Schizophrenia

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Clinical characterstics

Clinical characterisitics:

Chronic- there are harmful and subtle changes in an apparently normal young person, who gradually loses drive and motivation then start to drift away from friends. After months or even years of this decline in mental health, more obvious signs of disturbance such as delusional ideas or hallucinations appear

Acute- obvious signs such as hallucinations can appear quite suddely, usually after after a stressful event. The individual shows very disturbed behaviour within a few days

Diagnosis of schizophrenia:

Under DSM-IVR, describes six different types of schizophrenia:

  • Paranoid- the patient suffers from delusions of persecurion. Suffers are not incoherent and do not display inappropriate emotion, but they are extremely formal and quite intense
  • Disorganised- marked as indifference insensitivity to social surroundings. Chacterised by silliness, incoherence, often disregard of personal hygiene
  • Catatonic- the individual is very enegetic or agitated
  • Unfifferentiated- dustbin category, no consistent pattern of behaviour, not classified by other categories
  • Residual- absence of obvious symptoms, but individual displays odd behaviour, e.g. odd, magical bizzare thinking, marked social isolation or withdrawl
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Clinical characteristics

Diagnosis of scizophrenia:

Under DSM-IVR, diagnosis of schizophrenia requires at least a one-month duration of two or more positve symptoms

Positive symptoms: excess or distortion of normal symptom 

  • Delusions- bizarre beliefs that seem real to the person but are not. Mostly paranoid beliefs 
  • Experiences of control- the people may believe they are under control by alien force
  • Hallucinations- are bizzare, unreal perceptions of the enviroment that are usually auditory, and also may be visual, olfactory (smelling things) or tactile (feeling thing crawling on you)
  • Disordered thinking- the feeling that thoughts have been inserted or withdrawn from the mind. In some cases the person may believe thier thoughts are being broadcast so that others can hear them.

Negative symptoms: diminution or loss of normal function

  • Affective flattening- reduction in the range and intesity of emotional expression, including facial expression, voice tone, eye contact and body language
  • Alogia- poverty of speech, characterised by the lessening of speech fluency and productivity. This is throught to reflect showing or blocked throughts
  • Avolition- the reduction of, or inability to initiate and persist in, goal-directed behaviour (for example sitting in the house for hours everyday, doing nothing), it is often mistaken for apparent disinterest
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Issues: Reliability and Validity

  • The boundaries between schizophrenia and mood disorders (e.g. depression) are blurred, as they share many symptoms 
  • The process of diagnosis is subjective. Inter-reliability (the extent to which two or more diagnositicians would arrive at the same conclusion when faced with the same individual) has been found to be an issue when diagnoising schizophrenia
  • Diagnosed using 2 classification systems: ICD10 & DSM-IVR

Inter-rated reliability:

  • Becklooked at the inter-reliability between two psychiatrics when considering the cases of 154 patients. Inter-rater reliability was only 54%. However, in many of the cases, the patients gave them different information- meaning it's difficult to get them to get the same information from patients a lot of the time. They could exaggerate or lie
  • Blake- psychiatrics are 6 times more likely to diagnose Sz if the description refers to a black african-american compared to a white patient with the same symptoms
  • Copeland - gave the same discription of a patient to US and UK psychiatrists. Of the US psychiatrists, 69% diagnosed schizophrenia, but only 2% of UK psychiatrists gave the same diagnosis 

Symptom issues:

  • Rosenhan- "normal" people could get themselves diagnosed with scizophrenia and admitted to a psychiatric hospital, by claiming they were hearing voices. The hopsital was told that they would get pseubo-patients over a 3 month period- 41 patients were suspected of being fake during this time, and 19 had been diagnosed by two members of staff. There weren't any pseudo-patients. 
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Biological: Genetics

  • Sz seems to run in familites and have genetiv links. Genes for Sz are inherited, causing some symptoms. Presence of certian types of genetic mutations may cause the disorders to trigger. Genetics could cause excess production of/sensitivity to dopamine
  • Statistics suggests that the risk of developing scizophrenia rises the closer related you are to the sufferer:Grottesman & Shields (1972)- examined medical records of 57 Sz twins studied between 1948 and 1964. 23 twins were Mz and 34 were Dz. If one twin had Sz and the other didn't, they were assessed for at least 13 years to see if Sz developed later in their life. Mz twins with Sz- 42% chance of the other twin developing it. Dz twin with Sz- 9% chance of the other one developing it 
    • General population/spouse- 1%
    • Child- 13%
    • Non-identical twin- 17%
    • Identical twin- 48% 
  • Gottesman (1991)- went on to review over 40 other studies, similar to that of Grottesman and Shields. Similar results were found (reliability)- average concordence rate for Mz twins was 48% and for Dz twins was 17% 
  • Kety (1988)- studied 5,483 danish children who were adopted between 1923 and 1947. More adoptees that were seperated from a Sz biological parent developed Sz or a related disorder than control adoptees (32% vs 18%). Chilren born to non-schizophrenic parents but adopted by a schizophrenic parent didn't show rates of schizophrenia above those predicted for the general public 
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Biological: Genetics evaluation

