1. Schizophrenia in the Social Environment

2. Objectives  Describe schizophrenia in the context of developmental stages  Describe how schizophrenia affects males and females differently, as well as African Americans  Describe the status of individuals with schizophrenia within the macro system  Improve your overall understanding of schizophrenia

3. Outline  What is schizophrenia? –Causes, symptoms, etc.  Onset, course and prognosis  Shift in treatments (macro level information)

4. Schizophrenia

5. What is Schizophrenia? Chronic, severe and disabling thought disorder –Break from reality (psychotic episode) –Illogical and irrational thoughts –Extreme emotional and social disregulation –NOT Dissociative Identity Disorder

6. Schizophrenia Demographics Affects about 1-2% of population (2 million) More frequently seen in the lower socioeconomic classes More frequently seen in large cities vs. rural More frequently in divorced/separated families 10-15% may commit suicide Affects men and women equally Approximately 20% are homeless

7. Causes No known single cause Theoretical causes include genetics, environmental, and behavioral factors (drugs) No cure

8. Symptoms Positive Symptoms (delusions, hallucinations) –Pathological additions to normal behavior Negative Symptoms (flat affect) –Characteristics that are lacking or reduced Psychomotor Symptoms –Odd gestures –Excited Movement –Motionless stupor

9. Positive Symptoms Delusions-beliefs contrary to reality –Persecution –Reference –Grandeur –Control Disorganized Thinking/Speech –Loose Associations –Word Salad –Perseveration Heightened Perceptions & Hallucinations –Sensory Flooding –Hallucinations

10. Negative Symptoms Poverty of Speech A decrease in speech or speech content (catatonia) Blunted or Flat Affect –Flat-virtually no emotion –Ambivalence Social Withdrawal –Conflicted feelings about many things

11. Psychosocial Factors Disturbed Family Communication –Expressed Emotion Family members express critical or overprotective emotions (e.g. flat affect, staring) Predictive of relapse

12. Onset, Course and Prognosis

13. Childhood Precursors Some children who later develop SZ show (majority have normal childhoods): 1. Delayed developmental milestones (walking, etc) 2. More language and speech problems (predictor) 3. Poorer coordination (sports, phy ed class) 4. Poorer academic achievement 5. Poorer social functioning and fewer friends **Statistical associations not predictors** Source: Torrey, 2006 Surviving Schizophrenia

14. Onset 75% of those who get SZ are between the ages of 17 and 25; Unusual to get before 14 or after 30 Childhood SZ does occur but rare Postpartum SZ happens but is usually eventually diagnosed as manic depressive illness or major depression with psychotic features Late-onset SZ: Age 40 or over; more females than males and 1/3 go on to develop Alzheimer-type dementia

15. Questions Based on the article: What aspects of an individual's life are affected by the development of schizophrenia during middle adulthood? How does this affect their development, biologically, psychologically, and socially?

16. Predictors of Outcome Good vs. Worse Prognosis Consider “normal” prior to SZ Female No hx or relatives with SZ Family hx depression or bipolar disorder Sudden onset More positive symptoms Quick response to initial dose meds Good illness awarenessGood illness awareness Family hx of SZ Male Younger the age when SZ developed (15 vs.25) Slower, gradual onset Have more negative symptoms (flattened affect) Poor illness awarenessPoor illness awareness Poor initial response to meds

17. Illness awareness… or lack thereof

18. Two theories on lack of insight 1) Anosognosia (1) Anosognosia –Neurological term –Limited or no awareness –Strokes or brain tumors in the right side of the brain –Frontal lobe damage (2) Psychological defense mechanism –Blocking –Do not want to talk about illness episodes when better

19. Men and Schizophrenia Males earlier onset than females More severe in males Males do not respond well to antipsychotic meds-require higher doses than women (metabolic issue?) Higher relapse rate than women More trouble with long-term adjustment (e.g. marriage, work, level of function) when compared to women

20. African Americans and SZ Recent study shows African Americans has 3 fold increase in SZ when compared to whites Past studies show same Researchers not sure why

21. Long-term Prognosis Studies that follow individuals long-term generally show that the course of outcome is better after 30 years than after 10 years Illness seems to “die down” after many years Gets worse before it gets better

