Chapter 8 - Schizophrenia Spectrum and Other Psychotic Disorders PDF

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SLK 310(B) ADULT PSYCHOPATHOLOGY CHAPTER 8 SCHIZOPHRENIA SPECTRUM and OTHER PSYCHOTIC DISORDERS READ: Extraordinary People PG Psychosis unable to tell the difference what is real what is unreal Can take many forms one of the most severe puzzling is: o Schizophrenia at times these inds think communic...

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SLK 310(B) – ADULT PSYCHOPATHOLOGY

CHAPTER 8 SCHIZOPHRENIA SPECTRUM and OTHER PSYCHOTIC DISORDERS READ: Extraordinary People – PG.214 Psychosis  unable to tell the difference b/t what is real & what is unreal ➢ Can take many forms – one of the most severe & puzzling is: o Schizophrenia  at times these inds think & communicate clearly, have an accurate view of reality & function well in daily life & ▪ at other times, during the active phase of their illness, their thinking & speech are disorganised, they lose touch with reality & they have difficulty caring for themselves JUST SOME INFO ON SCHIZOPHRENIA (READ) • Schizophrenia & other psychotic disorders exact a heavy toll, including high medical costs ➢ more than 90% of ppl with psychotic disorders seek treatment in a mental health/general medicine facility in a given year • Most ppl who develop psychotic disorders do so in the late teenage/early adult years, when they are ready to begin contributing to society ➢ instead of pursuing their education, a career/a family, they may need continual services, including: o residential care, rehabilitative therapy, subsidised income & the help of social workers to obtain needed resources ▪ they may need these services for the rest of their lives as schizophrenia tends to be chronic • Majority of ppl with schizophrenia live independently/with their family – there are almost as many ppl with schizophrenia in jails, prisons, homeless shelters & on the street as there are in hospitals & nursing homes ➢ CJS & shelters often are repositories for ppl with schizophrenia who don’t have a family to support them/the resources to receive psychiatric help •

Symptoms, Diagnosis & Course Schizophrenia is a complex diagnosis with psychosis as its core diagnostic symptom • DSM-5 refers to schizophrenia spectrum = reflects the fact that there are 5 domains of symptoms that define psychotic disorders, & their number, severity & duration distinguish psychotic disorders from each other • Ppl with schizophrenia may show all/just some psychotic symptoms & the disorder can look different across ind ivs • 5 domains of psychotic symptoms: - delusions, - hallucinations, Positive symptoms - disorganised thought (speech), - disorganised/abnormal motor behaviour (including catatonia) & - negative symptoms (restricted emotional expression/affect) • Ppl with schizophrenia often show numerous cognitive deficits that RES has shown are linked to declines in functioning – not part of diagnostic criteria

Posi Positive tive Sy Symp mp mptom tom tomss Described as positive because they represent overt expressions of unusual perceptions, thoughts & behaviours

Delusions ideas that an indiv believes are true but that are highly unlikely & often simply impossible •

Most ppl occasionally hold beliefs that are likely to be wrong (eg. belief that they will win the lottery) o these self-deceptions differ from delusions in at least 3 ways: 1) Self-deceptions are at least possible, whereas delusions often are not a. EG  possible to win the lottery, not possible that body is dissolving 2) Ppl harbouring self-deceptions may think about these beliefs occasionally, but ppl with delusions tend to be preoccupied with them

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delusional ppl: i. look for evidence in support of their beliefs ii. attempt to convince others of these beliefs & iii. take actions based on them ❖ EG  filing lawsuits against ppl they believe are trying to control their mind 3) Ppl holding self-deceptions typically acknowledge that their beliefs may be wrong, but ppl holding delusions often are highly resistant to arguments/compelling facts that contradict their delusions a. They may view arguments others make against their beliefs as a conspiracy to silence them & as evidence of the truth of their beliefs

