SCHIZOPHRENIA LECTURE OUTLINE Historical perspective Incidence/prevalence Description Diagnostic...
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Transcript of SCHIZOPHRENIA LECTURE OUTLINE Historical perspective Incidence/prevalence Description Diagnostic...
SCHIZOPHRENIA
LECTURE OUTLINE
• Historical perspective
• Incidence/prevalence
• Description
• Diagnostic issues
• Etiology – Dynamic vulnerability model
• Treatment, rehabilitation, and early intervention
SCHIZOPHRENIA
Historical perspective
• Ancient and medieval times – demonic possession
• Morel (1852) – demence precoce
• Kraeplin (1893) – dementia praecox
• Bleuler (1911) – schizophrenia
• Today – family of problems, core is disordered thought
• Often confused with dissociative identity disorder (multiple personality disorder)
SCHIZOPHRENIA
Incidence/prevalence
• Lifetime prevalence rates range from .5% to 1%
• Low incidence rate also – 1 per 10,000 per year, but very debilitating disorder
• Onset from adolescence to age 45
• Men have earlier onset (18-25) than women (25-35)
SCHIZOPHRENIA
Description
• Process vs. reactive schizophrenia
• Usually it is the family who seeks treatment
• Frequent cause of psychiatric hospitalization (50% in psych hospitals)
• High rates of rehospitalization
• Severe impairment of social, occupation, educational functioning, resulting in poverty, poor housing, discrimination
SCHIZOPHRENIA
Description
• Formerly long-term stays in psych hospital, assumption of chronicity
• Harding et al. (1987) follow-up study of patients diagnosed with schizophrenia from Vermont State Hospital
• 20-25 years later, more than half showed considerable improvement
• current vision of recovery
SCHIZOPHRENIA
Description – Positive symptoms
• Delusions – false beliefs that have no basis in reality; persecutory, religious, grandiose, reference, somatic
• Hallucinations - false perceptions in the absence of any relevant sensory stimulus; auditory are most common; lack of control over hallucinations is key feature
SCHIZOPHRENIA
Description – Positive symptoms
• Disorganized speech – thought-content and thought-form symptomatology; derailment, neologisms, word salad, excessive concreteness
• Grossly disorganized behaviour – can be manifested in a variety of ways
SCHIZOPHRENIA
Description – Positive symptoms
• Catanonia – stuporous, rigidity, negativism, posturing, waxy flexibility; echopraxia and echolalia; excitement
SCHIZOPHRENIA
Description – Negative symptoms
• Reflect an erosion or loss of normal functions, patterns of experience and conduct
• Symptoms include: impoverishment of emotional expression, reactivity, and subjective experience (emotional blunting)
• Other symptoms include: thought blocking, avolition, anhedonia, asociality, attention deficits
SCHIZOPHRENIA
Description – Three main types of symptoms
• Psychomotor poverty
• Disorganization
• Reality distortion
SCHIZOPHRENIA
Diagnostic issues
DSM – IV lists 9 disorders under the category of schizophrenia and other psychotic disorders• Schizophrenia
• Schizophreniform disorder
• Schizoaffective disorder
• Delusional disorder
• Brief psychotic disorder
• Shared psychotic disorder
• Psychotic disorder due to a general medical condition
• Substance-induced psychotic disorder
• Psychotic disorder not otherwise specificed
SCHIZOPHRENIA
Diagnostic issues
• US-UK study (Cooper et al., 1982) – Schizophrenia more likely to be diagnosed in US, mood disorder in UK
• DSM-IV – must have 2 or more of: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviour, negative symptoms (only 1 needed if delusions are bizarre or voice keeps running commentary on person’s behaviour or thoughts)
SCHIZOPHRENIA
Diagnostic issues - Subtypes
• Paranoid – 35-40%
• Disorganized – 10%
• Catatonic – 10%
• Undifferentiated – 20%
• Residual – 20%
SCHIZOPHRENIA
Diagnostic issues – 2-factor theory
• Factor I – severity of disorder – paranoid type is less severe than other types
• Factor II – severity of symptoms – frequency and prominence of symptoms irrespective of subtype
SCHIZOPHRENIA
Etiology – Dynamic vulnerability model
• Genetic endowment
• Vulnerability
• Symptoms of schizophrenia
• Appraisal and coping
• Stressors
SCHIZOPHRENIA
Etiology – Vulnerabilities
• Developmental influences – studies of high-risk children
• Genetics – according to your text – 45% concordance for MZ twins, 10-15% for DZ; Torrey et al. (1994) review of 8 twin studies – 28% for MZ, 6% for DZ
• Biochemical influences – Dopamine hypothesis
SCHIZOPHRENIA
Etiology – Vulnerabilities
Evidence supporting dopamine hypothesis
• Anti-psychotic drugs reduce transmission of dopamine
• High number of dopamine receptors in brains of people with schizophrenia
• Amphetamine psychosis
