Outline and evaluate psychological therapies for schizophrenia (8+16)

Family therapy has been developed due to the possibility that schizophrenia is caused by family problems such as double-blind situations and expressed emotion (EE). This also aims to reduce relapse rates in patients with schizophrenia through contact with high EE family. Therapy aims to change aspects of he patient-relative relationship. It involves educating family about schizophrenia and teaching methods of coping, problem solving and family communication. 

Social Skill Training helps with aspects of daily life. Symptoms may be controlled by medication but an individual may still struggle to form friendships, find or keep a job or live independently. This training helps the patient acquire the skills they need to function better on a day to day basis e.g. employment, relationships, self-care and managing medication. 

CBT works by modifying delusional beliefs and hallucinations within sufferers. These may occur due to incorrect interpretations of the world around them, themselves, maladaptive thinking or disorder perceptions. The aim of CBT is to help the patient identify these 'faulty' and disorder belied and address them. Patients are taught to recognise signs of potential relapse before they build up into schizophrenic symptoms again. 

Left et al researched the effectiveness of treating high EE families. 10 patients were given a 2 year programme of family therapy and 9 were used as controls. 17% of the experimental groups that also took medication relapsed, 78% with medication alone and 83% relapses with no treatment. Therefore this suggests that family is effective in preventing relapse with no treatment. Therefore this suggests that family therapy is effective in preventing relapse. Reliability issues occur due to the problem of the lack of a consistent diagnosis for schizophrenia. Also family therapies may have only been used with those with mild schizophrenic symptoms. Different schizophrenics may have different results. Therefore results may be determines by how sever the initial symptoms were. 

Family therapy has only once been seen to be more effective in preventing relapse and not in preventing the onset of the illness. Therefore this is a major weakness for its treatment. Another issue is there is little research into family therapies long term effectiveness of the treatment. Improvement has only been seen short term therefore this may not be appropriate as a long term solution.

McGorry et al found CBT was effective with patients at risk of having a schizophrenic episode receiving different treatments. After 6 months 36% of patients receiving psychotherapy developed schizophrenia, with only 10% of those receiving CBT and drug therapy developed the disorder. This supports the use of CBT as an effective form of treatment. However, it is questionable whether CBT is appropriate as the lower risk of relapse could be due to the drugs rather than the CBT itself. Therefore the drug therapy may have been a confounding variable with CBT having potentially little to no effect. The CBT would be argued to help mask the disorder, through teaching functional behaviour. Therefore the underlying cause may remain. 

CBT suffers reductionism as it ignore individual differences and suggests all develop schizophrenia in the same way. It oversimplifies schizophrenia to cognitive thought processes when evidence strongly suggests a biological origin, which is ignored. CBT may only be effective with those who have milder forms of the disorder as an insight and awareness is needed to address problems. Those with severe schizophrenic symptoms may lack this. Appropriateness of CBT must be considered; if it only masks symptoms this raises ethical issues as patients may be encouraged to hide symptoms causing patients to be denied potentially more beneficial treatment. For example if schizophrenia has a biological cause drug therapies would be more appropriate. Therefore suggests CBT as an inappropriate treatment for some individuals.

Overall issues regarding psychological treatments are compared to anti-psychotic treatment, they appear to be less effective. Such therapies are also reductionist in ignoring biological influences which clearly play a role in schizophrenia. Due to this purely psychological therapies may be unlikely to provide long term benefits. 

Outline and evaluate biological therapies for schizophrenia (8+16)

The most frequent treatment for schizophrenia is use of anti-psychotic drugs. Conventional anti-psychotics such as Chlorpromazines were introduced in the 1950s. These are dopamine antagonists and work by blocking dopamine production through the D2 receptors in synapses that absorb dopamine therefore reducing positive symptoms such as hallucinations which are though to be caused by over-stimulation of the brain by dopamine. 

Anti-psychotics can be divided into first generational (typical) and second generation (atypical) varieties. Atypical anti-psychotics work by reducing serotonin activity in the brain. They then act on dopamine receptors leading the patient to show fewer side effects. 

