Schizophrenia 2021 PDF

Abnormal Psychology Schizophrenia and Other Psychotic Disorders Copyright © 2021 Pearson Education Ltd. Learning Objectives (1 of 2) 13.1 Describe the prevalence of schizophrenia and who is most affected. 13.2 Identify the symptoms of sch...

Abnormal Psychology Schizophrenia and Other Psychotic Disorders Copyright © 2021 Pearson Education Ltd. Learning Objectives (1 of 2) 13.1 Describe the prevalence of schizophrenia and who is most affected. 13.2 Identify the symptoms of schizophrenia as described in DSM-5. 13.3 List four different types of psychotic disorders and state one way in which each is different from schizophrenia. 13.4 Explain the genetic and biological risk and causal factors associated with schizophrenia. Copyright © 2021 Pearson Education Ltd. Learning Objectives (2 of 2) 13.5 Discuss how the brain is affected in schizophrenia. 13.6 Explain the psychosocial and cultural factors associated with schizophrenia. 13.7 Describe the clinical outcome of schizophrenia and how is it treated, noting the advantages and disadvantages associated with the use of antipsychotic medications. Copyright © 2021 Pearson Education Ltd. Schizophrenia (1 of 2) Learning Objective 13.1: Describe the prevalence of schizophrenia and who is most affected. Psychosis significant loss of contact with reality – Hallmark of schizophrenia Origins of the Schizophrenia Construct First clinical description appeared in 1810 Emil Kraepelin (1896) used term dementia praecox to refer to mental deterioration at early age Eugen Bleuler introduced term “schizophrenia” in 1911 – From Greek meaning “to split or crack” and “mind” – Not the same as multiple personalities Copyright © 2021 Pearson Education Ltd. Schizophrenia (2 of 2) Epidemiology Lifetime prevalence just under 1% Age of father (over 50) Parent in dry cleaning business First- and second-generation immigrants – Particularly those from black Caribbean and black African countries who live in majority white communities Onset: ages 18-30 More common and more severe in men Copyright © 2021 Pearson Education Ltd.  Figure 13.1 Onset of Schizophrenia Age distribution of onset of schizophrenia (first sign of mental disorder) for men and women. Copyright © 2021 Pearson Education Ltd. Clinical Picture (1 of 5) Learning Objective 13.2: Identify the symptoms of schizophrenia as described in DSM -5. Delusions Delusions are an erroneous belief that is fixed and firmly held despite clear contradictory evidence – Disturbance in the content of thought Examples: – Being controlled by external agents ▪ Private thoughts are being broadcast to others ▪ Thoughts have been inserted by external agency ▪ Thoughts withdrawn by external agency – Neutral environmental event (T.V., radio) have special meaning intended for one person – Delusions of bodily changes or removal of organs Copyright © 2021 Pearson Education Ltd. Clinical Picture (2 of 5) Hallucinations A hallucination is a sensory experience that seems real to the person having it, but occurs in the absence of any external perceptual stimulus – Can occur in any sensory modality – Auditory are most common Patients become emotionally involved with hallucinations – Incorporate them into delusions Copyright © 2021 Pearson Education Ltd. Clinical Picture (3 of 5) Disorganized Speech Disorder in thought form – Delusions are a disorder of thought content Fail to make sense even though they are using language in a conventional way – Words and combinations sound communicative – Listener is left with a lack of understanding – May make up new words (neologisms) Copyright © 2021 Pearson Education Ltd. Clinical Picture (4 of 5) Disorganized Behavior Impairment of goal-directed activity Occurs in areas of daily functioning – Examples: hygiene, silliness or unusual dress Catatonia involves almost no movement at all, sometimes in an unusual posture Catatonic stupor a virtual absence of all movement and speech Copyright © 2021 Pearson Education Ltd. Clinical Picture (5 of 5) Negative Symptoms Positive symptoms excess or distortion in normal behavior and experience Negative symptoms reflect an absence or deficit of normally present behaviors – Two domains – Reduced expressive behavior ▪ Voice, facial expression, speech ▪ Blunted or flat affect, or alogia (little speech) – Reductions in motivation or experience of pleasure ▪ Avolition: the inability to initiate or persist in goal-directed