Psychology Revision

Schizophrenia

Definition of Schizophrenia
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Schizophrenia literally means ³split mind´ and is the mental disorder most frequently associated with ³madness´. The male onset is about 4-5 years earlier than the female onset, but both genders are equally likely to develop the disorder. The number of cases is lower in some countries than others, and it tends to be lower in rural communities compared to urban communities, suggesting that it is related to poverty. Schizophrenia tends to develop through three stages: Prodromal phase (loss of motivation, withdrawal etc) Active phase (dominant symptoms appear such as hallucinations) Residual phase (gradual improvement in condition, decline in main symptoms)

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Clinical Diagnosis
To be diagnosed with schizophrenia, two or more of the following symptoms must be present for more than 6 months.

Schnider¶s first rank symptoms (positive)

Slater and Roth¶s second rank symptoms (negative)

Delusions y Hallucinations y Disorganised speech y Disorganised or catatonic behaviour
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Lack of emotion y Inability or unwillingness to speak y Lack of motivation y Inability to display appropriate emotional response.
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Types of Schizophrenia
Schizophrenia is split into subtypes. However it is often very difficult for psychiatrists to categorise schizophrenic patients. Type
Paranoid Schizophrenia (Most common)

Characteristics/Symptoms
‡Usually stable, often paranoid ‡Auditory hallucinations ‡Believes advertisements etc are specifically aimed at them ‡Agitated, argumentative ‡Shallow mood ‡Disorganised thoughts ‡Incoherent speech ‡Hyper and then come to a sudden stupor ‡Move around randomly ‡Automatically obedient or extremely resistent ‡Withdrawn from reality ‡Strange postures

Hebephrenic Schizophrenia (Disorganised, most associated with being ³crazy´) Catatonic Schizophrenia

Diagnosing Schizophrenia
Psychiatrists often use diagnostic books or guides to help them diagnose patients such as the ICD or DSM. These are generally effective at diagnosing patients as they are updated every couple of years. However, they are not without their problems. General advantages and disadvantages: Advantages Disadvantages 
It is standardised between lots of different people so it is useful in making sure everyone knows the correct diagnosis for each disorder. Change with time so it is current and adaptable to what is socially acceptable. Large data bases are used to compile the data, it is a rigorous scientific method. The WHO is not culture bound. IT is universally coded. Often culture biased to western capitalist cultures. Is subjective to public opinions and culture and time, therefore it is less scientific. All the books are published at different times, thus making some books more upto-date than others. The DSM comes from 27 main people so has limited opinions.

Diagnosing Schizophrenia
There are also many issues surrounding the classification and diagnosis of schizophrenia with reference to reliability (the extent to which psychiatrists can agree on the same diagnosis) and validity (the extent to which psychiatrists can accurately predict the development and prognosis)

Validity
Low predictive validity. Bleuer (1978) found that in a sample of 2000 patients, 20% recovered fully, whilst 40% recovered from positive symptoms and the remaining 40% continued to have psychotic episodes. This shows that the development of schizophrenia is more like a lottery as it develops differently for different people. Some patients go undiagnosed due to social stigmas. Kim and Berrios (2001) found that in Japan schizophrenia is µthe disease of the disorganised mind¶ and is so stigmatised that psychiatrists are actually reluctant to tell patients of their condition. Only 20% of those with schizophrenia are actually aware of it. There are no pathognomic symptoms, meaning that symptoms are not unique to one particular disorder. For example, disorganised thoughts could be due to a stress disorder, flattening of affect could be due to bi-polar and hallucinations are often linked with drug psychosis. This makes it hard to distinguish between which disorder is present and makes it even more difficult to determine which type of schizophrenia patients are suffering from.

