PSYCHOPATHOLOGY

Schizophrenia

CLASSIFICATION AND DIAGNOSIS OF

SCHIZOPHRENIA
The characteristics of schizophrenia
Schizophrenia is characterised by a profound disruption of cognition and emotion, which affects a persons language, thought, perception, affect and even sense of self.

Diagnostic criteria
Symptoms of schizophrenia are divided into positive and negative symptoms. Positive symptoms are those that appear to reflect an excess or distortion of normal functions. Negative symptoms are those that appear 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 has invaded 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 Disordered thinking Feeling that thoughts are being inserted or withdrawn from the mind.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 believe their thoughts are being broadcast. 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.

Negative Symptoms

ISSUES OF RELIABILITY AND VALIDITY

Reliability
In search of schizophrenia: Can psychiatrists agree on the same diagnosis when independently assessing patients? The publication on the DSM-III was designed to provide a more reliable system for classifying psychiatric disorders. This lead to claims of a reliable classification system, leading to a much greater agreement of who did and didnt have schizophrenia. However 30 years later there is still little evidence that the DSM is routinely used. Whaley (2001) found that inter-rater reliability in correlations of diagnosis was as low as 0.11. Unreliable symptoms: Klosterktter et al assessed 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. However it is also argued that a diagnosis of schizophrenia is too different for each individual, that diagnostic categories are not useful. 50 senior psychiatrists were asked to define between bizarre and nonbizarre symptoms the inter-rater reliability correlations were only around 0.40, concluding that the central diagnostic lack sufficient reliability for it to be a reliable method for defining schizophrenic patients.

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 from other psychotic disorders. (First rank symptoms, experiences of control / disordered thinking / hallucinations). These symptoms of schizophrenia could make diagnosis more reliable. Yet it has been pointed 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 same outcomes. 20% recover to previous level of functioning, 10% achieve significant and lasting improvement, 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 outcome such as gender and social skills and family tolerance of the patient.

BIOLOGICAL EXPLANATIONS OF
SCHIZOPHRENIA
Genetic Factors Commentary Genetic Factors Family Studies their Twin studies: Gottesman found individuals who have schizophrenia and determine whether that biological relatives are affected more than non-biological relatives. These studies have established

A crucial assumption is common among biological of identical and non-identical twins are schizophrenia is more that the environments relatives of a person with schizophrenia. (Children with equivalent. Therefore it is assumed that the greater concordance due schizophrenia between a schizophrenic parent have a concordance rate of 46%), this could be for to common rearing patters identical twins is because of greater genetic similarity rather than environmental similarity. or heredity. Joseph found that allow for researchers to investigate the contribution of geneticthe same Twin studies: Twins identical twins are treated more similarly, encounter and environmental environmentsIf the identical twins concordance rate is higher than non-identical twins then this suggests influences. (doing things together) and experience more identity confusion (frequently that the similarity is due to genetic factors. individuals) as apposed the data from prior 2001 being treated at the twins rather than twoJoseph (2004) calculated thatto non-identical twins. suggests that the concordance rate of identical twins was 40.4% and non-identical was 7.4%. However Therefore Joseph argues that the differences in concordance rates between identical and more recent studies, where nothing other than know whether the twins are identical or non-identical non-identical twins is due tothe researcher doesnt the environmental factors.

Adoption Studies identical twins is still higher than non-identical twins. concordance rate for

tended to report a lower concordance rate for identical twins (researcher bias), however despite this the

A centralstudies: Because of the difficulties of environmental influencesnot those who share genes i.e. Adoption assumption of adoption studies is that adoptees are on selectively placed and Theenvironment, studies ofa child whose mother was who have been reared apart are used. a parents who adopt genetically related individuals schizophrenic are no different to Tienari et adoptive parents who adoptof 164 adoptees whose biological is normal. Joseph claims that it is al whose findings were that children whose background mothers were diagnosed with schizophrenia, 11 also received potential of schizophrenia, compared to 4 been informed of the unlikely that this is the case, as a diagnosisadoptive parents would haveof the 197 adoptees born to non-schizophrenic children prior to adoption. genetic background ofmothers. These findings conclude that the genetic liability to schizophrenia had
been decisively confirmed.

