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Chapter 9
Schizophrenia
Abnormal Psychology, Twelfth
Edition
by
Ann M. Kring,
Sheri L. Johnson,
Gerald C. Davison,
& John M. Neale
Copyright © 2012 John Wiley & Sons, Inc. All rights reserved.
Chapter Outline
 Chapter 9: Schizophrenia

Clinical Descriptions of
I.
Schizophrenia
II. Etiology of Schizophrenia
III. Treatment of Schizophrenia

© 2012 John Wiley & Sons, Inc. All rights reserved.


Schizophrenia
 Major disturbances in thought, emotion,
and behavior
• Disordered thinking
 Ideas not logically related
 Faulty perception and attention
• Lack of emotional expressiveness
 Inappropriate or flat emotions
• Disturbances in movement or behavior
 Disheveled appearance
 Can disrupt interpersonal relationships,
diminish capacity to work or live
independently
 Significantly increased rates of suicide and
death
© 2012 John Wiley & Sons, Inc. All rights reserved.
Schizophrenia
 Lifetime prevalence ~1%
 Affects men slightly more often than
women
 Onset typically late adolescence or
early adulthood
• Men diagnosed at a slightly earlier age
 Diagnosed more frequently in African
Americans
• May reflect diagnostic bias

© 2012 John Wiley & Sons, Inc. All rights reserved.


Proposed DSM-5 Criteria for
Schizophrenia
 Two or more symptoms lasting for at least 1 month;
one symptom should be 1, 2, or 3:
1) Delusions
2) Hallucinations
3) Disorganized speech
4) Abnormal psychomotor behavior (catatonia)
5) Negative symptoms (blunted affect, avolition, asociality)
 Functioning in work, relationships, or self-care have
declined since onset
 Signs of disorder for at least 6 months; at least 1
month of the symptoms above; or, if during a
prodromal or residual phase, negative symptoms or
two or more of symptoms 1-4 in less severe form
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Clinical Description of
Schizophrenia
 Three major clusters of symptoms:
• Positive
• Negative
• Disorganized

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Positive Symptoms:
Behavioral Excesses and Distortions
 Delusions  Hallucinations
• Firmly held beliefs • Sensory experiences in
• Contrary to reality the absence of sensory
• Resistant to stimulation
disconfirming evidence
 Types of delusions:
• Persecutory delusions
 “The CIA planted a listening  Types of hallucinations:
device in my head” • Auditory
 65% have these
 74% have this symptom
• Thought insertion • Visual
• Thought broadcasting • Hearing voices
• Outside control  Increased levels of activity in
• Grandiose delusions Broca’s area during
hallucinations
• Ideas of reference
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Negative Symptoms:
Behavioral Deficits
 Avolition  Can be grouped
• Lack of interest; apathy
into 2 domains:
 Asociality
• Inability to form close • Experience domain
personal relationships  Motivation
 Anhendonia  Emotional experience
• Inability to experience  sociality
pleasure
 Consummatory pleasure • Expression domain
 Anticipatory pleasure  Outward expression
 Blunted affect of emotion
• Exhibits little or no affect in
 Vocalization
face or voice
 Alogia
• Reduction in speech

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Disorganized Symptoms
 Disorganized speech (Formal thought
disorder)
• Incoherence
 Inability to organize ideas
• Loose associations (derailment)
 Rambles, difficulty sticking to one topic
 Disorganized behavior
• Odd or peculiar behavior
 Silliness, agitation, unusual dress
 e.g., wearing several heavy coats in hot weather

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Movement Symptoms
 Catatonia
• Motor abnormalities
• Repetitive, complex gestures
 Usually of the fingers or hands
• Excitable, wild flailing of limbs
 Catatonic immobility
• Maintain unusual posture for long
periods of time
 e.g., stand on one leg
 Waxy flexibility
• Limbs can be manipulated and posed by
another person

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Table 9.2: Diagnoses of Schizophrenia
Spectrum and Other Psychotic Disorders

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Other Psychotic Disorders
 Schizophreniform Disorder
• Same symptoms as schizophrenia
• Symptom duration greater than 1 month but
less than 6 months
 Brief Psychotic Disorder
• Symptom duration of 1 day to 1 month
• Often triggered by extreme stress, such as
bereavement
 Schizoaffective Disorder
• Symptoms of both schizophrenia and mood
disorder
 DSM-5 likely to require appearance of major
© 2012 John Wiley & Sons, Inc. All rights reserved.
depressive or manic episode
Other Psychotic Disorders
 Delusional Disorder
• Delusions may include:
 Persecution
 Jealousy
 Being followed
 Erotomania
 Loved by a famous person
 Somatic delusions
• No other symptoms of schizophrenia
 Attenuated Psychosis Syndrome
• Possible new category in DSM-5
© 2012 John Wiley & Sons, Inc. All rights reserved.
Table 9.3:
Family and Twin Genetic Studies

