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Schizophrenia

By Aimee, Jo-Anna and David
by

Aimee Monash

on 13 May 2014

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Transcript of Schizophrenia

By Aimee and Jo-Anna
Schizophrenia
Symptoms Continued...
What is Schizophrenia?
Demonstration
Negative Symptoms
What are the symptoms?
Schizophrenic behaviours can be organised into positive and negative symptoms.
"Schizophrenia is a collection of diagnostic categories classified by the presence of severe disturbances in thought, behaviour and interpersonal relationships" (Malcom, 2012).
Video demonstrating different types of Schizophrenia and how it affects individuals
Basically, Schizophrenia is a mental disorder that is characterized by disruptions to thinking, emotions and a distorted perception of reality.
Positive Symptoms
Positive symptoms refer to the most visible, odd manifestations of psychosis, such as hallucinations, delusions, disorganized speech and behaviour.
Basically, if he/she is experiencing additional behaviours that are strange in context and not ordinary to their everyday life, the symptom is positive!
Confused or Disorganized Thinking
When ill, the affected individual will undergo a psychotic experience known as disordered thinking.
The everyday thoughts that let us live our daily lives become confused and don’t join up properly.
Delusions
A delusion is a false belief held by a person which is not held by others of the same cultural background.
Their content may include a variety of themes e.g., persecutory, referential, somatic, religious, or grandiose
Hallucinations
The person sees, hears, feels, smells or tastes something that is not actually there.
Auditory hallucinations are the most common. The hallucination is often of disembodied voices which no one else can hear.
Negative symptoms refer to a lack of ordinary qualities such as emotional feeling, motivation, planning, and personal hygiene.
Basically, if the individual's ordinary attitude and behaviour is diminishing, he/she is experiencing a negative symptom!
Flattened Affect
Patients with flattened affect appear very emotionless, or have a very limited range of emotions. They show little response to emotional or disturbing situations or images.
Avolition
Avolition is a general lack of drive or motivation to persue meaningful goals.
Alogia
Alogia, also known as poverty of speech, is characterized by a lack of additional, unprompted responses during a conversation.
What types of Schizophrenia are there?
The DSM-IV-TR recognises five sub-types of Schizophrenia
Paranoid Type
The essential feature of the Paranoid Type Schizophrenia is the presence of prominent delusions or auditory hallucinations!
Catatonic Type
The essential feature of the Catatonic Type is a psychomotor disturbance that may involve:

motoric immobility (e.g. waxy flexibility)
excessive motor activity (e.g. purposeless movements)
extreme negativism (e.g. resistence to all instructions)
mutism
peculiarities of voluntary movement (e.g. bizarre postures)
echolalia (e.g. mimicking words)
echopraxia (e.g. mimicking movements).
Disorganized Type
The essential features of the Disorganized Type Schizophrenia are disorganized speech, disorganized behavior, and flat or inappropriate affect!
Undifferentiated Type
The essential features of Undifferentiated Type Schizophrenia is the absence of symptoms that are better accounted for by paranoid, catatonic, undifferentiated and residual type Schizophrenia!
Residual Type
Residual Type Schizophrenia is diagnosed when there is evidence of a disturbance indicated by only negative symptoms.
History, Origins and Evolution
• In earlier centuries, patients were labelled insane and were treated much the same.
• Schizophrenia was first known as ‘dementia praecox’ in 1887.
• The term’ schizophrenia’ was developed by a Swiss psychiatrist called Eugen Bleuler in 1911.
• The first to classify mental disorders into categories Dr. Emile Krapelin.
• Bleuler and Krapelin distinguished that the disorder possesses both positive and negative symptoms
• Five types were defined in the DSM-III; paranoid, catatonic, undifferentiated, residual and disorganized type.
Aetiology of Schizophrenia
Causes and Implications
What are the causes of Schizophrenia and other Psychosis?
Schizophrenia is likely to be a combination of hereditary and other factors. It is probable that some people are born with a predisposition to develop this kind of illness, and that certain things, e.g. stress or use of drugs such, can trigger their first episode.
Genetics
Studies indicate that the risk of developing schizophrenia increases as the rate of genetic relatedness, that is, how closely blood related you are to the affected individual, increases.
Here are some stats:
•1% of spouses will develop the disorder (no genetic relationship)
•2.8% of grandchildren of the affected person will develop the disorder
•7.3% of siblings of the affected person will develop the disorder
•9.4% of children with only one affected parent will develop the disorder
•46.3% of children with both parents being affected will develop the disorder
Causes Continued...
Environmental Factors
Research suggests that a number of environmental factors throughout the course of the lifespan can play a crucial role in the development of the disorder, including, maternal infection during foetal development, early childhood trauma, exposure to illicit substances in middle childhood and early adolescents and wider social and environmental factors such as living in an urban location in later years.
Causes Continued...
Neurotransmitters and Brain Structure
Much of the research conducted on Schizophrenia is focussed on the neurotransmitters Dopamine and Serotonin as the main contributing factor to Psychosis.
Neurotransmitters
Evidence suggests that:
a) Drugs that reduce dopamine activity were found to be effective in treating the symptoms of Schizophrenia
b) The use of amphetamine that increase the release of dopamine, can produce symptoms of Schizophrenia
Brain Structure
Consistent findings has been that schizophrenic patients possess enlarged ventricles; these are the spaces in the brain that contain spinal fluid. This particular problem is known to cause lack of speech, withdrawn behaviour and issues with executive functioning, which can be directly associated with negative symptoms of Schizophrenia.
Causes Continued...
Psychosocial Factors
Research has shown that exposure to social factors such as residing in an urban environment, migration, being socially excluded and childhood abuse may increase the risk of psychosis later in life.
Cognitive models propose that these early experiences of stress and trauma result in the formation of dysfunction that in turn triggers the onset of psychotic symptoms (Bentall, 2006).
Triggering Factors
Among vulnerable individuals, the occurance of certain events will trigger the onset of psychosis (Reiger, 2011). Triggers can involve biological processes, psychosocial processes or a combination of the two.

