SLK 310 Chapter 8 Schizophrenia Spectrum and Other Psychotic Disorders PDF

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Chapter 8-Schizophrenia Spectrumand other Psychotic disorders Psychosiso Not being able to tell the difference between what is real and what is unreal Schizophreniao One of the most severe and puzzling psychotic disorders o At times think and communicate clearly and have an accurate view of realit...

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Chapter 8-Schizophrenia Spectrum and other Psychotic disorders 

Psychosis o

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Not being able to tell the difference between what is real and what is unreal

Schizophrenia o One of the most severe and puzzling psychotic disorders o At times think and communicate clearly and have an accurate view of reality o Other times during active phase their thinking and speech are disorganized, lose touch with reality and have difficulty caring for themselves

Symptoms, diagnosis and Course Schizophrenia is a complex disorder with psychosis as its core diagnostic system o DSM-5 refers to the schizophrenia spectrum to reflect the fact that there are 5 domains of symptoms o Define psychotic disorders, their numbers, severity and duration distinguish psychotic disorders from each other o People with schizophrenia may show all or some psychotic symptoms o 5 domains  4 kinds of positive symptoms  Delusions, hallucinations or disorganised speech and though and disorganized or abnormal motor behaviours  Negative symptoms  Restricted emotional expression or affect  People with schizophrenia often show numerous cognitive deficits that are linked to declines in functioning Positive symptoms o described as positive because they represent overt expressions of unusual perceptions, thoughts and behaviours o Delusions  ideas that an individual believes are true but that they are highly unlikely and often simply impossible  self-deceptions differ from delusions in 3 ways  deceptions are at least possible, delusions not possible  people harbouring self-deceptions may think about these beliefs occasionally, people harbouring delusions tend to be preoccupied with them  people holding self-deceptions typically acknowledge that their beliefs may be wrong, people holding delusions are o

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highly resistant to arguments or facts that contradict their delusions Types of delusions  Persecutory delusions (most common)  False belief that oneself or ones loved ones are being persecuted, watched or conspired against by others  Delusion of reference  Belief that everyday events, objects or people have an unusual personal significance ( believe that random events or comments are aimed at them)  Grandiose delusions  False belief that one has great power, knowledge or talent or that one is famous and powerful person  Delusions of thought insertion  Belief that another person or object in inserting thoughts into one’s mind

REFER TO TABLE 8.1 Types of Delusions Delusional beliefs can be simple (schizophrenic person believes stomach pain is due to the person across the room shooting a laser beam at him)  Delusions can often be complex with person clinging to beliefs for long periods Delusions also occur in persons with severe forms of depression or bipolar disorder o Delusions often consistent with their moods Types of delusions discussed can occur in all cultures, o the content of the delusion may differ due to belief systems and differences in peoples environments Hallucinations o Unreal perceptual experiences- of people with schizophrenia tend to be more frequent, complex and bizarre  They are not precipitated by sleep deprivation, stress or drugs o Hallucinations can involve any of the senses  Auditory hallucinations(most common)- hearing voices, music  May consist of a voice speaking the individuals thoughts aloud or a collection of voices speaking about the individual in third person  May seem to come from inside the individuals head or from somewhere outside  Often have negative quality, criticizing or threatening the person or telling them to hurt themselves  People may talk back to the voices  Visual hallucinations(second most common, often accompanied by auditory hallucinations)  Eg woman sees figure at end of her bed telling her to hurt herself  Tactile hallucinations ( involve perception that something is happening to the outside of their body  Eg: bugs are crawling up her back  Somatic hallucinations involve perception that something is happening inside the person’s body  Eg: worms eating their intestines  Types of delusions across cultures are similar, but content changes 

