Clinical Psychology 6 CLINICAL PSYCHOLOGY ‘A. Figure 6.1 The vibrant city of Rio, home of the study of by Cappi eal. on obsessive compulsive disorder [see page 344) Psychology is everywhere, and these are the colourful homes of the people of Rio de Janeiro, in Brazil, ne ofthe world's biggest and mast beautiful cities. This chapter includes various compulsory studies conducted in countries including Croatia (Orué etal 1997), the UK (Freeman et al, 2003; Lovell et al, 2006) and the USA (Chapman and DeLapp, 2013; Grant et al, 2008), but you will also learn about many other pieces of research to help you to evaluate the concepts, theories, treatments and therapies covered in this option, For example, on page 344, you will learn about an experiment conducted by Cappi etal (2014), in Brazil. The researchers found differences ina gene called OXTR between people with obsessive-compulsive disorder and healthy controls. This gene codes for oxytocin receptors, a hormone linked toa variety of psychiatric disorders.KEY TERMS: ‘schizophrenia coe pesitv symptoms ‘Negative symptoms. 6.0 Introducing Clinical Psychology What is Clinical Psychology? Clinical psychologists work with people with a wide range of mental and behavioural disorders. The job involves assessment and diagnosis using classification manuals such as tie International Statistical Classification of Diseases and Related Health Problems (ICD-11), published by the World Health Organization (WHO, 2018) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, published by the American Psychiatric Association (APA, 2013). These are the main two classification manuals used around the world and they contain hundreds of different disorders, each with detailed descriptions of signs and symptoms that can be used to holp make a diagnosis. Some countries have their own culturally relevant classification systems ~ for example, the Chinese Classification of Mental Disorders (CCMD-3), published by the Chinese Society of Psychiatry (CSP). You wil discover this is an important consideration as behaviours that may seem normal in one culture may not bein another. This can make it difficult to make useful and meaningful diagnoses if behaviour, thoughts and feetings are compared with norms and standards developed in other parts of the world. This helps to explain why clinical diagnosis isso controversial as although advances are being made every day with regard to blological markers, as yet there are no objective tests for any of the disorders discussed in this chapter. Therefore, diagnosis relies upon observation and self-report, including standardised psychometric tess (see page 186) to help determine the severity af symptoms and the effect they ae having onthe persor’s daily functioning and quality of ite Once a person has been diagnosed, this can open up options for treatment, including options based on the biological approach, such as drugs and electroconvulsive therapy (ECT), and psychological therapies based on theories from the cognitive and learning approaches. You will discover that there are many alternative explanations of each of the disorders, both biological and psychological, and each explanation has led to the development of different treatments and therapies. Careers in Clinical Psychology ‘Tf you would like to take your studies of Psychology beyond A Level and are interested in the field of Clinical Psychology, the first step to becoming a clinical psychologist in the UK is. ‘an undergraduate degree in Psychology, accredited by the British Psychological Society, or ‘a Master’ Level conversion course. This will allow you ta become a Chartered Member of the British Psychological Society, the first step to becoming a clinical psychologist. Next, you will need to gain a Doctorate Level degree in Clinical Psychology that has been approved by ‘the Health and Care Professions Council (HCPC). Once this has been achieved, you will have tthe right to use the approved title ‘clinical psychologist’ In order to get onto a Doctorate Level course, you are likely to need relevant work experience as an assistant psychologist or esearch assistant, although other work ‘experience in the caring occupations will also help you to gain insight and develop relevant skills and qualities to work in this area, For further information, visit https://careers.bps.org.uk/area/clinical, 6.1 Schizophrenia 6.1.1 Diagnostic criteria for schizophrenia ‘ABo}OYaASe je21UND BuIINPOSUI O'95 3 3 = g g & z 3 METHODOLOGY case studies generalisations from findings Some of you may know what it is like to live with a diagnosis of schizophrenia, as this disorder affects as many as 1 per cent of people across the world. If not, try to imagine what it might be like and how it might affect your everyday life, including your relationships with friends, family, teachers or your employer. How are people with disorders such as schizophrenia viewed in the culture where you live? ICD-11 only requires a person to have had symptoms for one month before a diagnosis can be gained. On the one hand, this can be considered a strength, but can you think of any reasons that it might also be a weakness? Which type of delusion do you think the woman in Figure 6.2 is suffering from? ‘A. Figure 6.2 Evenin the face of conflicting evidence, individuals who are delusional refuse toabandon their beliefs Diagnostic criteria (ICD-11) Schizophrenia isa psychotic disorder, meaning people with this diagnosis sometimes lose contact with reality. Tey find It difficult to tll the difference between real and imagined experiences and may not seek help as they Lack insight into their condition, According to the 1CD-1, schizophrenia should be diagnosed if a person shows atleast one of the core symptoms (see below) for at least one month. Two symptoms may be necessary in less clear-cut cases. Other causes ofthe symptoms must be eliminated before a diagnosis is rade — for example, substance misuse, side effects of medication or an underlying physical condition, such 2s a brain tumour. The ICD-11 categorises