Exam 3: Schizophrenia

Positive Symptoms: Presence ✅

• Alarm person experiencing them (hallucinations, delusions, disorganized thinking/behavior)

• Psychotic symptoms aren’t "positive" (something being good/useful) Factor or behavior is present that’s not normally expected; normal type of behavior experienced in its most extreme form (hearing voices, holding false beliefs)

• Symptoms divided into 2 groups: psychotic OR disorganized

Negative Symptoms: Absence ❌

Often greater impact on functioning of the person (flat affect, social withdrawal, difficulty initiating)

• Absence of typical behaviors or thoughts/feelings that are ordinarily present in persons w/ no mental illness

• Alogia: Reduced fluency of speech 💬

• Flat affect: Reduced emotional expression 😐

• Avolition: Loss of initiation & goal-directed behavior 🙂‍↔📅

• Anhedonia: Difficulty experiencing pleasure/enjoyment ☹

• Attentional impairment: Difficulties concentrating/screening out irrelevant information 😣

• More difficult to identify since they aren’t as overt as positive symptoms. Preference for being alone or isolated from others. Emotional “blunting” (individual displays minimal or severely decreased emotional response to issues in daily life).

• More poor quality of life, functional ability, and burden on others than positive symptoms.

• People w/ greater negative symptoms often have a history of poor adjustment before the onset of illness; response to medication is often limited.

4 Schizophrenia Symptom Clusters: Psychotic, disorganized (Positive); negative, affective

• If someone experiences a symptom in 1 of the clusters, they’re more likely to have other symptoms from that same cluster

• Not sub-types because they aren’t mutually exclusive; clients can express symptoms in multiple clusters!

Schizophrenia in TAY

• Symptoms may develop slowly, go unnoticed at first

• Substance use disorder & family hx of psychosis = risk factors

• Heavy cannabis use associated with earlier onset, greater severity

• *Onset often in late teens or early 20s 

  • Peak onset for men is 25 years old, women is 27 years old 

DSM-5 Diagnostic criteria: Person must present w/ at least 2 of the following (one of which must be delusions, hallucinations, or disorganized speech):

• Hallucinations, delusions, and/or disorganized speech

• Grossly disorganized/catatonic behavior

• Negative symptoms: flat affect, anhedonia, alogia, avolition, attentional impairment

• More components

  • Social/occupational dysfunction

  • Duration = 6+ months

  • Schizoaffective & mood disorder exclusions

  • Substance/general medical condition exclusion

  • Relationship to pervasive developmental disorder 

Diagnosis Specifiers: First episode, currently in acute episode

• 1st manifestation of the disorder meeting the defining diagnostic symptom and time criteria

• An acute episode is a time period in which the symptom criteria are fulfilled

Diagnosis Specifiers: First episode, currently in partial remission

• Partial remission is a period of time during which an improvement after a previous episode is maintained

• and in which the defining criteria of the disorder are only partially fulfilled

Diagnosis Specifiers: First episode, currently in full remission

Full remission = period of time after a previous episode during which no disorder-specific symptoms are present.

Diagnosis Specifiers: Multiple episodes, currently in acute episode

Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).

Diagnosis Specifiers: Multiple episodes, currently in…

• partial or full remission

• Or in general can be unspecified (no multiple/first/cont episodes)

Diagnosis Specifiers: Continuous

Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course.

