Download Schizophrenia - South Facing Slope

Childhood Mental Illness
Schizophrenia and Dissociative Disorders
Stage 6: Adolescence
 Recognition of behaviour and application of
knowledge to life decisions
 Child re-examines their social identity, making a
more conscious choice rather than unconscious
reactions to family dynamics
 May correspond with interest in wider material –
spirituality/religion, mythology, symbolism
through music, poetry, lyrics, archetypal figures
(celebrities), fashion.
Stage 6: Self-reflection
 Archetypal identity – childhood history is mapped
onto larger world-view
 Traumas may be seen in history or mythology (e.g.
poor mothering may influence fascination in
women’s rights)
 Personal life themes reflected in fairy tales,
movies, mythology or news stories, etc
Stage 6: Comparative theories
 Erikson: identity vs role confusion
 Piaget: Formal operations
 Hypothetical thinking and abstract concepts
 Metaphors and analogies
 Memories, comparison, time
 Values
Stage 6: Characteristics
 Intuition
 Insensitivity
 Perception
 Denial of reality
 Imagination
 Dogmatic
 Memory
(monopolarised)
 Obsessive
 Problems with
concentration
 Hallucinations etc
 Dreams
 Symbolic thought
 Visualisation
Archetypes of Development
 Mother
 Lover
 Hero
 Citizen/Healer
 Artist
 Manager/Seer
 Sage/Master
•What is mental illness?
Definitions
Psychopathology
Disorder
dysfunction
Normal
Health
The study of Nature, Development and treatment of
psychological disorders Through the scientific method
Syndrome or pattern of behaviour associated with distress or
disability or with significantly increased risk of suffering,
death, pain, disability or loss of freedom
When an internal mechanism is unable to perform its natural
/normal function
contain evidence from neurology, biology or medicine
a level of cognitive or emotional wellbeing or an absence of a
mental disorder
•The Scientific Method
Science is a systematic pursuit of knowledge through observation
•
Forming a theory
•
Experimentation (&
Data collection)
•
Forming a Hypothesis.
•
suggested explanation
of a phenomenon
•
APA DSM-IV-TR
American Psychiatric Association (2000)
Diagnostic and Statistical Manual Revision IV, Text Revision
•Origins of DSM
Kraeplin (1907) suggested that mental disorder
is caused by discrete identities as opposed to a
continuum
Dementia praecox  schizophrenia
• Manic Depression
• Paranoia (delusional disorder)
•
•5 Axes of Classification
Axis I : All Diagnostic categories except personality
disorders and Mental Retardation
• Axis II : Mental Retardation and Personality
Disorders
• Axis II is harder to treat and may not be
encouraged toward mental health clinicians (e.g.
dependent personality disorder)
• Axis I and II are the diagnoses of abnormal
behaviour
•
•5 Axes of Classification
Axis III : General Medical conditions (e.g. Depression
resulting from an endocrine gland dysfunction is an
Axis I diagnosis listed as caused by a medical problem)
• Axis IV : Psychosocial and Environmental Problems
• Axis V : Global Assessment of Functioning (GAF)
Scale
• Current level of adaptive functioning
• Social relationships, work and leisure time
• Scale 0-100 from ‘persistent danger of severely
hurting self or others’ to ‘superior functioning in a
wide range of activities
•
•DSM-IV-TR
•
•
Specific Diagnostic criteria
• Listing symptoms including descriptions of symptoms
• Many diagnostic categories, revised over time according
with research
• “Criteria Sets and Axes Provided for Further Study” (e.g.
Premenstrual Dysphoric Disorder, more debilitating than
Premenstrual Syndrome, Caffeine Withdrawl)
Characteristics of disorders
• Essential features, syndromes
• Summary of research literature (age of onset, course,
prevalence, sex ratio, family patterns, differential diagnosis)
• Associated features (lab findings, physical exams)
•Ethical and Cultural Considerations
Mental Illness is Universal. Symptoms of schizophrenia
(e.g. delusions and hallucinations) and depression (e.g.
loss of interest or pleasure in activities) are similar crossculturally.
However, cultures vary significantly in most mental
disorder, for example
willingness to seek help
available treatments
types of symptoms
language
Culture defines risk, symptom expression and outcomes
•Ethical and Cultural Considerations
Question: You feel a heavy heart, or a persistent
knot in your stomach
You would…
•Ethical and Cultural Considerations
•
•
Mexicans who immigrate to U.S. are 50% less likely to meet criteria for