Davis et al conducted a meta-analysis and found that over 70% of sufferers treated with anti-psychotics improved their conditions after 6 weeks. This suggests anti-psychotics were beneficial. However, 25% of sufferers also improved on placebo alone. Also 30% of those taking anti-psychotics did not improve. This suggests that effectiveness of drug therapies can vary between individuals therefore such differences must be taken into account when considering the appropriateness of treatment. The meta-analysis used over 100 studies therefore has high external validity and generalisations will be able to be made more accurately. Issues include demand characteristics may have affected whether treatment was successfully as some patients may have been more motivated and convinced the therapy would work. Therefore regardless of whether anti-psychotics or placebo was taken they would have had reduced symptoms. 

Double-blind trials contradict Davis' findings suggesting the overall effectiveness of anti-psychotics is argued to be around 60%. Such trails are used to objectively test and to reduce demand characteristics with research helping to increase reliability. However, such research highlights issues regarding determining the effectiveness of drugs, as results vary. Double-blind trials may only be reliable as a short term measure for the effectiveness of drug therapies. 

Drug therapies in the use of schizophrenia have had the major advantage of allowing suffers to lead normal lives where previously they may have been institutionalised for unmanageable symptoms. However, limitations occur for example not all patients responded to anti-psychotics, with around 40% being unresponsive. Both conventional and atypical anti-psychotics can produce negative side effects with conventional drugs being linked to Tardive Dyskinesia, a loss of muscle control, being irreversible in 75% of cases (Hill et al). Side effects raises problems of compliance and patients may stop taking them therefore causing schizophrenic symptoms to return or increase. 

ECT has previously been used in treatment although today is highly controversial. ECT uses electric currents to induce a seizure in the brain. This has been seen to reduce schizophrenic symptoms in some but it is not understood as to how this works. The appropriateness of ECT has been questioned as in studies comparing ECT and simulated ECT found little difference in effectiveness. Also due to the uncertainly of effectiveness and ethical issues surrounding treatment, today it is not used in the treatment of schizophrenia as there is not sufficient research support for its effectiveness according to for example NICE (National Institute for Health Care and Excellence).

Biological therapies are deterministic as patients are reinforced to believe that they have less control over their disorder and that their behaviours are dictated by their biology. Also biological treatment can only treat symptoms of schizophrenia therefore once the patient stops taking medication symptoms will likely return. Often anti-psychotics are combined with other therapies e.g. CBT as from research one has not been found to offer a complete cure. Such treatments are also reductions in assuming schizophrenia is caused solely by biological causes. But, other research suggests psychological factors and environmental factors also play a role in onset and maintenance.

It has been argued medical professionals prescribe pills in the best interest in the companies producing the medication. This creates ethical concerns as they are not working in the interest of the patient. Therefore such issues highlight many factors that the patients must consider before engaging in biological treatments. However, when they work are proven to be very beneficial. 

Outline and evaluate psychological explanations of schizophrenia (8+16)

One explanation for schizophrenia developing is due to the upbringing within schizophrenic families. The double blind hypothesis suggests schizophrenia is a consequence of abnormal patterns in family communication e.g. given mutually contradictory signals by another person, causes internal conflict and schizophrenic symptoms represent an attempt to escape for the double blind.

Expressed emotion (EE) has been linked to the maintenance of schizophrenia. This refers to the families that are constantly showing high levels of emotion such as hostility, criticism, over involvement and over concern. Schizophrenic patients returning the high EE homes were more like to relapse than those in low EE homes.

Cognitive explanations such as that proposed by Frith suggest that schizophrenic are unable to form a correct ‘meta-representation’ of reality. This occurs as different areas of the brain do not function together effectively causing faulty thinking processes. This causes disordered thoughts and hallucinations therefore suggesting the schizophrenic characteristics are a cause rather than a symptom.

Helmsley proposed failure to activate schemas an explanation. This is a breakdown between stored memories and new information. Since schemas are used to interpret the world when a breakdown occurs it effects schizophrenics’ ability to do this. Therefore they cannot breakdown information, causing sensory overload, resulting in delusional thoughts.

Vaughn et al investigated express emotion in families of hospitalised schizophrenics. A 51% relapse in high EE homes was found and a 13% relapse in low EE homes. They also found relapse rates increased with more contact with high EE relatives therefore supports the EE explanation. However, only half of patients relapsed when returning to high EE homes suggesting this may not be a complete explanation. Further problems occur as the EE theory suggest those in low EE homes should not have relapsed. Such as explanation is reductionist as they only consider the role of family members in relapse rates, when any social involvement, not just family members, could be considered high or low EE. Methodological problems are raised for example interviews were used to determine whether a family is low or high EE. This is subjective to the researcher’s interpretations therefore is not a reliable measure. Also extraneous variables could not be controlled therefore we cannot determine how much influence high EE families truly have in increasing relapse in patients.

