Studies of family concordance patterns for schizophrenia have found __________.

Types of schizophrenia

There are five main sub-types of schizophrenic disorder that you need to know:

·         Disorganised schizophrenia:
Disorganised behavior and rambling incoherent speech. Marked flattening or inappropriateness of affect.

·         Catatonic schizophrenia:
Psychomotor abnormality is the central characteristic. Adoption of strange postures and flailing limbs. Often will resist all attempts to move them.

 ·         Paranoid schizophrenia:
Delusions and or hallucinations are the predominant characteristics. Negative symptoms such as flattening of affect and poverty of speech are less apparent than in other types.

 ·         Undifferentiated schizophrenia:
This type is diagnosed when the patient shows symptoms of schizophrenia but does not fit into the three other types.

·         Residual schizophrenia:
Patients who have once suffered from more extreme schizophrenia but who now only have milder symptoms, such as bizarre thoughts, withdrawal and affective flattening.

Psychology moves on! Types and the DSM 5...

In the newest edition of the Diagnostic and Statistical Manual (2013) - the book used to diagnose mental illnesses - the subtypes of schizophrenia have been SCRAPPED!"The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) are eliminated due to their limited diagnostic stability, low reliability, and poor validity. These subtypes also have not been shown to exhibit distinctive patterns of treatment response or longitudinal course. Instead, a dimensional approach to rating severity for the core symptoms of schizophrenia is included in Section III to capture the important heterogeneity in symptom type and severity expressed across individuals with psychotic disorders."

In your own words, write a brief explanation of what this section means.

Assignment 1 - Section A questions

Answer these from memory:

13 (a) Explain, in your own words, what is meant by ‘type of schizophrenia’. [2] 
(b) Describe two types of schizophrenia [4]

Characterisitcs of schizophrenia

Although the 'types' of schizophrenia given above (and the symptoms given below) make it clear that there is a wide variety in schizophrenic behaviours and conditions, there are some common features that are characteristic of all schizophrenic diagnoses:

• Loss of contact with reality - All schizophrenics have difficulties distinguishing reality from fiction.
• Muddled or confused thoughts - As a result of things like hallucinations and delusions

Positive symptoms

Positive symptoms come from the patient's own individual reports. They include:

1. Hallucinations: hearing or seeing something that is not there.  The most common type of hallucination is ‘hearing voices’. Hallucinations can occur in all sense modalities.

2. Delusions: a delusion is an idea of belief that is fervently believed without question by the sufferer when in fact the idea has no real basis in reality.  Some frequent types are delusions of grandeur and persecutory delusions.

3. Disorganised Speech: As thoughts may be jumping from one topic to another in an unconnected and incoherent way, so will a sufferer’s speech. This is sometimes called a ‘word salad’.

4. Disorganised Behaviour: Unpredictable, sudden or unexpected behaviour, which can make dressing, washing etc difficult. In extreme cases this can include catatonia.

Negative symptoms

Negative symptoms are observable behaviours. They include:

1. Diminished emotional response:  emotional blunting whereby inappropriate, insensitive or indifferent feelings are exhibited.  Giggling at bad news, rapidly changing moods, feeling happy but looking sad.

2. Avolition (lack of will): tendency to withdraw from interactions with other people, loss of affection, loss of interest, inability to make decisions.

3. Absence of social functions: 

Note that it is difficult to diagnose schizophrenia from positive symptoms alone. They are subjective and can only be inferred on the basis of the individual’s reports.  Negative symptoms can be observed and therefore easier to diagnose. 

Assignment 2 - Diagnosis mnemonic

Think of a mnemonic using HDSBDAA (the first letters of the positive and negative symptoms of schizophrenia)

Assignment 3 - You are the psychiatrist

Watch the video to the right, which features interviews with four schizophrenic patients. How many of the diagnostic criteria that you have just learned can you identify? Would you personally diagnose them with the condition?

What about the patient described in this report? Would you diagnose them?

