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Chapter 11
Schizophrenia
Ch 11
Schizophrenia
• Schizophrenia is a psychotic disorder
involving disturbance of thought, emotion
and behavior
• The lifetime prevalence of schizophrenia is
about 1%
– Onset is usually in late adolescence
– Substance abuse is a co-morbid condition in
50% of schizophrenia patients
Ch 11.1
 Broad Impairments
 Delusions & Hallucinations
 Disorganized Speech & Behavior
 Inappropriate Emotions
 Psychosis: extreme mental
unrest with loss of reality contact
(Davison & Neale, p. 134)
 Cause is Unknown
 Affects 1 out of 100 People
 Often Begins (Ages 16 - 30)
 More Hospital Beds Than Any Other
Medical Illness
2.5% of Total U.S. Healthcare Budget
 Often Chronic
 Occurs in .2% to 1.5% Population
 Affects Men and Women Equally
– Age of Onset Varies Across Time
 Lower Life Expectancy
– Increased Risk of Suicide
 People with schizophrenia have
“split personalities.”
 People with schizophrenia are
intellectually disabled?
 People with schizophrenia are
dangerous?
 People with schizophrenia are
addicted to their drugs?
 Schizophrenia is NOT caused by
bad parenting or an unhappy
childhood.
 Schizophrenia is NOT due to a
weakness in character.
 Schizophrenia is NOT due to a
negative social label.
 Schizophrenia is NOT a hopeless
situation.
 Dementia (Loss of Mind)
 Praecox (Early, Premature)
 Kraepelin
– Categorization & Early Onset
 Eugen Bleuler
– Termed “Schizophrenia”
– Associative Splitting
 Positive Symptoms
– Displays of Abnormal Behavior
 Disorganized Symptoms
– Speech and Behavior
 Negative Symptoms
– Deficits in Affect, Speech,
Motivation
 Positive Symptoms
 Delusions
– Misrepresentation of Reality
– “Basic Feature of Madness”
 Examples
– Grandeur -- Importance
– Persecution -- Out to Get Me
 Positive Symptoms
 Hallucinations
– Absence of Sensory Stimulation
– Involve Any of the Senses
 Examples
– Auditory -- Voices (70%)
– Visual -- Seeing Things (25%)
– Tactile -- Crawling Sensation
Broca’s Area
(Speech)
Wernicke’s Area
(Hearing)
What Area Do You Think is
More Active With Auditory Hallucinations?
 Positive
Symptoms
 Disorganized Symptoms
 Disorganized Speech
– Difficulty in Communication
 Examples
– Tangentiality
– Loose Association or Derailment
 Positive
Symptoms
 Disorganized Symptoms
 Disorganized Behaviors
 Catatonia
– Spectrum
– Wild Agitation to Immobility
 Example
– Waxy Flexibility
– Inappropriate Affect
 Positive
 Disorganized
 Negative Symptoms
Symptoms
 Flat Affect -- “The Mask”
 Avolition -- “No Initiative”
 Alogia -- “Speech is Vacant”
 Anhedonia -- “No Pleasure”
 Asociality--”No social interest”
Positive Symptoms of
Schizophrenia
• Positive symptoms involve excesses or distortions
– Disorganized speech (thought disorder)
– Hallucinations are sensory experiences that occur in
the absence of environmental stimulation
• Hallucinations are commonly auditory
– Delusions are beliefs that are contrary to reality
• Persecutory delusions are common
Ch 11.2
Negative Symptoms of
Schizophrenia
• Negative schizophrenia symptoms are
characterized by behavioral deficits
– Avolition refers to a lack of energy and an inability to
persist in routine activities
– Alogia refers to a reduction in the amount or content of
speech
– Anhedonia is an inability to experience pleasure
– Asociality refers to a severe impairment in social
relationships
Ch 11.3
DSM-IV Schizophrenia
Categories
• Disorganized schizophrenia involves
– Disorganized speech and flat affect
– A general disruption of behavior
• Catatonic schizophrenia involves
– Prolonged motor immobility states that alternate with
periods of excitability
