A little review

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A little review

• The Externalizing Spectrum
• Which disorders are included?
• SUDs, CD, ASPD, ODD
• Which disorders are not included?
• Mood disorders, anxiety, etc
• Why the term externalizing?
• First, empirical research supports a high rate of
  comorbidity within these disorders. And, they
  generally Involve acting out instead of
  internalizing feelings, like in the case of
  depression.

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A little review

• Terminology
• Prognosis?
• is a medical term denoting the doctors
  prediction of how a patient's disease will
  progress, and whether there is chance of
  recovery.
• Diathesis?
• A vulnerability set in place that increases the
  likelihood of developing a disorder can be
  genetic, biological, or environmental!
• Theory of mind?
• Having a theory of mind means that we believe
  that other people have minds like ours and that
  we understand the behaviour of these others in
  terms of the contents of their minds their
  knowledge, beliefs and desires. (Frith, 2004)
• Initially found in a study of monkeys (Premack
  and Woodruff, 1978)

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Schizophrenia (Sz)Other Psychoses
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• Quote 1 If things turn by rotation of
  agriculture or levels in regards and timed to
  everythingmuch of abstraction has been left
  unsaid and undone in this product of milk syrup
  and others due to economics, differentials,
  subsidies, bankruptcy, tools buildings, national
  stocks, foundation crops, weather, trades, in
  levels of breakages, and fuses in electric too
  all formerly stated not necessarily factuated.
• Quote 2 I think there were some differences,
  theres no question, and will still be. Were
  talking about a major, major situation hereI
  mean, weve got a major rapport relationship of
  economics, major in the security, and all of
  that, we should not lose sight of.

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• Who said Quote 1?
• Hospitalized schizophrenia patient planning a
  holiday visit with her parents
• Who said Quote 2?
• George H.W. Bush (not the misunderestimated
  Bush) on trade talks with Japan

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The Unabomber

• Ted Kaczynski
• At the age of 10, his IQ was found to be 170. He
  skipped two grades, and entered Harvard at the
  age of 16
• Sent bombs to university researchers and airlines
  (UNABOM) beginning in 1978
• Published a raving manifesto against technology
• Arrested in 1996 after the most expensive manhunt
  in FBI history
• Stereotypes of Schizophrenia
• Paranoia
• Violence
• Super intelligence

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Schizophrenia Background

• Major international health problem
• Often chronic with marginal adjustment
• Only 16 recover fully
• 38 make good adjustment
• Around 12 need long term hospitalization
• Remainder marginal adjustment, in board and care
  homes, live with relatives
• Mortality at any given age doubled for Sz
• Includes death from all causes
• 10 commit suicide
• Cost to US economy about the same as cost of
  dealing with cancer

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Schizophrenia Background

• Worldwide Prevalence 1
• Evidence
• MF ratio in U.S. hospitals 21
• Peak age of onset late teens to early 20s
• Onset later in females, outcome better
• Is estrogen a protective factor?

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Sz age of onset distribution
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Characterizing Schizophrenia

• Complex syndrome that is difficult to define
  precisely
• Symptoms are so unusual as to fall outside the
  normal realm of human experiences
• Schizophrenia means split mind (Bleuler)
• Refers to a disintegration of the self or
  personality
• Introduced by Eugen Bleuler to emphasize that
  affect (emotions) and thoughts were disconnected
• Does not refer to split or multiple personality
  (DID)

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Key Historical Figures

• Emil Kraepelin (1899)
• Eugen Bleuler (1911)
• Kurt Schneider (1959)
• Paul Meehl (1963)
• All have been influential in modern-day
  conceptions of schizophrenia

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Characterizing Sz Emil Kraepelin

• Dementia praecox
• precocious dementia
• Implies mental deterioration occurring early in
  life with no recovery
• Kraepelins dementia
• Poor judgment
• Apathy
• Lack of emotional expression
• Reduction in voluntary activity
• Neglect of responsibilities self-care
• Poverty of speech
• Today called negative symptoms reflect absence
  of attributes shared by most people

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Characterizing Sz Eugen Bleuler

• Schizophrenias 4 as
• 1. Loose associations
• Unpredictable train of thought, incoherence
• Current notion of thought disorder originated
  with Bleuler
• Not clear what the link (association) is between
  words and ideas
• The water coming out of my skin is battle ship
  paint from my racing days with my daddy. You
  know, the destroyer was a flagship.
• Lettuce is a transformation of a dead cougar
  that suffered a relapse on the lions toe. And he
  swallowed the lion and something happened. Gloria
  and Tommy. Theyre two heads and theyre not
  whales. But they escaped with herds of vomit and
  things like that.

