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Schizophrenia
- 2. SCHIZOPHRENIAS ARE:SCHIZOPHRENIAS ARE: A group of biological disorders . . . That produce handicaps in thinking, learning and social relationships ... For which no cure is known . . . But new treatments promote improved quality of life.
- 3. Schizophrenia is not..Schizophrenia is not.. All Psychoses. Automatically Low Intelligence.Automatically Low Intelligence. Split Personality.Split Personality. Multiple Personality.Multiple Personality. Contagious.Contagious. Low Moral Integrity.Low Moral Integrity. Anyone’s Fault. Hopeless.
- 4. SchizophreniaSchizophrenia SchizophreniaSchizophrenia is a psychotic disorderis a psychotic disorder involving disturbance of thought,involving disturbance of thought, emotion and behavior.emotion and behavior. The lifetime prevalence ofThe lifetime prevalence of schizophrenia is about 1%:schizophrenia is about 1%: – Onset is usually in late adolescence.Onset is usually in late adolescence. – Substance abuse is a co-morbidSubstance abuse is a co-morbid condition in 50% of schizophrenics.condition in 50% of schizophrenics.
- 5. ď‚ż Broad Impairments.Broad Impairments. ď‚ż Delusions & Hallucinations.Delusions & Hallucinations. ď‚ż Disorganized Speech & Behavior.Disorganized Speech & Behavior. ď‚ż Inappropriate Emotions.Inappropriate Emotions. ď‚ż Psychosis: Extreme Mental UnrestPsychosis: Extreme Mental Unrest with Loss of Reality Contact.with Loss of Reality Contact. ď‚ż Broad Impairments.Broad Impairments. ď‚ż Delusions & Hallucinations.Delusions & Hallucinations. ď‚ż Disorganized Speech & Behavior.Disorganized Speech & Behavior. ď‚ż Inappropriate Emotions.Inappropriate Emotions. ď‚ż Psychosis: Extreme Mental UnrestPsychosis: Extreme Mental Unrest with Loss of Reality Contact.with Loss of Reality Contact.
- 6.  Dementia (Loss of Mind)  Praecox (Early, Premature)  Kraepelin – Categorization & Early Onset.  Eugen Bleuler – Termed “Schizophrenia”. – Associative Splitting.
- 7. ď‚ż Cause is Unknown. ď‚ż Affects 1 out of 100 People. ď‚ż Often Begins (Ages 16 - 30). ď‚ż More Hospital Beds Than Any Other Medical Illness 2.5% of Total U.S. Healthcare Budget.
- 8.  Often Chronic.  Occurs in 0.2% to 1.5% Population.  Affects Men & Women Equally: – Age of Onset Varies Across Time. – Very rare in elderly.Very rare in elderly.  Lower Life Expectancy: – Increased Risk of Suicide.
- 9. DSM-V Diagnosis ofDSM-V Diagnosis of SchizophreniaSchizophrenia Psychotic Symptoms (2 orPsychotic Symptoms (2 or more) formore) for 1 month period1 month period – Hallucinations.Hallucinations. – Delusions.Delusions. – Disorganized Speech.Disorganized Speech. – Disorganized or Catatonic Behavior.Disorganized or Catatonic Behavior. – Negative Symptoms.Negative Symptoms.
