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PowerPoint Lecture Notes Presentation

Chapter 11

Schizophrenia

Abnormal Psychology, Eleventh Editionby

Ann M. Kring, Gerald C. Davison, John M. Neale,& Sheri L. Johnson


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Copyright 2009 John Wiley & Sons, NY 2

Schizophrenia

One of the psychotic disorders

Major disturbances in: Thought

Emotion

Behavior

Disordered thinking

Faulty perception and attention

Inappropriate or flat emotions

Disturbances in movement or behavior Disrupted interpersonal relationships


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Schizophrenia

Disorder impacts families & friends

Difficult to live with someone who experiences

delusions, hallucinations, and paranoia.

Social skills deficits common Isolation, few social contacts

Symptoms impact employability

Often lead to unemployment & homelessness

Substance abuse & suicide rates high


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Schizophrenia

Lifetime prevalence ~1%

Affects men slightly more often thanwomen

Onset typically late adolescence or earlyadulthood Men diagnosed at a slightly earlier age

Diagnosed more frequently in African

Americans May reflect diagnostic bias


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DSM-IV-TR Criteria

Two or more symptoms lasting for at least 1month Delusions

Hallucinations

Disorganized speech Disorganized or catatonic behavior

Negative symptoms

Social and occupational functioning havedeclined since onset

Signs of disturbance for at least 6 mosAt least 1 mo. for delusions



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Clinical Description of

Schizophrenia

No single essential symptom

Heterogeneity of symptoms across patients


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Positive Symptoms: Behavioral

excesses

Delusions Firmly held beliefs Contrary to reality Resistant to disconfirming

evidence

Persecutory delusions

common The CIA planted a

listening device in myhead

Other common forms : Thought insertion Thought broadcasting

Grandiose delusions Ideas of reference

Hallucinations Sensory experiences in

the absence of sensorystimulation

Types of hallucinations Audible thoughts Voices commenting

Voices arguing

Increased levels ofactivity in Brocas areaduring hallucinations


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Negative Symptoms: Behavioral

deficits

Avolition Lack of interest; apathy

Alogia Reduction in speech

Anhendonia Inability to experience

pleasure Consummatory pleasure Anticipatory pleasure

Flat affect Exhibits little or no affect in

face or voice

Asociality

Inability to form closepersonal relationships

Negative symptoms

predict poor quality

of life post-

hospitalization (Ho

et al., 1998)



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Disorganized Symptoms

Disorganized speech (Formal thoughtdisorder) Incoherence

Inability to organize ideas

Loose associations (derailment) Rambles, difficulty sticking to one topic

Disorganized behavior Odd or peculiar behavior

Silliness, agitation, unusual dress e.g., wearing several heavy coats in hot weather


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Other Symptoms

Catatonia Motor abnormalities

Repetitive, complex gestures Usually of the fingers or hands

Excitable, wild flailing of limbs

Catatonic immobility Maintain unusual posture for long periods of time

e.g., stand on one leg

Waxy flexibility

Limbs can be manipulated and posed by anotherperson


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Other Symptoms

Inappropriate affect

Emotional responses inconsistent with

situation

e.g., laugh uncontrollably at a funeral


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Schizophrenia in DSM-IV-TR

Two or more of the following symptoms for atleast 1 month: Delusions

Hallucinations

Disorganized speech

Disorganized or catatonic behavior

Negative symptoms

Declining social and occupational functioning

Signs of disturbance for at least 6 months


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DSM-IV-TR Schizophrenia

Subtypes

Disorganized

Incoherence, disorganized speech and

behavior

Flat or inappropriate affect

Catatonic

Prolonged immobility or purposeless

agitation


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DSM-IV-TR Schizophrenia

Subtypes

Paranoid Delusions, hallucinations related to persecution or

grandiosity

Ideas of reference

Assigning personal significance to trivial or neutral events e.g., newscast on TV is about me

Undifferentiated Meet criteria for schizophrenia but not for a

subtype

Residual No longer meets criteria for schizophrenia but stillexhibits signs of the disorder


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Evaluation of Subtypes

Diagnosis of subtypes difficult

Reliability low

Poor predictive validity

Overlap of symptoms among subtypes


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Other Psychotic Disorders

Delusional Disorder

Delusions may include:

