Schizophrenia

Diagnosing schizophrenia At least two of the following:

- Hallucinations - Delusions (oft. linked to hallucinations) - Disorganised speech - Disorganised or catatonic behaviour - Negative symptoms

Social & occupational dysfunction Duration of several months Type 1 - Episodic, mainly positive symptoms Type 2 - Chronic, mainly negative symptoms

Problems with diagnosing A true diagnosis cannot be made until a

patient is clinically interviewed. Psychiatrists are relying on retrospective

data, given by a person whose ability to recall much relevant information is unpredictable.

Some may be exaggerating the truth – or blatantly lying!

Problems with diagnosing Beck et al (1961) looked at the inter-rater

reliability between 2 psychiatrists when considering the cases of 154 patients.

The reliability was only 54% - meaning they only agreed on a diagnoses for 54% of the 154 patients!

It was originally hoped that the use of diagnostic tools could provide a standardised method of recognising mental disorders.

However clear the diagnostic tool, the behaviour of an individual is always open to some interpretation. The process is subjective.

Sub types of schizophreniaDiagnostic subtypes Paranoid – delusions and frequent

hallucinations Catatonic – 2 of: immobility, excessive

motor activity, mutism, echolalia or echopraxia

Disorganised – disorganised speech, disorganised behaviour

Undifferentiated – symptoms are present but do not fall into any of the above categories

Test your knowledge1. Name 3 symptoms of schizophrenia2. Give two problems of diagnosing

schizophrenia3. List the 4 main sub-types

Explanations of schizophrenia

Biological: genetic, neurochemical, physiological abnormalities

Social cultural Labelling Family dysfunction

Genetics – Family studies Gottsman,1991, family studies have shown that the

greater the degree of genetic relatedness, the greater the risk of developing schizophrenia.

Children with two schizophrenic parents have a concordance rate of 46%, children of one schizophrenic parent 13% and siblings 9%.

This shows that genes do play an important factor, however if genes were the only cause of schizophrenia then the percentages surely should be 100%,

The study could be seen as deterministic; just because we are ‘predisposed’ with our genes cannot mean we necessarily get the disorder schizophrenia.

However, many researchers now accept that schizophrenia concordance rates in families may be more to do with common rearing patterns or other environmental factors that have nothing to do with heredity.

Genetics – twin studies Twin studies help researchers to work out whether its

nature or nuture influences. Joseph (2004) suggested that the concordance rate

for monozygotic twins were of 40.4% and for dizygotic twins 7.4%.

This shows that twins that share 100% of genes are still much more likely to get the disorder, but yet again as they do share 100% genes it should be a 100% if it was all down to genes, suggesting their must be other influences.

A crucial point to state is that it is assumed that monozygotic twins and dizogotic twins upbringing/environment is very similar. However, Joseph points out, that monozygotic twins are treated even more similarly as they are not treated individually, but as twins much more so than dizygotic.

Genetics – Adoption studies These are studies of genetically related

individuals who have been reared apart due to being adopted.

Tiennari (2000), found that of the 164 adoptees whose biological mothers had been diagnosed with schizophrenia , 6.7% also received a diagnosis of schizophrenia, compared to just 2% of the 197 control adoptees

Although only a small percentage, it still suggests that genes must play a role within schizophrenia.

Tiennari conducted his study within Finland, therefore we are not able to generalise this study to the rest of the world

Genetics - evaluation Twin studies there may be a predisposition to

develop schizophrenia, however, the fact that both twins do not always develop schizophrenia means that environmental factors must also play a part

No single gene has been identified for schizophrenia, questioning genetics as a valid explanation for schizophrenia.

Evience for concordance rates for schizophrenia are based on older twin studies which are less reliable due to changes in the diagnostic criteria. These days, diagnosis is much rigorous than it was 40 years ago so some of those diagnosed as schizophrenic 40 years ago might not meet the criteria now

Test your knowledge Explain how the biological explanation

accounts for schizophrenia? What have family studies found? What have twin studies found? What have adoption studies found? Give me two evaluative comments

Neurochemical – Dopamine hypothesis Dopamine is a neurotransmitter that

operates within the brain. The dopamine hypothesis states that

messages from neurons that transmit dopamine fire too easily or too often, leading to the characteristic symptoms of schizophrenia.

Schizophrenics are thought to have abnormally high numbers of D2 receptors on receiving neurons, resulting in more dopamine binding and therefore more neurons firing

Neurochemical – Dopamine hypothesisThree sources of evidence for dopamine includes: Amphetamines; this is a dopamine agonist, this stimulates

nerve cells containing dopamine causing the synapse to be ‘flooded’ – due to large doses of the drug can cause hallucinations and delusions of a schizophrenic episode.

