how much do we really understand about schizophrenia and to what extent is society responsible as a...

How much do we really understand about Schizophrenia and to what extent is society

responsible as a whole?

Contents Page:Subject Page number

- Abstract 4

- Introduction 4

- Rationale/Background 4

- Keywords 5

- Definition 5

- What is SZ? 6

- Symptoms 6

- Biological Explanations 7

o Structure of the Brain 7

o Genetic Inheritance 8

o Mapping of Chromosomal loci causing SZ 9

o Connection between SZ and Bipolar disorder 12

o Biochemical Factors 13

- Psychological Explanations 14

o Family Models 14

o Cognitive Models 14

o Societal Attitude to SZ 15

o Myths About SZ 15

Schizophrenics are dangerous 15

Schizophrenic have split personalities 16

SZ never get better 16

- Biological Therapies 17

o Drug Therapy (Chemotherapy) 17

- Psychological Therapies 17

o CBT (Cognitive-Behavioural Therapy) 17

o Family Interventions 18

- Conclusion 18

- Appendix 1: Consent Form + Questionnaire 19-20

- Appendix 2: Research Methods 21-23

- Appendix 3: Analysis 24-26

Figure 1: PET scans 7

Figure 2: MZ Twins 8Figure 3: Loci with a role in SZ 10

Table 1: Genes identified with a role in susceptibility to SZ

11

Figure 4: Neurotransmitter release 13Figure 5: 19th Century mental asylum 15

Figure 6: Pre-frontal lobotomy 17Figure 7: Bar Chart for analysis 25

AbstractSchizophrenia (SZ) affects a quarter of a million people in the UK. SZ is a psychotic disorder and unmedicated patients are unable to sustain relationships and become unable to present them selves appropriately thus have difficulty with employment may have hallucinations, delusions, social withdrawal, loss of sense of pleasure, apathy, loss of concentration, behaviour outside the social norm.This essay focuses on biological, psychological and environmental influences that have a role in an individual developing SZ. Brain development and brain injury play a part in susceptibility to SZ and better understanding of brain function is needed. Studies are however, difficult to replicate and more work needs to be done in this area. Inheritance is importance in SZ but it is not 100% based on genetic heritability. What genes will do is increases or decreases the risk of developing the disease in a given set of circumstances. Monozygotic twins have a 48% risk, children with two carrier parents have a 46% risk, dizygotic twins have a 17% risk, which falls to 4.5% risk of second-degree relatives compare to 1% risk in the population. 27 genes have been identified with SZ to date; interestingly dopamine was not among them, although the dopamine receptor is. Dopamine has been implicated by biochemical studies and its role has been elucidated by looking at the effect of drugs altering dopamine levels in inducing or supressing SZ.

Drugs and psychiatric therapies can be effective in some cases but the drugs have side effects and the talking therapies are not guaranteed to work. Emotional environment is important and families need to be supported and educated in successful parenting strategies. However, modern treatments that understand the cognitive deficits of SZ would be more effective than existing drug and talking therapies. Any future cure is likely to be based on understanding a person’s risk both genetic and environmental and targeting specific care (Insel 2010). Society should take responsibility for these people and make sure that they can be useful and fulfilled.

IntroductionThis essay will analyse what the mental disorder SZ is, examining in detail medical research including things such as; symptoms and behaviour of patients, how to identify this mental disorder what type of treatment is available. Furthermore it will explore society’s behaviour towards this disorder and scrutinising the question ‘To what extent are we responsible for the nurture and care of vulnerable individuals?’

Rationale/Background

In 2010, I travelled abroad to work in a hospital in Turkey. The hospital I had worked at treated mentally unstable patients ranging from OCD patients to severely affected Schizophrenic patients. I learned to manage and observe their behaviour. I was inspired to understand the cause of this disorder and how disruptions to the biology of the brain could lead to such symptoms. Understanding this better should lead to better treatments to help the young people involved and their families. This disease looks at the interface between biology, the chemistry of biology and psychology so my A levels in psychology, biology and chemistry student are very appropriate. I studied disorders last year within my psychology A-level course including SZ. This illness seems to me an area that is not well understood and where there is much on-going research. This essay will discuss the diagnosis of the disorder by symptoms, the cause of the disorder including genetics and environment and the treatment including talking therapies and drugs.

Keywords: - SZ: Schizophrenia - Psychosis: a severe mental disorder where cognitive processes are impaired with severe reduction in occupational and social functionality. - Monozygotic (MZ) twins: Genetically identical twins- Dizygotic (DZ) twins: Non- genetically identical twins- Concordance rate: statistical analysis in twin studies which identifies the statistical probability of a trait occurring in both twins. - Polymorphism: difference in DNA sequence- Positive symptoms: Hallucinations, delusions and behaviour outside social norm.- Negative symptoms: social withdrawal, apathy, inability to experience pleasure and defects in attention control.