Family based psychological explanations provides a nurture side to the nature/nurture debate. Such studies help us to gain a better understanding of innate predispositions that may bring about schizophrenic symptoms.

Weinberger et al found that the blood flow to the prefrontal cortex, during a card sort test, was different for those suffering schizophrenia. This led to the conclusions that schizophrenia was associated with poorly functioning cognitive activity. Such methods of testing are objective as they measure blood flow therefore in that sense are reliable. However, such studies only provide a correlational link with no proof that this difference in blood flow causes different cognitive processes which link to schizophrenia. There is also a lack of control of extraneous variables which may contribute as brain mechanisms are still not well understood. Such cognitive explanations have been criticised for being deterministic in suggesting we do not control our cognitive processes. It has been argued that consciousness and free will operate at different levels therefore a cognitive explanation is limited if it does not take free will into account.

Both Vaughn and Weinberger’s studies provide evidence that schizophrenia may have a psychological influence to some extent. However, generally a biological approach is more accepted. Cultural influence is ignored in both studies raising generalisation issues. Culture may influence onset as it has been found EE is less common out of western cultures. This may be due to non-western cultures being less committed to concepts of personal responsibility than western societies. Therefore they are less likely to blame someone with schizophrenia for their actions. However, purely psychological explanations are reductionist and ignore the role of biological influences which others suggest have more of an influence.

Outline and evaluate biological explanations of schizophrenia (8+16)

It is thought that genetic factors play a role in schizophrenia. However, research has failed to identify one or a small number of genes that are responsible for the disorder. Therefore the 'polygenic threshold model' has been suggested. This assumes that a genetic influence comes from an accumulation of small effects from a larger range of genes. 

Current research from twin, adoption and family studies suggest that genetic influence is not enough to account for the rate of those who are genetically related to develop schizophrenia. This led to the conclusion that environmental factors also contribute to schizophrenia onset. 

The Dopamine-Hypothesis states that the neurons transmitting dopamine fire too easily and too often leading to characteristic symptoms of schizophrenia. Schizophrenics are thought to have abnormally high levels of D2 receptors on receiving neurons resulting in more dopamine binding and thus more neurons firing. Dopamine plays a role in attention therefore disturbances in this process may lead to problems related to attention, perception and thoughts which are found in schizophrenics.

Joseph analysed data of schizophrenic twins finding a concordance rate of MZ twins of 40.4% and for DZ twins 7.4%. More recent methodologically sound studies e.g. 'blind' diagnosis, where the research does not know whether they are testing MZ or DZ twins, reported lower concordance rates for MZ twins. Despite this researchers still argue findings suggest a genetic link and MZ concordance is often higher than DZ concordance rates. Such research studies are inconclusive as to the exact degree of influence genetics has in determining likeliness of developing schizophrenia. It is likely other factors influence whether schizophrenia is developed when there is a biological predisposition. 

An issue with twin studies is they assume that MZ ans DZ twins share the same environments. However, Joseph et al highlighted that identical twins are more likely to be treated similarly and may be seen as one person, therefore share similar environments. This could explain the higher concordance rates with MZ twins due to environmental factors rather than genes alone. Also MZ twins share 100% of genes, the concordance rate remains at 40% and not 100% suggesting the environment still plays a mitigating role in schizophrenia onset. 

The diasthesis-stress model may apply here with both nature (genes) and nurture (environment) interacting. Schizophrenia onset may be caused by having a genetic vulnerability as well as being exposed to certain environmental triggers. This theory can be applied to help individuals with a genetic predisposition to avoid situations that may cause schizophrenic symptoms to show.

Cross et al found in post-mortem examinations comparing schizophrenics and a control group, found that a higher level of D2 receptors were found among schizophrenics, providing evidence to support the dopamine hypothesis. Other post mortem studies had concluded it was the drug treatments that the schizophrenics had been taking which caused this. However, Cross et al reported that these schizophrenics had not been taking drug treatment at the time of death, so contradicting other such studies that suggest anti-psychotics caused changed in the brain's response to dopamine. 

