Week 7 Schizophrenia Flashcards
Commonly Experienced Psychotic Symptoms
Distortions of perception and reality
Disorganised speech and thought disorder
Disorders of motor behaviour
Delusions
Firmly held erroneous beliefs about misinterpretations of perceptions or
- of reference
- of control
- of persecution
- nihilistic delusion
- of grandeur
Hallucinations
A sensory experience whereby perception related to something that isn’t really there
Auditory hallucinations
Reported by 70% (Cleghorn et
al., 1992)
Manifest as voices
–External voices commanding actions
–Two or more voices conversing with each other
–Commentary of own thoughts
Voices are perceived as distinct
from ind own thoughts
Visual and other hallucinations
Second most common
–Can take a defuse form
* Perception of colours, shapes
–Can take a specific form
* Partner or parent present
Skin tingling or burning
* Smells
* Unusual tasting food
Disorganised speech
Derailment or Loose Associations
Drifting quickly from one topic to another
‘What colour is your dress?’ ‘red…Santa
Claus…flying through the sky…God’
Tangentiality Answers to Qs may be tangential rather than relevant
Clanging
Thinking is driven by word sounds, e.g., rhyming or alliteration may lead to the appearance of logical connections where not in fact exists
Neologisms
Made-up words used in an attempt to
communicate
Word Salad
Language is so disorganised there seems no link between one phrase and the next
Poverty of Content
Conversation has very little substantive content
Disorders of Motor Behaviour
Catatonic and Grossly Disorganised Behaviour
Catatonic Behaviour
Catatonic stupor
Catatonic rigidity
Catatonic negativism
Catatonic excitement and
stereotypy
Grossly Disorganised Behaviour
Childlike and silly
Inappropriate to context
Unpredictable/agitated
Difficulty completing goal
directed activity
Appearance may be
dishevelled/inappropriate
Symptoms cont.
Affective Flattening
– Limited range and intensity of emotional expression
Alogia (Poverty of Speech)
– Lack of verbal fluency
Avolition (Apathy)
– Inability to carry out or complete normal day-to-day goal-orientated activities
The Nature of Psychotic Symptoms
Positive symptoms:
–Delusions
–Hallucinations
Disorganised Symptoms:
- Disorganised Speech (Incoherence)
- Grossly Disorganised or Catatonic Behaviour
*Negative symptoms:
–Affective Flattening, Alogia (Poverty of Speech) and Avolition (Apathy)
The Course of Psychotic Symptoms
Prodromal Stage, Active Stage, Residual Stage
Prodromal Stage
First symptoms late adolescence/early adulthood
–51% of individual with sz between 15 and 25 yrs
Onset usually represents a slow
deterioration over around 5 yrs
(Hafner et al., 2003)
–Withdrawal from normal life and social
interaction
–Inappropriate emotions
–Deterioration in personal care and work
or school performance
Onset usually associated with a
stressful life experience or period
of stress (Brown & Birley, 1968)
Active Stage
The stage in which an individual
begins to show unambiguous symptoms of
psychosis, including delusions, hallucinations,
disordered speech and communication, and a
range of full-blown symptoms
Residual Stage
Recovery gradual, many retain residual
symptomatology
* Cease to show positive symptoms
* Residual stage can be associated with negative symptoms
* Around 50% of individuals diagnosed with
schizophrenia will alternate between active and residual stages (Wiersma et al., 1998)
DSM-5 diagnoses
Schizotypal (Personality) Disorder
– Pervasive pattern of social and interpersonal deficits, below threshold
Delusional Disorder
– At least 1 month of delusions but no other psychotic symptoms
Brief Psychotic Disorder
– A disorder that lasts more than 1 day and remits by one month
Schizophreniform Disorder
– Symptomatically equivalent to Schizophrenia except for duration (1-6 months), no
requirement of decline in functioning
Schizophrenia
– Lasts for at least 6 months and includes at least 1 month of active-phase symptoms
Schizoaffective Disorder
– A Mood Episode and the active-phase symptoms of Schizophrenia co-occur
The Aetiology of Psychotic Symptoms
Most theories of schizophrenia have
generally attempted to explain only
specific aspects of the symptomatology
– E.g., acquisition of paranoid thinking
Diverse symptoms -> Diverse explanations of Cause
Diathesis-Stress Perspective
Psychosis caused by a combination of genetically inherited biological diathesis (a biological predisposition) and environmental stress
Those with a genetically pre-programmed disposition may not develop symptoms unless exposed to certain life stressors
– Early rearing factors (Schiffman et al., 2001)
– Dysfunctional familial relationships (Bateson, 1978)
– Inability to cope with stresses of normal adolescent development
(Harrop & Trower, 2001)
Aetiology of Psychotic Symptoms cont.
