A2 Psychology Unit 4

Schizophrenia

Schizophrenia• Defined as a split from reality

– Not split or multiple personality

• Onset is 18-25• Effects 1% of population• An umbrella term used to describe 3 different types of

symptoms– All characterised by a split form reality

• Key terms– Delusions

• Belief that is maintained despite there being arguments, data and refutation that should be concrete enough to destroy it

– Not religion, evolution, etc.

– Hallucinations• Perceptual experience with all of the components of a real sensory

experience but without the normal physical stimulus for it to be real

Clinical Characteristics• Positive (acute) symptoms

– Delusions• Grandeur

– Believe they are someone “grand” or famous– Believe they have “special” or “magical” powers

• Persecution– Believe that people are “plotting” against them– Being talked about by strangers– Thoughts are being interrupted or broadcast

– Hallucinations• Important for the diagnosis of Schizophrenia

• Occur more often than they do in other disorders

• Negative (chronic) symptoms– Apathy/avolition

• Lack of energy and interest in normal goals

– Withdrawal/asociality• Impaired social relationships

– Catatonia/cataleptic stupor• Standing motionless like a statue

• Adapting odd/bizarre postures

– Echolalia• Echoing of repetitive utterances of another person

• Copying the mannerisms of someone else

Clinical Characteristics• Disorganised (in-between) symptoms

– Disorganised speech• Problem organising ideas into words to be spoken• May also be inappropriate content

– Disorganised behaviour• Unable to organise and perform day to day activities

– Includes showering, dressing, preparing meals and eating

– Inappropriate affect• Silliness and laughter out of context

– Flat emotions• No emotional response in any situation• Face becomes immobile, eyes, lifeless, speech toneless

Types of Schizophrenia• Paranoid

– Mostly positive symptoms• Can show other symptoms

– Will be classified as paranoid if any positive symptoms are shown

• Catatonic– Mostly shows catatonic symptoms

– No positive symptoms

• Disorganised– Mostly shows disorganised symptoms

– No positive symptoms

• Undifferentiated– No clear pattern to symptoms

– No positive symptoms

• Residual– No longer display symptoms

Issues of Classification and Diagnosis• Classification

– Considerable overlap• Other psychological disorders have similar symptoms to Schizophrenia

– Co-morbidity• Person suffers from both Schizophrenia and another disorder

– Schizotypal personality disorder• Person suffers from Schizophrenic symptoms but not from the actual disorder• Specific to Schizophrenia

• Diagnosis– Reliability/validity

• Low reliability– Diagnosis is difficult– No one symptom is essential– Patients can differ greatly between one another but diagnosed as the same type

• Little predictive validity– Diagnosis gives very little insight into how to predict the course of the illness or appropriate treatment

• Rosenhan– Healthy participants complained about hearing voices (hallucinations)– After being admitted, said they were fine but took an average of 19 days to be discharged

» Nearly all classified as being in “remission”– Hard to diagnose Schizophrenia with good reliability and validity

» Low reliability for diagnosis– Evaluation

» Kety - If you lie to a doctor, they won’t diagnose you correctly» Ecological validity – field experiment» Population validity – done in different US states» Ethnocentric – only done in America

Issues of Classification and Diagnosis• Diagnosis

– Medical bias• Medical model resulted in complete neglect of non-biological explanations of Schizophrenia• Psychiatrics are doctors

– Represent the privileged minority

• Emphasis of doctor’s training is on biology and genetics• Drug treatments are successful and easy to use

– Could impact on the effort put into identifying the cause of the disorder

– Racism• Ethnic differences

– Cole and Pilisuk» Black people more likely to get drug treatment, less likely to get psychological treatment

– Cochrane» West Indian men less likely to go to GP with psychiatric issues, more likely to be admitted to psychiatric

hospital– Lipsedge and Littlewood

» Psychotic black patients twice as likely to be sectioned than native/immigrant whites

• Sociogenic hypothesis– High numbers of mental illnesses among ethnic minority groups due to stress of moving country

» Triggers diathesis for mental illness» Suggests that they would all remain mentally ill

• McKenzie– Caribbean immigrants in UK less likely to have a continuing psychotic illness compared to white British people

– Emphasise medical issues with diagnosis• Prejudice and ignorance of other cultures could also have a negative impact on reliability of diagnosis

• Debates– Is psychology a science?

