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Abnormal Psychology in a Changing
World
Eighth Edition
Jeffrey S. Nevid/Spencer A. Rathus/Beverly Greene
Chapter 12
Schizophrenia and Other Psychotic
Disorders
Prepared by:
Ashlea R. Smith, PhD
Argosy University-Phoenix
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Schizophrenia
• Schizophrenia – A chronic psychotic disorder characterized by
disturbed behavior, thinking, emotions, and perceptions.
• Acute episodes of schizophrenia are characterized by delusions,
hallucinations, illogical thinking, incoherent speech, and bizarre
behavior.
• Between acute episodes, people with schizophrenia may still be
unable to think clearly, may speak in a flat tone, may have
difficulty perceiving emotions in other people’s facial
expressions, and may show little if any facial expressions of
emotions themselves.
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Course of Development
• Schizophrenia typically develops during a person’s
late adolescence or early adulthood (Walker &
Tessner, 2008).
• In some cases, the onset of the disorder is acute and
occurs suddenly, within a few weeks or months.
• Then a rapid transformation in personality and
behavior leads to an acute psychotic episode.
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Course of Development
• Prodromal phase – In schizophrenia, the period of
decline in functioning that precedes the first acute
psychotic episode.
• Residual phase – In schizophrenia, the phase that follows
an acute phase, characterized by a return to the level of
functioning of the prodromal phase.
• These cognitive and social deficits can impede the ability
of schizophrenia patients to function effectively in social
and occupational roles even more severely than the severe
hallucinations and delusions of the psychotic episode.
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Prevalence
• About 1% of the adult population in the United States is
affected by schizophrenia, more than 2 million people in
total (International Schizophrenia Consortium, 2009;
Perala et al., 2007).
• The WHO estimates that about 24 million people
worldwide suffer from schizophrenia (Olson, 2001).
• The disorder typically begins in women between age 25
and mid 30s and in men 18 and 25.
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Diagnostic Features
• Schizophrenia is a pervasive disorder that affects a
wide range of psychological processes involving
cognition, affect, and behavior.
• The DSM-IV criteria for schizophrenia require that
psychotic behaviors be present at some point during
the course of the disorder and that signs of the
disorder be present for at least 6 months.
• People with briefer forms of psychosis receive other
diagnoses, such as brief psychotic disorder.
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DSM-IV-TR Diagnostic Criteria for
Schizophrenia
• Two or more of the following over a 1 month period:
-Delusions
-Hallucinations
-Incoherent speech
-Negative symptoms
• Difficulties in social functioning, work, or self-care
• Symptoms continuous for at least six months
• The disorder is not contributed to substance use or
another medical condition
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Diagnostic Features
• People with schizophrenia show a marked decline in
occupational and social functioning.
• Positive symptoms – Flagrant symptoms of
schizophrenia, such as hallucinations, delusions, bizarre
behavior, and thought disorder.
• Negative symptoms – Behavioral deficiencies
associated with schizophrenia, such as social skills
deficits, social withdrawal, flattened affect, poverty of
speech and thought, psychomotor retardation, and failure
to experience pleasure.
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Disturbed Thought and Speech
• Schizophrenia is characterized by positive
symptoms involving disturbances in thinking and
expression of thoughts through coherent, meaningful
speech.
• Aberrant thinking may be found in both the content
and form of thought.
• Delusions represent disturbed content of thought.
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Aberrant Content of Thought
• Delusions may take many forms. Some of the most common
types are:
– Delusions of persecution (e.g., “The CIA is out to get me”)
– Delusions of reference (“People on the bus are talking about me,”
or “People on TV are making fun of me,” or “The neighbors hear
everything I say. They’ve put bugs in the walls of my house”)
– Delusions of being controlled (believing that one’s thoughts,
feelings, impulses, or actions are controlled by external forces, such
as agents of the devil)
– Delusions of grandeur (believing oneself to be Jesus or believing
one is on a special mission, or having grand but illogical plans for
saving the world)
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Aberrant Content of Thought
• Unless we are engaged in daydreaming or purposefully
letting our thoughts wander, our thoughts tend to be
tightly knit together.
