Chapter 4 (Lecture)

Question 1

WHO Schizophrenia Highlights

Answer 1

• relatively low prevalence
• distress and impairment
• premature mortality and comorbid conditons
• stigma and rights violations experienced

Question 2

Burden of Schizophrenia

Answer 2

• one of the top 15 leading causes of disability worldwide
• the estimated average potential life lost for individuals with schizophrenia in the US is 28.5 years
• an estimated 4.9% of people with schizophrenia die by suicide, a rate that is far greater than the general population, with the highest risk in the early stages of illness

Question 3

Psychosis as a key feature

Answer 3

episodic breaks from reality, known as psychosis
- easier to see or identify as mental illness, but still very complex
- psychosis: widely misunderstood term - does not mean violence (false assumption), that stems from erroneous link with “psychopathy”

Question 4

definition of psychosis

Answer 4

a serious mental illness (such as schizophrenia) characterised by defective or lost contact with reality often with hallucinations or delusions

Question 5

definition of psychopathy

Answer 5

mental disorder especially when marked by egocentric and antisocial activity, a lack of remorse for one’s actions, an absence of empathy for others, and often criminal tendencies

Question 6

What is psychosis?

Answer 6

• mental state characterised by a profound disturbance in thinking
• individuals have difficulty distinguishing between “reality” and their own (false) perceptions of the world

May involve:
- hearing a voice others cannot hear
- believing something that others would think impossible
- difficulty navigating daily life due to these altered perceptions

Psychosis is a central feature of schizophrenia, and can be one of the most debilitating forms of mental illness

Question 7

What kind of mental disorders can psychosis be found in? (other than schizophrenia)

Answer 7

• bipolar disorder
• severe forms of depression
• schizoaffective disorder (blend of schizophrenia and mood disorders)
• delusional disorder (delusions similar to schizophrenia but not featuring other typical characteristics/symptoms)

Question 8

3 symptoms of schizophrenia

Answer 8

1. postive symptoms (hallucinations, delusions)
2. negative symptoms (deficits in “normal” behaviour
3. cognitive disturbances (symptoms of “disorganised” speech/cognition)

• “positive” and “negative” are not interpreted the way we view pos and neg
• positive symptoms (plus): experiencing new or additional mental phenomena, thought to be episodic or acute
• negative symptoms (minus): existing behaviours or feelings decline or disappear, thought to be chronic or persistent (present for years)

Question 9

positive symptoms: hallucinations

Answer 9

A sensory experience that occurs without any stimulus

• most common form found in schizophrenia is auditory hallucinations (hearing sounds/voices that aren’t there)
• common forms: voices providing running commentary on actions, issuing instructions, insulting or degrading language, personal attacks - but may also be calming/inspiring
• other forms: seeing things, feeling sensations on the skin (insects), or even smell or tastes - or multiple senses

Most hallucinations are experienced as frightening or unpleasant, but some may be comforting (soothing or calming sounds or smells)

Question 10

Positive symptoms: Delusions

Answer 10

delusions: holding a belief that most others consider impossible or highly improbable (example: possessing superpowers, being followed by foreign spies)
- described as being “irrational” or false beliefs, as a person continues to hold them even if presented with evidence to indicate untrue
- rational and true is subjective - making it difficult to determine what is reasonable or unreasonable thus making delusions difficult to define with precision

Question 11

How are delusions experienced?

Answer 11

delusions are experienced as very “real” sensations for the person having them: we don’t usually question the signals our senses transmit, people experiencing delusions are simply perceiving the world as they know it in that moment

• delusion is not completely objective: we can’t identify empirical evidence that “God” exists, yet many people believe in different Gods and we would not deem them delusional because of their faiths or beliefs - a belief that cannot be proven is not always delusional

Question 12

Complexity of Defining Delusions

Answer 12

• some researchers believe that thoughts should be evaluated on a spectrum, rather than a binary differentiating between healthy and unhealthy people (delusions are not only present among those diagnosed with a mental disorder)
• delusions need to be considered in the context of cultural norms, nature of beliefs, and intensity
• diagnosis of what constitutes “delusional” belief requires clinical judgment given that “reality” is difficult to ascertain
• consider spiritual beliefs, conspiracy theories, and other common beliefs (faith) these aren’t seen as delusions

