Case Study: C.Z.
Purpose:Analyze and apply critical thinking skills in the psychopathology of mental health patients and provide treatment and health promotion while applying evidence-based research.Scenario:
C.Z. is a 20-year-old Caucasian male who is in his second year of college. He is seeking treatment due to persistent fears that campus security and the local police are tracking and surveilling him. He cites occasional lags in his internet speed as evidence that surveillance devices are interfering with his electronics. His intense anxiety about this has begun getting in the way of his ability to complete schoolwork, and his friends are concerned he says they have told him, youre not making sense.
C.Z. occasionally laughs abruptly and inappropriately and sometimes stops speaking mid-sentence, looking off in the distance as though he sees or hears something. He expresses concern about electronics in the room (phone, computer) potentially being monitored and asks repeatedly about patient confidentiality, stating that he wants to be sure the police wont be informed about his treatment. His beliefs are fixed, and if they are challenged, his tone becomes hostile.
Questions:
Remember to answer these questions from your textbooks and NP guidelines. At all times, explain your answers.
Discuss the etiology, course, and the structural/functional abnormalities of schizophrenia.
Discuss the evidence-based pharmacological and nonpharmacological treatment for this patient using the US Clinical Guidelines.
Outline
Perspectives on Schizophrenia
Clinical Description, Symptoms, and Subtypes
Prevalence and Causes of Schizophrenia
Treatment of Schizophrenia
Nature of Schizophrenia and Psychosis:
History and Current Thinking
Historical background
Emil Kraepelin used the term dementia praecox to
describe schizophrenic syndrome
Early subtypes of schizophrenia Catatonia, h
paranoia
Eugen Bleuler introduced the term schizophrenia
Splitting of the mind
Nature of Schizophrenia and Psychosis:
History and Current Thinking
Impact of early ideas on current thinking
Many of Kraeplin and Bleulers ideas are still with us
Understanding onset and course considered
important
Psychotic behavior
May refer only to hallucinations or delusions or to
the unusual behavior (e.g., inappropriate
emotionality, strange actions) accompanying them
DSM-5 Criteria: Schizophrenia
A.
Two (or more) of the following, each present for a
significant portion of time during a one-month period:
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g., frequent derailment
or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms (i.e., diminished emotional
expression or avolition)
DSM-5 Criteria:
Schizophrenia
B.
For a significant portion of the time since the onset of
the disturbance, level of functioning in one or more
major areas, such as work, interpersonal relations, or
self-care, is markedly below the level achieved prior to
the onset.
C.
Continuous signs of the disturbance persist for at least
six months.
D.
Schizoaffective disorder and depressive or bipolar
disorder with psychotic features have been ruled out.
E.
The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
DSM-5 Criteria: Schizophrenia
F.
If there is a history of autistic spectrum disorder or a
communication disorder of childhood onset, the
additional diagnosis of schizophrenia is made only if
prominent delusions or hallucinations, in addition to
the other required symptoms of schizophrenia, are
also present for at least one month (or less if
successfully treated).
From American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders (5th ed.). Washington, DC.
Key Terms
Psychosis: Gross departure from reality, which may
include:
Hallucinations: Sensory experiences in the absence
of sensory input (e.g., hearing voices)
Delusions: Strong, inaccurate beliefs that persist in
the face of evidence to the contrary
Schizophrenia: A pervasive type of psychosis
characterized by disturbed thought, emotion, behavior
Schizophrenia:
Statistics
Onset and prevalence of schizophrenia
worldwide
About 0.2% to 1.5% (or about 1%
population)
Often develops in early adulthood
Can emerge at any time; childhood
cases are extremely rare but not
unheard of
Schizophrenia:
Statistics
Schizophrenia is generally chronic
Most suffer with moderate-to-severe
lifetime impairment
Life expectancy is slightly less than
average
Increased risk for suicide
Increased risk for accidents
Self care may be poorer
Schizophrenia:
StatisticsGender and Culture
Schizophrenia affects males and females
about equally
Females tend to have a better longterm prognosis
Onset slightly earlier for males
Cultural factors
Psychotic behaviors not always
pathologized
Yet schizophrenia is found at similar
rates in all cultures
Course of
Schizophrenia
The longitudinal course
shows how schizophrenia
progress from birth.
