Psychological explanations of schizophrenia

Psychological theories
Psychodynamic
Freud (1924) believed that schizophrenia was the result of two related processes, regression to a preego state and attempts to re-establish ego control. If the world of the schizophrenic has been particularly harsh, for example if his or her parents were cold and uncaring, an individual may regress to this early stage in their development before the ego properly formed and before he or she had developed a realistic awareness of the external world. Schizophrenia was thus seen by Freud as an infantile state, with some symptoms (e.g. delusions and grandeur) reflecting this primitive condition, and other symptoms (e.g. auditory hallucinations) reflecting the persons attempts to re-establish ego control.

Cognitive
This explanation of schizophrenia acknowledges the role of biological factors in causing the initial sensory experiences of schizophrenia, but claims that further features of the disorder appear as individuals attempt to understand those experiences. When schizophrenics first experience voices and other worrying sensory experiences, they turn to others to confirm the validity of what they are experiencing. Other people fail to confirm the reality of these experiences, so the schizophrenic comes to believe that others must be hiding the truth. They begin to reject feedback from those around them and develop delusional beliefs that they are being manipulated and persecuted by others.

Socio-cultural factors
Life events and schizophrenia
A major stress factor that has been associated with a higher risk of schizophrenic episodes is the occurrence of stressful life events. These are discrete stresses, such as the death of a close relative to the break-up of a relationship. A study by Brown and Birley (1968) found that, prior to a schizophrenic episode; patients who had previously experienced schizophrenia reported twice as many stressful life events compared to a health control group.

Family Relationships
Double-bind theory Bateson et al. (1956) suggest that children who frequently receive contradictory messages from their parents are more likely to develop schizophrenia. For example, if a mother tells her son that she loves him while turning her head away in disgust; the child receives two conflicting messages about their relationship on different communicative levels, one of affection on the vernal level, and one of animosity on the non-verbal level. The childs ability to respond to the mothers incapacitated by such contradictions because one message invalidates the other. These interactions prevent the development of an internally coherent construction of reality, and in the long run, this manifests itself as schizophrenic symptoms (e.g. flattened affect and withdrawal). These ideas were echoed in the work of psychiatrist R.D. Laing, who argues that what we call schizophrenia is actually a reasonable response to an insane world.

Expressed emotion Another family variable associated with schizophrenia is a negative emotional climate, or more specifically, a high degree of expressed emotions. Expressed emotion (EE) is a family communication style that involves criticism, hostility and emotional over-involvement. High levels of EE are most likely to influence a relapse rates. A patient returning to a family with high EE is

about four times more likely to relapse than a patient returning to a family with low EE (Linszen et al., 1997). In a study of the relapse rates among schizophrenics In Iran, Kalafi and Torabi (1996) found that the high prevalence of EE in Iranian culture (overprotective mothers and rejective fathers) was one of the main causes of schizophrenic relapses. It appears that the negative emotional climate in these families arouses the patient and leads to stress beyond his or her already impaired coping mechanisms, thus triggering a schizophrenic episode.

Labelling theory
The labelling theory of schizophrenia, popularised by Scheff (1999), states that social groups construct rules for members of their group to follow. The symptoms of schizophrenia (e.g. hallucinations and delusions, and bizarre behaviour) are seen as deviant from the rules we ascribe to normal experience. If a person displays these unusual forms of behaviour, they are considered deviant, and the label of schizophrenic may be applied. Once this diagnostic label is applied it becomes a self-fulfilling prophecy that promotes the development of other symptoms of schizophrenia (Comer, 2003)

Retrospective studies Brown and Birley (1968) reported that life events play an important role in
precipitating episodes of schizophrenia. They found that about 50% of people experience stressful life events in the 3 weeks prior to a schizophrenic episode, while only 12% reported one in the weeks prior to that. A control sample reported a low and unchanging level of stressful life events over the same period, suggesting that it was the life events that triggered the relapse.

