Chapters 10.  Schizophrenia

Slide 1: Time to think…

How do you handle stress?  Are there some ways that are more adaptive than others?  How do you handle things when you’re feeling overwhelmed and everything seems to be coming at you at once?

Slide 2: Some similar disorders...

Major depression with psychotic features

Bipolar with psychotic features

Schizotypal personality disorder

Schizoaffective disorder

 

Slide 3: Schizophrenia (APA, 1994)

(A) characteristic symptoms (2+)(significant period of time during 1  mo.):

(1) delusions;
(2) hallucinations;
(3) disorganized speech (i.e. incoherence);
(4) grossly disorganized or catatonic behavior;
(5) negative symptoms (i.e. affective flattening);

(B) social /occupational dysfunction- for a significant portion of the  time since the onset of the
      disturbance, one or more major   areas of functioning such as work, interpersonal relations, or
      self-care are markedly below the level achieved prior to the   onset (or when the onset is in childhood
      or adolescence, failure  to achieve expected level of interpersonal, academic, or occupational
       achievement);
(C) duration- (6 mo. +) with at least one month of symptoms that meet criterion A and may include
      periods of prodromal or residual symptoms.  During these prodromal or residual periods, the signs
      of the disturbance may be manifested by only negative symptoms or two or more of the symptoms
      listed in criterion A present in an attenuated form (i.e. odd beliefs, unusual perceptual experiences);
(D) schizoaffective and mood disorder exclusion- schizoaffective and mood disorder with psychotic
      features have been ruled out because either no major depressive, manic, or mixed episodes have
      occurred concurrently with the active-phase symptoms; or if mood episodes have occurred during
      active-phase symptoms, their total duration has been brief relative to the duration of the active and
      residual periods;
(E) substance/general medical condition exclusion- the disturbance is not due to the direct physiological
      effect of a substance or a general medical condition;
(F) relationship to a pervasive developmental disorder- if there is a history of autistic disorder or another
      pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent
      delusions or hallucinations are also present for at least one month.

Slide 4: Some numbers...

• About 1% of population
• Men are generally diagnosed at younger ages
• 47% abuse drugs or alcohol (4 1/2 times normal)
• Perhaps 75-90% smoke (about 25% of rest of population does)
• About 25% have episodes of depression
• About 50% attempt suicide; 10-15% complete (esp. young males)

 

Slide 5: Positive symptoms

• Delusions (grandeur, control, persecution, reference, somatic)
• Hallucinations
• Generally auditory
• Often critical or threatening
• Problematic thought processes
• difficulty screening out material
• nonsensical associations
• clang associations
• neologisms
• overinclusiveness
• Inappropriate affect
• Due to dopamine excess?

Slide 6: Delusions are often based on little data, but explain world

“Where do I know you from?” I asked a hefty woman with a tiny face…. I thought I knew her.
“In the cottage by the sea,” said the woman…, “I was you and you were me.”
This enigmatic message must be a piece to the puzzle.  I pondered it.  Grandma, before she died, had lived by the sea.  Suddenly I knew the woman was my grandma.
(Anonymous, 1990, in Sue, Sue, & Sue, 1997)

Slide 7: Nonsensical associations

Researcher: The cattle were in the pen.
Person with schizophrenia: Just like the one in my shirt pocket.
Holmes, 2001, p. 312

Slide 8: Clang associations

Oh you can have all the keys you want, they broke into the store and found peas, what’s the use of keys, policeman, watchman, dogs, dog show, the spaniel was the best dog this year, he is Spanish you know, Morrow castle what a big key they have Sampson, Schley, he drowned them all in the bay, gay, New York bay, Boradway, the White Way, … (Bleuler, 1936)

Slide 8: Neologism and tangential thought

Psychologist: How do you feel today?
Patient: Yes, sir, it’s a good day.  Full of rainbow you know.  They go along on their merry way without concern for asphyxiation or impurities.  Yes, sir, like unconcerned flappers of the cosmoblue.

Slide 9: Negative symptoms

• Social withdrawal
• Flat or inappropriate affect
• Absence of volition
• Poverty of speech
• Due to neural degeneration?  Irreversible?

Slide 10: Which would you prefer?

• Positive or negative symptoms?
• Gradual or rapid onset of symptoms

Slide 11: Long-term prognosis? (Shepherd, Watt, & Falloon, 1989)

Slide 12: Paranoid type (APA, 1994)

(A) preoccupation with one or more delusions or frequent auditory hallucinations;
(B) none of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or
      inappropriate affect.

Slide 12: Disorganized type (APA, 1994)

Each of the following:
(A) all of the following are prominent:
(1) disorganized speech;
(2) disorganized behavior;
(3) flat or inappropriate affect;
(B) the criteria are not met for catatonic type.

Slide 12: Catatonic type (APA, 1994)2 or more symptoms:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor;
(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli);
(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism;
(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing;
(5) echolalia or echopraxia.

Slide 13: God Prevails in Syracuse lawsuit

        SYRACUSE, N. Y. (AP) - A Pennsylvania man's lawsuit naming God as a defendant has been thrown out by a court in Syracuse.
        Donald Dxxxx, 63, of East McKeesport, Pa., blames God for not bringing him justice in a 30-year battle against his former employer, the steelmaker now called USX Corp.  The company fired him in 1968, when it was called U. S. Steel.
Dxxxx wanted God to return his youth and grant him the guitar-playing skills of famous guitarists, along with resurrecting his mother and his pet pigeon.  If God failed to appear in court, federal rules of civil procedure say he must lose by default, Dxxxx argued.
        U. S. District Judge Norman Mordue last week found the suit against God, former presidents Ronald Reagan and George Bush, the television networks, all 50 states, every single American, the FCC, all federal judges, and the 100th through 105th congresses to be frivolous. (Oil City Derrick, 3/15/99)

            What if his behavior is not the product of a mental illness?  How can you explain it?
 

