Schizophrenia

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Schizophrenia

• Other Psychotic Disorders

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Three Criteria Sets for all Psychotic Disorders

• 1st applies to all disorders in group defines
  requirements for psychosis
• 2nd defines attributes common to all
  schizophrenic disorders
• 3rd requirements about etiology, social
  impairment, diagnostic precedence applying to
  many but not all disorders
• All 3 sets tend to overlap

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SchizophreniaSplitting of the Mind

• Most debilitating baffling mental illness
• Distorted perception of reality
• Impaired capacity to reason, speak, behave
  rationally or spontaneously
• Impaired capacity to respond spontaneously with
  appropriate affect motivation
• Incongruity between different mental functions
• As betw thought content feeling
• As betw feeling overt activity
• Someone who laughs at a funeral

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Clinical Presentation

• Criticism of DSM-IV is that system becomes
  diagnosis by exclusion
• Criteria as a whole does not characterize
• Examples include
• Hypervigilant accountant suspicious others are
  plotting against him/her
• Housewife believes she is controlled by dead
  mothers voice
• Withdrawn apathetic college student brooding
  incessantly about reality of existence

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Important factors

• Specific set of symptoms, yet variety in severity
  from person to person
• Also variety with one person from one period of
  time to another
• Generally controlled with treatment
• More than 59 with continuous treatment recover
• Medication for entire life
• Treatment allows most people to work, live with
  families, enjoy friends

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Causes

• Much speculation
• Appears to run in families heredity link
• Schizophrenogenic Mother
• Previous discredited theory of bad parenting
  inadequate care
• Susceptibility/vulnerability to illness triggered
  by
• Environmental events viral infection changing
  body chemistry
• Highly stressful situation in adult life
• Combination of things

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Heredity

• With 1 parent with diagnosis
• 8-18 even if adopted by mentally healthy parents
• Both parents
• Risk ? 15-50
• Mentally healthy biological parents, but adoptive
  parents with diagnosis
• 1 chance of developing disorder
• Same chance as in general population
• One identical twin with disorder
• 50-60 sibling with identical genetics will also
  have disorder
• Do not inherit directly
• Appears when body is undergoing hormonal
  physical changes of adolescence
• Some researchers believe dormant during
  childhood
• Emerges as body brain undergo changes in
  puberty

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Key Points

• Age at onset
• Generally late adolescence, early adulthood rare
  later in life unless onset before 45 yrs
• Duration
• 6 months or more
• Unless Schizophreniform
• Loss of prior level of functioning
• Tendency toward chronicity
• Symptoms usually appear gradually
• Preparatory or prodromal period
• Symptoms include
• Tenseness, lack of concentration, sleep,
  withdraws from society
• Personality changes
• Work performance, appearance social
  relationships deteriorate

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Positive Negative Symptoms

• Diagnose when positive symptoms for minimum of 2
  weeks (other symptoms 6 mos.)
• Added features
• Excesses or distortions
• Hallucinations
• Delusions

• Negative Symptoms
• Lack of something
• Disorganized speech
• Diminution or loss of normal functioning

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Relapse Remission Phases

• Common
• Symptoms worsen or become better in cycles
• May suffer
• Delusions, hallucinations, or disordered thinking
  speech
• Appearance normal at times until psychotic phase
• Cannot think logically
• May lose all sense of identity
• May lose sense of significant others

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Delusions Hallucinations

• Delusions
• Thoughts that are fragmented with no basis in
  reality
• Also differ in degree of conviction
• Someone may be spying or planning to harm
• Strong belief
• May be wrong but has some basis in reality
• If bizarre delusions
• no other Criteria A needed
• Someone can insert thoughts into brain

• Hallucinations
• Sensory perception with compelling sense of
  reality of true perception but occurs W/O
  external stimulation of relevant sensory organ
• May or may not have insight into having
  hallucinations
• Distinguish from illusion actual stimulus
  misperceived /misinterpreted
• If voices are commenting or conversing
• no other Criteria A needed
• Ask if voices client hearing are own voice?
• Most common are voices
• Visual, tactile next

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Distortions of Ability

• Loss of knowing whether an event or situation
  perceived is real
• Waiting at a crosswalk, a voice says you smell
  really bad
• Real voice
• Jogger passing by
• In my head?
• Normal behaviors much of time
• Not so out of touch of realization that
• we eat 3 meals a day
• sleep at night
• drive on street etc.

