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CHAPTER 12
SCHIZOPHRENIA SPECTRUM AND
OTHER PSYCHOTIC DISORDERS
CHAPTER OVERVIEW
This chapter outlines the primary features of schizophrenia and related psychotic
disorders. Positive, negative, and disorganized symptoms as well as the historic subtypes of
schizophrenia are described. Related problems include schizophreniform, schizoaffective,
delusional, and brief psychotic disorders. Etiological factors, relapse, and treatment are discussed,
as are the significant changes in this category of diagnoses that has occurred in the switch to
DSM-5.
LEARNING OBJECTIVES
1.
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6.
Define schizophrenia and describe the different symptoms included in
this diagnosis.
Distinguish among positive, negative, and disorganized symptoms
of schizophrenia.
Describe the clinical characteristics and major subtypes of schizophrenia and other
psychotic disorders.
Describe the potential genetic, neurobiological, developmental, and psychosocial
contributions and risk factors for schizophrenia.
Describe the general goals of therapy for schizophrenia.
Describe the biological and psychosocial treatments for schizophrenia.
CHAPTER OUTLINE
PERSPECTIVES ON SCHIZOPHRENIA
Early Figures in Diagnosing Schizophrenia
Identifying Symptoms
CLINICAL DESCRIPTION, SYMPTOMS, AND SUBTYPES
Positive Symptoms
Negative Symptoms
Disorganized Symptoms
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Historic Schizophrenia Subtypes
Other Psychotic Disorders
PREVALENCE AND CAUSES OF SCHIZOPHRENIA
Statistics
Development
Cultural Factors
Genetic Influences
Neurobiological Influences
Psychological and Social Influences
TREATMENT OF SCHIZOPHRENIA
Biological Interventions
Psychosocial Interventions
Treatment across Cultures
Prevention
DETAILED OUTLINE
Perspectives on Schizophrenia
How is schizophrenia defined, and what symptoms are included in its diagnosis?
 Schizophrenia is a complex syndrome that has been recognized for many years. Perhaps the
earliest and best description of this disorder was published in 1809 by John Haslam in his
book Observations on Madness and Melancholy.
 A number of historic figures during the 19th and early 20th century contributed to the evolving
definitions and discovery of possible causes of this spectrum of disorders.
Clinical Description, Symptoms, and Subtypes
What are the distinctions among positive, negative, and disorganized symptoms of
schizophrenia?
What are the clinical characteristics of schizophrenia and other psychotic disorders?
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 Schizophrenia is characterized by a broad spectrum of cognitive and emotional dysfunctions
that include delusions and hallucinations, disorganized speech and behavior, and
inappropriate emotions.
 The symptoms of schizophrenia can be divided into positive, negative, and disorganized
symptoms. Positive symptoms are active manifestations of abnormal behavior, or an excess
or distortion of normal behavior, and include delusions and hallucinations. Negative
symptoms involve deficits in normal behavior on such dimensions as affect, speech, and
motivation. Disorganized symptoms include rambling speech, erratic behavior, and
inappropriate affect.
 DISCUSSION POINT:
From your perspective, which of the symptom types of schizophrenia would be most
distressing or debilitating?
 Psychotic behaviors, such as hallucinations and delusions, characterize several other
disorders; these include schizophreniform disorder (which includes people who experience
the symptoms of schizophrenia for less than 6 months); schizoaffective disorder (which
includes people who have symptoms of schizophrenia and who exhibit the characteristics of
mood disorders, such as depression and bipolar affective disorder); delusional disorder
(which includes people with a persistent belief that is contrary to reality, in the absence of the
other characteristics of schizophrenia); and brief psychotic disorder (which includes people
with one or more positive symptoms, such as delusions, hallucinations, or disorganized
speech or behavior over the course of less than a month).
 A proposed new disorder – attenuated psychosis syndrome – which includes one or more of
the symptoms of schizophrenia such as hallucinations or delusions, but the individual is
aware that these are unusual experiences and not typical for healthy persons. This syndrome
is included in the Appendix of DSM-5 as a disorder in need of further study.
Prevalence and Causes of Schizophrenia
What are the potential genetic, neurobiological, developmental, and psychosocial risk factors for
schizophrenia?
 A number of causative factors have been implicated for schizophrenia, including genetic
influences, neurotransmitter imbalances, structural damage to the brain caused by a prenatal
viral infection or birth injury, and psychological stressors.
