Schizophrenia Diagnostic Criteria PDF

Schizophrenia ============= 6.1.1 Diagonostic Criteria Schizophrenia = is a psychotic disorder meaning that it is characterized by severe and significant impairments in determining what is real and what is fantasy. **Diagnostic criteria:** according to the ICD -- 11; schizophrenia should be diagn...

Schizophrenia ============= 6.1.1 Diagonostic Criteria Schizophrenia = is a psychotic disorder meaning that it is characterized by severe and significant impairments in determining what is real and what is fantasy. **Diagnostic criteria:** according to the ICD -- 11; schizophrenia should be diagnosed if a person shows at least one of the core symptoms. It states that the symptoms should be present for at least a month. - Positive symptoms: 1. Hallucinations = these are perceptual experiences that may happen in the absence of external stimuli 2. Delusions = they are fixed beliefs that conflict with reality - Grandeur -- the person may see themselves as exceptional - Persecution -- the person may believe that other people may want to harm them - Reference -- the person may believe that situations or events have a person significance 3. Disorganized thinking - Negative symptoms: 1. Speech poverty = this can take the form of alogia ex. Delayed responses, lack of vocabulary 2. Avolition = this is a form of apathy in which the person takes no interest in life or themselves KEY STUDY: FREEMAN ET. AL Virtual reality -- are experiences delivered via headpieces in which project individual digital images. The images update at a rate at 60 frames per second to present a dynamic, immersive and 3 dimensional virtual scenes which creates the illusion of being physically present within the digital movement. Aim: this study examines whether neutral, non-threatening avatars could provoke persecutory thoughts in people with no previous clinical diagnoses and whether this was more common in people with higher levels of paranoia and emotional distress. Methodology: - Correlational study based on quantitative data gathered via questionnaires - 12 male and 12 female paid volunteers (mean age -- 26) were recruited from university college, London. All were mentally well. 21 were students whereas 3 were staff. Procedure: 1. Participants were trained in how to use VR equipment, including light weight headgear to track head position and orientation and a handheld joystick which allowed the participant to move around the virtual space 2. Next the half of the participants completed the Brief symptom Inventory, a 53-item questionnaire to assess mood, anxiety and psychotic symptoms in the last 7 days plus two, 20 item self-reports: the Spielberg state Anxiety Questionnaire and Paranoia scale 3. Next participants completed the virtual reality task; exploring a virtual library where 5 avatars sat in a small group, occasionally smiling, looking over and talking to one another. Participants were asked to explore the room and what they think about the people in the room and what they think about you. 4. 5 minutes later, all participants 'exited the room' and completed the questionnaires outlined above. They also completed the 15 item VR paranoia questionnaire which measured per secretory thoughts, ideas of reference and positive beliefs about the avatars 5. Finally, participants were interviewed about their experiences, including any feelings of distress. Later a clinical psychologist watched the videotaped interviews and rated them out of 6 for indications of persecutory ideation. Results: - Mean paranoia score was 31.8 with no significant difference between males and females - Persecutory thoughts (items 1-5 of VR questionnaire) were positively correlated with ideas of reference and negatively correlated with positive beliefs. There was a positively correlation between persecutory thoughts in the questionnaire and the interviews. - Finally, the VR persecutory ideation was positively correlated with paranoia, interpersonal sensitivity and anxiety all measured the BSI Strengths and weaknesses: 1. One weakness was that the participants reported relatively low levels of presence within the virtual library. Presence refers to the feelings of actually 'being there' and was measured on a six-point scale used in previous VR studies. The average presence rating was 2.3/6 which suggest that the findings might lack ecological validity as the participants were not fully immersed in the experience which may be due to a short time duration in the room 2. A strength was that half the participants answered the BSI, paranoia and anxiety questionnaires before and after their time in the virtual room and the other group only completed them after the VR experience. This was done to see whether completing the questionnaires primed the participants to experience persecutory thoughts while in the room. Sampling bias was a weakness since all the participants were from a London uni, recruited via advertisements; they were all free from prior clinical diagnoses and were relatively young. Idiographic vs nomothetic: - Quantitative data was collected using the VR-paranoia questionnaire which is a new psychometric test that can be analyzed using statistics to draw conclusions that can be generalized to a wider population (nomothetic) - They collected qualitative data through asking participants to explain their