mental illness than native born U.S. Citizens.
Over time, however, there is an increase to match U.S. citizens.
DSM-IV counteracts this by
1.
Providing a general framework for evaluating the role of culture and
ethnicity
2.
Describing cultural factors and ethnicity for each disorder
3.
Listing culture-bound syndromes (diagnoses likely to be seen in specific
regions)
Koro – South and East Asia : Intense anxiety of the penis or nipples
receding into the body possibly causing death
Taijin Kyofusho – intense anxiety about socially inappropriate behaviour,
blushing, insult of heirarchy through eye contact or body odour, etc.
- Overlaps with ‘Social Phobia’ and ‘Body Dysmorphic Disorder’
•Diagnosing Schizophrenia
“From the standpoint of social construction, we
emphasize the extent to which diagnoses are products
of their time and place. The relation of psychiatric
diagnoses to culture-societal structure, and historical
circumstance, is readily apparent if we look at the
times and places other than our own.”
Critical Psychology (Fox & Prilleltensky, 1997, p.108)
•General Criticisms
•
Too many diagnoses (almost 300)
•
•
Broad categories (e.g. religious doubt, non-compliance with treatment,
etc)
Comorbidity: 45% of people who meet criteria for at least one
psychiatric diagnosis will meet criteria for at least one more
•
Categorical (yes-no) diagnosis, rather than continuum (e.g. Do
you have high blood pressure (yes/no), where in the range of
blood pressure do you fall?)
•
Reliability: Vague language (e.g. “Mood is abnormally
elevated”)
Validity: Construct validity – inferred attribute (internal action,
e.g. anxiety)
•
•General Criticism
• The
use of standardised diagnostic criteria
offers strength in classification, but it is solely
for the benefit of labelling psychopathological
phenomena, telling little about the patients
• Bentall
(1993): Psychiatry has been unable to
reach a system of classification that is
scientifically valid
•General Criticism
• Diagnoses
are products of their time and place
Dreptomania – Slaves’ uncontrollable urge to
escape from slavery
• Kleptomania – emerged in parallel with large-scale
department stores
• Homosexuality – DSM diagnosis up to 1980
•
•DSM and Schizophrenia
• Two
people may receive a diagnosis of
schizophrenia while having little, if anything, in
common
• Panchreston
– purports to explain everything
but actually obscures the truth
•Diagnosing Schizophrenia
• History
Emil Kraepelin (1919)
• Dementia Praecox was characterised by early onset
followed by progressive deterioration
•
•
renamed schizophrenia by Eugen Bleuler in 1908
(Greek schizein phren, meaning “split mind”).
•
Between 0.5 % and 1.5% of all populations who have
been adequately studied develop schizophrenia
•Problems with Diagnosis:
•
Absence of biological and neuropsychological
abnormalities among the diagnostic material
•
No essential symptom must be present for a diagnosis
•
two people may receive the diagnosis while having little,
if anything, in common
•Problems with Diagnosis:
•
Prior to 1972, at least 40% of people diagnosed with
schizophrenia were actually suffering an affective
disorder
•
Within five years of the publication of DSM-III, the
diagnoses of schizophrenia in one large university
hospital decreased by 50 per cent.
•
25 per cent of patients diagnosed with manic
depression show “first-rank” symptoms of
schizophrenia, while 25 per cent of patients diagnosed
with schizophrenia do not
•Diagnosing Schizophrenia
• Schizotaxia:
first suggested by Meehl (1962)
characterised by predominance of negative
symptoms, can be assessed using eye tracking
and brain-structure abnormalities.
• Dysmetria:
unified theory of schizophrenia
based on neurodevelopmental disorder in the
circuitry between the frontal lobes, thalamus
and cerebellum
•Diagnosing Schizophrenia
• Diagnostic
classification is solely for the benefit
of labelling psychopathological phenomena,
telling little about the patients
• The
term “mental illness” is a semantic strategy
for medicalizing economic, moral, personal,
political, and social problems.” (Szasz, 2001)
Dissociative Disorders
 Dissociative Amnesia
 Memory loss, typical of a
 Dissociative Fugue
 Memory loss, accompanied by
 Depersonalisation Disorder
 Dissociative Identity Disorder
stressful experience
leaving home and establishing
a new identity
 Alteration in the experience of
the self
 At least two distinct
personalities that act
independently of each other
Dissociative Identity Disorder (DID)
 Different modes of being, thinking, feeling and




