Survey of Modern Psychology

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Survey of Modern Psychology

• Schizophrenia and Psychotic Disorders

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What is Schizophrenia?

• SCHIZOPHRENIA IS NOT MULTIPLE PERSONALITIES!

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Definitions

• Positive symptoms refer to presence of abnormal
  behavior, thoughts, beliefs, etc.
• Negative symptoms refer to absence of normal
  behavior (e.g., responsiveness to environment)

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Definitions

• Hallucination
• A distortion in perception that can occur through
  any of the senses
• Auditory, visual, olfactory, gustatory, and
  tactile
• Auditory hallucinations are the most common
• Delusion
• Erroneous beliefs that usually involve a
  misinterpretation of perceptions or experiences
• It can be difficult at times to differentiate a
  strongly held belief from a delusion. The
  determination depends largely on the degree of
  conviction with which the belief is held despite
  clear evidence to the contrary

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Psychotic Disorders

• Schizophrenia
• Schizophreniform Disorder
• Schizoaffective Disorder
• Delusional Disorder
• Brief Psychotic Disorder
• Shared Psychotic Disorder (Folie à Deux)

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Schizophrenia

• Characteristic symptoms Two (or more) of the
  following, each present for a significant portion
  of time during a 1- month period (or less if
  successfully treated)
• Delusions
• Hallucinations
• Disorganized speech (e.g., frequent derailment or
  incoherence)
• Grossly disorganized or catatonic behavior
• Negative symptoms, i.e., affective flattening,
  alogia, or avolition
• Note Only one Criterion A symptom is required if
  delusions are bizarre or hallucinations consist
  of a voice keeping up a running commentary on the
  persons behavior or thoughts, or two or more
  voices conversing with each other

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Schizophrenia

1. Social/occupational dysfunction for a
   significant portion of the time since the onset
   of the disturbance, one or more major areas of
   functioning such as work, interpersonal
   relations, or self-care are markedly below the
   level achieved prior to the onset (or when the
   onset is in childhood or adolescence, failure to
   achieve expected level of interpersonal,
   academic, or occupational achievement)

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Schizophrenia

1. Duration Continuous signs of the disturbance
   persist for at least 6 months. This 6-month
   period must include at least 1 month of symptoms
   (or less if successfully treated) that meet
   Criterion A (i.e., active-phase symptoms) and may
   include periods of prodromal or residual
   symptoms. During these prodromal or residual
   periods, the signs of the disturbance may be
   manifested by only negative symptoms or two or
   more symptoms listed in Criterion A present in an
   attenuated form (e.g., odd beliefs, unusual
   perceptual experiences)

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Schizophrenia

1. Schizoaffective and Mood Disorder exclusion
   Schizoaffective Disorder and Mood Disorder With
   Psychotic Features have been ruled out because
   either (1) no Major Depressive, Manic, or Mixed
   Episodes have occurred concurrently with the
   active-phase symptoms or (2) if mood episodes
   have occurred during active-phase symptoms, their
   total duration has been brief relative to the
   duration of the active and residual periods

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Schizophrenia

1. Substance/general medical condition exclusion
   The disturbance is not due to the direct
   physiological effects of a substance (e.g., a
   drug of abuse, a medication) or a general medical
   condition

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Schizophrenia

1. Relationship to a Pervasive Developmental
   Disorder If there is a history of Autistic
   Disorder or another Pervasive Developmental
   Disorder, the additional diagnosis of
   Schizophrenia is made only if prominent delusions
   or hallucinations are also present for at least a
   month (or less if successfully treated)

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Schizophreniform Disorder

• Criteria A, D, and E of Schizophrenia are met
• An episode of the disorder (including prodromal,
  active, and residual phases) lasts at least 1
  month but less than 6 months. (When the diagnosis
  must be made without waiting for recovery, it
  should be qualified as Provisional)
• This refers to symptoms and the exclusion of
  other mental disorders, medical conditions, or
  substance use

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Schizophreniform Disorder

• Specify if
• Without Good Prognostic Features
• With Good Prognostic Features as evidenced by
  two (or more) of the following
• Onset of prominent psychotic symptoms within 4
  weeks of the first noticeable change in usual
  behavior or functioning
• Confusion or perplexity at the height of the
  psychotic episode
• Good premorbid social and occupational
  functioning
• Absence of blunted or flat affect

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Schizophreniform Disorder Notes

