Schizophrenia

A severe mental disorder in which thoughts and emotions are diminished, affecting a person's thoughts, perception, emotions and their sense of self.

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Positive symptoms

Something which has been added to normal behaviour.

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Hallucinations - Positive symptoms

Unreal perceptions about the environment that can be auditory (hearing voices), visual (seeing lights or faces), olfactory (smelling things) or tactile.

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Delusions - Positive symptoms

Bizarre beliefs that seem real but are not. Can be paranoid (persecutory) or involve themselves (inflated belief about their own importance; some lost their sense of self so experience the God Complex).

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Disorganised speech - Positive symptoms

Unable to organise their thoughts and this shows in their speech; they slip from one topic to another (derailment) and in extreme cases they sound like they're speaking gibberish.

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Disorganised thinking - Positive symptoms

Feeling that thoughts have been inserted or withdrawn from their mind (sometimes they believe their thoughts are being broadcast on TV).

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Catatonic behaviour - Positive symptoms

Bizarre and abnormal motor movements e.g. holding the body rigidly or moving in a frenzied way.

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Negative symptoms

Something which has been lost from normal behaviour.

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Alogia (poverty of speech) - negative symptoms

The lessening of speech fluency and productivity; thought to reflect slowing or blocked thoughts.

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Avolition - Negative symptoms

Reduction of, inability or persistence in goal-directed behaviour e.g. sitting in the hours for every day, doing nothing.

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Affective flattening - Negative symptoms

Reduced range and intensity of emotional expression; facial expression, tone, eye contact.

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Anhedonia - Negative symptoms

Loss of interest or pleasure in most activities or lack of reaction to normally pleasurable stimuli.

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Social/ occupational dysfunction - Negative symptoms

One or more major areas of functioning (work, inter-personal relations or self-care) are below the level achieved before the onset of schizophrenia.

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Reliability in the diagnosis and classification of schizophrenia

The diagnosis is consistent and repeatable.

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Test-retest reliability - Reliability in the diagnosis and classification of schizophrenia

Clinicians should be able to reach the same conclusion at different times.

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Inter-rater reliability - Reliability in the diagnosis and classification of schizophrenia

Different clinicians are able to reach the same conclusion.

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Cultural differences in diagnosis - Reliability in the diagnosis and classification of schizophrenia

Variation between countries in diagnosing schizophrenia.

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Copeland (1971) - Cultural differences in diagnosis

Gave US and British psychiatrists a description of a patient; 69% of Us psychiatrists diagnosed schizophrenia compared with 2% of British psychiatrists

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Luhrmann et al (2015) - Cultural differences in diagnosis

Interviewed schizophrenic people from either Ghana, India or the US about the voices they heard. Many African and Indian patients described positive experiences with their voices whereas Americans reported their voices as violent and hateful.

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Validity in the diagnosis and classification of schizophrenia

To what extent a diagnosis is genuine and distinct from other disorders.

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Gender bias - Validity in the diagnosis and classification of schizophrenia

When the accuracy of diagnosis is dependent on the gender of the individual, because there are gender-biased diagnostic criteria or clinicians are basing their judgements on stereotypes about a gender.

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Broverman et al (1970) - Gender bias in diagnosis

Found that US clinicians saw mentally healthy 'adult' behaviour as mentally healthy 'male' behaviour.

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Symptom overlap - Validity in the diagnosis and classification of schizophrenia

Symptoms of a disorder may not be unique to that disorder but can be found in other disorders.

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Co-morbidity - Validity in the diagnosis and classification of schizophrenia

The extent that two conditions co-occur.

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Buckley et al (2009) - co-morbidity

Estimated that co-morbid depression occurs in 50% of patients.

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Loring and Powell (1988) - Support for gender bias in diagnosis

Had male and female psychiatrists read two cases of patients. When patients were described as male or no gender, 56% of psychiatrists diagnosed schizophrenia compared with 20% when the patients were described as female.

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Unreliable symptoms study

50 US psychiatrists had to differentiate between 'bizarre' and 'non-bizarre' delusions and produced inter-rater reliability correlations of 0.40. Concluded that this central diagnostic requirement lacks reliability.

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Biological explanations for schizophrenia

Emphasises the role of inherited factors and dysfunction of brain activity in the development of schizophrenia.

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Genetic factors - Biological explanations for schizophrenia

No one gene is thought to be responsible for schizophrenia but different combinations of genes make individuals more vulnerable to schizophrenia, though having these genes does not necessarily mean schizophrenia will develop.

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Family studies - Genetic factors; Biological explanations for schizophrenia

They have shown that schizophrenia is more common among biological relatives of a schizophrenic person and the closer the degree of genetic relatedness, the greater the risk.

