3.2: Schizophrenia

Schneider

Suggested two categories of schizophrenic behaviour; those which are exhibited in addition to normal behaviour (positive) and those which inhibit normal behaviour (negative). Characteristics.

Formnication

A type of tactile hallucination where an individual feels insects crawling on or under their skin. Characteristics.

Auditory, tactile and visual

The three types of hallucinations. A positive symptom. Characteristics.

Persecution, grandiosity, reference

The three types of delusions. A positive symptom. Characteristics.

Thought insertion

An element of disordered thinking where schizophrenics report feeling the thoughts in their head do not belong to them, and have been placed by another individual. A part of disordered thinking, and a positive symptom. Characteristics.

Disordered thinking

A symptom where an individual’s thoughts and speech move from topic to topic with no logical flow or reason. Often muddled and incoherent, making communication difficult. A positive symptom. Characteristics.

Catatonic

Behaviour which is characterised as fast, repetitive movements, or no movements at all. Individuals may pace, perform echopraxia, make loud noises and unexpected gestures or remain immobile for long periods of time in uncomfortable positions. They often resist being moved, or demonstrate waxy flexibility - movable limbs but a rigid posture. A negative symptom. Characteristics.

Echopraxia

Mimicking the movements of another person. A symptom of catatonic behavior. A negative symptom. Characteristics.

Avolition

Characteristics where individuals seem indifferent and unconcerned with their surroundings, and lack desire to engage in activities, including those previously pleasurable. They also have a lack of goal-directed behaviour. A negative symptom. Characteristics.

Flatness

Effect of schizophrenia where a person appears to have no emotion; either by showing no emotional intonation or facial expression. They often sound monotonous, and are perceived as apathetic. A negative symptom. Characteristics.

Compound complement 4

Gene that is used in synapse pruning during teens to early adulthood, by depositing the sister protein C3 to mark these areas as needing pruning. The higher the expression of the C4A form, the higher the likelihood of development schizophrenia. It is the highest risk factor, and is located on chromosome 6. Genes.

Joseph

Looked at concordance rates for schizophrenia pre 2001, and found MZ twins have a 40.5% concordance, and 7.4% for DZ concordance. Genes.

40.5 and 7.4

Rates of concordance for schizophrenia between MZ and DZ twins respectively. Found by Joseph. Genes.

6.7 and 2

Percentages of Finish adoptees with schizophrenic mothers who developed schizophrenia, and those with non-schizophrenic mothers who developed schizophrenia. Found by Tienari et al.

O’Donovan et al

Found 108 specific locations on the human genome that are linked with schizophrenia. 83 of these had not been found before, and genes were involved in both brain and immune system functioning. This suggests it is polygenic. Genes.

McCarroll et al

Alongside researchers from MIT and Harvard, using 65,000 genomes, 700 post mortem brains and mouse genetic engineering to find the complement compound 4 gene. Suggests its identification could be used to develop treatments. Genes.

Griffith et al

Gave dextro-amphetamines to non-schizophrenics. This induced psychosis, and participants experienced paranoid delusions and cold, detached emotional responses. Genes.

Limbic

System which contains D2 dopamine receptors, which are greatly affected by antipsychotics. Made up of the mesolimbic and mesocortical pathways. Dopamine.

Mesolimbic

Pathway where the signal originates in the ventral tegmental area and moves to the nucleus accumbens. When neurons firing too often or too quickly increases the dopamine in this area, overstimulation occurs, causing positive symptoms. Antipsychotics reduce this. Dopamine.

Mesocortical

Pathway where the signal originates in the ventral tegmental area and moves to the frontal lobe, and is linked to emotional responses and cognition. When there is too little dopamine in this area, negative symptoms can occur. Dopamine.

Davis et al

Found that too little dopamine, hypofunction, is evident in the D1 receptors in the frontal lobe of schizophrenics who experience cognitive impairments and other negative symptoms. Dopamine.

