Presentation on theme: "PSYCHOPATHOLOGY (Schizophrenia)"— Presentation transcript:
1PSYCHOPATHOLOGY (Schizophrenia) PSYA4 REVISIONPSYCHOPATHOLOGY (Schizophrenia)PsychopathologySchizophreniaDo not answer questions on depression, phobic disorders, OCD!!!• Clinical characteristics of the chosen disorder• Issues surrounding the classification and diagnosis of their chosen disorder, including reliability and validity• 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 effectivenessPSYCHOPATHOLOGY (Schizophrenia)
2Outline the clinical Characteristics of SZ More than just ‘symptoms’Explain, don’t list…POSITIVENEGATIVEHallucinations2 types?DelusionsThese are? Types?Poverty of Speech (alogia)Flat AffectSocial Withdrawal…‘OTHER’ SymptomsCatatoniaStupor, Waxy Flexibility,GegenhaltenInappropriate effectThis is?
3Outline the clinical Characteristics of SZ Other things you can mentionDiagnostic criteriaE.g. at least TWO characteristic symptoms present for a significant period (1mth); Significant signs of disturbance (social, occupational) for 6mths)Incidence rateSubtypes (be sure to say the characteristic symptoms of the subtype/s)Prognosis (include prodromal and active phase)Could mention the ‘new’ DSM criteria…
4Discuss 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 diagnosisRELIABILITY: do different clinicians give the same diagnosis; is a sufferer diagnosed with the same disorder on different occasionsVALIDITY: 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
5Discuss issues with the reliability and validity of the diagnosis and classification of SZ Consistency of DiagnosisMay 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 criteriaDifferences in the training and experiences of the clinician could lead to inconsistent diagnosisVALIDITYAccuracy of DiagnosisStudies suggest validity of diagnosis is lowCould 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 sufferersIssues 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)Mr B. tip - Use Rosenhan’s study as a LINK between reliability and validity issues…
6Discuss issues with the reliability and validity of the diagnosis and classification of SZ EVALUATION / COMMENTARYKey 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 SZOther commentary pointsEven with the problems, any diagnosis is better than no diagnosis because with diagnosis a patient wouldn’t receive treatmentHighlighting the problems with diagnosis has led to a number of improvements with the systemNew versions of DSM have a list of culture bound behaviorsClinician training has improved to increase awareness of biases, etcDSM V has got rid of subtypes as they believed this was causing problems due to overlapping symptomsDSM and ICD have been brought more in lineIncreased use of standardised procedures (e.g. Present State Examination) should increase reliability and validity of diagnosis
7Discuss 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, 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 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…In addition…This study shows…Finally, there is also the argument that a flawed diagnosis and classification system is better than no system at all. This is because…However, there are problems with this study…
8What 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.
9What 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 …
10Discuss Biological Explanations of SZ Need to know at least TWO for top mark bandsBio explanations includeGenetic abnormalitiesBiochemical - Neurotransmitter imbalancesNeuroanatomical AbnormalitiesViral HypothesisWhen evaluating, consider the general strengths and weaknesses of the BIOLOGICAL APPROACHWhere possible, link to specific symptoms!EXAMINERS LIKE RESEARCH WHEN DISCUSSING EXPLANATIONS
11Discuss Biological Explanations of SZ EVALUATIONEvidence - E.g. Gottesman / other family studiesDifficult 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 resultsSome animal researchProblems with research? ExtrapolationINCOMPLETE 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 SZDIATHESIS – STRESS the most complete explanationSOCIALLY 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…GENETICSSz is likely to have a genetic basis because of the observations that Sz is present in ALL CULTURES and tends to run in FAMILIESEstablished through TWIN, ADOPTION, FAMILY studies which assess CONCORDANCE ratesTop band detail - saying Sz is ‘genetic’ is too simplisticChromosone ____ (Gurling)Specific Gene? _______ (Tonegawa)
12Discuss Biological Explanations of SZ EVALUATIONEvidence and supporting observations / methodological problems with thesePost mortem studies and Animal studies useful for easy commentary points...CAUSE and EFFECT issuesBut 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 reductionistSame as before. Include reference to the idea that DA imbalance may itself be caused by something else (genetics)DeterministicMajor 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)BIOCHEMICALthe DOPAMINE HYPSimple...Initially thought to be the case because we know DA controls perception, motivation, attention and control of motor movementsSo 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).