Studies found that patients that were assessed as being high-risk of developing psychosis, and did in fact go on to develop Schizophrenia experienced significantly higher levels of stress hormones in their pituitary compared to other high-risk patients that did not develop the illness.
Treatment can do much to reduce and even eliminate the symptoms. Treatment should generally include a combination of medication and community support. Both are usually essential for the best outcome.
Medication
Anti-psychotic medications assist the brain to restore its usual chemical balance. This then helps reduce or eliminate some of the symptoms. Drug treatment is most useful in eliminating positive symptoms of schizophrenia, however, negative symptoms are usually only moderately improved, due to the fact that many anti-psychotic medications in turn cause negative symptoms.
Community Support Programs
Community support programs help the individual to see that they are not alone. These programs can include information; accommodation; help with finding suitable work; training and education; psychosocial rehabilitation and mutual support groups.
Cognitive Behaviour Therapy
CBT has been found to significantly increase the affected individual’s social and occupational functioning and has also shown to be effective in helping the individual to distinguish the rationality and reality of their disorganised thinking.
Case: Jerry
Diagnosis: Schizophrenia Residual Type
Brief History of Jerry
• Jerry is the youngest of two sons
• He was brought up in an upper-middle class family environment with his father being a successful executive for a German car company and his mother remaining at home to raise Jerry and his brother.
• Jerry seemed to have a happy childhood and got along well with his family, he received good grades throughout school, he had a successful social life in high-school; he dated often and participated in football and track, he attended a large state university to study mechanical engineering (it is in college that his odd behaviour became apparent)
• After leaving college, Jerry joined the army. He was discharged after two years and then got a job working in the fast-food industry.
• After leaving his job of only two weeks, Jerry ran into some problems and consequently went to live with his parents in Munich, Germany.
What are some of Jerry's notable symptoms?
Jerry's change in behaviour was first noticed during his freshman year of college.
• In his first year of college, his grades were considerably lower than his usual performance and he would frequently miss lectures and assignments.
• He seemed unconcerned about making friends or becoming active in campus activities and refused to get a job over the summer break and instead spent most of his time alone in his room or wandering aimlessly around the neighbourhood.
• After returning to university in autumn, Jerry’s found himself failing his subjects and was reported to be spending all of his time in bed either sleeping or mumbling to himself.
• He did not do his laundry all semester and often went without bathing for up to 10 days.
Jerry's Symptoms Continued...
• Records from the army showed that Jerry lacked motivation and paid poor attention to instruction although he never resisted orders, he had to be constantly supervised to ensure he actually carried them out.
• Two weeks after leaving his job, Jerry was arrested for shoplifting and after little news on Jerry’s whereabouts for some time he was picked up for vagrancy and disorderly conduct after harassing citizens in a park and reportedly making incoherent, strange remarks like shouting at a pile of garbage “Use your common sense!”.
• At the age of 37, Jerry was diagnosed and treated with Paranoid Schizophrenia. He was not at all concerned by his lack of permanent home, steady job, companionship or even consistent source of food.
• He constantly wandered off from his home and job without any perceptual purpose and withdrew from all social situations, however, when he did engage in conversation, his speech was vague and lacking in content.
How was Jerry treated?
• Jerry’s treatment was primarily pharmacological.
• 100mg Thorazine four times a day – Jerry’s psychologists’ prescribed such a low dosage simply to prevent a relapse of symptoms as Jerry’s history only included isolated instances of psychotic behaviour.
• In addition to taking medication, Jerry also participated in various therapeutic activities to improve his social and occupational skills, and community activities to promote a sense of control and responsibility. (delegating roles, creating a contingency contract)
• Participation in group therapy sessions to discuss interpersonal issues.
• Vocational training – Jerry was enrolled in workshops to learn how to perform unskilled tasks, such as washing dishes. This training helps to develop discipline in order to hold a steady job.
How effective was Jerry's treatment?
In this particular case, Jerry received treatment that provided an effective combination of pharmacological therapy and residential therapy that have been tailored to his needs.

