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Chapter 11 Schizophrenia Ch 11. Schizophrenia Schizophrenia is a psychotic disorder involving disturbance of thought, emotion and behavior The lifetime.

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Presentation on theme: "Chapter 11 Schizophrenia Ch 11. Schizophrenia Schizophrenia is a psychotic disorder involving disturbance of thought, emotion and behavior The lifetime."— Presentation transcript:

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

4  Cause is Unknown  Affects 1 out of 100 People  Often Begins (Ages )  More Hospital Beds Than Any Other Medical Illness 2.5% of Total U.S. Healthcare Budget  Cause is Unknown  Affects 1 out of 100 People  Often Begins (Ages )  More Hospital Beds Than Any Other Medical Illness 2.5% of Total U.S. Healthcare Budget

5  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  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  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?  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  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.  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  Dementia (Loss of Mind)  Praecox (Early, Premature)  Kraepelin –Categorization & Early Onset  Eugen Bleuler –Termed “Schizophrenia” –Associative Splitting  Dementia (Loss of Mind)  Praecox (Early, Premature)  Kraepelin –Categorization & Early Onset  Eugen Bleuler –Termed “Schizophrenia” –Associative Splitting

9  Positive Symptoms –Displays of Abnormal Behavior  Disorganized Symptoms –Speech and Behavior  Negative Symptoms –Deficits in Affect, Speech, Motivation  Positive Symptoms –Displays of Abnormal Behavior  Disorganized Symptoms –Speech and Behavior  Negative Symptoms –Deficits in Affect, Speech, Motivation

10  Positive Symptoms  Delusions –Misrepresentation of Reality –“Basic Feature of Madness”  Examples –Grandeur -- Importance –Persecution -- Out to Get Me  Delusions –Misrepresentation of Reality –“Basic Feature of Madness”  Examples –Grandeur -- Importance –Persecution -- Out to Get Me

11  Positive Symptoms  Hallucinations –Absence of Sensory Stimulation –Involve Any of the Senses  Examples –Auditory -- Voices (70%) –Visual -- Seeing Things (25%) –Tactile -- Crawling Sensation  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) Broca’s Area (Speech) Wernicke’s Area (Hearing) Wernicke’s Area (Hearing) What Area Do You Think is More Active With Auditory Hallucinations? What Area Do You Think is More Active With Auditory Hallucinations?

13  Disorganized Symptoms  Disorganized Speech –Difficulty in Communication  Examples –Tangentiality –Loose Association or Derailment  Disorganized Speech –Difficulty in Communication  Examples –Tangentiality –Loose Association or Derailment  Positive Symptoms  Positive Symptoms

14  Disorganized Behaviors  Catatonia –Spectrum –Wild Agitation to Immobility  Example –Waxy Flexibility –Inappropriate Affect  Disorganized Behaviors  Catatonia –Spectrum –Wild Agitation to Immobility  Example –Waxy Flexibility –Inappropriate Affect  Disorganized Symptoms  Positive Symptoms  Positive Symptoms

15  Positive  Disorganized Symptoms  Positive  Disorganized Symptoms  Negative Symptoms  Flat Affect -- “The Mask”  Avolition -- “No Initiative”  Alogia -- “Speech is Vacant”  Anhedonia -- “No Pleasure”  Asociality--”No social interest”  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  Paranoid Type  Disorganized Type  Catatonic Type  Undifferentiated Type  Residual Type  Paranoid Type  Disorganized Type  Catatonic Type  Undifferentiated Type  Residual Type

20  Delusions & Hallucinations  Intact Cognition and Affect  No Disorganized Speech  Best Prognosis  Delusions & Hallucinations  Intact Cognition and Affect  No Disorganized Speech  Best Prognosis

21  Paranoid Type  Disorganized Type  Catatonic Type  Undifferentiated Type  Residual Type  Paranoid Type  Disorganized Type  Catatonic Type  Undifferentiated Type  Residual Type

22  Disorganized Speech  Disorganized Behavior  Flat or Inappropriate Affect  Hallucinations and Delusions –Fragmented or Lacking a Theme  Often Chronic  Disorganized Speech  Disorganized Behavior  Flat or Inappropriate Affect  Hallucinations and Delusions –Fragmented or Lacking a Theme  Often Chronic

