week 7 Schizophrenia and related disorders Flashcards
1 outline the history of the diagnosis of schizophrenia, including reference to Kraepelin, and Bleuler;
Approx 1% prevalence. Full recovery with tx is only approx 1 in 7.
1809 Haslam published a portrayal of a form of insanity now believed to be schizophrenia.
1801-1809 Pinel was describing schizophrenia
1851ish Morel coined phrase demence (loss of mind) precoce (premature).
1899 Kraepelin combined the previously distinct disorders of catatonia(alternating b/n immobility and excited agitation), hebephrenia (silly/immature emotionality)and paranoia(delusions of grandeur or persecution) into the one disorder called dementia praecox. He also distinguished dementia praecox from depression and or bipolar.
1908 Bleuler introduced term schizophrenia (split mind). Schizophrenia, as now understood, is NOT split personality (dissociation from self) but is a split (or dissociation) from reality.
2 describe the major clinical symptoms of schizophrenia and classify them as positive, negative or disorganised symptoms;*
Schizophrenia symptoms are termed positive to mean excessive or additional (cf normal) or negative to signify deficits eg of emotions. Very loosely, positive symptoms more linked to increased dopamine whereas negative symptoms are more loosely associated with changes to brain structure, resulting in loss of neurons. Symptoms which are classified as disorganised are sometimes classified in their own category and sometimes categorised as positive.
Cannot actually be classified as schizophrenic without any positive symptoms, but can be classified as schizophrenic without any negative symptoms.
POSITIVE symptoms include: delusions (misrepresentation of reality or disordered thoughts)(in schizophrenia the delusions tend to be of the more bizarre variety), hallucinations (experience of a sensation without external input).
NEGATIVE symptoms include;apathy of thought, behaviour, emotion, speech. Approx 25 % of patients with schizophrenia have negative symptoms also. Avolition= without volition=inability to initiate and persist in an activity. Sometimes termed apathy.
Alogia =deficiency of speech. They may respond with the briefest answer and lack desire to add extra detail. Uncertain as to whether genuine non desire to communicate or actually just struggling with words and or thoughts.
Anhedonia=without experiencing pleasure. ie indifference to activities such as eating, socialising or sex (which most normals enjoy).
Asociality=lack of interest in social relations.
Affective flattening=lack of expected emotionality (although may still be feeling it internally).
DISORGANIZED symptoms; includes erratic behaviours affecting speech, motor control and emotional reactions. Sometimes have inappropriate affect=show the wrong emotion. Catatonia ranges from episodes of wild agitation to immobility.
Schizophrenia does not get better without tx.
3 discuss evidence related to the developmental course of schizophrenia;
The development of schizophrenia may or may not be able to be predicted. Some research has shown that children who had a parent with schizophrenia and who developed schizophrenia themselves later, displayed less positive emotionality and more negative affect as children.
Some early signs may be seen in children but are unable to be termed schizophrenia as may be part of a developmental disorder.
Most typically, there is a prodromal stage (in 85% of those who develop schizophrenia), where early mild signs are evident which may include ideas of reference, magical thinking, isolation and impairment of function. May then take 2-10 years before meet dx for a psychotic disorder. The greatest risk in going from at risk to having dx is in 1st 2 years after displaying some sins. Other riosk factors include length of duration of symptoms, lack of social support, worsening levels of function, and presence of negative and or disorganised signs.
Approx 22% will respond to tx and never have another psychotic episode and return to reasonable fn. 78% will have episodes of relapse which vary in severity. Suicide is also a higher risk for the group.
4 critically discuss evidence for genetic transmission, excess dopamine, brain abnormalities and viral infection as causes of schizophrenia;
Genetic studies have shown there is genetic risk contributions to developing schizophrenia and these are multiple genes not just one. If have a monozygous twin with schizophrenia, your genetic risk is 48%, if have dizygous twin with, your risk 17%, having any relative with schizophrenia increases your risk to 2-15%. General population without any relatives with, has risk factor of 1%.Risk of schizophrenia is also linked with risk of any psychotic disorder.
A child of a mother with schizophrenia is at increased risk of schizophrenia but if adopted, is at greater risk if brought up by a dysfnal family, and at less risk if brought up by a nurturing family.
Endophenotype=a measurable behaviour which is found at differing levels in individuals with and without condition and at intermediate level with those unaffected but with familial links. They may be a way to recognise dz risk factors and may serve as a stepping stone to in future identify genetic markers for dz. In schizophrenia, there is abnormal ability to smoothly track objects (ie a normal can follow a pendulum with eyes only without turning head but schizophrenics have more difficulty with this).
The dopamine system is thought to possibly be overly active in those with schizophrenia based on:
a) Antipsychotic meds (neuroleptics) are often effective at txing schizophrenia and they are dopamine antagonists.
b) neuroleptic drugs may produce side effects similar to Parkinson’s and this dz known to be linked with low levels of dopamine.
c) L-dopa, which is a drug used to treat parkinsons and a dopamine agonist, may cause schizophrenia-like symptoms in some.
d)amphetamines activate dopamine and may make psychotic symptoms worse in some people with schizophrenia.
