SCHIZOPHRENIA & PSYCHOSIS

DR. HILWA ABDULLAH @ MOHD. NOR

SKPX PSIKOLOGI ABNORMAL
22 OKTOBER 2019
https://www.nami.org/learn-
more/mental-health-
conditions/schizophrenia
3 Psychosis

– Psychosis: a loss of contact with reality

– A change in your ability to perceive and respond to the
environment

– Can be substance-induced – but most due to

schizophrenia.
SCHIZOPHRENIA

 Major disturbances in thought, emotion, and behavior

 Disordered thinking
 Ideas not logically related
 Faulty perception and attention
 Lack of emotional expressiveness
 Inappropriate or flat emotions
 Disturbances in movement or behavior
 Messy appearance
 Can disrupt interpersonal relationships, diminish capacity to work
or live independently
 Significantly increased rates of suicide and death
SCHIZOPHRENIA

Lifetime prevalence 1% (about 2.5 million Americans)

Affects men slightly more often than women
Onset typically late adolescence or early adulthood
 Men diagnosed at a slightly earlier age
More frequently found among low SES
Diagnosing Schizophrenia

– The DSM-5 calls for a diagnosis of schizophrenia only

after symptoms of psychosis continue for six months or
more
– Individuals must also show a deterioration in their work,
social relations, and ability to care for themselves
DSM-5 Criteria for
Schizophrenia
 Two or more symptoms lasting for at least 1 month; one symptom should be 1,
2, or 3:
1) Delusions
2) Hallucinations
3) Disorganized speech
4) Abnormal psychomotor behavior (catatonia)
5) Negative symptoms (blunted affect, avolition, asociality)
 Functioning in work, relationships, or self-care have declined since onset
 Signs of disorder for at least 6 months; at least 1 month of the symptoms above;
or, if during a prodromal or residual phase, negative symptoms or two or more
of symptoms 1-4 in less severe form
Clinical Description of
Schizophrenia

Three major clusters of symptoms:

– Positive
– Negative
– Disorganized
Clinical Description of Schizophrenia
hallucinations of a clown
https://www.youtube.com/watch?v=7csX
fSRXmZ0
Positive Symptoms
Delusions
 Firmly held beliefs
 Contrary to reality
 Resistant to disconfirming
evidence
Types of delusions:
Persecutory delusions
“The CIA planted a listening
device in my head”
65% have these
Thought insertion
Thought broadcasting
Outside control
Grandiose delusions
Ideas of reference
14 Positive Symptoms

– Types of delusions
– Persecutory
– Referential
– Somatic
– Religious
– Grandiose
– Thought withdrawal
– Thought insertion
15 Positive Symptoms

– Disorganized Thinking and Speech:

– Loose associations (derailment):
– “Kyra serves drinks at a bar. I love candy bars. I went to Hershey, PA when I was five years
old.”

– Neologisms (made-up words):

– “butterflower”

– Perseveration
– Patients repeat their words and statements again and again
– “Let’s go to supper at the supper club, with the supper, supper”

– Clang (rhymes):
– How are you? “Well, hell, it’s well to tell”
Positive Symptoms

Hallucinations Types of hallucinations:

 Sensory experiences in  Auditory
the absence of sensory 74% have this symptom
stimulation  Visual
 Hearing voices
Increased levels of activity in
Broca’s area during hallucinations
Negative Symptoms
 Avolition  Can be grouped into 2 domains:
– Lack of interest; apathy  Experience domain
 Asociality
– Motivation
– Inability to form close personal
relationships – Emotional experience
 Anhendonia – sociality
– Inability to experience pleasure  Expression domain
– Consummatory pleasure
– Outward expression of emotion
– Anticipatory pleasure
– Vocalization
 Blunted affect
– Exhibits little or no affect in face or voice
 Alogia
– Reduction in speech
Disorganized Symptoms

Disorganized speech (Formal thought disorder)

 Incoherence
– Inability to organize ideas
 Loose associations (derailment)
– Rambles, difficulty sticking to one topic
Disorganized behavior
 Odd or peculiar behavior
– Silliness, agitation, unusual dress
– e.g., wearing several heavy coats in hot weather
19 Psychomotor Symptoms

– Catatonic stupor – stop responding to environment,

motionless and mute
– Catatonic rigidity – rigid posture, resisting movement
– Catatonic posturing – awkward positions
– Catatonic excitement – “wild waving of arms &legs”
 Other Psychotic Disorders

Schizophreniform Disorder
– Same symptoms as schizophrenia
– Symptom duration greater than 1 month but less than 6 months
Brief Psychotic Disorder
– Symptom duration of 1 day to 1 month
– Often triggered by extreme stress, such as bereavement
Schizoaffective Disorder
– Symptoms of both schizophrenia and mood disorder
– DSM-5 likely to require appearance of major depressive or manic episode
 Other Psychotic Disorders

 Delusional Disorder
– Delusions may include:
– Persecution
– Jealousy
– Being followed
– Erotomania
– Loved by a famous person
– Somatic delusions
– No other symptoms of schizophrenia
Family and Twin Genetic Studies
Characteristics of Adopted Offspring of
Mothers with Schizophrenia
Etiology of Schizophrenia:
Genetics
 Identical twin affected 50%
 Fraternal twin affected 15%
 Both parent affected 35%
 One parent affected 15%
 Brother or sister affected 10%
 No affected relative 1%
 Etiology of Schizophrenia:
Neurotransmitters
Dopamine Theory
– Disorder due to excess levels of dopamine
– Drugs that alleviate symptoms reduce dopamine activity
– Amphetamines, which increase dopamine levels, can induce a psychosis

Theory revised
– Excess numbers of dopamine receptors or oversensitive dopamine receptors
– Localized mainly in the mesolimbic pathway
– Mesolimbic dopamine abnormalities mainly related to positive symptoms
– Underactive dopamine activity in the mesocortical pathway mainly related to negative
symptoms
The Brain and Schizophrenia
Brain abnormalities in Schizophrenia
Schizophrenics with negative and cognitive symptoms
exhibit neurological damage
How Are Schizophrenia and Other
Severe Mental Disorders Treated?

