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Chapter 11

PSY240 Chapter 11

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University of Toronto St. George
Hywel Morgan

Chapter 11: Schizophrenia  Schizophrenia: a psychotic disorder characterized by major disturbances in thought, emotion, and behavior.  Prevalence: 0.2% - 2%; lifetime prevalence is generally accepted to be 1%  It is underestimated because some people do not admit to have schizophrenia, and the population does not include homeless, hospitalized or supervised residential people.  Can be cultural variant  More males than females (1.4 times more)  Onset: late adolescence or early adulthood; earlier in men than women  Acute episodes of the symptoms  “Early treatment adaptations in case of early non-remission are mandatory” Schizophrenia and Comorbidity  Comorbid personality disorders are common and have implications for the course and clinical management of schizophrenia  Substance abuse is a major problem for people with schizophrenia; 37% of the people with schizophrenia comorbid with substance abuses.  Prodromal phase of schizophrenia: wide variety of comorbid psychiatric syndromes, esp MDD and cannabis dependence. 11.1 Clinical Symptoms of Schizophrenia  Several important factors: thought, perception, attention, motor behavior, emotion, life functioning, and duration of the symptoms  Key to understand schizophrenia: recognizing its heterogeneity at the empirical and conceptual levels Positive Symptoms  Positive Symptoms: comprise excesses or distortions, such as disorganized speech, hallucinations and delusions. It is the presence of too much of a behavior (abnormally)  Disorganized Speech  Also known as thought disorder, disorganized speech  Incoherence: the images and fragments of thought are not connected.  Loose associations or derailment: The person has difficulty to stick to one topic.  However, the patients with mood disorder in manic episode can have the problems with disorganized speeches, too. (misdiagnose with bipolar disorders)  Delusions  Beliefs held contrary to reality (such as persecuting others)  65% of the delusions are persecuted delusion  The delusions are likely presented as follow: o The person may be the unwilling recipient of bodily sensations or thoughts imposed by an external agency o People may believe that their thoughts are broadcast or transmitted, so that others know what they are thinking o People may think their thoughts are being stolen from them, suddenly and unexpectedly, by an external force o Some people believe that their feelings are controlled by an external force o Some people believe that their behavior is controlled by an external force o Some people believe that impulses to behave in certain ways are imposed on them by some external force  Hallucinations and Other Disorders of Perception  Hallucinations are the most dramatic distortions of perception. It’s the absence of sensory experiences and any stimulation from the environment.  More auditory than visual (74% of auditory hallucination)  The hallucinations are likely presented as follow:  Some people with report hearing their own thoughts spoken by another voice  Some people claim that they hear voices arguing  Some people hear voices commenting on their behavior Negative Symptoms  Negative symptoms consist of behavioral deficits.  Endure even beyond the acute episodes, and lead to a poor quality of the lives Early onset of brain damage (enlarged ventricles) and progressive loss of cognitive skills  However, the symptoms can be attributed to other factors such as flat affect can be a side-effect of antipsychotic medication  Hard to distinguish them from depressions; observing the clients over the periods is probably the only way to address this issue  Avolition: - A lack of energy and a seeming absence of interest in or an inability to persist in what are usually routine activities.  Alogia: - The sheer amount of speech is greatly reduced or - The amount of discourse is adequate, but it conveys little information and tends to be vague and repetitive  Anhedonia - An inability to experience pleasure; lack of interest in recreational, interrelationships and sex  Flat Affect - Virtually no stimulus can elicit an emotional response  Asociality - Poor social skills, and little interest in being with other people Other Symptoms (Disorganization)  Positive and negative symptoms do not necessarily reflect exclusive subtypes because they are dimensions that often coexist within the same person.  Bizarre behavior: talk to themselves in public  Catatonia Defined by several motor abnormalities, such as gesture repeatedly, using peculiar and complex sequences of finger, etc.  Catatonic immobility: clients adopt unusual postures and maintain them for very long periods of time.  Waxy flexibility: another person can move the persons’ limbs into strange positions that they maintain for extended periods.  Inappropriate Affect  The emotional responses are out of context  Easy to shift from one emotional state to another for no reason  Suicide rate is high 11.2 History of the Concept of Schizophrenia Early Descriptions  Dementia praecox: Mental enfeeblement, coined by Emil Kraepelin  Eugen Bleuler coined “schizophrenia” in 1908 The Historical Prevalence of Schizophrenia  Rates of schizophrenia have fallen sharply since the 1960s in inpatient prevalence (Kinston, Ontario)  In 1930s New York, prevalence rate is 20%, but it became to 80% in 1940 – 1952  Constant at 20% prevalence rate in Europe (London)  “Schizoaffective psychosis” used to describe the affective symptoms (Kasanin), which is used as one symptom by DSM-I and DSM-II  The concept is broadened by three additional diagnostic practices: 1. US clinicians tended to diagnose schizophrenia whenever delusions or hallucinations were present 2. People whom we would now diagnose as having a personality disorder were diagnosed as having schizophrenia in DSM-II 3. People with acute onsets of schizophrenic symptoms and a rapid recovery were diagnosed as having schizophrenia The DSM-IV-TR Diagnosis  Concept of schizophrenia shifted from the broad definition to a new definition that narrows the range in five ways: 1. The diagnostic criteria are presented in explicit and considerable detail 2. People with symptoms of a mood disorder are specifically excluded. Schizoaffective is now listed as schizoaffective disorder as one of the psychotic disorder. (mixture of schizophrenia and mood disorders) 3. DSM-IV-TR requires at least 6 months of disturbance for the diagnosis. 4. Mild forms of schizophrenia in DSM-II is diagnosed as personality disorder now 5. A person with delusional disorder is troubled by persistent persecutory delusions (different to paranoid schizophrenia)  Unlike the person with paranoid schizophrenia, the person with delusional disorder does not have disorganized speech or hallucinations, and the delusions are less bizarre  The criteria are well-applicable across cultures. A DSM-5 Proposal for Psychotic Risk Syndrome and Symptom Dimensions  Psychosis risk syndrome Categories of Schizophrenia in DSM-IV-TR  Heterogeneity of schizophrenic symptoms suggests the subtypes of the disorder.  Disorganized Schizophrenia  Speech is disorganized and difficult for a listener to follow  Inventing new words, accompanied by flat affect or shifts of inappropriate emotions
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