Age of onset

Urbanicity - schizophrenia in the city

Download the document below, which contains data from a large scale study of schizophrenia by Pedersen& Mortensen(2001). The questions will test your ability to interpret data and to draw conclusions.

Assignment 4 - Schizophrenia information service

Schizophrenia is a very misunderstood condition. It is often confused with dissociative identity disorder, and people also often believe that schizophrenics are all dangerous to other people.

Create an information brochure to inform the public about the true nature of the condition.

Implications for diagnosing schizophrenia... serious concerns

• DSM IV has low diagnostic reliability.  Different clinicians may arrive at different diagnoses because of the wide range of symptoms.  It is hard if not impossible to diagnose type 1 (positive) symptoms due to the fact they are unobservable.
• DSM IV has low predictive validity because the causes, treatments and prognosis are not the same for all patients (people don’t all fit into one classification)
• Classification may result in labelling.  This may lead to people being stigmatised with ensuing difficulties in work, relationships etc.
• Someone with schizophrenia may not realise they are ill and might refuse the treatment they need.  As a result they may be admitted to hospital against their will under the Mental Health Act. This raises serious ethical issues of consent.
  

Stop and think!! You've already seen these...

The same issues will be relevant here as with diagnosing almost any other mental illness! You've already seen these points on the 'Models' page, and they'll be repeated regularly. 

Assignment 5 - G2C Online research

First visit the schizophrenia page at the amazing G2C Online website.

Choose a topic from one of the following:

• Genes
• Biochemicals
• Cells
• Cognitions
• Environment

Now use the information on the website to prepare a presentation which you will be able to give to the rest of your class.

Assignment 6 - G2C questions

Use the G2C webpage for schizophrenia to answer the following questions. Submit the answers by email or through the homepage.

1. Why do neuroscientists suspect that several neurotransmitters may be involved in producing schizophrenia?
2. How are genes and neurotransmitters related to the appearance of schizophrenia?
3. Explain why the identical twin of an individual with schizophrenia is more likely to develop the disorder than a fraternal twin or older sibling, but is not guaranteed to develop it.
4. Identify regions of the brain thought to be involved in schizophrenia, and provide evidence why scientists think these areas are involved.
5. How can the use of animal models contribute to better understanding of schizophrenia?

Genetic studies will look at families and twins. For example, if one person in a pair of twins has a condition, researchers may want to establish the probability that the other twin will also be schizophrenic – this is called the concordance rate. Complete the worksheet to the right to introduce yourself to these ideas.

Evidence for the genetic explanation

Gottesman & Shields (1972) performed a twin study where they examined the records of 57 schizophrenics between 1948 and 1964.   

About 40% of the twins were determined to be MZ (monozygotic i.e. identical) and about 60% DZ (dizygotic/non-identical).  If the pair were discordant, where one had schizophrenia and the other did not, then the non-schizophrenic was followed for at least 13 years to see if it developed later.

Concordance rates, (i.e. probability of a twin having schizophrenia if its twin has the disorder) were as follows:

·         Monozygotic twins 42%

·         Dizygotic twins 9%

Click to enlarge

In another study, Gottesman (1991) summarised about 40 studies in a meta-analysis. The results are shown above.

Do these results show the same or different pattern to those of Gottesman & Shields (1972)? Explain your answer.

The direction of causality - a major issue in mental illness research

As you can see from the evaluation issues above, it is sometimes hard to tell what causes what in psychological illness. We are left with a 'chicken and egg' scenario, where we know that things have changed, but do not know exactly what has caused the change.

This is a major problem for lots of research. For example, if we find that a person with a condition has unusual neurotransmitter levels (see below), we don't know if the condition caused the neurotransmitter levels or if the neurotransmitter levels caused the condition! It is therefore an evaluation issue that you can use repeatedly in your essays, providing you understand it and link it clearly to the topic you have been asked about!

This picture is also very relevant to the nature/nurture debate! See below.

Evaluating the genetic explanation

• There is strong evidence for a genetic basis to schizophrenia from the studies of twins.  However, concordance rates are not 100% and therefore this data does not exclude environmental input.
  
