Introduction to Schizophrenia

Diagnosis and Classification

Schizophrenia is a severe mental disorder where people’s contact with reality is impaired, along with their
reasoning’s.

The two systems differ in classification of schizophrenia,

 In the DSM, only one of the positive symptoms must be present to have schizophrenia
 In the ICD, only two or more negative symptoms must be present to have schizophrenia

Classification- identify symptoms that go together

Diagnosis- identify symptoms and use classifications to identify the disorder

Symptoms of Schizophrenia
Positive symptoms Negative symptoms
 Delusions- beliefs that have no basis of  Avolition- loss of motivation to carry
reality, and behaves in ways bizarre to out every day work, for example taking
others. For example, beliefs about being part in hobbies and personal care
an important victim
 Hallucinations- unusual sensory  Speech poverty- a reduction in the
experiences that have no basis in reality, amount and quality of speech. This
or distorted perceptions of real things. For includes a delay in verbal responses
example, seeing or hearing things which during conversation.
aren’t there
 Positive symptoms of schizophrenia involve the gain of unusual abilities or experiences
 Negative symptoms of schizophrenia involve the loss of usual abilities or experiences
 1. Hallucinations 2. Avolition and speech poverty

One strength of diagnosis of schizophrenia is good reliability

A reliable diagnosis is consistent between inter rater and test retest. Researchers report excellent reliability for
schizophrenia diagnosis. DSM finds the inter-observer agreement of +.97 and test reliability of +.92. This means
that diagnosis of schizophrenia is consistently applied

One limitation of diagnosis of schizophrenia is low validity

Criteria of validity involves seeing whether different procedure used to assess the same individuals arrive at the
same diagnosis. Researchers had to assess 100 clients, whereas 68 were diagnoses with schizophrenia with
ICD, but only 39 with DSM. This means that schizophrenia is under- or -over diagnosed, suggesting criterion of
validity is low.

Another limitation is gender bias

Men with schizophrenia more often that women in a 1:4:1 ratio. This could be because more men are genetically
vulnerable, or women have better social support in masking the symptoms. This means that some women with
schizophrenia are not diagnosed so they miss out on helpful treatment.

Another further limitation is culture bias

Some symptoms such as hearing voices are sometimes accepted in cultures, for example afro Caribbean
societies hear voices from ancestors. Afro-Caribbean british men are up to 10 times more likely to be diagnosed
with schizophrenia, due to the over interpretation of symptoms by UK psychiatrists. This means Afro-Caribbean
men living in the UK appear to be discriminated against by a culturally-biased diagnostic system

Biological treatments for schizophrenia

Typical antipsychotics- Chlorpromazine

Works as an antagonist in the dopamine system. Antagonists are chemicals which reduce the action of
neurotransmitter. Dopamine is an excitatory transmitter; antagonists prevent the excitatory effect of dopamine.
Dopamine antagonists block dopamine receptors in the synapse of the brain

Dopamine is released by presynaptic neuron; this results in over productivity of dopamine. Chlorpromazine
attaches itself to the receptors in postsynaptic neuron, which means dopamine can’t attach itself.

there are more receptors in schizophrenia patients which means there will be an over activation of the signals in
the pathways. Chlorpromazine binds to the receptors but doesn’t activate them, this reduces the chemical signals
in the excess of dopamine.

Atypical antipsychotics- Clozapine and Risperidone

Atypical antipsychotics are new ways of inventing the drug, with less side effects. Two examples are: clozapine
and risperidone

Clozapine
Acts on the serotonin and glutamate receptors which are neurotransmitters, this action improves mood and
reduces depression. Clozapine is so effective that it’s prescribed when the patient is at risk of suicide. The major
side effect is that it comes with a fatal blood condition, therefore not available as an injection and only given at a
lower dose.
Risperidone
This works in the same way clozapine works, as it binds to dopamine and serotonin receptors. Risperidone binds
strongly to dopamine than clozapine does, this is given is small dosage to reduce the side effects, and works the
same way as chlorpromazine but lasts longer.