Question 13

4 main forms of delusions

Answer 13

1. Persecutory delusions: a person believes that others are “out to get them”, or that they are being targeted for mistreatment
2. Grandiose delusions: the person believes themselves to be in a position of great power, such as deity, celebrity, or a head of government
3. Delusions related to control: a person may believe that an external force is controlling their thoughts or body or that thoughts are being implanted or broadcasted aloud
4. Delusions of reference: believing that they are being communicated with in code (receiving secret hidden messages) through media or other sources

Question 14

Other forms of delusions (more common/less unusual)

Answer 14

• obsessive beliefs: thinking that partner is having an affair, without evidence
• erotomanic delusions: believing that a stranger or celebrity is in love with them
• delusions of guilt: deeply help belief that they have caused harm to others, when they have not
• somatic delusions: believing that they have a bodily malfunction or terrible illness, without evidence of this

Previously attempts were made to class delusions into bizarre and non-bizzare categories - no longer pursued due to difficulty agreeing on definition of “bizarre” (still some mention in the DSM)

Question 15

Positive Symptoms: Disorganised Speech

Answer 15

• unusual or disorganised speech patterns are a core component of schizophrenia

May include:
- switching topics suddenly and frequently
- using the same word repeatedly, may be because it holds special meaning to them (grave, gravely)
- non-responsive or unproductive answers to questions

May give the impression that the speaker is not making sense
- These characteristics have functioned to reduce use of psychotherapy (talking therapies) for schizophrenia, but this has been challenged recently

Question 16

Negative Symptoms

Answer 16

Relate to feelings and behaviours that are described as “deficits” in normal behaviour (lessened emotional and verbal engagement):

• blunted affect (facial expression and tone of voice is minimal)
• alogia (reduction in quantity of words spoken)
• avolition (lack of drive)
• asociality
• anhedonia (reduced experience of pleasure)

These symptoms may be more debilitating and limit function even more than positive - seen as being chronic or persistent (present for years), while positive symptoms are thought to be episodic or acute

Question 17

Negative symptoms continued…

Answer 17

Avolition: lack of drive, difficulty taking initiative to engage in routine tasks (including activities of daily living, eating/bathing)

• changes in social behaviour, especially increased isolation, perhaps stemming from difficulty maintaining relationships (due to symptoms)
• Anhedonia: inability to experience pleasure, a change in one’s sense of enjoyment (things are no longer pleasurable) - could also be a symptom of depression, or substance use disorder

Question 18

Disturbances in Cognition

Answer 18

deficits in:
- memory
- attention
- learning

These interfere greatly with functioning and disrupt a persons life significantly - impeding employment or education

Some researchers believe these are actually the primary hallmark of schizophrenia rather than psychosis

Question 19

Emil Kraepelin Debates and Controversies on Schizophrenia

Answer 19

Schizophrenia (as a diagnosis) has a relatively short history, emerging in the late 1800s

Emil advanced the idea that “dementia praecox” (premature dementia or precocious madness) was a specific disorder, not just a group of disconnected syndromes
- didn’t invent the term dementia praecox, but his conceptualisation foreshadows the contemporary view of schizophrenia
- “dementia”: deterioration of mental facilities, difficulty distinguishing between false perceptions and reality (cognitive disturbances, psychosis)
- “praecox”: very early onset, emerging in late adolescence
- distinct from “manic depression” (now bipolar disorder)

Question 20

Eugen Bleuler (Swiss Physician) Debates and Controversies of Schizophrenia

Answer 20

Disagreed with Emil Kraepelins ideas of dementia praecox, and used the term schizophrenia
- progressive mental decline was not inevitable, raging a diversity of outcomes was possible
- rather than seeking the condition as “hopeless”, thought treatment like talk therapy could be beneficial
- also not all affected individuals first experience symptoms in adolescence

Diagnostic priority given to communication and emotional “deficits” and “fragmentation of the personality”, rather than psychosis and psychotic symptoms (which Kraepelin thought were the key features)

Question 21

THERES MORE SLIDES THAT MIGHT BE BENEFICIAL (unit 4 Sept 25 slides)

Answer 21

LOOK AT THEM <3

Question 22

How to diagnose schizophrenia

Answer 22

• displaying 2 or more key criteria
• delusions or hallucinations or disorganised speech MUST BE present

AND:
B) reduced functioning is present
C) persisting for at least 6 months
D) not due to schizoaffective disorder or bipolar disorder with psychotic features (these have been ruled out)
E) not due to substance use or other medication

Question 23

Other diagnosis notes for schizophrenia

Answer 23

• onset and active phases
• first episode is thought to be particularly important from a treatment perspective and the course of the condition
• acute phase is when symptom criteria are fulfilled, partial and full remission have less or no symptoms

