Schizophrenia + Treatments

Introduction to Psychopathology

• Lecture notes copyright 2014, 2019, 2020, 2023, 2024, by Alan J. Fridlund, Ph.D.
• All rights reserved
• Copies permitted for internal student use in UCSB Psych 183
• For-profit reproduction prohibited without instructor permission
• Violates UC regulations and DMCA

Notice

• All course materials (lectures, discussions, handouts, examinations, web materials) are protected by US Federal Copyright Law and California Civil Code.
• Students cannot record lectures or distribute/sell course materials without written permission.

DSM-5-TR "Schizophrenia Spectrum and Other Psychotic Disorders"

• This is a section on classification systems concerning mental illnesses and disorders concerning psychosis.

What Defines a "Psychotic Disorder"?

• Delusions: Fixed beliefs not altered by conflicting evidence (grandiose, persecutory, somatic, religious, nihilistic, etc).
• Hallucinations: Vivid perceptual experiences without external stimulus (hearing voices, seeing things, intense smells or tastes).
• Disorganized thinking: Derailment, loose associations, neologisms, tangentiality, incoherence ("word salad").
• Disorganized motor behavior: Chaotic or bizarre movements, postures, stereotyped repetitive movements.

Major Disorders within DSM-5-TR "Schizophrenia Spectrum and Other Disorders"

• Schizotypal Personality Disorder: A personality disorder that can sometimes include delusional thinking.
• Delusional Disorder: One or more delusions lasting for at least a month, without other psychotic symptoms.
• Brief Psychotic Disorder: Presence of delusions, hallucinations, or disorganized speech or behavior, lasting less than one month. Half of people recover, but a significant portion relapse.
• Schizoaffective Disorder: History of either major depression or mania/hypomania in individuals with a diagnosis of schizophrenia.
• Substance/Medication-Induced Psychotic Disorder: Psychotic symptoms caused by substance use or medication side effects. (e.g., cannabis, amphetamines, cocaine, hallucinogens, opioids, etc.)

What is Schizophrenia?

• A disorder where psychotic symptoms are predominant.
• Affects approximately 1-2% of the population across cultures.
• Accounts for a significant portion of psychiatric inpatients and first admissions to mental hospitals.
• Historically a leading cause of homelessness (often surpassed by substance abuse epidemics).
• Causes significant impairment, as high as 30% attempting suicide, with an even greater percentage among unemployed males with depression.
• Diagnosed mid-19th Century.
• Morel (1860): "Dementia praecox" (premature dementia)
• Kraepelin (1898) : "Dementia praecox"
• Bleuler (1911): Schizophrenia ("shattered mind")

Risk Factors: Who Becomes Schizophrenic?

• Genetic relatedness: Increased risk with consanguinity.
• Twin concordance: Significantly higher in identical twins compared to fraternal twins (MZ > DZ).
• Environmental factors: Prenatal/perinatal complications like prolonged labor, forceps delivery, and maternal malnutrition
• Maternal Influenza: Higher risk with exposure during the 6th month of gestation.
• Seasonality: Higher likelihood of developing schizophrenia depending on the time of year of birth, often in the winter.
• Cannabis: Increased risk with adolescent marijuana use.
• Other infectious agents: Factors like rubella (German measles) and toxoplasmosis may influence.

Early views of Schizophrenia

• Metabolic disorder
• Double-binding mother

Typical Features of Schizophrenia

• Loss of previous functioning: Gradual or acute onset, which may indicate a better prognosis (acute)
• Disturbed language: Tangential, incoherent, rambling speech, often with private meanings
• Thought disorders: Formal thought disorder, altered thought boundaries (thought broadcasting/insertion/removal)
• Emotionality: Flat, inappropriate, or bizarre affect
• Social withdrawal: purposeless wandering
• Motor abnormalities: Reduced spontaneity, bizarre/stereotyped gestures, catatonia
• Other features (positive): Hallucinations/delusions (negative): Social withdrawal/flat affect

What Is the Damage in Schizophrenia?

