Transcript Paper 3 Option: Schizophrenia

Paper 3 Option: Schizophrenia
Classification and Diagnosis
What the spec says…
•
Classification of schizophrenia. Positive symptoms of schizophrenia, including
hallucinations and delusions. Negative symptoms of schizophrenia, including speech
poverty and avolition. Reliability and validity in diagnosis and classification of
schizophrenia, including reference to co-morbidity, culture and gender bias and symptom
overlap.
•
Biological explanations for schizophrenia: genetics, the dopamine hypothesis and neural
correlates.
•
Psychological explanations for schizophrenia: family dysfunction and cognitive explanations,
including dysfunctional thought processing.
•
Drug therapy: typical and atypical antipsychotics.
•
Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia. Token
economies as used in the management of schizophrenia.
•
The importance of an interactionist approach in explaining and treating schizophrenia; the
diathesis-stressmodel.
I have never…
• Been unable to speak the sentence in my
mind.
• Thought that people were watching me.
• Thought that people were talking about me.
• Lost interest in activities.
• Lost interest in food.
• Lost interest in socialising.
Is there a stigma to mental illness?
• Do you think Schizophrenia is ‘looked down on’, or
that sufferers are seen as ‘crazy’?
• How do you think that Schizophrenia is seen?
• What are our cultural attitudes – and are they
different to somewhere like America, or somewhere
like China?
What is depression?
What would you expect to be involved in
the diagnostic criteria for depression?
What would you look for to make your
diagnosis?
Clinical Characteristics
⦿ Schizophrenia
has been variously described as a
disintegration of the personality
⦿ A main feature is a split between thinking and
emotion
⦿ It involves a range of psychotic symptoms (where
there is a break from reality)
⦿ Generally, schizophrenic patients lack insight into
their condition, i.e. they do not realise that they are
ill
⦿ They must follow the pattern of symptoms (see next
slide)
Prevalence
•
•
•
•
The onset is typically in late adolescence and early
adulthood,onset- Men: 18–25 years; women: 25–35 years
The lifetime prevalence of schizophrenia is commonly given at
1%.
The incidence of schizophrenia is given as a range of between
7.5 and 16.3 cases per 100,000 of the population.
Men are more likely to suffer than females
Positive Symptoms
Positive symptoms are an excess or distortion of
normal functions which represent a change in
behaviour or thoughts, to include:
•
•
•
•
Delusions
Hallucinations
Catatonic or Disorganised Behaviour
Disorganised Speech
Delusions
•
An unshakable belief in something that is very unlikely,
bizarre or obviously untrue. One of the delusions
experienced in schizophrenia is paranoid delusions,
where an individual believes that something, or
someone, is deliberately trying to mislead, manipulate,
hurt or, in some cases, even kill them.
•
Another common delusion is the delusion of grandeur,
which is where an individual believes that they have some
imaginary power or authority, such as thinking that they
are on a mission from God or that they are a secret agent.
Hallucinations
Auditory/VisualUsually take the form of hearing voices that are not there.
These voices are normally critical and unfriendly.
Additionally, some people with schizophrenia may also see,
smell, taste and feel things that are not there.
Catatonic or Disorganised Behaviour
Where an individual behaves in ways that seem
inappropriate or strange to the norms of society.
- Can you think of any examples?
Disorganised Speech
Often known as a ‘word salad’, where an individual speaks
in ways that are completely incomprehensible.
For instance, sentences might not make sense, or topic of
conversation changes with little or no connection between
sentences.
Schizophrenia simulation
Negative Symptoms
A diminution or loss of normal functions to include:
⦿
Affective Flattening
⦿
Physical Anhedonia
⦿
Social Anhedonia
⦿
Avolition
⦿
Alogia
Negative Symptoms
A diminution or loss of normal functions to include:
⦿
A lack, or 'flattening', of emotions, where a person’s voice becomes dull and monotonous and
their face takes on a constant blank appearance (Affective Flattening).
⦿
An inability to enjoy things that they used to enjoy, food (Physical Anhedonia).
⦿
Social withdrawal, where they find it hard or become reluctant to speak to people (Social
Anhedonia).
⦿
Apathy, where they have a lack of motivation to follow through any plans and neglect
household chores, such as washing the dishes or cleaning their clothes (Avolition).
⦿
Speech poverty, where speech becomes lessened. It may be difficult to produce words or
coherent sentences (Alogia).
Task
Using your hand-out;
Match the description in the table to the symptoms at the
bottom of the page.
Challenge: In no more than 15 words, describe the difference
between positive and negative symptoms.
Exam Question
Discuss reliability and/or validity in relation to the
diagnosis and classification of schizophrenia.
(Total 8 marks)
Mark Scheme
Schizophrenia
Issues of Classification and Diagnosis
What the spec says…
•
Classification of schizophrenia. Positive symptoms of schizophrenia, including
hallucinations and delusions. Negative symptoms of schizophrenia, including speech
poverty and avolition. Reliability and validity in diagnosis and classification of
schizophrenia, including reference to co-morbidity, culture and gender bias and symptom
overlap.
•
Biological explanations for schizophrenia: genetics, the dopamine hypothesis and neural
correlates.
•
Psychological explanations for schizophrenia: family dysfunction and cognitive explanations,
including dysfunctional thought processing.
•
Drug therapy: typical and atypical antipsychotics.
•
Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia. Token
economies as used in the management of schizophrenia.
•
The importance of an interactionist approach in explaining and treating schizophrenia; the
diathesis-stressmodel.
When you come in…
From your knowledge of the DSM, brainstorm some
points for an answer to this question…
Discuss issues associated with the classification
and/or diagnosis of schizophrenia.
(Total 16 marks)
Issues around diagnosis of
Schizophrenia
⦿ There
are several issues surrounding the diagnosis of
Schizophrenia that need to be assessed.
⦿ These
include addressing issues surrounding the
reliability and validity of diagnosis.
Reliability of Classification Systems
⦿ Reliability
refers to the consistency of a measuring
instrument, such as a questionnaire or scale, to assess for
example, the severity of the schizophrenic symptoms.
⦿ Reliability
of such questionnaires or scales can be
measured in terms of whether 2 independent assessors
give similar diagnosis (inter-rater reliability) or whether
tests used to deliver these diagnoses are consistent over
time (test-retest reliability)
Classification Systems
The two most widely used
classifications systems for diagnosis of
schizophrenia are:
•
•
ICD-10
DSM-V
DSM- IV
⦿ The
Diagnostic and Statistical
Manual of Mental Disorder
(Edition 5), was last published
in 2013.
⦿ The DSM is produced by the
American Psychiatric
Association.
⦿ It is the most widely used
diagnostic tool in psychiatric
institutions throughout
America and some parts of
Europe.
ICD - 10
⦿ International
Statistical
Classification of Diseases
(known as ICD)- produced in
Europe by the World Health
Organisation (WHO) and is
currently in it’s 10th edition.
⦿ Used
in the UK and many
other European countries
Differences between ICD and DSM in
Diagnosis of Schizophrenia
DSM
One or more of the clinical characteristics must be present
for at least 6 months
ICD
Requires the signs to be apparent for one month.
What are the implications?
Task
Add to your brainstorm…
Discuss issues associated with the classification
and/or diagnosis of schizophrenia.
(Total 16 marks)
Reliability & Validity
⦿ Validity
refers to the extent that a diagnosis represents
something that is real and distinct from other disorders
and the extent that a classification system such as ICD or
DSM measure what it claims to measure.
⦿
Reliability and Validity are linked because if scientists
cannot agree who has Schiz. (low reliability) then
questions of what it actually is (i.e. validity) become
essentially meaningless.