symptoms into six dimensional descriptors (Reed eta, 2018), each rated on a four-point scale (not present, mild, moderate and severe) The dimensions inelude positive and negative symptoms, as well as symptoms relating to mood, cognition and behaviour Positive symptoms Positive refers to the presence of psychological abnormality as opposed to the absence of something we might consider to be hormal (oegative symptoms) The core positive symptoms Of schizophrenia are outtned below. Hallucinations These are involuntary perceptual experiences that happen in the absence of external stimuli. This means people with schizophrenia may see or hear things that others cannot, and they have no control over this. Hearing voices is a core symptom of schizophrenia, but hallucinations can also be visual, olfactory (smell) and somatosensory (touch).Experiences of influence, passivity or control This refers to the subjective experience that our thoughts, feelings and actions are being controlled by externa forces, ICD-11 refers to these unusual feelings as experiences, noting that delusional belies may develop as a way of explaining them. For example, we believe aliens are implanting thoughts into our brains because we fel that our thoughts do nat belong to us. » Thought withdrawal - the feeling that thoughts are being removed. » Thought insertion - the feeling that thoughts are being implanted. » Thought broadcasting - the feeling that thoughts are being transmitted to others. Delusions Delusions are fixed beliefs that conflict with reality. While some delusions relate to everyday situations, such as believing you are being monitored by the police, delusions can also be more bizarre, such as beliaving aliens are recruiting people to populate a new universe There are many different types of delusion, including: >» grandeur ~ the person may see themselves as exceptional in some way (e.g. having superhuman powers or abilities) »> persecution ~ the person may believe that other people want to harm them and may believe they are being spied on, followed or tricked (see page 236 for Key study: Freeman et a., 2003') » reference ~ the person may believe that situations or events have personal significance (meaning), such as they are being given a sign about how to behave ar about what is {going to happen in the future. Before a person is diagnosed with schizophrenia, weaker versions of the core symptoms may be shown. These are called prodromal symptoms. For example, a person with persecutory ideation may hold false beliefs but they are not as strong - for example, thinking people might have been talking about you versus being convinced they were talking about you, Other positive symptoms Other positive symptoms include disorganised thinking: people may often lose their ‘train ‘of thought’ (also known as derailment). This can lead to incoherent (muddled) speech and ‘word salads, where ideas become jumbled. The person may also create neologisms, where new words are created by mixing words together. Behaviour may also be disorganised, meaning actions, gestures and postures may be unexpected, inappropriate or apparently purposeless. Negative symptoms ‘As noted above, negative refers to an absence of thoughts, feelings or behaviours that would generally be considered psychologically normal. For example, people with schizophrenia sometimes experience flat affect, meaning they do not experience typical emotional highs and lows. They may experience avolition, which means they are not able to carry out goal- directed behaviours, like getting ready to go out or organising the ingredients to cook a meal. Other examples of negative symptoms include alogia (lack of spoken language), asociality (social withdrawal) and anhedonia (inability to experience pleasure). Age of onset The prevalence of schizophrenia i similar for males and females (about 0.3-0.7 per cent), but the age of onset is usualy earlier for males (early to mid-20s) compared with females (late 203) Late anset (ie. from age 40) Is more common in females. This disorder is rarely diagnosed in children under the age of 13 as the symptoms can overlap with various other disorders, such as autism and obsessive-compulsive disorder. This can make diagnosis, cult and unreliable. In some cases, the diagnosis is more obvious, as with the 14-year-old boy in the study by ‘Aneja et al. (2018), who shows clear symptoms and features ofthis disorder. ‘euasydoziy9s 195 3 3 = e a & z 3 Focus on: Aneja et al. (2018): A case study of schizophrenia Dr Jitender Aneja is an Associate Professor of Psychiatry in AIINS, Bathinda, India. Intrigued by human behaviour since high school, he was further inspired while working with children and their families during his undergraduate training, subsequently establishing child psychiatric units across Northern India To bring a change in others, change is essential within oneself. Every peroon hae a unique A Figures.3 (Q. Aneja, personal communication, 2021) CASE HISTORY ‘The boy came froma troubled home with an aggressive father. When he was ten, his parents divorced and he began living with his grandparents. His schoolwork suffered and by 12 he was not attending school at all. He was irritable, sad and often got into trouble for fighting. SYMPTOMS © Hearing voices that teased him © Poor sleep and self-care © Suspicious of his mother © Preferred to be alone, away from other people Muttered, laughed and shouted at unseen others Lack of insight into his condition © Spoke very little TREATMENT He was given sodium valporate, a drug often used ‘and violent outbursts increased, and he was often to treat bipolar disorder (see page 260). His mood ‘admitted to hospital, for his own safety. We will return and behaviour improved for a while but soon got to this case on page 251 when we consider the range worse again. Eventually, he was diagnosed with very- of antipsychotic medications for the treatment of early-onset schizophrenia IVEOSI. His aggressive schizophrenia Evaluating Aneja et al. (2018) One strength of this study is the detalled