Prospective studies- unlike retrospective studies, which study events in the past, prospective studies monitor
the presence or absence of stressful life events prospectively (i.e. in the future). Hirsch et al. (1996) followed 71 schizophrenic patients over a 48 week period. it was clear that life events made a significant cumulative contribution in the 12 months preceding relapse rather than having a more concentrated effect in the period just prior to the schizophrenic episode (as suggested by the retrospective studies).

Commentary
Psychotherapeutic explanations
There is no research evidence to support Freuds specific ideas concerning schizophrenia, except that subsequent psychoanalysis have claimed, like him, that disordered family patterns are the cause of this disorder. For example, Fromm-Reichmann (1948) described schizophrenegenic mothers or families who are rejecting, overprotective, dominant and moralistic, as important contributory influences in the development of schizophrenia. Studies have shown that parents of schizophrenic patients do behave differently from parents of other kinds of patients, particularly in the presence of disturbed offspring (Oltmanns et al., 1999) but this is as likely to be a consequence of their childrens problems as a cause.

Cognitive explanations
There is much evidence of a physical basis for the cognitive deficits associated with schizophrenia, for example, research by Meyer-Lindenberg et al. (2002), which found a link between excess dopamine in the prefrontal cortex, and working memory. The suggestion that madness is a consequence of disbelieving others receives curious support from a recent suggestion for treatment. Yollowlees et al. (2002) have developed a machine that produces virtual hallucinations, such as hearing the TV tell you to kill yourself, or one persons face morphing into another. The intention is to show schizophrenics that their hallucinations are not real. As yet there is no evidence that this will provide a successful treatment.

Life events and schizophrenia

Not all evidence supports the role of life events. For example, van Os et al. (1994) reported no link between life events and the onset of schizophrenia. Patients were not more likely to have had a major stressful life event in the 3 months preceding the onset of their illness. In a prospective part of the

study, those patients who had experienced a major life event went on to have a lower likelihood of relapse. Evidence that does suggest a link between life events and the onset of schizophrenia is only correlational. It could be that the beginnings of the disorder (e.g. erratic behaviour) were the cause of the major life events. Furthermore, life events after the onset of the disorder (e.g. losing ones job, divorce) may be a consequence rather than a cause of mental illness.

Family relationships
The importance of family relationships in the development of schizophrenia can be seen in an adoption study by Tienari et al. (1994). In this study those adopted children who had schizophrenic biological parents were more likely to become ill themselves than those children with non-schizophrenic biological parents. However, this difference only emerged in situations where the adopted family was rated as disturbed. In other words the illness only manifested itself under appropriate environmental conditions. Genetic vulnerability alone was not sufficient.

Double-bind theory
There is some evidence to support this particular account of how family relationships may lead to schizophrenia. Berger (1965) found that schizophrenics reported a higher recall of double-bind statements by their mothers than non-schizophrenics. However, this evidence may not be reliable, as patients recall may be affected by their schizophrenia. Liem (1974) measured patterns of parental communication in families with a schizophrenic child and found no difference compared to normal families. Hall and Levin (1980) analysed data from various previous studies and found no difference between families with and without a schizophrenic member in the degree to which verbal and non-verbal communication were in agreement.

Expressed emotion
The effects of expressed emotion have received much more universal empirical support than doublebind theory. However, there is the issue of whether EE is a cause or an effect of schizophrenia. Either way it has led to an effective form of therapy where high EE relatives are shown how to reduce levels of expressed emotion. Hogarty et al. (1991) found that such therapy can significantly reduce relapse rates. However, with all therapies, it is not clear whether the EE intervention was the key element of the therapy or whether other aspects of family intervention may have helped.

Expressed emotion and culture Although findings on expressed emotion have been replicated crossculturally, expressed emotion is much less common in families of people with schizophrenia outside the west (Jenkins and Karno, 1992). One possible explanation for this is that non-western cultures are less individualist and less committed to concepts of personal responsibility than western societies such as the US and UK. Thus, they are less likely to blame someone with schizophrenia for their actions.

Labelling theory
In a review of the evidence, Scheff (1974) evaluated 18 studies explicitly related to labelling theory. He judged 13 to be consistent with the theory and 5 to be inconsistent, thus concluding that the theory was supported by the evidence. A study which he assessed as supporting labelling theory was the Rosenhan study. Rosenhan found that once the label of schizophrenia had been applied, the diagnosis continued to influence the behaviour of staff toward the patient, even when it was no longer warranted.

