Module 6 - Schizophrenia

Question 1

What makes it difficult to predict how a person will be affected by schizophrenia?

Answer 1

Heterogeneity. (There is a tendency for people with the disorder to differ from each other in symptoms, family and personal background, response to treatment, and ability to live outside of hospital.

Question 2

Poor outcome for schizophrenia is more likely among what 3 populations:

Answer 2

1) Males

2) Individuals who develop the disorder at a younger age

3) Those who experience a longer delay between the first appearance of symptoms and treatment

Question 3

True or False?

Although “madness” in some form existed in the past, it is uncertain whether these historical disturbances included schizophrenia.

Answer 3

True.

Descriptions of madness and lunacy before about 1800 suggest that these conditions occurred at any time of life rather than primarily in young people. And auditory hallucinations (typical of schizophrenia) are extremely rare in cases of madness prior to 1700. Moreover, historically documented madness seldom lasted more than a few days, and was often drug and alcohol–induced or related to other diseases.

Question 4

The first recognizable descriptions of modern schizophrenia did not appear in English or French until the early years of the __________ century.

Answer 4

Nineteenth.

It has been speculated that increasing industrialization, the movement of people to cities from towns and countryside, and environmental changes may have been involved in the sudden and escalating emergence of schizophrenia in modern life.

Question 5

What are positive symptoms?

Answer 5

Exaggerated, distorted adaptations of normal behaviour. They include the more obvious signs of psychosis, namely, delusions, hallucinations, thought and speech disorder, and grossly disorganized or catatonic behaviour.

Question 6

What are negative symptoms?

Answer 6

Absence or loss of typical behaviours and experiences. Negative symptoms may take the form of sparse speech and language, social withdrawal, and avolition (apathy and loss of motivation). Anhedonia (an inability to feel pleasure, as well as lack of emotional responsiveness) and diminished attention and concentration are also considered negative symptoms.

Question 7

Flip to see DSM Criteria for Schizophrenia.

Answer 7

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expres- sion or avolition).

B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset

C. Continuous signs of the disturbance persist for at least
6 months. This 6-month period must include at least
1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symp- toms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

Question 8

What are hallucinations?

Answer 8

Misinterpretations of sensory perceptions that occur while a person is awake and conscious and in the absence of corresponding external stimuli.

Question 9

What type of hallucinations are the most common form experienced by patients with schizophrenia?

Answer 9

Auditory hallucinations, in which the person hears voices or noises.

Question 10

What are delusions?

Answer 10

Implausible beliefs that persist despite reliable contradictory evidence. They reflect a disorder of thought content.

Question 11

What are the 5 types of delusions?

Answer 11

1) Persecutory - or “paranoid” delusions, in which individuals believe that they are being pursued or targeted for sabotage, ridicule, or deception.

2) Referential - the belief that common, meaningless occurrences have significant and personal relevance.

3) Somatic - beliefs related to the patient’s body.

4) Religious - often involves the belief that biblical or other religious passages or stories offer the way to destroy or to save the world.

5) Delusions of grandeur - l a belief in divine or special powers that can change the course of history or provide a communication channel to God.

Question 12

What is the most common form of delusion?

Answer 12

Persecutory.

Question 13

What is the least common of the positive symptoms?

Answer 13

Disorganized speech & thought disorder

Question 14

What is avolition?

Answer 14

Refers to the inability to initiate and persevere in activities. Aka apathy. (negative symptom).

Question 15

What is anhedonia?

Answer 15

consistent with the patient’s apathy and denotes a lack of pleasure or reward experiences. (negative symptom)

Question 16

What is the difference between grossly disorganized behaviour and Catatonic behaviour?

Answer 16

Grossly disorganized behaviour = reflects difficulty with goal-directed behaviour. Manifests itself in unpredictable movements, dress, hygiene etc.

Catatonic = other end of motor spectrum. significant reduction in responsiveness to the environment wherein patients assume unusual and rigid postures, waxy inflexibility.