Other Things to Consider (Diagnosis Specifiers)

• Lack of insight

• Sleep deprivation

• More prone to heart disease, obesity, diabetes, oral disease, smoking

• Likely to experience poverty and stigma

• Be aware of self-stigma

• Suicidal ideation & successful attempts:

  • 4 in 10 people attempt suicide

  • 1 in 10 people are successful

• Cultural considerations: Bizarreness of delusions difficult to define across cultures; different behaviors, spiritual beliefs (talk in tongues) may be considered disorganized/delusional to 1 culture but acceptable in another

Delusion symptoms: Fixed false beliefs not open to change even when evidence contradicts them (distortions in thought)

• Grandeur

• Guilt

• Ill health

• Jealousy

• Persecution

• Reference

• Thought Control

Hallucination symptoms: Hearing, seeing, or feeling things that are not there

• Auditory = most common

• Visual

• Gustatory

• Tactile

• Olfactory

• Involuntary sensory experiences not related to external stimuli (distortions in perception)

Affective symptoms ☹:)

• Manic: elevated mood, excitement, euphoria

• Depressive: dysphoric mood characterized by sadness

Disorganized symptoms: Disorganized speech

Difficult to understand, jumps between topics, magical thinking, difficulties with abstraction

• Make loose associations

• Mental associations governed by rhymes, puns, babble

• Impaired to the point that interferes with communication

• “He tells me something in one morning and out the other”

• Circumstantial and tangential

• EX: not making sense, using nonsense words and/or skipping from one topic to another.

Disorganized symptoms: Disorganized, bizarre behavior

Behavior that is bizarre, exaggerated, emotive, or socially unacceptable – usually not goal directed

• Disheveled and dirty appearance

• Removing clothes in public

• Wild gestures

• Disorganized motor behavior: pacing, walking in circles,

• Catatonia: abnormalities in movement, behavior, and speech, where an individual may appear frozen, rigid, or exhibit purposeless motor activity

Disorganized symptoms: Inappropriate affect

Inconsistent w/ context or speech, giggling without a reason

Disorganized symptoms: Cognitive components 🧠

• Poor executive functioning: inability to understand information & use it to make decisions

• Trouble focusing/paying attention

• Problems with working memory: inability to use information immediately after learning it

Prodromal Phase (Early Stage)

time during which early intervention services are vital; if identified in the prodromal phase, case might be more effective due to early phase

• Period of gradual decline in functioning occurring prior to the first acute psychotic episode

  • Decreased interest in social activities, work, school

  • More bizarre behavior

  • Deteriorating hygiene 

Active Phase (Acute Stage): second phase, characterized by severe, noticeable symptoms of psychosis, often promoting a diagnosis 

• Signs: Hallucinations (seeing/hearing things not there), delusions (false, firm beliefs), disorganized speech or behavior, and extreme paranoia.

• Action: Requires immediate medical attention to manage symptoms

Residual Phase: Last Phase

• Signs: Mild, lingering hallucinations or delusions, diminished emotional expression, cognitive difficulties (difficulty concentrating), and persistent social withdrawal.

• Management: Continued treatment is crucial to prevent a return to the active phase

Antipsychotic Medications

• Since the mid-1950s. Earlier meds mostly effective for controlling delusions and hallucinations, but with many side effects; referred to as “typical” or first-generation psychotics

  • Thorazine, Haldol, Prolixine, Stelazine, Mellaril 

• Newer “atypical antipsychotics” (2nd generation) introduced in 1990: fewer side effects than older drugs

  • Clozapine, risperidone, olanzapine

• Antipsychotic or neuroleptic medications change the balance of chemicals in the brain and can help control the symptoms of the illness. These medications are effective, but they can have side effects. However, many of these side effects can be addressed, and should not prevent people from seeking treatment for this serious condition. Common side effects from antipsychotics may include: Sleepiness (sedation), weight gain, Other side effects include:

  • Feelings of restlessness or "jitters” Problems of movement and gait Muscle contractions. Long-term risks include a movement disorder called tardive dyskinesia, in which people move without meaning to. Newer drugs known as atypical antipsychotics appear to have fewer side effects. They also appear to help people who have not improved with the older medications. Treatment with medications is usually needed to prevent symptoms from coming back.

General Antipsychotic Med Side Effects

Dry mouth, constipation, sedation, blurred vision, drowsiness/dizziness, sexual dysfunction, tremors, tardive dyskinesia

First-Generation Medication Side Effects: MANY!

