PSYC 2284 - Chapter 14 Psychosis

Schizophrenia

Devasting psychotic disorder that may involve characteristic disturbances in thinking (delusions), perception (hallucinations), speech emotions, and behaviour. Characterized by a broad spectrum of cognitive and emotional dysfunctions.

• Complex syndrome that inevitably has devasting effect

• Can disrupt a person’s perception, thought, speech and movement

• Full recovery is rare

• Emotional and financial costs

• Majority of people with it in Canada are unemployed and living in poverty

• A number of behaviours or symptoms that aren’t necessarily shared by all the people who are given this diagnosis

• Often distorted in media implying that everyone with it is dangerous and violent, traits of anger and antisocial personality are better predictors of violence

Phonological Loop and Visual Spatial Sketchpad

Mental processes everyone has, the ability to talk to yourself or imagine something but still understand that it is in your head and not reality.

• For people with schizophrenia, they are unable to distinguish between reality and their imaginations

Catatonia

Disorder of movement involving immobility or excited agitation.

Hebephrenia

Silly and immature emotionality a characteristic of some types of schizophrenia

Paranoia

Person’s irrational beliefs that they are especially important (delusions of grandeur) or that other people are seeking to do them harm

Dementia Praecox

Latin term meaning “premature loss of mind” and early label for what is now called schizophrenia emphasizing the disorder’s frequent appearance during adolescence. Emil Kraepelins categorization.

Symptoms sharing similar underlying features:

• Catatonia

• Hebephrenia

• Paranoia

Even though manifestations may be different for each person, Kraepelin believed that an early onset at the heart of each disorder ultimately develops into “mental weakness”

Kraepelins Theories

Dementia praecox - an early age of onset and a poor outcome were characteristic, these patterns are not essential to manic depression (bipolar)

• He stereotyped behaviour

• Focus is on early onset and poor outcomes

Eugen Bleuler Theories

• Eugen Bleuler - introduced the term schizophrenia

• “Split mind” - Greek meaning of the word

• Believed that underlying all the unusual behaviours shown by people with this disorder was an associative splitting of the basic functions of personality

• Identified the different variants that were all included within the spectrum

Associative Splitting

Separation among basic functions of human personality (ex. cognition, emotion, perception) that is seen by some as the defining characteristic of schizophrenia

• Bleuler’s theories on Schizophrenia

• This concept emphasized the breaking of associative threads or the destruction of the forces that connect one function to the next

• Bleuler believed that difficulty keeping a consistent train of thought, characteristic of all persons with this disorder, led to many and diverse symptoms they displayed

• Focus on what Bleuler believed to be the universal underlying problem of splitting

Psychosis

Term used to characterize many unusual behaviours, although in its strictest sense it usually involves delusions and hallucinations. Schizophrenia often involves psychosis.

Schizophrenia Spectrum Disorder

Constitutes the group of diagnoses, DSM-5-TR includes schizophrenia and other related disorders.

Positive Symptoms of Schizophrenia

More overt symptoms such as delusions and hallucinations, displayed by some people with schizophrenia.

• Between 60 and 80 percent of people with schizophrenia experience hallucinations and 70 percent experience delusions

Delusion

Psychotic symptom involving disorder of thought content and presence of strong beliefs that are misrepresentations of reality.

• Delusion of grandeur - mistaken belief that the person is famous or powerful

• Delusions of persecution - others are out to get a person (can be most disturbing)

• Cotard’s syndrome - Person believes a part of their body has changed in some impossible way (Micro chip in them, taking extreme measures to help themselves)

• Capgras Syndrome - Person believes someone they know have been replaced by a double (Believe this with such conviction that it is incredibly difficult to change their ideas, multiple people replaced which makes it even harder for them to believe others)

Delusions may serve a purpose for people with schizophrenia who are otherwise quite upset by the changes taking place within themselves, serving as providing them with a sense of purpose and meaning in life (theory.)

