Transcript 21 Psychopathology III -- Wilson 2006

Psychopathology III:
Schizophrenia and Common
Psychotic Disorders
Michael Wilson, PhD
University of Illinois Department of Psychology
and
University of Illinois College of Medicine
A clinical vignette…
A 28 year-old male who lives in a group home is brought to the
ED for agitation. He says that his roommates are spying on
him by listening to him through the TV set. For this reason,
he has changed roommates a number of times over the past
5 years. He has poor grooming and seems preoccupied
when you talk to him. He reports that he is having trouble
listening to the doctor’s questions because “I am listening to
Abraham Lincoln in my head.” Testing is most likely to reveal:
A.
B.
C.
D.
E.
lack of orientation to time
lack of orientation to person
mental retardation
frontal lobe dysfunction
lack of orientation to place
Outline
•
•
•
•
Defining schizophrenia
Symptoms & diagnosis
Other psychotic disorders
Treatment modalities
What is schizophrenia?
• Schizophrenia, lit “split mind”
– coined by German psychiatrist Eugen Beuler
• Mixture of characteristic symptoms that
have been present for significant portion of
time
– no single symptom indicates schizophrenia
– must recognize a constellation of
signs/symptoms
Symptoms of Schizophrenia
• Positive symptoms
– includes disorganized
symptoms
• Negative symptoms
Positive symptoms
•
•
“Positive symptoms” = something present
which should not be there
usually an excess or distortion of normal
functions
–
delusions
•
•
•
•
fixed false beliefs that cannot be argued out of
are not shared by other members of culture
may involve a variety of themes: persecutory,
referential, somatic, grandiose
may be bizarre or non-bizarre
Positive symptoms
• Hallucinations
– may occur in any sensory modality
– auditory are most common
• usually experienced as voices
• may be familiar or unfamiliar
• isolated experiences such as hearing one’s name
or humming in one’s heard are not schizophrenic
Positive symptoms
• Disorganized thinking
– sometimes argued to be single most
important feature
– difficult to precisely define
– disorganized speech often used instead
• person may “slip off the track” from one topic to
another (derailment, loose associations)
• answers to questions may be obliquely related
(tangentiality)
• speech may simply be incomprehensible
(incoherence or word salad)
Positive symptoms
• Disorganized behavior
– may present in variety of ways
• behavior may range from childlike silliness to
unpredictable agitation
• may be completely inappropriate
– may note problems in any goal-directed
behavior
• grooming is usually poor
• usually unable to prepare meals
Negative Symptoms
• “Negative symptoms” = something missing
which should be there
– affective flattening
• especially common
• person’s face is immobile & unresponsive
– alogia
• poverty of speech
• brief empty replies to questions
• must not simply be unwilling to speak
Negative symptoms
• avolition
– inability to initiate & persist in goal-directed
activities
– person may sit for long periods of time, shows
little interest in work/social activities
• anhedonia
– loss of interest or pleasure
Negative symptoms
• Often difficult to evaluate
– occur on a continuum with normality
– relatively nonspecific
– may occur for a variety of reasons other than
schizophrenia (medications, depression, etc.)
DSM-IV Diagnosis of Schizophrenia
A. Characteristic symptoms: > 2 of the following
symptoms:
(1) delusions
(2) hallucinations
(3) disorganized speech
(4) grossly disorganized or catatonic behavior
(5) negative symptoms, i.e., affective flattening, alogia,
or avolition
Note: Only one symptom is required if delusions are bizarre or voices keep
up a running commentary on person’s thoughts or behavior, or two or more
voices are conversing with each other.
Diagnosis of Schizophrenia
B. The patient must have substantial
social/occupational dysfunction.
C. Disturbance persists for at least 6 months. This
6-month period must include at least 1 month of
symptoms that meet Criterion A and may
include periods of prodromal or residual
symptoms.
D. Schizoaffective Disorder and Mood Disorder
with Psychotic Features have been ruled out.
Diagnosis of Schizophrenia
E. Cannot be better explained by a substance or a
general medical condition.
