Schizophrenia

Which of the following correctly distinguishes positive and negative symptoms of schizophrenia?

• APositive symptoms are the pleasant, elevated experiences a patient reports (e.g. euphoria); negative symptoms are the distressing ones (e.g. persecutory delusions) that cause suffering
• BPositive symptoms are additional experiences beyond normal functioning (e.g. hallucinations); negative symptoms are a loss or reduction of normal functioning (e.g. avolition)✓
• CPositive symptoms are those confirmed by a positive result on a diagnostic test or brain scan; negative symptoms are those the clinician rules out during the assessment interview by exclusion
• DPositive symptoms are disturbances of thought and belief that are purely cognitive; negative symptoms are physical, motor abnormalities such as catatonia and abnormal posturing

Answer: Positive symptoms are additions to normal experience, such as hallucinations and delusions. Negative symptoms involve a loss or reduction of normal functioning, such as avolition (loss of motivation) and speech poverty. 'Positive/negative' refers to addition versus loss, not to whether the symptoms are pleasant.

Two clinicians using different diagnostic manuals reach different diagnoses for the same patient with schizophrenia. This is most directly a problem of:

• AConstruct validity of the diagnosis
• BSymptom overlap with depression and bipolar disorder
• CReliability of diagnosis, specifically low inter-rater reliability✓
• DGender bias in diagnosis, favouring men

Answer: When different clinicians fail to reach the same diagnosis for the same patient, this is a failure of inter-rater reliability (consistency of diagnosis between assessors). Validity concerns whether the diagnosis is accurate or measures a real condition, which is a separate issue.

Which finding provides the strongest support for a genetic explanation of schizophrenia?

• AAntipsychotic drugs that block the D2 receptor reduce the positive symptoms in most cases
• BConcordance rates are higher for monozygotic (MZ) twins than for dizygotic (DZ) twins✓
• CSchizophrenia is diagnosed far more often in inner-city areas than it is in rural ones
• DHigh levels of expressed emotion in the family reliably predict a relapse after discharge

Answer: Higher concordance for MZ twins (who share ~100% of genes) than DZ twins (who share ~50%) supports a genetic contribution, since the more genetically similar pair shows greater concordance. Drug effects relate to neurochemistry, and expressed emotion supports a psychological/family explanation.

The revised dopamine hypothesis proposes which pattern of dopamine activity in schizophrenia?

• AGlobally reduced dopamine (hypodopaminergia) throughout the brain, with the lowest levels recorded in the mesolimbic pathway and the basal ganglia
• BUniformly excessive dopamine in every brain region produced by an equal oversupply of D2 receptors right across the cortex and the subcortex
• CHyperdopaminergia in subcortical areas (e.g. excess D2 activity in the mesolimbic pathway) and hypodopaminergia in the prefrontal cortex✓
• DNormal dopamine transmission throughout the brain combined with an excess of serotonin at cortical receptors, which antipsychotic drugs correct

Answer: The updated dopamine hypothesis proposes hyperdopaminergia in subcortical regions (excess dopamine/D2 activity in the mesolimbic pathway, linked to positive symptoms) combined with hypodopaminergia in the prefrontal cortex (linked to negative/cognitive symptoms). The original hypothesis claimed only excess dopamine.

Which of the following is a cognitive explanation for the symptoms of schizophrenia?

• AHigh levels of expressed emotion within the family
• BExcess dopamine in the mesolimbic pathway
• CThe double-bind theory of contradictory communication
• DDysfunctional information processing, such as impaired metarepresentation and central control, leading to symptoms like hallucinations and disorganised speech✓

Answer: Frith's cognitive account explains symptoms through dysfunctional thought processing, namely impaired metarepresentation (insight into one's own intentions) and impaired central control. Expressed emotion and the double-bind are family/psychological explanations; excess dopamine is biological.

How do typical antipsychotics (e.g. chlorpromazine) primarily act, compared with atypical antipsychotics (e.g. clozapine)?

• ATypical antipsychotics act as dopamine agonists that increase D2 transmission in the brain, whereas atypical antipsychotics are antagonists that block those same D2 receptors irreversibly
• BTypical antipsychotics mainly block dopamine D2 receptors; atypical antipsychotics also reduce dopamine but bind more temporarily to D2 and act on serotonin receptors too✓
• CTypical antipsychotics act on serotonin receptors alone, whereas atypical antipsychotics act on dopamine receptors alone, which is why the two classes usually suit different symptom clusters
• DBoth classes increase dopamine and serotonin activity (agonism) in order to reduce symptoms

Answer: Typical antipsychotics are dopamine antagonists that block D2 receptors. Atypical antipsychotics also reduce dopamine activity but tend to occupy D2 receptors more transiently and additionally act on serotonin (and other) receptors, which can improve negative symptoms and reduce side effects.

In family therapy for schizophrenia, what is the main therapeutic aim?

• ATo replace antipsychotic medication with a talking therapy (CBT)
• BTo uncover the repressed childhood conflicts that lie behind the delusions, using free association and dream analysis with the patient and their parents present
• CTo reduce negative communication patterns and levels of expressed emotion within the family, thereby reducing the patient's stress and risk of relapse✓
• DTo challenge the patient's irrational delusional beliefs directly, by using reality testing and behavioural experiments in each of the weekly sessions with the therapist

Answer: Family therapy aims to improve family communication and reduce expressed emotion (criticism, hostility, over-involvement), lowering stress and relapse rates. Challenging delusions through reality testing describes CBT, and free association describes psychoanalysis.

