Schizophrenia

1. Schizophrenia Other Psychotic Disorders

2. Three Criteria Sets for all Psychotic Disorders • 1st – applies to all disorders in group; defines requirements for psychosis • 2nd – defines attributes common to all schizophrenic disorders • 3rd – requirements about etiology, social impairment, & diagnostic precedence applying to many but not all disorders • All 3 sets tend to overlap

3. Schizophrenia:Splitting of the Mind Most debilitating & baffling mental illness • Distorted perception of reality • Impaired capacity to reason, speak, & behave rationally or spontaneously • Impaired capacity to respond spontaneously with appropriate affect & motivation • Incongruity between different mental functions • As betw thought content & feeling • As betw feeling & overt activity • Someone who laughs at a funeral

4. Clinical Presentation • Criticism of DSM-IV is that system becomes diagnosis by exclusion • Criteria as a whole does not characterize • Examples include: • Hypervigilant accountant suspicious others are plotting against him/her • Housewife believes she is controlled by dead mother’s voice • Withdrawn & apathetic college student brooding incessantly about reality of existence

5. Important factors • Specific set of symptoms, yet variety in severity from person to person • Also variety with one person from one period of time to another • Generally controlled with treatment • More than 59% with continuous treatment recover • Medication for entire life • Treatment allows most people to work, live with families, & enjoy friends

6. Causes • Much speculation • Appears to run in families; heredity link • “Schizophrenogenic” Mother • Previous discredited theory of bad parenting; inadequate care • Susceptibility/vulnerability to illness triggered by: • Environmental events; viral infection changing body chemistry • Highly stressful situation in adult life • Combination of things

7. Heredity • With 1 parent with diagnosis • 8-18% even if adopted by mentally healthy parents • Both parents • Risk  15-50% • Mentally healthy biological parents, but adoptive parents with diagnosis • 1% chance of developing disorder • Same chance as in general population • One identical twin with disorder • 50-60% sibling with identical genetics will also have disorder • Do not inherit directly • Appears when body is undergoing hormonal & physical changes of adolescence • Some researchers believe “dormant” during childhood • Emerges as body & brain undergo changes in puberty

8. Key Points • Age at onset • Generally late adolescence, early adulthood; rare later in life unless onset before 45 yrs • Duration • 6 months or more • Unless Schizophreniform • Loss of prior level of functioning • Tendency toward chronicity • Symptoms usually appear gradually • Preparatory or prodromal period • Symptoms include: • Tenseness, lack of concentration, sleep, withdraws from society • Personality changes • Work performance, appearance & social relationships deteriorate

9. Diagnose when positive symptoms for minimum of 2 weeks (other symptoms 6 mos.) Added features Excesses or distortions Hallucinations Delusions Negative Symptoms Lack of something Disorganized speech Diminution or loss of normal functioning Positive & Negative Symptoms

10. Relapse & Remission Phases • Common • Symptoms worsen or become better in cycles • May suffer: • Delusions, hallucinations, or disordered thinking & speech • Appearance normal at times until psychotic phase • Cannot think logically • May lose all sense of identity • May lose sense of significant others

11. Delusions Thoughts that are fragmented with no basis in reality Also differ in degree of conviction Someone may be spying or planning to harm Strong belief May be wrong but has some basis in reality If bizarre delusions no other Criteria “A” needed Someone can insert thoughts into brain Hallucinations Sensory perception with compelling sense of reality of true perception but occurs W/O external stimulation of relevant sensory organ May or may not have insight into having hallucinations Distinguish from illusion– actual stimulus misperceived /misinterpreted If voices are commenting or conversing no other Criteria “A” needed Ask if “voices” client hearing are own voice? Most common are voices Visual, tactile next Delusions & Hallucinations

12. Distortions of Ability • Loss of knowing whether an event or situation perceived is real • Waiting at a crosswalk, a voice says “you smell really bad” • Real voice • Jogger passing by • In my head? • Normal behaviors much of time: • Not so out of touch of realization that: • we eat 3 meals a day • sleep at night • drive on street etc.

