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Schizophrenia


Affects 1%
of
population

More
common
for males



More common
for people from
cities than
countryside


Often occurs
between
ages 15 – 25
...

Criterion B – social / occupational dysfunction
One or more major areas functioning such as: work or self-care below the level achieved before the onset
of illness
Criterion C – Duration
Continuous signs of disturbance for at least 6 months
...

No disorganised speech or behaviour, or flat or
inappropriate affect
...


At least two of the following
Immobility, stupor (dazed state_, excessive
motor activity, extreme negativism or
echolalia or echopraxia (hearing voices)

Disorganised

Undifferentiated

Al following prominent:
disorganised speech and behaviour
and flat affect (absence of
expressed emotions and loss of
interest in life and not goal
directed
...


Positive
symptoms

Hallucinations
•
•
•

4



Noises, usually voices in mind, talking to themselves
and the person
...


Delusions
•
•
•
•


Disorganised speech

Irrational / false beliefs can take many forms
...
g
...


Disorganised or catatonic behaviour

Result of abnormal thought
processes
Problem organising thoughts
which is apparent in speech

Inability or motivation to initiate a task or complete it
...



Speech poverty (alogia)
refers to a reduction in amount and quality of speech
often accompanied by a delay in verbal responses in
conversation
...

Anhedonia
Loss of interest o pleasure in activities
...

overlaps with depression
...




3

Problems in diagnosis
Reliability
Lack of reliability between clinicians
...

DSM – 23 and 13
ICD - 44 and 24
Whaley – Inter-rater reliability correlations as low as 0
...


Test re-test reliability
Same clinician should diagnose the condition at different points in time

Culture
significant variation between countries
...

69% US diagnosed schizophrenia but only 2% of UK gave same diagnosis
...

Other ideas
Escher – 15000 non-schizophrenic individuals, 15% of participants reported they heard voices
...


It is a complicated condition which encompasses many different psychological abnormalities which have a
loss of contact with reality in common
...


Validity
Whether the assessment system measure whether someone has schizophrenia

Rosenthan
Example of how easy it is to be ‘misdiagnosed’
...

All diagnosed as schizophrenia and admitted to a hospital
However, when there acted normally but this behaviour was schizophrenic showing that
once a label has been given it is difficult to remove

Highlights an issue with the validity for the classification system if psychiatrists are unable to
distinguish between real and pseudo patients
...

Therefore, research findings
into the cause of schizo cannot
be generalised to most
...

When described as male, 56%
gave a diagnosis but when
female only 20%
Could be that women seem to
function better than men,
masking their symptoms
...

Could be that Britain triggers
the onset of illness as more
stressful
...


If:
Parent – 5%
Siblings – 10%
Siblings with 1 parent – 13%
Child with 2 parents – 46%
Grandchildren – 4%
However, if genetic than should be 100% so too deterministic
...


Gottesman
1948 – 1964, every patient admitted asked whether they had a twin
...

Furthermore, 20 years later found:
MZ – 46%
DZ – 14%
Different concordance rates in time so shows environment matters
...

Children who were adopted weeks after birth whose mother is schizo are studied
...

• 10% of the adopted children of schizo mothers were found to be
...


Evaluation
Schizoid
Concordance for MZ 3X than DZ but still a
discordance rate of 40%
However, studies show half of the discordance
group go on to develop ‘schizoid’
• Also, other twin could have been triggered
later in life but this was never followed up
...

E
...
always same gender MZ
...



No single gene for schizo has been identified
...

Different studies indicate different candidate genes and difference
combination
...


Outdated
Evidence based on older twin
studies is less reliable due to
changes in diagnostic criteria
...

It is important in the functioning of several brain systems implicated in symptoms
Evidence
drugs that increase dopaminergic activity in the brain (such as amphetamines) when taken by healthy
individuals result in psychotic symptoms
such drugs increase symptoms in schizo suffers
antipsychotic drugs which block dopaminergic neurons reduce psychotic symptoms such as
hallucinations and delusions
...


Evaluation
1) Leucht – meta-analysis of 212 studies and found drugs were more effective than placebos for
both positive and negative symptoms
...

1) Too simple – other neurotransmitters such as serotonin said to be associated
...
g
...

In contrast though, lower than normal levels in the prefrontal cortex linked with negative
symptoms
...
This led to theory that it was not increased dopamine but the heightened sensitivity of the receptors for
dopamine which led to an abundance of the chemical and symptoms
...

3) 6 times the density of D4 receptors in the brains
of patients and D4 is a sub-type of D2
...


1) Not clear whether increase
receptors is the cause of the
pathology or an effect of the
drugs taken
...




Neural correlates
Refers to measurements of the structure and function of the brain that correlate with the positive
symptoms of schizophrenia
...

Ventral striatum believed to be
involved in anticipation of
rewards for tasks, therefore,
abnormality in this area = lack
of motivation as cannot imagine
the feeling good after the task
...


