Module 6 - Schizophrenia

Question 1

How has our current view of schizophrenia developed over history?

Answer 1

First associated with madness and insanity

Ppl drew on spiritual interpretations for behaviour (devine punishment or possession)

Auditory hallucinations date back to 2000 BCE = episodes of madness

Beginnings of diagnostic conceptualization began in Europe in 19th century

Kraeplin - dementia praecox

Blueler first used term Schizophrenia in 1911 and commented on the heterogeneity (the variability and diversity of clinical and biological features seen in schizophrenia) and introduced basic and accessory symptoms. Accessory are now known as positive symptoms today.

Schnieder “first rank symptoms” (core symptoms of schizophrenia) - hearing voices conversing with each other, beleiving thoughts were broadcasted or under control of outside force. Although these things are no longer sufficient to diagnose schizophrenia, these first rank symptoms went on to the diagnosis of schizophrenia for decades before being finally excluded in the current version of DSM.

Symptoms overtime have remained remarkable stable but we now think of schizophrenia as on a spectrum, with different severities and effects of these symptoms

Question 2

Understanding how we have come to group together the symptoms we have grouped together

Question 3

How has our view of psychotic disorders developed into what we see today

Question 4

What are the major positive symptoms

Answer 4

Abnormal additions to mental life, including the delusions, hallucinations and disordered thought

Question 5

What are the major negative symptoms

Answer 5

Features of schizophrenia that comprise behavioural deficits, including loss of motivation, lack of emotional expression, and lack of interest in the environment.

Can be broadly classified as experiential or expressive.

Avolition/Apathy - lack of motivation
Anhedonia - loss of pleasure
Asociality - social withdrawal
Alogia - poverty of speech
Affective flattening - lack of emotional expressivity, diminished facial expression

Question 6

Hallucinations

Answer 6

False perceptions occurring in the absence of any relevant stimulus. Auditory hallucinations are the most common form (64-80% prevalence).

Question 7

Delusions

Answer 7

Fixed false beliefs that are unfounded and highly resistant to contradictory evidence.

-Persecutory delusions
-Religious delusions (taking on role of religious icon)
-Somatic delusions (believes body is changing)
-Referential delusions (common events/objects hold personal meaning)
-Grandiose delusions (special powers)

Delusions can be bizarre or non bizarre.

Bizarre = completely impossible, and do not derive from ordinary life experience

Delusions of loss of control are considered bizarre (thought withdrawal, thought insertion)

Question 8

Persuctory Delusions

Answer 8

Also called paranoid delusions.

Involve the belief that one is being conspired against, spied upon.

Most common type of delusion, occurring in 60% of people with delusions.

Question 9

Capgras syndrome

Answer 9

aka imposter syndrome. Can occur in psychotic disorders as well as neurological such as stoke or dementia

report that ppl well known to them have been replaced by substitutes.

Question 10

Disorganized Speech

Answer 10

Loosening of associations = when speech switches from topic to topic without obvious connection

Question 11

Thought disorder

Answer 11

Refers to disorganized linguistic communication through either verbal or written means.

Several types of thought disorder, but the common theme among them is that it is difficult to understand what they are trying to communicate.

Perservation is an example of thought disorder, in which a person becomes fixated on a specific word or idea and repeats it over and over

Most severe form of thought disorder = word salad

Question 12

Disorganized Behaviour

Answer 12

Refers to problems initiating and/or sustaining appropriate goal-directed behaviour. This can range from basic self care and grooming activities to social disinhibition, to outright bizarre and inappropriate behaviour.

Ex: inappropriate clothing for weather

Abnormal motor behaviour may include catatonia, waxy flexibility, posturing and mannerisms

Question 13

What is our current understanding of the etiology of schizophrenic spectrum disorder?

Answer 13

Biological-
- Dopamine hypothesis
- Neurobiological findings

Psychological -
- Neurocognition
- Social cognition
- Cognitive biases
- Social Factors

Question 14

Dopamine hypothesis (Biological etiology of schizophrenia)

Answer 14

Dopamine is involved in motivation and pleasure. The key neurotransmitter in the development of positive symptoms

This hypothesis suggests that shizophrenia results from an abnormally high level of dopamine in the brain.

Question 15

Neurobiological findings (Biological etiology of schizophrenia)

Answer 15

Assumption that nerve cell loss throughout different brain structures must be responsible for some various schizophrenic symptoms.

-Enlargement of ventricles
-Reduced grey matter (temporal and frontal lobes)
-Structural abnormalities (parietal, basal ganglia, corpus callosum, thalamus, cerebellum)

Most common structural finding in ppl with Schizophrenia is overall reduced grey matter volume in temporal lobes.

Temporal lobes linked to auditory hallucinations, whereas frontal lobe abnormalities linked more broadly to cognitive, negative and positive symptoms.

Question 16

Neurocognition (psychological etiology of schizophrenia)

Answer 16

Paper and pencil tests that assess different domains of cognitive functioning.

Impairments in neurocognitive functioning is one of the most common findings in schizophrenia, that it has been hypothesized that neurocognitive impairment is a core feature of the disorder.

Neurocognitive impairment worsens after the first episode.

First degree relatives that do not develop schizophrenia still display neurocognitive impairments, suggesting that it is associated with the disorder but not the cause

Question 17

Social cognition (psychological etiology of schizophrenia)

Answer 17

Refers to the cognitive abilities needed for understanding the social world.

Pl with schizophrenia have difficulty identifying other people’s emotions and challenging time with theory of mind

Question 18

Cognitive biases (psychological etiology of schizophrenia)

Answer 18

Schizophrenia is associated with how information is processed.

