Schizophrenia Spectrum
 

1.0  Schizophrenia Spectrum (Split mind). 2

2.0  Symptoms. 2

·       2.1 Positive Symptoms. 2

·       2.2 Negative Symptoms. 3

3.0  Cognitive Deficits. 4

4.0  Diagnosis. 4

5.0  Prognosis. 4

6.0  Other Psychotic Disorders. 5

7.0  Biological Theories: 5

·       7.1 Genetics: 5

·       7.2 Structural and Functional Brain Abnormalities: 5

·       7.3 Neurotransmitters: 5

8.0        Psychosocial Theories. 6

·       8.1 Social drift and urban birth: 6

·       8.2 Stress and Relapse: 6

·       8.3  Family: 6

·       8.4  Cognitive Perspective. 6

·       8.5 Cross-Cultural Perspective. 6

9.0         Treatment. 6

·       9.1 Biological Treatment. 6

·       9.2 Psychological and Social Treatment. 7

1.0  Schizophrenia Spectrum (Split mind)
               
                - 5 Domains of symptoms (4 positive , 1 negative)
                - Cognitive deficits (not criteria for diagnosis)
                - Anhedonia (but feel same amount of emotion and more physical arousal)
                - Recovery rate (40% employed, 37% functioning well)
                - Negative symptoms are the bigger problem (marker for low socioeconomic status)

 Psychosis: Being unable to differentiate between reality and illusion
 

2.0  Symptoms
 

• 2.1    Positive Symptoms: Overt expression
  -  Delusions
  - Hallucinations
  - Disorganized thought + speech + behaviour

   - Delusions: Person believes things that are highly unlikely or untrue, that are not amenable to change
                                       ! Not self-deceptions !
                                       à because, not possible, actively behave in concordance with the belief, resist neg. evidence

                               persecutory delusions:  being watched, tormented, spied after
                               delusion of reference: random events are meant to tell them something, related to them
                               grandiose delusion: believe that one is special or perceives superpower
                               delusion of thought insertion: belief that thoughts are controlled from outside
                               à can occur together in a story
                               à difference in content from cultural difference, maybe not abnormal if culture holds this belief
   
  

   

- Hallucinations: Unreal perceptual experiences, sometimes entwined with delusions

                             auditory: hearing voices, music à often negative qualities
                             visual: seeing things à often entwined with auditory

                                             tactile: something is happening outside, but to the body
                                             somatic: something is happening inside the body
                             à can be culture specific

 - Disorganized speech:

                             formal thought disorder: - Switch topics wildly without coherent transition (loose association,
                                                                                   derailment)
                                                                                - Can also be totally unrelated words or new words (neologisms)
                                                                                - Associations made not by meaning but by sound (clangs)
                             à women suffer less, cause speech in their brain works bilateral

- Disorganized behaviour / catatonic: Unpredictable untriggered agitation, shouting, swearing
                                                                             - Sometimes occur with delusions, hallucinations
                                                                             - Cant organize daily routines (dressing, eating, bathing)
                                                                             - Socially unacceptable behaviour

                             Catatonia: Behavior that is unresponsive to the environment
                                                   - Lack of response to instructions (negativism)
                                                   - Rigid, bizarre postures, total lack of response (mutism)
                                                   - Purposeless excessive motor activity (catatonic excitement)

• 2.2    Negative Symptoms: Loss of qualities of the person
  - persistent
  - difficult to treat

   - Restricted affect: - Reduction or absence of emotional epression
                                         - No eyecontact, gestures, or emotional content
                                         - Voice is monoton, emphasis, intonation, rhythm, tempo

   - Avolition/Asociality: - Inability to initiate/persist on set goals (work, school, home)
                                                 - Slowed movement, unmotivated
                                                 - Lack desire to interact with other people

3.0  Cognitive Deficits

- Deficit in attention, memory, processing speed
- Cannot manipulated or hold memory good
- Unable to filter relevant or irrelevant information (or find source of information)
à Affects social functioning severely
à Eventually cause of delusions or hallucinations when they try to make sense of the information
à Can lead to further symptoms and perpetuate or make it worse

- Relatives show cognitive impairment as well
- Early marker is congnitive impairment during childhood

