Schizophrenia

Question 1

What are the positive symptoms of schizophrenia?

Answer 1

Delusions, hallucinations and disorganised speech

Question 2

What are the negative symptoms of schizophrenia?

Answer 2

Flatttened affect, ‘speech poverty’ and ‘avolition’

Question 3

What are delusions?

Answer 3

False beliefs
-Persecution
(paranoid delusions)
-Delusions of control/thought insertion
-Delusions of grandeur

Question 4

What are hallucinations?

Answer 4

Unusual sensory experiences
-Auditory/visual
-Linked to the environment or not (distortion of what is there, or not based in reality at all)

Question 5

What is disorganised speech?

Answer 5

Incoherent, rambling (‘word salad’)
Topic shifting (‘derailing’)
Unrelated or irrelevant answers
Positive symptom in DSM-5

Question 6

What is flattened affect?

Answer 6

Not showing the usual signs of emotions

Question 7

What is speech poverty?

Answer 7

Loss of quality and quantity of speech (alogia)

Question 8

What is avolition?

Answer 8

Lack of initiative, lack of purposeful behaviour, apathetic, poor hygiene

Question 9

What is the classification and diagnosis of schizophrenia?

Answer 9

Two major systems are used to classify mental health disorders.
They identify clusters of symptoms that occur together and classify these as specific disorders.
Clinicians then use these as a base for a diagnosis.

Question 10

How is schizophrenia classified and diagnosed in the DSM-V TR?

Answer 10

‘Disorganised speech’ as a positive symptom
One positive symptom must be present for a diagnosis.

Question 11

How is schizophrenia classified and diagnosed in the ICD-11?

Answer 11

Two or more negative symptoms are enough for a diagnosis

Question 12

What did Tienari et al (2000) study and find?

Answer 12

Biological mother with sz more likely to mean adoptees have schizophrenia, lower if control with non-sz mother.
7% prevalence rate amongst adoptees whose biological mothers have sz (compared to 2% amongst control group) suggests a genetic cause

Question 13

What do twin studies show about sz?

Answer 13

Recent studies continue to show the greater the genetic similarity between family members, the higher the risk of schizophrenia. E.g Hilker et al (2018), 33% MZ and 7% DZ concordance rates, MZ twins share 100% of their genes, DZ only share 50%

Question 14

What is the role of mutations in developing sz?

Answer 14

Parental exposure to radiation, toxins, viruses. Immune system response to infection (eg. flu in the first trimester) is thought to affect foetus’ developing brain.
APA (advanced paternal age), 2% prevalence rate for fathers over 50.

Question 15

What is the role of candidate genes in sz?

Answer 15

Ripke et al identifies 108 separate variations associated with increased risk of sz. Candidate genes include those that code for the neurotransmitter dopamine (‘dopamine hypothesis’ is one of the main neural explanations’

Question 16

What environmental factors have affect development of sz?

Answer 16

Birth complications (eg pre-eclampsia (high blood pressure), birth prior to 32 weeks
Smoking THC rich cannabis: increased frequency/dose, plus age of use correlated (the younger, the more likely for sz)

Question 17

What is the role of diathesis stress in sz?

Answer 17

Tienari et al (2004) suggests genetics is only partial explanation, assessed adoptees genetic risk and the upbringing they experiences

Diathesis + stress
Genes + environment
Bio mother with sz + Poor parenting from adoptive parents (high criticism, low empathy)

Question 18

How does Tienari (2004) support the diathesis-stress model for sz?

Answer 18

Child rearing style characterised by high levels of conflict and criticism, low levels of empathy, implicated in development of sz, only in adoptees at high genetic risk, not those at low
Suggests both genetics and stressful upbringing important in development, supports diathesis-stress

Question 19

When was the original dopamine hypothesis made?

Answer 19

1960s

Question 20

When was the revised dopamine hypothesis made?

Answer 20

1990s

Question 21

What was the original dopamine hypothesis based on?

Answer 21

Based on the findings on the effects of different drugs on dopamine
Drugs preceded the theory about origins of schizophrenia

Question 22

What are amphetamines?

