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Copyright 2005 John Wiley & Sons, NY
Chapter 11
Schizophrenia
Schizophrenia精神分裂症
One of the psychotic disorders
Major disturbances in:
Thought
Emotion
Behavior
Disordered thinking
Faulty perception and attention
Inappropriate or flat emotions
Bizarre motor activity
Disrupted interpersonal relationships
Schizophrenia
Disorder impacts families & friends
Difficult to live with someone who experiences delusions, hallucinations, and paranoia.
Social skills deficits common
Isolation, few social contacts
Symptoms impact employability
Often lead to unemployment & homelessness
Substance abuse & suicide rates high
Schizophrenia
Lifetime prevalence ~1%
Occurs equally in men and women
Onset typically late adolescence or early adulthood
Men diagnosed at a slightly earlier age
Diagnosed more frequently in African Americans
May reflect diagnostician bias
Comorbidity: substance abuse
Clinical Description of Schizophrenia
No single essential symptom
Heterogeneity of symptoms across patients
Positive & negative symptoms positive , disorganized & negative symptoms
Positive Symptoms: excesses & distortions
Delusions
Firmly beliefs held contrary to reality
Resistant to disconfirming evidence
Persecutory delusions common : 65%
Hallucinations
Sensory experiences in the absence of sensory stimulation from the environment
More often auditory (74%) than visual
Patients misattribute their own voice as being someone else's voice
Increased levels of activity in Broca's area during hallucinations
problem in the connections between the frontal lobe areas ( the production of speech) and the temporal lobe areas (the understanding of speech)
Negative Symptoms: Behavioral deficits
These symptoms tend to endure beyond an acute episode
Avolition
Lack of interest and drive
Alogia
Poverty of speech
Poverty of content
Anhendonia
Inability to experience pleasure
Flat affect: 66%
Exhibits little or no affect in face or voice
Asociality
Inability to form close personal relationships
Beginning in childhood before the onset of other symptoms
Disorganized Symptoms
Disorganized speech
Incoherence
Inability to organize ideas
Loose associations (derailment)
Rambles, difficulty sticking to one topic
Problem in executive functioning (problem solving, planning, and making associations between thinking and feeling) and in the ability to perceive semantic information
Disorganized behavior
Odd or peculiar behavior
Silliness, agitation, unusual dress
Other Symptoms
Catatonia
Motor abnormalities
Repetitive, complex gestures
Usually of the fingers, hands and arm movements
Catatonic immobility
Maintain unusual posture for long periods of time
e.g., stand on one leg
Waxy flexibility
another person can move the patient's limbs into positions that the patient will then maintain for long periods of time
Other Symptoms
Inappropriate affect
Emotional responses inconsistent with situation
e.g., laugh uncontrollably at a funeral; shift rapidly from one emotional state to another for no discernible reason
This symptom is quite rare
Specific to schizophrenia
Criteria for Schizophrenia in DSM-IV-TR
Two or more of the following symptoms for at least 1 month:
Delusions
Hallucinations
Disorganized speech
Disorganized or catatonic behavior
Negative symptoms
Social and occupational functioning have declined since onset
Signs of disturbance for at least 6 months;
Categories of Schizophrenia in DSM-IV-TR
Disorganized schizophrenia
Incoherence, disorganized speech and behavior
Flat or inappropriate affect
Catatonic schizophrenia
Prolonged immobility or purposeless agitation
Seldom today
Paranoid schizophrenia
Delusions, hallucinations related to persecution or grandiosity
Grandiosity delusions: an exaggerated sense of their own importance, power, knowledge, or identity.
