ch 11- schizophrenia

schizophrenia

chronic, debilitating psychological disorder that touches every facet of the person’s life → characterized by a break with reality that typically takes the form of hallucinations and delusions and by a pattern of aberrant behavior

• hallucinations: sensory distortions such as hearing voices or seeing things

• delusions: fixed, false beliefs

course of development of schizophrenia

• typically begins during late adolescence or early adulthood

• same cases onset can occur suddenly

• prodromal phase

• residual phase

• its a chronic disorder but 1/2- 2/3 patients improve significantly overtime with medication and therapy

prodromal phase

gradual deterioration; characterized by subtle symptoms involving unusual thoughts or abnormal perceptions, as well as waning interest in social activities, difficulty meeting responsibilities of daily living; and impaired cognitive functioning involving problems with memory and attention, use of language, and ability to plan and organize one’s activities

• one of first signs of prodrome is lack of attention to one’s appearance

• over time behavior gets odd, speech becomes vague

• changes in personality may be so gradual that they may raise little concern among family and friends at firs

residual phase

after acute psychotic episodes, behavior returns to the level of the prodromal phase

• flagrant psychotic behaviors are absent but person is still impaired by significant cognitive, social and emotional deficits , and difficulties thinking or speaking clearly and holding unusual ideas

key features of schizophrenia

• acute episodes of schizophrenia involve break in reality

  • marked by delusions, hallucinations, illogical thinking, incoherent speech, and bizarre behavior

  • in between episodes may have lingering deficits

• 40% of patients have long periods of remission that last a year or longer

prevelence of schizophrenia

• 0.25-0.64 % of population of americans

• men have higher risk and develop disorder earlier

• peak period of life when psychotic symptoms first appear are middle 20s for men late 20s for women

features of schizophrenia cont

• differences in men and women suggest they develop different forms of schizophrenia or it affects different areas of the brain

  • men have more cognitive impairment, greater behavior deficits, and poorer response to drug therapy than women

  • women have higher level of functioning before the onset of the disorder and have less severe course of illness than men

• schizophrenia occurs universally across cultures but some particular symptoms that emerge may vary from culture to culture

  • visual hallucinations are more common in non-Western culture

dsm 5 criteria schizophrenia

A) two or more of the following, each present for a significant portion of time during a 1 month period (or less if successfully treated) at least one of these must be (1), (2), or (3)

• delusions (1)

• hallucinations (2)

• disorganized speech (3)

• grossly disorganized or catatonic behavior

• negative symptoms

(B) for a significant portion of time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning)

(C) continuous signs of the disturbance persist for at least 6 months. during this period must include at least 1 month of symptoms that meet criterion A, and must include periods of prodromal or residual symptoms. during these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in criterion A present in an attenuated for (odd beliefs, unusual perceptual experiences)

(D) schizoaffective disorder, depressive or bipolar disorder with psychotic features have been ruled out(E) disturbance is not attributable to the physiological effects of a substance or another medical condition

(F) if there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to other required symptoms of schizophrenia, are also present for a least one month

positive and negative symptoms of schizophrenia

positive symptoms: atypical excesses of behavior involving a break with reality, including hallucinations and delusional thinking

negative symptoms: behavioral deficits or absences of typical behaviors and emotions that affect a person’s ability to function in daily life

• includes lack of emotional responses, loss of motivation, loss of pleasure, lack of social relationships, limited verbal expression

Aberrant content of thought (disturbed thoughts and speech)

delusions involve disturbed content of thought in form of false beliefs that remain fixed despite their illogical bases

• delusions of persecution or paranoia

• delusions of reference

• delusions of being controlled

• delusions of grandeur

• thought broadcasting

• thought insertion

• thought withdrawal

aberrant forms of thought (disturbed thought and speech)

• people with schizophrenia tend to think in a disorganized, illogical fashion

• thought disorder: positive symptom of schizophrenia involving a breakdown in the organization, processing, and control of thoughts