• Anticholinergic side effects: blurred vision, constipation, urinary retention, dry mouth, light headedness, increased heart rate & confusion, impaired concentration, attention deficit, memory impairment. Can also lead to increased risk of falls for older adults 

  • Low potency agents (chlorpromazine, thioridazine) = High anticholinergic effects = High AC ❄

• Extrapyramidal side effects (EPSE)

  • Dystonia: involuntary sustained contraction of a skeletal muscle

  • Parkinsonism: tremors, pill rolling

  • Akathasia: constantly fidgety, pacing, restless

  • Tardive dyskinesia: Neurological syndrome caused by long-term use of antipsychotics

    • Repetitive, involuntary purposeless movements (grimacing, tongue protrusion, lip smacking). Rapid movements of arms, legs, trunk; involuntary movements of fingers

• Low EPSE (extrapyramidal side effects) = movement disorders like tardive dyskinesia & tremors

• High potency agents (Haldol): high EPSE & low anticholinergic effects

• HIGH POTENCY agents  = ↑ EPSE, ↓ AC

• LOW POTENCY agents  = ↓ EPSE, ↑ AC

Medication Side Effects: Atypical Antipsychotics

• Agranulocytosis: significant reduction in WBC leads to susceptibility to infection/death

• Considerable weight gain

• Diabetes due to risk of metabolic syndrome (abnormal glucose and lipid metabolism) 

Causes of schizophrenia - Genetic Theories

Based on strong evidence that supports schizophrenia is influenced by genetic factors 🧬

• Familial risks of developing schizophrenia: 41-65% for monozygotic twins

• Seen as a predisposing factor

• Likely caused by an interaction of genes rather than one specific gene

Causes of schizophrenia - Neurodevelopmental Theories

• Perinatal complications: Oxygen deprivation. Maternal viral infection

• Developmental: assumed to occur during adolescence

  • Abnormal brain maturation: enlargement of cerebral ventricles & decrease in cortical grey matter

  • Hypofrontality: reduced cerebral blood flow/metabolism in frontal lobe

Causes of schizophrenia - Dopamine Hypothesis

schizophrenia = overreactivity of dopamine transmission in brain

• Accidental finding that phenothiazine drugs, which block dopamine function, could reduce psychotic symptoms. Actions of amphetamines (stimulant drugs): increases dopamine activity in healthy individuals & causes symptoms mimicking paranoid schizophrenia

• Now thought to be simplistic, partly because newer antipsychotic meds (atypical antipsychotics) can be just as effective as older meds (typical antipsychotics), but also affects serotonin function & may have slightly less of a dopamine blocking effect.

Causes of schizophrenia - Diathesis Stress Theory

• exposure to stress necessary for individuals w/ biological predispositions to go on to express the condition

• Evidence suggests impaired stress tolerance or sensitivity to stress is associated w/ psychosis or worsening of symptoms

Causes of schizophrenia - Environmental Factors 🌎

• Minority status

• Urban environment

• Marijuana use 

Schizoaffective Disorder: Must meet criteria for Schizophrenia AND a mood disorder (major depressive or manic)

• Psychotic features & mood disturbances may occur at same time or appear on & off interchangeably

• A longitudinal illness that can't be diagnosed during the first episode

• Can impact all ADLs & IADLS

• Most people with this illness have periodic episodes, called relapses, when symptoms surface. While there is no cure, symptoms often can be controlled with proper treatment.

• Untreated, people with schizoaffective disorder may lead lonely lives and have trouble holding down a job or attending school. They may rely heavily on family or live in supported living environments, such as group homes.

Schizophrenia

• Chronic, severe, disabling brain disorder. Serious mental illness causing strange or unusual thinking, feelings, and behavior

• Treatable, but impacts many areas of function; presents in significantly different ways

• Typically a problem noted w/ dopamine receptors; medications can suppress these