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1

Schizophrenia - to diagnose - onset - remission

a chronic psychotic disorder with severely disturbed behavior, thinking, emotions and perceptions. Affects all facets of person’s life including cognition, affect, and behavior. - psychotic behaviors be present at some point during the course of the disorder and that signs of the disorder be present for at least six months and must be active and prominent for at least one month; at least two features of disorder be present (not just isolated delusional belief or hallucination) and that at least one of these must include the cardinal symptoms of delusions, hallucinations, or disorganized speech - develops in late adolescence -40% of shizo patients have long periods of remission lasting a year or longer. (even when unmedicated)

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Prevalence of schizophrenia 1. Us and Globa 2. Us treated/hospitilized 3. WHO 4. Gender diffs 5. Gender diffs 6. Culture diffs

•Affects 1% of US and 0.3-0.7% of the global population. •Nearly 1 million ppl in US are treated for schizo each year and a third of them require hospitalization. •WHO estimate that about 24 million suffer from schizophrenia •Men have slightly higher risk than women and tend to develop the disorder at an earlier age. ( Men’s first symptoms appear in early twenties; Women in late twenties) •Women tend to have a higher level of functioning before the onset of the disorder and tend to have less severe course than men. Men tend to have poorer response to drug therapy. Perhaps schizo affects different areas of the brain in men and women. - Hallucination more common in nonwestern

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Course of development - how many improve?

Most gradual but can be acute occurring suddenly within a few weeks or months. Psychotic behaviors may emerge gradually over several years, although early signs of deterioration may be observed. 1. Podromal Phase 2. Acute Phase 3. Residual phase - Although schizo is a chronic disorder, as many as one-half to two-thirds improve over time. Full retrun to normal behavior is uncommon but does occur in some cases. - Typically patients develop a chronic pattern of occasional acute episodes and continued cognitive emotiomal and moticational imparment in between episodes.

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Podromal Phase

period of gradual deterioration with symptoms of unuausal thoughts or abnormal perceptions (but no delusions/hallucinations), waning interest in social activites, difficulty meeting responsibilities of daily living, impaired cog functioning with memory and attention, use of language, ability to plan. First signs of podrome is lack of attention to ones appearance (failing to bathe, wearing same clothes) Speech becomes vague. Changes are so gradually they may be unconcering to family. Changes may be attributed to a phase the person is going through.

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Acute phase - symptoms (8)

behavior become bizarre; Acute episodes of schizo involve a break with reality with symptoms of delusions, hallucinations, illogical thinking, incoherent speech, and deficits such as being unable to think clearly, speaking in flat tone, having difficulty perceiving emotions and showing emotions.

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Residual phase

Follows the acute episodes; some enter this stage where behavior returns to level of prodromal phase. Psychotic behaviors are abset but person is still impaired by significant cognitive, social, and emotional deficits such as deep sense of apathy, and difficulties in thinking clearly, unusual ides like telepathy or clairvoyance.

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Positive symptoms 4-

involve break with reality; represented by hallucinations and delusions. Includes disturbed thought and speech (Aberrant content and form of thought)

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Negative symptoms (4)

affect persons ability to function and include 1. lack of emotions, 2. loss of motivation, 3. isolation, 4. limited output of speech (poverty of speech). Negative symptoms tend to persit even when positive ones have decreased and also have greater effect on person’s functioning than positive symptoms. They are also less responsive to antipsychotic drugs

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Aberrant content of thought - 7

•Delusions- abnormal content of thought; False beliefs that are fixed in persons mind despite their illogical bases and lack of evidence. They tend to remain unshakable even in face of evidence. 1.Delusions of persecution or paranoia 2.Delusions of reference (to others) 3.Delusions of being controlled 4.Delusions of grandeur 5.Thought broadcasting (thoughts are transmitted to external world) 6.Thought insertion (thoughts have been planted by external source) 7.Thought withdrawal ( thoughts have been removed from ones mind)

