Schizophrenia

Positive Symptoms

Hallucinations - when the sufferer perceives something that is not present, which could be visual, sensory or auditory, which is the most common form 

Delusions - an irrational belief that contradicts reality. Delusions of grandeur - believing they are important than they are. Delusions of persecution - believing that people are out to get them.

Disorganised Speech - they may not be able to keep a train of thought so they speak nonsense and it sounds jumbled, sometimes referred to as word salad

Negative Symptoms

Speech Poverty - giving brief or no response in a conversation and showing no extra effort

Avolition - a lack of drive, motivation or interest in achieving goals

Lack of emotion - not reacting to typically emotional situations or reacting inappropriately

1. Paranoid Schizophrenia:

Delusions and or hallucinations are the predominant characteristics. Negative symptoms such as flattening of affect and poverty of speech are less apparent than in other types.

2. Disorganised Schizophrenia:

Disorganised behaviour and rambling incoherent speech; 

3. Catatonic Schizophrenia:

Psychomotor abnormality is the central characteristic. Strange postures and flailing limbs.

4. Undifferentiated Schizophrenia:

When they have not enough symptoms to fit into a type or too many to fit into one single type.

2 Sets to Diagnose SZ

Confusion by having two alternate sets of diagnostic criteria, now closer than ever and definitions are clearer but still not identical. Can lead to effective treatment programs but can lead to labeling. Still significant differences despite constant reviews and updates

No Objective Tests

So is subjectively interpreted and clinicians may use different techniques. Seen in Beck's study when 2 psychiatrists considered 154 patients and they only agreed in 54%. 40 years on, Whaley found inter-rater reliability could be as low as 0.11 which shows updates in science are not improving diagnosis. Subjective nature leads to poor reliability.

Lack of Consistency Between Countries

Reliability challenged by a significant variation between countries which leads to culture bias. A psychiatrist may use their own life experience. Seen in the high diagnosis of SZ in afro-cariibean people compared to UK residents and higher diagnoses in lower classes. Lack of understanding of norms in cultures cause problems with reliability

Symptom Overlap

SZ has no unique symptoms e.g. negative symptoms are similar to symptoms of depression and bipolar disorder. Also, it was found cocaine abusers may have disorganised speech and hallucinations. May lead to incorrect treatment, no treatment or labelling. Hard to be accurate

Co-Morbidity

Makes it difficult to define boundaries between them. Weber found that psychiatric diagnoses also coincided with diagnoses like hypertension and type 2 diabetes as they receive a lower standard of care as a result. Leads to incorrect treatment which can result in further complications

Gender Bias

Occurs as females are seen as less mentally healthy. Broverman found that the ideal mental health behaviour was equated to male behaviour. This may give women more incorrect diagnoses or unwell men may be left with no treatment

Twin Studies - Gottesman found a 48% concordance rate of SZ in monozygotic twins. Identical Genain quadruplets all developed SZ. Good as Sheilds also found MZ twins raised in different families still have 50% concordance rate. Bad as it uses a small sample and may be different for every twin, MZ twins may be treated similarly so their environment should be the same and same genes should mean 100% concordance.

Adoption Studies - Tienari found of the 164 adoptees whose biological mothers had been diagnosed with SZ, 11 also had SZ compared to 4 from the 197 control adoptees from non-SZ mothers. This shows even without direct contact with a SZ sufferer, the likelihood increases to the biological predispostion to the disorder

Dopamine is a neurotransmitter in the brain that causes neurons to fire. Claims that an excess of this in certain regions is associated with the positive symptoms of SZ.

"Original" Dopamine Hypothesis - Excess of dopamine. Neurons fire too often. Transmit too many messages. Message overload may produce many of the symptoms of SZ. Found that drugs like amphetamine increase the amount of dopamine and large doses of this when given to a mentally healthy person could cause SZ symptoms or small doses to SZ sufferer may worsen symptoms.

"Revised" Dopamine Hypothesis - SZ sufferer may have an excess of dopamine receptors. More receptors lead to more firing. Too many messages. Some autopsies have found more dopamine receptors in SZ brains. Inconclusive though as other studies they have failed to reveal this

Supported by Leucht who carried out a meta-analysis of studies of antipsychotic versus placebo and found symptoms reduce when dopamine was normalised. 

