Episode 11 - Schizophrenia, Part 2

Sometimes there is, sometimes there isn't. So just a reminder, you have the paper assignment, right? It's available on the download side if you don't have a copy of it yet. Be sure to go get it. Your paper is due, actually not for a while. Nope, it's not due until week nine after Memorial Day. Yeah, but I recommend getting started on it early. Yeah, right, like that's going to happen. In addition, you'll have your exam on Monday. The study guides available on the download website also. And then next Wednesday, I'll talk about the creative project that you'll be embarking on. Does anybody know if you can plug the laptop into the library and get stuff out? Yes, of course, you can always use the computers there in the library, too. Okay, so, schizophrenia, I've got two more video clips to show you of individuals who have schizophrenia. I hope we can get to mental retardation and pervasive developmental disorders. If we can't, it's not that big of a deal. I don't have that much to add that's not in your textbook. But if you have questions about stuff in the textbook, we can talk about it. So let's take a look at Peter. Peter was diagnosed with the disorganized subtype of schizophrenia. And I think his video gives you a pretty good illustration of how the thinking, notice how the thinking is just kind of disconnected and unorganized. Fundamentally, it's this very sort of disorganized experience in his thoughts. He's going to tell you about a grand plan that he has for producing power. And it actually sort of kind of makes sense, but it's just all kind of weird and disconnected. So, he, I believe, was homeless and while they were filming this, he was not taking his anti-psychotic medication. So it gives you a good sense of the actual experience of psychosis. Hopefully, it'll play okay. It's going to do its little waiting game here. Come on, Peter, you can do it. Can we go through this last time? Schizophrenia consists of a group of psychotic disorders characterized by profoundly distorted thoughts, perceptions, and moods. People who suffer from schizophrenia often exhibit bizarre behavior and withdraw from the world around them. There are several subtypes of schizophrenia. In this video, you will see why Peter has been diagnosed as suffering from the subtype called disorganized schizophrenia. People with disorganized schizophrenia often express incoherent thoughts and ideas. Note that although Peter's individual sentences are grammatically correct, taken as a whole, his thoughts are rambling and often incomprehensible. I got TV2, they call it, TV2 is a surprise and they put little needles in his account. And then listen to your readers, if you know what they're not, I didn't know it. And then I was really, really fantastic, expensive equipment, they touched me, they said to me, "Hey, we can check your head, you know, or if your mouth shows up bruised, and the electricity is a little different across the scalp, your scalp, you're actually social security from that entry or upon its own. It's considered like soup or coffee, but it's must be, it would be a muscular disc, you know, type of thing." And so I said, "No, I don't think about it." And I said, "Did you think about it?" And I gave it right, you know, and I said, "Okay, okay, let's go." And then they put the needle in, the last one, they put it in, they put it like this. So when they did it, I had a saw, but when they pulled them out, they pulled my bird with it, that's a little teeny little bar, and all, every one of the places they put me. And they recorded it, and one person who wanted it didn't sell it or sell it to someone else. I don't know who, but they're able to give a response back because of the, how sick the devil is in my team, how sick the devil is, and with the needles, they're easy to focus a heavier field of picked up reception because of all the feelings I got. And so I, I think it's people like at Stanford, and technicians, wealthy technicians, and people that do stuff like NASA or any of that sort of stuff, aims to, I came right up to them and tried to sell them the last little one, but for them all money they didn't have, I should have just gave it to them. I like watching a doctor, Mr. Raju's, and I like my family, and I know it was a problem, but I would just say, you could just go leave my home because the situation was, he never had too many arrests, so I'm, and it's got to go, a little out of rough ups, you know. Hey, when you do that, where do you go like this first? I wanted to make it green, you know, I'm going to give my first away, oh, it didn't make it all green spot there, you know, awful, you know, but, that's just adorable, we are, Peter prides himself on his architectural ability, and spends many hours designing tools and even communities that he believes will help solve sexual problems. In the following interview, he discusses some of his recent ideas. I play, go out and I get those things I was talking about, and I come back when we spend the time just filming and I tell what they are, I'm coming to architecture. Concepts right here is a factor, a factor solve where you can actually get your turbine running by, by these many generator generators, these are generators creating enough current to turn a master turbine through a little power source without a dam or without solar energy. And I spent, often on many years in college, in trying to get this for an answer, it can, it's a briefing like this is an explanation for how when the generators spin and