experiences in their own words in semi structured interviews Individual vs situational: - A range of questionnaires were used to measure the trait of anxiety, paranoia and other clinical symptoms which are related to **individual explanations** - The VR research reveals environmental factors associated with persecutory thoughts, noting that experimental manipulation of aspects of virtual environment could help identify factors which is related to **situational explanations** 2. Explanations of Schizophrenia **Biological explanations:** Genetic explanations - Classic research: - Concordance rate means the presence of the same disorder or trait in both members of a pair of twins - Concordance rate for monozygotic twins (MZ) is 42% whereas for dizygotic twins is 9%. In MZ twins, twin 1 is more likely to get schizophrenia if twin 2's schizophrenia was severe - Contemporary research - Genome wide association (GWAS; a whole genome of people with or without the diagnosis of schizophrenia have been compared. Some genes are polymorphic meaning that they could come in different forms - Genetics of schizophrenia are extremely complex: thousands of gene variants have been linked to this complex condition polygenic - Affected genes are linked to many different proteins associated with the development (synthesis), transportation and breakdown of neurotransmitters such as dopamine. Meaning that the inheritance of certain alleles may be responsible for neurochemical imbalances - DiGeorge and COMR Gene: - Sometimes problems arise during all division and whole strands of DNA become duplicated or sometimes even deleted; this causes a 'printing error in biological manual' and can increase a person's risk chance - DiGeorge syndrome, a strand of DNA containing 30-40 genes is deleted from chromosome 22 which has been linked to the deletion of a specific gene called COMT - This gene does for an enzyme which breaks down neurotransmitters such as dopamine. Meaning that this gene could be partially responsible for the complex neurochemical imbalances - Some researchers believe that the DISC 1 gene increases the risk of schizophrenia due to its association with the neurotransmitter GABA. GABA is an inhibitory neurotransmitter which helps to regulate activity in neural circuits that communicate via dopamine and glutamate Biochemical explanations - Excess dopamine as a cause of schizophrenia - In the 1960s Arvid Carlsson and Margit Lindquist proposed that schizophrenia was caused by the excess of neurotransmitter dopamine deep in the brains iambic system and mesolimbic pathways. - This excess can be caused by many factors such as excess **L-Dopa**, the substance that dopamine is made from. Synapses that use dopamine may also be overreactive due to the differences in the number of receptors on the postsynaptic cell - Overtime, new evidence caused scientist to update this information for example, many people who were taking dopamine antagonists like chlorpromazine still suffered with negative symptoms and some experienced no improvement in symptoms at all - Dopamine efficiency as a cause of schizophrenia - In the 1990S, Kenneth Davis and colleagues suggested that a lack of dopamine in the **prefrontal cortex and mesocortical pathways** may explain the negative and cognitive symptoms - Symptoms such as disorganized thinking and speech could certainly result from problems with dopamine regulation as this neurotransmitter is important for shifting and directing attention - Overactivity in the mesolimbic pathways was thought to result from excess D2 dopamine receptors and /or low levels of enzyme beta-hydroxylase which breaks down dopamine. However, in 2006, Arvid and Marid Carlsson proposed the dopamine defiency hypothesis which proposed that the brain compensates for low levels of dopamine by increasing the number of receptors on the postsynaptic cell. This process is known as Up regulation Reductionism vs holism: - Dopamine hypothesis is highly reductionist; drugs such as clozapine which blocks dopamine and serotonin receptors and are often more effective than drugs that only block dopamine receptors and the efficacy of newer drugs, such as glutamate agonists, suggests that an exploration of interactions between a wide range of neurotransmitters may prove more fruitful than studies that focus on single neurotransmitters - Taking a holistic approach and recognizing how neurotransmitter levels are affected by experiences in the world and the ways in which we interpret them is also critical. It is important to recognize how the prognosis of conditions like schizophrenia can be affected by numerous individual and situational factors due to their impact on biology Determinism vs free will - The biological explanation of schizophrenia is deterministic in that it suggests that the workings of the brain are responsible for the symptoms of schizophrenia. Research usinf PET brain imagining, for example, demonstrates that people diagnosed with schizophrenia have decreased binding on their prefrontal D1 dopamine receptors in comparison with matched controls without schizophrenia - Furthermore, there are significant correlations between D1 binding, a severity of negative symptoms and performance on the Wisconsin Card sorting test. This supports dopamine deficiency as an explanation of negative and cognitive symptoms and the role of