case history. The information about the boy's schoolwork and home life suggest that he displayed prodromal (before onset) symptoms, such as loss of interest, social withdrawal and lack of self-care. This sort of in-depth, contextual information fs very helpful as it can increase the validity of a schizophrenia diagnosis, which can be difficult, especially in the case of someone of this age. © | tree stay focuses on a4 year child Can you think of any practical or ethical considerations relating to the use of children in psychological research that vwould have been relevant to Aneja eta ‘when conducting and reporting this case study? A. Figure 6.4 Aneja’s patient was admitted to hospital multiple times ‘A weakness of this study is that it only focuses on one child who may not represent the experience of children who hear voices in ather cuttures. The study took place in India where there is a lot of stigmatisation of people with mental health disorders (Thomas, 2018). This could mean that the family faced prejudice and lack of community support. This could have made the child's condition worse due to family stress. This is important as it means the findings may not generalise to VEOS in other cultures.@ Evaluating the diagnostic criteria ISSUES AND DEBATES Use of children in psychological research ne issue relating to this case study is that itfocuses on the experiences ofa 14-year-old child The boy would not be able to provide his own informed consent due tohis age and therefore his mother would have needed to give proxy consent for his participation in Dr Aneja's sessions and also for him to write up and publish the case study. This said, children are typically also asked for their consent and the study would not have taken place without the ‘boy's cooperation. When working with children as participants, researchers must find ways to-adapt the information they provide about their studies to make it as accessible as possible tothe children and help them to understand what willbe required in order to that they can make a decision about whether they would like to take part, what it means to have the right to withdraw and how their data willbe stored and be used. Children with mental health difficulties are highly vulnerable and theie rights and welfare are ofthe utmost importance. Applications to everyday life AA strength of the ICD-11 is that people only need to display symptoms for one month; other classification systems, such as the DSM-5, require a duration of six months before a firm diagnosis can be obtained, This is a strength as it means people should be able to ‘access treatment more rapidly. This is important because early treatment is correlated with better outcomes (Patel etal, 2014). Another strength of ICD-11 is the removal ofa set of subtypes that were previously used to classify schophrenia [e.g paranoid, catatonic, hebephrenic). These subtypes were based con the primary symptoms that a person displayed, but diagnoses were often unreliable {as symptoms often change overtime. ICD-I1 replaces the subtypes with the dimensional descriptors, meaning the doctor rates each of the different categories of symptoms: ‘according to their severity, This means people are likely ta receive a more reliable diagnosis that wilt help them to access the treatment that they require ‘Aweakness of the ICD-11 is that schizophrenia can be difficult to diagnose due to ‘symptam overlap. For example, catatonia and hallucinations may be experienced by people with depression but can be caused by drug withdrawal, stress and sleep deprivation. This means different clinicians may give different diagnoses depending on whether they cuccassfully eliminated ather disorders er physical causes for the person's symptoms. This decreases the reliability of the diagnosis of schizophrenia Cultural Differences ‘further weakness is the subjective nature of some of the symptoms, meaning clinicians may find it difficult to diagnose people from cultural backgrounds that differ from their own. For example, in Maori culture, matakites are visionaries [prophets] who hhear voices and these people are highty respected in the community [Lakeman, 2001). In Western cultures, the experiance of hearing voices is seen as pathological fa sign of illness), and this could lead to wrongful diagnosis. LEARNING LINK ‘The study by Aneja etal. focuses on the experiences of a 14-year-old boy. Think back to your AS Level studies: can you remember another case study that focused on a child participant who was also referred for support for his mental health? What similarities, ‘and differences are there between these two ease studies? ‘euasydoziy9s 19STUDY TIP “The case study by Aneja et al. is an example ofthe idiographic approach in Clinical Psychology, The ICD-i1 encourages both idiographic and nomothetic spproaches as. data about symptoms is gathered through a clinical interview regarding the individual's experiences lidiographie) but the clinician also rates each ofthe six dimensional descriptors on a four-point scale Inomotheticl. This approach could help psychologists to ‘make generalisations about the type of symptoms that are more common in people with differing ages of onset, for example TEST YOURSELF Viratis 14 and has been diagnosed with schizophrenia. He used to love football and attended a weekly youth elub. Explain how two diagnostic criteria relevant to this, disorder might affect Virat’s ability to participate in his usual clubs and activities. [4] Explain one weakness ofthe diagnostic criteria for schizophrenia. ta 3 2 Withreference to one research study, describe the diagnostic criteria (ICD-11] of schizophrenia, to b_ Evaluate the diagnostic criteria (ICD-11) of schizophrenia, including a discussion of idiographie versus nomothetic. tno Outline two features of the case study as.a research method for investigating schizophrenia a Semi-structured interviews are often used as part ofthe diagnosis of schizophrenia. Explain how interviewer bias could affect the validity ofthe data that is obtained. [4] Laila