Reliability
What issues with diagnosis do you think might arise from the
following;
Culture
Gender
Symptom overlap
Co-morbidity
Reliability: Culture
Copeland (1971)
Gave 134 US and 194 British psychiatrists a description of a patient.
- 69% of the US psychiatrists diagnosed schizophrenia
- only 2% of British psychiatrists diagnosed schizophrenia
Luhrmann (2015)
Interviewed 60 adults with a diagnosis of schizophrenia, and asked about the
voices they heard.
- 20 from Ghana, 20 from India, 20 from U.S
- Pps from Ghana & India reported positive experiences with their voices (playful,
offered advice)
- U.S. pps reported only negative experiences (hateful, violent)
Maybe the harsh/violent voices prevalent in the West is not inevitable in Schiz.?
Culture
⦿ Although Sz
occurs across cultures- finding in USA/UKmore frequently among African American and AfricanCaribbean pops
⦿ Not clear whether it reflects greater genetic vulnerability,
psychosocial factors , minority groupings or misdiagnosis.
⦿ Davison
& Neale (1994)
explain that in Asian cultures,
a person experiencing some
emotional turmoil is praised
& rewarded if they show no
expression of their emotions.
⦿ In
certain Arabic cultures
however, the outpouring of
public emotion is understood
and often encouraged.
⦿ Without
this knowledge, an
individual displaying overt
emotional behaviour may be
regarded as abnormal when
in fact it is not.
Validity: Gender
Broverman et al (1970)
Gave a sex-role stereotype questionnaire consisting of 122 bipolar
items to 79 actively functioning clinicians with 1 of 3 sets of
instructions: to describe a healthy, mature, socially competent (a)
adult, sex unspecified, (b) a man, or (c) a woman.
- Clinical judgments about the characteristics of healthy individuals
differed according to the sex of the person being assessed.
- Behaviors and characteristics judged healthy for an ‘adult, sex
unspecified’, which are presumed to reflect an ideal standard of
health, resembled behaviors judged healthy for ‘men’, but not for
women.
The result is that women were perceived as being less mentally
healthy.
Validity: Symptom Overlap
Ellason and Ross (1995) point out that people
with dissociative identity disorder have more
Schiz. symptoms than people diagnosed as
being schizophrenic!
This affects the validity of the diagnosis.
Validity: Symptom Overlap Task
Look at your assigned case study.
Decide whether the patient meets the general
schizophrenia criteria.
Can you recognise any symptoms of other
disorders there?
Validity: Co-morbidity
The extent to which two (or more) conditions
occur at the same time in a patient.
Some common co-morbidities in schizophrenic
patients include;
- Substance abuse
- Anxiety
- Depression
Validity: Co-morbidity
Buckley et al (2009)
- Co-morbidity of Depression is approx. 50%
- 47% co-morbidity of substance abuse
Swets et al (2014)
Meta-analysis
- 12% of Schiz. Patients also fulfilled the diagnostic criteria for OCD.
- Approx. 12% displayed significant OCD symptoms.
• Clinicians make dual diagnosis- appropriate treatment for both
disorders.
• DSM- multi-axial classification system encourages multiple diagnosis
Finally
Add some more points to your brainstorm…
Discuss issues associated with the classification
and/or diagnosis of schizophrenia.
(Total 16 marks)
When you come in…
Complete the gap-fill exercise to recap from last lesson.
Rosenhan (1973)
⦿ The problems with
the medical classification were
highlighted in the most famous investigation on hospital
practices. “On Being Sane in Insane Places”, Rosenhan
(1973).
⦿ An all-time
classic study in psychology that breaks some
of the unwritten rules in that the real participants are the
psychiatric establishment!
⦿ Rosenhan (1973) aimed
to test the hypothesis that
psychiatrists cannot reliably tell the difference between
people who are sane and those who are insane
On Being Sane in Insane Places
On Being Sane in Insane Places
⦿ Rosenhan
recruited 8 people (he worked with them
or knew him in some capacity).
⦿ Each
of the 8 people went to a psychiatric hospital
and reported only 1 symptom. That a voice said only
single words, like “thud”, “empty” or “hollow”.
⦿ When
admitted, they began to act “normally”. All
were diagnosed with suffering from schizophrenia
(apart from 1).
⦿ The
individuals stayed in the institutions for between
7 to 52 days.
On Being Sane in Insane Places
⦿ Rosenhan
told the institutions about his results, and warned
the hospital that they could expect other individuals to try &
get themselves admitted.
⦿ 41
patients were suspected of being fakes, and 19 of these
individuals had been diagnosed by 2 members of staff.
⦿ In
⦿A
fact, Rosenhan sent no-one at all!
good film to watch: One Flew Over the Cuckoo’s Nest
(is Jack Nicholson’s character mentally ill? Is he mad, bad or
sad? You decide!)
On Being Sane in Insane Places
⦿ This
study highlighted the unreliability of diagnosis.
⦿ However,
this study was conducted over 30 years ago.
Since then manuals have been improved and diagnostic
practise is very different. For example, categories and
definitions are more detailed and operationalised and
psychiatrists now use standardised interview schedules
when assessing patients.
⦿ Also
the ICD and DSM have been bought in line with one
another so they are now very similar.
Improving Reliability of Diagnosis
Write definitions for each of these key terms related to the
reliability of psychiatric diagnosis;
Inter-rater reliability
Test-retest reliability
How reliable is Diagnosis?
Write definitions for each of these key terms related to the
reliability of psychiatric diagnosis;
Inter-rater reliability the degree of agreement among raters. It gives
a score of how much homogeneity (consensus) there is in the ratings
given by judges.
Test-retest reliability the degree to which test results are consistent
over time. In order to measure test-retest reliability, we must first give
the same test to the same individuals on two occasions and correlate
the scores.
How reliable is Diagnosis?
Post it task on board ranging from totally unreliable to 100%
effective.
Improving Reliability
Kurt Schneider (1959)- tried to make the diagnosis of Sz more reliable:
⦿
He identified a group of symptoms characteristic of S but rarely found in other
mental disorders.
⦿
These ‘first-rank’ symptoms-useful in helping clinicians determine the diagnosis of
S- formed the basis of the current ICD-10 classification.
The first-rank symptoms of schizophrenia include:
• auditory hallucinations:
• thought withdrawal, insertion and interruption.
• thought broadcasting.
• somatic hallucinations.
• delusional perception.
• feelings or actions experienced as made or influenced by external agents.
Inter-Rater Reliability
⦿ The
inter-rater reliability of two
psychiatrists diagnosing
Schizophrenia is exceptionally low,
e.g. less then 50%-suggests that
psychiatrists do not know what
they are doing.
- Thus people who do not have Schizophrenia
may be included in research.
- May result in invalid conclusions about the
cause of the ‘illness’ and/or treatment.
I wonder what
the other bloke
thinks?
Inter-Rater Reliability
⦿ Beck
et al (1961) Found that agreement on diagnosis for
153 patients (where each was assessed by two
psychiatrists from a group of four) was only 54%. This was
often due to vague criteria for diagnosis and
inconsistencies in techniques to gather data. – Inter rater
reliability.
⦿ Whaley (2001) found
inter-rater reliability correlations in
the diagnosis of schizophrenia as low as 0.11
⦿ Incorrect diagnosis
-the result of problems with defining
Schizophrenia, e.g. if you cannot classify Schizophrenia
how can you diagnose it?
How valid is Diagnosis?
Validity of Psychiatric Diagnosis
• Diagnoses must be objective and reliable for them to be valid
(true).
• However no matter how reliable a diagnosis is as there are no
absolute standards against which to compare them there is
no way of proving they have received the correct diagnosis
(Holmes).
