Schizophrenia Spectrum Disorders Flashcards
Psychosis
- Refers to loss of contact with external reality characterised by:
- impaired perceptions
- thought processes
› Schizophrenia - ‘Split mind’ (Bleuer- 1857-1939)
1. Fragmentation of thoughts
2. Splitting of thoughts from emotions
3. Withdrawal from reality
NOT split personality (classified as Dissociative Identity Disorder
DSM-5: Schizophrenia
A. Two or more of following present for a significant
portion of time during a 1-month period (or less if
successfully treated) & at least one must be (1),
(2), or (3) below.
1) Delusions
2) Hallucinations
3) Disorganised Speech
4) Grossly disorganized or catatonic behaviour
5) Negative symptoms
- One month duration to determine different from other disorders
B. Clinically significant impact to functioning:
- Functioning is below that prior to onset of the disorder
C. Continuous signs of disturbance are present for at
least 6 months
- May include a gradual deterioration in functioning
- Must include at least one-month of psychotic symptoms
D-F. Not better accounted for by other diagnosis: schizoaffective,
substance, autism
Subtypes
› Schizotypal (Personality) Disorders, (odd, eccentric nut do not manifest clearly delusional ideation)
› Brief Psychotic Disorder (sudden, 1mth mood disorders)
› Schizoaffective (mood disorder criteria present)
› Substance-induced psychotic
› Psychosis due to a medical condition
› Catatonia & other unspecified (exclude neurodevelopmental or medical condition)
› Schizophrenia
Positive Symptoms
PRESENT & OBSERVABLE - Hallucinations - Delusions - Formal thought disorder - Behavioural disturbances - Disorganized, catatonia, odd movements/behaviours - Lack of insight (97%) --> don't acknowledge have illness
Negative Symptoms
AFFECTIVITY
- Social withdrawal (poor eye contact)
- Anhedonia –> inability to experience joy/happiness
- Emotional blunting (66%)
- Confusion
- Amotivational
- Apathy
- Self-neglect
- Poverty of speech
- Poverty of content
–> Presence of negative symptoms suggest poorer response to treatment
DSM-5: Hallucinations
DSM-5 (2013) defines hallucinations as
- Perception-like experiences that occur in absence of any external stimulus
(vivid, clear, & not under voluntary control)
- Occurs in clear sensorium (hypnogogic & hypnopompic not included) –> when falling asleep/waking up
› 75% of patients with schizophrenia report experiencing hallucinations including: - Auditory - Visual (not illusion/misperception) - Olfactory (smells) - Gustatory (taste) - Tactile (insects crawling)
Auditory Hallucinations
› 60%-70% report auditory hallucinations
› Hearing voices (Distinct from own thoughts).
- 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
Aggression in schizophrenia
- Schizophrenics being aggressive is a myth, reality is Schizophrenics are not more aggressive than general population, just attract attention due to bizarre behaviours & elements of grandiosity
Risk factors for hostility:
- Younger males (with past history of violence)
- Non-adherence with medication
- Substance use
- Impulsivity
DSM-5: Delusions
Delusions are: False firmly beliefs despite what others believe & despite evidence to contrary
- Beliefs are not culturally accepted
› Delusions typically categorised according to content &
bizarreness
Paranoid or Persecutory Delusions
- Most common type
- Fixed, false belief one is being harmed or persecuted by
particular person/group
Delusions of Reference
- Neutral event interpreted to have personal meaning for
individual, e.g., TV newsreader sending messages meant
specifically for them
Grandiose Delusions
- False belief that one has special powers, abilities, influence, achievements or another identity that typically relates to power, wealth or fame
Nihilistic Delusions
- Belief that one, bodily part, or world does not exist or has been destroyed
Delusions of Guilt
- Personal responsibility for events
Jealousy Delusions
(monosymptomatic delusions)
- usually such as partner having an affair
Erotomanic Delusions
False belief that patient’s romantic feelings are reciprocated (often by a famous other)
Misidentification Delusions
Identity of someone they know has been stolen (e.g., imposter has replaced a loved one)
Thought Disorder
Formal thought disorder: Disturbances in flow &/or form of speech (mess of ideas) –> (as opposed to content as in delusions)
Symptoms categorised into positive & negative manifestations
Negative manifestations
- Reduced stream of thoughts & poverty of speech
Positive manifestations
- Circumlocution (talking around a point but never getting to it)
- Derailment (comments slipping from one to next)
- Tangential (irrelevant responses)
- Echolalia (acute phase, repeating what someone is saying)
- Word salad (incomprehensible stream of words)
- Neologisms (idiosyncratic use of words, meanings: e.g., “Pass me the spoon, moon, I am cacoon”
Disorganised Behaviour
Grossly disorganized & abnormal motor behaviour: from
child-like silliness to unpredictable agitation
