Chapter 11 Schizophrenia

Ch 11

Schizophrenia

• Schizophrenia is a psychotic disorder involving disturbance of thought, emotion and behavior

• The lifetime prevalence of schizophrenia is about 1%– Onset is usually in late adolescence– Substance abuse is a co-morbid condition in

50% of schizophrenia patients

Ch 11.1

Broad Impairments Delusions & Hallucinations Disorganized Speech & Behavior Inappropriate Emotions Psychosis: extreme mental unrest

with loss of reality contact (Davison & Neale, p. 134)

Broad Impairments Delusions & Hallucinations Disorganized Speech & Behavior Inappropriate Emotions Psychosis: extreme mental unrest

with loss of reality contact (Davison & Neale, p. 134)

Cause is Unknown Affects 1 out of 100 People Often Begins (Ages 16 - 30) More Hospital Beds Than Any Other

Medical Illness2.5% of Total U.S. Healthcare Budget

Cause is Unknown Affects 1 out of 100 People Often Begins (Ages 16 - 30) More Hospital Beds Than Any Other

Medical Illness2.5% of Total U.S. Healthcare Budget

Often Chronic Occurs in .2% to 1.5% Population Affects Men and Women Equally

– Age of Onset Varies Across Time Lower Life Expectancy

– Increased Risk of Suicide

Often Chronic Occurs in .2% to 1.5% Population Affects Men and Women Equally

– Age of Onset Varies Across Time Lower Life Expectancy

– Increased Risk of Suicide

People with schizophrenia have “split personalities.”

People with schizophrenia are intellectually disabled?

People with schizophrenia are dangerous?

People with schizophrenia are addicted to their drugs?

People with schizophrenia have “split personalities.”

People with schizophrenia are intellectually disabled?

People with schizophrenia are dangerous?

People with schizophrenia are addicted to their drugs?

Schizophrenia is NOT caused by bad parenting or an unhappy childhood.

Schizophrenia is NOT due to a weakness in character.

Schizophrenia is NOT due to a negative social label.

Schizophrenia is NOT a hopeless situation.

Schizophrenia is NOT caused by bad parenting or an unhappy childhood.

Schizophrenia is NOT due to a weakness in character.

Schizophrenia is NOT due to a negative social label.

Schizophrenia is NOT a hopeless situation.

Dementia (Loss of Mind) Praecox (Early, Premature) Kraepelin

– Categorization & Early Onset Eugen Bleuler

– Termed “Schizophrenia”– Associative Splitting

Dementia (Loss of Mind) Praecox (Early, Premature) Kraepelin

– Categorization & Early Onset Eugen Bleuler

– Termed “Schizophrenia”– Associative Splitting

Positive Symptoms– Displays of Abnormal Behavior

Disorganized Symptoms– Speech and Behavior

Negative Symptoms

– Deficits in Affect, Speech, Motivation

Positive Symptoms– Displays of Abnormal Behavior

Disorganized Symptoms– Speech and Behavior

Negative Symptoms

– Deficits in Affect, Speech, Motivation

Positive Symptoms Positive Symptoms Delusions

– Misrepresentation of Reality– “Basic Feature of Madness”

Examples– Grandeur -- Importance– Persecution -- Out to Get Me

Delusions– Misrepresentation of Reality– “Basic Feature of Madness”

Examples– Grandeur -- Importance– Persecution -- Out to Get Me

Positive Symptoms Positive Symptoms Hallucinations

– Absence of Sensory Stimulation

– Involve Any of the Senses Examples

– Auditory -- Voices (70%)

– Visual -- Seeing Things (25%)

– Tactile -- Crawling Sensation

Hallucinations– Absence of Sensory Stimulation

– Involve Any of the Senses Examples

– Auditory -- Voices (70%)

– Visual -- Seeing Things (25%)

– Tactile -- Crawling Sensation

Broca’s Area(Speech)

Broca’s Area(Speech)

Wernicke’s Area(Hearing)

Wernicke’s Area(Hearing)

What Area Do You Think is More Active With Auditory Hallucinations?What Area Do You Think is More Active With Auditory Hallucinations?

