Schizophrenia and Other Psychotic Disorders
1
Nature of Schizophrenia and Psychosis
• Schizophrenia vs. Psychosis
– Broad term referring to hallucinations and/or delusions – – A type of psychosis with disturbed thought, language, and behavior –
2
Two Broad Categories of Psychotic Symptoms
• Positive symptoms are an excess or distortion of normal functions.
•
– –
•
– –
• Negative symptoms reflect a diminution or loss of normal functions
• Restrictions in the range and intensity of emotional expression
• Fluency and productivity of thought and speech • Initiation of goal-directed behavior
3
Positive Symptoms
4
Psychotic Dimension
5
Delusions
• Delusions – an erroneous belief that usually involves a misinterpretation of perceptions or experiences. Themes include:
–
– – –
–
– (most common) person believes he is being tormented, followed, tricked, spied on, or ridiculed – (common) person believes that certain gestures, comments, passages from books, newspapers, song lyrics, or other environmental cues are specifically directed at him Somatic – beliefs involve the body (e.g., The FBI has implanted an electrode in my brain) Religious – person’s delusions center on religious themes (e.g., I am God’s chosen messenger) Grandiose – person’s beliefs center on their “specialness” and have a elevated belief in their importance. (e.g., I can end the world’s starvation if people would listen.)
6
Hallucinations
• May occur in any sensory modality
– – hearing voices esp. two or more carrying on a commentary about you – – seeing ghosts, shadows – – smelling rotting flesh – – tasting rotten fish – – ants crawling on skin
• Note: Isolated experiences of hearing one’s name are also not indicative of schizophrenia.
7
Disorganization Dimension
8
Disorganized Thinking (“ ”)
• It is inferred from the person’s speech
– Slipping off track from one thought to another ( ) – Answers to questions are obliquely related or completely unrelated ( )
9
Disorganized Behavior
• • • Problems may be present in any form of goaldirected behavior • Person may appear , may dress in an unusual manner (wearing layered clothing on a hot day),
10
Catatonic Motor Behaviors
• Catatonic : Marked decrease in reactivity to the environment • Catatonic : Maintaining a rigid posture • Catatonic : Assuming inappropriate or bizarre postures • Catatonic : Purposeless and unstimulated motor activity
11
Negative Symptoms
12
Negative Symptoms
–common; face appears immobile and unresponsive, poor eye contact, reduced body language. • - (poverty of speech) – brief, laconic (concise), empty replies. • – inability to initiate/persist in goal-directed activities. May sit for long periods of time. • – loss of interest or pleasure
13
•
Associated Features
• % commit suicide ( % make at least one attempt). Specifics that increase this risk are:
– – – – – – –
14
Violence?
• Major psychiatric disorder AND substance abuse
15
Substance Abuse
• High comorbidity • Nicotine dependence estimates of %
16
Onset
• • • • Typically in late Onset prior to Men – (unimodal) Women – (bimodal with second peak after ) • Overall prevalence around %
17
Sex
• Women
– Better – Better – More
• Men
–
18
Differential DX
• Schizophreniform – difference only in timeframe. Schizophreniform is months, and schizophrenia is more than 6 months. • Brief Psychotic Disorder – • Delusional Disorder – Nonbizarre delusions
19
Subtypes of Schizophrenia
•
•
• • •
Type –one or more typically persecutory/grandiose delusions or frequent auditory hallucinations. Type – disorganized speech/behavior and flat/inappropriate affect Type – motoric issues predominant Type – does not meet criteria for the other types Type – absence of prominent symptoms but continuing evidence of the disturbance
20
Research Findings on Schizophrenia
• Family Studies – appear to inherit a tendency • Twin Studies - risk in monozygotic twins is % and % in dizygotic • Adoption Studies - risk remains high in adopted children with a biological parent who has it • Has a strong genetic component,
• Structural and Functional Abnormalities in the Brain
– Enlarged ventricles and reduced tissue volume
–
– Less active frontal lobes (a major dopamine pathway)
21
Causes of Schizophrenia: Psychological and Social Influences
• The Role of Stress
– May activate underlying vulnerability and/or increase risk of relapse (Stress-Diathesis Model)
• Family Interactions
– Families of people with schizophrenia show ineffective communication patterns – –
22
Treatment Issues for Schizophrenia
• Some family interactions affected the symptoms of the condition.