© 2019 Cengage. All rights reserved.
Causes of
Schizophrenia:
Findings From
Genetic
Research
Family studies
Inherit a tendency for schizophrenia,
not specific forms of schizophrenia
Risk increases with genetic relatedness
For example, having a twin with
schizophrenia incurs greater risk
than having an uncle with
schizophrenia
Risk of
Developing
Schizophrenia
Schizophrenia is highly
inheritable.
© 2019 Cengage. All rights reserved.
Causes of
Schizophrenia:
Findings From
Genetic
Research
Twin studies
Monozygotic twins versus fraternal
(dizygotic) twins
At greater risk if your identical twin
has schizophrenia supports role
of genes
Adoption studies
Adoptee risk for developing
schizophrenia remains high if a
biological parent has
schizophrenia
But risk is lower than for children
raised by their biological parent
with schizophrenia healthy
environment is a protective factor
Schizophrenia Among
Children of Twins
When one twin has been
diagnosed with schizophrenia,
being a paternal twin increase
the risk of inheriting
schizophrenia.
© 2019 Cengage. All rights reserved.
Search for
Genetic and
Behavioral
Markers of
Schizophrenia
Genetic markers: Linkage and association
studies
Endophentypes
Schizophrenia is likely to involve
multiple genes
Behavioral markers: Smooth-pursuit eye
movement
Schizophrenia patients show reduced
ability to track a moving object with their
eyes
Relatives of schizophrenic patients also
have deficits in this area
Causes of
Schizophrenia:
Neurobiological
Influences
The dopamine hypothesis: Schizophrenia is
partially caused by overactive dopamine
Drugs that increase dopamine
(agonists) result in schizophrenic-like
behavior
Drugs that decrease dopamine
(antagonists) reduce schizophrenic-like
behavior
Examples neuroleptics, L-dopa
for Parkinsons disease
Problem: Overly simplistic
Many neurotransmitters are likely
involved
Some ways drugs
affect
neurotransmission.
The dopamine
hypothesis
© 2019 Cengage. All rights reserved.
Causes of
Schizophrenia:
Other
Neurobiological
Influences
Structural and functional abnormalities in the
brain
Enlarged ventricles and reduced tissue
volume
Hypofrontality less active frontal lobes
A major dopamine pathway
Viral infections during early prenatal
development
Findings are inconclusive
Location of
Cerebrospinal
Fluid in the
Brain
© 2019 Cengage. All rights reserved.
Marijuana use also increases the risk for
developing schizophrenia in at-risk
individuals
Other
Neurobiological
Influences
Conclusions about neurobiology and
schizophrenia
Schizophrenia reflects diffuse
neurobiological dysregulation
Structural and functional brain
abnormalities
Not unique to schizophrenia
Cultural Differences in
Expressed Emotion
© 2019 Cengage. All rights reserved.
Causes of
Schizophrenia:
Psychological
and Social
Influences
The role of psychological factors
May function as the diathesis in a
diathesis-stress model
Exert only a minimal effect in producing
schizophrenia
Schizophrenia:
The Positive
Symptom
Cluster
The positive symptoms
Active manifestations of abnormal
behavior
Distortions or exaggerations of normal
behavior
Delusions: The basic feature of madness
Gross misrepresentations of reality
Most common:
Delusions of grandeur
Delusions of persecution
Schizophrenia:
The Positive
Symptom
Cluster
Hallucinations
Experience of sensory events without
environmental input
Can involve all senses (e.g., tasting
something when not eating, having skin
sensations when not being touched)
Most common: Auditory
Findings from SPECT studies
Neuroimaging: Part of the brain
most active during auditory
hallucinations = Brocas area,
involved in speech production (not
comprehension)
Major Areas of
Functioning of the
Cerebral Cortex
Brocas area is associated with
auditory hallucinations
© 2019 Cengage. All rights reserved.
