chapter 13 schizophrenic disorders copyright © 2006 pearson education canada inc

Chapter 13Schizophrenic Disorders

Copyright © 2006 Pearson Education Canada Inc.

Copyright © 2006 Pearson Education Canada Inc. 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


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.


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


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


Positive Symptoms

Hallucinations– auditory: often insulting or instructing – tactile (e.g., something crawling under skin)– somatic (e.g., an alien residing in the

stomach)


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


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”)


Symptoms and Features

Negative symptoms

– look for absence: poverty of speech, thought, hygiene, movement

– causes social withdrawal


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


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


Historical Perspective

dementia praecox (Kraepelin)splitting of associations (Bleuer) first ranked symptoms (Schneider)

– thought broadcasting


Contemporary Perspective: DSM-IV-TR

emphasis on 3 types of symptoms– positive symptoms– negative symptoms– disorganization


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


Subtypes: A) Catatonic

stupor excitement

– pacers, runners

posturing


Subtypes: B) Disorganized

disorganized, garbled speechdisorganized, “crazy” behaviourwildly inappropriate affect


Subtypes: C) Paranoid

preoccupation with one or more systematic delusions or auditory hallucinations

theme of persecution or grandiosityno catatonic or disorganized symptoms


Subtypes: D) Undifferentiated

meets the criteria for schizophrenia but does not fit the other subtypes


Subtypes: E) Residual

no current active phase symptomscontinuing negative symptoms


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


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


Course and Outcome

Onset: Sudden vs. Gradual Course: Undulating or Gradual Outcome: Recovered/Mild Impairment vs.

Moderate/severe Impairment


Suicide and Schizophrenia

Risk is 8-9 times normal population50% attempt suicide1.9% a year die by suicideUltimately 10-13% successful


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


Etiology: Biological Factors

geneticsneurological impairmentsneurochemical irregularities


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 %


Neuropathological Correlates

Structural and functional anomalies in frontal cortex and limbic areas:– enlarged ventricles– decreased hippocampal size – asymmetry in temporal cortex processing


Neurochemistry

dopamine hypothesis– neuroleptic drugs block post-synaptic

dopamine receptors– excessive post-synaptic receptors?

interactions of multiple neurotransmitters (e.g., GABA, serotonin)


Other Potential Biological Factors

intrauterine insult and birth complications

viral infectionsseason of birth


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


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


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)


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


Treatment

Other Medications: Antianxiety/Sleeping Medication (Ativan, Valium) Antidepressants (Prozac, Zoloft) Mood Stabilizers (Lithium, Tegretol)


Treatment

Psychosocial treatment– social skills training (e.g., modeling, role playing)– CBT


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


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


Case Study:Marilyn

paranoid schizophreniapsychotic belief in Cabir brothersauditory hallucinations visual hallucinations

chapter 13 schizophrenic disorders copyright © 2006 pearson education canada inc

Documents

following symptoms

spectrum of psychotic

b disorganized disorganized

disorganized sy

disorganized speechresidual

mild delusions hallucinations

systematic delusions

presence of delusions