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Schizophrenia - Coggle Diagram

- - - - Delusions of persecution - beliefs about people being out to get them
      - Delusions of grandeur - beliefs of being powerful and important
      - Beliefs which couldn't possibly be true, although they seem very real to patient
    - - When a person believes their thoughts are being interfered with in some way
      - Insertions - belief that thoughts are being inserted into their mind
      - Withdrawals - belief that thoughts are being removed from their mind
      - Broadcasts - belief that thoughts are being transmitted to others
    - - Auditory hallucinations such as hearing voices
        
        Usually increase paranoia and negative thoughts
      - Visual or tactical hallucinations are also possible
    - - Stereotypical - rocking back and forth, twitches & repetitive behaviour
      - Catatonia - staying in position for hours/days on end, cut off from the world
  - - - The inability to engage in goal-directed behaviours
      - Sufferer may spend hours or days at home doing and achieving nothing
    - - Affect = emotion
      - Sufferers don't demonstrate emotion
    - - Alogia
      - The sufferer rarely speaks or speaks incoherently/very briefly
      - Derailment is a feature of speech poverty characterised by speech consisting of a sequence of unrelated or only remotely related ideas with the topic changing from one sentence to the next
  - - - Paranoid - characterised by powerful delusions and hallucinations
      - Hebephrenic - presents only negative symptoms
      - Catatonic - loss of movement or gain of sig. over-activity
  - - - Buckley (2009) found those with S are also diagnosed with
        
        Depression (50%)
        
        Substance Abuse (47%)
        
        PTSD (29%)
        
        OCD (23%)
    - - Diagnosis isn't made easy as many symptoms overlap with other disorders
        
        Bipolar also has delusions and avolition
        
        Under ICD, a patient is likely to be diagnosed with bipolar instead of S, however, the same patient would be diagnosed with S under the DSM
      - A major issue in classification and diagnosis
    - - Suggests that S could be over-diagnosed with ICD or under-diagnosed with the DSM
      - This is poor validity and a weakness of the diagnosis
      - Studies have shown that the ICD is more likely to lead to diagnosis than the DSM
    - - Meta-analysis conducted in 2010 showed that for the preceding 30yrs, S was more commonly diagnosed in men than women
        
        Men may be more genetically vulnerable or there may be gender bias at play
        
        Many psychologists believe that S is under diagnosed in women because of their superior emotional and social functioning, whereas for men this isn't the same
        
        Prior to this data show no difference
    - - Psychiatrist 1 - 26/100 diagnosed with DSM and 44/100 with ICD
      - Psychiatrist 2 - 24/100 with DSM and 13/100 with ICD
      - Reliability was very poor
      - This along with Rosehan's study on being sane in insane places illustrates the poor reliability in diagnosing S
      - Cheniaux (2009) asked 2 psychiatrists to diagnose 100 patients using the ICD-10 and DSM-V criteria
    - - Given that rates in the Caribbean and Africa aren't in line with this, the issue cannot be biological and is likely to be culturally biassed
      - In many African cultures, hearing voices is a social norm, as are beliefs in communicating with gods/dead ancestors
      - African Americans and English people with Afro-Caribbean origins are several times more likely to be diagnosed with S than their white counterparts
      - The issue may be that when reporting these symptoms to a white, British psychiatrist, they aren't regarded in the same light, leading to bias in diagnosis
- - - - Proposed that a single schizogene caused a schizotypical personality
      - Without this gene, it doesn't matter how much stress you experience, you won't develop S without the gene
      - One of the earliest interactionist theories
      - However, if you have the gene, you are very vulnerable and having a schizophrenogenic mother may cause S
    - - Psychologists now propose that diathesis doesn't have to be biological, it could be psychological
      - Read (2001) showed that early trauma alters the developing brain, making the HPA system over active
      - Now clear that schizophrenia is polygenic and aetiologically heterogenous
    - - Cannabis use can increase the risk of developing S by making you 7x more likely to develop the disorder than a non-user
      - Likely due to its interference with the dopamine system in the brain
      - Many psychologists now propose that stress can be triggered by non-psychological factors - especially drug use
      - Many people who use cannabis don't develop the disorder, highlighting the importance of a diathesis first
    - - Many psychologists believe in biological causes of S, using drugs to treat this but psychological therapies to help manage symptoms
      - In the UK, this is the most common treatment programme
      - Most typical interactionist treatment is combining drugs and CBT
      - Other interactionist treatment programmes involve antipsychotic drugs & family therapy or token economies
      - It isn't common practise to use psychological treatments alone
    - - Houston (2008)
        
