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1. Schizophrenia PSYA4<br />Stephanie Usher<br /> 2. What do we need to know?<br /> 3. Schizophrenia has been variously described as a disintegration of…
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  • 1. Schizophrenia PSYA4<br />Stephanie Usher<br />
  • 2. What do we need to know?<br />
  • 3. Schizophrenia has been variously described as a disintegration of the personality<br />A main feature is a split between thinking and emotion. <br />It involves a range of psychotic symptoms (where there is a break from reality) <br />Generally, schizophrenic patients lack insight into their condition, i.e. they do not realise that they are ill. <br />They must follow the pattern of symptoms (see next slide)<br />It is not caused by:- <br />Inadequate parenting <br />Overzealous mothers <br />Poor family relations <br />It is not split personality<br />Clinical Characteristics<br />
  • 4. Sufferers of Schizophrenia must have at least two of the following symptoms, each present for a significant portion of time during a1-month period (or less if successfully treated)<br />Hallucinations (us. auditory or somatic)<br />Delusions (oft. linked to hallucinations)<br />Disorganised speech - jumping from one conversations topic to another apparently at random - or incoherence<br />Disorganised or catatonic behaviour<br />Negative symptoms - affective flattening (apparent lack of emotion), alogia (apparent inability or unwillingness to speak), or avolition (apparent inability or unwillingness to direct own activities)<br />Social & occupational dysfunction - For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset<br />Symptoms of the condition<br />
  • 5. Positive and Negative Symptoms <br />Negative symptoms<br /><ul><li>Affective flattening – reduction in range and intensity of emotional expression, including facial expression, tone of voice etc
  • 6. Alogia – lessening speech fluency
  • 7. Avolition – reduction or inability to take part in goal directed behaviour. </li></ul>Positive Symptoms<br /><ul><li>Delusions – paranoia, grandiosity
  • 8. Experiences of control – believe under control of alien force.
  • 9. Auditory hallucinations – bizarre, unreal perceptions, usually auditory.
  • 10. Disordered thinking – thoughts have been inserted or withdrawn from the mind.</li></ul> Diagnosis requires 1 month of two or more positive symptoms. <br />
  • 11. Subtypes of Schizophrenia<br />
  • 12. Can you think of any issues surrounding the diagnosis of Schizophrenia?<br />
  • 13. The BiologicalExplanations of Schizophrenia<br />Genetics<br />Neurochemical & hormones<br />Structural brainabnormalities<br />
  • 14. Biological Explanation: Genetics<br />Prevalence of schizophrenia is the same all over the world (about 1%)<br />Supports a biological view as prevalence does not vary with environment<br />Risk rises with degree of genetic relatedness<br />Spouse – 1% (same as G.P.)<br />Child – 13%<br />DZ twin – 17%<br />MZ twin – 48%<br />Kendleret al (1985) found that<br />1stdegree relatives of those with<br />schizophrenia are 18 times more<br />at risk than the general <br />Population<br />Children with both parents who<br />suffer from schizophrenia have <br />a CONCORDANCE RATE OF 46%<br />
  • 15. Biological Explanation: Genetics<br />The Copenhagen High-Risk Study (Ketyet al. 1962)<br /><ul><li>Ketyidentified 207 offspring of mothers diagnosed with schizophrenia (high risk) along with a matched control of 104 children with ‘healthy’ mothers (low risk) in 1962
  • 16. Control group were matched on age, gender, parental socio-economic status and urban/rural residence
  • 17. Children aged between 10-18 years at start of study
  • 18. Schizophrenia diagnosed in 16.2% of high risk group compared to 1.9% in low risk group</li></li></ul><li>Biological Explanation: Genetics<br /><ul><li>To research more on the impact of genetics on schizophrenia, we can compare concordance rates for identical (MZ) and fraternal (DZ) twins
  • 19. Both share the same environment but only MZ twins have identical genetics – if schizophrenia is genetically related, the concordance rate of schizophrenia should be much higher in MZ twins.