Allen
Auditory hallucinations have
been linked to lower activity
levels in the superior temporal
and anterior cingulate gyruses
...


Raz and Raz
Structural abnormalities such as
reduced brain tissue and
enlarged ventricles
...
6
...

Concluded – when genotype for schizo is identical, there is significantly diminished brain volume in the
twin with schizo
...


However, cannot tell if the abnormal working
causes schizo or that it could be that
symptoms lead to the abnormal functioning
...


Evaluation of biological
Reductionist
as suggest that a neurotransmitter is the only
cause of the symptoms
...


Deterministic
suggest that schizo is entirely the result of
biology but some freewill is involved in
accepting the label i
...




some cases of immune disorders, they have
been misdiagnosed as schizophrenia
...
Could be something else entirely
so blood test should be done when diagnosing

Greater objectivity in the measures used e
...

scans
...





Very small sample studied so difficult to
generalise
...




Psychological explanations
Family dysfunction
Double bind theory
Bateson et al suggested that communication between parents and offspring were sometimes
contradictory (using the phrase double bind)
...

• This may lead to children not trusting their own feelings and perceptions as cannot trust those of
others, growing up to mistrust all communications as shown sometimes by paranoid
schizophrenics
...
She stiffened, he removed his arm and she has ‘don’t you love me anymore’
...

This interaction may prevent development of an internally coherent construction of reality and in
the long term manifests itself as schizo symptoms such as flattened effect and withdrawal
...

Believed to be link with relatives
‘emotional over-involvement’
...


Bebbington
Meta-analysis of 26 studies of the role of EE a risk factor from
variety of countries between 1958-90
...
Relapse in these
high EE families averaged at 50% whist in the low EE it was
21%
...

Scazufca and Kuiper’s
Study shows that the level of EE is related to the family’s
estimation of the burden of care
...

It is the way the relatives see patients as affecting their social
life, employment finances etc
...


Why
The theory of EE suggests that those with schizo have lower tolerance for intense environmental stimuli
intense emotional comments and interactions with family
...

However, supporting families who are emotional undemanding help reduce their dependence on
medication and risk of relapse
...


The diathesis – stress model
where biological factors cause a predisposition
to develop it and stress factors in environment
may well be to do with family dysfunction and
expressed emotion
...
E
...
family
conflict, child abuse, emotional deprivation
...




Unclear whether EE is a causal agent in relapse rate or just a reaction
...


Not all patients who live in EE families
replaces and vice versa
...




Leff et al
communication pattern is also more evident
in western families – cultural bias
...
Might not give
sufficient accurate picture of family
interaction
...




A strength is that it implies the possibility of change within the family thus help for the patient

Cognitive explanations
5 processes
memory
language
attention
perception
thinking
•
•

Emphasises the role of dysfunctional thought processing – particularly in those who display the
characteristics of positive symptoms
...

Frith et al two kinds of dysfunctional thought processing

Metarepresentation
The cognitive ability to reflect on thoughts and
allows insight into our own intentions and goals
and interpret actions of others
...

Dysfunction in this would
Lead to disorganised speech and thought
disorder as a result from the inability to supress
automatic thoughts
...

Relate irrelevant events to themselves e
...
muffled voices as people criticising them or flashing lights as a
signal from god
...

They are considered to have impaired insight and inability to recognise cognitive distortions and
substitute more realistic explanations for the events
...

So the inner representation of on idea can override the actual sensory stimulus and produce an auditory
image that is as real as the transmission of actual sound
...


Conclusion
No single explanation can explain everything about schizophrenia so instead, many factors could implicate
...


Evaluation of cognitive

Unclear what causes what, including
whether cognitive factors are a cause
or result of neural correlates and
abnormal neurotransmitter levels
...

Howes and Murray
addressed this problem with an
integrated model which argue that
early vulnerability factors such as
genes together with exposure to
significant stressors sensitise the
dopamine system causes the release
of dopamine
...
E
...
delusion
patients seemed to jump to conclusions and lack reality
testing
...
Those with negative symptoms displayed
dysfunctional thought processes such as having low
expectations regarding pleasure and success

Stirling
compared 30 patients with schizo to a control group on
a range of cognitive tasks
...

Cognitive based theories have had some success which
reinforces that faulty cognition is source of some
symptoms
...


they bind to dopamine receptors thus
blocking their action


...

Chlorpromazine - also has a sedative effect and
used to calm patients
...


Found that 75% reduced positive but did not
reduce negative
Symptoms reduced within a few days
...

Do not have EPSE side-effects (movement
disorders) par occasional motor restlessness
...


Also, act on serotonin receptors and may
enhance the mood of patients which can be
important as 30% - 50% of patients attempt
suicide
...

Meltzer – may develop a blood disorder

Evaluation of drug treatment
Extrapyramidal side effects
they include muscle spasm and parkinsonism and half of patients taking typical antipsychotics
experience them
...


