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Schizophrenia Symptoms, Types Causes, Treatment, Case Studies for Evaluation.

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1 Schizophrenia Symptoms, Types Causes, Treatment, Case Studies for Evaluation

2 Schizophrenia: Definition The most debilitating psychosis and the closest to the layman’s definition of madness. Kraepelin (1896) called it dementia praecox (senility of youth) because the symptoms occur fairly early on in life and result in a gradual deterioration. Bleuler (1911) suggested that symptoms can occur later, and coined the term schizophrenia, (‘split mind’ in Greek) which symbolises the fragmentation of the sufferer's personality. Schizophrenia exists world-wide, but its symptoms can vary from culture to culture. Schizophrenia comprises a number of symptoms which in different combinations produce three different types of the disorder.

3 Symptoms of Schizophrenia First Rank Symptoms In Britain, schizophrenia is only diagnosed in the presence of one of the following ‘first rank’ symptoms (disturbances of subjective experience as reported verbally by the individual). 1) Disturbance of thought: the belief that thoughts are being inserted into the individual’s mind from outside (thought insertion) or removed from their mind by external forces (thought withdrawal), or that their thoughts are being made known to others (thought broadcasting). 2) Hallucinations (the experience of sensory stimuli which are not present) Auditory (the most common). ‘Voices’: offer a commentary on the individual's behaviour "he is eating his dinner"; make disparaging remarks about him "he eats like a pig ";give him commands "put the knife on the plate". ‘Voices’ may be a distortion of environmental noises (fridge or radiator noises interpreted as whispering) or projections of the individual's own thoughts (thoughts may enter the individual’s internal speech loop or even become spoken aloud without the individual realising that the thoughts / speech are his own (malfunction of the feedback loop). Somatic e.g. experience of electric shocks to the fingertips.

4 Symptoms of Schizophrenia (contd) 3 ) Delusions (beliefs which individuals are firmly convinced are true, regardless of evidence to the contrary). These can come in:- Delusions of grandeur: the individual is someone important or powerful (Christ, Napoleon). Delusions of persecution: the individual is being conspired against/interfered with by other people or organisations (M15, the Mafia). Delusions of reference: the individual believes that unrelated events have personal significance e.g. the words of a song refer to them personally. Other common delusions: the belief that nothing really exists and all things are simply shadows; the belief that one has been dead for years and it is observing the world from afar.

5 Other Symptoms These are symptoms not classified as ‘First Rank’ but are reported by observer’s of patients’ behaviour:- Thought Process Disorder a) Loose Association: the individual is unable to focus attention so he/she moves from one topic of thought to another in a disjointed, illogical way. b) Word Salad: disjointed thought leads to incoherent, rambling language association e.g. ‘I am the King of Spain, the daughter and the fruit tree, blossom in Spring’. c) Clang association: the sound of one word triggers association with another word e.g. ‘The King of Spain feels no pain in the drain of the crane’. d) Invention of new words and combining existing words in unusual ways e.g. ‘ belly bad luck and brutal and outrageous’ to describe stomach ache. e) Echolalia i.e. repetitive echoing of words spoken by others. Motor Symptoms a) Catatonia: the individual stays mute and motionless in a fixed position for hours or days on end. b) Stereotypes:the individual moves repetitively e.g. rocks to and fro. c) Agitation: including sudden, disturbing, unpredictable gestures and grimaces for no apparent reason.

6 Other Symptom (contd) Emotional Disturbance a) Blunting: apparent indifference to events which would normally provoke a strong emotional reaction. b) Inappropriate Affect: e.g. laughing when told bad news, reacting angrily if offered a gift. c) Flattened Affect: absence of emotional expression, speech is in monotone, no mobility of facial features, vacant gaze. Lack of Volition Loss of interest in the external and social world. Loss of drive. Inability to act, including inability to perform everyday living activities e.g. washing, cooking. Disordered Sense of Self Sufferer has little idea who he / she is and has no ego-boundaries. The sufferer displays autism, and lives in a fantasy world, taking no notice of the world around them.

7 Types of Schizophrenia Previously schizophrenia was classified into two types: Acute (TYPE 1) - also known as positive syndrome schizophrenia. - sudden onset, with delusions and hallucinations as early symptoms. Chronic (TYPE 11) - also known as negative syndrome schizophrenia. - insidious onset with a history of apathy and social withdrawal (loners) - worse prognosis than for acute schizophrenia.