activity – Presence of negative symptoms is not a good sign Copyright © 2021 Pearson Education Ltd. Other Psychotic Disorders (1 of 2) Learning Objective 13.3: List four different types of psychotic disorders and state one way in which each is different from schizophrenia. Schizoaffective Disorder Features of schizophrenia and severe mood disorder Diagnostic criteria revised in DSM-5 to improve reliability Schizophreniform Disorder Schizophrenia-like psychoses lasting at least 1 month but less than 6 months Do not warrant a schizophrenia diagnosis Copyright © 2021 Pearson Education Ltd. Other Psychotic Disorders (2 of 2) Delusional Disorder Delusional beliefs with otherwise normal behavior Erotomania delusion involves great love for a person, usually of higher status Brief Psychotic Disorder Sudden onset of psychotic symptoms or disorganized speech or catatonic behavior Copyright © 2021 Pearson Education Ltd. Genetic and Biological Factors (1 of 7) Learning Objective 13.4: Explain the genetic and biological risk and causal factors associated with schizophrenia. Genetic Factors Disorders of the schizophrenia type are “familial”—tend to “run in families” – The prevalence of schizophrenia in the first-degree relatives (parents, siblings, and offspring) is 10 percent – Second-degree relatives who share only 25 percent of their genes is closer to 3 percent Familial and genetic are not synonymous – A disorder can run in families for nongenetic reasons Copyright © 2021 Pearson Education Ltd. Figure 13.2 Risk of Developing Schizophrenia by Genetic Relationship Lifetime age-adjusted, averaged risks for the development of schizophrenia-related psychoses in classes of relatives differing in their degree of genetic relatedness. Copyright © 2021 Pearson Education Ltd. Genetic and Biological Factors (2 of 7) TWIN STUDIES Schizophrenia concordance rates for identical twins (28%) are higher than those for fraternal twins or ordinary siblings (6%) – If only genetic, the rate would be 100% between identical twins – Genes are not the whole story ADOPTION STUDIES Higher rates of schizophrenia among adopted children of schizophrenic biological parents THE QUALITY OF THE ADOPTIVE FAMILY Children at high genetic risk who were raised in healthy family environments did not develop problems any more frequently than did children at low genetic risk – Evidence of genotype–environment interaction in schizophrenia Copyright © 2021 Pearson Education Ltd. Figure 13.3 Fischer’s Study Because MZ twins have identical genes, the children of the well twin will have an elevated risk of schizophrenia even if their parent did not suffer from the disorder. Copyright © 2021 Pearson Education Ltd. Genetic and Biological Factors (3 of 7) MOLECULAR GENETICS Schizophrenia probably involves many genes working together Candidate genes: genes that are involved in processes that are believed to be aberrant in schizophrenia Genome-wide association study (GWAS): investigating entire genome ENDOPHENOTYPES Endophenotypes: discrete, stable, and measurable traits that are thought to be under genetic control Copyright © 2021 Pearson Education Ltd. Figure 13.4 The multifactorial etiology of schizophrenia includes (1) rare genes that have a large effect, (2) common genes that have a small effect, and (3) the environmental factors and gene–environmental interactions that confer risk for schizophrenia. Copyright © 2021 Pearson Education Ltd. Table 13.1 Sample Items Measuring Psychosis-Proneness blank blank Magical Ideation T F Things seem to be in different places when I get home, even though no one has been there. T F I have sometimes felt that strangers were reading my mind. T F At times, I have felt that a professor’s lecture was meant especially for me. blank blank Perceptual Aberration k T F Sometimes people whom I know well begin to look like strangers. T F Ordinary colors sometimes seem much too bright for me. T F Now and then, when I look in the mirror, my face seems quite different than usual. Copyright © 2021 Pearson Education Ltd. Genetic and Biological Factors (4 of 7) Prenatal Exposures VIRAL INFECTION Elevated rates of schizophrenia in children born to mothers who had been in their second trimester of pregnancy at the time of the influenza epidemic RHESUS INCOMPATIBILITY Mechanism involves oxygen deprivation, or hypoxia—risk for schizophrenia linked to birth complications Rh-incompatibility between