Homovanillic acid

A metabolite of dopamine, measured in cerebrospinal fluid from a lumbar puncture. This is extremely painful, and not entirely accurate as it can be affected by diet and drug use and vary between participants. Dopamine.

Faris and Dunham

Found that SCZ rates are increased for urban areas, but also in more populated areas of Chicago. SCZ rates also increased in areas of social conflict and mobility. Sociocultural.

Jones et al

Conducted a longitudinal study on children born in one week of March. There were 30 cases of SCZ, and researchers found they were more likely to have solitary play preferences at 4-6, and rate themselves less socially confident at 13. Sociocultural.

Cantor-Grace et al

Found those who are immigrants, or have a family history of immigration, had a higher risk of SCZ. Children of immigrants have a higher risk of SCZ. This suggests that the stress of racism and discrimination causes SCZ. Sociocultural.

DSM-5

Diagnostic manual that requires at least 6 months of prodromal or residual symptoms alongside 1 month of psychotic symptoms. Characteristics.

Bateson et al

Developed the double bind theory could be a SCZ risk factor by lowering a child’s ability to effectively understand or communicate, leading to maladaptive thoughts towards socialising and causing isolation. This can also lead to positive symptoms as a form of escapism. Families.

Double bind

Theory by Bateson that families who communicate ambiguously via expressing different paralanguage to the meaning of their words. This leaves a child with two conflicting messages that they cannot ignore or engage in metacommunication with due to their reliance on the parent. Families.

Brown

Developed the high expressed emotion theory. To prove this, he studied 156 SCZ men after release, finding those released to wives or parents had higher relapse rates than those released to lodgings or siblings. He then investigated parents and wives, finding they had higher levels of EE. Families.

High

EE level that consists of critical comments, hostility caused by unmanageable anger and irritation and emotional overinvolvement shown by high levels of happiness, sadness, self-sacrifice and extreme overprotectiveness. The latter is most apparent in parents who overcompensate for feelings of guilt due to their child’s illness. Families.

Low

EE level that consists of warmth measured by vocal qualities, smiling and empathy expressed towards the SCZ individual, and positive regard measured via reinforcing statements expressing appreciation and support of the SCZ individual. Families.

Berger

Interviewed SCZ individuals, finding they had a higher recall of double bind statements made by their mothers than non-SCZ controls. Families.

Kavanagh

Found that those with SCZ in a high EE family were 4x more likely to relapse than low EE families. Families.

Cuttings et al

Found that SCZ patients were able to understand criticisms, leading to higher stress and lower wellbeing. However, they were not as perceptive as emotional over involvement. This could present it as more or less harmful. Families.

Pharoah et al

Reviewed 53 randomised control studies, and concluded that family interventions decreased relapse frequency and hospital admissions. Also outlined that family interventions should include helping the carer to feel more supported, increase their ability to anticipate and solve problems, help boundary setting and reduce EE expressions. Families.

Freud

Developed the theory that SCZ was caused by a frustration or overindulgence in the first 2 months of the oral stage of development. Once stress occurs, SCZ regresses back to this stage. Freud.

Regression

An ego defense mechanism. Occurs when a person returns to an earlier stage of development. In SCZ, this is the oral stage, meaning there is no ego and the id is dominant. Freud.

Id

A dominance of this element of the tripartite personality occurs in those with SCZ. They become focused on themselves (narcissism), detach from reality with an active mind causing the creation of fantasies and develop hallucinations in order to interact with something. Freud.

Fromm-Reichman

A Neo-Freudian who developed the idea of the schizophrenogenic mother. She suggests these mothers were dominant in the home, controlling, overprotective, cold and distant. This stifles childhood development, leaving the child emotionally insecure. Freud.

Strupp et al

Found that psychodynamic techniques harm SCZ instead of benefitting, likely due to the difficulty of distinguishing between real memories. Freud agreed, due to their lack of insight, suggesting he believed there was no treatment. Freud.

Kasanin et al

Found evidence of an overprotective mother in 73.3% of SCZ hospital records. Low number, hospital records, no double blind, cause and effect issue. Freud.

