Schizophrenia

Question 1

How is Schizophrenia understood in the DSM-5?

Answer 1

• it is understood to exist on a spectrum from less severe to extremely severe (schizoaffective viewed as the most severe, with schizophrenia being right behind it)

Question 2

What were the early descriptions of schizophrenia?

Answer 2

• Concept formulated by Emil Kraepelin and Eugen Bleuler
• Kraepelin first presented his notion of dementia praecox (whereas Bleuler used the term ‘schizophrenia’).
• Kraepelin differentiated two groups of endogenous psychoses
  1) Manic-depressive illness
  2) Dementia praecox
• • Subtypes: Dementia paranoides, catatonia, and hebephrenia
• • Kraepelin believed that they shared a common core: an early onset (praecox) and a deteriorating course marked by a progressive intellectual deterioration (dementia)

Question 3

What were the three subtypes of schizophrenia included in the DSM-IV-TR?

Answer 3

• Heterogeneity of schizophrenic symptoms suggested the presence of subtypes of the disorder.
• Three types of schizophrenic disorders that were included in DSMIV-TR:
• • Disorganized (hebephrenic; trouble speaking and thinking coherently. Might use similar-sounding words and have flat or shifting affect. Changing from laughing to crying. Behaviour is disorganized and not goal-directed)
• • Catatonic (is also a negative symptom; immobility, frozen state or can be really hyperactive and excited. They engage in echolalia- repeating back the speech of others. Rare bc of medication development)
• • Paranoid (characterized by a lot of delusions- ideas that don’t match up with reality. Could be police following you, aliens abductions etc.)
• Were originally proposed by Kraepelin many years ago

Question 4

What changes were made to schizophrenia from the DSM-IV-TR to the DSM-IV?

Answer 4

• DSM-5 discontinued all of the “classic” subtypes of schizophrenia and rejected alternatives to take their place.
• DSM-5 includes a dimensional rating of symptoms that enables clinicians to consider the heterogeneity in symptom expression
• Most severe to least severe: Schizoaffective, Schizophrenia, Schizophreniform, Brief psychotic and delusional

Question 5

What are the positive symptoms of schizophrenia?

Answer 5

• Positive features: appear to reflect an excess or distortion of normal functions.
• Including distortions in thought content (delusions), perception (hallucinations), language and thought processes (disorganized speech), and self-monitoring of behaviour (grossly disorganized or catatonic behaviour).
• Two dimensions of positive symptoms
• • “psychotic dimension” includes delusions and hallucinations
• -“disorganized dimension” includes disorganized speech and behaviour

Question 6

What are the negative symptoms of schizophrenia?

Answer 6

Negative symptoms – appear to reflect a diminution or loss of normal functions.

• • Flat affect – Diminished emotional expression
• • Avolition – lack of energy
• • Alogia – Poverty of speech, amount of speech, poverty of content of speech etc.
• • Anhedonia – Lack of interest in recreational activities, relationships with others, and sex.
• • Asociality – Few friends, poor social skills, and little interest in being with others.

Question 7

What are the key features of schizophrenia?

Answer 7

• positive symptoms
• negative symptoms
• Delusions
• Hallucinations
• Grossly disorganized or abnormal motor behaviour
• Disorganized thinking
• Catatonia

Question 8

What are delusions?

Answer 8

Delusions are erroneous beliefs that usually involve a misrepresentation of perceptions or experience, and are resistant to change even in the face of conflicting evidence. Content may include a variety of themes:
- Persecutory delusions are the most common – the person believes they are being tormented, followed, tricked, spied on, or ridiculed.
- Referential delusions – believes that certain gestures,
comments, passages from books/newspapers, song lyrics (etc.) are directed at them.

Question 9

What are the different types of delusions?

Answer 9

• Grandiose delusions – believes they have exceptional abilities, wealth, or fame
• Erotomanic delusions – believes that another person is in love with him/her
• Nihilistic delusions – believes that a major catastrophe will occur
• Somatic delusions – believes that health or organ function is at risk

Question 10

What are bizarre vs. non-bizarre delusions?

