Chapter 14: Schizophrenia: The Most Dreaded Illness Abnormal Psychology Mar 12 & 24, 2009 Classes #17-18

Chapter 14:Chapter 14: Schizophrenia:Schizophrenia:

The Most Dreaded IllnessThe Most Dreaded Illness

Abnormal PsychologyAbnormal PsychologyMar 12 & 24, 2009Mar 12 & 24, 2009

Classes #17-18Classes #17-18

EtiologyEtiology

►Schizophrenia is a disease of the brainSchizophrenia is a disease of the brain►Changes in neurophysiological function Changes in neurophysiological function

that characterize schizophrenia have that characterize schizophrenia have been identifiedbeen identified

►Exact causes:Exact causes: UnknownUnknown

►Prevention:Prevention: UnknownUnknown

Prevalence and OnsetPrevalence and Onset

►1%1% of the general population of the general population►Onset: Onset:

Young adulthood (although late onset is Young adulthood (although late onset is possible)possible)

Risk FactorsRisk Factors

►Equal numbers of men are women are Equal numbers of men are women are diagnoseddiagnosed In men, symptoms begin earlier and are more In men, symptoms begin earlier and are more

severesevere►Rates of diagnosis differ by marital statusRates of diagnosis differ by marital status

3% of divorced or separated people3% of divorced or separated people 2% of single people2% of single people 1% of married people1% of married people

►It is unclear whether marital problems are a cause It is unclear whether marital problems are a cause or a resultor a result

Risk FactorsRisk Factors

► Rates of the disorder differ by ethnicity and Rates of the disorder differ by ethnicity and racerace About 2% of African Americans are diagnosed, About 2% of African Americans are diagnosed,

compared with 1.4% of Caucasianscompared with 1.4% of Caucasians► According to the census, however, African Americans According to the census, however, African Americans

are also more likely to be poor and to experience are also more likely to be poor and to experience marital separationmarital separation

► When controlling for these factors, rates of When controlling for these factors, rates of schizophrenia are equal for the two racial groupsschizophrenia are equal for the two racial groups

► Genetic factors appear to play a roleGenetic factors appear to play a role We’ll take a close look at the numbers laterWe’ll take a close look at the numbers later

Famous People DiagnosedFamous People Diagnosed

Nash portrayed in media: “He saw the world in a way no one could have imagined”

DSM-IV Diagnostic DSM-IV Diagnostic CriteriaCriteria

1. Individual has two or more of the following for a significant portion of time during a 1-month period (or less if successfully treated):a. Delusionsb. Hallucinationsc. Disorganized speechd. Grossly disorganized behavior or catatonic behaviore. Negative symptoms (affective flattening, alogia, or avolition)

2. Individual shows a decline in social oroccupational functioning

3. Symptoms persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that might criterion A (active-phase symptoms) and may include prodromal or residual symptoms.

4. Other psychotic disorders and medical conditions have been ruled out

DiagnosisDiagnosis

► The diagnosis of this disorder is difficult and The diagnosis of this disorder is difficult and controversial…controversial… Schizophrenia is a "diagnosis of exclusion" which Schizophrenia is a "diagnosis of exclusion" which

is made if no other psychotic disorder can account is made if no other psychotic disorder can account for the type of symptoms and their duration for the type of symptoms and their duration

► The following factors may suggest a The following factors may suggest a schizophrenia diagnosis but do not confirm it: schizophrenia diagnosis but do not confirm it: Developmental background Developmental background Genetic and family history Genetic and family history Changes from level of functioning prior to illness Changes from level of functioning prior to illness

Types of SchizophreniaTypes of Schizophrenia

►ParanoidParanoid►DisorganizedDisorganized►CatatonicCatatonic►UndifferentiatedUndifferentiated►ResidualResidual

Paranoid typeParanoid type

►Delusional thoughts of a persecution Delusional thoughts of a persecution or grandiose nature or grandiose nature

