Chapter 10 - Schizophrenia Flashcards

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1
Q

-schizophrenia is among the most

A

puzzling and disabling clinical syndromes. Schizophrenia touches every facet of an afflicted persons life

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2
Q

Acute episodes are characterized

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by delusions, hallucinations, illogical thinking (thought disorder), incoherent speech and bizarre behavior.

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3
Q

-Social stigma

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plays a large role as well

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4
Q

Between episodes

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people may still be unable to think clearly and my lack appropriate emotional responses to people and events in their lives

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5
Q

Schizophrenia

A

a chronic psychotic disorder characterized by acute episodes involving a break with reality, as manifested by such features as delusions, hallucinations, illogical thinking, incoherent speech, and bizarre behavior

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6
Q

-Emil Kraeplin (1856 – 1926)

A
  • Dementia Praecox - “out of one’s mind” - refers to premature impairment of mental abilities
    • “the loss of inner unity of thought, feeling, and acting” and results in ”disintegration of the personality:
    • progressive disease process
    • hallucinations , motoring abnormalities
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7
Q

-Eugen Bleuler (1857 – 1939) – the 4 A’s

A
  • Associations (loose) - ideas are strung together with little or no relationship between them and the person does not appear to be aware of the lack of connectedness
    • Affect (blunted of inappropriate) - emotional response of affect becomes flattened or inappropriate.
    • Ambivalence - hold ambivalent or conflicting feelings towards others, such as loving and hating them at the same time
    • Autism – withdrawal into a private fantasy world that is not bound by principles of logic, different than the disorder of childhood
  • delusions represent “secondary symptoms” that accompany the primary symptoms but do not define the disorder
    • introduced the term schizophrenia (Sz)
      • “split brain”
      • recognized variability in the course of the disorder
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8
Q

-Kurt Schneider (1887 – 1967)

A

-thought the 4 A’s overlapped too much with other disorder and wanted better differential criteria

- First-Rank Symptoms: 
	- central to diagnosis of Sz, initially thought to be unique to Sz
	- ABCD - pathognomonic indicator’s (he believed)

		- Auditory hallucinations 
		- Broadcasting of thought 
			- distinctly to other people 

		- Controlling of thought (Echo, Insertion, Withdrawal)
			- hearing their own thoughts out loud, transmitted thoughts into their heads, someone can remove their thoughts 

		- Delusions
			- irrational, but firmly held beliefs 

- Second-Rank Symptoms 
	- frequently associated with Sz, but not exclusively 
		- mood problems 
		- non-auditory hallucinations (visual, olfactory, haptic, gustatory)
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9
Q

Prevalence and Cost of Schizophrenia

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-1% of the the population; fifth leading cause of disability. Left untreated, it is a highly debilitating disorder
-social isolation
-early onset, few cases spontaneously enter remission permanently
– highly dependent on early diagnosis and treatment
-consequences can be devastating in virtually all main functional areas
-homelessness and victimization are common
-properly treated individuals with Sz are no more harmful that members of the general population
-often suspicious of family members and professionals, so to avoid Tx
-delusions may lead to fear that medications are poison or thought control agents
-medication side effects can be nasty
-poor compliance with social services and our reach workers make it permanency planning difficult
-may be reluctant to allow others into their residence to assess safety of home environment
-about 20x as likely as members of the general population to commit suicide
-more often to be victims than perpetrators of violence, most are withdrawn

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10
Q

Hallucinations

A

-there is clearly a cultural aspect to what people will see when they hallucinate
-hallucinations are not the same for everyone
-most common form of perceptual disturbance in Sz
-auditory are the most common 60-80% of cases
-tactile hallucinations (feeling like snakes crawling all over body) are also common
-visual hallucinations
-gustatory hallucinations – tasting things not present
-olfactory hallucinations – smelling things that are not present
-command hallucinations – being told to do something by the hallucination
Other types:
-grief induced
-drug induced
-lack of stimulation – dark room, float tanks

