Schizophrenic Behaviour

Characteristics:
Schizophrenia is a mental disorder reportedly suffered by 1% of the world population and most
commonly diagnosed between the ages of 15 and 35. The condition can affect a sufferer's thought
processes, physical functions and perceptions of reality. The symptoms of schizophrenia can vary
drastically between individual sufferers in terms of their type and severity. Some sufferers may only
encounter symptoms sporadically, whereas for others, these are more persistent.
Positive Symptoms of Schizophrenia:
The characteristics of schizophrenia include positive symptoms. These are symptoms in addition to
normal functioning.
• Hallucinations
• Delusions
• Disordered thinking (speech)
Hallucinations:
• Perceptions that are unreal that no one else can perceive.
• Hallucinations are usually auditory (e.g. hearing voices)
• They may also be visual (e.g. seeing lights or objects), olfactory (e.g. perceiving a disgusting
smell) or tactile (e.g. feeling something or someone)
Delusions:
These are false beliefs held by a person who refuses to accept evidence of their falseness.
• Delusions of persecution – Commonly involve an individual believing that person, group, or
organisation want to harm them (e.g. they are being followed or spied upon).
• Delusions of grandeur – Involve exaggerated beliefs about one's own abilities or importance
(e.g. being famous or having superpowers)
Disordered Thinking:
• Their thoughts (and therefore speech) jump from one topic to another, for no apparent
reason (described as derailment).
• They show no logical flow of discussion, and their speech is muddled and incoherent.
• They may say a mixture of random words or phrases that are linked together in a way that
does not make sense (known as word salad).
Negative Symptoms of Schizophrenia:
Negative symptoms involve a reduction in normal functioning:
• Avolition (or "apathy")
• Alogia (speech poverty)
• Flatness of affect
• Catatonic behaviour
Avolition (apathy):
• The difficulty to begin and maintain goal directed behaviour. This involves significantly
reduced self-motivation to take part in activities despite having the opportunity to do so.
Alogia (speech poverty):
• Reduction in the amount of speech.
Anhedonia:
• Where an individual does not react appropriately to pleasurable experiences. For example a
rugby fan may not demonstrate any pleasure at their team winning.
Flatness of affect:
• Appear to have no emotions including no facial expressions such as smiling. Speech patterns
are monotonous.
Catatonic behaviour:
• Bizarre and abnormal motor movements. For example, holding the body in a rigid stance,
moving in a frenzied way, peculiar facial movements, copying movements of others.
Individual Differences Explanation
 Psychodynamic Approach:
Fixation:
During the oral stage of psychosexual development, the infant will derive pleasure from sucking and
feeding, particularly from the mother's breast.
If the child is fed too much or too little, they may become fixated on this stage. This means that as an
adult they may show particular personality traits, and may also show certain behaviours that have
the aim of satisfying any oral desires such as nail biting, kissing, smoking, chewing gum, etc. Freud
argued that schizophrenics have become fixated at the very earliest stage of development.
Regression
If an individual with this oral fixation encounters an excessive amount of stress as an adult, they may
regress back to this early stage, and the schizophrenic becomes essentially like a new-born again. At
the oral stage, the ego is essentially non-existent, so the fantasies and the wish fulfilment of the id
can go unchecked. This can lead to the person being self-obsessed and narcissistic leading to
symptoms of schizophrenia such as delusions of grandeur and/or persecution.
Freud argues that this regression involves being focused on the self. This schizophrenic becomes
disengaged from the outside world and entirely inward focusing. This detachment from reality leads
to the creation of alternate realities that are not part of the real world. This can lead to symptoms
such as hallucinations and delusions.
Losing Touch with Reality
During the oral stage the ego is not well developed. The role of the ego is to control the id’s impulses
and to try to balance the demands of the id with the moral limitations imposed by the superego.
However if an individual regresses back to a point where the ego effectively doesn’t exist, there is
nothing stopping the id from operating completely unimpeded. Symptoms of schizophrenia, such as
hallucinations and delusions, then supposedly represent the unchecked activities of the id. The
person loses touch with reality, being unable to distinguish between reality and their desires and
fantasies.