DefinitionSZ is a psychotic disorder that includes a number of subtypes. Patients may suffer from confused cognitive processes i.e. thinking, confused emotions and behavior out side the norm. Schizophrenic patients cannot process sensory stimuli and can experience exaggerated perceptions of sound, colours and other normal environmental events. Paranoid delusions can lead to difficult interactions with other people and most unmedicated schizophrenic patients will be unable to sustain relationships. Furthermore they may become unable to present themselves appropriately i.e. have minimal personal hygiene and unable to look after themselves on a day-to-day level.

What is SZ?There are many ways that SZ can be characterised. Biological causes, psychological descriptions and environmental influences help describe and also understand SZ from different aspects. These different approaches may then further lead to the future refinement of drug and psychological therapies for schizophrenics. In this easy I shall be analysing the biological explanation of SZ, which is a complex approach that I will be breaking into sections.

SymptomsSZ usually begins in early adulthood. It comes with a set of symptoms including hallucinations and delusions described as psychotic symptoms and other symptoms like severely inappropriate emotional responses, disordered thinking, lack of or too much concentration, erratic behavior together with social and job related deterioration (OMIM).

Early in the history of describing SZ (1902) subtypes were identified: 1) Hebephrenic (silly mannerisms and laughter together with delusions and

regressive behavior) 2) Catatonic (stupor, repetitive behavior, mania, and stiffness or extreme

floppiness of legs and arms), and 3) Paranoid behaviour (extreme or irrational fear). How useful and valid these

subtypes are has been much debated especially since there is variation in their occurrence in affected families.

It is now understood that these elements are part of a spectrum of symptoms.Crow, in 1985 defined two types of SZ with different underlying pathology;

Type I SZ is defined as a genetically inherited disorder where there is overproduction of dopamine and generally results in symptoms such as hallucinations and delusions. Type II SZ is defined as a neurodevelopmental disorder resulting from prenatal insults (factors affecting baby whilst in the womb) or perinatal insults (problems around birth e.g. obstetric complications) and generally results in symptoms such as apathy, social withdrawal.

Involvement of brain structure due to malformation or injury has been heavily implicated in the development of SZ. Later research has shown that in some individuals identified with a first episode of SZ there is decreased volume of the frontal lobe and increased volume of the intersulcal cerebrospinal fluid (fluid bathing the brain) compared to controls matched for age, height, weight, parental social class and parental education. Abnormal eye movements are seen in between 40- 80% of patients and also in 25- 40% of their unaffected first-degree relatives but in fewer than 10% of healthy control subjects (OMIM).

Biological Explanations Of SZ

Structure of the BrainUnderstanding the role of brain development and injury in SZ is key to its treatment, management and prevention. Imbalances in the neurotransmitter dopamine were thought to be the prime cause of SZ however studies involving brain structure have helped understand abnormalities in the brain structure of individuals with SZ and show that SZ is a more complex disorder.

Frontal lobeResearch in 1990 showed by using PET scans that there is a reduced cerebral blood flow in the regions of the frontal lobe (important role in higher intellectual functioning and fluent expressions) compared to unaffected individuals. The reduced blood flow to this region causes symptoms such as an altered gait and posture and abnormal eye movements. (Figure 1)

Figure 1 – PET scans which show the reduced level of function in the frontal lobe. The different coloured areas represent different levels of activity in the brain. Red indicates high level of activity. Activity decreases as you go down the colour bar.

Limbic system Scientists in 1991 demonstrated there was also a disturbance in the limbic system (involves emotion) cause symptoms such as agitation in individuals. Auditory system)Scientists (from NISAD in Australia) have found abnormalities within the auditory system (enables humans to hear and understand speech). In schizophrenic individuals there is an over activity within the Wernicke area (speech area within the brain) which can create auditory hallucinations (voices are heard which are thought to be real by the patient).

Although much research has been carried out indicating that abnormalities within the brain may have some causal effect in SZ, on the other hand research into SZ is hard to conduct, interpret, and contradictory results have been published. Specifically what has caused a problem within the research community has been that results found within a study based on abnormalities of brain structure in a particular SZ individual are not found in other SZ individuals. This will only be resolved by carrying out more extensive and longitudinal studies working with families and the community at large.

