Chapter Eleven

1. Chapter Eleven Schizophrenia and Other Psychotic Disorders

2. The Symptoms of Schizophrenia • Schizophrenia: • A group of disorders characterized by severely impaired cognitive processes, personality disintegration, mood disturbances, and social withdrawal • Psychosis: condition involving loss of contact with or distorted view of reality • Lifetime prevalence: 1% of U.S. population • Cost is estimated at $62.7 billion annually

3. The Symptoms of Schizophrenia (cont’d.) • Four symptom categories that we will cover: • Positive symptoms • Negative symptoms • Cognitive symptoms • Psychomotor abnormalities • A newer perspective of Schizophrenia, referred to as the recovery model, mobilizes optimism and collaborative support focused on recovery, and envisions substantial return of function for many individuals with schizophrenia.

4. Positive Symptoms • Positive symptoms are symptoms added or present in the schizophrenic individual that are not present in a normal individual. • Involve unusual thoughts or perceptions, such as: • Delusions • Hallucinations • Disordered thinking • Bizarre behavior

5. Positive Symptoms (cont’d.) • Delusions: • False beliefs that are firmly and consistently held despite disconfirming evidence or logic • Individuals are unable to distinguish between private thoughts and external reality • Most individuals are either unaware or only moderately aware of the illogical nature of hallucinations or delusions • Poor insight

6. Positive Symptoms (cont’d.) Figure 11-1 Awareness of Psychotic Symptoms in Individuals with Schizophrenia Most individuals with schizophrenia are unaware or only modestly aware that they have symptoms of the disorder. The symptoms they are most unaware of include delusion, disordered thinking and blunt affect. Source: Amador (2003). Used by permission of Dr. Xavier Amador.

7. Positive Symptoms (cont’d.) • Delusional themes: • Delusions of grandeur • Delusions of control • Delusions of thought broadcasting • Delusions of persecution • Delusions of reference • Delusions of thought withdrawal

8. Positive Symptoms (cont’d.) • Most common delusion involves paranoid ideation • Individuals have high levels of anxiety and worry, and experience persecutory delusions • Rare delusion is Capgras syndrome • Belief in the existence of doubles who replace significant others • “Safety” behaviors may prevent individuals from encountering disconfirmatory evidence

9. Positive Symptoms (cont’d.) • Hallucinations: • Sensory perceptions not directly attributable to environmental stimuli: • Auditory (hearing) • Visual (seeing) • Olfactory (smelling) • Tactile (feelings) • Gustatory (tasting)

10. Positive Symptoms (cont’d.) • Auditory hallucinations are most common and can range from malevolent to benevolent • Greatest distress: • When voices are dominant and insulting, and individual lacks communication with the voices • Auditory hallucinations appear to be real to the individual

11. Positive Symptoms (cont’d.) • Disorganized thought and speech: • Common characteristic of schizophrenia • Loosening of associations (cognitive slippage) • Continual shifting from topic to topic without any apparent logical or meaningful connection between thoughts • Incoherent speech or bizarre, idiosyncratic responses • Overinclusiveness or abnormal categorization

12. Positive Symptoms (cont’d.) • Grossly abnormal psychomotor behavior: • Extremes in activity levels • Catatonia: characterized by marked disturbances in motor activity • Excited catatonia: Agitated and hyperactive; sleep little and are continually on the go. • Withdrawn catatonia: Extremely unresponsive. • show prolonged periods of stupor and mutism, despite their awareness of all that is going on around them. • Peculiar body movements or postures • Strange gestures or grimaces • Combination

13. Positive Symptoms (cont’d.) Figure 11-2 Prevalence of Symptoms in 30 Young Patients With Catatonia Catatonic symptoms can vary significantly. Source: Cornic, Consoli & Cohen (2007).

14. Negative Symptoms • Associated with inability or decreased ability to initiate actions or speech, express emotions, or feel pleasure • Avolition: inability to take action or focus on goals • Alogia: lack of meaningful speech • Asociality: minimal interest in social relationships • Restricted affect: severe or limited emotionality in situations in which emotional reactions are expected

15. Cognitive Symptoms • Associated with problems with attention, memory, and difficulty in developing a plan of action • Moderately severe to severe impairments • Poor executive functioning • Inability to sustain attention • Difficulty retaining and using recently learned information

16. Cultural Issues • Culture may affect how symptoms are viewed: • Japan: • Stigma indicated by term seishin-bunretsu-byou (a split in mind or spirit) • Less stigma in 2002 when term changed to togo-shitcho-sho (integration disorder) • Western countries: • African-American are more often diagnosed

17. Other Psychotic Disorders • Involve psychotic symptoms, but do not meet the diagnosis for schizophrenia • Include: • Brief psychotic disorder • Schizophreniform disorder • Delusional disorder • Schizoaffective disorder • Attenuated psychosis syndrome • Other specified psychotic disorder

