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Unformatted text preview: Schizophrenia and Other Psychotic Disorders Psychotic An Overview An Schizophrenia vs. Psychosis – Psychosis – Broad term (e.g., hallucinations, Psychosis delusions) – Schizophrenia – A type of psychosis Schizophrenia – Psychosis and Schizophrenia are Psychosis heterogeneous Lots of ways and reasons for psychosis Lots Different “types” of schizophrenia – Disturbed thought, emotion, behavior Historical Views Historical Emil Kraepelin Emil – – – – – dementia praecox dementia Subtypes: paranoid; catatonic; hebephrenic Subtypes: paranoid; “disease of the brain” distinct symptoms part of a broader syndrome Differentiated from manic-depressive illness Eugen Bleuler Eugen – “schizophrenia” – Four A’s Affect (anhedonia) Association Ambivalence (avolition) Autism – “positive” and “negative” symptoms DSM-IV Criteria DSM-IV A. Characteristic symptoms: Two (or more) of the following, Characteristic each present for a significant portion of time during a 1each month period (or less if successfully treated). 1. Delusions 2. Hallucinations 3. Disorganized speech (frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms Affective flattening, alogia, avolition A. B. C. D. Social/occupational dysfunction Continuous signs of disturbance for at least 6 months Not schizoaffective or mood disorder Not due to substance abuse “Positive” Symptom Cluster The Positive Symptoms The – Obvious manifestations of abnormal behavior – Excess or distortion of normal behavior Delusions: Distortion in thought content – Erroneous beliefs that involve misinterpretation of Erroneous perception or experiences. – Gross misrepresentations of reality Persecutory (most common) Referential Somatic Religious Grandiose “Bizarre” delusions are so characteristic – that is all that is Bizarre” needed for diagnosis (thought insertion; thought withdrawal) needed “Positive” Symptom Cluster Positive” Hallucinations: Hallucinations: – Experience of sensory events without input – Any sensory mode Any – Auditory is most common (“hearing voices”); “command” hallucinations Two or more voices conversing or one voice keeping a Two running commentary are highly characteristic – Findings from SPECT studies: Metacognition theory Metacognition Broca’s (speech production) not Broca’s Wernicke’s area (speech reception) Wernicke’s Listening to own thoughts “Negative” Symptom Cluster The Negative Symptoms The – Absence or insufficiency of normal behavior Variety of Negative Symptoms – Avolition (or apathy) – Lack of initiation and Avolition persistence (e.g., lack of hygiene) persistence – Alogia – Relative absence of speech Alogia – Anhedonia – Lack of pleasure, or indifference Anhedonia – Affective flattening – Little expressed emotion Face immobile and unresponsive May not be indicative of experienced emotion May experienced Flat affect may appear before other symptoms Flat “Disorganized” Symptom Cluster Disorganized Speech Disorganized – – – – Cognitive slippage – Illogical and incoherent speech Tangentiality – “Going off on a tangent” Tangentiality Loose associations – Conversation in unrelated directions Word salad; neologisms Disorganized Affect – Inappropriate emotional behavior Inappropriate Disorganized Behavior Disorganized – unusual behaviors (disheveled; odd appearance; unusual inappropriate or unpredictable behavior) inappropriate – Catatonia – Spectrum Catatonia Wild agitation, waxy flexibility, immobility Wild DSM Subtypes DSM Paranoid Type – Prominent hallucinations and delusions (persecutory or Prominent grandeur) but relatively intact cognitive skills and affect grandeur) – No disorganized behavior (speech, thought or affect) – Later onset and best prognosis Disorganized Type (hebephrenic) – Marked disruptions in speech and behavior Flat or inappropriate affect Self-absorption – Hallucinations and delusions—more fragmented than Hallucinations Paranoid type Paranoid – Develops early, tends to be chronic, associated with a Develops continuous course without remissions continuous Catatonic Type Catatonic DSM Subtypes – unusual motor responses and odd mannerisms Immobility Excessive motor activity Motor negativism Motor Waxy flexibility Waxy – echolalia and echopraxia – severe and quite rare Undifferentiated Type – – – Wastebasket category Major symptoms Fail to meet criteria for another type DSM Subtypes Residual Type Residual – Past diagnosis of schizophrenia – Absence of prominent delusions, hallucinations, Absence disorganized speech and behavior disorganized – Continue to display less extreme residual symptoms Continue Presence of negative symptoms common Or, attenuated positive symptoms Or, Other Psychotic Disorders Other Schizophreniform Disorder – Schizophrenic symptoms for few months Schizophrenic – Impaired functioning not required – Some never progress on to schizophrenia but more do Schizoaffective Disorder Schizoaffective – – – Symptoms of schizophrenia and a mood disorder Symptoms Prognosis similar to schizophrenia Need to have delusions and/or hallucinations that are Need present for at least 2 weeks in the absence of the mood disorder disorder Other Psychotic Disorders Delusional Disorder: Delusional – one or more nonbizarre delusions that persist for 1 one month or more month – Lack other positive and negative symptoms – Types of delusions include Erotomanic – someone else is in love with person Grandiose Jealous – spouse or partner is unfaithful Persecutory Somatic – involves bodily functions or sensations – Extremely rare – Better prognosis than schizophrenia Disorders with Psychotic Features Disorders Brief Psychotic Disorder – One or more positive symptoms of schizophrenia Delusions, hallucinations, disorganized behavior/speech Lasts at least 1 day but not longer than 1 month – – – – – – Not due to substance use Usually extreme stress or trauma Tends to remit on its owns Delusions from one person manifest in another Delusions “passer” is more dominant one in the relationship Little is known Little Shared Psychotic Disorder (Folie a Deux) Schizotypal Personality Disorder Schizotypal – May reflect a less severe form of schizophrenia Classification Systems Classification Process vs. Reactive – Process – Insidious onset, biologically based, negative symptoms, poor prognosis symptoms, – Reactive – Acute onset (extreme stress), notable behavioral activity, best prognosis behavioral Good vs. Poor Premorbid Functioning – Focus on prior functioning No longer widely used Type I vs. Type II – Type I – Positive symptoms, good response to medication, Type optimistic prognosis, and absence of intellectual impairment optimistic – Type II – Negative symptoms, poor response to medication, Type pessimistic prognosis, and intellectual impairments pessimistic Epidemiology Epidemiology Onset and Prevalence Onset – About 0.2% to 1.5% (or about 1% population) – Often develops in early adulthood early to mid-20s for men late 20s for women with bimodal distribution for women (second onset – in 40s) (second – “prodromal” signs earlier – Good prognosis Good premorbid adjustment, acute onset, later onset, female, Good precipitating events, immediate treatment, compliance, family history of mood problems, good interepisode functioning history Generally Chronic – Most suffer with moderate-to-severe lifetime impairment Most – Life expectancy is slightly less than average Schizophrenia Affects Males and Females About Equally Positive symptoms more treatable than negative symptoms Positive Genetics Genetics Family Studies – inherit general risk not subtype risk – Risk increases with genetic relatedness Twin Studies Twin – – – – – MZ : 48% DZ: 17% Both parents: 46% One parent: 16% Genain quadruplets Unshared environment Adoption Studies: – Risk for schizophrenia remains high in cases where a Risk biological parent has schizophrenia biological Markers Markers Genetic: Linkage and Association Studies – Linkage –link between disorders and other inherited Linkage traits or markers of which we know their genetic location (e.g., Dopamine) location – Association – compare people with and without Association disorder at genetic level disorder – Search for genetic markers is still inconclusive – Schizophrenia is likely to be polygenic Behavioral: compare people with and without Behavioral: schizophrenia on behavioral trait schizophrenia – Smooth pursuit eye movement Neurotransmitters Neurotransmitters Dopamine (DA) Dopamine – Drugs increase DA schizophrenic-like behavior Drugs – Drugs decrease DA reduce schizophrenic-like Drugs behavior behavior – side effects look like Parkinson’s disease – Problems some not helped by dopamine antagonists Little impact on negative symptoms “atypical antipsychotic” are NOT powerful DA antagonists Other theories – Excessive stimulation of D2 receptors in the striatum – Deficient stimulation of prefrontal D1 receptors Deficient – Alterations in prefrontal activity involving glutamate Neurobiology Neurobiology Structural and Functional Abnormalities Structural – Enlarged lateral ventricles (50 studies) Enlarged Not found in all schizophrenics Found in “healthy” siblings of schizophrenic patients Found – Hypofrontality – Less active frontal lobes Hypofrontality – Brain dysfunction appears before onset of SZ Viral infections during prenatal development Other prenatal problems; birth complications Other – Findings are inconclusive Psychological and Social Influences Psychological Stress – May activate underlying vulnerability – May also increase risk of relapse Family Interactions – Mothers originally blamed Mothers – High expressed emotion – Associated with relapse High Family members being critical, hostile or emotionally overFamily involved Early Treatments Treatment Treatment – Electric shock – Insulin comas – Frontal lobotomies Antipsychotic/Neuroleptic Medications – first line treatment first – Began in the 1950s Thorazine – early 1950s Haldol – 1957 New ones: Risperdal; Zyprexa; Seroquel; Clozaril – Most reduce or eliminate positive symptoms – Compliance with medication is often a problem Treatment Medication side effects Medication – Extrapyramidal Side Effects – movement problems Parkinsonian symptoms Parkinsonian Akathisia (feeling restless and a need to move) Akathisia Dystonia (abnormal muscle tone) – muscle spasms Tardive dyskinesia – involuntary movements of the tongue, face, mouth and jaw (e.g., tongue sticking out, chewing motions). Usually irreversible motions). – Caused by “typical antipsychotics” – Atypical – less EPS but more weight gain and some Atypical can cause life-threatening problems can – New methods for reducing noncompliance Injections Injections Psychosocial interventions Treatment Psychosocial Approaches: Psychosocial – Behavioral (i.e., token economies) on inpatient units; Behavioral operant conditioning (response are met with reinforcement or punishment) reinforcement – Community care programs Community – Social and living skills training – Behavioral family therapy Behavioral – Vocational rehabilitation Vocational ...
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