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Chapter 12
Schizophrenia and Other Psychotic Disorders
PSY 440: Abnormal Psychology
Rick GrieveWestern Kentucky University
psychotic disorderspsychotic disorders ––disorders so severe that the person has disorders so severe that the person has essentially lost touch with realityessentially lost touch with reality
schizophrenia (a psychotic disorder) is schizophrenia (a psychotic disorder) is characterized by the disruption of:characterized by the disruption of:
••normal perceptual and normal perceptual and thought processthought process
••personalitypersonality
•• affectaffect
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Nature of Schizophrenia and Psychosis: An Overview
Schizophrenia vs. PsychosisPsychosis – Broad term referring to hallucinations and/or delusions; noted in several disordersS hi h i A f h i i h di b dSchizophrenia – A type of psychosis with disturbed thought, language, and behavior
Historical BackgroundEmil Kraeplin – Used the term dementia praecox, “loss of the inner unity of thought, feeling , and acting”.Eugen Bleuler – Introduced the term “schizophrenia” or “splitting of the mind”; the 4 As:
Associations, Affect, Ambivalence, Autism
Nature of Schizophrenia andPsychosis: An Overview cont.)
Schneider – first rank vs. second rank symptomsContemporary practice –
Complex syndrome – heterogeneousIdentified by clusters of symptomsSeveral subtypesSeparate diagnoses that “look like” or share some of the same symptoms as schizophrenia – but are separate psychotic disorders
Schizophrenia: The “Positive” Symptom Cluster
The Positive Symptoms-Active manifestations of abnormal behavior, distortions of normal behaviorD l i G i t ti f litDelusions: Gross misrepresentations of reality
Persecution – “out to get me”Reference – “talking about me”Being controlled – “aliens make my body move”Grandeur – “I invented rock and roll”Truman Show delusion – “I am the star of a reality TV show.”Capgras delusion – “my loved one has been replaced by a double.”
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Schizophrenia: The “Positive” Symptom Cluster
Delusions typically have a “bizarre” quality – implausible, not understandable, not based on ordinary life experiences
Hallucinations: Experience of sensory eventsHallucinations: Experience of sensory events without environmental input; type of perceptual disturbance
Can involve all senses; auditory most common 70%Not unique to schizophreniaTypically hear voices
Schizophrenia: The “Negative” Symptom ClusterThe Negative Symptoms -Absence or insufficiency of normal behavior
Examples are emotional/social withdrawal, apathy, and poverty of thought/speechp y g p
Spectrum of Negative Symptoms Avolition (or apathy) – Refers to the inability to initiate and persist in activitiesAlogia – Refers to the relative absence of speech Anhedonia – Lack of pleasure, or indifference to pleasurable activitiesAffective flattening – Show little expressed emotion, but may still feel emotion
Schizophrenia: The “Negative” Symptom ClusterOther Negative Symptoms:
Cognitive deficitsPrimacy of impaired cognitiony p g
Social Withdrawal
Negative symptoms more debilitating than positive symptoms
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Schizophrenia: The “Disorganized” Symptom ClusterThe Disorganized Symptoms-Include severe and excess disruptions in speech, behavior, and emotion
Examples include rambling speech, erratic behavior, and inappropriate affect
Disorganized Speech Cognitive slippage – Refers to illogical and incoherent speechTangentiality – “Going off on a tangent” and not answering a question directly Loose associations or derailment – Taking conversation in unrelated directions
Disorganized Symptoms
Thought disorders can lead to the formation of:
Cl A i iClang AssociationsPerseverationWord Salad
Schizophrenia: “Disorganized”Symptom Cluster
Nature of Disorganized AffectInappropriate emotional behavior (e.g.,
i h h ld b l hi )crying when one should be laughing)Nature of Disorganized Behavior -includes a variety of unusual behaviors
Catatonia – Spectrum from wild agitation, waxy flexibility, to complete immobilityDifficulties performing activities of daily living
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More Disorganized Symptoms
Attentional DeficitsSocial Problems
DSM Diagnosis:DSM Diagnosis:Characteristic symptomsSocial/Educational/Occupational dysfunctionDurationDifferential DiagnosesRelationship with PDD
Subtypes of SchizophreniaParanoid Type
Intact cognitive skills and affect, and do not show disorganized behaviorHallucinations (auditory) and delusions center around a ( y)theme (grandeur or persecution)The best prognosis of all types of schizophrenia
Subtypes of Schizophrenia
Disorganized TypeMarked disruptions in speech and behavior, flat or inappropriate affectinappropriate affectHallucinations and delusions have a theme, but tend to be fragmentedThis type develops early, tends to be chronic, lacks periods of remissions
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Subtypes of SchizophreniaCatatonic Type
Show unusual motor responses and odd mannerisms (e.g., echolalia, echopraxia) This subtype tends to be severe and quite rare
Waxy Catatonia
Subtypes of SchizophreniaUndifferentiated Type
Wastebasket categoryMajor symptoms of schizophrenia, but fail to j y p p ,meet criteria for another type
Residual TypeOne past episode of schizophreniaContinue to display less extreme residual symptoms (e.g., odd beliefs)
