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Schizophrenia and other Psychotic Disorders Chapter 13
Introduction to Schizophrenia Schizophrenia is a severe disorder that is often associated with considerable impairments of functioning. This disorder is very profound and serious. It is also challenging and complex not only for the patient, but also their families. Schizophrenics often have diverse symptoms including: differences in perception, thinking, action, sense of self, and manner in relation to others. Psychosis – is the loss of contact with reality.
Origins of the Schizophrenia Construct The first description of schizophrenia was offered in 1810 by John Haslam at the Bethlem Hospital in London, England. Haslam described the symptoms (delusions) that are typical of schizophrenia. 50 years later, Belgian psychiatrist Benedict Morel talked about a 13 year old boy who had been brilliant in school and then had lost interest in his studies; increasingly becoming withdrawn, lethargic, isolated, and quiet. He had appeared to have forgotten everything that he had learned. At first, Morel thought the boy had some form of brain degenerative disease that came about due to heredity.
Origins of the Schizophrenia Construct Kraepelin, an observer of clinical phenomenon, described these patients with dementia praecox as someone who becomes suspicious of those around him, sees poison in his food, is followed by the police, feels his body is being influenced, thinks he is going to be shot, or that the neighbor is following everything that he does. Kraepelin also stated the disorder had hallucinations, apathy and indifference, withdrawn behavior, and an incapacity for regular work.
Origins of the Schizophrenic Construct Eugen Bleuler (a Swiss psychiatrist) gave the name of the disorder, schizophrenia. Sxizo means “to split or crack” and phren means “mind”. He named it this because of the disorganization of thought processes, a lack of coherence between thought and emotion, and an inward orientation away (split off) from reality. Schizophrenia is NOT multiple personality as it is wrongly displayed on television. There is not a split in personality. There is a split between the academic brain and the emotions of the person.
Epidemiology There is a less than 1% chance of developing schizophrenia. It is actually 0.7 percent. This is 1 out of 140 people. Not everyone has the same risk of getting schizophrenia. Those with a parent with schizophrenia have a higher risk of getting schizophrenia. People’s whose fathers are older (45-50 years of age) at the time of their birth have 2-3 times the normal risk of developing schizophrenia when they grow up. Having a parent that works as a dry cleaner means the child has more risk.
Epidemiology The vast majority of cases of schizophrenia begin in late adolescence and early adulthood, with 18-30 years of age being the peak time for the onset of the illness. When schizophrenia is found in children it is extremely rare. Schizophrenia is generally brought about in males at earlier ages than in females. There is a new peak in cases of schizophrenia between the ages of 20-24. After about 35, the risks for developing schizophrenia significantly drops with men. There is a second new rate of cases right about 40 years old. Men also tend to have a more severe form of schizophrenia. Brain abnormalities in males are much higher. Women are often misdiagnosed because their symptoms can be much less. Female sex hormones to play a protective role. When estrogen levels are low or are falling, psychotic symptoms in women with schizophrenia get worse. Declining levels of estrogen around menopause might explain the late-onset schizophrenia for women. Late onset of schizophrenia for women might be more severe than if it comes at an earlier age.
Delusions A delusion – is essentially an erroneous belief that is fixed and firmly held despite clear contradictory evidence. With a delusion, tricks are played on the mind. People with delusions believe things that others who share their social, religious, and cultures do not believe. A delusion is a disturbance in the content of thought. Not all people that suffer from delusions suffer from schizophrenia. 90% of schizophrenic patients have delusions, though.
Delusions With most people with schizophrenia, there is a thought that feelings, actions, or thoughts are being controlled by an outside source. Sometimes, they feel that their private thoughts are being broadcasted to others. They may also think that thoughts are being placed in their head by other external agencies. They might think that they have been robbed of one of their thoughts.
Delusions There are delusions of reference where a television program or a song on the radio is believed to have special and personal meaning intended only for the person. Delusions of body changes (e.g., the bowels do not work) or someone has removed their organs when they weren’t looking.
Hallucinations A hallucination is a sensory experience that seems real to the person having it, but occurs in the absence of any external perceptual stimulus. This is different from an illusion. Hallucinations can occur in any sensory modality (auditory, visual, olfactory, tactile, or gustatory). Hearing voices is the most common. Even deaf people who are diagnosed with schizophrenia sometimes report auditory hallucinations. Hallucinations can even be induced by healthy people if they are under a lot of stress and drink too much caffeine.
Hallucinations Hallucinations often have relevance for the patient at some affective, conceptual, or behavioral level. Patients can become emotionally involved in their hallucinations, often incorporating them into their delusions. Sometimes, these individuals will act on what the voices tell them to do. These individuals might perceive the voices to be superior to them. Generally, these voices will be of normal level and will say not so nice things. They can be abusive, critical, or bossy. Sometimes, they can be pleasant and support.
