Download Schizophrenia

Schizophrenia
Other Psychotic Disorders
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
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
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– Withdrawn & apathetic college student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
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
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
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
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
Positive & Negative
Symptoms
• 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
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
Delusions & Hallucinations
• 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
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.
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
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
Data
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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
Treatment
• No single “correct” treatment useful since
syndrome consisting of a number of
disorders
• Most effective
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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
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
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
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
Shared Psychotic Disorder
• Person develops delusion(s)
– similar in content to already established
delusion
– of another person with whom close
relationship
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
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
Psychotic Disorder NOS
• Syndromes with prominent psychotic
symptomatology
• Symptomatology not meeting criteria
for any specific Psychotic Disorder
Necessary Clinical
Information
• 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
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
Side Effects of Medication
• Most side effects disappear after few weeks
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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