Disorganized Symptoms Disorganized Symptoms Disorganized Speech

– Difficulty in Communication Examples

– Tangentiality– Loose Association or Derailment

Disorganized Speech– Difficulty in Communication

Examples– Tangentiality– Loose Association or Derailment

Positive

Symptoms

Positive

Symptoms

Disorganized Behaviors Catatonia

– Spectrum– Wild Agitation to Immobility

Example– Waxy Flexibility

– Inappropriate Affect

Disorganized Behaviors Catatonia

– Spectrum– Wild Agitation to Immobility

Example– Waxy Flexibility

– Inappropriate Affect

Disorganized Symptoms Disorganized Symptoms

Positive

Symptoms

Positive

Symptoms

Positive Disorganized

Symptoms

Positive Disorganized

Symptoms Negative Symptoms Negative Symptoms

Flat Affect -- “The Mask” Avolition -- “No Initiative” Alogia -- “Speech is Vacant” Anhedonia -- “No Pleasure” Asociality--”No social interest”

Flat Affect -- “The Mask” Avolition -- “No Initiative” Alogia -- “Speech is Vacant” Anhedonia -- “No Pleasure” Asociality--”No social interest”

Positive Symptoms of Schizophrenia

• Positive symptoms involve excesses or distortions– Disorganized speech (thought disorder)– Hallucinations are sensory experiences that occur in

the absence of environmental stimulation• Hallucinations are commonly auditory

– Delusions are beliefs that are contrary to reality• Persecutory delusions are common

Ch 11.2

Negative Symptoms of Schizophrenia

• Negative schizophrenia symptoms are characterized by behavioral deficits– Avolition refers to a lack of energy and an inability to

persist in routine activities– Alogia refers to a reduction in the amount or content of

speech– Anhedonia is an inability to experience pleasure– Asociality refers to a severe impairment in social

relationships

Ch 11.3

DSM-IV Schizophrenia Categories

• Disorganized schizophrenia involves – Disorganized speech and flat affect – A general disruption of behavior

• Catatonic schizophrenia involves – Prolonged motor immobility states that alternate with periods of

excitability

• Paranoid schizophrenia involves the presence of prominent delusions including persecution and grandiosity

• Undifferentiated schizophrenia and residual schizophrenia

Ch 11.4

Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type

Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type

Delusions & Hallucinations Intact Cognition and Affect No Disorganized Speech Best Prognosis

Delusions & Hallucinations Intact Cognition and Affect No Disorganized Speech Best Prognosis

Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type

Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type

Disorganized Speech Disorganized Behavior Flat or Inappropriate Affect Hallucinations and Delusions

– Fragmented or Lacking a Theme Often Chronic

Disorganized Speech Disorganized Behavior Flat or Inappropriate Affect Hallucinations and Delusions

– Fragmented or Lacking a Theme Often Chronic

Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type

Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type

Disorganized Speech Disorganized Behavior

Waxy flexibility, rigidity, odd mannerisms, mimicry

Flat or Inappropriate Affect Hallucinations and Delusions

– Fragmented or Lacking a Theme Often Chronic

Disorganized Speech Disorganized Behavior

Waxy flexibility, rigidity, odd mannerisms, mimicry

Flat or Inappropriate Affect Hallucinations and Delusions

– Fragmented or Lacking a Theme Often Chronic

Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type

Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type

Beginnings of Breakdown Major Sx of Schizophrenia DO NOT Meet Other Criteria “Wastebasket” Category

Beginnings of Breakdown Major Sx of Schizophrenia DO NOT Meet Other Criteria “Wastebasket” Category

Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type

Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type

Have Had One Episode Now Mostly Symptom Free

Have Had One Episode Now Mostly Symptom Free

Once a Schizophrenic, Always a Schizophrenic?