Evaluation of Reliability & Validity
Stigma can reduce Validity
⦿A
system for diagnosing schizophrenia cannot be considered
accurate if many cases go undiagnosed- due to certain social
stigmas and repercussions attached to diagnosing someone
with Sz. Although this can occur all over the world it is more
likely in a country such as Japan as schizophrenia literally
translates to 'disease of the disorganised mind.'
⦿ Kim
and Berrios (2001) researched this and found that in
Japan the idea of a 'disorganised mind' is so stigmatised that
psychiatrists are reluctant to tell patients of their condition. As
a result only 20% of those with schizophrenia are actually
aware of it, while the other 80% are left undiagnosed.
Evaluation of Validity
Validity
Support for gender bias - Diagnosis is not just affected by gender of the pt, but also
the diagnosing clinician.
Consequences of co-morbidity - A large study by Weber (2009) found that many Schiz.
patients also had diagnoses of medical problems (asthma, hypothyroidism etc.).
Concluded that the Schiz. diagnosis meant that pts received a lower standard of
care.
Differences in prognosis - There is much variation in outcome for people diagnosed
with Schiz. (20% recovering to previous functioning level, 10% achieving sig. &
lasting improvement, & 30% showing some improvement and intermittent
relapse). This mean a diagnosis has little ‘predictive validity’. What is more
influential is gender (Malmberg, 1998) and psycho-social factors like social skills,
academic achievement, and family support (Harrison, 2001).
Evaluation of Reliability
Reliability
Lack of inter-rater reliability - Despite improvements over the years in the revisions of
the DSM, there is little evidence for a high reliability of use by clinicians. Inter-rater
reliability correlations as low as 0.11 for Schiz. (Whaley, 2001). Also see Rosenhan
(1973).
Unreliable symptoms - One of the characteristic symptoms is ‘Bizarre delusions’. What
is bizarre? Mojtabi & Nicholson (1995) assessed inter-rater reliability for this and
found only 0.40 correlation.
More cultural differences - Difference in prognosis between ethnic minorities &
majorities. ‘Ethnic Culture Hypothesis’ suggests that ethnic minority groups
experience less distress from mental disorders due to the social structures that
exist in minority cultures (Brekke & Barrio, 1997 - shows support for this theory).
Task
Pick 4 evaluation points to KAE(D).
You can use the prompts available if you like.
Add these to your brainstorm from last lesson.
You will then have a full answer to the question;
Discuss issues associated with the classification and/or diagnosis of schizophrenia.
(Total 16 marks)
Finally
Find your face!
How confident are you in your understanding of
Classification & Diagnosis of Schizophrenia, and
issues around Validity & Reliability?
Schizophrenia
Biological Explanations for
Schizophrenia
What the spec says…
•
Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and
delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability
and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity,
culture and gender bias and symptom overlap.
•
Biological explanations for schizophrenia: genetics, the dopamine hypothesis and neural
correlates.
•
Psychological explanations for schizophrenia: family dysfunction and cognitive explanations,
including dysfunctional thought processing.
•
Drug therapy: typical and atypical antipsychotics.
•
Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia. Token
economies as used in the management of schizophrenia.
•
The importance of an interactionist approach in explaining and treating schizophrenia; the
diathesis-stressmodel.
When you come in…
You have three minutes to write down as much as you can about the
biological approach.
To help, use these headings;
• Basic assumptions of the biological approach about what causes behaviour
• General evaluation of the basic assumptions/beliefs of the biological
approach
• Main research methods used by the biological approach
• Evaluation of the above research methods.
Explanations – Biological
vs Psychological
Nature vs Nurture
Biological Explanations
Genetics – Family Studies
• Gottesman also studied families – he
concluded that if both your parents
suffer from Schizophrenia, then you have
a 46% chance of developing it yourself
(compared to a 1% chance of someone
selected at random will suffer)
• The more genetically similar relatives are,
the more concordance is found.
Family Evaluation
• This evidence again strongly suggests genetics is a factor
However:
• It could also be explained in terms of the fact that
genetically similar family members tend to spend more
time together and so environment could also affect.
Genetics – Twin Studies
• Gottesman (1991) suggests that
schizophrenia is inherited through
genes. Studied 40 twins - the
concordance rate for MZ twins is
about 48% and only about 17% for DZ
twins.
• Joseph (2004) found….
Genetics – Twin Studies
Kendler (1983)
• 30.9% concordance rate for MZ twins
• 6.5% concordance rate for DZ twins.
He suggests that twin studies of schizophrenia are not substantially biased by
the greater similarity in social environment of identical vs fraternal twins.
Genetic factors are as etiologically important in schizophrenia as in such
medical conditions as diabetes and hypertension. Twin studies of schizophrenia
probably provide a valid measure of the major etiologic role that genetic
factors play in schizophrenia.
Genetics – Twin Studies
Cardno et al (1999)
Based on ‘Maudsley Twin Register’ which uses strict diagnostic criteria.
- concordance rate of 26.5% for MZ
- concordance rate of 0% for DZ twins
Evaluation – Twin Studies
• However, the fact that the concordance rate for twins is not
100% means that Schizophrenia cannot be accounted for by
genetics alone
• As we already know, the higher concordance between MZ
twins could be explained by greater environmental similarity
rather than genetic similarity – MZ twins elicit more similar
treatment than DZ twins (so can be explained by other
theories)
• Also the sample size of such twin studies is always going to be
very small, so……..
Further Twin Evaluation
Twin studies do not all use the same diagnostic
criteria – Therefore different diagnosis will produce
different concordance rate.
Concordance rates can also be calculated differently
depending on the method used – questions the
reliability of such studies.
Genetics - Adoption Studies
• Tienari (2000) – 164 adopted children –
who biological mothers had
schizophrenia –they had a concordance
of 6.7% compared to 2% in adopted
children without schizophrenic parents.
• This is very strong evidence that
genetics are a risk factor for
schizophrenia.
Can you…?
• Describe Genetic factors of Schiz. in 100 words
-Family studies
-Twin studies
-Adoption
studies
Biochemical Factors – The
Dopamine Hypothesis
• This theory claims that excessive amounts
of dopamine or an oversensitivity of the
brain to dopamine is the cause of
schizophrenia
• There is strong empirical support which
suggests that dopamine plays an important
role in schizophrenia – e.g drugs which
block dopamine (Phenothiazine's) also
seem to reduce the symptoms of
schizophrenia.
• Dopamine is a neurotransmitter that helps control the brain's
reward and pleasure centers.
• Dopamine also helps regulate movement and emotional
responses, and it enables us not only to see rewards, but to
take action to move toward them.
• Dopamine deficiency results in Parkinson's Disease, and
people with low dopamine activity may be more prone to
addiction.
• The presence of a certain kind of dopamine receptor is also
associated with sensation-seeking.
• An agonist is a chemical that binds to a
receptor and activates the it to produce a
biological response.
• Whereas an agonist causes an action, an
antagonist blocks the action of the agonist
and an inverse agonist causes an action
opposite to that of the agonist.
The Dopamine Hypothesis Evaluation
• L-Dopa – a drug for Parkinson’s disease
actually increases dopamine – this in turn can
produce symptoms of schizophrenia.
• Post mortems of schizophrenics, show an
increase of dopamine in parts of the brain.
(Seeman,1987)
Dopamine Evaluation - Negatives
• Phenothiazines do not seem to work for everyone
therefore....
• Cause or effect?
• This theory is over simplistic and has been criticized
for using the treatment to determine the cause. This
is an AETIOLOGY FALLACY
Can you…?
• Label the image of the synapse.
