Chapter 12 Schizophrenia

Extra Credit Opportunity

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Research Paper

• Research paper worksheet 1 is due extended to Wednesday 3/12/25
• Understanding how to find, read, and interpret data, and interpret results is key.
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Psychosis

• Psychosis is a state where a person loses touch with reality.
• It most often occurs in schizophrenia patients, but can appear in other cases.

Schizophrenia

• Schizophrenia is a psychotic disorder involving deterioration of personal, social, and occupational functioning.
• Deterioration is a result of unusual perceptions, odd thoughts, disturbed emotions, and motor irregularities.
• Schizophrenia presents myriad symptoms varying from patient to patient.
• Schizophrenia may be a cluster of distinct disorders sharing traits.

Symptom Categories

• Symptoms are split into positive and negative categories.
• The textbook identifies a third category, psychomotor symptoms, but it is more common to use two categories.
• Positive symptoms are "added" to typical thoughts and behavior.
• Negative symptoms represent a "loss", a deficiency of typical thoughts and behavior.

Positive Symptoms

• Positive symptoms are pathological excesses/bizarre additions to a person's cognition, emotion, and behavior.
• Delusions
• Hallucinations
• Disorganized thinking and speech
• Incongruent affect
• Disorganized behavior

Delusions

• Delusions are strange, firmly held false beliefs, despite contrary evidence.
• Persecutory delusions involve the belief of being harmed, harassed, or conspired against, and these are the most common. Example: "The FBI and local police are conspiring to catch me in a sting operation."
• Referential delusions involve the belief that gestures/comments/environmental cues are directed at oneself, also very common. Example: "The strangers laughing at the café are secretly making fun of me."
• Grandiose delusions involve the belief of possessing exceptional abilities/wealth/fame. Example: "I have been chosen by God to save humanity, and I have secret powers."
• Erotomanic delusions are false beliefs that another person is in love. Example: "A famous actor is secretly in love with me and sending me signals through their movies."
• Somatic delusions involve preoccupation with health/organ function while believing in a severe while unverified medical condition. Example: "My liver has completely stopped working, even though my doctor says it's fine."
• Delusions of control involve the belief of one's body or actions being manipulated by an external force. Example: "A secret agency is controlling my movements and making me walk places I don't want to go."
• Thought insertion is the belief that foreign thoughts are being placed into one's mind. Example: "The government is planting evil thoughts in my head."
• Thought broadcasting is the belief that one's thoughts are being broadcast so others can hear them. Example: "Everyone around me can hear my thoughts when I think them."
• Delusions of reference might be a key foundation for many delusions.
• Some rare forms of delusions include Nihilistic delusion/Cotard's Syndrome: belief that oneself/world does not exist/is dead. Example: “I'm dead. I live in a graveyard."
• Capgras Syndrome is the belief that a loved one/close person has been replaced by an identical impostor. Example: “My mother looks like my mother, but she is actually a clone sent to spy on me.”

Hallucinations

• Hallucinations are sensory perceptions occurring without external stimuli.
• Auditory hallucinations are most common, often giving commands.
• Other types of Hallucinations include: visual, olfactory, gustatory, somatic, and tactile.
• A PET scan shows activity in Broca's area and auditory cortex, but not source-identifying areas in the frontal lobe.
• Patients may hear the sounds their brains produces, but are unable to tell where they originate from.
• Hallucinations and delusions typically occur.

Disorganized Thinking and Speech

• Formal thought disorder refers to disorganized thinking when speaking in peculiar ways.
• Derailment involves thoughts shift between unrelated topics with little connection. Example: "I went to the store to buy milk. The cows are in the field. The sun is shining bright today."
• Tangentiality involves responses stray from the topic/never reach the intended point. Example, in response to the question, "How is your sleep?": "Sleep is important. Beds are soft. I once saw a bed in a furniture store."
• Circumstantiality involves speech including excessive unnecessary details, but eventually reaching the point. Example, in response to the question, "How did you get hurt?": “I have dog—he’s a Labrador, I got him from my cousin, who’s a lawyer, we went to Yosemite last winter. I tripped when walking the dog this morning."
• Neologisms involves inventing new, nonsensical/word combining words. Example: calling "hat" as “headshoe" or saying, "The flibberfloon is watching me.”
• Clang Associations involves speech based on sound/rhyming/alliteration rather than meaning. Example: "The car is far on a star in a jar."
• Incoherence/Word Salad involves random mixtures of words lacking structure/meaning. Example: "Blue dog runs apple sky jump banana."
• Perserveration repeating the same word/phrase persistently, even when irrelevant. Example, in response to the question "Where do you live?": "New York… New York… New York…"

Incongruent Affect

• Incongruent affect is situationally unsuitable.
• Examples of Incongruent affect: laughing at sad situations, or an abrupt/unforeseen shift in mood
• Can be an emotional response to disorder features, like affect towards delusion/hallucination, not reality.

