Psycho Pathology Schizophrenia)

8/2/2019 Psycho Pathology Schizophrenia)

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PSYCHOPATHOLOGYSchizophrenia


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CLASSIFICATIONANDDIAGNOSISOFSCHIZOPHRENIA

The characteristics of schizophrenia

Schizophrenia is characterised by a profound disruption of cognition and emotion, which affects a personslanguage, thought, perception, affect and even sense of self.

Diagnostic criteria

Symptoms of schizophrenia are divided into positive and negative symptoms. Positive symptoms are thosethat appear to reflect an excess or distortion of normal functions. Negative symptoms are those thatappear to reflect a loss of normal functions. Under the DSM-IV-TR, the diagnosis of schizophrenia

requires at least a month of two or more positive symptoms.

Positive Symptoms

Delusions Bizarre beliefs that seem real to the person with schizophrenia, but are not real.

Experiences of control The person may believe they are under control of an alien force that hasinvaded their mind / body.

Hallucinations Bizarre, unreal perceptions of the environment (hearing voices, seeing lights / objects /

faces, smelling things, feeling things crawling on the skin).

Disordered thinking Feeling that thoughts are being inserted or withdrawn from the mind. May believetheir thoughts are being broadcast.

Negative Symptoms

Affective Flattening A reduction in the range and intensity of emotional expression, facial expression,voice tone, eye contact and body language.

Alogia Poverty of speech, less fluent and productive, showing blocked thoughts.

Avolition The reduction of / inability to have goal-directed behaviour.


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ISSUESOFRELIABILITYANDVALIDITY

Reliability

In search of schizophrenia: Can psychiatrists agree on the same diagnosis when independently assessingpatients? The publication on the DSM-III was designed to provide a more reliable system for classifyingpsychiatric disorders. This lead to claims of a reliable classification system, leading to a much greateragreement of who did and didnt have schizophrenia. However 30 years later there is still little evidencethat the DSM is routinely used. Whaley (2001) found that inter-rater reliability in correlations ofdiagnosis was as low as 0.11.

Unreliable symptoms: Klosterktter et alassessed 489 admissions to a psychiatric unit to determine whether

positive or negative symptoms were more suited for the determination of a diagnosis of schizophrenia.They found that positive symptoms were more useful for diagnosis than negative symptoms. Howeveritis also argued that a diagnosis of schizophrenia is too different for each individual, that diagnosticcategories are not useful. 50 senior psychiatrists were asked to define between bizarre and non-bizarre symptoms the inter-rater reliability correlations were only around 0.40, concluding that thecentral diagnostic lack sufficient reliability for it to be a reliable method for defining schizophrenicpatients.

Validity

If scientists cannot agree who has schizophrenia (low reliability) then this raises questions of what actually is(validity) schizophrenia.

Symptoms: Schneider listed all the psychotic symptoms that he believed distinguished schizophrenia fromother psychotic disorders. (First rank symptoms, experiences of control / disordered thinking /hallucinations). These symptoms of schizophrenia could make diagnosis more reliable. Yet it has beenpointed out that these symptoms are found in depression / bi-polar disorder.

Prognosis: There is no evidence that people who are diagnosed with schizophrenia will share the sameoutcomes. 20% recover to previous level of functioning, 10% achieve significant and lastingimprovement, 30% show some improvement with relapses. Therefore there is little predictive validity

some people never recover from the disorder, though many do. There are influences on the outcomesuch as gender and social skills and family tolerance of the patient.


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BIOLOGICALEXPLANATIONSOFSCHIZOPHRENIA

Genetic Factors

Family studies: Gottesman found individuals who have schizophrenia and determine whether their biologicalrelatives are affected more than non-biological relatives. These studies have established thatschizophrenia is more common among biological relatives of a person with schizophrenia. (Children witha schizophrenic parent have a concordance rate of 46%), this could be due to common rearing pattersor heredity.

