Schizophrenia Paper 3

Schizophrenia
A severe mental illness where contact with reality and insight are impaired.
Diagnosis and classification of schizophrenia
Classification of schizophrenia - process of organising symptoms into categories based on which
symptoms cluster together in sufferers.
Does not have a single defining characteristics but rather a cluster of symptoms some of which appear to
be unrelated
Two major systems for classification of mental disorder = ICD-10 and the DSM-5
These differ slightly in their classification and diagnosis of schizophrenia.
DSM-5 — one positive symptom ICD-10 — two or more negative symptom
ICD-10 also recognises a range of subtypes of schizophrenia such as paranoid schizophrenia (delusions
and hallucination), catatonic schizophrenia (disturbance to movement) and Hebephrenic schizophrenia
(negative symptoms).
Positive Symptoms Additional experiences beyond those of ordinary existence, such as hallucinations.
Hallucinations: unusual sensory experiences. Some related to environment and some not (voices heard).
Delusions: also known as paranoia, are irrational beliefs. Common delusions include being an important
historical, political or religious figure such as Jesus or Napoleon. It also involves being persecuted; by
government or alien or for having super powers. Delusions can make suffer behave differently that makes
sense to them and not anyone else because they believe someone else ins in control of them.
Negative Symptoms Involves loss of usual abilities and experiences.
Avolition: finding it difficult to begin or keep up with goal related activity. Reduced motivation to carry on.
Three sings of avolition; poor hygiene, lack of persistence in work or education and lack of energy.
Speech poverty: Changes in patterns of speech. It is negative symptom as it is reduction in amount and
quality of speech.
Evaluation
Reliability Means consistency. An important measure of reliability is inter-rater reliability, the extent to
which different assessors agree on their assessment. In the case of diagnosis - the extent to which two or
more mental health professionals arrive at the same diagnosis. Cheniaux et al has two psychiatrists
independently diagnose 100 patients using both DSM and ICD criteria. Inter-rater reliability was poor, one
diagnosed 26 with schizophrenia according to DSM and 44 according to ICD whereas the other was 13 and
24. Shows weakness in diagnosis of schizophrenia.
Validity- extent to which we are measuring what are intended to measure. There are a number of validity
issues to consider. One way to assess validity of diagnosis is criterion validity - do different assessment
systems reach the same diagnosis for the same patient: poor validity.
Co-morbidity -The phenomenon where two or more conditions occur together. Schizophrenia is commonly
diagnosed with other conditions such as depression and post traumatic stress disorder. This poses a
challenge for both classification and diagnosis of schizophrenia.
Symptom overlap -There is considerable symptom overlap between schizophrenia and other conditions
like bipolar disorder which both include symptoms such as delusions and avolition. This again questions the
validity of both the classification and diagnosis of schizophrenia.
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Biological explanations for schizophrenia
Genetic basic of schizophrenia
Schizophrenia runs in the family. It isn’t strong evidence for a genetic link as family members share genes
but also aspects of their environment. However, twin studies can illustrate the likelihood of genetics
influencing schizophrenia as identical twin shares 100% of the same DNA. If your identical twin has
schizophrenia, you have a 48% chance of developing it compared to fraternal twins - 17%.
Candidate genes. Individual genes are believed to be associated with the risk of developing
schizophrenia. Schizophrenia is polygenic - requires a number of factors to work in combination. Risk of
Schizophrenia is 1%.
The dopamine hypothesis
Neurotransmitters - The brain’s chemical messengers appear to work differently in the brain of a patient
with schizophrenia. Dopamine is believed to be involved - it is important in the functioning of several brain
system that are implicated in the symptoms of schizophrenia.
Hyperdopamineragia in the subcortex - original version of hypothesis focused on the possible role of
high levels or activity of dopamine in the subcortex (central areas of the brain). E.g excess dopamine
receptors in Broca’s area may be associated with poverty of speech or auditory hallucinations.
Hyperdopamineragia in the cortex - more recent version of hypothesis have focused on abnormal
dopamine systems in the brain’s cortex. Psychologists have identified a role for low levels of dopamine in
the prefrontal cortex in the negative symptoms of schizophrenia.
Neural correlates of schizophrenia- Measurements of the structure or function of the brain that correlate
with an experience. Both positive and negative symptoms have neural correlates.
Neural correlates of Negative symptoms: one negative symptom is avolition - loss of motivation.
Motivation involves loss of anticipation of reward. Ventral striatum is particularly involved in anticipation.
Neural correlates of positive symptoms: reduced activity in superior temporal gyrus and anterior
cingulate gyrus is a neural correlate of auditory hallucinations.

