What is a problem with the diagnosis of schizophrenia?
Problem: THE ISSUE OF VALIDITY
- Validity refers to whether we are assessing what we are intending to assess. An important measure of validity is criterion validity – how accurately a test measures the outcomes it was designed to measure.
- Cheniaux et al. (2009) Had two psychiatrists independently diagnose 100 patients using both DSM and ICD criteria. It was found that inter-rater reliability was poor, with one psychiatrist diagnosing 26 patients with schizophrenia according to the DSM and 44 according to the ICD, whereas the other diagnosed 13 with the DSM and 24 with the ICD.
- The fact that a total of 68 patients received a diagnosis with the ICD and only 39 with the DSM demonstrates that schizophrenia is either over or under diagnoses, either way criterion validity is low.
What is a positive of the diagnosis of schizophrenia?
Positive : Good reliability
- Although historically validity and reliability of diagnosis appears to be an issue, more recent research has suggested that it has good inter-rater reliability.
- Osorio et al. (2019) reported excellent reliability, when looking at 180 schizophrenic diagnoses, when consultants were interviewed post-diagnosis, they achieved an inter-rater reliability of +.97.
- Furthermore, on a second diagnosis, the same clinician tended to come to the same diagnosis, with a test-retest reliability score of +.92.
- So this suggests that when psychiatrists are encouraged to use the same diagnostic manual, then diagnosis is consistently applied.
What is an issue of diagnosing schizophrenia?
Problem : The issue of Comorbidity
- Comorbidity refers to the fact that two or more conditions occur together. If conditions occur together a lot of the time then this calls into question the validity of the diagnosis and classification because they might actually be a single condition.
- Schizophrenia is commonly diagnosed with other conditions.
- In one review Buckley at et (2009) concluded that half (50%) of patients with schizophrenia also have a diagnosis of depression, 47% substance abuse, 29% PTSD & 23% OCD.
- This is a problem for classification because it means schizophrenia may not exist as a distinct condition and is a problem for diagnosis as it suggests that at least some people diagnosed with schizophrenia may instead have unusual cases of conditions like depression
What is a limitation of diagnosing schizophrenia?
Limitation : The Issue of symptom overlap
Another limitation of schizophrenia diagnosis is the existence of symptom overlap with other conditions.
- There is considerable overlap between the symptoms of schizophrenia and the symptoms of other conditions, for example both schizophrenia and bipolar disorder involve positive symptoms such as delusions, and negative symptoms such as avolition.
- In terms of classification this suggests that schizophrenia and bipolar may not be two different conditions but variations of a single condition. In terms of diagnosis it means that schizophrenia is hard to distinguish from bi-polar disorder.
- As with comorbidity, symptom overlap means that schizophrenia may not exist as a distinct condition and that even if it does it is hard to diagnose. So both its classification and diagnosis are flawed.
What is a limitation of the schizophrenic diagnosis?
Problem : The Issue of Gender bias
A further limitation of schizophrenia diagnosis is the existence of gender bias. Since the 1980s men have been diagnosed with schizophrenia more commonly than women.
- Cotton et al. (2009) suggest this is due to the fact that women have closer social and familial relationships than men and hence get more support.
- This leads to women with schizophrenia functioning better than men, which may explain why some women have not been diagnosed with schizophrenia where men with similar symptoms might have been; the better interpersonal functioning may bias practitioners to underdiagnose schizophrenia, either because symptoms are masked altogether or because of the quality of interpersonal functioning makes the case seem too mild to warrant a diagnosis.
- This suggests that the validity of the diagnosis of schizophrenia is poor because our procedures for diagnosis work well only on patients of one gender.
What is a limitation of the schizophrenic diagnosis?
Problem : Culture Bias
A further limitation of schizophrenia diagnosis is the existence of culture bias.
- Afro-Caribbean people living in the UK are 9 times more likely to receive a diagnosis (Pinto & Jones 2008) compared to white British people, although people living in Afro-Caribbean countries are not, ruling out a genetic vulnerability. The most likely explanation for this is culture bias in diagnosis of clients by psychiatrist from a different cultural background.
