detailed chapter 11 notes

Chapter 11: Schizophrenia Schizophrenia: psychotic disorder characterized by major disturbances in thought, emotion, & behaviour - involves:  disordered thinking in which ideas are not logically related  faulty perception and attention flat or inappropriate affect, bizarre disturbances in motor activity they withdraw from people and reality, often into a fantasy life of delusions and hallucinations - estimates of prevalence in general population vary between 0.2 and 2% - accepted life time prevalence of 1% - Asian populations have the lowest prevalence rates for schizophrenia - incidence is higher in males than females - Male to female ratio of 1:4 - can begin in childhood, but mostly appears in late adolescence or early adulthood, somewhat earlier for men than woman - people with schizophrenia typically have many acute episodes of their symptoms, and between the episodes, they will often have less severe but still debilitating symptoms - most people with schizophrenia are treated within the community - comorbid personality disorders (avoidant, paranoid, dependent and antisocial) are common and have implications for the course and clinical management of schizophrenia - comorbid substance abuse is a major problem for people with schizophrenia  relationship is especially common among men and that childhood conduct disorder problems are potent risk factors for substance use disorders in schizophrenia - comorbid anxiety and mood disorders can impose an additional burden on people with schizophrenia and result in a further decline in perceived quality of life - PTSD is highly prevalent and underdiagnosed among military veterans with schizophrenia CLINICAL SYMPTOMS OF SCHIZOPHRENIA - Symptoms of schizophrenia involve disturbances in several major areas:  Thought  Perception  Attention  Motor behaviour  Affect or emotion  Life functioning - People with schizophrenia can differ from each other more than people with other disorders do. - no essential symptom must be present for a diagnosis of schizophrenia - DSM determines for diagnostician how many problems must be present and in what degree to justify a diagnosis - duration of the disorder is also important in diagnosis - 2 main categories of symptoms: Positive symptoms- comprise excesses or distortions  they are what define an acute episode of schizophrenia. The presence of too much of a behaviour that is not apparent in most people  Disorganized speech (also known as formal thought disorder): refers to problems in organizing ideas and in speaking so that listener can understand  Incoherence: speech is marked by disconnectedness, fragmented thoughts, and jumbled phrases – difficult to understand what person is saying  Loose associations or derailment: client has difficulty sticking to one topic and drifts off on a train of associations evoked by an idea from the past  the speech of many people with schizophrenia is not disorganized and disorganized speech does not discriminate well between schizophrenia and other psychoses, like mood disorders  Delusions: beliefs held contrary to reality  Persecutory delusions (think that everyone is plotting against them) are found in 65% of schizophrenics in a large cross national sample  Person may be the unwilling recipient of bodily sensations or thoughts imposed by an external agency (eg. X-ray entering body)  People may believe that their thoughts are broadcast or transmitted, so that others know what they are thinking  People may think their thoughts are stolen from them, suddenly and unexpectedly by an external force  believe that their feelings and behaviour are controlled by an external force  Some people believe that impulses to behave in certain ways are imposed on them by some external force  Delusions can also be found in individuals with other diagnoses, especially mania and delusional depression; however, delusions of people with schizophrenia are often more bizzare  Hallucinations: sensory experiences in the absence of any stimulation from the environment (often more auditory than visual)  74% of individuals reported auditory hallucinations in one sample  The world seems different or unreal to them  A person may mention changes in how his/her body feels, or the body becomes depersonalized that it feels like a machine  Hear their own thoughts spoken by another voice  Hear voices arguing  Hear voices commenting on their behaviour Negative symptoms- behavioural deficits, strong predictor of poor quality of life  negative symptoms are the absence of behaviour that should be evident in most people  tend to endure beyond an acute episode and have profound effect of people’s lives  negative symptoms may be associated with earlier onset of brain damage (eg. Enlarged ventricles) and progressive loss of cognitive skills (eg. IQ decline)  Avolition (apathy): lack of energy and seeming absence of interest in or inability to persist in what are usually routine activities  Clients may become inattentive to grooming and personal hygiene (uncombed hair, dirty nails, and dishevelled clothes)  Difficulty persisting at work, school, or household chores, and may spend much of their time