Schizophrenia: Biological and Social Factors

• Classification is the idea that symptoms that go together make a disorder.
• Diagnosis is identifying symptoms in an individual and using a classification system to identify the disorder.
• Schizophrenia (SCZ) is a severe mental disorder characterized by a disruption of language, thought, perception (including reality), emotions, movement, and sense of self.
• The prevalence of SCZ is roughly 1% and is more common in men, people in urban environments, and lower socio-economic groups.
• DSM-5 requires one positive symptom for diagnosis, such as hallucinations or delusions.
• ICD-10 requires two negative symptoms for diagnosis, such as speech poverty or avolition.

Reliability and Validity

• Reliability is consistency.
• Test-retest reliability involves using the same criteria for the same person and getting the same outcome.
• Inter-rater reliability involves different clinicians using the same criteria on the same person and getting the same outcome.
• Validity is the ability to measure what is claimed.
• Criterion validity involves using two different systems (DSM/ICD) on the same person and getting the same outcome.
• A Spearman's statistical test for correlation can correlate two outcomes; a significant positive correlation above 0.8 indicates the diagnosis is reliable/valid.

Diagnosis Reliability Statistics

• DSM-5 test-retest reliability is +0.92.
• DSM-5 inter-rater reliability is +0.97.
• The very strong positive correlations indicate that the diagnoses are consistent.

Issues with Diagnosis

• One study had eight "sane" confederates reporting false symptoms at a psychiatric hospital; nearly all were diagnosed with SCZ, with an average stay of 19 days, suggesting possible overdiagnosis.
• Comorbidity with depression (50%) and OCD (23%), symptom overlap, and shared delusions and avolition with bipolar disorder mean that diagnoses do not represent something clear and distinct, and could lead to misdiagnosis (over or under).
• Only 20% of patients recover with treatment, and 50% show limited improvement, whereas a diagnosis should lead to successful treatment.
• Men are diagnosed more (1.4:1 ratio) with SCZ, leading to the possibility that either men are genetically more vulnerable or that women have better social support systems.
• Despite showing similar symptoms in the US, men are still diagnosed more frequently, suggesting androcentric assumptions that women are naturally more delusional, and decreased quality of life may occur for women as they receive no access to treatment.
• In some Afro-Caribbean cultures, hearing voices is normal; Afro-Caribbean British men are 10x more likely to be diagnosed than white British men, potentially from discrimination by a biased diagnostic system, labels, stigma, and lower quality of life.

Genetic Explanations

• A strong relationship exists between the degree of genetic similarity and shared risk of SCZ; closer genetic relatedness means a greater predisposed risk (48% MZ vs 17% DZ vs 9% sibling vs 2% aunt/uncle).
• SCZ is polygenic as 108 genes are involved (each slightly increasing risk).
• It is aetiologically heterogeneous, meaning the risk is affected by combinations.
• A mutation in parental DNA and a positive correlation between paternal age (increased risk of sperm mutation) are associated with the risk of SCZ.
• Twin studies show MZ: 48% vs DZ: 17% concordance rates.
• One study found lower concordance rates than other studies examining twins, which may show some degree of biological basis, but the concordance is never 100 so cannot be solely genetic in origin.
• MZ twins are often treated the same, therefore have the same experiences, and so are more likely to both develop SCZ; this could be a confounding variable making twin study evidence unreliable.
• Attributing SCZ to genetics alone and ignoring environmental risk factors is overly reductionist; bio risk factors such as smoking cannabis and psych risk factors such as child/sex abuse are external, and genes alone do not provide a complete explanation.

Genetic Counselling

• Genetic counselling can advise potential parents with SCZ in their family on the risks of having a child with SCZ, which could lead to better parenting (stress-free upbringing, less dysfunctional family, reduced expressed emotion).
• This process could minimise the risk of development or make living with the condition more manageable.

