Download Schizophrenia and Other Psychotic Disorders Schizophrenia A

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Chapter 12
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Schizophrenia and
Other Psychotic
Disorders
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Sheila K. Grant, Ph.D.
Professor
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A Beautiful Mind.
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Course of Development
Prodromal phase - In schizophrenia, the period of
decline in functioning that precedes the first acute
psychotic episode.
Residual phase - In schizophrenia, the phase that
follows an acute phase, characterized by a return to the
level of functioning of the prodromal phase.
These cognitive and social deficits can impede the
ability of schizophrenia patients to function effectively
in social and occupational roles even more severely
than the severe hallucinations and delusions of the
psychotic episode.
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Schizophrenia
Schizophrenia - A chronic psychotic disorder
characterized by disturbed behavior, thinking,
emotions, and perceptions.
Acute episodes of schizophrenia are characterized by
delusions, hallucinations, illogical thinking, incoherent
speech, and bizarre behavior.
Between acute episodes, people with schizophrenia may
still be unable to think clearly, may speak in a flat tone,
may have difficulty perceiving emotions in other
people’s facial expressions, and may show little if any
facial expressions of emotions themselves.
Course of Development
Schizophrenia typically develops during a person’s late
teens or early 20s, a time when the brain is reaching
full maturation.
In about three of four cases, the first signs of
schizophrenia appear by the age of 25.
In some cases, the onset of the disorder is acute and
occurs suddenly, within a few weeks or months.
Then a rapid transformation in personality and
behavior leads to an acute psychotic episode.
Prevalence
About 1% of the adult population in the United States
is affected by schizophrenia, more than 2 million
people in total.
The WHO estimates that about 24 million people
worldwide suffer from schizophrenia.
Nearly 1 million people in the United States receive
treatment for schizophrenia each year, with about a
third of these requiring hospitalization.
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Prevalence
Men tend to have a slightly higher risk of developing
schizophrenia than women.
Women tend to develop the disorder somewhat later
than men do, with onset occurring most commonly
between age 25 and the mid-30s in women and
between age 18 and 25 in men (APA, 2000).
Women also tend to achieve a higher level of
functioning before the onset of the disorder and to
have a less severe course of illness than do men.
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Diagnostic Features
Schizophrenia is a pervasive disorder that affects a
wide range of psychological processes involving
cognition, affect, and behavior.
The DSM-IV criteria for schizophrenia require that
psychotic behaviors be present at some point during
the course of the disorder and that signs of the disorder
be present for at least 6 months.
People with briefer forms of psychosis receive other
diagnoses, such as brief psychotic disorder.
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Diagnostic Features
People with schizophrenia show a marked decline in
occupational and social functioning.
Positive symptoms -Flagrant symptoms of
schizophrenia, such as hallucinations, delusions,
bizarre behavior, and thought disorder.
Negative symptoms - Behavioral deficiencies
associated with schizophrenia, such as social skills
deficits, social withdrawal, flattened affect, poverty of
speech and thought, psychomotor retardation, and
failure to experience pleasure.
Diagnostic Features
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Overview of Schizophrenia
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Aberrant Content of Thought
Schizophrenia is characterized by positive symptoms
involving disturbances in thinking and expression of
thoughts through coherent, meaningful speech.
Aberrant thinking may be found in both the content
and form of thought.
Delusions represent disturbed content of thought.
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Aberrant Content of Thought
Delusions may take many forms. Some of the most common types
are:
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• Delusions of persecution (e.g., “The CIA is out to get me”)
• Delusions of reference (“People on the bus are talking about
me,” or “People on TV are making fun of me,” or “The neighbors
hear everything I say. They’ve put bugs in the walls of my house”)
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• Delusions of being controlled (believing that one’s thoughts,
feelings, impulses, or actions are controlled by external forces,
such as agents of the devil)
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• Delusions of grandeur (believing oneself to be Jesus or believing
one is on a special mission, or having grand but illogical plans for
saving the world)
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Filtering out extraneous stimuli.
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A painting by a schizophrenia patient.
The connections (or associations) between our thoughts
tend to be logical and coherent.
Thought disorder - A disturbance in thinking
characterized by the breakdown of logical associations
between thoughts.
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Unless we are engaged in daydreaming or purposefully
letting our thoughts wander, our thoughts tend to be
tightly knit together.
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Aberrant Forms of Thought
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Attentional Deficiencies
To read this you must screen out background noises
and other environmental stimuli.
Attention, the ability to focus on relevant stimuli and
ignore irrelevant ones, is basic to learning and
thinking.
People with schizophrenia often have difficulty filtering
out irrelevant stimuli, making it nearly impossible for
them to focus their attention, organize their thoughts,
and filter out unessential information.