F. If developmental disorder present, additional
diagnosis of schizophrenia is made only if
prominent delusions or hallucinations.
DSM-IV Subtypes
• Catatonic
•
Immobile behavior dominates, less common now
• Disorganized
•
Disorganized speech, behavior, and flat affect
• Paranoid
•
•
Delusions and/or auditory hallucinations
Not limited to persecutory themes
• Undifferentiated
•
not above, but Criterion A still met
• Residual
•
Criterion A no longer met, “burned out.”
Epidemiology - I
• Lifetime prevalence ~1%
– male = female
• All cultures have similar frequency
–
–
–
–
typically between late teens to mid-30s
earlier for males
rare prior to adolescence & after 55
may also begin > 45 years (much more common in women)
• Increased mortality rate from accidents and natural
causes
– life span shortened by ~ decade
– under-diagnosis of other medical illness
Epidemiology - II
• 10-15% suicide
– ~50% attempt
• Illness seems concentrated in lower
socioeconomic classes.
– “downward drift” vs. social causation
• Increased use vs. abuse vs. dependence
• ~1/3 or more of homeless population
– Disabling (over 50% unemployed)
• 50% of all inpatient psychiatry beds
Epidemiology - III
• Highest prevalence of Schizophrenia found in
those with lower SES…Why?
• Hypothesis 1: “Social Causation”
Negative factors related to low SES (e.g., stressful life
events, social isolation, poor nutrition) lead to
development of illness
• Hypothesis 2: “Social Selection”
Due to cognitive/social impairments in those who develop
the illness, they are less able to progress to college or
high-paying jobs so they drift to a lower SES
Are Schizophrenic People Violent?
• Most schizophrenics are far more likely to be
victims
– despite Hollywood portrayal
• However, elevated risk in some patients
– Best predictors are history of previous violence,
dangerous behavior while hospitalized, hallucinations or
delusions involving violence
Brennan PA, Mednick SA, Hodgins S. Major mental disorders and criminal violence in a Danish birth cohort. Arch Gen
Psychiatry. 2000 May;57(5):494-500.
Excluding Related Disorders
Before a diagnosis of schizophrenia can be given,
disorders with similar symptoms must be ruled out
as a possibility
• Mood Disorders with Psychotic Symptoms
• Schizoaffective Disorder
• Schizophreniform Disorder
• Brief Psychotic Disorder
• Delusional Disorder
Difference between Schizophrenia
and Mood Disorders with Psychosis
• Schizophrenia: If depression and mania
symptoms present, duration of mood
symptoms must be brief in comparison to
schizophrenia symptoms
• Mood disorders: psychotic symptoms only
occur during a manic or depressive episode
Schizophrenia vs. Schizoaffective Disorder
• For schizoaffective disorder:
– Delusions and hallucinations must be present
for at least 2 weeks without prominent mood
symptoms.
– Mood symptoms must be present for a
substantial portion of the psychotic
disturbance
• For schizophrenia:
– Length of time that mood symptoms are
present is brief in comparison to the duration
of psychotic disturbance
Schizophrenia, Brief Psychotic Disorder,
Schizophreniform Disorder
Brief psychotic Schizophreniform Schizophrenia
1 day
1 month
6 months
Delusional Disorder vs. Schizophrenia
• Non-bizarre delusions are the prominent
psychotic symptom in delusional disorder
• Other schizophrenic symptoms, such as
hallucinations, disorganized and negative
symptoms are absent in delusional disorder
So, what is the Difference…
…between Mood disorders + Psychosis,
Schizophrenia & Schizoaffective Disorder?
THE DURATION OF MOOD SYMPTOMS and
PSYCHOTIC SYMPTOMS
…between Schizophrenia, Schizophreniform
Disorder & Brief Psychotic Disorder?
THE DURATION OF ENTIRE DISTURBANCE
…between Schizophrenia & Delusional Disorder?
