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SchizophreniaSchizophreniaSchizophreniaSchizophrenia
Onset 18-35 yearOnset 18-35 yearPrevalence 0.6%Prevalence 0.6%Positive, negative and disorganisation symptomsPositive, negative and disorganisation symptomsCognitive disorderCognitive disorderMultifactorial genetic and non-genetic aetiologyMultifactorial genetic and non-genetic aetiologyDevelopmental originDevelopmental origin20% life-span reduction 20% life-span reduction Cost $200 billion/year worldwideCost $200 billion/year worldwide
Dopamine Hypothesis Dopamine Hypothesis Dopamine Hypothesis Dopamine Hypothesis
Mesolimbic pathwayMesolimbic pathway
Nigrostratial pathway Nigrostratial pathway (part of EP system)(part of EP system)
Tuberoinfundibular pathwayTuberoinfundibular pathway(inhibits prolactin release)(inhibits prolactin release)
Mesocortical pathwayMesocortical pathwayHypoactivity:Hypoactivity:
negative symptomsnegative symptoms
Hyperactivity:Hyperactivity:positive symptomspositive symptoms
Haloperidol and D2 Occupancy
11C-Raclopride PET Scan
Coregistered MRI Scan
BeforeTreatment
Haloperidol2 mg/d (74% Occ.)
11C-Raclopride PET Scan
Medication side effectsMedication side effectsMedication side effectsMedication side effects
ParkinsonismParkinsonism
AcathisiaAcathisia
DystoniaDystonia
HallucinationsHallucinations
Psychological modelsPsychological modelsPsychological modelsPsychological models
Lower level Lower level intrusionsintrusions
Appraisal of Appraisal of experience as experience as
externalexternalSymptomsSymptoms
Emotional Emotional changeschanges
Cognitive Cognitive attributionsattributions
Mood and psychosisMood and psychosisMood and psychosisMood and psychosis
Disturbed source monitoringDisturbed source monitoringDisturbed source monitoringDisturbed source monitoring
Voice distorterVoice distorterFrith et al, 1995Frith et al, 1995
Auditory hallucinationsAuditory hallucinationsAuditory hallucinationsAuditory hallucinations
DelusionsDelusions
Threatning/adverse events
delusions negative self concept
Need to readjust self concept
Positive self perception at the expense of others having a negative view of the person Bentall et al., 1994 Kinderman &
Bentall, 1996
External attribution of negative events: “others are to blame for the negative things that happen to me”
actual self ideal self
Attribution self-representation cycleAttribution self-representation cycleAttribution self-representation cycleAttribution self-representation cycle
Cumulative effect of LECumulative effect of LECumulative effect of LECumulative effect of LE
OnsetOnsetPsychosisPsychosis
Hirsch et al, 1996Hirsch et al, 1996
A B
85 15 15 85
Theory of mindTheory of mindTheory of mindTheory of mind
Frith & Corcoran, 1996Frith & Corcoran, 1996Frith & Corcoran, 1996Frith & Corcoran, 1996
First order false beliefFirst order false beliefFirst order false beliefFirst order false belief
John has five cigarettes left in his packet. He John has five cigarettes left in his packet. He puts his packet on the table and goes out of puts his packet on the table and goes out of
the room. Meanwhile, Janet comes in and takes the room. Meanwhile, Janet comes in and takes one of John’s cigarettes and leaves the room one of John’s cigarettes and leaves the room
without John knowing.without John knowing.
John has five cigarettes left in his packet. He John has five cigarettes left in his packet. He puts his packet on the table and goes out of puts his packet on the table and goes out of
the room. Meanwhile, Janet comes in and takes the room. Meanwhile, Janet comes in and takes one of John’s cigarettes and leaves the room one of John’s cigarettes and leaves the room
without John knowing.without John knowing.
ToM question: When John comes back for his cigarettes, how ToM question: When John comes back for his cigarettes, how many does he think he has left?many does he think he has left?ToM question: When John comes back for his cigarettes, how ToM question: When John comes back for his cigarettes, how many does he think he has left?many does he think he has left?
