Chapter 12

1. Chapter 12 Schizophrenia and Other Psychotic Disorders

2. Perspectives on Schizophrenia • Schizophrenia vs. psychosis • Psychosis is a state defined by a loss of contact with reality • Ability to perceive and respond to the environment is significantly disturbed; functioning is impaired • Symptoms may include hallucinations (false sensory perceptions) and/or delusions (false beliefs) • Schizophrenia is a specific type of psychosis • A formal DSM diagnosis

3. History of Schizophrenia and Psychosis • Historical background • Emil Kraepelin – used the term dementia praecox • Subtypes of schizophrenia – Catatonia, hebephrenia and paranoia • Eugen Bleuler – introduced the term “schizophrenia” • “Splitting of the mind”

4. The Clinical Picture of Schizophrenia • Schizophrenia produces many “clinical pictures” • The symptoms, triggers, course, and responsiveness to treatment vary greatly • Some clinicians have argued that schizophrenia is actually a group of distinct disorders that share common features

5. Schizophrenia: Positive Symptoms • Positive Symptoms • These “pathological excesses” are bizarre additions to a person’s behavior • Delusions – faulty interpretations of reality despite contradictory evidence • Persecution – others are trying to hurt them in some way • Reference – other people, television characters, or books are specifically talking to them • Influence – being controlled by external forces, such as the devil, aliens, or cosmic forces • Grandeur – convinced that they are powerful people who can save the world or have a special mission

6. Schizophrenia: Positive Symptoms • Positive Symptoms • Disorganized Speech (& Thinking) – external manifestation of a disorder in thought form • May include loose associations; neologisms; perseverations; and clang • *Your textbook refers to these symptoms separately as “disorganized” • Examples of Disorganized Speech (& Thinking) • Loose associations (or derailment) • Rapidly shift from one topic to another • “The problem is insects. My brother used to collect insects. He’s now a man 5 foot 10 inches. You know, 10 is my favorite number; I also like to dance, draw, and watch TV.” • Neologisms • Made-up words • “This desk is a cramstile”; “He’s an easterhorned head”

7. Schizophrenia: Positive Symptoms • Examples of Disorganized Speech (& Thinking) • Perseveration • Repeated words and statements • Clang • Rhyming to think or express self • How are you? “Well, hell, it’s well to tell” • How’s the weather? “So hot, you know it runs on a cot”

8. Schizophrenia: Positive Symptoms • Positive Symptoms • Hallucinations – a sensory experience that occurs in the absence of any external perceptual stimulus • Most common are auditory • Generally involve a running commentary and/or accusations • Spoken directly to or overheard by the hallucinator • Hallucinations can also include: visual, olfactory, tactile, gustatory • Heightened perceptions are also considered in this category • People may feel that their senses are being flooded by sights and sounds, making it impossible to attend to anything important

9. Schizophrenia: Positive Symptoms • Positive Symptoms • Psychomotor problems • Also know as disorganized and catatonic behavior • Includes impairment in areas of routine functioning; virtual absence of all movement and speech • e.g., awkward movements, repeated grimaces, and odd gestures • In extreme forms, these symptoms are collectively called catatonia • Includes stupor, rigidity, posturing, and excitement • Inappropriate affect • Emotions that are unsuited to the situation or inappropriate shifts in mood

10. Schizophrenia: Negative Symptoms • Negative Symptoms • These “pathological deficits” are characteristics that are lacking in an individual • Poverty of speech (Alogia) • Long lapses before responding to questions, or failure to answer • Reduction of quantity of speech • Slow speech • Avolition (apathy) motivation or directedness) • Feeling drained of energy; no initiation/interest in normal goals • Inability to start or follow through on a course of action; no persistence • Anhedonia – lack of pleasure, or indifference

11. Schizophrenia: Negative Symptoms • Negative Symptoms • Blunted and flat affect • Avoidance of eye contact • Immobile, expressionless face • Lack of expressed emotion; including when discussing emotional material • Apathetic and uninterested • Monotonous voice, low and difficult to hear • Social withdrawal • Withdrawal from social environment (and attend only to their own ideas and fantasies) • Seems to lead to a breakdown of social skills, including the ability to accurately recognize other people’s needs and emotions