Hallucinations

Psychotic symptom of a perceptual disturbance in which things are seen or heard or otherwise sensed although they are not real or actually present. Can involve any of the sense but auditory hallucinations are the most common form experienced

• People tend to experience hallucinations more frequently when they are unoccupied or restricted from sensory input

• A theory states that people who are hallucinating are not hearing the voices of others but are listening to their own thoughts or their own voices and cannot recognize the difference (cannot separate reality from their imagination)

• Another theory is that they arise from abnormal activation of the primary auditory cortex - associated with increased metabolic activity in the left primary auditory cortex and in the right middle temporal gyrus, as if they are actually hearing something

• These two mechanisms of misinterpretation of inner speech and abnormal activation may not be mutually exclusive

• Phonological loop activates in a different section - physiologically you are experiencing sound

Negative Symptoms of Schizophrenia

Less outgoing symptoms such as flat affect and poverty of speech, displayed by some people with schizophrenia. Indicates the absence or insufficiency of behaviour, including emotional and social withdrawal, apathy and poverty of thought or speech. Symptoms are usually chronic and last a lifetime.

Avolition

Apathy, or the inability to initiate or persist in important activities. People with this symptom show little interest in performing even the most basic daily functions including those associated with personal hygiene

• Associated with poor outcomes

• More extreme than in depression

Alogia

Deficiency in the amount or content of speech; a disturbance often seen in people with schizophrenia. They may respond to questions with very brief replies that have little content and may appear uninterested in the conversation. Such deficiency in communication is believed to reflect a negative thought disorder rather than inadequate communication skills.

• Sometimes takes the form of delayed comments or slow responses to questions

Anhedonia

Inability to experience pleasure associated with some schizophrenic and mood disorders. Presumed lack of pleasure experienced by some people with it. Signals an indifference to activities that would typically be considered pleasurable.

• Relates to a delay in seeking treatment for schizophrenia

Asociality

Lack of interest in or motivation for social interactions; a preference for solitary activities. Can be recognized as a separate symptom of schizophrenia spectrum disorders.

• Can also result from or be worsen by limited opportunities to interact with others, particularly for severely ill patients

• Patients with poor social or interpersonal functioning before the development of their psychosis also have greater levels of negative symptoms and greater social impairment at the time of their admission to a treatment program

• best predictor of this is chronic cognitive impairment suggesting that difficulties in processing information may contribute significantly to the social skills deficits and other social difficulties displayed by many patients

Flat Affect

Apparently emotionless demeanour (including toneless speech and vacant gaze) when a reaction would be expected. Do not show emotions when you would normally expect them to.

• May stare at you vacantly, speak in a flat an toneless manner and seem unaffected by things going on around them.

• Although they do not react openly to emotional situations, they may still be experiencing emotions - experiencing the appropriate emotion internally but not externally

• Flat or blunted affect

• May be a difficulty expressing emotion not a lack of feeling, may be less intense

Disorganized Symptoms of Schizophrenia

Least understood symptoms of schizophrenia that include erratic behaviours that affect speech, motor behaviour and emotional reactions.

• Exhibit curious behaviours such as hoarding objects or acting in unusual ways in public

Disorganized Speech

Style of talking often seen in people with schizophrenia that involves incoherence and a lack of typical logic patterns. People with schizophrenia often lack insight (awareness that they have a problem) and they experience associative splitting and cognitive slippage. Sometimes they jump from topic to topic and other times they talk illogically.

• Tangentiality - going off on a tangent instead of answering a specific question

• Loose association or derailment - Abruptly changed the topic of conversation to unrelated areas

• Very difficult to follow, don’t understand what they are saying or topic changes abruptly

Inappropriate Affect

Emotional displays that are improper for the situation. Laughing or crying at improper times, part of disorganized symptoms.

Catatonic Immobility

Disturbance of motor behaviour in which the person remains motionless, sometimes in an awkward posture, for extended periods of time. Motor dysfunctions that range from wild agitation to complete immobility.

• Separate schizophrenia spectrum disorder

• Active side some people pace excitedly or move their fingers or arms in stereotyped ways

• Other end of the extreme some people hold unusual postures as if they are fearful of something terrible happening if they move (Catatonic immobility) - Can also involve waxy flexibility or the tendency to keep their bodies and limbs in the position they are in until someone moves them

Diagnosing Schizophrenia

Requires two or more positive, negative or disorganized symptoms be present for at least 1 month with at least one of these symptoms including delusions, hallucinations or disorganized speech.