  • looseness of associations is sign of disorder

  • poverty of speech is another sign of disorder

    • less common signs: neologisms (made up words), perseveration (inappropriate but persistent repetition of same words), clanging (stringing together of words), and blocking (involuntary, abrupt interruption of speech of thought)

attentional deficiencies

core feature of schizophrenia is sensory deficit that makes it difficult to filter out irrelevant stimuli → makes it difficult to organize thoughts and focus attention

• hypervigilent

• eye movement dysfunction

• abnormal event related potentials

hypervigilant

acutely sensitive to extraneous sounds, especially during early stages

of the disorder

eye movement dysfunction

difficulty tracking slow moving targets across their field of vision, fall back then catch up in jerky movement

• common in people with schizophrenia and in first degree relatives → suggests its a biomarker (associated with genes linked to schizophrenia

abnormal event related potentials

event related potentials: brain wave patterns which occur in response to external stimuli such as sounds and flashes of light

• normally sensory gating mechanism in the brain suppresses event related potentials to a repeated stimulus occurring within the first hundredth of a second after stimulus is presented → people with schizophrenia doesn’t work effectively leading to sensory overload

hallucinations (perceptual disturbances)

auditory hallucinations is most common symptom of schizophrenia → 70% of schizophrenia patients have auditory hallucinations

• most voices are critical

• 5% of general population have experienced temporary hallucinations, does not mean they have schizophrenia

causes of hallucinations

• unknown, but speculations

• dopamine is thought to have an effect → anti psychotics block dopamine activity which reduces hallucinations

• auditory cortex becomes active during hallucinations even when there is no sound → scientists speculate auditory hallucinations might be form of internal speech which for unknown reasons becomes attributed to external sources rather than one’s own thoughts

• brain mechanisms involved with hallucinations involve number of interconnected symptoms → abnormalities in connections among neurons in the brain may disrupt brain circuits that allow us to distinguish reality from fantasy

emotional disturbances

• schizophrenia patients tend to have more negative and fewer positive emotions than healthy individuals

• flat affect: loss of normal emotional expression, may speak in monotone and maintain an expressionless face

  • may also display positive symptoms which involve exaggerated or inappropriate affect; example laughing for no reason or giggling at bad news

• even when not showing emotion, most schizophrenia patients internal emotions are like healthy people

  • lack capacity to express emotions outwardly

other types of impairments

• confused about personal identities

  • ego boundaries: failing to recognize themselves as unique individuals and be unclear about how much of what they experience is part of themselves

• difficulty perceiving emotions in others

• disturbances of volition

  • seen in residual or chronic state

  • characterized by apathy, which is loss of motivation or initiative to pursue goal directed activities

other types of impairments cont

• catatonia: unaware of the environment and maintain a fixed or rigid posture

  • waxy flexibility: adopting a fixed posture into which they have been positioned by others

• significant impairment to interpersonal relationships

  • withdraw from social interactions

psychodynamic perspective on schizo

schizophrenia represents the overwhelming of the ego by primitive sexual or aggressive drives or impulses arising from the id

• impulses threaten ego and give rise to intense intrapsychic conflict

• under such threat, the person regresses to an early period in the oral stage, referred to as primary narcissism

• input from id causes fantasies to become mistaken for reality

psychodynamic harry sullivan perspective

placed more emphasis on interpersonal than intrapsychic factors

• emphasized that impaired mother-child relationships can set the stage for gradual withdrawal from other people

• early childhood anxious and hostile interactions between the child and the parent lead the child to take refuge in a private fantasy world → cycle continues into adulthood, increasing demands causes person to become overhelmed and withdraw completely into world of fantasy

• critics point out that schizophrenic behavior and infantile behavior are different, so schizophrenia cannot be explained by regression

learning based perspective

• development of some forms of schizophrenic behavior can be understood in terms of conditioning and observational learning

• case study: Haughton and Ayllon

  • conditioned 54 yr old chronic schizophrenia patient to cling to broom using cigarette as reinforcement