Schizophrenogenic Mother
Psychodynamic theorists consider the mother–child relationship to be one of the crucial factors in
the development of schizophrenia. This concept proposes that the mothers of individuals who
develop schizophrenia are overprotective and controlling but at the same time rejecting and distant.
The mother’s overprotection stifles the child’s emotional development, while her emotional distance
deprives the child of personal security, thereby leaving an individual who is very vulnerable when
faced with stress.
Evaluation
Psychodynamic Approach:
Freudian concepts are out of date:
As the 20th century progressed, psychologists became dissatisfied with the unscientific, unfalsifiable
nature of psychodynamic concepts. The psychodynamic approach has difficulty producing testable
hypotheses, which has meant that the explanation it offers for disorders like schizophrenia is now
viewed as being little more than an interesting historical footnote.
Failure to produce an effective treatment:
Freud believed that individuals with schizophrenia were not suitable candidates for psychoanalysis,
as many individuals with schizophrenia lacked the insight necessary for this talking treatment. Later
psychodynamic researchers, such as John Rosen (1947), proposed that schizophrenia could indeed
be treated with psychoanalytical techniques.
However, research (e.g. Strupp et al.,1977) found that psychoanalytic therapies actually can lead to
deleterious and harmful rather than beneficial effects in those with schizophrenia. This may be
because psychoanalytic techniques often require the patient with schizophrenia to experience
memories and insights that they are emotionally incapable of dealing with, and trying to do so is
distressing for the patient.
Ultimately this suggests that if an effective therapy cannot be established from the theory, then the
underlying principles of the explanation has no merit.
Inconsistent support for schizophrenogenic mothers:
Although the idea of the schizophrenogenic mother was quite a popular concept from the 1940s to
the 1970s, the research base on which it resides is tenuous. Early research included one study by
Jacob Kasanin et al. (1934). He examined hospital case records and reported that he had found
evidence of maternal overprotection in 33 out of 45 cases of schizophrenia. This means that almost a
third of the cases didn’t have an overprotective mother, making it rather unconvincing evidence.
Furthermore his judgements may have been biased as he was not ‘blind’ to the hypothesis and may
have lacked objectivity.
Overlooks the role of genetics.
Psychodynamic explanations suggest that the development of schizophrenia is the consequence of
early experience, therefore a problem of nurture. However, there is strong evidence of biological
factors in schizophrenia.
Evidence also comes from adoption studies. For example, Leonard Heston (1966) reported on the
diagnosis for schizophrenia in 47 adoptees who had a biological mother with a diagnosis of
schizophrenia and 50 adoptees who did not have a biological mother with schizophrenia. Heston
found that 10.6% of those who had a biological mother with schizophrenia were also diagnosed with
schizophrenia, whereas 0% of those who did not have a biological mother with schizophrenia had
also been diagnosed. This suggests that it might be the co-occurrence of shared genes between
mother and child, rather than how the mother raises the child, that is responsible for schizophrenia.
Individual Differences Explanation
Cognitive Approach:
Explaining hallucinations:
Anthony Morrison (1998) proposed that triggers, such as sleep deprivation, can cause some
individuals to ‘hear’ voices in maladaptive ways. The individuals appraise these voices
inappropriately as belonging to the devil, for example. This elicits behaviours such as social
withdrawal or self-harm. The emotions that these behaviours produce, normally sadness and/or
shame, reinforce the messages being offered by the critical voices, causing them to be perpetuated
in a vicious circle.
Explaining negative symptoms:
Aaron Beck et al. (2008) have drawn heavily from the idea of the cognitive triad, usually used to
explain depression, to also offer a reasonable model of the negative symptoms seen in some
individuals with schizophrenia.
Beck et al. propose that the individual endorses dysfunctional beliefs about their performance and
their ability to experience pleasure, they also hold a cynical and gloomy view of the future.
Their mental filters only allow in negative messages and deficits in information processing bolster
their pessimistic view. These leads to the negative symptoms of schizophrenia such as flatness
of affect, avolition and anhedonia.
Lack of Preconscious Filter:
Frith (1979) argues that schizophrenia is the result of difficulties in inhibiting preconscious content.