BIOLOGICAL EXPLANATIONS OF
SCHIZOPHRENIA
The dopamine Commentary hypothesis Dopamine is a neurotransmitter that operates in The dopamine hypothesis states The dopamine hypothesis fire toothe brain. often, leading to the characteristicthat messages from neurons that transmit dopamine easily or symptoms of
schizophrenia. Schizophrenics are studies Post-mortem thought to have abnormally high levels of D receptors on receiving neurons, resulting in more dopamine binding and therefore more neurons firing. A problem with the dopamine hypothesis is that the drugs used to treat schizophrenia by Dopamine neurons play a key can actually increase it as the neurons struggle to compensate for blocking dopamine activity role in guiding attention, so disturbances in this process may well lead to the problems relating to attention, out post-mortem studies in people with schizophrenia. The key the deficiency. Haracz carried perception and thought foundof schizophrenics, and found that role played by dopamine in schizophrenia is as followed: those who had received antipsychotic drugs shortly before death had higher levels of Amphetamines This a drug with special relevance for dopamine than patientsiswho werent taking the drugs.our understanding of schizophrenia. It

Evidence from neuro-imaging research dopamine in the brain. By reducing the Antipsychotic Drugs These drugs block the activity of

stimulates the nerve cells containing dopamine causing the synapse to be flooded with dopamine. Large doses of the drug can cause hallucinations and delusions.

Sophisticated neuro-imaging techniques such as PET scans have failed todelusions. Because stimulation of dopamine, the drugs eliminate symptoms such as hallucinations and provide convincing evidence of the action of dopamine and eliminate brains of individuals with it suggests these drugs can block altered dopamine activity in the hallucinations and delusions, that dopamine is a contributory factor 2000) schizophrenia. (Copolov and Crook, to the disorder.
Parkinsons Disease Low levels of dopamine are found in people who suffer from Parkinsons disease. It was found that people Enlarged Ventricleswho were taking the drug to raise their dopamine levels, were having schizophrenic symptoms. (Grilly, 2002)

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

PSYCHOLOGICAL EXPLANATIONS OF
SCHIZOPHRENIA
Psychological Theories Psychodynamic Cognitive
This explanation of schizophrenia acknowledges the role of biological factors in causing the Freud (1924) believed that schizophrenia was the result of two related processes, regression initialto a pre-ego stage andof schizophrenia, but claims that furtherthe world of the disorder sensory experiences attempts to re-establish ego control. If features of the appear as individuals attemptparticularly harsh, for instance their parents were cold or schizophrenic had been to understand the experiences. When schizophrenics first experience voicesindividual may regress to this early stage in their development before the of uncaring, an / worrying sensory experiences, they turn to others to confirm the validity whatego was properly formed and people they have developed a realistic awareness of so the they are experiencing. Other before fail to confirm the validity of the experiences, the schizophrenicworld. Freud saw schizophrenia as anhiding thestage wherebegin to reject as external comes to believe that the others are infantile truth. They symptoms such feedback from those around them a primitive condition, and symptomsthey are being delusions of grandeur reflect and develop delusional beliefs that such as auditory manipulated by others. hallucinations reflecting the persons attempts to re-establish ego control.

Psychotherapeutic explanations Cognitive Explanations

There lot of evidence of a physical basis for the specific deficits associated with There isis no research evidence to support Freudscognitive idea of schizophrenia, except that many psychoanalysts have claimed, like him, that disordered family patterns dopamine in schizophrenia. Research by Meyer-Lindenberg et al, found a link between excess are the cause for the disorder. Fromm-Reichmann described that madness is a mothers or the prefrontal cortex and working memory. The suggestionschizophrenogenic consequence of families who are rejecting, overprotective, dominant and from treatment. Yellowlees disbelieving others receives support from a recent suggestionmoralistic as contributory et al haveinfluences to developing schizophrenia.virtual hallucinations, suchparents of the TV tell developed a machine which produces Studies have shown that as hearing schizophrenic or one persons face morphing into of other kind of patients, particularly you to kill yourself, patients act differently from parentsanother. The intention is to show when their schizophrenic offspring is present (Oltmanns et evidence that it will produce a schizophrenics that their hallucinations are not real. There is no al, 1999) but this is likely to be a consequence of successful treatment. their childrens problem.

