SCHIZOPHRENIA

SCHIZOPHRENIA
• Schizophrenia is a serious and chronic mental illness that impairs a
person's thoughts and behavior, and if untreated, can include psychosis.

• According to the diagnostic and statistical manual of mental disorders

(DSM) the person shows one or more of the following symptoms:
delusions, hallucinations, disorganized speech, disorganized or catatonic
behavior, flattening of emotions; or continual voices in the head giving a
running commentary of what is happening.

• Schizophrenia lasts for at least 6 months and includes at least 1 month of

active-phase symptoms.
Symptoms can be split into positive and negative:

• Positive refers to the addition of certain behaviors. For example,

hallucinations, delusions of grandeur or control and insertion of thoughts
are all positive.

• Negative refers to the removal of certain behaviors. For example, poverty

of speech, withdrawal from society and flattening of mood are all
negative.
POSITIVE SYMPTOMS

• Delusions - beliefs individuals hold which are not based on reality. For
example, falsely believing that other people are trying to harm or kill you.

• Hallucinations - Sensory experiences that may involve seeing and hearing

things that do not exist, e.g. 'hearing voices.
• Disorganized thoughts - thoughts may be mixed up and racing the
person's speech might be jumbled and impossible to understand.

• Catatonic behavior - the person may not react to things in the

environment and remain rigid and unmoving in awkward poses, or
engage in constant, repetitive movements.

Negative symptoms - a loss of normal functioning, such as loss of

speech, lack of typical facial expressions or avolition.
DIAGNOSIS OF SCHIZOPHRENIA

• Those with schizophrenia show at least one of the following symptoms:

delusions, hallucinations and/ or disorganized speech, and may also
include catatonic behavior or negative symptoms.

• These signs must have been present for at least six months and cannot be
attributed to use of illegal substances or medication.

• The individual must also show a reduction in normal functioning (for

example, difficulty maintaining personal relationships, caring for
themselves or going to work or school).
DELUSIONAL DISORDER

• Delusional disorder is a disorder characterised by persistent delusions, but

people suffering from it otherwise have quite normal behaviour, unlike those
with classic schizophrenia.

• It also excludes those suffering other psychotic symptoms (hallucinations,

disorganised speech, catatonia or negative symptoms).

• Delusions may be bizarre or non-bizarre.

• Bizarre means that they are clearly impossible or beyond the realm of
ordinary occurrence. For eg, delusional disorder with bizarre content
might involve believing that one's internal organs had been removed and
replaced with those of another, without leaving any wounds or scars.

• Non-bizarre delusions might include the belief that one's partner is

cheating on them, or that their boss wants to fire them.

• The main difference is that non-bizarre delusions could be true or

possible (but unlikely) whereas bizarre delusions may be logically
impossible or difficult to understand.
SYMPTOM ASSESSMENT USING VR (FREEMAN, 2008)
• Difficulties with diagnosing schizophrenia and related disorders can relate
to interpretation of the individual's experiences in the social world.

• Freeman (2008) explores the potential for the use of virtual reality to
eliminate such challenges when checking symptoms and developing
treatment for schizophrenia.

• VR involves using the technology for presenting different social

environments to the user, and has been applied successfully in the
treatment and management of other disorders, such as social phobias.
• Usually, symptom assessment has relied on an interviewer and patient
sitting in a clinical room and discussing behavior over the previous week
or month.

• One problem with this approach is that it relies on the individual

answering truthfully. Also, discussing existing personal circumstances
cannot rule out that beliefs of persecution are unfounded.

• Using VR, the assessment can be novel and standardized while assessing
actual behavior. It also can ensure that paranoid thoughts and behavior
are genuine, as the social situation is totally artificial.
• The VR technique in this study involved a specifically designed library
or underground train scene where the user takes a walk or ride in the
presences of other neutral avatars wearing VR headgear.

• This was trialed on a non-clinical population of around 200 students.

• Prior to the VR test, a large number of validated measurement tools were
used to profile each individual's levels of paranoid thinking, emotional
distress and other social and cognitive traits, such as the 16 item Green et
al. Paranoid Thoughts Scale (GPTS) Part B.
• Measures of persecutory thinking were also taken after being in the
virtual environment, along with visual analogue rating scales, and
an assessment of their degree of immersion in the virtual
environment.

• They found that those who scored highly on questionnaire

assessment of paranoia experienced high levels of persecutory
ideation during the VR trial.
• This meant that they were more likely to make comments such as
‘Lady sitting down next to me laughed at me when I walked past’,
rather than positive or neutral comments such as 'Getting on with my
own business’.