• Preconscious thought contains a huge amount of information from our senses that would
normally be filtered.
• Schizophrenia is seen as a result of the breakdown of this thought filtering process.
• Thoughts that would usually be filtered out as irrelevant or unimportant are now noticed and
treated as more significant than they really are.
• There is a sensory overload and can account for the positive symptoms of schizophrenia,
such as hallucinations, delusions and disorganised speech.
• According to Frith, these cognitive deficits are caused by abnormalities in those areas of the
brain that use dopamine, especially the pre-frontal cortex. His research has shown that
 schizophrenics have reduced blood flow to these areas (indicating reduced brain activity)
during certain cognitive tasks.
Compromised Theory of Mind:
More recently, Frith (1992) proposed that individuals with schizophrenia are working with a
compromised theory of one’s own and others’ minds. He believes that many of the symptoms seen
in those with schizophrenia are the result of disorders within three separate cognitive systems:
1. Disorders of willed action (i.e. voluntary behaviour) can explain negative and disorganised
symptoms of schizophrenia.
2. Disorders of self-monitoring can explain symptoms such as delusions of alien control and
vocal hallucinations.
3. Disorders of monitoring other persons’ thoughts and intentions can lead to symptoms such
as delusions of persecution.
Evaluation
Cognitive Approach:
Supporting research:
The cognitive models and theories proposed by researchers like Beck and Frith have led to a
tremendous amount of scientific research being conducted. For example, Deanna Barch et al. (1999)
compared performance on a Stroop test of people with schizophrenia and people without
schizophrenia. They found that found those with schizophrenia were slower and made more
mistakes on the Stroop test. They concluded that this was evidence that those with schizophrenia
couldn’t filter the information as effectively. This supports Frith’s idea that the attentional filters of
individuals with schizophrenia are defective.
A reductionist account:
Frith has offered a causal explanation for the deficits associated with schizophrenia. He has proposed
that the faulty operation of cognitive mechanisms is due to a disconnection of the functions within
the frontal cortex of the brain (decision making and action) and more posterior areas of the brain
(perception). He has even produced some supportive evidence by detecting changes in cerebral
blood flow in the brains of people with schizophrenia when completing cognitive tasks.
However, some critics suggest that Frith is being reductionist because this explanation reduces a
complex experience to the functioning of brain circuits.
Not a comprehensive theory:
Some researchers criticise the cognitive explanations as only being able to explain cognitive
symptoms of schizophrenia. Other symptoms of schizophrenia, such as issues with movement, are
not explained well by cognitive explanations.
In addition, cognitive explanations are criticised for only describing the cognitive deficits thought to
underlie symptoms of schizophrenia but do not always explain the origin of these deficits. In other
words, cognitive theories can explain the proximal causes of schizophrenia (i.e. what causes current
symptoms) but not the distal causes (i.e. the origins of the condition). This suggests that we should
perhaps be cautious about the claims made by the cognitive approach as a single explanation for the
disorder of schizophrenia.
An integrated model of schizophrenia:
Psychologists are now starting to appreciate that schizophrenia needs to be considered in a more
holistic way. Oliver Howes and Robin Murray (2014) have described an integrated model of
schizophrenia which proposes that genes or certain factors early in life (e.g. birth complications)
combine with life events or social stressors (e.g. poverty) and this provokes the dopamine system
into releasing dopamine. This increase in dopamine secretion causes problems with cognitive
processing, specifically delusions and hallucinations. The individual with schizophrenia then gets
caught in a vicious circle as the stress induced by experiencing these symptoms prompts the release
of more dopamine.
This sort of model suggests that the cognitive explanation alone is insufficient, but it can contribute
to a wider theory.
 Social Psychological Explanations
Dysfunctional Families:
Double Bind Theory:
Double bind communication involves contradictory verbal or non-verbal messages being expressed,
usually by a parent towards a child. The child may consequently feel trapped because they fear that
by responding to one of the messages they will fail to act on the other.
The child therefore gets two separate messages, and as these messages contradict each other, it
causes a conflict. Whatever the child's actions; they cannot win. They are in a double bind.
