SCHIZOPRHENIA - 1

A.

Early description/diagnosis of schizophrenia

1.

2.

B.
II.

Emil Kraepelin:
a.

Combined catatonic (i.e., alternating immobility and excited

agitation), hebephrenia (i.e., silly and immature emotionality),
and paranoia (i.e., delusions of grandeur and persecution) and
labeled them as falling under the heading dementia praecox.

b.

Distinguished dementia praecox from manic-depressive illness

by emphasizing onset and outcome. (Schiz. Onset early, poor
prognosis.)

Eugen Bleuler, a Swiss psychiatrist

a.

First to introduce the term schizophrenia; a term derived from

the Greek words for split (skhizen) and mind (phren).

b.

Bleuler believed that the core of schizophrenia rests in an

associative splitting of basic personality functions. This concept
emphasized the following:
i.

"Breaking of associative threads," or the breakdown of

forces that connect one function to the next.

ii.

Bleuler also believed that an inability to keep a constant

train of thought was the cause of all schizophrenic
symptoms.

Schizophrenic symptoms are heterogeneous--number of symptoms and

behaviors that are not shared by all persons with the diagnosis.

Clinical Description, Symptoms, and Subtypes

A.

The term psychotic refers to either delusions or hallucinations.

B.

Positive symptoms:
1.

Delusions refer to a belief that would be seen by most members of

society as a misrepresentation of reality; often referred to as a
disorder of thought content. Delusions often are called the basic
characteristic of madness. Some research suggests that delusions give
some patients a sense of meaning and purpose in life and result in less
depression. Thus, delusions may serve an adaptive function. Types of
delusions include:
a.

Delusions of grandeur, or the belief that one is particularly

famous or important.

b.

Delusions of persecution, or the belief that other people are

out to get or harm the person.

c.

More unusual delusions include Capgras syndrome, or the

belief that someone a person knows has been replaced by a
double, and Cotards syndrome, where the person believes
that a part of the body (e.g., brain) has changed in some
impossible way.

SCHIZOPRHENIA - 2
2.

Hallucinations can involve any of the senses; though auditory

hallucinations are most common in persons with schizophrenia.
a.

C.

D.

Single photon emission tomography (SPECT) has been used

to study cerebral blood flow in schizophrenic patients during
their auditory hallucinations. The part of the brain most active
during auditory hallucinations is Brocas area (i.e., the area
involved in speech production), not Wernicke's area (i.e., the
area involved in understanding and language comprehension).
This research supports the idea that auditory hallucinations do
not involve hearing voices of others, but rather listening to ones
own thoughts or voices, and a failure to recognize the difference.

Negative:
1.

Avolition (inc. show little interest in performing even the most basic
daily functions, such as personal hygiene)

2.

Alogia (inc. brief replies to questions with little content, delayed

comments or slowed responses to questions, or as disinterest in
conversation)

3.

Anhedonia

4.

Affective flattening, or flat affect (inc. little change in facial

expression, but not the experience of appropriate emotions)

Disorganized symptoms:
1.

2.

Disorganized speech:
a.

Cognitive slippage often manifests as illogical and incoherent

speech where the person jumps from one topic to the next.

b.

Tangentiality manifests as "going off on a tangent" rather than

answering a question directly.

c.

Loose associations or derailment

Other disorganized symptoms:

a.

Inappropriate affect

b.

Disorganized behavior (e.g., hoarding objects or acting in

unusual ways in public). Including:
i.

Catatonia (inc. catatonic immobility and/or waxy

flexibility).

SCHIZOPRHENIA - 3
E.

Schizophrenia subtypes
1.

Paranoid type
relatively intact cognitive skills and affect
do not generally show disorganized speech or flat affect
associated with the best prognosis.

2.

a.

Delusions and hallucinations usually have a theme of grandeur

or persecution.

b.

DSM-IV-TR criteria specify a preoccupation with one or more

delusions or auditory hallucinations but without marked display
of disorganized speech, disorganized or catatonic behavior, or
flat or inappropriate affect.

Disorganized type (hebephrenia)

marked disruptions in their speech and behavior, including flat or
inappropriate affect, and self-absorption
If hallucinations or delusions are present, they tend to be organized
around a theme, but are quite fragmented.
typically show problems early and their problems tend to be chronic,
lacking periods of remissions that characterize other forms of this
disorder.