18. Brief Psychotic Disorder and Schizophreniform Disorder • Brief psychotic disorder: • Psychotic episodes that last at least one day but less than one month • Can be caused by psychological trauma • Relatively uncommon • Schizophreniform disorder: • Psychotic episodes that last at least one month but less than six months • Shares anatomical and neural deficits of schizophrenia

19. Brief Psychotic Disorder and Schizophreniform Disorder (cont’d.) • Neither require impairment in social or occupational functioning • Diagnoses are often considered provisional diagnoses • Initial diagnoses based on currently available information

20. Brief Psychotic Disorder and Schizophreniform Disorder (cont’d.)

21. Delusional Disorder • Persistent, nonbizarre delusions without other odd behaviors • Common themes: • Erotomania • Grandiosity • Jealousy • Persecution • Somatic complaints

22. Schizoaffective Disorder • Existence of both symptoms of schizophrenia and major depressive or manic symptoms • Diagnosis is difficult as individual may have two separate mental disorders • Prognosis appears to be better than for schizophrenia but somewhat worse than with bipolar or depressive disorders. • Relatively rare, occurring in only 0.32 percent of the population.

23. Attenuated Psychosis Syndrome • “Milder” forms of delusions, hallucinations, or disorganized speech • Subject of much debate • Does it warrant a psychiatric diagnosis? • Reality-testing must be intact • Symptoms must be distressing or disabling and worsen in the last year • Symptoms of attenuated psychosis syndrome occurring in childhood and adolescence increase risk for psychiatric impairment in adulthood

24. Psychotic Disorder Not Elsewhere Classified • Psychotic symptoms that are not significant enough to meet criteria for specific psychotic disorder • Postpartum psychosis without a mood component • Persistent auditory hallucination without other symptoms • Nonbizarre hallucinations with mood symptoms • Psychotic symptoms of unknown etiology

25. The Course of Schizophrenia • Prodromal phase: • Onset and buildup of symptoms: • Social withdrawal and isolation • Peculiar behavior and inappropriate affect • Poor communication patterns • Neglect of personal grooming • Active phase: • Full-blown symptoms: • Severe disturbances in thinking • Deterioration in social relationships • Restricted or inappropriate affect

26. The Course of Schizophrenia (cont’d.) • Residual phase: • Symptoms no longer prominent • Symptom severity declines and individual shows mild impairment • Complete recovery is rare, but schizophrenics can lead productive lives

27. The Course of Schizophrenia (cont’d.) Figure 11-3 Varying Outcomes with Schizophrenia This figure shows five of the many outcomes possible with schizophrenia in individuals during a 15-year follow-up study. Source: Wiersma et al., 1998.

28. Long-Term Outcome Studies • Studies • 10 year study: majority improved over time; minority deteriorated • 15 year study: 40% showed periods of recovery; sizable minority were not on medication • Factors associated with positive outcome: • Gender, higher levels of education, being married, fewer negative symptoms, history of good work performance, ability to live independently, less depression and aggression, and peer support

29. Etiology of Schizophrenia Figure 11-4 Multipath Model of Schizophrenia The dimensions interact with one another and combine in different ways to result in schizophrenia.

30. Etiology of Schizophrenia (cont’d.) • Integration of heredity, psychological characteristics, cognitive processes, and social adversities • Underlying biological vulnerability combined with other risk characteristics can result in development of prodromal symptoms of schizophrenia

31. Etiology of Schizophrenia (cont’d.) Figure 11-5 Interactive Variables and the Onset of Clinical Psychosis This model shows how psychological and social factors may interact with genetic vulnerability to result in psychosis. Source: Doinguez et.al., (2010)

32. Biological Dimension • Genetics and heredity play important role • Disorder is understood to result from as many as 20 genes and their interactions • Schizophrenia is found among close relatives of people diagnosed with disorder • 16% chance for close relatives (e.g. mother/son) • 4% chance for distant relatives (e.g. aunt/niece) • 1% for general population • Risk of psychosis is increased by 40 percent in marijuana users.

33. Biological Dimension (cont’d.) Figure 11-6 Risk of Schizophrenia Among Blood Relatives of Individuals Diagnosed with Schizophrenia This figure reflects the estimate of the lifetime risk of developing schizophrenia- a risk that is strongly correlated with the degree of genetic influence. Source: Data from Gottesman (1978, 1991).

