LECTURE 10 *dpp*

schizoprenia a continuum of disorders

psychosis : cannot distinguish reality from non reality anymore

90% seek tretment in mental healt facitly or geneal medicine

3% of medical budget goes to schizophernia

onset in teenage life or early audlthood

0.5 to 2 % of genera population prevelence

1. delusions
2. hallucinations

→ delusions : indeas that individual belives are true but that are highly unlikey and often simply imposssible

changed in the DSM 5 from "erroneus belifs" to " fixed beliefs that are not amenable to change in light of conflicting evidence "

diffeences between delusions and self deceptions :

self deceptions are at least possible

delusions preoccupie the person more than should ( convinde others)

slef deceptions accept it may be wrong while delusons highly resitent to argumnts

1. persecutory delusions : they arebeing watched
2. delusion of reference : events or comments are adressed to them
3. grandiose delusions : they are one special being and they have powers
4. delusions of thought insertion : thoughts are being controlled by pther people

can be differentiated within cultures

British people contolled by TV

Pakistani : controlled by black magic

Japanes : people know thigs about them

Germas/Austian : they have commited a sin

shared belief system is not considered to be delusional

unreal perceptual expirences that are frequent , persisten, comple abd sometimes bizzare, often entwinde with delusions

1. auditory
2. visual
3. tactile
4. somatic

hearing voices music

most common hallucinations

may come form inside or outside the person

often negative quality (hur themselves , critsizing or thrtneing )

schizophrenic people may talk back

1. **visual hallucinations** : usually acompanied by auditory hallucnation
2. **tactile hallucinations** : somthing hapenning outside thier body like bugs crawling on their body
3. **somatic hallucinations** : something happening inside the body like worms eating their intestines

not only occur in psychoprenia ( 60% schizophrenia , 25% depression and 15% bipolar disorder)

differetiated by cultures

asians : ghost or ascedors come back to them

puerorican women , wrogfully dignosed in europe only due to traditions of visual religion

formal though disorder : slip form one topic to a seemingy unreated topic with little coherent transition

1. **loose associations or derailment** : the person woth schizpohenia sees clear connctions that are not actually there
2. **incoherence**: also know as world salad
3. **neologisms** : make up words that only have meaning to themselves
4. **clangs** : make association between words based on the sounds of the words not content
5. **repetition** : repeat sequnce of words over and over again

we can see siorganisd taught in the following forms :

men show more severe deficits in laguage

*due to more bilateral control then women

*more localized in men genrally

unpredictabke and apprently untriggered agitation ( shouting , swaring or pacing rapidl y)

unresponsiveness to environemnt

1. ne**gaivsm** : lack of response or instuctions
2. **mutism** : rigid, innapropriate or bizzare psoture or complete lack of motor repsonse
3. **catatonic exitment:** get excited really quicly for no apparent reason

called negative as person lacks certain qualities

less proeminet than positive symptoms

severe reduction in or abence of emotional expression

show fewer facial expressions ( avoind eye contact, less likely to gesture)

tone of voice may be flat with little rythm in tempo and loudness

however people have reserche the phenomenon concluded that people with chizophrenia feel the same just not show the same amout of emotion

hard to predict future emotional expirice , problemation in decion making

loss of ability to expirince plesure

inability to initiate or persit at common goal directe activities

physically slowed down in movements and seems unmotivated

personal higene and grooming are lacking

lack of desire to interact with others

to not be confused with people not wanting to socialise with them due to stigma

diagnosed only when they have but refuse frinds and family

attention, memory and processing speed , focusing and maintaing attention , working memory ability to hold information in memory

difficult to distinguish real from hallucinating thougths

deficits contribute to overall symptoms

soical relatioships also affented

immediate relative aslo show these difficulties even if theu do not schizophrenia

these deficits are present before symptoms of schizophrenia appear

often not improve over life course

Emil Kraepelin : dementia preaecox ( precocius demential )

premature deterioration of the brain

progressive, ireeversable and chronic

Eugen Bleurer : not agree

schizophrenia ( schizo = to spit , phrenia = mind )

breaking the associative threads

lack of neccry links between aspects of the mind

diorganised behaviour = inability to keep train of minf

A. two (or more) of the following, each present for more than a month period (less if treated sucesfully) at least one of 1,2 or 3

