PSYCHOTIC DISORDER

Schizophrenia

....who said that?

A Personal Account of a Schizophrenia Patient

“On the way to the store, I had a flat tire. I thought this was planned also. At the petrol pump, the man smiled at me with twinkle’s in their eyes and I knew they were closing in. I was done for. They would kill me. Suddenly I saw their faces in the skies…”

I developed a feeling that I smelled bad and that somewhere I had left a tap open and consequently would be responsible for destroying a building, and that if I accidentally struck a match, I would cause mass destruction and kill many people. I was suspicious about everyone…

A Personal Account of a Schizophrenia Patient

At first, I strained to hear the voices. They were soft and working in the form of a code. I broke the code after a long struggle. Then I could distinctly hear four voices. “The rotten prostitute…” said one. “The Gods will not leave her…” said the second. “I think you should kill yourself and spare God the trouble…” said the third one addressing directly to me…

Psychotic disorder and Psychosis

Psychotic disorder - difficulties with thinking

- distorted perceptions

- loss of contact with reality

Affect persons ability to - think clearly

- reason

- make good judgements

- communicate effectively

- behave appropriately

- understand the difference with reality and their imagination

Psychotic disorder and PsychosisIs what I see real? I’m becoming introvert and withdrawn

I have no energy!

I’m feeling very irritable

I’m depressedI can’t function effectivelyin my normal life anymore

The term PSYCHOSIS is used to describe someone who is experiencing many symptoms of a psychotic disorder.

Does NOT mean that they have to be“dangerous”“violent”“Psychopaths”“Serial killers”

A psychotic disorder may develop gradually or it may present abruptly.

Normally, it presents itself with a gradual behavioural and perceptual change, over an extended period of time.

The person is unable to tell the difference between perceptions constructed from sensory information and self generated perceptions based on sensory information that is not actually present.

PSYCHOTIC DISORDER

People with psychotic disorders: Often feel they want to withdraw from the

outside world. Their energy and emotions are affected. They may feel a loss of vitality. They may also feel depressed or irritable. Due to the nature of the symptoms, a

person’s ability to function effectively in everyday life may be significantly impaired.

The PRODROMAL phase

Early symptoms and signs of disease or disorder that precede its onset in a fully developed form.

Psychosis

It varies from person to person. We are all differentWarning signs

DSM-IV-TR

Diagnostic and statistical manual of mental disorders

Category;

“Schizophrenia and other psychotic disorders”

There are 9 disorders in this category.

3% of the population will experience a psychotic

disorder at some time in their life

Psychotic disorders affect males and females equally, although there is a younger age of onset in males (usually between 15 and 25 years).

The majority begin in late adolescence or early adulthood.

Biological factors

Contributing factors:- Genetic predisposition- Drug induced onset- Changes in brain activity

Management- Anti psychotic medication

Social factors

Contributing factors:- Social disadvantage- trauma- Psychosocial stress- Social stressor

Management- Psychoeducation- Family support- Social support- Removal of social stigma

Psychological factors

Contributing factors:- Impaired reasoning and memory

Management- Cognitive Behavioural therapy (CBT)- Cognitive remediation- Stress management

The Biopsychosocial framework

Schizophrenia and schizoaffective disorder account for more than 60% of the people with psychotic disorder

Swiss Psychiatrist Eugen BleulerCoined the term “Schizophrenia”In 1911

SchizophreniaSchizo - “Split”

Phrenos- “the mind”

“Split mind”Used in the context “split off” from reality...

Not Split Personality

The term “Split personality” is being used interchangeable with “schizophrenia” by some people in the wider community.

This is wrong

Schizophrenia

Disturbances in thinking

DELUSIONSHallucinations

DISORGANISED BEHAVIOUR

Is characterised by

Many people with Schizophrenia...

Hear and see things that are not there

Hold beliefs that are odd or not true

Speak and/or behave in a disorganised way that is often hard to understand

Loss of contact with reality

Everything looked vibrant, especially red; people took on a devilish look with black outlines and white shining eyes, all sorts of objects – chairs, buildings, obstacles – took on a life of their own; they seemed to make threatening gestures, to have an animistic outlook.

One day, while I was in the principal’s office, suddenly the room became enormous, illuminated by a dreadful electric light that cast false shadows. Everything was exact, smooth, artificial, extremely tense; the chairs and tables seemed models placed here and there. Pupils and teachers were puppets revolving without cause, without objective. I recognised nothing, nobody. It was as though reality, attenuated, had slipped away from all these things and these people. Profound dread overwhelmed me, and as though lost, I looked around desperately for help. I heard people talking, but I did not grasp the meaning of the words. The voices were metallic, without warmth or colour.

From time to time, a word detached itself from the rest. It repeated itself over and over in my head, absurd, as though cut off-by a knife.

Everything seems to grip my attention, although I am not particularly interested in anything. I am speaking to you just now, but I can hear noises going on next door and in the corridor.

I find it difficult to shut these out, and it makes it more difficult for me to concentrate on what I am saying to you. Often the silliest little things that are going on seem to interest me. That’s not even true; they don’t interest me, but I find myself pre–occupied with them and wasting a lot of time this way.

An outsider may see only someone ‘out of touch with reality’. In fact, we are experiencing so many realities that it is often confusing and sometimes totally overwhelming.

Sometimes when people speak to me, my head is overloaded. It’s too much to hold at once. It goes out as quick as it goes in. It makes you forget what you just heard because you can’t get hearing it long enough. It’s just words in the air unless you can figure it out from their faces.

My trouble is that I’ve got too many thoughts. You might think about something, let’s say that ashtray, and just think, oh yes, that’s for putting my cigarette in, but I would think of it and then I would think of a dozen different things connected with it at the same time.

People with Schizophrenia...

Have been diagnosed with help of the DSM, which states that you needto have experienced key symptoms for significant portion of time duringa one month period with some symptoms persisting for at least 6 months.

Have little insight into their disorder, meaning that they are oblivious to that they have a mental disorder.

SchizophreniaAnyone can develop schizophrenia. It affects about 1 in 100 people across allcountries, socioeconomic groups, cultures and subcultures.

It usually begins when people are aged between15 and 25 years of age, although it can emerge laterin life.

Males are slightly more likely to develop it than females.

Schizophrenia

There are two main types of symptoms.

Positive; in addition to normal experiences

- hallucinations

- delusions

- disorganised thoughts, speech and behaviour

Negative; loss or decrease in normal functioning

- loss of pleasure

- loss of interest

- loss of motivation

- loss of interest in socialisation

Symptoms of Schizophrenia

DELUSIONS

A delusion is a fixed, false belief that is held with absolute certainty, even when there is strong factual evidence that does not support it

Delusions of persecutions

Any belief that one is being tormented, followed, tricked or spied upon.

The most common type of delusion

- Believing that tracking device has been implanted in your brain

- Agents are trying to assassinate you.

We know where you l ive..

Delusion of reference

Any belief that that actions of others have a special relevance to you.

- Hearing a song on the radio that is about you.- Thinking that the news reader on TV is talking directly to you.

Delusions of control

Any belief that one is being controlled by external force.

- Belief that aliens are controlling your thoughts

Delusions of grandeur

Any belief that you are an important person, or you have done, will do something really significant.