Question 24

Overall debates and controversies of schizophrenia from Emil and Euguen

Answer 24

• In the late 19th century, physician first started to consider “schizophrenia” as a distinct disease
• The deterioration of mental abilities was central to the illness, as was the prevalence of delusions and hallucinations
• recognised that onset of the illness was often in adolescence

Question 25

Prevalence Debates on Schizophrenia

Answer 25

• WHO reported that 1% of population, globally (equally among men and women - described as “egalitarian” / equal opportunity)
• SFU says schizophrenia 0.36%, 14589 expected cases in BC & schizophrenia spectrum disorders is 0.55% 22290 expected cases (found in younger in males (30-44) and older females (45-64))
• NIMH stated that 1-year prevalence estimate changed from 1.1% to 0.3% in Nov 2017 and that the estimated population reduced from 2.8 million people living w schizophrenia to 750,000 individuals
• MDPS estimated that 1.8% of adults in the US have a diagnosis of a schizophrenia spectrum disorder

Question 26

Advantages of direct-to-consumer marketing of psychopharmaceutical medications

Answer 26

May raise awareness to pharmaceutical options for those suffering from mental illness are seeking help with medical professionals

Allows consumers to recognise symptoms, learn about disease, and seek medical attention for conditions that might otherwise go unidentified or untreated

Question 27

Disadvantages of direct-to-consumer marketing of psychopharmaceutical medications

Answer 27

• pharmaceutical marketing companies have huge marketing campaigns for many of their products. In the past they have under-reported harmful side effects of drugs (example: OxyContin). The average consumer - without background in medicine in research - may not understand nor seek out the list of full side effects
• illegal / black market demand for these drugs may go up
• research has found that physicians may feel pressure to prescribe patients drugs that they request, even if they are ambivalent about the choice of treatment

Question 28

What is direct-to-consumer (DTC) advertising?

Answer 28

pharmaceutical companies market their products directly to patients rather than to health care professionals

• Ads describe a disease and tell the viewer about specific drugs that can treat it
• Ads must also include the risks of taking this medication
• Only allowed in US and New Zealand - prohibited in Canada under the Food and Drug Act

Question 29

What are Reminder Ads?

Answer 29

commonly viewed on TV, magazines, or online which allow advertising of the brand name drug in the absence of information about the products use or risks

• only directed towards consumers not health care professionals !!
• Canada allows this

Question 30

What are disease-orientated and help-seeking ads?

Answer 30

do not advertise a specific brand but describe a condition and encourage consumers to ask their doctors about treatment

• Canada allows this

Question 31

General Debates and Controversies about schizophrenia

Answer 31

• No bio-markers for the diagnosis of schizophrenia
• There is no single gene identified as causing schizophrenia
• Hallucinations and delusions are difficult to objectively measure, especially when differences in culture, religion, and language are considered
• For many Indigenous groups, hearing voices isn’t strange or abnormal
• Non-western cultures, don’t find it uncommon to believe in demons, ghosts, mystic creatures that are responsible for making someone physically ill

Question 32

Debates and Controversies about diagnosis of schizophrenia continued

Answer 32

• determining whether a person has a schizophrenia depends heavily on the judgment of the person making the diagnosis (the diagnosis is shaped by professionals training and experience, but also their cultural background and expectations) - making it so subjective and difficult
• expression of mental illnesses is heavily informed by culture: people express mental distress in culturally appropriate ways
• leads to over and under diagnosis

Question 33

Debates regarding cause of schizophrenia (genetic theories)

Answer 33

Little consensus regarding etiology

• Family studies: cases where people diagnosed had been adopted; researchers compared rates of schizophrenia among both their adoptive and biological family memebers
• Twin studies: comparing monozygotic twins; if both twins developed schizophrenia, it would increase the likelihood that a genetic basis was involved
• No such thing as the “schizophrenia gene”; likely that many different genes (and particular variations of genes and alleles) may be responsible for increasing the risk of schizophrenia
• Risk associated with these genes and allele is not restricted to schizophrenia: the genetic risk is shared for other mental disorders, including bipolar, autism, depression

Question 34

Debates regarding cause (biological)

Answer 34

Questions about whether what researchers measure is a cause, correlation, or direct effect of schizophrenia

May be a result of:
- complications during birth
- advanced paternal age at time of conception
- use of cannabis
- maternal infections during pregnancy
- irregularities in a neurotransmitter called dopamine
- inflammation

Question 35

Debates regarding the cause of schizophrenia (class and SES)