- 10. Impairment in social or occupationalImpairment in social or occupational functioning.functioning. Duration of illness at least 6 months.Duration of illness at least 6 months. Symptoms not due to mood disorderSymptoms not due to mood disorder or schizoaffective disorder.or schizoaffective disorder. Symptoms not due to medical,Symptoms not due to medical, neurological or substance-inducedneurological or substance-induced disorder.disorder. DSM-V Diagnosis ofDSM-V Diagnosis of SchizophreniaSchizophrenia
- 11. SYMPTOM CLUSTERSSYMPTOM CLUSTERS POSITIVEPOSITIVE NEGATIVENEGATIVE HallucinationsHallucinations Few FeelingsFew Feelings DelusionsDelusions Loss of MotivationLoss of Motivation IMPAIRMENTSIMPAIRMENTS WorkWork RelationshipsRelationships Self-CareSelf-Care COGNITIVECOGNITIVE MOODMOOD MemoryMemory DepressionDepression Problem-SolvingProblem-Solving HopelessnessHopelessness
- 12. General SymptomsGeneral Symptoms Ego Boundary Issues.Ego Boundary Issues. Interpersonal Dysfunction.Interpersonal Dysfunction. Negative SymptomsNegative Symptoms (Andreasen’s “A”s)(Andreasen’s “A”s):: – Affective Flattening.Affective Flattening. – Alogia (without words).Alogia (without words). – Avolition (without will).Avolition (without will). – Anhedonia.Anhedonia. – Attentional Impairment.Attentional Impairment.
- 13. General SymptomsGeneral Symptoms Positive Symptoms:Positive Symptoms: – Delusions.Delusions. – Perception Disturbance:Perception Disturbance: Hallucinations.Hallucinations. – Affect.Affect. Euphoric (Happy).Euphoric (Happy). Dysphoric (Sad).Dysphoric (Sad). Flat.Flat. Inappropriate.Inappropriate. – Behavioral Dyscontrol.Behavioral Dyscontrol.
- 14. General SymptomsGeneral Symptoms Disorganized Thought & Speech:Disorganized Thought & Speech: –Formal Thought Disorder.Formal Thought Disorder. –Word Salad.Word Salad. –Clang Associations.Clang Associations. Disorganized or Catatonic Behavior:Disorganized or Catatonic Behavior: – Catatonic Stupor.Catatonic Stupor. – Catatonic Posturing.Catatonic Posturing. – Catatonic Excitement.Catatonic Excitement.
- 15. Clinical Features:Clinical Features: Formal Thought DisordersFormal Thought Disorders Neologisms.Neologisms. Tangentiality.Tangentiality. Derailment.Derailment. Loosening of associationsLoosening of associations (word salad).(word salad). Private word usage.Private word usage. Perseveration.Perseveration. Nonsequitors.Nonsequitors.
- 16. Clinical Features:Clinical Features: DelusionsDelusions Paranoid/Persecutory.Paranoid/Persecutory. Ideas of Reference.Ideas of Reference. External Locus ofExternal Locus of Control.Control. ThoughtThought Broadcasting.Broadcasting. Thought Insertion,Thought Insertion, WithdrawalWithdrawal.. Jealousy.Jealousy. Guilt.Guilt. Grandiosity.Grandiosity. ReligiousReligious Delusions.Delusions. SomaticSomatic Delusions.Delusions.
- 17. Clinical Features:Clinical Features: HallucinationsHallucinations Auditory.Auditory. Visual.Visual. Olfactory.Olfactory. Somatic/ Tactile.Somatic/ Tactile. Gustatory.Gustatory.
- 18. Clinical Features:Clinical Features: BehaviorBehavior Bizarre Dress & Appearance.Bizarre Dress & Appearance. Catatonia.Catatonia. Poor Impulse Control.Poor Impulse Control. Anger & Agitation.Anger & Agitation. StereotypiesStereotypies..
- 19. Clinical Features:Clinical Features: Mood & AffectMood & Affect Inappropriate Affect.Inappropriate Affect. Blunting of Affect/ Mood.Blunting of Affect/ Mood. Flat Affect.Flat Affect. Isolation or Dissociation of Affect.Isolation or Dissociation of Affect. Incongruent Affect.Incongruent Affect.
- 20. Prodromal & ResidualProdromal & Residual Prodromal:Prodromal: –Symptoms occurring before theSymptoms occurring before the psychotic break.psychotic break. Residual:Residual: –Symptoms occurring after theSymptoms occurring after the acute phase.acute phase.