Sartorius et al

Found that SCZ rates are consistent across cultures, including those mainly urban. This suggests the social drift hypothesis - those with SCZ have low socioeconomic statuses causing them to live in urban areas. Sociocultural.

Pedersen and Mortensen

Found that those at high risk of psychotic disorders, such as SCZ, reduced their likelihood of developing these if they moved to a more rural environment. Supports the social hypothesis - urban areas cause SCZ. Sociocultural.

Frith

Proposes that hallucinations are caused by an abnormal inner voice, a lack of preconscious filters (Attention Deficit Theory) and a compromised theory of mind. Cognitive.

Septo-hippocampal and prefrontal cortex

Frith proposed that irregularities in this brain area caused issues with inner voices. He believed those with SCZ are unable to monitor these voices, and attribute them to the outside world. Cognitive.

Attentional deficit

Theory by Firth where SCZ is seen as caused by a breakdown of thought filtering processes due abnormalities in parts of the brain that use dopamine. This prevents non-important preconscious information from being filtered out, causing too much information to overload the conscious. This leads to issues with memory recall, and attentional biases can then lead to delusions. Cognitive.

Preconscious

Thought that occurs without awareness. Normally, important information is filtered into conscious thought, but Frith believes those with SCZ have abnormalities in dopamine using areas of the brain which causes this filter to have issues. Proved this by finding reduced blood flow to these areas during certain cognitive tasks. Cognitive.

Theory of mind

An individual’s ability to understand everyone has their own minds, desires, knowledge and ideas. Frith argues this is impaired in those with SCZ, which is caused by disorders in 3 separate cognitive systems; willed action, self monitoring and monitoring others. Cognitive.

Willed action

One of three ToM disorders that causes SCZ, according to Frith. When a person is unable to plan and carry out behaviours, and forgets what tasks they have done and need to do. Cognitive.

Self monitoring

One of three ToM disorders that causes SCZ, according to Frith. When a person is unaware of their own intentions and the effort behaviour requires, meaning behaviour is only monitored through consequences. This can lead actions to be blamed on external forces. Cognitive.

Monitoring others

One of three ToM disorders that causes SCZ, according to Frith. When a person is unable to monitor and interpret the behaviours of others, leading to misunderstandings which can cause delusions. Cognitive.

Kuipers et al

Randomly allocated those with SCZ, with a positive and distressing medically resistant symptom, into two groups; CBT TAU and TAU. Found CBT had a 50% improvement, while TAU had a 31% improvement and a suicide. Also found clients are generally satisfied and view it as an appropriate way to deal with symptoms. CBT.

Barch et al

Compared Stroop test results between those with SCZ and those without, and found those with SCZ were slower and made more mistakes, showcasing the difficulty they have processing information. Cognitive.

Smith et al

Identified 5 key treatment components for CBT; engagement strategies, psychoeducation, cognitive strategies, behavioural skills training and relapse prevention strategies. CBT.

Engagement strategies

First key treatment component for CBT as identified by Smith et al. This is when a client and therapist discuss key concerns, such as symptoms and general fears. A rapport is aimed to be established, as those with SCZ may have negative experiences with healthcare. They also discuss past coping mechanisms, empowering the client. CBT.

Psychoeducation

Second key treatment component for CBT as identified by Smith et al. This teaches a client the characteristics of their illness, allowing symptoms to be decatastrophized, increase the understanding and assess a client’s past understanding of their symptoms and illness. CBT.

Cognitive strategies

Third key treatment component for CBT as identified by Smith et al. Includes methods to help deal with cognitive symptoms, such as homework activities, Socratic questioning and verbal challenges (ABCDE model). CBT.

Behavioural skills

Fourth key treatment component for CBT as identified by Smith et al. Involves training to help cope with antipsychotic side effects such as anxiety and depression, as well as some SCZ symptoms. An example is problem solving, where a behaviour is identified and defined, solutions are generated, alternatives are considered, a solution is decided and the outcome is then evaluated. CBT.