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11
Q

Phases of Sz – cyclic

A
  • usually afflicts young people at the very time they are making their way from the family into the outside world, develops in late teens to early 20s
  • sometimes there is an acute onset, where the disorder hits fast (within weeks or months)
  • Prodromal Phase
    • clinical config. that comes ahead of it
  • characterized by waning interest in social activities, increasing difficulty in meeting the responsibilities of daily life. Fail to bathe, wear same clothes repeatedly, increasingly odd or eccentric behavior, speech becomes vague or strange
  • may start gradually and then rise to a level of concern among family and friends
    • socially withdrawn, hard to perform day to day tasks, talking to themselves (not hallucinations yet), starting to look odd and eccentric
  • Acute Phase
    • this is where we see more elaborative symptoms. Hallucinations, thought disorder, disorganized speech,
  • talking to oneself of the street, collecting garbage, hoarding food
  • Residual Phase
    • a bit of a retraction of the primary symptoms, there is still an element of the thought disorder
  • closer to that of the prodromal phase
  • continued to be impaired due to a deep sense of apathy, difficulties in thinking or speaking clearly, harboring unusual ideas
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12
Q

-Prodromal Phase

A
  • clinical config. that comes ahead of it
  • characterized by waning interest in social activities, increasing difficulty in meeting the responsibilities of daily life. Fail to bathe, wear same clothes repeatedly, increasingly odd or eccentric behavior, speech becomes vague or strange
  • may start gradually and then rise to a level of concern among family and friends
    • socially withdrawn, hard to perform day to day tasks, talking to themselves (not hallucinations yet), starting to look odd and eccentric
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13
Q

-Acute Phase

A
  • this is where we see more elaborative symptoms. Hallucinations, thought disorder, disorganized speech,
  • talking to oneself of the street, collecting garbage, hoarding food
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14
Q

Residual Phase

A
  • a bit of a retraction of the primary symptoms, there is still an element of the thought disorder
  • closer to that of the prodromal phase
  • continued to be impaired due to a deep sense of apathy, difficulties in thinking or speaking clearly, harboring unusual ideas
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15
Q

Major Features of Sz

-Disturbances of thought and Speech

A

Disturbances in the Content of thought

  • seem to be unshakable, no matter how much evidence to the contrary is presented
    - delusions of persecution - police are out to get me
    - delusions of being controlled - demons controlling them or others
    - delusions of grandeur - believing themselves to be Jesus or something similar
  • delusions of reference – people on the bus are talking about me
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16
Q

-Thought broadcasting

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my thoughts leave my head on a type of mental-ticker tape. A person only needs to pass through the tape to know my thoughts

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17
Q

-Thought insertion

A

people are inserting their thoughts into my mind

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18
Q

-thought withdrawal -

A

people are sucking the thoughts out of the person’s head, leaving their mind empty

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19
Q

-Disorganized speech

A

people with Sz, tend to think in disorganized, illogical fashion which is reflected in their speech patterns. Labelled as a thought disorder

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20
Q

Thought disorder

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recognized by a breakdown in the organization, processing and control of thoughts. Speech in people with Sz is often disorganized and jumbled as a result. Usually unaware of the abnormalities

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21
Q

-Neologisms

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-are made up words and they are confident in what it means but if asked, they struggle to answer

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22
Q

-Perseveration

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-is that they keep returning to certain things, even when challenged, they can’t easily let it go

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23
Q

-Clanging and Blocking

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  • blocking is when they shut down,

- choosing words that rhyme, even if it doesn’t make sense (clanging)

24
Q

-Hyper-vigilance

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  • so aware of trying to find the perceived thing they are looking for (microphones etc.)
  • flooded by sights and sounds, unable to filter
25
Q

those with Sz may also experience a loss of

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initiative towards goal orientated activities – residual or chronic state

26
Q

-Causes of hallucinations

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-neuropathway abnormalities

27
Q

-Emotional Disturbances
-Flatness of effect
blunted affect -

A

reduction in emotional expression

28
Q

-flat affect

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absence of emotional expression

29
Q

-Inappropriate affect

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laugh at strange times, fearful, sad when it is stranger or inappropriate to do so
-Often in facial expression

30
Q

Other types of impairment

-Identity

A
  • they may believe they are god or the Devil, possessed by someone else
    • certain uncertain in who they are and who is in control
31
Q

