1. Chapter 13 Schizophrenic Disorders Copyright © 2006 Pearson Education Canada Inc.

2. 2 Overview @ Schizophrenia is a severe, progressive disorder than often starts in adolescence and generally has a poor outcome @ affects 1% of the population @ 221,000 Canadians in 1996 @ Canadian health care: $ billions annually

3. Copyright © 2006 Pearson Education Canada Inc. 3 Overview @ Similar prevalence for men and women - men are slightly higher @ for men onset is age 15-25 - average 21.9 @ for women onset is age 25-35 - average 26 @ 71% will experience their 1st symptoms by 25 y/o @ Key feature: psychotic symptoms - profound disturbance in thought, reality- testing, and affect.

4. Copyright © 2006 Pearson Education Canada Inc. 4 Course of Schizophrenia Prodromal – (usually in adolescence) - decreased level of functioning, social withdrawal, peculiar behaviours, neglect hygiene, changes in emotion Active – full spectrum of psychotic symptoms - i.e., hallucinations, delusions, disorganized speech Residual –return to prodromal but may also be mild delusions/ hallucinations/ continuing negative symptoms and impairment

5. Copyright © 2006 Pearson Education Canada Inc. 5 Symptoms and Features Positive symptoms – look for presence of delusions and hallucinations – Hallucinations: sensory experiences not caused by external stimulus – includes voices commenting on client’s behaviour or giving instruction – 60% of all hallucinations are auditory

6. Copyright © 2006 Pearson Education Canada Inc. 6 Positive Symptoms Hallucinations – auditory: often insulting or instructing – tactile (e.g., something crawling under skin) – somatic (e.g., an alien residing in the stomach)

7. Copyright © 2006 Pearson Education Canada Inc. 7 Positive Symptoms Delusions: idiosyncratic beliefs that are rigidly held despite their logical nature – defended even when shown contradictory evidence – person is preoccupied with the beliefs

8. Copyright © 2006 Pearson Education Canada Inc. 8 Positive Symptoms Delusions: persistent psychotic beliefs – persecutory (e.g., “others are spying on me”) – reference objects, people, events given personal significance (e.g., “the radio announcer is mocking me”) – grandeur (e.g., “I am Jesus”)

9. Copyright © 2006 Pearson Education Canada Inc. 9 Symptoms and Features Negative symptoms – look for absence: poverty of speech, thought, hygiene, movement – causes social withdrawal

10. Copyright © 2006 Pearson Education Canada Inc. 10 Negative Symptoms Affective Disturbance – flattened affect: failure to exhibit signs of emotion – inappropriate affect: incongruity of emotional state and behaviour – anhedonia: inability to experience pleasure Social and Linguistic Deficits – apathy – avolition – alogia

11. Copyright © 2006 Pearson Education Canada Inc. 11 Disorganization Thinking – loose associations: abruptly shifting topics – disorganized speech: saying things that don’t make sense – tangentiality: irrelevant responses Behaviour – catatonia: immobility and muscular rigidity – stupor – robot-like movements

12. Copyright © 2006 Pearson Education Canada Inc. 12 Historical Perspective dementia praecox (Kraepelin) splitting of associations (Bleuer) first ranked symptoms (Schneider) – thought broadcasting

13. Copyright © 2006 Pearson Education Canada Inc. 13 Contemporary Perspective: DSM-IV-TR emphasis on 3 types of symptoms – positive symptoms – negative symptoms – disorganization

14. Copyright © 2006 Pearson Education Canada Inc. 14 DSM-IV-TR Criteria for Schizophrenia During a one-month period, two or more of the following symptoms: delusions hallucinations disorganized speech grossly disorganized / catatonic behaviour negative symptoms

15. Copyright © 2006 Pearson Education Canada Inc. 15 Subtypes: A) Catatonic stupor excitement – pacers, runners posturing

16. Copyright © 2006 Pearson Education Canada Inc. 16 Subtypes: B) Disorganized disorganized, garbled speech disorganized, “crazy” behaviour wildly inappropriate affect

17. Copyright © 2006 Pearson Education Canada Inc. 17 Subtypes: C) Paranoid preoccupation with one or more systematic delusions or auditory hallucinations theme of persecution or grandiosity no catatonic or disorganized symptoms

18. Copyright © 2006 Pearson Education Canada Inc. 18 Subtypes: D) Undifferentiated meets the criteria for schizophrenia but does not fit the other subtypes

19. Copyright © 2006 Pearson Education Canada Inc. 19 Subtypes: E) Residual no current active phase symptoms continuing negative symptoms