acting that exists independently and come forth at
different times
“Alters” – primary alter
Diagnosis calls for inability of at least one alter to
recall important information
Usually at least one alter has no contact with the
others
Existence of alters must be chronic, cannot change
with drug treatment, etc.
Dissociative Identity Disorder (DID)
 Usually begins in childhood but rarely diagnosed
until adulthood
 Much more common in women
 People with DID do not show the thought disorder
and behavioural disorganisation characteristic of
schizophrenia
Etiology of D.I.D.
 Post-traumatic model
Begins in childhood as a result of severe physical or
sexual abuse
 Diathesis may be present whereby the child is particularly
likely to develop alters after trauma
 Coping strategies to trauma

 Sociocognitive model

DID may be resultant of therapy, where the patient is
expressing the way they have learned to enact social roles
Schizophrenia





Disturbance in thought, emotion and
behaviour
Disorganised thinking (not logically related)
Faulty perception and attention
Lack of emotional
expressiveness/inappropriate expressions
Disturbances in movement and
appearance
Schizophrenia
Frequently social withdrawal, delusions
and hallucinations
 Substance abuse rates are high (50%
comorbidity)
 Suicide rates high
 Equal in men and women
 Sometimes begins in childhood, usually
late adolescence or early adulthood

Schizophrenia in DSM
Disorganised schizophrenia
 Catatonic schizophrenia
 Paranoid schizophrenia
 Brief Disorders





Schizophreniform disorder
Brief psychotic disorder
Shizoaffective disorder
Delusional disorder



Positive: Excesses. Delusions,
Hallucinations
Negative: Avolition (apathy),
Alogia (poverty of speech or
poverty of content of speech), Flat
affect, Asociality, Anhedonia
Disorganised: Speech or
behaviour
Categorises acute episodes of schiz.
Excesses and distortions
Delusions:
Beliefs held contrary to reality and
firmly held in spite of disconfirming
evidence
Persecutory delusions (paranoia) in
65% cross-nationally
 Thoughts
have been placed into the mind
by an external source
 Thoughts are broadcast or transmitted
 Thoughts are being stolen from them by
an external force very suddenly
 Feelings or behaviours are controlled by
external force
 May
also be present in Bipolar disorder,
depression with psychotic features and
delusional disorder
 Delusions in schizophrenia are highly
implausible.
 Criteria for diagnosis involves the
necessity to have had at least two of the
“A-symptoms”, other psychotic illnesses
need only one
Hallucinations / Disturbances in
Perception
Sense of “unreality”, depersonalisation
Hallucinations:
Sensory experiences in the absence of
environmental stimuli
74% report auditory hallucinations
 Hearing
one’s own thoughts spoken by
another voice
 Voices arguing
 Voice(s) commenting on one’s behaviour
Schizophrenia patients with hallucinations are more
likely to misattribute recordings of their own
speech to a different source than are patients
without hallucinations or non-patient controls
 Broca’s area
 frontal lobes (production and organisation of
speech)
 temporal lobes (enable understanding of
speech)
Deficits
 Avolition
(apathy):
• Lack of energy, absence of interest in routine
activities, difficulty with work, school or
household chores
 Alogia:
• Poverty of speech. Poverty of content of
speech ***
 Anhedonia:
• Lessening of the experience of pleasure (e.g.
good food, sex, recreation)
• Can still derive pleasure from positive things
(in-the-moment pleasure)
 Flat
Affect:
• No emotional expression. 66% of patients
•
Does not refer to the inner experience
 Asociality:
• Few friends, poor social skills
 Speech:
• May repeat central ideas or themes,
disconnected.
• Loose associations, derailment
• Problems in executive functioning – problem
solving, planning, associations
 Behaviour:
• Sexual behaviour, agitation, hoarding, non-
conforming to community standards
 Catatonia:
• Motor abnormalities, complex sequences of
movement.
• May maintain poses for very long periods
 Inappropriate
Affect:
• Emotional responses out of context
• Rare and specific to schizophrenia

http://www.youtube.com/watch?v=aBKS
Oxqu7CQ
Etiology
Genetics
Family and Twin studies
 The largest single body of controlled studies of
the genetics of psychopathology
 can sometimes lack validity in the
determination of zygosity, sampling methods
and concordance calculation
 may skew results, including the pooling of data
from earlier, possibly unreliable sources

Genetics
44.3 % for monozygotic twins
 9.35% for children of patients
 Risk of developing schizophrenia increases
from one percent for the general population to
approximately ten per cent for first degree
relatives of those diagnosed
 negative symptoms have the strongest
evidence for hereditability
 Evidence from molecular genetics is
inconsistent and results are simply too varied
to justify any firm conclusions

Genetics
Association with the DTNBP1 gene
responsible for encoding the dysbindin
protein
 Also NRGI neuregulin 1
 Little is known about the actual purpose
of either gene or protein