Table above lists more common types of delusions • Most common = persecutory delusions  these ppl may believe they are being watched/tormented by other ppl they know, or by agenicies or persons in authority with whom they have never had direct contact ( eg. FBI) • Another common type = delusion of reference  ppl believe that random events/comments by others are directed at them • Grandiose delusions  beliefs that one is a special being/possesses special powers (eg. She believe she is the most intelligent person on earth) • Delusions of thought insertion Delusions can be simple & transient (eg. person with schizophrenia believes pain in stomach is result of someone shooting a laser beam at him) BUT • are often complex & elaborate, with the person clinging to these beliefs for long periods (READ: Profiles – pg.219) Delusions also occur in other disorders: indivs with severe forms of depression/bipolar disorder often have delusions that are consistent with their moods • When they are depressed they may believe they have committed some unforgiveable sin & when they are manic they may believe they are a deity Specific content of delusions can differ across cultures: • British  being controlled by televisions, radios & computers • Pakistani  being controlled by black magic ➢ Differences in content of delusions probably reflect differences in the cultures’ belief systems as well as differences in the ppl’s environments • Japanese  delusions of being slandered by others & that others know something terrible about them perhaps due to emphasis on being thought well of by others • German & Austrians  religious delusions of committing a sin, perhaps due to the influence of Christianity

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SLK 310(B) – ADULT PSYCHOPATHOLOGY Some theorists argue that odd/impossible beliefs that are part of a culture’s shared belief system cannot be considered delusions • if the ppl of a particular culture believe that the spirits of dead relatives watch over the living, then they are not considered delusional ➢ However, ppl who hold extreme manifestations of their culture’s shared belief systems are considered delusional o EG  person who believed that their dead relatives were causing her heart to rot would be considered delusional DSM-V changes the definition of delusions to “fixed beliefs that are not amendable to change in light of conflicting evidence” from “erroneous beliefs” (as in DSM-IV) because it is often highly difficult to establish the fully false nature of a belief

Hallucinations unreal perceptual experiences •

Hallucinations of ppl with schizophrenia tend to be more frequent, persistent, complex, sometimes more bizarre & often entwined with delusions ➢ They are not simply precipitated by sleep deprivation, stress/drugs o Hallucinations that occur due to alcohol/drug use usually are arbitrary perceptual experiences (flashes of light/blasts of noise) (READ: Profiles – pg.220)

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Hallucinations can involve any of the senses: ➢ Auditory hallucinations – hearing voices, music, etc are the most common & may consist of: o a voice speaking in the indiv’s thoughts aloud/carrying on a running commentary on the person’s behaviour o a collection of voices speaking about the ind in the 3rd person o voices issuing commands & instructions ▪ Voices may seem to come either from inside the person’s head/from elsewhere outside ✓ they often have a negative quality, criticising/threatening the indivs/telling them to hurt themselves/others ▪ They may talk back to the voices even as they are trying to talk to ppl who are actually in the room with them ➢ Visual hallucinations – often accompanied by auditory hallucinations ▪ EG  figure of man standing next to woman’s bed telling her she = damned & must die. o An ind’s hallucinations may be consistent with his/her delusions ▪ EG Person who thinks she = seeing Satan telling her she must die, may think she is related to him ➢ Tactile hallucinations – perception that something is happening to the outside of the person’s body o EG  bugs crawling up her back ➢ Somatic hallucinations – perception that something is happening inside the body – often very frightening o EG  worms are eating my intestines!!

Hallucinations do not only occur in schizophrenia & other psychotic disorders – also depression & bipolar disorder • The types of hallucinations ppl experience in different cultures appear to be similar, but the content of hallucinations may be culturally specific ➢ Asia  ghosts of ancestors ➢ Puerto Rico  images of future events • Clinicians must understand hallucinations in their cultural context

Disorganised Thought & Speech Disorganised thought & speech of schizo ppl = often referred to as  Formal thought disorder  disorganised thinking of ppl with schizophrenia • Most common forms of disorganisation is the tendency to slip from 1 topic to a seemingly unrelated topic with little coherent transition, often referred to as  loose associations or derailment • A person with schizophrenia may answer questions with unrelated/barely related comments o EG  when asked why in hospital, might answer “Spaghetti looks like worms. I really think its worms. Gophers dig tunnels but rats build nests” Chapter 8 – Schizophrenia Spectrum and Other Psychotic Disorders

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At times the person’s speech is so disorganised as to be totally incoherent to the listener o A form of speech known as ‘word salad’ ▪ Person may make up words that mean something only to him/her, known as neologisms, or ▪ May make associations b/t words based on the sounds of the words rather than on the content, known as clangs, or ▪ May repeat the same word/statement over & over again