Smoking and stress are still confounding variables as there is not a clear correlation between SZ and dopamine so it does not show cause and effect. May be that dopamine is a symptom of SZ and not a cause

A neural correlate is something within the brain that can be linked to a behaviour or condition.

Johnstone et al compared the size of ventricles in the brain of SZ sufferers versus without SZ and found that SZ is linked with enlarged ventricles and a reduction in the temporal and frontal lobe volume.

Boos et al found through fMRI that SZ participants had decreasing grey matter density and cortical thinning compared to others which suggests brain tissue differences can cause SZ 

Scientific as scans are objective so a difference can be recorded reliably. However, cause and effect may be hard to establish as there is no way of knowing structure directly causes SZ

Only looks at nature, and does not consider nurture.

This makes it reductionist as it only views behaviour as an effect from our biology. Does not take into account personal factors such as the environment. Evidence has shown psychological factors could affect SZ development. 

In order to achieve a holistic theory, both sides should be considered.

The diathesis-stress model is an alternative explanation for the cause of SZ as it suggests both nature and nurture are considered.

Family Dysfunction - presence of problems within a family that contributes to relapse rates in recovering SZs. Can include a lack of warmth from parents, overprotection or bad communication

Double Bind - Bateman suggested children who received contradictory messages from their parents were prevented from developing internally coherent reality which became SZ symptoms e.g. aggressively yelling "I love you" to their son.

Expressed Emotion - when the family talk about the patient in a hostile or over-concerned way which creates a negative emotional climate that makes a patient returning to a family with high EE 4 times more likely to relapse

Berger found that SZ patients recalled more double bind statements by their mothers than non-SZ but evidence is not reliable as recall is affected by SZ

Retrospective so no way of knowing if the disorder caused family dysfunction or vice versa, families were only studied after SZ developed

Dysfunctional Thought Processing - cognitive habits or beliefs that cause the individual to evaluate information inappropriately

Delusions - explained by an interpretation of their experiences that have been inadequately processed so they have an egocentric bias meaning they jump to conclusions about external events e.g. they are out to get me

Hallucinations - explained by an individual's thought being too focused on excessive attention and they cannot distinguish between self-generated experience and reality

Sarin and Wallin found that delusional patients were found to show biases in their focusing like conclusion jumping and lack of reality testing and their own thoughts were perceived as voices

Meyer-Lindenberg found people with SZ did worse in memory recall tasks showing their cognitive activity is reduced 

Thought processing could be a result of another explanation e.g. family dysfunction causes faulty thoughts meaning this is not an explanation, but an effect

Nurture and ignores all biological factors even though there has been evidence to show genetics and the biology of an individual may cause SZ

Reductionist as it is only describing behaviour in terms of the environment 

In order to achieve a holistic theory, both sides should be considered

An alternative explanation to SZ is the diathesis-stress model which looks at both nature and nurture and provides a holistic view

Both explanations alone view only one side. To avoid this, a holistic view should be taken

Sz is an interaction between having a biological predisposition makes you more likely to develop it e.g. MZ twins 48% concordance rate

However, Varess found children who experienced trauma were more likely to develop SZ. The stresses of living in a high urbanised environment can also trigger SZ such a money issues and stressful job.

Tienari found that in adoptees, 11 out of 14 who developed SZ had been in the genetically vulnerable category and the 3 who hadn't had been in high-stress families

However, the interviews were only once and expected so social desirability 

Vassos' meta-analysis found that the risk for SZ in urban areas was 2.37 higher than in rural areas

However, SZ studies do not use a big sample because of the nature of the disorder.

Drugs were not effective and patients were put into "safe" environments but in 1952, dopamine was discovered and antipsychotics could be made to treat SZ

TYPICAL antipsychotics - positive symptoms only e.g. chlorpromazine. Tries to reduce the effects of dopamine to reduce the symptoms.