they have a motor there that spins, one of the generators gets, it feeds the motor which can turn runs a little serious in these generator and once it gets going and it has a lower part where you can start to get it going. And here is the big time generator bringing you all the juice you want by, by when you get this chain, chain of, chain, the chain to spin this generator, when you spin it, it creates the current. Now this is the series of motors and generators is run turns into perpetual motion for you once you start it by spinning a generator to get the motor going and then when the motor gets going, it turns a series and one of the series generators brings back electricity to the motor when it keeps it going. And so that's, it's better giving a river bad at all. So when a hydro nuclear power plant starts to wear down and they need to store water and they need another source of electricity. If I was to remove trees and replant them somewhere else in the land that I bought I would do it for the name of the tree, the nature of the tree and all this here. I put a new one in this place in the house and the street look a little farther apart from their normal wooded big tree taking up and making it a happy hollow for Batman and Rob and the beginning mechanics. I can see you that's probably a little more. So can I come up and log this up here a whole lot of social problems. If I do it my way me, my way is I remove the tree and I take care of the tree and I pay them like $400 towards their rent if I had a money. Peter is currently living in a shelter for mentally ill and homeless people. While he is disconnected from many aspects of reality you will see that he remains aware of issues of social interaction. Note the loose associations in his cognitive behavior. I need to rest in my machine. I was thinking I want to see all these things. I wonder what people do for things. To know a town better what proficiency has gone on the pre-law and some such things and wonder what it would be like if I had about 11 encounters of social activity in my life for 41 years. I treat them like champagne. I am authentic. But I need to find something more around them. I am actually being injured by crotch but I thought it was possible but I thought the social therapy is something I never studied. And what kind of clinics have? Things like that. And I said when I was just pizza, I will get a girlfriend. Come on to her. Start talking and maybe get some more. It takes longer to get here. I need to wash my hair too. I am not a best comedian but I am at the same time. Peter has a beer and I will probably be staying in the organ most of my life. I want to hit that mic. So any comments about that? I will just have a question. Do they find that the disorganized subtype is more prone to violent crime? No. I don't know what the associations are between crime rates and different subtypes of schizophrenia. The general public has a perception of mental illness in general especially schizophrenia as being an illness that has a lot of criminal behavior, a lot of homicidal behavior, violent behavior. The prevalence is really not that much different. I don't think. How are they familiar with their sexual needs? They are more prone to rape. First of all, rape is not a crime that involves sexual. People don't rape because they want to have sex. It's a whole different motivation based on power relationships. I just don't know the data. It would be interesting to see that. I don't think there probably is much of a difference. The third clip is a fellow named Isador. Isador has a form of schizophrenia called the undifferentiated subtype. This subtype is kind of a catch-all subtype for behaviors that don't seem to fit any of the individual subtypes. Of course, we talked about the idea that the subtypes in general really aren't that useful. This will give you another view into a different form of behavior. Isador has been diagnosed as suffering from undifferentiated schizophrenia. In this subtype, there is no distinct pattern to the individual's behavior. In the following interview, Isador describes the origins of his disorder. He explains that a stressful encounter with a supernatural may have contributed to the gradual onset of his disorder. Later in the interview, Isador describes auditory hallucinations that he experiences and describes his efforts to communicate with this unseen person. Isador is currently receiving treatment and is living on his own in a sheltered living environment. In 1931, I became sick. Before this happened, before this happened, before I was sick, I saw a vision of Jesus. It wasn't just like my own imagination. I'm convinced that was a vision because I've never been sick at all. I wanted to walk in the morning on my window and saw him. He looked like a shrapnel of children. He spoke to me and said, "I'm the way the truth and the life are." He said, "The little flock do not warn the father is really the kingdom." It was really a shock to me because I didn't experience all this when I was in my dream. I never did. It was a shock to me. I'm not saying it was a shock to me. I'm not saying it was what made me sick. I was working up every three o'clock in the night. After this, I was so out of this world in Chicago that we were flying back. Instead of no airplane flying in the air, I fell to my plane inside the ocean. That's how I felt. I was praying and tongue sometimes that in the superiors, "What are you doing?" I said, "I'm praying." I saw more going on over the place with different countries