1. Chapter 11 Schizophrenia

2. 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

3. The Nature of Schizophrenia Broad Impairments
Delusions & Hallucinations
Disorganized Speech & Behavior
Inappropriate Emotions
Psychosis: extreme mental unrest with loss of reality contact (Davison & Neale, p. 134)

4. Schizophrenia: Facts and Statistics Cause is Unknown
Affects 1 out of 100 People
Often Begins (Ages )
More Hospital Beds Than Any Other Medical Illness
2.5% of Total U.S. Healthcare Budget

5. Schizophrenia: Facts and Statistics 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

6. Myths of Madness 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?

7. Myths of Madness
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.

8. Perspectives: The Concept of Schizophrenia
Dementia (Loss of Mind)
Praecox (Early, Premature)
Kraepelin
Categorization & Early Onset
Eugen Bleuler
Termed “Schizophrenia”
Associative Splitting

9. The Nature of Schizophrenia: Active Phase Symptoms
Positive Symptoms
Displays of Abnormal Behavior
Disorganized Symptoms
Speech and Behavior
Negative Symptoms
Deficits in Affect, Speech, Motivation

10. The Nature of Schizophrenia: Active Phase Symptoms
Positive Symptoms
Delusions
Misrepresentation of Reality
“Basic Feature of Madness”
Examples
Grandeur -- Importance
Persecution -- Out to Get Me

11. The Nature of Schizophrenia: Active Phase Symptoms
Positive Symptoms
Hallucinations
Absence of Sensory Stimulation
Involve Any of the Senses
Examples
Auditory -- Voices (70%)
Visual -- Seeing Things (25%)
Tactile -- Crawling Sensation

12. Hallucinations: A Window on the Brain Broca’s Area (Speech)
Wernicke’s Area
(Hearing)
What Area Do You Think is
More Active With Auditory Hallucinations?
Hallucinations:
A Window on the Brain

13. The Nature of Schizophrenia: Active Phase Symptoms
Positive
Symptoms
Disorganized Symptoms
Disorganized Speech
Difficulty in Communication
Examples
Tangentiality
Loose Association or Derailment

14. The Nature of Schizophrenia: Active Phase Symptoms
Positive
Symptoms
Disorganized Symptoms
Disorganized Behaviors
Catatonia
Spectrum
Wild Agitation to Immobility
Example
Waxy Flexibility
Inappropriate Affect

15. The Nature of Schizophrenia: Active Phase Symptoms
Positive
Disorganized
Symptoms
Negative Symptoms
Flat Affect -- “The Mask”
Avolition -- “No Initiative”
Alogia -- “Speech is Vacant”
Anhedonia -- “No Pleasure”
Asociality--”No social interest”

16. 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

17. 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

18. 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

19. Schizophrenia Subtypes Paranoid Type Disorganized Type Catatonic Type
Undifferentiated Type
Residual Type

20. Schizophrenia Subtypes: Paranoid Delusions & Hallucinations
Intact Cognition and Affect
No Disorganized Speech
Best Prognosis

21. Schizophrenia Subtypes Paranoid Type Disorganized Type Catatonic Type
Undifferentiated Type
Residual Type

22. Subtypes: Disorganized
Schizophrenia
Subtypes: Disorganized
Disorganized Speech
Disorganized Behavior
Flat or Inappropriate Affect
Hallucinations and Delusions
Fragmented or Lacking a Theme
Often Chronic

23. Schizophrenia Subtypes Paranoid Type Disorganized Type Catatonic Type
Undifferentiated Type
Residual Type

24. Schizophrenia Subtypes: Catatonic Disorganized Speech
Disorganized Behavior
Waxy flexibility, rigidity, odd mannerisms, mimicry
Flat or Inappropriate Affect
Hallucinations and Delusions
Fragmented or Lacking a Theme
Often Chronic

25. Schizophrenia Subtypes Paranoid Type Disorganized Type Catatonic Type
Undifferentiated Type
Residual Type

26. Subtypes: Undifferentiated
Schizophrenia
Subtypes: Undifferentiated
Beginnings of Breakdown
Major Sx of Schizophrenia
DO NOT Meet Other Criteria
“Wastebasket” Category

27. Schizophrenia Subtypes Paranoid Type Disorganized Type Catatonic Type
Undifferentiated Type
Residual Type

28. Schizophrenia Subtypes: Residual Once a Schizophrenic,
Have Had One Episode
Now Mostly Symptom Free
Once a Schizophrenic,
Always a Schizophrenic?

29. 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

30. Schizophrenia: Developmental Course 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?
Schizophrenia:
Developmental Course

31. 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

32. Genetic Studies of Schizophrenia
Relation to Percentage
Proband Schizophrenic
Spouse
Grandchildren
Nieces/nephews
Children
Siblings
DZ twins
MZ twins
Ch 11.6

33. The Causes of Schizophrenia Genetic Influences Runs in Families
Increased Risk Based on Genetic Relatedness
Search for Marker Genes
Smooth Pursuit Eye Tracking

34. Slide Image Taken from the NIMH website
Slide Image Taken from the NIMH website. Shows descreased activity in the frontal lobes of schizophrenic siblings

35. 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

36. 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

37. Dopamine Theory of Schizophrenia

38. The Causes of Schizophrenia Neurobiological Influences
Excess Dopamine (D2 Receptors)
Antagonists
Neuroleptics
Drugs That Reduce Dopamine
Negative Side Effects
L-Dopa (Agonist)
Amphetamines
Genetic Influences

39. 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)

40. 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

41. The Causes of Schizophrenia Brain Structure Genetic Neurobiological
Ventricle Enlargement
Genetic
Neurobiological
Influences

42. The Causes of Schizophrenia Brain Structure Genetic Neurobiological
Ventricle Enlargement
Hypofrontality
Picture Illustrating Hypofrontality was taken from the NIMH web site
Genetic
Neurobiological
Influences

43. 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

44. Causes of Schizophrenia: Psychological and Social Influences (cont.)
Figure Barlow/Durand, 3rd. Edition. Cultural differences in expressed emotion (EE)

45. 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

46. The Treatment of Schizophrenia Biological Interventions Neuroleptics
Haldol & Clozapine
Trial and Error
“Extrapyramidal” Side Effects
Tardive Dyskinesia
Akinesia
Atypical Antipsychotics: (Clozapine, Risperdal, Zyprexa,Seroquel, Geodon, Abilify)

47. Medical Treatment of Schizophrenia (cont.)
Table 13.2 Barlow/Durand, 3rd.
Antipsychotic medications

48. 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`

49. 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.

50. Psychosocial Treatment of Schizophrenia
Figure Barlow/Durand, 3rd. Edition
Studies on treatment of schizophrenia from 1980 to 1992

51. Summary of Schizophrenia and Psychotic Disorders
Figure 13.x1 Barlow/Durand, 3rd. Ed.
Exploring schizophrenia and its treatment

52. Summary of Schizophrenia and Psychotic Disorders (cont.)
Figure 13.x1 Barlow/Durand, 3rd Edition (cont.)
Exploring schizophrenia and its treatment

53. Other Psychotic Disorders Schizophreniform Disorder
Schizoaffective Disorder
Delusional Disorder
Brief Psychotic Disorder
Shared Psychotic Disorder
Folie a Deux