PSYA4 REVISION

PSYA4 REVISION

PSYCHOPATHOLOGY (Schizophrenia)PSYCHOPATHOLOGY (Schizophrenia)

Psychopathology

-Schizophrenia

Do not answer questions on depression, phobic disorders, OCD!!!

• Clinical characteristics of the chosen disorder

• Issues surrounding the classification and diagnosis of their chosen disorder, including reliability and validity

• Biological explanations of their chosen disorder, for example, genetics, biochemistry

• Psychological explanations of their chosen disorder, for example, behavioural, cognitive, psychodynamic and socio-cultural

• Biological therapies for their chosen disorder, including their evaluation in terms of appropriateness and effectiveness

•Psychological therapies for their chosen disorder, for example, behavioural, psychodynamic and cognitive-behavioural, including their evaluation in terms of appropriateness and effectiveness

Outline the clinical Characteristics of SZ

• More than just ‘symptoms’• Explain, don’t list…

POSITIVE NEGATIVE• Hallucinations 2 types?

• Delusions These are? Types?

• Poverty of Speech (alogia)

• Flat Affect

• Social Withdrawal…

‘OTHER’ Symptoms• Catatonia Stupor, Waxy Flexibility, Gegenhalten

• Inappropriate effect This is?

Outline the clinical Characteristics of SZ

Other things you can mention• Diagnostic criteria

– E.g. at least TWO characteristic symptoms present for a significant period (1mth); Significant signs of disturbance (social, occupational) for 6mths)

• Incidence rate • Subtypes (be sure to say the characteristic symptoms of the

subtype/s)• Prognosis (include prodromal and active phase)

• Could mention the ‘new’ DSM criteria…

Discuss issues with the reliability and validity of the diagnosis and classification of SZ

• Basically, this is asking ‘what are the problems associated with diagnosis and classification of SZ?’

• Must be prepared to talk about RELIABILITY and VALIDIDTY of diagnosis– RELIABILITY: do different clinicians give the same diagnosis; is a

sufferer diagnosed with the same disorder on different occasions– VALIDITY: Is the diagnosis accurate? i.e does the patient actually have

SZ? Have they been mis-diagnosed?

• Could mention the different types of reliability and validity in the context of diagnosis


RELIABILITY• Consistency of Diagnosis • May be as low as 0.11

(Whalley)• Could be due to a number of

reasons (make sure you explain)– Use of different diagnostic

procedures (ICDvsDSM) as each have different diagnostic criteria

– Differences in the training and experiences of the clinician could lead to inconsistent diagnosis

VALIDITY• Accuracy of Diagnosis • Studies suggest validity of

diagnosis is low• Could be due to a number of

reasons (make sure you explain)– Nature of SZ (e.g. absence of

pathognomic symptoms; no objective observable symptoms; co-morbidity issues; natural variability of SZ across time and sufferers

– Issues with the clinician (e.g. training and experience [inc. knowledge of culture bound symptoms – give an e.g!]; fear of labelling, discrimination and a self fulfilling prophecy)

Mr B. tip - Use Rosenhan’s study as a LINK between reliability and validity issues…


EVALUATION / COMMENTARY• Key Study = ROSENHAN ‘on being sane in insane places’ – shows diagnosis was

reliable but not valid. (make sure you can describe this)• But problems with this study include low temporal validity (child of it’s time), sample

issues – cannot say ALL institutions have the same issues with diagnosis of SZ

• Other commentary points– Even with the problems, any diagnosis is better than no diagnosis because with diagnosis a

patient wouldn’t receive treatment – Highlighting the problems with diagnosis has led to a number of improvements with the

system• New versions of DSM have a list of culture bound behaviors• Clinician training has improved to increase awareness of biases, etc• DSM V has got rid of subtypes as they believed this was causing problems due to overlapping

symptoms• DSM and ICD have been brought more in line• Increased use of standardised procedures (e.g. Present State Examination) should increase reliability

and validity of diagnosis

Discuss issues with the reliability and validity of the diagnosis and classification of SZ (8+16)

