Schizophrenia and Other Psychotic Disorders

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Schizophrenia and Other Psychotic Disorders

• I. Schizophrenia

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A. Historical Perspective

• Emil Kraepelin
• Associated with biological tradition in
  psychology
• First to classify schizophrenia (Sz) as a
  disorder
• Dementia praecox precocious (early) dementia
• Viewed Sz as a dementia or deterioration of the
  mind
• Focus on negative symptoms

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A. Historical Perspective (cont.)

• Eugen Bleuler
• Viewed Sz as a temporary breakdown in which the
  personality disintegrated ? person had a split
  mind
• Named the disorder schizophrenia split mind
• Led to lay people view that Sz is split
  personality or multiple personality disorder (now
  DID) its NOT

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Bleuler (cont.)

• Bleulers cardinal symptoms (4 As)
• Loose associations persons flow of thought is
  vague, unfocused
• Autistic withdrawal self-absorbed, withdrawn,
  highly idiosyncratic view of the world, fantasy
  life
• Ambivalence contradictory feelings about things
  of fundamental importance
• Disturbed affect inappropriate or absent affect

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A. Historical Perspective (cont.)

• Kurt Schneider
• First rank symptoms symptoms that violate the
  persons sense of autonomy by superimposing
  something
• Several first rank symptoms, including
• Voices conversing hallucination in which two or
  more voices are heard having a conversation
  theme of conversation often derogatory or
  accusatory of the patient
• Voices commenting hallucination in which a
  voice is commenting on patients thoughts or
  actions

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Schneider (cont.)

• Believed first rank symptoms were pathognomonic
  when present, it is sufficient for the diagnosis
• First rank symptoms are basis for DSM-IV criteria
  for Sz

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B. Features of Schizophrenia

• Case of Etta
• Positive symptoms represent excess or
  distortion of normal behavior
• Delusions disorder of thought content and
  presence of strong beliefs that are
  misrepresentations of reality
• Grandiose belief that one has special
  importance
• Persecutory belief that one is the subject of a
  master plot feeling of being mistreated
• Very common not diagnostically specific

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Delusions (cont.)

• Nihilistic belief that something does not exist
  (e.g., ones brain part of the world)
• Religious involves some religious theme
• Very common not diagnostically specific
• Bizarre belief in something that could not be
  true based on the persons culture
• Very specific to Sz (almost pathognomonic)

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1. Positive symptoms (cont.)

• Hallucinations perceptual disturbance in which
  things are sensed, although they are not actually
  present
• Auditory
• Most common type of hallucination
• Visual
• Second most common type of hallucination
• Other senses (olfactory, tactile, gustatory)

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1. Positive symptoms (cont.)

• Disorganized speech style of talking involving
  incoherence and lack of typical logical patterns
• Clang association rhyming words
• Neologism made-up words or phrases
• Word salad words/speech with no message
• Derailment deviation in the train of thought
• Knights move going from point A to point C
  without making a connection through point B

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1. Positive symptoms (cont.)

• Grossly disorganized or catatonic behavior
• Catatonia disorder of movement involving
  immobility or excited agitation

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B. Features of Schizophrenia (cont.)

• Negative symptoms deficits in normal behavior
• Flat affect emotionless demeanor when a
  reaction would be expected
• Avolition apathy or inability to initiate or
  persist in important activities
• Alogia deficiency in amount or content of
  speech
• Anhedonia inability to experience pleasure

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C. DSM-IV Criteria for Sz (p. 459)

• Two or more of the following present during a
  1-month period
• Delusions
• Hallucinations
• Disorganized speech (e.g., incoherence)
• Negative symptoms
• Note only 1 symptom required if delusions are
  bizarre, or hallucinations consist of voices
  commenting or voices conversing

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C. DSM-IV Criteria for Sz (cont.)

• Social/occupational dysfunction
• Duration signs for 6 months with at least 1
  month of active-phase symptoms
• Schizoaffective and mood disorders ruled out
• Not due to substance or GMC
• Relationship to pervasive developmental disorder
  Sz diagnosis made if prominent delusions/hallucina
  tions present for at least 1 month

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C. Criteria (cont.)

• Specify course and type
• Case of David paranoid Sz

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D. Course and Statistics

• Lifetime prevalence is about 1 worldwide
• Gender ratio about equal (may be slightly higher
  in males)
• Sex differences in onset, presentation, and course

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D. Course and Statistics

• Lifetime prevalence is about 1 worldwide
• Gender ratio about equal (may be slightly higher
  in males)
• Sex differences in onset, presentation, and
  course
• Median onset is early to mid-20s for men late
  20s for women
• Women tend to have more mood symptoms
• Women tend to have a better prognosis

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D. Course and statistics (cont.)

• Disorder may onset abruptly or gradually
• Most have a prodromal period ? social withdrawal,
  lose interest in work/school, deterioration of
  functioning

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D. Course and statistics (cont.)