Genetic Inheritance:Both genetic family studies in the 1980s and 1990s and psychological studies have suggested that genetic inheritance has a role in SZ (Gottesman, 1991, Kendler & Diehl, 1985, Moldin, 1998). These methodological studies have provided us with strong evidence that SZ is a highly inheritable disorder. Depending on how the disorder is characterised, which family groups were studied and the numbers examined; SZ has a heritability of approximately 0.7: complete heritability is 1.0.

The gold standard of testing for inheritance is to look at the likelihood of monozygotic twins (Figure 2) rose in different adopted families. These studies are hard to undertake and the numbers are not great but they do give strong indications of the degree to which gene play a part in the development of a disease. By highlighting that the risk for a particular individual developing SZ is higher in relatives of an affected individual with SZ, many studies followed. Moldin, 1998 suggested that the amount of genes shared is proportional to development of SZ and showed: (a) MZ (monozygotic) twins have a 48% risk (b) Children with two carrier parents have a 46% risk. (c) DZ (Dizygotic) twins or a child with one carrier parent have a 17% risk. (d) Second-Degree Relatives i.e. grandmother have a 4.25% risk. (e) 1% risk for the whole populationThese points made by (Moldin, 1998) have allowed further research into the difference in the percentage of risk. A number of twin studies (Gottessman, 1991) have helped us understand why the concordance rate for MZ twins will be higher than DZ twins. MZ twins have the same DNA and so a disorder that was completely genetic would be expected to be expressed in the phenotype of both twins to exactly the same degree irrespective of how or where they were brought up. In reality this is rarely the case since genetics interacts with the environment in most cases to some degree. In the case of SZ this degree appears to be around 80% genetic and 20% environment using measures of heritability. Many studies support the idea of a strong genetic link but with important environmental input.

Even though research into MZ and DZ twins have provided us strong evidence for the genetic heritability of SZ there are still problems with this type of research;

- Sample sizes are small due to the lack of being able to finding schizophrenic MZ twins

- The same diagnostic criteria cannot be used for twin studies so a comparison cannot be made therefore ‘different definitions produce different concordance rates (McGuffin et al.1984)’

- Different criteria may be used to diagnose SZ in MZ & DZ twins so comparisons may be flawed.

Fig 2: MZ twins

Although twin studies have demonstrated high heritability, there is not a 100% chance even when the relative is identical. Furthermore this concludes that SZ is a complex disease which interlinks with other factors i.e. more genes involved -27 genes are listed as having a role in the disorder on OMIM- or other environmental factors. SZ is not 100% based on genetic heritability, what genes will do is increase or decrease the risk of developing the disease in a given set of circumstances.

Mapping of chromosomal loci causing SZ:Genes for diseases are mapped and located by analysing DNA from normal and affected individuals. Scientists have looked at families where they had both affected and unaffected relatives. Regions of DNA that were inherited by only affected individuals were then examined for candidate genes. This was done using genetic markers such as repeat regions similar to those used in forensic science. In the post genomic era, the genetic markers of choice are single nucleotide polymorphisms or SNPs and these can also be used to identify candidate regions in large unrelated populations. If groups of patients are compared to normal individuals, regions of the genome inherited more often by the affected group are analysed using the completed human gene map and then candidate genes can be examined for alterations that might be causative. These can be small or large changes i.e. single nucleotide mutations that then alter the triplet code and change a single amino acid or deletions that result in a truncated protein, duplications that result in too much protein being expressed in cells or other mutations that alter the transcription process.Studies have revealed many genetic loci that are involved in the progression of the disorder (Figure 1) A study written up in the American Journal of Psychiatry in 2001 showed that there were four loci with a role in SZ and another four with a shared role in Bipolar disorder and SZ. It is interesting that these psychiatric disorders share loci and suggests that they may be part of the same disorder spectrum

Recently in a paper published in 2011, more loci have been identified that make the brain more likely to suffer to SZ. Mutations in the following genes have been identified as important in: DISC1, DISC 2 (1 and 2 involved in neuron growth and cortical development in the brain), NRG1 (Glial growth factor), DTNBP1 (involved in formation of organelles), RGS4 (activates GTPase), KCNH2 (potassium channel), COMT (guanine nucleotide binding protein), AKT1 (role in the developing nervous system). Even with these added to the genes identified in 2001 and all the others in Table 1, totaling 27, they still only explain the disease for a very small number of patients. To make things more complicated scientists find it hard to find the same loci in different study groups. This is the same problem that scientists have come across when trying to relate brain injury and development to SZ. Brain development is driven by gene expression and so the scientists in different fields need to integrate their findings more to advance the current understanding.

Figure 3: This picture came from the American Journal of Psychiatry and showed that there were four loci with a role in SZ and another four with a shared role in Bipolar disorder and SZ in 2001.