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Subtypes

• Priority of patterns
• Catatonic, if signs prominent
• rigidity, lack of response or acute agitation
• Disorganized
• Disorganized speech, disorganized behavior, flat
  or inappropriate affect
• Paranoid
• Preoccupation with delusions or auditory
  hallucinations
• No flat or inappropriate affect, catatonic
  behavior, disorganized speech, or disorganized
  behavior
• Undifferentiated
• Symptoms meet criteria A but not for paranoid,
  catatonic, or disorganized types
• Residual
• does not require fulfillment of common criteria
  set for schizophrenia
• Attenuated form of criteria

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Continuum of Schizophrenia

• Based on duration of episode
• Brief Psychotic?schizophreniform?schizophrenia
• Brief Psychotic Disorder
• Duration 1 day 1 month
• Eventual complete recovery
• Schizophreniform
• Duration 1 month 6 months
• Impaired social or occupational functioning not
  required buy may occur
• Schizophrenia
• Duration more than 6 months

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Data

• Affects men/women equally
• Estimates of developing disorder 1
• Onset in women typically 5 years later
• 150 of 100,00 persons develop
• Approximately ¼ hospital beds ½ psychiatric
  beds in US
• More than any other illness
• Relatively rare
• Most catastrophic mental illness
• Early age of onset, lifelong disability,
  emotional financial devastation
• Federal figures reflect 30 - 48 billion in
  direct medical costs, loss of productivity,
  social security pensions

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Treatment

• No single correct treatment useful since
  syndrome consisting of a number of disorders
• Most effective
• Psychopharmacology psychosocial therapies
• Antipsychotic medications treatment of choice
  since 50s
• Brings biochemical imbalances closer to norm
• Reduces hallucinations, delusions
• Helps maintain coherent thoughts
• Compliance necessary
• 60-80 not taking medication relapse in 1st yr
• Relapse rates fall to 10 if medication continued

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Schizoaffective Disorder Bipolar or Depressive
Type

• Continuously meet Criterion A
• Also major depressive episode, manic episode, or
  mixed episodes
• Includes delusions, hallucinations of 2 weeks
  time in absence of mood symptoms

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Delusional Disorder

• Persistent nonbizarre delusions
• 1 or more systematic circumscribed delusions
  often of persecutory nature
• 1 month time
• Never met Criterion A for Schizophrenia
• Function reasonable well
• aside from impact/ramifications of delusions
• If mood episodes, total duration brief
• Relatively uncommon with .05-.1 lifetime risk
• Usually mid-life disorder noticed by
  friends/family
• Hypersensitive, argumentative, litigious types
• Usually no voluntary help sought

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Types of Delusional Disorders

• Erotomania
• Another person, usually of higher status, is in
  love with person
• Grandiose
• Inflated worth, power, knowledge, identity, or
  special relationship to deity or famous person
• Jealous
• Individuals sexual partner is unfaithful
• Persecutory
• Being persecuted for no apparent reason
• Somatic
• Having some physical defect or general medical
  condition
• Mixed Type
• More than 1 type with no predominant theme
• Unspecified Type

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Shared Psychotic Disorder

• Person develops delusion(s)
• similar in content to already established
  delusion
• of another person with whom close relationship

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Psychotic Disorder Due to General Medical
Condition

• Prominent delusions or hallucinations
• Judged caused by general medical condition
• Do not occur exclusively during course of
  Dementia or Delirium

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Substance-Induced Psychotic Disorder

• Prominent delusions or hallucinations associated
  with evidence symptoms developed within 1 month
  of significant substance intoxication or
  withdrawal, or is etiologically related to
  medications use or toxin exposure
• Specific codes determined by specific substance

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Psychotic Disorder NOS

• Syndromes with prominent psychotic symptomatology
  
• Symptomatology not meeting criteria for any
  specific Psychotic Disorder

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Necessary Clinical Information

• History of
• documented psychiatric illness
• socially unusual, odd, or isolative behavior
• substance abuse
• medical illnesses

• Current experience
• hallucinations or odd perceptual experiences
• Disorganized thought or speech
• Delusions
• Negative symptoms
• (e.g., flat affect, avolition (no goal directed
  activity)
• Depression or mania
• Duration of symptoms

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Treatment of Delusional Disorders

• Extraordinarily difficult to treat
• Longer symptoms present, more oppositional to
  simple treatments
• Some culturally-induced syndromes may respond to
  relocation
• return to country of origin
• Emphasis on trusting relationship
• Systematic desensitization effective
• Antipsychotic medication takes edge off
  delusions
• Psychosocial treatment more possible
• Antidepressants also proved helpful

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Side Effects of Medication

• Most side effects disappear after few weeks
• Dry mouth
• Blurred vision, constipation
• Drowsiness
• Dizziness due to drop in blood pressure
• Some irreversible serious side effects
• Tardive Dyskinesia (TD)
• 20-30 develop
• Small tongue tremors, facial tics, abnormal jaw
  movements
• May progress into thrusting rolling tongue, lip
  smacking, pouting, grimacing, chewing or sucking
  motions
• Also spasmodic movements
• Usually do not progressively worse
• Severe in less than 5
• Can fade if medication discontinued
• Effectiveness of ending psychoses, validates risk