Episode 9 - Schizophrenia Pt 1 & Unquiet Mind Pt 3

So part three of an unquiet mind, I forgot my book at home. I have an extra one today. Oh, thank you. Thanks. So part one kind of gave us a little bit of an overview of Kay Redfield Jameson's history and sort of progress up until the point at which she really began to show symptoms and part two really focused on the symptoms and the outcome and the effects and then the treatments and how those were working for her. So part three as the title suggests is going to be about personal relationships and the value of personal relationships in the progress and recovery of someone with someone with bipolar disorder. Okay, so what do you want to talk about terms of part three. I mentioned to the first two parts which seem about the isolated and not very happy kind of a scatter. What we're talking about this alone is that as you mentioned she got part three into a meaningful relationship. First one then obviously made a difference in that it's a stability to her so you can have the issue and eventually I think we're still part three. Yeah, she put down the dose and all that and started to realize that she's still able to really well and think well if you met with all those things and he's still being stable on some way and not by the dose and relationship. What do you think about the relationship gave her the courage or really helped her in her recovery? What specifically about at least well we can talk about her relationship with David the Air Force, the Army officer, right? What was it about that relationship do you think? Okay, so here's an interesting paradox though. She loves the hypomania which has its own form of lack of structure, regimentation but yet she seems to also love this structure and regimentation that the relationship offers. How do you resolve that paradox or am I making more of it than it needs to be made of? So we are you know we're complex organisms you know we we have paradoxes within us that aren't necessarily resolved. What do you suppose it was about the regimentation and the structure? Comforting okay right so this relationship really represented kind of a return to her life when she was younger as part of the military family with a lot of predictability, regimentation. Did you notice what she said about the curtsying? So it depends who who's doing the curtsying I guess or who's being curtsied to. So she's almost resolving this conflict she had with this orderly regimented military life and the rules and protocols she sees that there's really some there's really some advantages so she's growing up a little bit too. What what what else let's see so she goes over visits with them and then and then he dies that's a bummer. Yeah yeah yeah and but she seems to handle that pretty well doesn't she? Yeah you know you'd think that if anything that kind of a stress would yeah that might be excuse enough to stop picking medication or what what do you make out of the the outcome of his death? It wasn't particular to referring to. 159. Okay so which part specifically sticks out for you? Is it that second paragraph there? Yeah yeah yeah so because of him life went on which is really weird as if without him life wouldn't have gone on it's kind of a funny thing to say. So what is it about him? What was it about him that really shifted things for her that really changed things for her? Yeah so his security the security that she found the the steadiness the and probably I think more acceptance more importantly the acceptance of her with her disorder right you know they're there didn't there really wasn't any doubt for him that that it seemed like there wasn't much of a doubt that he would accept her although there was that weird pause right when she when she tells him about this bipolar just go get the medicine and so so in a lot of ways it could have been almost anybody who was meaningful in her life but this just it just happened to be sort of the right person at the right time when she needed that particular support. And that allows her to really continue with the treatment and to really start to recover and build a new life. Yeah, I'm sorry. Chris. [INAUDIBLE] I think she was to her kind of like a cognitive therapy kind of reason that she's handled herself so well after. And he kind of said that he's gone. She's alive because she relearned her thinking by being and those are what those are changes that are perfect. And so just because this person's got these things that she learned from her about how to operate. Interesting. Yeah. Yeah, so you're right. And a lot of ways, because the goal of cognitive behavioral therapy is to change people's cognitive responses. They really did. They really was very therapeutic like that, yeah. That his relationship provided that. I didn't talk about that. What else? So he dies and then she goes back to L.A. And then she takes this sabbatical for a year. OK, a sabbatical is basically a paid vacation during which you're expected to do some research or produce some scholarly material that you don't have the time to do when you're in the middle of teaching as an academic or in her case, clinical practice and that kind of thing. So it kind of gives you some time off to do bigger things, bigger projects. And what's that? Yeah, yeah. Yeah. Well, they're getting, unfortunately, starting to become rare in academia even. So she goes over and she talks about living at Oxford and what do you make about all that? [INAUDIBLE] Yeah. [INAUDIBLE] So it's really different from L.A. Really different from her life in L.A. And the expectations and the pressures in L.A. Now, one of the things we saw earlier in the book was it seemed like when she was in England, and this was before she was in treatment. Her life was better. She didn't seem to have the kinds of complications that she did. [INAUDIBLE] [INAUDIBLE] Yeah. Yeah. [INAUDIBLE] [INAUDIBLE] [INAUDIBLE] Mm-hm. [INAUDIBLE] [INAUDIBLE] Any