SCHIZOPHRENIA and Other Psychotic Disorders

Kurt Vonnegut The Eden Express (1995)

Vonnegut Most diseases can be separated from one’s self and seen as foreign intruding entities. Schizophrenia is very poorly behaved in this respect. Colds, ulcers, flu, and cancer are things we get. Schizophrenic is something we are. It affects the thing we most identify with – as making us what we are.

Vonnegut continues… If these weren’t problems enough, schiz comes on slow and comes on fast, stays a minutes or days or years, can be heaven one moment, hell the next, enhances abilities and destroys them, back, and forth several times a day and always weaving itself inextricably into what we call ourselves. It can transform only a small corner of our lives or turn the whole show upside down, always giving few if any clues as to when it came or when it left or what was us and what was schiz.

Schizophrenia is one of the most severe mental disorders  It presents a wide range of disruptive symptoms and leads to a significant loss in ability to function independently  Its prognosis is generally poor and its course tends toward progressively more disabled functioning over time.

Schizophrenia has been observed for more than 3000 years.

Emil Kraepelin ( )  First identified the symptoms of schizophrenia  Named this cluster of symptoms “Dementia Praecox” in his 1883 text.

Paul Eugene Bleuler ( )  Bleuler renamed “Dementia Praecox” as “Schizophrenia.”  Bleuler, a Swiss psychiatrist, considered Schizophrenia to be a “fundamental disturbance” that split psychic functions and, in extreme cases, led to disorganization of the personality.  He defined Schizophrenia as an inability to maintain goal-directed behavior and integrated thinking.

Demographics for Schizophrenia  Schizophrenia is a relatively rare disorder: 0.2% to 1.0% of world population  However, persons with schizophrenia occupy over 30% of the total number of beds in psychiatric hospitals.  It was thought that the percentage of people worldwide who have schizophrenia is consistent across different cultures, but recent statistics have questioned that belief.  The most common age is between 15 and 35 years old

More Demographics  Generally psychotic symptoms begin after a gradual deterioration of social functioning and personal hygiene, and the development of flat or inappropriate affect.  Persons with slower onset tend to have a more negative prognosis than those in which schizophrenic symptoms develop rapidly.

Gender Issues  Schizophrenia occurs more often in males than females.  Age of onset is often later for women  Men are hospitalized more often than women and show a more deteriorating course  Women are more likely to be married and have children than males with schizophrenia  Women tend to have a higher social and sexual functioning before diagnosis.

Familial Pattern Some evidence is available that suggests a hereditary predisposition to schizophrenia: European family studies indicate a lifetime risk of about 6% in the parents of schizophrenic clients; 10% in their brothers and sisters, and 13% in their children, as compared with 1% in the general population. If one identical twin has schizophrenia, then there is a 50-60% probability that both are.

Risk Factors  There’s a high incidence of social phobia, obsessive- compulsive disorder, and panic attack in persons who later develop schizophrenia  Approximately 45% of those who have schizophrenia also abuse substances  Have a high rate of chronic illnesses in almost every system in the body (partly because of insufficient treatment).

Risk Factors (con’t.)  Approximately 20% of persons with schizophrenia attempt suicide  Approximately 10% complete the act  The suicide rate of the general population is.05%  Attempts generally occur just as symptoms begin to clear, not during psychotic periods  There is no evidence, however, that people with schizophrenia present any significant risk to others.  Persons with schizophrenia tend to commit fewer crimes than general population, although they are more frequently victims of crime.

Essential Features of Schizophrenia (See p. 312)  A mixture of characteristic signs and symptoms (both positive and negative) that have been present for a significant portion of time during a 1-month period (or for a shorter time if successfully treated), with some signs of the disorder persisting for at least 6 months. (Criteria A and C)  These sign and symptoms are associated with marked social or occupations dysfunction (Criterion

Schizophrenia Client must be ill for at least 6 months, with at least two of five symptom types:  Delusions  Hallucinations  Disorganized Behavior  Disorganized Speech  Negative Symptoms

Symptoms of Schizophrenia Delusions  A false belief that cannot be explained by the individual’s culture or education.  The individual cannot be persuaded that the belief is incorrect, despite evidence to the contrary or weight of opinion  Types of delusions: grandeur, guilt, ill health, jealousy, passivity, persecution, poverty, reference, and thought control.

Symptoms (continued) Hallucinations  A false sensory perception that occurs in the absence of a related sensory stimulus.  Hallucinations are nearly always abnormal  They can affect any of the fix sense, but auditory and visual are most common

Symptoms (continued) Auditory Hallucinations  The voices will often comment on behavior and, at times, give commands.  The command hallucinations may tell the individual to harm him/herself or others  Therefore, it’s important during examination to ask the client about the content of the auditory hallucinations, as well as any intent to act on them

Hallucinations (continued)  Visual Hallucinations often indicate a substance- induced psychotic disorder or a psychotic disorder due to a general medical condition (GMC)  Olfactory, tactile, and visual hallucinations are extremely rare, and they generally co-occur with auditory hallucinations.  Hallucinations must occur when the person is fully conscious

Symptoms (continued) Disorganized Speech  Also called loose association – mental associations are governed not by logic but by rhymes, puns, and other rules not apparent to the observer, or by no clear rules at all  Psychologically disorganized speech must be so badly impaired that it materially interferes with communication.

