Schizophrenia, Antisocial Personality Disorder, and Treatments

Hallucinations

• Can involve any sensory modality (auditory, visual, etc.).
• Auditory hallucinations are common, such as hearing voices (e.g., God, the devil).

Delusions

• False beliefs that are not based in reality.
• Often persecutory, where individuals believe others are out to get them.
• Example: A patient believing Samsung is tracking their every move.
• Delusions can be unconnected to personal experiences.
• Example: An individual believing a helicopter beamed a song into their head.
• Delusions of grandeur: Overinflated sense of importance.
• Example: Believing they have a cure for cancer without medical training.
• Delusional thinking can lead to dangerous actions (e.g., attempting to self-harm due to a false belief).

Disorganized Thoughts and Behavior

• Incoherent storytelling that is hard for others to follow.
• Loose associations between unrelated things.
• Considered a positive symptom.

Positive Symptoms of Schizophrenia

• Hallucinations.
• Delusions.
• Disorganized thoughts and behaviors (excessive and confusing information).

Negative Symptoms of Schizophrenia

• Flattened affect: Diminished or socially inappropriate emotional expressions.
• Example: Describing an emotionally charged situation with a flat affect.
• Reduced or slowed-down speech: Giving one-word answers or slow responses.
• Social withdrawal: Isolating themselves.
• Reduced eye contact: Can be unsettling to others.

Concreteness of Thought

• Difficulty thinking abstractly.
• Example: Taking the question "What's on your mind today?" literally.
• Example: Interpreting "Can I take your picture?" as a request to give a photograph.

Case Example: Gerald

• Exhibits disorganized thinking.
• Loosely connected thoughts.
• Delusional ideas (grandiose and paranoid).
• Disturbances in mood (absent or inappropriate).
• Disordered behavior and inexplicable mannerisms.
• Auditory hallucinations accusing him of assaulting women.
• Voices telling him to leave because he will be hurt.

Risk Factors for Schizophrenia

• Genetics play a role.
• Twin studies: If an identical twin has schizophrenia, there's a 48\% chance the other twin will also have it. For fraternal twins, the chance is significantly lower.
• If a biological parent has schizophrenia, there's approximately a 13\% chance the child will also have it.
• Underactive frontal lobes:
  • Frontal lobes are important for planning, decision-making, and controlling behavior.
  • Underactivity makes it harder to organize thoughts, make good decisions, and filter out irrelevant information.
• Enlarged ventricles:
  • Ventricles provide shock absorption for the brain.
  • Enlargement due to deterioration of brain tissue around the ventricles.
  • The causality between schizophrenia and deterioration is unclear.
• Environmental factors:
  • Mother getting the flu during the second trimester increases the child's likelihood of developing schizophrenia, especially if the child is genetically predisposed.
  • Children with biological parents who have schizophrenia are at increased risk if they experience adverse childhood experiences.
  • A stable and loving adoptive environment can decrease the likelihood of developing schizophrenia, even with genetic vulnerability.
• Vulnerability-stress or diathesis-stress model: Combines genetic and environmental factors.

Antisocial Personality Disorder

• Marked by guiltlessness, lawbreaking, exploitation of others, and deceitfulness.
• Individuals do not conform to social norms or obey rules.
• Deceitfulness: Tendency to lie or con others for personal gain.
• Manipulative and self-centered.
• Lack of empathy for others.
• Aggressiveness: More likely to get into physical altercations.
• Associated with criminal behavior (though not all individuals with the disorder commit crimes).
• The term "psychopathy" was used until the 1980s and then replaced with antisocial personality disorder in the DSM.
• Psychopaths: An extreme version of antisocial personality disorder with callousness and dangerousness.
• Not all individuals with antisocial personality disorder are violent or dangerous, but they tend to be manipulative and have reduced empathy.

Factors Associated with Antisocial Personality Disorder

• Genetic vulnerability: Tends to run in families.
• Childhood factors: Neglect, abuse, unstable parenting, exposure to violence.
• More likely in men than women.
• Linked to lower levels of arousal, leading to sensation-seeking behavior and crime.
• Reduced anxiety: Do not experience as much anxiety when anticipating punishment.
• Less active amygdala: The amygdala is involved in fear detection and anxiety.

Treatment of Antisocial Personality Disorder

• Individuals tend to be manipulative, including with therapists.
• Therapists try to build up mentalizing skills: Thinking about the thoughts, feelings, and emotions of others.
• Recognizing that others have emotions and needs can reduce harmful manipulative behavior.
• Progress tends to be slow, and treatment focuses on managing behaviors and symptoms rather than completely treating the disorder.

Clinical Psychology

• The subfield of psychology that focuses on preventing and treating psychological disorders.
• Two main types of approaches:
  • Psychotherapy: A nonmedical process used to treat psychological disorders through various methods; often referred to as "talk therapy."
  • Biological therapies: Treatments that help people manage their symptoms by altering bodily functions, such as prescription drugs.
• Psychiatrists can prescribe medication. They are medical doctors with intensive training in psychiatric hospitals.