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Bleuler 4 as Continued

• 2. Inappropriate affect
• Inappropriate Affect (emotional expression) and
  thought content are incongruent or contradictory
• Flat (blunt, restricted) Little or no affective
  expression

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Bleulers 4 as Continued

• 3. Autistic withdrawal
• Social withdrawal and loss of contact with
  reality
• 4. Ambivalence
• Contradictory feelings e.g., about self and
  others
• Bleulers lasting contributions
• Loose associations
• affect disturbance
• interpersonal relation deficit
• All still important to DSM definition of
  schizophrenia

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Schneiders first rank symptoms (FRS)

• Includes what are now considered to be positive
  symptoms reflect the presence of attributes
  shared by few addition of abnormal features
  e.g., hallucinations and delusions
• Involve the superimposition of something (an
  alien force) that violates the persons autonomy
  as a human being by taking over part of the mind
• When introduced, were considered to be
  pathognomonic sufficient for a diagnosis
• All are bizarre totally implausible given
  cultural beliefs

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FRS Continued

• Hallucinations
• Voices conversing
• Voices Commenting
• Delusions
• Thought withdrawal
• Thought insertion
• Thought broadcast
• Delusions of control
• FRS are still important to DSM definition of
  schizophrenia

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DSM-IV-TR Criteria for Scz

• A. Characteristic symptoms Two (or more) of the
  following, each present for a significant portion
  of time during a 1-month period (or less if
  successfully treated)(1) delusions(2)
  hallucinations(3) disorganized speech (e.g.,
  frequent derailment or incoherence)(4) grossly
  disorganized or catatonic behavior(5) negative
  symptoms, i.e., affective flattening, alogia, or
  avolitionNote Only one Criterion A symptom is
  required if delusions are bizarre or
  hallucinations consist of a voice keeping up a
  running commentary on the person's behavior or
  thoughts, or two or more voices conversing with
  each other.

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DSM-IV-TR Criteria for Scz, contd

• B. Social/occupational dysfunction For a
  significant portion of the time since the onset
  of the disturbance, one or more major areas of
  functioning such as work, interpersonal
  relations, or self-care are markedly below the
  level achieved prior to the onset (or when the
  onset is in childhood or adolescence, failure to
  achieve expected level of interpersonal,
  academic, or occupational achievement).
• C. Duration Continuous signs of the disturbance
  persist for at least 6 months. This 6-month
  period must include at least 1 month of symptoms
  (or less if successfully treated) that meet
  Criterion A (i.e., active-phase symptoms) and may
  include periods of prodromal or residual
  symptoms. During these prodromal or residual
  periods, the signs of the disturbance may be
  manifested by only negative symptoms or two or
  more symptoms listed in Criterion A present in an
  attenuated form (e.g., odd beliefs, unusual
  perceptual experiences).

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DSM-IV-TR Criteria for Scz, contd

• D. Schizoaffective and Mood Disorder exclusion
  Schizoaffective Disorder and Mood Disorder With
  Psychotic Features have been ruled out because
  either (1) no Major Depressive, Manic, or Mixed
  Episodes have occurred concurrently with the
  active-phase symptoms or (2) if mood episodes
  have occurred during active-phase symptoms, their
  total duration has been brief relative to the
  duration of the active and residual periods.
• E. Substance/general medical condition exclusion
  The disturbance is not due to the direct
  physiological effects of a substance (e.g., a
  drug of abuse, a medication) or a general medical
  condition.
• F. Relationship to a Pervasive Developmental
  Disorder If there is a history of Autistic
  Disorder or another Pervasive Developmental
  Disorder, the additional diagnosis of
  Schizophrenia is made only if prominent delusions
  or hallucinations are also present for at least a
  month (or less if successfully treated).

