Week 8 - Schizophrenia and other psychotic disorders Flashcards
Schizophrenia is characterized by an array of diverse symptoms, including (6)
extreme oddities in perception, thinking, action, sense of self, and manner of relating to others, and the hallmark, psychosis.
In schizophrenia there is a split within/between….(3)
the intellect,
between the intellect and emotion,
and between the intellect and external reality
The risk of developing schizophrenia over the course of one’s lifetime is actually around X.X per-cent
0.7
Risk factors of Schizophrenia
Having a parent with schizophrenia,
People whose fathers were older (50+; 2-3x)
Having a parent who works as a dry cleaner
First and second generation immigrants (particularly those form black caribbean and black african countries who live in majority white communities)
The characteristic age of onset of schizophrenia differs in men and women….(peak and fall)
In men, there is a peak in new cases of schizophrenia between ages 20 and 24. After about 35 the number falls markedly.
The incidence of schizophrenia in women peaks during the same age period, but the peak is less marked and drops more slowly (intersecting at 30-34, and then again around 50). Further, there is a second rise in new cases that begins around age 40, as well as a third spike in onset that occurs when women are in their early sixties
Males tend to have a more severe form of schizophrenia, and schizophrenia-related anomalies of brain structure (discussed later) are more severe in male patients than they are in female patients (T/F)
T
The M:F ratio for schizophrenia is:
The male-to-female ratio is 1.4:1
When estrogen levels are low (as is true premenstrually) or are falling, psychotic symptoms in women with schizophrenia often get _______
worse
A delusion is essentially…
an erroneous belief that is fixed and firmly held despite clear contradictory evidence
delusions are common in schizophrenia, occurring in more than ___ percent of patients at some time during their illness. (6 common examples).g.
90
E.g. - beliefs that one’s thoughts, feelings or actions are being controlled by external agents.
- private thoughts are being broadcast
- thoughts are being inserted by an external agency
- thoughts have been robbed
- delusions of reference, where some neutral environmental event (such as a television program or a song on the radio) is believed to have special and personal meaning intended only for the person
- Other strange propositions, including delusions of bodily changes (e.g., bowels do not work) or removal of organs, are also not uncommon
DSM-5 Criteria for. . . Schizophrenia
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expres-sion or avolition).
B. For a significant portion of the time since the onset of the dis-turbance, 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. Continuous signs of the disturbance persist for at least 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 pro-dromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be mani-fested by only negative symptoms or by two or more symp-toms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred con-currently with the active-phase symptoms, or (2) if mood epi-sodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communi-cation disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucina-tions, in addition to the other required symptoms of schizo-phrenia, are also present for at least 1 month (or less if successfully treated).
A hallucination is a sensory experience that
seems real to the person having it, but occurs in the absence of any external perceptual stimulus (any sensory modality, but auditory hallucinations are the most common)
In a sample recruited from seven different countries, auditory hallucinations were found in ____ percent of patients with schizophrenia (Bauer et al., 2011). In contrast, visual hallucinations were reported less frequently (___ percent of patients), and olfactory, tac-tile, and gustatory hallucinations were even more rare (__ - ___percent).
75
39
1–7
The majority of patients (___ percent) reported that their voices usually spoke at a normal conversational volume. Hallucinated voices were often those of ______, although sometimes unfamiliar voices or the voices of ____ and the ____ were heard
73
people known to the patient in real life
God or the Devil
Most patients reported that they heard (how many)____ _____ ____voice and that their hallucinations were worse when they were _____
more than one
alone
Neuroimaging studies that compare hallucinating patients with nonhallucinating patients suggest that patients with speech hallucinations have a reduction in brain (gray matter) volume in the left hemisphere auditory and speech perception areas (T/F)
T
neuroimaging studies reveal that hal-lucinating patients show increased activity in _____ area—an area of the frontal lobe that is involved in speech production.