Answer 10

• Delusions can be bizarre if they are clearly implausible, do not derive from ordinary experience, and are not understandable to peers.
• • Bizarre – belief that an outside force has removed my internal organs and replaced them with someone else’s organs (without leaving scars).
• • Nonbizarre – belief that I am being watched by the police or government.

Question 11

What are hallucinations?

Answer 11

• Hallucinations: Perception-like experiences that occur without an external stimulus. Vivid and clear. Not under voluntary control. Can occur in any sensory modality (auditory, visual, olfactory, gustatory, tactile).
• • Auditory are most common – usually experienced as voices (familiar or unfamiliar) that are perceived as distinct from the person’s own thoughts.

Question 12

What is grossly disorganized or abnormal motor behaviour?

Answer 12

• Grossly Disorganized Behaviour – may manifest in a variety of ways, including childlike silliness to unpredictable agitation.
• May involve difficulties in performing goal-directed behaviours.

Question 13

What is disorganized thinking (speech)?

Answer 13

Disorganized thinking (“thought disorder”) - due to difficulty in diagnosing “thought disorder” and because this is usually based on the individual’s speech, the emphasis here is on disorganized speech.

• Derailment or loose associations
• Tangentiality
• Incoherence or “word salad”

Question 14

What is catatonia?

Answer 14

• Catatonic Motor Behaviours – include a marked decrease in reactivity to the environment
• • Negativism – resistance to instructions
• • Catatonic mutism and stupor – complete unawareness
• • Catatonic rigidity – rigid posture
• • Catatonic posturing – assuming bizarre postures
• • Catatonic excitement – purposeless excessive motor activity

Question 15

What is inappropriate affect?

Answer 15

These are emotional responses which are out of context:

• The client may laugh on hearing that his or her mother just died.
• The client may become enraged when asked a simple question about how a new garment fits.
• Rapid shifts from one emotional state to another for no discernible reason.
• This symptom is quite rare, but its appearance is of considerable diagnostic importance because it is relatively specific to schizophrenia.

Question 16

What are the diagnostic criteria for schizophrenia?

Answer 16

A. Two or more of the following must be presen for a significant portion of time during a 1 month period. At least one of them must be 1, 2, or 3
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behaviour
5. Negative symptoms (i.e., diminished emotional expression 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 that meet criterion A. During these prodromal or residula periods, the signs of the disturbance may be manifested by only negative symptoms or in attenuated form (e.g., odd beliefs, unusual perceptual experiences)

Question 17

What are the impact of symptoms on life?

Answer 17

• Delusions and hallucinations may cause considerable distress, compounded by the fact that hopes and dreams have been shattered.
• Cognitive impairments and avolition make stable employment difficult, with impoverishment and often homelessness the result.
• Strange behaviour and social-skills deficits lead to loss of friends and a solitary existence.
• The strongest predictor of this social disability is chronic cognitive impairment
• High substance abuse rates perhaps reflect an attempt to achieve relief from negative emotions
• Little wonder, then, that the suicide rate among people with schizophrenia is high.

Question 18

What do twin and familystudies indicate about the genetic component of schizophrenia?

Answer 18

• Research indicates that the vulnerability to the illness can be inherited.
• Twin, adoption & family history methods indicate an elevated risk of the disorder for family members of someone with Schizophrenia
• MZ twins = 25-50%, DZ twins = 10-15%

Question 19

What have adoption studies find about the genetics of schizophrenia?

Answer 19

Adoption studies provide evidence that the tendency for Schizophrenia to run in families is primarily due to genetic factors, rather than the environmental influence of being exposed to a mentally ill family member.

Question 20

Is it just one gene involved?

Answer 20

Genetic studies lead to the conclusion that the disorder involves multiple genes, rather than a single gene.
- Specifically, the Serotonin Type 2a receptor gene (5-HT2a), and the Dopamine (D3) receptor gene, and several chromosomal regions (regions on chromosomes 6, 8, 13 & 22)

Question 21

Has research just found evidence for genetics?

Answer 21

• However, research indicates that genetic influences act together with environmental factors (a diathesis stress model).

Question 22

what are sporadic cases?

