Chapter 11 Schizophrenia
Ch 11
Schizophrenia
• Schizophrenia is a psychotic disorder involving disturbance of thought, emotion and behavior
• The lifetime prevalence of schizophrenia is about 1%– Onset is usually in late adolescence– Substance abuse is a co-morbid condition in
50% of schizophrenia patients
Ch 11.1
Broad Impairments Delusions & Hallucinations Disorganized Speech & Behavior Inappropriate Emotions Psychosis: extreme mental unrest
with loss of reality contact (Davison & Neale, p. 134)
Broad Impairments Delusions & Hallucinations Disorganized Speech & Behavior Inappropriate Emotions Psychosis: extreme mental unrest
with loss of reality contact (Davison & Neale, p. 134)
Cause is Unknown Affects 1 out of 100 People Often Begins (Ages 16 - 30) More Hospital Beds Than Any Other
Medical Illness2.5% of Total U.S. Healthcare Budget
Cause is Unknown Affects 1 out of 100 People Often Begins (Ages 16 - 30) More Hospital Beds Than Any Other
Medical Illness2.5% of Total U.S. Healthcare Budget
Often Chronic Occurs in .2% to 1.5% Population Affects Men and Women Equally
– Age of Onset Varies Across Time Lower Life Expectancy
– Increased Risk of Suicide
Often Chronic Occurs in .2% to 1.5% Population Affects Men and Women Equally
– Age of Onset Varies Across Time Lower Life Expectancy
– Increased Risk of Suicide
People with schizophrenia have “split personalities.”
People with schizophrenia are intellectually disabled?
People with schizophrenia are dangerous?
People with schizophrenia are addicted to their drugs?
People with schizophrenia have “split personalities.”
People with schizophrenia are intellectually disabled?
People with schizophrenia are dangerous?
People with schizophrenia are addicted to their drugs?
Schizophrenia is NOT caused by bad parenting or an unhappy childhood.
Schizophrenia is NOT due to a weakness in character.
Schizophrenia is NOT due to a negative social label.
Schizophrenia is NOT a hopeless situation.
Schizophrenia is NOT caused by bad parenting or an unhappy childhood.
Schizophrenia is NOT due to a weakness in character.
Schizophrenia is NOT due to a negative social label.
Schizophrenia is NOT a hopeless situation.
Dementia (Loss of Mind) Praecox (Early, Premature) Kraepelin
– Categorization & Early Onset Eugen Bleuler
– Termed “Schizophrenia”– Associative Splitting
Dementia (Loss of Mind) Praecox (Early, Premature) Kraepelin
– Categorization & Early Onset Eugen Bleuler
– Termed “Schizophrenia”– Associative Splitting
Positive Symptoms– Displays of Abnormal Behavior
Disorganized Symptoms– Speech and Behavior
Negative Symptoms
– Deficits in Affect, Speech, Motivation
Positive Symptoms– Displays of Abnormal Behavior
Disorganized Symptoms– Speech and Behavior
Negative Symptoms
– Deficits in Affect, Speech, Motivation
Positive Symptoms Positive Symptoms Delusions
– Misrepresentation of Reality– “Basic Feature of Madness”
Examples– Grandeur -- Importance– Persecution -- Out to Get Me
Delusions– Misrepresentation of Reality– “Basic Feature of Madness”
Examples– Grandeur -- Importance– Persecution -- Out to Get Me
Positive Symptoms Positive Symptoms Hallucinations
– Absence of Sensory Stimulation
– Involve Any of the Senses Examples
– Auditory -- Voices (70%)
– Visual -- Seeing Things (25%)
– Tactile -- Crawling Sensation
Hallucinations– Absence of Sensory Stimulation
– Involve Any of the Senses Examples
– Auditory -- Voices (70%)
– Visual -- Seeing Things (25%)
– Tactile -- Crawling Sensation
Broca’s Area(Speech)
Broca’s Area(Speech)
Wernicke’s Area(Hearing)
Wernicke’s Area(Hearing)
What Area Do You Think is More Active With Auditory Hallucinations?What Area Do You Think is More Active With Auditory Hallucinations?