3.

Catatonic type
unusual motor responses and odd mannerisms.
often show echolalia (i.e., repeating or mimicking the words of
others)
echopraxia (i.e., imitating the movements of others).
This subtype is relatively rare.

4.

Undifferentiated type do not neatly fit into any of the other subtypes
and include people with major symptoms of schizophrenia but who do
not meet criteria for paranoid, disorganized, or catatonic types.

5.

Residual type have had at least one episode of schizophrenia but are
no longer displaying the major symptoms.
Often display residual symptoms, such as negative beliefs, unusual or
bizarre ideas, social withdrawal, inactivity, and/or flat affect.

SCHIZOPRHENIA - 4
F.

Other disorders showing psychotic behaviors

1.

Schizophreniform disorder have experienced symptoms of

schizophrenia for a few months only and usually resume normal lives.
There are few studies of this disorder, with a lifetime prevalence of
0.2%.
a.

DSM-IV-TR criteria for schizophreniform disorder include

onset of psychotic symptoms within 4 weeks of the first
noticeable change in usual behavior,
confusion at the height of the psychotic episode,
good premorbid social and occupational functioning,
absence of blunted affect.

2.

Schizoaffective disorder
DSM-IV-TR criteria for schizoaffective disorder require the presence of
a mood disorder and delusions or hallucinations for at least 2 weeks in
the absence of prominent mood disorder symptoms.
The prognosis is similar as for people with schizophrenia and such
persons do not tend to get better on their own.

3.

Delusional disorder (non-bizarre delusions)

tend not to have flat affect, anhedonia, or other negative symptoms of
schizophrenia.
may, however, become socially isolated as a function of their
delusions.
a.

b.

The DSM-IV-TR recognizes the following delusional subtypes:

i.

erotomanic type is a delusion reflecting the irrational

belief of being loved by another person, usually of higher
status (e.g., celebrity stalkers).

ii.

grandiose type of delusion involves having beliefs of

inflated self-worth, power, knowledge, identity, or special
relationship to a deity or famous person.

iii.

jealous type of delusion believe that a sexual partner is

unfaithful.

iv.

persecutory type involves believing that oneself (or

someone close) is being malevolently treated in some way.

v.

somatic type that one has some physical defect or

medical disorder.

Delusional disorder is rare, affecting 24-30 people out of every

100,000. Average age of onset is in middle adulthood, and the
disorder is slightly more common in females than males.
Prognosis is better than schizophrenia, and features of delusional
disorder may have a genetic component.

SCHIZOPRHENIA - 5
4.

Brief psychotic disorder

one or more positive symptoms of schizophrenia (e.g., delusions,
hallucinations, or disorganized speech or behavior) within a one-month
period. This disorder is often precipitated by an extremely stressful
situation and commonly dissipates on its own.

5.

Shared psychotic disorder (folie a deux) develop delusions as a

result of a close relationship with someone else who has delusions.
Content of such delusions span the spectrum and little is known about
this condition.

6.

Schizotypal personality disorder (Chapter 11) is related to

psychotic disorders. The characteristics of this personality disorder are
similar to schizophrenia, but less severe.

SCHIZOPRHENIA - 6
I.

Prevalence and causes of schizophrenia

A.

Prevalence of schizophrenia worldwide is 0.2% to 1.5%,

it will affect about 1% of the population at some point.
Life expectancy slightly less than average.
Women have more favorable outcomes than men.
Onset greatest in early adulthood
Declines with age for males,
Reverse for females.
1.

A more widely accepted classification system, introduced in the mid1970s, emphasizes positive, negative, and more recently disorganized
symptoms. Accordingly, schizophrenia can be dichotomized into Type I
and Type II based on several characteristics, including symptoms,
response to medication, outcome, and presence of intellectual
impairment.
a.

Type I
positive symptoms,
good response to medication,
optimistic prognosis,
absence of intellectual impairment.

b.

Type II
negative symptoms
poor response to medication,
pessimistic prognosis,
intellectual impairments.

SCHIZOPRHENIA - 7
B.

