Transcript for:
Understanding Schizophrenia: Diagnosis and Treatment

so today I'm going to be covering the second topic from chapters in Clinical Psychology I've already posted one some time back on impulse control disorders this one is technically the first one that appears in order if you look at it from five chapters in The Textbook and this is on schizophrenia so if you've seen my video on impulse control disorders you would know that I talked about how the chapters in Clinical Psychology are split into three sections which are your diagnostic criteria then the explanations and finally you have your um treatment and management now the diagnostic criteria focuses on the guidelines that one must follow in order for an individual to be accurately diagnosed with a certain Disorder so we often refer to the international classification of diseases the ICD the 11th edition of it so the icd1 um you guys are probably familiar with the DSM which was looked at in the button phobia study and that's basically a manual with the criteria and symptoms for different psychological disorders so I believe the current one um that is being used is the dsm5 so similar to that we have another diagnostic tool or guideline which is the icd1 and like I said it stands for the international classification of diseases so that is a very reliable and validated diagnostic tool that we can use to help us characterize different disorders such as schizophrenia and help us understand what are the symptoms um what are the different uh types of disorders that fall under a certain disorder and um how long like what should be the duration in order for someone to be diagnosed with a disorder so all of that is covered in this section of the diagnostic criteria so let's see what we learned about schizophrenia in the diagnostic criteria so it falls under the logic category of psychotic disorders and psychotic disorders involve a major break from reality where the individual tends to perceive the world in a very different way than how others would so people who go through psychotic episodes under psychotic disorders they tend to view the in a very different manner um and you'll come across some symptoms that we'll be discussing but you're probably familiar with terms such as delusions and hallucinations right where people may hear or see things that are that seem very real to them but for others around them you know um they may not exist so their perception of the world uh in their mind is very different and they may start seeing or hearing voices or seeing things which don't necessarily exist so schizophrenia is a severe type of psychotic disorder and icd1 sorry characterizes schizophrenia by disturbances in an individual's thoughts feelings emotions and behaviors this is more of a general definition of what schizophrenia is according to the icd1 um it says over here that this was developed by the icd1 was developed by the World Health Organization and it is a global standard for coding health information and includes both physical and mental health disorders it's globally accepted so it's very validated and reliable tool okay moving on so according to the icd1 let's try to understand what are the symptoms of schizophrenia now the schizophrenia symptoms fall under two main categories positive symptoms and negative symptoms now you would think that positive symptoms refer to good and negative refers to bad but at the end of the day it's a disorder so you know symptoms aren't really ever good right so positive symptoms over here do not refer to good symptoms okay um the word positive over here has a different meaning they are essentially talking about um experiences that are an addition to normal behavior or a distortion of normal behavior or experience so think of positive as additional extra behaviors so more than the norm so almost like saying abnormal behaviors so unusual behaviors extra behaviors which people tend to not normally display okay for example hallucinations right um let's take a look at four examples of your positive symptoms that one may experience with schizophrenia disorder persistent delusions now delusions are a word that we tend to throw around um in our everyday um you know the way we use it in everyday life it's not very accurate the way we use it because delusions when someone is suffering from let's say delusional disorder it's very different to the way we understand delusions so delusions we know are false beliefs that people hold that are not really based on reality and it's common for people even without schizophrenia to be delusional experience certain delusions but the key term here is persistent delusions so what we'll see is in the whole of Clinical Psychology not just in this chapter of schizophrenia but there will be certain symptoms certain behaviors that you know um while you're also going over it you might think you know what this is something that applies to me this is something that I go through does that mean that I have this disorder will not necessarily because it's possible that individuals may experience symptoms or behavior similar to these symptoms but it's not for a prolonged period of time it's only when some of these symptoms are persistent extremely severe and causing a major hindrance to your daily life to your regular functioning that's when it becomes perhaps a symptom of a disorder so delusions are beliefs that people hold that are not based on reality for example thinking that someone wants to harm you thinking that um you know maybe someone is conspiring against you and is secretly plotting something against you and wants to hurt you or harm you now that's not completely possible but if it's highly unlikely you know for you to even think that way but you still do it's probably a delusion and if that's something that you are persistently and constantly thinking about it's a belief that you persistently have then it categorizes as a persistent delusion now delusions are beliefs hallucinations are more of sensory experiences where people see things or hear voices that don't exist so auditory hallucinations visual hallucinations you know people might see um certain um you know cartoon characters or they might start hallucinating About Angels or demons people have given different examples of what they see and you know a lot of people bring up the um another side of this argument which is that what if you know these are true you know because maybe it's uh they're trying to explain it from a spiritual or religious perspective that you know maybe they individual is able to see these um beings and we're not able to see it so that's a completely different um way of looking at it but from a psychological perspective we are going to analyze it as saying that these do not exist and they only exist in the mind of the patient with schizophrenia who's actually going through it who's suffering from it so you tend to view things you tend to see things you tend to hear voices that don't exist all right so and people who if you take certain drugs um it's possible that you may hallucinate so just because you're hallucinating and you're seeing things or you're hearing voices um as a result of a certain drug that you've taken or side effects of a medication that you've taken that doesn't mean you've got schizophrenia because the moment the effect of that drug wears off you know your behavior goes back to normal which is why again it says persistent hallucinations because someone with schizophrenia would not need to take the drugs for them to be experiencing these hallucinations it would occur more naturally and on a more consistent basis so that would be persistent hallucinations then we have thought disorder this is a third um positive symptom and as you can see these are all behaviors that are more than normal okay unusual abnormal behaviors an addition to the norm okay distorted behaviors almost so thought disorder is an inability to think and as a result speak in an organized manner so basically because you are unable to think clearly you're unable to speak clearly so your voice not your voice but your speech may seem very incoherent and very jumbled up and at times it will be very difficult for people to understand what you're trying to say because your thoughts are not organized and obviously if your thoughts aren't organized our speech is based on our thoughts so if our thoughts aren't aren't organized then when we speak our thoughts then our speech might be very incoherent and difficult to understand for other people so that's the third one the fourth one is similar to the first one experiences of influence passivity or control this is a belief that one's thoughts or actions are influenced or controlled by someone or something external so for example if you believe that aliens or the government are controlling you you and your thoughts and your emotions then this would be experiences of influence passivity or control where you feel that you're going through an experience that someone is controlling you controlling your mind controlling your thoughts controlling the way you behave and so on so these are all examples of positive symptoms let's take a look at negative symptoms now negative symptoms are symptoms where an individual um may experience certain behaviors that are less than normal okay so it's a level of functioning or experience that falls below normal levels and there are four types that we can talk about over here so positive symptoms are basically symptoms where you are experiencing additional Behavior negative symptoms are where you're experiencing behaviors that are less than normal so behaviors that you would normally expect people to display they're not even showing those for example avolition this is a lack of motivation and an individual with the disorder can experience this so avolition motivation is basically something that people can experience um you know certain things can motivate you but someone experiencing negative symptoms of schizophrenia particularly avolition May lack any real motivation to do anything along with that very common um negative symptom that people with schizophrenia display is flattened effect or flat effect this is when you look at their expressions and their face almost has a very flat expression they're not really displaying any visible emotion or expressions for example frowning smiling or any other type of expression they've got a very blank expression on their face third type is impaired cognitive function so people have a certain level of attention and memory but when you have a reduced level of memory or attention then that can be categorized as impaired cognitive function now again this doesn't mean that if you have poor memory and or you know very low attention span you've got a negative symptom of schizophrenia uh like again I said you have to meet the certain criteria that is mentioned in the icd1 so it's not that you just have to have one of these symptoms it's it could be combination of positive and negative symptoms and