Schizophrenia – Treby

‘Schizophrenia is characterised by Psychosis – a loss of contact with

reality’

Clinical Characteristics of Schizophrenia:

• Prevalence = 1% of the population(prevalence = The percentage of a population that is affected with a particular disease at a given time.)

Broken down into Positive Symptoms (Type I) and Negative Symptoms (Type II)

Symptoms:

Positive Symptoms:Where something is added to your personality.e.g.• Delusions – beliefs that seem

real, but aren’t.• Feeling they’re controlled by

something.• Hallucinations – either

auditory or visual.• Disordered thinking – the idea

that thoughts have been inserted into your mind.

Negative Symptoms:Where something is removed from your personality.e.g.• Affective flattening –

lack of emotion.• Alogia – poverty of

speech.• Avolition – having no

drive to do anything.

First Rank Symptoms – Schneider 1959

Schneider believed that first rank symptoms (Type I) such as:Delusions, feeling controlled by someone else, and hallucinationsWere only associated with schizophrenia.(However, these symptoms have also been linked with depression and bipolar.)SYNOPTICITY! Randy Gardener (1964) also experienced Type 1 symptoms, from sleep deprivation.

Different types of schizophrenia:1. Paranoid – Delusions &

hallucinations2. Catatonic – unusual motor

activity, extreme negativism, peculiar posturing. V. Rare.

3. Hebephrenic (ICD) or Disorganised (DSM) early age, disorganised speech, flat affect, some hallucinations & delusions.

4. Undifferentiated – Schizophrenic symptoms that don’t neatly fit a diagnosis.

5. Residual – At least one episode of schizophrenia experienced in the past. But no longer exhibiting signs of the disorder.

The ICD-10 also contains 2 other subtypes:Post-schizophrenic depression (a depressive episode after a schizophrenic illness.Simple schizophrenia (progressive development of negative symptoms, with no history of psychosis)

Classifying Mental Health Disorders:Diagnostic and Statistical Manual (DSM):• Published in America• English only• Predominantly used in the UK• Classifies 5 sub-types of schizophrenia• Looks after 6 months of symptoms• Used by professionalse.g. psychiatrists, psychologists, social workers.• Contains mental health statistics• Multi-axial approach – as it notes that

mental illness rarely exists without the influence of other factors in an individuals life:

Such as…1. Clinical syndromes2. Personality disorders3. Physical conditions4. Severity of psychosocial factors5. Highest level of functioning

International Classification of Diseases and related health problems (ICD): • Published by the WHO• International – multiple languages• Collection of health statistics• Classifies 7 sub-types of

schizophrenia• Looks after 1 month of symptoms• Mainly for disease – only chapter 5

is for mental health • Does NOT look at social factors• 10 categories of mental disorders

are identified• Looks mainly at positive symptoms

Evaluating classification systems:

Beck (1967) – RELIABILITYFour psychiatrists used the DSM to diagnose 153 patients.Each patient was interviewed separately with 2 psychologists.There was 54% agreement on diagnoses of schizophrenia, even less agreement on sub-types.• Small sample, not necessarily representative. (though,

mental health is not that prevalent)• People must be trained to understand DSM• Subjective• Lacks inter-rater reliability

Evaluating classification systems:

Cooper et al (1972) – CULTURAL RELATIVISMWhen patients (with identical symptoms) presented themselves. Schizophrenia was TWICE as likely to be diagnosed by New Yorker psychiatrists using the DSM than Londoner psychiatrists using the ICD.

The opposite was true of depression.• Unreliable • Cultural relativism – NY & L diagnose differently• Subjective

Evaluating classification systems:

Temperline (1970) – VALIDITYInterview with an actor was recorded. 7 groups were asked to assess his mental health.Groups consisted of professionals: e.g. psychiatrists, psychologists and law students.5/7 groups heard that the man being interviewed was interesting as he looks neurotic, but is actually psychotic. The 6th group heard nothing, and the 7th group heard he was healthy.