is examining the medical records of @ large sample of adutts with schizophrenia. She plots a graph to display the relationship between age of onset {and cognitive impairment. identify an appropriate type of graph for Laile's data, {Il 6 CLINICAL PSYCHOLOGY Key study: Using virtual reality to investigate persecutory ideation - Freeman et al. (2003) KEY TERMS: persecutory ideation virtual reality Which three items from the Brief Symptoms Inventory were positively correlated with persecutory ideation in the virtual library? Have you ever got the feeling that other people are talking about you? How might this affect how you interact and what you think and feel about these people?Freeman et al. (2003) did not tell their participants anything about the virtual ‘environment they were about to enter. This could be seen as both a strength and a weakness of the procedure. Why? Virtual reality fern virtual reality (VR) experiences are delivered via headpiaces which project individual digital images, separately to each eye. The images update at a rate of 60 frames per second to present a dynamic, immersive and three-dimensional virtual scene. Even the slightest movement of the head causes the scene to update. This creates the illusion of being physically present within the digital environment. The quality ofthis illusion relies heavily on the extent to which there is a match between body movements and the sensory information provided by the software though, so some VR experiences are more believable than others. ‘euasydoziy9s 19 © Have you ever experienced any sor of virtual reality? How did it feel? Did you get the sense of being present nthe vital werld? AIMS AND HYPOTHESES: This study examined whether neutral, non-threatening avatars could provoke persecutory thoughts in people with no previous clinical diagnoses and whether this was more common in people with higher levels of paranoia and emotional distress, METHODOLOGY This was a correlational study based on quantitative data gzthered via questionnaires. Qualitative datawas also SAMPLE ealetedinsemstructured iteraws,whichwers ater Twelvemale ae wele female pid alurters (mean Rae 4 age = 26] were recruited rom University College, London, a in the United Kingdom. All were mentally well. Twenty- one were students and three were administrative staff PROCEDURE First, participants were trained in how to use VR position and orientation and a handheld joystick which equipment, including lightweight headgear to track head allowed the participant to move around the virtual space.3 g Z 3 5 & a z a Next, half the participants completed the Brief Symptom Inventory (BSI), a 53-item questionnaire fo assess mood, ‘anxiety and psychotic symptoms in the last seven day, plus ‘two 20-item self-reports: the Spielberger State Anxiety Questionnaire and the Paranoia Scale [Fenigstein and Venable, 1992), which measures ideas of persecution and reference. Next, all participants completed the virtual reality task exploring a Veta library, where five avatars satin two small groups (a three anda pair), occasionally siting, ooking over ‘and talking to one another. Participants wore aed to Expiore the raom and try tofarm some impression of what you think about the people inthe room and what they think about you. Five minutes later, all participants ‘exited the room’ and completed the questionnaires outlined above (half of them for the second timel. They also completed the 15-iter \VR-Paranoia questionnaire [Table 6.11, which measured persecutory thoughts, ideas of reference and positive beliefs about the avatars. This was a new questionnaire, designed due to the lack of any pre-existing test of situation- ‘specific paranoia. Finally, participants were interviewed ‘about their experiences, including any feelings of distress. Later, a clinical psychologist watched the videotaped interviews and rated them out af six or indications of ppersecutory ideation - thats, their tendency to assume that other people were talking about them or out to hurt them. RESULTS ce ‘The mean paranoia score was 31.8 [minimum score 20, ‘maximum 100) with no significant difference between male ‘and females. This was relatively low compared with the mean of 42.7 ina previous study (Fenigstein and Vanable, 1992], Most people had positive beliefs sbout the avatars, but some endorsed more negative beliefs Table 6.2), Persecutory thoughts items 1-5 ofthe VR-Parancia questionnairel were positively correlated with ideas of Feference [items 6-10) end negatively correlated with 'Y Table 6. tems in the VR-Parancia questionnaire They were hostile towards me. They would have harmed me in some way if they could, ‘Someone in the room had it in for me. They were trying to make me distressed. They had bad intentions towards me. They were talking about me behind my back. They were saying negative things about me to each other. They were watching me. They were looking at me critically They were laughing at me. They were friendly towards me. They were pleasant people They were trustworthy. They hed kind intentions towards me. felt very safe in their company. positive beliets. There was a positive correlation between persecutory thoughts in the questionnaire and the Interviews. Finally, VR persecutory ideation was positively correlated with paranoia, interpersonal sensitivity and anxiety, all measured using the BSI. Table 6.3 provides comments from the semi-structured interviews {qualitative data, illustrating the range of positive and negative beliefs that participants had about the avatars. Y Table 6.2 Level of agreement of participants In=24] with statements from the 15-item VR-Paranoia questionnaire Disagree ‘Agree alittle | Moderately agree ‘Someone in the room had it in for me 5 5 3 They were talking about me behind my back i a 3 They were friendly towards me 4 10 9 YY Table 6.3 A selection of comments made about the tars [each comment is from a different participant] Positive Negative ‘Friendly people just being friendly and offering a smite" “They were very ignorant and unfriendly” "People