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Chapter 12

Schizophrenia and Other Psychotic Disorders

PSY 440: Abnormal Psychology

Rick GrieveWestern Kentucky University

psychotic disorderspsychotic disorders ––disorders so severe that the person has disorders so severe that the person has essentially lost touch with realityessentially lost touch with reality

schizophrenia (a psychotic disorder) is schizophrenia (a psychotic disorder) is characterized by the characterized by the disruptiondisruption of:of:

•• normal perceptual and normal perceptual and thought processthought process

•• personalitypersonality

•• affectaffect

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Nature of Schizophrenia and Psychosis: An Overview

Schizophrenia vs. PsychosisPsychosis – Broad term referring to hallucinations and/or delusions; noted in several disordersSchizophrenia – A type of psychosis with disturbed thought, language, and behavior

Historical BackgroundEmil Kraeplin – Used the term dementia praecox, “loss of the inner unity of thought, feeling , and acting”.Eugen Bleuler – Introduced the term “schizophrenia” or “splitting of the mind”; the 4 As:

Associations, Affect, Ambivalence, Autism

Nature of Schizophrenia andPsychosis: An Overview cont.)

Schneider – first rank vs. second rank symptomsContemporary practice –

Complex syndrome – heterogeneousIdentified by clusters of symptomsSeveral subtypesSeparate diagnoses that “look like” or share some of the same symptoms as schizophrenia – but are separate psychotic disorders

Schizophrenia: The “Positive” Symptom Cluster

The Positive Symptoms-Active manifestations of abnormal behavior, distortions of normal behaviorDelusions: Gross misrepresentations of reality

Persecution – “out to get me”Reference – “talking about me”Being controlled – “aliens make my body move”Grandeur – “I invented rock and roll”Typically have a “bizarre” quality – implausible, not understandable, not based on ordinary life experiences

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Schizophrenia: The “Positive”Symptom Cluster

Hallucinations: Experience of sensory events without environmental input; type of perceptual disturbance

Can involve all senses; auditory most common 70%Not unique to schizophreniaTypically hear voices

Schizophrenia: The “Negative” Symptom ClusterThe Negative Symptoms -Absence or insufficiency of normal behavior

Examples are emotional/social withdrawal, apathy, and poverty of thought/speech

Spectrum of Negative Symptoms Avolition (or apathy) – Refers to the inability to initiate and persist in activitiesAlogia – Refers to the relative absence of speech Anhedonia – Lack of pleasure, or indifference to pleasurable activitiesAffective flattening – Show little expressed emotion, but may still feel emotion

Schizophrenia: The “Negative” Symptom ClusterOther Negative Symptoms:

Cognitive deficitsPrimacy of impaired cognition

Social Withdrawal

Negative symptoms more debilitating than positive symptoms

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Schizophrenia: The “Disorganized” Symptom ClusterThe Disorganized Symptoms-Include severe and excess disruptions in speech, behavior, and emotion

Examples include rambling speech, erratic behavior, and inappropriate affect

Disorganized Speech Cognitive slippage – Refers to illogical and incoherent speechTangentiality – “Going off on a tangent” and not answering a question directly Loose associations or derailment – Taking conversation in unrelated directions

Disorganized Symptoms

Thought disorders can lead to the formation of:

Clang AssociationsPerseverationWord Salad

Schizophrenia: “Disorganized”Symptom Cluster

Nature of Disorganized AffectInappropriate emotional behavior (e.g., crying when one should be laughing)

Nature of Disorganized Behavior -includes a variety of unusual behaviors

Catatonia – Spectrum from wild agitation, waxy flexibility, to complete immobilityDifficulties performing activities of daily living

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More Disorganized Symptoms

Attentional DeficitsSocial Problems

DSM Diagnosis:Characteristic symptomsSocial/Educational/Occupational dysfunctionDurationDifferential DiagnosesRelationship with PDD

Subtypes of SchizophreniaParanoid Type

Intact cognitive skills and affect, and do not show disorganized behaviorHallucinations (auditory) and delusions center around a theme (grandeur or persecution)The best prognosis of all types of schizophrenia

Subtypes of Schizophrenia

Disorganized TypeMarked disruptions in speech and behavior, flat or inappropriate affectHallucinations and delusions have a theme, but tend to be fragmentedThis type develops early, tends to be chronic, lacks periods of remissions

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Subtypes of SchizophreniaCatatonic Type

Show unusual motor responses and odd mannerisms (e.g., echolalia, echopraxia) This subtype tends to be severe and quite rare

