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Q1.
Discuss the use of an interactionist approach in explaining and treating schizophrenia.
(Total 16 marks)
Q2.
Below are four evaluative statements about token economies as used in the treatment of schizophrenia. Which statement is TRUE?
 
A | Token economies can be used effectively in any environment. |
B | Token economies have a positive effect on thinking. |
C | Token economies help to promote acceptable behaviours. |
D | Token economies address the cause of the problem. |
(Total 1 mark)
Q3.
Briefly discuss two limitations of the family dysfunction explanation for schizophrenia.
(Total 6 marks)
Q4.
Outline and evaluate the use of antipsychotic drugs to treat schizophrenia.
(Total 8 marks)
Q5.
Briefly outline how cognitive behaviour therapy (CBT) is used to treat schizophrenia and explain one limitation of using CBT to treat schizophrenia.
(Total 4 marks)
Q6.
A researcher investigated the effectiveness of typical and atypical psychotics in schizophrenia patients with either negative or positive symptoms.
Percentages of patients with either negative or positive symptoms, responding well to typical or atypical antipsychotics.
 
| Number of patients responding well to atypical antipsychotics | Number of patients responding well to typical antipsychotics
Patients with negative symptoms | 30 | 16
Patients with positive symptoms | 60 | 60
What does the data in the table seem to show about the effectiveness of typical and atypical antipsychotics in the treatment of schizophrenia?
(Total 4 marks)
Q7.
Apart from effectiveness, briefly explain one limitation of drug therapy for schizophrenia.
(Total 2 marks)
Q8.
Discuss token economies as a method used in the management of schizophrenia.
(Total 8 marks)
Q9.
Read the item and then answer the questions that follow.
 
Two years ago Jenny was diagnosed with schizophrenia. She has been taking a typical antipsychotic drug and there have been improvements in her positive symptoms. However she still suffers negative symptoms and side effects. Her psychiatrist wants to change her medication from typical antipsychotics to one of the atypical antipsychotics and has also suggested cognitive behavioural therapy.
(a)  Outline one negative symptom of schizophrenia.
(2)
(b)  With reference to the item above, explain why Jenny’s psychiatrist wants to move her on to one of the atypical antipsychotics.
(4)
(c)  Briefly explain one advantage of cognitive behavioural therapy in the treatment of schizophrenia.
(2)
(Total 8 marks)
Q10.
Outline and compare two treatments for schizophrenia.
(Total 16 marks)
Q11.
‘Therapies can be time-consuming and, in some cases, uncomfortable for the client. It is, therefore, very important to offer the most appropriate and effective type of treatment.’
Outline and evaluate two or more therapies used in the treatment of schizophrenia.
(Total 16 marks)

Mark schemes
Q1.
[AO1 = 6 AO3 = 10]
 
Level | Mark | Description
4 | 13-16 | Knowledge of the interactionist approach to explaining and treating schizophrenia is accurate and generally well detailed. Discussion is thorough and effective. Minor detail and/or expansion of argument is sometimes lacking. The answer is clear, coherent and focused. Specialist terminology is used effectively.
3 | 9-12 | Knowledge of the interactionist approach to explaining and treating schizophrenia is evident but there are occasional inaccuracies/omissions. Discussion is mostly effective. The answer is mostly clear and organised but occasionally lacks focus. Specialist terminology is used appropriately.

2

5-8

Limited knowledge of the interactionist approach to explaining/treating schizophrenia is present. Focus is mainly on description. Any discussion is of limited effectiveness. The answer lacks clarity, accuracy and organisation in places. Specialist terminology is used inappropriately on occasions.
OR either explaining or treating at Level 3/4.