Ideas of reference: incorporate unimportant events within a delusional framework and read personal significance into the trivial activities of others
e.g., newscast on TV is about me
Undifferentiated schizophrenia
Meet criteria for schizophrenia but not for any of the 3 main subtypes
Residual schizophrenia
No longer meets full criteria for schizophrenia but still exhibits some signs of the disorder
Evaluation of Subtypes
Diagnosis of subtypes difficult
Reliability low
Poor predictive validity
Overlap of symptoms among subtypes
E.g. delusions
Other Psychotic Disorders
Schizophreniform Disorder
Symptoms are the same as those of schizophrenia
Symptom last only from 1 to 6 months
Brief Psychotic Disorder
Symptom duration of 1 day to 1 month
Often triggered by extreme stress
Other Psychotic Disorders
Schizoaffective Disorder
Symptoms of both mood disorder and schizophrenia
Delusional Disorder
Persistent delusions
Persecution, jealousy, being followed, erotomania, somatic
Non-bizarre delusions
e.g., jealousy, erotomania
No other symptoms of schizophrenia
Etiology of Schizophrenia: Genetics
Not likely that disorder caused by single gene
Behavior genetics research
Family studies & Twin studies (Table 11.2)
The risk increases as the genetic relationship between proband and relative becomes closer
MZ (44.3%)> DZ (12.08%)
Negative symptoms may have a stronger genetic component
Adoption studies
Table 11.3
Etiology of Schizophrenia: Genetics
Molecular genetics research
Linkage studies
A number of chromosomes implicated
Results inconsistent and marked by a failure to replicate
Association studies
Two genes identified
DTNBP1:encoding a protein called dysbindin
NGR1: linked to the neurotransmitter glutamate's receptors & the process of myelination
Table 11.2 Family and Twin Genetic Studies
Table 11.3 Characteristics of Adopted Offspring of Mothers with Schizophrenia
Etiology of Schizophrenia:
Evaluation of Genetic Research
Strong genetic component
Genetics doesn't completely explain the disorder
Diathesis-stress model
Genetic factors constitute underlying predisposition
Stress triggers onset
Limitations:
Can's specify exactly how a predisposition for schizophrenia is transmitted
The nature of the inherited diathesis remains unknown.
Etiology of Schizophrenia: Neurotransmitters
Dopamine Theory
Disorder due to excess levels of dopamine
Drugs that alleviate symptoms reduce dopamine activity (block D2 receptors)
Antipsychotic drugs produce side effects resembling the symptoms of Parkinson's disease (caused in part by low levels of dopamine)
Amphetamines, which increase dopamine levels, can induce a psychosis (like paranoid schizophrenia)
Theory revised
Excess numbers of dopamine receptors or oversensitive dopamine receptors in the mesolimbic pathway
Dopamine abnormalities mainly related to positive symptoms
Antipsychotics lessen positive symptoms but have little or no effect on negative symptoms
Figure 11.1 The Brain and Schizophrenia
Figure 11.2 Dopamine Theory of Schizophrenia
Etiology of Schizophrenia:
Evaluation of Dopamine Theory
Dopamine theory doesn't completely explain disorder
Antipsychotics block dopamine rapidly but symptom relief takes several weeks
To be effective, antipsychotics must reduce dopamine activity to below normal levels
Other neurotransmitters involved:
Serotonin
GABA
Glutamate
Etiology of Schizophrenia:
Brain Structure and Function
Enlarged Ventricles
Implies loss of brain cells
Correlate with
Poor performance on cognitive tests
Poor premorbid adjustment
Poor response to treatment
Not specific to schizophrenia
Reduced activity in prefrontal cortex
Involved in speech, executive functions, goal-directed behavior
Reductions in gray matter in the prefrontal cortex
May be related to dopamine underactivity
Etiology of Schizophrenia:
Brain Structure and Function
Congenital Factors
Damage during gestation or birth
Obstetrical complications rates high in patients with schizophrenia
Reduced supply of oxygen during delivery may result in loss of cortical gray matter
Viral damage to fetal brain
In Finnish study, schizophrenia rates higher when mother had flu in second trimester of pregnancy (Mednick et al., 1988)
Etiology of Schizophrenia: Brain Structure and Function
Developmental Factors
Prefrontal cortex matures in adolescence or early adulthood
Dopamine activity also peaks in adolescence
Excessive neuronal pruning
May explain why symptoms appear in late adolescence but brain damage occurs early in life
Etiology of Schizophrenia: Psychological Stress
Socioeconomic status
Highest rates of schizophrenia among urban poor.