• The high concordance rates in MZ twins may be explained by the fact that they tend to be treated more similarly than DZ twins and this greater environmental similarity, rather than genetic similarity, may be responsible for the higher level of concordance than in DZ twins.
  
• However, it could be argued that MZ twins elicit more similar treatment from their parents than do DZ twins.  This suggests that the greater genetic similarity of identical twins may be a cause, rather than an effect of their more similar parental treatment. Again – what is the direction of the relationship?
• These studies show that the cause of schizophrenia is not wholly genetic.  Inheritance may put people at risk but stressful life events may trigger the actual onset of the illness.
  
• It has not been identified whether a single gene or several genes are implicated or how they influence the emergence of symptoms.
• Genetic explanations are reductionist, as they reduce complex conditions to the supposed activity of just a small number of genes. This seems too simplistic.
• Genetic explanations are also deterministic. They seem to offer the sufferer no hope of controlling the condition themselves, as we cannot consciously control the activity of our genes.

We don't know what causes what in schizophrenia... The red arrows are possible causes, but we don't know which one is the most important in forming the condition.

Untangling causality - Adoption studies

The notion that genetic factors are important in producing schizophrenia is supported by adoption studies.  One approach is to look at adoptees with schizophrenia compared with their biological and adoptive parents. See the video above for more.

The answer is... IT'S BOTH!

It is important that you can take a balanced position on the nature/nurture debate. The answer is never all of one or all of the other. Studies which illustrate this are brilliant ways to conclude ANY essay on abnormality!E.g. Tienari (1991) who showed that there does appear to be a genetic basis to schizophrenia, but that even vulnerable individuals can be protected from schizophrenia if their upbringing is healthy.

Key issue - Biological explanations and the nature/nurture debate

As you will know from AS, there is a long standing debate of whether behaviour (or schizophrenia) is due to nature (i.e. inherited, genetic, innate) or whether it is due to nurture (i.e. learning, environment, upbringing etc.).

Schizophrenia is a condition that is often studied in relation to the nature/nurture debate. It has also been used as a question before in the exam. As with most questions in this exam, the important thing is NOT knowing more information, but using the information

One influential cognitive model of schizophrenia comes from Chris Frith. Frith’s model (1992) tried to explain what might lead to the positive symptoms of schizophrenia. His idea is that people schizophrenia are cognitively impaired (they do not have a clear enough grasp of their own thought processes), with the result that they are unable to distinguish between actions that are brought about by external forces and those that are generated internally. 

He believes that most of the symptoms of schizophrenia can be explained in terms of deficits in three cognitive processes:

· Inability to generate willed action;
· Inability to monitor willed action;
· Inability to monitor the beliefs and intentions of others.

For example, he proposes that the 'inability to generate willed intentions can lead to inaction/avolition or inappropriate actions (look back at the symptoms of schizophrenia if you can't remember them, to see how this links). This means that a sufferer might not do tasks that they needed to do, or might forget which ones they had done and which ones they hadn't. 

In contrast, the inability to monitor the beliefs and intentions of others can lead to delusions of reference, paranoid delusions, certain kinds of incoherence and third-person hallucinations. Your own thoughts and 'inner-voice' could be mis-interpreted as someone speaking to you

According to Frith, faulty operation of this mechanism is due to a functional disconnection between frontal areas of the brain concerned with action and more posterior areas of the brain that control perception. He has produced some evidence for his ideas by detecting changes in cerebral blood flow in the brains of people with schizophrenia when engaged in specific cognitive tasks. This shows a nice overlap between cognitive and biological explanations.

Cognitive psychologists are attempting to find evidence for genetic links by examining whether malfunctioning cognitive processing is a family trait.

Evaluating cognitive explanations of schizophrenia

• Frith has been criticised as being reductionist where his theory fails to take into account the role of environmental factors. 
• Cognitive theories don’t explain the causes, only the symptoms of schizophrenia. 
• Cognitive explanations can be easily combined with other models (such as biological models), to provide more complete explanations for conditions.
• The disorder is typically diagnosed in adulthood but as yet there is no scientific evidence that links childhood difficulties in information processing with later onset of schizophrenia.
  
