Schizophrenia

Psychological Explanations of Schizophrenia

Family Dysfunction

Family dysfunction is considered a sociocultural theory, focusing on the psychological environment’s role in contributing to the development of schizophrenia. This explanation posits that maladaptive relationships and poor communication patterns within families act as significant environmental stressors. 

• Double-bind Theory (Bateson et al.): This theory suggests that receiving contradictory messages from parents leaves children unable to process their social environment effectively. For example, if a mother tells her child she loves him, but recoils in disgust when he hugs her, the child receives mixed signals that are impossible to reconcile. Such contradictory communication and the conditional withdrawal of love lead to the child’s inability to develop a coherent sense of reality, potentially resulting in positive symptoms like disorganised thinking or paranoid delusions and negative symptoms like social withdrawal and flat affect.

• Expressed Emotion: This concept is primarily used to explain the high likelihood of relapse when individuals with schizophrenia leave a hospital and return to their family environment. Families high in expressed emotion, characterised by overt criticism, hostility, and emotional over-involvement, create a stressful environment that can precipitate a relapse. For example, a family member staying home to prevent loneliness rather than engaging in social activities can exacerbate the recovering individual’s guilt and stress, potentially leading to relapse.

Analysis of Family Dysfunction

Positive Evidence:

• Supportive Studies: Berger found that individuals with schizophrenia recalled more double-bind statements from their parents compared to those without the disorder. Wynne & Singer found that families with a schizophrenic member scored higher on communication deviance, indicating a confusing and contradictory communication style. Kavanagh reviewed 26 studies and found a 48% relapse rate in individuals returning to high expressed emotion homes versus 21% in low expressed emotion homes.

Negative Evidence:

• Weak and Subjective Evidence: The evidence supporting the role of family dysfunction, including studies on double-bind theory and expressed emotion, often relies on subjective observations or retrospective self-reports from individuals already diagnosed with schizophrenia, which can be biased by their symptoms.
• Causality Issues: Observations of expressed emotion are typically made after a diagnosis, making it difficult to determine whether these family dynamics are a cause or a consequence of dealing with schizophrenia.

Cognitive Explanations

Cognitive explanations focus on maladaptive information processing (IMP) in the development of schizophrenia. 

• Beck & Rector acknowledge the role of biological factors such as brain abnormalities, which make individuals more vulnerable to stressful life events, leading to dysfunctional beliefs.
• Frith et al. introduced the concepts of ‘metarepresentation’ and ‘central control’ to explain dysfunctional thought processes:
• Metarepresentation allows individuals to reflect on their intentions and understand that others may have different intentions. Deficits in this area can lead to positive symptoms of schizophrenia, as individuals struggle to recognise their actions as their own, experiencing them as controlled by external ‘alien’ forces.
• Central Control refers to the cognitive ability to suppress automatic responses while focusing on deliberate actions. Frith suggested that impairments in central control explain why individuals with schizophrenia experience derailment in their thoughts and speech, as they cannot suppress automatic responses to external stimuli effectively.

Analysis of Cognitive Explanations

Evidence for Cognitive Differences:

• Empirical Support: Shin et al. found that individuals with schizophrenia performed worse on tasks requiring facial perception. Ekman & Friesen noted that these individuals were also worse at recognising emotional expressions, contributing to social dysfunction. Stirling et al. observed that individuals with schizophrenia took twice as long to complete the Stroop test, which requires suppressing an impulsive response.

Comparative Analysis:

• Comparison with Family Dysfunction: There is significant evidence suggesting that cognitive processing in individuals with schizophrenia differs markedly from those without the disorder. However, the evidence for family dysfunction, particularly theories involving expressed emotion and double-bind situations, provides a more comprehensive explanation of how environmental factors interact with individual vulnerabilities to influence the onset and course of schizophrenia.

Psychological Therapies

Family Therapy

Family therapy, based on the psychodynamic approach, posits that family dysfunction is a significant stressor that can trigger the onset of schizophrenia. This therapy involves working with the patient and their closest relatives to modify family dynamics that contribute to stress.

Stages of Family Therapy:

1. Psychoeducation: Relatives are educated about schizophrenia and its symptoms, which helps reduce their frustration and increases empathy towards the patient. Pharoah et al. highlighted that understanding the irrational behaviours associated with schizophrenia can reduce anger and guilt among family members.
2. Social Support: Therapy sessions facilitate open discussions to mediate stressful interactions, reducing expressed emotion and potentially improving adherence to medication regimes. Awareness of external support networks is also emphasised.
3. Improving Communication and Problem-Solving Skills: Families are trained in healthier communication methods, which can involve the entire family or just specific members, enhancing the overall family dynamics and reducing relapse rates.

Analysis of Family Therapy

Positive Evidence:

• Meta-Analyses Support: Pilling et al. conducted a meta-analysis including 18 studies of family therapy involving 1467 patients, which showed reduced relapse rates and improved medication adherence among those undergoing family therapy compared to those who did not.

Negative Evidence:

• Limitations in Non-Hospital Settings: While family therapy is effective in reducing relapse rates and improving family dynamics, its effectiveness outside hospital settings is less certain. Critics like Lehman et al. have noted that the benefits of family therapy may not extend into the community, as family-induced stressors often re-emerge once the structured therapy ends.

