Prototypeofpopularviewofmentalillness
1. Chapter13
Chapter13
SchizophreniaandOtherPsychotic
Disorders
Schizophrenia:Description
0. Foundinallcultures
2. Characteristicsymptoms
0. Odditiesinperception,thinking,action,senseofself
andinteractionswithothers
3. Thehallmarkofschizophreniaispsychosisa
significantlossofcontactwithreality
Schizophrenia:OriginofConstruct
4. Originsofschizophreniaconstruct
1. 1810JohnHaslamatBethlehemHospitalinLondon
describedpatient
2. 1860BenedictMorel,Belgiumpsychiatrist,described
mentaldeterioration
3. 1896EmileKraepelin,Germanpsychiatrist,calledit
dementiapraecox
4. 1911EugeneBleuler,Swisspsychiatrist,termedin
schizophreniasplitmindbetweenthoughtand
emotion
Schizophrenia:Epidemiology
5. Schizophrenia(epidemiology)
5. Affectspeoplefromallwalksoflife
6. Isaboutasprevalentasepilepsy
6.
0. Lifetimerisk=1%
1. Higherriskiffatherisolderwhenchildconceived
2. HigherriskinwesternIrelandandCroatia
7. Usuallybeginsinlateadolescenceorearlyadulthood
(earlierinmenthaninwomen)
3. Positiveeffectsofestrogeninwomen
Schizophrenia:AgeDistributionofOnset
Schizophrenia:ClinicalPicture(I)
6. Twogeneraltypesofsymptompatterns:
7. Positivesymptomsofschizophreniareflectan
excessordistortioninanormalrepertoireof
behaviorandexperience
0. ThesesymptomsaretypicaloftypeIschizophrenia
8. Negativesymptomsreflectanabsenceordeficitof
normalbehaviors
8. ThesesymptomsaretypicaloftypeIIschizophrenia,
whichismoredifficulttotreat
Schizophrenia:ClinicalPicture(II)
9. Positivesymptoms:
10.Delusions(disturbanceincontentofthought)
9. Erroneousbeliefthatisfixedandfirmlyheldinspite
ofclearcontradictoryevidence
11.Hallucinations(disturbanceinsensoryexperience)
10. Sensoryexperiencethatoccursinabsenceofany
externalperceptualstimulusbuthasrelevanceto
patient
Schizophrenia:ClinicalPicture(III)
12.Positivesymptoms
12.
13.Disorganizedspeech(formofthought)
11. Distortioninformofthought;failuretomakesense;
cognitiveslippage;looseningofassociations
14.Disorganizedbehavior(disturbanceinbehavior)
12. Impairmentofgoaldirectedbehavior;deterioration
frompreviouslymasteredstandardsofperformance
Schizophrenia:ClinicalPicture(IV)
15.Negativesymptoms
16.Flatorbluntedemotionalexpressiveness
13. Despitehigherphysiologicalarousalandselfreport
offeelings
17.Alogia(verylittlespeech)
18.Avolition(inabilitytoinitiateactivities)
14. Inabilitytoinitiateorpersistingoaldirected
activities
15. Nointerestinactivities(sitandstareoffintospace)
Schizophrenia:GeneralCategory
19.Schizophreniaisanumbrellatermforavarietyof
disorderedprocessesofvariedetiologyand
developmentalpatternsandoutcomes
20.Averyheterogeneouscategory
21.Anumberofsubtypes
Schizophrenia:Subtypes(I)
22.Subtypesofschizophreniainclude:
22.
23.Paranoidtype(highestleveloffunctioning)
16. Historyofincreasingsuspiciousnessandserious
difficultiesininterpersonalrelations
17. Delusionsofgrandure,bizarreideasandplots
18. Absurdandillogicalbeliefsmaybehighly
elaborated
19. TypicallyaTypeIschizophrenic(positive
symptoms)
Schizophrenia:Subtypes(II)
24.Subtypesofschizophreniainclude:
25.Disorganizedtype(hebephrenic)
20. Earlierageandgradualonset
21. Poorprognosis
22. TypicallyaTypeIIschizophrenic(negative
symptoms)
Schizophrenia:Subtypes(III)
26.Subtypesofschizophreniainclude:
27.Catatonictype
23. Motorfunctioningeitherstuporormanicexcitement
24. Imitatebehavior(echopraxia)orspeech(echolalia)
25. TypicallyaTypeIIschizophrenic(negative
symptoms)
Schizophrenia:Subtypes(IV)
28.Subtypesofschizophreniainclude:
29.Undifferentiatedtype
29.
