Download Schizophrenia

CLINICAL CHARACTERISTICS
OF SCHIZOPHRENIA
Some films about the
symptoms of Schizophrenia
 https://www.youtube.com/watch?v=KBR
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 https://www.youtube.com/watch?v=LWY
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Learning objectives
 You must:

Identify two or more clinical characteristics of
schizophrenia
 You should:

Explain the differences between Type 1 and Type 2
 You could also:

Outline the difficulties when making a diagnosis
WHAT IS SCHIZOPHRENIA?
 Schizophrenia is not a multiple personality
 It is a psychotic disorder characterized by
the loss of contact with reality
 It has many different manifestations
with a few shared features
 Formerly referred to as:
 Lunacy, madness or insanity
NEUROSIS OR PSYCHOSES?
 NEUROSIS
 PSYCHOSES
 Mental health issues
that fall just outside
normal functioning but
the individual is in
touch with reality and
(potentially) knows they
are ill
 Mental health issues
where the individual has
lost touch with reality and
is not on a continuum with
normal mental health
Schizophrenia: Definition
 The most debilitating psychosis and the closest to the
layman’s definition of madness.
 Kraepelin (1896) called it dementia praecox (senility of
youth) because the symptoms occur fairly early on in
life and result in a gradual deterioration.
 Bleuler (1911) suggested that symptoms can occur
later, and coined the term schizophrenia, (‘split mind’ in
Greek) which symbolises the fragmentation of the
sufferer's personality.
 Schizophrenia exists world-wide, but its symptoms can
vary from culture to culture.
 Schizophrenia comprises a number of symptoms
which in different combinations produce three different
types of the disorder.
CLASSIFICATION
 POSITIVE SYMPTOMS – TYPE 1

Distortion of normal function
Delusions, hallucinations, disorganised speech, under the
control of an alien force, disordered thinking
 NEGATIVE SYMPTOMS – TYPE 2

Lack of normal function
Apathy, no emotion, flat effect, social withdrawal, Alogia
EVALUATION
 Positive symptoms



Can be affected by cultural differences
Tend to have greater weight when diagnosing
Hard to measure objectively
 Negative symptoms




Start before positive ones
Sometimes start years before diagnosis
Less affected by cultural factors
More objectively measured
DIAGNOSIS
Requires two or more POSITIVE symptoms
For a period of at least a month
•Can only be done by a psychiatrist
•As yet there is no physical way to diagnose
•Current research is looking at blood test or eye tracking
Schizophrenia onset
Source: CIHI (2001)
Symptoms of Schizophrenia
First Rank Symptoms
 In Britain, schizophrenia is only diagnosed in the presence of one of the following
‘first rank’ symptoms (disturbances of subjective experience as reported verbally
by the individual).
1) Disturbance of thought: the belief that thoughts are being inserted into the
individual’s mind from outside (thought insertion) or removed from their mind by
external forces (thought withdrawal), or that their thoughts are being made known
to others (thought broadcasting).
2) Hallucinations (the experience of sensory stimuli which are not present)
 Auditory (the most common). ‘Voices’: offer a commentary on the individual's
behaviour "he is eating his dinner";
 make disparaging remarks about him "he eats like a pig ";give him commands "put
the knife on the plate".
 ‘Voices’ may be a distortion of environmental noises (fridge or radiator noises
interpreted as whispering) or projections of the individual's own thoughts (thoughts
may enter the individual’s internal speech loop or even become spoken aloud
without the individual realising that the thoughts / speech are his own (malfunction
of the feedback loop).
 Somatic e.g. experience of electric shocks to the fingertips.
Symptoms of Schizophrenia
(contd)
3)