- Believe that you are Jesus Christ- Think you have the power to cure

cancer- Dictated the stories about Harry

Potter to JK Rowling

Thought broadcasting

Any belief that your inner and private thoughts will be broadcasted to other people.

- You might believe that that other people can read your mind every time you breathe out

Thought insertion

Any belief that thoughts are being inserted in your mind from an outside source.

Must buy coke…

Hallucinations

Perceptual distortions of sensory information during which the individual, sees, hears, feels, tastes or smells something that is interpreted as real but does NOT exist.

Hallucinations

The most common hallucination for people with schizophrenia is auditory hallucinations, which involves hearing voices.

Hallucinations

Critical hallucination; negative comments, running commentary about your actions, personal characteristics or actions.

“You are a loser”

“What are you doing that for?”

Hallucination

Command hallucination; hearing a voice that commands you to do things you might not normally do.

People experiencing hallucinations usually appear preoccupied to someone else because they are paying attention to what the voices are saying.

Disorganised speech

The speech of people with schizophrenia is frequently disconnected, illogical and jumbled and reflects the level of disorganisation or “fragmentation”, of their thinking. Making communication with others very difficult.

Derailment; All the traffic was going into the city. Why do villains in films always have dark hair? Ok, it’s Tuesday.

Perseveration; I really like Melbourne, Melbourne, Melbourne, Melbourne

Neologisms; I had Cotter on last night. (making up new words that has only meaning to them).

Clang; ‘Deck the halls with boughs of holly, folly, polly, hello Dolly, want a lollipop?

Grossly disorganised or catatonic behaviour

Grossly disorganised behaviour; fragmented behaviour, inappropriate, unusual, unpredictable, purposeless and erratic. Dress in an unusual manner.

GROSSLY DISORGANISED BEHAVIOUR

Examples of grossly disorganised behaviour:

Urinate on the street corner Behave in a silly manner at a funeral Display unpredictable agitation such

as shouting or swearing for no reason. May be unable to attend to personal

hygiene May be unable to prepare meals for

themselves May wear 5 different dresses

simultaneously

Catatonic behaviour

Catatonic behaviour; highly disturbed actions or movements, or lack of movement.

May range from extremely agitated state (frenzy like) to complete immobility and lack of speech (statue like) or somewhere between these 2 extremes.

Agitated state; shout, talk rapidly, wave or flap their arms around, pace back and forward.

Catatonic stupor; virtually motionless, statue like., seem totally unaware of environment for a long period of time.

e.g. May make no eye contact with others and are mute and motionless like a statue. May even appear as if they are unconscious, even though the person is usually aware of their environment and can m often recall events that occurred while in the catatonic state.

Catatonic behaviour

Catatonic posturing (catalepsy); stands motionless in a in a awkward, bizarre position for a long period of time.

Waxy flexibility; the person can be moulded into any position like a wax figure and hold that position indefinitely.

e.g. raise the persons arm and they will maintain that position until moved again

CATATONIC POSTURING

Catatonic posturing

Negative Symptoms

The loss or absence of normal though processes, emotions and behaviours typically experienced by mentally healthy individuals.

Often slow to develop More likely to first become apparent during

the prodromal phase of schizophrenia.

E.g. A person becomes gradually withdrawn socially

Negative Symptoms

Common negative symptoms of schizophrenia: Affective flattening

Reduction in the range and intensity of emotional expression, including facial expressions, voice tones and eye contact.

E.g. Person seems to stare, have blank look on face, speaks in a flat (monotonous) voice, doesn’t maintain eye contact and uses little or no body language when communicating.

Negative Symptoms

Avolition

Similar to apathy, when a person experiences a lack of energy or enthusiasm for doing anything.The person has difficulty with, or is unable to follow through on a course of action. E.g. They feel drained of energy, no longer interested in going out and meeting friends or participating in activities about which they were once enthusiastic.

NEGATIVE SYMPTOMS

Alogia (“poverty of speech”) is the reduction in speech content and fluency.e.g. The person may give very short empty replies to questions and finds it very difficult to carry on a normal conversation.ORe.g. The person may say quite a bit but will manage to convey little meaning.

BIOLOGICAL CONTRIBUTING FACTORS

The specific causes of schizophrenia remain unclear.

Although psychological and socio-cultural factors may influence it’s onset and course, it is considered to be primarily a brain disorder.

Biological factors contribute in ways such as: Genetics may play a role in it’s development as it

tends to run in families. Individuals with schizophrenia may have lower

levels of brain activity in frontal lobe and excessive activity of neurotransmitter dopamine..

GENETIC PREDISPOSITION

Research studies show people who have a biological relative with schizophrenia have a genetic predisposition or “tendency” to develop the disorder.

A genetic predisposition means having an increased risk for developing a mental or physical disorder due to factors associated with genetic inheritance.

GENETIC PREDISPOSITION

An individual though, may have a genetic predisposition which places them at a higher risk of developing schizophrenia, but does not mean they will definitely develop the disorder.

There is no single gene identified for schizophrenia.

Instead, a number of different genes are likely to contribute in subtle ways to the expression of the disorder.

STUDIES ON GENETIC PREDISPOSITION

U.S. psychiatrist and geneticist Irving Gottesman (1991) conducted a meta-analysis to examine how common schizophrenia is among family members with varying degrees of genetic similarity.

A meta-analysis is a type of review process that uses statistical procedures to combine the results of a number of studies that use similar research hypotheses. It takes into account factors such as sample size and other specific research procedures amongst different studies.

STUDIES ON GENETIC PREDISPOSITION

Results of 40 family and twin studies was analysed.

One study was of 4000 relatives and another of 3000 relatives so the data analysed was vast.

Gottesman found the greater the genetic similarity of relatives, the more likely they were to have been diagnosed with schizophrenia.

See Fig. 16.9 on p. 785.

STUDIES ON GENETIC PREDISPOSITION

Identical twins (share 100% of their genes) had a 48% risk.

i.e. If one twin has schizophrenia, the other one will too in 48 out of 100 pairs of identical twins.

Parents and biological children are much less genetically alike than identical twins.

i.e. If one parent has schizophrenia, there is a 17% chance of any of their biological children having it.

STUDIES ON GENETIC PREDISPOSITION

Gottesman’s findings indicate that schizophrenia is partly genetic in origin.

However, the risk is nowhere near as high as would be expected if the disorder was entirely genetic.

Other environmental factors (non-genetically determined) influence the development of schizophrenia.

STUDIES ON GENETIC PREDISPOSITION

It is difficult to separate the effects of genes and the environment on schizophrenia because twins are usually raised together.

So, adoption studies have been conducted to better understand the roles and genes and the environment separately.

Adoption studies involve researching individuals born to a parent(s) with schizophrenia but who have been adopted by other parents shortly after birth.

STUDIES ON GENETIC PREDISPOSITION

In one adoption study conducted by U.S. Psychiatrist Seymour Kety et al. (1988) traced adoption records of nearly 5500 adults who had been adopted early in life and found that 33 had schizophrenia.

A control group of 33 who did not have schizophrenia was selected from the same population (similar in age, schooling and sex to the individuals with schizophrenia).

STUDIES ON GENETIC PREDISPOSITION

Researchers located 365 biological and adoptive relatives of these 66 adoptees, including both parents and siblings.