ideas? [INAUDIBLE] OK. [INAUDIBLE] So they're more sort of structured. You want to elaborate on that? What do you think about that? I've got some ideas, but I want to see what you think. Well, the way people interact to each other is, I don't know what to say, more of it's normal. More formal, more hierarchical. Kind of a similar with what you do well. Yeah, so almost similar with military kind of structures. The Oxford system, she's one of the fellows and the Don, and they sit at the head table, and all the undergraduates sit below them. So in a lot of ways, she's really starting to dig this whole structure and hierarchy and stuff like that. And LA is very opposite of that. It's very egalitarian, very-- yeah, in fact, they probably despise. And in most of the United States, we don't generally like that kind of hierarchical structure. But so maybe that is partly comforting to her about one of the things that's comforting about England. Yeah, I hadn't thought about that. What else? Less frantic. [VIDEO PLAYBACK] So I'm not going to say that all of England or Scotland, everybody there that not everybody is more relaxed, maybe than she exists in LA. But yeah, there's probably is, in a lot of ways, a slower pace, things do move a little more slowly. And in academia there, there's less of the chasing after grant money that we tend to do in academia in the United States, I think. So that may have an effect, yeah. And she's not seeing patients either, which is going to make a big difference too. That's a lot of stress. Yeah, she's seen a lot of this responsibility. [VIDEO PLAYBACK] Even though she probably got it, she's so smart. It wasn't like her real field of interest. So it was less stress. Yeah. [VIDEO PLAYBACK] Obviously, yeah, you're supposed to be some stuff that you still have less stress. Because you've got to do a lot of things. Yeah. [VIDEO PLAYBACK] But she seems to do pretty well, even after sabbatical, and she travels back to LA. What else in here? Well, though she does say here that she really dreaded leaving. She said, on page 163, she talks about, my moods had held at a more even kill for longer than I could remember. My heart was newly alive, and my mind was in a glorious state. Having loped, grazed, and mulled, it's less medicated self through Oxford and St. George's. And this is going to introduce when she meets Richard Wyatt here. And that'll be her experience with Richard Wyatt. We'll comprise a good part of part four. How does-- what do you take of this guy? What's up? He's in over his head. He's in over his head, yeah, in some ways. Is he-- in what ways is he the same? In what ways is he different from David? OK. So he's got this kind of flip kind of attitude, which is very uncharacteristic, probably, of David's attitude. What else? [INAUDIBLE] OK. And how does that contrast with her relationship, for example, well, when she was married with her first husband? Was he not the hardest to be a little bit older? Well, he could have been. Is creativity in the same kind of as a point line? Yeah. but certainly her stability was better. different too. So it's a real intense contrast in a lot of ways, I think. What else? So he's not as sort of deep of a thinker, I guess, or he's not a contemplator. So he's very pragmatic. You might describe him as having his feet on the ground rather than sort of being flirty in some ways. Okay. How's that? Yeah. So maybe there are, you know, and you might think of the connection that you might see between his personality or characteristics and her fathers without, you know, if you took the mania away from her father, would he be a lot like Richard Wyatt? You don't think so? Oh, that's right. Okay. Okay. Okay. So we've got a bit of an issue coming up here. Why does she choose this guy? Because what? Proximity effect, yeah. There's something to be said for balance, yeah. Yeah. Yeah, when you have these two very intense analytical people in a relationship, and she tends toward the darker sides of moods probably, right? So, you know, that may keep, you know, if you get two people that tend to that way, maybe she's more likely to go into one of these dark moods. What else do you think about this relationship? Okay. Good. Okay. So she, you know, at this point in her progress and her therapy and her development, this may be the right person at the right time, in the same way that David was the right person at the right time. Good. I hadn't thought about that. Anything else here? So part four is pretty short. It's a very short sort of tying up some of the loose ends. And she's going to make a reference in part four to Jim Watson, who is the Watson of Watson and Crick, who discovered DNA and developed the ideas of DNA. It's interesting because he recently had to resign from the Cold Water Spring Institute, I think it's called, in New York, and Cold Harbor. Cold Spring Harbor lab, because he had made some quite offensive racist remarks about genetics and the intelligence of blacks versus whites. So I read that with a little bit of knowledge about that this guy is very, he's very outspoken, very mercurial in his temperament, very changing, very, so he's an interesting character. But anyway, anything else you want to bring up? So next class, I'll give you the assignment for your paper that you'll write for an unquiet mind. It's already actually available on the download site, if you want to download a copy now, but I'll go over it more in detail on Thursday. Wednesday, sorry. Next class, I should just say next class. 