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What is Schizophrenia?
- Literally means “split mind”: a split from reality i.e., not Multiple Personality Disorder
- Across the world, it affects ~1% of the population.
- The onset tends to be between 18 and 25 yrs. - having to leave home = stressful time
Different times of onset
- Chronic Onset (“Chronos” = time)
- There is often a subtle change in a normal young person who gradually loses drive and motivation, and starts to drift away from friends. After months or years of deterioration, more obvious signs of disturbance, such as delusional ideas or hallucinations appear.
- Acute Onset (“Acute” = sharp, pointed)
- Obvious signs such as hallucinations appear quite suddenly, usually after a stressful event, and the individual shows very disturbed behaviour within a few days.
- Or it can come on somewhere in between - very vague
- DSM-IV diagnoses schizophrenia if the person shows two or more symptoms for a period during one month:
- •Disorganised speech
- •Grossly disorganised or catatonic behaviour
Types of schizophrenia
- Positive symptoms (Type 1): Occur in addition to “normal functioning”.
- Negative symptoms (Type 2): Occur to detract from “normal functioning”.
Positive Symptoms: Delusions
- Bizarre beliefs that seem real to the person with schizophrenia, but are not real. Can’t be persuaded with evidence. (e.g., that you’re dead)
- (nb. Doesn’t include religious, philosophical, or scientific beliefs)
- Paranoia: being persecuted
- Grandeur: inflated sense of importance
- Reference: Behaviour/comments of others (or TV) are meant for them alone.
Positive Symptoms: Hallucinations
Hallucinations are important for the diagnosis of Schizophrenia as they occur more often in Sz than they do in other disorders.
- Affective (emotional) flattening
- Disorganised Speech/Behaviour
Affective (emotional) flattening
A reduction in the range and intensity of emotional expression. E.g., facial expression, voice tone, eye contact and body language.
Poverty of speech. e.g., lessening of speech fluency and productivity, thoughts to reflect slowing or blocked thoughts.
The reduction of, or inability to, initiate and persist in goal-directed behaviour (for example, sitting in the house for hours every day, doing nothing). It is often mistaken for apparent disinterest.
Standing motionless like a statue, or adopting odd/bizarre postures. Similarly, patients often adopt ‘odd’ postures or give strange facial ‘grimaces’.
- Incoherence – Repeated references to ideas with little or not connection.
- Loose associations - Conversation drifts from past to present with no clear context.
- Derailment - Difficulty staying on the same topic of conversation.
- Inappropriate Affect
- Here, the patient may show emotional responses that seem out of context.
- “Silliness and laughter out of context”.
- Bad news smiles and laughter, simple questions annoyed.
Types of Sz: Crow 1985
- Type I syndrome: Acute with positive symptoms
- Type II syndrome: Chronic with negative symptoms
Types of Sz
- Paranoid: delusions of grandeur &/or persecution, hallucinations
- Catatonic: excitability (sometimes aggressive) contrasted with catatonia.
- Disorganised: mild auditory hallucination, delusions, thought process disorders and disturbances of affect. Behaviour can appear bizarre.
- Residual: Those who had once experienced Sz, but no longer do (maybe a few positive symptoms).
- Undifferentiated: Miscellaneous. Symptoms don’t fit into other categories.
Issues with classification and diagnosis:
- Includes reliability and validity
- Diagnosis: do you have schizophrenia in the first place
- Classification: what type of schizophrenia
- Reliabilty: consistency; consistant diagnosis and symptoms - the as in a few weeks time
- Validity: It measure what it claims to measure
Issues with Classification
- Self-report measures
- Serious Overlap of symptoms between types of Sz.
- Comorbidity of Sz with other Mental illnesses.
- The problem of Schizotypal Personality Disorder.
Issues with classification: Self report measures
- The questionnaires usually include ambitious questions as it means one thing to you but another to the patient -ambiguity in answer
- Investigator bias - mind set about patient being paranoid - keep on questioning them on it
Issues with classification; Serious Overlap of symptoms between types of Sz.
- Paranoid - most types
- Hallucinations - all
- May affect reliability not a consistant diagnosis from different doctors -subjective opinion -lack inter-reliability
- Lack validty if symptoms overlap its hard to get right what type of sz you have
Issues with classification Comorbidity of Sz with other Mental illnesses.
