Course of Schizophrenia Flashcards
Prodromal Stage
Clear pattern of deterioration in premorbid level of functioning prior to psychotic episode
Premorbid
Time prior to psychotic episode
Prodromal stage
Increased social withdrawal ␣ Increasingly less attention is paid to personal hygiene and
grooming ␣ Onset of vague hallucinations or delusions
␣ Increased awareness of unusual perceptions ␣ Gradual increase in peculiar and eccentric behaviors ␣ Affect may become increasingly more blunted or
inappropriate
Prodromal stage: People report a sense of….
Don’t understand what’s going on ␣ Cannot understand why people are against them
Feel isolated ␣ Feel alone in the world ␣ This is when begin to withdrawal
␣ Anxiety and terror ␣ Afraid they are “descending” into madness
␣ Afraid of content of delusions
Prognosis can be based in part on prodromal stage: Poor prognosis
if long, insidious downhill course ␣ Over many years ␣ No clear precipitating stress ␣ No real time for premorbid adjustment
Prognosis can be based in part on prodromal stage: Better prognosis
If sudden onset of active psychotic episode ␣ May be clear precipitating stress ␣ Longer period for good level of premorbid functioning
Active Stage: psychotic episode
Presence of psychotic behaviors/symptoms Hallucinations Delusions Disturbance in speech Affective disturbance Psychomotor disturbance
Residual Stage
radual improvement in functioning ␣ Level of functioning expected for return is similar to
prodromal stage ␣ May be near premorbid stage ␣ Statistically, some impairment will follow
Residual Stage Features of the active stage will persist
Typically are not as strong ␣ Beliefs are less troublesome or identifiably not based in
reality ␣ Hallucination “volume” is decreased
␣ Problem with social withdrawal remains ␣ Compliance with and continued response to
medications will predict how long this phase lasts
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Favorable Prognostic Signs
Absence of premorbid personality disorders
␣ Social skills
␣ Adequate premorbid social functioning
brupt onset
␣ Presence of a clear precipitating event ␣ Later age of onset
␣ First episode at 17 vs late 20s or early 30s
Complications Associated with Schizophrenia: Shorter life expectancy
Some schizophrenic patients lead long lives ␣ For most part life span is shorter
Complications Associated with Schizophrenia:Increased suicide rate
Up to 10% with schizophrenia ␣ Highest period of risk is residual stage
␣ Generally individual has been through cycle and expects it again
␣ Decide to take action while they can
Complications Associated with Schizophrenia
␣ General decrease in self-care and hygiene ␣ Delusions can be self-threatening
Command hallucinations ␣ e.g., feet amputated because “voices” had told person to
spend the night outside
␣ Institutional neglect
Lack of adequate care by hospital ␣ Abuse by staff members ␣ Must be considered as contributing to shorter life-
expectancy
Complications Associated with Schizophrenia
␣ Deprived economic circumstances
25 to 50% of America’s homeless suffer from
some mental health disorder ␣ Most are diagnosable with schizophrenia or other severe
mental illness ␣ Also high number of substance abuse disorders
Victims of violent crime
More likely to be victim of violent crime than those
not diagnosed with schizophreni
Violence and Schizophrenia
␣ Are patients diagnosed with schizophrenia dangerous?