Answer 22

Dopamine agonists, increases dopamine
Causes psychosis in some people

Question 23

What are antipsychotics?

Answer 23

Dopamine antagonists, reduces dopamine
Reduces psychotic symptoms

Question 24

What is the original dopamine hypothesis?

Answer 24

Sz caused by hyperdopaminergia (an excess of dopamine) in the subcortex.
People with sz are thought to have abnormally high numbers of D2 receptors on receiving neurons, resulting in more dopamine binding and therefore more neurons firing.
For example, an excess of D2 receptors in the pathway from the subcortex to Broca’s area (responsible for speech production) may explain e.g. speech poverty and auditory hallucinations .

Question 25

What are dopamine pathways?

Answer 25

Neuronal connections where dopamine travels to different areas of the brain

Question 26

What is the cortex?

Answer 26

Outer layer of the brain, 3mm thick and highly folded, divided into 4 lobes, contain specialist areas

Question 27

What is the subcortex?

Answer 27

Beneath cortex, more primitave functions

Question 28

What is the Mesocortical pathway?

Answer 28

Cognition, memory, attention, emotional behaviour, learning

Question 29

What is the the nigrostriatal pathway ?

Answer 29

Movement, sensory stimuli

Question 30

What is the mesolimbic pathway?

Answer 30

Pleasure and rewards seeking behaviours, addiction, emotion, perception

Question 31

What is hyperdopaminergia? (revised hypothesis)

Answer 31

High levels of dopamine, occurs in the mesolimbic pathway in the subcortex explaining positive symptoms, such as hallucinations. Similar to the original dopamine hypothesis.

Question 32

What does the revised dopamine hypothesis propose?

Answer 32

Proposes varying levels of dopamine in different dopamine pathways in different brain regions.

Question 33

What is hypodopaminergia? (revised hypothesis)

Answer 33

Low levels of dopamine, occurs in the mesocortical pathway in the cortex. Areas affected include prefrontal cortex, which is responsible for cognitive functions and regulating emotions. This is said to explain negative symptoms, such as avolition (lack of motivation /goal-oriented activity) and cognitive dysfunction.

Question 34

What is the diathesis stress model used within the dopamine hypothesis?

Answer 34

Current versions of the dopamine hypothesis also explain the origins of this abnormal function, using a diathesis stress-model: genetic variations and early experiences of stress make some people more sensitive to cortical hypodopaminergia and subcortical hyperdopaminergia.

Question 35

What are the psychological explanations for schizophrenia?

Answer 35

Schizophrenogenic mother (psychodynamic) Double bind theory Expressed emotion (EE)

Question 36

What is the schizophrenogenic mother?

Answer 36

A cold, rejecting and controlling mother. The father is often passive and uninvolved.

Question 37

How does the schizophrenogenic mother lead to sz?

Answer 37

Caused in early childhood, the mothers high degree of control and criticism creates a family climate of tension and secrecy This leads to distrust of others, which triggers psychotic thinking and paranoid delusions of persecution, leading to sz

Question 38

What is the ‘double-bind’ explanation?

Answer 38

Identified a risk factor for sz is contradictory communication patterns within the family No escape to paradox, child cannot address the conflict without negative consequences

Question 38

What is Evidence for the schizophrenogenic mother?

Answer 38

Based on testimony of sz patients who were treated with psychoanalysis

Question 39

How does the double bind lead to sz?

Answer 39

Leads to a state of internal conflict, the world is experienced as confusing and dangerous, impacting development of an internally coherent construction of reality: disorganised thought. Delusions are developed as an escape from the conflict of the double bind.

Question 40

What is evidence for the double bind?

Answer 40

Theory is based on testimony from patients in clinical work

Question 41

What are family system theories?

Answer 41

Rather than blame the mother/parent, the focus is on communication and behaviour within the wider family system Behaviour of each family member may affect others If one person develops psychological disorder, problem might not lie within that person: behaviour may be manifestation of issue in wider family system

Question 42

What is 'expressed emotion'?