• The connections (or associations) between our thoughts
tend to be logical and coherent.
• Thought disorder – A disturbance in thinking
characterized by the breakdown of logical associations
between thoughts.
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Attentional Deficiencies
• To read this you must screen out background noises and
other environmental stimuli.
• Attention, the ability to focus on relevant stimuli and
ignore irrelevant ones is basic to learning and thinking.
• People with schizophrenia often have difficulty filtering
out irrelevant stimuli, making it nearly impossible for
them to focus their attention, organize their thoughts,
and filter out unessential information.
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Eye Movement Dysfunction
• About one in three chronic schizophrenia patients
shows evidence of eye movement dysfunction (Ross,
2000).
• Patients with this dysfunction (also called eye tracking
dysfunction) have abnormal movements of the eyes
when they track a moving target across their field of
vision.
• Rather than steadily tracking the target, the eyes fall
back and then catch up in a kind of jerky movement.
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Abnormal Event-Related-Potentials
• Researchers have also studied brain wave patterns, called eventrelated potentials, or ERPs, that occur in response to external
stimuli like sounds and flashes of light.
• ERPs can be broken down into various components that emerge
at different intervals following the presentation of a stimulus.
• Schizophrenia patients also show reduced levels of lateroccurring ERPs.
• These later-occurring ERPs are believed to be involved in the
process of focusing attention on a stimulus in order to extract
meaningful information.
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Hallucinations
• Hallucinations – Perceptions occurring in the absence of
external stimuli that become confused with reality.
• Hallucinations can involve any of the senses.
• Auditory hallucinations (“hearing voices”) are most common,
affecting about three of four schizophrenia patients.
• Tactile hallucinations (such as tingling, electrical, or burning
sensations).
• Somatic hallucinations (such as feeling like snakes are crawling
inside one’s belly).
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Hallucinations
• Visual hallucinations (seeing things that are not there)
• Gustatory hallucinations (tasting things that are not
present)
• Olfactory hallucinations (sensing odors that are not
present) are rarer.
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Hallucinations
• Hallucinations are not unique to schizophrenia.
• People with major depression and mania sometimes experience
hallucinations.
• Nor are hallucinations invariably a sign of psychopathology.
• They are common and socially valued in some cultures (Bentall,
1990).
• In a study of nonpatients, 5% of respondents reported
experiencing auditory hallucinations (Honig et al., 1998).
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Causes of Hallucinations
• The causes of psychotic hallucinations remain unknown.
• Drugs that lead to increased production of dopamine, such as
cocaine, can induce hallucinations.
• Hallucinations may represent a type of inner speech (silent self
talk) (Jones & Fernyhough, 2007).
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Emotional Disturbances
• Disturbed emotional response in schizophrenia may
involve negative symptoms, such as a loss of normal
affect or emotional expression, which is labeled blunted
affect or flat affect.
• Flat affect is inferred from the absence of emotional
expression in the face and voice.
• People with schizophrenia may speak in a monotone
and maintain an expressionless face, or “mask.”
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Other Types of Impairment
• People who suffer from schizophrenia may become
confused about their personal identities—the cluster of
attributes and characteristics that define themselves as
individuals and give meaning and direction to their lives.
• They may fail to recognize themselves as unique individuals
and be unclear about how much of what they experience is
part of themselves.
• In psychodynamic terms, this phenomenon is sometimes
referred to as loss of ego boundaries.
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Other Types of Impairment
• Disturbances of volition are most often seen in the
residual or chronic state.
• People with schizophrenia may show highly excited or
wild behavior or may slow to a state of stupor.
• People with schizophrenia also show significant
impairment in interpersonal relationships.
