1. Chapter 13 Schizophrenia and Other Psychotic Disorders

2. Nature of Schizophrenia and Psychosis: An Overview
Schizophrenia vs. Psychosis
Psychosis – Broad term (e.g., hallucinations, delusions)
Schizophrenia – A type of psychosis
Psychosis and Schizophrenia are heterogeneous
Disturbed thought, emotion, behavior

3. Nature of Schizophrenia and Psychosis: History and Current Thinking
Historical Background
Benedict Morel – Introduced dementia praecox
Demence (loss of mind) precoce (early, premature)
Emil Kraepelin – Used the term dementia praecox
Focused on subtypes of schizophrenia
Eugen Bleuler – Introduced the term “schizophrenia”
“Splitting of the mind”
Impact of Early Ideas on Current Thinking
Many of Kraeplin and Bleuler’s ideas are still with us
Understanding onset and course considered important

4. Table 13.1
Table Early Figures in the History of Schizophrenia

5. Schizophrenia: The “Positive” Symptom Cluster
The Positive Symptoms
Active manifestations of abnormal behavior
Distortions of normal behavior
Delusions: The Basic Feature of Madness
Gross misrepresentations of reality
Include delusions of grandeur or persecution
Hallucinations: Auditory and/or Visual
Experience of sensory events without environmental input
Can involve all senses
Findings from SPECT studies

6. Etta

7. Schizophrenia: The “Positive” Symptom Cluster (cont.)
Figure Major areas of functioning of the cerebral cortex. In most people, only the left hemisphere is specialized for language.

8. Schizophrenia: The “Negative” Symptom Cluster
The Negative Symptoms
Absence or insufficiency of normal behavior
Spectrum of Negative Symptoms
Avolition (or apathy) – Lack of initiation and persistence
Alogia – Relative absence of speech
Anhedonia – Lack of pleasure, or indifference
Affective flattening – Little expressed emotion

9. Schizophrenia: The “Disorganized” Symptom Cluster
The Disorganized Symptoms
Include severe and excess disruptions
Speech, behavior, and emotion
Nature of Disorganized Speech
Cognitive slippage – Illogical and incoherent speech
Tangentiality – “Going off on a tangent”
Loose associations – Conversation in unrelated directions
Nature of Disorganized Affect
Inappropriate emotional behavior
Nature of Disorganized Behavior
Includes a variety of unusual behaviors
Catatonia – Spectrum
Wild agitation, waxy flexibility, immobility

10. Subtypes of Schizophrenia
Paranoid Type
Intact cognitive skills and affect
Do not show disorganized behavior
Hallucinations and delusions – Grandeur or persecution
The best prognosis of all types of schizophrenia
Disorganized Type
Marked disruptions in speech and behavior
Flat or inappropriate affect
Hallucinations and delusions – Tend to be fragmented
Develops early, tends to be chronic, lacks remissions

11. Subtypes of Schizophrenia (cont.)
Catatonic Type
Show unusual motor responses and odd mannerisms
Examples include echolalia and echopraxia
Tends to be severe and quite rare
Undifferentiated Type
Wastebasket category
Major symptoms of schizophrenia
Fail to meet criteria for another type
Residual Type
One past episode of schizophrenia
Continue to display less extreme residual symptoms

12. Other Disorders with Psychotic Features
Schizophreniform Disorder
Schizophrenic symptoms for a few months
Associated with good premorbid functioning
Most resume normal lives
Schizoaffective Disorder
Symptoms of schizophrenia and a mood disorder
Both disorders are independent of one another
Prognosis is similar for people with schizophrenia
Such persons do not tend to get better on their own

13. Other Disorders with Psychotic Features (cont.)
Delusional Disorder
Delusions that are contrary to reality
Lack other positive and negative symptoms
Types of delusions include
Erotomanic
Grandiose
Jealous
Persecutory
Somatic
Extremely rare
Better prognosis than schizophrenia

14. Additional Disorders with Psychotic Features
Brief Psychotic Disorder
One or more positive symptoms of schizophrenia
Usually precipitated by extreme stress or trauma
Tends to remit on its owns
Shared Psychotic Disorder
Delusions from one person manifest in another person
Little is known about this condition
Schizotypal Personality Disorder
May reflect a less severe form of schizophrenia

15. Classification Systems and Their Relation to Schizophrenia
Process vs. Reactive Distinction
Process – Insidious onset, biologically based, negative symptoms, poor prognosis
Reactive – Acute onset (extreme stress), notable behavioral activity, best prognosis
Good vs. Poor Premorbid Functioning in Schizophrenia
Focus on functioning prior to developing schizophrenia
No longer widely used
Type I vs. Type II Distinction
Type I – Positive symptoms, good response to medication, optimistic prognosis, and absence of intellectual impairment
Type II – Negative symptoms, poor response to medication, pessimistic prognosis, and intellectual impairments

16. Schizophrenia: Some Facts and Statistics
Onset and Prevalence of Schizophrenia worldwide
About 0.2% to 1.5% (or about 1% population)
Often develops in early adulthood
Can emerge at any time
Schizophrenia Is Generally Chronic
Most suffer with moderate-to-severe lifetime impairment
Life expectancy is slightly less than average
Schizophrenia Affects Males and Females About Equally
Females tend to have a better long-term prognosis
Onset differs between males and females
Schizophrenia has a Strong Genetic Component

17. Schizophrenia: Some Facts and Statistics (cont.)
Figure The natural history of schizophrenia: a 5-year follow-up. Copyright 1989 by Cambridge University Press. Reprinted with the permission of Cambridge University Press.