The diathesis-stress model, as used in the interactionist approach to schizophrenia, proposes that the disorder develops when:

• AStress is sufficient by itself to cause schizophrenia, so a severe life event (e.g. bereavement or redundancy) will trigger the disorder in an unpredisposed person
• BA genetic predisposition inevitably causes the disorder regardless of environment, so anyone carrying the relevant candidate genes goes on to develop schizophrenia in adulthood
• CBiological factors alone determine onset, with the environment playing no part, so the timing of the first episode is set by brain maturation rather than by life events
• DA vulnerability (diathesis, e.g. genetic or early trauma) interacts with a stressor (e.g. an environmental or psychological trigger) to produce the disorder✓

Answer: The diathesis-stress model is interactionist: it argues schizophrenia develops when an underlying vulnerability (diathesis, which the modern model recognises can be genetic or psychological, such as early trauma) is triggered by a stressor. Neither the diathesis nor the stress alone is sufficient.

What distinguishes positive from negative symptoms of schizophrenia?

• APositive symptoms remove experiences, negative ones add abnormal experiences
• BPositive symptoms respond to drugs, negative ones respond to therapy
• CPositive appear first and negative always appear later
• DPositive add experiences, negative remove normal functioning✓

Answer: Positive symptoms such as hallucinations and delusions are additions to normal experience; negative symptoms such as avolition and speech poverty are deficits. Negative symptoms respond less well to antipsychotics.

What is the revised dopamine hypothesis?

• AHyperdopaminergia in the cortex and hypodopaminergia subcortically
• BHyperdopaminergia subcortically and hypodopaminergia in the cortex✓
• CUniformly raised dopamine throughout the whole brain
• DUniformly lowered dopamine throughout the whole brain

Answer: Excess dopamine in subcortical areas such as Broca's is linked to positive symptoms, while low prefrontal dopamine is linked to negative ones. The original version could not explain negative symptoms at all.

What is a criticism of using antipsychotics alone?

• AThey cure the disorder but produce no measurable side effects
• BThey work only in patients who also receive family therapy
• CThey manage symptoms without addressing psychological factors✓
• DThey have never been shown to reduce symptoms in trials

Answer: Typical antipsychotics carry a real risk of tardive dyskinesia, and adherence is a problem. The evidence for symptom reduction is strong, but outcomes improve when medication is combined with psychological therapy.

What does the double-bind theory propose?

• AContradictory family communication leaves the child unable to respond correctly✓
• BContradictory family communication has no measurable effect on later development
• CGenetic vulnerability alone accounts entirely for the onset of the disorder
• DTwo separate genes must be inherited for the disorder to appear

Answer: Bateson argued that mixed messages with no way to comment leave the child confused about reality. The evidence is largely retrospective and it risks blaming families, which is a serious ethical objection.

What does CBT for schizophrenia aim to do?

• ARemove the hallucinations entirely within a few short sessions
• BReplace antipsychotic medication in every single case of the disorder
• CIdentify the unconscious childhood conflict causing symptoms
• DHelp patients understand and challenge their delusional beliefs✓

Answer: CBTp normalises experiences and helps patients test the reality of their beliefs, reducing distress even when symptoms persist. It is used alongside medication rather than instead of it.

What is expressed emotion and why does it matter?

• AHigh family warmth and support predicting faster recovery
• BThe patient's own emotional expression during an episode
• CHigh family criticism and involvement predicting relapse✓
• DThe emotional tone used by clinicians during diagnosis

Answer: Households high in criticism, hostility and emotional over-involvement are associated with markedly higher relapse rates. It is a source of stress in the diathesis-stress model and a target for family therapy.

What is symptom overlap in the context of diagnosis?

• AOne patient shows several different symptoms at the same time
• BTwo separate clinicians reach the same diagnostic conclusion
• CThe same symptom appears in DSM and ICD alike
• DSymptoms of schizophrenia also appear in other disorders✓

Answer: Avolition appears in depression and delusions in bipolar disorder, which questions whether schizophrenia is a distinct condition. Co-morbidity — having two disorders at once — raises the same concern.

What is token economy based on?

• AClassical conditioning, using an unconditioned stimulus
• BSocial learning, using vicarious reinforcement
• CCognitive restructuring of maladaptive beliefs
• DOperant conditioning, using secondary reinforcers✓

Answer: Tokens are exchanged for privileges, reinforcing desirable behaviours in institutional settings. It manages behaviour rather than treating the disorder, and raises ethical concerns about withholding basic entitlements.

What does the interactionist approach to schizophrenia propose?

• AGenetic vulnerability alone determines who develops the disorder
• BEnvironmental stress alone determines who develops the disorder
• CGenetic vulnerability combines with environmental stress✓
• DNeither genetic nor environmental factors are relevant

Answer: Meehl's original diathesis-stress model has been broadened so that the diathesis may be genetic or from early trauma, and the stressor may include cannabis use. It supports combining medication with psychological therapy.