This lecture is about the DSM category called: Schizophrenia Spectrum and Other Psychotic
Disorders (which includes all the disorder today as well as Schizotypal PD which is next week)
All psychotic disorders share features related to distortion of reality and range in severity.
Psychotic symptoms refer to hallucinations and/or delusions. Schizophrenia is a disorder on the
severe end of psychotic disorders.
Schizophrenia and related disorders’ symptoms can be categorized as one of three things:
Positive symptoms (something is added that wasn’t previously occurring such as delusions or
hallucinations), Negative symptoms (decreased ability to perform or experience things),
Disorganized symptoms (Thoughts/behaviours which are erratic, unusual).
In general, diagnosis of psychotic symptoms involves properly assessing and determining: The
presence of the possible symptoms listed above, the time course, and whether or not mood
symptoms/episodes are present.
Delusions are false beliefs held with conviction despite firm counter-evidence or lack of logical
support. The delusions usually have an egocentric bias (I’m too good) or have to do with
something external (People are out to get me). There is a broad range in how concerned someone
is with the logic behind their delusions. For example, high logic delusions involve a person
attempting to justify/reason the delusion (ex. Rats are eating my brain so I purposely hit my brain
to activate neurons to electrocute them. However, overtime I am not losing my ability to do
things associated with the brain parts the rats are in and there are two explanations for this:
Either the brain has a capacity for rapid regeneration or the remaining brain cells are
compensating). The person may have no logic in their delusion and is thus unaware that the
delusion is an unusual belief to have (this is much more common).
Side note: the difference between a delusion and a “firmly held belief” is that a delusion persists
even with counter-evidence but firmly held beliefs less likely to persist with counter evidence.
Sometimes delusions are specified as bizarre or non-bizarre. Bizarre delusions are objectively
implausible and not understood by same-culture peers. (Ex. Someone came into my house,
replaced my kidney, left no mark behind, and now the kidneys are controlling me this is
obviously physically impossible). Example of non-bizarre: Cops are wiretapping my home
while this is unlikely this is still technically possible.
There are different themes of delusions: 1. Persecution (somebody is plotting to hurt me)
2. Reference (This book was written for me or This TV show is trying to warn my partner about
me) 3. Grandeur (I have a relationship with someone important or I am important myself
4. Control (somebody is controlling my mind or body) 5. Thought broadcasting (People can
hear my thoughts)
Hallucinations are perception-like experiences without an actual external stimulus or voluntary
control (you didn’t force yourself to perceive there is a ghost in front of you). Hallucinations can
occur in any sensory modality (but auditory is the most common with ¾ of schizophrenia
patients). Hallucinations don’t count if they happen while falling asleep or waking up. Auditory
hallucinations are common in the general pop (4-25% of people) Negative symptoms are the decreased ability to initiate action or speech, exercise emotion, or
feel pleasure. They are the most persistent and steady symptoms of schizophrenia and their
severity predicts/correlated with prognosis. The two main ones involved in schizophrenia are:
Diminished emotional expression (so they have a flat affect which includes voice, facial
expression, eye contact, voice intonation, hand/head movements BUT internally they could feel
affect so if they write a journal they will express emotional experiences) and Avolition
(decreased initiated goal-directed activities so the person can sit idle for a long time, have less
social contact, or a poorer hygiene). Additional ones include: Alogia (little to none speech
output), Anhedonia, Asociality (lack of interest in social interaction)
There are two types of Disorganized symptoms:
1. Disorganized thinking (speech) – Can include derailment/loose associations in that they
are constantly switching topics with no logical narrative. Can also include
incoherence/”word salad” in that the individual words make sense but the words together
do not mean anything/are incoherent (PSY270). However this disorganized thinking
occurs in that the person can think sensibly but the things that are said don’t make sense.
A less severe version of disorganized thinking tends to be present in the prodromal
period. This symptom can lead to social isolation
2. Grossly disorganized/abnormal motor behaviour
A. Disorganized can either mean silly/childish activity or unpredictable agitation (calm
then all of a sudden gets agitated)
B. Catatonic behaviour which is a marked decrease in responsivity to the environment.
Different types: Negativism (ignorance/resistance to instructions), Mutism (complete
lack of verbal production), Stupor (complete lack of motor responses), Echoalia
(mimicking someone’s speech), Echoproxia (mimicking someone’s movements).
(the slide before “Schizophrenia” titled “This Diagnostic Category” come back to it)
Schizophrenia
Terminology: The premorbid phase refers to the time before any clear signs of schizophrenia.
There may be subtle deficits in social or cognitive function but not in a way where you would
think they are in the prodromal or active phase. The Prodromal phase precedes the onset of the
disorder (precedes onset as in precede when criteria are actually met). Active-phase symptoms
meet Criteria A for schizophrenia (they usually come and go in the disorder). Residual phase
refers to following the diminishment of active-phase symptoms (this is remission).
See slides 20-22 for DSM. Some notes: As you can imagine, this is a very heterogeneous
disorder (take 100 people with schiz and all will present it quite differently in different
combinations of the DSM symptoms). There is also heterogeneity in severity and duration of the
active-phase symptoms (but remember overall requirement of impairment in 1+ areas)
Disturbance in criteria C refers to when you feel unusual (i.e. you realize that you don’t feel like
your normal self and the disturbance symptoms may or may not be meeting criteria A). Criteria
C: 1 month must be active phase and the rest can be a combo of prodromal, active, or residual symptoms. Criteria F: Many of the –ve or disorganized symptoms of schiz could be observed in
autism.
Schizophrenia Associated Features:
Lack of insight is fairly common and lower insight is associated with higher relapse rates (i.e.
return of active phase symptoms), more likely to refuse medication (makes sense since they
believe the things are real and that they are not ill), poorer course of illness (longer course)
There are often cognitive impairments (both premorbid and during all the phases) such as
reduced memory, executive function (inhibition), processing speed, attention disruptions (lower
attention allocated in a goal-directed manner). As well, any self-reflective processes involved in
reality testing tends to be low (Reality testing means to step back and analyze your beliefs to see
if they are actually true based on the evidence and can it be replaced by an alternative). Some say
that these cognitive impairments are part of the cause of the endurance of delusions,
hallucinations, lack of reality testing.
Aggression? Vast majority of people with schiz are no more aggressive than average but are
more likely to be victims of aggression than general pop. Only a minority of cases are associated
with hostility/aggression (more frequent among young men, those with history of violence)
Schiz is generally chronic and only a small minority recover completely (i.e. return to premorbid
functioning). There is a broad range of long-term outcomes and often these people require
support systems to help them in their daily lives. There is often cycling of onset and remissions
of active phase symptoms. Sometimes there is progressive deterioration over the course of life
(more impaired).
Schiz statistics: 1% life time prevalence. Often some signs of abnormality present in early years
(ex. emotionality such as negative or reactive). There is an even sex ratio (women tend to have
somewhat better outcomes in men but women have onset in late 20s and beyond whereas men
have onset in early 20s). It is associated with a shorter life expectancy due to increased risk of
suicide, accidents, obesity, smoking.
Schizophrenia Etiological Factors
Brain damage in youngsters is one possible cause. There is also a genetic component to
schizophrenia Family studies have shown that parents’ severity symptoms in line with kid
severity of symptoms. Some studies find that there is a more general genetic predisposition for
psychotic disorders to run in families rather than just specifically schizophrenia.
Risk is also correlated with the proportion of genes shared with an affected individual.
Monozygotic twins = 50% concordance rate, Dizygotic = 18-20%, Siblings = 7%.
Nieces/nephews = 4%. We know that monozygotic twins have the ex
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