Twin studies: Twins allow for researchers to investigate the contribution of genetic and environmental

influences. If the identical twins concordance rate is higher than non-identical twins then this suggeststhat the similarity is due to genetic factors. Joseph (2004) calculated that the data from prior 2001suggests that the concordance rate of identical twins was 40.4% and non-identical was 7.4%. Howevermore recent studies, where the researcher doesnt know whether the twins are identical or non-identicaltended to report a lower concordance rate for identical twins (researcher bias), however despite this theconcordance rate for identical twins is still higher than non-identical twins.

Adoption studies: Because of the difficulties of environmental influences on those who share genes andenvironment, studies of genetically related individuals who have been reared apart are used. Tienari et

alwhose findings were that of 164 adoptees whose biological mothers were diagnosed withschizophrenia, 11 also received a diagnosis of schizophrenia, compared to 4 of the 197 adoptees bornto non-schizophrenic mothers. These findings conclude that the genetic liability to schizophrenia hadbeen decisively confirmed.

Commentary Genetic FactorsTwin StudiesA crucial assumption is that the environments of identical and non-identical twins areequivalent. Therefore it is assumed that the greater concordance for schizophrenia betweenidentical twins is because of greater genetic similarity rather than environmental similarity.Joseph found that identical twins are treated more similarly, encounter the same

environments (doing things together) and experience more identity confusion (frequentlybeing treated at the twins rather than two individuals) as apposed to non-identical twins.Therefore Joseph argues that the differences in concordance rates between identical andnon-identical twins is due to nothing other than the environmental factors.

Adoption StudiesA central assumption of adoption studies is that adoptees are not selectively placed i.e.

The parents who adopt a child whose mother was schizophrenic are no different to a

adoptive parents who adopt children whose background is normal. Joseph claims that it isunlikely that this is the case, as potential adoptive parents would have been informed of thegenetic background of children prior to adoption.


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BIOLOGICALEXPLANATIONSOFSCHIZOPHRENIA

The dopamine hypothesisDopamine is a neurotransmitter that operates in the brain. The dopamine hypothesis states that messages

from neurons that transmit dopamine fire too easily or often, leading to the characteristic symptoms ofschizophrenia.

Schizophrenics are thought to have abnormally high levels of D receptors on receiving neurons, resulting inmore dopamine binding and therefore more neurons firing.

Dopamine neurons play a key role in guiding attention, so disturbances in this process may well lead to theproblems relating to attention, perception and thought found in people with schizophrenia. The key roleplayed by dopamine in schizophrenia is as followed:

Amphetamines This is a drug with special relevance for our understanding of schizophrenia. Itstimulates the nerve cells containing dopamine causing the synapse to be flooded with dopamine. Largedoses of the drug can cause hallucinations and delusions.

Antipsychotic Drugs These drugs block the activity of dopamine in the brain. By reducing thestimulation of dopamine, the drugs eliminate symptoms such as hallucinations and delusions. Because

these drugs can block the action of dopamine and eliminate hallucinations and delusions, it suggeststhat dopamine isa contributory factor to the disorder.

Parkinsons Disease Low levels of dopamine are found in people who suffer from Parkinsons disease.It was found that people who were taking the drug to raise their dopamine levels, were havingschizophrenic symptoms. (Grilly, 2002)

CommentaryThe dopamine hypothesis

Post-mortem studiesA problem with the dopamine hypothesis is that the drugs used to treat schizophrenia by

blocking dopamine activity can actually increase it as the neurons struggle to compensate forthe deficiency. Haracz carried out post-mortem studies of schizophrenics, and found thatthose who had received antipsychotic drugs shortly before death had higher levels ofdopamine than patients who werent taking the drugs.

Evidence from neuro-imaging researchSophisticated neuro-imaging techniques such as PET scans have failed to provide

convincing evidence of altered dopamine activity in the brains of individuals withschizophrenia. (Copolov and Crook, 2000)

Enlarged VentriclesA meta analysis of over 90 CT scan studies revealed that enlarged ventricles may be due tothe use of antipsychotic medication. A study by Lyon et alfound that as the dose ofmedication increased, the density of brain tissue decreased, leading to enlarged ventricles.