biological determinism Nature vs nurture: - The role of nature is that there is a wealth of research evidence to support this explanation of schizophrenia. Ex, in one study rats were injected with amphetamines over a 3-week period. Amphetamines is known to increase dopamine activity. The rats showed a range of schizophrenic like behaviors, including strange movements and social withdrawal. Furthermore, the rats' symptoms were alleviated when they were given drugs to block their D1 dopamine receptors - Depatie and Lal 2001 found that apomorphine, a dopamine agonist does not worsen symptoms in people who already have a diagnosis of this disorder and neither does it trigger symptoms in those that do not which highlights the nurture side **Psychological explanations** Cognitive explanation - Errors in self-monitoring - People experience internal monologue; the cognitive theory of schizophrenia suggest that people with schizophrenia have a difficulty distinguishing between auditory stimuli that occur outside their own mind and their self-generated, inner voice. They may mistakenly perceive their sub-local thoughts as coming from external source. - Experiences of influence can be understood with the reference to a person's inability to recognize the difference between internally and externally generated stimuli. Which shows the possible line between the abnormal sensory experience, experiences of influence and the format on of beliefs - Difficulties with mentalizing - Schizophrenia has some overlaps with autism and Frith 1992 beliefs that the difficulties in mentalizing may result in persecutory delusions and paranoia. Furthermore, an underdeveloped theory of mind may mean that people with schizophrenia believe that others have the same opinion of them as they have of themselves - Thinking errors and biases - In schizophrenia, abnormal beliefs may be formed and maintained if people fail to update their understanding based on new evidence - People with schizophrenia tend to draw conclusions based on insufficient evidence and show a bias against counter evidence 3. Treatment and management **Biological treatments** - Biochemical: - These treatments often include the use of antipsychotic medications which are often administered orally as tablets or syrups but can also be given trans dermally in creams, gels, patches and sprays. People who receive medications will need regular checkups to monitor their symptoms and any side effects - Typical anti psychotics: - They work by blocking dopamine receptors on the postsynaptic cell, without activating them. This means the dopamine cannot bind the receptor, reducing signaling between synapses that communicate using this specific neurotransmitter - Rugs that work this way are called dopamine **antagonists** and can be effective in reducing positive symptoms of schizophrenia. The first of these drugs was called chlorpromazine - A typical antipsychotic - From 1980s, researchers began developing atypical antipsychotics which these drugs block dopamine and serotine receptors. Serotine is an inhibitory neurotransmitter which increases the likelihood of postsynaptic neuron firing an action potential and is involved in regulating arousal, alertness and mood - Texas medication algotherimh project - TMAP was designed to assit doctors in the prescriptpiton of anti psychotoics. At first it was suggested using an atypical drug called risperidone and if it doesn't work, then they would use another a typical drug such ashloperidol - Some patients are especially resistant to biochemical interventions and the final stages of the TMAP include combining antipsychotics with other types of medication such as mood stabilizers such as lithium Evaluating biochemical treatment - Randomized control trials - The use of biochemical treatments is supported by experimental evidence, for example data from over 10,000 people taking 18 different antipsychotics was examined in a meta-analysis of 56 randomized control trials - 17 drugs had lower relapse rates than the placebos which demonstrates that drugs treatment can be an effective alternative to hospitalization - Side affetcs and relapse - Side effects can be unpleasant and even fatal. Dizziness, drowsiness and restlessness are common as well as nausea, constipation and excessive weight gain. Typical antipsychotics, often lead to tardive dyskinesia characterized by uncontrollable blinking, jerking, and twitching - Drug treatments are ineffective for 30-70% of people. Efficacy decreases the longer the start of the treatment is delayed, and the greatest gains are made within the first 5 years. As well as 50-60% of people relapse - Electroconvulsive therapy: - Electroconvulsive therapy involves delivering electrical impulses (70-150) to both sides or one side of the brain via electrodes placed on the scalp. The pulses last up to one second and cause thousands of neurons to fire at the same time, including a brief, controlled seizure of up to one minute - The therapy includeds two or three sessions, per week for the first month and monthly or fortnightly 'maintenant doses' for up to one year - ECT can be used to treat a range of conditions including schizophrenia. This treatment is not an alternative medication, but it is used in addition to medication - Modified ECT us used under general anesthetic using muscle relaxants so the person cannot