Abnormal Psych Final

schizophrenia is characterized by

- broad spectrum of cognitive and emotional dysfunctions including delusions and hallucinations, disorganized speech and behavior, and inappropriate emotions

Emil Kraepelin

* used term "dementia praecox" to describe schizophrenic syndrome
* early subtypes of schizophrenia: catatonia, hebephrenia, paranoia

catatonia definition

- alternating immobility and excited agitation

hebephrenia

silly and immature emotionality

Eugene Bleuler

* introduced the term "schizophrenia"
* Identified the different variants that were included within a spectrum

psychotic behavior

refers only to hallucinations or delusions or to unusual behavior (e.g., inappropriate emotionality, strange actions) accompanying them

positive symptoms

* positive signs of psychosis, excesses or distortions of normal function
* E.g., hallucinations and delusions

negative symptoms

* Negative symptoms: deficits or normal functions or absence of behavior that's typically apparent in most people
* E.g., avolition, alogia, social withdrawal

disorganized symptoms

* variety of erratic behaviors related to speech, motor behavior, and emotional reactions
* E.g., disorganized speech, inappropriate or flat affect, catatonia

positive symptom cluster includes

delusions and hallucinations

delusions are referred to as

basic feature of madness

delusions

gross misrepresentations of reality

most common delusions

* Delusions of grandeur
* Delusions of persecution

hallucinations

* experience of sensory events without environmental input
* can involve all senses (e.g., tasting something when not eating, having skin sensations when not being touched)

most common type of hallucination

auditory

what part of brain is most active during auditory hallucinations

Broca's area

Broca's area

involved in speech production (not comprehension)

spectrum of negative symptoms

* avolition (or apathy): lack of initiation and persistence
* alogia: relative absence of speech
* anhedonia: lack of pleasure, or indifference
* affective flattening: little expressed emotion

negative symptoms are ____ over time and ______ responsive to treatment

stable; less

what type of symptoms are associated with poor prognosis

negative symptoms

nature of disorganized speech

* cognitive slippage: illogical and incoherent speech
* tangentiality: going off on a tangent
* loose associations: conversation in unrelated directions

disorganized thought and speech include

* loosening of associations
* excessive concreteness
* neologisms
* word salad

disorganized affect

laughing/crying at inappropriate times

disorganized motor disturbances include

* stupor or motor immobility: waxy flexibility, cataplexy
* hyperactivity that has no apparent purpose and isn't influenced by external stimuli
* mutism or marked negativism
* peculiar behavior such as posturing
* echopraxia and echolalia

DSM-5 for catatonia specifier

* Clinical picture is dominated by 3+ of the following symptoms
* Stupor (i.e. no psychomotor activity; not actively relating to environment)
* Cataplexy (i.e., passive induction of a posture held against gravity)
* Waxy flexibility (i.e. slight, even resistance to positioning by examiner)
* Mutism (i.e., no, or very little verbal response \[exclude if known aphasia\])
* Negativism (i.e., opposition or no response to instructions or external stimuli)
* Posturing (i.e., spontaneous and active maintenance of a posture against gravity)
* Mannerism (i.e., odd, circumstantial caricature of normal actions)
* Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements)
* Agitation, not influenced by external stimuli
* Grimacing
* Echolalia (i.e., mimicking another's speech)
* Echopraxia (i.e., mimicking another's movements)

stupor

* no psychomotor activity
* not actively relating to environment

cataplexy

passive induction of a posture held against gravity

waxy flexibility

slight, even resistance to positioning by examiner

mutism

no, or very little verbal response

negativism

opposition or no response to instructions or external stimuli

posturing

spontaneous and active maintenance of a posture against gravity

mannerism

odd, circumstantial caricature of normal actions

stereotypy

repetitive, abnormally frequent, non-goal-directed movements

echolalia

mimicking another's speech

echopraxia

mimicking another's movements

subtypes of schizophrenia

* previously divided into subtypes based on content of psychosis
* included paranoid, catatonic, residual, disorganized, and undifferentiated