Memory question: How many cigarettes are really left in Memory question: How many cigarettes are really left in John’s packet?John’s packet?Memory question: How many cigarettes are really left in Memory question: How many cigarettes are really left in John’s packet?John’s packet?
Cascade model of psychotic symptomsCascade model of psychotic symptomsCascade model of psychotic symptomsCascade model of psychotic symptoms
Jones, 1994Jones, 1994
Theory of mind Theory of mind difficultiesdifficulties
Difficulties making inferences about Difficulties making inferences about other children’s mental statesother children’s mental states
Increasingly unsure of self, Increasingly unsure of self, social withdrawalsocial withdrawal
Decreasing opportunities for social Decreasing opportunities for social interaction and reality testinginteraction and reality testing
Social isolationSocial isolation
Paranoid Paranoid attributionsattributions
CBTCBTCBTCBT
Delusions: guided discovery, socratic questioningDelusions: guided discovery, socratic questioning
Hallucinations: attributions, coping mechanismsHallucinations: attributions, coping mechanisms
Thought disorder: “thought linking”Thought disorder: “thought linking”
Negative symptoms: paced activity schedules, Negative symptoms: paced activity schedules, mastery diarymastery diary
Delusions: guided discovery, socratic questioningDelusions: guided discovery, socratic questioning
Hallucinations: attributions, coping mechanismsHallucinations: attributions, coping mechanisms
Thought disorder: “thought linking”Thought disorder: “thought linking”
Negative symptoms: paced activity schedules, Negative symptoms: paced activity schedules, mastery diarymastery diary
Prodromal phase of symptomsProdromal phase of symptomsProdromal phase of symptomsProdromal phase of symptoms
0
1
2
Years before 1st admission
Mean number of symptoms
Unspecific symptoms
Negative symptoms
Positive symptoms
Häfner et al, 1999Häfner et al, 1999
73% had prodromal symptoms73% had prodromal symptoms
onset social disabilities 2-4 onset social disabilities 2-4 years before first admissionyears before first admission
Outcome of Outcome of childhood psychotic experiencechildhood psychotic experiencessOutcome of Outcome of childhood psychotic experiencechildhood psychotic experiencess
0369
121518212427
Rate schizophre-
niform disorder age 26
age 11 NOpsychotic
experience
age 11psychotic
experience
N=761 – CIDI interviewsN=761 – CIDI interviews
Poulton et al Arch Gen Psych, 2000Poulton et al Arch Gen Psych, 2000
Transition modelTransition modelTransition modelTransition model
Psychotic Psychotic experience experience
(pre-)(pre-)
First episode First episode of disorder of disorder
(post-)(post-)
TimeTime
The process of needThe process of needThe process of needThe process of need
Psychotic experiencePsychotic experience
AttributionsAttributions
Need for careNeed for care
Emotional changeEmotional change
CopingCoping
Are voices more likely to result in need for Are voices more likely to result in need for care in the presence of delusions?care in the presence of delusions?
Are voices more likely to result in need for Are voices more likely to result in need for care in the presence of delusions?care in the presence of delusions?
