Chapter 11 Schizophrenia

1. Chapter 11 Schizophrenia Ch 11

2. Schizophrenia • Schizophrenia is a psychotic disorder involving disturbance of thought, emotion and behavior • The lifetime prevalence of schizophrenia is about 1% • Onset is usually in late adolescence • Substance abuse is a co-morbid condition in 50% of schizophrenia patients Ch 11.1

3. The Nature of Schizophrenia • Broad Impairments • Delusions & Hallucinations • Disorganized Speech & Behavior • Inappropriate Emotions • Psychosis: extreme mental unrest with loss of reality contact (Davison & Neale, p. 134)

4. Schizophrenia: Facts and Statistics • Cause is Unknown • Affects 1 out of 100 People • Often Begins (Ages 16 - 30) • More Hospital Beds Than Any Other Medical Illness 2.5% of Total U.S. Healthcare Budget

5. Schizophrenia: Facts and Statistics • Often Chronic • Occurs in .2% to 1.5% Population • Affects Men and Women Equally • Age of Onset Varies Across Time • Lower Life Expectancy • Increased Risk of Suicide

6. Myths of Madness • People with schizophrenia have “split personalities.” • People with schizophrenia are intellectually disabled? • People with schizophrenia are dangerous? • People with schizophrenia are addicted to their drugs?

7. Myths of Madness • Schizophrenia is NOT caused by bad parenting or an unhappy childhood. • Schizophrenia is NOT due to a weakness in character. • Schizophrenia is NOT due to a negative social label. • Schizophrenia is NOT a hopeless situation.

8. Perspectives: The Concept of Schizophrenia • Dementia (Loss of Mind) • Praecox (Early, Premature) • Kraepelin • Categorization & Early Onset • Eugen Bleuler • Termed “Schizophrenia” • Associative Splitting

9. The Nature of Schizophrenia: Active Phase Symptoms • Positive Symptoms • Displays of Abnormal Behavior • Disorganized Symptoms • Speech and Behavior • Negative Symptoms • Deficits in Affect, Speech, Motivation

10. The Nature of Schizophrenia: Active Phase Symptoms • Positive Symptoms • Delusions • Misrepresentation of Reality • “Basic Feature of Madness” • Examples • Grandeur -- Importance • Persecution -- Out to Get Me

11. The Nature of Schizophrenia: Active Phase Symptoms • Positive Symptoms • Hallucinations • Absence of Sensory Stimulation • Involve Any of the Senses • Examples • Auditory -- Voices (70%) • Visual -- Seeing Things (25%) • Tactile -- Crawling Sensation

12. Broca’s Area (Speech) Wernicke’s Area (Hearing) What Area Do You Think is More Active With Auditory Hallucinations? Hallucinations: A Window on the Brain

13. The Nature of Schizophrenia: Active Phase Symptoms • Positive Symptoms • Disorganized Symptoms • Disorganized Speech • Difficulty in Communication • Examples • Tangentiality • Loose Association or Derailment

14. The Nature of Schizophrenia: Active Phase Symptoms • Positive Symptoms • Disorganized Symptoms • Disorganized Behaviors • Catatonia • Spectrum • Wild Agitation to Immobility • Example • Waxy Flexibility • Inappropriate Affect

15. The Nature of Schizophrenia: Active Phase Symptoms • Positive • Disorganized Symptoms • Negative Symptoms • Flat Affect -- “The Mask” • Avolition -- “No Initiative” • Alogia -- “Speech is Vacant” • Anhedonia -- “No Pleasure” • Asociality--”No social interest”

16. Positive Symptoms of Schizophrenia • Positive symptoms involve excesses or distortions • Disorganized speech (thought disorder) • Hallucinations are sensory experiences that occur in the absence of environmental stimulation • Hallucinations are commonly auditory • Delusions are beliefs that are contrary to reality • Persecutory delusions are common Ch 11.2

17. Negative Symptoms of Schizophrenia • Negative schizophrenia symptoms are characterized by behavioral deficits • Avolition refers to a lack of energy and an inability to persist in routine activities • Alogia refers to a reduction in the amount or content of speech • Anhedonia is an inability to experience pleasure • Asociality refers to a severe impairment in social relationships Ch 11.3