Disorganized Symptoms Disorganized Symptoms Disorganized Speech
– Difficulty in Communication Examples
– Tangentiality– Loose Association or Derailment
Disorganized Speech– Difficulty in Communication
Examples– Tangentiality– Loose Association or Derailment
Positive
Symptoms
Positive
Symptoms
Disorganized Behaviors Catatonia
– Spectrum– Wild Agitation to Immobility
Example– Waxy Flexibility
– Inappropriate Affect
Disorganized Behaviors Catatonia
– Spectrum– Wild Agitation to Immobility
Example– Waxy Flexibility
– Inappropriate Affect
Disorganized Symptoms Disorganized Symptoms
Positive
Symptoms
Positive
Symptoms
Positive Disorganized
Symptoms
Positive Disorganized
Symptoms Negative Symptoms Negative Symptoms
Flat Affect -- “The Mask” Avolition -- “No Initiative” Alogia -- “Speech is Vacant” Anhedonia -- “No Pleasure” Asociality--”No social interest”
Flat Affect -- “The Mask” Avolition -- “No Initiative” Alogia -- “Speech is Vacant” Anhedonia -- “No Pleasure” Asociality--”No social interest”
Positive Symptoms of Schizophrenia
• Positive symptoms involve excesses or distortions– Disorganized speech (thought disorder)– Hallucinations are sensory experiences that occur in
the absence of environmental stimulation• Hallucinations are commonly auditory
– Delusions are beliefs that are contrary to reality• Persecutory delusions are common
Ch 11.2
Negative Symptoms of Schizophrenia
• Negative schizophrenia symptoms are characterized by behavioral deficits– Avolition refers to a lack of energy and an inability to
persist in routine activities– Alogia refers to a reduction in the amount or content of
speech– Anhedonia is an inability to experience pleasure– Asociality refers to a severe impairment in social
relationships
Ch 11.3
DSM-IV Schizophrenia Categories
• Disorganized schizophrenia involves – Disorganized speech and flat affect – A general disruption of behavior
• Catatonic schizophrenia involves – Prolonged motor immobility states that alternate with periods of
excitability
• Paranoid schizophrenia involves the presence of prominent delusions including persecution and grandiosity
• Undifferentiated schizophrenia and residual schizophrenia
Ch 11.4
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Delusions & Hallucinations Intact Cognition and Affect No Disorganized Speech Best Prognosis
Delusions & Hallucinations Intact Cognition and Affect No Disorganized Speech Best Prognosis
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Disorganized Speech Disorganized Behavior Flat or Inappropriate Affect Hallucinations and Delusions
– Fragmented or Lacking a Theme Often Chronic
Disorganized Speech Disorganized Behavior Flat or Inappropriate Affect Hallucinations and Delusions
– Fragmented or Lacking a Theme Often Chronic
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Disorganized Speech Disorganized Behavior
Waxy flexibility, rigidity, odd mannerisms, mimicry
Flat or Inappropriate Affect Hallucinations and Delusions
– Fragmented or Lacking a Theme Often Chronic
Disorganized Speech Disorganized Behavior
Waxy flexibility, rigidity, odd mannerisms, mimicry
Flat or Inappropriate Affect Hallucinations and Delusions
– Fragmented or Lacking a Theme Often Chronic
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Beginnings of Breakdown Major Sx of Schizophrenia DO NOT Meet Other Criteria “Wastebasket” Category
Beginnings of Breakdown Major Sx of Schizophrenia DO NOT Meet Other Criteria “Wastebasket” Category
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Have Had One Episode Now Mostly Symptom Free
Have Had One Episode Now Mostly Symptom Free
Once a Schizophrenic, Always a Schizophrenic?