Slide 14: An inside view of paranoia

• The sane (me) vs. the liars, and the stupid (them) in a never ending battle for “truth,” “justice,” and “freedom” in the American Way.  A technocracy disguised as a democracy.  Not guilt ever, no lo contendere always.
• The mind-controller (whose range is astronomical), synchronizes special microwave frequencies to the brain, creating an electromagnetic force field in which the natural electro-chemical energy emitted from it: (thoughts or brainwaves): is picked up by remote control and decoded with micro-computer chips for use all over the system of communications.                                           Nolen-Hoeksema, 1998, p. 225

Slide 15: More paranoia and overinculsiveness

Things that relate, the town of Antelope, Oregon, Jonestown, Charlie Manson, the Hillside Strangler, the Zodiac Killer, Watergate, King's trial in L.A., and many more.  In the last 7 years alone over 23 Starwars scientists committed suicide for no apparent reason.  The Aids coverup, the conference in South America in 87 had over 1000 doctors claim that insects can transmit it.  To be able to read one's thoughts and place thoughts in one's mind without the person knowing it's being done.  Realization is a reality of bioelectromagnetic control, which is thought transfer and emotional control, recording individual brainwave frequencies of thought, sensation, and emotions.                   Nolen-Hoeksema, 1998, p. 221

Slide 16: Paranoia or not?

        Da De asked, "Are you sure it wasn't just an accident?" "The street was empty.  He didn't have to hit me.  However, the bus passing at that precise moment might have been coincidental." "The whole thing could have been an accident," Da De argued. "No, I have seen the same man before.  The man who helped me up told me the man had a mop of black hair and a bright-colored bicycle saddle." From Da De's expression, I thought he knew who the man was.  After a moment's hesitation, he said, "Would you be angry if I give you a little advice?" "Fire away!" I said, leaning back in my chair ready to listen to him. "Do you realize that there are people in positions of power who hate your guts?  You make them think you despise them.  They want to be looked up to, feared and respected.  But they think you laugh at them.  Why don't you hide your contempt for them and just take it easy sometimes?" "How do I take it easy'?" I asked Da De. "Don't react when something happens.  Don't get angry.”
       Cheng, 1986, p. 456, after having been imprisoned and tortured during the Cultural Revolution.  Her daughter was murdered.

Slide 17: Time to think…

Everything has a consequence and often both positive and negative consequences.  Why might people choose not to take the medicine that (at least partially) restored their mental health?

Slide 12: John Nash ('94), Nobel laureate in Economics, diagnosed with paranoid schizophrenia

So at the present time I seem to be thinking rationally again in the style that is characteristic of scientists. However this is not entirely a matter of joy as if someone returned from physical disability to good physical health. One aspect of this is that rationality of thought imposes a limit on a person's concept of his relation to the cosmos….[W]ithout his "madness" Zarathustra would necessarily have been only another of the millions or billions of human individuals who have lived and then been forgotten.

Slide 13: Theories of causation

• Schizophrenogenic family
• Genetics
• Dopamine hypothesis
• Brain deterioration/virus
• Breakdown in attentional filter
• Diathesis-stress

Slide 14: Role of genetics (Gottesman, 1991)

Slide 15: Figure 10.04

Slide 15: Reduction in positive symptoms (Kane et al., 1988)

Slide 16: Reduction in negative symptoms (Kane et al., 1988)

Slide 17: Brain deterioration

Slide 18: Problems in attention (Lawson et al, 1967)

Slide 19: Side effects of antipsychotics

• Extrapyramidal side effects:
• akinesia -- expressionless face, slow motor activity, monotonous speech
• tardive dyskinesia -- involuntary movements of mouth, face, & tongue (as many as 20% of P)
• Cognitive side effects
• grogginess
• sedation
• difficulty thinking

Slide 20: Side effect or normal?

Slide 21: Why don't people take their medicine? (clues from HIV)

• forgetting
• medication interferes with lifestyle (e.g., meals, other activities)
• falling asleep
• change in routine (e.g., weekend, travel)
• alcohol or drug use
• stress
• pessimism about HIV
• need to conceal medication from others
• younger age
• complexity of regimen
• higher number of medications
• lower levels of coping efficacy
• depressed mood
sited in The AIDS Educator, 5/99

Slide 22: Factors improving compliance with medication

• Quality of doctor/patient relationship
• Low cost of medication
• Few side effects
• Greater social support

Slide 23: Psychosocial interventions

• Not enough by themselves, but the following are
• helpful adjuncts to medication:
• Token economy to teach basic skills
• Family therapy

Slide 24: Expressed emotion (Hooley, 1985)

• High expressed emotion:
• "I always say, 'Why don't you pick up a book, do a crossword or something like that to keep your mind off it.'  That's even too much trouble."
• "I've tried to jolly him out of it and pestered him into doing things.  Maybe I've overdone it, I don't know.”
• "I know  it's better for her to be on her own, to get away from me and try to do things on her own.”
• Low expressed emotion:
• "Whatever she does suits me."
• "I just tend to let it go because I know that when she wants to speak she will speak."

Slide 25: Goals of therapy for families of people with schizophrenia

• Give information about the disorder
• Give communications skills so family can become more empathic listeners
• Teach more constructive ways of expressing negative feelings
• Teach effective problem solving to help family resolve problems & conflicts
Hogarty and  colleagues (1986, 1991)

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Last modified November 1, 2001.