Schizophrenia:
The Negative
Symptom
Cluster
The negative symptoms
Absence or insufficiency of normal
behavior
Spectrum of negative symptoms
Avolition (or apathy) lack of initiation
and persistence
Alogia relative absence of speech
Anhedonia lack of pleasure, or
indifference
Affective flattening little expressed
emotion
Schizophrenia:
The
Disorganized
Symptom
Cluster
The disorganized symptoms
Confused or abnormal speech,
behavior, and emotion
Nature of disorganized speech
Cognitive slippage illogical and
incoherent speech
Tangentiality going off on a tangent
Loose associations conversation in
unrelated directions
Schizophrenia:
The
Disorganized
Symptom
Cluster
Nature of disorganized affect
Inappropriate emotional behavior
Nature of disorganized behavior
Includes a variety of unusual behaviors
Catatonia
May be considered a psychotic
spectrum disorder in its own right
or, when occurring in the presence
of schizophrenia, a symptom of
schizophrenia
Subtypes of
Schizophrenia:
A Thing of the
Past
Schizophrenia was previously divided into
subtypes based on content of psychosis
This is no longer the case in DSM-5, but
outdated terms are still in partial use
Included paranoid, catatonic, residual (minor
symptoms persist after past episode),
disorganized (many disorganized
symptoms) and undifferentiated
Other
Schizophrenia
Spectrum
Disorders
Schizophreniform disorder
Psychotic symptoms lasting between
one and six months (less than six
months = schizophrenia)
Brief psychotic disorder
Psychotic symptoms lasting less than
one month
Both disorders associated with relatively
good functioning
Most patients resume normal lives
DSM-5 Criteria: Schizophreniform
Disorder
A. Two (or more) of the following, each present for a
significant portion of time during a one-month period:
(1) delusions, (2) hallucinations, (3) disorganized
speech (e.g., frequent derailment or incoherence),
(4) grossly disorganized or catatonic behavior, (5)
negative symptoms.
B. An episode of the disorder lasts at least one month but
less than six months.
C. Schizoaffective disorder and depressive or bipolar
disorder with psychotic features have been ruled out.
DSM-5 Criteria: Schizophreniform
Disorder
D.
The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse) or another
medical condition.
Specify if:
With good prognostic features: This specifier
requires the presence of at least two of the
following features: onset of prominent psychotic
symptoms within four weeks of the first noticeable
change in usual behavior or functioning; confusion
or perplexity; good premorbid social and
occupational functioning; and absence of blunted
or flat affect.
Without good prognostic features: This specifier is
applied if two or more of the above features have
not been present.
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC.
DSM-5 Criteria: Brief
Psychotic Disorder
A. Presence of one (or more) of the following symptoms. At
least one of these must be (1), (2), or (3):
1. delusions
2. hallucinations
3. disorganized speech (e.g., frequent derailment or
incoherence)
4. grossly disorganized or catatonic behavior.
Note: Do not include a symptom if it is a culturally
sanctioned response.
DSM-5 Criteria: Brief
Psychotic Disorder
B. Duration of an episode of the disturbance is at least one day
but less than one month, with eventual full return to
premorbid level of functioning.
C. The disturbance is not better explained by major depressive
of bipolar disorder with psychotic features or another
psychotic disorder such as schizophrenia or catatonia, and is
not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical
condition.
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC.
Other
Schizophrenia
Spectrum
Disorders:
Schizoaffective
Disorder
Schizoaffective disorder
Symptoms of schizophrenia +
additional experience of a major mood
episode (depressive or manic)
Psychotic symptoms must also occur
outside the mood disturbance
Prognosis is similar for people with
schizophrenia
Such persons do not tend to get better
on their own
DSM-5 Criteria: Schizoaffective
Disorder
A. An uninterrupted period of illness during which there is a
major mood episode (major depressive or manic)
concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion
A1: Depressed mood.
B. Delusions or hallucinations for two or more weeks in the
absence of a major mood episode (depressive or manic)
during the lifetime duration of the illness.
DSM-5 Criteria: Schizoaffective
Disorder
B. Symptoms that meet criteria for a major mood episode
are present for the majority of the total duration of the
active and residual portions of the illness.
