Chapter Eleven

1. Chapter Eleven Schizophrenia and Other Psychotic Disorders

2. In Class Exercise • https://www.youtube.com/watch?v=afbKXWCQMvE • Take out a piece of paper and write your to do list for this week.

3. The Symptoms of Schizophrenia • Schizophrenia: • A group of disorders characterized by severely impaired cognitive processes, personality disintegration, mood disturbances, and social withdrawal • Psychosis: condition involving loss of contact with or distorted view of reality • Lifetime prevalence: 1% of U.S. population

4. Positive Symptoms • Delusions: • False beliefs that are firmly and consistently held despite disconfirming evidence or logic • Individuals are unable to distinguish between private thoughts and external reality • Most individuals are either unaware or only moderately aware of the illogical nature of hallucinations or delusions • Poor insight

5. Positive Symptoms (cont’d.) Figure 11-1 Awareness of Psychotic Symptoms in Individuals with Schizophrenia Most individuals with schizophrenia are unaware or only modestly aware that they have symptoms of the disorder. The symptoms they are most unaware of include delusion, disordered thinking and blunt affect. Source: Amador (2003). Used by permission of Dr. Xavier Amador.

6. Positive Symptoms (cont’d.) • Delusional themes: • Delusions of grandeur • Delusions of control • Delusions of thought broadcasting • Delusions of persecution • Delusions of reference • Delusions of thought withdrawal • Most common delusion involves paranoid ideation

7. Positive Symptoms (cont’d.) • Hallucinations: • Sensory perceptions not directly attributable to environmental stimuli: • Auditory (hearing) • Visual (seeing) • Olfactory (smelling) • Tactile (feelings) • Gustatory (tasting)

8. Positive Symptoms (cont’d.) • Auditory hallucinations are most common and can range from malevolent to benevolent • Greatest distress: • When voices are dominant and insulting, and individual lacks communication with the voices • Auditory hallucinations appear to be real to the individual

9. Positive Symptoms (cont’d.) • Disorganized thought and speech: • Common characteristic of schizophrenia • Loosening of associations (cognitive slippage) • Continual shifting from topic to topic without any apparent logical or meaningful connection between thoughts • Incoherent speech or bizarre, idiosyncratic responses

10. Positive Symptoms (cont’d.) • Grossly abnormal psychomotor behavior: • Extremes in activity levels • Catatonia: characterized by marked disturbances in motor activity • Excited catatonia • Withdrawn catatonia • Peculiar body movements or postures • Strange gestures or grimaces • Combination

11. Negative Symptoms • Associated with inability or decreased ability to initiate actions or speech, express emotions, or feel pleasure • Avolition: inability to take action or focus on goals • Alogia: lack of meaningful speech • Asociality: minimal interest in social relationships • Restricted affect: severe or limited emotionality in situations in which emotional reactions are expected

12. Cognitive Symptoms • Associated with problems with attention, memory, and difficulty in developing a plan of action • Moderately severe to severe impairments • Poor executive functioning • Inability to sustain attention • Difficulty retaining and using recently learned information

13. Video • http://www.ted.com/talks/eleanor_longden_the_voices_in_my_head

14. Other Psychotic Disorders • Involve psychotic symptoms, but do not meet the diagnosis for schizophrenia • Include: • Brief psychotic disorder • Schizophreniform disorder • Delusional disorder • Schizoaffective disorder • Attenuated psychosis syndrome • Other specified psychotic disorder

15. Brief Psychotic Disorder and Schizophreniform Disorder • Brief psychotic disorder: • Psychotic episodes that last at least one day but less than one month • Can be caused by psychological trauma • Relatively uncommon • Schizophreniform disorder: • Psychotic episodes that last at least one month but less than six months • Shares anatomical and neural deficits of schizophrenia

16. Brief Psychotic Disorder and Schizophreniform Disorder (cont’d.) • Neither require impairment in social or occupational functioning • Diagnoses are often considered provisional diagnoses • Initial diagnoses based on currently available information

17. Brief Psychotic Disorder and Schizophreniform Disorder (cont’d.)

18. Delusional Disorder • Persistent, nonbizarre delusions without other odd behaviors • Common themes: • Erotomania • Grandiosity • Jealousy • Persecution • Somatic complaints

