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PSYC 3140
Joel Goldberg

Chapter 11: Schizophrenia  If you are unable to tell the difference between what is real and what is unreal, you are suffering from psychosis.  One of the most common psychotic disorders is schizophrenia, which consists of unreal or disorganized thoughts and perceptions as well as verbal, cognitive, and behavioural deficits.  In Canada, 0.5% - 2.0% of the population has been diagnosed with a schizophrenia- spectrum disorder. o Schizophrenia, schizoaffective disorder, delusional disorder…  Nearly half (41%) are in jails, prisons, homeless shelters, hospitals, nursing homes, etc.  Incidences of schizophrenia tend to be higher among immigrants than native-born populations.  Schizophrenia may be more common in men, although gender differences vary among studies and with the criteria used to diagnose schizophrenia. o Women with schizophrenia tend to have better premorbid histories than men. o More likely to graduate high school or university, to have married with children, and to have developed good social skills. o Onset for women is later (late 20s, early 30s) than it is for men (late teens, early 20s). o Women show fewer cognitive deficits than men, particularly in verbal processing.  Reasons for gender differences may be due to estrogen, which regulates dopamine, which is a component of schizophrenia. o May also be due to the pace of prenatal brain development; it is hormonally regulated, so slower for males. Symptoms, Diagnosis, and Prognosis of Schizophrenia…  Symptoms o Two categories of symptoms:  Positive (type I symptoms) are the presence of unusual perceptions, thoughts, or behaviours. These symptoms represent very salient experiences.  Include delusions, hallucinations, disorganized thought and speech, and disorganized or catatonic behaviour.  Can occur in other disorders as well, particularly in depression and bipolar disorder.  Many people with schizophrenia are also depressed or show mood swings.  If psychotic symptoms appear during periods of clear mania or depression, it is mood disorder with psychotic features.  If psychotic symptoms appear in the absence of depression or mania, or if the mania or depression doesn’t meet the criteria for a mood disorder, it is schizophrenia or schizoaffective disorder.  Delusions are ideas that an individual believes are true but are highly unlikely and often simply impossible.  People often hold beliefs that are likely to be wrong, such as winning the lottery, but those are called self-deceptions.  Self-deceptions are not completely implausible; delusions often are.  Self-deceptions may be thought of occasionally; delusions are all consuming.  People with self-deceptions often acknowledge they’re wrong; people with delusions are extremely resistant to counter- arguments.  A persecutory delusion is heard about the most; it’s the belief that they are being watched or tormented by people they know (e.g. professors, agencies, etc.).  A delusion of reference is the belief that random events or comments by others are directed at them (e.g. the local news anchor is reporting on their movements, etc.).  A grandiose delusion is the belief that one is a special person or being or possesses special powers. May believe they are the most intelligent, insightful and creative person on the earth, etc.  A delusion of thought insertion is the belief that one’s thoughts are being controlled by outside forces.  Delusions can be simple and transient, but are often complex and elaborate.  The different kinds of delusions can occur at the same time.  Content of delusions may differ across cultures.  White people may fear prosecution from the government, while Caribbean people may think people are trying to kill them with curses.  In Japan = delusions of slander and that someone knows something horrible about them.  German and Austrian people = fear that they’ve committed a sin.  A belief being odd doesn’t make it a delusion  unless it is odd within the culture.  Hallucinations are unreal perceptual experiences.  Sometimes unreal experiences happen to people, however, they are usually during times of stress, when they’re tired, or under the influence.  An auditory hallucination is the most common type of hallucination (e.g. hearing voices, music, etc.), and is more common in women than men. Often times they hear voices accusing them of evil deeds or threatening them. Voices may also tell them to harm themselves.  A visual hallucination is often accompanied by an auditory hallucination.  Hallucinations can also involve any sensory modality; tactile hallucinations = perception that something is happening to the outside of one’s body (e.g. bugs crawling up the back), and somatic hallucinations = perception that something is happening inside one’s body (e.g. worms are eating one’s intestines).  Content of hallucinations varies by culture.  Disorganized thinking of people with schizophrenia is referred to as formal thought disorder.  