►AnxietyAnxiety►Anger Anger ►Violence Violence ►Argumentative Argumentative

Disorganized typeDisorganized type

► Incoherence (not understandable) Incoherence (not understandable) ► Regressive behavior Regressive behavior ► Flat Affect Flat Affect ► Delusions Delusions ► Hallucinations (mostly auditory)Hallucinations (mostly auditory)► Inappropriate Laughter Inappropriate Laughter ► Mannerisms Mannerisms ► Social WithdrawalSocial Withdrawal

Catatonic typeCatatonic type

► Motor disturbances Motor disturbances ► StuporStupor► Negativism Negativism ► Rigidity Rigidity ► ExcitementExcitement► May be unable to take care of personal May be unable to take care of personal

needs needs ► Decreased sensitivity to painful stimulusDecreased sensitivity to painful stimulus

Undifferentiated typeUndifferentiated type

►May have symptoms of more than one May have symptoms of more than one subtype of schizophrenia subtype of schizophrenia

Residual typeResidual type

►The prominent symptoms of the illness The prominent symptoms of the illness have abated but some features, such have abated but some features, such as hallucinations and flat affect, may as hallucinations and flat affect, may remain remain

Symptoms of Symptoms of SchizophreniaSchizophrenia

►Cognitive symptomsCognitive symptoms HallucinationsHallucinations DelusionsDelusions

►Delusions of persecutionDelusions of persecution►Delusions of referenceDelusions of reference►Delusions of identityDelusions of identity►Delusions of grandiosityDelusions of grandiosity►Delusions of thought-broadcastingDelusions of thought-broadcasting


►Cognitive symptomsCognitive symptoms Disturbed thought processesDisturbed thought processes

►Word saladWord salad►Dementia praecoxDementia praecox►Schizophrenic deficitSchizophrenic deficit

Cognitive flooding (stimulus Cognitive flooding (stimulus overload)overload)


►Mood symptomsMood symptoms DepressionDepression Inappropriate emotional responsesInappropriate emotional responses

►Physical symptomsPhysical symptoms Effects of drugsEffects of drugs Motor symptomsMotor symptoms

Copyright 2001 by Allkyn and Bacon 20

Positive and Negative Positive and Negative Symptoms of Symptoms of SchizophreniaSchizophrenia

Positive and Negative Positive and Negative Symptoms of Symptoms of SchizophreniaSchizophrenia

Schizophrenia

Positive Symptoms

Negative Symptoms• Blunted and Flat Affect • Poverty of speech (alogia)• Inability to experience positive feelings• Apathy• Inattentiveness

Psychoticism• Hallucinations• Delusions• Heightened perceptions

Disorganization• Thought disorders• Bizarre behaviors• Inappropriate affect• Loose associations• Neologisms• Clang Associations

Copyright 2001 by Allkyn and Bacon 21

Characteristics Associated with Characteristics Associated with Positive and Negative Positive and Negative

SymptomsSymptoms

Characteristics Associated with Characteristics Associated with Positive and Negative Positive and Negative

SymptomsSymptoms

Onset Later Earlier

Stability over time Symptoms fluctuate Symptoms consistentover time

Frequency of More frequent in More frequent inoccurrence women men

Response to Good Poortreatment

Characteristic Positive symptoms Negative symptomsCharacteristic Positive symptoms Negative symptoms

Issues Associated with Issues Associated with SchizophreniaSchizophrenia

►Sociocultural factorsSociocultural factors AgeAge GenderGender EthnicityEthnicity Socioeconomic classSocioeconomic class

►Downward social driftDownward social drift►Bias in diagnosisBias in diagnosis►Bias in treatmentBias in treatment►Bias in self-presentationBias in self-presentation

Explanations for Explanations for SchizophreniaSchizophrenia

►Psychodynamic explanationsPsychodynamic explanations Problems with child-rearingProblems with child-rearing StressStress

Physiological Physiological ExplanationsExplanations

► Problems with NeurotransmittersProblems with Neurotransmitters The Dopamine TheoryThe Dopamine Theory The Serotonin ExplanationThe Serotonin Explanation