4.0  Diagnosis

- Disorder since 19 century ( earlier called dementia praecox)
- Links between aspects of the mind are not there
- Symptoms can be similar to autism spectrum (therefore psychosis symptoms must be present)

- 2+ symptoms of psychosis (delusion, hallucination, disorganized speech) acute minimum 1 month
à acute phase
- additionally other symptoms that impair functioning for minimum 6 months

prodromal symptoms: before acute phase
residual symptoms: after acute phase
à indicate start or diminishing of the active phase (symptoms are less worse)
 

5.0  Prognosis

- Mostly years of impairment
- 10 years less life-expectancy
- Suffer more from infections and other diseases
- 10-15% suicide rate
- Functioning improves with age (cause reduction in dopamine levels?)
- Women: - better prognosis
                    - better recovery rate, less hospitalization, social adjustment
                    - Less cognitive deficits, less brain abnormality
                    - Better prenatal development (less likelihood for disorder)
                     à Estrogen affects dopamine regulation in positive way
               
- Sociocultural factors: - Developing countries better recovery rate à collectivist culture, lower discrimi.

6.0  Other Psychotic Disorders

• Schizoaffective disorder: Mix with Mood-Disorder (manic episode, MDD)
                                                     - Requires at least 2 weeks of psychotic symptoms
• Schizophreniform disorder: Criteria A,D,E and symptoms last from 1-6 months, not more
                                                          - Quick onset of symptoms
                                                          - 66% will develop Schizophrenia
• Brief psychotic disorder: Sudden onset of psychotic features, disorganized behaviour
                                                    - Episode lasts between 1 day and 1 month
                                                    - Usually excellent recovery
• Delusional disorder: Delusions that last min 1 month, no other psychotic symptoms, lack in functioning !!
                                           - Females are more at risk
• Schizotypal personality disorder: Lifelong pattern of oddities and bad self-concept, thinking, behaviour, relation
                                                                     ships
                                                                     - No sense of independent self and trouble setting realistic goals.
                                                                     - Restricted emotional expression or odd
                                                                     - can´t understand others and have few relationships
                                                                     - Perceive others as deceitful, hostile à socially anxious, isolated
                                                                     - Can´t hold up attention, bad memory, learning
                                                                     à have same genetic traits and neurological abnormalities

7.0  Biological Theories:

• 7.1    Genetics:
  - polygenetic disease
  - genetic transmission
  - 50% genes shared = 10% chance of schizophrenia, 25% = 3%, normal population risk 1-2%
  - Twinstudies: 80% of variation in schizophrenia is determined by genetical factors 20% epigenetic/psychosocial
   
• 7.2    Structural and Functional Brain Abnormalities:
  - reduction of gray matter in cortex (medial, temporal, superior, prefrontal)
  à prefrontal cortex (attention, planning, emotional expression) connects to limbic system (emotion + cognition)
       ,basal ganglia (motor movement) and other areas.
  - Affects volume and shape of hippocampus (memory formation) à abnormality also found in relatives
  - reduction of white matter (connects parts of brain) in parts of working memory
  - Enlarged ventricles (fluid filled spaces in brain)

  - Abnormalities can be tied to birth complications (perinatal hypoxia) à epigenetic factor
  - Influenza /herpes epidemics /famine, (especially 2^nd trimester of pregnancy) à brain development stage

• 7.3    Neurotransmitters:
  - Dopamine dysfunction in different areas (excess/lack)
  - 1. Theory: Dopamine alone, supported by evidence of dopamine regulating drugs
  - 2. Theory: Negative symptoms not controlled by dopamine à something else must be in play
  à more complicated theory proposes that mesolimbic system (subcortic, salience and reward) has excess activity
       of dopamine. Low dopamine activity in prefrontal cortex à leads to negative symptoms
  - Serotonin also plays important role (regulate dopamine activity
  - GABA (gamma-aminobutyric acid
  - Glutamate neurons (Major excitatory pathway in cortex, limbic system, thalamus  (lack leads to cognitive +
    emotional symptoms)

8.0 Psychosocial Theories

• 8.1    Social drift and urban birth:
  - Social drift: symptoms interfere with functioning à person drifts downward in socioeconomic status
  - Urban birth: 5x times more likely to develop schizophrenia à exposed to viruses and co

