Schizophrenia

Schizophrenia is a mental health disorder involving psychosis, known for its positive (adding an experience) and negative (taking away an experience) symptoms.

They are referred to as positive (adding an experience) and negative symptoms (taking away an experience).

Hallucinations. Delusions. Disorganised Speech. Psychomotor Disturbances.

Avolition. Affective Flattening. Alogia. Anhedonia.

There are three main biological explanations for schizophrenia, these are genetics, the dopamine hypothesis and neural correlates.

By making someone more likely to develop schizophrenia due to their genes. They are predisposed to developing schizophrenia.

Neural correlates are instances where brain structure differences correlate with some psychological disorders or symptoms.

The main explanations are family dysfunctions and cognitive explanations.

The schizophrenogenic mother, the double bind theory, and expressed emotions (EE).

Treatments can include biological therapies and psychological therapies, for instance, CBT is a psychological therapy, and using typical antipsychotics is a biological therapy. 

Antipsychotic drug treatments, known as typical and atypical antipsychotics. 

CBT. Family therapy. Token economies. 

The interactionist approach is the combination of biological and psychological treatments for schizophrenia.

The diathesis-stress model is the most well-known interactionist approach.

​​​​​Reliability is the level of agreement different psychiatrists can reach on a single diagnosis for one individual, across both time and cultures, given that there is no change in the symptoms of the disorder.

The test-retest and the inter-rater reliability tests can be used to determine reliability.

In Cheniaux (2009), two psychiatrists had to assess 100 patients using the DSM and the ICD. They found that inter-rater reliability was poor, as one psychiatrist diagnosed 26 patients with schizophrenia using the DSM while diagnosing 44 patients with schizophrenia using the ICD.

Validity is the legitimacy of a test, i.e., whether what the psychiatrist uses to diagnose a person measures what it purports to measure. If it is valid, the diagnosis represents something real and is different from other disorders.

Construct validity and content validity.

Comorbidity is when two or more disorders coincide in a person.

Buckley et al. (2009) found that comorbid depression occurs in 50% of patients with schizophrenia.

Symptom overlap is the significant overlap between the symptoms of schizophrenia and other disorders.

Bambole et al. (2013) noted that patients diagnosed with schizophrenia and bipolar disorder have both positive and negative symptoms, making it difficult to distinguish between them.

Gender bias in the classification and diagnosis of schizophrenia occurs when the diagnosis is dependent on the patient’s gender. What symptoms they display and explain is usually irrelevant, as judgments are made based on their gender.

Longenecker (201) found that, since 1980, more men have been diagnosed with schizophrenia than women. This finding raises issues both in the diagnosis of women (whether under or overdiagnosed) and the overdiagnosis of men.

Cultural bias exists because some psychiatrists diagnose a patient differently if the patient is from a different cultural background. They judge the patient according to what they think is acceptable in their own culture, rather than looking at the patient objectively and considering the patient’s culture and what is acceptable in the patient’s cultural views.

Tortelli et al. (2015) noted that despite improved study methods over time, there has been a higher rate of psychotic disorders in black, Caribbean ethnic groups in England over the past 60 years.

It can mean the disorder may not be justified in being a diagnosable disease.

Treatment may not be effective and will not address the root cause of the symptoms directly.

A dysfunctional family is one that lacks empathy and shows signs of unhealthy interactions between parents, and/or between parents and their children. This may create a confusing situation for the child, which may, in turn, produce erratic behaviours in the child.

Highly critical, controlling, and rejecting (other examples include cold, uncaring, suspicious. Any 3)

 Bateson et al. (1956).

A parent saying ‘I love you’ whilst turning away in disgust is an example of a contradictory statement. A parent telling a child they did something good whilst sneering and speaking angrily is also an example.

Consistent exposure to contradictory statements can cause confusion about what is real or true. Bonus point: This can lead to paranoid thoughts, which in turn can lead to delusions and hallucinations. These are known as schizophrenic symptoms.

Emotional over-involvement is when a parent indulges in excessive self-sacrifice and overprotective behaviours, leading to patients relying on them and lacking self-reliance.

There is a higher chance of relapsing into schizophrenic behaviours and symptoms if a patient returns to a family with high levels of expressed emotions.

Lidz suggested that having emotionally distant parents can lead to symptoms of schizophrenia. He also said that biological explanations are speculative compared to his research, which studies the whole patient. 

In expressed emotion households, Kavanagh (1992) found that in over 26 studies, the mean relapse rate for patients living with caregivers or families with high levels of EE was 48%, compared to 21% for families with low EE. This suggests family dysfunction in households has an effect on the patient.

Placing blame on family members tends to cause parental guilt, which can result in feelings of stress and anxiety. It isn’t ethical to blame family members for a diagnosis of schizophrenia, and these views are considered outdated by most psychiatrists and psychologists.

