CLINICAL CHARACTERISTICS OF SCHIZOPHRENIA

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Learning objectives  You must: Identify two or more clinical characteristics of schizophrenia  You should: Explain the differences between Type 1 and Type 2  You could also: Outline the difficulties when making a diagnosis

WHAT IS SCHIZOPHRENIA?  Schizophrenia is not a multiple personality  It is a psychotic disorder characterized by the loss of contact with reality  It has many different manifestations with a few shared features  Formerly referred to as: Lunacy, madness or insanity

NEUROSIS OR PSYCHOSES?  NEUROSIS  Mental health issues that fall just outside normal functioning but the individual is in touch with reality and (potentially) knows they are ill  PSYCHOSES  Mental health issues where the individual has lost touch with reality and is not on a continuum with normal mental health

Schizophrenia: Definition  The most debilitating psychosis and the closest to the layman’s definition of madness.  Kraepelin (1896) called it dementia praecox (senility of youth) because the symptoms occur fairly early on in life and result in a gradual deterioration.  Bleuler (1911) suggested that symptoms can occur later, and coined the term schizophrenia, (‘split mind’ in Greek) which symbolises the fragmentation of the sufferer's personality.  Schizophrenia exists world-wide, but its symptoms can vary from culture to culture.  Schizophrenia comprises a number of symptoms which in different combinations produce three different types of the disorder.

CLASSIFICATION  POSITIVE SYMPTOMS – TYPE 1 Distortion of normal function  NEGATIVE SYMPTOMS – TYPE 2 Lack of normal function Delusions, hallucinations, disorganised speech, under the control of an alien force, disordered thinking Apathy, no emotion, flat effect, social withdrawal, Alogia

EVALUATION  Positive symptoms Can be affected by cultural differences Tend to have greater weight when diagnosing Hard to measure objectively  Negative symptoms Start before positive ones Sometimes start years before diagnosis Less affected by cultural factors More objectively measured

DIAGNOSIS Requires two or more POSITIVE symptoms For a period of at least a month Can only be done by a psychiatrist As yet there is no physical way to diagnose Current research is looking at blood test or eye tracking

Schizophrenia onset Source: CIHI (2001)

Symptoms of Schizophrenia First Rank Symptoms  In Britain, schizophrenia is only diagnosed in the presence of one of the following ‘first rank’ symptoms (disturbances of subjective experience as reported verbally by the individual). 1) Disturbance of thought: the belief that thoughts are being inserted into the individual’s mind from outside (thought insertion) or removed from their mind by external forces (thought withdrawal), or that their thoughts are being made known to others (thought broadcasting). 2) Hallucinations (the experience of sensory stimuli which are not present)  Auditory (the most common). ‘Voices’: offer a commentary on the individual's behaviour "he is eating his dinner";  make disparaging remarks about him "he eats like a pig ";give him commands "put the knife on the plate".  ‘Voices’ may be a distortion of environmental noises (fridge or radiator noises interpreted as whispering) or projections of the individual's own thoughts (thoughts may enter the individual’s internal speech loop or even become spoken aloud without the individual realising that the thoughts / speech are his own (malfunction of the feedback loop).  Somatic e.g. experience of electric shocks to the fingertips.

Symptoms of Schizophrenia (contd) 3 ) Delusions (beliefs which individuals are firmly convinced are true, regardless of evidence to the contrary). These can come in:-  Delusions of grandeur: the individual is someone important or powerful (Christ, Napoleon).  Delusions of persecution: the individual is being conspired against/interfered with by other people or organisations (M15, the Mafia).  Delusions of reference: the individual believes that unrelated events have personal significance e.g. the words of a song refer to them personally.  Other common delusions: the belief that nothing really exists and all things are simply shadows; the belief that one has been dead for years and it is observing the world from afar.

