PSYA4 REVISION

PSYCHOPATHOLOGY (Schizophrenia)

-Schizophrenia • Issues surrounding the classification and diagnosis of their chosen disorder, including

reliability and validity

Do not answer questions on depression, phobic disorders, OCD!!!

•

Biological

explanations of their chosen disorder, for example, genetics, biochemistry

• Psychological

explanations of their chosen disorder, for example, 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

Outline the clinical Characteristics of SZ

• •

More than just ‘symptoms’ Explain, don’t list…

POSITIVE

• Hallucinations

2 types?

NEGATIVE

• Poverty of Speech (alogia) • Flat Affect • Delusions

These are? Types?

• Social Withdrawal… ‘

OTHER

’

Symptoms

• Catatonia

Stupor, Waxy Flexibility, Gegenhalten

• Inappropriate effect

This is?

Outline the clinical Characteristics of SZ

• • • •

Other things you can mention

Diagnostic criteria

– E.g. at least TWO characteristic symptoms present for a significant period (1mth); Significant signs of disturbance (social, occupational) for 6mths)

Incidence rate Subtypes (be sure to say the characteristic symptoms of the subtype/s) Prognosis (include prodromal and active phase)

•

Could mention the ‘new’ DSM criteria…

Discuss issues with the reliability and validity of the diagnosis and classification of SZ

•

Basically, this is asking ‘what are the problems associated with diagnosis and classification of SZ?’

•

Must be prepared to talk about RELIABILITY and VALIDIDTY of diagnosis

– RELIABILITY: do different clinicians give the same diagnosis; is a sufferer diagnosed with the same disorder on different occasions – VALIDITY: Is the diagnosis accurate? i.e does the patient actually have SZ? Have they been mis-diagnosed?

•

Could mention the different types of reliability and validity in the context of diagnosis

Discuss issues with the reliability and validity of the diagnosis and classification of SZ

• • • RELIABILITY Consistency of Diagnosis May be as low as 0.11 (Whalley) Could be due to a number of reasons (make sure you explain) – –

Use of different diagnostic

procedures (ICDvsDSM) as each have different diagnostic criteria

Differences in the training and experiences of the clinician

could lead to inconsistent diagnosis

Mr B. tip - Use Rosenhan’s study as a LINK between reliability and validity issues…

• • • VALIDITY Accuracy of Diagnosis Studies suggest validity of diagnosis is low Could be due to a number of reasons (make sure you explain) – Nature of SZ (e.g. absence of pathognomic symptoms; no objective observable symptoms; co-morbidity issues; natural variability of SZ across time and sufferers – Issues with the clinician (e.g. training and experience [inc.

knowledge of culture bound symptoms – give an e.g!]; fear of labelling, discrimination and a self fulfilling prophecy)

Discuss issues with the reliability and validity of the diagnosis and classification of SZ

• •

EVALUATION / COMMENTARY

Key Study = ROSENHAN ‘on being sane in insane places’ – shows diagnosis was reliable but not valid. (make sure you can describe this) But problems with this study include low temporal validity (child of it’s time), sample issues – cannot say ALL institutions have the same issues with diagnosis of SZ • Other commentary points – Even with the problems, any diagnosis is better than no diagnosis because with diagnosis a patient wouldn’t receive treatment – Highlighting the problems with diagnosis has led to a number of improvements with the system •

New versions of DSM have a list of culture bound behaviors

•

Clinician training has improved to increase awareness of biases, etc

•

DSM V has got rid of subtypes as they believed this was causing problems due to overlapping symptoms

•

DSM and ICD have been brought more in line

•

Increased use of standardised procedures (e.g. Present State Examination) should increase reliability and validity of diagnosis

Discuss issues with the reliability and validity of the diagnosis and classification of SZ (8+16)