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Table 9.4: Characteristics of Adopted
Offspring of Mothers with Schizophrenia

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Etiology of Schizophrenia:
Genetic Factors
 Genetically heterogeneous
• Not likely that disorder caused by single gene
 Family studies
• Relatives at increased risk
• Negative symptoms have stronger genetic component
 Twin studies
• 44% risk for MZ twins vs. 12% risk for DZ twins
• Children of non-schizophrenic MZ twin were more likely to
develop schizophrenia (9.4% vs. 1% in general population)
 Adoption studies
• Increased likelihood of developing psychotic disorders
 Familial high-risk studies
• Differing negative vs. positive symptomatology
© 2012 John Wiley & Sons, Inc. All rights reserved.
Etiology of Schizophrenia:
Genetic Factors
 Association studies
• Two genes associated with schizophrenia
 DTNGP1
 NGR1
• Two genes associated with cognitive deficits
 COMT
 BDNF
 Genome-wide scans
• Identification of gene mutations
• Several identified but results need to be
replicated

© 2012 John Wiley & Sons, Inc. All rights reserved.


Etiology of Schizophrenia:
Neurotransmitters
 Dopamine Theory
• Disorder due to excess levels of dopamine
 Drugs that alleviate symptoms reduce dopamine activity
 Amphetamines, which increase dopamine levels, can
induce a psychosis
 Theory revised
• Excess numbers of dopamine receptors or
oversensitive dopamine receptors
• Localized mainly in the mesolimbic pathway
 Mesolimbic dopamine abnormalities mainly related to
positive symptoms
• Underactive dopamine activity in the mesocortical
pathway mainly related to negative symptoms
© 2012 John Wiley & Sons, Inc. All rights reserved.
Figure 9.2: The Brain and
Schizophrenia

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Figure 9.3: Dopamine Theory of
Schizophrenia

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Etiology of Schizophrenia:
Evaluation of Dopamine Theory
 Dopamine theory doesn’t completely
explain disorder
• Antipsychotics block dopamine rapidly but
symptom relief takes several weeks
• To be effective, antipsychotics must reduce
dopamine activity to below normal levels
 Other neurotransmitters involved:
• Serotonin
• GABA
• Glutamate
 Medication that targets glutamate shows promise

© 2012 John Wiley & Sons, Inc. All rights reserved.


Etiology of Schizophrenia:
Brain Structure and Function
 Enlarged ventricles
• Implies loss of brain cells
• Correlate with
 Poor performance on cognitive tests
 Poor premorbid adjustment
 Poor response to treatment

© 2012 John Wiley & Sons, Inc. All rights reserved.


Etiology of Schizophrenia:
Brain Structure and Function
 Prefrontal Cortex
• Many behaviors disrupted by schizophrenia (e.g.,
speech, decision making) are governed by
prefrontal cortex
• Individuals with schizophrenia show impairments
on neuropsychological tests of prefrontal cortex
(e.g., memory)
• Individuals with schizophrenia show low metabolic
rates in prefrontal cortex
 Failure to show frontal activated related to negative
symptoms
• Disrupted communication among neurons due to
loss of dendritic spines
 Disconnection Syndrome
© 2012 John Wiley & Sons, Inc. All rights reserved.
Figure 9.4: Micrograph of a
Neuron

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Etiology of Schizophrenia:
Brain Structure and Function
 Structural and functional
abnormalities in temporal cortex
• Temporal gyrus
• Hippocampus
• Amygdala
• Anterior cingulate
 Reduced gray matter and volume
evident

© 2012 John Wiley & Sons, Inc. All rights reserved.


Etiology of Schizophrenia:
Brain Structure and Function
 Environmental Factors
• Damage during gestation or birth
 Obstetrical complications rates high in patients
with schizophrenia
 Reduced supply of oxygen during delivery may result in
loss of cortical matter
• Viral damage to fetal brain
 Presence of parasite, toxoplasma gondii,
associated with 2.5x greater risk of developing
schizophrenia
 In Finnish study, schizophrenia rates higher when
mother had flu in second trimester of pregnancy

© 2012 John Wiley & Sons, Inc. All rights reserved.


Etiology of Schizophrenia:
Brain Structure and Function
 Developmental factors
• Prefrontal cortex matures in adolescence or early
adulthood
• Dopamine activity also peaks in adolescence
• Stress activates HPA system which triggers cortisol
secretion
 Cortisol increases dopamine activity
• Excessive pruning of synaptic connections
• Use of cannabis during adolescence associated with
increased risk
 May explain why symptoms appear in late
adolescence but brain damage occurs early in life

© 2012 John Wiley & Sons, Inc. All rights reserved.


