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Chapter 13

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University of Waterloo
Allison Kelly

PSYCH 257: March 12, 2013 Chapter 13: Schizophrenia and Other Psychotic Disorders Schizophrenia: devastating psychotic disorder that may involve characteristic disturbances in thinking (delusions), perception (hallucinations), speech, emotions, and behaviour Perspectives on the Concept of Schizophrenia EARLY FIGURES IN DIAGNOSING SCHIZOPHRENIA Emil Kraepelin has 2 important accomplishments in the description and categorization of schizophrenia: 1) Combined several symptoms of insanity under the term of dementia praecox (“premature loss of mind”, early label for schizophrenia emphasizing the disorder’s frequent appearance during adolescence) - Catatonia: disorder of movement involving immobility or excited agitation - Hebephrenia: silly and immature emotionality - Paranoia: irrational delusions of grandeur or persecution 2) Distinguished dementia praecox from bipolar disorder - Dementia praecox involves early age of onset and a poor outcome Eugen Bleuler - Introduced the term schizophrenia (combined the Greek words of “split” and “mind” - Believed that there was an associative splitting of the basic functions of personality (eg. cognition, emotion, perception) - Disorder defined by the difficulty of keeping a consistent train of thought IDENTIFYING SYMPTOMS - Unlike many other mental disorders, schizophrenia cannot be defined by a particular behaviour, way of thinking, or emotion - People with schizophrenia do not necessarily share all the same behaviours or symptoms Clinical Description - Schizophrenia involves psychotic behaviour o Psychotic: disorder involving delusions, hallucinations, loss of contact with reality or disorganized speech or behaviour - Must have 2 or more characteristic symptoms for at least one month: delusions, hallucinations, disorganized speech, grossly disorganized behaviour, and negative symptoms - 2 people may receive the same diagnosis but have different symptoms POSITIVE SYMPTOMS: more overt symptoms of schizophrenia Delusions: psychotic symptoms involving disorder of thought content and presence of strong beliefs that are misrepresentations of reality Types of delusions: o Delusion of grandeur o Delusion of persecution o Cotard’s syndrome: person believes a part of his/ her body has changed in some impossible way o Capgras syndrome: person believes that someone he/she knows has been replaced by a double - Individuals with current delusions expressed a much stronger sense of purpose and meaning in like and less depression in comparison to people who previously had delusions HALLUCINATIONS: psychotic symptom of a perceptual disturbance in which things are seen or heard or otherwise sensed although they are not real or actually present - Auditory hallucinations (hearing things that aren’t there) are the most common - One theory is that auditory hallucinations are actually one’s own voice (not the voice of others), but one is unable to recognize the difference - Another theory is that auditory hallucinations arise from the abnormal activation of the primary auditory cortex o Auditory hallucinations were found to be associated with increased metabolic activity in the left primary auditory cortex and in the right middle temporal gyrus NEGATIVE SYMPTOMS: less outgoing symptoms, such as flat affect and poverty of speech, indicates the absence or insufficiency of normal behaviour Avolition: apathy, or the inability to initiate or persist in important activities o Little interest in performing the most basic of functions (eg. maintaining personal hygiene) o Avolition is more highly associated with poor outcome Algoia: deficiency in the amount or content of speech o May respond to questions with brief replies that have little content o May appear uninterested in the conversation o May have trouble finding the right words to formulate thoughts o Delayed comments or slow responses to questions Anhedonia: inability to experience pleasure o Indifference to activities that would be considered pleasurable (eg. eating, social interactions, and sexual relations) o Relates to a delay in seeking treatment for schizophrenia Flat Affect: apparently meaningless demeanour (including toneless speech and vacant gaze) when a reaction is expected o Vacant stare, flat and toneless speech, seem unaffected by the things going on around them o Responding to the situation on the inside but not reacting openly o Difficulty expressing emotion, not a lack a emotion Asociality: severe deficits in social relationships o Few friendships, little interest in socializing, and poor social skills o Also associated with shyness