8 Types of Schizophrenia (contd) Now schizophrenia is classified into four main types: Disorganised Schizophrenia: (the most severe type) onset: adolescence or early adulthood; Disorganised thought and language (loose association and word salad); Disorganised delusions and vivid hallucinations, inappropriate and flattened affect; Disorganised behaviour and extreme social withdrawal Catatonic Schizophrenia Catatonia or agitation; loss of drive; echolalia (involuntary repetition of sounds uttered by others) Paranoid Schizophrenia onset: later than other types; Well organised delusions and hallucinations; Language, behaviour and the ability to carry out daily functions remain relatively normal. Paranoid schizophrenics show the highest level of awareness! Undifferentiated Schizophrenia is a diagnosis for people with mixed symptoms who don’t fit any of the types clearly. Other related disorders include: a) Brief psychotic disorder b) Substance Induced psychotic disorder

9 Evaluating the Types of Schizophrenia Although these types form the basis of current diagnostic systems, their usefulness is often questioned. Because diagnosing types of schizophrenia is extremely difficult, diagnostic reliability is dramatically reduced. Furthermore, these sub-types have little predictive validity; that is, the diagnosis of one over another form of schizophrenia provides little information that is helpful in either treating or in predicting the course of the problems. There is also considerable overlap among the types. For example, patients with all forms of Schizophrenia may have delusions. Kraepelin’s system of sub-typing has not proved to be a useful way of dealing with the variability in schizophrenic behaviours.

10 Evaluating the Types of Schizophrenia (contd) A system that is currently attracting much attention distinguishes between positive and negative symptoms (as opposed to types of patients) continues to be used increasingly in research on the aetiology of schizophrenia. Aetiology is defined as the science that deals with the causes or origin of disease, the factors which produce or predispose toward a certain disease or disorder. It is a medical term. Andreasen and Olsen (1982) evaluated fifty-two patients with schizophrenia and found that sixteen could be regarded as having predominantly negative symptoms, eighteen as having predominantly positive symptoms, and eighteen as having mixed symptoms. Although these data suggest that it is possible to talk about types of schizophrenia, subsequent research has indicate that most patients with schizophrenia show mixed symptoms (e.g. Andreasen, Flaum et al.,1990) and that very few patients fit into the pure positive or pure negative types.

11 The Course of Schizophrenia Patients with Schizophrenia have been seen to go through three phases/stages:- 1.Pro-modal phase: Characterised by a steady deterioration including emotional flatness and loss of drive. In Type 1, this is short, in Type 11 the onset is insidious (harmful). 2.Active Phase: involves major symptoms 3.Residual Phase: when the sufferer is in remission (return to the pro-modal phase). Note:- The three stages are not always clearly separable and the duration of each phase is variable. A third of sufferers have one or two acute episodes (active phase) and then return to normal. A third have periods of acute episodes and remissions (residual phase) A third deteriorate progressively (from active to chronic symptoms) over time

12 Evaluating Schizophrenia: Focusing on Case Studies

13 Family history research Twin studies Adoption studies DNA Markers GENETICS Biochemical imbalance Brain damage Viral theory Birth complications BRAIN ABNORMALITY BIOGENIC EXPLANATIONS FOR SCHIZOPHRENIA You need to be able to describe and evaluate TWO pieces of research in each of the following areas

14 Family History Studies The Copenhagen High-Risk study (Kety et al 1962,1974,1989). Procedure identified 207 children with a schizophrenic mother (high risk group) and 104 with a non- schizophrenic mother (controls). Found that at age 42, a total of 67 of the high risk group had been diagnosed as having either schizophrenia or schizotypal personality disorder versus 7 in the low risk group This meant a 35% risk of developing schizophrenia in the high risk group versus a 7% risk for controls. Study number one

15 Family History Studies Zimbardo (1995) He compiled a risk table from studies of European populations between 1920 and Among the general population the risk of developing schizophrenia is 1%. He found for a brother or sister of a schizophrenic it is 9%, for a child with one schizophrenic parent 13%, for a child with two schizophrenic parents 46%. The degree of risk of developing schizophrenia also correlates highly with the degree of genetic relatedness to a family member who has suffered from the disease. Study number two

16 Twin Studies Gottesman and Shields (1982) Concordance study on a dozen pairs of MZ twins, reared apart 58% concordance rate Suggest some commentary Study number four Study number three Cardno (1999) Concordance study of DZ & MZ twins reared together 5.3% DZ concordance 40% MZ concordance Evaluation

17 Adoption studies Study number five Israeli High Risk study (Marcus 1967 and 1987) Procedure identified 50 children with a schizophrenic parent (high risk group) and 50 children with non schizophrenic parents (controls). Half from each group were brought up in a kibbutz (communally, separate from their parents) the other half in families At a 13 year follow-up 22 of the high risk group had been diagnosed with schizophrenia but only 4 of the control group (16 were kibbutz raised, 10 from traditional families). Is this evidence any more reliable? If so why?

