Chapter13 - Chapter 13 Chapter 13 Schizophrenia and Other...

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Unformatted text preview: Chapter 13 Chapter 13 Schizophrenia and Other Psychotic Disorders Schizophrenia: Description 0. Prototype of popular view of mental illness 1. Found in all cultures 2. Characteristic symptoms 0. Oddities in perception, thinking, action, sense of self and interactions with others 3. The hallmark of schizophrenia is psychosis– a significant loss of contact with reality Schizophrenia: Origin of Construct 4. Origins of schizophrenia construct 1. 1810 John Haslam at Bethlehem Hospital in London described patient 2. 1860 Benedict Morel, Belgium psychiatrist, described mental deterioration 3. 1896 Emile Kraepelin, German psychiatrist, called it dementia praecox 4. 1911 Eugene Bleuler, Swiss psychiatrist, termed in ‘schizophrenia’ – split mind between thought and emotion Schizophrenia: Epidemiology 5. Schizophrenia (epidemiology) 5. Affects people from all walks of life 6. Is about as prevalent as epilepsy 6. 0. Lifetime risk = 1% 1. Higher risk if father is older when child conceived 2. Higher risk in western Ireland and Croatia 7. Usually begins in late adolescence or early adulthood (earlier in men than in women) 3. Positive effects of estrogen in women Schizophrenia: Age Distribution of Onset Schizophrenia: Clinical Picture (I) 6. Two general types of symptom patterns: 7. Positive symptoms of schizophrenia reflect an excess or distortion in a normal repertoire of behavior and experience 0. These symptoms are typical of type I schizophrenia 8. Negative symptoms reflect an absence or deficit of normal behaviors 8. These symptoms are typical of type II schizophrenia, which is more difficult to treat Schizophrenia: Clinical Picture (II) 9. Positive symptoms: 10.Delusions (disturbance in content of thought) 9. Erroneous belief that is fixed and firmly held in spite of clear contradictory evidence 11.Hallucinations (disturbance in sensory experience) 10. Sensory experience that occurs in absence of any external perceptual stimulus but has relevance to patient Schizophrenia: Clinical Picture (III) 12.Positive symptoms 12. 13.Disorganized speech (form of thought) 11. Distortion in form of thought; failure to make sense; cognitive slippage; loosening of associations 14.Disorganized behavior (disturbance in behavior) 12. Impairment of goal directed behavior; deterioration from previously mastered standards of performance Schizophrenia: Clinical Picture (IV) 15.Negative symptoms 16.Flat or blunted emotional expressiveness 13. Despite higher physiological arousal and self­report of feelings 17.Alogia (very little speech) 18.Avolition (inability to initiate activities) 14. Inability to initiate or persist in goal directed activities 15. No interest in activities (sit and stare off into space) Schizophrenia: General Category 19.Schizophrenia is an umbrella term for a variety of disordered processes of varied etiology and developmental patterns and outcomes 20.A very heterogeneous category 21.A number of subtypes Schizophrenia: Subtypes (I) 22.Subtypes of schizophrenia include: 22. 23.Paranoid type (highest level of functioning) 16. History of increasing suspiciousness and serious difficulties in interpersonal relations 17. Delusions of grandure, bizarre ideas and plots 18. Absurd and illogical beliefs ­ may be highly elaborated 19. Typically a Type I schizophrenic (positive symptoms) Schizophrenia: Subtypes (II) 24.Subtypes of schizophrenia include: 25.Disorganized type (hebephrenic) 20. Earlier age and gradual onset 21. Poor prognosis 22. Typically a Type II schizophrenic (negative symptoms) Schizophrenia: Subtypes (III) 26.Subtypes of schizophrenia include: 27.Catatonic type 23. Motor functioning either stupor or manic excitement 24. Imitate behavior (echopraxia) or speech (echolalia) 25. Typically a Type II schizophrenic (negative symptoms) Schizophrenia: Subtypes (IV) 28.Subtypes of schizophrenia include: 29.Undifferentiated type 29. 26. 27. 28. 29. Catch­all ­ doesn't clearly fit into other types May be mix of symptoms May be early phase of another type Could be either a Type I or Type II schizophrenic Schizophrenia: Subtypes (V) 30.Subtypes of schizophrenia include: 31.Residual type 30. Had previous episode 31. Not now showing positive symptoms, but showing negative symptoms in mild form (could be a function of medication) 32. Possibly previously showing Type I (positive) schizophrenic symptoms Other Psychotic Disorders (I) 32.Other psychotic disorders include: 33.Schizoaffective disorder 33. Hybrid schizophrenia and mood disorder 34. Psychotic with marked mood changes 35. Better prognosis than schizophrenia Other Psychotic Disorders (II) 34.Other psychotic disorders include: 35.Schizophreniform disorder 36. Brief (1 month) schizophrenic like psychosis 37. Does not warrant diagnosis of schizophrenia 38. Similar to brief psychosis 38. Other Psychotic Disorders (III) 36.Other psychotic disorders include: 37.Delusional disorder (only delusions) 39. Normal except for delusions 40. No gross disorganization or performance deficiencies Other Psychotic Disorders (IV) 38.Other psychotic disorders include: 39.Brief psychotic disorder 41. 