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German psychiatrist Emil Kraepelin provided the most enduring description ... Kraepelin focused on early onset and poor outcomes, Bleuler highlighted what he ...

Week 1: Chapter 13: Schizophrenia Perspectives on Schizophrenia Early Figures in Diagnosing Schizophrenia - German psychiatrist Emil Kraepelin provided the most enduring description & categorization of schizophrenia - 2 of Kraepelin’s accomplishments are important: 1. combined several symptoms of insanity that had usually been viewed as reflecting separate and distinct disorders: catatonia (al-ternating immobility and excited agitation), hebephrenia (silly and immature emotionality) and paranoia (delusions of grandeur or persecution) o thought these symptoms shared similar underlying features and included them under the Latin term dementia praecox o believed an early onset at the heart of each disorder develops into “mental weakness” 2. distinguished dementia praecox from manic-depressive illness (bipolar disorder) - noted the numerous symptoms in people with dementia praecox, including hallucinations, delusions, negativism and stereotyped behavior - Eugen Bleuler, introduced the term schizophrenia • label was significant because it signaled Bleuler’s departure from Kraepelin on what he thought was the core problem • combination of the Greek words for “split” (skhizein) and “mind” (phren), reflected Bleuler’s belief that underlying all the unusual behaviors shown by people with this disorder was an associative splitting of the basic functions of personality • concept emphasized the “breaking of associative threads,” or destruction of forces that connect one function to the next • Bleuler believed that a difficulty keeping a consistent train of thought characteristic of all people with this disorder led to the many and diverse symptoms they displayed - Kraepelin focused on early onset and poor outcomes, Bleuler highlighted what he be ieved to be the universal underlying problem • unfortunately, concept of “split mind” inspired the incorrect use of schizophrenia as split or multiple personality

Identifying Symptoms - schizophrenia is a number of behaviors/symptoms that aren’t necessarily shared by all people given this diagnosis - researchers have identified clusters of symptoms that make up the disorder of schizophrenia

Clinical Description DSM 5 Criteria A. characteristic symptoms: 2+ of 5 symptoms must be present for at least 1 month:

1. delusions 2. hallucinations 3. disorganized speech 4. disorganized/catatonic behaviour 5. negative symptoms *** major change in DSM-5 is that schizophrenia subtypes are eliminated (ie. paranoid, disorganized, catatonic, undifferentiated, residual) due to poor psychometric strength & lack of differential treatment response • clinicians now rate severity of schizophrenia on a 0-4 dimensional scale, the Clinician-Rated Dimensions of Psychosis Symptom Survey (ie. not present, equivocal, mild, moderate & severe) • the scale applies to the 5 main schizophrenia symptoms mentioned above in addition to impaired cognition, depression & mania - there is not yet universal agreement about which symptoms should be included under these 3 main categories • positive symptoms – generally include the more active manifestations of abnormal behavior or an excess or distortion of normal behavior; these include delusions and hallucinations • negative symptoms – involve deficits in normal behavior in such areas as speech and motivation • disorganized symptoms – include rambling speech, erratic behavior, and inappropriate affect - diagnosis of schizophrenia requires 2 or more positive, negative, &/or disorganized symptoms present for at least 1 mth

Positive Symptoms - positive symptoms: more overt symptoms, such as delusions & hallucinations, displayed by some people w/ schizophrenia - b/w 50% & 70% of people w/ schizophrenia experience hallucinations, delusions, or both Delusions - delusion: psychotic symptom involving disorder of thought content & presence of strong beliefs that are misrepresentations of reality - because of its importance in schizophrenia, delusion has been called “the basic characteristic of madness” - delusion of grandeur (a mistaken belief that the person is famous or powerful) - delusions of persecution (belief that others are “out to get them”, can be most disturbing) - other unusual delusions include: • Capgras syndrome: person believes someone he or she knows has been replaced by a double • Cotard’s syndrome: person believes he is dead - why do individuals’ delusions exist even after being contradicted? • beliefs viewed as result of brain dysfunction – new info not properly integrated o study showed schizophrenics to produce less of a specific brain wave associated w/ integration of new info • delusional beliefs viewed as an attempt to deal with/relieve anxiety & stress o ie. person develops “stories” around some issue—ie. a famous person is in love w/ her (erotomania)— that helps person make sense out of uncontrollable anxieties in a tumultuous world Hallucinations - hallucinations: psychotic symptoms of perceptual disturbance in which things are seen, heard, or otherwise sensed although they aren’t actually present - auditory hallucinations are most common form experienced by people w/ schizophrenia - one theory of auditory verbal hallucinations states that people who are hallucinating aren’t hearing the voices of others but are listening to their own thoughts/voices & can’t recognize the difference - another theory states that auditory verbal hallucinations arise from abnormal activation of the primary auditory cortex

