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Chapter 11


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University of Toronto Scarborough
Konstantine Zakzanis

Chapter 11: Schizophrenia • Schizophrenia is a psychotic disorder characterized by major disturbances in thoughts, emotions, 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. • Hospitalization rates are typically much higher among young men relative to young women. About 10% of people with schizophrenia commit suicide. • Despite recent advances in treatment, many people with schizophrenia remain chronically disabled. The disability can be attributed to symptoms inherent to schizophrenia, as well as the comorbid disorders from which approximately 50% of those with schizophrenia suffer. Schizophrenia and Comorbidity • Comorbid personality disorders (e.g. avoidant, paranoid, dependent, and antisocial) are common and have implications for the course and clinical management of schizophrenia, that treatment should include evaluation of co-occurring substance use disorders (especially alcohol and cannabis abuse or dependence) and that attention to associated mood (especially Major Depression Disorder) and anxiety syndromes (particularly social phobia) may be important for “optimal” outcomes. • Comorbid substance abuse is a major problem for people with schizophrenia. • Comorbidity with OCD is also related to a previous history of suicidal ideation and suicide attempts. Clinical Symptoms of Schizophrenia • The symptoms of people with schizophrenia involve disturbances in several major areas: thought, perception, and attention; motor behaviour; affect or emotion; and life functioning. • No essential symptom must be present for a diagnosis of schizophrenia. Thus, people with schizophrenia can differ from each other more than do people with other disorders. Positive Symptoms • Positive symptoms comprise excess or distortions, such as disorganized speech, hallucinations, and delusions. They are what define, for the most part, an acute episode of schizophrenia. Positive symptoms are the presence of too much of a behaviour that is not apparent in most people. While the negative symptoms are the absence of a behaviour that should be evident in most people. Disorganized Speech • Also known as formal thought disorder, disorganized speech refers to problems in organizing ideas and in speaking so that a listener can understand. • Speech may also be disordered by what are called loose associations, or derailment. In these cases, the person may be more successful in communicating with a listener but has difficulty sticking to one topic. • Disturbances in speech were at one time regarded as the principal clinical symptoms of schizophrenia, and they remain one of the criteria for the diagnosis. Delusions • Delusions, beliefs held contrary to reality, are common positive symptoms of schizophrenia. • The following descriptions of these delusions are draw from Mellor (1970) ­ The person may be the unwilling recipient of bodily sensations of thoughts imposed by an external agency. ­ People may believe that their thoughts are broadcast or transmitted, so that others know what they are thinking. ­ People may think their thoughts are being stolen from them, suddenly and unexpectedly, by an external force. ­ Some people believe that their feelings are controlled by an external force. ­ Some people believe that their behaviour is controlled by an external force. ­ Some people believe that impulses to behave in certain ways are imposed on them by some external force. Hallucinations and Other Disorders of Perception • The most dramatic distortion of perception are hallucinations, sensory experiences in the absence of any stimulation from the environment. • Some people with schizophrenia report hearing their own thoughts spoken by another voice. • Some people claim that they hear voices arguing. • Some people hear voices commenting on their behaviour. Negative Symptoms • The negative symptoms of schizophrenia consist of behavioural deficits, such as avolition, alogia, anhedonia, flat affect, and asociality. • There is also some evidence that negative symptoms are associated with earlier onset of brain damage (e.g. enlarged ventricles) and progressive loss of cognitive skills. Avolition • Apathy or avolition refers to a lack of energy and a seeming absence of interest in or an inability to persist in what are usually routine activities. Alogia • A negative thought disorder, alogia can takes several forms. In poverty of speech, the sheer amount of speech is greatly reduced. In poverty of content of speech, the amount of discourse is adequate, but it conveys little information and tends to be vague and repetitive. Anhedonia • An inability to experience pleasure is called anhedonia. It is 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 symptoms are report that normally pleasurable activities are not enjoyable for them. Flat Affect • In people with flat affect, virtually no stimulus can elicit an emotional response. The client may stare vacantly, the muscles of the face flaccid, the eyes lifeless. When spoken to, the client answers in a flat and toneless voice. Asociality • Some people with schizophrenia have severely impaired social relationships, a characteristic referred to as asociality. They have few friends, poor social skills, and little interest in being with other people. Catatonia • Catatonia is defined by several motor abnormalities. • At the other end of the spectrum is catatonic immobility: clients adopt unusual postures and maintain them for very long periods of time. • Catatonic people may also have waxy flexibility, whereby another person can move the person’s limbs into strange positions