Question 17

The DSM-5 states that the individual must have at least one of three core positive symptoms. What are those 3 symptoms?

Answer 17

delusions

hallucinations

disorganized speech for a diagnosis.

Question 18

What is brief psychotic disorder or schizophreniform disorder?

Answer 18

Exhibit key symptoms of schizophrenia (e.g., hallucinations, delusions, disorganized speech), but with durations of less than one month and one to six months, respectively.

Question 19

What is delusional disorder?

Answer 19

Persistent delusions for one month or more without overtly bizarre behaviour or other schizophrenia symptoms.

Question 20

What is schizoaffective disorder?

Answer 20

Is defined by the same symptoms that describe schizophrenia, but concurrent with a major depressive or manic mood episode. The mood symptoms must be present for approximately half of the illness duration after the onset of psychosis. Like schizophrenia, symptoms persist for six months or more.

Question 21

How does schizophrenia differ from other psychotic disorders?

Answer 21

In that impairment in level of daily life functioning is required for diagnosis.

Question 22

Who gained considerable experience treating people with schizophrenia and liked to tell the story of how he “discovered” the connection between psychosis and the collective unconscious?

Answer 22

Carl Jung.

Question 23

True or False?

Recent studies support the idea that low socio-economic status at birth makes development of a psychotic disorder more likely.

Answer 23

True.

Question 24

What is Meehl’s theory?

Answer 24

Proposes a biological diathesis, termed “hypokrisia,” that occurs throughout the brain, making nerve cells abnormally reactive to incoming stimulation. A single gene inherited from either parent causes this diathesis. However, the “schizogene” is often expressed weakly in a person and its effects may be compensated by other genes, as well as by experience and environmental influences. Hence, not everyone with the schizogene develops schizophrenia. Hypokrisia does not cause intellectual disability or other gross disorders of brain function. What it does produce is a subtler disturbance that Meehl called “cognitive slippage.” Information is disorganized, incoherent, and “scrambled.”

The unselective neuronal firing that causes cognitive slippage gives rise to a gradual increase in punitive, unpleasant social experiences. The brain amplifies feelings of pain and weakens pleasure, making interpersonal relations difficult. This aversive drift is related to negative symptoms such as social withdrawal and disinterest.

Question 25

All of the diathesis-stress theories of schizophrenia hypothesize a biological vulnerability that is either inherited or acquired very early in life. The vulnerability may take the form of neuroanatomical or neurochemical abnormalities, or both. It is the interaction of these abnormalities with maturation, stress, and life events that eventually causes schizophrenia.

Question 26

T/F?

Schizophrenia is observed to recur in some families,

Answer 26

True.

even in relatively “high-risk” situation, about 87 percent of people with a parent who has schizophrenia will remain free of the disorder. This “familiality” effect, shows that the likelihood of a person developing schizophrenia is much higher if a biological relative also has the disorder. The risk is highest for someone with an identical, or monozygotic, twin and then falls off stepwise as the degree of genetic relatedness diminishes.

Question 27

What is the principle of incomplete penetrance?

Answer 27

A proportion of people with a dominant gene will fail to show the effect of that gene.

Question 28

True or False?

The idea that one major gene causes schizophrenia is both supported by the facts and accepted by most researchers.

Answer 28

False.

Over the last several decades, research has moved increasingly to complex multiple gene models in accounting for the inheritance of schizophrenia. It is possible that as many as 600 “risk” genes may be involved in the disorder.

Question 29

The diathesis-stress approach to understanding etiology assumes that a genetic predisposition is only part of the pathway that eventually causes an illness. There must be stressors as well, including other biological or environmental and social events that accumulate and propel the vulnerable person toward schizophrenia.

What are some possible stressors?