• 8.2    Stress and Relapse:
  - Stressful episodes trigger disorder/relapse
  - downward spiral (prodromal symptoms lead to withdrawal, and so on)

• 8.3    Family:
  - First theorists blamed mothers (double bind situations = conflicting messages to child)
  à develop distorted view of themselves and others

  expressed emotion: Conflicting messages, anger and hostility + sometimes support toward ill person.
                                           à Ill person is overwhelmed by ambiguous information à can´t cope with all the stress
                                           à symptoms of schizophrenia
   - Expressed emotion is not so much of a problem in developing countries

• 8.4    Cognitive Perspective
  - Difficulty in attention, inhibition and communication skills lead them to reserve resources (withdraw)
  - Delusions – Person tries to make sense of perceptual experiences
  - Hallucinations – Perceptual hypersensitivity
  - Negative symptoms – Expectations about social interactions à withdraw in order not to stress out more
               à cognitive therapy helps to identify and cope with stressful events and dispute psychotic symptoms,
                    create expectations of positive outcomes (against negative symptoms)

• 8.5    Cross-Cultural Perspective
  - Most cultures have biological explanation
  - Also spiritual and family explanations

9.0    Treatment

• 9.1    Biological Treatment
  - Medications (insulin coma therapy, 1930, not used anymore)
  - Brain surgery (not used anymore)
  - Electroconvulsive ECT
  - 1950 Antipsychotic drugs = Neuroleptics (eg. Chlorpromazine)

               Typical Antipsychotics:

               - Chlorpromazine: Calm agitation, antipsychotic, others (trifluoperazine, thioridazine, phenazine)
                                                    à Block dopamine receptors. Can control positive symptoms
               - Butyrophenone: no explanation given
               - Thioxanthenes: no explanation given

  à 25% of people do not respons to these, if they help, people still are dysfunctional, high relapse rate 78-98%
  à side effects: grogginess, dry motugh, blurred vision, drooling, sexual dysfunction, visual problems, weight gain/lo
       ss, constipation, menstrual problems, depression, akinesia: slowed motor movement, speech, expressionless face,
       Parkinson similar symptoms, akathesis: agitation leads to uncontrolled movements
       tardive dyskinesia: involuntary movement of facial features (tongue, mouth, face, jaw)

               Atypical Antipsychotics:

               - Clozapine: Binds to D4 dopamine receptor, reduces negative + positive symptoms
               - Risperidone: na
               - Olanazapine: na
               - Ziprasidone: na

  à side effects: dizziness, nausea, sedation, seizues, hypersalivation, weight gain, tachycardia,
                              agranulocytosis: deficiency of granulocytes à higher infection rate
                                 concentration problems
   

• 9.2    Psychological and Social Treatment
               - Increase social skills à reduce isolation, apathy, stress, risk of relapse

               9.2.1      Behavioral, Cognitive, Social Treatments
              
                               - Cognitive Treatment: Recognize and change beliefs
                               - Behavioral Treatment: Operant conditioning, modelling of right and socially desired behaviour
                                                                à Token economies
                               - Social interventions: Self-help support groups, roleplaying, discussion, relief

               9.2.2      Family Therapy

                               - Teach family about causes, symptoms, medications of schizophrenia – basic education
                               - Teach them communication + problem solving skills + behavioural techniques to teach the ill person
                               à highly decrease relapse rate combined with drugs
                               !!!! Cultural background needs to be considered !!!!

               9.2.3      Assertive Community Treatment programs
                              
                               - Community mental health movement
                               à Tries to deinstitutionalize care, reintegrate ill in society/family à fail cause no funding
                               - Provide allround service, 24/7
                               - Homebased treatment helps reduce relapse or need for institutional care.