VoicesVoices
No delusional No delusional ideationideation
Delusional Delusional ideationideation
SchizophreniaSchizophrenia
T1T1
T2T2
T3T3
De Clérambault, 1947; Maher & Ross, 1974De Clérambault, 1947; Maher & Ross, 1974
CannabisCannabis
No pre-existing No pre-existing psychosispsychosis
Pre-existing Pre-existing psychosispsychosis
Psychosis outcomePsychosis outcome
Interaction with pre-existing psychosisInteraction with pre-existing psychosisInteraction with pre-existing psychosisInteraction with pre-existing psychosis
T1T1
T3T3
2.2%2.2% 54.7%54.7%
American Journal of Epidemiology, 2002American Journal of Epidemiology, 2002
Lack of motivationLack of motivation
Blunting of affectBlunting of affect
Ventricular enlargementVentricular enlargementVentricular enlargementVentricular enlargement
Fetal programming and morbidity accumulationFetal programming and morbidity accumulationFetal programming and morbidity accumulationFetal programming and morbidity accumulation
Verbal learning:Verbal learning:remembering verbal informationremembering verbal information
Immediate or working memory:Immediate or working memory:keeping in mind limited informationkeeping in mind limited informationfor a short-term for a short-term
Problem solving:Problem solving:planning and sequencing actionsplanning and sequencing actions
Sustained attention:Sustained attention:target from noise discrimination over timetarget from noise discrimination over time
Cognitive ConstructsCognitive ConstructsCognitive ConstructsCognitive Constructs
Cognitive Constructs - Verbal LearningCognitive Constructs - Verbal LearningCognitive Constructs - Verbal LearningCognitive Constructs - Verbal Learning
Definition:Definition: ability to acquire, store, and retrieve verbal information for more than a few minutes ability to acquire, store, and retrieve verbal information for more than a few minutes
Example:Example: California California Verbal Learning TestVerbal Learning Test
Activities of daily living:Activities of daily living: remembering information from a remembering information from a rehabilitation program, class, vocational setting, clinic visitrehabilitation program, class, vocational setting, clinic visit
drilldrillplumsplumsvestvestparsleyparsleygrapesgrapespaprikapaprikasweatersweaterwrenchwrench
chiveschivestangerinestangerineschiselchiseljacketjacketnutmegnutmegapricotsapricotsplierspliersslacksslacks
Definition:Definition: ability to hold information “on line” in a temporary store and/or to ability to hold information “on line” in a temporary store and/or to manipulate the informationmanipulate the information
Example:Example: Letter Number Sequencing Test Letter Number Sequencing Test
Activities of daily living:Activities of daily living: carrying on a social carrying on a social conversation, switching between different tasks conversation, switching between different tasks
K3B4K3B4 _ _ _ _ _ _ _ _
R8C3G5R8C3G5 _ _ _ _ _ __ _ _ _ _ _
Cognitive Constructs – Working MemoryCognitive Constructs – Working MemoryCognitive Constructs – Working MemoryCognitive Constructs – Working Memory
Definition:Definition: ability to plan, sequence, self-monitor, comprehend, and implement rules ability to plan, sequence, self-monitor, comprehend, and implement rules
Example:Example:Wisconsin CardWisconsin CardSorting TestSorting Test
Activities of daily living:Activities of daily living: planning a meal, using planning a meal, using public transportation, following steps for a job taskpublic transportation, following steps for a job task
Cognitive Constructs – Problem SolvingCognitive Constructs – Problem SolvingCognitive Constructs – Problem SolvingCognitive Constructs – Problem Solving
100 ms
Definition:Definition: ability to respond to targets, not respond to nontargets, over a period of time ability to respond to targets, not respond to nontargets, over a period of time
Example:Example: Continuous Performance Test Continuous Performance Test
Activities of daily living:Activities of daily living: identifying relevant information identifying relevant information in a social interaction, discussions with a doctor in a social interaction, discussions with a doctor
“Press when you see a 7 preceded by a 3”
Stimulus
Response
1 second
66 55 77 44 33 77 99
hold hold hold hold hold press holdTime
Cognitive Constructs – Sustained AttentionCognitive Constructs – Sustained AttentionCognitive Constructs – Sustained AttentionCognitive Constructs – Sustained Attention
Cochrane cognitive Cochrane cognitive rehabilitationrehabilitation
Family Guidelines Family Guidelines (examples)(examples)Family Guidelines Family Guidelines (examples)(examples)
Go slowGo slow
Solve problems step-by-stepSolve problems step-by-step
Keep it simpleKeep it simple
Keep it coolKeep it cool
Give each other spaceGive each other space
Lower expectationsLower expectations
McFarlane, 2002McFarlane, 2002
Disorganised speechDisorganised speech
Pro generale continuatie en in Pro generale continuatie en in particuliere explicatie op uw particuliere explicatie op uw singuliere interrogatie onze singuliere interrogatie onze
affirmamentatie. Ontelbaarheid van affirmamentatie. Ontelbaarheid van levensverhalen zijn aan deze levensverhalen zijn aan deze bladzee gesneefd, frêle als bladzee gesneefd, frêle als
flikflokjes, zooisel van boven, als flikflokjes, zooisel van boven, als een wjoengand waaigat vol een wjoengand waaigat vol
dwaereldriften. dwaereldriften.
