Schizophrenia 

delusions is what?

∙ Loss of contact with reality- delusions, hallucinations

∙ Disorganized patterns of thinking

∙ Gross interferences in functioning- less relationships, employment,  etc...

∙ Includes all dimensions of functioning- thoughts, behaviors, emotions,  motor functions, etc...

Common Misconceptions

∙ It’s not DID

o “Schizophrenia” means "split-mind", but is referring to split from reality

∙ Schizophrenics DO NOT tend to be violent towards themselves or  others

∙ Not all cases are chronic

Schizophrenia Symptoms- lots of heterogeneity among symptoms, broken  down into 3 groups: positive, negative, psychomotor 

1) Positive Symptoms- presence of something that is normally absent  (e.g., hallucination, delusions)

a. Delusions

b. Disorganization of thoughts + speech

c. Heightened perceptions + hallucinations

What is Schizophrenia?

d. Inappropriate affect 

Delusions: ideas believed wholeheartedly (no basis in fact) *degree of conviction varies

Types of delusions:

1) Delusions of persecution- someone is trying to harm you physically,  socially, etc...

a. "I don't trust my neighbor", "the CIA is tracking me"

b. *violence usually as self-defense against delusions

2) Delusions of reference- take some source of benign sound, sight,  etc...and think there is personal relevance when there is none  

a. ex: porch lights as a sign to run for president)

3) Delusions of grandeur- believing you are someone better than you  are (Jesus, celebrity, king, etc...)

4) Delusions of control- believing you are in control of some other  being, or that you are being controlled by others (behaviors,  actions, are not your own)

Disorganization of thought and speech

What are the Schizophrenia Symptoms?

1) Loose associations- ideas jump from one to another, thinly connected  thoughts, goes further and further from topic

2) Neologisms- made up words (ex: strategeries)

3) Perseveration- repetition of thoughts or statement, making same  mistakes on test even when they're wrong, coming back to same  themes in conversations, keep repeating same phraseWe also discuss several other topics like ecn 001a class notes

4) Clanging- word choice is governed by sounds, not by grammar or logic (certain syllables may sound good together, but make no sense)

Heightened perceptions and hallucinations- feeling that sensations are  being flooded

Hallucinations: perceptions that occur in the absence of external stimuli

1) Auditory (most common)- voices can be commentary, negative/hostile  voices, positive voices (more negative voices cause more destruction)

a. Some people may befriend their voices

b. Voices may interrupt thinking

c. Voices can talk to each other

d. Voices can be in line with your inner thoughts OR can be  completely disconnected from reality

*people may come up with delusional thoughts about why they  can hear voices (ex: "I'm hearing voices because the CIA implanted  a chip in my ear")

2) Visual- visions may seem very real, or could be blurry, a shadow 3) Tactile- electricity, something crawling on them, something biting them

4) Somatic- has to do with body; organs moving around, body is changing shape and size, belief that they have a parasite inside them ("have you experienced any change in your head shape?") If you want to learn more check out professor o cools

5) Olfactory (least common)- smelling things that aren't there (smells can  be pleasant or unpleasant)

Inappropriate affect- mismatch of emotion and context (laughing a funeral, crying during a comedy)

Negative Symptoms- something lacking from normal experiences

Ex: lack of affect/motivation, social withdrawal 

1) Poverty of speech (alogia)- people just don't say much more than 1  word responses Don't forget about the age old question of color coding notes key

a. Poverty in amount

b. Poverty of content (say lots of words, but not a lot of stuff that  means anything)

2) Blunted affect- absence of emotional expression, not responsive to  stimulus

3) Loss of volition (avolition)- apathy' lack of motivation (drained of  energy, reluctant to do things, or could be motivated and just doesn't  follow through on things)

4) Loss of pleasure- anhedonia

a. Anticipatory pleasure- looking forward to something

b. Consummatory pleasure- momentary pleasure during enjoyable  tasks

*schizophrenics lack anticipatory pleasure-->leads to  

unwillingness to do things due to lack of motivation

5) Social withdrawal- asociality; prefer to be left alone, no motivation for  interaction, fewer opportunities for social engagement as you continue  isolating yourself

*Consider: is social withdraw a primary negative symptom or a  secondary effect of  

paranoia (a positive symptom)?