1

1-4

Knowledge of the interactionist approach to explaining/treating schizophrenia is very limited. Discussion is limited, poorly focused or absent. The answer as a whole lacks clarity, has many inaccuracies and is poorly organised. Specialist terminology is either absent or inappropriately used.
OR either explaining or treating at Level 2.

| 0 | No relevant content.
Possible content:
•   considers the combined effects of biological, psychological and social factors on the development of schizophrenia
•   diathesis-stress model combines effects of internal vulnerability and external stress trigger
•   vulnerability (diathesis) originally thought to be genetic, now includes vulnerabilities due to childhood trauma which might have affected brain development
•   stress trigger would be any negative psychological experience, eg breakdown of relationship, academic pressure etc
•   an interactionist treatment approach would include combining anti-psychotic medication with psychological therapy.
Possible discussion points:
•   revised understanding of diathesis − move from focus purely on single gene effect to polygenic effect
•   use of evidence that vulnerability may be neurodevelopmental (Read 2001), due to birth trauma (Cannon 2002), early psychological trauma (Ingram and Luxton 2005)
•   revised understanding of stress trigger − now includes any risk trigger, eg substance abuse
•   implications for treatment − relative effectiveness of single treatments versus multidisciplinary approach
•   use of evidence to support effectiveness of combined treatments, eg Tarrier 2004
•   links to broader theories/explanations, eg behaviourism, the biological approach, psychodynamic theory
•   links to broader debates, eg reductionism v holism.
Credit other relevant material.
[16]
Q2.
[AO3 = 1]
1 mark
C
Q3.
[AO3 = 6]
 
Level | Marks | Description
3 | 5 – 6 | Discussion of two limitations is clear and effective. The answer is coherent and well organised with effective use of specialist terminology.
2 | 3 – 4 | Discussion of two limitations is evident although one or both lack detail. The answer is mostly organised with some appropriate use of specialist terminology. OR 3 marks for one limitation discussed at the top of Level 3.
1 | 1 – 2 | At least one limitation is presented but discussion is limited/muddled. The answer lacks organisation and specialist terminology is either absent or inappropriately used. OR one limitation discussed at Level 2.
| 0 | No relevant content.
Possible limitations and discussion:
•        ethical problems – parents feel responsible for their child’s illness causing even greater stress and anxiety. Out-dated views that were once accepted are no longer tolerated by families and are now seen as destructive rather than productive
•        unreliability of recall leading to data that may lack validity – patients report childhood experiences retrospectively. Recall may be inaccurate and distorted by the need to explain. Prospective evidence is rare
•        family dysfunction may be the result of the child’s disturbing behaviour rather than the cause – impossible to show cause and effect
•        discussion of limitations via comparison with alternatives, eg ample evidence that there is a biological cause
•        family dysfunction might act as a trigger but the basic cause is biological (dopamine hypothesis, genetic evidence)
•        counterargument to the limitation given.
Credit other relevant limitations.
Q4.
[AO1 = 3 AO3 = 5]
 
Level | Marks | Description
4 | 7 – 8 | Knowledge of the use of antipsychotic drugs to treat schizophrenia is accurate with some detail. Evaluation is thorough and effective. Minor detail and/or expansion of argument is sometimes lacking. The answer is clear, coherent and focused. Specialist terminology is used effectively.
3 | 5 – 6 | Knowledge of the use of antipsychotic drugs to treat schizophrenia is evident but there are occasional inaccuracies/omissions. Evaluation is mostly effective. The answer is mostly clear and organised but occasionally lacks focus. Specialist terminology is used appropriately.
2 | 3 – 4 | Limited knowledge of the use of antipsychotic drugs to treat schizophrenia is present. Focus is mainly on description. Any evaluation is of limited effectiveness. The answer lacks clarity, accuracy and organisation in places. Specialist terminology is used inappropriately on occasions.
1 | 1 – 2 | Knowledge of the use of antipsychotic drugs to treat schizophrenia is very limited. Evaluation is limited, poorly focused or absent. The answer as a whole lacks clarity, has many inaccuracies and is poorly organised. Specialist terminology is either absent or inappropriately used.
| 0 | No relevant content.
Outline:
•        typical antipsychotics (eg chlorpromazine) are dopamine antagonists reducing dopamine activity by blocking dopamine receptors at the synapse. This reduces positive symptoms such as hallucinations and has a calming/sedative effect
•        atypical antipsychotics (eg clozapine and risperidone) block dopamine receptors and also act on other neurotransmitters eg acetylcholine and serotonin; also address the negative symptoms such as avolition.
Possible evaluation:
•        use of evidence re effectiveness in reduction of symptoms and/or relapse rates, eg Thornley 2003
•        side effects – typical antipsychotics: dry mouth, constipation, lethargy and confusion, involuntary muscle movement – tardive dyskinesia; atypical antipsychotics: weight gain, cardiovascular problems, agranulocytosis (autoimmune disorder affecting white blood cells)
•        comparison of effectiveness, eg atypical antipsychotics v typical antipsychotics, eg Bagnall 2003, Marder 1996
•        comparison with other treatments, eg cognitive therapy, family therapy
•        need to assess long-term benefits – many studies focus on short-term effects only
•        enhanced quality of life: for patients who can live independently / outside of institutional care; for family members
•        economic implications eg cost in relation to other treatments / hospitalisation; analysis of benefit re ability of patient to return to work.
Credit other relevant material.
Q5.
 