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Aberrant forms of thought - common symptoms(3) - less common (4)

•Thinking is disorganized, illogical; called thought disorder •Thought disorder- disturbance in thinking characterized by breakdown of logical associations between thoughts; often occurs in acute episodes but may linger into residual phases. (a positive symptom) Loosness of association is a cardinal sign of this disorder. 1. Speech may jump from one topic to another, unaware of this. 2. Speech may be completely incomprehensible 3. poverty of speech. Less common signs are 1. neologisms (made up words), 2. preservation (inaproprate but persistent repetition of the same words or train of thought), 3. clanging (stringing together of words or sound on the basis of rhyming), 4. blocking (involuntary abrupt interruption of speech or thought). •Many patients but not all show evidence of thought disorder.

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Schizo and childhood

•Cognitive defictis in schizo patients tend to emerge in childhood •Recent Denmark study showed that even in early childhood children who later developed schizo showed delays in reaching certain developmental milestons like walking without support. Suggest that schizo involves developmental processes that may have roots in childhood.

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Attentional deficiencies - Attention - deficiencies in schizo (2) - Research

•Attention is the ability to focus on relevant stimuli and ignore irrelevant ones. - Those with schizo often have trouble filtering out irrelevant stimuli making it hard to focus, organized thoughts and filter out unessential info. - They also appear to by hyperviligant or acutely sensitive to extraneous sounds. During acute episodes they may become flooded by these stimuli, overwhelming ability to make sense of enviro. -Brain abnormalities assoc with schizo may lead to deficit in ability to filter. Researchers believe that underlying genetic factors may explain the development of the sensory filtering defictin in ppl with schizo.

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Eye movement dysfunction (4) -Cause, relations, research

•Many patients have form of eye movement dysfunction such as difficutly tracking a slow moving target. Rather tan the eyes steadily tracking the target, they fall back and then catuch up in a kind of jerky movement. - Appears to involve defects in brains control of visual attention. -Common in ppl with schizo in their first degree relatives. Suggests it might be a genetically transmitted trait or biomarker- assoc with genes linked to schizo. -Investigators reported with 98% accuracy in discriminating ppl with schizo based on eye movement indicators. However its role is limited because it is not unique to schizo; ppl with bipolar sometimes have this.

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Abnormal Event Related potentials - Normal - Schizo patients - ERPs in schizo

•Research has studied brain wave patterns (ERPs) that occur in response to external stimuli such as sounds and flashes of light. Normally a sensory gating mechanism in brain inhibits or suppresses ERPs to a repeated stimulu occurring within the first 100th of a second after a stimulu is presenting. -This gating mechanism allows the brain to disregard irrelevant stimuli but it doesn’t work for schizos. As a result schizo’s may have greater difficutlty filtering out distracting stimuli leading to a sensory overlowed. •Patients also show weaker ERPs occurring around 300 milliseconds after a sound or flash of light. These ERPs are involved in process of focusing attention on a sitmulit to extrat info from it.

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Hallucinations - types (7)

most common form of perceptual disturbances which are sensory perceptions experienced in the abscnece of external stimulation. Difficult to distinguish from reality. Can involve various senses. Person can hear, see, smell things that are not there. 1. Auditory most common kind; affects 3 out of 4 2. Tactile- (tingling, burning, sensations) 3. Somatic- feeling of snakes crawling in belly 4. Visual * rare 5. Gustatory - tasting *rare 6. Olfactory - smelling *rare 7. Command hallucinations- voices that instruct them to do certain acts like harming themselves. Often cause patients to be hospitalized out of concern they will harm themselves or others. often go undetected by doctors

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Other times of hallucinations (5)