Table 1: Genes that have been identified as having a possible role in susceptibility to SZ. (http://us-east.omim.org)

Location Gene/Locus Gene function

1 1p36.2 SCZD12

2 1p36.22 MTHFR

3 1q32.1 CHI3L1

4 1q42.2 DISC1 Involved in neuron growth and cortical development in the brain

5 1q42.2 DISC2 Involved in neuron growth and cortical development in the brain

6 3p25.2 SYN2

7 3q13.31 DRD3 Dopamine receptor

8 5q23-q35 SCZD1

9 6p23 SCZD3

10 6p22.3 DTNBP1 Involved in formation of organelles

11 6q13-q26 SCZD5

12 7q36.1 KCHN2 Potassium channel

13 8p21 SCZD6 (NRG1) Glial growth factor

14 10q22.3 SCZD11

15 11p14.1 GPR48

16 11q14-q21 SCZD2

17 12q24.11 DAO

18 13q14.2 HTR2A

19 13q32 SCZD7

20 13q33.2 DAOA

21 14q32.33 AKT1 Role in the developing nervous system

22 15q15 SCZD10

23 18p SCZD8

24 22q11.21 COMT Guanine nucleotide binding protein

25 22q11.21 RTN4R

26 22q12.3 APOL4

27 22q12.3 APOL2

http://us-east.omim.org/

If the whole field is reviewed as can be found on the OMIM website (http://us-east.omim.org) fourteen chromosomes to date have been found to have loci on them that may have a role in the disease. These are chromosomes 1, 3,5,6,7,8,10,11,12,13,14,15,18 and 22. This may be because most human genes are expressed in the brain during fetal and neonatal development and disturbances in different areas of neural development may result in similar symptoms. The genetic studies have not suggested that dopamine levels are the only important factor in looking at causes of SZ, though the metabolism of dopamine may be disturbed by alterations of many different expressed proteins. Interestingly, no loci have been found on either the X or the Y chromosome, which fits with the observation that this disease affects males and females equally. Strikingly, dopamine (DBH) itself has not been identified as a susceptibility locus in the studies to date, although a dopamine receptor (DRD3) has.

Connection between SZ and Bipolar disorder and othersSZ and bipolar disorder are mostly considered to be different, but patients who show many symptoms of both disorders can be described as having schizoaffective disorder. This supports the idea that SZ and bipolar disorder are variant expressions of a spectrum in addition to having similar disease frequencies, ages of onset and no link to gender (OMIM).



Biochemical Factors:Dopamine is a key neurotransmitter (Figure 3). There have been many neurotransmitters associated with SZ, however recent research into dopamine has been very promising for the future of SZ individuals. According to scientists the role of dopamine in SZ has results in an excess of dopamine activity at certain synaptic sites. Post-mortem examinations have shown that individuals with SZ have an increase of dopamine in parts of the brain (Seeman, 1987).The importance of dopamine is supported by various studies that examine how drugs utilised to treat SZ or resulting in SZ type symptoms function. The antipsychotic drug phenothiazine blocks the uptake of dopamine at the synapse and this helps ease some of the major symptoms in SZ. The drug L-dopa, used in the treatment of Parkinson’s disease, acts by increasing dopamine levels, this drug however produces symptom of SZ in some previously unaffected individuals. Amphetamines, which are psycho-stimulants, used clinically and recreationally also increase dopamine levels and can cause symptoms of SZ in some previously unaffected individuals.

As has been discussed in the section on genetics, however, dopamine is not the whole story. Drugs that act on dopamine may not work with every affected SZ individual. There is not an association with dopamine in all SZ patients although there is a strong correlation. Evidence from post-mortem examinations may not be easy to extrapolate to a wide range of individuals since they tend to involve individuals who have undertaken antipsychotic (neuroleptic) drugs for years. So the increase in dopamine levels may not be entirely caused due to the disorder.

Figure 4: Neurotransmitter release (dopamine) in brain neuronal synapse (http://cmbi.cjmu.edu.cn)

Psychological Explanations Of Schizophrenia

Family ModelsBased on the theory of the double-blind technique (Bateson, 1956) a child undergoes repeated experiences with one or more family members. A parent may expose the child to contradictory messages such as ‘go play with your sisters’ this may indicate the parent is being caring however the way it is said (tone, body language) may show the parent wants to get rid of the child. Confusion in the child’s mind may lead to self-deception and a false concept of reality along with inability to communicate effectively. Research has shown that there is increase risk, above the population norm of 1%, of SZ in what psychiatrists may label as ‘dysfunctional families’. This can be described as a family environment where children experience an excess of family conflict; they misbehave at home or at school, and often endure abuse from family members continually and regularly, leading themselves and other members to become accustomed to such events.

