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Schizophrenia and Other Psychotic Disorders Dr Seddigh

Nature of Schizophrenia and Psychosis: An Overview Schizophrenia vs. Psychosis Psychosis – Broad term (e.g., hallucinations, delusions) Schizophrenia – A type of psychosis Psychosis and Schizophrenia are heterogeneous Disturbed thought, emotion, behavior

Differential Diagnosis Medical/surgical/ substance-induced Psychotic d/o due to GMC Dementias Delirium Medications Substance induced Amphetamines Cocaine Withdrawal states Hallucinogens Alcohol Mood disorders Bipolar disorder Major depression with psychotic features

PSYCHOSIS “Functional” disorders Mood disorders Substance induced “organic” mental disorders “Functional” disorders Delirium Dementia Amnestic d/o Schizophrenia “spectrum” disorders

Table 13.1 Table 13.1 Early Figures in the History of Schizophrenia

Schizophrenia: The “Positive” Symptom Cluster The Positive Symptoms Active manifestations of abnormal behavior Distortions of normal behavior Delusions: The Basic Feature of Madness Gross misrepresentations of reality Include delusions of grandeur or persecution Hallucinations: Auditory and/or Visual Experience of sensory events without environmental input Can involve all senses but most common is auditory

Schizophrenia: The “Negative” Symptom Cluster The Negative Symptoms Absence or insufficiency of normal behavior Spectrum of Negative Symptoms Avolition (or apathy) – Lack of initiation and persistence Alogia – Relative absence of speech Anhedonia – Lack of pleasure, or indifference Affective flattening – Little expressed emotion

Schizophrenia: The “Disorganized” Symptom Cluster The Disorganized Symptoms Include severe and excess disruptions Speech, behavior, and emotion Nature of Disorganized Speech Cognitive slippage – Illogical and incoherent speech Tangentiality – “Going off on a tangent” Loose associations – Conversation in unrelated directions Nature of Disorganized Affect Inappropriate emotional behavior Nature of Disorganized Behavior Includes a variety of unusual behaviors Catatonia – Spectrum Wild agitation, waxy flexibility, immobility

Hallucinations (Positive Symptom) False sense perception Types Auditory – hear something that is not there, most common hallucination Tactile – feel something that is not there Visual – see something that is not there, more commonly results from substance use or brain d Olfactory/Gustatory – smell or taste something that is not there Somatic – feels like something is going on inside the body

Delusions (Positive Symptom) Fixed, false beliefs Types Bizarre – something that the person’s culture would view as implausible Thought insertion – thoughts are being inserted into person’s head Thought withdrawal – thoughts are being taken out of person’s head Thought broadcast – thoughts are being broadcasted Control – person is being controlled by something or someone else Somatic – things happening to body Grandiose – exaggeration of self

Disorganized Speech (Positive Symptom) Speech that is hard to understand or follow, impairs communication Types Loose associations – speech goes from one place to another, but is based on some sort of association between two things Incoherence – lacks clarity, intelligibility, relevance Frequent derailment – gets off track, loses track of topic Clang – speech goes from one place to another based on sounds Neologisms – made up words

Disorganized Speech: Geometric Analogy Normal: goal directed and linear Tangential Q A A Q Incoherence A Q Circumlocution Loosening of Associations A Q A Q

Grossly Disorganized or Catatonic Behavior (Positive Symptom) Grossly Disorganized Behavior Child-like silliness Unpredictable or inappropriate behavior Unpredictable agitation Markedly disheveled appearance Dresses in unusual manner Clearly inappropriate sexual behavior Catatonic Behavior Stupor Rigidity or posturing Negativism (resistance to a person moving them) Waxy flexibility or catalepsy (limbs remain in the position they are placed)

Schizophrenia Two or more of the following, each present for a significant portion of the time during a 1-month period** Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms **Exception to the 2+ symptom requirement: only 1 psychotic symptom required if: Delusion is bizarre Hallucination consists of

Subtypes of Schizophrenia Paranoid Type Intact cognitive skills and affect Do not show disorganized behavior Hallucinations and delusions – Grandeur or persecution The best prognosis of all types of schizophrenia Disorganized Type Marked disruptions in speech and behavior Flat or inappropriate affect Hallucinations and delusions – Tend to be fragmented Develops early, tends to be chronic, lacks remissions

