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Schizophrenia - Coggle Diagram

- - - - Dopamine antagonist
      - Dosage
        
        1000mg
        
        Generally to 400-800mg/d
      - Effects
        
        Reduces hallucinations
        
        Sedative effect
        
        Side effect
      - Administration
        
        Oral
        
        Injection
        
        Syrup
      - Thornley et al.(2003) :check:
        
        13 trials with 1121 participants
        
        Better functioning
        
        Reduced symptom severity
        
        Chlorpromazine vs control (placebo)
        
        3 trials with 512 participants
        
        Lower relapse rate
      - Kapur et al. (2000)
        
        Efficacy threshold
        
        60-75% of D2 receptors
        
        Undesirable side effects on other dopamine pathways
  - - - Dosage
        
        300-450mg/d
      - Agranulocytosis
      - Action
        
        Serotonin
        
        Glutamate
        
        Dopamine
      - Herbert Meltzer (2012) :check:
        
        Effective in 30-50% of treatment resistant cases
    - - Dosage
        
        Generally 4-8mg
        
        Maximum 12mg
      - Stronger bond than Clozapine
      - Fewer side effects (Meltzer 2013) :check::
      - Administration
        
        Tablets
        
        Injection
        
        Syrup
    - - Meta analysis (15 studies)
      - Efficacy of typical vs atypical
      - No sig. difference on symptoms
      - Less side effects for atypical antipsychotics
        
        Better adherence
    - - Rapid dissociation vs typcial antipsychotics
      - Typical antipsychotics block only D2 receptors
      - Atypical antipsychotics have high affinity for serotonin receptors, lower for D2 receptors
  - - - Agitation
      - Sleepiness
      - Stiff jaw
      - Weight gain
      - Itchy skin
      - Diziness
    - - Dopamine supersensitivity
        
        Lip smacking
        
        Blinking
        
        Grimacing
    - - Hypothalamus (body systems)
        
        High temperature
        
        Coma
        
        Delerium
        
        Fatal - 0.1-2% occurence
    - - Greater than 50% experience side effects
      - Motor activity
  - - - Calming effect of antipsychotics -> easy to demonstrate positive effects
        
        Chemical cosh argument (Moncrieff, 2013) :red_cross:
        
        Ethical concerns of usage of antipsychotics used to 'calm' patients
      - Most study short-term vs long-term effects
      - Successful trials have been published multiple times - exaggerated positive evidence?
- - - - Activating event
      - Beliefs
      - Consequences
  - - - Group vs individual
      - Double bind theory
      - Schizophregenic mother
      - Expressed emotion
    - - Forming a therapeutic alliance with all family
      - Reducing stress of caring for relative
      - Improving problem solving
      - Helping family members achieving balance
      - Improving family members balance
    - - Phase 1
        
        Basic emotional and practical support
        
        Information sharing
      - Phase 2
        
        Identifying resources
        
        Do's and Don'ts for family members
      - Phase 3
        
        Encourages mutual understanding
        
        Creates a 'safe' space
      - Phase 4
        
        Identify unhelpful patterns of interaction
      - Phase 5
        
        Skills training
        
        Stress management skills
      - Phase 6
        
        Relapse prevention
      - Phase 7
        
        Maintenance for future
  - - - Key benefits
        
        Counteracts unhelpful lifestyle habits
        
        Normalises behaviours required
        
        Reinforcing targeted behaviour to improve QOL
      - Focuses on helping institutionalized
        
        Targets consequences of institutionalisation - Matson et al. (2016)
        
        Condition-related (apathy)
        
        Personal care
        
        Social behaviours
    - - Skinnerian principles
        
        Behavioural therapy
        
        Operant conditioning
      - Reinforcers
        
        Tokens are secondary (generalised) reinforcers
        
        Meaningful rewards are primary reinforcers
        
        Food
        
        Privileges
        
        Sran & Borreno (2010)
        