of Europe. One of them seems like this flasks. Michael Star was so low, kind of going on. The struggle is not to go to heaven, but the struggle is like taking over Earth, planet Earth. That was this big struggle now. When I came back, they put me in the hospital, not in mental hospitals, I kept with. They said, "They haven't rested, you haven't drank, you haven't eaten, all you have been doing is praying." I was in the hospital in the hospital. I was there for a whole night. When I was there, I was in a different existence. They gave me shots to make me to sleep. I couldn't sleep. I was like climbing different steps. It's like a sort of world, and they start seeing the same different existence. I gave me one step after the other, like a big building, and seeing people with colors, blue, white, yellow, and seeing different things. I was wondering, "Is this what heaven is like?" And then, I didn't know, but the next time I woke up, I was in a mental hospital. That was the greatest shock of my life. Sometimes I asked, "What is your name?" I was in a vision. It was like a dream. I was sleeping, and this is before I came in. This person was on top of me, but the body was made of gold. It's not like human body. So, we and I, we were dressed together. That's what it looked like. And then, normally, if I'm sleeping, and people knock, or do any smart enough, I wake up. My cousin said he came to my apartment, and was knocking, and knocking for a total of millions that I didn't get up. Normally, people do that, and I will wake up later. So at the end I asked this big, what is your name? Then he said my name is William. And then this up here, that was him, yeah. And I think it might be time to tell me that God wants me to do his will, yeah. I can get that light back there. Any comments on that? I'm sorry, Victor, you had a question earlier. Yeah, yeah. What would happen if he started giving the medication he needed? Would he see those as something he did that makes sense? Or would he still do it make sense of all things possible? If the medication is effective in clearing up those dissociations in his cognition, then yeah, sure. So you didn't deal with make sense of what do you do? Well, make sense of what doesn't make sense. Yeah, no, I don't think so. Yeah, no more so than you would be able to. You know, you look at what he has there and it's sort of like kind of sort of makes sense. But you know, of course the engineering is all wrong, but yeah. Yeah, yeah. Back to the other guy. So his fellow techniques I didn't think to do would be disorganized aspect of the subtype war. I don't know, no. I don't know if typically disorganized schizophrenia has problems in spelling. Typically the grammar and everything is generally okay. And so I would suspect it's education more than the disease. Yeah, but I'm not sure. That's a good question. No, no, no, I wouldn't think so. Yeah, when you're when you're in the delusion, everything is normal, but it's abnormal. Obviously, yeah. Okay, so diagnosis in schizophrenia. We talked a little bit about diagnosis last time. The DSM4 requires that the symptoms of schizophrenia be present for at least six months. And the acute symptoms have to be there for at least a month. The acute symptoms being, you know, the very immediate kinds of behavioral problems and cognitive problems that are associated with schizophrenia. It also, the DSM also says that there has to be a significant impairment in occupational, social, or occupational functioning. Occupational, social, or personal. And the interesting thing about the schizophrenia diagnosis is that if you have a major depression or manic or some sort of a mixed episode disorder, then if those have occurred concurrently with the schizophrenia symptoms, then we've got a different diagnosis for that. And also, we always rule out substance use disorders in any kind of a diagnosis of a psychological disorder. One substance use disorder that will cause symptoms like paranoid, the paranoid form of schizophrenia, is amphetamine psychosis. And fortunately, after you discontinue the amphetamines, usually the symptoms will go away, the psychotic symptoms will go away. Questions on that stuff? Okay, most of everybody's done scribbling. Now, as I said, there are some disorders that also have some of the symptoms of schizophrenia or schizophrenia like symptoms, but they fall under a different diagnosis. And mostly because the treatments for those disorders will tend to be different than the treatments for the schizophrenia disorders. And so when we make a differential diagnosis of disorders that have psychotic episodes, most disorders will have a particular diagnostic code that says, for example, major depressive disorder with psychotic features. And because it's not just schizophrenia where we can see psychosis occurring. Now, there are some particular disorders which are similar, but different than schizophrenia. Schizophrenia is where you have schizophrenia symptoms concurrent with symptoms of a mood disorder. And it requires that those schizophrenia symptoms be present for at least two weeks. And during that two week period, you can't have symptoms of the mood disorder. So if you have a major depressive disorder and the person is exhibiting schizophrenia, there has to be a period of time where for at least two weeks that they don't experience depression, but they do have symptoms of schizophrenia. Another disorder that is similar, but has a different diagnosis, is called delusional disorder. Schizophrenia, remember, has