it also depends on the severity and the duration and lastly Catatonia so catatonic behaviors are or Catatonia is a lack of movement or speech so if you've ever met someone with schizophrenia you would perhaps notice that they don't really have any they're not very animated in their movement and their expressions they're often in very still rigid poses where they don't really move much and you might not even see them speaking much at all perhaps even at times just you know staring into space or just staying in one position and you know it's almost like a statue so that's Catatonia so again as you can see these are all behaviors regular normal behavior that are lacking in um these individuals so these would be negative symptoms and in order to be diagnosed with schizophrenia symptoms must have persisted for at least a month so when we say persistent hallucinations persistent delusions we are saying pretty much just you know at least a month and again it cannot be attributed to any other health condition any other any other psychological disorder substance abuse or even side effects of medication so if these symptoms are the result of side effects of medication alcohol um drugs or any other health condition then it cannot be considered as schizophrenia this is the diagnostic criteria um let's take a look at an example study to help us understand a real life case of a child with schizophrenia so this is a case study it's an example study now example studies are important as well so if anyone tells you that just focus on the key studies and not not example studies that is a lie both are equally important and you can be questioned on literally anything in uh a chapter so you can't really leave anything out so this is in 2018 by anija and it was on a boy who was 10 years old who started showing uh decline in his academic studies and general behavior and it was around two years later by the age of 12 where he really started showing some symptoms of schizophrenia for example auditory hallucinations where he started to hear voices and he believed that his mother along with other people could communicate with these voices he would often Scream and Shout at these voices and or at people who weren't there he talked to himself a lot he became quite erratic he his self-care declined wouldn't be sleeping much um he was taken to hospital where he was treated with medication to try and control his symptoms from getting worse and because he became really aggressive he was eventually reled relased from hospital through the medication sorry he was released from hospital once his aggressive behaviors were kept in check through the medication okay um he was diagnosed with having early onset schizophrenia now early onset disorders are disorders that occur in childhood so you would think that most disorders occur in adulthood but no it's possible for children to also get some certain disorders and experience symptoms of certain disorders and if children experience certain disorders then we categorize that as early onset disorders so this child was diagnosed with early onset schizophrenia so some of his behaviors were kept in check with medication however he still suffered from some negative symptoms and because of those negative symptoms he displayed behaviors such as social withdrawal apathy and this would lead to him resisting wanting to go into school because obviously you know it would um be a little difficult for him cause him psychological harm because you know he's going through a lot of mental distress because of his condition this was very short and simple case study to help us understand a real life example of a child with schizophrenia now we're still under the diagnostic criteria because we're still learning about different symptoms and one of the symptoms was persistent delusions so over here we're talking about types of delusions okay um delusional disorder is a type of psychotic disorder as well and delusions are part of schizophrenia it's a symptom of schizophrenia but you can have delusions in isolation you can have delusional disorder where you know you only have delusions and you may not necessarily have the other symptoms of schizophrenia as well but because delusions are part and they're one of the positive symptoms of schizophrenia um we are going to be discussing the different types of delusions that someone with schizophrenia could potentially experience so delusions fall under two types bizarre and non-bizarre bizarre delusions are those that are highly unlikely almost impossible you know like like perhaps believing that aliens abducted you and conducted experiments on you so almost like impossible so for them to occur but you believe that it did so that's a bizarre delusion okay a non-bizarre delusion is one that is highly unlikely but still probable for example thinking that your partner is having an affair and cheating on you now let's say you know you don't really have any evidence or any reason to think that way so that would be you know delusion but it's still something that is not completely unrealistic so that would Cate be categorized as a non-bizarre delusion so there are three types of delusions that are in your syllabus persecuted delusions are perhaps the most common that people with schizophrenia experience this is a delusion where an individual believes that others are conspiring against them and are pursuing them to cause them harm so if you ever met someone with schizophrenia you might notice this erratic behaviors of behavior of theirs where they feel that you you know there's someone who wants to harm them or some people who want to harm them um they can become very paranoid as well and I actually um know someone um who wasn't taking their medication and then they started becoming very hostile and aggressive so their family had to call the doctor uh the doctors to come and take them to the hospital to kind of control their behaviors and almost force them the medication um so this individual when they saw the doctors come they thought that these doctors are hear from you know some people from the government who have come to take her away and do experiments on her so she thought that they were conspiring against her and they wanted to harm her so she kind of locked herself up in the room and then when they came up to kind of get her out she went to the balcony and I think she was also like trying to jump over the roof or something so just to try to escape them so you know it's that's definitely a persecuted delusion that she was experiencing so these are perhaps the most common delusions that people with schizophrenia experience um because they become so paranoid their behaviors can become erratic and aggressive and at times it can even make them very dangerous to others around them grandio delusion is another type where people believe that they have some special ability or special power for example you know there's some superhero or they have some very special status or purpose in life like they're the savior of mankind or something right so at times they might think that you right now I'm living a normal life but I am destined for greatness now obviously that's people can think that way and you know you can use that to motivate you to achieve great things in life but if you genuinely believe that your you've been put on this Earth for this particular purpose to save Mankind and you know you are a Humanity Savior and you've got some special skill special power which only you have that's probably a grandio delusion delusions of reference is a belief that some experiences in the environment such as a TV program is talking about you okay you're part of some event watching ing a TV is and you think it's based on you and they're talking about you so that's delusions of reference now there are other types of delusions as well these two were part of the previous syllabus so I'll still cover them even though they're not any they're no longer there in your textbook but it's good to know a few more just in case otomatic and jealousy delusions otomatic delusions are delusions where you believe that someone is in love with you again it's possible but if it's let's say someone you haven't even ever met like for example you know you think you've never met Cristiano Ronaldo but you think that he's absolutely in love with you you know that's obviously a delusion it's an aotomatic delusion jealousy delusion a belief that one's partner is cheating on them again this is more of a non-bizarre delusion yes you know if there are reasons for you to think that way fair enough but if there's absolutely no reason for you to think this and you still are believing it then it's probably more of a delusion and similar to schizophrenia for someone to be diagnosed with delusional delusional disorder you must experience these symptoms for at least a month or longer and it should not be attributed to substance abuse or explained by any other psychological or mental disorders now every chapter in Clinical Psychology has one key study and although key studies are important it doesn't mean you focus only on these and you ignore the example studies but key studies are a little more detailed um key studies are definitely going to be included in paper 4 uh there is no guarantee that they will come in paper three sometimes your six Mark describe and 10 Mark evaluation can be just on the entire key study and at other times it could be on two or three example studies so you know make sure you've covered everything and don't leave any one particular topic out so let's take a look at the key study the key study for this chapter falls in the diagnostic criteria and with this we can conclude the diagnostic criteria for schizophrenia and the name of the key study is symptom assessment using Virtual Reality by Freeman in 2003 so if any of you ever do any research on the Freeman study let's say you decide to you know um go online and get some more information about this study for the purpose of your studying and your um you know maybe you want to get some extra information about the study for your exam you might come across another study by Freeman which was conducted in 2008 and that was similar to this but it was a different study as you know because it was on different participants the setup was different and that was actually a study that was part of the previous syllabus this time they're giving the 2003 study as opposed to the 2008 one so if you do come across another VR study by Freeman please don't get confused don't mix up the two so what is VR virtual reality um you guys your age should be familiar with this you know a lot of people um nowadays you have these games that are based on where you put on this headgear and there is the screen uh and you can have some controls or gloves so you're completely immersed in this computer simulation in this fake environment and the characters or animations that are in this environment are referred to as avatars and you know you may interact with them if you're playing