  • Might not be genes in Mz twins- could be similar enviroments (same clothing, same friends, threated in the same manner)
  • It's not entirely genetic- otherwise concordence rate for Mz twins would be 100%
  • Twins are adopted into similar enviroments, sometimes even to members of the same family, meaning they still had the same enviroment
  • Small samples of twins schizophrenia- both are rare, even more rare for someone to be a twin with scizophrenia 
  • The fact that schizophrenia runs in families may be due to factors that have nothing to do with heritability (e.g. expressed emotions)
  • Adopted children from schizophrenic backgrounds may be adopted by particular types of adoptive parents, making conclusions difficult to draw
  • Heston (1970)- if a Mz twin has scizophrenia, there is a 90% profitability of the other twin having "some sort" of mental disorder (not necessarily schizophrenia)
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Biological: Neurotransmitters

The dopamine hypothesis

  • The dopamine hypothesis states that schizophrenia results as an excess to dopamine. Neurons that transmit dopamine fire to easily or too often, leading to symptoms of schizophrenia. 
  • Schizophrenics- abnormally high levels of D2 receptors. Evidence shows that large doses of amphetamines (dopamine agonist) cause hallucinations and delusions.
  • Antipsychotic drugs- block dopamine and eliminate positive symptoms 
  • Snyder- medication used to treat Parkinson's disease (L-DOPA) gives them an increase in dopamine levels, which has been shown to cause schizophrenic symptoms.
  • Grilly- Parkinson's sufferes taking the drug L-dopa to raise their dopamine developed schizophrenic type symptoms
  • Comer- dopamine is linked to attention and may lead to problems with attention which is thought to be found in people with schizophrenia
  • Randrup & Munkvad- amphetamines increase dopamine activity. Rats were given amphetamines and found it induced behaviours similar to that seen in schizophrenics. They then found they could reverse this by giving them antipsychotic drugs 
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Biological: Neurotransmitters evaluation

  • Most widely accepted explanation of schizophrenia 
  • Amphetamines increase levels of dopamine, making schizophrenic symptoms worse
  • Studies are carried out post-mortem, meaning we can't infer causation
  • Drugs affecting dopamine levels don't help all patients
  • Amphetamines increase dopamine as well as other neurotransmitters, so we can't immediately say schizophrenia is caused by dopamine levels being too high
  • Cause and effect is not established (whether Sz causes an excess in dopamine or vice versa)
  • Neuroimaging stuides failed to provide convincing evidence for altered dopamine activity
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Psychological: Psychodynamic

  • Result of regression to pre-ego stage and attempts to re-establish ego control- regression reverts us to the oral stage (up 1 years old, this shatters the ego and leaves the ID in charge meaning that we focus on ourselves and lose touch with reality. Hallucinations are caused by the person trying to regain touch with reality
  • Some schizophrenic symptoms reflect infantile state, other symptoms are an attempts to re-established control. Further features of disorder appear as individual attempt to understand their experiences 
  • They may reject feedback from others and develop delusional beliefs

Familiy systems theory

  • Fromm-Reichman- schizophrenia is caused by schizophrenogenic families. The mother convey conflicting messages to the child, and are cold and dominating. They reject the child yet still demand they show emotional expression. They found a link between schizophrenogenic famileies and those with high emotional tension, many secrets, close alliances and conspiacies. They showed vauge patterns of communication between member of the familiy, had high levels of conflic and lacked the ability to arrive at resolutions
  • Brown et al- focused on emotion expressed within the familiy of the schizophrenic sufferer 9 months follow up study of schizophrenic patients who had gone home to thier families after being released from hospital. Family members were interviewed and divided into two groups- high expressed emotion (high EE) and low expressed emotions (low EE. 10% of patients returning to low EE homes relapsed in 9 months, and 58% relapsed in the high EE group. 
  • Vaughn & Leff- high EE in families was linked to high rates of relapse in recovering patients (51% relapse in high EE families, 13% relapse in low EE families)
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Psychological: Psychodynamic evaluation

