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Copyright © 2010 Allyn & Bacon Chapter 13 Schizophrenia and Other Psychotic Disorders

Copyright © 2010 Allyn & Bacon 3 SchizophreniaSchizophrenia  The hallmark of schizophrenia is psychosis—a significant loss of contact with reality  Schizophrenia  Affects people from all walks of life  Is about as prevalent as epilepsy  Usually begins in late adolescence or early adulthood  The hallmark of schizophrenia is psychosis—a significant loss of contact with reality  Schizophrenia  Affects people from all walks of life  Is about as prevalent as epilepsy  Usually begins in late adolescence or early adulthood

Copyright © 2010 Allyn & Bacon 4 Origins of the Schizophrenia Construct  First clinical description appeared in 1810  Emil Kraepelin used term dementia praecox to refer to mental deterioration at early age  Eugen Bleuler introduced term “schizophrenia” in 1911  Schizophrenia as split personality is a major misconception  First clinical description appeared in 1810  Emil Kraepelin used term dementia praecox to refer to mental deterioration at early age  Eugen Bleuler introduced term “schizophrenia” in 1911  Schizophrenia as split personality is a major misconception

Copyright © 2010 Allyn & Bacon 5 EpidemiologyEpidemiology  Lifetime risk for developing schizophrenia is about 1%  Risk is higher for those with older fathers and in certain countries  Typically begins in late adolescence or early adulthood  Schizophrenia tends to be more common and severe in men than women  Lifetime risk for developing schizophrenia is about 1%  Risk is higher for those with older fathers and in certain countries  Typically begins in late adolescence or early adulthood  Schizophrenia tends to be more common and severe in men than women

Copyright © 2010 Allyn & Bacon 6 Figure 13.1: Age Distribution of Onset of Schizophrenia

Copyright © 2010 Allyn & Bacon 7 Clinical Picture  Hallmark symptoms include:  Delusions  Hallucinations  Disorganized speech  Disorganized and catatonic behavior  Hallmark symptoms include:  Delusions  Hallucinations  Disorganized speech  Disorganized and catatonic behavior

Copyright © 2010 Allyn & Bacon 8 DelusionsDelusions  An erroneous belief that is fixed and firmly held despite clear contradictory evidence  Disturbance in the content of thought  Examples include:  Made feelings or impulses  Thought broadcasting  Thought insertion or withdrawal  Delusions of reference  An erroneous belief that is fixed and firmly held despite clear contradictory evidence  Disturbance in the content of thought  Examples include:  Made feelings or impulses  Thought broadcasting  Thought insertion or withdrawal  Delusions of reference

Copyright © 2010 Allyn & Bacon 9 HallucinationsHallucinations  A sensory experience that seems real but occurs in the absence of any external perceptual stimulus  Can occur in any sensory modality  Auditory is most common  PET and fMRI studies suggest that auditory hallucinations may be misperceived subvocal speech  A sensory experience that seems real but occurs in the absence of any external perceptual stimulus  Can occur in any sensory modality  Auditory is most common  PET and fMRI studies suggest that auditory hallucinations may be misperceived subvocal speech

Copyright © 2010 Allyn & Bacon 10 Disorganized Speech  Failure to make sense despite conforming to semantic and syntactic rules of speech  “Cognitive slippage,” “loosening” of associations, or “incoherence”  A disturbance in the form (not content) of thought  Failure to make sense despite conforming to semantic and syntactic rules of speech  “Cognitive slippage,” “loosening” of associations, or “incoherence”  A disturbance in the form (not content) of thought

Copyright © 2010 Allyn & Bacon 11 Disorganized and Catatonic Behavior  Impairment of goal-directed activity  Occurs in areas of daily functioning  Work  Social relations  Self-care (hygiene, safety, dress)  Catatonia involves almost no movement at all, sometimes in an unusual posture  Impairment of goal-directed activity  Occurs in areas of daily functioning  Work  Social relations  Self-care (hygiene, safety, dress)  Catatonia involves almost no movement at all, sometimes in an unusual posture

Copyright © 2010 Allyn & Bacon 12 Positive and Negative Symptoms  Positive symptoms of schizophrenia reflect an excess or distortion in a normal repertoire of behavior and experience such as:  Delusions  Hallucinations  Disorganized speech  Disorganized behavior  Positive symptoms of schizophrenia reflect an excess or distortion in a normal repertoire of behavior and experience such as:  Delusions  Hallucinations  Disorganized speech  Disorganized behavior

