13- Schizo Flashcards

1
Q

History

A

Emil Kraepelin => Recall medical model / classification of “syndromes”

Refined unitary concept of “psychosis” into two distinct syndromes:

  • Dementia Praecox = dx with progressive deterioration (Unlike other dementias, begins at early age)
  • Manic Depression

=> Differentiated BP and Schz as distinct dx but evidence now for common genetic vulnerability and continuum of dysfunction

Eugen Bleuler (1857 –1939) => Swiss psychiatrist, contemporary of Kraepelin

Argued against notion that this phenomena was best characterized as dementia (deterioration) praecox (early onset) => Did not always deteriorate + Could emerge at later age

=> In 1911, used the term “schizophrenia” for the first time aka “schizo” (to split, or crack) “phren” (mind)

  • Dx characterized primarily by loss of association between thought processes, emotion, and behavior
  • Caused by neurobiological disease process
  • Gives rise to secondary sx ex: hallucinations, delusions
  • Distinction from “multiple personality disorder” => Or dissociative identity disorder (DID) in DSM-5
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2
Q

Schizo DSM-5 Criteria

A

Need at least TWO of the following:

  • Delusions*
  • Hallucinations*
  • Disorganized speech*
  • Grossly disorganized or catatonic beh
  • Negative symptoms

=> With marked functional impairment, sx present for 6 months and includes at least one month of active symptoms

  • Ruled out other disorders ex: unipolar, bipolar, schizoaffective disorder
  • Not attributable to substance use
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3
Q

Delusions

A

Dx of thought content

  • False belief based on an incorrect inference
  • Firmly held despite contradictory evidence
  • Delusions are extreme end of continuum
  • Mild end: over-valued ideas => False belief, but willing to entertain the idea that it’s false (Common in schizotypal PD + prodromal (low sx lvl) schizo)

Ex:

  • Thought broadcasting
  • Thought insertion
  • Grandiose delusions
  • Delusions of jealousy
  • Nihilistic delusions (nothing is real, everyone is dead)
  • Persecutory delusions (ex: under cover agents)
  • Delusions of reference (everything in your env is for you)
  • Religious delusions
  • Somatic delusions
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4
Q

Hallucinations

A
  • Continuum from illusions to hallucinations
  • Can occur in all sensory modalities => Auditory*, visual, olfactory, tactile, gustatory

=> Auditory: Perceived as distinct from one’s own thoughts, Speak at normal conversational volume, Often reflect voices of people they know, Most often derogatory

Are they really hearing voices though? => Alternative explanation: Do they misinterpret their own self talk?

=> Study: Sample of Schizophrenic patients with hallucinations, Schizophrenic patients without hallucinations, Healthy controls

Participants read complimentary, derogatory, or neutral adjectives + Recorded them, altered pitch, and played it back to them then ask if source is self, someone else, or unsure

Results:

  • Schz w/ hallucinations more likely to misidentify their distorted speech as belonging to someone else
  • Especially likely if derogatory words (vs. neutral or complimentary)
  • Not just uncertain, but rather positively misidentifying

=> Misattribution of sensory experience + Lots of support for this with brain imaging studies

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5
Q

Disorganized Speech and Catatonic Beh

A

Also disorder of thought form

  • Communicates words and sounds, but
    doesn’t make sense
  • Loosening of associations or “derailment”
  • Word salad
  • Alogia (don’t speak aka poverty of speech)
  • Neologisms (make up words)
  • Blocking (talk…. then stop)

Catatonic Beh => Psychomotor deficits ranging agitation to immobility with unpredictable movements

Problems with everyday activities ex: dressing, hygiene

  • Catatonia => Stupor (rigid posture), Waxy flexibility (can mold them), Much rarer now than 100 years ago
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6
Q

Negative and Positive Sx

A

Neg Sx (absence of ~):

Affect => Blunted/flat affect

  • Appear emotionally unexpressive and nonresponsive, but physiological measures reveal heightened reactivity
  • Inappropriate affect (don’t match sit)
  • Problems perceiving others’ emotions

