Transcript Schizophrenia

SCHIZOPHRENIA
and Other Psychotic Disorders
Kurt Vonnegut
The Eden Express (1995)
Vonnegut
Most diseases can be separated from
one’s self and seen as foreign intruding
entities. Schizophrenia is very poorly
behaved in this respect. Colds, ulcers, flu,
and cancer are things we get.
Schizophrenic is something we are. It
affects the thing we most identify with –
as making us what we are.
Vonnegut continues…
If these weren’t problems enough, schiz comes
on slow and comes on fast, stays a minutes or
days or years, can be heaven one moment, hell
the next, enhances abilities and destroys them,
back, and forth several times a day and
always weaving itself inextricably into what we
call ourselves. It can transform only a small
corner of our lives or turn the whole show
upside down, always giving few if any clues as
to when it came or when it left or what was us
and what was schiz.
Schizophrenia is one of the most severe
mental disorders
It presents a wide range of disruptive
symptoms and leads to a significant loss in
ability to function independently
 Its prognosis is generally poor and its
course tends toward progressively more
disabled functioning over time.
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Schizophrenia has been observed for
more than 3000 years.
Emil Kraepelin (1850-1926)
First identified the symptoms of schizophrenia
 Named this cluster of symptoms “Dementia
Praecox” in his 1883 text.
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Paul Eugene Bleuler (1857-1939)
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Bleuler renamed “Dementia Praecox” as
“Schizophrenia.”
Bleuler, a Swiss psychiatrist, considered Schizophrenia
to be a “fundamental disturbance” that split psychic
functions and, in extreme cases, led to disorganization
of the personality.
He defined Schizophrenia as an inability to maintain
goal-directed behavior and integrated thinking.
Demographics for Schizophrenia
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Schizophrenia is a relatively rare disorder: 0.2% to
1.0% of world population
However, persons with schizophrenia occupy over 30%
of the total number of beds in psychiatric hospitals.
It was thought that the percentage of people
worldwide who have schizophrenia is consistent across
different cultures, but recent statistics have questioned
that belief.
The most common age is between 15 and 35 years
old
More Demographics
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Generally psychotic symptoms begin after a
gradual deterioration of social functioning and
personal hygiene, and the development of flat or
inappropriate affect.
Persons with slower onset tend to have a more
negative prognosis than those in which schizophrenic
symptoms develop rapidly.
Gender Issues
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Schizophrenia occurs more often in males than
females.
Age of onset is often later for women
Men are hospitalized more often than women and
show a more deteriorating course
Women are more likely to be married and have
children than males with schizophrenia
Women tend to have a higher social and sexual
functioning before diagnosis.
Familial Pattern
Some evidence is available that suggests a
hereditary predisposition to schizophrenia:
European family studies indicate a lifetime risk of
about 6% in the parents of schizophrenic clients; 10%
in their brothers and sisters, and 13% in their children,
as compared with 1% in the general population.
If one identical twin has schizophrenia, then there is a
50-60% probability that both are.
Risk Factors
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There’s a high incidence of social phobia, obsessivecompulsive disorder, and panic attack in persons
who later develop schizophrenia
Approximately 45% of those who have
schizophrenia also abuse substances
Have a high rate of chronic illnesses in almost every
system in the body (partly because of insufficient
treatment).
Risk Factors (con’t.)
Approximately 20% of persons with schizophrenia
attempt suicide
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Approximately 10% complete the act
The suicide rate of the general population is .05%
Attempts generally occur just as symptoms begin to clear,
not during psychotic periods
There is no evidence, however, that people with
schizophrenia present any significant risk to others.
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Persons with schizophrenia tend to commit fewer crimes
than general population, although they are more
frequently victims of crime.
