Schizophrenia Part 2

Question 1

What is cognitive behavioural therapy

Answer 1

• this is a combination of cognitive therapy (a way of changing maladaptive thoughts and beliefs) and behaviuoral therapy ( a way of changing behaviour in response to these thoughts and beliefs)

Question 2

What is CBTp

Answer 2

cognitive behavioural therapy for psychosis

Question 3

Describe CBTp

Answer 3

• Basic assumption is that people often have distorted beliefs which influence feeling and behaviours
• For example someone with schizophrenia may believe that their behaviour is being controlled by someone or something else and delusions are the result from faulty interpretations of events.
• CBTp is used to help the patient identify and correct these faulty interpretations -
• Can be delivered in groups but it is usually delivered on a one to one basis
• NICE recommend at least 16 sessions when used in treatment of schizophrenia
• Aim is to establish links between their thoughts, feeling or actions and their symptoms as well as their general level of functioning by monitoring they are able to consider alternative ways of explaining why they feel and behave the way that they do reducing distress and improving functioning

Question 4

How does CBTp work

Answer 4

• Patients are encouraged to trace back the origins of their symptoms in order to get an idea of how they developed, they also evaluate the content of their delusions or of any voices which allows them to test the validity of their faulty beliefs
• May be set behavioural assignments to improve functioning
• During CBTp the therapist lets the patient develop their own alternatives to these previous maladaptive beliefs and look for alternative explanations and coping strategies that are present in the patients mind.

Question 5

Evaluation of cognitive behavioural therapy: Advantages of CBTp over standard care

Answer 5

• NICE review od treatments found consistent evidence that when compared with standard care, it was effective in reducing rehospitalisation rates up to 18 months following the end of treatment
• Reducing symptom severity and there is improvement in social interaction and functioning
• However most studies of the effectiveness of CBTp have been conducted with patients treated at the same time as antipsychotic medication therefore difficult to assess on its own

Question 6

Evaluation of cognitive behavioural therapy: Effectiveness of CBTp is dependent on stage of the disorder

Answer 6

• More effective when available at specific stages of the disorder and when the delivery of the treatment is adjusted to the stage that they are on
• Addington and Addington 2005 – claimed that in the initial acute phase of schizophrenia self-reflection is not appropriate but when psychotic symptoms stabilise the individual benefit more from group based CBTp, this normalises the experience by meeting other individuals with similar issues
• If they have more experience of their schizophrenia then they benefit more from individual CBTp

Question 7

Evaluation of cognitive behavioural therapy: Lack of availability of CBTp

Answer 7

• Predicted that only 1 in 10 get access to the therapy
• Haddock et al in the North West of England found that out of 187 schizophrenic patients only 13 had been offered CBTp and of those who are offered it as a treatment a significant number refuse or fail to attend therapy sessions

Question 8

Evaluation of cognitive behavioural therapy: The benefits of CBTp may have been overstated

Answer 8

• More recent and methodological sound meta-anaylses of the effectiveness of CBTp as a sole treatment for schizophrenia suggest that its effectiveness may be lower than thought
• Jauhar et al – revealed that only a small therapeutic effect on the key symptoms of schizophrenia
• Small affects disappeared when symptoms were assessed as blind
• Studies investigating CBTp have similar design flaws and lack of originality as they are usually taking antipsychotic drugs

Question 9

Evaluation of cognitive behavioural therapy: Problems with meta-analyses of CBTp as a treatment for schizophrenia

Answer 9

• Failure to take into account study quality
• Some studies fail to randomly allocate participants to either a CBTp or control conditions
• Others fail to mask the treatment condition for interviewers carrying out assessments of symptoms and general functioning, but all of these studies are grouped together for a meta-analysis
• Juni et al concluded that there was clear evidence that the problems associated with methodologically weak trials translated into bias findings about the effectiveness
• Wykes et al found the more rigorous the study the weaker the effect of CBTp

Question 10

What is family therapy

Answer 10

• This is the name given to a range of interventions aimed at the family of someone with schizophrenia in their guidance and treatment of it

Question 11

Describe family therapy

Answer 11

• Offered between a period of 3 to 12 months and at least 10 sessions, reduces the levels of expressed emotion within the family as this could increase the chance of relapse
• Garety et al estimated the relapse rate for individuals who receive family therapy at 25% compared to 50% of those who receive standard care alone
• Provides family members with information about schizophrenia and finds ways to support the individual and resolve any practical problems
• Should involve the individual as well as the family as they are often paranoid about their treatment so when they are there it reduces the paranoia

Question 12

Describe the procedure of Pharoah et al

Family therapy

Answer 12

• Reviewed 53 studies published between 2002 and 210 to investigate the effectiveness of family intervention, they were conducted in Europe, Asia and North America
• Compared outcomes from family therapy to standard care and they concentrated on randomised studies