• Paranoid schizophrenia involves the presence of
prominent delusions including persecution and
grandiosity
• Undifferentiated schizophrenia and residual
schizophrenia
Ch 11.4
 Paranoid Type
 Disorganized Type
 Catatonic Type
 Undifferentiated Type
 Residual Type
 Delusions & Hallucinations
 Intact Cognition and Affect
 No Disorganized Speech
 Best Prognosis
 Paranoid Type
 Disorganized Type
 Catatonic Type
 Undifferentiated Type
 Residual Type
 Disorganized Speech
 Disorganized Behavior
 Flat or Inappropriate Affect
 Hallucinations and Delusions
– Fragmented or Lacking a Theme
 Often Chronic
 Paranoid Type
 Disorganized Type
 Catatonic Type
 Undifferentiated Type
 Residual Type
 Disorganized Speech
 Disorganized Behavior
Waxy flexibility, rigidity, odd
mannerisms, mimicry
 Flat or Inappropriate Affect
 Hallucinations and Delusions
– Fragmented or Lacking a Theme
 Often Chronic
 Paranoid Type
 Disorganized Type
 Catatonic Type
 Undifferentiated Type
 Residual Type
 Beginnings of Breakdown
 Major Sx of Schizophrenia
 DO NOT Meet Other Criteria
 “Wastebasket” Category
 Paranoid Type
 Disorganized Type
 Catatonic Type
 Undifferentiated Type
 Residual Type
 Have Had One Episode
 Now Mostly Symptom Free
Once a Schizophrenic,
Always a Schizophrenic?
Classification Systems and Their
Relation to Schizophrenia
Process vs. Reactive Distinction
Process – Insidious onset, biologically based, negative symptoms,
poor prognosis
Reactive – Acute onset (extreme stress), notable behavioral activity,
best prognosis
Good vs. Poor Premorbid Functioning in Schizophrenia
Focus on person’s level of function prior to developing schizophrenia
No longer widely used
Type I vs. Type II Distinction and Schizophrenia
Type I – Positive symptoms, good response to medication,
optimistic prognosis, and absence of intellectual impairment
Type II – Negative symptoms, poor response to medication,
pessimistic prognosis, and intellectual impairments
 Early Brain Damage
 Neurological “Soft Signs”
– Attentional and Reflex Problems
(Nasrallah & Smeltzer, 2002)
 Runs In Families
– High Expressed Emotion & Relapse
– What is the Genetic Risk?
Etiology of Schizophrenia
• Genetic studies using twin, family and
adoption techniques reveal that a
predisposition for schizophrenia is
transmitted genetically
• Brain pathology, possibly including damage
to the fetal brain from virus-like diseases,
are likely biological vulnerabilities for
schizophrenia (diathesis)
Ch 11.5
Genetic Studies of
Schizophrenia
Relation to
Proband
Percentage
Schizophrenic
Spouse
Grandchildren
Nieces/nephews
Children
Siblings
DZ twins
MZ twins
1.00
2.84
2.65
9.35
7.30
12.08
44.30
Ch 11.6
 Genetic Influences
 Runs in Families
 Increased Risk Based on Genetic Relatedness
 Search for Marker Genes
Smooth Pursuit Eye Tracking
Biochemistry of Schizophrenia
• Dopamine theory holds that the positive
symptoms of schizophrenia result from excessive
activity of dopamine in brain
– Anti-schizophrenia drugs block dopamine receptors
• The anti-schizophrenia drugs take several weeks to act
clinically, yet rapidly block dopamine receptors
– Ingestion of amphetamine can induce psychosis;
amphetamine causes the release of dopamine from
neurons
Ch 11.7
Figure 11.1 Dopamine Activity in
Mesolimbic and Mesocortical Pathways
•Overactivity of dopamine neurons
in the mesolimbic pathway may
cause positive symptoms.
–Antipsychotics which block dopamine
receptors lessen positive symptoms
•Underactivity of dopamine neurons
in the mesocortical pathway in the l
prefrontal cortex may cause
negative symptoms
–Antipsychotics have little or no effect
on negative symptoms.