1. delusions
2. hallucinations
3. disorganised speech
4. grossly diorganised or catatonic behaviour
5. negative symptoms

B. For significta time since onset of the diturbances, level of functionin in one or more major areas( work , intrpesonal relationships or slef caare) is markebly below the level

C. Continous signs of disturbances persist for at least 6 months ( must incude at least one month of symptoms )

6 months before the active phase individual may show predominetly negative symptoms ( gradually slipping off)

6 months after the active phase individual may show predominetly negative symptoms

after the first onset of acute episode individuals may have chronic residual sympotms → relpse in acute episodes

symptoms of autism can easlity be seen as psychotic(catatonia) → that is why delusions and hallucinations need to be present

parania not part of DSM5 naymroe

less responsive to medication than positive

people wit schizophrenia live 10 to 20 years shorter than without

suffer from infectious and circulatory dieses at a higher rate than normal people without disorder

5-10% commit suicide
howevr many are able to sabillize actoss life span within 5 to 10 years of firt episode

women with schizophrenia

*have better porgnosis than men

*less hospitalised less often than men

*show milder negative symptoms

*have better social adjustment when they are not psychotic

*onset wetwen late 20 and early 30

*show fewer cognitive deficits than men

*estorgen may affect regualtion of dopamine

exposure to toxins corelated with schizophrenic symptoms

high dopamine level corelated to symptoms

functioning seems to imporve with age

more benign course of action in developing countries than developed countris

less diabling in developing coutires possibly due to :

better social enviroment

broader and closer family

spread responsbility to take care of one

lower criticsm , hostility and overinvolvemnt

evidence shows contrary to general wisdom that many people with schizophrenia achieve a good level of functionin over time

1. schizoaffective
2. shizopherinform
3. breif psychotic disorder
4. delusionsl disorder
5. schziotypal repsonality disorder

mix of schizophrenia and mood disorder

expience psychotic symptoms

mood symptoms meeting criteria of depressive and manic episode

mood symptoms must be present for majority of the period illnes

at least 2 weeks of hallucintions without mood symptoms

between schizphrenia and bried psychotic disorder

meed criteria A,D,E of schizphrenia

but show symptoms that last only 1 to 6 month duration requirment

quick onset of symptoms and later will be dignosticated with schizophrenia

suddern onset of dilusion , hallucination , diorgnaised spees and or disorganised beghaviour

symptoms last 1 day to 1 month

they emerge after major stressor or no apparent reason

high risk of relapse but most people show excellent outcome

dilusions lasting at least 1 moth regarding rel life situations

being followed , poisoned, cheted

rare : 0.2 % prevelence

affect more females than males

later in life onset

liflong patter of oddities relating others and own behaviour

trouble understanding others or percive as odd

grap on relaity but suspiciousness

deficit in working memory , learning, recall similar to but less seve than schizophrenia

episodes of symptomatic of rief psychotic disorder that evetually may lead to schizphrenia

DSM5 also considers a personality disorder

not one gen is accountable for the

one set of genes may contribute to the negative symptoms

→ family studies

as genetic similarity yo a person with schizophrenia decreases, an individual's risk of developing also decreases

biological relative , increases chances but does not mean person will developm

87% with schisophrenic parents do not develop

63% have no first or second degree relative

concordance rate MZ 46%
conocrdance rate DZ 14% rate
genes can be turned on or of as DNA can be chmically changed in different environments
particular genes regulating dopamine

especially in medial temporal , superior temporal and prefrontal aereas

important in language

emotional expression

planning and garring our plans

connect to all other cortical reagins

major development in teenage years

can explain why onset is within this period

formation of long term memories

abnormal hippocampal activation in schizphrenic patients

abnormalities in volume and shape of hippocampus

similar abnomalities in firt degree relives

particularly areas associated with memory

early signs of diroder rather than consequnces of diesese process

fluid filled spaces in the brain

atrophy or deterioration in other brain tissue

patients show social , emotional and behavioural deficits

less responsive to medication

history of obstetric difficulies

hypoxia 9 oxygen deprivation at birth of few weeks before/after birth) 30%

oxygen deprivation + genetic vulnerability = developing disorder

viral infections while being pregnant

second trimester development is crucial → majour structural deficits otherwhise

babies born in spring more vulnerable as the pregnancy was during winte/ autumn ( more linkey of sicknesss)