Task
• Describe biological explanations in 100 words
(the dopamine hypothesis)
-D2 receptors
-Amphetamines
-Antipsychotic drugs
-Parkinson’s disease
Neuroanatomy - Brain Structure
There is growing evidence that schizophrenia is
down to physical abnormalities in the brain.
Szesko et al found that the ‘asymmetry’ found in
normal brains – in the prefrontal cortex is
absent in people with schizophrenia.
Brain Structure
People with
schizophrenia have
abnormally large
ventricles in the brain.
Ventricles are fluid filled
cavities. This means that
the brains of
schizophrenics are
lighter than normal.
Brain Structure Evidence
• Andreasen et (1990) – conducted a
very well controlled CAT scan study
and found significant enlargement of
the ventricles in schizophrenics
compared to controls.
• However this was only the case for
men and not for women. Therefore
can’t generalise to everyone.
Evaluation
• Research is difficult to interpret and there
have been contradictory findings.
• Difficult to establish cause and effect – as
many participants have suffered from
schizophrenia for a while and have been
undergoing treatment. So.......
Further Evaluation
• The main problem with such
studies is that it is not found in
all schizophrenics. This has lead
to further research done by
Crow (1985).
• He suggested two types of
schizophrenia with two
biological causes.
Two Syndrome Hypothesis - Crow 1985
• Type one - genetically inherited
associated with dopamine –
characterised by positive symptoms.
• Type Two – Neurodevelopmenal
disorder – to do with Brain structure
– characterised by negative
symptoms.
Summary
• Biological explanations do account
for schizophrenia, however the fact
that there is no conclusive
explanation that accounts for all
schizophrenics – psychological
explanations need to be considered.
Plenary
Stepping stones
In small groups, arrange the pieces of information into
a coherent argument by discussing each one and
placing them in the correct order.
Exam Question
• TASK: Exam Question: PLAN THE QUESTION
Describe and evaluate biological explanations
for schizophrenia. Refer to evidence in your
answer.
(Total 16 marks)
Mark Scheme
Challenge
• What are the two biological explanations of
Sz?
• What does the dopamine hypothesis state?
• How do amphetamines help us understand
Sz?
• How do antipsychotic drugs work?
• What happened to people suffering from
parkinsons who were taking the drug L-dopa?
Schizophrenia
Psychological Explanations for
Schizophrenia
What the spec says…
•
Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and
delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability
and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity,
culture and gender bias and symptom overlap.
•
Biological explanations for schizophrenia: genetics, the dopamine hypothesis and neural
correlates.
•
Psychological explanations for schizophrenia: family dysfunction and cognitive
explanations, including dysfunctional thought processing.
•
Drug therapy: typical and atypical antipsychotics.
•
Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia. Token
economies as used in the management of schizophrenia.
•
The importance of an interactionist approach in explaining and treating schizophrenia; the
diathesis-stressmodel.
When you come in…
Read the descriptions of double bind
communication in action.
Try to identify where the contradictory signals
occur.
Make notes so you can discuss them later.
Double Bind Theory (Bateson, 1956)
•
The double bind hypothesis is a psychological explanation which can be classed as
a socio-cultural explanation.
•
Bateson suggested that schizophrenia is best understood as a wider problem
occurring within the family.
•
It is not an inborn mental disorder but instead is a learned confusion in thinking.
•
Schiz. can be attributed to the exposure to, and participation in dysfunctional
communication patterns in the family.
•
An example of this dysfunctional communication pattern is double bind
communication.
•
Double bind communication is where a pair of messages are mutually
contradictory.
Double Bind Theory (Bateson, 1956)
For example…
“A mother tells her son/daughter that they are not affectionate enough but when the child
shows affection, the mother pushes them away with the comment “grow up, you big baby”.
•
Small children in particular have difficulty with these contradictory messages and can neither
ignore the message nor leave the relationship because they are so dependent upon their
parent(s).
•
If the situation cannot be resolved by the individual (by being ignored, or leaving the
situation) then the situation becomes a double-bind one.
•
Parents who send out mutually contradictory signals such as in the example above place their
children in impossible situations where they cannot act in one way without in some way
going against their parent’s apparent wishes.
Double Bind Theory (Bateson, 1956)
•
The child doesn't know how to respond to the conflict between the words and the body
language.
•
If the child cannot resolve the confusion, then he/she is in a double bind situation.
•
This causes confusion and leads to a state of internal conflict.
•
Prolonged exposure to such interactions prevents the development of an internally coherent
construction of reality.
Double Bind Theory (Bateson, 1956)
How does this lead to the development of schizophrenia?
•
The result is that children lose their grip on reality and if double bind messages are presented
continually and habitually within the family context from infancy on by the time the child is
old enough to have identified the double bind situation, it has already been internalised and
the child is unable to confront it.
The solution then is to create an escape from the conflicting logical demands of the
double bind into the world of the delusions.
Expressed Emotion
Expressed Emotion (EE) is a qualitative measure of the amount of emotion displayed within the
family setting, usually by family members or care takers.
It can be measured by using the Camberwell Family Interview or the Five Minute Speech
Sample.
The theory proposes that a high level of EE within the home of the schizophrenic can:
Worsen the prognosis in patients with schizophrenia
Increase the likelihood of relapse and readmission into hospital for the patient.
A high EE household is made up of three dimensions:
Three dimensions of Expressed Emotion
1. Hostility:
Hostility is a negative attitude directed at the patient because the family feels that the disorder is
controllable and that the patient is choosing not to get better. Problems in the family are often
blamed on the patient. The family believes that the cause of many of the family’s problems is the
patient’s mental illness.
2. Emotional over-involvement:
It is termed emotional over-involvement when the family members blame themselves for the
mental illness. This is commonly found in females. The family member shows a lot of concern for
the patient and the disorder. This is the opposite of a hostile attitude, but still has the same
negative effect on the patient as it makes the patient feel guilty. The pity from the relative causes
too much stress and the patient relapses to cope with the pity.
3. Critical Comments:
Critical attitudes are combinations of hostile and emotional over-involvement. It shows an
openness that the disorder is not entirely in the patients control but there is still negative
criticism. Critical parents often influence the patient’s siblings to be the same way.
How does this result in relapse?
This high level of EE becomes too much for the patient to handle as they have
to deal with criticism from those they would need support from in their time
of recovery.
This stress may cause the patient to relapse and make them fall into a cycle of
rehabilitation and relapse.
The only way to escape this cycle is for the family to go through Family
Intervention Therapy together.
This will greatly lower family conflicts and reduce the amount of EE within the
household.
How do you measure the amount of EE within a
household?
(You don’t need to go into much detail on this in your outline)
Camberwell Family Interview:
• The EE status of the family members can be assessed with the Camberwell Family
Interview (CFI) after the patient had been admitted to in-patient care.
• The CFI is conducted with the patient's close relatives (family caregiver) without
the patient being present.
• During the interview, relative's speech is recorded and later used for coding.
• The interview focuses on the level of stress in the household, irritability among the
family members, participation of the patient in routine household tasks and the
daily routines of the patient and various family members or overall family
functioning.
• If a close family member makes six or more critical comments and makes any
statement that is rated as hostile, or shows indication of marked over involvement
(a rating of 3 or more on a 0 – 5 scale), the relative is classified as high in EE.
How do you measure the amount of EE within a
household?
(You don’t need to go into much detail on this in your outline)
Five Minute Speech Sample:
•
The five-minute speech sample (FMSS) is similar to the CFI in that family members
talk about their patient and their relationship for five uninterrupted minutes and
the speech is recorded and later coded for the overall level of EE.
•
One or more critical comments, negative comments about their relationship, or a
critical statement at the start of the interview are all indicative of high criticism on
FMSS,
Task
You are the psychologist —
Code the statements from an interview with a family
member and say whether they relate to hostility,
emotional over-involvement, or critical comments.
