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Schizophrenia

Overview of the topic Schizophrenia in A2 Psychology. (Information from revision notes and text books)
by

Sarah Jane

on 3 April 2014

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Transcript of Schizophrenia

Section B: Psychopathology -Schizophrenia

Schizophrenia is a long-term mental illness which causes a range of different psychological symptoms such as:
Hallucinations
Delusions
Muddled 'thoughts
Changes in behaviour
The illness...
Symptoms are classed into two groups: Positive & Negative symptoms.

Positive symptoms include; Delusions, Hallucinations, Confused thoughts, changes in behaviour and experiences of control.
Negative symptoms include; Affective flattening, Alogia, Avolition, loss of motivation in life & activities such as relationships, lack of concentration & not being able to iniate a conversation and feeling uncomfortable around others.
Causes of Schizophrenia
There are many causes of Schizophrenia, but the exact cause is unknown. Research suggests that it could be a combination of genetic and environmental factors that can make people develop the condition. Current thinking suggests that people are more prone to developing the condition due to stressful lives, i.e. losing a loved one, or divorce could trigger a psychotic episode.

There are factors which increase your risk these are;
Genetics
Brain Development
Neurotransmitters
Pregnancy & Birth Complications

There are also triggers. Triggers are things that may cause Schizophrenia in people who are at risk, these include;
Stress
Drugs
Common Misconceptions!
There are two common misconceptions people have towards Schizophrenia. The first being that those who suffer with the condition have a 'split personality'. This is not true. The second misconception is that people are violent and display psychotic behaviour, this is also not true. Both of these misconceptions were created by the media and it's representation of those suffering with the condition.
Diagnosing Schizophrenia...
There is no individual test for Schizophrenia, the condition is diagnosed by a specialist in mental healt after an assessment. The earlier Schizophrenia is diagnosed, the more succesful the outcome is.
To make a diagnosis, mental health specialists will use a 'diagnosis checklist' where the presence of certain symptoms indicate that a person may have Schizophrenia.

Schizophrenia can normally be diagnosed if:
You have two or more of the following symptoms; delusions, hallucinations, disordered thoughts or behaviour or the presence of negative symptoms, such as a flattening of emotions.
Your symptoms have had an impact on your daily life, i.e. ability to work, daily tasks, study etc.
You have experienced these symptoms longer than 6 months.
All other possible causes such as drug use or depression have been ruled out.
It may not be clear whether or not people have the condition, there are other related illnesses which have similar symptoms.
Bipolar Disorder: People with this disorder experience dramatic mood changes, and like Schizophrenia, hear voices in their heads and experience hallucinations & delusions.
Schizoaffective Disorder: This is similar to Schizophrenia and Bipolar Disorder in that it has similar symptoms, but unlike these two conditions, it only happens once in a person's life or recur intermittently and is often triggered by stress.
Treating Schizophrenia...
Schizophrenia is normally treated by a combination of therapy and medication.
The National Institute for Health and Clinical Excellence (NICE) has produced guidelines for people with schizophrenia and how they should be cared for. They state that anyone providing treatment & care for people with schizophrenia should:
develop supportive relationship with patients and their carers
explain causes and treatment options, keep clinical language to a minimum, and provide written information at every stage of the process
enable easy access to assessment and treatment
work with patients, and their families & carers if they agree, to write advance statements about their mental and physical healthcare
take into account the needs of the patient’s family or carers and offer a carers' assessment.
encourage patients and their families & carers to join self-help and support groups
Types of Medication:
Doctors usually prescribe Neuroleptic drugs or antipsychotic drugs in order to control the 'positive symptoms. There are two types of antipsychotic drugs; Typical & Atypical. Typical antipsychotics are first generation antipsychotics developed in the 1950s, Atypical antipsychotics are newer generation antipsychotics developed in the 1990s. However these drugs have side effects, however not everyone suffers with them, and severity can differ within different people, these side effects are:

Shaking & trembling
Muscle spasms & twitching
Drowsiness
Weight gain
Blurred vision
Constipation
Lack of sex drive
Dry mouth

Other neuroleptic drugs such as Chlorpromazine & Haloperidol have been associated with long-term side effects including involuntary movements & muscl spasms which may be permanent,


There have been drugs which have been developed to have fewer neuromuscular side effects, these are;
Risperidone
Amisulpride
Olanzapine
Paliperidone
Quetiapine

Antipsychotics reduce feelings of anxiety or aggression within a few hours of use, however they may take several days or weeks to reduce other symptoms, such as hallucinations or delusional thoughts.
These types of drugs are recommended as initial treatment for symptoms of an acute schizophrenic episode. They work by blocking the effect of the chemical dopamine on the brain.
Onset Symptoms...
There are also onset symptoms which can indicate whether a person is suffering with Schizophrenia, these include:
Social Isolation/Withdrawal
Irrational, bizarre and odd statements or beliefs
Increased paranoia or questioning others motivations
Becoming more motionless
Hostility or suspiciousness
Increasing reliance on drugs & alcohol
Lack of motivation
Speaking in a strange manner unlike themselves
Innappropriate laughter
Insomnia or oversleeping
Deteioration of personal appearance and hygeine
Although these symptoms may not lead to Schizophrenia, a number of them occuring at once could be a sign.
What is Schizophrenia?
Approaches to schizophrenia...
Approaches...
Some psychogical approaches concerning Schizophrenia are more credible than others.

The Behavioural & Psychodynamic views on Schizophrenia are a bit pants...

However, Psychosocial approaches on the other hand offer a little bit more in trying to explain the circumstances that surround the disorder.

But the Cognitive approach offers a better explanation of Schizophrenia.
Behavioural Approach...
Suggests that Schizophrenic behaviour is
conditioned
&
learnt through observation.
Offers some understanding of how Schizophrenic characteristics are are maintained, as those sufferening with the condition are given special treatment, therefore their
behaviour is reinforced
.
Doesn't contribute enough to the understanding of underlying causes.
Negative Reinforcement
- Attention seeking, a child may see that when a parent has a Schizophrenic episode they receive attention. The child may then start to behave in a similar way to gain attention themselves.
Positive Reinforcement -
The parent who is Schizophrenic may be removed or taken away (cause of stress/tension removed) to ensure the health of the child, who may be taken to hospital.
Psychodynamic Approach...
This approach suggests that people will develop Schizophrenia as they cannot resolve the
conflict between the demands of the id and the overwhelming guilt forced upon by the Superego.
This then causes individuals to
regress to an earlier, infantile stage of development.
This approach also explains the idea of 'Schizophrenogenic families' which is talked about in more detail in Psychosocial Factors.
However, one major issue with this approach is that there is no evidence to support this view, and like the Behavioural approach, it fails to explain the complexity of the disorder.
Schizophrenia in Psychology....
Psychopathology Overview...
Psychopathology is the study of psychological disorders and their origins. There are strong links with abnormality unit in AS, in terms of defining boundaries between normal & abnormal behaviour.
Mental disorders take different forms with treatments varying greatly. Some work for some disorders, but not for others.
A classification criteria has been made to ensure that the right diagnosis can be made.
There are 2 classification systems in Psychopathology:
ICD - International Classification System for Diseases
DSM - Diagnostic and Statistical Manual for Mental Disorders.
The
ICD-1 states:
"A mental disorder is a clinically recognisable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction should not be included in mental disorder as defined here."
WHO (1991)
DSM-IV-TR states:
"A mental disorder is a clinically significant, behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (or pain) or disability (impairment) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom."
Diagnosis of psychiatric disorders focuses not on underlying causes but observable symptoms and behaviours. Regularly occurring clusters of behaviours and symptoms are known as 'Syndromes'
Benefits to diagnosing a mental disorder:
C
U
T
C
P
R

