Lecture 15 - Schizophrenia Flashcards
History
Dementia Praecox
* Emile Kraepelin
* First to propose groupings of psychotic syndromes
* Dementia (dementia) Praecox (early)
* A disorder with progressive deterioration; unlike other
dementias, begins at an early age
* BP and Schz distinct disorders
* Evidence for common genes and continuum of dysfunction
Schizophrenia
* Eugen Bleuler
* Swiss Psychiatrist, contemporary of Kraepelin
* Did not always deteriorate, could emerge at later age
* 1911 used term “schizophrenia”
-“Schizo” (to split, or crack) “phren” (mind)
* Disorder characterized primarily by disorganization of thought
processes
* Split from reality
* Distinction from “multiple personality disorder” or dissociative
identity disorder
* Considered Schizophrenia a group of disorders, not a single
disease state
* Led to very broad definition, more subjective
Diagnosis
*Psychotic disorder
*Disconnect from reality
* Among the most devastating forms of psychopathology
* Chronic
* Often strikes in adolescence
* Used to be institutionalized
*Because of how defined, not necessarily difference between countries
* Six Major Signs/ Symptoms
- PERCEPTION
* Hallucinations
* Continuum from illusions to hallucinations
-Illusion (stimulus present but misperceived) vs. hallucination (no stimulus but perception occurs OR negative hallucination (stimulus present, but no perception occurs))
* Can occur in all sensory modalities:
- Visual, olfactory, tactile, somatic, gustatory
- Audible thoughts
- Voices conversing about patient
- Voices commenting on your behavior
- Somatic passivity experiences = feeling like something external is entering the body (imagining an x-ray and feeling like there is a warm spot behind their neck for example)
Maybe voices = Misinterpreted self-talk
-Believing internal thoughts to be external
Study:
Complimentary, derogatory, or neutral messages
Distortion of their own voice
Had to choose if distorted voice was themselves, someone else or unsure
People with schizophrenia and hallucinations were much more likely to make misattribution (it’s someone else speaking), especially if words were derogatory (negative)
- CONTENT OF THOUGHT
* Delusions
* False belief based on an incorrect inference
* Firmly believed despite contradictory evidence
* Mild end: over-valued idea
- False belief, but willing to entertain the idea that it’s false
- Common in schizotypal PD
- Also common in prodromal schizophrenia
–Showing signs but have not yet met criteria for schizophrenia
DELUSIONS
* Controlled by outside force
* Grandiose delusions: more important than you really are
* Delusions of jealousy: Belief spouse being unfaithful, mother loves sibling more than you…
* Nihilistic delusions: self or the world does not exist
* Persecutory delusions: belief that people are out to get you, plotting, grand scheme
* Delusions of reference: Belief event, object or person is trying to signal something significant to you, hidden message
* Somatic delusions: something terribly wrong with part of the body (ex: that’s not my hand, I have wings)
* Thought withdrawal: Thoughts being extracted forcibly from your head by someone or something
* Thought insertion: Thoughts having belong to someone else or being inserted into your mind by some other force/someone else
* Thought diffusion/ broadcasting: Can’t hear own thoughts but everyone else can hear them
* Made impulses: External force is causing you to do things
* Made feelings: emotions are being forced upon you, inserted into your brain, by external force
* Made volitional acts: Have volition, but attribute it to someone or something else (similar to made impulses, but with volition)
Patients often have multiple fragmented delusions
- FORM OF THOUGHT
Formal thought disorder/ speech disorder
* Derailment: hard time following a logic, hop onto other completely unrelated topics. Not same as pressured speech/flight of ideas in a manic episode
* Word salad: Saying words, but no grammatical structure, no apparent connection or logic between words
* Alogia: Poverty of speech, saying very little, or very little content in the speech, doesn’t convey much
* Neologisms: create new words or change meaning of words
* Blocking: speaking and stops abruptly, middle of a thought (often accompanied by thought removal delusion)
* Illogical thinking: …
Lewis Wayne cat paintings
Illustrate progression of thought disorganization in schizophrenia
(but we don’t know order in which cats were painted) - AFFECT
* Blunted/ flat
-Anhedonia - Blunted/flat affect
* Inappropriate
- Can be chilling
-(ex: laughing or smiling when talking about parent who just died)
* Problems perceiving others’ emotions - PSYCHOMOTOR
Catatonia: response not contingent (appropriate) upon what is happening in the environment
- Much rarer now than 100 years ago (we don’t know why)
* Catalepsy/ waxy flexibility: immobile, can move the patient and they will stay in that position
* Stupor: immobile, conscious, not responding in any way to the environment
* Posturing: on their own expressing strange poses or facial expressions
* Mutism: not speaking at all
* Catatonic excitement: pacing around, unrelated to anything in the environment, without purpose
* Catatonic negativism: Immobile, resisting all attempts to be moved
* Echolalia: senseless repetition of a word or phrase
* Echopraxia: : Imitating movements repeatedly - DISORDER OF RELATING
* Very withdrawn
* Preoccupied with a fantasy world
* Disordered volition: disturbances in goal directed activity (not much will or volition, aimeless)
* Anhedonia
To get a diagnosis
POSITIVE VS NEGATIVE symptoms
* Positive: the presence of symptoms that shouldn’t be
there
- Hallucinations, delusions, inappropriate affect
* Negative: absence of something that should be there
- Blunted affect, alogia, avolition
* Positive tend to respond better to medications
* Negative symptoms often very hard to treat
* Used to use positive/negative to classify
* But very few people have only negative
DSM-5
Need at least TWO of the following:
* Delusions
-*Hallucinations
* Disorganized speech and behavior
+all of the following:
* Grossly disorganized or catatonic behavior
* Negative symptoms
* Level of functioning markedly lower than prior to onset
* Symptoms present for six months and include at least one month of active symptoms.