Other Symptoms These are symptoms not classified as ‘First Rank’ but are reported by observer’s of patients’ behaviour:- Thought Process Disorder  a) Loose Association: the individual is unable to focus attention so he/she moves from one topic of thought to another in a disjointed, illogical way.  b) Word Salad: disjointed thought leads to incoherent, rambling language association e.g. ‘I am the King of Spain, the daughter and the fruit tree, blossom in Spring’.  c) Clang association: the sound of one word triggers association with another word e.g. ‘The King of Spain feels no pain in the drain of the crane’.  d) Invention of new words and combining existing words in unusual ways e.g. ‘ belly bad luck and brutal and outrageous’ to describe stomach ache.  e) Echolalia i.e. repetitive echoing of words spoken by others. Motor Symptoms  a) Catatonia: the individual stays mute and motionless in a fixed position for hours or days on end.  b) Stereotypes:the individual moves repetitively e.g. rocks to and fro.  c) Agitation: including sudden, disturbing, unpredictable gestures and grimaces for no apparent reason.

Other Symptom (contd) Emotional Disturbance  a) Blunting: apparent indifference to events which would normally provoke a strong emotional reaction.  b) Inappropriate Affect: e.g. laughing when told bad news, reacting angrily if offered a gift.  c) Flattened Affect: absence of emotional expression, speech is in monotone, no mobility of facial features, vacant gaze. Lack of Volition  Loss of interest in the external and social world. Loss of drive.  Inability to act, including inability to perform everyday living activities e.g. washing, cooking. Disordered Sense of Self  Sufferer has little idea who he / she is and has no ego- boundaries. The sufferer displays autism, and lives in a fantasy world, taking no notice of the world around them.

Types of Schizophrenia  Previously schizophrenia was classified into two types: Acute (TYPE 1) - also known as positive syndrome schizophrenia. - sudden onset, with delusions and hallucinations as early symptoms. Chronic (TYPE 11) - also known as negative syndrome schizophrenia. - insidious onset with a history of apathy and social withdrawal (loners) - worse prognosis than for acute schizophrenia.

Types of Schizophrenia (contd) Now schizophrenia is classified into four main types: Disorganised Schizophrenia: (the most severe type) onset: adolescence or early adulthood; Disorganised thought and language (loose association and word salad); Disorganised delusions and vivid hallucinations, inappropriate and flattened affect; Disorganised behaviour and extreme social withdrawal Catatonic Schizophrenia Catatonia or agitation; loss of drive; echolalia (involuntary repetition of sounds uttered by others) Paranoid Schizophrenia onset: later than other types; Well organised delusions and hallucinations; Language, behaviour and the ability to carry out daily functions remain relatively normal. Paranoid schizophrenics show the highest level of awareness! Undifferentiated Schizophrenia is a diagnosis for people with mixed symptoms who don’t fit any of the types clearly. Other related disorders include: a) Brief psychotic disorder b) Substance Induced psychotic disorder

Evaluating the Types of Schizophrenia  Although these types form the basis of current diagnostic systems, their usefulness is often questioned. Because diagnosing types of schizophrenia is extremely difficult, diagnostic reliability is dramatically reduced.  Furthermore, these sub-types have little predictive validity; that is, the diagnosis of one over another form of schizophrenia provides little information that is helpful in either treating or in predicting the course of the problems.  There is also considerable overlap among the types. For example, patients with all forms of Schizophrenia may have delusions. Kraepelin’s system of sub-typing has not proved to be a useful way of dealing with the variability in schizophrenic behaviours.

Evaluating the Types of Schizophrenia (contd)  A system that is currently attracting much attention distinguishes between positive and negative symptoms (as opposed to types of patients) continues to be used increasingly in research on the aetiology of schizophrenia.  Aetiology is defined as the science that deals with the causes or origin of disease, the factors which produce or predispose toward a certain disease or disorder. It is a medical term.  Andreasen and Olsen (1982) evaluated fifty-two patients with schizophrenia and found that sixteen could be regarded as having predominantly negative symptoms, eighteen as having predominantly positive symptoms, and eighteen as having mixed symptoms.  Although these data suggest that it is possible to talk about types of schizophrenia, subsequent research has indicate that most patients with schizophrenia show mixed symptoms (e.g. Andreasen, Flaum et al.,1990) and that very few patients fit into the pure positive or pure negative types.