and inhibition in childhood o Best predictor of asociality is chronic cognitive impairment (difficulties in processing information) DISORGANIZED SYMPTOMS: variety of erratic behaviours that affect speech, motor behaviour, and emotional reactions Disorganized speech: style of talking that involves incoherence and a lack of typical logical patterns o Tangentiality: going off on a tangent instead of answering the question o Cognitive slippage, associative splitting, loose association, derailment Inappropriate Affect: emotional displays that are improper for the situation o Laughing or crying at improper times o Bizarre behaviours (eg. hoarding objects or acting in unusual ways in public) Disorganized Behaviour o Catatonia: disorder of movement involving immobility or excited agitation Catatonic immobility: Wild agitation (eg. disturbance of motor behaviour in excitedly move their which the person remains fingers or arms in motionless, sometimes in an stereotyped ways) awkward position for extended o Waxy flexibility: the tendency to keep their bodies and limbs in the position they are put in by someone else SCHIZOPHRENIA SUBTYPES System for subtyping schizophrenia into 2 types, emphasizing the positive, negative, and disorganized symptoms by Strauss, Carpenter, and Bartko - Type I: positive symptoms of hallucinations and delusions, good response to medication, optimistic prognosis, absence of intellectual impairment - Type II: negative symptoms of flat affect, poverty of speech (algoia), poor response to medication, pessimistic prognosis, and intellectual impairments Alternative system of subtypes based on Kraepelin’s concept of schizophrenia: Paranoid Type: type of schizophrenia with symptoms primarily involving delusions, hallucinations o Speech, motor, and emotional behaviour are relatively intact (do not have disorganized speech or flat effect) o Typically have a better prognosis than other forms of schizophrenia o Delusions and hallucinations usually share a theme (eg. grandeur or persecution) o Patients with the paranoid type of schizophrenia are suggested to have particular deficits in social information processing Disorganized Type (hebephrenic): type of schizophrenia featuring disrupted speech and behaviour, disjointed delusions, and hallucinations, and silly or flat affect o May seem self-absorbed and spend considerable amounts of time looking at themselves in the mirror o Delusions or hallucinations, if present, are not organized around a central theme o Experience difficulty early, problems are chronic, and lack improvement in symptoms Catatonic Type: type of schizophrenia in which motor disturbances (rigidity, agitation, odd- mannerisms) pre-dominate o Display odd mannerisms with their bodies and faces o Echolalia: repeat or mimic the words of others o Echopraxia: repeat or mimic the movements of others o Subtypes of catatonic schizophrenia: - “negative withdrawal”- immobility, posturing, mutism - “automatic”- routine obedience, waxy flexibility - “repetitive/echo”- grimacing, perseveration, echolalia - “agitated/recessive”- excitement, impulsivity, combativeness Undifferentiated Type: category for individuals who meet the criteria for schizophrenia but not for any one of the defined subtypes Residual Type: people who have experienced at least one episode of schizophrenia, and no longer display its major symptoms but still have some residual symptoms o Residual symptoms: negative beliefs, unusual ideas that are delusions, social withdrawal, bizarre thoughts, inactivity, and flat affect OTHER PSYCHOTIC DISORDERS Schizophreniform Disorder: psychotic disorder involving the symptoms of schizophrenia but lasting less than six months o Onset of psychotic symptoms within 4 weeks of the first noticeable change in usual behaviour, confusion at the height of the episode, good premorbid social and occupational functioning, and the absence of blunted or flat affect Schizoaffective Disorder: psychotic disorder featuring symptoms of both schizophrenia and major mood disorder o Individuals do not get better on their own and are likely to continue experiencing difficulties for many years o There must have been delusions/ hallucinations for at least 2 weeks without prominent mood symptoms Delusional Disorder: psychotic disorder featuring a persistent belief contrary to reality but no other symptoms of schizophrenia o May become socially isolated because of their suspicion of others o Delusions are long-standing, sometimes persisting several years o Delusional subtypes: - Erotomanic: mistaken belief that a higher-status and unsuspecting person is in love with him/her (eg. celebrity stalkers) - Grandiose: belief in one’s inflated worth, power, knowledge, identity, or