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Gottesman (1991) - Family studies

Found that children with two schizophrenic parents had a concordance rate of 46%, children with one schizophrenic parent a rate of 13% and siblings a concordance rate of 9%.

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Twin studies - Genetic factors; Biological explanations for schizophrenia

Allow researchers to investigate the contribution of genetic and environmental influences. If monozygotic twins are more concordant than dizygotic, this suggests that the greater similarity is due to genetic factors.

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Joseph (2004) - Twin studies

Reviewed schizophrenia twin studies prior to 2001 and found a concordance rate for MZ twins of 40.4% and 7.4% for DZ twins.

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Adoption studies - Genetic factors; Biological explanations for schizophrenia

It is difficult to disentangle genetic and environmental influences so studies of genetically related individuals who have been reared apart are used.

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Tienari et al (2000) - Adoption studies

Found that 11 of adoptees whose biological mothers had been diagnosed with schizophrenia developed schizophrenia compared to 4 of adoptees born to non-schizophrenic mothers.

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Joseph (2004) - MZ twins encounter more similar environments

MZ twins are treated more similarly, encounter more similar environments and experience more 'identity confusion'. So, the differences in concordance rate between MZ and DZ twins reflect nothing more than the environmental differences.

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Noll (2009) - Challenges to the dopamine hypothesis

Argued that antipsychotic drugs don't alleviate hallucinations and delusions in about one-third of people. In some people, hallucinations and delusions are present despite normal levels of dopamine so blocking the D2 receptors has little effect.

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Family dysfunction - Psychological explanations for schizophrenia

These explanations claim that schizophrenia is caused by abnormal patterns of communication within the family.

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Bateson et al (1956) - Double bind theory; Family dysfunction

Suggest that children who receive contradictory messages from their parents are more likely to develop schizophrenia.

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Double bind theory - Family dysfunction; Psychological explanations for schizophrenia

A child receives conflicting messages about their relationship on different communicative levels and they find it difficult to respond. This prevents the child developing a coherent construction of reality and in the long-term, causes schizophrenia.

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Expressed emotion (EE) - Family dysfunction

A family communication style in which family members of a psychiatric patient talk about the patient in a critical way or in a way that suggests emotional over-involvement and over-concern for the patient.

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Linszen et al (1997) - Expressed emotion

Found that a patient with a high EE family are about four times more likely to relapse than a patient whose family is low in EE.

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Tienari et al (1994) - Support for family relationships

Showed that adopted children born to schizophrenic biological parents were more likely to become ill than children with non-schizophrenic parents, but this only occurred when the adopted family was rated as disturbed.

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Berger (1965) - Support for double bind theory

Found that schizophrenics reported more double bind statements by their mothers than non-schizophrenics. But, this may not be reliable as schizophrenics’ recall could be affected by their schizophrenia.

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Cognitive explanations - Psychological explanations for schizophrenia

These emphasise the role of dysfunctional thought processing (ways of thinking which cause the individual to evaluate information inappropriately) in schizophrenia, particularly with the positive symptoms of schizophrenia.

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Cognitive explanations of delusions

A characteristic of delusional thinking is individuals see themselves as a key component in events (egocentric bias) and jumps to conclusions about external events.

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Cognitive explanations of hallucinations

They focus excessive attention on auditory stimuli (hypervigilance) and so have a higher expectancy of a voice occuring than normal individuals.

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Sarin and Wallin (2014) - Support for the cognitive model of schizophrenia

Reviewed research and found evidence for the idea that positive symptoms were due to faulty cognition. Found that delusional patients had biases in their information processing e.g. jumping to conclusions and lack of reality testing.

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Drug therapy

The treatment of mental disorders through the use of antipsychotics to reduce the symptoms of the disorder.

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How do antipsychotics work?

By reducing dopaminergic transmission - reducing the action of dopamine in areas of the brain associated with schizophrenic symptoms.

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Typical antipsychotics

Used mainly to combat the positive symptoms of schizophrenia. Dopamine antagonists which bind to but do not stimulate dopamine receptors e.g. D2 receptors in the mesolimbic dopamine pathway and so block their action.

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Kapur et al (2000) - Blocking of D2 receptors by typical antipsychotics

Estimate that between 60% and 75% of D2 receptors in the mesolimbic dopamine pathway must be blocked for these drugs to be effective. But, to do this, a similar no. of D2 receptors in other areas of the brain must be blocked, causing side effects.

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What are the differences between typical and atypical antipsychotics?

Atypical antipsychotics carry a lower risk of extrapyramidal side effects, have a beneficial effect on negative symptoms and cognitive impairment and are suitable for treatment-resistant patients.

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Atypical antipsychotics

They temporarily block D2 receptors and then rapidly dissociate to allow normal dopamine transmission. This rapid dissociation is thought to be responsible for the lower levels of extrapyramidal side effects found with typical antipsychotics.