the mother and fetus may increase the risk of brain abnormalities Copyright © 2021 Pearson Education Ltd. Genetic and Biological Factors (5 of 7) PREGNANCY AND BIRTH COMPLICATIONS Many delivery problems (breech delivery, prolonged labor, or the umbilical cord around the baby’s neck) affect the newborn’s oxygen supply EARLY NUTRITIONAL DEFICIENCY Schizophrenia might be caused or triggered by environmental events MATERNAL STRESS Extremely stressful event late in 1st trimester/early in 2nd trimester of pregnancy increases schizophrenia risk Copyright © 2021 Pearson Education Ltd. Genetic and Biological Factors (6 of 7) Genes and Environment in Schizophrenia: A Synthesis The focus on MZ concordance rates causes an overestimate of the heritability of schizophrenia – Chorionic arrangements could mean different environments – Around two-thirds of MZ embryos are monochorionic—share a placenta and blood supply Genetic liability to schizophrenia may predispose an individual to suffer more from the environment than those without the genetic predisposition Copyright © 2021 Pearson Education Ltd. Figure 13.5 Chorionic Arrangement in Twins (A) Dichorionic twins, who can be either dizygotic or monozygotic, have separate placentas and separate fetal circulation. (B) Monochorionic twins, who are always monozygotic, have a single placenta and shared circulation. Copyright © 2021 Pearson Education Ltd. Genetic and Biological Factors (7 of 7) A Neurodevelopmental Perspective The stage is set for schizophrenia early in life – Problems may not appear until the brain is mature Research focuses on those showing prodomal—very early signs of schizophrenia Attenuated psychosis syndrome is not part of DSM-5 as a disorder in need of further study Copyright © 2021 Pearson Education Ltd. Structural and Functional Brain Abnormalities (1 of 10) Learning Objective 13.5: Discuss how the brain is affected in schizophrenia. Neurocognition Cognitive impairment is a core feature of schizophrenia – Apparent even before there is a diagnosable illness Lower IQ may be a risk factor; higher IQ may be protective in some way Patients with schizophrenia are not able to respond to a stimulus as quickly and appropriately Deficits are apparent in the earliest stages of visual and auditory processing Copyright © 2021 Pearson Education Ltd. Figure 13.6 Normal and Abnormal Eye Tracking of a Sinusoidal Wave The top pattern is the target, the middle pattern is a record of normal tracking, and the lowest pattern is the kind of abnormal record produced by some patients with schizophrenia. Copyright © 2021 Pearson Education Ltd. Structural and Functional Brain Abnormalities (2 of 10) Social Cognition Social cognition: how we recognize, think about, and respond to social information, including the emotions and intentions of others People with schizophrenia show significant impairments in social cognition – Failure to spot the kinds of subtle (or not so subtle) social hints – Difficulty recognizing emotion in faces and emotion being conveyed in speech Copyright © 2021 Pearson Education Ltd. Structural and Functional Brain Abnormalities (3 of 10) Loss of Brain Volume Patients with schizophrenia have enlarged brain ventricles – Males more affected than females – Indicator of a reduction in brain tissue Decrease in brain volume is present very early in the illness Progressive brain deterioration continues for many years Copyright © 2021 Pearson Education Ltd. Figure 13.7 Gray Matter Changes and Psychosis Onset These cortical surface maps show the brain regions in which converters to psychosis show significantly greater progressive loss of gray matter thickness relative to controls and nonconverters. The prefrontal cortex is particularly affected. Copyright © 2021 Pearson Education Ltd. Structural and Functional Brain Abnormalities (4 of 10) Affected Brain Areas Reductions in the volume of regions in the frontal and temporal lobes – More specifically, in the volume of medial temporal areas: the amygdala, the hippocampus, and the thalamus Brain structure is abnormal, but the abnormality is linked to: – Stage of illness – Use of medications – Other factors Copyright © 2021 Pearson Education Ltd. Structural and Functional Brain Abnormalities (5 of 10) White Matter Problems White matter is crucially important for the connectivity of the brain – White matter abnormalities have been shown to be correlated with cognitive