Transcript Schizophrenia & Other Psychotic Disorders

Schizophrenia & Other
Psychotic Disorders
Historical Approaches
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Kraeplin early descriptions
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Classifies symptoms
Differentiates mania
Bleuler
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Associative splitting of personality
Schizophrenia:
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Lost touch with reality
Disruption of:
 Normal thought
processes
 Perception
 Personality
 Affect
SYMPTOMS OF
SCHIZOPHRENIA
symptoms –
deviant behaviors
 delusions, hallucinations, thoughts
 negative symptoms –
deficit symptoms
 Lack of normal function
 positive
POSITIVE SYMPTOMS
disorder –
disrupted cognitive functioning
 most dramatic and obvious symptom
 thought
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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
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Delusions
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Paranoid/persecution
Grandeur
Capgas syndrome – double of other’s
Cotard’s syndrome – part of body
changed
Change vs. fixed
POSITIVE SYMPTOMS
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hallucinations –
perceptual experiences that feel real
although there is nothing to perceive
Visual
Auditory
tactile
Attention Problems
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Difficulty focusing
attention
Esp. during first
stages
Bombarded
Attention is critical to
functioning
Negative Symptoms
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Negative = absent
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25% patients
NEGATIVE SYMPTOMS
 Anhedonia
 Avolition
 Alogia
 flat
- interest
- movement
- content or quantity of speech
or blunted affect
OTHER SYMPTOMS
–
a psychomotor disturbance of
movement and posture
 catatonia
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catatonic stupor
waxy flexibility
OTHER SYMPTOMS
affect –
unusual and sometimes bizarre
emotional responses
 inappropriate
OTHER SYMPTOMS
of insight –
lack of awareness that one’s experiences
are unusual or abnormal
 lack
Schizophrenia is not…
 Split
personality disorder
 Multiple personality disorder
 Schizophrenia = “splitting of the
mind”
 Ambivalence
CLINICAL COURSE
course –
specific pattern of changes in
symptomatology over time
 clinical
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prodromal phase
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active phase
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residual phase
Schizophrenia
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1% lifetime
prevalence
Equal men &
women
Consistent across
cultures
(differences in dx
and recovery)
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More in lower class
Early life
Women later
AGE OF RISK FOR
SCHIZOPHRENIA
(A) Age at first diagnosis
20
15
Proportion 10
Males
Females
5
0
5
10 15 20 25 30 35 40 45 50
Age (in years)
Source : Adapted from I.I. Gottesman, Schizophrenia Genesis: The Origins of Madness (New
York: Freeman, 1991.)
AGE OF RISK FOR
SCHIZOPHRENIA
(B) Age of risk
100
80
Cumulative 60
Proportion 40
Males
Females
20
0
5
10 15 20 25 30 35 40 45 50
Age (in years)
Source : Adapted from I.I. Gottesman, Schizophrenia Genesis: The Origins of Madness (New
York: Freeman,1991.)
TYPICAL COURSES FOR
SCHIZOPHRENIA
(A) CHRONIC
GRADUAL ONSET & VERY POOR PROGNOSIS
TYPICAL COURSES FOR
SCHIZOPHRENIA
(B) EPISODIC
OCCASIONAL EPISODES WITH
NEARLY NORMAL FUNCTIONING BETWEEN THEM
TYPICAL COURSES FOR
SCHIZOPHRENIA
22%
(C) SINGLE EPISODE
BRIEF PERIOD OF PSYCHOSIS & NEARLY
COMPLETE RECOVERY WITH NO OTHER EPISODES
SUBTYPES OF
SCHIZOPHRENIA
disorganized
catatonic
paranoid
undifferentiated
residual
SUBTYPES OF
SCHIZOPHRENIA
disorganized
catatonic
paranoid
undifferentiated
residual
characterized by
disorganized
speech or
behavior and flat
or inappropriate
affect
SUBTYPES OF
SCHIZOPHRENIA
disorganized
catatonic
paranoid
undifferentiated
residual
characterized by
psychomotor
disturbance of
movement and
posture
SUBTYPES OF
SCHIZOPHRENIA
disorganized
catatonic
paranoid
undifferentiated
residual
characterized by
fixed delusions of
persecution
SUBTYPES OF
SCHIZOPHRENIA
disorganized
catatonic
paranoid
undifferentiated
residual
diagnosis used for
people who meet
the criteria for
schizophrenia but
do not clearly fit
into the above
subtypes
SUBTYPES OF
SCHIZOPHRENIA
disorganized
catatonic
paranoid
undifferentiated
residual
symptom patterns
found in individuals
with schizophrenia
during periods of
relative remission
including cognitive
slippage
Development of Schizophrenia
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Abnormal signs childhood
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Less positive affect
More negative affect
Older adults
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↓ positive symptoms
↑ negative symptoms
CAUSES OF SCHIZOPHRENIA
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THEORIES OF CAUSE
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Hypothesized causes/predispositions
Not mutually exclusive
Theories are specific - overlap
CAUSES of Schizophrenia
4.