ommunication
nderstanding
reatment
auses
revention
esearch
Differences between the ICD-10 and the DSM-TR-IV...
Duration: DSM requires symptoms present for 6 months. ICD requires one month.
Emphasis: DSM emphasises the course of the disorder and accompanying functional impairment. ICD focuses more on first-rank symptoms (symptoms rarely found in disorders other than schizophrenia).
Dimensions: DSM is multi-axel which means that various factors are taken into consideration before a diagnosis is made e.g. personality type.
Validity issues concerning the diagnosis of schizophrenia...
Disorders similar to Schizophrenia
: There are individuals who display similar symptoms to Schizophrenia but don't meet the criteria e.g. shizoid personality disorder and schizotypal disorder. Validity affected where these variations exist. Difficult to diagnose a person displaying schizophrenia-type symptoms. The boundary between classifications is blurred. Led to criticisms concerning the portrayal by the diagnostic symptoms where schizophrenia is depicted as an absolute condition i.e. 'all or nothing'.
Dimensional or categorical disorder:
Schizophrenia should be a dimensional disorder where it's classification should relate to the
degree
to which problems are experienced not the presence or absence of them e.g. some may experience hallucinations but have found ways to to cope with them and so their functioning in life is not affected.
Schizophrenia as a multiple disorder:
Individuals diagnosed can present with different problems. Suggests that there is no single underlying causal factor. Individuals don't respond in the same way to treatments. This then suggests that there is a lack of validity in the diagnosis of schizophrenia. It is argued that each of the symptoms of schizophrenia should be seen as a disorder in its own right, with its own cause and treatment.
Differential diagnosis:
Often difficult to distinguish between schizophrenia and seemingly unrelated syndromes e.g. those with temporal lobe epilepsy/experiences of drugs.
Dual diagnosis:
Co-morbidity is common, which is where one person diagnosed with one mental disorder similtaneously show symptoms of anothe. The multi-axial DSM encourages multiple diagnoses to be made where it might not always be appropriate.
Cultural variations: Harrison
et al.
(1998) -
Schizophrenia diagnosed more frequently in African-Americans and African-Caribbean populations. Difficult to determine whether this is due to greater genetic vulnerablity or psychosocial factors (as being part of an ethnic minority). Misdiagnosis may occur where there is a misinterpretation of cultural differences in behaviour as being symptoms of schizophrenia.
AO3
Biological explanations of Schizophrenia...
Genetic Explanations:
Evidence from family studies:
First-degree relatives (offspring, parents and siblings) share 50% of their genes, secon-degree relatives share 25%.
Family studies involve the comparison of rates of schizophrenia in relatives of diagnosed cases compared with relatives of controls.
There is evidence that the closer the biological relationship, the greater the risk of schizophrenia developing.
Evidence from twin studies:
Twin studies compare the difference in concordance rates (likelihood of both twins being affected with the disorder) between identical (MZ) and non-identical (DZ) twins.
Only the MZ twins have identical genes.
There is a higher concordance rate in MZ compared to DZ twins.
MZ twins reared apart can be used to distinguish the effects of genetics and environment. (Turkheimer)
Evidence from adoption studies:
Adopted children who develop schizophrenia cab be compared to their biological and adoptive parents.
If schizophrenia has a genetic component, the development of the disorder should be maintained even if there is a change in environment, such as being raised by non-biological parents.
Adoption studies attempt to highlight such genetic influence.
Biochemical explanations of schizophrenia:
The Dopamine Hypothesis:
Dopamine is a neurotransmitter that is found in them limbic system
Over-activity in the dopamine-controlled parts of the brain can result in schizophrenia.
Phenothiazines which inhibit dopamine activity can reduce the symptoms of schizophrenia.
L-dopa, a dopamine releasing drug, can cause schizophrenic symptoms in non-psychotic people.
LSD/amphetamines increase dopamine activity and induce schizophrenic symptoms.
Research/Evaluation:
Research/Evaluation:
Neuroanatomical explanations:
Magnetic Resonance Imaging:
A non-invasive technique where radio waves are recorded from the brain.
Recordings are computerised and assembled into a 3D image of the brain structures.
Theses studies show definite structural abnormalities in the brains of patients with schizophrenia.
Research/Evaluation:
Strong evidence that gentics are a risk factor for schizophrenia.
However, risk for other twin developing disorder is 50%, suggesting genetic influences don't offer a complete explanations.
89% of sufferers don't have a relative who has been diagnosed with the disorder.
Research into location of specific genes has not produced definitive results. Impossible to understand underlying mechanism that leads from genetic risk to the disorder.
Falkai et al. (1998)
: examinations of brains from dead patients show that there is an excess of dopamine in the left amygdala.
Wong et al. (1986):
PET scans show greater dopamine recepto density in the caudate nuclei in those with schizophrenia.
It is difficult to determine if increases ini dopamine found in the brain regions are the result of schizophrenia or the cause of it.
Drugs tend to be effective at alleviating positive symptoms , but not negative symptoms, suggesting that all of the symptoms of schizophrenia may not be directly related to dopamine.
Biochemical explanation is
reductionist
where stress/irrational thought processes are not taken into consideration.
Treating Schizophrenia...
Psychological Explanations of Schizophrenia...
Psychological Therapies...
Family Interventions/Therapy -
Aims to reduce the level of negative expressed emotion in the family.
Family members given information on the disorder and ways of managing it e.g. improving communication styles, lowering expressed emotion, adjusting expectations and expanding social networks.
Involves family members as well as the individual with the condition.