both bizarre, typically bizarre and non-bizar hallucinations that are involved or delusions. And in delusional disorder, those delusions are always non-bizar. And in schizophrenia, the impairment in social occupational or personal functioning is very global. It affects all areas of the person's life. Whereas with delusional disorder, it typically will only affect those parts of the person's life where they have delusions. So if they have delusions involving work, those impairments will typically only occur in those areas. And then brief psychotic disorder essentially is what happens if you have some sort of symptoms that match schizophrenia, but they're only around for a month at the most. And if they resolve after a month, then it's not considered schizophrenia. And the anti-psychotic drugs will generally take a few to several weeks to take effect anyway. So by the time you give somebody the anti-psychotic drugs, and they start working, the disorder will be gone. Questions on that? Okay. Where does schizophrenia come from? The current thinking is that there is some biological predisposition for schizophrenia. Strong evidence of a genetic predisposition to status from a meta-analysis by Thomas Bouchard published in 2004. And he finds that about 80% of the variance between twin pairs in whether they develop schizophrenia or not can be explained by genetics. That means that about 20% is explained by environment. And so that's this idea of the biopsychosocial model. We don't have just a biological factor. We've got the biology, the predisposition, the diathesis stress, where you've got the predisposition and the additional factors of the psychological coping and the social pressures that are involved. There's also good evidence regarding brain abnormality issues. First of all, in people with schizophrenia, when we give them autopsies after they die, the brains are consistently have lower volume of brain tissue than normals. In addition, we also see these enlarged ventricles inside the brain. The ventricles in your brain produce cerebrospinal fluid, which circulates around your brain and provides nutrients and carries waste products away. And those ventricles tend to be enlarged. They also tend to show higher levels of dopinominergic activity. And this involves receptors that are sensitive to dopamine, the neurotransmitter dopamine. So it may be that they tend to have more receptors or those receptors that exist are more active or more easily stimulated than in normals. And dopamine, remember, is the neurotransmitter that's associated with pleasure and euphoria. The fourth piece of evidence that comes in to play with brain abnormality is that negative symptoms tend to be associated with abnormal activity in the prefrontal cortex. Now again, why these things are the way they are, is it a factor that leads to the disease or some of these factors of the disease? It's really unclear. So there's a lot more research yet to be done on this stuff. So aside from the biological, then we've got the psychosocial factors. And one of the first proposals for Y schizophrenia emerges comes from Sigmund Freud. The Freud proposed that schizophrenia was caused by what he called schizophrenogenic mothers. So mothers who induced schizophrenia essentially in their children, how's that for a guilt trip, huh? And so he identified the characteristics of these mothers that they tended to be very rejecting of their children. They also were prone to regression. So the regression is the idea that you regress to an earlier stage in development when you didn't have these sexual conflicts. And he also proposed that these mothers had ego dysfunctions. So they had a difficult time managing the conflict of the id and the super ego, right? The behavioral model says that the symptoms of schizophrenia are reinforced from operant conditioning. And so the idea here is that there's a reinforcement involved in attending to stimuli that are irrelevant in your environment and disattending to relevant stimuli. So this is why people with schizophrenia, it was proposed, are out of touch with reality. They're just paying attention to the wrong things and they get some sort of reinforcement from that. The cognitive perspective says most likely these brain abnormalities that we see in the biological model are a result in this sort of bizarre perceptual experiences that people have. So the hallucinations, the delusions. And then finally the family systems model says that family systems have people in roles. And if people step out of those roles, what happens is the family system has to put them back into those roles. And so one of the psychiatrists who proposed some of these ideas was Ardi Lang. And Lang proposed that families of people with schizophrenia were actually the cause of these people's bizarre behavior. And so he published a number of books. This is probably the most relevant sanity madness in the family. And so he profiles these different families and how their family system actually encourages the development of the symptoms. So most of this stuff with the exception of the cognitive perspective is really discredited and doesn't have any real good evidence behind it, scientific evidence. So the main perspective is the idea of the biology, the biological predispositions. And then the psychosocial stressors and coping that result in schizophrenia. Questions on these ideas? Let's talk about treatment. So the main, the first line sort of treatment for schizophrenia symptoms when someone comes in and they're experiencing