Schizophrenic Spectrum Psych 300 Nov. 21 PDF

Psychotic disorders: Nov.21 Psychosis: What is psychosis? Extreme reality distortion. Certain delusions o Extreme disorder of thought content Certain hallucinations (Hear, see things that others don’t experience) o Sensory phenomena without external input...

Psychotic disorders: Nov.21 Psychosis: What is psychosis? Extreme reality distortion. Certain delusions o Extreme disorder of thought content Certain hallucinations (Hear, see things that others don’t experience) o Sensory phenomena without external input How to determine? Too extreme, bizarre and excessive delusions and thought processes. Schizophrenic spectrum: A range of different disorders. Schizotypal personality disorder Delusional disorder Brief psychotic episode Schizophreniform disorder Schizophrenia (most prevalent) also named **schizoaffective disorder Schizophrenia: When to diagnose? Very well-developed delusions and hallucinations. Need only 2 positive and/ negative symptoms of psychosis. Onset on teens and young adults. Florid symptoms present for at least one month. Negative and positive symptoms for at least 6 months. Key characteristics: Heterogenous characters diagnosis. (Ex: Are very intelligent and functional in particular areas yet dysfunctional in others. Hard to do research on). Positive symptoms: 1. Delusions: What: disorders of thought content. Fixed beliefs despite contradictory beliefs. Persecution o Being harmed Reference o things have special meaning (ex: if raining this means you are dying) Influence o one’s body being controlled o thought insertion o thought broadcasting in which others could hear ones thoughts Cotard’s syndrome (believe body parts don’t exist) Capgras syndrome (people replaced by identical copy) 2. Hallucinations (not necessary) What: sensory events with any environmental input. Auditory (most common) Visual Olfactory (believe oneself smells bad) Gustatory (bad taste ex. being poisoned) 3. Disorganized speech (thinking) Derailment Tangential thinking Incoherence Neologisms (making new language/words) Clang associations (putting words together because they rhyme) 4. Disorganized behavior Childlike silliness Unpredictable agitation Catatonic motor behavior (unable to move) o Waxy problem (do not move in any position they are in) Public masturbation  Negative symptoms: 1. Criterion A Flat affect- no expression of emotions (poker face) Avolition o Unable to motivate oneself to do something Alogia o Poor speech (not enough content in speech ex: ok, yes, no) Anhedonia o Unable to experience pleasure and joy Asociality o Reduced social activity, unable to build relationships 2. Criterion B: social/occupational impairment Education – many unable to continue Employment- majority unemployed Social- unable to marry 3. Criterion C: continued signs of disturbance/symptoms for at least 6 months. Clinical picture: Low rate (1%) Slow onset (prodromal period) Men > women o Men onset earlier (late teens) o Women (mid 20s) Early treatment crucial (as continues symptoms worsen) Course variable o Some only have one episode and treated o Higher rate of multiple episodes and remission o Chronic course o Progressive worsening (hospitalized entire lives) Heterogenous (variable symptoms) Variable insight (confused/seek help) Culture can influence (more common in developed cultures)  o Why? Result of toxic chemical in industrial cities, more doctors to recognize, social support less Reduced life expectancy (10 years less) o Suicide o Health issues (cardiovascular, metabolic, diabetes..) o Substance abuse (cannabis, marijuana…) Spectrum disorders: **schizophrenia most common Different in spectrum depends on impairment and length. Attenuated psychosis syndrome: What? Displays distortions in thinking of reality. (Key features: delusion and hallucinations) When? Some symptoms Good insight Prodromal stage Managed with medication Schizotypal personality disorder: What? More circumscribed than schizophrenia. **ideas of reference = idea that people are observing you 1. Stable condition marked by: Social and interpersonal deficits (at least 5 of following) o Ideas of reference o Odd beliefs/magical thinking o Unusual perceptual experiences o Socially isolated  o Excessive social anxiety o Speech not impaired Under personality disorders o Schizotypal personality disorder o Schizoid disorder Dimensional vs. Categorical models Delusional disorder: What? One or more delusions that last one month. Only symptom is delusional. **more circumscribed than other spectrum disorders (patient functions well yet occasionally affected) Erotomaniac- usually a famous person is in love with them (ex: their therapist…) Grandiose Jealous (more in men) Persecution (sense that people are after them-on and off) Somatic (something in body has changed – poisoning) Prevalence: Very rare Onset later Brief psychotic disorder: What: have positive symptoms. Lasts short period of time 1day-1month. Delusions Hallucinations Disorganized speech Disorganized behavior o Prevalence low (9%) Difference: Good prognosis – resolved on its own Schizophreniform disorder: What: positive and negative symptoms. last for 6 months Difference: Good prognosis o Prevalence very low (0.2%) Schizoaffective disorder: What: combination of schizophrenia and an affective disorder (bipolar, depression…). **hard to initially diagnose How? Must look over time to understand the symptoms. o Prevalence very low (0.3%) Etiology: most known for schizophrenia (not the spectrum but very close) 1. Genetic contributions: a. Family heritability – 46% (2 parents) 17% (1 parent) chance of development b. Identical twins- have higher % of development c. Overall 40-60% (80% for spectrum disorders) d. Adoption studies- if biological parents have schizophrenia even if child is adopted they have a high % of being diagnosed 2. Biochemical factors (dopamine) Neurochemical circuit differences for schizophrenia. Most accepted theory: Dopamine theory o Excessive dopamine Two factor theory: o Insufficient dopamine in pre-frontal area o Excessive dopamine striatal areas (D2 receptor sites) Treatment: 1. Dopamine antagonists  Contrary evidence: 1. Dopamine antagonist not universally effective 2. Clozapine – weak dopamine antagonist is effective 3. Dopamine down regulates but does not change the symptoms immediately 4. Unable to reduce negative symptoms (positive symptoms more effective) Biochemical factors: another contributor of schizophrenia Glutamate theory – dysfunction in glutamate activity. Why? GABA dysfunction or excessive dopamine Brain structure and function: contributor Areas of the brain that have abnormalities. According to FMRI: Less activity in frontal areas of the brain o Hypofrontality: low activity of the frontal lobe Enlarged ventricles: fluid in the brain is larger (due to shrinking of grey matter) Changes in brain structure are correlated with schizophrenia but unknown if they cause schizophrenia. Possible: medications or lifestyle changes may cause the brain function changes. Contemporary models: Neurodevelopmental: dysfunction in early cortical development o Children with certain behaviours higher % to develop schizophrenia o Onset higher in adolescence when brain re-wiring Some factors are: (early at birth can see signs of schizophrenia) ▪ Smaller head circumference ▪ Slower to reach developmental milestones ▪ Higher rates of left-handedness ▪ Minor physical/facial anomalies Birth complication: Premature birth Hypoxia (insufficient oxygen) Obstetric complications Fetus complications: Physical stress of mother 1st trimester (effect on developing fetus) Maternal exposure to flu and viruses 2nd trimester Theory of microglia: Dysfunction of microglia. How? Microglia overactive in frontal lobes and removes essential cells. Microglia functions by GABA and glutamate. **microglia = removed damaged cells, maintain other cells Neurons developing in fetus. Cortical development: Growth in grey and white matter. Multiple hit model: the process of developing schizophrenia due to various contributors. Psychosocial contributions: Likelihood of recurrence, not cause o Stressful life events o Family processes ▪ Study disapproved that a schizophrenia mother would impact the child ▪ Psychotic child which treated return to home cause relapse. why? Parents who are ▪ Hostile ▪ Critical ▪ Over controlling ▪ Family stress **schizophrenic individual are vulnerable to negative expressions. Treatments: schizophrenia Biological treatment: First line treatment: biochemical o Effect on positive symptoms First generation of antipsychotics: Advantages: Patients released from hospitalization Disadvantages: Negative symptoms (tuned out, lacking motivation and communication) not treated. Side effects present (neurological) o Akinesia- impaired movement o Tardive dyskinesia- tongue movement problems (high % permanent problem) o Parkinson’s Many did not want to take (not compliant) Not a cure but management Non-responders high (30-50%)  Second generation antipsychotics: Ex: clozapine, olanzapine… Reduce negative symptoms to greater extent Lower rate of side effects Fewer suicide Reduced relapsed Disadvantages: Increase weight (diabetes) Higher chance of seizure Immune dysfunction Psychosocial treatment: Using environmental consequences to shape behaviour. Operant conditioning: token economy programs in institutional settings (ex: if wake up early you receive a token, if not talk about delusions you get a token) o The program worked during hospitalization and 6 months after release. Relapse occurred Skill training: practice communication and socialization (long process) Behavioral family treatment to reduce expressed emotions (educate family to reduce stress on patient and prevent relapse) Study: Drugs and education highest cure. Drugs and psychosocial treatment lowest cure. A new direction: 1. Cognitive therapy (not a cure) a. Identify triggers for symptoms b. Identify anxiety-provoking beleifs (delusions) i. Reframe positive symptoms ii. Provide alternative explanations Purpose: improve insights of thoughts. Feature: Relationship with patient must be very good to avoid discontinuation. c. Treatment effectiveness- low but reduction in symptoms Long-term treatment response: Some have symptoms remained (33%) Long-term institutional care (12%) Greater number function well after 15-25 years (38%) Some improve in social behavior and functioning (10%) **no cure for schizophrenia yet