PSYCHOLOGICAL EXPLANATIONS OF
SCHIZOPHRENIA
Socio-Cultural Factors Life events and schizophrenia
The occurrence of stressful life events had been linked to a greater risk of schizophrenic symptoms. These are discrete stresses such as death of a close relative or the break up of a relationship. Brown and Birley found that, prior to a schizophrenic episode, patients who had previously experienced schizophrenia reported twice as many stressful life evens compared to a healthy control group. The mechanisms which stress factors trigger schizophrenia are not know, although high levels of physiological arousal associated with neurotransmitter 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 link between life events and schizophrenia. Patients were not more likely to have had a major stressful life event in the three months preceding the onset of their illness. In a prospective part of the study, those patients who had experienced a major life event went on to have a lower likelihood of relapse. Evidence that does suggest a link between life events and the onset of schizophrenia is only correlational. It could be that the beginnings of the disorder (e.g. Erratic behaviour) were the cause of the major life events. 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.

BIOLOGICAL THERAPIES FOR SCHIZOPHRENIA

Commentary of conventional antipsychotics Appropriateness of atypical antipsychotics Relapse likelihood of tardive dyskinesia significant difference in terms of relapse rates between treatment is Antipsychotic Medication Lower rates A review by Davis et al found a One of the main claims of atypical antipsychotics and
placebo groups in every study reviewed, demonstrating the therapeutic effectiveness of these drugs. They found that the lower likelihood of the patients whose person with the wasasupported in asstudyas they possibly Antipsychotic 55% of tardive dyskinesia. were claim disorder function a well by Jeste et al relapse occurred in medication helps the drugs This replaced by placebo, and 19% of those who remained on which found tardive dyskinesia increasing their people after 9 monthswellbeing. Conventional the drug. in their life, as well as rates in 30% of feelings of subjective of treatment with can Other factors are important one of but just 5% for thoseal review found that antipsychotic drugs did make conventional antipsychotics, the studies in the Davis etthe positive symptoms of schizophrenia a antipsychotics are used primarily to combat treated with atypical antipsychotics. significant difference, but only for those living with the hostility and criticism in their home environment, the relapse in Fewer side effects and thought disturbances placebo condition the relapse rate was 92%.the those (hallucinations Atypical antipsychotics may ultimately be more appropriate in For such conditions on medication was 53%, but for those indeaths and psychosocial dopamine system) The Critics argue that if side effects, the from an over-reactive treatment of schizophrenia becauseno significantfewer side effects, which in turn means that but atypical antipsychotic there taken combat thesea between those on medicationits relapse) living in a supportive environment, werewas there are differencecost-benefit analysisschizophrenia, and consequences drugs also into account, positive symptoms of of (12% those there are (15% relapse).continue some beneficial and therefore see symptoms as in a are more likely to patients placeboclaims that they havetheir medicationseffects on negativethe benefits. well.

ETHICAL ISSUES: INHUMANE TREATMENT?

advantages would most probably be negative. In the US recently a settlement was awarded to Conventional antipsychotic antipsychotics Appropriateness of conventional drugs a tardive dyskinesia sufferer on the basis of the Human Rights Act, which states no side shall including tardive dyskinesia Tardive dyskinesia - Conventional antipsychotics may have worrying one effects,be subjected to Basic mechanism of of the psychotic drugs is toand feet). Above 30% of of dopamine so reducewill (uncontrollable inhuman or degrading treatment or punishment (Ross people taking antipsychotics the movements anti lips, tongue, face, hands reduce the effects and Read symptoms of schizophrenia. Conventional antipsychotics bind to the dopamine receptors, develop tardive dyskinesia, and it is irreversible in 75% of cases. 2004) Motivational deficitssimulate them, argue that being prescribed medication reinforcesthe view that there is but do not Ross and Read thus blocking their action. By reducing the simulation of something wrong with you. Preventing the individual from thinking about possible stressors (life history / current dopamine in the brain this can eliminate hallucinations and delusions.
circumstances) which might be a trigger for their condition. This reduces their motivations to look for possible solutions that might alleviate these stressors and reduce their suffering. Atypical antipsychotic drugs

Atypical antipsychotic drugs also act on Effectiveness of atypical antipsychotics the dopamine system, but are thought to block Atypical versus conventional antipsychotics- A too. It has been argued that they superiorityonly temporarily serotonin receptors in the brain meta-analysis published showed that the help by of these drugs was only small. This analysis D2 receptors and then rapidly detaching themselves to allow normal occupying the found that two of the new drugs tested were only slightly more effective than conventional antipsychotics, while the other two were no more effective. dopamine transition. There is thought to be lower levels of side effects from with the Effectiveness with negative symptoms The claim that atypical antipsychotics are particularly effectiveatypicalnegative antipsychotics than very small support. In the Leucht et symptoms of schizophrenia hasconventional antipsychotics. al study two of the atypical drugs were slightly more
effective than the conventional antipsychotics, one was as effective and one slightly worse.

