Schizophrenia WB

8/12/2019 Schizophrenia WB

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Psychopathology

(Abnormality)

PSYA4Unit 4


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Issue with classification and diagnosis

Key word Definition

Classification

Diagnosis

Task: What diagnostic tools are used to diagnose psychological disorders?

1.

2.

Problems with classification and diagnosis

Task: Match the criticism with the correct response

Criticism Response

Extension:

How can the problems of classification and diagnosis be overcome?

You cannot treat mental illness the sameway as a physical illness

Thomas Szasz (1962) The myth of mental

illness- classifications encourage treating

problems of living as an illness. It

removes responsibility from the

individual for solving their own problems

Diagnosis someone can lead to stigmas.

An individual with a mental illness may

be wrongly judged. Labelling sociallydeviant behaviour as a mental illness

causes more problems for that person

Some individuals do not fit neatly into

diagnostic categories

Mental illness should not solely onlybe diagnosed by socially deviant

behaviour but by the presence of a

range of symptoms

Although few individuals do not fit

into the existing categories this is not

a reason to abandon classification

systems

There is evidence for the existence of

certain distinct syndromes which are

bought about by factors other thanstressful living

It is not the diagnostic labels which

lead to stigmas. People were

stigmatised before diagnostic

categories


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Diagnosing schizophrenia

1. What is schizophrenia (SZ)?

2. Facts about SZSchizophrenia is the most common and well known psychotic disorder, in most countries of

the world it occurs in around 1% of the population over 18.

Task: watch the video clip and make a list of facts about SZ

3. According to DSM-IV the criteria for SZ include:


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4. Identify at least 3 positive and 3 negative symptoms of SZPositive Negative

Extension:

How many positive and negative symptoms are identified within the DSM-IV?

Which are easier to treat with drugs- positive or negative symptoms?

5. Onset of SzAcute Chronic


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So if a person presents with any combination of the above signs and symptoms a clinician

would diagnose them with SZ, right? Well in fact it is not that simple! The reason for this

is that there are five sub-types of SZ, each with varying characteristics.

Sub type of SZ Characteristics

Paranoid

Catatonic

Hebephrenic

disorganised)

Undifferentiated

Residual

Extension:

Read the case study- can you diagnose WG?


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Issues surrounding the classification and diagnosis of Schizophrenia

Reliability of diagnosis

There is no official diagnostic test for schizophrenia. However, to try and help diagnose

schizophrenia more accurately clinicians often use other diagnostic tools that have been developed.Other tools include the Schneider Criteria, Research Diagnostic Criteria, St Louis Criteria etc.all of

these are still used by clinicians.

Farmer et al (1988)found high levels of reliability using the standard interview technique known as

PSE (Present State Examination).

People diagnosed with schizophrenia often have very different symptoms, the course of the illness is

different, their response to treatment is different and the causal factors are different.

There are two classification systems used for schizophrenias including DSM-IV- TR and ICD-10.

Initially the two classification systems were very different. Prior to the 1970s there was a significantdifference in the prevalence rates of schizophrenia in different countries. In America, the rate of

people diagnosed with schizophrenia was quite high compared with other countriesit has been

suggested that this is because their classification systems were much broader.

In the US 20% of patients were diagnosed with schizophrenia in the 1930s, but in1950s this went up to 80%.

Whereas in London at the Maudsley Hospital in London, the diagnosis rate of 20%remained constant over that period (Cooper et al 1972).

To try and fix these differences the two classification systems (DSM-IV and ICD-10) were made more

similar.

This has led people to suggest that schizophrenia is not a single disorder and various sub-types have

been suggested. However, the validity of these sub-types has been questioned.

Sub-types of schizophrenia:

1. Paranoiddelusions and hallucinations. Do not usually have absence of feelings andemotions of disorganised speech.

2. Catatonicunusual motor activity (either agitation or immobility), often extreme negativismand strange posturingvery rare disorder.

3. Hebephrenic (ICD) or Disorganised (DSM)often begins early age, incoherent anddisorganised speech, lack of feelings or emotions (known as flat affect). Sometimes

hallucinations and delusions.

4. Undifferentiateddiagnosed when showing clear schizophrenic symptoms that do notfit into the other categories.

5. Residualat least one episode of schizophrenia but no longer showing obvious signs of thedisorder.


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1. What is the diagnostic test for schizophrenia?

2. What is reliability?

3. Is the diagnostic test for SZ reliable? Fill in the tablePoint Example Explanation

Twodiagnosticmanuals

Inter-reliability?