residual

minor symptoms persist after past episode

schizophreniform disorder

- psychotic symptoms lasting between 1-6 months (> 6 months = schizophrenia)

prognosis of schizophreniform disorder

* associated with good functioning
* most patients resume normal lives

lifetime prevalence of schizophreniform disorder

about 0.2%

DSM-5 for schizophreniform disorder

- 2 (or more) of following, each present for significant time during 1-month period (or less if successfully treated) At least one must be 1, 2, or 3o Delusionso Hallucinationso Disorganized speech (e.g., frequent derailment or incoherence)o Grossly disorganized or catatonic behavioro Negative symptoms (i.e., diminished emotional expression or avolition)- Episode of disorder lasts at least 1 month but less than 6 months. When diagnosis must be made without waiting for recovery, it should be qualified as provisional- Schizoaffective disorder and depressive or bipolar disorder with psychotic features ruled out because no major depressive or manic episodes have occurred with active-phase symptoms or if mood episodes have occurred during active-phase symptoms, they've been present for minority of total duration of active and residual period of illness- Disturbance not attributable to substance or other medical condition- Specify ifo With good prognostic features: requires presence of at least 2 of following features· Onset of prominent psychotic symptoms within 4 weeks of first noticeable change in behavior or functioning· Confusion or perplexity· Good premorbid social and occupational functioning· Absence of blunted or flat affecto Without good prognostic features: 2 or more of the above features haven't been presento With catatonia

schizoaffective disorder

* symptoms of schizophrenia and additional experiences of major mood episode
* psychotic symptoms must also occur outside mood disturbance

prognosis of schizoaffective disorder

* similar for people with schizophrenia
* people don't tend to get better on their own

DSM-5 for schizoaffective disorder

* Uninterrupted period of illness during which there's a major mood episode (major depressive or manic) with criterion A of schizophrenia
* Note: major depressive episode must include Criterion A1
* Delusions or hallucinations for 2 or more weeks in absence of major mood episode during lifetime duration of illness
* Symptoms that meet criteria for major mood episode are present for majority of total duration of active and residual portions of illness- Disturbance not attributable to substance or another medical condition
* Specify whether
* Bipolar type - if manic episode is part of presentation. Major depressive episodes may also occur
* Depressive type - only major depressive episodes are part of presentation
* Specify if
* With catatonia

key feature of delusional disorder

* delusions that are contrary to reality
* lack other positive and negative symptoms

types of delusions included in delusional disorder

* erotomanic
* grandiose
* jealous
* persecutory
* somatic

erotomanic delusions

- irrational belief that one is loved by another person, usually of higher status

jealous delusions

- believes sexual partner is unfaithful

somatic delusions

person feels afflicted by a physical defect or general medical condition

prognosis of delusional disorder

better than schizophrenia

DSM-5 for delusional disorder

* Presence of one (or more) delusions with duration of 1 month or longer
* Criterion A for schizophrenia hasn't been met
* Note: hallucinations, if present, aren't prominent and are related to delusional theme (e.g., sensation of being infested with insects associated with delusions of infestation)
* Apart from impact of delusion(s) or its ramifications, functioning isn't markedly impaired, and behavior isn't obviously bizarre or odd
* If manic/depressive episodes have occurred, have been brief relative to duration of delusional periods
* Disturbance isn't attributable to substance or other medical condition and isn't better explained by another disorder, such as body dysmorphia or OCD
* Specify whether
* Erotomanic type
* Grandiose type
* Jealous type
* Persecutory type
* Somatic type
* Mixed type - no delusional theme predominated
* Unspecified type - dominant delusional belief can't be determined or isn't described in specific types

delusional disorder prevalence

* very rare, affects 26-60 individuals per 100,000
* later onset, between ages 35-55
* somewhat more common in females (55% patients are female)

what are other causes of psychotic disorders

may occur as result of substance use, some medications, and some medical conditions

why is knowing causes of psychotic disorders important

* important for treatment
* address underlying cause

psychotic disorders due to other causes include

* substance/medication-induced psychotic disorder
* psychotic disorder associated with another medical condition

