The Problem With Diagnostic Criteria:
· The personal and social characteristics affect the diagnosis, behaviours change from day to day, so maybe given 2 different diagnosis depending on which behaviour they are attending to.
The assessment procedure?
· There are lots of different assessment procedures, so different assessments will provide different amounts and different types of data, this reduces the reliability.
Cultural issues with the criteria?
DSM- White, middle class, western males= Ethnocentric, racist, sexist and biased against lower classes. In this case, the criteria for schizophrenia could be said not to be valid.
Study.. Rates of diagnosis among ethnic groups:
Aim: Goater (GOATMAN) In’v different rates of diagnosis of Schiz in ethnic groups in London.
Method: 5-year study of Schiz in different ethnic groups in London was undertaken. People from different ethnic groups in London, followed for 5 yrs to see how many from each were diagnosed with Schiz.
Results: Ppl from black ethnic minority groups were found to be more likely to be detained by the police, taken to hospital by police and given emergency injections. They were also more likely to be diagnosed with Schiz.
Con: Misdiagnosis of Schiz is more likely to occur amongst black ethnic minority groups.
Absence of emotion:
Aim Kring and Neale (CRINGE NAIL) to show that lack of appropriate facial expressions in ppl with Schiz does not mean emotions are not being felt and expre.
Method: Ppl diagnosed as Schiz and non-sufferers watched films with strong emotional content. During the films, the facial expressions of both groups were obv. After watching the film p’s were asked about their emotional exp.
Results: Schiz suff’s displayed less facial emotions whilst watching the film than non schiz. HE, both groups reported similar high levels of emotional exp whilst watching the film.
Con: Ppl with Schiz exp similar, appropriate and intense emo to those ppl who are not Schiz. HE the Schiz group do not show these emotions in there facial expressions
· Family studies
· Twin studies
· Adoption studies
· Grandchild= 2%
· Child with 1 Schiz Parent= 9%
· With 2 Schiz Parent= 46%
· Siblings 7-10%
· DZ- 12%
· MZ- 48%
Kendler (K BENDER) et al.
First degree relatives of ppl with Schiz are 18x more likely to develop the disorder themselves.
Kety (KATEY) High-risk Denmark study
· 207 children, 107 matched control children
· Aged 10-18 at start
· Follow-up done
· Schiz diagnosed in 16.2% of high risk, 1.9% low risk
· Schiz personality diagnosed in 18.3% of high risk, 5% low risk
· Combined 35%: 6.9%
Simiular findings reported.
Gottesman (GOTH MAN) and Sheilds:
· Twin register to find twins reared apart.
· Found 58% concordance.
Fischer (thats fisher price)
· 9.4% of offspring whose parents was non-affected discordant MZ twins developed Schiz
· 40% concordance rate for MZ and 5.3% for DZ
Tienari- Finnish Adoption Study
· Id’nt adopted offspring whom mothers had been diagnosed with Schiz (112) plus 135 matched controls.
· 7% of children whose mothers had Schiz had developed the disorder, compared to 1.5% of the control.
KETY (Katy again). Danish adoption study
· National sample
· High rates of diagnosis in adoptees whose biological parents had the same diagnosis.
Neuroanatomical explanations of schizophrenia
Structure of the brain in people who have Schiz:
The limbic system: critical for forming memories and expr pleasure, motivational and emotional activities.
Inside is the Hippocampus associated with memories and spatial awareness.
The Hippocampus in sufferers of Schiz is smaller.
Significant cell loss and unusual cell connections have also been found within the Hippocampus..
It is also thought that abnormal development in the 3rd trimester of pregnancy is linked to Schiz.
Gray matter (Cerebral cortex) has about 2/3 of the brain mass and lies over and around most structures of the brain- the most highly developed part used for thinking, perceiving, producing and understand language. In the 3rd trimester this is developing quickly.