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PSYCHOLOGICALEXPLANATIONSOFSCHIZOPHRENIA

Psychological Theories

Psychodynamic

Freud (1924) believed that schizophrenia was the result of two related processes, regressionto a pre-ego stage and attempts to re-establish ego control. If the world of theschizophrenic had been particularly harsh, for instance their parents were cold oruncaring, an individual may regress to this early stage in their development before theego was properly formed and before they have developed a realistic awareness of theexternal world. Freud saw schizophrenia as an infantile stage where symptoms such asdelusions of grandeur reflect a primitive condition, and symptoms such as auditoryhallucinations reflecting the persons attempts to re-establish ego control.

Psychotherapeutic explanations

There is no research evidence to support Freuds specific idea of schizophrenia, except that

many psychoanalysts have claimed, like him, that disordered family patterns are thecause for the disorder. Fromm-Reichmann described schizophrenogenic mothers orfamilies who are rejecting, overprotective, dominant and moralistic as contributoryinfluences to developing schizophrenia. Studies have shown that parents ofschizophrenic patients act differently from parents of other kind of patients, particularlywhen their schizophrenic offspring is present (Oltmanns et al, 1999) but this is likely to bea consequence of their childrens problem.

CognitiveThis explanation of schizophrenia acknowledges the role of biological factors in causing theinitial sensory experiences of schizophrenia, but claims that further features of the disorderappear as individuals attempt to understand the experiences. When schizophrenics firstexperience voices / worrying sensory experiences, they turn to others to confirm the validity of

what they are experiencing. Other people fail to confirm the validity of the experiences, so theschizophrenic comes to believe that the others are hiding the truth. They begin to rejectfeedback from those around them and develop delusional beliefs that they are beingmanipulated by others.

Cognitive ExplanationsThere is lot of evidence of a physical basis for the cognitive deficits associated with

schizophrenia. Research by Meyer-Lindenberg et al, found a link between excess dopamine inthe prefrontal cortex and working memory. The suggestion that madness is a consequence of

disbelieving others receives support from a recent suggestion from treatment. Yellowlees et alhave developed a machine which produces virtual hallucinations, such as hearing the TV tellyou to kill yourself, or one persons face morphing into another. The intention is to show

schizophrenics that their hallucinations are not real. There is no evidence that it will produce asuccessful treatment.


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PSYCHOLOGICALEXPLANATIONSOFSCHIZOPHRENIA

Socio-Cultural Factors

Life events and schizophrenia

The occurrence of stressful life events had been linked to a greater risk of schizophrenicsymptoms. These are discrete stresses such as death of a close relative or the break upof a relationship. Brown and Birley found that, prior to a schizophrenic episode, patientswho had previously experienced schizophrenia reported twice as many stressful life

evens compared to a healthy control group. The mechanisms which stress factors triggerschizophrenia are not know, although high levels of physiological arousal associated withneurotransmitter changes are thought to be involved.

Commentary on Socio-Cultural Factors

Not all evidence supports the role of life events. For example van Os et al reported no linkbetween life events and schizophrenia. Patients were not more likely to have had a majorstressful life event in the three months preceding the onset of their illness. In aprospective part of the study, those patients who had experienced a major life event wenton to have a lower likelihood of relapse. Evidence that does suggest a link between lifeevents and the onset of schizophrenia is only correlational. It could be that thebeginnings of the disorder (e.g. Erratic behaviour) were the cause of the major lifeevents. Furthermore, life events after the onset of the disorder (e.g. Loosing ones job /

divorce) may be a consequence rather than a cause of mental illness.


