1. Sociocultural factors & SZ:
Family Relationships
‘Double Bind’ and EE
Life Events
Social Labelling

2. Family Relationships : Double-Bind Hypothesis
‘Double-bind’ communication is witnessed in the schizophrenogenic mother.
Double-bind communication is contradictory communication. For example, a mother will ask for a hug and then pull away – the child is placed in a ‘no win’ scenario.
The child cannot avoid displeasing the parent, thus can become confused and suspicious – this can contribute to the onset of schizophrenia.

3. Double Bind theory – Bateson et al, 1956
Children who receive contradictory messages from their parents are more likely to develop Sz because child’s ability to respond is incapacitated by the contradictions / conflicting message (e.g. Verbal affection, non-verbal animosity)
Prolonged exposure to these interactions prevents development of a coherent construction of reality.
Which in the long run manifests itself as Sz symptoms, e.g. flattened affect, delusions, hallucinations, incoherent thinking and speaking and some cases paranoia.

4. Family Relationships: Expressed Emotion
Expressed Emotion (EE) refers to hostility, criticalness and concern in the family environment after someone has been diagnosed. It therefore exams the development of schizophrenia as opposed to the onset.
Negative emotion or a high degree of expressed emotion (EE) is associated with schizophrenia.
SO, EE = a family communication style that involves criticism, hostility, and emotional over-involvement.

5. Expressed emotion
Brown et al (1966) examined progression of schizophrenia when patients were discharged from hospital and lived with their families.
Families were either high EE or low EE.
58% of patients who returned to high EE families relapsed, compared to only 10% of those who returned to low EE families.
Linzen et al 1997: patients returning to a family with high EE is 4 times more likely to relapse

6. Expressed Emotion – Research Support
Kalafi and Torabi 1996: studied the rate of relapse in schizophrenics in Iran.
Found: High prevalence of EE in Iranian culture (overprotective mothers and rejecting fathers) was one of the main causes of relapse.
Conclusion: Negative emotional climate (environment) in families seems to arouse patients and leads to stress beyond his or her coping methods.

7. Life events and Schizophrenia
Occurrence of stressful LE’s have been linked to schizophrenia.
LE’s = death of a close friend, break up of a relationship, job loss
Falloon et al 1996 argues high levels of physiological arousal associated with neurotransmitters in the stress response are thought to be the cause.

8. Life event and Schizophrenia – Research Support
Retrospective studies (study past events)
Brown and Birley (1968) LE’s play a significant role in predicting episodes of schizophrenia.
Found: 50% people experienced major LE in 3 weeks prior to episode. Only 12% reported on 9 weeks prior. Control sample reported a low and unchanging level of LE’s over the same period, suggesting LE’s trigger a relapse.
20 SZ patients who relapsed today
“how many of you had a LE 9 weeks ago?”  2 person puts his hand up
“how many of you had a LE 3 weeks ago?”  10 person puts their hands up
10 SZ patients who did NOT relapse today
“how many of you had a LE 9 weeks ago?”  1 person puts his hand up
“how many of you had a LE 3 weeks ago?”  1 person puts their hands up

9. Life event and Schizophrenia – Research Support
Retrospective studies (study past events)
20 SZ patients who relapsed today
“how many of you had a LE 9 weeks ago?”
 2 person puts his hand up
“how many of you had a LE within the last 3 weeks ago?”
 10 person puts their hands up
20 SZ patients who did NOT relapse today
 1 person puts his hand up
 1 person puts their hands up

10. Life events and Schizophrenia – Research Support
Prospective Studies (study present into the future):
Hirsch et al (1996) followed 71 schizophrenic patients over 48 weeks.
Found: LE’s made a significant, successive (continuous build up) contribution in 12 months prior to relapse than a concentrated effect just prior to an episode.

11. Sociocultural Factors
Social Labelling
Scheff (1999) promoted the labelling theory of schizophrenia.
Theory states social groups create the concept of psychiatric deviance by constructing rules for group members to follow.
Thus symptoms of schizophrenia seen as deviating from the rules that we attribute to ‘normal’ experience or behaviour.
Those who display unusual behaviour are considered deviant & the label Sz may be applied, becoming a self fulfilling prophecy promoting the development of other symptoms of schizophrenia

12. Schizophrenia & Life Events
Urban living as a risk factor

13. Ezra Susser
In the past 10 years, major birth cohort studies in developed countries have revealed that the incidence of schizophrenia is about 2 times higher among people in cities (than rural environment)
"It's not clear if it is birth in cities, or upbringing in cities, but there is something about city living that increases risk … Where you are born and brought up is a larger contributing factor to risk than genetic predisposition.
Indeed, 34.6% of schizophrenia cases would be prevented if people were not born and brought up in cities, compared to 5.4% of cases that would be prevented if people did not have parents or siblings who suffered from the illness” Susser (2004).

14. Lewis et al 1992
Investigated the association between place of upbringing and the incidence of SZ with data from a cohort of 49,191 Swedish males
Incidence of SZ was 1.65 times higher among men brought up in cities than in those who had had a rural upbringing.
The association persisted despite adjustment for other factors associated with city life such as cannabis use, parental divorce, and family history of psychiatric disorder.

15. Sundquist et al 2004
A study of 4.4 million men and women in Sweden found a 68%–77% increased risk of psychosis (a broader term that includes schizophrenia) for people living in the most urbanized environments.
A significant proportion of these is likely to be accounted for by people who have schizophrenia

16. Psychodynamic APPROACH
Freud (1924) - Schizophrenia is the result of:
Regression to a pre-ego stage
Attempts to re-establish ego control
Ego = driven by the reality principle which works to satisfy the ID in realistic ways. Makes the child accommodate to the demands of the environment.

17. Regression to a pre-ego stage.
Harsh upbringing, e.g. uncaring parents, may regress child back to a developmental stage before the ego was sufficiently formed, before the child had developed realistic awareness of the external world.
Schizophrenia is seen as an infantile state, positive symptoms of delusions of grandeur reflect this condition.
Whereas auditory hallucinations reflect a persons attempt to re-establish ego control of reality.

18. Evaluation of Approach
No research evidence to support this
Subsequent psychoanalysts have claimed disordered family patterns are cause
Fromm-Reichmann (1948)
schizophrenogenic mothers
Rejecting, overprotective, dominant, moralistic families
Parents of patients do behave differently
Oltmanns et al, 1999
Could be consequence OR ‘trigger’ rather than cause