Negative Symptoms - negative symptoms: less outgoing symptoms (ie. flat affect & poverty of speech) displayed by some people w/ schizophrenia - usually indicate the absence or insufficiency of normal behavior - include apathy, poverty of (ie. limited) thought or speech, & emotional & social withdrawal - approximately 25% of people with schizophrenia display these symptoms Avolition - avolition: apathy, or the inability to initiate or persist in important activities - the prefix a, meaning “without,” & volition, which means “an act of willing, choosing, or deciding,” - show little interest in performing basic day-to-day functions, including those associated w/ personal hygiene Alogia - alogia: deficiency in the amount or content of speech, a disturbance often seen in people with schizophrenia - a (“without”) & logos (“words”) - may respond to questions with brief replies that have little content & may appear uninterested in the conversation - such deficiency in communication is believed to reflect a negative thought disorder rather than inadequate communication skills • some researchers, for example, suggest people w/ alogia may have trouble finding the right words to formulate their thoughts - sometimes alogia takes the form of delayed comments or slow responses to questions; talking w/ individuals who manifest this symptom can be extremely frustrating, making you feel as if you are “pulling teeth” to get them to respond Anhedonia - anhedonia: inability to experience pleasure, associated with some mood and schizophrenic disorders - a (“without”) & the word hedonic (“per- taining to pleasure”) - like some mood disorders, anhedonia signals an indifference to activities that would typically be considered pleasurable, including eating, social interactions & sexual relations Affective Flattening - flat affect: apparently emotionless demeanor (including toneless speech & vacant gaze) when a reaction would be expected Asociality - severe deficits in social relationships (ie. few friendship, little interest in socializing & poor social skills) - best predictor of asociality in schizophrenics is the chronic cognitive impairment, suggesting difficulties in processing info may contribute significantly to the social skills deficits & other social difficulties displayed by many patients

Disorganized Symptoms - disorganized symptoms: variety of erratic behaviours that affect speech, motor behaviour & emotional reactions - prevalence of these behaviors among those with schizophrenia is unclear Disorganized Speech - disorganized speech: style of talking often seen in people with schizophrenia, involving incoherence and a lack of typical logic patterns - people with schizophrenia often lack insight, an awareness that they have a problem - they experience what Bleuler called “associative splitting” & what researcher Paul Meehl called “cognitive slippage”

these terms describe speech problems of people w/ schizophrenia: sometimes they jump from topic to topic, at other times they talk illogically - tangentiality: going off on a tangent instead of answering a specific question Inappropriate Affect & Disorganized Behavior - inappropriate affect: laughing or crying at inappropriate times - schizophrenics engage in a number of other “active” behaviors that are usually viewed as unusual - catatonic immobility: disturbance of motor behavior in which the person remains motionless, sometimes in an awkward posture, for extended periods • can also involve waxy flexibility, or the tendency to keep their bodies and limbs in the position they are put in by someone else - to receive a diagnosis of schizophrenia, a person must display 2 or more positive, negative, &/or disorganized symptoms for a major portion of at least 1 mth