– Relapse increases if family members were either:
• •
– Relapse less common when family saw the patient
• •
– Families that lacked information about the illness, had high ambitions for the patient, and attributed the behaviors associated with the symptoms as being under the patient’s control tended to be overly critical and overly involved.
23
Treatment Issues for Schizophrenia (cont.)
• As a result of this, family collaboration in treatment and psychoeducation was instituted (Anderson et al., 1991) • Benefits of family inclusion:
– – – – –
24
Medications
• Standard Antipsychotics
– Examples:
• Atypical Antipsychotics (usually less side effects)
– Examples:
25
5 Major Medication Side Effects
1.
–
– –
– due to blocking DA receptors – 3 types
– slowed movements, decreased facial expression, resting tremor, shuffling gait – sustained muscle spasms usually of the neck – can be quite painful and frightening – intense feeling of restlessness – severe akathisia is associated with increased noncompliance and increased risk of suicide
2.
– – – – – –
– due to blockage of ACh receptors.
Leads to dry membranes (eyes and mouth especially) Blurred vision (especially near vision) Intestinal slowing (constipation) Difficulty urinating Sedation Sexual dysfunction
26
Major Side Effects (cont.)
3. adrenergic sites
– Leads to orthostatic hypotension (when the person stands up, blood pressure drops precipitously, leading to a transient lightheadedness and potentially a fall and injury).
– blocks alpha-
27
Major Side Effects (cont.)
4. – abnormal, involuntary, rhythmic movements of the mouth, tongue, and lips, including:
– protruding tongue, mouth puckering, lip smacking, and chewing motions; – irregular, purposeless involuntary quick movements of the extremities, flailing or jerky in appearance; – continuous, writhing movements of extremities, including trunk and pelvis
28
Major Side Effects (cont.)
5.
– – – – – Weight gain (I think this is common.) Agranulocytosis (rare blood disorder) – believed due to a contaminant in some drug preps and not the drug itself Grand mal seizures Neuroleptic Malignant Syndrome (NMS) – rare but potentially fatal reaction characterized by fever, confusion, and rigidity. Aplastic anemia / hepatitis – clozapine – weekly blood testing of white blood cell count
•
Discontinuation of meds has been shown to increase relapse rates.
29
Delusional Disorder
30
Delusional Disorder
• Nonbizarre delusions that are contrary to reality without other major schizophrenia symptoms • Extremely rare, with a better prognosis than schizophrenia
31
Delusional Disorder Types
–
– – – –
Type: delusions that another person, usually of higher status, is in love with the individual Type: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person Type: delusions that the individual’s sexual partner is unfaithful Type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way (most common type) Type: delusions that the person has some physical defect or general medical condition (e.g., emitting a horrible smell)
32
(a misidentification delusion)
• People displaying this syndrome believe that important people in their lives (e.g., family members) have been replaced by exact doubles. No hallucinations or illusions are involved; rather it is a belief. Those afflicted may even believe that they themselves are represented somewhere by a double they never see. Not all persons with close emotional ties are believed to be doubled; and these unreplaced persons are always identified accurately. People with these beliefs usually possess normal perceptions and memories but are obviously disturbed emotionally with paranoid tendencies (Berson, 1983).
33
Videos
• • • • • • Etta (Schizophrenia) Positive v. Negative Symptoms Common Symptoms Schizophrenia Symptoms (Video #26) Schizophrenia Etiology (Video #27) Schizophrenia Pharmacological Treatment (Video #28)
34