- 21. SubtypesSubtypes Catatonic:Catatonic: – Motoric Immobility.Motoric Immobility. – Purposeless Motor Activity.Purposeless Motor Activity. – Mute.Mute. – Echolalia.Echolalia. – Posturing.Posturing. – Delusions Centered on Death & Destruction.Delusions Centered on Death & Destruction.
- 22. SubtypesSubtypes Disorganized:Disorganized: –Disorganized Speech.Disorganized Speech. –Disorganized Behavior.Disorganized Behavior. –Flat or Inappropriate Affect.Flat or Inappropriate Affect. –Fragmented Delusions.Fragmented Delusions. –Delusions Less Coherent.Delusions Less Coherent.
- 23. SubtypesSubtypes Paranoid:Paranoid: – Preoccupation with one or more delusions.Preoccupation with one or more delusions. – Delusions of persecution which are complex.Delusions of persecution which are complex. – Hallucinations.Hallucinations. – No disorganized speech.No disorganized speech. – No disorganized or catatonic behavior.No disorganized or catatonic behavior. – No flat or inappropriate affect.No flat or inappropriate affect.
- 24. SubtypesSubtypes Undifferentiated:Undifferentiated: –Has Negative Symptoms.Has Negative Symptoms. –Does not meet criteria forDoes not meet criteria for any other subtype.any other subtype.
- 25. Risk Factors for SchizophreniaRisk Factors for Schizophrenia Having a parent with schizophrenia.Having a parent with schizophrenia. Poverty.Poverty. Race.Race. Older age of father.Older age of father. Born during winter month.Born during winter month. Complicating birth delivery.Complicating birth delivery.
- 26. Etiology of SchizophreniaEtiology of Schizophrenia Genetic Studies:Genetic Studies: Reveal that aReveal that a predisposition for schizophrenia ispredisposition for schizophrenia is transmitted genetically.transmitted genetically. Brain Pathology:Brain Pathology: Is likely biologicalIs likely biological vulnerabilities for schizophrenia.vulnerabilities for schizophrenia. Biochemistry:Biochemistry: Dopamine Theory.Dopamine Theory. Psychology:Psychology: Diathesis-Stress model,Diathesis-Stress model, Social Class & Expressed Emotions.Social Class & Expressed Emotions.
- 27. GENETIC RISKGENETIC RISK If you have aIf you have a Your chance of gettingYour chance of getting Schizophrenic. . .Schizophrenic. . . schizophrenia is ...schizophrenia is ... Identical TwinIdentical Twin 46%46% Both ParentsBoth Parents 48%48% DZ Twin, Sibling or ParentDZ Twin, Sibling or Parent 12%12% ChildrenChildren 9%9% Aunt, Nephew, Nieces, GrandparentAunt, Nephew, Nieces, Grandparent 5%5% First Cousin, Great AuntFirst Cousin, Great Aunt 2%2% No RelativesNo Relatives 1%1%
- 28. SCHIZOPHRENIA ALTERSSCHIZOPHRENIA ALTERS BRAIN FUNCTIONINGBRAIN FUNCTIONING
- 29. Brain PathologyBrain Pathology Brains of Schizophrenic Patients Show:Brains of Schizophrenic Patients Show: – Reduced volume of temporal & frontalReduced volume of temporal & frontal cortex.cortex. – Enlarged ventricles (Reflecting loss of brainEnlarged ventricles (Reflecting loss of brain cells).cells). For 12 of 15 twins, the schizophrenic twinFor 12 of 15 twins, the schizophrenic twin could be identified by enlarged ventricles.could be identified by enlarged ventricles. – Reduced metabolic activity within prefrontalReduced metabolic activity within prefrontal
- 30. FRONTAL LOBES GOVERNFRONTAL LOBES GOVERN • Drive & Ambition • Problem Solving • Cognitive Flexibility • Capacity to Plan • Time Sequential Thinking • Social Awareness • Empathy • Mood • Insight • Impulsivity • Judgment • Abstraction • Working Memory
- 31. REDUCED FRONTALREDUCED FRONTAL LOBE ACTIVITYLOBE ACTIVITY Normal Schizophrenia
- 32. TEMPORAL LOBETEMPORAL LOBE FUNCTIONSFUNCTIONS PerceptionPerception Reality OrientationReality Orientation MemoryMemory
- 33. REDUCED TEMPORALREDUCED TEMPORAL LOBE STRUCTURESLOBE STRUCTURES
- 34. BASAL GANGLIABASAL GANGLIA FUNCTIONSFUNCTIONS • Inhibit Unwanted Sensory Input. • Filter Out Irrelevant Sensory Input. • Regulate Arousal. • Govern Concentration.
