Schizophrenia

One of the most serious behavioral disorders

= Psychotic disorder with severe disturbance of:

· Thought (language-cognitive BBR)

· Emotion (verbal-emotional & emotional-motivational BBRs)

· Behavior (sensory-motor BBR)

· Social or occupational functioning

( S2 consequences of above)

Schizophrenia

Disturbances may involve:

· Perception (hallucinations)

· Inferential thinking (delusions)

· Language and communication (disorganized speech or mute)

· Self-monitoring (may be unaware)

· Emotions (flat or inappropriate)

· Hedonic capacity (loss of pleasure)

· Volition (few goal directed behaviors)

· Disorganized behavior (odd mannerisms)

Schizophrenia

DSM IV Diagnostic Criteria

A. Two+ of the following positive or negative symptoms for at least one month:

4 POSITIVE SYMPTOMS

(excess or distortion of normal functions)

· Delusions (erroneous belief)

· Hallucinations (erroneous perception)

· Disorganized speech

· Disorganized or catatonic behavior

Schizophrenia

DSM IV Diagnostic Criteria con’d

A. con’d

5 NEGATIVE SYMPTOMS

(restriction in range or intensity of normal functions)

· flat affect

· alogia

· avolition

· anhedonia

· asociality

Schizophrenia

DSM IV Diagnostic Criteria con’d

B. Deterioration of social, occupational, and self-care functioning (or failure to achieve expected level of functioning)

C. Subclinical symptoms for at least 6 months (e.g., odd beliefs)

Schizophrenia

DSM IV Diagnostic Criteria con’d

POSITIVE SYMPTOMS

A.1. Delusions (positive symptom)

· Persecutory (common)

· Referential (common)

· Somatic

· Grandiose

· Control

· Guilt or sin

Schizophrenia

DSM IV Diagnostic Criteria con’d

A.2 Hallucinations (positive symptom)

· Can involve perceptual changes in any of the senses

o Auditory (common)

o Visual (common)

o Olfactory

o Gustatory

o Tactile

o Somatic

Schizophrenia

DSM IV Diagnostic Criteria con’d

A.2 Hallucinations (positive symptom) con’d

· Common among people without SZ

At least 15% of healthy people experience hallucinations (Chapman, Edell, & Chapman, 1980)

o e.g., hearing the voice of someone who is not there

o e.g. listening to one's "conscience"

Schizophrenia

DSM IV Diagnostic Criteria con’d

A.2 Hallucinations (positive symptom) con’d

· Does not include sensory experiences while falling asleep or waking up

· Does not include recreational drug induced hallucinations

· Typically hallucinations are perceived as distinct from the person's own thoughts, senses, and perceptions

Schizophrenia

DSM IV Diagnostic Criteria con’d

A.3 Disorganized speech (positive symptom)

· Incoherence

· Loose associations (derailment)

o e.g., changes topics frequently w/ no transitions

o e.g., clang associations

· Word salad

Schizophrenia

DSM IV Diagnostic Criteria con’d

A.3 Disorganized speech (positive symptom) con’d

· Neologisms

· Perseveration

· Inappropriate affect
Schizophrenia

DSM IV Diagnostic Criteria con’d

A.3 Disorganized speech (positive symptom) con’d

Example of disorganized speech:

"Over 1000 doctors have said AIDS is a cover up. In South America, there was a conference. The war in Iraq down by Waikiki it was done. Done, done, done, done. But the rucker took it over. Then the dog. The dog is Spog. Frog. Leap. Heap, steep, creep, deep, gotta go beep. "

Schizophrenia

DSM IV Diagnostic Criteria con’d

A.4. Disorganized or catatonic behavior (positive)

Catatonia

Immobility

Stupor

Rigidity

Waxy flexibility

Disorganized

Unpredictable

Nonfunctional

Schizophrenia

DSM IV Diagnostic Criteria con’d

NEGATIVE SYMPTOMS

1. Flat Affect (negative symptom)

· does not mean person is not experiencing emotions

· evidence for flat affect if inferred from overt behavior

· e.g., Kring & Neale (1996) demonstrated that people with and without SZ responded similarly to an emotionally charged movie in terms of facial expressions and physiological arousal

