CPch9 - Schizophrenia Flashcards
(96 cards)
1
Q
General Info
A
2
Q
What is Psychosis?
A
A disruption in the experience of reality
3
Q
What is the prevalence of psychotic experiences?
A
About 2/100 people will experience a psychotic experience in a given year (not every year, in one, any year)
- In Adolescents the prevalence is highest, with 5/100
- In Older Adults the prevalence is the lowest, with 1/100
30% of those who have a PE, will experience another within the same year
4
Q
What is Schizophrenia?
A
It’s a disorder that has recurring episodes of psychosis that are correlated with a general misperception of reality
5
Q
What are the characteristics of schizphrenia?
A
- Disordered thinking (not logically related ideas)
- Faulty attention and perception
- Lack of emotional expressiveness
- Disturbances in behavior
- Delusions (odd beliefs) & Hallucinations
6
Q
What is the comorbidity of schizophrenia?
A
- Substance Use Disorders
- Bipolar Disorders
Especially Bipolar Disorders, probably because of similar genetic vulnerability
7
Q
What are the mortality rates for people that have schizophrenia?
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Higher mortality rates in general (doesn’t specify causes)
- They’re 12x more likely to die from suicide than people without schizophrenia
8
Q
Gender
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- Slightly more in men than in women
- Women have a few more symptoms than men, but their social functioning remains better
9
Q
When is the onset of schizophrenia?
A
It appears in adolescence/early adulthood, specifically from 16-30 years old.
- “Peak” in men: early to mid 20’s
- “Peak’ in women: late 20’s
(Onset in men is a bit earlier than women)
10
Q
What is the Lifetime Prevalence of schizophrenia?
A
0.7 - 1%
11
Q
Other notes
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People with schizophrenia have acute episodes of symptoms and then less severe, different symptoms between episodes
!!! People only have some of the symptoms at any given time. People with schizophrenia in general can never have all the symptoms stated in the DSM-5 !!!
12
Q
Symptoms
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13
Q
What are the 3 types of symptoms for schizophrenia?
A
- Positive (Psychotic) Symptoms
- Negative Symptoms
- Disorganized symptoms
14
Q
(Positive Symptoms)
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15
Q
What are positive symptoms?
A
The symptoms prevalent in schizophrenic episodes.
They consist of (add to the the rnomal experience):
- Delusions
- Hallucinations
16
Q
What are Delusions?
A
Beliefs contrary to reality and firmly held despite disconfirming evidence
17
Q
What are some examples of Delusions?
A
- Thought Insertion: My thoughts have been placed in my head by somebody/something else
- Thought Broadcasting: My thoughts are being broadcasted and people can hear what I’m thinking
- Delusion of reference: Find personal significance in others trivial activities (When other stuff are happening in the environment that have got nothing to do with me, I truly think that it has got something to do with me, e.g. if I overhear two people having a conversation about the weather, I will think the others are saying something about me)
- Delusion of control: External forces are controlling me
- Grandiose delusion
- Persecutory delusion: Somebody’s conspiring against me/ chasing me
18
Q
What are the most common and least common delusions?
A
- Most common: Delusion of reference and persecution
- Least common: Somatic (something is wrong with my body), Grandiose, Erotomanic (when you think somebody else is crazy in love with you), Nihilistic (that everything will be destroyed) Delusion
19
Q
What are Hallucinations?
A
Sensory experiences without any external stimulation from the environment
About 5%-28% of the general population has/will have an audiovisual hallucination
20
Q
What are the most common hallucinations?
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Auditory (>visual). But hallucinations can occur in all sensations
- Hearing one’s own thoughts as if they’re being spoken by another voice
- Hearing a voice commenting on one’s own behavior
~ The louder, longer and more frequent the hallucinations, the more unpleasant people find them
~ If Hallucinations entail a familiar voice, of somebody we know, then we find them more pleasant
21
Q
What is a biological explanation for these auditory hallucinations?
