Treatment of Schizophrenia



| |Sub-sections |read text book? |have notes? |understand this? |Revised this? |

| |Naming the symptoms of SZ | | | | |

|Diagnosis of schizophrenia | | | | | |

| | | | | | |

| |Differentiating Type 1 and Type 2 symptoms | | | | |

| |Validity of diagnosis | | | | |

| |Does using DSM-IV make diagnosis more reliable? | | | | |

| |Genetics (inheritance) - Bio | | | | |

|Aetiology (i.e. explanations) of| | | | | |

|Schizophrenia | | | | | |

| |The dopamine hypothesis – Bio | | | | |

| |Abnormal brain structure – Bio | | | | |

| |It is learnt -Behavioural | | | | |

| |Faulty cognition of the biologically-based initial | | | | |

| |symptoms - Cognitive | | | | |

| |It is a Psychodynamic defence | | | | |

| |(Regression to pre-ego stage) | | | | |

| |Family relation | | | | |

| |- Double Bind | | | | |

| |-Expressed Emotions | | | | |

| |Life Events | | | | |

| |Diathesis-stress model | | | | |

| |Drugs to reduce the effects of dopamine (bio) | | | | |

|Therapies for Schizophrenia | | | | | |

| |ECT (bio) | | | | |

| |Behavioural Therapy | | | | |

| |CBT | | | | |

| |Psychanalysis | | | | |

UNIT 3: SCHIZOPHRENIA - What is schizophrenia?

The term schizophrenia is widely used in the mental health system. Doctors may describe it as a psychosis. They mean that, in their view, a person can't distinguish their own intense thoughts, ideas, perceptions and imaginings from reality (the shared perceptions, sets of ideas and values that other people in that culture hold to be real). Among other symptoms, a person might be hearing voices, or may believe that other people can read their mind and control their thoughts.

Many people prefer to look at schizophrenia 'holistically', and argue that these symptoms are logical or natural reactions to adverse life events. In other words, an extreme form of distress. They emphasise the need to think about individual experience, and the importance of understanding what the experiences mean to the individual. Hearing voices, for instance, holds a different significance within different cultures and spiritual belief systems.

How do doctors diagnose schizophrenia?

When someone becomes unwell, they are likely to show drastic changes in their behaviour. They may be upset, anxious, confused and suspicious of other people, particularly anyone who doesn't agree with their perceptions. They may be reluctant to believe they need help. Doctors will want to rule out other physical or mental health problems. They will look for various 'positive' symptoms (strange thinking, hallucinations and delusions) and 'negative' symptoms (apathy, emotional flatness, inability to concentrate, wanting to avoid people or to be protected).

Strange thinking ('Thought disorder')

A person may be unable to follow a logical sequence of thought; their ideas may seem jumbled and make little sense to others. Conversation may be very difficult and this may contribute to a sense of loneliness and isolation.

Hallucinations

Some people hear voices that others around them don't hear. (Some people hear other sounds.) The voices may be familiar, friendly or critical. They might discuss the hearer's thoughts or behaviour, or they might issue orders. Up to four per cent of the population hears voices, according to some research, and for most, they present no problem. But people who are diagnosed with schizophrenia seem to hear mostly critical or unfriendly voices. They may have heard voices all their lives, but a stressful life event might have made the voices harsher and more difficult to deal with.

Delusions

Delusions are usually beliefs or experiences that are not in line with a generally accepted reality. For instance, someone might believe secret agents are following them or that outside forces are controlling them or putting thoughts into their mind.

Negative symptoms

Other symptoms, such as being withdrawn, apathetic, and unable to concentrate, are described as 'negative' rather than 'positive', because they reflect a lack of ‘normal’ functions. It can be very difficult to tell whether they are part of the schizophrenia, or whether the person is reacting to other symptoms they find frightening and distressing. For instance, depending on what kind of experience they are having, someone might be quiet and immobile for hours, or move about constantly. Such symptoms could also be a response to other people's behaviour towards them. It's all too often the case that someone with a mental health problem is discriminated against or ignored, causing them to feel isolated and depressed.

| |Schizophrenia Syllabus |

|In relation to their chosen|Information to know; |

|disorder: | |

|schizophrenia | |

| |Clinical characteristics of the chosen disorder |

| |Issues surrounding the classification and diagnosis of their chosen |

| |Biological explanations of their chosen disorder, for example, genetics, |

| |Biochemistry |

| |Psychological explanations of their chosen disorder; behavioural, cognitive, psychodynamic and socio-cultural |

| |Biological therapies for their chosen disorder, including their evaluation |

| |in terms of appropriateness and effectiveness |

| |Psychological therapies for their chosen disorder, for example, |

| |behavioural, psychodynamic and cognitive-behavioural, including their |

| |evaluation in terms of appropriateness and effectiveness |

Clinical Characteristics

• 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

Symptoms of the condition

Sufferers of Schizophrenia must have at least two of the following symptoms, each present for a significant portion of time during a1-month period (or less if successfully treated)

◦ Hallucinations (us. auditory or somatic)

◦ Delusions (oft. linked to hallucinations)

◦ Disorganised speech - jumping from one conversations topic to another apparently at random - or incoherence

◦ Disorganised or catatonic behaviour

◦ Negative symptoms - affective flattening (apparent lack of emotion), alogia (apparent inability or unwillingness to speak), or avolition (apparent inability or unwillingness to direct own activities)

◦ Social & occupational dysfunction - For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset

Positive Symptoms

← Delusions – paranoia, grandiosity

← Experiences of control – believe under control of alien force.

← Auditory hallucinations – bizarre, unreal perceptions, usually auditory.

← Disordered thinking – thoughts have been inserted or withdrawn from the mind.

Negative symptoms

← Affective flattening – reduction in range and intensity of emotional expression, including facial expression, tone of voice etc

← Alogia – lessening speech fluency

← Avolition – reduction or inability to take part in goal directed behaviour.

Diagnosis requires 1 month of two or more positive symptoms.

Subtypes of Schizophrenia

Paranoid Type

• Preoccupation with one or more delusions or frequent auditory hallucinations. No disorganized speech, disorganized or catatonic behaviour, or flat or inappropriate affect.

Catatonic Type

• immobility or stupor excessive motor activity that is apparently purposeless, extreme negativism, strange voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing.

Disorganized Type

• Must have all; disorganized speech, disorganized behaviour, flat or inappropriate affect and not meet the criteria for Catatonic Type.

Undifferentiated Type

• Variation between symptoms, not fitting into a particular type

Residual Type

• Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behaviour. Plus presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia

Problems with Validity of classification systems

Validity means that a diagnostic system assesses what it claims to be assessing.

The diagnostic classification systems are based on categories, assuming that all mental disorders are different. There are about five types of schizophrenia with diverse symptoms, so how can they all be termed “schizophrenia”. There is evidence to suggest that there are problems with this categorical approach:

1. Comorbidity: This describes people who suffer from two or more mental disorders. People with schizophrenia usually show comorbidity, such as depression or bipolar disorder (manic depression). Comorbidity occurs because the symptoms of different disorders overlap. For example, major depression and schizophrenia both involve very low levels of motivation. This creates problems of reliability. Does the low motivation reflect depression or schizophrenia, or both?

2. Aetiological validity – the same causes are found in all people. This is not the case with schizophrenia: The causes may be one of biological or psychological or both.

3. Predictive validity - classification categories should predict outcome of a disorder.

There are problems of establishing validity when diagnosing schizophrenic.