• In related laboratory studies, Freeman reports that individuals who

experience auditory hallucinations in the real world also experienced
them in the VR environment.
EVALUATION

• The study by Freeman (2008) used a fairly large sample: however, it did
not represent a clinical population.

• The specially designed VR programme adopts a standardised approach

to assessment which increases the reliability of measurement.

• However, it compromises the ecological validity of the assessment.

• It also continues to rely on self-report, which may lead to response bias.
 ISSUES & DEBATES

• The VR trials outlined by Freeman (2008) have good relevance to

everyday life, meaning that they can be used to assess patient symptoms,
as well as potentially identify causal factors and treatment strategies.

• However, the method has not been used extensively in clinical

populations, meaning it is yet to be determined whether it can replace
conventional clinical interviews and questionnaires in diagnosing
schizophrenia.
• The diagnosis of schizophrenia and other psychotic disorders is
particularly open to criticism because it relies on culturally based
expectations of what constitutes normal social behavior - cultural bias

• There are also social norms around interacting in public, levels of eye
contact and personal space which vary among cultures.

• Use of VR in diagnosing symptoms would need to take such factors into

consideration to avoid creating biased interpretations of individuals'
behavior and comments.
EXPLANATIONS OF SCHIZOPHRENIA AND
DELUSIONAL DISORDER

• Genetic (Gottesman & Shields, 1972)

• Biochemical (dopamine hypothesis) (Lindström et al., 1999)
• Cognitive (Frith, 1992)
GENETIC (GOTTESMAN & SHIELDS, 1972)

• This idea states that there is a link between schizophrenia and inherited
genetic material.

• If this is the case then the closer our genetic link is to someone diagnosed
with schizophrenia, the more likely we are to be diagnosed ourselves.

• Gottesman and Shields (1972) carried out twin study research into the
genetic inheritance of schizophrenia.
• Schizophrenic symptoms are believed to have identifiable genetic
markers which may be inherited.

• Twin studies are highly useful in the study of genetic influence,

because they allow researchers to establish the relative influences of
nature and nurture.

• For example, identical or monozygotic (MZ) twins share their entire

DNA, whereas non-identical or dizygotic (DZ) twins only share around
50% of their DNA.
• If the occurrence of the disorder is no higher in MZ twins than DZ
twins, researchers may conclude that there is little genetic concordance.

• They took a sample of 57 twins (24 MZ & 33 DZ) from 467 who were
registered at the Maudsley Hospital in London between 1948 and 1964.

• Twins were identified as MZ or DZ using blood group and fingerprint

analysis. 

•  The researchers interviewed both the patients and their twins and also
they took cognitive tests, some of whom also had a diagnosis of
schizophrenia.
• In order to ensure the validity of diagnosis, case summaries of each
participant were independently evaluated by judges external to the research.

• Gottesman and Shields found that approximately 50% of MZ twins had a

shared schizophrenic status, but that concordance was much lower in DZ
twins (around 9%).

• In MZ twins, the co-twin was more likely to be schizophrenic if the illness

of their twin was severe. There was then a high likelihood their co twin also
showed some schizophrenic symptoms, whereas in mild cases co-twin
concordance was far lower.
EVALUATION

• The study used a large sample of MZ and DZ twins. Although the

results are likely to be representative of twins with schizophrenia
because of the sample size.

• The findings may not be generalizable to non-twin individuals.

• Also, the sample was drawn from only one hospital.
• However, assessments were made in part by independent judges,
reducing researcher bias.

• They also collected data using qualitative methods such as interviews,

which can gain in-depth data about participants, though may be more
subjective.
BIOCHEMICAL (DOPAMINE HYPOTHESIS)
(LINDSTRÖM et al., 1999)

• This idea is based around the idea that schizophrenia is caused by an

excess of dopamine in the brain.

• The dopamine hypothesis states that the brains of those with

schizophrenia produce more dopamine than those without the disorder.

• Dopamine is a neurotransmitter which enables communication between

two neurons across a small junction known as a 'synapse
• This hypothesis identifies a link between excessive amounts of
dopamine or dopamine receptors and positive symptoms of
schizophrenia and related disorders.

• Excess amount of dopamine in particular brain regions can be related

to certain symptoms, like an increase in the Broca's region (responsible
for formation of language) can impair logical speech, a classic
symptom of schizophrenia.
• Drugs like amphetamines and cocaine can increase the level of
dopamine in the brain. Large increases in dopamine production are
correlated with an increase in the reporting of hallucinations and
delusions.

• In those with schizophrenia, the effect of ingesting these drugs is to

worsen positive symptoms.

