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University of Toronto Scarborough
Konstantine Zakzanis

Chapter 11 - Schizophrenia:  Schizophrenia – a psychotic disorder characterize by major disturbances in thought, emotion and behaviour: disordered thinking in which ideas are not logically related, faulty perception and attention, flat or inappropriate affect and bizarre disturbances in motor activity  Withdrawal from others into fantasy life with delusions  Prevalence b/w 0.2% and 2%, lifetime prevalence 1%  Asian population have lowest prevalence rates  Higher in males than females  Usually appears in late adolescence or early adulthood  Have acute episodes, in b/w episodes still have issues  10% of people with schizophrenia commit suicide  2004: 234 305 with schizophrenia in Canada, 374 deaths, costs 6.85 billion (70% productivity lost) Schizophrenia and Comorbidity:  Comorbid personality disorders (avoidant, paranoid, dependent, antisocial) are common, mood, anxiety, drug abuse  37% with substance abuse disorder also  OCD and schizophrenia often leads to suicide attempts  PTSD is highly prevalent and underdiagnosed in many military veterans  Familial association b/w schizophrenia and depression and anxiety  MDD and cannabis dependence, while developing schizophrenia Clinical Symptoms of Schizophrenia:  Disturbances in: thought ,perception and attention, motor behaviour, affect or emotion, and life functioning  Main symptoms into 2 categories: positive and negative Positive Symptoms:  Excesses or distortions, such as disorganized speech, hallucinations and delusions  Define an acute episode of schizophrenia  Presence of too much of what is present in normal people  Negative = absence of behaviour that should be evident in normal people Disorganized Speech:  Aka formal thought disorder  Problems in organizing ideas and in speaking so that a listener can understand  Incoherence - lack of clarity or organization (found in patients with schizophrenia)  Loose associations/derailment – person may be more successful in communicating with a listener, but difficulty sticking to one topic, drift off evoked by idea of the past Delusions:  Beliefs held contrary to reality  Common positive symptoms of schizophrenia o Unwilling recipient of bodily sensations or thoughts imposed by an external agency o Believe their thoughts are broadcasted or transmitted o Thoughts being stolen by an external force o Feelings controlled by an external force o Behaviour controlled by an external force o Impulses to behave a certain way by an external force Hallucinations and other Disorders of Perception:  World seems different or unreal to them  Hallucinations – most dramatic distortions of perception, sensory experiences in the absence of any stimulation from the environment o More often auditory than visual (74%) o Can be very frightening o Occur more often in schizophrenic people  Own thoughts spoken by another voice, hear voices arguing, hear voices commenting on their behaviour Negative Symptoms:  Behavioural deficits such as avolition, alogia, anhedonia, flat affect and asociality  Endure beyond an acute episode  Strong predictor of a poor quality of life  Associated with earlier onset brain damage and progressive loss of cognitive skills  Flat affect (lack of emotional expressiveness) can be result of anti-psychotic medications  Specificity also an issue hard to see differences between flat affect and depression Avolition:  Aka apathy  Lack of energy and a seeming absence of interest in or an inability to persist in what are usually routine activities  Clients become inattentive to grooming, hygiene  Difficulty persisting at work, school, household chores and sit around doing nothing Alogia:  Negative thought disorder that can take several forms  Poverty of speech: Sheer amount of speech is greatly reduced  Poverty of content speech: repetitive, long speech that is vague Anhedonia:  Inability to experience pleasure  Lack of interest in recreational activities, failure to develop close relationships, no interest in sex  Clients aware of this symptom Flat Affect:  Virtually no stimulus can initiate an emotional response  Client may seem lifeless  Speak in a flat and toneless voice  Refers only to the OUTWARD expression of emotion Asociality:  Severely impaired social relationships  More childhood social troubles, more shy, no interest in making friends Other Symptoms:  2 other symptoms don’t fit the models: catatonia and inappropriate affect Catatonia:  Several motor abnormalities – increase in