Chapter 9 - Schizophrenia

Question 1

History of schizophrenia

Answer 1

Madness
Behaviour had spiritual interpretations, result of divine punishment or demonic possession

Question 2

Historical people and schizophrenia

Answer 2

Kraeplin called in dementia praecox - early dementia
Bleuler - termed it schizophrenia in 1911 - described it as a group of disorders - basic (negative) and accessory (positive) symptoms
Schneider - first rank symptoms - core symptoms that if present indicated schizophrenia

Question 3

DSM 5 assessment

Answer 3

6 criteria =
A - core symptoms
B - problems with work or social functioning
C - 6 months, 1 month active symptoms
D - exclusion of schizoaffective or mood disorders
E - disturbance not caused by substance use or medical condition
F - consider autism, communication disorder

Question 4

Core symptoms

Answer 4

Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviour, negative symptoms
2/5 must be present - either delusions, hallucinations, or disorganized speech must be present

Question 5

Schizophrenia prevalence

Answer 5

1% worldwide
30% newly diagnosed cases are between age 20-34
Equal distribution of men and women
Men diagnosed younger

Question 6

Schizoaffective disorder

Answer 6

Similar, contains added element of diagnosed mood episode that occurs at same time as schizophrenia symptoms
2 weeks before or after mood symptoms of only delusions and hallucinations
Bipolar type and depressive type
0.3% prevalence

Question 7

Schizophreniform disorder

Answer 7

Same criteria as schizophrenia, lasts between 1-6 months
No decline in functioning requirement

Question 8

Delusional disorder

Answer 8

Delusions for at least one month, no other psychotic symptoms, functioning not markedly impaired, behaviour is not bizarre or odd
0.2%

Question 9

Brief psychotic disorder

Answer 9

Positive symptoms present for more than one day but remit by one month
May account for 9% of cases of first episode psychosis

Question 10

Substance/medication induced psychotic disorder

Answer 10

Positive symptoms occur due to initiation or withdrawal from a drug, medication, toxin
Diagnosed in 25% of people presenting with first episode of psychosis

Question 11

Psychotic disorder due to another medical condition

Answer 11

Hallucinations or delusions caused by physiological effects of another disorder - epilepsy

More common in over 65yrs

Question 12

Other psychotic disorders

Answer 12

Not enough info to make any other diagnoses but there is still psychosis symptoms

Question 13

Hallucinations

Answer 13

Abnormal perceptual experiences, any sensory modality
Voices - say negative things, command hallucinations
Visual - partially formed images, scenes that play out

Context of clear sensorium
Hypnogogic and hypnopompic - sleep - normal
10% auditory, 7% visual lifetime prevalence

Question 14

Delusions

Answer 14

Fixed false beliefs, unfounded and resistant to contradictory evidence
Persecutory - paranoid, conspired against, followed, spied - most common at 60%
Grandiose - special powers, abilities, knowledge - religious delusions
Somatic - ones body is changing
Referential - common events hold a personally relevant meaning

Bizarre - impossible (thought withdrawal and insertion, delusions of control), non-bizarre - unlikely

Question 15

Thought disorder and disorganized speech

Answer 15

Difficult to understand what they are trying to communicate

Loosening of associations - switch from topic to topic with little connection
Tangentiality - someone’s response is unrelated to the topic
Perseveration - fixated on a word or phrase and repeats it
Neologisms - made up words, real word in irregular context
World salad - incoherent and impossible to understand

Question 16

Negative symptoms

Answer 16

Experiential - decrease in ability to experience enjoyment from situation and to motivate oneself - avolition, anhedonia, asociality

Expressive - impairments in ability to interact with social world as a result of limited speech or difficulty with emotional expressions - alogia, affective flattening

Question 17

Disorganized behaviour and motor symptoms

Answer 17

Problems initiating and/or sustaining appropriate goal directed behaviour
Catatonia - decrease in reactivity, may go rigid, repetitive behaviours, go silent
Wave flexibility - someone will maintain physical positions that others put them in
Odd mannerisms - mimicking, grimacing, staring
Posturing

Question 18

Cognitive symptoms

Answer 18

Impairments in attention, learning, memory, processing speed, problem solving

Impairments in social cognition - emotion regulation, inferring others thoughts, reacting emotionally to others

Persist after psychosis has been treated

Question 19

Diathesis stress model explanation

Answer 19

Suggest that an inherited biological vulnerability interacts with environmental stressors to result in psychosis development