Evaluation
Multiple sources of evidence for genetic vulnerability- adoption, family and genetic linkage studies all
point to a role of genetic makeup in vulnerability in Schizophrenia supporting biological explanations.
Mixed evidence for the dopamine hypothesis- as predicted, some research shows some dopamine
agonists make symptoms worse and antipsychotic drugs are dopamine antagonists. However some genes
associated with vulnerability to schizophrenia code for unrelated chemicals.
The correlation-causation problem- neural correlates of schizophrenia don’t show whether they cause it.
Other factors could well be involved.
Role of mutation- positive correlation between paternal age and risk of Schizophrenia supports existence
of a genetic basis.
Role of psychological environment is important yet unclear- appears to be an important role for the
psychological environment which suggests biological explanations for Schizophrenia aren’t complete.
 Schizophrenia Paper 3
Psychological explanations for schizophrenia
Family dysfunction- Psychologists have tried to link Schizophrenia to childhood and adult experiences of
living in a dysfunctional family.
The schizophrenogenic mother: Fromm-Reichmann - proposed an explanation for S based on accounts
she heard from her patients about their childhood. FR noted that many of her patients spoke of a particular
type of parent called schizophrenogenic mother; cold rejected and controlling, tends to create a family
climate characterised by tension and secrecy. This led to distrust, then paranoid delusions and then S.
Double-bind theory: Family climate is important in the development of schizophrenia but emphasises the
role of communication style within the family. The developing child regularly finds themselves trapped in
situations where they fear they are doing the wrong thing but receive mixed messages about it and feel
unable to comment on the unfairness of the situation or seek clarification. When they get it wrong, which is
often, they are punished by withdrawal of love which leaves them confused and understands the world as
dangerous leading to delusions or disorganised thinking.
Expressed emotion and Schizophrenia: EE is the level of emotion, in particular negative emotion
expressed towards a patient by their carers. It has several element; verbal criticisms, hostility and needless
self-sacrifice. This is a serious source of stress for the patient and an explanation for relapse in patients
with Schizophrenia. It can also trigger the onset of schizophrenia in vulnerable persons.
Cognitive explanations - focuses on the role of mental processes. Schizophrenia is associated with
several types of abnormal information processing and can provide explanations for Schizophrenia as a
whole. Schizophrenia is characterised by disruption of normal thought processing. We can see it in many of
its symptoms - page before.
Frith et al - two kinds of dysfunctional thought processing that could underline symptoms
Metarepresentation = ability to reflect on thoughts and behaviour. This allow us insight into our own
intentions and goals. It also allows us to interpret the actions of others. Dysfunction in M.. would explain
hallucinations of voice and delusions.
Central control = cognitive ability to suppress automatic responses while we perform deliberate actions.
Disorganised speech and thought disorder could result from inability to suppress automatic thoughts and
speech.
Evaluation
Support for family dysfunction as a risk factor- a large proportion of patients report childhood sexual
abuse- Read et al, or insecure attachment (Berry et al). This supports the link between upbringing and
Schizophrenia- however most evidence is retrospective lacking validity,
Weak evidence for family-based explanation- little or no direct evidence for the schizophrenogenic
mother or double bind theory. Family based explanations may encourage blaming of parents whose
children develop Schizophrenia.
Strong evidence for dysfunctional thought processing- Stirling et al- patients with Schizophrenia took
longer to complete the Stroop task, showing cognitive impairment. However, doesn’t tell us about the origin
of symptoms.
Evidence for biological factors isn’t adequately considered- strong support for biological explanations
challenge value of psychological explanations. However it does seem likely Schizophrenia has important
biological and psychological factors.
Direction of causality- there is no clear evidence for the direction of causality between cognitive and
biological factors.
 Schizophrenia Paper 3
Biological therapies for schizophrenia: Drug Therapy
Drug therapies- most common treatment for schizophrenia involves the use of antipsychotic drugs. Taken
as tablets or form of syrup. Also available in injections. Could be for long term or short term use.