        Childhood sexual abuse was found to be the most important diathesis
        
        Drug use was found to be the most important stress
        
        Supported the modern diathesis and stress theories
        
        Highlights that early models oversimplify and that avenues for further research should investigate open interpretations of diathesis and stress
      - Support
        
        Tarrier found that people with S receiving 20 sessions of CBT and drug therapy did better than sufferers receiving drug therapy or supportive counselling with drug therapy
        
        Patients in the drugs and CBt group made the best recovery
        
        Treatment was less effective in the drug and counselling group
        
        No patients in the drugs-only group were symptom free
      - Tienari (2004)
        
        Adoptive parents were assessed for parenting style and comparisons were made with a control group of adopted children without genetic vulnerability
        
        Parenting style of high criticism and conflict and low empathy was found to be associated wtih S in the genetically vulnerable children only
        
        Children adopted from 19,000 Finnish mothers with S between 1960/70 were followed up
        
        Shows the importance of diathesis and stress in the development of S
        
        Investigated the interactionism of genetic vulnerability & parenting style
      - Sudak (2011)
        
        CBT gives patients rational insight into the benefits of the drug treatment, increasing the chances of improvement and decreasing chances of relapse
        
        Illustrates the benefit of combining treatments
        
        Report that antipsychotic drug medication combined with CBT strengthens adherence to drug treatment
      - Treatment-Causation Fallacy
        
        Just because many treatment programmes seem to be successful using both antipsychotics and psychological treatments doesn't mean that the interactionist approach is completley correct in explaining S development
        
        Psychologists point out that either treatment could just help manage symptoms not the cause
- - - - AO1
        
        Appears to be polygenic - a number of genes working in combination to cause it
        
        It also seems to be aetiologically heterogenous in that different combinations of factors could be the cause
      - AO3
        
        Ripke
        
        Found 108 separate genetic variations were associated with developing S
        
        These genes were largely linked to functioning of dopamine pathways within the brain
        
        Compared the genetic makeup of 37,000 patients with S and 113,000 controls
    - - AO1
        
        There are 2 major theories proposing what is wrong with the system
        
        Hyperdopaminergia in the Subcortex
        
        An excess of dopamine receptors in Broca's area could explain alogia, derailment and auditory hallucinations
        
        High levels of dopamine in the most central and oldest part of the brain
        
        Dopamine is believed to work differently in patients with S
        
        Hypodopaminergia in the Pre-Frontal Cortex
        
        More recent research has pointed to the possibility of low dopamine levels in parts of the neocortex
        
        The prefrontal cortex is responsible for higher order processes such as decision making, thinking processes
        
        This could explain symptoms such as avolition & cog. disturbances
      - AO3
        
        Drug Treatment
        
        Evidence for the dopamine hypothesis comes from 2 diff. types of drugs
        
        Antipsychotics or dopamine antagonists which block dopamine
        
        Antipsychotics have been shown to be effective in reducing schizophrenia symptoms in hundreds of peer reviewed studies
        
        Dopamine agonists such as amphetamines which increase dopamine
        
        When amphetamines are given to S patients, their symptoms increase dramatically
        
        They can even produce symptoms in healthy individuals
        
        The efficacy of these 2 types of drug lend support to the DH
        
        Ripke
        
        Some of the genes identified in Ripke's study don't relate to dopamine pathways in any way
        
        The neurotransmitter glutamate is now being investigated as an alternative biological explanation
    - - AO1
        
        Systematic version of family/twin studies can be used to show that schizophrenia has biological roots
        
        We can compare concordance rates in various first, second and third degree relatives to work out the likelihood that schizophrenia has genetic links
      - AO3
        
        Irving Gottesman (1991)
        
        This is because MZ twins, followed by other first degree relatives, were far more likely than second and third relatives to develop S
        
        MZ twins had a 48% risk factor, DZ twins had 17% and a child with a schizophrenic parent at 13%
        
        Carried out a seminal meta-analysis and found sig. evidence that S has a biological basis
        
        The study showed that the closer the genetic makeup of the individual to the patient with S, the greater the risk of the developing the disorder
        
        Tienari et al (2004)
        
        Carried out longitudinal adoption studies in Finland and found that children with schizophrenia mothers were 7 times more likely than controls to develop S despite living, since birth, with adoptive parents who had no mental health problems
    - - AO1
        
