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Stephanie Usher

In relation to their chosen disorder: schizophrenia

Information to know;

Clinical characteristics of the chosen disorder

Issues surrounding the classification and diagnosis of their chosen

Biological explanations of their chosen disorder, for example, genetics, biochemistry

Psychological explanations of their chosen disorder; behavioural, cognitive, psychodynamic and socio-cultural Biological therapies for their chosen disorder, including their evaluation in terms of appropriateness and effectiveness Psychological therapies for their chosen disorder, for example, behavioural, psychodynamic and cognitive-behavioural, including their evaluation in terms of appropriateness and effectiveness

Schizophrenia has been variously described as a disintegration of the personality A main feature is a split between thinking and emotion. It involves a range of psychotic symptoms (where there is a break from reality) Generally, schizophrenic patients lack insight into their condition, i.e. they do not realise that they are ill. They must follow the pattern of symptoms (see next slide) It is not caused by: Inadequate parenting Overzealous mothers Poor family relations It is not split personality

Schizophrenia is one of the most chronic and disabling of the major mental illnesses affecting thought processes In order for a diagnosis to be made, two or more of the symptoms must be present for more than one month along with reduced social functioning The symptoms are separated into two categories; positive and negative. Positive symptoms are an excess or distortion of normal functions and negative symptoms are an diminution or loss of normal functions.

A distinction has been made between type 1 and type 2 schizophrenia. Type 1 is dominated by positive symptoms and type two by the negative.

Positive Symptoms Negative symptoms Delusions paranoia, grandiosity Reduction in range and intensity of Experiences of control believe emotional expression, including facial under control of alien force (smiling expression, tone of voice etc after bad news). Alogia lessening speech fluency Auditory hallucinations bizarre, Avolition reduction or inability to unreal perceptions, usually auditory. take part in goal directed behaviour. Thought disturbance and disordered Reactivity is not expected thinking thoughts have been Thought blocking inserted or withdrawn from the mind. Asocial behaviour Language impairments Emotional blunting Disorganised behaviour Reflects a loss of normal functions catatonia immobility echopraxia, Psychomotor catatonia echolalia immobility and frenetic activity

Catatonic Type 10%

Paranoid Type 35-40% (less severe) Preoccupation with one or more delusions or frequent auditory hallucinations. No disorganized speech, disorganized or catatonic behaviour, or flat or inappropriate affect.

immobility or stupor excessive motor activity that is apparently purposeless, extreme negativism, strange voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing.

Disorganized Type 10% Must have all; disorganized speech, disorganized behaviour, flat or inappropriate affect and not meet the criteria for Catatonic Type. Undifferentiated Type 20% Variation between symptoms, not fitting into a particular type

Residual Type 20% Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behaviour. Plus presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia

General issues; Reliability concerns consistency of measurements, in relation to the classification and diagnosis; inter-rater reliability whether two or more clinicians make the same diagnosis when independently assessing a patient. Some of this error may be due to the fact that the same patient may give different information to different doctors. Test-retest reliability whether the same clinician gives the same diagnosis when given the same information Obviously a diagnosis is useless if it fails to be consistent; BECK found 54% consistency when four experienced clinicians diagnosed 153 patients.

There is both evidence for and against the reliability of a diagnosis of schizophrenia; PRO the diagnosis of schizophrenia has relatively high reliability (+.81) ANTI Read et al reported that test-retest reliability was as low as +.31 and also described a 1970 study where 194 British and 134 American psychiatrists were asked to provide a diagnosis on the basis of a case description. 69% Americans diagnosed schizophrenia and only 2% of British did. INCONSISTENCY. Despite low reliability, the classification schemes are still useful as they are better than nothing Classification systems are always being improved!

Reliability an unreliable diagnosis cannot be valid Predictive validity if diagnosis results in successful treatment then the diagnosis must have been valid Aetiological validity the cause of the disorder should be the same for all the patients in the category Descriptive validity patients in different diagnostic categories should differ from each other Cultural bias western classification is culturally bias

2. 3.