34. Biological Dimension (cont’d.) • Shift in research from demonstrating involvement of heredity to identifying genes involved • Endophenotypes: • Characteristics that are measurable and heritable • Working memory • Executive function • Sustained attention • Verbal memory

35. Biological Dimension (cont’d.) • Neurostructures: • Schizophrenics have smaller cortical volumes and ventricular enlargement • Ventricular enlargement is also present in healthy siblings of individuals with schizophrenia • Loss of brain cells in cortex over six-year period • Differences in brain structure between individuals with and without schizophrenia is relatively small • Abnormalities may result from antipsychotic medication

36. Biological Dimension (cont’d.) • Neurotransmitters: • Dopamine hypothesis: • Schizophrenia results from excess dopamine activity at certain synaptic sites • Support from research with three drugs: • Phenothiazines: block dopamine receptor sites • L-dopa: sometimes produces schizophrenic-like symptoms • Amphetamines: symptoms similar to acute paranoid schizophrenia in non-schizophrenics

37. Biological Dimension (cont’d.) • Concordance rate: • Likelihood that both members of a twin pair will show same characteristics • Less than 50% when one identical twin has disorder, so non-shared environmental influences (physical, psychological, social) must also play role • Prenatal and Perinatal trauma • prenatal infections, obstetric complications, and head trauma associated with schizophrenic • Adults with schizophrenia more likely to have had developmental delays

38. Psychological Dimension • Use of cocaine, amphetamines, alcohol, and especially cannabis increase chances of developing psychotic disorder • Cognitive patterns and unusual beliefs preceding onset of psychotic symptoms • Some researchers believe that it is the interpretation of events that causes distress and disability, rather than experience itself

39. Psychological Dimension (cont’d.)

40. Social Dimension • Family influence is controversial • Certain social conditions have influence: • Severe physical abuse from mothers prior to 12 years of age • Positive remarks and warmth expressed by caregivers improved symptoms • Maltreatment by adult or bullying • High-risk children are more sensitive to effects of adverse and healthy child-rearing practices

41. Social Dimension (cont’d.) Figure 11-7 Risk of Psychotic Symptoms at Age 11 Associated With Cumulative Childhood Trauma Youth exposed to both bullying and childhood maltreatment demonstrate a significantly increased risk of developing psychotic symptoms Source: Arsenault et al. (2011)

42. Social Dimension (cont’d.) • Expressed emotion (EE): • Negative communication pattern found among some relatives of individuals with schizophrenia; associated with higher relapse rates • Interpretations of findings: • High-EE environment may lead directly to relapse • Severely ill individual may cause high-EE patterns • Bidirectional model: • Individual’s behaviors or symptoms may cause family members to attempt to exert control and react to symptoms with frustration, producing more symptoms

43. Social Dimension (cont’d.) Figure 11-8 Possible Relationships Between High Rates of Expressed Emotion and Relapse Rates in Patients with Schizophrenia This figure shows several ways in which expressed emotions and relapse rates can be related.

44. Sociocultural Dimension • Age differences found: • Occurs earlier in men than women, then ratio shifts in mid-forties to fifties from more women than men diagnosed • Later onset of women is possibly due to protective effects of estrogen, which diminish after menopause • Estrogen replacement therapy has improved cognitive functioning among women with schizophrenia.

45. Sociocultural Dimension (cont’d.) • Other social risk factors: • Lower educational level of parents • Lower occupational status of fathers • Living in poorer residential areas at birth • Migration among 1st and 2nd generation immigrants to U.K. • Culture affects the way disorder is viewed • Indigenous belief systems influence views of etiology and treatment

46. Treatment of Schizophrenia • Antipsychotic medication: • Can reduce intensity of symptoms • Dosage levels must be monitored • Can produce side effects • Reduce severity of positive symptoms of schizophrenia (e.g., hallucinations and delusions) • Offer little relief for negative symptoms (e.g., social withdrawal, apathy, impaired personal hygiene)

47. Treatment of Schizophrenia (cont’d.) • Antipsychotic medication: • Older drugs performed as well as newer ones, but cost significantly less • Questions regarding effectiveness and side effects of newer drugs when compared to older drugs • High rates of discontinuation due to intolerable side effects or failure to control symptoms • Extrapyramidal symptoms were not seen more frequently with older drugs than with newer ones

48. Treatment of Schizophrenia (cont’d.) • Antipsychotic medication: • Extrapyramidal side effects include: • Parkinsonism (muscle tremors, shakiness) • Dystonia (slow, involuntary movement) • Akathesis (motor restlessness) • Neuroleptic malignant syndrome (muscle rigidity and autonomic instability; fatal if untreated) • Metabolic syndrome: • Medical condition associated with obesity, diabetes, high cholesterol, and hypertension

49. Treatment of Schizophrenia (cont’d.) • Psychosocial therapy: • Most beneficial is combination of antipsychotic medication and psychotherapy • Tailored to address: • Social communication • Deficits in emotional perception and in understanding beliefs and attitudes of others • Difficulties with employment • Lack of social networks

50. Treatment of Schizophrenia (cont’d.) • Cognitive-behavioral therapy: • Teaching coping skills to: • Manage positive and negative symptoms • Address cognitive deficits • Show improvements in normal functioning • Mindfulness training: • Accept symptoms in nonjudgmental manner • Enhances feelings of self-control, reducing negative symptoms