Chapter 12 Schizophrenia and Other Psychotic Disorders PSY 440: Abnormal Psychology Rick Grieve Western Kentucky University

Špsychotic disorders – disorders so severe that the person has essentially lost touch with reality

Šschizophrenia (a psychotic disorder) is characterized by the disruption of: • normal perceptual and thought process • personality • affect

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Nature of Schizophrenia and Psychosis: An Overview Š Schizophrenia vs. Psychosis „

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Psychosis – Broad term referring to hallucinations and/or delusions; noted in several disorders S hi Schizophrenia h i – A type off psychosis h i with i h di disturbed b d thought, language, and behavior

Š Historical Background „

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Emil Kraeplin – Used the term dementia praecox, “loss of the inner unity of thought, feeling , and acting”. Eugen Bleuler – Introduced the term “schizophrenia” or “splitting of the mind”; the 4 As: z

Associations, Affect, Ambivalence, Autism

Nature of Schizophrenia and Psychosis: An Overview cont.) Š Schneider – first rank vs. second rank symptoms Š Contemporary practice – „

Complex syndrome – heterogeneous z Identified

by clusters of symptoms subtypes z Separate diagnoses that “look like” or share some of the same symptoms as schizophrenia – but are separate psychotic disorders z Several

Schizophrenia: The “Positive” Symptom Cluster Š The Positive Symptoms-Active manifestations of abnormal behavior, distortions of normal behavior ŠD Delusions: l i G Gross misrepresentations i t ti off reality lit „ „ „ „ „ „

Persecution – “out to get me” Reference – “talking about me” Being controlled – “aliens make my body move” Grandeur – “I invented rock and roll” Truman Show delusion – “I am the star of a reality TV show.” Capgras delusion – “my loved one has been replaced by a double.”

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Schizophrenia: The “Positive” Symptom Cluster Š Delusions typically have a “bizarre” quality – implausible, not understandable, not based on ordinary life experiences

Š Hallucinations: Experience of sensory events without environmental input; type of perceptual disturbance „ Can involve all senses; auditory most common 70% „ Not unique to schizophrenia „ Typically hear voices

Schizophrenia: The “Negative” Symptom Cluster Š The Negative Symptoms -Absence or insufficiency of

normal behavior „ Examples are emotional/social withdrawal, apathy, and poverty p y of thought/speech g p

Š Spectrum of Negative Symptoms „

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Avolition (or apathy) – Refers to the inability to initiate and persist in activities Alogia – Refers to the relative absence of speech Anhedonia – Lack of pleasure, or indifference to pleasurable activities Affective flattening – Show little expressed emotion, but may still feel emotion

Schizophrenia: The “Negative” Symptom Cluster Š Other Negative Symptoms: „

Cognitive deficits

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Social Withdrawal

z

Primacyy of impaired p cognition g

Š Negative symptoms more debilitating than positive symptoms

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Schizophrenia: The “Disorganized” Symptom Cluster Š The Disorganized Symptoms-Include severe and excess

disruptions in speech, behavior, and emotion „ Examples include rambling speech, erratic behavior, and inappropriate affect

Š Disorganized Speech „

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Cognitive slippage – Refers to illogical and incoherent speech Tangentiality – “Going off on a tangent” and not answering a question directly Loose associations or derailment – Taking conversation in unrelated directions

Disorganized Symptoms Š Thought disorders can lead to the formation of: „ „ „

Clang Associations Cl A i i Perseveration Word Salad

Schizophrenia: “Disorganized” Symptom Cluster Š Nature of Disorganized Affect „

Inappropriate emotional behavior (e.g., crying i when h one should h ld b be llaughing) hi )

Š Nature of Disorganized Behavior -

includes a variety of unusual behaviors „ Catatonia – Spectrum from wild agitation, waxy flexibility, to complete immobility „ Difficulties performing activities of daily living

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More Disorganized Symptoms „ „

Attentional Deficits Social Problems

Š DSM Diagnosis: „ „ „ „ „

Characteristic symptoms Social/Educational/Occupational dysfunction Duration Differential Diagnoses Relationship with PDD

Subtypes of Schizophrenia Š Paranoid Type „

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Intact cognitive skills and affect, and do not show disorganized behavior Hallucinations ((auditory) y) and delusions center around a theme (grandeur or persecution) The best prognosis of all types of schizophrenia

Subtypes of Schizophrenia Š Disorganized Type „

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Marked disruptions in speech and behavior, flat or inappropriate affect Hallucinations and delusions have a theme, but tend to be fragmented This type develops early, tends to be chronic, lacks periods of remissions