20. Copyright © 2006 Pearson Education Canada Inc. 20 Delusional Disorder : preoccupation with nonbizarre delusions for at least one month Non-bizarre delusion – being followed, poisoned, deceived, spied on, or loved from a distance (erotomania) Usually no odd behaviours, hallucinations, or negative symptoms Other Psychotic Disorders

21. Copyright © 2006 Pearson Education Canada Inc. 21 Other Psychotic Disorders Schizoaffective Disorder – mix of schizophrenia and mood disorder, but psychotic symptoms are present at some point without mood d/o Schizophreniform Disorder – less than 6 months Brief psychotic Disorder – psychotic symptoms for 1 day to one month – typically after major trauma

22. Copyright © 2006 Pearson Education Canada Inc. 22 Course and Outcome Onset: Sudden vs. Gradual Course: Undulating or Gradual Outcome: Recovered/Mild Impairment vs. Moderate/severe Impairment

23. Copyright © 2006 Pearson Education Canada Inc. 23 Suicide and Schizophrenia Risk is 8-9 times normal population 50% attempt suicide 1.9% a year die by suicide Ultimately 10-13% successful

24. Copyright © 2006 Pearson Education Canada Inc. 24 Epidemiology Culture – cross-cultural consistency – improved prognosis in developing countries Social Class – adverse social and economic circumstances increases the probability that persons who are genetically predisposed will develop clinical symptoms

25. Copyright © 2006 Pearson Education Canada Inc. 25 Etiology: Biological Factors genetics neurological impairments neurochemical irregularities

26. Copyright © 2006 Pearson Education Canada Inc. 26 Genetics risk is greater is family member is affected 10-15 risk for first line relatives 3% for second line relative 46% if both parents are affected twin concordance rates – MZ: 48 % – DZ: 17 %

27. Copyright © 2006 Pearson Education Canada Inc. 27 Neuropathological Correlates Structural and functional anomalies in frontal cortex and limbic areas: – enlarged ventricles – decreased hippocampal size – asymmetry in temporal cortex processing

28. Copyright © 2006 Pearson Education Canada Inc. 28 Neurochemistry dopamine hypothesis – neuroleptic drugs block post-synaptic dopamine receptors – excessive post-synaptic receptors? interactions of multiple neurotransmitters (e.g., GABA, serotonin)

29. Copyright © 2006 Pearson Education Canada Inc. 29 Other Potential Biological Factors intrauterine insult and birth complications viral infections season of birth

30. Copyright © 2006 Pearson Education Canada Inc. 30 Epidemiology: Psychological Factors Expressed Emotion (EE) – related to rate of relapse – patients who returned home to at least 1 member who has high EE were more likely than low EE families to relapse

31. Copyright © 2006 Pearson Education Canada Inc. 31 Treatment Antipsychotic Medication – began in 1950’s (e.g., Thorazine) – reduced the severity of symptoms – 50% showed significant improvement - 4-6 weeks – continued maintenance medication reduced relapse rate

32. Copyright © 2006 Pearson Education Canada Inc. 32 Treatment * Compliance Problems * Motor Side Effects Extrapyramidal Symptoms: muscular rigidity, tremors, agitation Tardive Dyskinesia: involuntary movements of the mouth and face, spasmodic movements of trunk and body – increased use of atypical antipsychotics (clozapine)

33. Copyright © 2006 Pearson Education Canada Inc. 33 Treatment Atypical Antipsychotic Medication – began in 1990’s (e.g., Clozaril, Haldol, Risperdal, Zyprexa) – As effective in treating positive symptoms; more effective in treating negative symptoms – 30% of patients who did not improve on other medication improved on atypical antipsychotics – As with classical antipsychotics, target receptors in the cortex, limbic system, and also acts on serotonin

34. Copyright © 2006 Pearson Education Canada Inc. 34 Treatment Other Medications: Antianxiety/Sleeping Medication (Ativan, Valium) Antidepressants (Prozac, Zoloft) Mood Stabilizers (Lithium, Tegretol)

35. Copyright © 2006 Pearson Education Canada Inc. 35 Treatment Psychosocial treatment – social skills training (e.g., modeling, role playing) – CBT

36. Copyright © 2006 Pearson Education Canada Inc. 36 Treatment Assertive Community Treatment – provide an array of psychological interventions and medication on a regular basis in the community (e.g., case management) – effective in reducing inpatient hospital stays

37. Copyright © 2006 Pearson Education Canada Inc. 37 Treatment Institutional Programs – Hospitalization:(2-3 weeks) is often needed for acute psychosis – Crisis Houses: often provides an alternative to hospitalization. Less expensive - provides learning programs

38. Copyright © 2006 Pearson Education Canada Inc. 38 Case Study: Marilyn paranoid schizophrenia psychotic belief in Cabir brothers auditory hallucinations visual hallucinations