[AO1 = 2 AO3 = 2]
 
Level | Marks | Description
2 | 3 – 4 | Outline of the use of CBT for schizophrenia is clear and has some detail. A limitation relevant to schizophrenia is clearly explained. The answer is generally coherent with effective use of terminology.

1

1 – 2

Outline of the use of CBT lacks clarity, detail and link to schizophrenia. The limitation is generic / stated rather than explained. The answer as a whole is not clearly expressed. Terminology is either absent or inappropriately used.

Either outline or limitation done well.

| 0 | No relevant content.
Outline
Possible content:
•        challenging beliefs (including origin of ‘voices’) and reality testing to reduce distress
•        use of positive self-talk
•        coping strategy enhancement through education and symptom targeting
•        cognitive restructuring via ABCDE framework. Identifying activating event (A), exploring beliefs (B), recognising consequences (C), disputing irrational beliefs (D), restructured belief (E).
Credit other relevant aspects of cognitive behaviour therapy.
Possible limitations:
•        CBT requires self-awareness and willingness to engage with process (positive symptoms lead to lack of awareness; negative symptoms lead to reluctance / inability to engage)
•        practical issues, eg length of therapy (leading to drop out at times of severe episodes)
•        not all clients are suited to vigorous confrontation.
Credit other relevant limitations.
Q6.
 
[AO2 = 4]
 
Level | Marks | Description
2 | 3 – 4 | Knowledge of the effectiveness of atypical and typical antipsychotics on positive and negative symptoms is clear and mostly accurate. The findings in the table are used appropriately. The answer is generally coherent with effective use of terminology.
1 | 1 – 2 | Some knowledge of the effectiveness of atypical and typical antipsychotics and positive and negative symptoms is evident. Use of findings from the table is not always effective. The answer lacks accuracy and detail. Use of terminology is either absent or inappropriate.
| 0 | No relevant content.
•        Atypical and typical antipsychotics are equally effective against positive symptoms with more than half of patients responding well
•        The main difference is that negative symptoms respond better to atypical antipsychotics, 30% improve compared with typical antipsychotics 16%
•        Atypical antipsychotics are more effective against negative symptoms
•        These findings support the view that they act on different neurotransmitters
Q7.
 
[AO3 = 2]
Content:
•        All drugs have side effects that can be severe and may lead to patients avoiding medication and hence to relapse
•        It is questionable whether or not severely affected patients can give informed consent to medication
•        Drugs may simply be supressing symptoms
2 marks for a clear and coherent limitation
1 mark for a vague/muddled limitation or limitation merely identified
Q8.
 