They disagreed with the idea that mental health should be looked at purely from a biological point of view. They rejected the current medical model.

Fromm-Reichmann (1948)

He found that schizophrenic patients, when compared to controls, had a higher recall of double bind statements from their childhood.

They found that schizophrenic patients living in high EE spaces produced more than double the baseline recurrent rate of symptoms.

Parents being consistently cold towards the child.

It focuses primarily on how a patient processes information and is concerned ultimately with how they think.

It affects the ability to filter preconscious thoughts due to a faulty attention system.

Bentall’s.

Abnormal attention in those with persecutory delusions (an inability to recognise what is reality), is paid to threatening stimuli. Patients are biased towards these stimuli as a result of a lack of self-monitoring. Their delusions and hallucinations are blamed on the outside world or external sources.

There is a fundamental breakdown in memory and perception in those with schizophrenia, an issue occurring between the two and how they work together. THERE IS A LACK OF SCHEMAS/ACTIVATION OF SCHEMAS.

This is how we identify that we are responsible for our thoughts, behaviours and actions. It is the key to self-awareness and can explain multiple positive symptoms.

Frith’s 1992 study, where PET scans revealed reduced blood flow to the frontal cortex. This is associated with negative symptoms such as avolition and the inability to suppress automatic thoughts.

This is the ability to suppress or override automatic thoughts, actions, and speech in response to stimuli.

Patients find it hard to resist the urge to respond to stimuli, and then struggle to explain why. This can result in issues with delusions and their understanding of reality.  

Stroop test, where schizophrenic patients took twice as long to say the colour of the ink rather than reading the written word. This suggests issues with thought processing and central control dysfunction. 

It is reductionist (devolves schizophrenia to its simplest form).

Typical and Atypical.

Typical antipsychotics are the first generation of drug therapies available for schizophrenia. They work by blocking dopamine 2 (D2) receptors in the mesolimbic pathway in the brain. They’re known as dopamine-antagonists.

Atypical antipsychotics are considered to be the second generation of antipsychotic drug treatments. They work by blocking dopamine receptors in the limbic pathway of the brain and affecting other neurotransmitters - acetylcholine, glutamate and serotonin.

Tardive dyskinesia, akathisia, dry mouth.

Tardive dyskinesia (less severe), weight gain, cardiovascular problems.

Cognitive behavioural therapy, family therapy and token economy.

Assessment and engagement. Includes the ABC(DE) and the CSE models.

Through reality testing, normalisation and critical analysis of ideas together.

Family therapy, also known as systemic therapy, is a form of psychological treatment used for patients with schizophrenia, involving a therapist and group sessions.

Preliminary analysis and information transfer.

It is the process of educating the family involved about the disorder and the effects of outside influences on it.

They are reward systems put in place to encourage good behaviours in a patient with schizophrenia, treating maladaptive behaviours (behaviours preventing a patient from adapting to new situations).

Primary reinforcers are the reward, and they give power and are associated with the tokens, which are the secondary reinforcers (usually tangible/physical items to be exchanged for the reward).

The interactionist approach is the consideration of how the combination of biological, psychological, and social factors explain the development of schizophrenia.

It suggests that schizophrenia is due to a diathesis (an internal vulnerability) and an environmental trigger (stressor). It is a polygenetic disorder triggered by something environmental.

Yes.

Birthing complications, childhood trauma and academic pressures.

Drug therapies are the biological side of treatment for schizophrenia. 

Typical and atypical.

Typical antipsychotics are the first generation of drug therapies available for schizophrenia. They were developed in the 1950s, and have lost popularity since the advent of atypical antipsychotics for several reasons.

They work by blocking the dopamine 2 receptor (D2), reducing the uptake of dopamine in the mesolimbic pathway (also known as the reward pathway), and can differ in potency. By blocking the D2 receptors and effectively calming the dopamine system in the brain, typical antipsychotics lower the intensity of positive symptoms. They can often be referred to as dopamine antagonists.

Dry mouth, constipation, low energy, sedation, tardive dyskinesia (uncontrollable muscle movements usually affecting the face), akathisia (uncomfortable restlessness).

Atypical antipsychotics are considered to be the second generation of antipsychotic drug treatments. Developed in the 1970s, it was stated that they avoid the more severe side effects of typical antipsychotics.

They work somewhat similarly to typical antipsychotics in that they block D2 dopamine receptors in the limbic system, however, they do not affect D3 receptors in other parts of the brain. The reduction of intensity in positive symptoms occurs as a result, but they also act on other neurotransmitters such as serotonin and glutamate.

Cardiovascular problems, weight gain, drowsiness, diabetes, tardive Dyskinesia (uncontrollable muscle movements usually affecting the face) - although, this is less likely to happen with atypical antipsychotics.