- 35. LIMBIC SYSTEMLIMBIC SYSTEM FUNCTIONSFUNCTIONS • Understanding Emotional Events. • Linking Current Perception to Past Memories. • Learning from Experience.
- 36. REDUCED LIMBICREDUCED LIMBIC SYSTEM STRUCTURESSYSTEM STRUCTURES
- 37. Biochemistry of SchizophreniaBiochemistry of Schizophrenia Dopamine Theory:Dopamine Theory: holds that the positiveholds that the positive symptoms of schizophrenia result fromsymptoms of schizophrenia result from excessive activity of dopamine in brainexcessive activity of dopamine in brain – Anti-schizophrenia drugs block dopamineAnti-schizophrenia drugs block dopamine receptors.receptors. – Ingestion of amphetamine can induceIngestion of amphetamine can induce psychosis; amphetamine causes the releasepsychosis; amphetamine causes the release of dopamine from neurons.of dopamine from neurons.
- 39. Psychological StressPsychological Stress Diathesis-Stress modelDiathesis-Stress model (Stressful Life Events(Stressful Life Events)).. Low Social Class & SchizophreniaLow Social Class & Schizophrenia – Socio-Genic Hypothesis.Socio-Genic Hypothesis. – Social-Selection Theory.Social-Selection Theory. Expressed Emotion (EE): Research shows howExpressed Emotion (EE): Research shows how family & social environmental context affectsfamily & social environmental context affects re-hospitalization rates.re-hospitalization rates. Limited Social Network.Limited Social Network.
- 40. Diathesis-Stress ModelDiathesis-Stress Model Diathesis “Predisposing Causes” (Hereditary Predisposition) Stress “Precipitating Causes” (Situational Factors) Disorder Recovery “Maintaining Causes” Physical Conditions Bio-Psycho-Social Approach • Emphasizes Interaction of Biological and Social Factors
- 41. . Cukor D et al. JASN 2007;18:3042-3055 ©2007 by American Society of Nephrology
- 42. . Cukor D et al. JASN 2007;18:3042-3055 ©2007 by American Society of Nephrology
- 43. Differential DiagnosisDifferential Diagnosis Medical Conditions: A variety of generalMedical Conditions: A variety of general medical conditions can present with psychoticmedical conditions can present with psychotic symptoms.symptoms. – Dementia & Brain Tumor.Dementia & Brain Tumor. Substance Abuse.Substance Abuse. Schizoaffective Disorder.Schizoaffective Disorder. Mood Disorder with Psychotic Feature.Mood Disorder with Psychotic Feature. Delusion Disorder (difficult to distinguishDelusion Disorder (difficult to distinguish from Paranoid Type of Schizophrenia).from Paranoid Type of Schizophrenia).
- 44. Schizo- phrenia Usually insidious Many Chronic >6 months Delusional disorder Varies (usually insidious) Delusions only Chronic >1 mo. Brief psychotic disorder Sudden Varies Limited <1 mo. Onset Symptoms Course Duration Differential DiagnosisDifferential Diagnosis
- 45. Shorter Life ExpectancyShorter Life Expectancy Comorbidity:Comorbidity: 80 - 90% nicotine dependent.80 - 90% nicotine dependent. 10% commit suicide.10% commit suicide. 20 - 40% make at least one attempt20 - 40% make at least one attempt over the course of the illness.over the course of the illness. – Those at Risk: males, under age 45,Those at Risk: males, under age 45, depressed, unemployed, recentlydepressed, unemployed, recently hospitalized.hospitalized.