Neural Explanations

• The dopamine hypothesis states that increased dopamine activity (hyperdopaminergia) in the subcortex is associated with hallucinations and speech poverty, caused by an excess of DA receptors in pathways linking the subcortex to Broca's area.
• The revised dopamine hypothesis suggests that reduced dopamine activity (hypodopaminergia) in the prefrontal cortex (thinking/decisions) is linked to negative symptoms and has been shown by PET scans.
• Low activity in the venal striatum is correlated with the severity of negative symptoms, such as avolition; lower activity means worse symptoms.
• Low activity in the anterior cingulate gyrus and the superior temporal gyrus is correlated with hallucinations.
• Enlarged ventricles, 15% larger in SCZ than the control, are associated with negative symptoms.
• Amphetamines that increase dopamine have been found to mimic SCZ symptoms, while antipsychotic drugs that reduce dopamine activity reduce symptoms, suggesting a complex relationship between dopamine and SCZ.
• Research from scanning and post-mortems show raised levels of glutamate in SCZs and several candidate genes have been identified that influence glutamate activity, thus the dopamine hypothesis alone doesn't explain SCZ fully, and the effectiveness of clozapine may be due to its dual impact on DA and glutamate.
• Research shows that amphetamines that increase DA can cause SCZ-like symptoms and antipsychotics that target DA reduce symptoms, but apomorphine increases DA with no SCZ symptoms, leading to debates highlighting the differences between amphetamine psychosis and SCZ.
• Correlations can explain symptoms, but explanation may not be useful as the cause is unknown, and incomplete explanations mean there are no treatments, therefore cause and effect cannot be established.

Biological Therapies

• Chlorpromazine is a typical antipsychotic and dopamine antagonist that blocks D2 receptors, reducing dopamine activity and positive symptoms, but has a sedation effect as well as possible irreversible tardive dyskinesia (facial tremors) and rare but fatal neuroleptic malignant syndrome.
• Clozapine is an atypical antipsychotic that normalizes activity of dopamine, serotonin, and glutamate; it has a temporary effect that reduces positive and negative symptoms, depression, and anxiety, and improves mood and cognitive functioning, and it has less severe tardive dyskinesia and immune system side effects.
• Risperidone, another atypical antipsychotic, normalises dopamine and serotonin activity, binds more strongly to DA and 5ht receptors, and can be given in lower doses with fewer side effects.
• Chlorpromazine has been proven to be better than a placebo, and Clozapine being more effective than Chlorpromazine in up to 50% of treatment-resistant cases indicate they are effective, but both have fatal side effects.

Concerns around Treatments

• Appropriateness and ethics of prescribing is questionable, as most drugs tackle high levels of DA in the subcortex while other areas of the brain have low DA, meaning that drugs shouldn't make symptoms worse.
• Antipsychotics may simply calm patients and make them manageable/easier to work with, which may help with therapy compliance, but given other options they may have some benefits.

Psychological Explanations - Family Dysfunction

• Family dysfunction is composed of abnormal processes within a family such as poor communication, cold parenting, and high levels of expressed emotion, all risk factors for developing and maintaining SCZ.
• The schizophrenogenic mother is cold, rejecting, and controlling, creating a climate of tension/secrecy (distrust -> paranoid delusions) and insecure attachment correlation.
• Double-bind theory involves contradictory messages about right/wrong, where withdrawal of love is the punishment, leading to a fear of doing the wrong thing and causing anxiousness/uncertainty (disorganised thinking) and insecure construction of reality (paranoid delusions), along with unexpressed unfairness.
• Expressed emotions are negative home/hostile environments with high levels of criticism, family voice sacrifice/guilt, which are a source of stress.
• A high number of SCZ patients have insecure attachments from inconsistent parenting where, a history of SA or PA in 68% women and 59% men suggests FD makes people more vulnerable to SCZ.

Criticisms of Family Dysfunction Explanations

• Theories are based on clinical observations and are not objective; subjective self-reports and informal assessments may fail to recognize that parent stress could be caused by the child, and a SCZ patient's recollection isn't always trustworthy.
• Research identifying the role of childhood trauma and attachment types raises ethical concerns, since it blames parents.

Family Therapy

• FT is a psychological therapy carried out with all or some family members, and is aimed improve their communication and reducing stress.
• It reduces negative emotions such as stress, expressed emotion, anger, and guilt, and double-blind communication.
• Patients are encouraged towards a therapeutic alliance, psychoeducation, improving ability to foresee and solve problems and creating appropriate boundary setting.
• Burbach includes sharing information and identifying family resources offered is useful for mutual understanding, and skills training, such as stress management techniques, can prevent relapse.