• Age onset may relate to course
• Early onset
• More likely male
• Poor adjustment before onset
• Lower educational achievement
• Evidence of more structural brain abnormalities
• More prominent negative symptoms
• More cognitive impairment
• Worse outcome

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Age related to course (cont.)

• Late onset
• More likely female
• Less evidence of structural brain abnormalities
• Less cognitive impairment
• Better outcome

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D. Course and statistics (cont.0

• Life expectancy is lower than non-Sz because of
  suicide or accidents

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E. Causal Influences

• Biological influences
• Gottesman (1991) reviewed evidence from twin and
  family studies ? showed clear genetic influence

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1. Biological influences (cont.)

• Gottesman Bertelsen (1989)
• Examined Sz in the children of discordant MZ and
  DZ pairs

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Gottesman Bertelsen (cont.)

• 1 risk for Sz in children of unaffected DZ twins
  (same risk as in general population)
• 17 risk for Sz in children of affected parents
  AND in children of unaffected MZ co-twins ?
  environment is important, too

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E. Causal Influences (cont.)

• Neurobiological influences
• a) Dopamine
• Dopamine hypothesis symptoms of Sz result from
  overactivity of dopamine system, specifically the
  D2 receptor

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Dopamine Hypothesis (cont.)

• Evidence for the hypothesis
• Many effective neuroleptic (antipsychotic) drugs
  block dopamine receptors ? reduces activity of
  dopamine
• L-dopa treats Parkinsons disease by increasing
  dopamine activity ? sometimes produces Sz-like
  symptoms
• Evidence against
• New Sz meds (clozapine) acts weakly on D2
  receptor and blocks serotonin

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Dopamine Hypothesis (cont.)

• Conclusion dopamine is not the only
  neurotransmitter responsible for Sz symtpoms
• More likely relationship between dopamine and
  serotonin is at play

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2. Neurobiological influences (cont.)

• b) Brain structure
• Many (not all) Sz patients show enlarged lateral
  ventricles

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2. Neurobiological influences (cont.)

• b) Brain structure
• Many (not all) Sz patients show enlarged lateral
  ventricles
• Implies smaller brain mass
• Due to atrophy or lack of development
• Ventricle enlargement found more often in males
  and in older patients with longer disorder course

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2. Neurobiological influences (cont.)

• c) viral infection
• Some think Sz is like a viral infection causing
  brain abnormalities
• Evidence from studies showing abnormal brain cell
  migration in Sz patients ? suggests problems in
  neural development known to be caused by viral
  infection

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E. Causal Influences (cont.)

• Developmental influences
• Why does Sz onset in late teens/20s if genetic
  liability present from birth?
• Breslin Weinberger (1990) theory based on
  animal and human research on brain abnormalities
  and functional deficits
• Areas affected by Sz are those that naturally
  develop later in adolescence or early adulthood
• Person can have the brain damage (e.g., from
  viral infection) but not show disorder until
  brain reaches natural developmental milestone

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E. Causal Influences (cont.)

• Psychological and environmental factors
• Stressful life events in childhood or prior to
  onset
• Birth complications (low weight, problems during
  pregnancy)

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E. Causal Influences (cont.)

• Two-hit hypothesis
• Diathesis-stress model genetic liability is
  necessary but not sufficient for the disorder to
  manifest, need environment (stressor)
• Two-hit hypothesis
• Hit 1 genetic vulnerability toward Sz or 1st
  trimester insult that causes neural development
  problems
• Hit 2 environmental stressor that triggers onset

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F. Treatment

• Drugs
• Neuroleptics (antipsychotics) used to treat
  active phase symtpoms
• Most drugs are dopamine antagonists ? reduce
  dopamine activity
• Some newer drugs act primarily on serotinin
• Drugs help about 60 of patients

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1. Drugs (cont.)

• Many patients stop taking drugs due to side
  effects
• Grogginess, blurred vision, dry mouth
• Akinesia expressionless face, slow motor
  activity, and monotone speech
• Tardive dyskinesia involuntary movements of the
  tongue, face, mouth, or jaw (e.g., chewing
  motion, lip smacking)
• From long-term, high dose use
• Irreversible

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1. Drugs (cont.)

• Clozapine (Risperdal, Zyprexa)
• Second-generation neuroleptics
• Fewer side effects

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F. Treatment (cont.)

• Psychosocial treatment
• Social skills training
• Vocational training
• Family interventions
• Expressed emotion communications in families
  marked by high criticism, hostility, and
  emotional overinvolvement
• High EE in families is related to relapse of Sz

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Summary

• Schizophrenia has a heterogeneous presentation
• Positive and negative symptom spectrums
• Diathesis-stress model of etiology
• Treatment usually includes medication not
  effective for all side effects