Copyright © 2010 Allyn & Bacon 13 Positive and Negative Symptoms  Negative symptoms reflect an absence or deficit of behaviors that are normally present  Flat or blunted emotional expressiveness  Alogia  Avolition  Negative symptoms reflect an absence or deficit of behaviors that are normally present  Flat or blunted emotional expressiveness  Alogia  Avolition

Copyright © 2010 Allyn & Bacon Subtypes of Schizophrenia  Subtypes of schizophrenia include:  Paranoid type  Disorganized type  Catatonic type  Undifferentiated type  Residual type  Subtypes of schizophrenia include:  Paranoid type  Disorganized type  Catatonic type  Undifferentiated type  Residual type 14

Copyright © 2010 Allyn & Bacon 15 Other Psychotic Disorders  Other psychotic disorders include:  Schizoaffective disorder  Hybrid of schizophrenia and mood disorder  Schizophreniform disorder  Like schizophrenia but only 1-6 months long  Delusional disorder  Delusions but otherwise normal behavior  Brief psychotic disorder  Usually lasts only a matter of days  Shared psychotic disorder  A second person believes delusions of the first  Other psychotic disorders include:  Schizoaffective disorder  Hybrid of schizophrenia and mood disorder  Schizophreniform disorder  Like schizophrenia but only 1-6 months long  Delusional disorder  Delusions but otherwise normal behavior  Brief psychotic disorder  Usually lasts only a matter of days  Shared psychotic disorder  A second person believes delusions of the first

Copyright © 2010 Allyn & Bacon 16 Risk and Causal Factors  Genetic factors are clearly implicated in schizophrenia  As the following slide shows, having a relative with the disorder significantly raises a person’s risk of developing schizophrenia  Genetic factors are clearly implicated in schizophrenia  As the following slide shows, having a relative with the disorder significantly raises a person’s risk of developing schizophrenia

Copyright © 2010 Allyn & Bacon 17 Figure 13.2: Risk of Developing Schizophrenia Based on Shared Genes

Copyright © 2010 Allyn & Bacon Genetic Factors  Monozygotic twins (of schizophrenics) are much more likely to develop schizophrenia than are dizygotic twins 18

Copyright © 2010 Allyn & Bacon 19 Genetic Factors  The influence of genetics is revealed by  Twin studies  Higher concordance rate for MZ than DZ twins  Adoption studies  Schizophrenia more common in biological than adoptive families of adoptees  Studies of molecular genetics  Unlikely that schizophrenia is linked to only one gene  The influence of genetics is revealed by  Twin studies  Higher concordance rate for MZ than DZ twins  Adoption studies  Schizophrenia more common in biological than adoptive families of adoptees  Studies of molecular genetics  Unlikely that schizophrenia is linked to only one gene

Copyright © 2010 Allyn & Bacon 20 Prenatal Exposures  Other factors that have been implicated in the development of schizophrenia include:  Prenatal infection  Rhesus incompatibility  Early nutritional deficiencies  Perinatal birth complications  Other factors that have been implicated in the development of schizophrenia include:  Prenatal infection  Rhesus incompatibility  Early nutritional deficiencies  Perinatal birth complications

Copyright © 2010 Allyn & Bacon 21 Genes and Environment in Schizophrenia: A Synthesis  Current thinking emphasizes the interplay between multiple genetic and environmental factors  Schizophrenia is genetically influenced but not genetically determined  Current thinking emphasizes the interplay between multiple genetic and environmental factors  Schizophrenia is genetically influenced but not genetically determined

Copyright © 2010 Allyn & Bacon 22 A Neurodevelopmental Perspective  A lesion in the brain is thought to lie dormant until normal developmental changes occur  These changes expose the problems that result from this brain abnormality  Developmental precursors may include motor abnormalities, low positive facial emotion, and high negative facial emotion  A lesion in the brain is thought to lie dormant until normal developmental changes occur  These changes expose the problems that result from this brain abnormality  Developmental precursors may include motor abnormalities, low positive facial emotion, and high negative facial emotion

Copyright © 2010 Allyn & Bacon 23 Other Biological Factors  Many brain areas are abnormal in schizophrenia including:  Decreased brain volume  Enlarged ventricles  Frontal lobe dysfunction  Reduced volume of the thalamus  Abnormalities in temporal lobe areas such as the hippocampus and amygdala  Abnormalities are not found in all patients  Many brain areas are abnormal in schizophrenia including:  Decreased brain volume  Enlarged ventricles  Frontal lobe dysfunction  Reduced volume of the thalamus  Abnormalities in temporal lobe areas such as the hippocampus and amygdala  Abnormalities are not found in all patients

