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Chapter 12

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SCHIZOPRHENIA - 1 A. Early description/diagnosis of schizophrenia 1. Emil Kraepelin: a. Combined catatonic (i.e., alternating immobility and excited agitation), hebephrenia (i.e., silly and immature emotionality), and paranoia (i.e., delusions of grandeur and persecution) and labeled them as falling under the heading dementia praecox. b. Distinguished dementia praecox from manic-depressive illness by emphasizing onset and outcome. (Schiz. Onset early, poor prognosis.) 2. Eugen Bleuler, a Swiss psychiatrist a. First to introduce the term schizophrenia; a term derived from the Greek words for split (skhizen) and mind (phren). b. Bleuler believed that the core of schizophrenia rests in an associative splitting of basic personality functions. This concept emphasized the following: i. "Breaking of associative threads," or the breakdown of forces that connect one function to the next. ii. Bleuler also believed that an inability to keep a constant train of thought was the cause of all schizophrenic symptoms. B. Schizophrenic symptoms are heterogeneous--number of symptoms and behaviors that are not shared by all persons with the diagnosis. II. Clinical Description, Symptoms, and Subtypes A. The term psychotic refers to either delusions or hallucinations. B. Positive symptoms: 1. Delusions refer to a belief that would be seen by most members of society as a misrepresentation of reality; often referred to as a disorder of thought content. Delusions often are called the basic characteristic of madness. Some research suggests that delusions give some patients a sense of meaning and purpose in life and result in less depression. Thus, delusions may serve an adaptive function. Types of delusions include: a. Delusions of grandeur, or the belief that one is particularly famous or important. b. Delusions of persecution, or the belief that other people are out to get or harm the person. c. More unusual delusions include Capgras syndrome, or the belief that someone a person knows has been replaced by a double, and Cotard’s syndrome, where the person believes that a part of the body (e.g., brain) has changed in some impossible way. SCHIZOPRHENIA - 2 2. Hallucinations can involve any of the senses; though auditory hallucinations are most common in persons with schizophrenia. a. Single photon emission tomography (SPECT) has been used to study cerebral blood flow in schizophrenic patients during their auditory hallucinations. The part of the brain most active during auditory hallucinations is Broca’s area (i.e., the area involved in speech production), not Wernicke's area (i.e., the area involved in understanding and language comprehension). This research supports the idea that auditory hallucinations do not involve hearing voices of others, but rather listening to one’s own thoughts or voices, and a failure to recognize the difference. C. Negative: 1. Avolition (inc. show little interest in performing even the most basic daily functions, such as personal hygiene) 2. Alogia (inc. brief replies to questions with little content, delayed comments or slowed responses to questions, or as disinterest in conversation) 3. Anhedonia 4. Affective flattening, or flat affect (inc. little change in facial expression, but not the experience of appropriate emotions) D. Disorganized symptoms: 1. Disorganized speech: a. Cognitive slippage often manifests as illogical and incoherent speech where the person jumps from one topic to the next. b. Tangentiality manifests as "going off on a tangent" rather than answering a question directly. c. Loose associations or derailment 2. Other disorganized symptoms: a. Inappropriate affect b. Disorganized behavior (e.g., hoarding objects or acting in unusual ways in public). Including: i. Catatonia (inc. catatonic immobility and/or waxy flexibility). SCHIZOPRHENIA - 3 E. Schizophrenia subtypes 1. Paranoid type relatively intact cognitive skills and affect do not generally show disorganized speech or flat affect associated with the best prognosis. a. Delusions and hallucinations usually have a theme of grandeur or persecution. b. DSM-IV-TR criteria specify a preoccupation with one or more delusions or auditory hallucinations but without marked display of disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. 2. Disorganized type (hebephrenia) marked disruptions in their speech and behavior, including flat or inappropriate affect, and self-absorption If hallucinations or delusions are present, they tend to be organized around a theme, but are quite fragmented. typically show problems early and their problems tend to be chronic, lacking periods of remissions that characterize other forms of this disorder. 3. Catatonic type unusual motor responses and odd mannerisms. often show echolalia (i.e., repeating or mimicking the words of others) echopraxia (i.e., imitating the movements of others). This subtype is relatively rare. 4. Undifferentiated type do not neatly fit into any of the other subtypes and include people with major symptoms of schizophrenia but who do not meet criteria for paranoid, disorganized, or catatonic types. 5. Residual type have had at least one episode of schizophrenia but are no longer displaying the major symptoms. Often display residual symptoms, such as negative beliefs, unusual or bizarre ideas, social withdrawal, inactivity, and/or flat affect. SCHIZOPRHENIA - 4 F. Other disorders showing psychotic behaviors 1. Schizophreniform disorder have experienced symptoms of schizophrenia for a few months only and usually resume normal lives. There are few studies of this disorder, with a lifetime prevalence of 0.2%. a. DSM-IV-TR 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 social and occupational functioning, absence of blunted affect. 