examples of visuses proven higher rate of schizophrenia

symptoms caused by excess levels of dopamine in brian

praticulary in prefrontal cortex

drug used to reduce → phenothiazine and neuroleptics ( block dopamine reuptake )

amphetamines increase incidence of positive symptoms

more receptors of dopamine also linked with more symtoms

however dopamine theory does not explain negative symptoms ( no reaction to drugs especially for negative symptoms )

after medication → dopamine levels chage quicly → symptoms take longer → why?

1. mesolimbic pahway : processing salince and reward

ecess dopamine here considered part of process of hallucinoation and delusions

atypical drugs : bind to a specific type of dopamine receptor in mesolimbic system blocking the action

2. low dopamine activity in prefrontal area of the brain

lack o fmotivation and inabilty to care for self

serotionine neurons regulate dopamine neuros in mesolimbic system

this interaction might be crucial in schizphrenia

some reserchers found unusual GABA levels

deficits GABA could contribute to cognitivr and emotional symptoms

PCP and ketamine , that block GABA receptors cause hallucinations and delusions in otherwhise heatly individuals

**social drift** : due to symptomatolgy they end up in lower econoic class ( no education = no jobs)

urban birth : more people born in bigger cities→ link could be as urban cities imly more stressful lifelstyle

most pressure on mothers

overprotective and rejecting behaviour

due to not letting children develop an autonomous sens of self → feel worthelss and unlovable

constantly communicating conflicting messages to their children

cannot trust their feelings or perception of the world → distorted perception

families in high expressed emotion/ overinvolved are opverprotective

critical , hostile and resntful towards them

more likely to suffer from relapes of psychosis than those whose families are low in expressedemotion

family characterised by low warmth more likey to develop full syndrome

high levels of expressed emotion = higher rate of relapse

more negative symptoms may eclict more expressed emotion

fundamnetal difficulties in attention , inhibition and adherence to rules of communication

try to conserve their limitide cognitive resources

delusions may appar in people who try to explain strange perceptual expicinves

hallucinations result form hypersensitivity to perceptual imput

coupled with sttributed expirinces to external source

grater sucess in reducing symptoms than does imply providing patients with support

brain surgery in attempt to 'fix'

calmer after surgery

experinced significant cognitive and emotional deficits as a result

massive insuline intake

went into coma

emerge from coma but not much better

very dangerous

bated, fed, prevented form hurting themselves

physical restrains \few recieved any treatment that actually reduce symptoms

phenothiazines → calms agitation and reduces hallucinations and delusions

trifuoperazine / thrioridazine / fluphenazine / pherepenazine → block receptors for dopamine

control positive symptoms

taken even when asymptomatic

other antipsychotics : butyrophrnonrd and thioxanes

25% dp not respond to them

more effective with positive symptoms

of discontinued 78% will relapse within 1 year

97% will rwlapse within 2 years

30 % erelapse even on medication

akinesia → slowed motor activity motorus speeck and expresionless face

parkinsons symptoms due to lowered dopamine

akathesis → unable to stay still and agitation

tardive dyskinesia → involuntary moveemnts of tounge , face , mouth and jaw

irreversabile

occurs in 20% people with log term use of phenothiazines

seem to be more effective

binds D4 dopamine receptor

influnces several neurotransmitters inscluding serotonine

used when not responsive to phenothiazines

redcues both positive and negative symptoms

increase every day functionin

reduce risk of relapse

learn to seek help

change demoralising attitudes

token exonomy

teach family to avoind bizare comments of patient

discuss impact of the disorder

basic education on schizpohrenia ( innapropriate behaviours)

reduce self balme of family

learn how to interact andlearn specific behavioural techniques

more effective in reducing relapse rate by 24%

increase patient's adherence to taking medications