special relationship to a deity or a famous person - Jealous: believes sexual partner is unfaithful - Persecutory: belief that he/she is being malevolently treated in some way - Somatic: person feels afflicted by a physical defect or general medical condition o Delusions could be happening (plausible) but aren’t o Delusion disorder is rare; with a late onset (40’s); affect more females than males o People with delusions are able function relatively well and lead normal lives Brief Psychotic Disorder: psychotic disturbance involving delusions, hallucinations, or disorganized speech/ behaviour o Lasts one month or less; regaining previous ability to function in day-today activities o Occurs in reaction to a stressor Shared Psychotic Disorder (Folie à Deux): psychotic disturbance in which an individual develops a delusion similar to that of a person with whom he/ she shares a close relationship with o Suggested that it occurs in predisposed individuals who become socially isolated with a psychotic person Schizotypical Disorder: personality disorder displaying less severe characteristics of schizophrenia STATISTICS - Generally chronic, people have difficulty functioning in society despite improvements from treatment - Low ability to relate to others → tend not to establish and maintain significant relationships → may never marry or have children - Lifetime prevalence rate is around 1% of the population - Life expectancy is slightly lower; partly due to the higher rate of suicide, accidents, obesity, smoking, angina, and respiratory problems - Age of onset for men diminishes with age; age of onset for women is slightly lower than men; more women than men affected later in life - Women have more favourable outcomes than men DEVELOPMENT - Abnormal signs are present before characteristic symptoms appear o More abnormal emotional reactions, less positive and more negative affect - Although the age of onset varies, schizophrenia is generally seen by early childhood - Brain damage in the early developmental period may lie dormant until later development - People with schizophrenia at birth and early childhood tend to fare better than people who don’t o The earlier the damage occurs, the more time the brain has to compensate - Older adults tend to display fewer positive symptoms (delusions, hallucinations) and more negative symptoms (speech and cognitive difficulties) - Most people fluctuate between severe and moderate levels of impairment throughout their lives CULTURAL FACTORS - Schizophrenia is universal, affecting all racial and cultural groups - Course and outcome may differ from culture to culture o Ex. in Columbia, India, and Nigeria, more people improve significantly/ recover than other countries; perhaps due to cultural variations or prevalent biological differences - Blacks were more likely to be detained against their will, brought to the hospital by the police, and given emergency injections → not a cultural distinction but a misdiagnosis - Other factors (eg. cannabis abuse) may contribute to higher rates of psychiatric admissions Causes GENETIC INFLUENCES - Genes are responsible to making some individuals vulnerable to schizophrenia - No single gene is responsible but multiple genes combine to produce vulnerability Family Studies o Kallman found that the severity of the parent’s disorder influenced the likelihood of the children having schizophrenia o All forms of schizophrenia were seen within families; inherit a general predisposition for schizophrenia that manifests in the same form or a different one from your parent o Families that have a member with schizophrenia are at risk for a range of psychotic disorders related schizophrenia Twin Studies o Genain quadruplets all had schizophrenia but the time of onset, symptoms and diagnoses, the course of the disorder, and their outcomes all differed o Despite being raised in the same environment, personal experiences will result in varying degrees of biological and environmental stress Adoption Studies o Even when raised away from their biological parents, children of parents with schizophrenia have a much higher change of having the disorder themselves o Being raised in a healthy, supportive home environment reduces the risk of schizophrenia The Offspring of Twins o Can be a “carrier” (have the genes that predispose you to schizophrenia but not show the disorder yourself) o The probability of you having schizophrenia when your parent… - Is an identical twin with schizophrenia → 17% - Has an identical twin with schizophrenia → 17% - Is a fraternal twin with schizophrenia → 17% - Has a fraternal twin with schizophrenia → 2% Gene-Environment Interactions o Havi
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