impairments Patients have reductions in white matter volume as well as structural abnormalities in the white matter itself – Abnormalities are found in first-episode patients and in people at genetic high risk for the disorder – Dysconnectivity: abnormal integration between distinct brain regions, particularly those involving the frontal lobes Copyright © 2021 Pearson Education Ltd. Structural and Functional Brain Abnormalities (6 of 10) Brain Functioning Some patients show abnormally low frontal lobe activation (known as “hypofrontality”) when they are involved in mentally challenging tasks Impaired functioning of the frontal lobes is found in patients in the early stages of schizophrenia and in people at high risk for developing the disorder Dysfunction of the temporal lobes is also found – May be a problem with how activity in different brain regions gets coordinated Copyright © 2021 Pearson Education Ltd. Figure 13.8 The Brain in Schizophrenia Many brain regions and systems operate abnormally in schizophrenia, including those highlighted here. Copyright © 2021 Pearson Education Ltd. Structural and Functional Brain Abnormalities (7 of 10) Cytoarchitecture If cells fail to migrate properly, the overall organization of cells in the brain (the brain’s cytoarchitecture) will be compromised – Increase in neuronal density in some areas of the brains of patients with schizophrenia Abnormalities in the distribution of cells in the cortex and hippocampus Patients with schizophrenia are missing “inhibitory interneurons” – May be less able to regulate or dampen down overactivity in certain neural circuits Copyright © 2021 Pearson Education Ltd. Figure 13.9 Cytoarchitecture and Neural Development The upper diagram shows examples of normal and abnormal pyramidal cell orientation in the hippocampus. The lower diagram is a schematic representation of stained neurons and the “downward-shift” phenomenon. Premature arrest of cell migration during development may underlie the high frequency of cells in lower regions close to white matter and their relative paucity near the cortical surface. Copyright © 2021 Pearson Education Ltd. Structural and Functional Brain Abnormalities (8 of 10) Brain Development in Adolescence Major brain changes take place during adolescence, as the brain matures – If problems occur, schizophrenia may be the result People who were in the hospital for a head injury have a 65 percent increase risk for schizophrenia – If a head injury occurs between the ages of 11 and 15, the risk of schizophrenia is increased by 85 percent Copyright © 2021 Pearson Education Ltd. Structural and Functional Brain Abnormalities (9 of 10) Synthesis Genes can create an enhanced susceptibility to aversive environmental events It is unlikely that schizophrenia is the result of any one problem in any one specific region of the brain Subtle brain abnormalities in some key functional circuits may wreak havoc with normal functioning Copyright © 2021 Pearson Education Ltd. Structural and Functional Brain Abnormalities (10 of 10) Neurochemistry Alterations in brain chemistry may be associated with abnormal states Dopamine: a neurotransmitter linked to schizophrenia – Chlorpromazine blocks dopamine receptors and help patients – Amphetamines produce excess dopamine and mimic a psychotic state that looks like schizophrenia – L-DOPA treated patients display psychotic symptoms Glutamate: an excitatory neurotransmitter – When glutamate receptors are blocked it creates schizophrenic like symptoms Copyright © 2021 Pearson Education Ltd. Psychosocial and Cultural Aspects (1 of 6) Learning Objective 13.6: Explain the psychosocial and cultural factors associated with schizophrenia. Do Bad Families Cause Schizophrenia? Popular theories in the past blaming the family do not have empirical support If the child is not at genetic risk for schizophrenia, adverse family environments and communication deviance have little consequence Copyright © 2021 Pearson Education Ltd. Psychosocial and Cultural Aspects (2 of 6) Families and Relapse Expressed emotion (EE): a measure of the family environment based on how a family member speaks about the patient during a private interview with a researcher – Three main elements: criticism, hostility, and emotional overinvolvement (EOI) High-EE home environment more than doubles the chance of a relapse – Especially strong for chronically ill patients Researchers