Schizophrenia Subtypes - 3 divisions: 1. paranoid (delusions of grandeur or persecution) 2. disorganized (or hebephrenic; silly & immature emotionality) 3. catatonic (alternate immobility & excited agitation) Paranoid Type - paranoid type of schizophrenia: type of schizophrenia in which symptoms primarily involve delusions and hallucinations; speech and motor and emotional behavior are relatively intact Disorganized Type - disorganized type of schizophrenia: type of schizophrenia featuring disrupted speech and behavior, disjointed delusions and hallucinations, and silly or flat affect - if delusions or hallucinations are present, they tend not to be organized around a central theme, as in the paranoid type, but are more fragmented • this subtype was previously called hebephrenic • individuals with this diagnosis tend to show signs of difficulty early & their problems are often chronic, lacking the remissions (improvement of symptoms) that characterize other forms of the disorder Catatonic Type - catatonic type of schizophrenia: type of schizophrenia in which motor disturbances (rigidity, agitation & odd mannerisms) predominate - display unusual motor responses of remaining in fixed positions (“waxy flexibility” because their limbs & body position can be moved by others) & engaging in excessive activity, individuals w/ the catatonic type of schizophrenia sometimes display odd mannerisms w/ their bodies & faces, including grimacing - sometimes repeat or mimic words of others (echolalia) or movements of others (echopraxia) - may be subtypes of catatonic schizophrenia, w/ some individuals showing primarily symptoms of labeled: • “negative withdrawal” (immobility, posturing, mutism) • “automatic” (routine obedience, waxy flexi- bility) • “repetitive/echo” (grimacing, perseveration, echolalia) • “agitated/resistive” (excitement, impulsivity, combativeness) Undifferentiated Type

- undifferentiated type of schizophrenia: category for individuals who meet the criteria for schizophrenia but not for one of the defined subtypes - have the major symptoms of schizophrenia but who do not meet the criteria for paranoid, disorganized, or catatonic types Residual Type - residual type of schizophrenia: people who have experienced at least one episode of schizophrenia but no longer display its major symptoms - may still display residual or “leftover” symptoms, such as negative beliefs, or have unusual ideas that aren’t fully delusional - residual symptoms can include social withdrawal, bizarre thoughts, inactivity & flat affect Other Psychotic Disorders - several other categories of disorders represent significant variations of psychotic behaviors some individuals experience that don’t fit neatly under the heading of schizophrenia Schizophreniform Disorder - schizophreniform disorder: psychotic disorder involving the symptoms of schizophrenia but lasting less than 6 mts - diagnostic criteria for schizophreniform disorder include onset of psychotic symptoms within 4 weeks of the first noticeable change in usual behavior, confusion at the height of the psychotic episode, good premorbid (before the psychotic episode) social and occupational function- ing (functioning before the psychotic episode), and the absence of blunted or flat affect

Schizoaffective Disorder - schizoaffective disorder: psychotic disorder featuring symptoms of both schizophrenia & major mood disorder - prognosis is similar to the prognosis for people w/ schizophrenia -> individuals tend not to get better on their own & are likely to continue experiencing major life difficulties for many years - criteria for schizoaffective disorder require, in addition to the presence of a mood disorder, delusions or hallucinations for at least 2 wks in the absence of prominent mood symptoms *** DSM 5 attempts to make schizoaffective disorder a more longitudinal diagnosis in line with other disorders such as depression and bipolar disorder • key change -> a major mood episode must be present for most of the time during the schizoaffective disorder (helps clinicians distinguish variations among people w/ depression & psychotic symptoms) Delusional Disorder - delusional disorder: psychotic disorder featuring a persistent belief contrary to reality (delusion) but no other symptoms of schizophrenia - characterized by a persistent delusion that isn’t the result of an organic factor such as brain seizures or of any severe psychosis - individuals w/ delusional disorder tend not to have flat affect, anhedonia, or other negative symptoms of schizophrenia; importantly, however, they may become socially isolated bc. they’re suspicious of others - delusions are often long-standing, sometimes persisting over several years - DSM-IV-TR recognizes the following delusional subtypes: • erotomanic: irrational belief that one is loved by another person, usually of higher status • grandiose: believing in one’s inflated worth, power, knowledge, identity, or special relationship to a deity or famous person • jealous: believes the sexual partner is unfaithful • persecutory: believing oneself (or someone close) is being malevolently treated in some way