- Catatonic behaviour: (medication reduced prevalence but recent data
found prevalence of 32% (Ungvari et al., 2005)
- Extreme negativism (resistance instructions)
- Immobility (“waxy flexibility”)
- Catatonic excitement : Excessive purposeless physical activity
- Peculiar voluntary movements (posture, repetition, grimacing)
- Mutism; Echolalia; Echopraxia: imitating speech; movement
Prevalence
Lifetime prevalence of schizophrenia ranges from 1-2%
› Male to Female ratio: 3:2
Age of Onset
› Typical onset in late adolescence & early adulthood (tends to be later for women)
–> usually person functions very well until onset
› Onset typically preceded by a gradual deterioration in functioning followed by appearance of more acute symptoms
› Onset coincides with an often stressful time of life, further complicated by impact of schizophrenia
› Early onset associated with poorer outcomes
Course of Schizophrenia
Course highly variable
› One or more episodes with periods of normal (or near normal)
functioning between episodes
- 66% difficulty with at least one daily living activity
› Most remain chronically unwell with a deteriorating course
- 50% classified as unable to work
-
Phases of Schizophrenia
Course described in separate phases:
- Prodromal Phase: Median length for symptoms to develop is 2-years but highly variable (Yung et al., 2003)
- Acute Phase: Typically one year between onset of active symptoms & treatment –> acute phase symptoms become more pronounced, longer they leave before treatment the worse they get
- Response to treatment related to duration of untreated psychosis
- Early Recovery Phase
- Late Recovery Phase: Reintegration
- 80%-90% relapse within 2-5 years of treatment
Affect
› Anxiety & perplexity - Sufferers is often frightened, perplexed & confused over emerging symptoms - Irritability - 30% of patients attempt suicide - 5-10% suicide
–> suicide particularly in younger patients
Prognostic Factors
Good premorbid functioning • Acute onset • Later age of onset (females) • Precipitating event (e.g., drug induced psychosis) • Low substance use • Brief duration of active phase • Absence of structural brain abnormalities • No family history of schizophrenia
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
Aetiological Factors
Not homogenous, no single cause
Heterogeneous range of disorders with common underlying biological vulnerability
Genetics & Environmental, Social & Psychological –>
Neurodevelopmental Abnormalities –> Neurotransmitter dysregulation –> Schizophrenia
Genetic Factors
Degree of risk related to degree of genetic relatedness:
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
› Adoption studies have shown that:
- Higher rates among children whose biological parents have schizophrenia (18.8%), compared to children with no biological parents with schizophrenia (10.1%)
Biochemical Factors
Dopamine hypothesis: Overproduction or oversensitivity of dopamine receptors
1. Excess L-Dopa in Parkinson’s precipitate psychotic episodes
2. Amphetamine (dopamine agonist) psychosis: abnormally large responses to low amphetamine doses
- Suggests over-sensitivity rather than excessive dopamine level
3. Response to anti-dopaminergic medication (e.g. chlorpromazine)
Effective in 60% with more impact on positive symptoms
4. Lack of impact on negative symptoms hints at two separate syndromes
i. Caused by dopamine activity & associated with +ve symptoms
ii. Caused by brain degeneration & associated with –ve
symptoms.
Neuroanatomical Factors
› Most consistent neuroanatomical finding:
- 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
Other factors
Obstetric complications, viruses, urban birth, nutritional factors & paternal age, seaonal variation
› 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 noncomplications
- Older fathers age can increase likelihood
- 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
- -> Little/no evidence socioeconomic status in aetiology
Treatment
Medication is primary intervention: 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 Neuroleptics
› Medication non-compliance given common side effects:
- 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 Interventions
Psychological interventions designed to target specific
deficits or objectives
- Social skills training for interpersonal deficits
- Medication compliance
- Managing delusions/hallucinations
- Reduction of stresses
› CBT potential non-pharmacological treatment
Psychological treatment not pretending delusions are not there, but reduce stress and learn how to deal with them
CBT
CBT helps patients to:
- 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’)
Efficacy of CBT
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
Family Therapy
Family Therapy interventions were developed in response to higher relapse rates for patients from families high in Expressed Emotion (EE)
› Family interventions provide:
- 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