               9.2.4      Traditional Healers:

                               - Spiritual rituals, herbes.
                               - Explanations of affectiveness:
                                                              
                                               1. Structural model: Interrelated levels of experience, cognition, body, emotion
                                                                                       à Symptoms when these are disbalanced
                                               2. Social support model: Conflicting social situations are reason
                                                                                                  à Tries to motivate social circle to carry
                                               3. Persuasive model: Rituals can change the meaning of the illness for person
                                               4. Clinical model: Placebo effect, faith in the healers ways
              
                                              

   

  Eating Disorders

   

  9.1 Anorexia Nervosa. 1

  9.2 Bulimia Nervosa. 1

  9.3 Binge-Eating Disorder. 1

  9.4 Other Specified Feeding or Eating Disorders. 1

  9.5 Obesity. 2

  9.6 Theorie of Eating Disorders. 2

  9.6.1 Biological factors. 2

  9.6.2 Sociocultural and Psychological Factors. 2

  9.7 Treatment for Eating Disorders. 2

  9.7.1 Psychotherapy. 2

  9.7.2 Biological Therapy. 3

   

   

  9.1 Anorexia Nervosa

   

• Selfstarvation
• Cognitions: Need lose more weight, Distorted bodyimage, fear of gaining weight
• Chronically fatigued
• Begins in adolescence, duration 7 years female, 3 years male
• Comorbid (anxiety, depression, suicidal, impulsive) à more for binge/purge type than restricting
• Consequences: Cardiovascular problems, bradycardia (slowing of heartrate), arrhythmia (irregular heart beat)

• Heart failure, expansion of stomach, Bone weakness (due to lack of estrogen), immune. Sys. Probs)

• Hypothalamus, Serotonie, Dopamine, + hormones mulfunctioning

•  

  Restricting type: no purging behaviours or binge eating, weightloss only due to exercise/fasting

  Binge/purge type: involved in binge eating and purging (Defining feature to bulimia nervosa: below healthy weight

   

  Amenorrhea: Menstrual periods stop

   

  9.2 Bulimia Nervosa

   

• Uncontrolled eating bingeing  followed by purging (to prevent weight gain)
• Still kind of normal bodyweight or even too much
• 114+ episodes per week
• Amounts of food larger than circumstances require
• Selfevaluation heavily influenced on body image
• Begins in adolescence, is chronic à 15 years
• Consequences: Electrolyte imbalance from fluid loss (from purging) à heart failures
• Serotonin related

•  

   

   

   

   

  9.3 Binge-Eating Disorder

   

• Does not engage in purging behaviour very often to compensate
• Significantly overweight
• Cognitions: Disgusted by themselves, ashamed
• Comorbid: Depression, anxiety, substance abuse, personality disorders
• Duration from 814 years
• 2 subtypes: dieting subtype (maintain strict diet besides bingeing)

• Depressive subtype (eat to quell emotions, are depressed, low self-esteem)

   

  9.4 Other Specified Feeding or Eating Disorders

   

                  Partial Syndrome: Does not meet full criteria for anorexia or bulimia nervosa (e.g. fewer binges)

                                                       Highly concerned and judgemental about their weight

                                                       Show psychological problems at age 20 (90%)

   

                  Atypical anorexia nervosa: Meets all symptoms but bodyweight is normal or above

   

                  Bulimia nervosa of low frequency/or limited duration: less than once a week and/or less than 3 months

   

                  Night eating disorder: Cravings after dinner in the night, lack of control of eating, begins in adolescence + chronic

                                                                  Not sleep-eating, (unconscious eating during sleep)

   

  9.5 Obesity

   

• Risk factor to development of mental disorders
• Result of using of antipsychotic drugs (psychotropic drugs)
• BMI over 30
• Consequences: Coronary heart disease, hypertension, stroke, type 2 diabetes, cancer.
• Caused by environment (toxic food, fast food, refined food) and lack of physical activity
• Prevention: Eat nutrientdense food, 30 min sports per day, healthy environment, healthy mindset.

•  

  Bariatric surgery: Used over BMI 40. Bypass, food intake is limited.

   

   

   

   

   

   

   

   

   

   

   

  9.6 Theorie of Eating Disorders

   

              9.6.1 Biological factors

   

• Heritability ca 50%
• Runs in families
• Hormone changes during puberty
• Hypothalamus (regulates eating, receives messages about food consumption and controls further intake)
• Neurotransmitter malfunction (serotonin, dopamine, norepinephrine
• Hormones (cortisol, insulin)

•  

  9.6.2 Sociocultural and Psychological Factors

   

• Media Pressure, peer pressure (worse than media pressure)
• Some sports that are weightdependent or aesthetic

•  

  Cognitive factors: Low-selfesteem, perfectionism, concerned with opinion of others, dichotomous thinking style

   

  Emotion Regulation Difficulties: Maladaptive way of coping with negative emotions à emotional eating to feel

                                                                  Better.