• somatic: feels afflicted by a physical defect or general medical condition - these delusions differ from the more bizarre types often found in people w/ schizophrenia because • in delusional disorder the imagined events could be happening but aren’t (ie mistakenly believing you are being followed) • in schizophrenia, the imagined events aren’t possible (ie. believing your brain waves broadcast your thoughts to other people around the world) **** as with schizophrenia, no DSM-5b distinction made b/w bizarre & non-bizarre delusions in delusional disorder (specifier now included for bizarre content) • new exclusion: delusional disorder must not be better explained by OCD or body dysmorphic disorder • delusional disorder is no longer separate from shared delusional disorder in DSM-5 o if a person shares delusional beliefs but doesn’t meet criteria for delusional disorder, then an “other specified” disorder related to psychosis can be used Brief Psychotic Disorder - brief psychotic disorder: psychotic disturbance involving delusions, hallucinations, or disorganized speech or behavior but lasting less than 1 mth; often occurs in reaction to a stressor - individuals often regain their previous ability to function well in day-to-day activities - brief psychotic disorder is often precipitated by extremely stressful situation Shared Psychotic Disorder (Folie à Deux) ****removed in DSM 5 - shared psychotic disorder (folie à deux): psychotic disturbance in which individuals develop a delusion similar to that of a person w/ whom they share a close relationship - content and nature of the delusion originate with the partner & can range from the relatively bizarre (believing enemies are sending harmful gamma rays through your house) to the fairly ordinary (believing you are about to receive a major promotion despite evidence to the contrary) Schizotypal Personality Disorder - schizotypal personality disorder: Cluster A (odd or eccentric) personality disorder involving a pervasive pattern of interpersonal deficits featuring acute discomfort w/, & reduced capacity for, close relationships, as well as cognitive or perceptual distortions & eccentricities of behavior Catatonia**** - new DSM 5 disorder - DSM-5 alters the catatonia definition to include 3 of 12 characteristic symptoms in whatever capacity it is used - catatonia may be a specifier for psychotic disorders as well as depressive & bipolar disorders, but can also be a separate diagnosis w/ another medical condition

Statistics - generally chronic & most people affected have difficulty functioning in society - tend not to establish/maintain significant relationships - even with improvement after treatment, schizophrenics are likely to experience lifetime difficulties - lifetime prevalence rate of schizophrenia is roughly equivalent for men and women, & is estimated to be 0.2% to 1.5% in the general population (means the disorder will affect around 1% of the population at some point) - difference between the sexes in age of onset is clear • men –likelihood of onset diminishes w/ age, but can still first occur after age 75 • frequency of onset for women is lower than men until age 36, when the relative risk for onset switches w/ more women being affected later in life • women appear to have more favorable outcomes than do men

Development - research suggests children who later develop schizophrenia show some abnormal signs before they display symptoms • their emotional reactions may be abnormal w/ less positive & more negative affect than their unaffected siblings - schizophrenia is generally seen by early childhood - possibility that brain damage very early in the developmental period causes later schizophrenia • damage may lie dormant until later in development when signs of schizophrenia first appear - research has suggested those who show early sigs of abnormality at birth & during early childhood tend to fare better than those who don’t • one possible explanation for this is that the earlier the damage occurs, the more time the brain has to compensate for it, which results in milder symptoms - older adults tend to display fewer positive symptons (delusions, hallucinations) & more negative symptoms (speech & cognitive difficulties)

Cultural Factors - schizophrenia is universal, affecting all racial & cultural groups studied so far but the course & outcome of schizophrenia vary from culture to culture - differing rates of schizophrenia may be partially the result of misdiagnosis rather than any real cultural distinctions - however, an additional factor contributing to this imbalance may be the levels of stress associated w/ factors such as stigma & isolation - also may be genetic variants unique to certain racial groups that contribute to the development of schizophrenia - high cannabis use may also be a contributing factor

