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PowerPoint Lecture Notes Presentation Chapter 9 SchizophreniaAbnormal Psychology, Thirteenth Edition

by Ann M. Kring,Sheri L. Johnson, Gerald C. Davison,& John M. Neale

2015 John Wiley & Sons, Inc. All rights reserved.

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Chapter OutlineChapter 9: SchizophreniaI. Clinical Descriptions of SchizophreniaII. Etiology of SchizophreniaIII. Treatment of Schizophrenia


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SchizophreniaMajor disturbances in thought, emotion, and behavior Disordered thinkingIdeas not logically relatedFaulty perception and attentionLack of emotional expressivenessInappropriate or flat emotionsDisturbances in movement or behaviorDisheveled appearanceCan disrupt interpersonal relationships, diminish capacity to work or live independentlySignificantly increased rates of suicide and death 2015 John Wiley & Sons, Inc. All rights reserved.

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SchizophreniaLifetime prevalence ~1%Affects men slightly more often than womenOnset typically late adolescence or early adulthoodMen diagnosed at a slightly earlier ageDiagnosed more frequently in African AmericansMay reflect diagnostic bias 2015 John Wiley & Sons, Inc. All rights reserved.

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DSM-5 Criteria for SchizophreniaTwo or more of the following symptoms for at least 1 month; one symptom should be either 1, 2, or 3:(1) delusions(2) hallucinations(3) disorganized speech(4) disorganized (catatonic) behavior(5) negative symptoms (diminished motivation or emotional expression)Functioning in work, relationships, or self-care has declined since onsetSigns of disorder for at least 6 months; if during a prodromal or residual phase, negative symptoms or two or more of symptoms 1-4 in less severe form 2015 John Wiley & Sons, Inc. All rights reserved.

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Clinical Description of SchizophreniaThree major clusters of symptoms:PositiveNegativeDisorganized


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Positive Symptoms: Behavioral Excesses and DistortionsDelusionsFirmly held beliefsContrary to realityResistant to disconfirming evidenceTypes of delusions: Persecutory delusionsThe CIA planted a listening device in my head65% have theseThought insertionThought broadcastingOutside controlGrandiose delusionsIdeas of reference

HallucinationsSensory experiences in the absence of sensory stimulation

Types of hallucinations:Auditory74% have this symptomVisualHearing voicesIncreased levels of activity in Brocas area during hallucinations


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Negative Symptoms: Behavioral DeficitsAvolitionLack of interest; apathyAsocialityInability to form close personal relationshipsAnhendoniaInability to experience pleasureConsummatory pleasureAnticipatory pleasureBlunted affectExhibits little or no affect in face or voiceAlogiaReduction in speechCan be grouped into 2 domains:Experience domainMotivationEmotional experienceSocialityExpression domainOutward expression of emotionVocalization 2015 John Wiley & Sons, Inc. All rights reserved.

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Disorganized SymptomsDisorganized speech (formal thought disorder)IncoherenceInability to organize ideas Loose associations (derailment)Rambles, difficulty sticking to one topicDisorganized behaviorOdd or peculiar behaviorSilliness, agitation, unusual dresse.g., wearing several heavy coats in hot weather 2015 John Wiley & Sons, Inc. All rights reserved.

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Movement SymptomsCatatoniaMotor abnormalitiesRepetitive, complex gesturesUsually of the fingers or handsExcitable, wild flailing of limbsCatatonic immobilityMaintain unusual posture for long periods of timee.g., stand on one legWaxy flexibilityLimbs can be manipulated and posed by another person 2015 John Wiley & Sons, Inc. All rights reserved.