In the context of diagnosis of SZ, reliability refers to… (could bring in inter-rater and test-retest)

It is suggested that the reliability of diagnosis is low. Whalley found…

This could be due to a number of reasons. For example the fact that different clinicians use different diagnostic tools…

Another reason for low reliability in the diagnosis of sz is…

In evaluation, there is research which has investigated the reliability and validity of SZ diagnosis. One piece of research is Rosenhan’s ‘on being sane in insane places…

This study shows…

So Rosenhan shows that there are issues with the validity of SZ diagnosis. In the context of diagnosis, validity means…

However, there are problems with this study…

One reason that diagnosis of SZ may lack validity is…

Another reason to explain the low validity of SZ diagnosis is…

In evaluation, identifying the issues with diagnosis of SZ has resulted in a number of practical applications which have improved modern diagnosis of the disorder. This includes… (NB say why it helps!)

In addition…

Finally, there is also the argument that a flawed diagnosis and classification system is better than no system at all. This is because…

What is wrong with these answers?(and can you spot any errors?)

One explanation is the Dopamine hypothesis, which suggests increased action at dopamine pathways causes schizophrenia. High DA action may be caused by a number of aspects, such as over sensitive D1 receptors and poorly functioning enzymes which break down DA. DA is thought to play a primary role in the processing of sensory information, movement and motivation.

According to the cognitive theory, schizophrenia may be caused by irrational thoughts which lead to cognitive distortions – literally abnormal processing of sensory information. In more detail, this abnormal processing may be a result of damage to cognitive systems such as the central monitoring system. This system is responsible for labelling actions as ‘being done by me’.

Psychodynamic theory offers an alternative psychological theory. Here, the root cause is unconscious conflicts which arise as a result of trauma in adulthood. This trauma may cause abnormal development of the tri-partite personality (ID, EGO, SUPER EGO). For example, it may cause the EGO to perform maladaptive use of defence mechanisms such as regression when a person is faced with trauma. Here a person is psychologically ‘going back’ to an early stage in their life.

What is wrong with these answers?(and can you spot any errors?)

One explanation is the Dopamine hypothesis, which suggests increased action at dopamine pathways causes schizophrenia. High DA action may be caused by a number of aspects, such as over sensitive D2 receptors and poorly functioning enzymes which break down DA. DA is thought to play a primary role in the processing of sensory information, movement and motivation. For schizophrenia, the DA hypothesis makes sense as it would explain the classic symptoms where these aspects are abnormal, such as social withdrawal (loss of motivation) and catatonia (movement abnormalities)

According to the cognitive theory, schizophrenia may be caused by irrational thoughts which lead to cognitive distortions – literally abnormal processing of sensory information. In more detail, this abnormal processing may be a result of damage to cognitive systems such as the central monitoring system. This system is responsible for labelling actions as ‘being done by me’. For schizophrenia, this makes sense as many symptoms could be explained by this. For example, auditory hallucinations may be a person who doesn’t recognise that their inner voice is their own and instead attributes it to an external source (e.g. God)

Psychodynamic theory offers an alternative psychological theory. Here, the root cause is unconscious conflicts which arise as a result of trauma in childhood. This trauma may cause abnormal development of the tri-partite personality (ID, EGO, SUPER EGO). For example, it may cause the EGO to perform maladaptive use of defence mechanisms such as regression when a person is faced with trauma. Here a person is psychologically ‘going back’ to an early stage in their life, prior to the trauma they experienced, as this makes them feel psychologically ‘safe’. For schizophrenia, this makes sense as many symptoms can be classed as childlike, such as neologisms (making up words) and even visual hallucinations which may be representative of childhood imaginary friends (these may serve a further psychological purpose however …

Discuss Biological Explanations of SZ

• Need to know at least TWO for top mark bands• Bio explanations include

– Genetic abnormalities– Biochemical - Neurotransmitter imbalances– Neuroanatomical Abnormalities – Viral Hypothesis

• When evaluating, consider the general strengths and weaknesses of the BIOLOGICAL APPROACH

• Where possible, link to specific symptoms!

