Schizophrenia chapter 13

• affects 1% of pupulation
• most debilitating psychiatric disorder
• equal rates for the sexes: but most men have younger age onset and more severe courses
• Hispanic Americans 3 times as high: may be due to differential reporting, diagnostic bias, greater family stressors, lower SES backgrounds

• characteristic symptoms: two or more of the following, each present for significant time during active phase (1 month)
• - delusion (powerfully held false beliefs)
• -hallucinations (auditory must be more than 2 words)
• - diorganized speech (loose assocations, get lost in their thoughts)
• - grossly disorganized or catatonic behavior ( highly agitated, pacing or catonic- statue like)
• negative symptoms:
• eg flat affect - no emotion,
• alogia -no words
• avolition -no desire to do anything
• - social/occupational dysfunction : for significant time since onset of the disturbance, one or more major areas of functioning markedly below level acheived prior to onset
• - duration: continous signs of the disturbance persist for at least 6 months

• type 1 (positive symptoms)
• type 2 (negative symptoms)

expressive (way too expressive); hallucinations, delusions and disordered thoughts, disorganized speech and behavior, inappropriate affect, motor disturbances. 75% of all cases. this time prognosis, and reponds better to medication

non-expressive quiet, dont draw attention to self; flat affect, alogia, avolition, poorer premorbid functioning (social withdrawal were odd before prognosis, whien they are diagnosed family is not surprised) much worse prognosis, 25% of cases

• 1.disorgnaized
• 2. catatonic
• 3. motoric immobility
• 4. paranoid
• 5. residual

• diorganized speech and behavior, inappropriate affect
• proccupied with bizarre and scattered delusions and hallucinations; very "childish" behavior
• earliest age of onset (16-17) with slow but severe deterioration. poor prognosis

motoric immobility (including waxy flexibility- statue like poses but you can move them) excessive, purposeless motor activity; posturing or stereotype

sometimes alternate between withdrawn and excited states; can become violent in excited states

onset usualy late teens early 20s; associated with further deterioration and poorer prognosis

preoccupation with one or more delusions or frequent auditory hallucinations (no bizarre speech, movement or affect disturbances)

most common are delusions or persecution, then grandeur; prone to anger if challenged

onset usually early - mid 20s; less deterioration and better prognosis

most common subtype, and quicker recovery

catch all category

no prominent delusions, hallucinations, disorganized speech, or grossly disorganized behavior; exhibits symptoms in attenuated form; usually had previous schizophrenic episode

undifferentiated: meets symptoms of schizophrenia but not criteria of specific subtype. (may not have enough time to diagnose with subtype. quick mental health status)

prodromal

Active

Residual

• withdrawal, increasingly odd behaviors
• (person starts withdrawing, isolating themselves. becoming odd magical thinking and acting "odd")

full-blown psychosis, loss of reality contact

in recovery of schizophrenia (rule of thirds)

• folie a duex
• delusion develops in person (reciever) in context of close relationship with another who has established delusion (controller). Receiver usually dependent on controller and begins to accept controller's beliefs/views over time
• (e.g. CIA watching us)

there are many difficulties in studying the etiologies of schizophrenia, so there are only therectical ones

• very little research support
• aruge that patinet continuously misinterprets sensory input. Example: misinterprets "voices in head" as belonging to others. Humming to self or just keeping mouth open reduces or eliminates subvocalization

• very little research support
• argue that disturbed behavior is learned early as a result of problems in reinforcement systems (eg. rewarded for odd behavior, being withdrawn) and/or was not taught about acceptable responses to social cues. may be modeling bizarre behavior of parent with schizophrenia

• very little research support.
• patients are extremely regressed to a pre-ego state so cannot deal with reality well. experiencing Primary narcissism

very self-indulgent, self-absorbed, child-like

• dopamine hypothesis
• genetics
• neurological abnormalities

excess of DA in brains of patients supported by research finding that antipsychotic drugs bind to DA receptors. Problem with long-term use: tardive dskinesia

• a permanent brain damage from being on the drugs too long
• effects are irreversible

higher concordance rates among MZ twins (40-60%) than DZ twins (10-15%); adoption studies find genetics more critical than if adoptive parents had disorder

focus on severe/chronic cases;fail to consider parents' psychological staes;interviewer bias

• esp for Type 2
• ventricular enlargment (much bigger gaps in brain)
• diminished volume of temporal and/or frontal lobes
• decreased cerebral flow to frontal lobes
• diminshed volume of hippocampus
• dont know if these differences are due to the schizophrenia or if they were born this way

• social labeling, family problems and social class/cultural background. more likely to account for schizophrenia as "triggers" or as maintenance factors
• social labeling: chilren who exhibit odd behaviors and/or report magical beliefs labeled as "crazy", leading to self-fulfiling prophecy
• social class theories: rates are 5 times higher in persons of lower SES classes
• cross-cultural comparisons
• diathesis-stress model