Antipsychotic drugs (dopamine antagonists) which block the activity of dopamine in the brain, by reducing the stimulation of the dopamine system, eliminates hallucinations and delusions. By alleviating many of the symptoms of schizophrenia, antipsychotic drugs strengthened the case for dopamine being a significant contributory factor.

Amphetamines and cocaine which increase the levels of dopamine in the brain can cause the positive symptoms of schizophrenia and exaggerate them in people who already have the disorder.

Neurochemical – Dopamine hypothesis: Evaluation Post mortems have revealed higher then

normal levels of D2 dopamine receptors in the brains of schizophrenics

PET scan of schizophrenics have found similar results

However, you can’t establish cause and effect

The dopamine hypothesis is over simplistic as there are lots of neurotransmitters involved, not just dopamine.

Physiological abnormalities Liberman et al, (2001) found that

schizophrenics have enlarged ventricle within the brain.

Weyandt (2006) suggested the enlarged ventricles are related the negative symptoms of schizophrenia

Other research has suggested that pregnant mothers who have the flu during the last trimester in pregnancy are more likely to have a child who is schizophrenic

Physiological abnormalities - evaluation Findings are inconsistent Cause and effect can not be established

with brain abnormalities Fails to take into account environmental

factors It is deterministic It is over simplistic

Test you knowledge Explain the dopamine hypothesis Give a piece of evidence that supports it Give 2 evaluative comments Name a physiological abnormality that

is thought to lead to schizophrenia Give 2 evaluative comments

Socio-cultural: Labelling Szasz (1962) suggests that once a person is

labelled as schizophrenic it influences the way a person behaves and the way they are treated by others. Therefore being labelled as schizophrenic becomes a self-fulfilling prophecy

This is supported by Rosenhan’s study in which 8 healthy people pretended to be experiencing schizophrenic symptoms in order to be admitted to a psychiatric ward but once admitted acted normally. Their normal behaviour was interpreted by the nurses and doctors as schizophrenic behaviour

This shows that people are treated differently once they are labelled as schizophrenic

Social-cultural: Family dysfunction The relationships and patterns of communication

within a family have been identified as possible stress factors responsible for causing or contributing to the development of schizophrenia

Research has shown that parents of schizophrenics show three dysfunctional characteristics:

High levels of conflict Difficulties in communication Highly critical and controlling

Social-cultural: Family dysfunction Bateson et al (1956) identified faulty communication

within a family as a possible cause of schizophrenia. Bateson (1956) introduced the term ‘double bind’ to describe the ‘no win’ situation that children are often put in by one or both parents.

A double bind is where a parent verbally gives one message and non-verbally conveys the opposite message. For example, the mother might ask for a cuddle, but then hold the child at arms length

As a result, the child becomes confused, doubtful and uncertain about how to respond and starts to become withdrawn and show negative symptoms of schizophrenia

Social-cultural: Family dysfunction

Nomura et al (2005) found that when a person recovering from the active phase of schizophrenia goes back into a family where criticism, hostility and disapproval (high expressed emotion) are common features of communication, the person is likely to relapse.

Butzlaff and Hooley (1998) reviewed over 20 studies of expressed emotion and found that 70% of schizophrenics in such families relapsed within a year, compared to just 30% in families with low levels of expressed emotion

Brown et al (1966) also found in families where expressed emotion was high 58% relapsed compared to 10% where expressed emotion was low

Family dysfunction - evaluation Schizophrenic people are very disruptive to family

life so it is hard to say that high expressed emotion causes schizophrenia, it could be the result of having a schizophrenic person in the family

The diathesis-stress model of schizophrenia states that biological factors cause a predisposition to develop schizophrenia but an environmental cue is needed to trigger its development. High expressed emotion may be the environmental cue that triggers the schizophrenia in such families

Treatments that involve reducing the levels of expressed emotion in families were successful in reducing relapse rates (Doane et al,1985)

Test you knowledge Name the two social-cultural

explanations What is a self fulfilling prophecy? What study supports labelling? What is family dysfunction? Name a strength and a weakness of the

family dysfunction explanation

Treatments of schizophrenia Biological treatments – drugs Cognitive/behavioural – Psychotherapy Social - Community care

Biological treatments - drugs There are two main types of antipsychotic

drugs that are used to treat schizophrenics, conventional and atypical drugs.

Conventional drugs are also called neuroleptics because they often cause unwanted side effects of physical movements, such as muscle tremors. Chloropromazine was the most common conventional antipsychotic drug in the 1950’s and they work on reducing the strength and frequency of hallucinations and other positive symptoms by blocking the receptors for dopamine. This results in reduced levels of dopamine

Conventional drugs: evaluation Conventional drugs led to a dramatic reduction

in the number of schizophrenics in long-term hospitalisation in the 1950’s and 1960’s.