Answer 29

One possible stressor is a mother’s exposure to common viruses such as influenza, or “the flu,” during pregnancy. Such exposures are linked with increased risk of schizophrenia in the offspring. However, the incidence of the disorder in people exposed to the virus is still extremely low. Perhaps viral exposure is one of many potential stressors that interact with genetic predisposition and other factors to influence etiology.

Birth-related complications have been proposed as one of these “other” factors. However, once again, most people with the illness do not have these abnormalities, even though they occur more often than expected by chance or in comparison to healthy people.

Question 30

T/F:

There is recent evidence that a significant portion of high-risk adolescents show early signs of having cognitive deficits.

Answer 30

True

For example, as early as the age of 13, about a third show lower general intellectual ability (IQ), and motor problems by the age of 16.

Question 31

T/F

There is recent evidence that traumatic experiences in childhood are associated with psychotic experiences later in life, especially in adolescents who also use marijuana.

Answer 31

True.

Question 32

What is expressed emotion?

Answer 32

Negative interpersonal communications directed at the family member with the disorder. (Ie: family hostility, lack of support, critical attitudes, and over-involvement.)

Also, a range of adverse experiences, from physical and sexual abuse to bullying, almost triple the likelihood that a psychotic disorder will develop.

Question 33

What is the idea of a cumulative liability for schizophrenia?

Answer 33

Schizophenia shows itself early in behaviour and increases with adverse environmental events and stresses over the course of childhood and adolescence.

Question 34

T/F

Most researchers believe that schizophrenia can be explained completely as a form of frontal brain disorder.

Answer 34

False.

Although few researchers believe that schizophrenia can be explained completely as a form of frontal brain disorder, the frontal hypothesis remains one of the earliest and most consistent attempts to relate the disorder to a specific brain system.

Question 35

What is the most popular neuropsychological measure in schizophrenia research?

Answer 35

Wisconsin Card Sorting Test (WCST)

Question 36

Researchers have found complex patterns of structural abnormalities in patients with schizophrenia such as:

Answer 36

The third and lateral ventricles, fluid-filled spaces deep in the brain, are abnormally large in patients, suggesting compression or loss of existing nerve tissue.

Reduced grey matter (tissue containing nerve cell bodies) in the medial and superior temporal, and frontal lobes.

Structural differences in patients with schizophrenia include parietal lobe, basal ganglia, corpus callosum, thalamus, and cerebellar abnormalities.

Question 37

In addition to structural changes, functional activation changes, as measured by both fMRI and PET, have been well documented in patients with schizophrenia such as:

Question 38

T/F

Many patients cannot be distinguished from healthy people with structural MRI or functional PET imaging.

Answer 38

True.

Only about 25 percent of patients with schizophrenia have abnormally reduced frontal brain volumes, and less than 50 percent have reduced blood flow or metabolism in the frontal region when engaged in a mental “activation” task.

Question 39

One of the most researched regions includes the ________________ and its many connections with other regions, including the frontal lobes.

Answer 39

left temporal lobe

(controls aspects of attention, the understanding of speech and written language, and interpretation of the visual world. Associated structures are the amygdala and hippocampus which colour these interpretations with emotion and store them in memory.)

Question 40

This evidence indicates that, from a biological perspective, the brain regions mediating the perception and storage of meaning and the creation of emotional associations are also the regions involved in schizophrenia. However, research has not yet demonstrated this involvement in a very convincing way. It is cognitive performance and abilities that appear to be most severely compromised by the disorder, whereas biological findings are often abnormal in only a minority of patients.

Answer 40

(Just a fact that seemed important)

Question 41

DTI (diffusion tensor imaging) studies indicate that the left arcuate fasciculus (a band of white matter that acts as a bridge between frontal and posterior parts of the brain) is the most affected white matter tract in patients who experience auditory hallucinations.

Answer 41

(Just another fact. Sorry - I’m getting tired. This chapter is so long!)

Question 42

What is the The Dopamine Hypothesis?

