1. Abnormal Psychology, Twelfth Edition by Ann M. Kring, Sheri L. Johnson, Gerald C. Davison, & John M. Neale & John M. Neale Copyright © 2012 John Wiley & Sons, Inc. All rights reserved.

2.  Chapter 9: Schizophrenia I. Clinical Descriptions of Schizophrenia II. Etiology of Schizophrenia III. Treatment of Schizophrenia © 2012 John Wiley & Sons, Inc. All rights reserved.

3.  Major disturbances in thought, emotion, and behavior Disordered thinking Disordered thinking  Ideas not logically related  Faulty perception and attention Lack of emotional expressiveness Lack of emotional expressiveness  Inappropriate or flat emotions Disturbances in movement or behavior Disturbances in movement or behavior  Disheveled appearance  Can disrupt interpersonal relationships, diminish capacity to work or live independently  Significantly increased rates of suicide and death © 2012 John Wiley & Sons, Inc. All rights reserved.

4.  Lifetime prevalence ~1%  Affects men slightly more often than women  Onset typically late adolescence or early adulthood Men diagnosed at a slightly earlier age Men diagnosed at a slightly earlier age  Diagnosed more frequently in African Americans May reflect diagnostic bias May reflect diagnostic bias © 2012 John Wiley & Sons, Inc. All rights reserved.

5.  Two or more symptoms lasting for at least 1 month; one symptom should be 1, 2, or 3: 1) Delusions 2) Hallucinations 3) Disorganized speech 4) Abnormal psychomotor behavior (catatonia) 5) Negative symptoms (blunted affect, avolition, asociality)  Functioning in work, relationships, or self-care have declined since onset  Signs of disorder for at least 6 months; at least 1 month of the symptoms above; or, if during a prodromal or residual phase, negative symptoms or two or more of symptoms 1-4 in less severe form © 2012 John Wiley & Sons, Inc. All rights reserved.

6.  Three major clusters of symptoms: Positive Positive Negative Negative Disorganized Disorganized © 2012 John Wiley & Sons, Inc. All rights reserved.

7.  Delusions Firmly held beliefs Firmly held beliefs Contrary to reality Contrary to reality Resistant to disconfirming evidence Resistant to disconfirming evidence  Types of delusions: Persecutory delusions Persecutory delusions  “The CIA planted a listening device in my head”  65% have these Thought insertion Thought insertion Thought broadcasting Thought broadcasting Outside control Outside control Grandiose delusions Grandiose delusions Ideas of reference Ideas of reference  Hallucinations Sensory experiences in the absence of sensory stimulation Sensory experiences in the absence of sensory stimulation  Types of hallucinations: Auditory Auditory  74% have this symptom Visual Visual Hearing voices Hearing voices  Increased levels of activity in Broca’s area during hallucinations © 2012 John Wiley & Sons, Inc. All rights reserved.

8.  Avolition Lack of interest; apathy Lack of interest; apathy  Asociality Inability to form close personal relationships Inability to form close personal relationships  Anhendonia Inability to experience pleasure Inability to experience pleasure  Consummatory pleasure  Anticipatory pleasure  Blunted affect Exhibits little or no affect in face or voice Exhibits little or no affect in face or voice  Alogia Reduction in speech Reduction in speech  Can be grouped into 2 domains: Experience domain Experience domain  Motivation  Emotional experience  sociality Expression domain Expression domain  Outward expression of emotion  Vocalization © 2012 John Wiley & Sons, Inc. All rights reserved.

9.  Disorganized speech (Formal thought disorder) Incoherence Incoherence  Inability to organize ideas Loose associations (derailment) Loose associations (derailment)  Rambles, difficulty sticking to one topic  Disorganized behavior Odd or peculiar behavior Odd or peculiar behavior  Silliness, agitation, unusual dress  e.g., wearing several heavy coats in hot weather © 2012 John Wiley & Sons, Inc. All rights reserved.

