Psychology: Schizophrenia

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Clinical Characteristics

CLASSIFICATION AND DIAGNOSIS

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Characteristic symptoms include delusions, hallucinations, disorganised speech, affective flattening, alogia and avolition.

Symptoms have to last for around 6 months, but if the symptoms are severe it can be as little as one month.

Work, home or social life must be affected by the symptoms of schizophrenia.

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Positive Symptoms

CLASSIFICATION AND DIAGNOSIS

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Positive symptoms are those that reflect and excess of normal function. These include:

Hallucinations - these are bizarre and unreal perceptions of the environment. They usually come in auditory form (such as hearing voices) but can be visual and tactile as well.

Delusions - these are bizarre beliefs that seem to be real to the sufferer. These can be paranoid and can also involve thinking they are bigger in the universe than they actually are.

Disordered thinking - the feeling that thoughts have been inserted, withdrawn or broadcast to others.

Experiences of Control - the person may believe that an external force is controlling them.

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Negative Symptoms

CLASSIFICATION AND DIAGNOSIS

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Negative symptoms are those that represent a decrease or a loss of normal functioning. These include:

Affective flattening - a reduction in the range and intensity of emotional expression.

Alogia - poverty of speech, characterised by the lessening of speech fluency and productivity.

Avolition - the reduction or inability to initiate in goal directed behaviour, often mistaken for disinterest.

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Type I and Type II

CLASSIFICATION AND DIAGNOSIS

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Type I is dominated mainly by positive symptoms whereas type II is mainly dominated by negative symptoms. Type II has a poorer prognosis.

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Subtypes

CLASSIFICATION AND DIAGNOSIS

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Paranoid type - positive symptoms mainly, awareness and language are relatively unimpaired.

Disorganised type - disorganised speech and behaviour, vivid hallucinations, flat emotion and inappropriate affect. This is the most severe form.

Catatonic type - apathy and psychomotor disturbances.

Undifferentiated type psychotic symptoms are present, but the criteria for paranoid, disorganised, or catatonic type have not been met.

Residual type - where positive symptoms are present at a low intensity only.

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Diagnostic Manuals

CLASSIFICATION AND DIAGNOSIS

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There are two main classification systems: the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). The DSM is mainly used in the USA and the UK.

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Reliability Over Time

CLASSIFICATION AND DIAGNOSIS

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Beck et al (1962) found a concordance rate of 54% when using the DSM, and then Soderberg et al (2005) found a concordance rate of 81%.

Nilsson et al (2000) found a 60% concordance rate when using the ICD, and then Jakobsen et al (2005) found a concordance rate of 98%.

This shows that the updating of the classification systems is making them more reliable over time.

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Unreliable Symptoms

CLASSIFICATION AND DIAGNOSIS

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Someone can be diagnosed with schizophrenia if their only symptom is delusions, if the delusions are "bizarre". When 50 senior clinicians were asked to define bizarre in terms of delusions they was a correlation as low as 0.11.

This suggests that the symptoms themselves are unclear and therefore unreliable.

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Validity of Symptoms

CLASSIFICATION AND DIAGNOSIS

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Schizophrenia has some symptoms that are unique to schizophrenia, these are called first-rank symptoms and include delusions and experiences of control. The existence of first rank symptoms would make diagnosis much easier. However, some schizophrenic symptoms are the same as other diseases such as depression or bipolar. This creates illness confusion and it is difficult to diagnose which illness it could be.

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Prognosis Validity

CLASSIFICATION AND DIAGNOSIS

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People who are diagnosed with schizophrenia do not always share the same outcome. As the outcomes vary so much, even for those who are diagnosed with the same subtype of schizophrenia, the illness lacks predictive validity.

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Rosenhan Study

CLASSIFICATION AND DIAGNOSIS

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Rosenhan (1973) demonstrated the problems of both the reliability and validity of diagnosing schizophrenia. Several pseudo patients entered psychiatric hospitals saying that they were hearing voices that repeated words like "thud", "empty" and "hollow". They were diagnosed with schizophrenia based on these symptoms alone and were detained indefinitely. Once inside the patients acted normally, but every action was interpreted as a consequence of the disorder.