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Other Disorders with Psychotic Features
Schizophreniform DisorderSchizophrenic symptoms for a few monthsAssociated with good premorbid functioning; most resume normal lives
Schizoaffective DisorderSymptoms of both schizophrenia and a mood disorder
Other Disorders with Psychotic Features (cont.)Delusional Disorder
Delusions that are contrary to reality without th j hi h i tother major schizophrenia symptoms
Many show other negative symptoms of schizophreniaType of delusions include erotomanic, grandiose, jealous, persecutory, and somaticThis condition is extremely rare, with a better prognosis than schizophrenia
Additional Disorders with Psychotic Features
Brief Psychotic DisorderExperience one or more: delusions, hallucination, disorganized speech or grossly disorganize ordisorganized speech or grossly disorganize or catatonic behavior - positive symptoms of schizophreniaUsually precipitated by extreme stress or traumaTends to remit on its owns
Schizotypal Personality DisorderMay reflect a less severe form of schizophrenia
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Schizophrenia in Childhood
Very rareUses the same criteria as adultsHigh incidence rate of trauma
Schizophrenia: Facts and Statistics
Onset and Prevalence of SchizophreniaAbout 1% populationOnset in early adulthood, but can emerge at any timey , g y
Schizophrenia Is Generally ChronicMost suffer with lifelong moderate-to-severe impairment Life expectancy is slightly less than average
Figure 13.2Gender differences in onset of schizophrenia in a sample of 470 patients
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Schizophrenia: Facts and Statistics
Schizophrenia – Gender DifferencesFemales tend to have a better long-term prognosisOnset –males 18-25 years; females – 25-35 years & y ; yafter 40Men more negative symptoms; women more affective, positive
Strong Genetic Component
Causes: Findings From Genetic Research
Family StudiesInherit a tendency for schizophrenia, not a specific form of schizophreniaOther family members are at increased riskOther family members are at increased risk
Twin StudiesRisk of schizophrenia in monozygotic twins is 48%Risk of schizophrenia drops to 17% for fraternal (dizygotic) twins
Adoption Studies Risk of schizophrenia remains high in adopted children with a biological parent suffering from schizophrenia
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Figure 13.6Risk for schizophrenia among children of twins
Causes:Findings From Genetic Research
Summary of Genetic ResearchRisk of schizophrenia increases as a function of genetic relatednessOne need not show symptoms of schizophrenia to pass on relevant genesSchizophrenia has a strong genetic component, but genes alone are not enough
Genetic & Behavioral Markers of Schizophrenia
The Search for Genetic Markers: Linkage and Association Studies
S f i i i i iSearch for genetic markers is still inconclusiveSchizophrenia is likely to involve multiple genes
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Causes of Schizophrenia: Neurotransmitter Influences
Neurobiology and Neurochemistry: The Dopamine Hypothesis
Drugs that increase dopamine (agonists), result in schizophrenic-like behaviorDrugs that decrease dopamine (antagonists), reduce schizophrenic-like behaviorExamples include neuroleptics and L-Dopa for Parkinson’s diseaseThe dopamine hypothesis proved problematic and overly simplisticCurrent theories emphasize several neurotransmitters and their interaction
Causes: Other Neurobiological Influences
Glutamate hypothesis
Structural and Functional Abnormalities in the BrainStructural and Functional Abnormalities in the Brain Enlarged ventricles and reduced tissue volumeHypofrontality – Less active frontal lobes (a major dopamine pathway)
Viral Infections During Early Prenatal Development The relation between early viral exposure and schizophrenia is inconclusive
Causes: Other Neurobiological Influences
Conclusions About Neurobiology and Schizophrenia
Schizophrenia is associated with diffuseSchizophrenia is associated with diffuse Neurobiological DysregulationStructural and functional abnormalities in the brain are not unique to Schizophrenia
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Causes of Schizophrenia
The Role of StressMay activate underlying vulnerability and/or i i k f lincrease risk of relapse
Causes of Schizophrenia
Family InteractionsFamilies of people with schizophrenia show ineffective communication patterns – communication deviancepHigh expressed emotion in the family is associated with relapse
The Role of Psychological Factors Psychological factors likely exert only a minimal effect in producing schizophrenia
i lt l i bli lt l i bl
CAUSES OF SCHIZOPHRENIACAUSES OF SCHIZOPHRENIA
ENVIRONMENTAL CONTRIBUTIONSENVIRONMENTAL CONTRIBUTIONS
sociocultural variablessociocultural variables••downward drift hypothesisdownward drift hypothesis ––theory that lower social class is a theory that lower social class is a result, rather than a cause, of result, rather than a cause, of schizophreniaschizophrenia
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SCHIZOPHRENIA AND SOCIAL CLASS
40
50
60
0
10
20
30Proportion
Upper Middle LowerSocial Class
General Population Patients Fathers BrothersSource : After E. M. Goldberg and S. Linda. Morrison, “Schizophrenia and Social Class.” British Journal of Psychiatry, 109 (1963); 785-802.
