Positive Symptoms

Schizophrenia

Features:

Schizophrenia is found universally at a rate of about 1.4-4.6 per 1000 people. About a quarter of people who have had schizophrenia recover and don’t relapse. About a quarter of people who have schizophrenia never recover. That leaves 50% who have periods of recovery and periods of symptoms. The positive symptoms can be overcome, but negative symptoms and tend to remain.

Positive Symptoms:

Positive symptoms are about changes in thinking in the person. These include:

Hallucinations – seeing or hearing things that aren’t there. Hearing voices in some cultures is not seen as a sign of mental disorder, but of a personal spiritual capability. In these cases, the voices are often kind and positive, whereas with schizophrenia the voices are often harsh and critical. Critical voices provide a running commentary on what the person is doing. Tells the person what to do – usually uncharacteristic acts.

Delusions – false beliefs. Such as someone thinking their movements are being controlled nu someone else. A common form of delusion is the paranoid delusion; the sufferer believes that someone is trying to mislead, manipulate or even kill them. Someone suffers from delusions of grandeur when they think they are in a prominent position of power, such as a King, or that they possess special power, such as the cure to cancer. Delusions can also take the form of the person thinking that unrelated things are in fact intended to relate to them, they may feel that a newspaper headline carries a secret message for them. Delusions can lead to strange behaviour such as covering windows to shut out the sound of God.

Thought disorders – makes a person’s speech hard to follow. They might also lose concentration at work or complain of having muddled thinking. The person may become disorganised. Further developments of thought disorders are ‘thought insertion’ (a person thinks their own thoughts are put there by someone else) or ‘thought broadcasting’ (thinking others can hear their thoughts).

Evaluation:Positive symptoms tend to have greater weight when diagnosing schizophrenia but, as was explained earlier, they can be affected by cultural differences so perhaps should not be weighted as strongly as negative symptoms, which might be more objectively measured.

Negative Symptoms:

Negative symptoms often start before positive ones, sometimes years before schizophrenia is diagnosed. This is known as the prodromal period. They include:

Lack of energy and apathy – for example, no motivation to do daily chores.

Social withdrawal – for example, avoiding family and friends and not going out.

Flatness of emotions, where the face becomes emotionless and the voice dull with no rise and fall.

Not looking after appearance and self, and generally not adhering to expectations with regard to preserving a sense of self.

Evaluation:Negative symptoms seem less affected by cultural factors and it has been suggested that they can be more objectively measured. Hearing voices, for example, is hard if not impossible to measure. Lack of energy, flatness of emotions or social withdrawal might be more easily monitored. Prodromal features have been found to be present in many adolescents and cannot be taken to indicate the onset of schizophrenia.

Types of Schizophrenia:

Paranoid: someone being suspicious of others and having delusions of grandeur, often hallucinations.

Disorganised:disorganised, hard to follow speech, inappropriate mood for situation.

Catatonic: when someone is very withdrawn and isolated and has little physical movement.

Residual: where there are low level positive symptoms but psychotic symptoms are present.

Undifferentiated: when the person doesn’t fit the other types.

Explanation 1:BIOLOGICAL

Dopamine hypothesis

Excess of the neurotransmitter dopamine possibly causes schizophrenia. The presence of an excess number of dopamine receptors at the synapses causes the symptoms. It explains why hallucinations may occur as the brain is too active. It is possible that the increase in dopamine in one site of the brain (mesolimbic pathway) contributes to positive symptoms and in another site (mesocortical pathway) to negative symptoms. It suggests a strong genetic link and allows antipsychotic drugs such as chlorpromazine to be used to reduce schizophrenic symptoms. Also, it explains (PET scan evidence) why schizophrenics have enlarged ventricles compared to non-sufferers and smaller frontal lobes (development of the receptors in one area might inhibit their development in another).

Evidence: Randrup & Munkvad (1996)

Randrup & Munkvad aimed to see whether schizophrenia-like symptoms could be induced in non-human animals by giving them amphetamines. Amphetamines worsen schizophrenic-like symptoms by releasing dopamine at the central synapses. The procedure involved injecting rats with doses of amphetamines. They reported all the known symptoms of schizophrenia were found. They concluded the experiment with a number of different animals, including dogs, cats, pigeons, pigs and squirrels, all showing that stereotypical schizophrenic activity can be produced by amphetamines. This supports the theory that dopamine contributes to schizophrenia.

Evaluation

Antipsychotic drugs, like chlorpromazine, block post-synaptic receptor sites. If the receptors are blocked, then less dopamine will be taken up so the effects of dopamine are reduced symptoms of schizophrenia are alleviated.

Drugs given to increase dopamine production in sufferers from Parkinson’s disease can experience symptoms of schizophrenia, therefore dopamine relates to schizophrenic symptoms.