35. Why don't we, we'll talk a little bit about schizophrenia and then we'll take a break. You want to bring the room back to a classroom for a minute. Oh, there you go. Thank you. I'm not too scary. I've also, let's see, I marked your quizzes and get those back to you at the break. Give you some details about that. Okay, so, schizophrenia. Any questions or anything in particular you want to talk more about in terms of schizophrenia? Yep. Okay, so how difficult would it be for someone to fake schizophrenia? Okay, good question. Let me think about that for a few minutes. >> What else, anything else? >> It makes reference to the idea of the lines. It's probably one of the key versions of my team. Like that that I actually understand. >> Okay, go ahead. >> Okay, so the question is how well does a beautiful mind, which is movie based on the life of John Nash? How well does that movie portray schizophrenia? It's been a couple of years since I've seen that movie. I think it does generally a pretty good job. I know that it is inaccurate in a number of places. I've seen people who actually knew John Nash and knew his symptoms. And there are some liberties that are taken with the story. For example, that whole scene with the glass in the library, writing on the glass thing that never even took place at all. And it was in his dorm room, wasn't it? I can't remember. And so, maybe it was actually in the dorm room that it took place and not the library. The symptomology is relatively close. I remember blocking at a certain point toward the end of the movie. But I can't remember what it was that was giving me a problem. Generally, it's not a bad portrayal of schizophrenia. But again, as I told you before, when I use video clips in here, I generally don't like to use fictional movies because they all -- they do all have errors in them. It's just in order to keep the story interesting. Sometimes you have to modify things. But it's worth watching. And in fact, it's a good exercise to watch it and find for yourself what the errors are. Yeah. Yeah. Yeah, it's a good movie. And what else? Yeah. [ Inaudible Remark ] Yeah. So, are you asking, is there a correlation between high intelligence and the development of schizophrenia? Nope. Nope. [ Inaudible Remark ] So -- [ Inaudible Remark ] Those are probably the more interesting stories, too. Rather than the dull stories of the typical individual with schizophrenia who comes from quite impoverished environment, low socioeconomic status. But we'll talk about that as we go through. Anything else? [ Inaudible Remark ] So, what is the difference between -- how would you do a differential diagnosis between schizophrenia and other disorders that have -- do you mean delusions? [ Inaudible Remark ] Okay. Okay, yeah. We will talk a little bit about some differential diagnosis stuff. Anything else? Okay. So, let's -- as you know that I like to do -- let's talk a little bit about the history of schizophrenia. So, we go back essentially in terms of describing schizophrenia as it's currently described. Creplin, Emil Creplin, described a syndrome that he called dementia precox. And what he described in this syndrome was the idea that there was a gradual decline in intellectual functioning, but also that that decline was permanent. It wasn't as if there was a decline and then it came back up. So, rather, this real gradual and at the same time permanent decline. And on autopsy, one of the things that he found out was that these patients also exhibited some sort of premature deterioration of brain tissue. So, it was pretty clear right from the beginning that this disorder has some biological characteristics to it that are going to be important. He gets followed up by a bluer and bluer was important because he actually developed some of the ideas on how the symptoms could be classified and how you could organize the classification of the symptoms. Because one of the characteristics of schizophrenia is that it comes in a lot of different varieties and the symptoms for the different varieties are sometimes quite complex and varied. So, it's going to be difficult to treat it as one disorder. But he defined the core essence of schizophrenia as being this idea of splitting. And this splitting means that the ideas, the concepts, the thoughts you had earlier, and the associations that you had built up between those thoughts and ideas and concepts suddenly start to disappear. And what you wind up with is a lot of sort of jumbled ideas that are not really connected and whole. And so, this idea of splitting is going to be the key aspect of the name. Schizo means split. So, the idea of a split mind essentially is what schizophrenia came down to. Now, the problem with this definition is that you're going to confuse this. And in fact, it gets confused all the time in common culture, in popular culture and common parlance. Because of this idea of a split, people confuse schizophrenia with what disorder. What used to be called multiple personality disorders now called dissociative identity disorder. So, it's the splitting of these associations, not the splitting of personalities. And so, a lot of times what you'll find is somebody in the popular press or the media or a politician. I think I heard a politician say one time that their opponent had a schizophrenic approach to healthcare. They wanted it one way and they wanted it another way. And so, when you encounter that, I hope it irritates you as much as it irritates me. If it doesn't, I haven't done my job. The next important name in the history of schizophrenia is Moniz Antonio Aguas Moniz. He's a Portuguese physician. And Moniz found in the 1930s that when he went in through an operation in chimpanzees, and severed the connections of the neural tissue in the prefrontal cortex, that what he got was these chimpanzees that previously were very violent, very agitated, suddenly became very calm. And that's one of the characteristics of some people who have schizophrenia, is they have this very agitated experience. And that's one of the reasons that they will oftentimes be treated in hospitals because it's very difficult to have somebody like that at home. And so at this time, essentially all we had to do, all we could do to treat people was to put them in cages, lock them up, you know, lock them to their beds so they couldn't hurt themselves, they