Psychological therapies for schizophrenia

Cognitive behavioural therapy
The basic assumption of CBT is that people often have distorted beliefs, which influence their behaviour in maladaptive ways. For example, someone with schizophrenia may believe that their behaviour is being controlled by someone or something else. Delusions are thought to result from faulty interpretations of events, and cognitive therapy is used to help the patient to identify and correct these.

CBT techniques
In CBT, patients are encouraged to trace back the origins of their symptoms in order to get a better idea of how the symptoms might have developed. They are also encouraged to evaluate the content of their delusions or of any internal voices they hear, and to consider ways in which they might test the validity of their faulty beliefs. Patients might also be set behavioural assignments with the aim of improving their general level of functioning. The learning of maladaptive responses to lifes problems is often the result of distorted thinking by the schizophrenic, or mistakes in assessing cause and effect (for example assuming that something terrible has happened because they wished it). During CBT the therapist lets the patient develop their own alternatives to these previous maladaptive beliefs, ideally by looking for alternative explanations and coping strategies that are already present in the patients mind. Outcome studies measure how well a patient does after a particular treatment, compared with the accepted form of treatment for that condition. Outcome studies of CBT suggest that patients who receive cognitive therapy experience fewer hallucinations and delusions and recover their functioning to a greater extent than those who receive antipsychotic medication alone. Drury et al. (1996) found benefits in terms of reduction of positive symptoms and a 25-50% reduction in recovery time for patients given a combination of antipsychotic medication and CBT. A subsequent study by Kuipers et al. (1997) confirmed these advantages, but also noted that there were lower patient drop-out rates and greater patient satisfaction when CBT was used in addition to antipsychotic medication.

Outcome studies

Effectiveness of CBT
Supporting research Research has tended to show that CBT has a significant effect on improving the
symptoms of patients with schizophrenia. For example Gould et al. found hat all seven studies in their metaanalysis reported a statistically significant decrease in the positive symptoms of schizophrenia after treatment.

How much is due to the effects of CBT alone? Most studies of the effectiveness of CBT have been
conducted with patients treated at the same time with antipsychotic medication. It has been difficult, therefore to assess the effectiveness of CBT independent of antipsychotic medication.

Appropriateness of CBT
Negative symptoms CBT for schizophrenia works by trying to generate less disturbing explanations for
psychotic experiences, rather than trying to eliminate them completely. Negative symptoms may well serve a useful function for the person and so can be understood as safety behaviours. For example, within a psychiatric setting, the strong expression of emotions might lead to increases in medication or hospital admission. Similarly, inactivity withdrawal might be seen as a way of avoiding making positive symptoms worse. CBT, therefore, offers some hope of alleviating these maladaptive thought processes.

Who benefits? The use of CBT in conjunction with medications seems to have benefits, but it is commonly
believed within psychiatry than not everyone with schizophrenia may benefit from CBT. For example, in a study of 142 schizophrenic patients in Hampshire, Kingdon and Kirschen (2006) found that many patients were not deemed suitable for CBT because psychiatrists believed they would not fully engage with the therapy. In particular they found that older people were deemed less suitable than younger patients.

Psychodynamic therapy: Psychoanalysis

Psychoanalytic therapy is based in the assumption that individuals are often unaware of the influence of unconscious conflicts on their current psychological state. The ain of psychoanalysis is to help bring these conflicts into the conscious mind where they can be dealt with. The psychoanalytical approach to schizophrenia assumes that all the symptoms are meaningful and are a product of the life history of the individual patient.

