1. Alice Cheng, Ph.D. University of Hartford
Ch. 12 Schizphrenia
Alice Cheng, Ph.D.
University of Hartford

2. 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.

3. 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

4. Prevalence, Onset, and Course
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

5. 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.

6. Age Distribution of Onset of Schizophrenia
Age Distribution of Onset of Schizophrenia 30
Males n=117
Females n=131 20
Percentage 10
12-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
Age group

7. 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.

8. 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.

9. Overview of Schizophrenia

10. Subtypes of Schizophrenia
Subtypes of schizophrenia include
Paranoid type
Disorganized type
Catatonic type
Undifferentiated type
Residual type

11. The Clinical Picture in Schizophrenia
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

12. 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

13. Other Psychotic Disorders
Other psychotic disorders include
Schizoaffective disorder
Schizophreniform disorder
Delusional disorder
Brief psychotic disorder
Shared psychotic disorder

14. 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.

15. Diagnostic Features

16. 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.

17. 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.

18. 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)

19. 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

20. 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”

21. 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”

22. 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.

23. A painting by a schizophrenia patient.
Paintings or drawings by schizophrenia patients often express the bizarre quality of their thought patterns.

26. This clip shows the gradual descent to psychosis, as you can see, there is a reason why the disorder is called schizo-phrenia. A

27. 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.

28. 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.

29. 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).

30. 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.

31. 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

32. 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.”

33. 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

34. 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

35. Differential diagnosis
Psychotic disorder due to a GMC/ substance use
Mood disorder w/ Psychotic Features
Delusional Disorder
Psychotic disorder NOS
Personality Disorders

36. 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.

37. 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.

38. 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.

39. 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 lose control of their bladders and bowels.

40. Catatonic Type
Catatonic type - The subtype of schizophrenia characterized by gross disturbances in motor activity, such as catatonic stupor.
People with catatonic schizophrenia may show unusual mannerisms or grimacing or maintain bizarre, apparently strenuous postures for hours, although their limbs become stiff or swollen.
A striking but less common feature is waxy flexibility, which involves adopting a fixed posture into which they have been positioned by others.

41. Paranoid Type
Paranoid type - The subtype of schizophrenia characterized by hallucinations and systematized delusions, commonly involving themes of persecution.
The behavior and speech of someone with paranoid schizophrenia does not show the marked disorganization typical of the disorganized type, nor is there a prominent display of flattened or inappropriate affect or catatonic behavior.
The delusions often involve themes of grandeur, persecution, or jealousy.

42. Type I versus Type II Schizophrenia
Type I schizophrenia is characterized by the more flagrant or positive symptoms of schizophrenia we describe earlier, such as hallucinations, delusions, and looseness of associations, as well as by an abrupt onset, preserved intellectual ability, and a more favorable response to antipsychotic medication.
Type II schizophrenia corresponds to a pattern consisting largely of the deficit or negative symptoms of schizophrenia, such as lack of emotional expression, low or absent levels of motivation, loss of ability to experience pleasure, social withdrawal, and poverty of speech, as well as by a more gradual onset, intellectual impairment, and poorer response to antipsychotic drugs.

43. Psychodynamic Perspectives
Within the psychodynamic perspective, schizophrenia represents the overwhelming of the ego by primitive sexual or aggressive drives or impulses arising from the id.
These impulses threaten the ego and give rise to intense intrapsychic conflict.
Under such a threat, the person regresses to an early period in the oral stage, referred to as primary narcissism.

44. Learning Perspectives
Although learning theory does not offer a complete explanation of schizophrenia, the development of some forms of schizophrenic behavior can be understood in terms of the principles of conditioning and observational learning.
From this perspective, people with schizophrenia learn to exhibit certain bizarre behaviors when these are more likely to be reinforced than normal behaviors.
Social-cognitive theorists suggest that modeling of schizophrenic behavior can occur within the mental hospital, where patients may begin to model themselves after fellow patients who act strangely

45. Genetic Factors
The closer the genetic relationship between schizophrenia patients and their family members, the greater the likelihood (or concordance rate) that the relatives will also have schizophrenia.
Overall, first-degree relatives of people with schizophrenia (parents, children, or siblings) have about a tenfold greater risk of developing schizophrenia than do members of the general population.
The fact that families share common environments as well as common genes requires that we dig deeper to examine the genetic underpinnings of schizophrenia.