A
Increased activity in Broca’s and Wernicke’s Areas. This shows that there’s a problem in connections between frontal lobe (speech production) and temporal lobes (speech comprehension)
22
Q
What hallucinations are prevalent in children and in what form?
A
- Auditory hallucinations: About 9% of 8 year old children have auditory hallucinations. But in general they don’t persist. 76% of 12 or 13 year old’s don’t have such hallucinations anymore
- Imaginary friends (Audiovisual): 46% of children aged 5 to 12 years old
23
Q
(Negative Symptoms)
A
24
Q
What are Negative Symptoms?
A
Present also beyond an acute episode, and the presence of such symptoms strongly predicts a poor quality of life.
(!!! They’re not only present when there’s not an acute episode, can also be present during one !!!)
They consist of:
- Avolition
- Asociality
- Anhedonia (Motivation and Pleasure Domain)
- Blunted Affect
- Alogia (Expression Domain)
25
What is Avolition?
It's diminished motivation and seeming absence of interest or persistence in everyday activities
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What has a study on people with schizophrenia and avolition shown?
People with schizophrenia have:
- less motivation than controls in goals regarding self-expression, gaining new skills, knowledge or praise
- more motivation than controls in goals that aim to reduce boredom
- same motivation as controls in goals regarding interacting with others and avoiding criticism
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What is Asociality?
Severe impairments in social relationships
- few friends, poor social skills
- No desire for close social relationships
- Want to spend much time alone
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What is Anhedonia?
Reduced motivation or ability to experience pleasure. People with schizophrenia though have deficits in anticipatory pleasure, not consummatory pleasure
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What is the Blunted Affect?
Lack of outward expression (inner experience though is as strong, maybe even stronger than people without schizo. at sometimes)
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What is Alogia?
Reduction in amount of speech.
- People answer with one or two word and won't elaborate, even when asked to
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What are the most common and least common negative symptoms?
- Most common: Blunted affect, avolition
- Less common: Alogia, Anhedonia, Asociality
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(Disorganized Symptoms)
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What are the two main disorganized symptoms?
- Disorganized speech (also called Formal thought Disorder)
- Disorganized Behavior
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What is Disorganized Speech (Formal thought Disorder)?
- Problems in organizing ideas when speaking so that the listener can understand, OR
- Loose associations (derailment): The person is more successful in communicating with another person (can organize ideas better), but has difficulty sticking to one topic (drifts aways)
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What is Disorganized Behavior?
Lose ability to organize behavior and make it conform to community standards. Also they have difficulties performing everyday tasks.
36
What is Catatonia?
Repeated gestures and using peculiar and complex sequences of fingers, hand and arm movements.
- Some show increased level of activity, energy and excitement, as if they have mania
- Other have immobility: They maintain specific postures for a very long time
(Catatonia is seldomly seen today: medication works on the disturbed movements or postures)
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What are some other general Schizophrenic symptoms?
- Disrupted self experience (depersonalization)
- Social Cognition, mentalizing and metacognition deficits
- Anosognosia
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What are the criteria for diagnosing Schizophrenia?
- At least two symptoms, and one of them must be hallucinations, delusions, or disorganized speech.
- Symptoms must be there for at least 6 months (ask for explanation of slides)
- Clinicians must differentiate between a psychotic episode and a psychotic disorder
(Usually clinicians used semi-structured interviews)
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Other Similar Disorders
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What is Schizophreniform Disorder?
Same symptoms as schizophrenia, but symptoms must be there for at least 1 month
(Schizophreniform -> Schizophrenia)
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What is a Brief Psychotic Disorder?
Same symptoms as Schizphrenia, but symptoms last for 1 day to 1 month
(Brief Psychotic Disorder -> Schizophreniform -> Schizophrenia)
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What is a Schizoaffective Disorder?
