Clinical Characteristics and theories.

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Criteria for the Diagnosis of Schizophrenia (DSM-I

Two or more of the following must be present for a significant amount of time over a one month period (Less if treated)

  • Delusions
  • Hallucinations
  • Disorganised Speech (Derailment or incoherence)
  • Disorganised or Catatonic Behaviour
  • Negative symptoms (I.E. alogia - lacking fluent conversation, avolition - lack of motivation to achieve goals and Affective Flattening - lack of emotion)
  • Social/Occupational dysfunction - For a significant amount of time they must lack appropriate functioning in work, interpersonal relations or self-care.
  • Duration - Disturbance must continue for at least 6 months - must involve at least one symptom.
  • No other mood disorders can have also occurred recently.
  • Cannot be due to the misuse of drugs, side affect of a drug or a known brain disorder.
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Characteristics of Schizophrenia

Schizophrenia is not split personality nor a multiple personality disorder. It is a disruption of Cognition and emotion which affects a persons language, thought, perception and even a sense of self.

Schizophrenia and Violence - Is virtually non existent, although the media insist it is. Diefenbach (1997) found that around 8% of diagnosed Schizophrenics commit a serious act of violence. This percentage is greater than the percentage of sufferers of mental disorders and less than those who suffer from other mental disorders (i.e. Depression).

  • Reliability - Argued that Psychiatrists do not follow the DSM classification of Schizophrenia in order to diagnose it, making the percentages unreliable. Whaley (2001) found that inter-rater reliability correlations in the diagnosis of Schizophrenia to be as low as 0.11.
  • Unreliability of Symptoms - Kisterkotter et al (1994) - assessed 489 admissions to a psychiatric unit in Germany to assess whether +\- symptoms were more suited to the diagnosis of Schiz. They found positive symptoms were more useful than negative symptoms.
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Characteristics of Schizophrenia continued...

  • Validity - Symptoms - Schneider (1959) Distinguished first-rank symptoms (those symptoms primarily involved in schiz). They included delusions of being controlled by an external force, hearing hallucinatory voices that comment on thoughts and actions. If these are present, the diagnosis of Schizophrenia is more reliable. However Ellason & Ross (1995) point out that people with Dissociative Identity Disorder (DID) have more Schizophrenic symptoms than those who are actually Diagnosed with Schizophrenia.
  • Prognosis - The prognosis always varies. Around 20% of sufferers recover to their previous level of functioning and 10% reaching significant lasting improvement with intermittent relapses. Schizophrenia has little predictive validity. Some people never recover from the disorder although many do. Gender (Malmberg et al, 1998) and psychosocial factors, social skills, academic achievement and family tolerance of Schizophrenic behaviour (Harrison et al, 2001) influences the outcome of Schizophrenia.
  • Cultural Differences - Big variation of Diagnosis in different cultures. Copeland et al (1971) gave a description of a patient to 134 US and 194 British Psychiatrists. 69% of the US psychiatrists diagnosed schizophrenia but only 2% of British psychiatrists gave the same diagnosis.
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Biological explanations - Genetic Factors

  • Family Studies: Determines if theres a biological link in Schizophrenia sufferers. Family studies have found that the closer the relation, the more likely it is Schizophrenia will develop. It has been found that children with two Schizophrenic parents have a concordance rate of 46% whereas children with one schizophrenic parent had a concordance rate of 13% and siblings 9%. However, researchers suggest this may be to do with the rearing patterns rather than being heredity.
  • Twin Studies - Gives psychologist the chance to investigate the genetic and environmental contributions schizophrenia has. monozygotic (MZ) twins share 100% of their genes, where as dizygotic (DZ) twins share only 50% of their genes. Joseph (2004) calculated the data collected from all twin studies conducted before 2001 and found a 40.4% concordance rate with Monozygotic twins and 7.4% concordance rate with dizygotic twins. However, more recent studies using 'blind diagnoses' showed a lower concordance rate with MZ twins - however researchers still insist genetics still play a part in Schizophrenia.
  • Adoption Studies - investigates environmental affects. Tienari (2000) in Finland. Found that those whose biological mothers had schiz only 11 of the 164 (6.7%) had schiz. The control group (non-schiz mothers) only 4 of 197 had schizophrenia.
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Biological Explanations - The Dopamine Hypothesis

This hypothesis states that messages from neurons that transmit dopamine fire too easily or too often, leading to the symptoms of Schizophrenia. Schizophrenia sufferers are found to have abnormally high numbers of D2 receptors receiving neurons resulting in more Dopamine binding and more neurons firing. Dopamine neurons play the main role in guiding attention, so this disturbance can lead to the symptoms of Schizophrenia (Comer, 2003).