►Positive symptomsPositive symptoms►Negative SymptomsNegative Symptoms

High Neurological Activity and SymptomsHigh Neurological Activity and Symptoms►Prefrontal CortexPrefrontal Cortex►Temporal CortexTemporal Cortex

► Problems with Brain Development and ActivityProblems with Brain Development and Activity► Genetic FactorsGenetic Factors► Biological TraumasBiological Traumas

Carlsson & Lindqvist (1963)Carlsson & Lindqvist (1963)

► The Dopamine TheoryThe Dopamine Theory Speculated that an abnormality in the Speculated that an abnormality in the

brain processes causes there to be an brain processes causes there to be an excess of dopamineexcess of dopamine

A high level of dopamine receptors is A high level of dopamine receptors is related to positive symptomsrelated to positive symptoms

The Dopamine ExplanationThe Dopamine Explanation

►L-dopaL-dopa Used to treat Parkinson’s patients who are Used to treat Parkinson’s patients who are

thought to have too low levels of thought to have too low levels of dopamine causing motor problemsdopamine causing motor problems

Unfortunately, although it helps with the Unfortunately, although it helps with the motor problems it also can produce motor problems it also can produce positive symptoms of schizophrenia in positive symptoms of schizophrenia in these individualsthese individuals

The Serotonin ExplanationThe Serotonin Explanation(Positive Symptoms)(Positive Symptoms)

►When serotonin levels are low, When serotonin levels are low, inhibitory neurons become inhibitory neurons become underactive and do not reduce the underactive and do not reduce the activity of the excitatory neurons activity of the excitatory neurons

►Thus, the activity of the excitatory Thus, the activity of the excitatory neurons becomes to high and we see neurons becomes to high and we see positive symptoms positive symptoms

The Serotonin ExplanationThe Serotonin Explanation(Negative Symptoms)(Negative Symptoms)

► Low levels of serotonin can contribute to Low levels of serotonin can contribute to negative symptoms of schizophrenia negative symptoms of schizophrenia because these low levels can cause because these low levels can cause depressiondepression

► The depression then provides the basis for The depression then provides the basis for the negative symptoms (apathy, poverty of the negative symptoms (apathy, poverty of thought, etc.)thought, etc.)

High Neurological Activity and High Neurological Activity and SymptomsSymptoms

►Prefrontal CortexPrefrontal Cortex This is where information from different This is where information from different

parts of the brain is integrated and where parts of the brain is integrated and where thought processes occurthought processes occur

Too much activity here causes positive Too much activity here causes positive symptoms (thought processes are symptoms (thought processes are disrupted)disrupted)

►EvidenceEvidence Pet Scans Pet Scans ““Angel Dust”Angel Dust”

High Neurological Activity High Neurological Activity and Symptomsand Symptoms

► Temporal CortexTemporal Cortex This is where memories for auditory and visual This is where memories for auditory and visual

experiences are storedexperiences are stored High activity here can activate those memories High activity here can activate those memories

and result in hallucinationsand result in hallucinations Causing people to believe that they are really Causing people to believe that they are really

hearing voiceshearing voices

High Neurological Activity High Neurological Activity and Symptomsand Symptoms

► PET scans reveal higher brain activity when PET scans reveal higher brain activity when people are hallucinating people are hallucinating

► Strong evidence linking high neurological Strong evidence linking high neurological activity in prefrontal and temporal cortexes activity in prefrontal and temporal cortexes with positive symptomswith positive symptoms

Specific neuronal circuits involving the

thalamus, caudate-putamen, anterior

cingulate, limbic cortex,

auditory cortex,

hippocampus and parahippocampal

gyrus are activated in schizophrenics

during auditory hallucinations.

