Schizophrenias

1. Schizophrenias Schizophrenia as psychosis Diagnostic features Aetiology and development Treatment Cato Grønnerød PSY2600

2. Schizophrenia as Psychosis • Schizophrenia is the most common and best known of the psychoses • Psychoses • Originally: disease of the brain • Later: lack of insight into own condition • Other psychoses: • Schizophreniform disorder • Schizo-affective disorder • Delusional disorders

3. Schizophrenia as Psychosis • To be diagnosed, schizophrenia must impact upon more than one psychological process • Thought • Emotion • Perception • Communication • Psychomotor behaviour • Frequently several of these are affected simultaneously or at different periods

4. History • Schizophrenia was separated from ”insanity” in 1809 • Emil Kraepelin • Separated manic depression from ”dementia praecox” • Eugen Bleuler • Coined the term ”schizophrenia” • Defined symptoms • Adolf Meyer • Psychological explanations

5. What schizophrenia is not • Schizophrenia is NOT split-personality • Split between though and emotion • Schizophrenia is NOT leading to raving maniacs, lunacy, or unhinged, demented behaviour • Patients are mostly shy and withdrawn • Schizophrenia is NOT necessarily a lifetime disorder • Many suffer from episodes, then recover

6. Diagnosis and Diagnostic Issues • Careful diagnosis is important: • Affects 1% of population • Can be a lifelong diagnosis • Can be severe and the impact on social and work functioning, real and prospective may be very significant • Management, especially with medication, can have long term and irreversible consequences • Risk of suicide is high

7. Diagnostic Issues • Diagnosis is based largely on exclusion of other, possible diagnoses • Schizo-affective and mood disorders, drug use, somatic/neuropsychological condition, developmental disorders • Three major criteria • Characteristic symptoms • ‘Positive’ and ‘negative’ • Duration • Dysfunction

8. Symptoms: Delusions • “False beliefs that resist all argument and are sustained in the face of evidence that normally would be sufficient to destroy them” • Common to other psychoses, but are mood incongruent in schizophrenia • Bizarre to outsiders

9. Symptoms: Delusions • Five main kinds of delusion • Delusions of grandeur • Delusions of control • Delusions of persecution • Delusions of reference • Somatic delusions • Other kinds of delusions • Delusional jealousy, erotomanic delusion, thought broadcasting

10. Symptoms: Hallucinations • “False sensory perceptions that have a compelling sense of reality, even in the absence of external stimuli that ordinarily provoke such perceptions” • Auditory hallucinations most common • Distinguished from ordinary experience by • Their pervasiveness • Their lack of controllability • The person’s lack of awareness regarding the division between self and perceptual experience

11. Symptoms: Disorganized Speech • ‘Word Salad’ • Words and concepts are so disconnected that there is no logical thread (incoherent) • Loose association • Associations are made but are irrelevant or out of context • Clang association • Words are connected by the way they sound • Neologisms • Words ‘made up’ by the person that have no literal meaning

12. Symptoms: Disorganized or Catatonic Behavior • Inappropriate emotional and behavioural responses • Severe lack of concentration or coherence • Inability to ‘repair’ situations • Characterised by extreme slowing of motor behaviour for longer-than-natural periods • Often appearing ‘frozen’, often in rigid and strange postures and positions, immovable, mute and unresponsive

13. Negative Symptoms • Reduction in normal behaviour and a withdrawal from normal life • Less dramatic or well known, but usually appear first and are more pervasive • Flattening of affect • Severe social withdrawal • Severe reduction in energy and interest levels • Poor attention to hygiene and personal grooming • Severe reduction in responsiveness

14. Types of Schizophrenia • Paranoid Schizophrenia • Delusions and auditory hallucinations of persecution and/ or grandeur • Complex and intense but not disoriented • Irrational to observers • Catatonic Schizophrenia • Extreme motor behaviour states – either frozen or overly excited/agitated • Some report delusions or hallucinations in these states • “Negativism” – will do the opposite of what is instructed