Waxy Catatonia

Subtypes of SchizophreniaUndifferentiated Type

Wastebasket categoryMajor symptoms of schizophrenia, but fail to meet criteria for another type

Residual TypeOne past episode of schizophreniaContinue to display less extreme residual symptoms (e.g., odd beliefs)

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Other Disorders with Psychotic Features

Schizophreniform DisorderSchizophrenic symptoms for a few monthsAssociated with good premorbidfunctioning; most resume normal lives

Schizoaffective DisorderSymptoms of both schizophrenia and a mood disorder

Other Disorders with Psychotic Features (cont.)Delusional Disorder

Delusions that are contrary to reality without other major schizophrenia symptomsMany show other negative symptoms of schizophreniaType of delusions include erotomanic, grandiose, jealous, persecutory, and somaticThis condition is extremely rare, with a better prognosis than schizophrenia

Additional Disorders with Psychotic Features

Brief Psychotic DisorderExperience one or more: delusions, hallucination, disorganized speech or grossly disorganize or catatonic behavior - positive symptoms of schizophreniaUsually precipitated by extreme stress or traumaTends to remit on its owns

Schizotypal Personality DisorderMay reflect a less severe form of schizophrenia

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Schizophrenia in Childhood

Very rareUses the same criteria as adultsHigh incidence rate of trauma

Schizophrenia: Facts and Statistics

Onset and Prevalence of SchizophreniaAbout 1% populationOnset in early adulthood, but can emerge at any time

Schizophrenia Is Generally ChronicMost suffer with lifelong moderate-to-severe impairment Life expectancy is slightly less than average

Figure 13.2Gender differences in onset of schizophrenia in a sample of 470 patients

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Schizophrenia: Facts and Statistics

Schizophrenia – Gender DifferencesFemales tend to have a better long-term prognosisOnset –males 18-25 years; females – 25-35 years & after 40Men more negative symptoms; women more affective, positive

Strong Genetic Component

Causes: Findings From Genetic Research

Family StudiesInherit a tendency for schizophrenia, not a specific form of schizophreniaOther family members are at increased risk

Twin StudiesRisk of schizophrenia in monozygotic twins is 48%Risk of schizophrenia drops to 17% for fraternal (dizygotic) twins

Adoption Studies Risk of schizophrenia remains high in adopted children with a biological parent suffering from schizophrenia

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Figure 13.6Risk for schizophrenia among children of twins

Causes:Findings From Genetic Research

Summary of Genetic ResearchRisk of schizophrenia increases as a function of genetic relatednessOne need not show symptoms of schizophrenia to pass on relevant genesSchizophrenia has a strong genetic component, but genes alone are not enough

Genetic & Behavioral Markers of Schizophrenia

The Search for Genetic Markers: Linkage and Association Studies

Search for genetic markers is still inconclusiveSchizophrenia is likely to involve multiple genes

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Causes of Schizophrenia: Neurotransmitter Influences

Neurobiology and Neurochemistry: The Dopamine Hypothesis

Drugs that increase dopamine (agonists), result in schizophrenic-like behaviorDrugs that decrease dopamine (antagonists), reduce schizophrenic-like behaviorExamples include neuroleptics and L-Dopa for Parkinson’s diseaseThe dopamine hypothesis proved problematic and overly simplisticCurrent theories emphasize several neurotransmitters and their interaction

Causes: Other Neurobiological Influences

Glutamate hypothesis

Structural and Functional Abnormalities in the Brain Enlarged ventricles and reduced tissue volumeHypofrontality – Less active frontal lobes (a major dopamine pathway)

Viral Infections During Early Prenatal Development The relation between early viral exposure and schizophrenia is inconclusive

Causes: Other Neurobiological Influences

Conclusions About Neurobiology and Schizophrenia

Schizophrenia is associated with diffuse Neurobiological DysregulationStructural and functional abnormalities in the brain are not unique to Schizophrenia

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Causes of Schizophrenia

The Role of StressMay activate underlying vulnerability and/or increase risk of relapse

Causes of Schizophrenia

Family InteractionsFamilies of people with schizophrenia show ineffective communication patterns – communication devianceHigh expressed emotion in the family is associated with relapse

The Role of Psychological Factors Psychological factors likely exert only a minimal effect in producing schizophrenia

sociocultural variablessociocultural variables•• downward drift hypothesisdownward drift hypothesis ––theory that lower social class is a theory that lower social class is a result, rather than a cause, of result, rather than a cause, of schizophreniaschizophrenia