Once a Schizophrenic, Always a Schizophrenic?
Classification Systems and Their Relation to Schizophrenia
Process vs. Reactive Distinction Process – Insidious onset, biologically based, negative symptoms, poor prognosisReactive – Acute onset (extreme stress), notable behavioral activity,best prognosis
Good vs. Poor Premorbid Functioning in SchizophreniaFocus on person’s level of function prior to developing schizophreniaNo longer widely used
Type I vs. Type II Distinction and SchizophreniaType I – Positive symptoms, good response to medication, optimistic prognosis, and absence of intellectual impairmentType II – Negative symptoms, poor response to medication, pessimistic prognosis, and intellectual impairments
Early Brain Damage Neurological “Soft Signs”
– Attentional and Reflex Problems (Nasrallah & Smeltzer, 2002)
Runs In Families– High Expressed Emotion & Relapse
– What is the Genetic Risk?
Early Brain Damage Neurological “Soft Signs”
– Attentional and Reflex Problems (Nasrallah & Smeltzer, 2002)
Runs In Families– High Expressed Emotion & Relapse
– What is the Genetic Risk?
Etiology of Schizophrenia
• Genetic studies using twin, family and adoption techniques reveal that a predisposition for schizophrenia is transmitted genetically
• Brain pathology, possibly including damage to the fetal brain from virus-like diseases, are likely biological vulnerabilities for schizophrenia (diathesis)
Ch 11.5
Genetic Studies of Schizophrenia
Relation to PercentageProband Schizophrenic
Spouse 1.00Grandchildren 2.84Nieces/nephews 2.65Children 9.35Siblings 7.30DZ twins 12.08MZ twins 44.30
Ch 11.6
Runs in Families Increased Risk Based on Genetic Relatedness Search for Marker Genes
Smooth Pursuit Eye Tracking
Runs in Families Increased Risk Based on Genetic Relatedness Search for Marker Genes
Smooth Pursuit Eye Tracking
Genetic Influences Genetic Influences
Biochemistry of Schizophrenia
• Dopamine theory holds that the positive symptoms of schizophrenia result from excessive activity of dopamine in brain– Anti-schizophrenia drugs block dopamine receptors
• The anti-schizophrenia drugs take several weeks to act clinically, yet rapidly block dopamine receptors
– Ingestion of amphetamine can induce psychosis; amphetamine causes the release of dopamine from neurons
Ch 11.7
Figure 11.1 Dopamine Activity in Mesolimbic and Mesocortical Pathways
Ch 11.8
•Overactivity of dopamine neurons in the mesolimbic pathway may cause positive symptoms.
–Antipsychotics which block dopamine receptors lessen positive symptoms
•Underactivity of dopamine neurons in the mesocortical pathway in the l prefrontal cortex may cause negative symptoms
–Antipsychotics have little or no effect on negative symptoms.
Dopamine Theory of Schizophrenia
Antagonists– Neuroleptics
– Drugs That Reduce Dopamine
– Negative Side Effects
– L-Dopa (Agonist)
– Amphetamines
Antagonists– Neuroleptics
– Drugs That Reduce Dopamine
– Negative Side Effects
– L-Dopa (Agonist)
– Amphetamines Genetic Influences Genetic Influences
Neurobiological Influences Neurobiological Influences
Excess Dopamine (D2 Receptors) Excess Dopamine (D2 Receptors)
Glutamate Theory
• PCP (“angel dust”) and ketamine (an anesthetic) mimic the positive and negative symptoms of schizophrenia (Javitt & Cole, 2004)
• These drugs block the action of a form of glutamate receptor (NMDA receptor)
• NMDA receptor blockade may produce the dopamine dysfunction seen in schizophrenia, as if too little dopamine were present in the prefrontal cortex (negative symptoms) and too much dopamine in the mesolimbic area (positive symptoms)
Brain Pathology in Schizophrenia
• Brains of schizophrenic patients show– Reduced volume of temporal and frontal cortex – Enlarged ventricles (reflecting loss of brain cells)
• For 12 of 15 twins, the schizophrenic twin could be identified by enlarged ventricles
– Reduced metabolic activity within prefrontal cortex (frontal hypoactivation)
Ch 11.9
Ventricle Enlargement Ventricle Enlargement
Genetic Neurobiological
Influences
Genetic Neurobiological
Influences
Brain Structure Brain Structure
Ventricle Enlargement Ventricle Enlargement
Genetic Neurobiological
Influences
Genetic Neurobiological
Influences
Brain Structure Brain Structure
Hypofrontality Hypofrontality
Psychological Stress & Schizophrenia
• Example of diathesis-stress model• Social class and schizophrenia
– Sociogenic hypothesis– Social-Selection theory (more research support)
• Expressed emotion (EE) - Research shows how family and social environmental context affects re-hospitalization rates
• High-Risk studies of schizophrenia
Causes of Schizophrenia:Psychological and Social Influences
(cont.)