In a normal brain the 2 hemispheres would be a-symmetrical in a person who has Schiz this is much less evident.
Raz and Raz:
Compared the ventricular volume in people with Schiz and control groups. The reported a slight increase in size over half the samples.
In’vt twin pairs for structural abnormalities. Used 15MZ each pair was diagnosed with Schiz each went under a MRI scan.
Twins with Schiz had a smaller hippocampus in 14 out 15 twin pairs, also twins with Schiz had less brain tissue, and significantly diminished brain volume.
H.E difficult to tell if this is a cause or effect of Schiz
Evaluation of Studies:-
· Attempts to link structural changes to particular symptoms have not shown to be consistent with findings.
· Some brain abnormalities that are found are not understood well enough by scientist to say that a casual link has been found.
· Highly more likely to suggest environment contributes to Schiz rather than biologically predisposed to develop Schiz.
-Profound thought disturbance, cause or effect?
-Thought that the normal mechanism that operate the brain to filter and process incoming stimuli is defective in Schiz sufferers, so experience the world in a very different way.
Evidence shows that some people with Schiz are poor at laboratory task which require them to pay attention to some stimuli but ignore others.
Problems when processing various types of info e.g. visual and auditory and attention skills.
Understanding other peoples behaviour might help us explain some of the experiences associated with Schiz.
Social behaviour depends on using other ppls behaviour as clues for there thoughts, Schiz sufferers are unable to do this.
Cognitive defects have been used an explanation to explain some behaviours shown by sufferers of Schiz:- Reduced levels of emotion, disorganised speech, and delusion.
3 Main Conclusion:-
1. This deficits can leave people vulnerable, this can cause stressful events resulting in emotion pressure and increased cognitive deficits and lead to futher ones.
The selective attention and particular interputations and v’s of the world
The delusion that other people are trying to kill them or harm them. Research Delusions are associated with specific biases in reasoning about and explaining, social situations, they assume that other people cause things that go wrong with there life
Auditory Hallucinations:- People see them selves in terms of their social network, some see them selves as powerless compared to others and vice versa.
This can lead to some people feeling worthlessness, most people experience an ‘inner voice’. With sufferers of Auditory Hallucinations they mistake this voice as speech from an external source.
This causes the exp gap seen between themselves and others in there social network is mirrored in the relationship with the ‘voice’, the bigger the gap the more powerfull the voice.
Aim: Sterling (SILVER) In’v the ability of Schiz patients to monitor their own output.
Method: 3 groups: A group with reality distortion symps, one without, and a control group of ppl without Schiz.
P’s had to produce simple drawings of geometric shapes (some Exp there arm was hidden behind a screen so they couldn’t see when they were drawing). After completion the p’s had to select the drawing they had done from a selection of 4 the others were the same drawing but rotated each time.
Results: Schiz with reality distortion symp’s made more incorrect identif’c than the other 2 groups, the poor performance was found to be unrelated to the paitents health condition.
Conclusion: Schiz patients suffering from reality distortion are poor @ monitorting there own output. Schiz exp could be the result of faulty info processing.
· It does help to explain the origins of certain symptoms.
· The idea of cognitive biases provided usefull insights which have added to the understanding of behaviours
· Cognitive impairments often result from brain injury, but these rarely result in mental disorders. According to the cognitive theory, and damage to the brain should result in some kind of disorder.
The Dopamine Hypotheis (2 versions):-
Dopamine= Neurotransmitter which causes neurons to fire
The Original Version:-
Schiz= Excess of Dopamine – Fire to often and transmit too many messages.
· Large doses given to people with no history of Psychological disorder produces symptoms similar to paranoid Schiz.
· Antipsychotic drugs= blocking dopamine receptors and prevent dopamine-receiving neurons from firing.
· In’v that when rats were given amphetamines which produced symptoms alike to them of Schiz could reverse the effects by using antipsychotic drugs.
· L-dopa can produce Schiz symptoms in people with no history of the disorder.
