Schizophrenia & Other Psychotic Disorders

Historical Approaches Kraeplin early descriptions Classifies symptoms Differentiates mania Bleuler Associative splitting of personality

Schizophrenia: Lost touch with reality Disruption of: Normal thought processes Perception Personality Affect

positive symptoms – deviant behaviors delusions, hallucinations, thoughts negative symptoms – deficit symptoms Lack of normal function SYMPTOMS OF SCHIZOPHRENIA

thought disorder – disrupted cognitive functioning most dramatic and obvious symptom loosening of associations word salad – seems as if sense Neologisms – new words clang associations - sounds of words POSITIVE SYMPTOMS

delusions – not objectively true not be accepted as true within culture person holds firmly in spite of contrary evidence POSITIVE SYMPTOMS

Delusions Paranoid/persecution Grandeur Capgas syndrome – double of other’s Cotard’s syndrome – part of body changed Change vs. fixed

hallucinations – perceptual experiences that feel real although there is nothing to perceive Visual Auditory tactile POSITIVE SYMPTOMS

Attention Problems Difficulty focusing attention Esp. during first stages Bombarded Attention is critical to functioning

Negative Symptoms Negative = absent 25% patients

Anhedonia - interest Avolition - movement Alogia - content or quantity of speech flat or blunted affect NEGATIVE SYMPTOMS

catatonia – a psychomotor disturbance of movement and posture catatonic stupor waxy flexibility OTHER SYMPTOMS

inappropriate affect – unusual and sometimes bizarre emotional responses OTHER SYMPTOMS

lack of insight – lack of awareness that one’s experiences are unusual or abnormal

Schizophrenia is not… Split personality disorder Multiple personality disorder Schizophrenia = “splitting of the mind” Ambivalence

clinical course – specific pattern of changes in symptomatology over time prodromal phase active phase residual phase CLINICAL COURSE

Schizophrenia 1% lifetime prevalence Equal men & women Consistent across cultures (differences in dx and recovery) More in lower class Early life Women later

AGE OF RISK FOR SCHIZOPHRENIA Source : Adapted from I.I. Gottesman, Schizophrenia Genesis: The Origins of Madness (New York: Freeman, 1991.)

AGE OF RISK FOR SCHIZOPHRENIA Source : Adapted from I.I. Gottesman, Schizophrenia Genesis: The Origins of Madness (New York: Freeman,1991.)

TYPICAL COURSES FOR SCHIZOPHRENIA GRADUAL ONSET & VERY POOR PROGNOSIS (A) CHRONIC GRADUAL ONSET & VERY POOR PROGNOSIS

TYPICAL COURSES FOR SCHIZOPHRENIA OCCASIONAL EPISODES WITH NEARLY NORMAL FUNCTIONING BETWEEN THEM (B) EPISODIC OCCASIONAL EPISODES WITH NEARLY NORMAL FUNCTIONING BETWEEN THEM

TYPICAL COURSES FOR SCHIZOPHRENIA BRIEF PERIOD OF PSYCHOSIS & NEARLY COMPLETE RECOVERY WITH NO OTHER EPISODES (C) SINGLE EPISODE BRIEF PERIOD OF PSYCHOSIS & NEARLY COMPLETE RECOVERY WITH NO OTHER EPISODES 22%

SUBTYPES OF SCHIZOPHRENIA disorganized catatonic paranoid undifferentiated residual

characterized by disorganized speech or behavior and flat or inappropriate affect disorganized catatonic paranoid undifferentiated residual

SUBTYPES OF SCHIZOPHRENIA characterized by psychomotor disturbance of movement and posture disorganized catatonic paranoid undifferentiated residual

SUBTYPES OF SCHIZOPHRENIA characterized by fixed delusions of persecution disorganized catatonic paranoid undifferentiated residual

SUBTYPES OF SCHIZOPHRENIA diagnosis used for people who meet the criteria for schizophrenia but do not clearly fit into the above subtypes disorganized catatonic paranoid undifferentiated residual

SUBTYPES OF SCHIZOPHRENIA symptom patterns found in individuals with schizophrenia during periods of relative remission including cognitive slippage disorganized catatonic paranoid undifferentiated residual

Development of Schizophrenia Abnormal signs childhood Less positive affect More negative affect Older adults ↓ positive symptoms ↑ negative symptoms

CAUSES OF SCHIZOPHRENIA THEORIES OF CAUSE Hypothesized causes/predispositions Not mutually exclusive Theories are specific - overlap

CAUSES of Schizophrenia 1. Genetics 2. Neurobiology 3. Psychological and Social 4. Psychodynamic Theories Diathesis – Stress Models

Genetics & Schizophrenia Genes are responsible for some people’s vulnerability to schizophrenia Inherent general predisposition, not type

