Schizophrenia; understanding and issues
- 1. Schizophrenia Sushma Rathee Assistant Clinical Psychologist, PGIMER, Chandigarh Email sushmaratheecp@gmail.com Schizophrenia; understanding and issues
- 2. Schizophrenia Definition – mental condition involving distorted perceptions of reality and inability to function in most aspects of life
- 3. Schizophrenia The term schizophrenia was introduced into the medical language at the beginning of this century by the Swiss psychiatrist Bleuler. So far, no society or culture anywhere in the world has been found free from schizophrenia and there is evidence that this puzzling illness represents a serious public health problem.
- 4. Schizophrenia The most debilitating mental illnesses Greek terms - "splitting of the mind” do not have more than one distinct personality distortions in their perceptions, feelings, and relationships with the world around them. 1% of the population suffer (in 12 m period) 4
- 5. History Emil Kraepelin: This illness develops relatively early in life, and its course is likely deteriorating and chronic; deterioration reminded dementia (“Dementia praecox”), but was not followed by any organic changes of the brain, detectable at that time. Eugen Bleuler: He renamed Kraepelin’s dementia praecox as schizophrenia (1911); he recognized the cognitive impairment in this illness, which he named as a “splitting of mind”. Kurt Schneider: He emphasized the role of psychotic symptoms, as hallucinations, delusions and gave them the privilege of “the first rank symptoms” even in the concept of the diagnosis of schizophrenia.
- 6. 4 A (Bleuler) Bleuler maintained, that for the diagnosis of schizophrenia are most important the following four fundamental symptoms: Affective Blunting Disturbance of Association Autism Ambivalence These groups of symptoms, are called four A “s” and Bleuler thought, that they are primary for diagnosis.
- 7. Course of Illness Course of schizophrenia: continuous without temporary improvement episodic with progressive or stable deficit episodic with complete or incomplete remission Typical stages of schizophrenia: prodromal phase active phase residual phase
- 8. Course Age (Years) Good Function of Psychopathology Poor 15 20 30 40 50 60 70 Premorbid Progression Stable Relapsing Psycho-logical Functioning
- 10. Clinical Picture Diagnostic manuals: lCD-10 (International Classification of Disease, WHO) DSM-IV (Diagnostic and Statistical Manual, APA) Clinical picture of schizophrenia is according to lCD-10, defined from the point of view of the presence and expression of primary and/or secondary symptoms (at present covered by the terms negative and positive symptoms).
- 11. Two Categories of Symptoms in Schizophrenia Positive symptoms Negative symptoms
- 12. Positive Symptoms Distortions or excesses of normal functioning delusions, hallucinations, disorganized speech, thought disturbances, motor disturbances Positive symptoms are generally more responsive to treatment than negative symptoms
- 13. Delusions False beliefs that are firmly and consistently held despite disconfirming evidence or logic Individuals with mania or delusional depression may also experience delusions. However, the delusions of patients with schizophrenia are often more bizarre (highly implausible).
- 14. Types of Delusions Delusions of Grandeur Belief that one is a famous or powerful person from the past or present Delusions of Control Belief that some external force is trying to take control of one’s thoughts (thought insertion), body, or behavior
- 15. Cont…. Thought Broadcasting Belief that one’s thoughts are being broadcast or transmitted to others Thought Withdrawal Belief that one’s thoughts are being removed from one’s mind Delusions of Reference Belief that all happenings revolve around oneself, and/or one is always the center of attention Delusions of Persecution Belief that one is the target of others’ mistreatment, evil plots, and/or murderous intent
- 16. Hallucinations Sensory experiences in the absence of any stimulation from the environment Any sensory modality may be involved Auditory (Hearing); Visual (Seeing); Olfactory (Smelling); Tactile (Feeling); Gustatory (Tasting); Auditory hallucinations are most common.
