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)

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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)

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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

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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

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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

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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

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Description – Positive symptoms

• Catanonia – stuporous, rigidity, negativism, posturing, waxy flexibility; echopraxia and echolalia; excitement

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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

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Description – Three main types of symptoms

• Psychomotor poverty

• Disorganization

• Reality distortion

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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

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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)

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Diagnostic issues - Subtypes

• Paranoid – 35-40%

• Disorganized – 10%

• Catatonic – 10%

• Undifferentiated – 20%

• Residual – 20%

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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

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Etiology – Dynamic vulnerability model

• Genetic endowment

• Vulnerability

• Symptoms of schizophrenia

• Appraisal and coping

• Stressors

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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

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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)

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Etiology – Vulnerabilities

• Prenatal and perinatal influences

• Neuroanatomical – basal ganglia and thalamus, front lobes, temporal lobes and ventricles

• Neurodevelopmental factors – synaptic density

• Personality factors

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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

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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

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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

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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)

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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

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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

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Treatments – Paul & Lentz (1977) study

Therapeutic milieu program

• Expectations

• Involvement

• Group cohesion

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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

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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

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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

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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)

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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 (A-way express, the Raging Spoon)

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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