26.
27.
28.
29.
Catchalldoesn'tclearlyfitintoothertypes
Maybemixofsymptoms
Maybeearlyphaseofanothertype
CouldbeeitheraTypeIorTypeIIschizophrenic
Schizophrenia:Subtypes(V)
30.Subtypesofschizophreniainclude:
31.Residualtype
30. Hadpreviousepisode
31. Notnowshowingpositivesymptoms,butshowing
negativesymptomsinmildform(couldbeafunction
ofmedication)
32. PossiblypreviouslyshowingTypeI(positive)
schizophrenicsymptoms
OtherPsychoticDisorders(I)
32.Otherpsychoticdisordersinclude:
33.Schizoaffectivedisorder
33. Hybridschizophreniaandmooddisorder
34. Psychoticwithmarkedmoodchanges
35. Betterprognosisthanschizophrenia
OtherPsychoticDisorders(II)
34.Otherpsychoticdisordersinclude:
35.Schizophreniformdisorder
36. Brief(1month)schizophreniclikepsychosis
37. Doesnotwarrantdiagnosisofschizophrenia
38. Similartobriefpsychosis
38.
OtherPsychoticDisorders(III)
36.Otherpsychoticdisordersinclude:
37.Delusionaldisorder(onlydelusions)
39. Normalexceptfordelusions
40. Nogrossdisorganizationorperformance
deficiencies
OtherPsychoticDisorders(IV)
38.Otherpsychoticdisordersinclude:
39.Briefpsychoticdisorder
41.
42.
43.
Suddenonsetandlastingonlyafewdays
Returntonormalafterepisode
Maybetriggeredbystress
OtherPsychoticDisorders(V)
40.Otherpsychoticdisordersinclude:
41.Sharedpsychoticdisorder(folieadeux)
nd
st
44. 2 ndpersonbelievesdelusionsof1 stperson
45. Personhasverycloserelationshipwithdelusional
person
WhatCausesSchizophrenia?
46. Prototypicalmodel:complexinterplayofgeneticand
environmentalfactors
47. Nextslideillustratesamodelofcausationreflecting
thecomplexityoffactorsinvolved
48. Completediscussionofcausesandtreatmentof
schizophreniainnextlectureonschizophrenia
Schizophrenia:CausesandTreatment
Schizophrenia:CausesandTreatment
WhatCausesSchizophrenia?
49. Prototypicalmodel:complexinterplayofgeneticand
environmentalfactors
50. Geneticfactorsareclearlyimplicatedin
schizophrenia
4. Runsinfamilieshigherthanexpectedratesamong
biologicalrelatives
51. Asthefollowingslideshows,havingarelativewith
thedisordersignificantlyraisesapersonsriskof
developingschizophrenia
5. Closerrelative,greaterriskfirstdegree(sibling)vs
seconddegree(cousin))
CausalFactors:GeneticsandtheFamily
CausalFactors:GeneticsandTwins
42.Monozygotictwinsaremorelikelytodevelop
schizophreniathanaredizygotictwins
CausalFactors:Genetics&the
Environment
43.Concerningroleofgenetics:
52. Genesdoplayalargerolebutdonottellwhole
storyenvironmentdoesplayarole
53. Itislikelythatgenesaretriggeredbyenvironmental
events
54. Further,geneticmakeupmayincreasevulnerability
54.