  • after pattern was repeated, the woman would not let go of the broom

• social cognitive theorists

  • modeling of schizophrenic behavior can occur within the mental hospital

biological perspectives

• genetic factors

  • first degree relatives have 10x greater risk of developing schizophrenia than average population

• concordance rates

  • 48% for identical twins

  • 17% for fraternal twins

• genetic and environmental factors contribute

• cross fostering study: compares incidence of schizophrenia among children whose biological parents either had or didn’t have schizophrenia and who were reared by adoptive parents who either had or didnt have schizophrenia

• presently, investigators are now zeroing in on particular genes linked to schizophrenia

  • no single gene responsible for schizophrenia → many different genes contribute to the development of brain abnormalities that, together with stressful environmental influences, lead to schizophrenia

• older fathers stand increased risk of developing schizophrenia and autism

dopomine hypothesis

overactivity of dopamine transmission of brain

• source of evidence is found in effects of antipsychotic drugs called neuroleptics

• first generation of neuroleptics are called phenothiazines

  • thorazine, mellaril, and prolixin

• neuroleptic drugs act like a dam against dopamine → help stop delusions and hallucinations

biochemical factors

• dopamine hypothesis

• amphetamines can mimic paranoid schizophrenia in normal people

• evidence points to irregularities in neural pathways that utilize dopamine in brains of people with schizophrenia

• another theory is decreased dopamine may help explain development of negative symptoms

  • glutamate and GABA may also be involved

viral infections and vitamin d deficiency in prenatal development

• schizophrenia is more likely in people who are born in winter in northern hemisphere, time of year associated with the flu

• sweden suggests risk posed by prenatal infections may be limited to offspring whose mothers had psychiatric disorders

• children born with vitamin D deficiency had 44% higher risk of later developing schizophrenia

brain abnormalities

• loss or thinning of brain tissue (gray matter)

• clearest signs of deterioration of brain tissue are abnromally enlarged ventricles

• brain may have been damaged or failed to develop normally during prenatal development or early childhood as result of genetic factors or environmental influences

  • not all cases involve structural damage to brain tissue

evidence linking genetic variations in schizophrenia to a thinning or pruning of synaptic connections in the prefrontal cortex of people with schizophrenia

• prefrontal abnormalities may explain why people with schizophrenia have problems with working memory

• people with schizophrenia may have relatively few pathways (think of them as roadways) in the prefrontal cortex for information to pass from one neuron to another → results in messages becoming bottled up in the veritable “traffic jam” in the brain → results in confused and disorganized thinking

evidence also points to abnormalities in brain circutry connecting the prefrontal cortex and lower brain structures including the thalamus and parts of limbic system involved in regulating emotions and memory

communication deviance (role of family)

pattern of unclear, vague, disruptive, or fragmented communication that is often found among parents and family members of people with schizophrenia

• high communication deviance parents often have difficulty focusing on what their children are saying, and verbally attack them rather than offering constructive criticism

• parents with high communication deviance stand higher than average risk of having children with schizophrenia spectrum disorders

expressed emotion (role of family)

• pattern of responding to the family member with schizophrenia in hostile, critical, and unsupportive ways

• people who live in high EE family environments have more than twice the risk of suffering a relapse as those from low EE families

• high EE relatives show less empathy, tolerance, and flexibility than low EE relatives and tend to believe that their relatives with schizophrenia can exercise greater control over their disturbed behavior

• cultural differences in both the frequency of EE in family members of patients with schizophrenia and the effects these behaviors have on the patients

  • chinese families with high levels of EE are more likely than low EE families to view the psychotic behavior of a family member with schizophrenia as within the persons control

  • high EE families are more common in industrialized countries such as US and China vs developing countries such as India

  • high EE in african american families were associated with better outcomes → critical comments may be perceived as signs of caring and concern rather than rejection