   

  Family Dynamics: Parents are onvercontrolling, do not allow expression of negative emotions

• low parental warmth, high demands

•                                      Children cannot separate from their parents à food intake gives them control

   

  9.7 Treatment for Eating Disorders

   

              9.7.1 Psychotherapy

   

                  Anorexia:

• Difficult to engage them in therapy, cause they value their thinness
• CBT: Confront overevalutation of thinness, rewards for weightgains, relaxation techniques
• Family therapy: Parents take control of weight and child can get it back by eating healthy

•  

  Bulimia + Bingeing

• CBT: Confront cognitions about weight and shape of body, teach healthy food intake schedules (36 months)
• Interpersonal Therapy: Adresses problems with relationships (nondirective)
• Supportiveexpressive psychodynamic therapy: talk about problems (especially relationships)
• Behavioural: reinforcement of food intake, monitor food intake, coping techniques to avoid bingeing

•  

  9.7.2 Biological Therapy

   

• SSRI (bulimia)
• Antidepressants (anorexia)
• Olanzapine (antipsychotic drug, sideeffect: Restore weight)

•  

Index

Stress, Coping, Adjustment and Health. 1

16.1 Models of the Personality and effect on Stress and Health. 1

7.1 The Concept of Stress. 2

7.1.4 Varieties of Stress. 3

7.1.1 Stress Response. 3

7.1.2 Major Life Events. 3

7.1.3 Daily Hassles. 3

7.2 Coping Strategies. 3

7.2.1 Attributional Style. 3

7.2.2 Role of Positive Emotions. 4

7.2.3 Management of Emotions. 4

7.2.4 Disclosure. 4

7.3 Type A and D Personality and Cardiovascular Disease. 4

Stress, Coping, Adjustment and Health

• How can psychology change people´s risk behaviours?
• Leading causes of death are not disease, but lifestylefactors (smoking, stress, sports, emotions)

Health Psychology: Study how stable behavioural and psychological factors (e.g. personality) affect health

• Personalities that are unassertive, emotionally inhibited, aggressive, hostile are prone to disease

Stress: Subjective reaction produced by an event that feels uncontrollable or threatening (lack of resources)

16.1 Models of the Personality and effect on Stress and Health

• Models are not mutually exclusive: They may overlap ect..
• Personality traits of conscientiousness, positive emotionality, low hostility, low neuroticism, high competence (efficiency) = best predictors of health

                Interactional model: Personality influences relationship between stress and illness

                                                         Limitation: Coping responses are not consistently adaptive or maladapitve

                Transactional model:     Personality has 3 effects:              1. Influences exposure to certain events

                                                                                                                                2. Influences interpretation or appraisal of event

                                                                                                                                3. Influences coping. Interactional model

                Health behaviour model: Does not directly influence stress and illness, but indirectly by engaging in health-

                                                                    Promoting behaviours (e.g sports, visiting the doc)

                Predisposition model: Personality and illness are influenced by underlying causes (e.g. genes)

• Third variable (confound) influences the others (e.g. enhanced sympathetic nervous system activity might cause both.

Illness behaviour model: Focuses on the actions that people take when they think they have an illness.

• E.g. Neuroticism personality tends to just complain instead of going to doc.

7.1 The Concept of Stress

                Stressors: Events that cause stress

• 1. Produce feeling of being overwhelmed (intensity)

2. Outside of power of influence – uncontrollable

3. Produce opposing tendencies: wanting or not wanting an object or activity or (person)

                à defined by appraisal of person: (subjective cognitive response)

                Primary appraisal: This is a threat to my personal goals

                Secondary appraisal: I do not have the resources

7.1.4 Varieties of Stress

                Acute stress: sudden onset of demands (stress in the here and now)

                Episodic acute stress: recurrent episodes of acute stress that are expected

                Traumatic stress: High intensity acute stress, effects last for years or lifetime. Hardcore symptoms à PTSD

                Chronic stress: Stress does not end à leads to serious systematic illness (diabetes, cardiovascular, immune sys.)