Antipsychotics have been found to have proven efficacy in treating positive and negative symptoms of schizophrenia. They reduce institutionalised hospital treatments and encourage patient independence. Atypical antipsychotics have shown to have fewer side effects than typical antipsychotics, although both are effective at treating symptoms.

Antipsychotics cause severe side effects in some patients, such as tardive dyskinesia, and therefore many patients stop taking their medication, creating a revolving door of treatment. They are only suppressing the symptoms of schizophrenia, not treating the root cause. There’s also not enough evidence to suggest second-generation antipsychotics are significantly better than first-generation antipsychotics, so there’s no need to separate them as such.

They found that when 15 antipsychotic drugs were compared to their controls (placebo) in the acute treatment of schizophrenia, they were more effective than their placebos, so treatments targeting dopamine are effective in reducing symptoms.

When comparing haloperidol to risperidone, low doses of antipsychotic drugs were able to significantly improve symptoms of psychosis associated with schizophrenia in first-episode patients

Khan found that antipsychotics were effective for at least one year, however, there was no evidence to suggest that second-generation antipsychotics were more effective than first-generation antipsychotics.

Combined treatment of antipsychotics and CBT seems to be the most effective treatment plan.

CBT is a form of psychological therapy that focuses on teaching patients to recognise their dysfunctional thoughts and behaviours, how to rationalise these thoughts using logic, and how to avoid acting on these thoughts.

Around 6 to 12 weeks depending on the patient’s needs.

Assessment and engagement.

The ABC and CSE methods.

The ABC method includes finding out the patient's Activating event, Behaviours and beliefs, and the Consequences of these beliefs. ABC was expanded in the 1990s to include Disputing the beliefs (D) and restructuring the Events (E).

By reality testing, normalisation, and critically analysing ideas together, developing new explanations as a result. This helps patients see past their delusions and hallucinations using logic and encouraging independence.

Coping Strategy Enhancement (CSE) encourages patients to develop and apply their coping strategies, teaching them how to do so in the hopes of reducing the frequency and intensity of their psychotic symptoms.

By education and rapport training, building trust between the clinician and the patient to find out what the current coping strategies are and developing them/new ones. CSE also targets specific symptoms to develop coping strategies for and normally assigns homework/a monitoring system for the patient. 

CBT has been proven to be effective in treating positive and negative symptoms in studies (Turkington et al., 2006). It has also been shown to reduce relapse rates and readmissions to hospitals.

It’s a lengthy process, so it has issues with being more expensive than drug treatments and patients often drop out early. Most meta-analysis reviews fail to consider potential biases, and Jauhar et al. (2014) found that, when including the examination of potential biases in their meta-analysis of CBT effects on schizophrenic symptoms, CBT has a therapeutic effect in the ‘small’ range, reducing further when biases (masking, publication bias) are taken into account.

They found that CBT had large clinical effects on positive and negative symptoms.

If something is being masked, it means it is being kept hidden from the individual being studied and/or the investigators to avoid potential bias occurring.

Publication bias.

It is when patients are taught that their negative thoughts are not always inappropriate or bad, and can be normal in certain situations.

They found that CBT is not appropriate for every patient with schizophrenia. It depends on the individual and how they respond to treatment, and how severe their symptoms are.

Family therapy, also known as systemic therapy, is a form of psychological treatment used for patients with schizophrenia, involving a therapist and group sessions.

Usually, family therapy lasts for up to a year.

Family therapy intends to improve patient and family relationships and communication styles. This should address issues such as stress in the household, reducing levels of expressed emotion (EE) and relapse rate in schizophrenia. 

Preliminary analysis, information transfer, and communication training.

This is where families and households undergo interviews and observations with a therapist to identify the problem areas and strengths of the family.

This is where the therapist encourages patients and the family to learn about the facts and causes of schizophrenia. This includes the influence of drugs and the effects issues such as additional stress and unwarranted guilt can cause for the patient AND the caregiver/family members. 

It is the process of educating the family involved about the disorder and the effects of outside influences on it.

Communication training is the process of teaching family members how to communicate with each other without relying on negative behaviours and exacerbating symptoms/feelings of stress and guilt. This is for the patient and the family members.

Family therapy intends to change the whole family’s behaviour, not just the patient. This removes a lot of pressure from the patient and justifiably addresses issues outside their control. It reduces levels of EE, self-sacrifice in family members, and conflicts within the household.

It reduces levels of relapse rates in patients with schizophrenia.

It is a lengthy process, and families can drop out due to the severity of symptoms or unresolved conflicts.

In patients with schizophrenia, those with standard outpatient care had a relapse rate of 50% within nine months. However, those who had family therapy had a relapse rate of only 8% within nine months. After two years, 50% of patients with family therapy relapsed, and 75% without family therapy.

Family therapy is an effective treatment when reducing rates of relapse. However, it may only be a short-term solution.

