Psychoses are a class of disorders in which reality contact is
radically impaired
Psychoses are most severe of all psychological disorders
Schizophrenia
Schizophrenia describes group of psychoses
The Prevalence of Schizophrenia
About 1-2% had or will have schizophrenic episode
Rates are similar in other countries
Patients occupy half of hospital beds or are released to smaller
facilities or into community
Health care cost of schizophrenia is approximately $19 billion
The History of the Diagnostic Category
In 1896, Emil Kraepelin proposed type of psychosis dementia praecox
Begins in adolescence
Leads to irreversible mental breakdown
Term means premature mental deterioration
Eugene Bleuler argued dementia praecox was poor description
Disorder not necessarily premature
Most patients did not have complete mental deterioration
Proposed term schizophrenia
Term schizophrenia refers to split among different
psychic functions within single personality
Does not refer to dissociative identity disorder
The Symptoms of Schizophrenia
DSM-IV and DSM-IV-TR list five characteristic symptoms
Two or more symptoms must be shown for at least two months
and disturbed behavior exhibited for at least six months
Episodes that last less than a month, diagnosis of brief psychotic
disorder is used
Episodes that last at least a month but less than six months,
diagnosis of schizophreniform disorder
Disorders of Thought and Language
Delusions
Delusions are firmly held beliefs that have no
basis in reality
Delusions affect at least three-quarters of schizophrenic
patients
Most schizophrenics do not realize the implausibility
of their firmly held beliefs and will not abandon them
Patterns include delusions of persecution, delusions
of control, delusions of reference, delusions of grandeur,
delusions of sin and guilt, hypochondriacal delusions, and
nihilistic delusions
Thought delusions include thought broadcasting, thought
insertion, and thought withdrawal
Delusions may represent way schizophrenics explain to
themselves their mental chaos
Loosening of Associations
Loosening of associations refers to characteristics
of speech whereby ideas jump from one track to another
Problem may lie in mind's way of dealing with associations
whereby process of editing breaks down
Patients with schizophrenia have particular problems
with subtle secondary associations
Research suggests that patients do not understand context
well enough to process the last word of a sentence
Poverty of Content
Poverty of content characterizes the lack of meaning
conveyed
Speech may include many words with correct grammar
Neologisms
Some suggest schizophrenics have difficulty in finding
the right words with which to say something
Neologisms are new words that result from combining
parts of two or more regular words or using words in a new
way
Clanging (Clang Association)
Clanging is the pairing of words that have no relation
to one another beyond fact that they rhyme or sound alike
Clanging speech often sounds like nonsense
Word Salad
Language may show complete breakdown on associational
process
Becomes impossible to determine any links between successive
words and phrase
Word salad refers to speech in which words and
phrases are combined into completely disorganized fashion
Neologism--words are combined to make a "new word"
that is usually undefinable by the schizophrenic patient and
the person it is directed to
Disorders of Perception
Breakdown of Selective Attention
Schizophrenics seem unable to focus and concentrate on
important stimuli in environment
Researchers believe that breakdown of selective attention
may underlie most of the other symptoms
Hallucinations
Hallucinations are perceptions in the absence of
any appropriate external stimulus
Auditory hallucinations are the most common, notably
hearing two or more voices
Visual hallucinations are second most common
Some patients do realize that hallucinations are not
real; severely psychotic patients believe hallucinations are
real perceptions
Disorders of Mood
Some patients have deep depression or manic elation or an
alternation between the two; diagnosis of schizoaffective disorder
is used
Two or more patterns of mood disorders can be found
Blunted affect, whereby patient shows little emotion
Flat affect, whereby the patient shows no emotion
Inappropriate affect refers to an expression
of emotion unsuitable to the situation; the inappropriateness
is subtle and typically involves facial expression, gestures
associated with being happy
Disorders of Motor Behavior
In some cases, motor behavior is normal
Motor behavior can include repetitive motor behaviors, purposeless
behavior called stereotypy
Sometimes high levels of motor activity are seen
More common is inactivity where person is in a catatonic stupor
Social Withdrawal
Emotional detachment is early sign