Motivation => kind of overlap with depression

  • Very socially withdrawn
  • Anhedonia
  • Avolition => no motivation to do things in a goal-directed way

Positive vs. Negative Symptoms

  • Positive = presence of sx that shouldn’t be there ex: hallucinations, delusions, inappropriate affect => tend to respond better to medz
  • Negative = absence of something that should be there ex: blunted affect, alogia, avolition, anhedonia => often very hard to treat (poorer prognosis with negative sx)
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7
Q

Schizoaffective Dx

A

People with schizophrenic features AND a severe mood dx => Mood disorder can be unipolar or bipolar

  • Need to have delusions or hallucinations for at least 2 weeks in the absence of mood episode
  • Symptoms of mood episode present for at least 50% of the total duration of illness
  • Not attributable to effects of substance

=> Issues:

  • Poor reliability
  • Controversial since introduction in 1933
  • Not clearly a distinct dx
  • Prognosis is somewhere between schizophrenia and mood dx
  • Long-term prognosis for schizoaffective > schizophrenia
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8
Q

Epidemio

A

Prevalence Rates & Gender Differences

  • Lifetime prevalence rate about .7% to 1%
  • M:F ratio is about 1.4:1
  • Males tend to have more severe sx
  • Some gender difference may be accounted for by bias in dx => Women also presenting with depressive sx and less severe psychotic sx more likely to be diagnosed with something else
  • Female sex hormones (estrogen) may also be protective => Postmenopausal, estrogen decreases *Late-onset schizophrenia more common in women

Age of Onset => Most onset in late adolescence and early adulthood (18 to 30)

  • Gender differences in onset
  • Schizophrenia in childhood rare
  • Extremely rare to see onset before age 13
  • More common boys

Course => Study: Followed 208 patients for 20 years

  • 22% had very bad outcomes (continually psychotic)
  • 52% had intermediate outcomes (symptoms, but not continually psychotic)
  • 22% had improved

=> Many attempts to re-examine these data have
found same pattern of findings

  • More insidious onset associated with poorer outcomes (vs. acute onset)
  • Course is very heterogeneous => Probably because dx is heterogeneous

=> Variation as function of country

  • Studies consistently find better outcomes for ind with schizo in developing countries
  • Despite poorer countries having less access to mental health resources and services ex: less likely to be on antipsychotic medz

Unclear why, but have proposed cultural explanations => Greater dependence on social network

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9
Q

Comorbidity and Violence

A

Subs abuse very common =>

  • Especially alcohol and nicotine
  • Nicotine may play self-medicating role
  • Subs can also trigger sx => improve fcting & improve cognitive deficits that axe ass with attention, memory, sensory processing

=> Average life expectancy is approx. 20 years shorter than general population

Suicide

  • About 20% will make at least one attempt
  • 5% die by suicide
  • Especially young men
  • Some evidence that those with best premorbid functioning more at risk

=> Common perception that people with schizophrenia are dangerous and aggressive

Likely a slight increase in risk (population wide)

Aggression more common if:

  • Male
  • History of violence
  • Non-adherence to taking meds
  • Impulsive personality traits

=> Link between schizophrenia and aggression is probably best accounted for by substance use *Substance use alone increases risk of aggression

Majority of people with schizophrenia more likely
to be victims of violence or suicide

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10
Q

Etiology - Genes and Env

A

Schizophrenia has long been known to run in families => Risk increases with increasing genetic similarity and Also find higher rates of schizotypal PD in families of person with schizo

Twin Studies

  • Higher concordance rates for Mz twins than for Dz twins
  • Meta-analyses suggest concordance rates of: Mz: 28% * Dz: 6% (Heritable, but not as heritable as bipolar)

Study: Offspring => Incidence rate of schizophrenia 17.4% (kids have High genetic risk + Low environmental risk)