couldn't hurt anybody else. While Moniz decides, you know what, these kinds of behaviors are so similar to humans that have schizophrenia that maybe we could try this in humans and see if it works. And lo and behold, it does. And this will become what's known as the prefrontal lobotomy. And so essentially here's what the lobotomy does. If this is your brain, here's your cerebellum. And your limbic system is up in here with the thalamus and the hypothalamus and the hippocampus and the amygdala, well, what he did essentially was he severed this connection between the limbic system which is associated with emotion and the prefrontal cortex which is associated with higher functioning, executive functioning, right? And when they did that operation, what they found was that some of the people got better. And essentially throughout the course of the lobotomy, it came out in thirds about a third of the people who got a lobotomy was better, about a third wound up the same, there's no change, and about a third were worse off at the end. That's a pretty dismal record, even in baseball, 33% isn't too good. So but don't forget that this is really the only thing that they had to treat people with this really awful debilitating disease. And the state hospitals were in such a state of being overcrowded because of all the people who had to be hospitalized, basically for the rest of their life with this disease, that they were desperate for some kind of a treatment that would help relieve their burden. And so this guy comes along, what happens is Moniz does this thing in Portugal. And in the 1940s, fellow from the United States named Walter Freeman, will develop a way to do this operation here in the United States. And he became impatient with it because the original way that they would do this operation was that they would drill a hole in the side of your head, and then they would insert these basically like spatulas and insert them in the side of your head and then several of the connections. It was very precise, but it also required anesthesia and it was a complicated operation. You could only do one in a day, maybe two. And Walter Freeman said, "Look, there's all these people suffering in these hospitals. I want to help them." And so, in order to simplify this operation one day, he got the brilliant idea that if you, there's a very thin layer of bone between your eyeball and your brain. And in the back of your, in the back of your orbital socket, and what he decided was that maybe we could somehow get to the brain through this thin little piece of bone. And he took a couple of ice picks from home, and this is in the time when you had ice boxes, right? So every house had these ice picks, and they were usually about this long, and in a real sharp. And he found a way to do it what he called transorbital lobotomy. And the transorbital lobotomy meant that you went through the orbital socket. So he would take these ice picks, and basically you can insert them into your eye socket, and you go around to the eye, so you don't damage the eye. And then orient them so that they're resting against that thin piece of bone. And he would take a mallet, you know, like a rubber mallet or a wooden hammer, and tap up through that piece of bone. And now he had the ice pick in your brain, and he could go to work severing these connections in the prefrontal lobotomy, in the prefrontal cortex. So he developed this procedure, and it was a great hit. Because he could do like 10, 12 of these things a day, because he didn't have all the complications of surgery. So anyway, he started going around the country and demonstrating this procedure, and he actually drove in his station wagon, which he called the lobotomy bill. It's swear to God, this is, you know, as far as I can tell, I've done a lot of research on this, and it really did exist. And so he would travel around the country and demonstrate this procedure. And it was very desirable for the people who ran these institutions. And a lot of the people who got the lobotomy were the real indigent clients, the clients that didn't have someone to take care of them, and that were very poor, and these hospitals were overburdened with these poor people. Well, if a third of them got better and you could send them home, that was great. The other third actually got worse, but they just turned into vegetable, so you could send them home, too, because they weren't dangerous to anybody. So you basically got toothed. Yeah. And I love to tell this story, because it really illustrates the desperation that people in mental health were facing with this disorder that was, you know, something you couldn't, we really didn't have any treatments for it. And how lucky we are that in 1952, Henri-Libery develops the first anti-psychotic drugs, the first of which will be a chlorpromazine. And this will become the basis for the drug, which is called Thorazine. And this is the first drug that you can give to clients with schizophrenia. And you got like almost 100% would respond to the drug. And so now what we start to see is these huge warehouses of people in the 1950s are going to start emptying out over the next couple of decades. And so more and more people are going to be able to leave the hospital, go back home or go back into the community. So it, you know, I can't overstate enough the importance of this stuff, because it really changed the lives of a lot of people with schizophrenia, markedly for the better. Plus the level of treatment that they were going to get is better. Yeah, it was, it was discovered. Most drug discoveries are accidental in a lot of ways, yeah. So that was one that was accidentally discovered. Questions on this? The dark side of Walter Freeman was that the transorbital lobotomy began to go out of favor, shortly right around the time of these drug developments. There were beginning to show up. For the first time, so you've been doing this for about 