Genetics
Neurobiology
Psychological and Social
Psychodynamic Theories
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Diathesis – Stress Models
1.
2.
3.
Genetics & Schizophrenia
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Genes are responsible for some people’s
vulnerability to schizophrenia
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Inherent general predisposition, not type
SCHIZOPHRENIA IN FAMILIES
RELATIONSHIP
Identical twins
First-degree
relatives
% GENES SHARED ON
AVERAGE
100%
RISK
48%
50%
Parents
6%
Siblings
9%
Fraternal
twins
17%
Children
13%
Twin & Adoption Studies
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Genetic studies of families do not allow us to
decide:
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Environment? (Nurture)
Genetics? (Nature)
Twin & Adoption studies allow us to separate
effects
Genetic Markers
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Smooth-pursuit eye
movement
Neurobiology of Schizophrenia
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1.
2.
3.
4.
Dopamine is too active
Antipsychotic drugs work. They decrease
dopamine (by blocking)
They produce side effects similar to Parkinson’s.
Parkinson’s = too little dopamine
L-dopa, given to Parkinson’s patients, which
increases dopamine, can produce schizophrenialike symptoms
Amphetamines, which increase dopamine, can
make schizophrenia worse
Brain Structure
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Enlarged ventricles
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Adjacent brain parts underdeveloped?
Frontal lobes = less active neurotransmitters
Viral Infection Risk
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Recent introduction of
schizophrenia (1800s)
↑ in urban areas
Prenatal exposure to flu
Prenatal brain damage
Psychological & Social
Influences - Stress
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Retrospective research shows role of
stressful events in onset
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Prospective research – relapse preceded by
higher rates of stress
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Might also increase depression, which increases
risk of relapse
Psychological & Social
Influences - Family
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Schizophrenogenic
mothers
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Double bind
communication
Psychological & Social
Influences - Family
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Expressed Emotion
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Consists of:
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In discharged patients, those with less family
contact had fewer relapses
Criticism/disapproval
Hostility/animosity
Emotional overinvolvement
3.7 times increase in relapse (!)
Expressed Emotion
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High:
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“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:
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“I just tend to let it go because I know that when
she wants to speak, she will speak.”
PSYCHODYNAMIC FACTORS
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Freud
Primary Narcissism
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Newborn
Lack ego
Thoughts = reality
Fragile Ego?
Overwhelming early trauma?
Diathesis Stress Models
X
Treatment of Schizophrenia
1.
Biological
2.
Psychosocial
Biological Interventions
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Historical biological interventions include:
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Lobotomies
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Sever frontal lobes from lower portions of brain
Insulin coma therapy
Electroconvulsive therapy
Antipsychotic Medication
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Medical breakthrough 1950s – neuroleptics
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60% effective
Mostly effect positive symptoms
Effect dopamine, but other neurotransmitters
as well
Antipsychotic Medication
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New antipsychotics
 Clozapine
 Risperidone
 Olanzapine
Less side effects than early
antipsychotics
Problem: Medication
Compliance
7% of patients refuse to take prescribed
antipsychotic medication
Negative relationships with doctors
Cost of medication
Lack of social support
Negative side effects
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1.
2.
3.
4.
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5.
tardive dyskinesia in 20% of long-term users
Beliefs about medication use (25%)
Psychosocial Interventions
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Psychodynamic treatments
Inpatient treatment
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most treatment, until recently
 Decreased due to changes in involuntary
hospitalization laws
 200,000 with serious disorders are homeless
Psychosocial Interventions
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Token economies
 Contribute to
increased self-care
 More discharge
Psychosocial Interventions
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Social skills building
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Model pieces
Role-play
Practice in vivo
Psychosocial Interventions
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Behavioral Family Therapy
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Psychoeducation – symptoms, causes,
medication compliance
Communication skills
Problem-solving skills
Most beneficial if ongoing
Psychosocial Interventions
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Cognitive Treatment
 Periods of mild symptoms
 Label voices as thoughts
 Slow + time consuming
Living with Schizophrenia
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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
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2.
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4.
Awareness of the signs, symptoms and
consequences
General attributions re: illness, symptoms,
consequences
Self-concept
Psychological defensiveness
Why is Insight Important?
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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
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Predicting outcome is virtually impossible
Recent research has indicated prognosis is
better than originally expected
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20-40 year longitudinal studies
Some research suggests 20-50% “fully recover”
later in life
Other Psychotic Disorders
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2.
Delusional Disorders
Schizoaffective Disorder
Delusional Disorders
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Marked by dramatic and stable delusions
Other symptoms not present
Can develop at any age
Presence of “nonbizarre” delusions
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Can conceivably be true
Any hallucinations are mild
Function as normal when delusions not
present
Causes of Delusional
Disorders
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No genetic link w/ schizophrenia
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Links with avoidant & paranoid P.Ds
Spontaneous recovery within months
Chronic course w/ no recovery
Difficult to treat
Schizoaffective Disorder
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Schizophrenia + mood disorder symptoms
Diagnostic category may not be stable