were nicer than real people” ‘Sometimes appeared hostile, sometimes rude” "Part of a game (Acting but being shy) ‘Te was their space: youre the stranger” ‘Ttwas nice when they smiled, made me feel welcome” "They were telling me to go away’ ‘They looked friendly that was my overall impression” “One person was very shy and another had hated me’ ‘Tsmiled and chuckled” “The two women looked more threatening” ‘Some were intimidatingCONCLUSIONS Consistent with previous research, emotional processes linked to anxiety and interpersonal sensitivity contribute directly tothe development of persecutory ideation, highlighting that VR holds ‘great promise’ not only as a tool for enhancing theoretical understanding but also as a way of helping individuals to evaluate and reduce persecutory Ideation and delusions. @ Methodological strengths and weaknesses (One weakness was that the participants reported relatively low levels of presence within ‘the virtual library. Presence refers to feelings of actually ‘being there’ and was measured on a six-point scale used in previous VR studies. The average presence rating was 2.3/6 (the higher the score, the more present the participants felt), This suggests thatthe Findings may lack ecological validity asthe participants were not fully immersed in the experience; this may be due tothe short duration in the room (ive minutes) andthe relatively passive nature of the task ‘euasydoziy9s 19 ‘Astrenath was that half the participants answered the BSI, paranota and anxiety ‘questionnaires before and after their time in the virtual room and the other group only completed them after the VR experience. This was done to see whether completing the ‘questionnaires primed the participants to experience persecutory thoughts while in the room. This did not appear to be the case, suggesting that any such thoughts were triggered by the avatars and not the overall procedure. ‘Another weakness is sampling bias. The participants were all drawn from a London university, recruited via advertisements: they were all fee from prior clinical diagnoses and were relatively young (mean age = 26). The participants would all have been relatively ‘intelligent and interested in psychology and virtual reality. This means that the findings may not generalise to people outside this population. ISSUES AND DEBATES Idiographic versus nomothetic strength of this study was that it used both nomothetic and idiographic approaches. uantitative data was collected using the VR-Parancia questionnaire [designed specifically for this study to measure situation-specific persecutory ideation ~ see Table 61). This new psychometric test collected self-reported data on 4-point scales (0-3: ‘donot agree’ to “tally agree’, which can be analysed using statistics in order to draw conclusions that can bbe generalised tothe wider target population, thus illustrated the use ofthe nomothetic ‘approach. However, Freeman etal also took an idiagraphie approach when they collected qualitative data through asking participants to explain their experiences in their awn words in ‘semi-structured interviews. Using both approaches and types of data increases the validity fof Freeman at al’ findings regarding the frequency of persecutory ideation inthe general population, Ethics Freeman et al. (2003) checked to see whether time spent in the room created any distress during the semi-structured interview and found that this was not the case. Also, anxiety scores were very similar before and after the VR task, suggesting that tthe experience did not leave the participants with any lasting psychological harm. Furthermore, all participants gave their consent to take part, although they were not told anything about the environment they were about to enter and were not told that tthe study was about persecutory thoughts. This means consent was not fully informed, but given the stress-free nature of the VR environment, this was justified due to the potential benefits to society. e6 CLINICAL PSYCHOLOGY ISSUES AND DEBATES Application to everyday life ‘strength of this study is that ithelps to deepen our tunderstanding ofthe cognitive and emotional processes that underpin the development of psychotic symptoms. Exploring how people interpret mental states/intentions in others in VR settings can inform theoretical models of schizophrenia, and in turn, the development of new VR therapies where people can focus on developing new ways of interacting in the real world, This wil only be possible if the VR environments have strong ecological validity, such asincorporating credible avatars that demonstrate a full range of human behaviours. Individual and situational explanations ‘This study highlights the role of both individual ‘and situational explanations in the development REFLECTION of persecutory ideation, A range of questionnaires. were used to measure trait anxiety, paranoia and ‘other clinical symptoms le.g. The Spielberger State Anxiety Questionnaire) and these relate to individual explanations [[e. that certain people are more vulnerable to developing psychotic symptoms due to the way they typically process information from the social and physical world). But the researchers also point to the potential for VR research to reveal environmental (cituationall factors associated with persecutory thoughts, noting that experimental ‘manipulation of aspects ofthe virtual environment could help to identify factors which make such thoughts more or less likely Do you agree with Freeman et al. regarding the potential of virtual reality to revolutionise therapy for people with schizophrenia and other clinical disorders? Ifyou were conducting research in this area, how might you improve this study and/or design your own study to investigate persecutory ideation using VR technology? How could Freeman et al. check the reliability of their new scale? ‘A. Figure 6.6 In this pioneering study, Freeman et a. created a brand-new questionnaire to measure situation-specific paranoia, something that had not previously been done before (see Table 