The second version:
· Studies failed to find evidence to support the original version.
· Instead of an excess of Dopamine there was an excess of receptors.
· More receptors= more firing and production of messages.
· Owen: Increased No of Dopamine receptors in the Caudate Nuclei.
· Wong:- Used PET scans= dopamine receptor density is in the Caudate Nuclei is greater in those with Schiz.
· Has experiment support, the hypothesis has a valid explanation for the Dev of Schiz.
· The use of amphetamines it worsens positive symptoms associated Schiz but lessens the negative symptoms of chronic Schiz, Can only be linked to acute Schiz rather than the dev of the disorder as a whole.
· Reductionist:- Reducing Schiz as a complex disorder down to an increase in Dopamine, it is not taking in other account.
~Social and Psychological explanations~
Lower class have higher rates of Schiz.
SOCIAL SELECTION THEORY:- Ppl with Schiz drift down the social ladder into the lowest social class= Loss of job, or the limitation of low-paid an low-skilled jobs.
SOCIOGENIC THEORY:- Being at the bottom of society= Humiliating, and degrading, bringing little respect, these experiences are more likely to onset Schiz.
· Study= England and Wales. Found that M Schiz tended to have jobs that were lower in pay and status than those of their fathers= more likely to move out of the class they were brought up in
· Gold berg and Morrison (WHOOPIE AND SHOP) (Support social selection) USA fathers of Schiz were more likely to be from the lower social class, Schiz tend to remain in the same class as they were born.
~Family Systems Theory~
Can family life influence the onset of Schiz? Dysfunctional family theory.
The Schizophrenogenic mother= Domineering and insensitive, overprotective and rejecting... Contradictory! Verbally accepting yet behaviourally rejecting.
This faulty communication can be the onset of Schiz.
However there is little evidence to support this.
The double bind hypothesis:- the idea of contradictory communication developed. E.g. the mother says she wants a hug but then pulls way from the child as they hug, the child is then in a double bind situation (no win) the confusion caused maybe the onset of Schiz
Expressed emotion: Family interaction affect the development of Schiz.
Brown et al Exam’d the progress of Schiz discharged from hospital and returned to there familys. Familys were classified in terms of the EE (Expressed Emotion) Familys with high EE showed hostility or high concern for the patient 58% that returned to high EE familys relapsed compared to only 10% in low EE- Later study’s produced similar findings
· Dysfunctional families contribute to the onset of Schiz tho the opposite maybe true
· Families in high EE lead to the increase of of Schiz symptoms.
Laing (LANG) Schiz is a label, a form of violence by some people on others. The family, GP, and Psychiatrist conspire against the Schiz in order to preserve their definition of reality... Treated them as if they were sick, imprisoned them in mental hospitals
Rosenhan (ROSE AND HAM)
to prove that psychiatrists are unable to tell the difference between sane and insane and therefore psychiatric diagnosis and classifications are unreliable (labelling is also clearly big part)
8 normal people e.g. students, PSYCHIATRIST, housewife, decorator e.g. presented them self’s as insane pretending to hear voices. These symptoms plus there name and occupations were only the fake things; all 8 were admitted to the psychiatric hospital.
They were eventually discharged as ‘Schiz’ it took on average 19 days to convince staff they were sain.
A second experiment was conducted, members of a teaching hospital were told about the findings of the original study and were warned it may happen again, every staff was asked to rate every new patient as imposter or not.
193 patients admitted, 41 were alleged imposters by staff member 23 were suspected by one psychiatrist and a further 19 by another psychiatrist and one staff member..
All were genuine patients.
ü Theoretical significant: provides a sorely needed reminder of the human mind propensity to rearrange or reframe facts to achieve consistency with pre-existing beliefs
o More than just a label: the label ‘Schiz’ isn’t just a label there is truth behind it, it is also a mistake to argue eiter labelling or mental illness; its false dichotomy.