DSM-5 for substance/medication-induced psychotic disorder

- Presence of one or both of followingo Delusionso Hallucinations- There's evidence from history, physical exam, or lab findings of both 1 and 2o Symptoms in Criterion A developed during, or soon after substance intoxication or withdrawal or after exposure to a medicationo Involved substance/medication is capable of producing symptoms in Criterion A- Disturbance not better explained by psychotic disorder that's not substance/medication-induced. Evidence of independent psychotic disorder could include followingo Symptoms preceded onset of substance/medication useo Symptoms persist for substantial period (1 month) after cessation of acute withdrawal or severe intoxicationo Evidence of independent non-substance/medication-induced psychotic disorder- Disturbance doesn't occur exclusively during the course of a delirium- Disturbance causes significant distress or impairment- Note: this diagnosis should be made instead of diagnosis of substance intoxication or substance withdrawal only when symptoms in Criterion A predominate in clinical picture and when they're sufficiently severe to warrant attention

DSM-5 for psychotic disorder associated with another medical condition

* Prominent hallucinations or delusions
* Evidence from history, physical exam, lab findings that disturbance is direct pathophysiological consequence of another medical condition
* Disturbance not better explained by another disorder
* Disturbance doesn't occur exclusively during course of delirium

brief psychotic disorder

* positive symptoms or disorganized symptoms
* lasts less than 1 month
* briefest duration of all psychotic disorders
* typically precipitated by trauma or stress

DSM-5 for brief psychotic disorder

- Presence of 1+ symptoms. At least 1 must be 1, 2, or 3o Delusionso Hallucinationso Disorganized speecho Grossly disorganized or catatonic behavior- Note: don't include symptom if it's culturally sanctioned response- Duration of episode of disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning- Disturbance not better explained by major depressive or bipolar disorder with psychotic features, or another psychotic disorder, and isn't attributable to substance or another medical condition- Specify ifo With marked stressor(s) (brief reactive psychosis)· Symptoms occur in response to events that would be stressful to almost anyone in similar circumstances in individual's cultureo Without marked stressor(s)· Symptoms don't occur in response to events that would be stressful to almost anyone in similar circumstances in individual's cultureo With postpartum onset· If onset is during pregnancy or within 4 weeks postpartumo With catatonia

attenuated psychosis syndrome

* refers to individuals who are at high risk for developing schizophrenia or beginning to show signs of schizophrenia
* have good insight into own symptoms

discuss label for attenuated psychosis syndrome

- label designed to focus attention on individuals who could benefit from early intervention

prevalence of schizophrenia

- about 0.2-1.5% (or about 1% population)

onset of schizophrenia

* develops in early adulthood
* can emerge any time
* childhood cases are very rare but not unheard of

schizophrenia course

* chronic
* most suffer with moderate-to-severe lifetime impairment

life expectancy for schizophrenia

* slightly less than average
* increased risk for suicide
* increased risk for accidents
* self-care may be poorer

prodomal phase

* 85% experience
* 1-2 years before serious symptoms
* less severe, yet unusual symptoms: ideas of reference, magical thinking, illusions, isolation, impairment in functioning, lack of initiative, interests or energy

schizophrenia gender

* affects males/females equally
* females have better long-term prognosis
* onset earlier for males

cultural factors schizophrenia

- psychotic behaviors not always pathologized- schizophrenia is found at similar rates in all cultures

phases of schizophrena

* premorbid: mild motor, cognitive and social impairments
* prodromal: unusual, psychotic-like behaviors
* onset/deterioration: positive, negative, cognitive and mood symptoms
* chronic/residual: positive, negative, and cognitive symptoms

genetic causes of schizophrenia

* family studies
* twin studies
* adoption studies
* genetic markers
* behavioral markers