In the context of diagnosis of SZ, reliability refers to… (could bring in inter-rater and test-retest) So Rosenhan shows that there are issues with the validity of SZ diagnosis. In the context of diagnosis, validity means… It is suggested that the reliability of diagnosis is low. Whalley found… One reason that diagnosis of SZ may lack validity is… This could be due to a number of reasons. For example the fact that different clinicians use different diagnostic tools… Another reason to explain the low validity of SZ diagnosis is… Another reason for low reliability in the diagnosis of sz is… In evaluation, there is research which has investigated the reliability and validity of SZ diagnosis. One piece of research is Rosenhan’s ‘on being sane in insane places… This study shows… However, there are problems with this study… In evaluation, identifying the issues with diagnosis of SZ has resulted in a number of practical applications which have improved modern diagnosis of the disorder. This includes… (NB say

why it helps!)

In addition… Finally, there is also the argument that a flawed diagnosis and classification system is better than no system at all. This is because…

What is wrong with these answers?

(and can you spot any errors?)

One explanation is the Dopamine hypothesis, which suggests increased action at dopamine pathways causes schizophrenia. High DA action may be caused by a number of aspects, such as over sensitive D1 receptors and poorly functioning enzymes which break down DA. DA is thought to play a primary role in the processing of sensory information, movement and motivation.

According to the cognitive theory, schizophrenia may be caused by irrational thoughts which lead to cognitive distortions – literally abnormal processing of sensory information. In more detail, this abnormal processing may be a result of damage to cognitive systems such as the central monitoring system. This system is responsible for labelling actions as ‘being done by me’.

Psychodynamic theory offers an alternative psychological theory. Here, the root cause is unconscious conflicts which arise as a result of trauma in adulthood. This trauma may cause abnormal development of the tri-partite personality (ID, EGO, SUPER EGO). For example, it may cause the EGO to perform maladaptive use of defence mechanisms such as regression when a person is faced with trauma. Here a person is psychologically ‘going back’ to an early stage in their life.

What is wrong with these answers?

(and can you spot any errors?)

One explanation is the Dopamine hypothesis, which suggests increased action at dopamine pathways causes schizophrenia. High DA action may be caused by a number of aspects, such as over sensitive D2 receptors and poorly functioning enzymes which break down DA. DA is thought to play a primary role in the processing of sensory information, movement and motivation. For schizophrenia, the DA hypothesis makes sense as it would explain the classic symptoms where these aspects are abnormal, such as social withdrawal (loss of motivation) and catatonia (movement abnormalities) According to the cognitive theory, schizophrenia may be caused by irrational thoughts which lead to cognitive distortions – literally abnormal processing of sensory information. In more detail, this abnormal processing may be a result of damage to cognitive systems such as the central monitoring system. This system is responsible for labelling actions as ‘being done by me’. For schizophrenia, this makes sense as many symptoms could be explained by this. For example, auditory hallucinations may be a person who doesn’t recognise that their inner voice is their own and instead attributes it to an external source (e.g. God) Psychodynamic theory offers an alternative psychological theory. Here, the root cause is unconscious conflicts which arise as a result of trauma in childhood. This trauma may cause abnormal development of the tri-partite personality (ID, EGO, SUPER EGO). For example, it may cause the EGO to perform maladaptive use of defence mechanisms such as regression when a person is faced with trauma. Here a person is psychologically ‘going back’ to an early stage in their life, prior to the trauma they experienced, as this makes them feel psychologically ‘safe’. For schizophrenia, this makes sense as many symptoms can be classed as childlike, such as neologisms (making up words) and even visual hallucinations which may be representative of childhood imaginary friends (these may serve a further psychological purpose however …

Discuss Biological Explanations of SZ

• • Need to know at least TWO for top mark bands

Bio explanations include

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Genetic abnormalities

–

Biochemical - Neurotransmitter imbalances

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Neuroanatomical Abnormalities

–

Viral Hypothesis

• When evaluating, consider the general strengths and weaknesses of the BIOLOGICAL APPROACH • Where possible, link to specific symptoms!