Relatives were organised into 4 groups: 1. biological relatives of adoptees with

schizophrenia 2. adoptive relatives of adoptees with schizophrenia 3. biological relatives of adoptees without

schizophrenia 4. adoptive relatives of adoptees without

schizophrenia

STUDIES ON GENETIC PREDISPOSITION

37 of the relatives were found to qualify for a diagnosis of schizophrenia or another psychotic disorder.

Most of these 37 relatives turned out to be the biological relatives of the adoptees with schizophrenia.

In total, 14% of the biological relatives of adoptees with schizophrenia were themselves also diagnosed with the disorder, but only 2.7% of their adoptive relatives were given this diagnosis.

STUDIES ON GENETIC PREDISPOSITION

Biological and adoptive relatives of the adoptees without schizophrenia had schizophrenia prevalence rates of 3.4% and 5.5% respectively.

i.e. Biological = 3.4%, Adoptive = 5.5% These results add to the substantial evidence

supporting heredity as a contributing factor in schizophrenia.

Adoption studies consistently show that if either biological parent had schizophrenia, the adopted individual is at greater risk to develop it.

DRUG-INDUCED ONSET

The effects of certain drugs, particularly those that stimulate increased production of dopamine can “trigger” psychotic symptoms similar to those experienced by an individual with schizophrenia.

These drugs generally fall into 4 groups: 1. Hallucinogens (e.g. LSD) 2. Stimulants (e.g. Amphetamines. Cocaine, Ecstasy) 3. Phencyclidine (e.g. PCP or “angel dust”) 4. Cannabis (e.g. Marijuana, skunk, hashish)

DRUG-INDUCED ONSET

LSD - a person under the influence of LSD may see and hear things that do not physically exist in reallity

Cocaine or cannabis – a person under the influence of cocaine or cannabis may have paranoid delusions.

If a person experiences psychotic symptoms while under the influence of a drug, then they are experiencing drug-induced psychosis.

DRUG-INDUCED PSYCHOSIS

Drug-induced psychosis is called substance-induced psychotic disorder in the DSM.

Drug-induced psychosis is a disorder characterised by delusions and hallucinations that are judged to be due to the direct physiological effects of a drug.

In some individuals, these symptoms are temporary and disappear once the drug wears off, but for others, the symptoms do not go away when the effects of the drug wear off.

DRUG-INDUCED PSYCHOSIS The duration and severity of drug-induced

psychosis depends on a number of factors: Quantity consumed Frequency of consumption Potency (strength) of drug consumed Half-life of the drug consumedHalf-life if the period of time required for the

concentration or amount of drug in the body to be reduced by one half and is a measure of the time it takes for the drug’s active effects to wear off.

e.g. Person with Cannabis-induced psychotic disorder may experience psychotic symptoms up to 10 days after the effects of the cannabis wears off.

DRUG-INDUCED PSYCHOSIS

Some people will recover from an episode of drug-induced psychosis. But for others, the psychotic symptoms may persist and the drug use triggers the onset of a recurrent lifelong psychotic illness such as schizophrenia.

CHANGES IN BRAIN ACTIVITY Functional neuroimaging techniques that

capture detailed images of both the structure and function of the brain have provided evidence of specific abnormalities among people with schizophrenia.

The prefrontal cortex is the forward part of the frontal lobes and levels of brain activity in this area are involved in research on schizophrenia patients.

CHANGES IN BRAIN ACTIVITY Swedish researchers Ingvar and Franzen (1974)

measured the brain activity in 31 people with chronic schizophrenia (13 women, 18 men) and compared the results with those of a matched control group.

They found significantly reduced level of brain activity in frontal lobes of people with schizophrenia compared to the control group.

This was isolated to the prefrontal area.

CHANGES IN BRAIN ACTIVITY

Ingvar and Franzen called this reduced level of brain activity hypofrontality and the term is now used to describe reduction in brain activity in the frontal cortex, particularly in the prefrontal cortex.

Another study where participants with schizophrenia were given different cognitive tasks such as card sorting and matching to perform during PET scanning showed that compared with people who had healthy brains doing the same tasks, the people with schizophrenia failed to show the task-related increase in prefrontal functioning in order to meet the cognitive demands of the tasks.

CHANGES IN BRAIN ACTIVITY

Twin studies where scans of an identical twin with schizophrenia are compared with the other twin without schizophrenia have shown similar results.

There are other studies on hypofrontality using cognitive tasks though, that DO NOT support these findings.

The reasons for hypofrontality in SOME people remains unclear. One explanation is that neurons in the frontal cortex of people with schizophrenia tend to have less bushy dendrites, which may contribute to a less active prefrontal cortex.

BRAIN ACTIVATION DURING AUDITORY HALLUCINATIONS

Functional neuroimaging studies have found that the primary auditory cortex is activated during auditory hallucinations.

Read Box 16.4 on page 789.

The brain activity of people hearing “imaginary” voices (as in auditory hallucinations) is similar to the brain activity that occurs in any person’s brain when they hear “real” voices talking to them.

USE OF MEDICATION TO TREAT PSYCHOSIS

The neurotransmitter dopamine is found in only a few areas of the brain but is believed to have a contributory role in the development of schizophrenia when it is present in higher than normal levels or its activity is excessive.

Dopamine is a neurotransmitter believed to be involved in: Pleasure, motivation, emotional arousal,

control of voluntary movements.

USE OF MEDICATION TO TREAT PSYCHOSIS

Dopamine can produce different effects in different areas of the brain. E.g. In some brain areas, low levels

produce tremors and decreased mobility of Parkinson’s disease.

E.g. In other brain areas, it is concentrated in relatively large amounts and is involved in our experience of a distinct sense of pleasure. This area (a neural pathway) is commonly called the “dopamine reward system”.

USE OF MEDICATION TO TREAT PSYCHOSIS The dopamine hypothesis states that

the positive symptoms of schizophrenia are related to the excessive activity of dopamine normally found in the brain.

The dopamine hypothesis is based on 2 observations: 1. Anti-psychotic medications block or

reduce dopamine activity in the brain which reduces psychotic symptoms.

2. Drugs that enhance dopamine activity in the brain such as amphetamines (“speed”) cocaine, and levodopa (L-dopa) can produce or worsen psychotic symptoms.

USE OF MEDICATION TO TREAT PSYCHOSIS

There is now considerable evidence that the dopamine hypothesis is inadequate.

Many individuals with schizophrenia do not respond to dopamine blocking medications and those who do seldom show a complete remission from symptoms.

For many individuals, these medications reduce some but not all psychotic symptoms.

USE OF MEDICATION TO TREAT PSYCHOSIS Recent studies also show other

neurotransmitters are also involved in schizophrenia.

This suggests the disorder is a complex interaction among a range of different neurotransmitters and therefore biochemical processes.

Anti-psychotic medications are also called anti-psychotics and neuroleptics. They are drugs designed to relieve the symptoms of psychosis such as paranoia, confused thinking, delusions and hallucinations.

USE OF MEDICATION TO TREAT PSYCHOSIS

Prescribed only by medical practitioners and psychiatrists, they are commonly used alongside psychotherapies.

Anti-psychotic medications are dopamine antagonists which means they reduce the symptoms of psychosis by blocking dopamine activity at the synapse and therefore the effect that dopamine has on the brain.

USE OF MEDICATION TO TREAT PSYCHOSIS

The medication can be taken orally (as a tablet or syrup or as an injection (called a “depot”).

