M I C H E L E R I G G S L C S WJ A N U A R Y 3 , 2 0 1 5

THOUGHT DISORDERSSCHIZOPHRENIA

WHAT ARE THOUGHT DISORDERS? WHO GETS THEM AND WHY?

• In psychiatry thought disorders are a disorder of cognitive organization, characteristic of psychotic mental illness, in which thoughts and conversation appear illogical and lacking in sequence and may be bizarre and delusional in content.

• A thought disorder may be a symptom of many different mental disorders, but is most commonly associated with schizophrenia or some related psychotic disorder (Psych Central).

• About 1% of Americans have schizophrenia (NIMH).• Schizophrenia typically begins in early adulthood between the ages of 15-25. Men tend to develop

schizophrenia slightly earlier than women experiencing their symptoms between 16-25 years of age.• Women generally develop symptoms several years later with the average age of onset being recorded as 25

years of age. • Schizophrenia onset is quite rare for people under 10 or over 40 years of age, however the National

Institute of Mental Health is currently conducting a childhood-onset schizophrenia study.• 10% of people who have a first degree relative with the disorder such as a parent, brother or sister are

likely to develop the disorder. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) also develop the disorder more often than the general population (NIMH).

• The highest risk occurs in identical twins with a 40-65% chance of developing the disorder if one twin has the disorder.

• Studies continue to suggest that schizophrenia results in part when a certain gene that is key to making important brain chemicals malfunctions. Scientists think that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine and glutamate and possibly others play a role in developing schizophrenia (NIMH).

SIGNS & SYMPTOMS

• Not everyone who has schizophrenia experiences every symptom. Some people experience a few symptoms, others many. The severity of symptoms varies with each person and varies over time.

• The top 10 signs of schizophrenia are:• Delusions – A fixed, false beliefs, not amendable by logic or experience. There are a variety of types.

Delusions are most commonly persecutory, but may be somatic, grandiose, religious or nihilistic. No one type of delusion is specific to any particular disorder (such as schizophrenia).

• Hallucinations – Perceptions without external stimuli. Most are commonly auditory in nature, but may be any type. Auditory hallucinations are often voices, mumbled or distinct, they may be male or female or both and may be maladaptive in nature. Visual can be simple or complex, in or outside the field of vision and are usually normal color rather than black or white. Olfactory and gustatory generally occur together as unpleasant tastes and smells. Tactile or haptic may include any sensation, for example, an electrical sensation or the feeling of bugs on skin (formication).

• Disorganized Thinking - Inability to connect thoughts into logical sequence, becoming disorganized/fragmented.

• Agitation• Disorganized speech- Frequent derailment or incoherence, (word salads), disjointed or rambling monologs.• Grossly disorganized or catatonic behaviors• Lack of drive or initiative• Social withdrawal• Apathy• Emotional unresponsiveness

SIGNS & SYMPTOMS CONT.

• The symptoms of schizophrenia fall into 3 broad categories: Positive Symptoms, Negative Symptoms, and Cognitive Symptoms.

• Positive Symptoms include:• Hallucinations• Delusions• Disorganized Thinking• Movement Disorders• Negative Symptoms include:• Flat affect• Lack of pleasure in everyday life• Lack of ability to begin and sustain planned activities• Speaking little, even when forced to interact.• Cognitive Symptoms include:• Poor executive functioning ( the ability to understand information and use it to make decisions)• Trouble focusing or paying attention• Problems with working memory (the ability to use information immediately after learning it).

NEUROBIOLOGICAL FACTORS

• Schizophrenia is characterized by significant deficits in information processing: the multiple ability necessary for thinking, learning, and remembering.

• People with schizophrenia tend to have a variety of problems with attention, concentrating and memory. They process information much slower than others, they have difficulty discriminating important from unimportant stimuli, such as what the interpersonal partner is saying vs. voices coming from other conversations or the TV. They have problems with concentrat6ing, focusing attention, sustaining attention over time, or focusing in difficult conditions such as when under stress or when presented with a highly complex task.

• Clients also frequently have problems with memory, especially with short-term verbal memory (e.g., what someone said or told them to do) and working memory (e.g., ability to retain information on line while making a decision of solving a problem).

• Individuals with schizophrenia often seem forgetful or distracted, and they may be accused of not paying attention or not caring about important things. In fact, the real problem may be that the information is not presented in a way that adjusts for their attention problems (e.g., slowly, clearly, and with repetition) or they simply cannot remember what they did hear unless they are provided with reminders.

• People with schizophrenia have trouble with problem solving in part because they have difficulty in drawing abstractions or deducing relationships between events (cause and effect).

