Schizophrenia Flashcards
What is Schizophrenia NOT
“Split personality”
Violent/Dangerous/Unpredictable/Out-of-Control
Untreatable
All the same
Four people with schizophrenia
Why the misconceptions?
“Schizophrenic” has been used to describe the erratic behavior
of the weather, the stock market, and even the 2002 New
England Patriots’ football team.
schizophrenia
category of psychotic disorders
Schizophrenia is the most common diagnosis in this group of disorders
psychosis
impairment of reality testing
Different types of symptoms
positive symptoms
negative symptoms
symptoms of disorganization
positive symptoms
a. Sensory perception (hallucinations)
b. Ideations (delusions)
positive=psychotic
pathological excesses (50-70% experience)
! Delusions (firmly held beliefs)
! Hallucinations (sensory experience in absence of environmental stimuli or input)
negative symptoms
a. Social/motivational deficits
b. Decreased expressions of emotion
symptoms of disorganization
a. Disorganized speech/thought
b. Disorganized behavior
schizophrenia prevalence
! Present in humans through recorded history ! 1% of most populations (roughly similar worldwide with some differences) ! About 2.5 million Americans currently have the disorder ! Appears in all socioeconomic groups; found more frequently in the lower levels ! Stress of poverty causes the disorder? ! Downward Drift? ! Disorder causes victims from higher social levels to fall to lower social levels and remain at lower levels
making sense of schizophrenia
In 1960s: being sane in an insane world; constructive inward search
! R.D. Laing: “The experience and behavior that gets labeled schizophrenic is a
special strategy that a person invents in order to live in an unlivable situation.”
! Floyd Pinkerton: The Wall
! Half of people with schizophrenia will attempt suicide (role of
remission)
! Age
! Positive symptoms dwindle, negative symptoms come to forefront
! Late adolescence – early adulthood onset (20-32)
! Prodromal symptoms
! Stress plays major precipitating role
! No gender differences in prevalence, although men & women have
different courses
! Peak ages of onset: males 20–28 years and females 26–32 years
! More recent data suggest prevalence higher in MEN
clinical features of schizophrenia
chart
interesting schizophrenia fact
more severe course the less likely to kill themselves
DSM-5 diagnosis
five key symptoms: 1) delusions 2) hallucinations 3) disorganized speech 4) disorganized or catatonic behavior 5) negative symptoms !two of these five symptoms are required AND at least one symptom must be one of the first three (delusions, hallucinations, disorganized speech).
History-Emil Kraepelin
This illness develops relatively early
in life, and its course is likely deteriorating and
chronic; deterioration reminded dementia („Dementia
praecox“).
History-Eugen Bleuler
He renamed Kraepelin’s dementia
praecox as schizophrenia (1911); he recognized the
cognitive impairment in this illness, which he named
as a „splitting“ of mind.
Kurt Schneider
He emphasized the role of psychotic
symptoms, as hallucinations, delusions and gave
them the privilege of „the first rank symptoms”
delusions
persecution, reference
Jesus, Satan, Heads of State
hallucinations
Vast majority auditory (could be olfactory)
Command
Visual hallucinations are morphing what is already there
edgar allen poe quote
“Have I not told you that what
you mistake for madness is but
the overacuteness of senses?”
errotomania:
thinking you have a special relationship with someone who might not even know you exist
disorganization in terms of speech
Rambling speech Jumping topic to topic
Word salad, “clanging”, loose associations
Neologisms
disorganization in terms of behavior
Inappropriate affect
Agitation
Repetition (echolalia)
Bizarre Behavior (ex: pouring OJ on head)
disordered thought
DISORDERED THOUGHT seems to be core of what disease is about
hallucinations more florid/dramatic…responsive to medications
loose associations (derailment)
“The problem is insects. My brother used to collect insects. He’s now a man 5 foot 10 inches. You know, 10 is my favorite number; I also like to dance, draw, and watch TV.”