EXAMINERS LIKE RESEARCH WHEN DISCUSSING EXPLANATIONS

Discuss Biological Explanations of SZ

• • • • •

GENETICS

Sz is likely to have a genetic basis because of the observations that Sz is present in ALL CULTURES and tends to run in FAMILIES Established through TWIN, ADOPTION, FAMILY studies which assess CONCORDANCE rates Top band detail - saying Sz is ‘genetic’ is too simplistic Chromosone ____ (Gurling) Specific Gene? _______ (Tonegawa) • • • • • • • • EVALUATION Evidence - E.g. Gottesman / other family studies – Difficult to separate the effects of nature and nurture (shared environment criticism); problems with the operationalisation of SZ – different studies use different criteria making it difficult to compare results Some animal research – Problems with research? Extrapolation INCOMPLETE because...

PARSIMONIOUS but too Simplistic as it doesn’t take into account psychological factors such as… which research has suggested may play a role in SZ DIATHESIS – STRESS the most complete explanation SOCIALLY SENSITIVE (who does it blame? Why is this a problem?) NEGATIVE MORAL IMPLICATIONS – may diffuse responsibility for the disorder away from the sufferer which may have treatment implications (i.e. they feel that because the disorder is not ‘their’ fault, there is no point in seeking treatment) BUT there may be PRACTICAL APPLICATIONS…

Discuss Biological Explanations of SZ

• • • •

BIOCHEMICAL

the DOPAMINE HYP Simple...

Initially thought to be the case because we know DA controls perception, motivation, attention and control of motor movements So this explains symptoms including...

• High DA could be caused by a number of factors including… • Other observations which indicate high DA causes Sz (e.g. drug use which causes increased action at serotonin sites is often accompanied with SZ type symptoms, including hallucinations, delusions). • • • • • • • • • • • EVALUATION Evidence and supporting observations / methodological problems with these Post mortem studies and Animal studies useful for easy commentary points...

CAUSE and EFFECT issues

But why do we think it high DA is a cause and not an effect?

But the TREATMENT AETIOLOGICAL FALLACY...

INCOMPLETE (can explain positive but not negative symptoms)

However, negative symptoms may be a result of positive symptoms (e.g. social withdrawal may be caused by delusions)

Parsimonious but reductionist Same as before. Include reference to the idea that DA imbalance may itself be caused by something else (genetics) Deterministic Major Practical application... (use research to support. “this study shows that drugs are an effective treatment for SZ. As they are based in the dopamine hypothesis, this in turn VALIDATES the dopamine hypothesis of SZ)

Discuss Biological Explanations of SZ Third / Back-up Theory

• • •

NEUROANATOMICAL

Enlarged Ventricles Indicates atrophy to certain brain regions / areas associated with cognitive and behavioural functions; link to symptoms Accidents, genetics, may cause abnormalities •

VIRAL HYPOTHESIS

Sz caused by a virus which is contracted during pregnancy (third trimester?) • • • EVALUATION Difficult to verify (retrospective?) Incomplete General points too… • • EVALUATION Objective methods used to support this theory (brain scans) General points too!

Discuss Psychological Explanations of SZ

• •

As with biological explanations, you need to know TWO for the top mark band

Psych Explanations include

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Cognitive (damage to cognitive systems)

–

Psychodynamic (early trauma, abnormal tri-partite personality, family systems [e.g. double bind; schizophrenogenic mothers])

–

Behavioural / Social

• •

As before, remember to evaluate the approach on which the theory is based Where possible, link to specific symptoms

EXAMINERS LIKE RESEARCH WHEN DISCUSSING EXPLANATIONS

Discuss Psychological Explanations of SZ

• •

COGNITIVE

Sz a result of irrational thoughts / errors in cognitive processing – Delusions, hallucinations, etc These may be caused by damage to cognitive processing systems • Metarepresentation system (overall control) but includes...

– Central Monitoring System • Responsible for...

• Damage would lead to...

– Supervisory attentional system • Responsible for...

