Download Types of schizophrenia - Westminster Kingsway College

There are 3 first rank symptoms:
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1
Passivity experiences. These
are:
Thoughts coming into the mind
from outside.
Thoughts which seem to be taken
out of the mind.
Thoughts which are broadcast.
First Rank Symptoms
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2
Hallucinations:
These can occur in any sensory form but they are usually
auditory.
Usually a voice is heard commenting on character and giving
commands.
Sometimes the hallucinations affect the sense of touch, when
the body feels either on fire or numb, for example.
The person may sometimes feel separated from the body.
Friston (1995) says that schizophrenics find it difficult to
connect different areas of the brain.
In the brain we have an auditory feedback loop which tells us
that the voice in our heads is our own.
Schizophrenics don’t make this connection. They are often
not aware that they are talking out loud.
First Rank Symptoms
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3
Delusions: There are 4 types:
Delusions of grandeur – such as a belief that
a person is Napoleon, God, Queen Victoria, etc.
Delusions of persecution – such as the CIA or
FBI are after you.
Delusions of reference – objects and events
have negative influences. For example, the TV
sends out negative messages.
Delusions of nihilism – the destruction of
everything, all is purposeless – the belief that
nothing exists and that the person or individual
has been dead for years and has been observing
themselves from a distant place.
The Second Rank Symptoms of
Schizophrenia:
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These are:
Thought process disorder – we are bombarded
with sensory information and most people focus
on the information that is important at that time.
Schizophrenics find it hard to focus on specific
bits of sensory information and so find it difficult
to concentrate. This is the reason for the
individual shifting from one topic to another.
Sometimes the language can be completely
jumbled, and in psychology, this is called a ‘word
salad’. One word can lead to an association which
is not connected with what was said before.
Another aspect of this condition is thought
blocking or stopping in the middle of a sentence.
2nd Rank Symptoms
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Disturbance of affect (emotions) – There are
3 types of emotional disturbance:
Blunting - the emotional actions are not as acute
as most other individuals.
Flattening – there appears to be no emotional
tone to the voice. On occasions when most
people would respond with anger or joy, a
schizophrenic would respond in a monotone.
Inappropriate affect (emotion) – the wrong
emotions are displayed in situations that
shouldn’t elicit such a response, eg laughing at
news of a death.
Second Rank Symptoms
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Psychomotor disturbances – one of
the main psychomotor disturbances is
catatonia – a posture is adopted which
may be maintained for days.
Attempting to move someone in such a
state can bring on physical violence.
Catatonics are also silent.
Another psychomotor disturbance is
stereotypy (repetitive behaviour). This
is when the person makes repetitive
movements, eg the movement of
knitting a sweater.
2nd Rank Symptoms
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Lack of volition – lack of will to
do something, eg talk or
participate.
This is when the person does not
have the will to interact with
others.
If the state gets very bad, the
person is completely unresponsive
to others.
Types of schizophrenia
1 Hebephrenic schizophrenia –
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This form of schizophrenia results in severe disturbance of
language which often leads to incoherence.
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It is progressive and irreversible and usually starts in
adolescence.
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They often have many delusions and/or hallucinations
which generally are sexual or religious.
2
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Simple schizophrenia
Simple schizophrenia – the
onset is usually in late
adolescence and the symptoms
are:
Withdrawal from reality.
Lack of drive.
A sharp decline in academic
performance.
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Catatonic schizophrenia
A posture is adopted which may be maintained for days.
Attempting to move someone in such a state can bring on
physical violence.
Catatonics are also silent.
Another psychomotor disturbance is stereotypy (repetitive
behaviour). This is when the person makes repetitive
movements, eg the movement of knitting a sweater.
One other symptom is that catatonics can be moved into
any shape, which is termed ‘waxy flexibility’. There are
two main types of catatonia:
Agitated catatonia – this is when they make excited and
violent movements.
Mutism – this is when they are totally unresponsive but
they are often aware of what you are saying.
Another form is when the person does the opposite of what
you ask them to do.
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Paranoid schizophrenia
The onset of paranoid
schizophrenia is usually later than
adolescence.
They have delusions and
hallucinations of persecution.
However, their awareness is high
and language and behaviour are
almost the same as other peoples.
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Atypical schizophrenia
This category has been used for
people who are not easy to
classify.
Some people who have very
unusual thoughts or emotions are
put into this category.