18. DSM-IV Schizophrenia Categories • Disorganized schizophrenia involves • Disorganized speech and flat affect • A general disruption of behavior • Catatonic schizophrenia involves • Prolonged motor immobility states that alternate with periods of excitability • Paranoid schizophrenia involves the presence of prominent delusions including persecution and grandiosity • Undifferentiated schizophrenia and residual schizophrenia Ch 11.4

19. Schizophrenia Subtypes • Paranoid Type • Disorganized Type • Catatonic Type • Undifferentiated Type • Residual Type

20. Schizophrenia Subtypes: Paranoid • Delusions & Hallucinations • Intact Cognition and Affect • No Disorganized Speech • Best Prognosis

21. Schizophrenia Subtypes • Paranoid Type • Disorganized Type • Catatonic Type • Undifferentiated Type • Residual Type

22. Schizophrenia Subtypes: Disorganized • Disorganized Speech • Disorganized Behavior • Flat or Inappropriate Affect • Hallucinations and Delusions • Fragmented or Lacking a Theme • Often Chronic

23. Schizophrenia Subtypes • Paranoid Type • Disorganized Type • Catatonic Type • Undifferentiated Type • Residual Type

24. Schizophrenia Subtypes: Catatonic • Disorganized Speech • Disorganized Behavior • Waxy flexibility, rigidity, odd mannerisms, mimicry • Flat or Inappropriate Affect • Hallucinations and Delusions • Fragmented or Lacking a Theme • Often Chronic

25. Schizophrenia Subtypes • Paranoid Type • Disorganized Type • Catatonic Type • Undifferentiated Type • Residual Type

26. Schizophrenia Subtypes: Undifferentiated • Beginnings of Breakdown • Major Sx of Schizophrenia • DO NOTMeet Other Criteria • “Wastebasket” Category

27. Schizophrenia Subtypes • Paranoid Type • Disorganized Type • Catatonic Type • Undifferentiated Type • Residual Type

28. Schizophrenia Subtypes: Residual • Have Had One Episode • Now Mostly Symptom Free Once a Schizophrenic, Always a Schizophrenic?

29. Classification Systems and Their Relation to Schizophrenia • Process vs. Reactive Distinction • Process – Insidious onset, biologically based, negative symptoms, • poor prognosis • Reactive – Acute onset (extreme stress), notable behavioral activity, • best prognosis • Good vs. Poor Premorbid Functioning in Schizophrenia • Focus on person’s level of function prior to developing schizophrenia • No longer widely used • Type I vs. Type II Distinction and Schizophrenia • Type I – Positive symptoms, good response to medication, • optimistic prognosis, and absence of intellectual impairment • Type II – Negative symptoms, poor response to medication, • pessimistic prognosis, and intellectual impairments

30. Early Brain Damage • Neurological “Soft Signs” • Attentional and Reflex Problems (Nasrallah & Smeltzer, 2002) • Runs In Families • High Expressed Emotion & Relapse • What is the Genetic Risk? Schizophrenia: Developmental Course

31. Etiology of Schizophrenia • Genetic studies using twin, family and adoption techniques reveal that a predisposition for schizophrenia is transmitted genetically • Brain pathology, possibly including damage to the fetal brain from virus-like diseases, are likely biological vulnerabilities for schizophrenia (diathesis) Ch 11.5

32. Genetic Studies of Schizophrenia Relation to Percentage Proband Schizophrenic Spouse 1.00 Grandchildren 2.84 Nieces/nephews 2.65 Children 9.35 Siblings 7.30 DZ twins 12.08 MZ twins 44.30 Ch 11.6

33. The Causes of Schizophrenia • Genetic Influences • Runs in Families • Increased Risk Based on Genetic Relatedness • Search for Marker Genes Smooth Pursuit Eye Tracking

35. Biochemistry of Schizophrenia • Dopamine theory holds that the positive symptoms of schizophrenia result from excessive activity of dopamine in brain • Anti-schizophrenia drugs block dopamine receptors • The anti-schizophrenia drugs take several weeks to act clinically, yet rapidly block dopamine receptors • Ingestion of amphetamine can induce psychosis; amphetamine causes the release of dopamine from neurons Ch 11.7