The depot releases the drug slowly over some weeks which is preferred by some people who find remembering to take tablets difficult.

Recommended dosage depends on the type of drug, the condition for which it is prescribed and other factors. They must be taken exactly as directed, never in larger or more frequent doses and never for longer periods than directed.

USE OF MEDICATION TO TREAT PSYCHOSIS

Taking the medication strictly as directed is important for all but especially older people, who may be more sensitive to this type of medication.

People must also not stop taking their medication as withdrawal symptoms following discontinuation can be severe.

ANTI-PSYCHOTIC MEDICATIONS There are 2 main types of anti-psychotic

medications:

1. Typical anti-psychotics – “first generation” anti-psychotics developing in the 1950s e.g. Haldol, Thorazine and Mellaril

2. Atypical anti-psychotics – newer “second generation” anti-psychotics developed since the 1990s. e.g. Risperdal, Zyprexa, Clozaril, Seroquel.

ANTI-PSYCHOTIC MEDICATIONS Both types are effective, but the newer atypical

anti-psychotics have advantages over the typical ones.

Atypical anti-psychotics have fewer side effects such as:

Trembling Stiffening of muscles Less risk of developing tardive dyskinesia

(movement of mouth, tongue and sometimes other parts of the body over which the person has no control.

ANTI-PSYCHOTIC MEDICATIONS

Atypical anti-psychotics do not block dopamine activity in the motor cortex areas of the brain, instead they more selectively target other brain areas associated with psychotic symptoms.

They are more likely to cause weight gain though.

They are more effective in treating the negative symptoms of schizophrenia such as apathy and flat emotions.

The incidence of “revolving door” pattern of hospitalisation and rehospitalisation is lessened.

ANTI-PSYCHOTIC MEDICATIONS Both types of anti-psychotic medications can relieve

symptoms of psychosis, they have 4 main limitations. They do not actually cure schizophrenia. Psychotic symptoms often return if the person stops taking

the medication. The medications can produce a number of very unpleasant

side effects such as nausea and weight gain that can cause people to stop taking the medication.

Although they can block dopamine activity almost instantly (within minutes) the psychotic symptoms usually do not subside until about 4 to 6 weeks and it can take several months before the full benefits are felt.

ANTI-PSYCHOTIC MEDICATIONS The side effects can be felt long before the

benefits.

Read side effects listed in Box 16.5 on page 792.

This delay is onset of therapeutic benefits may indicate that other factors associated with neurotransmission may also be important in alleviating symptoms rather than simply the decreased level of dopamine activity.

PSYCHOLOGICAL CONTRIBUTING FACTORS It is estimated that as many as 85% of people

diagnosed with schizophrenia experience problems with cognition.

Cognitive problems may be evident before psychotic symptoms start, leading to a decline in work or academic performance.

Early cognitive symptom is poor attention with memory difficulty and visual motor speed also possible to appear before psychotic symptoms.

PSYCHOLOGICAL CONTRIBUTING FACTORS

Cognitive problems can affect abilities including: Paying attention Remembering and recalling information Processing information quickly Responding to information quickly Thinking critically, planning organising, problem

solving Initiating speech

Two cognitive problems that have been extensively researched in relation to schizophrenia are impairments in reasoning and memory.

IMPAIRED MECHANISMS FOR REASONING AND MEMORY

Reasoning uses our memories of information learnt through past experiences.

Thus when memory is impaired, our reasoning in various situations can also be impaired.

Both these impairments are highly prevalent in people with schizophrenia.

IMPAIRED REASONING

There are many types of reasoning: Deductive reasoning Inductive reasoning Analogical reasoning Probabilistic reasoning

Although there are differences, they all involve purposeful thinking using principles of logic.

Generally, reasoning involves goal-directed thinking in which inferences are made or conclusions are drawn from known or assumed facts or pieces of information.

IMPAIRED REASONING Reasoning allows us to solve problems, thus

allowing us to deal with the challenges met in everyday life.

Let’s look at one example of impaired reasoning i.e. “jumping to conclusions” when using probabilistic reasoning.

Probabilistic reasoning involves making judgements related to probability or the likelihood of something happening or being true.e.g. Probability you have a cold after sneezing 3 times, or how likely it is it will rain tomorrow.

IMPAIRED REASONING

Research suggests that people with schizophrenia often have an impairment in probabilistic reasoning that affects how they interpret social situations.

This type of reasoning impairment has also been implicated as a contributing factor to the development and persistence of delusions.

Delusions occur in approx. 75% of people with schizophrenia and are consistently shown by research to be associated with reduced data gathering, belief inflexibility and impaired working memory.

IMPAIRED REASONING

This type of impairment is a cognitive bias, or tendency to process information in a particular way called “jumping to conclusions”.

“Jumping to conclusions” involves making hasty judgements or decisions on the basis of inadequate or ambiguous information, typically resulting in unjustifiable or incorrect conclusions.

Usually there is more information available than is actually used which affects the conclusions drawn.

IMPAIRED REASONING

When judgements and decisions are reached in this way, the person usually holds them with greater confidence and inflexibility than others would.

People experiencing delusional beliefs tend to reach unwarranted conclusions about the causes of events very quickly, do it on the basis of reduced data gathering, and stick to the first explanation for an event that comes to mind.e.g. Woman reading letter from DHS while police helicopter flying overhead (page 794).

IMPAIRED REASONING

Impairment in probabilistic reasoning is hypothesised to lead to rapid acceptance and confirmation of beliefs, even if there is little or no evidence to support them.

E.G. “Beads task” (page 795)

IMPAIRED MEMORY

People with schizophrenia tend to perform poorly on a wide range of memory tasks.

Memory impairment for people with schizophrenia can be comprehensive and involves all memory systems and sub-systems - e.g. Sensory memory, working memory (STM) and/or all types of LTM.

Individuals vary on the severity of impairment in each memory system.

IMPAIRED MEMORY Memory impairment is one of the major

disabilities associated with schizophrenia. Memory impairment can interfere with

management programs of an individual’s schizophrenia.

Causes of memory impairment remain unclear but are generally believed to have a neurological basis.

Some of the older “typical” anti-psychotic medications may cause or exacerbate memory impairment.

IMPAIRED MEMORY U.S. psychologist Andre Aleman and a team of

psychiatrists (1999) conducted a meta-analysis of 70 research studies on memory impairment published in the previous 20 years.

The findings revealed wide ranging memory impairment in people with schizophrenia.

Both free recall and cued recall from LTM were poor, whereas recognition showed less but still significant impairment.

IMPAIRED MEMORY

Recall and recognition were poor for both verbal and non-verbal (visual) material.

Storage duration of newly learned materials was both in tests on both immediate and delayed recall or recognition.

Extent of memory impairment was not affected by age, medication or severity of symptoms.

IMPAIRED MEMORY

Controlling for attention had very little effect on differences in performance on LTM recall between people with schizophrenia and the control group.

People with schizophrenia for long periods of time did not perform worse than those recently diagnosed.

More recent studies show that although both explicit and implicit long term memories are impaired, episodic memories of past events and personal experiences tend to show the greatest impairment.

IMPAIRED MEMORY

E.g. If read a story, people with schizophrenia learn and recall much less than a control group.When story is repeated, they gain less information from repeated exposure than control group participants - i.e. Show a reduced “learning curve”.