        Compared general vs singular reinforcers
        
        General tokens (exchangeable for variety of food items) were induced higher response rates than those exchangeable for just one preferably food item
        
        Frequency
        
        High frequency exchange during early stages helps reinforce behaviour
        
        Kazdin (1977) found if more time passes between exchange of token and collection of item, effectiveness can decrease
    - - Research support
        
        Ayllon & Azrin (1968)
        
        Gave out 'One gift' tokens on female Sz ward
        
        Domestic chores e.g. making bed
        
        Exchanged for privileges e.g. watching a movie
        
        Dramatically increased target behaviours
        
        Dickerson et al. (2005)
        
        11 of 13 studies found beneficial effect of token economies
        
        Several methodological shortcomings, limits impact assessment of this impact
        
        Concluded TE help improve adaptive behaviours in Sz patients
        
        Comer (2013)
        
        Major issue with many studies is lack of control condition
        
        Generally all enrolled in ward, not experimental vs control grp
        
        Is staff attention the confounding variable for example?
      - Ethical concerns
        
        Basic human rights should not be manipulated?
        
        Clinicians exert control
      - Efficacy
        
        Real wold utility? (Corrigan, 1991)
        
        Highly controlled ward environment
        
        TE unlikely effective in outside of inpatient setting
        
        Conclusive effect?
        
        McMonagle & Sultana (2000) still suggest importance of TE if RCTs can be provided
        
        Recommend developing countries are opportunity to answer this question where TE still used
        
        Few RCTs generally considered unacceptable level of evidence
  - - - Jauhar et al. (2014) :check:
        
        small significant effect on
        
        positive symptoms
        
        negative symptoms
        
        34 studies
      - Strengths & limitations
        
        Limitations :red_cross:
        
        Ethical
        
        Addressing symptoms vs challenging freedom of thought
        
        Long treatment length
        
        Requires engagement
        
        Negative symptoms to unwillingness
        
        Expensive
        
        Strengths :check::
        
        Doesn't produce side-effects
      - Pontillo et al. (2016) :check:
        
        Reductions in frequency and severity of auditory hallucinations
      - Thomas (2015) :red_cross:
        
        Different studies involve different techniques
        
        Different individuals have different combinations of +ve and -ve symptoms
        
        Hard to determine efficacy for a given individual
      - Sensky et al. (2000) :check:
        
        Drug-resistant patients
        
        Reduction in +ve & -ve symptoms even at 9 month follow up
        
        19 sessions of CBT
    - - Pharoah et al. (2010) :check:
        
        Moderate evidence
        
        Improves QOL
        
        Reduces hospital readmission
        
        Overall
        
        Inconsistent findings
        
        Weak evidence
      - Lobban et al. (2013) :check:
        
        50 family therapy studies
        
        60% showed sig. positive impact on one of
        
        Coping
        
        problem-solving
        
        family functioning
        
        relationship quality
      - Garety et al. (2008) :red_cross:
        
        No better outcomes for family therapy than families with carers
        
        low relapse rates vs 'no carer' group
        
        Low levels of EE in carers indicates potential cultural change in approach to Sz
    - - McMonagle and Sultana (2009) :red_cross:
        
        3 studies
        
        110 patients
        
        Randomly allocated
        
        Only one showed improvement in symptoms
        
        None yielded behaviour change
      - Ethical issues :red_cross:
        
        Milder symptoms = more priveleges
        
        Restricting rewards for those with (more serious) mental disorders
        
        Are behavioural conditioning techniques degrading to patients?
      - Alternatives :red_cross:
        
        Art therapy - Chiang et al. (2019)
        
        High-gain, low risk
        
        Modest effect, but pleasant & ethical appraoch
      - Effectiveness
        
        Low in those with strong negative symptoms
      - Comer (2013) :red_cross:
        
        In reality often lack of control group
        
        Difficult to eradicate variables such as staff attention
      - Corrigan (1991) :red_cross:
        