46. The familial risk of schizophrenia.
Generally speaking, the more closely one is related to people who have developed schizophrenia, the greater the risk of developing schizophrenia for oneself.
Monozygotic (MZ) twins, whose genetic heritages are identical, are much more likely than dizygotic (DZ) twins, whose genes overlap by 50%, to be concordant for schizophrenia.

47. Causal Factors in Schizophrenia
Monozygotic twins (of schizophrenics) are much more likely to develop schizophrenia than are dizygotic twins

48. Biochemical Factors
Contemporary biological investigations of schizophrenia have focused on the role of the neurotransmitter dopamine.
The leading biochemical model of schizophrenia, the dopamine hypothesis, posits that schizophrenia involves an overreactivity of dopamine transmission in the brain.
Increasing evidence supports the view that schizophrenia involves an irregularity in dopamine transmission in the brain

49. Brain Abnormalities
We have compelling evidence of both structural changes (loss of brain tissue) and functional disturbance (abnormalities of functioning) in the brains of schizophrenia patients.
However, we have yet to discover any one source of pathology in the brain that is specific to schizophrenia or present in all cases of schizophrenia.
The most prominent finding of structural changes is the loss of brain tissue (gray matter) of about 5% on the average in schizophrenia patients as compared to normal controls.

50. Loss of brain tissue in adolescents with early-onset schizophrenia.
The brains of adolescents with early-onset schizophrenia (right image) show a substantial loss of gray matter. Some shrinkage of gray matter occurs normally during adolescence (left image), but the loss is more pronounced in adolescents with schizophrenia.

51. Structural changes in the brain of a person with schizophrenia as compared with that of a normal subject.
The magnetic resonance imaging (MRI) of the brain of a person with schizophrenia (left) shows a relatively shrunken hippocampus (yellow) and relatively enlarged, fluid-filled ventricles (white) when compared to the structures of the normal subject (right).

52. PET scans of people with schizophrenia versus normals.
Positron emission tomography (PET) scan evidence of the metabolic processes of the brain shows relatively less metabolic activity (indicated by less yellow and red) in the frontal lobes of the brains of people with schizophrenia. PET scans of the brains of four normal people are shown in the top row, and PET scans of the brains of four people with schizophrenia are shown below.

53. Biological Aspects decreased brain volume enlarged ventricles
Many brain areas are abnormal in schizophrenia including
decreased brain volume
enlarged ventricles
frontal lobe dysfunction
reduced volume of the thalamus
abnormalities in temporal lobe areas such as the hippocampus and amygdala
Abnormalities are not found in all patients

54. Causal Factors in Schizophrenia
Other factors that have been implicated in the development of schizophrenia include
prenatal exposure to the influenza virus
early nutritional deficiencies
prenatal birth complications
Current thinking emphasizes the interplay between genetic and environmental factors

55. Family Theories
An early, but since discredited theory, focused on the role of the schizophrenogenic mother (Fromm-Reichmann, 1948, 1950).
In what some feminists view as historic psychiatric sexism, the schizophrenogenic mother was described as cold, aloof, overprotective, and domineering.
She was characterized as stripping her children of self-esteem, stifling their independence, and forcing them into dependency on her.
Children reared by such mothers were believed to be at special risk for developing schizophrenia if their fathers were passive and failed to counteract the mother’s pathogenic influences.

56. Communication Deviance
Communication deviance (CD) is a pattern of unclear, vague, disruptive, or fragmented communication that is often found among parents and family members of schizophrenia patients.
CD is speech that is hard to follow and from which it is difficult to extract any shared meaning.
High CD parents often have difficulty focusing on what their children are saying.

57. Expressed Emotion
Another form of disturbed family communication, expressed emotion (EE), is a pattern of responding to the schizophrenic family member in hostile, critical, and unsupportive ways.
Schizophrenia patients from high EE families stand a higher risk of relapsing than those with low EE (more supportive) families.
High EE relatives typically show less empathy, tolerance, and flexibility than low EE relatives.

58. Relapse rates of people with schizophrenia in high and low EE families.
People with schizophrenia whose families are high in expressed emotion (EE) are at greater risk of relapse than those whose families are low in EE. Whereas low-EE families may help protect the family member with schizophrenia from environmental stressors, high-EE families may impose additional stress.