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Invalid Diagnosis

CLASSIFICATION AND DIAGNOSIS

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The Rosenhan study demonstrated the problems of incorrect diagnosis. If a patient is diagnosed as schizophrenic when they are not then they may be given the wrong drugs which could have no effect or cause them to decline.

As well as this, there is a stigma attached to being schizophrenic which can make it very hard to get a job or achieve in other aspects of life. If an individual is diagnosed incorrectly they will be unfairly judged for the rest of their lives.

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Cultural Differences

CLASSIFICATION AND DIAGNOSIS

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There have been found to be cultural differences in the diagnosis of schizophrenia. Psychiatrists from the US and the UK were provided with a description of a patient. 69% of the US psychiatrists diagnosed the patient with schizophrenia, whereas only 2% of the UK psychiatrists did.

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Genetic Factors: Family Studies

BIOLOGICAL EXPLANATIONS

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Family studies have established that schizophrenia is more common in biological relatives, and the closer the genetic relatives the more likely they will develop schizophrenia. Children with two schizophrenic parents have a concordance rate of 46%, children with one schizophrenic have a concordance rate of 13% and siblings have a 9% concordance rate.

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Genetic Factors: Twin Studies

BIOLOGICAL EXPLANATIONS

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Twin studies offer a unique opportunity as monozygotic twins (MZ) share 100% of their DNA, and dizygotic twins (DZ) share 50%.

Joseph (2004) assessed all the twin studies surrounding schizophrenia that happened before 2001. He found that MZ twins had a concordance rate of 40.4% whereas DZ twins only had a concordance rate of 7.4%.

However, more methodologically sound experiments, such as those that use blind diagnosis (where the researchers do not know which twins are MZ and DZ) found lower rates of correlation, suggesting deterministic approaches.

Also, MZ twins are treated differently to DZ twins. MZ twins are treated more similarly and suffer from more identity confusion and it could be that it is these environmental differences rather than the genetic factors that cause the onset of schizophrenia.

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Genetic Factors: Adoption Studies

BIOLOGICAL EXPLANATIONS

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Adoption studies provide an opportunity to look at the biological and environmental influences when they are separated. Tienara et al (2000) conducted an adoption study in Finland. Of those children whose biological mothers were schizophrenic, 6.7% were also diagnosed, whereas of those children whose biological mothers weren't schizophrenic only 2% were diagnosed.

However, children are selectively placed when it comes to adoption. If children who are susceptible to schizophrenia are placed in specific families, but it might bet that these families are what causes the onset and not the genetic factors.

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The Dopamine Hypothesis

BIOLOGICAL EXPLANATIONS

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The dopamine hypothesis suggests that neurons that transmit dopamine fire too easily or too often which leads to the characteristic symptoms. Schizophrenics are thought to have an excess of D2 receptors. The evidence for the dopamine hypothesis comes in 3 forms:

Amphetamines - these are dopamine agonist and when taken stimulate the dopamine neurons and it floods the brain with dopamine. When this is taken it can cause hallucinations and delusions.

Antipsychotic drugs - these are dopamine antagonists and inhibit dopamine activity. This drug alleviates most of the symptoms of schizophrenia.

Parkinson's disease - people who suffer from Parkinson's have a lack of dopamine. When given L-dopa to increase their dopamine some developed schizophrenic like symptoms.

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The Dopamine Hypothesis: Post Mortem Studies and Neuroimaging

BIOLOGICAL EXPLANATIONS

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A major problem for the dopamine hypothesis is the fact that drugs used to treat schizophrenia by blocking dopamine actually can increase the amount of dopamine as it tries to account for the blockage. Post mortem studies of schizophrenics have shown that the people who showed elevated levels of dopamine had received antipsychotic drugs shortly before death, whereas those who hadn't taken the drugs had relatively normal levels of dopamine.