4. One of the biggest controversies in relation to classification and diagnosis is to do with cultural relativism and variations in diagnosis. For example in some Asian countries people are not expected to show emotional expression, whereas in certain Arabic cultures public emotion is encouraged and understood. Without this knowledge a person displaying overt emotional behaviour in a Western culture might be regarded as abnormal. Schizophrenia is diagnosed more in African Americans and Afro Caribbean populations: Black People are also more likely to be misdiagnosed for schizophrenia, when they have mood disorders. Misdiagnosis can be the result of stereotyping their behaviours.

5. There is difficulty in distinguishing between schizophrenia and other separate syndromes e.g. temporal lobe epilepsy or drug induced psychosis.

1) The Biological Explanations of Schizophrenia:

1.1) GENETIC Explanations:

← Prevalence of schizophrenia is the same all over the world (about 1%)

◦ Supports a biological view as prevalence does not vary with environment

← Risk rises with degree of genetic relatedness

◦ Spouse – 1% (same as G.P.)

◦ Child – 13%

◦ DZ twin – 17%

◦ MZ twin – 48%

Kendler et al (1985) found that

← 1st degree relatives of those with schizophrenia are 18 times more at risk than the general Population

← Children with both parents who suffer from schizophrenia have a CONCORDANCE RATE OF 46%

The Copenhagen High-Risk Study (Kety et al. 1962)

← Kety identified 207 offspring of mothers diagnosed with schizophrenia (high risk) along with a matched control of 104 children with ‘healthy’ mothers (low risk) in 1962

← Control group were matched on age, gender, parental socio-economic status and urban/rural residence

← Children aged between 10-18 years at start of study

← Schizophrenia diagnosed in 16.2% of high risk group compared to 1.9% in low risk group

So where does that leave us...

← To research more on the impact of genetics on schizophrenia, we can compare concordance rates for identical (MZ) and fraternal (DZ) twins

← Both share the same environment but only MZ twins have identical genetics – if schizophrenia is genetically related, the concordance rate of schizophrenia should be much higher in MZ twins.

← To prove this many studies have been conducted – ALL OF THEM show much higher concordance rate in MZ than DZ twins

← To prove the genetic influence further, you have to research the power of genetics in separate environments - researchers have sought out MZ twins reared apart where at least 1 has been diagnosed with schizophrenia

Gottesman & Shields (1982)

Used the Maudsley twin register and found 58% (7 out of 12) MZ (identical) twins reared apart were concordant for schizophrenia; so points at role of GENES since it’s what they had in common.

Although twin, adoption and family studies continue to prove that the degree of risk of obtaining schizophrenia increases with degree of genetic relatedness, there are two factors which stop us concluding biology as the singular source;

← No twin study has yet shown 100% concordance in MZ twins

← Studies conducted so far don’t tell us which genes might be important for the transmission of schizophrenia.

1.2) BIOCHEMICAL Explanations:

The dopamine hypothesis

Comer (2003)

← Dopamine is one of the many neurotransmitters operating in the brain.

← Schizophrenics are thought to have an abnormally high number of D2 receptors on their receiving neurons, resulting in more dopamine binding and therefore more neurons firing.

← Dopamine neurons play a key role in guiding attention, so it is thought that disturbances in this process may lead to the problems of attention and thought found in people with schizophrenia.

← A group of drugs were developed in the 1950s called phenothiazines, which bind to the D2 receptors, effectively blocking the transmission of nerve impulses through these receptors and therefore reducing deficit found in schizophrenic.

1.3) STRUCTURAL BRAIN ABNORMALITIES Explanations:

← Schizophrenia may be a structural brain abnormality.

← Stevens (1982) cites the fact that many schizophrenics display symptoms indicating neurological disease - especially decreased eye blinking, lack of the blink reflex, poor visual pursuits and poor pupil reactions to light. Some schizophrenics underwent perinatal complications and may have suffered a lack of oxygen resulting in possible brain damage.

← Researchers have found that many schizophrenics have enlarged ventricles, these are cavities in the brain that supply nutrients and remove waste.

← Torrey (2002) found that the ventricles of a schizophrenic are 15% bigger on average than normal.

← Bornstein et al (1992) found that people with schizophrenia and enlarged ventricles tend to display negative rather than positive symptoms and have greater cognitive disturbances and a poorer response to traditional antipsychotics.

Meyer – Lindenberg et al (2002) examined brain activity in schizophrenics engaged on a working memory task.

← Their prefrontal cortex showed reduced activation reflecting their poor performance on such tasks.

← At the same time dopamine levels were elevated suggesting that a dysfunction of the prefrontal cortex is linked to dopamine abnormalities.

 

Sigmundssen (2001) found that patients with type 2 schizophrenia have smaller amounts of grey matter and smaller temporal and frontal lobes.

← This supporting the view that enlarged ventricles are significant only because they indicate reduced brain matter, which may be related to brain damage.

( Evaluation of Biological Approach

✓ Humane approach; poses no blame on the individual or their families – states that the people who become ill are purely “unlucky”

✓ Tends to provoke little fear or stigma

✓ Effective treatments

✓ Well established scientific treatments

← Reductionist approach (complex phenomenon reduced to a single biological mechanism)

← Animal studies (how much can we infer from them to humans?)

← Treats symptoms, not causes (but mainly because ‘causes’ are so unclear!)

2) The Psychological Explanations of Schizophrenia:

2.1) Behavioural Explanations:

← Behaviourists argue that learning plays a key role in the development of schizophrenia. One suggestion is that early experience of punishment may lead the child to retreat into a rewarding inner world. Others then label them as ‘odd’ or ‘strange’.

← Scheff’s (1966) labelling theory suggests that individuals labelled in this way may continue to act in ways that conform to this label. Bizarre behaviour is rewarded with attention, and becomes more and more exaggerated in a continuous cycle before being labelled as ‘schizophrenic’

← Behaviourists have attempted to explain schizophrenia as the consequences of faulty learning.

← If a child receives little or no social reinforcement early on in life, the child will attend to inappropriate and irrelevant environmental cues, instead of focusing on social stimuli in the normal way.

← Behaviourists explain the fact that schizophrenia runs in families as a function of social learning. Bizarre behaviour by parents is copied by children. Parents then reinforce this behaviour and the behaviour becomes progressively more unusual, until eventually the child acquires the label of being ‘schizophrenic’.

Behavioural Evaluation:

← The validity of the behavioural model is moderately supported by the success of behavioural therapies used with schizophrenic patients.

← Social skills training techniques have been used to help schizophrenics acquire useful social skills (Rodger et al.,2002). Allyon & Azrin (1968) have shown that schizophrenics have learned to make their own beds, comb their own hair etc. when given rewards for doing so.

← Finally Roder et al. (2002) has demonstrated that social skills training techniques have been used to help schizophrenics acquire social skills.

← The success of such programmes in teaching new skills and reintegrating schizophrenics back into the community suggests that these are skills that schizophrenics failed to learn in the first place.

← Overall this research can explain how schizophrenia symptoms are maintained but it does not adequately explain where they came from in the first place.

← Critics claim that labelling theory ignores strong genetic evidence and trivialises a serious disorder.

✓ Experimentally tested

✓ Speaks on the present, as well as the past (validity)

✓ Moderately effective treatments

✓ Accounts for cultural differences

← Simple model (reductionist)

← Animal studies (again, how much can we infer to humans?)