1. Hallucinations are not unique to schizo’s; those with depression, and mania can have them. They may also occur in those without psychiatric conditions and are assoc with high fevers, sates of bereavement (hearing voice of departed loved one), and unusually low levels of sensory stimulation (lying in dark room for long time) or Mirage. Unlike ppl with disorders ppl who have these types of fleeting hallucinations realize they are not real. 2. We also hallucinate in dreams and religious experiences. 3. They can also happen in wake states in response to hallucinogenic drugs like LSD. Drug induced hallucinations tend to be visual and often involve abstract shapes. Schizo hallucinations in contrast tend to be more fully formed and complex. 4. Hallucinations may also arise during delirium tremens which often occur when withdrawaling from chronic alcoholism. 5. They can also occur as side effects of medications or in neurological disorders like Parkinsons

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Causes of hallucinations (5)

- Unknown 1. Dopamine is implicated bc antipsy drugs block dop activity to reduce hallucinations. Drugs that increase dop activity like cocaine can induce them. 2. Bc hallucinations can resemble dreamlike states they may be connected to a failure of brain mechanisms that normally prevent dream images from intruding on waking states. 3. Auditory hallucinations may represent a type of inner speech (silent self-talk). Many of us talk to ourselves so auditory hallucinations may be a projection of the patient’s own internal voice onto external sources in schizo. 4. Possibility that they brain may mistake inner speech for external sounds. Investigators found the auditory cortex becomes active during autiory hallucinations in absence of real sounds. 5. defects in deeper brain structure may lead brain to create its own reality. This alt reality goes unchecked bc the higher thinking centers in the brain, located in frontal lobes, may fail to perform this reality check on these images to determine if they are real. * Research does support brain imaging studies showing abnormalities in the frontal lobes of schizo’s.

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Treatment for hallucinations

-CBT teaches hallucinatiors to reattribute their voices to themselves to change how they respond to the voices. Also trained to recognize the situational cues assoc with the hallucinations. - CBT is useful along with drug therapy to treate hallucintations and delusional thinking.

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Emotional distrubances (4)

•Disturbed emotional responses may involve negative symtoms such as loss of norm emotional expression AKA flat effect- abscenece of emotional expression in face and voice. Speak in monotone and maintain a maks. The may not experience a normal range of emotional response to ppl and events •They may also display positive symptoms with involve exaggerated or inappropriate effect (lauging for no reason) •It isnot clear wether emotional blunt is result of not being able to express emotions, to report emotions, or to acutally expereicne them. •Evidence shows that patients experience more intense neg emotions and less intense positive ones and may lack capacity to express emotions outwardly

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other impairments (6)

1. May become confused about their identities- cluster of traits that define themselves and give meaning and direction in life AKA loss of ego boundaries 2. May also have trouble adopting a third-party perspective- failing to perceive their own behavior and verbalization as socially inappropriate bc they cannot se things from another person point of view 3. Disturbances in volition- often seen in the residual or chronic state. These neg symptoms are loss of initiative to pursue goal directed activites. Unable to carry out plans and lack of interest/drive. 4. Catatonia- impaired cog and motor functioning; Unaware of environment and maintain a fixed or rigid posture that can be strenuous postitions for hours as limbs become stiff or swollen. They may exhibt odd gestures and bizarre facial expressions and become unresponsive and curtail spontaneous movement. Thy may show highly excited but purposless behavior or slow down to a state of stupor. 6. Waxy flexibility - some with cataonia display this which involves adopting a fixed posture into which they have been positioned by others. They wont respond to questions during this period; later they will report that they heard what others were saying

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Catatonia in other disorders -3

Catatonia also used to describe non psych medical conditions: Brian disorders, drug intoxication, and metabolic disorders. Found more often in ppl with mood disorders than schizo**

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Psychodynamic perspective of schizophrenia

•Represents the overwhelming of the ego by primitive sexual or aggressive drives or impulses arriving from the id. Impulses threaten the ego and give rise to intense intrapsychic conflict. •Under this threat the person regresses to an early period in the oral stage called primary narcissism-in this period infant has not yet learned that the world is distinct from self. Bc ego mediates relationship between self and world, breakdown in ego accounts for detachment from reality. Input from id cause fantasise to become mistaken for reality. Primitive impulses may also carry more weight than social norms and be expressed in bizarre behavior.