Children who grow up encountering these double bind statements on a regular basis learn that they
have no idea how to respond in a reasonable way in conversations. As these interactions are with a
role model they will grow up believing that this is how normal relationships work, and in the future
they will struggle in establishing normal relationships.
Bateson argues that these double bind statements could eventually lead to the hallucinations and
delusions of schizophrenia. These symptoms arise as a means of escaping the conflict caused by
these contradictory double bind statements. Double bind statements can also cause the child to
respond with maladaptive thinking patterns to help them navigate social situations.
Expressed Emotion:
EE is another example of family dysfunction which explains schizophrenia and involves members of a
family interacting with a schizophrenic relative in a negative manner. EE may involve:
• Verbal criticism of the patient
• Hostility towards the patient, including anger and rejection
• Over involvement in the patient's life
High levels of EE are often a reason for relapse because when patients return to their family after a
course of therapy it is difficult for them to escape the negative emotional environment. High levels of
EE can be a source of stress for the individual because schizophrenics often have a lower tolerance
for intense environmental stimuli and impaired coping mechanisms. This can lead to decreased self-
esteem and social withdrawal because they are made to feel worthless and have an over-
dependence on others because they are given little freedom to live their own life.
Brown (1959) investigated 156 men with schizophrenia after they had been discharged. He found
that relapse was strongly connected with the type of home the men were discharged to. Those men
discharged to stay with their parents or wives were more likely to relapse than those men who lived
in lodgings or with their siblings. Later, Brown conducted many interviews with the wives and parents
of individuals with schizophrenia. He found a relationship between the amount of expressed emotion
(EE) and the likelihood of relapse:
• Critical comments about the behaviour of the individuals with schizophrenia were counted
by Brown. Comments such as They are so lazy, they don't help around the house' were made
by high EE caregivers, while low EE caregivers tended to acknowledge these behaviours were
due to their illness.
• Hostility was noted as generally being present in the interviews with high EE caregivers. This
hostility was thought to be the result of unmanageable anger, irritation and ultimately the
rejection of the patient.
• Emotional over-involvement (EOI) manifests itself in high levels of both happiness and
sadness, excessive self-sacrifice, and extreme overprotective behaviour of the caregiver
toward the individual with schizophrenia.
• Warmth was measured by the vocal qualities, smiling and empathy expressed when the
caregiver was talking about the individual with schizophrenia. Warmth was generally evident
in low EE caregivers.
• Positive regard is the number of reinforcing statements in which the caregiver expresses
support and appreciation of the individual with schizophrenia. This was lacking in low EE
caregivers.
Evaluation
 Dysfunctional Families:
Double bind: Cause or effect:
Not all studies have found a significant difference in the quality of communications within families
that have a member with schizophrenia. Liem (1974), for example, found that the communications
offered in a structured task by the parents of 11 sons with schizophrenia were no more disordered
than the communications offered by parents of 11 sons who did not have schizophrenia.
Liem suggested that those studies that did find a difference in parental communications may actually
just be detecting parents having to adapt their communication styles when dealing with a
schizophrenic child. This suggests that the communication difficulties on which the double bind
theory is based are really just an effect rather than the cause of schizophrenia.
Where do double bind communications come from?
Koopmans (1997) notes that incidental variations in family interactions that would normally have had
little effect, may, at times of family disruption, lead to double bind communications. Although this
may offer a reasonable explanation for how the double bind communications could be established in
a family, there seems to be little empirical evidence to support this idea.
Furthermore the double bind communications may be a symptom of pathology in the parent and
therefore it could be the pathology rather than the superficial communications which is the greater
problem.
Research support for expressed emotion:
Early research (e.g. Vaughn and Leff, 1976) offered clear support for the role of expressed emotion in
relapse rates. The researchers found that 53% of those individuals with schizophrenia who had a high
EE relative relapsed within nine months, whereas only 12% of those with low EE relatives relapsed.
However, McCreadie and Phillips (1998) failed to find higher subsequent 6- and 12-month relapse
rates among individuals with schizophrenia living in high EE homes. This suggests that, although
expressed emotion may be a significant factor in the relapse of some individuals, it is not the only
factor that determines relapse.
