Schizophrenia (profound disruption of cognition

and emotion)
Classification and diagnosis of schizophrenia:
Clinical characteristics:

Positive symptoms (excess/distortion of normal functions) include:

Delusions = bizarre beliefs that seem real but arent; can be paranoid in
nature.
Hallucinations = bizarre, unreal perceptions of environment;
auditory/visual/olfactory/tactile.
Disordered thinking = feeling that thoughts have been added/removed from
mind; tangential, incoherent, loosely associated speech, believe their thoughts
are being broadcast to others.

Negative symptoms (diminution/loss of normal functions) include:

Affective flattening = reduction in range and intensity of emotional
expressions e.g. voice tone.
Alogia = poverty of speech (less speech fluency + productivity).
Avolition = reduction of and inability to persist in goal-directed behaviour.

Sub-types of schizophrenia:
Disorganised (incoherent thoughts + speech, delusions + hallucinations,
inappropriate behaviour).
Catatonic (alternation between catatonic state and negativism, catatonic
excitement).
Paranoid (organised and complex delusions, auditory hallucinations).
Residual (gradual development of minor problems e.g. social withdrawal)>
Undifferentiated (unclassifiable symptoms)
Type 1 (positive symptoms) and type 2 (negative symptoms).

Issues of reliability and validity:

Classification systems are:
DSM (Diagnostic and Statistical Manual) produced in US and used as diagnostic
tool in psych institutions in US and Europe
ICD-10 (10th revision of International Statistical Classification of Diseases and
Related Health Problems).
DSM vs. ICD:
DSM: individuals must show have 1+ clinical characteristic present for 6
months before diagnosed; is multi-axial in that it takes a lot of factors into
account (e.g. biological, psychological, social) to assess person that merely
using symptoms; suggests there are five subtypes; culturally biased as made by
and for US (a non-US behaviour may be seen as schizo by US standards so
incorrect diagnosis).
ICD: requires signs to be evident for 1 month only so are individuals arent at
risk and can receive appropriate treatment sooner; but emphasis on first-rank
symptoms and ignores other factors; seven different subtypes; less culturally
biased as it can be applied worldwide.
Cheniaux et al investigated I-R reliability of both systems and found that
despite both was above +0.50, ICD was able to diagnose more schizophrenics
than DSM according to their criteria.

 Mojtabi + Nicholson: b/c only one characteristic is required for diagnosis; 50

senior psychiatrists were asked to differentiate between bizarre/non-bizarre

delusions = produced I-R correlations of +.40 = lacks sufficient reliability for it
to be a reliable method of distinguishing between schiz or non-schiz.
Reliability (consistency of measuring instrument to assess for example the
severity of persons symptoms).
Inter-rater reliability (whether two independent assessors gave similar diagnosis)
issue was fixed by the DSM-III (designed to provide more reliable criteria for
classifying disorders) according to Carson so should therefore increase reliability of
diagnosis.
But little evidence to support this as Whaley found inter-rater reliability
correlations in schiz diagnosis as low as +.11 //Rosenhans PPs presented
themselves to psychiatric hospitals and claimed they were hearing unfamiliar
voice; they were all admitted as having schizophrenia; no-one noticed they were
normal so Rosenhan warned hospitals of pseudo-patients and even though he
hadnt sent any, there was a 21% detection rate = unreliability in diagnosis of
schizophrenia but this study is 30+ years old so things have improved e.g. more
detailed //Beck et al found that agreement on diagnosis for 153 patients (where
each was assessed by two psychiatrists from a group of four) was only 54%, often
due to vague criteria for diagnosis and inconsistencies in techniques to gather
data.
Test-retest reliability (whether tests used to deliver diagnoses are consistent over
time) use cognitive screening tests like RBANS to measure degree of
neuropsychological impairment to help diagnose schizophrenia Wilks et al
found T-R reliability of +.84 after administering two alternate forms of RBAN to
schizos over intervals from 1-134 days.
Prescott et al analysed T-R reliability of several measures of attention +
information processing inn 14 chronic schizos = found performance on these
measures over 6 months = stable!
Validity (extent that a diagnosis represents something that is real and distinct
from other disorders and that the extent that a classification system measures
what it claims to measure).
Harrison et al reported that incidence rate for schizo was 8x higher for AfroCaribbean groups than for white groups which can be explained by social factors
e.g. poor housing and social isolation but could also be because of misdiagnosis
due to cultural differences in language + mannerisms
Symptoms of schizo can be found in other diseases too; Ellason and Ross points
out that people with DID had more schiz symptoms than people with schizophrenia.
Comorbidity (extent that 2+ conditions co-occur).
Buckley et al estimates that comorbid depression occurs in 50% of patients and
47% of patients also have a lifetime diagnosis of comorbid substance abuse and
such comorbidity creates difficulties in diagnosis of a disorder and deciding the
treatment to use//Weber et al examined nearly 6 million hospital discharge
records to calculate comorbidity rates and found that 45% of comorbidity was
psychiatric/behaviour related diagnoses but rest were non-psych diagnoses e.g.
asthma, concluding that schizos will receive lower standard of medical care,
adversely affecting their prognosis//Kessler et al found rate for attempted suicide
rose from 1% for those with schiz alone to 40% for those with at least one
comorbid mood disorder.=
Positive vs. negative symptoms: Klosterkotter et al looked at 489 psychiatric
hospital admissions and found that positive symptoms were better at providing a
valid diagnosis than negative symptoms.
Prognosis (the likely course of a medical condition): schizos rarely share the
symptoms or the same outcomes. 20% fully recover, 10% achieve significant and