- means sz can occur with another mental illness - most likely depression as they overlap with sz such as negative symptoms
- Sim et al 2006: studies 142 hopitalised sz patients 32% had an additional mental illness
- Those 32% didn't recover as well as those that didn't have comorbidty
- Take the symptoms of depression for sz and place them in the wrong category which would lead to the wrong treatment -lack of validity
Issues with classification: The problem of Schizotypal Personality Disorder.
- DSM-IV-TR schizotypal personality
- Overlaps a lot with schizophrenia such as the symptoms are
- paranoid ideation
- odd thinking and speech etc
- reduces validty as it may mean its not a valid diagnosis
- Chapman et al. (1994)
Chapman et al. (1994)
Found that people who scored higly on schizotypal personality were more likely to develop full-blown schizophrenia within the next 10 years
Practical Issues with diagnosis
- Allardyce (2006)
- Beck et al. (1962)
- Soderberg et al. (2005)
- Heather (1976)
- Sz isn’t one mental illness
- theres extremes in sz as the negative symptoms are very different compared to positive symptoms
- Probably to separate mental illnesses yet we give them the same label and treat them the same - lack inter-reliability -symptoms aren't consistant within sz
- Lacks validity - may mislabel the person low reliability because of the subjective nature of the diagnosis - relies on one persons opinion - tested by using inter-reliability
Beck et al. (1962) and Soderberg et al. (2005)
- Beck et al. (1962) reported a 54% concordance rate between practitioner’s diagnoses when assessing 153 patients, while Soderberg et al. (2005) reported a concordance rate of 81% using DSM-IV. This suggests classification systems have become reliable over time.
- However some studies found inter-reliability as low as 0.114 - little predictive validity - don't know whether there positive or negative symptoms
Argues that very few causes of mental disorder are known and there is only a 50% chance of predicting what treatment a patient will receive based on diagnosis, suggesting diagnosis of schizophrenia has low validity.
- Sent 8 healthy people (5m+3f) went to 12 psychiatric hospitals
- Auditory hallucinations - 'empty', 'hallow' and 'thud'
- 7 were admitted, they acted normally and on average took 19 days to be released (7 to 52 days) - released with a diagnosis of sz in remission
- He then said to a hospital that he would send more 'pseudopatients' to see if they could spot them. the hospital reported 41 genuine patients were fake - he sent no fake patients
- Lacks validity: shows they don't understand sz properly - weren't able to detect that people didn't have sz BUT good inter-reliability 7/8 got admitted - consistant
- Inconstistancy and a unreliable measure of treatment - detecting that they were not insane - large range 7 -52 days - cant predict it
- The DSM has changed -increase reliability
- lacks temporal validity - this would not represent what would happen today
Sociological Issues with Diagnosis
- Sz is more common in African-Americans and African-Caribbean populations than in other groups (Harrison et al. 1988).
- Reasons why: because of stress of moving to a different group - building a new life
- segregation - big gap in the amount of income black and white people can earn
- Racisim - to label certain groups with a mental illness because they are not the same as white people
Sociological Issues with Diagnosis studies
- Cole & Pilisuk (1976)
- Black people more likely to get drug treatment and less likely to get psychological treatment.
- Cochrane (1977)
- West Indian men are less likely to go to GP with a psychiatric issue, but are more likely to be admitted to psychiatric hospital.
- Lipsedge & Littlewood (1979)
- Psychotic black patients are twice as likely to be ‘sectioned’ than native or immigrant whites.
Sociological Issues with Diagnosis evaluation
Culture has changed - people are more equal - may mean if this was done today the findings would be different
Biological explainations: Genetics
- The more genes you share with a aperson with sz the more like you will get it too.
- Therefore there is a genetic compound to sz.