• Includes a dimensional assessment that rates the severity of the individuals symptoms on a 0-4 scale

• Two people can receive the same diagnosis but behave very differently, proper treatment depends on differentiating individuals in terms of their varying symptoms

• Don’t need to always experience negative symptoms or disorganized symptoms to be diagnosed - can even diagnose without hallucinations or delusions

Schizophreniform Disorder

Psychotic disorder involving the symptoms of schizophrenia but lasting less than 6 months. They can usually resume normal lives afterward if the psychosis episode does not continue.

• In between brief psychosis disorder and schizophrenia

• No mood episodes involved

Provisional Diagnosis

Can only diagnosis someone officially if they are out of the psychosis state, during their state they can only receive a provisional diagnosis so they can receive some form of treatment and attention.

• While a person is in active psychosis, they do not meet the criteria for any psychosis disorders, only when the person recovers from it

• Can diagnosis someone with provisional schizophreniform if it does not progress further into schizophrenia and they are still experiencing an episode

Prognostic Features

Predicts the likely course of the diagnosis

Good Prognosis Features - Predicts high likelihood of recovery or successful management of the disorder, if they are confused or have brief seconds of clarity, if the onset was rapid

Without Good Prognostic Features - Not an easy recovery or may not recover at all

Schizoaffective Disorder

Psychotic disorder featuring symptoms of both schizophrenia and major mood disorder

• Psychosis period features episodes of mood fluctuations like mania or depression

• Prognosis is similar to people with schizophrenia, individuals tend not to get better on their own and are likely to continue experiencing major life difficulties for many years

• There has to have been delusions or hallucinations for at least two weeks in the absence of prominent mood symptoms (mood is only a feature of the over all psychosis)

• Mood episodes come and go but the psychosis is consistent

• You can experience only 1 mood episode to be diagnosed but this has to be a depressive episode

• If you experience mood episodes with some psychosis this is a mood disorder not a psychosis disorder, psychosis comes and goes where the mood is more stable

• Stable psychosis with mood fluctuations - psychosis disorder

• Most serious disorder of all disorders

• Perpetual state of psychosis and experiencing manic and depressive episodes

Delusional Disorder

Psychotic disorder featuring a persistent belief contrary to reality (delusion) but no other symptoms of schizophrenia. Persistent delusion that is not the result of an organic factor such as brain seizures or of any severe psychosis.

• Tend not to have flat affect, anhedonia or other negative symptoms of schizophrenia

• They may become socially isolated because they are suspicious of others

• Delusions are often long-standing

• Not as extreme as in schizophrenia, imagined events could be happening but aren’t (In schizophrenia the imagined events are not always possible)

• Only includes delusions, no other real symptoms, functioning usually is normal otherwise

• May involve some hallucinations but they are related to the delusions

• Bizarre (impossible) vs. non bizarre (possible to happen in reality)

Delusional Subtypes

Erotomanic type - Someone’s mistaken belief that a higher-status and unsuspecting person is in love with them, often motivates the patient to engage in an unrelenting pursuit of the person in attempts to communicate with that person

Grandiose type - Conviction of having some great (but unrecognized) talent or insight or having made some important discovery

Jealous type - Delusions that their spouse or lover is unfaithful

Persecutory type - involves the individual’s belief that they are being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals

Somatic type - delusions that involves bodily functions or sensations

Mixed type - no one delusional theme predominates

Unspecified type - dominant delusional belief cannot be clearly determined or is not described in the specific types

Shared Psychotic Disorder (Folie a deux)

Psychotic disturbance in which an individual develops a delusion similar to that of a person with whom they share a close relationships.