Psychodynamic techniques
The therapist attempts to create an alliance with the patient by offering real help with what the patient perceives as the problem. The more severe the disorder for the individual patient, the more support the therapist must provide. In the early part of the twentieth century, Freud believed that schizophrenics could not be analysed because they couldnt form a transference with the analyst. Transference refers to the process by which emotions that are originally associated with one person (such as a parent) are unconsciously shifted onto the analyst. In the wake of Freuds pessimistic assessment of the value of psychoanalysis in the treatment of schizophrenia, only a handful of therapists specialised in this technique, or variations of it. However, other forms of psychodynamic therapy have sometimes been found successful in treating schizophrenia. These have in common with Freudian psychoanalysis the belief that the first task of any psychodynamic therapy is to win the trust of the patient and to build a relationship with them. The therapist achieves this by replacing the harsh and punishing conscience, probably based on the patients parents, with one that is less destructive and more supportive. As the patient gets healthier, the patient takes a more active role (and the therapist takes a less active role) in their own recovery.

A meta-analysis of studies of psychotherapy for schizophrenia

Gottdiener (2000) reviewed 37 studies published between 1954 and 1999 covering 2642 patients with a mean age of 31.1 years. They found that overall, 66% of those receiving psychotherapy improved after treatment, compared with only 35% of those who did not receive psychotherapy. Specific results are summarised below: a. Type of psychotherapy- results showed that psychoanalytic and cognitive behavioural therapies produced similar levels of therapeutic benefit. b. Use with antipsychotic medication- results showed no difference in improvement when psychotherapy was accompanied by antipsychotic medication compared to psychotherapy alone. c. Outpatients versus inpatients- results showed that outpatients (i.e. treated outside the context of a psychiatric institution) improved t a higher rate than inpatients.

Effectiveness of psychodynamic therapy

Supporting research Malmberg and Fenton (2001) argue that it is impossible to draw definite conclusions
for or against the effectiveness of psychodynamic therapy. In fact the Schizophrenia Patient Outcome Research Team (PORT) has even argued that some forms of psychodynamic therapy are harmful for patients with schizophrenia. Despite this, a Meta analysis of 37 studies (Gottdiener, 2000) concluded that psychodynamic therapy was an effective treatment for schizophrenia.

Contradictory findings research on the effectiveness of psychodynamic therapy for schizophrenia has
produced contradictory findings. For example, May (1968) found that patients treated with this therapy together with antipsychotic medication, had significantly better outcomes than those treated with the therapy alone. What was even more damning was that antipsychotic medication alone was superior to psychodynamic therapy. However, Karon and VandenBos (1981) found the opposite, with patients treated with therapy improving more than those receiving medication alone.

Appropriateness of psychodynamic therapy

Combination therapy despite the fact that evidence for the effectiveness of psychodynamic therapy in
schizophrenia is not entirely convincing, the treatment guidelines of the APA (American Psychiatric Association) recommend that supportive interviewers such as psychodynamic therapy are appropriate when combined with antipsychotic medication.

Costs and benefits one argument against using psychodynamic therapy is that it is expensive
(psychodynamic therapists are expensive and the treatment is usually long term) prevents it being adopted on a large scale. Some critics argue that because it does not appear more effective than antipsychotic medication, psychodynamic therapy is not worth the extra expense. However, there is evidence to suggest that the overall cost of treating schizophrenics decreases with the use of therapy because they are less likely to seek inpatient treatment and are more likely to gain employment (Karon and VandenBos, 1981).

Methodical limitations of psychodynamic outcome studies

In the Gottdiener study there were a number of methodical issues that prevented firm conclusions being drawn about the effectiveness of psychotherapy as a treatment for schizophrenia.

1.

2.

Number of studies the relatively small number if studies meant that it was difficult to assess the impact of variables such as therapist training or experience. Random allocation about half of the studies reviewed did not allocate patients randomly to treatment conditions, thus introducing a treatment bias that may possibly have affected the results.

Ethical issues in schizophrenia research

Research on therapies for schizophrenia must be carried out in a way that doesnt place vulnerable individuals at unreasonable risk. The BPS advice that when participants take part in a psychological investigation they should not, in doing so, be increasing the probability that they would come to any form of harm. The possibility for harm is heightened when dealing with vulnerable groups such as patients with schizophrenia. The potential for harm in outcome studies of schizophrenia include those associated with medication discontinuation, the use of placebo conditions and capacity for informed consent.