schizophrenia culture vs diagnosis psychology 9990 students a level

schizophrenia

1. Paper 3 Option: Schizophrenia Classification and Diagnosis

2. 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-stress model.

3. 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. I have never…

4. 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?

5. 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?

6. 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) Clinical Characteristics

7. 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 Prevalence

8. 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 Positive Symptoms

9. 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. Delusions

10. Auditory/Visual- Usually 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. Hallucinations

11. W here an individual behaves in ways that seem inappropriate or strange to the norms of society. - Can you think of any examples? Catatonic or Disorganised Behaviour

12. 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. Disorganised Speech

13. Schizophrenia simulation

14. A diminution or loss of normal functions to include: Affective Flattening Physical Anhedonia Social Anhedonia Avolition Alogia Negative Symptoms

15. 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 ). Negative Symptoms

16. 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. Task

17. Discuss reliability and/or validity in relation to the diagnosis and classification of schizophrenia. (Total 8 marks) Exam Question

18. Mark Scheme

19. Schizophrenia Issues of Classification and Diagnosis

20. 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-stress model.

21. 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) When you come in…

22. 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. Issues around diagnosis of Schizophrenia

23. 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 ) Reliability of Classification Systems

24. The two most widely used classifications systems for diagnosis of schizophrenia are: ICD-10 DSM-V Classification Systems

25. 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.

26. 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 10 th edition. Used in the UK and many other European countries

27. DSM O ne 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? Differences between ICD and DSM in Diagnosis of Schizophrenia

28. Add to your brainstorm… Discuss issues associated with the classification and/or diagnosis of schizophrenia. (Total 16 marks) Task

29. 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 & Validity

30. Reliability What issues with diagnosis do you think might arise from the following; Culture Gender Symptom overlap Co-morbidity

31. 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 .?

32. Although Sz occurs across cultures- finding in USA/UK- more frequently among African American and African- Caribbean pops Not clear whether it reflects greater genetic vulnerability, psychosocial factors , minority groupings or misdiagnosis . Culture

33. 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.

34. 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.

35. 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.

36. 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?

37. Mike Mike is a 33 year old divorced male with two children he rarely ever sees,  ages 8 and 10. He has never been seen by a psychiatrist.  His family doctor has tried to get him to see a local psychiatrist but Mike refuses to go. Mike says he knows someone has removed his brain and replaced it with someone else's.  He believes that this brain is controlling him and that he is not responsible for his actions.  He works everyday and has been in his current job for 15 years.  He says he has lots of friends but sometimes he thinks its one of them who did this to him. He is convinced that he must protect his brain by wearing a hat (even to bed) He can speak fine and goes to work everyday. He doesn’t think his thoughts are unusual.

38. Susan Susan is 20 years old. She suffered with depression when she was 15. She has now been discharged from her psychiatrist and been free of depression for the last three years. She is taking her final university exams and has had trouble sleeping and has experienced bad dreams for the last few weeks. She is feeling really stressed out and overwhelmed.

39. Tommy Tommy is 41.According to family he has always been withdrawn and at times his behaviour is inappropriate. His sister-in-law gave the example of him waking her up in the middle of the night to cook home some breakfast! Over the last year Tommy frequently talks at length and is difficult to understand. He often goes days without speaking to people .

40. Mary Mary is 21 and was first presented to the psychiatric services as an out-patient at the age of 19.She gave a two month history of social withdrawal associated with paranoid delusions A diagnosis of probable paranoid schizophrenia was made and she was treated However, her condition continued to deteriorate. Over the next two months she became retarded and mute, and was admitted to hospital. At this time she began to have episodes of freezing and started to walk backwards. During her freezing episodes she should stand rigid for hours and ignored any instructions from nurses to move.  