Also, PET scans have allowed researchers to investigate dopamine activity more precisely than in previous studies. However, they have yet to provide evidence of altered dopamine activity in the brains of schizophrenics.

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Enlarged Ventricles

BIOLOGICAL EXPLANATIONS

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Research has linked schizophrenia, particularly type II, to abnormalities in brain structure.

Torrey (2002) found that enlarged ventricles in the brains of schizophrenics, which may be due to lesser developed areas of the brain.

Kim et al (2000) found evidence of smaller frontal lobes and abnormal blood flow to certain areas in the brain.

However, studies provide inconsistent evidence and it has also been suggested that enlarged ventricles are a result of the antipsychotic medication rather than the illness.

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Antipsychotic Medication: Conventional Drugs

BIOLOGICAL THERAPIES

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Conventional drugs aim to combat mainly positive symptoms by reducing the dopamine levels. Conventional drugs are dopamine antagonists are bind to the D2 receptors so that dopamine cannot.

Davis et al (1980) tested the effectiveness of conventional drugs using a placebo comparison. In every study reviewed the drugs proved to have fewer relapse rates.

However, there are other factors. In one study the drugs were only effective if the person went back to a stable family. Families who were hostile and high in EE caused more relapses and lessened the effects of the drug.

Also, there are side effects such as tardive dyskinesia which limits movement exterior limbs. About 30% of the people taking the drug develop it and it is irreversible in 75% of cases.

There are also motivational problems. It has been suggested by providing medication it suggests something is wrong and limits the amount the individual tries to do to get better as they think the drugs will do it for them.

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Antipsychotic Medication: Atypical Drugs

BIOLOGICAL THERAPIES

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Atypical drugs also act on dopamine and are thought to block serotonin as well, but this is uncertain. Atypical drugs occupy the D2 receptors but are not as permanent as conventional drugs which is why side effects are reduced.

According to meta-analyses atypical drugs are only slightly more effective than conventional drugs. It is also claimed that atypical drugs work on the negative symptoms as well but there is only marginal support, and some is inconsistent.

However, there is a lower likelihood of tardive dyskenesia. Only 5% of people taking atypical drugs developed the problem in comparison the the 30% of people taking conventional drugs. There are also less side effects in general meaning the treatment is more appropriate and easier for the patient.

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Electroconvulsive Therapy (ECT)

BIOLOGICAL THERAPIES

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ECT was developed due to the link between schizophrenia and induced seizures. The earliest records show poor results with fewer recoveries for those who received ECT than those who didn't.

During ECT an electric current is passed through two electrodes to induce a seizure. One is placed on the non-dominant side of brain and the other on the forehead. The patient is injected with a muscle relaxant first so that they do not hurt themselves or the people around them. They are also put under anaesthetic so they are not aware of what is happening. Normally 3 to 15 treatments is required depending on the patient.

Tharyan and Adams (2005) carried out a review of many studies on ECT. They found that real ECT provided more improvement that placebo ECT.

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ECT: Effectiveness and Appropriateness

BIOLOGICAL THERAPIES

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There have been questions as to how effective the treatment is. In comparison to drug treatment there has been seem to be little or no long term benefits.

There have also been inconsistent studies in terms of real ECT versus placebo ECT. Studies have found little or no improvement for either suggesting that it doesn't necessarily work - it is only the psychological belief that it works.

As well as this, it is also considered a fairly dangerous option. There are risks such as memory dysfunction and brain damage which means the treatment has declined in the UK.

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Cognitive Explanations

PSYCHOLOGICAL EXPLANATIONS

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Cognitive psychologists suggest that disturbed thinking processes are a cause of schizophrenia. The causes of cognitive problems are thought to be due to biological abnormalities in the brain. Therefore, this approach integrates cognitive deficits to biological explanations. There are many types of cognitive models including Frith (1992) and Helmsley (1993).

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Cognitive Explanations: Frith

PSYCHOLOGICAL EXPLANATIONS

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Frith (1992) suggests that schizophrenics cannot distinguish between actions that happen due to external events and those that happen because of internal events. People without schizophrenia have a clear divide between conscious and pre-conscious processing. Conscious processing is used when something requires high order processing or attention, whereas pre-conscious processing is how we filter out unnecessary information.