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Characterizing Schizotypy Meehl

• Responsible for concept of schizotype person
  with genetic diathesis for schizophrenia who is
  odd
• Cognitive Slippage related to loose
  associations, involves idiosyncratic but
  comprehensible use of language
• Define hay
• A means of maintenance of the cow.
• Define guillotine
• A device for separating the body from the head.
• Anhedonia Inability to experience pleasure,
  reward, fun
• Physical tangible rewards and experiences
  arent reinforcing
• Social find interpersonal relationships
  unrewarding, perhaps aversive

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Other Sx Thought Form Disorder

• Disorganized speech (includes loose associations)
• Neologisms made up words and phrases
• Clang associations say words because they rhyme
• Word salad jumble of nonsensical words
• Thats to keep the boogers from eating the
  woogers. Well. It was a jigger and a bigger and
  me and Ill swap you for a got you and a
  fair-haired far for a bar and a jar for a tar and
  a rang, dang ting tang for a bee-shag, he-hag.
• Response from a disturbed patient when asked why
  he was hitting his head

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Other Sx Thought Content Disorder

• Delusions
• Partial vs. Full vs. Encapsulated
• Delusions can be described and rate in a number
  of ways (e.g., in terms of bizarreness,
  conviction, pervasiveness, preoccupation,
  crystallization, etc.)
• Persecutory
• Grandiose
• Religious
• Reference

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Other Symptoms Hallucinations

• Types of hallucinations
• Pseudohallucination
• True hallucination
• Hypnagogic Hallucination
• llusions
• Auditory most common
• Can involve any sense
• Often thematically linked to delusions

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Major Categorization of Scz Symptoms

• Positive
• hallucinations
• delusions
• Negative
• social and physical anhedonia
• flattened affect
• Disorganized
• disorganized speech (loose associations,
  clanging)
• disorganized and bizarre behavior

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DSM Subtypes I

• Paranoid (common)
• Characterized by preoccupation with delusions
• (DSM preoccupation with hallucinations
  possible)
• Suspicious, grandiose
• Better prognosis than other subtypes
• Disorganized (hebephrenic)
• Incoherent speech
• Disorganized behavior
• Disturbed affect
• Fragmentary delusions

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DSM Subtypes II

• Catatonic (rare)
• Marked psychomotor disturbance
• Stuporous - Immobility, posturing, mute waxy
  flexibility
• Excited - High energy, purposeless, stereotyped
  behavior
• Undifferentiated (second most common type)
• Blend of other subtypes
• Residual (common for outpatients)
• Meets criteria for Sz in past but not currently
• Has persisting mild symptoms

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Algorithm for determining subtypes

• Catatonic Type assigned whenever there are
  prominent catatonic symptoms, regardless of other
  symptoms present
• Disorganized Type assigned whenever disorganized
  speech or behavior OR flat or inapropriate affect
  are present (but catatonic symptoms are not
  present)
• Paranoid Type assigned whenever there is a
  preoccupation with delusions or frequent
  hallucinations are prominent (unless Catatonia or
  Disorganized Type is present)

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Algorithm for determining subtypes, contd

• Undifferentiated describes presentation that
  includes prominent active phase symptoms but the
  patient does not meet criteria for Catatonic,
  Disorganized, or Paranoid Types)
• Residual Type for presentations in which there
  is continuing evidence of a disturbance, but
  criteria for the active-phase symptoms are no
  longer met. The person did at one time meet
  criteria for Schizophrenia (or Schizoaffective
  d/o). Normally see a lot of negative symptoms
• That said..
• Limited value in clinical and research settings
• Empirically supported research suggests that
  grouping or rating patients based on the three
  main dimensions (positive, negative, and
  disorganized) might be more useful.

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Other Psychoses

• Schizoaffective disorder
• Schizophreniform disorder lasts
• Brief (reactive) psychotic disorder lasts mo
• Delusional disorder
• Shared psychotic disorder
• Folie a deux

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