• Much less prevalent than Schizophrenia
• Does not require impairment in functioning
  (though most individuals do experience
  impairment)

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Schizophrenia Subtypes

• The subtypes of Schizophrenia are defined by the
  predominant symptomatology at the time of
  evaluation
• Paranoid Type
• Preoccupation with one or more delusions or
  frequent auditory hallucinations
• None of the following is prominent disorganized
  speech, disorganized or catatonic behavior, or
  flat or inappropriate affect

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Schizophrenia Subtypes - Paranoid

• Delusions are typically persecutory or grandiose,
  or both
• Delusions with other themes (e.g., jealousy,
  religiosity, or somatization) may also occur
• Delusions and hallucinations are usually
  organized around a coherent theme, and
  hallucinations are related to the delusions
• Associated features include anxiety, anger,
  aloofness, and argumentativeness.
• The individual may have a superior and
  patronizing manner and either a stilted, formal
  quality or extreme intensity in interpersonal
  interactions.

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Schizophrenia Subtypes - Paranoid

• Persecutory delusions may predispose the
  individual to suicidal behavior the combination
  of persecutory and grandiose delusions with anger
  may predispose the individual to violence
• Onset tends to be later in life and more stable
• Usually show little or no impairment on cognitive
  testing
• The prognosis may be better than other types of
  schizophrenia

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Schizophrenia Subtypes

• Disorganized Type
• All of the following are prominent
• Disorganized speech
• Disorganized behavior
• Flat or inappropriate affect
• The criteria are not met for Catatonic Type

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Schizophrenia Subtypes - Disorganized

• The disorganized speech may be accompanied by
  silliness and laughter that are not closely
  related to the content of the speech
• The behavioral disorganization (i.e., lack of
  goal orientation) may lead to severe disruption
  in the ability to perform activities of daily
  living (e.g., showering, dressing, or preparing
  meals)

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Schizophrenia Subtypes - Disorganized

• If present, delusions and hallucinations are not
  organized around a coherent theme
• Associated features include grimacing,
  mannerisms, and other oddities of behavior
• There is often impaired performance on cognitive
  tests
• Usually associated with poor pre-morbid
  functioning, early and insidious onset, and a
  continuous course without significant remissions

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Schizophrenia Subtypes - Catatonic

• A type of Schizophrenia in which the clinical
  picture is dominated by at least two of the
  following
• Motoric immobility as evidenced by catalepsy
  (including waxy flexibility) or stupor
• Excessive motor activity (that is apparently
  purposeless and not influenced by external
  stimuli)
• Extreme negativism (an apparently motiveless
  resistance to all instructions or maintenance of
  a rigid posture against attempts to be moved) or
  mutism
• Peculiarities of voluntary movement as evinced by
  posturing (voluntary assumption of inappropriate
  or bizarre postures), stereotyped movements,
  prominent mannerisms, or prominent grimacing
• Echolalia or echopraxia

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Schizophrenia Subtypes - Catatonic

• Catalepsy waxy flexibility
• Echolalia senseless repetition of a word or
  phrase that was just spoken by another rperson
• Echopraxia repetitive imitation of the movements
  of another person
• There may be increased risk for harm to the self
  or others
• self harm risks particularly include
  malnutrition, exhaustion, and self-inflicted
  injury

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Schizophrenia

• Undifferentiated Type
• A type of Schizophrenia in which symptoms that
  meet Criterion A are present, but the criteria
  are not met for the Paranoid, Disorganized, or
  Catatonic Type
• Residual Type
• Absence of prominent delusions, hallucinations,
  disorganized speech, and grossly disorganized or
  catatonic behavior
• There is continuing evidence of the disturbance,
  as indicated by the presence of negative symptoms
  or two or more symptoms listed in Criterion A for
  Schizophrenia, present in an attenuated form
  (e.g., odd beliefs, unusual perceptive
  experiences)

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Common Types of Delusions

• Persecutory
• Referential
• Somatic
• Religious
• Grandiose
• Thought broadcasting
• Thought insertion or withdrawal

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Types of Delusions Persecutory

• These are the most common type of delusion
• The person believes that he or she is being
  tormented, followed, tricked, spied on, or
  ridiculed
• Examples DE, LG

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Types of Delusions Referential

• Also very common
• The person believes that certain gestures,
  comments, passages from books, newspapers, song
  lyrics, or other environmental cues are
  specifically directed at him or her