(use a different coloured highlighter for each)
Cognitive Approach Assumptions
· The cognitive explanation of schizophrenia is based
around the idea of faulty information processing and
faulty thinking.
· In non-schizophrenic brains, we are able to filter
incoming stimuli and process them to extract meaning.
· It is thought that these filtering mechanisms and
processing systems are defective in the brains of
schizophrenics.
Explaining hallucinations:
· The cognitive approach agrees with the biological
approach in that during hallucinations they suggest the
brains of people with Sz are producing strange and
unreal sensations (triggered biologically)
· The cognitive approach then says the disorder
develops further when the individual attempts to
understand the sensory experiences and is then
worsened by those around them.
How is it made worse?
· When people with Sz first experience voices and
other worrying sensory experiences, they turn to
others to confirm the validity of what they are
experiencing.
· Other people fail to confirm the reality of these
experiences and so the person comes to believe that
others must be hiding the truth.
· They begin to reject feedback from those around
them and develop delusional beliefs that they are being
manipulated and persecuted by others.
What’s going on inside the ‘black box’?
People
are
laughing
on the
bus
There’s
something
wrong with
me
What’s going on inside the ‘black box’?
My
papers
are not
where I
left them
People are
trying to
sabotage
my career
What’s going on inside the ‘black box’?
I can’t
hear
what
people
are
saying
My family is
plotting
against me
Task
What symptom(s) of Sz can this explain?
How?
Faulty processing filter
In a person without Sz, they are able to distinguish between information that is
important and information that isn’t.
However in the mind of a person with Sz, they are have a faulty processing system and
it said they have an inability to distinguish between information that is already stored
and new incoming information.
As a result, the person with Sz is subjected to sensory overload and does not know
which aspects of a situation to attend to and which to ignore. This may result in them:
Being confused.
Not being able to grasp what actually reality.
COGNTIVE MALFUNCTIONS
• In a normal brain there is a mechanism that filters
incoming stimuli
• In a Schizophrenic brain the mechanism
malfunctions and lets in too much stimuli,
– Cannot focus
– Unable to interpret information correctly
– World is very different
• The most dramatic distortions of perception are
hallucinations.
• More often auditory (74%) than visual
• Can be very frightening
PET AND MRI scans
PET SCANS
• MRI SCANS
• Injected with glucose
containing tiny radioactive
tracer
• Areas of the brain most
active use up the glucose
• Positrons are emitted that
is picked up by the scanner
• Colour 3D
• Patient is put in a cylinder
containing a strong magnet.
• Radio waves cause atoms in
body to resonate
• Different types of body
tissues resonate at different
frequencies
• Can see through bone
• B&W 2D
Helmsley (1993)
• suggests there is a breakdown between information that has
already been stored in memory and new incoming sensory
information
– Stored information (schemas) are not activated which
results in sensory overload
– Internal thoughts are not recognised as coming from
memory and so are attributed to external sources
(auditory hallucinations)
Frith’s Model (1992)
• Attempts to explain the onset and
maintenance of positive symptoms
– Verbal hallucinations, delusions of control,
thought insertion
• People are unable to distinguish between
actions that are brought about by external
forces and those that are generated from
internal thoughts
• A basic failure in the self monitoring
processes.
Frith’s Model (1992)
• Most symptoms can be explain in terms of deficits in
3 cognitive processes;
– Inability to generate willed action
– Inability to monitor willed action
– Inability to monitor the beliefs and intentions of others
• Found that there is a disconnection between the
frontal areas of the brain concerned with action and
the rear areas that control perception.
• As such Schizophrenics cannot meta represent
action.
Task
What symptom(s) of Sz can this explain?
How?
Frith’s model
Frith suggested that people with Sz fail to monitor their
own thoughts correctly and so misattribute them to the
outside world.
When a person with Sz hears voices, it is actually their
own inner speech being misinterpreted however they
may believe that someone or something in the external
world is communicating with them.
Task
What symptom(s) of Sz can this explain?
How?
Evaluation Task
How much evaluation of the Cognitive explanation to
Schizophrenia can you come up with yourselves?
- Don’t use the book to begin with.
Evaluation
+ Meyer-Lynderberg et al (2000) found a link between excess levels of dopamine in
the prefrontal cortex and dysfunctions of the working memory.
- Working memory dysfunction is associated with cognitive disorganisation which
is typical of people with Sz.
This supports the idea that the underlying biological factors as well as faulty
information processing systems are involved in Sz.
+ The cognitive explanation has given rise to Cognitive Behavioural Therapy which
seems to improve the outcome for many people with Sz and has no side-effects.
However..
- The approach does not really explain the cause of Sz. It can only really explain the
symptoms of the disorder, we still have to look to biological explanations for cause.
- The approach also only mainly explains the positive symptoms of the approach.
Overall: How effective do you think the cognitive explanation of Sz is?
Exam Question
Evaluate psychological explanations of schizophrenia.
(Total 16 marks)
Mark Scheme
AO2 / AO3 = 16
Candidates are required to provide an evaluation of psychological explanations of
schizophrenia. The question refers to explanations in the plural since it could be
difficult for candidates to provide sufficient evaluative material on a single
psychological explanation for full marks. However, given that evaluative points are
often relevant to more than one explanation, no partial performance criteria apply for
this question.
Candidates can legitimately refer to biological explanations but answers will only gain
credit where the material is clearly used to offer commentary on the worth of
psychological explanations. Detailed descriptions of biological explanations cannot
gain credit. Similarly, detailed descriptions of psychological explanations cannot gain
credit – the focus in this part of the question is on evaluation.
Mark Scheme
The evaluation can be both positive and negative:
One criticism of psychodynamic theory, for example, is that it places responsibility on
mothers. The behavioural explanation is criticised, for example, because it is hard to
accept that the bizarre and complex patterns of behaviour seen in people with
schizophrenia can be acquired through simple learning processes; the cognitive
explanation can be criticised for being descriptive rather than explanatory.
More general evaluations that apply to most psychological explanations include the
following:
none of them can adequately account for the indisputable fact that schizophrenia runs
in families and that the increased risk is directly associated with the degree of
relatedness.
There is a lack of strong empirical evidence to support the psychological explanations
and there is also a problem of disentangling cause and effect (eg does faulty thinking
cause schizophrenia or vice versa?). It is also legitimate to refer to therapies ie that
treatments arising from psychodynamic and behavioural explanations appear to have
little therapeutic effect in schizophrenia.
Mark Scheme
Another general point concerns the diversity of symptoms found in people diagnosed
either with schizophrenia or a sub-type of schizophrenia – it may be the case, for
example, that some explanations can account for certain symptoms better than
others.
Candidates might also use the diathesis-stress model as a way of reconciling biological
and psychological explanations.
Schizophrenia
Drug Therapy
What the spec says…
•
Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and
delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability
and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity,
culture and gender bias and symptom overlap.
•
Biological explanations for schizophrenia: genetics, the dopamine hypothesis and neural
correlates.
•
Psychological explanations for schizophrenia: family dysfunction and cognitive explanations,
including dysfunctional thought processing.
•
Drug therapy: typical and atypical antipsychotics.
•
Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia. Token
economies as used in the management of schizophrenia.
•
The importance of an interactionist approach in explaining and treating schizophrenia; the
diathesis-stressmodel.
Lets remind ourselves how
neurotransmitters work
Lets remind ourselves how
neurotransmitters work
DOPAMINE HYPOTHESIS
The Dopamine hypothesis states that the
brain of schizophrenic patients produces
more dopamine than normal brains.