Both Joseph and Cross' studies support a biological explanation, with study support for genetics remaining greater than that of the dopamine hypothesis, however neither are conclusive. Both genetic and neurochemical explanations have been criticised for being reductions as the ignore the role of free will and suggests all human being are driven by biological impulses that are beyond our control, which is untrue.

The nature/nurture debate suggests that out innate biological makeup gives us a predisposition to develop schizophrenic tendencies, but it is nature which is important in creating the circumstance for these behaviours to show. Therefore a consideration of both biological and psychological factors may be the most accurate explanation of how schizophrenia is developed. 

Discuss issues associated with the classification and/or diagnosis of schizophrenia

Reliability is the extent to which psychiatrist can agree on the same diagnosis when independently assessing patients. Some parts of the world use the DSM and others may use the ICD to diagnosis schizophrenia. Issues of reliability occur as the DSM and ICD have different diagnostic criteria. Also the classification criteria changes over time for example the DSM-5 has dropped some sub-categorises of schizophrenia suggesting previous error. Diagnosis may also suffer cultural bias as in one country may diagnosis someone as normal and in another as schizophrenic. Therefore diagnosis is dependent on which identification tool is used and where in the world the individual is highlighting how inconsistent diagnosis actually is. 

This raises issues of validity demonstrating that schizophrenia is not understood well enough to make diagnosis accurately. Validity, in this case, is the extent a diagnosis claims to accurately diagnose schizophrenia. Invalid diagnosis raises ethical issues for example being labelled as schizophrenic could affect other areas of life such as employment or how others perceive the individual. Diagnosis relies on patients reporting symptoms therefore makes an objective diagnosis difficult. 

Copeland et al highlighted cultural differences in diagnosis and how it can vary between countries. They gave a description of a patient to US and British psychiatrists; 69% of US diagnosed with schizophrenia, while only 2% of British made this diagnosis. Therefore, differences exist in what people expect symptoms to look like and highlights further issues is diagnosis. As, behaviour in one country could be seen as relatively normal but in another could be symptoms of schizophrenia. This study highlights that some clinician may be inclined to offer a certain diagnosis possibly due to them 'liking' a certain disorder. 

Rosanhan found when healthy individuals presented themselves to psychiatric hospitals in the US, claiming to hear voices they were all admitted, being diagnosed as schizophrenic. This highlights an issue of the lack of expertise in make a valid diagnosis. Additionally, in a follow up study Rosanhan warned hospitals he would be sending 'fake patients' this resulted in a 21% detection rate despite no fake patients ever being sent. This further highlights how diagnosis methods can be unreliable meaning current understanding of schizophrenia is insufficient and lacks validity. 

Ellason and Ross stated people with Dissociative Identity Disorder (DID) had more schizophrenic symptoms than schizophrenics themselves. This raises issues of comordability as symptoms may appear schizophrenia but it may be due to a combination of other illness resembling it, making reliable diagnosis and treatment difficult. If we do not accurately know what schizophrenia is, we cannot treat it sufficiently. People diagnosed with schizophrenia rarely share the same symptoms, and there is little evidence they share the same outcomes. Therefore even with an accurate diagnosis it is still difficult to recommend a suitable treatment for the individual. 

Diagnosis can lead to positive outcomes for example it presents the patient with the opportunity to receive treatment which would not have been available if undiagnosed. It may also help raise the patients self-efficacy through dispelling any feeling of guilt regarding their behaviour as schizophrenia can be offered as an explanation. However, negative implications can arise from diagnosis such as the risk of misdiagnosis which raises serious ethical issues as it could prevent sufferers from gaining the most beneficial treatment. A diagnosis may also lead individuals to believe that they have little or no control in directing their lived which could affect feeling of self-esteem or self-worth. This may then lead to stigmatising form others further worsening the individuals symptoms. 

Tools such as the DSM are often used for diagnosis however these can be seen as reductionist as they reduce down a complex disorder to a few symptoms which cannot be operationalised effectively. This highlights the importance of the physician to understand the patient and their own interpretations of their symptoms to make the most beneficial and appropriate diagnosis. 

Outline the clinical characteristics of schizophrenia (8)

Schizophrenia is a disorder characterised by the individual losing touch with reality. Under the DSM-5 diagnosis of schizophrenia requires two or more identified symptoms to be present for a one month period to be diagnosed.