EXAMINERS LIKE RESEARCH WHEN DISCUSSING EXPLANATIONS


GENETICS• Sz is likely to have a genetic basis

because of the observations that Sz is present in ALL CULTURES and tends to run in FAMILIES

• Established through TWIN, ADOPTION, FAMILY studies which assess CONCORDANCE rates

• Top band detail - saying Sz is ‘genetic’ is too simplistic

• Chromosone ____ (Gurling)• Specific Gene? _______

(Tonegawa)

EVALUATION• Evidence - E.g. Gottesman / other family studies

– Difficult to separate the effects of nature and nurture (shared environment criticism); problems with the operationalisation of SZ – different studies use different criteria making it difficult to compare results

• Some animal research– Problems with research? Extrapolation

• INCOMPLETE because...• PARSIMONIOUS but too Simplistic as it doesn’t

take into account psychological factors such as… which research has suggested may play a role in SZ

• DIATHESIS – STRESS the most complete explanation

• SOCIALLY SENSITIVE (who does it blame? Why is this a problem?)

• NEGATIVE MORAL IMPLICATIONS – may diffuse responsibility for the disorder away from the sufferer which may have treatment implications (i.e. they feel that because the disorder is not ‘their’ fault, there is no point in seeking treatment)

• BUT there may be PRACTICAL APPLICATIONS…


BIOCHEMICAL• the DOPAMINE HYP• Simple...• Initially thought to be the case because

we know DA controls perception, motivation, attention and control of motor movements

• So this explains symptoms including...

• High DA could be caused by a number of factors including…

• Other observations which indicate high DA causes Sz (e.g. drug use which causes increased action at serotonin sites is often accompanied with SZ type symptoms, including hallucinations, delusions).

EVALUATION• Evidence and supporting observations /

methodological problems with these• Post mortem studies and Animal studies useful for

easy commentary points...

• CAUSE and EFFECT issues• But why do we think it high DA is a cause and not an

effect?• But the TREATMENT AETIOLOGICAL FALLACY...

• INCOMPLETE (can explain positive but not negative symptoms)

• However, negative symptoms may be a result of positive symptoms (e.g. social withdrawal may be caused by delusions)

• Parsimonious but reductionist• Same as before. Include reference to the idea that DA

imbalance may itself be caused by something else (genetics)

• Deterministic

• Major Practical application... (use research to support. “this study shows that drugs are an effective treatment for SZ. As they are based in the dopamine hypothesis, this in turn VALIDATES the dopamine hypothesis of SZ)

Discuss Biological Explanations of SZThird / Back-up Theory

NEUROANATOMICAL • Enlarged Ventricles • Indicates atrophy to certain

brain regions / areas associated with cognitive and behavioural functions; link to symptoms

• Accidents, genetics, may cause abnormalities

EVALUATION• Objective methods used to

support this theory (brain scans)• General points too!

VIRAL HYPOTHESIS• Sz caused by a virus which

is contracted during pregnancy (third trimester?)

EVALUATION• Difficult to verify

(retrospective?)• Incomplete• General points too…

Discuss Psychological Explanations of SZ

• As with biological explanations, you need to know TWO for the top mark band

• Psych Explanations include– Cognitive (damage to cognitive systems)– Psychodynamic (early trauma, abnormal tri-partite personality, family

systems [e.g. double bind; schizophrenogenic mothers])– Behavioural / Social

• As before, remember to evaluate the approach on which the theory is based

• Where possible, link to specific symptoms

EXAMINERS LIKE RESEARCH WHEN DISCUSSING EXPLANATIONS


COGNITIVE• Sz a result of irrational thoughts /

errors in cognitive processing– Delusions, hallucinations, etc

• These may be caused by damage to cognitive processing systems

• Metarepresentation system (overall control) but includes...– Central Monitoring System

• Responsible for...• Damage would lead to...