[AO1 = 3 AO3 = 5]
 
Level | Marks | Description
4 | 7 – 8 | Outline of token economies is generally accurate and mostly well detailed. Discussion is thorough and effective. The answer is clear, coherent and focused. Specialist terminology is used effectively. Minor detail sometimes lacking.
3 | 5 – 6 | Outline of token economies is generally accurate. Discussion is mostly effective. The answer is mostly clear and organised. Specialist terminology mostly used effectively.
2 | 3 – 4 | Outline of token economies is present. There are some inaccuracies. Discussion is sometimes effective. There is some appropriate use of specialist terminology.
1 | 1 – 2 | Outline of token economies is limited and lacks detail. There is substantial inaccuracy/muddle. Discussion is limited, poorly focused or absent. Specialist terminology either absent or inappropriately used.
| 0 | No relevant content.
Possible content:
•        Outline of token economies – awarding of ‘tokens’ when patients with schizophrenia show desirable behaviour. Tokens can be exchanged later for eg sweets
•        Based on Skinnerian operant conditioning principles
•        Used for behavioural shaping and management so that patients in long stay hospitals are easier to manage
Possible discussion points:
•        Evidence suggests token economies can be effective in improving behaviour in psychiatric hospitals
•        Token economies do not address symptoms of schizophrenia, so they are not a ‘treatment’
•        Not effective with unresponsive patients eg with negative symptoms
•        Ethical issues – treats patients as lab rats
Credit other relevant information.
Q9.
(a)  [AO1 = 2]
1 mark for brief outline of relevant symptom
Plus
1 further mark for accurate elaboration
Possible content:
•   Speech poverty refers to limited speech output with limited, often repetitive content.
•   Avolition refers to a lack of purposeful, willed behaviour
Credit other relevant symptoms eg psychomotor retardation.
(b)  [AO2 = 4]
 
Level | Marks | Description
2 | 3 – 4 | Knowledge of the action/effects of typical and atypical antipsychotics is clear and mostly accurate. The material is applied appropriately. The answer is generally coherent with effective use of terminology.
1 | 1 – 2 | Some knowledge of the action/effects of typical and atypical antipsychotics is evident. Application is not always effective. The answer lacks accuracy and detail. Use of terminology is either absent or inappropriate.
| 0 | No relevant content.
Possible content:
•   Atypical antipsychotics have been shown to be more effective against negative symptoms
•   Typical antipsychotics (such as chlorpromazine) are liable to produce movement side effects, sometimes resembling Parkinson’s disease.
•   They mainly affect dopamine pathways
•   Atypical antipsychotics are less liable to produce movement side effects; they have less action on the dopamine system, and instead affect a wide range of neurotransmitter systems
(c)  [AO3 = 2]
1 mark for brief explanation of advantage
Plus
1 further mark for accurate elaboration
Possible content:
•   Allows patient to take some responsibility for own treatment
•   Enhances effectiveness in other areas of life
•   Research supports its effectiveness alongside drug therapy
•   Effectiveness can be long term/ongoing
Credit other relevant advantages.
Q10.
 
Marks for this question: AO1 = 6, AO3 = 10
 
Level | Marks | Description
4 | 13 – 16 | Knowledge is accurate and generally well detailed. Comparison is thorough and effective. The answer is clear, coherent and focused. Specialist terminology is used effectively. Minor detail and / or expansion of argument sometimes lacking.
3 | 9 – 12 | Knowledge is evident. There are occasional inaccuracies. Comparison is apparent and mostly effective. The answer is mostly clear and organised. Specialist terminology is mostly used effectively. Lacks focus in places.
2 | 5 – 8 | Some knowledge is present. Focus is mainly on description. Any comparison is only partly effective. The answer lacks clarity, accuracy and organisation in places. Specialist terminology is used inappropriately on occasions.
1 | 1 – 4 | Knowledge is limited. Comparison is limited, poorly focused or absent. The answer as a whole lacks clarity, has many inaccuracies and is poorly organised. Specialist terminology either absent or inappropriately used.
| 0 | No relevant content.
Please note that although the content for this mark scheme remains the same, on most mark schemes for the new AQA Specification (Sept 2015 onwards) content appears as a bulleted list.
AO1
Marks for outlines of two treatments for schizophrenia. It is acceptable to outline two different drug treatments although most students are likely to focus on anti-psychotic drugs and a form of psychotherapy (ie a non-biological treatment).
Antipsychotic drugs include traditional neuroleptics which block dopamine, eg chlorpromazine and more recently introduced atypical anti-psychotics, eg clozapine and risperidone which act on dopamine and serotonin.
Psychotherapies include: cognitive behaviour therapy to give coping strategies to gain control of the hallucinations and delusions; cognitive therapy involving reality testing and challenge; behaviour therapy, eg token economies used in institutions; family therapy to increase tolerance and reduce negative attitudes; milieu therapy to enhance normalisation. Credit use of psychodynamic therapy if student makes a case for its use.
Note that community care in itself is not a treatment therefore not appropriate.
AO3
Marks for comparison of the two treatments. Comparison points will vary according to the treatments used but should include discussion of relative effectiveness. Further comparison points might include: use of evidence to support claims of effectiveness; durability of effect over the long-term; suitability for different sub-types / symptoms; comparison of side-effects, either physical or other unintended outcomes; differences in attitudes towards the two types of treatment, either patient attitudes or more widely; preference for combination treatments; individual differences in preference and responsiveness; role of patient, ie passive / active; discussion of the usefulness of specific treatments in the context of institutionalisation v community care can also be credited. Credit evaluation of evidence where used in comparison / discussion.
Credit use of relevant evidence.
Q11.
 