Twin studies can also overestimate genetic heritability

Genetic Vulnerability

  • Clear that genes play a role
  • Attempts to identify “schizogenes” => Over 600 possible genes identified each making small contribution to outcome
  • Also clear that genes don’t explain everything (not 100% concordance rates)
  • Adoption studies demonstrate that the environment you are raised in matters => Adopted kids of biological parent with schizophrenia have heightened risk BUT no risk if they are raised in healthy adopted family env

*Genes are not deterministic

Shared Environment

  • 2/3 of Mz twins are monochorionic (share placenta and blood supply)
  • Dz twins are always dichorionic
  • Schiz concordance rates for Mz twins that are monochorionic are higher than Mz twins that are dichorionic
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11
Q

Risk Factors (5)

A

1- Prenatal Viral Infections

  • Mother’s exposure to viral infections during pregnancy
  • Major epidemic of influenza in Finland => Increased risk of Schiz among children of moms who were at their second trimester at the time of the epidemic *But, can’t tell if moms were actually exposed or not
  • Direct evidence: Measured antibodies for viruses during pregnancy => Found increased risk of later schizophrenia

=> What is the mechanism? New research looking at immune response

2- Season of Birth

  • Small but significant increase in risk for people born in late winter, early spring (5-10% increase)
  • Viral infections most common in fall and early winter => Mom would be in second trimester of gestation for people born in late winter, early spring
  • Others propose that lack of vitamin D exposure can influence prenatal brain developmental

3- Birth Complications

  • Schiz more likely to have experienced birth complications than healthy controls ex: prolonged labor, preterm delivery, low birth weight, fetal distress, breathing difficulties
  • All can result in hypoxia/anoxia
  • Hypoxia/anoxia at birth can also result in structural brain changes and alter sensitivity to dopamine

4- Advanced Paternal Age

  • Advanced paternal age at conception associated with increased risk of Schiz
  • Evidence suggests this might best be accounted for by association between late fatherhood and schizotypal PD => Men with schizotypal PD more likely to marry late

5- Social Class

  • Schizophrenics tend to have lower SES

Two competing hypotheses:

  • Social causation
  • Social drift
  • Social drift: Family of schizophrenic not necessarily at low SES
  • Social causation: Immigrants have higher rates of Schiz, but country of origin do not
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12
Q

Etiology - Neurocognitive (4)

A

1- Neurocognitive Impairments

  • Frontal brain deficiency hypothesis
  • Consistently see poor performance on neuropsychological tests that rely on frontal lobe ex: attention, language, memory
  • Cognitive impairments appear early on => Low IQ risk factor for Schiz * Likely not just consequence of the illness (However, deficits can be magnified in acute phases)

Ex: Wisconsin Card Sorting Task => don’t have flexible thinking

2- Smooth Pursuit => deficits in smooth pursuit in Schiz patients

  • Also see deficits in first-degree relatives of Schiz patients
  • Stable over time
  • Seems to not just be due to attentional dysfunction => Don’t find this in ADHD samples

3- Loss of Brain Volume

  • Lots of evidence for decreased whole brain volume in schizophrenia (About 3% less volume than controls)
  • Even in recent-onset (suggests not a result of tx)
  • Progressive loss of gray matter after onset
  • Progressive deterioration also continues for many years into the illness => Re: Kraepelin’s dementia praecox

4- Gray Matter Deficits

  • Also evident in discordant Mz twins of schizophrenics
  • Not explained by antipsychotic medz or other tx
  • Not explained by damage from the illness itself
  • May be a causal risk factor under genetic control
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13
Q

Dopamine Hypothesis

A

One of the most enduring theories of schizophrenia

  • Therapeutic effects of antipsychotic drug on schizophrenic symptoms worked on dopamine system => Blocks dopamine D2 receptors
  • Cocaine, amphetamines boost DA activity => Can result in psychosis, paranoia, distorted sense of reality
  • L-DOPA for Parkinsons => Suggestive, but none provide direct evidence

Previously challenging to study

  • One approach was to use postmortem brains
  • Challenging because most people with Schiz are on antipsychotics

Technological advances with PET scans

  • Too much dopamine synthesized and released into synapse
  • Some evidence for increased D2 and D3 receptors (although more likely linked to treatment effects)

Revised dopamine hypothesis

  • Excess DA transmission in striatum
  • Reduced DA transmission in frontal lobes

How might DA influence schizophrenic sx?