Once a Schizophrenic, Always a Schizophrenic?

Classification Systems and Their Relation to Schizophrenia

Process vs. Reactive Distinction Process – Insidious onset, biologically based, negative symptoms, poor prognosisReactive – Acute onset (extreme stress), notable behavioral activity,best prognosis

Good vs. Poor Premorbid Functioning in SchizophreniaFocus on person’s level of function prior to developing schizophreniaNo longer widely used

Type I vs. Type II Distinction and SchizophreniaType I – Positive symptoms, good response to medication, optimistic prognosis, and absence of intellectual impairmentType II – Negative symptoms, poor response to medication, pessimistic prognosis, and intellectual impairments

Early Brain Damage Neurological “Soft Signs”

– Attentional and Reflex Problems (Nasrallah & Smeltzer, 2002)

Runs In Families– High Expressed Emotion & Relapse

– What is the Genetic Risk?

Early Brain Damage Neurological “Soft Signs”

– Attentional and Reflex Problems (Nasrallah & Smeltzer, 2002)

Runs In Families– High Expressed Emotion & Relapse

– What is the Genetic Risk?

Etiology of Schizophrenia

• Genetic studies using twin, family and adoption techniques reveal that a predisposition for schizophrenia is transmitted genetically

• Brain pathology, possibly including damage to the fetal brain from virus-like diseases, are likely biological vulnerabilities for schizophrenia (diathesis)

Ch 11.5

Genetic Studies of Schizophrenia

Relation to PercentageProband Schizophrenic

Spouse 1.00Grandchildren 2.84Nieces/nephews 2.65Children 9.35Siblings 7.30DZ twins 12.08MZ twins 44.30

Ch 11.6

Runs in Families Increased Risk Based on Genetic Relatedness Search for Marker Genes

Smooth Pursuit Eye Tracking

Runs in Families Increased Risk Based on Genetic Relatedness Search for Marker Genes

Smooth Pursuit Eye Tracking

Genetic Influences Genetic Influences

Biochemistry of Schizophrenia

• Dopamine theory holds that the positive symptoms of schizophrenia result from excessive activity of dopamine in brain– Anti-schizophrenia drugs block dopamine receptors

• The anti-schizophrenia drugs take several weeks to act clinically, yet rapidly block dopamine receptors

– Ingestion of amphetamine can induce psychosis; amphetamine causes the release of dopamine from neurons

Ch 11.7

Figure 11.1 Dopamine Activity in Mesolimbic and Mesocortical Pathways

Ch 11.8

•Overactivity of dopamine neurons in the mesolimbic pathway may cause positive symptoms.

–Antipsychotics which block dopamine receptors lessen positive symptoms

•Underactivity of dopamine neurons in the mesocortical pathway in the l prefrontal cortex may cause negative symptoms

–Antipsychotics have little or no effect on negative symptoms.

Dopamine Theory of Schizophrenia

Antagonists– Neuroleptics

– Drugs That Reduce Dopamine

– Negative Side Effects

– L-Dopa (Agonist)

– Amphetamines

Antagonists– Neuroleptics

– Drugs That Reduce Dopamine

– Negative Side Effects

– L-Dopa (Agonist)

– Amphetamines Genetic Influences Genetic Influences

Neurobiological Influences Neurobiological Influences

Excess Dopamine (D2 Receptors) Excess Dopamine (D2 Receptors)

Glutamate Theory

• PCP (“angel dust”) and ketamine (an anesthetic) mimic the positive and negative symptoms of schizophrenia (Javitt & Cole, 2004)

• These drugs block the action of a form of glutamate receptor (NMDA receptor)

• NMDA receptor blockade may produce the dopamine dysfunction seen in schizophrenia, as if too little dopamine were present in the prefrontal cortex (negative symptoms) and too much dopamine in the mesolimbic area (positive symptoms)