12. Diagnosing Schizophrenia • Including the above 4 positive symptoms (not inappropriate affect) and the negative symptoms (total of 5), if an individual has any two of the five symptoms for a significant portion of time for a 1-month period they may be diagnosed with schizophrenia • Overall disturbance lasts for at least 6 months

13. Diagnosing Schizophrenia • Subtypes of schizophrenia include: • Paranoid type • Preoccupation with delusions and/or frequent hallucinations • No evidence of marked disorganized speech, disorganized or catatonic behavior, flat or inappropriate affect • Best prognosis of all types • Disorganized type • Disorganized speech • Disorganized behavior • Flat or inappropriate affect • May have delusions or hallucinations • No evidence of catatonic schizophrenia • Develops early, tends to be chronic, lacks remissions

14. Diagnosing Schizophrenia • Subtypes of schizophrenia include: • Catatonic type • Dominated by at least two of the following: • Immobile body or stupor • Excessive motor activity that is purposeless and unrelated to outside stimuli • Extreme negativism (resistance to being moved, or to follow instructions) or mutism • Assumption of bizarre postures, or stereotyped movements or mannerisms • Echolalia (mimic the phrases of others) or echopraxia (imitate the actions of others) • Tends to be severe and rare

15. Diagnosing Schizophrenia • Subtypes of schizophrenia include: • Undifferentiated type • “Wastebasket” category • Symptoms of schizophrenia that do not meet criteria for the Paranoid, Disorganized, or Catatonic types • Residual type • At least one past episode of schizophrenia (currently moving towards remission) • Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior • Continued evidence of schizophrenia (e.g., negative symptoms), or mild psychotic symptoms (e.g., odd beliefs, unusual perceptual experiences) – i.e., “residual” symptoms

16. Other Psychotic Disorders • Schizophreniform Disorder • Symptoms of Schizophrenia that lasts at least 1 month but less than 6 months • Associated with good premorbid functioning • Schizoaffective Disorder • An illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode that co-occurs with symptoms of Schizophrenia • During the illness, there must be a period of at least 2 weeks where delusions and hallucinations have been present without mood symptoms • The mood symptoms are present for a substantial portion of the total illness time

17. Other Psychotic Disorders • Brief Psychotic Disorder • Presence of one or more of the following: delusions, hallucinations, disorganized speech or grossly disorganized or catatonic behavior • Usually precipitated by extreme stress or trauma • The episode lasts for at least 1 day but less than 1 month, with an eventual full return to normal functioning • A diagnosis of Mood Disorder with Psychotic Features, Schizoaffective Disorder, or Schizophrenia is ruled out • Tends to remit on its own • Shared Psychotic Disorder • A delusion develops in the context of a close relationship with another person who already has an established delusion • The delusion is similar in content to that of the person who already has the established delusion • Other Psychotic Disorders are ruled out

18. Other Psychotic Disorders • Delusional Disorder • Nonbizarre delusions (i.e., involving situations that could occur in real life such as being followed or being poisoned) that last for at least 1 month • No evidence of full-blown schizophrenia • Apart from the delusion, the person’s functioning is not markedly impaired; neither is behavior obviously odd or bizarre • Types of delusions include (see intro slide?) • Erotomanic • Grandiose • Jealous • Persecutory • Somatic • Extremely rare • Better prognosis than schizophrenia

19. What Is the Course of Schizophrenia? • Many sufferers experience three phases: • Prodromal – beginning of deterioration; mild symptoms • Active – symptoms become increasingly apparent • Residual – a return to prodromal levels • One-quarter of patients fully recover; three-quarters continue to have residual problems

20. What Is the Course of Schizophrenia?

21. What Is the Course of Schizophrenia? • Each phase of the disorder may last for days or years • A fuller recovery from the disorder is more likely in people: • With high premorbid functioning • Whose disorder was triggered by stress • With rapid onset • With later onset