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Subtypes of Schizophrenia Š Catatonic Type „

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Show unusual motor responses and odd mannerisms (e.g., echolalia, echopraxia) This subtype tends to be severe and quite rare

Waxy Catatonia

Subtypes of Schizophrenia Š Undifferentiated Type „ „

Wastebasket category Major j symptoms y p of schizophrenia, p , but fail to meet criteria for another type

Š Residual Type „ „

One past episode of schizophrenia Continue to display less extreme residual symptoms (e.g., odd beliefs)

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Other Disorders with Psychotic Features Š Schizophreniform Disorder Schizophrenic symptoms for a few months „ Associated with good premorbid functioning; most resume normal lives „

Š Schizoaffective Disorder „

Symptoms of both schizophrenia and a mood disorder

Other Disorders with Psychotic Features (cont.) Š Delusional Disorder „

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Delusions that are contrary to reality without other th major j schizophrenia hi h i symptoms t Many show other negative symptoms of schizophrenia Type of delusions include erotomanic, grandiose, jealous, persecutory, and somatic This condition is extremely rare, with a better prognosis than schizophrenia

Additional Disorders with Psychotic Features Š Brief Psychotic Disorder „

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Experience one or more: delusions, hallucination, disorganized speech or grossly disorganize or catatonic behavior - positive symptoms of schizophrenia Usually precipitated by extreme stress or trauma Tends to remit on its owns

Š Schizotypal Personality Disorder „

May reflect a less severe form of schizophrenia

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Schizophrenia in Childhood Š Very rare Š Uses the same criteria as adults Š High incidence rate of trauma

Schizophrenia: Facts and Statistics Š Onset and Prevalence of Schizophrenia „ „

About 1% population Onset in earlyy adulthood,, but can emerge g at anyy time

Š Schizophrenia Is Generally Chronic „

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Most suffer with lifelong moderate-to-severe impairment Life expectancy is slightly less than average

Figure 13.2 Gender differences in onset of schizophrenia in a sample of 470 patients

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Schizophrenia: Facts and Statistics Š Schizophrenia – Gender Differences „ „

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Females tend to have a better long-term prognosis Onset –males 18-25 yyears;; females – 25-35 yyears & after 40 Men more negative symptoms; women more affective, positive

Š Strong Genetic Component

Causes: Findings From Genetic Research Š Family Studies „

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Inherit a tendency for schizophrenia, not a specific form of schizophrenia Other family members are at increased risk

Š Twin Studies „ „

Risk of schizophrenia in monozygotic twins is 48% Risk of schizophrenia drops to 17% for fraternal (dizygotic) twins

Š Adoption Studies „

Risk of schizophrenia remains high in adopted children with a biological parent suffering from schizophrenia

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Figure 13.6 Risk for schizophrenia among children of twins

Causes:Findings From Genetic Research Š Summary of Genetic Research Risk of schizophrenia increases as a function of genetic relatedness „ One need not show symptoms of schizophrenia to pass on relevant genes „ Schizophrenia has a strong genetic component, but genes alone are not enough „

Genetic & Behavioral Markers of Schizophrenia Š The Search for Genetic Markers: Linkage and Association Studies „ „

Search ffor genetic S i markers iis still i inconclusive i i Schizophrenia is likely to involve multiple genes

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Causes of Schizophrenia: Neurotransmitter Influences Š Neurobiology and Neurochemistry: The Dopamine Hypothesis „

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Drugs that increase dopamine (agonists), result in schizophrenic-like behavior Drugs that decrease dopamine (antagonists), reduce schizophrenic-like behavior Examples include neuroleptics and L-Dopa for Parkinson’s disease The dopamine hypothesis proved problematic and overly simplistic Current theories emphasize several neurotransmitters and their interaction

Causes: Other Neurobiological Influences Š Glutamate hypothesis Š Structural and Functional Abnormalities in the Brain „ „

Enlarged ventricles and reduced tissue volume Hypofrontality – Less active frontal lobes (a major dopamine pathway)

Š Viral Infections During Early Prenatal Development „

The relation between early viral exposure and schizophrenia is inconclusive

Causes: Other Neurobiological Influences Š Conclusions About Neurobiology and Schizophrenia „

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Schizophrenia is associated with diffuse Neurobiological Dysregulation Structural and functional abnormalities in the brain are not unique to Schizophrenia