Answer 22

• Intriguing new results have emerged from research on people without a family history of schizophrenia who nevertheless developed schizophrenia (who are referred to as “sporadic cases”) and these studies have illustrated the neural complexity involved in schizophrenia.
• It has been found in these investigations that schizophrenia seems to reflect relatively rare protein-altering gene mutations that have implicated up to 40 genes, including a disruption in DCGR2 . This is a gene found in the 22q11.2 microdeletion region known for vulnerability to schizophrenia
• Many of these gene mutations may have taken place in early development.

Question 23

What is the dopamine hypothesis?

Answer 23

Schizophrenia: biochemical disorder involving excess dopamine activity

• Evidence for dopamine hypothesis: Drugs effective in treating schizophrenia decrease dopamine activity and Also produce side effects similar to Parkinson’s disease which is caused in part by low dopamine
• other clues provided by amphetamine psychosis (closely resembles paranoid schizo and can exacerbate schizo. Amphetamines cause release of norepinephrine and dopamine. Dopamine though to be the culprit of the symptoms)

Question 24

What is the role of serotonin in Schizophrenia?

Answer 24

• Newer drugs used in treating schizophrenia implicate neurotransmitters such as serotonin in the disorder.
• Dopamine neurons generally modulate the activity of other neural systems; for example, in the prefrontal cortex, they regulate GABA neurons.
• Similarly, serotonin neurons regulate dopamine neurons in the mesolimbic pathway. Thus, dopamine may be only one piece in a much more complicated puzzle.

Question 25

What is the role of glutamate in schizophrenia?

Answer 25

• Glutamate, a transmitter that is widespread in the human brain, may also play a role
• Low levels of glutamate have been found in cerebrospinal fluid of people with schizophrenia and postmortem studies have revealed low levels of the enzyme needed to produce glutamate

Question 26

How do drugs that reduce/increase dopamine provide evidence for dopamine playing a central role in schizophrenia?

Answer 26

Dopamine seems to play a central role:

• Drugs that reduce dopamine activity also diminish psychotic symptoms
• Drugs that heighten Dopamine activity exacerbate or trigger psychotic episodes
• Antipsychotic drugs block Dopamine receptors (the D2 subtype) – the newer “atypical” antipsychotic drugs have the same effect but cause fewer side effects.

Question 27

What differences in brain structure have been observed in patients with schizophrenic?

Answer 27

• Enlarged ventricles which implies a loss of subcortical brain cells
• Consistent findings indicate structural problems in the hippocampus, the basal
  ganglia, and in the prefrontal and temporal cortex
• Often noted in males

Question 28

What are some structural problems in people with schizophrenia?

Answer 28

• Reduction in cortical grey matter in both the temporal and frontal regions and reduced volume in basal ganglia (e.g., the caudate nucleus) and limbic structures
• Correlated with impaired performance on neuropsychological tests, poor adjustment prior to the onset of the disorder, and poor response to drug treatment

Question 29

What is a possible interpretation of the brain abnormalities associated with schizophrenia?

Answer 29

• A possible interpretation of these brain abnormalities is that they are the consequence of damage during gestation or birth.
• The presence at birth or in infancy of“craniofacial/ midline anomalies and/or early functional impairments that commonly occur as a symptom of CNS [central nervous system] anomaly” were associated with a doubling of the risk for schizophrenia spectrum disorder (a group or array of disorders related to and including schizophrenia).

Question 30

What are the prenatal and postnatal factors associated with schizophrenia?

Answer 30

• Another risk factor for Schizophrenia is maternal infection.
• Risk rate for Schizophrenia is elevated for individuals born shortly after a flu epidemic.
• This is consistent with “season-of-birth” effect on Schizophrenia.
• A disproportionate number of patients with schizophrenia are born during the Winter months – possibly reflecting a seasonal exposure to viral infections during the second trimester (an important time for brain development)
• Stressful events during pregnancy (i.e. death of a spouse) are associated with greater risk for Schizophrenia

Question 31

What is the relationship between psychological stress and schizophrenia?

Answer 31

• Research indicates that stressful life events can worsen the course of Schizophrenia
• • The number of stressful life events increases in the months immediately preceding a relapse
• Stress exposure can also contribute to the onset of symptoms in vulnerable individuals
• • The offspring of parents with schizophrenia manifest significantly greater increases in behaviour problems if they are exposed to abuse/neglect
• • High-risk offspring are more likely to develop schizophrenia if they are raised in an institutional setting rather than by family

Question 32

What is the role of impaired insight in treatment?