Others may have schizophrenic
reactions which only last for a few
months.
Why is diagnosis difficult?
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The question that needs to be asked is:
Can there be so many different types of schizophrenia?
This suggests that there is no single, underlying factor. If
there was, we would expect all people with schizophrenia
to show exactly the same set of characteristics.
This has led some researchers to question the validity of
schizophrenia as a diagnosis and suggest that the term
should be abandoned.
According to this view, each of the symptoms of
schizophrenia should be seen as a disorder in its own
right.
There are some individuals who show symptoms similar to
those seen in schizophrenia but who do not exactly meet
the criteria, for example, schizophreniform psychosis -
Schizophreniform disorder
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The symptoms of both disorders can
include delusions, hallucinations,
disorganized speech, disorganized or
catatonic behavior, and social withdrawal.
While impairment in social, occupational, or
academic functioning is required for the
diagnosis of schizophrenia, in
schizophreniform disorder an individual's
level of functioning may or may not be
affected.
Diagnostic problems
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While the onset of schizophrenia is often gradual
over a number of months or years, the onset of
schizophreniform disorder can be relatively rapid.
Some psychologists believe that schizophrenia
should be seen in terms of the degree to which
problems are experienced, not simply the presence
or absence of such problems.
For example, it has been found that people who
have not been diagnosed with schizophrenia can
nevertheless experience on the its main symptoms
(ie hearing voices) but the have strategies to cope
with them and they do not feel disabled by them.
Diagnostic problems
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It can also be difficult for clinicians to
distinguish between schizophrenia and
other seemingly quite separate syndromes.
For example, people with temporal lobe
epilepsy often show similar symptoms to
those of schizophrenia.
Certain recreational drugs can cause
psychotic behaviour and can be difficult to
distinguish between drug-induced psychosis
and schizophrenia.
Explanations of schizophrenia:
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Genetic explanations:
In the general population, 1 in a 100 people suffers from
schizophrenia – 1%
If one parent is schizophrenic, the chances of a child becoming
schizophrenic is 1 in 5 -20%
If both parents are schizophrenic, the chances go up to 1 in 2. – 50%
When studies are done in genetics and genetic links, identical and
non-identical twins are looked at for the purposes of research.
Identical twins have the same genetic material.
When one identical twin has schizophrenia, there is a 42% chance
that the other will have schizophrenia as well.
When one non-identical twin has schizophrenia, there is a 9% chance
of the other having schizophrenia.
When identical twins are separated at birth and are therefore in
different environments, the percentage is still as high. 42%
This suggests a genetic influence. However, no twin study has yet
shown 100 per cent concordance in monozygotic twins (identical
twins). This suggests genetics cannot offer a complete explanation.
The Risks of Getting Schizophrenia
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The risks:
Source: Treatment Advocacy Centre
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After a person has been diagnosed with
schizophrenia in a family, the chance for a
sibling to also be diagnosed with
schizophrenia is 7 to 9 percent.
If a parent has schizophrenia, the chance
for a child to have the disorder is 10 to 15
percent.
Risks increase with multiple affected
family members.
Genetic explanation continued:
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There seems to be a genetic link but the gene
responsible has not been identified.
There is probably not one crucial gene but lots of
little genes, each of which play only a minor role.
Since 2001, about 6 or these schizophrenia genes
have been found. The strongest evidence is for a
gene called Neuregulin.
It is important to emphasize that neither
Neuregulin nor any other gene make it inevitable
that a person gets schizophrenia, it is just that
different forms of these genes affect an
individual’s risk of this happening.
Genetic explanation continued:
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Psychologists have looked at environmental
factors as well.
Heston (1966) looked at children who were
adopted by non-schizophrenic parents but whose
biological mothers were schizophrenic. 10% of
these children developed schizophrenia.
Klanning et al (1996) demonstrated by using the
new Danish Twin Register that if one
schizophrenic twin is admitted into hospital, the
likelihood of the other being admitted is 28%
higher than the general population.
Biochemical explanations:
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Schizophrenics have very high levels of dopamine in
the brain, and dopamine receptors are 6 times
greater in certain areas of the brain than is
evidenced in non-schizophrenics.
Psychoactive drugs, such as cocaine and
amphetamines, can produce reactions which are
similar to certain types of schizophrenia, such as
feelings of persecution and hallucinations. These
psychoactive drugs are known to increase the
production of dopamine.