• The content and nature of the delusion originate with the partner and can range from the relatively bizarre to the fairly ordinary

• Previous versions of the DSM included this, now it is under delusional symptoms in the context of a relationship with an individual with prominent delusions

• Onset is relatively late - 35 to 55 but because people can lead relatively ordinary lives they may not seek treatment until their symptoms become most disruptive

• Seems to afflict more females than males

• Research on families suggests that the characteristics of suspiciousness, jealousy, and secretiveness may occur more often among the relatives of people with delusional disorder than among the population (Some aspect of the disorder may be inherited)

Substance-Induced Psychotic Disorder

Psychosis caused by the ingestion of medications, psychoactive drugs or toxins

Psychotic Disorder Due to Another Medical Condition

Condition that is characterized by hallucinations or delusions and that is the direct result of another physiological disorder such as a stroke or brain tumour.

Brief Psychotic Disorder

Psychotic disturbance involving delusions, hallucinations or disorganized speech or behaviour but lasting less than 1 month; often occurs in reaction to a stressor.

• Requires a full return to pre psychosis self

• No negative symptoms because these symptoms are often chronic and last a life time

• Once you get past it you don’t usually fully return to your normal functioning

Attenuated Psychosis Syndrome

Disorder involving the onset of psychotic symptoms such as hallucinations and delusions which puts a person at high risk for schizophrenia.

• May have some symptoms but they are aware of the troubling nature of these symptoms

Prevalence

• Schizophrenia is generally chronic and most people with the disorder have a very difficult time functioning in society, especially true of their ability to relate to others; they tend not to establish or maintain significant relationships and therefore many people with schizophrenia never marry or have children

• The delusions of people with schizophrenia are likely to be outside the realm of possibility

• Even when people improve with treatment, many are likely to experience difficulties throughout their lives such as loneliness

• People with it tend to live 10 to 15 years less than average partly because of the higher rates of suicide and accidents among them, also due to the higher rates of obesity, smoking, angina and respiratory problems and health problems associated with medication to treat schizophrenia

• For men, the likelihood of onset diminishes with age but it can still first occur after the age of 75

• Frequency of onset for women is lower than for men until age 36 when the relative risk for onset switches with more women than men being affected later in life

• Women appear to have more favourable outcomes than do men

Development of Schizophrenia

More severe symptoms of schizophrenia first occur in late adolescence or early adulthood, but there are some signs of development in early childhood.

• Children who go on to develop it show early clinical features such as mild physical anomalies, poor motor coordination and mild cognitive and social problems - these could also be signs of other disorders which makes it challenging to differentiate

• Very rare for it to be diagnosed in childhood

• Age of onset is late 20s to early 30s

Prodromal Stage

Period during which some symptoms appear but before development of full symptoms. A one- to two-year period when less severe yet unusual behaviours start to show themselves but before serious symptoms occur. Can take 2 to 10 years for a person to fully develop schizophrenia.

• Includes ideas of reference, magical thinking, and illusions

• Other symptoms like isolation, marked impairment in functioning and a lack of initiative, interests or energy

• Once symptoms appear, it can take anywhere from two years to around 10 years before a person at high risk (mild positive symptoms, decline in functioning) meets the full criteria for a psychotic disorder

• Highest period of risk can be in the first 2 years for patients to develop a full-fledged psychotic disorder

• Risk factors for going from high risk to developing the disorder include the length of duration of symptoms before seeking help, baseline functioning and the presence of negative symptoms

• Hiding symptoms from others, personality factors and the amount and quality of social support may also play a role in the amount of time it takes a person to first seek treatment

Cultural Factors of Schizophrenia

Schizophrenia is universal, affecting all cultural groups studied so far

• The course and outcome of schizophrenia vary from culture to culture - These differences may be due to cultural variations or biological influences

• Outcomes are better in less wealthy countries and some have suggested the idea that the lack of access to pharmacological treatments may be the reason

• More Black people receive the diagnosis of schizophrenia than do white people - possibly due to the fact that people from ethnic minority groups may be victims of bias and stereotyping

Biological Contributions

Genes are responsible for making some individuals vulnerable to schizophrenia

• May inherit a general predisposition for schizophrenia that manifests in the same form or a different one from that of your parent

• The risk of having it varies according to how many genes an individual shares with someone who has the disorder