- BUT sz must have some enviromenet factors as if it was 100% gnetic then if you shared 100% same genes (MZ twins) if would mean you would 100% get sz
Genetic studies (biological explanations)
- Torrey 1992
- Tienan et al 1991
- Wahlberg et al 1991
Torrey 1992 found:
- MZ: 28% (identical twins)
- DZ: 6% (non-identical twins)
- BUT we must remember that they usually have shared the same environment
Tienan et al 1991
- 155 mothers who had given up their child for adoption
- Compared to 155 children adopted from non-sz parents 10.3% of those with sz mothers developed sz 1.1% of those with non-sz parents developed sz
Wahlberg et al 1991
- Followed up Tienan and compared the adopted environment.
- He found that the chances of developing sz was also dependent on the amount of communication deviance.
- Thus theres a genetic and environment interaction.
Biochemistry: Andreason et al 1987
- Findings showed that the more frequently you smoke cannabis the more chance of you developing sz.
- It also showed if you have smoked weed more than 50 times it has more than quadrupled the chances
- Might mean that someone who is going to develop sz is the kind of person to smoke cannabis – correlation is not causation.
The dopamine hypothesis
- 1.over production of dopamine
- 2.over sensitive receptors
- 3.poor regulation of dopamine
- antipsychotic drugs block dopamine receptors and seem to work
- patients who take L-dopa (increase dopamine) for Parkinson disease can exhibit sz symptoms
- Amphetamines increase dopamine levels and can cause hallucinations and paranoia
- Dobtmortems of sz patients show greater density of dopamine receptors in parts of the brain
- Some studies show that sz have lower levels of dopamine in certain areas of the brain
The dopamine hypothesis studies
- Cafisson 1999: implicates other neurotransmitters in the development of sz (e.g. serotonin and glutamate)
- Vakammen (1977): some studies report that amphetamines can reduce sz symptoms
- Kety 1975: L-DOPA and anti-psychotic drugs have a similar therapeutic value
- Falkai et al 1988: Autopsies have found that people with sz have a larger than usual number of dopamine receptors increasing dopamine activity and receptor density (left amygdala and caudate nucleus putamen) Concluded that DA production is abnormal for sz
Evaluation for dopamine hypothesis
- There is a lack of correspondence between taking the drugs and signs of clinical effectiveness.
- It takes 4 weeks to see any sign that the drugs are working when they begin to block dopamine immediately.
- We cannot seem to explain this time difference – shows that dopamine cannot soley affect sz otherwise it would be cured immediately
Biological Treatments banner headline
- According to the Biological approach, Sz is caused by physical issues with the brain.
- Therefore therapy will be something that changes the brain. e.g., drugs change the effectiveness of neurotransmitters in the brain. ECT stimulates the brain.
- Two types:
- e.g., Thorazine and Haldol
- Aka. Neuroleptic. Reduce positive symptoms but can produce symptoms linked to neurological diseases.
- Reduces Dopamine activity within 48 hrs. Although takes a few weeks to work, are generally considered to be effective in reducing positive symptoms.
- Comer (2001)
- Jackson 2001
- Sampath et al. (1992)
- Windgassen (1992)
Typical Antipsychotics reduce positive schizophrenic symptoms in the majority of patients and appear to be a more effective treatment for schizophrenia than any of the other treatments used alone.
Doesn’t work with Negative
Sampath et al. (1992)
- Patients that had been taking neuroleptics for 5 years either:
- Went on to a placebo -75% relapsed within a year.
- Continued on the drug - 33 % relapsed within a year.
- Sedation (50%)
- Concentration (17%)
- Blurred Vision (16%)
- Parkinsonian symptoms
- Neuroleptic Malignant Syndrome (2%)
- Tardive Dyskinesia (>20%)
Atypical antipsychotic drugs
- e.g., Clozaril & Olanzapine
- They work in a similar way to typical drugs but they also work on serotonin.
- Have fewer side effects.
- Can help people who did not respond to the Typical.
Atypical drug studies
- Awad & Voruganti (1999)
- Meltzer (1999)
- Remington & Kapur (2000)
Awad & Voruganti (1999)
- Found that conventional drugs have fewer side effects than neuroleptic drugs
- Help 85% of sz patients compared to 65% given typical drugs (neuroleptic drugs) responded well to the atypical drug clozapine
- Effective - treats more patients - responding better
- Appropriate - seem to be more effective and work better
Remington and Kapur 2000
Atypical drugs are more use in helping patients suffering mainly from negative symptoms
- One of the side effects from taking clozapine 1-2% risk of this
- Reduces white blood cells and the condition can be life threatening. However olanzapine doesn't cause this
Drug treatment Effectiveness
- Most effective therapy for treating schizophrenia.
