Schizophrenia Flashcards
What differentiates psychosis from other disorders
loss of contact with external reality- impaired perceptions and thought processes
Split mind, not split personality- fragmentation of thoughts, splitting of thoughts from emotions, withdrawal from reality
Lack of insight (97%)
Typical symptoms in schizophrenia
A.
Hallucinations- 75% experience (auditory 60-70%, visual, olfactory, gustatory, tactile-insects crawling)
Delusions- beliefs
Disorganised speech- formal thought disorder- disturbances in flow/form of speech rather than content
Grossly disorganised motor movements and catatonic behaviour
Negative symptoms
B. Impact to functioning- worse than prior to onset or what is expected culturally
C. At least 6 months of disturbance- may be gradual deterioration- at least one-month of positive psychotic symptoms
Prevalence and age of onset
1-2%- lifetime prevalence
male to female: 3:2
Age of onset: late adolescence and early adulthood (tends to be later for women)
Onset coincides with stressful time of life
Early onset associated with poorer outcomes
Relapse risk factors
Poor premorbid Slow insidious onset Prominent negative symptoms Duration of untreated psychosis Slower or less complete recovery Lower socioeconomic class Migrant status Social support network Family history
Aetiology- genetic
Genes determine susceptibility - disorder triggered by other factors
7.3% siblings
9.4% for children of one affected parent
46.3% for children with two affected parents
Twin studies concordance rates:
12.1% for DZ twins
44.3% for MZ twins
Subtypes
Schizotypal- personality disorder
Brief Psychotic Disorder (sudden,
Negative symptoms
social withdrawal (poor eye contact) anhedonia- lack of pleasure emotional blunting (66%) confusion amotivational apathy self-neglect poverty of speech poverty of content
Types of auditory hallucinations
Voices inside head or coming from external sources
Own thoughts spoken aloud (describing feeling/thinking, fears or worries)
Can be comforting
Derogatory or insulting voices
Third person commentary
Commands to perform unacceptable behaviors
Cross-cultural studies: similar forms across societies but cultural differences in content & interpretation
Are schizophrenics aggressive? risk factors
not any more than general public. Risk factors for hostility: Younger males (with past history of violence) Non-adherence with medication Substance use Impulsivity
Types of delusions
Paranoid/ Persecutory- most common- one is being harmed or persecuted by person/group
Delusions of Reference- neutral event interpreted to have personal meaning for individual e.g. newspresenter
Grandiose- special powers, abilities, influence
Nihilistic- belief that one, bodily part or world doesn’t exist or has been destroyed
Guilt- responsibility for events
Jealousy delusions (monosymptomatic)
Erotomanic delusions- romantic feelings reciprocated
Misidentification- identity of someone they know has been stolen- loved one is actually an imposter
Is thought disorder specific to schizophrenia?
No- just way of describing disorganised form rather than content of thought- also present in depression, mania etc.
Positive and negative manifestations of thought disorder
negative: reduced stream of thoughts and poverty of speech
positive: circumlocution, derailment (comments slipping from one to next)
tangential (irrelevant responses)
echolalia (repeat what they’re saying-acute phase)
word salad (incomprehensible stream of words)
neologisms (rhyming)
Catatonic behaviour
extreme negativism (resistant to instructions)
immobility (waxy flexibility)
catatonic excitement: excessive purposeless physical activity
Peculiar voluntary movments
posture, repetition, grimacing
mutism, echolalia, echopraxia, imitating speech
Course
highly variable
one or more episodes- periods of normal (or near normal) in between- 66% difficulty with at least one daily living activity
most remain chronically unwell with deteriotrating course
50% unable to work
Prevalence of suicide
Attempted: 30%
Complete 5-10%
Neurobiological aetiology
Overproduction of dopamine or oversensitivity of dopamine receptors
- excess L-Dopa in Parkinson’s causes psychosis
- abnormally large responses to low amphetamine doses (dopamine agonist)- over-sensitivity
- response to anti-dopaminergic medication- effective in 60%- more on positive, not negative(maybe more brain degeneration)
Neuroanatomical
Enlarged ventricles in schizophrenia (post-mortem; CT scans; MRI studies)
Relative size more than twice that of normal controls
Most likely cause is loss of brain tissue; scans indicate chronic schizophrenia is associated with brain abnormalities
Greater brain tissue loss in prefrontal cortex
Linked to negative symptoms (damage to executive functioning system)
Recent findings of smaller left hippocampal volume in those:
With schizophrenia
At very high risk of developing schizophrenia
Without a family history
Structural brain abnormalities appear to predate onset of psychosis & worsens with progressive illness
Early neurodevelopmental damage (e.g., from viruses) may play a key aetiological role
Obstetric complications, viruses, urban birth, nutritional factors & paternal age, seaonal variation (Murray et al., 1992; Cannon et al., 2003)
Birth trauma & maternal viral infections
Nature & timing of factors obscure but ischaemia/hypoxia & influenza/viral infections likely
Nutritional deficiencies may contribute to adverse neurological development
Risk for those with birth complications is four times that for non-complications
History of birth complications found in 40%
10 times greater likelihood of complicated caesarean birth
Seasonal variations & place of birth Greater likelihood of winter or spring birth ? Viral illnesses or vitamin D deficiency (brain development) Two-fold increase in risk for urban births Schizophrenia more common among lower socioeconomic classes & more prevalent in lower class districts of many cities of the industrial world (? drift hypothesis)
Treatment: medication
60% of clients with positive symptoms respond: Block D2 & D3 dopamine receptors
10%-20% do not show symptom improvement in response to medication
Relapse rates high with 40% relapsing within one year
Side effects of medication
Sedation
Extrapyramidal side effects:
Symptoms resembling Parkinson’s Disease
Tardive dyskinesia (abnormal movements, facial grimacing, lip smacking)
Finger tremors, shuffling gait, drooling, chewing, twisted posture
Side effects often treated with anti-Parkinson drugs
Weight gain, diabetes, heart disease
Clozapine additional side effects:
blood abnormalities; reduced white blood count
Psychological
Social skills training for interpersonal deficits (have to be culturally aware- Egyptian evil eye
Medication compliance
Managing delusions/hallucinations
Reduction of stresses
CBT potential non-pharmacological treatment
What can CBT help with?
Delusions
Notice early signs of relapse
Understand relationship between thoughts, feelings & behaviours
Challenge beliefs about not being able to manage one’s thoughts & behaviours
Learn strategies to cope with symptoms & stressors
Evaluate evidence supporting delusional beliefs versus alternative beliefs (e.g., recognize inner experiences such as ‘thoughts’ can be misattributed to external sources, like ‘voices’)
Is CBT effective?
Tarrier et al. (2000) found that CBT showed better outcomes than standard treatment in:
Reducing relapse, hospitalisation, positive & negative symptoms
Improving social functioning
Gains maintained at 2 year follow up
CBT shown to reduce numbers who go on to develop psychosis in ‘high risk’ groups
What do Family Interventions focus on?
Education about schizophrenia and its treatment
Realistic goal setting skills
Communications training (empathic not critical)
Problem Solving skills
Promote social support
Family interventions shown to reduce relapse & enhance family support
Why was Family Therapy developed?
in response to higher relapse rates for patients from families high in Expressed Emotion (EE)