Figure 13.9 Barlow/Durand, 3rd. Edition. Cultural differences in expressed emotion (EE)
Therapies for Schizophrenia• Psychosurgery
– Prefrontal lobotomy • Drug therapies
– Antipsychotic medications that block dopamine receptors• Chlorpromazine (Thorazine)
– Became widely available in 1954• Others include haloperidol (Haldol) and thiothixene (Navane)
– Reduce agitation, violent behavior, and other emotional and behavioral excesses.
– Disadvantages:• Side effects especially extrapyramidal side effects• About 30% of patients do not respond• Little or no effect on negative symptoms
– Newer medications: • Clozapine (Clozaril), respiradone (Risperdal)
Ch 11.10
Haldol & Clozapine Trial and Error “Extrapyramidal” Side Effects
Tardive Dyskinesia
Akinesia
Atypical Antipsychotics: (Clozapine, Risperdal, Zyprexa,Seroquel, Geodon, Abilify)
Haldol & Clozapine Trial and Error “Extrapyramidal” Side Effects
Tardive Dyskinesia
Akinesia
Atypical Antipsychotics: (Clozapine, Risperdal, Zyprexa,Seroquel, Geodon, Abilify)
Biological Interventions Neuroleptics
Biological Interventions Neuroleptics
Medical Treatment of Schizophrenia (cont.)
Table 13.2 Barlow/Durand, 3rd.Antipsychotic medications
Psychological Treatments for Schizophrenia
• Social-skills training involves teaching behaviors to interact successfully with others
• Family therapy aims to reduced expressed emotion (hostility, overly critical)
• Cognitive-behavioral therapy demonstrates that maladaptive behaviors and beliefs of some patients can be changed– Personal therapy aims to reduce expressed emotion, uses
relaxation techniques and teaches social skills
Ch 11.11`
Cognitive-Behavioral Therapies
• Personal Therapy– Patients are taught
• To recognize inappropriate affect • To recognize signs of relapse• Relaxation techniques to reduce anxiety & anger• Rational emotive therapy techniques to reduce frustration and
prevent explosive or inappropriate interpersonal behavior. • Social skills training to enhance interpersonal functioning.
Psychosocial Treatment of Schizophrenia
Figure 13.10 Barlow/Durand, 3rd. EditionStudies on treatment of schizophrenia from 1980 to 1992
Summary of Schizophrenia and Psychotic Disorders
Figure 13.x1 Barlow/Durand, 3rd. Ed.Exploring schizophrenia and its treatment
Summary of Schizophrenia and Psychotic Disorders (cont.)
Figure 13.x1 Barlow/Durand, 3rd Edition (cont.)Exploring schizophrenia and its treatment
Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Brief Psychotic Disorder Shared Psychotic Disorder
Folie a Deux
Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Brief Psychotic Disorder Shared Psychotic Disorder
Folie a Deux