–Evidence comes from
–studies with drugs
–post mortems
–pet scans
Normal Level of
Dopamine In The
Human Brain
Elevated Level of Dopamine In The
Brain of a Schizophrenic Patient
(specifically the D2 receptor)
 Neurons that use the transmitter ‘dopamine’ fire too often and
transmit too many messages or too often.
 Certain D2 receptors are known to play a key role in guiding attention.
 Lowering DA activity helps remove the symptoms of schizophrenia
Biological therapies for Schizophrenia
• There was no effective treatment for Sz prior to the 1950’s
until 1952 when dopamine was discovered and drugs were
developed that had a direct effect on the action of the
dopamine neurotransmitter.
• Drugs which markedly reduced the symptoms in people who
were severely ill became known as antipsychotics.
• Antipsychotics are given to treat the most disturbing forms of
psychotic illness such as schizophrenia and bipolar disorder.
• There are two types of antipsychotic drugs:
Biological therapies for Schizophrenia
• Typical Anti-Psychotic Drugs
- Used to combat positive symptoms
(hallucinations/thought disturbances)
- Work by reducing the amount of Dopamine.
- Chlorpromazine, Pimozide
• Atypical Anti-Psychotic Drugs
- Also treat positive symptoms in addition to
Negative symptoms
- Clozapine, Rispiridone
Typical Anti-Psychotic Drugs
· They work by binding to dopamine receptors (particularly D2
receptors) and thus blocking their action, not stimulating them.
· By reducing the stimulation of the dopamine system in the
brain, antipsychotic drugs can eliminate the hallucinations and
delusions experienced by patients with Sz.
· The effectiveness of these dopamine antagonists in reducing
the symptoms of Sz is what led to the development of the
dopamine hypothesis.
Typical Anti-Psychotic Drugs
Kapur et al (2000)
Approx. 60-75% of D₂ receptors need to be blocked in the
mesolimbic pathway for drugs to be effective.
• Unfortunately this also mean the D₂ receptors in the rest of
the brain are blocked too, leading to side effects.
Typical Anti-Psychotic Drugs
Side Effects
One example of such side effects is where the
extrapyramidal network in the cerebral cortex is
impacted.
This area is concerned with movements & motor
activity.
Prolonged use of Typical neuroleptics can lead to side
effects such as involuntary movements of tongue, face,
jaw etc. (Tardive Dyskinisia)
Atypical Anti-Psychotic Drugs
• Examples of this type of drug include clozapine, these newer type of
drugs, founded in the 1990’s, are said to combat the positive symptoms of
Sz as well as the negative symptoms too.
• This is because as well as acting on the dopamine system they are also
thought to block serotonin receptors.
• In the same way as conventional psychotics they also bind to D2 receptors
but rather than permanently block the dopamine action, they temporarily
bind to the receptors and then rapidly dissociate to allow normal
dopamine transmission.
Atypical Anti-Psychotic Drugs
Task: Complete the grid showing the similarities &
differences between the two types of neuroleptics.
Typical
Similarity
Similarity
Difference
Difference
Atypical
Task: Complete the grid showing the similarities &
differences between the two types of neuroleptics.
Typical
Atypical
Similarity
Lowers the amount of
dopamine.
Lowers the amount of
dopamine.
Similarity
Bad side effects such as
tardive dyskinesia.
Bad side effects such as
agranulocytosis.
Similarity
Based on assumptions from
Biological approach.
Based on assumptions from
Biological approach.
Also affects Serotonin.
Difference
Only affect one
neurotransmitter – Dopamine.
Difference
Has little effect on negative
symptoms.
Works to alleviate positive
and negative symptoms,.
Research methods evaluation task
Leucht (2012) conducted a meta-analysis
- Included nearly 6000 patients
- 64% of placebo group relapsed within 12 months
- 27% of drug group relapsed within 12 months
1. Write a two mark definition of a meta analysis?
2. How many people were in each condition?
Research methods evaluation task
Leucht (2012) conducted a meta-analysis
- Included nearly 6000 patients
- 64% of placebo group relapsed within 12 months
- 27% of drug group relapsed within 12 months
1. Write a two mark definition of a meta analysis?
A research method in which the researcher statistically analyses the findings of a
number of studies to investigate overall effect.
2. How many people were in each condition?
- 1,920
Evaluation Task: Complete the summary table of some
evaluation for the two main drug treatments.
Typical
Success rates
Side effects
Relapse rates
Compliance
rates
Ethical issues
Atypical
Appropriateness of drug therapy
• Drugs treat the symptoms
of the disorder, but not the
cause.
• An antipsychotic drug
cannot seek out and
kill/change the cause of
schizophrenia.
• We don’t know what the
cause of schizophrenia is –
so all drugs do is help
reduce the effect of the
illness.
Appropriateness of drug therapy
• Some sufferers who undertake drug therapy are
liable to relapse after the drugs have been
discontinued.
• Sufferers can also get used to drug therapy, their
bodies begin to compensate and change, therefore
dependency becomes an issue.
• As a consequence, higher and higher doses are
needed.
Appropriateness of drug therapy
• There are some serious side effects related to
antipsychotic drugs
• Between 20-25% of sufferers will suffer from
some form of disordered motor movements
like tremors and involuntary tics.
(E.g. Tardive Dyskenisia)
• This is a reason why about 50% of sufferers
stop taking drugs within the 1st year. However,
the newer forms of antipsychotic drugs have
been found to be more effective.
Effectiveness of drug therapy
• For most sufferers, antipsychotic drugs successfully
calm the effects of schizophrenia.
• Silverman (1987) stated that antipsychotics have
beneficial side effects for some people in increasing
levels of attention and information processing.
• Chlorpromazine is probably the most widely used
antipsychotic and was 1st used on schizophrenia
patients in 1952 by Delay & Deniker.
• Chlorpromazine has been found to be more effective
than the phenothiazines, helping approximately 8085% of schizophrenics (Kane, 1992)
Ethics of drug therapy
• Discuss as a class the cost/benefit of taking
neuroleptics as a treatment for Schizophrenia.
• Which type is better? Have a look at what
Crossley (2010) says on page 147.
Task
Overall, is it worth taking antipsychotic
medication to treat schizophrenia?
List at least 3 points for each side of the debate
For
Against
Challenge
Choose one of the Studies from below and look
at the report.
Summarise them in 100 words or less.
• Lieberman et al (2005)
• Schooler et al (2005)
• Kahn et al (2008)
How do I start to revise this?
•
•
•
•
Biological treatments – need 2 – drug therapy is 1.
Antipsychotic drugs (neuroleptics)
Alleviate + symptoms by blocking dopamine
2 types – typical (chlorpromazine) & atypical
(risperidone)
• Appropriateness – treat symptoms not cause, liable
to relapse, dependency, side effects, positive
symptoms only.
• Effectiveness – Increase attention/info. Processing,
chlorpromazine helps 80-85% of sufferers.
Essay question part 1
‘Therapies can be time-consuming and, in some cases,
uncomfortable for the client. It is, therefore, very
important to offer the most appropriate and effective
type of treatment.’
Outline and evaluate two or more therapies used in
the treatment of schizophrenia.
(Total 16 marks)
Just do one for now. How many marks for outline and
evaluate?
Mark scheme
Mark scheme
Schizophrenia
Cognitive Behavioural Therapy
What the spec says…
•
Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and
delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability
and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity,
culture and gender bias and symptom overlap.
•
Biological explanations for schizophrenia: genetics, the dopamine hypothesis and neural
correlates.
•
Psychological explanations for schizophrenia: family dysfunction and cognitive explanations,
including dysfunctional thought processing.
•
Drug therapy: typical and atypical antipsychotics.
•
Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia.
Token economies as used in the management of schizophrenia.