lasting improvements and 30% show improvement with intermittent relapses. This
means that a schizophrenia diagnosis has low predictive validity.

Explanations of schizophrenia:
Biological explanations:

Genetic factors:
Family studies: Found that schizophrenia is more common among biological
relatives of schizophrenic + closer the degree of genetic relatedness, the
greater the risk Gottesman found that kids with two Sz parents have
concordance rate of 46% whereas those with one Sz parent 13%.
May be due to common rearing patterns/other non-heredity factors.
Twin studies: Joseph found that pooled data for all twin studies carried out
prior to 2001 shows concordance rate of 40.4% for monozygotic twins and 7.4%
for dizygotic twins but recent methodologically sound studies (blind diagnoses
where they dont know if twins are MZ/DZ) found lower conc. rates for MZ twins
but always higher for them so genetic liability is confirmed.
Assumption is that environments of MZ and DZ twins are same but
Joseph suggested that MZ twins encounter things together and are
treated similar and experience more identity confusion so concordance
rates reflect the environmental differences.
Adoption studies: used to disentangle genetic and environmental influences
for people who share genes but not environment Tienari et al in Finland
found that 6.7% of adoptees whos biological mother was SZ also received
diagnosis of SZ compared to 2% born to non-SZ mothers.
Joseph argues that the case of adoptive parents who adopt kids with Sz
parents are no different from adoptive parents who adopt kids with nonSz parents are no different is bullshit as countries e.g. Denmark and US
are informed of genetic background of kids.

The dopamine hypothesis: messages from neurones that transmit dopamine fire
too easily/often leading to Sz symptoms; Sz people have high number of D2
receptors on receiving neurons meaning theres more dopamine binding and so
more neurons firing Comer suggests that because dopamine neurons play key
role in guiding attention, disturbances in this process leads to Sz symptoms.
Amphetamine is a dopamine agonist (stimulates nerve cells containing
dopamine, causing synapses to be flooded with dopamine) large doses = Sz
symptoms hallucinations/delusions.
Antipsychotic drugs are dopamine antagonists (block stimulation of dopamine
system) that alleviate Sz symptoms.
Haracz found that post-mortem studies of Sz patients show that those
who had taken antipsych drugs before death had higher levels of
dopamine as opposed to those who didnt receive medication who had
normal levels of dopamine.
Those with Parkinsons disease have low levels of dopamine and Grilly found
that those who took L-dopa drug to raise dopamine levels developed Sz-like
symptoms.
Wong et al used PET scans and found higher levels of dopamine in Sz
people compared to control group but Copolov and Crook suggest that
neuroimaging studies havent provided convincing evidence of dopamine
activity of Sz people yet.

Psychological explanations:

Psychological theories:
Psychodynamic: Freud believed that Sz was result of regression to a pre-ego
stage + attempts to re-establish ego control Parents being cold/uncaring =
causing child to regress back into infantile state where the ego is not yet properly
formed symptoms include: delusions of grandeur (believing you can fly etc.) +
auditory hallucinations could be seen as an individuals attempt to re-establish ego
control.
Fromm-Reichman described schizophrenogenic mothers/overprotective,
dominant, rejecting families as contributory influences of Sz
But Oltmanns et al found that parents of Sz kids behave differently once
kid is diagnosed, not prior to, so therefore Sz is not due to parental
influence.
Bateson et als double-bind theory supports Freud as children who get
mixed-messages from their parents are more likely to develop
schizophrenia; prolonged exposure disrupts a childs internally coherent
construction of reality (perception of reality).
Cognitive: acknowledges biological factors as causing initial sensory experiences
of Sz but further symptoms stem from people trying to make sense of their
symptoms; reject feedback from others and believe that their beliefs are
manipulated by others.
Meyer-Lindenberg et als study looked at physical bases for cognitive
deficits associated with schizophrenia found link between excess
dopamine in prefrontal cortex and working memory.
Yellowlees et al developed machine that produces virtual hallucinations
e.g. hearing a TV telling you to kill yourself so show how Sz people that
their hallucinations arent real but no evidence that this is a successful
treatment.
Bentall found that Sz people have trouble with processing information
shown in Stroop tests colour words (red and green) are substituted for
emotional words (death and laughter) and Sz ppl take longer than non-Sz
to name the words so automatic subconscious processing may account
for positive symptoms but Stroop tests may be unreliable due to
individual differences
Socio-cultural factors:
Life-events and schizophrenia: factor that has been associated with a higher
risk of Sz episodes is occurrence of stressful life events but not known how
stress triggers schizophrenia, although high levels of physiological arousal
associated with neurotransmitter changes are thought to be involved.
Brown and Birley found that approximately 50% of people experienced
a major life event in the 3 weeks prior to a schizophrenic episode,
whereas only 12% reported one in the 9 weeks prior to that.
Hirsch et al followed 71 Sz patients over a 48-week period; life events
shown to make a significant cumulative contribution in the 12 months
before a relapse rather than having a more concentrated effect in the
period just before an episode.
But van Os et al reported no link between life events and Sz.
Family relationships:
o Double-bind theory: Bateson et al suggest that children who frequently
receive contradictory messages from their parents are more likely to develop Sz
because this prevents them from developing a consistent construction of reality
and manifests itself into Sz symptoms e.g. withdrawal kid unable to respond
b/c contradictions of messages.

Berger found that Sz ppl reported a high recall of double-bind statements

by their mothers than non-Sz (although their recall might have been
influenced by their Sz).
Liem found no difference in patterns of parental communication in
families of Sz and non-Sz
o Expressed emotion: a family communication style involving
criticism/hostility/emotional over-involvement so thought to be that high levels
of EE influence relapse rates.
Linszen et al found that patient returning to family with high levels of
EE is 4x more likely to relapse than patient returning to family with low
EE.
Study in Iran, Kalafi and Torabi found that high relevance of EE in
Iranian culture was ne of main causes of Sz relapses negative
emotional climate arouses patient, leading to stress beyond Szs already
impaired coping mechanisms so triggering Sz episode.
But is it cause or effect of Sz???
Labelling theory: Schef states that social groups construct rules for their
members to follow so Sz symptoms like delusions are deviant from rules we ascribe
to normal experiences so if person displays these symptoms, they are deviant and
Sz label Is applied which becomes a self-fulfilling prophecy that promotes
development of other Sz symptoms.
Schef evaluated 18 studies and found that 13 of those were consistent
with self-fulfilling prophecy.

Biological therapies:
Antipsychotic medication:
Conventional antipsychotic drugs: e.g. chlorpromazine are used to combat +e
symptoms (products of overactive dopamine system reduces effects of
dopamine by acting as dopamine antagonists by binding to D2 receptors on postsynaptic cell (not stimulate) to block their action.
Efectiveness: Davis et als review found significant difference in
relapse rates between treatment and placebo group//Vaughn and Lef
found that they did work but only in EE environments (relapse rates
were 53% there but 92% in placebo condition and those living in
supportive homes = no significant diff. between med vs. placebo.
Appropriateness: worrying side effects e.g. tardive dyskeniska//Ross
and Reed argue that being prescribed meds reinforces idea that youre
abnormal, reducing their motivation to look for solutions for their
possible stressors.

Atypical antipsychotic drugs: e.g. clozapine also combat +e symptoms but

claims that it can also combat e too they block serotonin receptors too but
mainly thought to temporarily occupy D2 receptors and then rapidly dissociating =
allows normal dopamine transmission responsible for lower levels of side effects
e.g. tardive dyskinesia (mouth/tongue involuntarily moves).
Efectiveness: Leucht et als meta-analysis found that they were only
slightly more effective than conventional antipsychotics and even not
effective and also found marginal support for claim that AADs are
effective with e symptoms.
Appropriateness: decreased levels of tardive dyskinesia as Jeste et
al found that TD rates were only 5% for those treated with AADs
compared to 30% with CADs//fewer side effects to patient more likely
to continue their medication so more benefits.