Shared environment or shared genes:
The evidence presented by the Schizophrenia Working Group of the Psychiatric Genomics
Consortium (2014) found 108 genetic loci associated with schizophrenia. This evidence initially might
seem to suggest a very contradictory viewpoint to the role of family relationships as a cause for
schizophrenia. However using a diathesis–stress model it could be that family relationships may act
as a psychosocial trigger that causes genetically vulnerable individuals to develop schizophrenia.
Social Psychological Explanations
Sociocultural Factors:
Urbanicity:
It may be possible that the move towards urban living could account for some of the mental illness
that we observe. One key finding that is consistently demonstrated is that the rate of schizophrenia
in urban areas is much higher than in rural areas.
• Increased socioeconomic adversity and/or poverty in urban areas could contribute to a
stressful home life for families. This could lead to less than optimal family relationships, and
could increase the likelihood of high levels of expressed emotion.
• Krabbendam and Os (2005) identified factors such as the greater socioeconomic adversity for
urban dwellers as well as environmental pollution, overcrowding, drug abuse and exposure
to toxins and infectious agents. One of the most likely candidates may be the greater social
stress that occurs from living in a densely populated area.
Social Isolation:
Schizophrenics are often very socially isolated from others. Isolated from mainstream society.
Struggle to communicate with others. They may retreat and withdraw from society.
• Research has found a link between childhood isolation, poor interpersonal relationships in
childhood and early adulthood and the risk of schizophrenia. Schizophrenics tend to have
childhoods that were solitary, with few friends, and a lack of social support.
 • More prone to stress and social anxiety. No one can provide feedback about their thoughts
or behaviour. This lack of feedback allows the individual to nurture these inappropriate ways
of behaving.
• People with no social network have their thoughts unchallenged and may become resistant
to change.
• Their symptoms of schizophrenia can go unnoticed for a long time, then their thought
patterns are too ingrained and may be resistant to treatment.
• Jones et al. (1994) reported the findings of a longitudinal study of 5,362 people born in a
specific week in March 1946. Between ages 16 and 43 years, 30 cases of schizophrenia were
diagnosed. The researchers found that those individuals diagnosed with schizophrenia were
more likely to show solitary play at ages 4 and 6 years, and at 13 years were more likely to
rate themselves as less socially confident.
Ethnicity and Discrimination:
• Statistics have shown that higher than expected numbers of individuals of Afro-Caribbean
descent are diagnosed with schizophrenia. This group is also more likely to find themselves
being compulsorily admitted as opposed to voluntarily admitted to psychiatric hospitals
(Ineichen, 1984).
• This suggests a bias in the diagnosis. The higher rate may be due to discrimination and
racism. The increased stress caused by being an immigrant or ethnic minority may be the
trigger that leads to a higher incidence of the disorder.
Evaluation
Sociocultural Factors:
Urbanicity:
We cannot be sure that living in an urban environment actually increases the social stress of the
individual, as compared to living in a rural environment. In a seeming paradox, general health is
normally considered to be better in urban rather than rural areas because of easier access to
healthcare, higher employment rates and better educational levels. In addition, those living in an
urban area may experience higher levels of social capital – features of social life and environment
that enable people to act effectively with each other. McKenzie et al. (2002) proposed that higher
levels of social capital may actually protect us from stress. Therefore it is unclear exactly how the
mechanism that underlies urbanicity seems to work; it may just be social stress, or it may be a
more complex interplay of other possible environmental risk factors, such as pollution.
Which comes first?
Does living in an urban environment lead to greater risk of schizophrenia, or does having
schizophrenia mean you are more likely to live in an urban environment? The social drift hypothesis
proposes that once diagnosed with a mental disorder, like schizophrenia, individuals demonstrate a
decline in their socioeconomic status and as such may move to less salubrious areas, which tend to
be in the inner city. As such, this gives a false impression of urbanicity being a cause of disorders such
as schizophrenia whereas it may be an effect.
However, Pedersen and Mortensen (2001) reported that those individuals who had a high risk of
psychotic disorders reduced the likelihood of developing schizophrenia if they moved to a more rural
environment.