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Types of Delusions Somatic

• A delusion that ones body has been changed or
  altered
• Example LP

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Types of Delusions Religious

• A delusion with religious or spiritual content
• It does not match the religions actual beliefs
  or tenets

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Types of Delusions Grandiose

• An individual exaggerates his or her sense of
  self-importance and is convinced that he or she
  has special powers, talents, or abilities
• Sometimes, the individual may actually believe
  that he or she is a famous person
• More commonly, a person with this delusion
  believes he or she has accomplished some great
  achievement for which they have not received
  sufficient recognition
• Example LG

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Types of Delusions Thought Broadcasting

• A belief that ones thoughts can be heard aloud
• Example RO

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Types of Delusions Thought Insertion Thought
Withdrawal

• The belief that others can put thoughts in, or
  remove thoughts from, the persons brain

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Delusions

• A delusion is considered bizarre if it is
  completely impossible and unrealistic
• A non-bizarre delusion is still false, but could
  occur
• Ex. belief that one is being watched by the police

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Schizophrenia - Demographics

• In the US and UK non-White people are more often
  diagnosed with schizophrenia
• It is unclear whether there is a a true
  difference in the rates of Schizophrenia, or only
  in diagnosis
• People in non-industrialized nations tend to have
  a better outcome than people in industrialized
  nations
• Women are more likely to have positive symptoms,
  men are more likely to have negative symptoms
• There is a slightly higher incidence of
  Schizophrenia in men than women
• Women tend to have a short term better outcome
  than men, but over time it evens out

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Schizophrenia - Demographics

• Prevalence among adults is .5 - 1.5
• A later age of onset is associated with a better
  prognosis
• Individuals with an earlier onset tend to have
  poorer premorbid adjustment, lower educational
  achievement, more evidence of brain
  abnormalities, and more cognitive impairment

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Schizophrenia - Demographics

• Men
• Median age of onset early to mid 20s
• Modal age of onset between 18 and 25
• Women
• Median age of onset late 20s
• Bimodal age of onset
• Between 25 and 35
• Over 40

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Schizophrenia Associated Findings

• The lateral ventricles are consistently found to
  be larger among people with Schizophrenia

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Schizophrenia Associated Findings

• Decreased volume of the temporal lobe
• Increased size of the basal ganglia (though this
  may be due to the medications used to treat
  Schizophrenia rather than the disorder itself)
• Decreased blood flow in the front of the brain

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Schizophrenia Associated Features and Disorders

• A majority of people with Schizophrenia have poor
  insight
• This makes noncompliance with treatment and
  therefore relapse more likely
• Anxiety and phobias are common
• Approximately 10 of Schizophrenics commit
  suicide
• 20 - 40 make at least one attempt
• Suicide is particularly common immediately after
  a psychotic period
• Schizophrenics overall are not any more prone to
  violence than the average person, but it varies
  by subgroup
• Risks include noncompliance, male, younger, past
  history of violence, substance abuse

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Schizophrenia Associated Features and Disorders

• Extremely high comorbidity with substance abuse
• 80 - 90 of people with Schizophrenia report
  being regular cigarette smokers
• There is a high incidence of Obsessive-Compulsive
  Disorder and Panic Disorder among Schizophrenics
  and one of these disorders often precedes the
  diagnosis of Schizophrenia
• It is unclear whether the disorder is separate
• Other risks include prenatal exposure to flu,
  prenatal exposure to famine, obstetric
  complications, and CNS infection in early
  childhood

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Schizophrenia Treatment

• Antipsychotic medications are the most popular
  and effective treatment
• It is generally believed that psychoanalysis
  should not be used
• Other forms of therapy/talk therapy may be used
  in conjunction with medications to deal with
  nonbiological components of the disorder (e.g.,
  social training, self-care)
• A longer time between onset of psychosis and
  treatment is suggested to be linked to a worse
  outcome

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Schizophrenia Treatment

• Approximately 60 of Schizophrenics treated with
  medications recover to the point of full
  remission
• The other 40 show improvement to varying levels
• Some require chronic hospitalization, others are
  functional but continue to have some symptoms
• A 4 6 week trial period on a medication is
  recommended for most patients to determine
  whether a medication is working

