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3. Schizophrenia and Other Psychotic Disorders
Dr Seddigh

4. 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

5. Differential Diagnosis
Medical/surgical/ substance-induced
Psychotic d/o due to GMC
Dementias
Delirium
Medications
Substance induced
Amphetamines
Cocaine
Withdrawal states
Hallucinogens
Alcohol
Mood disorders
Bipolar disorder
Major depression with psychotic features

6. PSYCHOSIS “Functional” disorders Mood disorders
Substance
induced
“organic” mental disorders
“Functional”
disorders
Delirium
Dementia
Amnestic d/o
Schizophrenia “spectrum” disorders

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

9. 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 but most common is auditory

10. 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

11. 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

12. Hallucinations (Positive Symptom)
False sense perception
Types
Auditory – hear something that is not there, most common hallucination
Tactile – feel something that is not there
Visual – see something that is not there, more commonly results from substance use or brain d
Olfactory/Gustatory – smell or taste something that is not there
Somatic – feels like something is going on inside the body

13. Delusions (Positive Symptom)
Fixed, false beliefs
Types
Bizarre – something that the person’s culture would view as implausible
Thought insertion – thoughts are being inserted into person’s head
Thought withdrawal – thoughts are being taken out of person’s head
Thought broadcast – thoughts are being broadcasted
Control – person is being controlled by something or someone else
Somatic – things happening to body
Grandiose – exaggeration of self

14. Disorganized Speech (Positive Symptom)
Speech that is hard to understand or follow, impairs communication
Types
Loose associations – speech goes from one place to another, but is based on some sort of association between two things
Incoherence – lacks clarity, intelligibility, relevance
Frequent derailment – gets off track, loses track of topic
Clang – speech goes from one place to another based on sounds
Neologisms – made up words

15. Disorganized Speech: Geometric Analogy
Normal: goal directed and linear
Tangential Q A A Q
Incoherence A Q
Circumlocution
Loosening of Associations A Q A Q

16. Grossly Disorganized or Catatonic Behavior (Positive Symptom)
Grossly Disorganized Behavior
Child-like silliness
Unpredictable or inappropriate behavior
Unpredictable agitation
Markedly disheveled appearance
Dresses in unusual manner
Clearly inappropriate sexual behavior
Catatonic Behavior
Stupor
Rigidity or posturing
Negativism (resistance to a person moving them)
Waxy flexibility or catalepsy (limbs remain in the position they are placed)

17. Schizophrenia
Two or more of the following, each present for a significant portion of the time during a 1-month period**
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
**Exception to the 2+ symptom requirement: only 1 psychotic symptom required if:
Delusion is bizarre
Hallucination consists of

19. 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

20. 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

21. 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

22. 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

24. 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

25. 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 decrease dopamine, L-Dopa for Parkinson’s disease increases dopamine
Dopamine hypothesis is problematic and overly simplistic
Current theories – Emphasize many neurotransmitters

27. 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 Mid-Prenatal Development
Findings are inconclusive
Conclusions About Neurobiology and Schizophrenia
Schizophrenia – Diffuse neurobiological dysregulation
Structural and functional brain abnormalities
Not unique to schizophrenia

28. Ventricular enlargement in monozygotic twin with schizophrenia
Barondes, 1993

30. 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

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

32. 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

33. 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

34. 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

35. Exploring Schizophrenia

36. Exploring Schizophrenia (cont.)

38. GOOD
LUCK