One strength of antipsychotics is evidence of their effectiveness

Thornley reviewed data from 13 trials and found chlorpromazine was associated with better functioning and
reduced symptom severity compared with placebo

There is also support for the benefits of atypical antipsychotics. Meltzer concluded that clozapine is more
effective than typical antipsychotics, and that it’s effective in 30-50% of treatment-resistant cases.

This means as far as we know, we can tell that antipsychotics work.

One limitation of antipsychotic drugs is the likelihood of side effects.

Typical antipsychotics are associated with dizziness, agitation, sleepiness and weight gain. Long-term use can
lead to involuntary facial movements due to dopamine’s super sensitivity

The most serious side effect is NMS, caused by the blocking of dopamine in the hypothalamus, which means
there is disrupted regulation of the body system.

This means antipsychotics can do harm instead of good, and individuals may avoid them which reduces
effectiveness

Another explanation could be the chemical cosh

Its believed anti-psychotics are used in hospitals to calm people with schizophrenia and make them easier to
work with.

However, calming people distressed by hallucinations makes them feel better and allows them to engage with
other treatments, for example CBT

This means antibiotics aren’t the best treatment for schizophrenia, and maybe other factors are involved in its
success

Explain how chlorpromazine works as a dopamine antagonist [6]

Chlorpromazine is as a typical antipsychotic; they work as antagonists in the dopamine system and aim to reduce
the action of dopamine. Dopamine antagonists work by blocking dopamine receptors in the synapse in the brain,
reducing the action of dopamine, dopamine levels build-up after taking chlorpromazine, but then production is
reduced. This normalises neurotransmission in the key areas of the brain which reduces the symptoms such as
hallucinations. Chlorpromazine has an effect on histamine receptors which lead to a sedation effect.
Chlorpromazine can be used to calm anxious patients when first administered to a hospital
Psychological therapy for schizophrenia
Cognitive Behavioural Therapy
Discuss CBT as a treatment schizophrenia [8]

CBT aims to deal with thoughts and mental behaviour, CBT helps patients understand where their delusions and
hallucinations come from to help with their maladaptive behaviour. One technique used is Reality Testing, where
the therapist examines the likelihood that the irrational beliefs are true.

One strength of CBT is its effectiveness.

Researchers examined 30 participants who had schizophrenia with CBT and found that there are significant
effects on the symptoms such as the frequency and severity of hallucinations.

Researchers have found reductions in auditory hallucinations. Clinical advice has found that NICE also
recommends CBT for schizophrenia.

This shows that clinical evidence supports the use of CBT for schizophrenia.

This links to the fact that CBT is favored over drug therapy, this is because CBT establishes a rapport between
the therapist, which makes the schizophrenic patient feel a peace of mind, knowing their experience of
schizophrenia is being expressed to someone that can help them.

One limitation of CBT is the quality of evidence

CBT symptoms may vary from one person to another. Research has found that different studies have different
CBT techniques to treat positive and negative symptoms.

The benefits of CBT have a wide variety of effects due to the different techniques.

This makes it hard to say how effective CBT is for a particular person with schizophrenia.

This links to the idiographic debate, that every individual is different and unique in their own nature, meaning it’s
hard for data to be replicated.

Family Therapy
Discuss Family therapy as a treatment schizophrenia [8]

Family therapy aims to improve the quality of communication and interaction with family members. For example,
it reduces levels of expressed emotions and negative symptoms such as anger and guilt, which creates stress.
Family therapy helps with the ability to maintain a balance between supporting the individual with schizophrenia
and living their own lives.

One strength of family therapy for schizophrenia is its effectiveness.

A review of studies concluded that family therapy was one of the most consistently effective treatments available
for schizophrenia. In particular relapse rates were found to be reduced, typically by 60%.