that they maintain for extended periods. Inappropriate Affect • Some people with schizophrenia have inappropriate affect. The emotional response of these individuals are out of context; for example, the client may laugh on hearing that his or her mother just died or become enraged when asked a simple question about how a new garment fits. History of The Concept of Schizophrenia Early Descriptions • The concept of schizophrenia was formulated by two European psychiatrists, Emil Kraepelin and Eugen Bleuler. Kraepelin first presented his notion of dementia praecox the early term for schizophrenia in 1898. • Dementia praecox included several diagnostic concepts – dementia paranoids, catatonia, and hebephrenia – that had been regarded as distinct entities by clinicians in previous decades. • The “dementia” in dementia praecox is not the same as the dementias we discuss in the chapter on aging, defined principally by severe memory impairments. The Historical Prevalence of Schizophrenia • The concept of schizophrenia was further broadened by three additional diagnostic practices: 1. U.S clinicians tended to diagnose schizophrenia whenever delusions or hallucinations were present. Because these symptoms, particularly delusions, occur also in mood disorders, many people with a DSM-II diagnosis of schizophrenia may actually have had a mood disorder. 2. People whom we would now diagnose as having a personality disorder were diagnosed as having schizophrenia according to DSM-II criteria. 3. People with an acute onset of schizophrenic symptoms and a rapid recovery were diagnosed as having schizophrenia. The DSM-IV-TR Diagnosis • DSM-IV-TR requires at least six months of disturbance for the diagnosis. The six-month period must include at least one month of the active phase, which is defined by the presence of at least two of the following: delusions, hallucinations, disorganize speech, grossly disorganized catatonic behaviour, and negative symptoms. • A person with delusional disorder is troubled by persistent persecutory delusions or by delusional jealousy, which is the unfounded conviction that a spouse or lover is unfaithful. There are also delusions of being followed, somatic delusions (believing that some internal organ is malfunctioning) and delusions of erotomania (believing that one is loved by some other person, usually a complete stranger with a higher social status. DSM-Proposal For Psychotic Risk Syndrome and Symptom Dimensions • Psychosis risk syndrome: Syndrome proposed by DSM-5 work group to identify young people at risk of developing schizophrenia or other psychoses. Disorganized Schizophrenia • Kraepelin’s hebephrenic form of schizophrenia is called disorganized schizophrenia in DSM-IV-TR. Speech is disorganized and difficult for a listener to follow. Catatonic Schizophrenia • The most obvious symptoms of catatonic schizophrenia are the catatonic symptoms described earlier. Clients typically alternate between catatonic immobility and wild excitement, but one of these symptoms may predominate. These clients resist instructions and suggestions and often echo (repeat back) the speech of others. Paranoid Schizophrenia • The diagnosis paranoid schizophrenia is assigned to a substantial number of recently admitted clients to psychiatric hospitals. The key to this diagnosis is the presence of prominent delusions. Delusions of persecution are most common, but clients may experience grandiose delusion, in which they have an exaggerated sense of their own importance, power, knowledge, or identity. Some clients are plagued by delusional jealousy, the unsubstantiated belied that their partner is unfaithful. • Clients with paranoid schizophrenia often develop ideas of reference; they incorporate unimportant events within a delusional framework and read personal significance into the trivial activities of others. Evaluation of the Subtypes • Undifferentiated schizophrenia applies to people who meet the diagnostic criteria of schizophrenia but not the criteria for any of the three subtypes. The diagnosis of residual schizophrenia is used when the client no longer meets the full criteria for schizophrenia but still shows some signs of the disorder. Etiology of Schizophrenia Family Studies • The negative symptoms of schizophrenia appear to have a stronger genetic component. Adoption Studies • Children reread without contact with their so-called pathogenic mothers were still more likely o become schizophrenic than were the control participants. Molecular Genetics • It does not appear that the genetic predisposition to schizophrenia is transmitted by a single gene; several multi- or polygenic models remain viable. • The hunt for schizophrenia-related gens has proven more difficult than expected for several reasons, including: 1. Lack of preciseness in defining the boundaries of the clinical phenotype. 2. Absence of biological tests that confirm diagnostic categorization. 3. Clinical heterogeneity and the complex nature of schizophrenia. • Endophenotypes are characteristics that reflect the actions of genes predisposing an individual to a disorder, even in the absence of diagnosable pathology. Biochemical Factors Dopamine Activity • The theory that schizophrenia is related to excess activity of dopamine is based principally on the knowledge that drugs effective in treating schizophrenia reduce dopamine activity. • The dopamine receptors that are blocked by first-generation or conventional antipsychotics are called D2 receptors. • Further indirect support for the dopamine theory comes from the literature on amphetamine psychosis. Amphetamines can produce a state that closely resembles paranoid schizophrenia. • Exc
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