41. Dave Dave is 24. Over the last 3 months he has been having visions of aliens walking round him when he goes to work. His speech has become rambling and often his friends cannot tell what he is saying. A few weeks ago Dave was told his old college friend had died and in response he laughed. He has stopped showering regularly and believes that his water system has been poisoned. He has lost a lot of weight as he no longer bothers to cook. His neighbor was worried about Dave when she saw him sitting on the floor in the corner shop grimacing.

42. 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

43. 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

44. Add some more points to your brainstorm… Discuss issues associated with the classification and/or diagnosis of schizophrenia. (Total 16 marks) Finally

45. Complete the gap-fill exercise to recap from last lesson. When you come in…

46. 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 Rosenhan (1973)

47. On Being Sane in Insane Places

48. 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

49. 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 fact, Rosenhan sent no-one at all! A 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

50. 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. On Being Sane in Insane Places

51. 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

52. 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.

53. How reliable is Diagnosis? Post it task on board ranging from totally unreliable to 100% effective.

54. 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. Improving Reliability

55. 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

56. 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? Inter- Rater Reliability

57. Crow (1985) believes that Sz is too broad a term because at least two very different conditions exist. Type I syndrome- acute disorder characterised by positive symptoms ( exaggerations of normal beh .) Type II syndrome- chronic disorder- negative symptoms such as flattening of affect, apathy and poverty of speech. Further evidence for this view comes from research that shows that Type 1 and Type 2 Schizophrenics do respond very differently to psychological and biological treatments , e.g. Typical and Atypical Phenothiazines have more success with relieving positive symptoms as does CBT. Problems with above division- people do not fit neatly into one or other category. Blurred distinction between some subtypes- some people diagnosed in one category later develop symptoms from another- weakens reliability Use of Sub-Types

58. Moreover, Schizophrenia has many different categories and symptoms , e.g. Paranoid, Catatonic and Hebephrenic (disorganised). Some of these subtypes have very different qualities; especially Catatonic Schizophrenia where the person can lay motionless in rigid poses for days. Use of Sub-Types

59. 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).

60. 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 Reliability & Validity

61. 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 Validity

62. 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). Evaluation of Reliability

63. 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) Task

64. Find your face! How confident are you in your understanding of Classification & Diagnosis of Schizophrenia, and issues around Validity & Reliability? Finally

65. Schizophrenia Biological Explanations for Schizophrenia

66. 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-stress model.

67. 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.

68. Explanations – Biological vs Psychological Nature vs Nurture

69. Biological Explanations

70. 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.

71. 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.

72. 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….

73. 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.

74. 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

75. 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……..

76. 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.

77. 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.

78. Can you…? Describe Genetic factors of Schiz. in 100 words -Family studies -Twin studies -Adoption studies

79. 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.

80. 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.

81. 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.

82. 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)

83. 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

84. Can you…? Label the image of the synapse .

85. Task Describe biological explanations in 100 words (the dopamine hypothesis) - D2 receptors -Amphetamines -Antipsychotic drugs -Parkinson’s disease

86. 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.

87. 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.

88. 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.

89. 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.......

90. 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.

91. 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.

92. 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.

93. 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.

94. Exam Question TASK: Exam Question: PLAN THE QUESTION Describe and evaluate biological explanations for schizophrenia. Refer to evidence in your answer. (Total 16 marks)

95. Mark Scheme

96. 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?

97. Schizophrenia Psychological Explanations for Schizophrenia

98. 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-stress model.

99. 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.

100. 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.

101. 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.  

102. 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.  

103. 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.

104. 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:

105. 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.  

106. 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.  

107. 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.  

108. 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,

109. 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)

110. 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.  

111. 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.    

112. 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.

113. What’s going on inside the ‘black box’? People are laughing on the bus There’s something wrong with me

114. What’s going on inside the ‘black box’? My papers are not where I left them People are trying to sabotage my career

115. What’s going on inside the ‘black box’? I can’t hear what people are saying My family is plotting against me

116. Task What symptom(s) of Sz can this explain? How?

117. 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.  