- Some symptoms of schizophrenia, particularly hearing voices, have different meanings in different cultures. For example, in some Afro-Caribbean, such as Haiti, societies voices may be attributed to communication from ancestors. However, when presented to a practitioner from a different culture, these experience may seem bizarre or irrational.
- This appears to lead to an over interpretation of symptoms in black British people (Escobar, 2012). This means the Afro-Caribbean people may be discriminated against by a culturally biased diagnostic system.
What is a strength of biological explanations of schizophrenia?
Strength : Support for gentic Vulnerability
There is now very strong evidence for genetic vulnerability to schizophrenia from a variety of sources.
- Gottesman (1991) shows how genetic similarity and shared risk of schizophrenia are closely related. Adoption studies (Tienari et al. 2004) shows that children of schizophrenia sufferers are still at heightened risk of schizophrenia if adopted into families with no history of the condition.
- Furthermore a recent study by Hilker et al. (2018) showed a concordance rate of 33% for identical twin and 7% for non-identical twins.
- These findings don’t mean that schizophrenia is entirely genetic, however it does suggest that genetic factors make some people more vulnerable to developing schizophrenia than others.
What is a weakness of the biological explanations for schizophrenia?
Weakness : Biological Determinsm
One limitation of the genetic explanation is there is clear evidence to show that environmental factors also increase the risk of developing schizophrenia.
- These environmental factors include both biological and psychological influences. Biological risk factors include birth complications (Morgan et al. 2017) and smoking THC-rich cannabis in teenage years. Psychological risk factors include childhood trauma which leaves people more vulnerable to adult mental health problems in general but there is now evidence for a particular link with schizophrenia.
- In one study by Mørkved et al. (2017), researchers found 67% of people with schizophrenia and related psychotic conditions reported at least one childhood trauma as opposed to 38% of a matched group with non-psychotic mental health problems.
This means that genetic factors alone cannot provide a complete explanation for schizophrenia.
What is a strength of the dopamine hypothesis?
Strength : Dopamine Hypothesis - Evidence from drug studies
There is support from a number of sources for abnormal dopamine functioning in schizophrenia.
- Dopamine agonists like amphetamines that increase the levels of dopamine makes schizophrenia worse and can produce schizophrenia like symptoms in non-sufferers (Curran et al. 2004). Antipsychotic drugs, on the other hand, work by reducing dopamine activity (Tauscher et al. 2014) and are used effectively with many schizophrenic patients.
- Furthermore, research has suggested that a number of candidate genes implicated in schizophrenia act on the production of DA or DA receptors
- All of this strongly suggests that dopamine is involved in the symptoms of schizophrenia.
What is a limitation of the dopamine hypothesis?
Dopamine hypothesis: The role of glutamate
One limitation of the dopamine hypothesis is evidence for a central role of glutamate.
- Post-mortem and live scanning studies have consistently found raised levels of the neurotransmitter glutamate in several brain regions of people with schizophrenia (McCutcheon et al. 2020). In addition, several candidate genes for schizophrenia are believed to be involved in glutamate production or processing.
- This means that an equally strong case can be made for a role for other neurotransmitters
What is a strength of using biological treatments for schizophrenia?
Strength : Evidence for effectiveness
A strength of the impact of drug treatments comes from the large body of evidence to support the idea that both typical and atypical antipsychotics are at least moderately effective in tackling the symptoms of schizophrenia.
- Thornley et al. (2003) reviewed studies comparing the effects of chlorpromazine to control groups. Data from 13 trials with 1121 participants showed the chlorpromazine was associated with better overall functioning and reduced symptom severity when compared to the placebo.
- Furthermore Meltzer (2012) concluded that clozapine is more effective than typical antipsychotics and other atypical antipsychotics, and that it is effective in 30-50% of treatment-resistant cases where typical antipsychotics have failed.
- This research provides evidence that shows that as far as we can tell, antipsychotics work in the treatment of schizophrenia.
What is a problem of using drugs to treat schizophrenia?
Weakness: problems with research
However, Healy (2012) has suggested that there are serious flaws with evidence for effectiveness.
