Chapter 9 - Schizophrenia Flashcards by Julianna Douglas

History of schizophrenia

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

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Historical people and schizophrenia

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

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DSM 5 assessment

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

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Core symptoms

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

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Schizophrenia prevalence

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

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Schizoaffective disorder

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

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Schizophreniform disorder

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

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Delusional disorder

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

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Brief psychotic disorder

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

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Substance/medication induced psychotic disorder

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

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Psychotic disorder due to another medical condition

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

More common in over 65yrs

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Other psychotic disorders

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

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Hallucinations

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

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Delusions

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

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Thought disorder and disorganized speech

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

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Negative symptoms

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

Disorganized behaviour and motor symptoms

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

Cognitive symptoms

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

Diathesis stress model explanation

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

Neurodevelopmental model

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

The dopamine hypothesis

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

Neurobiological findings

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

Neurocognition

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

Social cognition

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

Cognitive biases

Delusions - jumping to conclusions, bias against disconfirming evidence Hallucinations - source monitoring - misattribute internal stimulation to an external source

Social factors contributing to schizophrenia

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

Premorbid phase

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

Prodromal phase

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

Psychotic phase

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

Stable phase

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

Recovery statistics

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

Antipsychotic medication

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

CBT-p

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

Cognitive remediation

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

Family therapy and psychoeducation

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

Skills training

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

Early intervention for psychosis

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

Clinical high risk state

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

Culture and schizophrenia

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