Broca’s
Modern research approaches support the old idea that Auditory hallucinations are really a form of….
misperceived subvocal speech
Disorganized speech is…
the external manifestation of a disorder in thought form.
neologisms (df)
(literally, “new words”)
Formal thought disorder (df)
a term clinicians use to refer to problems in the way that disorganized thought is expressed in disorganized speech)
Catatonia (df)
The patient with catatonia may show a virtual absence of all movement and speech and be in what is called a catatonic stupor. At other times, the patient may hold an unusual posture for an extended period of time without any seeming discomfort
Positive symptoms are those that reflect…
an excess or distortion in a normal repertoire of behavior and experience, such as delusions and hallucinations. Disorganized thinking (as revealed by disorganized speech) is also thought of in this way.
Negative symptoms reflect…
an absence or deficit of behaviors that are normally present.
1) reduced expressive behavior—either in voice, facial expression, gestures, or speech (blunted or flat affect, or alogia (very little speech))
2) reductions in motivation or in the experience of pleasure (avolition or anhedonia).
The inability to initiate or persist in goal-directed activity is called _____.
avolition
For example, the patient may sit for long periods of time staring into space or watching TV with lit-tle interest in any outside work or social activities
the presence of negative symptoms in the clinical picture is a good sign for the patient’s future outcome (T/F)
F
List four different types of psychotic disorders and state one way in which each is different from schizophrenia.
schizoaffective disorder (hybrid between Schizophrenia and Mood disorder)
schizophreniform disorder (schizophrenia-like psychoses that last at least a month but do not last for 6 months and so do not warrant a diagnosis of schizophrenia)
delusional disorder (delusional beliefs (e.g. erotomania [great love for a person, usually of higher status], but no gross disorganisation and performance deficiencies, and general behavioural deterioration is rare)
and brief psychotic disorder.
DSM-5 Criteria for. . . Schizoaffective Disorder
A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
DSM-5 Criteria for. . .Schizophreniform Disorder
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if success-fully treated). At least one of these must be (1), (2), or (3):
- Delusions.
- Hallucinations.
- Disorganized speech (e.g., frequent derailment or incoherence).
- Grossly disorganized or catatonic behavior.
- Negative symptoms (i.e., diminished emotional expression or avolition).
B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional.”
C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
DSM-5 Criteria for. . . Delusional Disorder
A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder.
Temporal versions of Schizophrenia (in chrono order)
Brief Psychotic Disorder (<1 month)
Schizophreniform Disorder (1-6 months)
Schizophrenia (6+ months)
DSM-5 Criteria for. . . Brief Psychotic Disorder
A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
Note: Do not include a symptom if it is a culturally sanctioned response.
B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning.
C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
Index cases (i.e. Proband)
the diagnosed group of people who provide the starting point for inquiry
The prevalence of schizophrenia in the first-degree relatives (parents, siblings, and offspring) of a proband with schizophrenia is about ___ percent. While only ____ for second-degree relatives.
10
3
As with the mood disorders, schizophrenia concordance rates for identical twins are routinely and consistently found to be significantly higher than those for fraternal twins or ordinary siblings (T/F)
T (45-50% vs 15-20%)
The overall pair-wise concordance rate of Schizophrenia is ___percent in MZ twins and ___ percent in DZ twins
28
6
This suggests that a reduction in shared genes from 100 percent to 50 percent reduces the risk by nearly 80%.
Fischer reasoned that genetic influences, if present, would be just as likely to show up in the ____X____of the twins without schizophrenia in discordant pairs as they would be to show up in the ___X____of the twins with schizophrenia (because they share all their genes in common)
offspring
Gottesman and Bertelson (1989) reported an age-corrected incidence rate for schizophrenia of __.__ percent for the off-spring of the MZ twins without schizophrenia (i.e., the well MZ twins).
17.4
Communication deviance is…
a measure of how under-standable and “easy to follow” the speech of a family mem-ber is.