• nervios: cultural label attached to wide range of troubling behaviors including anxiety, schizophrenia, depression and one that carries less stigma and more positive expectations than the label of schizophrenia

diathesis stress model

biomedical approaches

antipsychotic drugs help control flagrant behavior patterns such as delusional thinking, hallucinations and reduces need for long term hospitalization

first generation antipsychotics phenothiazines

• chlorpromazine (thorazine)

• thioridazine (mellaril)

• trifluoperazine (stelazine)

• fluphenazine (prolixin)

- haloperidol (hadol) similar but chemically different from phenothiazines

- block dopamine receptors in the brain which reduce symptoms such as hallucinations and delusions

• effectiveness has been repeatedly demonstrated in double blind placebo controlled studies

tardive dyskinesia

• side effect from long term use of neuroleptics

• can take different forms

  • frequent eye blinking

  • involuntary chewing and eye movements

  • lip smacking or puckering

  • facial grimacing

  • involuntary movements of the limbs and trunk

• most common among older people and women

second generation antipsychotics referred to as atypical antipsychotics

same level of effectiveness as first gen antipsychotics but carry fewer side effects and lower risk of tardive dyskinesia

• clozapine (clozaril)

• risperidone (risperdal)

• olanzapine (zyprexa)

side effects

• cardiac death

• susbtantial weight gain

• seizures

• metabolic disorders-

• lethal disorder where body does not produce enough white blood cells

sociocultural factors in biomedical treatment

• asians and hispanics require lower doses than european americans

• asians experience more side effects

• african americans were less likely to recieve new generation of atypical antipsychotics

psychosocial approaches

• psychoanalysis

• learning based therapies

• CBT

• psychosocial rehabilitation

• family intervention programs

• combined approaches

psychoanalysis

harry sullivan and frieda fromm-reichmann adapted techiques for schizophrenia

learning based therapies

selective reinforcement behavior: providing attention for appropriate behavior and extinguishing bizarre verbalizations through withdrawal of attention

token economy: individuals in inpatient units are rewarded for appropriate behavior with tokens, such as plastic chips, that can be exchanged for tangible reinforcers

social skills training: clients are taught conversational skills and other appropriate social behaviors through coaching, modeling, behavioral rehearsal and feedback

CBT

• focuses on changing thinking patterns to help patients with schizophrenia control their hallucinations by means of reattributing their voices to their internal voice or self

• help patients avoid cognitive errors such as jumping to conclusions, replace delusional beliefs, combat negative symptoms

• Aaron Beck proposes the types of cognitive biases we see in depression patients also play role in accounting for both positive and negative symptoms in schizophrenia patients

psychosocial rehabilitation

• help patients strengthen cognitive skills such as attention and memory

• self help clubs (clubhouses) and rehabilitation centers have popped up to help patients find a place in society

  • provides members with social support and help finding educational opportunities and employment

family intervention programs

works with families to help them cope with burden of care and assist them in developing more cooperative, less confrontational ways of relating to others

combined approaches

drug therapy combined with psychological approaches is most effective

brief psychotic disorder

applies to psychotic disorder that lasts from a day to a month and is characteried by at least one of the following features

• delusions

• hallucinations

• disorganized speech

• grossly disorganized or catatonic behavior

eventually there is a full return of functioning

Schizophreniform Disorder

consists of abnormal behavior identical to those in schizophrenia that have persisted for at least one month but fewer than six months

• usually reclassified as schizophrenia or schizoaffective disorder

delusional disorder

applies to people who hold persistent, clearly delusional beliefs, often involving paranoid themes

• affects an estimated 20 people in 10,000 during their lifetime

• apart from delusion, the individual’s behavior may not show evidence of obviously bizarre or odd behavior

Schizoaffective Disorder

refers to mood disorder in which one experiences a major mood disorder and psychotic features associated with schizophrenia

• in terms of severity of disturbed behavior, schizoaffective is on low end and schizophrenia on the higher end

Schizoaffective Disorder prevelance

• 0.3% prevalence

• chronic and responds well to anti-psychotics

• schizoaffective disorder and schizophrenia appear to share genetic link