a game it seems very real to you so VR is you know used obviously for the purpose of games and Leisure but it can also be used for purposes psychological purposes as well for example um VR has been used for helping people with you know focusing on their public speaking improving their public speaking people with social anxiety who get a little nervous and anxious around people in their daily lives they can perhaps train to become a little more confident around uh a lot of people by putting on this VR headgear and being around a bunch of avatars so they know the environment isn't real but um by doing so they can kind of condition themselves to be a little more comfortable around a group of people without actually having to be around a group of people and once you know they're a little more comfortable in the VR setup then perhaps they can you know go to the real world and then see if they feel an improvement in their social anxiety or not so yes it's used for um many purposes it can also be used to help people with psychological disorders such as treating phobias okay for example social anxiety some people have agoraphobia which is a phobia of being in you know public spaces so in this study Freeman is using virtual reality to assess symptoms of persecutory ideation which is pretty much the same as persecutory delusions we just talked about persecutory delusions so persecutory ideations is the idea that you think someone wants to harm you is conspiring against you so we want to see if we can use Virtual Reality to assess for symptoms of persecution ideation or persecuted Illusions so in the real world if you have persecuted Illusions it can be a little difficult to determine if these are real or not you know if you think someone is conspiring against you someone wants to harm you someone is judging you someone is laughing at you um it's difficult for us to ascertain if that is a delusion or if that is really the case because in the real world you know there are a lot of variables that you cannot control but in a VR setup you know the entire setup is artificial so if you're interacting with these animated avatars and you think that they want to harm you or they want to hurt you and they're judging you or laughing at you and you genuinely believe that then we know that that is definitely a persecuted illusion because it's not even a real setting they're not real people so this could be a good way to help us understand if someone might be experiencing persecutory ideation which is why this is called symptom assessment using VR using virtual reality as a tool to assess for symptoms such as persecutory ideation in people because therapy can be a little difficult um to try and really say for sure if the symptoms that or the delusions are describing are real or not so VR is perhaps giving us a deeper insight into an individual's possible delusions now the catch here is that the sample of the study isn't on people with schizophrenia it's actually done on a non-clinical group a non-clinical group means a group of people without any mental or psychological disorders or mental illnesses so the sample of Freeman study are actually people without any Med mental illness they don't have schizophrenia and I told you earlier it's possible for people even without a disorder to have delusions to have persecuted Illusions because you can be paranoid about things but again it doesn't mean that you are you have delusional disorder because you know we talked about the diagnostic criteria it should be there for at least like um a month and it should be persistent but it is possible that people without the disorder can experience these um delusions as well you can be paranoid you can experience certain delusions even though they don't necessarily have to be persistent but nonclinical people and people without disorders they can have uh ideas of persecution that's why it's good called persecutory ideation you have certain ideas or thoughts of paranoia in certain situations right it's it's common you know you might be in a certain situation where there are people around you you hear them laughing and you know you you think that they're laughing at you you think they're judging you which in reality might not be the case it's human nature so that's um you know because paranoia is associated persecutory ideation persecuted delusions so rather than really calling it a delusion that's why instead we're referring it to as uty ideation okay ideas of persecutory thoughts or paranoid thoughts so that's something that people without any disorder can experience as well and we want to see if we can assess those symptoms assess these behaviors assess these ideations while using VR so the sample of the study will actually be tested in a VR setup where they'll be interacting with these avatars these animated characters in a simulation and we want to assess if we can pick up any persecutory iations that these participants May display so the sample is not a very large one it's just 24 individuals 12 male 12 female 21 of whom are actually students from University College London in the UK and three of them are admin staff making up the average age of 26 years not a very generalizable sample um none of the participants had any mental illness so you cannot generalize it to people with um mental illnesses you cannot ize it to a larger group of people people outside this University people outside UK so you know cultural differences must be taken into consideration they're all of certain age range as well so generalizability would be a weakness of this study and they were recruited through a volunteer sample um where they responded to an ad this is important for paper four research methods what's the procedure now now I've said it's a lab experiment but to be fair it's more of a correlational study um um with the use of self-report um treat it like a controlled setup which is why I've called it the lab experiment but it's not really an experiment because technically there isn't an ibdv but there are many controls it's better to refer to this as a correlational study with the use of a lot of self-report the participants were initially trained on how to use the VR and the setup that they would be in would be a library scene so the simulation was of a library they would each view the simulation for 5 minutes so that's a control and um it would involve uh five avatars three of them sitting on a certain desk and two of them sitting on another desk displaying different types of behavior such as smiling looking at the participant talking and so on um the participants weren't really told that their persecutory ideation was being tested because you want to avoid demand characteristics instead we were told they were told that they have to um interact or be immersed in this VR setup for around 5 minutes in this Library setup and they have to form an impression on what they think or basically form an impression on these avatars and give their opinions on what they think the avatars are thinking about them so if you are a participant I'm going to tell you to put this headgear on you'll be in this Library setup the simulation you'll see these avatars I'm going to ask you to tell me what you think these avatars are thinking about you okay and you know these questions some of them will be positive some of them will be negative um just to get an idea if you have like negative ideas about these avatars do you think that they are looking at you or judging you in a negative way so are you developing negative opinions about them or positive opinions about them that's basically what the participants are being told and that is something we do want to assess but for the purpose of testing for persecutory ideation so that purpose was not set to the participants now how are we going to collect data so you would think that you know if they're in a VR we could observe them and we could see if they're showing any persecutory ideation but it's difficult to observe that because persecutory ideations are thoughts and beliefs you can't observe someone's thoughts um so even if they are in this five minute setup and people are feeling you know or going through experiences of persecutory ideation um where the thing that avatars are maybe looking at them judging them um talking about them behind their backs that's something that we might not be able to very easily observe so observation wouldn't be the best technique to collect data instead self-report would make more sense where we can actually ask the participants what they think what do you think is going on how do you feel what do you so that's why we told them that they have to form an impression about the avatars and let us know their opinions about what they think the avatars are going through and think now one of the ways in which we can collect the this information is through questionnaires and the other is through interviews so basically self-report and a lot of questionnaires are actually being used to collect data so it's a relatively holistic approach to collecting information about um your symptoms one of the more important questionnaires being used is the brief symptom inventory you can just remember this as the BSI if you want you don't need to know the full form this is a 53 item self-report questionnaire which means the participants have to rate themselves and I think it's on a scale of 1 to four and it's assessing nine different symptom Dimensions over the past one week so what this questionnaire is doing if you see the term brief symptom inventory so it's getting an idea about different types of symptoms that you may be experiencing what type of symptoms nine different types which include things like depression anxiety interpersonal sensitivity which is a feeling of discomfort um or inferiority when you're interacting with people so you know sometimes people they interact with others and they feel a sense of inferiority almost like an inferiority complex when talking to others that's interpersonal sensitivity so we've got nine such symptoms and you know there'll be some items on interpersonal sensitivity some on depression some on anxiety some on hostility and so on this makes up a total of 53 items and you have to rate whichever of these symptoms which of these items for each of these respective nine symptoms apply to you or you feel you know relate to you or at least have related to you within the past one week okay the reason why you want to get information on these symptoms is because it's a correlational study we want to see if there is a correlation between any of these symptoms and persecutory ideation so for example if you're a very anxious person are you also someone who's likely to experience more persecutory ideation which would make sense because persecutor ideation is you know where you kind of feel a little paranoid because you think people are talking about you they want to harm you they want to hurt you and if you think that way then you know it's common for you to maybe feel