Cognitive ModelsPsychiatrists suggest that poor emotional environments alter the way people process information and have put forward cognitive models to explain normal and impaired information processing. One cognitive model deals with the impaired thought processes in SZ, explaining this impairment in terms of attentional impairment. This means that mechanisms within the brain of SZ individuals have defective processing systems; these systems should filter out incoming stimuli and find meaning. Research has been conducted which shows that schizophrenics show poor performance in information processing tasks specifically visual tracking, size estimation and short term memory usage The points of these models is so that psychiatrists can try to identify how deficits arose and then treat them or advise families and/or their carers how to avoid increasing risk to their offspring

Societal Attitudes to SZ

Societal attitudes to mental illness have changed a great deal in the last 100 or so years. Individuals were poorly diagnosed and grouped together with widely differing diagnoses in prison-like conditions (Figure 3). The terms of diagnosis were crude and have passed into our language as derogatory terms like ‘cretin’ and ‘mongoloid.

Figure 5: 19th century mental asylum

Myths About Schizophrenia

Arising from past attitudes schizophrenics have been labeled many horrible words such as; lunatics, madmen, raving maniacs, unhinged, deranged and demented. These words have caused people who have been diagnosed with the disorder to be labeled as dangerous people, unpredictable, impossible to understand and completely out of control. Furthermore these words or descriptions do not reflect the true character of an individual schizophrenic and has caused unhelpful stereotyping among society.

There has been three popular myths about SZ patients, these are;

· Schizophrenics are always dangerous

· Schizophrenics have split personalities

· Once a schizophrenic always a schizophrenic as they never get better

Schizophrenics Are Dangerous

People diagnosed with the disorder may often yell, scream or even occasionally hurt someone however, it is not clear whether these problems arise from the disorder itself, whether it is a reaction to society for being treated in a particular way whether these are responses to the use of drugs or alcohol or if aggression is a side effects of some treatments. Society assumes that criminals are less dangerous than schizophrenics however in reality this is untrue and it rests mainly on ignorance and fear as schizophrenics. Affected individuals, instead of being dangerous, are generally withdrawn from society and preoccupied with their own problems (Nature editorial 2010).

Schizophrenics Have Split Personalities

This misconception of split personalities is an omnipresent myth about the disorder, generally this myth is maintained in the news, movies and television shows which does not help overcome the misunderstanding of Schizophrenic behaviour. This idea of split personalities was thought to have derived from the origins of the word schizophrenia; schizo = split, phreno = mind. Eugen Bleuler in the 20th century came up with the idea that psychological functions that most ‘normal’ people have are divided in Schizophrenics which causes them to have splitting in emotions and thoughts. Bleuler’s view is no longer as widely believed by psychiatrists but still persists in the general population.

Schizophrenics Never Get Better

Treatments that have been used for over 50 years have no offered the hoped for cure. At present the diagnosis is made late in the development of the disease, when psychosis is obvious and treatment aims only reducing psychotic symptoms (insel 2010). In some individuals this is extremely successful and they only experience one psychotic episode in their lifetime.

Some people think that questionnaires for teenagers can predict risk for SZ but this has worried other people since it may stigmatize them and runs the risk of treating people who don’t need that treatment. Other people feel it is better to over diagnose than to let people suffer the disease (Dobbs 2010).

Society at the moment is not investing enough in research into developing new drugs, pharmaceutical companies are pulling out of the search because the work is difficult and expensive and the drugs often have bad side effects (Abbot 2010).

Modern treatments that understand the cognitive deficits of SZ would be more effective. In the future it would be ideal to find a cure and this is likely to be based on understanding a person’s risk both genetic and environmental and targeting specific care (insel 2010). Society should take responsibility for those people and make sure that they can be useful and fulfilled.

Biological TherapiesBefore the 50’s individuals who were diagnosed with SZ were institutionalised into overcrowded, unhygienic and unstimulating environments. For treatment in the cases of SZ often straitjackets were used to minimise movement, procedures called the prefrontal lobotomy (Moniz, 1936) – the frontal lobes which involves emotions, reasoning, planning, movement and parts of speech – where the frontal lobes were removed. This however led to severe cognitive and emotional impairment.