- 46. STRATEGY OF TREATMENTSTRATEGY OF TREATMENT Control Symptoms with Medication.Control Symptoms with Medication. Form A Personal Relationship.Form A Personal Relationship. Teach Disease Management Skills.Teach Disease Management Skills. Teach Compensatory Techniques.Teach Compensatory Techniques. Help Maximize Unique Potential.Help Maximize Unique Potential.
- 47. Therapies for SchizophreniaTherapies for Schizophrenia Biological Treatments:Biological Treatments: – Electroconvulsive and insulin coma shock treatments wereElectroconvulsive and insulin coma shock treatments were minimally effective.minimally effective. – Psychosurgery is the intentional destruction of brain tissuePsychosurgery is the intentional destruction of brain tissue to alter behavior.to alter behavior. – Prefrontal lobotomy was used to treat schizophrenia.Prefrontal lobotomy was used to treat schizophrenia. Drug Therapies Supplanted Psychosurgery:Drug Therapies Supplanted Psychosurgery: – Use of Neuroleptic Medications to treat positive symptomsUse of Neuroleptic Medications to treat positive symptoms of schizophrenia: Chlorpromazine was introduced in the USof schizophrenia: Chlorpromazine was introduced in the US in 1954.in 1954. – Use of Atypical Antipsychotics to treat positive, negative &Use of Atypical Antipsychotics to treat positive, negative & quality of life.quality of life.
- 48. ANTIPSYCHOTICANTIPSYCHOTIC MEDICATIONS REDUCEMEDICATIONS REDUCE Hallucinations & Delusions.Hallucinations & Delusions. Negative Symptoms.Negative Symptoms. Bizarre Behavior.Bizarre Behavior. Agitation.Agitation. Hostility & Aggression.Hostility & Aggression. Disordered Thinking.Disordered Thinking.
- 49. ANTIPSYCHOTICANTIPSYCHOTIC MEDICATIONMEDICATION Reduces relapse rates.Reduces relapse rates. Reduces brain dysfunction.Reduces brain dysfunction. Improved medications available.Improved medications available. Unique and individual response.Unique and individual response. First step to recovery.First step to recovery.
- 50. Psychological TreatmentsPsychological Treatments Social-Skills Training:Social-Skills Training: Involves teaching behaviors to interactInvolves teaching behaviors to interact successfully with others.successfully with others. Family Therapy:Family Therapy: Aims to reduced expressed emotionAims to reduced expressed emotion (hostility, overly critical).(hostility, overly critical). Cognitive-Behavioral Therapy:Cognitive-Behavioral Therapy: DDemonstrates that maladaptive behaviors &emonstrates that maladaptive behaviors & beliefs of some patients can be changed.beliefs of some patients can be changed.
- 51. Well-being: physical, psychological, social & spiritualWell-being: physical, psychological, social & spiritual Quality of LifeQuality of Life Physical Functional Ability Strength/Fatigue Sleep & Rest Nausea Appetite Constipation Pain Psychological Anxiety Depression Enjoyment/Leisure Pain Distress Happiness Fear Cognition/Attention Social Financial Burden Caregiver Burden Roles & Relationships Affection Sexual Function Appearance Spiritual Hope Suffering Meaning of Pain Religiosity Transcendence Quality of Life
Editor's Notes
- The person with schizophrenia wants to be able to work, have friends, and take care of himself. His ability to do this is impaired by four types of symptoms. Often the cognitive impairments of memory, attention, learning, and problem solving and the moods of depression and hopelessness create more impairment than the symptoms that define the diagnosis. Symptoms are classified as “positive” because of the presence of something that others do not have (i.e., the presence of delusions or disorganized speech are positive symptoms). Symptoms are classified as “negative” because of the absence of something that others do have (i.e., the lack of energy or interest in activities are negative symptoms), Today we will focus first on treating the illness and then on promoting recovery of functioning.