activity, wild flailing of the limbs  Catatonic immobility- client adopt unusual postures and maintain them for very long periods of time  Wavy flexibility – another person can move the person’s limbs into strange positions that they can maintain or extended periods Inappropriate Affect:  Emotional responses are out of context  Likely to shift rapidly from emotional states for no reason  Symptom is quite rare, but relatively specific to schizophrenia History of the Concept of Schizophrenia: Early Descriptions:  Formulated by 2 European psychiatrists: Emil Kraeplin and Eugen Bleuler  Kraepelin: dementia praecox – early term for schizophrenia o 2 major groups of endogenous, or internally caused psychoses: manic depressive illness and dementia praecox o Dementia praecox included – dementia paranoids, catatonia and hebephrenia o They shared a common core: an early onset (praecox) and intellectual deterioration (dementia- mental enfeeblement)  Eugen Bleuler: believed the disorder did not have an early onset and believed that it did not inevitably progress towards dementia o Term: schizophrenia (schizein = split, phren =mind) o Breaking of associative threads o Attentional difficulties are a result from a loss of purposeful direction in thought o Blocking (loss of train of thought) – complete disruption of person’s associative threads o Led to a broader concept of schizophrenia Historical Prevalence of Schizophrenia:  Rates of schizophrenia fallen since the 1960s  Kasanin: schizoaffective psychosis – describes the disturbances in clients  Concept of schizophrenia broadened by 3 additional practices: (rapid increase in US b/c) o US clinicians tended to diagnose schizophrenia whenever delusions/hallucinations were present (these people may just have a mood disorder) o People who would be diagnosed with a personality disorder now diagnosed with schizophrenia o People with acute onset of schizophrenic symptoms with rapid recovery were diagnosed with having schizophrenia DSM-IV-TR Diagnosis:  More narrow range now, 5 ways to diagnose: o Diagnostic criteria are presented in explicit and considerable detail o People with symptoms of mood disorder excluded (mix of schizophrenia and mood = schizoaffective) o Requires at least 6 months of disturbance for diagnosis (one month active phase with 2 symptoms (or just one if bizarre), remaining time can be prodromal (before active phase) or residual (after active phase)), acute episode = scizophreniform disorder or brief psychotic disorder (one day to one month) o Mild forms of schizophrenia now diagnosed as personality disorders o Differentiates between paranoid schizophrenia and delusional disorder  Delusional disorder – troubled by persistent persecutory delusions or by delusional jealousy (ie. Think spouse is unfaithful)  Somatic delusions – believe organ is malfunctioning  Delusions of erotomania – believe one is loved by another person usually a complete stranger with a higher social status  People in developing countries have a more acute onset and more favourable course than those in industrialized societies DSM-5 Proposal for psychotic risk syndrome and symptom dimensions:  Psychotic risk syndrome  Among 6 criteria: one of delusions, hallucinations or disorganized speech  9 dimensions of core symptoms: hallucinations, delusions, disorganization, abnormal psychomotor behaviour, restricted emotional expression, avolition, impaired cognition, depression, mania Categories of Schizophrenia in DSM-IV-TR:  3 types of schizophrenic disorders: disorganized (hebephrenic), catatonic and paranoid, originally proposed by Kraepelin 1) Disorganized Schizophrenia:  Speech is disorganized and hard for listener to follow  Clients invent new words speak incoherently  Flat affect or experience shifts of emotion  Behaviour disorganized and not goal directed  May completely neglect their appearance 2) Catatonic Schizophrenia:  Clients typically alternate between catatonic immobility and wild excitement but one symptom may predominate  Clients resist instruction and often repeat back the speech of others  Onset is more sudden that other forms of schizophrenia  Seldom seen today b/c drug therapy works effectively  Was misdiagnosed before with what was lethargica (sleeping sickness) 3) Paranoid Schizophrenia:  Presence of prominent delusions (persecution delusions most common)  Grandiose delusions – exaggerated sense of their own importance, power, knowledge or identity  Delusional jealousy – unsubstantiated belief that their partner is unfaithful  Vivid auditory hallucinations