The Course of Schizophrenia Patients with Schizophrenia have been seen to go through three phases/stages:- 1.Prodromal phase: Characterised by a steady deterioration including emotional flatness and loss of drive. In Type 1, this is short, in Type 11 the onset is insidious (harmful). 2.Active Phase: involves major symptoms 3.Residual Phase: when the sufferer is in remission (return to the pro- modal phase). Note:-  The three stages are not always clearly separable and the duration of each phase is variable.  A third of sufferers have one or two acute episodes (active phase) and then return to normal.  A third have periods of acute episodes and remissions (residual phase)  A third deteriorate progressively (from active to chronic symptoms) over time

PROGNOSIS  ‘Rule of the thirds’ (rule of thumb): 1/3 recover more or less completely 1/3 episodic impairment 1/3 chronic decline  With treatment about 60% of patients manage a relatively normal life  Prognosis better in non-industrialised societies

Sample question  Outline two or more clinical characteristics of schizophrenia (5 marks)  Approx 6 minutes of AO1

Outline two or more clinical characteristics of schizophrenia (5 marks)  The symptoms of schizophrenia are divided into positive and negative. Positive symptoms reflect a distortion of normal function, and include delusions (bizarre beliefs that appear real but are not), a sense of being controlled (e.g. by an alien force), auditory hallucinations (e.g. hearing voices), and disordered thinking (e.g. the belief that thoughts are being broadcast to others). Negative symptoms reflect a lessening or loss of normal function, and include affective flattening (a reduction in the range and intensity of emotional expression), alogia (poverty of speech) and avolition (the inability to initiate and persist in goal-directed behaviour). A diagnosis of schizophrenia requires at least a one-month duration of two or more positive symptoms. Negative symptoms often persist during periods of few positive symptoms.

QUIZ  What sub type is it if a person is suspicious of others or has delusions of grandeur?  What sub type is it if a person is very withdrawn and isolated with little physical movement?  What % of those diagnosed manage to lead a normal life  What is the diagnosis of schizophrenia  Is a distortion of normal function a positive or negative symptom  What is the difference between psychosis and neurosis?  What age is the onset for males?

QUIZ - answers  What sub type is it if a person is suspicious of others or has delusions of grandeur? (paranoid)  What sub type is it if a person is very withdrawn and isolated with little physical movement? (catatonic)  What % of those diagnosed manage to lead a normal life (60%)  What is the diagnosis of schizophrenia (2 or more symptoms for 1 month)  Is a distortion of normal function a positive or negative symptom (+)  What is the difference between psychosis and neurosis? (with psychosis the individual has lost touch with reality)  What age is the onset for males? (15 yrs)

Appendix (taken from Wiki) AlogiaNormal speech Q: Do you have any children? A: Yes. Q: How many? A: Two. Q: How old are they? A: Six and sixteen. Q: Are they boys or girls? A: One of each. Q: Who is the sixteen-year-old? A: The boy. Q: What is his name? A: Edmond. Q: And the girl's? A: Alice. Q: Do you have any children? A: Yes, a boy and a girl. Q: How old are they? A: Edmond is sixteen and Alice is six.

Psychosis vs. Neurosis PsychosisNeurosis SchizophreniaAnxiety disorders, panic disorders Manic depression (bipolar)Post traumatic stress Whole of personality affectedPart of personality affected Lacks insight - Does not recognise they have problem Has insight (recognizes they have a problem) Loses contact with realityRetains contact with reality No obvious cause Often begins as a response to a stressor Hallucinations and delusions Not normal behaviourExaggeration of normal behaviour Treated mainly by physical methods Treated mainly by psychological methods