– Supervisory attentional system• Responsible for...• Damage would lead to…

EVALUATION• Supporting evidence

– E.g. Frith and Done experimental fluency tasks – compared to a control, SZ produced fewer self initiated behaviours, indicating damage to the SAS

– But serious methodological Issues with the study (task lacked mundane realism so may tell us little about SZ in real life; sample issues

• UNSCIENTIFIC and UNFALSIFIABLE – based on abstract concepts (CMS, SAS) which are difficult to test empirically. Relies on subjective opinion

• Cause and effect issues

• More complete and less reductionist compared to bio theories as it can explain positive AND negative symptoms

• Recognises Nature (bio) influences (these may be the root cause of cog deficits)

• Practical Applications – therapies can be focused on specific cognitive systems

• Successful Therapy (CBT) derived from this approach validates the theory


EVALUATION• EVIDENCE E.g. OLTMAN

– Problems with evidence– Based on RETROSPECTIVE DATA, Subjective,

bias, sample issues blah blah blah

• ABSTRACT AND UNFALSIFIABLE– Difficult to test using empirical methods.

Heavily reliant on subjective opinions (prone to bias)

• CAUSE AND EFFECT ISSUES? It may be that the schizophrenics behaviour causes the family unit to be dysfunctional (e.g. double bind situations)

• INCOMPLETE and OVERLY DETERMINISTIC

• TOO SIMPLISTIC – Emphasises Nurture over nature– diathesis stress a better approach? (N.B this

approach lends itself very nicely to diathesis-stress)

• NEGATIVE MORAL IMPLICATIONS BUT DOES HAVE PRACTICAL APPLICATIONS

PSYCHODYNAMIC • Sz caused initially by NEGATIVE EARLY

EXPERIENCES (e.g. Early trauma, such as...)• This leads to unconscious conflicts (ID, EGO,

Super EGO), specifically…• EGO may shatter – ID becomes dominant;

results in primary narcissism (which is…); this would cause symptoms including...

• To regain control, the EGO may overuse defence mechanisms such as REGRESSION (which is…) as an attempt to go back to a time prior to the trauma. This can explain symptoms such as…

• Could also bring in the role of dysfunctional families and explain HOW these contribute to SZ

• Schizophrenogenic mothers (characteristics?)• Double Bind situations• High expressed emotions (relapse as opposed to

starting point)

Discuss Psychological Explanations of SZBEHAVIOURAL• Social learning • SZ may observe and imitate symptoms

from, for e.g. family members, especially if it is observed being reinforced (vicarious reinforcement). Can explain why the disorder appears to run in families)

• Operant Conditioning • Learn SZ symptoms are followed by with

positive reinforcement in the form of attention, etc

• Absence of learning of ‘normal’ behaviour

• As SZ is a complex disorder, it is unlikely that ALL symptoms are a result of maladaptive learning (but some symptoms may be caused by other symptoms so learning may be the cause of the key symptoms…)

SOCIO-CULTURAL• SZ caused by stress and

pressures of living in an urban environment

• Causes client to socially withdraw / escape into a psychological fantasy world

• BUT... Urban drift argument suggests SZs move to urban areas to access treatment so this explains the high occurrences of Sz in urban locations (cause and effect

• Diathesis-Stress?

THERAPIES for Schizophrenia

• TWO biological therapies– EARLY BIO TREATMENTS (ECT, Lobotomies)– DRUGS (typical and atypical anti-psychotics)

• TWO psychological therapies– CBT– TOKEN ECONOMY

Must be able to evaluate in relation to APPROPRIATENESS and EFFECTIVENESS so use these

terms!