118. 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 How do cognitive psychologists study the brain?

119. PET AND MRI scans PET 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 MRI SCANS 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

120. 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)

121. 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.

122. 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. Frith’s Model (1992)

123. Task What symptom(s) of Sz can this explain? How?

124. 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.

125. Task What symptom(s) of Sz can this explain? How?

126. 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.

127. 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?  

128. Exam Question Evaluate psychological explanations of schizophrenia. (Total 16 marks)

129. 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.

130. 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.

131. 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.

132. Schizophrenia Drug Therapy

133. 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-stress model.

134. Lets remind ourselves how neurotransmitters work

135. Lets remind ourselves how neurotransmitters work

136. 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

137. 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

138. 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:

139. 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

140. 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.  

141. 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.

142. 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 )

143. At ypical 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.

144. At ypical Anti-Psychotic Drugs

145. Task : Complete the grid showing the similarities & differences between the two types of neuroleptics . Typical Atypical Similarity Similarity Difference Difference

146. 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. Difference Only affect one neurotransmitter – Dopamine. Also affects Serotonin. Difference Has little effect on negative symptoms. Works to alleviate positive and negative symptoms,.

147. 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 Write a two mark definition of a meta analysis? How many people were in each condition?

148. 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 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. H ow many people were in each condition? - 1,920

149. Evaluation Task : Complete the summary table of some evaluation for the two main drug treatments. Typical Atypical Success rates Side effects Relapse rates Compliance rates Ethical issues

150. 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.

151. 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.

152. 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 1 st year. However, the newer forms of antipsychotic drugs have been found to be more effective.

153. 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 1 st used on schizophrenia patients in 1952 by Delay & Deniker. Chlorpromazine has been found to be more effective than the phenothiazines , helping approximately 80-85% of schizophrenics (Kane, 1992)

154. 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.

155. Task Overall, is it worth taking antipsychotic medication to treat schizophrenia? List at least 3 points for each side of the debate For Against

156. 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)

157. 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.

158. 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?

159. Mark scheme

160. Mark scheme

161. Schizophrenia Cognitive Behavioural Therapy

162. 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-stress model.

163. When you come in… What can you remember about CBT? Ellis ABC Beck Negative Triad

164. 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

165. 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.

166. 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.

167. 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.”

168. 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.

169. 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.

170. Station 5 Developing alternative explanations Very CBT technique of discussing alternative explanations for unhealthy assumptions. This can be done in collaboration with the therapist.

171. Station 6 Assessment The client expresses their experiences and symptoms to the therapist. Goals and expectations of therapy can be established here.

172. The CBTp phases Assessment Engagement The ABC Model Normalisation Critical Collaborative Analysis Developing Alternative Explanations

173. Psychological Treatment; Behavioural What do you think some of these techniques might involve? Implosion- Flooding- Modeling-

174. 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 fear-producing 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.

175. 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-cognitive-behavioural-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.

176. 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 .

177. 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.

178. 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.

179. Evaluation of behavioural Approach Effective treatments Cognitive sense Patient responsible Unethical? Impractical methodology? Restricted application

180. K. A. E. D K Knowledge A Application E Evaluation D Discussion

181. 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 .

182. 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.

183. Mark scheme

184. Mark scheme

185. 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-stress model.

186. 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.

187. 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.

188. 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.

189. 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).

190. Key Study Task What did Pharoah (2010) have to say about the effectiveness of Family Therapy in patients with Schizophrenia? (Page 150) Why was random allocation important for this study? What are some ethical issues around allocating patients to a control group or a therapy group? Can you think of any evaluation of this study?

191. 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…

192. 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.

193. 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-stress model.

194. 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 . When you come in…

195. 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.

196. 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.

197. 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.

198. 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

199. 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

200. 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.

201. 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.

202. Exam Question Discuss token economies as a method used in the management of schizophrenia. (Total 8 marks)