Normally only important things reach our conscious thoughts, but schizophrenics have a defective filter which means they get overwhelmed. This can cause delusions and hallucinations which are though to be caused by source confused information.

Frith believed this faulty filter was due to problems with the neurological pathways between the hippocampus and the pre-frontal cortex, which is further linked by faulty dopamine regulation.

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Cognitive Explanations: Helmsley

PSYCHOLOGICAL EXPLANATIONS

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Helmsley (1993) suggests that schizophrenic symptoms are caused by a failure to use schemas. Schemas are out packages of knowledge about things and situations that have developed through past experience. Schemas allow us to understand and interact effectively with the world around us. The schizophrenics fail to use the schemas and treat all situations as novel, which is overwhelming, exhausting and confusing which leads to the characteristic symptom of disordering thinking.

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Cognitive Explanations: CBT

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The cognitive approach can be seen as quite reductionist as it cannot explain all the symptoms or all the forms of schizophrenia and doesn't take into account many triggering factors. However, it could be argued that, by focussing on the elements of disordered thinking the approach has led to the use of Cognitive Behavioural Therapy (CBT) in the treatment of schizophrenia, which combined with drug therapy, has enabled patients to manage their symptoms and continue with almost normal life.

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Cognitive Explanations: Evaluation

PSYCHOLOGICAL EXPLANATIONS

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The models provide a way of explaining many of the symptoms of schizophrenia and therefore has good face validity, but they do not explain negative symptoms.

This model is strengthened by it's biological links which suggests schizophrenia has an organic cause. However, it does not take into account environmental factors. It has been found that stressful events are likely to trigger the onset.

The evidence for this model is also conflicting. While some research has shown that schizophrenics do poorly on cognitive tests, when they are paid their performance score increases. This suggests that schizophrenics simply lack motivation.

There are also good genetic links to schizophrenia. Parke et al (1995) found cognitive deficits in people with schizophrenia and their first degree relatives. However, it is unclear how these relatives do not develop the illness themselves.

The diathesis-stress model should be used to explain the cognitive approach.

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Family Relationships

PSYCHOLOGICAL EXPLANATIONS

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Some explanations of schizophrenia look at the role of dysfunctional family relationships, which are often based on the psychodynamic approach. Some are seen as a cause of the onset, and some are thought to work to maintain the illness and cause relapses in the patient.

Family relationships can be seen to be an important factor in the development of schizophrenia and genetics have been proven not to be 100% causal. The diathesis stress model works here.

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Family Relationships: Double-Bind Theory

PSYCHOLOGICAL EXPLANATIONS

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Bateson et al (1956) developed the double-bind theory which focusses around the concept that faulty communication can induce the onset of schizophrenia. It was suggested that contradictory messages can create feelings of confusion in the child. If continued through childhood the child may develop an unrealistic conception of the world. Although, R. D. Lang suggested that schizophrenia is a sane response to an insane world.

Berger (1965) found that schizophrenics reported a higher number of double-bind events from their mothers that non-schizophrenics. However, their information is unreliable due to their illness itself. Observational studies have also found no evidence that schizophrenics encounter more double-bind events that non-schizophrenics.

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Family Relationships: Expressed Emotion

PSYCHOLOGICAL EXPLANATIONS

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Another family variable is the amount of expressed emotion (EE) found within a household. EE is normally a negative mood climate and has been associated with schizophrenia. Linszen et al (1997) found that a schizophrenic returning to a high EE home is 4 times more likely to relapse. It is thought that the negative surroundings exceed the schizophrenics already impaired coping mechanisms.

The effects of EE have found more support that the double-bind theory. However, EE has also been labelled as a maintenance theory. It is also unclear as to whether EE is a cause or a consequence of schizophrenia, as the family may become strained trying to deal with a schizophrenic. Finally, it has provided development for therapies that include family training on how to deal with the individual with the illness.