Causes Genetic Influences - genes are responsible for making some individuals vulnerable - no single gene Family Studies - the more severe the parent’s schizophrenia, the more likely the children to developing it - don’t inherit a specific type of schizophrenia, inherit general predisposition - appears to be some familial risk for a spectrum of psychotic disorders related to schizophrenia - risk of schizophrenia varies according to how many genes an individual shares w/ someone who has the disorder • monozygotic twins have greatest chance – 48% Twin Studies - 48% – identical (monozygotic) twin - 17% –fraternal (dizygotic) twin w/ schizophrenia - 1% – any relatives w/ schizophrenia (compared to someone w/ no relatives w/ disorder) - the Genain quadruplets – 4 women w/ same genetic predisposition all had schizophrenia • time of onset for schizophrenia, symptoms & diagnoses, course of disorder & their outcomes all differed significantly from sister to sister • different experiences physically & socially can result in vastly different outcomes Adoption Studies - adoption studies have distinguished the role of the environment & genetics in relation to the disorder - schizophrenia represents a spectrum of related disorders, all of which overlap genetically - adopted child w/ biological mother w/ schizophrenia – 5% chance of developing schizophrenia

- even raised separately from biological parents, children of parents w/ schizophrenia have a much higher chance - protective factor – being brought up in a healthy, supportive home (gene-environment interaction) The Offspring of Twins - 1.7% of the children w/ non-schizophrenic parents developed schizophrenia - individuals can be a “carrier” for schizophrenia Gene-Environment Interactions - cannabis use in youth is an established but modest risk factor for psychosis in adulthood - certain genes may act as vulnerability factors + specific environmental pathogens at crucial developmental stages = development of schizophrenia Linkage & Association Studies - genetic linkage & association studies rely on traits that are inherited in families (ie. blood types) - because we know the location of the genes for these traits (marker genes), we can infer the location of the disorder genes that are inherited along w/ them - in searching for markers, researchers look for common traits other than symptoms of the disorder - eye-tracking deficit associated w/ mainly positive symptoms, may be a marker for schizophrenia (called smooth-pursuit eye movement) Evidence for Multiple Genes - quantitative trait loci – schizophrenia involves more than one gene - probably caused by several genes located at different sites throughout the chromosomes

Neurobiological Influences Dopamine - neurotransmitters are released from the synaptic vesicles at the end of the axon, cross the gap & are taken up by receptors in the dendrite of the next axon1= • chemical messages are sent this way • the chemical messages can be increased by agonistic agents or decreased by antagonistic (hostile) agents - neurotransmitter messages can be influenced in several ways: • increased by agonistic agents (assist w/ the transference & if extreme, can produce too much) o increase neurotransmitter production o increase release of neurotransmitter o activate neurotransmitter receptors at dendrites • decreased by antagonistic agents (slow down or stop messages from being transmitted) o prevent release of neurotransmitter o block receptor uptake at dendrites o cause synaptic vesicle leaks reducing amount of neurotransmitter released - effectiveness of antipsychotics suggests overactive dopamine system in people w/ schizophrenia - schizophrenia research has focused on 2 dopamine sites: D 1 & D2 - clues to role of dopamine in schizophrenia 1. antipsychotic drugs (neuroleptics) that are often effective in treating schizophrenia are dopamine antagonists, partially blocking the brain’s use of dopamine 2. antipsychotics can produce negative side effects similar to those in Parkinson’s (disorder of insufficient dopamine) 3. L-dopa (dopamine agonist used for Parkinson’s treatment) produces schizophrenic-like symptoms 4. amphetamines (dopamine agonist) can make psychotic symptoms worse in schizophrenics