– For much of human history, people with schizophrenia were

considered beyond help and without hope

– Though schizophrenia is still hard to treat, the discovery of

antipsychotic drugs has enabled people with the disorder to
think clearly and profit from psychotherapies

– A historical perspective of treatment allows the best

understanding of the nature, problems, and promise of
modern approaches
 Institutional Care in the Past

– For more than half of the 20th

century, people with schizophrenia
were considered insane and were
institutionalized in public mental
hospitals

– Because patients failed to respond

to traditional therapies, the primary
goals of the hospitals were to
restrain them and give them food,
shelter, and clothing
 Antipsychotic Drugs

– While milieu therapy and token economies helped improve treatment

outcomes, it was the discovery of antipsychotic drugs in the 1950s that
revolutionized treatment for those with schizophrenia

– It was discovered that one group of antihistamines, phenothiazines,

could be used to calm patients about to undergo surgery

– Psychiatrists tested one of the drugs, chlorpromazine, on six patients

with psychosis and observed a sharp reduction in their symptoms
Antipsychotic Drugs

– Antipsychotic drugs developed throughout the

1960s, 1970s, and 1980s are now referred to as
“conventional” antipsychotic drugs

– Drugs developed in recent years are known as

“atypical” antipsychotics
Treatment of Schizophrenia: Medications

 First-generation antipsychotic medications (neuroleptics; 1950s)

 Phenothiazines (Thorazine), butyrophenones (Haldol), thioxanthenes (Navane)
– Reduce agitation, violent behavior
– Block dopamine receptors
– Little effect on negative symptoms
 Extrapyramidal side effects
– Tardive dyskinesia
– Neuroleptic malignant syndrome
 Maintenance dosages to prevent relapse
 Treatment of Schizophrenia: Medications
 Second-generation antipsychotics
 Clozapine (Clozaril)
– Impacts serotonin receptors
 Fewer motor side effects
 Less treatment noncompliance
 Reduces relapse
 Side effects
– Can impair immune symptom functioning
– Seizures, dizziness, fatigue, drooling, weight gain
 Newer medications may improve cognitive function:
 Olanzapine (Zyprexa)
 Risperidone (Risperdal)
 How Effective Are Antipsychotic Drugs?

– Research has repeatedly shown that antipsychotic drugs reduce

schizophrenia symptoms in the majority of patients
– In direct comparisons, drugs appear to be more effective than any other
approach used alone

– In most cases, the drugs produce the maximum level of improvement

within the first six months of treatment
– Symptoms may return if patients stop taking the drugs too soon
How Effective Are Antipsychotic Drugs?

– Antipsychotic drugs, particularly the conventional ones, reduce the

positive symptoms of schizophrenia more completely, or at least
more quickly, than the negative symptoms

– Although the use of such drugs is now widely accepted, patients often
dislike the powerful effects of the drugs, and some refuse to take them
 The Unwanted Effects of
Conventional Antipsychotic Drugs

– The most common unwanted effects produce Parkinsonian symptoms,

reactions that closely resemble the features of the neurological disorder
Parkinson’s disease, including:

– Muscle tremor and rigidity

– Dystonia (bizarre movements of the face, neck, tongue, and back)
– Akathisia (great restlessness, agitation, and discomfort in the limbs)
Unwanted Effects of
Conventional Antipsychotic Drugs

– A more difficult side effect of conventional antipsychotic drugs

appears up to one year after starting the medication
– This reaction, called tardive dyskinesia, involves involuntary
movements, usually of the mouth, lips, tongue, legs, or body
– It affects more than 10% of those taking the drugs
– It can be IRREVERSIBLE!
 New Antipsychotic Drugs
– Recently, new drugs have been developed

– Called “atypical” because their biological operation differs from that

of conventional antipsychotics
– They appear more effective than conventional drugs, especially for negative
symptoms
– They cause few extrapyramidal side effects
(i.e., movement disorders)

– Examples: Clozaril, Risperdal,

Zyprexa, Seroquel, Geodon,
and Abilify
 Psychotherapy

– Before the discovery of antipsychotic drugs, psychotherapy was not an

option for people with schizophrenia
– Most were simply too far removed from reality to profit from
psychotherapy

– Today, psychotherapy can be very helpful when used in combination with

medication
– The most helpful forms of psychotherapy include insight therapy and
two broader sociocultural therapies: family therapy and social therapy
– These approaches are often combined
 Psychological Treatments
 Social skills training
 Teach skills for managing interpersonal situations
– Completing a job application
– Reading bus schedules
– Make appointments
 Involves role-playing and other practice exercises, both in group and in vivo
 Family therapy to reduce Expressed Emotion
 Educate family about causes, symptoms, and signs of relapse
 Stress importance of medication
 Help family to avoid blaming patient
 Improve family communication and problem-solving
 Encourage expanded support networks
 Instill hope
 Psychological Treatments
Cognitive behavioral therapy
 Recognize and challenge delusional beliefs
 Recognize and challenge expectations associated with negative symptoms
– e.g., “Nothing will make me feel better so why bother?”

Cognitive remediation training (CRT)

– Improve attention, memory, problem solving and other cognitive-based symptoms
Case management
– Multidisciplinary team to provide comprehensive services
Residential treatment
– Vocational rehabilitation
THANK YOU