Evaluation -

Meta-analysis from Pharoah et al. (2003) showed that family interventions such as these were effective in reducing the rates of relapse and the rates of admission to hospital in people with Schizophrenia.
May also be appropriate because it can improve compliance with taking medication. This contributes to effective outcomes of drug therapy.
However, analysis has revealed that there is a wide range of outcomes so the results may be inconclusive.
Therapy is still in use, but is suited to patients who still live with or are in close contact with their families.

Social Skills Training -
Those with Schizophrenia have a number of issues with social skills, such as social interactions, self-care, coping with stressful situations, managing symptoms and appraising social situations.
Aims to teach complex interpersonal skills so that individuals suffering with Schizophrenia can manage their lives more effectively.
Evaluation -
Results of these interventions are positive, however it seems that gains are not always maintained after the programme has ended.
This approach tends to work better and therefore be more appropriate in conjunction with other therapies.
Hogarty (2002) found that patients who received social skills training and was on medication adjusted to living in the community and avoided re-hospitalisation more successfully than other groups on medication or social skills training alone.

Cognitive-Behavioural Therapy (CBT) -
The main psychological treatment of Schizophrenia is Cognitive-Behavioural Therapy. CBT used to appropriate for those who are capable of gaining reasonable insight into their problems.
Now, some therapists have seen a role for CBT with psychotic patients, more specifically, those suffering with Schizophrenia. CBT is based on the idea that most mental disorders arise from irrational thinking. The goal is, therefore, is to adjust the thinking patterns and alter inappropriate beliefs.
There is one particular type of cognitive intervention, this is called belief modification. This teaches strategies to stop delusional beliefs and hallucinations.
Involves a process called Cognitive Challenge. Clients are taught to regard their delusions and hallucinations as hypotheses rather than reality. Then learn to challenge their initial negative interpretations.

