SLK 310 Chapter 8 Schizophrenia Spectrum and Other Psychotic Disorders 2 PDF

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Schizophrenia Spectrum and Other Psychotic DisordersHallucinations: when people hear, see and feel things that aren’t realDelusions: when people have fixed beliefs that are unrealistic/unlikelyPsychotic: Such experiences and beliefs that are out of touch with realityPsychosis: experience of being un...

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Schizophrenia Spectrum and Other Psychotic Disorders Hallucinations: when people hear, see and feel things that aren’t real Delusions: when people have fixed beliefs that are unrealistic/unlikely Psychotic: Such experiences and beliefs that are out of touch with reality Psychosis: experience of being unable to tell what is real and what is unreal Schizophrenia on the Continuum 1. Schizotypal personality disorder: involves moderate symptoms resembling schizophrenia but with a retained grasp on reality. People usually speak in odd eccentric ways, have unusual beliefs or perception and difficulty relating to other people 2. Delusional disorder: individuals have persistent beliefs (delusions) that are contrary to reality, but lack other symptoms of schizophrenia and are often not impaired in their functioning and delusions tend to be about things that are possible but untrue 3. Brief psychotic disorder: individuals have symptoms of schizophrenia for 1 month or less 4. Schizophrenicform: individuals have schizophrenic symptoms for 1-6 months but then usually resume their normal lives 5. Schizoaffective disorder: a mixed picture of schizophrenia and major depression or mania 6. Other: substance psychotic (or catatonic) disorder that is either substance induced or associated with other medical conditions Schizophrenia is a severe form of psychosis   

At times people with this disorder think and communicate clearly, have an accurate view of reality and function well in daily life Other times during active phase they have difficulty even caring for themselves Developed in late teenage years or early adult years

Schizophrenia Symptoms, Diagnosis, and Course Complex disorder with psychosis and DSM 5 refers to schizophrenia spectrum to reflect that there are 5 domains that define psychotic disorders. Their number, severity and duration separate the psychotic disorders from one another 1. 2. 3. 4. 5.

Delusions Hallucinations Disorganized thought and speech Disorganized or abnormal behaviour Negative symptoms (restricted emotional expression)

Positive symptoms Described as positive because they represent obvious expression of unusual perceptions, thought and behaviours 1. Delusions

Definition: When people have fixed beliefs that are highly unrealistic/unlikely and often simply impossible Differences in Self deception vs. Delusion 1. Self deception is at least possible (even if unlikely), delusions are not 2. People harbouring these self-deceptions think about these beliefs occasionally but people with delusions tend to be preoccupied with them 3. People with self-deceptions typically acknowledge that their beliefs may be wrong but people with delusions often are highly resistant to arguments or compelling facts that contradict their delusions. Types of delusions         

Persecutory delusion: false belief that oneself of loved ones are being persecuted, watched or conspired against by others Delusion of reference: belief that everyday objects or other people have an unusual personal significance Grandiose delusion: false belief that one has great power, knowledge or talent or that one is a famous and powerful person Delusion of being controlled: ones thoughts feelings or behaviours are being imposed or controlled by an external force Thought broadcasting: belief that one’s thoughts are being broadcast from one’s mind for others to hear Thought withdrawal: belief that thoughts are being removed from one’s mind by another person or object Thought insertion: belief that another person or object is inserting thoughts into one’s mind Delusion of guilt or sin: false belief that one has committed for a terrible act or is responsible for a terrible event Somatic delusion: false belief that one’s appearance or parts of one’s body is diseased or altered.

Culture and delusions   

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Delusions mentioned likely occur in all cultures but the specific content of delusions can differ across cultures These differences reflect the difference in cultural belief systems and differences in people environments People who hold extreme manifestations of their cultures shared beliefs systems are considered delusional  NB e.g. of odd/impossible beliefs apart from cultural beliefs: person believes dead relatives are causing their heart to rot Bizarre delusions: strongly held beliefs that are clearly implausible, not understandable to same culture peers and do not derive from ordinary life experiences Non-bizarre delusions: strongly held beliefs that are possible in reality but are not true

2. Hallucinations Definition: unreal perceptual experiences of people with schizophrenia tend to be frequent, persistent, complex sometimes more bizarre and often entwined with delusions Not due to sleep deprivation, stress or drugs

Hallucinations can involve any of these senses Auditory: most common    

Consist of a voice or collective voices speaking the individuals thoughts aloud, carrying on commentary of person’s behaviour or issuing commands May appear to come from inside or outside persons head Often negative quality, criticizing or threatening the person or telling them to hurt themselves or others People with schizophrenia might talk back to voices even with others around

Visual: second most common  

Often accompanied by auditory Consistent with delusions

Tactile 

Perceptions that something is happening to the outside of persons body

Somatic 

Perception that something is happening inside persons body, often frightening hallucinations

