoms quickly return when the drugs stop. There is a lack of evidence showing the long-term benefits of medication as most studies look at the short-term effects.

Answer 77

One limitation is that it has severe side effects. This is a limitation because long term use can result in tardive dyskinesia which manifests as involuntary facial movements such as blinking and lip smacking. While they may be effective, the severity of the side effects means the costs outweigh the benefits therefore they are not an appropriate treatment.

Answer 78

Both types of drugs have side effects, and due to the severity of the side effects, two thirds of people stop taking them, resulting in symptoms returning and a ’revolving door’ effect of people leaving treatment and returning when their symptoms become too serious to control.

Answer 79

Drugs are often prescribed and forcefully given to those experiencing severe schizophrenia symptoms. There are ethical issues with this as the patients cannot give informed consent. This is particularly problematic given the severe side effects.

Answer 80

- Treatment involves getting the patient to challenge their irrational beliefs about their experiences and their distorted perceptions so that they can modify their hallucinations and delusions. - It also attempts to change negative attitudes and to get them to seek help when the schizophrenic symptoms become severe rather than withdraw from society.

Answer 81

One CBT is personal therapy which focuses on the hallucinations and delusions which distresses sufferers. - Identify delusions – the therapy works on positive symptoms such as hearing voices and tries to change the perception about these symptoms feeling out of their control (hearing things for example) - Analysis and challenge of evidence on which delusions are based. Tests the reality of the evidence. For example, questions as to whether the beliefs are to be true are raised. - Helps with relaxation strategies – identify situations they found stressful and help them develop coping strategies such as relaxation. - Helps them recognise signs of relapse or when the delusions have returned.

Answer 82

CBT requires engagement from the patient, but negative symptoms like avolition may lead the patient to be unwilling to take part, or positive symptoms lead to distrust of the therapist, meaning that it may not be a practical treatment for severely schizophrenic individuals. In these cases, anti-psychotic medication can be used first to reduce the severity of the symptoms, but this would reduce the effectiveness of using CBT as a sole treatment for schizophrenic symptoms.

Answer 83

Sensky (2000) showed that patients who had resisted drug treatments had a reduction in positive and negative symptoms when treated with CBT. They also continued to improve even 9 months after treatment had ended. This suggests that psychological therapy can be effective even in cases when drugs are not.

Answer 84

A problem with CBT is that it’s a lengthy process. It requires commitment from the patient and the clinician, a suitable setting, and 6 to 12 weeks or more. It’s expensive compared to simply using antipsychotic drugs and patients often end treatment early, meaning that it is impractical for some schizophrenics.

Answer 85

Research evidence by Kingdon and Turkington (1991) found that 35 out of 65 patients with schizophrenia (54%) in a five-year follow-up were free of symptoms when normalising and standard CBT techniques were used. This evidence shows that more than 50% of patients were eventually free of symptoms, which indicates that CBT is useful in treating patients with schizophrenia. Therefore, this supports the use of CBT as a form of treatment for schizophrenia

Answer 86

Research evidence by Drury et al looked at CBT in an acute phase and found that CBT patients showed fewer psychotic symptoms at week 7 of a 12-week intervention than those in a comparison group. The CBT group average (median) stay in hospital was 49 days compared with 108 days for the comparison group which had another therapy involving activities and informal support. This is strong evidence to support the use of CBT as a form of treatment for schizophrenia as it has been proven to show improvements in patients with schizophrenia in a short amount of time.

Answer 87

However, in the long-term CBT appears to be cost effective. Elizabeth Kuipers et al. (1998) analysed the economic impact of offering CBT to individuals with schizophrenia in addition to using antipsychotic medication. The researchers reported that the costs involved in delivering CBT were likely to be offset by the reduced utilisation of service costs in the future.