2. Schizoaffective disorder DSM-IV-TR criteria for schizoaffective disorder require the presence of a mood disorder and delusions or hallucinations for at least 2 weeks in the absence of prominent mood disorder symptoms. The prognosis is similar as for people with schizophrenia and such persons do not tend to get better on their own. 3. Delusional disorder (non-bizarre delusions) tend not to have flat affect, anhedonia, or other negative symptoms of schizophrenia. may, however, become socially isolated as a function of their delusions. a. The DSM-IV-TR recognizes the following delusional subtypes: i. erotomanic type is a delusion reflecting the irrational belief of being loved by another person, usually of higher status (e.g., celebrity stalkers). ii. grandiose type of delusion involves having beliefs of inflated self-worth, power, knowledge, identity, or special relationship to a deity or famous person. iii. jealous type of delusion believe that a sexual partner is unfaithful. iv. persecutory type involves believing that oneself (or someone close) is being malevolently treated in some way. v. somatic type that one has some physical defect or medical disorder. b. Delusional disorder is rare, affecting 24-30 people out of every 100,000. Average age of onset is in middle adulthood, and the disorder is slightly more common in females than males. Prognosis is better than schizophrenia, and features of delusional disorder may have a genetic component. SCHIZOPRHENIA - 5 4. Brief psychotic disorder one or more positive symptoms of schizophrenia (e.g., delusions, hallucinations, or disorganized speech or behavior) within a one-month period. This disorder is often precipitated by an extremely stressful situation and commonly dissipates on its own. 5. Shared psychotic disorder (folie a deux) develop delusions as a result of a close relationship with someone else who has delusions. Content of such delusions span the spectrum and little is known about this condition. 6. Schizotypal personality disorder (Chapter 11) is related to psychotic disorders. The characteristics of this personality disorder are similar to schizophrenia, but less severe. SCHIZOPRHENIA - 6 I. Prevalence and causes of schizophrenia A. Prevalence of schizophrenia worldwide is 0.2% to 1.5%, it will affect about 1% of the population at some point. Life expectancy slightly less than average. Women have more favorable outcomes than men. Onset greatest in early adulthood Declines with age for males, Reverse for females. 1. A more widely accepted classification system, introduced in the mid- 1970s, emphasizes positive, negative, and more recently disorganized symptoms. Accordingly, schizophrenia can be dichotomized into Type I and Type II based on several characteristics, including symptoms, response to medication, outcome, and presence of intellectual impairment. a. Type I positive symptoms, good response to medication, optimistic prognosis, absence of intellectual impairment. b. Type II negative symptoms poor response to medication, pessimistic prognosis, intellectual impairments. SCHIZOPRHENIA - 7 B. Children who eventually develop schizophrenia tend to show early abnormal signs such as more negative affect and less positive affect. It may be that brain damage early in development causes schizophrenia. Research suggests that people with schizophrenia who demonstrate early signs of abnormality at birth and during early childhood tend to do better in the long run than those that do not. Brain plasticity allows the brain to compensate for such deficits over time, whereas this is more difficult in a fully developed brain later in life. Older adults display fewer positive symptoms and more negative symptoms, suggesting that schizophrenia may improve over time. Most persons with schizophrenia fluctuate between severe and moderate levels of impairment throughout their lives, and relapse is common. C. Schizophrenia appears to be a universal world-wide phenomenon; however, the course and outcome of schizophrenia varies from culture to culture. In the U.S., more African-Americans are diagnosed with schizophrenia than whites, this difference may reflect misdiagnosis due to bias against some minority groups. SCHIZOPRHENIA - 8 D. Genetic influences are responsible for making some individuals vulnerable to schizophrenia. 1. Family studies have shown that the more severe the parent’s schizophrenia, the more likely the children were to develop it also. All forms of schizophrenia were also seen within families with histories of schizophrenia, meaning that we do not inherit a specific type of schizophrenia, but a general predisposition for schizophrenia that may differ from one family member to the next. Family members of a person with schizophrenia are also at increased risk not just for schizophrenia, but a spectrum of psychotic disorders. a. Risk for schizophrenia is associated with degree of genetic relatedness to the person with schizophrenia. Having any family member with schizophrenia increases the risk of schizophrenia in other family members above what is expected in the general population. 2. Twin studies indicate a confluence of genetic and environmental factors. monozygotic twins - 48%. Fraternal twins - 17% Genain quadruplets who shared identical genes and were raised in the same household, but differed in terms of the onset of schizophrenia, the symptoms, diagnoses, course of the disorder, and outcomes. Genain comes from the Greek meani
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