sitting around doing nothing  Alogia: negative thought disorder  Contains two aspects: 1) In poverty of speech, the sheer amount of speech is greatly reduced 2) In poverty of content of speech, amount of speech is adequate, but it conveys little information and tends to be vague and repetitive  Anhedonia: inability to experience pleasure  Manifested as a lack of interest in recreational activities, failure to develop close relationships with other people, and lack of interest in sex  Clients are aware of this symptom  Flat affect: virtually no stimulus can elicit an emotional response  Client may stare vacantly, muscles of the face drooping, eyes lifeless  Clients answers in flat and toneless voice  Flat affect found in majority of people with schizophrenia  Refers only to the outward expression of emotion and not to the person’s inner experience – clients reported same amount of emotion and were physiologically aroused similarly to regular individuals after watching emotional films, but they were much less facially expressive than regular individuals  Asociality: having severely impaired social relationships  Individuals have few friends, poor social skills, and little interest in being with other people  This symptom is often the first to appear, beginning in childhood Other symptoms:  Catatonia: several motor abnormalities, including repeated gesturing, using peculiar and sometimes complex sequence of finger, hand and arm movements that often seem to be purposeful  Unusual increase in their overall level of activity (which might include much excitement, wild flailing of the limbs, and great expenditure of energy similar to that seen in mania)  Catatonic immobility: clients adopt unusual postures and maintain them for very long periods of time (eg. stand on one leg, with the other tucked up toward the buttocks)  Waxy flexibility: another person can move the person’s limbs into strange positions that they maintain for extended periods  Inappropriate affect: emotional response of these individuals are out of context (client may laugh when he has heard someone has died, or become enraged when asked a simple question about how a new garment fits)  Clients are likely to shift rapidly from one emotional state to another for no apparent reason  Symptom is quite rare, but its appearance is of considerable diagnostic importance because it is very specific to schizophrenia HISTORY OF THE CONCEPT OF SCHIZOPHRENIA - Concept of schizophrenia was formulated by Emil Kraepelin and Eugen Bleuler - The early term for schizophrenia was dementia praecox -Kraepelin differentiated between two major groups of endogenous (internally caused) psychoses: manic depressive illness and dementia praecox - noted that dementia praecox tended to have an early onset (praecox) and intellectual deterioration (dementia) - Bleuler stated that early onset and intellectual deterioration does not always occur, thus called it schizophrenia from term schizein (split) and phren (mind) - came up with the concept of “breaking of associative threads (words/thoughts)” as a diagnostic symptom - data from several countries suggests that rates of schizophrenia have fallen sharply since 1960s, but have had an increase in the frequency of diagnoses of schizophrenia in US during the 20 century (due to expanded diagnostic categories) - beginning in the DSM-III and continuing in DSM-IV, US concept of schizophrenia shifted considerably from broad definition to new definition that narrows the range of people diagnosed with schizophrenia  people with symptoms of a mood disorder are specifically excluded  have schizophrenia – schizoaffective type disorder which comprises a mixture of symptoms of schizophrenia and mood disorders  requires at least six months of disturbances for diagnosis, which must have had two of the following: delusions, hallucinations, disorganized speech, disorganized behaviour, and negative symptoms  if sumptoms last only from one to six months, is categorized as schizophreniform disorder  DSM-IV differentiates between paranoid schizophrenia and delusional disorder - Delusional disorder: person is troubled by persistent persecutory delusions or by delusional jealousy (unfounded conviction that spouse or lover is cheating)  may believe that they are being followed, have somatic delusions (believing some internal organ is malfunctioning) and have delusions of erotomania (believing that 1 is loved by some other person (usually a complete stranger) - one proposal for DSM-5 is introduction of psychosis risk syndrome, which will allow young people at risk for later manifestation of schizophrenia to be identified and be treated early Categories of schizophrenia in DSM-IV: - there are three types of schizophrenic disorders included: 1) Disorganized (hebephrenic):  Speech is disorganized and difficult for a listener to follow  Clients may speak incoherently, stringing together similar-sounding words and even inventing new words, often accompanied by silliness or laughter  May have flat affect or experience constant shifts of emotion, breaking into inexplicable fits of laughter and crying  Behaviour is disorganized and not goal directed  