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BIOLOGICALTHERAPIESFORSCHIZOPHRENIA

Antipsychotic Medication

Antipsychotic medication helps the person with the disorder function as well as they possiblycan in their life, as well as increasing their feelings of subjective wellbeing. Conventionalantipsychotics are used primarily to combat the positive symptoms of schizophrenia(hallucinations and thought disturbances from an over-reactive dopamine system) Theatypical antipsychotic drugs also combat these positive symptoms of schizophrenia, but

there are claims that they have some beneficial effects on negative symptoms as well.Conventional antipsychotic drugs

Basic mechanism of anti psychotic drugs is to reduce the effects of dopamine so reduce thesymptoms of schizophrenia. Conventional antipsychotics bind to the dopamine receptors,but do not simulate them, thus blocking their action. By reducing the simulation ofdopamine in the brain this can eliminate hallucinations and delusions.

Atypical antipsychotic drugs

Atypical antipsychotic drugs also act on the dopamine system, but are thought to blockserotonin receptors in the brain too. It has been argued that they help by only temporarilyoccupying the D2 receptors and then rapidly detaching themselves to allow normaldopamine transition. There is thought to be lower levels of side effects from atypicalantipsychotics than conventional antipsychotics.

Commentary of conventional antipsychoticsRelapse rates A review by Davis et alfound a significant difference in terms of relapse rates between treatment andplacebo groups in every study reviewed, demonstrating the therapeutic effectiveness of these drugs. They found thatrelapse occurred in 55% of the patients whose drugs were replaced by a placebo, and 19% of those who remained onthe drug.Other factors are important one of the studies in the Davis et alreview found that antipsychotic drugs did make asignificant difference, but only for those living with the hostility and criticism in their home environment, the relapse insuch conditions on medication was 53%, but for those in the placebo condition the relapse rate was 92%. For thoseliving in a supportive environment, there was no significant difference between those on medication (12% relapse) andthose in a placebo (15% relapse).

Appropriateness of conventional antipsychoticsTardive dyskinesia - Conventional antipsychotics may have worrying side effects, including tardive dyskinesia(uncontrollable movements of the lips, tongue, face, hands and feet). Above 30% of people taking antipsychotics willdevelop tardive dyskinesia, and it is irreversible in 75% of cases.Motivational deficitsRoss and Read argue that being prescribed medication reinforces the view that there issomething wrong with you. Preventing the individual from thinking about possible stressors (life history / current

circumstances) which might be a trigger for their condition. This reduces their motivations to look for possible solutionsthat might alleviate these stressors and reduce their suffering.

Effectiveness of atypical antipsychoticsAtypical versus conventional antipsychotics- A meta-analysis published showed that the superiority of these drugs wasonly small. This analysis found that two of the new drugs tested were only slightly more effective than conventional

antipsychotics, while the other two were no more effective.Effectiveness with negative symptoms The claim that atypical antipsychotics are particularly effective with the negativesymptoms of schizophrenia has very small support. In the Leucht et al study two of the atypical drugs were slightly more

effective than the conventional antipsychotics, one was as effective and one slightly worse.

Appropriateness of atypical antipsychoticsLower likelihood of tardive dyskinesia One of the main claims of atypical antipsychotics isthe lower likelihood of tardive dyskinesia. This claim was supported in a study by Jeste et alwhich found tardive dyskinesia rates in 30% of people after 9 months of treatment withconventional antipsychotics, but just 5% for those treated with atypical antipsychotics.Fewer side effects Atypical antipsychotics may ultimately be more appropriate in thetreatment of schizophrenia because there are fewer side effects, which in turn means thatpatients are more likely to continue their medications and therefore see the benefits.

ETHICAL ISSUES: INHUMANE TREATMENT?Critics argue that if side effects, deaths and psychosocialconsequences were taken into account, a cost-benefit analysis of its

advantages would most probably be negative. In the US recently asettlement was awarded to a tardive dyskinesiasufferer on the basisof the Human Rights Act, which states no one shall be subjected to

inhuman or degrading treatment or punishment (Ross and Read

2004)


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ELECTROCONVULSIVETHERAPY (ECT)