Cognitive Behavioral Therapy (CBT)

CBT for schizophrenia focuses on identifying and changing dysfunctional thought processes and is usually implemented after the initiation of drug therapy.

• Methodology: The therapy involves breaking down negative thought patterns into manageable parts and identifying triggers for these thoughts. Collaboratively, therapists and patients work through these triggers using techniques like Ellis’ ABC model to challenge and reframe dysfunctional beliefs.

Analysis of CBT

Positive Evidence:

• Controlled Trials: Morrison et al. conducted a randomised, single-blind study of 74 patients who refused drug therapy, finding that those who received CBT in addition to standard care showed significantly better clinical outcomes at 9 and 18 months compared to those who received standard care alone.

Negative Evidence:

• Combination with Drug Therapy: Research suggests that CBT is most effective when combined with drug therapy. Studies like those by Terrier et al. have shown that combining CBT with medications leads to significant reductions in psychotic symptoms, supporting an interactionist approach that utilises both psychological and pharmacological interventions.

Token Economy for Managing Schizophrenia

Token economy systems use principles of behavioural psychology, specifically operant conditioning, to manage schizophrenia, particularly in institutional settings.

• Mechanics of Token Economy: This approach involves rewarding desirable behaviours with tokens, which act as secondary reinforcers. These tokens can be exchanged for primary reinforcers such as snacks, extra recreational time, or other privileges. The use of tokens helps to modify behaviours, such as encouraging patients to get dressed instead of staying in pyjamas all day, which are often developed due to long-term institutionalisation.
• Rationale: Tokens are preferred over immediate rewards because they help mitigate ‘delay discounting’, where the value of a reward decreases if it is not immediate. Over time, the tokens themselves become valuable to the patients, reinforcing the desired behaviour.

Analysis of Token Economy

Positive Evidence:

• Effectiveness in Institutional Settings: Studies like those conducted by Ayllon & Azrin have shown significant improvements in a wide range of behaviours within just 20 days of implementing a token economy system. Lehman et al. also advocate for token economies as an effective means of modifying behaviour in institutionalised settings.

Negative Evidence:

• Limitations Outside Hospital Settings: Lehman et al. acknowledge that the benefits of a token economy often do not translate well to community settings. Once patients leave the structured environment where tokens are a motivator, the previously modified behaviours may not persist.
• Ethical Concerns: Token economies can create disparities among patients, as those with less severe symptoms are often better able to perform the rewarded behaviours. This disparity can lead to additional discrimination against more severely affected patients, who may find it more challenging to earn rewards.

Drug Therapy: Typical and Atypical Antipsychotics

Drug therapy does not cure schizophrenia but can significantly reduce symptoms, allowing individuals to function more normally. 

• Typical Antipsychotics (e.g., Chlorpromazine): Initially developed for allergies, these drugs were found to have calming effects and were repurposed for schizophrenia treatment. They work as dopamine antagonists, blocking dopamine receptors and reducing symptoms such as hallucinations. However, they require high doses due to their low potency.

• Atypical Antipsychotics (e.g., Clozapine): These drugs bind to dopamine receptors less intensely than typical antipsychotics but also affect serotonin and glutamate receptors, which can improve mood and cognitive function and reduce depression. They are especially used in cases resistant to typical antipsychotics but can have severe side effects, including potentially fatal conditions.

Analysis of Drug Therapy

Positive Evidence:

• Effectiveness of Antipsychotics: Research such as that by Thornley et al., who reviewed 13 trials, found chlorpromazine to be associated with better functioning and reduced symptoms compared to placebos. Atypical antipsychotics have been shown to be effective in 30-50% of cases resistant to typical antipsychotics.

Negative Evidence:

• Side Effects: The use of antipsychotics can lead to severe side effects, such as tardive dyskinesia and significant weight gain, which can detract from the quality of life and reduce compliance with medication regimens.

Interactionist Approach: Diathesis-Stress Model

The interactionist approach in schizophrenia combines biological, psychological, and social factors. The diathesis-stress model posits that schizophrenia results from a genetic vulnerability (diathesis) triggered by environmental stressors.

• Evolution of the Model: The original model by Meehl suggested a single ‘schizogene’ that made individuals more sensitive to stress. However, current understanding acknowledges that schizophrenia is polygenic, involving multiple genes that may contribute to neural abnormalities.

• Stress Triggers: Long-term stress can lead to the release of cortisol, which may trigger the onset of schizophrenia. This model supports using a combination of therapies (antipsychotics and CBT) to treat schizophrenia effectively, as antipsychotics can reduce disordered thinking, making psychological therapies more effective.

Analysis of the Diathesis-Stress Model

Positive Evidence:

• Support for Genetic and Environmental Factors: Studies like that by Tienari et al. have shown that children adopted from mothers with schizophrenia are more likely to develop the disorder if placed in a high-stress family environment, indicating the need for both genetic susceptibility and environmental stress for schizophrenia to develop.

Negative Evidence:

• Simplification of Causative Factors: The model has been criticised for oversimplifying the causative factors of schizophrenia. Not all triggers are psychological; for example, substance use such as cannabis can also precipitate schizophrenia in vulnerable individuals. Furthermore, environmental factors like childhood trauma may act as both a diathesis and a stressor, complicating the model further.