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Chapter 10

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Psychology 2030A/B
David Vollick

Chapter 10 - Schizophrenia, Spectrum, and Other Psychotic Disorders Psychotic Disorders • Psychotic disorders are characterized by unusual thinking, distorted perceptions, and odd behaviors o People afflicted are considered to be out of touch with reality and unable to think in a logical and coherent manner o They sometimes behave oddly, talking or mumbling to themselves or gesturing at someone no one else can see What is psychosis? • Psychosis = severe mental condition characterized by loss of contact with reality; usually takes the form of a delusion (false belief) or a hallucination (false sense of perception), or both o Delusions = being spied on, being part of a resistance movement o False sensory perceptions = seeing cartoon characters that were not there • Can affect every aspect of functioning • Hallucinations or del usions alone do not necessarily mean that the individual has a psychotic disorder, such as schizophrenia; psychotic symptoms can be present in individuals with bipolar disorder, major depressive disorder, PTSD, and substance -related disorders as well as medical illnesses (brain tumors, Alzheimer’s, Parkinson’s, brain injuries, etc) • Additionally, 2-12% of adults have had brief psychotic experiences o However, the voices that they hear are positive and they felt in control of the experience, not negative and out of control as in people with psychotic disorders What is schizophrenia? • Schizophrenia = a severe disorder characterized by disorganization in thought, perception, and behavior o They do not think logically, perceive the world accurately, or behave in a wa y that permits normal everyday life and work o Government is spying on them, voices on the radio are speaking directly to them, etc o As a result of these delusions and/or hallucinations, they behave oddly • Condition creates severe impairment and is often chronic • Defined 100 years ago by Kraepelin and Bleuler o Kraepelin called this disorder dementia praecox ▯ Dementia (pervasive disturbances of perceptual and cognitive faculties) ▯ Praecox (early life onset) o Bleuler focused on 4 core symptoms (ambivalence, dist urbances of affect, disturbance of association, and preference for fantasy over realty) and renamed the condition schizophrenia ▯ Schizo (split); phrenia (mind) ▯ Highlights the splitting of thought, affect, and behavior that occurs among those with the disorder • Misconceptions: o It is very difficult to understand the experience of schizophrenia, so many mistaken ideas about this disorder exist o People with schizophrenia DO NOT have split personalities (like Dr. Jekyll and Mr. Hyde) ▯ Schizo means split between a n individual’s thought and feelings, not splitting of the personality ▯ ~2/3 of people surveyed believed that schizophrenia involve split personalities o Many people also think that schizophrenia involved multiple personalities (dissociative identity disorder, DID) ▯ Schizophrenia results in an inability to perceive the environment appropriately or deal with it adequately ▯ People with schizophrenia DO NOT have split of multiple personalities Schizophrenia in depth • Symptoms: o Delusions (+) o Disorganized or catatonic behavior o Hallucinations (+) o Negative symptoms o Disorganized speech • Positive symptoms (denotes the presence of an abnormal behavior within the individual) o These are the behaviors that most people associate with schizophrenia o Consists of unusual thoughts, feelings, behaviors o Vary in intensity; often responsive to treatment o Delusions ▯ Fixed beliefs that are not changeable when presented with conflicting evid ence ▯ Persecutory delusions are the most common (consist if the belief that someone is harming or attempting to harm the person) ▯ Delusions of influence (beliefs that others control one’s behavior or thoughts) • E.g. government is inserting thoughts into the ir head or that evil forces are stealing thoughts o Hallucinations ▯ Perception like experience without an external stimulus (such as hearing voices when no one is present; seeing things no one else can see) ▯ Auditory hallucinations are the most common (these voices often keep a running commentary on the individual’s behavior or several voices that have a conversation) ▯ Visual hallucinations are less common (common visions include seeing the devil or a dead relative or friend) ▯ Tactile, olfactory, and gustatory hallucinations are the least common ▯ Note: hallucinations may persist despite mediation, but many patients are able to function at some level and maintain some contact with reality even if hallucinating o Disorganized thinking ▯ Assessed by abnormality of spee ch ▯ Loose associations (thoughts that have little or not logical connection to the next thought) ▯ Thought blocking (unusually long pauses in the patient’s speech that occur during a conversation) ▯ Clang associations (speech is governed by words that sound al ike, rather than words that have meaning) o Catatonia ▯ Grossly disorganized or abnormal motor behavior ▯ During a catatonic state, the patient may not move or make eye contact with others; they may be mute or muscularly rigid (statue) ▯ Waxy flexibility - when present, parts of the body remain frozen in a particular posture when positioned that way by another person • Negative Symptoms (absence of behaviors that exist in the general population) o Behaviors, emotions, or thought processes (cognitions) that exist in people without a psychiatric disorder but are absent in people with schizophrenia o Diminished emotional expression ▯ Reduced or immobile facial expressions and a flat, monotonic vocal tone that does not change even when the topic of conversatio n becomes emotionally laden o Anhedonia = Lack of capacity for pleasure; the person feels no joy or happiness o Avolition = Inability to initiate or follow through on plans o Alogia = Decreased quality and/or quantity of speech o Psychomotor retardation ▯ Slowed mental or physical activities o Unlike positive symptoms that can largely be controlled by medications, negative symptoms are treatment-resistant and tend to persist and restrict the person’s ability to hold a job, go to school, take care of personal responsibilities o Cognitive impairments ▯ Common in people with schizophrenia ▯ Includes impairments in visual