Previous subtypes of Sz (NOT in DSM-5)

-Disorganized

A

-ranging from child-like to unpredictable agitation
-referred Hebephrenic
typified by shallow and inappropriate emotional responses, foolish or bizarre behaviour, false beliefs (delusions), and false perceptions (hallucinations)

32
Q

-Catatonic

A

-catatonia – gross disturbances in motor activity and cognitive functioning
Stupor-relative or complete unconsciousness in which a person is not generally aware of or responsive to the environment
-Waxy flexibility - adopting a fixed posture into which people with Sz have been positioned by others
-Rigid - uncomfortable positions, unable to move

33
Q

-Paranoid

A

-used to trump everything else, delusions about them more being harmed, conspiracies in the world, reacting out of fear

34
Q

Negative symptoms

A

features of sz characterized by the absence of normal behavior. Negative symptoms are deficits or behavioral deficits, such as social-skills deficit, social withdrawal, flattened affect, poverty of speech and thought, psychomotor retardation, or failure to experience pleasure in pleasant activities. Represent the more enduring or persistent characteristics of the disorder

35
Q

Positive symptoms

A

the more flagrant symptoms of sz characterized by the presence of abnormal behavior such as hallucinations, delusions, thought disorder, disorganized speech and disorganized behavior

36
Q

-undifferentiated

A

-wasn’t a clear case

37
Q

Type I vs Type II Sz – alternate conceptualization (Crow, 1980)

A
positive symptoms (type I had mostly positive and type II had mostly negative) and negative symptoms 
-premorbid functioning: poorer in type II
38
Q

A person diagnosed with disorganized Sz

A

-one of the features of disorganized Sz is grossly inappropriate affect, as shown by this young man who continuously giggles, laughs and makes facial grimaces fro no apparent reason

39
Q

A person diagnosed with catatonic Sz

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-people with catatonic Sz may remain in unusual, difficult positions for hours, event though their limbs become stiff or swollen. They may seem oblivious to their environment, even to people who are talking about them. Yet, they may later say that they heard what was being said. Peridots of stupor may alternate with periods of agitation

40
Q

DSM-5 Criteria: Schizophrenia

A

DSM-5 Criteria: Schizophrenia
A. Two (or more) of the following, each present for a significant portion of time during a 1 -month period (or less if successfully treated). At least one of these must be (1 ), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (i.e., diminished emotional expression or avolition)
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
• C. Continuous signs of the disturbance persist for at least 6 months. This 6- month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
• D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1 ) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness
• E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
• F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).
• Specifiers:
– First episode, currently in acute phase
– First episode, currently in partial
– Multiple episodes, currently in acute phase
– Multiple episodes, currently in full remission
– Continuous – no break, constant kind of thing
– Unspecified
– With catatonia

41
Q

Versus Schizoaffective Disorder

A
  • A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1 : Depressed mood.
  • B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
  • C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
  • D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition
42
Q

Other Differentials

  • Mood disorders with psychotic features
  • Brief Psychotic Disorder
A

-tend to affect men more than women (middle age), and the person kinda just looses it, nervous breakdown, caused by stress

43
Q

-Delusional Disorder

A

-do not have the psychotic features but you have the delusions

44
Q

-Substance-Induced Psychotic Disorder

A

speaks for itself

45
Q

-Schizophreniform Disorder

A

-looks identical to Sz criteria but it doesn’t last for 6 months

46
Q

-Schizotypal Personality Disorder

A
  • has got a lot of negative features, but few of the positive features, and are tame is present
  • the boundaries between these can be so unclear that many scholars have argued for the removal of separate diagnostic categories
47
Q

Theoretical Perspectives

-Psychodynamic Perspective

A
  • overwhelming of the ego by primitive sexual or aggressive drives/impulses arising from the id
    • Primary Narcissism
      • has got more to do with paranoia than anything else.
      • predates a good understanding of psychosis,
      • I’m so narcissistic, that’s all about me
    • Harry Stack Sullivan
    • Mother-Child Relationships - mother withdraws, child withdraws from society (private world)
  • more focus on interpersonal relationships
48
Q
  • Learning Perspectives