Men with schizophrenia tend to show more severe deficits in language • language is controlled more bilaterally (by both sides of brain) in women than in men ➢ thus, brain abnormalities associated with schizophrenia may not affect women’s language & thought as much as they could use both sides of brain to compensate for deficits ➢ in contrast, language is more localised in men o so when these areas of the brain are affected by schizophrenia, men may not be as able to compensate for the deficits

Disorganised/Catatonic Behaviour Disorganised behaviour often frightens others • may display unpredictable & apparently untriggered agitation  suddenly shouting, swearing/pacing rapidly ➢ They may occur in response to hallucinations/delusions • They often have trouble organising their daily routines of bathing, dressing properly & eating regularly ➢ Because their attention & memory are impaired, it takes all their concentration to accomplish even 1 simple task i.e. brushing their teeth • May engage in socially unacceptable behaviour (public masturbation) • Many are disheveled & dirty, sometimes wearing few clothes on a cold day/heavy clothes on a very hot day Catatonia  disorganised behaviour that reflects unresponsiveness to the environment • Ranges from a lack of response to instructions = negativism • To showing a rigid, inappropriate/bizarre posture • To a complete lack of verbal/motor responses = eg. mutism • Catatonic excitement = person shows purposeless & excessive motor activity for no apparent reason ➢ indiv may articulate a number of delusions/hallucinations/may become incoherent

Ne Negati gati gative ve Sym Sympto pto ptom ms All seem negative, but some = explicitly labelled negative symptoms  because they involve the loss of certain qualities of the person, rather than behaviours/thoughts that the person expresses overtly • Core negative symptoms in schizophrenia are restricted affect & avolition/asociality • Positive symptoms may seem more debilitating, BUT the presence of strong negative symptoms is more associated with poor outcomes as they tend to be persistent & more difficult to treat • Negative symptoms are less prominent in other psychotic disorders

Restricted Affect severe reduction in/absence of emotional expression in ppl with schizophrenia • • •

Show fewer facial expressions of emotion, may avoid eye contact & are less likely to use gestures to communicate emotional info than ppl without the disorder Tone of voice may be flat, with little change in ➢ emphasis, intonation (speech melody), rhythm, tempo/loudness to indicate emotion/social engagement Ppl with schizophrenia who show no emotion may be experiencing intense emotion that they cannot express ➢ The self-report questionnaires often find schizo ppl reporting significant anhedonia  loss of ability to feel pleasure o Study in lab  indiv’s response to standardized positive stimuli (eg. pleasant outdoor scenes) = assessed ▪ Schizo ppl  often report as much positive affect as those without it ❖ Thus, schizo ppl who show no emotion may be experiencing intense emotion that they cannot express

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Self-report questionnaires of anhedonia by schizo ppl may reflect limitations in self-report questionnaires/secondary problems with depression which is common in schizophrenia

Avolition/Asociality Avolition inability to initiate/persist at common, goal-directed activities including those at work, school & at home • • •

Person is physically slowed in his/her movements & seems unmotivated He/she may sit around all day doing almost nothing Personal hygiene & grooming are lacking

Avolition may be expressed as asociality  the lack of desire to interact with other ppl • Indivs with schizophrenia = are often withdrawn & socially isolated ➢ Some of this social isolation can be the result of the stigma of schizophrenia o families sometimes dissociate themselves from their members with schizophrenia & ppl often shun them • Asociality should be diagnosed only when the indiv has access to welcoming family & friends but shows no interest in socialising with them

Cogn Cogniti iti itive ve Defic Deficit it itss • • •

Show deficits in basic cognitive processes, including attention, memory & processing speed They have greater difficulty focusing & maintaining their attention at will ➢ EG  tracking moving object with eyes Show deficits in: ➢ working memory, ➢ the ability to hold info in memory & ➢ manipulate it o These deficits in attention & memory make it difficult for ppl with schizophrenia to pay attention to relevant info & to suppress unwanted/irrelevant info ➢ RESULT They find it difficult to distinguish the thoughts in their mind that are relevant to the situation at hand & to ignore stimuli in the environment that are not relevant to what they are doing o As a result ➢ These deficits taken together may contribute to the hallucinations, delusions, disorganised thought & behaviour & avolition of ppl with schizophrenia