Answer 88

This suggests that, although the use of CBT may initially be more costly, in the longer term those costs are likely to be recouped because the individuals with schizophrenia are less likely to need emergency psychiatric services. This has economic implications for the NHS because this money used on re-hospitalisation can be saved for other health treatments, reducing the burden on the NHS. It also allows patients to go back to work quicker and contribute to the economy.

Answer 89

CBT does not provide the side effects of drug therapies, making it a preferred treatment plan for many patients and arguably the better treatment. High face validity.

Answer 90

As there is strong evidence that relapse is related to stress and expressed emotion within the family, it seems likely that CBT should be employed alongside family therapy in order to reduce the pressures on the individual patient.

Answer 91

Family dysfunction can increase the risk of relapse of schizophrenic patients, so family therapies attempt to improve the home situation of the person with schizophrenia to reduce this risk. This is a family-centred therapy, intended to change the behaviour of the whole family, not just the person with schizophrenia and is thus a different solution to other treatments.

Answer 92

One of the main aims of family therapy is to educate the family on the symptoms of schizophrenia (psychoeducation) in order to help them to be more understanding of the patient’s behaviour.

Answer 93

The other aims of family therapy are to: - Reduce the conflict in the family by addressing anger within the family, - To reduce the stress caused by caring for the schizophrenic person, - To reduce the self-sacrifice by getting carers to consider and find ways to make time for their own needs, - To improve communication by considering how to limit expressed emotion, and by improving problem solving skills within the family by predicting problems and having solutions ready.

Answer 94

Family therapy is about improving symptoms aiding the homelife of the family, ultimately avoiding admission to amental health facility. This is not a cure for schizophrenia, but simply controls symptoms to reduce relapse and thus readmission, therefore it does not treat the root cause of schizophrenia.

Answer 95

Pharaoh et al. (2003) meta – analysis found family interventions help the patient to understand their illness and to live with it, developing emotional strength and coping skills, thus reducing rates of relapse.

Answer 96

Research suggests that a combination of drugs and family therapy may be a more effective form of treatment. A study by Anderson et al. (1991) found a relapse rate of almost 40% when patients had drugs only, compared to only 20 % when Family Therapy or Social Skills training were used, and the relapse rate was less than 5% when both were used together with the medication.

Answer 97

Leff (1985) looked at the aftercare of patients who had been hospitalised with schizophrenia. Of those provided with standard outpatient care, 50% had relapsed within 9 months, compared to only 8% of those who received family therapy. After two years this had risen to 50% of those who received the therapy and 75% of those with standard outpatient care. This suggests that family therapy is helpful in reducing readmission in the short term, however, families may not maintain positive behaviour patterns in the longer term.

Answer 98

One strength is that family therapy has economic benefits as it is highly cost effective because it reduces relapse rates, so the patients are less likely to take up hospital beds and resources. The NICE review of family therapy studies demonstrated that it was associated with significant cost savings when offered to patients alongside the standard care – relapse rates are also lower which suggests the savings could be even higher.

Answer 99

Further evidence for this comes from the Schizophrenia Commission who found that family therapy saved £1004 a patient compared to the standard over three years.

Answer 100

An explanation for lower levels of rehospitalisation could be partly because family members have been trained to help sufferers manage their medication, providing further evidence for using family therapy as an effective treatment of schizophrenia.

Answer 101

Therapy is long (often taking up to a year), meaning that patients and family may drop out part way through therapy at times of severe episodes as symptoms may get worse before they get better.

Answer 102

Lobban (2013) reports that other family members felt they were able to cope better thanks to family therapy. In more extreme cases the patient might be unable to cope with the pressures of having to discuss their ideas and feelings and could become stressed by the therapy, or over-fixated with the details of their illness.

Answer 103

Token economies are a behavioural therapy technique based on Skinner’s operant conditioning. This is learning through reinforcement of desired behaviours.

Answer 104

The tokens themselves are used as a kind of positive reinforcement. They are given as an immediate reward for patients showing a predefined target behaviour (such as washing). The tokens are then exchanged for something the patient wants such as activities or chocolate.