Disorganized Speech and Behavior Disorganized speech is the external manifestation of a disorder in thought form. The affected person fails to make sense, despite seeming to conform to the semantic and syntactic rules governing verbal communication. The disorganized speech is not because of low intelligence, poor education, or cultural deprivation. In this type of speech, the words and word combinations sound communicative, but the listener is left with little or not understanding of the point the speaker is trying to make. Completely new or made- up words are known as neologisms. This disorganized thought process is called formal thought disorder.
Disorganized Speech and Behavior Goal-directed activity is almost universally disrupted in schizophrenia. The impairment occurs in areas of routine daily functioning, such as work, social relations, and self-care, to the extent that observers note that the person is not himself or herself anymore. They may disregard of personal safety and health. Behavior can come across as silliness or unusual dress (wearing a scarf, gloves, and an overcoat in the summer).
Disorganized Speech and Behavior Catatonia – the patient may show a virtual absence of all movement and speech and be in what is called a catatonic stupor. The patient may hold an unusual posture for an extended period of time without any seeming discomfort.
Positive and Negative Symptoms In the times of Bleuler, there were two times of schizophrenia: positive and negative syndrome schizophrenia. This changed because a disorganized symptom was recognized. Positive symptoms – are those that reflect an excess or distortion in a normal repertoire of behavior and experience, such as delusions and hallucinations.
Positive and Negative Symptoms Negative symptoms – reflect an absence or deficit of behaviors that are normally present. Symptoms of negative include: flat affect (blunted emotional expressiveness), alogia (very little speech, and avolition (the inability to initiate or persist in goal-directed activities. Most patients will show both of these symptoms at some point in their disorder. Lots of negative symptoms are not a good sign for the patient’s future outcome. Even though patients of schizophrenia may show flat affect, they may be holding very strong emotions within them.
Other Psychotic Disorders In the DSM, there is a category of diagnoses called schizoaffective disorder. This diagnosis is a hybrid in that it is used to describe people who have features of schizophrenia and severe mood disorders. The person has psychotic symptoms that meet criteria for schizophrenia, but also have marked changes in mood for long amounts of time. There are two types of schizoaffective disorder (bipolar and unipolar subtype). Generally, the people that are right in the middle of being diagnosed with a mood disorder or schizophrenia tend to be put into this label. The long-term outcome for these patients is much better than those with schizophrenia.
Risk and Causal Factors There is no one factor that can fully explain the etiology of schizophrenia. It is not the result of a genetic switch being flipped. There is a complex interplay between genetic and environmental factors as responsible. Genes that deal with schizophrenia tend to run in the family. There are higher than normal rates of schizophrenia amongst biological relatives. Those individual that have an individual in the nuclear family with schizophrenia makes it a 10% risk factor of an individual developing this disorder. Relatives at length – 3%. Family studies by themselves cannot help scientists to fully understand where this disorder comes from. Twin and adoption studies are very important to help figure out this puzzle.
Twin Studies Rates of schizophrenia in identical twins are routinely and consistently found to be significantly higher than for fraternal twins or siblings. There is a 28% chance of development given an identical twin. 6% in a dizygotic twin. If schizophrenia were exclusively a genetic disorder, the concordance rate for identical twins would be 100%. Genes definitely play a role in causing schizophrenia. Genes do not tell the whole story, though.
Adoption Studies Scientists cannot assume that any differences found between identical twins and fraternal twins are attributable to genes. The idea behind this is that the environments of the identical twins are no more similar than the environments of fraternal twins. But, this is not true. If we state that identical and fraternal twins have the exact same environment, there will be a problem with our experimentation.
Adoption Studies In adoption studies, concordance rates for schizophrenia are compared for the biological and the adoptive relatives of persons who have been adopted out of their biological families at an early age (preferably at birth) and have developed schizophrenia. The first type of this kind of study was conducted by Heston in 1966. Heston looked at 47 kids that were born to mothers who were in a mental hospital suffering from schizophrenia. The children had been placed in foster homes or relatives homes within 72 hours. Heston found that 16.6% of these children were later diagnosed with schizophrenia. None of the 50 control children (selected from among residents of the same foster homes whose biological mothers did not have schizophrenia) developed schizophrenia. These mothers were more likely to be diagnosed as mentally retarded, neurotic, or psychopathic, more active in criminal behavior, and spent more time in jail. This might mean that these mothers have forms of psychopathology.
The Quality of the Adoptive Family When researchers looked at healthy adoptive families, they found that less adopted children with high risks for schizophrenia actually developed the disorder due to the structure of the family. Bad adoptive families did not fair well as these high risk individuals were much more likely to develop schizophrenia. It is very unlikely that schizophrenia will be located and identified as a mutated gene. Linked analysis – the symptoms or traits of some disorders are generally next to traits that are alike it. It makes finding the genes for these disorders much easier. Scientists are still studying the areas of some chromosomes including: 1, 2, 6, 8, 13, and 22.