Psych Disorders - CH 13: Schizophrenia Spectrum and Other Psychotic Disorders

Schizophrenia

Characterized by a broad spectrum of cognitive and emotional dysfunction including:

• delusions and hallucinations

• disorganized speech and behavior

• inappropriate emotions

Dementia praecox

• Emil Kraepelin used it to describe schizophrenia syndrome ( and differentiate it from manic-depression)

• Characterized by

  • Early age of onset

  • Poor outcome

  • Specific symptoms (hallucinations, delusions, negativism, stereotyped behavior) 

Eugen Bleuler

• introduced term “schizophrenia”

• Greek for split mind

• Breaking of associative threads, which he thought was the root problem in the disorder 

Positive symptoms 

having experiences that are not usual 

Delusions

• unchangeable belief in something that is not true

• Ex: delusions of grandeur or persecution

Hallucinations

Seeing, hearing, or feeling something that isn’t there

Negative symptoms

Not having experiences that are usual

Avolition

inability to initiate and persist in activites 

Alogia

absence of speech

Anhendonia

lack of interest or pleasure

Asociality

lack of motivation for social interactions/relationships

Flat Affect

not showing emotions when emotions would normally be expected

Tangenital speech

• Disorganized speech symptom

• Constantly going off on tangents with no clear line of thought in what the person is saying and not returning to the topic 

Loose associations/derailment

• Disorganized speech symptom

• Abruptly changing the topic to something completely unrelated 

Word salad

• Disorganized speech symptom

• Using a mix of random words/phrases that don’t make sense 

Inappropriate affect

• Disorganized speech symptom

• Laughing or crying at inappropriate times

Disorganized behavior

• Disorganized speech symptom

• Includes widly exaggerated movements and immobility (catatonic immobility) 

Schizophreniform disorder

• Psychotic disorder lasting between 1 to 6 months (> 6 months would be diagnosed with schizophrenia) 

• Associated with relatively good functioning 

• Most patients resume normal lives

• Lifetime prevalence: ~0.2%

Schizoaffective disorder

• Symptoms of schizophrenia + additional experience of a major mood episode (depressive or manic) 

• Psychotic symptoms must also occur outside the mood disturbance 

• Prognosis is similar for people with schizophrenia 

• Timing of psychotic vs mood symptoms is key to diagnosis 

If psychosis first and then mood

Schizoaffective

If mood first and then psychosis

MDD or Bipolar with Psychotic features

Delusional disorder

characterized by delusions that are contrary to reality

• lack other positive and negative symptoms 

• better prognosis than schizophrenia

Erotomanic

delusion that another person is in love with you

Grandiose

conviction of having some great (but unrecognized) talent or insight or having made some important discovery 

Jealous

delusion that spouse/partner is unfaithful

Persecutory

delusion that person is being persecuted

Somatic

delusion about bodily functions/sensation

Catatonia

• unusual motor responses, particularly immobility or agitation, and odd mannerisms

• tends to be severe and quite rare 

• May be present in psychotic disorder or diagnosed alone and may include

  • Stupor, mutism, maintaining the same pose for hours 

  • Opposition or lack of response to instructions 

  • Repetitive, meaningless motor behaviors 

  • Mimicking others’ speech or movement 

Psychosis may be caused by

• Substance/medication-induced psychotic disorder

  • Usually cocaine or other stimulants or psychedelics 

• Psychotic disorder associated with another medical condition 

Brief psychotic disorder

• characterized by positive symptoms of schizophrenia (ex: hallucinations or delusions) or disorganized symptoms

• Lasts less than one month 

• briefest duration of all psychotic disorders 

• typically precipitated by trauma or stress 

Attenuated psychosis syndrome 

• identified as a condition in need of further study in DSM-5

• Refers to individuals who are at high risk for developing schizophrenia or beginning to show signs of schizophrenia 

  • Referred to as the “prodrome” 

• Label designed to focus attention on these individuals who could benefit from early intervention

• Tend to have good insight into own symptoms 

Schizophrenia Stats

• ~1% population

• often develops in early adulthood 

• can emerge any time; childhood cases are extremely rare 

How does schizophrenia affect men and women? 

• Equally 

• Females tend to have a better long-term prognosis 

• Onset earlier for men

How is schizophrenia found around cultures?