        Neural correlates are investigations of which brain structures or brain functions correlate with which behaviour
        
        Both positive and negative symptoms of schizophrenia are associated with specific neural correlates
      - AO3
        
        Research Support
        
        The following areas were all found to be functioning differently in S patients
        
        Wernicke's and Broca's Area (speech) which would explain auditory hallucinations
        
        Occipital lobe (vision) would explain the visual hallucinations
        
        Basal ganglia (movement) would explain psychomotor disturbances
        
        Ventral Striatum (motivation) would explain avolition
  - - - AO1
        
        There is a negative correlation with year and dosage - today doctors tend to administer lower dosages
        
        Typical antipsychotics work on the dopamine hypothesis
        
        Initial dosage is much smaller and then built up
        
        Chlorpromazine is a dopamine antagonist - it blocks dopamine receptors in the synapses of the brain, reducing the action of dopamine
        
        Daily dosage can go as high as 1000mg, most patients are in the range of 400-800mg
        
        This helps reduce symptoms like hallucinations and is also an effective sedative
        
        Oldest form of antipsychotic, around since 1950s
        
        The syrups is absorbed faster than tablets so this is often used upon initial hospital arrival
        
        E.g. chlorpromazine
      - AO3
        
        Side Effects
        
        Typical antipsychotics
        
        Dizziness, agitation, sleepiness, stiff jaw, weight gain, itchy skin
        
        Involuntary motor action - where prolonged use causes facial spasms like grimacing, blinking and lip-smacking
        
        NMS is caused by blockage of dopamine in the hypothalamus and can be fatal
        
        Symptoms range from high temp, then delirium to coma
        
        This condition has declined over time as doctors are prescribing lower dosages
        
        Less than 2% of users of antipsychotics will experience this side effect these days
        
        Ethics
        
        Some campaigners claim that practitioners have made inappropriate use of the sedative effects of dopamine
        
        They claim they have been used in hospitals to calm patients and make them easier to work with rather than to benefit the patients themselves
        
        NICE guidelines do recommend short-term use with overly agitated patients, however, this is a guideline which some campaigners are trying to remove
        
        Effectiveness
        
        Thornley (2003) reviewed studies comparing chlorpromazine to a placebo
        
        Data from 13 trials with 1121 ppts showed chlorpromazine was associated w/ better overall functioning, reducing sympom severity and lower relapse rate
    - - The aim was to develop medication as powerful as chlorpromazine but with fewer side effects
      - Clozapine
        
        AO1
        
        People who take it have to have regular blood tests to ensure they're not developing a rare blood condition associated with this type of medication
        
        Because of the potential side effects, clozapine isn't available as an injection
        
        Began being used in 1970s
        
        Dosage is lower than chlorpromazine, typically 300-450mg a day
        
        Clozapine is used when other treatments fail
        
        This drug doesn't just act on dopamine receptors but serotonin and glutamate too, so it's more powerful, improving mood and depressive symptoms too
        
        AO3
        
        Between 30-50% of patients with S attempt suicide so this can be life-saving when patients are suicidal due to how effectively it improves mood
        
        Meltzer (2012)
        
        Concluded clozapine is more effective than typical antipsychotics (30-50%) where typical have failed
      - These drugs originated in the 1970s
      - Risperidone
        
        AO1
        
        Tablets, syrup or injection
        
        Very small dose - begin at 4-8mg, with a max dose of 12mg
        
        Aims to be just as effective as clozapine but without the side effects
        
        Risperidone is believed to be more powerful than clozapine & chlorpromazine
        
        Newer type of atypical antipsychotics
        
        Binds to receptors more effectively which is why only a small dosage is required
        
        AO3
        
        Inconclusive
        
        Several studies have compared effectiveness of clozapine and other atypical antipsychotics like risperidone but results have been inconclusive
        
        Perhaps because some patients respond better to one drug than another
        
        Theoretical Issue
        
        If the issue is low and not high levels of dopamine, then obviously antipsychotic medications will not be effective
        
        However, this doesn't explain why amphetamines which increase dopamine levels make symptoms worse
        
        Hypodopaminergia is also highlighted as an issue
        
        Antipsychotic drugs are still by far the most widely used medical treatment
- - - - Schizophrenogenic Mother
        
        Schizophrenogenic mothers are cold and rejecting
        
        They are controlling, create tension and secrecy in the home which later manifests itself in the paranoid delusions the patient will develop
        