Positive sx can be explained by increased DA activity

  • Aberrant salience
  • Increased DA may cause pts to attend more to
    irrelevant stimuli
  • Patients may struggle to make sense of everyday experiences

Negative sx can be explained by decreased DA activity

  • Anhedonia, avolition, alogia
  • Cognitive impairments (working memory)
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14
Q

Etiology - Cannabis Use

A

People with schizophrenia are 2x more likely to smoke weed => Correlate? Or cause?

  • Evidence that it predicts onset of Schiz => But could they just be in early stages of disorder? Significant effect even when controlling for childhood sx of psychosis
  • THC increases DA synthesis
  • Cannabis use exacerbates symptoms in people with Schiz
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15
Q

Etiology - Family Env (EE)

A
  • “Schizophrenogenic mother”
  • Expressed Emotion => Deinstitutionalization of patients (Some go home to live with parents/Some live solitary lives)
  • Expressed emotion (EE) refers to caregiver’s attitudes toward child with mental dx

Three components:

  • Criticism
  • Hostility
  • Emotional overinvolvement

=> Repeatedly shown to predict relapse *Regardless of characteristics of patients

  • When EE is lowered, relapse rates decrease
  • Suggests EE may at least play causal role in relapse
  • Idea is that high EE increases stress for the patient

Vicious Cycle => Patient says something strange, High EE family more likely to criticize, Increases probability of another strange remark, Increases probability of more criticism

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16
Q

Tx - Pharmaco

A

Psychopharmacology

Prior to the development of antipsychotics (1950s) most patients with schizophrenia spent their lives in psychiatric institutions

  • Antipsychotics among the first tx to offer relief from positive sx of psychosis
  • Made deinstitutionalization possible for many
  • Hospital stays now reserved for acute phase of dx
  • Antipsychotics are dopamine antagonists

First Generation (ex: chlorpromazine, haloperidol)

  • Some pts experience extrapyramidal effects
  • Similar to Parkinson’s: stooped posture, muscular rigidity, shuffling gate, drooling
  • Can be treated with anti-Parkinson’s drugs => But also have negative side effects
  • After prolonged use, may develop Tardive Dyskinesia (Eye twitching, tongue thrusting) & Effects may be permanent for some

Second Generation (ex: risperidone, olanzapine, quetiapine, aripiprazole)

  • Cause fewer extrapyramidal sx
  • Largely not more effective (exception is Clozapine)
  • Do have mood stabilizing properties => Helpful for bipolar
  • Largely more expensive
  • Side effects: drowsiness, considerable weight gain, diabetes, loss of white blood cells

Conclusion

  • Usage is long-term => Because schizophrenia is often chronic in nature but does not “cure” schizophrenia *Only controls sx
  • Lots of side effects
  • Many pts tempted to stop taking medication when they feel better => Increases risk of relapse, medz can be delivered via long-acting intramuscular injections
  • Only useful for positive sx, less for negative sx *Some patients don’t benefit at all
17
Q

Tx - Psychosocial

A

Psychosocial Interventions

  • Family therapy effective adjunct => Especially for high EE families

Skills training:

  • Social: Improve interpersonal communication and interactions
  • Living: Enhance ability to deal with daily activities (ex: household tasks)

Cognitive Behavioral Therapy (change beliefs and consequences about event)

Until recently, not considered a viable option => Schizophrenia was considered to be too impairing

Goals are:

  • Reduce emotional disturbance
  • Reduce psychotic sx
  • Decrease social impairments
  • Reduce risk of relapse

=> May be helpful for positive sx but Not very helpful for negative symptoms