“One of the most elusive diseases known to man and unknown to
medicine””
Joyce, 1936Joyce, 1936
CatatoniaCatatoniaCatatoniaCatatonia
FinFin
Definition:Definition: a composite score representing memory, attention, visuospatial skills, language, etc a composite score representing memory, attention, visuospatial skills, language, etc
Example:Example: Repeatable Battery for Assessment of Neuropsychological Status Repeatable Battery for Assessment of Neuropsychological Status
Activities of daily living:Activities of daily living: large associations with most types of community large associations with most types of community adaptation including social, vocational, and rehabilitation successadaptation including social, vocational, and rehabilitation success
Brief (25-min) paper and pencil test with 2 alternate formsBrief (25-min) paper and pencil test with 2 alternate forms
Subtests:Subtests: - Immediate memory - Immediate memory - Visuospatial/constructional - Visuospatial/constructional - Language (naming and fluency)- Language (naming and fluency)- Attention- Attention- Delayed memory- Delayed memory- Total score - Total score
Summary Score From Screening TestSummary Score From Screening TestSummary Score From Screening TestSummary Score From Screening Test
PsychotherapyPsychotherapyPsychotherapyPsychotherapy
Psychological modelsPsychological modelsPsychological modelsPsychological models
Lower level Lower level intrusionsintrusions
Appraisal of Appraisal of experience as experience as
externalexternalSymptomsSymptoms
Reasoning biasesReasoning biases
Attribution biasesAttribution biases
Dysfunctional schemataDysfunctional schemata
IsolationIsolation
Adverse environmentsAdverse environments
Emotional Emotional changeschanges
Garety, Kuipers, Fowler, Garety, Kuipers, Fowler, FreemanFreeman & & Bebbington, 2001; Bebbington, 2001;
Bentall et al, 2002; Chadwick & Bentall et al, 2002; Chadwick & Birchwood, 1994; Morrison et Birchwood, 1994; Morrison et al, 1995; Hemsley et al, 1993al, 1995; Hemsley et al, 1993
CBTCBTCBTCBT Tarrier et al, 1993Tarrier et al, 1993 Drury et al, 1996Drury et al, 1996 Kuypers et al, 1997Kuypers et al, 1997 Tarrier et al, 1998Tarrier et al, 1998 Sensky et al, 2000Sensky et al, 2000 Lewis et al, 2000Lewis et al, 2000 Turkington et al, 2000Turkington et al, 2000
First episodeFirst episode
BefriendingBefriending
Supp. counsellingSupp. counselling
““Real life”Real life”
““TAU”TAU”
PsychotherapyPsychotherapyPsychotherapyPsychotherapy
Theory of mindTheory of mind
Self-monitoringSelf-monitoring
•AuditoryAuditory
•MotorMotor
•MemoryMemory
Probabilistic reasoning biasProbabilistic reasoning bias
Dysfunctional attributions/ self-esteemDysfunctional attributions/ self-esteem
Theory of mindTheory of mind
Self-monitoringSelf-monitoring
•AuditoryAuditory
•MotorMotor
•MemoryMemory
Probabilistic reasoning biasProbabilistic reasoning bias
Dysfunctional attributions/ self-esteemDysfunctional attributions/ self-esteem
Sandy en Ivan gaan samen met de trein naar Sandy en Ivan gaan samen met de trein naar huis. Sally woont in Weert maar de trein stopt huis. Sally woont in Weert maar de trein stopt niet in Weert. Sandy moet in Roermond niet in Weert. Sandy moet in Roermond uitstappen en met de bus verder gaan. Als uitstappen en met de bus verder gaan. Als Sandy eventjes weg is om een tijdschrift te Sandy eventjes weg is om een tijdschrift te kopen wordt er omgeroepen dat de trein wel in kopen wordt er omgeroepen dat de trein wel in Weert stopt. Een conducteur vertelt Ivan dat de Weert stopt. Een conducteur vertelt Ivan dat de trein wel doorgaat naar Weert en Ivan gaat trein wel doorgaat naar Weert en Ivan gaat Sandy zoeken om het nieuws te vertellen. Nog Sandy zoeken om het nieuws te vertellen. Nog voor Ivan haar gevonden heeft is ook Sandy voor Ivan haar gevonden heeft is ook Sandy reeds op de hoogte van de verandering. reeds op de hoogte van de verandering. Uiteindelijk komt Ivan haar weer tegen net nadat Uiteindelijk komt Ivan haar weer tegen net nadat ze haar ticket gekocht heeft.ze haar ticket gekocht heeft.