* Unipolar, bipolar depression, schizoaffective disorder ruled out
* Not attributable to substance
SCHIZOAFFECTIVE DISORDER
- People with schizophrenic features and severe mood disorder
- Mood disorders can be unipolar or bipolar; must currently meet
criteria for depressed mood - Delusions or hallucinations for 2 or more weeks in the absence of a
mood episode during lifetime duration of illness - Sx of major mood episode present for the majority of illness
- Not attributable to effects of a substance
- Poor reliability
- Controversial since introduction in 1933
- Not clearly a distinct diagnosis
- Also not clearly an atypical form of Mood disorder/ Schizophrenia
- Prognosis is somewhere between schizophrenia and mood disorders
- Long-term prognosis for Schizoaffective > Schizophrenia
PREVALENCE
AND COURSE of schizophrenia
- Average prevalence rate about .7% to 1%
- M: F ratio about 1.4:1
- Women tend to present with more sx of depression
- May explain imbalance in diagnoses
- Female sex hormones (estrogen) may also be protective
- Postmenopausal, estrogen decreases
- Late-onset schizophrenia more common in Women
peak male age = 24
peak female age = 20-24, and goes back up 45-49
Schizophrenia in childhood (under 13)
* Extremely rare, more common in boys
* Onset always insidious; hard to tell where it began
* Almost always characterized by early speech and language problems
- Adult-onset also had early speech and language problems
* Delayed motor development, poor coordination
* Long-term follow-up: continue to show signs and symptoms
* Very small % remit; some remain continuously psychotic
* Tend to see high rates of Schizotypal PD and Schizophrenia in relatives
Course
* Only 20% to 30% of individuals with schizophrenia able to live
independently and/or maintain job (Grebb & Cancro, 1989).
* Another 20% to 30% of individuals with schizophrenia have persistent
moderate symptoms and impairment,
* Remaining 50% experience severe impairment for the remainder of their
lives.
* 15‐year study:
* Only about 40% had one or more periods of recovery
* People with schizophrenia have poorer clinical and functional prognoses
than those with other psychotic and most nonpsychotic mental
disorders.
All data here in western/industrialized countries
More benign course in countries in development
-higher demands placed on people in western countries
-also because more vulnerable foetus (typical of schizophrenia) more likely to survive in western countries (better medicine)
-less industrialized, easier to be functioning part of society
People tend to die younger
Average 20 years younger than general population
But increasing over time
Suicide and cardiovascular disease top two causes of death (much more likely to smoke cigarette! Stimulant that helps manage symptoms)
Also antipsychotic drugs
PROGNOSTIC INDICATORS
GOOD: (better course)
* Good premorbid adjustment (e.g., had friends)
* Acute onset (less than 1 month)
* Manic and depressive symptoms
* Confusion or disorientation during psychosis
* Family hx of mood disorder
BAD: (worse course)
* Poor premorbid adjustment
* Insidious, gradual onset
* Negative symptoms (esp. blunted affect)
* Family history of schizophrenia
* In some studies a lower IQ
- 80% of patients with 5 good predictors good outcome, 40% of patients with other group
Comorbidity and Characteristics
Substance abuse very common
* Especially alcohol and nicotine
* Nicotine incredibly common
-More than 50% report smoking on a daily basis
* Substances may also play a role in triggering
Suicide
* Abt. 20% will attempt on one or more occasions
* 5% succeed
* Especially for schizophrenic young men
* Some evidence that those with best premorbid functioning more at risk
Schizophrenia and Violence
* A perception that people with Schizophrenia are dangerous and
aggressive
* Very slight increase in risk– population wide
* Aggression most common in younger male pts with hx of
violence
- Tendency to stop taking meds, impulsivity, sub abuse
- Drug use/ abuse alone increases risk more
* Majority of people with Schizophrenia more likely to be victims
of violence
- Or suicide
RISK AND
CAUSAL
FACTORS
Twin Studies
* Higher concordance for Mz twins than Dz
twins (or any other family member)
* Concordance in Mz: 28%
* Concordance in Dz: 6%
* Heritable, but not as heritable as e.g., Bipolar
Assumes that environment doesn’t play more of a role in monozygotic twins than in dizygotic twins
False (because mx twins share a placenta, often treated more similar due to identical appearance…)
Makes us overestimate the genetic heritability (because environment plays a role!)