Coressley
no significant difference in
effects on symptoms for
both drugs but difference
in the type of side effects
...


Because of side effects there are ethical
issues leading to many discuss the costs of
medication outweighing the benefits
...

Both drugs similar time but different reasons
...


Cole et al
Found after 6 weeks of
treatment with conventional
antipsychotic drugs, patients
showed significant
improvement compared to
those with a placebo
...


...




Drugs can lead to
improvement in the
daily lives of families
and ease problems
placed on society
...




Sliverman – can have beneficial
side effects such as increasing
levels of attention and information
processing

Thronley – reviewed studies
comparing the effects of typical
psychotic drugs to a placebo and
found that typical drug was
associated with better overall
functioning and relapse rate was
also lower
...

Furthermore,
Become popular as bi-monthly injections which
ensure adherence to a routine, prevent relapse but
these drugs are means of controlling not curing
psychosis
...

Often drugs are used as a combination therapy, drugs reduce symptoms so that CBT can be effective
...

• Usually referred to CBTp
Differs slightly from conventional CBT methods
...


The ABC model

Activating event that causes their irrational Beliefs as well as the Consequences
...


Normalisation

Knowing that there are other people who experience the same things can help
reduce feelings of isolation and anxiety
...


link thoughts and
actions to symptoms
so that patients can
consider alternative
explanations for the
way they feel
...




Will not remove
symptoms but
hopefully reduce
distress and improve
functioning

Requires self-awareness and willingness to engage
...


Evaluation of CBTp
CBTp appeared to be effective at certain stages
...
Useful
after drugs reduced symptoms
...
187 patients only
6
...


Problems with meta-analyses
As do not consider the
differences in studies e
...
some
don’t randomly allocate and
some fail to mask the treatment
condition for interviews
...



Gould et al
meta-analysis and found a significant
decrease in positive symptoms
...




Durury - faster response
to treatment when CBTp
and drugs than just
drugs
...




Family therapy
Expressed emotion
We know it is more likely for someone to relapse if
from a family where they experience high levels of
expressed emotions

Therefore, family therapy seeks to
treat members of the family as well
as the patient
...

NICE recommends it should be offered to all
individuals diagnosed who live or who are in contact
with family
...

Hopefully leads to more supportive and warm atmosphere meaning better progress and relatives feel
more positive and more effective in their supporting roles
The therapist encourages the relatives to ask questions and learn more about the disorder
...

Garety
Relapse rates are reduced to 2%
following family therapy as
opposed to 50% for those
receiving standard health care
alone
...

However, study claims all the studies in the meta-analysis used random allocation yet there is evidence
that this may not be the case
...



Evaluation
Hogarty – investigated the effectiveness of family therapy in comparison to three other types of treatment
...

Found that 40% of those with medication-only relapsed compared to 20% who received medication plus social
skills or family therapy
...

Economic benefits of family therapy – the cost is offset by reduction in hospital costs because of lower relapse
rates – costs 8,000 a week for a person in an institution but 2,000 for therapies
...
Lobban – analysed the results of 50 studies
with 60% reporting a significant positive impact of the intervention on at least one outcome category for
relatives e
...
coping skills
...

Used to manage behaviour of patients especially those who have developed maladaptive behaviour
through spending too long in institutions
...
g
...



Rewards must
genuinely reward the
person

Tokens given
immediately to
increase their effect
...
g
...




By paring the tokens with the reinforcing stimulus, thee neutral
token eventually acquires the same reinforcing properties
Ayllon and Azrin
Women ward
Rewarded with tokens for self-care and exchanged for privileges like watching films etc
...

Key issues in token economy are to establish
What is a desired behaviour, what is a token, what is a reward, how many tokens for each reward etc
...


Milby - programmes successful
in hospitals and preparing to
leave but do not know if the
effects worked long term

Can be administered by anyone
with taken and are relatively cheap
so there are more benefits than
costs


Corrigan – only useful in
institutions as in
community where
monitored for only a few
hours are day there is less
significant impact
...

Other factors may affect such as
increased staff attention
...



10 – 20% of people do not
respond well to it
...


The interactionist approach
The diathesis stress model
Sees schizo because of the interaction between biological and environmental influences
...


•

Reviewed nearly 20,000 women admitted to a Finnish hospital and identified those who had been
diagnosed at least once with schizo and this list was checked to find those mothers who had one or
more of their offspring adopted
...
Psychiatrist also assessed family functioning’s in
the adoptive families such OPAS scale
...


Evaluation
Implications for treatment –
interactionist model
acknowledges both bio and
psychological factors and
therefore compatible for
combining medication and
CBTp and this has become
the standard practices

Diatheses may not be entirely genetic
thus the original model is over simple

Most DS models emphasis genetic
vulnerability however increased biological
risk may be because of brain damage
caused by environmental factors
...



There are difficulties in determine causal
stress





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