Schizophrenia in Schizophrenia in the Social the Social

EnvironmentEnvironment

ObjectivesObjectives

Describe schizophrenia in the context of developmental stages

Describe how schizophrenia affects males and females differently, as well as African Americans

Describe the status of individuals with schizophrenia within the macro system

Improve your overall understanding of schizophrenia

OutlineOutlineWhat is schizophrenia?

–Causes, symptoms, etc.Onset, course and prognosis

Shift in treatments (macro level information)

SchizophreniaSchizophrenia

What is Schizophrenia?What is Schizophrenia?

• Chronic, severe and disabling thought disorder–Break from reality (psychotic episode)

– Illogical and irrational thoughts–Extreme emotional and social disregulation

–NOT Dissociative Identity Disorder

Schizophrenia Schizophrenia DemographicsDemographics

• Affects about 1-2% of population (2 million)• More frequently seen in the lower

socioeconomic classes• More frequently seen in large cities vs.

rural• More frequently in divorced/separated

families• 10-15% may commit suicide• Affects men and women equally• Approximately 20% are homeless

CausesCauses

• No known single cause • Theoretical causes include genetics,

environmental, and behavioral factors (drugs)

• No cure

SymptomsSymptoms• Positive Symptoms (delusions,

hallucinations)– Pathological additions to normal behavior

• Negative Symptoms (flat affect)– Characteristics that are lacking or reduced

• Psychomotor Symptoms– Odd gestures– Excited Movement– Motionless stupor

Positive SymptomsPositive Symptoms• Delusions-beliefs

contrary to reality– Persecution– Reference– Grandeur– Control

• Disorganized Thinking/Speech– Loose Associations– Word Salad– Perseveration

• Heightened Perceptions & Hallucinations – Sensory Flooding– Hallucinations

Negative SymptomsNegative Symptoms

• Poverty of Speech• A decrease in speech

or speech content (catatonia)

• Blunted or Flat Affect– Flat-virtually no

emotion– Ambivalence

• Social Withdrawal– Conflicted feelings

about many things

Psychosocial FactorsPsychosocial Factors• Disturbed Family

Communication– Expressed Emotion

•Family members express critical or overprotective emotions (e.g. flat affect, staring)

•Predictive of relapse

Onset, Course Onset, Course and Prognosisand Prognosis

Childhood PrecursorsChildhood PrecursorsSome children who later develop SZ show

(majority have normal childhoods):

1. Delayed developmental milestones (walking, etc)

2. More language and speech problems (predictor)

3. Poorer coordination (sports, phy ed class)4. Poorer academic achievement5. Poorer social functioning and fewer friends **Statistical associations not predictors**

Source: Torrey, 2006 Surviving Schizophrenia

OnsetOnset• 75% of those who get SZ are between the

ages of 17 and 25; Unusual to get before 14 or after 30

• Childhood SZ does occur but rare • Postpartum SZ happens but is usually

eventually diagnosed as manic depressive illness or major depression with psychotic features

• Late-onset SZ: Age 40 or over; more females than males and 1/3 go on to develop Alzheimer-type dementia

QuestionsQuestionsBased on the article: •What aspects of an individual's life are affected by the development of schizophrenia during middle adulthood?

•How does this affect their development, biologically, psychologically, and socially?

Predictors of OutcomePredictors of OutcomeGood vs. Worse PrognosisGood vs. Worse Prognosis

• Consider “normal” prior to SZ

• Female• No hx or relatives with

SZ• Family hx depression or

bipolar disorder• Sudden onset• More positive symptoms• Quick response to initial

dose meds• Good illness awarenessGood illness awareness

• Family hx of SZ• Male• Younger the age when

SZ developed (15 vs.25)• Slower, gradual onset• Have more negative

symptoms (flattened affect)

• Poor illness Poor illness awarenessawareness

• Poor initial response to meds

Illness awareness…Illness awareness…or lack thereofor lack thereof

Two theories on lack of Two theories on lack of insightinsight

(1) Anosognosia1) Anosognosia– Neurological term– Limited or no awareness– Strokes or brain tumors in the right side of the brain– Frontal lobe damage

(2) Psychological defense (2) Psychological defense mechanismmechanism

– Blocking– Do not want to talk about illness episodes when better

Men and Men and SchizophreniaSchizophrenia

• Males earlier onset than females

• More severe in males• Males do not respond well

to antipsychotic meds-require higher doses than women (metabolic issue?)