•
The importance of an interactionist approach in explaining and treating schizophrenia; the
diathesis-stressmodel.
When you come in…
What can you remember about CBT?
Ellis
ABC
Beck
Negative
Triad
CBTp
The CBT approach to treatment differs slightly from
conventional CBT methods.
The aims of this therapy are:
•
•
•
•
To challenge and modify delusory beliefs
To help the patient to identify delusions
To challenge those delusions by looking at evidence
To help the patient to begin to test the reality of the
evidence
Task: The CBTp phases
• In your groups, gather information from one of the
stations.
• Groups then change – must include someone from
each of the stations.
• In these new groups explain to each other what
you’ve learned. As a group, decide on the order in
which you think the CBTp phases progress.
Station 1
Critical collaborative analysis
• Gentle questioning is used by the therapist to help the patient understand
their illogical thought processes.
“If your voices are real, why can’t anyone else hear
them?”
• The therapeutic relationship is essential here so that questioning can be
used in a non-threatening way.
• This means there needs to be trust between therapist and patient. The
core conditions of empathy and UPR must also be present.
Station 2
The ABC Model
• Patient describes (A)ctivating event that is the cause
of their irrational (B)eliefs/behaviour, as well as the
(C)onsequences.
• These beliefs can then be challenged or disputed and
changed.
“People won’t like me if I tell them about my voices.”
Becomes
“Some may, some may not. Friends might find it
interesting.”
Station 3
Engagement
• The therapist provides a therapeutic environment for
the patient where they can engage in therapy.
• This includes the therapist empathising with the
patient’s perspective, feelings of distress etc.
• The therapist must also stress that explanations for
the patients’ distress can be developed together.
Station 4
Normalisation
• Knowing that there are other people who experience
the same things as you can help to greatly reduce
feelings of isolation and anxiety.
• Placing psychotic experiences on a continuum of
‘normal’ experiences can help patients feel less
stigmatised.
Station 5
Developing alternative explanations
• Very CBT technique of discussing alternative
explanations for unhealthy assumptions.
• This can be done in collaboration with the therapist.
Station 6
Assessment
• The client expresses their experiences and symptoms
to the therapist.
• Goals and expectations of therapy can be established
here.
The CBTp phases
1. Assessment
2. Engagement
3. The ABC Model
4. Normalisation
5. Critical Collaborative Analysis
6. Developing Alternative Explanations
Psychological Treatment;
Behavioural
What do you think some of these techniques might involve?
 Implosion Flooding Modeling-
Psychological Treatment;
Behavioural
 Implosion- Extinguishing anxiety by inducing the client to imagine
intensely anxiety-provoking scenes that, because they produce no
harmful consequences, lose their power to induce fear.
 Flooding- Extinguishing anxiety by exposing the clients to actual fearproducing situations that, because they produce no harmful
consequences, lose their power to induce fear.
 Modeling- Exposing clients to desired behaviour that is modeled by an
other person, and rewarding the client for imitating that behaviour.
Evaluation of CBT
The National Institute for Clinical Excellence (NICE)
-
CBTp is more effective in reducing rehospitalisation rates after 18 months than
standard care alone (neuroleptics).
- CBTp is also effective in reducing severity of symptoms and can improve social
functioning.
They say…
“CBTp in conjunction with antipsychotic medication, or on its own if medication is
declined, can improve outcomes such as psychotic symptoms. It should form part
of a broad-based approach that combines different treatment options tailored to
the needs of individual service users.”
- https://www.nice.org.uk/guidance/qs80/chapter/quality-statement-2-cognitivebehavioural-therapy
What can we do with this information?
However,
- Difficult to establish the effectiveness of CBTp alone, as most patients use it in
conjunction with Anti-Psychotics.
Evaluation of CBT
Despite the NICE recommendations, approximately 1 in 10 of those who need
it, are able to access CBTp
Haddock et al (2013)
- Of 187 randomly selected schizophrenic patients from the North West of
England, 6.9% had been offered CBTp.
Evaluation of CBT
Doesn’t work for everybody
 i.e. not suitable when the patient are deluding as they cannot fully engage
with the therapy
 Depending on the stage of disorder, depends on the success of treatment.
 Addington and Addinton (2005) suggest that initial acute phase is not
conducive to self-reflection, therefore engagement will be a problem.
 They say that once symptoms have stabilised with medications, group
CBTp may be more beneficial.
Evaluation of CBT
 Gould et al. carried out a meta-analysis of seven studies and found a
significant decrease in the positive symptoms of Sz.
 Kuipers et al. found that when combined with antipsychotic drugs there
was a lower drop out rate and greater patient satisfaction.
One of the problems with meta-analyses is that they do not consider the
quality of studies
- E.g Some don’t randomly allocate to each condition.
Evaluation of behavioural Approach
 Effective treatments
 Cognitive sense
 Patient responsible
 Unethical?
 Impractical methodology?
 Restricted application
K. A. E. D
K Knowledge
A Application
E Evaluation
D Discussion
K. A. E. D
K
There is research to suggest that CBTp is effective in managing symptoms of
Schizophrenia in patients. For example, Gould et al. carried out a meta-analysis of seven
studies and found a significant decrease in the positive symptoms of Sz.
A For example, by getting patients to identify the activating event for their experiences of
paranoid delusions, and challenging those beliefs, patients are able to develop new,
more beneficial coping strategies.
E
However, much of the research into the effectiveness of CBTp has been meta-analyses.
This presents a problem in that they do not consider the quality of the studies being
discussed. For example, some studies do not randomly allocate participants to each
condition, which might negatively influence the reliability of the study. There is
therefore a potential to reach unreliable conclusions as to the effectiveness of CBTp for
individuals with Schizophrenia (Juni et al, 2001).
D Despite this, there is much support for CBTp to be used as a treatment for patients
diagnosed with Schizophrenia. NICE (2014) recommend it as a preferred line of
treatment alongside traditional neuroleptic drug therapy. However, Haddock (2013)
found that there is a lack of availability of CBTp, and that in a sample of 187 randomly
selected patients, only 6.9% had been offered CBTp.
Essay question part 1
‘Therapies can be time-consuming and, in some cases,
uncomfortable for the client. It is, therefore, very
important to offer the most appropriate and effective
type of treatment.’
Outline and evaluate two or more therapies used in
the treatment of schizophrenia.
(Total 16 marks)
Add to your answer from Drug therapies using the work
you’ve just completed.
Mark scheme
Mark scheme
What the spec says…
•
Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and
delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability
and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity,
culture and gender bias and symptom overlap.
•
Biological explanations for schizophrenia: genetics, the dopamine hypothesis and neural
correlates.
•
Psychological explanations for schizophrenia: family dysfunction and cognitive explanations,
including dysfunctional thought processing.
•
Drug therapy: typical and atypical antipsychotics.
•
Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia.
Token economies as used in the management of schizophrenia.
•
The importance of an interactionist approach in explaining and treating schizophrenia; the
diathesis-stressmodel.
Family Therapy
Expressed Emotion
• Through our understanding of the expressed emotion explanation of Sz,
we know that people with Sz are more likely to relapse if they come from
families where they experience high levels of criticism, hostility and over
involvement.
• Therefore Family Therapy seeks to treat members of the family as well as
the the patient with Sz.
• The hope is to hopefully reduce the high level of EE within the household
which is causing the relapse.
Family Therapy
How it works
Family therapy usually takes place within the people’s homes and typically
two family therapists will work with the relatives and patient.
It lasts between 3-12 months with sessions every 2-4 weeks. A minimum of
10 sessions are recommended by NICE.
The therapists work with the family and the patient to develop strategies to
cope better with the mental disorder and its symptoms.