  • Amphetamines - Dopamine agonist, stimulates the nerve cells containing dopamine causing the synapse to be flooded with it. Large doses can cause the symptoms of Schizophrenia.
  • Antipsychotic drugs - They all block the activity of Dopamine to the brain. This causes eliminates hallucinations and delusions, as these drugs are an antagonist. The effectiveness of the drug suggests that Dopamine plays a major part in Schizophrenia.
  • Parkinson's disease - Low levels of dopamine are present in those who suffer from Parkinson's disease. It was found that those taking the drug L-Dopa to raise their levels of Dopamine were developing Schizophrenic symptoms.
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Evaluation of Biological Explanations - Genetic Fa

(Twin Studies) It is assumed that both MZ and DZ twins live in the same type of environment, surrounded by similarities. However Joseph (2004) points out that it is in fact more likely for MZ twins to be treated more similarly, and whom are more likely to do things together & experience more identity confusion than DZ twins. DZ twins are more likely to be treated as individuals. Due to this Joseph suggests the differences in concordance rates are to do with the environment rather than genetics.

(Adoption Studies) A common misconception with adoption is that the children are not selectively placed. Joseph (2004) Claims that this is very unlikely. In countries like Denmark and the US, adoptive parents are informed of the genetic background of the child they wish to adopt. As Kringlen (1987) pointed out - 'Because the adoptive parents evidently received information about the child's biological parents, one might wonder who would adopt such a child.'

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Evaluation of Biological explanations - The Dopami

  • Post-Mortem Studies - A major problem with blocking dopamine activity is that this can actually increase the neurons struggle in order to compensate the deficiency. Haracz (1982) reviewed post-morten studies of Schizophrenics. It was found that those with elevated dopamine levels before death had received anti-psychotic drugs. Schizophrenics who had not just had anti-psychotic drugs dopamine levels were normal.
  • Evidence from neuroimaging research - PET scans have allowed researchers to investigate dopamine activity more precisely than before. Despite this, they have failed to provide convincing evidence that altered dopamine activity is linked to Schizophrenia (Copolov & Crook, 2000)
  • Enlarged Ventricles - meta-analysis of over 90 CT scan studies showed a link between enlarged ventricles and Schizophrenia (Copolov & Crook, 2000). This could be due to the use of anti-psychotic medication. Lyon et al (1981) found that as the dosage increased, the density of brain tissue decreased which lead to enlarged ventricles. Torrey (2002) states that the ventricles of a person with Schizophrenia are about 15% bigger than normal. Schizophrenic patients with enlarged ventricles show more negative rather than positive symptoms &cognitive disturbances and poorer response to antipsychotics (Bornstein et al, 1992)
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Biological Therapies - Drug treatment

Conventional Anti-psychotic drugs - Reduce the effects of dopamine which reduces the effects of Schizophrenia - They are dopamine agonists as they bind to dopamine receptors (D2 receptors) therefore blocking the dopamine activity. This results in elimination of hallucinations and delusions, they deal with the positive symptoms of Schizophrenia. One example of a conventional drug would be 'Chlorpromazine'. This drug treatment lead to the development of the Dopamine Hypothesis.

Effectiveness of Conventional Anti-psychotic Drugs - Davis et al (1980) analysed the results of 29 studies (3519 people). He found that relapes occured 55% of the time when patients were given placebos and 19% of people relapsed when given anti-psychotic drugs. Although this proves they work, Ross and Read (2004) pointed out that 45% of people on placebos did not relapse, showing that even when given placebos people can recover.

Vaughn and Leff (1976) found that anti-psychotic drugs only made a significant difference to those in hostile environments. 52% on medication would relapse & 92% on placebos would relapse. However those in more supportive environments relapsed 12% (on meds) and 15% (on placebos).