Social isolation may be cause or effect:
Social isolation may also be questioned as a cause or an effect. Os et al. (2000) claimed that single
people who lived in neighbourhoods with few other single people were at greater risk of developing
schizophrenia, arguably because this increased the individual’s isolation and loneliness. This suggests
that social isolation is a valid explanation as a cause of schizophrenia.
However one weakness in this argument is that we really cannot ascertain if the apparent social
isolation is a cause of schizophrenia or if it is just an early indicator of psychosis.
Ethnicity or discrimination may be the causal factor:
It is important to find out whether it is the ethnicity of the individual that places them at higher risk
of schizophrenia or if the manifestation of symptoms is the product of prejudice and discrimination
in psychiatric services.
On the other hand, Boydell et al. (2001) note that incidence rates of schizophrenia increased in
ethnic minorities as the proportion of ethnic minorities in the locality fell, suggesting that social
experience (isolation, discrimination, etc.) contributed to development of the illness.
Methods of Modifying Behaviour
Antipsychotic Drugs:
Conventional antipsychotics:
• First generation of antipsychotics that has been in use since the 1950s.
• Dopamine antagonist- Stops dopamine production through blocking the receptors in
synapses that absorb dopamine (D2 receptors in the mesolimbic pathway).
• Example- Chlorpromazine
• Reduces- The positive symptoms of schizophrenia e.g. hallucinations and delusions.
Atypical antipsychotics:
• Used since the 1990s. They were developed to improve the effectiveness of drugs in
suppressing the symptoms of psychosis, to improve the negative symptoms, cognitive
impairments and also to minimise side effects.
• Blocks dopamine receptors, but bind temporarily, allowing normal dopamine transmission.
Also binds to serotonin receptors (improve mood) and glutamate receptors (improve
anxiety).
• Example- Clozapine- Used in response to patients who are unresponsive or intolerant of
other antipsychotics.
• Reduces- Both positive and negative symptoms of schizophrenia. It is also successful in
reducing the rate of suicidal behaviour, in the high risk cases of schizophrenia, as cognitive
functioning is improved.
Differences:
• Some report that atypical antipsychotics are different from conventional antipsychotics
because they are received at fewer dopamine D2 receptor sites and at more D1 and D4
receptor sites.
• Another difference is that most atypical antipsychotics also antagonise (i.e. they bind to a
receptor, blocking its usual function) the serotonin receptor 5-HT2A, to the same degree as
they antagonise the dopamine D2 receptor.
• Another difference is the actual amount of time they occupy the D2 receptor sites. Seeman
(2002) reports on the 'fast-off’ theory; this proposes that atypical antipsychotics bind more
loosely to the D2 receptor sites than conventional antipsychotics. This means that, although
the blockade has a therapeutic effect, it does not last long enough to also produce the side
effects seen in conventional antipsychotics (such as tardive dyskinesia, which involves
involuntary writhing or tic-like movements of the tongue, mouth, face or whole body).
Evaluation
Effectiveness:
Effectiveness of conventional antipsychotics:
Cole et al. (1964) suggested that psychiatry could treat mental disorder in the same way that physical
disorders are treated - by using drugs. They found that 75% of those given a conventional
antipsychotic were considered to be 'much improved' compared with only 25% of those given a
placebo. In addition, they note that none of the patients given the antipsychotic were considered to
have gotten worse, in comparison to 48% of those given a placebo.
This sort of finding was revolutionary as, before the prescription of conventional antipsychotics,
schizophrenia was largely considered by many psychiatrists to be untreatable.
Comparing conventional and atypical antipsychotics:
Atypical antipsychotics are generally considered to be more effective than conventional
antipsychotics. Ravanic et al. (2009) compared the effectiveness of clozapine, chlorpromazine, and
haloperidol (another conventional antipsychotic) in 325 individuals with schizophrenia. The
researchers found that over a period of five years there were significant differences in psychometric
scores measuring schizophrenic symptoms, favouring clozapine.
They also found clozapine had fewer adverse effects (average of 0.9 adverse events per patient) than
haloperidol (2.7) and chlorpromazine (3.2).
This suggests that atypical antipsychotics are a more effective and preferable option when treating
schizophrenia.