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 Clinicians must understand hallucinations in cultural context Disorganised thought and speech  Disorganized thinking of people with schizophrenia is often referred to as formal thought disorder  One of most common forms of disorganization is tendency to slip from one topic to a seemingly unrelated topic with little coherent transition  Often referred to as loose associations or derailment  Person may answer questions with unrelated or barely related comments  Speech can be so disorganized that it can be totally incoherent to the listener, a form of speech known as ‘’worm salad’’  Person may make up words only known to him or her known as neologisms  Or person may maker associations between words based on sound rather than content, known as clangs  Or may repeat the same statement over and over again  Men with schizophrenia tend to show ,ore deficits in language than women do  Possibly cos language is controlled more bilaterally (by both sides of the brain) in women than men  Language is more localized in men, so when these areas of the brain are affected by schizophrenia, men might not be able to compensate for the deficits o Disorganized catatonic behaviour  People with schizophrenia may display unpredictable and untriggered agitation  Suddenly shouting, swearing or pacing rapidly  Responses may occur due to hallucinations or delusions  People with schizophrenia often have trouble organizing their daily routines of bathing, dressing properly and eating regularly.  Because attention and memory are impaired, it takes all their concentration to accomplish a simple task (brushing teeth)  May engage in social unacceptable behaviour such as public masturbation  Many dishevelled, dirty, wearing few clothes on a cold day or lots on a hot day  Catatonia is disorganized behaviour that reflects unresponsiveness to the environment  Ranges from lack of response to instructions to showing a rigid, inappropriate or bizarre posture, to a complete lack of motor or verbal responses  Catatonic excitement- the person shows purposeless and excessive motor activity for no apparent reason  May accumulate a number of delusions or hallucinations or may be incoherent Negative symptoms o Involve the loss of certain qualities of the person, rather than behaviour or thoughts that the person expresses overtly o The core negative symptoms of schizophrenia are restricted to affect and Avolition and asociality o Negative symptoms are more persistent and difficult to treat  But are less prominent in other psychotic disorders o Restricted affect o

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Refers to a severe reduction or absence in emotional expression in people with schizophrenia  Show fewer facial expressions, avoid eye contact and are less likely to use gestures to communicate emotional information than people without the disorder  Tone of voice may be flat, little change in emphasis, tempo or loudness to indicate emotion or social engagement  People with schizophrenia report significant anhedonia ( loss in ability to experience pleasure)  People with schizophrenia may experience intense emotion that they are not able to express o Avolition and asociality  Avolition is the inability to initiate or persist at common, goal directed activities including those at home, work or school  Person physical slowed down in their movements and seems unmotivated  May sit around all day doing nothing, lacking personal grooming and hygiene  Avolition may be expressed as asociality (the lack of desire to interact with other people) o Often withdrawn and socially isolated o Isolation may be due to stigma of schizophrenia  Families may dissociate themselves from their members with schizophrenia  Asociality should only be diagnosed when individual has access to loving, welcoming family but has no interest in socializing with them Cognitive deficits o People with schizophrenia show deficits in basic cognitive processes including attention, memory and processing speed o Have greater difficulty focussing and maintaining attention at will ( tracking moving object with eyes) o Sow deficits in working memory, ability to hold info in memory and manipulate and use it  Deficits in attention and memory make it difficult to pay attention to relevant info and suppress irrelevant info  Deficits may contribute to hallucinations, delusions, disorganized thought and behaviour and Avolition o Social relationships and work performance are severely affected and daily functioning is impaired o Immediate relatives of people with schizophrenia show many of these cognitive deficits before they develop acute symptoms of disorder  Cognitive deficits don’t often improve over course of disorder or with treatment o Cognitive deficits may be early marker of risk for schizophrenia and may contribute to development of other symptoms Diagnosis o Kraepelin labelled disorder dementia praecox (precocious dementia) because he believed disorder results from premature deterioration of the brain  Viewed disorder as progressive, irreversible and chronic o Bleuler disagreed and said disorder develops at an early age and always leads to severe deterioration of the brain 

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Introduced label ‘’schizophrenia’’ (splitting mind) Believes disorder involves splitting of usually integrated psychic functions of mental associations, thoughts and emotions Argued that attentional problems seen in schizophrenia are due to a lack of necessary links between aspects of the mind and that disorganized behaviour is similarly due to an inability to maintain a train of thought

