Week 7 Schizophrenia

Question 1

Commonly Experienced Psychotic Symptoms

Answer 1

Distortions of perception and reality

Disorganised speech and thought disorder

Disorders of motor behaviour

Question 2

Delusions

Answer 2

Firmly held erroneous beliefs about misinterpretations of perceptions or

• of reference
• of control
• of persecution
• nihilistic delusion
• of grandeur

Question 3

Hallucinations

Answer 3

A sensory experience whereby perception related to something that isn’t really there

Question 4

Auditory hallucinations

Answer 4

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

Question 5

Visual and other hallucinations

Answer 5

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

Question 6

Disorganised speech

Answer 6

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

Question 7

Disorders of Motor Behaviour

Answer 7

Catatonic and Grossly Disorganised Behaviour

Question 8

Catatonic Behaviour

Answer 8

Catatonic stupor
Catatonic rigidity
Catatonic negativism
Catatonic excitement and
stereotypy

Question 9

Grossly Disorganised Behaviour

Answer 9

Childlike and silly
Inappropriate to context
Unpredictable/agitated
Difficulty completing goal
directed activity
Appearance may be
dishevelled/inappropriate

Question 10

Symptoms cont.

Answer 10

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

Question 11

The Nature of Psychotic Symptoms

Answer 11

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)

Question 12

The Course of Psychotic Symptoms

Answer 12

Prodromal Stage, Active Stage, Residual Stage

Question 13

Prodromal Stage

Answer 13

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)

Question 14

Active Stage

Answer 14

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

Question 15

Residual Stage

Answer 15

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)

Question 16

DSM-5 diagnoses

Answer 16

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

Question 17

The Aetiology of Psychotic Symptoms

Answer 17

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

Question 18

Diathesis-Stress Perspective

Answer 18

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)

Question 19

Aetiology of Psychotic Symptoms cont.

Answer 19

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

Question 20

Psychodynamic Theories

Answer 20

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

Question 21

Person-Centered Theory

Answer 21

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

Question 22

Behavioural Theories

Answer 22

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

Question 23

Familial Factors - Communication Deviance (CD)

Answer 23

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)

Question 24

Familial Factors - Expressed Emotion (EE)

Answer 24

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)

Question 25

Treatment for Psychosis

Answer 25

Biological Treatment

Family Interventions

Psychological Therapies

Question 26

Biological Treatments

Answer 26

Typical Psychotics
Less Typical Psychotics
Atypical Antipsychotics
Positives and Negatives of drugs

Question 27

Social Skills Training

Answer 27

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)

Question 28

CBT

Answer 28

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

Question 29

Family-based Programmes

Answer 29

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)

Question 30

Case Study - Bill

Answer 30

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

Question 31

Bill’s first interview

Answer 31

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

Question 32

Bill: Therapy Progression

Answer 32

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

Question 33

Bill’s History - Family

Answer 33

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

Question 34

Bill’s interpersonal relationships as a child

Answer 34

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

Question 35

Bill’s Interpersonal Relationships as an adult

Answer 35

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

Question 36

Bill’s sexual relationships

Answer 36

– 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

Question 37

Bill: Conceptualisation and Treatment

Answer 37

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

Question 38

Addressing Bill’s Mumbling

Answer 38

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

Question 39

Addressing Bill’s routine

Answer 39

Sister to reinforce appropriate
behaviour and ignore
inappropriate behaviour
–Breakfast

Question 40

Addressing Bill’s interpersonal problems

Answer 40

*Exposure to anxiety-provoking stimuli through
*Rehearsal of phone calls
*Practicing conversations to enable Bill to call old friends
*Included homework

Question 41

Evidence of psychotic symptoms - Bill

Answer 41

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

Question 42

Bill outcome: behavioural intervention

Answer 42

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

Question 43

Bill outcome: biological intervention

Answer 43

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