Schizophrenia and Other Psychotic Disorders

1. Schizophrenia and Other Psychotic Disorders

2. Clinical Description • Positive symptoms • more active manifestations of abnormal behavior, excess or distortion of normal behavior • delusions • identity • persecution • grandeur • reference • control • hallucinations

3. Clinical Description • Negative symptoms • deficits in normal behavior • Avolition: inability to initiate and persist in activities • Alogia: diminished speech • Anhedonia: indifference to pleasurable activities • Affective flattening: don’t show emotions you would expect

4. Clinical Description • Disorganized symptoms • Disorganized speech • illogical, jump from topic to topic, loose associations • Inappropriate affect • Disorganized behavior • bizarre behavior • catatonic behavior: wild agitation to immobility, waxy flexibility

5. DSM-IV Criteria • 2 of following x 1 month (or less if treated) • Delusions • Hallucinations • Disorganized speech • Grossly disorganized or catatonic behavior • Negative symptoms • Social/occupational dysfunction • Duration: 6 months

6. Subtypes • Paranoid • Delusions and hallucinations have theme (persecution or grandeur) • Cognitive skills and affect intact • Better prognosis

7. Subtypes • Catatonic • Unusual motor behavior • waxy flexibility • remaining in a fixed position • remaining rigid • engaging in excessive activity • Odd mannerisms of body and face • Echolalia • Echopraxia

8. Subtypes • Disorganized • Marked disruptions in speech and behavior • Flat or inappropriate affect • Delusions lack theme • Undifferentiated • Don’t fit neatly into other previous categories

9. Subtypes • Residual • “leftover” symtoms • Symptoms present, but in milder form • Unusual ideas that are not fully delusional • Unusual sensory perceptions that are not full blown hallucinations • Negative symptoms: social withdrawal, inactivity, flat affect

10. Prevalence and Onset • prevalence • 1% • roughly equal for men and women • onset • early adulthood (late teens/early 20s)

11. Course • onset may be gradual or sudden • complete recovery is rare • minority (22%) have only one episode, with minimal subsequent impairment • most (78%) experience several episodes • fluctuate between severe and moderate levels of impairment throughout life

12. Other Psychotic Disorders • Brief Psychotic Disorder • Symptoms last more than 1 day and less than 1 month. • Often follows extreme stress • Schizophreniform Disorder • Symptoms last 1-6 months.

13. Other Psychotic Disorders • Schizoaffective Disorder • Psychotic symptoms and mood symptoms occur together • Psychotic symptoms must be preceded or followed by 2 weeks of delusions or hallucinations without prominent mood symptoms

14. Other Psychotic Disorders • Delusional Disorder • Delusions without other symptoms of schizophrenia (no negative symptoms) • Delusions are nonbizzarre (could occur in real life)

15. Causes: Genetic Influences • Genes are responsible for making some people vulnerable to schizophrenia • Twin studies • Adoption studies • Family studies • the closer your genetic relationship to someone with schizophrenia, the higher your risk

16. Personal risk: given differing degrees of biological relatedness • MZ twin = 48% • DZ twin = 17% • 1 parent = 15% • 1 sibling = 7% • grandparent = 5% • general population = 1%

17. Genetics: continued • Can be carrier without showing symptoms • if your parent is the MZ twin with schizophrenia, your risk is about 17% • if your parent is the MZ twin without schizophrenia, your risk is still about 17% • Problems with smooth-pursuit eye movement as genetic marker

18. Causes: Neurobiological Influences • Leading theory • schizophrenia is caused by overactivity at synapses that use dopamine

19. Dopamine Theory • Evidence supporting: • dopamine antagonists (Haldol) reduce symptoms • drugs appear to block D2 receptors • dopamine antagonists cause side effects similar to Parkinson’s disease (due to insufficient dopamine) • L-dopa (dopamine agonist) produces schizophrenia-like symptoms in some people • amphetamines (dopamine agonists) can make psychotic symptoms worse in some people

20. Dopamine Theory • Evidence against: • dopamine antagonists don’t help everyone • dopamine antagonists are only partially effective at reducing negative symptoms • although drugs block dopamine quickly, it takes several days or weeks for symptoms to subside • Recent research suggests relation of serotonin to dopamine is important

21. Causes: Neurobiological Influences • Brain structure • Evidence for neurological damage, pregnancy and delivery complications • Enlarged ventricles • Underactivity in frontal lobes: associated with negative sx • Viral infection • Influenza during 2nd trimester • May disrupt migration of brain cells from inner portion to cortex

22. Causes: Psychological and Social Influences • Instability of early family rearing environment • may trigger the onset of schizophrenia in people with underlying genetic vulnerability • Stress • May trigger relapse • Families • High expressed emotion (criticism, hostility, emotional overinvolvement) associated with relapse

23. Treatment: Biological • Neuroleptic medications • Different classes: • Low potency: chlorpromazine (Thorazine), thioridazine (Mellaril) • High potency: haloperidol (Haldol). More effective at reducing symptoms, but more likely to cause EPS • Newer: clozapine (Clozaril), risperidone (Risperdal). Have fewer motor side effects.

24. Limitations of Meds • Meds are a treatment, not a cure • 55% relapse when go off meds • Meds reduce positive symptoms, but are less effective for negative symptoms • 10% not helped by meds • Side effects

25. Side Effects • Superficial • Dry mouth, sedation, blurred vision, constipation, weight gain, • EPS (extrapyramidal sx): slowed/awkward motor activity, tremor • Serious • Tardive dyskinesia: involuntary movements of lips, mouth, tongue, face. • Develops in 20%. • Associated with long-term use. Irreversible.

26. Psychosocial Treatments • Token economies on inpatient units • Improves social skills, self-care, and vocational skills • More likely to be discharged • Social skills training • Initial effects positive, but fade over time • Less likely to relapse than meds alone • Independent living skills training • Teach patients how to identify warning signs of relapse, cope with symptoms, manage meds • Initial results suggest decreased relapse

27. Psychosocial Treatments • Family therapy • factual information about disease • meds • side effects • identification of warning signs regarding a relapse • decreased expressed emotion • increased support for patient • communication skills • problem solving skills • Reduces relapse better than meds alone