- drugs that ↑ dopamine (agonists like amphetamine) show ↑ schizophrenic behaviour - drugs that ↓ dopamine (antagonists) show ↓ schizophrenic symptoms 5. the use of dopamine antagonists are only partly helpful in reducing the negative symptoms (flat affect, anhedonia, etc.) of schizophrenia & a # of people w/ schizophrenia are not helped by them - clozapine is effective w/ many people who were not helped w/ traditional neuroleptic medications • however, clozapine is one of the weakest dopamine antagonists by far • although dopamine is involved in the symptoms of schizophrenia, the relationship is more complicated - current thinking suggests 3 specific neurochemical abnormalities simultaneously at play in schizophrenic brains: 1. schizophrenia is partially the result of excessive stimulation of striatal dopamine D 2 receptors • most effective antipsychotic drugs all share dopamine D2 receptor antagonism (help block the stimulation of the D2 receptors) 2. deficiency in the stimulation of prefrontal D 1 receptors • although some dopamine sites may be overactive (striatal D2), a second type of dopamine site in the brain area used for planning/organizing (prefrontal D1 receptors) appears to be less active & may account for negative symptoms (ie. avolition) 3. another area of neurochemical interest involves research on alterations in prefrontal activity involving glutamate transmission • glutamate is an excitatory neurotransmitter that is found in all areas of the brain • glutamate receptors of interest are the NMDA receptors • recreational drugs (like ketamine & PCP) known to be NMDA antagonists suggest a deficit in glutamate or blocking of NMDA sites may be associated w/ some symptoms of schizophrenia Brain Structure - adults w/schizophrenia show deficits in ability to perform certain tasks & to attend during reaction time exercises • this suggests that brain damage or dysfunction may cause or accompany schizophrenia - abnormally large lateral ventricles in people w/ schizophrenia • enlargement indicates either adjacent parts haven’t developed fully or have atrophied (allowing them to grow) - different experiences among twins predisposed to the disorder could damage the brain & cause schizophrenic symptoms - less active frontal lobes in people w/ schizophrenia, called hypofrontality (“hypo” means less active/deficient) - hypofrontality seems to be associated w/ the negative symptoms of schizophrenia & w/ the eye-tracking deficits - several brain sites implicated in cognitive dysfunction in schizophrenia • prefrontal cortex, related cortical regions & subcortical circuits (including thalamus & striatum) Viral Infection - hypothesis that schizophrenia is a new phenomenon involving some newly introduced virus • a “schizo-virus” could have caused some cases of this debilitating disorder • evidence that a virus-like disease may account for some cases • higher prevalence among men in urban areas suggests they are more likely to be exposed to infectious agents than others - schizophrenia may be associated w/ prenatal exposure to influenza • 2nd trimester developmental problems may be associated w/ schizophrenia - study: number of ridges on the fingertips of the twins w/o schizophrenia differed very little from each other, but a great deal among one-third of the twin pairs who were discordant for schizophrenia • a ridge count may be a marker of prenatal brain damage

Psychological & Social Influences

- we know that early brain trauma, perhaps resulting from a second-trimester virus-like attack or obstetrical complications, may generate physical stress that contributes to schizophrenia • however, not all people w/ schizophrenia have enlarged ventricles, nor do they all have a hypofrontality or excessive activity in their dopamine systems - do emotional stressors or family interaction patterns initiate the symptoms of schizophrenia? Stress - relapses (when their symptoms return or worsen) occurred when stressful life events increased during the previous month • or that the stressful life events can increase depression among people w/ schizophrenia, which in turn may contribute to relapse - a significant negative correlation b/w social class & schizophrenia – tendency for individuals w/ schizophrenia is found in the lowest social classes (social environment) - sociogenic hypothesis – the lower social class is stressful, predisposing those from the lower social classes to an increased likelihood of schizophrenia - social selection hypothesis – if the illness makes them less able to hold a job, individuals w/ schizophrenia may experience a downward social drift into the lower social classes - social support can help in reducing the negative impact of stress in both physical & mental health disorders (mood disorders & chronic pain) Families & Relapse - family interactions contribute to relapse after initial symptoms of schizophrenia through a particular emotional communication style known as expressed emotion (EE) • high expressed emotion in a family are a good predictor of relapse among people w/ chronic schizophrenia = 3.7 times more likely to relapse - patients who have limited contact w/ relatives do better than patients who spent longer periods w/ their families • if the level of criticism (disapproval), hostility (animosity) & emotional overinvolvement (intrusiveness) expressed by the families was high, patients tended to relapse - family communications involving high levels of expressed emotion are characterized by intrusiveness, high levels of emotional response, a negative attitude toward the illness on the part of family members, & low tolerance & unrealistic expectations of the patient - there are cultural variations in how families react to someone w/ schizophrenia, & their reactions do not cause the disorder • however, critical & hostile environments clearly provide additional stressors that can in turn lead to more relapses