Essential Features of Schizophrenia
(See p. 312)
 A mixture of characteristic signs and symptoms
(both positive and negative) that have been present
for a significant portion of time during a 1-month
period (or for a shorter time if successfully treated),
with some signs of the disorder persisting for at
least 6 months. (Criteria A and C)
 These sign and symptoms are associated with
marked social or occupations dysfunction (Criterion
Schizophrenia
Client must be ill for at least 6 months, with at least
two of five symptom types:
 Delusions
 Hallucinations
 Disorganized Behavior
 Disorganized Speech
 Negative Symptoms
Symptoms of Schizophrenia
Delusions
 A false belief that cannot be explained by the
individual’s culture or education.
 The individual cannot be persuaded that the belief is
incorrect, despite evidence to the contrary or weight
of opinion
 Types of delusions: grandeur, guilt, ill health, jealousy,
passivity, persecution, poverty, reference, and thought
control.
Symptoms (continued)
Hallucinations
 A false sensory perception that occurs in the
absence of a related sensory stimulus.
 Hallucinations
are nearly always abnormal
 They can affect any of the fix sense, but auditory and
visual are most common
Symptoms (continued)
Auditory Hallucinations
 The
voices will often comment on behavior and, at times,
give commands.
 The command hallucinations may tell the individual to
harm him/herself or others
 Therefore, it’s important during examination to ask the
client about the content of the auditory hallucinations, as
well as any intent to act on them
Hallucinations (continued)
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Visual Hallucinations often indicate a substanceinduced psychotic disorder or a psychotic disorder
due to a general medical condition (GMC)
Olfactory, tactile, and visual hallucinations are
extremely rare, and they generally co-occur with
auditory hallucinations.
Hallucinations must occur when the person is fully
conscious
Symptoms (continued)
Disorganized Speech
 Also called loose association – mental associations
are governed not by logic but by rhymes, puns, and
other rules not apparent to the observer, or by no
clear rules at all
 Psychologically disorganized speech must be so
badly impaired that it materially interferes with
communication.
Symptoms (continued)
Disorganized Behavior
Physical actions that do not appear to
be goal-directed (e.g., taking off one’s
clothes in public, repeatedly making
the sign of the cross, assuming and
maintaining postures) may indicate
psychosis.
Symptoms (continued)
Negative Symptoms
 These symptoms are called “negative”
because they give the impression that
something has been taken away from
the individual, not added, as in the
case with hallucinations and delusions.
 Negative symptoms reduce the apparent textural
richness of an individual’s personality
Symptoms (continued)
Negative Symptoms - lack or are the absence of
something, such as:
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Inexpressive faces, blank looks, unresponsiveness (flat or
blunted affect)
Loss of will, spontaneity, and initiative to do things
(avolition)
Seeming lack of interest in the world and other people,
social withdrawal (asociality)
Apparent inability to show or feel pleasure (anhedonia)
Loss of adaptive personal and social skills
Symptoms (continued)
Negative Symptoms
Attention impairment
 Markedly reduced amount or fluency of speech, poverty of
speech (i.e., speech conveys little information) (alogia),
 Increased speech latency (abnormal period of time to
respond to another person’s comment)
 Negative motor symptoms; e.g., maintaining bizarre
postures, passively allowing one’s body to be manipulated
by others, catatonic stupor (no response or interaction with
external environment)
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Definition of Five Types
of Schizophrenia
#1 Paranoid Type
These clients have persecutory delusions and
auditory hallucinations, but no negative symptoms,
disorganized speech, or catatonic behavior.
Paranoid Type (continued)
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Often appear the most normal
Better able to take care own day-to-day needs
Relatively late age of onset (average age of 35
years)
Delusions are typically persecutory or grandiose,
or both & organized around a coherent theme.
Hallucinations are also related to the delusional
theme.
However, the delusion or auditory hallucinations
for this diagnosis are not required to have
paranoid content.
#2 Disorganized Type
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In this subtype, negative symptoms and disorganized
speech and behavior are more prominent than
delusions and hallucinations
People with this type are frequently the most
obviously psychotic of all
They often deteriorate rapidly, talk gibberish, and
neglect hygiene and appearance.