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Schizophrenia Treatment

• Medications used for Schizophrenia block dopamine
  receptors (dopamine antagonists)
• Newer medications act on both serotonin and
  dopamine
• For patients who are noncompliant with
  medication, injections are available
• Approximately 40 - 50 become noncompliant
  within two years

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First Generation Antipsychotic Medications
(Dopamine antagonists)

• These largely act as tranquilizers
• Side effects include restlessness, tremors, and
  Tardive Dyskinesia, and weight gain
• Thorazine is known for causing significant
  sedation
• Thorazine shuffle

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First Generation Antipsychotic Medications
(Dopamine antagonists)
Brand Name Generic
Mellaril Thioridazine
Prolixin Fluphenazine
Serentil Mesoridazine
Stelazine Trifluoperazine
Thorazine Chlorpromazine
Trifalon Perphenazine
Haldol Haloperidol
Loxitane Loxapine
Moban Molindone
Navane Thiothixene
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Second Generation Antipsychotics/Atypical
Antipsychotics

• Atypical antipsychotics act on serotonin as well
  as dopamine
• They are often not as effective as the first
  generation antipsychotics, but have fewer side
  effects

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Second Generation Antipsychotics/Atypical
Antipsychotics
Brand Name Generic
Clorazil Clozapine
Risperdal Risperidone
Seroquel Quetiapine
Zyprexa Olanzapine
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Tardive Dyskinesia

• Tardive Dyskinesia may develop as a side effect
  of antipsychotic medication and can be permanent
• This was particularly problematic with the
  earlier medications
• Tardive Dyskinesia is considered an area for
  further study in the DSM-IV-TR

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Tardive Dyskinesia

• Involuntary movements of the tongue, jaw, trunk,
  or extremities have developed in association with
  the use of neuroleptic medication
• The involuntary movements are present over a
  period of at least 4 weeks and occur in any of
  the following patterns
• Choreiform movements (i.e., rapid, jerky,
  nonrepetitive)
• Athetoid movements (i.e., slow, sinuous,
  continual)
• Rhythmic movements (i.e., stereotypies)

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Tardive Dyskinesia

1. The signs or symptoms in Criteria A and B develop
   during exposure to a neuroleptic medication or
   within 4 weeks of withdrawal from an oral (or
   within 8 weeks of withdrawal from a depot)
   neuroleptic medication
2. There has been exposure to neuroleptic medication
   for at least 3 months (1 month if age 60 or
   older)
3. The symptoms are not due to a neurological or
   general medical condition, ill-fitting dentures,
   or exposure to other medications that cause acute
   reversible dyskinesia. Evidence that the symptoms
   are due to one of these etiologies might include
   the following the symptoms precede the exposure
   to the neuroleptic medication or unexplained
   focal neurological signs are present
4. The symptoms are not better accounted for by a
   neuroleptic-induced acute movement disorder

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Tardive Dyskinesia

• http//www.youtube.com/watch?vFUr8ltXh1Pc

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Schizoaffective Disorder

• An uninterrupted period of illness during which,
  at some time, there is a Major Depressive, Manic,
  or Mixed Episode concurrent with symptoms that
  meet Criterion A for Schizophrenia. In addition,
  during the same period of illness, there have
  been delusions or hallucinations for at least 2
  weeks in the absence of prominent mood symptoms
• The minimum amount of time that a Schizoaffective
  episode can last is one month (to meet Criterion
  A for Schizophrenia, the symptoms must last at
  least 1 month)
• The mood symptoms must be present for a
  substantial portion of the entire period of
  illness (e.g., Depressive symptoms lasting for 5
  weeks in the course of 4 years of Schizophrenic
  symptoms would not apply)

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Schizoaffective Disorder

• An uninterrupted period of illness during which,
  at some time, there is either a Major Depressive
  Episode, a Manic Episode, or a Mixed Episode
  concurrent with symptoms that meet Criterion A
  for Schizophrenia
• Note The Major Depressive Episode must include
  Criterion A1 depressed mood
• During the same period of illness, there have
  been delusions or hallucinations for at least 2
  weeks in the absence of prominent mood symptoms

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Schizoaffective Disorder

1. Symptoms that meet criteria for a mood episode
   are present for a substantial portion of the
   total duration of the active and residual periods
   of the illness
2. The disturbance is not due to the direct
   physiological effects of a substance (e.g., a
   drug of abuse, a medication) or a general medical
   condition

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Schizoaffective Disorder Notes