            7.1.1 Stress Response

• Pattern of emotional and physiological reactions (fight or flight + sympathetic nervous system increase)

General adaption syndrome (GAS): Caused by constant exposure to stressors

                                3 Stages:              1. Alarm stage: Fight or flight response + sympathetic NS activation (also peripheral NS)

                                                                2. Resistance stage: Stressor continues for a longer period. Body uses resources to cope                                                                                             on above average consumption

                                                                3. Exhaustion stage: Physiological resources depleted à illness

            7.1.2 Major Life Events

• Highly stressfull events to which people have to adjust their way of life.
• Researcher made a list of most stressful events.
• Most stressful events score high on the 3 factors of stressors (intensity, conflict, uncontrollability)
• Research: More stressors = higher likelihood of developing a cold

7.1.3 Daily Hassles

• Chronic and repetitive stressors (weekendjob, studying psychology, deadlines)
• Negative cognitions such as worry about weight, little things ect.
• Do not evoke the GAS Syndrome

7.2 Coping Strategies

            7.2.1 Attributional Style

• How do people explain the events happening to them?
• 3 dimensions:            stable vs unstable

Internal vs external

Specific vs global

                CAVE technique: Analysing publications in terms of the 3 dimensions

                Dispositional optimism: Expectation that good events will happen in the future and bad events will be rare

• Focus on expectation on explanation
• Optimistic bias: Perceive to be at lower risk than the true risk actually is.
• Higher likelihood for posttraumatic growth (reevaluation of life after serious event + more happiness and health after this event

Self-efficacy: Belief that one has the resources/ability to deal with the problem at hand and achieve the goals

7.2.2 Role of Positive Emotions

• Positive emotions are beneficial to stress because:   1. Sustain coping efforts

2. provide break from stress

3. give time to restore resources and social relationship

• Broaden and build model: Positive emotions broaden narrowed perspective and help to build social relationships and restore resources
• Positive emotions after stress help regeneration
• 3 positive emotion coping strategies:              1. Positive reappraisal: focus on the good things (opportunites)

2. Problem focused coping: Think and act to deal with the cause of the stressor. Or the things they can control

3. Creating positive events: Humour, watch youtube motivation

à research field of positive Psychology: focus on what influences us positively instead of negatively

            7.2.3 Management of Emotions

                Emotional inhibition: Hold anxiety and emotions inside. Psychoanalysts think this is major reason for illness

• Inhibition causes increased physiological arousal due to effort
• Worse interpersonal relationships, insecure, lower level of well-being
• Brain area involved: Prefrontral cortex. Planning, executive control
• Correlates with: low relationship satisfaction and low commitment, high conflict.

!!!! When chronic: chronic sympathetic NS arousal à increased likelihood of cardiovascular disease & other. !!!!

7.2.4 Disclosure

• Sharing private aspects of ones life with someone. Like emotional inhibition: Takes effort to keep it inside.

à  Enclosure leads to depression, anxiety, disease, Social relationships withdraw (cause they feel rejected)

• Works because: Relieves from tension of keeping it inside. Allows reinterpretation/understanding. Eventually also habituation (to the emotional response). Change representation of even in persons mind.

Writing paradigm: Writing is like talking. Just put it out somewhere and the stress goes away.

• The more the better (also talking)
• Associated with objective and subjective well-being

7.3 Type A and D Personality and Cardiovascular Disease

                Type A: Syndrome that consists of 3 traits:

• Competitive achievement motivation: need competition
• Time urgency: Sense of wasting time
• Hostility: Become frustrated and aggressive when blocked from their goal (independent and most defining trait for cardiov. Dis. ) à leads to inflammation of arteries by elevating leukocytes (white blood cells)

Arteriosclerosis: Slow blocking of arteries, /through fat and cholesterol. May lead
                                 to heart attack, tear on the walls of the arteries.

                Type D: Distressed personality: 2 traits

• Negative affectivity: tendency to experience frequent negative emotions
• Social inhibition: not share emotions and thoughts or worry in social situations (evaluation fear)
• Have exaggerated stress resonse (more cortisol, thus inflammation) à risk increases for disease