Schizophrenia Flashcards
Psychosis and neurosis
So far we’ve focused on neurosis: distress and impairment without detachments from reality
Psychosis: significant loss of contact with reality
•generally seen as more severe/greater impairments
•persistent in severe cases of many disorders
Schizophrenia
Most commonly associated with negative stereotypes (crazy image)
Distortions in
•perception, thinking, behaviours, sense of self, and relating to others
Untreated: significant impairments in most domains of life
History
•Late 1800s: dementia praecox (decline in cognitive functioning at a young age), with D/H, apathy/indifference, withdrawn
•Early 1900s: schizophrenia (split mind) - not multiple personalities, but different lines of thought (feelings are different than thoughts, observations of the world are different than what they actually are)
Delusions
inaccurate beliefs that are fixed/firmly held that often lack evidence/there’s contrary evidence
•ex: believing in aliens is fine, but being 100% certain is a delusion
•Not shared by social/religious groups
•On a spectrum with cognitive distortions (ex: believing people see you in a certain way/SAD, and obsessions (OCD) to extremes)
•90% of schizophrenia patients experience delusions at some point
•Delusions + hallucinations = positive symptoms
Common themes of delusions in schizophrenia
1. thoughts/feelings/actions being controlled by external agents
•thought broadcasting (my thoughts are being sent to other agents against my will), thought insertion (someone implemented thoughts into my head), and thought withdrawal (someone stole my thoughts)
2. delusions of reference (ex: watching the news and thinking AC is trying to send me a personal message)
3. bodily changes (ex: believing you had a surgery when you didn’t)
4. paranoia (ex: people are after me)
Hallucinations
Sensory experience in the absence of external stimulus
•different than an illusion (misinterpretation of external stimulus)
•auditory hallucinations are much more common (73% auditory, 39% visual, 1-7% olfactory gustatory or tactile)
•Influenced by person’s stress, fears, and self esteem (ex: low SE = negative/mean voices)
Can have significant involvement in
1. emotional (hearing voices can be very scary)
2. cognitive (delusions and hallucinations work together - government is in my head taking my thoughts AND I can hear them)
3. Behavioural (thought that makes you do something)
Auditory hallucinations
Common themes
1. 70% are normal volume
2. Familiar voices are most common (can be your own) vs god/devil voices
3. Often more than one voice
4. More prominent when you’re alone
5. Most voices are rude/critical/demanding
•supportive voices can happen (pet names)
Do they really hear voices?
•difficult to answer
•fMRIs and TMS studies have shown brain associations with speak generation/Broca
•more likely that people are misinterpreting their internally generated self talk
Disorganized speech and behaviour
Speech: disturbance of thought form
•can use language/speak correctly but they can’t really figure out what they’re trying to communicate/very disorganized
*formal thought disorder: disorganized thoughts observed through disorganized speech (ex: schizophrenic letter)
Common features of FTD
•neologism: use of made up words
•word salad: bunch of words that don’t convey a clear idea
•loose associations: ideas expressed seem unrelated (unlike mania in B, it can be slow)
•clang associations: words chosen for how they sound rather than the meaning
Behaviour: disruption to goal oriented behaviour
•ex: work, social relationships, self care
•inability to account for safety, hygiene, and health
•poor decision making (silliness, unusual dress, not dealing with things/conforming to social standards)
•person doesn’t seem like themselves anymore
Catatonia (come back to this)
Severe psychomotor disturbance
•important to not confuse with psychomotor effects of antipsychotic side effects
•stupor, catalepsy, waxy flexibility (can pose patients)
•mutism, negativism
•posturing (putting themselves in abnormal positions), mannerisms (funny facial expressions)
•stereotypies, agitation
•echolalia (repeating what others say), echopraxia
Negative behaviours
Positive symptoms are more dramatic/threatening to others, but negative are more debilitating (impairs living)
•more negative symptoms = worse outcomes and less effectively treated by antipsychotics
Common negative behaviours
