Paper 3 - Schizophrenia

DSM V 

• According to the DSM V two or more primary symptoms should be present for a significant portion of time during a one month period to be diagnosed with schizophrenia. 
• At least one of these primary symptoms should be positive; these are additional experiences beyond the ordinary. 
• Such as hallucinations, these are sensory experiences that have to basis in reality eg. hearing voices or seeing things that aren't there.
• According to the DSM V an individual should also experience one of more secondary symptoms, so their work, interpersonal relations or self-care are markedly below the level acheived prior to the oset, this disturbance should be present for at least six months. 

ICD 10

• In the ICD 10 two or more negative symptoms are sufficient for a schizophrenic diagnosis; these involve the loss of usual abilities or experiences. 
• Such as speech poverty, a reduction in the amount of quality of speech including delays during spoken conversation. 

Reliability - (P) limitation, low inter-rater (E) Chenieux 2009 2 psychiatrists 100 patients (E) DSM 26/13, different in ICD too (L) inconsistency limits diagnosis

Validity - (P) limitation, lacks concurrent (E) eg Chenieux 2009 more likely ICD than DSM (E) ICD 44/24 out of 100 DSM 26/13 (L) ICD over diagnosed, DSM under diagnosed 

Symptom Overap - (P) schzophrenia and bipolar (E) poitive delusions and negative avolition (E) misdiagnosis reduces validity (L) different treatment so may be ineffective

Co-Morbidity - (P) limitation, co-morbidity (E) commonly occur with other conditions (E) Buckley 2009 50% depression 47% substance abuse 23% OCD (L) better seen as one condition

Gender Bias - (P) problem of gender bias (E) Longnecker 2010 since 1980 men>women (E) Cotton 2009 females function better (L) women underdiagnosed 

Culture Bias - (P) limitation, culture bias (E) African-Americans more (E) not in Africa, cultural differences hearing voices acceptable or not (L) limitation, lack validity due to misrepresentations and side effects of treatments. 

• Genetic = Schizophrenia is a polygenic diorder; Ripke (2014) studied 37000 patients and found 108 seperate genetic variations associated with increased risk
• One group of these genetic variations may cause one kind of schiophrenia in one person but a different group of genes may cause the disorder in another person making schizophrenia aetiologically heterogenous. 

• Neural = The genes associated with increased risk include those coding for the function of dopamine and glutamate.
• The dopamine hypothesis suggests that the positive symptoms of schizophrenia are associated with high levels of dopamine in the subcortex; this is due to the fact that too much dopamine activity could lead to excessive thinking, contributing to delusions and hallucinations. 
• The negative symptoms of schiophrenia have been associated woth low levels of dopamine in the cortex; less plesure could effect motivation contributing to avolition. 
• The neural explanation also suggests that the negative symptoms of schizophrenia are caused bylower levels of activity n the ventral stratum; this is the part of the brain involved in the anticipation of reward, it follows that reduced activity in this area of the brain is linked to reduced motivation and therefore avolition

Supporting Evidence - (P) twin studies (E) Gottesman 48% concordance mz 17% dz (E) 100% genes mz 50% genes dz (L) demonstrates genetic basis

Critique - (P) assume same environment (E) mz same gender (E) concorance rates dont match genes (L) reduces internal validity

Oppoing Research - (P) Stiling (E) stroop task, twice as long (E) dysfunction in central control (L) incomlete explanation du to genetic basis belief 

Debates - (P) Reductionist (E) single cause conduct experiments (E) oversimplify, effectiveness of family theray (L) diathesis stress better, genes and schizophrenogenic mother 

Applications - (P) therapy (E) typical antipsychotics block post-syn dopamine (E) reduced number of receptors, reduce dopamine (L) effectiveness reinforces hyperdoapminergia

• One psychological explanation of schizophrenia is family dysfunction; this assumes that schizophrenia is caused by abnomal patterns of communcation within a family. 
• One family variable associated with schizophrenia is a schizophrenogenic mother; this mother is cold, rejecting and cotrolling
• this leads to the onset of schizophrenia as it creates a family climate characterised by tension and secrecy causing distrust in the child, this distrust devlops into paranoid delusions and ultimately schizophrenia. 
• Another family characteristic linked to schizophrenia is double bind behaviour, this is caused by mixed messaged from parents causing the child to feel as though they cant do anything right, resulting in paranoia
• It has also been shown that schizophrenics returning to families with high expressed emotion (EE) are more likely to relapse
• EE is operationalised as including criticism, hostility and over-emotional involvement; this may trigger relapse due to the high levels of stress created.