• Patients with Parkinson's disease are often treated with a synthetic

form of dopamine called L-dopa. If their dosage is too high, it also
creates symptoms in these individuals identical to those in people with
schizophrenia, such as hallucinations.
• Post-mortem studies have found that the brains of deceased individuals
with schizophrenia have a larger number of dopamine receptors than
those without the disorder.

• Wise et al. (1974) found that brain fluid from deceased patients had
abnormally low levels of the enzyme which breaks down dopamine,
suggesting it may have been present in excessive quantities.
• Positron emission tomography (PET) scan analysis of dopamine usage
indicates a greater number of receptors in the striatum, limbic system
and cortex of the brain in those with schizophrenia than in those
without.

• And excessive dopamine activity in these areas may be linked to

positive symptoms.

• However, Nestler, 1997 suggests that decreased dopamine activity in

the prefrontal cortex of schizophrenia patients may correlate with
negative symptoms such as flattened affect.
COGNITIVE (FRITH, 1992)
• The cognitive approach to abnormality recognizes that biological
factors contribute in some way to the positive symptoms of
schizophrenia.

• Frith (1992) accepts the role of biochemical processes, brain structure

and genetic influence on the disorder.

• However, since no one genetic, structural or biochemical cause has

been identified, he sought to frame the signs and symptoms of
schizophrenia in a cognitive manner.
• The idea here is that schizophrenia is caused by faulty information
processing, rather than relying solely on physiological explanations.

• He describes schizophrenia as an abnormality of self monitoring as

when patients fail to recognize that their perceived hallucinations are in
fact just inner speech (the kind of self-talk people normally
experience),

• It leads them to attribute what they are hearing to someone else, e.g. a
voice speaking to them from an external source.
• He tested this with schizophrenic patients by asking them to decide
whether items that had been read out loud were done so by themselves,
an experimenter or a computer.

• Schizophrenic patients with incoherent speech as a symptom performed

worst at the task, which may be linked to memory and attention
difficulties crucial for self-monitoring,

• Delusional thinking may also arise from a misinterpretation of

perception.
• Thoughts that are actually self-generated instead appear to be coming
from an external source for a person with schizophrenia and become
incorporated in the individual's set of beliefs.

• These failures in monitoring can lead to delusions of alien control,

auditory hallucinations and thought insertion.

• And their inability to monitor the intentions of others can lead to

delusions of paranoia and incoherence.
• Frith explains that those experiencing negative symptoms such as a
lack of action have difficulty generating spontaneous actions.

• This may arise in part due to impaired theory of mind, which creates
problems in recognizing the intentions of others.

• A flattening of affect, lack of speech and social withdrawal all result

from difficulties in monitoring their own mental states and the states of
others.
ISSUES & DEBATES

• The nature versus nurture debate is particularly relevant to

understanding explanations of schizophrenia and related disorders.

• The longitudinal twin study technique employed by Gottesman and

Shields (1972) attempts to establish a causal link between genetics

(nature) and mental disorder. However, it is likely that MZ twins are

not only more genetically similar than DZ twins, but are more likely to

be treated more similarly by others.

• This is because they are always the same gender (unlike DZs), and may
look much more alike. DZ twins, although they are the same age and live
in the same environment, may experience life more like ordinary non-twin
siblings. This means that not all differences between MZ and DZ twins
can be simply attributed to genetics.

• Biological and cognitive explanations are often considered reductionist.

Gottesman and Shields attribute the origin of schizophrenia to particular
genes or gene combinations, the most simple biological explanation
possible.
• However, they do acknowledge that environmental factors are
important to the onset of the disorder.

• The dopamine hypothesis also indicates a specific biological origin,

namely disruption to the normal uptake of a particular neurotransmitter.

• The cognitive theory put forward by Frith is more holistic as it takes

into account mental processing as well as biological causes, but could
still be said to ignore social and environmental causes for the disorder. 
• All three explanations point to individual explanations not situational
ones.

• Psychologists from the social or psychodynamic traditions would look

towards situational factors that contribute to the disorder, such as
traumatic events on difficulty with forming early relationships.
TREATMENT OF SCHIZOPHRENIA

• Biochemical
• Electroconvulsive Therapy (ECT)
• Token economy (Paul & Lentz, 1977)
• Cognitive behavioural therapy (CBT, Sensky et al., 2000)
BIOCHEMICAL

• This treatment centres on using drugs to alleviate the symptoms of

schizophrenia. They can be broadly divided into two types as
antipsychotics and atypical antipsychotics. These are also known as
first and second generation antipsychotics.

