Schizophrenia

Clinical Characteristics Positive Symptoms (AO1): Delusions (bizarre beliefs that seem real to the schizophrenic but have no grounds in reality. Include paranoid delusions, delusions of grandeur and delusions of reference) Experiences of Control (person believes they are under the control of an external force that has invaded their mind or body) Hallucinations (unreal perceptions of the environment. Can be auditory, visual, tactile or olfactory) Disordered Thinking (includes feelings that thoughts have been inserted or withdrawn from the mind, or that thoughts are being broadcast) Negative Symptoms (AO1): Affective flattening (a reduction in the range and intensity of emotional expression) Alogia (speech deficiency) Avolition (an inability to initiate and persist in goal-directed behaviour) Types of Schizophrenia (AO1): Disorganised (delusions, hallucinations, incoherent speech and large mood swings) Catatonic (total immobility for large periods of time and avolition) Paranoid (delusions of persecution) Undifferentiated (includes patients who do not clearly belong to any other category) Residual (includes various negative symptoms but no positive ones) Classification and Diagnosis Diagnostic Criteria (AO1): A one-month duration of two or more positive symptoms Only one positive symptom is needed if delusions are bizarre Continuous signs of disturbance must persist for 6 months Major areas of functioning must be compromised for a significant portion of the time after the onset of the disturbance The disturbance must not be due to other disorders or illnesses Issues with Classification and Diagnosis (AO2): Inter-rater reliability correlations in the diagnosis of schizophrenia are 0.11 What constitutes a bizarre delusion is unclear. Inter-rater reliability is around 0.40 among senior US psychiatrists The diagnostic criteria are forced to be very diffuse to cover the broad range of schizophrenic symptoms Rosenhan - On Being Sane in Insane Places. Eight pseudopatients complained of hearing voices in their head and were admitted to psychiatric hospitals with schizophrenia. Afterwards, they behaved normally. Throughout their stay, none of the staff recognised that they were not experiencing mental health difficulties. Suggests low reliability in recognition of schizophrenia Cultural variation - Dobuan tribe. Dobuan society is characterised by a mistrust of others that we would call paranoia. The diagnostic criteria are not reliable if they do not extend across cultures Cultural variation - Study gave description of a patient to 134 US and 194 British psychiatrists. 69% of US psychiatrists diagnosed schizophrenia, compared to 2% of British psychiatrists Suggestion that categorical approach should be replaced by a continuum Biological Explanations Genetics (AO1): Family studies: Schizophrenia is more common among biological relatives of a person with schizophrenia. Two schizophrenic parents: 46%. One schizophrenic parent: 13%. Siblings: 9% Twin studies: Concordance rates between monozygotic and dizygotic twins. MZ: 40%. DZ: 7.4%. Lower rates than earlier study due to tighter methodology Adoption studies: Of 164 adopted children whose biological mothers were schizophrenic, 6.7% were diagnosed with schizophrenia compared to 2% of a control group Genetics (AO2): Twin studies: An assumption is that environments for monozygotic and dizygotic twins are equivalent. However, MZ twins experience identity confusion, do more things together, and have fewer individual differences that might cause them to be treated differently e.g. gender. This means their higher concordance rate may be due to a more similar environment and not more similar genes Twin studies: Concordance rates between monozygotic twins are not 100% so there must be some environmental influence on the development of schizophrenia Adoption studies: An assumption of adoption studies is that adopted children are not selectively placed. However, potential adoptive parents are likely to know about the child's genetic background and this may influence the type of person who adopts children with a schizophrenic genetic background, meaning that they may experience a different type of environment to other adopted children Methodological problems: Most adoption studies would not have found a statistically significant concordance rate between children and their schizophrenic biological parents without broadening the definition to include non-psychotic "schizophrenia spectrum" disorders Biochemistry (AO1): The Dopamine Hypothesis: Schizophrenics are thought to have abnormally high numbers of D2 receptors, resulting in more dopamine binding and more impulses firing Amphetamines: Dopamine agonists (increase dopamine levels). Can produce