15 years without any kind of peer review or without any kind of review of his methods and the outcomes. And after about 15 years, people started to look up the data on his patients and look at the outcomes and they started finding out that it really didn't work for a lot of people. And so the public, the opinion in the scientific community really turned against Walter Freeman. And what he wound up doing, because he couldn't do this in hospitals anymore, but he was convinced that it was really a useful operation for people, was he started doing them privately. So he would put an ad in a paper a few weeks before he was going to be in town and he would rent, you know, like a hotel room and he would say, you know, if you have somebody with schizophrenia or behavioral problems come to my hotel and I'll evaluate the case. And so he would do these operations and some of the patients weren't even, didn't even have schizophrenia and so it just, it really, it's a real tragic story in the history of psychosurgery as if there aren't any, as if there aren't any tragic stories in the history of psychosurgery. So who's going to get schizophrenia? Well, it occurs cross-culturally. This is one of the few psychological disorders that essentially has the same symptomology regardless of culture. For example, in depression, the symptomology in East Asia tends to be more of a somatic symptomology. So people will tend to have more body aches, headaches, digestive problems. Then they do emotional disturbances like in the United States that's the primary symptom is the emotional disturbance. But in schizophrenia, the symptomology is essentially the same across cultures. But in developing countries, we tend to see a better prognosis. That is, people's quality of life in terms of recovery from the disorder. I'm sorry. Whoops. I didn't mean to hit that. Their prognosis in terms of recovery tends to be better. And that may be because of the enhanced levels of social support that typically exist in cultures which are in these developing countries. So they tend to have more extended family support, for example. Whereas in the developed countries, we tend to have these nuclear families where there isn't that extended family support network. It occurs at roughly twice the rate of the general population in individuals who are living alone. And what's causing that is not very clear. First of all, there may be less social support which we know is useful in treatment for schizophrenia. But also, if they aren't living alone, if they have a cohabitant, that cohabitant may actually take care of the individual with schizophrenia and cover for them so that they don't have to seek help or seek a diagnosis. Now, as the disorder gets worse and worse and worse, it's going to be less easy to do that. But that may be possibly two factors there. We do see a higher rate in lower socioeconomic status groups. And again, it's unclear whether there's something about the propensity of being in a lower socioeconomic status group that leads to schizophrenia like other things that are associated with that, like poverty, not eating well as a young child, environmental influences as a young child, it may be common or at least part of it is due to the idea that with schizophrenia, it's very difficult to work. It's very difficult to maintain a standard of living. And so people with schizophrenia tend to experience what's called downward social mobility. So they tend to start making less money. Their jobs tend to be less permanent, more temporary. And their socioeconomic status generally goes down anyway. [ Inaudible ] Schizophrenia treatment. Second highest medical cost treatment cost. I'm not too surprised. Although I would tend to think that the reason for that would be the drugs that they may have been using were on patent. So they were higher cost. Yeah, but I'm not sure about that. There are some anti-psychotics that are off patent now and are a lower cost. But now we're starting to shift to the atypical anti-psychotics which are still on patent. So yeah, question. [ Inaudible ] Women who do what? [ Inaudible ] Postpartum schizophrenia? No, not heard of it. Men tend to develop schizophrenia at an earlier age, late adolescence, early 20s. Women tend to catch up with the prevalence over time. So it's about equal in the general population. Women tend to emerge in women in their mid to late 20s, rather than early 20s. And as I said earlier, no, there is no strong correlation with intelligence. So it'll occur equally. It's an equal opportunity intelligence disease. Other questions about demographics? It's about four. I want to take a break until about ten after. And then we'll finish her up. Okay, we're back. Let's talk about diagnosing schizophrenia. First of all, schizophrenia has two broad categories of symptoms. One type of symptom is referred to as positive and the other type is referred to as negative. That doesn't have anything to do with the positive symptoms being desirable and the negative being undesirable. They're both undesirable, but it has more to do with how they exhibit themselves. And I'll talk more about those later. The primary symptom that's associated with schizophrenia and they'll differentiate it from the other disorders is the presence of both delusions and hallucinations. Hallucinations in schizophrenia typically take the form of auditory hallucinations. And so you will hear voices talking to you. And what's important about these particular auditory hallucinations that'll differentiate themselves from hallucinations that might occur in other disorders, for example, in obsessive-compulsive disorder, the obsessions will sometimes take the form of auditory hallucinations. But in schizophrenia, these auditory hallucinations will always be perceived as coming from outside the individual. So they're voices that are not the individual's interior voice, but rather external voices that are typically giving