Children who eventually develop schizophrenia tend to show early abnormal

signs such as more negative affect and less positive affect.
It may be that brain damage early in development causes schizophrenia.
Research suggests that people with schizophrenia who demonstrate early
signs of abnormality at birth and during early childhood tend to do better in
the long run than those that do not.
Brain plasticity allows the brain to compensate for such deficits over time,
whereas this is more difficult in a fully developed brain later in life.
Older adults display fewer positive symptoms and more negative symptoms,
suggesting that schizophrenia may improve over time.
Most persons with schizophrenia fluctuate between severe and moderate
levels of impairment throughout their lives, and relapse is common.

C.

Schizophrenia appears to be a universal world-wide phenomenon;

however, the course and outcome of schizophrenia varies from culture to
culture.
In the U.S., more African-Americans are diagnosed with schizophrenia than
whites,
this difference may reflect misdiagnosis due to bias against some minority
groups.

SCHIZOPRHENIA - 8
D.

Genetic influences are responsible for making some individuals vulnerable to

schizophrenia.
1.

Family studies have shown that the more severe the parents
schizophrenia, the more likely the children were to develop it also.
All forms of schizophrenia were also seen within families with histories
of schizophrenia,
meaning that we do not inherit a specific type of schizophrenia, but a
general predisposition for schizophrenia that may differ from one
family member to the next.
Family members of a person with schizophrenia are also at increased
risk not just for schizophrenia, but a spectrum of psychotic disorders.
a.

2.

Risk for schizophrenia is associated with degree of genetic

relatedness to the person with schizophrenia. Having any family
member with schizophrenia increases the risk of schizophrenia in
other family members above what is expected in the general
population.

Twin studies indicate a confluence of genetic and environmental

factors.
monozygotic twins - 48%.
Fraternal twins - 17%
Genain quadruplets who shared identical genes and were raised in the
same household, but differed in terms of the onset of schizophrenia,
the symptoms, diagnoses, course of the disorder, and outcomes.
Genain comes from the Greek meaning "dreadful gene." This case
reveals the concept of unshared environments, which may lead to
different outcomes for the same disorder even within the same
household.

3.

Adoption studies:
Children of biological mothers with schizophrenia have a much
higher chance of developing schizophrenia themselves, even when
raised away from their biological parents.

SCHIZOPRHENIA - 9
4.
a.

17% chance of developing schizophrenia, regardless of whether

the identical twin parent has schizophrenia or the parents twin is
unaffected.

b.

If the parent is a fraternal twin with schizophrenia, then their

children have about a 17% chance of developing schizophrenia.
If the fraternal twin parent does not have schizophrenia but their
fraternal twin does, the risk in the children drops to about 2%.

5.

Several potential markers for schizophrenia have been studied.

Smooth-pursuit eye movement or eye-tracking refers to a procedure
involving keeping ones head still while visually tracking a moving
pendulum back and forth. This tracking ability is deficient in many
persons with schizophrenia, including relatives of schizophrenic
persons. This work suggests that eye-tracking may be a marker for
schizophrenia.

SCHIZOPRHENIA - 10
E.

Neurobiological influences with regard to brain functioning in schizophrenia

dates back as far as Emil Kraepelin. Several hypotheses have been proposed
since then and include:
1.

2.

3.

The dopamine hypothesis of schizophrenia argues that schizophrenia is

the result of an excess of dopamine in the brain. This hypothesis was
popularized by several of the following findings showing that when
drugs are administered that are known to increase dopamine
(agonists), schizophrenic behavior increases, whereas with drugs that
are known to decrease dopamine activity (antagonists), schizophrenia
symptoms tend to diminish:
a.

Antipsychotic neuroleptic drugs (i.e., dopamine antagonists) are

effective in treating schizophrenia. Such drugs work primarily by
blocking the D2 dopamine receptors

b.

The negative side effects are similar to those seen in persons

with Parkinson's disease; a disorder known to be due to
insufficient levels of dopamine.

c.

The drug L-dopa (i.e., a dopamine agonist) that is used to treat

people with Parkinsons disease, and can result in schizophrenialike symptoms.

d.

Amphetamines (i.e., drugs that activate dopamine) can make

psychotic symptoms worse in people with schizophrenia.

e.

Such observations led to the view that schizophrenia was due to

excessive dopamine activity involving the D2 dopamine
receptors.

Arguments against the dopamine theory include the following:

a.