Sociocultural Theories
* Familial Factors
* Communication Deficits
* EE
Biological Theories
* Genetic Factors
* Biochemical
* Factors – dopamine hypothesis
* Brain Abnormalities
Psychological Theories
* Psychodynamic Theories
* Behavioural Theories
* Person-centred
* Cognitive Theories
Psychodynamic Theories
Freud
– Regression to a previous ego state resulting in preoccupation with the self
– Regression to primary narcissism
* Loss of contact with reality
* Cold and unnurturing parents
Fromm-Reichmann (1948)
– Schizophrenogenic mother
* A cold, rejecting, distant and dominating mother who causes schizophrenia
Little objective evidence supporting
psychodynamic theories of psychosis
Person-Centered Theory
Rogers
– Behaviour has little consistency to
it
– Words may make little sense
– Emotions may be inappropriate
– May lose the ability to differentiate self and non-self
– Become disoriented and passive
Behavioural Theories
Psychotic behaviours may be rewarded
through a process of operant reinforcement (Ullman & Krasner, 1975)
Extinction studies can be used to eliminate
inappropriate psychotic behaviours (e.g.
Ayllon, 1963)
Maintenance of behaviours
Acquisition of behaviours
Familial Factors - Communication Deviance (CD)
Communications difficult for ordinary listeners to follow
–Abandoned/abruptly ceased remarks or sentences
–Inconsistent references to events or situations
–Using words or phrases oddly or wrongly
–Use of peculiar logic
A stable characteristic of families with offspring who develop psychotic symptoms (Wahlberg et al., 2001)
A risk factor for psychotic symptoms independently of any biological or inherited
predisposition (Wahlberg et al., 2004)
Familial Factors - Expressed Emotion (EE)
Extent to which one family member is extremely critical of the individual
and their behaviour
Relapse rates much higher for patients returning to high EE homes (Hooley,
2007)
High EE families
–Have an attributional style that blames the sufferer for his/her condition (Weisman
et al., 2000)
Interventions to moderate
EE in a family
–Can have beneficial effects on symptoms (Hogarty et al., 1986)
Treatment for Psychosis
Biological Treatment
Family Interventions
Psychological Therapies
Biological Treatments
Typical Psychotics
Less Typical Psychotics
Atypical Antipsychotics
Positives and Negatives of drugs
Social Skills Training
Learning skills for basic everyday interactions
– Conversational skills, appropriate physical
gestures, eye contact and positive appropriate facial expressions (Smith et al.,
1996)
* Role-playing, modelling and positive reinforcement
Better social skills,
independent living and lower
rates of re-hospitalisation
(Hogarty, 2002)
CBT
Delusional thoughts and beliefs and
hallucinations
– Generate alternative explanations for
delusional beliefs
– Challenging interpretations of
hallucinations/generating alternative
explanations
– Incorporating ‘reality’ tests for clients
to test out the reality of their beliefs
(e.g. Chadwick & Lowe, 1994)
Learning to identify signs of relapse
and cope with medication regimes
Dealing with stressors/negative
feedback
Identifying inappropriate responses
to events
Family-based Programmes
Elements of supportive family management
– Education
* Diagnosis, prevalence and aetiology of symptoms
* Antipsychotic medication
* Helping sufferer comply with medication regime
* Recognition of signs of relapse
– Taught
* Social skills to help solve family problems
* To share experiences and avoid blaming
For high EE families
– Family-based programmes in conjunction with medication have been found to be beneficial (Falloon et al., 1999; Schooler et al., 1997)
Case Study - Bill
Socially isolated
Exhibiting ‘peculiar behaviour’
Spends most of time daydreaming
Often talks to himself
Occasionally says things that make little sense
25, single, unemployed, living with sister
Contact with mental health services - please sister and husband who was worried about influence on children
Bill’s first interview