3) Psychomotor Symptoms: disturbances in movement; seen in most  severe cases of shizophrenia

Catatonia: Abnormal movement due to disturbance of mental state/mental  illness

1. Catatonic stupor- completely unresponsive, unaware of external  environment

a. Treat: first give anti-psychotics then give anti-depressant (see if  catatonia is due to schizophrenia or depression)

2. Catatonic rigidity: stay in a position for hours on end, refuse to move

3. Catatonic posturing- "waxy flexibility", they will stay in whatever  position you move them in Don't forget about the age old question of ampathic

4. Catatonic excitement- hyper, moving in very animated ways, can't stay still

Course of Disorder

Usually emerges between late teens and mid-30’s

∙ Males- late adolescent-mid 20's (disorder is usually worse for males,  possibly because they get disorder earlier

∙ Females-20's to early 30's

*Can't diagnose reliably until later in life/ first psychotic episode Course varies, but generally 3 phases:

1. Prodromal phase- pre-illness period; have signs that might indicate  symptoms

a. Can last months to years, declines in functioning, star doing  fewer things, start withdrawing socially, presence of some  psychotic symptoms:

b. Brief intermittent psychotic symptom- comes and goes, doesn't  cause enough disruptions to be declared a full psychotic  

symptom

c. Attenuated positive symptom- lesser form of positive symptom  (ex: you THINK you hear a voice, but you're not sure; you THINK  people are out to get you, but you're not sure that's reasonable

d. *this phase may or may not lead to schizophrenia

e. *if signs are there, you can start early treatment to try  preventing schizophrenia

i. (Only successful 30% of the time currently)

2. Active phase- have first psychotic episode; actively psychotic, lots of  symptoms impairing function

a. relapse, recurring active phases can occur We also discuss several other topics like microbiology quiz 2

3. Residual phase- return back to level of functioning at prodromal  phase

Recovery- no symptoms; where we want patients to reach

Rule of quarters- outcomes of schizophrenia varies

∙ 25% people: Prodromal-->active-->residual-->recovery (never have a  psychotic episode again)

∙ 25% people: Prodromal-->active-->residual-->recovery (ONLY if they  stay on treatment)

∙ 25% people: Prodromal-->active-->residual-->active-->residual (switch back and forth but don't reach recovery)

∙ 25% people: Prodromal-->active (never fully reach residual and  recovery phase' these individuals stay in mental institutions, live with  others who can take care of them)

Diagnostic Criteria for Schizophrenia 

At least 2 within 1 month; at least one must be 1, 2, or 3:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior We also discuss several other topics like Q: What’s more important, civil liberties or civil rights?

5. Negative symptoms

6. Dysfunction -work, interpersonal relations, self-care are markedly  diminished (usually in all categories)

7. Duration – continuous signs of disturbance for at least 6 months, can  include prodromal or residual periods

Ex: Prodromal for 5 months, then 1 month of delusions--> qualify for  schizophrenia

*1-5 are part of Criterion A symptoms (delusions, hallucinations  disorganized speech, disorganized/catatonic behavior, negative  symptoms)

Associated Features

∙ Dysphoric mood-possible comorbitity with mood disorders (ex:  depression)

∙ Disturbance in sleeping and eating patterns- as a result of positive  symptoms or just happens due to chemical imbalances

∙ Inability to concentrate- cognitive remediation done to help improve  mental functioning needed to do day-to-day tasks

∙ Lack of insight- lack awareness of your illness (insight varies among  patients)

o Better insightbetter adherence to treatment

Type I vs. Type II Schizophrenia

Type 1

Type 2

Positive symptoms

delusions/hallucinations

Negative symptoms- blunted/flat  affect, social withdrawal

Relatively good premorbid

adjustment (do well before getting  symptoms)

Relatively poor premorbid adjustment

Good response to antipsychotic drugs

Poor response to antipsychotic drugs

Fair outcome of disorder

Poor outcome of disorder

Abnormal NT activity

Abnormal brain structures

Schizophrenia: Etiology

Diathesis-Stress Model- predisposition makes you vulnerable, environmental  stress kickstarts disorder

Schizophrenia is due to:

∙ genetically inherited diathesis (biological predisposition)