Eye Movement Dysfunction
About one in three chronic schizophrenia patients
shows evidence of eye movement dysfunction (Ross,
2000).
Patients with this dysfunction (also called eye tracking
dysfunction) have abnormal movements of the eyes
when they track a moving target across their field of
vision.
Rather than steadily tracking the target, the eyes fall
back and then catch up in a kind of jerky movement.
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Abnormal Event-Related Potentials
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Researchers have also studied brain wave patterns,
called event-related potentials, or ERPs, that occur
in response to external stimuli like sounds and flashes
of light.
ERPs can be broken down into various components
that emerge at different intervals following the
presentation of a stimulus.
Schizophrenia patients also show reduced levels of
later-occurring ERPs.
These later-occurring ERPs are believed to be involved
in the process of focusing attention on a stimulus in
order to extract meaningful information.
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Hallucinations
Visual hallucinations (seeing things that are not
there)
Gustatory hallucinations (tasting things that are
not present),
Olfactory hallucinations (sensing odors that are not
present) are rarer.
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Emotional Disturbances
Disturbances of affect or emotional response in
schizophrenia may involve negative symptoms, such
as a loss of normal affect or emotional expression,
which is labeled blunted affect or flat affect.
Flat affect is inferred from the absence of emotional
expression in the face and voice.
People with schizophrenia may speak in a monotone
and maintain an expressionless face, or “mask.”
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Hallucinations
Hallucinations - Perceptions occurring in the
absence of external stimuli that become confused with
reality.
Hallucinations can involve any of the senses.
Auditory hallucinations (“hearing voices”) are
most common, affecting about three of four
schizophrenia patients.
Tactile hallucinations (such as tingling, electrical,
or burning sensations).
Somatic hallucinations (such as feeling like snakes
are crawling inside one’s belly).
Hallucinations
Hallucinations are not unique to schizophrenia.
People with major depression and mania sometimes
experience hallucinations.
Nor are hallucinations invariably a sign of
psychopathology.
They are common and socially valued in some
cultures
The Case of Georgiana
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“Then it got out of hand, where I couldn’t control
coming and going, back and forth, and in my
body, out of my body, it was no longer under my
control.”
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Other Types of Impairment
People who suffer from schizophrenia may become
confused about their personal identities—the cluster of
attributes and characteristics that define themselves as
individuals and give meaning and direction to their
lives.
They may fail to recognize themselves as unique
individuals and be unclear about how much of what
they experience is part of themselves.
In psychodynamic terms, this phenomenon is
sometimes referred to as loss of ego boundaries.
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Disorganized Type
Disorganized type - The subtype of schizophrenia
characterized by disorganized behavior, bizarre
delusions, and vivid hallucinations.
People with disorganized schizophrenia display
silliness and giddiness of mood, giggling and talking
nonsensically.
They often neglect their appearance and hygiene and
lose control of their bladders and bowels.
People with schizophrenia also show significant
impairment in interpersonal relationships.
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A young man diagnosed with
disorganized schizophrenia.
People with schizophrenia may show highly excited or
wild behavior or may slow to a state of stupor.
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Disturbances of volition are most often seen in the
residual or chronic state.
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Other Types of Impairment
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Subtypes of Schizophrenia
The DSM-IV lists three specific types of schizophrenia:
disorganized, catatonic, and paranoid.
People with schizophrenia who display active psychotic
features, such as hallucinations, delusions,
incoherent speech, or confused or disorganized
behavior, but who do not meet the specifications of the
other types, are considered to be of an undifferentiated
type.
Others who have no prominent psychotic features at the
time of evaluation but have some residual features (for
example, social withdrawal, peculiar behavior, blunted
or inappropriate affect, strange beliefs or thoughts)
would be classified as having a residual type of
schizophrenia.
Catatonic Type
Catatonic type - The subtype of schizophrenia
characterized by gross disturbances in motor activity,
such as catatonic stupor.
People with catatonic schizophrenia may show unusual
mannerisms or grimacing or maintain bizarre,
apparently strenuous postures for hours, although
their limbs become stiff or swollen.
A striking but less common feature is waxy flexibility,
which involves adopting a fixed posture into which
they have been positioned by others.
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Paranoid Type
Paranoid type - The subtype of schizophrenia
characterized by hallucinations and systematized
delusions, commonly involving themes of persecution.
The behavior and speech of someone with paranoid
schizophrenia does not show the marked
disorganization typical of the disorganized type,
nor is there a prominent display of flattened or
inappropriate affect or catatonic behavior.
The delusions often involve themes of grandeur,
persecution, or jealousy.