When recalling episodic events, people with schizophrenia show more errors and omissions than control group participants.

IMPAIRED MEMORY

One study also found that episodic memory impairment is present in the prodromal phase – before the presence of obvious psychotic symptoms.

What they did yesterday, where they left their house keys earlier in the day, the emotions felt during a past event as well as times and places can all be examples of episodic memory impairment in people with schizophrenia.

IMPAIRED MEMORY

Episodic memory impairment can be so severe that the person is “trapped in the present”.

Episodic memory impairment contributes to some key symptoms of schizophrenia such as disorganised behaviour and impairments in daily functioning.

MANAGEMENT OF SCHIZOPHRENIA

In conjunction with medication, 2 effective psychotherapeutic approaches in reducing psychotic symptoms and improving daily functioning are:

COGNITIVE BEHAVIOURAL THERAPY (CBT) COGNITIVE REMEDIATION

Stress management is also important in minimising the influence of stressors that can trigger or exacerbate psychotic symptoms.

COGNITIVE BEHAVIOURAL THERAPY

As people with schizophrenia have a different reasoning style to those who don’t, therapy that assists a person with schizophrenia to identify and change the thoughts responsible for maintaining their symptoms.

Cognitive Behavioural Therapy (CBT) is a type of therapy that combines cognitive and behavioural therapies to help people overcome or more effectively manage psychological problems and mental disorders.

CBT

CBT is based on the assumption that the way people feel and behave is largely a product of the way they think.

A person can change the way they feel and behave by thinking about a situation in a more balanced and helpful way.

It does NOT aim to persuade someone their current way of thinking is “wrong” or “irrational”.

CBT

CBT aims to assist the individual to identify where they may have become trapped or stuck in their way of thinking and to assist them to discover other ways of looking at their situation.

The “Cognitive” component of CBT in the management of schizophrenia involves helping the client to become aware that in some situations they may be “jumping to conclusions”, identify the thoughts that may be misinterpretations of situations, carefully examine each thought and evaluate how realistic it is, then try to generate alternative thoughts that are more realistic, helpful and balanced.

CBT

When using cognitive strategies to treat delusions:1. First try to gain a thorough understanding of the delusions from the client’s perspective and encourage them to explore the evidence for the delusion (i.e. Why they believe it)2. Gain some agreement with the client that the conclusions they have come to might be a misinterpretation of what has occurred. E.g. Quick examination of likelihood of potential alternative hypotheses to explain events.

CBT

3. Once there is some agreement from the client there is a “chance” that alternative conclusions could be considered then the mental health professional introduces information about reasoning biases (i.e. Jumping to conclusions) to provide the client with an explanation of how they might have arrived at their delusional interpretation of events.

Read example in text on page 798.

CBT

British psychologist Hazel Nelson (2005) proposes using the “feeling brain – logical brain” model to help people with schizophrenia understand how reasoning can lead to wrong conclusions. She argues it would be helpful in situations where we use our “feeling brain” to think and reason emotionally about things to get our “logical brain” which thinks and reasons calmly and rationally – more involved.

Read example in text on page 799.

CBT

The aim of the cognitive component in CBT is not to get the client to fully reject their delusion. They may continue to believe and accept it to a certain degree but the goal is to reduce the amount of distress it causes and the amount of time they spend thinking about it – this then has a positive effect on their mood and behaviour.

CBT

The “Behavioural” component of CBT in the management of schizophrenia may consist of 2 components:

Behavioural experiments Behavioural strategies

Behavioural experiments are planned experiential (“hands on”) activities undertaken by clients in or between CBT sessions. Their purpose is to help the person “test out” the accuracy of their delusional thoughts.

CBT – Behavioural experiments By doing behavioural experiments the client may

come to realise that their delusions may not be 100% true.

Steps in setting up behavioural experiments is similar to the steps in any scientific research: Make a prediction Review existing evidence for and against the

prediction Devise a specific experiment to test the validity of

the prediction Note results Draw conclusions

CBT – Behavioural experiments Read example of woman with delusion that police

move her furniture at home while out on page 800.

Some delusional beliefs may be difficult to adequately modify through behavioural experiments e.g. ASIO agents bugging a person’s house or aliens from outer space are watching a person’s every move.

Clients with schizophrenia also often come up with a reason why the behavioural experiment didn’t “disprove” their delusion. E.g. Police only come some days, or they must have known the trap was set.

CBT – Behavioural strategies Behavioural experiments therefore, will not

always guarantee a person will modify their commitment to their delusion.

So another behavioural therapeutic approach may be used.

Behavioural strategies are behaviourally based interventions that help reduce the impact of hallucinations or preoccupation with a delusion on a person’s life.

CBT – Behavioural strategies Some behavioural strategies for auditory

hallucinations include: Put a standard earplug in one ear Using an iPod with headphones Talking out aloud or taking quietly to themselves

so no one can hear Distraction (talking to someone, reading a book,

playing a computer game or Xbox, watching TV) Engaging in physical activity (e.g. A run or brisk

walk) Reducing stimulation or stress (e.g. Relaxing,

sitting somewhere quiet, having a sleep)

COGNITIVE REMEDIATION

Cognitive remediation is a general term that refers to the use of training techniques to promote improvement in targeted cognitive impairments.

The purpose of cognitive remediation is to decrease the everyday problems faced, thereby improving the quality of their lives.

Initially developed for those with brain injury, now used with people with schizophrenia or other neuropsychological problems or mental disorders that involve cognitive impairments.

COGNITIVE REMEDIATION

Techniques are tailored to each individual’s needs and abilities.

Cognitive remediation involves behavioural techniques but does not replace medical treatments or psychotherapy – rather, it complements their effects.

As with psychotherapy, it is important the individual is able and willing to be actively involved in the management process.

COGNITIVE REMEDIATION

Cognitive remediation techniques involve teaching clients specific information processing skills targeted at one or more difficulties.

Techniques may focus on: Attention and concentration Reasoning Memory Problem solving Decision making Organisation Executive functioning

COGNITIVE REMEDIATION

Individual is first assessed in order to identify specific cognitive impairments that are interfering with everyday functioning in significant ways.

The assessment also enables monitoring of improvements – before, during and after remediation.

There are many different approaches to remediation with each emphasising different therapeutic styles and specific techniques.

COGNITIVE REMEDIATION

Some approaches: Use computer software programs Paper and pencil tasks Conducted in clinical setting Conducted in individual’s home For individuals For small groups

In all approaches, the objectives are set and each individual’s progress in achieving these are monitored.

COGNITIVE REMEDIATION

Length of a remediation program varies according to individual’s specific problems and needs.

E.g. Improving memory skills may take months or years

Improving organisational skills may take a few days or a few weeks.

A program of cognitive remediation for people with schizophrenia who have cognitive difficulties is called the Neuropsychological Educational Approach to Remediation (NEAR).

COGNITIVE REMEDIATION – “NEAR”

NEAR is a group based program providing highly individualised training by allowing each person in the group to work at their own pace on tasks carefully chosen to engage and address their specific cognitive needs.

Participation is twice a week with each session typically 60 to 90 minutes duration.

When starting the program, clients initially complete computer-based tasks, choosing exercises from the list of software shown to them by the therapist.