#3 Catatonic Type
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The cardinal symptoms are excessively retarded or
excited activity and bizarre behavior.
May have many of the basic symptoms of
Schizophrenia, but their abnormal physical
movements set them apart.
 Motor
activity may be speeded up
 However, behavior is more typically slow or retarded,
sometimes to the point of stupor.
#4 Undifferentiated Type
These clients will have some or all of the five basic
types of psychotic symptoms.
 None of these symptoms dominates the clinical
picture.
 If the person does not have the paranoid,
disorganized, or catatonic type, but still has
schizophrenic symptoms, then s/he probably has the
Undifferentiated Type.
#5 Residual Type
This type might be diagnosed in a person whose
diagnosis of Schizophrenia is already established,
and
 Who has either been treated or improved
spontaneously - to the point of no longer having
enough symptoms for a diagnosis of active
Schizophrenia
 After an acute psychosis has markedly improved,
these clients usually still seem somewhat unusual, odd,
or peculiar.
Classification
of Longitudinal Course
Definitions:
Episode. A period of prominent psychotic symptoms
Interepisode. A period between episodes
Continuous. Prominent psychotic symptoms are present
throughout the period of observation.
Residual phase. Occurs after remission of prominent psychotic
symptoms
Classification
of Longitudinal Course (con’t.)
Six Types (applied only after at least 1 year since
initial onset of active-phase symptoms):
1. Episodic With Interepisode Residual
Symptoms, also specify if:
With Prominent Negative Symptoms
2. Episodic, also specify if:
With Prominent Negative Symptoms
Classification
of Longitudinal Course (con’t.)
3. Continuous (prominent psychotic symptoms are present
throughout the period of observation) also specify if:
With Prominent Negative Symptoms
4. Single Episode in Partial Remission;
also specify if: With Prominent Negative Symptoms
5. Single Episode in Full Remission
6. Other or Unspecified Pattern
Treatment of Schizophrenia
Treatment is multi-faceted:
 Antipsychotic
drugs
 Psychological therapy
 Social rehabilitation
 Family support
 Community care
Treatment (continued)
Antipsychotic Drugs
 More
than two dozen antipsychotic drugs are
available.
 These drugs reduce days in the hospital and number of
hospitalizations
 There is some evidence that starting drugs early on
may improve (or even “cure”) the severity of the
disease.
Treatment (continued)
Psychological Treatment
Individual psychotherapy for people with schizophrenia must
be done very carefully, because introspection and selfdisclosure may cause intense emotions and even a psychotic
episode
 What seems best is practical advice and support, helping the
client to distinguish reality from illusion, and setting specific
goals
 Group therapy can be helpful for it provides an opportunity
to be with others in the same situation and learn from them.
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Treatment (continued)
Social Rehabilitation
Social skills training has been very helpful, for it
teaches (through role-playing sessions) how to live in
the community.
Treatment (continued)
Family Support
In working with families, a new approach is family
crisis management, which gives information to
family members about schizophrenia, teaches them
to communicate better with one another, and trains
them in identifying and solving specific problems
that arise within the family.
Treatment (continued)
Community Care
Although government funding is inadequate, people with
schizophrenia need much community support, such as shelter,
care, companionship, job counseling, and rehabilitation.
 A whole team, including family members, social workers,
physicians, nurses, psychotherapists, vocational counseling,
and others are essential.
 Case managers are essential, because they serve as
advocates, monitor treatment (including taking medication),
represent clients at welfare hearings, and accompany them
to appointments.
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Prognosis
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Remember the recovery from schizophrenia by
Nobel Prize-winning scientist, John Nash, as told in
the biography and film, A Beautiful Mind.
Five long-term studies in the last twenty years have
shown improvement even among those who seemed
hopelessly ill.
According to Grinsponn & Bakalar (1990), people
with schizophrenia show a fairly high rate of recovery
– usual partial, sometimes complete.