2.2) Cognitive Explanations:

← Hemsley (1993) suggested schizophrenics cannot distinguish between information that is already stored and new incoming information. As a result, schizophrenics are subjected to sensory overload and do not know which aspects of a situation to attend to and which to ignore.

← The role of biological factors is acknowledged in this explanation – it says that the condition has always existed, but is worsened by those around them

← When schizophrenics first hear voices and experience any other worrying sensory experiences, they turn to their friends and relatives to confirm the validity of what they are experiencing. Some people fail to confirm the reality of these experiences, so the schizophrenic comes to believe they must be hiding the truth.

← Individuals then begin to reject feedback from those around them and develop delusional beliefs that they are being manipulated and persecuted.

← Yellowlees et al have developed a curious treatment, where patience watch a machine that produces virtual hallucinations, such as hearing the television tell you to kill yourself or one person’s face morphing into another’s. This is to show schizophrenics that their hallucinations are not real, that disbelieving others is a consequence of madness.

Cognitive Evaluation:

✓ Focuses on the current cognitions

✓ Plenty of research into the idea

✓ Influential and popular model

✓ Includes biological and the psychological

✓ Empowers the individual to change

← Ignores the environmental influences

← Unscientific

← Blaming the individual can make the disorder worse

← Is thinking irrational?

← Which is the cause? Which is the effect?

3) Sociocultural Explanations:

2.3.1) Life events

← A major stress factor that has been associated with a higher risk of schizophrenic episodes is the occurrence of stressful life events, such as the death of a relative, job loss or the break up of an intimate relationship. It is not known how stress triggers schizophrenia, although high levels of physiological arousal associated with neurotransmitter changes are thought to be involved.

← Brown and Birley (1968) 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 (1996) followed 71 schizophrenic patients over a 48 week period. Life events made a significant cumulative contribution in the 12 months preceding relapse rather than having a more concentrated effect in the period just prior to the schizophrenic episode.

← Although not all evidence supports the role of life events, in one study it was found that there was no link between life events and the onset of schizophrenia, patients being equally likely to have a major life event or not in the 3 months before the schizophrenic episode.

2.3.2) Family relationships

← Double Bind theory – Bateson et al 1956

← Children who receive contradictory messages from their parents are more likely to develop schizophrenia.

← Conflicting message = mother says I love you, but turns her head away in disgust. Child received conflicting message about their relationship on different levels.

← Verbal affection, non-verbal animosity (strong dislike)

Bateson et al argued Child’s ability to respond is incapacitated by the contradictions.

Prolonged exposure to these interactions prevents the development of a coherent construction of reality.

Which in the long run manifests itself as schizophrenic symptoms, e.g. flattened effect, delusions, hallucinations, incoherent thinking and speaking and some cases paranoia.

2.3.3) Social Labelling

← Scheff (1999) promoted the labelling theory of schizophrenia.

← Theory states social groups create the concept of psychiatric deviance by constructing rules for group members to follow.

← Thus the symptoms of schizophrenia are seen as deviating (going against) from the rules that we attribute to ‘normal’ experience or behaviour.

← Therefore those who display unusual behaviour are considered deviant and the label schizophrenic may be applied which becomes a self fulfilling prophecy that promotes the development of other symptoms of schizophrenia (Comer 2003).

Treatments for Schizophrenia

Introduction

Prevention of Schizophrenia

Schizophrenia has no known method of prevention, but early diagnosis followed by appropriate treatment help decrease symptoms of the illness.

There is no known cure for Schizophrenia but there is treatment aimed at reducing the symptoms. Treatment may be in form of medications, psychosocial therapy, hospitalization and Psychosurgery. Hospitalization is preferred when dealing with patients who exhibit severe symptoms of Schizophrenia. The aim of hospitalization is to prevent them from hurting or injuring themselves and gain stability as they take medication.

3) Biological Treatments

3.1) Electro-convulsive therapy for Schizophrenia

Only use ECT if you have to look at TWO BIOLOGICAL therapies for Schizophrenia. ECT is rarely used in this country and would never be used as a first line of treatment. Make sure you say this clearly if you mention ECT.

Always choose drug treatment as your first biological treatment.

Electro-convulsive therapy (ECT) was widely used for Schizophrenia in the 1950s.

A small current of 0.6 amps is passed through the brain, for about half a second.

This causes a seizure (similar to epilepsy) which lasts for about a minute.

ECT is usually given 3 times per week for up to 5 weeks.

Muscle relaxant drugs are used to prevent full convulsions, along with anaesthetic to calm the patient.

For Schizophrenia, the standard ECT treatment is unilateral, i.e. one electrode on the temple of the non-dominant brain hemisphere and one electrode in the middle of the forehead.

ECT was used because it was observed that, in some patients with epilepsy, psychotic symptoms and seizures occur alternately i.e. when the patient has seizures there are no psychotic symptoms, but psychotic symptoms appear when seizures are controlled. Also it was noted that when a Diabetic patients was accidentally overdosed on insulin and had massive fits as a result all psychotic symptoms disappeared.

Research evidence, criticism and evaluation

ECT in England today Psychiatrists in England today do not consider it to be an effective treatment for Schizophrenia, although it is effective for profoundly depressed people who do not respond to drug treatment or are at high risk of suicide, However, there are schizophrenic patients who are also drug resistant or experiencing or worried about drug side-effects. The overuse of ECT to control very disturbed patients in the 50s and 60s is a major factor in its lack of use today and also raises serious ethical issues, such as a lack of informed consent.

ECT world-wide. Psychiatrists in other countries (e.g. India, Japan, Nigeria, Iran) may still use ECT for some patients with Schizophrenia, sometimes without anaesthetic

Research study Khalilian (2006)

Kalilian argues that too little attention is paid to patients with negative symptoms, since Neuroleptic drugs are more effective for controlling positive symptoms such as hallucinations. He proposes that ECT in combination with drug therapy might be effective for patients with negative symptoms. ECT might enhance permeability through the blood brain barrier (BBB) so that clozapine can pass through and act on the brain tissue. This avoids high oral doses of clozapine, which leads to side-effects on other organs of the body.

Method Khalilian conducted in a small placebo-controlled trial of drug-resistant patients. 18 participants were assigned to 3 treatment groups: clozapine alone, ECT alone and a combination clozapine and ECT. He gained written informed consent from patients before treatment (Can psychotic patients give consent? Diminished responsibility?). A reliable test, the Positive and Negative Syndrome Scale, (PANSS) was to assess functioning before and after treatment; a matched pairs design was based on functioning. Anaesthetic was used; this also acted as a control so that the clozapine alone group did not realise they had not had ECT.

Findings: Combination therapy was superior to either therapy on its own; significant improvement was found in 71% combination treatment patients compared to 40% having ECT alone and 46% clozapine alone. No adverse effects were found.

However, Khalilian admits that the number of patients was small and the duration of remission was not studied.

Work out the A02? (Memory loss, ethics, just biological, not really sure why it works)

3.2) Psychosurgery

As with ECT only use PSYCHOSURGERY if you have to look at TWO BIOLOGICAL therapies for Schizophrenia. PSYCHOSURGERY is rarely used in this country and would never be used as a first line of treatment. Make sure you say this clearly if you mention PSYCHOSURGERY. Always choose drug treatment as your first biological treatment.

Psychosurgery through an operation known as lobotomy is used in very limited cases on patients with chronic and severe Schizophrenia. The operation is considered hazardous due to the serious damage it can cause to a person.