Jealousy, erotomania, & somatic delusions

No other symptoms of schizophrenia

T bl 11 3 F il d T i


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Table 11.3 Family and Twin

Genetic Studies



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Table 11.4 Characteristics of Adopted Offspring

of Mothers with Schizophrenia

Insert Table 11.4 HERE (Table 11.3 in

previous edition)



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Molecular Genetics Research

Not likely that disorder caused by single gene Linkage studies

A number of chromosomes implicated

Results inconsistent and marked by a failure to replicate

Association studies

Two genes identified DTNGP1

NGR1

Genome-wide scans

Identification of gene mutations

Several identified but results need to be replicated


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Etiology of Schizophrenia: Evaluation

of Genetic Research

Genetics doesnt completely explain the

disorder

Diathesis-stress model

Genetic factors constitute underlying predisposition

Stress triggers onset

Schizophrenia may be genetically heterogeneous

from person to person

Genetic research doesnt reveal what is inherited Eye tracking studies

Etiology of Schizophrenia:


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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 topositive symptoms

Figure 11 1 The Brain and


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Figure 11.1 The Brain and

Schizophrenia


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Figure 11.2 Dopamine Theory of

Schizophrenia

Eti l f S hi h i E l ti


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Etiology of Schizophrenia: Evaluation

of Dopamine Theory

Dopamine theory doesnt completely explaindisorderAntipsychotics 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

Etiology of Schizophrenia: Brain


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Structure and Function

Enlarged Ventricles Implies loss of brain cells

Correlate with Poor performance on cognitive tests

Poor premorbid adjustment Poor response to treatment

Reduced activity in prefrontal cortex Involved in speech, executive functions,

goal-directed behavior

May be related to dopamine underactivity



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Prefrontal Cortex Many behaviors disrupted by schizophrenia

(e.g., speech, decision making) are governedby prefrontal cortex

Individuals with schizophrenia showimpairments on neuropsychological tests ofprefrontal cortex (e.g., memory)

Individuals with schizophrenia show lowmetabolic rates in prefrontal cortex. Failure to show frontal activated related to negative

symptoms

Figure 11 3 Micrograph of a


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Figure 11.3 Micrograph of a

Neuron



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Congenital Factors Damage during gestation or birth

Obstetrical complications rates high in patients withschizophrenia 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(Mednick et al., 1988)

Maternal exposure to parasite associated withhigher rates of schizophrenia in their offspring



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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 inlife



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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

Etiology of Schizophrenia: Family


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Etiology of Schizophrenia: Family

Factors

Schizophrenogenic mother

Cold, domineering, conflict inducing

No support for this theory

Communication deviance (CD) Hostility and poor communication

Family CD predicted onset in one longitudinalstudy (Norton, 1982)

CD not specific to families of schizophrenicpatients



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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



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Developmental Studies

Developmental histories of children who

later developed schizophrenia

Lower IQ

More often delinquent and withdrawn

Coding of home movies

Poorer motor skills

More expression of negative emotion



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Developmental Studies

High risk studies Danish children with a schizophrenic mother who laterdeveloped disorder (Mednick & Schulsinger, 1968) Negative symptom patients

More pregnancy birth complications

Failure to show electrodermal responding

Positive symptom patients Family instability

Australian study (Yung et al., 1995) Reduced gray matter volume predicted later

development of psychotic disorder

North American Prodrome LongitudinalStudy (NAPLS)

Treatment of Schizophrenia:


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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




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p

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)


Table 11.5 Summary of Major


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y j

Schizophrenia Drugs

Insert Table 11.5 (previously numbered

11.4)



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Psychological Treatments

Patient Outcomes Research Team(PORT; Lehman et al., 2004) treatmentrecommendation:

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 practiceexercises, both in group and in vivo


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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


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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


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COPYRIGHT

Copyright 2009 by John Wiley & Sons, New

York, NY. All rights reserved. No part of the

material protected by this copyright may be

reproduced or utilized in any form or by any

means, electronic or mechanical, including

photocopying, recording or by any information

storage and retrieval system, without written

permission of the copyright owner.

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