Ch 11.8
Dopamine Theory of
Schizophrenia
 Neurobiological Influences
 Excess Dopamine (D2 Receptors)
 Antagonists
–
–
–
–
–
Neuroleptics
Drugs That Reduce Dopamine
Negative Side Effects
L-Dopa (Agonist)
Amphetamines
 Genetic Influences
Glutamate Theory
• PCP (“angel dust”) and ketamine (an anesthetic)
mimic the positive and negative symptoms of
schizophrenia (Javitt & Cole, 2004)
• These drugs block the action of a form of
glutamate receptor (NMDA receptor)
• NMDA receptor blockade may produce the
dopamine dysfunction seen in schizophrenia, as
if too little dopamine were present in the
prefrontal cortex (negative symptoms) and too
much dopamine in the mesolimbic area (positive
symptoms)
Brain Pathology in
Schizophrenia
• Brains of schizophrenic patients show
– Reduced volume of temporal and frontal cortex
– Enlarged ventricles (reflecting loss of brain cells)
• For 12 of 15 twins, the schizophrenic twin could be
identified by enlarged ventricles
– Reduced metabolic activity within prefrontal
cortex (frontal hypoactivation)
Ch 11.9
 Brain Structure
 Ventricle Enlargement
 Genetic
 Neurobiological
Influences
 Brain Structure
 Ventricle Enlargement
 Hypofrontality
 Genetic
 Neurobiological
Influences
Psychological Stress &
Schizophrenia
• Example of diathesis-stress model
• Social class and schizophrenia
– Sociogenic hypothesis
– Social-Selection theory (more research
support)
• Expressed emotion (EE) - Research shows
how family and social environmental
context affects re-hospitalization rates
• High-Risk studies of schizophrenia
Causes of Schizophrenia:
Psychological and Social Influences
(cont.)
Figure 13.9 Barlow/Durand, 3rd. Edition. Cultural differences in expressed
emotion (EE)
Therapies for Schizophrenia
• Psychosurgery
– Prefrontal lobotomy
• Drug therapies
– Antipsychotic medications that block dopamine receptors
• Chlorpromazine (Thorazine)
– Became widely available in 1954
• Others include haloperidol (Haldol) and thiothixene (Navane)
– Reduce agitation, violent behavior, and other emotional and
behavioral excesses.
– Disadvantages:
• Side effects especially extrapyramidal side effects
• About 30% of patients do not respond
• Little or no effect on negative symptoms
– Newer medications:
• Clozapine (Clozaril), respiradone (Risperdal)
Ch 11.10
 Biological Interventions
 Neuroleptics
 Haldol & Clozapine
 Trial and Error
 “Extrapyramidal” Side Effects
Tardive Dyskinesia
Akinesia
Atypical Antipsychotics: (Clozapine, Risperdal,
Zyprexa,Seroquel, Geodon, Abilify)
Medical Treatment of
Schizophrenia (cont.)
Table 13.2 Barlow/Durand, 3rd.
Antipsychotic medications
Psychological Treatments for
Schizophrenia
• Social-skills training involves teaching behaviors
to interact successfully with others
• Family therapy aims to reduced expressed
emotion (hostility, overly critical)
• Cognitive-behavioral therapy demonstrates that
maladaptive behaviors and beliefs of some
patients can be changed
– Personal therapy aims to reduce expressed emotion,
uses relaxation techniques and teaches social skills
Ch 11.11`
Cognitive-Behavioral
Therapies
• Personal Therapy
– Patients are taught
•
•
•
•
To recognize inappropriate affect
To recognize signs of relapse
Relaxation techniques to reduce anxiety & anger
Rational emotive therapy techniques to reduce frustration and
prevent explosive or inappropriate interpersonal behavior.
• Social skills training to enhance interpersonal functioning.
Psychosocial Treatment of
Schizophrenia
Figure 13.10 Barlow/Durand, 3rd. Edition
Studies on treatment of schizophrenia from 1980 to 1992
Summary of Schizophrenia
and Psychotic Disorders
Figure 13.x1 Barlow/Durand, 3rd. Ed.
Exploring schizophrenia and its treatment
Summary of Schizophrenia and
Psychotic Disorders (cont.)
Figure 13.x1 Barlow/Durand, 3rd Edition (cont.)
Exploring schizophrenia and its treatment
 Schizophreniform Disorder
 Schizoaffective Disorder
 Delusional Disorder
 Brief Psychotic Disorder
 Shared Psychotic Disorder
Folie a Deux