Involves regressing back to Freud’s anal stage, the stage were the infant is only concerned with their own needs, HE there is a conflict between a person’s needs and their exp of the ‘real world’
E.G If parents withhold love and nurturance; this can lead to the self indulgent symptoms of Schiz such as delusions of grandeur ‘seeing themselves as famous people like Christ
HE the person is still living in the real world, and fined it hard to cope with their new found self in the real world, and with this mean trying to re-establish contact with reality which can result in further Schiz symptoms e.g. auditory hallucinations
Largely bypassed because they are difficult to opertaionalise- a form in which they can be measured and tested- they have gone out of fashion
Treatment of Schiz
The Role of Community Care
Schiz used to be cared for in institutes now days there’s a lot my emphasis on community care of them, the No of hospital beds for mental ill has been vastly reduced by 2/3rds:
o 1970s lead to the rejection of medical concepts of mental illness and a preference for support in the community.
o Research was emerging which suggested that institutional care could be determined because hospitals increased – symptoms
o The discovery of neuroleptic drugs allowed psychiatrists to expand outpatient care.
Community care prevents relapse and the interventions between psychotic episodes.
Each patients has a co-worker who keeps an eye on them, finds them shelter, support, on-going psychotherapy in an environment where social skills can be enhanced with monitored medication.
Stein and Test In’v the efficacy of community care compared to that of in patients- aftercare.
2 groups of 65, 1 group were retrieving inpatients aftercare and the other community care.
58 of the control group were admitted back into hospital while only 12 of the community care group.
HE the gains were gradually lost. Patients in community care were not cured but were able to survive due to the support given to them.
The research made it clear a lot of financial effort is needed in order to make community care worth it.
Evaluation of Community Care
ü Supporters of community care argue that quality of life can be improved at no extra cost.
ü It is a highly effective treatment.
o If support is withdrawn then relapse is highly likely to occur.
Neuroleptic Drugs and atypical antipsychotic drugs
ND- Can produce serious side effects, used to treat acute Schiz, usually used when the person feels unwell or under stress, and the continuation in till recovery.
ND= Chlorpromazine- Reduces the strength of hallucinations= Blocks dopamine receptors, HE needs to be taken at a constant rate.
All of these drug reduce dopamine receptors in the brain, and severely reduce positive symptoms.
Cole et al (COAL)
8wks of treatment on antipsychotic drugs 75% of ppl showed significant ^^ in their symptoms compared to that of a group whom had been treated with a placebo.
Side effects include:
· Severe muscle tremor.
· Shuffling of feet when walking.
· Rigid facial expression.
· Restlessness and limb discomfort.
Atypical antipsychotic drugs
Capable of removing both positive and negative Schiz symptoms.
A-typical= work less to reduce the level of dopamine but also change the levels serotonin.
ELSESSER ET AL (ABITCH) 85%- Atypical, 65%- ND
66% that have not responded to ND will respond to A-typical within 12 months.
SIDE EFFECT OF A-TYPICAL:-
· Weight gain.
· Irregular heartbeat.
· Dramatic drop in the level of blood cells (Very rare).
Evaluation of Anti-Psychotic drugs
ü The work for around 80% of patient’s.
· The drugs only reduce the symptoms, they don’t cure.
· Both types of drugs have unwanted side effects which are distressing for both the patient and the family.
~The Behavioural Approach~
The bizarre behaviour is reinforced by the attention they receive.
OPERANT CONDITIONING’ reward appropriate behaviours= works best with people who are constantly supervised, the behaviour can then constantly be reinforced.
TOKEN IDEA- Tokens when collected for good behaviour can be exchanged for different things.
Paul and Lentz: In’v the effectiveness of tokens.
Tokens were given to P’s for appropriate behaviours that they could exchanged, this was kept up for 6years with the behaviours monitored
Both positive and negative features reduced over time, many were able to discharge, it showed this theory can be successful HE if the behaviour is no longer reinforced the P’s can relapse.