4.1) LEARNING LINKS ‘Think back (othe studies that you covered at AS Level, such as Hélzel eta, Iminafulness ‘and brain scansl, Piliavin t al. [subway Samaritans), Saavedra and Silverman. (button phobia} and Pozzulo et al. line-ups]. Psychologists have used VR to research mindfulness, altruism, phobias and eyewitness testimony, showing the many and varied uses of this technology. Can you think how these studies might have been done differently ifthe researchers were able to incorporate VR into their procedures? Compare the original methodologies with your ideas for the new VR versions. Would the VR versions be better or worse than the originals, and why?KEY TERMS heritability polymorphism allele dopamine upregulation polygenic STUDY TIP (One thing that isa ite tricky with this study is the fact that Freeman et al assessed paranoia in two cifferent ways that could be easily confused, so make sure that you ‘Understand this part ofthe procedure, A useful way of thinking about these two ‘measurements is to think about trats versus states, Traits are ways of thinking and feeling that are fairly stable - they endure over time, from one situation to another. Freeman et ‘al. measured trait parancie’ using the ESI and the parancia scale. States refer to ways of thinking feeling and behaving that are a reaction to a specific situation. In this study, Freeman etal. measured persecutory ideation and ideas of reference relating o the ‘avatars in the virtual library using the VR-paranoia questionnaire, designed specificaly for this study in order to measure state paranoia, TEST YOURSELF Explain one weakness of Freeman etal 2003} rela Describe how Freeman measured persecutory ideation in this study. ‘2 Describe the study by Freeman etal (2003 on virtual reality to investigate persecutory ideation, 'b Evaluate this study by Freeman et al. [2003], including a discussion of individual and situational explanations. State an appropriate fully operationalised directional hypothesis for Freeman et al. (2003). Suggest two weaknesses of self-reports (e.g. questionnaires and interviews). such as those used in Freeman etal (2003) Explain one strength and one weakness of the sampling technique used in this study. 6.1.2 Explanations of schizophrenia Biological explanations of schizophrenia Rus Twin studies involve comparing concordance rates. Can you remember what this term means? Think! Imagine a friend of yours has just found out that their sister has schizophrenia. She asks you to explain it to her, but she does not know much about biology or psychology. How would you make it easy for her to understand? fad Twin studies have historically been used to investigate the heritability of mental disorders, but cross-cultural studies can help to illuminate the relative contribution of nature versus nurture. Ifthe prevalence of schizophrenia was roughly the same worldwide regardless of difference in cultural practices, what would this tell us? ‘euasydoziy9s 196 CLINICAL PSYCHOLOGY What evidence can you think of that suggests that nurture can have more of an impact on ‘our wellbeing than nature? ‘A. Figure 6.7 The deletion of a strand of DNA curing cell division could resutt in the loss, of a whole string of genes, a biological issue which may have a lifelong impact on our psychological functioning, Genetic explanation Classic research Classic family and twin studies (see page 365) suggest that, while schizophrenia is not just genetic, there is a strong argument for the heritability of this disorder. For example, the concordance rate for monozygotic (MZ) twvins is 42 per cent but only 9 per cent for dizygotic (02) twins (Gottesman and Shields, 1966). Since the siblings in both groups (MZ and DZ) were raised in the same household, the higher concordance rate in MZ twins was thought to bbe due to the greater amount of shared DNA. Contemporary research More recently, the whole genomes of people with and without a diagnosis of schizophrenia have been compared to see whether they vary in consistent ays, These studies ae called genome-wide association studies (GWAS). Some genes are polymorphic, meaning they come in different forms. GWAS studies have helped to identify which versions (alleles) are more common in people with schizophrenia However, the genetics of schizophrenia is extremely complex; thousands of gene variants hhave been linked to this complex condition (Smeland et a., 2020) and, therefore, it is referred to as polygenic. Often the affected genes are linked to the many different proteins associated with the development (synthesis) transportation and breakdown of rneurotransmitters such as dopamine. This means that the inheritance of certain alleles may be responsible for neurachemical imbalances associated with schizophrenia, DiGeorge and the COMT gene Aside from the inheritance of less than favourable alleles, sometimes problems arise during cell division and whole strands of DNA become duplicated or even deleted; this causes a ‘printing error in the biological manual’ and can increase a person's risk of developing schizophrenia. For example, in DiGeorge syndrome, a strand of DNA containing 30-40 ‘genes is deleted from chromosome 22, One in four people with this condition develop schizophrenia, compared with less than 1 in 100 people without DiGeorge syndrome. This hhas been linked to the deletion of a specific gene called COMT (kim et al., 2020). This gene ‘codes for an enzyme which breaks down neurotransmitters such as dopamine. This suggests that the absence of this gene could be partially responsible for the complex neurochemical ‘imbalances that seem to underpin the symptoms of schizophrenia.