23  Paranoid Type  Disorganized Type  Catatonic Type  Undifferentiated Type  Residual Type  Paranoid Type  Disorganized Type  Catatonic Type  Undifferentiated Type  Residual Type

24  Disorganized Speech  Disorganized Behavior  Waxy flexibility, rigidity, odd mannerisms, mimicry  Flat or Inappropriate Affect  Hallucinations and Delusions –Fragmented or Lacking a Theme  Often Chronic  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  Paranoid Type  Disorganized Type  Catatonic Type  Undifferentiated Type  Residual Type  Paranoid Type  Disorganized Type  Catatonic Type  Undifferentiated Type  Residual Type

26  Beginnings of Breakdown  Major Sx of Schizophrenia  DO NOT Meet Other Criteria  “Wastebasket” Category  Beginnings of Breakdown  Major Sx of Schizophrenia  DO NOT Meet Other Criteria  “Wastebasket” Category

27  Paranoid Type  Disorganized Type  Catatonic Type  Undifferentiated Type  Residual Type  Paranoid Type  Disorganized Type  Catatonic Type  Undifferentiated Type  Residual Type

28  Have Had One Episode  Now Mostly Symptom Free  Have Had One Episode  Now Mostly Symptom Free Once a Schizophrenic, Always a Schizophrenic? 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?  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?

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 toPercentage ProbandSchizophrenic Spouse 1.00 Grandchildren 2.84 Nieces/nephews 2.65 Children 9.35 Siblings 7.30 DZ twins12.08 MZ twins44.30 Ch 11.6

33  Runs in Families  Increased Risk Based on Genetic Relatedness  Search for Marker Genes Smooth Pursuit Eye Tracking  Runs in Families  Increased Risk Based on Genetic Relatedness  Search for Marker Genes Smooth Pursuit Eye Tracking  Genetic Influences

34

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 Ch 11.8 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.

37 Dopamine Theory of Schizophrenia

38  Antagonists –Neuroleptics –Drugs That Reduce Dopamine –Negative Side Effects –L-Dopa (Agonist) –Amphetamines  Antagonists –Neuroleptics –Drugs That Reduce Dopamine –Negative Side Effects –L-Dopa (Agonist) –Amphetamines  Genetic Influences  Neurobiological Influences  Excess Dopamine (D2 Receptors)

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  Ventricle Enlargement  Genetic  Neurobiological Influences  Genetic  Neurobiological Influences  Brain Structure

42  Ventricle Enlargement  Genetic  Neurobiological Influences  Genetic  Neurobiological Influences  Brain Structure  Hypofrontality

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 13.9 Barlow/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  Haldol & Clozapine  Trial and Error  “Extrapyramidal” Side Effects Tardive Dyskinesia Akinesia Atypical Antipsychotics: (Clozapine, Risperdal, Zyprexa,Seroquel, Geodon, Abilify)  Haldol & Clozapine  Trial and Error  “Extrapyramidal” Side Effects Tardive Dyskinesia Akinesia Atypical Antipsychotics: (Clozapine, Risperdal, Zyprexa,Seroquel, Geodon, Abilify)  Biological Interventions  Neuroleptics  Biological Interventions  Neuroleptics

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 Barlow/Durand, 3rd. Edition Studies on treatment of schizophrenia from 1980 to 1992

51 Summary of Schizophrenia and Psychotic Disorders Figure 13.x1 Barlow/Durand, 3rd. Ed. Exploring schizophrenia and its treatment

52 Summary of Schizophrenia and Psychotic Disorders (cont.) Figure 13.x1 Barlow/Durand, 3rd Edition (cont.) Exploring schizophrenia and its treatment

53  Schizophreniform Disorder  Schizoaffective Disorder  Delusional Disorder  Brief Psychotic Disorder  Shared Psychotic Disorder  Folie a Deux  Schizophreniform Disorder  Schizoaffective Disorder  Delusional Disorder  Brief Psychotic Disorder  Shared Psychotic Disorder  Folie a Deux


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