ü Token ECONOMIES are based on scientific principles of the behaviour therapy, which have been scientifically validated in numerous studies.
û The cost of running it may be high, staff have to constantly monitor and administer tokens and the privileges that come can be costly... do the benefits outweigh the issue of cost?
û There is also evidence that token economises do not change the behaviour, but the desired behaviour are fake.
Focus on In’dv symptoms e.g. hallucinations.
TARRIER (TERRIER DOG) In’vt the use of coping strategies during psychotic episodes, 25 P’s with Schiz who Exp a hallucinations or delusions during an psychotic episode were In’tv.
1/3rd Id’t ‘triggers’ to the symptoms e.g. traffic noise- 75% reported major distress while 1/3rd reported disruption to thinking and behaviour. Many disclosed the use of coping behaviour e.g. positive thinking.
Coping strategies help with patients to cope with their symptoms.
HE Requires p’s to recall there Ex’pr and communicate effectively this is not always possible in sufferers of Schiz.
New treatment came from this study:-
Involved new teaching techniques patients based on their own preferred strategy= Reduce the frequency and intensity of psychotic symptoms.
The initial steps involved:
1. Assess the experience and content of the P’s .e.g. is there one or more voices?
2. Assess the emotion response e.g. how did the voices make you feel?
3. Assess the person thought that went with the emotion e.g. did you think you were in danger?
4. Assess any prior warning or antecedent e.g. can you tell when the voice is going to appear?
5. Assess the Ind’v coping strategies e.g. how do you cope with this?
6. The ind’v will then rate each strategy by effectiveness.
Therapy then leads to 2 outcomes:
· The involvement of creating an ambience and shared understanding so that therapies and client can work together.
· Symptom targeting: usually one were a coping strategy is already in use, the strategy will be enhanced and practised. The client may then be asked to use and assess the effectiveness of the strategy.
Study (TERRIER AGAIN)
The effectiveness of CSE of problem solving therapy in 49 p’s whom were taken anti-psychotic drugs but still experienced psychotic symptoms.
P’s were randomely allocated to treatment rooms, for 10 1 hour sessions.
50% improvement in positive symptoms compared to that of a control group of p’s on the waiting list- still apparent 6months after, P’s given CSE reported significant change in there coping skills.
ü Research suggest that CSE is highly effective.
ü Provides ppl a mean to deal with their symptoms, as well as reducing the frequency and intensity, sufferers are able to become more independent.
û 47% drop out rate in TERRIERS study, and so it’s a small sample which makes it difficult to generalise results.
Communication+ High EE= Schiz, efforts have been made to change this trough family therapy the main objectives are:
· To get family member more tolerant than critical.
· To help all family members feel less guilt and feel less responsible for causing the illness.
· To improve + communication and decrease – communication.
Help groups for family members also exist, these allow families to get together to provide, support, discuss and maintain motivation to support the member with Sciz.
STUDY HOGARTY ET AL (HOG HEART WHY?)
In’vt the effectiveness of family therapy in camparison to 3 other types of treatment for Schiz people with Schiz received either:
· Medication only.
· Medication + ** training.
· Medication + Family therapy.· Medication + ** training, and FT
Follow up 1 year after, relapse was measured.
40% of the medication, compared to that of 20% in the ** or FT category, no relapse when both were together.
FT does help to prevent relapse. Follow up study was done after there 2nd year when FT and ** had stopped, they found ^^ of relapse, emphasis on the continuation of therapy in the recovery stage.
ü Research indicates that FT does help in preventing relapse.
û It is expensive to offer the FT as part of a ‘treatment package’ deal.
û The FT provides way’s of dealing wit stress, so there is less stress imprinted on to the P’s while FT is under way, HE relapse appeared once FT had stopped, could be due to the family being alone with the high level of stress inability to cope.