commands or denigrating the person in some way or that may involve profanity and things like that. Question? And how does this differ from somebody who's saying that's Alzheimer's? I'm not familiar with Alzheimer's. I couldn't tell you. Sorry. Yeah. Then they also need to have the presence of delusions. And delusions essentially are beliefs that are false. And you can't objectively verify them. And more importantly, those false beliefs can't be corrected by reasoning with the person. And so something like cognitive behavioral therapy isn't going to work very well with someone who's experiencing delusions. You can't talk them out of these experiences they're having. These experiences are subjectively real to the person. And the delusions will typically come in two broad categories. One that we call bizarre delusions. Bizarre delusions are delusions that are not plausible, given our objective experience of reality. For example, a common delusion will be being possessed by some sort of evil force, and oftentimes being under the influence of aliens. So these are delusions that have these really strange components to them. As contrasted to the non-bizarre, which are relatively reasonable delusions, they could happen in reality. But the likelihood of them happening is probably pretty low. So for example, here's one that is perfectly reasonable. People will have a delusion that they're being followed. And of course, you can't find the person following them, but they have this subjective experience of being followed. Or not uncommon is also that people will have a delusion that a celebrity is in love with them. And they might have to take a trip to see the celebrity consummate their love maybe, yeah. They also, the delusion, the form of the delusions will change across cultures. These basic symptomology, this basic symptomology will stay in place. But the culture will bring in its own ideas and symbols into the delusions. So the delusions will incorporate the contemporary culture. But across cultures, we see these broad symptoms occurring. These are, for the most part, considered positive symptoms, OK? In addition, we also tend to see disorganized thinking. So this idea of the split mind, the split of associations. So your thinking becomes weird, disorganized, disjointed. And also, your speaking can become disorganized. So people will engage in things like word salad, where they'll come out with a whole series of words which are totally disconnected. And they don't have any logical connection between the words. But oftentimes, there's a rhythm to them or there's some other connecting principle in these words. Ecolalia is a condition where people will sit there and continuously repeat phrases or particular sounds. And then, in addition to thinking and speaking, sometimes there are behavior problems. And so people will exhibit inappropriate responses to stimuli. Or if they're asked a question or spoken to, they might utter some sort of word that's totally inappropriate in that situation or context. As I said, those are mostly the positive symptoms. The negative symptoms have to do with basically the positive symptoms have to do with being out there, right? The patient is out there. The negative symptoms have to do with the patient withdrawing. And so what you'll oftentimes see is flattened affect. So their moods will tend to be very flat, not high, not low, just constant flat. Alogia, so sometimes they will stop speaking for time periods. But they also sometimes will have, there's a form of schizophrenia, catatonic, which has catatonia as one of the characteristics, and that's actually a period where someone will stop speaking, they'll stop becoming responsive, they'll stop moving, very disturbing. And then, avalition basically, they stop having motivation to do things. They will basically not have any reason to do anything. It's almost like depression. Alogia is people stop speaking. It doesn't seem to be a problem with, for example, the brain area is related to speech production, but rather, they just are, for whatever reason, not speaking at all, yeah. What's the difference between that and the patient, or a person who is always speaking at the same time? Aphasia, no, aphasia has to do with not being able to, if I remember correctly, aphasia is not being able to recognize the parts of an object, or the whole object, and just seeing the parts one way or the other. I get aphasia, and there's another syndrome that I forget, that I forget the name of, that I get mixed up. Echolalia, yeah, but they tend to sit and repeat phrases and sounds. Yeah, yeah, it's not an impairment. It's not a cognitive speech production impairment, but rather a behavior that's repetitive, yeah. Yeah, it does have a lot of these sort of compulsive kinds of characteristics. In the same way that, oh, I forget what I was going to tie into that, oh, yeah, it does have a lot of that compulsive kind of characteristic to it, yeah. But the difference is going to be what, no, the knowledge of irrationality, yeah. So there's no knowledge of irrationality here, these people are delusional, yeah. Flat effect means emotion, flattened emotions, yeah, affect is another word for emotion. Psychologists like to do that. We can't ever use the common word we have to make up a new one, helps us think we're smart. So I've got three, you know, whatever gets you through the night, huh? I've got three video clips here. One shows a woman named Valerie, and Valerie has what's identified as the paranoid subtype of schizophrenia. Peter has a second subtype called disorganized and then Isidore is the third one and he has a subtype identified as undifferentiated. The subtypes in schizophrenia, the classification of the subtypes and the use of subtypes, or let's just say the usefulness of subtypes in a diagnostic system are controversial right now. A lot of people don't think the subtypes are very useful. The treatments don't differ, for