13. Subtypes • Priority of patterns • Catatonic, if signs prominent • rigidity, lack of response or acute agitation • Disorganized • Disorganized speech, disorganized behavior, flat or inappropriate affect • Paranoid • Preoccupation with delusions or auditory hallucinations • No flat or inappropriate affect, catatonic behavior, disorganized speech, or disorganized behavior • Undifferentiated • Symptoms meet criteria A but not for paranoid, catatonic, or disorganized types • Residual • does not require fulfillment of common criteria set for schizophrenia • Attenuated form of criteria

14. Continuum of Schizophrenia Based on duration of episode Brief Psychoticschizophreniformschizophrenia • Brief Psychotic Disorder • Duration 1 day – 1 month • Eventual complete recovery • Schizophreniform • Duration 1 month – 6 months • Impaired social or occupational functioning not required buy may occur • Schizophrenia • Duration more than 6 months

15. Data • Affects men/women equally • Estimates of developing disorder = 1% • Onset in women typically 5 years later • 150 of 100,00 persons develop • Approximately ¼ hospital beds & ½ psychiatric beds in US • More than any other illness • Relatively rare • Most catastrophic mental illness • Early age of onset, lifelong disability, emotional & financial devastation • Federal figures reflect $30 - $48 billion in direct medical costs, loss of productivity, & social security pensions

16. Treatment • No single “correct” treatment useful since syndrome consisting of a number of disorders • Most effective • Psychopharmacology & psychosocial therapies • Antipsychotic medications treatment of choice since 50’s • Brings biochemical imbalances closer to norm • Reduces hallucinations, delusions • Helps maintain coherent thoughts • Compliance necessary • 60-80% not taking medication relapse in 1st yr • Relapse rates fall to 10% if medication continued

17. Schizoaffective Disorder: Bipolar or Depressive Type • Continuously meet Criterion A • Also major depressive episode, manic episode, or mixed episodes • Includes delusions, hallucinations of 2 weeks time in absence of mood symptoms

18. Delusional Disorder • Persistent nonbizarre delusions • 1 or more systematic & circumscribed delusions often of persecutory nature • 1 month time • Never met Criterion “A” for Schizophrenia • Function reasonable well • aside from impact/ramifications of delusions • If mood episodes, total duration brief • Relatively uncommon with .05-.1% lifetime risk • Usually mid-life disorder noticed by friends/family • Hypersensitive, argumentative, & litigious types • Usually no voluntary help sought

19. Types of Delusional Disorders • Erotomania • Another person, usually of higher status, is in love with person • Grandiose • Inflated worth, power, knowledge, identity, or special relationship to deity or famous person • Jealous • Individual’s sexual partner is unfaithful • Persecutory • Being persecuted for no apparent reason • Somatic • Having some physical defect or general medical condition • Mixed Type • More than 1 type with no predominant theme • Unspecified Type

20. Shared Psychotic Disorder • Person develops delusion(s) • similar in content to already established delusion • of another person with whom close relationship

21. Psychotic Disorder Due to General Medical Condition • Prominent delusions or hallucinations • Judged caused by general medical condition • Do not occur exclusively during course of Dementia or Delirium

22. Substance-Induced Psychotic Disorder • Prominent delusions or hallucinations associated with evidence symptoms developed within 1 month of significant substance intoxication or withdrawal, or is etiologically related to medications use or toxin exposure • Specific codes determined by specific substance

23. Psychotic Disorder NOS • Syndromes with prominent psychotic symptomatology • Symptomatology not meeting criteria for any specific Psychotic Disorder

24. History of: documented psychiatric illness socially unusual, odd, or isolative behavior substance abuse medical illnesses Current experience hallucinations or odd perceptual experiences Disorganized thought or speech Delusions Negative symptoms (e.g., flat affect, avolition (no goal directed activity) Depression or mania Duration of symptoms Necessary Clinical Information

25. Treatment of Delusional Disorders • Extraordinarily difficult to treat • Longer symptoms present, more oppositional to simple treatments • Some culturally-induced syndromes may respond to relocation • return to country of origin • Emphasis on trusting relationship • Systematic desensitization effective • Antipsychotic medication takes “edge” off delusions • Psychosocial treatment more possible • Antidepressants also proved helpful

26. Side Effects of Medication • Most side effects disappear after few weeks • Dry mouth • Blurred vision, constipation • Drowsiness • Dizziness due to drop in blood pressure • Some irreversible & serious side effects • Tardive Dyskinesia (TD) • 20-30% develop • Small tongue tremors, facial tics, abnormal jaw movements • May progress into thrusting & rolling tongue, lip smacking, pouting, grimacing, chewing or sucking motions • Also spasmodic movements • Usually do not progressively worse • Severe in less than 5% • Can fade if medication discontinued • Effectiveness of ending psychoses, validates risk