Week 3 Schizophrenia

Question 1

History of Schizophrenia

Answer 1

Emil Kraepelin (1899) - Dementia Praecox - believed that the brains of individuals who developed schizophrenia had begun to deteriorate prematurely.

Eugene Bleuler (1911) - “Schizophrenia”
Four core disturbances:
*Affect
*Ambivalence
*Associations
*Preference for fantasy over reality

Question 2

Myths about schizophrenia

Answer 2

People with schizophrenia, dangerois or split personlity.

Question 3

Epidemiology

Answer 3

“Schizophrenia”
Four core disturbances:
*Affect
*Ambivalence
*Associations
*Preference for fantasy over reality

Question 4

Epidemiology Continued

Answer 4

Described in all cultures & SES groups
* Industrial nations: disproportionate % are lower SES
* The most expensive of all mental disorders:
- Direct treatment costs - Loss of productivity
* Public assistance costs
* Shorter average lifespan

Question 5

DSM-5-TR Criteria

Answer 5

A. Characteristic Symptoms Two or more of the following each present for a
significant portion of time during a 1-month period. At least one must be
(1), (2), or (3)
1. Delusions
2. Hallucinations
3. Disorganised speech (frequent derailment or incoherence)
4. Grossly disorganised or catatonic behaviour
5. Negative symptoms
p Affect flattening
p Alogia
p Avolition

Question 6

DSM-5-TR Continued

Answer 6

B. Social Occupational Dysfunction
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 (or when the onset is in childhood or adolescence, there is
failure to achieve expected level of interpersonal, academic, or occupational functioning)
C. Duration continuous signs for 6 months
This 6-month period must include at least 1 month of symptoms (or less if successfully treated)
that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or
residual symptoms.
D. Exclusion: Schizoaffective & Mood Disorder
E. Exclusion: Substance/general Medical Condition
F. Relationship to Autism Spectrum Disorder or a communication
disorder

Question 7

Characteristic Symptoms - POSITIVE Symptoms

Answer 7

Positive symptoms. “Excess” behaviours such as:
* Delusions
* Hallucinations
* Loose associations
* Disorganised behaviour

Question 8

Characteristic symptoms - NEGATIVE symptoms

Answer 8

• Flat affect
• Apathy
• Social withdrawal
• Poor attention

Question 9

Characteristic symptoms - Disturbance of Perception

Answer 9

• Hallucinations - Percept like experience occurring in the
  absence of appropriate stimulus and not under voluntary control
  Ÿ Auditory
  Ÿ Visual
  Ÿ Olfactory
  Ÿ Gustatory
  Tactile

Question 10

Characteristic Symptoms - Disturbances in form of thought

Answer 10

• Disturbances in production and organisation of thought -
  revealed by peculiarities/disorganisation of speech:
• Loosening of Associations
  Ÿ Neologism
  Ÿ Perseveration
  Ÿ Word salad
  Ÿ Circumstantiality
  Ÿ Tangentiality

Question 11

Characteristic symptoms - Disturbances in Affect

Answer 11

Expression of outward emotion
- restricted affect
- Blunted affect
- Flat affect

Question 12

Characteristic symptoms - Disturbances in social behaviour

Answer 12

• Avolition – decreased self initiated purposeful activities
• Anhedonia – decreased ability to experience pleasure
• Asociality – decreased interest in social interactions

Question 13

Do individuals with Schizophrenia experience challenges across many domains, if so, what are they?

Answer 13

This can include structure of thought, the experience of emotions and in perception.

Question 14

Schizophrenia Specifics - Duration

Answer 14

• First episode, currently in acute episode
• First episode, currently in partial remission
• First episode, currently in full remission
• Multiple episode, currently in acute episode
• Multiple episode, currently in partial remission
• Multiple episode, currently in full remission
• Continuous
• Unspecified - people diagnosed as schizophrenic who don’t fall neatly into
  one category

Question 15

Schizophrenia Specifics - Catatonia

Answer 15

Disturbances in psychomotor behaviour
- Collectively called Catatonia
Catatonic Stupor
Cataonic rigidity
Catatonic excitement

Question 16

Schizophrenia specifiers: Severity

Answer 16

• Severity based on assessment of primary symptoms of
  psychosis
  ŸDelusions
  ŸHallucinations
  ŸDisorganised speech
  ŸAbnormal psychomotor behaviour
  ŸNegative symptoms
  ŸRated on a 5 point scale (most severe in the last 7 days) from 0
  (not present) to 4 (present and severe)

Question 17

Why can symptom profiles be diverse?

Answer 17

No single symptom is pathognomonic of schizophrenia
* Diagnosis relies on recognition of a constellation of symptoms
associated with impaired social or occupational functioning
* Individuals with the disorder will vary on most features
* Severity of symptoms an important additional consideration

Question 18

Cognitive impairments in Schizophrenia

Answer 18

• Many individuals with schizophrenia experience cognitive
  impairments across a range of domains
• Declarative memory
• Working memory
• Language function
• Executive/attention function
• Sensory processing
• Predict functional outcome
• Persist during symptom recovery

Question 19

What are the phases of schizophrenia

Answer 19

Episodic, Residual phase, active phase, predromal phase

Question 20

What is Prognosis in schizophrenia ?