        Impractical outside inpatient environment
        
        Lack external relevance
      - Cooper et al. (2007)
        
        Individualised and tailored to patient :check:
        
        Requires good therapeutic realtionship :red_cross:
      - Glowacki et al. (2016) :check:
        
        studies between 1999-2013
        
        seven high quality studies in hostpital settings
        
        all showed reduction in negative symptoms and a decline in unwanted behaviours
      - Dickerson et al. (2005) :check:
        
        11 of 13 studies reviewed had beneficial impacts directly attributable to token economies
        
        Some studies had major methodological shortcomings
    - - Improve QOL
      - Do not 'cure'
    - - Often lacks randomisation
      - Often no control group
- - - - Fromm-Reichmann (1948)
        
        Family environment
        
        Tension
        
        Secrecy
      - Parental characteristics
        
        Mother
        
        Cold
        
        Rejecting
        
        Controlling
        
        Father
        
        Passive
      - Paranoid delusions
    - - Characteristics
        
        A communication style...
        
        Hyper-critical
        
        Emotional/exaggerated over-involvment
        
        Hostile manner
        
        Negative emotional climate
      - Supporting evidence
        
        Kuipers et al. (1983)
        
        Found high EE relatives talked more and listened less
        
        Linszen et al. (1997)
        
        EE increases relapse rates
        
        Patients returning to families are 4x more likely to relapse than those in families with low EE
        
        Butzlaff & Hooley (1998)
        
        Meta-analysis of 27 studies
        
        Relapse into Sz is sig. more likely in families with expressed emotion
    - - Bateson et al. (1956, 1972)
        
        Contradictory messages
        
        Flattened affect
        
        Withdrawal
        
        Disorganised thinking
        
        Paranoia
        
        Environment
        
        Unable to comment, seek clarification
        
        Internally incoherent construction of reality
        
        considered only a risk factor, not causal
    - - Insecure attachments - Read et al. (2005)
        
        Adults with Sz disproportionally likely to have insecure attachment
        
        69% of women and 59% of men with Sz have history of physical/sexual abuse
      - Direction of causality
      - Tienari (2004)
        
        36.8% vs 5.8% Sz in unhealth vs healthy families
        
        Suggests family dysfunction plays a role
      - Validity (Harrington, 2012) https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60546-7/fulltext
  - - - Issues with Metarepresentation
        
        Lack of ability to identify thoughts/actions as your own
        
        Results in delusions and feelings that thoughts and actions are controlled by an outside force
      - Lack of central control
        
        Frith (1979)
        
        Difficulty suppressing automatic actions and speech
        
        Explains
        
        Automatic urges - delusions
        
        Speech contol -> speech derailment
      - Evaluation
        
        +ve evidence for dysfunctional thought processing
        
        Stirling et al. (2006) :check:
        
        Stroop test
        
        30 patients Sz
        
        18 patients control
        
        Sz significantly slower (2x as long as control)
        
        Frith (1992) :check:
        
        30 patients with Sz
        
        PET scans
        
        Suggest biologial differences of Sz
        
        Decreased blood flow in frontal cortex assoc. with Avolition
        
        Increased activity in temporal lobe assoc. with those with reality distortion
        
        :red_cross: Only addresses how patients with Sz think, doesn't explin cause
        
        :red_cross: Explains certain (positive) symptoms better than others (e.g. delusions)
        
        :red_cross: Is a reductionist explanation looking at a complex disorder with only individual cognitive symptoms
      - Attention deficit theory
        
        Frith (1979)
        
        Sz unable to filter pre-conscious thoughts
        
        Conscious mind over-loaded
        
        Explains +ve symptoms
        
        Hallucinations
        
        Delusions
- - - - Hallucinations
      - Delusions
      - Speech disorganisation
    - - Avolition
      - Speech poverty
  - - - 2 or more negative symptoms
      - at least 1 month
    - - 2 or more negative + 1 positive symptom
      - at least 6 months
    - - Reliability
        