toenvironmentalfactors
55. Thus,geneticenvironmentinteraction
56. Also,multiplegenesinvolvedsothatdose
determineslikelihoodandseverityofdisorder
CausalFactors:EarlyBiologicalInfluences
57. Otherfactorsthathavebeenimplicatedinthe
developmentofschizophreniainclude
6. Prenatalexposuretotheinfluenzavirus
0. Mother'santibodiesdisruptneurologicaldevelopment
7. During4thto7thmonthofgestation
1. Earlynutritionaldeficiencies(notedduringwar)
8. Prenatalbirthcomplications(e.g.hypoxia)
58. Currentthinkingemphasizestheinterplaybetween
geneticandenvironmentalfactors
9. Multiplicityofgenes;predisposingfactors;environment
CausalFactors:Neurodevelopmental
Dysfunction(I)
59. Alesioninthebrainisthoughttoliedormantuntil
normaldevelopmentalchangesoccur(possiblyonly
atfullneurologicalmaturation)
nd
60. Duetodisruptioninneuralcellmigrationduring2
trimestercreatesproblemininternalconnectivityof
thebrain
CausalFactors:Neurodevelopmental
Dysfunction(II)
61. Theseneuralchangesexposetheproblemsthat
61.
resultfromthisbrainabnormality
62. Preschizophrenicchildrenshowmoremotor
abnormalities,problemsinattention,lowersocial
competence
CausalFactors:BiologicalAspects
(Structure)(I)
63. Manybrain(CAT,PET,MRI)areasareabnormalin
schizophreniaincluding
10. Decreasedbrainvolume(3%less)
11. Enlargedventricles(lessbrainvolume)
12. Frontallobedysfunction(esp.leftside)
13. Reducedvolumeofthethalamus(input)
2. Reducedabilitytohandlesensoryinput
14. Abnormalitiesintemporallobeareassuchasthe
hippocampusandamygdala
64. Abnormalitiesarenotfoundinallpatients
CausalFactors:BiologicalAspects
(Structure)(II)
44.Theabovedifferencesfurthersuggestaneuro
developmentaldisordersincelowerbrainvolumeis
foundearlyinschizophrenics
45.Thisreflectsproblemsinthecytoarchitectureor
organizationofthebrainwhichiscompromisedif
themigrationofneuronsdoesntoccurnormallyin
thefetalbrain
CausalFactors:BiologicalAspects
CausalFactors:BiologicalAspects
(Process)(I)
46.Neurotransmittersimplicatedinschizophrenia
include
65. Dopamine(excess)(chlorpromazine)
15. Thedopaminehypothesis
16. Dopaminedetermineshowmuchsalienceisgiven
internalandexternalstimuli
17. Excessofdopamineresultsinaberrantsalience
66. Glutamate(excitatory)(deficit)(PCP)
18. Theglutamatehypothesis
19. Blockingofglutamateresultsincognitivesymptomsof
schizophrenia(slippage)
CausalFactors:BiologicalAspects
(Process)(II)
67. Neurocognitivedeficitsfoundinpeoplewith
schizophreniainclude
20. Attentionaldeficits(allocationofresources)
21. Eyetrackingdysfunctions
68. Evidenceofproblemswithactivefunctional
allocationofattentionalresources
22. Unabletoattendwellondemand
23. Attentionaldysfunctionsmaybeindicationofbiological
susceptibilitytoschizophrenia
CausalFactors:BiologicalandPsychosocial
Connections
69. Connectionbetweenbiologyandenvironment:
24. Stresscausesreleaseofcortisolwhichtriggers
dopamineactivityandsuppressesglutamaterelease
70. Followingslidesconsiderstressesthatcouldplaya
70.
role
25. Family
26. Society
CausalFactors:Psychosocial&Cultural
Aspects(Family)(I)
71. Manytheoriesaboutbadfamiliescausing
schizophreniahavenotstoodthetestoftime
including
72. Theideaoftheschizophrenicmother
27. Cold,aloof
73. Thedoublebindhypothesis
28. Parentpresentschildwithfeelingsanddemandsthat
aremutuallyincompatible
74. Weakevidenceforeithertheory
CausalFactors:Psychosocial&Cultural
Aspects(Family)(II)
75. Instead,communicationproblemsmaybetheresult
ofhavingaschizophrenicinthefamily
29. Amorphous,fragmentedcommunication
30. Stressoftryingtocommunicatewithsomeonewhois
schizophrenic
76. Patientswithschizophreniaaremorelikelyto
relapseiftheirfamiliesarehighinexpressedemotion
(EE)
31. Hostility,criticism,emotionaloverinvolvement
32. Reflectsstresssensitivenatureofschizophrenia
CausalFactors:Psychosocial&Cultural
Aspects(Social)
77. Alargebodyofevidenceindicatesthatthelower
77.