Positive symptoms that occur in excess of normal functions such as delusions which are bizarre beliefs that are not real, including inflated beliefs about ones own power and importance. Experience of control; include the individual believes they are being controlled by an external force such as God, aliens or spirits that have invaded their mind. Hallucinations; include bizarre unreal perceptions of the environment e.g. hearing voices. Disordered thinking; is thoughts being inserted or withdrawn from ones mind. In some cases a person may think their thoughts are being broadcast to others. 

Negative symptoms are those that reflect a diminution or loss of normal functions including affective flattening; a reduced range and intensity in expressing emotions e.g. facial expressions and tone of voice. Alogia is speech that is not fluent or productive with sparse relies or there is a lack of speech. This is believed to show a blocked or slowed down thought process. Avolition is 'poverty of will' or a lack of drive or motivation to pursue meaningful goals or socialise. The person may be confused and show disinterest. 

In addition to this one of the symptoms must be delusions, hallucinations or disordered speech which must persist for 6 months for a diagnosis. 

Outline and evaluate research into celebrity stalking (8+16)

Stalking is define as 'the wilful, malicious and repeated following or harassment of another person threatening his or her safety', with celebrity stalking constituting for about 1% of stalking cases. 

Two types of stalking have been identified; love obsession and simple obsessional stalking. Love obsession is a fixation with another person (such as a celebrity) which they have no personal connection with. Stalkers of this type suffer from delusional thought patterns and may suffer a mental disorder such as schizophrenia. Most are unable to create real relationships therefore create fictitious ones which they try to act out in real life. The second type, simple obsessional stalking, is more common and distinguished by some previous personal relationship having existed between the stalker and the victim before the stalking behaviour began. 

The two main explanations for stalking are personality theory and attachment theory. Personality theory suggests stalking is an extreme form of celebrity worship by those who score highly in the borderline-pathological dimensions of the CAS (celebrity attitude scale). Attachment theory proposes that celebrity stalking may be an extreme manifestation of the insecure attachment type. 

Bartholomew and Horowitz proposed a model of adult attachment styles. One of these is 'pre-occupied' and has been linked to celebrity stalking. Individuals with this type of attachment have a negative self-model and a positive other-model. Therefore the individual seeks validation from others. Meloy claims that celebrity stalking could be indicative of abnormal attachments. Individuals with this attachment may engage in celebrity stalking because they over value others and perceive contact with celebrities will indicate they are accepted and valued, thus challenging their negative views on themselves. 

Tonin found a significant number of stalkers were found to have insecure attachments compared to a control group. Therefore this supports the theory that certain attachment types can lead to increased likelihood of stalking. However, self-report measures were used to measure attachment type through the use of questionnaires. This may lack reliability as they are often subjective to how the individual was feeling that day therefore their assessed attachment type may not be accurate. Additionally, questionnaires were used to assess the stalkers' retrospective childhood attachment styles. Such measures require the individual to answer questionnaires about their childhood which they may not remember leading them to guess answers to questions further hindering reliability and validity in determining their attachment type. Therefore firm conclusions cannot be drawn between attachment and susceptibility of stalking. 

Maltby et al claimed that the tendency to engage in stalking behaviour may actually be indicative of underlying psychopathology. They found scores of OCD correlated with measures of the CAS intense-personal and borderline-pathological. Stalkers sometimes behave irrationally toward their victims, which may reflect underlying psychopathology. However, this is correlational data and cause and effect cannot be determined. Not everyone with OCD develops stalking behaviour and not all stalkers will have OCD tendencies, therefore to assume this is reductionist. Additionally, this explanation is deterministic and ignores the role of free will humans have in behaviour. Individuals have the capability to control whether they stalk someone however this is ignored in research. 

Research into stalking has real world applications for example the creation of anti-stalking legislation. In the UK and US there are anti-stalking laws. The issue with these laws is that there are still basic rights of freedom and fans are encouraged to be adoring. It may become difficult to assess when fans behaviour becomes stalking. Therefore this highlights the importance of research into stalking as it aids in determining what factors make an individual most likely to display stalking behaviour, helping to protect celebrities. 

However, such research evidence may be socially sensitive as it may lead to stigmatising against or observation of those with such traits or personality types. Even though it is not certain that they will develop stalking behaviour.