Welcome to Clinical Psychology: Understanding Schizophrenia (9990)

Hello! This chapter focuses on Schizophrenia, a complex and often misunderstood mental condition. As clinical psychologists, our job is to understand how these disorders are diagnosed, what might cause them, and how they can be treated effectively.

Schizophrenia is classified as a psychotic disorder, meaning the individual often loses touch with reality. Don't worry if the terminology seems heavy; we will break down the criteria, the competing explanations, and the key research step-by-step!

Quick Review: What is Clinical Psychology?

Clinical Psychology is the specialist option that deals with the diagnosis, explanation, and treatment/management of mental and behavioural disorders (conditions). Schizophrenia is a prime example of a severe mental disorder studied in this field.

1.1.1 Diagnostic Criteria for Schizophrenia (ICD-11)

Psychologists and psychiatrists use standardized classification systems to ensure consistent diagnosis across the world. The syllabus specifies the use of the ICD-11 (International Classification of Diseases, 11th Edition) criteria.

Identifying the Symptoms: Positive and Negative

Schizophrenia symptoms are typically grouped into two main categories:

1. Positive Symptoms: These are additions to a person’s normal mental life. Think of them as things that are "added" on, which should not be there.

  • Delusions: False beliefs that are firmly held despite clear evidence to the contrary.
    • Example: A person might believe they are Jesus (delusions of grandeur) or that the FBI is tracking them through their television (persecutory delusions/ideation).
  • Hallucinations: Sensory experiences that seem real but are created by the mind. The most common type is auditory (hearing voices).
  • Disorganised Speech/Thinking: Switching topics rapidly, making up words, or speaking in a way that is illogical (often called "word salad").

2. Negative Symptoms: These are deficits, meaning normal abilities are "taken away" or reduced.

  • Alogia (Poverty of Speech): A reduction in the amount and quality of speech.
  • Avolition: A reduction, or complete lack, of motivation and goal-directed behaviour (e.g., inability to start or finish tasks).
  • Affective Flattening (Blunted Affect): A reduction in the range and intensity of emotional expression (e.g., having a 'flat' facial expression or monotonic voice).

Did you know? Diagnosis requires the presence of certain key symptoms (often positive ones like delusions or hallucinations) for a significant period (typically one month or more), coupled with impaired functioning.

Key Study: Freeman et al. (2003) - Virtual Reality and Persecutory Ideation

This study investigates a specific positive symptom: delusions of persecution (or persecutory ideation). This is the belief that others are trying to harm, monitor, or conspire against the individual.

Context and Aim:

The aim was to use Virtual Reality (VR) technology to investigate how paranoia develops and how severe it is, specifically focusing on non-clinical samples that score high on paranoia questionnaires. VR allows researchers to safely expose participants to environments that might trigger persecutory thoughts (e.g., a virtual bus or shop).

Design and Procedure:

  • Method: Experimental design using VR technology.
  • Participants: Non-clinical volunteers who scored either high or low on measures of paranoia.
  • Procedure: Participants were immersed in a virtual environment (e.g., an underground train journey). They were asked to interact with virtual characters (avatars) and then complete questionnaires assessing their persecutory ideation (e.g., "Was anyone looking at you suspiciously?") and anxiety levels.

Results and Conclusions:

  • Participants who scored higher on real-world paranoia measures showed higher levels of persecutory ideation and experienced greater anxiety in the VR environment.
  • The conclusion was that VR is a valid tool for investigating persecutory ideation and that paranoid thoughts occur even in safe, neutral virtual environments for those prone to paranoia.

Key Takeaway for Diagnosis:

VR technology offers an objective way to measure subjective experiences like paranoia, providing strong evidence for individual differences in how people interpret neutral social situations.

1.1.2 Explanations of Schizophrenia

Why does schizophrenia occur? Explanations fall into two main categories: biological and psychological (cognitive).

A. Biological Explanations (Nature & Reductionism)

Genetic Explanation

The fact that schizophrenia often runs in families strongly suggests a genetic component.

  • If you have an identical twin with schizophrenia, your risk is about 48%.
  • If you have a sibling, the risk is about 9%.

This explanation is reductionist because it reduces the complex disorder down to inherited factors (DNA) and ignores environmental influences.

Biochemical Explanation: The Dopamine Hypothesis

This is the most famous biological theory. It focuses on the neurotransmitter Dopamine, which is crucial for attention, pleasure, and movement.

  • The Hypothesis: Schizophrenia is caused by an excessive amount of dopamine activity in certain areas of the brain.
  • Evidence:
    • Drugs that increase dopamine levels (like amphetamines) can induce positive symptoms (hallucinations, delusions) in healthy people.
    • Antipsychotic drugs (the treatment) work by blocking dopamine receptors, which reduces the severity of positive symptoms.

Analogy: Think of dopamine like the fuel pedal in a car. In Schizophrenia, the pedal is pushed down too hard, leading to overwhelming thoughts and sensory overload.

B. Psychological Explanation (Cognitive)

The cognitive approach focuses on the faulty mental processes (thinking errors) that characterise the disorder.

