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University of Guelph
PSYC 3390
Mary Manson

Abnormal Psychology –Week 10 Schizophrenia -a significant loss of contact with reality, referred to as psychosis. DSM-IV-TR Criteria-  2 or more of the following present for a significant portion of one month: delusions, hallucinations, disorganized speech, catatonic/grossly disorganized behaviour, negative symptoms. -only one symptom is needed if delusions are bizarre/hallucinations consist of a voice keeping a running commentary of person’s behaviour/thoughts, or 2+voices conversing. dysfunction in work, interpersonal relations or self-care signs of disturbance for at least 6 months Case Study: Emilio: 40 years old: looks 10 years younger: his mother is afraid of him- dresses in a ragged overcoat, slippers, ball cap and medals around his neck. Affect ranges from anger at his mother to giggling. Childlike speech and manner. Walks with a mincing step and exaggerated hip movements. Stopped taking meds 1 month ago and has since begun hearing voices and act more bizarre. Speech often rhymes and is incoherent. Has been hospitalized 12 times, doesn’t take meds after leaving hospital. Dropped out of school at 16, hasn’t been able to hold a job, lives with mom but often disappears for months at a time. -schizophrenia is about as prevalent as epilepsy. Lifetime morbid risk = 1.0% (1 out of every 100 people who live to at least 55 will develop schizophrenia) -children whose fathers are older (45-50 years) at the time of their birth have 2-3 times the normal risk of developing schizophrenia -people of Afro-Caribbean origin living in the UK have a higher rate -rates are unusually high in western Ireland and Croatia, and especially low in Papua New Guinea. -often begins in late adolescence, early childhood. Sometimes, but rarely found in children. Can also have initial onset at middle age, but not typically. -tends to begin earlier in men (peaks between 20-24 years), peaks at the same age for women, but peak is much lower. After 35, men developing schizophrenia drops drastically, where women has a second increase that begins around 40 years. -average age of onset: men- 25 years, women- 29 years -males often develop more severe forms of schizophrenia. -it is likely that schizophrenia is milder in women because of higher levels of estrogen (when estrogen levels are low/falling, psychotic symptoms in women with schizophrenia often get worse). The protective effect of estrogen may then help the delayed onset of schizophrenia in women. Declining levels of estrogen around menopause might explain the late-onset. Origins -first clinical description of schizophrenia- John Haslam at Bethlem Hospital in London.  James Tilly Matthews was patient. Suffered Delusions -50 years later, Belgian psychiatrist Benedict Morel  13 year old boy who had been brilliant in school suddenly became withdrawn, lethargic, reclusive and forgot everything he’d learned.- described it as demence precoce (mental deterioration at an early age) -German psychiatrist emil kraepelin- best known for his description of schizophrenia. Used the term dementia praecox to refer to a group of conditions that seemed to feature mental deterioration beginning early in life. – described the patient as someone who “becomes suspeicious of those around him, sees poison in his food, is pursued by the police, feels his body is being influenced, or thinks that he is going to be shot or that the neighbours are jeering at him”- also noted that the disorder was characterized by hallucinations, apathy and indifference, withdrawn behaviour and incapacity for regular work. -Swiss Psychiatrist Eugen Bleuler used the term schizophrenia (schizien= German for split, phren = Greek meaning mind) meant it as a jeckyll and hyde sort of thing Delusions -delusion= an erroneous belief that is fixed and firmly held despite clear contradictory evidence. -comes from the latin verb ludere, meaning to play (ie tricks on the mind) -disturbance in the content of thought (believe in things that others of similar background do not_ -ie false beliefs: people with delusions don’t always have schizophrenia Hallucinations -Hallucination: a sensory experience that occurs in the absence of any external perceptual stimulus. -very different from an illusion (which is a misperception of an existing stimulus) -occur in any sensory modality (5 senses) -auditory hallucinations are the most common (75%) -visual hallucinations are uncommon (less than 15%), tactile hallucinations even more rare. -hallucinations often have relevance for the patient at an