- The risk of developing schizophrenia increases if you have a blood relative who has the illness. Common questions and answers about genetic risk are: 1. Q: One of my children has schizophrenia. What are the chances of the other children developing schizophrenia? A: Twelve percent each until they pass the age of risk. These first degree relatives share 50% of the same genes. 2. Q: My daughter with schizophrenia wants to have a child. What is the risk? A: Twelve percent if the father does not also have schizophrenia; but 48% if both parents have the illness. 3. Q: My son has schizophrenia; his sister wants to have children. What is the risk? A: Risk is 5%. These second degree relatives (uncle-niece) share 25% of the same genes. 4. Q: What if there are multiple relatives in the family tree with schizophrenia? A: The risks are roughly accumulative; e.g. having a brother and an aunt would make the risk of developing schizophrenia 17% (12% + 5% = 17%). Refer families to Schizophrenia and Genetic Risks by Gottesman on their reading list.
- This view is from the bottom of the brain (from the neck looking up). It allows us to see most of the areas of the brain that are impacted by schizophrenia. (1) Schizophrenia involves structural and functional deficits in the frontal and temporal lobes of the cerebral cortex (gray and white matter near the surface) and in the deeper structures including the thalamus, basal ganglia and limbic system. Dysfunctions can be seen in specific brain areas and especially in the neural circuits which coordinate the functions of the brain. The location and severity of the deficits determine the specific type and severity of symptoms for each person. As we discuss these deficits, I will be describing schizophrenia in its most severe form. This is important so that you can understand the experience and empathize with the struggles of someone attempting to overcome this devastating illness. No person with schizophrenia has all of these deficits and most people with schizophrenia receive treatment that reduces the severity of the deficits. This information can harm you if you now think that your relative is much more impaired than is the case. Take the parts of this description that fit your relative so that you may better understand. Discard any parts that do not fit your relative. Schizophrenia is very different in different people.
- The frontal lobes perform the executive (planning, problem solving, regulating, and decision-making) functions of the brain. Humans have proportionally larger frontal lobes than any other animal. These large frontal lobes give us the ability to create complex and coherent long-range plans. They help us to decide whether to stick with a plan or modify it when circumstances change. The frontal lobes help us to understand the external environment and the actions and feelings of others. They also regulate our internal environment of emotions and impulses. Complex memory, analysis and problem solving functions are done in the frontal lobes. Therefore, the level of frontal lobe activity is highly correlated with a person’s ability to work and to live independently. (2) Schizophrenia often directly causes structural and functional deficits in specific areas of the brain including in the frontal lobes. It can also cause dysfunctions in the neural circuits which coordinate the interactions between the different areas of the brain.
- This new brain imaging technique shows a lower level of frontal activity (top of slide) for a person with schizophrenia. Activity is shown using the color spectrum: red is highest activity, then orange, yellow, green, blue and finally purple is lowest level. (4) This person has frontal lobes but they don’t work well. Notice how much less orange and yellow (high activity) is present. Similarly, some paraplegics have legs, but the legs can’t function. The person’s lack of understanding of social situations often leads to behavior that we perceive as bizarre and misunderstand. [Example: A woman with schizophrenia who deeply loved her mother and longed for a visit wrote: “During the visit I tried to establish contact with her to feel that she was actually there, alive and sensitive. But it was futile. Though I certainly recognized her, she became part of the unreal world. I knew her name and everything about her, yet she appeared strange, unreal, like a statue. I saw her eyes, her nose, her lips moving, heard her voice and understood what she said perfectly, yet I was in the presence of a stranger. To restore contact between us I made desperate efforts to break through the invisible dividing wall, but the harder I tried, the less successful I was, and the uneasiness grew apace. I pinched her to make her real, but the nurses took her away, leaving me totally alone.” The nursing note reads: “Patient hostile towards and attacked Mother. Advise Mother not to visit.”]