psychosis. Other effects include hyperactivity, grandiosity, paranoia, anxiety and insomnia Antipsychotics: Dopamine antagonists. Eliminate symptoms such as hallucinations and delusions Parkinson's Disease: Low levels of dopamine associated with Parkinson's. L-Dopa, a dopamine agonist, is used to reduce symptoms. When a dosage is given that is too large, schizophrenic-type symptoms develop Biochemistry (AO2): Post-mortem studies: Only schizophrenics with elevated dopamine levels were those who had been taking antipsychotic drugs shortly before death. Suggests drugs may actually increase dopamine levels as neurones compensate for the deficiency Neuroimaging research: PET scans have failed to provide convincing evidence of altered dopamine activity in the brains of schizophrenics Brain Structure (AO1): Brain ventricles: Lateral ventricles are on average 15% larger in schizophrenics Patients with enlarged ventricles tend to display more negative symptoms, greater cognitive disturbances, and poorer responses to traditional antipsychotic medication Brain Structure (AO2): Link between enlarged ventricles and schizophrenic symptoms is correlational, so cause and effect cannot be established. It may be that enlarged ventricles are caused by anti-psychotic medication There is a substantial overlap between schizophrenics and control groups. Enlarged ventricles cannot be the sole cause of schizophrenia, as some people with large ventricles are healthy, and some schizophrenics have average-sized ventricles Psychological Explanations Psychodynamic Theory (AO1): Suggests that schizophrenia is the result of regression to a pre-ego state and subsequent attempts to reestablish ego control This may occur if the world of the schizophrenic has been harsh, causing them to regress to an early stage in their development, before a realistic awareness of the outside world had been developed Delusions of grandeur are explained by the dominance of the id, and auditory hallucinations are explained as the ego attempting to reestablish control Psychodynamic Theory (AO2): One of the first systematic attempts to explain schizophrenia. Highlights importance of childhood in contributing to later mental health There is very little research evidence supporting the theory's assertions, as the concepts are unscientific and unfalsifiable Schizophrenogenic mothers are mothers who are rejecting, overprotecting, dominant or moralistic. Schizophrenics tend to have mothers who behave in this manner, especially in the presence of their offspring. De-emphasises the importance of biological factors. Does not explain why schizophrenia often has a sudden onset in late adolescence or early adulthood. Gives a very limited understanding of the disorder Cognitive Theory (AO1): Suggestion that schizophrenic symptoms occur as a result of a deficit of selective attention. Symptoms such as hallucinations, delusions and alogia arise from a poor ability to concentrate Suggestion that symptoms occur as a result of a poor ability to self monitor, and failing to keep track of one's own intentions, leading to mistakenly regarding one's own inner speech as alien Suggestion that schizophrenics have poor Theory of Mind, and cannot understand others' mindsets. This leads to paranoid behaviour as they misinterpret the intentions of other people Cognitive Theory (AO2): It is possible to link cognitive theory and biological theory, strengthening both. It has been found that working memory is impaired in schizophrenics. Dopamine plays a role in working memory. This could explain why imbalanced dopamine levels lead to schizophrenia There is evidence of a physical basis for the cognitive deficit. It has been found that the larynx of schizophrenics is often active during auditory hallucinations, supporting the idea that they mistake their own inner speech for alien Schizophrenic patients perform badly on tests designed to measure Theory of Mind. However, their poor performance could be due to an information-processing overload, and it may be that they would have performed badly on any test Socio-Cultural Explanations Life Events (AO1): Stressful life events are associated with a higher risk of schizophrenic episodes In a study, around 50% of schizophrenics had had a stressful life event in the 3 weeks prior to their schizophrenic episode. People who had experienced schizophrenia had twice the amount of stressful life events as a healthy control group Neurotransmitters and hormones associated with stress may trigger schizophrenic episodes, as they raise physiological arousal In a prospective study over a 48-week period, it was clear that life events had a significant cumulative contribution to a relapse Life Events (AO2): There is conflicting evidence. One study found