  • The development of biological explanation makes this less fashionable. The cognitive explanation also contributes to this fall in popularity 
  • Frued blames the mothers- a lot of research has shown that the parent aren't uncaring and cold: they are in fact sensitive and caring, scared and devastated by their child's scizophrenia 
  • If this theory can explain schizophrenia, surely it shoudl be able to develop a therapy? There hasn't been any real breakthroughs with schizophrenics who have undergone psychodynamic therapy
  • Data from the familiy system is nearly always retrospective- is is accurate and reliable? Perhaps the high EE is caused by schizophrenia, not the other way around
  • Can't be the only cause- many relapse when not with their families
  • Fromm-Reinmann's theory has had little support. Waring and Ricks- most mothers of schizophrenics were actually shy, withdrawn and suffering from anxiety 
  • Little evidence to support psychodynamic view of schizophrenia
  • Behaviour of parents assumed to be key influence in development of schizophrenia but may be consequence rather than cause
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Psychological: Cognitive

  • Acknowledges that hallucinations are triggered biologically but are developed further when the person attempts to understand their sensory experiences. Schizophenic is caused by disorganised and disordered thinking. 
  • Zimmbardo- When schizphrenics first hear voices they turn to other to validate what they are experienceing. When others fail to conform the reality of these experiences, the schizophrenic believes that they are hiding the truth. They begin to reject feedback from those around them and develop delusional beliefs that they are being manipulated and persecuted by others. 

Firth- model of psychosis: most symptoms can be expained in terms of deflicsts to 3 cognitive processes

  • Inability to generate willed actions
  • Inability to monitor willed actions
  • Inability to monitor the beliefs and intentions of others
  • Firth found a disconnection between frontal area (actions) and rear area (perception) of the brain. People are unable to distinguish between actions brought about by external forces and that which are generated by internal thoughts. This attempts to explain onset and maintence of positive symptoms
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Psychological: Cognitive evaluation

  • Unable to explain the causes of schizophrenia, only some symptoms e.g. negative symptoms
  • Too deterministic- not all cognitive impairments lead to mental disorders
  • Can explain development of delusions- we form biases that affect how we see the world
  • Has been found that some cognitve impairment are genetically linked but not enough research to implicate schizophrenia therefore difficulty to generalise and assess validity 
  • Cause and effect
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Socio-cultrual factors

Life events

  • Diathesis stress model- predisposed to schizophrenia, triggered by stressful life event e.g. death of family member 
  • Brown and Birley - proir to schizophrenic episodes, suffers reported twice as many stressful life event as non-schizophrenics (control group) 
    • Some evidence challenges link between life events and scizophrenia = evidence for link is only correlational, not casual 

Double-bind theory

  • Contradictory messages from parents prevent coherent construction of reality, leads to schizophrenic symptoms
  • Bateson- children who frequently recieved contradicting messages from thier parents were more likely to develop schizophrenia. Schizophrenics recalled more double-bind statements from mother

 

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Socio-cultrual factors

Expressed Emotion (EE)

  • Family communication style involving critisim, hostility and emotional over-involvement
  • Leads to stress beyond impaired coping mechanisms and so schizophrenia 
    • Has led to effective therapy for relatives
  • Bobbington & Kuipers- meta-analysis of studies from a variety of studies 1958-1990 investigating the risk of relapse in patients returning to high EE compared to low EE. Found that 52% of families were high EE. Chance of relapse high=50% & low=10%
    • Not 100% so other factors must apply
    • Doesn't establish cause and effect, just a relationship- unclear whether EE is a casual agent in the relapse or a reactionto the behaviour 

Labelling theory

  • Symptoms of schizophrenia seen as deviant from rules ascribed to normal expereience. Diagonstic label leads to self-fulfulling prophecy 
  • Szasz- claimed schizophrenia did not exist but was society's way of classifying individuals who do not follow society's social norms 
  • Scheff- being diagnosed causes a stigma and creates expectations from the patient and others which result in the sufferer conforming to the role- self-fulfilling phrophecy
    • Scheff- 13 of 18 studies consistent with predictions of labelling theory
    • Link support in both retrospective (Brown and Birley) and prospective (Hisch) studies
    • Cultural differences- what is seen as abnormal for one culture is not necessarily so for another 
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Biological therapies- ECT