- The temporal lobe functions related to schizophrenia are perception (hallucinations), reality orientation (delusions), and memory (failure to learn from experience). Hallucinations are false perceptions in any of the senses (i.e., hearing, seeing, smelling, or feeling something that is not real). The most common hallucinations are hearing voices that berate, threaten, comment on the person’s behavior or tell him what to do. Delusions are obviously untrue beliefs that are not shared by the person’s subculture [Give examples of subcultural or religious beliefs that are not delusions.] and which are not subject to disconfirmation by any evidence [Give example. Sample: “CIA put wires in my walls.” You tear the walls apart. “The wires are invisible.”] Delusions are often bizarre; they contain new words, machines, or activities that do not exist. Sometimes the person creates a new vocabulary to describe his unique perceptions. [Give an example.] The most common delusions are of being controlled or persecuted, of having one’s thoughts broadcasted or inserted, or of events having special meaning to the person. For example in the movie Promise , James Woods believes that TV salesmen are speaking uniquely to him so he does whatever they tell him to do.
- This scan is taken from the front, so that the left portion of the brain is shown on the right side of the scan. The left temporal lobes (right arrow) are partially missing in this person with schizophrenia. It is easier to see that the ventricles (left arrow pointing to a dark fluid filled space) are larger. Enlarged ventricles are not the problem; the problem is that certain regions of the temporal lobe, that should be located in the space occupied by the enlarged ventricles, are absent. Absence or dysfunction in the sensory language center of the left temporal lobe may be the cause of auditory hallucinations. (6) This person would have great difficulty knowing what was real. As one person wrote: “What then does schizophrenia mean to me? It means fatigue and confusion, it means trying to separate every experience into the real and unreal and sometimes not being aware of where the edges overlap. It means trying to think straight when there is a maze of experiences getting in the way and when thoughts are continually being sucked out of your head. It means feeling sometimes that you are inside your head and visualizing yourself walking over your brain, or watching another girl wearing your clothes and carrying out actions as you think them. It means knowing that you are continually watched and that you can never succeed in life because the laws are all against you and knowing that your ultimate destruction is never far away.” 14
- Basal ganglia include several brain structures such as the hippocampus, caudate, and putamen. The structures of the basal ganglia overlap with the temporal lobes and limbic system. These structures focus the brain on relevant information by screening out irrelevant stimuli. At any one time most of the brain is working by inhibiting thoughts, feelings, and actions. We are capable of doing so many things that, unless most are inhibited, chaos ensues. Imagine all of the things that you did today. Your brain must tell your body to not do any of those activities in order for you to concentrate and learn from this lecture. It must also screen out thoughts and feelings about work or social plans for you to focus on what I am saying. Basal ganglia must be very active in screening out sensory input so that you can focus and maintain concentration. People who have schizophrenia are limited in their ability to screen out irrelevant stimuli. Therefore, they have greater difficulty functioning in environments that contain more stimulation. Basal ganglia also perform many coordinating functions. They physically connect to the frontal lobes and translate the actions plans, formed in the frontal lobes, into behaviors which will fulfill these plans. Coordinating goal-directed behavior is one important function of the basal ganglia.
- The limbic system includes the amygdala and parahippocampus and shares structures with the basal ganglia and temporal lobes. Dysfunction in this area causes great difficulty in social situations. Most people with schizophrenia have the component social skills; they can smile, make eye contact, ask questions. The problem is that they can’t understand the emotional context of the situation and which behavior to use. They can’t perceive whether a listener wants them to go on or to stop. They can’t judge whether to use sympathy or laughter. They cannot connect what they see and hear to the past experiences, which provide the bases for understanding and empathy. (8) Remember Dennis’ misunderstanding of the social cues and communication. Therefore, he immediately returned with his wagon to Mr. Wilson’s house because Mr. Wilson is going to “fix his wagon” the next time he visits.