Answer 42

Researchers in the early 1960s identified a group of brain chemicals involved in the therapeutic effects of antipsychotic drug action. This research showed that dopamine, a type of neurotransmitter, plays a major role in therapeutic drug effects. The hypothesis that dopamine is central to schizophrenia has been one of the most enduring ideas about the disorder. The strongest support for a connection between abnormal dopamine activity or dysregulation and schizophrenia comes from studies showing that antipsychotic drugs such as chlorpromazine reduce symptoms by blocking dopamine receptors, especially the dopamine D2 receptor subtype.

Also supporting the dopamine hypothesis of schizophrenia was the observation that several drugs, including cocaine and amphetamine, accentuate or boost dopamine activity rather than blocking it.

Question 43

T/F

The evidence on drug effects and dopamine is suggestive, but it does not prove that something is wrong in the dopamine systems of people with schizophrenia or that abnormalities in the neurotransmitter cause the disorder in the first place.

Answer 43

True.

Question 44

What is the “final common pathway” to psychosis in schizophrenia?

Answer 44

In the most recent revision of the dopamine hypothesis, Howes and Kapur (2009) hypothesize that mul- tiple “hits” (e.g., pregnancy and obstetric complications, stress and trauma, drug use, and genes) interact to result in dopamine dysregulation. The authors claim that this dysregulation is the “final common pathway” to psychosis in schizophrenia.

Question 45

What are the pharmacological treatments for schizophrenia?

Answer 45

Antipsychotic Medication

Chlorpromazine and its chemical relatives, as well as a “new generation” of medications, alleviate the frequency and severity of hallucinations and delusions, thought disorder, and, to a lesser degree, the negative symptoms of the illness.

Risperidone and Olanzapine are more recently developed drugs that provide symptom control with fewer side effects than the older chlorpromazine family of drugs.

Question 46

What was the first genuine anti- psychotic medication?

Answer 46

Chlorpromazine

Question 47

The most disabling aspect of schizophrenia may be the _______________ associated with the disorder rather than the positive and negative symptoms.

Answer 47

Cognitive impairment.

Question 48

Is CBT recommended for schizophrenia?

Answer 48

Yes.

Studies have revealed that at least one form of psychotherapy may indeed be helpful in treating this population. Indeed, CBT is now recommended as a standard of care by the National Institute for Clinical Excellence, with a particular focus on four principal problems experienced by psychotic patients: (1) emotional disturbance, (2) psychotic symptoms such as delusions and hallucinations, (3) social disabilities, and (4) risk of relapse.

CBT theory maintains that emotional and behavioural disturbances are influenced by subjective interpretation of life and illness experiences.

Question 49

What is normalization?

Answer 49

One form of psychoeducation that helps patients understand symptoms by comparing their experiences to those of mentally healthy adults. For example, therapists explain that anomalous experiences can occur in healthy adults who are suffering from sleep or sensory deprivation or from unusually high levels of stress.

Question 50

What are other types of psychotherapy for schizophrenia?

Answer 50

1) Social skills training - learning-based intervention model for the treatment of functional disabilities. Unlike the symptom-focused CBT approaches, social skills training provides rehabilitation for patients with schizophrenia to develop practical social and living skills.

2) Cognitive remediation - target higher-level thinking skills such as memory, attention, and executive functions to enhance cognitive ability by teaching compensatory strategies, providing practice exercises, and holding group discussions.

3) Family Therapy - aims for active involvement of each member of the family in the treatment process. The family system is of particular importance because of the current focus on deinstitutionalization; patients with schizophrenia struggle in adjusting to community life, which may include residing with family members.

4) Early Intervention - medication and psychological therapies are provided before a person develops prolonged psychosis. Prodrome refers to the period before the appearance of psychotic symptoms when vulnerable adolescents often become withdrawn and suspicious.

Question 51

T/F

Epigenetic processes that turn genes on and off may be as important in causing schizophrenia as the genes themselves.

Answer 51

True.