- 17. Common Auditory Hallucinations in Schizophrenia Hearing own thoughts spoken by another voice Hearing voices that are arguing Hearing voices commenting on one’s own behavior
- 18. Disorganized Speech / Thought Disturbances Problems in organizing ideas and speaking so that a listener can understand. Loose Associations (cognitive slippage) continual shifting from topic to topic without any apparent or logical connection between thoughts. Neologisms new, seemingly meaningless words that are formed by combining words.
- 19. Disorganized Motor Disturbances Extreme activity levels (unusually high or low), peculiar body movements or postures (e.g., catatonic schizophrenia), strange gestures and grimaces.
- 20. Negative Symptoms Behavioral deficits that endure beyond an acute episode of schizophrenia More negative symptoms are associated with a poorer prognosis Some negative symptoms might be secondary to medications and/or institutionalization
- 21. Types of Negative Symptoms Anhedonia inability to feel pleasure; lack of interest or enjoyment in activities or relationships Avolition inability or lack of energy to engage in routine (e.g., personal hygiene) and/or goal-directed (e.g., work, school) activities Alogia lack of meaningful speech, poverty of speech (reduced amount of speech) or poverty of content of speech (little information is conveyed; vague, repetitive) Asociality Impairments in social relationships; few friends, poor social skills, little interest in being with other people
- 22. Cont… Flat Affect No stimulus can elicit an emotional response Patient may stare vacantly, with lifeless eyes and expressionless face. Voice may be toneless. Flat affect refers only to outward expression, not necessarily internal experience.
- 23. Common subtypes of Schizophrenia 1) Paranoid: Delusions or hallucinations are prominent 2) Hebephrenic: Sustained flattened or incongruous affect Lack of goal directed behaviour Prominent thought disorder
- 24. Cont…. 3) Catatonic: Sustained evidence over at least two weeks of catatonic behaviour including stupor, excitement, posturing, and rigidity 4) Simple: Considerable loss of personal drive Progressive deepening of negative symptoms Pronounced decline in social, academic, or employment performance
- 26. Causes of Schizophrenia Genetic factors Chemical imbalance & physical abnormalities – neurotransmitters, brain structures Biological factors – age, virus. Environmental factors – chronic life stressors, changes. 26
- 27. What causes schizophrenia? Are genes important? While the lifetime risk in the general population in just below 1%, it is 6.5% in first degree relatives of patients, and it rises to more than 40% in monozygotic twins of affected people.
- 29. Causes - genetic influences Identical twin affected 50% Fraternal twin affected 15% Both parent affected 35% One parent affected 15% Brother or sister affected 10% No affected relative 1% 29
- 30. Early onset schizophrenia: Wave of gray matter loss - begins in parietal cortex and spreads forward
- 31. Can drug abuse cause schizophrenia? We know that stimulants like cocaine and amphetamines can induce a picture clinically identical to paranoid schizophrenia, and recent reports have also implicated cannabis.
- 32. Etiology of Schizophrenia The etiology and pathogenesis of schizophrenia is not known It is accepted, that schizophrenia is „the group of schizophrenias“ which origin is multifactorial: Internal factors – genetic, inborn, biochemical External factors – trauma, infection of CNS, stress
- 33. Dopamine Hypothesis The most influential and plausible are the hypotheses, based on the supposed disorder of neurotransmission in the brain, derived mainly from 1. the effects of antipsychotic drugs that have in common the ability to inhibit the dopaminergic system by blocking action of dopamine in the brain 2. dopamine-releasing drugs (amphetamine, mescaline, diethyl amide of lysergic acid - LSD) that can induce state closely resembling paranoid schizophrenia
- 34. Classical dopamine hypothesis of schizophrenia: Psychotic symptoms are related to dopaminergic hyperactivity in the brain. Hyperactivity of dopaminergic systems during schizophrenia is result of increased sensitivity and density of dopamine D2 receptors in the different parts of the brain.