- The almond-shaped area (in the lower right portion of the slide) is the amygdala, an important part of the limbic system. In this person with schizophrenia the amygdala is missing. (See the arrow.) (9) The amygdala and other limbic system structures connect emotional experience to thinking. They allow a person to understand and analyze feelings and perceptions. They produce appropriate feelings in response to specific thoughts and perceptions. Damage to the amygdala reduces the ability to perform these functions. Damage also impairs learning, especially learning of emotionally charged material. Imagine trying to learn social skills if you could not understand the emotional responses of others and the role that your behavior has in creating those responses. (10) Faulty connections of the limbic system to the frontal lobes also disconnect current behavior from long term plans and goals. People’s behavior is more random, based solely on the impulses and responses of the moment. Impulses not goals direct behavior. Therefore, people often experience their identities as fragmented, with no way of organizing thoughts and feelings into a coherent sense of self or directing behavior towards their goals. (11)
- The first aspect of treatment is to control the symptoms with medication. Without this, little else works. A major dilemma occurs when the person refuses medication. It is an important human right to be able to refuse mind altering medication. However, schizophrenia causes brain deficits which impair the person’s ability to understand and make judgments about his illness. [Analogy: Waiting to provide treatment until a person with schizophrenia asks for it is similar to saying that treatment will be provided for someone with a broken leg if he walks to treatment.] Therefore, it is sometimes appropriate to give medication against the person’s will for brief periods. The goal of involuntary treatment is always to restore brain functioning so that the person has the understanding and judgment to make rational choices about his life. The next step is to create a positive relationship much like a student has with a special teacher. In this relationship, the professional believes in the person’s worth and abilities, and does everything that she can to help the person realize his potential. [Give examples of professional behaviors which promote a positive rehabilitation relationship.] Specific curricula exist to teach people how to recognize and manage their symptoms and to use strengths to compensate for handicaps. [Give examples of symptom management and skill building methods.] The ultimate goal is always defined by the person; it is her unique picture of a complete and fulfilling life. 6
- Antipsychotic medications reduce the positive symptoms of schizophrenia, especially the more bizarre symptoms. For some people, the medication totally eliminates symptoms, but for most, it only reduces them. For example, medication might reduce an ever-present, overpowering auditory hallucination to an occasional quiet background voice. Reducing the frequency and intensity of symptoms allows the person to learn to control or ignore the symptoms. Instead of being obsessed with and controlled by her symptoms, she can be in the “driver’s seat” of her life. Medication partially restores the person’s ability to think and learn so she can benefit from rehabilitation. When the person is acutely ill, antipsychotic medication reduces severe negative symptoms such as apathy or withdrawal. In the stable phase of the illness, however, traditional antipsychotics do little to help the negative, mood, or cognitive symptoms and medication side effects may worsen negative symptoms. (48). Newer antipsychotic medications that do reduce negative symptoms will be discussed later.
- To summarize the main points about antipsychotic medication: Antipsychotic medications are effective. They reduce relapse and reduce the brain dysfunctions caused by schizophrenia. The new antipsychotic medications have fewer side effects and a broader range of action. Each person responds differently to these medications. A frustrating period of trial and error is often required to find the best medicine and dose. All antipsychotics are about equally effective in reducing positive symptoms. Newer medications seem to provide greater reduction of negative, cognitive and mood symptoms. All low-dose strategies increase relapse but have other advantages that make them an option for persons who are stable, knowledgeable, and can monitor their symptoms. Injectable medications are a good option for some. Medication is the most important, but only the first, step in treatment. After medication controls symptoms, rehabilitation can help the person rebuild a meaningful life. Next week we will discuss the second step to recovery, psychosocial rehabilitation. 29