• Psychosurgery involves damaging the brain in order to bring about behavioural changes.

• The 1st use of psychosurgery to treat Schizophrenia came in the 1930’s with attempts to sever the connections between the frontal lobes and the rest of the brain.

• The patients treated were calmer and displayed none of the symptoms of the disorder of Schizophrenia: however, they were sluggish and apathetic and had no real quality of life.

• The ‘ice-pick’ lobotomy involved an instrument very similar to an ice pick being inserted under the upper eye-lid and hammered up into the brain through the orbital socket followed by a rotation to sever connections. Some psychiatrists boasted that they could treat a dozen patients in a single morning.

• The exact figure is not known, but it is estimated that some 18,000 lobotomies were performed in the USA alone between 1939 and 1951. By the 1970s, the use of frontal lobe lobotomies had all but died out due to the introduction of drug therapies. Between 1980 and 1986, 32 lobotomies were performed in France and around 15 each year in the UK. Some are still carried out in this country, although usually only in very exceptional circumstances.

Is psycho Surgery an appropriate treatment for Schizophrenia?

• Studies using MRI have shown that there is abnormal functioning in the frontal lobes of schizophrenics. Not consistently though

• A surgery that reduces the functioning of the frontal lobe may actually help to control the symptoms of some sufferers.

• Such a drastic step as deliberately damaging the brain can ever be justified is a matter of debate.

• A very serious problem with psychosurgery is that it is totally irreversible; it cannot be undone; the side effects are permanent.

Major loss of memory, emotional disturbance, loss of creativity, personality change, lack of social inhibition and other serious problems have been noted as side effects of psychosurgery.

Is psycho Surgery Effective?

• Between 1942 and 1954, 41% of patients who underwent such procedures ‘recovered’ or “greatly improved”, 28% were “minimally improved”, 25% showed “no change”, 4% had died, and 2% were made worse. (Tooth & Newton, 1961).

• Some psychologists have taken issue with findings like these. These issues generally surround the definition of the term ‘recovered’. This term is wholly inappropriate when discussing the effects of psychosurgery on sufferers of Schizophrenia.

• Psychosurgery reduces the symptoms in the same way that drinking alcohol ‘cures’ anxiety & stress.

Work out the A02? (Memory loss, ethics, just biological, not really sure why it works)

4) Medications/ Chemotherapy - Drug treatments

To relieve symptoms such as insomnia, nervousness, depression, fears, voices, feelings of suspicion, and confused thinking. Also to improve patient’s concentration

The Biological Approach explains mental disorders in terms of abnormalities of the central nervous system, i.e. that there is something wrong with the workings of the brain. For example, Schizophrenia has been explained as being caused by an excess of the neurotransmitter dopamine. This suggests that drugs which alter levels of the various neurotransmitters, by blocking receptor sites, inhibiting reuptake or improving the break down of molecules following release for example may be effective in alleviating symptoms.

Keys Terms

- Agonists: Drugs that increase Neurotransmitter availability, e.g. stimulants.

- Antagonist: Drugs that reduce Neurotransmitter availability, e.g. Blockers.

- Anti psychotics: Drugs that reduce Neurotransmitter availability, e.g. Antagonists or Blockers.

- Neuroleptics: Another name for Antipsychotics. There is subtle differences between Neuroleptics and Antipsychotics, e.g. on which Dopamine receptors they work on: D1, D2, D3 etc. If interested ‘Google’ the difference between them, AQA do not expect it!

- Typical Antipsychotic drugs: Conventional Antipsychotics (1950’s) that reduce Dopamine only. Also they usually only reduce positive symptoms. They are very likely to cause the side effect of Tardive Dyskinesia in 20-30 % of users.

- Atypical Antipsychotic drugs: Newer Antipsychotics (1990’s) that reduce Dopamine and Serotonin. Also they reduce positive and negative symptoms. They are much less likely to cause the side effect of Tardive Dyskinesia, but more likely to cause Agranulocytosis.

- Tardive Dyskinesia: is a difficult-to-treat form of Dyskinesia (disorder resulting in involuntary, repetitive body movements) that can be Tardive (having a slow or belated onset).It frequently appears after long-term or high-dose use of Typical antipsychotic drugs. Tardive Dyskinesia is characterized by repetitive, involuntary, purposeless movements, such as grimacing, tongue protrusion, lip smacking, puckering and pursing of the lips, and rapid eye blinking. Rapid movements of the extremities may also occur. Impaired movements of the fingers may also appear.

4.1) Typical Drugs – Typical drugs block Dopamine only.

Antipsychotics are the primary medications for treating Schizophrenia. Conventional or Typical Antipsychotics were introduced in the 1950's and all had similar ability to relieve the positive symptoms of Schizophrenia. This medicine reduces disturbing symptoms like hallucinations and delusions. Typical Antipsychotics help relieve the positive symptoms of Schizophrenia by helping to correct an imbalance in the chemicals that enable brain cells to communicate with each other. As with drug treatments for other physical illnesses, many patients with severe mental illnesses may need to try several different antipsychotic medications before they find the one, or the combination of medications, that works best for them.

Doctors will usually prescribe a Typical Anti-psychotic medication, such as Chlorpromazine or Haloperidol, following the first psychotic episode of Schizophrenia. There are many Typical drugs available (see tables below for examples).Doctors will only try one drug at a time and monitor the patient carefully for changes in symptoms and any side effects. Drug treatments need to be started quickly in order to be most effective, and those patients who remain untreated for many years often do not benefit when treatments is finally started.

These conventional Typical Antipsychotics (Neuroleptics) have similar ability to relieve the positive symptoms of Schizophrenia. Most of these older "conventional" antipsychotics differed slightly in the side effects they produced. These conventional antipsychotics include Chlorpromazine (Thorazine), Fluphenazine (Prolixin), Haloperidol (Haldol), Thiothixene (Navane), Trifluoperazine (Stelazine), Perphenazine (Trilafon), and Thioridazine (Mellaril). Individual patients react differently to different treatments and doctors have their own preferences which they develop through experience with many patients and hence, it is not as simple as there being one drug per disorder.

4.2) Atypical Drugs - Atypical drugs block Dopamine and Serotonin.

In the last decade new "Atypical" antipsychotics have been introduced. Compared to the older "conventional" antipsychotics these medications appear to be at least equally effective for helping reduce the positive symptoms like hallucinations and delusions - but may be better than the older medications at relieving the negative symptoms of the illness, such as withdrawal, thinking problems, and lack of energy. There is however no concrete evidence of how effective they are at relieving negative symptoms. The Atypical antipsychotics include risperidone (Risperdal), Clozapine (Clozaril), Olanzapine (Zyprexa), Quetiapine (Seroquel), and Ziprasidone (Geodon).

If symptoms do not improve with the use of typical anti-psychotics, then an Atypical -anti-psychotic such as Zyprexa, Risperidone or Clozapine might be used. The reason they were not given first is Atypical drugs can a cause life threatening condition called Agranulocytosis (esp. Clozapine). These suppresses the development of bone marrow, in turn reducing white blood cells which can lead to infection, blood tests are taken for the first six months on this medication

Clozapine was the first Atypical antipsychotic in the United States and seems to be one of the most effective medications, particularly for people who have not responded well to other medications. Treatment-resistant schizophrenia" is a term used for the failure of symptoms to respond satisfactorily to at least two different Antipsychotics for other patients who are unwilling or unable to take medication regularly, long-acting depot preparations of antipsychotics may be given every two weeks to achieve control. America and Australia are two countries with laws allowing the forced administration of this type of medication on those who refuse but are otherwise stable and living in the community.