Research suggests that other neurotransmitters are likely involved (e.g., NE and glutamate)
SCHIZOPHRENIA
Etiology – Vulnerabilities
• Prenatal and perinatal influences
• Neuroanatomical – basal ganglia and thalamus, front lobes, temporal lobes and ventricles
• Neurodevelopmental factors – synaptic density
• Personality factors
SCHIZOPHRENIA
Etiology – Stressors
• Family dynamics – “schizophrenogenic mothers,” double-bind hypothesis, expressed emotion (criticism, hostility, overinvolvement)
• Cultural influences – people who experience schizophrenia in developing countries appear to do better than those in industrialized nations
SCHIZOPHRENIA
Etiology – Stressors
• Social status – SES inversely related to rates of schizophrenia; social selection vs. social causation (sociogenic) hypotheses
• Labelling theory
• Other stressors – child sexual abuse
SCHIZOPHRENIA
Treatments – The medical model
• Some past “treatments” – insulin coma therapy, lobotomy
• Pharmacotherapy – anti-psychotic drugs; problem of side-effects (EPS) and Tardive Dyskenesia
• ECT
• Individual therapy, family therapy and psychoeducation, group therapy by professionals – inpatient and outpatient
SCHIZOPHRENIA
Treatments – The medical model
• Mental hospitalization – Goffman (1961), Asylums, the total institution, “disculturation,” “closing the ranks,” “spoiled identity”
• Efforts to reform the mental hospital – therapeutic community (Maxwell Jones) and token economies (behaviourism)
SCHIZOPHRENIA
Treatments – Paul & Lentz (1977) study
• Comparative study – therapeutic community (milieu), token economy, typical hospitalization
• 28 participants randomly assigned to the 3 groups (half men, half women)
• All with diagnosis of schizophrenia, all receiving drug treatment
• > 1/3 mute or incontinent
• Average of 17 years of hospitalization
SCHIZOPHRENIA
Treatments – Paul & Lentz (1977) study
Common elements of milieu and token economy
• Residents, not “patients”
• Residents not sick, expected to be responsible
• Informal relations
• Open communication between staff and residents
• Same staff operated the 2 programs
SCHIZOPHRENIA
Treatments – Paul & Lentz (1977) study
Therapeutic milieu program
• Expectations
• Involvement
• Group cohesion
SCHIZOPHRENIA
Treatments – Paul & Lentz (1977) study
Outcomes
• Improved behaviour greatest for token economy residents
• Release rates – token economy (96%), milieu (68%), hospital (46%) at 18-month follow-up after release
SCHIZOPHRENIA
Treatments – Paul & Lentz (1977) study
Outcomes
• Cost-effectiveness – token economy was most cost-effective
• only 10% of token economy residents and 18% of milieu residents remained on psychotropic medications
SCHIZOPHRENIA
Treatments – Shift to community
• What happens after hospitalization? (Goering et al., 1981) – psychiatric aftercare in Toronto
• Deinstitutionalization or transinstitutionalization? From mental hospital to general hospital psychiatric wards
• First person accounts
SCHIZOPHRENIA
Treatments – Shift to community
Community mental health approaches
• Programs of Assertive Community Treatment (PACT, Stein & Test, 1980) and case management
• Supportive housing – the residential continuum (from halfway house to group home to supervised apartment to independent living)
SCHIZOPHRENIA
Treatments – Shift to community
• Supported housing, employment, and education (Paul Carling, 1995) – “choose, get, and keep” philosophy, consumer control and self-determination, community integration
• Self-help and consumer/survivor initiatives – “a home, a job, a friend,” self-help groups and organizations, consumer-run businesses (A-way express, the Raging Spoon)
SCHIZOPHRENIA
Early intervention?
• Several projects, beginning in Australia, aimed at early psychosis intervention
• Phases of psychotic episode – prodrome, actue symptoms, recovery
• Gatekeeper education, quick access to treatment, home-based treatment, low-dose drug treatment – designed to intervene early in first episodes
SCHIZOPHRENIA SUMMARY
• A very rare but disabling disorder
• Characterized by loss of contact with reality, including delusions, hallucinations, disorganized speech and behaviour, and negative symptoms
• Several different sub-types
• Great deal of heterogeneity in how this disorder is manifested
SCHIZOPHRENIA SUMMARY
• A very mysterious disorder in terms of its origins/causes
• Several different lines of research are being pursued to examine vulnerabilities and stressors
• The medical model (hospitalization and drug therapy) has been the dominant way of responding to this disorder
SCHIZOPHRENIA SUMMARY
• Many problems with this model
• Newer approaches include a variety of community mental health programs and early psychosis intervention