        Chenieux et al. (2009)
        
        2 psychiatrists diagnosed 100 patients usings DSM + ICD
        
        Psychiatrist 1
        
        DSM - 26
        
        ICD - 44
        
        Psychiatrist 2
        
        DSM - 13
        
        ICD - 24
        
        Regier et al. (2013)
        
        kappa score of 0.46
        
        kappa score 0.7 = good
        
        Whaley (2001)
        
        Inter-rater reliability as low as 0.11
      - Validity
      - Co-morbidity - Buckley et al. (2009)
        
        depression in 50%
        
        substance abuse in 47%
        
        OCD in 23%
        
        PTSD in 29%
      - Symptom overlap
        
        Depression
        
        PTSD
        
        Bipolar disorder
      - Bias
        
        Gender bias - Longenecker et al. (2010)
        
        1980 onwards, greater prevalence in men
        
        Cultural bias
        
        Escobar (2012) suggest white Psychiatrists diagnosing black people
        
        Over-interpret symptoms
        
        Distrust honesty
        
        Copeland (1971)
        
        134 US Psychiatrists
        
        194 British Psychiatrists
        
        69% US vs 2% GBR diagnosed patient description with Schizophrenia
        
        Luhrmann et al. (2015)
        
        60 adults w/ Schizophrenia
        
        Ghana - describe positive experiences
        
        India - describe positive experiences
        
        US - voices considered hateful/violent
- - - - Ripke et al. (2014)
        
        36,000 schizophrenia cases
        
        108 genetic loci associated with development of schizophrenia
        
        Different genetic influences
        
        Nervous system
        
        Immune system
        
        Aetiologically heterogenous
    - - Adoption studies
        
        Tienari (2004) - Children of schizophrenic mothers adopted out
        
        Healthy family env - 5.8% schiz
        
        Unhealthy families - 38% schizophrenia
      - Mutation
        
        Brown et al., 2002
        
        +ve correlations between paternal age (increased risk of sperm mutation) and risk of schizophrenia
        
        0.7% in fathers under 25 yo :arrow_right: 2% in fathers >50yo
      - Environmental influences
    - - Gottesman (1991)
        
        Concordance rate
        
        48% MZ twins
        
        1% gen. pop
      - Hikler et al (2018) Concordance rate
        
        33% MZ twins
        
        7% DZ twins
  - - - Neurotransmitters
        
        Hypodopaminergia (cortex) Davis et al. (1991)
        
        Goldman-Rakic et al. (2004)
        
        Low dopamine in prefrontal cortex PET scans (Patel et al., 2010)
        
        Poor thinking/decision making
        
        Revised dopamine hypothesis (Davis & Kahn, 1991)
        
        mesolimbic pathway
        
        Hyperdopaminergia (sub-cortex)
        
        Excess dopamine in Broca's area
        
        Auditory hallucinations
        
        speech poverty
    - - Hallucinations
        
        Allen et al. (2007)
        
        Anterior cingulate gyrus
        
        Superior temporal lobe
    - - Avolition
        
        Juckel et al. (2006)
        
        Ventral striatum
        
        Negative correlation
    - - Dopamine agonists (L-Dopa)
        
        Creates schizophrenic symptoms in healthy patients
      - Antipsychotic drugs
        
        Leucht et al.
        
        meta-analysis (212 studies)
        
        effectiveness of drug treatments that normalise dopamine levels
        
        Suggests a biological mechanism/link for schizophrenia
      - Glutamate
        
        Associated with attention/learning/memory
        
        Found in low levels in people with schizophrenia
      - Correlation-causation
      - Noll (2009) :red_cross:
        
        Drugs don't alleviate symptoms (hallucinations and delusions) in 1/3rd of patients
        
        Hallucinations and delusions present despite dopamine levels being normal
        
        Dopamine not the sole cause of positive symptoms, other neurotransmitter systems (independent of dopaminergic system) are responsible
      - Vita et al. (2012) :check: - Meta analysis of grey matter deficits
        