Sociogenic hypothesis
Stress of poverty causes disorder
Social selection theory
Downward drift in socioeconomic status
Turner & Wagonfield (1968) studied SES of patients' fathers
Results support social selection hypothesis
Etiology of Schizophrenia: psychological
Family-related factors
Schizophrenogenic mother
Cold, rejecting, overprotective, domineering, conflict-inducing
No support for this theory
Communication deviance (CD)
Hostility and poor communication
Family CD predicted onset in one longitudinal study (Norton, 1982)
CD not specific to families of schizophrenic patients
Etiology of Schizophrenia:psychological
Families and Relapse
Family environment impacts rehospitalization
Expressed Emotion (EE; Brown et al., 1966)
Hostility, critical comments, emotional overinvolvement
Relapse rate: High EE (58%) > Low EE (10%)
Bi-directional association
The expression of unusual thoughts by the pt → increased critical comments by family members
Critical comments by family members increased expression of unusual thoughts by the pt
Etiology of Schizophrenia:
Developmental Studies
Developmental histories of children who later developed schizophrenia (in the 1960s)
Lower IQ
More often delinquent and withdrawn
Coding of home movies
Poorer motor skills
More expression of negative emotion
Etiology of Schizophrenia: Developmental Studies
High risk studies
Danish children with a schizophrenic mother who later developed disorder (Mednick & Schulsinger, 1968)
Negative symptom patients
More pregnancy birth complications
Failure to show electrodermal responding
Positive symptom patients
Family instability
Divorce or institutionalization
Australian study (Yung et al., 1995)
MRI found reduced gray matter volume predicted later development of psychotic disorder
Treatment of Schizophrenia: Medications
Traditional antipsychotic drugs & their side effects
Antipsychotic medications (1950s)
Chlorpromazine (Thorazine), haloperidol (Haldol),
Block dopamine receptors
Reduce the positive and disorganized symptoms
Side effects
Dizziness, blurred vision, restlessness, sexual dysfunction
Extrapyramidal side effects
Stem from dysfunctions of the nerve tracts that descend from the brain to spinal motor neurons; resemble the symptoms of Parkinson's disease
Tremors of the fingers, a shuffling gait, & drooling
Dystonia, dyskinesia
Treatment of Schizophrenia: Medications
Atypical antipsychotic medications
Clozapine (Clozaril)
Fewer motor side effects
Less likely to drop out of treatment
Impact on serotonin receptors
Side effects
Can impair immune symptom functioning in 1% pts by lowering the number of white blood cells
Seizures, dizziness, fatigue, drooling, weight gain
Relate to type 2 Diabetes
Psychological Treatments: Psychoanalytic therapy
Freud
Little value in psychotherapy for psychotic disorders
Schizophrenics were incapable of establishing the close interpersonal relationship essential for analysis
Harry Stack Sullivan
Develop trusting therapist-patient relationship
Teach adult forms of communication
Foster insight into role of past
Psychological Treatments
Recent types of psychosocial treatments are more active, present-focused, and reality-oriented
Social skills training
Teach effective social behaviors
Family therapy to reduce EE
Educate family about causes, symptoms, and signs of relapse
Stress importance of antipsychotic medication
Help family to avoid blaming patient
Improve family communication and problem-solving
Encourage expanded support networks
Instill hope that things can improve
Psychological Treatments
Cognitive behavioral therapy
Recognize and challenge cognitive distortions
Recognize and challenge expectations associated with negative symptoms
e.g., low expectations for success and pleasure
Cognitive enhancement therapy (CET)
Improve attention, memory, problem solving and other cognitive based symptoms
Psychological Treatments
Other therapies
Personal therapy: leads to less relapse
Teaching the pt how to recognize inappropriate affect & to notice small signs of relapse
Learn skills to deal with these problems
Case management
Residential treatment (halfway houses)
Vocational rehabilitation
6553
·上一篇：Schiffert健康中心
·下一篇：sepsis:arandomized
Chapter 11
Schizophrenia
Schizophrenia精神分裂症
One of the psychotic disorders
Major disturbances in:
Thought
Emotion
Behavior
Disordered thinking
Faulty perception and attention
Inappropriate or flat emotions
Bizarre motor activity
Disrupted interpersonal relationships
Schizophrenia
Disorder impacts families & friends
Difficult to live with someone who experiences delusions, hallucinations, and paranoia.