3. Disorganized thought and speech  Often referred to as formal thought disorder  Most common is the tendency to slip from one topic to a seemingly unrelated topic (loose association)  Persons speech can be so disorganised it is totally incoherent to listener  May make up words that mean something only to them (neologisms)  May make associations between words based in the sounds of the words rather than meaning  May repeat words over and over again  Men tend to show more severe deficits in language than women because women control language with both sides of brain and men not therefore compensate during schizophrenia 4. Disorganized or catatonic behaviour  Behaviour often frightens others  Unpredictable and apparently untriggered agitation (may be in response to hallucination or delusions)  Often have trouble organizing their daily routines of bathing dressing, eating and takes all of their concentration to accomplish even one simple task  May engage in socially unacceptable behaviours, such as public masturbation  Catatonia: disorganised behaviour the reflects unresponsiveness to the environment  Ranges from lack of responses from instructions  Rigid, inappropriate posture  Lack of verbal responses (mutism)  Catatonic excitement: person shows purposeless and excessive motor activity for no apparent reason Negative symptoms

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Negative because they involve the loss of certain qualities of the person rather than behaviours or thoughts that the person expresses directly Negative symptoms are more associated with poor outcomes than strong positive symptoms because negative symptoms are persistent and difficult to treat Less prominent in other psychotic disorders

Core negative symptoms in schizophrenia: 

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Restricted affect- severe reduction or absence of emotional expression  Fewer facial expressions, avoid eye contact, uses less gestures to communicate emotional information  Tone of voice may be flat, little change in emphasis, tempo or loudness to show emotion or social engagement  May experience intense emotion that they are unable to express  Anhedonia: loss of the ability to experience pleasure Asociality/avolition: inability to initiate or persist at normal goal directed activities  Physically slowed down and movements seem unmotivated  Persons hygiene and grooming are lacking  May sit around and do nothing  Often withdrawn and socially isolated  May be expressed as Asociality: lack of desire to interact with others (should only be diagnosed if they have access to welcoming friends and family with no interest in socializing with them)

Cognitive deficits (not part of DSM 5 but is probably present in schizophrenic patients)    

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Deficits in basic cognitive processes, including attention, memory and processing speed Greater difficulty focusing and maintaining attention at will Deficits in working memory Makes it difficult for them to pay attention to relative information and suppress unwanted info  These deficits may contribute to hallucinations, delusions, disorganized thought and behaviours and avolition Show cognitive deficits before they develop acute symptoms Cognitive deficits do not improve over the course of the disorder or with treatment

Diagnosis of schizophrenia  

Was labelled as dementia praecox (precocious dementia) because it was believed to be premature deterioration of the brain. Emil Kraepelin viewed disorder as progressive, irreversible and chronic. Eugen Bleuler disagreed and introduced schizophrenia meaning split mind  Believed that the disorder involves the splitting of usually integrated psychic functions of mental associations, thoughts, and emotions.  Primary underlying symptoms of schizophrenia is the breaking of associative threads (breaking of associations among thought, language, memory, and problem solving)  Attentional problems are due to lack of the necessary links between aspects of the mind and that the disorganized behaviour is similarly due to an inability to maintain a train of thought.

DSM-5 Diagnostic Criteria for Schizophrenia

A. Two or more of the following present for a significant amount of time during a 1 month period. At least one must be 1, 2 or 3 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Disorganized or catatonic behaviour 5. Negative symptoms (avolition or restricted affect) B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or selfcare, is clearly below the level achieved prior to the onset C. Continuous signs of the disturbance persist for at least 6 months. Must include 1 month of symptoms and may include prodormal or residual symptoms. D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the active phase and residual periods of the illness E. Disturbance is not attributed to physiological effects of a substance or another medical condition F. If there is a history of autism spectrum disorder or communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent required symptoms of schizophrenia are also present for at least 1 month Specify if with catatonia Phases DSM-5 diagnosis of schizophrenia Acute phase: (A.) individual must show 2 or more symptoms of psychosis (at least 1 must be hallucinations, delusions or disorganized speech) consistently and acutely for at least 1 month  

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Must show to have some symptoms for at least 6 months to a degree that impairs functioning During, before or after the 6 month active phase (meeting criteria A) person may show predominant negative symptoms and milder positive symptoms.  This is known as prodormal symptoms (before acute phase)  Residual symptoms: after acute phase May be mistake for autism: only schizophrenia if hallucinations and delusions are clearly present Negative symptoms are less responsive to medication than positive

Prognosis (likely course of disorder) Gender and age factors 

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Women tend to have better prognosis  Hospitalized less often and for briefer times  Milder symptoms between periods of acute phase symptoms  Better social adjustments when not schizophrenic  Men develop earlier  Women show less cognitive deficits Oestrogen may affect regulation of dopamine in ways that protect women

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Both men and women functioning seem to improve with age  Find treatments that help stabilize  Learn to recognize early symptoms and prevent relapse  Aging brain might reduce likelihood of new episodes

Sociocultural factors 

Tends to have less threatening course in developing countries  Broader and closer family networks = assisting in care  Lower relapse because of lower level of criticism and over involvement

Other Psychotic Disorders Schizoaffective Disorder    

Mix of schizophrenia and mood disorder Experience psychotic symptoms and meet criteria for major depression or manic episode Persistent illness during which there are major mood episodes Unlike mood disorders with psychotic features, schizoaffective disorder requires at least 2 weeks of hallucinations or delusions without mood symptoms.