18 Adoption studies Study number six The Finnish Adoption Study (Tienari, 1969 and 1987) Procedure identified two groups of adopted children. 112 adoptees with a schizophrenic biological parent (high risk group) and 135 adoptees without a schizophrenic parent (controls). At an 18 year follow-up, 7% of the high risk group had been diagnosed as schizophrenic and only 1.5% of the controls. Can you see a pattern emerging from all these findings?

19 Debate!!! Schizophrenia is inherited Summarise the evidence of the case for a genetic cause Summarise some of the problems with this evidence Why? Are there other possible causes?

20 Cause One:Brain Biochemistry The Dopamine Hypothesis

21 DrugEffect on Dopamine Levels Symptoms in the Individual Phenothiazine (anti-psychotics) Reduces disordered thoughts and behaviour symptomatic of Acute schizophrenia. Side-effect: Parkinson- like stiffness and tremors. Cocaine and Amphetamines Can cause paranoia and hallucinations. Exacerbates schizophrenic symptoms in sufferers (Davis 1974) L-dopaReduces Parkinson’s stiffness and tremors. Side-effect: Can produce Acute schizophrenic symptoms. The hypothesis suggests a positive correlation between high levels of dopamine in the brain and Acute symptoms of schizophrenia. relies on drug effects for evidence. Iverson (1979) thought schizophrenics suffered from excessive dopamine production, as he found high levels of dopamine in the brains of schizophrenics at post-mortem. But Davis et al (1991) showed that schizophrenics have 6 times more dopamine receptor sites and / or more sensitive post-synaptic receptors causing more dopamine to be utilised.

22 Discussion Acute symptoms respond well to dopamine treatment but Chronic symptoms don’t. What are the implications of this finding? Does increased dopamine production cause schizophrenia or does schizophrenia cause increased dopamine production? What kind of relationship has been shown? Dopamine is also implicated in psychiatric disorders other than schizophrenia. Is it the cause or merely a factor? Women are less susceptible to schizophrenia than men and more likely to suffer late onset. Oestrogen is thought to provide a neuro- protective effect against the disease (Seena 1997). What evidence is the hypothesis based on? What is the Treatment-Aetiology fallacy?

23 Cause Two: Brain Abnormality Research involving MRI and CAT scan research on live patients has found the following structural abnormalities in the schizophrenic brain.

24 Unusually large ventricles (fluid filled cavities) (Brown et al 1986)

25

26 Cortical abnormalities like reduced activity (red area) (Goldstein et al 1999)

27 25% reduction of grey matter in the frontal & temporal lobes (Kwon et al 1999)

28 Areas of the brain

29 Affected parts of the brain in a schizophrenic patient

30 Lack of normal asymmetry in the brains of schizophrenics Young et al (1991)

31 (Possible) Cause Three: Viral Theories Torrey & Peterson (1976) theorise that contracting the influenza A virus in the weeks of pregnancy, when the brain is in a crucial stage of development, causes brain damage which later manifests as schizophrenia. Not until puberty do hormonal changes reveal the brain damage and from this age the brain damage may manifest as schizophrenic symptoms

32 Extended Activity The following books/films depict Schizophrenic behaviour and activity and are worth a watch:- 1.A Beautiful Mind chronicled the life of John Forbes Nash, a Nobel- Prize-winning mathematician who was diagnosed with schizophrenia.A Beautiful MindJohn Forbes NashNobel- Prize 2.EastEnders featured a very successful storyline in 1996 that involved a character suffering from schizophrenia, triggered by the loss of a relative.EastEnders 3.In the book Misery by Stephen King, the antagonist Annie Wilkes is thought to suffer from a form of schizophrenia, in addition to other psychological disorders that makes her very argumentative and not able to easily distinguish between fiction and reality.MiseryStephen KingAnnie Wilkes You tube clip: Causes of Schizophrenia


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