When looking at family therapies reduction effect on relapse rates, after around six months, this effect reduces dramatically, and evidence of improvement was not sustained past six months.

Lobban (2013) found that family members felt they were coping better thanks to family therapy. Thus, family therapy reduces the pressures and resulting negative systems that develop due to poor support systems at home.

Token economy systems (TES) are a form of psychological therapy in which a reward system is used to manage maladaptive behaviours; patients earn tokens through good behaviour and then exchange them for rewards.

The theory of operant conditioning.

Maladaptive behaviours are behaviours that prevent patients from adapting to new or difficult situations – most often they result in negative/difficult behaviours.

Issues with bad hygiene, disruptive behaviours, and lower socialisation with other patients/members of staff.

The reward acts as the primary reinforcer.

The tokens act as the secondary reinforcers.

Personal care, condition related behaviour, and social behaviour.

Patients have to want to do certain behaviours for TES to be applicable.

Avolition.

It is effective in reducing negative symptoms, increasing adaptive behaviours, reducing maladaptive behaviours, and causing a decline in undesirable behaviours.

It gives professionals/medical staff significant power of control over the behaviour of the patients. It also has methodological issues in the studies that were reviewed and is not maintained outside of a hospital setting.

Glowacki et al. (2016), in a meta-analysis of seven high-quality studies of the effectiveness of TES in hospitals, found that all studies showed decreased negative symptoms and a decrease in the frequency of undesirable behaviours (violence and aggression).

Kazdin (1982) found that changes that were developed during a patient’s time in hospital using TES did not remain once they were discharged. Although TES is a way to alleviate symptoms, it is not a cure. 

The interactionist approach to schizophrenia examines how the combination of biological, psychological, and social factors explains the development of schizophrenia.

The best-known mechanism of the interactionist approach is the diathesis-stress model.

The diathesis-stress model, first introduced by Meehl (1962), is a psychological concept that holds that schizophrenia is due to a diathesis (an internal vulnerability) and an environmental trigger (stressor).

Yes.

Meehl argued it was due to a single gene ('schizogene'). If a person did not have this gene or genetic susceptibility, no external stressors could cause schizophrenia.

No, it is now considered a polygenetic disorder.

An internal vulnerability.

It considers the patient as a whole person, not just their mental disorder.

In patients with extreme or severe schizophrenic symptoms (hallucinations, extreme aggression, delusions, and paranoia), as described in the article on drug therapy, the patient can first be treated with biological drugs to combat these symptoms and then receive psychological treatment.

They found significant benefits to combined therapy over 18 months compared to treatment with antipsychotic medication alone. Patients had fewer positive symptoms, were less severe, and spent fewer days in the hospital. Therefore, the interactionist approach is more effective than antipsychotic treatments alone.

Read (2001) developed the idea that vulnerability might be related to nervous system development. They proposed that when traumatic experiences occur early enough in life or are particularly severe, these experiences are associated with biological abnormalities such as dopamine, norepinephrine, and serotonin abnormalities, acting as a diathesis by altering neurological development.

When reviewing pregnancy complications related to schizophrenia, they found that three categories had a high association with schizophrenia: pregnancy complications, abnormal growth and development, and delivery complications.

Substance abuse, early childhood trauma, academic failure.

It is a form of psychosis/mental illness.

The ICD (International Classification of Diseases) and the DSM (Diagnostic and Statistical Manual of Mental Disorders).

In America. The ICD is used worldwide but uses the DSM as a base.

According to the ICD, for a patient to be diagnosed with schizophrenia, they have to have negative symptoms for at least one month consistently, with one or more of the following: incoherent speech, catatonic behaviours, avolition, and some positive symptoms, such as delusional perceptions and hallucinations, i.e., hearing voices.

Positive symptoms for at least one month consistently, such as: Delusions, hallucinations, disorganised speech – these are prioritised in the diagnosis, and the following symptoms are also considered (although the first three must be present), disorganised behaviour, catatonic behaviour.

Hallucinations, delusions, and disorganised speech.

Avolition, speech poverty (alogia), and affective flattening. 

Through poor hygiene, lack of motivation/perseverance, and energy.

The labelling of a mental illness, especially schizophrenia, in some cases leads to stereotyping and negative public attitudes.

Diagnostic and Statistical Manual of Mental Disorders.

International Classification of Diseases. 

They found that labelling people with schizophrenia strongly negatively impacts public opinion.

Scheff (1999) suggested that mental illness labelling profoundly affected the stigmatised patients and almost created a self-fulfilling prophecy, i.e. patients began to behave as they were 'expected' to as schizophrenic or mentally ill people after being labelled.

Alogia (speech poverty) refers to a decrease in the quality and quantity of speech. Patients speak slower, less, and delay their responses.

Anhedonia is the inability to feel positive emotions fully.