Difficulty assessing the effectiveness of antipsychotics:
Non-compliance is a particular issue in individuals with chronic schizophrenia because many of these
individuals tend to lack the necessary 'insight into their own condition’ - they don't believe they have
a problem and therefore don't take the medication.
Rettenbacher and colleagues (2004) found full compliance in only 54.2% of individuals with
schizophrenia, partial compliance in 8.3% of individuals with schizophrenia and non-compliance in
37.5% of those with schizophrenia. This suggests that 'in the real world' antipsychotics may not be as
effective as they seem to be in the closely controlled 'clinical studies' discussed above.
Ethical Implications:
Side effects:
Both conventional and atypical antipsychotics is that they have side effects, such as tardive
dyskinesia and Parkinsonianism. There are many side effects such as Parkinsonism (tremors and
instability) and seizures, as well as tardive dyskinesia and agranulocytosis. As a result, psychiatrists
have to consider if the benefits offered to each individual are worth the potential costs of the side
effects.
Chemical straightjackets:
The antipsychiatry movement claims that antipsychotics are little more than chemical straightjackets.
Psychiatrist Szasz (1960) argued that using physical treatments for mental disorder is no more
sophisticated than believing in demonology. He suggested that the concept of mental illness was
simply a way of excluding non-conformists from society.
This highlights an important ethical dilemma. Are antipsychotics administered to alleviate suffering
or to increase compliance with institutional regimes and society in general? On the other hand, if we
offer the ‘right to refuse’ antipsychotic medication, we need to be aware of possible consequences
(e.g. harm to self or others).
Social Implications:
Asylums or care in the community:
Psychiatrist Lawrie claims that ‘Antipsychotic drugs revolutionised the care of schizophrenia,
changing it from an incurable condition which required institutionalisation to one that could be
treated in the community, with the potential for independent living and recovery’ (2011). This
emphasises the social revolution which took place with the introduction of antipsychotics – which
was beneficial both for patients because they could lead more normal lives and beneficial for society
because of the costs of lifetime hospitalisation.
Risk of violence:
Individuals with schizophrenia who do not follow their drug therapy may pose a threat to themselves
or others. Tiihonen et al. (2006) noted a 37-fold increase in suicide in patients who stopped taking
their medication. The NCISH (2015) report that 346 homicides had been committed in England by
people with a history of schizophrenia between 2003 and 2013 (6% of the total homicide rate); they
also reported 29% of these individuals had been non-adherent with drug treatment in the month
before the homicide.
Methods of Modifying Behaviour
Cognitive Behavioural Therapy:
Irrational thinking:
The purpose of CBT is to help an individual consider and organise their disordered thoughts in a
rational way. CBT helps to make the client aware of the connections between their disordered
thinking and their illness.
These techniques primarily help to deal with positive symptoms of schizophrenia, such as
hallucinations and delusions, but they are also effective in making the client more self-reliant when
dealing with their illness because they have the task of challenging their own perceptions.
Key components:
• CBT usually takes place weekly or fortnightly for between 5 and 20 sessions.
• Patients are encouraged to trace back the origins of their symptoms in order to gain insight
into the way in which they may have developed. Offering psychological explanations may
help reduce the stress and anxiety that can go along with the illness.
• Smith (2003) identified the key components of using CBT for schizophrenia.
Engagement strategies:
Preliminary sessions are used to provide the opportunity to talk at length about potential worries
and any symptoms that are of particular concern to the client. This is especially important as clients
may have had negative experiences with previous therapists or others from psychiatric services or
the client may be experiencing elevated levels of paranoia as a result of their illness. The therapist
and the client will discuss any natural coping strategies the client is using to manage their symptoms:
this allows the client to appreciate their rate as an expert in their own symptoms.
Psychoeducation:
They must first develop an understanding of their illness. The schizophrenic learns about the
characteristics of their illness and to learn that their behaviour is a symptom of the illness and can be
managed. This decatastrophises and normalises the symptoms such as delusions and hallucinations.
Once this understanding has been gained, the therapist and patient will then investigate the specific
symptoms of the patient themselves, identifying the context of their symptoms, and their possible
psychosis "trigger" factors.
