Chapter 9 - IPFW.edu

Report
Abnormal Psychology, Twelfth Edition
by
Ann M. Kring,
Sheri L. Johnson,
Gerald C. Davison,
& John M. Neale
Copyright © 2012 John Wiley & Sons, Inc. All rights reserved.
 Chapter
9: Schizophrenia
I. Clinical
Descriptions of Schizophrenia
II. Etiology of Schizophrenia
III. Treatment of Schizophrenia
© 2012 John Wiley & Sons, Inc. All rights reserved.
 Major
disturbances in thought, emotion, and
behavior
• Disordered thinking
 Ideas not logically related
 Faulty perception and attention
• Lack of emotional expressiveness
 Inappropriate or flat emotions
• Disturbances in movement or behavior
 Disheveled appearance
 Can
disrupt interpersonal relationships, diminish
capacity to work or live independently
 Significantly increased rates of suicide and death
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 Lifetime
prevalence ~1%
 Affects men slightly more often than
women
 Onset typically late adolescence or early
adulthood
• Men diagnosed at a slightly earlier age
 Diagnosed
Americans
more frequently in African
• May reflect diagnostic bias
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
Two or more symptoms lasting for at least 1 month;
one symptom should be 1, 2, or 3:
1)
2)
3)
4)
5)
Delusions
Hallucinations
Disorganized speech
Abnormal psychomotor behavior (catatonia)
Negative symptoms (blunted affect, avolition, asociality)
Functioning in work, relationships, or self-care have
declined since onset
 Signs of disorder for at least 6 months; at least 1
month of the symptoms above; or, if during a
prodromal or residual phase, negative symptoms or
two or more of symptoms 1-4 in less severe form

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 Three
major clusters of symptoms:
• Positive
• Negative
• Disorganized
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
Delusions

Hallucinations
• Sensory experiences in the
• Firmly held beliefs
• Contrary to reality
• Resistant to disconfirming
absence of sensory
stimulation
evidence

Types of delusions:
• Persecutory delusions
 “The CIA planted a listening
device in my head”
 65% have these
•
•
•
•
•
Thought insertion
Thought broadcasting
Outside control
Grandiose delusions
Ideas of reference

Types of hallucinations:
• Auditory
 74% have this symptom
• Visual
• Hearing voices
 Increased levels of activity in
Broca’s area during hallucinations
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
Avolition
• Lack of interest; apathy

Asociality
• Inability to form close personal
 Can
be grouped into
2 domains:
• Experience domain
 Motivation
 Emotional experience
 sociality
relationships

Anhendonia
• Inability to experience
pleasure
 Consummatory pleasure
 Anticipatory pleasure

• Expression domain
Blunted affect
• Exhibits little or no affect in
face or voice

Alogia
• Reduction in speech
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 Outward expression of
emotion
 Vocalization
 Disorganized
speech (Formal thought disorder)
• 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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 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
another person
© 2012 John Wiley & Sons, Inc. All rights reserved.
© 2012 John Wiley & Sons, Inc. All rights reserved.
 Schizophreniform
Disorder
• Same symptoms as schizophrenia
• Symptom duration greater than 1 month but less than 6
months
 Brief
Psychotic Disorder
• Symptom duration of 1 day to 1 month
• Often triggered by extreme stress, such as bereavement
 Schizoaffective
Disorder
• Symptoms of both schizophrenia and mood disorder
 DSM-5 likely to require appearance of major depressive or
manic episode
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 Delusional
Disorder
• Delusions may include:
 Persecution
 Jealousy
 Being followed
 Erotomania
 Loved by a famous person
 Somatic delusions
• No other symptoms of schizophrenia
 Attenuated
Psychosis Syndrome
• Possible new category in DSM-5
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© 2012 John Wiley & Sons, Inc. All rights reserved.
© 2012 John Wiley & Sons, Inc. All rights reserved.