- Ulmann and Krasner

A
  • Reinforcement for behaving in a manner consistent with SZ, social reinforcement
  • may have grown up in an environment w/o reinforcement resulting in disturbed patterns of behavior
    - Secondary gains: inadvertent reinforcement of bizarre behaviour
    - Haughton and Aylin (1965): Broom case
  • conditioned a woman to hold a broom, reinforced by cigarettes
49
Q
  • Biological Perspectives

- Genetic factors

A
  • tends to run in the family, lots of evidence shows that a genetic relationship with someone with Sz increases your likelihood by 2
    - cross-fostering studies
    - kids separated at birth, raised in different homes but their parents had a condition, they study to see if they happen to also have the condition
    • Biochemical factors
      • dopamine theory - biochemical theory of Sz that proposes Sz involves the action of dopamine
  • over reactivity of dopamine of dopamine receptors in the brain
    - neuroleptic drugs
  • block dopamine receptors
    • Viral infections
  • could be caused by an immune system reaction that happened in childhood
    • Brain abnormalities
      • Hippocampus and amygdala – limbic systems – regulating emotions and higher mental functions, including memory
  • enlargements of brain ventricles (hollow spaces in the brain) - sometimes
  • sometimes – abnormalities in the frontal or temporal lobes
  • abnormalities int eh frontal lobes may explain why those with Sz have issues with formulating concepts, organizing thoughts and behaviors, higher-level cognitive tasks
  • Amygdala
50
Q

Tying it Together

-Diathesis stress model

A
  • research evidence supporting the diathesis-stress model
    • acute stress trend to predict onset in genetically vulnerable people.
    • people either COMT gene more likely to develop psychosis with cannabis
    • genetic liability - longitudinal studies for kids that have a genetic liability due to parents with Sz or another genetic relative 10 – 25% of developing the disorder (one parent) two parents (45%)
  • environmental factors – disturbed adoptive families result in more kids with Sz than non-disturbed. Difficult pregnancy could also play into the risk
51
Q

Treatment and Theoretical Perspectives

-Family Theories

A
  • Schizophrenogenic Mother - pathogenic parent
    • cold, aloof, withholding affecting
    • child withdraws, foreclosing on opportunities to socialize
    • retreats into a fantasy world and begins to behave according to that imagined environment
  • Excessive levels of expressed emotion (hostility toward patient)
  • Double-bind communications theory
  • transmits two mutually incompatible messages
  • mother may freeze up when child approaches, but the scolds the child for staying away
  • no matter what the child does, it is incorrect essentially
    • children being shaped to say what they think parents “want” to hear
    • incompatible with true feelings

-Expressed emotion
-family members are hostile, critical, unsupportive of other family members
-communication deviance
-describes a pattern characterized by unclear, vague, disruptive, or fragmented parental communication
-tend to attack kids personally rather than offer constructive criticism and subject them to double-bind
Family factors: causes or sources of stress?

52
Q

-Biological Approaches

A
  • Antipsychotic drugs
    - Phenothiazines; Haloperidol
    - Tardive Dyskinsia (TD) - movement disorder characterized by involuntary movements of the face. Mouth, neck, trunk or extremities caused by long-term use of anti-psychotics
    • Atypical antipsychotics
      • agranulocytosis
    • Sociocultural factors in treatment
      • it’s really about support
53
Q

-Psychoanalytic Approaches

A
  • Personal Therapy (psychodynamic)

- Freud was of the opinion that psychoanalysis was not helpful in the treatment of Sz

54
Q

-Learning-Based Approach

A
  • Token economies have shown to improve social functioning and reduce psychotic behavior
    • Social Skills training
      • lots of evidence speaking to social maladjustment
      • social rejection and lack of support worsen outcomes
  • CBT with social skills
  • stress management, identify triggers,
  • significant, long-term improvement on psychotic effects and social functioning
55
Q

-Psychosocial Rehab

A
  • focuses on functional practical adaptation
    - public transportation
    - Job skills (often in a sheltered environment)
    - Appointment of a public guardian/trustee
56
Q

-Family Intervention Programs

A
  • Education

- Early intervention is critical