Schizophrenia & Psychosis

Final Exam

Negative Personal impact of psychosis

• Fundamental breakdown in basic cognitive processes

  • Experience of reality is warped in either one’s senses or beliefs

• Highly debilitating: Low quality of life, job/school difficulties, impaired relationships, very hard for families

  • 10% of those with schizophrenia commit suicide

Symptoms of schizophrenia/psychosis

Positive Symptoms

• Hallucinations

  • Auditory, visual, olfactory, tactile

• Delusions

  • Paranoid, grandiose

  • Preoccupying

Negative symptoms

• Low Affect

• Diminished Emotional Expression

• Avolition

• Alogia

• Socially Withdrawn

Disorganization

• Tangentiality

• Loose associations

• Catatonic behavior

• Inappropriate affect

Difference between pos. & neg. symptoms

Positive → Added experiences

Negative → Loss or reduction of normal functions

Positive symptoms

Presense of PSYCHOSIS

• False sensory experiences and beliefs

Hallucinations

• Visual, olfactory, auditory, tactile

Delusions

• Paranoid, Grandiose

• Preoccupying

Hallucinations

False sensory experiences unrelated to or highly distorting reality

• Auditory: hearing voices, whispers, noises that aren’t truly there

  • Voices often make commans or harshly criticize client

  • Voices may talk with, argue with, or contraict one another

• Visual: Faces chanigng shape or expression, family members, religious figures, animals, etc

• Olfactory: Highly unpleasant, non-existent odors

• Tactile: Bugs craling on skin, burning, pain

Delusions

Highly unlikely beliefs that are strongly-held and resistant to change

• Often absurd to most people

• Typically paranoid and not shared by anyone else

• Clients often defend delusoins despite strong contradictory evidence

  • Clients are unable to take perspective of another person regarding the belief

• Often incoherenet, complex, bizarre, and hard to understand

Paranoid delusions

Beliefs expecting danger or harm to oneself

Grandiose

Beliefs that onself or others are highly special, powerful, or endowed with exceptional abilties

Preoccupying

Cannot stop thinking or talking about delusions

Negative symptoms

Absense of certain responses

• Reductions/defecits in motivation, social interaction, emotional responding

Low Affect — Responses/functions missing from or reduced in the person

Alogia — impoverished thinking, having nothing to say, reduction in speech

Avolition — decrease in will and motivation

Diminished emotional expression/bunted affect

Flattened nonverbal display of emotional responses

• “Bunted Affect”

• Faces are expressionless and apathetic

• Monotone voice, no emotional inflection

  • Anhedonia

Anhedonia

Inability to experience pleasure from activities and hobbies that were once enjoyable

Avolition

Lack of will/motivation

• Apathy, indecisiveness, ambivalence, and loss of will power

Alogia

Reductions in speech from “impoverished thinking”

• Having nothing to say

• Thoughts may come to a halt before they’re completed

Social withdrawal

Isolation often devlopes before positive symptoms

• May withdraw to lessen stimulation (stim. increases pos. symptoms)

Not showering and not taking care of oneself

Disorganizations symptoms

Verbal communication problems and odd behaviors

Think in disconnected, loosely-associated ideas

• Disorganized speech

• Tangentiality

• Loose associatons

• Unusual motor behaviors

  • Catatonic behavior

  • Inappropriate affect

Disorganized speech (“word salad”)

Statements that don’t make sense to others

Tangentiality

Irrelevant responses to questions

Loose associations

Bizarre, abrupt shifts in topic

Perseveration

The repetition of actions or thoughts despite feedback that it’s incorrect

Perserving insight/feelings/personality in spite of the disorder

Abnormal motor behaviors

Rigid posturing, repetitious hand movements, pacing, facial ticks

Catatonic behavior

Immobility and fixed posturing

• Suporous state — Reduce responsiveness to stimuli

  • Are still aware of their surroundings

Stuporous state

Reduce responsiveness to stimuli

• Are still aware of their surroundings

Inappropriate affect

Emotional reactions are inconsistent with the situation

Diagnoses of psychotic disorders

Two ore more of the following symptoms for at least 1 month:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized/catatonic behavior

5. Negative symptoms

• Level of functioning is significantly lower than before onset

• Continuous signs of disturbance last for at least 6 months

Schizophrenia

Severe mental disorder characterized by a break in reality (psychosis), involving symptoms like hallucinations, delusions, disorganized thinking/speech, and diminished emotional expression or motivation.