C. The disturbance is not attributable to the effects of a
substance (e.g., a drug of abuse, a medication) or
another medical condition.
From American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders (5th ed.). Washington, DC.
Psychotic
Disorders
due to Other
Causes
Psychosis may occur as the result of
substance use, some medications and some
medical conditions
Knowing these causes is important for
treatment
Address underlying cause
Include:
Substance/medication-induced
psychotic disorder
Psychotic disorder associated with
another medical condition
DSM-5 Criteria: Substance/MedicationInduced Psychotic Disorder
A. Presence of either/both of delusions or hallucinations.
B. There is evidence from the history, physical examination,
or laboratory findings of both (1) and (2):
1. The symptoms in Criterion A developed during, or
soon after substance intoxication or withdrawal or
after exposure to a medication.
2. The involved substance/medication is capable of
producing the symptoms in Criterion A.
C. The disturbance is not better explained by a psychotic
disorder that is not substance/medication-induced. Such
evidence of an independent psychotic disorder could
include:
DSM-5 Criteria: Substance/MedicationInduced Psychotic Disorder
The symptoms preceded the onset of the
substance/medication use; the symptoms persist for
a substantial period of time after the cessation of
acute withdrawal or severe intoxication; there is
other evidence of an independent nonsubstance/medication induced psychotic disorder.
D.
The disturbance does not occur exclusively during the
course of a delirium.
E.
The disturbance causes clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
DSM-5 Criteria: Psychotic Disorder
Associated with Another Condition
A. Prominent hallucinations or delusions.
B. There is evidence from the history, physical examination, or
laboratory findings that the disturbance is the direct
pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental
disorder.
D. The disturbance does not occur exclusively during the course of a
delirium.
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC.
Causes of Schizophrenia: Psychological
and Social Influences, Part 1
The role of stress
May activate underlying vulnerability
May also increase risk of relapse
Family interactions
Unsupported theories
Schizophrenogenic mother
Double bind communication
High expressed emotion (EE) associated with
relapse
Historical precursors
Medical
Treatment of
Schizophrenia
Insulin Coma
Electroconvulsive Therapy
Development of antipsychotic (neuroleptic)
medications
Often the first line treatment for
schizophrenia
Began in the 1950s
Most reduce or eliminate positive
symptoms
Acute and permanent side effects are
common
Parkinsons-like side effects
Tardive dyskinesia
Compliance with medication is
often a problem
Noncompliance with medication
Historical precursors-psychodynamic therapy
Psychosocial
Treatment of
Schizophrenia
Psychosocial approaches
Behavioral (i.e., token economies) on
inpatient units: Reward adaptive
behavior
Community care programs
Social and living skills training
Behavioral family therapy
Vocational rehabilitation
Psychosocial
Treatment of
Schizophrenia
Psychosocial approaches cont.
Illness management and recovery:
Engages patient as an active
participant in his/her care, focusing on
goal setting and dealing with functional
impairment
Cultural considerations: Important to
take into account cultural factors that
influence individuals understanding of
their own illness
Prevention: Identify at-risk children and
intervene (e.g., with supportive,
nurturing environments, social skills
training)
Summary of
Schizophrenia
and Psychotic
Disorders
Schizophrenia spectrum of dysfunctions
Affecting cognitive, emotional, and
behavioral domains
Positive, negative, and disorganized
symptom clusters
DSM-5 documents a range of
psychotic disorders
Several bio-psycho-social variables
are involved
Successful treatment rarely includes
complete recovery
References
American Psychiatric Association.
(2013). Diagnostic and statistical manual
of mental disorders (DSM-5®). American
Psychiatric Pub.
O’Donoghue, E. K., Morris, E. M.,
Oliver, J. E., & Johns, L. C. (2018). ACT for
psychosis recovery: A practical manual for
group-based interventions using
acceptance and commitment therapy. New
Harbinger Publications.
Torrey, E. F. (2019). Surviving
schizophrenia: A family manual (7th ed.).
HarperCollins.
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