• First generation antipsychotics emerged in the 1950s, whereas the

second generation of these drugs came into usage during the 1990s.
Both types reduce the severity of psychotic symptoms in those
suffering from schizophrenia and related disorders.
• These drugs affect different neurotransmitters such as serotonin and
norepinephrine, depending on the individual antipsychotic.

• After one week, patients may appear less hostile and agitated, and after
two or three weeks many report diminished positive symptoms.

• The use of antipsychotic drugs has been thoroughly researched using

randomised control trials (RCT). These trials are often double-blind
placebo controlled.

• It is shown that around 50% of those taking antipsychotic medication

show significant improvement in their condition after four to six weeks.
• Around 30-40% show partial improvement; but a substantial minority of
those remaining patients show little to no improvement in their
functioning, which is known as treatment resistant' schizophrenia.

• Relapse rates using antipsychotics can be quite high. One reason for this is
that patients are usually directed to keep taking medication after acute
psychotic episodes, even in periods of remission.

• The medication can cause unpleasant side effects such as weight gain,
drowsiness, extrapyramidal symptoms (EPS) and tardive dyskenesia (TD).
• When an individual experiences a reduction in symptoms combined with
unpleasant side effects, non-adherence to medication may arise.

• Atypical antipsychotics are less likely to produce unwanted side effects

such as EPS and TD than first generation antipsychotics.

• Atypical antipsychotics may also carry increased risk of side effects such
as weight gain and obesity, which can lead to heart disease and diabetes.
ELECTRO-CONVULSIVE THERAPY (ECT)

• ECT is another biological treatment which has been applied to help

alleviate symptoms of schizophrenia and related disorders.

• ECT is basically a procedure where a person receives a brief

application of electricity to induce a seizure.

• Early attempts at this were not pleasant but nowadays patients are
anaesthetized and given muscle relaxants.
• Electrodes are fitted to specific areas of the head and a small electrical
current is passed through them for no longer than one second.

• The seizure may last up to 1 minute and the patient regains consciousness
in around 15 minutes.

• Patients usually undergo a course of ECT treatments ranging from six to

12 sessions, although some may need fewer. It is typically given twice a
week during the treatment period, or less commonly at longer intervals in
order to prevent relapse of symptoms.
• Instead of applying ECT bilaterally (across both brain hemispheres), it
is now applied unilaterally to the non dominant hemisphere to reduce
memory loss.

• There will always be debate about whether ECT should be used for any
mental health issue as clinicians and psychologists are divided on the
severity of the therapy itself and the longer-term side effects.

• Despite improvements to the technique, there are still significant risks

involved to the individual. 
• The procedure affects the central nervous system and cardiovascular
system, which can be dangerous for those with pre-existing medical
conditions.

• Memory loss is still a common side effect of ECT. More serious but
extremely rare side effects can include lasting neurological damage or
even death.

• ECT is rarely used in the treatment of schizophrenia because of a lack of

evidence to suggest it is more effective than other forms of therapy, such
as antipsychotics.
• Evidence suggests that ECT can be effective during acute episodes of
psychosis where fast, short-term improvement of severe symptoms is needed.

• There is also some evidence indicating it may be most effective for

individuals experiencing catatonic symptoms (NICE, 2015).

• Thirthalli et al (2009) reported that in a sample of schizophrenics (split into

catatonic and noncatatonic), those who were catatonic required fewer ECT
sessions to help control their symptoms.
 TOKEN ECONOMY (PAUL & LENTZ, 1977)

• Token economies are based on the idea of operant conditioning (rewards

and learning by consequence). Behaviour is shaped towards something
desired by giving out tokens (e.g. plastic chips or a stamp) every time a
relevant behaviour is shown.

• Patients can accrue these tokens and exchange them for something they
would like (e.g. money, food vouchers).
• Patients continue to show desired behaviors as they want to earn tokens
to exchange for primary reinforcers that fulfil a direct biological need
(e.g. satisfying hunger or giving enjoyment).

• Ayllon & Azrin (1968) introduced a token economy to a psychiatric

hospital in a ward for long-stay female patients. Patients were rewarded
for behaviors such as brushing their hair, making their bed and having a
neat appearance. Their behavior rapidly improved and it also had a
benefit for staff morale as staff were seeing more positive behaviours.
• Paul and Lentz (1977) investigated the effectiveness of token economy
to reinforce appropriate behavior with schizophrenic patients.

• The participants were 84 individuals with chronic admissions to

psychiatric institutions who were split into three different groups as
milieu therapy, traditional existing hospital management of
schizophrenia and a token economy system in a hospital ward.