36. Figure 11.1 Dopamine Activity in Mesolimbic and Mesocortical Pathways • Overactivity of dopamine neurons • in the mesolimbic pathway may • cause positive symptoms. • Antipsychotics which block dopamine • receptors lessen positive symptoms • Underactivity of dopamine neurons • in the mesocortical pathway in the l • prefrontal cortex may cause • negative symptoms • Antipsychotics have little or no effect • on negative symptoms. Ch 11.8

37. Dopamine Theory of Schizophrenia

38. The Causes of Schizophrenia • Neurobiological Influences • Excess Dopamine (D2 Receptors) • Antagonists • Neuroleptics • Drugs That Reduce Dopamine • Negative Side Effects • L-Dopa (Agonist) • Amphetamines • Genetic Influences

39. Glutamate Theory • PCP (“angel dust”) and ketamine (an anesthetic) mimic the positive and negative symptoms of schizophrenia (Javitt & Cole, 2004) • These drugs block the action of a form of glutamate receptor (NMDA receptor) • NMDA receptor blockade may produce the dopamine dysfunction seen in schizophrenia, as if too little dopamine were present in the prefrontal cortex (negative symptoms) and too much dopamine in the mesolimbic area (positive symptoms)

40. Brain Pathology in Schizophrenia • Brains of schizophrenic patients show • Reduced volume of temporal and frontal cortex • Enlarged ventricles (reflecting loss of brain cells) • For 12 of 15 twins, the schizophrenic twin could be identified by enlarged ventricles • Reduced metabolic activity within prefrontal cortex (frontal hypoactivation) Ch 11.9

41. The Causes of Schizophrenia • Brain Structure • Ventricle Enlargement • Genetic • Neurobiological Influences

42. The Causes of Schizophrenia • Brain Structure • Ventricle Enlargement • Hypofrontality • Genetic • Neurobiological Influences

43. Psychological Stress & Schizophrenia • Example of diathesis-stress model • Social class and schizophrenia • Sociogenic hypothesis • Social-Selection theory (more research support) • Expressed emotion (EE) - Research shows how family and social environmental context affects re-hospitalization rates • High-Risk studies of schizophrenia

44. Causes of Schizophrenia:Psychological and Social Influences (cont.) Figure 13.9Barlow/Durand, 3rd. Edition. Cultural differences in expressed emotion (EE)

45. Therapies for Schizophrenia • Psychosurgery • Prefrontal lobotomy • Drug therapies • Antipsychotic medications that block dopamine receptors • Chlorpromazine (Thorazine) • Became widely available in 1954 • Others include haloperidol (Haldol) and thiothixene (Navane) • Reduce agitation, violent behavior, and other emotional and behavioral excesses. • Disadvantages: • Side effects especially extrapyramidal side effects • About 30% of patients do not respond • Little or no effect on negative symptoms • Newer medications: • Clozapine (Clozaril), respiradone (Risperdal) Ch 11.10

46. The Treatment of Schizophrenia • Biological Interventions • Neuroleptics • Haldol & Clozapine • Trial and Error • “Extrapyramidal” Side Effects Tardive Dyskinesia Akinesia Atypical Antipsychotics: (Clozapine, Risperdal, Zyprexa,Seroquel, Geodon, Abilify)

47. Medical Treatment of Schizophrenia (cont.) Table 13.2 Barlow/Durand, 3rd. Antipsychotic medications

48. Psychological Treatments for Schizophrenia • Social-skills training involves teaching behaviors to interact successfully with others • Family therapy aims to reduced expressed emotion (hostility, overly critical) • Cognitive-behavioral therapy demonstrates that maladaptive behaviors and beliefs of some patients can be changed • Personal therapy aims to reduce expressed emotion, uses relaxation techniques and teaches social skills Ch 11.11`

49. Cognitive-Behavioral Therapies • Personal Therapy • Patients are taught • To recognize inappropriate affect • To recognize signs of relapse • Relaxation techniques to reduce anxiety & anger • Rational emotive therapy techniques to reduce frustration and prevent explosive or inappropriate interpersonal behavior. • Social skills training to enhance interpersonal functioning.

50. Psychosocial Treatment of Schizophrenia Figure 13.10 Barlow/Durand, 3rd. Edition Studies on treatment of schizophrenia from 1980 to 1992