 DISCUSSION POINT:
What are some possible explanations for gender differences in the onset of schizophrenia?
How might gender influence the prognosis of someone with this disorder?
 Relapse appears to be triggered by hostile and critical family environments characterized by
high expressed emotion.
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 DISCUSSION POINT:
With the contribution of endophenotype research to the understanding of schizophrenia,
how might the diagnosis and classification of this disorder change? How is treatment likely
to be affected?
Treatment of Schizophrenia
What are the goals of therapy for schizophrenia?
What biological and psychosocial treatments for schizophrenia are available?
 Successful treatment for people with schizophrenia rarely includes complete recovery. The
quality of life for these individuals can be meaningfully affected, however, by combining
antipsychotic medications with psychosocial approaches, employment support, and
community-based and family interventions.
 Treatment typically involves antipsychotic drugs that are usually administered with a variety
of psychosocial treatments, with the goal of reducing relapse and improving skills in deficits
and compliance in taking the medications. The effectiveness of treatment is limited, because
schizophrenia is typically a chronic disorder.
KEY TERMS
schizophrenia, 447
catatonia, 448
hebephrenia, 448
paranoia, 448
dementia praecox, 448
associative splitting, 448
psychotic behavior, 449
positive symptoms, 450
delusion, 450
hallucination, 451
negative symptoms, 452
avolition, 453
alogia, 453
anhedonia, 453
flat affect, 453
disorganized speech, 454
inappropriate affect, 454
catatonic immobility, 454
schizophreniform disorder, 454
schizoaffective disorder, 455
delusional disorder, 455
shared psychotic disorder (folie à deux), 456
substance-induced psychotic disorder, 457
psychotic disorder associated with another
medical condition, 457
brief psychotic disorder, 457
attenuated psychosis syndrome, 458
prodromal stage, 459
schizotypal personality disorder, 459
schizophrenogenic mother, 467
double bind communication, 467
expressed emotion (EE), 467
token economy, 471
IDEAS FOR INSTRUCTION
1.
Activity: Name that Symptom! To test students’ understanding of the different
symptoms of schizophrenia, divide the class into several teams. Prepare clinical examples
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of the various symptom categories. Take turns reading an example to each team, which
then has a chance to determine the symptom being described. If the first team does not get
the answer correct, then the next team can try. Examples of the clinical symptoms include
the following:
a. Disorder of thought content or delusion. The flicker of candles communicates
secret messages about me to aliens.
b. Delusion of grandeur. I am Queen of Eastern Europe.
c. Delusion of persecution. The CIA is tracking me and planning on assassinating me
in my sleep.
d. Auditory hallucination. Voices tell me to jump out of windows.
e. Visual hallucination. I can see large spiders crawling up my walls.
f. Olfactory hallucination. I smell my family’s pets around me.
g. Tactile hallucination. I feel little bugs crawling under my skin.
h. Tangentiality. Oh, you want to know where I was, well, my brother called me to
come over and he works on cars at a shop in town that has money problems.
i. Loose association. I went to the store, but the violin was fixed so I could return to
church and pray.
j. Waxy flexibility and catatonic immobility. (Demonstrate).
k. Alogia. (Ask a student to question you and then respond in monosyllables).
These represent one example per symptom, but you can provide additional examples.
Keep score so you can determine the team that wins the most points.
You may want to reward the winning team with extra credit points to get students invested
in learning the material.
2.
Video Activity: Schizophrenia. Show the film segment from Abnormal Psychology
Inside/Out that presents an interview with a patient named Edna, who displays disordered
thoughts and delusions. This segment nicely demonstrates positive and negative
symptoms, disorganized thoughts, and delusions associated with schizophrenia. During
the interview, Edna also displays extrapyramidal symptoms. Ask your students to try and
identify and classify the symptoms she displays during the interview and to attempt to
diagnose her type of schizophrenia.
3.
Schizophrenia. The word schizophrenia is so widely misused that you should spend
some time differentiating schizophrenia from dissociative identity disorder (previously
known as multiple personality disorder) by developing a lecture on this topic. A short
history of terminology, from Kraepelin’s dementia praecox to Bleuler’s schizophrenia,
would be useful… A listing of Bleuler’s four As (what he considered to be the
fundamental symptoms of the schizophrenic spectrum disorders) helps dispel the idea
that schizophrenics are anything like the main character in The Three Faces of Eve. The
four As are association (thought disorder), affect (inappropriate or blunted), ambivalence
(indecisive in carrying out daily activities), and autism (withdrawal into self).