Completely neglect their appearance (never bathing or combing hair) 2) Catatonic:  May alternate between catatonic immobility and wild excitement, but one of these symptoms may predominate  Resist instructions and suggestions and often echo the speech of others  This type is rarely seen today (perhaps because drug therapy works effectively on these bizarre motor processes), but its onset is more sudden than other forms of schizophrenia 3) Paranoid  Mainly involves the presence of predominant delusions (delusions of torments are most common)  Grandiose delusions: exaggerated sense of their own importance, power, knowledge, or identity  Delusional jealousy: unsubstantiated belief that their partner is unfaithful  May also have delusions about a sense of being tormented or spied on  Vivid auditory hallucinations often accompany the delusions  Often develop Ideas of reference: incorporate unimportant/unrelated events within a delusional framework and read personal significance into the trivial activities of others  Are often agitated, argumentative, angry and sometimes violent  More alert, emotionally responsive, and verbal than are people with other types of schizophrenia  Language is not disorganized, although it is filled with delusions - since diagnosing types of schizophrenia is extremely difficult, the reliability of these subtypes is reduced, and they have very little predictive validity (diagnosis of one over another form of schizophrenia provides little information about treating or predicting the course of problems) - also have additional supplemental types in DSM-IV:  Undifferentiated schizophrenia: people who meet the diagnostic criteria for schizophrenia but not the criteria for any of the 3 subtypes  Residual schizophrenia: client no longer meets the full criteria for schizophrenia but still shows some signs of the disorder - Heinrichs and Awad conducted a cluster analysis that identified subtypes of schizophrenia based on performances on Wisconsin Card Sorting, Weschler Adult Intelligence Scale, and measures of motor function and verbal memory:  cluster analysis identified five subtypes:  Normative, intact cognition  Executive subtype- distinguished by impairment on the Wisconsin Card Sorting test  Executive-motor subtype- had deficits in card sorting and motor functioning  Motor subtype- had deficits only in motor functioning  Dementia subtype- had pervasive and generalized cognitive impairment - Heinrichs identified several explanations for why the link between schizophrenia and cognition is much stronger:  There is disorder-related brain disturbance that could have a pervasive influence on brain systems that are active in information processing  Cognitive deficits reflect genetically determined constraints  Possible influence of chronic stress and distress on cognition in people prone to schizophrenia - research has indicated that most people with schizophrenia show mixed symptoms and very few clients fit into the pure positive or negative types - DSM-5 is looking at discontinuing the use of subtypes since they are rarely used in diagnosis, except for paranoid schizophrenia ETIOLOGY OF SCHIZOPHRENIA 1) Genetic data: - The family, twin, and adoption methods employed in the research have led researchers to conclude that a predisposition to schizophrenia is inherited Family studies  Relatives of people with schizophrenia are at increased risk, and risk increases as genetic relationship between proband and relative becomes closer  Negative symptoms of schizophrenia appear to have a stronger genetic component  Relatives of a schizophrenic index case may share not only genes but also common experiences (behaviour of a parent with schizophrenia could be very disturbing to a developing child), thus, we cannot say its purely genetic Twin studies  Concordance for identical twins is greater than fraternal  However concordance rates is less than 100% in both, thus genetic transmission alone cannot account for schizophrenia  Concordance does not increase when the proband is more severely ill Adoption studies  People who were adopted were less disabled than the children of mothers with schizophrenia  Children reared without contact with their so-called pathogenic mothers were still more likely to become schizophrenic than were the control participants  Allow the removal of confounding influences of the environment - Like other mental disorders, schizophrenia is defined by behaviour; it is a phenotype and thus reflects the influence of both genes and environment - the Genain quadruplets: all the Genain sisters developed schizophrenia by age 24 sisters experienced very different life outcomes even though they share the same genetic background – one experienced severe impairement, two of them showed better functioning but never had substantial careers or got married, while the other was able to work, marry and raise a family despite developing schizophrenia  demonstrate that course of disorder can be variable and that not all people diagnosed with schizophrenia are alike 2) Biochemical factors: - schizophrenia may be related to excess activity of dopamine – evidence seen in that antipsyc