Diagnosing Schizophrenia
Reliability
There is very little evidence to support the claim that diagnostic manuals are routinely used with high reliability. Whaley (2001) found that inter-rater reliability correlations were as low as 0.11. Beck et al (1962) found that agreement on diagnosis for 152 patients was only 54% when assessed by two psychiatrists. Rosenhan (1973) managed to get 8 healthy people admitted into a mental institute by claiming to hear single words like ³hollow´ and ³thud´. When he told the hospital to expect pseudo patients, they accused 41 out of 193 genuine patients of being fakes. Klostercotter (1994) assessed 489 admissions to psychiatric wards and found that positive symptoms were more useful for diagnosis than negative ones, concluding that the symptoms themselves are unreliable. Subjective symptoms ± diagnosis often includes things such as ³bizarre behaviour´, however this is subjective to what people believe to be bizarre. Copeland et al (1971) gave a discription of a patient to 134 US psychiatrists and 194 British psychiatrists and found that 64% of US psycs diagnosed the patient as schizophrenic, whilst only 2% of British psycs gave the same diagnosis.

Explanations
The cognitive approach

The cognitive approach
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This approach assumes that schizophrenia is caused by disorganised and disordered thought processes. According to Frith(1979), schizophrenia is the result of a faulty attention system. Huge quantities of information that would usually be filtered is not, resulting in an overload. Insignificant information is then considered to be more important that it actually is. This accounts for the positive symptoms of schizophrenia, such as disorganised speech and auditory hallucinations. Firth also found that cognitive deficits are caused by abnormalities in the areas of the brain that use dopamine. He showed that schizophrenics tended to have less blood flow in these areas when asked to perform cognitive tasks. According to Bentall(1994), there is an attentional bias towards stimuli associated with danger, such as knives. These receive automatic priority in processing and may be exaggerated in the process. This sort of bias causes positive symptoms such as paranoia. This idea is shown on how schizophrenics perform on stroop tests. Studies have shown that schizophrenics take longer to name the colour of ink when emotional words such as ³laugh´ or ³cry´ are printed in the colour.

Evaluations
Advantages Biology is taken into account. Studies have shown that schizophrenics are more sensitive to emotions than normal people. This suggests that there is great processing of the stimuli. Disadvantages ³Schizophrenics have not been proven to be any harder to distract that a normal person when doing cognitive tasks. ³It doesn¶t offer an explanation to negative symptoms. ³The idea of an overload in the brain or extended processing is impossible to prove. ³Lots of people have attention problems but are not schizophrenic.

Treatments
Cognitive-behavioural therapy is aimed to address the sufferer¶s dysfunctional emotions. y CBT aims to help the sufferer challenge irrational emotions and irrational thoughts, such as feeling sad for no reason, or thinking that their family is trying to kill them. y CBT has been criticised because it is not yet known whether the irrational thoughts are a symptom of schizophrenia or the cause.
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Evaluation of Treatments
Advantages Zimmerman et al (2005) found that CBT was effective in treating positive symptoms of schizophrenia. Often, stressors can cause relapse in schizophrenics. CBT can help schizophrenics recognise that their reaction to stressors is irrational and therefore react in a more appropriate manner. Is successful when used in conjunction with drug therapy. Disadvantages ³Turkington et al (1998) found that CBT was only successful in treating patients in the short term. ³Zimmerman et al (2005) found that it is not successful in treating all subtypes of schizophrenia

Explanations
The Behavioural Approach

The behavioural approach
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This approach assumes that schizophrenia is caused badly learnt behaviour through operant conditioning. Children may be given sympathy and attention for bizarre behaviour and so continue the behaviour. They may be punished by being labelled as ³odd´ but then take it as a description of themselves and continue to act odd in order to conform to the label. Liberman (1982) suggested that if a child receives little or no social reinforcement early on in life (neglect), the child will focus on environmental cues rather than concentrating on stimuli in the normal way. As a result, the child¶s responses will appear bizarre. Those who observe the child¶s behaviour will either respond erratically or avoid it. This will reinforce the negative behaviour, eventually deteriorating into a psychotic state. Behaviourists explain the fact that schizophrenia rates tend to run higher in families as a function of social learning. The child copies the behaviour of the parent until eventually they are given the label ³schizophrenic´.

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Evaluations
Advantages Offers hope because you can relearn behaviour. Disadvantages ³Doesn¶t take into account biology, therefore it is reductionist. ³It can not be generalised to other cultures. Acceptable learnt behaviour may be unacceptable in another country. ³It is unlikely that hallucinations and thought disturbances can be acquired through reinforcement.

Treatments
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Token economy programmes can produce significant improvements as schizophrenics begin to show more desirable behaviour. Ayllon and Azrin(1968) set up a token economy inside a psychiatric institution. They found that the level of socially desirable behaviour increased as patients went from performing an average of 5 chores a day to around 40.