However, in some people it has a serious side effect of dramatically lowering the number of white blood cells produced (Agranulocytosis). People taking Clozapine must have their blood monitored every one or two weeks to count the number of white blood cells in the bloodstream. For this reason Clozapine is usually the last Atypical antipsychotic prescribed, and is usually used as a last line treatment for people that do not respond well to other medications or have frequent relapses.

Current treatment guidelines recommend using one of the Atypical antipsychotics other than clozapine as a first line treatment option for newly diagnosed patients. However, for people already taking a conventional antipsychotic medication that is working well, a change to an Atypical may not be the best option. People thinking of changing their medication should always consult with their doctor and work together to develop the safest and effective treatment plan possible.

A01 research between Typical and Atypical

Typical antipsychotics

• Davis et al: when reviewing the relapse rate of 29 studies it was found that there was a higher relapse rate using the placebo (55%) : drug(19%)

• Ross et al: the previous study is misleading as it doesn’t take into account that 45% of people did benefit from the placebo

• Davis et al: when comparing 2 environments which the drug was given: placebo. In a hostile and critical environment the relapse rate using drugs was 53%: 92% placebo. In a supportive environment the relapse rate using drugs was 12%: 15% placebo

• Many worrying side effects

• Ross et al: drugs reduce the effects but not the cause, and therefore they decrease the motivation of the patient to find their cause of schizophrenia.

Atypical antipsychotics

• Acts on both dopamine and serotonin receptors

• Temporarily block the receptors

• Less occurrence of Tardive Dyskinesia

• Jeste et al: after 9 months 30% of patients using conventional drugs developed the disease: 5% using atypical.

• There are fewer side effects therefore patients are more likely to continue taking the drug and see the benefits

• Leutch et al: 2/4 atypical drugs were more effective compared to conventional – the other 2 showed no difference

• 2/4 atypical drugs were more effective at treating the positive symptoms: conventional

A02 – Evaluation of drug therapies

Positive A02 points specific to Typical and Atypical Antipsychotic drugs

Before Antipsychotic drugs, 50% of patients admitted to hospital stayed there for life. The treatment of inmates in lunatic asylums was brutal or non existent (ECT, psycho surgery, insulin shock therapy etc.) and the living conditions were disgraceful. Hospital staff mainly used methods to control, contain and restrain patients not treat them: straight jackets, padded cells. In comparison, today only 3% of Schizophrenics are in hospital and usually only for a few weeks. Therefore the treatment of the mentally ill in western/individualistic societies has changed radically for the better.

Antipsychotic drugs decreased many of the most disturbing symptoms, e.g. delusions and hallucinations (Typical and Atypical) and Atypical decreased some of the negative symptoms as well; although it should be noted that only with limited degrees of success.

As a result, the lives of Schizophrenic patients may have been revolutionized. They enable people to get on better with their lives, jobs and relationships to a certain degree! It is disputed how much they are able to live normal lives.

They enable patients to respond more rationally to psychological therapies (i.e. allows patients to ACCESS psychological therapies)

Negative A02 points specific to Typical and Atypical Antipsychotic drugs

Tolerance – needing more of the drug to get the same effect

Addiction/Dependence – needing the drug, either physically, or for a feeling of psychological well being

Withdrawal – sometimes coming off the drug produces symptoms far worse than the original ones

Risk of “pharmacological straitjackets”-keeping patients ‘zombied’ for the benefit of the hospital and family

Risk of side effects

However, people may stop treatment because of medication side effects, disorganized thinking, or because they feel the medication is no longer working. Apparently, people with Schizophrenia who stop taking prescribed medication are at a high risk of relapse into an acute psychotic episode.

50% of patients stop taking their medication after the first year

75% of patients stop taking their medication by the second year.

Of those still taking drugs, 40% relapse in the first year and 15% each subsequent year. These figures imply that chemotherapy is not very effective as most patients discontinue treatment (because of medication side effects, disorganized thinking, or because they feel the medication is no longer working). Plus a significant amount of patients are not symptom free.

All the Antipsychotic medications have side effects. Different medications produce different side effects, and people differ in the amount and severity of side effects they experience. Side effects can often be treated by changing the dose of the medication, switching to a different medication, or treating the side effect directly with an additional medication. Common inconvenient side effects of all antipsychotic drugs used to treat Schizophrenia include: dry mouth, constipation, blurred vision, and drowsiness. Some people experience sexual dysfunction or decreased sexual desire, menstrual changes, and significant weight gain (100 pounds) = Diabetes, .Other common side effects relate to muscles and movement problems. These side effects include: restlessness, stiffness, tremors, muscle spasms, and one of the most unpleasant and serious side effects, a condition called Tardive Dyskinesia. Tardive Dyskinesia most common with Typical anti psychotics but can still occur with Atypical. Anti psychotics too.

This condition usually develops after several years of taking antipsychotic medications and more predominantly in older adults. Tardive Dyskinesia affects 20 to 30 percent of people taking conventional antipsychotic medications. Tardive Dyskinesia can be treated with additional medications or by lowering the dosage of the antipsychotic if possible.

Some findings indicate that drugs may not even be necessary. In the long term, many schizophrenic individuals function better without antipsychotic medicine so perhaps this indicates nurture may be more important.. In a 2007 study, only 28% of patients who were not being treated medicinally showed signs of psychotic activity, while 64% of those on antipsychotics had psychotic activity.

Furthermore, people who suffer from schizophrenia in the Third World are twice as likely to recover as sufferers in the West, according to a report by the World Health Organisation WHO). The World Health Organization conducted two long-term follow-up studies involving more than 2,000 people suffering from schizophrenia in different countries. These studies found patients have much better long-term outcomes in developing countries (India, Colombia and Nigeria) than in developed countries (USA, UK, Ireland, Denmark, Czech Republic, Slovakia, Japan, and Russia),despite the fact antipsychotic drugs are typically not widely available in poorer countries, raising questions about the effectiveness of such drug-based treatments.

In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. Multiple international surveys by the World Health Organization over several decades have indicated that the outcome for people diagnosed with schizophrenia in non-Western countries is on average better there than for people in the West Many clinicians and researchers suspect the relative levels of social connectedness and acceptance are the difference, although further cross-cultural studies are seeking to clarify the findings.

Professor Leff, of the Institute of Psychiatry in London said the outcome was better in the in non western countries because of strong support networks, the opportunity to work and lack of stigma in areas where beliefs in witchcraft and karma mean the condition is accepted more easily.

"The large number of people in households [in developing countries] means that there is a network of people who can share the responsibility for the patient's care and recovery. There is a strong sense of duty and they all share the burden. In the West you are more likely to find a middle- aged person with schizophrenia being cared for by one carer and the burden of emotional and physical care falls on one person."

Cultures that avoid confrontation also worked in schizophrenics' favour.