10.  Catatonia Motor abnormalities Motor abnormalities Repetitive, complex gestures Repetitive, complex gestures  Usually of the fingers or hands Excitable, wild flailing of limbs Excitable, wild flailing of limbs  Catatonic immobility Maintain unusual posture for long periods of time Maintain unusual posture for long periods of time  e.g., stand on one leg  Waxy flexibility Limbs can be manipulated and posed by another person Limbs can be manipulated and posed by another person © 2012 John Wiley & Sons, Inc. All rights reserved.

12.  Schizophreniform Disorder Same symptoms as schizophrenia Same symptoms as schizophrenia Symptom duration greater than 1 month but less than 6 months Symptom duration greater than 1 month but less than 6 months  Brief Psychotic Disorder Symptom duration of 1 day to 1 month Symptom duration of 1 day to 1 month Often triggered by extreme stress, such as bereavement Often triggered by extreme stress, such as bereavement  Schizoaffective Disorder Symptoms of both schizophrenia and mood disorder Symptoms of both schizophrenia and mood disorder  DSM-5 likely to require appearance of major depressive or manic episode © 2012 John Wiley & Sons, Inc. All rights reserved.

13.  Delusional Disorder Delusions may include: Delusions may include:  Persecution  Jealousy  Being followed  Erotomania  Loved by a famous person  Somatic delusions No other symptoms of schizophrenia No other symptoms of schizophrenia  Attenuated Psychosis Syndrome Possible new category in DSM-5 Possible new category in DSM-5 © 2012 John Wiley & Sons, Inc. All rights reserved.

16.  Genetically heterogeneous Not likely that disorder caused by single gene Not likely that disorder caused by single gene  Family studies Relatives at increased risk Relatives at increased risk Negative symptoms have stronger genetic component Negative symptoms have stronger genetic component  Twin studies 44% risk for MZ twins vs. 12% risk for DZ twins 44% risk for MZ twins vs. 12% risk for DZ twins Children of non-schizophrenic MZ twin were more likely to develop schizophrenia (9.4% vs. 1% in general population) Children of non-schizophrenic MZ twin were more likely to develop schizophrenia (9.4% vs. 1% in general population)  Adoption studies Increased likelihood of developing psychotic disorders Increased likelihood of developing psychotic disorders  Familial high-risk studies Differing negative vs. positive symptomatology Differing negative vs. positive symptomatology © 2012 John Wiley & Sons, Inc. All rights reserved.

17.  Association studies Two genes associated with schizophrenia Two genes associated with schizophrenia  DTNGP1  NGR1 Two genes associated with cognitive deficits Two genes associated with cognitive deficits  COMT  BDNF  Genome-wide scans Identification of gene mutations Identification of gene mutations Several identified but results need to be replicated Several identified but results need to be replicated © 2012 John Wiley & Sons, Inc. All rights reserved.

18.  Dopamine Theory Disorder due to excess levels of dopamine Disorder due to excess levels of dopamine  Drugs that alleviate symptoms reduce dopamine activity  Amphetamines, which increase dopamine levels, can induce a psychosis  Theory revised Excess numbers of dopamine receptors or oversensitive dopamine receptors Excess numbers of dopamine receptors or oversensitive dopamine receptors Localized mainly in the mesolimbic pathway Localized mainly in the mesolimbic pathway  Mesolimbic dopamine abnormalities mainly related to positive symptoms Underactive dopamine activity in the mesocortical pathway mainly related to negative symptoms Underactive dopamine activity in the mesocortical pathway mainly related to negative symptoms © 2012 John Wiley & Sons, Inc. All rights reserved.

21.  Dopamine theory doesn’t completely explain disorder Antipsychotics block dopamine rapidly but symptom relief takes several weeks Antipsychotics block dopamine rapidly but symptom relief takes several weeks To be effective, antipsychotics must reduce dopamine activity to below normal levels To be effective, antipsychotics must reduce dopamine activity to below normal levels  Other neurotransmitters involved: Serotonin Serotonin GABA GABA Glutamate Glutamate  Medication that targets glutamate shows promise © 2012 John Wiley & Sons, Inc. All rights reserved.

22.  Enlarged ventricles Implies loss of brain cells Implies loss of brain cells Correlate with Correlate with  Poor performance on cognitive tests  Poor premorbid adjustment  Poor response to treatment © 2012 John Wiley & Sons, Inc. All rights reserved.