Disorganized Behavior

• Disorganized behavior manifests in diverse ways, like childlike "silliness” to unpredictable agitation such as awkward movements, repeated grimaces, and odd gestures.
• Catatonia is an extreme form characterized by decreased reactivity to the environment.

Catatonia

• Negativism: resistance to instructions
• Mutism: complete lack of verbal responses
• Stupor: complete lack of motor responses
• Posturing/Catalepsy: maintaining a rigid, inappropriate or bizarre posture, sometime against gravity
• Waxy flexibility: patient can be positioned by the examiner, allowing limbs to remain in imposed positions
• Catatonic excitement: purposeless and excessive motor activity without obvious cause

Negative Symptoms

• Negative symptoms include pathological deficits, lacking traits most people have.
• The five "A"s of negative symptoms:
  • Affective flattening
  • Alogia
  • Anhedonia
  • Asociality
    • Avolition
• Affective flattening involves less emotion than most people, such as an immobile face, avoidance of eye contact, and monotonous voice,
• Alogia involves poverty of speech, such as a reduction of the quantity of speech content that says very little.
• Anhedonia is defined as loss of pleasure in doing things and can be similar to what is observed in a depressive state.
• Asociality is social withdrawal.
• Withdrawal from the social environment focuses only on own ideals and fantasies.
• Withdrawal leads to lack of social skills, especially with understanding of the needs of the emotions of others.
• Avolition represents a lack of motivation, or apathy.
• There are feelings of draining and loss of interest of goals.
• There's an inability to start or follow through on the course of action.
• Its difficult performing most things in daily life such as personal hygiene.

Diagnosing Schizophrenia

• Display two or more of the criteria much of the time for one month, some of which must be delusions, hallucinations, or disorganized speech.
• Display one or more: delusions, hallucinations, disorganized speech, disorganized behavior.
• Negative symptoms
• Individual functions much more poorly when compared to prior to having symptoms.
• Individual must display some impaired functioning for at least 5 additional months beyond the initial month.
• All other possible causes of the symptoms must be ruled out such as substance abuse, mood disorders, and autism.

Schizophrenia Spectrum Disorders

• Schizophreniform Disorder: Is similar to Schizophrenia except only require one month of intensive symptoms. Does not last to 6 months symptoms including prodromal, active, and residual phases.
• Brief Psychotic Disorder: Having symptoms of delusion, hallucination or disorganized speech. For at least 1 day, but less than 1 month.
• Schizoaffective Disorder: Exhibit symptoms of schizophrenia and recurrent symptoms for the duration of the illness. Psychotic symptoms should continue for at least two weeks in the absence of the psychotic symptoms. Does not have significant mood component.
• Delusional Disorder: Have symptoms of delusion for more than 1 month and no other psychotic symptoms.

Clinical Picture and Diagnosis

• Schizophrenia first appears in the late teens and mid-thirties.
• The disorder affects both men and women equally, with a 1% life prevalence
• There are three phases of schizophrenia:
  • Prodromal: Beginning of deterioration; mild symptoms.
  • Active: Symptoms become apparent.
  • Residual: Return to prodromal-like levels.
• A distinction between Type 1 and Type 2 schizophrenia helps predict the course of the disorder.
  • Type I schizophrenia is dominated by positive symptoms, about 80-85%.
  • Type II schizophrenia is dominated by negative symptoms, about 15-20%.

Biological Views

• Inheritance and brain activity play key roles in schizophrenia's development.
• Genetic factors include relatives of people with schizophrenia and direct genetic linkage research and molecular biology.
• Viral problems include exposure to viruses before birth, interrupted fetal brain development, supported by animal models, and involving links to the late winter birth.
• Circuits including the prefrontal cortex, hippocampus, amygdala, thalamus, striatum, and substantia nigra, are key and the interconnectivity among different parts are problematic.
• The dopamine hypothesis indicates high levels of neurotransmitter dopamine may be related to psychosis.
• Certain neurons using dopamine fire too often, producing schizophrenia symptoms.
• Phenothiazine, the first antipsychotic medication, was found unexpectedly.
• Patients on phenothiazine developed symptoms like Parkinson's disease, due to low level of dopamine.
• Parkinson's disease patients, when given L-dopa, developed psychotic symptoms.
• Antipsychotic medications act as dopamine antagonists that occupying dopamine receptor sites on the neuron, to prevent dopamine binding.
• Five dopamine receptors: D1-D5
• Phenothiazine bind most strongly to D2 receptors.
• Second-generation antipsychotic medications bind to D-1 receptors, and to other receptors like serotine, glutamate, and GABA.