∙ environmental stress (certain kinds of psychological events, personal  stress, or societal expectations)

Etiology: Biological stats (% chance of getting schizophrenia) General population-1%

If you're spouse has schizophrenia- 2%

Grandchildren-5%

Children- 13%

Dizygotic twins- 17%

Monozygotic twins- 48% (proof that environment still plays a role) Etiology: Biological (genetics)

Family studies 

The more closely one is related to individual with Sz, the more likely one is to  develop disorder

Twin studies 

Concordance rate for MZ twins: ~46%

Concordance rate for DZ twins: 17%

Adoption studies 

Children of Sz parent who were adopted developed disorder at same rate as children of Sz parent who remained with biological parent

PASSOVER EDITION BONUS!!!

Etiology: Biological (NTs)

Dopamine Hypothesis 

∙ Schizophrenia is connected to excess dopamine activity

∙ Stems from research on phenothiazenes, a class of antipsychotic  drugs that block

∙ the brain’s receptor sites for dopamine

Proof: work pretty well for some individuals-->means dopamine must cause  problems

1. Potency of medication is proportional to amount of dopamine they  block

2. L-dopa- dopamine medicine-->worsens psychotic symptoms

3. Helps with Parkinson's, if schizophrenics are given too  

muchphenothiazenes, they start developing Parkinson's symptoms 4. Amphetamines (dopamine releasers) cause psychotic symptoms

Criticism: too much dopamine, over-sensitive receptors, too many  receptors? Not sure...

1. Medication we give starts blocking dopamine immediately, but it takes  weeks for symptoms to get better (might need meds to start  treatment, but there must be something else going on)

2. Don't see excess dopamine metabolites in CSF when looking for excess dopamine in schizophrenics

3. Evidence points toward serotonin as another contributor

a. LSD- inc serotonin-->hallucinations (hmmm, schizophrenia also  causes hallucinations)

4. Serotonin can also be used for treatment

5. Emerging evidence for glutamate being involved

Etiology: Brain structure

∙ Increased ventricular size 

∙ Smaller frontal cortex (executive functions)

∙ Smaller temporal lobes (memory, auditory perception, emotion,  language)

∙ Smaller amygdala (emotion)

Changes could be related to prenatal brain injury

BUT

There also seems to be a deterioration of brain matter over time for  schizophrenics

(possible association with anti-psychotics, are we speeding up the process?)

Winter/spring hypothesis 

∙ Winter/spring months seem to have higher risks of schizophrenia (.1%  increased chance)

∙ Summer months are least affected

Theory: Increased maternal exposure to viruses during 2nd trimester in fall  could affect fetus

Etiology: Brain Function (structure + function do not always have  correlation)

∙ Hypofrontality- decreased blood flow to prefrontal cortex (impaired  judgement, exec. functioning)

∙ Impaired temporal cortex function

o Healthy control- more activation in temporal lobe, amygdala,  and show higher levels of performance

Etiology: Sociocultural 

Social labeling- once you become labeled, it's hard to get out of that role, act  crazy because it's expected

Family dysfunction 

1. Schizophrenogenic families- cold and dominant, conflict-inducing  parent leads to schizophrenic child

2. Expressed emotion: Hostility, criticism, emotional over-involvement

a. Rates of schizophrenia are 4x higher in families of high  expressed emotions

3. Bi-directional interactions- schizophrenic patient becomes  hostile/critical towards family-->family becomes more hostile/critical-- >back and forth amplification worsens problems

Etiology: Neurodevelopmental

Weinberger’s model- before, schizophrenia was thought of as an adult  disease, but Weinberger thought it was a developmental disorder

∙ Early problems with motor skills- abnormal movements (short, jerky  movements)

∙ IQ- lower IQ scores early in life (but this is also true for other disorders  too)

∙ Obstetric complications- complications during birth (low birth weight,  cord around neck, blood pressure issues, abnormal head size, etc...)