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Other Psychotic DisordersSchizophreniform DisorderSame symptoms as schizophreniaSymptom duration greater than 1 month but less than 6 monthsSymptoms must include either hallucinations, delusions, or disorganized speech Brief Psychotic DisorderSymptom duration of 1 day to 1 monthOften triggered by extreme stress, such as bereavementSymptoms must include either hallucinations, delusions, or disorganized speech Schizoaffective DisorderSymptoms of both schizophrenia and either a depressive or manic episode Symptoms of a major mood episode are present for a majority of the duration the illness


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Other Psychotic DisordersDelusional DisorderDelusions may include:PersecutionJealousyBeing followedErotomaniaLoved by a famous person Somatic delusionsNo other symptoms of schizophrenia


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Table 9.2: Family and Twin Genetic Studies


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Table 9.3: Characteristics of Adopted Offspring of Mothers with Schizophrenia


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Etiology of Schizophrenia:Genetic FactorsGenetically heterogeneousNot likely that disorder caused by single geneFamily studiesRelatives at increased risk Negative symptoms have stronger genetic componentTwin studies44% risk for MZ twins vs. 12% risk for DZ twinsChildren of non-schizophrenic MZ twin were more likely to develop schizophrenia (9.4% vs. 1% in general population)Adoption studiesIncreased likelihood of developing psychotic disordersFamilial high-risk studiesDiffering negative vs. positive symptomatology 2015 John Wiley & Sons, Inc. All rights reserved.

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Etiology of Schizophrenia:Genetic FactorsAssociation studiesTwo genes associated with schizophreniaDTNGP1NGR1Two genes associated with cognitive deficitsCOMTBDNFGenome-wide scansIdentification of gene mutationsSeveral identified but results need to be replicated 2015 John Wiley & Sons, Inc. All rights reserved.

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Etiology of Schizophrenia: NeurotransmittersDopamine TheoryDisorder due to excess levels of dopamineDrugs that alleviate symptoms reduce dopamine activityAmphetamines, which increase dopamine levels, can induce a psychosisTheory revisedExcess numbers of dopamine receptors or oversensitive dopamine receptorsLocalized mainly in the mesolimbic pathway Mesolimbic dopamine abnormalities mainly related to positive symptomsUnderactive dopamine activity in the mesocortical pathway mainly related to negative symptoms 2015 John Wiley & Sons, Inc. All rights reserved.

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Figure 9.2: The Brain and Schizophrenia


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Figure 9.3: Dopamine Theory of Schizophrenia


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Etiology of Schizophrenia: Evaluation of Dopamine TheoryDopamine theory doesnt completely explain disorderAntipsychotics block dopamine rapidly but symptom relief takes several weeksTo be effective, antipsychotics must reduce dopamine activity to below normal levelsOther neurotransmitters involved:Serotonin GABAGlutamate Medication that targets glutamate shows promise 2015 John Wiley & Sons, Inc. All rights reserved.

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Etiology of Schizophrenia: Brain Structure and Function Enlarged ventricles Implies loss of brain cellsCorrelate withPoor performance on cognitive testsPoor premorbid adjustmentPoor response to treatment 2015 John Wiley & Sons, Inc. All rights reserved.

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Etiology of Schizophrenia: Brain Structure and FunctionPrefrontal CortexMany 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 low metabolic rates in prefrontal cortexFailure to show frontal activaty related to negative symptomsDisrupted communication among neurons due to loss of dendritic spinesDisconnection Syndrome


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Figure 9.4: Micrograph of a Neuron


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Etiology of Schizophrenia: Brain Structure and FunctionStructural and functional abnormalities in temporal cortexTemporal gyrusHippocampusAmygdalaAnterior cingulateReduced gray matter and volume evidentDisrupted connectivity in the brain 2015 John Wiley & Sons, Inc. All rights reserved.

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Etiology of Schizophrenia: Brain Structure and FunctionEnvironmental FactorsDamage during gestation or birthObstetrical complications rates high in patients with schizophreniaReduced supply of oxygen during delivery may result in loss of cortical matterViral damage to fetal brainPresence of parasite, toxoplasma gondii, associated with 2.5x greater risk of developing schizophreniaIn Finnish study, schizophrenia rates higher when mother had flu in second trimester of pregnancy 2015 John Wiley & Sons, Inc. All rights reserved.

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Etiology of Schizophrenia: Brain Structure and FunctionDevelopmental factorsPrefrontal cortex matures in adolescence or early adulthoodDopamine activity also peaks in adolescenceStress activates HPA system, which triggers cortisol secretionCortisol increases dopamine activityExcessive pruning of synaptic connectionsUse of cannabis during adolescence associated with increased riskMay explain why symptoms appear in late adolescence but brain damage occurs early in life 2015 John Wiley & Sons, Inc. All rights reserved.

