Understanding Schizophrenia, Bipolar and Borderline Disorder

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UNDERSTANDING SCHIZOPHRENIA AND ASSOCIATED
CONDITIONs

• Dr Douglas Kong
• Retired psychiatrist
• Executive/business and life coach

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What this 2 workshop covers

• 1st workshop understanding the mentally
  troubled
• Schizophrenia and associated CONDITIONS
• Anxiety and depression
• 2nd workshop helping the mentally troubled
• Schizophrenia and associated disorders
• Anxiety and depression
• Focus of workshop simple, effective, within
  your means ways of helping the patient to feel
  better
• These strategies do not in any way constitute
  treatment

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Important note

• This 2 workshop does not qualify you to be a
  counsellor nor equip you to be a psychiatric case
  worker.
• In no way should you use your knowledge gained
  here to help people beyond your competence as
  defined by your training, skills and experience.

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What fascinates layman about Schizophrenia

• Abnormal behaviour speaking to themselves
• In appropriate social behaviour
• Tendency to violence
• Self-neglect and lack of self-care
• Lack of motivation
• Unable to complete assigned tasks

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What is schizophrenia

• Severe mental illness
• Proportion of them go downhill rapidly
• While may have episodes when they did not do well
• Only a small proportion do well

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Symptoms of schizophrenia

• Hallucinations mostly verbal
• Delusions
• Cognitive impairment
• Social withdrawal

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Verbal hallucinations

• Voices may converse with the patient
• Voices may comment on the patients actions and
  behaviour
• Voices may command the patient to do certain
  actions
• Voices may make fun of or ridicule patient

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Parts of the brain activated during hallucinations
Temporal lobe
Speech Area
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Negative symptoms of schizophrenia

• Reduced emotional responsiveness
• Absence or lack of motivation
• Asocial or reduced level of socialization
• Poverty of speech
• anhedonia
• Reduced movement sometimes frozen state
  catatonia

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Importance of negative symptoms

• Points to brain damage
• Supported by enlarged cavities in the brain
• Loss of gray matter in frontal and parietal lobes
• Enlarged amygdala with enlarge white matter areas
• Impaired cognitive function
• Decreased prefrontal brain function
• May be considered as disease of intellectual
  function

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What causes Schizophrenia

• Dopamine excessive
• Accounts for positive symptoms
• Drug treatment supports it early antipsychotics
  block dopamine action
• Amphetamine effects support it
• Against it
• Negative symptoms unaffected
• Deterioration unaffected as well

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Glutamate in Schizophrenia
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The NMDA receptor
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Loss of grey matter in Schizophrenia
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Enlarged ventricles in Schizophrenia
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Possible mechanisms

• Deficit of glutamate, glutamate-dopamine balance
  disrupted
• Abnormalities of nerve wiring
• Neuregulins
• Abnormalities in synapse function
• Affects long term potentiation (LTP)
• Inhibition of NMDA receptor
• Stimulate of production of NMDA receptors by
  growth factors

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Bipolar Disorder - Mania

• BD are mood disorders
• Genetic and family history significant
• Commonly affect the functioning of limbic system
• Includes Depression, Manic Depression
• Mania Mood is abnormally high
• Depression Mood is abnormally low
• Terminology
• Type I Manic Depression, Mania
• Type II - Depression

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Bipolar Disorder Is Multidimensional
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Symptoms of Mania/Hypomania

• Elevated/irritable mood
• Inflated self-esteem/grandiosity
• Decreased need for sleep
• More talkative
• Racing thoughts
• Distractible
• Increase in activity/agitation
• Increased involvement in pleasurable activities
• ?3 symptoms DSM-IV bipolar I, manic episode

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Bipolar Disorderthe Big Picture

• 1 of every 4 or 5 untreated bipolar individuals
  commits suicide
• Low proportion of patients in treatment (30),
  despite effectiveness of available treatments
• Bipolar disorder consists of episodes that can be
  described as manic, mixed, hypomanic, depressed,
  and euthymic
• Symptoms encompass exaggerations of normal mood
  (eg, sadness, joy, irritability, rage,
  creativity)
• Depressive state most common

Judd et al. Arch Gen Psychiatry 200259530-537
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Bipolar Disorder - Mania
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Manic Bipolar Disorders

• Bipolar Disorders can be progressively severe
• Most with treatment can be stable
• HBR 10-20 businessmen are bipolars
• Mildly manic can be the life and soul of party
• Distinguish from Schizophrenia,
• make you like them when mild
• Make you frightened of them when aggressive

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Borderline Disorder

• Impulsive and risky behavior, such as risky
  driving, unsafe sex, gambling sprees or illegal
  drug use
• Awareness of destructive behavior, including
  self-injury, but sometimes feeling unable to
  change it
• Wide mood swings
• Short but intense episodes of anxiety or
  depression
• Inappropriate anger and antagonistic behavior,
  sometimes escalating into physical fights
• Difficulty controlling emotions or impulses
• Suicidal behavior
• Feeling misunderstood, neglected, alone, empty or
  hopeless
• Fear of being alone
• Feelings of self-hate and self-loathing

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Borderline functioning

• When you have borderline personality disorder,
  you often have an insecure sense of who you are.
  Your self-image, self-identity or sense of self
  often rapidly changes. You may view yourself as
  evil or bad, and sometimes you may feel as if you
  don't exist at all. An unstable self-image often
  leads to frequent changes in jobs, friendships,
  goals and values.
• Your relationships are usually in turmoil. You
  may idealize someone one moment and then abruptly
  and dramatically shift to fury and hate over
  perceived slights or even minor
  misunderstandings. This is because people with
  borderline personality disorder often have
  difficulty accepting gray areas things seem to
  be either black or white.

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Borderlines biological vulnerabilities

• Impairment of neural circuits modulating emotion
• Diminished serotonin and overactive
  noradrenaline
• Overactivity of the amygdala pronounced with
  stress or substances such as alcohol
• Reduction of inhibitory activity of the
  prefrontal cortex in suppressing negative
  emotions
• Reduced activity of GABAergic neurons to inhibit
  mood swings

Davidson RJ, Putnam KM Larson CL, Science,
2000 Davidson RJ, Jackson DC, Kalin NH, Psychol
Bull. 2000 Siever LJ, Frankenburg HW, Science,
2000
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Significance of borderline

• History of trauma
• Disruption of normal attachment
• Association with Bipolar Disorder, Post Traumatic
  Stress Disorder
• Associated with genetic abnormalities eg Xyy
• Association with abnormal EEG abnormality
• In treatment, poor compliance with medication
• Risk of overdose with histrionic features
• Frequent use of medical facilities
• Frequent use of whatever community services

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Borderline disorder