These were effective in improving and maintaining Jerry's Residual Type Schizophrenia, e.g. he has no problems with the use of public transport, he was able to live in an apartment (although he remains supervised), he works three times a week and attends group therapy sessions once a week and his attendance to both work and therapy remains around 90%.

Although Jerry's treatment enabled him to be somewhat independent and productive there is little chance that he will be fully independent.
DSM-IV-TR Diagnosis
About one in a hundred people will develop schizophrenia at some time in their lives. Most of these will be first affected in their late teens and early twenties.
Treatment
What are the current treatments available?
Are there any cross-cultural issues?
Limitations in pharmacological treatment of a Psychotic Disorder
Further Research Needed
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Retrieved from http://dsm.psychiatryonline.org/book.aspx?bookid=2

Malcom, J. (2012). 101681 Abnormal psychology case studies . North Ryde: McGraw Hill.

Mueser, K.T., McGurk, S.R. (2004). Schizophrenia. The Lancet, 363(9246), 2063-2072. doi:10.1016/S0140-6736(04)16458-1

Obiols, J. E. (2012). DSM 5: Precedents, present and prospects. International Journal of Clinical and Health Psychology, 12(2), 281-290. Retrieved from http://search.proquest.com/docview/1010341363?accountid=36155

Reiger, E. (2012). Abnormal psychology leading researcher perspectives (2nd ed.). Sydney: McGraw Hill.

Stephens, J.H., Ota, K.Y., Carpenter, W.T. Jr., & Shaffer, J.W. (1980). Diagnostic criteria for schizophrenia: Prognostic implications and diagnostic overlap, Psychiatry Research, 2(1), 1-12. doi:10.1016/0165-1781(80)90002-5.

Walker, E., Kestler, L., Bollini, A., & Hochman, K. M. (2004). Schizophrenia: Etiology and course. Annual Review of Psychology, 55, 401-30. Retrieved from http://search.proquest.com/docview/205848550?accountid=36155

Weisman, A. G. (1997). Understanding Cross-Cultural Prognostic Variability for Schizophrenia. Cultural Diversity And Mental Health, 3(1), 23-35. doi:10.1037/1099-9809.3.1.23
References
•Epidemiologists have argued that the frequency of Schizophrenia and variation cross-culturally. There is an increased prevalence rate of developing the illness among migrants and in developed nations compared to developing nations and a further increased risk for those living in an urban environment compared to a rural setting.

•A number of psychiatrists have reported that the majority of psychotic patients they treated tended to suffer from a disease process. Observations have led to suggestions that the course of schizophrenia in developing countries may not be as malicious as that observed in industrialized Western settings.
Access to Resources:
Research has shown that a large amount of people that have been diagnosed with a mental illness, like Schizophrenia, are incarcerated in prisons, rather than being admitted into the mental health system.
Treatment Methods:
The treatment methods that are offered to patients are quite limited. Family intervention and CBT have proven to be extremely effective in reducing rates of relapse, but they are rarely available to many sufferers.
Re-evaluation of medications and intervention techniques will assist those suffering from co-morbid substance abuse, depression, and other problems that delay recovery from psychosis.
Community Knowledge and Support
Many people that are diagnosed with a psychotic illness continue to suffer from stigma and have limited access to sufficient housing, employment and educational support.
SANE Australia www.sane.org
Early Psychosis Prevention and Intervention Centre www.eppic.org.au
International Early Psychosis Association www.iepa.org.au
Headspace www.headspace.org.au
Jerry has been diagnosed with Schizophrenia of the Residual Type:
DSM-IV-TR Criteria for Schizophrenia
Delusions, Hallucinations, Disorganized Speech, Catatonic/Disorganized Behaviour, Negative Symptoms

