1. Schizophrenia & Other Psychotic Disorders

2. Historical Approaches Kraeplin early descriptions Classifies symptoms Differentiates mania Bleuler Associative splitting of personality

3. Schizophrenia: Lost touch with reality Disruption of: Normal thought processes Perception Personality Affect

4. positive symptoms – deviant behaviors delusions, hallucinations, thoughts negative symptoms – deficit symptoms Lack of normal function SYMPTOMS OF SCHIZOPHRENIA

5. thought disorder – disrupted cognitive functioning most dramatic and obvious symptom loosening of associations word salad – seems as if sense Neologisms – new words clang associations - sounds of words POSITIVE SYMPTOMS

6. delusions – not objectively true not be accepted as true within culture person holds firmly in spite of contrary evidence POSITIVE SYMPTOMS

7. Delusions Paranoid/persecution Grandeur Capgas syndrome – double of other’s Cotard’s syndrome – part of body changed Change vs. fixed

8. hallucinations – perceptual experiences that feel real although there is nothing to perceive Visual Auditory tactile POSITIVE SYMPTOMS

9. Attention Problems Difficulty focusing attention Esp. during first stages Bombarded Attention is critical to functioning

10. Negative Symptoms Negative = absent 25% patients

11. Anhedonia - interest Avolition - movement Alogia - content or quantity of speech flat or blunted affect NEGATIVE SYMPTOMS

12. catatonia – a psychomotor disturbance of movement and posture catatonic stupor waxy flexibility OTHER SYMPTOMS

13. inappropriate affect – unusual and sometimes bizarre emotional responses OTHER SYMPTOMS

14. lack of insight – lack of awareness that one’s experiences are unusual or abnormal

15. Schizophrenia is not… Split personality disorder Multiple personality disorder Schizophrenia = “splitting of the mind” Ambivalence

16. clinical course – specific pattern of changes in symptomatology over time prodromal phase active phase residual phase CLINICAL COURSE

17. Schizophrenia 1% lifetime prevalence Equal men & women Consistent across cultures (differences in dx and recovery) More in lower class Early life Women later

18. AGE OF RISK FOR SCHIZOPHRENIA Source : Adapted from I.I. Gottesman, Schizophrenia Genesis: The Origins of Madness (New York: Freeman, 1991.)

19. AGE OF RISK FOR SCHIZOPHRENIA Source : Adapted from I.I. Gottesman, Schizophrenia Genesis: The Origins of Madness (New York: Freeman,1991.)

20. TYPICAL COURSES FOR SCHIZOPHRENIA GRADUAL ONSET & VERY POOR PROGNOSIS (A) CHRONIC GRADUAL ONSET & VERY POOR PROGNOSIS

21. TYPICAL COURSES FOR SCHIZOPHRENIA OCCASIONAL EPISODES WITH NEARLY NORMAL FUNCTIONING BETWEEN THEM (B) EPISODIC OCCASIONAL EPISODES WITH NEARLY NORMAL FUNCTIONING BETWEEN THEM

22. TYPICAL COURSES FOR SCHIZOPHRENIA BRIEF PERIOD OF PSYCHOSIS & NEARLY COMPLETE RECOVERY WITH NO OTHER EPISODES (C) SINGLE EPISODE BRIEF PERIOD OF PSYCHOSIS & NEARLY COMPLETE RECOVERY WITH NO OTHER EPISODES 22%

23. SUBTYPES OF SCHIZOPHRENIA disorganized catatonic paranoid undifferentiated residual

24. characterized by disorganized speech or behavior and flat or inappropriate affect disorganized catatonic paranoid undifferentiated residual

25. SUBTYPES OF SCHIZOPHRENIA characterized by psychomotor disturbance of movement and posture disorganized catatonic paranoid undifferentiated residual

26. SUBTYPES OF SCHIZOPHRENIA characterized by fixed delusions of persecution disorganized catatonic paranoid undifferentiated residual

27. SUBTYPES OF SCHIZOPHRENIA diagnosis used for people who meet the criteria for schizophrenia but do not clearly fit into the above subtypes disorganized catatonic paranoid undifferentiated residual

28. SUBTYPES OF SCHIZOPHRENIA symptom patterns found in individuals with schizophrenia during periods of relative remission including cognitive slippage disorganized catatonic paranoid undifferentiated residual

29. Development of Schizophrenia Abnormal signs childhood Less positive affect More negative affect Older adults ↓ positive symptoms ↑ negative symptoms

30. CAUSES OF SCHIZOPHRENIA THEORIES OF CAUSE Hypothesized causes/predispositions Not mutually exclusive Theories are specific - overlap

31. CAUSES of Schizophrenia 1. Genetics 2. Neurobiology 3. Psychological and Social 4. Psychodynamic Theories Diathesis – Stress Models

32. Genetics & Schizophrenia Genes are responsible for some people’s vulnerability to schizophrenia Inherent general predisposition, not type