Symptoms (continued) Disorganized Behavior Physical actions that do not appear to be goal-directed (e.g., taking off one’s clothes in public, repeatedly making the sign of the cross, assuming and maintaining postures) may indicate psychosis.

Symptoms (continued) Negative Symptoms  These symptoms are called “negative” because they give the impression that something has been taken away from the individual, not added, as in the case with hallucinations and delusions.  Negative symptoms reduce the apparent textural richness of an individual’s personality

Symptoms (continued) Negative Symptoms - lack or are the absence of something, such as:  Inexpressive faces, blank looks, unresponsiveness (flat or blunted affect)  Loss of will, spontaneity, and initiative to do things (avolition)  Seeming lack of interest in the world and other people, social withdrawal (asociality)  Apparent inability to show or feel pleasure (anhedonia)  Loss of adaptive personal and social skills

Symptoms (continued) Negative Symptoms  Attention impairment  Markedly reduced amount or fluency of speech, poverty of speech (i.e., speech conveys little information) (alogia),  Increased speech latency (abnormal period of time to respond to another person’s comment)  Negative motor symptoms; e.g., maintaining bizarre postures, passively allowing one’s body to be manipulated by others, catatonic stupor (no response or interaction with external environment)

Definition of Five Types of Schizophrenia #1Paranoid Type These clients have persecutory delusions and auditory hallucinations, but no negative symptoms, disorganized speech, or catatonic behavior.

Paranoid Type (continued)  Often appear the most normal  Better able to take care own day-to-day needs  Relatively late age of onset (average age of 35 years)  Delusions are typically persecutory or grandiose, or both & organized around a coherent theme.  Hallucinations are also related to the delusional theme.  However, the delusion or auditory hallucinations for this diagnosis are not required to have paranoid content.

#2 Disorganized Type  In this subtype, negative symptoms and disorganized speech and behavior are more prominent than delusions and hallucinations  People with this type are frequently the most obviously psychotic of all  They often deteriorate rapidly, talk gibberish, and neglect hygiene and appearance.

#3 Catatonic Type The cardinal symptoms are excessively retarded or excited activity and bizarre behavior.  May have many of the basic symptoms of Schizophrenia, but their abnormal physical movements set them apart.  Motor activity may be speeded up  However, behavior is more typically slow or retarded, sometimes to the point of stupor.

#4 Undifferentiated Type These clients will have some or all of the five basic types of psychotic symptoms.  None of these symptoms dominates the clinical picture.  If the person does not have the paranoid, disorganized, or catatonic type, but still has schizophrenic symptoms, then s/he probably has the Undifferentiated Type.

#5 Residual Type This type might be diagnosed in a person whose diagnosis of Schizophrenia is already established, and  Who has either been treated or improved spontaneously - to the point of no longer having enough symptoms for a diagnosis of active Schizophrenia  After an acute psychosis has markedly improved, these clients usually still seem somewhat unusual, odd, or peculiar.

Classification of Longitudinal Course Definitions: Episode. A period of prominent psychotic symptoms Interepisode. A period between episodes Continuous. Prominent psychotic symptoms are present throughout the period of observation. Residual phase. Occurs after remission of prominent psychotic symptoms

Classification of Longitudinal Course (con’t.) Six Types (applied only after at least 1 year since initial onset of active-phase symptoms): 1.Episodic With Interepisode Residual Symptoms, also specify if: With Prominent Negative Symptoms 2.Episodic, also specify if: With Prominent Negative Symptoms

Classification of Longitudinal Course (con’t.) 3. Continuous (prominent psychotic symptoms are present throughout the period of observation) also specify if: With Prominent Negative Symptoms 4. Single Episode in Partial Remission; also specify if: With Prominent Negative Symptoms 5. Single Episode in Full Remission 6. Other or Unspecified Pattern

Treatment of Schizophrenia Treatment is multi-faceted:  Antipsychotic drugs  Psychological therapy  Social rehabilitation  Family support  Community care

Treatment (continued) Antipsychotic Drugs  More than two dozen antipsychotic drugs are available.  These drugs reduce days in the hospital and number of hospitalizations  There is some evidence that starting drugs early on may improve (or even “cure”) the severity of the disease.

Treatment (continued) Psychological Treatment  Individual psychotherapy for people with schizophrenia must be done very carefully, because introspection and self- disclosure may cause intense emotions and even a psychotic episode  What seems best is practical advice and support, helping the client to distinguish reality from illusion, and setting specific goals  Group therapy can be helpful for it provides an opportunity to be with others in the same situation and learn from them.