59. Family Factors in Schizophrenia: Causes or Sources of Stress?
No evidence supports the belief that family factors, such as negative family interactions, lead to schizophrenia in children who do not have a genetic vulnerability.
Rather, a genetic vulnerability to schizophrenia renders individuals more susceptible to troubled family and social relationships.
Within the diathesis–stress model, disturbed patterns of family interaction and communication represent sources of life stress that increase the risks of developing schizophrenia among people with a genetic predisposition for the disorder

60. Endophenotypes
Endophenotypes - Measurable processes or mechanisms not apparent to the naked eye, which are the means by which an organism’s genetic code comes to affect its observable characteristics or phenotypes.
Investigators are investigating a number of possible endophenotypes in schizophrenia, including disturbances in brain circuitry, deficits in working memory and cognitive abilities, and abnormalities of neurotransmitter functioning.
To better understand how schizophrenia develops, we need to dig under the surface to see how genes affect underlying processes, and how these processes in turn contribute to the development of the disorder.

61. From genes to vulnerabilty.

62. Biological Approaches
Tardive dyskinesia (TD) - A disorder characterized by involuntary movements of the face, mouth, neck, trunk, or extremities and caused by long-term use of antipsychotic medication.
Antipsychotic medication helped control the more flagrant behavior patterns of schizophrenia and reduced the need for long-term hospitalization when taken on a maintenance or continuing basis after an acute episode.
Yet for many patients with chronic schizophrenia, entering a hospital is like going through a revolving door: they are repeatedly admitted and discharged.
Many are simply discharged to the streets once they are stabilized on medication and receive little if any follow-up care.

63. Sociocultural Factors in Treatment
Ethnicity may also play a role in the family’s involvement in treatment.
In a study of 26 Asian Americans and 26 non-Hispanic White Americans with schizophrenia, family members of the Asian American patients were more frequently involved in the treatment program.
For example, family members were more likely to accompany the Asian American patients to their medication evaluation sessions.

64. Psychodynamic Therapy
Freud did not believe that traditional psychoanalysis was well suited to the treatment of schizophrenia.
The withdrawal into a fantasy world that typifies schizophrenia prevents the individual with schizophrenia from forming a meaningful relationship with the psychoanalyst.
The techniques of classical psychoanalysis, Freud wrote, must “be replaced by others; and we do not know yet whether we shall succeed in finding a substitute”.

65. Learning-Based Therapies
Therapy methods include the following:
1. Selective reinforcement of behavior, such as providing attention for appropriate behavior and extinguishing bizarre verbalizations through withdrawal of attention.
2. Token economy, in which individuals on inpatient units are rewarded for appropriate behavior with tokens, such as plastic chips, that can be exchanged for tangible reinforcers such as desirable goods or privileges.
3. Social skills training, in which clients are taught conversational skills and other appropriate social behaviors through coaching, modeling, behavior rehearsal, and feedback.

66. Psychosocial Rehabilitation
People with schizophrenia typically have difficulties functioning in social and occupational roles and performing work that depends upon basic cognitive abilities involving attention and memory.
These problems limit their ability to adjust to community life, even in the absence of overt psychotic behavior.
Recently, promising results were reported for cognitive rehabilitation training to help schizophrenia patients strengthen such basic cognitive skills as attention and memory.

67. Family Intervention Programs
Family conflicts and negative family interactions can heap stress on family members with schizophrenia, increasing the risk of recurrent episodes.
Researchers and clinicians have worked with families of people with schizophrenia to help them cope with the burdens of care and assist them in developing more cooperative, less-confrontational ways of relating to others.
In sum, no single treatment approach meets all the needs of people with schizophrenia.

68. Other Forms Of Psychosis
Brief psychotic disorder - A psychotic disorder lasting from a day to a month that often follows exposure to a major stressor.
Schizophreniform disorder - A psychotic disorder lasting less than 6 months in duration, with features that resemble schizophrenia.
Delusional disorder - A type of psychosis characterized by persistent delusions, often of a paranoid nature, that do not have the bizarre quality of the type found in paranoid schizophrenia.

69. Biological Approaches

70. Other Forms Of Psychosis
Erotomania - A delusional disorder characterized by the belief that one is loved by someone of high social status.
Schizoaffective disorder - A type of psychotic disorder in which individuals experience both severe mood disturbance and features associated with schizophrenia.

71. The End