chapter 13 schizophrenia
Causes: biological factors -genetics -family studies -twin studies -adoption studies
*strong support for a genetic influence genetics- the role of genetics has been studied more extensively with schizophrenia the with any other mental disorder. The evidence suggests an important genetic component family studies- as genetic similarity increases btw two people, the risk for schizophrenia increases; siblings have a 50 percent chance and nieces and nephews and cousins have a 25 percent chance twin studies- higher concordance rates among schizophrenics for monozygotic (48%) than dizygotic twins (17 %) adoption studies- children of schizophrenic parents who are adopted by non schizophrenic parents are as likely to be diagnosed with schizophrenia as they would be if their schizophrenic parent had raised them.
Related psychotic disorders: delusional disorder
- individual does not meet the full symptomatic criteria for schizophrenia; exhibits preoccupation with non bizarre delusions; the present of hallucination, disorganized speech or gross disorganized or catatonic behaviors rules out this diagnosis -the symptoms of behavior is not bizarre and that social and occupational functioning are not impaired except for those areas that are directly affected by the delusional belief
Cross cultural comparison
-although observed in virtually every culture, frequencies vary from 8 to 43 cases for every 100,000 people -higher incidence occurs in urban than in rural areas, but socioeconomic status does not appear to play a substantial role in frequency -substancial cross cultural differences have been uncovered regarding the course of schizophrenia.... clinical and social outcomes better in deleloped countries than in less developed countries -most favorable clinical outcome that was observed was in Nigeria and India---> accepting and greater tolerance
Schizophrenia general symptoms
-changes in the way a person thinks, feels, and relates to other people and the outside environment - no single symptom or specific set of symptoms is characteristic of all schizophrenia patients
Related psychotic disorders: brief psychotic disorder
-individual exhibits psychotic symptoms for at least one day but no longer than one month, often following a markedly stressful event -an episode of this sort is accompanied by confusion -after the symptoms are resolved the person returns to the same level of functioning. -schizophreniform disorder- same diagnostic criteria as schizophrenia but for a reduced duration
negative symtoms- apathy, abolition and alogia
-malfunction of interpersonal relationships, socially withdrawn -develops before the onset of symptoms such as hallucinations and delusions -withdrawal seen among many schizo patients is accompanied by indecisiveness, ambivalence (uncertainty) and loss of will power. AVOLITION- lack of will -becomes apathetic and ceases to work toward personal goals or to function independently ex) sitting in chair all day not washing or combing hair ALOGIA- impoverished thinking. speechless!!! -poverty of speech-reductio in amount of speech -dont have anything to say thought blocking= patient's train of speech is interrupted before a thought or idea is completed.
prodromal phase and symptoms
-precedes the active phase and is marked by an obvious deterioration in role functioning as a student, employee or homemaker -person's friends and relatives often view the beginning of the prodromal phase as a change in his or her personality. symptoms: similar to those associated with schizotypal personality disorder. Include peculiar behavior, unusual perceptual experiences, outburst of anger, increased tension and restlessness. -social withdrawal, indecisiveness and lack of will power are often seen
Causes: biological factors -spectrum of schizophrenic disorders -molecular genetics
-spectrum of schizophrenic disorders: the overall pattern of results suggests that vulnerability to schizophrenia is sometimes expressed as schizophrenia-like personality traits and other types of psychoses -molecular genetics: 1) the mode of transmission has not been well identified 2)although research suggests a genetic component, no specific genes related to schizophrenia have been identified conclusively --> the COMT gene has attracted special interest as it is associated with a small but consistent increase in schizophrenia likelihood
course and outcome