- 35. Contemporary Models Dopamine hypothesis revisited: various neurotransmitter systems probably takes place in the etiology of schizophrenia (norepinephric, serotonergic, glutamatergic, some peptidergic systems); based on effects of atypical antipsychotics especially. Contemporary models of schizophrenia conceptualize it as a neurocognitive disorder, with the various signs and symptoms reflecting the downstream effects of a more fundamental cognitive deficit: the symptoms of schizophrenia arise from “cognitive dysmetria” (Nancy C. Andreasen) concept of schizophrenia as a neurodevelopmental disorder (Daniel R. Weinberger)
- 36. Neurodevelopmental Model Presence of “silent lesion” in the brain, mostly in the parts, important for the development of integration (frontal, parietal and temporal), which is caused by different factors (genetic, inborn, infection, trauma) during very early development of the brain in prenatal or early postnatal period of life. It does not interfere too much with the basic brain functioning in early years, but expresses itself in the time, when the subject is stressed by demands of growing needs for integration, during formative years in adolescence and young adulthood.
- 37. Causes… 4. Neurotransmitters (Biological) *too much dopamine, low levels of serotonin and glutamate
- 38. Causes… Brain Abnormalities (Biological): * Reduced number of neurons * Enlarged ventricles * Thalamus abnormalities
- 40. Causes… Prenatal Damage * Malnutrition * Viruses
- 41. Causes… Environment * Family Stress * Poor Social Interactions * Infections or Viruses at an early age * Trauma at an early age
- 42. Causes… Reinforcement of a bizarre behavior (Behaviorists)
- 43. KH2F0905 09_05 Percentage of Risk General Population Offspring of Two Schizophre- nic Parents Spouse First Cousin Uncle or Aunt Nephew or Niece Grand- child Half Sibling Parent Sibling Fraternal Twin Offspring of One Schizophre- nic Parent Identical Twin 50 40 30 20 10 0 Second-Degree Relative First-Degree Relative 1% 2% 2% 2% 4% 5% 6% 6% 9% Relationship to Schizophrenic Person 60 Third-Degree Relative Unrelated Person 13% 17% 46% 48%
- 45. Incidence and prevalence: Incidence studies of relatively rare disorders, such as schizophrenia, are difficult to carry out. Surveys have been carried out in various countries, however, and almost all show incidence rates per year of schizophrenia in adults within a quite narrow range between 0.1 and 0.4 per 1000 population.
- 46. Consequences of schizophrenia 95% of sufferers – lasts a lifetime 1/3 of homeless suffer from Schizophrenia 15% no respond to medicine; 75% partial effective 20-50% attempt suicide, 10% kill themselves 20% shorter life expectancy 25% experience secondary depression 46
- 47. Comorbidity In recent years, a number studies of diagnostic patterns in both clinical and community samples have shown that comorbidity among mental disorders is fairly common (Kessler, 1995). Schizophrenia is no exception: the risk in people with schizophrenia of meeting criteria for other mental disorders is many times higher than in the general population. In relation to treatment and prognostic issues, comorbidity with depression and substance abuse is especially relevant.
- 49. Clinical issues: Current operationalized diagnostic systems, while undoubtedly very reliable, leave the question of validity unanswered in the absence of external validating criteria. Diagnosis of schizophrenia should therefore be considered a provisional tool that organizes currently available scientific knowledge for practical purposes, but leaves the door open to future developments.
- 50. Cont… Since the boundaries between schizophrenia and other psychotic disorders are ill-defined, differential diagnosis, particularly during the early stages, can be difficult. No single sign or symptom is specific of schizophrenia so the diagnosis always requires clusters of symptoms to be recognized over a period of time. Careful standardized diagnostic assessment, while useful for research, may not be necessary in clinical practice.
- 51. Cont… The diagnosis of schizophrenia does not carry enough information for treatment planning. Symptoms suggestive of schizophrenia can be found in a number of neurological and psychiatric disorders. Non-compliance with medical regimen. Caregiver’s needs - cope with strange and frightening behaviors i.e. apathy, poor personal hygiene, violence.