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Subtypes of Schizophrenia
• The DSM-IV lists three specific types of schizophrenia:
disorganized, catatonic, and paranoid.
• People with schizophrenia who display active psychotic features,
such as hallucinations, delusions, incoherent speech, or
confused or disorganized behavior, but who do not meet the
specifications of the other types, are considered to be of an
undifferentiated type.
• Others who have no prominent psychotic features at the time of
evaluation but have some residual features (for example, social
withdrawal, peculiar behavior, blunted or inappropriate affect,
strange beliefs or thoughts) would be classified as having a
residual type of schizophrenia.
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Disorganized Type
• Disorganized type – The subtype of schizophrenia
characterized by disorganized behavior, bizarre
delusions, and vivid hallucinations.
• People with disorganized schizophrenia display
silliness and giddiness of mood, giggling and talking
nonsensically.
• They often neglect their appearance and hygiene and
lose control of their bladders and bowels.
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Catatonic Type
• Catatonic type – The subtype of schizophrenia
characterized by gross disturbances in motor activity,
such as catatonic stupor.
• People with catatonic schizophrenia may show unusual
mannerisms or grimacing or maintain bizarre, apparently
strenuous postures for hours, although their limbs
become stiff or swollen.
• A striking but less common feature is waxy flexibility,
which involves adopting a fixed posture into which they
have been positioned by others.
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Paranoid Type
• Paranoid type – The subtype of schizophrenia
characterized by hallucinations and systematized
delusions, commonly involving themes of persecution.
• The behavior and speech of someone with paranoid
schizophrenia does not show the marked disorganization
typical of the disorganized type, nor is there a prominent
display of flattened or inappropriate affect or catatonic
behavior.
• The delusions often involve themes of grandeur,
persecution, or jealousy.
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Type I versus Type II Schizophrenia
• Type I schizophrenia is characterized by the more flagrant or
positive symptoms of schizophrenia we describe earlier, such
as hallucinations, delusions, and looseness of associations, as
well as by an abrupt onset, preserved intellectual ability, and a
more favorable response to antipsychotic medication.
• Type II schizophrenia corresponds to a pattern consisting
largely of the deficit or negative symptoms of schizophrenia,
such as lack of emotional expression, low or absent levels of
motivation, loss of ability to experience pleasure, social
withdrawal, and poverty of speech, as well as by a more
gradual onset, intellectual impairment, and poorer response to
antipsychotic drugs.
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Psychodynamic Perspectives
• Within the psychodynamic perspective, schizophrenia
represents the overwhelming of the ego by primitive
sexual or aggressive drives or impulses arising from
the id.
• These impulses threaten the ego and give rise to
intense intrapsychic conflict.
• Under such a threat, the person regresses to an early
period in the oral stage, referred to as primary
narcissism.
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Learning Perspectives
• Although learning theory does not offer a complete explanation
of schizophrenia, the development of some forms of
schizophrenic behavior can be understood in terms of the
principles of conditioning and observational learning.
• From this perspective, people with schizophrenia learn to
exhibit certain bizarre behaviors when these are more likely to
be reinforced than normal behaviors.
• Social-cognitive theorists suggest that modeling of
schizophrenic behavior can occur within the mental hospital,
where patients may begin to model themselves after fellow
patients who act strangely.
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Genetic Factors
• The closer the genetic relationship between schizophrenia
patients and their family members, the greater the likelihood (or
concordance rate) that the relatives will also have
schizophrenia.
• Overall, first-degree relatives of people with schizophrenia
(parents, children, or siblings) have about a tenfold greater risk
of developing schizophrenia than do members of the general
population.
• The fact that families share common environments as well as
common genes requires that we dig deeper to examine the
genetic underpinnings of schizophrenia.
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The familial risk of schizophrenia
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Biochemical Factors
• Contemporary biological investigations of schizophrenia
have focused on the role of the neurotransmitter
dopamine.