Social skills deficits common
Isolation, few social contacts
Symptoms impact employability
Often lead to unemployment & homelessness
Substance abuse & suicide rates high
Schizophrenia
Lifetime prevalence ~1%
Occurs equally in men and women
Onset typically late adolescence or early adulthood
Men diagnosed at a slightly earlier age
Diagnosed more frequently in African Americans
May reflect diagnostician bias
Comorbidity: substance abuse
Clinical Description of Schizophrenia
No single essential symptom
Heterogeneity of symptoms across patients
Positive & negative symptoms positive , disorganized & negative symptoms
Positive Symptoms: excesses & distortions
Delusions
Firmly beliefs held contrary to reality
Resistant to disconfirming evidence
Persecutory delusions common : 65%
Hallucinations
Sensory experiences in the absence of sensory stimulation from the environment
More often auditory (74%) than visual
Patients misattribute their own voice as being someone else's voice
Increased levels of activity in Broca's area during hallucinations
problem in the connections between the frontal lobe areas ( the production of speech) and the temporal lobe areas (the understanding of speech)
Negative Symptoms: Behavioral deficits
These symptoms tend to endure beyond an acute episode
Avolition
Lack of interest and drive
Alogia
Poverty of speech
Poverty of content
Anhendonia
Inability to experience pleasure
Flat affect: 66%
Exhibits little or no affect in face or voice
Asociality
Inability to form close personal relationships
Beginning in childhood before the onset of other symptoms
Disorganized Symptoms
Disorganized speech
Incoherence
Inability to organize ideas
Loose associations (derailment)
Rambles, difficulty sticking to one topic
Problem in executive functioning (problem solving, planning, and making associations between thinking and feeling) and in the ability to perceive semantic information
Disorganized behavior
Odd or peculiar behavior
Silliness, agitation, unusual dress
Other Symptoms
Catatonia
Motor abnormalities
Repetitive, complex gestures
Usually of the fingers, hands and arm movements
Catatonic immobility
Maintain unusual posture for long periods of time
e.g., stand on one leg
Waxy flexibility
another person can move the patient's limbs into positions that the patient will then maintain for long periods of time
Other Symptoms
Inappropriate affect
Emotional responses inconsistent with situation
e.g., laugh uncontrollably at a funeral; shift rapidly from one emotional state to another for no discernible reason
This symptom is quite rare
Specific to schizophrenia
Criteria for Schizophrenia in DSM-IV-TR
Two or more of the following symptoms for at least 1 month:
Delusions
Hallucinations
Disorganized speech
Disorganized or catatonic behavior
Negative symptoms
Social and occupational functioning have declined since onset
Signs of disturbance for at least 6 months;
Categories of Schizophrenia in DSM-IV-TR
Disorganized schizophrenia
Incoherence, disorganized speech and behavior
Flat or inappropriate affect
Catatonic schizophrenia
Prolonged immobility or purposeless agitation
Seldom today
Paranoid schizophrenia
Delusions, hallucinations related to persecution or grandiosity
Grandiosity delusions: an exaggerated sense of their own importance, power, knowledge, or identity.