Bio Therapies 1EARLY BIO TREATMENTS• Based on the assumptions that

abnormal neurological activity (e.g. in the PFL) causes SZ

• ECT– Bilateral and Unilateral– Short term muscle relaxant and

anaesthetic given to…– Small shock (0.6amps) for 1-2 seconds– Causes convulsions and Seizures– Repeated 2-3 times a week for 4-6 weeks– Thought to work because…

• LOBOTOMIES– Sever the connections to the frontal

lobes– Classic vs Trans-orbital procedure

EVALUATION• Evidence of effectiveness

(Tooth and Newton, Tharyan and Adams – ECT vs Placebo)– Methodological issues

including OPERATIONALISATION of improvement

• ETHICAL issues may make the therapies not appropriate

BIO Therapies 2DRUGS• Typical Anti-Psychotics

– Based on the dopamine hypothesis which suggests…

– APs are DA agonists in that they reduce the action at DA sites

– Typical• Bind to DA receptors, increase the

production of enzymes which break down DA to reduce DA action

– A-TYPICAL Anti-psychotics• Action in the NIGROSTRIATAL

DOPAMINE PATHWAY and MESOLIMBIC DOPAMINE PATHWAY (e.g. they affect other NTs); ‘hit and run’ approach)

EVALUATION• Lots of Evidence of effectiveness

– But there are problems with the evidence (e.g. lack of a placebo control does not allow us to rule out psychological effects; sample issues e.g. only one type of SZ investigated; poor operationalisation of improvement.)

• Not effective for all– Typical APs very good at treating Positive

but not negative symptoms; A typical more effective for negative

• APs only effective as a chemical straightjacket. We know this because– So a more complete therapy would involves

• ETHICAL issues – Side effects? Dependence?– Revolving door problem?– Cost-benefit analysis is key– Atypical APs have fewer side effects so are

more appropriate• But APs have PRACTICAL ADVANTAGES

making them more appropriate than other psychological therapies…

Psych Therapies 1

CBT• Based on the assumption

that irrational cognitions lead to distortions in information processing which leads to SZ symptoms

• THREE stages– Identification of irrational

beliefs– Challenge and dispute

irrational beliefs (e.g. through the use of experiments)

– Replace and restructure belief system and practise real world application (may involve the use of a diary)

EVALUATION• Evidence of effectiveness plus methodological commentary

– Pilling; Tarrier (good use of a control);

• More Effective in the long term (e.g. compared to drugs) because they focus on the root cause of SZ (irrational thoughts) AND teach practical strategies which can be used in the future – Most effective when used in combination with AP medication

(KOPELOWICZ)

• Not effective and appropriate for all symptoms (serious delusions / extreme psychosis – a person will never accept their beliefs are irrational)

• Not effective/appropriate with young, low IQ, elderly, because they will not understand the complex therapy

• Appropriateness questioned on ethical grounds - Confrontational nature may cause anxiety

• Ignores important causal factors (biological) so may not be appropriate unless combined with AP

• Practical advantages compared to other psych therapies (limited to a small number of sessions over a few weeks) but has disadvantages compared to drugs (CBT needs a well trained therapist to deliver, etc)

Psych Therapies 2TOKEN ECONOMY• Based on the behavioural

theories which suggests SZ is nothing more than a set of abnormal learned behaviours so therefore these can be replaced with learnt ‘normal’ behaviours

• OPERANT CONDITIONING is key– Token given for normal

behaviour (positive reinforcement)

– Token is secondary reinforcer because…

– Tokens exchanged for primary reinforcers suchs as…

– Punishment may occur when a client shows SZ symptoms (token taken away)

• MAKE SURE YOU APPLY!

EVALUATION• Evidence of effectiveness and methodological issues

– Ayllon and Azrin (only used female SZs so...); Paul and Lentz (operationalisation of improvement)

• Not effective in the long term as symptoms return outside of the structured institute where the TE was taking place – suggests TE does not treat the root cause and that clients ‘fake’ improvement to achieve tokens

• Appropriateness questioned on ethical grounds because TE may involve clients being denied basic human rights until they achieve tokens (food, etc)

• Not appropriate due to PRACTICAL DISADVANTAGES as it requires trained professionals to administer a TE programme and constant monitoring – BUT improvements are quick so it is an appropriate way to

quickly control symptoms within institutions

• Alternative treatments more successful and more appropriate…– Use evidence to support this point (e.g. APs effective in 85%

of cases; LIBERMAN compared CBT and TE and found CBT was more effective in long term)

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PSYA4 REVISION