-typically begins during adolescent and early adulthood and typically has a poor outcome -has historically been seen as severe and progressive but some people with schizophrenia have more positive outcomes -best predictor of symptom severity at follow up is severity of psychotic symptoms at initial assessment -recent evidence indicates that while some patients do have positive outcomes, relatively few are able to achieve successful aging
Psychosocial treatment—long-term strategies
1) Family-oriented aftercare involves an education component to improve coping skills of family members. *goal: Goals are to eliminate unrealistic expectations and improve communication., reduce relapse rate 2) Social skills training (SST) a.Involves modeling, role-playing, and reinforcement of positive behaviors b.Seems to improve social adjustment but may not reduce relapse rates -
Causes: biological factors- Dopamine hypothesis
1) developed while trying to understand how antipsychotic drugs called neuroleptics decrease symptoms oh schizophrenia 2) it is unclear if people with schizophrenia show differences in dopaminergic activity and D2 receptors prior to taking antipsychotic medication 3) dopamine hypothesis focuses on the function of specific dopamine pathways in the limbic area of the brain -hypothesis is overly simplistic 1) some patients do not respond to drugs that block dopamine 2)with antipsychotics, dopamine blockage is immediate, but symptoms do not remit for days to weeks 3) new antipsychotic drugs act primarily on other neurotransmitters but they are also effective 4) schizophrenia may involve a complex interaction between dopamine and serotonin receptors -current theories focus on other NT's including serotonin, GABA and glutamate
Causes: biological factors -linkage studies
1) theoretically, genetic influence could be due to a single gene or a number of genes; polygenic influence is most likely 2) research has not been able to specify a gene(s) responsible for schizophrenia but specific regions of chromosomes have been implicated 3) the enzyme, catechol-O-methyltransferase (COMT), involved in breaking down dopamine, may play an important role in schizophrenia, the COMT gene is on chromosome 22
Treatment: Antipsychotic medication
1)Use of medications with people with schizophrenia began in 1950 with phenothiazines (e.g., Thorazine), which had a calming effect and allowed for deinstitutionalization. 2) Antipsychotic drugs reduce the severity of and sometimes eliminate psychotic symptoms a.About half of patients show significant improvement within four to six weeks; some show only mild improvement (30-40 percent); about a quarter show no improvement b.Continued maintenance medication after the acute phase may reduce relapse rate from 65-70 percent to about 40 percent. c.Unfortunately, 25 percent do not improve on antipsychotic drugs.
DSM contains 6 criteria for schizophrenia
1)two or more of the following for a significant portion of time during a 1 month period.. at least one of these must be a, b or c a) delusions b)Hallucinations c) Disorganized speech d) grossly disorganized or catatonic behavior e) negative symptoms 2) functioning in a major area of life must suffer for a meaningful portion of time since the onset of symptoms 3) continuous signs of disturbance for at least a 6 month period 4) schizoaffective and depressive or bipolar disorder must have been ruled out 5) symptoms not attribute to the effects of a substance 6) if there is history of autism spectrum disorders, the diagnosis of schizophrenia may only remade if prominent delusions or hallucinations, n addition to the other required symptoms of schizophrenia are also present for atleast 1 month
Second-generation antipsychotics—introduced in the U.S. in the 1990s
1.As effective in treating positive symptoms as traditional antipsychotics; less likely to produce tardive dyskinesia 2.Are no more effective in reducing negative symptoms than are traditonal antipsychotics, although, this is contrary to early expectations and reports; also, many serious side effects are common for the second-generation antipsychotics: weight gain and risk for medical conditions, such as diabetes, hypertension, and coronary artery disease 3.They produce a broader range of neurochemical actions in the brain than do the first-generation antipsychotic drugs, acting on both serotonin receptors and dopamine receptors, leading to more success with reduction of positive symptoms and, perhaps, less risk of motor symptom development.