• Damage would lead to… • • • • • • • EVALUATION Supporting evidence – E.g. Frith and Done experimental fluency tasks – compared to a control, SZ produced fewer self initiated behaviours, indicating damage to the SAS – But serious methodological Issues with the study (task lacked mundane realism so may tell us little about SZ in real life; sample issues UNSCIENTIFIC and UNFALSIFIABLE – based on abstract concepts (CMS, SAS) which are difficult to test empirically. Relies on subjective opinion Cause and effect issues More complete and less reductionist compared to bio theories as it can explain positive AND negative symptoms Recognises Nature (bio) influences (these may be the root cause of cog deficits) Practical Applications – therapies can be focused on specific cognitive systems Successful Therapy (CBT) derived from this approach validates the theory

Discuss Psychological Explanations of SZ

• • • • • • • •

PSYCHODYNAMIC

Sz caused initially by NEGATIVE EARLY EXPERIENCES (e.g. Early trauma, such as...) This leads to unconscious conflicts (ID, EGO, Super EGO), specifically… EGO may shatter – ID becomes dominant; results in primary narcissism (which is…); this would cause symptoms including... To regain control, the EGO may overuse

defence mechanisms such as REGRESSION

(which is…) as an attempt to go back to a time prior to the trauma. This can explain symptoms such as… • • • • Could also bring in the role of dysfunctional families and explain HOW these contribute to SZ

Schizophrenogenic mothers (characteristics?) Double Bind situations High expressed emotions (relapse as opposed to starting point)

• • EVALUATION EVIDENCE E.g. OLTMAN – Problems with evidence – Based on RETROSPECTIVE DATA, Subjective, bias, sample issues blah blah blah ABSTRACT AND UNFALSIFIABLE – Difficult to test using empirical methods. Heavily reliant on subjective opinions (prone to bias) CAUSE AND EFFECT ISSUES? It may be that the schizophrenics behaviour causes the family unit to be dysfunctional (e.g. double bind situations) INCOMPLETE and OVERLY DETERMINISTIC TOO SIMPLISTIC – Emphasises Nurture over nature – diathesis stress a better approach? (N.B this approach lends itself very nicely to diathesis stress) NEGATIVE MORAL IMPLICATIONS BUT DOES HAVE PRACTICAL APPLICATIONS

Discuss Psychological Explanations of SZ

• •

BEHAVIOURAL

Social learning SZ may observe and imitate symptoms from, for e.g. family members, especially if it is observed being reinforced (vicarious reinforcement). Can explain why the disorder appears to run in families) • •

SOCIO-CULTURAL

SZ caused by stress and pressures of living in an urban environment Causes client to socially withdraw / escape into a psychological fantasy world • • • Operant Conditioning Learn SZ symptoms are followed by with positive reinforcement in the form of attention, etc Absence of learning of ‘normal’ behaviour •

As SZ is a complex disorder, it is unlikely that ALL symptoms are a result of maladaptive learning (but some symptoms may be caused by other symptoms so learning may be the cause of the key symptoms…)

• •

BUT... Urban drift argument suggests SZs move to urban areas to access treatment so this explains the high occurrences of Sz in urban locations (cause and effect Diathesis-Stress?

THERAPIES for Schizophrenia

•

TWO biological therapies

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EARLY BIO TREATMENTS (ECT, Lobotomies)

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DRUGS (typical and atypical anti-psychotics)

•

TWO psychological therapies

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CBT

–

TOKEN ECONOMY

Must be able to evaluate in relation to APPROPRIATENESS and EFFECTIVENESS so use these terms!

