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

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 Thinking that something is controlling you- i.e. an electronic implant Thinking that people can read your mind/ or control your thoughts

Delusions: Paranoid, the most common type Delusions: Paranoid, the most common type. These are persecutory in nature, examples: 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. Religious delusions- that you are Jesus, God, a prophet, or the antichrist. Delusions of grandeur- 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 Significant human toll on the individual and the family (quality of life) One of the top ten most debilitating conditions in the world (DALY)

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

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) Schizoaffective disorder (patient suffers from schizophrenia and depression, main, or mixed) Delusional disorder (presence of nonbizarre delusion) Shared psychotic disorder (two people sharing a delusional belief)

Etiology Biological -Dopamine hypothesis (the presence of too much dopamine in the neural synapse) -Neurotransmitters -Genetics -Neuroanatomy (structural and functional abnormalities in the brain) -Viral theories and prenatal stressors -Synaptic pruning (process in which weaker synaptic contacts in the brain are eliminated and stronger connections strengthened)

Genetics and Environment: Schizophrenia 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. 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.”

Figure 10.2 Neurodevelopmental Model of Schizophrenia

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) -Atypical antipsychotics (medications that treat positive symptoms, less likely to produce side effects, and affect negative symptoms and cognitive impairments) -Side effects -Tardive dyskinesia (abnormal and involuntary motor movements of the face, mouth, limbs, and trunk)

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)

Research Hot Topic: Transcranial Magnetic Stimulation (TMS) Goal (provide stimulation to a targeted area of the cerebral cortex to change brain activity) Use of small coil placed over the scalp to induce electrical current Based on neuroimaging studies Decreases (temporarily) the frequency of hallucinations Reduction in positive symptoms (reduced frequency of voices and reduced distraction) Does not reduce delusions Time-limited results and need for further studies