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Harry Stack Sullivan

Psychodynamic theorists who placed more emphasis on interpersonal than on intrapsy conflicts. Emphasized the impaired mother-child relationships can set the stage for gradual withdrawal from others. In childhood, anxious and hostile interactions between child and parent cand lead the child to take refuge in a private fantasy. A vicious cycle ensues: more child withdraws, less opportunity there is to develop a sense of trust in others and social skills necessary to establish intimacy. When faced with increasing demands of work and school later on, person withdraws completely.

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Learning Perspective -example

•Some forms of schizo behavior can be understood by classical and observational learning. Ppl with schizo learn to exhibt abnormal behavior when these are more likely to be reinforced than normal behaviors -Operant conditioning: Haughton and Ayllon conditioned a 54 year old women with chronic schizo to cling to a broom. Reinforced by cigarette.

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socio-cognitive perspective

modeling of behavior can occur within the mental hospital when those begin to model themselves after fellow patients who act strangely. Hospital staff may also pay attention to those who exhibt bizarre behavior. •This theory works somewhat however, most with schizo develop it prior to exporsure of others.

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Biological perspective -4 -genetic relationship ( 3 subtheories)

1. Closer the genetic relationship between patient and family memebers the greater the likelihood that their relative will develop. 2. Overall first degree relatives of ppl with schizo have about a tenfold risk of developing schizo 3. Children of parents who both have schizo have less than a 50% chance of developing 4. MZ twins show about 48% or more than twice the rate found among DZ twins (However, identical twins may be treated the same) 5. No single gene responsible but a combo of common variations or genetic mutations 6. Offspring of older fathers stand a greater chance of developing bc sperm mutations - dopamine hypothesis, viral infections, brain abnormalities,

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adoptee studies (2)

•To sort out environmental factors, use adoption studies of high risk schizo children. Their risk of schizo was related to the prescence of schizo in the bio of parents not their adoptive parents. •Also, children with high risk who were raised in low SES homes have higher risk

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cross fostering study - study

another method to tease out genetic environmental influences. Compares the incidence of schizo among children whose bio parents either had or didn’t have shizo and were reared by adoptive parnts who either had or didnt have schizo. - Wenmark’s Denmark study; found risk of schizo related to presence of schizo in the childrens bio parents but not in adoptive parents. High risk children were almost twice as likely to develop schizo as those of nonschizo bio parents regardless of whether they were reared by a parent with schizo.

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Dopamine hypothesis - 2 sources of evidence - other neuroT's

leading biochem model of schizo; posits that it involves overreactivity of dop trans in brain; possibility that overreactivity of dopamine recpetors may be resoponsible for positive symptoms whereas decrease dopamine may help explain neg ones. 1. Major source of evidence found among antipsychotic drugs called neuroleptics- block dop receptors; inhibit excessive transmission of neural impulses that give rise to schizo behavior. 2. More evidence found in actions of amphetamines- stimulant drugs. Increase dopamine in synamptic cleft by blocking its reuptake by presynaptic neurons. When used in larged doses these drugs can cause symtoms sim to schizo like paranoia -evidence of roles of serotonin, acetylcholing, glutamate, and GAMA

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Viral infections - Investigators evidence (4) (rate)

•Prenatal rubella (german measles) is a viral infection that casues later mental retardation. 1.Evidence points to possible links between prenatal infections and later development of schizo 2.Investigators found a sevenfold greater risk of schizo in individuals exposed to the flu during the three months of prenatal development 3.Risk of schizo is greater in ppl who are born in the winter and early spring months in northern hemisphere (time of flu) 4.Even if viral evidence was discovered it would only account for a small fraction of cases