PET scans have shown that genes linked with dopamine production are found with greater frequency in those with schizophrenia.

The brains of those with schizophrenia seem to be different, e.g. grey matter differences in the front and temporal lobes. Such brain changes, at an early age, link with sensitivity to dopamine.

PET scans show that blocking dopamine receptors doesn’t always remove schizophrenic symptoms. However, if antipsychotic drugs are administered early on in the disorder, then more than 90% of patients respond.

Blocking dopamine receptors happens almost immediately but effects aren’t noticed for several days. This suggests that something other than excess dopamine is causing the psychotic symptoms.

Amphetamines (cause excess dopamine, resulting in psychosis symptoms) only produce positive symptoms of schizophrenia, which suggests that the dopamine hypothesis is not a sufficient explanation.

Social and environmental factors seem to trigger schizophrenia, so a biological explanation is not sufficient. Perhaps stressful events in life can trigger production of excess dopamine.

Research Methods (AO3)

Evidence also comes from unrelated events, such as how medication affects those with Parkinson’s disease or how using recreational drugs leads to psychotic symptoms.
Dopamine receptors are implicated in many different studies, which tends to give the hypothesis reliability.
‘Biological’ research methods such as PET scans and animal studies have good controls and have qualitative data (scientific) which means the findings are credible. / Something else to do with schizophrenia may have caused the differences in dopamine receptors, rather than dopamine receptor differences causing schizophrenia.
Animals are used to investigate dopamine pathways and the effects of drugs on them. Findings from animal studies can’t legitimately be generalised to humans because there are differences in animal brains and the functioning of their nervous systems.

Explanation 2:SOCIAL

Environmental Breeder hypothesis

All social explanations look at factors in society that result in schizophrenia. This is because there is a higher incidence of schizophrenia in lower classes, the unemployed and those living in deprived areas. The Social Drift idea says that those with schizophrenia become lower class (social movement) because of the difficulties that arise from having schizophrenia. The idea of Social Adversity says that characteristics associated with living in urban areas (declining inner-city areas with social deprivation, unemployment, poor housing and low social status) lead to schizophrenia. Features in the environment that might affect the development of schizophrenia seem to be adversity in adult life, unemployment and poverty, social isolation, living in inner-city areas with poor housing and overcrowding, high levels of crime and drug use, and separation from parents as a child.

Evidence

Social Drift:

One study to supportcompared the social class of schizophrenia men with their fathers’ social class, using official statistics, found that though schizophrenic men were in the lower classes, their fathers generally were not. Those who developed schizophrenia didn’t achieve well in their education as children, had problems in adolescence and difficulty keeping their job.

Social Adversity:

There is a higher record of schizophrenia compared to rural ones. Studies in Chicago, London and Stockholm have shown above average incidences of schizophrenia.

Hjem et al (2004) conducted a study in Sweden that showed that social adversity in childhood lead to schizophrenia later in life. (Longitudinal study research method: lots of detail).

Evaluation

The idea helps to explain the fact that there are statistically more people with schizophrenia in the lower classes that are concentrated in inner-city areas. The hypothesis helps to explain both social drift and social adversity.

Those in lower socioeconomic groups, living alone, unemployed and living in poverty might be more likely to be diagnosed with schizophrenia. This suggests that there might be a diagnosis problem, not an environmental problem.

It might be that poverty, unemployment and lack of social support are stressors and it is this stress that causes the schizophrenia, not the environment itself.

It is hard to separate environmental factors to see if they cause schizophrenia or if they are the result of schizophrenia.

The Stress-Diathesis Model suggests that behaviour comes in part from a genetic predisposition and in part from the environment. Gottesman and Shields thought that particular genes predispose someone to schizophrenia by lowering the threshold for coping with stress. Even if there is a single gene for schizophrenia, their explanation still stands that there is a genetic tendency to schizophrenia that can be triggered by environmental factors.

Treatment 1: BIOLOGICAL

Drug Therapy

Drug treatment was first introduced in the 1950’s and can be called chemotherapy, which is an overall term for therapy using chemicals. A patient is only put on one antipsychotic drug at a time. However, antidepressants can be used at the same time and anticonvulsants might also be prescribed.If dopamine is linked to schizophrenia, then drugs that target dopamine transmission should reduce the symptoms of schizophrenia, e.g. Chlorpromazine acts by blocking dopamine receptors and therefore reducing its effects. Antipsychotic drugs are used to treat schizophrenia and suppress hallucinations and delusions. There are two types of drugs; ‘typical’ ones which are well established and ‘atypical’ which are less widely used but have fewer side-effects and act in different ways to ‘typical’ antipsychotic drugs.

Symptoms of typical drugs:

• Sleepiness and tiredness;
• Shaking and muscle spasms;
• Low blood pressure;
• Problems with sex drive;
• Weight gain.

