Download 15 Schizophrenia

SCHIZOPHRENIA
LECTURE OUTLINE
• Historical perspective
• Incidence/prevalence
• Description
• Diagnostic issues
• Etiology – Dynamic vulnerability model
• Treatment, rehabilitation, and early
intervention
SCHIZOPHRENIA
Historical perspective
• Ancient and medieval times – demonic
possession
• Morel (1852) – demence precoce
• Kraeplin (1893) – dementia praecox
• Bleuler (1911) – schizophrenia
• Today – family of problems, core is disordered
thought
• Often confused with dissociative identity
disorder (multiple personality disorder)
SCHIZOPHRENIA
Incidence/prevalence
• Lifetime prevalence rates range from .5%
to 1%
• Low incidence rate also – 1 per 10,000 per
year, but very debilitating disorder
• Onset from adolescence to age 45
• Men have earlier onset (18-25) than
women (25-35)
SCHIZOPHRENIA
Description
• Process vs. reactive schizophrenia
• Usually it is the family who seeks treatment
• Frequent cause of psychiatric
hospitalization (50% in psych hospitals)
• High rates of rehospitalization
• Severe impairment of social, occupation,
educational functioning, resulting in poverty,
poor housing, discrimination
SCHIZOPHRENIA
Description
• Formerly long-term stays in psych hospital,
assumption of chronicity
• Harding et al. (1987) follow-up study of
patients diagnosed with schizophrenia from
Vermont State Hospital
• 20-25 years later, more than half showed
considerable improvement
• current vision of recovery
SCHIZOPHRENIA
Description – Positive symptoms
• Delusions – false beliefs that have no
basis in reality; persecutory, religious,
grandiose, reference, somatic
• Hallucinations - false perceptions in the
absence of any relevant sensory stimulus;
auditory are most common; lack of control
over hallucinations is key feature
SCHIZOPHRENIA
Description – Positive symptoms
• Disorganized speech – thought-content
and thought-form symptomatology;
derailment, neologisms, word salad,
excessive concreteness
• Grossly disorganized behaviour – can be
manifested in a variety of ways
SCHIZOPHRENIA
Description – Positive symptoms
• Catanonia – stuporous, rigidity,
negativism, posturing, waxy flexibility;
echopraxia and echolalia; excitement
SCHIZOPHRENIA
Description – Negative symptoms
• Reflect an erosion or loss of normal
functions, patterns of experience and
conduct
• Symptoms include: impoverishment of
emotional expression, reactivity, and
subjective experience (emotional blunting)
• Other symptoms include: thought
blocking, avolition, anhedonia, asociality,
attention deficits
SCHIZOPHRENIA
Description – Three main types of
symptoms
• Psychomotor poverty
• Disorganization
• Reality distortion
SCHIZOPHRENIA
Diagnostic issues
DSM – IV lists 9 disorders under the category of
schizophrenia and other psychotic disorders
• Schizophrenia
• Schizophreniform disorder
• Schizoaffective disorder
• Delusional disorder
• Brief psychotic disorder
• Shared psychotic disorder
• Psychotic disorder due to a general medical condition
• Substance-induced psychotic disorder
• Psychotic disorder not otherwise specificed
SCHIZOPHRENIA
Diagnostic issues
• US-UK study (Cooper et al., 1982) –
Schizophrenia more likely to be diagnosed
in US, mood disorder in UK
• DSM-IV – must have 2 or more of:
delusions, hallucinations, disorganized
speech, grossly disorganized or catatonic
behaviour, negative symptoms (only 1
needed if delusions are bizarre or voice
keeps running commentary on person’s
behaviour or thoughts)
SCHIZOPHRENIA
Diagnostic issues - Subtypes
• Paranoid – 35-40%
• Disorganized – 10%
• Catatonic – 10%
• Undifferentiated – 20%
• Residual – 20%
SCHIZOPHRENIA
Diagnostic issues – 2-factor theory
• Factor I – severity of disorder – paranoid
type is less severe than other types
• Factor II – severity of symptoms –
frequency and prominence of symptoms
irrespective of subtype
SCHIZOPHRENIA
Etiology – Dynamic vulnerability model
• Genetic endowment
• Vulnerability
• Symptoms of schizophrenia
• Appraisal and coping
• Stressors
SCHIZOPHRENIA
Etiology – Vulnerabilities
• Developmental influences – studies of
high-risk children
• Genetics – according to your text – 45%
concordance for MZ twins, 10-15% for DZ;
Torrey et al. (1994) review of 8 twin studies
– 28% for MZ, 6% for DZ
• Biochemical influences – Dopamine
hypothesis
SCHIZOPHRENIA
Etiology – Vulnerabilities
Evidence supporting dopamine hypothesis
• Anti-psychotic drugs reduce transmission of
dopamine
• High number of dopamine receptors in
brains of people with schizophrenia
• Amphetamine psychosis
Research suggests that other
neurotransmitters are likely involved (e.g., NE
and glutamate)
SCHIZOPHRENIA