anxious so that's why we're taking a look at these other symptoms and seeing if there's any correlation between these symptoms and persecutory ideation so you will let us know if you're experiencing persecutory ideation through certain questions that will be asked of you on the VR experience on the VR simulation and then we'll get an idea about any other symptoms through these questionnaires and then we'll see if there is a link or not okay um other questionnaires are just a general anxiety questionnaire a paranoia questionnaire um a sense of presence to see how much you felt that you were actually a part of that VR setup or did you feel like it was very fake and you know because if you think it's not very real and you are not very immersed in it then you might just be giving demand characteristics so if you're genuinely very involved and immersed in it and it feels very real to you then your responses will be a little more genuine and also specific ideations of persecution so people can have different persecutory ideation some might think that you know they want to harm me others might think that they're making fun of me so different types of persecutory ideations we're asking them questions on that as well there was also semi-structured interview that was cond conducted where you know we asked them questions about their anxiety about the parano and so on the questionnaires are mostly Clos ended on the rating scale from 1 to four now half of the participants with an equal number of males and females actually took the questionnaire once before going through the VR setup and then once again after the VR setup and the other half took it only after the VR simulation now why half the participants taking it before and after and the other half only after um again I guess you could say for demand characteristics to be tested because you know if there is a difference in the scores between those who are taking the questionnaire only once after the simulation and those who are taking it twice once before and one after then maybe you know um that is suggesting some sort of confounding variable because what if you're rating yourselves as being very paranoid or very anxious or maybe not at all paranoid or not anxious you go through the VR setup and then your ratings change after you take the questionnaire again so that's somewhat of a comparison that we're trying to make which is why half the participants are taking the question at tce once before and once after and um the other half are taking it only after the T what are the results there was a significant correlation between the scores on the paranoia questionnaire and the paranoia score in the interview so while interviewing you if you're rating you as being someone high in paranoia paranoia for those of you who don't know is basically when you are a little suspicious of people and that causes you to be a very you know be very worried and you know thinking that people want to hurt you or you know it's kind of like persecutory ideations so paranor is very closely linked to that um so those who actually rated themselves high on paranoia they also had a high score during the interview when the interviewer was trying to assess for your paranoia scores majority of the people had positive opinions of the avatars but some did show ideas of persecution for example one of the items that was given to the participants in the questionnaire was to rate if they thought that the avatars were talking about them behind their backs so the item they were talking about me behind my back 11 of the 24 did not agree with this so 11 are you know not really suggesting ideas of persecution eight slightly agreed three moderately agreed two totally agreed so there were two people who definitely experienced persecutory ideation and another three who potentially did and eight who kind of slightly did so there are some people you know with certain ideas of persecution um some more so than others so you know individual differences um but there were no differences in the scores or significant differences in the scores of males or females or even those who took the question there twice compared to those who took it um okay thoughts persecutory thoughts about avatars and paranoia SC do not have any significant correlation an important point is the second one those who actually had higher interpersonal sensitivity and higher anxiety were also the ones who had high levels of persecutory ideation in the VR so we seeing two very strong positive correlations anxiety levels and interpersonal sensitivity levels were very positively correlated with higher levels of persecutory thoughts so the more anxious the more interpersonal sensitivity that you have the more you're likely to experience persecutory ideations at least in this VR setup okay so the results conclude that um people do attribute mental states to VR characters and um they are usually positive but they can also be persecutory in nature and those with more levels or higher levels of interpersonal sensitivity or anxiety are also people who are more likely to experience these persecutory ideations so that is the study um we could maybe quickly evaluate it so I talked about the generalizability being low um sticking to some weaknesses maybe ethics because you know the volunteered so yes it's um there is consent but they weren't really told about um the real aim that they were testing for persecutory ideations you can kind of argue that consent wasn't provided provided for the true purpose of the study and potential psychological harm particularly those participants who did experience persecutory ideation and thought the avatars were maybe talking for example talking about them behind their backs so a little bit of ethical issues here um reliability the strength very standardized procedure everyone went through the same five minute simulation with the same avatars given the same rating skills to on so standardized procedure easily replicable for reliability um validity is also High because it was a very holistic approach so it's not reductionist if you talk about the issues and debates um because we're using multiple techniques to gathered data multiple questionnaires interviews quantitative qualitative data so you know looking at different symptoms and the link between different symptoms with persecutory ideation so it's a relatively holistic approach um what else can we say in terms of the individual situational debate I would say it's individual because everyone was in the same VR situation of a library but there was a big difference in persecutory ideation so 11 did not have any eight slightly three moderate and two total so these differences in scores are attributed to individual characteristics okay uh some were more anxious than others some had higher interpersonal sensitivity than others all of these individ ual traits are the reasons for why some people had higher persecutory ideations than others or why some did not have any at all so these are all individual points so the individual explanation is being favored rather than the situational over here the application of the study is um quite High because we can now use VR to assess symptoms of persecutory ideation in a valid manner because in the real world it might be a little more difficult to determine if the delusions are real or not um but in the VR setup we do know because it's an artificial setup so any persecutory ideation or any thoughts we know are um genuine um thoughts and they're not actually a case where the Avatar does want to harm you because we know it's not real setup but you know so that can be helpful in you know um diagnosing or assessing symptoms at least of um persecutory ideation but the issue is that one it's not generalizable so that can lower the general the application because it's not applicable to other a larger group of people people of different ages what about those who are older who don't really know how to use um virtual reality they might be really uncomfortable what about people of other cultures who you know um don't are not really accustomed to using VR so for them just the idea of being in a simulation can cause them a certain sense of paranoia in certain cultures so we must take into account cultural differences as well um ecological validity is also low because obviously just because they're showing persecutory ideation in we are it does not necessarily mean that this will um be the same behavior that people may display in the real world right because what is done in a simulation in an artificial setting cannot very easily be applied to real world experiences so ecological validity would be a weakness as well and we can end with one last issue in debate of the nomothetic ideographic debate ideographic refers to case studies qualitative data one individual um this is not a case study this is done on a group of people and you know it's getting a lot of quantitative data through um close-ended questionnaires and self-reports so this is favoring the nomothetic side of the debate on that note we can move on to the second um topic which is the explanations which focuses on the cause of the disorder and explanations in all five chapters all five disorders are typically split into biological explanations and psychological explanations so let's take a look at um the biological explanations of schizophrenia and within the biological explanations we have two the first one being the genetic explanation now over here we're looking at the role of obviously genes and the three types of studies that we'll be looking at to see if there is any genetic link for schizophrenia one is family studies which is the idea that you know if someone a close family member has schizophrenia um does that increase your chance of potentially developing the disorder more so than you know it um being developed generally because in the general population your chances of developing schizophrenia are 1% but does that shoot up if you have a close family member with the disorder so those are family studies then we have two twin studies so we want to see what is the likelihood that if one twin has schizophrenia the other is perhaps going to develop symptoms as well and over here we'll compare um Iden to nonidentical twins as well and thirdly adoption studies so let's take a look at what the genetic explanation says start off with family studies so family studies are studies conducted to investigate whether biological relatives of those with a disorder are more likely than non-biological relatives to be similarly affected um there's not much of a detailed study here but it says that a general trend has been shown um where people with close family members who have the disorder are also more at risk of developing symptoms of the disorder and um yeah so family studies again there's not much information here but what we do know is that if you have a close family member with the disorder your chances of developing the disorder increase compared to the general populations for