Schizophrenia

Etymology

• Schizophrenia (pronounced /ˌskɪtsɵˈfrɛniə/ or /ˌskɪtsɵˈfriːniə/), from the Greek roots skhizein (σχίζειν, "to split") and phrēn, phren- (φρήν, φρεν-; "mind") is a psychiatric diagnosis that describes a neuropsychiatric and mental disorder characterized by abnormalities in the perception or expression of reality

Causes of schizophrenia

• Genetic – polygenic, chromosomal regions increasing susceptibility, rare DNA deletions and duplications

• Prenatal factors – factors affect early neurodevelopment; those born in winter or spring; prenatal exposure to infections

• Social factors – living in an urban environment, poverty, etc

• Recreational drug use• Schizophrenia as a social construct

Schizophrenia

• Schizophrenia is a chronic, severe, and disabling brain disorder that affects about 1.1 percent of the U.S. population age 18 and older in a given year

• People with schizophrenia sometimes hear voices others don’t hear, believe that others are broadcasting their thoughts to the world, or become convinced that others are plotting to harm them. These experiences can make them fearful and withdrawn and cause difficulties when they try to have relationships with others.

Manifestations of Schizophrenia

• Delusions, false personal beliefs held with conviction in spite of reason or evidence to the contrary, not explained by that person's cultural context

• Hallucinations, perceptions (can be sound, sight, touch, smell, or taste) that occur in the absence of an actual external stimulus (Auditory hallucinations, those of voice or other sounds, are the most common type of hallucinations in schizophrenia.)

• Disorganized thoughts and behaviors • Disorganized speech • Catatonic behavior, in which the affected person's body may

be rigid and the person may be unresponsive

Definition

• a term, coined by Bleuler synonymous with and replacing

dementia praecox; a common type of psychosis, characterized

by a disorder in perception, content of thought, and thought

processes (hallucinations and delusions), and extensive

withdrawal of one's interest from other people and the

outside world, and the investment of it in one's own; now

considered a group or spectrum of schizophrenic disorders

rather than as a single entity.

Symptoms

• Positive symptoms - reflect an excess or distortion of normal functions

• Negative symptoms - reflect a diminution or loss of normal functions

• Cognitive symtoms – difficulties with concentration and memory

Positive Symptoms of Schizophrenia

• Delusions - • Hallucinations• Disorganized speech/thinking• Grossly disorganized behavior• Catatonic behaviors• Other symptoms

Delusions

• False beliefs strongly held in spite of invalidating evidence, especially as a symptom of mental illness

• Paranoid delusions or delusions of persecution• Delusions of reference (things in the environment

seem to be related to you)• Somatic delusions (false beliefs about your body)• Delusions of grandeur (you believe you are very

special or have special powers or abilities)

Hallucinations

• Distortions or exaggerations of perception in any of the senses

• Auditory hallucinations are the most common followed by visual

• Types: auditory, visual, tactile, olfactory and gustatory

Disorganized Speech/Thinking

• Frequent derailment or incoherence• Also known as “word salads”, thought disorder, or

loosening of associations• Ongoing disjointed or rambling monologues - in

which a person seems to talking to himself/herself or imagined people or voices.

• Severe enough to substantially impair effective communication

• Disorganized thinking is usually assessed primarily based on the person’s speech.

Grossly Disorganized Behavior

• Difficulty in goal-directed behavior leading to ADL difficulties

• Unpredictable agitation or silliness• Social disinhibition• Behaviors that are bizarre to onlookers• Purposelessness

Catatonic Behavior

• Characterized by a marked decrease in reaction to the immediate surrounding environment

• Sometimes taking the form of motionless and apparent unawareness, rigid or bizarre postures, or aimless excess motor activity.

Other Symptoms

• Sometimes present in schizophrenia but not often enough to be definitional alone

• Include affect inappropriate to the situation or stimuli, unusual motor behavior (pacing, rocking), depersonalization, derealization, and somatic preoccupations.

Negative Symptoms of Schizophrenia

• Affective flattening – decreased range and intensity of emotional expression (facial expression, voice tone, eye contact, and body language)

• Alogia – poverty of speech (decreased speech fluency and productivity manifested as short, empty replies to questions)

• Avolition - reduction, difficulty, or inability to initiate and persist in goal-directed behavior; it is often mistaken for apparent disinterest.

Types of Schizophrenia

• Paranoid schizophrenia• Disorganized or Hebephrenic Schizophrenia• Catatonic Schizophrenia• Residual Schizophrenia• Schizoaffective Disorder• Undifferentiated Schizophrenia

Paranoid Schizophrenia

• Very suspicious of others and often have grand schemes of persecution at the root of their behavior

• Hallucinations and delusions are prominent and common parts of the illness

Disorganized or Hebephrenic Schizophrenia

• In this case the person is verbally incoherent and may have moods and emotions that are not appropriate to the situation.

• Hallucinations are not usually present.

Catatonic Schizophrenia

• The person is extremely withdrawn, negative and isolated, and has marked psychomotor disturbances.

• Characterized by a marked decrease in reaction to the immediate surrounding environment, sometimes taking the form of motionless and apparent unawareness, rigid or bizarre postures, or aimless excess motor activity.

Residual Schizophrenia

• In this case the person is not currently suffering from delusions, hallucinations, or disorganized speech and behavior, but lacks motivation and interest in day-to-day living.

Schizoaffective Disorder

• These people have symptoms of schizophrenia as well as mood disorder such as major depression, bipolar mania, or mixed mania.

Undifferentiated Schizophrenia

• Conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the above subtypes

• Or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics.