• Biological approach ignores all social factors

Evaluating Therapies

• Effectiveness– Problems researching

• Placebo effect– Drug more effective than placebo

• Double blind– Researcher and participant interpret improvement due to nature of treatment

– General problems• Drug fallacy

– Relieves symptoms but doesn’t make it better

• Curative or palliative– Does it actually help or just relieve the symptoms

• Relapse

• Appropriateness– Side effects

• Does it make us better

– Compliance• Are we forcing them

– ECT

– Ethical issues• Should we be doing it

Biological Explanation - Genetics• Large amount of research suggests that development of Schizophrenia may be

partially genetic• One of the key issues is the methodology involved in research• Family studies

– Closer the person is related to someone with Schizophrenia, greater chance of developing disorder

– Gottesman• Reviewed concordance rates from family studies of Schizophrenia• Both parents = 46%• One parent = 16%• Sibling = 8%• All considerably higher than 1% of general population

– Can offer some explanation but is unlikely data fully accounts for the disorder• Family members normally experience the same environment

• Twin studies– Expect to see a higher concordance rate for MZ twins than DZ twins

– Kendler• 50% concordance for MZ twins

– Thinking they were DZ’s did not decrease chances of developing the disease

• 15% concordance for DZ twins– Believing they were identical did not increase chances of developing the disease

– Methodology issue• Designed to identify effect of genetic variation• Assumed all environmental factors will be the same

– Not always the case

Biological Explanation - Genetics

• Adoption studies– Studying children with Schizophrenic parents but brought up in an alternative

environment– Factors out environmental factors like family dynamics– Tienari

• Finnish adoption study

• 155 Schizophrenic mothers gave children up for adoption– Compared to 155 children adopted from non-Schizophrenic parents

• 10.3% with Schizophrenic mothers developed Schizophrenia

• 1.1% without Schizophrenic mothers developed Schizophrenia

• Genetic factors are clearly important but environmental are of equal importance

• Debates– Reductionist

• Over-emphasises genetic factors involved

• Over-simplified

• Allows in-depth research into genetic factors

Biological Explanation - Neurological• Brain abnormalities

– Kraeplin• Considered Schizophrenia a disease of the brain from abnormalities in the structure• Ethical issues

– Researchers use post-mortems to establish evidence

– Only identified after death– Can’t tell whether Schizophrenia was the cause of abnormalities or if it was a result of the brain

abnormalities– PET and MRI scans allow researchers to look at a living brain

• During onset and more advanced Schizophrenia• Brown

– Found decreased brain weight and enlarged ventricles

• Young– Normal amygdale is asymmetrical but in Schizophrenic patients it is not

• Flaum– Enlarged ventricles in Schizophrenia patients

• Buchsbaum– Found abnormalities in frontal lobe, hippocampus and amygdale

– No agreement on where changes need to be– Evidence does support structural brain abnormalities

• Research is done on dead or already diagnosed patients– Can’t see if damage was always present

• Debates– Is psychology a science

• Science always seeks to attempt to falsify its theory• Always be suspicious of evidence with no empirical casual relationship

– Reductionist• Over-emphasises neurological factors involved

– Deterministic• If brain abnormalities are the cause of Schizophrenia, everyone with a brain abnormality should get it

Biological Explanation - Biochemical• Imbalances in neurochemicals can cause Schizophrenic like symptoms

– Prolonged use of LSD has been known for inducing similar symptoms to Schizophrenia• Antabuse (drug for alcoholism) has the same effect

• Dopamine hypothesis– Excessive levels of Dopamine in the brain cause Schizophrenia

• Over production• Faulty regulation• Over sensitive receptors

– Support• Anti-psychotic drugs block Dopamine receptors

– Appears to be successful• L-Dopa of Parkinson's increases Dopamine

– Causes Schizophrenic symptoms• Amphatamines increase Dopamine

– Cause hallucinations and paranoia• Post-mortems of patients show greater density of Dopamine receptors

– Issues• Davis

– Drugs decrease Dopamine almost immediately– Full behavioural effects only begin to take place 2-3 weeks later

• Cohen– May be due to other delayed effects on the brain

• To be effective, Dopamine levels have to be reduced below normal levels– Just to normal levels should be enough if this was the case

– Contradictory evidence• Carlsson

– Implicates other neurotransmitters in development of Schizophrenia• Van Kammen

– Some studies report that Amphetamines reduce Schizophrenic symptoms• Kety

– L-Dopa and Antipsychotics have similar therapeutic value

Psychological Explanation - Psychodynamic• Schizophrenics fixate at the oral stage