Answer 20

~ 20-30% experience minimal impact on overall social/work
functioning
~ 20-30% experience moderate symptoms
~ 40-60% remain significantly impaired

Question 21

What are the outcome predictors of schizophrenia?

Answer 21

Good Outcome
* Good premorbid adjustment
* No family history of schizophrenia
* Sudden onset
* Precipitating stress
* Good response to medication
* Positive symptoms
* Later age of onset
* Female gender

Poorer Outcome
* Poor premorbid adjustment
* Family history of schizophrenia
* Slow onset
* No precipitating stress
* Poor response to medication
* Negative symptoms
* Early age of onset
* Male gender

Question 22

Schizophreniform Disorder

Answer 22

Duration at least 1 month but less than 6 months
- Impaired social/occupational functioning not required

Question 23

Schizoaffective Disorder

Answer 23

• Symptoms fall on the boundary between schizophrenia and mood
  disorders
• Prominent episode of mood disturbance concurrent with Criterion A
  schizophrenia symptoms
• Delusions/hallucinations for at least 2 weeks in absence of prominent mood disturbance

Question 24

Delusional Disorder

Answer 24

One or more delusions and has neber met criteria A for schizophrenia

Question 25

Brief psychotic Disorder

Answer 25

Sudden onset of at least one: delusions, hallucinations, disorganised speech, disorganised/catatonic behaviour - Lasts at least one day but less than month and full return to premorbid functioning

Question 26

The Biological view of schizophrenia

Answer 26

Genetics Twin adoption and family studies, There are genetic linage studies Hetergeneous disorder, with a likelyhood of their being a polygenic influence.

Question 27

What are some biochemical abnormality theories?

Answer 27

Dopamine hypothesis - Dopamine hyperactivity linked to positive symptoms of schiz D2 receptors target antipsychotic medication

Question 28

Problems in the dopamine hypothesis

Answer 28

*Problems with the dopamine hypothesis - Many of the drugs used to treat schizophrenia are effective in treating other disorders. - Clozapine primarily blocks serotonin receptors *Current research focuses on many neurotransmitters: -Serotonin pathways -GABA and glutamate

Question 29

The biological view - alterations in brain structure and function

Answer 29

* Differences in structure and function of multiple brain regions between individuals with and without schizophrenia (based on neuroimaging) * Differences also evidence in cellular architecture, and white matter connectivity * Likely changes in broad neural connectivity * No evidence for a single pathological process identifiable on an individual basis

Question 30

Limitations of biological view

Answer 30

* Difficult to determine whether the abnormality is related to the disease process or to treatment * A single pathological process in the brain can cause a wide range of phenomena in different individuals

Question 31

Psychosocial factors - behaviour view

Answer 31

* Limited value in understanding aetiology: * Failure to attend to relevant social cues results in bizarre responses to environment * Acquisition of bizarre behaviours through operant conditioning * Unable to fully account for the origins of the various symptoms of schizophrenia * More successful in modifying problematic behaviours: * Appropriate verbal responses and social behaviours can be learned with systematic ignoring of bizarre behaviours and reinforcement of appropriate responses

Question 32

What are the psychosocial factors, in theoretical frameworks that focuses on family views for schiz?

Answer 32

Schizophrenogenic mother (Fromm-Reichmann, 1948) * Double-bind communication (Bateson, 1956) * Family structure (Lidz, 1973) * Communication deviance (Wynne & Singer, 1963) * Expressed emotion (Vaughn & Leff, 1976)

Question 33

Psychosocial factors - Express emotions (Vaughn & Leff, 1976)

Answer 33

Expressed emotion *Family stress may precipitate relapses *Family stress = expressed emotion - Criticism - Hostility - Emotional over-involvement *Person with schizophrenia is 3.7 times more likely to relapse if living in a High vs. a Low EE family *Low specificity – but highlighted the family environment as a target for intervention

Question 34

What are the limitations of the family views theories?

Answer 34

Earlier views were not based on empirical evidence * Many of the findings are correlational * These family patterns also occur in families of patients with other disorders * Reciprocal relationship between patient and family members not taken into account * The impact of living with a family member with schizophrenia neglected

Question 35

What is the Diathesis-Stress theory?

Answer 35

When the Diatheses: * Genetic factors * Physical trauma prenatally or during birth * Brain or neurotransmitter abnormalities * Psychosis-prone personality And the Stressors: * Physical trauma, prenatally or during birth * Psychological and social stressors and environmental hazards associated with urban living and poverty * Family environment with high EE Come together and screate Schizophrenia

Question 36

What are some treatements for schiz?

Answer 36

Cognitive Behavioural Therapy * Psychoeducation * Social skills training * Coping strategies enhancement training - Problem solving - Strategies for maximising medication compliance - Identification of relapse warning signals - Stress management strategies Broad rehabilitation approach * Focuses on broader practical difficulties Family interventions * Supplementing drug treatment with family intervention reduces relapse Anti-psychotics * Positive symptoms respond better than negative symptoms. * About 25% do not improve on classical antipsychoticsrugs. * Unwanted effects of traditional anti-psychotic drugs, eg. tardive dyskinesia

Question 37

More treatments..

Answer 37

The community approach * Deinstitutionalisation * Effective community care * Coordinated services * Short-term hospitalisation * Partial hospitalisation * Community house/halfway houses - Advocacy