no link between life events and schizophrenia. Patients were not more likely to have experienced a stressful life event in the three months prior to a schizophrenic episode, and patients who had experienced a stressful life event did not have higher relapse rates The research is correlational. It could be that schizophrenic symptoms were the cause of the stressful life events. Cause and effect cannot be established Theories about life events do not consider the impact the life event has in a personal context. This has not been considered in studies, which rate the negativity of a life event externally, and may explain the conflicting results Family Relationships (AO1): Double-bind Theory: suggests that children who frequently receive contradictory messages from parents are more likely to develop schizophrenia when they are older as they cannot work out which of the conflicting messages are true and struggle to form an accurate perception of reality Expressed Emotion: Suggests that families with communication styles high in criticism, hostility and emotional over-involvement increase relapse rates of schizophrenics by about four times. The negative emotional climate leads to stress beyond the impaired coping mechanisms of the schizophrenic patient and leads to a schizophrenic episode Family Relationships (AO2): It has been found that schizophrenics recall more double-bind statements by their mothers than non-schizophrenics, however, this evidence may not be reliable as the patients' capacity to recall may be affected by their schizophrenia In a study of letters written from parents to their hospitalised children, it was found that the extent to which those letters contained double-bind communication was the same regardless of whether the children suffered from schizophrenia or another disorder. However, only one level of communication was analysed, which might not be representative Therapy based on training families to reduce hostility and criticism, causes patients to be less likely to relapse It has been suggested that family relationships may trigger a biological predisposition. It has been found that adopted children with schizophrenic biological mothers are more likely to develop it themselves than a matched control group, but only if the adoptive family is later rated as "disturbed" Labelling Theory (AO1):Suggests that schizophrenic symptoms are seen as deviant to social norms, and cause a diagnosis of schizophrenia to be given, which then becomes a self-fulfilling prophecy, promoting the development of other schizophrenic behaviourLabelling Theory (AO2): In a meta-analysis of 18 studies to do with labelling theory, 13 were consistent with the proposals and 5 were not, suggesting that it is generally well supported On Being Sane in Insane Places (outlined earlier). Staff treated pseudopatients as schizophrenics even though their behaviour was normal, suggesting that how someone is labelled affects how they are treated Biological Therapies Drug Therapy (AO1): Conventional antipsychotics: Reduce dopamine levels by binding to D2 receptors, preventing dopamine from binding to them Atypical antipsychotics are thought to block serotonin receptors as well as dopamine receptors. They occupy dopamine receptors only temporarily, rapidly dissociating to allow normal dopamine transmission, meaning they have fewer side effects Drug Therapy (AO2): Effectiveness of conventional antipsychotics: A significant difference has been found in the relapse rates of schizophrenics treated with conventional antipsychotics and a placebo, but this depends on the home environment. When the patient is returning to a hostile environment, relapse rates with medication are 53% and with a placebo, 92%. When the patient is returning to a supportive environment, relapse rates for medication (12%) and placebo (15%) are not significantly different Appropriateness of conventional antipsychotics: Side effects include tardive dyskinesia (uncontrollable movements of the lips, tongue, face, hands and feet). About 30% of people taking conventional antipsychotics develop tardive dyskinesia and in 75% of cases it is irreversible. It is also argued that being given medication prevents an individual from looking for solutions to underlying causes that may have triggered their condition Effectiveness of atypical antipsychotics: There is little support to suggest that atypical antipsychotics are more effective than conventional antipsychotics Appropriateness of atypical antipsychotics: There is a reduced chance of tardive dyskinesia (rate of 5%). Having fewer side effects makes patients more likely to continue with their medication and this may make it more effective Schizophrenics on medication have to have frequent tests to monitor