• The leading biochemical model of schizophrenia, the
dopamine hypothesis, posits that schizophrenia involves
an overreactivity of dopamine transmission in the brain.
• Increasing evidence supports the view that schizophrenia
involves an irregularity in dopamine transmission in the
brain.
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Viral Infections
• The answer is not clear whether or not viral
infections can cause schizophrenia in a newborn
child.
• Intriguing evidence does point to possible links
between prenatal infections and schizophrenia
(Babulas et al, 2006; Brown et al., 2009).
• Investigators found exposure to the “flu” virus in the
1st trimester of pregnancy found sevenfold risk of
schizophrenia.
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Brain Abnormalities
• We have compelling evidence of both structural changes
(loss of brain tissue) and functional disturbance
(abnormalities of functioning) in the brains of schizophrenia
patients.
• However, we have yet to discover any one source of
pathology in the brain that is specific to schizophrenia or
present in all cases of schizophrenia.
• The most prominent finding of structural changes is the loss
of brain tissue (gray matter) of about 5% on the average in
schizophrenia patients as compared to normal controls
(Brans et al., 2008; Ellison-Wright & Bullmore, 2010).
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Family Theories
• An early, but since discredited theory, focused on the role of the
schizophrenogenic mother (Fromm-Reichmann, 1948, 1950).
• In what some feminists view as historic psychiatric sexism, the
schizophrenogenic mother was described as cold, aloof,
overprotective, and domineering.
• She was characterized as stripping her children of self-esteem,
stifling their independence, and forcing them into dependency
on her.
• Children reared by such mothers were believed to be at special
risk for developing schizophrenia if their fathers were passive
and failed to counteract the mother’s pathogenic influences.
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Communication Deviance
• Communication deviance (CD) is a pattern of
unclear, vague, disruptive, or fragmented
communication that is often found among parents
and family members of schizophrenia patients.
• CD is speech that is hard to follow and from which it
is difficult to extract any shared meaning.
• High CD parents often have difficulty focusing on
what their children are saying.
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Expressed Emotion
• Another form of disturbed family communication,
expressed emotion (EE), is a pattern of responding to the
schizophrenic family member in hostile, critical, and
unsupportive ways (A. Weisman et al., 2006).
• Schizophrenia patients from high EE families stand a
higher risk of relapsing than those with low EE (more
supportive) families (Kopelowicz et al., 2006; van
Humbeeck et al., 2002).
• High EE relatives typically show less empathy, tolerance,
and flexibility than low EE relatives (Weisman et al.,
2000).
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Relapse rates of people with schizophrenia
in high and low EE families.
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Family Factors in Schizophrenia:
Causes or Sources of Stress?
• No evidence supports the belief that family factors, such as
negative family interactions, lead to schizophrenia in
children who do not have a genetic vulnerability.
• Rather, a genetic vulnerability to schizophrenia renders
individuals more susceptible to troubled family and social
relationships (Reiss, 2005; Tienari et al., 2004).
• Within the diathesis–stress model, disturbed patterns of
family interaction and communication represent sources of
life stress that increase the risks of developing schizophrenia
among people with a genetic predisposition for the disorder.
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Endophenotypes
• Endophenotypes – Measurable processes or mechanisms not
apparent to the naked eye, which are the means by which an
organism’s genetic code comes to affect its observable
characteristics or phenotypes.
• Investigators are investigating a number of possible
endophenotypes in schizophrenia, including disturbances in brain
circuitry, deficits in working memory and cognitive abilities, and
abnormalities of neurotransmitter functioning.
• To better understand how schizophrenia develops, we need to dig
under the surface to see how genes affect underlying processes,
and how these processes in turn contribute to the development of
the disorder.
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From genes to vulnerability.
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Biological Approaches
• Tardive dyskinesia (TD) – A disorder characterized by
involuntary movements of the face, mouth, neck, trunk, or
extremities and caused by long-term use of antipsychotic
medication.