end to be less violent than general population ␣ Control for history of substance abuse and violence prior
to first schizophrenic episode
␣ Patients diagnosed with paranoid schizophrenia can be dangerous at times
␣ Especially if become part of their delusional system ␣ May be “defending themselves”
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Research on relapse and remission - 5-year follow-up research results by Zubin et al., 1989
Group 1: 22% one episode, no problems following recovery from episode
78% several episodes and varying degrees of lasting impairment
Group 2: Several episodes with minimal impairment (35%)
Group 3: Impairment after single episode and increased impairment later (no return to normality) (8%)
Group 4: Impairment increasing after several episodes (no return to normality) (35%)
Predisposing Factors: Lower socioeconomic status levels (SES) associated with increased prevalence rates
ay be several contributing factors: ␣ Stressors
␣ May be more severe stressors on those in lower SES ␣ Accounting
␣ Poorer people are counted more because of the institutions they are in (county vs. private hospitals)
Downward Drift Hypothesis
Person with SMI will drift down to lower SES levels with progression of disorder
Does not matter at which SES level you begin
Concordance rates
Monozygotic twins ␣ Typically cited around 48% ␣ Ranges vary wildly ␣ 10% to 55% Dizygotic twins ␣ Rate is about 15%
Psychotic spectrum disorders
May include other disorders such as BD and MDD
Disorganized Schizophrenia
Early onset ␣ 15-25 years old ␣ Also known as hebephrenic schizophrenia
␣ All of the following are prominent ␣ Disorganized speech
␣ Lack of systematized delusions ␣ Disorganized behavior ␣ Flat or inappropriate affect
␣ Worst prognosis of disorder subtypes ␣ Extreme social impairment ␣ Few or only short periods of remission during
Catatonic Schizophrenia
ssential feature is psychomotor disturbance
␣ Diagnostic criteria (two or more) ␣ Motoric immobility
␣ Catalepsy ␣ Including waxy flexibility
␣ Stupor ␣ Excessive motor activity
␣ Catatonic agitation ␣ Apparently purposeless ␣ Not influenced by external stimuli
Catatonic Schizophrenic: Motor activity continued
Periods of stupor may alternate with periods of
excitement ␣ Complications of stupor or excitation
␣ Malnutrition ␣ Self-inflicted injury ␣ Exhaustion ␣ Risk of head injury
␣ Extreme negativism or mutism ␣ Apparently motiveless resistance to all instructions ␣ Maintenance of rigid posture against attempts to be
moved
Paranoid Schizophrenia
Preoccupation with one or more delusions or frequent auditory hallucinations
␣ Often see delusions of grandiosity or delusions of persecution
␣ Cannot have any prominent disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect
Undifferentiated Schizophrenia
Any disorder diagnosed as schizophrenic, but does not quite fit any of the other subtypes
␣ There’s a little bit of everything in this ␣ Some prominent psychotic features
must be present to warrant diagnosis
Residual Type
Individual must have history of at least one schizophrenic episode with prominent psychotic features
␣ Must not at the present time be suffering from prominent hallucinations or delusions
␣ Usually see social withdrawal ␣ Often see some negative symptoms ␣ May see continued hallucinations or delusions
␣ Much less troubling to patient
Dopamine (DA) Hypothesis
␣ Most popular hypothesis today
Schizophrenia caused by excessive amounts of dopamine
␣ Could be hypersensitivity to DA at post synaptic receptor
␣ Could be problems with particular receptor DA (DA2, 3, 4) sites
Bateson’s Double-bind hypothesis
Communications theorist ␣ Required intense relationship with someone child
is dependent upon ␣ Child cares about that ␣ Parent sends conflicting messages simultaneously
␣ “Give me a big hug” and becoming stiff and unreceiving ␣ Child can’t comment on mixed messages and
cannot leave ␣ Child retreats into own inner world
␣ Research does NOT support this
Expressed Emotion (EE) Brown, Vaughn & Leff
Refers to type of communication patterns between family members
␣ Types of EE ␣ Hostile
␣ Emotional over-involvement ␣ Critical
Expressed Emotion (EE)
Data do NOT support that high EE causes
first episode of schizophrenia
␣ Higher relapse rates when patients released from hospital into high EE families
␣ Implication for treatment come out of relapse rate correlation
␣ Also used with BD I treatments now
Differential Relapse Rates
Patients on medications
In families with high
high EE low EE
levels of expressed emotions
Treatment
Earlier treatments ␣ Locked up ␣ Sedation ␣ Insulin coma
␣ Electroconvulsive Therapy (ECT) ␣ Controlled studies indicate it is not useful for
schizophrenia
␣ Psychosurgery ␣ Lobotomies (1930s-1950s)
Treatment
Advent of drug treatments
␣ Antihistamines had a calming effect
␣ Thorazine discovered as antipsychotic medication
␣ Early 1950s ␣ Major tranquilizing properties ␣ Very commonly used antipsychotic medication ␣ DA receptor blocker
Dopamine antagonists
␣ Block post-synaptic receptors
␣ Potent side effects ␣ See Parkinsonian symptom
Tardive dyskenesia (TD)
Irreversible damage to nervous system ␣ Involuntary facial movement, grimacing,
tongue protrusion ␣ Very distracting and distressing to patient
␣ These must be used with great caution
Atypical Antipsychotics
␣ Clozapine, Risperdal, Zyprexa, Abilify
Do not appear to create same terrible side effects ␣ More effective than older drugs on both positive
and negative symptoms ␣ Tend to act on 5-HT and DA ␣ Some have specific bindings on DA receptors
(possible D3 agonists, too)
Milieu Therapy
Put person in healing therapeutic environment ␣ Involves expectation patients behave in “normal”
ways ␣ Expected to
␣ Engage in group activities ␣ Help one another and be supportive ␣ Act responsibly ␣ Participate in decisions affecting functioning of ward
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