- For example most studies are of short-term effects only and some successful trials have had their data published multiple times, exaggerating the size of the evidence base for positive effects.
- Also, because antipsychotics have powerful calming effect, it is easy to demonstrate that they have some positive affect on people experiencing symptoms of schizophrenia this is not the same as saying they really reduce the severity of psychosis.
This means that the evidence base for antipsychotic effectiveness is less impressive than it first appears.
What is a problem of using durgs to treat schizophrenia?
Problem : Serious side effects
One limitation of antipsychotic drugs is the likelihood of side-effects.
- Typical antipsychotics are associated with a range of side-effects including dizziness, agitation, sleepiness, stiff jaw, weight gain and itchy skin. Long-term use can result in Tardive dyskinesia, which is caused by dopamine super sensitivity and causes involuntary facial movements such as grimacing, blinking and lip-smacking.
- The most serious side-effects of antipsychotics is neuroleptic malignant syndrome. This is believed to be caused when the drug blocks dopamine action in the hypothalamus, an area in the brain associated with the regulation of a number of body systems. NMS results in high temperature, delirium and coma, and can be fatal. Estimates of its frequency range from less than .1% to just over 2%.
- This means antipsychotics can do harm as well as good an individual to experience these may avoid such treatments, which makes the treatment ineffective.
What is a problem of using antipsychotics?
Probolem : The chemical cost
The use of antipsychotics poses a bit of a moral dilemma.
- On the one hand however, the short-term use of antipsychotic medication is recommended by the National Institute of Clinical excellence. They calm patients distressed by hallucinations and delusions, which almost certainly makes them feel better. Additionally they allow patients to engage with other treatments, such as CBT, and services, such as meeting social workers, which are both undoubtedly positive things.
- On the other hand it is widely believed that antipsychotics have been used in hospital situations to calm people with schizophrenia and make them easier for staff to work with, reducing them to a zombie like state, rather than for the benefit of the people themselves. Furthermore Drugs can be said to be dehumanising as they take away individual personal responsibility and control when they may not have consented to treatment as they may not be in a position (in a psychotic state) to give consent and if they are sectioned then treatment can also be enforced.
- Perhaps the prescription of antipsychotic medication should be reserved for patients experiencing great levels of distress, preventing them from accessing alternative treatments and ultimately progressing with their recovery, rather than being the first step treatment for the majority of patients.
What is a strength of research into family dysfunction?
Point : One strength of these explanatiobs is evidence linking family dysfunction to schizophrenia. Indicators of family dysfunction include secure attachment type and exposure to childhood trauma, especially abuse
* According to a review by John Read (2005) adults with schizophrenia or disporportiantely likely to have an insecure attachment, particularly type c or b. Read et al also reported that 69% of women and 59% of men with schizophrenia have a history of physical and/or emotional abuse
* Futhermore, research by Morkved (2017) found that most adults with shizophrenia reported at least one childhood trauma mostly abuse
What does this mean?
This strongly suggests that family dysfunction makes people more vulnerable to schizophrenia
What is a weakness of research into family dysfunction?
Point : However, there is poor evidence base for any of these family dysfunction explanations
* For example, there is plenty of evidemce supporting the idea that childhood family based stress is asscociated with schizophrenia but there is also none to support the importance of traditional family based theories such as the schizophregenic mother and the double blind
* Both of these theories are based on clinical observations of patients and informal assessments of the personality of the mothers’ of patients, but not systematic evidence
What does this mean?
This means that family examination have not been able to account for the line between childhood trauma and schizophrenia
What is an issue wih research into family dysfunction?
Point : Research into the link between family dysfunction and schizophrenia can pose a moral dilemma
* Although early explanations for the family-schizophrenia link have no research support, research in this area may be useful in showing that insecure attachment and experience of childhood trauma may affect individual vulnerability to schizophrenia.
* On the other hand, this area of research is very socially sensitive as it can lead to parent blaming and adds insult to injury for parents who are having to watch their child experience symptoms of schizophrenia.
What does this mean?