Neurobiology
Abnormalities in both brain structure and function
 enlarged ventricles (also in BP and often in non-
patients)
 under activity of the prefrontal lobes during abstract
reasoning tasks, and abnormal functioning of the
temporal lobes
 no single brain abnormality is pathognomonic for
schizophrenia, though abnormalities are probably
present in a large percentage
Developmental Factors
High rates of delivery complications (e.g.
influenza virus in second trimester)
 insecure attachment relations, early
trauma and sexual abuse
 vague patterns of familial
communication with high levels of
conflict
 Pruning – abnormal elimination of
synaptic connections

Developmental Factors

Family
 Communication Deviance (CD) – hostility and
poor communication, can predict onset of schiz
 Expressed Emotion (EE) – hostility, critical
comments, emotional overinvolvement
○ 58% experience relapse

Developmental history
 shows boys as “disagreeable”, girls as “passive”
 Poorer motor skills, negative expression
 Not clear as evidence of etiology
Social Factors

Sociogenic hypothesis
 Stresses from low Socio-economic status

Social Selction Theory
 Gradually move to lower SES
 More supported by research
Treatment

Medication:
 4560 RP antihistamine were accidentally discovered induced
a state of indifference in schizophrenic patients, which later
led to the establishment of chlorpromazine

Neuroleptics
 chloropromazine and phenothiazine, butyropenones
(haloperidol, “Haldol”), thioxanthenes (“Navane”)

good correlation between the neuroleptics to
dopamine receptors and their clinical effectiveness as
anti-psychotic drugs (for positive symptoms)
Medication

Dopaminergic mechanisms
 Two Dopamine Pathways involved in the
integration of
○
○
○
○

sensory information (the hypothalamus),
emotion (the amygdala),
memory (the hippocampus), and
executive function and planning (the prefrontal cortex)
Amphetamines induce symptoms such as
hallucinations and paranoia
 the effects of amphetamines can be controlled
using anti-psychotic drugs
Medication
about 30%, do not respond to
neuroleptics antipsychotic drugs
 have little or no effect over negative
symptoms (which are due to
underactivity of dopamine neurons in the
prefrontal cortex, rather than dopamine
excess)

Medication
75% of the patients to whom these are
prescribed stop taking them within 2 years
because of the extremely unpleasant side
effects
 40% - 65% of out-patients stop regular
antipsychotic medication within six weeks

Medication

Side-effects: dizziness, restlessness,
sexual dysfunction and tardive dyskinesia
(lip-smacking, involuntary movements)
 anti-psychotic treatments may increase the size
of the basal ganglia and thalamus as well as
other abnormalities in brain structure and
function
 Extrapyramidal side-effects: dysfunction in nerve
tracts from the brain to spinal motor neurons.
○ Parkinsons syndrome. Hand tremors, drooling
Medication

Atypical Antipsychotic drugs:
 Clozapine (“Clozaril”) – alternative.
○ Patients less likely to discontinue treatment
○ Some side-effects reduced
 Olanzapine (“Zyprexa”), Risperidone (“Risperdal”)
○ Early studies showed fewer side effects
○ May improve short term memory

Lieberman et al 2005:
 75% stop taking medication
 Related to development of type 2 diabetes and
pancreatitis
 Not more effective and not fewer side-effects
Treatment
Symptom Management Agenda set by
drug companies, who are patrons of
conferences and medical journals
 Psychoanalysis is not backed up with
evidence
 Most promising approaches emphasize
both pharmacological and psychosocial
interventions

Cognitive Behavioural Therapy
Helps reduce hallucinations and
delusions
 Attaches nonpsychotic meanings to
paranoid symptoms, reduce intensity
and anxiety
 Recognition of inappropriate affect
 Family therapy, reduction of high EE
 Social Skills training

Treatment

Paul & Lentz (1977) Social Learning Programs
 Long term, seriously ill patients with schizophrenia
divided into
 Social Learning ward - behavioural context – tokens,
modeling, communication, conflict resolution. Kept busy
85% of waking hours
 Mileu Therapy Ward – Therapeutic community. Positive
reinforcement, busy 85% of time, participate in ward
functioning
 Routine Hospital Management – 5% of waking time
occupied

90% of all patients were receiving antipsychotic
drugs
Paul & Lentz (1977)
Social learning and mileu therapy groups
reduced in positive, negative and disorganised
symptoms
 Groups 1 & 2 learned self-care, housekeeping,
social and vocational skills
 10% of Social Learning and 7% of Mileu
therapy patients left the centre for independent
living
 Antipsychotic use dropped to 18% in mileutherapy, 11% in social leaning, and increased
to 100% in Routine ward.
