1.1 Schizophrenia

Schizophrenia literal translation = split mind. Implied translation ‘split’ from reality (major break)

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Schizophrenia is the disintegration of the process of thinking and emotional responsiveness. Function impairment-incongruent from reality.

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It is essentially a psychotic disorder wherein individuals have a major break from reality and how they perceive the world is vastly different to how an unaffected person views it.

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→ ICD11 classifies schizophrenia as disturbances with the many aspects of a person's thoughts, feelings, experiences, and behaviour.

Core symptoms of schizophrenia as described by the ICD11:

1. Persistent Delusions – Thoughts that are not based on reality. (Positive Symptom)

2. Persistent Hallucinations – Sensory experiences like seeing things and hearing things that are not actually occurring. (Positive Symptom)

3. Thought Disorder – Inability to think or speak coherently. (Negative symptom)

4. Experience of Influence – The belief that your thoughts and actions are controlled by someone and/or something else. (Positive Symptom)

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→ Other Common Symptoms:

1. Avolition – A lack of motivation (Negative symptom)

2. Flat Affect – Emotionless expressions (Negative symptom)

3. Impaired cognitive function – Reduced memory or attention (Negative symptom)

4. Catatonia – Lack of movement or speech (Negative symptom)

5. Anhedonia – Loss of pleasure or satisfaction (Negative symptom)

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→ What is Early Onset? Early onset is when a psychological disorder starts at a younger age than average. Schizophrenia usually occurs during early adulthood so younger children having it is known as early onset. 3 months and must be specific to that person.

 

There are 3 types of delusions:

1. Persecutory Delusion: Strong belief that you’re in danger and others are trying to harm you and conspire against you.

2. Grandiose Delusion: Belief that you are someone with special powers/abilities.

3. Delusions of reference: Belief that things in an environment are about you.

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EXAMPLE CASE STUDY: ANEJA ET AL.

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Case study about a boy with an aggressive father. He was 10 when his parents separated, and he moved in with his grandparents. Symptoms he had:

Irritability, Sadness, Hearing voices teasing him, Muttering, and shouting at unseen others, School work suffered at age 12, Preferred to be alone, Poor sleep and self-care. Lacked insight into his condition.

Treatment given: Sodium Valproate drug used to treat bipolar disorder; his mood improved for a while but then got worse again. He was diagnosed with VEOS very-early-onset schizophrenia. He still had negative symptoms after the medication.

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KEY STUDY NAME: FREEMAN (2003) – VIRTUAL REALITY

 

Aim: To investigate whether participants without a history of mental illness have thoughts of a persecutory nature in virtual reality.

Research also wanted to find if there are cognitive or emotional factors that predict the likelihood of persecutory ideation being shown in VR.

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Background: VR was invented in the early 1990s-2000s, and it was a new technology used in psychology. Additionally, VR can be used to treat a range of psychological disorders like phobias and anxiety.

Rothbaum et al. (2000) found that VR had been successful in treating individuals with phobias, especially through exposure therapy wherein little by little the participant is exposed to higher levels of fearful situations of their phobia stimuli.

Slater et al. (1999) found that VR could also be used to remove anxiety in people through avatars to overcome their fears.

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Main Theories Explained: Persecutory ideation definition: The belief that people want to hurt you, despite there being no evidence to back it up.

Persecutory ideation is the MOST COMMON symptom of schizophrenia.

It leads to complete social withdrawal and difficulty doing day-to-day tasks because patients fear hostility from others. Therefore, the use of VR can help psychologists develop a better understanding of this psychological disorder, which can then lead to better ways of treatment and teaching them how to cope.

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Method (Research method & design):This was a PILOT study conducted to investigate whether the technique of VR would be appropriate. A lab experiment was used as the virtual reality space (Library) was a controlled environment. Questionnaires were used and a semi-structured interview.

 

Materials:

-VR environment displayed with a projection system.

-InterSense tracker monitoring participants' head position and orientation.

-Joystick held in right hand

-Lightweight Crystal eyeglasses that deliver a view of the virtual world.

Sample

-24 individuals

-12 male, 12 female

-Volunteer sample

-Recruited by responding to an advertisement within the University College London.

-21 were students, and 3 were administrative staff.

-All without a history of mental illness

-2 conditions, one completing the questionnaire before entering the VR environment and one after.

-Males and females were balanced in each condition.

-All participants paid for their participation

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Variables:

Independent variable: Usage of Virtual Reality

Dependant Variable: Questionnaires

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Procedure: Consent was obtained for participation. Participants were not told about the aims of the study to avoid demand characteristics. Individuals were trained on how to use the VR and then asked to enter the environment of a library.

The researchers asked, “Please explore the room and try to form some impression of what you think about the people in the room and what they think about you.”

There were 5 avatars in the library: 3 sat at one desk and the 2 others were at another desk on the other side of the room. Sometimes the avatars showed ambiguous behaviour like smiling or talking to each other.