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Causes of Schizophrenia Š The Role of Stress „

May activate underlying vulnerability and/or i increase risk i k off relapse l

Causes of Schizophrenia Š Family Interactions „

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Families of people with schizophrenia show ineffective patterns – communication deviance communication p High expressed emotion in the family is associated with relapse

Š The Role of Psychological Factors „

Psychological factors likely exert only a minimal effect in producing schizophrenia

CAUSES OF SCHIZOPHRENIA ŠENVIRONMENTAL CONTRIBUTIONS

sociocultural i lt l variables i bl • downward drift hypothesis – theory that lower social class is a result, rather than a cause, of schizophrenia

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SCHIZOPHRENIA AND SOCIAL CLASS 60 50 40 Proportion 30 20 10 0

Upper

Middle

Lower

Social Class General Population

Patients

Fathers

Brothers

Source : After E. M. Goldberg and S. Linda. Morrison, “Schizophrenia and Social Class.” British Journal of Psychiatry, 109 (1963); 785-802.

CLINICAL COURSE Šclinical course – specific pattern of changes in symptomatology t t l over time ti „

prodromal phase

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active phase

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residual phase

TYPICAL COURSES FOR SCHIZOPHRENIA

(A) CHRONIC GRADUAL ONSET & VERY POOR PROGNOSIS

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TYPICAL COURSES FOR SCHIZOPHRENIA

(B) EPISODIC OCCASIONAL EPISODES WITH NEARLY NORMAL FUNCTIONING BETWEEN THEM

TYPICAL COURSES FOR SCHIZOPHRENIA

(C) SINGLE EPISODE BRIEF PERIOD OF PSYCHOSIS & NEARLY COMPLETE RECOVERY WITH NO OTHER EPISODES

Treatments Š Neuroleptic drugs are begun first – stabilizes and reduces symptoms Š Psychosocial treatments come next „ „ „

Prevent relapse Compensate for skills deficits Improve medication compliance

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Pharmacological Interventions Š Antipsychotic (Neuroleptic) Medications „

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Medication treatment is often the first line treatment for schizophrenia Began in the 1950s Most reduce or eliminate the positive symptoms of schizophrenia Acute and permanent extrapyramidal and Parkinson-like side effects are common Compliance with medication is often a problem Many people continue to experience symptoms, even with meds

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Pharmacological Interventions Š CATIE

Psychosocial Treatment of Schizophrenia Š Psychosocial Approaches: Overview and Goals „ „ „ „ „

Behavioral (i.e., token economies) on inpatient units Communityy care p programs g Social and living skills training Behavioral family therapy Vocational rehabilitation

Š Psychosocial Approaches Are Usually a Necessary Part of Medication Therapy Š CBT

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TREATING SCHIZOPHRENIA ŠHOSPITALIZATION AND BEYOND

protecting the individual and others stabilizing the individual rehabilitating the individual

References Š American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (Fourth Ed.). Washington, D. C.: Author. Š Chambless, D. L., Bryan, A. D., Aiken, L. S., Steketee, G., & Hooley, J. M. (1999). The structure of expressed emotion: A three-construct representation. Psychological Assessment, 11, 67-76. Š Durand, V. M., & Barlow, D. H. (2006). Essentials of abnormal psychology (4th Edition). Pacific Grove, CA: Wadsworth. Š Gaudiano, B. A. (2005). Cognitive behavior therapis for psychotic disorders: Current empirical status and future directions. Clinical Psychology: Research and Practice, 12, 33-50. Š Heinrichs, R. W. (2005). The primacy of cognition in schizophrenia. American Psychologist, 60, 229-242.

References Š Š Š

Š Š Š

Morrison, J. (1995). The first interview: Revised for DSM-IV. New York: The Guilford Press. Kersting, K. (2005). Serious rehabilitation: Psychologist-developed treatments are providing hope for people with serious mental illness. APA Monitor on Psychology, 36 (1), 38-41. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. R., Hughes, M., Eshleman, S., Wittchen, H. U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-IIIR psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8-19. McKinney, R., & Fiedler, S. (2004). Schizophrenia: Some recent advances and implications for behavioral intervention. the Behavior Therapist, 6, 122-125. Nairne, J. S. (1999). Psychology: The adaptive mind (2nd Ed.). Albany, NY: Brooks/Cole Publishing Company. Nichols, O. T. (2005, November). Headlines in psychopharmacology. Symposium presented at the annual meeting of the Kentucky Psychological Association, Louisville, KY.

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