They are very successful at reducing the positive symptoms but do not work on negative symptoms

However, they have to be taken regularly or the hallucinations and delusions return with greater severity

The drugs must be taken even if there have been no positive symptoms for a long time

The drugs have terrible side effects such as muscle tremors, restlessness, and jerky movements

Atypical antipsychotic drugs Atypical drugs are a new generation of

drugs which reduce both positive and negative symptoms of schizophrenia.

They work less on reducing the level of dopamine but do work on changing the level of serotonin in the brain.

Atypical drugs are often effective with people who have not responded to conventional drugs.

Atypical drugs: evaluation They reduce both positive and negative

symptoms of schizophrenia The reduction of symptoms means the

schizophrenic person can lead a relatively normal life

The drugs have to be taken constantly or the person will relapse

Atypical drugs have side effects such as weight gain, nausea, irregular heartbeat and excessive salivation

Test your knowledge What are the two main types of drugs? Which type work on only the positive

symptoms of schizophrenia? Give two positives and two negatives

about drug treatment

Psychotherapy – Psychoanalytic therapyFreud viewed schizophrenia as a

result of the ego being overwhelmed by demands of both the id and the superego. He said hearing voices was a result of critical ‘superego voices’ criticising the person inadequacies. Delusions of grandeur is a device the ego uses to satisfy the superego but has no basis in reality.

Psychoanalytic therapy: evaluation Generally, psychoanalytic therapy is of little value

in treating people with schizophrenia. For psychoanalytical therapy to work a person needs to have insight into their condition and be able to talk rationally about themselves, which schizophrenics can not do.

Furthermore, using psychoanalytic therapy on people who have partially recovered from the extremes of schizophrenia may result in the return of positive and negative symptoms. This is because the ego may feel unable to cope with talking about the condition directly. So to protect itself it may retreat into delusion, hallucination and social withdrawal.

Psychotherapy: Insight therapy Insight therapy is based on the idea that people with

schizophrenia can be helped to have greater insight and understanding of their symptoms. Treatment requires one-to-one therapy, with the therapist attempting to gain the trust of the person so that he or she feels safe to discuss their disturbing thoughts.

More recently , cognitive therapy has been developed based on the diathesis-stress model. Cognitive therapy attempts help change the negative attitudes that they person may have and attempts to change the perception of being out of control (hearing things) to being in control, by regarding the voices that they hear as someone trying to talk to them. This approach attempts to help the person challenge their delusions rather than hide them.

Insight therapy: Evaluation It requires the person to have insight

into their disorder which is not always possible

Talking about the delusions and hallucinations may cause someone to relapse

Cognitive therapy is a new treatment and because of this it is too early to fully assess its effectiveness

Psychotherapy – Family therapy Family therapy looks at changing the

communication patterns of the families of schizophrenics, especially those with high expressed emotion.

The main objectives of family therapy are to: get family members to be more tolerant

and less critical, to help family members feel less guilt and

less responsibility for causing the illness, to improve positive communication and

decrease negative communication

Family therapy: evaluation Family therapy has been found to be

very effective and successful in reducing relapse

It works best in conjunction with other treatments such as antipsychotic drugs

However, family therapy training needs to be on-going otherwise there is a chance of relapse for the schizophrenic (Hogarty et al, 1986)

Test your knowledge Name the three types of psychotherapy Who’s work in the psychoanalytic treatment

based on? Outline the stages of Psychoanalytic therapy Outline 2 criticisms of the psychoanalytic

therapy Outline how insight therapy works Give 2 criticisms of insight therapy Outline family therapy Give a strength and a criticism of family

therapy

Social: Community care Community care is a broad approach to the

treatment of schizophrenia that involves supported living arrangements, ongoing psychotherapy, social skills training, family therapy and medication monitoring.

Stein and Test (1980) compared the effectiveness of hospitalisation compared to community care and found the unsupported patients discharged from hospital showed high relapse rate (58 out of 65) compared to just 12 out of the 65 from the community care group.

This shows community care is very successful and preventing relapse and hospitalisation

Community care: evaluation It is a holistic approach that looks at helping all

areas of the schizophrenics life If done properly it is very successful at aiding

recovery and preventing relapse It reduces time spent in hospitals It allows the person to live a relatively normal

life However, is very expensive and difficult to set

up. If the support is withdrawn then relapse will

occur, causing a return to the active phase of schizophrenia

It puts a lot of responsibility back onto the family

Test your knowledge Outline what community care involves Give two strengths and two weaknesses

of community care