After 5 minutes the participants were asked to leave the VR Room and complete a questionnaire and semi-structured interview. To allow for the possibility that the questionnaires after the VR prime participants for persecutory thoughts half did the questionnaire before entering the room and the other half after they went in.

Types of Measures Used

• Brief Symptom Inventory (BSI): 53-item self-report measure designed to assess 9 symptoms; 1- somatization (which is the manifestation of psychological distress through physical symptoms. 2-Obsessive-Compulsive. 3-Interpersonal Sensitivity (this is a tendency to focus on feelings of inadequacy or inferiority.) and 4- Depression. 5-Anxiety. 6-Hostility. 7-Phobic Anxiety. 8-Paranoid Ideation and 9-Psychoticism. Each item is rated on a 5-point scale of 0-4.

• Other questionnaires measured anxiety and paranoia, as well as a ‘sense of presence’ this is the extent to which the participants felt a part of the virtual world. The questionnaires included closed questions.

• Semi-structured interviews to find out participant's feelings and thoughts about the VR experience.

 

Results: Persecutory thoughts were positively correlated with ideas of reference and negatively correlated with positive beliefs.

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Conclusions: Emotional processes linked to anxiety and interpersonal sensitivity contribute directly to the development of persecutory ideation. Therefore, proving VRS great promise as a tool for enhancing theoretical understanding.

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Strengths:

• Ethical: Gave consent, had the right to withdraw, and were debriefed afterwards.

• No gender bias as an equal split between males and females

• A standardized approach increases reliability.

• Quantitative and Qualitative data gathered.

• The control group used increased validity and ensured the questionnaires themselves didn’t elicit feelings of persecutory ideation.

• Application to real life as This study shows us how people respond and interpret behaviours and intentions in avatars in VR but doesn’t show for certain how people would respond to similar real situations.

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Weaknesses:

• Lacks ecological validity because participants were not fully immersed in the experience; this may be due to the short duration in the room and the relatively passive nature of the task.

• The task lacks mundane realism.

• Sampling bias: All participants were recruited from London University so all the participants would be intelligent and/or relatively interested in psychology and virtual reality.

• Unable to generalize due to small sample.

• Response bias due to self-report measure.

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EXPLANATIONS FOR SCHIZOPHRENIA: 
BIOLOGICAL Genetic:

Genetic explanation states that genes or combinations of genes are passed onto an offspring from parents which can cause the disorder to develop. There are Family studies, Twin studies, and Adoption studies to support this theory.

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→ Twin studies: a type of study that compares sets of twins to analyze similarities and differences, this includes things like intelligence and mental disorders. Monozygotic (Identical twins that share their entire DNA) and Dizygotic (Fraternal / Nonidentical Twins that only share around 50% of their DNA) are both studied. 
•    GOTTESMAN AND SHEILDS (1991) – suggested that developing schizophrenia went from 1% in the general population to 48% if you have an identical twin with schizophrenia.
•    CARDNO (2002) – showed a concordance rate (concordance: the presence of a particular observable trait or disorder in both individuals between family members and within a set of twins) of 26.5% MZ and 0% for DZ twins. 
•    HILKER ET AL. (2017) – Carried out a twin study with over 30,000 twin pairs in Denmark. Hilker et al. concluded that heritability (the extent to which the presence of a disorder or trait is due to genetic variation in the population) of schizophrenia was 79%

→ Family Study: a type of study investigating whether biological relatives of those with a disorder are more likely to be affected.
Family studies show trends in developing a disorder when they share a higher proportion of genes with their family. 
→ Adoption Study: This type of study looks at similarities between adopted individuals and their biological parents as a way of investigating differing influences of biology and environment. 
•    TIENARI ET AL. (2007) – Found schizophrenia in 6.7% of adoptees with a biological mother with the disorder. This was compared to just 4% of a control group (adoptees born to mothers without schizophrenia.) This suggests that there is a genetic influence on the development of SZ.

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BIOLOGICAL Biochemical: 

Dopamine hypothesis: People with schizophrenia produce more dopamine than the brains of people without SZ. 

Dopamine is a type of neurotransmitter (a chemical messenger that enables communication between neurons in the brain). 
Research suggests: 1. Neurons that use dopamine fire too often. 
2. Send too much information. Or 3. Excess of dopamine in particular brain regions can be related to certain symptoms. E.g., Excess of dopamine in Broca’s Region impairs your logical speech which leads to catatonia. 

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Biochemical (dopamine hypothesis) The dopamine hypothesis of schizophrenia states that symptoms may be caused by an excess of dopamine in the mid-brain and a reduction in dopamine in the prefrontal cortex.