  

Image source: http://www.cartoonstock.com/directory/s/schizophrenic.asp

Assignment 7 - Section C question

In the Section C 6 mark questions in the exam you will need to be able to write about half a page describing a theory or model. Check that you can do this for the models of schizophrenia by writing half a page on each of the models in this section from memory.

Submit your answer through the form on the home page

Neuroleptic drugs (drugs that reduce psychotic symptoms) are often used in the treatment of schizophrenia.  

Chlorpromazine is an example of an anti-psychotic drug

• The mode of action is to block dopamine receptors in the brain, which means that the post synaptic receptor sites do not respond to dopamine. 
• These reduce the positive symptoms of schizophrenia (e.g. delusions, hallucinations)…
• … however; they have little effect on the negative symptoms (e.g. lack of motivation and emotion, social withdrawal).
• Minor side effects include dry mouth and throat, weight gain and drowsiness. 
• Major side effects are body stiffness or spasms (similar to Parkinson's disease - which makes sense) and involuntary movements of the mouth and tongue (Tardive dyskinesia).

However... Newer atypical antipsychotic drugs work on a wider range of neurotransmitters, for example, Clozapine.  Its mode of action is to block serotonin as well as dopamine receptor sites. Julien (2005) found that clozapine was an effective treatment of schizophrenia. It has been found to be effective for 50% of people who did not respond to other drugs, perhaps because it affects serotonin. However…

1)    It is much more expensive than most other drugs for schizophrenia

2)   Side effects - It can produce a potentially fatal blood disease in 1-2% of schizophrenic patients and weekly blood monitoring is required.

Also, because they implicate other neurotransmitters, these drugs cast doubt on the dopamine hypothesis as a complete explanation.

Assignment 8 - Ethical implications of biological treatments

Compulsory medication sometimes occurs for schizophrenics, and the reduction of the more severe symptoms of schizophrenia has obvious advantages for the carers and families of schizophrenics.  Does this mean that patients could or should be given medication without their consent?  Should the human rights of one person take precedence over those of another person or society?
Create a table like the one in the picture below, with as many advantages and disadvantages of biological treatments for the individual and for society.

General evaluation of drug treatments for schizophrenia

• Neuroleptic drugs that block dopamine at the synapse typically reduce many of the symptoms of schizophrenia. However, they affect positive symptoms such as delusions and hallucinations more than negative symptoms such as apathy and immobility.
  
• Anti-schizophrenic drugs have been referred to as pharmacological strait jackets because they only alleviate or contain symptoms, they don’t provide a complete cure. They treat the symptoms not the cause.
  
• Whilst drugs have enabled care in the community, re-admission rates to hospital are high and many patients relapse in the first year after discharge if the drugs are discontinued. Davis et al. (1993) found that if antipsychotic drugs are stopped abruptly then symptoms recur. Patients also often refuse to comply with treatment because of side effects. 
• Schizophrenic patients are often reluctant to take neuroleptic drugs because of the side effects.  As a result, they are sometimes given injections of long-lasting neuroleptics, thus removing the decision whether or not to take a tablet. This clearly has ethical implications. 
  
• They are not a full cure. Around 25% of patients show no improvement with traditional neuroleptics, and a further 30-40% do not show full remission.

The procedure of ECT involves an electric current of between 70 and 130 volts being passed through the non-dominant brain hemisphere, and an anaesthetic and muscle relaxants are given before the treatment itself. 6 to 9 treatments may be given over a month or so. 

Originally used by Cerletti and Bini (1938) to help patients with schizophrenia but it was eventually deemed an ineffective treatment for schizophrenia. Today ECT is used to treat depression, but very rarely for schizophrenia

from http://aspsychologyblackpoolsixth.weebly.com/treatments-of-abnormality.html

This video should give you a clear idea of what a modern ECT session looks like...