affective, conceptual or behavioural level (ie: Nayani and David (1996) studied hallucinating patients – 73% reported that the voices usually spke at conversational volume and were often voices of people known to the patient in real life. Voices of God/Devil also sometimes heard. -voices were often worse when alone and rude/vulgar, criticizing, bossy or abusive. -some voices can be pleasant and supportive -PET and fMRI scans show that patients with auditory hallucinations show increased activity in Broca’s area (involved in speech production) rather than the auditory Wernicke’s area) similar patterns to normal people asked to imagine someone talking to them -research suggests that auditory hallucinations occur when patients misinterpret their own self-talk/inner speech Disorganized Speech -disorganized speech is the external manifestation of a disorder in thought form. -an affected person fails to make sense, despite seeming to conform to the semantic and syntactic rules of communication. -Meehl described it as “cognitive slippage” (incoherence) -words and combinations sound communicative, but in fact they make no sense. In some cases, completely new words (neologisms) appear in the patient’s speech. (ie: detone) Disorganized and Catatonic hehaviour -disorganized behaviour is an impairment of routine daily functioning such as work, relations and self-care (ie dressing in unusual manner- scarf/parka on a hot day) -Catatonia- patient may show absence of all movement and speech (called a catatonic stupor). At other times, the patient may hold an unusual posture for an extended period of time without discomfort. Negative symptoms -positive symptoms are those that reflect an excess or distortion in a normal repertoire of behaviour and experience (ie delusions/hallucinations -negative symptoms reflect an absence or deficit of behaviours that are normally present (ie flat emotion, little speech, avolition (no ability to initiate goal-directed activities) -a preponderance of neg symptoms is not a good sign for the patient’s future outcome. Subtypes of Schizophrenia Paranoid –shows a history of increasing suspiciousness and of severe difficulties in interpersonal relationships. – persecutory delusions are more frequent. Delusions of grandeur are also common as an explanation to why they are being persecuted, followed or spied on. -DSM: preoccupation with delusions/frequent auditory hallucinations; no evidence of marked disorganized speech, disorganized catatonic behaviour or inappropriate affect. Disorganized- usually occurs at an earlier age and has a gradual, insidious onset. DSM– characterized by disorganized speech, disorganized behaviour, flat or inappropriate affect, no evidence of catatonic schizophrenia. : ie case study Emilio -hallucinations/delusions may be present, but not formed into a meaningful story like paranoid Catatonic- central feature is pronounced motor signs, either of an excited or stuporous type. Highly suggestible and will obey commands/imitate actions of others (echopraxia) or mimic phrases (echolalia. -DSM:2 of the following: immobile body/stupor, excessive motor activity that is purposeless and unrelated to outside stimuli, extreme negativism (resistance to being moved/follow instructions)/mutism, assumption of bizarre postures, Echolalia or echopraxia. Undifferentiated type- meets the usual criteria for schizophrenia in varying combinations and does not clearly fit into one of the previous types. Residual type- used for people who have suffered at least one episode of schizophrenia but do not show any prominent positive symptoms (ie hallucinations, delusions or disorganized speech/behaviour. Contains mostly negative symptoms. Other psychotic disorders Schizoaffective disorder-an illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed episode that co-occurs with symptoms of Schizophrenia (delusions, hallucinations, disorganized, or negative symptoms). During the illness, there must be a period of at least 2 weeks where delusions have been present without mood symptoms, but the mood symptoms are present for a substantial proportion of the total illness time -unclear whether this is a variant of schizophrenia or a mood disorder. -long term (10 year) outcome is better for schizoaffective patients than for schizophrenic Schizophreniform disorder- symptoms of schizophrenia; an episode of the disorder (including the prodromal, active and residual phases) that lasts at least 1 month but less than 6 months, so do not warrant a diagnosis of schizophrenia. – could be early onset of later schizophrenia Selusional disorder- nonbizarre dilusions (ie: involving situations that could occur in real life such as being followed/poisoned) that last at least 1 month, no evidence of full-blown schizophrenia, apart from the delusion functioning is not markedly impaired; neither is behaviour obviously odd/bizarre. Brief psychotic disorder-presence of one or more of: delusions, hallucinations, disorganized speech/behaviour/catatonic behaviour. Episode lasts at least one day, less than one munth with an eventual return to normal functioning. Diagnosis of Mood disorder with psychotic features: schizoaffective disorder or schizophrenia is ruled out. Shared psychotic disorder-aka folie a deux-a delusion that develops in someone who has a very close relationship with someone who is delusion. The delusion is similar in content to that of the person who established the delusion. Causes of Schizophrenia Genetic-10% likely prevalence of schizophrenia in the first-degree relatives (parents, siblings, children). 3% for second degree relatives (half-siblings, aunts, uncles, cousins). 50% prevalence for identical twins. Twin studies- the most famous concordance rate for schizophrenia is in the Genain quadruplets (monozygotic)- all were concordant for schizophrenia, but discordant in severity of illness. Most severe was the sister born last. Third born was the highest functioning. Eventually went into remission. Higher concordance among identical siblings (monozygotic) -not exclusively a genetic disorder however, because the concordance rate for identical twins is only 50%, not 100%. -twin studies show that environment also plays a role Age-correlated incidence rate -17.4% for the offspring of nonschizophrenic monozygotic twins- very similar to the rate of di-zygotic twins Twin and Adoption studies -Heston’s study began by identifying mothers with schizophrenia and then tracing what had happened to their adopted- away offspring. An alternative approach involves locating adult patients with schizophrenia who were adopted early in life and then looking at rates of schizophrenia in their biological and adoptive relatives. -Finland adoption study: One measure of the family environment that the researchers looked at was communication deviance ( Wahlberg & Wynne, 1997). Communication deviance is a measure of how understandable and “ easy to follow” the speech of a family member is. Vague, confusing, and unclear communication reflects high communication deviance. What Wahlberg and colleagues found was that it was the combination of genetic risk and high communica-tion deviance in the adopted families that was problem-atic. Children who were at genetic risk and who lived in families where there was high communication deviance showed high levels of thought disorder at the time of the follow- up. -children with a genetic risk for schizophrenia are more likely to develop the disorder if they are raised in dysfunctional family environments: suggest that our genetic makeup may control how sensitive we are to certain aspects of our environments. Molecular genetics -linkage analysis: using DNA markers, researchers can locate a few important genes associated with observable traits (ie colour blindness)- they are looking to see if something like schizophrenia co-occurs with any known DNA marker traits. -candidate genes-genes known to be involved in some of the processes thought to be aberrant in schizophrenia (ie genes implicated in dopamine metabolism) Prenatal issues -because more people in the northern hemisphere with schizophrena are born between January and March (than would be expected by chance)- Kraepelin suggested that perhaps some seasonal factor (ie a virus) could cause schizophrenia during prenatal/perinatal development. -similarly, 1957 there was a flu epidemic in finland-Researchers found elevated rates of schizophrenia of kids born to mothers who had been in their 2 ndtrimester of pregnancy during the epidemic. -Rheus (Rh) incompatibility (when an Rh negative mother carries an Rh positive fetus) is also associated with increased risk for schizophrenia. Possibly because of hypoxia -research also shows that complicated pregnancies/deliveries are associated with schizophrenia Development -studies viewing home videos found that preschizophrenic children showed more motor abnormali-ties including unusual hand movements than their healthy siblings; they also showed less positive facial emotion and more negative facial emotion. In some instances these dif-ferences were apparent by age 2. (Walker) -endophenotypes- discrete, measurable traits thought to be linked to specific genes that might be important in schizophrenia. Biological