Phenothiazines are drugs given to schizophrenics to
reduce the effects of schizophrenia. These drugs
reduce the concentration of dopamine in the brain –
eg Largactil.
Even though there is evidence that dopamine is
linked to schizophrenia, caution must be exercised
when saying that it causes schizophrenia.
Biochemical explanations continued:
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The causes are probably more complex, and there is
evidence that not all schizophrenics react positively to
phenothiazines.
Crow et al (1982) pointed out that phenothiazines only
reduce the symptoms of the Type 1 conditions, which
are hallucinations and delusions. They do not reduce
the ill-effects of the Type 2 symptoms, such as
problems with speech, diminished drive, and loss of
emotional content.
This suggests that schizophrenia may have more than
one cause. Dopamine appears to be linked with
delusions and hallucinations, but not with the other
symptoms.
Genetics may play a part, in that it predisposes certain
people to schizophrenia, but environmental factors may
trigger a schizophrenic attack.
Neuroanatomical explanations:
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Magnetic resonance imaging (MRI) has been a
tremendous breakthrough because it provides a
picture of the living brain. MRI studies show quite
definite structural abnormalities in the brains of
many patients with schizophrenia.
Brown et al, 1986, found decreased brain weight
and enlarged ventricles, which are cavities in the
brain that hold cerebrospinal fluid.
One of the main problems in trying to understand
the causal direction is that, so far, brain imaging in
relation to schizophrenia has mainly been restricted
to people who have already been diagnosed. Hence,
it is not clear whether structural abnormalities
predispose to schizophrenia, or whether the onset of
clinical symptoms cause structural damage.
Schizophrenia and Brain Tissue Loss
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Significant Loss of Brain Gray Matter:
Individuals with schizophrenia, including those
who have never been treated, have a reduced
volume of grey matter in the brain, especially in
the temporal and frontal lobes.
Recently neuroscientists have detected grey
matter loss of up to 25% (in some areas).
The damage started in the parietal, or outer,
regions of the brain but spread to the rest of the
brain over a five year period.
Patients with the worst brain tissue loss also had
the worst symptoms, which included
hallucinations, delusions, bizarre and psychotic
thoughts, hearing voices, and depression.
Early and late grey matter deficits
New drug research
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Please note that while there is significant loss of
brain grey matter, this is not a reason to lose all
hope.
There are reasons to believe that this grey matter
loss may be reversible.
Moreover, the NIMH is currently researching a
drug that seems to have potential for reversing
the cognitive decline that is caused by
schizophrenia, and there are many drug
companies also now researching in this area.
It is anticipated that we will see some significant
announcements related to these developments in
the next few years.
Pregnancy and birth factors as
explanations for schizophrenia:
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Since the late 1920s, it has been noticed that an
overwhelmingly high proportion of people diagnosed with
schizophrenia were born in the winter and early spring.
A number of viral infections, such as measles, scarlet
fever, polio, diphtheria and pneumonia, and in particular,
influenza A, have been suggested as an explanation of
schizophrenia.
Influenza A is most prevalent in the winter and could
explain the high proportion of winter births in those
diagnosed with schizophrenia.
It is thought that the 25 to 30 week foetus is most
vulnerable because of accelerated growth in the cerebral
cortex at this time. It is hypothesized that the viral
infection enters the brain and gestates until it is activated
by hormonal changes in puberty.
Alternatively, there may be a gradual degeneration of the
brain which eventually becomes so severe that symptoms
of schizophrenia emerge.
Torrey et al, 1988, found that peaks in schizophrenia
diagnosis have corresponded with major flu epidemics.
Diathesis-Stress explanations:
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Although it has been well established that
biological factors are important in explaining the
origins of schizophrenia, it is clear that
environmental influences also have a part to play.
The reasoning behind this theory is that certain
individuals have a constitutional predisposition to
the disorder, but will only go on to develop
schizophrenia if they are exposed to stressful
situations.
Stressful events in the environment, such as
major life events, traumatic experiences, or
dysfunctional families, may then act as a ‘trigger’
in a high-risk individual.
Psychological explanations:
The role of social and family
relationships
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This theory was proposed by Bateson who
suggested that schizophrenia can be created by
parents imposing a ‘no win’ situation on their
children.
Whatever the child does, the child is wrong and
whatever the child wants, they cannot have - no
matter what they do to get it.
Bateson proposed the ‘double bind’ hypothesis,
where children are given conflicting messages
from parents who express care, yet at the same
time appear critical.