Researchers also concluded that using family therapy as mental health initially starts to decline is particularly
promising. Clinical advice from NICE recommends family therapy for everyone with a diagnosis of schizophrenia.

This means that family therapy is likely to be of benefit to people with both early and ‘full blown’ schizophrenia.

A further strength of family therapy is that it benefits the family

Therapy is not just for the benefit of the identified patient but also for the families that provide the bulk of care. A
review of evidence concluded that these effects are important because families provide the bulk of care for
people with schizophrenia.

By strengthening the functioning of a whole family, family therapy lessens the negative impact of schizophrenia
on other family members and strengthens the ability of the family to support the person with schizophrenia.

This means that family therapy has wider benefits beyond the obvious positive impact on the identified patient.

Token economies to manage schizophrenia

Token economies help to improve quality of life within the hospital setting, for example becoming sociable with
other residents. It also encourages people to return to normal behaviour, making it easier to adapt into the
community, for example making your bed

Tokens are given after performing desirable behaviour. Target behaviours are decided based on knowledge of a
person. Tokens have no value themselves but are swapped for rewards such as magazines or sweets.

Token economies are examples of behaviour modification, based on operant conditioning. Tokens are secondary
enforces, exchanging for rewards are directly rewarding. Tokens can be exchanged for primary reinforcers, which
are also called generalized reinforcers, which have a more powerful effect

One limitation with the use of token economies to manage schizophrenia is the ethical issues raised.

The use of token economies raises ethical issues because it gives professionals power to control the behaviour
of the patient, which involves forcing one person's norms on other.

Restricting the availability of pleasures (e.g., having sweets or seeing films) to people who don’t behave as
desired means that seriously ill people, who are already experiencing distressing symptoms, have an even worse
time.

This means that the benefits of token economies may be outweighed by their impact on personal freedom and
short-term reduction in quality of life.

One strength of token economies is its effectiveness

Researchers identified seven high quality studies that examined the effectiveness of token economies for people
with schizophrenia and involved patients living in a hospital setting.

All the studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours.
This supports the value of token economies.

This means that there is a serious question over the evidence for the effectiveness of token economies.

A further limitation of token economies is the existence of more pleasant and ethical alternatives.
Other approaches don’t raise ethical issues, for example art therapy is a high-gain low-risk approach to
managing schizophrenia.

Even if the benefits of art therapy are modest, this is true for all approaches to treatment and management of
schizophrenia and art therapy is a pleasant experience

This means that art therapy might be a good alternative to token economies

Asha is a 23-year-old male. He has been on the psychiatric ward for 8 months. Although his positive
symptoms seem to be responding well to chlorpromazine, he is now showing signs of apathy; he doesn't
want to shower or brush his teeth: Before being diagnosed with schizophrenia, he enjoyed weight
training and playing video games.

Imagine you are the manager of a psychiatric ward and are running the token economy system. Create a
token economy plan for this particular patient [4]

Token
Target behaviour Reward per tokens
value
14 tokens for the whole day- gets to play video
Showering by himself 3
games
26 tokens for the whole span of two weeks- go
Brushing teeth daily 2
outside for walk
Interacts in a pro-social way to staff members 28 tokens for the whole of the week- gets to have
4
requests dessert
If he shows daily interests in group activities 5 15- gets to play video games

Using your knowledge of token economies, explain what they are, how they work, and what is your
rationale behind them. Refer to Asha in your answer [6]

Token economies are an example of operant conditioning, this means that positive behaviour will be reinforced
when given a reward. Asha is showing signs of Apathy when he enters the psychiatric ward, to help improve his
behaviour, the ward gives him a token every time he shows interests in group activities. This will then help him
become more encouraged.

Token economies are secondary reinforces, meaning that they only gain value when they are associated with
meaningful awards. If Asha successfully completes multiple tasks effectively, such as showering, these functional
behaviours will help him when he leaves the hospital, so that the rewards are meaningful and have application to
the outside world to benefit him.

