In the 1970s a class of drug called Phenothiazine, an anti-psychotic drug started the deinstitutionalization movement. It was believed back then with the invention of this type of medication, there is no need to hospitalized patients for life, hence almost all insane asylums were shut down in the nation. Replacing them were community mental health clinics, were most patients were treated as out-patients. Things didn't work out as planned and a new problem emerged.
What is the problem I am referring to? And how do you propose to solve the problem?
Psychotic Disorders Ch. 12 Schizphrenia Alice Cheng, Ph.D. University of Hartford Schizophrenia Schizophrenia - A chronic psychotic disorder characterized by disturbed behavior, thinking, emotions, and perceptions. Acute episodes of schizophrenia are characterized by delusions, hallucinations, illogical thinking, incoherent speech, and bizarre behavior. Between acute episodes, people with schizophrenia may still be unable to think clearly, may speak in a flat tone, may have difficulty perceiving emotions in other people’s facial expressions, and may show little if any facial expressions of emotions themselves. * Schizophrenia The hallmark of schizophrenia is psychosis– a significant loss of contact with reality Schizophrenia affects people from all walks of life is about as prevalent as epilepsy usually begins in late adolescence or early adulthood 0 * Prevalence, Onset, and Course 1% among adults Mid 20-s for men, late 20-s for women (age and gender significance) Exacerbations, partial remission, chronicity 0 * Prevalence Men tend to have a slightly higher risk of developing schizophrenia than women. Women tend to develop the disorder somewhat later than men do, with onset occurring most commonly between age 25 and the mid-30s in women and between age 18 and 25 in men (APA, 2000). Women also tend to achieve a higher level of functioning before the onset of the disorder and to have a less severe course of illness than do men. * Age Distribution of Onset of Schizophrenia 30 20 10 0 12-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 Age group Percentage 0 Malesn=117 Femalesn=131 * Course of Development Schizophrenia typically develops during a person’s late teens or early 20s, a time when the brain is reaching full maturation. In about three of four cases, the first signs of schizophrenia appear by the age of 25. In some cases, the onset of the disorder is acute and occurs suddenly, within a few weeks or months. Then a rapid transformation in personality and behavior leads to an acute psychotic episode. * Course of Development Prodromal phase - In schizophrenia, the period of decline in functioning that precedes the first acute psychotic episode. Residual phase - In schizophrenia, the phase that follows an acute phase, characterized by a return to the level of functioning of the prodromal phase. These cognitive and social deficits can impede the ability of schizophrenia patients to function effectively in social and occupational roles even more severely than the severe hallucinations and delusions of the psychotic episode. * Overview of Schizophrenia * Subtypes of Schizophrenia Subtypes of schizophrenia include Paranoid type Disorganized type Catatonic type Undifferentiated type Residual type * The Clinical Picture in Schizophrenia Positive symptoms of schizophrenia reflect an excess or distortion in a normal repertoire of behavior and experience such as Delusions Hallucinations Disorganized speech Disorganized behavior These symptoms are typical of type I schizophrenia 0 * The Clinical Picture in Schizophrenia Negative symptoms reflect an absence or deficit of behaviors that are normally present Flat or blunted emotional expressiveness Alogia Avolition These symptoms are typical of type II schizophrenia, which is more difficult to treat * Other Psychotic Disorders Other psychotic disorders include Schizoaffective disorder Schizophreniform disorder Delusional disorder Brief psychotic disorder Shared psychotic disorder * Diagnostic Features Schizophrenia is a pervasive disorder that affects a wide range of psychological processes involving cognition, affect, and behavior. The DSM-IV criteria for schizophrenia require that psychotic behaviors be present at some point during the course of the disorder and that signs of the disorder be present for at least 6 months. People with briefer forms of psychosis receive other diagnoses, such as brief psychotic disorder. * Diagnostic Features * Aberrant Forms of Thought Unless we are engaged in daydreaming or purposefully letting our thoughts wander, our thoughts tend to be tightly knit together. The connections (or associations) between our thoughts tend to be logical and coherent. Thought disorder - A disturbance in thinking characterized by the breakdown of logical associations between thoughts. * Symptoms Delusions - Implausible Beliefs So it happened that witches and wizards came to live with me. They started fighting me with occultic forces. In the midst of this I decided to show them I was not afraid of them. I banged on their doors and maybe hit one of them. So the landlord and policemen came and I got locked in a cell. And here evil spirits would come near and move away. * Aberrant Content of Thought Delusions may take many forms. Some of the most common types are: • Delusions of persecution (e.g., “The CIA is out to get me”) • Delusions of reference (“People on the bus are talking about me,” or “People on TV are making fun of me,” or “The neighbors hear everything I say. They’ve put bugs in the walls of my house”) • Delusions of being controlled (believing that one’s thoughts, feelings, impulses, or actions are controlled by external forces, such as agents of the devil) • Delusions of grandeur (believing oneself to be Jesus or believing one is on a special mission, or having grand but illogical plans for saving the world) * Delusions - Thought Insertion I came to believe that a local pharmacist was tormenting me by inserting his thoughts into my head, stealing mine and inducing me to buy things I had no use for. The only way I could escape the influence of his deadly radiation was to walk