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Chapter 13

Chapter 13.docx

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PSYC 235
Meredith Chivers

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Week 1: Chapter 13: Schizophrenia Perspectives on Schizophrenia Early Figures in Diagnosing Schizophrenia - German psychiatrist Emil Kraepelin provided the most enduring description & categorization of schizophrenia - 2 of Kraepelin’s accomplishments are important: 1. combined several symptoms of insanity that had usually been viewed as reflecting separate and distinct disorders: catatonia (al-ternating immobility and excited agitation), hebephrenia (silly and immature emotionality) and paranoia (delusions of grandeur or persecution) o thought these symptoms shared similar underlying features and included them under the Latin term dementia praecox o believed an early onset at the heart of each disorder develops into “mental weakness” 2. distinguished dementia praecox from manic-depressive illness (bipolar disorder) - noted the numerous symptoms in people with dementia praecox, including hallucinations, delusions, negativism and stereotyped behavior - Eugen Bleuler, introduced the term schizophrenia • label was significant because it signaled Bleuler’s departure from Kraepelin on what he thought was the core problem • combination of the Greek words for “split” (skhizein) and “mind” (phren), reflected Bleuler’s belief that underlying all the unusual behaviors shown by people with this disorder was an associative splitting of the basic functions of personality • concept emphasized the “breaking of associative threads,” or destruction of forces that connect one function to the next • Bleuler believed that a difficulty keeping a consistent train of thought characteristic of all people with this disorder led to the many and diverse symptoms they displayed - Kraepelin focused on early onset and poor outcomes, Bleuler highlighted what he be ieved to be the universal underlying problem • unfortunately, concept of “split mind” inspired the incorrect use of schizophrenia as split or multiple personality Identifying Symptoms - schizophrenia is a number of behaviors/symptoms that aren’t necessarily shared by all people given this diagnosis - researchers have identified clusters of symptoms that make up the disorder of schizophrenia Clinical Description DSM 5 Criteria A. characteristic symptoms: 2+ of 5 symptoms must be present for at least 1 month: 1. delusions 2. hallucinations 3. disorganized speech 4. disorganized/catatonic behaviour 5. negative symptoms *** major change in DSM-5 is that schizophrenia subtypes are eliminated (ie. paranoid, disorganized, catatonic, undifferentiated, residual) due to poor psychometric strength & lack of differential treatment response • clinicians now rate severity of schizophrenia on a 0-4 dimensional scale, the Clinician-Rated Dimensions of Psychosis Symptom Survey (ie. not present, equivocal, mild, moderate & severe) • the scale applies to the 5 main schizophrenia symptoms mentioned above in addition to impaired cognition, depression & mania - there is not yet universal agreement about which symptoms should be included under these 3 main categories • positive symptoms – generally include the more active manifestations of abnormal behavior or an excess or distortion of normal behavior; these include delusions and hallucinations • negative symptoms – involve deficits in normal behavior in such areas as speech and motivation • disorganized symptoms – include rambling speech, erratic behavior, and inappropriate affect - diagnosis of schizophrenia requires 2 or more positive, negative, &/or disorganized symptoms present for at least 1 mth Positive Symptoms - positive symptoms: more overt symptoms, such as delusions & hallucinations, displayed by some people w/ schizophrenia - b/w 50% & 70% of people w/ schizophrenia experience hallucinations, delusions, or both Delusions - delusion: psychotic symptom involving disorder of thought content & presence of strong beliefs that are misrepresentations of reality - because of its importance in schizophrenia, delusion has been called “the basic characteristic of madness” - delusion of grandeur (a mistaken belief that the person is famous or powerful) - delusions of persecution (belief that others are “out to get them”, can be most disturbing) - other unusual delusions include: • Capgras syndrome: person believes someone he or she knows has been replaced by a double • Cotard’s syndrome: person believes he is dead - why do individuals’delusions exist even after being contradicted? • beliefs viewed as result of brain dysfunction – new info not properly integrated o study showed schizophrenics to produce less of a specific brain wave associated w/ integration of new info • delusional beliefs viewed as an attempt to deal with/relieve anxiety & stress o ie. person develops “stories” around some issue—ie. a famous person is in love w/ her (erotomania)— that helps person make sense out of uncontrollable anxieties in a tumultuous world Hallucinations - hallucinations: psychotic symptoms of perceptual disturbance in which things are seen, heard, or otherwise sensed although they aren’t actually present - auditory hallucinations are most common form experienced by people w/ schizophrenia - one theory of auditory verbal hallucinations states that people who are hallucinating aren’t hearing the voices of others but are listening to their own thoughts/voices & can’t recognize the difference - another theory states that auditory verbal hallucinations arise from abnormal activation of the primary auditory cortex Negative Symptoms - negative symptoms: less outgoing symptoms (ie. flat affect & poverty of speech) displayed by some people w/ schizophrenia - usually indicate the absence or insufficiency of normal behavior - include apathy, poverty of (ie. limited) thought or speech, & emotional & social withdrawal - approximately 25% of people with schizophrenia display these symptoms Avolition - avolition: apathy, or the inability to initiate or persist in important activities - the prefix a, meaning “without,” & volition, which means “an act of willing, choosing, or deciding,” - show little interest in performing basic day-to-day functions, including those associated w/ personal hygiene Alogia - alogia: deficiency in the amount or content of speech, a disturbance often seen in people with schizophrenia - a (“without”) & logos (“words”) - may respond to questions with brief replies that have little content & may appear uninterested in the conversation - such deficiency in communication is believed to reflect a negative thought disorder rather than inadequate communication skills • some researchers, for example, suggest people w/ alogia may have trouble finding the right words to formulate their thoughts - sometimes alogia takes the form of delayed comments or slow responses to questions; talking w/ individuals who manifest this symptom can be extremely frustrating, making you feel as if you are “pulling teeth” to get them to respond Anhedonia - anhedonia: inability to experience pleasure, associated with some mood and schizophrenic disorders - a (“without”) & the word hedonic (“per- taining to pleasure”) - like some mood disorders, anhedonia signals an indifference to activities that would typically be considered pleasurable, including eating, social interactions & sexual relations Affective Flattening - flat affect: apparently emotionless demeanor (including toneless speech & vacant gaze) when a reaction would be expected Asociality - severe deficits in social relationships (ie. few friendship, little interest in socializing & poor social skills) - best predictor of asociality in schizophrenics is the chronic cognitive impairment, suggesting difficulties in processing info may contribute significantly to the social skills deficits & other social difficulties displayed by many patients Disorganized Symptoms - disorganized symptoms: variety of erratic behaviours that affect speech, motor behaviour & emotional reactions - prevalence of these behaviors among those with schizophrenia is unclear Disorganized Speech - disorganized speech: style of talking often seen in people with schizophrenia, involving incoherence and a lack of typical logic patterns - people with schizophrenia often lack insight, an awareness that they have a problem - they experience what Bleuler called “associative splitting” & what researcher Paul Meehl called “cognitive slippage” • these terms describe speech problems of people w/ schizophrenia: sometimes they jump from topic to topic, at other times they talk illogically - tangentiality: going off on a tangent instead of answering a specific question Inappropriate Affect & Disorganized Behavior - inappropriate affect: laughing or crying at inappropriate times - schizophrenics engage in a number of other “active” behaviors that are usually viewed as unusual - catatonic immobility: disturbance of motor behavior in which the person remains motionless, sometimes in an awkward posture, for extended periods • can also involve waxy flexibility, or the tendency to keep their bodies and limbs in the position they are put in by someone else - to receive a diagnosis of schizophrenia, a person must display 2 or more positive, negative, &/or disorganized symptoms for a major portion of at least 1 mth Schizophrenia Subtypes - 3 divisions: 1. paranoid (delusions of grandeur or persecution) 2. disorganized (or hebephrenic; silly & immature emotionality) 3. catatonic (alternate immobility & excited agitation) Paranoid Type - paranoid type of schizophrenia: type of schizophrenia in which symptoms primarily involve delusions and hallucinations; speech and motor and emotional behavior are relatively intact Disorganized Type - disorganized type of schizophrenia: type of schizophrenia featuring disrupted speech and behavior, disjointed delusions and hallucinations, and silly or flat affect - if delusions or hallucinations are present, they tend not to be organized around a central theme, as in the paranoid type, but are more fragmented • this subtype was previously called hebephrenic • individuals with this diagnosis tend to show signs of difficulty early & their problems are often chronic, lacking the remissions (improvement of symptoms) that characterize other forms of the disorder Catatonic Type - catatonic type of schizophrenia: type of schizophrenia in which motor disturbances (rigidity, agitation & odd mannerisms) predominate - display unusual motor responses of remaining in fixed positions (“waxy flexibility” because their limbs & body position can be moved by others) & engaging in excessive activity, individuals w/ the catatonic type of schizophrenia sometimes display odd mannerisms w/ their bodies & faces, including grimacing - sometimes repeat or mimic words of others (echolalia) or movements of others (echopraxia) - may be subtypes of catatonic schizophrenia, w/ some individuals showing primarily symptoms of labeled: • “negative withdrawal” (immobility, posturing, mutism) • “automatic” (routine obedience, waxy flexi- bility) • “repetitive/echo” (grimacing, perseveration, echolalia) • “agitated/resistive” (excitement, impulsivity, combativeness) Undifferentiated Type - undifferentiated type of schizophrenia: category for individuals who meet the criteria for schizophrenia but not for one of the defined subtypes - have the major symptoms of schizophrenia but who do not meet the criteria for paranoid, disorganized, or catatonic types Residual Type - residual type of schizophrenia: people who have experienced at least one episode of schizophrenia but no longer display its major symptoms - may still display residual or “leftover” symptoms, such as negative beliefs, or have unusual ideas that aren’t fully delusional - residual symptoms can include social withdrawal, bizarre thoughts, inactivity & flat affect Other Psychotic Disorders - several other categories of disorders represent significant variations of psychotic behaviors some individuals experience that don’t fit neatly under the heading of schizophrenia Schizophreniform Disorder - schizophreniform disorder: psychotic disorder involving the symptoms of schizophrenia but lasting less than 6 mts - diagnostic criteria for schizophreniform disorder include onset of psychotic symptoms within 4 weeks of the first noticeable change in usual behavior, confusion at the height of the psychotic episode, good premorbid (before the psychotic episode) social and occupational function- ing (functioning before the psychotic episode), and the absence of blunted or flat affect Schizoaffective Disorder - schizoaffective disorder: psychotic disorder featuring symptoms of both schizophrenia & major mood disorder - prognosis is similar to the prognosis for people w/ schizophrenia -> individuals tend not to get better on their own & are likely to continue experiencing major life difficulties for many years - criteria for schizoaffective disorder require, in addition to the presence of a mood disorder, delusions or hallucinations for at least 2 wks in the absence of prominent mood symptoms *** DSM 5 attempts to make schizoaffective disorder a more longitudinal diagnosis in line with other disorders such as depression and bipolar disorder • key change -> a major mood episode must be present for most of the time during the schizoaffective disorder (helps clinicians distinguish variations among people w/ depression & psychotic symptoms) Delusional Disorder - delusional disorder: psychotic disorder featuring a persistent belief contrary to reality (delusion) but no other symptoms of schizophrenia - characterized by a persistent delusion that isn’t the result of an organic factor such as brain seizures or of any severe psychosis - individuals w/ delusional disorder tend not to have flat affect, anhedonia, or other negative symptoms of schizophrenia; importantly, however, they may become socially isolated bc. they’re suspicious of others - delusions are often long-standing, sometimes persisting over several years - DSM-IV-TR recognizes the following delusional subtypes: • erotomanic: irrational belief that one is loved by another person, usually of higher status • grandiose: believing in one’s inflated worth, power, knowledge, identity, or special relationship to a deity or famous person • jealous: believes the sexual partner is unfaithful • persecutory: believing oneself (or someone close) is being malevolently treated in some way • somatic: feels afflicted by a physical defect or general medical condition - these delusions differ from the more bizarre types often found in people w/ schizophrenia because • in delusional disorder the imagined events could be happening but aren’t (ie mistakenly believing you are being followed) • in schizophrenia, the imagined events aren’t possible (ie. believing your brain waves broadcast your thoughts to other people around the world) **** as with schizophrenia, no DSM-5b distinction made b/w bizarre & non-bizarre delusions in delusional disorder (specifier now included for bizarre content) • new exclusion: delusional disorder must not be better explained by OCD or body dysmorphic disorder • delusional disorder is no longer separate from shared delusional disorder in DSM-5 o if a person shares delusional beliefs but doesn’t meet criteria for delusional disorder, then an “other specified” disorder related to psychosis can be used Brief Psychotic Disorder - brief psychotic disorder: psychotic disturbance involving delusions, hallucinations, or disorganized speech or behavior but lasting less than 1 mth; often occurs in reaction to a stressor - individuals often regain their previous ability to function well in day-to-day activities - brief psychotic disorder is often precipitated by extremely stressful situation Shared Psychotic Disorder (Folie à Deux) ****removed in DSM 5 - shared psychotic disorder (folie à deux): psychotic disturbance in which individuals develop a delusion similar to that of a person w/ whom they share a close relationship - content and nature of the delusion originate with the partner & can range from the relatively bizarre (believing enemies are sending harmful gamma rays through your house) to the fairly ordinary (believing you are about to receive a major promotion despite evidence to the contrary) Schizotypal Personality Disorder - schizotypal personality disorder: ClusterA(odd or eccentric) personality disorder involving a pervasive pattern of interpersonal deficits featuring acute discomfort w/, & reduced capacity for, close relationships, as well as cognitive or perceptual distortions & eccentricities of behavior Catatonia**** - new DSM 5 disorder - DSM-5 alters the catatonia definition to include 3 of 12 characteristic symptoms in whatever capacity it is used - catatonia may be a specifier for psychotic disorders as well as depressive & bipolar disorders, but can also be a separate diagnosis w/ another medical condition Statistics - generally chronic & most people affected have difficulty functioning in society - tend not to establish/maintain significant relationships - even with improvement after treatment, schizophrenics are likely to experience lifetime difficulties - lifetime prevalence rate of schizophrenia is roughly equivalent for men and women, & is estimated to be 0.2% to 1.5% in the general population (means the disorder will affect around 1% of the population at some point) - difference between the
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