Similar rates

Family studies of schizophrenia

• Inherit a tendency for schizophrenia but not specific forms 

• Risk increases with genetic relatedness 

Twin studies of schizophreia

Monozygotic twins have greater concordance than dizgotic twins

Adoption studies of schizophrenia

• Adoptee risk for developing schizophrenia is high if a biological parent had schizophrenia 

• But risk is lower for children raised by their biological parent with schizophrenia 

Genetic markers

linkage and association studies

Endophenotypes

• basic processes linked to the disorder (phenotype) that should be strongly linked to genes than the disorder itself 

• Potential endophenotype: smooth-pursuit eye movement 

  • Individuals with schizophrenia show reduced ability to track a moving object with their eyes

  • Relatives of schizophrenic patients also have deficits in this area 

Dopamine hypothesis

Schizophrenia is partially caused by overactive dopamine

Dopamine hypothesis Evidence

• Drugs that increase dopamine (agonists) result in schizophrenic-like behavior

• Drugs that decrease dopamine (antagonists) reduce schizophrenic like behavior 

• Problem: overly simplistic 

  • Many neurotransmitters are likely involved 

Structural and functional abnormalities in the brain of Shizophrenia

• Enlarged ventricles (hollow chambers in the brain) and reduced tissue volume 

• Hypofrontality — les active frontal lobes 

  • major dopamine pathway 

The role of stress

• may activate underlying vulnerability

• may also increase risk of relapse 

Expressed emotions (EE)

inetsnity of emotions expressed by family members (includes criticism and can include blaming the patient) 

• HIGH EE associated with relapse 

Schizophrenogenic

mother: cold, dominant rejecting

Double bind communication

communication that has two conflicting messages ( I care about you; I don’t care about you)

Prior to 1950s, medical treatments were ineffective and sometimes barbaric

• Massive doses of insulin to induce comas 

• Frontal lobotomies 

Development of antipsychotic medications

• Often the first line treatment for schizophrenia 

• Began in the 1950s 

• Most reduce or eliminate positive symptoms 

• Primarily affect dopamine system, but also affect serotonergic and glutamate system 

Acute and permanent side effects may occur with both first-generation and second generation antipsychotics 

• Parkinson’s like side effects (tremors)

• Tardive dyskinesia: involuntary repetitive movements in the body 

Compliance with medication is often a problem:

• aversion to side effects 

• financial cost

• poor relationship with doctors 

• paranoia 

What is a historical precursor to schizophrenia?

Psychodynamic therapy wasn’t effective

Psychosocial approches to Schizophrenia

• Behavioral methods like the token economy that reward adaptive behavior 

• Community care programs 

• Social and living skills training

• Virtual reality based interventions

• Behavioral family therapy resembles classroom education

• Vocational rehabilitation 

Illness management and recovery

• engages patient as an active participant in care

• continuous goal setting and tracking

• modules include social skills training, stress management, substance use 

Cultural considerations 

• Take into account cultural factors that influence individuals’ understanding of their own illness (ex: supernatural beliefs) 

• Involve family and community if possible 

Recovery-oriented Cognitive Therapy (CT-R) strengths based approach focuses on 

• Activating adaptive modes of living

• Developing meaningful aspirations 

• Engaging in personally meaningful activities to bring about one’s desired life 

Recovery-oriented Cognitive Therapy (CT-R) targets 

• difficulty assessing motivation

• difficulty connecting and communicating with others

• distressing voices/hallucinations

• beliefs that are hard for people to understand

• disagreement regarding the presence of a mental health condition

Preventing Schizophrenia

• Identify at risk children

  • Relatives of individuals with schizophrenia 

• Foster supportive, stable enviornments

• Offer additonal treatment at prodromal stages, including social skills training 

Clinical High Risk for Psychosis

• Presence of > 1 brief limited psychotic symptom

  • At least 1x/week during the past month

  • Hallucinations, delusions, formal thought disorder

• Presence of >1 attenuated psychotic symptom

  • Lasting for several minutes on 1 day in the past month; no more than 1 hour per day for 4 days per week in the last month 

  • Ideas of reference, odd beliefs/magical thinking, paranoid ideation, unusual perceptual experiences, odd thinking and speech 

• Presence of a genetic risk (family history of psychosis) in combo with recent significant decline in psychosocial functioning

(T/F) Most medications for schizoprenia affect the dopamine system

True: Most medications for schizophrenia an other psychotic disorders are dopamine antagonists, although some also affect serotonin and glutamate 

(T/F) Even the new antispychotic drugs have significant side effects

True: Although it had been hoped that the second-generation medications would be more acceptable, they have similar side-effect profiles to the first-generation drugs 

(T/F) Psychodynamic therapy is useful in the treatment of psychotic disorders

False: Psychodynamic approaches are not only helpful in treating people with psychotic disorders, they may be harmful

(T/F) Illness management and recovery engages the person with schizophrenia as an active participant in treatment 

True: Illness management and recovery focuses on helping the individual become an active participant in treatment, including providing education about the disorder, teaching effective use of medication strategies for collaborating with clinicians, and coping with symptoms when they recur