- 52. Cont… Depression - part of the symptoms, be masked during acute stage Relapse - stressors, noncompliance Stress & coping - Substance abuse -30% have dual diagnosis, cause negative effect on the treatment & poor outcomes Work - no work, inability, no motivation 52
- 53. Common in all cultures, genders, and races Men tend to develop symptoms earlier
- 54. Other issues: Mortality: Although schizophrenia is not in itself a fatal disease, death rates of people with schizophrenia are at least twice as high as those in the general population. Suicide: However, recent studies of people with schizophrenia living in the community showed suicide and other accidents as leading causes of death in both developing and developed countries. Social disability: self-care, which refers to personal hygiene, dressing and feeding. Occupational performance: Which refers to expected functioning in paid activities, studying, homemaking.
- 55. Cont… Functioning in relation to family and household members, which refers to expected interactions with spouses, parents, children or other relatives. Functioning in a broader social context, which refers to socially appropriate interaction with community members, and participation in leisure and other social activities. Social stigma: Social stigma refers to a set of deeply discrediting attributes, related to negative attitudes and beliefs towards a group of people, likely to affect a person’s identity and thus leading to a damaged sense of self through social rejection, discrimination and social isolation.
- 56. Impact on caregivers The economic burden related to the need to support the patient and the loss of productivity of the family unit. Emotional reactions to the patient’s illness, such as guilt, a feeling of loss and fear about the future. The stress of coping with disturbed behaviour. Disruption of household routine. Problems of coping with social withdrawal or awkward interpersonal behaviour. Curtailment of social activities.
Editor's Notes
- #5: Symptoms of schzo do not usually fully emerge until early teens or young adulthood
- #12: -A table with the positive, negative, and cognitive symptoms of schizophrenia is found on Pg. 553
- #13: -Details about the positive symptoms are found in the 2nd and 3rd paragraphs of the section titled “Description”
- #14: -Definition of “delusions” is on Pg. 552 -Specifically, information about delusions is in the 2nd paragraph in the section titled “Description”
- #15: -Delusions of grandeur and delusions of control are also found on Pg. 552 -Specifically, in the 2nd paragraph in the section titled “Description”
- #16: -Thought broadcasting and thought withdrawal not in book.
- #17: -Information about hallucinations found in 3rd paragraph in the section titled “Description” on Pg. 552.
- #19: -Loose association and neologisms not found in book
- #20: -Disorganized motor disturbances found on Pg. 552 -Specifically, in the 4th paragraph under the section titled “Description”
- #21: --Negative symptoms found on Pg. 552, in the 4th paragraph in the section titled “Description”
- #22: -Anhedonia is found on Pg. 552 (italicized, not in bold print) -”Avolition” term itself not mentioned in book, however, lack of initiative is listed as a symptom
- #23: -The term “flat affect” itself is not mentioned in book, however, flattened emotional response is listed as a symptom on Pg. 552.
- #27: Chemical imbalances: Neurotransmitter; Dopamine increased; organic factor is more popular now Physical abnormalities: Brain structures changed; Increased ventricular brain ratios, Brain atrophy, cerebral blood flow↓ Biological factors- Chemical structures change in the body; Teenager onset ; Viral infection in a mother during pregnancy Environmental factors- Psychodynamic theories: life event, stress, emotional strain ;Personality development -Freud; Erikson; Sullivan ;Family theories - double-bind theories; blame theories; dysfunctional families
- #31: -Section titled “Evidence for Brain Abnormalities in Schizophrenia” (Pg. 557) -Details of brain tissue damage for schizophrenics found in the 2nd and 3rd paragraphs specifically
- #47: Secondary depression may come from negative symptoms; isolation; fewer personal resources for support and comfort.
- #53: Disability, dysfunction, disadvantage,