Benefits of Family Therapy

• Some benefits may be improved medication compliance, less relapse, and less hospital readmission.
• Conclusions recommend FT as an effective treatment for SCZ may reduce relapse rates by 50-60% and be beneficial for both the patient and the economy.
• FT helps family members who carry the bulk of care for the patient, lessens the negative impact of SCZ symptoms, and strengthens the family's ability to give support, with good practical value.
• FT may reduce stress, expressed emotion, and double-blind communication in a household, but it may not alleviate symptoms on its own unless paired with drug therapy and/or CBTp.

Cognitive Explanations

• Dysfunctional thought processing involves impaired cognition, such as egocentric bias where patients jump to conclusions.
• A lack of reality testing can lead them to ignore beliefs that are irrational, and shows reduced processing in the ventral striatum associated with negative symptoms.
• Dysfunctional or poor metarepresentation can cause SCZ where patients fail to recognize voice/thoughts as your own and therefore suffer hallucinations and delusions.
• Dysfunctional or poor central control causes an inability to suppress autonomic thoughts, which explains disorganised speech and derailment since each word triggers an automatic thought someone cannot suppress.
• Sensory hypervigilance includes greater attention to auditory stimuli.
• The Stroop test produces replicable, empirical evidence for dysfunctional thought processing due to poor central control, where SCZ's take 2x as long to complete as non-SCZ's.

Criticisms of Cognitive Explanations

• Only proximal origins of symptoms are explained. Distal explanations such as biological and genetic factors.
• The cognitive explanations explain only present symptoms.
• Abnormal cognition may be partially genetic from brain abnormalities.

CBTp

• Therapist and client critically collaborate using ICR to gently dispute irrational beliefs, which are replaced with healthier beliefs, where they identify irrational thoughts to help the client make symptoms normal.
• Gently challenging these beliefs and exploring alternative thinking can help restructure the client's beliefs, and therapists may develop strategies to counter irrational thoughts.

Activating Events

• Activating events can be identified. For example, "door bang"
• Irrational beliefs can be explored. For example, "gun shot from mafia."
• Consequences can be recognised. For example, "hiding in cupboard."
• Dispute irrational beliefs. For example, " why would mafia be here?"
• Beliefs can be restructured effectively with behaviour therapy
• Symptoms are not cured but patterns of thinking can be reduced, for management and coping.
• NICE recommends CBT for SCZ, research and clinical advice points to it.
• CBT varies different studies focus on different techniques, so the execution of CBT varies making assessment difficult.
• CBT obviously improves QoL and ability to cope, but as a partial treatment cannot ignore biological contributions to SCZ.

Token Economy

• TE is a management tool used in long-term hospital treatment to tackle institutionalisation, based on behaviour modification by way of operant conditioning.
• Although it doesn't cure SCZ, it helps improve personal care, related behaviour, social behaviour, and QoL.
• It normalises behaviour, making it easier for SCZ patients to adapt back into the community.
• Primary reinforcers include luxury items or rewards.
• Secondary reinforcers are tokens that can be exchanged for rewards
• As a immediate reward system there is targeted reinforcement.
• A small evidence base has file drawer problem that raises questions.
• Professionals have power to control behaviour, which may unfairly impose their norms in unethical ways.
• Compared to art therapy there are ethical alternatives.
• It can only be maintained short term in hospitals.

Interactionist Explanations

• Meehl's DSM believed SCZ couldn't develop without a 'schizogene.'
• Modern DSM states SCZ is from vulnerability + negative experience trigger.

Diathesis

• Biological predisposition (108 candidate genes).
• Damaged active HPA system from trauma.

Stress factors

• Stress could be due to; cannabis, urban environments, chronic stress and high EE stress.
• Tienari Adoption showed these elements of interactions are important.
• Meehl argued schizogene has been proved to be false instead there is no one combination that is eclectic.
• Practical Value Treatments can be combination based.
• Aetiological fallacy is an error in logic that leads to incorrect conclusions.
• Urban cities provides more stress for these people.
• This approach looks internal and external factors and treatments.
• Drug therapies can address biological problems where family therapy address environmental.
• Long term treatments prevent relapse.
• These treatments make clients more manageable and can commit more.
• Though combination are effective its not always and its could have value.
• Combination and time is costly but there is a better QoL.

Explore schizophrenia's biological and social underpinnings. Learn about brain activity, ventricle size, dopamine's role, and clozapine's impact. Examine the limitations of brain scan correlations and cultural biases in diagnosis. Understand genetic heterogeneity and the complexities of twin studies.