REFER TO TABLE 8.2- DSM 5 Diagnostic Criteria for Schizophrenia o

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Prodromal symptoms (before acute phase)/ residual symptoms (after acute phase)  Individual may show predominantly negative symptoms, with milder forms of positive symptoms  During prodromal family may report individual as ‘’slipping away’’ When experiencing prodromal and residual symptoms, people with schizophrenia may be withdrawn and uninterested in others  May express beliefs that are unusual but not delusional  Strange perceptual experiences (sensing another person in the room)  May speak in disorganized and tangential way but remain coherent  Behaviour may be peculiar Left untreated, schizophrenia is both chronic and episodic  After first onset of an acute episode, individuals may have chronic residual symptoms punctuated by relapses into acute episodes Strange behaviours and asociality in schizophrenia may resemble symptoms of autism spectrum disorders  To distinguish the 2 disorders  schizophrenia can be diagnosed only if delusions/hallucinations are clearly present  severe deficits in social interaction control to autism spectrum disorder begin very early in the developmental period impact of schizophrenia on people’s lives is enormous negative symptoms are less responsive to medication than positive symptoms  if many negative symptoms, (compared to more positive symptoms)  have lower levels of education attainment  less success holding jobs  poorer performance on cognitive tasks  poorer prognosis with medication, a person with schizophrenia may be able to overcome the hallucinations, delusions and thought disturbances but may not be able to overcome the restricted affect and Avolition  person may remain chronically unmotivated, unresponsive and socially isolated paranoid schizophrenia  have delusions and hallucinations that involve themes of persecution and grandiosity  delusions focus on being hunted, spied on, persecuted and conspired against by others  including government, media, family, friends and complete strangers  may believe that anyone who disagrees with their delusions is part of the conspiracy

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become angry, suspicious and even violent may be lucid and articulate

Prognosis Schizophrenia is one of the most severe and debilitating metal disorders o Many people suffer symptoms and impairment for many years, even with treatment Life expectancy of people with schizophrenia is as much as 10 years shorter than that of people without People with schizophrenia suffer from o Infectious and circulatory diseases at a higher rate than people without 10-15 percent of people with schizophrenia commit suicide Many people do not show a progressive deterioration and instead stabilize for 5-10 years after first episode showing few or no relapses and regaining moderately good level of functioning o Gender and age factors  Women tend to have better prognosis than men  Women are hospitalized less often and for shorter periods than men  Women show milder negative symptoms between periods of active phase symptoms and have better social adjustment when they aren’t psychotic  Women diagnosed with schizophrenia tend to have better prior histories to men  More likely to have graduated from highs school,  To have married, had children  And develop good social skills  Onset of schizophrenia in late 20s, early 30s in women. In men often develop in their late teens or early 20s  Women show fewer cognitive deficits than men  Oestrogen may affect the regulation of dopamine, a neurotransmitter implicated in schizophrenia, in ways that are protective for women  Exposure to toxins and illness in utero increases the risk for abnormal brain development and development of schizophrenia  Studies show men have greater abnormalities in brain structure and functioning than females  In men and women with schizophrenia, functioning tends to improve with age  Due to them finding treatments to help them stabilize  Or families learn to recognize early symptoms of relapse and seek earlier treatment before symptoms become acute  Aging of brain might somehow reduce the likelihood of new episodes of schizophrenia o Sociocultural factors  Schizophrenia tends to have more benign course in developing countries  Persons with schizophrenia in countries such as India, Nigeria, Colombia are less disabled by the disorder in the long term than people in Great Britain, Denmark and US  Social environment of people with schizophrenia in developing countries may facilitate adaptation and recovery better than in developed countries  In developing countries broader and closer family networks surround people with schizophrenia