Hallucinations are associated with neuronal activity

Part of Figure 60-2

Gross neuroanatomical abnormalities in schizophreniaGross neuroanatomical abnormalities in schizophrenia

Decreased cortical gray matter (not shown here)Decreased cortical gray matter (not shown here)

Unaffected twin Schizophrenic twin

Increased size of cerebral ventriclesIncreased size of cerebral ventricles

Figure 60-5

(lateral and 3rd) and decreased brain volume is the most replicated finding. Ventricular enlargement is found in affected twins of monozygotic pairs discordant for schizophrenia. This enlargement appears to be stable when patients are followed up prospectively.

Especially evident in superior temporal gyrus, dorsal prefrontal cortex and limbic areas such as the hippocampal formation and anterior cingulate cortex. These abnormalities may be present in first-episode, never-medicated patients.

Decreased numbers of neurons have been found in the hippocampus and the Decreased numbers of neurons have been found in the hippocampus and the dorsolateral prefrontal cortex. dorsolateral prefrontal cortex.

In studies of monozygotic twins discordant for schizophrenia, there is In studies of monozygotic twins discordant for schizophrenia, there is diminished activation of the dorsolateral prefrontal cortex as measured by diminished activation of the dorsolateral prefrontal cortex as measured by SPECT and PET.SPECT and PET.

Cellular neuronal abnormalities in schizophrenia (not shown Cellular neuronal abnormalities in schizophrenia (not shown here)here)

Abnormal dendridic spines Abnormal dendridic spines in prefrontal cortex- layer 3in prefrontal cortex- layer 3

Subcellular neuronal Subcellular neuronal abnormalities in abnormalities in schizophreniaschizophrenia

Unaffected

Schizophrenic #1

Schizophrenic #2

Problems with Brain Problems with Brain Development and ActivityDevelopment and Activity

► Neurodevelopmental TheoryNeurodevelopmental Theory This theory suggests that areas of the brain This theory suggests that areas of the brain

do not develop adequately and/or deteriorate do not develop adequately and/or deteriorate faster than normalfaster than normal►Proposes that a proportion Proposes that a proportion

of schizophrenia is the result of an early of schizophrenia is the result of an early brain insultbrain insult For example: difficult pregnancy, mother For example: difficult pregnancy, mother

near starvation during pregnancy, flu near starvation during pregnancy, flu during pregnancy, etc. (Mednick, 1970)during pregnancy, etc. (Mednick, 1970)


► Specific problems with brain structures Specific problems with brain structures causing negative symptomscausing negative symptoms Reversed hemispheric dominanceReversed hemispheric dominance

►For most people their left hemisphere is largerFor most people their left hemisphere is larger►Not so for many schizophrenia patientsNot so for many schizophrenia patients►Idea here is that since the left (more verbal Idea here is that since the left (more verbal

and analytical) is underdeveloped leading to and analytical) is underdeveloped leading to negative symptomsnegative symptoms


► Specific problems with brain structures Specific problems with brain structures causing negative symptomscausing negative symptoms Failure of Neural MigrationFailure of Neural Migration

► Neurons are not in right placesNeurons are not in right places► This occurs during prenatal development and briefly This occurs during prenatal development and briefly

after birthafter birth Cortical Atrophy -- Cortical Atrophy -- Progressive loss or deterioration of Progressive loss or deterioration of

neuronsneurons► Cerebral cortex is somewhat shrunken in about one-third of Cerebral cortex is somewhat shrunken in about one-third of

schizophrenicsschizophrenics► Cerebral ventricles are enlarged (these are canals that go Cerebral ventricles are enlarged (these are canals that go

through the brain and carry away waste materials)through the brain and carry away waste materials)► Basically, is a sign of brain deterioration and causes a loss of Basically, is a sign of brain deterioration and causes a loss of

neurons (found in at least 20% of schizophrenics)neurons (found in at least 20% of schizophrenics)


►HypofrontalityHypofrontality Prefrontal cortex is underactive causing Prefrontal cortex is underactive causing

negative symptoms negative symptoms

Genain Quadruplets: 1 in 100,000,000

History of Treatment of Schizophrenia

• Psychosurgery– Prefrontal Lobotomy

(introduced in 1935)