• De novo mutations - can occur as a result of a mutation in a germ cell of one of the parents or in the fertilized egg after conception, even twins can have very different prenatal and family experience and therefore be exposed to varying degrees of stress

• Gene-environment interaction with a good home environment reducing the risk of schizophrenia

• You can have genes that predispose you to schizophrenia, not show the disorder yourself but still pass on the genes to your children (can be the carrier for schizophrenia)

Gene-Environment Interactions

Combination of a particular genetic profile was particularly likely to develop schizophrenia in adulthood, but this was only true if these individuals had used cannabis as teenagers. Possibility that certain genes may act as vulnerability factors that interact with specific environmental pathogens at crucial developmental stages leading to the development of schizophrenia

Linkage and Search for Markers and Multiple Genes

• Genetic risk arises from many common genes each with a small effect that might be detected by genome-wide association studies

Markers

• Smooth-Pursuit Eye Movement (eye-tracking) - While keeping your head still you have to be able to track a moving pendulum with your eyes, the ability to track objects smoothly across the visual field is deficient in many people who have schizophrenia (Does not seem to be the result of drug treatment of institutionalization), also seems to be a problem in relatives

• Eye-tracking deficits appear to be associated with both negative and positive symptoms, more strongly associated with positive symptoms

Multiple Genes

• Involves more than one gene - quantitative trait loci, the schizophrenia we see most often is probably caused by several genes located at different sites throughout the chromosomes, this model would clarify why there can be different severity levels and why the risk increases with the number of affected relatives in the family

Influence of Dopamine

Neurotransmitters are released from the storage vessels (synaptic vesicles) at the end of the axon, cross the gap and are taken up by receptors in the dendrite of the next axon. Chemical messengers are transported in this way from neuron to neuron throughout the brain.

• Chemical messengers can be increased by agonistic agents or decreased by antagonistic agents

• Antagonistic effects slow down or stop messages from being transmitted by preventing the release of the neurotransmitter, blocking uptake at the level of the dendrite or causing leaks that reduce the amount of neurotransmitter ultimately released

• Agonistic effects assist with the transference of chemical messages and can produce too much neurotransmitter activity by increasing production or release of the neurotransmitter and by affecting more receptors at the dendrites

• Anti-psychotics point to the possibility that the dopamine system is too active

• Partially the result of excessive stimulation of striatal dopamine receptors (The striatum is part of the basal ganglia) - these cells control movement, balance and walking and they rely on dopamine to function

• Most effective antipsychotic drugs all share dopamine receptor antagonism (they help block the stimulation of the receptors)

• Deficiency in the stimulation of prefrontal receptors - although some dopamine sites may be overactive, a second type of dopamine site appears to be less active which may account for negative symptoms

• Lower prefrontal activity in people with schizophrenia is referred to as hypofrontality

• Alterations in prefrontal activity involving glutamate transmission - excitatory neurotransmitter that is found in all areas of the brain, drugs like PCP and ketamine can result in psychotic-like behaviour in people without schizophrenia and can exacerbate psychotic symptoms in those with schizophrenia - they are both antagonists which suggests that a deficit in glutamate or blocking of NMDA sites may be involved in some symptoms

Clues of Dopamine’s Role

1. Antipsychotic drugs (neuroleptics) that are often effective are dopamine antagonists, partially blocking the brains use of dopamine (Slowing down or stopping messages)

2. These drugs can produce negative side effects similar to those observed in Parkinson’s disease (Known to be due to insufficient dopamine)

3. The drug L-dopa (agonist used to treat people with Parkison’s disease) produces schizophrenia-like symptoms in some people

4. Amphetamines which also activate dopamine, can make psychotic symptoms worse in some people with schizophrenia

When drugs administered that are known to increase dopamine (agonists), schizophrenic symptoms increases, when drugs that are known to decrease dopamine activity (antagonists) are used, schizophrenic symptoms tend to diminish

Inconsistency in Dopamine Theory

1. A significant number of people with schizophrenia are not helped by the use of dopamine antagonists

2. Although the neuroleptics block the reception of dopamine quite quickly, the relevant symptoms subside only after several days or weeks, much more slowly than researchers would expect

3. These drugs are only partly helpful in reducing the negative symptoms of schizophrenia

Clozapine is one of the weakest dopamine antagonists, much less able to block the dopamine sites than other drugs but it is effective with people who are not helped with traditional neuroleptic medications.