A mix of Schizophrenia and Mood Disorders. According to DSM-5, there has to be either a depressive or manic episode
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What is Delusional Disorder?
Person has many Delusions, usually a few more delusions than those in Schizophrenia (erotomanic, somatic, nihilistic are some examples)
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Etiology - Genes
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What have Behavior Genetics Research shown about schizophrenia?
- There's a big genetic/heritable component to schizophrenia, but environment also plays a specific role
--> MZ twins: If one twin has schizophrenia, the other has a 44.3% to have schizophrenia as well (Big %, but not only genetic. If it was only genetic, given that MZ twins share all their genes, the 5 would be 100. This shows that environment does play a role)
- Having a parent with schizophrenia increases the risk for developing schizophrenia AND any other disorder (especially Bipolar Disorders)
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What did the old approach in Molecular Genetics Research study, and what did they find?
They observed candidate genes for schizophrenia, by establishing how often a gene and a phenotype occur.
--> DRD2: A gene that codes the dopamine D2 receptor: associated with schizophrenia
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What did the newer approach in Molecular Genetics Research study, and what did they find?
They used GWAS to observe CNV's and SNP's.
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What were the findings regrading CNV's?
They found over 50 rare mutations that were 3x more likely to appear in people with schizophrenia compared to those without. Some of these CNV's were responsible for risk factors such as deficits in the N.T. glutamate and proteins that promote the proper placement of neurons during development
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What is a problem with the findings on CNV's?
- These mutations were identified in only 20% if people with schizophrenia
- These mutations were identified also in ASD and intellectual disability
So these CNV's might not be specific to schizophrenia
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What were the findings regarding SNP's
Over 108 genetic loci containing SNP's that are associated with schizophrenia
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What is a problem with the findings on SNP's?
Same problem with CNV's
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Etiology - Neurotransmitters
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What is the Dopamine Theory?
(Older belief, which is still true): Schizophrenia is related to excess activity of dopamine.
--> Antipsychotic drugs block the D2 receptor, thus dopamine activity decreases, symptoms decrease.
Newer studies have shown that interactions between stress and other parts of the brain (e.g. HPA axis, Hippocampus) lead to excess dopamine
54
What is a problem with antipsychotic drugs?
These drugs only alleviate disorganized and positive symptoms. Negative symptoms though are mainly associated with low levels of dopamine (e.g. anticipatory pleasure deficits are linked to striatum, which is heavily dependent on dopamine). So drugs don't treat these symptoms, on the contrary, maybe they make them even worse
55
What are some findings on other Neurotransmitters and their association with shcizophrenia?
- Serotonin: New drugs block the 5HT2 serotonin receptor as well, alleviate symptoms
- Glutamate: low levels in cerebropsinal fluid and PFC, as well as low levels of the enzyme that creates glutamate, are associated with schizophrenia
~ Also deficits with NDMA receptors (part of glutamate system) -> might be associated with disorganized & positive symptoms
BUT: medication targeting glutamate has a very moderate effect
56
Etiology - Brain Regions
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What is observed in the Brain's Ventricles of those who have schizophrenia?
Enlarged Ventricles indicate loss of brain cells (This doesn't happen due to the side effects of medication)
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What is observed in the PFC of those who have schizophrenia?
People with schizophrenia have a reduction in gray matter and overall volume (size) (Antipsychotic drugs may contribute to this as well)
--> Reduction in volume of gray matter isn't because of decrease of neurons, but because of decrease in dendritic spines (dendrites): Communication among neurons is disrupted ("Disconnection syndrome")
~ Result is speech/behavioral disorganization.
~ Maybe dendrite loss is due to CNV's
~ People with schizophrenia perform worse than controls on neuropsychological tests of PFC (e.g. working memory)
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What is observed in the Temporal Cortices of those who have schizophrenia?
There are structural and functional abnormalities:
- reduced volume in basal ganglia, amygdala, thalamus and especially hippocampus (even relatives of those with schizophrenia have reduced hippocampal volume)
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What might be a potential cause for the reduced hippocampal volume?