Not inheriting the disorder itself
So what?
We do not really know
Genotypes-Endophenotypes-Phenotypes
* Genoptype → Phenotype
-Endophenotypes = bridging concept between genotypes and phenotypes
* Phenotypes very complex phenomena, multiply-determined, often poorly defined
* Endophenotype: intermediate step between microscopic genes and nerve cells
and the experiential and psychological phenotype
* must segregate with illness in the population.
* must be heritable.
* must not be state-dependent (i.e., manifests whether illness is active or in remission).
* must co-segregate with illness within families.
* must be present at a higher rate within affected families than in the population.
* must be amenable to reliable measurement, and be specific to the illness of interest.
Eye tracking abnormalities = Potential endophenotype (difficulty following smooth line)
- Social class and ethnic minorities
- Schizophrenics tend to have lower SES
- Social Causation vs. Social selection/ downward drift theories
- Social Selection: Family of origin (any differences?)
-Evidence for social selection
–harder to get and keep a job
–not related to family of origin being poor or something - Social Causation: Immigrants to U.K. and Netherlands from
Caribbean and Africa - Stress?
-Maybe immigration and schizophrenia = stress explanation (stress exposure triggers)
-especially in areas with smaller minority populations
Black = more likely diagnosed with schizo, white = more likely diagnosed bipolar
Bias
Risk factors pt.2
Advanced Paternal Age
increased risk of schizo offspring
* Advanced Paternal age at conception
associated with increased risk
* Cause?
* Mutations?: Genetic mutations from age?
* Personality?: Maybe men with schizotypal personalities have children later?
Birth complications
* Schizophrenic pts more likely to have
experienced birth complications
* Breech delivery, prolonged labor,
umbilical cord around neck
* All can result in hypoxia/ anoxia
* Anoxia (no oxygen) at birth can also result in DA (dopamine)
supersensitivity
Prenatal exposure
* Viral infections
- Influenza epidemic in 2nd trimester
* Ecological fallacy
* Antibodies during pregnancy, later
Schizophrenia
- Herpes Simplex II, rubella, influenza
* Direct evidence
* Particularly during 2nd trimester
Season of birth
* Small but significant increase for
people born in late winter, early
spring
* 5-15% increase
* Northern and Southern hemispheres
* Stronger further from equator
* # of Viruses can cause fetal damage
* More common in fall and early
winter
* Second trimester of pregnancy
Malnutrition in pregnancy
* Dutch Hunger Winter
* Rates about 2X normal in individuals conceived
during the famine
* General lack of nutrition?
* Specific lack of folate or iron?
* Replicated following famine in China 1959-1961
Neurodevelopment in 2nd trimester
* Neural migration an important
task of 2nd trimester
* Disruptions can affect neural
connectivity
* Particularly cortical connectivity
* Could result in decreased gray
matter (cortical matter)
-Thinner cortices
-Less grey matter
* Also could result in cell death
Whole brain volume
* Lots of evidence for decreased whole brain volume in
Schizophrenia
* Even in recent-onset
* (suggests not a result of treatment)
* Progressive loss of gray matter over time
* Progressive deterioration also continues for many
years into the illness
* Kraepelin’s dementia praecox
Gray matter deficits
* Also evident in discordant Mz
twins of Schizophrenics
* Not explained by antipsychotic
medications or other
treatments
* Not explained by damage from
the illness itself
* May be under genetic control
Dopamine Hypothesis
- Antipsychotic drugs work on DA system
- Block D2 receptors
- Cocaine, amphetamines boost DA activity
- Can result in psychosis, paranoia, distorted sense of reality
- L-DOPA for Parkinsons
- low levels of dopamine
-L-DOPA used for it can cause hallucinations - Suggestive
- CSF studies
- DA receptors?