The role of dopamine may be more complicated.

Brain Structure

• Children with a parent who has the disorder tend to show a subtle but observable neurological problems (atypical reflexes and inattentiveness)

• Size of ventricles - showing enlargement in some but not all brains in people with schizophrenia, unusually large lateral and third ventricles, indicates that’s either adjacent parts of the brain have not developed fully or have atrophied, not seen in everyone, observed more often in men than in women, seem to enlarge in proportion to age and to the duration of the schizophrenia

• Identical twins can experience different environments even before they are born - competing for nutrients, birth complications, obstetrical complications

• Less active in frontal lobe (hypofrontality), seems to be associated with the negative symptoms of schizophrenia

• Deficient activity in a specific region called the dorsolateral prefrontal cortex - less activity recorded here

• Dysfunction in regions like the prefrontal cortex, other related cortical regions and subcortical circuits including the thalamus and the stratum, occurring before the onset of schizophrenia, brain damage may develop progressively beginning before the symptoms are apparent

Viral Infections

Idea that schizophrenia is a recent phenomenon that may involve a newly introduced virus, evidence that a virus-like disease may account for some cases.

• Higher prevalence of schizophrenia among men living in urban areas implies that they are more likely to have been exposed to infectious agents than are their peers in less populated areas

• Some association with prenatal exposure to influenza

• Parasite Toxoplasma gondii is found in cats (in their feces, transmission by ingestion of oocysts from litter boxes) - parasite is able to affect brain function in utero

• If some interruption in the second trimester fetal development resulted in schizophrenia, it would also affect the fingertip dermal cells, ridge count may be a marker of prenatal brain damage

Influence of Stress

• Living in a large city is associated with an increased risk of developing schizophrenia - stress of urban living may precipitate its onset

• Healthy people who engage in combat during a war often display temporary symptoms that resemble those of schizophrenia

• People whose onset of schizophrenia could be dated within a week, these individuals had experienced a high number of stressful events in the three weeks before showing signs of the disorder

• Seasonality of birth - being born during the winter increases a persons chance for later developing schizophrenia

• Issue of relying on retrospective research (Studying after-the-fact reports)

• Stressful life events can increase depression which may contribute to relapse

• SES can play a role - those with lower SES are at risk for developing it, (1) life is more stressful when someone has a lower SES (sociogenic hypothesis), (2) Adverse effects of schizophrenia on a person’s ability to hold a job (social selection hypothesis)

• Higher levels of social support from non-family members in the social network predicted better outcomes dive years later

Schizophrenogenic

According to an obsolete, unsupported theory, a cold, dominating, rejecting parent who was thought to cause schizophrenia in their offspring. Used in the past.

Double Blind

According to an obsolete, unsupported theory, the practice of transmitting conflicting messages that was thought to cause schizophrenia. The parent communicates messages that have two conflicting meanings. Past ideas.

Expressed Emotion

Hostility, criticism and overinvolvement demonstrated by some families toward a family member with a psychological disorder, this can often contribute to the person’s relapse.

• Focus is on the relapse

• If the level of criticism (disapproval), hostility (animosity) and emotional overinvolvement (intrusiveness) expressed by the families was high, patients tended to relapse

• Ratings of high EE in a family are a good predictor of relapse among people with chronic schizophrenia

• Cultural variations in how families react to someone with schizophrenia, what may appear as overinvolvement in one culture may be viewed as supportive in other cultures.

• Critical comments and emotional overinvolvement may be family responses to a patient’s unusual and disturbing behaviour rather than a cause - certain kinds of patient behaviour do evoke hostility in family members, supporting the position that the relation between the behaviour of patients with schizophrenia and EE in family members is a reciprocal process

Old Biological Interventions

• Injecting massive doses of insulin to induce comas - it carried great risk of serious illness and death

• Prefrontal lobotomies and ECT’s for it (ECT’s were found to not be beneficial) - ECT’s sometimes recommended for severe depressive episodes in schizophrenia

Neuroleptics

When effective they help people think more clearly and reduce or eliminate hallucinations and delusions, working by affecting positive symptoms and to a lesser extent the negative and disorganized symptoms.