- It is a palliative treatment not curative good because it can stop side effects occurring so reduces extreme symptoms
- Some patients become resistant to drugs.
Drug treatment Appropriateness
- •Evidence for a biological basis, so a biological therapy is fitting.
- •The side effects potentially very serious - argranulocytosis
- •Compliance of patients taking medication can be low - effectively means you have failed to take control of your body - don't feel you
- •It is a palliative treatment not curative.
- •There isn’t really a suitable alternative
ECT Effectiveness studies
- Tharyan & Adams (2005) did a meta-analysis on ECT treatments on Sz. It has short-term effects, although it wasn’t as effective as drugs. There were few long-term benefits.
- Braga & Petrides (2005) reviewed 42 studies and found that ECT with drugs was a safe and effective treatment strategy, especially for those resistant to conventional treatments.
- Chanpattanna (2007) gave ECT + drugs to patients who were found to be resistant to typical drugs.
- Found a reduction in Positive Symptoms, improved quality of life and social functioning.
- There was no effect (or even a worsening) of negative symptoms.
- Only really works in combination with drugs.
- Only really works for positive symptoms.
- Only really works in the short-term.
- Only really is palliative rather than curative.
- It works.
- Sz is a biological illness, and ECT is a biological treatment.
- We don’t know how it works or what effects (damage?) it is having on the brain.
- There are side effects such as memory loss, cognitive impairments, and brain damage.
- Most Sz strongly oppose being given ECT, and so ethically are we able to force them?
- It is palliative not curative, nor does it last for long, and it doesn’t work on Negative symptoms.
Social Causation Hypothesise
- Some theorists have suggested mental illnesses among ethnic minority groups is due to the STRESS of moving country triggering a DIATHESIS for mental illness.
- This theory can be linked to include people from lower class groups as well.
- The harder and more stressful your life, the greater the risk of schizophrenia.
- The 4 main findings:-
- Sz more common in decaying innercity areas than poor rural ones.
- Sz almost 7x more common in African-Caribbeans than whites.
- Average Sz rates in Caribbean countries is similar to that in the UK.
- 2nd Gen African-Caribbean immigrants have a higher Sz risk than 1st gen.
Behaviourism banner headline
According to this approach the Social Learning Theory causes sz because Sz children develop Sz from imitating their parents/siblings.
- Vicarious Reinforcement can explain disorganised behaviour - see someone acting strange which leads to them getting attention so you copy them to get attention too.
- Imitation - Halluncinations of Grandeur - look at people (popular/famous) thinking their best - copy them then get rewarded with more attention
- Operant conditioning - Halluncinations - reporting them you get rewarded with lots of attentions
- Liberman (1982)
- Ullman and Krasner (1969)
- Children with bad parents develop behaviours from any external stimuli they can find.
- In some cases, these reinforce bizarre behaviour.
- e.g., Delusions of grandeur, persecution, etc
- e.g., If we all experience hallucinations, these people are rewarded for feeding them and making a big deal from them.
- Once these develop, they are unintentionally reinforced by parents/peers/whoever. Or they can be self-reinforcing (e.g., negative reinforcement; it makes them special when otherwise they are “nobodys”)
Ullman and Krasner (1969)
Reported that staff in hospital paid more attention to those who displayed characteristics of the disorder. The patient saw that if they disobeyed and played up, the staff would make a fuss over them.
Evaluation of behaviourism
- Behaviourism cannot explain why many Sz show similar symptoms without ever having witnessed such behaviour before,or why the disorder tends to first occur in late adolescence or early adulthood.
- It assumes that Sz is only the expression of symptoms. i.e., they aren’t actually hallucinating, but are only being rewarded for reporting hallucinations.
- Furthermore, Sz is distressing to have, and it is therefore unlikely that it is rewarding to have Sz.
- Doesn't take into account all factors - biological
- Only able to explain positive symptoms
- Operant Conditioning:
- The Token Economy
- Since Sz is a learned mental illness, treatment is by unlearning it.