Delusions (beliefs which individuals are firmly convinced are true,
regardless of evidence to the contrary). These can come in:-
Delusions of grandeur: the individual is someone important or
powerful (Christ, Napoleon).
 Delusions of persecution: the individual is being conspired
against/interfered with by other people or organisations (M15, the
Mafia).
 Delusions of reference: the individual believes that unrelated
events have personal significance e.g. the words of a song refer
to them personally.
 Other common delusions: the belief that nothing really exists and
all things are simply shadows; the belief that one has been dead
for years and it is observing the world from afar.
Other Symptoms
These are symptoms not classified as ‘First Rank’ but are reported by observer’s of
patients’ behaviour:Thought Process Disorder
 a) Loose Association: the individual is unable to focus attention so he/she moves
from one topic of thought to another in a disjointed, illogical way.
 b) Word Salad: disjointed thought leads to incoherent, rambling language
association e.g. ‘I am the King of Spain, the daughter and the fruit tree, blossom in
Spring’.
 c) Clang association: the sound of one word triggers association with another
word e.g. ‘The King of Spain feels no pain in the drain of the crane’.
 d) Invention of new words and combining existing words in unusual ways e.g. ‘
belly bad luck and brutal and outrageous’ to describe stomach ache.
 e) Echolalia i.e. repetitive echoing of words spoken by others.
Motor Symptoms
 a) Catatonia: the individual stays mute and motionless in a fixed position for hours
or days on end.
 b) Stereotypes: the individual moves repetitively e.g. rocks to and fro.
 c) Agitation: including sudden, disturbing, unpredictable gestures and grimaces for
no apparent reason.
Other Symptom (contd)
Emotional Disturbance
 a) Blunting: apparent indifference to events which would normally
provoke a strong emotional reaction.
 b) Inappropriate Affect: e.g. laughing when told bad news,
reacting angrily if offered a gift.
 c) Flattened Affect: absence of emotional expression, speech is in
monotone, no mobility of facial features, vacant gaze.
Lack of Volition
 Loss of interest in the external and social world. Loss of drive.
 Inability to act, including inability to perform everyday living
activities e.g. washing, cooking.
Disordered Sense of Self
 Sufferer has little idea who he / she is and has no egoboundaries. The sufferer displays autism, and lives in a fantasy
world, taking no notice of the world around them.
Types of Schizophrenia
 Previously schizophrenia was classified into two types:
Acute (TYPE 1)
also known as positive syndrome schizophrenia.
sudden onset, with delusions and hallucinations as
early symptoms.
Chronic (TYPE 11)
also known as negative syndrome schizophrenia.
insidious onset with a history of apathy and social
withdrawal (loners)
worse prognosis than for acute schizophrenia.
Types of Schizophrenia (contd)
Now schizophrenia is classified into four main types:
Disorganised Schizophrenia: (the most severe type) onset:
adolescence or early adulthood; Disorganised thought and
language (loose association and word salad); Disorganised
delusions and vivid hallucinations, inappropriate and flattened
affect; Disorganised behaviour and extreme social withdrawal
Catatonic Schizophrenia Catatonia or agitation; loss of drive;
echolalia (involuntary repetition of sounds uttered by others)
Paranoid Schizophrenia onset: later than other types; Well
organised delusions and hallucinations; Language, behaviour and
the ability to carry out daily functions remain relatively normal.
Paranoid schizophrenics show the highest level of awareness!
Undifferentiated Schizophrenia is a diagnosis for people with
mixed symptoms who don’t fit any of the types clearly. Other
related disorders include:
a) Brief psychotic disorder b) Substance Induced psychotic disorder
Evaluating the Types of
Schizophrenia
 Although these types form the basis of current diagnostic
systems, their usefulness is often questioned. Because
diagnosing types of schizophrenia is extremely difficult, diagnostic
reliability is dramatically reduced.
 Furthermore, these sub-types have little predictive validity; that is,
the diagnosis of one over another form of schizophrenia provides
little information that is helpful in either treating or in predicting the
course of the problems.
 There is also considerable overlap among the types. For
example, patients with all forms of Schizophrenia may have
delusions. Kraepelin’s system of sub-typing has not proved to be
a useful way of dealing with the variability in schizophrenic
behaviours.
Evaluating the Types of
Schizophrenia (contd)
 A system that is currently attracting much attention distinguishes
between positive and negative symptoms (as opposed to types of