  • Faulty Filtering: Individuals with schizophrenia may have difficulty filtering out irrelevant stimuli (sights, sounds, thoughts). This leads to sensory overload.
  • Misattribution: Because of this overload, they try to make sense of the incoming information by forming incorrect beliefs (delusions).
    • Example: A person hears their own internal thoughts but attributes them to an external source, leading to the hallucination of hearing voices.
    • They might see a neutral expression on a stranger’s face but misinterpret it as hostile, reinforcing their persecutory delusions.

Key Takeaway for Explanations:

Biological explanations (Dopamine/Genetic) are often reductionist and support determinism (the cause is unavoidable). Cognitive explanations (Faulty Filtering) support a more holistic view, seeing the illness as an interpretation problem that can potentially be corrected (linking to CBT).

1.1.3 Treatment and Management of Schizophrenia

Treatment for schizophrenia is usually a combination of biological and psychological approaches.

A. Biological Treatments

1. Antipsychotic Medication (Biochemical)

These medications primarily work by altering the levels of neurotransmitters, especially dopamine.

  • Typical (First Generation) Antipsychotics: E.g., Chlorpromazine.
    • Action: They block the D2 dopamine receptors in the brain.
    • Effectiveness: Highly effective against positive symptoms (delusions, hallucinations).
    • Side Effects: Often severe, including movement disorders like tardive dyskinesia (involuntary movements, e.g., facial twitching).
  • Atypical (Second Generation) Antipsychotics: E.g., Clozapine, Risperidone.
    • Action: They also target dopamine receptors but generally have a milder effect and also block serotonin receptors.
    • Effectiveness: Effective against both positive and negative symptoms.
    • Side Effects: Fewer severe motor side effects, but still significant (e.g., weight gain, risk of agranulocytosis).
2. Electro-Convulsive Therapy (ECT)

A medical procedure where electrical currents are passed through the brain to deliberately trigger a brief seizure.

  • Use: Not a primary treatment for schizophrenia. It is typically reserved for severe cases, especially those with catatonia (extreme lack of movement or responsiveness) or when medication has failed entirely.

B. Psychological Therapy

Cognitive-Behavioural Therapy (CBT)

CBT helps patients manage their symptoms by challenging and changing their maladaptive thoughts and behaviours.

  • The Goal: Not to cure the schizophrenia, but to make symptoms less stressful and overwhelming.
  • How it works:
    • 1. Assessment: Patient identifies distressing symptoms (e.g., "The voices are telling me I am evil").
    • 2. Belief Challenge: The therapist challenges the reality of the symptom (e.g., testing the voice's power or origin).
    • 3. Coping Strategy Development: Patients learn techniques like distraction or relaxation to cope with persistent symptoms, enabling them to return to everyday life.

Example Study: Sensky et al. (2000) - Evaluating CBT for Treatment-Resistant Schizophrenia

This study investigates the effectiveness of CBT for patients whose schizophrenia symptoms had not improved despite having taken medication for years (treatment-resistant).

Aim: To compare the effectiveness of CBT versus a non-specific control intervention (befriending) in patients with treatment-resistant schizophrenia.

Procedure:

  • 16 patients resistant to medication were randomly allocated to either the CBT group or the befriending control group.
  • All participants received 19 sessions over 9 months.
  • Symptoms were assessed using standardized scales at the end of treatment and at a 9-month follow-up.

Results:

  • Initially, both groups showed improvement (possibly due to the human contact in the befriending group).
  • However, at the 9-month follow-up, the patients who received CBT continued to improve, while the befriending group showed a slight relapse.

Conclusion:

CBT is an effective treatment for even treatment-resistant schizophrenia and provides longer-lasting benefits than supportive, non-specific treatments, suggesting that changing cognitive patterns is key to sustained management.

Key Takeaway for Treatment:

While biological treatments (drugs) are essential for managing the acute phase, psychological treatments (CBT) are crucial for long-term management and quality of life.

Issues and Debates in Schizophrenia

When discussing Schizophrenia, you must be ready to apply the following A-Level debates:

1. Nature versus Nurture (Explanations)
  • Nature (Biological): The strong evidence for genetics and the role of dopamine supports the idea that schizophrenia is predetermined by biology.
  • Nurture (Situational/Cognitive): Psychological theories suggest that environmental factors (stressors, poor coping, faulty thinking) play a role in developing or managing the symptoms.
2. Reductionism versus Holism (Explanations/Treatments)
  • Reductionism: The Dopamine Hypothesis is highly reductionist, reducing a complex experience (like hearing voices) to a chemical imbalance (too much dopamine).
  • Holism: The use of CBT combined with medication (often called the diathesis-stress model approach) is more holistic, considering both biological vulnerability and environmental/cognitive factors.
3. Determinism versus Free-Will (Treatments)
  • Determinism: Biological explanations imply biological determinism—if the cause is genetics or chemistry, the person has no control. Biological treatments (drugs) are determined by chemical needs.
  • Free-Will: Psychological treatments like CBT rely on the patient exercising free-will and motivation to challenge their thoughts and practice new coping strategies.
4. Idiographic versus Nomothetic (Diagnosis/Research)
  • Nomothetic: The use of ICD-11 criteria and standard assessment tools (like symptom checklists) is nomothetic—aiming to create general laws for diagnosis.
  • Idiographic: Using a detailed case study of a patient with schizophrenia (as required by the syllabus content) provides deep, unique information, which is an idiographic approach.