- Since the Behaviourist considers Sz to only be a set of observable symptoms, the therapy only aims to remove those symptoms.
- This is by giving them no attention for the sz symptom but rewarding the 'normal behaviour' - shapes the behaviour
Token Economy Effectiveness studies
- Ayllon & Azrin (1968)
- Paul & Lentz (1977)
Ayllon & Azrin (1968)
- Hospitalised Female patients with Sz (mean time in hospital = 16 yrs) were given tokens for appropriate behaviours.
- e.g., brushing hair, making beds.
- The tokens were exchanged for activities such as watching films, extra visits to the canteen.
- The mean number of chores increased from 5 to over 40.
- This shapes the behaviour away from Sz symptoms, and towards more “normal” behaviour.
Paul & Lentz (1977)
- Used the TE with long-term Sz patients. They developed social and work skills, were able to look after themselves, and symptoms were reduced.
- Five years later, 98% of these patients had been discharged, compared to 45% in the control group.
Token Economy Effectiveness
- They work to change behaviours in highly-structured institutions so long as the tokens are given.
- Only deal with a few symptoms of Sz.
- Produce more “normal” behaviours, but don’t really affect the mind of the people with Sz.
Token Economy Appropriateness
- Can help with negative symptoms because they provide incentives for more active behaviours.
- Dickerson (2005): they can then be used to prop-up more conventional treatments.
- The “desired behaviours” are near-completely determined by the therapists/staff without consultation of the patients.
- They don’t really deal with positive symptoms. They may suppress them, but they don’t treat them.
- It only focuses on the behaviours, and doesn’t care about cognitive or biological features.
- It doesn’t work outside of institutions, and the benefits stop on release.
- Mental illnesses are caused by issues in the unconcious mind perhaps fixations from childhood consists of three major assumptions
- 1. sz fixate in the oral stage - harsh uncaring upbringing
- 2. Later in life, regression to oral stage means that they abandon the ego (reality principle) explaining their break with reality - delusions of grandeur and creation of neologism
- 3. The individauls will still try to keep contact with the real world which results in further sz symptoms - hearing voices of God telling you are Alan sugar makes the situation feel more real
Evaluation of psychodynamic approach
- There has been little research on Frauds explanation
- Most mothers of sz are not harsh and withholding as fraud assumpted
- Its very complex explanation, it involves assumptions about fixation, regression, stages of psychodynamic development - very little support
- Not scientific cant measure the unconscious mind
- Warning and Kicks 1965
Warning and Kicks 1965
- Found mothers of sz tend to be more anxious, shy, withdrawn and incoherent.
- The mothers of sz tend to be inadequate in various ways but not those assumed by Fraud.
Psychodynamic Treatments - Psychoanalysis
- Bring the Oral fixation into conscious awareness and achieve insight.
- Dream analysis
- Free Association
Identify the manifest content to understand the latent context - purely subjective
Where you lay down and talk continously to try figure out underlying causes - talking freely without censorship - theorpist sit behind them so no reaction is seen
Directly talk to the unconscious mind and access memory's which would be locked
Effectiveness of Psychoanalysis
- Malmberg & Fenton (2009) reviewed psychodynamic therapies and found that they have little benefit unless used alongside drug treatments. i.e., psychoanalysis only works if you also are taking drugs…
- May (1968) found that patients treated with this therapy with drugs had significantly better outcomes than those treated with the therapy alone.
Appropriateness of Psychoanalysis
- The validity of the underlying psychodynamic theory is questionable. If this isn’t what causes Sz, then is the treatment effective?
- Psychoanalysis is very expensive (per session, and needs many sessions!). Should the NHS fund this?