Different

ypes ofSZ


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Issues surrounding the classification and diagnosis of Schizophrenia validity of diagnosis

Key term Definition

Validity

Co-morbidity

1. Rosenhan (1973) - On being sane in insane places


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Issues surrounding the classification and diagnosis of Schizophrenia validity of diagnosis

Factor to

consider

Explanation Example

Does Sz really

exist?

Cultural variation

Dual diagnosis

Language

difficulties

Co morbidity


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Biological explanation of Schizophrenia - Genetics

Learning objectives:

To be able to explain the extent to which Sz could be genetic To discuss research into twin and adoption studies To evaluate research into the genetic basis of Sz

There are various ways to decide whether or not genetic factors are important in SZ. What

studies are used to investigate genetic link.

1.

2.

3.

The Genetic Hypothesis

1. Twin studiesMuch of the evidence concerning the involvement of genetic factors in SZ comes from the

study of twins. Researchers want to establish the probability that the other twin is also SZ-

this is known as concordance.

There are two types of twins, and they are different from one another in two ways:

MZ (___________________________) twins: only egg is fertilised buttwo foetuses

develop, so they share % of their DNA.

DZ (_____________________) twins: . eggs are fertilised at the same time, so they

share. % of their DNA, and are no more related than normal siblings. They are

sometimes called twins.

Rosenthal (1963) -(the Genain quadruplets) studied quadruplets in which all four girls were

identical to each other. All four of them developed SZ, although they did differ in age of

onset and the precise symptoms. It is worth noting that they had a dreadful and aberrant

childhood, so the conclusion of this investigation is not clear-cut.

Gottesman (1991):

Cardno et al (1999)


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Issues with twin studies

Point Example Explanation

Rarity of twins

Concordance rate

Problems with

diagnosis-

different

diagnostic

criteria

2. Family studiesGottesman et al (1991)found that the likelihood of an individual developing Sz is

proportional to the amount of genes they share (If a member of your family has Sz then the

closer you are to them genetically, the more likely you are to develop Sz)

The findings from this study were as follows:

MZ twins - ____ Children of two affected parents - ___ DZ twins - ____ Grandchildren - ____ The general population - ___

Kendler et al (1985)

Issues with family studies


Nature-nurture

debate


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3. Adoption studiesThese allow us to study individuals born to a Sz sufferer but raised by parents with no

history of SZ; this allows us to investigate the nature-nurture debate; separating out the

effects of environmental and genetic factors.

Kety (1994):

Tienari (1991):

Evaluation- The Genetic Hypothesis

+/-/

DA


Reductionist

Nature-

nurture

debate

Diathesis-

stress model

VULNERABILITY +

STRESS = DISORDER

It is now thought that our genes and our environments interact in some way.

DIATHESIS means susceptibility to illness. STRESS is the psychological reaction to

meaningful events. The more susceptible you are, the less triggers you need

Deterministic

Psychology is

a science


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Biological explanation of Schizophrenia - Neurotransmitters


To be able to explain the dopamine hypothesis of Sz To discuss research and evidence to support the dopamine hypothesis To be able to evaluate the dopamine hypothesis

The dopamine hypothesis

Genetic factors may lead to differences in brain chemistry, so that it is the brain chemistry

that is the immediate casual factor. Biochemical abnormalities may be important in the

development and maintenance of SZ. Some psychologists suggest that the neurotransmitter

dopamine is involved in causing schizophrenia. It first began following the discovery that

schizophrenic post-mortems revealed a high level of the neurotransmitter. Therefore, it

was first believed that schizophrenia resulted from an excess of dopamine (Seidman 1983).

A slightly different view is that neurons in the brain of SZ patients are oversensitive to

dopamine.

What three pieces of evidence exist, that link schizophrenia with dopamine?

Hint: what drugs are used to treat SZ?

Drug How it works/ its link with SZ

Chlorpromazine Blocks dopamine receptors

Post-mortem

and PET Scan


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Despite this amount of support, the dopamine hypothesis is not without its limitations:

+/-

/IDA


Individual

differences

L-dopa and amphetamines do not worsen symptoms in all

people suffering from schizophrenia

The difficulty

with post-

mortems

Variable

results in

research

PET scans carried out

more recently (Farde et

al, 1990) have not

replicated Wongs

findings.