It should be noted however that some psychologists believe that because anti psychotic drugs only really reduce positive symptoms this proves that negative, Type 2 Schizophrenia and positive, Type 1 Schizophrenia are two different disorders.

|Drug |T or A? |How? |Side Effects |Research |

| | | | | |

|Chlorpromazine |Typical |Blocks dopamine |Muscle tightening in neck and jaw, Tardive |Barlow & Durand (1995) chlorpromazine is |

| | |receptor sites and |Dyskinesia, decrease of spontaneous movement, , |effective in reducing schizophrenic |

| | |thus decreases |decrease in emotional spontaneity and |symptoms in about 60% of cases. Most |

| | |dopamine activity |motivation, motor restlessness and fidgeting, |impact on positive symptoms; treated |

| | | |sedation, dry mouth, constipation, weight gain. |patients may still suffer from severe |

| | | | |negative symptoms. |

| | | | | |

|Haloperidol |Typical |Blocks dopamine |55% relapse rate in Schooler et al (2005) study.|Schooler et al (2005) randomly allocated |

| | |receptor sites and |Side effects same as above. |555 patients in first episode of |

| | |thus decreases | |Schizophrenia, to either treatment with |

| | |dopamine activity | |haloperidol or risperidone. In both |

| | | | |groups 75% showed a reduction in |

| | | | |symptoms. |

| | | | | |

|Clozapine |Atypical |Blocks both dopamine |Similar side effects to typical anti-psychotics |Pickar et al (1992) compared clozapine |

| | |and serotonin receptor|but Tardive Dyskinesia much reduced. Fewer side |with other Neuroleptics and a placebo and|

| | |sites. |effects than typical or first generation |found clozapine to be the most effective |

| | | |anti-psychotics. Rare side effect: |in reducing symptoms, even in patients |

| | | |Agranulocytosis, (dangerously low levels of |who had previously been treatment |

| | | |white blood cells) can be fatal. |resistant. |

| | | | | |

|Risperidone |Atypical |Blocks both dopamine |Lower relapse rate than haloperidol, 45% |Emsley (2008) found that patients who |

| | |and serotonin receptor|compared with 55%, (Schooler et al 2005); Also |were injected with risperidone early in |

| | |sites. |fewer side effects than haloperidol; similar |course of disorder had low relapse rates |

| | | |side effects to typical anti-psychotics; weight |and high remission rates; 84% of patients|

| | | |gain, severe anxiety, sedation, insomnia, sexual|showed at least a 50% reduction in both |

| | | |dysfunction, low blood pressure, muscle |+ve and –ve symptoms and 64% went into |

| | | |stiffness, muscle pain, tremors, increased |remission. |

| | | |salivation, and stuffy nose. Also associated | |

| | | |with diabetes, increased risk of suicide and | |

| | | |tumors. | |

5) Psychological Treatments

5.1) Cognitive Behavioural Therapy (CBT)

CBT is an intervention for changing both thoughts and behaviour, representing an umbrella term for many different therapies that share the common aim of changing both cognitions and behaviour. CBT will be discussed generally in this article.

Background

Cognitive psychologists look at how people: perceive, anticipate and evaluate events rather than the events themselves. For example how someone perceives exams. It is not the exam itself, it is how someone perceives, anticipates and evaluates taking exams. If they have optimistic or healthy cognitions than their perception of examinations will be realistic and healthy, even if they fail! The main premise of CBT is that cognitions affect behaviour: Healthy cognitions lead to normal behaviour. Faulty cognitions lead to abnormal behaviour, emotions and perceptions. (self fulfilling prophecy). You are what you think you are!

The CBT therapist encourages the client to become aware of beliefs which contribute to dysfunctional behaviour. This involves direct questioning such as: “Tell me what you think about exams?” “Tell me why you think Madonna wants to marry you? The therapist does not comment upon the client’s beliefs, but instead they are treated as a hypothesis and examined for validity.

“CBT is a form of psychotherapy that attempts to change the patient's unhealthy thoughts and actions. The patient learns to identify distorted thought patterns and beliefs, and to replace them with more productive ways of thinking and acting.”

CBT for Schizophrenia (summarised)

The aims of the therapy are as follows:

• To discover that we all have inherent tendencies to certain negative thoughts that evoke unhappiness and disturbance - especially in response to particular trigger situations.

• To help the patient to identify delusions.

• To challenge and modify delusory beliefs (make irrational thoughts rational). To challenge those delusions by looking at evidence. To help the patient to begin to test the reality of the evidence.

• Recognise negative thoughts. Once patients accept that fact, they can learn to spot these negative thoughts as they arise, and then challenge and re-think them. To trace back the symptoms to get a better idea of how they developed

• Evaluate the context of the patients delusions and hallucinations by considering ways to test the validity of their faulty beliefs

• Set behavioural assignments to improve general Levels of functioning

• Let the patient develop their own alternatives to their previous maladaptive behaviour by looking at coping strategies and alternative explanations.

• Distraction strategies for hallucinations and delusions. Drowning out voices by shouting or turning up the volume of the TV.

• Behavioural Strategies include: initiation of social contact and/or withdrawal of social contact, deep breathing and other relaxation techniques.

• Positive self talk.

An examples of a faulty cognition

Another example, related to paranoia, is the following: A person is leaving his neighborhood supermarket and notices some men in hoodies and sunglasses walking past the shop. He has the thought, “those men are with a gang and are probably following me so they can mug me”. This perception leads him to feel threatened (emotion), and as a result, he decides not to go to that shop anymore (behavior). Following this incident, he starts to avoid other places because of increased paranoia, and therefore becomes more isolated. As you can see from these examples, having certain thoughts or beliefs dictates how a person feels and what they decide to do or not do. These thoughts can create a vicious cycle of avoidance, depression, paranoia, social isolation or distress, which unfortunately can keep a person from achieving personal goals or things that they want from life (such as a job, friends, their own flat, a family, etc).

CBT theory in detail

In addition, CBT presumes that one's symptoms are not random, or fully “biological” in nature, but that they are related to one’s “psychology” and that they are personally meaningful. For instance, CBT theory suggests that someone hearing voices telling him that he is a terrible person is not a random occurrence; it is likely that this person was told that at some point in his life and/or is struggling with his own feelings of worthlessness.

Another theory behind CBT for schizophrenia is that stress makes symptoms considerably worse. So, if a person can learn skills to handle stress more effectively, it is also likely that the person’s symptoms (such as voices or negative symptoms) will also decrease.

← CBT strategies to challenge & help modify delusory beliefs

◦ Identify delusions

◦ Challenge evidence on which delusions are based

◦ Design ‘experiments’ to test reality of this evidence

← Normalising strategies where patient is taught to understand the nature of schiz. symptoms

◦ Challenge ‘catastrophising’ beliefs about schizophrenia

◦ Help patient feel that symptoms are understandable and ‘normal’

Therapy in Detail

The CBT therapist uses specialized techniques to help the client identify his or her unhelpful thoughts (or cognitions) and teaches skills to aid the client in modifying “maladaptive” cognitions over time. In addition, the therapist helps the client identify which coping strategies he or she currently uses to deal with stress, paranoia, voices, depression or anxiety, and evaluates with the client what is working and what is not working. Through trial and error, the therapist and client strive to optimize coping strategies. The therapist and client together decide what they will work on, and they are really studying the symptoms and problems together, in order to learn what triggers the symptoms and what makes the symptoms better. There is always a session agenda, created by the client and the therapist at the beginning of the session to determine what will get discussed at the session. And each week, an out-of-session homework assignment is decided upon together, so that the client can have the opportunity to practice a skill learned in session that week. CBT is also very present-oriented in that the majority of the time is spent on what the person is currently experiencing. While therapists acknowledge that what happened in one’s past and in one’s family is very important to know how clients became who they are, CBT stays focused more in current situations. Therapists feel that is the best way to help a person move forward and work towards his/her own individual goals.