- Says the the way you think about the world has gone wrong due to the cognitive thought process
- Mckenna 2006 selective attention
- Frith 1992 - self monitoring and theory of mind
- Hemsly 2005 memory
Cognitive theory studies
- McGuigan 1966
- McGuigan et al 1996
- Johns et al 2001
- Drury et al
Mckenna 2006 - selective attention
- He argued that many of the symptoms of sz occurs as a result of defect in selective attention (poor communication skills)
- Symptoms such as disorganised speech, speaking uninformatively, delusions and hallucinations might all depend at least in part of the poor ability of person with sz to concentrate - cant pay attention to one particular thing
Frith 1992 - self monitoring
- He argued that important cognitive factors are associated with the development of sz
- Positive symptoms of sz (delusions of control and auditory hallucinations) might occur because individuals with self monitoring so fail to keep track of their own intentions
- Regard their own thoughts as alien and as having come from someone else - explains auditory hallucinations
Frith 1992 theory of mind
- He also argued that individuals with sz have another important cognitive defect - the ability to understand peoples mental state
- If they lack this it could explain some of their delusions and also explain why paranoid sz are suspicious of other intentions
Hemsly 2005 - memory
- Perception and memory fail to combine effectively in sz
- You don't remember what your meant to do in our everyday lives, we used stored knowledge (much of it in the form of schemas) to allow us to predict what is going to happen next more generally, memory helps to ensure that we attend to and perceive the most important stimuli in the environment - helps us keep track of our goals
- People with sz are unable to do this as their concentration is poor and they attend to unimportant or irrelevant aspect of the environment - poor integration of memory and perception = disorganised thinking and behaviour
- The vocal cords of the patients with sz who often active during the time they claimed to be experiencing auditory hallucinations
- Suggests they mistook their own inner speech for that of someone else
- Supports poor self-monitoring - your creating the voices its just your not aware its you
McGuigan et al 1996
- They found patients who suffered with sz who had hallucinations had reduced activity in parts of their brain that monitored inner speech
- Supports self monitoring - part of your brain is weaker when sz
Johns et al 2001
Found that sz with hallucinations and without hallucinations where unable to tell that it was their own voice distorted however the control group could, shows people with sz have poor self monitoring
Drury et al
Found people with sz scored lowly on test which measures someones theory mind
Cognitive Treatments - Cognitive Behavioural Therapy
- A more holistic approach that incorporates cognitive and behavioural components.
- Cognitive: Aims to challenge and change maladaptive thought processes.
- Behavioural: To challenge and demonstrate irrational thoughts about the world.
A simple form of CBT
Challenging delusions by asking for alternative explanations, followed by “reality testing” by planning out a task that will reveal the validity of the interpretations in the real world.
Coping Strategy Enhancement Tarrier (1987)
- 75% Sz who experience delusions and/or hallucinations used coping strategies. e.g., distraction, positive self-talk.
- 72% of these said that at least one was particularly effective, and those that used more strategies were the most successful.
Coping Strategy Enhancement (CSE)
- 1.Situation set up so therapist and client can work together to improve coping strategies.
- 2.Emphasises hallucinations and delusions do not make you mad since we all have them.
- 3.Select one hallucination / delusion.
- 4.Client given task (homework) to apply coping strategy to the hallucination / delusion.
- 5.Therapist and client devise ways to make coping strategy more effective.
Effectiveness CBT studies
- Tarrier et al. (1993)
- Pfammatter et al. (2006)
- Turkington et al. 2003
Tarrier et al. (1993)
- Tarrier et al. (1993) tested CSE. These patients showed a reduction in positive symptoms compared to a control group. This improvement remained 6-months later.
- However, there was a near-50% dropout rate in the treatment.
Pfammatter et al. (2006)
CBT showed moderate reduction in positive symptoms. However they couldn’t identify which parts of CBT were actually effective.
Turkington et al. 2003
Furthermore, maybe the CBT seems better than a control group not because CBT works, but because people with Sz who don’t get treatment (or inadequate treatment) simply get worse
- Many symptoms of Sz are cognitive in nature (e.g., ) so a cognitive based therapy is fitting.
- Many people with Sz already use coping strategies so it is appropriate to build on these. It doesn’t remove symptoms, but helps them to cope with them.
- It only works for certain positive symptoms.
- It ignores the biological factors in Sz.
- CBT doesn’t treat Sz, but only deals with the reaction to Sz. i.e., you still have it, but you’re not distressed any more.
- Maybe CBT can help with the co-morbid mental illness.
- Issues: can't measure extent to what someone has sz so cant measure the reduction of it.