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Chapter 11

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Chapter 11 • Psychosis: unable to tell the difference between what is real and what is unreal; many forms and causes; number of psychotic disorders in the DSM • Schizophreniform disorder: same symptoms as schizophrenia, lasting more than one month but less than six months • Schizoaffective disorder: symptoms of schizophrenia coinciding with symptoms of depression or mania, but at least two week period when only symptoms of schizophrenia present • Delusional disorder: evidence only of non-bizarre delusions (ex: one if being followed or deceived) of at least one month’s duration; functioning at relatively high level • Brief psychotic disorder: presence of delusions, hallucinations, disorganized speech or behaviour for at least one day but less than one month • Shared psychotic disorder: individual in a close relationship with someone who is delusional with similar delusions (aka folie a deux) • Substance induced psychotic disorder: hallucinations or delusions caused by the direct physiological affects of a substance (like cocaine) • Schizophrenia: at least one month of acute symptoms of delusions, hallucinations, disorganized thought and speech, disorganized behaviour and negative symptoms and at least six months of some symptoms of disorder • Costs of schizophrenia: over 90% of sufferers seek treatment in a mental health facility; direct health care and non-health care costs $2.02 billion a year but with other factors estimated to be $6.85 billion; likely to develop in late teenage or early adult years; need continual services as it tends to be a lifelong disorder • Prevalence: 0.5-2% of the Canadian population diagnosed with a schizophrenia- spectrum disorder; very stigmatized; research suggest most sufferers live independent or in their family’s home; higher incidence in immigrants than native born populations; more common in men than women and women tend to have better premorbid histories; female onset in late 20s or early 30s and they show fewer cognitive deficits o Gender differences: not well understood; oestrogen may affect dopamine regulation in ways that are protective for women; normal sexual differences in brain might explain cognitive deficits; slower pace of prenatal brain development in male (higher risk for brain insults); greater abnormalities in brain structure/functioning in male sufferers than female Symptoms • Positive symptoms: type I symptoms; characterized by presence of unusual perceptions, thoughts or behaviours; represent very salient experiences; can occur in other disorders so can make differentiation between schizophrenia and mood disorder with psychotic features; psychotic symptoms should occur substantially in absence of depression or mania for diagnosis of schizophrenia • Delusions: ideas that an individual believes are true but are unlikely or simply impossible; different from self-deceptions in that delusions are often completely implausible (which self-deceptions are not), people tend to be preoccupied with their delusions, looking for evidence and taking action based on them and people holding delusions are resistant to arguments/compelling facts contradicting these delusions; can be simple and transient but are often complex, elaborate and long- standing; several types can co-occur and work together o Persecutory delusion: oneself or one’s loved ones are being persecuted, watched or conspired against by others o Delusion of reference: random events are directed at oneself; connected to persecutory and sometimes part of a grandiose belief system o Grandiose delusion: one has great power, knowledge or talent or that one is a famous and powerful person o Delusions of being controlled: one’s thoughts, feelings or behaviours are being imposed or controlled by an external force  Thought broadcasting: one’s thoughts are being broadcast from one’s mind for others to hear  Thought insertion: another person/object is inserting thoughts into one’s head  Thought withdrawal: thoughts are being removed from one’s head by another person/object o Delusion of guilt/sin: one has committed a terrible act or is responsible for a terrible event o Somatic delusion: one’s appearance or body part is diseased/altered • Hallucination: unreal perceptual experiences; can occur in otherwise healthy people precipitated by exhaustion, stress, alcohol or drugs; can involve any sensory modality o Auditory hallucination: hearing voices, music, etc; most common type; more common in women than men; ex: accusatory voices, voices encouraging self-harm; schizophrenics can try to talk back to the voices o Visual hallucination: often accompanied by auditory ones; ex: see Satan o Tactile hallucinations: perception that something is happening to the outside of one’s body; ex: bugs crawling on flesh o Somatic hallucination: perception that something is happening inside one’s body; ex: worms are eating one’s intestines • Disorganized thought and speech: often referred to as formal thought disorder; tendency to slip from one topic to seemingly unrelated topic with little coherent transition (loosening of associations or derailment); word salads; making up words that have meaning only to oneself (neologisms); repeat words or statements (perseverate); schizophrenic men tend to show more severe deficits in language than women, possibly because language is controlled more bilaterally in women while it is quite localized in men o Smooth pursuit eye movement: keeping one’s head still and tracking a moving object; suggests cognitive and attentive deficits; one study suggests deficits may be relatively independent of schizophrenia symptoms • Working memory: deficits in capacity to hold information in memory and manipulate it; hard to suppress unwanted or irrelevant information or to pay attention to relevant information; impair ability to learn and retrieve new information; research suggests