Schizophrenia and Other Psychotic Disorders Chapter 10

Chapter Outline Psychotic Disorders Etiology of Schizophrenia Treatment of Schizophrenia and Other Psychotic Disorders Reviewing Learning Objectives A psychotic experience is a single event that can be experienced by anyone, and when these experiences become frequent or continuous is when they are called psychotic disorders. Understand that multiple personality and split personality are different than schizophrenia, which represents a disconnection between one’s thoughts, feelings, and behaviors. Three categories of symptoms exist for a patient with schizophrenia: positive symptoms, negative symptoms, and cognitive symptoms. It is important to consider race, culture, and ethnicity in one’s diagnosis, etiology, and treatment of schizophrenia. Brain abnormalities can result from prenatal development, genetic alterations, parental environmental factors, or obstetrical complications related to the neurodevelopmental model of schizophrenia. Biological, prenatal, and environmental factors can produce schizophrenia. Schizophrenia is a chronic disorder, and full remission is rare, with treatment consisting of medication and psychological interventions.

Psychotic Disorders Characterized by continous disturbance for at least 6 months due to key symptoms including unusual bizarre thinking (delusions), distorted perceptions (hallucinations), odd behaviors, and negative symptoms such as emotional flatness or apathy continuous disturbance (i.e. debilitating symptoms) be present for at least six months, including at least one month of certain key symptoms (active symptoms: delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms such as severe emotional flatness or apathy)

Psychotic Disorders Psychosis – a severe mental condition characterized by a loss of contact with reality Delusion – a false belief Hallucination – a false sensory perception continuous disturbance (i.e. debilitating symptoms) be present for at least six months, including at least one month of certain key symptoms (active symptoms: delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms such as severe emotional flatness or apathy)

What Is Schizophrenia? A severe psychological disorder characterized by disorganization in thought, perception, and behavior Looks peculiar Little or no insight into their problem when in active phase

What Is Schizophrenia? -First defined over 100 years ago by German psychiatrist Emil Kraepelin -Dementia praecox -Dementia (pervasive disturbances of perceptual and cognitive faculties) -Praecox (early life onset) -Schizophrenia vs. DID

According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), to be diagnosed with schizophrenia, three diagnostic criteria must be met Dsm-v: At least one of these three Characteristic symptoms: Two or more of the following, each present for much of the time during a one-month period (or less, if symptoms remitted with treatment). Delusions Hallucinations Disorganized speech, which is a manifestation of formal thought disorder Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior Negative symptoms: Blunted affect (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation) If the delusions are judged to be bizarre, or hallucinations consist of hearing one voice participating in a running commentary of the patient's actions or of hearing two or more voices conversing with each other, only that symptom is required above. The speech disorganization criterion is only met if it is severe enough to substantially impair communication.

According to the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), to be diagnosed with schizophrenia, three diagnostic criteria must be met Social or occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset. Significant duration: Continuous signs of the disturbance persist for at least six months. This six-month period must include at least one month of symptoms (or less, if symptoms remitted with treatment). If signs of disturbance are present for more than a month but less than six months, the diagnosis of schizophreniform disorder is applied.[9] Psychotic symptoms lasting less than a month may be diagnosed as brief psychotic disorder, and various conditions may be classed as psychotic disorder not otherwise specified. Schizophrenia cannot be diagnosed if symptoms of mood disorder are substantially present (although schizoaffective disorder could be diagnosed), or if symptoms of pervasive developmental disorder are present unless prominent delusions or hallucinations are also present, or if the symptoms are the direct physiological result of a general medical condition or a substance, such as abuse of a drug or medication.

Positive Symptoms of Schizophrenia Group of symptoms including unusual thoughts, feelings, and behaviors 1. Delusions (bizarre unusual beliefs and thoughts): 2. Hallucinations 3. Disorganized speech 4. Disorganized behaviors Catatonia and waxy flexibility

Positive Symptom 1: Delusions Delusions (bizarre unusual beliefs and thoughts): Paranoid, persecutory delusions (see examples): the most common type Delusions of influence - thought insertion or withdrawal (thoughts are put in or taken away…), thought broadcasting

Delusions: Paranoid, the most common type Delusions: Paranoid, the most common type. These are persecutory in nature, examples: Overpowering, intense feeling that people are talking about you, looking at you Overpowering, intense feeling you are being watched, followed, and spied on (tracking devices, implants, hidden cameras) Thinking that someone is trying to poison your food or harrass you

Delusions: examples of types Delusions of influence: Thinking that something is controlling you- i.e. an electronic implant Thinking that people can read your mind/ or control your thoughts Thinking that your thoughts are being broadcast over the radio or tv Delusions of reference Thinking that random events convey a special meaning to you.