Temperline – continued!With those that heard he was neurotic, a majority of them said that he was neuroticAnd there was further disagreement amongst professionalsGroup that heard he was mentally healthy: 100% said healthyThis shows that the DSM and ICD may lack validity as some diagnoses may already be formed from existing preconceptions rather than using the manuals themselves

Temperline – evaluation:• People look at the labels rather their own

opinion• Groups are all from different backgrounds

(extraneous variable)• Individual differences amongst professionals –

subjective

Evaluating classification systems:

Rosenhan (1973) – LABELLINGEight people with no history of mental illness rocked up at a psychiatric hospital; claiming to be hearing voices in their head.Other than this, they answered further questions as mentally healthy individuals.They were all admitted, once in, they acted completely normally.Staff reported normal behaviour as if it were abnormal.One patient kept notes in a diary. This was described as ‘excessive note taking’.After, Rosenhan told a hospital about the study, and warned there would be more pseudo-patients. He never sent any. But staff recorded that 43 of the 93 admitted patients were pseudo-patients.• Ethical Issues – sending healthy people to a place for mentally ill• Self fulfilling prophecy could have caused these people to get ill• ‘labelling’ caused the nurses to act differently, which could cause long-term

damage where people may be unable to get a job• Shows diagnosis should be more rigorous

Biological:

Nature: genetics, brain damage, biochemistry, infection

They differ from your nurture i.e. peers, upbringing, culture, friends, environment

Biological – Genetics:

Definitions!Word Definition

Schizophrenia Psychosis… Loss of contact with reality

Monozygotic twin (MZ) Identical twin (same genetics)

Dizygotic twin (DZ) Non-identical (different genetics)

Concordance rate Likelihood of one twin getting same illness as the other twin

Twin studies Studies involving twins, if they’re MZ then they have same genes, so we can see if they were influenced by nature (genes) or nurture (upbringing)

Adoption studies Studies involving adopted children to see whether or not they have same genetic disorders as their real parents to see if illnesses are inherited

Twin study - Cardno et al (2002):

• Diagnosed schizophrenia in twins• Used ‘Maudsley Twin Register’ to get

strict diagnosis• Showed 26.5% concordance rates in MZ

twins• 0% concordance rates in DZ twins

This shows that it is your genetics (nature) that affects schizophrenia rather than your environment (nurture).

2002

Evaluation – Cardno et al (2002):

• MZ twins are relatively rare, out of all, schizophrenia only has a prevalence of 1%... Always will be small sample size.

Adoption study – Kety (1994):

• High rates of schizophrenia in individuals who’s parents had schizophrenia, but had been adopted by psychologically healthy parents.

Shows that genetics are more important than your environment. Supports Cardno et al (2002)

1994

Adoption study -Tienari (1991):

(in the Finnish Adoption Study)

• Matched groups, each with 155 adopted kids• Group one = schizophrenic mother’s (10%

developed schizophrenia)

• Group two = psychologically healthy mother’s (1% developed schizophrenia)

1991

Strengths & weaknesses (A02):Strengths Weaknesses

Twin Studies: MZ have same genetic makeup, so you can test Nature vs Nurture

Objective (quant data)

Twins are rare

Different criteria for different twin studies (so, Cardno used Maudsley, but other people use others)

Concordance rates measured differently = subjective

Adoption Studies: Nature vs nurture

Objective (quant data)

Bigger sample sizes possible than twin = more generalisable

Individual differences (life events)

Extraneous variables e.g. life events…

Biological – Biochemistry:

Dopamine Hypothesis:The dopamine hypothesis suggests that

messages from neurons that transmit dopamine fire either too often, or too regularly. Is is thought that schizophrenics have high numbers of the D2 receptors on the receiving neurons, therefore more dopamine binds to the cell.

Comer (2003): Dopamine plays a role in attention. Disturbances may lead to problems with focussing, and the perception problems found in schizophrenia.

Supports hypothesis – Grilly (2002):

Parkinson’s disease:- Degenerative neurological condition - Low levels of dopamine- Prescribed ‘L-Dopa’ to raise dopamine in brain- Some individuals went on to develop

schizophrenic-type symptoms

Ethical issues – protection from harm

Supports hypothesis – Anti-psychotic drugs:

• Anti-psychotic drugs block activity of dopamine in brain

• By doing so, schizophrenic symptoms (e.g. hallucinations and delusions) are alleviates

• They are known as dopamine antagonists

Supports hypothesis – Amphetamines (like speed):

• Drugs that act as dopamine agonists • Means that synapses get flooded with

dopamine• Large doses can cause hallucinations and

delusions (characteristics of schizophrenia)

Hard to test – ethical issues – protection from harm and … Drugs are illegal’n’ting

Supports hypothesis and contradicts hypothesis – PET Scans:

• Wong et al (1986) used PET Scans and found dopamine activity was greater in schizophrenics compared to a control

• However, Copolov and Crook (2000) have not found evidence of altered dopamine activity in schizophrenic’s brains.