  • Patient lies on the bed and anaesthetics and muscle relaxent are administed
  • Electrodes are fixed to the non-dominent hemosphere (right)
  • 70-130 volts into the brain through the electrodes for 0.5 seconds
  • Current should induce convulsions that should last for about a minute
  • Threatment given 2/3 time a week for 3/4 weeks 
    • It was found that psychotic symptoms and seziures occured alternately in schizophrenic epileptics
    • Ethical issues- protection from harm
    • Negative side effects- memory loss
    • No greater sucess rate than drug therapies, caises unnecessary stress in patient life
    • Still used in other countries- e.g. Japan, India, Iran- cultural differences in treatment
    • Most effective along side drug treatments

Tharyan and Adams- review of 26 studies found "real" ECT more effective than "sham" ECT

Sarita - no difference in symptoms reduction between ECT and stimulated ECT

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Biological treatment: Antipsychotics

  • There are two types of antipsychotic drugs:
    • Typical (e.g. phenothyiazines) works by binding to dopamine receptors and preventing the stimulation of them. Have a temporary effect of lowering positive symptoms. There are many side effects: 30% of patients get tardive dyskinesic, 75% of which the effect are irreversible 
    • Atypical (e.g. clozapine) temporarily blocks receptors for dopamine and serotonin. After medication wears off there is a rapid flow of dopamine which causes tardive dyskinesic (less likely than typical). They are more expensive than typical drugs and although have less side effectz. 2% of patients develop a fatal blood disease (ethical issues)
  • Davis- higher relapse rate in patients whose drugs were replaced with placebo than those who remained on drugs 
  • Antipsychotic drugs are more effect for those living with hostility and critisism 
  • 30% of people develop TD
  • Being prescribed medication creates motivational deficits which prevent positive action against illness
  • Ross and Read- placebo studies not a fair test because proportion of relapse explained by withdrawal effects 
  • Patients are more likely to contribue with medication if fewer side effects 
  • Kane- chorpromazine has been found to be more effective than the phenothizaine's, helping 80-85% of schizophrenics compared to the 65-75% helped by phenothizane
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Psychological therapies: CBT

  • Aims to challenge maladaptive thoughts and replace them with constructive thinking that will lead to healthy behaviour. Paitents are encouraged to test the validity of faulty beliefs they hold.
    • 1) traces origin of symptoms to understand how they might have developed
    • 2) evaluate content of delusions/hallucinations
  • Patient allowed to develop own alternatives to maladaptive belief. Outcome show that patients recieving CBT experience fewer delusions than those recieving antipsychotics medication alone. 
  • Lower patient drop-out rates and greater patient satisfaction wtih CBT than antipsychotic medication
  • Aaron Beck- mental disorders are primarily due to errors of logic, so addressing them will have an effect on behaviour
  • Effectiveness- meta-analysis found significant decreases in positive symptoms after CBT treatment 
  • Most CBT studies also involve antipsychotic medication, therefore difficult to assess effects of CBT alone
  • CBT works by generating less distressing explanation for psychotic experiences rather than trying to eliminate them
  • Psychiatrist believe that older patients are less likely to benefit from CBT
  • Ethical issues arise in placebo conditions where patients are denied effective treatment
  • Not effective for type 2- as they would not participate in treatment 
  • Long term- takes a lot of time and money 
  • Psychotic disorders- not aware of irration thought- how can CBT make them aware of this?
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Psychological therapies: psychoanalysis

  • Psychoanalysis based on assumption that individuals unware of influence of unconsious conflicts on their current psychological state.
  • Therapists creates an alliance with patient by offering help with what patient percieves as the problem. All psychodynamic therapies build trust with patient by replacing harsh parental conscience with one that it more supportive. As the patient gets healthier they take a more active role.
  • Gottidiener- reviewed 37 studies published between 1954 ro 1999 covering 2642 patients with a mean age of 31.1 years. They found that overall, 66% of those recieving psychotherapy improved after treatment, compared with only 35% of those who did not recieve psychotherapy. 
  • Some forms of psychodynamic therapy can even be harmful in treatnent of schizophrenia 
  • Research on effectiveness of psychodynamic therapy shows contridictory findings. 
  • Supportive psychotherapies appropriate when combined with antipsychotic medication
  • Psychodynamic therapy long and expensive, but may have benefits in that it might make patient more able to seek employment
  • Methodological issues limitation of psychodynamic outcome studies include lack of random allocation to therapy conditions
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