Neologisms
(made-up words)
“This desk is a cramstile”
“He’s an easterhorned head”
Flusterated
Preservation symptom of disorganized speech
Patients repeat their words and statements again and again
Clang
rhymes
How are you? “Well, hell, it’s well to tell”
How’s the weather? “So hot, you know it runs on a cot”
word salad
“Much of abstraction has been left unsaid and undone in
these products milk syrup, and others, due to economics,
differentials, subsidies, bankruptcy, tools, buildings, bonds,
national stocks, foundation craps, weather, trades,
government in levels of breakages and fuses in electronics too
all formerly states not necessarily factuated”
negative symptoms
avolition alogia thought blocking anhedonia blunted/flat affect social withdrawal
avolition
inability to initiate
behavior (I.e. showering)
alogia
poverty of speech–difficult to access info
ex: hit two bears with one stone -> do two things at once
anhedonia
no pleasure in things you use to enjoy
blunted/flat affect
toneless expression
social withdrawal
absence of social connectedness, absence of affect, apathy
psychomotor symptoms
People with schizophrenia sometimes experience
psychomotor symptoms
–Awkward movements, repeated grimaces, odd gestures
These symptoms may take extreme forms,
collectively called catatonia
– Ranges from wild agitation to immobility
–Examples: pace excitedly or move fingers or arm in
stereotyped ways OR hold unusual postures (waxy flexibility)
schizophrenia & suicide
The general risk for suicide is higher at certain times in the
course of the disease:
! Within the first 5 years of onset of the disease
! During the first 6 months after hospitalization
! Following an acute psychotic episode
! The widespread use of antipsychotic drugs over the past
decade does not appear to have had much effect on suicide
rates. In fact, evidence suggests that the use of these drugs
as a way of reducing hospitalization time is increasing the
incidence of suicide. Depression, not delusions, appears to be
the most important motive for suicide in these patients.
course of schizophrenia
- continuous without temporary improvement
- episodic with progressive or stable deficit
- episodic with complete or incomplete remission
many sufferers experience three phases:
prodromal
active
residual
prodromal phase
beginning of deterioration; mild symptoms
BIG prodromal phase
active phase
symptoms become increasingly apparent
residual phase
a return to prodromal levels
- One-quarter of patients fully recover; three-quarters continue to have residual problems
Course
chart
early signs
! Social withdrawal ! Hostility or suspiciousness ! Deterioration of personal hygiene ! Flat, expressionless gaze ! Inability to cry or express joy ! Inappropriate laughter or crying ! Depression ! Oversleeping or insomnia ! Odd or irrational statements ! Forgetful; unable to concentrate ! Extreme reaction to criticism ! Strange use of words or way of speaking
North American Prodrome Longitudinal Study (NAPLS)
! Collaboration between 8 programs focusing on the psychosis
prodrome.
! Funded by the National Institute of Mental Health (NIMH), the sites
are located at Emory University, Harvard University, University of
Calgary, UCLA, UCSD, University of North Carolina Chapel Hill, Yale
University, and Zucker Hillside Hospital
! Combining different types of information—cognitive testing,
clinical features (e.g., unusual thoughts, suspiciousness,
decline in social functioning), a history of traumatic events,
and a family history of psychosis—over 70 percent of those
identified as high risk went on to develop psychosis.
! Accuracy appears equal to or better than our predictions of
heart disease or dementia.
Course and Prognosis
! Each phase of the disorder may last for days or years
! A fuller recovery from the disorder is more likely in people:
! With high premorbid functioning
! Whose disorder was triggered by stress
! With abrupt onset
! With later onset (during middle age)
–abrupt onset is more likely to get notice and treat quickly, but if there’s a long onset, there might be a change in brain structure
Etiology
! The etiology and pathogenesis of schizophrenia is not known ! It is accepted, that schizophrenia is „the group of schizophrenias“ which origin is multifactorial: ! internal factors – genetic, inborn, biochemical ! external factors – trauma, infection of CNS, stress -factors occurring long before the formal onset of the illness (probably in gestation) disrupt the course of normal brain development resulting in subtle alterations of specific neurons and circuits --high heritability rate
Developing country aspect
if you have schizophrenia, you better live in in developing country.
How can we interpret it?
-can anti-psychotic make the course worse?
-US in fact has great medical care
-Maybe US has worse patient (biological deficit) more severe population
Neurochemical causes
Dopamine Hypothesis
!Antipsychotic meds work (block dopamine receptors)
!Symptoms worsen with drugs that increase dopamine
! L-Dopa for Parkinson’s (low dopamine in substantia
nigra)
! dopamine levels raised everywhere in brain – become
psychotic
! Overmedicate schizophrenia – Parkinson’s symptoms
!Post-mortem brain studies show more dopamine
receptors in frontal cortex
!Amphetamines can cause psychotic symptoms
Dopamine problem
too much dopamine could be a cause but too little creates a tremor
Schizophrenia and drugs
people with schizophrenia don’t tend to do cocaine or hallucinogens
Biochemical Abnormalities Cause
!Dopamine may be overactive in people with
schizophrenia because of a larger-than-usual number
of dopamine receptors (particularly D-2) or their
dopamine receptors may operate abnormally
! Autopsy findings have found an unusually large number of
dopamine receptors in people with schizophrenia
! Imaging studies have revealed particularly high occupancy
levels of dopamine at D-2 receptors in patients with
schizophrenia
! block dopamine receptors, specifically D2 receptors, reduce
schizophrenia symptoms.