clinical course –specific pattern of changes in
t t l ti
CLINICAL COURSECLINICAL COURSE
symptomatology over timeprodromal phaseactive phaseresidual phase
TYPICAL COURSES FOR SCHIZOPHRENIA
(A) CHRONICGRADUAL ONSET & VERY POOR PROGNOSISGRADUAL ONSET & VERY POOR PROGNOSIS
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TYPICAL COURSES FOR SCHIZOPHRENIA
(B) EPISODICOCCASIONAL EPISODES WITH OCCASIONAL EPISODES WITH
NEARLY NORMAL FUNCTIONING BETWEEN THEMNEARLY NORMAL FUNCTIONING BETWEEN THEM
TYPICAL COURSES FOR SCHIZOPHRENIA
(C) SINGLE EPISODEBRIEF PERIOD OF PSYCHOSIS & NEARLY BRIEF PERIOD OF PSYCHOSIS & NEARLY
COMPLETE RECOVERY WITH NO OTHER EPISODESCOMPLETE RECOVERY WITH NO OTHER EPISODES
Treatments
Neuroleptic drugs are begun first – stabilizes and reduces symptomsPsychosocial treatments come next
Prevent relapseCompensate for skills deficitsImprove medication compliance
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Pharmacological Interventions
Antipsychotic (Neuroleptic) MedicationsMedication treatment is often the first line treatment for schizophreniaBegan in the 1950sMost reduce or eliminate the positive symptoms of schizophreniaAcute and permanent extrapyramidal and Parkinson-like side effects are commonCompliance with medication is often a problemMany people continue to experience symptoms, even with meds
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Pharmacological Interventions
CATIE
Psychosocial Treatment of Schizophrenia
Psychosocial Approaches: Overview and GoalsBehavioral (i.e., token economies) on inpatient unitsCommunity care programsy p gSocial and living skills trainingBehavioral family therapy Vocational rehabilitation
Psychosocial Approaches Are Usually a Necessary Part of Medication TherapyCBT
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HOSPITALIZATIONHOSPITALIZATION AND BEYOND
TREATING SCHIZOPHRENIATREATING SCHIZOPHRENIA
protecting the individual and protecting the individual and othersothers
stabilizing the individualstabilizing the individualrehabilitating the individualrehabilitating the individual
References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (Fourth Ed.). Washington, D. C.: Author.Chambless, D. L., Bryan, A. D., Aiken, L. S., Steketee, G., & Hooley, J. M. (1999). The structure of expressed emotion: A three-construct representation. Psychological Assessment, 11, 67-76.Durand, V. M., & Barlow, D. H. (2006). Essentials of abnormal psychology (4th Edition). Pacific Grove, CA: Wadsworth.Gaudiano, B. A. (2005). Cognitive behavior therapis for psychotic disorders: Current empirical status and future directions. Clinical Psychology: Research and Practice, 12, 33-50.Heinrichs, R. W. (2005). The primacy of cognition in schizophrenia. American Psychologist, 60, 229-242.
References
Morrison, J. (1995). The first interview: Revised for DSM-IV. New York: The Guilford Press.Kersting, K. (2005). Serious rehabilitation: Psychologist-developed treatments are providing hope for people with serious mental illness. APA Monitor on Psychology, 36 (1), 38-41.Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. R., Hughes, M., Eshleman, S., Wittchen, H. U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8-19.McKinney, R., & Fiedler, S. (2004). Schizophrenia: Some recent advances and implications for behavioral intervention. the Behavior Therapist, 6, 122-125.Nairne, J. S. (1999). Psychology: The adaptive mind (2nd Ed.). Albany, NY: Brooks/Cole Publishing Company.Nichols, O. T. (2005, November). Headlines in psychopharmacology. Symposium presented at the annual meeting of the Kentucky Psychological Association, Louisville, KY.