A02 positive

• In general, CBT is different from other psychotherapies in that it is very structured and mutual and tends to be fairly short-term (approximately 10-24 sessions, depending on the client). Frequently the treatment is very problem orientated and prescriptive, and individuals are active collaborators." The short duration of 5-20 weeks in most cases is appealing to insurance companies.

• CBT is generally perceived by researchers to be an evidence-based, cost-effective form of treatment that can be successfully applied to a broad range of psychopathologies, including Schizophrenia.

• Overall, CBT tends to have well-specified treatment goals and clear guidelines for assessing treatment progress

• It has flexibility in meeting individual needs.

• In general, CBT tends to have Emphasis on building self-efficacy (belief in one's own ability to perform a task.)

A02 Negative

• Research on the effectiveness of CBT is very mixed: On the one hand, advocates claim that CBT tends to have the largest effect on helping with psychotic symptoms (like voices and delusions) at the end of treatment, and also helps to maintain those gains when treatment is over (relapse). And that in particular, CBT has been found to reduce the severity of these symptoms and also the distress that these symptoms cause in people who have them. An interesting point is that both anti psychotics and CBT are effective in treating positive symptoms only, lending more support to the notion that they are different disorders. Other positive research is:

• Drury et al (1996) : when using CBT and drugs there was a 25-50% reduction in positive symptoms and recovery time.

• Kuipers et al (1997): when using CBT there was increased satisfaction and low dropout rates

• This type of treatment has been shown to be effective for reducing the positive symptoms of schizophrenia, for reducing relapse and for enhancing recovery when schizophrenia is diagnosed early.

• Chadwick and Lowe (1993) found that CBT reduced delusions in 10/12 of the patients in their study. However, whilst it helps around 70% of patients, it has made the other 30% deteriorate (Kingdom and Turkington, 1996).

• However very recently many psychologists have criticised the previous studies that have endorsed CBT as effective treatments for Schizophrenia. (See this review of CBT meta-analyses by Butler et al., 2006). Their conclusions are: CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates. Butler says “Lately we've been treated to a plethora of articles and press releases saying that antidepressants are worthless and no better than placebo. The present meta-analysis by Lynch et al. (2009) came to the same conclusion about CBT in schizophrenia.

The press release is quite blunt:” Cognitive Therapy Is Of No Value in Schizophrenia, Science Daily (June 26, 2009) — Research co-led by an academic at the University of Hertfordshire, concludes that cognitive behavioural therapy (CBT) is of no value in schizophrenia”

• The results of the review suggest that CBT is ineffective in treating schizophrenia. The meta-analysis included studies examining the effectiveness of CBT against symptoms in schizophrenia and in reducing relapse in schizophrenia. Rigorous criteria were used when selecting only well-conducted clinical trials of CBT for inclusion: A major criticism of CBT of previous research in this area has been that the studies have all employed inadequately delivered psychological treatments for comparison and poor controls.

• Dickerson (2000) also examined 20 studies of CBT in schizophrenia and concluded that the effects of CBT were less apparent when compared with other psychological treatment that controlled for therapy time. Moreover that CBT for Schizophrenia research encompasses patients who vary considerably in symptom presentation and course, number of hospital admissions, self-esteem, depression, suicidality, social/family support, response to medication, etc. Cognitive–behavioural therapy as a descriptor is similarly imprecise. Therefore findings were invalid and unreliable.

• Does CBT really provide added value when compared with other non-specific psychological interventions? E.g. EE therapy? Plus research from non western countries shows that Schizophrenia has a better prognosis if families are supportive.

• CBT has been criticised for only dealing with the present and not examining a patient’s personal and family history. These may be important arrears to discuss, especially as current research is now suggesting abuse may be the stress factor that triggers the disorder.

• Is CBT really effective for Schizophrenia? Positive symptoms are associated with higher levels of Dopamine. Higher levels of Dopamine activity are observed in persons who take street drugs. One would not expect a person high on crack or cocaine; a Dopamine agonist to be able to be talked out of being high. Similarly is it too much to expect that a Schizophrenic experiencing similar effects from their high levels of Dopamine would be lucid enough to respond to CBT? Plus attention deficits may make it impossible to concentrate. Stabilise patients with drugs for therapy?

• Many CBT therapists advocate drug therapy in conjunction with CBT as a result, it is difficult to work out which has been effective or not when assessing CBT.

• Do CBT therapists see the world through rose tinted spectacles? Sometimes life is horrible. Maybe some of a patients thoughts are not faulty and negative maybe they are real reflections of what is happening in their lives.

5.2) Psychoanalysis

• Based on 3 points

• Patients are unaware of their unconscious conflict

• They bring their conflicts into their conscious mind

• All symptoms are meaningful and are caused by the history of the patient

• The psychoanalyst aims to:

• Build trust with the patient and learn their history

• Replace their destructive consciousness with a more supportive, less destructive one

• Once the patient has become healthier the patient will take a more active role in his/her therapy

A02:

• Fenton : limited justifiability due to the lack of evidence or the lack of ability to produce experimental data due to the nature of the theory

• Gottdiener (2002) : out of 37 studies 67% patients improved with this treatment : 35% of patients on no treatment

• May : psychoanalysis and drugs combined were more effective than psychoanalysis alone.

• APA F: psychoanalysis is only appropriate when combined with drug treatment

• As the treatment is expensive and only moderately effective, LT use is low and therefore not very appropriate.

6) ISSUES & DEBATES:

6.1) Nature versus Nurture

If cause is not one thing, e.g. neither just nature (biological) nor nurture (psychological: cognitive, psycho-dynamic, Behavioural etc) than should treatment reflect this? E.g. treatment should be both biological (drugs) and psychological (counselling). CBT actually reflects a more eclectic approach to treatment as it recognises that the best outcomes involve CBT and Anti psychotics. Presumably this is to ensure that the patient is more stable and can therefore be more responsive to CBT.

Below is a really interesting article on the matter:

“Though the simplest of environmental potential causes for schizophrenia taught to most students is something not unlike the diathesis-stress model, whereby a person has a biological predisposition to a disorder and decreased amounts of stress are needed to trigger its onset, there are several other non-genetic factors that have been offered as potential causes or catalysts to the development of schizophrenia.

     Warner (2000) mentions both obstetric complications and viruses as potential causes. Data seem to show that nearly forty percent of schizophrenics had a history of obstetric complications, such as prolonged labor, and that children born of complications have twice the risk for developing schizophrenia as those who had no complications during birth. The risk of intrauterine brain damage is increased if a woman contracts a viral illness during pregnancy. Data show that more schizophrenics are born in late winter or spring as well, and that this trend increases sometimes after viral illnesses like influenza, measles or chickenpox occur.

     

Another major cluster of potential catalysts for the development and triggers for schizophrenia are the abuses: physical especially. Warner (2000) promptly notes, and devotes an entire section to it, that bad parenting does not cause schizophrenia. This is meant to clarify that neglect; confusing parenting styles and other such conditions that may not cause optimal developmental outcome do not cause or even greatly enhance the risk for schizophrenia. However, data has shown that severe physical abuses seem to lend themselves to greater risks for developing psychoses.