Causal and Maintaining Factors

Social Factors

∙ Premorbid functioning- functioning before disorder, worse  functioning=worse symptoms of disorder

∙ Difficulties in social problem solving--> harder to get jobs, maintain  relationships

∙ Poor social skills- needed for day to day relations

∙ Poor social cognition- attentions and memory relating to social things  (bad at understanding what others mean, hard time remembering  people)

∙ Social networks- only interact with others diagnosed with schizophrenia (may narrow down their scope of reality if they are in a mental hospital surrounded by others mentally ill) BUT interactions can also be positive and supportive

Environmental Factors

∙ EE

∙ Life Events- stressors (finances, crime, loneliness, concerns about not  being able to achieve goals)

∙ Social Class- usually lower SEC, urbanicity (living in inner cities) ∙ Season of birth- exposure to viruses during fetal development

Treatment: Medication

Typical: blocks the dopamine (D2) receptor

∙ Side effects – extrapyramidal symptoms (motor control much like  Parkinson's)

o Tardive dyskinesia- uncontrollable movements

Atypical- newer generation (1980s)

Blocks D2 receptors AND serotonin (5-HT2) receptor

∙ Fewer motor side effects BUT no difference in effectiveness, and there  are still other side effects (rapid weight gain, dry mouth, etc...)

*Treatments are usually biological

Treatment: CBT

Why adjunctive treatments?- complementary treatments that help alongside  meds

∙ Medications have little effect on negative symptoms

o 25 to 50% still experience residual symptoms

o 45 to 60% are noncompliant with medication

Techniques:

∙ Psychoeducation and medication compliance

∙ Strong focus on monitoring and coping- monitor symptoms (when  are they the worse?) and find ways to cope with them (ex: if patient  doesn’t hear voices when listening to music, encourage them to listen  to music to manage symptoms)  

∙ Basically help patient find way to relieve symptoms themselves ∙ Use behavioral experiments- challenge/test delusional beliefs

∙ Use role-plays- help patients develop practical + social skills through  fake scenarios (pretending to interview them for a job, helping them  balance checkbooks, etc…)

∙ fCBT- focus on how symptoms interfere with achieving goals, not  symptom reduction

o don’t reduce symptoms

o only try to reduce their impact on your life

Efficacy- general pretty effective; typically start patients with biological  treatments first, then supplement with CBT

Treatment: Psychosocial

∙ Insight therapy – therapist challenges patients statements,  expresses opinions, and provides guidance

o About trying to understand illness + difficulties it produces

∙ Family therapy – therapist offers guidance, training, practical advice,  psychoeducation about disorder, and emotional support and empathy

o Educate family on schizophrenia (cognitive problems, symptoms, sings of relapse)

o Give information on medications

o Provide coping skills, reduce blame and avoidance

o Teach healthy communication skills, how to address  

conflicts/feelings

o Encourage expansion of social network (find bigger support  system)

∙ Social therapy – therapist offers practical advice and tries to improve  individual’s problem solving, decision making, and social skills—about  practical skills

o Usually done by social workers, people who have access to the  right sources

o Help patients find employment, housing, etc…

Schizophreniform Disorder- shorter period of symptoms than  schizophrenia

At least 2, during a 1 month period: criterion A symptoms

1. Delusions

2. Hallucination

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

∙ Duration of more than 1 month but less than 6 months and then  they recover

Specifier:  

Provisional- symptoms are ongoing, not at 6 month mark yet BUT could reach 6 months and become schizophrenia

Good prognostic indicators

∙ Good premorbid functions

∙ Absence of blunted/flat affect

∙ Rapid onset of symptoms (within 4 weeks, not a long period of  deterioration)

∙ Confusion during psychotic episode (person knows there is something  wrong)

*1/3 of people diagnosed will recover and not receive any further diagnosis

Schizoaffective Disorder- mood episode is involved 

Uninterrupted period of illness in which there is a major mood  episode concurrent with Criterion A of schizophrenia

∙ Delusions or hallucinations for 2 or more weeks in the absence of  major mood episodes (psychotic episodes in the absence of mood  episodes)

∙ Mood symptoms are present for at least 50% of the total duration of  the illness  

o If not, could classify as schizophrenia and comorbitity with a  mood disorder 

*NOT mood disorder with psychotic features:

∙ Psychosis ONLY happens during mood episodes

Reminder:

2 weeks for depressive episode diagnosis

1 week for manic episode diagnosis

More common in women, than men

Specifiers:

Bipolar subtype

Depressive subtype

Brief Psychotic Disorder 

Presence of one or more of the following:

∙ Delusions 

∙ Hallucinations

∙ Disorganized speech

∙ Grossly disorganized or catatonic behavior

∙ Duration is more than 1 day but less than 1 month

Tend to have full recovery

Sudden onset, usually due to significant stressor

Specifiers:

∙ With a mark stressor (disorder was triggered by stressor) ∙ Without a mark stressor  

∙ With postpartum onset (within 4 weeks)

Timeframe: If longer than a month + pick up more symptoms-- >schizophreniform-->continues for up to 6 months-->schizophrenia

Delusional Disorder- ONLY SHOW DELUSION SYMPTOMS Presence of one or more delusions with a duration of 1 month or longer ∙ Has never met criteria for schizophrenia

∙ Apart from delusions, functioning is not impaired and behavior not odd  or bizarre

*Usually return to normal functioning afterwards

Prevalence- .2% population

∙ 55% female

∙ 45% male

Possible causes:

∙ Hearing loss

∙ Early dementia

Types of Delusions (no actual evidence)

Specifiers:

Erotomanic- idea that person of higher status is in love with them (idealized  romantic delusions)

Grandiose

Jealous- ex: think someone's cheating on you

Persecutory

Somatic

Other Specified Schizophrenia Spectrum and Other Psychotic  Disorder (OSSSOPD)

Psychotic symptoms that exist independently without other symptoms Specifiers:

∙ Persistent auditory hallucinations

∙ Delusions with significant overlapping mood episodes- cross between  delusional disorder and schizoaffective disorder without any  other symptoms

o Have 2 weeks of delusions independent of moods

o Have moods for at least 50% of delusions

∙ Attenuated psychosis syndrome- positive symptoms but to a lesser  degree (diagnosis given to someone in prodromal period)

∙ Delusional symptoms in partner in individual with delusional disorder most likely for mother/daughter pairs, usually when daughter is of  lower intellectual functioning

o Daughter hears about delusions from mother-->develops those  delusions as well

Others…

Psychotic Disorder Due to a General Medical Condition Ex: Tumors, epilepsy, infections, stroke

Substance-Induced Psychotic Disorder 

Substance effects mimic psychosis

Ex: Amphetamines, cocaine, marijuana cause paranoia; LSD causes  hallucinations

∙ Diagnosed if you continue having symptoms after drug effects wear off

∙ If symptoms persist after a month, now consider other psychotic  disorders

∙ If extreme symptoms show up during use of substance, also consider  an underlying psychotic problem

Disorders of Childhood

Disruptive Disorders 

ADHD, ODD, CD

Emotional Disorders

Depression, separation anxiety, other anxiety disorders

Neurodevelopmental Disorders

Autism spectrum disorder, intellectual disability, specific learning disorder

Autism Spectrum Disorder 

A Brief History

1943: Leo Kanner’s “Autistic Disturbances of Affective Contact”

– “fundamental disorder is the children’s inability to relate  themselves in the ordinary way to people and situations from  the beginning of life”

1944: Hans Asperger “Autistic Psychopathy in Childhood”

– “little professors”

– “severe and characteristic difficulties of social integration”

* Both focus in on social difficulties, not showing a normal way of relating to  the world

Autism as a Diagnosis (coined in 1911)

USED TO BE USED TO DESCRIBE SCHIZOPHRENIA

“Autism” coined to characterize the “relative and absolute predominance of  the inner life” observed in patients with schizophrenia (Bleuler, 1911)

DSM I (1952) and DSM II (1968) only list “childhood schizophrenia”, with  autism as a characteristic

1980- Autism, as a distinct disorder (DSM lll)

– Research during the 1970s key for differentiating autism and  schizophrenia

1. Developmental timelines very different (schizophrenia won't show  until late teens-30s)

2. SCZ and autism do not co-occur in families (risk for one doesn’t  affect risk for other)

DSM-5 Diagnostic Criterion

• One unified label: Autism Spectrum Disorder 

Include Asperger Syndrome, PDD-NOS, and Childhood Disintegrative  Disorder

Criteria:

Persistent deficits in social communication and social interaction across  multiple contexts (need all symptoms):