Transorbital Lobotomy (introduced in 1948)Referred to as “the icepick lobotomy”

• Before

• During

Transorbital Lobotomy

• After

History of Drug Treatment of History of Drug Treatment of SchizophreniaSchizophrenia

►Until the mid-1950’s the prognosis for Until the mid-1950’s the prognosis for schizophrenics was very unfavorableschizophrenics was very unfavorable

►Most were institutionalized for the rest Most were institutionalized for the rest of their lives in large mental hospitals of their lives in large mental hospitals Only about 30% would ever be discharged Only about 30% would ever be discharged

after enteringafter entering

History of Drug Treatment of History of Drug Treatment of SchizophreniaSchizophrenia

► Medications brought tremendous Medications brought tremendous “overnight” change -- “overnight” change --

► Chlorpromazine was the firstChlorpromazine was the first These drugs don’t cure the illness but often can These drugs don’t cure the illness but often can

control itcontrol it Originally referred to as “mild tranquilizers”Originally referred to as “mild tranquilizers”

Contemporary TreatmentsContemporary Treatments

► Today, a schizophrenia patient is often treated in an Today, a schizophrenia patient is often treated in an outpatient clinic and those that enter a mental outpatient clinic and those that enter a mental institution have about a 90% chance of being institution have about a 90% chance of being discharged in a matter of weeks or monthsdischarged in a matter of weeks or months

► The primary goal of modern drug therapy is to The primary goal of modern drug therapy is to reduce the high level of neurological activity reduce the high level of neurological activity

► This is accomplished with a group of drugs called This is accomplished with a group of drugs called neurolepticsneuroleptics These drugs block the receptors on the postsynaptic neuron so These drugs block the receptors on the postsynaptic neuron so

that dopamine cannot enter the receptor and cause the neuron to that dopamine cannot enter the receptor and cause the neuron to firefire

These drugs also reduce the sensitivity of the postsynaptic These drugs also reduce the sensitivity of the postsynaptic receptors – less sensitive, less likely to fire.receptors – less sensitive, less likely to fire.

Some of the newer neuroleptics also increase the levels of Some of the newer neuroleptics also increase the levels of serotoninserotonin

Types of NeurolepticsTypes of Neuroleptics

► NeurolepticsNeuroleptics Low-potency NeurolepticsLow-potency Neuroleptics

► MellarilMellaril► ThorazineThorazine

High-potency NeurolepticsHigh-potency Neuroleptics► HaldolHaldol► NavaneNavane

Atypical NeurolepticsAtypical Neuroleptics► ClozarilClozaril► RisperidalRisperidal► ZyprexaZyprexa

Low-Potency NeurolepticsLow-Potency Neuroleptics

► Popular in 1960’s – 1970’sPopular in 1960’s – 1970’s► Blocks 75%-80% of dopamine receptorsBlocks 75%-80% of dopamine receptors► Helps with positive symptoms but not with Helps with positive symptoms but not with

negative symptomsnegative symptoms

High-Potency High-Potency NeurolepticsNeuroleptics

► These drugs released in 1970’sThese drugs released in 1970’s► Blocks about 80% of dopamine receptorsBlocks about 80% of dopamine receptors► Much more effective than LP meds but at a Much more effective than LP meds but at a

priceprice► Drastic side-effectsDrastic side-effects

Parkinson-type symptomsParkinson-type symptoms

► No help with negative symptomsNo help with negative symptoms

Atypical NeurolepticsAtypical Neuroleptics► Released in 1980’s (Clozaril)Released in 1980’s (Clozaril)► Block less dopamine receptors (about 65%)Block less dopamine receptors (about 65%)► More selective in their blockingMore selective in their blocking

Block receptors leading to frontal and temporal lobes (as Block receptors leading to frontal and temporal lobes (as the LP and HP drugs do) but block fewer receptors in nerve the LP and HP drugs do) but block fewer receptors in nerve tracts associated with movementtracts associated with movement