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A person diagnosed with
catatonic schizophrenia.
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Paranoid Schizophrenia.
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Type I versus Type II Schizophrenia
Type I schizophrenia is characterized by the more
flagrant or positive symptoms of schizophrenia we
describe earlier, such as hallucinations, delusions, and
looseness of associations, as well as by an abrupt
onset, preserved intellectual ability, and a more
favorable response to antipsychotic medication.
Type II schizophrenia corresponds to a pattern
consisting largely of the deficit or negative
symptoms of schizophrenia, such as lack of emotional
expression, low or absent levels of motivation, loss of
ability to experience pleasure, social withdrawal, and
poverty of speech, as well as by a more gradual onset,
intellectual impairment, and poorer response to
antipsychotic drugs.
Psychodynamic Perspectives
Within the psychodynamic perspective, schizophrenia
represents the overwhelming of the ego by primitive
sexual or aggressive drives or impulses arising from the
id.
These impulses threaten the ego and give rise to
intense intrapsychic conflict.
Under such a threat, the person regresses to an early
period in the oral stage, referred to as primary
narcissism.
Learning Perspectives
Although learning theory does not offer a complete
explanation of schizophrenia, the development of some
forms of schizophrenic behavior can be understood in
terms of the principles of conditioning and
observational learning.
From this perspective, people with schizophrenia learn
to exhibit certain bizarre behaviors when these are
more likely to be reinforced than normal behaviors.
Social-cognitive theorists suggest that modeling of
schizophrenic behavior can occur within the mental
hospital, where patients may begin to model
themselves after fellow patients who act strangely
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Genetic Factors
The closer the genetic relationship between
schizophrenia patients and their family members, the
greater the likelihood (or concordance rate) that the
relatives will also have schizophrenia.
Overall, first-degree relatives of people with
schizophrenia (parents, children, or siblings) have
about a tenfold greater risk of developing
schizophrenia than do members of the general
population.
The fact that families share common environments as
well as common genes requires that we dig deeper to
examine the genetic underpinnings of schizophrenia.
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Biochemical Factors
Contemporary biological investigations of
schizophrenia have focused on the role of the
neurotransmitter dopamine.
The leading biochemical model of schizophrenia, the
dopamine hypothesis, posits that schizophrenia
involves an overreactivity of dopamine transmission in
the brain.
Increasing evidence supports the view that
schizophrenia involves an irregularity in dopamine
transmission in the brain
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Generally speaking, the
more closely one is
related to people who
have developed
schizophrenia, the
greater the risk of
developing
schizophrenia for
oneself.
Monozygotic (MZ)
twins, whose genetic
heritages are identical,
are much more likely
than dizygotic (DZ)
twins, whose genes
overlap by 50%, to be
concordant for
schizophrenia.
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The familial risk of schizophrenia.
Loss of brain tissue in adolescents with
early-onset schizophrenia.
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Brain Abnormalities
We have compelling evidence of both structural
changes (loss of brain tissue) and functional
disturbance (abnormalities of functioning) in the
brains of schizophrenia patients.
However, we have yet to discover any one source of
pathology in the brain that is specific to schizophrenia
or present in all cases of schizophrenia.
The most prominent finding of structural changes is
the loss of brain tissue (gray matter) of about 5% on
the average in schizophrenia patients as compared to
normal controls.
Structural changes in the brain of a
person with schizophrenia as compared
with that of a normal subject.
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PET scans of people with schizophrenia
versus normals.
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Communication Deviance
Communication deviance (CD) is a pattern of
unclear, vague, disruptive, or fragmented
communication that is often found among parents and
family members of schizophrenia patients.
CD is speech that is hard to follow and from which it is
difficult to extract any shared meaning.
High CD parents often have difficulty focusing on what
their children are saying.
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Relapse rates of people with
schizophrenia in high and low EE families.
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Family Theories
An early, but since discredited theory, focused on the
role of the schizophrenogenic mother (FrommReichmann, 1948, 1950).
In what some feminists view as historic psychiatric
sexism, the schizophrenogenic mother was
described as cold, aloof, overprotective, and
domineering.
She was characterized as stripping her children of selfesteem, stifling their independence, and forcing them
into dependency on her.
Children reared by such mothers were believed to be at
special risk for developing schizophrenia if their fathers
were passive and failed to counteract the mother’s
pathogenic influences.
Expressed Emotion
Another form of disturbed family communication,
expressed emotion (EE), is a pattern of responding
to the schizophrenic family member in hostile, critical,
and unsupportive ways.
Schizophrenia patients from high EE families stand a
higher risk of relapsing than those with low EE (more
supportive) families.