Social/Occupational Dysfunction

Duration i.e. at least 6 months

Schizoaffective & Mood Disorder Exclusion

Substance/General Medical Condition Exclusion

No history of Pervasive Developmental Disorder
DSM-IV-TR Criteria for 295.60 Residual Type
Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior

There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms
OR
Two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form
300.12 Amnesia or 300.13 Dissociative Fugue
Sudden, unexpected travel away from home place of work, with inability to recall their past

Confusion about personal identity or assumption of a new identity

Exclusion of Dissociative Identity Disorder and disturbance is not due to the effects of a substance or a general medical condition

The symptoms cause distress or impairment in social, occupational, or other important areas of functioning.
HOWEVER
Dissociative Fugue and Amnesia may be excluded from diagnosis due to the absence of positive and negative schizophrenic symptoms as well as the fact that individuals with Schizophrenia do not have memory problems.
314.00 ADHD Inattentive Type
Often fails to give close attention to details or instruction

Often does not seem to listen when spoken to directly

Often does not follow through on instructions

Often easily distracted by extraneous stimuli

Forgetful in daily activities
HOWEVER
Attention Deficit Hyperactivity Disorder can be excluded as a diagnosis as Jerry's symptoms become present outside of the age-group onset and because the symptoms occur concurrent with the course of Schizophrenia
299.80 Asperger's Disorder
Failure to develop peer relationships appropriate to developmental level

Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people

Lack of social or emotional reciprocity
HOWEVER
Jerry does not exhibit symptoms relative to section B of Asperger's disorder including stereotyped or restricted patterns of interest, repetitive motor mannerisms or preoccupation with parts of objects. in absence of these category B symptoms and with criteria being met for Schizophrenia, Asperger's must be excluded
301.20 Schizoid Personality Disorder (Premorbid)
Jerry displays symptoms that may be accounted for by Schizoid Personality Disorder (as the Jerry's symptoms are present prior to the onset of Schizophrenia, the 'premorbid' specifier is added):
Neither desires nor enjoys close relationships
Lacks close friends or confidants
Appears indifferent to the praise or criticism of others
Shows emotional coldness, detachment, or flattened affectivity
Patients with Schizoid Personality may also present further symptoms including difficulty expressing anger, lacking in emotion, passive reactions, difficulty responding to important life events and leading a directionless life. Jerry presents these symptoms along with having few friendships and/or relationships and an impairment to occupational functioning.
Jerry's Diagnosis in Conclusion
Jerry's diagnosis is Schizophrenia Residual Type with Premorbid Schizoid Personality Disorder
No bizarre positive symptoms, but he still displays some illogical thinking
Daily functioning is poor, blunted emotional affect and is socially withdrawn
Patients with this disorder can have a long history of negative symptoms
Deficit in goals, planning and taking on responsibilities and lacking a sense of meaning
Anti-psychotic medications aim to block an overactivity of dopamine receptors in the brain, however, many of these medicinal treatments only work to eliminate positive symptoms of psychosis and can in fact cause negative symptoms, therefore they do not work to improve disorders that are dominated by negative symptoms, much like Residual Type Schizophrenia

Side-effects of anti-psychotic treatment can also include rapid and large weight gain, decreased growth velocity, osteoporosis and reduced appetite and abdominal pain
Future directions in diagnosis of Psychotic Disorders
A new diagnostic category will be introduced in the DSM-V known as 'Attenuated Psychotic Disorder'. It will focus on "high-risk" individuals and will attempt to improve outcomes for illness sufferers.
Symptoms include:
Unusual thought content
Suspiciousness
Perceptual disturbances
Controversy
This group will be 20-30% more likely to develop Schizophrenia within the next 2 years compared to a population proportion of 0.02% (Obiols, 2012).
The introduction of this disorder may also increase the number of false diagnosis' by 70-80% (Obiols, 2012).
The symptoms are closely associated with distress, disability and dysfunction. Treatments methods will include CBT along with medication.
Demonstration
Janie was raised in a Protestant home but stopped going to church in her teens. After the onset of bipolar symptoms, though, she began going to more than one service a week, volunteering, joining study groups, and seeking personal religious counseling from the minister
Case #1
Case #2
Ed had never been to any religious service or events in his life, but as he developed symptoms of a mental illness, later diagnosed as schizophrenia, he began talking to friends about God more and more, reading the Bible, eventually falling to his knees and praying aloud regardless of where he was
Case #3
When Terri, a devout Jew all her life, developed schizoaffective disorder, she became convinced that God felt she was unworthy and attempted suicide
Case #4
James, who has bipolar disorder, began to focus more on his religious beliefs when his symptoms began, finding they help sustain him in difficult times
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