A combination of increased stress reactivity and disruption of the HPA axis (connection of stress and memory)
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Etiology - Connectivity
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What connectivity deficits are observed in people with schizophrenia?
- Less connectivity in white matter in frontal-temporal cortices (maybe this can also be a predisposing factors/genetic vulnerability)
- Less connectivity in brain networks (frontoparietal and default-mode networks). This correlates with poor performance on cognitive tests and negative symptoms (Diminished connectivity also exists in relatives of those with schizophrenia -> maybe this can also be a predisposing factors/genetic vulnerability)
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Does rTMS help in reducing negative symptoms?
Yes.
rTMS in PFC reduces negative symptoms and increases performance on cognitive tasks
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What is a factor that might result in greater reduction of symptoms?
Greater connectivity between striatum and other brain regions
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Etiology - Environment
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How can early Complication result in schizophrenia?
- Damage during gestation or birth (delivery complications): highly associated with schizophrenia, but only in those who also have a genetic vulnerability
- maternal infections (during pregnancy)
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If such damage happens during pregnancy or birth, why are the problems of schizophrenia expressed during adolescence/adulthood?
- PFC might be damaged early on, but it starts developing and starts being used a lot to guide behavior in adolescence/adulthood
- Dopamine activity peaks in adolescence
- Adolescence is full of stress (stress -> HPA axis -> cortisol -> dopamine, so stress increases dopamine)
- Cannabis use (in adolescence or adulthood) correlates with schizophrenia. (Associated both as a risk factor and as a factor that makes symptoms worse)
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Etiology - Psychological influences
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What is true about stress in people with schizophrenia?
People with schizophrenia don't have more stress than people without schizophrenia, but react more, and more intensely to everyday stressors (they're more vulnerable to stressors). This also predicts increases in negative moods.
70
What are some sociocultural factors that influence schizophrenia?
- Poverty
- Trauma
- Urbanicity
- Migration
71
What is the relationship between Poverty and schizophrenia?
The more poverty increases, so does schizophrenia. BUT: Problem of causality (poverty -> schizophrenia, or schizophrenia -> poverty). There's lots of evidence indicating towards schizo. -> poverty
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What is the relationship between Trauma and schizophrenia?
(As with all disorders) increases the likelihood of developing schizophrenia
- 50-98% of people with schizophrenia have experienced a trauma in during their lifetime
- 80% of people experience their psychotic episodes as traumatic (10% comorbidity with PTSD)
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What is the relationship between Urbanicity and schizophrenia?
Because living in such areas might be more stressful or might have higher chances of infection from toxins/bacteria -> urban people are 3x more likely to develop schizophrenia than those living in rural areas.
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What is the relationship between Migration and schizophrenia?
1st generation: 3x more likely to develop schizophrenia.
2nd generation: 4x more likely to develop schizophrenia
!!! Risk is especially higher for people of color: reflects diagnostic bias, greater exposure to stress, less access to treatment, or a combination from one of the 3 !!!
75
How can Families contribute to schizophrenia?
Families of people with schizophrenia in general communicate more vaguely and have higher conflicts.
76
What is expressed Emotion (EE) and how does it correlate with schizophrenia?
Expressed emotion is a combination of the following 3 characteristics:
- critical comments
- hostility
- emotional overinvolvement (all of these towards the family member with schizophrenia)
~ in High EE families, the family member with schizo. goes back to the hospital
~ in Low EE families, the family member with schizo. relapses
BUT: problem of causality (schizo. <-> EE)
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What are some cultural differences regarding EE?
- European American caregivers are higher in EE than Mexican American caregivers
- European American caregivers are higher on critical comments and hostility, Mexican Amercians are more divided on the 3 characteristics, sometimes higher on emotional overinvolvement
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Etiology - Development
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What are some general factors in childhood that predict if somebody will have schizo.?