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Etiology of Schizophrenia: Psychological StressReaction to stressIndividuals with schizophrenia and their first-degree relatives more reactive to stressGreater decreases in positive mood and increases in negative moodSocioeconomic statusHighest rates of schizophrenia among urban poor Sociogenic hypothesisStress of poverty causes disorderSocial selection theoryDownward drift in socioeconomic statusResearch supports social selection


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Etiology of Schizophrenia: Family FactorsSchizophrenogenic mother Cold, domineering, conflict-inducingNo support for this theory

Communication deviance (CD)Hostility and poor communicationInconclusive at this time


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Etiology of Schizophrenia: Families and RelapseFamily environment impacts relapseExpressed Emotion (EE)Hostility, critical comments, emotional overinvolvementBidirectional association Unusual patient thoughts increased critical commentsIncreased critical comments unusual patient thoughts


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Etiology of Schizophrenia: Developmental StudiesUse of retrospective or follow-back studiesDevelopmental histories of children who later developed schizophreniaLower IQMore often delinquent (boys) and withdrawn (girls)Coding of home moviesPoorer motor skillsMore expression of negative emotion 2015 John Wiley & Sons, Inc. All rights reserved.

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Etiology of Schizophrenia: Developmental StudiesNew Zealand studyCognitive deficits evident at early ageAustralian studyReduced gray matter volume predicted later development of psychotic disorderNorth American Prodrome Longitudinal Study Identified factors associated with development of psychosisHaving a biological relative with schizophreniaRecent decline in functioningHigh levels of pos 2015 John Wiley & Sons, Inc. All rights reserved.

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Treatment of Schizophrenia: MedicationsFirst-generation antipsychotic medications (neuroleptics; 1950s)Phenothiazines (Thorazine), butyrophenones (Haldol), thioxanthenes (Navane)Reduce agitation, violent behaviorBlock dopamine receptorsLittle effect on negative symptomsExtrapyramidal side effectsTardive dyskinesiaNeuroleptic malignant syndromeMaintenance dosages to prevent relapse 2015 John Wiley & Sons, Inc. All rights reserved.

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Treatment of Schizophrenia: MedicationsSecond-generation antipsychoticsClozapine (Clozaril)Impacts serotonin receptorsFewer motor side effectsLess treatment noncomplianceReduces relapseSide effectsCan impair immune symptom functioningSeizures, dizziness, fatigue, drooling, weight gainNewer medications may improve cognitive function:Olanzapine (Zyprexa)Risperidone (Risperdal) 2015 John Wiley & Sons, Inc. All rights reserved.

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Table 9.4 Summary of Major Schizophrenia Drugs


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Treatment of Schizophrenia: MedicationsClinical Antipsychotic Trials of Intervention Effectiveness (CATIE) studySecond-generation drugs were not more effective than the older, first-generation drugSecond-generation drugs did not produce fewer unpleasant side effectsNearly three-quarters stopped taking the medications before study endedSecond-generation antipsychotics have serious side effectsWeight gain, diabetes, pancreatitisDisturbing trend for people of color:Not prescribed second-generation antipsychotics 2015 John Wiley & Sons, Inc. All rights reserved.

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Psychological TreatmentsPatient Outcomes Research Team (PORT) treatment recommendation:Medication PLUS psychosocial interventionSocial skills trainingTeach skills for managing interpersonal situationsCompleting a job applicationReading bus schedulesMake appointmentsInvolves role-playing and other practice exercises, both in group and in vivo


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Psychological TreatmentsFamily therapy to reduce expressed emotionEducate family about causes, symptoms, and signs of relapseStress importance of medicationHelp family to avoid blaming patientImprove family communication and problem-solvingEncourage expanded support networksInstill hope 2015 John Wiley & Sons, Inc. All rights reserved.

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Psychological TreatmentsCognitive behavioral therapyRecognize and challenge delusional beliefsRecognize and challenge expectations associated with negative symptomse.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 symptomsCase managementMultidisciplinary team to provide comprehensive servicesResidential treatmentVocational rehabilitation


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