Answer 105

This may involve behaviour shaping, where behaviours are progressively changed, with tokens first given for small changes in behaviour leading up to the ideal behaviour. This helps reduce negative symptoms of schizophrenia such as social withdrawal (Eating and hygiene) by using token economies to modify their behaviour.

Answer 106

Therefore, this treatment is designed to produce easier to manage behaviour within the mental hospital, or to prepare long stay patients for transfer into the community.

Answer 107

Evidence by Dickerson who found when reviewing the findings of 13 studies, token economies can be effective in improving the adaptive behaviour of people with schizophrenia.

Answer 108

Treatment is not effective with severely unresponsive patients such as those with strong negative symptoms, so not allowing them to take part but letting the more mildly affected patients take part in token therapy could be seen as punishing them for the severity of their illness.

Answer 109

Some more mildly affected patients may refuse to engage in this therapy as they may find it infantilising/degrading as it is very similar in procedure to the sticker charts that small children have to encourage good behaviour, with valueless tokens used to indicate a small treat when behaviour is good, and to the clicker training that is used on dogs and other animals

Answer 110

One limitation is that token economies may not generalise beyond the hospital setting. Within a psychiatric unit, inpatients receive 24-hour care so there's better control for staff to monitor and reward patients appropriately. However, with outpatients it becomes impossible to reward the patient every time they perform a desirable act as outpatients only receives day treatment for a few hours a day. This results in a situation where the desired behaviour becomes depended on the reinforcer- if the reinforcer stops so does the desired behaviour- this is called extinction and makes relapse likely. This is a weakness of token economy as they may only be useful to change unwanted behaviour of hospitalised patients and be less useful for patients living in the community.

Answer 111

Difficulties assessing the success of studies tend to be uncontrolled. When token economy systems were introduced into a psychiatric ward, typically all patients are brought into the programme rather than having an experimental group which goes through the token economy programme and a control group that doesn't. This means that patients improvements can only be compared to their past behaviours rather than the behaviour of a control group. This comparison may be misleading as other factors (such as an increase in staff attention) may be causing the patients improvements rather than the token economy.

Answer 112

Token economies do not directly treat symptoms of schizophrenia, they only attempt to manage negative symptoms such as poor attention, poor motivation, and withdrawal.

Answer 113

The use of token economies in the treatment of schizophrenia may have unintended consequences, potentially worsening the condition if the targeted behaviours are inappropriate or unattainable for the patient. For instance, if a schizophrenic individual is rewarded only when they exhibit behaviour suggesting they are not experiencing hallucinations, they might become adept at concealing these symptoms without actually addressing the underlying issue. This could create a situation where staff may find it challenging to identify and intervene when the patient acts on hallucinations or delusions, especially if the external appearance seems normal. In such cases, the patient's ability to effectively hide their struggles might lead to situations where they carry out dangerous actions prompted by hallucinations, putting both themselves and others at risk. Therefore, token economies could have dangerous consequences because we do not know for sure if these symptoms have been adequately addressed if hidden.

Answer 114

A programme of token economy behaviour management is less potentially harmful than drug therapy so it may be more ethically valid to some extent

Answer 115

- A longitudinal (18 months) experiment in which the independent variable was tokens awarded for either positive behaviour or tokens were awarded regardless of the patients’ behaviour: both groups improved in terms of social withdrawal but overall symptoms did not change for either group i.e. a token economy has limited power in symptom management

Answer 116

One advantage of a token economy is patients becoming more independent and active, which has the knock-on effect of nurses' increased respect for the patients, leading to the patients becoming even more motivated and developing positive self-esteem. This indicates that token economies are an effective way of helping with institutionalisation which occurs when a patient has been in the hospital for a long time. Also, where token economies have been used on hospital wards they have helped to create a more healthy, safe and stable environment