Answer 42

A qualitative measure of emotion displayed in family setting, usually by family/caregivers of patient High level of EE in the home can worsen the prognosis of schizophrenia Hostility Criticism Overconcern

Question 43

How does expressed emotion lead to sz?

Answer 43

Anger is directed at the patient usually because family feels disorder is controllable, and patient is choosing not to get better. Wider family problems are also blamed on patient, rejected as a result. Also involves high levels of negative comments, may be accompanied by violence. Critical parents can influence the patient’s siblings behaviour. Family member is over-involved in the life of the person with disorder, deny their own well-being, blame themselves for the disorder. Usually counter-productive: it causes too much stress and the patient relapses.

Question 44

What is evidence for expressed emotion?

Answer 44

Observations of patients who had returned back to their families after a hospital stay Determined through taping an interview (the Camberwell Family Interview) with family members. Verbal statements, tone of voice, body language are coded to emotion displayed. Answers are then analysed and rated for the number and frequency of comments which reflect the key features of high EE.

Question 45

What does the cognitive approach say sz is caused by?

Answer 45

Dysfunctional thought processing

Question 46

What is egocentric bias?

Answer 46

Individual perceives self as central component in events. A patient with schizophrenia will tend to relate irrelevant events to themselves and consequently arrive at false conclusions.

Question 47

What symptoms of schizophrenia may egocentric bias lead to?

Answer 47

Delusions (of both persecution and grandeur eg muffled voices criticising them or lightning is messages from God)

Question 48

What is lack of reality testing?

Answer 48

Patients with schizophrenia do not go through the same processes of reality testing, such as checking external sources, that others would do. (Beck and Rector, 2005). Unwilling/unable to go through normal processes of reality testing and findings more realistic explanations

Question 49

What symptoms of schizophrenia may lack of reality testing lead to?

Answer 49

Maintains delusions and hallucinations as unwilling or unable to consider more realistic explanations for events or to consider they are wrong

Question 50

What is dysfunction in metarepresentation?

Answer 50

Cognitive ability to reflect on thoughts, intentions and behaviours: ‘thinking about thinking’. Allows insight into own thoughts, intentions and goals and to interpret the actions of others. According to Frith (1992) people with schizophrenia have a dysfunction in metarepresentation, become confused as to where their inner thoughts are coming from and attribute an external cause. Also become confused as to the thoughts and intentions others.

Question 51

What is metarepresentation?

Answer 51

Cognitive ability to reflect on own thoughts, behaviours and intentions, thinking about thinking Also involved ability to reflect on thoughts and behaviour of other people: theory of mind Dysfunctional in schizophrenia

Question 52

What symptoms of schizophrenia may dysfunction in metarepresentation lead to?

Answer 52

Subjective representations of reality are mistaken for objective reality Auditory hallucinations, delusions of thought insertion Paranoid delusions: other have hostile and deceptive intentions

Question 53

What is poor central control?

Answer 53

Cognitive ability to suppress automatic responses while performing deliberate actions. E.g Stroop test, central control is shown in the ability to suppress the automatic tendency to read the word aloud when you should be naming the font colour of the word. Schizophrenia patients take 2x as long, exhibit increased interference consisten with distractibility in everyday life

Question 54

What is central control?

Answer 54

Cognitive ability to suppress automatic responses while performing deliberate actions instead Poor in schizophrenia

Question 55

What symptoms of schizophrenia may poor central control lead to?

Answer 55

Disorganised thought/speech Derailment = cannot suppress automatic word associations

Question 56

What is the typical/first generation antipsychotic example?

Answer 56

Chloropromazine

Question 57

What is the atypical/second generation antipsychotic example?

Answer 57

Clozapine

Question 58

How do typical antipsychotics work?

Answer 58

Dopamine antagonists, means they reduce the action of dopamine Chlorpromazine does this by binding to dopamine receptors (D2 receptors) on the postsynaptic neuron, blocking transmission of DA By normalising levels of dopamine transmission in the mesolimbic pathway, this normalised dopamine in this pathway, reducing/eliminating hallucinations

Question 59

How do atypical antipsychotics work?