Delusions: examples of types Religious delusions that you are Jesus, God, a prophet, or the antichrist. Delusions of grandeur/self significance the belief that you have an important mission, special purpose, or are an unrecognized genius, or famous person. Delusions that someone, often a famous person, is in love with you when in reality they aren't (erotomania)

Positive Symptom 2: Hallucinations Hallucinations: False sensory experiences that have no basis in the external world

Hallucinations: Auditory, the most common type (70 %) Features of auditory hallucinations: Either inside the person's head or externally. When external: sound as real as an actual voice, may appear as if they come from no apparent source, other times they come from real people who don't actually say anything, other times a person will hallucinate sounds. When inside their heads: as if their inner thoughts are no longer alone. (New) Voices can talk to each other, talk to themselves, or comment on the person's actions. The majority of the time the voices are negative. Hallucinations seem as real as any other experience to the person with schizophrenia

Hallucinations: Visual, the second most common type Features of visual hallucinations Initial manifestation: Overacuteness of the senses, In the middle: Illusions, and On the far end/extreme: Actual hallucination

Positive Symptoms 3: Disorganized Speech Loose associations (see example) Clang associations (see example) Thought blocking (sudden halt to speech) Word salad (putting together meaningless words) Racing thoughts Making up new words (neologism)

Loose associations: A lack of logical relationship between thoughts and ideas. With effort, meaning might be found… " …I need to go to the store to buy some band-aids. I read an article about how expensive AIDS drugs are. People take too many street drugs. The streets should be clean from the rain today, etc" The need to go to the store to buy band-aids is forgotten. “I love you. Bread is the staff of life. Haven’t I seen you in church? I think incest is horrible.”

Clang association: combining unrelated words or phrases simply because they have similar sounds, rhyming " Well, when we was first bit on the slit on the rit and the man on the ran or the pan on the ban and the sand on the man and the pan on the ban and the can on the man on the fan on the pan " " When I think of my dad, rad, mad, pad, lad, sad. "

Positive Symptom 4: Disorganized or catatonic behavior Disorganized behavior is not goal directed, does not make sense in the context. Examples: Taking clothes off on a flight Laughing or screaming at inappropriate times Also, Strange postures: Catatonia and waxy flexibility

Negative Symptoms Behaviors, emotions, or thought processes that are absent in people with schizophrenia Blunted or flattened affect (a blank face, no smile no expression) Anhedonia (inability to experience and/or express joy or pleasure from activities ) Avolition (lack of initiative or motivation) Alogia (poverty of speech, tendency to say a little) Social withdrawal Neglect of personal hygiene

Cognitive Impairments – Not used as a diagnostic criteria, but are often observed Difficulty maintaining attention Memory problems Difficulty making sense of information Difficulty planning and structuring activities Lack of insight (anosognosia)

Functional Impairment of Schizophrenia Symptom severity equals the level of impairment If not treated for a year, longterm outcome is worse Long-term outcome of schizophrenia is still poor Significant human toll on the individual and the family (quality of life) One of the top ten most debilitating conditions in the world (disability adjusted life years - DALY) Some do have periods of recovery: About 40% shows recovery from schizophrenia, about a half are in recovery

Functional Impairment of Schizophrenia Cultural factors Those in developing countries have more positive outcomes compared to those in developed countries Violence …violent acts committed by people with schizophrenia is higher than the rates of violence from the general population. Some researchers have reported that 8% of patients committed a violent act upon being discharged from a hospital stay, and 15% committed a violent act after their first year of being hospitalized.

Epidemiology of Schizophrenia Prevalence rates averages 1% to 0.3 to 1.6% of U.S. general population 16 to 40 of every 100,000 people develop schizophrenia The onset for schizophrenia could be acute or gradual, meaning the individual could have the disorder for years before actively showing psychotic symptoms.

Epidemiology of Schizophrenia Gradual onset (some deterioration of functioning) Prodromal phase (social withdrawal or deterioration in hygiene) Acute phase (starts to exhibit positive symptoms) Residual phase (psychotic symptoms are no longer present but negative symptoms remain)

Sex, Race, Ethnicity, and Development Women (develop schizophrenia at a later age and tend to have milder forms) Developmental factors: Situational anx, nervous, depression, psychotic-like experiences: magical thinking, ideas of reference, delusions of reference in childhood Less sociable, subtle neuromotor abnormalities in childhood (raised elbows, eye movement, involuntary hand or facial movements) Paranoid Schizophrenia is the most common subtype at 39.8% and Catatonic subtype is more rare at 6.7%.

Sex, Race, Ethnicity, and Development Hormonal and sociocultural implications Symptoms common across racial and ethnic groups African Americans (more likely to be diagnosed than white and Latino patients) EOS (schizophrenia that develops before the age of 18) Paranoid Schizophrenia is the most common subtype at 39.8% and Catatonic subtype is more rare at 6.7%.