CAUSES OF SCHIZOPHRENIACAUSES OF SCHIZOPHRENIA

ENVIRONMENTAL CONTRIBUTIONSENVIRONMENTAL CONTRIBUTIONS

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SCHIZOPHRENIA AND SOCIAL CLASS

0

10

20

30

40

50

60

Proportion

Upper Middle LowerSocial Class

General Population Patients Fathers BrothersSource : After E. M. Goldberg and S. Linda. Morrison, “Schizophrenia and Social Class.” British Journal of Psychiatry, 109 (1963); 785-802.

clinical course –specific pattern of changes in symptomatology over time

prodromal phaseactive phaseresidual phase

CLINICAL COURSECLINICAL COURSE

TYPICAL COURSES FOR SCHIZOPHRENIA

(A) CHRONICGRADUAL ONSET & VERY POOR PROGNOSISGRADUAL ONSET & VERY POOR PROGNOSIS

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TYPICAL COURSES FOR SCHIZOPHRENIA

(B) EPISODICOCCASIONAL EPISODES WITH OCCASIONAL EPISODES WITH

NEARLY NORMAL FUNCTIONING BETWEEN THEMNEARLY NORMAL FUNCTIONING BETWEEN THEM

TYPICAL COURSES FOR SCHIZOPHRENIA

(C) SINGLE EPISODEBRIEF PERIOD OF PSYCHOSIS & NEARLY BRIEF PERIOD OF PSYCHOSIS & NEARLY

COMPLETE RECOVERY WITH NO OTHER EPISODESCOMPLETE RECOVERY WITH NO OTHER EPISODES

TreatmentsNeuroleptic drugs are begun first – stabilizes and reduces symptomsPsychosocial treatments come next

Prevent relapseCompensate for skills deficitsImprove medication compliance

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Pharmacological Interventions

Antipsychotic (Neuroleptic) MedicationsMedication treatment is often the first line treatment for schizophreniaBegan in the 1950sMost reduce or eliminate the positive symptoms of schizophreniaAcute and permanent extrapyramidal and Parkinson-like side effects are commonCompliance with medication is often a problemMany people continue to experience symptoms, even with meds

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Pharmacological Interventions

CATIE

Psychosocial Treatment of Schizophrenia

Psychosocial Approaches: Overview and GoalsBehavioral (i.e., token economies) on inpatient unitsCommunity care programsSocial and living skills trainingBehavioral family therapy Vocational rehabilitation

Psychosocial Approaches Are Usually a Necessary Part of Medication TherapyCBT

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HOSPITALIZATIONHOSPITALIZATION AND BEYOND

protecting the individual and protecting the individual and othersothers

stabilizing the individualstabilizing the individualrehabilitating the individualrehabilitating the individual

TREATING SCHIZOPHRENIATREATING SCHIZOPHRENIA

References

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (Fourth Ed.). Washington, D. C.: Author.Chambless, D. L., Bryan, A. D., Aiken, L. S., Steketee, G., & Hooley, J. M. (1999). The structure of expressed emotion: A three-construct representation. Psychological Assessment, 11, 67-76.Durand, V. M., & Barlow, D. H. (2006). Essentials of abnormal psychology (4th Edition). Pacific Grove, CA: Wadsworth.Gaudiano, B. A. (2005). Cognitive behavior therapis for psychotic disorders: Current empirical status and future directions. Clinical Psychology: Research and Practice, 12, 33-50.Heinrichs, R. W. (2005). The primacy of cognition in schizophrenia. American Psychologist, 60, 229-242.

References

Morrison, J. (1995). The first interview: Revised for DSM-IV. New York: The Guilford Press.Kersting, K. (2005). Serious rehabilitation: Psychologist-developed treatments are providing hope for people with serious mental illness. APA Monitor on Psychology, 36 (1), 38-41.Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. R., Hughes, M., Eshleman, S., Wittchen, H. U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National ComorbiditySurvey. Archives of General Psychiatry, 51, 8-19.McKinney, R., & Fiedler, S. (2004). Schizophrenia: Some recent advances and implications for behavioral intervention. the Behavior Therapist, 6, 122-125.Nairne, J. S. (1999). Psychology: The adaptive mind (2nd Ed.). Albany, NY: Brooks/Cole Publishing Company.Nichols, O. T. (2005, November). Headlines in psychopharmacology. Symposium presented at the annual meeting of the Kentucky Psychological Association, Louisville, KY.