However, psychologists should not shy away from investigating sensitive topics. With the correct precautions and considerations taken (how will it be used, the validity of the research etc.), the benefits of such research will highly outweigh the costs and will have countless real-world applications in attachment, childcare, parenting skills, social work, and many more.
What is a strength for the coginitive explanations of schizophrenia?
Point : One strength of coginitive explanations is evidence for dysfunctional processing
* John Stirling at al. (2006) compared the performance on a range of cognitive tasks in 30 people with schizophrenia and a control group of 30 people without schizophrenia.
* Tasks included the Stroop task, in which patients have to name the font-colours of colour-words, so have to suppress the tendency to read the words aloud. As predicted by Frith et al.’s Central control theory, people with schizophrenia took longer – over twice as long on average – to name the font colours.
What does this mean?
This suggests that the cognitive processes of people with schizophrenia are impaired.
What is a limiation of the coginitive explanations of schizophrenia?
Point: However, a limitation of coginitive explanations is that they only explain proximal origins of symptoms
* Cognitive explanations for schizophrenia are proximal explanations because they explain what is happening right now to produce symptoms – as distinct from distal explanations which focus on what initially caused the condition, such as genetic and family dysfunction explanations.
* What is currently unclear and not well addressed is how genetic variation or childhood trauma may lead to problems with metarepresentation or central control.
What does this mean?
This means that cognitive theories on their own only provide partial explanations for schizophrenia.
What is a strength of using token economy systems to manage schizophrenia?
Evidence for effectivness
Glowacki et al., (2016)
Meta-analysis of of 7 high quality studies conducted between 1999 and 2003 on the effectiveness of TES for people with chronic mental health issues.
In a hospital setting
All studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours
This supports the value of token economies.
What is a weakness of research into token economy systems?
Methodological issues : small sample sizes
Seven studies is quite a small evidence base to support the effectiveness of the technique.
Small numbers of studies file drawer problem
Bias towards positive published findings undesirable results have been filed away
This means that there is a serious question over the evidence for the effectiveness of token economies.
what is a weakness of using token economy systems to manage schizophrenia?
** Ethical Issues**
It gives professionals considerable power to control the behaviour of the patient.
Imposition of norms on an individual problematic if issues aren’t approached sensitively.
Restriction of personal freedoms
Patients who have the most distressing symptoms, could have an even worse time due to the removal of small pleasures.
This has lead to legal action taken by relatives of patients and the ultimately the decline of the use of TES.
Impact on personal freedom and short-term quality of life may outweigh the benefits.
what is a problem of using token economy systems to manage schizophrenia?
Alternative apporach
* For example, Chiang et al concluded that art therapy may be a better alternative token economy
* Although the sample sizes are small, it presents art therapy as low risk high gain
* The overall effects of art therapy may be modest but unlike other approaches, it is lesss confrontational, has lower risk of side effects and ethical abuse and overall a pleasant experience for the patient. It is also recommended by the NICE.
As a result, art therapy is a positive experience for the patient and carries less risk which makes it a more appropiate management of schizoprhenia
What is a strength of using CBT to treat schizophrenia?
CBT- evidence for effectiveness
* A strength of CBT for schizophrenia is that there is evidence for its effectiveness.
* Jauhar et al (2014) reviewed 34 studies of using CBT with schizophrenia, concluding that there is clear evidence for small, but significant effects on both positive and negative symptoms.
* Other studies have focused on symptoms for example, Pontillo et al (2016) found reductions in frequency and severity of auditory hallucinations. Clinical advice from the National Institute for Health and Care Excellence (NICE, 2019) recommends CBT for schizophrenia.
* This means that both research and clinical experience support the benefits of CBT for schizophrenia
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evaluation points : approaches31
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evaluation : social influence44
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evaluation: Attachments45
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Evaluation : Biopsychology34
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Evaluation : memory27
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Psychopathology : abnormality18
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Psychopathology : Phobias33
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Psychopathology : depression26
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Psychopathology : OCD23
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Relationships: evaluation37
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Issues and Debates : evaluation31
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Schizophrenia : Evaluation30
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Forensic psychology AO1+AO286