Delusional disorder

Preoccupied with delusions that are not especially bizarre for at least one month

• DO NOT meet criteria for schizophrenia

  • Cannot have hallucinations, disorganized speech, catatonic behavior, or negative symptoms

• Social/occupational functioning is only impaired in areas directly affected by the delusional belief

Brief psychotic disorder

Exhibit psychotic symptoms for at least one day, but no more than one month

• Hallucinations, delusions, disorganized speech, or disorganized behavior

Accompanied by confusion and emotional turmoil

• Often followed a very stressful event

• After psychotic episode, experience turns to normal

Schizoaffective disorder

Combination of a mood disorder & schizophrenia

1. Uninterrupted period pf psychosis during which there is a major mood episode at the same tme

2. Must have delusions or hallucinations for 2+ weels in the absence of mood episode at some poiint across lifetime duration of illness

3. Symptoms meeting criteria for a mood epsiode are present for majority of the period of psychosis

If delusions/hallucinations are present ONLY during a depressive or manic episode, it is NOT schizoaffective disorder

Age of schizophrenia onset

late teens, early adolescence (15-35)

Time course and outcomes of schizophrenia

Onsets in late adolescence or early adulthood (ages 15 - 35)

1. Prodromal phase

2. Active phase

3. Residual phase

Prodromal phase

Lowerting the role function, personality changes, odd behaviors, outbursts, restlessness, and unusual perceptual experiences

Active phase

Full psychotic symptoms (hallucination, delusions, word salad)

Residual phase

Positive symptoms lessen, negative symptoms may remain, similar to prodromal

Gender differences in schizophrenia

• Men are 30-40% more likely to deveop schizophrenia than women

• Avg age for men to exhibit symptoms is younger by 4-5 years

• Men are more likely to exhibit negative symptoms and follow a chronic, deteriorating course

Either schizophrenia is a single disorder that has varied expression in men and women, or that there are two subtypes of schizophrenia with an early onset that affects men more than women and another with a later onset that affects women more than men

Cross-cultural comparisons of schizophrenia (Textbook maybe?)

• Universal disorder

  • Frequency is not constant around the world

• Urban populations have higher rates than rural areas, but incidence is not related to a country’s economic status

Clinical and social outcomes were significantly better for schizophrenic patients in developing countries than in developed countires

• Greater tolerance and acceptance extended to people with psychotic symptoms in developing countries

Causes of schizophrenia (Biological)

Schizophrenia runs in families

• Heritability >0.8; identical twins have a concordance rate of 48% and fraternal twins have 17%

Causes of schizophrenia (Social)

Childhood trauma

Family issues

Poverty

Discrimination

Causes of schizophrenia (Psychological)

Early life trauma

• Abuse/neglect, bullying

Severe stress

• Job loss, Breakup

Social adversity

• Social isolation, dysfunctional family environment

Genetic contribution to schizophrenia

• Genetic vulnerability to schizophrenia may not be expressed as the full disorder, but rather as other types of psychoses or personality traits

  • Risk genes lead to issues along the schizophrenia spectrum

Inherited schizophrenia spectrum symptoms

Risk gnes lead to issues along the schizophrenia spectrum

Molecular genetics

Only a few genes that make a reliable, small-but-significant impact

• COMT Gene (Catechol O-methyltransferase)

COMT (Catechol O-methyltransferase)

Gene responsible for an enzyme involved in breaking down dopamine

• One form of this gene puts a person at a small increased risk for schizophrenia

Pregnancy and birth complications

Problems with pregnancy and birth are associated with later devlopement of schizophrenia