thesocioeconomicstatusthehighertheprevalence
ofschizophrenia
78. Twotheorieshavebeenpresentedtoexplainthis
(thesociogenic&thesocialdrifthypotheses)
79. Essentiallybothhypothesesarguethaturbanliving,
lowersocioeconomiclevels,immigration,social
conflictallincreaseriskfordevelopmentof
schizophrenia
33. Thesefactorsincreasestress,thusincreaserisk
TreatmentandClinicalOutcome
TreatmentandClinicalOutcome:Recovery
80. Recoveryfromschizophreniais:
34. 1/3rdrecover
35. 1/3rdimprove
36. 1/3rdremainthesame
81. Thelowertheseverityofnegativesymptoms,the
higherthelikelihoodofrecovery
37. Thelatertheonset,thebettertheprognosis
38. Thebetterthepremorbidfunctioning,thebetterthe
prognosis
TreatmentandClinicalOutcome:Recovery
Percentageoffollowedupschizophrenicsattainingsocial
recoveryoverthepastcentury
TreatmentandClinicalOutcome:
Treatments
47.Beforethe1950s,therewerefewtreatment
47.
optionsECT,permanenthospitalization
48.Afterthe1950s,theavailabilityofantipsychotics
andpharmocotherapyallowedforoutpatient
treatment
TreatmentandClinicalOutcome:Drugs(I)
49.Antipsychoticdrugsworkbyblockingdopamine
receptors
50.Therearetwotypesofantipsychotics
82. Conventionalantipsychotics(neuroleptics)
83. Novelantipsychotics
TreatmentandClinicalOutcome:Drugs(II)
51.Conventionalantipsychotics(e.g.thorazine,
haldol)workafter36weeks
84. Dobestforpatientswithpositivesymptoms
85. Functionasdopamineantagonists
86. Havetheproblemsofsideeffects:drowsiness,
weightgain,parkinsoniansymptoms,tardive
dyskenesia(extrapyramidaleffects)
TreatmentandClinicalOutcome:Drugs(III)
52.Patientstakingnovelantipsychotics(e.g.clozaril,
risperdal,seroquel)
87. Havefewerextrapyramidal(motorabnormality)side
effects
88. Tendtodobetteroverall
89. Eleviatebothpositiveandnegativesymptoms
90. Stillmaycausedrowsinessandweightgain
53.Evenwithmedication,difficultyfunctioning
53.
TreatmentsandClinicalOutcome:
Psychosocial(I)
54.Psychosocialapproachesinclude
91. Casemanagement(communityliving)
39. Abrokerwhohelpspatientfunctioninthecommunity
locatinghousing,jobstreatment
92. Socialskillstraining(interpersonalskills)
40. Helpinacquiringinterpersonalskillsforemployment,
relationships,selfcare
TreatmentsandClinicalOutcome:
Psychosocial(II)
55.Psychosocialapproachesinclude
93. Cognitivebehavioraltherapy(attention)
41. Cognitivetrainingtochallengedelusions
94. Otherformsofindividualtreatment(support)
42. Socialsupport;increasedsocialinteraction
TreatmentsandClinicalOutcome:Family
56.Familytherapy
95. Providesfamilieswithcommunicationskills
43. Lessamorphous,fragmented
96. Reduceshighlevelsofexpressedemotion
44. Lowerhostility,criticism,emotionaloverinvolvement
97. Reducesrelapserates
98. Educatesfamilyaboutschizophrenia
UnresolvedIssues
57.Canschizophreniabeprevented?
57.
EndofChapter13