Genetics Neurochemical & hormones Structural brain abnormalities


Kendler et al (1985) found that 1st degree relatives of those with schizophrenia are 18 times more at risk than the general Population Children with both parents who suffer from schizophrenia have a CONCORDANCE RATE OF 46%

Prevalence of schizophrenia is the same all over the world (about 1%) Supports a biological view as prevalence does not vary with environment Risk rises with degree of genetic relatedness Spouse 1% (same as G.P.) Child 13% DZ twin 17% MZ twin 48%

The Copenhagen High-Risk Study (Kety et al. 1962) Kety identified 207 offspring of mothers diagnosed with schizophrenia (high risk) along with a matched control of 104 children with healthy mothers (low risk) in 1962 Control group were matched on age, gender, parental socioeconomic status and urban/rural residence Children aged between 10-18 years at start of study Schizophrenia diagnosed in 16.2% of high risk group compared to 1.9% in low risk group

Sherrington found that chromosome 5 has evidence of susceptible schizophrenia.

To research more on the impact of genetics on schizophrenia, we can compare concordance rates for identical (MZ) and fraternal (DZ) twins Both share the same environment but only MZ twins have identical genetics if schizophrenia is genetically related, the concordance rate of schizophrenia should be much higher in MZ twins. To prove this many studies have been conducted ALL OF THEM show much higher concordance rate in MZ than DZ twins To prove the genetic influence further, you have to research the power of genetics in separate environments - researchers have sought out MZ twins reared apart where at least 1 has been diagnosed with schizophrenia

Used the Maudsley twin register and found 58% (7/12 MZ twins reared apart) were concordant for schizophrenia

Although twin, adoption and family studies continue to prove that the degree of risk of obtaining schizophrenia increases with degree of genetic relatedness, there are two factors which stop us concluding biology as the source; No twin study has yet shown 100% concordance in MZ twins Studies conducted so far dont tell us which genes might be important for the transmission of schizophrenia.

The dopamine hypothesis- Comer (2003) Dopamine is one of the many neurotransmitters operating in the brain. Schizophrenics are thought to have an abnormally high number of D2 receptors on their receiving neurons, resulting in more dopamine binding and therefore more neurons firing. Dopamine neurons play a key role in guiding attention, so it is thought that disturbances in this process may lead to the problems of attention and thought found in people with schizophrenia. A group of drugs were developed in the 1950s called phenothiazines, which bind to the D2 receptors, effectively blocking the transmission of nerve impulses through these receptors and therefore reducing deficit found in schizophrenic. High number of receptors in the brain of schizophrenics

Schizophrenia may be a structural abnormality. Stevens (1982) cites the fact that many schizophrenics display symptoms indicating neurological disease - especially decreased eye blinking, lack of the blink reflex, poor visual pursuits and poor pupil reactions to light. Some schizophrenics underwent perinatal complications and may have suffered a lack of oxygen resulting in possible brain damage.

Researchers have found that many schizophrenics have enlarged ventricles, these are cavities in the brain that supply nutrients and remove waste. Torrey (2002) found that the ventricles of a schizophrenic are 15% bigger on average than normal. Bornstein et al (1992) found that people with schizophrenia and enlarged ventricles tend to display negative rather than positive symptoms and have greater cognitive disturbances and a poorer response to traditional antipsychotics.

Humane approach; poses no blame on the individual or their families states that the people who become ill are purely unlucky Tends to provoke little fear or stigma Effective treatments Well established scientific treatments Reductionist approach Animal studies Relies on self report Treats symptoms, not causes

Meyer Lindenberg et al (2002) examined brain activity in schizophrenics engaged on a working memory task. Their prefrontal cortex showed reduced activation reflecting their poor performance on such tasks. At the same time dopamine levels were elevated suggesting that a dysfunction of the prefrontal cortex is linked to dopamine abnormalities.
Sigmundssen (2001) found that patients with type 2 schizophrenia have smaller amounts of grey matter and smaller temporal and frontal lobes. This supporting the view that enlarged ventricles are significant only because they indicate reduced brain matter, which may be related to brain damage.

Behavioural Cognitive Psychodynamic socio-cultural

Freud believed that schizophrenia was the result of two related processes (sexual abuse) Regression to a pre ego state Attempts to re-establish ego control.