High EE relatives typically show less empathy,
tolerance, and flexibility than low EE relatives.
Family Factors in Schizophrenia:
Causes or Sources of Stress?
No evidence supports the belief that family factors,
such as negative family interactions, lead to
schizophrenia in children who do not have a genetic
vulnerability.
Rather, a genetic vulnerability to schizophrenia
renders individuals more susceptible to troubled
family and social relationships.
Within the diathesis–stress model, disturbed
patterns of family interaction and communication
represent sources of life stress that increase the risks
of developing schizophrenia among people with a
genetic predisposition for the disorder
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Endophenotypes
Endophenotypes - Measurable processes or
mechanisms not apparent to the naked eye, which are
the means by which an organism’s genetic code comes
to affect its observable characteristics or phenotypes.
Investigators are investigating a number of possible
endophenotypes in schizophrenia, including
disturbances in brain circuitry, deficits in working
memory and cognitive abilities, and abnormalities of
neurotransmitter functioning.
To better understand how schizophrenia develops, we
need to dig under the surface to see how genes affect
underlying processes, and how these processes in turn
contribute to the development of the disorder.
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From genes to vulnerabilty.
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Biological Approaches
Tardive dyskinesia (TD) - A disorder characterized by
involuntary movements of the face, mouth, neck, trunk, or
extremities and caused by long-term use of antipsychotic
medication.
Antipsychotic medication helped control the more flagrant
behavior patterns of schizophrenia and reduced the need for
long-term hospitalization when taken on a maintenance or
continuing basis after an acute episode.
Yet for many patients with chronic schizophrenia, entering a
hospital is like going through a revolving door: they are
repeatedly admitted and discharged.
Many are simply discharged to the streets once they are
stabilized on medication and receive little if any follow-up
care.
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Sociocultural Factors in
Treatment
Ethnicity may also play a role in the family’s
involvement in treatment.
In a study of 26 Asian Americans and 26 non-Hispanic
White Americans with schizophrenia, family members
of the Asian American patients were more frequently
involved in the treatment program.
For example, family members were more likely to
accompany the Asian American patients to their
medication evaluation sessions.
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Psychodynamic Therapy
Freud did not believe that traditional psychoanalysis
was well suited to the treatment of schizophrenia.
The withdrawal into a fantasy world that typifies
schizophrenia prevents the individual with
schizophrenia from forming a meaningful relationship
with the psychoanalyst.
The techniques of classical psychoanalysis, Freud
wrote, must “be replaced by others; and we do not
know yet whether we shall succeed in finding a
substitute”.
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Learning-Based Therapies
Therapy methods include the following:
1. Selective reinforcement of behavior, such as
providing attention for appropriate behavior and
extinguishing bizarre verbalizations through
withdrawal of attention.
2. Token economy, in which individuals on inpatient
units are rewarded for appropriate behavior with
tokens, such as plastic chips, that can be exchanged for
tangible reinforcers such as desirable goods or
privileges.
3. Social skills training, in which clients are taught
conversational skills and other appropriate social
behaviors through coaching, modeling, behavior
rehearsal, and feedback.
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Psychosocial Rehabilitation
People with schizophrenia typically have difficulties
functioning in social and occupational roles and
performing work that depends upon basic cognitive
abilities involving attention and memory.
These problems limit their ability to adjust to
community life, even in the absence of overt psychotic
behavior.
Recently, promising results were reported for cognitive
rehabilitation training to help schizophrenia patients
strengthen such basic cognitive skills as attention and
memory.
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Brief psychotic disorder - A psychotic disorder
lasting from a day to a month that often follows
exposure to a major stressor.
Schizophreniform disorder - A psychotic disorder
lasting less than 6 months in duration, with features
that resemble schizophrenia.
Delusional disorder - A type of psychosis
characterized by persistent delusions, often of a
paranoid nature, that do not have the bizarre quality of
the type found in paranoid schizophrenia.
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Schizoaffective disorder - A type of psychotic
disorder in which individuals experience both severe
mood disturbance and features associated with
schizophrenia.
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Biological Approaches
Erotomania - A delusional disorder characterized by
the belief that one is loved by someone of high social
status.
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Other Forms Of Psychosis
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In sum, no single treatment approach meets all the
needs of people with schizophrenia.
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Other Forms Of Psychosis
Researchers and clinicians have worked with families of
people with schizophrenia to help them cope with the
burdens of care and assist them in developing more
cooperative, less-confrontational ways of relating to
others.
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Family conflicts and negative family interactions can
heap stress on family members with schizophrenia,
increasing the risk of recurrent episodes.
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Family Intervention Programs
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QUESTIONS?
10