Evidence: Meltzer et al. (2004)

Meltzer carried out studies to look at the use of drug therapy on schizophrenia patients. He chose 481 patients with schizophrenia and randomly assigned them to groups. The groups had either a placebo, 4 investigational drugs (new antipsychotic drugs) or a Haloperidol (established antipsychotic drug) for 6 weeks. The study gathered information about positive and negative symptoms, severity of the illness and a score from the psychiatric rating scale. Haloperidol gave significant improvements in all aspects of functioning tested compared with the placebo group so the study appeared to have validity. Two of the new drugs also showed improvements in several of the measures compared with the placebo. The other 2 new drugs showed no improvements.

Meltzer concluded that Haloperidol improves symptoms of schizophrenia and that drug therapy does work to an extent.

Evaluation

Drugs are thought to be better than pre-1950’s treatments as they are seen as more ethical and more effective.

Drug treatment rests on strong biological evidence about the causes of schizophrenia so is underpinned by theory which helps in considering its effectiveness.

It’s cheap, ethical and practical to give people drugs.

Schizophrenic patients don’t continue to take the drugs prescribed (in 50% of cases). It might be that problems in functioning means they might find the side-effects too uncomfortable or forget.

Rosenhan found that patients in institutions preferred to hide their drugs rather than take them.

Drugs have been called a ‘chemical straight jacket’ and some people think that such control by society is unacceptable and unethical.

Antipsychotic drugs have side effects and aren’t a ‘cure-all’ treatment as they don’t cure negative symptoms of schizophrenia.

Drugs don’t take into account a patients environmental or social problems which might contribute to relapses. Social treatments such as ACT programmes address these issues.

Treatment 2: SOCIAL

Assertive Community Therapy

Assertive Community Therapy (ACT) is used for people that have frequent lapses of hospitalisation to help them be cared for in the community. It helps to make patients independent and avoid homelessness by assisting their recovery. It is a multidisciplinary approach that uses professionals such as nurses and social workers to rehabilitate the person suffering with the disorder offering a holistic treatment that looks at all of the individual’s needs. If patients worsen, they can go into hospital on a short basis if a relapse occurs. The ACT programme is used in many countries (UK, Australia, Canada and USA) but can have problems being replicated in less densely populated countries where people are more spread apart. It is an evidence-based treatment because there is evidence for its effectiveness.

Evidence

Bond (2001) summarised 25 control studies that looked at the effectiveness of ACT compared with standard community care and found that ACT was effective as the clients were engaged and it prevented rehospitalisation. He also states that by preventing hospitalisation, the treatment increases a client’s choices and freedom.

Myeser et al. (1998) found that ACT was useful across genders, ages and different cultures (ethnocentric) and reported no negative aspects of the program.

Dixon (2000) found that since the 1980’s; ACT has been seen as the model for mental health practice.

Gormory (2001) suggests that ACT is paternalistic and coercive, in that the client does not have the choice of whether or not to undergo such treatment (social control). It is suggested that 11% of clients feel forced into the treatment. It seems that case managers are more active in setting limits for clients who have more symptoms, more arrests, many hospitalisations and more recent substance abuse, so there may be some coercion in such severe cases.

Evaluation

Good for those who have many relapses because it might be problems with living outside the hospital that lead to such episodes. Social skills training can help improve interactions.

If targeted on high users of in-patient care, ACT can substantially reduce the costs of hospital care whilst improving outcomes and patient satisfaction.

Evidence suggests ACT is consistent across numerous reviews studies and is effective in managing the care of severely mentally ill people in the community.

Although ACT help to prevent relapse, the therapy doesn’t have an effect on reducing the positive and negative symptoms of schizophrenia – it just helps the patient cope with the disorder.

ACT only works in highly populated areas where there are more schizophrenic patients and therefore staff in the community.

Clients surrender all responsibility for making decisions and taking care of themselves.

Research Method 1

TWIN STUDIES

This method involves comparing MZ (monozygotic) and DZ (dizygotic) twins to see what differences there are in the incidence of certain characteristics. MZ twins are genetically identical and share 100% of their genes as they come from one egg. DZ twins only share 50% of their genes as they come from two eggs.If a characteristic is completely genetically given (nature), MZ twins would both show characteristics. If a characteristic comes from environmental influences and factures (nurture), then MZ twins will not share the characteristic any more than DZ twins.

With regard to schizophrenia, if one twin has the disorder and the condition is inherited it would be expected that both MZ twins would have the disorder. With DZ twins, there is only a 50% chance both twins would inherit schizophrenia.

Evaluation

There is no other way to study genetic influences so clearly because no other humans share 100% of their DNA.

Although the amount of DNA they share differs, both MZ and DZ twins share their environments, so there is a natural control over environmental effects.

MZ twins share their DNA but even in the womb they may experience different environments which may lead them to develop differently.