Supporting Evidence - (P) demonstrate impact of EE in relapse (E) Bebbington and Kuipers 1994 meta-analysis 26 studies (E) statistically significant difference high EE 50% low EE 21% (L) Support EE

Criticism - (P) limitation, correlational (E) high EE causes relapse (E) relapse may cause EE (L) corelate, reduce validity, cant establish cause and effect

Opposing Relapse - (P) Gottesman 1991 (E) 48% MZ  and 17% DZ (E) genetic basis same environment (L) psychological explanation incomplete 

Debates - (P) reductionist, dysfunction in family (E) conduct experiments, identify single cause (E) oversimplify, antipsychotics (L) diathesis stress better genes onset by schizophrenogenic mother

Applications - (P) therapy (E) Family therapy understand condition (E) reduces stress and EE in family  (L) effectiveness reinforces EE

• One psychological explanation od schizophrenia is cognitive dysfunction; this assumes that schizophrenia is caused by abnormal thought processing 
• One cognitive impairment associated with schizophrenia is dysfunction in metarepresentation; this would disrupt an individuals ability to recognise their thoughts and actions as their own
• If somebody believes their own actions are actually being carried out by somebody else this would contribute to delusions
• If somebody cant recognise the thoughts in their head as their own this will be seen as an auditory hallucination
• Another cognitive impairment is dysfunction in central control, this leads to the inability to supress automatic thoughts triggered by another thought
• If somebody changes topic mid-sentence, this will be seen as disorganised speech. 

Supporting Evidence -  (P) Stirling 2006 (E) Name the ink colour of the colour word (E) schizophrenics took twice as long (L) demonstrates dysfunction in central control

Critique - (P) limitation, correlational (E) dysfunction lead to pos symptoms like speech disorganisation (E) positive symptoms cause dysfunction (L) corelate, low validity, cause and effect

Opposing Research - (P) Gottesman 1991 (E) MZ 48% DZ 17% (E) genetic basis same environment (L) abnormal though processing incomplete explanation 

Debates - (P) limitation, partial explanation (E) can cause of symptoms (E) cant explain the origin (L) biological and psychological need explaining 

Application - (P) therapy (E) CBT coping strategies  (E) dysfunction in central control is helped (L) effectiveness reinforces cognitive basis

• The most common treatment for schizophrenia involves the use of antipsychotics; typical antipsychotics work by acting as an antagonist in the dopamine system
• They block the postsynaptic dopamine receptors, which prevents dopamine from building and so reduces activity in dopaminergic areas of the brain. 
• Typical antipsychotics reduce the positive symptoms of schizophrenia, primarily due to the sedative effect of the drug. 
• When typical antipsychotics are not effective, the dose can be increased by up to 800mg, alternatively newer atypical antipsychotics can be tried. 
• Atypical antipsychotics work by binding to dopamine receptors but in addiction acts on serotonin receptors and glutamate receptors. 
• This medication reduces the negative symptoms of schizophrenia as well as the positive due to the different neurotransmitters targeted; eg, serotonin can help to increase mood, aiding avolition. 

Time - (P) strength, quick to access (E) typical antipsychotics, admitted to hospital to reduce anxiety (E) Atypical antipsychotics reduce suicide risk mood enhancing effects (L) 30-50% attempt suicide

Effectiveness - (P) Cole 1964 (E) typical 76% improved compared to placebo 25% (E) Meltzer 2012typical failed, atypical 30-50% effctive (L) positive and negative symptoms

Acceptability - (P) strength, not disruptive (E) passive role, take drug (E) limitation, motivation (L) Trust, hallucinations and delusions 

Relapse - (P) high, not lasting (E) relapse within weeks (E) no permenant change to dopamine system (L) Long term would be CBT and drugs 

Side Effects - (P) limitation, severe (E) typical antipsychotics, dizziness, sleepiness, weight gain, stiff joints, itchy skin, long term involuntary facial movements (E) Atypical supress immune system (L) limitation, reduce quality of life 

• One cognitive behavioural therapy used to treat schizophrenia is coping strategy enhancement; the aim of this treatment is to teach individuals how to use coping strategies to reduce the frequency and intensity of psychotic symptoms 
• CSE (coping strategy enhancement) begins with initial assessment, there is a thourough behaviour analysis of each symptom as well as an assessment of any coping strategies the subject may already employ 
• This helps with the dysfunction in misrepresentation due to increased insight and understanding of their symptoms 
• CSE then progresses on to education and rapport training; this involves creating an ambience and shared understanding so that the therapist and client can work together
• The final stage is symptom targeting; here an existing coping strategy is enhanced and practiced during the sessions and for homework
• This helps with dysfunction in cemtral control as they learn to block out their automatic negative thoughts through coping strategies

Time - (P) limitation, hard to access (E) long waiting lists (E) series of sessions (L) limitation, mental health can deteriorate high suicide risk

Effectiveness - (P) tarrier (E) Effectiveness tested for those who found drugs ineffective (E) 50% improvement in positive symptoms (L) effectiveness still in 6 month supports CBT treatment 

Acceptability - (P) limitation, disruptive (E) active role learning coping strategies (E) limitation, lack motivation (L) strength active responsibility 

Relapse - (P) strength lower than drugs (E) long term solutions due to coping strategies (E) EG auditory hallucinations heavy metal to drown out and relieve (L) more effective than drugs 

Side Effects - (P) strength no physical side effects (E) eg no weight gain (E) positive psychological side effects improve self-esteem (L) strength, improves quality of life so continue the therapy