42. 43. Sudden onset and lasting only a few days Return to normal after episode May be triggered by stress Other Psychotic Disorders (V) 40.Other psychotic disorders include: 41.Shared psychotic disorder (folie a deux) nd st 44. 2 nd person believes delusions of 1 st person 45. Person has very close relationship with delusional person What Causes Schizophrenia? 46. Prototypical model: complex interplay of genetic and environmental factors 47. Next slide illustrates a model of causation reflecting the complexity of factors involved 48. Complete discussion of causes and treatment of schizophrenia in next lecture on schizophrenia Schizophrenia: Causes and Treatment Schizophrenia: Causes and Treatment What Causes Schizophrenia? 49. Prototypical model: complex interplay of genetic and environmental factors 50. Genetic factors are clearly implicated in schizophrenia 4. Runs in families ­ higher than expected rates among biological relatives 51. As the following slide shows, having a relative with the disorder significantly raises a person’s risk of developing schizophrenia 5. Closer relative, greater risk – first degree (sibling) vs second degree (cousin) ) Causal Factors: Genetics and the Family Causal Factors: Genetics and Twins 42.Monozygotic twins are more likely to develop schizophrenia than are dizygotic twins Causal Factors: Genetics & the Environment 43.Concerning role of genetics: 52. Genes do play a large role but do not tell whole story ­ environment does play a role 53. It is likely that genes are triggered by environmental events 54. Further, genetic make­up may increase vulnerability 54. to environmental factors 55. Thus, genetic – environment interaction 56. Also, multiple genes involved so that ‘dose’ determines likelihood and severity of disorder Causal Factors: Early Biological Influences 57. Other factors that have been implicated in the development of schizophrenia include 6. Prenatal exposure to the influenza virus 0. During 4th to 7th month of gestation 1. Mother's antibodies disrupt neurological development 7. Early nutritional deficiencies (noted during war) 8. Prenatal birth complications (e.g. hypoxia) 58. Current thinking emphasizes the interplay between genetic and environmental factors 9. Multiplicity of genes; predisposing factors; environment Causal Factors: Neurodevelopmental Dysfunction (I) 59. A lesion in the brain is thought to lie dormant until normal developmental changes occur (possibly only at full neurological maturation) nd 60. Due to disruption in neural cell migration during 2 trimester creates problem in internal connectivity of the brain Causal Factors: Neurodevelopmental Dysfunction (II) 61. These neural changes expose the problems that 61. result from this brain abnormality 62. Pre­schizophrenic children show more motor abnormalities, problems in attention, lower social competence Causal Factors: Biological Aspects (Structure) (I) 63. Many brain (CAT, PET, MRI) areas are abnormal in schizophrenia including 10. Decreased brain volume (3% less) 11. Enlarged ventricles (less brain volume) 12. Frontal lobe dysfunction (esp. left side) 13. Reduced volume of the thalamus (input) 2. Reduced ability to handle sensory input 14. Abnormalities in temporal lobe areas such as the hippocampus and amygdala 64. Abnormalities are not found in all patients Causal Factors: Biological Aspects (Structure) (II) 44.The above differences further suggest a neuro­ developmental disorder since lower brain volume is found early in schizophrenics 45.This reflects problems in the cyto­architecture or organization of the brain which is compromised if the migration of neurons doesn’t occur normally in the fetal brain Causal Factors: Biological Aspects Causal Factors: Biological Aspects (Process) (I) 46.Neurotransmitters implicated in schizophrenia include 65. Dopamine (excess) (chlorpromazine) 15. The dopamine hypothesis 16. Dopamine determines how much salience is given internal and external stimuli 17. Excess of dopamine results in aberrant salience 66. Glutamate (excitatory) (deficit) (PCP) 18. The glutamate hypothesis 19. Blocking of glutamate results in cognitive symptoms of schizophrenia (slippage) Causal Factors: Biological Aspects (Process) (II) 