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SUPPLEMENTARY READING MATERIAL
Additional Readings:
Andreasen, N. C., & Flaum, M. (1991). Schizophrenia: The characteristic symptoms.
Schizophrenia Bulletin, 17, 27-48.
Birchwood, M. J. (1989). Schizophrenia: An integrated approach to research and
treatment. New York: New York University Press.
Brown, M. J., & Roberts, D. P. (2000). Growing up with a schizophrenic mother.
Jefferson, NC: McFarland.
Chapman, L. J., & Chapman, J. P. (1980). Scales for rating psychotic and psychotic-like
experiences as continua. Schizophrenia Bulletin, 6, 476-489.
Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA:
Houghton Mifflin Company. Chapter 7, Schizophrenia.
Cromwell, R. L., & Snyder, C. R. (Eds.) (1993). Schizophrenia: Origins, processes,
treatment, and outcome. New York: Oxford University Press.
Farber, S. (Ed.) (1993). Madness, heresy, and the rumor of angels: The revolt against the
mental health system. Chicago: Open Court.
Fowles, D. C. (1992). Schizophrenia: Diathesis-stress revisited. Annual Review of
Psychology, 43, 303-336.
Gray, J. A., Feldon, J., Rawlins, J. N. P., Hemsley, D. R., & Smith, A. D. (1991). The
neuropsychology of schizophrenia. Behavioral and Brain Sciences, 14, 1-84.
Green, M. F. (2001). Schizophrenia revealed: From neurons to social interactions. New
York: W. W. Norton.
Hatfield, A. B., & Lefley, H. P. (1993). Surviving mental illness: Stress, coping and
adaptation. New York: Guildford.
Heinrichs, R. W. (2001). In search of madness: Schizophrenia and neuroscience. New
York: Oxford University Press.
Johnstone, E. C., Humphreys, M. S., Lang, F. H., Lawrie, S. M., & Sandler, R. (1999).
Schizophrenia: Concepts and clinical management. New York: Cambridge University
Press.
Leudar, I., & Thomas, P. (2000). Voices of reason, voices of insanity: Studies of verbal
hallucinations. Florence, KY: Taylor and Francis/Routledge.
Lidz, T. (1985). Schizophrenia and the family. New York: International Universities
Press.
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Malone, J. A. (1992). Schizophrenia: Handbook for clinical care. Thorofare, NJ: SLACK
Inc.
Nicholson, I. R., & Neufeld, R. W. J. (1993). Classification of the schizophrenias
according to symptomatology: A two-factor model. Journal of Abnormal Psychology,
102, 259-270.
Robbins, M. (1993). Experiences of schizophrenia: An integration of the personal,
scientific, and therapeutic. New York: Guilford Press.
Sattler, D., Shabatay, V., & Kramer, G. (1998). Abnormal psychology in context: Voices
and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 7, Schizophrenia.
Schiller, L., & Bennett, A. (1996). The quiet room: A journey out of the torment of
madness. New York: Harper.
Straube, E. R., & Hahlweg, K. (Eds.) (1990). Schizophrenia: Concepts, vulnerability, and
intervention. New York: Springer-Verlag.
Torrey, E. F. (1995). Surviving schizophrenia: A manual for families, consumers, and
providers. New York: Harper.
Warner, R. (2000). The environment of schizophrenia: Innovations in practice, policy
and communications. Philadelphia, PA: Brunner-Routledge.
Weiden, P. J., Diamond, R. J., Scheifler, P. L., Flynn, L., Diamond, R. I., & Ross, R.
(Eds.) (1999). Breakthroughs in antipsychotic medications: A guide for consumers,
families, and clinicians. New York: W.W. Norton.
SUGGESTED VIDEOS
Antipsychotic agents. (Insight Media). Examining the medications used to alleviate psychotic
symptoms, this video features reenactments that illustrate positive and negative symptoms as
well as such features as cognitive dysfunction and dysphonic mood. It presents commonly
prescribed agents used in the treatment of acute psychotic symptoms; addresses precautions, side
effects, and drug interactions; and includes interviews in which professionals and patients
discuss the impact of antipsychotic agents on patients with psychotic symptoms. (23 min)
A beautiful mind. This film presents the life of John Nash, a Nobel Prize-winning
mathematician, and his experience with schizophrenia. (Instructors may wish to emphasize that
the movie takes great license with the actual life story of Dr. Nash. The depiction of
hallucinations, delusions, and the difficulty a person with schizophrenia may have distinguishing
reality from fantasy is nonetheless very valuable as a teaching tool)
Birdy. This film depicts a catatonic inpatient in a military hospital who is also a Vietnam
veteran.