The dopamine hypothesis of schizophrenia suggests that a high level of activity of dopamine D2 receptor neurotransmission in subcortical and limbic brain regions contributes to positive symptoms of schizophrenia, whereas negative and cognitive symptoms of the disorder can be attributed to heightened activity of dopamine D1 receptor neurotransmission in the prefrontal cortex.

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Evidence from Drug trials: LINDSTRÖM ET AL (1999): Patients with Parkinson’s disease take medication to control their symptoms. The drug is a synthetic form of dopamine called L-dopa. This increases dopamine levels in your body. If their dosage is too high symptoms of SZ like hallucinations develop.

Evidence from post-mortem trials: WISE ET AL. (1974): found brain fluid from deceased SZ patients with abnormally low levels of the enzyme that breaks down dopamine. 

Evidence from Positron Emission Tomography (PET) scans: These scans of the brain indicate a greater number of receptors in the striatum, limbic system, and cortex of the brain in those with schizophrenia than in those without. NESTLER (1997) suggests that decreased dopamine activity in the prefrontal cortex of schizophrenia patients may correlate with negative symptoms such as flattened affect.

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PSYCHOLOGICAL – Cognitive: 

Cognitive-behavioral therapy: treatment that incorporates aspects of cognitive and behavioural approaches to treating psych disorders.

FRITH (2015) describes schizophrenia as an “abnormality of self-monitoring.” This means patients have difficulty distinguishing between auditory stimuli that occur outside their mind (e.g., in the physical and social environment) and their self-generated, inner voice.
FRITH (1992) Believes people with SZ have difficulty mentalizing.

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TREATMENTS FOR SCHIZOPHRENIA: 
BIOLOGICAL (biochemical) TREATMENTS

Acute episode: a period during which a person is suffering from psychotic symptoms such as hallucinations or delusions.
In 1950 antipsychotics were invented which work through reducing dopamine and as a result reducing symptoms.
→ Delusional Disorder – It’s a false fixed belief. Believing in something completely even though nobody else believes it. 

Antipsychotics are given as the first treatments along with CBT. 

Typical antipsychotics: Developed in the 1950s to reduce the effect of dopamine to reduce positive symptoms. Typical APs are referred to as first gen drugs. These drugs block dopamine receptors so that there is less dopamine activity.  An example is chlorpromazine. These reduce positive symptoms like hallucinations and delusions. There are many undesirable side effects to these. (side effects can range from mild to severe and affect physical, emotional, or cognitive functioning)

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Atypical antipsychotics: Developed in the 1990s they affect dopamine levels to reduce positive and negative symptoms of SZ. Referred to as Second generation drugs. These drugs have a lower risk of side effects and are effective on treatment-resistant patients. Example: clozapine. These drugs are less risky than typical ones, they rapidly dissociate (they only block dopamine activity for a short period).
Relapse rates are high for this method. 

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Electro-Convulsive Therapy: A person receives a brief amount of electricity to the brain to induce a seizure. The patient is anaesthetized and given a sedative. Electrical current is passed through the head for no longer than a second via electrodes attached to the skull. The seizure will last for up to one minute. Can be bilateral – across both brain hemispheres or unilateral – across the non-dominant hemisphere. 

This is used to reduce the symptoms of SZ. This method if not paired with anti-anxiety drugs leads to patients being traumatized and suffering from broken bones. Memory Loss is a common side effect of ECT.

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PSYCHOLOGICAL TREATMENTS (cognitive behavioural therapy) 

This is a method that incorporates cognitive and behaviourist approaches to psychology. CBT is a talking therapy designed to help people change by recognizing and challenging the thoughts that underlie their behaviours. CBT is usually used in conjunction with antipsychotic drugs so that the patient is stable enough to engage in therapy.

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EXAMPLE STUDY: SENKSY ET AL. 

Carried out a randomized control trial to test the effectiveness of CBT and to see if CBT itself is effective rather than the experience of just talking to others. 

An experiment was done on a control group of 90 participants aged 16-60 with a diagnosis of treatment-resistant SZ. It was an independent measures design as participants were randomly allocated either treatment condition; be it CBT or befriending.
(In befriending it was informal one-on-one sessions from discussing hobbies, sports, or current affairs.) Patients received a mean of 19 sessions. Those in the CBT condition have 2 professional nurses who engaged with the patient about the emergence of the disorder to what their specific symptoms were like. (Nurses challenged beliefs and asked patients to keep voice diaries to generate coping strategies) 
Patients were assessed by blind raters – they didn’t know which participant was in which condition. At the 9-month follow-up, the patients completed 2 assessment scales:
1-    Comprehensive Psychiatric Rating Scale (CPRS).
2-    Assessment of Negative Symptoms (SANS)
Results found both groups had a substantial decrease in both +ive and -ive symptoms. After the 9-month follow up the CBT group had still shown retained improvement in symptoms but in the befriending group, it was no longer evident. 
Showing overall that CBT is an effective treatment as the benefits of therapy continue for at least 9 months after.