Withdrawal from involvement with environment and other people
May be due to social handicaps and attentional problems
The Course of Schizophrenia
The Prodromal Phase
Onset of schizophrenia may be sudden in some cases, occurring
in a few days
Onset of schizophrenia may occur gradually over years
Downhill slide known as the prodromal phase
The Active Phase
In active phase, patient shows prominent symptoms of
schizophrenia
No one patient is likely to show all symptoms
The Residual Phase
Active phase is followed by residual phase in most
patients
In residual phase, patient shows behavior similar to prodromal
phase
Patient may show symptoms such as blunted or flat affect
Some patients may return to normal functioning, but is usually
not typical
More typical pattern is increasingly impaired functioning
between episodes of residual phase
Schizophrenic tend to die about 10 years younger than other
people
The Subtypes of Schizophrenia
Schizophrenia has been divided into subtypes based on behavior;
but often problematic
Subtype diagnosis may have value in research
DSM-IV and DSM-IV-TR list five subtypes and include
undifferentiated type and residual type
Disorganized Schizophrenia
Disorganized schizophrenia best fits the stereotype
of a crazy person
Three symptoms are characteristic
Pronounced incoherence of speech (e.g., neologisms, clanging,
word salad)
Mood disturbance
Disorganized behavior or lack of goal orientation
May also show other symptoms
Onset is usually gradual and occurs at early age
Catatonic Schizophrenia
Catatonic schizophrenia marked by disturbance in motor
behavior
Disturbance can be in form of catatonic stupor or complete
immobility, remaining in this state for weeks
May also show waxy flexibility at times and at other times
shows frenzied motor activity
Bizarre postures require extraordinary expenditure of energy
Patients may also show catatonic rigidity and echolalia,
parroting what is said to them; echopraxia and catatonic negativism
are other symptoms
Paranoid Schizophrenia
Paranoid schizophrenia involved delusions and/or hallucinations
related to themes of persecution and grandeur
Far more common than disorganized or catatonic types
Paranoid schizophrenics show better functioning and are more
"normal" than disorganized or catatonic types
Active phase appears after 25 years of age and is preceded
by years of fear and suspicion
Dimensions of Schizophrenia
Examining dimensions provides another way to study schizophrenia
Dimensions allow patients to fall somewhere on the dimensions
Process-Reactive, or Good-Poor Premorbid
Process-reactive dimension describes onset of schizophrenia
Process schizophrenia describes gradual onset
Reactive schizophrenia describes sudden onset triggered
by traumatic event
Biogenic psychosis focuses on process; psychological
psychosis focuses on reactive
Good-bad premorbid dimension refers to how well patient
was functioning before onset
Process (or poor premorbid) associated with long history
of poor adjustment; more likely to have long hospitalizations
Reactive (or good premorbid) associated with normal
history
Positive-Negative Symptoms
Positive-negative dimension attracted attention
Positive symptoms characterized by presence of
something that is normally absent
Negative symptoms characterized by absence of
something that is normally present
Negative symptoms associated with poor premorbid adjustment
tend to have earlier onset and worse prognosis
Related to different kinds of cognitive problems
May be two biologically distinct types of schizophrenia
Type I schizophrenia associated with positive
symptoms and tends to respond to medication
Type II schizophrenia associated with negative
symptoms and does not respond well to medication
Some symptoms may be in response to primary symptoms
Paranoid-Nonparanoid
Paranoid-nonparanoid dimension refers to presence or absence
of delusions of persecution and/or grandeur
May be related to process-reaction dimension
Groups at Risk for Schizophrenia
Symptoms may differ depending on culture
There are certain known risk factors associated with schizophrenia
such as socioeconomic status, age, gender
Delusional Disorder
The Symptoms of Delusional Disorder
Delusional system is the fundamental abnormality in delusional
disorder
In other aspects, individual seems normal
Does not include other characteristic symptoms of schizophrenia
DSM-IV and DSM-IV-TR list five categories of delusional
disorder
Persecutory type involves belief that one is being threatened
or maltreated by others
Grandiose type refers to belief that person is endowed with
extraordinary power or knowledge
Jealous type is delusion that one's sexual partner is being
unfaithful
Erotomanic type refers to belief that person of high status
is in love with patient