If the world of the schizophrenic is particularly harsh, for example if his or her parents are cold and uncaring, a child may regress to a stage of development before the ego was properly formed and before the child had developed a realistic awareness of the external world. Schizophrenia was thus seen by Freud as an infantile state, some symptoms (e.g. delusions of grandeur) reflecting this primitive condition, others (e.g. auditory hallucinations) reflecting the persons attempts to re-establish ego control. Although there is no research evidence to support Freuds specific ideas, except that disordered family patterns are the cause of the disorder. Oltmanns et al found that the parents of schizophrenic patients do behave differently from the parents of other kinds of patients, particularly in the presence of their schizophrenic offspring.

Stresses the importance of psychological factors (very freud) Stresses the importance of childhood Influential theory Importance of the unconscious mind The importance of childhood is sometimes overstressed Problems validating the study (no studies have been carried out as proof) Poor methodology Blames parents

Behaviourists argue that learning plays a key role in the development of schizophrenia. One suggestion is that early experience of punishment may lead the child to retreat into a rewarding inner world. Others then label them as odd or strange. Scheffs (1966) labelling theory suggests that individuals labelled in this way may continue to act in ways that conform to this label. Bizarre behaviour is rewarded with attention, and becomes more and more exaggerated in a continuous cycle before being labelled as schizophrenic

Behaviourists have attempted to explain schizophrenia as the consequences of faulty learning. If a child receives little or no social reinforcement early on in life, the child will attend to inappropriate and irrelevant environmental cues, instead of focusing on social stimuli in the normal way. Behaviourists explain the fact that schizophrenia runs in families as a function of social learning. Bizarre behaviour by parents is copied by children. Parents then reinforce this behaviour and the behaviour becomes progressively more unusual, until eventually the child acquires the label of being schizophrenic.

The validity of the behavioural model is moderately supported by the success of behavioural therapies used with schizophrenic patients. Social skills training techniques have been used to help schizophrenics acquire useful social skills (Rodger et al.,2002). Allyon & Azrin (1968) have shown that schizophrenics have learned to make their own beds, comb their own hair etc. when given rewards for doing so. Finally Roder et al. (2002) has demonstrated that social skills training techniques have been used to help schizophrenics acquire social skills. The success of such programmes in teaching new skills and reintegrating schizophrenics back into the community suggests that these are skills that schizophrenics failed to learn in the first place. Overall this research can explain how schizophrenia symptoms are maintained but it does not adequately explain where they came from in the first place. Critics claim that labelling theory ignores strong genetic evidence and trivialises a serious disorder.

In what ways could it be argued that the behaviourist approach to schizophrenia is reductionist?

Experimentally tested Speaks on the present, as well as the past (validity) Effective treatments Accounts for cultural differences Simple model (reductionist) Animal studies Unethical?

Hemsley (1993) suggested schizophrenics cannot distinguish between information that is already stored and new incoming information. As a result, schizophrenics are subjected to sensory overload and do not know which aspects of a situation to attend to and which to ignore. The role of biological factors is acknowledged in this explanation it says that the condition has always existed, but is worsened by those around them When schizophrenics first hear voices and experience any other worrying sensory experiences, they turn to their friends and relatives to confirm the validity of what they are experiencing. Some people fail to confirm the reality of these experiences, so the schizophrenic comes to believe they must be hiding the truth. Individuals then begin to reject feedback from those around them and develop delusional beliefs that they are being manipulated and persecuted. Yellowlees et al have developed a curious treatment, where patience watch a machine that produces virtual hallucinations, such as hearing the television tell you to kill yourself or one persons face morphing into anothers. This is to show schizophrenics that their hallucinations are not real, that disbelieving others is a consequence of madness.

Focuses on the current cognitions Plenty of research into the idea Influential and popular model Includes biological and the psychological Empowers the individual to change Ignores the environmental influences Unscientific Blaming the individual can make the disorder worse Is thinking irrational? Which is the cause? Which is the effect?

