SCHIZOPHRENIAS

SCHIZOPHRENIA AS PSYCHOSIS

DIAGNOSTIC FEATURES

AETIOLOGY AND DEVELOPMENT

TREATMENTCato Grønnerød

PSY2600

SCHIZOPHRENIA AS PSYCHOSIS

Schizophrenia is the most common and best known of the psychoses

Psychoses• Originally: disease of the brain• Later: lack of insight into own condition• Other psychoses:

• Schizophreniform disorder• Schizo-affective disorder• Delusional disorders

SCHIZOPHRENIA AS PSYCHOSIS

To be diagnosed, schizophrenia must impact upon more than one psychological process• Thought• Emotion• Perception• Communication• Psychomotor behaviour

Frequently several of these are affected simultaneously or at different periods

HISTORY

Schizophrenia was separated from ”insanity” in 1809

Emil Kraepelin• Separated manic depression from ”dementia praecox”

Eugen Bleuler• Coined the term ”schizophrenia”• Defined symptoms

Adolf Meyer• Psychological explanations

WHAT SCHIZOPHRENIA IS NOT

Schizophrenia is NOT split-personality• Split between though and emotion

Schizophrenia is NOT leading to raving maniacs, lunacy, or unhinged, demented behaviour• Patients are mostly shy and withdrawn

Schizophrenia is NOT necessarily a lifetime disorder• Many suffer from episodes, then recover

DIAGNOSIS AND DIAGNOSTIC ISSUES

Careful diagnosis is important: • Affects 1% of population• Can be a lifelong diagnosis• Can be severe and the impact on social and work

functioning, real and prospective may be very significant

• Management, especially with medication, can have long term and irreversible consequences

• Risk of suicide is high

DIAGNOSTIC ISSUES

Diagnosis is based largely on exclusion of other, possible diagnoses• Schizo-affective and mood disorders, drug use,

somatic/neuropsychological condition, developmental disorders

Three major criteria• Characteristic symptoms

• ‘Positive’ and ‘negative’

• Duration• Dysfunction

SYMPTOMS: DELUSIONS

“False beliefs that resist all argument and are sustained in the face of evidence that normally would be sufficient to destroy them”

Common to other psychoses, but are mood incongruent in schizophrenia

Bizarre to outsiders

SYMPTOMS: DELUSIONS

Five main kinds of delusion• Delusions of grandeur• Delusions of control• Delusions of persecution• Delusions of reference• Somatic delusions

Other kinds of delusions• Delusional jealousy, erotomanic delusion, thought

broadcasting

SYMPTOMS: HALLUCINATIONS “False sensory perceptions that have a

compelling sense of reality, even in the absence of external stimuli that ordinarily provoke such perceptions”

Auditory hallucinations most common Distinguished from ordinary experience by

• Their pervasiveness• Their lack of controllability• The person’s lack of awareness regarding the division

between self and perceptual experience

SYMPTOMS: DISORGANIZED SPEECH ‘Word Salad’

• Words and concepts are so disconnected that there is no logical thread (incoherent)

Loose association• Associations are made but are irrelevant or out of context

Clang association• Words are connected by the way they sound

Neologisms• Words ‘made up’ by the person that have no literal

meaning

SYMPTOMS: DISORGANIZED OR CATATONIC BEHAVIOR

Inappropriate emotional and behavioural responses

Severe lack of concentration or coherence Inability to ‘repair’ situations Characterised by extreme slowing of motor

behaviour for longer-than-natural periods Often appearing ‘frozen’, often in rigid and

strange postures and positions, immovable, mute and unresponsive

NEGATIVE SYMPTOMS

Reduction in normal behaviour and a withdrawal from normal life

Less dramatic or well known, but usually appear first and are more pervasive• Flattening of affect• Severe social withdrawal• Severe reduction in energy and interest levels• Poor attention to hygiene and personal grooming• Severe reduction in responsiveness

TYPES OF SCHIZOPHRENIA

Paranoid Schizophrenia• Delusions and auditory hallucinations of persecution

and/ or grandeur• Complex and intense but not disoriented• Irrational to observers

Catatonic Schizophrenia• Extreme motor behaviour states – either frozen or

overly excited/agitated• Some report delusions or hallucinations in these states• “Negativism” – will do the opposite of what is instructed