Vraag: voor welk station denkt Ivan dat Sandy Vraag: voor welk station denkt Ivan dat Sandy een ticket gekocht heeft?een ticket gekocht heeft?
CBTCBTCBTCBT EngagementEngagement Identiying antecedentsIdentiying antecedents Normalising rationaleNormalising rationale Diagnosing comorbid depression/anxietyDiagnosing comorbid depression/anxiety Agreement on working planAgreement on working plan
EngagementEngagement Identiying antecedentsIdentiying antecedents Normalising rationaleNormalising rationale Diagnosing comorbid depression/anxietyDiagnosing comorbid depression/anxiety Agreement on working planAgreement on working plan
The process of needThe process of needThe process of needThe process of need
Psychotic experiencePsychotic experience
AttributionsAttributions
Need for careNeed for care
Emotional changeEmotional change
The process of needThe process of needThe process of needThe process of need
Psychotic experiencePsychotic experience
Need for careNeed for care
CopingCoping
Pathways to carePathways to carePathways to carePathways to care
Filter 1Filter 1
Filter 2Filter 2
Filter 3Filter 3
Filter 4Filter 4Psychiatric hospitalPsychiatric hospital
Psychiatric out patientPsychiatric out patient
GP recognisedGP recognised
General populationGeneral population
GP practiceGP practice
Population interventionPopulation intervention
Level of riskLevel of risk
FrequencyFrequency
Population interventionPopulation interventionPopulation interventionPopulation intervention
Filter 1Filter 1
Filter 2Filter 2
Filter 3Filter 3
Filter 4Filter 4Psychiatric hospitalPsychiatric hospital
General populationGeneral population
Schizophrenia is rareSchizophrenia is rareSchizophrenia is rareSchizophrenia is rare
N=10,000N=10,000
Age 20 Age 20 yearsyears
Age 21 Age 21 yearsyears N=2N=2
Life course epidemiology of psychosisLife course epidemiology of psychosisLife course epidemiology of psychosisLife course epidemiology of psychosis
ageage22 2525
prem
orbid
leve
l
prem
orbid
leve
l
of funct
ionin
g
of funct
ionin
g
First signFirst sign
secondarysecondarypreventionprevention
TreatmentTreatment
First episodeFirst episode
1.1 year1.1 year0.9 year0.9 year
The Finnish adoption studyThe Finnish adoption studyThe Finnish adoption studyThe Finnish adoption study
Genetic riskGenetic risk
Risk adultRisk adultschizophreniaschizophrenia
Dysfunctional adoptive familyDysfunctional adoptive family
Tienari et al, 1996Tienari et al, 1996
Non-dysfuntional adoptive familyNon-dysfuntional adoptive family
Low EE
High EE
< 35 hrs.
> 35 hrs.
On med.
No med.
No med.
On med.
No med.
On med.
Total
13%13%
51%51%
69%69%
28%28%
92%92%
53%53%
42%42%
15%15%
15%15%
12%12%
N= N= 128128
Low EE = 71High EE = 57
Vaughn & Leff, 1976Vaughn & Leff, 1976