1. Severe maternal malnutrition early in pregnancy

2. Disease/infections in the mother prior to birth

3. Labor and delivery complications

• Extended labor, breech delivery, umbilical cord choking

Pregnancy and birth complications (Labor and delivery complications)

Birth recorns show mothers of later schizophrenia patients experienced more complications in labor and delivery such as

• Extended labor, breech delivery, umbilical cord choking

  • May reduce availability of oxygen to newborn’s brain

Neurobiology of schizophrenia

Schizophrenia affects many different regions of the brain, but generally with the disorder:

• Have lower total volume of brain tissue overall (smaller brain)

• Have enlarge ventricles

Decreased size of limbic system, a set of brain areas responsible for regulation of emotion and integration of thought and feeling

• Malfunctioning temporal lobes (perceiving and creating speech)

• Decreased frontal lobe activity

Ventricles

Fluid-filled cavities in the brain

• People with schizophrenia have enlarge ventricles

The dopamine hypothesis

Proposal that those with schizophrenia may have overactive or excessive dopamine activity in the limbic system

• Likely due to high number of post-sypnatic dopamine “D2” receptors

• Recent research suggests many aspects of schizophrenia cannot be attributable to only excess dopamine reactivity

Influence of social class

Highest prevalence of schizophrenia is in areas of lowest SES

• Those of lower socioeconomic status are exposed to more stress

  • Social Causation Hypothesis (Class → Schizophrenia)

  • Social Selection Hypothesis (Schizophrenia → Class)

Social causation hypothesis

Stress/events associated with low SES are a causal factor for schizophrenia

• Poor nutrition, higher stress, social isolation

Social selection hypothesis

Schizophrenia may lead a person to have lower SES by imparing education and job success, forcing them into lower social classes

Expressed Emotion (EE)

1. Repeatedly communicating hostility & criticism toward patient OR

2. Excessive expression of overprotection, worrying, & concern

Those who return home to relatives high in EE have a higher 9 month relapse rate

(Family interaction is not a cause of onset)

Vulnerability markers

Genetic and environmental intearctions

Cognitive issues

Neurophysiological anomalies

Brain structural changes

Behavioral/environmental factors

General principles of treatments of schizophrenia/psychosis

Treatment is generally long-term & intensive

• Psychotic episodes need to be treated and further episodes prevented

• Often requires provision of housing, community support, special job training, help w/ disability benefits, transportation

• Many different professionals must work together in such cases

Antipsychotic medication

Specifically reduce severity of psychosis (mostly positive symptoms)

• Requires 2-3 weeks of use to take effect on hallucinations/delusions

• Maintenance Medication

On antipsychotics, ~half of patients are very improved after 1 to 1.5 months, yet 25% do not improve

• Blocks post-sypnatic dopamine “D2” receptors

Maintenance medication

Medication that should be taken wven when psychosis is not active for prevention

Chlorpromazine (Thorazine)

Antipsychotic medication used to treat schizophrenia

Side effects of antipsychotics

Antipsychotics have strong side effects that generally effect motor behavior

Extrapyramidal symptoms (Short-term)

• Muscular rigidity, tremors, restless agitation to be moving (Akathisia), peculiar involuntary postures. Milder

Tardive dyskinesia (Long-term)

• More severe motor symptoms from prolonged antipsychotic use

• Spasmodic face and limb movements, jerking and writhing

• Irreversible in some patients

Assertive community treatment

Psychosocial interventions that is delivered by an interdisciplinary team of clinicians

• provides a combination of psychological treatments

  • education, support, skills training, and rehabilitation, as well as medication

• Effort to maintain seriously disordered patients in the community and to miniize the need for hospitalization

  • Go to the consumer instead of the consumer coming to them

  • Reduces the # of days a patient speds in the psychiatric hospital

• More cost effective

Insitutional Programs

Some patients are chronically disturbed and require long-term institutional treatment

• Social learning programs (token economics)

• Goal is to increase the frequency of desired behavior, such as appropriate grooming and participation in social activities, and to decrease the frequency of undesirable behaviors

  • Reinforced behaviors