disorganization symptoms- abnormal motor behavior
CATATONIA- most often refers to immobility and marked muscular rigidity but it also can refer to excitement and overactivity **associated with a stuporous state or general reduced responsiveness. unaware of his or her surroundings -ex) rubbing hands together in a special pattern for hours at a time, reduced or awkward spontaneous movements, unusual posture INAPPROPRIATE AFFECT- affective responses that are obviously inconsistent with the person's situation *incongruity and lack of adaptability in emotional expression ex) giggling when describing private terror that felt in the presence of her family...marsha's speech was inconsistent with her expression, her gestures and her voice quality
the search for markers of vulnerability
The workgroup for DSM-5 considered including attenuated psychosis syndrome, which would involve the prodromal symptoms of schizophrenia, but it was ultimately placed in section III A promising option might be to identify the endophenotype, a component or trait that lies somewhere on the pathway between the genotype, which lays the foundation for the disorder, and full-blown symptoms of the disorder. Ideally, any markers will meet the following criteria: 1. Able to distinguish between those who have developed schizophrenia and those who have not 2.Stable characteristic over time 3Able to identify biological relatives of people with schizophrenia 4.Able to predict who will develop schizophrenia 5.Vulnerability markers have been called endophenotypes Possible markers include the following: 1.Working memory impairment 2.Eye-tracking dysfunction
Motor side effects of antipsychotic drugs
a.Extrapyramidal symptoms (EPS)—muscular rigidity, tremors, restless agitation, involuntary postures, and motor inertia are quite common; may diminish after three to four months; other medications can minimize the severity of EPS b.Tardive dyskinesia (TD)—involuntary movements of the mouth and face, spasmodic movements of the trunk and body; sometimes it is irreversible; approximately 20 percent of patients develop TD after long-term neuroleptic use
Assertive community treatment (ACT)
a.Focus is on providing an array of psychological interventions and medication on a regular and continuous basis in the community b.Studies suggest it is effective in reducing inpatient hospital days and, despite its expense, it is cost-effective. c.Psychosocial intervention that is delivered by an interdisciplinary team of clinicians
Institutional programs
a.Hospitalization (at least two to three weeks) is often needed for acute psychosis. b.Social learning programs: behaviorally-based (e.g., using a token economy system); effective for increasing adaptive behaviors and decreasing problem behaviors c.Institutionalization with social learning programs has been shown to lead to positive long-term outcomes.
Cognitive therapy
a.Interventions may focus on cognitive procedures that evaluate, test, and correct distorted ways of thinking about self and environment; some cognitive approaches are specific to deficits often found in schizophrenic patients. b.Cognitive enhancement therapy aims to improve cognitive capacities; both cold cognitive functions (e.g. working memory) and social cognitive skills are targeted.
related psychotic disorders: schizoaffective disorder
an ambiguous and somewhat controversial category; symptoms of schizophrenic disturbance overlap with a depressive manic episode, but psychotic symptoms are present at some point without mood disorder symptoms
negative symptom- blunted affect
blunted affect or called diminished emotional expression=flattening or restriction of the person's nonverbal display of emotional responses -inhibit signs of emotion or feeling -neither happy or sad and they appear to be completely indifferent to their surroundings. -faces are expressionless and apathetic -voices lack fluctuations in pitch and volume -lack of concern for themselves and others and events hold little consequence
causes: psychological factors
family interactions- previously, it had been hypothesized that communication and behavior within families was a causal factor; this is not the case, however (most of these initial studies lacked control groups) -For people with schizophrenia, relapse is associated with family patterns of interaction characterized by high levels of **expressed emotion** (EE)—negative or intrusive attitudes and behavior toward the patient, High EE also predicts relapse for other disorders. -Cross-cultural studies reveal that high expressed emotion tends to be more prominent in Western countries, possibly serving to explain the more severe course/outcome of the disorder in the West. -Patients with mood disorders, eating disorders, panic disorder with agoraphobia, and obsessive-compulsive disorder are also more likely to relapse following discharge if they are living with a high EE relative. ***Interaction between genetics and environment provides the most sensible model to explain schizophrenia.