Typical antipsychotics- Includes Chlorpromazine (taken as tablets, syrup or injections).

There is a strong association between the use of typical antipsychotic drugs like Chlorpromazine and the
dopamine hypothesis. It works as an antagonists, a chemical which reduce the action of a
neurotransmitter. It blocks dopamine receptors in the synapses of the brain, reducing action of dopamine. It
initially increases its level but then its production is decreased. It normalises neurotransmission in key
areas of brain thus reducing symptoms. It is also an effective sedative. It calms patients.

Atypical antipsychotics- Aim of developing newer drugs was to maintain or improve upon the
effectiveness of drugs in suppressing the symptoms of psychosis and minimise side effects. There are a
range of atypical drugs and they don’t all work the same way. Clozapine - was less used as some patients
developed a blood condition but brought back as treatment for Schizophrenia. It binds to dopamine
receptors but acts on serotonin and glutamate receptors. This helps improve mood and reduce depression.
Not available as an injection due to side effects. Risperidone - Binds to dopamine and serotonin receptors.
Binds stronger than clozapine and is therefore effective in much smaller doses. Leads to fewer side effects.

Evaluation
Evidence for effectiveness- There is a large body of evidence to support the idea that both typical and
atypical antipsychotic drugs are at least moderately effective in tackling symptoms of schizophrenia.
Thornley et al: reviewed studies comparing effects of Chlorpromazine to control conditions in which patients
received a placebo. Data from 13 trials showed that Chlorpromazine was associated with better overall
functioning and reduced symptoms severity. Relapse rate was also lower.
Serious side effects - Typical antipsychotic drugs are associated with dizziness, agitation, sleepiness, stiff
jaw and weight gain. Long term- involuntary facial movements. Also high temperatures, delirium and
comas. As typical doses declined, this has become rarer. Atypical antipsychotic drugs: Clozapine = blood
condition.
Problems with the evidence for effectiveness Although there is mass amounts of evidence for the
effectiveness of these drugs, there are been some challenges to their usefulness. Healy argue that some
successful trials have had their data published many times exaggerating the evidence for positive effects.
Healy also suggests that because antipsychotic drugs have powerful calming effects, it is easy to
demonstrate that they have some positive effects on patients - it is not the same as saying it reduce the
severity of the psychosis.
The chemical cosh argument It is widely believed that antipsychotic drugs are used in hospitals to calm
patients and make it easier for staff to work with them rather than for benefits of patients. It could be
considered unethical as it is effectively controlling their behaviour and dehumanising them.
 Schizophrenia Paper 3
Psychological therapies for schizophrenia

Cognitive behaviour therapy Involves helping patients identify irrational thoughts and trying to change
them. This may involve argument or a discussion of how likely the patient’s beliefs are to be true.
Patients can be helped to make sense of how their delusions and hallucinations impact on their feelings
and behaviour. Just understanding where the symptoms come from can be helpful for patients.
Family therapy takes place with family members rather than individual patients aiming to improve the
quality of communication and interaction between family members. There are a range of approaches; some
psychologists see the family as the cause of the problem whilst others are more concerned in reducing
stress within families which could contribute to relapse in patients. Family therapy aims to reduce
expressed emotions.
A range of strategies by which family therapists aim to improve functioning to a family:
Form therapeutic alliance with all family members
reduce stress of caring for a relative with schizophrenia
reduce anger and guilt in family members
help balance their own lives and caring for patient.
These strategies work by reducing levels of stress and expressed emotions.
Token economies
Reward systems used to manage the behaviour of patients with S, especially those who developed
patterns of maladaptive behaviour through spending long hours in psychiatric hospitals. In such
circumstances, it is common for patients to develop bad hygiene and remain in pyjamas. Modifying such
habits won’t cure Schizophrenia but improves patients quality of life.
Token - discs given to patients when they carry about desirable behaviour - reinforcement.
Rewards - tokens can be swapped for tangible rewards. Acts as secondary reinforcement.