SCHIZOPHRENIA IN FAMILIES RELATION- SHIP % GENES SHARED ON AVERAGE RISK Identical twins100%48% First-degree 50% relatives Parents 6% Siblings 9% Fraternal17% twins Children13%

Twin & Adoption Studies Genetic studies of families do not allow us to decide: Environment? (Nurture) Genetics? (Nature) Twin & Adoption studies allow us to separate effects

Genetic Markers Smooth-pursuit eye movement

Neurobiology of Schizophrenia Dopamine is too active 1. Antipsychotic drugs work. They decrease dopamine (by blocking) 2. They produce side effects similar to Parkinson’s. Parkinson’s = too little dopamine 3. L-dopa, given to Parkinson’s patients, which increases dopamine, can produce schizophrenia- like symptoms 4. Amphetamines, which increase dopamine, can make schizophrenia worse

Brain Structure Enlarged ventricles Adjacent brain parts underdeveloped? Frontal lobes = less active neurotransmitters

Viral Infection Risk Recent introduction of schizophrenia (1800s) ↑ in urban areas Prenatal exposure to flu Prenatal brain damage

Psychological & Social Influences - Stress Retrospective research shows role of stressful events in onset Prospective research – relapse preceded by higher rates of stress Might also increase depression, which increases risk of relapse

Psychological & Social Influences - Family Schizophrenogenic mothers Double bind communication

Psychological & Social Influences - Family Expressed Emotion In discharged patients, those with less family contact had fewer relapses Consists of: Criticism/disapproval Hostility/animosity Emotional overinvolvement 3.7 times increase in relapse (!)

Expressed Emotion High: “I’ve tried to jolly him out of it and pestered him into doing things. Maybe I’ve overdone it. I don’t know.” Low: “I just tend to let it go because I know that when she wants to speak, she will speak.”

PSYCHODYNAMIC FACTORS Freud Primary Narcissism Newborn Lack ego Thoughts = reality Fragile Ego? Overwhelming early trauma?

Diathesis Stress Models X

Treatment of Schizophrenia 1. Biological 2. Psychosocial

Biological Interventions Historical biological interventions include: Lobotomies Sever frontal lobes from lower portions of brain Insulin coma therapy Electroconvulsive therapy

Antipsychotic Medication Medical breakthrough 1950s – neuroleptics 60% effective Mostly effect positive symptoms Effect dopamine, but other neurotransmitters as well

Antipsychotic Medication New antipsychotics Clozapine Risperidone Olanzapine Less side effects than early antipsychotics

Problem: Medication Compliance 7% of patients refuse to take prescribed antipsychotic medication 1. Negative relationships with doctors 2. Cost of medication 3. Lack of social support 4. Negative side effects tardive dyskinesia in 20% of long-term users 5. Beliefs about medication use (25%)

Psychosocial Interventions Psychodynamic treatments Inpatient treatment most treatment, until recently Decreased due to changes in involuntary hospitalization laws 200,000 with serious disorders are homeless

Psychosocial Interventions Token economies Contribute to increased self-care More discharge

Psychosocial Interventions Social skills building Model pieces Role-play Practice in vivo

Psychosocial Interventions Behavioral Family Therapy Psychoeducation – symptoms, causes, medication compliance Communication skills Problem-solving skills Most beneficial if ongoing

Psychosocial Interventions Cognitive Treatment Periods of mild symptoms Label voices as thoughts Slow + time consuming

Living with Schizophrenia 40-60% of patients live with their family 10-20% of homeless individuals have schizophrenia 10% of patients will commit suicide 50% will experience comorbid substance abuse 33% will experience physical/sexual assault

Schizophrenia & Awareness/Insight 1. Awareness of the signs, symptoms and consequences 2. General attributions re: illness, symptoms, consequences 3. Self-concept 4. Psychological defensiveness

Why is Insight Important? High rates of poor insight in schizophrenia A symptom? Low insight = less positive outcomes Low insight = less compliance Low insight = higher rates relapse High insight = better psychosocial functioning (jobs, friends, less hospitalization)

Prognosis of Schizophrenia Predicting outcome is virtually impossible Recent research has indicated prognosis is better than originally expected year longitudinal studies Some research suggests 20-50% “fully recover” later in life

Other Psychotic Disorders 1. Delusional Disorders 2. Schizoaffective Disorder

Delusional Disorders Marked by dramatic and stable delusions Other symptoms not present Can develop at any age Presence of “nonbizarre” delusions Can conceivably be true Any hallucinations are mild Function as normal when delusions not present

Causes of Delusional Disorders No genetic link w/ schizophrenia Links with avoidant & paranoid P.Ds Spontaneous recovery within months Chronic course w/ no recovery Difficult to treat

Schizoaffective Disorder Schizophrenia + mood disorder symptoms Diagnostic category may not be stable