23.  Prefrontal Cortex Many behaviors disrupted by schizophrenia (e.g., speech, decision making) are governed by prefrontal cortex Many behaviors disrupted by schizophrenia (e.g., speech, decision making) are governed by prefrontal cortex Individuals with schizophrenia show impairments on neuropsychological tests of prefrontal cortex (e.g., memory) Individuals with schizophrenia show impairments on neuropsychological tests of prefrontal cortex (e.g., memory) Individuals with schizophrenia show low metabolic rates in prefrontal cortex Individuals with schizophrenia show low metabolic rates in prefrontal cortex  Failure to show frontal activated related to negative symptoms Disrupted communication among neurons due to loss of dendritic spines Disrupted communication among neurons due to loss of dendritic spines  Disconnection Syndrome © 2012 John Wiley & Sons, Inc. All rights reserved.

25.  Structural and functional abnormalities in temporal cortex Temporal gyrus Temporal gyrus Hippocampus Hippocampus Amygdala Amygdala Anterior cingulate Anterior cingulate  Reduced gray matter and volume evident © 2012 John Wiley & Sons, Inc. All rights reserved.

26.  Environmental Factors Damage during gestation or birth Damage during gestation or birth  Obstetrical complications rates high in patients with schizophrenia  Reduced supply of oxygen during delivery may result in loss of cortical matter Viral damage to fetal brain Viral damage to fetal brain  Presence of parasite, toxoplasma gondii, associated with 2.5x greater risk of developing schizophrenia  In Finnish study, schizophrenia rates higher when mother had flu in second trimester of pregnancy © 2012 John Wiley & Sons, Inc. All rights reserved.

27.  Developmental factors Prefrontal cortex matures in adolescence or early adulthood Prefrontal cortex matures in adolescence or early adulthood Dopamine activity also peaks in adolescence Dopamine activity also peaks in adolescence Stress activates HPA system which triggers cortisol secretion Stress activates HPA system which triggers cortisol secretion  Cortisol increases dopamine activity Excessive pruning of synaptic connections Excessive pruning of synaptic connections Use of cannabis during adolescence associated with increased risk Use of cannabis during adolescence associated with increased risk  May explain why symptoms appear in late adolescence but brain damage occurs early in life © 2012 John Wiley & Sons, Inc. All rights reserved.

28.  Reaction to stress Individuals with schizophrenia and their first-degree relatives more reactive to stress Individuals with schizophrenia and their first-degree relatives more reactive to stress  Greater decreases in positive mood and increases in negative mood  Socioeconomic status Highest rates of schizophrenia among urban poor Highest rates of schizophrenia among urban poor  Sociogenic hypothesis  Stress of poverty causes disorder  Social selection theory  Downward drift in socioeconomic status Research supports social selection Research supports social selection © 2012 John Wiley & Sons, Inc. All rights reserved.

29.  Schizophrenogenic mother Cold, domineering, conflict inducing Cold, domineering, conflict inducing No support for this theory No support for this theory  Communication deviance (CD) Hostility and poor communication Hostility and poor communication Inconclusive at this time Inconclusive at this time © 2012 John Wiley & Sons, Inc. All rights reserved.

30.  Family environment impacts relapse  Expressed Emotion (EE) Hostility, critical comments, emotional overinvolvement Hostility, critical comments, emotional overinvolvement  Bidirectional association Unusual patient thoughts → increased critical comments Unusual patient thoughts → increased critical comments Increased critical comments → unusual patient thoughts Increased critical comments → unusual patient thoughts © 2012 John Wiley & Sons, Inc. All rights reserved.

31.  Use of retrospective or “follow-back” studies  Developmental histories of children who later developed schizophrenia Lower IQ Lower IQ More often delinquent (boys) and withdrawn (girls) More often delinquent (boys) and withdrawn (girls)  Coding of home movies Poorer motor skills Poorer motor skills More expression of negative emotion More expression of negative emotion © 2012 John Wiley & Sons, Inc. All rights reserved.