be injured during the seizure. Researchers are still unsure how ECT works but it is believed that the shocks trigger the release of neurotransmitters like dopamine and serotonin. Furthermore, it has also been suggested that the seizures are associated with gene expression - Evalutating ECT - Applications to everyday life: - Improvement can be rapid and significant in people previously classed as treatment-resistant. For example, in just 8 weeks, Petrides et al found that 50% of their American sample showed a reduction in symptoms of 40% or more when their usual dose of clozapine was combined with ECT - In single blind studies such as petrides et al, the clinicians who assessed the participants symptoms were unaware which treatment group they were in but the participants themselves knew if they have received the ECT or not which suggest that the greater improvement had been increased by expectancy of positive outcomes **Psychological treatment** - Cognitive behavioral therapy - Originally developed for mood and anxiety disorder, cognitive behavioral therapy has been adapted fir people with schizophrenia. CBT therapists will begin by developing a trusting and accepting relationship called a therapeutic alliance - Exploring events, beliefs and feelings - Therapists help clients to develop self-awareness through understanding the links between daily events, physical sensations, thoughts and feelings. The therapist helps the person to explore how thoughts are interlinked and how they reflect our core beliefs - Preventing relapse through stress management - Symptoms of schizophrenia can be extremely distressing and can lead to extreme stress which can exacerbate symptoms and lead further decompensation. Therefore, CBT therapy aims to develop coping skills, including stress management - A key treatment is to help the person identify early warning signs that precede decompensation, as a proactive initiation of coping strategies and stress reduction. Evaluating CBT - One ethical strength of CBT is that the therapist and client work collaboratively, removing the imbalance of power which is a feature of biological treatments. With both the ECT and drug treatments, the client role is minimum but with CBT, they are responsible for their own progress. This is a strength as people with mental problems often face prejudice and discrimination in society, so a therapy that also develops self-efficacy may help to rebuild the persons self-worth. - A weakness of CBT is that it relies on the quality of therapeutic alliance and some patients may lack the necessary communication skills to connect with the therapist. Furthermore, people with low levels of literacy, organizational skills or motivation may be unable to complete their homework exercises between sessions meaning that the CBT may only be effective for some clients and others may require additional support between sessions. 1. Ninety 16- to 60-year-old participants with schizophrenia were randomly allocated to either CBT group or the befriending group. All were prescribed a daily dose of at least 300mg of chlorpromazine for a minimum of six months but still experienced positive symptoms. Treatment was delivered by two experienced nurses who received regular supervision. Symptoms were assessed by 'blind' raters. They were assessed before the treatment started, post treatment and nine months after treatment ended. 2. CBT sessions = therapists worked closely with the patients to understand the dev elopement of both positive and negative symptoms. 3. Befriending = this group received the same amount of contact time with a therapist, at a similary spaced intervals. Therapists were empathic and non-directive. They talked about hobbies, sports and current affairs. Results: - Participants attended an average of 19 sessions in nine months. There was no significant difference in the number of sessions attended by the CBT group compared with the befriending group. Both groups showed a reduction in post treatment symptoms but only the CBT group showed continued improvement at the nine month follow up assessment. Conclusions - CBT was more effective than befriending patients continued to improve post symptoms to follow up, unlike befriending, where initial improvements were no longer evident at follow up. Strengths: - One strength was that all treatment sessions were audiotaped, and a blind rather than randomly selected a sample of the tapes to assess the quality of the treatment which improved internal validity as the rater was able to check that the befriending sessions did not contain elements of CBT and that the CBT sessions covered all the expected elements. - One strength was the sample was selected from five clinical services in London, Newcastle, Cleveland and Durham UK. Which generalized wider and more confident. Weaknesses: - It is unclear whether CBT would be effective on its own as, in this study, it was combined with a drug treatment. Although initially the participants were not responding to their medications, they were still taking them. Therefore, it's possible that it was the combination own drugs and CBT. - The longitudinal design, which meant that some of the participants were excluded due to not completing enough therapy sessions. Participants drop out can reduce the representatives of the sample, thus limiting generalization that can be drawn