- Challenging b/c most ppl w/ Schizophrenia on antipsychotics
- Best evidence seems to be: excess DA transmission in
striatum, reduced DA transmission in frontal lobes - Aberrant salience = Attaching to things that are not salient to everyone else
- Increased DA may cause pts to attend more to
irrelevant stimuli - Pts may struggle to make sense of everyday
experiences - Failure to respond to meaningful reward
cues - Anhedonia
- Negative symptoms
- Abnormal movements
- Oral-facial
- Upper limb dyskinesias = slight tremor to total disconnection
- Movement abnormalities also present
throughout premorbid period - DLPFC (dorsolateral prefrontal cortex)
- Activity heavily regulated by DA
- Working Memory
- A process where info is held in memory for a short
time for the purpose of doing other things - May be implicated in Schizophrenia
- Cognitive deficits consistent in Schizophrenia
- Tested WM deficits in Scizophrenic,
HC, Bipolar - Deficits unique to Schiz
- Later studies:
- Evident when ill and when healthy
- In college students with schizotypal
symptoms - Evident in 1st degree relatives
Cannabis
- People with Schizophrenia 2x more likely to smoke
weed - Correlate? Or Cause?
- Evidence that it predicts onset of Schiz
- Sig. even controlling for childhood sx of psychosis
- THC increases DA synthesis
- Cannabis use exacerbates sx in people with
Schizophrenia
-Exacerbates gray matter loss
Expressed Emotion
- Deinstitutionalization of patients
- Some went home to families
- Some lived solitary lives
- EE (expressed emotion):
- Criticism
- Hostility
- Emotional overinvolvement
Expressed emotion is
* Repeatedly shown to predict relapse
* Regardless of characteristics of the pt.
* When EE is lowered, relapse rates
decrease
* EE may play a causal role
* Stress
* Attributions
- Pt says something strange
- Family member criticizes
- Increases the probability of another strange
remark - Increases probability of more criticism
BUT - EE non-specific
- Also predicts worse outcomes in depression,
bipolar - Seems to be protective for BPD!
EE can be lowered with family therapy
High EE in families of people with many different mental disorders, not just schizophrenia (non-specific)
Treatment
(unrelated to treatment but…)
Non-psychotic voice hearers
Don’t experience distress
Typically in community that welcome these hallucinations
-voices of the dead, psychic, gift
Antipsychotics:
Can induce really rapid decrease of symptoms (within 24 hours!!)
Only about 8% will still keep having hallucinations
The earlier get meds the better tend to do
Dopamine antagonists
Side-effects:
1st generation:
Extreme weight gain
Drowsiness
Dry mouth
EPS = involuntary muscle movements (twitches, spasms…)
2nd generation:
Few EPS
Not more effective at treating schizo
More expensive
Can cause other problems like loss of white blood cells, brain tissue loss…
Psychosocial Treatments
* Family therapy often effective adjunct
* Especially high EE families
* Psychoeducation
* Improve coping and problem-solving
skills
* Enhance communication skills
CBT for Schizophrenia
* Until recently, not considered a viable option
* Schizophrenia considered too impairing
* May be helpful for positive symptoms
* Not very helpful for negative symptoms
Goals are:
* Decrease intensity of positive symptoms
* Reduce relapse
* Decrease social disabilities
Coming to terms with hallucinations
Intervene on the beliefs (ABC)
ABC model
A= Activating event (ex: voices)
B = Beliefs (ex: I’ll never be normal)
C = Consequence (ex: emotions like depression, behavior like isolation)
How can we change these beliefs?
Hearing Voices Network
* Peer-support groups for people who hear voices
* People may or may not be Schizophrenic
* Founded 1988 by Dutch Psychiatrist Marius Romme
* Argues that hearing voices alone is not an indication of
psychopathology
* Voices may be accommodated
* Major aim is to reduce distress associated with auditory
hallucinations
* No (compelling) existing data demonstrating they are
effective
* Need for study
* People with auditory hallucinations often drawn to them
Examples of srtategies: “develop your rules of engagement”
ex: “i am too busy to talk to you rn, come back after dinner”, shouting and swearing at the voices (ex: use a phone in public if you want to shout at the voices and not draw attention)
“selective listening”… take what is useful from the voices and ignore the rest
* Some evidence they are more
effective for ppl with lower social
functioning
* May provide only social contact
* Limited evidence for reduced distress
associated with voices
* Reduce the stress
* Change power of the voices
* Change perceived control over voices