• one psychological therapy used to treat schizophrenia is family therapy, this aims to improve the functioning and communication of a family with a member suffering from schizophrenia 
• one strategy used in family therapy is psychoeducation, this involves helping the merson and the carers to better understand the illness 
• This can help to reduce a family members criticisms due to their increased insight into the condition 
• During family therapy the individual with schizophrenia is also encouraged to talk to their family and explain what support they find helpful and what makes things worse for them, this can help to reduce over-emotional involvement 
• Another strategy includes helping family members acheive a balance between caring for the individual with schizophrenia and maintaining their own lives, helping to reduce anger and hostility 
• These strategies work by reducing stress and expressed emotion, which in turn help to reduce relapse and readmission to hospital

Time - (P) Limitation, hard to access (E) Waiting lists (E) 10 sessions, 3-12 months (L) Limitation, risk of suicide 

Effectiveness - (P) Pharo 2010 (E) 53 studies reviewed between 2002-10 family intervention (E) Reduction in relapse reduction in hospital admissions up to 24 months (E) Main reason was increased medication compliance (E) More likely to reap benefits, comply with routine (L) NICE guidelines family therapy for those with or in contact with family 

Acceptability - (P) Strength, active role (E) Family feel helpless therapy is involvement (E) Active role is limitation for patient (L) Limitation, lack motivation 

Side Effects - (P) Limitation, problems within family (E) Family feel bad, fell responsible (E) Patient feel bad troubled family situation (L) More stress, EE results in relapse

• Token economies are a form of behavioural therapy, where desirable behaviours are encouraged through operant conditioning 
• Tokens are given immediately to patients when they have carried out a desirable behaviour that has been targeted; this may be getting dressed in the morning, or making the bed
• Tokens become secondary reinforcers when the patient learns that they can be used to obtain rewards 
• The primary reinforcers are anything that give people pleasure EG. food, or anything that removes unpleasant states EG. watching tv to alleviate boredom 
• The idea is that once the tokens are seen as rewarding the individual will engage more often with desirable behaviours because the behaviour becomes linked to these rewards and privelidges 
• Modifying bad habits does not cure schizophrenia but it does improve their quality of life

Time - (P) strength, easy to impliment (E) easy to recieve tokens no waiting lists (E) strength, stimulus-response links (L) engagement prevents suicide 

Effectiveness - (P) Dickerson 2005 (E) 13 studies reviewed (E) 11 beneficial effects (L) strength demonstrates effectiveness 

Acceptability - (P) limitation, disruptive to patients lives (E) active role, get out of bed (E) limitation, not motivate due to avolition (L) strength, take responsibility 

Relapse - (P) limitation, high relapse rates (E) based on continuous reinforcement (E) leave hospital, unlikely to be rewarded so no reinforcement (L) continuous reinforcement extinction, reduction in quality of life. 

Side Effects - (P) limitation, controversial (E) more available to those with neg symptoms (E) severely ill not able to perform so discriminated (L) Reduced usage of token economies in the psychiatric system

Tokens are paired with rewarding stimuliand so become secondary reinforcers 

Patients engage in target behaviours or reduce innapropriate ones

Patients are given tokens for engaging in these target behaviours

Patients trade these tokens for access to desirable items or other privelidges

Its a loop!

• Explaining = One example of an interactionist approach to explaining schizophrenia is the diathesis stress model; this combines the effects of the internal vulnerability and external stress triggers
• EG if an individual inherits candidate genes that code for the functioning of dopamine this will make them more vulnerable to developing schizophrenia 
• If they are then subject to to psychological stress as a result of parenting then schizophrenia will arise, this stress could arise from being part of a high EE family
• The vulnerability (diathesis) part of the diagram was origionally thought to be genetic, but it now includes vulnerability due to childhood trauma when it might have effected brain development. 

• Treating = An interactionist approach to treatment would combine biological and psychological therapies in order to tackle the different aspects of the condition 
• EG an individual may start by taking antipsychotic drugs to tackle the underlying neurochemical cause of the positive and negative symptoms of schizophrenia
• This may then be combined wiht family therapy, reducing stress and EE helps to reduce the liklihood of relapse and hospital re-admission arguable due to the increased compliance with their medication

Explaining =

Diathesis                   Stress

Gene for dopamine + High EE family = Schizophrenia

Treating = 

Biological            Psychological

Antipsychotics + Family therapy = Effective treatment 

1. (P) Human behaviour is complex, no single cause (E) EG, bio not explain stirling 06 stroop task (E) Cog not explain antipsychotics reduce dopamine (L) Recognises complexity, full

2. (P) Evidence to support (E) Tienarin 04 children adopted familys mother schiz (E) Criticism and conflict lead to schiz with high risk (L) Both genetic and stress from family 

3. (P) Support effectiveness treatment combo (E) Tarrier 04 med + CBT, med + counselling or just med (E) Two combo lower symptoms (L) Clear practical advantage of interactionist 

4. (P) Promblem, causation fallacy (E) Bio + pscyh is more effective but not necessarily correct (E) Drugs help not necessarily gen basis (L) Reduce validity, more research needed

5. (P) Further evidence NICE guidelines both CBT and antipsych (E) NHS lacks funding, more on secure care (E) 38 day admission = £12000 (L) Effective but many issues in practice