Genetically heterogeneous
• Not likely that disorder caused by single gene

Family studies
• Relatives at increased risk
• Negative symptoms have stronger genetic component

Twin studies
• 44% risk for MZ twins vs. 12% risk for DZ twins
• Children of non-schizophrenic MZ twin were more likely to
develop schizophrenia (9.4% vs. 1% in general population)

Adoption studies
• Increased likelihood of developing psychotic disorders

Familial high-risk studies
• Differing negative vs. positive symptomatology
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 Association
studies
• Two genes associated with schizophrenia
 DTNGP1
 NGR1
• Two genes associated with cognitive deficits
 COMT
 BDNF
 Genome-wide
scans
• Identification of gene mutations
• Several identified but results need to be replicated
© 2012 John Wiley & Sons, Inc. All rights reserved.
 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
 Mesolimbic dopamine abnormalities mainly related to positive
symptoms
• Underactive dopamine activity in the mesocortical
pathway mainly related to negative symptoms
© 2012 John Wiley & Sons, Inc. All rights reserved.
© 2012 John Wiley & Sons, Inc. All rights reserved.
© 2012 John Wiley & Sons, Inc. All rights reserved.
 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
© 2012 John Wiley & Sons, Inc. All rights reserved.
 Enlarged
ventricles
• Implies loss of brain cells
• Correlate with
 Poor performance on cognitive tests
 Poor premorbid adjustment
 Poor response to treatment
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 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
 Failure to show frontal activated related to negative
symptoms
• Disrupted communication among neurons due to
loss of dendritic spines
 Disconnection Syndrome
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© 2012 John Wiley & Sons, Inc. All rights reserved.
 Structural
and functional abnormalities in
temporal cortex
•
•
•
•
Temporal gyrus
Hippocampus
Amygdala
Anterior cingulate
 Reduced
gray matter and volume evident
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 Environmental 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
 Presence of parasite, toxoplasma gondii, associated with
2.5x greater risk of developing schizophrenia
 In Finnish study, schizophrenia rates higher when mother
had flu in second trimester of pregnancy
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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
• Excessive pruning of synaptic connections
• Use of cannabis during adolescence associated with
increased risk
 May
explain why symptoms appear in late
adolescence but brain damage occurs early in life
© 2012 John Wiley & Sons, Inc. All rights reserved.
 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
© 2012 John Wiley & Sons, Inc. All rights reserved.
 Schizophrenogenic mother
• Cold, domineering, conflict inducing
• No support for this theory
 Communication deviance (CD)
• Hostility and poor communication
• Inconclusive at this time
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 Family
environment impacts relapse
 Expressed Emotion (EE)
• Hostility, critical comments, emotional overinvolvement
 Bidirectional
association
• Unusual patient thoughts → increased critical comments
• Increased critical comments → unusual patient thoughts
© 2012 John Wiley & Sons, Inc. All rights reserved.
 Use
of retrospective or “follow-back” studies
 Developmental histories of children who
later developed schizophrenia
• Lower IQ
• More often delinquent (boys) and withdrawn (girls)
 Coding
of home movies
• Poorer motor skills
• More expression of negative emotion
© 2012 John Wiley & Sons, Inc. All rights reserved.
 New
Zealand study
• Cognitive deficits evident at early age
 Australian
study
• Reduced gray matter volume predicted later development of
psychotic disorder
 North
American Prodrome Longitudinal Study
• Identified factors associated with development of psychosis
 Having a biological relative with schizophrenia
 Recent decline in functioning
 High levels of pos
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 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
• Neuroleptic malignant syndrome
 Maintenance dosages to prevent
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relapse
 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)
© 2012 John Wiley & Sons, Inc. All rights reserved.
© 2012 John Wiley & Sons, Inc. All rights reserved.
 Clinical
Antipsychotic Trials of Intervention
Effectiveness (CATIE) study
• Second-generation drugs were not more effective
than the older, first-generation drug
• Second-generation drugs did not produce fewer
unpleasant side effects
• Nearly three-quarters stopped taking the
medications before study ended
 Second-generation
antipsychotics have
serious side effects
• Weight gain, diabetes, pancreatitis
 Disturbing trend for people of color:
• Not prescribed second generation antipsychotics
© 2012 John Wiley & Sons, Inc. All rights reserved.
 Patient
Outcomes Research Team (PORT)
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
© 2012 John Wiley & Sons, Inc. All rights reserved.
 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
© 2012 John Wiley & Sons, Inc. All rights reserved.
 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
remediation training or cognitive
enhancement therapy (CET)
• Improve attention, memory, problem solving and other
cognitive-based symptoms
 Case management
• Multidisciplinary team to provide comprehensive services
 Residential treatment
• Vocational rehabilitation
© 2012 John Wiley & Sons, Inc. All rights reserved.
Copyright 2012 by John Wiley & Sons, Inc. 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.
© 2012 John Wiley & Sons, Inc. All rights reserved.

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