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Schizophrenia. The most puzzling/disabling syndrome History of the concept Emil Kraepelin first defined demenita praecox out of one’s mind before maturity loss of inner unity of thought, feeling, & acting. Eugene Bleuler renamed dementia praecox to schizophrenia cut/split brain.

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Schizophrenia l.jpg
Schizophrenia

  • The most puzzling/disabling syndrome

  • History of the concept

    • Emil Kraepelin first defined demenita praecox

      • out of one’s mind before maturity

      • loss of inner unity of thought, feeling, & acting.

    • Eugene Bleuler renamed dementia praecox to schizophrenia

      • cut/split brain


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  • 4 symptoms

    • 1) associations: thoughts become disturbed

    • 2) affect: emotional response becomes flattened or inappropriate.

    • 3) ambivalence: hold conflicting feelings towards others.

    • 4) autism: withdrawal into private fantasy world.

  • According to Bleuler, hallucinations and delusions were secondary.

  • His definition was broader than Kraepelin’s.


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Schneider

  • A contemporary view

    • He felt Bleuler’s criteria were too vague.

    • First rank symptoms

      • Symptoms that are central to the diagnosis and not present in other disorders. For example, halucinations, delusions. Today we recognize that some of his first-rank symptoms are found among other disorders such as bipolar d/o

    • Second rank symptoms

      • Symptoms may be present in other disorders. For example, disturbance in mood/thinking.


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  • For some, the onset is acute; while for others, it may take years before behaviors emerge.

  • Prodromal phase - the period of decline that precedes the development of the first acute psychotic episode.

  • Residual phase - the phase that follows an acute phase, characterized by a return to a level of functioning that was typical of the prodromal phase.


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Briefer forms of Psychosis years before behaviors emerge.

  • Brief Psychotic Disorder

    • A psychotic disorder that lasts from 1 wk to 1 month

    • Characterized by 1 of the following:

      • delusions

      • hallucinations

      • disorganized speech

      • catatonic or disorganized behavior.


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Cont. briefer years before behaviors emerge.

  • Schizophreniform

    • identical behavior to schizophrenia but lasts at least 1 month to less than 6 months.

  • Other parts of the schizophrenia spectrum

    • Schizoid,

    • Paranoid,

    • Schizotypal personality d/o (mild)

    • Schizoaffective D/o : psychotic features with mood disturbance

  • Distinction is in degree


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Features of Schizophrenia years before behaviors emerge.

  • Males have an earlier onset.

    • A poorer history of adjustment prior to onset,

    • more cognitive impairment,

    • more behavioral deficits and,

    • poorer response to medication.


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  • Disturbances in thought/speech years before behaviors emerge.

    • content - for example, delusions such as

      • delusions of persecution,

      • delusions of reference,

      • delusions of being controlled

      • delusions of grandeur

    • Thought broadcasting

    • Thought insertion

    • thought withdrawal

    • Disturbance in the form of thought

      • breakdown in organization, processing


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  • Control of thoughts years before behaviors emerge.

    • looseness of associations

    • neologisms: a word made up by the speaker

    • perseveration (repetition of words or train of thought)

    • clanging (stringing together words on the basis of rhyming)

    • blocking (involuntary abrupt interruption of speech or thought)

  • Thought Disorder persisting beyond acute episodes are connected with poorer prognoses.


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    • Deficits in attention years before behaviors emerge.

      • Appear to have difficulty filtering out irrelevant distracting stimuli

    • Deficiencies in orienting response

      • Orienting responses - involuntary pattern of responses to incoming stimulus, ie., pupil dilation, brain waves associated with attention and changes in GSR) Schizophrenics show abnormal OR’s


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    • Perceptual Disturbances are people with the EMD who are bipolar.

      • hallucinations

        • auditory most common

        • tactile/somatic are also common

        • visual, gustatory, olfactory are rarer.

        • Command hallucinations = more aggression > hospitalization.

      • Sometimes normals hallucinate during grief but the individual can distinguish from reality. May have hallucinations when withdrawing from ETOH/or as side-effects from medications


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    • Emotional disturbances - flat affect are people with the EMD who are bipolar.

    • Other disturbances - loss of ego boundaries (fail to recognize themselves as unique individuals)

    • Motor behavior may be excited or slow (stupor)


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    Types of Schizophrenia are people with the EMD who are bipolar.

    • Disorganized

      • Confused behavior, incoherence, loose association, vivid, frequent hallucination, flattened affect, disorganized delusions with sexual/religious themes.

    • Catatonic

      • marked impaired motor behavior. Catatonics are mute/how no evidence of attending to those around.


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    Cont. types of schizophrenia are people with the EMD who are bipolar.

    • Paranoid

      • preoccupied with one/more delusions or have frequent auditory hallucinations. Delusions involve themes of grandeur or persecution.


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    Dimensions of Schizophrenia are people with the EMD who are bipolar.

    • Process-reactive dimension

      • Process schizophrenia - develops more slowly insidiously (less favorable recovery)

      • Reactive schizophrenia - follows a precipitating stressor (premorbid adjustment)


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    Cont. Dimensions are people with the EMD who are bipolar.