Treatment - today, neuroleptic drugs (that are invaluable in reducing symptoms for many people) are typically used in combination w/ a variety of psychosocial treatments to reduce relapse & compensate for skills deficits Biological Interventions - 1930s – insulin-induced coma therapy & psychosurgery (including prefrontal lobotomies) • electroconvulsion therapy (ECT) in late 1930s for schizophrenia; still used today in severe cases of depression - 1950s – neuroleptics introduced by Heinz Lehmann provided first real hope that help was available for schizophrenics • when effective, neuroleptics help think more clearly & reduce or eliminate hallucinations & delusions • affect the positive symptoms & to a lesser extent, the negative & disorganized ones (ie. social deficits) • neuroleptics are dopamine antagonists • earliest neuroleptics, antipsychotics, effective for 60% of patients - newer antipsychotics (ie. clozapine) now prescribed to more than ¾ of patients w/ schizophrenia in Canada

• fewer side effects & more effective in reducing positive & negative symptoms than conventional antipsychotics • newer antipsychotics can reduce severity of tardive dyskinesia - many people w/ schizophrenia do not routinely take their medication; 7% refuse to take at all - one of the major obstacles to drug treatment for schizophrenia is compliance • patients discontinue medication bc. of negative side effects, negative doctor-patient relationships, cost of the medication & poor social support Psychosocial Interventions - psychosocial interventions are now used to treat schizophrenia, as well as increase medication-taking compliance by helping patients communicate better w/ professionals about concerns - token economies (residents could earn access to meals & small luxuries by behaving appropriately) for inpatients encourage appropriate socialization, participation in group sessions, & self-care such as bed-making, while discouraging violent outbursts • patients did better than others on social, self-care & vocational skills & more could be discharged from the hospital - deinstitutionalization (bc of court rulings to limit involuntary institutionalization, success of antipsychotics & healthcare cutbacks) • consequence is many people w/ schizophrenia or other serious psychological disorders are homeless • women increasingly expected to care for mentally ill family members - good news of deinstitutionalization • more attention focused on supporting mentally ill in the community - one of the most subtle effects of schizophrenia is its negative impact on the ability to relate to others • clinicians attempt to reteach social skills like basic conversation, assertiveness & relationship building - traditional therapy • therapists divide complex social skills into their component parts, which they model then role-play w/ clients to practice new skills in the “real world” • challenge of teaching social skills is maintaining • programs often teach people ways in which they can adapt to their disorder and live in the community - behavioural family therapy • used to inform families about schizophrenia & treatment; taught communication skills to be more empathic • learn to constructively address issues & problem solving skills • to be more supportive & reduce their level of expressed emotion (EE) • family members are informed about the disorder & its treatment & learn communication & problem-solving skills to interact w/ schizophrenic family member • results are significant in the first year, but less strong 2 years after intervention (therapy must be ongoing) - early intervention important in affecting the course of the disorder over time & future relapses - cognitive-behavioural therapy (CBT) • people aren’t inherently irrational, but have a set of irrational beliefs that can be altered through CBT intervention • usually applied to auditory hallucinations & delusions (but strategies developed to treat both negative & positive symptoms) • CBT produces large clinical effects on both positive & negative symptoms & overall severity of schizophrenia • CBT shown to improve the degree of conviction in delusional beliefs, severity of overall symptoms & depression Treatment Across Cultures - in Africa, people w/ schizophrenia are kept in prisons because of the lack of adequate alternatives - movement from housing people in institutional settings to community care is ongoing in Western countries

Prevention - one strategy for preventing a disorder such as schizophrenia is to identify & treat children who may be at risk for getting the disorder later in life • 13% of the children born to parents who have schizophrenia are likely to develop the disorder (increase in prospective & longitudinal studies) - factors such as birth complications & certain early illnesses (viruses) may trigger the onset of schizophrenia, especially among those individuals who are genetically predisposed • therefore, interventions such as vaccinations against viruses for women of childbearing age & interventions related to improving prenatal nutrition & care may be effective prevention measures

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