that memory deficits are so comprehensive no single model can account for the heterogeneity of dysfunction • Disorganized/catatonic behaviour: unpredictable or untriggered agitation, suddenly shouting, swearing or pacing; socially unacceptable behaviour; trouble organizing daily routines; concentration used to accomplish a single task o Catatonia: group of disorganized behaviours that reflect an extreme lack of responsiveness to the outside world o Catatonic excitement: one type in schizophrenia; person becomes wildly agitated for no apparent reason and is difficult to subdue; may articulate delusions or hallucinations and be incoherent; can be infused with angry and agitated outbursts • Negative symptoms: type II symptoms; losses or deficits in certain domains; absence of usual emotional and behavioural responses; difficult to diagnose reliably as involve absence (not presence) of behaviours, lie on a continuum between normal and abnormal and can be caused by a host of other factors (social isolation, depression, medicine side effects); less responsive to medications • Affective flattening: also called blunted affect; severe reduction in or complete absence of emotional responses to the environment; monotone, unresponsive body language, immobile face, lack of eye contact; distinguish between this lack of overt expression of emotion and actual experience of emotion/arousal (which schizophrenics do report but often can’t express) • Alogia: poverty of speech; severe reduction in or complete absence of speech; may not initiate speech or give brief, empty replies; lack of motivation to speak or lack of thinking? • Avolition: inability to persist at common goal-directed activities; difficulty completing tasks and is disorganized, careless and unmotivated; may withdraw and become socially isolated • Other symptoms: depression, anxiety, substance abuse, inappropriate affect, anhedonia and impaired social skills; many are not part of formal diagnostic criteria but occur frequently • Inappropriate affect: laughing at sad things or crying at happy ones; inappropriate emotional reactions as opposed to flattened reactions; may occur because they are thinking about something other than what is occurring in the environment or because brain processes that match stimuli with the proper emotions and emotional responses aren’t working properly • Anhedonia: loss of interest in everything in life (similar to what characterizes depression); lose ability to experience, not just express, emotion • Impaired social skills: difficulty in holding conversations, maintaining relationships and holding a job; due more to negative symptoms than positive ones; negative symptoms can lead to lower educational attainments, less success in holding jobs, poorer performance on cognitive tasks, poorer prognosis; chronic disengaged mode Diagnosis • Emile Kraepelin: German psychiatrist credited with the most comprehensive and accurate description of schizophrenia; labelled disorder dementia praecox (precocious dementia) in 1883 and believed it resulted from premature deterioration of the brain; thought it progressive, irreversible and chronic; narrow definition so only a small percentage of people received the diagnosis; Europeans th stuck with this definition into 20 century • Eugen Bleuler: disagreed with Kraepelin’s view that this disorder always developed at an early age and always led to severe deterioration; introduced the label schizophrenia (“split” and “mind”); believed it involve the splitting of usually integrated psychic functions of mental associations, thoughts, emotions; th much broader and this definition was adopted by clinicians in the US in early 20 century; pendulum did swing back towards narrower definition in 1980 • DSM IV TR diagnostic criteria: presence of severe symptoms for at least one month and the presence of some symptoms for at least six months o Core symptoms: two or more of the following present for at least a one- month period – delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviour or negative symptoms o Social/occupational functioning: significant impairment in work, academic performance, interpersonal relationships or self-care o Duration: continuous signs of the disturbance for at least six months; at least one month of this period must include symptoms that meet Criterion A above • Before and after onset: unusual but not delusional beliefs; strange perceptual experiences but not full blow hallucinations; remain coherent but speak in tangential way; peculiar behaviour; negative symptoms especially prominent o Prodromal symptoms: present before people go into acute phase of schizophrenia o Residual symptoms: present after they come out of the acute phase • Diagnostic criteria for schizoaffective disorder: main difference between this and schizophrenia is presence of severe mood symptoms in schizoaffective; schizophrenic symptoms present even when mood symptoms are absent o Uninterrupted period of illness during which, at some time, there is either a major depressive episode, a manic episode or a mixed episode concurrent with symptoms that meet Criterion A for schizophrenia o During the same period of illness, there have been delusions or hallucinations for at least two weeks in the absence of prominent mood symptoms o Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness • Type I schizophrenia: positive symptoms much more prominent than negative • Type II schizophrenia: negative symptoms much more prominent than positive; distinction not part of DSM IV diagnostic framework • Schizophrenia subtypes: DSM division; three have specific symptoms that differentiate them from each other; other two are not characterized by specific differentiating symptoms but by a mix that are either acute or attenuated; not uncommon to experience multiple subtypes over time • Paranoid schizophrenia: best known and most researched; prominent delusions and hallucinations that involve themes of persecution