• Antipsychotic medication helped control the more flagrant
behavior patterns of schizophrenia and reduced the need for
long-term hospitalization when taken on a maintenance or
continuing basis after an acute episode.
• Yet for many patients with chronic schizophrenia, entering a
hospital is like going through a revolving door: they are
repeatedly admitted and discharged.
• Many are simply discharged to the streets once they are
stabilized on medication and receive little if any follow-up
care.
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Antipsychotic Drugs
• Antipsychotic drugs block dopamine receptors in the brain,
which reduces dopamine activity in the brain and helps quell
the more obvious symptoms such as hallucinations and
delusions.
• Phenothiazines:
-Chlorpromasine (Thorazine)
-Thioridazine (Mellaril)
-Trifluoperazine (Stelazine)
-Fluphenazine (Prolixin)
-Haloperidol (Haldol)
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Sociocultural Factors in Treatment
• Ethnicity may also play a role in the family’s involvement in
treatment.
• In a study of 26 Asian Americans and 26 non-Hispanic White
Americans with schizophrenia, family members of the Asian
American patients were more frequently involved in the
treatment program (Lin et al., 1991).
• For example, family members were more likely to accompany
the Asian American patients to their medication evaluation
sessions.
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Psychodynamic Theory
• Freud did not believe that traditional psychoanalysis
was well suited to the treatment of schizophrenia.
• The withdrawal into a fantasy world that typifies
schizophrenia prevents the individual with
schizophrenia from forming a meaningful relationship
with the psychoanalyst.
• The techniques of classical psychoanalysis, Freud
wrote, must “be replaced by others; and we do not
know yet whether we shall succeed in finding a
substitute” (as cited in Arieti, 1974, p. 532).
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Learning-Based Therapies
• Therapy methods include the following:
– 1. Selective reinforcement of behavior, such as providing
attention for appropriate behavior and extinguishing bizarre
verbalizations through withdrawal of attention.
– 2. Token economy, in which individuals on inpatient units
are rewarded for appropriate behavior with tokens, such as
plastic chips, that can be exchanged for tangible reinforcers
such as desirable goods or privileges.
– 3. Social skills training, in which clients are taught
conversational skills and other appropriate social behaviors
through coaching, modeling, behavior rehearsal, and
feedback.
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Psychosocial Rehabilitation
• People with schizophrenia typically have difficulties
functioning in social and occupational roles and
performing work that depends upon basic cognitive
abilities involving attention and memory.
• These problems limit their ability to adjust to community
life, even in the absence of overt psychotic behavior.
• Recently, promising results were reported for cognitive
rehabilitation training to help schizophrenia patients
strengthen such basic cognitive skills as attention and
memory (Hogarty et al., 2004; Penades et al., 2006).
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Family Intervention Programs
• Family conflicts and negative family interactions can heap
stress on family members with schizophrenia, increasing the
risk of recurrent episodes.
• Researchers and clinicians have worked with families of
people with schizophrenia to help them cope with the
burdens of care and assist them in developing more
cooperative, less-confrontational ways of relating to others.
• In sum, no single treatment approach meets all the needs of
people with schizophrenia.
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Other Forms of Psychosis
• Brief psychotic disorder – A psychotic disorder lasting
from a day to a month that often follows exposure to a
major stressor.
• Schizophreniform disorder – A psychotic disorder lasting
less than 6 months in duration, with features that resemble
schizophrenia.
• Delusional disorder – A type of psychosis characterized
by persistent delusions, often of a paranoid nature, that do
not have the bizarre quality of the type found in paranoid
schizophrenia.
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Other Forms of Psychosis
• Erotomania – A delusional disorder characterized by
the belief that one is loved by someone of high social
status.
• Schizoaffective disorder – A type of psychotic
disorder in which individuals experience both severe
mood disturbance and features associated with
schizophrenia.
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The End
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