22. Schizophrenia: Statistics • Onset and prevalence of schizophrenia worldwide • About 0.2% to 1.5% (or about 1% population) • Often develops in early adulthood • Can emerge at any time • Generally chronic • Most suffer with moderate-to-severe lifetime impairment • Life expectancy is slightly less than average • Increased risk of suicide and physical illness

23. Schizophrenia: Statistics • Schizophrenia affects males and females about equally • Females tend to have a better long-term prognosis • Onset differs between males and females • In men, symptoms begin earlier (aver age 21 in men, compared to 27 in women) and are typically more severe

24. Schizophrenia: Statistics - Age Distribution of Onset Males n=117 Females n=131 30 20 Percentage 10 0 12-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 Age group

25. Schizophrenia: Causes – Genetics • Family studies • Inherit a tendency for schizophrenia, not forms of schizophrenia • Risk increases with genetic relatedness

26. Schizophrenia: Causes – Genetics

27. Schizophrenia: Causes – Neurobiological Influences • The dopamine hypothesis • Drugs that increase dopamine (agonists) • Result in schizophrenic-like behavior • Drugs that decrease dopamine (antagonists) • Reduce schizophrenic-like behavior • Examples – neuroleptics, L-Dopa for Parkinson’s disease • Dopamine hypothesis is problematic and overly simplistic • Current theories – emphasize many neurotransmitters

28. Schizophrenia: Causes – Neurobiological Influences

29. Schizophrenia: Causes – Psychological and Social Influences • *The role of psychological factors exert only a minimal effect in producing schizophrenia • The role of stress • May activate underlying vulnerability • May also increase risk of relapse

30. Schizophrenia: Causes – Psychological and Social Influences • Family dysfunctioning • One of the best-known family theories of schizophrenia is the double-bind hypothesis: • Some parents repeatedly communicate pairs of mutually contradictory messages that place the child in so-called double-bind situations; the child cannot avoid displeasing the parents because nothing the child does is right • In theory, the symptoms of schizophrenia represent the child’s attempt to deal with the double binds

31. Schizophrenia: Causes – Psychological and Social Influences • Family dysfunctioning • Double-bind messages typically consist of a “primary” verbal communication and an accompanying contradictory nonverbal “metacommunication” • E.g., one person says, “I’m glad to see you,” but frowns and avoids eye contact • According to the double-bind theory, a child repeatedly exposed to these communications will adopt a special strategy for coping with them and may progress toward paranoid schizophrenia • This theory is closely related to the psychodynamic notion of a schizophrenogenic mother • It has been similarly unsupported by research, but is popular in clinical practice

32. Schizophrenia: Causes – Psychological and Social Influences • Family dysfunctioning • A number of studies suggest that schizophrenia is often linked to family stress: • Parents of people with the disorder often: • Display more conflict • Have greater difficulty communicating • Are more critical of and overinvolved with their children than other parents • Family theorists have long recognized that some families are high in “expressed emotion” – family members frequently express criticism and hostility and intrude on each other’s privacy • Individuals who are trying to recover from schizophrenia are almost four times more likely to relapse if they live with such a family

33. Schizophrenia: Causes – Psychological and Social Influences

34. Schizophrenia: Treatments - Medications • Medications appear to be the most effective approach in reducing schizophrenic symptoms • Antipsychotic drugs, particularly the conventional ones (i.e., first generation), reduce positive symptoms more effectively than negative symptoms • Many side effects, often producing movement problems • e.g., tardive dyskinesia • Newer drugs (i.e., second generation) are called “atypical” because their biological operation differs from that of conventional antipsychotics • Generally more effective, including negative symptoms • Few movement side effects • Do carry the risk of potential fatal drop in white blood cells

35. Schizophrenia: Treatments - Psychosocial • Psychosocial approaches: Overview and goals • Behavioral (i.e., token economies) on inpatient units • Community care programs • Social and living skills training • Includes: practical advice, problem solving, decision making, social skills training, medication management, employment counseling, financial assistance, housing • Behavioral family therapy • e.g., focus on psychoeducation, family stress, and expressed emotion • Vocational rehabilitation • Cultural considerations