• Early views (discredited): metabolic disorder, double binding. Modern studies indicate structural brain damage.
• Cellular derangement: Loss of gray matter, enlarged ventricles (loss is significantly faster with heavy and early cannabis use) . Loss of prefrontal white matter.
• Disordered brain activity: Abnormal function evident in PET and fMRI neuroimaging studies, impacting frontal/temporal language areas, basal ganglia, and cerebellum.
• Neurotransmitter dysfunction: Dopamine hypothesis (overactive dopamine pathways in schizophrenia compared to healthy individuals) , interactions between dopamine and serotonin.

Positive vs. Negative Symptom -Predominant Schizophrenia

• Positive symptoms: often characterized by excesses or distortions of normal functions. (e.g., delusions, hallucinations, disorganized speech) tend to increase in the later stages of life
• Negative symptoms: often involve deficits or reductions of normal functions. (e.g., flat affect, avolition, alogia, anhedonia, asociality) tend to decrease in the later stages

Positive-Symptom Schizophrenia and Parkinson’s Disease: The Dopamine (DA) Seesaw

• Drugs increasing brain DA turnover can resemble positive symptoms in schizophrenia
• Classical antipsychotics lower DA turnover ("blocking"), inducing Parkinson's-like motor symptoms.
• Individuals with Parkinson's taking medications to increase DA levels may experience psychotic symptoms.
• Serotonin (5-HT) is involved, with modern antipsychotics affecting both DA and 5-HT systems

Treatments for Schizophrenia

• Medication: Acute treatment (sedution/chemical restraint), long-term normalization. Compliance is often below 30%.
• Individual and Family Psychotherapy: Addressing patient adjustment and symptoms. Specific approaches include families/friends.
• Symptom Self-monitoring: Building patient compliance.
• Supervised living/rehab: Assisted outpatient programs, halfway houses, day hospitals.

Medication for Schizophrenia

• Classical antipsychotics (Haldol, Prolixin, Mellaril and Thorazine): Historically used primarily. These are generally not first-line treatments now.
• Second-generation antipsychotics (Atypical) (Abilify, Clozaril, Geodon, Invega, Latuda, Risperdal, Seroquel, Vraylar, and Zyprexa): Used more frequently due to fewer side effects and improved efficacy for negative symptoms.
• Cobenfy: A new medication targeting muscarinic receptors that has promising results for treating both positive and negative symptoms, but treatment cost and further efficacy and side effects still require further research

Side Effects of Antipsychotic Medications

• Drowsiness/sedation (often beneficial in agitated patients)
• Increased risk of metabolic syndrome (weight gain, dysregulated blood lipids, and glucose)
• Movement side effects (akathisia, pseudoparkinsonism, tardive dyskinesia): more common with older antipsychotics.

Other Disorders in Which Antipsychotic Medications Are Sometimes Used

• Major depression with psychotic features
• Severe generalized anxiety disorder that doesn't respond to anti-anxiety medication
• Bipolar disorder
• Personality disorders (paranoid, schizoid, schizotypal).
• Borderline personality disorder (temporary psychotic episodes)
• Acute and Post-traumatic stress disorders (paranoid episodes)

Is Schizophrenia a Violent Disorder?

• It's a misconception that schizophrenia is inherently violent.
• Prior history of violence and drug/alcohol abuse are better predictors of violent behavior.
• In individuals with schizophrenia, violence more often leads to non-compliance with medication and experiences with "command hallucinations" that order violent action

Prognosis in Schizophrenia

• Historically, a rule of thirds (1/3 improve, 1/3 stay the same, 1/3 deteriorate)
• Prognosis may be worse with accurate diagnoses of Bipolar disorder misdiagnosed as schizophrenia.
• Medication has been increasingly effective
• Incidence is declining likely due to better prenatal/infant nutrition, and public health initiatives

Hallucinations in Schizophrenia

• Primarily auditory (malevolent/taunting voices, command hallucinations)
• Also visual, tactile, or olfactory, often indicative of other medical issues (seizures, drug abuse, toxic encephalopathy).

Seasonality of Births of Individuals Later Diagnosed with Schizophrenia

• Increased likelihood of birth during certain periods of the year.

This quiz covers material from the DSM-5-TR on schizophrenia spectrum and other psychotic disorders, highlighting symptoms like delusions and hallucinations.