ELECTROCONVULSIVE THERAPY (ECT)

ECT
Historical Origins - ECT Effectiveness of The idea that schizophrenia could somehow be cured by inducing
seizures study which compared ECT with simulated ECT (the for schizophrenia) was An Americanfollowed reports that dementia praecox (an early name patients are anesthetised but raregiven the electric shock, concluded that ECT produced resultswith dementiadifferent not in patients with severe epilepsy, and that seizures in patients that were no praecox somehow than antipsychotic medication. However an Indian study the clinical use of from or worsereduced the symptoms of the disorder. The first studies offound no difference in this technique specifically for the treatment of schizophrenia were disappointing, with symptom reduction between 36 schizophrenia patients given either ECT or simulated ECT lower rates of recovery for ECT patients compared to those who did not receive ECT (Karagulla, 1950) Appropriateness of ECT Because there are ECT? - risks associated with ECT, including the scalp to create a What happens insignificantAn electric current is passed through memory dysfunction, brain damage and even death, the use of thisacting barbiturate, so they are unconscious before seizure. The patient is given a short technique had declined. In the UK, the decline between 1979 and 1999given,59% (Read, 2004) a nerve blocking agent to paralyse the the electric shock is was then they are given muscles of the body to prevent them from contracting during a seizure and preventing fractures. The seizures last up to a minute, which effects the entire brain. A patient usually requires between 3 and 15 treatments.

PSYCHOLOGICAL THERAPIES FOR

SCHIZOPHRENIA
Psychological Therapies
Cognitive-behavioural therapy (CBT)
Event: See a man outside house Interpretat ion: Hes following me
Behaviour: Take evasive action, avoid going out.

Effectiveness of CBT

CBT it used to help schizophrenic patients recognise their delusional a significantcorrecton improving the Supporting Research - Research had tended to show that CBT has beliefs and effect them. symptoms of patients with schizophrenia. Gould et back the origins of their symptoms in meta-analysis CBT Techniques patients are encouraged to trace al found that all seven studies in their order to get a better reported a how the symptoms might have developed. The symptoms of schizophrenia after treatment. of their idea of statistically significant decrease in the positive patient is encouraged to evaluate the content How much is or of to the effectsvoices they hear, Mostto consider the effectiveness of can test the validity of their delusions due any internal of CBT alone? - and studies of ways in which they CBT have been conducted with patients treated at the same time with antipsychoticassignments Therefore it is difficult to asses level of faulty beliefs. Patients might also be set behavioural medication. with the aim of improving their the effectiveness of CBT without antipsychotic medication. problems is often the consequence of disordered functioning. Learning maladaptive responses to lifes thinking by the schizophrenic. During CBT, the therapist lets the patient develop their own alternative explanations and coping CBT Appropriateness ofstrategies that are already present in the patients mind. Negative Symptoms Outcome Studies CBT for schizophrenia works by trying to generate less distressing explanations for psychotic experiences, rather than trying to eliminate them completely. Negative symptoms may serve a useful Outcome for the person and so can bepatient does as safety behaviours. For example, within a psychiatric form function studies measure how well a understood after a particular treatment, compared with the accepted of treatment for that condition. Outcome studies seen as a way of avoiding making receive symptoms setting, the strong expression of emotions might be of CBT suggests that patients who positive cognitive therapy experience fewer hallucinations hope of alleviating recover their functioning to a greater extent than those worse. CBT therefore, offers some and delusions and these maladaptive thought processes. who receive The use of CBT with medication seems al have that benefits in also of a reduction of Who benefits? -antipsychotic medication alone. Drury et to foundbenefits, but it isterms believed that not positive symptoms schizophrenia may benefit from CBT. In for patients given a combination of antipsychotic everyone withand a 25-50% reduction in recovery time a study of 142 schizophrenic patients in Hampshire, medication and CBT. were not suitable for al noted that psychiatrists believed that would not fully engage found that many patients A study by Kuipers etCBT becausethere were lower patients drop-out rates and greater patient satisfaction when CBT was less in addition to antipsychotic medication. with the therapy. Older patients were deemed usedsuitable that younger patients.