Marks for this question: AO1 = 6, AO3 = 10
 
Level | Marks | Description
4 | 13 – 16 | Knowledge is accurate and generally well detailed. At least two therapies evident. Discussion / evaluation / application is thorough and effective. The answer is clear, coherent and focused. Specialist terminology is used effectively. Minor detail and / or expansion of argument sometimes lacking.
3 | 9 – 12 | Knowledge is evident. There are occasional inaccuracies. At least two therapies present. Discussion / evaluation / application is apparent and mostly effective. The answer is mostly clear and organised. Specialist terminology is mostly used effectively. Lacks focus in places.

2

5 – 8

Some knowledge is present. Focus is mainly on description. Any discussion / evaluation / application is only partly effective. The answer lacks clarity, accuracy and organisation in places. Specialist terminology is used inappropriately on occasions.
One therapy only at Level 4

1

1 – 4

Knowledge is limited. Discussion / evaluation / application is limited, poorly focused or absent. The answer as a whole lacks clarity, has many inaccuracies and is poorly organised. Specialist terminology either absent or inappropriately used.
One therapy only at Level 3

| 0 | No relevant content.
Please note that although the content for this mark scheme remains the same, on most mark schemes for the new AQA Specification (Sept 2015 onwards) content appears as a bulleted list.
AO1
The question does not specify biological or psychological therapies so either or both are acceptable. The most likely therapy to be described is drug therapy, but various others are acceptable. Examiners should be mindful of a depth / breadth trade-off here.
The important point is that therapies must be described in the context of schizophrenia. Descriptions of therapies which are not appropriate for schizophrenia such as systematic desensitisation are not creditworthy. However, discussion of unsuitable treatments could be made relevant as part of the discussion.
There are some treatments which were used for schizophrenia in the past but are no longer considered suitable in most cases, eg ECT. Although creditworthy, discussion should make clear the limited contemporary use of such treatments.
Answers which offer two different forms of drug therapy are acceptable if they have different modes of action.
AO3
Candidates are likely to evaluate therapies in terms of the issues raised in the quotation, but the wording allows discussion of a wider range. Evaluation must be relevant to therapies suited to schizophrenia. Material on other therapies will only be creditworthy if it is explicitly used to offer relevant commentary.
Issues of appropriateness could include:
•        the nature of the disorder means that some therapies are more appropriate than others
•        factors affecting the choice of treatment, eg financial constraints, availability of appropriate therapist, accuracy of original diagnosis
•        ethical issues, eg possible harmful side-effects, issues of informed consent, dehumanising effects of some treatments.
Issues of effectiveness could include:
•        problems of measuring effectiveness, eg when to measure, how to measure, what criteria to choose
•        wide range of symptoms – treatments might be effective for some but not others
•        placebo effects.
Credit could be for evaluation of research in terms of methodological issues, reliability, validity and the extent to which generalisations can be made, eg treatment outcome research often has problems of operational definition and issues concerning the allocation of participants to treatment groups.