19. Schizoaffective Disorder • Existence of both symptoms of schizophrenia and major depressive or manic symptoms • Diagnosis is difficult as individual may have two separate mental disorders • Relatively rare

20. Psychotic Disorder Not Elsewhere Classified • Psychotic symptoms that are not significant enough to meet criteria for specific psychotic disorder • Postpartum psychosis without a mood component • Persistent auditory hallucination without other symptoms • Nonbizarre hallucinations with mood symptoms • Psychotic symptoms of unknown etiology

21. The Course of Schizophrenia • Prodromal phase: • Onset and buildup of symptoms: • Social withdrawal and isolation • Peculiar behavior and inappropriate affect • Poor communication patterns • Neglect of personal grooming • Active phase: • Full-blown symptoms: • Severe disturbances in thinking • Deterioration in social relationships • Restricted or inappropriate affect

22. The Course of Schizophrenia (cont’d.) • Residual phase: • Symptoms no longer prominent • Symptom severity declines and individual shows mild impairment • Complete recovery is rare, but schizophrenics can lead productive lives

23. The Course of Schizophrenia (cont’d.) Figure 11-3 Varying Outcomes with Schizophrenia This figure shows five of the many outcomes possible with schizophrenia in individuals during a 15-year follow-up study. Source: Wiersma et al., 1998.

24. Etiology of Schizophrenia Figure 11-4 Multipath Model of Schizophrenia The dimensions interact with one another and combine in different ways to result in schizophrenia.

25. Biological Dimension • Genetics and heredity play important role • Disorder is understood to result from as many as 20 genes and their interactions • Schizophrenia is found among close relatives of people diagnosed with disorder • 16% chance for close relatives (e.g. mother/son) • 4% chance for distant relatives (e.g. aunt/niece) • 1% for general population

26. Biological Dimension (cont’d.) Figure 11-6 Risk of Schizophrenia Among Blood Relatives of Individuals Diagnosed with Schizophrenia This figure reflects the estimate of the lifetime risk of developing schizophrenia- a risk that is strongly correlated with the degree of genetic influence. Source: Data from Gottesman (1978, 1991).

27. Biological Dimension (cont’d.) • Neurostructures: • Schizophrenics have smaller cortical volumes (also found in healthy individuals) and ventricular enlargement • Loss of brain cells in cortex over six-year period • Differences in brain structure between individuals with and without schizophrenia is relatively small • Abnormalities may result from antipsychotic medication

28. Biological Dimension (cont’d.) • Neurotransmitters: • Dopamine hypothesis: • Schizophrenia results from excess dopamine activity at certain synaptic sites • Support from research with three drugs: • Phenothiazines: block dopamine receptor sites • L-dopa: sometimes produces schizophrenic-like symptoms • Amphetamines: symptoms similar to acute paranoid schizophrenia in non-schizophrenics

29. Psychological Dimension • Use of cocaine, amphetamines, alcohol, and especially cannabis increase chances of developing psychotic disorder

30. Social Dimension • Family influence is controversial • Certain social conditions have influence: • Severe physical abuse from mothers prior to 12 years of age • Positive remarks and warmth expressed by caregivers improved symptoms • Maltreatment by adult or bullying • High-risk children are more sensitive to effects of adverse and healthy child-rearing practices

31. Social Dimension (cont’d.) Figure 11-7 Risk of Psychotic Symptoms at Age 11 Associated With Cumulative Childhood Trauma Youth exposed to both bullying and childhood maltreatment demonstrate a significantly increased risk of developing psychotic symptoms Source: Arsenault et al. (2011)

32. Social Dimension (cont’d.) • Expressed emotion (EE): • Negative communication pattern found among some relatives of individuals with schizophrenia; associated with higher relapse rates • Interpretations of findings: • High-EE environment may lead directly to relapse • Severely ill individual may cause high-EE patterns

33. Treatment of Schizophrenia • Antipsychotic medication: • Can reduce intensity of symptoms • Dosage levels must be monitored • Can produce side effects • Reduce severity of positive symptoms of schizophrenia (e.g., hallucinations and delusions) • Offer little relief for negative symptoms (e.g., social withdrawal, apathy, impaired personal hygiene)

34. Treatment of Schizophrenia (cont’d.) • Antipsychotic medication: • Extrapyramidal side effects include: • Parkinsonism (muscle tremors, shakiness) • Dystonia (slow, involuntary movement) • Akathesis (motor restlessness) • Neuroleptic malignant syndrome (muscle rigidity) • Metabolic syndrome: • Medical condition associated with obesity, diabetes, high cholesterol, and hypertension