22. Schizophrenia and Life Expectancy People with SZ tend to die younger WHY? Suicide (12x times higher than gen pop) Diseases (diabetes type II, heart disease, etc) Unhealthy lifestyles (smoking) Inadequate medical care and lack of access Homelessness

23. Schizophrenia & Violence Violence is NOT a symptom Risk Factors –History of violence –Substance abuse –Off medication and actively psychotic -Lack of illness insight Most violent crimes are not committed by persons with schizophrenia, and most persons with schizophrenia do not commit violent crimes. -NIMH

24. SZ Treatment –Cognitive techniques –Behavioral strategies –Family & Group therapy *Often combined with medication

25. SZ can be very difficult to treat Nearly half of those diagnosed do not know that they are sick Co-occurring disorders Medication side effects Laws and Insurance Companies** Lack of social and familial support Stigma and discrimination SZ Difficult to understand

26. SZ and Macro Systems

27. Question Psychiatric hospitals across the country are down-sizing and closing…Less help and fewer beds…No observable decrease in the # of people needing help… Does anyone know where many of these individuals who are still in need of help are winding up?

28. Big Shift Mental health system to the…

29. Current Conditions By the end of 2006, there were 2.3 million confined individuals. 16 to 37.5% of those individuals are diagnosed with an SMI (bipolar, SZ, SZA) 2 to 4 times higher than found in the general public HRW estimates 200,000 to 400,000 SMI

30. Not a New Problem 19 th century Dorothea Dix Hospitals remained the primary treatment of SMI for next 150 years

31. Trend of Incarcerating SMI Began to notice increase in the number of SMI being jailed beginning in the 1970’s –Teplin and Colleagues and Cook County, Illinois Failure of the mental health system

32. Possible causes of incarceration of those with SMI Deinstitutionalization beginning in 1950’s Lack of community mental health centers and services-did not want to treat SMI Lack of housing –Led to Homelessness (1/3 have SMI) Social welfare policies (Medicare/Medicaid)

33. Possible Causes…continued Changes in drug laws Strict inpatient laws Inability to recognize illness –50% of people with schizophrenia and bipolar disorder do not recognize they are ill Penrose's theory

34. Mental Health Courts and Federal Laws Congress saw increasing levels of SMI as a problem 2000 America’s Law Enforcement and Mental Health Project Act (ALEMHP) (S.1865), P.L. 106-515. President Clinton 2004 Mentally Ill Offender Treatment and Crime Reduction Act of 2004 (MIOTCRA) P.L. 108-414. President Bush

35. What is a Mental Health Court? Similar to drug courts Forensic courts that manage the cases of those with mental illness charged with committing misdemeanors and/or felony crimes. Approximately 130 in operation-growing Based on “therapeutic jurisprudence” Problem: Treatment after crime committed

36. NAMI Mental Health in Pennsylvania Report Card NAMI D+ (Nationally D+) –Infrastructure: C- –Information: D- –Access: D- –Services: C- –Recovery Supports: C-

37. Mental Health and Pittsburgh State inmate re-entry program in Allegheny County (MHC program) –2001: 3 rd largest mental health facility in PA –20-25% inmates mentally ill RAND study –1 st study to examine cost of program –Cost effectiveness took effect after 2 years –Received more mental health services and spent fewer days in jail (criminal court)

38. Mental Health Laws and SZ in Pittsburgh Most restrictive laws in the nation

39. Troy Hill Jr.

40. Consequences of Strict Laws Fatally attacked one brother and hurt another Diagnosed as having paranoid SZ Tried to seek help but was turned away

41. Powerful Letter “ I have made thousands of mistakes in my life, but my worst mistake, the one I lament almost daily, [was] working … to pass the state's Mental Health Procedures Act” -Bill Shane-Former PA Legislator Thursday Sept 13, 2007 Pittsburgh Post Gazette

42. Summary Most people who develop SZ do so at late adolescence/early adulthood Schizophrenia is still a very misunderstood disease Many people with SZ do not receive or accept treatment Many are now involved in the criminal justice system

43. Questions or Comments?