18. Causes of Schizophrenia: Findings From Genetic Research
Family Studies
Inherit a tendency for schizophrenia
Do not inherit specific forms of schizophrenia
Risk increases with genetic relatedness
Twin Studies
Monozygotic twins – Risk for schizophrenia is 48%
Fraternal (dizygotic) twins – Risk drops to 17%
Adoption Studies -- Risk for schizophrenia remains high
Cases where a biological parent has schizophrenia
Summary of Genetic Research
Risk for schizophrenia increases with genetic relatedness
Risk is transmitted independently of diagnosis
Strong genetic component does not explain everything

19. Causes of Schizophrenia: Findings From Genetic Research (cont).
Figure Risk for schizophrenia among children of twins.

20. Search for Genetic and Behavioral Markers of Schizophrenia
Genetic Markers: Linkage and Association Studies
Search for genetic markers is still inconclusive
Schizophrenia is likely to involve multiple genes
Behavioral Markers: Smooth-Pursuit Eye Movement
The procedure – Eye-tracking a moving object
Tracking deficits – Schizophrenics and their relatives

21. Causes of Schizophrenia: Neurotransmitter Influences
The Dopamine Hypothesis
Drugs that increase dopamine (agonists)
Result in schizophrenic-like behavior
Drugs that decrease dopamine (antagonists)
Reduce schizophrenic-like behavior
Examples – Neuroleptics, L-Dopa for Parkinson’s disease
Dopamine hypothesis is problematic and overly simplistic
Current theories – Emphasize many neurotransmitters

22. Causes of Schizophrenia: Neurotransmitter Influences (cont.)
Figure Some ways drugs affect neurotransmission.

23. Causes of Schizophrenia: Other Neurobiological Influences
Structural and Functional Abnormalities in the Brain
Enlarged ventricles and reduced tissue volume
Hypofrontality – Less active frontal lobes
A major dopamine pathway
Viral Infections During Early Prenatal Development
Findings are inconclusive
Conclusions About Neurobiology and Schizophrenia
Schizophrenia – Diffuse neurobiological dysregulation
Structural and functional brain abnormalities
Not unique to schizophrenia

24. Causes of Schizophrenia: Other Neurobiological Influences (cont.)
Figure Location of the cerebrospinal fluid in the human brain. This extracellular fluid surrounds and cushions the brain and spinal cord. It also fills the four interconnected cavities (cerebral ventricles) within the brain and the central canal of the spinal cord.

25. Causes of Schizophrenia: Psychological and Social Influences
The Role of Stress
May activate underlying vulnerability
May also increase risk of relapse
Family Interactions
Families – Show ineffective communication patterns
High expressed emotion – Associated with relapse
The Role of Psychological Factors
Exert only a minimal effect in producing schizophrenia

26. Cultural Differences
Figure 13.8 Cultural differences in expressed emotion (EE).

27. Medical Treatment of Schizophrenia
Historical Precursors
Development of Antipsychotic (Neuroleptic) Medications
Often the first line treatment for schizophrenia
Began in the 1950s
Most reduce or eliminate positive symptoms
Acute and permanent side effects are common
Extrapyramidal and Parkinson-like side effects
Tardive dyskinesia
Compliance with medication is often a problem
Transcranial Magnetic Stimulation
Relatively untested procedure for hallucinations

28. Schizophrenia Drug

29. Table 13.2
Table Commonly Used Antipsychotic

30. Psychosocial Treatment of Schizophrenia
Historical Precursors
Psychosocial Approaches: Overview and Goals
Behavioral (i.e., token economies) on inpatient units
Community care programs
Social and living skills training
Behavioral family therapy
Vocational rehabilitation
Psychosocial Approaches
A necessary part of medication therapy

31. Studies on Treatment
Figure Studies on treatment of schizophrenia from 1980 to 1992 (from Falloon, Brooker, & Graham-Hole, 1992).

32. Summary of Schizophrenia and Psychotic Disorders
Schizophrenia – Spectrum of Dysfunctions
Affecting cognitive, emotional, and behavioral domains
Positive, negative, and disorganized symptom clusters
DSM-IV and DSM-IV-TR
Five subtypes of schizophrenia
Includes other disorders with psychotic features
Several Bio-Psycho-Social Variables are Involved
Successful Treatment Rarely Includes Complete Recovery

33. Exploring Schizophrenia

34. Exploring Schizophrenia (cont.)

35. Exploring Schizophrenia (cont.)

36. Exploring Schizophrenia (cont.)

37. Exploring Schizophrenia (cont.)

38. Exploring Schizophrenia (cont.)

39. Exploring Schizophrenia (cont.)