Etiology – Vulnerabilities
• Prenatal and perinatal influences
• Neuroanatomical – basal ganglia and
thalamus, front lobes, temporal lobes and
ventricles
• Neurodevelopmental factors – synaptic
density
• Personality factors
SCHIZOPHRENIA
Etiology – Stressors
• Family dynamics – “schizophrenogenic
mothers,” double-bind hypothesis, expressed
emotion (criticism, hostility, overinvolvement)
• Cultural influences – people who experience
schizophrenia in developing countries appear
to do better than those in industrialized
nations
SCHIZOPHRENIA
Etiology – Stressors
• Social status – SES inversely related to rates
of schizophrenia; social selection vs. social
causation (sociogenic) hypotheses
• Labelling theory
• Other stressors – child sexual abuse
SCHIZOPHRENIA
Treatments – The medical model
• Some past “treatments” – insulin coma
therapy, lobotomy
• Pharmacotherapy – anti-psychotic drugs;
problem of side-effects (EPS) and Tardive
Dyskenesia
• ECT
• Individual therapy, family therapy and
psychoeducation, group therapy by
professionals – inpatient and outpatient
SCHIZOPHRENIA
Treatments – The medical model
• Mental hospitalization – Goffman (1961),
Asylums, the total institution,
“disculturation,” “closing the ranks,” “spoiled
identity”
• Efforts to reform the mental hospital –
therapeutic community (Maxwell Jones) and
token economies (behaviourism)
SCHIZOPHRENIA
Treatments – Paul & Lentz (1977) study
• Comparative study – therapeutic community
(milieu), token economy, typical
hospitalization
• 28 participants randomly assigned to the 3
groups (half men, half women)
• All with diagnosis of schizophrenia, all
receiving drug treatment
• > 1/3 mute or incontinent
• Average of 17 years of hospitalization
SCHIZOPHRENIA
Treatments – Paul & Lentz (1977) study
Common elements of milieu and token
economy
• Residents, not “patients”
• Residents not sick, expected to be responsible
• Informal relations
• Open communication between staff and
residents
• Same staff operated the 2 programs
SCHIZOPHRENIA
Treatments – Paul & Lentz (1977) study
Therapeutic milieu program
• Expectations
• Involvement
• Group cohesion
SCHIZOPHRENIA
Treatments – Paul & Lentz (1977) study
Outcomes
• Improved behaviour greatest for token
economy residents
• Release rates – token economy (96%), milieu
(68%), hospital (46%) at 18-month follow-up
after release
SCHIZOPHRENIA
Treatments – Paul & Lentz (1977) study
Outcomes
• Cost-effectiveness – token economy was
most cost-effective
• only 10% of token economy residents and
18% of milieu residents remained on
psychotropic medications
SCHIZOPHRENIA
Treatments – Shift to community
• What happens after hospitalization?
(Goering et al., 1981) – psychiatric aftercare in
Toronto
• Deinstitutionalization or
transinstitutionalization? From mental
hospital to general hospital psychiatric wards
• First person accounts
SCHIZOPHRENIA
Treatments – Shift to community
Community mental health approaches
• Programs of Assertive Community
Treatment (PACT, Stein & Test, 1980) and case
management
• Supportive housing – the residential
continuum (from halfway house to group
home to supervised apartment to independent
living)
SCHIZOPHRENIA
Treatments – Shift to community
• Supported housing, employment, and
education (Paul Carling, 1995) – “choose, get,
and keep” philosophy, consumer control and
self-determination, community integration
• Self-help and consumer/survivor initiatives –
“a home, a job, a friend,” self-help groups and
organizations, consumer-run businesses (Away express, the Raging Spoon)
SCHIZOPHRENIA
Early intervention?
• Several projects, beginning in Australia,
aimed at early psychosis intervention
• Phases of psychotic episode – prodrome,
actue symptoms, recovery
• Gatekeeper education, quick access to
treatment, home-based treatment, low-dose
drug treatment – designed to intervene early
in first episodes
SCHIZOPHRENIA
SUMMARY
• A very rare but disabling disorder
• Characterized by loss of contact with
reality, including delusions, hallucinations,
disorganized speech and behaviour, and
negative symptoms
• Several different sub-types
• Great deal of heterogeneity in how this
disorder is manifested
SCHIZOPHRENIA
SUMMARY
• A very mysterious disorder in terms of its
origins/causes
• Several different lines of research are
being pursued to examine vulnerabilities
and stressors
• The medical model (hospitalization and
drug therapy) has been the dominant way
of responding to this disorder
SCHIZOPHRENIA
SUMMARY
• Many problems with this model
• Newer approaches include a variety of
community mental health programs and
early psychosis intervention