ECT

Historical Origins - The idea that schizophrenia could somehow be cured by inducingseizures followed reports that dementia praecox(an early name for schizophrenia) wasrare in patients with severe epilepsy, and that seizures in patients with dementia praecoxsomehow reduced the symptoms of the disorder. The first studies of the clinical use ofthis technique specifically for the treatment of schizophrenia were disappointing, withlower rates of recovery for ECT patients compared to those who did not receive ECT(Karagulla, 1950)

What happens in ECT? - An electric current is passed through the scalp to create aseizure. The patient is given a short acting barbiturate, so they are unconscious beforethe electric shock is given, then they are given a nerve blocking agent to paralyse themuscles of the body to prevent them from contracting during a seizure and preventingfractures. The seizures last up to a minute, which effects the entire brain. A patientusually requires between 3 and 15 treatments.

Effectiveness of ECTAn American study which compared ECT with simulated ECT (the patients are anesthetised

but not given the electric shock, concluded that ECT produced results that were no differentfrom or worse than antipsychotic medication. However an Indian study found no difference insymptom reduction between 36 schizophrenia patients given either ECT or simulated ECT

Appropriateness of ECTBecause there are significant risks associated with ECT, including memory dysfunction, braindamage and even death, the use of this technique had declined. In the UK, the declinebetween 1979 and 1999 was 59% (Read, 2004)


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PSYCHOLOGICALTHERAPIESFORSCHIZOPHRENIA

Psychological Therapies

Cognitive-behavioural therapy (CBT)

CBT it used to help schizophrenic patients recognise their delusional beliefs and correct them.

CBT Techniques patients are encouraged to trace back the origins of their symptoms in order to get a betteridea of how the symptoms might have developed. The patient is encouraged to evaluate the content of theirdelusions or of any internal voices they hear, and to consider ways in which they can test the validity of theirfaulty beliefs. Patients might also be set behavioural assignments with the aim of improving their level offunctioning. Learning maladaptive responses to lifes problems is often the consequence of disordered

thinking by the schizophrenic. During CBT, the therapist lets the patient develop their own alternativeexplanations and coping strategies that are already present in the patients mind.

Outcome Studies

Outcome studies measure how well a patient does after a particular treatment, compared with the accepted formof treatment for that condition. Outcome studies of CBT suggests that patients who receive cognitive therapyexperience fewer hallucinations and delusions and recover their functioning to a greater extent than those

who receive antipsychotic medication alone. Drury et alfound that benefits in terms of a reduction of positivesymptoms and a 25-50% reduction in recovery time for patients given a combination of antipsychoticmedication and CBT. A study by Kuipers et alnoted that there were lower patients drop-out rates andgreater patient satisfaction when CBT was used in addition to antipsychotic medication.

Event:See aman

outsidehouse

Interpretation: Hesfollowing

me

Behaviour:Take

evasiveaction,avoid

going out.

Effectiveness of CBTSupporting Research - Research had tended to show that CBT has a significant effect on improving thesymptoms of patients with schizophrenia. Gould et alfound that all seven studies in their meta-analysisreported a statistically significant decrease in the positive symptoms of schizophrenia after treatment.How much is due to the effects of CBT alone? - Most studies of the effectiveness of CBT have been conductedwith patients treated at the same time with antipsychotic medication. Therefore it is difficult to asses the

effectiveness of CBT without antipsychotic medication.

Appropriateness of CBTNegative Symptoms - CBT for schizophrenia works by trying to generate less distressing explanations forpsychotic experiences, rather than trying to eliminate them completely. Negative symptoms may serve a usefulfunction for the person and so can be understood as safety behaviours. For example, within a psychiatric

setting, the strong expression of emotions might be seen as a way of avoiding making positive symptomsworse. CBT therefore, offers some hope of alleviating these maladaptive thought processes.

Who benefits? - The use of CBT with medication seems to have benefits, but it is also believed that noteveryone with schizophrenia may benefit from CBT. In a study of 142 schizophrenic patients in Hampshire,found that many patients were not suitable for CBT because psychiatrists believed that would not fully engagewith the therapy. Older patients were deemed less suitable that younger patients.

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