Info & stimulation constantly flood their consciousness & they are unable to filter out what id irrelevant/determine the source of the info • Which makes it difficult for them to: ▪ concentrate, ▪ maintain a coherent stream of thought/conversation, ▪ perform a basic task or ▪ distinguish real from unreal ➢ Social relationships & work performance are severely affected & daily functioning is impaired ➢ Delusions & hallucinations may develop as indivs try to make sense of thoughts & perceptions bombarding their consciousness • Immediate relatives also show many of these cognitive deficits to a less severe degree, even if they don’t show the symptoms of schizophrenia ➢ Longitudinal studies  many ppl show these cognitive deficits before they develop acute symptoms of the disorder & cognitive deficits often don’t improve over the course of the disorder/with treatment Cognitive deficits may be an early marker of risk for schizophrenia & may contribute to the development of other symptoms & strongly contribute to the disability of the illness

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Dia Diagno gno gnosis sis Emil Kraepelin  labelled the disorder dementia praecox (preconscious dementia), because • He believed it results from premature deterioration of the brain & • Viewed it as progressive, irreversible & chronic Eugen Bleuler  disagreed with Kraepelin’s view that disorder develops at an early age & always leads to severe deterioration of the brain • He introduced the label schizophrenia from Greek words schizein (to split) & phren (mind) ➢ He believed it involved the splitting of usually integrated psychic functions of mental associations, thoughts & emotions (not as the splitting of distinct personalities as in DID) • He argued  Primary problem underlying the symptoms of schizophrenia is the “breaking of associative threads” = a breaking of associations among thought, language, memory & problem solving • He said  Attentional problems viewed are due to lack of the necessary links b/t aspects of the mind & that the disorganised behaviour is similarly due to an inability to maintain a train of thought Acc to DSM-5  In order to be diagnosed with schizophrenia, an indiv must show 2/more symptoms of psychosis, at least 1 of which should be delusions, hallucinations/disorganised speech • Acute phase = these symptoms must be consistently & acutely present for at least 1 month • The indiv must have some symptoms of the disorder for at least 6 months to a degree that impairs social/occupational functioning • Symptoms cannot be due to ingestion of a substance, a medical disease/a mood disorder During the 6 months before & after the active phase (Criterion A) the indiv may show: • predominantly negative symptoms, with milder forms of the positive symptoms referred to as prodromal symptoms (before the acute phase) & residual symptoms (after the acute phase) ➢ When experiencing prodromal & residual symptoms, ppl with schizophrenia may: o be withdrawn & uninterested in others o express beliefs that are unusual but not delusional o have strange perceptual experiences (sensing another person in the room), without reporting full blown hallucinations o speak in a somewhat disorganised & tangential way but remain coherent ➢ Behaviour may be peculiar (collecting scraps of paper), but not grossly disorganised ➢ During prodromal phase, family members & friends may perceive the person as “gradually slipping away” Left untreated, schizophrenia is both chronic & episodic. • after the first onset of an acute episode, indivs may have chronic residual symptoms punctuated by relapses in acute episodes Odd behaviours & asociality can resemble autism spectrum disorders • Schizophrenia can only be diagnosed if delusions &/or hallucinations are clearly present & the severe deficits in social interaction control to ASD begin very early in the developmental period Impact of schizophrenic symptoms on ppl’s lives is enormous • difficulties in functioning are tied to negative symptoms (lack of motivation & appropriate emotional responding) as well as positive symptoms ➢ Those who show many negative symptoms have lower levels of educational attainment & less success holding jobs, poorer performance on cognitive tasks, & a poorer prognosis than do those with predominantly positive symptoms ➢ Negative symptoms are less responsive to medication than positive ones o With medication, person with schizophrenia may be able to overcome the hallucinations, delusions & thought disturbances, but may not be able to overcome restricted affect & avolition ▪ Thus, person may remain chronically unresponsive, unmotivated & socially isolated even when not acutely psychotic DSM-V dropped the DSM-IV subtypes of schizophrenia because evidence supporting their diagnostic stability, validity & usefulness is not strong Chapter 8 – Schizophrenia Spectrum and Other Psychotic Disorders

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Prog Prognos nos nosis is READ: Pro Profiles, files, PG. PG.225 225 • • • • • •

Schizophrenia = 1 of the most severe & debilitating mental disorders & many ppl wi...