One of the most common forms of disorganization is a tendency to slip from one topic to a seemingly unrelated topic with little coherent transition, often referred to as loosening of associations, or derailment.  A Person with schizophrenia may answer questions with comments that are barely related to the question. o At times it is so disorganized and incoherent it is referred to as a word salad.  Neologisms = make up words that only mean something to them.  Clangs = make associations based on the sounds of words, rather than the content of the word.  May perservate; stay on the same word or statement.  People with schizophrenia have difficulty in a wide range of cognitive tasks. o Deficits in smooth pursuit eye movement (AKA eye tracking); keep head still and track a moving object. o This suggests deficits in fundamental attention processes. o May not have anything to do with schizophrenia; study found that people were impaired no matter how severe their symptoms were.  People with schizophrenia often show deficits in working memory. o Hold information in memory and manipulate it. o Results in them being unable to suppress unwanted or irrelevant information or to pay attention to relevant information. o Basically, find it hard to identify their thoughts, and ignore stimuli that are not relevant to what they are thinking. o Also impairs retrieval and learning new information.  These deficits may contribute to issues in reasoning, communication and problem solving.  Men tend to show more severe deficits in language compared to women. o Argued that language is controlled more bilaterally in women than men. o Therefore, women can compensate.  Disorganized and Catatonic Behaviour  May display unpredictable and apparently untriggered agitation. o Suddenly shouting and swearing, etc. o May engage in socially inappropriate behaviour, such as masturbating in public.  Many are disheveled and dirty. o E.g. too many clothes on a hot day, too few on a cold day.  Often have trouble with daily routines. o E.g. bathing, brushing teeth, etc.  Catatonia = disorganized behaviour that reflect an extreme lack of responsiveness to the outside world. o Catatonic excitement = person becomes wildly agitated for no apparent reason and is difficult to subdue.  May articulate delusions or hallucinations, and be largely incoherent.  Negative (type II symptoms) represent losses or deficits in certain domains. They involve the absence of behaviours rather than the presence of behaviours.  Affective Flattening o Severe reductions in, or even complete absence of, emotional response. o AKA blunted affect. o People often speak in a monotone voice, no emotional responses, and may not make eye contact with others. o It is a lack of overt emotional expression.  Study showed that areas of the brain still lit up, they just can’t express it.  Algolia o Poverty of speech. Reduction in speaking. o May give brief, empty replies. o Could be due to a lack of motivation.  Avolition o Inability to persist in common, goal-directed activities. o Disorganized and careless. o May sit around and do nothing; may become socially isolated.  Negative symptoms of schizophrenia may be difficult to diagnose, because: o They involve an absence of behaviours, rather than the presence of them, making them more difficult to detect. o They lie on a continuum between normal and abnormal, rather than being clearly bizarre. o Things other than schizophrenia, such as mood disorders or a side-effect of medication can cause them. o Other symptoms  Inappropriate Affect  Such as laughing at sad things or crying at happy things.  This could happen because they’re thinking about and responding too other things outside the environment.  Could also happen because pathways between stimuli and proper responses aren’t working properly.  Anhedonia  A loss of interest in everything in life.  Lose the ability to experience emotion.  Impaired Social Skills  E.g. difficulty holding relationships, holding a job, etc.  May be due to negative symptoms, rather than the positive symptoms  People with a lot of negative symptoms have: o Lower educational achievements o Less success in holding jobs o Poorer prognosis  Negative symptoms are less responsive to medication.  Diagnosis o Has been recognized since the early nineteenth century. o Emil Kraepelin = most comprehensive and accurate description of schizophrenia.  First labeled dementia praecox because he believed it to be a premature deterioration of the brain.  Viewed it as progressive, irreversible and chronic.  Definition was a narrow one. o Eugen Bleuler disagreed with Kraepelin that it developed at a younger age.  He named it “schizo” = split and “phrenia” = mind.  Believed that it was a splitting of mental associations, thoughts, and emotions, NOT a splitting of personalities (like DID).  Broader view of the disorder. o In early twentieth century, US took Bleuler’s version; Europe stayed with Kraepelin. o In 1980, the DSM took a more narrow definition of schizophrenia. o Now:  Must show symptoms for at least six months.  