This means that

Cause and

effect


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Biological explanation threeNeuroanatomical factors


To be able to explain how Sz could be the result of brain abnormalities To evaluate the influence of neuroanatomical factors on Sz

There is an increasing amount of evidence to suggest that people with schizophrenia may

have abnormalities in the structure of their brains. Stevens (1982) cites the fact that many

schizophrenics display symptoms indicating neurological disease - especially decreased eye

blinking, lack of the blink reflex, poor visual pursuits and poor pupil reactions to light. Some

schizophrenics underwent prenatal complications and may have suffered a lack of oxygen

resulting in possible brain damage.

Frontal lobe abnormalities

This area is responsible for higher intellectual functioning and fluent language, and the

frontal lobes of schizophrenics have been found to be smaller than non-schizophrenics.

Buchsbaum (1990)

Ventricle abnormalities

The ventricles in the brain are fluidfilled cavities, which appear to be larger in people with

schizophrenia (particularly the left ventricles).

Brown et al (1986)

Flaum et al (1995)


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Extension:

Neurodevelopmental hypothesis

Brain lesions occurring very early in development (possibly) before birth can make

individuals affected vulnerable to SZ.

Wright et al (1999) - reported data from several countries on the incidence of SZ in children

born to mothers who had flu during pregnancy. There was an elevated risk of SZ in these

children especially when mothers had flu between the fourth and seventh month of the

pregnancy.

Dalman et al (1999)

Van Os and Selten (1998)


Cause and

effect

Conflicting

indings

Different areas in the brain

associated with SZ

Other

actors?

Brain abnormalities are not

present in all people with

Sz, therefore it has been

suggested that there are

two types of Sz; each having

a different underlying

pathology

Type 1

Type 2


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Biological Treatments for SZ

Biological psychologists have claimed that mental illness resembles physical illness and the

cause of mental illness resembles those of physical illness. Mental illness is depends on

some underlying organic problem and the best form of treatment involves direct

manipulation of the physiological system within the body. For these reasons the mostcommon biological treatment is drug therapy.

Neuroleptic/ antipsychotic drugs (drugs that reduce psychotic symptoms but can also

produce some of the symptoms of neurological diseases) are often used in the treatment of

schizophrenia.

Drug How does it work?

Phenothiazine/

Chlorpromazine

(conventional

drugs- first

generation)

Note: only worked for 75% of patients- additional reading below

Clozapine

(Atypical anti-

psychotic drugs-

second

generation)

Note: more effective than conventional drugs in treating the negative symptoms of SZ as well

as positive symptoms. More successful in treating the 25% of patients who were not helped by

first generation of drugs.

Windgassen (1992) found that:

about half of SZ patients taking neuroleptics (conventional drugs) reportedgrogginess or sedation;

18 % reported problems with concentration; 16% had problems with salivation; 16% had blurred vision 20% who had taken the drug for over a year develop the symptoms of tardive

dyskinesia- these symptoms include involuntary sucking and chewing, jerky

movements of the limbs and writhing movements of the mouth or face and the

effects can be permanent.


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Evaluation of drug therapy


Treating the

symptoms notthe cause

Side effects

Cost

Responsibility

taken away

from patient

and give it

directly to the

therapist or

psychiatrist

Patients

compliance

with

treatment

Some patients

do not

respond to

drug

treatment.

About 30-40% of patients

treated with drug therapy

do not respond to

treatment.

Individual differences are ignored. This figure questions the usefulness

and effectives of drug therapy for treating SZ.


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Additional reading:

As far back as the Middle Ages, those suffering from mental illness had holes cut in their

skulls to allow the devils to allegedly causing the illness to escape. This practice was known

as trepanning. It did not produce any cures and many of those who were subjected to thisprocedure did not survive the operation.

Psychosurgery is the use of brain surgery to reduce psychological or behavioural disorders. In

the 1930s Moniz used the surgical method of prefrontal lobotomy, in which fibres running

from the frontal lobe to other parts of the brain were cut. Moniz and others claimed that this

procedure made SZ patients less violent and agitated and much easier to manage. About

70,000 lobotomies were carried out between 1935 and 1955. The side effects of this

operation were so severe that this procedure is rarely performed anymore. These side effects

include apathy, diminished intellectual powers, impaired judgement, comas and death.


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Psychological explanations of schizophrenia- Psychodynamic Theory


To be able to outline the psychodynamic explanation of SZ To discuss research and evidence to support the psychodynamic explanation of SZ To be able to evaluate the psychodynamic explanation of SZ

Sigmund Freuds psychodynamic theory was primarily developed to deal with anxiety and

neuroses. Freuds original ideas focusedupon psychosexual developments and how children

came to terms with their sexuality. This original emphasis makes it hard to apply this

approach to SZ. Although Freud is not the only psychodynamic therapist he is the most

influential, and such therapist, even if they play down the psychosexual element of the

theory, still focus on childhood problems as a start of a process that will result in SZ.

