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Chapter 13 - Schizophrenia • Criteria 1. Symptoms (2 of 5 for 1 month) Content of thought: a. Delusions - belief with no basis in reality b. Hallucinations – perception in absence of stimuli ** Form of thought c. Disorganized, incoherent Behavior d. Disorganized, agitated, or catatonic Emotion e. Flat or inappropriate affect - withdrawal, poverty of speech Positive vs. Negative Symptoms - Positive = excess or distortion - Negative = loss of normal behavior 2. Social/Occupational dysfunction - work, relationships, hygiene - loss of identity 3. Duration > 6 months (Sxs in #1 at least 1 month) 4. Exclusions - not from drugs, medical problems, or mood disorder • INDIVIDUAL DIFFERENCES Course • Onset - late teens to mid-30s - rarely before adolescence - either acute or gradual (most are gradual) • Phases a. Prodromal - slow development of negative symptoms - often misinterpreted b. Acute - appearance of positive, psychotic symptoms c. Residual - positive sxs remit, negative sxs remain - return to prodromal d. Remission - never recovered -> labeled for life vs. Third world • Progression = variable - chronic - vs. gradually deteriorating - vs. swings between better & worse - vs. remission Subtypes 1. Paranoid Type - Thematic delusions (eg, paranoid or grandiose) Or frequent auditory hallucinations - Often intact cognition & affect - Stilted, aloof, superior - Mixed evidence for suicidal or homicidal - Best prognosis (lack of negative sxs) 2. Disorganized Type - Incoherent speech & behavior - daily chores difficult - disorganized delusions and/or hallucinations - Flat/inappropriate affect - appear silly/immature - Insidious, early onset - Poor prognosis - continuous course without remissions • 3. Catatonic Type Psychomotor disturbance - immobility, stupor, odd postures waxy flexibility Or - agitation, purposeless movement Negativism, mutism, resistance Echolalia, echopraxia 4.Undifferentiated Type - schizophrenic sxs - but don’t meet criteria for types 1-3 - catchall dx 5.Residual Type - 1+ episode of acute positive sxs - no positive sxs currently - continuing negative sxs - eccentric, odd beliefs - transition between full-blown episode and remission? - may be present for years Other Psychotic Disorders 1. Brief Psychotic Disorder Positive sxs - hallucinations, delusions, loose associations, disorganized beh. Follows acute stressor No prodromal or residual phase Lasts < 1 month Return to normal fxing High suicide risk 2.Delusional Disorder - 1 fixed non-bizarre delusion - no other problems 3.Personality Disorders a. Paranoid – suspicious b. Schizoid – withdrawn c. Schizotypal – odd 4.Schizophreniform Disorder - sxs of schizophrenia - lasts < 6 months - most develop schizophrenia or schizoaffective disorder - no decline in fxing 5.Schizoaffective Disorder - schizophrenia & a mood disorder Etiology Genetic Contributions • Clear genetic basis • Increased risk based on relatedness Family Studies • < 1% in population • 17% if parent or parent’s MZ twin Twin Studies • MZ twins = 50% • DZ = ~ 15% Adoption Studies • Biological risk = 10-17% • Environmental risk = < 1% Unknowns • Means of transmission • One or more genes (polygenetic would explain spectrum) Neurobiology & Neuroanotomy 1.Excess of Dopamine (DA) - some antipsychotics are DA antagonists (block use of DA) - side effects (tardive dyskinesia: TD) similar to Parkinson’s • Parkinson’s = inadequate DA - L-dopa increases DA for Parkinson’s - amphetamines activate DA & can worsen psychotic sxs in people with schizophrenia SUM: Increase DA => increase schizo. & decrease Parkinson’s Decrease DA => decrease schizo. & increase Parkinson’s BUT: 1. Antipsychotics don’t always work 2. Antipsychotics ineffective for negative sxs 3. Decrease in DA in some brain areas (may account for subtype differences) • Thus, complex interaction of DA, SE, & possibly other neurotransmitters 2.Brain Structure - neurological damage? a. Behavioral signs - abnormal reflexes - decreased attention b.Atrophy - enlarged ventricles - often, but not always - related to perinatal problems? c. Decreased frontal lobe fx - related to negative sxs - more common in men - associated with worse premorbid adjustment & prognosis d. Abnormal temporal lobe & limbic system fx - related to auditory hallucinations - disconnection between thought & emotion? e. Abnormal thalamic fx - incoherence? 3.Viral Infections? Family Contributions NOT "Schizophrenogenic Mother" • Cold, aloof, overprotective • Double-bind communication Family Interaction **Expressed emotion = criticism, hostility, overinvolvement => risk of relapse Diathesis-Stress Model Diatheses: • Genes • Perinatal trauma? • Viral infection? Stressors: • Single caregiver • Lack of support • Family high in expressed emotion • Low SES Treatment • Antipsychotic Medication Neuroleptics • Side effects => noncompliance - grogginess, blurred vision, mouth dryness, loss of voices - TD (tardive dyskinesia) Clozapine (& now Risperdone) • Blocks another DA receptor • Treats positive & negative sxs • Fewer side effects (like TD) • Fatal for 2% Monthly Drug Cost (1997) • Clozapine • Haloperidol 317.03 1.76 2005 • Clozapine • Haloperidol 15.95 14.95 Behavioral Treatment 1. 2. 3. 4. 5. Token economies Social skills training Therapeutic community – Szasz, Laing Psychosocial rehabilitation Family Therapy Predictors of Recovery 1. Good premorbid adjustment 2. A precipitating stressor 3. Sudden onset - acute positive symptoms 4. Older age of onset 5. Affective Problems - anxiety/depression are good - hopelessness is bad 6. Type of Schizophrenia Best = Paranoid (with acute onset) Worst = Undifferentiated, chronic & Disorganized (both have more negative sxs) 7. Supportive Family 8. Response to Treatment - to medication, therapy, staff - resigned is worse