        Fromm-Reichmann worked with many patients and from their accounts of childhood developed a psychodynamic theory of the Mother's behaviour as a causal explanation of the development of S
      - Double-Bind Theory
        
        A child wants to avoid displeasing parents at all costs but when it's unclear what the right thing to do is, when this changes or is inconsistent across both parents, the child is stuck in a double bind
        
        The subsequent withdrawal of love they experience when they displease a parent makes the world confusing and dangerous, and manifests itself in symptoms of disorganised thinking later on
        
        Bateman proposed that communication issues within the family during childhood could be a potential risk factor in the development of S
      - Psychologists have linked S to living in a dysfunctional family
      - Expressed Emotion
        
        This concerns a parent having excessive levels of neg. emotion towards their child and being excessively involved in their life
        
        They are hyper-critical, hostile, angry and rejecting
        
        This parenting style is also linked to high levels of relapse in patients and also the diathesis stress model
      - AO3
        
        Lack of Evidence and Ethical Implications
        
        Outdated research involved interviewing parents to see if they fitted the criteria described, an idea modern psychiatrists utterly reject
        
        These theories are now considered unethical and impossible to measure experimentally
        
        Very little evidence exits which lends any validity to these theories
        
        Research Support
        
        Read (2005) carried out a meta-analysis of 45 studies and found that 69% of female patients and 59% of male patients with S had a history of CA
        
        Validity
        
        One major issue with any childhood based research evidence is validity
        
        The majority of research asks adults to reflect memories from their childhood which is unfallible
        
        Modern studies are attempting to be prospective instead in that they follow up children with particular experiences in order to draw links between development of S and early family dysfunction
    - - Dysfunction in Metarepresentation
        
        When you can't do this, you might not recognise that you had a particular thought or action and attribute to another
        
        Explains auditory hallucinations and delusions like thought-insertion
        
        Metarepresentation is your ability to reflect on your thoughts and behaviours and interpret the behaviour of others
      - Dysfunction of Central Control
        
        Derailment or disorganised speech could arise from our inability to suppress the constant associations that come into our head while we are expressing something
        
        Normally, we can stay on one path of thought but dysfunction would result in us being derailed into a new topic in every few seconds
        
        Central control is the ability to suppress automatic responses while carrying out deliberate action
      - Frith identified 2 types of dysfunctional thought processing which could lead to S
      - AO3
        
        Research Support
        
        Schizophrenia patients took over twice as long to name the colours as the controls
        
        This is support for the CC theory, in that the patients were unable to suppress the impulse to read the word not the colour
        
        Stirling et al (2006) compared 30 schizophrenic patients with controls on a range of tasks including the stroop test
        
        Doesn't Establish the Cause
        
        The major issue is that on one hand we have hundred of studies that illustrate schizophrenic patients do function cognitively different to controls
        
        On the other hand, we have no evidence as to why
        
        We know which neural correlates are causing which symptoms but have no idea why S developed
        
        Cog. explanations don't shed the light on the origin of the disorder
  - - - Therapists meet regularly over 9-12 months with the patient and family members, who are encouraged to talk openly about the patient's symptoms, behaviour and progress with their treatment and how the patient's illness affects them
      - Family members are taught to support each other
      - Main aims
        
        Increase tolerance levels and decrease criticism between family members
        
        Decrease feelings of guilt and responsibility for causing the illness among family members
        
        Improve positive and decrease negative forms of communication
      - There is an overall emphasis on openness with no details remaining confidential
      - The treatment involves the whole family, not just the one with S, with the family becoming a support network
      - Openness
        
        With the emphasis on openness, there can be an issue with family members being reluctant to share sensitive info, as it may cause or reopen family tensions
        
        Openness of all family members is key in effective treatment
        
        Cost
        
        The Schizophrenia Commission (2012) estimates that family therapy is cheaper than standard care by £1004) per patient over 3yrs, suggesting it's a relatively cost-effective treatment
        
        Research Support
        
        Pilling et al (2002) performed a meta-analysis of several forms of psychological treatment for S, including 18 studies of family therapy with 1467 patients
        
        Family therapy had the smallest no. patients who relapsed & the lowest number of hospital readmissions
        
        In the first 9 months, 50% of those receiving routine care relapsed compared with 8% of those receiving family therapy
        
        These studies suggest family therapy is an effective form of treatment
        
        Leff et al (1985) compared family therapy w/ routine outpatient care for S with families high in expressed emotion
        