Answer 35

• disproportionate occurrence (higher prevalence) in poorer neighbourhoods and among people with lower incomes
• due to reduced access to healthcare (increasing the likelihood of birth complications), generate more stress (due to increased threats of violence or fewer protective factors, like parks and exercise opportunities), low income (martial and parental conflict, poor nutrition) - social environment factors
• drift hypothesis: suggests that the disproportionate number of people diagnosed with schizophrenia in lower incomes area is primarily a consequence of their illness, rather than a cause of it
• schizophrenia and symptoms propel people down the SES ladder: disorganised thinking might pose employment and education difficulties resulting in less income
• stresses associated with living in lower income neighbourhoods might exacerbate a persons symptoms, the drift model suggests they are not the direct cause

Question 36

Debates on the cause of schizophrenia (race and culture)

Answer 36

Disproportionality is not due to a real difference in rates of schizophrenia, rather practitioner bias might partially be to blame

• racial and ethic bias in diagnosis: physicians are disproportionality drawn from middle or upper class, their own class biases may guide their interpretation of others behaviour or even the diagnostic criteria
• There is evidence of racial and cultural bias in the diagnosis of schizophrenia: more likely to be diagnosed

Question 37

Schizophrenia and the brain

Answer 37

• current research examines whether causes can be observed in the brain with function fMRI or PET scans
• difficult to tell if brain differences are causes of consequences of schizophrenia, may also be influenced by medications altering brain structures and functions due to long term treatment (cause vs correlation)
• sample sizes for studies are small, not conclusive
• cannot diagnosis individuals as having a specific mental illness on the basis of a brains can & no universal consensus on exactly what a “schizophrenic brain” looks like

Question 38

What is fMRI?

Answer 38

functional magnetic resonance imaging

• measures the small changes in blood flow that occur with brain activity

Question 39

what is a PET scan?

Answer 39

nuclear medicine imaging test

• uses a form of radioactive sugar to create 3D colour images to see how your body cells are working

Question 40

Treatment debates for Schizophrenia

Answer 40

previous: malarial fever therapy, insulin coma treatment, Cardiazol shock treatment, electroconvulsive therapy (ECT) and lobotomy

Medication is currently the first line of treatment for symptoms of psychosis
- chlorpromazine was the first effective anti-psychotic (viewed as miracle drug) (alleviated many symptoms, had difficult side effects, allowed patients to move from institutions to the community)

Question 41

Treatment debate for schizophrenia (medications)

Answer 41

• Typical antipsychotics (including haloperidol and others)
• Atypical antipsychotics (including risperidone)

These drugs are not “cures” and there is evidence that their positive benefits may have been overstated

Question 42

Treatment debates for schizophrenia (antipsychotic side effects)

Answer 42

• Tardive dyskinesia (typical antipsychotic): a syndrome where people experience involuntary and uncomfortable movements of the face, mouth, and tongue
• Parkinsonism (typical): refers to various neurodegenerative diseases that manifest with motor symptoms such as rigidity, tremors, and bradykinesia (slowness of movement and peed). Parkinson disease accounts for approx 80% of cases
• weight gain (atypical)
• metabolic syndrome (atypical): group of conditions that together raise your risk of canary heart disease, diabetes, stroke, and other serious health problems - also called insulin resistance syndrome
• increase in overall mortality, perhaps due to long term use

Question 43

Treatment debate for schizophrenia (therapies and other factors)

Answer 43

• cognitive therapies (CBT and metacognitive training: MCT)
• housing and employment support
• modelling and role-playing
• family support
• peer support

Question 44

Stigma of schizophrenia

Answer 44

People with schizophrenia are characterised as damaged, different, deranged - this is not fair or accurate
This stigma has impacts at the societal and individual level:
- foster misunderstanding of schizophrenia, causes, and treatment
- increases stress and decreases the likelihood that a person will seek treatment and care
- may extend to care providers, and promote negative stereotypes, and mitigate against funding care

Question 45

Stigma and Popular Representations of Schizophrenia

Answer 45

• media depicts people with mental illness as dangerous or violent
• people with mental illness are more likely to be victims of violence than to perpetrate violence (rare cases get over-exposed and become disproportionally visible)
• others misinformed stereotypes in popular culture link schizophrenia with unique intelligence or creative abilities (genius, “mad” genius) & healthcare practitioners are subject to negative and potentially harmful depictions in media and entertainment
• self-stigma prevents people from disclosing a diagnosis or seeking help

Examples: Harley Quinn