DSM-5 Diagnostic Criteria for Schizoaffective Disorder A. An uninterrupted period of illness during which there is a major mood episode (depressive of manic) current with Criterion A of schizophrenia B. Delusions or hallucinations for 2 or more weeks in the absence of major mood episode (episode or manic) during the lifetime of the illness C. Symptoms that meet criteria for major mood episode are present for the majority of the total duration of the active and residual portions of the illness D. The disturbance is not attributable to the effects of a substance (e.g. drug abuse, a medication) or another medical condition Specify type:  

Bipolar type: A manic episode is part of the presentation. Major depressive episode may also occur Depressive type: in only major depressive episodes are part of the presentations

Specify if: With catatonia Schizophrenicform Disorder 

Eventually are diagnosed with schizophrenia or schizoaffective disorder

DSM-5 Diagnostic Criteria for Schizophrenicform Disorder A. Criterion A, D and E of schizophrenia are met B. An episode of the disorder lasts but less than 6 months. Brief Psychotic Disorder:

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Individuals show a sudden onset of delusions, hallucinations, disorganized speech, and/or disorganized behaviour. Episode lasts between 1 day and 1 month after which symptoms completely remit. Emerge often after a major stressor. (car accident) At other times no stressor is apparent

DSM-5 Diagnostic Criteria for Brief Psychotic Disorder A. Presence of one or more of the following symptoms. At least one of these must be (1), (2), or 3 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Disorganized or catatonic behaviour B. Duration of an episode of the disturbance is at least 1 day and less than 1 month, with eventual full return to premorbid level of functioning (previous level of functioning before episode). C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder and is not attributed to the physiological effects of a substance or another medical condition Specify if   

With marked stressor(s) (brief reactive psychosis): if symptoms occur in response to events (stressors) Without marked stressor(s): if symptoms do not occur in response to events With postpartum onset: if onset is during pregnancy or within 4 weeks postpartum

Delusional Disorder:    

Have delusions lasting at least 1 month regarding situations that occur in real life, such as being followed Unlike schizophrenia, they do not show any other psychotic symptoms Other than behaviours following delusions, they do not act oddly / have difficulty functioning. Tends to be later in life than most disorders, more common in females than men.

DSM- 5 Diagnostic Criteria for Delusional Disorder A. The presence of one (or more) delusions with a duration of 1 month or longer B. Criterion A of schizophrenia has never been met C. Apart from the impact of the delusion(s), functioning is not markedly impaired, and behaviour is not obviously bizarre or odd. D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. E. The disturbance Is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder Specify whether  

Erotomanic type: the central themes of the delusion are that another person is in love with the individual Grandiose type: the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery

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Jealous type: the central theme of the delusion is that one’s spouse of lover is unfaithful Persecutory type: the central theme of the delusion is the belief that one is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals Somatic type: the central theme of the delusion involves bodily functions or sensations Mixed type: no one delusional theme predominates Unspecified type: the dominant delusional belief cannot be clearly determined

Schizotypal Personality Disorder:   

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Lifelong pattern of significant oddities in their self-concept, their ways of relating to others, and their thinking and behaviour. Do not have strong and independent sense of self and may have trouble setting realistic or clear goals. Few close relationships and trouble understanding the behaviours or others.  Perceive other people as deceitful and hostile and may be socially anxious and isolated because of suspiciousness. Think and behave in ways that are very odd, although they maintain their grasp on reality.  May believe that random events or circumstances are related to them Perceptions are also odd, example thinking they see people in the patterns of wallpaper May be easily distracted or fixated on an object for long periods of time Show deficits in working memory, learning and recall similar but less severe than schizophrenia.

DSM-5 Diagnostic Criteria for Schizotypal Personality Disorder A. pervasive pattern of social and interpersonal deficits marked by acute discomfort, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour, beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following: 1. Ideas of reference 2. Odd beliefs or magical thinking that influences behaviour 3. Unusual perceptual experiences 4. Odd thinking and speech 5. Suspiciousness or paranoid ideation. 6. Inappropriate or constricted affect 7. Behaviour or appearance that is odd 8. Lack of close friends or confidants other than first-degree relatives 9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgment about self B. Does not occur exclusively during the course of schizophrenia, bipolar disorder, or depressive disorder with psychotic features, another psychotic disorder or autism spectrum disorder Psychosocial Perspectives of Schizophrenia 1. Social Drift and Urban Birth  Social drift theory is supported because schizophrenia symptoms interfere with education and ability to hold job.  Drift downward in social classes.  Born in large city rather that in small town

2. Stress and Relapse  While stress may not cause someone to develop schizophrenia, they may trigger new episodes in people with the disorders. 3. Schizophrenia and Family  Mothers who intimidate their children, not letting them develo...