• Higher relapse rate than women

• More trouble with long-term adjustment (e.g. marriage, work, level of function) when compared to women

African Americans and SZAfrican Americans and SZ

• Recent study shows African

Americans has 3 fold increase

in SZ when compared to whites

• Past studies show same• Researchers not sure why

Long-term PrognosisLong-term Prognosis

Studies that follow individuals long-term generally show that the course of

outcome is better after 30 years than after 10 years

• Illness seems to “die down” after many years

• Gets worse before it gets better

Schizophrenia and Life Schizophrenia and Life ExpectancyExpectancy

People with SZ tend to die youngerPeople with SZ tend to die younger

WHY?WHY?• Suicide (12x times higher than gen pop)• Diseases (diabetes type II, heart

disease, etc)• Unhealthy lifestyles (smoking)• Inadequate medical care and lack of

access• Homelessness

Schizophrenia & Schizophrenia & ViolenceViolence

• Violence is NOT a symptom

• Risk Factors– History of

violence– Substance abuse– Off medication and

actively psychotic-Lack of illness

insight

Most violent crimes are not committed

by persons with schizophrenia, and most persons with

schizophrenia do not commit violent

crimes.

-NIMH

SZ TreatmentSZ Treatment

– Cognitive techniques

– Behavioral strategies

– Family & Group therapy

*Often combined with medication

SZ can be very difficult SZ can be very difficult to treatto treat

• Nearly half of those diagnosed do not know that they are sick

• Co-occurring disorders• Medication side effects• Laws and Insurance Companies**• Lack of social and familial support • Stigma and discrimination • SZ Difficult to understand

SZ and Macro SystemsSZ and Macro Systems

QuestionQuestion Psychiatric hospitals across the

country are down-sizing and closing…Less help and fewer beds…No observable decrease in the # of people needing help…

Does anyone know where many of Does anyone know where many of these individuals who are still in these individuals who are still in

need of help are winding up?need of help are winding up?

Big ShiftBig ShiftMental health system to

the…

Current ConditionsCurrent Conditions

• By the end of 2006, there were 2.3 million confined individuals.

• 16 to 37.5% of those individuals are diagnosed with an SMI (bipolar, SZ, SZA)

• 2 to 4 times higher than found in the general public

• HRW estimates 200,000 to 400,000 SMI

Not a New ProblemNot a New Problem

•19th century•Dorothea Dix •Hospitals remained the primary treatment of SMI for next 150 years

Trend of Incarcerating Trend of Incarcerating SMISMI

• Began to notice increase in the number of SMI being jailed beginning in the 1970’s–Teplin and Colleagues and Cook County, Illinois

•Failure of the mental health system

Possible causes of Possible causes of incarceration of those with incarceration of those with

SMISMI• Deinstitutionalization beginning in 1950’s• Lack of community mental health centers

and services-did not want to treat SMI• Lack of housing

– Led to Homelessness (1/3 have SMI)• Social welfare policies

(Medicare/Medicaid)

Possible Causes…continuedPossible Causes…continued

• Changes in drug laws• Strict inpatient laws• Inability to recognize illness

– 50% of people with schizophrenia and bipolar disorder do not recognize they are ill

• Penrose's theory

Mental Health Courts and Mental Health Courts and Federal LawsFederal Laws

• Congress saw increasing levels of SMI as a problem

• 2000 America’s Law Enforcement and Mental Health Project Act (ALEMHP) (S.1865), P.L. 106-515. President Clinton

• 2004 Mentally Ill Offender Treatment and Crime Reduction Act of 2004 (MIOTCRA) P.L. 108-414. President Bush

What is a Mental Health What is a Mental Health Court?Court?

• Similar to drug courts• Forensic courts that manage the cases of

those with mental illness charged with committing misdemeanors and/or felony crimes.

• Approximately 130 in operation-growing• Based on “therapeutic jurisprudence”• Problem: Treatment after crime

committed

NAMI Mental Health in NAMI Mental Health in Pennsylvania Report CardPennsylvania Report Card

• NAMI D+ (Nationally D+)– Infrastructure: C-

– Information: D-

– Access: D-

– Services: C-

– Recovery Supports: C-

Mental Health and Mental Health and PittsburghPittsburgh

• State inmate re-entry program in Allegheny County (MHC program)– 2001: 3rd largest mental health facility in PA– 20-25% inmates mentally ill

• RAND study– 1st study to examine cost of program– Cost effectiveness took effect after 2 years– Received more mental health services and

spent fewer days in jail (criminal court)

Mental Health Laws and SZ in Mental Health Laws and SZ in PittsburghPittsburgh

Most restrictive laws in the

nation

Troy Hill Jr.Troy Hill Jr.

Consequences of Consequences of Strict LawsStrict Laws

• Fatally attacked one brother and hurt another

• Diagnosed as having paranoid SZ• Tried to seek help but was turned

away

Powerful LetterPowerful Letter

“I have made thousands of mistakes in my life, but my worst mistake, the one I lament almost daily, [was] working … to pass the state's Mental Health Procedures Act”-Bill Shane-Former PA Legislator Thursday Sept 13, 2007 Pittsburgh Post Gazette

SummarySummary• Most people who develop SZ do so at

late adolescence/early adulthood• Schizophrenia is still a very

misunderstood disease• Many people with SZ do not receive

or accept treatment• Many are now involved in the criminal

justice system

Questions or Questions or Comments?Comments?