Many persons with schizophrenia are not helped with dopamine

antagonists.

b.

Neuroleptics work to block dopamine quickly, but the relevant

symptoms remit long after.

c.

Neuroleptics do little to help the negative symptoms.

d.

It is unclear whether people with schizophrenia have more D2

receptors than others.

e.

Genetic-linkage studies do not support a clear connection

between schizophrenia and the gene region for the D2 receptors.

f.

The drug clozapine is effective for many persons not helped by

traditional neuroleptic medication, and yet it is one of the
weakest dopamine antagonists.

Recent work has focused on the relation between dopamine and

serotonin in the context of schizophrenia symptoms. Two studies
suggest that the dopamine-serotonin relation may better explain the
effects of neuroleptic drugs than looking at dopamine alone.

4.

5.

Evidence for neurological damage in persons with schizophrenia is

partially derived from the fact that children at risk for the disorder
often show abnormal reflexes and attentional problems. Such
problems tend to persist into adulthood.
a.

Positive symptoms of schizophrenia may be related to excessive

dopamine activity, but negative symptoms may be related to
structural brain abnormalities such as enlarged lateral ventricles.
However, many people without schizophrenia have such
abnormalities.

b.

The frontal lobes of people with schizophrenia tend to be less

active than in people without the disorder; a phenomenon known
as hypofrontality. The deficits appear in a dorsolateral prefrontal
cortex of the frontal lobes. This prefrontal area is also one site of
a major dopamine pathway in the brain.

Some have hypothesized that schizophrenia is a recent phenomenon

historically, appearing during the past 200 years, and may involve
some recently introduced virus. There is evidence that a virus-like
disease may account for some cases of schizophrenia, particularly
prenatal exposure to influenza.
a.

F.

Evidence for developmental problems during the second

trimester of fetal development has led to an interest in fingertip
dermal cells that migrate to the cortex of the brain and produce
fingerprint ridges. Migration of such cells would be disrupted if a
virus occurred during this critical period of development. The
number of fingertip ridges in twins without schizophrenia differs
little, but substantial differences are seen in one-third of twins
discordant for the disorder. This work suggests that finger-tip
ridge count may be a marker of potential brain damage.

Psychological and social influences

1.

Research on stress and schizophrenia suggests that extreme stress

can produce psychotic-like symptoms in otherwise normal persons.
Stress appears related to activation of a schizophrenia predisposition
and risk for relapse.

2.

Family interactions and their effect on schizophrenia has been the

focus of a great deal of research. The term schizophrenogenic was
used for a time to describe a mother whose cold, dominant, and
rejecting nature was thought to cause schizophrenia in her children.
The term double-bind was also used to portray a type of
communication that produced conflicting messages (e.g., saying "I
love you" coupled with a stiff/distant hug), resulting in schizophrenia.
Both terms are no longer widely used. Recent work has focused on
how family interactions contribute to relapse from schizophrenia, not
in the onset of schizophrenia.
a.

Expressed emotion is a term describing a particular family

communication style that is related to schizophrenic relapse.
High expressed emotion characterized by criticism, hostility, and

emotional over-involvement is strongly related to risk for

relapse. Persons with schizophrenia living in a family with high
expressed emotion are 3.7 times more likely to relapse than if
they lived in a family low in expressed emotion.
G.

Treatment of Schizophrenia
A. Historically, the treatment of schizophrenia was highly medicalized. For
instance, primitive brain surgeries were used as early as the 1500s,
and similar, albeit more sophisticated, procedures were used in the
1950s (e.g., prefrontal lobotomies). Modern Westernized treatment of
schizophrenia usually begins with neuroleptic drugs in combination
with psychosocial treatments aimed at reducing relapse, compensating
for skills deficits, and to improve compliance with medication
regimens.
B. Biological interventions
1. During the 1930s, persons with schizophrenia may have
undergone one of several biological interventions, including:
a.

Insulin coma therapy involved injections of massive doses

of insulin to induce a coma in persons suffering from
schizophrenia. Though many thought this procedure was
helpful, serious illness and death often occurred.

b.

Psychosurgery, including prefrontal lobotomies, was also

introduced in the 1930s. Prefrontal lobotomies involved
severing the frontal lobes from the lower portion of the
brain, resulting in calmed behavior but severe cognitive
and emotional deficits. Such procedures are still used in
some primitive cultures.

c.