Drug Therapy (Chemotherapy)Antipsychotic drugs (neuroleptics) such as Chlorpromazine have updated the treatment for SZ. Founded by Delay & Deniker (1952) chlorpromazine has been a success in reducing psychotic symptoms of hallucination and delusions. The drug works by blocking the excessive release of dopamine and so the positive symptoms are controlled. With the use of neuroleptics SZ patients are able to live outside institutions.However, the drugs do not work against negative symptoms of SZ and long-term use

is required, as symptoms may appear when medication is not taken. Furthermore, the drugs are not successful with every patient, 30% of patients may not have reduced symptoms or may not want to take neuroleptics. Also some drugs produce some distressing and sometimes irreversible side effects (drowsiness, dehydration, depression). Usage of neuroleptics over 7 years may also induce the disorder Tardive Dyskinesia (irreversible and produces uncontrollable lip and tongue movement)

Psychological Therapies Treatments that involve both drugs and psychological interventions have been the most successful way in treating SZ patients. Psychological interventions help patients not to be re-hospitalised due to poor social function.

CBT (Cognitive Behavioural Therapy:CBT therapies underline the cause of distress made by feelings and pattern of thinking from the individual. The individual is encouraged to search for any feelings or incidents within the patient’s life that may of triggered stress causing SZ to evolve. Research has found that CBT improves short-term mental state however CBT is costly and highly trained professionals are needed to conduct this form of therapy. Although evidence for CBT how some decrease in relapse rates and also increase short-term mental state this evidence is to little to generalise and does not mean it is effective for all patients with SZ.

Family Interventions:Family interventions were included as part of biological treatment, as they help social functioning with the family of the patient and within society. Family Interventions try to reduce stress within the patient’s life by helping family members and also the patient understand what the disorder is and how it can be dealt with rather than overcome. The main goals of the sessions involve providing family members with skills that enable them to cope with a SZ individual within their family. Studies have shown that family interventions are successful in reducing relapse of the disorder as the individual and both family members are able to deal with and understand the disorder.

Conclusion:In conclusion SZ is now clearly defined than it was 100 years ago, making it easier to diagnose and to study affected individuals and their families. These studies have been done looking at brain structure, brain biochemistry, genetic and via psychological analysis. Research has suggested that dopamine is important in the brain, brain injury may be a cause of SZ and that genetic inheritance is important for some individuals. Psychological studies suggest that the home environment is important in changing someone’s status from being susceptible to being affected.

Figure 6: Pre-frontal Lobotomy

Drugs and psychiatric therapies can be effective in some cases but the drugs have side effects and the talking therapies are not guaranteed to work. Emotional environment is important and families need to be supported and educated in successful parenting strategies. However, modern treatments that understand the cognitive deficits of SZ would be more effective than existing drug and talking therapies. Any future cure is likely to be based on understanding a person’s risk both genetic and environmental and targeting specific care (Insel 2010). Society should take responsibility for these people and make sure that they can be useful and fulfilled. My questionnaire have suggested that people do feel that society should take responsibility for looking after vulnerable individuals and this is hopeful for the future of individuals with SZ.

Appendix 1: Consent form + Questionnaire

Consent Form:

I am carrying out a research that will look at how much society really knows and feels about Schizophrenia as a mental disorder. I am interested in belief based or experienced views and how this reflects as our actions or thoughts into Schizophrenia

I will be asking you to fill out a questionnaire, which will be analysed in my research paper. If you agree to take part you can withdraw at any time and your data can be withdrawn any time up until the date of publication. Your data will be anonymous and all of your personal details will be kept fully confidential.

If you agree please sign the consent form

Questionnaire On Schizophrenia:

Age: Gender:

1) How much do you know about mental disorders?

a. Can you list or give me any examples you know?

b. Do you know the symptoms of the disorder you have just named me?

2) Have you heard of the mental disorder Schizophrenia?

a. If you have where have you found this information?

b. What do you think are the symptoms of Schizophrenia?

3) Given that there are about 62 million people in Britain. How many people in Britain do you think have been diagnosed with schizophrenia?

(Circle your answer)

a. Quarter of a million peopleb. 1 million peoplec. 2.2 million peopled. 6-12 million people

4) Case Scenario: How would you feel if you saw someone talking to his or herself? (Circle your answer)

a. Sadb. Embarrassedc. Walk Awayd. Funny

5) Do you think that society is responsible for mentally unstable patients? If so, why / why not? To what extent?

Appendix 2:

Primary Resources:

Questionnaires: My aim by using a questionnaire is to gather a large sample of views from the public on a specific topic such as Schizophrenia. I wanted to establish what people do and think in relation to my topic which enables me to further analyse different views. I

have also included a consent form for participants allowing their fully informed consent, agreeing me to publish their results in my dissertation. My target audience

is based on anyone above the age of 18, I have added some lines above my questionnaire which identifies the gender and age of my participants, this may give

me further insight into different attitudes which may be affected by age.