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Evaluation of Treatments
Advantages The treatment helps improve their behaviour in the short term Offers hope to the patients, giving them the chance to relearn behaviour. Disadvantages ³It only works in the short term. ³It does not work outside a controlled setting, therefore there is a high relapse rate when schizophrenics leave the institutions. ³The patient¶s behaviour could be superficial because they just want a reward. ³Ethical issues are present because it isn¶t actually addressing the disorder, it is just making their behaviour more acceptable by others.

Explanations
The Psychodynamic Approach

The Psychodynamic approach
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This approach was influenced by Freud and assumes that mental disorders are due to unconscious processes and fixations in early development stages. This theory assumes that behaviour is a result of processes in ³the mind´. However, it has been criticised by many because ³the mind´ is only a theory and can not be proven or disproven. This makes it un-falsifiable and therefore unscientific. The treatment includes psychoanalysis such as ³talking therapy´, free association and hypnotherapy. However, free association and hypnotherapy have been found ineffective in treating schizophrenia. Drake and Sederer(1986) actually found that therapies such as ³talk therapy´ often make symptoms much worse.

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Explanations
Social Approach

The social approach
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This approach assumes that schizophrenia is caused by family relationships. Bateson et al (1956) concluded that parents can cause their children to become schizophrenic by putting them in no-win situations. EG saying they¶re never affectionate but then saying they¶re too old to be cuddled. This often leaves the child feeling confused about their actions. Wayne et al (1977) carried out a study and found that children are more likely to become schizophrenic when their parents don¶t acknowledge what the child says. This is deviant communication and leaves the child doubting their words and actions. Fromm-Reichmann (1948) found that a high percentage of schizophrenics viewed their parents as being ineffectual and often felt inadequate. A number of studies have shown that most schizophrenics come from high maintenance families. Linzen et al (1997) concluded that families who react with high expressed emotion, hostility and intrusion are more likely to cause schizophrenic characteristics amongst their children. Lidz et al researched 14 families who had schizophrenic offspring and found that in 8 of the families, marital schism was present, in the remaining 6 families, marital skew was present.

Evaluations
Advantages Sufficient evidence found. Explains concordance rate between siblings. Takes responsibility away from the sufferer. This model has lead to the use of effective treatments. Disadvantages ³Studies can not show cause and effect as it is unethical to place people in this situation. ³All studies are conducted retrospectively and therefore could be biased. ³Some schizophrenics come from ideal families that do not seem to have any big problems at all. ³Not everyone with family problems becomes schizophrenic. ³Difficult to obtain evidence as families don¶t always like to be observed.

Treatments
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Family Education ± educating families on how to create a more reassuring home has been successful in avoiding relapse. Person-centred therapy ± This is where the patient speaks about their feelings towards their parents in a nonjudgemental environment. The therapist offers support and acceptance regardless of what the patient says.

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Evaluation of Treatments
Advantages Treatments have proven to be successful in relieving negative symptoms of schizophrenia and avoiding relapse. Reducing the levels of high expressed emotions in families makes other members of the household less likely to develop schizophrenia. Disadvantages ³Sometimes family education is unsuccessful in cases where the family is completely unsupportive.

Explanations
Biological Approach: Biochemical/Biomedical/Neuro-chemical/ Dopamine hypothesis, Neurodevelopmental Approach, Genetics

The biochemical approach
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This approach has about one million billion kazillion different names. The main biochemical explanation is the dopamine hypothesis. It assumes that schizophrenia is caused by problems with neurotransmitters that release too much dopamine which causes the positive symptoms of schizophrenia. Post mortem studies have shown high levels of dopamine in the brains of schizophrenics. Amphetamine causes simulation of dopamine and usually cause schizophrenic-like symptoms. Davis(1974) reported that amphetamine and cocaine intensifies the schizophrenic symptoms in diagnosed schizophrenics Amango (1999) reported that schizophrenics blink more than nonschizophrenics when staring into space and have poor pupillary reactions to light, which are clear indicators of neurological disease. McNeill(1993) commented that ³a considerable body of evidence points to the existence of structural abnormalities in the brains of schizophrenics´ However, Davis et al(1991) found that not all schizophrenic patients did have high levels of dopamine.