33. SCHIZOPHRENIA IN FAMILIES RELATION- SHIP % GENES SHARED ON AVERAGE RISK Identical twins100%48% First-degree 50% relatives Parents 6% Siblings 9% Fraternal17% twins Children13%

34. Twin & Adoption Studies Genetic studies of families do not allow us to decide: Environment? (Nurture) Genetics? (Nature) Twin & Adoption studies allow us to separate effects

35. Genetic Markers Smooth-pursuit eye movement

36. Neurobiology of Schizophrenia Dopamine is too active 1. Antipsychotic drugs work. They decrease dopamine (by blocking) 2. They produce side effects similar to Parkinson’s. Parkinson’s = too little dopamine 3. L-dopa, given to Parkinson’s patients, which increases dopamine, can produce schizophrenia- like symptoms 4. Amphetamines, which increase dopamine, can make schizophrenia worse

37. Brain Structure Enlarged ventricles Adjacent brain parts underdeveloped? Frontal lobes = less active neurotransmitters

38. Viral Infection Risk Recent introduction of schizophrenia (1800s) ↑ in urban areas Prenatal exposure to flu Prenatal brain damage

39. Psychological & Social Influences - Stress Retrospective research shows role of stressful events in onset Prospective research – relapse preceded by higher rates of stress Might also increase depression, which increases risk of relapse

40. Psychological & Social Influences - Family Schizophrenogenic mothers Double bind communication

41. Psychological & Social Influences - Family Expressed Emotion In discharged patients, those with less family contact had fewer relapses Consists of: Criticism/disapproval Hostility/animosity Emotional overinvolvement 3.7 times increase in relapse (!)

42. Expressed Emotion High: “I’ve tried to jolly him out of it and pestered him into doing things. Maybe I’ve overdone it. I don’t know.” Low: “I just tend to let it go because I know that when she wants to speak, she will speak.”

43. PSYCHODYNAMIC FACTORS Freud Primary Narcissism Newborn Lack ego Thoughts = reality Fragile Ego? Overwhelming early trauma?

44. Diathesis Stress Models X

45. Treatment of Schizophrenia 1. Biological 2. Psychosocial

46. Biological Interventions Historical biological interventions include: Lobotomies Sever frontal lobes from lower portions of brain Insulin coma therapy Electroconvulsive therapy

47. Antipsychotic Medication Medical breakthrough 1950s – neuroleptics 60% effective Mostly effect positive symptoms Effect dopamine, but other neurotransmitters as well

48. Antipsychotic Medication New antipsychotics Clozapine Risperidone Olanzapine Less side effects than early antipsychotics

49. Problem: Medication Compliance 7% of patients refuse to take prescribed antipsychotic medication 1. Negative relationships with doctors 2. Cost of medication 3. Lack of social support 4. Negative side effects tardive dyskinesia in 20% of long-term users 5. Beliefs about medication use (25%)

50. Psychosocial Interventions Psychodynamic treatments Inpatient treatment most treatment, until recently Decreased due to changes in involuntary hospitalization laws 200,000 with serious disorders are homeless

51. Psychosocial Interventions Token economies Contribute to increased self-care More discharge

52. Psychosocial Interventions Social skills building Model pieces Role-play Practice in vivo

53. Psychosocial Interventions Behavioral Family Therapy Psychoeducation – symptoms, causes, medication compliance Communication skills Problem-solving skills Most beneficial if ongoing

54. Psychosocial Interventions Cognitive Treatment Periods of mild symptoms Label voices as thoughts Slow + time consuming

55. Living with Schizophrenia 40-60% of patients live with their family 10-20% of homeless individuals have schizophrenia 10% of patients will commit suicide 50% will experience comorbid substance abuse 33% will experience physical/sexual assault

56. Schizophrenia & Awareness/Insight 1. Awareness of the signs, symptoms and consequences 2. General attributions re: illness, symptoms, consequences 3. Self-concept 4. Psychological defensiveness

57. Why is Insight Important? High rates of poor insight in schizophrenia A symptom? Low insight = less positive outcomes Low insight = less compliance Low insight = higher rates relapse High insight = better psychosocial functioning (jobs, friends, less hospitalization)

58. Prognosis of Schizophrenia Predicting outcome is virtually impossible Recent research has indicated prognosis is better than originally expected 20-40 year longitudinal studies Some research suggests 20-50% “fully recover” later in life

59. Other Psychotic Disorders 1. Delusional Disorders 2. Schizoaffective Disorder

60. Delusional Disorders Marked by dramatic and stable delusions Other symptoms not present Can develop at any age Presence of “nonbizarre” delusions Can conceivably be true Any hallucinations are mild Function as normal when delusions not present

61. Causes of Delusional Disorders No genetic link w/ schizophrenia Links with avoidant & paranoid P.Ds Spontaneous recovery within months Chronic course w/ no recovery Difficult to treat

62. Schizoaffective Disorder Schizophrenia + mood disorder symptoms Diagnostic category may not be stable