1. Marked deficits in nonverbal and verbal communication used for social  interaction

a. Reduced eye-to-eye gaze, gesturing, facial expressivity

2. Lack of social-emotional reciprocity (no response to what other person  says, no back and forth)

a. Abnormal social approach and initiation; reduced sharing b. Hard to understand the context of the situation

c. Failure to develop, maintain, and understand relationships

3. Difficulty making friends; reduced interest in people; inability to adjust  behavior to different social contexts

Restricted, repetitive patterns of behavior, interests, or activities (at least 2): 1. Stereotyped or repetitive motor or verbal behaviors

a. Motor stereotypies; echolalia (repeating things they hear);  repetitive use of objects

b. Stemming- repetitive motor movements (like clapping)

2. Excessive adherence to routines or insistence on sameness a. Ritualized behavior; distress to small changes

3. Restricted fixated interests

a. Abnormal in intensity and focus

4. Unusual sensory behaviors

a. Adverse reaction to specific sounds or textures; indifference  to pain/heat/cold; fascination with lights or spinning objects

Symptoms must be present in early childhood

Symptoms together limit and impair everyday functioning (if these symptoms work for their lives, no diagnosis necessary)

Autism Today: Basic Characteristics

Affects all ethnic and socioeconomic groups

Three to four times more prevalent in males 

Theory: autism as an extreme expression of the male brain Familial transmission (10 times greater risk in family)

Soaring Prevalence Rate:

o 1975- 1 in 5000

o 2009- 1 in 110 (1 in 70 for boys, 1 in 375 girls)

o 2012- 1 in 88

o Currently: 1 in 68

Explaining the Increase

Autism has always been there

The expanding definition of autism- spectrum is now very wide Better diagnosis at both ends

o Differentiation at the lower end

o Identification at the higher end (now that we include a greater range of functioning)

Increased awareness by practitioners and families

o Now checking for early signs of autism, families are now more  aware of signs of autism-->more screenings

Social factors:  

Parental age- higher age of parents, esp father increase likelihood

Assortative mating- like-minded people get together and reproduce (ex:  people who are work in specific field are more likely to have autism-->get  together and have children with increased likelihood of autism)

Broad autism phenotypes- traits of autism are prevalent through all  populations, some just have more than others (ex: social awkwardness,  aloofness)

o Two people who have these traits have a higher likelihood of having an autistic child

• Other yet unexplained contributors?

– No empirical support for infant vaccines as a cause – Cannot yet rule out other environmental factors

Cognition/IQ

Between 40-60% have intellectual disability (IQ below 70)

Impaired intelligence

Memory- difficulty with people working memory, good long-term memory Weak central coherence- focus on detail instead of holistic thing *Central coherence- understanding how things come together Savant skills- an outlier

Childhood disorders

ADHD- hyperactivity/impulsivity (fidgeting, running, restlessness, incessant  talking), abnormal inattention (forgetfulness, easily distracted, careless  mistakes)

Result in: poor social skills, aggressive

behavior, and overestimation of one’s social abilities

Conduct Disorder- Repetitive, persistent behavior pattern that violates basic rights of others or conventional social norms (aggression towards  others, destruction of property, theft, conning, serious violation of rules)

Oppositional Defiant Disorder

*ODD is diagnosed if a child does not meet the criteria for conduct disorder May not have extreme physical aggressiveness, but exhibits behaviors like: Losing temper, arguing, refusing to comply, and being  

spiteful/touchy/vindictive

Depression

Same symptoms as adults EXCEPT:

Children show more guilt but lower rates of early-morning wakefulness, early morning depression, loss of appetite, and weight loss

Separation Anxiety Disorder

Excessive anxiety about being away from home/parents, worry that  something bad will happen to parents, nightmares about separation, physical  symptoms (headaches, pains)

Other anxiety disorders

Social anxiety disorder- extreme shyness; children will play only with family  members or familiar peers, avoiding strangers both young and old Avoidance prevents them from enjoying activities (playgrounds, games with  other children)

*Selective mutism- won’t speak in unfamiliar social environments

Intellectual disability

Intellectual deficit of 2 or more standard deviations in IQ below average (<70) Deficits in communication, social participation, work or school, independence  at home/community; need support of others to function

*takes culture into consideration

Learning disability

Difficulties in learning basic academic skills

∙ Dyscalculia: math

∙ Dyslexia: reading

*Not consistent with age, intelligence, deficits in educational opportunities