• Dopamine antagonists - Major actions in the brain is to interfere with the dopamine neurotransmitter system, they can also affect other systems like the serotonergic system

• Conventional antipsychotics earliest neuroleptic drugs

• Many people experience unpleasant side effects from conventional antipsychotics while newer ones have fewer serious side effects - newer drugs can reduce the severity of long-standing tardive dyskinesia

• Newer may be more effective than conventional antipsychotics in reducing both negative and positive symptoms and they may be helpful in improving cognitive functioning (among patients experiencing their first episode of psychosis)

• They only work when they are taken properly aka following a routine which many do not follow this

• Many patients stop taking their medication periodically

• Either dopamine is too much or the person is too receptive to dopamine

• Neuroleptics reduce the amount of dopamine or dopamine binding receptors (Typical antipsychotics and first generation)

Medication

MAO sometimes prescribed but only if necessary, if combined with certain foods or alcohol it could kill a person. Newer antipsychotics have less negative side effects but TD is still possible and their impact on negative symptoms is less. They help with cognitive functioning, during psychotic episodes cognitive functioning declines and you start to trust yourself a little less. Excessive dopamine in your system can slowly lead to brain damage with longer psychosis episodes.

Number One Issue with Medication

Patients noncompliance could be due to negative doctor-patient relationships, cost of the medication, stigma and poor social support. Negative side effects are a major factor in patient refusal, side effects like grogginess, blurred vision and dry mouth

Extrapyramidal symptoms:

• Include motor difficulties similar to those experienced by people with Parkinson’s disease (parkinsonian symptoms)

• Akinesia - one of the most common, includes an expressionless face, slow motor activity and monotonous speech

• Tardive Dyskinesia - involuntary movement of the tongue, face, mouth or jaw and can include protrusions of the tongue, puffing of the cheeks puckering of the mouth and chewing movements, seems to result from long term use of high doses of medication and is often irreversible

• Feeling sedations or grogginess, others complain about deterioration in the ability to think or concentrate, problems with salivation or blurred vision

• Clozapine a newer medication produces fewer negative side effects but it still produces negative effects that are potentially life threatening

• Introducing injectable medications - patients can have their medication injected every few weeks, an option to help nonadherence, associated with reduced hospitalization rates and care costs

• Psychosocial interventions also used to help with compliance

• Can live normal and healthy lives if they continue taking medication and other treatment

Transcranial Magnetic Stimulation

Used for the treatment of hallucinations - uses wire coils to repeatedly generate magnetic fields that pass through the skull to the brain. This input seems to interrupt the normal communication temporarily to that part of the brain.

• Generally ineffective in treating the auditory hallucinations - can treat but it lasts less than 1 month

Psychodynamic and Psychoanalytical Interventions

Historically thought that the disorder results from problems in adapting to the world because of early experiences. Individuals who could achieve insight into the presumed role of their personal histories could be safely led to deal with their existing situations. Their efforts may be harmful though instead of being helpful.

• Interpreting other peoples thoughts and dreams

Psychosocial Interventions

• Problems with ineffectiveness, inconsistent use, side effects and relapse with drug treatments suggest that they alone may not be effective for people

• Historically treated in hospital settings with “moral treatment” which emphasized improving patients socialization, helping them establish routines for self-control and showing them the value of work and religion.

Token Economy

Social learning behaviour modification system in which individuals earn items they can exchange for desired rewards by displaying appropriate behaviours. Tokens could be taken away by being disruptive or otherwise acting inappropriately. An environment for inpatients that encouraged appropriate socialization, participation in group sessions and self-care such as bed-making while discouraging violent outbursts.