COGNITIVE REMEDIATION – “NEAR”

About 2/3 of the time is spent completing individual cognitive activities on the computer, and 1/3 of the time in a “bridging group”.

The “bridging group” is a discussion about how their computer activities relate to things they do in everyday life.

Participants in the “bridging group” share strategies for solving problems on the cognitive exercises and in real life. The therapist in the NEAR sessions observes, motivates or provides specific assistance by suggesting ways of overcoming problems.

COGNITIVE REMEDIATION – “NEAR”

Studies have provided evidence of the effectiveness of the NEAR program for people with schizophrenia.

Australian study in 2010 compared outcomes for an “immediate treatment” group of 22 participants who engaged in 20-30 sessions of NEAR over a 16 week period with a “waiting list” of participants who did not engage in any NEAR sessions during the same period who became the control group.

COGNITIVE REMEDIATION – “NEAR”

Following the NEAR sessions, significant improvement in the “immediate treatment” group was found compared to the “waiting list” group in attention, visual processing speed, executive functioning, verbal and visual memory.

When the “waiting list” group then engaged in the same number of sessions, both groups were found to show similar levels of improvement.

COGNITIVE REMEDIATION – “NEAR”

Gains in both groups persisted when participants were reassessed four months after the program ended.

A meta-analysis of 26 studies involving 1151 participants also showed that cognitive remediation produced at least moderate improvements for all participants in cognitive performance, symptoms and everyday functioning.

The meta-analysis also found that cognitive remediation was even more effective when combined with psychotherapy.

STRESS MANAGEMENT

Individuals with schizophrenia can be very sensitive to stress and change so stress management is important.

Stress management involves the use of various techniques to alleviate or cope with the effects of stress, usually for the purpose of improving everyday functioning.

The same stress management techniques used by those without schizophrenia (biofeedback, meditation and relaxation, physical exercise and social support) are also effective for those with schizophrenia.

STRESS MANAGEMENT

Additional techniques for people with schizophrenia may also include:

Learning strategies for active problem-solving Learning to recognise stress symptoms Awareness of when stress may be experienced

or has commenced.

Research indicates that reducing stress through stress management techniques for people with schizophrenia can help prevent relapse or rehospitalisation.

SOCIO-CULTURAL FACTORS

Socio-cultural factors involved in the development and persistence of schizophrenia are in 2 categories:

1. RISK FACTORS – factors in an individual’s environment that

can increase the likelihood of the onset of schizophrenia or worsen symptoms of those already with the disorder.

2. SUPPORT or PROTECTIVE FACTORS - factors that can decrease the likelihood of

the onset of schizophrenia or alleviate symptoms of those already with the disorder.

RISK FACTORS

Risk factors for schizophrenia include:SOCIAL DISADVANTAGE

- circumstances precluding access to life opportunitiesTRAUMA

- extremely distressful eventsPSYCHO-SOCIAL STRESS

- stress due to experiences in everyday life

SOCIAL DISADVANTAGE

Social disadvantage is a broad term used to refer to the range of difficulties that block life opportunities and prevent people from fully participating in society.

E.g. Poverty, poor physical or psychological health, disability, lack of education, lack of work skills, being subject to unfair treatment or discrimination

Rate of schizophrenia tends to be similar across all cultures throughout the world, but research shows it is disproportionately concentrated among people who are socially disadvantaged.

SOCIAL DISADVANTAGE

Socioeconomic status (SES) is a common measure of social disadvantage.

Socioeconomic status is a combined and total measure of an individual’s or family’s social and economic position (“status”) in society, relative to others based on income, education and employment (or occupation).

SES is typically divided into 3 categories – high, middle and low SES.

SOCIAL DISADVANTAGE

People in high SES or middle SES can experience social disadvantage due to disability or ethnicity for example, but there is far more prevalence of social disadvantage in people with low SES.

In some large cities, schizophrenia is up to 5 times more common among people living in the poorest areas and at the lowest socioeconomic level than at the highest.

Two hypotheses have been proposed to explain this prevalence: Social causation hypothesis and Social drift hypothesis.

SOCIAL CAUSATION HYPOTHESIS The social causation hypothesis proposes that

being a member of the low SES group can trigger the development or onset of schizophrenia.

One reason given to support this hypothesis is that in this group, people have more exposure to chronically stressful life experiences – e.g. Ongoing lack of basic necessities, poor accommodation, menial employment, unemployment, financial worries, feeling a lack of control over one’s circumstances.

SOCIAL CAUSATION HYPOTHESIS People in the low SES group also tend to

have less access to social support.

People in the middle and high SES groups tend to have more positive life experiences to offset the negative ones, have a bigger social network and better access to social support when needed.

SOCIAL DRIFT HYPOTHESIS

The social drift hypothesis is also called the downward drift hypothesis and it proposes that people are in a low SES group as a consequence of schizophrenia.

This hypothesis proposes that the deterioration of mental health or onset of schizophrenia occurs first, resulting in their “drifting downward” to the lowest SES group.

SOCIAL DRIFT HYPOTHESIS

The schizophrenia creates difficulties in effectively functioning in everyday life so they are unable to maintain full time employment which leads to financial difficulties which can lead to “drifting” to poorer areas.

Research evidence supports both hypotheses. Each is applicable to some individuals.

TRAUMA

In relation to mental health, trauma refers to an event that a person experiences, witnesses or confronts that is extremely distressing and to which the person’s response involves intense fear, helplessness or horror.

In many cases, the threat of personal harm is sufficient to produce trauma.

The effects of psychological trauma may be partly overcome, entirely overcome or not overcome.

TRAUMA

The individual’s subjective response is an important part of understanding their immediate and subsequent psychological functioning following trauma.

Research indicates that certain events are more likely to be perceived as traumatic by most people: Childhood sexual, physical or emotional abuse Rape Natural disasters War experiences Serious car accidents

TRAUMA

The psychological effects of trauma vary among individuals but are likely to be most severe if the trauma is: Caused by another person and is repeated,

unpredictable, multifaceted, sadistic, Experienced in childhood and/or committed by a

caregiver.

Research indicates that key psychotic symptoms of schizophrenia such as delusions and hallucinations, are more prevalent among people who have experienced psychological trauma than among the general population.

TRAUMA

Research has shown that experiencing one trauma did not significantly increase the likelihood of psychosis. However, experiencing two or more types of trauma significantly increased the likelihood of psychosis, with dramatic increases associated with experiencing all trauma types.

This DOES NOT MEAN however, that trauma actually causes schizophrenia.

If a person has a genetic predisposition to schizophrenia, it is possible that exposure to a trauma may result in the onset of schizophrenia through interaction with other contributory factors.

TRAUMA

Research evidence indicates that it is more likely that an individual will NOT develop schizophrenia as a result of trauma, as most people who have experienced trauma do not develop psychotic symptoms, schizophrenia or any other psychotic disorder.

PSYCHO-SOCIAL STRESS

Stress in itself does not cause schizophrenia.

Stress though, can act upon a pre-existing vulnerability to trigger the onset of schizophrenia or worsen symptoms.

A psycho-social stressor is any event arising in the course of everyday life through interaction with others or society in general that causes or contributes to a stress response.

E.g. Daily hassles, extraordinary and unexpected major life events that can cause trauma, inadequacy of personal resources or social support.