► Help with negative symptomsHelp with negative symptoms Increases serotonin levels which can also help reduce Increases serotonin levels which can also help reduce

dopamine activitydopamine activity Can also reduce depression associated with illnessCan also reduce depression associated with illness

► Side-effect:Side-effect: About 2% of those taking Clozaril experience sudden drop About 2% of those taking Clozaril experience sudden drop

of white blood cellsof white blood cells► Newer drugs (Risperidal and Zyprexa) do not cause thisNewer drugs (Risperidal and Zyprexa) do not cause this

Big developments in 1990’sBig developments in 1990’s

Atypical NeurolepticsAtypical Neuroleptics

►So why don’t why only use these So why don’t why only use these now???now???

Side Effects of Drug Side Effects of Drug TherapyTherapy

►Mild symptomsMild symptoms Dryness of mouth or excessive salivationDryness of mouth or excessive salivation Blurred visionBlurred vision GrogginessGrogginess ConstipationConstipation Sensitivity to lightSensitivity to light Reduced sexual arousalReduced sexual arousal

Side Effects of Drug Side Effects of Drug TherapyTherapy

► More serious symptomsMore serious symptoms Tardive DyskinesiaTardive Dyskinesia

►Involuntary muscle movementsInvoluntary muscle movements AkathisiaAkathisia

►Inability to sit stillInability to sit still Malignant Neuroleptic SyndromeMalignant Neuroleptic Syndrome

►Muscular rigidityMuscular rigidity►Very high temperature leading to brain damageVery high temperature leading to brain damage►Fluctuating blood pressure leading to stroke or Fluctuating blood pressure leading to stroke or

comacoma►Most likely to occur with high-potency neuroleptics Most likely to occur with high-potency neuroleptics ►Occurs more often in womenOccurs more often in women►Is very rare as it occurs in less than 1% of patients Is very rare as it occurs in less than 1% of patients

taking these drugstaking these drugs

ComplicationsComplications

► Noncompliance with medicationNoncompliance with medication ► Physical illnessPhysical illness ► Substance abuseSubstance abuse► DepressionDepression► Suicide Suicide

PrognosisPrognosis

► Bad newsBad news Unfortunately, the rate of readmission is extremely high as Unfortunately, the rate of readmission is extremely high as

about two-thirds again need helpabout two-thirds again need help

► Good newsGood news About one-third recoverAbout one-third recover Which technically means that they remain symptom-free Which technically means that they remain symptom-free

for five yearsfor five years

► Bad newsBad news Problems with non-complianceProblems with non-compliance These drugs are a life-long situation as patients that stop These drugs are a life-long situation as patients that stop

taking the drugs will see the symptoms return and most taking the drugs will see the symptoms return and most often worsenoften worsen

Other Psychotic DisordersOther Psychotic Disorders

► Brief Psychotic DisorderBrief Psychotic Disorder► Schizophreniform DisorderSchizophreniform Disorder► Schizoaffective DisorderSchizoaffective Disorder► Delusional DisorderDelusional Disorder► Shared Psychotic DisorderShared Psychotic Disorder► Psychotic Disorder due to a general medical Psychotic Disorder due to a general medical

conditioncondition► Substance-induced Psychotic DisorderSubstance-induced Psychotic Disorder

CreditsCredits

► http://www.dmacc.cc.ia.us/instructors/acstevens/241ppts/comer5e_lehttp://www.dmacc.cc.ia.us/instructors/acstevens/241ppts/comer5e_lecture_Ch14.ppt#314,2,Psychosiscture_Ch14.ppt#314,2,Psychosis

► http://www.its.caltech.edu/~lester/Bi-150/Lecture-23-2007-Bi-http://www.its.caltech.edu/~lester/Bi-150/Lecture-23-2007-Bi-CNS150.ppt#408,6,Slide 6CNS150.ppt#408,6,Slide 6

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Chapter 14: Schizophrenia: The Most Dreaded Illness Abnormal Psychology Mar 12 & 24, 2009 Classes #17-18