Vague, confusing, and unclear communication reflects high communication deviance
Children who were at genetic risk and who lived in families where there was high _____ ______ or ___ ____ ____ showed high levels of thought disorder at the time of the follow-up
communication deviance
adverse family environments
In other words, if they are raised in a benign environment, even children who are at genetic risk for schizophrenia appear to do….
very well.
Candidate genes are…
genes that are involved in processes that are believed to be aberrant in schizophrenia
COMT (catechol-O-methyltransferase) gene is….
is located on chromosome 22 and is involved in dopamine metabolism.
One problem with candidate gene studies is that…
the findings from one study often fail to replicate in another study.
genome-wide association study (GWAS) df
Unlike other genetic approaches where only a few genetic regions are tested, in a GWAS the entire genome is investigated.
Recent research has shown links between deletions and duplications of DNA (these are called copy number variations or CNVs) and __________.
CNVs have also been implicated in (3)
schizophrenia
autism, ADHD, and intellectual disability
The multifactorial etiology of schizophrenia includes (3)
(1) rare genes that have a large effect,
(2) common genes that have a small effect, and
(3) the environmental factors and gene–environmental interactions that confer risk for schizophrenia.
endophenotypes (df)
discrete, stable, and measurable traits that are thought to be under genetic control
influenza exposure during the first trimester of pregnancy was associated with a ______increased risk of schizophrenia or schizophrenia spectrum disorders in the offspring
sevenfold
More generally, influenza exposure during the first half of pregnancy was associated with a _____increase in risk.
threefold
Other maternal infections such as ______(German measles) and ________(a very common parasitic infection) that occur during pregnancy have also been linked to increased risk for the later development of schizophrenia
rubella
toxoplasmosis
We also know from animal studies that cytokines play a role in shaping brain development and that fetal exposure to _____________________ _______________ can lead to abnormalities in brain structure and functioning—many of which are highly relevant to schizo-phrenia
proinflammatory cytokines
when maternal levels of __-_____ ____ were high, the offspring had a nearly 60 percent higher risk of developing schizophrenia decades later
C-reactive protein
the rate of schizophrenia is about __.__ percent in males who are Rh-incompatible with their mothers. For males who have no such incompatibility with their mothers, the rate of schizophrenia is __.__ percent
2.1
0.8
Patients with schizophrenia are much more likely to have been born following a pregnancy or delivery that was compli-cated in some way (T/F)
T
Those who were conceived at the height of the famine had a _____ increase in their risk of later develop-ing schizophrenia
twofold
If a mother experiences an extremely stressful event late in her ____ trimester of pregnancy or early in the ____trimester, the risk of schizophrenia in her child is increased
first
second
Around two-thirds of MZ embryos are ___________________, which means they share a placenta and blood supply. The remaining MZ twins and all DZ twins are ________; they have separate placentas and separate fetal circulations
monochorionic
dichorionic
The concordance figure for dichorionic MZ twins is very similar to that generally reported for DZ twins (T/F)
T
A genetic liability to schizophrenia may ____________ an individual to suffer more damage from environ-mental insults than would be the case in the absence of the genetic predisposition. Give example:
predispose
enlarged ventricles (fluid-filled spaces in the brain)
Although very speculative at this time, it is possible that genetic vulnerability to schizophrenia could be explained by greater genetic vulnerability to _____.
infection
One of the most consistent findings from high-risk research is that children with a genetic risk for schizophrenia are more deviant than control children on research tasks that measure _____
Attention
Although we might have suspected that schizophrenia would first begin to show itself via hallucinations or delusions, it may be that the first signs of the illness can instead be found in the way that children ______
move.