• Seems to be less common than Schizophrenia
• Younger people are more likely to experience
  Bipolar Type, while older adults are more likely
  to experience Depressive Type
• Schizoaffective Disorder is more common in women
  (mostly because more women experience the
  Depressive Type)
• The prognosis may be better for the Bipolar Type
• The prognosis is better if there is a
  precipitating event/stressor
• Age of onset is usually early adulthood, but it
  can occur any time

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Delusional Disorder

1. Nonbizarre delusions (i.e., involving situations
   that occur in real life, such as being followed,
   poisoned, infected, loved at a distance, or
   deceived by spouse or lover, or having a disease)
   of at least 1 month's duration
2. Criterion A for Schizophrenia has never been met.
   Note tactile and olfactory hallucinations may be
   present in Delusional Disorder if they are
   related to the delusional theme

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Delusional Disorder

1. Apart from the impact of the delusion(s) or its
   ramifications, functioning is not markedly
   impaired and behavior is not obviously odd or
   bizarre
2. If mood episodes have occurred concurrently with
   delusions, their total duration has been brief
   relative to the duration of the delusional
   periods
3. The disturbance is not due to the direct
   physiological effects of a substance (e.g., a
   drug of abuse, a medication) or a general medical
   condition

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Delusional DisorderSpecify type (the following
types are assigned based on the predominant
delusional theme

• Erotomanic Type delusions that another person,
  usually of higher status, is in love with the
  individual
• Grandiose Type delusions of inflated worth,
  power, knowledge, identity, or special
  relationship to a deity or famous person
• Jealous Type delusions that the individuals
  sexual partner is unfaithful
• Persecutory Type delusions that the person (or
  someone to whom the person is close) is being
  malevolently treated in some way

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Delusional DisorderSpecify type (the following
types are assigned based on the predominant
delusional theme

• Somatic Type delusions that the person has some
  physical defect or general medical condition
• Mixed Type delusions characteristic of more than
  one of the above types but no one theme
  predominates
• Unspecified Type

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Delusional Disorder Notes

• Fairly uncommon
• 1 - 2 of inpatients
• About .03 in the total population
• Persecutory delusions are the most common
• When there is a precipitating event or stressor,
  the prognosis tends to be better
• Age of onset varies
• Some studies have found a higher incidence in
  relatives of Schizophrenics, others have found no
  relationship

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Brief Psychotic Disorder

• Presence of one (or more) of the following
  symptoms
• Delusions
• Hallucinations
• Disorganized speech (e.g., frequent derailment or
  incoherence)
• Grossly disorganized or catatonic behavior
• Note Do not include a symptom if it is a
  culturally sanctioned response pattern
• Duration of an episode of the disturbance is at
  least 1 day but less than 1 month, with eventual
  full return to premorbid level of functioning

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Brief Psychotic Disorder

• The disturbance is not better accounted for by a
  Mood Disorder With Psychotic Features,
  Schizoaffective Disorder, or Schizophrenia and is
  not due to the direct physiological effects of a
  substance (e.g., a drug of abuse, a medication)
  or a general medical condition
• Specify if
• With Marked Stressor(s) (brief reactive
  psychosis) if symptoms occur shortly after and
  apparently in response to events that, singly or
  together, would be markedly stressful to almost
  anyone in similar circumstances in the persons
  culture
• Without Marked Stressor(s) if psychotic symptoms
  do not occur shortly after, or are not apparently
  in response to events that, singly or together,
  would be markedly stressful to almost anyone in
  similar circumstances in the persons culture
• With Postpartum Onset if onset is within 4 weeks
  postpartum

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Shared Psychotic Disorder (Folie à Deux)

1. A delusion develops in an individual in the
   context of a close relationship with another
   person(s) who has an already-established delusion
2. The delusion is similar in content to that of
   other person who already has the established
   delusion
3. The disturbance is not better accounted for by
   another Psychotic Disorder (e.g., Schizophrenia)
   or a Mood Disorder With Psychotic Features and is
   not due to the direct physiological effects of a
   substance (e.g., a drug of abuse, a medication)
   or a general medical condition

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Shared Psychotic Disorder (Folie à Deux)

• The first person is usually schizophrenic
• The people involved usually have had a very close
  relationship (e.g., are related by blood or
  marriage)
• With separation, the second persons belief
  usually disappears
• Without intervention, it tends to be chronic and
  often not come up in clinical settings
• Somewhat more common in women than men