patients) continues to be used increasingly in research on the
aetiology of schizophrenia.
 Aetiology is defined as the science that deals with the causes or
origin of disease, the factors which produce or predispose toward
a certain disease or disorder. It is a medical term.
 Andreasen and Olsen (1982) evaluated fifty-two patients with
schizophrenia and found that sixteen could be regarded as having
predominantly negative symptoms, eighteen as having
predominantly positive symptoms, and eighteen as having mixed
symptoms.
 Although these data suggest that it is possible to talk about types
of schizophrenia, subsequent research has indicate that most
patients with schizophrenia show mixed symptoms (e.g.
Andreasen, Flaum et al.,1990) and that very few patients fit into
the pure positive or pure negative types.
The Course of Schizophrenia
Patients with Schizophrenia have been seen to go through three
phases/stages:1. Prodromal phase: Characterised by a steady deterioration including
emotional flatness and loss of drive. In Type 1, this is short, in Type 11
the onset is insidious (harmful).
2. Active Phase: involves major symptoms
3. Residual Phase: when the sufferer is in remission (return to the promodal phase).
Note: The three stages are not always clearly separable and the duration of
each phase is variable.
 A third of sufferers have one or two acute episodes (active phase) and
then return to normal.
 A third have periods of acute episodes and remissions (residual phase)
 A third deteriorate progressively (from active to chronic symptoms) over
time
PROGNOSIS
 ‘Rule of the thirds’ (rule of thumb):
 1/3 recover more or less completely
 1/3 episodic impairment
 1/3 chronic decline
 With treatment about 60% of patients manage a
relatively normal life
 Prognosis better in non-industrialised societies
Sample question
 Outline two or more clinical
characteristics of schizophrenia
(5 marks)
 Approx 6 minutes of AO1
Outline two or more clinical
characteristics of schizophrenia
(5 marks)
 The symptoms of schizophrenia are divided into positive and
negative. Positive symptoms reflect a distortion of normal
function, and include delusions (bizarre beliefs that appear
real but are not), a sense of being controlled (e.g. by an alien
force), auditory hallucinations (e.g. hearing voices), and
disordered thinking (e.g. the belief that thoughts are being
broadcast to others). Negative symptoms reflect a lessening
or loss of normal function, and include affective flattening (a
reduction in the range and intensity of emotional expression),
alogia (poverty of speech) and avolition (the inability to
initiate and persist in goal-directed behaviour). A diagnosis of
schizophrenia requires at least a one-month duration of two or
more positive symptoms. Negative symptoms often persist
during periods of few positive symptoms.
QUIZ
1.
2.
3.
4.
5.
6.
7.
What sub type is it if a person is suspicious of others
or has delusions of grandeur?
What sub type is it if a person is very withdrawn and
isolated with little physical movement?
What % of those diagnosed manage to lead a
normal life
What is the diagnosis of schizophrenia
Is a distortion of normal function a positive or
negative symptom
What is the difference between psychosis and
neurosis?
What age is the onset for males?
QUIZ - answers
1.
2.
3.
4.
5.
6.
7.
What sub type is it if a person is suspicious of others or has
delusions of grandeur? (paranoid)
What sub type is it if a person is very withdrawn and isolated
with little physical movement? (catatonic)
What % of those diagnosed manage to lead a normal life (60%)
What is the diagnosis of schizophrenia (2 or more symptoms for
1 month)
Is a distortion of normal function a positive or negative symptom
(+)
What is the difference between psychosis and neurosis? (with
psychosis the individual has lost touch with reality)
What age is the onset for males? (15 yrs)
Appendix (taken from Wiki)
Alogia
Q: Do you have any children?
A: Yes.
Q: How many?
A: Two.
Q: How old are they?
A: Six and sixteen.
Q: Are they boys or girls?
A: One of each.
Q: Who is the sixteen-year-old?
A: The boy.
Q: What is his name?
A: Edmond.
Q: And the girl's?
A: Alice.
Normal speech
Q: Do you have any children?
A: Yes, a boy and a girl.
Q: How old are they?
A: Edmond is sixteen and Alice is six.
Psychosis vs. Neurosis
Psychosis
Neurosis
Schizophrenia
Anxiety disorders, panic disorders
Manic depression (bipolar)
Post traumatic stress
Whole of personality affected
Part of personality affected
Lacks insight - Does not
recognise they have problem
Has insight (recognizes they have a
problem)
Loses contact with reality
Retains contact with reality
No obvious cause
Often begins as a response to a
stressor
Hallucinations and delusions
Not normal behaviour
Exaggeration of normal behaviour
Treated mainly by physical
methods
Treated mainly by psychological
methods