Spoke quietly
Frequent hesitations
Occasionally blinked and shook his head
Seemed friendly
Shy
Uneasy
Discussed daily activities
Unsuccessful efforts to fit in with family routine
Bill believed if he could stop ‘daydreaming’, problems would be solved
Expressed a wish to become better organised
Bill: Therapy Progression
Social Contacts
Concern regarding sexual
orientation
–Had had some limited and fleeting sexual experiences (men and women)
‘Scruples’
Thoughts (‘daydreaming’)–Frequent and irregular intervals distracted by intrusive and repetitive thoughts alien to his own
value system
Compulsions
–Repetition of sequence of
self-statements
Bill’s History - Family
Youngest of 4 children
Both parents 1st generation
Irish Americans
Many relatives still living in
Ireland
Bill’s childhood filled with stories of Irish
heritage
Much closer to mother
Caught in the middle of parents’
frequent arguments
Father – firefighter, ‘harsh’ and ‘distant’, had an extended affair
Bill came to hate his father
‘A son should respect and
admire his father’
Became ill when Bill was 12
Bill remembered wishing he
would die – he did
Bill’s interpersonal relationships as a child
No close friends as a child
Not enjoy company or games other children played
Described himself as clumsy, effeminate
Preferred to be alone or with his mother
Good student
–Finished near the top of his class
Bill’s Interpersonal Relationships as an adult
Got his own apartment
Work
– Bank clerk (2 years, resigned) – not associate with work colleagues
– Lift operator (1 year, fired)
* Could spend time thinking
about what he wanted to
do
* Gradually became distant
and disorganised
Moved back in with mother and
then to sister’s
Bill’s sexual relationships
– First sexual experience while
working at the bank with male
– Bill described it as moderately
enjoyable, more anxiety
provoking
– Small number of other sexual
encounters with men and with a
few women over next 2 years
– Only one lasted more than a few
days, but remained causal
Bill: Conceptualisation and Treatment
Not immediately obvious that Bill was psychotic, ambiguity surrounding cog impairment - CBT, delay re: biological intervention
Initially therapist adopted a passive,
non-directive manner
* To establish a trusting relationship with Bill
* Help Bill to explore concerns re:
sexual experiences, to improve his social and sexual relationships (with women or
men)
Followed by a more active, directive role
* Identified specific problems needed to
address
* Bill’s routine, mumbling and lack of
social contacts with peers
Addressing Bill’s Mumbling
Used a ‘stimulus-control’ procedure
* Bill to select one place in the house where he was permitted to ‘daydream’ and talk to himself
* Whenever he felt the urge to daydream or repeat his ‘scruples’, he was to go to the
specific spot before engaging in these behaviours
Addressing Bill’s routine
Sister to reinforce appropriate
behaviour and ignore
inappropriate behaviour
–Breakfast
Addressing Bill’s interpersonal problems
*Exposure to anxiety-provoking stimuli through
*Rehearsal of phone calls
*Practicing conversations to enable Bill to call old friends
*Included homework
Evidence of psychotic symptoms - Bill
Delusional beliefs and auditory hallucinations –
biological intervention
*Referred to psychiatrist
–Diagnosis and prescription of Risperidone
–Hospitalisation not necessary
*Not considered dangerous, sister able to supervise activity closely
Bill outcome: behavioural intervention
Modest effect–Bill kept more regular hours
in his routine–Positive results re: self-talk
(although not eliminated entirely) and social
interactions
Continued living with sister
required supportive environment
Unlikely to resume normal occupational and social roles in near future
Bill outcome: biological intervention
Positive effect
–Virtual disappearance of intrusive thoughts
*Reduced self-talk considerably
–Delusions remained intact, although fear of observation and threat of death were
less immediate