the levels of different substances in their blood, and if the levels of some substances get too high, they may need to be taken immediately off the medication, leading to a rapid relapse Electroconvulsive Therapy (AO1): ECT involves passing an electric current through the head to induce brains seizures Procedure: Short-acting barbituate is used to render the patient unconscious. Nerve blocking agents are used to paralyse muscles. Approximately 0.6 amps of electricity are passed through the brain for around 0.5 seconds, inducing seizures lasting around 1 minute. Usually 3-15 treatments are used Improvements have been made since it was first used: Muscle relaxants are administered to reduce the size of convulsions, the current is applied to specific brain hemispheres and general anaesthetics are used Electroconvulsive Therapy (AO2): ECT has been found to be more effective than a placebo condition ("sham" ECT) at reducing the symptoms of schizophrenia. It has been found to be less effective than antipsychotic medication and ineffective in the long term. There is limited evidence to suggest that a combination of ECT and antipsychotic medication is effective Inconsistent findings: one meta-analysis found no difference in the symptom reduction caused by ECT and antipsychotic medication, yet other studies have found no difference in symptom reduction between real and "sham" ECT In the UK, usage of ECT has declined by 59% between 1959-1999 due to the significant risks involved including memory dysfunction, brain damage and death ECT has been found to be useful for cases of schizophrenia that have proved to be untreatable by any other method All Biological Therapies (AO2)Biological therapies treat the symptoms, not the cause of the disorder. The disorder is managed, but not cured Psychological Therapies Cognitive Behavioural Therapy (AO1): The premise of CBT is that patients have distorted beliefs which influence their behaviour in maladaptive ways CBT techniques: Tracing back to the origin of the symptoms to see how they developed, evaluate the content of delusions and test their validity, give behavioural assignments and coping strategies such as distraction, concentration on a particular task, and positive self-talk Cognitive Behavioural Therapy (AO2): Outcome studies suggest that patients who receive CBT experience fewer hallucinations and delusions, and recover their functioning to a greater extent than those on medication. Combining CBT and antipsychotic medication reduces recovery time by 20-25% Meta-analyses have found that CBT significantly improves symptoms, however, most of the studies into the effectiveness of CBT have been conducted on patients being treated simultaneously with antipsychotic medication, making it difficult to independently assess the effectiveness of CBT CBT is not suitable for everyone with schizophrenia, as many patients are rated as unsuitable for CBT as they did not have the capacity to engage fully with the therapy. Older people have been found to benefit less than younger people Psychoanalysis (AO1): The premise of psychoanalysis is that individuals are often unaware of unconscious conflicts which produce symptoms Freud believed that schizophrenics couldn't be treated with psychoanalytic therapy because he believed they couldn't form a transference with the psychoanalyst The main techniques of psychoanalytic therapy are transference (unconsciously shifting emotions onto the therapist) and conscience-replacement (involves replacing a harsh and punishing conscience with one that is less destructive) Psychoanalysis (AO2): One meta-analysis of 37 studies found that 66% of people receiving psychoanalytic therapy improved after treatment, giving it the same success rate as CBT. However, half the studies assessed did not allocate patients randomly to conditions, introducing a treatment bias It is argued that it is impossible to draw conclusions about the effectiveness of psychoanalytic therapy because it is based on unmeasurable and unscientific concepts Inconsistent findings: Some studies have found that antipsychotic medication is more effective that psychoanalysis, some studies have found the opposite, and some studies have found that a combination is most effective Psychoanalytic therapy is expensive and takes a long time to produce results, although it is argued that it is worth the extra expense to reduce the chances of a relapse and the need for inpatient treatment All Therapies (AO2):Ethics: There is the potential to cause patients harm when investigating the effectiveness of therapies, for example medical discontinuation and placebos. It is also suggested that many schizophrenics do not have the capacity to give their informed consent to participate in studies