     

A study done by Belkin in 1994 looked at sexual abuse as a potential catalyst to the development of schizophrenia. The Minnesota Multiphasic Personality Inventory (MMPI) was administered to 105 sexually abused patients and a matching sample of 105 control patients in order to compare their personality characteristics. The survivors of sexual abuse were found to have scored higher on the Psychopathic Deviate and Schizophrenia scales. The researchers feel that this indicates higher levels of interpersonal discord and social alienation among sexually abused subjects and control subjects with no history of sexual abuse. It was found that more psychopathology existed with histories of male-to-male abuse, and the age that was most impressionable to inducing social discomfort among victims is six to eleven years (subjects abused in this time scored higher on the measures than those of other age groups). Though this study seems to find a correlation between abuse as a child and a greater risk for psychopathologies in later life, it does not find a causal relationship in such things. In other words, sexual abuse as a child could not be proven to be a precursor to developing schizophrenia; merely, it demonstrated a greater chance that such abuse was conducive to developing such psychopathologies.

   

 A study done by Wexler (1997) expanded on the earlier research of Belkin by including physical abuse in his research. His aim was to examine the relationship between childhood sexual and physical abuse and adult psychiatric illness in a sample of diagnostically diverse patients. For his study, he took a sample of 264 patients that had histories of abuse, and 689 who had no histories of this abuse. Through analyzing hospital records and conducting interviews, the primary finding was that there was a greater incidence (three for every one) of major depression and schizophrenia in subjects with histories of abuse than subjects with no such history. This study was only problematic in that it demonstrates only a correlation, and tells us nothing about the actual validity of the thought that abuse contributes to the development of depression and schizophrenic symptoms. However, paired with other research in the same subject matter, it seems to support the general findings that abuse certainly highly positively correlates to the development of psychopathological symptoms.

    

Based on all of these such findings, and other studies of the same and similar subjects, Read (2001) proposed a new model for the development of schizophrenia. It was intended to offer a more comprehensive look at the problem than the diathesis-stress model. The traumagenic neurodevelopmental model (TN model) was proposed in response to the high incidences of child abuse in subjects diagnosed with schizophrenia and schizophrenic symptoms. According to Read, a genetic deficit creates a predisposing vulnerability in the form of oversensitivity to stress. Highly stressful situations can trigger the onset of schizophrenic symptoms, and so children who have been sexually, emotionally and physically abused stand much higher risks of developing this disorder. Those with a genetic predisposition to the oversensitivity to stress have an even greater chance of this development. A very prominent aspect of this theory is the notion that those people who are severely enough abused as children can actually develop abnormalities in the brain that underlie the heightened sensitivity to stress so often found in schizophrenics. These people do not necessarily need to have a genetic predisposition. This model seems to be very comprehensive, but is still in testing stages. It is relatively new, and seems to have promise.

     

Holowka (2003) addresses dissociation. This study strengthens the TN model by finding strong correlations between emotional, physical and sexual abuse and dissociative symptoms and schizophrenia in adulthood. Twenty-six patients were administered the Dissociative Experiences Scale and the Childhood Trauma Questionnaire. What the study found was that emotional abuse had the greatest correlation between schizophrenic and dissociative symptoms, corroborating the theory that heightened levels of stress physiologically can trigger dissociative symptoms. Physical abuse has a lower correlation but is still high. The authors of this study maintain that emotional abuse may play an important role in the etiology of dissociation in schizophrenia. This is still controversial”

6.2) Determinism?

You can’t help yourself must rely on drugs. No free will. Parents can do nothing. This contradicts evidence from cross cultural studies and patients receiving CBT and those receiving no meds.

ON THE OTHER HAND, CBT presumes persons have free will and can change their behaviour. This is a refreshing and optimistic view of humanity. On the negative side persons can be blamed for not changing and held responsible for their actions.

6.3) Reductionism?

Reducing treatment to blocking Dopamine suggests that cause and treatment is biological only. Research shows it is not just biological? Eclectic approaches are more effective.

ON THE OTHER HAND, reducing treatment to changing faulty cognitions suggests that cause and treatment is cognitive only, although many CBT therapists advocate drug therapy in conjunction with CBT however research shows cause is not just biological nor to do with faulty cognitions and that family dynamics and abuse may play apart in aetiology. Therefore family therapy should also be considered

6.4) Ethics?

E.g. Informed consent - can the mentally ill give informed consent? Horrendous side effects. Should you give placebos to Schizophrenics?

6.5) Is Psychology a science?

See above table of A01 research. Is the research scientific experimental, are the quasi/natural experiments? Why is it difficult to research drug treatments? Ideally you would compare patients with who are on different drugs. Can’t control extraneous variables if you do this. You should not give placebos and randomly allocate schizophrenics to different drugs groups as it is unethical when someone is that seriously ill and maybe very depressed.

Schizophrenia as a diagnosis pulls together a group of people who vary considerably in symptom presentation and course, number of hospital admissions, self-esteem, depression, suicidality, social/family support, response to medication, etc. This makes the research less valid d and reliable. Again if the classification of Schizophrenia is invalid (think of our previous discussion here) then how can treatments be effective? If you asses Schizophrenia incorrectly then, your patients may not have it hence treatments will not reflect real Schizophrenia.

For the time being, there are only correlational, loose experimental or shady-at-best results to go on. One study outcome seems to raise questions about another, and so on.

‘Cognitive–behavioural therapy’ as a descriptor is similarly imprecise. At present the label is applied to a wide range of interventions, ranging from a few sessions of support and psycho-education, through to specific interventions for individual symptoms, and therapies that last 20–50 sessions and claim to be weakening not only the full range of positive and negative symptoms but also enduring models of self (schemata). Therapy might be delivered individually or in groups. Then there are therapists themselves: trials are not always using therapists who are accredited cognitive–behavioural therapists, let alone those who are accredited and practised with psychosis.

What this points to is that there is no one CBT for schizophrenia. Rather, there are a range of CBT therapies, some with different underlying theoretical models, offered to a diverse group of patients by therapists who vary in ability and experience.

Sample Exam Questions:

a) Describe two explanations of the Schizophrenia (8 marks)

b) Evaluate these explanations of Schizophrenia (16 marks)

- Describe and evaluate biological treatments for Schizophrenia (24 marks)

-Discuss psychological and biological treatments for Schizophrenia (24 marks)

- Describe and evaluate at least two issues in classifying or diagnosing schizophrenia (24 marks)

- Describe and evaluate two psychological explanations of Schizophrenia (24 marks)

a) Explain issues relating to classifying schizophrenia as a mental disorder (4)

b) Discuss two explanations of schizophrenia from different perspectives in psychology (9 and 11 marks)

a) Describe the clinical characteristics of Schizophrenia (8 marks)

b) Explain and evaluate issues relating to the diagnosis of Schizophrenia as a mental disorder (16 marks)

The factors in Schizophrenia can be organised into those that

- create a vulnerability (Predisposing),

- those that trigger the disorder (precipitating),

- and those that maintain it (perpetuating).

| | | |

| | | |

| | | |

|re-disposing |recipitating |erpetuating |

| | | |

| | | |

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| | | |

| | | |

| | | |

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[pic]

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Task: Considering the theories we have looked at, organise the following in the table below. If you are not sure, write it in pencil. Note certain factors could go in more than 1.

1. Life events 7. Neurodevelopment Hypothesis

2. Family conflict 8.Dysfuncitonal family dynamics

3. Genetics 9.Biochemistry

4. Expressed emotion

5. Faulty cognition

6. Reinforcement HINT: There are 3 in each

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