Somatic type involves false conviction that one is suffering
from physical abnormality or disorder
Problems in the Study of Schizophrenia
Subjects available for research are hospitalized and take antipsychotic
drugs
Any differences may be function of medication or hospitalization
Disagreement with what actually constitutes schizophrenia creates
problem for research
Differential deficits are specific to disorder in question and
presumably central to it
Problems faced by subjects may not lead directly to disorder
To show differential deficits, research must show schizophrenics
consistently showing differences
Schizophrenia: Theory and Therapy
The Neuroscience Perspective
Genetic Studies
Family Studies
Earliest genetic studies were family studies
Children of one and two schizophrenic parent(s)have 13%
and 46% chance, respectively, of becoming schizophrenic
Compared to general population risk of 1-2%
Person with a schizophrenic first-degree relative is
10 times likelier to develop schizophrenia
Twin Studies
Average concordance rate for MZ twins is 46% compared
to 14% for DZ twins
Concordance differences tends to be greater when index
twin has more severe symptoms
There are several problems with twin studies, such as
small sample and sharing of environment
Twins reared apart share same intrauterine environment
Research now examining offspring of MZ twins who are discordant
for schizophrenia
Adoption Studies
Subjects in adoption studies are those children who are
adopted away from their biological families as infants
Several studies show that adopted children who later
become schizophrenic are much more likely to have biological,
rather than adoptive relatives with schizophrenia
Mode of Transmission
Researchers suspect that schizophrenia is caused by variety
of genetic subtypes
Others suggest that schizophrenia is product of many
genes and their combination with environmental factors
Genetic High-Risk Studies
Genetic high-risk studies examine children who were born
of schizophrenic mothers and are therefore genetically vulnerable
to schizophrenia
Research has identified factors that separate high-risk
children who developed schizophrenia from high-risk and low-risk
children who remain normal: home life, early separation and
institutionalization, school problems and criminal behavior;
attention problems; and birth complications
Studies support role of genetic inheritance
High rate of attention problems suggests that attention
deficits are primary symptoms
Specific types of stress may lead to schizophrenia
Behavioral High-Risk Studies
Behavioral high-risk studies select high-risk people on
basis of behavioral traits associated with schizophrenia
Perceptual Aberration-Magical Ideation Scale used to
screen subjects
Perceptual abnormalities often show up in histories
of those who are later diagnosed with schizophrenia
Brain-Imaging Studies
New brain-imaging techniques include PET, CT, and MRI
Chronic schizophrenics have smaller than normal brain size
Brain ventricles tend to be enlarged
May be result of cumulative effect of antipsychotic drugs
Evidence suggests similar abnormalities in first-episode
schizophrenics
Abnormalities found near structures near ventricles
During cognitive tests, PET scans reveal abnormally low frontal-lobe
activity
Frontal cortex abnormalities associated with negative symptoms
Temporal lobe and limbic structure abnormalities associated
with positive symptoms
Abnormalities found in connections among basal ganglia, temporal
lobe, and frontal lobe
Prenatal Brain Injury
High rate of birth complications seen in many schizophrenics
Evidence suggests brain schizophrenics may have suffered trauma
during second trimester
Disruptions may have occurred in neural migration during second
trimester
Twin studies found signs of problems during second trimester
Biochemical Research: The Dopamine Hypothesis
Dopamine hypothesis suggests schizophrenia associated with
excess activity in parts of brain that use dopamine
Major line of evidence from research on antipsychotic drugs
Other supporting evidence comes from studies with stimulants
amphetamine and methylphenidate, which increase dopamine activity
in brain
Link may exist between schizophrenia and Parkinson's disease
Drugs used for Parkinson's disease can produce schizophrenic-like
symptoms
Antipsychotic drugs can produce tardive dyskinesia
There is evidence against dopamine hypothesis
Biological explanation probably will involve combination of
biochemical imbalances
Chemotherapy
Antipsychotic drugs used to relieve symptoms
Most widely used group is phenothiazines
Newer drugs often work better than phenothiazines for Type
II, negative-symptom patients
Problems associated with antipsychotic drugs
About 20-40% get little or no relief from drugs
Long term use can have serious side effects such as
tardive dyskinesia