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Biological Therapies - Drug Treatment

Appropriateness of Conventional Anti-psychotics - Tardive dyskinesia can be a side affect of such drugs. About 30% of people taking the drug can develop it, and it is irreversible in 75% of cases (Hill, 1986)

Ross and Read (2004) also argue that being given the drugs reinforces the view that their is something wrong with the patient. This distracts them from whatever has caused the discontent which has triggered their Schizophrenia. This reduces their motivation to think of other solutions therefore reducing the symptoms.

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Biological Therapies - Drug treatment

  • Atypical anti-psychotic Drugs - They block serotonin receptors in the brain as well as dopamine. Kapur & Remington (2001) argue that the drugs do not involve serotonin or other neurotransmitters but only the dopamine system & the D2 receptors. They temporarily occupy the D2 receptors then rapidly dissociating to allow normal dopamine transmission. Atypical drugs are thought to be responsible for the lower levels of side affecs (i.e. Tardive dyskinesia) compared to conventional drugs.
  • Conventional or Atypical? - A meta-analysis conducted by Leucht et al (1999) showed that Atypical Drugs were not much more affective than conventional drugs. It was found that two of the drugs were slightly more effective than the conventional and the other two were no more effective.
  • Effectiveness with negative symptoms - Again the Leucht et al (1999) study showed that two were effective against negative symptoms, one was as effective as conventional and the last was slightly worse. There is not much support for this theory.
  • Appropriateness of Atypical drugs - The chance of developing tardive dyskinesia decreased from 30% to 5% when treated with Atypical drugs (jeste et al, 1999). There are also less side affects, meaning patients can continue treatment with this drug and get a better result.
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Biological Therapies - ECT

Electroconvulsive Therapy (ECT) - Electrodes are placed above the temple on the non-dominant side of the brain, and the other in the middle of the forehead. The patient is first injected with short-acting Barbiturate to ensure they are unconscious before the shocks are administered. They are then given a nerve blocking agent in order to prevent any fracturing. A current of about 0.6 amps is then administered which induces a seizure lasting around 1 minuet which affects the entire brain. 3-15 treatments are usually required.

Tharyan and Adams (2005) conducted a review of 26 studies which included 798 participants in total to evaluate the effectiveness of the ECT. It was compared to patients who had undergone a fake version of the treatment. It was found that more people benefited from the real ECT rather than the placebo, however it was not indicated whether or no the effects were long lasting. When ECT was compared to drug treatment, drug treatment was much more popular. The combination of the two has also not been proved to be much better than using one or the other. Use of both the ECT and drug treatment should only be used when the symptoms need to be reduced significantly or the patient is not responding to drug treatment.

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Biological Therapies - ECT

Effectiveness of ECT - An 'American Psychiatric Association' review in 2001 listed 19 studies that compared ECT with 'stimulated' ECT. It was found that the results were no different or worse than anti-psychotic drug treatment. However an Indian study (Sarita et al, 1998) found no difference in symptom reduction between 36 schizophrenia patients given either ECT or antipsychotic drugs.

Appropriateness of ECT - There are serious risks with ECT treatment (Memory disfunction & even death) This means that the use of ECT has reduced fro, 1979-1999 by 59% (Read, 2004)

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Psychological Explanations of Schizophrenia

  • Psychodynamic - Freud (1924) believed that Schizophrenia was the result of two related processes, regression to a pre-ego stage and attempts to re-establish ego control. For example if an individual is brought up in a hostile environment they would regress into this early stage of their development before the ego was properly formed and before he/she would have developed a realistic awareness for the external world. Freud believed Schizophrenia to be an infantile state reflecting a persons attempt to re-establish ego control.
  • Freud's theory cannot be disproven nor proven. However studies have shown that parents of Schizophrenic children act different to the parents of children with other disorders (Oltmanns et al, 1999)
  • Cognitive explanations - When Schizophrenic's attempt to understand what they are going through, they ask others. If other people do not confirm what they are hearing as normal; they believe that others are hiding something. This results in delusional beliefs that they are being manipulated and persecuted by others.
  • Meyer-Lindenberg et al (2002) - found a link between excess dopamine in the prefrontal cortex and working memory. The idea that the disbelief of others can cause Schiz has been developed into a treatment by Yellowlees et al (2002). Patients are shown their delusions on a comp to prove they aren't real.
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Psychological factors - Socio-Cultural Factors