Subtypes of Schizophrenia (cont.) Catatonic Type Show unusual motor responses and odd mannerisms Examples include echolalia and echopraxia Tends to be severe and quite rare Undifferentiated Type Wastebasket category Major symptoms of schizophrenia Fail to meet criteria for another type Residual Type One past episode of schizophrenia Continue to display less extreme residual symptoms

Schizophrenia: Some Facts and Statistics Onset and Prevalence of Schizophrenia worldwide About 0.2% to 1.5% (or about 1% population) Often develops in early adulthood Can emerge at any time Schizophrenia Is Generally Chronic Most suffer with moderate-to-severe lifetime impairment Life expectancy is slightly less than average Schizophrenia Affects Males and Females About Equally Females tend to have a better long-term prognosis Onset differs between males and females Schizophrenia has a Strong Genetic Component

Causes of Schizophrenia: Findings From Genetic Research Family Studies Inherit a tendency for schizophrenia Do not inherit specific forms of schizophrenia Risk increases with genetic relatedness Twin Studies Monozygotic twins – Risk for schizophrenia is 48% Fraternal (dizygotic) twins – Risk drops to 17% Adoption Studies -- Risk for schizophrenia remains high Cases where a biological parent has schizophrenia Summary of Genetic Research Risk for schizophrenia increases with genetic relatedness Risk is transmitted independently of diagnosis Strong genetic component does not explain everything

Search for Genetic and Behavioral Markers of Schizophrenia Genetic Markers: Linkage and Association Studies Search for genetic markers is still inconclusive Schizophrenia is likely to involve multiple genes Behavioral Markers: Smooth-Pursuit Eye Movement The procedure – Eye-tracking a moving object Tracking deficits – Schizophrenics and their relatives

Causes of Schizophrenia: Neurotransmitter Influences The Dopamine Hypothesis Drugs that increase dopamine (agonists) Result in schizophrenic-like behavior Drugs that decrease dopamine (antagonists) Reduce schizophrenic-like behavior Examples – Neuroleptics decrease dopamine, L-Dopa for Parkinson’s disease increases dopamine Dopamine hypothesis is problematic and overly simplistic Current theories – Emphasize many neurotransmitters

Causes of Schizophrenia: Other Neurobiological Influences Structural and Functional Abnormalities in the Brain Enlarged ventricles and reduced tissue volume Hypofrontality – Less active frontal lobes A major dopamine pathway Viral Infections During Mid-Prenatal Development Findings are inconclusive Conclusions About Neurobiology and Schizophrenia Schizophrenia – Diffuse neurobiological dysregulation Structural and functional brain abnormalities Not unique to schizophrenia

Ventricular enlargement in monozygotic twin with schizophrenia Barondes, 1993

Causes of Schizophrenia: Psychological and Social Influences The Role of Stress May activate underlying vulnerability May also increase risk of relapse Family Interactions Families – Show ineffective communication patterns High expressed emotion – Associated with relapse The Role of Psychological Factors Exert only a minimal effect in producing schizophrenia

Cultural Differences Figure 13.8 Cultural differences in expressed emotion (EE).

Medical Treatment of Schizophrenia Historical Precursors Development of Antipsychotic (Neuroleptic) Medications Often the first line treatment for schizophrenia Began in the 1950s Most reduce or eliminate positive symptoms Acute and permanent side effects are common Extrapyramidal and Parkinson-like side effects Tardive dyskinesia Compliance with medication is often a problem

Psychosocial Treatment of Schizophrenia Historical Precursors Psychosocial Approaches: Overview and Goals Behavioral (i.e., token economies) on inpatient units Community care programs Social and living skills training Behavioral family therapy Vocational rehabilitation Psychosocial Approaches A necessary part of medication therapy

Summary of Schizophrenia and Psychotic Disorders Schizophrenia – Spectrum of Dysfunctions Affecting cognitive, emotional, and behavioral domains Positive, negative, and disorganized symptom clusters DSM-IV and DSM-IV-TR Five subtypes of schizophrenia Includes other disorders with psychotic features Several Bio-Psycho-Social Variables are Involved Successful Treatment Rarely Includes Complete Recovery

Exploring Schizophrenia

Exploring Schizophrenia (cont.)

GOOD LUCK