and grandiosity; many do not show grossly disorganized speech/behaviour but may be lucid and articulate with elaborate stories of plotting; highly resistant to arguments against delusions; can act arrogantly; suicidal or violent towards others; prognosis better than for other types of schizophrenia; can live independently, hold a job and show better cognitive/social functioning; onset occurs later in life and psychotic episodes are triggered by stress; considered milder, less insidious form • Disorganized schizophrenia: incoherence in cognition, speech and behaviour and flat/inappropriate affect; odd, stereotyped behaviours and frequent grimacing or mannerisms; may be so disorganized they don’t bathe, dress or eat if left alone; early onset and continuous course, which is often unresponsive to treatment; most disabled by the disorder • Catatonic schizophrenia: very rare, not well researched, most distinct features; variety of motor behaviours and ways of speaking that suggest almost complete unresponsiveness to their environment; diagnosis requires two of the following symptoms – catatonic stupor (remaining motionless for long periods of time), catatonic excitement (excessive and purposeless motor activity), maintenance of rigid postures or complete mutism for long periods of time, odd mannerisms (grimacing or hand flapping) and echolalia (senseless repetition of words just spoken by others) or echopraxia (repetitive imitation of another’s movements) • Undifferentiated schizophrenia: acute symptoms that meet the criteria for schizophrenia (delusions, hallucinations, disorganized speech, disorganized behaviour, negative symptoms) but don’t meet the criteria for one of the three subtypes; relatively early onset, chronic and difficult to treat • Residual schizophrenia: at least one acute episode of acute positive symptoms of schizophrenia but no current positive symptoms; continual signs of the disorder, including negative symptoms and mild versions of positive ones; can have these chronically for several years Prognosis • Factoids: between 50-80% of the people will be re-hospitalized for schizophrenic episodes; ten year less life expectancy for schizophrenics; 10-15% commit suicide; higher incidence of infectious and circulatory disease; most people do not show progressive deterioration in functioning across the life span and most stabilize within 5-10 years of their first episode; duration of episodes and number of re-hospitalizations decline as one ages; between 20-30% of treated people recover substantially or completely within 10-20 years of onset; poorer courses compared to other disorders • Age and gender factors: women have a more favourable course than men; hospitalized less often and for briefer periods, show milder negative symptoms and show better social adjustment (may be do to later onset); functioning might improve with age as may find treatments, learn to recognize symptoms, aging of brain might reduce likelihood of new episodes, reduction of dopamine in brain • Socio-cultural factors: more benign course in developing countries (less likely to remain incapacitated); social environments may facilitate adaptation and recovery better; broader and closer family networks (no one person responsible for care); lower measures of hostility, criticism and over-involvement; deviant behaviour may be more socially acceptable in men than in women; women have better social skills or larger networks Biological theories of schizophrenia • Genetic contributors: gene for schizophrenia has not been found and many scientists believe that no single genetic abnormality accounts for this complex disorder or set of disorders; some argue for a polygenic additive model (certain number/configuration of genes); having more disordered genes increases both the likelihood of developing schizophrenia and the severity of the disorder o Family studies: Gottesman discovers that one’s risk for developing schizophrenia decreases substantially as one’s genetic relationship to a person with schizophrenia becomes more distant; children of two parents with schizophrenia and monozygotic twins of schizophrenics (10% chance) share the greatest number of genes; increases risk but does not mean an individual will develop schizophrenia; doesn’t necessarily indicate genetic transmission as exposure to stressful, chaotic environment and poor parent-child skills can influence outcome o Adoption studies: strong evidence that adoptees carried genetic risk for schizophrenia (Heston); biological relatives of adoptees with schizophrenia 10x more likely to have a diagnosis than biological relatives of adoptees without (Kety); 10% of children whose biological mothers had schizophrenia have developed it (Tienari) o Twin studies: concordance for monozygotics 46% and 14% for dyzygotic; 83% of variation in schizophrenia due to genetic factors, which may play in even greater role in the more severe forms than in mild forms; other biological, environmental or birth factors can influence manifestation of the disorder • Structural brain abnormalities: neurodevelopmental disorder; variety of factors lead to abnormal development of brain in utero and early in life o Enlarged ventricles: major structural abnormality found most consistently in schizophrenia; ventricles are fluid filled spaces in the brain; enlarged ones suggest atrophy or deterioration in other brain tissue; schizophrenics with ventricular enlargement also show reductions in the prefrontal areas of the brain and an abnormal connection between the prefrontal cortex and the amygdala and hippocampus  Effects: tend to show social, emotional and behavioural deficits before core symptoms, have more severe symptoms and less responsiveness to meds; men have more severely enlarged ventricles (maybe because men show greater loss of tissue volume/increase in ventrical size with age and so neuroanatomical abnormalities are exacerbat
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