  • Life Events - A major stress factor has been associated with a higher risk of Schizophrenia. Brown & Birley (1968) found that 50% of people experience a stressful life event 3 weeks prior to a schizophrenic episode, while 12% experience the event 9 weeks before. A healthy control sample reported no stressful life events therefore no schiz; suggesting there is a link. High levels of psychological arousal associated with neurotransmitters has also been found (Falloon et al, 1996). However Van Os et al (1994) reported no link between Schizophrenia and stressful life events, he suggested that major life events are more likely to be a consequence of Schizophrenia rather than a cause.
  • Family Relationships - Double-bind theory - Bateson et al (1956) stated that children who receive contradicting messages from their parents are more likely to develop schizophrenia (e.g. being told that they are loved whilst their parent pulls a face of disgust). Messages invalidate each other, this prevents the child creating a coherent construction of reality.
  • Berger (1965) found that schizophrenics recalled more contradicting interaction with their parents than non schizophrenics. However this relocation could be affected by their Schizophrenia. Liem (1974) & Hall and Levin (1980) both found no difference.
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Psychological factors - Socio-cultural explanation

  • Expressed Emotion (EE) - Negative and over-emotional involvement can cause relapse. Linszen et al (1997) stated that schizophrenics returning to homes with high levels of EE were four times more likely to relapse than those who were not. kalafi & Torabi (1996) also found the same thing. However, although this theory has more support than the double - bind theory, there is still the issue of whether or not EE is a cause or an effect of Schizophrenia. However this theory has lead to a therapy in which sufferers are showed how to reduce their EE (Hogarty et al, 1991). However it is still impossible to state whether the therapy was the sole purpose of recovery or whether family intervention helped.
  • Labelling Theory (LT) - This was developed by Scheff (1999) - he stated that as we have norms and values in which society follows, anybody who deviates from this are considered 'not normal' therefore being labelled as Schizophrenic. Once this Label is applied, it becomes a self-fulfilling prophecy which develops the symptoms of Schizophrenia (Comer 2003). Scheff (1974) evaluated 18 studies to see if they could be applied to the labelling theory. he found that 13 could be applied and 5 could not showing support for the theory.
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Psychological therapies - Cognitive-behavioural th

  • Patients look back to find out why their symptoms started
  • They are also encouraged to evaluate their symptoms and are told to consider the reliability of them.
  • patients can also be set behavioural assignments to help improve their general functioning. Helping them to realise that their problems are usually due to their irregular thinking. CBT allows patients to think of other reasons for their disordered thinking.
  • Outcome studies are conducted to measure the effect this treatment has on the condition. The results show that people recover better from this therapy than they do using drugs. Drury et al (1996) found reduction of positive symptoms and a 25-50% reduction in recovery time for patients given a combination of drugs and CBT. Kuipers et al (1997) also confirmed that drop out rates for treatment was significantly lower when CBT and drug therapy was combined.
  • Effectiveness of ECT - Gould et al conducted a meta-analysis of 7 studies and found a decrease in positive symptoms of Schizophrenia. However the majority of the time CBT is combined with drugs, so it is difficult to determine if CBT is as effective on it's own.
  • Appropriateness of CBT - generates less distressing excuses for behaviour rather than eliminating them completely.
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Psychological treatments - Psychodynamic Therapy:

  • This therapy attempts to bring subconscious worries into the conscious mind so they can be dealt with.
  • the therapist starts a friendship with the patient and offers to help them with whatever they perceive to be the problem at the time. This can only be achieved by the psychologist gaining the patients trust. Although Freud though this was not possible, it has proven to be effective.
  • Gottdiener (2000) reviewed 37 studies published between 1954 & 1999 covering 2642 patients with their mean age at 31.1 years. It was found that 66% of those receiving psychotherapy improved after treatment, compared with only 35% of those who did not receive psychotherapy.
  • Malmberg & Fenton (2001) argue that it is impossible to draw definite conclusions against psychodynamic therapy.
  • May (1986) found that patients treated with drugs and therapy had better outcomes than those treated with the therapy alone. Antipsychotic drugs have been found to be more effective than the therapy.
  • Karon & Vandenbos (1981) found the opposite, patients recovered better with the therapy.
  • It's recommended that psychodynamic therapy is combined with drugs.
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