Answer 59

Dopamine antagonist, only temporarily block D2 receptors, then rapidly disassociate to allow normal dopamine transmission. Less extrapyramidal side effects (movement) to than typical antipsychotics. Also act on serotonin and glutamate receptors, reducing negative symptoms (depression, anxiety), improving cognitive function

Question 60

What are the side effects of typical antipsychotics?

Answer 60

However, blocking dopamine in other pathways produces side effects; nigrostiatal pathway, extrapyramidal side effects (tardive dyskinesia) Movement related side effects

Question 61

What are the assumptions of family therapy as a treatment for schizophrenia?

Answer 61

Sz is made worse by living in a dysfunctional family (high EE = high stress = more likely to relapse) NICE recommendation, close family relationships = often most essential support patient has in managing their condition (move away from blaming family) Living with mental illness can increase stress in family, all members need support

Question 62

What are the goals of family therapy as a treatment for schizophrenia?

Answer 62

Reduce expressions of EE (anger, criticism, guilt, stress), this can reduce relapse and hospital admission Family can help to increase compliance with taking medication and recovery Ease family relations so that members can get on with everyday life

Question 63

What are the strategies of family therapy as a treatment for schizophrenia?

Answer 63

Therapeutic alliance: therapist meets with family and patient to mediate effective discussion, supporting family to listen to one another, problem solve together Patient needs to be actively involved in discussions to reduce suspicion and paranoia, delusions, have agency and allow them to have a say in what happens Psychoeducation: increase understanding of illness and maintaining reasonable explanations, understanding what is and isn’t helpful Setting boundaries for carers: balance of caring for self and patient

Question 64

What is normalisation in CBT for schizophrenia?

Answer 64

The patient is told that their symptoms (such as hearing voices) are not unusual.

Question 65

What is the ABC model used in schizophrenia?

Answer 65

The patient identifies activating events (A) to understand triggers. They explore the beliefs (B) that lead to emotional and behavioural consequences (C). The patient comes to understand that their own beliefs (B) are actually the cause of (C), not the event (A) itself.

Question 66

What is critical collaborative analysis within schizophrenia?

Answer 66

The therapist uses gentle questioning to help the patient to understand their illogical beliefs. May question the delusions and hallucinations

Question 67

What is developing alternative explanations in CBT for schizophrenia?

Answer 67

The patient, with the help of the therapist, is encouraged to develop their own alternative beliefs/explanations. For example, finding alternative explanations for hearing voices such as lack of sleep

Question 68

What is behavioural activation in CBT for schizophrenia?

Answer 68

The patient is encouraged to engage in helpful behaviours, such as interacting with the voices in a more positive way

Question 69

What is meant by an ‘interactionist’ explanation?

Answer 69

Various factors interact in the development of sz (social, biological, psychological), combined effect cannot be predicted by each one separately, explanation has implications for treatments, leads to combined treatment

Question 70

What is meant by the ‘diathesis-stress’ model?

Answer 70

Diathesis: underlying factors leading to vulnerability Stressors: trigger the condition Also known as biosocial approach

Question 71

Name both the diathesis and the stress in Meehl’s original diathesis-stress model

Answer 71

Genetic: schizogene leads to schizotypic personality, sensitive to stress (discredited as 108 different genes, not just one) Chronic stress in childhood and adolescence, in particular having schizophrenogenic mother (discredited as parent blaming, other stressors)

Question 72

Explain what could cause the diathesis according to the modern diathesis-stress model.

Answer 72

Diathesis can result from a range of factors beyond just genes (multiple genes, rather than one single ‘schizogene’, are still considered to play a role) (Genetic factors, exposure to flue virus during gestation, birth complications, early psychological trauma) Recognises that stress can result from factors other than poor parenting. (family dysfunction, trauma (abuse, neglect), parenting style, exposure to chemicals eg cannabis, stressful life events, living in highly urbanised environment)

Question 73

Which treatments are often offered in combination in the treatment of schizophrenia in the UK?

Answer 73

Antipsychotics combined with psychological therapies (eg CBT, family therapy, art therapy). Those who want to ttry psychological interventions are told that they are more effective alongside drugs