Token economies are systems based in the ideas of behaviourism, specifically operant conditioning and positive reinforcement (as well as occasionally using negative reinforcement and punishment).  Secondary reinforcement is a system whereby desirable behaviour is rewarded with a token or point, which can later be exchanged for a reward once a certain number of tokens have been earned. Token economies have been used to reward socially desirable behaviour of long-term patients in psychiatric institutions.  For example, for making their bed they might get a reward or a token, which they can then exchanged for a primary reinforcer such as goods or watching a favourite TV programme.

Evaluating token economies 

• Paul and Lentz (1977) both found that token economies produced improvements in self-care and pro-social behaviour, even in chronic, institutionalised schizophrenics.
  
• However, whilst token economies work when the schizophrenic person is in the institution, once they are removed from the institution the reward is removed and the improved behaviour ceases.
  
• Behavioural treatments do not remove cognitive symptoms such as hearing voices or delusions.

Paul and Lentz (1977)

AIM: to investigate the effectiveness of operant conditioning by reinforcing appropriate behaviour in schizophrenic patients.

METHOD: patients were given tokens each time they behaved appropriately.  These could be used to purchase small luxury items.  Patients also received individual behavioural treatments tailored to suit their needs. 

RESULTS: both positive and negative symptoms were reduced, leading to more hospital discharges when compared to a control group.  Only 11% of patients needed drug treatment compared to 100% of the control group.

CONCLUSION: operant conditioning can be an effective means of improving behaviour in people with chronic schizophrenia.

The cognitive approach would treat schizophrenia by trying to deal with the clients disturbed thought processes.  

E.g. controlling hearing voices using cognitive behavioural techniques…

• The process begins by asking the patient to focus on the nature of the voices they hear, for example thinking about the tone or whether the voice is male or female.
  
• Therapists then try to help the patient to understand that the voices are part of their own thought processes.  
  
• They are also encouraged to develop strategies against the wishes of the inner voices: for example, choosing to pay attention to the voices only at certain times of the day.

Assignment 9 - Interpreting real research - Sensky (2000)

Read the research paper by Sensky (2000) below. Produce an APFCC summary of the research. Try to find a number of different ways that the results of the study could be interpreted. Submit your summary through form on the homepage. 

sensky_et_al_2000_schizophrenia_cognitive_behaviour_therapy.pdf

Download File

Evaluating CBT as a treatment for schizophrenia

• Shown to be effective in many cases. Improves symptoms, recovery and relapse rates
• Can be used in conjunction with other therapies (e.g. drugs)
• No side effects (unlike drugs)
• It could be argues that its not very rational to teach patients to see life through rose coloured spectacles
• Doesn’t work for everybody
• Expensive and time consuming

Exam tip - evaluating models and treatments using contrasting approaches

When evaluating different models and their treatments, try to understand where theories agree and disagree with each other. A very effective evaluation tool is to be able to contrast different models with each other. For example:

P - One issue with drug therapies for schizophrenia is that the drugs can have side effects.
E - For example, chlorpromazine may lead to stiffness and muscles spasms similar to the symptoms of Parkinson's disease.
E - Side effects are a serious problem as they may encourage patients to stop taking the drug, with the danger that they might then relapse.
Contrast - CBT, in contrast, has no side effects as it is purely a talk-based therapy, therefore it may be a better option for many patients who have had a negative reaction to drugs.

Revision

Can you define the following terms from memory?

Affective flattening, Delusion, Dopamine, DSM-V, Glutamate, Hallucination, Disorganized speech, Negative symptom, Positive symptom, Psychotic symptom, Schizophrenia, Serotonin

Extension

Schizophrenia at different levels of explanation

Different levels of explanation... in this picture for depression

It is important to understand that the different approaches to psychology are not necessarily rivals, whose explanations always contradict each other. This is not true. In fact, different approaches may simply be describing the same process, but from a different level of explanation.

analysing_schizophrenia_at_different_levels_of_explanation_-_use_with_g2c_website.docx

Download File

The prezi below touches on a number of fascinating issues surrounding schizophrenia and other mental illnesses. Highly recommended!