Chapter 7 Psychotic Disorders PDF

9/1/2024 Copyright Notice Do not remove this notice. 1 CHAPTER 7 PSYCHOTIC DISORDERS Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd R...

9/1/2024 Copyright Notice Do not remove this notice. 1 CHAPTER 7 PSYCHOTIC DISORDERS Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-2 2 1  9/1/2024 LEARNING OBJECTIVES 7.1 Outline the defining symptoms of psychosis 7.2 Describe the symptoms of the various DSM-5 psychotic disorders and the problems associated with psychosis 7.3 Describe the evolution in the diagnostic criteria for schizophrenia and the controversies in the field regarding this diagnosis 7.4 Outline the prevalence, age of onset and stages of psychosis 7.5 Describe the range of factors implicated in the aetiology of psychosis 7.6 Describe the main treatment priorities in relation to the phases of psychosis and the range of evidence-based treatment options Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-3 3 Historical Conceptualisations of Psychotic Disorders Kraeplin identified 'dementia praecox', meaning 'senility of the young'. Bleuler coined the term 'schizophrenia' meaning 'split mind'. Schneider argued for 'first rank symptoms' that were specific to schizophrenia. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-4 4 2  9/1/2024 Schizophrenia(s) “For the sake of convenience, I use the word in the singular although it is apparent that the group includes several diseases” (Eugen Bleuler, 1911) Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-5 5 Psychotic Disorders Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-6 6 3  9/1/2024 DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Schizophreniform Disorder Brief Psychotic Disorder Schizoaffective Disorder Delusional Disorder Schizotypal (Personality) Disorder Substance-Induced Psychotic Disorder Psychotic Disorder due to a medical condition. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-7 7 DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Schizophreniform Disorder Brief Psychotic Disorder Schizoaffective Disorder Delusional Disorder Schizotypal (Personality) Disorder Substance-Induced Psychotic Disorder Psychotic Disorder due to a medical condition. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-8 8 4  9/1/2024 Key Features of the Psychotic Disorders: Delusions Hallucinations Disorganised Thinking Disorganised or Abnormal Motor Behaviour Negative Symptoms Important to remember that “psychosis” is not limited to psychotic disorders. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-9 9 Principal Psychotic Experiences Delusions: – Firmly held beliefs opposed to reality but maintained in spite of strong evidence to the contrary. Hallucinations: – a perceptual experiences involving perceiving something that is not there (positive) or not perceiving something that is there (negative). Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-10 10 5  9/1/2024 Delusions - Longer Definition A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture (e.g., it is not an article of religious faith). When a false belief involves a value judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility. Delusional conviction occurs on a continuum and can sometimes be inferred from an individual’s behavior. It is often difficult to distinguish between a delusion and an overvalued idea (in which case the individual has an unreasonable belief or idea but does not hold it as firmly as in the case with a delusion). Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-11 11 Kinds of Delusions Bizarre: A delusion that involves a phenomenon that the person’s culture would regard as totally implausible. Delusional jealousy: The delusion that one’s relational partner is unfaithful. Erotomanic: A delusion that another person, usually of higher status, is in love with the individual. Grandiose: A delusion of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-12 12 6  9/1/2024 Kinds of Delusions of being controlled: A delusion in which feelings, impulses, thoughts, or actions are experienced as being under the control of some external force rather than being under one’s own control. of Reference: A delusion whose theme is that events, objects, or other persons in one’s immediate environment have a particular and unusual significance. These delusions are usually of a negative or pejorative nature, but also may be grandiose in content. This differs from an idea of reference, in which the false belief is not as firmly held nor as fully organized into a true belief. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-13 13 Kinds of Delusions Persecutory: A delusion in which the central theme is that one (or someone to whom one is close) is being attacked, harassed, cheated, persecuted, or conspired against. Somatic: A delusion whose main content pertains to the appearance or functioning of one’s body. Thought broadcasting: The delusion that one’s thoughts are being broadcast out loud so that they can be perceived by others. Thought insertion: The delusion that certain of one’s thoughts are not one’s own, but rather are inserted into one’s mind. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-14 14 7  9/1/2024 Delusional Content in Various Disorders Schizophrenia – Variety of often bizarre content – Being controlled or persecuted by others – Finding reference to oneself in other’s behavior or in printed materials Depressive Disorders – Unjustified guilty – Perceived bodily changes Bipolar Disorders (Mania) – Great self-importance – Grandiosity Delusional disorder – Loved by celebrity/high-status person – Suspect spouse or lover of being unfaithful – Possession of special and unrecognized talent – These are all non-bizarre Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-15 15 Key Features of the Psychotic Disorders: Delusions Hallucinations Disorganised Thinking Disorganised or Abnormal Motor Behaviour Negative Symptoms Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-16 16 8  9/1/2024 Hallucinations – Longer Definition A sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Hallucinations should be distinguished from illusions, in which an actual external stimulus is misperceived or misinterpreted. A person may or may not have insight into the fact that he or she is having a hallucination. One person with auditory hallucinations may recognize that he or she is having a false sensory experience, whereas another may be convinced that the source of the sensory experience has an independent physical reality. The term hallucination is not ordinarily applied to the false perceptions that occur during dreaming, while falling asleep (hypnogogic), or when awakening (hypnopompic). Transient hallucinatory experiences may occur in people without a mental disorder. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-17 17 Kinds of Hallucinations Auditory: A hallucination involving the perception of sound, most commonly of voices. Some clinicians and investigators would not include those experiences perceived as coming from inside the head and would instead limit the concept of true auditory hallucinations to those sounds whose source is perceived as being external. However, as used in the DSM, no distinction is made as to whether the source of the voices is perceived as being inside or outside of the head. Gustatory: A hallucination involving the perception of taste (usually unpleasant). Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-18 18 9  9/1/2024 Kinds of Hallucinations Olfactory: A hallucination involving the perception of odor, such as burning rubber or decaying fish. Somatic: A hallucination involving the perception of a physical experience localized within the body (such as a feeling of electricity). A somatic hallucination is to be distinguished from physical sensations arising from an as-yet undiagnosed medical condition, from hypochondriacal preoccupation with normal physical sensations, and from a tactile hallucination. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-19 19 Kinds of Hallucinations Tactile: A hallucination involving the perception of being touched or of something being under one’s skin. The most common tactile hallucinations are the sensation of electric shocks and formication (the sensation of something creeping or crawling on or under the skin). Visual: A hallucination involving sight, which may consist of formed images, such as of people, or of unformed images, such as flashes of light. Visual hallucinations should be distinguished from illusions, which are misperceptions of real external stimuli. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-20 20 10  9/1/2024 Key Features of the Psychotic Disorders: Delusions Hallucinations Disorganised Thinking Disorganised or Abnormal Motor Behaviour Negative Symptoms Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-21 21 Disorganised Thinking in Psychotic Disorders Disorganisation Loosening of associations Confusion Disturbances in logical sequencing and coherence of thought Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-22 22 11  9/1/2024 PLAY VIDEO Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-23 23 Key Features of the Psychotic Disorders: Delusions Hallucinations Disorganised Thinking Disorganised or Abnormal Motor Behaviour Negative Symptoms Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-24 24 12  9/1/2024 Disorganised Behaviour Grossly disorganised or catatonic behaviour – Catatonia refers to a number of symptoms such as stupor, catalepsy, mutism, odd mannerism, waxy flexibility and stereotypic movements. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-25 25 Disorganised Behaviour Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-26 26 13  9/1/2024 Key Features of the Psychotic Disorders: Delusions Hallucinations Disorganised Thinking Disorganised or Abnormal Motor Behaviour Negative Symptoms Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-27 27 Positive and Negative Symptoms Positive – Delusions – – Hallucinations – – Disordered speech – Disorganised and bizarre behavior Negative – Flat affect – Poverty of speech – Lack of motivation or directedness – Loss of energy – Loss of feelings of pleasure Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-28 28 14  9/1/2024 DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders As with previous chapters, with various disorders, I will try to cover: – General Description (diagnostic criteria, etc.) – Epidemiology of schizophrenia – Aetiology (causes), with focus on schizophrenia – Treatment Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-29 29 DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Schizophreniform Disorder Brief Psychotic Disorder Schizoaffective Disorder Delusional Disorder Schizotypal (Personality) Disorder Substance-Induced Psychotic Disorder Psychotic Disorder due to a medical condition. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-30 30 15  9/1/2024 DSM-5-TR Diagnostic 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 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms. B. For a significant portion of the time since the onset of the disturbance, 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). Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-31 31 DSM-5-TR Diagnostic Criteria for Schizophrenia 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 prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms 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 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. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-32 32 16  9/1/2024 DSM-5-TR Diagnostic Criteria for Schizophrenia E. The disturbance is not attributable to the physiological effects of a substance or another medical condition. F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated). Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-33 33 PLAY VIDEO Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-34 34 17  9/1/2024 Schizophrenia Subtypes These were eliminated with DSM-5 but may still be meaningful. Disorganised – Incoherence, disorganized speech and behavior – Flat or inappropriate affect Catatonic – Prolonged immobility or purposeless agitation Paranoid – Delusions, hallucinations related to persecution or grandiosity – No other obvious cognitive deficits Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-35 35 Schizophrenia Subtypes Diagnosis of subtypes difficult – Reliability low Poor predictive validity for some Overlap of symptoms among subtypes Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-36 36 18  9/1/2024 DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Schizophreniform Disorder Brief Psychotic Disorder Schizoaffective Disorder Delusional Disorder Schizotypal (Personality) Disorder Substance-Induced Psychotic Disorder Psychotic Disorder due to a medical condition. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-37 37 DSM-5-TR Diagnostic 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 successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms. 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. Other Psychotic or mood disorders ruled out. D. Not attributable to drugs or a medical condition. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-38 38 19  9/1/2024 DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Schizophreniform Disorder Brief Psychotic Disorder Schizoaffective Disorder Delusional Disorder Schizotypal (Personality) Disorder Substance-Induced Psychotic Disorder Psychotic Disorder due to a medical condition. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-39 39 DSM-5-TR Diagnostic Criteria for Brief Psychotic Disorder A. Presence of one of the following symptoms. At least one of these must be (1), (2), or (3). 1. Delusions. 2. Hallucinations. 3. Disorganized speech. 4. Grossly disorganized behaviour. 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 or another medical condition. Can specify with or without marked stressors or with post-partum onset. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-40 40 20  9/1/2024 DSM-5-TR Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Schizophreniform Disorder Brief Psychotic Disorder Schizoaffective Disorder Delusional Disorder Schizotypal (Personality) Disorder Substance-Induced Psychotic Disorder Psychotic Disorder due to a medical condition. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-41 41 DSM-5-TR Diagnostic 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 (the active phase) of schizophrenia. B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the same 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. Not attributable to drugs or a medical condition. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-42 42 21  9/1/2024 DSM-5-TR Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Schizophreniform Disorder Brief Psychotic Disorder Schizoaffective Disorder Delusional Disorder Schizotypal (Personality) Disorder Substance-Induced Psychotic Disorder Psychotic Disorder due to a medical condition. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-43 43 DSM-5-TR Diagnostic 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. C. Apart from the impact of the delusion(s) or it’s 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…. Copyright © 2022 American Psychiatric Association Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-44 44 22  9/1/2024 Subtypes of Delusional Disorder Erotomanic type Grandiose type Jealous type Persecutory type Somatic type Also delusional symptoms in partner of individual with delusional disorder (folie à deux) Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-45 45 Folie à deux ("the folly of two")? Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-46 46 23  9/1/2024 DSM-5-TR Schizophrenia Spectrum and Other Psychotic Disorders As with previous chapters, with various disorders, I will try to cover: – General Description (diagnostic criteria, etc.) – Epidemiology of schizophrenia – Aetiology (causes), with focus on schizophrenia – Treatment Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-47 47 Epidemiology of Schizophrenia Lifetime prevalence is approx. 1–2 per cent For every three men who develop schizophrenia, two women will develop the disorder Increased prevalence rate among migrants, people living in developed nations, and for those born in urban (compared to rural) settings Peak onset is in late adolescence and early adulthood Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-48 48 24  9/1/2024 Epidemiology of Schizophrenia: Course Premorbid phase—presence of risk factors prior to the onset of any symptoms Prodromal phase—preliminary period of decline in mental state and functioning prior to onset Acute phase—active positive and negative symptoms Early recovery phase—associated with depression and anxiety Later recovery phase—challenges with reintegrating into social, recreational and vocational pursuits Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-49 49 Course of Schizophrenia Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-50 50 25  9/1/2024 Epidemiology of Schizophrenia: Course Relapse is associated with discontinuation of medication, substance abuse and poor premorbid history. High expressed emotion is strongly linked to relapse. Sizable minority of patients will suffer severe and enduring psychosis—this is usually associated with earlier and more gradual onset of symptoms, as well as substance abuse and personality traits Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-51 51 Epidemiology of Schizophrenia: Associated Features Patients with psychosis often experience depression. Suicide rates are very high in people with psychosis. Anxiety and trauma-related problems are common in people with psychosis. Substance abuse is common in people with psychosis and this can worsen the symptoms. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-52 52 26  9/1/2024 Epidemiology of Schizophrenia: Associated Features Quality of life is affected in people with psychosis, for example, 40–50 per cent of individuals with a psychotic disorder are unemployed. There is stigma associated with a diagnosis perpetuated by certain myths of the disorder such as increased risk of violence. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-53 53 DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders As with previous chapters, with various disorders, I will try to cover: – General Description (diagnostic criteria, etc.) – Epidemiology of schizophrenia – Aetiology (causes), with focus on schizophrenia – Treatment Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-54 54 27  9/1/2024 Aetiology of Schizophrenia Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-55 55 Family and Twin Genetic Studies Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-56 56 28  9/1/2024 Schizophrenia and Relatedness Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-57 57 Genetics of Schizophrenia Gottesman (1991) reviewed 13 studies – DZ = 17% MZ = 48% Torrey (1994) reviewed 8 methodologically sound studies – DZ = 6% MZ = 28% Higher concordance if proband is severely disturbed Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-58 58 29  9/1/2024 Genetics of Schizophrenia Twin Concordance Rates Disorder Identical Fraternal Huntington’s Disease 100 20 Down’s Syndrome 98 2 Epilepsy 61 10 Mental Retardation 60 9 Bipolar Disorder 56 14 Cerebral Palsy 40 0 Autism 36 0 Schizophrenia 28 6 Multiple Sclerosis 27 2 Parkinson’s Disease 0 7 Adapted from Torrey, 1992 Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-59 59 Genetics of Schizophrenia And interestingly – For 89% of all people diagnosed with schizophrenia neither parent will have schizophrenia and 63% will have no 1st or 2nd degree relative with the disorder Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-60 60 30  9/1/2024 Genain Quadruplets Genain = Dreadful Gene Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-61 61 Nora, Iris, Myra and Hester Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-62 62 31  9/1/2024 Interaction of Genetic Factors and Stress Tienari et al. (1994) found that children of mothers with schizophrenia went on to develop psychiatric disorders in general only if the adopted families were dysfunctional. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-63 63 Interaction of Genetic Factors and Stress Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-64 64 32  9/1/2024 Aetiology of Schizophrenia: Evaluation of Genetic Research Genetics doesn’t completely explain the disorder Diathesis-stress model – Genetic factors constitute underlying predisposition – Stress triggers onset Schizophrenia may be genetically heterogeneous from person to person or there may be genetic sub-types. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-65 65 Aetiology of Schizophrenia: Neurotransmitters Dopamine Theory – Disorder due to excess levels of dopamine  Drugs that alleviate symptoms reduce dopamine activity  Amphetamines, which increase dopamine levels, can induce a psychosis Theory revised – Excess numbers of dopamine receptors or oversensitive dopamine receptors – Localized mainly in the mesolimbic pathway Dopamine abnormalities mainly related to positive symptoms Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-66 66 33  9/1/2024 Aetiology of Schizophrenia: Evaluation of Dopamine Theory Dopamine theory doesn’t completely explain disorder – Antipsychotics block dopamine rapidly but symptom relief takes several weeks – To be effective, antipsychotics must reduce dopamine activity to below normal levels Other neurotransmitters involved: – Serotonin – GABA – Glutamate  Medication that targets glutamate shows promise Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-67 67 Aetiology of Schizophrenia: Brain Structure and Function Enlarged Ventricles – Implies loss of brain cells – Correlate with  Poor performance on cognitive tests  Poor premorbid adjustment  Poor response to treatment – May be medication induced Reduced activity in prefrontal cortex – Involved in speech, executive functions, goal-directed behavior – May be related to dopamine underactivity Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-68 68 34  9/1/2024 Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-69 69 Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-70 70 35  9/1/2024 Aetiology of Schizophrenia: Brain Structure and Function Prefrontal Cortex – Many behaviors disrupted by schizophrenia (e.g., speech, decision making) are governed by prefrontal cortex – Individuals with schizophrenia show impairments on neuropsychological tests of prefrontal cortex (e.g., memory) – Individuals with schizophrenia show low metabolic rates in prefrontal cortex. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-71 71 Aetiology of Schizophrenia: Brain Structure and Function Congenital Factors – Damage during gestation or birth  Obstetrical complications rates high in patients with schizophrenia Reduced supply of oxygen during delivery may result in loss of cortical matter – Viral damage to fetal brain  In Finnish study, schizophrenia rates higher when mother had flu in second trimester of pregnancy  Maternal exposure to parasite associated with higher rates of schizophrenia in their offspring Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-72 72 36  9/1/2024 Prenatal Exposure to Influenza and Adult Schizophrenia Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-73 73 Aetiology of Schizophrenia: Brain Structure and Function Developmental Factors – Prefrontal cortex matures in adolescence or early adulthood – Dopamine activity also peaks in adolescence – Stress activates HPA system which triggers cortisol secretion  Cortisol increases dopamine activity May explain why symptoms appear in late adolescence but brain damage occurs early in life Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-74 74 37  9/1/2024 Aetiology of Schizophrenia: Psychological Stress Reaction to stress – Individuals with schizophrenia and their first-degree relatives more reactive to stress  Greater decreases in positive mood and increases in negative mood Socioeconomic status – Highest rates of schizophrenia among urban poor.  Sociogenic hypothesis Stress of poverty causes disorder  Social selection theory Downward drift in socioeconomic status – Research supports social selection Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-75 75 Aetiology of Schizophrenia: Family Factors Schizophrenogenic mother – Cold, domineering, conflict inducing – No causal support for this theory Communication deviance (CD) – Hostility and poor communication  Family CD predicted onset in one longitudinal study (Norton, 1982)  CD not specific to families of schizophrenic patients Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-76 76 38  9/1/2024 Aetiology of Schizophrenia: Families and Relapse Family environment impacts rehospitalization Expressed Emotion (EE; Brown et al., 1966) – Hostility, critical comments, emotional overinvolvement Bi-directional association – Unusual patient thoughts → increased critical comments – Increased critical comments → unusual patient thoughts Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-77 77 Aetiology of Schizophrenia: Families and Relapse Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-78 78 39  9/1/2024 Aetiology of Schizophrenia: Childhood Trauma High rates of reported abuse among persons with psychotic disorders Particularly associated with positive symptoms Often ignored. Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-79 79 Types of Research on Schizophrenia Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-80 80 40  9/1/2024 Genain Quadruplets Genes or Environment? Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-81 81 Childhood Trauma Hallucinations Decontextualised trauma flashbacks? Dissociative events Paranoid delusions Faulty attempts to explain trauma-based hallucinations Beliefs developed from abuse Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-82 82 41  9/1/2024 DSM-5-TR Schizophrenia Spectrum and Other Psychotic Disorders As with previous chapters, with various disorders, I will try to cover: – General Description (diagnostic criteria, etc.) – Epidemiology of schizophrenia – Aetiology (causes), with focus on schizophrenia – Treatment Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-83 83 Treatment of Schizophrenia Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-84 84 42  9/1/2024 Treatment of Schizophrenia: Medications First generation antipsychotic medications (Neuroleptics; 1950s) – Phenothiazines (Thorazine), butyrophenones (Haldol), thioxanthenes (Navane)  Reduce agitation, violent behavior  Block dopamine receptors  Little effect on negative symptoms Extrapyramidal side effects – Tardive Dyskinesia Maintenance dosages to prevent relapse Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-85 85 Treatment of Schizophrenia: Medications Second generation antipsychotics – Clozapine (Clozaril)  Impacts serotonin receptors – Fewer motor side effects – Less treatment noncompliance – Reduces relapse Side effects – Can impair immune symptom functioning – Seizures, dizziness, fatigue, drooling, weight gain Newer medications may improve cognitive function: – Olanzapine (Zyprexa) – Risperidone (Risperdal) Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-86 86 43  9/1/2024 Treatment of Schizophrenia: Psychological Approaches Patient Outcomes Research Team (PORT; Lehman et al., 2004) treatment recommendation: – Medication PLUS psychosocial intervention Social skills training – Teach skills for managing interpersonal situations  Completing a job application  Reading bus schedules  Make appointments – Involves role-playing and other practice exercises, both in group and in vivo Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-87 87 Treatment of Schizophrenia: Psychological Approaches Family therapy to reduce Expressed Emotion – Educate family about causes, symptoms, and signs of relapse – Stress importance of medication – Help family to avoid blaming patient – Improve family communication and problem-solving – Encourage expanded support networks – Instill hope Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-88 88 44  9/1/2024 Treatment of Schizophrenia: Psychological Approaches Cognitive behavioral therapy – Recognize and challenge delusional beliefs – Recognize and challenge expectations associated with negative symptoms  e.g., “Nothing will make me feel better so why bother?” Cognitive enhancement therapy (CET) – Improve attention, memory, problem solving and other cognitive based symptoms Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-89 89 Treatment of Schizophrenia: Prodromal Phase Emphasises early detection of those at risk, and intensive intervention to prevent progression to a more severe and enduring disturbance Good evidence for the use of anti-psychotics in combination with cognitive behaviour therapy Morrison (2004) found that cognitive behaviour therapy alone can reduce transition to psychosis in high-risk individuals Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-90 90 45  9/1/2024 Treatment of Schizophrenia: Prodromal Phase Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-91 91 Treatment of Schizophrenia: Acute Phase Need 24-hour access to treatment, or hospitalisation Psychoeducation Pharmacological approaches – Antipsychotic medications, benzodiazepines Address co-morbidities, including substance use Psychosocial approaches – Target social and occupational functioning Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-92 92 46  9/1/2024 Treatment of Schizophrenia: Relapse Prevention Relapse rates are high, especially if medication is discontinued by patient Psychological support for both individual and family is important Cognitive model of relapse helps patients to have a sense of control over their symptoms Group-based interventions to encourage social support and reintegration into society Family interventions to reduce high expressed emotion have been found to be effective in reducing relapse rates Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-93 93 Treatment of Psychotic Disorders: Relapse Prevention Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-94 94 47  9/1/2024 Any Questions? If so, post them online Copyright © 2017 McGraw-Hill Education (Australia) Pty Ltd Rieger, Abnormal Psychology, 4e 7-95 95 48