  • 20. To prove this many studies have been conducted – ALL OF THEM show much higher concordance rate in MZ than DZ twins
  • 21. To prove the genetic influence further, you have to research the power of genetics in separate environments - researchers have sought out MZ twins reared apart where at least 1 has been diagnosed with schizophrenia</li></ul>Gottesman & Shields (1982)<br />Used the Maudsley twin register and found 58% (7/12 MZ twins reared apart) were concordant for schizophrenia<br />
  • 22. Biological Explanation: Genetics<br />Although twin, adoption and family studies continue to prove that the degree of risk of obtainingschizophrenia increases withdegree of genetic relatedness, there are two factors which stop us concluding biology as the source;<br /><ul><li>No twin study has yet shown 100% concordance in MZ twins
  • 23. Studies conducted so far don’t tell us which genes might be important for the transmission of schizophrenia. </li></li></ul><li>Biochemical Explanation<br />The dopamine hypothesis- Comer (2003)<br />Dopamine is one of the many neurotransmitters operating in the brain. <br />Schizophrenics are thought to have an abnormally high number of D2 receptors on their receiving neurons, resulting in more dopamine binding and therefore more neurons firing. <br />Dopamine neurons play a key role in guiding attention, so it is thought that disturbances in this process may lead to the problems of attention and thought found in people with schizophrenia. <br />A group of drugs were developed in the 1950s called phenothiazines, which bind to the D2 receptors, effectively blocking the transmission of nerve impulses through these receptors and therefore reducing deficit found in schizophrenic. <br />
  • 24. Biological Explanation: <br />Structural Brain Abnormalities<br />Schizophrenia may be a structural abnormality. <br />Stevens (1982) cites the fact that many schizophrenics display symptoms indicating neurological disease - especially decreased eye blinking, lack of the blink reflex, poor visual pursuits and poor pupil reactions to light. Some schizophrenics underwent perinatal complications and may have suffered a lack of oxygen resulting in possible brain damage.<br />Researchers have found that many schizophrenics have enlarged ventricles, these are cavities in the brain that supply nutrients and remove waste. <br />Torrey (2002) found that the ventricles of a schizophrenic are 15% bigger on average than normal. <br />Bornstein et al (1992) found that people with schizophrenia and enlarged ventricles tend to display negative rather than positive symptoms and have greater cognitive disturbances and a poorer response to traditional antipsychotics. <br />
  • 25. <ul><li>Humane approach; poses no blame on the individual or their families – states that the people who become ill are purely “unlucky”
  • 26. Tends to provoke little fear or stigma
  • 27. Effective treatments
  • 28. Well established scientific treatments
  • 29. Reductionist approach
  • 30. Animal studies
  • 31. Relies on self report
  • 32. Treats symptoms, not causes</li></ul>Evaluation of Biological Approach<br />
  • 33. Biological Explanation: <br />Structural Brain Abnormalities<br />Meyer – Lindenberg et al (2002) examined brain activity in schizophrenics engaged on a working memory task. <br />Their prefrontal cortex showed reduced activation reflecting their poor performance on such tasks.<br />At the same time dopamine levels were elevated suggesting that a dysfunction of the prefrontal cortex is linked to dopamine abnormalities. <br /> <br />Sigmundssen (2001) found that patients with type 2 schizophrenia have smaller amounts of grey matter and smaller temporal and frontal lobes. <br />This supporting the view that enlarged ventricles are significant only because they indicate reduced brain matter, which may be related to brain damage. <br />
  • 34. ThePsychologicalExplanations of Schizophrenia<br />Behavioural<br />Cognitive<br />psychodynamic <br />socio-cultural<br />
  • 35. Freud believed that schizophrenia was the result of two related processes<br />Regression to a pre ego state<br />Attempts to re-establish ego control.<br /> <br />If the world of the schizophrenic is particularly harsh, for example if his or her parents are cold and uncaring, a child may regress to a stage of development before the ego was properly formed and before the child had developed a realistic awareness of the external world. <br />Schizophrenia was thus seen by Freud as an infantile state, some symptoms (e.g. delusions of grandeur) reflecting this primitive condition, others (e.g. auditory hallucinations) reflecting the persons attempts to re-establish ego control.<br />Although there is no research evidence to support Freud’s specific ideas, except that disordered family patterns are the cause of the disorder. <br />Oltmannset alfound that the parents of schizophrenic patients do behave differently from the parents of other kinds of patients, particularly in the presence of their schizophrenic offspring.<br />Psychological ExplanationsPsychodynamic <br />
