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Chapter 12

Schizophrenia and Other Psychotic

Disorders

Sheila K. Grant, Ph.D. Professor

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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.

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A Beautiful Mind. B

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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.

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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.

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Prevalence About 1% of the adult population in the United States is affected by schizophrenia, more than 2 million people in total.

The WHO estimates that about 24 million people worldwide suffer from schizophrenia.

Nearly 1 million people in the United States receive treatment for schizophrenia each year, with about a third of these requiring hospitalization.

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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.

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Overview of Schizophrenia

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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.

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Diagnostic Features

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Diagnostic Features People with schizophrenia show a marked decline in occupational and social functioning.

Positive symptoms -Flagrant symptoms of schizophrenia, such as hallucinations, delusions, bizarre behavior, and thought disorder.

Negative symptoms - Behavioral deficiencies associated with schizophrenia, such as social skills deficits, social withdrawal, flattened affect, poverty of speech and thought, psychomotor retardation, and failure to experience pleasure.

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Aberrant Content of Thought Schizophrenia is characterized by positive symptoms involving disturbances in thinking and expression of thoughts through coherent, meaningful speech.

Aberrant thinking may be found in both the content and form of thought.

Delusions represent disturbed content of thought.

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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)

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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.

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Filtering out extraneous stimuli. B

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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.

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A painting by a schizophrenia patient. B

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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.

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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.

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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).

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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.

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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

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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.”

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The Case of Georgiana

“Then it got out of hand, where I couldn’t control coming and going, back and forth, and in my body, out of my body, it was no longer under my control.”

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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.

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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.

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A young man diagnosed with disorganized schizophrenia.

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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.

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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.

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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.

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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.

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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.

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A person diagnosed with catatonic schizophrenia.

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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.

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Paranoid Schizophrenia. B

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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

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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.

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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.

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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

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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.

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Loss of brain tissue in adolescents with early-onset schizophrenia.

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Structural changes in the brain of a person with schizophrenia as compared

with that of a normal subject.

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PET scans of people with schizophrenia versus normals.

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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.

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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.

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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.

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Relapse rates of people with schizophrenia in high and low EE families.

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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

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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.

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From genes to vulnerabilty.

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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.

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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.

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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”.

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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.

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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.

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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.

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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.

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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.

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QUESTIONS?