1. Reduced expressiveness: don’t make as many gestures, expressions, or talk
•blunt/flat affect: have feelings but lack expression
•alogia: reduced speech
- Reduced motivation
•abolition: lack of motivated behaviours
•anhedonia: lack of experiencing pleasure - Withdrawal from social relationships
•autism: original definition - person becomes fixated on their inner world that others don’t connect with
Cognitive impairments
Not part of diagnosis but still very important
- lower general IQ (worse when symptoms are active)
- lower attention, working memory processing speed, and learning ability
- worse verbal fluency (disorganized speech)
- worse executive functioning, and social cognition
Schizophrenia diagnosis
2+ of the following for longer than a month •delusions •hallucinations •disorganized speech •disorganized/catatonic behaviour •negative symptoms
Impairment in 1+
•work, relationships, or self care
Disturbance for 6+ months
•prodromal (mostly negative) and residual symptoms count as part of the disturbance
Schizoaffective disorder diagnosis
Period of illness which includes a major mood episode (manic or depressive)
•delusions and hallucinations for 2 weeks outside of mood episode during period of illness
•psychosis must be more apparent than mood or its another disorder, but mood symptoms are continuous for majority of illness period
•Better prognosis than schizophrenia, worse than MMD or bipolar
•sweet/charming affect (unlike flat affect with schizophrenia)
Prevalence (limited data)
•Lifetime: 0.3-1%
•Non-deteriorating (doesn’t get worse like schizophrenia)
Schizophrenia prevalence
Lifetime: 0.3-0.7%
•more common in men(1.4:1)
•age of onset:
•M: peak from 20-24
•F: smaller peak in 20s, then another peak in 40-50s (potentially due to estrogen being a protective effect)
•higher risk in children with older fathers (50+)
•higher risk in 1st/2nd generation immigrants (especially of African decent living in majority white areas)
Biological factors
Strong genetic component (but environment is important) •Diathesis stress model •MZ twin with schizophrenia (50%) •DZ twin with schizophrenia (15-20%) •Parent with schizophrenia (5%)
Genetic overlap with
•bipolar, autism, ADHD, and intellectual disability
Candidate gene •COMT - dopamine metabolism GWAS •108 important genomes identified •related to dopamine, glutamate, and immune function CHART
Parental environmental factors (association-not large effect)
- viral infections (flu)
- rhesus incompatibility: incompatibility between mom and child so moms immune system attacks child
- Obstetric complications (oxygen supply disruption)
- Early nutritional deficiency (ex: Dutch post WWII)
- Maternal stress (possible HPA axis involvement)
Brain abnormalities
1. brain volume loss: enlarged ventricles, reduced gray matter volume (frontal/temporal lobes most effected)
•FL: hypofrontality -negative symptoms/cognitive deficits
•TL: dysregulation - lack of suppression in default network
2. disrupted cell organization in hippocampus
basal ganglia/limbic system: paranoia, hallucinations, emotional difficulty
3. white matter abnormalities: disrupted connectivity
4. corpus callousum in children of schizophrenics
Drugs and neurotransmitters
- Dopamine hyperactivity: aberrant salience of irrelevent stimuli (trouble filtering irrelevant info - too much focus on internal world
•dopamine antagonists: amphetamines or cocaine - can have psychosis like symptoms/make schizophrenia worse
•L-DOPA: dopamine precursor (how dopamine is created in your body) so if you give people this drug overtime there will be psychosis symptoms
•antipsychotics: dopamine antagonists (block receptors/reduce dopamine activity) - Glutamate hyperactivity: most common neuron in the brain
•cytoarchitecture: dysregulated GABA inhibition of glutamate
•NDMA antagonists - PCP, ketamine - Endocannabinoid system
•cannabis exacerbates symptoms in ppl vulnerable to schizophrenia
Social factors
- Severe stress trigger or worsen symptoms
•possible cortisol/HPA axis involvement - Family environment
•communication deviance: if the family communicates in unclear/confusing ways it can bring about symptoms
•expressed emotion: criticism, hostility, and emotional hyper involvement (when my mom gets upset and does nothing when I’m upset)
•living alone lowers chances of relapse/symptom severity - Immigration (darker skin, higher risk0
•1st generation: 2.7x, 2nd generation: 4.5x
•minority stress hypothesis: social disadvantage-more likely to develop schizophrenia