Ethics and Responsibility Inaccurate diagnosis may result Inattention to cultural different behavior Lack of cultural competence among clinicians Language barriers Few bilingual therapists Diagnostic errors Racial bias is a real factor in the diagnosis of Schizophrenia Determine diagnosis based solely on a person’s symptoms without knowing race

Other Psychotic Disorders Brief psychotic disorder (sudden onset of psychotic symptoms does not last for more than a month) Schizophreniform disorder (identical to schizophrenia but the illness is less than 6 months, less functional impairment) Schizoaffective disorder (patient suffers from schizophrenia and major depressive, manic, or mixed) Delusional disorder (presence of nonbizarre delusion) Shared psychotic disorder (two people sharing a delusional belief) The primary change to schizoaffective disorder is the requirement that a major mood episode be pres - ent for a majority of the disorder’s total duration after Criterion A has been met. This change was made on both conceptual and psychometric grounds. It makes schizoaffective disorder a longitudinal instead of a cross-sectional diagnosis—more comparable to schizophrenia, bipolar disorder, and major depres sive disorder, which are bridged by this condition.

Etiology Biological -Dopamine hypothesis (the presence of too much dopamine in the neural synapse) Too much dopamine in the limbic system (positive symptoms), too little in the cortical areas (negative symptoms) -Neurotransmitters related to cognitive impairments Serotonin – slowed speech, lack of initiative etc. as found in depression GABA and glutamate – learning and remembering new material

Etiology Biological 60-84 % concordance in monozygotic twins -Genetics 60-84 % concordance in monozygotic twins 15% risk if one parent, 50% risk if both parents -Neuroanatomy (structural and functional abnormalities in the brain) Enlarged ventricles Reduction in cortical areas (gray matter) of the brain Mild structural abnormalities at the level of brain cells, and modified neuronal connections The ventricles of the brain are a communicating network of cavities filled with cerebrospinal fluid (CSF) and located within the brain parenchyma. The ventricular system is composed of 2 lateral ventricles, the third ventricle, the cerebral aqueduct, and the fourth ventricle (see the following images). The choroid plexuses located in the ventricles produce CSF, which fills the ventricles and subarachnoid space, following a cycle of constant production and reabsorption.

Etiology Biological --Viral theories (influenza) and prenatal stressors (obstetric complications) -Synaptic pruning (process in which weaker synaptic contacts in the brain are eliminated and stronger connections strengthened – occurs at a faster rate beginning in childhood for those with schizophrenia – > affects beh, motor, and cog development! -- impaired peer relationships, social isolation, disruptive beh (preadolescent boys), withdrawal (preadolescent girls) The ventricles of the brain are a communicating network of cavities filled with cerebrospinal fluid (CSF) and located within the brain parenchyma. The ventricular system is composed of 2 lateral ventricles, the third ventricle, the cerebral aqueduct, and the fourth ventricle (see the following images). The choroid plexuses located in the ventricles produce CSF, which fills the ventricles and subarachnoid space, following a cycle of constant production and reabsorption.

Genetics and Environment: Schizophrenia Let’s examine the evidence 1. A research study found that 36.8% of the biological children of schizophrenic mothers who were raised in “disordered” family environment developed a “schizophrenic spectrum disorder.” Fact: Both genetic and environmental factors increase the risk of psychotic disorders, but even without the genetic risk and “healthy family environment,” 4.8% of individuals still develop the disorder. Evidence: The research shows both factors play a role.

Etiology Family Influences -The cause of the disorder is not the same as what people believe is responsible for their suffering -Expressed emotion (describes the level of emotional involvement and attitudes that exist within a family of a patient with schizophrenia) -A variety of cultural explanations for the disorder (biological, social, supernatural, and family environment) -Gene-environment correlation (the same person who provides one’s genetic make-up also provides the environment in which one lives)

Treatment of Schizophrenia Pharmacological -Antipsychotics (a class of medications that block dopamine receptors) -Typical antipsychotics (medications that reduce the positive symptoms) - Side effects: Tardive dyskinesia (abnormal and involuntary motor movements of the face, mouth, limbs, and trunk) -Atypical antipsychotics medications that treat positive symptoms, less likely to produce side effects (but could lead to diabetes, high fat components in the blood), and affect negative symptoms and cognitive impairments

Treatment of Schizophrenia Psychosocial -Psychoeducation (both patient and family members are educated about disorder) -CBT (used to reduce or eliminate psychotic symptoms) -Social skills training (teaches the basics of social interaction and both verbal and nonverbal skills) -Supported employment (a psychosocial intervention that provides job skills)