67. Neurocognitive deficits found in people with schizophrenia include 20. Attentional deficits (allocation of resources) 21. Eye­tracking dysfunctions 68. Evidence of problems with active functional allocation of attentional resources 22. Unable to attend well on demand 23. Attentional dysfunctions may be indication of biological susceptibility to schizophrenia Causal Factors: Biological and Psychosocial Connections 69. Connection between biology and environment: 24. Stress causes release of cortisol which triggers dopamine activity and suppresses glutamate release 70. Following slides consider stresses that could play a 70. role 25. Family 26. Society Causal Factors: Psychosocial & Cultural Aspects (Family) (I) 71. Many theories about bad families causing schizophrenia have not stood the test of time including 72. The idea of the “schizophrenic mother” 27. Cold, aloof 73. The double­bind hypothesis 28. Parent presents child with feelings and demands that are mutually incompatible 74. Weak evidence for either theory Causal Factors: Psychosocial & Cultural Aspects (Family) (II) 75. Instead, communication problems may be the result of having a schizophrenic in the family 29. Amorphous, fragmented communication 30. Stress of trying to communicate with someone who is schizophrenic 76. Patients with schizophrenia are more likely to relapse if their families are high in expressed emotion (EE) 31. Hostility, criticism, emotional over­involvement 32. Reflects stress­sensitive nature of schizophrenia Causal Factors: Psychosocial & Cultural Aspects (Social) 77. A large body of evidence indicates that the lower 77. the socioeconomic status the higher the prevalence of schizophrenia 78. Two theories have been presented to explain this (the sociogenic & the social drift hypotheses) 79. Essentially both hypotheses argue that urban living, lower socioeconomic levels, immigration, social conflict all increase risk for development of schizophrenia 33. These factors increase stress, thus increase risk Treatment and Clinical Outcome Treatment and Clinical Outcome: Recovery 80. Recovery from schizophrenia is: 34. 1/3rd recover 35. 1/3rd improve 36. 1/3rd remain the same 81. The lower the severity of negative symptoms, the higher the likelihood of recovery 37. The later the onset, the better the prognosis 38. The better the premorbid functioning, the better the prognosis Treatment and Clinical Outcome: Recovery Percentage of followed­up schizophrenics attaining social recovery over the past century Treatment and Clinical Outcome: Treatments 47.Before the 1950’s, there were few treatment 47. options – ECT, permanent hospitalization 48.After the 1950’s, the availability of antipsychotics and pharmocotherapy allowed for outpatient treatment Treatment and Clinical Outcome: Drugs (I) 49.Antipsychotic drugs work by blocking dopamine receptors 50.There are two types of antipsychotics 82. Conventional antipsychotics (neuroleptics) 83. Novel antipsychotics Treatment and Clinical Outcome: Drugs (II) 51.Conventional antipsychotics (e.g. thorazine, haldol) work after 3­6 weeks 84. Do best for patients with positive symptoms 85. Function as dopamine antagonists 86. Have the problems of side effects: drowsiness, weight gain, parkinsonian symptoms, tardive dyskenesia (extrapyramidal effects) Treatment and Clinical Outcome: Drugs (III) 52.Patients taking novel antipsychotics (e.g. clozaril, risperdal, seroquel) 87. Have fewer extrapyramidal (motor abnormality) side effects 88. Tend to do better overall 89. Eleviate both positive and negative symptoms 90. Still may cause drowsiness and weight gain 53.Even with medication, difficulty functioning 53. Treatments and Clinical Outcome: Psychosocial (I) 54.Psychosocial approaches include 91. Case management (community living) 39. A broker who helps patient function in the community locating housing, jobs treatment 92. Social­skills training (interpersonal skills) 40. Help in acquiring interpersonal skills for employment, relationships, self­care Treatments and Clinical Outcome: Psychosocial (II) 55.Psychosocial approaches include 93. Cognitive­behavioral therapy (attention) 41. Cognitive training to challenge delusions 94. Other forms of individual treatment (support) 42. Social support; increased social interaction Treatments and Clinical Outcome: Family 56.Family therapy 95. Provides families with communication skills 43. Less amorphous, fragmented 96. Reduces high levels of expressed emotion 44. Lower hostility, criticism, emotional over­involvement 97. Reduces relapse rates 98. Educates family about schizophrenia Unresolved Issues 57.Can schizophrenia be prevented? 57. End of Chapter 13 ...
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