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Cognitive Behavioural Therapy

PSYCHOLOGICAL THERAPIES

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CBT is based on the assumption that the individual has some form of faulty thought process. In schizophrenia, it is thought that delusions and hallucinations are a result of faulty thinking.

In CBT patients are encouraged to trace back the origins of their symptoms in order to get a better understanding of how the symptoms might have developed. As well as this, the patients are asked to look at the contents of their delusions and evaluate how valid and real they actually are.

Patients are also often given "homework" tasks as well. These tasks aim to improve general functioning on a day to day basis.

In schizophrenics, the learning of maladaptive responses to life's problems is often the result of distorted thinking or mistakes in assessing cause and effect. During CBT the therapist lets the patient develop their own alternatives to these previous beliefs, ideally by looking for alternative explanations and coping strategies that they are already aware of.

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CBT: Outcome Studies

PSYCHOLOGICAL THERAPIES

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Outcome studies measure how well a patient does after a particular treatment, compared with the accepted form of treatment for the condition.

Outcome studies of CBT suggest that patients who receive cognitive therapy experience fewer hallucinations and delusions and recover more of their original functioning that those who receive antipsychotic medication alone.

Drury et al (1996) found benefits of using both CBT and medication. A 25 to 50% reduction in recovery time and an overall reduction of positive symptoms.

Kuipers et al (1997) found the same advantages, but also found that there were lower patient drop out rates when CBT was used in addition to antipsychotic medication.

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CBT: Effectiveness and Appropriateness

PSYCHOLOGICAL THERAPIES

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Research has tended to show that CBT has a significant effect on improving the symptoms of patients with schizophrenia. For example, Gould et al found a significant decrease in the positive symptoms after treatment in their meta-analysis. However, most studies of CBT have involved medication and so it is difficult to assess the therapy individually.

It has been thought that the negative symptoms such as withdrawal are a way of coping with the positive symptoms. Therefore if CBT decreases the positive symptoms it should also reduce negative symptoms indirectly.

It has also been suggested that not everyone is suitable for CBT. Kingdon and Kirschen (2006) studies 142 schizophrenics and found that many patients were not deemed suitable for CBT because psychiatrists thought that they would not fully engage with the therapy. Often older patients were deemed less suitable than younger patients. They have to want to get better.

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Behavioural Therapy - Token Economy

PSYCHOLOGICAL THERAPIES

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Token Economy (TE) works by providing institutionalised patients tokens when they engage in specified behaviours, such as taking part with group activities. The tokens can be exchanged for luxuries such as food or privileges. The tokens act as secondary reinforcers and the luxuries are the primary reinforcers.

This therapy focusses on the negative symptoms mainly, and trying to ease schizophrenics back into the social world.

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TE: Effectiveness and Appropriateness

PSYCHOLOGICAL THERAPIES

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Allyon and Azrin (1968) used TE to control the behaviour of 45 chronic schizophrenics who had been institutionalised for an average of 16 years. They were given tokens for making their beds or combing their hair ect. The number of chores the patients took part in increased daily.

The drawback to this therapy is that it often fails to transfer to outside life as people cannot monitor and therefore reward the schizophrenic all the time. McMonagle and Sultana (2000) reviewed several studies and found low support maintenance of behaviours beyond the treatment programme. However, Woods et al (1984) found long term effects.

The effectiveness of tokens may be due to other factors, such as being positively reinforcing for the nursing staff, who feel they are making positive gains and therefore are stimulated to continue. They also help to structure the situation and ensure consistent rewards.

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Ethical Issues

PSYCHOLOGICAL THERAPIES

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Research on therapies for schizophrenia must be carried out in a way that doesn't place vulnerable individuals in danger. The BPS advise that when participants take part in a psychological investigation they should not, in doing so, be increasing the probability that they would come to any harm. This could occur when one type of therapy, be it biological or psychological, is stopped for another experimental form which may not work and therefore they are likely to relapse. This also happens with the use of the placebo.

As we as this, it is difficult to comply to informed consent when the schizophrenics may not be in the right frame of mind to confirm.