Several genes are implicated in schizophrenia - heritable

But, not everyone has an underlying vulnerability to the disorder, and people develop psychosis with no obvious stressful situation preceding it

Question 20

Neurodevelopmental model

Answer 20

Disorder of atypical development where schizophrenia is the end state - small changes during development push development onto a path that end in schizophrenia

Risk for schizophrenia can be increased at every stage for development

Question 21

The dopamine hypothesis

Answer 21

Original - schizophrenia results from high levels of dopamine in the brain

Version 2 - dopamine is in excess in subcortical brain regions and deficient in cortical regions - explains both positive and negative symptoms

Third - dopamine can explain positive symptoms in a variety of disorders

Question 22

Neurobiological findings

Answer 22

Structural brain changes - enlargement of ventricles, fluid filled spaces, reduced grey matter
Functional changes - reduced levels of default mode network activation.

Question 23

Neurocognition

Answer 23

Neuropsychological tests - assess cognitive abilities - common finding in schizophrenia
Neurocognition is one of the strongest predictors of how well someone is able to function in the community

Question 24

Social cognition

Answer 24

Cognitive abilities necessary for understanding the social world
Individuals with schizophrenia have trouble using theory of mind

Question 25

Cognitive biases

Answer 25

Delusions - jumping to conclusions, bias against disconfirming evidence

Hallucinations - source monitoring - misattribute internal stimulation to an external source

Question 26

Social factors contributing to schizophrenia

Answer 26

Social defeat theory - chronic exposure to negative social experiences leads to sensitization of dopaminergic system and may increase risk for schizophrenia

Urban upbringing, migration, childhood trauma, low intelligence, drug abuse

Question 27

Premorbid phase

Answer 27

Childhood
Mild impairments in cognitive, social, academic, motivational functioning
More likely to have more severe symptoms and be treatment resistant

Question 28

Prodromal phase

Answer 28

Early adolescence
Sub-threshold positive symptoms, comorbid mood and anxiety symptoms, difficulty functioning in everyday life
Up to 90% experience
Average length of 5 years

Question 29

Psychotic phase

Answer 29

FEP - first time someone meets schizophrenia criteria
Late adolescence, early adulthood
Deterioration takes place after - critical time for intervention
20-40% recover after first FEP

Question 30

Stable phase

Answer 30

10-15% unremitting - multiple episodes of psychosis
Treatment resistant - inadequate response to two or more types of antipsychotic medication -1/3

Question 31

Recovery statistics

Answer 31

20-60% - remission
40-60% extended remission of hallucinations and delusions
13-31% functional recovery

Question 32

Antipsychotic medication

Answer 32

First generation or typical - antagonists for D2 dopamine receptors, reducing dopamine in brain - neurological side effects like tardive dyskinesia

Second generation or atypical - also increases serotonin - metabolic side effects

Clozapine - good for treatment resistant disorders - side effect called agranulocytosis- body makes less white blood cells

Question 33

CBT-p

Answer 33

Targets positive symptoms
Effective in early stages of disorder, can reduce likelihood of transition from prodromal to FEP by 50%
Targets distress and impairment in addition to the symptom
May be equivalent to antipsychotics

Question 34

Cognitive remediation

Answer 34

Focus on treating neurocognitive impairments in attention, memory, problem solving

Computerized cognitive training - practice increasingly difficult exercises
Strategy monitoring - develop new strangles for the training
Functional generalization - generalize training to everyday functions

Question 35

Family therapy and psychoeducation

Answer 35

Integrate family support into the treatment - families can support recovery
Families with high levels of expressed emotion are associated with increases risk of relapse

Question 36

Skills training

Answer 36

Teach skills required for daily living
Social skills, verbal skills, functioning skills

Question 37

Early intervention for psychosis

Answer 37

Rapid intervention is important to reduce duration of untreated psychosis and improve treatment outcomes

Question 38

Clinical high risk state

Answer 38

Associated with psychiatric symptoms like mood, anxiety, substance misuse, difficulties with everyday functioning

To find out risk look at 1) presence of attenuated psychotic symptoms like sub-threshold psychotic like disturbances 2) brief intermittent psychotic symptoms that are too transient to meet diagnostic criteria 3) genetic risks and functioning deterioration

Question 39

Culture and schizophrenia

Answer 39

Culture can shape manifestation of psychosis - affects content of delusions and hallucinations

Hallucinations viewed as less harmful in some places

In cultures that favours spiritual explanations, traditional healing interventions can manage psychosis symptoms