Ideas of reference: incorporate unimportant events within a delusional framework and read personal significance into the trivial activities of others
e.g., newscast on TV is about me
Undifferentiated schizophrenia
Meet criteria for schizophrenia but not for any of the 3 main subtypes
Residual schizophrenia
No longer meets full criteria for schizophrenia but still exhibits some signs of the disorder
Evaluation of Subtypes
Diagnosis of subtypes difficult
Reliability low
Poor predictive validity
Overlap of symptoms among subtypes
E.g. delusions
Other Psychotic Disorders
Schizophreniform Disorder
Symptoms are the same as those of schizophrenia
Symptom last only from 1 to 6 months
Brief Psychotic Disorder
Symptom duration of 1 day to 1 month
Often triggered by extreme stress
Other Psychotic Disorders
Schizoaffective Disorder
Symptoms of both mood disorder and schizophrenia
Delusional Disorder
Persistent delusions
Persecution, jealousy, being followed, erotomania, somatic
Non-bizarre delusions
e.g., jealousy, erotomania
No other symptoms of schizophrenia
Etiology of Schizophrenia: Genetics
Not likely that disorder caused by single gene
Behavior genetics research
Family studies & Twin studies (Table 11.2)
The risk increases as the genetic relationship between proband and relative becomes closer
MZ (44.3%)> DZ (12.08%)
Negative symptoms may have a stronger genetic component
Adoption studies
Table 11.3
Etiology of Schizophrenia: Genetics
Molecular genetics research
Linkage studies
A number of chromosomes implicated
Results inconsistent and marked by a failure to replicate
Association studies
Two genes identified
DTNBP1:encoding a protein called dysbindin
NGR1: linked to the neurotransmitter glutamate's receptors & the process of myelination
Table 11.2 Family and Twin Genetic Studies
Table 11.3 Characteristics of Adopted Offspring of Mothers with Schizophrenia
Etiology of Schizophrenia:
Evaluation of Genetic Research
Strong genetic component
Genetics doesn't completely explain the disorder
Diathesis-stress model
Genetic factors constitute underlying predisposition
Stress triggers onset
Limitations:
Can's specify exactly how a predisposition for schizophrenia is transmitted
The nature of the inherited diathesis remains unknown.
Etiology of Schizophrenia: Neurotransmitters
Dopamine Theory
Disorder due to excess levels of dopamine
Drugs that alleviate symptoms reduce dopamine activity (block D2 receptors)
Antipsychotic drugs produce side effects resembling the symptoms of Parkinson's disease (caused in part by low levels of dopamine)
Amphetamines, which increase dopamine levels, can induce a psychosis (like paranoid schizophrenia)
Theory revised
Excess numbers of dopamine receptors or oversensitive dopamine receptors in the mesolimbic pathway
Dopamine abnormalities mainly related to positive symptoms
Antipsychotics lessen positive symptoms but have little or no effect on negative symptoms
Figure 11.1 The Brain and Schizophrenia
Figure 11.2 Dopamine Theory of Schizophrenia
Etiology of Schizophrenia:
Evaluation of Dopamine Theory
Dopamine theory doesn't completely explain disorder
Antipsychotics block dopamine rapidly but symptom relief takes several weeks
To be effective, antipsychotics must reduce dopamine activity to below normal levels
Other neurotransmitters involved:
Serotonin
GABA
Glutamate
Etiology of Schizophrenia:
Brain Structure and Function
Enlarged Ventricles
Implies loss of brain cells
Correlate with
Poor performance on cognitive tests
Poor premorbid adjustment
Poor response to treatment
Not specific to schizophrenia
Reduced activity in prefrontal cortex
Involved in speech, executive functions, goal-directed behavior
Reductions in gray matter in the prefrontal cortex
May be related to dopamine underactivity
Etiology of Schizophrenia:
Brain Structure and Function
Congenital Factors
Damage during gestation or birth
Obstetrical complications rates high in patients with schizophrenia
Reduced supply of oxygen during delivery may result in loss of cortical gray matter
Viral damage to fetal brain
In Finnish study, schizophrenia rates higher when mother had flu in second trimester of pregnancy (Mednick et al., 1988)
Etiology of Schizophrenia: Brain Structure and Function
Developmental Factors
Prefrontal cortex matures in adolescence or early adulthood
Dopamine activity also peaks in adolescence
Excessive neuronal pruning
May explain why symptoms appear in late adolescence but brain damage occurs early in life
Etiology of Schizophrenia: Psychological Stress
Socioeconomic status
Highest rates of schizophrenia among urban poor.