and verbal learning and memory, inability to pay attention, decreased speed of information processing, impaired abstract reasoning and executive functioning (solving problems and make decisions) ▯ This is one of the earliest signs of schizophrenia (however, some people with schizophrenia have normal or above -normal cognitive abilities) o Social cognition deficits ▯ Deficits in the ability to perceive, interpret, and understand social information including other people’s beliefs, attitudes, and emotions ▯ Lack the skills for positive social interactions ▯ Inability to understand sarcasm and lies • Comorbidity o Depression affects 45% of those diagnosed with s chizophrenia; 5% commit suicide o 47% also have anxiety disorders o PTSD is also quite common (because schizophrenia leaves patients vulnerable to victimization, and violence as a result of poor living conditions or homelessness) o Substance related disorders among 50% of those diagnosed ▯ Alcohol most common ▯ Self-medication hypothesis -- perhaps the use of alcohol or drugs could be a strategy to cope with or escape from negative symptoms (inability to feel pleasure) Functional Impairment • Correlation: severity of symptoms and the degree to which those symptoms impair the person’s ability to function • Treatment should begin as soon as possible to limit the chronic nature of the disorder • Takes a significant toll on the person and his/her fami ly • High social and economic burden makes it VERY debilitating • Little chance of recovery; positive symptoms can be lessened with medication and may go into remission • 50% of patients are “in recovery” - meaning that they still may have symptoms of the diso rder but are able to manage other aspects of their life (work, education, friendships, self -determination) • Comorbidities increase the chance of poor overall outcome • Patients also have increased risk of infectious diseases, physical injury as a result of v iolent victimization, and smoking-related and other illnesses • Cultural factors play a role in the course of schizophrenia o Positive outcomes are more often found in developing countries than in developed nations ▯ Differences in social support, central role of family caring for the ill, differing beliefs about the etiology of the disorder Ethics and Responsibility • A common misconception is that schizophrenia is associated with violence • Violence: Patients with depression and bipolar > schizophrenics > gener al population • Violence is more likely in schizophrenic patients WITH a substance use problem • People with schizophrenia are often victims of violence (their impaired cognitive and emotional status makes them easy targets); their disorder also limits wherethey live and their income Epidemiology • Same prevalence among different cultures... • Lifelong prevalence: 0.3-1.6% of the US population • Each year, 16-40/100000 people develop schizophrenia • Higher incidence among: o People who live in urban settings o Those who move to a new area/country o Males • Onset can be gradual or acute; Gradual onset: o Prodromal phase (social withdrawal or deterioration in personal hygiene may occur) o Acute phase (he/she exhibits the positive symptoms including hallucinations, delusions, th ought disorder) o Residual phase (occurs after an acute phase; psychotic symptoms are no longer present, but the negative symptoms often remain) Sex, Race, Ethnicity • Women develop schizophrenia at a later age than men o Women also often have a milder form of the disorder and experience fewer hospitalizations o WHY? ▯ When the disorder develops later, individuals have more opportunity to achieve adolescent and young adult developmental milestones and develop better social functioning? ▯ May be related to hormonal ( estrogen is very protective) or sociocultural factors? • Symptoms of psychosis are consistent across racial and ethnic groups, however rates of diagnosis vary o African Americans are more likely to be diagnosed than whites and Latinos o Cultural insensitivities lead to misinterpretation of symptoms and inaccurate diagnosis Ethics and Responsibility • Racial bias appears to be a very real factor in the diagnosis of schizophrenia • Determining diagnosis without patient and clinician meeting face to face might eliminate potential racial bias o When a clinician makes a diagnosis from the notes of an interview (rather than conducting the interview himself), African Americans are no more likely to be diagnosed than others o Therefore, the patient’s characteristics, not just the symptoms, may play a role in determining a diagnosis • Inaccurate diagnosis due to: o Inattention to culturally different behavior o Lack of cultural competence o Language barriers o Few bilingual therapists o Diagnostic errors as a result of inadequate clinical interviews conducted in busy outpatient clinics Developmental Factors • Adults with schizophrenia were significantly less sociable when they were children • People who developed schizophrenia also had subtle general neuro-motor abnormalities as children • Schizophrenia usually begins in late adolescence or early adulthood; 23% develop the disorder after age 40 • 1% of adults have schizophrenia, only 0.01% if people under 18 suffer from schizophrenia • Early onset schizophrenia -- poorer outlook; have biological deterioration of the brain from an early age; most have persistent symptoms throughout their whole lives o Those with EOS are more impaired, have more psychotic episodes, need more psychiatric care, more impaired social functioning and independent living • The earlier the onset, the more severe the outcome • Even before delusions and hallucinations begin, children with schizophrenia are socially withdrawn, have difficulty interacting with peers, have school adjus tment problems Other Psychotic Disorders • Schizophrenia is the most common type of psychotic disorder, but there are others… • Brief psychotic disorder o Sudden onset of any psychotic symptom (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) o Disorder resolves after 1 day and does not last for more than 1 month o Often the onset is associated with a significant psychosocial stressor • Schizophreniform disorder o Symptoms are identical to schizophrenia with two differences: ▯ Duration of the illness is shorter (1 -6 months) ▯ Impaired social or occupational functioning is a possibility,
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