Schizophrenia Spectrum and Other Psychotic Disorders

Psychosis

• Inability to differentiate between what is real and what is unreal

• Schizophrenia: severe form of psychosis where individuals alternate between the following phases:

  • Clear thinking and communication with an accurate view of reality, and proper functioning of daily life

  • Active phase of illness → thinking and speech are disorganized, people lose touch with reality, and have difficult caring for themselves

Schizophrenia Spectrum

• Refers to five domains of symptoms that define psychotic disorders

  • Include positive symptoms (4 domains) and negative symptoms (1 domain)

  • Number, severity, and duration of symptoms distinguish psychotic disorders from each others

• All or just some psychotic symptoms manifest in individuals suffering from schizophrenia and the disorder differs across individuals

Symptoms, Diagnosis, and Course

Positive Symptoms

• Overt expressions of unusual perceptions, thoughts, and behaviors (i.e. added features)

• Delusion: Ideas that an individual believes to be true but that are highly unlikely or impossible

• Hallucinations: unreal perceptual experiences

  • Auditory, visual, and tactile

• Formal thought disorder: tendency to slip from one topic to another unrelated topic with little coherent transition

  • Referred to as loose associations or derailment

  • Word salad

  • Ask your patient to tell a story with a beginning, middle, and end

Types of Delusions

• Disorganized behavior: display unpredictable and apparently untriggered agitation

  • Disheveled appearance

  • Inappropriate sexual behavior

  • Shouting or swearing

• Catatonia: disorganized behavior that reflects unresponsiveness to the environment

  • Stupor

  • Rigidity

  • Posturing 

  • Excitement 

Negative Symptoms

• Involved the loss of certain qualities of the person, rather than behaviors or thoughts that the person expresses overtly

• Restricted affect: severe reduction in or absence of emotional expression

• Avolition: inability to initiate or persist at common, goal-directed activities

  • Cognitive deficits - deficits in basic cognitive processes, including attention, memory, and processing speed

DSM-5 Diagnostic Criteria for Schizophrenia

• DSM-5: individual must show two or more symptoms of psychosis; one of which should be delusions, hallucination, or disorganized speech

  • Acute phase → presence of symptoms, consistently and acutely for at least one month

  • In addition, symptoms of the disorder must occur for at least 6 months and impair social or occupational functioning

    • Prodromal symptoms: lessened symptoms preceding the acute phase

    • Residual symptoms: lessened symptoms following the acute phase

Prognosis

• Re-hospitalization rates between 50-80%

• Many people stabilize after the first episode within 5-10 years

• Gender and age factors

  • Women tend to develop the disorder later, have milder symptoms, and have a more favorable course than do men

  • Functioning improves with age

• Sociocultural factors

  • Schizophrenia tends to have a more benign course in developing countries than in developed countries

Other Psychotic Disorders

Brief Psychotic Disorder

• Sudden onset of delusions, hallucinations, disorganized speech and/or disorganized behavior lasting between 1 day and 1 month before remitting

Schizophreniform Disorder

• Meets criteria A, D, E of schizophrenia with symptoms that last only 1 to 6 months

• About ⅔ of people diagnosed later develop Schizophrenia

Schizoaffective Disorder

• Mix of schizophrenia symptoms and a major depressive or manic episode

• Must experience 2 weeks of hallucinations and delusions without mood symptoms

  • Affect relates to feeling and mood

  • If individual experiences hallucinations and delusions at the same time as major depressive disorder, they are diagnosed with a subtype called major depressive with psychotic symptoms

B criteria is the most important for studying!!

Other Psychotic Disorders

Delusional Disorder

• Delusions lasting at least 1 month regarding situations that occur in real life

• Behavioral Deterioration rarely observed

Schizotypal Personality Disorder

• Lifelong pattern of significant oddities in self concept, ways of relating to others, thinking, and behavior

• Covered more in Personality Disorders

Biological Theories

• Genetic transmission

  • Family Studies - Biological relative (particularly monozygotic twin or two diagnosed parents) with schizophrenia increases an individual’s risk (but does not guarantee it will manifest) 

  • Adoption studies - Generally indicate nature has a greater effect than nurture

    • Parent with schizophrenia creates a stressful environment for children

• Structural and functional abnormalities in specific areas of the brain

  • Reduced grey matter in the cortex and white matter important to working memory and connectivity

  • Enlarged ventricles (fluid filled spaces in the brian 

  • Aberration in the normal development of the prefrontal cortex

• Birth Complications or prenatal exposure to viruses affect brain development

• Neurotransmitter theories

  • Excess levels of dopamine contribute to schizophrenia

    • Drugs that increase the functional level of dopamine increased in the incidence of the positive symptoms

    • Neuroimaging studies → presence of more receptors for dopamine and higher levels of dopamine

Cross Cultural Perspectives

• Most cultures have a biological explanation for the disorder, including the general idea that it runs in families

• Intermingled with biological theories, some cultures may place significance on other attributes like

  • Stress

  • Lack of spiritual piety 

  • Family dynamics

Psychosocial Perspectives

Treatment

Biological Treatments

• Affective in positive symptoms but not great in side effects

• Typical antipsychotics are effective on positive symptoms

  • Phenothiazines: calm agitation and reduce hallucinations and delusions

  • Blocks receptors for dopamine thereby reducing its action in the brain

  • Bad side effects

    • Akinesia: slowed motor activity, monotonous speech, expressionless face

    • Akathisia: agitation, inability to be still

    • Tardive dyskinesia: neurological disorder involving involuntary movement of the tongue, face, mouth, or jaw

      • Many come off the medication

Psychological and Social Treatments

• Comprehensive approaches that address:

  • Behavioral deficits: social learning theory and operant conditioning

  • Cognitive deficits: recognize and change demoralizing attitudes

  • Social deficits: problem-solving skills applicable to common social situations

• Family therapy

  • Basic education of the illness

  • Training of family members to communicate effectively and encourage appropriate behaviors

  • Disorders impact on caregivers

• Assertive community treatment programs - comprehensive services to meet the patients’ needs 24 hours a day from experts such as:

  • Medical professionals

  • Social workers

  • Psychologists

• Cross culturally, traditional healers tend toward these models

  • Structural model: reintegration of levels of experience (body, emotion, cognition, society, and culture)

  • Social support model: reintegration into a positive social network

  • Persuasive model: Rituals can transform the meaning of symptoms for patients

  • Clinical model: faith in traditional healer to cure is sufficient

Disorder and demographic group

Differences in treatment groups