(it is hard to find someone on schizophrenia who isn’t on medication)
Brain Structure Cause
Early brain damage or abnormalities? “Silent lesions” ! Enlarged cranial ventricles ! Fewer neurons in frontal cortex & lower levels of neurons affecting frontal maturation ! Methodological limitations ! Malnutrition v. Disease ! Medications ! Rapid autopsy teams remove brain ~30 minutes after death ! Unmedicated schizophrenia patient (research gold)
Auditory Hallucinations
Wernicke’s Area
Broca’s Area
-misinterpreting own thoughts thinking its someone else or being paranoid
some people report hearing more than one voice
Wernicke’s Area
understanding of written and spoken language
Broca’s Area
production of language
Viral problems cause
--large number of people with schizophrenia were born in winter months --mothers of children with schizophrenia were more often exposed to the influenza virus during pregnancy than mothers of children without schizophrenia !inflammatory processes !prenatal exposure to infection (winter births; fingerprints) !recent-onset schizophrenia increased interleukin-1beta (IL-1B; proinflammatory cytokine) ! The brain's immune defense system is activated in schizophrenia
Feline Connection
toxoplasma gondii (parasite; toxoplasmosis) ! cat “ schizophrenia connection
! Animals: infection with
Toxoplasma gondii can alter behavior & neurotransmitter
function.
! Human beings: acute
infection with T. gondii can produce psychotic
symptoms similar to those
displayed by persons with
schizophrenia
Gray matter brain structure
people with schizophrenia have less gray matter so ventricles swell to fill that space
Research gold
unmedicated schizophrenia
who just had first psychotic break
-not unique to schizophrenia
Schizophrenia and Cigarrettes
75% of schizophrenics smoke cigarrettes
People born around the equator
less schizophrenia cases in any months doesn’t matter if its winder, maybe because not as distinct four seasons, more sun, more vitamin D
markers of inflammation
also present in PTSD and depression
Inflammation: Minocycline
remember schiz may be due to inflammatory processes in the brain
! Drug was prescribed to a young male patient with no previous
psychiatric history but became agitated and suffered auditory
hallucinations, anxiety and insomnia.
! Blood tests and brain scans showed nothing unusual and he
was started on the powerful anti-psychotic drug Halperidol.
! The treatment had no effect and he was still suffering from psychotic
symptoms a week later when he developed severe pneumonia and
was prescribed the antibiotic Minocycline to treat the infection.
! Researchers testing Minocycline in patients with schizophrenia
around the world
Gene Factors
!the concordance rate in monozygotic twins is greater than that observed in dizygotic twins !adopted children of schizophrenic parents have the same risk of schizophrenia as their biological rather than their adoptive parents
Strong Genetic Link
! Chances increase with number of relatives afflicted.
! MZ twins = 47%
! DZ twins = 17%
! Genain Quadruplets = 100%
Genain Quadruplets
Nora, Iris, Myra*, Hester**
! Nora and Myra were thought to be brighter
and taller, were treated better by their
parents, and were more successful
in life than the other two
! Iris/Hester - circumcision
! CT scans revealed no differences in brains
Genes and environment important!
Genetic factors
! Twins have received particular research study
! Studies of identical twins have found that if one twin develops the
disorder, there is a 48% chance that the other twin will do so as well
! If the twins are fraternal, the second twin has a 17% chance of developing
the disorder
! Very limited understanding of how genes alter brain development to
produce schizophrenia and other disorders.
! More specific knowledge would provide clues about mechanisms of
prevention and treatment.
! Gene variants that increase the risk for schizophrenia increase the
risk for other disorders, such as developmental delay, autism, and
bipolar disorder.