In the late 1930s, electroconvulsive therapy (ECT) was

advanced as a treatment for schizophrenia, but was found
to be of little help.

2. During the 1950s, several neuroleptic drugs were introduced to

relieve the symptoms of schizophrenia. Such drugs affect the
positive symptoms of schizophrenia (i.e., reduce or eliminate
hallucinations and delusions), and help persons think more
clearly. Such drugs are not equally effective for all persons and
often involve a trial and error process to find a medication that
works best. Many persons with schizophrenia stop taking their
medications from time to time, mostly because of the negative
side effects of such drugs.
a.

The earliest neuroleptic drugs, called conventional

antipsychotics, work in about 60% of persons who try
them, but include several unpleasant side effects.

b.

Newer medications, such as clozapine, risperidone, and

olanzapine, have fewer serious side effects than
conventional antipsychotics.

3. Factors affecting noncompliance with medications include a

negative patient-doctor relationship, cost of medication, poor
social support, and unwanted negative side effects. Side effects
of neuroleptics may include extrapyramidal or Parkinsonian
symptoms.
a.

One such symptom is akinesia, which is characterized by

an expressionless face, slowed motor activity, and
monotonous speech.

b.

Another extrapyramidal symptom is tardive dyskinesia,

which involves involuntary movements of the tongue, face,
mouth, or jaw and can include protrusions of the tongue,
puffing of the cheeks, puckering of the mouth, and
chewing movements. Tardive dyskinesia results from high
doses of antipsychotic medications administered over long
periods of time. Tardive dyskinesia is often irreversible.

4. A newer, and not-as-yet validated, procedure for the treatment

of hallucinations involves exposing the individual to magnetic
fields. This procedure, called transcranial magnetic stimulation,
uses wire coils to repeatedly generate magnetic fields that pass
through the skull to the brain. One study has demonstrated
reductions in hallucinations following this procedure.
C. Psychosocial interventions
0. Today, few believe that psychological factors cause
schizophrenia or that traditional psychotherapeutic approaches
alone are curative; however, psychosocial approaches have an
important role in treatment.
1. Behavioral approaches for inpatients are designed to encourage
and foster appropriate socialization, participation in group
sessions, and self-care, while discouraging violent outbursts.
Such interventions rely on token economy systems, in which
residents earn access to meals and small luxuries by behaving
appropriately. Patients in such programs do better than those
who are not part of them.
2. Clinicians also reduce the routine institutionalization of persons
with schizophrenia by implementing community care programs.
3. The more insidious negative effects of schizophrenia are on
social behavior, or the persons ability to relate to other people.
Treatments here target and attempt to re-teach social skills such
as how to have a basic conversation, assertiveness, and
relationship building. Modeling, role-play, feedback, and practice
are emphasized. Maintenance of these skills may be problematic,
however.
4. Independent living skills programs focus on teaching a range of
skills that persons with schizophrenia can use to better adapt to
their disorder and the challenges of community living. Such a

program is often multidisciplinary and seems to help prevent

relapse.
5. Behavioral family therapy has been used as a means to teach
families of persons with schizophrenia to be more supportive,
particularly families high in expressed emotion. Such procedures
provide education about schizophrenia, teach communication
skills, address more constructive ways of expressing negative
feelings, and emphasize problem solving. This type of therapy
seems to require ongoing work, as its effectiveness diminishes
after 1 year.
6. Vocational rehabilitation is used to help persons with
schizophrenia gain and maintain employment, and may include
hands-on job coaches.
D. Treatment across cultures and prevention efforts
0. Cultural factors seem to play a role in the treatment of
schizophrenia. For example, Hispanics are less likely to seek help
in institutional settings and rely instead on family support. In
China, the preferred treatment for schizophrenia is antipsychotic
medication and most are treated outside of hospitals. In Africa,
persons with schizophrenia are kept in prisons.
1. Prevention of schizophrenia focuses on identifying and treating
children who may be at risk for the disorder later in life.
Instability of early family rearing environment seems related to
subsequent risk for developing schizophrenia in at risk children.
Preventive efforts may focus on birth complications and early
illnesses, particularly among those who are genetically
predisposed.