Question 13

Describe the findings of Pharoah et al

Family therapy

Answer 13

• Mental state – overall impression was mixed, some reported an improvement in the overall mental state whereas others did not
• Compliance with medication – use of family intervention increased patients compliance with medication
• Social functioning – although appearing to show some improvement on general functioning it did not have an impact on concrete outcomes such as living independently
• Reduction in relapse and readmission – reduction in the risk of relapse and reduction in hospital admission during treatment and in 24 months after

Question 14

Evaluation of Family therapy: Why is family therapy effective

Answer 14

• Pharoah et al – meta-analysis established that family therapy can be effective in improving clinical outcomes such as mental state and social functioning
• Increases medication compliance as they are more likely to reap the benefits of medication

Question 15

Evaluation of Family therapy:Methodological limitations of family therapy studies

Answer 15

• Problem with random allocation – although all 53 studies claimed to have randomly allocated participants to treatment conditions the researchers noted that a large number of studies used in the review were from the peoples republic of China, they stated that they used random allocation but they did not
• Lack of blinding – possibility of observer bias where raters were not blinded to the condition to which people were allocated, 10 studies reported that no blinding was used and 16 did not report at all

Question 16

Evaluation of Family therapy: Economic benefits of family therapy

Answer 16

• NICE reviewed that it saves a significant amount of cost compared to standard care, less likely to relapse so less hospital rates
• Reduces relapse for a long time therefore saving costs in family therapy

Question 17

Evaluation of Family therapy:Impact on family members

Answer 17

• Lobban et al – analysed the results of 50 family studies and included an intervention to support relatives
• 60% reported a positive impact of the intervention on at least one outcome for relatives, for example coping and problem-solving skills, as well as family functioning and relationship quality
• Methodological studies were generally poor so it made it difficult to distinguish between effective and from ineffective interventions

Question 18

Evaluation of Family therapy:Is family therapy worthwhile

Answer 18

• Garety et al failed to shown any better outcomes for patients given sessions of family therapy
• Individuals in both groups were found to have unexpectedly low rates of relapse compared with the no carer group, the carers did not show expressed emotion
• He suggested for many people that family intervention may not improve outcomes further than a good standard of treatment as usual

Question 19

What is token economy

Answer 19

• It is a form of behavioural therapy where clinicians set target behaviours that they believe will improve the patients engagement in daily activities, may be something as simple as the patient brushing their hair or dressing themselves or helping another patient

Question 20

How does token economy work

Answer 20

• Tokens are awarded when they engage in the activity, they can be exchanged for rewards and privileges, therefore they associate this behaviour with rewards
• Ayllon and Azrin used a token economy on a ward of female schizophrenic patients who had been hospitalised for years, they were given plastic tokens each embossed with the words one gift for there behaviour they were then exchanged for things like getting to watch a movie, this dramatically increased the number of desirable behaviours that they carried out

Question 21

What are the important parts of token economy

Answer 21

• Assigning value to the tokens
• reinforcing target behaviours
• the trade

Question 22

Describe assigning value to the tokens

Answer 22

• The behaviour needs to be repeated and presented alongside or immediately before the reinforcing stimulus which may be a reward such as food or privileges, by pairing they require the same reinforcing properties
• Classical conditioning

Question 23

describe reinforcing target behaviours

Answer 23

• When a token it exchanged for a variety of different privileges and rewards it is referred to as generalised reinforcer, they are more powerful when they can get multiple items on the token
• Sran and Borrero 2010 – compared behaviours reinforced by tokens that could be exchanged for one single highly preferred edible item with tokens that could be exchanged for a variety, all participants had higher rates of responding in those sessions where tokens could be exchanged for a variety of items.

Question 24

Describe “the trade”

Answer 24

• Important is the exchange of tokens for backup rewards chose by the clinician such as being able to watch a movie
• During early stages frequent exchange periods mean that the patients can be quickly reinforced and target behaviours can then increase in frequency
• Effectiveness of the token economy may decrease if more time passes between presentation of the token and reward

Question 25

Evaluation of token economy: research support

Answer 25

• Dickerson et al – provided research support for the effectiveness of token economies in a psychiatric setting, they reviewed 13 studies of the use of token systems in treatment
• 11 had reported beneficial effects due to the token economies
• Therefore they had an overall beneficial effect, however they did caution that many of the studies showed shortcomings that limited their impact in the overall assessment

Question 26

Evaluation of token economy: difficulties assessing the success of a token economy

Answer 26

• Comer 2013 – suggests that a problem is that the use is uncontrolled, when a token economy system is introduced all patients are brought into the system rather than an experimental group therefore patients improvements can only be compared with their past behaviours rather than a control group
• May be due to an increase in staff attention that leads to better effectiveness and improvement

Question 27

Evaluation of token economy: less useful for patients living in the community

Answer 27

• Only works in a hospital setting where it can be regulated
• Corrigan 1991 argues that there are problems administering it in a community as its difficult to monitor and reward and control as they only receive treatment for a few hours a day so therefore can only be used for part of the day and cannot be maintained beyond the environment