Ex: development of delusions is associated with a combination of cognitive biases. Ppl with Schizophrenia are more likely to jump to conclusions and this bias is specifically associated with delusions.

Delusions are also associated with bias against disconfirmatory evidence (BADE) and this causes delusions to be highly resistant.

Theories of hallucinations have been linked to a cognitive bias known as source monitoring - which refers to the ability of the brain to determine and remember whether the source of stimuli is internal or external

Question 19

Social factors (psychological etiology of schizophrenia)

Answer 19

Although social factors may fit most clearly as the stressor with the diathesis-stress model, it is also possible that social factors may explain the biological and psychological changes that put someone at risk to develop schizophrenia.

The social defeat theory suggests that chronic exposure to negative social experiences leads to sensitization of the dopamenegeric system and may increase risk for schizophrenia.

5 of the most common social factors that increase risk:
1) urban upbringing (1.5-3x higher)
2) Migration (2.9x)
3) childhood trauma (2.7x)
4) low intelligence (3.5x)
5) drug abuse (doubles risk)

Question 20

Theories for how schizophrenia disorders arise and what the evidence is for those theories?

Answer 20

Diathesis-stress models-
View that a predisposition to develop the diathesis (disorder), interacting with the experince of stress causes mental disorders.
-Viewed as a biological vulnerability - genetic component that ppl have higher risk with first degree relative
-One parent with schizophrenia increases risk to 13% (gen pop risk is only 1%)

Neurodevelopemental models -
many small changes during the course of development lead to the manifestation of schizophrenia.

Evidence comes from findings that at all stages of development, risk for schizophrenia can be increased.
-Maternal infection, famine
-Delays as child; impairments in gross motor movements and speech acquisition, atypical social development
-Child who Later development typically display poorer relationships, social isolation, and social anxiety

Question 21

What are the effective treatments

Answer 21

-Antipsychotic medication
-Psychosocial treatment (largely classified into either psychotherapy or skills training)
-Cognitive behavioural therapy (CBT-P)
-Cognitive remediation
-Family therapy and psychoeducation
-Skills training

Question 22

Antipsychotic medication

Answer 22

Medication alone is not effective. Medications are typically effective on positive symptoms, with small effect on negative symptoms and little to no effect on negative symptoms.

Clozapine is most effective, but is not a first choice treatment because of severe side effects such as agranulocytosis.

Question 23

CBT-P

Answer 23

Cognitive behavioural therapy for psychosis - CBT adapted to target positive symptoms and the distress and functional impairment that result from the symptoms in addition to the symptom itself.

Evidence that it improves both hallucinations and delusions, and improves ability to funciton in every day life.

Effective in early stages and can reduce the likelihood of transitioning from prodromal to FEP by approx 50%

A collaborative therapy that helps make sense of how symptoms develop and are maintained.

Question 24

Cognitive remediation

Answer 24

Focused on treating neurocognitive impairments in domains such as attention, memory and problem solving.

• functional generalization
• Computerized cognitive training
• strategy monitoring

Question 25

Psychosis

Answer 25

loss of touch with reality that is characterized by symptoms of hallucinations, delusions

Question 26

Diagnostic Criteria for schizophrenia

Answer 26

A. 2 or more must be present for a significant portion of a 1 month treatment (or less if successfully treated) and at least of 1, 2 or 3 must be present. Core Symptoms:
1) Delusions
2) Hallucinations
3) Disorganized speech (frequent derailment of incoherence)
4) Grossly disorganized or catatonic behaviour
5) Negative symptoms

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

C. Persistent signs of the symptoms for at least 6 months. This 6 month period must include one month (or less is successfully treated) of symptoms that meet criteria A.

D. Shizoaffective or bipolar with psychotic features has been ruled out

E. Not attributable to substance or other medical condition

F. If there is a history of ASD or communication disorder of childhood onset, the additional diagnoses of schizophrenia is only made if prominent delusions or hallucinations, in addition to the other symptoms of shizophrenia, are also present for at least 1 month (or less is successfully treated).

Question 27

Schizoaffective disorder

Answer 27

Similar to schizophrenia but contains an added element of diagnosed mood episode that occurs at the same time of schizophrenic symptoms. This period of co-occurring symptoms must have preceded or followed by at least two weeks of delusions or hallucinations without the mood symptoms.

Two subtypes:
1) Bipolar type
2) Depressive type

Question 28

Schizophreniform disorder

Answer 28

Characterized by same diagnostic criteria as schizophrenia, but only lasts between 1-6 months

Question 29

Delusional disorder

Answer 29

Experiencing delusions for at least one month and not experiencing any other psychotic symptoms.

Functioning is not markedly impaired, and behaviour is not obviously bizarre or odd.

Question 30

Brief psychotic disorder

Answer 30

If positive symptoms (A1-A4) are present for more than 1 day and remit within 1 month. (If symptoms persist between 1-6months then shizophreniform disorder is diagnosed).

Question 31

Cognitive symptoms of Schizophrenia

Answer 31

Attention, memory, learning, processing speed and problem solving

Also can affect social cognition such as emotion recognition, being able to infer other peoples thoughts and intentions and reacting emotionally to others.

Question 32

Premorbid stage

Answer 32

starting in childhood, mild impairments in cognitive, social, academic, motivational functioning

Ex: learning difficulties, depression, social isolation

Question 33

Prodromal stage

Answer 33

Adolesence - sub-threshold positive symptoms, comorbid mood and anxiety symptoms and difficulty functioning in everyday life.

Ex: anxious, withdrawn, suspicious of those around them.

Question 34

Psychotic Phase

Answer 34

First episode psychosis (FEP), typically occurs in late adolescence or early adulthood