Electroconvulsive therapy:
ECT works by using an electrical shock to cause seizure (short period of irregular
brain activity) seizure releases rush of chemical neurotransmitters
temporarily alters function (eg. perception/memory etc.) given up to 3 or 4 times
a week and usually for maximum of 12 treatments before each treatment,
patient given anesthetic (to induce sleep) + muscle relaxant electrical shock
applied to patients head (via electrodes), lasting only 1 or 2 seconds (high
voltage/low amperage) makes brain have seizure.
Efectiveness: American Psychiatric Association review listed 19
studies that compared ECT with simulated ECT (i.e. given anaesthesia
but no ECT) found ECT didnt produce results worse/different from
antipsychotic medication//Sarita et al found no difference in symptom
reduction between ECT/simulated ECT.
Appropriateness: Read found decline in its usage in UK due to
significant risks e.g. memory dysfunction.

Psychological therapies:

Cognitive-behavioural therapy:
Assumes that people have distorted beliefs that influence their behaviour in
maladaptive ways.
Patients are encouraged to: trace back origins of their symptoms so they have an
idea of how the symptoms developed AND to evaluate content of their delusions
AND to consider validity of their faulty beliefs.
May also be set behavioural assignments to improve their general level of
functioning.
Distorted thinking leads to maladaptive responses to lifes issues so therapist lets
patient develop own alternatives to their previous maladaptive beliefs.
Outcome studies look at how well patient has performed after particular treatment
compared to accepted form of treatment for Sz they suggest that Sz people
have fewer hallucinations and delusions and recover their functioning to a greater
extent than just using antipsych drugs alone.
Drury et al: reduction of +e symptoms and 25-50% reduction in recovery time for
Sz patient using both CBT + antipsych drugs.
Kuipers et al: confirmed these advantages and found lower dropout rate and
greater patient satisfaction when CBT + antipsych = combined!
Efectiveness: Gould et als found that seven studies meta-analysis
all reported decrease in +e symptoms after treatment//but difficult to
assess CBTs effectiveness alone without antipsych drugs because
patients are treatment with both.
Appropriateness: -e symptoms are seen as useful because they can
alleviate maladaptive thought processes e.g. withdrawal can help
patient avoid making +e symptoms worse//study in Hampshire,
Kingdon and Kirschen found that many patients werent suitable for
CBT because psychiatrists believed they wouldnt engage with therapy
esp. older people.
Psychodynamic therapy Psychoanalysis:
Assumes that people are not aware of the influence of unconscious conflicts on
their current psychological state AND that all symptoms are meaningful (products
of life history)
Aims to help bring out those conflicts into conscious so they can be dealt with.

 Therapist aims to create alliance with patient offer real help with patients
problem (the more severe the case, the more support needs to be provided).
Freud stated that Sz ppl couldnt be analysed due to inability to form transference
(process by which emotions originally associated with one person are
unconsciously shifted onto analyst) with analyst.
Psychoanalysis refers to treatment including: free association, TAT tests, hypnotic
regression and dream analysis.
From these the analyst uncovers the unconscious conflicts causing the patient's
symptoms and interprets them for the patient to create a subjective resolution of
the problem.
Efectiveness: Malmberg + Fenton: difficult to draw definite
conclusions for/against effectiveness but Gottdieners meta-analysis of
37 studies of 2642 patients fond that 66% of them improved with
psychotherapy compared to 35% who didnt receive psychotherapy yet
contradictory findings e.g. May found that psychotherapy alone isnt
effective and that antipsych drugs alone are best whereas Karon +
VandenBos found that those treated with therapy improved more than
those treated with drugs alone.
Appropriateness: American Psychiatric Association recommend that
therapy is appropriate when combined with drugs//but therapy is
expensive and long-term preventing it being adopted on a large scale
and its not worth the expense because it doesnt outweigh drugs.
Issues are things like:

Reductionism: Breaking down a complex phenomenon into more simple

components.

Cultural Bias: when people of one culture make assumptions on another based on
their own cultural norms and practices. You can use this one almost anywhere!

Role of Animals in research: can we generalize animal research to humans? Do the

costs outweigh the benefits?

Gender Bias: When one gender is used in research and psychologists assume that
it can be applied to the opposite gender.

Ethical Issues: like danger, psychological harm etc.

Debates are:

Nature v Nurture: are we the product of biology (nature) or of the environment

(nurture)?

Free will v determinism: determinism (like fate) is the view that an individuals
behaviour is shaped or controlled by internal or external factors. Free will is used to
refer to when an individual is seen as being capable of self-determination i.e. we
shape our lives.

Psychology as a science: how scientific is the research for example using as case
study lacks scientific measures as it does not produce quantitative data. A lab
experiment on the other hand helps identify psychology as a science. e.g If your

talking about something biological evaluate it it by saying is is biologically

reductionist and say why, because it ignores environmental factors etc