Cognitive strategies:
• Dysfunctional thought diary
• Behavioural Experiments
Behavioural skills training:
The behavioural aspects of CBT aim to give the patient behavioural strategies that can help them
cope both with the symptoms, and the negative secondary symptoms such as anxiety or depression.
These strategies include relaxation, distraction and problem solving.
Relapse prevention strategies:
The therapist and patient work together to create a checklist of warning signs that might signal a
relapse of the illness, as well as identifying situations or triggers that might make relapse more likely.
They use this to develop a plan that could be employed when relapse seems likely. This involves the
inclusion of the social network of the schizophrenic, such as friends and family who need to know
what kind of support can be offered during these periods to help.
Evaluation
Effectiveness:
An effective form of treatment:
Sixty individuals with schizophrenia who each had a 'positive and distressing symptom that was
medication resistant' were randomly allocated to either a CBT plus standard care condition or a
standard care only condition (Kuipers et al. (1997)). After nine months of therapy, the researchers
found that:
• In the CBT plus standard care condition, 50% of the participants were considered to have
improved with only one individual becoming worse.
• In the standard care-only condition, 31% were considered to have improved with three
people becoming worse and another committing suicide.
This research suggests that although the improvements offered by CBT plus standard care may only
seem marginal (only 50% benefitted), it is significantly better than standard care only.
Contradictory evidence:
Not all research has suggested that CBT is effective in treating schizophrenia. Jauhar et al. (2014)
reported only a 'small therapeutic effect' from using CBT with clients with schizophrenia.
However a month later, Morrison et al. (2014) reported that CBT significantly reduced psychiatric
symptoms in individuals with schizophrenia.
Short-term effectiveness:
The effectiveness of CBT in treating schizophrenia seems to be limited to studies that have only
investigated short-term programmes.
Research which has investigated the longer-term effectiveness of CBT has not been as positive.
Tarrier et al. (2004) studied individuals who either received CBT shortly after diagnosis or received
standard care. Eighteen months later the CBT group had the same relapse rate as clients who had
just standard care. This suggests that the effects of CBT were short-lived.
However Tarrier et al noted that the individuals in the CBT condition seemed to be less negatively
affected by their symptoms than those who hadn't had CBT. This suggests that there were long-term
benefits, but this obviously depends on how such benefits are assessed.
Ethical Implications:
Potentially a negative experience for clients:
Kuipers et al. (1997) reported that clients were generally satisfied with their experience of CBT and
that they thought it was an appropriate way to deal with their problems. Reviewing the suitability of
a therapy from the client's perspective is undoubtedly an important aspect in assessing the value of
such therapy, especially its ethical impact.
Some psychiatrists may limit access to CBT:
Some of those working in psychiatric services may not feel that CBT is a viable option for many
people suffering from schizophrenia. This decision may be based on the fact that the client does not
accept or believe that their diagnosis of schizophrenia is accurate, or the therapist may not believe
the client would not be able to engage with CBT, or that the individual is doing well with just
antipsychotic medication.
In fact, Kingdon and Kirschen, 2006 reported that of the 142 individuals who had been diagnosed
with schizophrenia in a specified time frame, only 49% of these had been referred for CBT.
This poses a very particular ethical issue: psychiatric prejudice may be limiting the access to CBT in
individuals who could benefit from it.
Social Implications:
Is CBT being offered to everyone?
In the recent National Audit of Schizophrenia conducted by the Royal College of Psychiatrists (2014),
there were significant variations in the amount of people with schizophrenia who were being offered
and taking up CBT in the various Trusts. The audit claimed that in the different trusts, the number of
people being offered CBT for schizophrenia ranged from 67% to only 14%, with an average of 50% of
people reporting that their trust had not offered them CBT.
CBT is cost effective:
Kuipers et al. (1998) analysed the economic impact of offering CBT to individuals with schizophrenia
in addition to using antipsychotic medication. The researchers reported that the costs involved in
delivering CBT were likely to be offset by the reduced utilisation of service costs in the future. This
suggests that, although the use of CBT may initially be more costly, in the longer term those costs are
likely to recouped because individuals with schizophrenia are less likely to need emergency
psychiatric services. This is a benefit to all because money is saved for other health treatments.