‘Some researchers betieve the ‘disrupted in schizophreniat or the DISC1 gene increases the risk (of schizophrenia due to its association with the neurotransmitter GABA. GABA is an inhibitory neurotransmitter which helps to regulate activity in neural circuits that communicate via dopamine and glutamate. Again, an abnormality ofthis gene could, therefore, increase vulnerability to excess dopaminergic activity and subsequent symptoms of schizophrenia. Evaluating genetic explanations Astrength of the genetic explanation of schizophrenia is that it is supported by research ‘evidence. For example, there are two versions of the COMT gene called ‘Met’ and ‘Val’ and research suggests that the Va allele ts associated with decreased dopamine activity in the preftontal cortex, decreased cognitive performance and a slightly elevated risk of schizophrenia (Egan et al., 2001). This is important evidence to support both the role of genetic Factors and the dopamine deficiency hypothesis. This sad, there is some evidence to Suggest the effect of the Vl alele on cognition may be stronger in men with schizophrenia than women (Wang eta, 2020) There is also research evidence to support the role of the DISC1 gene variant in schizophrenia, For example, in a large Scottish family with an unusually high rate of schizophrenia, 34 family members carried this gene (St Clair et al., 1990). More recently, a meta-analysis of the findings of 14 animal experiments suggests that this may be linked to the impact of DISC1 ‘on presynaptic dopamine dysregulation (Dahoun et al., 2017). This is an important finding as animal experiments are tightly controlled, meaning the findings have greater internal valicity. This said, the contribution of DISCL is highly contested and has also been linked with a range of other mental health conditions, in addition to schizophrenia (Sullivan, 2013). ISSUES AND DEBATES Nature versus nurture ‘Although there are a wealth of twin studies to support the role of genetics (naturel in schizophrenia, the validity of these findings is questionable, It is assumed that MZ twin pairs living in the same household will be exposed to environmental factors that are similar to pairs of OZ. cent of their ONA. This suggests that nurture may play a greater role in schizophrenia than previously thought. Reductionism versus holism ‘A further weakness is this explanation is overly reductionist; taking this perspective may limit awareness of the range of treatment options. While our genome may ‘euasydoziy9s 19 twins, but this is highly unlikely. As MZ twins are always the same gender, look more similar than DZ twins and are more likely to share similar temperaments, they are likely to be parented more similarly than OZ twins. This ‘means that the degree of both genetic and environmental similarity differs between MZ and DZ twins, making it impossible to infer thatthe higher concordance rate for schizophrenia in MZ twins is due to them sharing 100 per Biochemical impact the way we process information and experience the world, research suggests that itis possible to train ‘ourselves to interpret our thoughts in more beneficial ways. On page 255, we wil consider the benefits of cognitive- behavioural therapy as a way of successfully managing both positive and negative symptoms. This is important ‘as it demonstrates that nurture can override nature when environmental experiences are carefully curated Excess dopamine as a cause of schizophrenia In the 1960s, Arvid Carlsson and Margit Lindqvist proposed that schizophrenia was caused by ‘an excess of the neurotransmitter dopamine, deep in the brai's limbic system and mesolimbic pathways (Carlsson and Lindqvist, 1963). This excess can be caused by many factors, such as ‘excess L-Dopa, the substance that dopamine {s made from. Synapses that use dopamine may also be overactive due ta differences in the number of receptors on the postsynaptic call ver time, new evidence caused scientists to update this explanation. For example, many people who were taking dopamine antagonists like chlorpromazine (page 251) still suffered with negative symptoms and some experienced no improvement in symptoms at al.Dopamine deficiency as a cause of schizophrenia In the 1990s, Kenneth Davis and colleagues suggested that a lack of dopamine in the prefrontal cortex and mesocortical pathways may explain the negative and cognitive symptoms (Davis etal, 1991). Symptoms such as disorganised thinking and speech could certainly result from problems with dopamine regulation as this neurotransmitter i, important for shifting and directing attention. Over the years, further contradictory evidence revealed that the updated hypothesis, was still over-simplified. Overactivity in the mesolimbic pathways was thought to result from excess D2 dopamine receptors and/or low levels of the enzyme beta-hydroxylase, which breaks down dopamine. However, in 2006, Arvid and Maria Carlsson proposed the dopamine deficiency hypothesis, suggesting that the brain compensates for low levels of dopamine by increasing the number of receptors on the postsynaptic cell. This process is known as upregulation. : © ‘As you look at the synapse diagram in Figure 6.8, think about the stages of i hneurotrananission; how many different reasons can you tink of as to why someone might have high (or Low) levels of dopaminergic activity in their brain? Newotransmiters : : Z 3 2 3 z 3 Presynaptic Postsynaptic terminal A. Figure 6.8 Synaptic transmission @ Evaluating the dopamine hypothesis ISSUES AND DEBATES Nature versus nurture strength of the dopamine hypothesis and thus the role of nature is thal there is wealth of research evidence to support this explanation of schizophrenia. In one study, rats were injected with amphetamines over a three-week period. Amphetamine is known ‘to increase dopamine activity (Tenn et al, 2003). The rats showed a range of schizophrenic-like behaviours, including strange movements and social withdrawal Furthermore, the rats’ symptoms were alleviated when they were given drugs to block their D1 dopamine receptors. This supports the role of biological factors (nature) in schizophrenia but also underlines the importance of environmental factors {nurture} such 2s drug taking Despite many studies supporting the rale of a dopamine dysfunction as a potential cause of schizophrenia, Dépatie and Lal {200'] found that apomorphine, 2 dopamine agonist, does not worsen symptoms in people who already have