In my questionnaire I used two types of questions; Open-ended questions and closed questions (Fixed choice questions). The advantages of using an open-ended question I was able to gather detailed and rich data, which encouraged the individual to express their feelings creating a realistic answer. The advantages of using a closed question endorsed me to quantitatively collect the data that allowed further statistical analysis. However, my using a questionnaire also has disadvantages such as social desirability, untruthful responses and different interpretations of questions.

Online Forum:http://www.facebook.com/groups/301806969848006/I created an online forum that would enable me reach out to a wider audience to access a wider range of opinions. I have made the forum public so that anyone can access and fill out the questionnaire online. I hope that I will have conflicting ideas within some people which will lead to a debate, this may help me compare and contrast different viewpoints in detail. Participants are able to join or withdraw any time, and any results will be sent back to me by a email or a document this is so that answers are kept confidential. Some weaknesses of this type of source may be social desirability as some participants may want acceptance by others therefore they will not put forward their truthful views and beliefs.

Online Chat:http://www.schizophrenia-online.com/Entering this website I found myself talking and asking question with people who have Schizophrenia. This enabled me to gather personal views from individuals who suffer from this disorder. By asking questions within this online chat I also had quick responses.

Case Studies:

http://www.schizophrenia-online.com/

http://www.facebook.com/groups/301806969848006/

I have looked into a case study based on the famous mathematician John Forbes Nash, Jr. By looking into a case study it provides rich, meaningful qualitative data involving the production of a case history this may be a longitudinal or retrospective study. There are many advantages of case studies such as; high levels of ecological validity as it is realistic this may result in challenging established thinking and may lead to new psychological insights.Furthermore using case studies also has some limitations; they are difficult to replicate therefore difficult to establish the reliability of the data found from the case study, due to it’s idiographic nature it is difficult to generalise the results beyond the individual or group being studied which leads to a low population validity, in addition the possibility of researcher bias is high which further calls into question its scientific credibility.

Secondary Research:Books:

A2 Psychology: -I am using my psychology book as it has a lot of information within chapter 34 based on abnormalities such as Schizophrenia I will also be using some aspects within Chapter 30-31 based on attitudes to media; this will help me address the issue of

Advanced Psychology: Atypical Behaviour: -This book goes hand in hand with my A2 psychology book however it provides more detailed text and insight into topics including Schizophrenia within chapter 3.5 on page 70

Schizophrenia by Daniel R. Weinberger & Paul J. Harrison: -I will be using the first chapter of this book which I had found on Google books which discusses the past, present and futuristic view on schizophrenia. It is also very recently published, 2011, which helps me gain the most up-to-date information.

Overview Booklets:I have gathered some booklets from the NIMH – National Institute of Mental Health which gives me a 15 page overview about schizophrenia, this again like the books I have picked up from the library etc. provides me with the same basic knowledge however it is more condensed and allows me to read some information quicker than for example using a book.

Newspaper Articles:I have gathered some newspaper articles from www.psychminded.co.uk, The Guardian, The Observer. These articles can range from actually creating a positive view or a negative one towards the public. They article or the newspaper company may be bias against e.g. biological treatments.

Leaflets:

http://www.psychminded.co.uk/

The use of leaflets helps me summarise a clear idea of what Schizophrenia is in a range of 2-4 pages. This helps individual who are unclear of what Schizophrenia is understand in basic terms what the disorder is, who it affects, what they could do about it, their next steps, understanding of definitions related to the disorder.

Websites:Generally I found most of my relevant information through websites on the Internet. The use of internet has many advantages; by providing me information from any date ranging from old information to any up to date recent information, it is a fast way to find information and communicate to organizations or people. It is also easy to get information on a particular subject if you enter a key term and furthermore it is a cheap and environmentally friendly way of accessing information.Like many sources the Internet also has disadvantages. There can be an overdose/overkill of information and it may be difficult and time consuming to be able to find any relevant information. Reliability of any source from the Internet can be doubtful and some information may be bias. The websites I have used are listed below with reasons in why I have used them and also discuss some possible strengths and weaknesses of each website; www.wikipedia.co.uk Wikipedia is a credible website which does have information from most aspects of schizophrenia which may be valid and written from people within the medical arena however I have found some sources to be false or incorrect on Wikipedia which questions the reliability of the sources found on this website.