delusions and hallucinations. First thing you have to do is try to get them back into your objective reality or your subjective reality, I guess. And the way to do that is through the use of anti-psychotic drugs. The anti-psychotic drugs work primarily from blocking dopamine and serotonin receptors. So it raises the levels of dopamine, raises the levels of serotonin. The neuroleptic class of anti-psychotics, which are sometimes also called the classical anti-psychotics, work pretty quickly. Within several weeks you've got remission of the symptoms. So that's the good part. The bad part is they have associated with them one of the side effects of tarte of dyskinesia. Tarte of dyskinesia is motor muscle control problems. So it'll oftentimes take the form of facial tics, maybe muscular tics like that. But for a long time, the neuroleptics was all we had to treat schizophrenia. And not too long ago, a newer class of anti-psychotics came on the market. The what are called the atypical anti-psychotics. And the nice thing about the atypical anti-psychotics is that there are fewer motor disturbances involved. So you don't get these strange motor movement issues. But we do see problems with weight gain on the atypical anti-psychotics. So an obesity is obviously a major consideration. You don't want to solve one disease and create another one. So and the atypical anti-psychotics work much better in treating the negative symptoms of schizophrenia. So the withdrawal and inward kind of symptoms. In addition to the anti-psychotics, cognitive behavioral therapy can work. Once someone is not any longer delusional, then you can start working with cognitive behavioral therapy to help them start developing the behaviors that they need to function well in their environment. And then there are also some newer therapies, specialized therapies for schizophrenia, which mostly involve helping people develop the life skills that they may not have developed when they were symptomatic. And then also the ability to start developing the cognitive capacities, again, that may have been disrupted during the illness. So both of these tend to work pretty well, but they're relatively new, so there's not a lot of data for them. And then, you know, the issue is that this. This is not just a disease for the individual because the family has been affected by the disorder and it has a strong effect on other people in the family. So oftentimes family therapy is used in addition to try to reintegrate the person into the family system, to try to help the family system accommodate this new person, right? And to help that person stay in treatment. One of the big problems with schizophrenia is that the tarte dyskinesia effects or the weight gain effects with the antipsychotics are really undesirable and so people will stop taking their medication once they're normal, right? So once they're not delusional anymore, it's very tempting to not want to take the medication. So it's really important for the family to help the person with medication compliance so that they don't follow off the wagon, so to speak. No, the question is once someone has had remission for a period of time from the symptoms while they're taking antipsychotics, when they stop taking antipsychotics, do they recognize that they're becoming delusional again, typically not. They, life will just seem normal to them and other objective observers will notice that their behavior is becoming more bizarre or disorganized, yeah. Plus, it kind of sneaks back in, it's not like they're stopping the medication one day and they're floridly psychotic the next. Well, we didn't get a chance to talk about mental retardation or pervasive developmental disorders. I don't have much to say about that anyway, that's not in your textbook. The only things that I will say is pervasive developmental disorders are known as the autistic spectrum disorders, because there's a wide range of symptoms that are involved from very impaired communication, very impaired social functioning, very impaired learning to people that are only mildly impaired in those areas, but may have behavioral ticks and, but otherwise, are really quite functional in the Asperger's range, for example. So it can be quite variable, the treatments, the best treatment for autism, really the only one that shows any clinical effectiveness is applied behavioral therapy or applied behavior analysis, I should say. And that is basically just operant conditioning, providing rewards when they engage in desirable behaviors and not providing rewards when they don't. And so it's really just training the person up to engage in appropriate behaviors. And there's some controversy about it, because it's unclear to what degree that will flow over into, you know, will generalize to other areas that aren't being actively trained with operant conditioning. So basically, are you just sort of training a person like you would a dog to behave the way you want them to, or is there something going on inside that's changing their cognitions? Really unclear. The treatment is also very difficult to determine what is going to work, because each individual responds very differently to different treatments for some people, for example, SSRI antidepressants helped dramatically for other people they don't do a thing, for some people, you know, cognitive therapy works for others it doesn't. So it's really quite variable and a very difficult disorder to treat. Any questions? I think you're ready for the exam. So I'll see you on Monday, study well.