During six months, there must be:  At least one month of acute symptoms, during which two or more broad symptoms occur enough to impair functioning. o Prodromal symptoms = present before people go into the acute (active) phase. o Residual symptoms = present after they come out of the acute (active) phase. o During these phases, people may experience beliefs that are delusional but not unusual. o May have strange perceptual experiences. o May speak oddly, but remain coherent. o Negative symptoms are especially prominent during these phases. o During prodominal phase, family members may feel individual is “slipping away”. o Schizoaffective disorder = mix of schizophrenia and mood disorders.  With evidence that schizophrenic symptoms are present when the mood disorder is absent.  Must also experience both at once.  E.g. major depression and hallucinations. o Difference between schizoaffective disorder and mood disorder with psychotic features is that schizoaffective disorder has hallucinations and delusions without mood symptoms for at least two weeks. o Diagnosis of schizoaffective disorder is a controversial one. o Type I schizophrenia = positive symptoms are much more prominent than negative symptoms. o Type II schizophrenia = negative symptoms are much more prominent than positive symptoms. o Five subtypes of schizophrenia  Paranoid Schizophrenia  People have prominent delusions and hallucinations that involve themes of persecution and grandiosity.  Many do not show grossly disorganized speech or behaviour.  May be lucid and articulate, with elaborate stories of how people are after them.  People are highly resistant to any arguments against their delusions.  Combination of persecutory and grandiose delusions can lead people with this type of schizophrenia to be suicidal or violent towards others.  Prognosis for paranoid schizophrenia is better than it is for other types of schizophrenia. o More likely to be able to hold down a job and show better social and cognitive functioning.  Onset tends to occur later in life; episodes of psychosis are often triggered by stress.  In general, considered to be a milder form of schizophrenia.  Disorganized Schizophrenia  Do not have well-formed delusions or hallucinations. Instead, thoughts and behaviours are severely disorganized.  People may speak in word salads.  Prone to odd, stereotyped behaviours such as frequent grimacing and flapping their hands.  In severe cases, may not bathe, dress, or eat if left by themselves.  Emotional experiences and expressions of people are also quite disturbed.  Early onset and continuous. Unresponsive to treatment. People are most disabled by this type of schizophrenia.  Catatonic Schizophrenia  Rare, so not very well researched.  Show a variety of motor behaviours and ways of speaking that suggest they’re completely unresponsive to the environment.  Diagnosis requires two of the following: o Catatonic stupor. o Catatonic excitement. o Maintenance of rigid posture or complete mutism for long periods. o Odd mannerisms (e.g. hand flapping). o Echolalia = senseless repetition of words spoken by others or echopraxia = repetitive imitation of another person.  Undifferentiated and Residual Schizophrenia  Undifferentiated schizophrenia = symptoms that meet the criteria for schizophrenia, but do not meet the criteria for paranoid, catatonic, or disorganized schizophrenia. o Relatively early onset, chronic, and difficult to treat.  Residual schizophrenia = At least one acute episode of acute positive schizophrenia, but do not currently have any symptoms. o Continue to have signs, but never develop it.  Prognosis o Schizophrenia is more chronic and debilitating than other mental disorders. o 50-80% of people hospitalized once for schizophrenia will be hospitalized again. o Life expectancy is 10 years younger. o People suffer from infectious and circulatory diseases at a higher rate than those without schizophrenia. o As many as 10-15% commit suicide. o Age and Gender Factors  Women who develop the disorder have a more favourable course than men who develop it.  Women hospitalized less, and for briefer periods.  Women have milder negative symptoms between periods of acute positive symptoms.  Women have better social adjustment when they are not psychotic.  Possibly due to the fact that women develop schizophrenia at a later age.  Functioning seems to improve with age.  Maybe because they find treatments or have family to support them.  Aging of the brain may not promote new episodes.  Maybe also due to a reduction in dopamine in the brain. o Sociocultural factors  Tends to have a more benign course in developing countries (in contrast to developed countries).  Less severe in places like Nigeria, Colombia, etc; over places like the US and UK.  In developing countries, it may facilitate adaptation and recovery better.  In developing countries, individuals seem to have broader, closer networks
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