www.schizophrenia.comThis website provides a lot of information such as symptoms, causes, brain pictures, success stories etc. Furthermore it also provides some personal insight into some people’s stories which may be very nice for someone with schizophrenia actually searching for some insight about their disorder. Links from this website are also listed as primary evidence – success stories

www.omim.org/entry/613025This website represents the cytogenetic location of schizophrenia in our body and how this genetic change expresses itself in the phenotype. As I am a biologist and chemist I loved this website as it pin pointed the exact biological aspect of this mental disorder.

http://omim.org/entry/181500The website used here is the same website above however this entry features a variety of aspects in schizophrenia. I liked this entry compared to any sort of book or website I had read. This text unlike others gave additional information such as some psychologists who have looked further into the topic discussed or found an evidence from experiments which may support or go against any pre-findings.

http://omim.org/entry/181500

http://www.omim.org/entry/613025

http://www.schizophrenia.com/

http://www.wikipedia.co.uk/

http://www.clivir.com/lessons/show/schizophrenia-statistics-facts-and-information.htmlThis website offered me a range of statistics and facts based on schizophrenic patients, this was useful as I am going to be able to use this information in my discussion and analysis for particular topics such as; how many people are diagnosed, how many of these diagnosed patients are fully treated etc. Also on this website it discusses some new treatments. This expands on current knowledge and presents new up to date findings which is a positive aspect of this particular website.

Appendix 3: Analysis

In my primary research I chose to give out questionnaires to the public to understand public opinion and answer the question ‘How much do people understand about SZ?’ I emailed my questionnaire to thirty members of the public, both males and females at an age range of 16 and over, however I only had 20 responses. I wanted to understand (a) what were the commonest disorders that people had heard of and how aware they were of the symptoms and how accurate their descriptions were. I was particularly interested in people’s conceptions of SZ and whether they were aware of the symptoms, in addition to how accurate these conceptions were. I also wanted to know if people were aware of the prevalence of this condition.Question 4 and 5 were focused on people’s attitude to SZ and whether they thought that we were all responsible for helping these vulnerable individuals or that this was a problem that was nothing to do with them.

In my questionnaire I used different types of questions including open and closed questions allowing the public to give both a quick representation of their opinion with limited choices of answers and also some detailed answers allowing me to deepen my understanding of their opinions. This was a more efficient way to gather my results and it was not too time consuming.The limitations of my methodology are that the subjects chosen were people for whom I knew the email address and tended to be from an educated background and relatively high socioeconomic grouping. The opinions from this group may not represent the general opinions in the UK.

The data obtained will be quantitatively analysed except for question 5. The scorer of high numbers of points will be most aware of SZ and the lowest number of points will represent individuals who are least aware. I will evaluate the questions by allocating points as follows:

1.a. 1 point for SZ in the answer and 1 for any other disorder mentioned

up to 3b. 1 point for each correct symptom of SZ mentioned out of:

hallucinations, delusions, social withdrawal, loss of sense of pleasure, apathy, loss of concentration, behaviour outside the social norm, up to a maximum of 5

- Similarly for other disorders mentioned.

http://www.clivir.com/lessons/show/schizophrenia-statistics-facts-and-information.html

http://www.clivir.com/lessons/show/schizophrenia-statistics-facts-and-information.html

Total possible score 18

2.a. Possible sources will be scored as: Web (2), Media (films magazines,

news papers, journals)(3), Education (4), Friends and relatives or has condition (5), other (1)

b. Score for symptoms as above but no points for repeated information.Total possible score 6

3. 1 point for ‘Quarter of a million people’. Total possible score 1

4. Points as follows: -

a. Sad (3)b. Embarrassed (1)c. Walk Away (2)d. Funny (0)

For questions 1-4 the scores will be banded as 0 -8 Low 9 – 18 Medium 19-27 High

5. Will be scored asSociety is responsible and should help SZ individuals:

Disagree strongly (0) Disagree (1) Neutral (2) Agree (3) Agree strongly (4)

The band for 1-4 will be compared to question 5 scores and any correlation will be identified using a bar chart.The hypothesis that I am testing is that the more highly educated and aware an individual is about SZ the more likely that they will take a sympathetic view towards affected individuals and believe that society should support them.Figure 1: Score for question 1-4 plotted as a bar chart against score for question 5 and ranked in numerical order.

Figure 7: Bar chart. Score band compared to Q5 scoring.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 200

1

2

3

4

5

Score band compared to Question 5 Scoring

Score bandQ5 score

Number of Participants

Scor

ing

poi

nts

The analysis of my data is inconclusive however; this is probably due to there begin a small sample number. From my study most people believe that society is responsible for looking after people with schizophrenia. The data may look different if the questionnaire was given to people from varied socio-economic background, as most of my sample was from university-educated people. To improve this study a sample of 200 people on the street might be a better way to gather reliable data.