twin studies there is very important um study by godsman in 1991 got and Shields and gsman noted that um the likelihood of developing schizophrenia is 1% in the general population but this increases to almost 50% if you have an identical twin with schizophrenia so this was tested through a study that he did on 57 pairs of twins which he actually got from a larger group of 467 twins at the modley hospital in London between 1948 and 1964 so 57 pairs of Twins and the twins that he got for his study were either monozygotic or dizygotic twins now monozygotic or dizygotic you don't have to know the full form you can refer to them as MZ for monozygotic or DZ for dizygotic monozygotic twins are identical twins twins that share 100% of their DNA completely identical and dizygotic are those that share 50% of their DNA and are non-identical twins and how did we find out whether the participants from the 57 how many were identical how many were nonidentical well you would think obviously by looking at them we' be able to tell but for a more valid um conclusion DNA testing was done to ascertain U which of these twins were um MZ and which were DZ now what is godsman looking for between these MZ and DZ twins he's looking for something called concordance concordance is the likelihood of one twin developing a certain trait and the Cowin also possessing that trait so concordance over here is the likelihood that if one twin has schizophrenic symptoms what's the likelihood that the other is going to potentially also develop the disorder okay so from the 57 24 were MZ Twins and 33 were DZ MZ being identical DZ being nonidentical now you obviously would you know um be able to figure out that MZ twins who share 100% of their DNA there's a greater chance or a greater concordance of schizophrenia for MZ twins than DZ twins because they share more of their DNA results actually showed a 50% concordance rate among MZ twins whereas for the DZ twins there was only a 9% concordance rate suggesting a genetic link so if you are an identical twin and your CT TN has schizophrenia your chances of developing schizophrenia shoot up by 50% whereas if if your Cowin who's non-identical to you you are DZ Twins and your Cowin as schizophrenia then your chances are only 9% so this was one twin study is it generalizable not at all um it's not even done on regular siblings it's only specifically twins so that's a bit of an issue with the study in terms of it generalizability hilker is the other twin study this is on a more large scale okay three 30,000 twin pairs in Denmark how did he get so many many twins he got their information through two national registers the Danish twin register and the Danish psychiatric Central register and when analyzing those who had schizophrenia he found a 79% heritability rate so for those twins who did have schizophrenia um they found that there was a 79% heritability of genetic link which means that their Cowin was also likely to also have the disorder so a 79% genetic link okay of them both developing the trait of schizophrenia and lastly adoption studies this looks at the similarities between adopted individuals and their biological parents so we want to compare children who have schizophrenia um those who have a biological mother with schizophrenia to those who do not who have a biological mother without schizophrenia so the children in the study who we studying are all who TN in 2000 is studying are all there most of them are children with SK schizophrenia and we're comparing those with a biological mother who has schizophrenia to those who have biological mother without schizophrenia and there was 6.7% children with schizophrenia who also had a biological mother with schizophrenia compared to only 4% of children who had a biological mother without schizophrenia so although they were adopted there was a higher chance of children developing schizophrenia if their biological mother also had it as opposed to if their biolog iCal mother did not have it what's the purpose of this study they're adopted maybe their schizophrenia could have been environmental that's what you want to see are those whose biological mothers who don't have schizophrenia are those the kids who are more likely to develop disorder or the ones whose biological mother does have schizophrenia and the ones whose biological mother did have schizophrenia more of those kids also developed the disorder compared to those whose biological mother did not 6.7% compared to 4% suggesting it is more genetic than it could be in environmental now this was the genetic explanation the three topics in terms of the nature nurture debate it's definitely nature because it's trying to explain the onset of schizophrenia through biological factors okay genetic um it's reductionist however because we're ignoring other factors we're ignoring biochemical factors the role of certain chemicals in the brain we are ignoring psychological or environmental factors which could perhaps explain the the onset of the disorder and even within uh the role of genetics it's focusing on for example godsman is focusing only on twins what about regular siblings right so it's very reductionist it's deterministic because if you have a c twin and you're identical then your cwin has schizophrenia then your chances shoot up by 50% that's not something you can do really anything about it's not your free will so it is deterministic it's also noetic because we're kind of establishing this law that if you have if you're an MZ twin then your concordance rate shoots up compared to a DZ twin right so um it's like a law that you're establishing about human behavior that genetics does play a role in u the onset of schizophrenia um so yeah these are just some evaluative points let's move on to the second biological explanation this is the biochemical explanation also referred to as the dopamine hypothesis dopamine is a neurotransmitter it's a chemical in the brain now to understand the role of dopamine we have to understand how the brain works your brain has billions of neurons or cells if you remember we talked about this in the as level study of on mindfulness by holil we understood how the brain works you've got cells or neurons in your brain okay and you know that signals are constantly being sent and received in your brain right messages are being sent and received that's how you understand information that's how you process information that's how you respond to information around you through these messages and signals being sent in your brain so these messages and signals are being sent from one neuron to the other and these neurons are in different areas of the brain so certain messages will be sent to for example neurons in the brokas region which is a part of the brain that is responsible for formation of language which allows you to speak allows you to talk allows you to speak in a certain language it's all because of messages being sent and received now how are these messages being transmitted from one neuron to the other through neurotransmitters okay these are chemicals that carry signals and messages from one neuron to the other one example of this chemical or these chemicals or neurotransmitters which carry signals is dopamine dopamine is a chemical or a neurotransmitter in your brain that carries messages from one part of the brain to the other and dopamine is referred to as a happy chemical when you get your grade and you get an A Grade you feel excitement you feel good you feel you know happiness that's because there's been an increase of dopamine in um your statom which would be the reward center of your brain so that particular part of the brain which is responsible for you feeling a sense of reward and excitement that would be receiving a boost of dopamine and dopamine is carrying the message of happiness right so that's basically what dopamine does that's how it works the dopamine hypothesis states that people with schizophrenia actually have un unusually and abnormally high levels of dopamine so dopamine increasing in the brain is not a bad thing you feel happy you feel good and then it goes back to normal because people have got an enzyme in their brain that kind of breaks down the dopamine allowing it to not be too high and being in a regular regulated and normal amount because once dopamine is in an unusually an abnormally high level in the brain it can cause problems it can cause you to now behave abnormally so the idea is that high levels of dopamine can lead to positive symptoms of schizophrenia okay so it does not necessarily mean that you're only going to be very happy too much doain for a long period of time can cause your brain to malfunction a little where you start experiencing positive symptoms such as hallucinations and delusions so under the biochemical explanation we're going to be looking at multiple pieces of evidence not just one study but multiple small small studies or pieces of evidence to kind of um understand the role of dopamine in the onset of schizophrenia so let's take a look at what it says it is believed that certain parts of the brain when they receive excessive or high amounts of dopamine such as the broas region which is an area responsible for the formation of Lang language it can affect and impair the individual's speech which is a symptom of schizophrenia so thought disorder um which leads to you speaking in an incoherent and illogical manner one reason for that could be explained by high levels of dopamine being produced in the broka region because that's the area responsible for formation of language so if there is excessive dopamine in that region it would allow you to not be able to think properly not allow you to therefore speak properly either so one of the positive symptoms can be explained this way you probably wondering why is the brain producing high levels of dopamine okay it's something that occurs naturally it's not something that the individual is choosing to do themselves can you choose to increase your own dopamine levels absolutely how you can take drugs you can take certain medications whose side effects would be that you increase dopamine but then that's not schizophrenia because that's something that's you know you're doing yourself but when the brain naturally has higher levels of dopamine receptors and the brain is naturally producing more dopamine then obviously it's deterministic and you know that's likely to cause um positive symptoms let's take a look at another example of how dopamine could lead to schizophrenia symptoms drug trials are conducted on people with and without schizophrenia drugs such as inamin cocaine and we've seen that um these drugs can actually lead to symptoms such as hallucinations and delusions because you know if people take drugs they take alcohol sometimes they hallucinate they start becoming deluded because these drugs increase the um level of dopamine in their brain that does not necessarily mean they have schizophrenia but it's just evidence showing you that dopamine can