• Patients did better than others on social self-care and vocational skills and more of them could be discharged from the hospital

Institutionalization

• Less people being hospitalized due to rulings that limit involuntary hospitalization partly due to the relative success of antipsychotic medication and because of the fiscal crisis and ensuing cutbacks in health care.

• The consequence of deinstitutionalization, many people with schizophrenia or other serious psychological disorders are without a residence

• Family members are increasingly expected to bear the burden of caring for someone who has mental illness

• More attention is being focused on supporting these people in their communities among their friends and families - when adequate community support is provided, these people fare no worse and sometimes fare better in the community than in institutions

• Trend is leaning more towards the possibly the more difficult task of addressing complex problems in the less predictable and insecure world outside

Impacts of Schizophrenia and Social Relations

• A more insidious effect

• Negative impact on a person’s ability to relate to other people

• Can be the most visible impairment displayed by people and can prevent them from getting and keeping jobs and making friends

• Clinicians attempt to reteach social skills such as basic conversation, assertiveness and relationship building, divide complex social skills into their component parts which they model

• Clients role-play and practice their new skills in the real world while receiving feedback and encouragement

• Challenge is maintaining the effects over a long time in different settings

Behavioural Family Therapy

• Resembles classroom education

• Family members are informed about schizophrenia and its treatment, relieved of the myth that they caused the disorder and taught practical facts about antipsychotic medications and their side effects

• Helped with communication skills so they can become more empathic listeners and they learn constructive ways of expressing negative feelings to replace the harsh criticism that characterizes some family interactions

• Learning problem-solving skills to help them resolve conflicts that arise

• Effects are significant during the first year but less robust two years after intervention - must be ongoing if patients and families are to benefit

Employment Issues

Adults with schizophrenia face great obstacles to maintaining gainful employment, social skills deficits make reliable job performance and adequate employee relationships a struggle.

• Some programs focus on vocational rehabilitation such as supportive employment

• Providing coaches who give on-the-job training may help some people to maintain meaningful jobs

• Social skills training, family intervention and vocational rehabilitation may be helpful additions to biological treatments for schizophrenia in terms of avoiding or delaying relapse

Early Intervention

Can be important in affecting the course of the disorder overtime, getting help in the early stages is critical. Getting them onto the right medication and into effective psychotherapy as soon as possible and providing information and support to affected families right away can reduce the severity of future relapses.

Key Elements

• Reduction of duration of untreated psychosis through education - awareness

• Assessment and the context of care: building a therapeutic alliance

• Family engagement and support

• Comprehensive, phase-specific, individualized treatment including low-dose antipsychotic medication, psychoeducation and psychosocial support

• Prolonged engagement to sustain gains

Cognitive Behavioural Therapy for Schizophrenia

Belief that people with schizophrenia are not inherently irrational but instead have a set of irrational beliefs that are amenable to intervention with cognitive and behavioural techniques.

• Usually applied to auditory hallucinations and delusions although strategies have been developed to treat both positive and negative symptoms

• Strategies are adaptations of CBT strategies successfully used in the treatment of depression and anxiety

Different Treatments Across Cultures

China - Most frequently used treatment is antipsychotic medication although they also receive traditional herbal medicine and acupuncture. Financial and cultural reasons, more people in China are treated outside the hospital (Hold more religious beliefs about the cause and the treatments, translating into practice)

South Africa - Most report using traditional healers who sometimes recommend the use of oral treatments to induce vomiting, enemas, and the slaughter of cattle to appease the spirits

Bali - Supernatural beliefs about the cause of schizophrenia among family members lead to limited use of antipsychotic medication in treatment

Africa - For many countries in Africa people are often kept in prisons primarily because of the lack of adequate alternatives

Prevention

• Identify and treat children who may be at risk for getting the disorder later in life, children of parents who have schizophrenia are considered high-risk

• Treatment of persons in the prodromal stages of the disorder - individual is beginning to show early mild signs of schizophrenia but is aware of these changes

• Cannot fully prevent but strongly discouraging the use of hallucinogenic

Instability of the Early Family-Rearing Environment

Suggests that environmental influences may trigger the onset of schizophrenia

• Poor parenting may place additional strain on a vulnerable person who is already at risk