a circuit a mile in diameter around his drug store and then I felt terrified and in terrible danger * Delusion of control Passivity experience Possession by demons which take control of the patient “The evil spirit gets into my hands when washing. It controls my mind. It doesn’t allow me to think about what I want to think about. It blocks my mind; holds down my mind so I am not able to reason” * Disorganized Speech Formal thought disorder Loosening of associations - can’t form sentences because they skip from A to B When the cat’s away the mice will play “If something has to do with freedom to do with something you want to do. When they’re gone you can do whatever it is. Do you want it another way? When something is injured or you have been injured, then you aren’t like you were catching mice” * Attentional Deficiencies To read this you must screen out background noises and other environmental stimuli. Attention, the ability to focus on relevant stimuli and ignore irrelevant ones, is basic to learning and thinking. People with schizophrenia often have difficulty filtering out irrelevant stimuli, making it nearly impossible for them to focus their attention, organize their thoughts, and filter out unessential information. * A painting by a schizophrenia patient. Paintings or drawings by schizophrenia patients often express the bizarre quality of their thought patterns. * This clip shows the gradual descent to psychosis, as you can see, there is a reason why the disorder is called schizo-phrenia. http://www.youtube.com/watch?v=p8MIe7_u_tA Eye Movement Dysfunction About one in three chronic schizophrenia patients shows evidence of eye movement dysfunction (Ross, 2000). Patients with this dysfunction (also called eye tracking dysfunction) have abnormal movements of the eyes when they track a moving target across their field of vision. Rather than steadily tracking the target, the eyes fall back and then catch up in a kind of jerky movement. * Abnormal Event-Related Potentials Researchers have also studied brain wave patterns, called event-related potentials, or ERPs, that occur in response to external stimuli like sounds and flashes of light. ERPs can be broken down into various components that emerge at different intervals following the presentation of a stimulus. Schizophrenia patients also show reduced levels of later-occurring ERPs. These later-occurring ERPs are believed to be involved in the process of focusing attention on a stimulus in order to extract meaningful information. * Hallucinations Hallucinations - Perceptions occurring in the absence of external stimuli that become confused with reality. Hallucinations can involve any of the senses. Auditory hallucinations (“hearing voices”) are most common, affecting about three of four schizophrenia patients. Tactile hallucinations (such as tingling, electrical, or burning sensations). Somatic hallucinations (such as feeling like snakes are crawling inside one’s belly). * Hallucinations Visual hallucinations (seeing things that are not there) Gustatory hallucinations (tasting things that are not present), Olfactory hallucinations (sensing odors that are not present) are rarer. * Hallucinations Hallucinations are not unique to schizophrenia. People with major depression and mania sometimes experience hallucinations. Nor are hallucinations invariably a sign of psychopathology. They are common and socially valued in some cultures * Emotional Disturbances Disturbances of affect or emotional response in schizophrenia may involve negative symptoms, such as a loss of normal affect or emotional expression, which is labeled blunted affect or flat affect. Flat affect is inferred from the absence of emotional expression in the face and voice. People with schizophrenia may speak in a monotone and maintain an expressionless face, or “mask.” * Disorganized Behavior Catatonia Motor immobility or excessive motor activity For example Repetitively rubbing hands for hours Lying in a strange position for hours even though it may be extremely uncomfortable * Negative Symptoms Absence of normal processes Flat emotion/affect Reduction in speech/behavior Reduction in social behavior Apathy, lack of interest Is not depression - is not anguished per se * Differential diagnosis Psychotic disorder due to a GMC/ substance use Mood disorder w/ Psychotic Features Delusional Disorder Psychotic disorder NOS Personality Disorders * Other Types of Impairment People who suffer from schizophrenia may become confused about their personal identities—the cluster of attributes and characteristics that define themselves as individuals and give meaning and direction to their lives. They may fail to recognize themselves as unique individuals and be unclear about how much of what they experience is part of themselves. In psychodynamic terms, this phenomenon is sometimes referred to as loss of ego boundaries. * Other Types of Impairment Disturbances of volition are most often seen in the residual or chronic state. People with schizophrenia may show highly excited or wild behavior or may slow to a state of stupor. People with schizophrenia also show significant impairment in interpersonal relationships. * Subtypes of Schizophrenia The DSM-IV lists three specific types of schizophrenia: disorganized, catatonic, and paranoid. People with schizophrenia who display active psychotic features, such as hallucinations, delusions, incoherent speech, or confused or disorganized behavior, but who do not meet the specifications of the other types, are considered to be of an undifferentiated type. Others who have no prominent psychotic features at the time of evaluation but have some residual features (for example, social withdrawal, peculiar behavior, blunted or inappropriate affect, strange beliefs or thoughts) would be classified as having a residual type of schizophrenia. * Disorganized Type Disorganized type - The subtype of schizophrenia characterized by disorganized behavior, bizarre delusions, and vivid hallucinations. People with disorganized schizophrenia display silliness and giddiness of mood, giggling and talking nonsensically. They often neglect their appearance and hygiene and