Schizophrenia

DSM IV Diagnostic Criteria con’d

2. Alogia (negative symptom)

3. Avolition (negative symptom)

4. Anhedonia (negative symptom)

5. Asociality (negative symptom)

Schizophrenia

Impact of Positive & Negative Symptoms

· Positive symptoms are more bizarre than negative symptoms -à elicit fear in others

· Negative symptoms create more difficulties than positive symptoms in order to function independently in society

Schizophrenia

Impact of Positive & Negative Symptoms con’d

People with SZ & predominant negative symptoms are more likely to exhibit

· Lower educational attainment

· Less success in holding jobs

· Lower rate of marriage (30% - 40%) than general population (80%)

· Poorer performance on cognitive tasks

· Poorer prognosis

· Poorer response to medication

· Poorer response to behavioral therapy

Schizophrenia

General

· The lifetime prevalence is about 1%

· Onset is usually in late adolescence (early as 5 y/o) to mid-30's

· Substance abuse is a co-morbid condition in 50% of schizophrenia patients

· Life expectancy lower than general population

· Approx. 10% of people with SZ commit suicide

· Homicide rate 16 times higher than among people without SZ (Schwartz et al., 2003)

Schizophrenia

Suicide

Suicide risk factors among people with SZ:

· Male

· Under 30 y/o

· Depressive symptoms

· Unemployed

· Recent hospital discharge

Schizophrenia

Homicide

Risk factors found by Schwartz et al. (2003):

· Male

· Late onset

· Aggressive

· Hostile

· Substance withdrawal

· Intoxication

· Suspicious (paranoid)

Schizophrenia

General

· Women have later onset, more predominant mood symptoms, and better prognosis

· Equal diagnosis for males and females

· Males more likely to be hospitalized

· No laboratory findings have been identified that are diagnostic of SZ

· Not a disease (with known cause) but a disorder (cause unknown)

Schizophrenia

Subtypes

· Subtypes have evolved over the years

o Subtype does not indicate etiology

o Subtype does not indicate particular treatment

o No taxonomy of subtypes has gained universal acceptance

· Research literature offers several taxonomies:

o paranoid vs. non-paranoid; former better recovery

o acute vs. chronic; former better recovery

Schizophrenia

DSM Subtypes

3 Major DSM Subtypes

· Disorganized schizophrenia

· Catatonic schizophrenia

· Paranoid schizophrenia

Schizophrenia

Etiology & Course

ETIOLOGY

· SZ remains a disorder rather than a disease as cause is unknown

COURSE

· Eggers & Bunk (1997): long-term course of 44 people with schizophrenia in Germany found 40 yrs. since diagnosis (avg. age of onset 13y/o):

o 25% in complete remission

o 25% in partial remission

o 50% in poor remission

o earlier onset predicted poor prognosis

o acute onset predicted better prognosis

Schizophrenia Etiology

Diathesis Stress Paragigm

· Familial concordance (genetics) = Diathesis

Response to medication

Evidence of brain structure anomalies

· Dysfunctional learning history--e.g., modeling and reinforcement of odd behaviors = Diathesis

Response to behavior therapy

· Negative life events, including a family with inconsistent reinforcement contingencies (operant conditioning and modeling) = Stress

Schizophrenia

Etiology & Treatment con’d

Diathesis-Stress TX Most Effective:

· Behavioral treatment (token economy and skills training)

· Medication to reduce positive symptoms (and possibly create negative ones)

Lieberman et al. (2005) 74% discontinue drugs

due to side effects and ineffectiveness

Schizophrenia

Anti-Psychotic Medication

= Major Tranquilizers= Neuroleptics

(e.g., Haloperidol/Clozapine)

Short-term effect: reduction of some schizophrenic symptoms, such as

Hallucinations

Delusions

Bizarre motor behaviors

But less effective with other symptoms, such as:

Fragmented thoughts

Incoherence

Blunted affect

Schizophrenia

Anti-Psychotic Medication con’d

Side effects of anti-psychotic medications:

Parkinsonism (motor tremors and loss of control)

Extrapyramidal movement disorders

Endocrine disorders

Sexual performance dysfunctions

Menstrual changes

Blurred vision

Glaucoma

Dry mouth

Constipation

Urinary retention

Memory impairment

Sedation

Drowsiness

Schizophrenia

Anti-Psychotic Medication con’d

Side effects of anti-psychotic medications con’d:

Weight gain

Dizziness

Rapid heart rate

Postural hypotension

Pigmentation of skin

Pigment deposits in the retina

Impaired vision

Decreased pituitary function

Allergic reactions

Liver dysfunction

Blood disorders (e.g., reduced white blood cells count)

Hypotension

Fever

Exacerbation of diabetes mellitus

Agitation

Schizophrenia

Anti-Psychotic Medication con’d

Side effects of anti-psychotic medications con’d:

Anxiety

Insomnia

Headache

Nausea

* many side-effects are not reversible

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program

· Includes medication and Paul and Lentz (1977) model of treatment (referred to as the Libermann model)

· Learning/ behavioral orientation

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

· One of the most significant recent trends in the treatment of schizophrenia, particularly as treatment for most individuals has moved out of chronic stays in inpatient wards and into the outpatient community, is the psychosocial rehabilitation model.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

· The most unique aspect of this model is its changed conception of individuals with schizophrenia as active partners in planning their own goals and treatment, and positive expectations regarding their ability to improve their independent functioning.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

· The following tenets of the psychosocial rehabilitation were described by Cnaan, Blankertz, Messinger, and Gardner (1988; Psychosocial Rehabilitation Journal, 11, 60-77).

Underutilization of Full Human Capacity.
Assumption is that each person can improve his or her level of functioning, that "Life is a process of growth and change and all persons, even the most disabled, are capable of growth and change."

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

Cnaan con’d

Equipping People with Skills.
Rather than focusing on clinical symptoms, the psychosocial rehabilitation approach focuses on the presence or absence of skills needed for independent living. Therefore, treatment aims to teach job skills, daily living skills, skills for interacting with others, and skills for utilizing available resources in the community.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

Cnaan cont’d

Self-Determination.
People with schizophrenia are viewed as adults with the right and ability to participate in decision-making and live by their consequences. Except in emergency situations, clients participate fully in making goals, can reject goals set by others, and are viewed as intelligent consumers who provide important feedback.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

Cnaan cont’d

Normalization.
The ultimate goal of psychosocial rehabilitation is independent living in the community, with minimal, if any, support.

Differential Needs and Care.
Treatment is individualized to recognize the unique skills and problem areas for each individual person. No common plan for progression, but rather each individual has a unique path & speed for recovery.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

Cnaan cont’d

Commitment of Staff.
The psychosocial rehabilitation model only works when staff is sufficient in number & dedication to outreach services, crises response, and remaining optimistic in the face of slow progress.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

Cnaan cont’d

Deprofessionalization of Service.
Relationships between staff & clients (aka consumers) based on common humanity more than professional barriers. Interaction includes the exchange of contradictory ideas in an atmosphere of mutual respect, and the rehabilitation process is demystified.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

Cnaan cont’d

Early Intervention.
Crisis intervention is provided as soon as early warning signs of decompensation are observed. In addition, clients are educated to recognize their own warning signs and elicit help from staff early on.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

Cnaan cont’d

Environmental Approach.
Attention is paid to making changes in the immediate environment through the help of relatives, employers, and others in one’s social network. Families are included in the care giving process and provided with education and support. Staff works actively to reduce discrimination in employment and housing settings.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

Cnaan cont’d

Changing the Environment.
In addition to addressing a client’s immediate environment psychosocial rehabilitation focuses on changes in broader social institutions, including medical services, income support policies, legislation regarding rights, and public attitudes/stigma.

No Limits on Participation.
No limits are set on length of TX and few selection criteria are set. The idea is to avoid excluding those with severe symptoms or to end intervention before change is effected.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

Cnaan cont’d

Work-Centered Process.
The opportunity to aspire to & achieve gainful employment is "a deeply generative and reintegrative force in the life of every human being." Work is central theme in psychosocial rehabilitation.

Schizophrenia

Diathesis Stress Treatment Example

Hawaii State Hospital Psychosocial Rehabilitation Program con’d

Cnaan cont’d

Social Rather than Medical Supremacy.
While medical model focuses on illness, the psychosocial rehabilitation model stresses skill-building & social support systems for coping with life’s stresses. The focus is on present & future functioning, not etiology & past functioning.