1. Chapter 13 - Schizophrenia Criteria 1.Symptoms (2 of 5 for 1 month) Content of thought: a.Delusions - belief with no basis in reality b.Hallucinations – perception in absence of stimuli

2. Form of thought **c.Disorganized, incoherent Behavior d.Disorganized, agitated, or catatonic

3. Emotion e.Flat or inappropriate affect - withdrawal, poverty of speech Positive vs. Negative Symptoms - Positive = excess or distortion - Negative = loss of normal behavior

4. 2.Social/Occupational dysfunction - work, relationships, hygiene - loss of identity 3.Duration > 6 months (Sxs in #1 at least 1 month)

5. 4.Exclusions - not from drugs, medical problems, or mood disorder INDIVIDUAL DIFFERENCES

6. Course Onset - late teens to mid-30s - rarely before adolescence - either acute or gradual (most are gradual)

7. Phases a.Prodromal - slow development of negative symptoms - often misinterpreted

8. b.Acute - appearance of positive, psychotic symptoms c.Residual - positive sxs remit, negative sxs remain - return to prodromal

9. d.Remission - never recovered -> labeled for life vs. Third world

10. Progression = variable - chronic - vs. gradually deteriorating - vs. swings between better & worse - vs. remission

11. Subtypes 1.Paranoid Type - Thematic delusions (eg, paranoid or grandiose) Or frequent auditory hallucinations - Often intact cognition & affect - Stilted, aloof, superior - Mixed evidence for suicidal or homicidal - Best prognosis (lack of negative sxs)

12. 2.Disorganized Type - Incoherent speech & behavior - daily chores difficult - disorganized delusions and/or hallucinations - Flat/inappropriate affect - appear silly/immature - Insidious, early onset - Poor prognosis - continuous course without remissions

13. 3.Catatonic Type Psychomotor disturbance - immobility, stupor, odd postures waxy flexibility Or- agitation, purposeless movement Negativism, mutism, resistance Echolalia, echopraxia

14. 4.Undifferentiated Type - schizophrenic sxs - but don’t meet criteria for types 1-3 - catchall dx

15. 5.Residual Type - 1+ episode of acute positive sxs - no positive sxs currently - continuing negative sxs - eccentric, odd beliefs - transition between full-blown episode and remission? - may be present for years

16. Other Psychotic Disorders 1.Brief Psychotic Disorder Positive sxs - hallucinations, delusions, loose associations, disorganized beh. Follows acute stressor No prodromal or residual phase Lasts < 1 month Return to normal fxing High suicide risk

17. 2.Delusional Disorder - 1 fixed non-bizarre delusion - no other problems

18. 3.Personality Disorders a.Paranoid – suspicious b.Schizoid – withdrawn c.Schizotypal – odd

19. 4.Schizophreniform Disorder - sxs of schizophrenia - lasts < 6 months - most develop schizophrenia or schizoaffective disorder - no decline in fxing

20. 5.Schizoaffective Disorder - schizophrenia & a mood disorder

21. Etiology Genetic Contributions Clear genetic basis Increased risk based on relatedness

22. Family Studies < 1% in population 17% if parent or parent’s MZ twin Twin Studies MZ twins = 50% DZ = ~ 15%

23. Adoption Studies Biological risk = 10-17% Environmental risk = < 1% Unknowns Means of transmission One or more genes (polygenetic would explain spectrum)

24. Neurobiology & Neuroanotomy 1.Excess of Dopamine (DA) - some antipsychotics are DA antagonists (block use of DA) - side effects (tardive dyskinesia: TD) similar to Parkinson’s

25. Parkinson’s = inadequate DA - L-dopa increases DA for Parkinson’s - amphetamines activate DA & can worsen psychotic sxs in people with schizophrenia

26. SUM:Increase DA => increase schizo. & decrease Parkinson’s Decrease DA => decrease schizo. & increase Parkinson’s

27. BUT: 1.Antipsychotics don’t always work 2.Antipsychotics ineffective for negative sxs 3.Decrease in DA in some brain areas (may account for subtype differences)

28. Thus, complex interaction of DA, SE, & possibly other neurotransmitters

29. 2.Brain Structure - neurological damage? a.Behavioral signs - abnormal reflexes - decreased attention

30. b.Atrophy - enlarged ventricles - often, but not always - related to perinatal problems?

31. c.Decreased frontal lobe fx - related to negative sxs - more common in men - associated with worse premorbid adjustment & prognosis

32. d.Abnormal temporal lobe & limbic system fx - related to auditory hallucinations - disconnection between thought & emotion?

33. e.Abnormal thalamic fx - incoherence?

34. 3.Viral Infections?

35. Family Contributions NOT "Schizophrenogenic Mother" Cold, aloof, overprotective Double-bind communication

36. Family Interaction **Expressed emotion = criticism, hostility, overinvolvement => risk of relapse

37. Diathesis-Stress Model Diatheses: Genes Perinatal trauma? Viral infection?

38. Stressors: Single caregiver Lack of support Family high in expressed emotion Low SES

39. Treatment Antipsychotic Medication Neuroleptics Side effects => noncompliance - grogginess, blurred vision, mouth dryness, loss of voices - TD (tardive dyskinesia)

40. Clozapine (& now Risperdone) Blocks another DA receptor Treats positive & negative sxs Fewer side effects (like TD) Fatal for 2%

41. Monthly Drug Cost (1997) Clozapine317.03 Haloperidol 1.76

42. 2005 Clozapine 15.95 Haloperidol 14.95

43. Behavioral Treatment 1.Token economies 2.Social skills training 3. Therapeutic community – Szasz, Laing 4.Psychosocial rehabilitation 5.Family Therapy

44. Predictors of Recovery 1.Good premorbid adjustment 2.A precipitating stressor 3.Sudden onset - acute positive symptoms 4.Older age of onset 5.Affective Problems - anxiety/depression are good - hopelessness is bad

45. 6.Type of Schizophrenia Best = Paranoid (with acute onset) Worst = Undifferentiated, chronic & Disorganized (both have more negative sxs) 7.Supportive Family 8.Response to Treatment - to medication, therapy, staff - resigned is worse