The Schizophrenic Family

The basic psychodynamic assumption for the development of schizophrenia stems from

some type of disruption to early family relationships.

Klein (1946) and Bion (1967) proposed that all children go through stages of development in

which they are dominated by feelings of persecution and omnipotence. A poor relationship

with the primary carer can prevent a child outgrowing these beliefs, resulting in the child

becoming vulnerable to developing schizophrenia later in life.

If a child develops a schizophrenic core of personality due to poor early relationships, then

as an adult, they may regress to these characteristicsclassic symptoms of schizophrenia.

1. What symptoms could be considered examples of regression?

Some theorist have argues that there are abnormal and inadequate patterns of

communication within families of SZ patients.

2. The characteristics of a SZ family include

3. Bateson et al (1956) double bind hypothesis states that

4. According to Lidz (1973), schizophrenics' families are frequently marked by maritalschism or marital skew.


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Marital schism.

Expressed Emotion

There is evidence that the interactions within families can play a key role in maintaining the

symptoms of individuals already suffering from SZ. What seems to be important is the

extent to which a family engages in expressed emotion, which involves criticism, hostility

and emotional overinvolvment. Individuals who have suffered from SZ and who live in

families with high expressed emotion are nearly four times as likely to relapse compared

with those who live in families with low expressed emotion (Kavangh 1992).

When those with SZ improve enough to return home from a period of hospitalisation, their

family might treat them differently from how they treated them before. This can be in the

form of being excessively concerned as well as showing negative emotions such as hostility

or resentment.

The direction of causality is not clear in studies of expressed emotion is not clear in studiesof expressed emotion. One possibility is that expressed emotion within the family causes

relapse. Another possibility is that individuals who are in poor psychological shape are more

likely to provoke expressed emotion from members of their family.


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Evaluation of Psychodynamic explanation for SZ


Does not

explain the

variety of

symptoms

caused by SZ

Blames the

family-

deterministic

Its approach to

childhood

developmental

problems it

too simplistic

Causality

Difficulty to

falsify

The approach cannot be

falsified because it is based

on the assumption that

unconscious forces play a role

in disorders

Unconscious forces/desires cannot...

Little evidence


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Psychological explanations of schizophrenia - Cognitive

Cognitive theorists assume that these cognitive deficits are linked to underlying

physiological abnormalities; meaning that neurological and cognitive ideas are combined in

what is referred to as a neuropsychological model.

The cognitive model views thought disturbances as causes rather than consequences, and

Maher (1968) sees the use of bizarre language as a result of faulty information processing.

Two of the most famous neuropsychological theories are by Frith (1992) and Helmsley

(1993).

Firth- failure to understand context

Firth (1993) talks of SZ as a failure to appreciate the context of a situation. This, for example

would make it difficult to work out the beliefs and intentions of those around you. If, forexample, someone stood to offer you a seat on the bus, you might think they had done so

because you were carrying a lot of shopping. Someone with SZ on the other hand, might

interpret the gesture with suspicion or even with paranoia.

Firth believes that this behaviour is caused by under activity of the frontal lobes of the brain,

which handle motivation and action. This is underpinned by an irregularity of the neural

pathways connecting the hippocampus to the pre-frontal cortex (linked to dopamine

regulation in this part of the brain).

Frith proposes that Sz suffers are not able to distinguish between actions influenced byexternal forces and those driven by internal intentions.

Frith (1992) also argued that positive symptoms of SZ may occur because SZ have problems

with self-monitoring. What happens is that patients fail to keep track of their own

intentions, as a consequence of which they mistakenly experience their own thoughts as

alien.

Hemsley- failure to utilize schemas

Helmsley believes that some of the symptoms of Sz arise from a disconnection between

stored knowledge and current sensory input. Our stored knowledge is referred to as ourschemas. He suggested schizophrenics cannot distinguish between information that is

already stored and new incoming information. As a result, schizophrenics are subjected to

sensory overload and do not know which aspects of a situation to attend to and which to

ignore.


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Evaluation of Cognitive explanation for SZ


Limited but

valuable

Causality

Genetic

origin of

cognitive

impairments

Differences

between

Firth and

Hemsleys

theories


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Evaluation of the Behavioural explanation for SZ


Are all the

behaviours

common to

SZ learnt?

Positive symptoms:

Causality

Limited

Documents

Schizophrenia WB