Etiology of Schizophrenia:
Psychological Stress
 Reaction to stress
• Individuals with schizophrenia and their first-
degree relatives more reactive to stress
 Greater decreases in positive mood and increases in
negative mood
 Socioeconomic status
• Highest rates of schizophrenia among urban
poor
 Sociogenic hypothesis
 Stress of poverty causes disorder
 Social selection theory
 Downward drift in socioeconomic status
• Research supports social selection

© 2012 John Wiley & Sons, Inc. All rights reserved.


Etiology of Schizophrenia:
Family Factors
 Schizophrenogenic mother
• Cold, domineering, conflict inducing
• No support for this theory

 Communication deviance (CD)


• Hostility and poor communication
• Inconclusive at this time

© 2012 John Wiley & Sons, Inc. All rights reserved.


Etiology of Schizophrenia:
Families and Relapse
 Family environment impacts relapse
 Expressed Emotion (EE)
• Hostility, critical comments, emotional
overinvolvement
 Bidirectional association
• Unusual patient thoughts → increased critical
comments
• Increased critical comments → unusual patient
thoughts

© 2012 John Wiley & Sons, Inc. All rights reserved.


Etiology of Schizophrenia:
Developmental Studies
 Use of retrospective or “follow-back”
studies
 Developmental histories of children
who later developed schizophrenia
• Lower IQ
• More often delinquent (boys) and withdrawn
(girls)
 Coding of home movies
• Poorer motor skills
• More expression of negative emotion
© 2012 John Wiley & Sons, Inc. All rights reserved.
Etiology of Schizophrenia:
Developmental Studies
 New Zealand study
• Cognitive deficits evident at early age
 Australian study
• Reduced gray matter volume predicted later
development of psychotic disorder
 North American Prodrome Longitudinal
Study
• Identified factors associated with development of
psychosis
 Having a biological relative with schizophrenia
 Recent decline in functioning
 High levels of pos

© 2012 John Wiley & Sons, Inc. All rights reserved.


Treatment of Schizophrenia:
Medications
 First-generation antipsychotic
medications (neuroleptics; 1950s)
• Phenothiazines (Thorazine), butyrophenones
(Haldol), thioxanthenes (Navane)
 Reduce agitation, violent behavior
 Block dopamine receptors
 Little effect on negative symptoms
 Extrapyramidal side effects
• Tardive dyskinesia
• Neuroleptic malignant syndrome
 Maintenance dosages to prevent relapse
© 2012 John Wiley & Sons, Inc. All rights reserved.
Treatment of Schizophrenia:
Medications
 Second-generation antipsychotics
• Clozapine (Clozaril)
 Impacts serotonin receptors
• Fewer motor side effects
• Less treatment noncompliance
• Reduces relapse
 Side effects
• Can impair immune symptom functioning
• Seizures, dizziness, fatigue, drooling, weight gain
 Newer medications may improve cognitive
function:
• Olanzapine (Zyprexa)
• Risperidone (Risperdal)
© 2012 John Wiley & Sons, Inc. All rights reserved.
Table 9.5 Summary of Major
Schizophrenia Drugs

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Treatment of Schizophrenia:
Medications
 Clinical Antipsychotic Trials of Intervention
Effectiveness (CATIE) study
• Second-generation drugs were not more effective
than the older, first-generation drug
• Second-generation drugs did not produce fewer
unpleasant side effects
• Nearly three-quarters stopped taking the
medications before study ended
 Second-generation antipsychotics have
serious side effects
• Weight gain, diabetes, pancreatitis
 Disturbing trend for people of color:
• Not prescribed second generation antipsychotics
© 2012 John Wiley & Sons, Inc. All rights reserved.
Psychological Treatments
 Patient Outcomes Research Team
(PORT) treatment recommendation:
• Medication PLUS psychosocial intervention
 Social skills training
• Teach skills for managing interpersonal
situations
 Completing a job application
 Reading bus schedules
 Make appointments
• Involves role-playing and other practice
exercises, both in group and in vivo

© 2012 John Wiley & Sons, Inc. All rights reserved.


Psychological Treatments
 Family therapy to reduce Expressed
Emotion
• Educate family about causes, symptoms, and
signs of relapse
• Stress importance of medication
• Help family to avoid blaming patient
• Improve family communication and problem-
solving
• Encourage expanded support networks
• Instill hope

© 2012 John Wiley & Sons, Inc. All rights reserved.


Psychological Treatments
 Cognitive behavioral therapy
• Recognize and challenge delusional beliefs
• Recognize and challenge expectations associated with
negative symptoms
 e.g., “Nothing will make me feel better so why bother?”
 Cognitive remediation training or cognitive
enhancement therapy (CET)
• Improve attention, memory, problem solving and other
cognitive-based symptoms
 Case management
• Multidisciplinary team to provide comprehensive services
 Residential treatment
• Vocational rehabilitation
© 2012 John Wiley & Sons, Inc. All rights reserved.
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Copyright 2012 by John Wiley & Sons, Inc.
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© 2012 John Wiley & Sons, Inc. All rights reserved.