Cognitive Symptoms of Schizophrenia

• Difficulties with concentration and memory• Disorganized thinking• Slow thinking• Difficulty understanding• Poor concentration• Poor memory• Difficulty expressing thoughts• Difficulty integrating thoughts, feelings and

behavior

Diagnostic Criteria

• Two or more of the characteristic symptoms for a significant portion of time during a 1-month period or less if successfully treated

• Social/occupational dysfunction• Duration: Continuous signs of the disturbance persist for at least 6

months. This 6-month period must include at least 1 month of symptoms

• Schizoaffective and mood disorder exclusion• Substance/general medical condition exclusion• 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 a month (or less if successfully treated

On 28 March 1941, Woolf committed suicide. She put on her overcoat, filled its pockets with stones, then walked into the River Ouse near her home and drowned herself. Woolf's skeletonised body was not found until 18 April. Her husband buried her cremated remains under a tree in the garden of Monk's House, their home in Rodmell, Sussex.

I feel certain that I am going mad again. I feel we can't go through another of those terrible times. And I can't recover this time. I begin to hear voices, and I can't concentrate. So I am doing what seems the best thing to do. You have given me the greatest possible happiness. You have been in every way all that anyone could be. I don't think two people could have been happier 'til this terrible disease came. I can't fight any longer. I know that I am spoiling your life, that without me you could work. And you will I know. You see I can't even write this properly. I can't read. What I want to say is I owe all the happiness of my life to you. You have been entirely patient with me and incredibly good. I want to say that — everybody knows it. If anybody could have saved me it would have been you. Everything has gone from me but the certainty of your goodness. I can't go on spoiling your life any longer. I don't think two people could have been happier than we have been. V.

John Nash, a US mathematician, began showing signs of paranoid schizophrenia during his college years. Despite having stopped taking his prescribed medication, Nash continued his studies and was awarded the Nobel Prize in 1994. His life was depicted in the 2001 film A Beautiful Mind.

Treatment

• Because the causes of schizophrenia are still unknown, treatments focus on eliminating the symptoms of the disease

• Antipsychotic medications• Various psychosocial treatments

Typical Antipsychotic Medications

• Available since the mid-1950's (typical drugs)• Chlorpromazine (Thorazine)• Haloperidol (Haldol)• Perphenazine (Etrafon, Trilafon)• Fluphenazine (Prolixin)

Second generation or atypical antipsychotics

• Developed in the 1990’s• Clozapine (Clozaril)• Risperidone (Risperdal)• Olanzapine (Zyprexa)• Quetiapine (Seroquel)• Ziprasidone (Geodon)• Aripiprazole (Abilify)• Paliperidone (Invega).

Side Effects of Antipsychotics

• Drowsiness • Dizziness when changing positions • Blurred vision• Rapid heartbeat • Sensitivity to the sun • Skin rashes• Menstrual problems for women

Side Effects of Typical Antipsychotics

• Rigidity• Persistent muscle spasms• Tremors• Restlessness• Tardive dyskinesia (TD) – with long-term use• TD causes muscle movements a person can't

control. The movements commonly happen around the mouth

Side Effects of Atypical Antipsychotics

• Atypical antipsychotic medications can cause major weight gain and changes in a person's metabolism. This may increase a person's risk of getting diabetes and high cholesterol.

• A person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking an atypical antipsychotic medication

Psychosocial Treatments

• Improving illness-management skills• Integrated treatment for co-occurring

substance abuse• Rehabilitation• Family education• Cognitive behavioral therapy• Self-help groups

Schizophrenia and Suicide

• Suicide is one of the leading causes of death for people with schizophrenia

• Up to 40% of schizophrenics will attempt suicide at least once

• Suicide is particularly likely to be attempted when they are very psychotic and out of touch with reality, when they are very depressed, and in the first 6 to 9 months of medications when they are thinking more clearly and learn of their condition

Schizophrenia and Violence

• At best a contentious topic• Current research indicates that the percentage of

people with schizophrenia who commit violent acts is higher than the percentage of people without any disorder, but lower than is found for disorders such as alcoholism

• Individuals with a diagnosis of schizophrenia are often the victims of violent crime—at least 14 times more often than they are perpetrators.

Dopamine and Schizophrenia

• Some of the most obvious evidence for this theory is from the effects of drugs such as amphetamine and cocaine. These drugs (and others like them) increase levels of dopamine in the brain and can cause symptoms which resemble those present in psychosis, particularly after large doses or prolonged use.

• Similarly, those treated with dopamine enhancing levodopa for Parkinson's disease can experience psychotic side effects mimicking the symptoms of schizophrenia.

New Findings on Schizophrenia

• Schizophrenia may blur the boundary between internal and external realities by overactivating a brain system that is involved in self-reflection, and thus causing an exaggerated focus on self, a new MIT and Harvard brain imaging study has found.

New Findings…

• In this study, appearing Jan. 19 in the advance online issue of the Proceedings of the National Academy of Sciences, found that schizophrenia also involves an excess of connectivity between the so-called default brain regions, which are involved in self-reflection and become active when we are thinking about nothing in particular, or thinking about ourselves.

New Findings…

• "We think this may reflect an inability of people with schizophrenia to direct mental resources away from internal thoughts and feelings and toward the external world in order to perform difficult tasks," Whitfield-Gabrieli explained.

New Findings…

• The hyperactive default system could also help to explain hallucinations and paranoia by making neutral external stimuli seem inappropriately self-relevant. For instance, if brain regions whose activity normally signifies self-focus are active while listening to a voice on television, the person may perceive that the voice is speaking directly to them.

New Findings…

• "People normally suppress this default system when they perform challenging tasks, but we found that patients with schizophrenia don't do this," said John D. Gabrieli, a professor in the McGovern Institute for Brain Research at MIT and one of the study's 13 authors. "We think this could help to explain the cognitive and psychological symptoms of schizophrenia."