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Dark side of the moon. (Fanlight Productions). This film documents the struggles and
successes of three formerly homeless men with mental illnesses. (25 min)
Deficits of mind and brain. (Available through your Cengage Learning representative).
The second module begins with an overview of schizophrenia. Also provided are diagnostic
criteria and examples of patients in therapy (showing thought insertion, thought withdrawal, and
paranoid delusions). In the second portion of this module, four patients suffering from
schizophrenia are presented. The third portion of this module uses the Wisconsin Card Sorting
Task to demonstrate how lesion location has different effects on task completion. The fourth
portion introduces PET imaging techniques for isolating patterns in cerebral processing across
brain structures, the fifth describes cognitive deficits, and the sixth covers cognitive neuroscience
and schizophrenia. The last portion covers genetics and schizophrenia.
First break. (Fanlight Productions). This film documents the impact of the “first break” of
mental illness in three young people in their teens and early twenties, as well as the effects on
their families. (51 min)
I never promised you a rose garden. The patient depicted in this film has command
hallucinations that tell her to kill herself. The film provides a sympathetic portrayal of psychiatry
and treatment.
One flew over the cuckoo’s nest. This classic film stars Jack Nicholson as a patient in a
psychiatric hospital. The film depicts life on an inpatient ward, including controversial
treatments such as ECT and frontal lobotomies.
Repulsion. This is an intense film about sexual repression and psychotic decompensation,
providing good examples of hallucinations.
Rosenhan’s Experiment: Being Sane in Insane Places. (Insight Media). In 1973,
psychologist David Rosenhan conducted a study in which eight mentally healthy pseudo-patients
entered psychiatric institutions in order to test the validity of psychiatric diagnosis. The pseudopatients mimicked symptoms of either schizophrenia or bipolar disorder to get admitted and then
quickly stopped these behaviors once inside the hospital. This DVD looks at the methodological
strengths and weaknesses of this classic study, reviews its findings, and considers its relevance
today. (19 min)
The snake pit. This is one of the first films to document the treatment of patients in
mental hospitals.
To Define True Madness: Concepts of Schizophrenia. (Insight Media). Exploring
historical ideas of mental illness in different cultures, this program shows how early theories of
mental illness based on spirit or divine possession gave way to secular, scientific views. It
considers the sense of self and the idea of losing one’s mind, questioning if this defines a
society’s ideas of personhood. (59 min)
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ONLINE RESOURCES
Mental Health Net Schizophrenia
http://www.mentalhealth.com/home/dx/schizophrenia.html
This page provides an outstanding starting point for up-to-date information about the
diagnosis, etiology, and treatment of schizophrenia, including numerous links to patient and
scholarly websites.
National Alliance of the Mentally Ill
http://www.nami.org
This site is a useful resource for information related to the treatment of severe mental
illness, including legal issues and national health policy guidelines.
NIMH Schizophrenia: Questions and Answers
http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml
This is a site containing questions and answers regarding schizophrenia provided by the
National Institute of Health.
Psych Central -- Schizophrenia
http://psychcentral.com/disorders/sx31.htm
Site with lots of information about schizophrenia and available treatment options.
Schizophrenia.Com Home Page
http://www.schizophrenia.com/
Provides links to other webpages devoted to schizophrenia. This is a good starting place
for finding information on schizophrenia on the Internet.
NPR “‘My Lobotomy’: Howard Dully’s Journey”
http://www.npr.org/2005/11/16/5014080/my-lobotomy-howard-dullys-journey
The story behind the main advocate of the lobotomy in America, as narrated by one of his
patients.
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WARNING SIGNS OF
SCHIZOPHRENIA
 Hearing or seeing something that isn’t there
 A constant feeling of being watched
 Peculiar or nonsensical way of speaking or writing
 Strange body positioning
 Feeling indifferent to very important situations
 Deterioration of academic or work performance
 A change in personal hygiene and appearance
 A change in personality
 Irrational, angry, or fearful response to loved ones
 Inability to sleep or concentrate
 Inappropriate or bizarre behavior
 Increased withdrawal from social situations
 Extreme preoccupation with religion or the occult
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