lead to symptoms that we experience in schizophrenia such as Del delusions and hallucinations now Parkinson's disease is a disease um where you know people have it's basically um I have relative with this disorder um Muhammad Ali the famous boxer had part in in his later stages of his life you'll see that you know they have difficulty to maintain their motor ability so they start moving in a way that they can't really control the movement of their body they might start shaking a lot or squirming a lot so one way to treat that is by giving a synthetic dopamine drug so rather than you know if the dopamine levels aren't increasing naturally in the brain we can give you a drug that would um artificially increase the dopamine through a synthetic drug called elova although this has been useful in treating um or reducing symptoms of Parkinson's it has certain side effects for example people who taken this drug with Parkinson's have reported some positive symptoms of schizophrenia side effects such as hallucinations right another piece of evidence postmortem studies autopsies um of people with schizophrenia so we went through brain scans of these autopsies and we found that these people when they were alive their brains had actually been producing higher levels of dopamine than a regular person's brain um I told you that there is a certain enzyme that helps break down dopamine wise found that people with schizophrenia have low levels of this enzyme that is one reason why the dopamine is actually being produced in high levels because this enzyme is in lower levels in their brain so not allowing the dopamine to be regulated in normal amounts so this could be one reason as to why the dopamine is in higher amounts than reg pet scans brain scans of people with um schizophrenia compared to those without schizophrenia showed that um there were uh the scans actually showed higher levels of dopamine in certain areas of the brain with people of people with schizophrenia compared to those without right for example areas such as the lyic system the stre atom and the cortex if you can remember these areas of the brain that'll be great so far we've talked about positive symptoms but what about negative symptoms does dopamine have any role to play negative symptoms nestler in 1997 actually found that certain other areas of the brain if they go through lower levels of dopamine such as the prefrontal cortex it can actually lead to negative symptoms so high levels of dopin in areas of the brain could lead to positive symptoms but in other areas such as the prefrontal cortex if there are lower levels of doine than normal you can actually experience negative SYM symptoms such as flat effect so if one area of the brain has got high levels of dopamine it might be leading to positive symptoms but if another area is going through unusually low levels of dopamine then it might lead to negative symptoms such as flat effect so clearly all of these different examples are showing you that dopamine has a role to play in the onset of positive and negative symptoms of schizophrenia so the biochemical explanation or the dopamine hypothesis is is it reductionist is it holistic well there are multiple pieces of evidences to show that it is important so I guess the different evidences holistic but the end of the day all of them were focused on just one explanation which is that of dopamine it's not taking into account the role of genetics it's not taking into account the role of environmental factors so I guess you could conclude that this dopamine hypothesis is reductionist it is also deterministic because we're clearly focusing on the role of Nature and no one chooses to have high or low levels of dopa it's something that occurs naturally so free will is not being favored over here either and it's also noetic because it's not a case study it's almost like a law that we're establishing that if your brain is naturally producing high levels of dopamine you will experience positive symptoms of schizophrenia right it's it's like a rule almost that is being established so um that's also nomothetic um cultural differences not really because it's biological it's not not looking at the nurture side it's looking at the nature side so cultural differences wouldn't really apply because it's noetic and the last explanation is the psychological explanation and under the psychological explanation we have the cognitive explanation by frit in 1992 now frit is acknowledging the role of biological factors he's saying yes I agree that schizophrenia could have a genetic link I understand that dopamine has an important role to play but it wouldn't be fair to say that these are the only factors so he's taking a more holistic approach he's actually trying to understand schizophrenia from a cognitive or a psychological perspective that there is a problem in your thinking your thought process illogical or irrational thinking that is causing you to experience these symptoms so let's see what he says he believes that schizophrenia is abnormality of self-monitoring which means all all of us have thoughts in our head all of us think to ourselves sometimes we think you know out loud sometimes we have very strong positive intense thoughts some of us have minor simpler thoughts but at the end of the day we know that these thoughts are internal we know that these thoughts are our own coming from our own mind and we are you know in somewhat control of them people with schizophrenia however are unable to perceive this they believe according to frit that these thoughts that are coming from their own mind are actually voices from an external source so they are struggling to identify their own thoughts as theirs coming from their mind and instead they think that they are voices that they are hearing coming from an external Source rather than internal thoughts from their own mind so he refers to it as um abnormality of self-monitoring because they're unable to monitor their own thoughts and they think it's coming from an external source which could explain auditory hallucinations so this misinterpretation of perception this misperception this misinterpretation of their thoughts causing them to think that this is external rather than internal could be the reason so he tests this Theory out how does he test it out on patients with schizophrenia items are read out and the patients are asked if these items were read out by the patients themselves by an experimental or by a computer and those schizophrenia patients who actually had incoherent speech and thought disorder as their major symptoms were the ones who struggle the most so suggesting that if these people are unable to identify if actual words that are being read out actual voices that they can hear that are being read out they're unable to identify where these voices are coming from who is reading it out then obviously they will struggle to identify where their own internal thoughts are coming from so it makes makes sense that this is possible that they think that their own inner thoughts are coming from an external Source because when they're hearing actual voices when they are hearing someone speak something or read something out to them they're unable to figure out where these voices are coming from from themselves from a computer from someone else so this abnormality of monitoring this abnormality of monitoring is basically the reason why they are unable to um acknowledge that these thoughts of theirs are internal and they attributed to external thoughts so that could explain certain positive symptoms but for negative symptoms um frit is saying that low levels of theory of mind could be the result of uh negative symptoms theory of mind if you remember from Baron Cohan is your ability to judge other people's emotions think of things from other people's perspectives and point of view now people with schizophrenia who might have low theory of mind they're unable to perceive things from another person's perspective and because of that they're unable to interact with them engage with them socially they're unable to show any real levels of empathy and as a result of that it is common for them to not show any real expression or emotion and hence show negative symptoms such as flat effect so through these cognitive elements frit is trying to explain explain um the onset of schizophrenia so that's the cognitive explanation of schizophrenia and if you were to evaluate this we would say that it is a little more holistic than the biological explanations and rather than reductionism it's um looking at a few more factors and rather than it being deterministic it is also free will because you have you could say it's a little deterministic because they're not choosing to think this way it's a thought that's coming naturally to them but they have that choice to change the way they want to think so there is room for free will through therapy perhaps they could alter their thoughts and you know they could realize that these thoughts are intern are internal rather than external so it's not entirely deterministic it's not hard determinism it is soft determinism which is the idea that maybe the cause is perhaps something that is not within your control but it does not have to permanently be like that there is room for change there is the element of Free Will present over here and lastly we have the treatment and management okay the treatment and management of schizophrenia can also be broken up into biological and psychological and in any chapter it's usually like that because if you have a biological explanation for a disorder it only makes sense to treat it biologically if dopamine is a high levels of the brain which is causing the disorder then the biological treatment would be focusing on reducing that dopamine level if the cause is psychological then the treatment would be psychological as well if there are issues in your thoughts then the treatment would be focusing on rectifying or fixing those thoughts and making making them more rational so the treatment and management of schizophrenia would be biological which includes two types biochemical treatments which would be the use of drugs mainly typical and anti and atypical antis psychotics and the second biological treatment would be ECT electroconvulsive therapy and then we have one single um psychological or cognitive treatment which would be cognitive behavioral therapy which is just regular therapy talking therapy with a therapist so talking about the biochemical treatment we've got antis psychotic drugs typical and atypical now the purpose of these drugs would be if you take a look at the biochemical explanation it was that there are high levels of dopamine or there is high levels of dopamine in the brain that is resulting in schizophrenia symptoms positive symptoms mainly so if the Doane levels are high then the purpose of these drugs would be to counter the high levels of dopamine and reduce the dopamine schizophrenia is a psychotic disorder so the antis psychotic