    • Positive/Negative symptoms

      • Positive symptoms

        • hallucinations, delusions, thought disorder

      • Negative symptoms

        • behavioral deficits: low motivation, flat affect, loss of pleasure

      • Presence of negative symptoms associated with poorer premorbid functioning, lower education, more gradual onset, enduring disability.


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    Cont. Dimensions are people with the EMD who are bipolar.

    • Type I and Type II

      • Type I

        • has an abrupt onset

        • symptoms such as hallucinations, delusions, and loose associations.

        • Favorable response to medication.


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    • Type II are people with the EMD who are bipolar.

      • Symptoms

        • Flat affect

        • social withdrawal and

        • poverty of speech

      • Poor prognosis


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    Theoretical Perspectives are people with the EMD who are bipolar.

    • Psychodynamic

      • Schizophrenia represent the ego overtaken by primitive sexual/aggressive impulses of the id. Regresses to an early stage, oral known as primary narcissism. Because ego mediates between self/outer world, the breakdown in ego functioning accounts for detachment from reality. Input from id causes fantasies to become mistaken for reality resulting in hallucinations/delusions.


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    Cont. Psychodynamic are people with the EMD who are bipolar.

    • Sullivan

      • Emphasized impaired mother/child relationship.

      • Anxious/hostile interactions lead child to take refuge in fantasy.

      • Produces a cycle: the more the child withdraws, the less opportunity there is to develop a sense of trust that is necessary to establish intimacy.

      • Have not been able to demonstrate early childhood experiences predict schizophrenia.


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    Learning are people with the EMD who are bipolar.

    • Although learning theory may not account for schizophrenia, the principles of conditioning and observational learning may play a role in the development of some forms of schizophrenic behavior. Behavior is learned through reinforcement.


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    Biological are people with the EMD who are bipolar.

    • Genetic

      • contribution is strong. Mode of transmission is unknown.

      • Most prevailing view is diathesis-stress model: combines biological and psychosocial.

    • Biochemical factors

      • Dopamine theory

        • overreactivity of dopamine receptors: they use more dopamine. Studies with neuroleptics such as phenothiazines, and amphetamines.

      • Viral infection


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    • Brain abnormalities are people with the EMD who are bipolar.

      • enlarged brain ventricles

      • Neurotransmitter disturbances shown by tracking blood flow with PET scans, EEG and MRI’s in the preforntal cortex. Some evidence that the hippocampus and amygdala are involved.

    • Diathesis-Stress model

      • supporting evidence: schizophrenia usually begins in adolescence when stress increases.

      • Schizophrenia is twice as likely to occur among the poor.

      • Children of schizophrenia: 10-25% chance with one schizophrenic parent; 45% chance with two schizophrenic parents.


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    Family theory are people with the EMD who are bipolar.

    • Schizophrenigenic mother

    • double-bind

    • Communication deviance (excessive vagueness/blurring -attack children/double-bind)

    • Another measure of disturbed family communication is expressed emotion- measured by the # of critical comments by the relative about the patient, hostility toward the patient, emotional overinvolvement. Some research suggests high EE may play a role in course of schizophrenia.


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    Treatment are people with the EMD who are bipolar.

    • Biological

      • Neuroleptics led to deinstitutionalization

        • Examples of neuroleptics

          • phenothiazines: Haldol, Thorazine, Clozapine (new)

          • affects both dopamine/norephinphrine,

          • traditional neuroleptics affect + symptoms and not the - symptoms as well but the new neuroleptics address both.

          • Side-effects: Traditional neuroleptics can cause tardive dyskinesia (a movement disorder affecting mouth, face, neck, trunk, extremities, lip smacking, grimacing. Most common is eye blinks. Risks of TD increase with age/more common with older, female patients.


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    Cont. Biological are people with the EMD who are bipolar.

    • Clozapine doesn’t lead to TD but may cause agrnulocytosis, not enough white blood cells. Users must have routine blood tests.


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    Psychodynamic are people with the EMD who are bipolar.

    • Freud did not believe psychoanalysis was well suited to treat schizophrenia because unable to form meaningful relationship.


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    Learning are people with the EMD who are bipolar.

    • Direct modification of behavior and development of more adaptive behavior.

    • Paul/Lentz study with 2 groups: applied social -learning principles and a therapeutic community. Social learning group did better, but programs require strong administration, skilled leaders, extensive staff training.


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    Cont. Learning are people with the EMD who are bipolar.

    • Social skills training (another application of social-learning) use of role playing to encourage modeling, direct instruction, shaping, coaching.

    • Sheltered workshops that provide training, modeling of task, rehearsal with + feedback was beneficial to schizophrenia. Fountain House, a self-help club provided some of these services.

    • Family intervention program showed decrease in recurrence rates.


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    Delusional Disorder are people with the EMD who are bipolar.

    • Relatively uncommon

    • persistent delusions that often but not always involve paranoid themes.

    • No confused/jumbled thinking.

    • Hallucinations, when they occur, are not as prominent.

    • Distinguish between paranoid personality (exaggerated or unwarranted suspicions of others but not outright delusions as in delusional d/o or schizophrenia.


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