Answer 32

• A major problem with any kind of treatment for schizophrenia is that many clients lack insight into their impaired condition and refuse any treatment
• As they don’t believe they have a disorder, they feel they don’t need professional intervention, particularly when it includes hospitalization or drugs.
• This is especially true of people with paranoid schizophrenia, who may regard any therapy as a threatening intrusion by hostile outside forces.

Question 33

What is the multi-point treatment course for Schizophrenia?

Answer 33

Multi-point treatment course that consists of several strategies known to improve functional outcome:

• Selection and application of antipsychotic medication to control acute psychotic symptoms, including strategies for maintaining adherence
• Identification and treatment of comorbid disorders, including substance use and depressive disorders
• Use of psychosocial treatment approaches with demonstrated effectiveness in improving symptoms and ability to function socially and vocationally

Question 34

What biological treatments were used in the 1930’s?

Answer 34

• Insulin Coma Therapy
• Electroconvulsive Therapy (ECT; electric shocks)
• Prefrontal lobotomy (taking parts of the brain out surgically.not used anymore)

Question 35

What is repetitive transcranial magnetic stimulation?

Answer 35

• Modern and non-invasive approach is repetitive transcranial magnetic stimulation;
• initial evidence suggests that this stimulation is effective in relieving the symptoms of schizophrenia, especially auditory hallucinations

Question 36

What were first generation (conventional) antipsychotic drugs?

Answer 36

• Although the antipsychotics reduce some of the positive symptoms of schizophrenia, they are not a cure.
• About 30 to 50% of people with schizophrenia do not respond favourably to conventional antipsychotics, although some of these clients may respond to some of the newer antipsychotic drugs (e.g., clozapine).
• There has been success in treating psychosis.
• Effective treatments for cognitive aspects and negative symptoms are “unmet therapeutic challenges.

Question 37

What were the problems with first generation (conventional) antipsychotic drugs?

Answer 37

• Problem = Many side effects
• • Half quit due to side effects
• Second-generation (atypical) antipsychotic drugs
• • Less likely to cause side effects

Question 38

What are psychological treatments for schizophrenia?

Answer 38

• Psychological treatments for schizophrenia typically come in two forms: psychosocial treatments and cognitive behavioural interventions.
• Psychosocial strategies can play an important role in increasing the effectiveness of medication treatment and decreasing the relapse rate

Question 39

What is social skills training for schizophrenia?

Answer 39

• Designed to teach people with schizophrenia behaviours that can help them succeed in a wide variety of interpersonal situations.
• Therapeutic approach focuses on three key elements: receiving skills (i.e., social cognition), processing skills, and behavioural responses in social interaction.
• A meta-analysis of RCT investigations concluded that this approach yields significant improvements across a variety of indicators, including skill acquisition, social interaction, and appropriate personal assertiveness in social situations

Question 40

What is family therapy?

Answer 40

• Many people with schizophrenia who are discharged from psychiatric hospitals go home to their families.
• Family interventions differ in length, setting, and specific techniques.

Question 41

What is the purpose of family therapy?

Answer 41

• These therapies have several features in common beyond the overall purpose of calming things down for the client by calming things down for the family:
• -They educate clients and families about the biological vulnerability that predisposes people to schizophrenia, cognitive problems inherent to schizophrenia, the symptoms of the disorder, and signs of impending relapse.
• They provide information about and advice on monitoring the effects of antipsychotic medication.
• They encourage family members to blame neither themselves nor the client for the disorder and for the difficulties all are having in coping with it.

Question 42

What is cognitive behavioural therapy for schizophrenia?

Answer 42

• Cognitive-Behavioural Therapy – to help patients deal directly with their symptoms. Can be effective at reducing hallucinations and delusions.
• Dysfunctional attitudes predict reduced life functioning in people with schizophrenia and they have even been linked with the internalization of stigma
• Defeatist beliefs: An example of a defeatist belief is “If you cannot do something well, there is little point in doing it at all.”