Dopamine antagonist in that it binds to the receptors (particularly D2) but they do not stimulate them, so blocking their action by blocking stimulation. Hence reducing positive symptoms

Good as Davis et al found difference between relapse rates in those that had typical drugs and those that had the placebo drug

Worrying side effects include permanent brain damage including tardive dyskinesia which is uncontrollable movement

Used to treat positive and negative symptoms e.g. clozapine. Sometimes called second generation drugs

Acts on the dopamine system but also blocks serotonin receptors as well in the brain. Temporaily block the D2 receptors and then rapidly dissociate to allow normal dopamine transmission.

It is thought that this characteristic is responsible for the lower levels of side effects found with these drugs when compared to conventional antipsychotics

Good as it shows fewer and milder side effects than typical drugs like not leading to brain damage so offers a good alternative when in some cases the side effects have been too strong

Meta-analysis found that only two new drugs were "slightly" more effective whereas the other two were no more effective and may have made the negative symptoms worse

Drugs overall a great treatment as they rationalise behaviour helping the patient to function adequately in an everyday life and sometimes completely clearly the patient from symptoms

Argued to only control their behaviour so they are more socially acceptable and easier to manage but does not treat the cause so may be constantly being re-admitted and discharged from hospital

Ross and Read found that being prescribed medication reinforces the view that there is "something wrong with you" which prevents their motivation to look for other possible solutions

To be the most effective, psychological treatments should be used as well so the patient does not rely on drugs and can learn to look for deeper problems and find long-term solutions

NICE recommended all patients offered CBT, at least 16 sessions. Drugs still leave persistent symptoms. Aims to help establish links between their thoughts feelings or actions.

Initial Assessment - trust is established, thoughts are expressed and realistic goals may be set

ABC model - activating event is discussed and their beliefs can be rationalised

Normalisation - showing how behaviour is not normal but in a way that makes recovery seem achievable and likely so their anxiety is reduced

Critical Collaborative Assessment - without stress, question to understand illogical thinking

Developing Alternative Explanations - now we can explain their unhealthy thinking with ideas and see how it can be resolved

Evidence shows it is effective in reducing rehospitalisation up to 18 months and improving socially

Haddock found 13 out of 187 random patients had been offered as there is limited availability

Families with high expressed emotion have high relapse rates so aims to reduce this stress and reduce the need for hospitalisation

PURL

Psychoeducation - relative is taught about the illness and trained so they can understand and deal with it better at home themselves

United - Forming alliances with the carer so there is less burden and "emotional climate"

Remove - reduce all the anger expressions and maintaining reasonable expectations

Limits - Encouraged to set appropriate limits which may be some degree of separation

Pharoah et al's meta-analysis establishes that family therapy can be effective in improving clinical outcomes such as mental state and social functioning

Realistically can't be done without drug therapy to avoid a psychotic episode and rationally think

Based on operant conditioning of reinforcement. Used like currency in psychiatric institutions

Tokens are first paired with rewarding stimuli

Patient engages in the target behaviour

Patient is given tokens for engaging correctly

Patient trades in tokens for access to the reward items

Dickerson found 11 out of 13 studies of token economy in a psychiatric setting had directly been beneficial so overall concluded it increases adaptive behaviour in SZ patients

Less useful in psychiatric wards as there is less control than in a 24-hour care setting so less effective

Ethics have been questioned as it is manipulating vulnerable people in order for them to become "socially acceptable" and they may have to give up privacy which is accepted as a human right

Singular best treatment - drugs as 2 thirds respond well with them and symptoms reduce or go away completely

Drugs do not find a long term solution as it only seeks to fix physical symptoms whereas CBT is NICE recommended and all psychotherapies looks to cure the illness permanently 

In Britain, it is standard practice to treat patients with a combination of both treatments

Psychotherapies are usually used alongside drugs to so the patient can think rationally

Douglas Turkington pointed out CBT can relieve symptoms even if there are still biological causes behind SZ so an interactionist model must be adopted

Nicholas Tarrier found that medication and counseling or CBT both reduced symptoms better than medication alone, alone there were no differences in hospital readmission

Drugs may help but it does not mean that SZ is caused biologically just as using both therapies does not mean that the interactionist approach is right. This is called the treatment-causation fallacy