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Leucht et al (2012) - Support for antipsychotic drugs; Antipsychotics vs. placebo

Meta-analysis of patients who had been put on typical or atypical antipsychotics and some patients were taken off this and given a placebo. Within 12 months, 64% of those on the placebo had relapsed compared with 27% of those on antipsychotics.

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Extrapyramidal side effects - Limitation of typical antipsychotics

The most common extrapyramidal effects are the Parkinsonian and related symptoms which resemble the symptoms of Parkinson’s disease. More than half patients taking typical antipsychotics experience these side effects.

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Tardive dyskinesia - Extrapyramidal side effects; Limitation of typical antipsychotics

When people use antipsychotic drugs for a long time, they experience tardive dyskinesia - involuntary movements of the tongue, mouth and jaw.

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Cognitive behavioural therapy

A combination of cognitive therapy (a way of changing maladaptive thoughts and beliefs) and behavioural therapy (a way of changing behaviour).

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The NICE review of treatments - CBTp; Advantage of CBTp over standard care

Found consistent evidence that when compared with standard care (antipsychotic drugs alone), CBTp was effective in reducing rehospitalisation rates up to 18 months after the end of treatment.

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Haddock et al (2013) - Lack of availability of CBTp

Conducted a survey in northwest England and found that out of 187 schizophrenic patients, only 13 had been offered CBTp.

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Addington and Addington (2005) - Effectiveness of CBTp is dependent on stage of the disorder; More effective at specific stages of the disorder and when the therapy is adjusted for the stage the individual is at

Claim that self-reflection is not appropriate in the acute stage of schizophrenia.

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Jauhar et al (2014) - The benefits of CBTp may have been overstated

Meta-analysis showed that when CBTp was used on its own, there was only one 'small' therapeutic effect on the key symptoms. When assessors didn't know if patient was in therapy or control condition, this disappeared.

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Lobban et al (2013) - Family therapy has a positive impact on family members

Meta-analysis that involved an intervention to help relatives. 60% of studies showed a significant positive impact on at least one outcome for relatives e.g. coping. But, these studies had poor methodology quality.

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Pharoah et al (2010) - Family therapy's effectiveness

Found that patients showed some improvement in mental state, social functioning and relapse rates, but they suggest this may have more to do with how it increases patient's compliance with medication.

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Token economy

A form of behavioural therapy in which clinicians set target behaviours that they hope will improve the patient’s negative symptoms and their engagement in daily activities. Tokens are awarded for target behaviours. These can be exchanged for rewards

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Primary reinforcers

Things that give pleasure (food or comfort) or remove unpleasant states (alleviate boredom).

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Secondary reinforcers

Have no value initially but acquire their reinforcing properties due to being paired with primary reinforcers. In a token economy, tokens are secondary reinforcers.

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Sran and Borrero (2010) - Reinforcing target behaviours in a token economy

Found that participants responded more when tokens could be exchanged for a variety of edible items compared with when the tokens could be exchanged for one edible item.

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Dickerson et al (2005) - Support for the token economy

Reviewed 13 token economy studies and in 11 studies, they found there were beneficial effects of the use of the token economy. But, many of these had methodological shortcomings.

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Comer (2013) - Difficulties assessing the effectiveness of token economies

Suggests a problem with token economy studies in that they tend to be uncontrolled and there is no control group. Patients' improvements can only be compared with their past behaviour. Claims that other factors could be responsible for this.

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Corrigan (1991) - Less useful for patients living in the community

Argues there are problems administering the token economy method with outpatients who only receive treatment for a few hours a day and so token economy can only be used for this time.

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The diathesis-stress model

Proposes that schizophrenia is the result of an interaction between biological (the diathesis) and environmental (stress) influences.

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Tienari et al (2004) - Support for diathesis in schizophrenia

Found that the identical twin of a schizophrenic person is at greater risk of developing schizophrenia than a sibling or fraternal twin. But, in about 50% of identical twins when one twin is diagnosed, the other never meets the diagnostic criteria.

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Varese et al (2012) - Support for stressful life events triggering schizophrenia

Found that children who experienced severe trauma before the age of 16 were three times more likely to develop to develop schizophrenia in later life than the general population.

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Vassos et al (2012) - Support for high levels of urbanisation being associated with an increased risk for schizophrenia

Meta -analysis which showed that people in urban environments were estimated to have a 2.37 times higher risk of developing schizophrenia than people in rural areas.

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Romans-Clarkson et al (1990) - Urban environments are not necessarily more stressful

Found no urban-rural differences in women’s mental health.

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Hammen (1992) - problems determining causal stress; stressors early in life can influence how people respond to later stressful events and their susceptibility to scizophrenia

Argues that early stressors set up maladaptive coping methods causing an individual to be able to cope less with later stressors.

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Schizophrenia

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