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The Neurodevelopmental approach This model assumes that schizophrenia is caused by badly developed brain structures.
Post mortems suggest that a disease could have damaged the brain structure in early development and may have only healed partially. Some schizophrenics went through a difficult birth and therefore could have suffered a lack of oxygen. The reported amount of schizophrenics has decreased over time, indicating that better maternity care has helped. Chua and McKenna (1995) pointed out that the only well-established structural abnormality in the brains of schizophrenics is lateral ventricular enlargement which is also found in some non-schizophrenics. Min et al (1999) claim that there are substantial shape differences in the thalami of schizophrenics. Torrey et al (1993) believe that schizophrenia may be the result of a virus effecting prenatal development, causing brain cells to only reach 85% of development. O¶callaghan et al reported an increased risk of schizophrenia for those in the 5th month of foetal development during the 1957 influenza pandemic. The virus can then re-activate in puberty because of the hormone changes. Bracha et al(1993) found that if one MZ twin develops schizophrenia, it is more likely to have hand deformities than the other twin. Suggesting that abnormalities are due to development. Stevens (1982) said that ³whatever causes the damage only affects those with an inherited susceptibility to schizophrenia´.

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The genetic approach
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This model assumes that schizophrenia is caused by genes. There is a sufficient amount of evidence to suggest that the closer the genetic relationship, the greater the risk of developing schizophrenia. Kendler (1985) demonstrated that relatives of those with schizophrenia are 18 times more at risk than the general population. Gottesman(1991) found that schizophrenia is more common in the biological relatives of a schizophrenic and that the closer the degree of genetic relatedness, the greater the risk. Identical twins are 42% more likely to develop schizophrenia whilst non-identical twins only have a 9% concordance rate. This shows that genetics may play a part but is not the sole factor in developing schizophrenia. Heston (1966) examined 47 children born to schizophrenic mothers who were adopted before the age of one month. He compared them with a group of 50 children who were born to nonschizophrenic mothers and reared in their biological families. He found that 5 of the schizophrenic mothers group developed schizophrenic, whilst none in the other group did.

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Evaluations
Advantages 
Sufficient evidence found. This model has lead to the use of effective treatments.

Disadvantages
³Post mortem studies are unreliable as the brain structure changes after death. ³It is unclear whether excess dopamine is a result or cause of schizophrenia. ³It is unlikely that dopamine is the sole factor in schizophrenia as neurotransmitter disorders are present in other manias but do not display the same symptoms. ³Only successful in explaining type 1 symptoms. ³It is hard to establish between environmental and genetic causes as twins still share the same environment in the womb, therefore one can not be sure whether it is a genetic or environmental cause, eg virus. ³Siblings are often reared in the same environment, making it difficult to conclude whether it is genetics or outside influences.

Treatments
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Anti-psychotic drugs such as phenothiazines are very successful in reducing type one symptoms of schizophrenia. They block/inhibit dopamine activity.

Evaluation of Treatments
Advantages Treatments have proven to be successful in relieving positive symptoms of schizophrenia. Drugs are effective long term. Disadvantages ³Sometimes drug treatments don¶t work. ³Sometimes the drug treatments eventually become useless at treating the disorder. ³They only relieve positive symptoms.

Explanations
Diathesis-stress model

The diathesis approach
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This approach was proposed by Gottesman and Reilly(2003). The model suggests that schizophrenia is due to a biological vulnerability which is then triggered by a psychological/environmental stressor. This vulnerability may be due to genetics or the result of illness in early life. Tienari (1987) did a longitudinal study into environmental factors by assessing the quality of parenting. He did this by following a group of children who had been born to schizophrenic mothers but adopted before the age of 1 month. He found that all the cases of schizophrenia occurred in those with ³disturbed´ families, whilst those whose environments were rated ³healthy´ actually seemed to have a lower risk of becoming schizophrenic than the general population.

Evaluations
Advantages Sufficient evidence found. Takes responsibility away from the sufferer. Is not reductionist. Longitudinal studies are often more reliable because they¶re not done in retrospect. Disadvantages ³Conflicting evidence present. ³Studies may be corrupted by bias.

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