example, whether someone has a paranoid subtype or a disorganized subtype. So what is really the usefulness of that diagnostic category, but that's still something that is being resolved? Anyway, hopefully these will help you kind of get an idea of what these people are experiencing. Come on, Valerie, you can do it. Okay, let's try that again. Let's try that again. Come on, Valerie. Okay. I'm going to get a faster computer. A fast one. This gets a freiniate is a psychotic disorder that involves distortions of ponds. Did you hit that light back there Rick? Thanks. I'm not sure if you can have devastating effects in all aspects of the person's life. The DSM identifies by sometimes of schizophrenia. Paranoids schizophrenia which is profound in the segment involves marked delusions either of persecution or grantor and audio hallucinations that are often believed to themes of persecution or a grantor. In this first segment she describes her early psychotic episodes and she describes her infusion and fear when she was first committed to the psychiatric hospital. I was married eight years and the last four years of marriage was getting pretty bad. And I often wondered if I had an tendency towards mental illness and the stress and strain in the marriage is what brought it out. There's nobody else in my family in the psychosis. I know my mom. I didn't get sick until about 28-29. It's a little later in the average which means I was fortunate that I would have a graduate school education. The point where I was sick but I kind of slid from reality into unreality without any real shock change. My first episode was a belief that there were people infiltrating our church and that they were trying to destroy our church community. Finally I told my husband about it and he thought that was just totally wacko. He got people in the church with the people and there was no one there doing anything submersive and then there was something wrong with my mom. The pastor agreed that they put them in the psych ward. I was just sure that the people running the psych ward weren't going to kill me. I was sure that the medicine they were giving me was poison. At one point they told me I was trying to smother my roommate with a pillow. I had no recollection of this. At some point in the average I passed out and I woke up in the isolation room straight down and I had terrible feeling of anxiety and attention that nothing seemed to relieve. It was just blood torture. Sometimes the schizophrenia caused people to become emotionally blunt and incoherate. People with paranoid schizophrenia however remain emotionally expressive and loosened. They will typically construct an intricate and complex delusions about the nature of their persecution. In the following segment no family's delusions and consider how they might have developed and how they will reinforce the vital daily experiences. That was sick. I was unable to work for a good 10, 12 years in there because they were trying different medications and some work better than others. I had been hospitalized for ten times and I had other episodes during those years of terror and fear and so forth. At this point in my life I had accepted that I was mentally ill so I went off to medicine again and I had a solution that all cars in the United States were plugged into a giant computer system that controlled where they went and how much traffic was going at any given time at any place in the country. I had this idea in my mind that if I didn't get out and drive the car for so many hours every day somebody in my family would be killed. And we had me and all people believed like me in my imaginary world had to go out and do time driving cars tying up the computer system so that these other people wouldn't die. At the time I made perfect sense. I'd get out there and drive for hours. At one point in time I drove away over to our home and I was three days without sleeping and finally I ended up in a car accident and crashed into a rock wall. It seemed very real. There was a terrible fear of death. I was really into the religious thing and I was into the concept of martyrdom and I may have to be a martyr and die for my faith because people were against me because of my beliefs. And I believe that maybe they'd be a bomb in the car and the car would blow off because they want to fill me that way or maybe they want to strangle me or they'd come to my home and drag me off somewhere and torture me. There was a lot of death and fear, just pure, raw fear. And it was just as real as me sitting here talking to you right now. My husband's drove along with me for two or three years. And towards the end I had this hallucination where I felt that I was being fired on through the TV set. My family was deeply Protestant so in my mixed-up, psychotic world it was the Catholics that put that word up, persecuting me. And in my illusion I thought that the local priest was spying on me through the TV set and if I wasn't in front of that TV set 24 hours a day they were going to come after me and drag me off and torture me. And so I finally got to a point where I decided I wouldn't have put up with this even if I hadn't done, I would get rid of that TV set and wouldn't have controlled me that way. So I took the TV set and I smashed it on the horn of the fireplace. And that was the last drop of my husband. After that he decided I was violent and he was afraid I might kill him. And so he at that point called COPS and I was taking the whole place to take care of the hospital. It's just that I run out of that house and we're still having illusions of people hiding under my bed coming up to kill me at night or at one point I felt like demons were choking me at another point. I thought I heard angels singing and that's the thing with this mental illness. You can have bad ones and you can have good ones. And then good ones, I wouldn't mind having again. When I saw Christ in heaven it was