PSYCHO-SOCIAL STRESS

One or more stressful events of sufficient strength may interact with other risk factors and trigger the onset of schizophrenia or relapse, depending on the interaction between the person and the event.

Most research on psycho-social stressors has focused on the effects of family environments.

E.g. Dysfunctional parenting, disturbed family communication styles, constantly critical parental styles that induce guilt.

PSYCHO-SOCIAL STRESS

A 40 year longitudinal study found the adopted children with a biological mother who had schizophrenia had a much higher rate of schizophrenia than did the control group when the children were raised in a psychologically dysfunctional family environment.

When children were raised in a psychologically healthy adoptive family environment, they were about as likely as the control group children to develop schizophrenia.

PSYCHO-SOCIAL STRESS

However, living in a psychologically health family environment did not make children with a genetic history of schizophrenia immune to the development of the disorder as 5.8% of the “high genetic risk” children developed schizophrenia even though their family environment was psychologically healthy.

See Fig. 16.24 on page 807.

The healthy psychological environment MIGHT counteract an individual’s genetic predisposition and thus vulnerability to schizophrenia.

PSYCHO-SOCIAL STRESS

Other family environment research involving psycho-social stress is focused on a specific communication pattern called expressed emotion.

Expressed emotion (EE) is a negative communication pattern that is observed among some relatives of individuals with schizophrenia and that is associated with relapse rates.

EXPRESSED EMOTION (EE) Expressed emotion has 5 elements:

Critical comments – criticisms rate on content and/or tone.

Hostility – statements of dislike or resentment to family member with schizophrenia

Emotional overinvolvement – presence of an exaggerated emotional response to the person’s mental disorder.

Warmth – the sympathy, concern and empathy relatives show when talking about family member with schizophrenia, interest and enthusiasm for their activities, number of spontaneous expressions of affection, tone of voice

Positive remarks – statements that express praise, approval or appreciation of the behaviour or personality of the family member with schizophrenia.

EXPRESSED EMOTION (EE)

The 5 elements are used to calculate an EE index or “score”.

High EE family environment tends to be stressful due to lots of negative criticism, overinvolvement of certain family members and expressed hostility.

E.g. Belief that the psychotic symptoms are under the control of the person – “you’ve caused the family alot of trouble”

Low EE environments are not stressful and characterised by warmth, affection, positive comments and interactions.

EXPRESSED EMOTION (EE)

The EE index strongly predicts the course of schizophrenia NOT it’s cause.

An Australian meta-analysis of 26 research studies by Kavanagh (1992) found that more than twice as many people suffer relapse in a high-EE environment (48%) than in a low-EE environment (21%).

A limitation of Kavanagh’s review is that it was based on studies in Anglo-American families and high-EE is not associated with relapse in Mexican-American families as found by Lopez et al. (2004)

EXPRESSED EMOTION (EE)

There is concern that the EE explanation of relapse may be used to blame families for schizophrenia.

However, negative behaviour patterns of family members is supported by research to be a source of stress that can actually increase the chance that psychotic symptoms of schizophrenia will persist or worsen, at least in certain socio-cultural environments.

The dysfunction in families may also be due to the bizarre behaviour of the family member with schizophrenia which may promote dysfunctional communication and interaction within the family.

STRESS-VULNERABILITY MODEL

The role of psychosocial and other stressors may be explained by the stress-vulnerability model.

The stress-vulnerability model proposes that:1. Vulnerability to schizophrenia is mainly biological2. Different individuals have differing degrees of vulnerability3. Vulnerability is influenced partly by genetic influences on

development and partly by environmental risk factors4. Risk factors such as exposure to poor parenting, a high

stress environment or inadequate coping skills may help determine whether schizophrenia appears, it’s course and likelihood of relapse.

5. Protective factors such as good social support and taking medication as prescribed may also influence the course of the disorder and likelihood of relapse.

SUPPORT FACTORS

Support may be provided by:

Psychoeducation (learning about the disorder)

Caring social environments (including the family)

Removal of social stigma

PSYCHOEDUCATION

Psychoeducation is the process of increasing an individual’s knowledge and understanding of their mental disorder and it’s management.

It is based on the assumption that knowledge assists with coping effectively with psychotic symptoms, reducing the likelihood of relapse or rehospitalisation.

It is part of an overall management plan, often involving family members and other carers of the individual with schizophrenia.

PSYCHOEDUCATION

Psychoeducation can be implemented in a number of different formats, depending on factors such as the individual’s symptoms, age, and their circumstances and needs.

Psychoeducation programs can be: Group based Family based Parent based Individually implemented

Most commonly psychoeducation programs involve the individual with schizophrenia.

PSYCHOEDUCATION

Psychoeducation programs may involve: Interactive learning such as role plays and

discussion Resources such as pamphlets, DVDs and

computer-based training programs

Research has shown that the more educated the person is about their mental disorder the more control the person has over their disorder.

PSYCHOEDUCATION

Common content of psychoeducation programs for schizophrenia are: The nature of the disorder (e.g. Symptoms, diagnosis) What schizophrenia is like for individuals Stigma attached to diagnosis Experience of living with someone who has schizophrenia Identifying trigger factors Medication Role of hospitalisation Types of psychotherapies available Realistic expectations Healthy lifestyle Stress management Emergency responses Financial, legal and social support available

PSYCHOEDUCATION

Benefits include: Improved co-operation with treatment (e.g.

Taking medication) Improved co-operation with therapeutic

strategies Increased awareness of “early warning signs”

of relapse Reduced number of hospital admissions due to

psychotic symptoms Improvements in daily functioning Improvements in understanding of their illness.

SUPPORTIVE SOCIAL ENVIRONMENTS

Family Family is often the primary source of long

term support. Research shows that recovery is aided if

management strategies involve a teamwork approach between the individual and their family, doctor and mental health professional.

Families can provide ongoing emotional support as well as practical support to take medications, attend scheduled appointments, eat healthily and get regular physical exercise etc.

SUPPORTIVE SOCIAL ENVIRONMENTS

Family Following psychoeducation the family can

provide information to help clarify a diagnosis and aspects of medical treatment

Help identify early warning signs or symptoms Keep records of effectiveness of medication Access community resources Encouraging role in assisting return to social,

academic and vocational activities.

SUPPORTIVE SOCIAL ENVIRONMENTS

Family The primary family caregiver must first come to

terms with the diagnosis of the family member as the diagnosis can have a serious emotional impact on the family as well as the individual.They may feel angry this has happened in the family, concerned for the impact on themselves and the family, confusion, a sense of loss and grief at how the person has been changed by their illness.

It is important to acknowledge and talk about these feelings, seeking professional support if necessary.

SUPPORTIVE SOCIAL ENVIRONMENTS

Family The carer needs to develop a sense of

balance between: Acknowledging effects of the illness Wanting to do things to help the person but

encouraging them to be independent Showing care but not being overinvolved Giving the person time but having time for

self and other family members too Encouraging the person to do things but

not being unrealistic and demanding

SUPPORTIVE SOCIAL ENVIRONMENTS

Social networks Research indicates the social support provided outside

the immediate family is also important in the management of schizophrenia and can reduce the risk of relapse.

The social network refers to the various individuals or groups who maintain relationships with an individual in different aspects of their lives.

The relationships in a social network usually have some kind of significance to the individual e.g. Relatives, close and other friends, neighbours, work colleagues, teachers, acquaintances, family doctor, priest, local shopkeeper, hairdresser etc.

