Transcript document

Chapter 13 - Schizophrenia
• Criteria
1. Symptoms (2 of 5 for 1 month)
Content of thought:
a.
Delusions - belief with no basis in
reality
b. Hallucinations – perception in
absence of stimuli
**
Form of thought
c.
Disorganized, incoherent
Behavior
d. Disorganized, agitated, or
catatonic
Emotion
e.
Flat or inappropriate affect
- withdrawal, poverty of speech
Positive vs. Negative Symptoms
- Positive = excess or distortion
- Negative = loss of normal behavior
2. Social/Occupational dysfunction
- work, relationships, hygiene
- loss of identity
3. Duration
> 6 months
(Sxs in #1 at least 1 month)
4. Exclusions
- not from drugs, medical problems,
or mood disorder
• INDIVIDUAL DIFFERENCES
Course
• Onset
- late teens to mid-30s
- rarely before adolescence
- either acute or gradual (most are gradual)
• Phases
a. Prodromal
- slow development of negative
symptoms
- often misinterpreted
b. Acute
- appearance of positive, psychotic
symptoms
c. Residual
- positive sxs remit, negative sxs remain
- return to prodromal
d. Remission
- never recovered
-> labeled for life
vs. Third world
• Progression = variable
- chronic
- vs. gradually deteriorating
- vs. swings between better & worse
- vs. remission
Subtypes
1. Paranoid Type
- Thematic delusions (eg, paranoid or grandiose)
Or frequent auditory hallucinations
- Often intact cognition & affect
- Stilted, aloof, superior
- Mixed evidence for suicidal or homicidal
- Best prognosis
(lack of negative sxs)
2. Disorganized Type
- Incoherent speech & behavior
- daily chores difficult
- disorganized delusions and/or hallucinations
- Flat/inappropriate affect
- appear silly/immature
- Insidious, early onset
- Poor prognosis
- continuous course without remissions
• 3. Catatonic Type
Psychomotor disturbance
- immobility, stupor, odd postures
waxy flexibility
Or
- agitation, purposeless movement
Negativism, mutism, resistance
Echolalia, echopraxia
4.Undifferentiated Type
- schizophrenic sxs
- but don’t meet criteria for types 1-3
- catchall dx
5.Residual Type
- 1+ episode of acute positive sxs
- no positive sxs currently
- continuing negative sxs
- eccentric, odd beliefs
- transition between full-blown episode and
remission?
- may be present for years
Other Psychotic Disorders
1. Brief Psychotic Disorder
Positive sxs
- hallucinations, delusions, loose
associations, disorganized beh.
Follows acute stressor
No prodromal or residual phase
Lasts < 1 month
Return to normal fxing
High suicide risk
2.Delusional Disorder
- 1 fixed non-bizarre delusion
- no other problems
3.Personality Disorders
a. Paranoid – suspicious
b. Schizoid – withdrawn
c. Schizotypal – odd
4.Schizophreniform Disorder
- sxs of schizophrenia
- lasts < 6 months
- most develop schizophrenia or
schizoaffective disorder
- no decline in fxing
5.Schizoaffective Disorder
- schizophrenia & a mood disorder
Etiology
Genetic Contributions
• Clear genetic basis
• Increased risk based on relatedness
Family Studies
• < 1% in population
• 17% if parent or parent’s MZ twin
Twin Studies
• MZ twins = 50%
• DZ = ~ 15%
Adoption Studies
• Biological risk = 10-17%
• Environmental risk = < 1%
Unknowns
• Means of transmission
• One or more genes
(polygenetic would explain spectrum)
Neurobiology & Neuroanotomy
1.Excess of Dopamine (DA)
- some antipsychotics are DA antagonists
(block use of DA)
- side effects (tardive dyskinesia: TD)
similar to Parkinson’s
• Parkinson’s = inadequate DA
- L-dopa increases DA for Parkinson’s
- amphetamines activate DA & can worsen
psychotic sxs in people with schizophrenia
SUM:
Increase DA => increase schizo.
& decrease Parkinson’s
Decrease DA => decrease schizo.
& increase Parkinson’s
BUT: 1. Antipsychotics don’t always work
2. Antipsychotics ineffective for
negative sxs
3. Decrease in DA in some brain
areas (may account for subtype
differences)
• Thus, complex interaction of DA, SE, &
possibly other neurotransmitters
2.Brain Structure - neurological damage?
a. Behavioral signs
- abnormal reflexes
- decreased attention
b.Atrophy
- enlarged ventricles
- often, but not always
- related to perinatal problems?
c. Decreased frontal lobe fx
- related to negative sxs
- more common in men
- associated with worse premorbid
adjustment & prognosis
d. Abnormal temporal lobe & limbic system
fx
- related to auditory hallucinations
- disconnection between thought &
emotion?
e. Abnormal thalamic fx
- incoherence?
3.Viral Infections?
Family Contributions
NOT "Schizophrenogenic Mother"
• Cold, aloof, overprotective
• Double-bind communication
Family Interaction
**Expressed emotion
= criticism, hostility, overinvolvement
=> risk of relapse
Diathesis-Stress Model
Diatheses:
• Genes
• Perinatal trauma?
• Viral infection?
Stressors:
• Single caregiver
• Lack of support
• Family high in expressed emotion
• Low SES
Treatment
• Antipsychotic Medication
Neuroleptics
• Side effects => noncompliance
- grogginess, blurred vision, mouth dryness,
loss of voices
- TD (tardive dyskinesia)
Clozapine (& now Risperdone)
• Blocks another DA receptor
• Treats positive & negative sxs
• Fewer side effects (like TD)
• Fatal for 2%
Monthly Drug Cost (1997)
• Clozapine
• Haloperidol
317.03
1.76
2005
• Clozapine
• Haloperidol
15.95
14.95
Behavioral Treatment
1.
2.
3.
4.
5.
Token economies
Social skills training
Therapeutic community – Szasz, Laing
Psychosocial rehabilitation
Family Therapy
Predictors of Recovery
1. Good premorbid adjustment
2. A precipitating stressor
3. Sudden onset
- acute positive symptoms
4. Older age of onset
5. Affective Problems
- anxiety/depression are good
- hopelessness is bad
6. Type of Schizophrenia
Best = Paranoid (with acute onset)
Worst = Undifferentiated, chronic
& Disorganized
(both have more negative sxs)
7. Supportive Family
8. Response to Treatment
- to medication, therapy, staff
- resigned is worse