Brain Pathology in Schizophrenia

• Brains of schizophrenic patients show– Reduced volume of temporal and frontal cortex – Enlarged ventricles (reflecting loss of brain cells)

• For 12 of 15 twins, the schizophrenic twin could be identified by enlarged ventricles

– Reduced metabolic activity within prefrontal cortex (frontal hypoactivation)

Ch 11.9

Ventricle Enlargement Ventricle Enlargement

Genetic Neurobiological

Influences

Genetic Neurobiological

Influences

Brain Structure Brain Structure

Ventricle Enlargement Ventricle Enlargement

Genetic Neurobiological

Influences

Genetic Neurobiological

Influences

Brain Structure Brain Structure

Hypofrontality Hypofrontality

Psychological Stress & Schizophrenia

• Example of diathesis-stress model• Social class and schizophrenia

– Sociogenic hypothesis– Social-Selection theory (more research support)

• Expressed emotion (EE) - Research shows how family and social environmental context affects re-hospitalization rates

• High-Risk studies of schizophrenia

Causes of Schizophrenia:Psychological and Social Influences

(cont.)

Figure 13.9 Barlow/Durand, 3rd. Edition. Cultural differences in expressed emotion (EE)

Therapies for Schizophrenia• Psychosurgery

– Prefrontal lobotomy • Drug therapies

– Antipsychotic medications that block dopamine receptors• Chlorpromazine (Thorazine)

– Became widely available in 1954• Others include haloperidol (Haldol) and thiothixene (Navane)

– Reduce agitation, violent behavior, and other emotional and behavioral excesses.

– Disadvantages:• Side effects especially extrapyramidal side effects• About 30% of patients do not respond• Little or no effect on negative symptoms

– Newer medications: • Clozapine (Clozaril), respiradone (Risperdal)

Ch 11.10

Haldol & Clozapine Trial and Error “Extrapyramidal” Side Effects

Tardive Dyskinesia

Akinesia

Atypical Antipsychotics: (Clozapine, Risperdal, Zyprexa,Seroquel, Geodon, Abilify)

Haldol & Clozapine Trial and Error “Extrapyramidal” Side Effects

Tardive Dyskinesia

Akinesia

Atypical Antipsychotics: (Clozapine, Risperdal, Zyprexa,Seroquel, Geodon, Abilify)

Biological Interventions Neuroleptics

Biological Interventions Neuroleptics

Medical Treatment of Schizophrenia (cont.)

Table 13.2 Barlow/Durand, 3rd.Antipsychotic medications

Psychological Treatments for Schizophrenia

• Social-skills training involves teaching behaviors to interact successfully with others

• Family therapy aims to reduced expressed emotion (hostility, overly critical)

• Cognitive-behavioral therapy demonstrates that maladaptive behaviors and beliefs of some patients can be changed– Personal therapy aims to reduce expressed emotion, uses

relaxation techniques and teaches social skills

Ch 11.11`

Cognitive-Behavioral Therapies

• Personal Therapy– Patients are taught

• To recognize inappropriate affect • To recognize signs of relapse• Relaxation techniques to reduce anxiety & anger• Rational emotive therapy techniques to reduce frustration and

prevent explosive or inappropriate interpersonal behavior. • Social skills training to enhance interpersonal functioning.

Psychosocial Treatment of Schizophrenia

Figure 13.10 Barlow/Durand, 3rd. EditionStudies on treatment of schizophrenia from 1980 to 1992

Summary of Schizophrenia and Psychotic Disorders

Figure 13.x1 Barlow/Durand, 3rd. Ed.Exploring schizophrenia and its treatment

Summary of Schizophrenia and Psychotic Disorders (cont.)

Figure 13.x1 Barlow/Durand, 3rd Edition (cont.)Exploring schizophrenia and its treatment

Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Brief Psychotic Disorder Shared Psychotic Disorder

Folie a Deux

Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Brief Psychotic Disorder Shared Psychotic Disorder

Folie a Deux