Sociogenic hypothesis
Stress of poverty causes disorder
Social selection theory
Downward drift in socioeconomic status
Turner & Wagonfield (1968) studied SES of patients' fathers
Results support social selection hypothesis
Etiology of Schizophrenia: psychological
Family-related factors
Schizophrenogenic mother
Cold, rejecting, overprotective, domineering, conflict-inducing
No support for this theory
Communication deviance (CD)
Hostility and poor communication
Family CD predicted onset in one longitudinal study (Norton, 1982)
CD not specific to families of schizophrenic patients
Etiology of Schizophrenia:psychological
Families and Relapse
Family environment impacts rehospitalization
Expressed Emotion (EE; Brown et al., 1966)
Hostility, critical comments, emotional overinvolvement
Relapse rate: High EE (58%) > Low EE (10%)
Bi-directional association
The expression of unusual thoughts by the pt → increased critical comments by family members
Critical comments by family members increased expression of unusual thoughts by the pt
Etiology of Schizophrenia:
Developmental Studies
Developmental histories of children who later developed schizophrenia (in the 1960s)
Lower IQ
More often delinquent and withdrawn
Coding of home movies
Poorer motor skills
More expression of negative emotion
Etiology of Schizophrenia: Developmental Studies
High risk studies
Danish children with a schizophrenic mother who later developed disorder (Mednick & Schulsinger, 1968)
Negative symptom patients
More pregnancy birth complications
Failure to show electrodermal responding
Positive symptom patients
Family instability
Divorce or institutionalization
Australian study (Yung et al., 1995)
MRI found reduced gray matter volume predicted later development of psychotic disorder
Treatment of Schizophrenia: Medications
Traditional antipsychotic drugs & their side effects
Antipsychotic medications (1950s)
Chlorpromazine (Thorazine), haloperidol (Haldol),
Block dopamine receptors
Reduce the positive and disorganized symptoms
Side effects
Dizziness, blurred vision, restlessness, sexual dysfunction
Extrapyramidal side effects
Stem from dysfunctions of the nerve tracts that descend from the brain to spinal motor neurons; resemble the symptoms of Parkinson's disease
Tremors of the fingers, a shuffling gait, & drooling
Dystonia, dyskinesia
Treatment of Schizophrenia: Medications
Atypical antipsychotic medications
Clozapine (Clozaril)
Fewer motor side effects
Less likely to drop out of treatment
Impact on serotonin receptors
Side effects
Can impair immune symptom functioning in 1% pts by lowering the number of white blood cells
Seizures, dizziness, fatigue, drooling, weight gain
Relate to type 2 Diabetes
Psychological Treatments: Psychoanalytic therapy
Freud
Little value in psychotherapy for psychotic disorders
Schizophrenics were incapable of establishing the close interpersonal relationship essential for analysis
Harry Stack Sullivan
Develop trusting therapist-patient relationship
Teach adult forms of communication
Foster insight into role of past
Psychological Treatments
Recent types of psychosocial treatments are more active, present-focused, and reality-oriented
Social skills training
Teach effective social behaviors
Family therapy to reduce EE
Educate family about causes, symptoms, and signs of relapse
Stress importance of antipsychotic medication
Help family to avoid blaming patient
Improve family communication and problem-solving
Encourage expanded support networks
Instill hope that things can improve
Psychological Treatments
Cognitive behavioral therapy
Recognize and challenge cognitive distortions
Recognize and challenge expectations associated with negative symptoms
e.g., low expectations for success and pleasure
Cognitive enhancement therapy (CET)
Improve attention, memory, problem solving and other cognitive based symptoms
Psychological Treatments
Other therapies
Personal therapy: leads to less relapse
Teaching the pt how to recognize inappropriate affect & to notice small signs of relapse
Learn skills to deal with these problems
Case management
Residential treatment (halfway houses)
Vocational rehabilitation
6553
·上一篇：Schiffert健康中心
·下一篇：sepsis:arandomized
