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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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    1. 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

    2. 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.

    3. 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.

    4. In contemporary Diagnostic practices, criteria has become tighter. • Approximately 2 million people (1%) in US treated for schizophrenia. • No clear gender differences in rate. • Typically develops in adolescence or early adulthood. People disengage from society.

    5. 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.

    6. Briefer forms of Psychosis • 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.

    7. Cont. briefer • 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

    8. Features of Schizophrenia • Males have an earlier onset. • A poorer history of adjustment prior to onset, • more cognitive impairment, • more behavioral deficits and, • poorer response to medication.

    9. Disturbances in thought/speech • 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

    10. Control of thoughts • 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.

    11. Deficits in attention • 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

    12. Eye movement dysfunction may be genetic marker, but there are people with the EMD who are bipolar. • Event related potentials - Schizophrenics show greater early ERP components than normal > difficult with attention.

    13. Perceptual Disturbances • 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

    14. Emotional disturbances - flat affect • Other disturbances - loss of ego boundaries (fail to recognize themselves as unique individuals) • Motor behavior may be excited or slow (stupor)

    15. Types of Schizophrenia • 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.

    16. Cont. types of schizophrenia • Paranoid • preoccupied with one/more delusions or have frequent auditory hallucinations. Delusions involve themes of grandeur or persecution.

    17. Dimensions of Schizophrenia • Process-reactive dimension • Process schizophrenia - develops more slowly insidiously (less favorable recovery) • Reactive schizophrenia - follows a precipitating stressor (premorbid adjustment)

    18. Cont. Dimensions • 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.

    19. Cont. Dimensions • Type I and Type II • Type I • has an abrupt onset • symptoms such as hallucinations, delusions, and loose associations. • Favorable response to medication.

    20. Type II • Symptoms • Flat affect • social withdrawal and • poverty of speech • Poor prognosis

    21. Theoretical Perspectives • 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.

    22. Cont. Psychodynamic • 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.

    23. Learning • 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.

    24. Biological • 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

    25. Brain abnormalities • 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.

    26. Family theory • 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.

    27. Treatment • 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.

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

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

    30. Learning • 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.

    31. Cont. Learning • 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.

    32. Delusional Disorder • 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.