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Theory to Treatment Schizophrenia Psychopathology Julianne Carroll The Schizophrenic Picture Between a half and two thirds of sufferers: • can’t work • live alone • don’t develop adequate social relations • die younger • are at a higher risk of HIV • more likely to be victims of crime • are often painfully aware of their situation DSM IV Diagnostic Assumptions • There are no biological indicators. • Negative symptoms play a predominant role • there must be a prodromal period of at least 6 months • schizophrenia (Sz) is a discrete disease entity • there is the possibility that Sz may lie at the end of a continuum of psychopathology or neurophysiological dysfunction Any Way Out? • Kaepelin suggests a deteriorating course • Harding et al (1987) reported that after 32 years 1/2 to 2/3 of chronic patients discharged were symptom free and had reasonable adjustments to community life Heterogeneity • • • • Crow’s 2 Syndrome Model Buchanan & Carpenter’s 3 Factor Model Deficit Syndrome Core Deficit Hypothesis Positive and Negative Symptoms Neurotransmitter positive symptoms disturbance (responsive to neuroleptics) neuroanatomical negative symptoms disturbance(s) (unresponsive to neuroleptics) 3 Factor Model • hallucinations and delusions • negative symptoms • cognitive impairment Deficit Syndrome • Fundamental question: which negative symptoms are primary and enduring? • Criteria for diagnosis: 1) DSM IV Sz 2) 2 symptoms present for 12 months - affective flattening - alogia - avolition *not accounted for by: - depression/anxiety - drug effects - environmental deprivation Core Deficit • Bleuler (1911, 1950) proposed thought disorder as the hallmark symptom of Sz and made the first attempt to specify a primary cognitive deficit theorized to underly an array of symptoms. • It’s the disconnection of ‘associative threads’ that leads to confused & bizarre thinking. Social Competence • Pre-morbid social competence is among the best predictors of long term outcome which comes first? The chicken or the egg? • Social dysfunction is now considered quite fundamental in the diagnosis of Sz and has been linked to cognitive functioning, specifically an inability to learn specific Stress - Vulnerability Model Predisposing Factors: • • • • Dopaminergic anomalies Cognitive (info. Processing) deficits Autonomic hyperactivity to aversive stimuli Schizotypal personality traits Precipitating Factors: • An unsupportive/critical family environment • overstimulated social environment • stressful life events Perpetuating Factors: • • • • Processing capacity overload Tonic autonomic hyperarousal impaired processing of social stimuli further impairment to processing of social cues • disruption of coping abilities • Dysfunctional behaviors create environmental stressors Protective Factors • Coping abilities (cognitive and behavioral) • A supportive family • Psychosocial interventions Stress-Vulnerability Model Psychotic episode Precipitating factors +ve Predisposing factors Protective factors -ve P e r p e t u a t I n g Where Do We Fit In? Psychosocial Treatments: • • • • • Individual Psychotherapy CBT Behaviour Therapy Cognitive Family Therapy Family Education ”psychoeducation”