Treatment (continued) Social Rehabilitation Social skills training has been very helpful, for it teaches (through role-playing sessions) how to live in the community.

Treatment (continued) Family Support In working with families, a new approach is family crisis management, which gives information to family members about schizophrenia, teaches them to communicate better with one another, and trains them in identifying and solving specific problems that arise within the family.

Treatment (continued) Community Care  Although government funding is inadequate, people with schizophrenia need much community support, such as shelter, care, companionship, job counseling, and rehabilitation.  A whole team, including family members, social workers, physicians, nurses, psychotherapists, vocational counseling, and others are essential.  Case managers are essential, because they serve as advocates, monitor treatment (including taking medication), represent clients at welfare hearings, and accompany them to appointments.

Prognosis  Remember the recovery from schizophrenia by Nobel Prize-winning scientist, John Nash, as told in the biography and film, A Beautiful Mind.  Five long-term studies in the last twenty years have shown improvement even among those who seemed hopelessly ill.

According to Grinsponn & Bakalar (1990), people with schizophrenia show a fairly high rate of recovery – usual partial, sometimes complete.  About 10% require permanent hospitalization  About 25% require a high degree of supervision and care for most of their lives  50-75% recover some capacity to care for themselves, work, and participate in society  15% are able to live independently without medications or other treatment

Schizophrenia is a terrible burden to those who suffer from it. However, it is important that those, who care for people with schizophrenia, show by their words, actions, and attitudes that they believe recovery is possible. To deny that reality, either explicitly and implicitly, betrays hope and discourages healing.

Other Psychotic Disorders Schizophrenia-Like Disorders (3 types) 1.Schizophreniform Disorder (p. 317)  This category is for clients who have all the symptoms of schizophrenia, but for only one to six months – less than the time specified for Schizophrenia and more than the time for Brief Psychotic Disorder.  Impaired social or occupational functioning is not required.

Schizophreniform Disorder (con’t.) Specifiers  With Good Prognostic Features – if two of the following are present:  Onset of psychotic symptoms are within 4 weeks of the first noticeable change in usual behavior or functioning  Confusion or perplexity at height of psychotic episode  Good premorbid social and occupational functioning  Absence of blunted or flat affect  Without Good Prognostic Features

Schizophreniform Disorder (con’t.) Course About 1/3 recover within the 6-month period and receive Schizophreniform as a final diagnosis Remaining 2/3 progress to a diagnosis of Schizophrenia or Schizoaffective Disorder

Other Psychotic Disorders Schizophrenia-Like Disorders 2.Schizoaffective Disorder  For at least one month, these clients have had symptoms of Schizophrenia; at the same time, they have prominent symptoms of depression, mania, or mixed episode.  The depression symptoms must meet Criterion A1, p. 312  A hard diagnosis – requires observation over time and multiple sources of information Specifiers  Bipolar Type  Depressive Type

Other Psychotic Disorders Schizophrenia-Like Disorders 3. Brief Psychotic Disorder These clients have at least one of the basic psychotic symptoms for less than one month. Specifiers  With Marked Stressor(s): Symptoms occur in response to events  Without Marked Stressor(s): Symptoms do are not in response to events  With Postpartum Onset: Symptoms occur within 4 weeks of birth

Three Psychotic Disorders form a Continuum: Based on duration of episode Brief Psychotic Disorder (duration 1 day to 1 month) Schizophreniform Disorder (duration 1 month to 6 months) Schizophrenia (duration more than 6 months)

Disorders with Delusions Delusional Disorder. Although these clients have delusions (which are not bizarre), they have none of the other symptoms of Schizophrenia Shared Psychotic Disorder (Folie a Deux) This condition is diagnosed when a client develops delusions similar to those held by a relative or other close associate(s).

Other Psychotic Disorders  Psychotic disorder Due to a GMC A variety of medical and neurological conditions can produce psychotic symptoms.  Substance-Induced Psychotic Disorder Alcohol or other substances can cause psychotic symptom  Psychotic Disorder NOS This is for clients with symptoms that do not seem to fit any of the specified categories.

Disorders with Psychosis as a Symptom Mood disorder with psychosis. Clients with severe Major Depressive Episode or Manic Episode can have hallucinations and mood-congruent delusions. Cognitive disorder with psychosis. Many demented clients have hallucinations or delusions Personality Disorders. Clients with Borderline Personality Disorder may have transient periods (minutes or hours) when they appear delusional.

Disorders that Masquerade as Psychosis but are not Specific Phobia. Some phobic avoidance behaviors can appear quite strange without being psychotic. Mental Retardation. These clients may at times speak or act bizarrely. Somatization Disorder. Sometimes these clients will report pseudo-hallucinations or pseudo-delusions. Factitious Disorder. May feign delusions or hallucinations to obtain hospital/medical care Malingering. May feign delusions or hallucinations to obtain money (insurance of disability payments), avoid work (such as military), or avoid punishment.