aspects -brain volume- compared with controls, patients with schizophrenia have enlarged brain ventricles, with males possi-bly being more affected than females- only in a minority of patients, and also in patients with alzheimers, huntington’s and alcoholics. Enlarged brain ventricles are important because they are an indicator of a deficit in the amount of brain tissue. Brain areas- Many studies have demonstrated that patients with schizophrenia show ab-normally low frontal lobe activation ( known as “ hy-pofrontality”) when they engage in mentally challenging tasks such as the Wisconsin Card Sorting Test or in other tests generally thought to require substantial frontal lobe involvement. Moreover, according to research conducted by R. Walter Heinrichs at York University, the poor perfor-mance on such cognitive tasks is one of the most striking ways that people with schizophrenia differ from normal controls ( Heinrichs, 2005). Essentially, the frontal lobes do not seem to be able to kick into action when patients per-form complex tasks Cytoarchitecture- overall organization of cells in the brain. Canadian Focus- RWJ (Jim) Neufeld- developed a comprehensive dynamic vulnerability model, which posits that genetic factors and environmental stressors interact in complex, mutually reinforcing ways: According to the model, genetic vulnerability to schizophrenia influences the person’s ability to cope and affects the way she or he appraises ( interprets) stressful events. In turn, coping is said to influence the genetically mediated vulnerability to develop schizophrenia symptoms. Neurochemistry- chemical imbalances in the brain. Dopamine (the dopamine hypothesis)- chlorpromazine (used to treat schizophrenia) linked to the blocking of dopamine receptors. Amphetamines produce a functional excess of dopamine: as seen in the 50s, the abuse of amphetamines led to a form of psychosis that involved paranoia and auditory hallucinations. Finally, studies done that treated patients by giving them drugs that increase amount of dopamine in the brain led to psychosis. Glutamate- an excitatory neurotransmitter that is widespread in the brain, researchers have begun to suspect that a dysfunction in glutamate transmission might be involved in schizophrenia. First, PCP, or angel dust, is known to block glutamate receptors. PCP also induces symptoms ( both positive and negative) that are very similar to those of schizophrenia. -physicians had to stop using ketamine, which is an anesthetic, because when it is given intravenously to normal subjects, it produces schizophrenia- like positive and negative symptoms: but not when given to kids, This suggests that age ( and brain maturity) determines whether ketamine causes psychosis. -Somewhere between 54 and 86 percent of people with schizophrenia also show eye- tracking dysfunction and are deficient in their ability to track a moving target such as a pendulum -Mad House by Clea Simon- grew up with 2 older siblings who developed schizophrenia. -expressed emotion, or EE. Expressed emotion is a measure of the family envi-ronment that is based on how a family member speaks about the patient during a private interview with a researcher. It has three main elements: criticism, hostility, and emotional overinvolvement ( EOI). The most important of these is crit-icism, which reflects dislike or disapproval of the patient.--> might trigger relapse because of schizophrenia stress sensitivity. -Being raised in an urban environment seems to increase a person’s risk of developing schizophrenia. Recent immigrants are also at higher risk. immigrants with darker skin have a much higher risk of de-veloping schizophrenia than do immigrants with lighter skin- because of discrimination? -schizophrenia development twice as likely in the general population who smoke weed Clinical outcome: The most recent studies of clinical outcome show that 15 to 25 years after developing schizo-phrenia, around 38 percent of patients have a generally favourable outcome and can be thought of as being recovered -Finally, patients who live in less industrialized countries do better than patients who live in more industrialized nations Pharmacological approaches First- generation antipsychotics are medications like chlorpromazine ( Largactil) and haloperidol ( Haldol) that were among the first to be used to treat psychotic disorders. Sometimes referred to as neuroleptics ( literally, “ seizing the neuron”),- revolutionized treatment second- generation antipsychotic medications are risperidone ( Risperdal), olanza
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