Bio Therapies 1

•

EARLY BIO TREATMENTS

Based on the assumptions that abnormal neurological activity (e.g. in the PFL) causes SZ •

ECT

– – – – – – Bilateral and Unilateral Short term muscle relaxant and anaesthetic given to… Small shock (0.6amps) for 1-2 seconds Causes convulsions and Seizures Repeated 2-3 times a week for 4-6 weeks Thought to work because… •

LOBOTOMIES

– Sever the connections to the frontal lobes – Classic vs Trans-orbital procedure • • EVALUATION Evidence of effectiveness (Tooth and Newton, Tharyan and Adams – ECT vs Placebo) – Methodological issues including OPERATIONALISATION of improvement ETHICAL issues may make the therapies not appropriate

BIO Therapies 2

•

DRUGS Typical Anti-Psychotics

– – – – Based on the dopamine hypothesis which suggests… APs are DA agonists in that they reduce the action at DA sites Typical • Bind to DA receptors, increase the production of enzymes which break down DA to reduce DA action

A-TYPICAL Anti-psychotics

• Action in the NIGROSTRIATAL DOPAMINE PATHWAY and MESOLIMBIC DOPAMINE PATHWAY (e.g. they affect other NTs); ‘hit and run’ approach) • EVALUATION

Lots of Evidence of effectiveness

– But there are problems with the evidence (e.g. lack of a placebo control does not allow us to rule out psychological effects; sample issues e.g. only one type of SZ investigated; poor operationalisation of improvement.) • • • •

Not effective for all

– Typical APs very good at treating Positive but not negative symptoms; A typical more effective for negative

APs only effective as a chemical straightjacket. We know this because

– So a more complete therapy would involves

ETHICAL issues

– Side effects? Dependence?

– Revolving door problem?

– Cost-benefit analysis is key – Atypical APs have fewer side effects so are more appropriate

But APs have PRACTICAL ADVANTAGES making them more appropriate than other psychological therapies…

Psych Therapies 1

• •

CBT

Based on the assumption that irrational cognitions lead to distortions in information processing which leads to SZ symptoms THREE stages – Identification of irrational beliefs – Challenge and dispute irrational beliefs (e.g. through the use of experiments) – Replace and restructure belief system and practise real world application (may involve the use of a diary) • • • • • • • EVALUATION

Evidence of effectiveness plus methodological commentary

–

Pilling; Tarrier (good use of a control); More Effective in the long term (e.g. compared to drugs) because they focus on the root cause of SZ (irrational thoughts) AND teach practical strategies which can be used in the future

–

Most effective when used in combination with AP medication (KOPELOWICZ) Not effective and appropriate for all symptoms (serious delusions / extreme psychosis – a person will never accept their beliefs are irrational) Not effective/appropriate with young, low IQ, elderly, because they will not understand the complex therapy Appropriateness questioned on ethical grounds - Confrontational nature may cause anxiety Ignores important causal factors (biological) so may not be appropriate unless combined with AP Practical advantages compared to other psych therapies (limited to a small number of sessions over a few weeks) but has disadvantages compared to drugs (CBT needs a well trained therapist to deliver, etc)

•

Psych Therapies 2

• •

TOKEN ECONOMY

Based on the behavioural theories which suggests SZ is nothing more than a set of abnormal learned behaviours so therefore these can be replaced with learnt ‘normal’ behaviours OPERANT CONDITIONING is key – Token given for normal behaviour (positive reinforcement) – Token is secondary reinforcer because… • • • – Tokens exchanged for primary reinforcers suchs as… – Punishment may occur when a client shows SZ symptoms (token taken away) • EVALUATION

Evidence of effectiveness and methodological issues

–

Ayllon and Azrin (only used female SZs so...); Paul and Lentz (operationalisation of improvement) Not effective in the long term as symptoms return outside of the structured institute where the TE was taking place – suggests TE does not treat the root cause and that clients ‘fake’ improvement to achieve tokens Appropriateness questioned on ethical grounds because TE may involve clients being denied basic human rights until they achieve tokens (food, etc) Not appropriate due to PRACTICAL DISADVANTAGES as it requires trained professionals to administer a TE programme and constant monitoring

–

BUT improvements are quick so it is an appropriate way to quickly control symptoms within institutions

• MAKE SURE YOU APPLY!

Alternative treatments more successful and more appropriate…

–

Use evidence to support this point (e.g. APs effective in 85% of cases; LIBERMAN compared CBT and TE and found CBT was more effective in long term)