Rationale for token economies makes it so that they can improve on their hygiene or interact with others.
Modifying behaviour improves their quality of life and also improves their life style conditions. This means Asha
will be able to successfully respond to others and not show negative signs, for example his apathy and not
listening to the staff if he takes part in the token system.
Interactionist approach to schizophrenia: the
diathesis stress model
The approach also known as the biosocial approach, because there are biological and sociological factors in the
development of schizophrenia and that these interact in varying degrees. Diathesis means vulnerability. Stress
means negative psychological experience. This model states both are necessary to develop this condition.

Meehl’s model (old model)

The DSM was entirely genetic, the result of a single ‘schizogene’. This led to the development of a biologically
based schizotypical personality, one characteristic is sensitive to stress. Without the schizogene, no stress would
lead to schizophrenia. Carriers of the gene combined with the stress, the schizophrenogenic mother results in the
trigger of schizophrenia.

Modern understanding of diathesis

The modern understanding argues the model can be biological, but also psychological. If it is biological, then it’s
polygenic, as each gene appears to increase the vulnerability. The modern understanding argues psychological
trauma as proposed to a neurodevelopmental model in which childhood trauma alters the brain, which alters the
way we become alert in the fight/flight system

Modern understanding of stress

The modern understanding argues that any risks can trigger schizophrenia. Recent research shows that
cannabis can increase schizophrenia by 7 times. This results as the trigger are the diathesis (vulnerability) is
present. This is because it interferes with the dopamine system.

Treatment according to the interactionist model

Antipsychotic drugs and CBT- antipsychotic drugs are taken with CBT. This requires adopting an interactionist
model, sink its not possible to adopt a biological approach, tell patients their condition is biological has no
psychological significance, and then they treat them with CBT.

In the UK, it’s the standard to treat people with CBT and drugs. in the US, there’s a conflict between
psychological and biological models of schizophrenia which may have led to slower adoption of the interactionist
model

One strength is support for the role of vulnerability and stress.

Studies which involved adopted children who were separated from their mothers were diagnosed with
schizophrenia. The adoptive parents’ parenting styles were assessed and compared with a control group of
adoptees with no genetic risk.
A child rearing style with high levels of criticism and conflict and low levels of empathy was implicated in the
development of schizophrenia but only for children with a high genetic risk.

This shows that a combination of genetic vulnerability and family stress leads to an increased risk of
schizophrenia

One limitation is that it’s over simplistic

Multiple genes increase vulnerability, with a small effect of its own. There is no schizogene, stress comes in
many forms, including dysfunctional parenting.

Researchers now believe stress can include biological factors, for example researchers have found childhood
sexual trauma was a diathesis, and cannabis was the trigger.

This means that there are multiple factors, biological and psychological, affecting diathesis and stress.

Another strength is real-world application of interaction

Researchers randomly allocated 350 participants to a medication and CBT group or supportive counselling
group, or a medication group only.

The participants in two combination groups showed lower symptom levels than those in the control group.

This means there is advantages of adopting the interactionist approach in the form of superior treatment of
outcomes

Outline the interactionist approach to explaining schizophrenia [6]

Meehl argues that the DSM is entirely genetic, due to the result of a single ‘schizogene’. This led to the
development of a biologically based schizotypical personality. Carriers of the schizophrenogenic gene, combined
with the stress, which is the schizophrenogenic mother, results in the trigger of schizophrenia

The modern understanding argues the model can be biological, but also psychological. If it is biological, then it’s
polygenic, as each gene appears to increase the vulnerability. The modern understanding argues psychological
trauma as proposed to a neurodevelopmental model in which childhood trauma alters the brain, which alters the
way we become alert in the fight/flight system

The modern understanding argues that any risks can trigger schizophrenia. Recent research shows that
cannabis can increase schizophrenia by 7 times. This results as the trigger are the diathesis (vulnerability) is
present. This is because it interferes with the dopamine system.