family studies of schizophrenia

* inherit tendency for schizophrenia, not specific forms of schizophrenia
* risk increases with genetic relatedness (e.g., having twin with schizophrenia incurs greater risk than having uncle with schizophrenia)

twin studies of schizophrenia

* monozygotic twins vs. fraternal (dizygotic) twins
* at greater risk if identical twin has schizophrenia
* supports role of genes

adoption studies of schizophrenia

* adoptee risk for developing schizophrenia remains high if biological parent has schizophrenia
* but risk I slower than for children raised by biological parent with schizophrenia (healthy environment is protective factor)

genetic markers for schizophrenia

* genetic markers: linkage and association studies
* endophenotypes
* schizophrenia likely to involve multiple genes

behavioral marker for schizophrenia

* behavioral marker (endophenotype): smooth-pursuit eye movement
* schizophrenia patients show reduced ability to track moving object with eyes
* relatives of schizophrenic patients also have deficits in this area

neurobiological causes of schizophrenia

* dopamine hypothesis
* structural and functional abnormalities in the brain
* viral infections during early prenatal development
* marijuana use

dopamine hypothesis

* schizophrenia is partially caused by overactive dopamine
* drugs that increase dopamine (agonists) result in schizophrenic-like behavior
* drugs that decrease dopamine (antagonists) reduce schizophrenic-like behavior (neuroleptics, L-Dopa for Parkinson's disease)

problem with dopamine hypothesis

* overly simplistic
* many neurotransmitters are likely involved

abnormalities in brain cause of schizophrenia

* enlarged ventricles and reduced tissue volume
* hypofrontality: less active frontal lobes (major dopamine pathway)

viral infections cause of schizophrenia

- findings are inconclusive

marijuana use and schizophrenia

- use increases risk for developing schizophrenia in at-risk individuals

psychological and social causes of schizophrenia

* stress
* family interactions

role of stress in schizophrenia

* may activate underlying vulnerability
* may increase risk of relapse

family interactions of schizophrenia

* unsupported theorieso schizophrenogenic mothero double bind communication
* high expressed emotion (EE) is associated with relapse

schizophrenogenic mother

mother whose cold, dominant and rejecting nature was thought to cause schizophrenia in her children

double bind communication

a communication style that produced conflicting messages which caused schizophrenia to develop

role of psychological factors in schizophrenia

* may function as diathesis in diathesis-stress model
* exert only minimal effect in producing schizophrenia

development of antipsychotic (neuroleptic) medications

* first line of treatment for schizophrenia
* most reduce/eliminate positive symptoms
* affect dopamine system, but also serotonergic and glutamate systems

what is common with first-generation medications

* acute and permanent side effects
* Parkinson's-like side effects
* tardive dyskinesia

why is compliance with medication a problem

* aversion to side effects
* financial cost
* poor relationship with doctors

psychosocial approaches for schizophrenia

* behavioral (I.e., token economies) on inpatient units
* community care programs
* social and living skills training
* behavioral family therapy
* vocational rehabilitation

token economies

reward adaptive behavior

illness management and recovery for schizophrenia

* engages patient as an active participant in care
* continuous goal setting and tracking
* modules include social skills training, stress management, substance use

cultural considerations for schizophrenia

* take into account cultural factors that influence individuals' understanding of their own illness (e.g., supernatural beliefs)
* involve family and community if possible

prevention of schizophrenia

* identify at-risk children (relatives of individuals with schizophrenia)
* foster supportive, stable environments
* offer additional treatment at prodromal stages, including social skills training

when are neurodevelopmental disorders first diagnosed

in infancy, childhood, or adolescence

list the neurodevelopmental disorders

* ADHD
* specific learning disorder
* autism spectrum disorder
* intellectual disability
* communication and motor disorders

normal vs. abnormal development

consider age and environment of child

developmental psychopathology

* study of how disorders arise and change
* disruption of early skills can affect later development
* caution: don't excessively pathologize childhood behavior that's part of normal development

central features of ADHD

* inattention
* overactivity
* impulsivity