  • 36. Evaluation of Psychodynamic Approach<br /><ul><li>Stresses the importance of psychological factors (very freud)
  • 37. Stresses the importance of childhood
  • 38. Influential theory
  • 39. Importance of the unconscious mind
  • 40. The importance of childhood is sometimes overstressed
  • 41. Problems validating the study (no studies have been carried out as proof)
  • 42. Poor methodology
  • 43. Blames parents</li></li></ul><li>Behaviourists argue that learning plays a key role in the development of schizophrenia. One suggestion is that early experience of punishment may lead the child to retreat into a rewarding inner world. Others then label them as ‘odd’ or ‘strange’. <br />Scheff’s (1966) labelling theory suggests that individuals labelled in this way may continue to act in ways that conform to this label. Bizarre behaviour is rewarded with attention, and becomes more and more exaggerated in a continuous cycle before being labelled as ‘schizophrenic’<br />Behaviourists have attempted to explain schizophrenia as the consequences of faulty learning. <br />If a child receives little or no social reinforcement early on in life, the child will attend to inappropriate and irrelevant environmental cues, instead of focusing on social stimuli in the normal way. <br />Behaviourists explain the fact that schizophrenia runs in families as a function of social learning. Bizarre behaviour by parents is copied by children. Parents then reinforce this behaviour and the behaviour becomes progressively more unusual, until eventually the child acquires the label of being ‘schizophrenic’.<br />Psychological Explanations;Behavioural<br />
  • 44. Evalution<br />The validity of the behavioural model is moderately supported by the success of behavioural therapies used with schizophrenic patients. <br />Social skills training techniques have been used to help schizophrenics acquire useful social skills (Rodger et al.,2002). Allyon & Azrin (1968) have shown that schizophrenics have learned to make their own beds, comb their own hair etc. when given rewards for doing so. <br />Finally Roder et al. (2002) has demonstrated that social skills training techniques have been used to help schizophrenics acquire social skills. <br />The success of such programmes in teaching new skills and reintegrating schizophrenics back into the community suggests that these are skills that schizophrenics failed to learn in the first place.<br />Overall this research can explain how schizophrenia symptoms are maintained but it does not adequately explain where they came from in the first place.<br />Critics claim that labelling theory ignores strong genetic evidence and trivialises a serious disorder. <br />In what ways could it be argued that the behaviourist approach to schizophrenia is reductionist?<br />
  • 45. Further Evaluation of Behavioural Approach<br /><ul><li>Experimentally tested
  • 46. Speaks on the present, as well as the past (validity)
  • 47. Effective treatments
  • 48. Accounts for cultural differences
  • 49. Simple model (reductionist)
  • 50. Animal studies
  • 51. Unethical?</li></li></ul><li>Hemsley(1993) suggested schizophrenics cannot distinguish between information that is already stored and new incoming information. As a result, schizophrenics are subjected to sensory overload and do not know which aspects of a situation to attend to and which to ignore. <br />The role of biological factors is acknowledged in this explanation – it says that the condition has always existed, but is worsened by those around them<br />When schizophrenics first hear voices and experience any other worrying sensory experiences, they turn to their friends and relatives to confirm the validity of what they are experiencing. Some people fail to confirm the reality of these experiences, so the schizophrenic comes to believe they must be hiding the truth. <br />Individuals then begin to reject feedback from those around them and develop delusional beliefs that they are being manipulated and persecuted. <br />Yellowleeset al have developed a curious treatment, where patience watch a machine that produces virtual hallucinations, such as hearing the television tell you to kill yourself or one person’s face morphing into another’s. This is to show schizophrenics that their hallucinations are not real, that disbelieving others is a consequence of madness. <br />Psychological Explanation;Cognitive<br />
  • 52. Evaluation of Cognitive Approach<br /><ul><li>Focuses on the current cognitions
  • 53. Plenty of research into the idea
  • 54. Influential and popular model
  • 55. Includes biological and the psychological
  • 56. Empowers the individual to change
  • 57. Ignores the environmental influences
  • 58. Unscientific
  • 59. Blaming the individual can make the disorder worse
  • 60. Is thinking irrational?