        Importance
        
        A very important treatment for young patients still living at home with family
      - Based on the idea that as FD can play a role in development of S, altering relationship and communication patterns within dysfunctional families and lowering levels of expressed emotion should help S recover
    - - With S, it's important that the reward is immediate after the patient demonstrates the behavioural change
      - The tokens can then be exchanged for goods or privileges
      - Token economies are particularly aimed at changing neg. symptoms of S, such as low motivation, poor attention and social withdrawal
      - Desired behaviour can be things like examples of self-care, adherence to medication regime and social interaction
      - Mainly used with long-term hospitalised patients to enable them to leave hospital and live relatively independently within the community
      - AO3
        
        Independence
        
        A risk of long-term hospitalisation for schizophrenics is institutionalisation but an advantage of TE is patients becoming more independent and active, increasing nurses' regard for patients, leading to patients becoming more motivated and developing a pos. self-image
        
        Safety
        
        Another unforeseen advantage is that their use facilitates a safer and more stable therapeutic environment
        
        Staff and patient injuries reduce, thus decreasing staff absenteeism and emergency incident levels
        
        Research Support
        
        Rewarded with tokens that could be exchanged for viewing a film or visiting the canteen for self-care behaviours, the average number of daily chores rose from 5 to 42, illustrating the success of token economy in getting patients to take more responsibility for themselves
        
        Dickerson et al (2005) reviewed 13 studies of token economy, finding the technique generally useful in increasing the adaptive behaviour of patients which implies it to be an effective treatment
        
        Ayllon & Azrin (1968) found token economies a successful technique when used with female S patients hospitalised for an average of 16yrs
        
        Token economy worked best in combination with psychological and drug therapies
        
        RLA
        
        The problem is desirable behaviour becomes dependent on being reinforced, upon release in the community, reinforcements cease, leading to high re-admittance rates
        
        Silverstein et al (2009) found that S living in the community often have trouble performing jobs where they are paid on a long-term basis, such as monthly but engage quite readily in situations using TE where they are rewarded hourly or daily
        
        Suggests that schizophrenics need to be paid on a more short-term basis when in employment
      - Behaviourist therapeutic approach based on principles of operant conditioning and reinforcement where tokens are awarded for demonstrations of desired behavioural change
    - - Drawings are often used to display links between sufferers' thoughts, actions and emotions
      - Understanding where symptoms originate from can be useful in reducing sufferers' anxiety levels
      - CBT is then undertaken around once every 10 days, for about 12 sessions, to identify and alter irrational thinking
      - Personal Therapy
        
        Techniques used are
        
        Challenging the meanings of intrusive thoughts
        
        Distractions from intrusive thoughts
        
        Increasing/decreasing social activity to distract low moods
        
        Using relaxation strategies
        
        PT is also used to tackle problems faced by schizophrenics discharged from hospital, taking place in small groups or one-to-one
        
        Involves detailed evaluation of problems and experiences, their triggers & consequences and strategies being used to cope
        
        Patients are taught to recognise small signs of relapse, which can build up to produce cog. distortions and unsuitable social behaviour
      - Antipsychotic drugs are usually given first to reduce psychotic thought processes, so that CBT can be more effective
      - AO3
        
        Jauhar et al (2014)
        
        Found only a small therapeutic effect on symptoms, including pos. symptoms, such as delusions and hallucinations, which CBT targets
        
        This small effect disappeared when only studies using blind testing were considered
        
        Performed a meta-analysis of 50 studies of CBT for S conducted over the last 20yrs
        
        This strongly questions whether CBT should be used for S
        
        Empathy
        
        For CBT to be effective, developing empathy, respect and honesty between patient and practitioner is important
        
        Supported by Rathod et al (2005) finding that non-Afro-Caribbean therapists had less success using CBT with Afro-Caribbean patients than white patients, as empathy between such clinicians and patients was harder to establish
        
        Tarrier (2000)
        
        1/3 of patients receiving CBT achieved 50% reduction in psychotic experiences, with 15% free of all pos. symptoms, compared to 15% reduction in psychotic experiences in the counselling group, with 7% free of all pos. symptoms
        
        People with S receiving 20 sessions of PT coupled with drug therapy did better than sufferers receiving drug therapy alone or counselling with drug therapy
        
        No patients in the drugs-only group were symptom free
        
        Suitability
        
        CBT isn't suitable for all patients, especially those too disorientated, agitated or paranoid to form alliances with practitioners
      - Aims to help patients with S by changing their maladaptive thinking and distorted perceptions in order to modify hallucinations and delusional beliefs