Evaluation: Effectiveness -
There is significant amount which has shown that CBT can be effective in treating Schizophrenia. Turkington et al. (2000) found that CBT has a significant effect on both groups of symptoms, and that it could be delivered effectively through brief intervention programmes delivered by community psychiatric nurses.
Belief modification is a new approach to treating Schizophrenia and there haven’t been many evaluative studies to support or go against this approach. However, Jones et al. (2000) did carry out a meta-analysis on trials of belief modification and he found that it had reduced both frequency and intensity of hallucinations. However it was less effective in changing delusional beliefs but it did seem to reduce the accompanying distress.
Drury et al. (2000) reported on a study which belief modification was part of the treatment programme. The study showed that immediate and short-term gains were encouraging, however after a follow-up of 5 years, the treatment group had showed no advantage over a control group. This then suggests that other cognitive interventions are required in order to achieve long-term benefits.
Appropriateness -
CBT does not offer a cure for Schizophrenia. Although it has been shown to reduce symptoms and new cognitive treatments continue to be developed , it does not offer a cure and is more of a way of ‘normalising’ symptoms, helping sufferers to cope with the symptoms.
However, unlike drug treatments, CBT is more ethical towards the patient. Drug treatments have been labelled as ‘dehumanising’ as they take away the control of the patient, whereas with CBT, it is a collaborative treatment which means it involves the active cooperation of both the client and the clinician. Because of this it often avoids being criticised as causing the client to become the passive recipient of treatment.


Biological Treatments...
Drug Therapy -
Drug therapy or chemotherapy is the most common treatment for Schizophrenia. It uses antipsychotic drugs, some are called ‘Conventional’ drugs others are called ‘Atypical’ drugs.
‘Conventional’ drugs work by reducing the effects of dopamine, ‘Atypical’ drugs work on reducing serotonin activity.
A certain class of drugs called Phenothiazines, also known as neuroleptics, work by blocking dopamine receptors within the brain. The most frequently used is Chlorpromazine.
There is evidence which suggests that these types of drugs can reduce the positive symptoms i.e. hallucinations, in many sufferers of Schizophrenia. These drugs produce the maximum benefits after the first 6 months of use.
Atypical drugs on the other hand, such as Clozapine work by blocking serotonin receptors rather than dopamine receptors.
Research has shown that these types of drugs are more effective than the conventional antipsychotic drugs.

Evaluation: Effectiveness-
Both types of drugs have been shown in many studies to be an effective form of treatment. They produce a sedative effect, and can dramatically reduce psychotic symptoms like hallucinations and delusions.
This then enables patients suffering with Schizophrenia to live relatively normal lives within the community and has changed Schizophrenia into a hospital ‘short-stay’ condition. Many patients in the UK are now treated on an outpatient basis.
However, conventional drugs have little effect on negative symptoms, compared to atypical drugs which seem to improve both positive and negative symptoms.
Furthermore, it has been found that the symptoms will return if patients stop taking the drugs. This then leads to patients being kept on maintenance doses for long periods of time. This then increases the risk of serious side effects.

Appropriateness -
One major issue with these types of antipsychotics are side effects. Conventional drugs produce some very serious side effects. These side effects include symptoms which are similar to those found in Parkinson’s disease.
These symptoms include stiffness, immobility and tremors. In serious cases, it can lead to a condition called ‘Tardive Dyskinesia’ which causes uncontrollable sucking and smacking of the lips and facial tics.
Other side effects include low blood pressure, blurred vision and constipation.
However newer drugs such as atypical antipsychotics are more effective and have less side effects than the conventional drugs.
Atypical drugs are also quite expensive and can cause unwanted weight gain.
Compliance is another issue. Some patients refuse to comply with the drug treatment due to either fear of the side effects or just poor memory. If a patient stops taking the medication, the symptoms return, this has been called the ‘Revolving-door syndrome’.
One way of stopping this is by administering depot antipsychotic medication. This involves the patient having an injection which is given by a nurse and can be done either at home or at a hospital and slowly releases the medication into the body over a number of weeks.
An advantage of this is that the patient does not have to remember to take set tablets everyday.
Finally, drug treatments can be seen as unethical in the sense that drug treatments are ‘dehumanising’ and take away the control and responsibility of the patient.
Informed Consent is also an issue here as when a patient is in a psychotic state they cannot give truly informed consent about their treatment.
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