BUT;
a)some people with schizophrenia are not helped by dopamine antagonists.
b)although neuroleptics block dopamine receptors quite quickly, symptoms subside after days to weeks
c) neuroleptics are only partially helpful in reducing the negative symptoms.
FURTHER; Olanzapine is effective for many who were not helped by traditional neuroleptics. Olanzapine is actually a weak dopamine antagonist
Schizophrenia now thought to come from excessive stimulation of striatal dopamine d2 receptors.These cells involved in movement. Most effective neuroleptics block d2 receptors. But there may also in schizophrenia be deficiency of stimulation of dopamine d1 receptors in the prefrontal cortex (hypofrontality). In addition, glutamate imbalances may be involved in schizophrenia. N-methyl-d-aspartate (NMDA) receptors are a type of glutamate receptor. Pcp and ketamine are NDMA antagonists and can cause psychotic symptoms in those with schizophrenia.
BRAIN STRUCTURE;not absolute, but those with schizophrenia more likely to have increased lateral ventricle size (possibly linked to prenatal exposure to influenza virus), maybe an obstetrical difficulty at birth, and or hypofrontality (less activity in the frontal lobes), occasional hyperfrontality, and various sites may be involved in cognitive dysfunction where abnormalities may exist prior to onset of schizophrenia.
The use of cannabis is not definitively linked to schizophrenia, but thought may trigger it in some with specific genetic vulnerability, and possibly if schizophrenic, more likely to have a cannabis use disorder.
5 critically discuss evidence for psychological and social influences;
Stress may obviously play a part in precipitating or perpetuating or pre-disposing.
EXPRESSED EMOTION is a particular style of emotion expression and may be high or low in different families. High expressed emotion tends to be “you should do this… or this… “repeatedly etc. Whereas low expressed emotion is more “ well you just do what you need to, and I’ll be here if you need me” etc. A high expressed emotion tends to view schizophrenia as you could beat this if you put an effort in. Studies are now showing that tthose with schizophrenia whose families express great levels of high expressed emotionality, are more likely to relapse.
Also thought living in cities means have higher risk of schizophrenia.
6 evaluate the efficacy of biological and psychosocial therapies for schizophrenia.
Anti-psychotic medications help many people with schizophrenia to reduce hallucinations/delusions, think more clearly and reduce agitation. Less effective for negative or disorganised symptoms. But some do not respond to one drug, but may respond to another. 60-70% of schizophrenics are helped by a medication such as conventional haldol or thorazine. Atypical or newer drugs include risperidone and olanzipine. However with most of the antipsychotic meds there is a fairly high rate of unacceptable side effects reported such as grogginess, blurred vision, and mouth dryness. more serious side effects include akinesia (expressionless face, slow motor activity and monotonous speech), and tardive dyskinesia (involuntary movements of face and tongue) which are often irreversible even after drug withdrawal. Generally, there is less than ideal patient compliance.Injectable meds dosed every few weeks have also been developed but still have a reasonable level of poor patient compliance.
Modafinil is a cognitive enhancer drug which is now sometimes used in combination with anti-psychotics.
Transcranial magnetic stimulation has been used to target the brain areas involved in hallucinations, and some reports show a subsequent reduction in hallucinations, although the effect may only last a month or so.
Psychotherapy in various forms is now thought to be of benefit in treating schizophrenia whe usedin conjunction with medications. Areas which can be focussed upon include increasing medication understanding and compliance, being able to better communicate with healthcare providers, improving social skills and being able to hold a job, recognising warning signs of relapses and managing, family conflict resolution skills etc. Most likely , the more levels of address, the more chance of success.
other psychotic disorders
SCHIZOPHRENIFORM disorder;Schizophrenia symptoms but for only a few months. no flat affect. Symptoms often disappear.
SHIZOAFFECTIVE DISORDER;schizophrenia symptoms but also with depression or bi-polar signs. Does not clear without medication.lifelong affected usually.
DELUSIONAL DISORDER;has a persistent delusion.Tend not to have any of the negative symptoms of schizophrenia. Often become socially isolated due to their suspicions of others. Subtypes of delusion include erotomanic, grandiose, jealous, persecutory and somatic. These delusions tend to be of the more maybe plausible variety cf those of schizophrenia. Delusion is usually singular whereas in schizophrenia, if have delusions, are usually multiple. Very rare (24-60 people per 100 000). Of those with a psychotic disorder, only 2-8% have delusional disorder. Av age of first admission into psychiatric care for delusional disorder is 35-55 years. Many can be functional for long time. Slightly more women affected than men.
BRIEF PSYCHOTIC DISORDER; symptoms of delusions/hallucinations and disorganised speech lasting 1 month or less. often precipitated by extreme stress. Often self clears and regain former level of functionality.
ATTENUATED PSYCHOSIS SYNDROME:maybe do have schizophrenia but symptoms less than 6 months and are aware themselves that there is something wrong and so seek help.
SCHIZOTYPAL PERSONALITY DISORDER; related to schizophrenia and possibly shared genetic risk, but is different