Examiner reports
Q1.
This question was rarely well-answered, although some students could explain different conceptualisations of diathesis-stress and make good use of evidence from twin and adoption research and evidence for the effectiveness of combined treatments. Answers were sometimes poorly balanced, with the emphasis on the interactionist approach to explaining and very little about treating. As with the nature-nurture question, less effective answers often treated each side of the argument separately, with an outline and evaluation of the biological explanation, followed by the same for family dysfunction and the same for treatments. A small number of students seemed unaware of the meaning of the term ‘interactionist’ and misinterpreted this as a question about how dysfunctional family/social interactions might lead to the development of schizophrenia. Occasionally, answers slipped back into nature-nurture mode giving examiners a curious sense of déjà vu.
Q2.
This question was answered correctly by the majority of students.
Q3.
Most students could offer two valid imitations, although these were often cursory or insufficiently discussed. Blaming the family and the issue of cause and effect were usually effective routes to credit. Comparisons with other explanations, mainly biological, were not always very effective as they tended to stray into discussion of the alternative. A number of answers focused on family therapy rather than on the explanation. The frequently seen assertion that the family dysfunction explanation is ‘reductionist’ was surprising given the many and varied ways in which families might be dysfunctional, and only serves to illustrate the widespread misuse of the term.
Q4.
This question was usually well answered. Despite the fact that named drugs were often misspelt or the names appeared to have been deliberately obscured by use of wiggly handwriting, there were some excellent accounts of their action. In less competent answers, typical and atypical antipsychotics were confused, both in terms of names, action and side effects. Evaluations tended to cover side effects, effectiveness and comparison with alternatives. Just occasionally, students considered the implications for the economy to good effect.
Q10.
 
This question presented problems for two reasons. Firstly, many students mistakenly presented community care as a treatment. Secondly, even where two legitimate treatments were offered, there was minimal comparison. Where community care was offered as a treatment, it was often evident that students understood that it is an alternative living arrangement, which, in itself, does include treatment. Some students even said so. Wherever it was noted that, whilst in community care, treatments such as social skills training might be available, then this could be credited as one of the treatments. Those students who did present community care as a treatment tended to score marks in the bottom two bands. That said, even students presenting two legitimate treatments often scored quite poorly because they failed to compare.
Q11.
 
Some candidates wasted time in their answers by including detailed descriptions of schizophrenia or explanations of its origin. This was only credit-worthy where it provided clear underpinning for the explanation of the therapy. There were some excellent well–detailed answers, especially on drugs, where students showed an impressive knowledge of the relevant drugs and their mode of action. There were also some detailed accounts of CBT showing good understanding of how it works in the context of schizophrenia. Other psychological therapies were often less well done. For example, where candidates selected token economy, the description and evaluation lacked any understanding of how it is used with this particular client group.
Many candidates were not well prepared for this question and wrote generally about therapies without making them explicitly relevant to schizophrenia. Psychoanalysis, in particular, is difficult to make relevant to schizophrenia except in the rare instances when candidates referred specifically to the work of Sullivan. Some candidates, having given a general description of psychoanalysis then actually acknowledged that ‘Freud said it wouldn’t work’. ECT was accepted but, given that NICE does not recommend it as a first-line therapy for most cases of schizophrenia in the UK and that the APA in the USA suggest it only when other treatments have been tried and failed, it was disappointing to see so many answers in which it was offered uncritically as a mainstream therapy for schizophrenia. Similarly, 70 year-old psychosurgery techniques were often described in long and gory detail without any apparent understanding of current practice.
In some answers, the evaluation was actually better than the description and some candidates made good use of outcome studies to support their arguments. However, in many answers AO2/3 was generic and unsupported by evidence. The same points were repeated for each type of therapy. In particular, ‘drop–in’ references to issues and debates such as ‘It is reductionist’ or ‘It is determinist’ showed weak understanding and gained little or no credit. Candidates would have benefited from taking a little more time to plan their answer in order to achieve coherent elaboration and a clear line of argument.
Given the new organisation of the specification which requires candidates to have studied therapies in the context of a particular disorder, the lack of understanding and ability to make material explicitly relevant to schizophrenia shown in a large number of answers was rather disappointing.

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