Schizophrenia and Other Psychotic Disorders

History

Originally called Dementia Praecox which into concepts of “madness” and cognitive decline into one disorder

• “Split mind”- destruction of forces connecting one function to another

• Normal connections most people experience don’t occur here, split between thought and emotion

Delusions

Bizarre and strongly held beliefs despite significant evidence to contrary

Delusions of Grandeur

e.g., I am god, I am god’s representative on Earth, belief you are Satan or Satan’s minion, usually exclusively a view about self

Delusions of Persecution

Forces are conspiring to cause you or your loved ones harm (e.g., supernatural forces, government branches)

Delusions of Reference

Belief that coincidences aren’t just coincidences, have to determine the message

Cap Gras

People in your life have been replaced by someone else

Hallucinations

Bizarre sensory perceptions that do not exist in reality

• Other people don’t have access to your sensory experiences

• Can involve any of the 5 senses

• Auditory most common than visual

Disorganized speech

Problems with verbal communication, cognition doesn’t match speech

Tangentality

Talking about something and then transition to something else, somehow connect back to original point

Loose Associations

Neologisms, “clanging”, get stuck on meaningless aspects of conversation

Grossly Disorganized or Catatonic Behavior

Agitation or immobility

Catatonia

Waxy flexibility, inability to move body parts

Inappropriate affect

Abnormal ways of locomoting/gross motor movements

Echoproxia

Copy what others are doing

Negative symptoms

Abscense or insufficiency of normal behavior

Negative symptoms: Flat Affect

Not expressing emotion at all, can’t gage how person feels

Negative symptoms: Avolition

No desire to do anything

Negative symptoms: Alogia

Poverty of speech content or speech production, person can talk, but doesn’t say anything

Negative symptoms: Anhedonia

Lack of interest in things one used to find enjoyable, no pleasure found in anything

Schizophrenia Criterion

2 of the symptoms for at least 1 month

Schizophrenia Course

Total course must be 6 months with active phase lasting at least 1 month

Who gets schizophrenia?

• Mean age at onset: 25, large range around the mean

• Gender differences: men onset slightly earlier, after not many differences

• Lifetime prevalence: 1%

• Somewhat higher incidence in African Americans

• Generally episodic course

Genetics

• Need biological component to create disorder

• Monozygotic twins 60% in common, 15% dyzgotic twins

Dopamine Hypothesis

• Proliferation of D2 receptors (in striatum), excessive amount of D2 receptors, excessive amount of dopamine

• Underactivity in D1 receptors (in prefrontal cortex)

Glutamate hypothesis

Possibly NMDA receptor deficiency

Serotonin

Probably involved, but not clear how

Ventricular enlargement

More severe cases have larger ventricles, also correlated with how long disorder has been occurring, causes other brain parts to shrink

• Ventricular size in childhood doesn’t seem to predict size in adulthood

Hypofrontality

Decreased activity in broca’s area as active as if they were speaking, seen under fmri

• Possible consequence in D1 underactivity

• Brain registers auditory hallucinations as if you were speaking

• Misorganized cells in schizophrenia

Perinatal Development

• More people with schizophrenia born in February

• Being stressed compromises immune response, which would impact third trimester as it occurs in November/December, height of cold/flu season

Hypoxia

Potential risk if baby suffers around time of birth (cord wrapped around baby’s neck)

Biological Markers

• Seem to be associated with increased risk of schizophrenia

• These are factors that don’t directly cause schizophrenia, but seem to be related to genes that predict schizophrenia

• Olfactory bulb: decreased sense of smell

• Smooth-pursuit eye movement: decreased ability to track smooth moving object

Neuroleptics (First-generation antipsychotics)

• Blocks dopamine receptors

• 60-75% of people have a reduction in symptoms, but people don’t like taking them

• Side effects: anticholingeric effects, extrapyamidal effects, tardive kinesia

• Very high rate of non-complicance, highest: 75%

Atypical Antipsychotics (Second Gen.)

• Specifically blocks D2 receptors, also blocks 5-HT2 receptors

• Much more tolerable side effect profile

• Problem: Agranulocytosis (Clorezil only): patients had a harder time fighting illness, because broke down immune cells

• Side effect: drastic weight gain

Muscarinic agonists (Cobenfy)

• Facilitate Ach Muscarinic M4 and M1 receptors

• Which then modulates D2 and NMDA

• Side effect of manipulating muscarinic: uncontrollable vomiting

• Modulated here to reduce nausea

• Very new drug, unsure how effective it will be

• Helps improve positive and negative symptoms, more tolerable side effect profile

Psychosurgery

Not used anymore, didn’t effect symptoms, made symptoms easier to manage

Schizophrenogenic family (mother)

• Cold, dominant, rejecting mother

• Double-bind communication (kid can never come out ahead)

• Verbal behavior doesn’t match nonverbal behavior

• No empirical support

• Led to development of family therapy

Expressed emotion

• Criticism, hostility, and emotional overinvolvement

• Relapse: expressed emotion at home increases relapse rates

City life

More people live in city than suburbs, social drift hypothesis

Cognitive-Behavior Therapy

• Adjunctive treatment only (need to occur with medication)

• Can’t process reality without medication

• Thought influences emotion and behavior

• Interpretations of experience paramount

• Beliefs are possibilities, not facts

• Delusions are VERY strongly held beliefs

• Medications marks delusions and hallucination less viable, CBT helps manage

Strategies

• Normalizing, generating alternatives, behavioral experiments

• Explain as many exaggerated version of normal experience

• Develop as many possible plausible alternative as possible

• Behavioral experiments have to be extremely collaborative, people respond generally well

Brief Psychotic Disorder

At least 1 schizophrenia symptom for at least 1 day, but no more than a month

• Must be one of the positive symptoms, return to normal functioning after

Schizophreniform Disorder

• Two schizophrenia symptoms for at least 1 month, but less than 6 months

• Duration is too short

Delusional Disorder

• Delusions are present at least a month, but delusions aren’t bizarre, plausible

Delusional Disorder: Erotomanic type

Believing someone of a higher status is in love with you

Delusional Disorder: Grandiose type

Believe you have a greater status, power, wealth than you actually do

Delusional Disorder: Jealous Type

Believe partner is being unfaithful

Delusional Disorder: Persecutory type

Persecution is reasonably plausible

Delusional Disorder: Somatic type

Some sort of physical defect or medical condition that isn’t true

Shared Psychotic Disorder

Being near someone suffering from disorder causes you to begin to buy into others delusions

Schizoaffective disorder

Schizophrenia symptoms than appearance of depressive symptoms