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Chapter 13
Schizophrenic Disorders
Copyright © 2006 Pearson Education Canada Inc.
Overview
Schizophrenia is a severe, progressive disorder
than often starts in adolescence and generally
has a poor outcome
affects 1% of the population
221,000 Canadians in 1996
Canadian health care: $ billions annually
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Overview
Similar prevalence for men and women - men are
slightly higher
for men onset is age 15-25 - average 21.9
for women onset is age 25-35 - average 26
71% will experience their 1st symptoms by 25 y/o
Key feature: psychotic symptoms profound disturbance in thought, realitytesting, and affect.
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Course of Schizophrenia
• Prodromal
– (usually in adolescence) - decreased level of functioning, social
withdrawal, peculiar behaviours, neglect hygiene, changes in
emotion
• Active
– full spectrum of psychotic symptoms - i.e., hallucinations, delusions,
disorganized speech
• Residual
–return to prodromal but may also be mild delusions/ hallucinations/
continuing negative symptoms and impairment
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Symptoms and Features

Positive symptoms
–
–
–
–
look for presence of delusions and
hallucinations
Hallucinations: sensory experiences not
caused by external stimulus
includes voices commenting on client’s
behaviour or giving instruction
60% of all hallucinations are auditory
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Positive Symptoms

Hallucinations
–
–
–
auditory: often insulting or instructing
tactile (e.g., something crawling under skin)
somatic (e.g., an alien residing in the
stomach)
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Positive Symptoms

Delusions: idiosyncratic beliefs that are rigidly
held despite their logical nature
–
–
defended even when shown contradictory
evidence
person is preoccupied with the beliefs
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Positive Symptoms

Delusions: persistent psychotic beliefs
–
–
persecutory (e.g., “others are spying on
me”)
reference
 objects,
people, events given personal
significance (e.g., “the radio announcer is
mocking me”)
–
grandeur (e.g., “I am Jesus”)
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Symptoms and Features

Negative symptoms
–
–
look for absence: poverty of speech, thought,
hygiene, movement
causes social withdrawal
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Negative Symptoms

Affective Disturbance
–
–
–

flattened affect: failure to exhibit signs of emotion
inappropriate affect: incongruity of emotional state
and behaviour
anhedonia: inability to experience pleasure
Social and Linguistic Deficits
–
–
–
apathy
avolition
alogia
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Disorganization

Thinking
–
–
–

loose associations: abruptly shifting topics
disorganized speech: saying things that don’t make
sense
tangentiality: irrelevant responses
Behaviour
–
–
–
catatonia: immobility and muscular rigidity
stupor
robot-like movements
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Historical Perspective
dementia praecox (Kraepelin)
 splitting of associations (Bleuer)
 first ranked symptoms (Schneider)

–
thought broadcasting
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Contemporary Perspective: DSM-IV-TR

emphasis on 3 types of symptoms
–
–
–
positive symptoms
negative symptoms
disorganization
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DSM-IV-TR Criteria for Schizophrenia
During a one-month period, two or more of
the following symptoms:





delusions
hallucinations
disorganized speech
grossly disorganized / catatonic behaviour
negative symptoms
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Subtypes: A) Catatonic
 stupor
 excitement
–
pacers, runners
 posturing
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Subtypes: B) Disorganized
 disorganized,
garbled speech
 disorganized, “crazy” behaviour
 wildly inappropriate affect
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Subtypes: C) Paranoid
preoccupation with one or more
systematic delusions or auditory
hallucinations
 theme of persecution or grandiosity
 no catatonic or disorganized symptoms

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Subtypes: D) Undifferentiated
 meets
the criteria for schizophrenia
but does not fit the other subtypes
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Subtypes: E) Residual
 no
current active phase symptoms
 continuing negative symptoms
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Other Psychotic Disorders

Delusional Disorder : preoccupation with
nonbizarre delusions for at least one month

Non-bizarre delusion
– being followed, poisoned, deceived, spied on,
or loved from a distance (erotomania)

Usually no odd behaviours, hallucinations, or
negative symptoms
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Other Psychotic Disorders

Schizoaffective Disorder
–

Schizophreniform Disorder
–

mix of schizophrenia and mood disorder, but psychotic
symptoms are present at some point without mood d/o
less than 6 months
Brief psychotic Disorder
–
–
psychotic symptoms for 1 day to one month
typically after major trauma
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Course and Outcome



Onset: Sudden vs. Gradual
Course: Undulating or Gradual
Outcome: Recovered/Mild Impairment vs.
Moderate/severe Impairment
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Suicide and Schizophrenia
Risk is 8-9 times normal population
 50% attempt suicide
 1.9% a year die by suicide
 Ultimately 10-13% successful

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Epidemiology

Culture
–
–
cross-cultural consistency
improved prognosis in developing countries

Social Class
–
adverse social and economic circumstances increases
the probability that persons who are genetically
predisposed will develop clinical symptoms
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Etiology: Biological Factors
genetics
 neurological impairments
 neurochemical irregularities

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Genetics





risk is greater is family member is affected
10-15 risk for first line relatives
3% for second line relative
46% if both parents are affected
twin concordance rates
– MZ: 48 %
– DZ: 17 %
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Neuropathological Correlates

Structural and functional anomalies in
frontal cortex and limbic areas:
–
–
–
enlarged ventricles
decreased hippocampal size
asymmetry in temporal cortex processing
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Neurochemistry

dopamine hypothesis
–
–

neuroleptic drugs block post-synaptic
dopamine receptors
excessive post-synaptic receptors?
interactions of multiple
neurotransmitters (e.g., GABA,
serotonin)
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Other Potential Biological Factors
 intrauterine
insult and birth
complications
 viral infections
 season of birth
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Epidemiology: Psychological Factors
Expressed Emotion (EE)
–
–
related to rate of relapse
patients who returned home to at least 1
member who has high EE were more likely
than low EE families to relapse
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Treatment

Antipsychotic Medication
–
–
–
–
began in 1950’s (e.g., Thorazine)
reduced the severity of symptoms
50% showed significant improvement - 4-6 weeks
continued maintenance medication reduced relapse
rate
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Treatment
*
*
Compliance Problems
Motor Side Effects
Extrapyramidal Symptoms: muscular rigidity, tremors,
agitation
Tardive Dyskinesia: involuntary movements of the
mouth and face, spasmodic movements of trunk and
body
–
increased use of atypical antipsychotics (clozapine)
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Treatment

Atypical Antipsychotic Medication
–
–
–
–
began in 1990’s (e.g., Clozaril, Haldol, Risperdal,
Zyprexa)
As effective in treating positive symptoms; more
effective in treating negative symptoms
30% of patients who did not improve on other
medication improved on atypical antipsychotics
As with classical antipsychotics, target receptors in the
cortex, limbic system, and also acts on serotonin
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Treatment




Other Medications:
Antianxiety/Sleeping Medication (Ativan, Valium)
Antidepressants (Prozac, Zoloft)
Mood Stabilizers (Lithium, Tegretol)
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Treatment

Psychosocial treatment
–
–
social skills training (e.g., modeling, role playing)
CBT
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Treatment

Assertive Community Treatment
–
provide an array of psychological interventions and
medication on a regular basis in the community (e.g.,
case management)
–
effective in reducing inpatient hospital stays
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Treatment

Institutional Programs
–
Hospitalization:(2-3 weeks) is often needed for acute
psychosis
–
Crisis Houses: often provides an alternative to
hospitalization. Less expensive - provides learning
programs
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Case Study:
Marilyn
paranoid schizophrenia
 psychotic belief in Cabir brothers
 auditory hallucinations
 visual hallucinations

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