Schizophrenia

HISTORY AND FACTS 

n  Emil Kraepelin: First to differentiate schizophrenia (then, dementia praecox) from manic-depressive psychosis

n  Dementia: progressive deterioration

n  Praecox: “early harvest” to denote early onset

n  Eugene Bleuler: Changed name to schizophrenia to denote splitting of personality’s functions

n  NOT “split personality”

n  Pervasive impairment in a full range of functions, i.e., thoughts, feelings, perception and behavior

n  Medicated vs unmedicated patient may well give the impression of two different people

n  Worldwide prevalence rate of 1%

n  In the 80s, 50% of psychiatric hospital beds were occupied by persons with schizophrenic disorders (closer to 33% today)

n  About 1 in 3 of the homeless have a schizophrenic disorder

n  3% of the prison population; 6% of maximum security prisoners

n  1 in 4 attempt suicide, 1 in 10 are eventually successful

n  Equal gender distribution, but this is complex… early onset in males, better prognosis for females

n  Generally onset in males, 20-25, females 25-30

n  Females show another peek after age 45

n  Course is more severe for males and for females with late onset

n  Seen in all SES groups but more common in lower SES… this relationship is complex

n  Chicken-Egg problem

n  Kraepelin and Bleuler thought they were secondary, but today, hallucinations and/or delusions are recognized as primary symptoms and at the core of the diagnosis

n  Other characterizations: acute vs chronic, good premorbid vs bad premorbid, excesses vs deficits, positive vs negative symptoms

n  Importantly: Persons with schizophrenic disorders are often mischaracterized as dangerous because of Hollywood portrayals… truth is just the opposite

n  The core symptoms of schizophrenia are at the basis of what we call psychosis or psychotic, i.e., delusions and hallucinations (positive symptoms)

n  Delusion: a false belief, a misrepresentation of reality… some are bizarre, some are not

n  Hallucination: a sensory experience without any input from the surrounding environment

n  Almost always auditory in schizophrenia

n  Note depiction in “Beautiful Mind”

DIAGNOSTIC CRITERIA

n   Two or more of the following:

n  Delusions

n  Hallucinations

n  Disorganized speech

n  Grossly disorganized or catatonic behavior

n  Negative symptoms

n  Flat affect

n  Alogia or Avolition

n  Anhedonia

n  Major impairment in functioning

n  Persistent symptoms for six months with one month of primary symptoms (May include prodromal or residual phase of the illness)

n  Rule out schizoaffective disorder or mood disorder

n  Rule out effects of psychoactive substance use

n  Rule out medical or neurological condition

n  Rule in or out co-existing pervasive developmental disorder (autism, Asperger’s, etc.)

Subtypes of schizophrenia

n  Paranoid

n  Disorganized

n  Catatonic

n  Undifferentiated

n  Residual

n  Other Psychotic Disorder

Positive vs. Negative Distinctions

n  Positive (Type I)

n  Presence of positive (identifiable) symptoms

n  Good response to medication

n  Optimistic prognosis

n  Absence of intellectual impairment

n  Negative (Type II)

n  Presence of negative symptoms (absence of behaviors)

n  Poor response to medication

n  Pessimistic prognosis

n  Intellectual impairments obvious

Etiology of Schizophrenia

n  Evidence is clear that stress can precipitate the first appearance of schizophrenia and can precipitate a relapse during residual or recovery phase, but genetic vulnerability usually present

n  No support over the years for “schizophrenogenic mother” as cause (double bind, mixed messages, ambivalence)

n  Note research on “Expressed Emotions” in families, a kind of “generic henpecking”

 

Treatment for schizophrenia

n  Appearance of Chlorpromazine (Thorazine, Stelazine) in the 1950s helped empty hospitals

n  These are the neuroleptics, dopamine antagonists

n  Not all pts respond, and side effects can be devastating and irreversible (e.g., tardive dyskinesia)

n  New drugs (atypical antipsychotics) in the 1990s came from benzodiazapine family (clozapine and olanzapine) and helped many who were unresponsive to conventional antipsychotics, not without their side effects (agranulocytosis)

n  Rip Van Winkle phenomenon

n  Freud never advocated psychoanalysis for schizophrenia; when tried, usually failure

n  Despite dramatic tx effects in some, the outcome of psychopharmacological approaches to schizophrenia is still only marginally effective (around 50%)

n  Supportive psychotherapy may help sustaining adjustment but medication will always be necessary for persons with schizophrenia

n  Interesting findings from behavior modification; note work of Teodoro Ayllon and Nathan Azrin on Token Economy