35. Treatment of Schizophrenia (cont’d.) • Psychosocial therapy: • Most beneficial is combination of antipsychotic medication and psychotherapy • Tailored to address: • Social communication • Deficits in emotional perception and in understanding beliefs and attitudes of others • Difficulties with employment • Lack of social networks

36. Treatment of Schizophrenia (cont’d.) • Cognitive-behavioral therapy: • Teaching coping skills to: • Manage positive and negative symptoms • Address cognitive deficits • Show improvements in normal functioning • Mindfulness training: • Accept symptoms in nonjudgmental manner • Enhances feelings of self-control, reducing negative symptoms

37. Treatment of Schizophrenia (cont’d.) • Cognitive-behavioral therapy steps: • Engagement • Assessment • Identification of negative beliefs • Normalization • Collaborative analysis of symptoms • Developing alternative explanations

38. Treatment of Schizophrenia (cont’d.) • Family communication and education: • Normalize family experience • Demonstrate concern, empathy, sympathy • Educate family members about schizophrenia • Avoid blame • Identify strengths and competencies • Develop stress management skills • Teach family to cope with symptoms • Strengthen communication

39. Meet Wendy • Wendy is in her mid twenties and has become less and less able to perform her work at a local bank. She complains that her thoughts are unconnected and uncontrollable. She hears things that other people do not hear. She looks confused. • list questions or observations that, when answered, would support a diagnosis for each of the three psychotic disorders.

40. I almost forgot… • She believes her parents are trying to poison her and that she is Christ • She has come to your mental hospital. Please write down a treatment plan for Wendy on the handout. Think of a treatment plan involving several components—medication, cognitive therapy, social skills training, family therapy, and so forth.

41. Chapter Thirteen Sexual Dysfunction, Gender Dysphoria, and Paraphilic Disorders

42. Disorders of Sex and Gender

43. Sexual Dysfunctions • SEXUAL DYSFUNCTIONS • Are disorders in which people cannot respond normally in key areas of sexual functioning • Involve as many as 30 percent of men and 45 percent of women in the United States, who suffer from such a dysfunction during their lives • Are often interrelated to other dysfunctions

44. Sexual Dysfunctions • The human sexual response has a cycle with four phases • Desire • Excitement • Orgasm • Resolution

45. The Normal Sexual Response Cycle

46. Sexual Dysfunctions

47. Disorders of Desire • Desire phase of the sexual response cycle • Consists of an interest in or urge to have sex, sexual fantasies, and sexual attraction to others • Two dysfunctions affect this phase • MALE HYPOACTIVE SEXUAL DESIRE DISORDER • FEMALE SEXUAL INTEREST/AROUSAL DISORDER Dx Checklist • Male Hypoactive Sexual Desire Disorder • For at least 6 months, individual repeatedly experiences few or no sexual thoughts, fantasies, or desires. • Individual experiences significant distress about this. • Female Sexual Interest/Arousal Disorder • For at least 6 months, individual usually displays reduced or no sexual interest and arousal, characterized by the reduction or absence of at least three of the following: • Sexual interest • Sexual thoughts or fantasies • Sexual initiation or receptiveness • Excitement or pleasure during sex • Responsiveness to sexual cues • Genital or nongenital sensations during sex. • Individual experiences significant distress.

48. Disorders of Desire: Causes Most cases of low sexual desire or sexual aversion are caused primarily by sociocultural and psychological factors, but biological conditions can also lower sex drive

49. What Techniques Are Applied to Particular Dysfunctions? • Disorders of desire • These disorders are among the most difficult to treat because of the many issues that feed into them • Therapists typically apply a combination of techniques • Affectual awareness, self-instruction training, behavioral approaches, and biological interventions

50. Disorders of Excitement • ERECTILE DISORDER (ED) • Characterized by persistent inability to attain or maintain an erection during sexual activity • Occurs in as much as 25 percent of the general male population • Found in half of all adult men, who have erectile difficulty during intercourse at least some of the time Dx Checklist • Erectile Disorder • For at least 6 months, individual usually finds it very difficult to obtain an erection, maintain an erection, and/or achieve past levels of erectile rigidity during sex. • Individual experiences significant distress.