15. Types of Schizophrenia • Disorganised Schizophrenia • Incoherent, emotionally and contextually inappropriate behaviour • Spontaneous affect, unsolicited conversation that continues despite cues to stop • Sometimes delusions but less organised than in paranoid schizophrenia • Poor hygiene and self care • Undifferentiated Schizophrenia • Psychotic symptoms and poor interpersonal functioning but does not meet criteria for the other types

16. Types of Schizophrenia • Residual Schizophrenia • Often in the aftermath of other schizophrenic episodes • Absence of prominent symptoms but continued and marked presence of two of the following • Social isolation or withdrawal • Impairment in role functioning • “Peculiar” behaviour • Impairment in personal grooming and hygiene • Blunt, flat or inappropriate emotional expression • Odd, magical or bizarre thinking • Unusual perceptual experiences • Apathy

17. Types of Schizophrenia • Acute • Sudden onset of flurid symptoms • Often precipitating incident • ”Good premorbid” • Better prognosis • Chronic • Prolonged and gradual decline • No stressor • ”Poor premorbid” • Poorer prognosis

18. Perceptual Deficits • Patients often report perceptual abnormalities • Difficulty understanding speech • Spatial distortions • Longer time to identify targets in backward masking tests • Problems when estimating sizes • Difficulties discriminating tones • Abnormal eyetracking movements • Jerky saccadic eye movements

19. Cognitive Deficits • Overinclusiveness • Tendency to form concepts from both relevant and irrelevant information • Impared ability to resist distracting information • Defective attentional filter • Prepulse is less effective in reducing the startle response in patients • Connected to maternal deprivation in animal studies • Lacking a theory of mind

20. Other Deficits • Motoric function • Unusual posturing (catatonic stupor) • Below average on motor proficiency and coordination • Slower reaction times • Emotional • Difficulties recognizing facial expressions • Some difficulties understanding interpersonal situations • More difficult when trying to implement solutions to interpersonal problems

21. Sources of Vulnerability • Genetic factors • Strong heritability for schizophrenia • Severity in proband increases risk for co-twin • Closeness of relationship determines risk • Adopted children of mothers with schizophrenia have higher risk of mental illness • Increased risk in unstable adoption families

22. Sources of Vulnerability • Pre- and Perinatal Factors • Prenatal viral infections • Birth complications/trauma • Exposure to stress during pregnancy • Childhood markers • Attention deficits • Delayed motoric development • Emotional instability • Increases at the onset of puberty • Schizotypal PD often precedes schizophrenia

23. Sources of Vulnerability • Neurochemical factors • Dopamine hypothesis • Antipsychotic drugs inhibit dopamine • Increased dopamine levels lead to psychosis • Motor symptoms a side effect of drugs • Increased density of dopamine receptors • High levels of serotonine • Brain structure • Enlarged ventricles • Reduced frontal and temporal lobes

24. Sources of Vulnerability • Social vulnerability • Expressed emotion • Cynical and hostile comments and marked overinvolvement by care takers • Social class • Social environment and culture • Diathesis-stress theory • More vulnerable • Stress caused by dysfunction?

25. Treatment of Schizophrenia • Drug therapy • Until the development of effective medications, prognosis was very poor • Chlorpromazine and haloperidol • Sedate but also seem to selectively reduce disordered thought and hallucinations • Best with the positive rather than negative symptoms • Strong and distressing side effects, most notably tardive dyskinesia

26. Treatment of Schizophrenia • Drug therapy • New drug treatments (different neurochemical effects) • Clozapine, Olanzapine, Risperidone • More effective, fewer side effects • Block fewer dopamine receptors, plus a majority of serotonin receptors • May cause depression • Early medication will restrict later severity

27. Treatment of Schizophrenia • Psychological Treatments • Address the cognitive, emotional and behavioral symptoms and outcomes • Cognitive rehabilitation • Focus on attention, memory and executive functions • Interpersonal training • Integrated Psychological Therapy • Program of Assertive Community Treatment