Ensures that one person is solely responsible for the care of a person  Families in developing countries less hostile, criticising and overinvolved than families in developed countries o May help lower relapse rates for members with schizophrenia Other psychotic disorders o Schizophrenia has the worst long term outcome of all disorders, followed by schizoaffective disorder, schizophreniform disorder and other psychotic disorders o Schizoaffective disorder REFER TO TABLE 8.3  Mix of schizophrenia and mood disorder  People simultaneously experience psychotic symptoms (delusions, hallucinations, disorganized speech, negative symptoms) and prominent mood symptoms of major depressive or manic episode  Mood symptoms must be present for majority of period of illness  Unlike mood disorders, schizoaffective disorder requires at least 2 weeks of hallucinations or delusions without mood symptoms o Schizophreniform disorder REFER TO TABLE 8.4  Functional impairments might be present may be present, they are not necessary for diagnosis of schizophreniform disorder  Individuals with this disorder who have good prognosis, have a quick onset of symptoms, functioned well previously and experience confusion but not blunted or flat affect  Individuals who do not show 2 or more of these features are said to be good prognostic features  Majority of individuals with schizophreniform disorder will eventually receive a diagnosis of schizophrenia or schizoaffective disorder o Brief psychotic disorder REFER TO TABLE 8.5  People show sudden onset of delusions, hallucinations, disorganized speech and or disorganized behaviour  Episode only lasts between 1 day and 1 month after which the symptoms completely remit  Symptoms sometimes emerge after a major stressor (big accident)  Risk of relapse is high, but most people show excellent outcome o Delusional disorder REFER TO TABLE 8.6  Have delusions lasting at least 1 month regarding situations that occur in real life, such as being poisoned, being deceived by a spouse, or having a disease  Do not show any psychotic symptoms  Other than behaviours that may follow after delusions, they do not act oddly or have difficulty functioning  May be rare in general population  Affects females more than males  Onset tends to be later in life with average age of first admission to psychiatric facility being 40-49 o Schizotypal personality disorder REFER TO TABLE 8.7  Have lifelong pattern of significant oddities in their self-concept, their ways of relating to others and their thinking and behaviour  Don’t have strong and independent sense of self and may have trouble setting realistic goals  Emotional expression may be restricted  May have few close relationships and trouble understanding the behaviours of others o

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Tend to perceive other people as deceitful and hostile and may be social anxious or isolated because of their suspiciousness May believe that random events or circumstances are related to them  May think it highly significant that a fire occurred in a shop they were in yesterday Perceptions are odd  Think they see people in patterns of wallpaper May be easily distracted or fixate on an object for long periods of time, lost in thought Show deficits in working memory, learning and recall but all less severe than schizophrenia Share same genetic traits and neurological abnormalities as people with schizophrenia

Biological theories 

Genetic contributors to schizophrenia o Scientists believe that no single genetic abnormality accounts for this complex disorder o May be different genes that are responsible for different symptoms of the disorder  One set of genes may contribute to positive symptoms and another set of genes to negative symptoms o Family studies  Children of 2 parents with schizophrenia and monozygotic twins of people with schizophrenia share the greatest number of genes with people with schizophrenia  These people also have the greatest risk of developing schizophrenia at some stage of their life  As genetic similarity to person with schizophrenia decreases, so does the chances of that person developing schizophrenia  1st degree relative of a person with schizophrenia (shares 50 percent of genes) has 10 percent chance of developing the disorder  Niece or nephew of person with schizophrenia (share about 25 percent of genes) with person with schizophrenia has on 3 percent chance of developing schizophrenia  General population has risk of about 1-2 percent o Adoption studies  A home with a parent with schizophrenia can be a stressful environment  When parent is psychotic, child may be exposed to illogical thought, mood swings and chaotic behaviour  Residual symptoms of schizophrenia ( affect, lack of motivation and disorganization) may impair the parents childcare skills o Twin studies  Concordance rate of monozygotic twins- 46 percent and for dizygotic twins is 14 percent  Even if person has genetic risk for schizophrenia, many other biological and environmental factors may influence how he or she manifests the disorder  Some of these events might alter genes that guide brain development

Structural and functional brain abnormalities 

Scientists can examine the structure of the brain through the use of o

Position emission tomography (PET scans)

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Computerized axial tomography (CAT scans)

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Magnetic resonance imaging (MRI)

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These techniques have proven major structural and functional defi...