a diagnosis of this disorder ‘and neither does it trigger symptoms in those that do nat. Findings such as this are hard to explain and suggest that the picture may be far more complicated, potentially, highlighting the role of nurture in predicting the impact of biolagical factors,Reductionism versus holism A limitation ofall the different versions ofthe dopamine hypothesis i that they are highly ‘reductionist. The idea thata single neuratransmitter is responsible for schizophreniais ‘no longer accepted. Drugs such as clozapine {see page 251), which block dopamine and serotonin receptors, are often more effective than drugs that only block dopamine receptors {e.g. chlorpromazine! and the efficacy of newer drugs, such as glutamate agonists, suggests that an exploration of the interactions between a wide range of neurotransmitters may prove more fruitful than studies that focus on single neurotransmitiers. Taking a holistic ‘approach and recognising how neurotransmitter levels are affected by experiencesin the world and the ways in which we interpret them is also critical. Throughout this text we have focused on ways in which various lifestyle choices including mindfulness, sleep, exercise ‘and diet can affect our neurochemistry and it is therefore important to recagnise how the ‘prognosis of conditions like schizophrenia can be affected by numerous individual and situational factors, due to their impact on aur biology. Determinism versus free will The biological explanation of schizophrenia is deterministic in that it suggests that the workings of the brain are responsible for the symptoms of schizophrenia. Research using PET brain imaging, for example, demonstrates that people diagnosed with schizophrenia have decreased binding on their prefrontal DI dopamine receptors in comparison with matched controls without schizophrenia [Okubo et a. 1997). Furthermore, there were significant correlations between D1 binding, severity of negative symptoms and performance on the Wisconsin Card Sorting Test [a measure of cognitive ability. This supports dopamine deficiency as an explanation of negative and cognitive symptoms and the role of biological determiniem. LEARNING LINKS Think back to the biological approach from AS Level and you will remember the study by Dement and Kleitman (steep and dreams}, Researchers believe that REM sleep is an important time when synapses are ‘cleaned out’ and neurotransmitters replenished for the coming day. This suggests that improved sleep quality could help people to prove their mental health. Unfortunately, sleep is often disrupted by disorders like schizophrenia, worsening people's symptoms even more. STUDY TIP Comparison involves explaining how the two things are similar and how they are different. Ifyou were asked to compare the two explanations discussed on this page, you could examine the evidence for and against each explanation, including the research methods that have been used. You could also look tthe applications tothe real world e.g. treatments for schizophrenial and you could thnk about how each explanation relates to the issues ond debates, TEST YOURSELF Jameela has schizophrenia. She experiences hallucinations and is very socially withdrawn, Her doctor explains to her family that her symptoms may be caused by ‘an imbalance of dopamine in her brain. Explain the dopamine hypothesis with reference to Jameela’s symptoms. ta Compare the genetic and the biochemical explanations of schizophrenic (6 ‘a Describe one or more genetic explanations of schizophrenia. to 'b Evaluate the genetic explanationls| of schizophrenia, including a discussion cof nature and nurture. tno) Outline one advantage and one disedvantage of using animal experiments as research method for investigating schizophrenia, (a ‘euasydoziy9s 196 CLINICAL PSYCHOLOGY KEY TERMS. self-monitoring error internal monologue 5 Aresearcher finds a correlation between severity of schizophrenia symptoms and dopamine activity. Explain why the researcher cannot conclude that excess dopamine causes schizophrenia. a (Chase works with families where one member has schizophrenia, He has created 2a set of rating scales to measure people's feelings about their family member's diagnosis, Identify a suitable measure of central tendency and measure of spread for Chase's data, fa Psychological explanation of schizophrenia What does Frith mean by self-monitoring and how is this related to positive symptoms of schizophrenia? Do you hear an internal voice sometimes when you are thinking or reading? Not everyone does. Some people see their thoughts as images or actually see printed words in their heads as they think. Asking friends and family to explain how they think about certain things can be very interesting - not everyone processes information in the same way, even for people without mental disorders. Experiments like the ones described on this page can help us to understand more about how people with schizophrenia think but the evidence they provide does not reflect the full range of people with this disorder. What sort of people do you think are more likely to take part in such studies? Why is this problematic? ‘Te was as if parts of my brain ‘awoke’ which had been dormant, and I became interested in a wide assortment of people, events, places, and ideas which normally ‘would make no impression on me. The walk of a stranger on the street could be a ‘sign’ ‘to me which I must interpret. Every face in the windows of a passing streetcar would be engraved on my mind, all of them concentrating on me and trying to pass me some sort of message’ (MacDonald, 1960) Which symptoms of schizophrenia do you recognise in this quote? In Dr Longden’s TED talk, she notes that the ‘most violent and critical voices’ felated to ‘the most damaged aspects ‘A. Figure 49 Cognitive neuropsychologist of herself. How does this fit with Frith’s Chris Frith cites the following quote as ideas about self-monitoring? 2 guiding principle in his research into schizophrenia: Reality eaves a lt to the imagination’ UJohn Lennon}