DSM – IV CRITERIA FOR SCHIZOPHRENIA

• Two or more symptoms, each present for a significant portion of time during a 1month period• Delusions• Hallucinations• Disorganized Speech• Grossly Disorganized or Catatonic Behavior• Negative Symptoms• Social/occupational dysfunction• Continuous signs of disturbance persist for at least 6 months

SUBTYPES

• Paranoid type:• Preoccupation with one or more delusions or frequent auditory hallucinations• None of the following are present: disorganized speech, disorganized or catatonic behavior, flat or inappropriate affect

• Disorganized type:• Disorganized speech, disorganized behavior, and flat or inappropriate affect are prominent

• Catatonic type:• Dominated by at least 2 of the following:• Motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor• Excessive motor activity• Extreme negativism (motiveless resistance to instruction or maintenance of rigid posture) or mutism• Peculiarities of voluntary movement• Echolalia or echopraxia

• Residual type:• Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior• Continuing evidence of the disturbance as indicated by the presence of negative symptoms or 2 or more symptoms in and

attenuated form

• Undifferentiated type

WHAT ABOUT SUBSTANCE ABUSE?

• It is often assumed that people with schizophrenia use substances to reduce psychotic symptoms and alleviate the sedating side effects of medications. However, the most common reasons given for use of alcohol and other drugs are to “get high” and to reduce negative affective states such as social anxiety, tension, depression, and boredom (Spencer et al., 2002).

• An extensive body of research on substance abuse and addiction in the general population indicates that critical factors in abstinence and controlled use of addictive substances include high levels of motivation to quit, the ability to exert self-control in the face of temptation (urges), cognitive and behavioral coping skills, and social supports. Unfortunately, people with schizophrenia who abuse substances often have limitations in each of these areas.

• A second issue is the profound and pervasive cognitive impairment that characterizes schizophrenia. People have multiple problems in information processing, including deficits in attention, memory, and higher-level cognitive processes, such as problem solving, abstract reasoning, and the ability to integrate situational context or previous experiences into ongoing information processing. The higher-level cognitive deficits may make it very difficult for people with schizophrenia to engage in the complex processes necessary for self-directed behavior change, the essential feature in abstaining from substances.

• Research states that schizophrenia can sometimes be “triggered” by heavy use of hallucinogenic drugs, especially LSD/ACID; but it appears that one has to have a genetic predisposition towards developing schizophrenia for this to occur.

• There is also mounting evidence that regular marijuana use increases the chance that a teenager will develop some form of psychosis, and another study reports that marijuana use can hasten the onset of psychosis by three years.

THINGS I HAVE LEARNED AND THINGS TO REMEMBER

• People with schizophrenia often do not think they are sick and therefore often will refuse medications which in turn lead to acute episodes often leading to hospitalization.

• People also have their own perceptions and their own realities and that…is their reality and often times no amount of trying to “make them see things from your perspective” will change their perception because, just as your reality and mine are ours…theirs is theirs. It is paramount that we meet these client’s where they are at. That doesn’t mean you have to say “sure John, you’re right, you don’t need your diabetic medications because indeed God has healed you”. No, what that means is that you assess for safety, you treat them with respect and kindness and try to wrap them tightly in services to help them remain safe and independent in their communities.

• I had heard from staff time and time again about “behaviors” from clients, “She won’t do anything unless she can have a soda”. Well..then give her a soda. We have to remember that these are people who cannot associate cause and effect. Sure it may be a “behavior”, but it’s not like a behavior that some of us experience with people who have personality traits etc.

• I have asked people whom I have worked with about what it was like when they were a child and most cannot remember, not the way that you or I do. Fond memories that we can look back on and laugh and share with others. People who are highly acute and chronic I have found do not really remember what it was like before they became ill.

• Contrary to some beliefs, people with schizophrenia are not usually violent, in fact most crimes are not committed by people with schizophrenia. There are some symptoms that are associated with violence, such as delusions of persecution, but more times than not, the violence is done against themselves.

• People with schizophrenia attempt suicide much more often than others. About 10% (especially young adult males) die by suicide.

• People with schizophrenia are our sons, our daughters, mothers, fathers, brothers, friends, cousins. Each person who suffers is a human being and deserves respect and kindness and understanding. Everyone’s story matters!

VOICE SIMULATOR (EXPLICIT LANGUAGE)

• This is a short clip of a young man’s voices that he hears. If you are able, try to listen with head phones on so you can experience what he experiences. He reports these are the negative voices that he hears and this is his experience. Imagine having to listen to this all day, every day.

• https://www.youtube.com/watch?v=PLOybGBX3PY

• Below is a clip that Anderson Cooper did regarding voices and his experience

http://www.hlntv.com/video/2014/06/11/schizophrenic-day-cooper-cnn-hln

REFERENCES

• Cognitive Therapy of Schizophrenia: David G. Kingdon; Douglas Turkington• Social Skills Training for Schizophrenia: Alan S. Bellack; Kim T. Mueser; Susan Gingerich; Julie Agresta• National Institute of Mental Health (NIMH)• Schizophrenia.org