Relapse prevention

Final key treatment component for CBT as identified by Smith et al. When early indicators of relapse, such as behaviours, alterations to relationships, feelings and thoughts, are identified and plans are drawn up to prepare for if they are experienced, such as support available. CBT.

Tarrier et al

Studied individuals who received CBT or TAU shortly after their diagnosis. Found they had the same relapse rates 18 months later, however the CBT group was found to be less negatively affected by their symptoms. This suggests any benefits may only work in the short term. CBT.

National Audit of Schizophrenia

Found that CBT was offered at various rates, ranging from 14-67% across NHS trusts, indicating clinician bias, less funding or a cultural issue. Average of 50%. Contrasts NICE guidelines that all patients should be offered CBT. CBT.

Bentall et al

Argues that CBT puts too much emphasis on controlling, rather than understanding thought processes. The root causes of positive symptoms could lie in childhood, or even recent trauma, meaning if this is not addressed CBT could cause high levels of psychological harm. CBT.

Kuipers et al

Analysed costs of antipsychotics and CBT, and concluded that money spent on CBT was offset by the reduced usage of service costs in the future, such as inpatient wards. CBT.

Typical

Antipsychotics which act as antagonists to D2 (and potentially 1, 3, 4 and 5) dopamine receptors, and affect serotonin receptors. Have worse side effects, as this antagonism works all over the body and not just the mesolimbic system.

Atypical

Antipsychotics that work as antagonists to less D2 receptors, and more D1 and D4 sites. They also antagonise serotonin receptor 5-HT2A equally, which increases dopamine in mesocortical and nigrostriatal systems, balancing dopamine antagonism. They also attach looser.

5-HT2A

Serotonin receptor antagonised by atypical antipsychotics, leading to more dopamine being released in the mesocortical and nigrostriatal systems, reducing affective and motor side effects respectively.

Seeman et al

Proposed the fast off theory - atypical antipsychotics bind more loosely than typical, meaning they do not last long enough to cause harsh side effects.

Ravanic et al

Compared clozapine (atypical) to chlorpromazine (typical) antipsychotics. Clozapine reduced psychiatric symptoms more, and had less adverse side effects.

Valenstein et al

Found that 40% of those with SCZ had poor adherence to antipsychotics, however clozapine only had 4.6%, suggesting it’s more effective. Additionally, younger people and African Americans had worse adherence rates than their counterparts.

Chlorpromazine and clozapine

Examples of a typical and atypical antipsychotic respectively. The first typical antipsychotic with a low potency, which can cause tardive dyskinesia, and the atypical antipsychotic can cause agranulocytosis and requires fortnightly blood tests.

Tardive dyskinesia

Side effect of antipsychotics where an individual’s face, body or both make sudden, irregular movements which cannot be controlled. Worse for typical antipsychotics.

Agranulocytosis

Side effect caused by clozapine where white blood cells drop by a life threatening amount. Regular blood tests, weekly than fortnightly, are required, which could be seen to add to the costs of SCZ.

Steingard

Psychiatrist who argues those with SCZ should be given more autonomy over their drug choices, and QoL should be prioritized. Argues the risks of long term antipsychotics should be explained to allow for full informed consent.

Wunderink et al

Compared those with SCZ who remained on drugs to those who stopped when they felt better and retook them when symptoms returned. Found the latter were more likely to get a job and return to regular life activities. They had equal relapse rates.

Ajnakina et al

Found that in Europe, 58.1% of SCZ patients were hospitalised at a follow up, suggesting asylum rates have not dropped as much as they are presented. However, length of stay has decreased, while black people and those who have gone longer without treatment still had longer lengths of stay.

5000 and 33

Cost in thousands of a single psychiatric stay in the UK, compared to the cost in billion of antipsychotics in 2022.

Valdo Calocane

A person with SCZ who killed 3 people, who had been unmedicated and hadn’t been in touch with psychiatric services for 12 months before the killings, suggesting it is service failures and not SCZ that causes violence.