TYPE OF DELUSION & PRESENCE/ABSENCE
OF OTHER SYMPTOMS
Etiology: Genes
• Adoption and twin studies indicate a genetic
influence
• Pairwise concordance rates show:
– MZ concordance = 48 percent
– DZ concordance = 17 percent
• Twin concordance rate also implicate other factors
beyond genetics
Long-term Clinical Course
• Classically, consists of exacerbations and
remissions
– remissions often will not return patient to “baseline”
level of functioning
– Progression may plateau about 5 years after initial
diagnosis
– Antipsychotic medications improve acute and longterm outcome
– Long-term prognosis is not totally good or bad:
• 1/4 have a good outcome
• 1/4 continue to have moderate symptoms
• 1/2 remain significantly impaired with current treatment
Treatment Modalities
• Psychopharmacologic
– Classical antipsychotics
– “Atypical” antipsychotics
– Other agents
• Psychosocial
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Supportive therapy
Social skills training
Case management
Working with families
Treatment: Classical Antipsychotic
Medications
1. Target dopamine receptors
2. Work well for positive symptoms
(somewhat effective for 75% of patients)
3. Induce side effects resembling Parkinson’s Disease:
-Extrapyramidal Symptoms
Tremors, agitation, involuntary posturing, motor rigidity and inertia
-Tardive Dyskinesia
Involuntary movements of mouth and face (lip puckering, chewing)
and spasmodic body movements
Classical Antipsychotics
• Divided into a high potency and a low potency group
– Potency = amount of drug to give effect
– Example of high potency = haloperidol (Haldol)
– Example of low potency = chlorpromazine (Thorazine).
• High potency drugs bind D2 receptors more strongly
– also worse with extrapyramidal symptom (EPS) side effects
– They are inexpensive but have unpleasant side effects
Treatment: Atypical Antipsychotics
1. Better for negative symptoms
2. Also have side effects (Clozapine has 1-2% chance
of agranulocytosis)
3. Affect other neurotransmitters like serotonin and
norepinephrine
4. Relapse rates are high if medication stops
Treatment: Psychosocial
• Medication does not meet many needs of clients
– such as improving social competence, housing stability,
employment, etc.
• Psychosocial treatments focus on long-term strategies
– try to improve patient’s life other than reduction of psychotic
symptoms
• Types of psychosocial treatment include:
– Family therapy
– Social skills training
– Vocational rehabilitation
– Assertive community treatment (ACT)
Assertive Community Treatment
• A comprehensive team works together to
meet the needs of the client including:
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Psychiatrists
Nurses
Social workers
Vocational counselors
Recreational counselors
• Staff to client ratio is high, staff are is
available 24/7, and contact with clients is
frequent
Brain changes in schizophrenia
• Structural changes
– lateral ventricles are enlarged
– decreased brain volume diffusely
– temporal lobe structures particularly affected
• hippocampus, amygdala, etc.
• Functional changes
– functional abnormalities widespread
– consistently shows less activity in frontal lobes
Dorsolateral Prefrontal Cortex
(DLPFC)
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manipulating information
behavioral inhibition
selective attention
working memory
Social and Family Effects
• Better prognosis for patient:
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Married
Good social support system
Good premorbid social and other functioning
Low levels of “expressed emotion” (hostile, critical,
intrusive over-involvement)
• Now discredited theories blamed family,
especially mothers
– Education still needed to help correct this
misconception
A clinical vignette…
A 28 year-old male who lives in a group home is brought to the
ED for agitation. He says that his roommates are spying on
him by listening to him through the TV set. For this reason,
he has changed roommates a number of times over the past
5 years. He has poor grooming and seems preoccupied
when you talk to him. He reports that he is having trouble
listening to the doctor’s questions because “I am listening to
Abraham Lincoln in my head.” Neuropsych testing is most
likely to reveal:
A.
B.
C.
D.
E.
lack of orientation to time
lack of orientation to person
mental retardation
frontal lobe dysfunction
lack of orientation to place
Readings
• Fadem, BRS: Behavioral Science chapter
11