- Low IQ
- Poor motor skills
- More frequent expression of negative emotions in childhood
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What has a study shown regarding the cognitive decline in people with schizophrenia?
People who were just diagnosed with schizophrenia were assessed 10 years later:
- IQ, verbal learning, memory: declined
- Executive functioning, processing speed, visuospatial skills: didn't decline
(not all cognitive skills decline)
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Treatment - (Medication)
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What must clinicians do when they have a patient with schizophrenia?
When they administer the drugs, they must carefully monitor in order to prevent the heavy side effects. Those who respond well to the drugs are kept on maintenance doses (just enough to continue therapeutic effect, because of many side effects)
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What is the common problem of both 1st and 2nd generation medications?
Both treatments reduce positive and disorganized symptoms, but have little/no effect/negative effect on negative symptoms
!!! For both treatments, only 23% respond well to the drugs !!!
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What are the many side effects?
- Sedation, Dizziness, Restlessness, blurred vision, sexual dysfunction
- Extrapyramidal side effects (like symptoms of Parkinson's)
- Dystonia: muscular rigidity
- Dyskinesia: Abnormal motion of voluntary and involuntary muscles
~ tardive dyskinesia: dyskinesia in muscles of mouth
- Akasthesia: inability to remain still
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What are some general statistics regarding 1st generation medications?
- 30% of people didn't respond well to the drugs
- 1/2 quit after a year, 3/4 after 2 years, because of the two many unpleasant side effects.
That's why they created the 2nd generation medication
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Are 2nd generation drugs more effective than the 1st?
No.
- They have different side effects, but still they're all unpleasant, as unpleasant as 1st generation (e.g. different side FX is weight gain -> other serious problems)
- Nearly 3/4 of patients stop taking the drugs after 18 months
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What is a cultural problem when it comes to giving people medication?
African Americans tend to only receive 1st generation drugs.
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Treatment - (Psychological)
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What are some psychological treatment methods for schizophrenia?
- Social Skills training
- Family Therapy
- Psychoeducation
- CBTp
- CBSST
- NAVIGATE
- Residential Treatment Homes
90
What is Social Skills Training?
Teaches people how to manage a wide variety of interpersonal situations:
- Helps patients achieve fewer relapses, better social functioning, higher quality of life
- Usually a component of other treatments
- May even reduce negative symptoms
- Effective when paired with family therapy
91
What are the aspects of Family Therapy?
- Education on schizophrenia: info about genetic/neurobiological factors that lead to it, cognitive problems associated with it, symptoms and signs of relapse
- Info about antipsychotic medication (pros, cons and side effects)
- Teach family members to avoid blaming themselves or the relative with the disorder
- Teach family members to express themselves in a constructive and empathetic manner instead of a critical one. This leads to less stressful interpersonal conflicts and better problem-solving
- Help family members expand their social networks (especially support networks)
- Instill hope
(In general, it's effective in reducing relapse and improving symptoms and functioning)
92
What is CBTp?
A specific CBT for psychosis (p = psychosis).
- Clinician challenges delusional beliefs of the patient. The patient is then able to attach a nonpsychotic meaning to paranoid symptoms, and is thus able to reduce their intensity and aversive nature
- Also effective in reducing negative symptoms
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What is CBSST?
CBT + Social Skills training.
It's a group therapy which usually lasts longer than normal CBT (usually from 6-9 months)
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What is NAVIGATE?
A treatment method that entails:
- Medication
- Family
- Psychoeducation
- Individual Therapy
- Help with employment & education
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For whom are Residential Treatment Homes helpful?
Helpful for those that can't live alone or with family. It helps them return to ordinary community/social life and get employment
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In general, what is very important regarding treatment for schizophrenia?
- Combined and Comprehensive treatments in community settings are important to develop and implement for people with schizophrenia
- The earlier the treatment, the better