32.  New Zealand study Cognitive deficits evident at early age Cognitive deficits evident at early age  Australian study Reduced gray matter volume predicted later development of psychotic disorder Reduced gray matter volume predicted later development of psychotic disorder  North American Prodrome Longitudinal Study Identified factors associated with development of psychosis Identified factors associated with development of psychosis  Having a biological relative with schizophrenia  Recent decline in functioning  High levels of pos © 2012 John Wiley & Sons, Inc. All rights reserved.

33.  First-generation antipsychotic medications (neuroleptics; 1950s) Phenothiazines (Thorazine), butyrophenones (Haldol), thioxanthenes (Navane) Phenothiazines (Thorazine), butyrophenones (Haldol), thioxanthenes (Navane)  Reduce agitation, violent behavior  Block dopamine receptors  Little effect on negative symptoms  Extrapyramidal side effects Tardive dyskinesia Tardive dyskinesia Neuroleptic malignant syndrome Neuroleptic malignant syndrome  Maintenance dosages to prevent relapse © 2012 John Wiley & Sons, Inc. All rights reserved.

34.  Second-generation antipsychotics Clozapine (Clozaril) Clozapine (Clozaril)  Impacts serotonin receptors Fewer motor side effects Fewer motor side effects Less treatment noncompliance Less treatment noncompliance Reduces relapse Reduces relapse  Side effects Can impair immune symptom functioning Can impair immune symptom functioning Seizures, dizziness, fatigue, drooling, weight gain Seizures, dizziness, fatigue, drooling, weight gain  Newer medications may improve cognitive function: Olanzapine (Zyprexa) Olanzapine (Zyprexa) Risperidone (Risperdal) Risperidone (Risperdal) © 2012 John Wiley & Sons, Inc. All rights reserved.

36.  Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study Second-generation drugs were not more effective than the older, first-generation drug Second-generation drugs were not more effective than the older, first-generation drug Second-generation drugs did not produce fewer unpleasant side effects Second-generation drugs did not produce fewer unpleasant side effects Nearly three-quarters stopped taking the medications before study ended Nearly three-quarters stopped taking the medications before study ended  Second-generation antipsychotics have serious side effects Weight gain, diabetes, pancreatitis Weight gain, diabetes, pancreatitis  Disturbing trend for people of color: Not prescribed second generation antipsychotics Not prescribed second generation antipsychotics © 2012 John Wiley & Sons, Inc. All rights reserved.

37.  Patient Outcomes Research Team (PORT) treatment recommendation: Medication PLUS psychosocial intervention Medication PLUS psychosocial intervention  Social skills training Teach skills for managing interpersonal situations Teach skills for managing interpersonal situations  Completing a job application  Reading bus schedules  Make appointments Involves role-playing and other practice exercises, both in group and in vivo Involves role-playing and other practice exercises, both in group and in vivo © 2012 John Wiley & Sons, Inc. All rights reserved.

38.  Family therapy to reduce Expressed Emotion Educate family about causes, symptoms, and signs of relapse Educate family about causes, symptoms, and signs of relapse Stress importance of medication Stress importance of medication Help family to avoid blaming patient Help family to avoid blaming patient Improve family communication and problem-solving Improve family communication and problem-solving Encourage expanded support networks Encourage expanded support networks Instill hope Instill hope © 2012 John Wiley & Sons, Inc. All rights reserved.

39.  Cognitive behavioral therapy Recognize and challenge delusional beliefs Recognize and challenge delusional beliefs Recognize and challenge expectations associated with negative symptoms Recognize and challenge expectations associated with negative symptoms  e.g., “Nothing will make me feel better so why bother?”  Cognitive remediation training or cognitive enhancement therapy (CET) Improve attention, memory, problem solving and other cognitive-based symptoms Improve attention, memory, problem solving and other cognitive-based symptoms  Case management Multidisciplinary team to provide comprehensive services Multidisciplinary team to provide comprehensive services  Residential treatment Vocational rehabilitation Vocational rehabilitation © 2012 John Wiley & Sons, Inc. All rights reserved.

40. Copyright 2012 by John Wiley & Sons, Inc. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission of the copyright owner. © 2012 John Wiley & Sons, Inc. All rights reserved.