Effectiveness of Psychotherapy

• A meta-analysis found convincing evidence that psychotherapy is effective. 80\% of those who received psychotherapy reported better health outcomes than those who did not.
• Psychotherapy uses evidence-based treatment, using a treatment program that is supported by science.
• Effective in a remote context, such as during the COVID-19 pandemic.
• Placebo effect: Thinking you are receiving psychotherapy can be effective.

Evidence-Based Practice

• Using the best available research: Using empirically supported treatments.
• Cognitive behavioral therapy has emerged as one of the best empirically supported treatments for various psychological disorders.
• Therapist expertise and clinical judgment: Adapting treatment if an empirically supported approach is not working.
• Client characteristics and preferences: Respecting the client's preferences, even if the therapist thinks a different treatment would be best.

Factors Important for the Effectiveness of Psychotherapy

• Therapeutic alliance: The relationship between the client and the therapist.
  • Characterized by trust, respect, and cooperation.
  • Consensus about goals, course of the treatment.
  • A strong therapeutic alliance predicts the likelihood that therapy will be successful.
• Characteristics of the therapist: Empathetic and understanding therapists tend to have better results. Level of experience also matters.
• Characteristics of the client: Being an active participant in the therapy.
  • The client's participation was the single best predictor of whether or not the therapy was effective.
  • Levels of social support also seem to matter.
• Strong predictor of having a good outcome is the extent to which the client wants to be there and is motivated to make the therapy work.

Cognitive Behavioral Therapy (CBT)

• Negative or unhelpful thoughts and feelings can play a major role in psychological problems.
• Address these maladaptive cognitions and maladaptive patterns of behavior and correct those patterns of behavior. You can address things like systematic desensitization and using classical conditioning to try to combat things like phobias.

Drug Therapies

• Drug treatments revolutionized mental healthcare in the 20th century.
• Medications are now commonly used to treat psychological disorders.
• There is no perfect amount of neurotransmitter in your brain, so it's not a perfect one-to-one relationship between neurotransmitter levels and symptoms.
• Drugs are often used in conjunction with psychotherapy.

Antipsychotic Drugs

• Aim to diminish agitated behavior, reduce tension, and decrease hallucinations.
• Used to treat schizophrenia.
• Very powerful medications with potentially severe side effects.
• Neuroleptics: A type antipsychotic drug that works by blocking dopamine's action in the brain.
• Effective at treating the positive symptoms of schizophrenia but are not really effective to treat the negative symptoms of schizophrenia.
• Treat the symptoms of schizophrenia but don't really address the cause.

Antidepressant Drugs

• Selective Serotonin Reuptake Inhibitors (SSRIs):
  • Block the reuptake process, making it more likely that neuron two is going to brain.
  • Tend to have very few side effects, and the side effects tend to be relatively mild.
  • Commonly prescribed antidepressants.
  • It typically takes anywhere from two to three weeks before the individual will start to see an improvement in their depressive symptoms.

Antianxiety Drugs

• Sometimes known as tranquilizers because they tend to make people a little calmer and a little less excitable.
• Benzodiazepines:
  • Influence the amount of GABA in the brain, increasing the amount of GABA.
  • GABA is an inhibitory neurotransmitter, meaning it's used to reduce activity in the brain. (Brain’s break pedal).
• If you've ever consumed alcohol and you've noticed that it has a calming effect or that it reduces anxiety that's because ethanol passes through the blood brain barrier and it effectively mimics what GABA does in the brain.
• Benzodiazepines side effects are inhibitory and can lead to things like drowsiness and fatigue.
• Individuals using benzodiazepines are usually told not to drive or operate machines due to the increased threat they propose due to lack of inhibitions.
• Can also be very, very addictive and can lead to things like dependence.

Treatment for Bipolar Disorder

• Lithium: Largely considered the gold standard for medication treating bipolar disorder because it seems to be effective at treating both manic and depressive episodes.
• Very effective at reducing suicide rates in those with bipolar disorder.
• Lithium exact mechanism for improving bipolar disorder is still a bit of a mystery, but it is thought to influence or increase the volume of the hippocampus.
• Has to be carefully monitored by the clinician.
  • If you give someone too much lithium that can be very toxic so it has to be monitored very closely by a specialist.

Alternative Biological Therapies

• Electroconvulsive Therapy (ECT) or Electroshock Therapy:
  • Uses small electric currents to produce a small, somewhat controlled seizure.
  • Used for very resistant cases of things like depression where therapies and medications simply aren't working.
  • Patients with cases are given electrical brain stimulation where electrodes are placed on the scalp passing currents to about one second pulses of electricity.
  • ECT is thought to be fairly safe one of the big side effects is that you will get this short-term amnesia.
    • Very common for patients to not remember things that happened right before the procedure; oftentimes, though those memories come back and are thought to be a fairly safe procedure.
• Transcranial Magnetic Stimulation (TMS):
  • Uses a small magnetic field to stimulate certain brain areas.
  • Stimulating can be very targeted via electromagnetic energy within certain areas of the brain to activate.
  • TMS has become a very popular method for treating depression even more popular than ECT. Still, though, it's often only used for treatment-resistant depression.
  • Clinicians might try TMS when drugs and psychotherapy aren't working.
  • It is a little unclear exactly how it works, but the idea is that stimulating those brain areas might be changing the patterns of activity in those brain areas, so increasing the amount of neurotransmitters in those areas, you get the general understanding.