About 10% require permanent hospitalization
 About 25% require a high degree of supervision and care
for most of their lives
 50-75% recover some capacity to care for themselves, work,
and participate in society
 15% are able to live independently without medications or
other treatment
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Schizophrenia is a terrible burden to those who
suffer from it. However, it is important that those,
who care for people with schizophrenia, show by
their words, actions, and attitudes that they believe
recovery is possible. To deny that reality, either
explicitly and implicitly, betrays hope and
discourages healing.
Other Psychotic Disorders
Schizophrenia-Like Disorders (3 types)
1.
Schizophreniform Disorder (p. 317)
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This category is for clients who have
all the symptoms of schizophrenia, but
for only one to six months – less than
the time specified for Schizophrenia
and more than the time for Brief
Psychotic Disorder.
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Impaired social or occupational functioning
is not required.
Schizophreniform Disorder (con’t.)
Specifiers
 With Good Prognostic Features – if two of the
following are present:
 Onset
of psychotic symptoms are within 4 weeks of the
first noticeable change in usual behavior or functioning
 Confusion or perplexity at height of psychotic episode
 Good premorbid social and occupational functioning
 Absence of blunted or flat affect
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Without Good Prognostic Features
Schizophreniform Disorder (con’t.)
Course
About 1/3 recover within the 6-month period and
receive Schizophreniform as a final diagnosis
Remaining 2/3 progress to a diagnosis of
Schizophrenia or Schizoaffective Disorder
Other Psychotic Disorders
Schizophrenia-Like Disorders
2. Schizoaffective Disorder
For at least one month, these clients have had symptoms
of Schizophrenia; at the same time, they have prominent
symptoms of depression, mania, or mixed episode.
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The depression symptoms must meet Criterion A1, p. 312
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A hard diagnosis – requires observation over time and
multiple sources of information
Specifiers
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Bipolar Type
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Depressive Type
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Other Psychotic Disorders
Schizophrenia-Like Disorders
Brief Psychotic Disorder
These clients have at least one of the basic psychotic
symptoms for less than one month.
Specifiers
3.
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With Marked Stressor(s): Symptoms occur in response to
events
Without Marked Stressor(s): Symptoms do are not in
response to events
With Postpartum Onset: Symptoms occur within 4 weeks of
birth
Three Psychotic Disorders form
a Continuum: Based on duration of episode
Brief Psychotic Disorder (duration 1 day to 1 month)
Schizophreniform Disorder (duration 1 month to 6 months)
Schizophrenia (duration more than 6 months)
Disorders with Delusions
Delusional Disorder. Although these clients have
delusions (which are not bizarre), they have none of
the other symptoms of Schizophrenia
Shared Psychotic Disorder (Folie a Deux)
This condition is diagnosed when a client develops
delusions similar to those held by a relative or other
close associate(s).
Other Psychotic Disorders
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Psychotic disorder Due to a GMC
A variety of medical and neurological conditions
can produce psychotic symptoms.
Substance-Induced Psychotic Disorder
Alcohol or other substances can cause psychotic
symptom
Psychotic Disorder NOS
This is for clients with symptoms that do not seem to
fit any of the specified categories.
Disorders with Psychosis as a Symptom
Mood disorder with psychosis. Clients with severe
Major Depressive Episode or Manic Episode can have
hallucinations and mood-congruent delusions.
Cognitive disorder with psychosis. Many demented
clients have hallucinations or delusions
Personality Disorders. Clients with Borderline
Personality Disorder may have transient periods
(minutes or hours) when they appear delusional.
Disorders that Masquerade as Psychosis
but are not
Specific Phobia. Some phobic avoidance behaviors can appear
quite strange without being psychotic.
Mental Retardation. These clients may at times speak or act
bizarrely.
Somatization Disorder. Sometimes these clients will report
pseudo-hallucinations or pseudo-delusions.
Factitious Disorder. May feign delusions or hallucinations to
obtain hospital/medical care
Malingering. May feign delusions or hallucinations to obtain
money (insurance of disability payments), avoid work (such as
military), or avoid punishment.