        19 studies found Sz patients had greater reduction in cortical grey matter over time compared to controls
        
        Reduction specific to
        
        Frontal lobes
        
        Parietal lobes
        
        Temporal lobes
      - Addington et al. (2015) - Treatment implications
        
        Longitudinal study uses different assessments
        
        neural correlates can help detect need for early interventions
        
        'treatment as prevention' - allowing at risk patients to be treated before psychosis develops.
    - - Johnstone (1976)
        
        Schizophrenia patients with enlarged ventricles
        
        Torrey (2002) :check:
        
        15% enlargement of ventricles in schizophrenics
        
        Schizophrenic brains lighter than controls
- - - - Meehl's model (1962)
        
        Biologically based
        
        Schizogene
        
        Entirely genetic
    - - Modern stress
        
        stress was traditionally psychological
        
        cannabis use interference with dopamine system
      - Ripke et al (2014)
        
        No single 'schizogene'
        
        Polygenetic
        
        108 genetic loci
        
        Aetiologically heterogenous
      - Ingram and Luxton (2005)
        
        range of factors involved like psychological trauma :
        
        trauma becomes the diathesis (vulnerability) rather than the stressor
      - Read et al. (2001)
        
        neurodevelopmental model
        
        trauma alters the developing brain
        
        e.g. child abuse might alter the HPA (hypothalamic-pituitary-adrenal) system making it over-active
      - Tienari et al. (2004) 20,000 Finnish mothers with schizophrenia
        
        Comparison
        
        Children with mothers with schizophrenia
        
        Adopted away - 145
        
        11
        
        Control group with no family history
        
        158
        
        3
        
        Assessment
        
        12 years
        
        21 years
        
        Family functioning - OULU Family rating scale (OPAS)
        
        Scoring
        
        High - unhealthy environment
        
        Low - healthy environment
        
        Empathy
        
        Offspring conflict
        
        Insecurity
        
        14 developed schizophrenia
        
        Low OPAS ratings were protective
        
        High OPAS ratings predictive of schizophrenia in high risk individuals
        
        Evaluation
        
        OPAS assessed at one time point, which fails to reflect developmental changes in family function over time :red_cross:
        
        Reciprocal relationship between adoptees and adoptive family makes causal relationships difficult to determine :red_cross:
    - - Urbanisation
        
        Vassos et al. (2012) Risk in urban env. 2.37x higher than in rural :check:
        
        Romans-Clarkson et al. (1990) found no urban rural differences in mental health in NZ women :flag-nz: :female_sign: :red_cross:
        
        Paykel et al. (2000) found differences but these disappeared when controlling for socio-economic differences :red_cross:
        
        The suggestion that urbanisation and social adversity are synonymous is an oversimplification
      - Diathesis is not exclusively genetic
        
        Verdoux et al. (1998) :check:
        
        Obstetric complications increases risk of Sz 4x
        
        Weinberger (1995) :red_cross:
        
        Birth complications and neurological abnormalities are caused by compromised foetus
      - Causal stress
        
        Hammen (1992)
        
        Maladaptive coping skills > compromised reslience > :arrow_up: vulnerability
        
        Rather than an individual stressful event 'triggering' Sz
      - Implications for treatment
        
        Borglum et al. (2014)
        
        Women with CMV during pregnancy and gene defect present in both mother and child more likely to develop Sz
        
        Antiviral medicine during pregnancy if carriers of gene defect
      - Gottesman (1991)
        
        Concordance rates
        
        MZ - 48%
        
        DZ - 17%
        
        Gen. pop. - 1%
      - Tarrier (1998) :check:
        
        Routine treatment (antipsychotics only)
        
        Routine (antipsychotics + CBT)
        
        Significant improvement in positive symtpoms
        
        Fewer days in hospital receiving care
  - - - Antipsychotics
      - CBT
    - - Biological & Psychological intervention compatibility