TYPES OF SCHIZOPHRENIA Disorganised Schizophrenia

• Incoherent, emotionally and contextually inappropriate behaviour

• Spontaneous affect, unsolicited conversation that continues despite cues to stop

• Sometimes delusions but less organised than in paranoid schizophrenia

• Poor hygiene and self care

Undifferentiated Schizophrenia• Psychotic symptoms and poor interpersonal functioning

but does not meet criteria for the other types

TYPES OF SCHIZOPHRENIA Residual Schizophrenia

• Often in the aftermath of other schizophrenic episodes• Absence of prominent symptoms but continued and

marked presence of two of the following• Social isolation or withdrawal• Impairment in role functioning• “Peculiar” behaviour• Impairment in personal grooming and hygiene• Blunt, flat or inappropriate emotional expression• Odd, magical or bizarre thinking• Unusual perceptual experiences• Apathy

TYPES OF SCHIZOPHRENIA

Acute• Sudden onset of flurid symptoms• Often precipitating incident• ”Good premorbid”• Better prognosis

Chronic• Prolonged and gradual decline• No stressor• ”Poor premorbid”• Poorer prognosis

PERCEPTUAL DEFICITS

Patients often report perceptual abnormalities• Difficulty understanding speech• Spatial distortions

Longer time to identify targets in backward masking tests

Problems when estimating sizes Difficulties discriminating tones Abnormal eyetracking movements

• Jerky saccadic eye movements

COGNITIVE DEFICITS

Overinclusiveness• Tendency to form concepts from both relevant and

irrelevant information• Impared ability to resist distracting information

Defective attentional filter• Prepulse is less effective in reducing the startle

response in patients• Connected to maternal deprivation in animal studies

Lacking a theory of mind

OTHER DEFICITS

Motoric function• Unusual posturing (catatonic stupor)• Below average on motor proficiency and coordination• Slower reaction times

Emotional• Difficulties recognizing facial expressions• Some difficulties understanding interpersonal

situations• More difficult when trying to implement solutions to

interpersonal problems

SOURCES OF VULNERABILITY

Genetic factors• Strong heritability for schizophrenia• Severity in proband increases risk for co-twin• Closeness of relationship determines risk• Adopted children of mothers with schizophrenia have

higher risk of mental illness• Increased risk in unstable adoption families

SOURCES OF VULNERABILITY

Pre- and Perinatal Factors• Prenatal viral infections• Birth complications/trauma• Exposure to stress during pregnancy

Childhood markers• Attention deficits• Delayed motoric development• Emotional instability• Increases at the onset of puberty• Schizotypal PD often precedes schizophrenia

SOURCES OF VULNERABILITY

Neurochemical factors• Dopamine hypothesis

• Antipsychotic drugs inhibit dopamine• Increased dopamine levels lead to psychosis• Motor symptoms a side effect of drugs• Increased density of dopamine receptors

• High levels of serotonine

Brain structure• Enlarged ventricles• Reduced frontal and temporal lobes

SOURCES OF VULNERABILITY

Social vulnerability• Expressed emotion

• Cynical and hostile comments and marked overinvolvement by care takers

• Social class• Social environment and culture

Diathesis-stress theory• More vulnerable• Stress caused by dysfunction?

TREATMENT OF SCHIZOPHRENIA

Drug therapy• Until the development of effective medications,

prognosis was very poor• Chlorpromazine and haloperidol

• Sedate but also seem to selectively reduce disordered thought and hallucinations

• Best with the positive rather than negative symptoms• Strong and distressing side effects, most notably tardive

dyskinesia

TREATMENT OF SCHIZOPHRENIA

Drug therapy• New drug treatments (different neurochemical effects)

• Clozapine, Olanzapine, Risperidone• More effective, fewer side effects• Block fewer dopamine receptors, plus a majority of

serotonin receptors

• May cause depression

Early medication will restrict later severity

TREATMENT OF SCHIZOPHRENIA

Psychological Treatments• Address the cognitive, emotional and behavioral

symptoms and outcomes• Cognitive rehabilitation

• Focus on attention, memory and executive functions

• Interpersonal training• Integrated Psychological Therapy• Program of Assertive Community Treatment