Copyright © 2010 Allyn & Bacon 24 Figure 13.6: Enlarged Brain Ventricles in Schizophrenic Twin

Copyright © 2010 Allyn & Bacon 25 Other Biological Factors  Neurotransmitters implicated in schizophrenia include:  Dopamine  Glutamate  Cytoarchitecture, or overall organization of cells in the brain, may be compromised  Neurotransmitters implicated in schizophrenia include:  Dopamine  Glutamate  Cytoarchitecture, or overall organization of cells in the brain, may be compromised

Copyright © 2010 Allyn & Bacon 26 Figure 13.9: Cytoarchitecture and Neural Development

Copyright © 2010 Allyn & Bacon NeurocognitionNeurocognition  Neurocognitive deficits found in people with schizophrenia include:  Attentional deficits  Eye-tracking dysfunctions  In general, people with schizophrenia struggle to attend well on demand  Neurocognitive deficits found in people with schizophrenia include:  Attentional deficits  Eye-tracking dysfunctions  In general, people with schizophrenia struggle to attend well on demand 27

Copyright © 2010 Allyn & Bacon 28 Figure 13.11: A Diathesis-Stress Model of Schizophrenia

Copyright © 2010 Allyn & Bacon 29 Psychosocial and Cultural Factors  Many theories about bad families causing schizophrenia have not stood the test of time including:  The idea of the “schizophrenic mother”  The double-bind hypothesis  Instead, communication problems may be the result of having a schizophrenic in the family  Patients with schizophrenia are more likely to relapse if their families are high in expressed emotion  Many theories about bad families causing schizophrenia have not stood the test of time including:  The idea of the “schizophrenic mother”  The double-bind hypothesis  Instead, communication problems may be the result of having a schizophrenic in the family  Patients with schizophrenia are more likely to relapse if their families are high in expressed emotion

Copyright © 2010 Allyn & Bacon 30 Psychosocial and Cultural Aspects  A large body of evidence indicates that the lower the socioeconomic status, the higher the prevalence of schizophrenia  Immigrants have higher rates of schizophrenia than natives  People with schizophrenia are twice as likely than the general population to smoke cannabis  A large body of evidence indicates that the lower the socioeconomic status, the higher the prevalence of schizophrenia  Immigrants have higher rates of schizophrenia than natives  People with schizophrenia are twice as likely than the general population to smoke cannabis

Copyright © 2010 Allyn & Bacon 31 Figure 13.12: Cannabis Use in Adolescence and Psychosis in Adulthood

Copyright © 2010 Allyn & Bacon 32 Treatments and Outcomes  Before the 1950s, the prognosis for schizophrenia was bleak  Antipsychotic drugs, introduced in the 1950s, dramatically improved the prognosis  Currently, about 38% of people diagnosed with schizophrenia function well years later  Long-term institutionalization is necessary for about 12%  Before the 1950s, the prognosis for schizophrenia was bleak  Antipsychotic drugs, introduced in the 1950s, dramatically improved the prognosis  Currently, about 38% of people diagnosed with schizophrenia function well years later  Long-term institutionalization is necessary for about 12%

Copyright © 2010 Allyn & Bacon Pharmacological Approaches  Antipsychotic drugs work by blocking dopamine receptors  Patients taking second-generation antipsychotics  Have fewer extrapyramidal (motor abnormality) side effects  Tend to do better overall  Side effects can be very troubling  Antipsychotic drugs work by blocking dopamine receptors  Patients taking second-generation antipsychotics  Have fewer extrapyramidal (motor abnormality) side effects  Tend to do better overall  Side effects can be very troubling 33

Copyright © 2010 Allyn & Bacon 34 Psychosocial Approaches  Psychosocial approaches include:  Family therapy  Case management  Social-skills training  Cognitive remediation  Cognitive-behavioral therapy  Other forms of individual treatment  Psychosocial approaches include:  Family therapy  Case management  Social-skills training  Cognitive remediation  Cognitive-behavioral therapy  Other forms of individual treatment

Copyright © 2010 Allyn & Bacon 35 Unresolved Issues  Can schizophrenia be prevented?  By improving prenatal care for women with schizophrenia in their biological families?  By reducing cannabis abuse in teens?  By identifying and intervening with people at high risk for developing schizophrenia?  By intervening early with people who have developed schizophrenia?  Can schizophrenia be prevented?  By improving prenatal care for women with schizophrenia in their biological families?  By reducing cannabis abuse in teens?  By identifying and intervening with people at high risk for developing schizophrenia?  By intervening early with people who have developed schizophrenia?

Copyright © 2010 Allyn & Bacon End of Chapter 13