Evaluation
Treatments improve quality of life but do not cure All psychological treatments aim to make
schizophrenia more manageable in some way improving their quality of life. Whilst these things are worth
doing, they do not cure schizophrenia.
Ethical issues Token economy systems have proved controversial. The major issue is that privileges,
service and so on become more available to patients with mild symptoms and less so for those with severe
symptoms of Schizophrenia that prevent them from complying to desirable behaviours. This means most
severely discriminated patients suffer discrimination.
Alternative psychological treatments There are other treatment options that are available such as art-
therapy which can help symptoms such as isolation and social withdrawal. This allows patients to express
their feelings through a different medium than talking therapy, especially useful for those with
communication difficulties. It is unlikely that one type of therapy will address all the symptoms involved in
Schizophrenia
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Interactionist approach
An approach that acknowledges that there are biological, psychological and societal factors in the
development of schizophrenia.

The diathesis-stress model says that both a vulnerability to schizophrenia and a stress trigger are
necessary in order to develop the condition. One or more underlying factors make a personal particularly
vulnerable to developing schizophrenia but the onset is triggered by stress,
Meehl’s model - in original DS model, vulnerability was entirely genetic, the result of a single ‘schizogene’.
This led to development of a biologically based schizotypic personality (one characteristic is sensitivity to
stress). Meehl claims that if a person does not have the schizogene, then no amount of stress would lead
to schizophrenia.
The modern understanding of diathesis - one way our understanding of diathesis has changed is that it
is now clear that many genes appear to increase genetic vulnerability, not a single schizogene. Modern
views of diathesis also includes a range of factors beyond the genetic, including psychological trauma so
trauma become the diathesis rather than the stressor.
The modern understanding of stress - in original model, stress was seen as psychological in nature, in
particular relating to parenting. Although psychological stress, including that resulting from parenting may
still be considered important, a modern definition of stress includes anything that risks triggering
Schizophrenia such as cannabis.
Treatment according to the interactionists model compatible with both biological and psychological
treatments. The model is associated with combining antipsychotic medication and psychological therapies,
commonly CBT. Psychologists claims that it is perfectly possible to believe in biological causes of
schizophrenia and still practise CBT to relieve symptoms. However it does require adopting the
interactionist model. Britain - combination of both used.

Evaluation
Original diathesis stress model is too simple- The classic model of single schizogene and schizophrenic
parenting style as major source of stress is known to be simple. Multiple genes increase vulnerability to
schizophrenia, each having a small effect of its own. Also stress can come in many forms. Therefore
vulnerability and stress do not have one single source. Now vulnerability can be result of early trauma as
well as genetic makeup and stress can come in many forms including biological. Study found childhood
sexual trauma as vulnerability factors and cannabis as trigger.
Support for the effectiveness of combinations of treatments Tarrier et al - 315 patients were randomly
allocated to a medication or CBT group, medication and supportive counselling or control group of
medication only. Patients in first two groups showed lower symptom levels than those in control group.
We don’t know exactly how diathesis and stress work There is strong evidence to suggest that some
sort of underlying vulnerability coupled with stress leads to Schizophrenia. We also have well informed
suggestions for how vulnerabilities and stress may lead to symptoms but we do not fully understand
mechanisms by which the symptoms of S appear and how stress and vulnerability produce them.
Incomplete understanding- we don’t understand the mechanisms by which symptoms of schizophrenia
appear and how vulnerability and stress affect them.