may accompany  Ideas of reference – incorporate unimportant events within a delusional framework and read personal significance into the trivial activities of others  Agitated, argumentative, angry and somewhat violent  Emotionally responsive  More alert and verbal than people with other types of schizophrenia  Language is not disorganized Evaluation of the Subtypes:  Subtypes have little predictive validity  Considerable overlap among the types (all forms people have delusions)  Undifferentiated schizophrenia – people who meet diagnostic category but NOT for any of the 3 subtypes  Residual schizophrenia – used when the client no longer meets the full criteria for schizophrenia but still shows some signs of the disorder  Heinrichs: primacy of cognition, link of schizophrenia to cognition strong because of influence on brain systems that have a role in information processing, cognitive factors reflect genetically determined constraints, possible influence of stress/distress on cognition in people prone to schizophrenia  Andreasen and Olsen: most people with schizophrenia show mixed symptoms (+ & -), very few were purely positive or negative  Some studies show 3 symptoms: split positive into 2 categories: delusions and hallucination AND disorganized component (bizarre behaviour and disorganized speech)  DSM-5: reject all classic types of schizophrenia and rejected alternatives take their place o Why? Because subtypes rarely used with the exception of paranoid schizophrenia and maybe undifferentiated schizophrenia o Findings do not point to a single system of subtyping Etiology of Schizophrenia: The Genetic Data:  Predisposition genetically to schizophrenia (inherited)  Identical twin very likely to have schizophrenia Family Studies:  Relatives with people with schizophrenia at a HIGH risk  Negative symptoms have a stronger genetic component  Relatives also at risk for other disorders (less severe forms of schizophrenia)  Also influence of environment as a key factor (ie. Parent influences child) Twin Studies:  Identical twins (44.4%), fraternal (12.08%)  Predisposition increases when twin more severely ill  Environment could be the main factor (intrauterine environment – share same blood supply)  Fischer: non-schizophrenic twins would have genotype for schizophrenia, just not expressed o Might pass along an increased risk for children  Negative symptoms have a stronger genetic component Adoption Studies:  Children of women with schizophrenia more likely to be diagnoses as mentally defective, psychopathic, neurotic  More frequently involved in criminal activity  Children reared away from schizophrenic mothers still schizophrenic (therefore strong genetic factor) Molecular Genetics:  Thaker (why hunt for schizophrenic genes is hard) o Lack of preciseness in defining boundaries of clinical phenotype o Absence of biological tests that confirm diagnostic categorization o Clinical heterogeneity and the complex nature of schizophrenia  Endophenotypic strategy – Gottesman and Shields – reflect actions of genes predisposing an ind to a disorder even in the absence of diagnosable pathology o Ind endophenotypes assumed to be determined by fewer genes o Thus complexity would be reduced  Serotonin type 2A receptor gene dopamine D3 receptor gene and chromosomal regions 6, 8, 13 and 22  Microdeletion of chromosome 22  DTNBP1  G protein signalling 4 – gene localized to chromosome lq23  Overlap between schizophrenia and bipolar disorder Evaluation of the Genetic Data:  Schizophrenia defined by behaviour  Must keep in mind diff between genotype and phenotype  Genian quadruplets – (diasthesis stress and biopsychosocial models)  Stress required to spark schizophrenia  Not been possible to specify how predisposition of schizophrenia transmitted  Exact nature of inherited diasthesis is unknown The Genain Quadruplets:  All sisters had schizophrenia by age 24  Sisters experienced very diff life outcomes  Hester – severe impairment, never completed high school  Iris and Nora – better, but never had careers/married  Myra – worked, married and raise a family  Course of disorder can vary Biochemical Factors:  Neurotransmitter – norepinephrine and serotonin  Dopamine – best researched factor Dopamine Activity:  Excess activity of dopamine  Anti-psychotic drugs produced effects of Parkinson’s disease (low dopamine)  Anti – psychotic drugs block dopamine receptors (D2 receptors)  Excess activity in dopamine nerve tracts  Dopamine theory – amphetamine psycho
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