Life events A major stress factor that has been associated with a higher risk of schizophrenic episodes is the occurrence of stressful life events, such as the death of a relative, job loss or the break up of an intimate relationship. It is not known how stress triggers schizophrenia, although high levels of physiological arousal associated with neurotransmitter changes are thought to be involved. Brown and Birley (1968) found that approximately 50% of people experienced a major life event in the 3 weeks prior to a schizophrenic episode, whereas only 12% reported one in the 9 weeks prior to that. Hirsch et al (1996) followed 71 schizophrenic patients over a 48 week period. Life events made a significant cumulative contribution in the 12 months preceding relapse rather than having a more concentrated effect in the period just prior to the schizophrenic episode. Although not all evidence supports the role of life events, in one study it was found that there was no link between life events and the onset of schizophrenia, patients being equally likely to have a major life event or not in the 3 months before the schizophrenic episode.

Family relationships Double Bind theory Bateson et al 1956 Children who receive contradictory messages from their parents are more likely to develop schizophrenia. Conflicting message = mother says I love you, but turns her head away in disgust. Child received conflicting message about their relationship on different levels. Verbal affection, non-verbal animosity (strong dislike)

Bateson et al argued Childs ability to respond is incapacitated by the contradictions.

Prolonged exposure to these interactions prevents the development of a coherent construction of reality. Which in the long run manifests itself as schizophrenic symptoms, e.g. flattened effect, delusions, hallucinations, incoherent thinking and speaking and some cases paranoia.

Social Labelling Theory Scheff (1999) promoted the labelling theory of schizophrenia. Theory states social groups create the concept of psychiatric deviance by constructing rules for group members to follow. Thus the symptoms of schizophrenia are seen as deviating (going against) from the rules that we attribute to normal experience or behaviour. Therefore those who display unusual behaviour are considered deviant and the label schizophrenic may be applied which becomes a self fulfilling prophecy that promotes the development of other symptoms of schizophrenia (Comer 2003).

Pharmacotherapy - Antipsychotic Drugs Electroconvulsive Therapy (ECT) Mental hospitalization

Ancient therapies; Lobotomy Ice cold baths Insulin coma therapy

ECT is not considered a first line treatment but may be prescribed in cases where other treatments have failed. It is only measurably effective where symptoms of catatonia are present and in terms of treatment for drug-resistant catatonic schizophrenia It is not otherwise recommended as a treatment for schizophrenia ECT works by using an electrical shock to cause a seizure (a short period of irregular brain activity). This seizure releases a rush of chemical neurotransmitters and temporarily alters function (eg. perception/memory etc)

ECT is given up to 3 or 4 times a week and usually for a maximum of 12 treatments. Before each treatment, an intravenous line is attached and through it the patient will be given an anesthetic (to induce sleep) and a muscle relaxant. Then an electrical shock is applied to the patients head (via electrodes). The shock will last only 1 or 2 seconds (high voltage / low amperage) and will make the brain have a seizure. This seizure is controlled by the medicines to stop/reduce the body having a grand muscular spasm. The somewhat dazed patient will then wake up within 5 to 10 minutes after the treatment.

Side effects may result from both the anesthesia and the ECT. Common side effects include temporary short-term memory loss, confusion, paranoia, nausea, muscle aches and headache. Some people may have longer-lasting/permanent problems with memory/paranoia. Nowadays, rare cases result in death. (In the past it was often caused by poor calibration of the shock, coupled with a lack of muscle relaxants)

ECT can have an immediate beneficial effect Significant benefit of ECT over placebo Huge research shows no damage to brain after ECT Risk of cognitive impairment Unscientific Risk of becoming used for social control?

Drugs used to treat schizophrenia are called ANTIPSYCHOTIC drugs, they work to suppress hallucinations and delusions Antipsychotic drugs are known as TYPICAL and ATYPICAL TYPICAL = well established ATYPICAL = newer and less widely used ATYPICAL ANTIPSYCHOTIC DRUGS tend to have fewer side effects and act in different ways to typical antipsychotic drugs A patient is only ever on ONE psychotic drug at a time (anti depressants can be taken at the same time) ONE DRUG DOES NOT TREAT EACH MENTAL ILLNESS depends on the individual response to drug treatments and clinicians preference for some drugs

Research suggests people with schizophrenia have been shown to have more dopamine activity (or sensitivity) in their brains Thus, if a person has too much dopamine activity in one part of the brain, this will produce too much "perception". For example, seeing and hearing things that aren't there (and thus thinking they come from somewhere e.g. television, radio etc). Researchers have therefore created drugs which can block the dopamine receptors and reduce dopamine activity

The atypical antipsychotics (also known as second generation antipsychotics) are a group of unrelated* antipsychotic drugs used to treat psychiatric conditions. Atypicals such as Clozapine work differently from typicals in that they only attach to the specific D2 dopamine receptors (with a transient blocking action on excessive perceptionisation). Atypicals are preferred to conventional antipsychotics because they produce less side affects (eg. tardive diskinesia*) Good for positive symptoms, however comparative affects on negative schizophrenia are marginal (Leucht et al, 1999).

