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Lecture 8

PSY240H1 Lecture 8: Schizophrenia & Other Psychotic Disorders

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Christine Burton

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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