New drugs being developed that have lower risk for tardive
dyskinesia
While drugs have reduced number of chronically hospitalized
patients, some suggest it has led to revolving door admission
The Cognitive Perspective
Cognitive theorists focus on the diathesis
Biological abnormality causes attention deficits that create a
predisposition to schizophrenia
Overattention
Overattention related to Type I, positive-symptom schizophrenia
Symptoms of Type I are product of their overattention
Information processing functions are overburdened and nervous
system over aroused, and cannot screen out stimuli
Many studies support poor selective attention and distractibility
Inability to screen out distractions related to Type I, positive-symptom
schizophrenia, but not to Type II, negative-symptom schizophrenia
Underattention
Type II schizophrenics appear to be under-attentive to external
stimuli
Studies using orienting response and backward-masking paradigm
support theory
Underattention leads to negative symptoms
Vulnerability
Cognitive abnormalities have been found in remitted schizophrenics,
their biological relatives, and high-risk individuals
Longitudinal studies must be conducted for solid confirmation
of attention-dysfunction hypothesis
Cognitive Therapy
Cognitive therapy in earliest stages
In cognitive rehabilitation, techniques from rehabilitation
therapy are used
Patients given tasks that require skills that are defective
Defective skills are built up by instruction, prompting,
and monetary rewards
Another approach focuses on hallucinations and delusions
Techniques used involve questioning patient
Therapists suggest alternative explanations
Therapy also teaches patient coping devices to deal
with unwelcome thoughts
Gains in cognitive therapy may not generalize to other areas
of cognition
The Interpersonal Perspective
Trouble in the family is the focus in family systems perspective
Expressed Emotion
Expressed emotion (EE) refers to what people in family
say to one another
Expressed emotion based on level of criticism and level
of emotional over-involvement
Patients who live with high-EE relatives were three
to four times more likely to have been rehospitalized
Some studies have not found link between schizophrenia and
EE
Many studies suggest that a negative and emotionally charged
family atmosphere may be related to onset and course of schizophrenia
Communication Deviance
Double-bind communication believed to characterize communication
between child and parent
Double-bind communication gives child mutually contradictory
messages
Parent implicitly forbids child to point out contradiction
Research shows that families of schizophrenics tend to have
unusual communication patterns
Communication deviance (CD) refers to number of deviant
or idiosyncratic responses
Communication deviance correlated with expressed emotion
Communication deviance may be result of child's disorder
Family communication patterns may place individual at
risk for schizophrenia
Treatment for Families
Treatments developed for families of schizophrenic patients
Studies suggest that family therapy lowers risk of relapse
Problem-solving therapy applied to groups of families may
be superior
The Behavioral Perspective
Learned Nonresponsiveness
Schizophrenics have not learned to respond to social stimuli
React to idiosyncratically chosen stimuli
Rewarded for bizarre responses
Relearning Normal Behavior
Direct Reinforcement
Behavior is changed by changing consequences of behavior
A number of ethical and legal questions raised by treatment
The Token Economy
Token economy refers to giving patients tokens
for performing target behavior
Tokens exchanged for backup reinforcers
Token economies are very useful in improving behavior
Social-Skills Training
Social-skills training attempts to reduce inappropriate
social behavior by teaching patients
Role-playing is critical component
Social-skills training can be effective but may not
generalize to patients' daily lives
Some patients do retain skills and make better adjustment
to community
The Sociocultural Perspective
Released patients require many kinds of assistance
Community treatment programs must maintain active involvement
with patients long-term
Assertive community treatment provides greater range of services
readily available
Personal therapy provides one-on-one case-management treatment
and focuses on control of emotions
Internal coping taught to identify signs of upcoming stress
Personal therapy is long-term, lasting about three years
Outcomes of personal therapy are promising
Unitary Theories: Diathesis and Stress
Researchers are looking for both genetic and environmental causes
Several stresses have been identified that convert diathesis into
schizophrenia
Relapses tend to be preceded by increase in stressful life events