drugs would be drugs to kind of reduce the symptoms that's where the name comes from and we've got typical and atypical because these are drugs that were developed in different eras typical antic psychotic drugs were developed much earlier in the 1950s and then newer versions more advanced versions with fewer side effects were developed in 1990s so the first generation ones um or the 1990s ones sorry the 1950s the atypical sorry the typical ones in 1950s were referred to as first generation antic psychotics and the 1990s atypical ones were referred to as second generation antic psychotics now how do they work so they work by reducing the positive symptoms of schizophrenia and what they do is block the dopamine receptors so they don't allow for the dopamine to be in higher levels in certain areas of the brain they stop the dopamine from passing from one area to the other they stop the dopamine from being increased in areas of the brain and technically if that is what it's doing then the dopamine in certain areas of the brain is being reduced which is kind of what we need to do in order to treat the symptoms but the problem is the first generation drugs the 1950 ones they would block the dopamine receptors for a longer period of time now it's okay to block the dopamine so that you know it's reduced and it goes down to a normal level but blocking it for too long is not natural and that would cause some side effects two particular side effects that would be the result of these typical antic psychotics would be extra paramal syndrome and tardive discinesia I know these are terms which will be very difficult for you to remember and spell so we can just learn the abbreviation EPs and TD now what are these side effects these are basically things like um facial spasms muscle spasms involuntary movement shaking Etc so these would be some side effects of the first generation drugs the newer 1990s atypical antipsychotics the second generation drugs work the same way as the first ones but the differ is they block the dopamine intermittently so for shorter periods of time so they work the same way but because they're not blocking the dopamine for longer periods of time there are fewer side effects so EPs and TD these side effects that were there with um the first generation antis psychotics they're not an issue with the second generation antis psychotics and they tend to be they tend to work better on people with treatment resistant schizophrenia now treatment resistant schizophrenia would be U people who on whom drugs are ineffective so sometimes you build toen so sometimes the drugs don't work so the first generation drugs perhaps would not always work on everyone with schizophrenia but these second generation drugs have a higher chance of working on these same patients on whom maybe the first generation drugs were ineffective randomized control trials were conducted to test the effectiveness of these drugs randomized control trials would be randomly allocating participants to either an experimental group or a control group and it was a double blind Placebo control technique which means the participants would be randomly allocated either to the antis psychotic drug condition or to a control group where they would be given a placebo which is like a fake drug like a saline solution or something now the patients are patients with schizophrenia and half of them are going to be randomly allocated to the antis psychotic condition the other half are going to be given the placebo and neither of the two know that you know there is a placebo condition so they're blind to it and the researchers also are unaware which group is being given what so it is a double blind technique to avoid demand characteristics and researcher bias and increase validity the results showed that after 4 to 6 weeks there was a 50% Improvement in the participants conditions who took the antis psychotics 30 to 40% showed partial Improvement and only around 10% showed little to no improvement so those 10% were the ones who had treatment res resistant schizophrenia but majority participants did see a decline in their symptoms after taking the antis psychotic drugs much more compared to what we saw in the placebo condition however some issues are that there are relapse rates because people only take these drugs when they're going through certain psycho otic episodes and once the episode is over because it's a short-term solution right it's not a long-term solution you go through a psychotic episode you want a quick fix you take the drug it might help you but that does mean that doesn't mean that you've resolved the issue you haven't cured yourself you've just treated yourself temporarily and there are many other side effects as well weight gain drowsiness for the first generation drugs EPS TD and other types of um disorders not not disorders symptoms or side effects that you can experience so in terms of its application yes it's useful because it's relatively quick to take um less time consuming but overall application would be low because um you can only get these drugs with a prescription from a psychiatrist and there can be certain side effects of the drugs as well and it may not necessarily be effective on everyone it might be you know if you have treatment resistant it might not work on you and there are of course chances of relapse um in terms of nature nurture this is definitely more um nature because it's a biochemical treatment okay focusing on reducing dopamine which is biological in order to treat you um is it deterministic or free will a bit of both you can choose whether you want to take the drug or not but the effect that the drug is H is having is deterministic you're not choosing whether it will have a strong effect on you or not in some cases it may not work at all so that's not something that you can necessarily control because everyone's biology everyone's physiology is different so that's deterministic it's also reductionist because it's just one way of treating you okay which is reducing dopamine levels um it's not accompanied by any form of therapy or any other sort of treatment either so it's definitely um reductionist um validity is there because it's a randomized control trial so we're comparing placebos to um rcts with a double blind technique so reducing demand characteristics reducing researcher bias and it's giving us quantitative data the percentages right so that's something we can use to compare the effectiveness and how effective it is on different people and because it's working differently on different people it's faving the individual explanation okay it doesn't everyone's in the same situation everyone who's in the antis psychotic drug is getting the same drug for the same period of time but it's having a different effect it's 50% of the participants are going through a huge Improvement 20 to 30% partial and 10% have no improvement so obviously individual differences every everyone's physiology again is different so it works differently for different people the second biological treatment is electroconvulsive therapy now this isn't your go-to treatment this is more of a last resort because it's a very risky and dangerous um treatment technique so if you have tried every other technique therapy drugs you've got treatment resistance schizophrenia then maybe you can consider this one this is a form of biological treatment that involves passing Electric through the brain in order to induce seizures so you're actually giving electrical currents passing electricity in the brain uh your brain has two hemispheres the left and right so either we do it unilaterally which means we pass electricity in one in one half of the brain and then the other Hemisphere or bilaterally which means both hemispheres at the same time which could be a little more dangerous so it depends but either way you are inducing seizures you're causing seizures to the participant and again we don't have too much evidence as to why but this apparently helps to reduce the symptoms of schizophrenia this was initially tested on cattle in 1930s and modified to be tested on humans but they were not given any proper anti-anxiety drugs or precautionary measures were not taken so it was very dangerous people would have neurological or brain damage memory loss broken bones and sometimes it could even lead to death modern ECT is a lot safer it starts with giving the patient anti- anxiety drugs so they completely relaxed you can undergo around 6 to 12 sessions of it or fewer depending from Patient to Patient typically given twice a week it is applied either unilaterally or bilaterally where electricity is passed either through one Hemisphere or both at the same time and um this can lead to short-term memory loss okay it has its risks it can cause neurological damage maybe even that but that's in an extreme case because modern e is much safer it cannot be self-administered it has to be done so with um the presence of um an experienced individual who knows how to run this um rare side effects include neurological damage or even death so it's not your goto technique it's a last resort um it's definitely biological in nature so it's not nurtured at all you're not learning anything over here there's no environmental influences it's pure biological it's definitely favoring the nature side because electricity is being passed or induced into the brain to induce leisures which are then helping you or trying to treat your condition um what else in terms of Ethics it's not the most ethical so application is very low um that's why it's a last resort it's very risky it's very dangerous so the application isn't very high of this um it can work differently on different people different side effects okay some it can be riskier on some people not so much in others so it's definitely individual and yeah so again some evaluative points for this and typically it's more useful for people with severe symptoms rather than minor symptoms okay um and the last one the psychological treatment CBT cognitive behavioral therapy this is a form of therapy that aims at changing your cognitions or your thoughts in order to change your behaviors so immediately it's focusing not just on thoughts but also on Behavior so it's a more holistic approach compared to the biological techniques um again linked very closely to the cognitive or psychological explanation frit told us that you know it's got to do with your thinking so if your thoughts are the reason for your schizophrenic symptoms such as auditory hallucinations or delusions then the aim would be to change your thoughts to alter your thoughts and to make you think in a more logical and rational Manner and if you are aware of this and you're able to alter your thoughts and think in a more rational manner that might allow you to reduce your symptoms so you have somewhat of a control over here over your thoughts that you can change which might then alter your symptoms and reduce them so immediately we can consider the role of