are still trying to understand how EE affects the brain Copyright © 2021 Pearson Education Ltd. Psychosocial and Cultural Aspects (3 of 6) Urban Living One study showed children who spend the first 15 years of life in an urban setting were 2.75 times more likely to develop schizophrenia than those in rural settings It is estimated if we all lived in relatively rural settings the number of schizophrenia cases could decrease by 30% Copyright © 2021 Pearson Education Ltd. Psychosocial and Cultural Aspects (4 of 6) Immigration Recent immigrants have a much higher risk There is no evidence that this can be explained by cultural misunderstandings Immigrants with darker skin have a much higher risk of developing schizophrenia than those with lighter skin Healthy people who feel discriminated against are more likely to develop psychotic symptoms than healthy people who do not perceive any discrimination Copyright © 2021 Pearson Education Ltd. Psychosocial and Cultural Aspects (5 of 6) Cannabis Use and Abuse People with schizophrenia are twice as likely to smoke cannabis as people in the general population – This could be a correlate and not a cause – The majority of cannabis users never develop schizophrenia Cannabis may accelerate the progressive brain changes that seem to go along with schizophrenia Copyright © 2021 Pearson Education Ltd. Figure 13.10 Brain Volume Changes over 5 Years in Patients with Schizophrenia and Healthy Comparison Subjects Patients with schizophrenia who also use cannabis show more loss of gray matter over the course of a 5-year follow-up than patients who do not use cannabis or healthy controls. Copyright © 2021 Pearson Education Ltd. Psychosocial and Cultural Aspects (6 of 6) A Diathesis-Stress Model of Schizophrenia Biological factors play a role – Genetic predispositions is shaped by environmental factors such as prenatal exposures, infections, and stressors No simple answer to what causes schizophrenia – Genetics and environment combine in such a way that brain pathways develop abnormally Copyright © 2021 Pearson Education Ltd. Table 13.2 Nongenetic Risk Factors for Schizophrenia Nongenetic Risk Factor Older father Virus exposure Obstetric complications Urban upbringing Head injury Cannabis use Migrant status Copyright © 2021 Pearson Education Ltd. Figure 13.11 A Diathesis–Stress Model of Schizophrenia Genetic factors and acquired constitutional factors (such as prenatal events and birth complications) combine to result in brain vulnerability. Normal maturational processes, combined with stress factors (family stress, cannabis use, urban living, immigration, etc.), may push the vulnerable person across the threshold and into schizophrenia. Copyright © 2021 Pearson Education Ltd. Treatments and Outcomes (1 of 4) Learning Objective 13.7: Describe the clinical outcome of schizophrenia and how it is treated, noting the advantages and disadvantages associated with the use of antipsychotic medications. Clinical Outcome Around 38% of patients have a favorable outcome and can be thought of as being recovered 15 to 25 years after development of the disorder – They do not return to how they were before they became ill Around 12 percent of patients need long-term institutionalization Around one-third show signs of continued negative symptoms Copyright © 2021 Pearson Education Ltd. Treatments and Outcomes (2 of 4) Pharmacological Approaches FIRST-GENERATION ANTIPSYCHOTICS Block the action of dopamine SECOND-GENERATION ANTIPSYCHOTICS Fewer extrapyramidal symptoms OTHER APPROACHES Researching the role of estrogen Copyright © 2021 Pearson Education Ltd. Figure 13.12 Estrogen Treatment and Positive Symptoms Positive symptoms at baseline (day 0) and on days 7, 14, 21, and 28 for the estrogen and placebo groups. Copyright © 2021 Pearson Education Ltd. Treatments and Outcomes (3 of 4) THE PATIENT’S PERSPECTIVE Not all patients benefit from antipsychotic medications May show clinical improvement but still need help Side effects may lead patients to discontinue taking the medication Some patients may try to avoid taking medications because, to them, needing to take medications confirms that they are mentally ill Copyright © 2021 Pearson Education Ltd. Treatments and Outcomes (4 of 4) CASE MANAGEMENT FAMILY THERAPY PSYCHOEDUCATION SOCIAL-SKILLS TRAINING COGNITIVE REMEDIATION COGNITIVE-BEHAVIOR THERAPY EXERCISE Copyright © 2021 Pearson Education Ltd.