Almost all aspects of ______(involving attention, language, and memory) are impaired for those with schizophrenia
cognition
Researchers think that a sharp decline in cognitive ability (and IQ) occurs during the period of transition from the premorbid period into full-blown illness because
patients who have only recently become ill perform about the same on neuropsychological tests as patients who have been ill for many years
Examples of poor cognition in S
RT,
Continuous Performance Test
Working memory
Visual and auditory processing
Smooth-pursuit eye movement
poor P50 suppression
social cognition
Enlarged brain ventricles are important because they
are an indicator of…
a reduction in the amount of brain tissue.
MRI studies of patients with schizophrenia show about a ___ percent reduction in whole brain volume relative to that in controls
3
Loss of gray matter does seem to coincide with the lass of mass in the…
prefrontal cortext
psychosis and cortical thinning go hand in hand (T/F)
T
gray matter loss leads to inflammatio (T/F)
F - unknown. Perhaps the reverse.
in addition to being a neurodevelopmental disorder, schizophrenia is also a neuroprogressive disorder characterized by a…
loss of brain tissue over time
Of particular importance is the finding that patients with schizophrenia are missing particular types of neurons known as _____ ______
“inhibitory interneurons”
The dopamine hypothesis dates back to the 1960s and was derived from three important observations (3)
- The pharmacological action (and success of) of the drug chlorpromazine (Thorazine)
- Amphetamines are drugs that produce a functional excess of dopamine (i.e., the brain acts as if there is too much dopamine in the system), the abuse of which were linked to a form of psychosis.
- Psychotic symptoms induced by L-DOPA (dopamine+ drug for parkinsons)
Glutamate (an excitatory neurotransmitter) that is widespread in the brain is also thought to be related to schizophrenia because…(2)
- PCP, or angel dust, is known to block glutamate receptors and induces symptoms (both positive and negative) that are very similar to those of schizophrenia.
- Ketamine blocks glutamate receptors and produces both negative and positive schizophrenia-like symptoms.4. NMDA receptor activitiy is important for cognitive processes that are compromised
Researchers have examined concentrations of glutamate in the postmortem and living brains of patients with schizophrenia and found _____ levels of glutamate in both the ____ and ____ compared with the levels in control subjects
lower
prefrontal cortex and the hippocampus
Expressed emotion is (df + 3 elements)
a measure of the family environment that is based on how a family member speaks about the patient during a private interview with a researcher. It has three main elements: criticism, hostility, and emotional overinvolvement (EOI).
Hostility is
a more extreme form of criticism that indicates a dislike or rejection of the patient as a person.
The most important elements of the Expressed Emotion measure is criticism, which reflects….
dislike or disapproval of the patient
Emotional overinvolvement [EOI] (of EE) reflects a
dramatic or over-concerned attitude on the part of the family member toward the patient’s illness.
Urban living increases susceptibility to S by _____ times. It has been estimated that everyone living rurally would decrease the prevelance of S by ____%
2.75
30%
Found that first-generation immigrants (i.e., those born in another country) had ___ times the risk of develop-ing schizophrenia; for second-generation immigrants (i.e., those with one or both parents having been born abroad), the relative risk was even higher at ___.
2.7
4.5
Studies of clinical outcome show that 15 to 25 years after developing schizophrenia, around 38 percent of patients…
have a generally favorable outcome and can be thought of as being recovered
For example, in highly industrialized cultures (U.S. Europe), more than __ percent of families are high in EE, compared to as low as ___ to __ in ___ and __ respectively.
50
24 to 41
Mexican American and Higni-speaking Indian Samples respectively.
((UK)men with schizophrenia die ___.__ years earlier than would be expected based on national norms
For women with schizoaffective disorder the reduction in life span is ___.__ years
14.6
17.5
extrapyramidal side effects (EPS)
These are involuntary movement abnormalities (muscle spasms, rigidity, shaking) that resemble Parkinson’s disease
tardive dyskinesia.
This involves marked involun-tary movements of the lips and tongue (and sometimes the hands and neck).
neuroleptic malignant syndrome
This condition is characterized by high fever and extreme muscle rigidity, and if left untreated it can be fatal.
