Psychology Chapter on Schizophrenia

Schizophrenia Spectrum and Other Psychotic Disorders

• The word schizophrenia is derived from the Greek words skhizo (split) and phren (mind).
• Schizophrenia requires comprehensive, multidisciplinary treatment.
• It is one of the most costly mental illnesses, causing lengthy hospitalizations, family distress, and significant financial burden for individuals and governments.
• Schizophrenia causes disturbances in thought processes, perception, and affect.
• The lifetime prevalence of schizophrenia in the United States is about 1%.

Phases of Schizophrenia

• Phase 1 (Personality/Premorbid phase): Characterized by shy, withdrawn behavior, poor peer relationships, difficulties in school, and sometimes antisocial behavior.
• Phase 2 (Prodromal phase): Lasts from weeks to years, marked by deterioration in role functioning and social withdrawal; substantial functional impairment also occurs. Symptoms include depressed mood, poor concentration, fatigue, and sudden onset of obsessive-compulsive behaviors.
• Phase 3 (Acute schizophrenic episode): Psychotic symptoms are prominent, including delusions and hallucinations, and impairment in work, social relations, and self-care.
• Phase 4 (Residual phase): Similar to the prodromal phase, with symptoms like flat affect and impairment in role functioning.

Prognosis

• Positive prognosis factors include good premorbid functioning, later age of onset, female gender, abrupt onset precipitated by a stressful event, associated mood disturbance, and brief duration of active-phase symptoms.
• Continued positive prognosis factors include minimal residual symptoms, absence of structural brain abnormalities, normal neurological functioning, and no family history of schizophrenia.

Predisposing Factors

• Biological: Genetics (5-10%)
• Biochemical: One theory suggests schizophrenia may be caused by an excess of dopamine activity in the brain. Abnormalities in other neurotransmitters are also possible.

Physiological Factors

• Viral infection
• Anatomical abnormalities
• Electrophysiology
• Epilepsy
• Huntington's disease
• Birth trauma
• Head injury in adulthood
• Alcohol abuse
• Cerebral tumor
• Cerebrovascular accident
• Systemic lupus erythematosus

Psychological Factors

• Psychosocial theories lack biological credibility.
• Sociocultural factors like poverty may influence schizophrenia development. The idea of 'downward drift' is controversial, suggesting poor socioeconomic conditions as a consequence, rather than a cause, of the disorder.
• Schizophrenia is most likely a combination of biological and environmental factors.

Types of Schizophrenia and Other Psychotic Disorders

• Delusional disorder: Characterized by prominent, non-bizarre delusions (e.g., erotomanic, grandiose, jealous, persecutory, somatic, mixed).
• Brief psychotic disorder: Sudden onset of symptoms, lasting less than a month, often triggered by a psychosocial stressor. Patient returns to baseline functioning after the event.
• Substance/medication-induced psychotic disorder: Hallucinations or delusions directly caused by substance intoxication or withdrawal.
• Psychotic disorder due to another medical condition: Hallucinations and delusions associated with a general medical condition.
• Catatonic disorder due to another medical condition: Catatonic symptoms due to the physiological consequences of a general medical condition.
• Schizophreniform disorder: Shares symptoms with schizophrenia but lasts for at least one month but less than six months.
• Schizoaffective disorder: Schizophrenic symptoms accompanied by mood episodes (mania or depression).

Positive Symptoms

• Content of thought: Delusions (fixed, false personal beliefs), persecutory, grandiose, somatic, erotomanic, and jealous delusions.
• Form of thought:
  • Associative looseness
  • Neologisms
  • Concrete thinking
  • Clang associations
  • Word salad
  • Circumstantiality
  • Tangentiality
  • Mutism
  • Perseveration
• Perception: Hallucinations (false sensory perceptions), auditory, visual, tactile, gustatory, olfactory, and illusions (misperceptions).
  • Echopraxia (repeating movements seen in others)

Negative Symptoms

• Affect: Inappropriate affect (emotions incongruent with circumstances), blunt/flat affect (weak emotional tone); apathy (lack of interest).
• Avolition: Inability to initiate goal-directed activity.
• Emotional ambivalence: Coexistence of conflicting emotions.
• Deterioration in personal appearance (poor personal hygiene)
• Impaired interpersonal functioning: Difficulty with social relationships, clinging, intruding on personal space. Social isolation: Focusing inward
• Lack of insight, Anergia (lack of energy): Deficiency of energy. Anhedonia: Inability to experience pleasure. Lack of abstract thinking:
• Associated features:
  • Waxy flexibility
  • Posturing
  • Pacing and rocking
  • Regression
  • Eye movement abnormalities

Nursing Diagnoses

• Related to schizophrenia:* Disturbed sensory perception, disturbed thought processes, social isolation, risk for violence (self-directed or other-directed), impaired verbal communication, and self-care deficit. Also consider possible family coping issues.

Management of Illness

• Connection of exacerbation of symptoms to stress periods
• Appropriate medication management
• Side effects of medication
• Importance of not stopping medications
• When to contact healthcare provider
• Relaxation techniques
• Social skills training
• Daily living skills training

Support Services

• Financial assistance
• Legal assistance
• Caregiver support groups
• Respite care
• Home healthcare

Treatment Modalities (Psychological)

• Individual psychotherapy (long-term, difficult due to interpersonal impairment)
• Group therapy (some success in long-term)
• Behavior therapy (challenging to generalize outside treatment setting)

Social Treatments

• Social skills training (role-playing for appropriate social behaviors, eye contact, communication)
• Family therapy (help family members cope with long-term illness)

Program of Assertive Community Treatment (ACT)

• Team approach for comprehensive community-based psychiatric care, rehabilitation, and support, focused on serious, persistent mental illness.

Recovery Model

• A concept of healing and transformation, enabling persons with mental illness to live a meaningful life in the community while striving to achieve his or her full potential.
• Supported by recovery research as an obtainable objective for individuals with schizophrenia.

Recovery After an Initial Schizophrenia Episode (RAISE)

• Case management program. A team approach to providing comprehensive, community-based psychiatric treatment, rehabilitation, and support.

Psychopharmacology

• Refer to Chapter 4 and pages 367-370 (in the text).