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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. Schizophrenia is one of the most chronic and disabling of the major mental illnesses affecting thought processes<br />In order for a diagnosis to be made, two or more of the symptoms must be present for more than one month along with reduced social functioning<br />The symptoms are separated into two categories; positive and negative. Positive symptoms are an excess or distortion of normal functions and negative symptoms are an diminution or loss of normal functions.<br />Schizophrenia <br />
  • 5. Positive and Negative Symptoms <br />A distinction has been made between type 1 and type 2 schizophrenia. Type 1 is dominated by positive symptoms and type two by the negative.<br />Positive Symptoms<br /><ul><li>Delusions – paranoia, grandiosity
  • 6. Experiences of control – believe under control of alien force (smiling after bad news).
  • 7. Auditory hallucinations – bizarre, unreal perceptions, usually auditory.
  • 8. Thought disturbance and disordered thinking – thoughts have been inserted or withdrawn from the mind.
  • 9. Language impairments
  • 10. Disorganised behaviour
  • 11. catatonia – immobility – echopraxia, echolalia</li></ul>Negative symptoms<br /><ul><li>Reduction in range and intensity of emotional expression, including facial expression, tone of voice etc
  • 12. Alogia – lessening speech fluency
  • 13. Avolition – reduction or inability to take part in goal directed behaviour.
  • 14. Reactivity is not expected
  • 15. Thought blocking
  • 16. Asocial behaviour
  • 17. Emotional blunting
  • 18. Reflects a loss of normal functions
  • 19. Psychomotor – catatonia – immobility and frenetic activity</li></li></ul><li>Subtypes of Schizophrenia<br />
  • 20. Can you think of any issues surrounding the diagnosis of Schizophrenia?<br />General issues; <br />Reliability concerns consistency of measurements, in relation to the classification and diagnosis;<br /><ul><li> inter-rater reliability – whether two or more clinicians make the same diagnosis when independently assessing a patient. Some of this error may be due to the fact that the same patient may give different information to different doctors.
  • 21. Test-retest reliability – whether the same clinician gives the same diagnosis when given the same information
  • 22. Obviously a diagnosis is useless if it fails to be consistent; BECK found 54% consistency when four experienced clinicians diagnosed 153 patients.</li></li></ul><li>Issues surrounding the diagnosis of Schizophrenia<br />There is both evidence for and against the reliability of a diagnosis of schizophrenia;<br />PRO – the diagnosis of schizophrenia has relatively high reliability (+.81)<br />ANTI – Read et al reported that test-retest reliability was as low as +.31 and also described a 1970 study where 194 British and 134 American psychiatrists were asked to provide a diagnosis on the basis of a case description. 69% American’s diagnosed schizophrenia and only 2% of British did. INCONSISTENCY. <br />Despite low reliability, the classification schemes are still useful as they are better than nothing<br />Classification systems are always being improved!<br />
  • 23. Validity<br />Reliability – an unreliable diagnosis cannot be valid<br />Predictive validity – if diagnosis results in successful treatment then the diagnosis must have been valid<br />Aetiological validity – the cause of the disorder should be the same for all the patients in the category<br />Descriptive validity – patients in different diagnostic categories should differ from each other<br />Cultural bias – western classification is culturally bias<br />
  • 24. The BiologicalExplanations of Schizophrenia<br />Genetics<br />Neurochemical & hormones<br />Structural brainabnormalities<br />
  • 25. 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 />1st degree 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 />
  • 26. 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
  • 27. Control group were matched on age, gender, parental socio-economic status and urban/rural residence
  • 28. Children aged between 10-18 years at start of study
  • 29. Schizophrenia diagnosed in 16.2% of high risk group compared to 1.9% in low risk group</li></ul>Sherrington found that chromosome 5 has evidence of susceptible schizophrenia.<br />
  • 30. 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
  • 31. 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.
  • 32. To prove this many studies have been conducted – ALL OF THEM show much higher concordance rate in MZ than DZ twins
  • 33. 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 />
  • 34. 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
  • 35. 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 />High number of receptors in the brain of schizophrenics<br />
  • 36. 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 />
  • 37. <ul><li>Humane approach; poses no blame on the individual or their families – states that the people who become ill are purely “unlucky”
  • 38. Tends to provoke little fear or stigma
  • 39. Effective treatments
  • 40. Well established scientific treatments
  • 41. Reductionist approach
  • 42. Animal studies
  • 43. Relies on self report
  • 44. Treats symptoms, not causes</li></ul>Evaluation of Biological Approach<br />
  • 45. 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 />
  • 46. ThePsychologicalExplanations of Schizophrenia<br />Behavioural<br />Cognitive<br />Psychodynamic <br />socio-cultural <br />
  • 47. Freud believed that schizophrenia was the result of two related processes (sexual abuse)<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 />Oltmanns et 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 />
  • 48. Evaluation of Psychodynamic Approach<br /><ul><li>Stresses the importance of psychological factors (very freud)
  • 49. Stresses the importance of childhood
  • 50. Influential theory
  • 51. Importance of the unconscious mind
  • 52. The importance of childhood is sometimes overstressed
  • 53. Problems validating the study (no studies have been carried out as proof)
  • 54. Poor methodology
  • 55. 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 />
  • 56. 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 />
  • 57. Further Evaluation of Behavioural Approach<br /><ul><li>Experimentally tested
  • 58. Speaks on the present, as well as the past (validity)
  • 59. Effective treatments
  • 60. Accounts for cultural differences
  • 61. Simple model (reductionist)
  • 62. Animal studies
  • 63. 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 />Yellowlees et 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 />
  • 64. Evaluation of Cognitive Approach<br /><ul><li>Focuses on the current cognitions
  • 65. Plenty of research into the idea
  • 66. Influential and popular model
  • 67. Includes biological and the psychological
  • 68. Empowers the individual to change
  • 69. Ignores the environmental influences
  • 70. Unscientific
  • 71. Blaming the individual can make the disorder worse
  • 72. Is thinking irrational?
  • 73. 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 />
  • 74. Psychological Explanation;Sociocultural factors <br />Family relationships <br /><ul><li>Double Bind theory – Bateson et al 1956
  • 75. Children who receive contradictory messages from their parents are more likely to develop schizophrenia.
  • 76. Conflicting message = mother says I love you, but turns her head away in disgust. Child received conflicting message about their relationship on different levels.
  • 77. 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
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