Question 28

Evaluation of token economy: Ethical concerns

Answer 28

• In order to make reinforcement effective they may exercise control over primary reinforcers such as food or access to activities
• Patients then may exchange tokens if they display target behaviour
• Generally accepted that all humans should have an access to food and hygiene and they cannot be violated regardless of positive consequences

Question 29

Evaluation of token economy: Does it actually work

Answer 29

• McMonagle and Sultana suggests that the token economy may be important if randomised trials could be carried out but this is only important in developing countries were it is still practised therefore they could see how effective it actually is

Question 30

An interactionist approach

- what is the diathesis stress model

Answer 30

this explains mental disorders as the result of an interaction between biological and environmental influences

Question 31

Describe the diathesis-stress model (An interactionist approach)

Answer 31

Diathesis
- Schizophrenia has a genetic component in terms of vulnerability
- Shown in identical twin studies
- Adoptive relatives do not share the increased risk of biological relatives therefore showing environmental factors are also at play
Stress
- Stress can be from childhood trauma to living in urbanised spaces
- Varese et al found that children who experience sever trauma before the age of 16 were three times likely to develop schizophrenia than in their others general lifetime
- Relationship between the level of trauma and the likelihood of developing schizophrenia
- Research shown that high level of urbanisation is linked with developing a range of psychosis
- Meta- analysis study Vassos et al found that the risk for schizophrenia is in the most urban environments is 2.37 times higher than in most rural environments
- More adverse living conditions of densely populated environments contribute but only a tiny amount develop schizophrenia
The additive nature of diathesis and stress
- Minor stressors may lead to the onset of the disorder for an individual who is highly vulnerable or major stressful event may cause it in someone who is low in vulnerability
- Both together help develop the disorder

Question 32

(An interactionist approach)

describe the procedure of Tienari et al

Answer 32

• Hospital records were reviewed for nearly 20,000 women admitted to Finnish psychiatric hospitals between 1960 and 1979
• Those who had been diagnosed at least once with schizophrenia or psychosis
• The list was checked to find mothers who had one or more of their offspring adopted away
• Resulting sample of 145 adopted away offspring was then matched with a sample of 158 adoptees without the genetic risk
• Both groups were assessed independently after a median interval of 12 years and a follow up of 21 years
• They assessed family functioning using the OPAS, measures family using lack of empathy and insecurity

Question 33

(An interactionist approach)

describe the findings of Tienari et al

Answer 33

• Of the 202 adoptees 14 had developed schizophrenia, and 11 of these were from the high risk group with mothers who had previously had schizophrenia
• Healthy adoptive families lowered the risk for even those with high risk while high OAPS rating increased the risk
• Adoptive family stress was a significant predictor of the development of schizophrenia

Question 34

Evaluation of interactionist approach: Diathesis may not be exclusively genetic

Answer 34

• Most models emphasis the idea in terms of genetic influences alone which are assumed to cause neurochemical abnormalities that increase the risk of schizophrenia, this increased risk can result from brain damage from environmental factors
• They may develop a vulnerability to schizophrenia from birth difficulties
• Verdoux et al – estimated that the risk of developing schizophrenia later in life for individuals who experienced complications at birth is four times likely than those who had no complications

Question 35

Evaluation of interactionist approach: Urban environments are not necessarily more stressful

Answer 35

• Romans-Clarkson et al disagreed with Vassos et al, as they found no mental health differences between urban and rural women in New Zealand
• Also noted these differences disappeared after adjusting for the socioeconomic differences from the two groups, therefore it could be social adversity that causes the problem and urbanisation is an over-simplification

Question 36

Evaluation of interactionist approach: Difficulties in determining causal stress

Answer 36

• Things that happen early in life can influence how we respond to stressors later and increase there susceptibility to the disorder
• Hammen 1992 argues that the maladaptive methods of coping with stress in childhood and throughout development means that the individual fails to develop effective coping skills which compromises their resilience and increases vulnerability
• Therefore they make life generally more stressful for the individual and trigger mental illness

Question 37

Evaluation of interactionist approach: Limitations of the Tienari et al study

Answer 37

• Assessment of adoptive family functioning – they were assessing the family at only one point in a given time, fails to reflect developmental changes in family functioning
• Reciprocal interactions between the adoptive family and adoptees makes it impossible to determine how much of the stress is observed is assigned to the family and how much the adoptee causes

Question 38

Evaluation of interactionist approach: Implications for treatment

Answer 38

• Control factors that could lead to schizophrenia
• Borglum et al – found that women infected with cytomegalovirus during pregnancy were more likely to develop a child with schizophrenia but only if mother and child carried agene defect therefore anti-viral medicine can prevent the onset of schizophrenia in the offspring of women to have the gene deficit.