Cultural factors
! All cultures experience schizophrenia- including people in remote
locations
! Western Culture
! African-American men overdiagnosed (?) “ Schizophrenia as political weapon
! Emotional disharmony (1920s-1950s)” assaultive & belligerent (civil rights) (DSM-II 1968)
! Jonathan M. Metzl: Protest Psychosis
! FBI & Malcom X
! Some fare better in certain cultures: psychosocial environments of
developing countries tend to be more supportive than developed
countries, leading to more favorable outcomes for people with
schizophrenia
! More acceptance
! Course & outcome in developing countries
! Social labeling – Rosenhan pseudo-patient study (1973) good interrator reliability
Psychological factors
Immigrant paradox NOT true for schizophrenia
! Stressful life events
! Prenatal stress (fetuses during famines china/netherlands= higher
incidence of schizophrenia), mechanical trauma at birth (brief hypoxia),
shared placenta by identical twins)
! Acute stressors
! Immigration
! Discrimination
! Social defeat (social exclusion)
! social rank or social economic status may be
exceptionally harmful
Expressed Emotion (EE)
–criticism, hostility, emotional overinvolvement
! Individuals who are trying to recover from schizophrenia are almost four
times more likely to relapse if they live with such a family
which is a modifiable risk factor
-families comment on negative symptoms mainly
Critical comments and hostility: ways in which family
members use their tone of voice to convey their feelings
(anger, rejection, irritability, ignorance, blaming, negligence,
etc)
sociocultural views
! EE is of interest to researchers and clinicians because it
predicts symptom relapse in patients and because familybased
interventions that seek to reduce EE have had success
in decreasing patients’ relapse rates
! Researchers have positioned EE within the diathesis-stress
model of psychopathology, characterizing it as an
environmental stressor that can potentially precipitate/cause
relapse of psychosis among people with a genetic
vulnerability.
emotional overinvolvement
behavior such as caregivers
blaming themselves, sacrificing things, being overprotective of
the identified patient, excessively being concerned for
identified patient, neglecting personal needs of self
etiological influences
Children born in urban environments are at an increased risk for schizophrenia. ! dose-response effect ! Stress is a factor related to onset, severity, and expression of schizophrenia. ! exacerbates symptoms, and may increase psychotic episodes. ! research also shows that stress is likely a casual factor for the development of schizophrenia.
urbanicity
to be raised in an urban (people density) environment, higher schizophrenia risk
Why?
air quality, sickness, crime rate, nature, traumatic events, exposure to cats
Etiology take home message
! No evidence that schizophrenia is entirely caused by only
genetic or only social factors
! Intricate interplay of genetics/biology and social/
environmental factors is the culprit.
! Evidence for social factors has shown a dose-response effect,
! The more of the social factor present (dose), the greater the risk for
schizophrenia (response).
BIG GENETIC COMPONENT
Treatment
divided into three phases
- acute: reduce severity of symptoms (meds)
- stabilization: consolidate treatment gains & help patient attain stabile living situation
- maintenance(symptoms are in partial or complete remission): reduce residual symptoms, prevent relapse, and improve functioning
Medication
is primary most successful intervention (antipsychotics)
–Neuroleptics: first effective meds (haldol, thorazine; 60% benefit)
–Atypicals: milder side effects? (abilify, risperdone, zyprexa, seroquel, geodon)
weight gain, diabetes and high blood
cholesterol
clozapine* = agranulocytosis and seizures
Minocycline(anti-biotic)
Medication non-compliance is an issue
agranulocytosis
a precipitous drop in white blood cell count
Tardive Dyskinesia
side effect causing involuntary movement around tongue and mouth-irreversible
Side effects
Extrapyramidal Side Effects
–akinesia (inability to initiate movement;
monotonous speech,
expressionless face)
–akathisia (inability to remain motionless)
–Tardive Dyskinesia - lick
smacking, chewing, etc
Clozapine Pros and Cons
- Superior efficacy for positive symptoms
- Possible advantages for negative symptoms
- Virtually no EPS or TD
- Advantages in reducing hostility, suicidality
- Associated with agranulocytosis (1-2%) ! WBC count monitoring required
- Seizure risk (3-5%)
- Warning for myocarditis
- Significant weight gain, sedation, orthostasis, tachycardia, sialorrhea, constipation
- Costly
- Fair acceptability by patients
Psychosocial treatment
Build social and self care skills (establishing routines)
! Family education
! Modify family communication
! Community support Programs
! Independent living skills (symptom management/med management)
CBT treatment in addition to meds
– May be useful for avolition/apathy (symptom severity)
– Adherence to medications – communicating with healthcare
professionals
–Help with weekly goals
–May be useful in reducing frequency or distress associated with positive symptoms, particularly auditory hallucinations.