– Harsh, uncaring upbringing– Regress back to oral stage before ego (reality complex) is developed

• Explains split from reality

• Claims this is what leads to self important symptoms

• Individual will try to keep contact with the real world– Leads to further symptoms

• Hearing God tell them they are someone famous to make sense of it

Psychodynamics

Hermeneutic All interpretations

Psychology is a science which does not like

hermeneutic

• Not empirical (observable and measurable)• Not falsifiable (conjecture – just an idea)

•No “real” evidence

Theories are based on looking at Schizophrenics

and interpreting their symptoms to identify a cause – just guessing

But

• Schizophrenia is hard to explain as all patients are different

• Hard to diagnose as all diagnosis's are different

• Science can only produce nomothetic general explanations that can’t apply to all Schizophrenics

• Maybe an explanation that incorporates scientific factors with idiographic, individual, hermeneutic explanations would provide a better understanding of individual differences found among patients

Psychological Explanation - Cognitive

• Cognitive impairments shown are involved in development of disorder

• Claims as features appear (hearing voices) individuals try to make sense of them– Ask others to confirm validity

– When they don’t the person may believe that others are hiding the truth

– Could lead to further delusions• Especially delusions of persecution

• Possible cognitive impairments– McKenna

• Disorganised speech could be due to inability to concentrate

– Frith• Delusions and hallucinations due to not recognising own intentions• Paranoid Schizophrenic behaviour due to inability to infer others intentions

– Helmsly• Disorganised thinking or unexpected behaviour due to loss of schemas or

memory confusion

Psychological Explanation - Behavioural• Faulty learning

– Childhood experience impacts on rest of life– Little or no social reinforcement forces child to learn from inappropriate external sources

• Could result in child’s verbal and/or behavioural responses being bizarre

– Anyone observing child’s behaviour will either• Avoid it – not challenging behaviour• React erratically – reinforcing behaviour

– Cycle will eventually deteriorate into a psychotic state

• Schizophregenic family– Arieti

• Personality of parents could be possible explanation– Cold, rejecting, dominating and prudish mother

– Detached, humourless, weak and passive father

– Mishler and Waxler• Mother with a Schizophrenic daughter and “healthy” daughter will act differently around the two

– Mothers reactions affect daughters condition

– Parental personality rarely used as singular cause

• Debates– Reductionist

• Over-emphasises impact of faulty learning– Holistic approach should be taken

– Deterministic• If it is really all down to a persons childhood, anyone with this childhood should have the disorder

Socio Cultural Explanation• Mental illnesses among ethnic minorities because of stress

from moving to a different country– Triggers diathesis for the disorder

• Theory can be linked to include lower class groups• Harder and more stressful life = more likely to get

Schizophrenia• Cooper

– More common in decaying intercity areas compared to poor rural ones– 7x more common in African-Caribbean's than white’s– Average rates in Caribbean countries similar to UK– 2nd generation African-Caribbean’s have higher risk than 1st generation

• Higher because they have suffered stress of living in UK for longer

• Debates– Reductionist

• Over-emphasises impact of stress on development of the disorder

– Deterministic• If stress is the cause, anyone suffering from stress should get the disorder

Biological Treatments - Drugs• Chemotherapy neuroleptics

– Block activity of Dopamine in the brain

• Typical antipsychotic drugs– Several weeks of treatment before any sign of symptoms diminishing

– Are eventually effective in treating positive symptoms

– Jackson• No good evidence for there being an effect on treating negative symptoms

– More effective treatment than any other when used alone• Most effective is combining the treatments

– Sampath• Half patients who were taking neuroleptic drug for 5 years were switch to a placebo• 75% relapsed with placebo within 1 year

– Only 33% relapse with drug

• Placebo not as effective as typical antipsychotic drug• Placebo group could have thought themselves into relapse• Typical antipsychotics are effective but not always appropriate

– Windgassen/side effects• 50% of patients suffered from grogginess• 18% had problems with concentration• 16% blurred vision• Many develop Parkinson’s symptoms• 2% develop neuroleptic malignant syndrome

– Muscle rigidity, altered consciousness, fever, possibly fatal– Treatment stopped possibly developing this disease

• Tardive dyskinesia– Involuntary sucking and chewing, jerky movements, writhing movements of mouth and face– Can be permanent

Biological Treatments - Drugs• Atypical antipsychotic drugs

– Work in a similar way to typical antipsychotics but also work on serotonin

– Advantages• Have fewer side effects• Can help patients who did not respond to typical antipsychotics• More effective in treating negative symptoms as well as positive