• Over around four and a half years, Paul and Lentz compared the
outcomes of these three different forms of treatment.
• Patients in this token economy condition were given a 'token' as a
reward for appropriate behaviours such as self-care, attending therapy
and engaging socially. Although the tokens had no value in themselves,
they could be exchanged for luxury items, such as clothing, TV use,
sweets and cigarettes.

• The behaviour of the patient groups was monitored through time-

sampled observations, standardized  questionnaire scales and individual
interviews. Some overall reduction in both positive and negative
symptoms was observed.
• The system was most effective at reducing catatonic behavior and social
withdrawal but less successful in reducing hallucinations and delusional
thinking.

• Results indicates that 97% of the token economy group were subsequently able
to live independently in the community for between 1.5 and five years,
compared to 71% in the milieu group and 45% in the hospital group.

• The researchers concluded that operant conditioning can be an effective method

of managing the symptoms of schizophrenia and ensuring good potential for
long-term discharge of patients.
 EVALUATION

• This study involved intensive staff training to ensure rewards were

administered reliably. Staff were monitored and issued with a manual to
ensure procedures were standardized.

• Such rigorous enforcement in other hospitals and indeed the outside world
might not be possible, which lowers the ecological validity of the study.

• There are ethical issues with denying privileges to patients who do not behave
appropriately and may become demotivated and distressed by the therapy.
COGNITIVE BEHAVIOURAL THERAPY
(SENSKY ET AL., 2000)

• This type of therapy aims to change or modify people's thoughts and

beliefs and also change the way that they process information. A
therapist will challenge irrational and faulty thoughts as well as
behaviors that are not helping.

• CBT is an approach to the treatment of mental health disorders which

incorporates principles of both the cognitive and behaviorist
approaches to psychology.
• Patients may be set tasks outside of the face-to-face therapy to help
challenge faulty thoughts and beliefs.

• For schizophrenia, the intention of CBT would be to help patients make

sense of the psychotic experiences and reduce the negative effects of the
condition plus any distress they may be feeling.

• Sensky et al. (2000) carried out a randomized control trial to compare the
effectiveness of CBT with a control group who engaged in 'befriending.
Befriending sessions included informal one-to-one discussions about
hobbies, sports or current affairs. 
• Ninety patients aged 16-60 years with a diagnosis of treatment-resistant
schizophrenia from five clinical services received a mean average of 19
sessions of CBT or befriending over the treatment period.
• They were randomly allocated to either treatment condition, making this
an independent groups design.
• Each intervention was delivered by two experienced nurses. The CBT
treatment followed distinct stages, including engaging with the patient
and discussing the emergence of their disorder, before tackling specific
symptoms.
• For example, those with auditory hallucinations engaged in a joint
critical analysis with the nurse to challenge beliefs about the nature and
origin of the voices.

• Patients kept voice diaries to record what they were hearing in order to
generate coping strategies.

• Participants were assessed by blind raters before the start of their

treatment, at treatment completion (up to nine months) and at a nine
month follow-up.
• They used a number of standardized, validated assessment scales such as
the Comprehensive Psychiatric Rating Scale (CPRS) and Scale for the
Assessment of Negative Symptoms (SANS).

• Results showed that both groups showed a significant overall reduction in

both positive and negative symptoms of schizophrenia.

• At the follow-up stage, the CBT group continued to improve in reduction

of positive symptoms, whereas those in the befriending group did not.
EVALUATION

• Sensky et al. (2000) used an RCT design, which increased validity.

Assessors were blind to the treatment group they were assessing, which
removes any bias they might have felt for or against the treatment.

• Participants were from several different clinics across the UK, so the
sample was probably fairly representative.

• The nurses in both conditions were carefully trained and monitored

which ensured they used a standardized approach to the CBT.
ISSUES & DEBATES

• The treatment of schizophrenia and related disorders has important

application to real life.

• Biochemical treatment in the form of antipsychotics is usually the

primary treatment for the disorder, and has been shown to be effective
in reducing the positive symptoms of schizophrenia in the majority of
people. This reduces hospitalization and can improve quality of life.

• ECT is far less effective and is likely only to be used in urgent, acute
cases or those with primarily catatonic symptoms.
• The lasting impact of token economies on those with schizophrenia was
evidenced in the study by Paul and Lentz (1977); but, implementing the
system requires specific conditions and rigorous training and
enforcement by clinical staff.

• The effectiveness of CBT treatment by Sensky et al. (2000) is fairly

significant, and may offer hope to individuals who have not responded
well to antipsychotic medication.
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