SUPPORTIVE SOCIAL ENVIRONMENTS

Social networks Which of these people are important and

thus part of a social network depends on the individual’s lifestyle.

Within a social network, some people know each other and thus have some kind of connection with each other, as well as with the individual.

SUPPORTIVE SOCIAL ENVIRONMENTS

Social networksMain benefit of a person’s social network is it gives access to social support (help or assistance) from other people when needed.

Appraisal support – someone to talk to and obtain feedback about how they’re feeling

Tangible assistance – help with routine chores at times when energy and enthusiasm for such tasks is low

Information support – e.g. The web address of a social network for people with schizophrenia, the location of a community support group or info about the potential value of these sources of support

Emotional support – help in coping with problems being experienced or just having someone to spend time with and feel like someone cares and understands

SUPPORTIVE SOCIAL NETWORKS Social networks Research indicates that social support

may be a predictor of long term survival among people with schizophrenia.

Results of one study indicated that people with schizophrenia who had frequent social interaction lived on average 25% longer than people with schizophrenia who had little or no social interaction.

REMOVAL OF SOCIAL STIGMA Stigma means a mark or sign of disgrace or

discredit.

To stigmatise means to regard a person as unworthy or disgraceful.

Social stigma describes the attitudes, beliefs and behaviour towards people who are stigmatised.

In relation to mental disorders, social stigma refers to negative attitudes and beliefs held in the wider community and society in general that motivate people to fear, reject, avoid and discriminate against people with a mental disorder.

REMOVAL OF SOCIAL STIGMA All mental disorders attract some degree

of stigma. Schizophrenia is the most stigmatised of

all.

Social stigma has 3 components: Stereotyping Prejudice Discrimination

REMOVAL OF SOCIAL STIGMA Stereotyping – grouping or

categorising people and attributing the same characteristics to all the individuals in that group, regardless of group members’ individual differences.

A problem with stereotyping is that it can lead to prejudice, which can then result in discrimination.

REMOVAL OF SOCIAL STIGMA Prejudice – holding a negative attitude towards the

members of a group, based solely on their membership of that group.

Discrimination – the behavioural consequence of prejudice – refers to positive or negative behaviour that is directed towards a group and its members.

Discrimination based on prejudice results in the unfavourable treatment of a person e.g. Denial of opportunities in education, employment, housing, financial loans, health insurance, access to certain premises, clubs and sports solely because of their history of schizophrenia.

REMOVAL OF SOCIAL STIGMA Social stigma against people with

schizophrenia occurs mainly because of a misunderstanding of the disorder.

E.g. That they are violent, unpredictable, incompetent, unintelligent etc.

One explanation for this social stigma is the fictional way movies, TV, and books portray people with schizophrenia.

REMOVAL OF SOCIAL STIGMA Social stigma can have profound negative effects

on the wellbeing of the person with schizophrenia. It can result in self stigma.

Self stigma occurs when individuals with a mental disorder apply negative stereotypes to themselves.

E.g. “I am weak”, “I will always be loony”, “I must have done something to bring this on myself”

Stigma adds unnecessary stress, lowers self esteem and increases feelings of hopelessness.

REMOVAL OF SOCIAL STIGMA People with self-stigma may be so

embarrassed or ashamed by the symptoms they try to conceal them and fail to seek support. This can be harmful as:

Longer periods of medically untreated psychosis are related to slower recovery rates and reduced chances of full recovery, greater relapse rates and lower levels of social and occupational functioning.

Early diagnosis and treatment leads to improved recovery and a better outcome.

REMOVAL OF SOCIAL STIGMA Copy Table 16.1 on page 813

A nationwide Australian study on the mental health and wellbeing of people with a mental disorder found: People with psychotic disorders are often

victims of violence Social isolation is widespread among people

with a psychotic disorder Almost 40% reported having no “best friend”

with whom they could share thoughts and feelings

REMOVAL OF SOCIAL STIGMA A study conducted in 2000 by SANE Australia

found that the number one factor that would improve the lives of people with schizophrenia was removal of social stigma – responses from people with schizophrenia, families, carers, and mental health workers.

Three strategies for the removal of social stigma are: 1. Protest (reactive) 2. Education (proactive) 3. Interpersonal contact (proactive)

REMOVAL OF SOCIAL STIGMA Protest A reactive strategy that attempts to change inappropriate

stereotypes and negative attitudes by actively and visibly highlighting misrepresentations about schizophrenia (and other mental disorders) when they occur.

E.g. SANE Australia runs an internet based program called StigmaWatch that monitors print and electronic media and asks the public for reports of stigma.

SANE then reports cases on their website, contacts directly those responsible who are encouraged to engage in more accurate reporting in the future.

StigmaWatch also provide positive feedback to the media about accurate and responsible reporting and portrayals of mental disorder.

REMOVAL OF SOCIAL STIGMA Protest E.g. SANE Australia and the portrayal of schizophrenia

in the Jim Carrey movie “Me, Myself and Irene” – protest resulted in changes to the promotion for the home video version in Australia.

Individuals can also protest against social stigma by giving appropriate feedback to friends, relatives and others who use terms such as “psycho”, “lunatic”, “nutter”, or “schizo”.

Also, using language such as “a person with schizophrenia” rather than “a schizophrenic” emphasises the disorder is a part but not all of the individual.

REMOVAL OF SOCIAL STIGMA Education Education attempts to remove social stigma by

providing the community with information about mental illnesses that helps people identify inaccurate and negative stereotypes and replace these with accurate, factual information.

Education can be in forms such as: Books, brochures Lectures DVDs, audio CDs Posters Curriculum materials for school programs TV commercials

REMOVAL OF SOCIAL STIGMA Education A key aspect of StigmaWatch by SANE Australia

is to educate via positive feedback to the media about accurate and responsible portrayals of mental disorders.

Research shows that the more knowledgeable people in the general population are about mental disorders, the less likely they are to endorse, support or engage in stigma and discrimination.

REMOVAL OF SOCIAL STIGMA Interpersonal contact For many in the general population, their

only known exposure to people who they perceive as having a mental disorder is of people who are homeless and not receiving any treatment or support, and are seen talking to themselves or going through rubbish bins.This adds to the stigma as this becomes the standard image of people with a mental disorder.

REMOVAL OF SOCIAL STIGMA Interpersonal contact Research shows that public attitudes towards

people with a mental disorder found that previous contact with someone who has a mental disorder is associated with more positive attitudes and reduced social stigma.

So, a strategy that promotes interpersonal contact with members of the stigmatised group, by encouraging or creating opportunities for face to face mutual interaction is important in reducing social stigma.

REMOVAL OF SOCIAL STIGMA Interpersonal contact The more familiar a person is with a mental

disorder, the more likely they will be accepting of those individuals with the disorder and less likely to fear and avoid them.

Knowing them provides accurate information that most people with the disorder are not dangerous and can lead worthwhile lives, corrects any negative stereotypes and prejudiced attitudes and thus, their negative behaviour.

REMOVAL OF SOCIAL STIGMA Interpersonal contact Not as effective as direct interpersonal

contact, but programs that use prominent “speakers” who have a mental disorder to make presentations in schools and the wider community are another means of contact to help break down stereotypes, reduce prejudice and stigmatisation.