Highly effective Proven to prevent the reoccurrence of the mental disorder Most people are tolerant to the side effects

Are not effective in treating every patient Nasty side effects muscle stiffness, slowing, shakiness, change in appetite, diabetes, cardiovascular Drugs do not CURE the disorder Delayed effects?



Cognitive Behavioural Therapy (CBT) Psychodynamic Therapy

Psychological treatments, such as cognitive behavioural therapy (CBT), can help people with schizophrenia to cope better with the symptoms of hallucinations or delusions. Psychological treatments can also help to treat some of the negative symptoms of schizophrenia, such as apathy or a lack of volition/hedonism (motivation / enjoyment in life).

Cognitive behavioural therapy (CBT) is based on the idea that most unwanted thinking patterns, and emotional and behavioural reactions are learnt over a long period of time.

The CBT approach to treatment differs slightly from conventional CBT methods. The aims of this therapy are as follows: To challenge and modify delusory beliefs To help the patient to identify delusions To challenge those delusions by looking at evidence To help the patient to begin to test the reality of the evidence

For example, you may be taught to recognize examples of delusional thinking in yourself. You may then receive help and advice about how you can avoid acting on these thoughts. Most people will require between eight to 20 sessions of CBT over the space of six to 12 months. CBT sessions usually last for about an hour. This type of treatment has been shown to be effective for reducing the positive symptoms of schizophrenia, for reducing relapse and for enhancing recovery when schizophrenia is diagnosed early.

CBT strategies to challenge & help modify delusory beliefs Identify delusions Challenge evidence on which delusions are based Design experiments to test reality of this evidence Chadwick & Lowe (1993) significant reductions in delusions in 10 out of 12 patients Normalising strategies where patient is taught to understand the nature of schiz. symptoms Challenge catastrophising beliefs about schizophrenia Help patient feel that symptoms are understandable and normal Helps 70% of patients although other 30% may deteriorate (Kingdon & Turkington, 1996)

Shown to be incredibly effective Not very rational to teach patients to see life through rose coloured spectacles Doesnt work for everybody

Psychoanalysis was first developed by Freud (1880s) and further developed by the Neo-Freudians. Psychoanalysis refers to treatment including: free association, TAT tests, hypnotic regression and dream analysis. From these the analyst uncovers the unconscious conflicts causing the patient's symptoms and interprets them for the patient to create a subjective resolution of the problem

Implosion- Extinguishing anxiety by inducing the client to imagine intensely anxiety-provoking scenes that, because they produce no harmful consequences, lose their power to induce fear. Flooding- Extinguishing anxiety by exposing the clients to actual fear-producing situations that, because they produce no harmful consequences, lose their power to induce fear. Modeling- Exposing clients to desired behaviour that is modeled by an other person, and rewarding the client for imitating that behaviour.

Effective treatments Cognitive sense Patient responsible Unethical? Impractical methodology? Restricted application

Describe two explanations of the Schizophrenia (9 marks) Evaluate these explanations of Schizophrenia (16 marks) Psychologists believe that Schizophrenia can be explained solely by biological factors Discuss this claim with reference to the above quotation.

Describe and evaluate at least two issues in classifying or diagnosing schizophrenia (25 marks)
a) Explain issues relating to classifying schizophrenia as a mental disorder (5) b) Discuss two explanations of schizophrenia from different perspectives in psychology (9 and 11 marks) Describe and evaluate two psychological explanations of Schizophrenia (25 marks)
Describe the clinical characteristics of Schizophrenia (9 marks) Explain and evaluate issues relating to the diagnosis of Schizophrenia as a mental disorder (16 marks)

Discuss the extent to which biological therapies can be used to treat Schizophrenia with reference to the above quotation (25 marks)