13Discuss Biological Explanations of SZ Third / Back-up Theory NEUROANATOMICALEnlarged VentriclesIndicates atrophy to certain brain regions / areas associated with cognitive and behavioural functions; link to symptomsAccidents, genetics, may cause abnormalitiesEVALUATIONObjective methods used to support this theory (brain scans)General points too!VIRAL HYPOTHESISSz caused by a virus which is contracted during pregnancy (third trimester?)EVALUATIONDifficult to verify (retrospective?)IncompleteGeneral points too…
14Discuss Psychological Explanations of SZ As with biological explanations, you need to know TWO for the top mark bandPsych Explanations includeCognitive (damage to cognitive systems)Psychodynamic (early trauma, abnormal tri-partite personality, family systems [e.g. double bind; schizophrenogenic mothers])Behavioural / SocialAs before, remember to evaluate the approach on which the theory is basedWhere possible, link to specific symptomsEXAMINERS LIKE RESEARCH WHEN DISCUSSING EXPLANATIONS
15Discuss Psychological Explanations of SZ EVALUATIONSupporting evidenceE.g. Frith and Done experimental fluency tasks – compared to a control, SZ produced fewer self initiated behaviours, indicating damage to the SASBut serious methodological Issues with the study (task lacked mundane realism so may tell us little about SZ in real life; sample issuesUNSCIENTIFIC and UNFALSIFIABLE – based on abstract concepts (CMS, SAS) which are difficult to test empirically. Relies on subjective opinionCause and effect issuesMore complete and less reductionist compared to bio theories as it can explain positive AND negative symptomsRecognises Nature (bio) influences (these may be the root cause of cog deficits)Practical Applications – therapies can be focused on specific cognitive systemsSuccessful Therapy (CBT) derived from this approach validates the theoryCOGNITIVESz a result of irrational thoughts / errors in cognitive processingDelusions, hallucinations, etcThese may be caused by damage to cognitive processing systemsMetarepresentation system (overall control) but includes...Central Monitoring SystemResponsible for...Damage would lead to...Supervisory attentional systemDamage would lead to…
16Discuss Psychological Explanations of SZ EVALUATIONEVIDENCE E.g. OLTMANProblems with evidenceBased on RETROSPECTIVE DATA, Subjective, bias, sample issues blah blah blahABSTRACT AND UNFALSIFIABLEDifficult 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 DETERMINISTICTOO SIMPLISTICEmphasises Nurture over naturediathesis stress a better approach? (N.B this approach lends itself very nicely to diathesis-stress)NEGATIVE MORAL IMPLICATIONS BUT DOES HAVE PRACTICAL APPLICATIONSPSYCHODYNAMICSz 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 SZSchizophrenogenic mothers (characteristics?)Double Bind situationsHigh expressed emotions (relapse as opposed to starting point)
17Discuss Psychological Explanations of SZ BEHAVIOURALSocial learningSZ 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)Operant ConditioningLearn SZ symptoms are followed by with positive reinforcement in the form of attention, etcAbsence of learning of ‘normal’ behaviourAs 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…)SOCIO-CULTURALSZ caused by stress and pressures of living in an urban environmentCauses client to socially withdraw / escape into a psychological fantasy worldBUT... 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 effectDiathesis-Stress?
18THERAPIES for Schizophrenia TWO biological therapiesEARLY BIO TREATMENTS (ECT, Lobotomies)DRUGS (typical and atypical anti-psychotics)TWO psychological therapiesCBTTOKEN ECONOMYMust be able to evaluate in relation to APPROPRIATENESS and EFFECTIVENESS so use these terms!
19Bio Therapies 1 EARLY BIO TREATMENTS Based on the assumptions that abnormal neurological activity (e.g. in the PFL) causes SZECTBilateral and UnilateralShort term muscle relaxant and anaesthetic given to…Small shock (0.6amps) for 1-2 secondsCauses convulsions and SeizuresRepeated 2-3 times a week for 4-6 weeksThought to work because…LOBOTOMIESSever the connections to the frontal lobesClassic vs Trans-orbital procedureEVALUATIONEvidence of effectiveness (Tooth and Newton, Tharyan and Adams – ECT vs Placebo)Methodological issues including OPERATIONALISATION of improvementETHICAL issues may make the therapies not appropriate
20BIO Therapies 2 DRUGS Typical Anti-Psychotics EVALUATION Lots of Evidence of effectivenessBut 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 allTypical APs very good at treating Positive but not negative symptoms; A typical more effective for negativeAPs only effective as a chemical straightjacket. We know this becauseSo a more complete therapy would involvesETHICAL issuesSide effects? Dependence?Revolving door problem?Cost-benefit analysis is keyAtypical APs have fewer side effects so are more appropriateBut APs have PRACTICAL ADVANTAGES making them more appropriate than other psychological therapies…DRUGSTypical Anti-PsychoticsBased on the dopamine hypothesis which suggests…APs are DA agonists in that they reduce the action at DA sitesTypicalBind to DA receptors, increase the production of enzymes which break down DA to reduce DA actionA-TYPICAL Anti-psychoticsAction in the NIGROSTRIATAL DOPAMINE PATHWAY and MESOLIMBIC DOPAMINE PATHWAY (e.g. they affect other NTs); ‘hit and run’ approach)
21Psych Therapies 1EVALUATIONEvidence of effectiveness plus methodological commentaryPilling; 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 futureMost 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 therapyAppropriateness questioned on ethical grounds - Confrontational nature may cause anxietyIgnores important causal factors (biological) so may not be appropriate unless combined with APPractical 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)CBTBased on the assumption that irrational cognitions lead to distortions in information processing which leads to SZ symptomsTHREE stagesIdentification of irrational beliefsChallenge 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)
22Psych Therapies 2 TOKEN ECONOMY EVALUATIONEvidence of effectiveness and methodological issuesAyllon 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 tokensAppropriateness 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 monitoringBUT improvements are quick so it is an appropriate way to quickly control symptoms within institutionsAlternative 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)TOKEN ECONOMYBased 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’ behavioursOPERANT CONDITIONING is keyToken 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)MAKE SURE YOU APPLY!