Free Will over here so CBT is a form of therapy for treatment of mental disorders that incorporates both the behavioral approach as well as the cognitive approach so again changing your thoughts to change your behaviors it is a form of talking therapy between the therapist and the patient and you try to under understand the origin of the behavior and then you try to treat it it helps reducing distress disability and hospitalization and um some people who do not respond well to medication some people are looking for a more long-term solution a more permanent solution might go for therapy because medication is more shortterm medication has side effects therapy does not have side effects therapy can maybe you know overcome the issue altogether because it is more long-term um medication might just help you in the short run so you know this has its pros and cons which we'll discuss once we evaluate this so let's take a look at this a study is carried out by sinsky in 200000 again using randomized control trials where participants are allocated to one of two conditions so all the patients are patients who have treatment resistant schizophrenia and they're either allocated randomly to the CBT group or to a control group which should be the befriending group so let's take a look at what's Happening Here befriending involves one to one sessions or discussions about Hobbies Sports and current affairs so those schizophrenia patients who are randomly allocated to the befriending condition in the study would be with an experienced nurse and they would just be talking about General topics such as Hobbies current affairs Sports and you know random topics so befriending means literally socializing so they're not really going through any particular therapy as such okay um there were total of 90 patients 16 to 16 years of age all diagnosed with treatment resistant schizophrenia from five different Clinical Services each went through 19 sessions of either CBT or befriending depending on whichever one they were randomly allocated to those who were randomly allocated to the CBD condition that was also conducted by another experienced nurse but let's see what they're going through the CBT treatment involved the patients engaging with the nurses to discuss the emergence of their disorder before tackling specific symptoms so first the doctor or nurse is going to actually talk about how the symptoms start in the first place so what are your symptoms how did they begin you know is there a cognitive origin for it has it got anything to do with your own irrational thinking remember abnormality of self-monitoring that fit discussed um what was it misinterpretation of perception so incorrectly perceiving your thoughts as being internal sorry as being external rather than internal so trying to help you understand the origin because if you're aware of the fact that maybe this is you know a cognitive issue and it's got something to do with you know your thinking then once you create that awareness then only can you change those thoughts can then only can you tackle the symptoms so for example patients who suffered from auditory hallucinations were made to go through something called a joint critical analysis which means both the nurse and the patient would together critic Ally analyze their thoughts so if you're going through you know um auditory hallucinations you're hearing voices you will kind of almost challenge the origin of these voices do you genuinely believe that they're external or do you think there's a possibility they could be internal and come from your own head from your own mind so together the therapist and the patient will talk about this and try to make the patient realize that this might be internal rather than external so we're challenging these the origin of these symptoms patients were encouraged to keep voice Diaries so you know even outside therapy every time they felt that the hearing voices they record them and then we can discuss them at therapy and we can come up with coping strategies to help you deal with these and make you realize that they might be internal rather than external so blind um raters would assess both the groups at you know a couple of phases once at the beginning of the treatment then once at the end of the 19 sessions which would be um 9 months and then at further 9mon followup to see the long-term effectiveness of the treatments that um the groups are going through how are they getting um assessments of their symptoms through two questionnaires one is called the cprs and the other is called the SS so through these questionnaires the raters are going to be rating and when we say blind raters that means the raters do not know which participant is in which condition so through these assessments the um the raters are going to be rating positive and negative symptoms because that's what these two questionnaires are used for to assess positive and negative symptoms of schizophrenia so through these questionnaires through these assessments the raters are going to be assessing um the 90 patients in terms of any positive and negative symptoms that they may be displaying once at the beginning of the treatment so we have a baseline to get an idea of the severity of their positive and negative symptoms then once at the end of the 9month period to see if there's any Improvement in positive and negative symptoms and which group had a greater Improvement the CBT group or the befriending group and then at a further 9 month followup once the treatment stops to see the impact of the treatment in a longer term okay the result showed that both groups showed a significant decrease in positive and negative symptoms so from the first time when they began the study up to the 19 sessions once they were ended at 9 months both groups actually showed the significant decrease however at a follow-up stage the CBT group continued to show a decline in their positive symptoms so if you compare the befriending um condition to the CBT condition both at the end of N9 months show the decrease in their symptoms but the CBT group once treatment sto continue to experience a decline in their positive symptoms suggesting that CBT has a better long-term impact than befriending let's look take a look at the exact numbers from 46 people allocated to the CBT group 29 patients showed 50% or greater reduction in symptoms in the cprs scale which is positive symptoms and 23 showed 50% or greater reduction in symptoms in the SN scale s ands scale which is negative symptoms at the 9month followup period but for the 44 patients in the befriending group only 17 showed 50% of Greater reduction in positive symptoms and 23% sorry 23 showed 50% or more reduction in negative symptoms at a followup uh point so clearly the results are showing us that those in the CBT group had a greater reduction in positive symptoms compared to uh the befriending group at a 9month followup okay so for the evaluation of the psychological treatment it's definitely free will because you have the choice to change your thoughts yes it's being done with the help of an experienced therapist but you at the end of the day are acknowledging that even though the disorder might be out of my control it's deterministic at least the cause I can choose to change the symptoms by choosing to change my thoughts I can acknowledge I can learn I can deal with these symptoms through coping strategies through recording in voice Diaries through the help of a therapist with joint critical analysis that I can acknowledge that these thoughts might be internal rather than external and that can help me overcome positive symptoms such as auditory hallucinations and not only in the short term but even over a longer period so this is more of a long term solution um than drugs so there is greater application here there is less um you know it's something that does not have any side effects so again more application um you know it's not a short-term solution so you know it's effective on people with treatment resistant schizophrenia on whom drugs were ineffective so a lot of application the only reason application would be low is people may want a quick solution rather than a long-term solution not everyone is open to therapy cultural differences in some cultures it may be seen as a taboo to go for therapy so people may not be open in certain cultures to therapy it might be expensive as well it might be timec consuming some people might be a little hesitant to discuss their problems with the therapist some people might have such severe symptoms that they may not even be able to acknowledge that the fact that you know these thoughts are internal and you know therapy may not work on them at all so maybe drug or antis psychotic drugs are the only option for them so application can go both ways but in terms of nature nurture this is nurture because you're learning a technique you're learning coping strategies you're learning to overcome your symptoms by changing your thoughts okay there's a cognitive element and the behavioral element by changing your thoughts by acknowledging that your thoughts are irrational and fixing them with the help of a therapist changing them with the help of a therapist you are changing your behaviors you're no longer experiencing positive symptoms so it's definitely um nurture okay and although might be a little reductionist because it's focusing just on the thoughts um it's slightly more holistic than the biological treatments at least because it's both cognitive and behavioral so it involves two elements so I would say it's holistic okay in terms of um some research method terms it's valid because there is a double blind sorry there is um yeah there is a double blind technique where neither the raters know which condition the participants in nor do the participants um there is a it's a randomized control trial so randomly allocated participants so you know validity is there um what else do we have um quantitative data so you can compare the results of the two groups in the short term and in the long term um questionnaires are being used um assessments are being used such as the cprs and SS to provide us with a valid tool to get um the data to compare the results okay um any other point that I might want to make about the evaluation um I guess that's pretty much it so on that note we can conclude the entire chapter of schizophrenia and of course if anyone has any further queries questions please please feel free to reach out to me on WhatsApp as always link to my WhatsApp groups in the description below and access to these slides and these notes uh in the Google Drive that you will find uh in the description of um these WhatsApp groups so feel free to join and feel free to reach out to me if you have any questions my contact number and my um email ID are present on the first slide of this presentation so hope this was helpful thank you very much and see you next time with more videos on Clinical Psychology so take care everyone until next time bye-bye