– Research evidence• Awad and Voruganti

– Fewer side effects than typical antipsychotics– Benefited 85% of patients compared to 65% who took typical antipsychotics

• Meltzer– 1/3 who had shown no improvement with typical responded well to the atypical drugs

– Side effects• Agranulocytosis

– Very dangerous side effect– Can kill– Immune system shuts down– 1-2% risk– Olanzapine does not seem to cause it

– Effectiveness• Most effective therapy for treatment• Drug fallacy

– Only palliative, not curative

• Some patients become resistant to drugs

– Appropriateness• Evidence for biological basis of disorder so biological treatment is logical• Drug fallacy

– Palliative not curative

• Compliance of patients taking medication

Biological Treatments - ECT• We don’t know how it works• Generally forced upon you

– Only used as a last resort, when there is not other option

• Therapeutic effects on mental health• Almost never effective• Research evidence

– Tharyan• Meta-analysis found ECT is beneficial short-term but not long-term

– Braya and Petrides• Meta-analysis found ECT is effective when used alongside drug treatment

– Chanpattana• Used in conjunction with antipsychotics has a significant reduction in positive symptoms

• Effectiveness– Effective for patients who haven’t responded to antipsychotic drugs

– Effective for positive symptoms

– Only short term

– Palliative not curative

– Not as effective as when used for depression

– Very rarely used

• Appropriateness– Clear evidence for biological beginning of disorder so biological treatment makes sense

– Very serious disorder therefore radical treatment seems appropriate

– Side effects• Though usually short lived

– Inappropriate to use a treatment we have little understanding of

Psychological Treatments - Behavioural• All behaviour is learnt through operant and classical condition and social learning theory

• Treatment– Token economy

• Based on operant conditioning• Rewarding desired behaviour• Ayllon and Azrin

– Rewarded patients with tokens for performing “normal” actions» Tokens could be exchanged for activities

– Number of chores performed by patients increased from 5 to 40+

• Paul and Lentz– Used token economy on long term, hospitalised patients– Patients developed various social and work related skills– Became better at looking after themselves– Symptoms were reduced– Results were achieved when a reduction of drugs were given to the patients– After 4.5 years, 98% of token economy patients had been released

» Only 45% non-token economy patients released

• Effectiveness– Help patients develop new skills– Very successful in institutions

• Not effective once rewards are removed

– Only deals with a few of the symptoms• Negative and disorganised

– Produces more “normal” behaviours but has no impact on cognition

• Appropriateness– Effective incentive to remove some very undesirable behaviour– Can be used effectively alongside other treatments– Desired behaviour chosen by staff not patients

• No free choice

– No effect on positive symptoms– Changes only last while reinforcement is present

Psychological Treatments - Cognitive• Change maladaptive thoughts to replace unwanted behaviours

• Coping Strategy Enhancement– Situation set up so therapist and client can work together to improve coping strategies– Emphasises that having hallucinations and delusions do not make you mad

• Everyone has them now and then

– Select one hallucination or delusion– Client given task to apply coping strategy to the hallucination/delusions– Therapist and client devise ways to make coping strategy more effective

• Effectiveness– Tarrier

• Patients showed a significant reduction in positive symptoms than those on a waiting list for treatment– Improvement still there 6 months after treatment

• Improved coping skills – Associated with decreased hallucinations and delusions

• Almost half participants refused to take part or dropped out

– Pfammatter• Meta-analysis• CSE moderately effective in reducing positive symptoms and a slight improvement in social networking• Showed we don’t know why it is effective• Several different aspects to CSE treatment

– Has not been established which is most important

– Turkington• Great majority of findings compare CSE to other control treatments and is found more effective• Difference could be because CSE is especially effective or control treatment is inadequate• Control treatments sometimes given by non-experts• Use of inadequate control treatments might explain some findings

• Appropriateness– Many symptoms are cognitive in nature so cognitive based therapy s fitting– Many patients already use coping strategies so is appropriate to build on pre-existing ones– Only works for certain positive symptoms– Ignores the biological factors in Schizophrenia

Psychological Treatments - Psychodynamic• Need to bring oral fixation to conscious awareness and gain insight

• Treatments– Hypnosis– Free association– Dream analysis

• Effectiveness– It doesn’t work– Even Freud admitted it wasn’t effective

• Appropriateness– If it doesn’t work we shouldn’t do it