Dopamine hypothesis – evaluation:

• Objective – Quantitative data, scientific

• PET Scans (Wong et al 1986)

• Hormonal• Reliable • Deterministic – no

blame

• Reductionist – no consideration for social events, may ignore actual cause

• Nature vs Nurture –NATURE, good as no blame. BUT, could lead to passive patients

Psychodynamic approach:

Freud (1924):

• Believed schizophrenia was a result of TWO processes:

1) Regression to a pre-ego state2) Attempts to re-establish ego control

Freud (1924):

Freud believed that schizophrenia came from:- Parents being cold/uncaring- Causing child to regress back into infantile state- Where the ego is not yet properly formed- Symptoms include: Delusions of grandeur

(believing you can fly etc)- But also, auditory hallucinations could be seen as

an individual’s attempt to re-establish ego control

Supporting Freud – Fromm-Reichmann (1948):

• Overprotective, rejecting, dominant, and moralistic mothers can contribute to children developing schizophrenia

• Supports Freud in that the condition stems from childhood

Supports Freud – Bateson et al (1956):

• Children who get mixed-messages from their parents are more likely to develop schizophrenia

• For example, if a mother was to tell her child she loved them, but look away in disgust if the child did something wrong. = mixed messages

• Prolonged exposure disrupts a child’s internally coherent construction of reality (perception of reality)

DOUBLE-BIND THEORY

Argues Freud – Oltmanns et al (1991):

• Parents act differently once their child has been labelled as schizophrenic

• Not prior to• Therefore it is not parental influence

and it argues Freud

• (SYNOPTIC: kinda like in Rosenhan’s 1973 pseudo-patients study as the nurses reacted to them differently once they had been labelled)

Psychodynamic approach AO2:

• Supporting research – Fromm-Reichmann (1948) (use other two in AO1)

• Considers social influences such as upbringing

• Individual differences

• Subjective

• Simplistic – biology not considered

Cognitive for schizophrenia:

Cognitive:

• Cognitive approach looks at biological factors for schizophrenia, says Type I/positive symptoms come from biology

• But further symptoms stem from people trying to make sense of their symptoms

• They reject feedback from others and believe that their beliefs are manipulated by others

Cognitive – Frith (1979):

• Argues schizophrenia comes from faulty attention systems

• with an inability to filter out unnecessary info that they have gathered through their senses

• This leads to illusion of distorted thoughts

Does not consider individual differences

Cognitive – Bentall (1994):

• Schizophrenics have trouble with processing information• Shown in Stroop tests: Colour words (red and green) are

substituted for emotional words (death and laughter), • Schizophrenics take longer than non-schizophrenics to

name the words.• Automatic subconscious processing – may account for

positive symptomsStroop tests may be unreliableIndividual differences

What have we learnt thus far…?

• Cognitive psychology is concerned with thought processes such as memory and attention.

• The cognitive approach to psychology recognises that biological factors contribute to the positive symptoms of schizophrenia. Other symptoms, such as negative symptoms develop from the individual attempting to make sense of an experience.

More stuff we’ve learnt…

• People provide information they need to maintain a grasp on reality and if this does not happen, psychosis may occur (loss of contact with reality) and people may become paranoid they are being controlled by someone else.

• A faulty attention system is blame as the reason for schizophrenia (Frith, 1979) as they can not filter out unnecessary information which leads to problems with attention.

Even more…

• This is shown further by Bentall (1994) who used the Stroop test to show problems with how people with schizophrenia process information, showing disruption with the processing of emotional words.

Supports cognitive – Meyer-Lindenberg et al (2002):

• Excessive dopamine in the prefrontal cortex has direct impact on the working memory.

• Where the schizophrenia stems from a disbelief in others(Synoptic – links to dopamine hypothesis)Objective (hormones)

lindenberg&

Supports cognitive – Yellowleese et al (2002):

• Developed a virtual hallucination machine• E.g. hearing a TV telling you to kill yourself• These were shown to schizophrenics to show

their own hallucinations were unreal & irrational

Ethical issues – protection from harm

Argues Cognitive – McKenna (1994):

• Schizophrenics aren’t more easily distracted than non-schizophrenics in cognitive tasks

Historical validity Lab study may affect results Distraction = subjective

Cognitive AO2:

• Yellowleese et al (2002)

• Free will

• Application to real life: treatments

• More holistic – approach believes that positive symptoms have a biological influence

• McKenna (1994)

• Individual differences

Treatment of schizophrenia:

Antipsychotic drugs:

• Chemotherapy (chemical treatments) used to treat symptoms of psychotic disorders such as schizophrenia and manic depression

• Two types of antipsychotic drugs:

Conventional and atypical…

Antipsychotic drugs:

Conventional:• E.g. ChlorPROmazine (pro –

treats positive symptoms)• Such as hallucinations and

delusions• Reduces the effects of

dopamine by blocking receptors

• Dopamine antagonists• Side effects

Atypical antipsychotic drugs:• E.g. Clozapine• Works on both positive and

negative symptoms (depression & apathy)

• Acts on dopamine & serotonin receptors

• Side effects include tardive dyskinesia (involuntary movement of mouth and tongue)

• Less side effects

Effectiveness and appropriateness of conventional and atypical drugs:

Conventional:• Luft B (2006) Found that

conventional drugs are associated with sudden death whereas atypicals are not

• Hill (1986) found that 30% of people taking conventional develop Tardive Dyskinesia

• Ross and Read (2004) – Motivational deficits, such as labelling, reinforcing ‘something’s wrong with you’ which is unethical

Atypical:• Leucht et al (1999) - Meta-

analysis showed that atypical are only a little better.

• Jeste et al (1999) - Side effects. Less chance of Tardive Dyskinesia (5% of people)

• Davis et al (1980) – Relapse. Placebo = 55% relapsedAtypicals = 2-22% relapsed

Individual differences etc etc

Antipsychotic drugs AO2

• Biological

• Objective

• Real life application

• Deterministic

• Reductionist – individual differences

Psychological therapies for schizophrenia:

Psychoanalysis:

• Getting to your subconscious to see if your childhood affected you – usually associated with Freud’s psychodynamic approach

• Freud believed that this approach would not work as schizophrenics are unable to form a transference with the analyst

• This is when the emotions of a patient are unconsciously shifted onto the analyst

SubjectiveCheapQuickCan combine with medicine

Appropriateness of psychoanalysis – Gottdiener (2000):

• Meta-analysis of 37 studies• Covering 2642 patients• 66% of them improved after

treatment using psychotherapy/psyschoanalysis

Effectiveness of psychoanalysis: Malmberg and Fenton (2001)

• It is impossible to draw a definite conclusion for or against the effectiveness of psychoanalysis.

• In fact the schizophrenia patient outcome research team (PORT) has even argued that psychoanalysis may be harmful to schizophrenics

Effectiveness of psychoanalysis:

• Therapists are expensive

• Patients often treated over a long time

• Prevents it being adopted on a large scale

• Costly & time consuming

Cognitive behavioural therapy:

• Caused by faulty thinking. Trying to find root of the problem to prove irrational thoughts are irrational

• Look at alternative explanations for maladaptive beliefs

• Treats symptoms rather than causeFocuses on ‘negative behaviours’ which are also deemed the ‘safest behaviours’

• People need to be trained to do it

Appropriateness of CBT - Kingdon and Kirschen (2006):

• 142 patients were tested, and found that many patients were not suitable for CBT as they would not fully engage with it.

• In general, it was less effective on older folk than younger ones

Effectiveness of CBT: Gould et al (2001):

• Meta-analysis of 7 studies• Reported that there was a

statistically significant decrease in the positive symptoms of schizophrenia after treatment

7 studiespositive symptoms

Evaluation for psychological therapies of schizophrenia – AO2:

• Comment on effectiveness and appropriateness for each

• Can be used along side drug therapies

• Comment on effectiveness and appropriateness for each

• Simplistic – only treating thoughts even though cognitive theory suggests that positive symptoms derive from biological influences

• People have to be trained to do CBT and psychoanalysis which is expensive, time consuming

• Individual differences – some people might not respond as well to drug treatment as others

Key words:Word Definition

Psychosis Loss of contact with reality

Positive symptoms Added to personality e.g. delusions and hallucinations

Negative symptoms Something removed from your personality, such as alogia = loss of speech

Biochemistry Hormones and neurotransmitters

Chemotherapy Treatments based on chemicals

Serotonin A neurotransmitter, low levels of this have been linked to depression

Dopamine A neurotransmitter, high levels have been linked to schizophrenia in the dopamine hypothesis

MOAAARR definitions!Word Definition

Dopamine antagonist Chemical which inhibits effect of dopamine

Placebo ‘fake’ version of a drug which tests whether the drug has biological impacts

Relapse When you lose your symptoms of abnormality, but then they come back

Neurotransmitter Chemicals that transmit impulses across a synapse causing a change in behaviour