Antipsychotic Drugs

• Antipsychotic medications were discovered in the 1950s as antihistamines and calmers for surgery patients.
• Chlorpromazine was tested and tested for patients with psychosis which resulted in sharp symptom reduction.
• Chlorpromazine was approved for sale in 1954.
• First-generation antipsychotic drugs (neuroleptic drugs) include thioridazine (Mellaril), fluphenazine (Prolixin), trifluoperazine (Stelazine), and haloperidol (Haldol).
• Symptoms reduce in about 70 percent of patients diagnosed with schizophrenia on antipsychotics.
• Positive symptoms of schizophrenia are reduced more completely/quickly than negative symptoms.
• Extrapyramidal effects (DSM-5-TR: antipsychotic medication-induced movement disorder) area unwanted effect of first-generation antipsychotics.

Extrapyramidal effects

• Parkinsonian and related symptoms: tremors, muscle rigidity, shake, move slowly, muscle contractions (dystonia), restlessness (akathisia); patients often need to take antiparkinson drug.
• Tardive dyskinesia: late-appearing movement disorder, often after six months of taking medication; involuntary tongue/lips/face/hand/leg/body movements.

Second-generation atypical antipsychotic drugs

• Risperidone (Risperdal)
• Clozapine (Clozaril)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Iloperidone (Fanapt)
• Lurasidone (Latuda)
• Paliperidone (Invega)
• Asenapine (Saphris)
• Second-generation antipsychotics differ from first-generation agents in that it is received fewer Dopamine D2 receptors and more D1 and serotin receptors, is at least as effective or often more, reduce positive some negative symptoms, cause fewer extrapyramidal symptoms, and less tardive dyskinesia

Other contributing factors

• Diagnostic rates of schizophrenia are higher in some minority populations, such as in LGBTQ+ population, BIPOC population, and immigrants, possibly due to minority stress, as well as overdiagnosis and biases by clinicians.
• Schizophrenia is linked to family stress, especially families with high expressed emotions (e.g., conflicts, criticism, disapproval, etc.), leading to high expressed emotion and relapse.
• Schizophrenia includes a genetic predisposition due to a dysfunctional brain circuit and significant life stressors, including difficult family interactions, or negative environmental factors.

The developmental psychopathology view of the disorder

• The impact of a dysfunction brain circuit impacts the the hypothalamic-pituitary- adrenal (HPA) stress pathway.
• Chronic stress reactions lead to adysfunctional immune system, characterized by heightened inflammation throughout the brain, indicating diathesis-stress model.

Treatments

• Asylum care occurred between 1845 and 1955 which saw overcrowding, lobotomy, and understaffing.
• An Improvement movement occurred in the 1950s, as Milieu therapy, which was based on the humanistic and behavior principles.

More improved community programs and therapies

• Milieu therapy was an important feature by promoting patient communication, self-respect, but also individual responsibility.
• Token economy system helped with rewards and patients were open to positive reinforcement.
• Positive and non-violent treatments were effective in the community.
• Early methods of therapy were rare, with treatment being developed after the anti psychosis therapies.
• Cognitive therapies help to re-train patients as well as learn some job related exercises to improve skill and positive health choices.

Coordinated care

• A social community that is helpful for giving patients access as well as being able to talk to therapist for improving their health.
• Hallucination Therapists help guide patients improve and change the ways to react to their hallucinations.
• Improving on making sense of self control and helping improve over time.

Family and other community support

• Patients, communities live in support with family while express and emotions, stress and empathy.
• Helpful methods include drug therapy and reducing hospital readmissions.

Community Approach

• In 1963 congress past community health. Patients could have options after the variety of problems can lead to different mental services.

• Community treatment failure: There was a small numbers as well as people got treated that were to late

• Coordinated services , short term , and group houses helped to change this problem.

• Treatment was necessary but the majority or all people can improve for positive reinforcement to get back to normal lives