  • 61. Which is the cause? Which is the effect?</li></li></ul><li>Psychological Explanation;Sociocultural factors <br />Life events <br />A major stress factor that has been associated with a higher risk of schizophrenic episodes is the occurrence of stressful life events, such as the death of a relative, job loss or the break up of an intimate relationship. It is not known how stress triggers schizophrenia, although high levels of physiological arousal associated with neurotransmitter changes are thought to be involved. <br />Brown and Birley (1968) found that approximately 50% of people experienced a major life event in the 3 weeks prior to a schizophrenic episode, whereas only 12% reported one in the 9 weeks prior to that. <br />Hirsch et al (1996) followed 71 schizophrenic patients over a 48 week period. Life events made a significant cumulative contribution in the 12 months preceding relapse rather than having a more concentrated effect in the period just prior to the schizophrenic episode. <br />Although not all evidence supports the role of life events, in one study it was found that there was no link between life events and the onset of schizophrenia, patients being equally likely to have a major life event or not in the 3 months before the schizophrenic episode. <br />
  • 62. Psychological Explanation;Sociocultural factors <br />Family relationships <br /><ul><li>Double Bind theory – Bateson et al 1956
  • 63. Children who receive contradictory messages from their parents are more likely to develop schizophrenia.
  • 64. Conflicting message = mother says I love you, but turns her head away in disgust. Child received conflicting message about their relationship on different levels.
  • 65. Verbal affection, non-verbal animosity (strong dislike)</li></ul>Bateson et al argued Child’s ability to respond is incapacitated by the contradictions.<br />Prolonged exposure to these interactions prevents the development of a coherent construction of reality.<br />Which in the long run manifests itself as schizophrenic symptoms, e.g. flattened effect, delusions, hallucinations, incoherent thinking and speaking and some cases paranoia. <br />
  • 66. Psychological Explanation;Sociocultural factors <br />Social Labelling<br />Scheff (1999) promoted the labelling theory of schizophrenia. <br />Theory states social groups create the concept of psychiatric deviance by constructing rules for group members to follow.<br />Thus the symptoms of schizophrenia are seen as deviating (going against) from the rules that we attribute to ‘normal’ experience or behaviour.<br />Therefore those who display unusual behaviour are considered deviant and the label schizophrenic may be applied which becomes a self fulfilling prophecy that promotes the development of other symptoms of schizophrenia (Comer 2003).<br />
  • 67. The BiologicalTreatment of Schizophrenia<br />Antipsychotic Drugs <br />Electroconvulsive Therapy (ECT)<br />
  • 68. Biological Treatment;ECT<br />ECT is not considered a first line treatment but may be prescribed in cases where other treatments have failed. <br />It is only measurably effective where symptoms of catatonia are present and in terms of treatment for drug-resistant catatonic schizophrenia<br />It is not otherwise recommended as a treatment for schizophrenia<br />ECT works by using an electrical shock to cause a seizure (a short period of irregular brain activity). <br />This seizure releases a ‘rush’ of chemical neurotransmitters and temporarily alters function (eg. perception/memory etc)<br />
  • 69. Biological Treatment;ECT<br />ECT is given up to 3 or 4 times a week and usually for a maximum of 12 treatments.<br />Before each treatment, an intravenous line is attached and through it the patient will be given an anesthetic (to induce sleep) and a muscle relaxant. <br />Then an electrical shock is applied to the patient’s head (via electrodes). The shock will last only 1 or 2 seconds (high voltage / low amperage) and will make the brain have a seizure. <br />This seizure is controlled by the medicines to stop/reduce the body having a grand muscular spasm.<br />The somewhat dazed patient will th
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