residual phase
follows the active phase of the disorder and is defined by signs and symptoms that are similar in many responses to those seen during the prodromal phase -at this point the most dramatic symptoms of psychosis have improved, but the person continues to be impaired in various ways. negative symptoms such as impoverished expression of emotions may remain pronounced during the residual phase
Causes: biological factors -neuropathology
identifying differences in the structure of the brain -STRUCTURE BRAIN IMAGING- (MRI) has found smaller total brain tissue volume, enlarged ventricles and smaller size limit system structures in people with schizophrenia 1) unclear if these differences are a sign of generalized brain deterioration 2)unclear if these differences are associated with specific types of schizophrenia FUNCTIONAL BRAIN IMAGING-(PET) suggest dysfunction in frontal cortex and temporal lobes of people with schizophrenia and mood disorders
delusions
idiosyncratic beliefs that are rigidly held in spite of their preposterous nature. -false beliefs based on incorrect inferences about reality. -express and defend their beliefs with utmost conviction, even when presented with contradictory evidence -preoccupation -unable to consider the perspective that other people hold with regard to their beliefs. -typically personal delusions -common delusions: belief that thoughts are being inserted into a patients head, other people are reading the patients thoughts or that the patient is being controlled by mysterious external forces. -many focus on grandiose(father is the master of the universe) or paranoid content
Negative symptom- anhedonia
inability to experience pleasure, lack of positive subjective feelings -lose interest in recreational activities and social relationships -unable to experience please from physical sensation such as taste and touch -also found among ppl who are severely depressed
negative symptoms
include characteristics such as a lack of initiative, social withdrawal, and deficits in emotional responding. -absence of normal functioning -more subtle and difficult to recognize -more stable over time
Eugen Bleuler
introduced the term "schizophrenia", termed referred to the splitting of mental associations -one unfortunate consequence of this description has been its confusion with dissociative identity disorder
frequency of schizophrenia
life time morbidity risk is approx 1 percent. one out of every 100 people will experience or display symptoms of schizophrenia at some time during their lives -men are about 30 -40 percent more likley to develop schizophrenia than are women -early onset affects men more often than it affects women, while later onset affects women more than it affects men -males are more likely to experience negative symptoms -some theorists argue that there are two different types of schizophrenia; one version that has an easier onset and affect men and another that occurs later and affects women
disorganization symptoms- loose association, tangentiality and perseveration
loose association= shifting topics too abruptly or derailment tangentiality= replying to a question with an irrelevant response perseveration=persistently repeating the same word or phrase over and over again
hallucinations
most obvious perceptual symptom -sensory experiences the are not caused by actual external stimuli . -most often auditory senses, although can occur in any of those senses -many patients hear voices that comment on their behavior or give them instructions. others hear voices that argue with one another. -can be comforting or pleasing
Causes: biological factors -pregnancy and birth complications -viral infections
pregnancy and birth complications: mothers of people who develop schizophrenia were more likely to have experienced problems before and during birth. It is possible that pre and perinatal problems interact with genetic factors -viral infections: people with schizophrenia are more likely to have been born during the winter months; it is possible that they had more viral infections during winter months, but this hypothesis has not received direct support
phases of schizophrenia
prodromal phase active phase residual phase -variable and unpredictable duration
positive symptoms
psychotic symptoms, include hallucinations and delusions. -presence of abnormal function (such as hearing a voice that is not really there)
Causes: social factors
social class- an inverse relationship exists between social class and schizophrenia SOCIAL CAUSATION HYPOTHESIS: social class hardships cause schizophrenia SOCIAL SELECTION HYPOTHESIS:people with schizophrenia gradually fall into the lower social classes -research has supported both hypotheses to some extent -higher risk among social immigrants (ppl who moved to a new country); may be partially due to the fact that migrants tend to settle in cities where they may face greater exposure to discrimination -in general, the results of studies on socioeconomic status suggest that schizophrenia may be at least partially influenced by social factors
Manfred Bleuler
studied 208 schizophrenic patients who had been admitted to swiss hospitals during 1942 and 1943. after 23 years, 53 percent of pattens were recovered or significantly improved
active phase
symptoms such as hallucinations, delusions and disorganized speech are characteristic of the active phase of the disorder.
onset of schizophrenia
typically occurs during adolescence or early adulthood. The period of risk for the development of a first episode is considered to be between the ages of 15 and 35
Schizophrenia
various combinations of psychotic symptoms in the absence of other forms of disturbance such as mood disorders (especially manic episodes), substance dependence, delirium or dementia 10% of schizophrenic patients commit suicide -2nd leading cause of disease burden most people do not recover completely and many become homeless
disorganization
verbal communication problems and bizarre behavior -disorganized speech= the tendency of patients to say things that don't make sense. Making irrelevant responses to questions, expressing disconnected ideas, and using words in peculiar ways. (also known as thought disorder)