It was thought that this led to confusion, selfdoubt and eventual withdrawal.
The role of family relations:
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Another view was proposed by Lidz (1973).
He suggests that schizophrenics often come from
families in which parents experience constant
discord.
Sometimes both parents have severe problems
and sometimes one parent appears to be
emotionally demanding and distressed.
Erica Fromm observed that many schizophrenics
have mothers who are domineering, neglecting,
guilt producing and cold.
The role of family relations continued:
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In the past 50 years, there has been
some interest in the idea that disturbed
patterns of communication within families
might be a factor in the development of
schizophrenia.
The term ‘schizophrenogenic families’ was
used to describe families with high
emotional tension, with many secrets,
close alliances and conspiracies.
The criticism of this approach is that
many people from these types of
background do not become schizophrenic.
The Psychodynamic explanation
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This is basically an idea that Freud proposed.
The first stage of development is the oral phase, when the
infant’s main pleasure comes from sucking.
At this stage the child is completely egocentric. The baby
believes that the mother and itself are one. At this stage the id
is totally dominant. The id is all the drives we have. Infants
demand the satisfaction of their drives.
Psychodynamic theory suggests that in the case of schizophrenia
the person regresses to the oral stage of development.
The ego (the person we wish to show the world we are) is
overwhelmed by the id or the demands of the id.
The superego (all the things authority figures tell you you should
and shouldn’t be) is overwhelmed by the id’s drives and feels
unbearable guilt.
During the oral stage, the infant is egocentric and believes in its
complete self importance.
When people regress to the oral stage, they suffer from delusions
of self-importance and fantasies become confused with realities,
which leads to hallucinations.
The main criticism of this model is that schizophrenic behaviour
does not resemble infantile behaviour.
Behavioural explanations:
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The behaviourists believe that all behaviour
occurs because of reinforcements.
They argue that schizophrenic behaviour becomes
pronounced because it is a reinforced form of
attention.
Attempts have been made to change behaviour
through conditioning.
The main criticisms are:
Very little evidence exists to suggest that
conditioning changes schizophrenic behaviour.
How do they start behaving in this way without
models to copy?
Cognitive explanations:
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Many schizophrenics have problems with language and
thought processing.
Maher (1968) proposed the idea that schizophrenics cannot
concentrate on more than one or two aspects of sensory
information.
The cognitive psychologists argue that schizophrenics are
bombarded with sensory information and explain catatonic
behaviour as the individual ‘shutting down’ because they
cannot take any more sensory bombardment.
As people with schizophrenia are subjected to sensory
overload and do not know which aspects of a situation to
attend to and which to ignore, it means that superficial
incidents might be seen as highly relevant and significant.
For example, a conversation at the next table in a restaurant
might be interpreted as being personally relevant. In other
words, the person may think the conversation is about them
personally.
Cognitive explanations continued:
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Apart from attentional deficits, schizophrenics have
abnormalities of memory, which becomes apparent
when trying to problem solve or do similar tasks.
They appear to forget what they have been taught and
approach a similar but new task as if they have never
encountered anything like it before.
These difficulties are associated with abnormal
functioning of the frontal lobes.
The main criticisms of the cognitive explanations are
that they do not really explain the causes of
schizophrenia.
They merely propose that schizophrenia is an illness
associated with a breakdown in the ability to
concentrate on one or a few things at one time.
Current psychological thinking:
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By the mid-1970s, psychologists had become more
interested in the part the family might play in the
course, rather than the cause of schizophrenia.
Vaughn and Leff, 1976, observed that patients with
schizophrenia who returned to homes where a high
level of emotion was expressed, (high EE) such as
hostility, criticism, over-involvement and over-concern,
showed a greater tendency to relapse than those
returning to homes where emotional ups and downs
and negativity were low (low EE).
It was found that the relapse rate increased to 92% in
high EE homes with increased contact coupled with no
medication.
Twenty years on, EE has now become a well
established ‘maintenance’ model of schizophrenia.
Conclusions:
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Adoption studies show that the family in
which a child is brought up in makes
little, if any, difference to that child’s risk
of developing schizophrenia. Evidence
clearly demonstrates a biological link.
On the other hand, psychological factors
undoubtedly influence the course of the
illness; that is, the chances of a patient
with schizophrenia relapsing and
becoming ill again are affected by how
the people around them behave.