This hopefully leads to a more supportive and warm atmosphere which helps
the patient make better progress and the relatives to feel more positive
about, and more effective in, their supporting roles.
Family Therapy
How it works
The relatives are made more aware of the information regarding psychosis
and the particular diagnosis their relative has been given.
The therapist encourages the relatives to ask questions and learn more about
the disorder so they can properly understand the difficulties the patient faces.
The patient will also be asked to discuss their symptoms with the family as
they are the expert in this situation!
The goal is also to provide the whole family with practical coping skills which
enables them to manage the everyday difficulties arising from having Sz in the
family.
Family Therapy
Family members learn more constructive ways of communicating and are
encouraged to concentrate on any good things that happen rather than
negative events.
The relatives and the patient are also told that it is normal to feel angry and
impatient towards each other but that they need to find ways of coping with
these feelings without resorting back to high EE patterns of behaviour (which
increase relapse).
Lastly, the family and the patient are trained to recognise the early signs of
relapse so that they can respond rapidly to reduce the severity of it.
Garety (2008) - Relapse rates are reduced to 25% following Family Therapy,
as opposed to 50% for those receiving standard care alone (neuroleptics).
Key Study Task
1.
What did Pharoah (2010) have to say about the effectiveness of Family
Therapy in patients with Schizophrenia? (Page 150)
2.
Why was random allocation important for this study?
3.
What are some ethical issues around allocating patients to a control
group or a therapy group?
4.
Can you think of any evaluation of this study?
Evaluation of Family Therapy
National Collaborating Centre for Mental Health (NCCMH, 2009)
Sample: A meta-analysis involving 32 studies and nearly 2500 participants.
Method: Compared those having family intervention therapy to those
receiving standard (drug) therapy.
Findings: The relapse rate in the family intervention condition was 26% and in
the control (standard care) condition it was 50%. There was also a reduction
in hospital admissions during treatment and in the severity of symptoms both
during and up to 24 months following
Therefore…
Task: Evaluation of Family Therapy
What other evaluation can you put together?
You have 5 minutes to get as many points as you can.
We shall compile them on the board as a class via ‘Creeping Death’!
Consider both effectiveness and appropriateness of this therapy.
What the spec says…
•
Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and
delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability
and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity,
culture and gender bias and symptom overlap.
•
Biological explanations for schizophrenia: genetics, the dopamine hypothesis and neural
correlates.
•
Psychological explanations for schizophrenia: family dysfunction and cognitive explanations,
including dysfunctional thought processing.
•
Drug therapy: typical and atypical antipsychotics.
•
Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia.
Token economies as used in the management of schizophrenia.
•
The importance of an interactionist approach in explaining and treating schizophrenia; the
diathesis-stressmodel.
When you come in…
• Think back to what you
learnt about the learning
theory & generalisation &
operant conditioning at AS
level.
• Remind yourself about
positive and negative
reinforcement and
punishment.
Token Economy
A technique which reinforces appropriate behaviour by giving or
withholding tokens which can be exchanged for privileges.
Ayllon & Azrin (1968)
Used Token Economy in women's ward in a mental institution in the US.
- They were rewarded with tokens for self-care
- These could be exchanged for privileges like watching films etc.
- ‘Desirable’ behaviours increased significantly.
- However, these decreased significantly once the system was withdrawn.
Token Economy
• A token economy programme involves a system of rewards being set up
for desired behaviour, sometimes with punishments to discourage
behaviour which is undesirable.
• Rewards are usually tokens or points, and these can be periodically
exchanged for something that the individual wants.
• This is an important part of the programme as
the rewards must genuinely reward the person.
Token Economy
• Desirable behaviour such as co-operation and compliance is reinforced
with the use of tokens.
• These tokens have no intrinsic value and are called secondary reinforcers.
• They can however be exchanged for primary reinforcers which are things
that are wanted by the person.
Procedure of a Token Economy
Programme
It is very important that there are clear definitions of:
•
•
•
•
•
what is a desired behaviour
what is a token
how tokens are allocated
what is a reward
how there will be gradual changing of the giving of tokens to
shape the behaviour
• how many tokens there are for each reward
• how the reward will be removed once the behaviour is
achieved
Task: Evaluation of a Token Economy
Programme
Using the textbook/ internet, evaluate the use of TEP’s in
Schizophrenia treatment.
- Do they work?
- What evidence do you have?
- Why TEP’s may not work
- Advantages of TEP’s
Evaluation of a Token Economy
Programme
In the 1970’a when TEP’s were evaluated to see if they worked, it
was concluded that they did not!
Ayllon and Milan (1979) reviewed a number of programmes and
found that they worked for certain behaviours e.g. the general
keeping of rules and control over interpersonal aggression.
Milby (1975) found that programmes were successful in
psychiatric hospitals and helped in preparing someone to
leave hospital BUT we do not know if the effects worked long
term.
Evaluation of a Token Economy
Programme
+ Can be administered by anyone (with training) and tokens and
rewards are relatively cheap, so the programme is not
expensive and there are more benefits than costs.
+ Has been found to be successful by many studies, even
though approx. 10 – 20 % of people do not respond well to
TEP’s.
- Learning may not transfer to the home environment, so there
might be relapse.
- Programmes have to be carefully planned and controlled, and
there are many areas where problems can occur such as lack
of consistency from staff.
Exam Question
Discuss token economies as a method used in the management
of schizophrenia.
(Total 8 marks)
Mark Scheme
Possible content:
• Outline of token economies – awarding of ‘tokens’ when patients with schizophrenia
show desirable behaviour. Tokens can be exchanged later for eg sweets
• Based on Skinnerian operant conditioning principles
• Used for behavioural shaping and management so that patients in long stay hospitals
are easier to manage
Possible discussion points:
• Evidence suggests token economies can be effective in improving behaviour in
psychiatric hospitals
• Token economies do not address symptoms of schizophrenia, so they are not a
‘treatment’
• Not effective with unresponsive patients eg with negative symptoms
• Ethical issues – treats patients as lab rats
Credit other relevant information.
Homework
1.
Read pages 154-155 & the Pp slides provided, on an Interactionist Approach
to Schizophrenia.
- In particular what did Tienari (2004) do?
1.
2.
Watch this video https://youtu.be/CuQHSKLXu2c
Create 2 exam style questions based on this information
(minimum 8 marks)
- 1 Outline question
- 1 Evaluate question
Bring these with you next lesson.
It is essential you do this otherwise you won’t be able to participate in the
lesson.
What the spec says…
•
Classification of schizophrenia. Positive symptoms of schizophrenia, including hallucinations and
delusions. Negative symptoms of schizophrenia, including speech poverty and avolition. Reliability
and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity,
culture and gender bias and symptom overlap.
•
Biological explanations for schizophrenia: genetics, the dopamine hypothesis and neural
correlates.
•
Psychological explanations for schizophrenia: family dysfunction and cognitive explanations,
including dysfunctional thought processing.
•
Drug therapy: typical and atypical antipsychotics.
•
Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia. Token
economies as used in the management of schizophrenia.
•
The importance of an interactionist approach in explaining and treating schizophrenia; the
diathesis-stressmodel.
When you come in…
Write your exam style questions on the board.
Task: Diathesis-Stress Model
1. Divide into small groups - each group has one of these
questions
2. Each group spends ten minutes to write everything that
comes to mind in relation to the topic (no books or notes!)
3. Afterwards, each group migrates to another table and looks
at another question and the comments which have already
been recorded, reviewing them and adding additional
comments.
4. After each group has added comments to all other groups’
questions, return to the initial question, review the
additional comments provided, and summarize to the entire
class.
Homework
Revise for the end of topic test!