• social causation
• social selection

• (breeder hypothesis)
• persons in low SES classes have more/stronger life stressors

• downward drift hypothesis
• debilitating effects of schizophrenia cause patients to gravitate to lower SES classes

• in developing countries, schizophrenia showe more rapid onset, shorter duration, and better prognosis than in western countries
• perphaps due to less focus on or greater acceptance of illness and/or stronger expectations that person will soon reintegrated into society (get better we need you)

• vulnerability to schizophrena (eg. biological) is compounded by impact of life factors/stressors. when negative factors outweigh positives, cognitive functioning becomes "overloaded"
• prime vulnerabilities: difficulty sustaining attention and overreacting to mild stimuli

• institutional care
• psychosurgeries
• pharmacological treatments
• CBT
• family therapies
• community service

• improvements in 1960s led to more human treatment.
• examples
• token economies,
• mileu therapy (put in charge of something)

• neuroleptics to decrease DA levels
• experimental drugs to increase glutamate (deals with memory and stimulations)

• Cognitive-behavior therapy
• focus on cognitive differentiations, social perception, verbal communication, social skills

alter dynamics and communication patterns (high EE) to prevent relapse

after-care with case managers, partial hospitalization, halfway houses, occupational training for community service

• brieft psychotic disorder
• schizophreniform disorder
• schizoaffective disorder
• shared psychotic disorder
• delusional disorder

• (brieft reactive psychosis)
• one or more psychotic symptoms (delusions, hallucinations, disorganized speech, or disorganized behavior) but duration is from 1 day to no longer than 1 month, and eventually full recovery. clear stressor is always present

schizophrenia's psychotic symptoms are present with no marked deterioration in functioning; duration of episode lasts at least 1 month but less than 6months; usually a stressor is present. disorder has a longer recovery period than above category but in most cases person returns to premorbid functioning

an uninterrupted period of illness (about 1 month) during which person's symptoms meet the criteria for both schizophrenia and a major mood episode (major depressive, manic or mixed). person exhibits 1 month of active schizophrenia with the mood disorer and then 2 weeks of schizophrenia without the mood disorder. prognosis here is poorer than with cases of major mood disorders but is better than seen with schizophrenia only if the mood disorder began before initial schizophrenic episode was expereinced.

delusion develops in an individual in the context of a close relationship with another person(s). who has an already-established delusion; and the delusion is similar in context to that of the person with the established delusion. person with existing psychosis is the controller whereas person who acquires delusion is the reciever. receiver is usually dependent on the controller and over time, begins to accept the beliefs/views of the controller

• for @ least 1m, person experiences 1 or more non-bizarre delusions (are plausible &usually derived from everyday 'misinterpreted' experiences). person has never met criteria for schizophrenia. behavior not obviously odd or bizarre, functioning not markedly impaired; any impairment is directly related to delusion (eg. quit job as 'mafia hit men' are out to get him or her)
• 1. examples: persecutory, grandiose,jealous, erotomania, somatic
• 2. age of onset is usually in adulthood, typically middle age or older. persecutory type is most common and may have chronic course since people do not seek treatment.
• 3. development of delusional thinking usually proeeds as follows:
• person is increasingly socially isoloated> distrust of other develops>engages in selective perception of situations/events with decreased corrective feedback as is isolated> anxiety or anger is triggered by these misperceptions>leading person to develop "insight" as to causes for these feelings and identifies "real target" for his/her anxiety or anger > cognitive deterioration begins as person ruminates about delusional content and, in this particular context, can experience a break with reality.

• 1.schizophrenogenic mother
• 2. double bind communication
• 3. schismatic family
• 4. skewed family
• 5. pseudomutual family
• 6. scapegoat theory
• 7. high emotional expression

mother is cold and aloof one min and then overprotective and overconcerned the next, in order to satisfy her own emotional needs. child becomes confused and doesnt know what to expect from mother; identify development is affect and ability to acertain reality questioned

family members tell the child one thing and then implicitly contradict that message. child has no clear idea how to perceive situation as is receving two contrracdictory messages and cannot attend to both. ability to ascertain reality is reduced.

parents have severe and chronic marital discord and undermine one another in front of the child. triangulation is common- each parent tries to enlist the child as an ally against the other parent. may affect female child more severely than male

parents' marital relationship is totally unbalanced; one parent as all the power and usually the parent also has a serious mental disturbance. may affect male children more severely than female children

family appears to be the perfect "family" on the surface but in reality members are very inflexible, rigid in their roles and cannot adapt well to changes that occur in the environment and/or in family members

the child is blamed by the family for any family problems and is therefore given the "identified patient" role to play in the family. the greater the child's disturbance, the less likely other family members need to focus on and deal with their own issues and/or contributions to the child's disturbance

the child is frequently exposed to statements indicating dislike, resentment, disapproval, criticism, overprotection, or over-involvment. related to relapse rates as high as 48%