absolutely gorgeous. I was a red sky and Jesus standing there with crown on his head and his arms out spread. And it was a beautiful vision now. I talked to the preacher about it and he said it was probably because of all the medicine I was on. Paranoids gets afraid it begins to be expressed relatively later in life than other subtypes and usually does not appear until after age 25. Although Paranoids gets afraid it can be devastating. This subtype responds well to medications and it has the highest rate of recovery. In the final segment, Valerie explains that she can't recover once she was committed to a psychiatric facility that was able to sustain her medical treatment. As you watch, be sure to note the various factors that Valerie believes contributed to her recovery. I think my first start getting well was I put in damage, which was about 10 years ago. And prior to my damage experience, I began medicine and then I stopped taking it from the control room. Then everybody gave me an idea for not going off the medicine and I have another episode that I wanted to cite for you. You may try another medicine and I come home and after a while I quit taking that. It took me a long time to come to a point where I realized and accepted the fact that I was mentally ill. I really didn't mean medication just in that kind of a question. One day I came to the point where I thought that the only person I could have decent conversation with was the doctor or staff member, because everybody else knew more of the news. And they said, "Well, you know, I think you're getting better because there are many more days where I can stay at home. Without the medication I would probably still be mentally ill, but they found the medication that helped me and along with the treatment of medication I'm on. I'm looking in them half now and I find it absolutely fascinating. I love my job. It worked out because it was really great. I can't imagine looking at anything else. For you, I was a week in a regular job, like if you have a person, you get wages, I get benefits, I get medication, and I'm really really happy with what I'm doing." All I was afraid of computers, that was a part of my illness too, you know, the giant computer system tying up the cards and all that. And so I finally came to Pluton, where I realized I was going to have no more of our computer but I was going to keep my job. So I went out to the community college and started taking computer classes. And I discovered that computers are the most fascinating one-way thing, and they're not terrible, but all the scary things about to work. So a lot of my goals is to become a computer expert. I'm going to hit the light back there. So comments on that? Yep. Oh, I thought it was really funny that her husband, last year, after she wrote the TV. I won't even give that sexist comment the dignity of her response. Yes, ma'am? Where she said about the, she thought that if people in her family were going to die, she didn't do this thing, that was very, it reminded me a lot of those things. Yeah. Yeah, very, very typical of OCD, yeah. No, the treatments are entirely different, the genetic predisposition is much lower in OCD, there's very little difference, there are some similarities, but no, they're not related. I mean, as far as we know now, yeah. Well, the more that we are able to map out the human genome, the better we'll know what at least the genetic relationships might be between some of these disorders. Other questions or comments about Valerie? It seems to be doing pretty well, huh? Very good prognosis, you know, she seems to be real stable in the medication and able to hold a job, and so, you know, if you think about the general prevalence of these disorders is about 1% of the population, if you have four classes in each class as 25 people in it, it seems fairly likely, although the college population is different than the general population, it seems fairly likely you might have sat in a class with someone who has schizophrenia and is, you know, and is managing their illness. Yeah, that's true, especially for women, yeah, the onset does come later for women, typically. Although the average age, I think of credit classes here, is 26, I think, and it's 36 or all classes here, yeah. You'd be surprised, they look young, but any other questions or comments? I don't think it would be very high. I think the paranoid subtype, the onset is relatively acute and relatively severe. I don't think it's one of those that they'll be functional for a while, and then they start becoming dysfunctional. You know, like I said, they may have someone who covers for them, you know, her husband, for example, you know, before the symptoms got too bad, he was able to manage it, but, yeah, I think it's pretty unlikely that they'll be able to be functional. The delusions will just get in the way, what's that? Is there any such thing as subclinical schizophrenia? That's a good question, I don't think so. You know, there's nothing in the DSM about subclinical schizophrenia, but here's what I'll tell you, people have religious experiences. They see God, they see Jesus. Those are their subjective experiences. Those people are still functional, they're able to hold down jobs and work and everything. Is that a form of subclinical schizophrenia, maybe? But if someone is functional, then according to the DSM, as long as it's not impairing their social, occupational, or interpersonal functioning, then, you know, it's not classified as a disorder, yeah. We're getting close to quitting time, so why don't we quit there, and we'll pick up next time. Now, you're going to read, for next time, the chapter on mental retardation and pervasive developmental disorders. I'm not going to cover mental retardation in class, but I will cover autism in the pervasive developmental disorders, just so you know. And oh, the quiz, maximum eight points out of ten on that one, not ten out of ten.