B B E E H H Chapter 12 Schizophrenia - A chronic psychotic disorder A A characterized by disturbed behavior, thinking, V V , and perceptions. I Schizophrenia and I O O Acute episodes of schizophrenia are characterized by R Other Psychotic R delusions, hallucinations, illogical thinking, incoherent Disorders speech, and bizarre behavior. D D I I Between acute episodes, people with schizophrenia may S S Sheila K. Grant, Ph.D. still be unable to think clearly, may speak in a flat tone, O O Professor may have difficulty perceiving emotions in other R R people’s facial expressions, and may show little if any D D facial expressions of emotions themselves. E E R R S S

B B E A Beautiful Mind. E Course of Development H H Schizophrenia typically develops during a person’s late A A teens or early 20s, a time when the brain is reaching V V full maturation. I I O O In about three of four cases, the first signs of R R schizophrenia appear by the age of 25.

D D In some cases, the onset of the disorder is acute and I I occurs suddenly, within a few weeks or months. S S O O Then a rapid transformation in personality and R R behavior leads to an acute psychotic episode. D D E E R R S S

B B E Course of Development E Prevalence H H Prodromal phase - In schizophrenia, the period of A A About 1% of the adult population in the United States decline in functioning that precedes the first acute V V is affected by schizophrenia, more than 2 million psychotic episode. I I people in total. O O Residual phase - In schizophrenia, the phase that R R The WHO estimates that about 24 million people follows an acute phase, characterized by a return to the worldwide suffer from schizophrenia. level of functioning of the prodromal phase. D D I I Nearly 1 million people in the United States receive These cognitive and social deficits can impede the S S treatment for schizophrenia each year, with about a ability of schizophrenia patients to function effectively O O third of these requiring hospitalization. in social and occupational roles even more severely R R than the severe hallucinations and delusions of the D D psychotic episode. E E R R S S

1 B B E Prevalence E Overview of Schizophrenia H H A Men tend to have a slightly higher risk of developing A V schizophrenia than women. V I I O Women tend to develop the disorder somewhat later O R than men do, with onset occurring most commonly R between age 25 and the mid-30s in women and

D between age 18 and 25 in men (APA, 2000). D I I S Women also tend to achieve a higher level of S O functioning before the onset of the disorder and to O R have a less severe course of illness than do men. R D D E E R R S S

B B E Diagnostic Features E Diagnostic Features H H Schizophrenia is a pervasive disorder that affects a A A wide range of psychological processes involving V V cognition, , and behavior. I I O O The DSM-IV criteria for schizophrenia require that R R psychotic behaviors be present at some point during the course of the disorder and that signs of the disorder D D be present for at least 6 months. I I S S People with briefer forms of psychosis receive other O O diagnoses, such as brief psychotic disorder. R R D D E E R R S S

B B E Diagnostic Features E Aberrant Content of Thought H H Schizophrenia is characterized by positive symptoms A People with schizophrenia show a marked decline in A involving disturbances in thinking and expression of V occupational and social functioning. V I I thoughts through coherent, meaningful speech. O Positive symptoms -Flagrant symptoms of O Aberrant thinking may be found in both the content R schizophrenia, such as hallucinations, delusions, R bizarre behavior, and thought disorder. and form of thought.

D D I Negative symptoms - Behavioral deficiencies I Delusions represent disturbed content of thought. S associated with schizophrenia, such as social skills S O deficits, social withdrawal, flattened affect, poverty of O R speech and thought, psychomotor retardation, and R D failure to experience . D E E R R S S

2 B B E Aberrant Content of Thought E Aberrant Forms of Thought H H Delusions may take many forms. Some of the most common types Unless we are engaged in daydreaming or purposefully A are: A V V letting our thoughts wander, our thoughts tend to be I • Delusions of persecution (e.g., “The CIA is out to get me”) I tightly knit together. O O • Delusions of reference (“People on the bus are talking about R R The connections (or associations) between our thoughts me,” or “People on TV are making fun of me,” or “The neighbors tend to be logical and coherent. hear everything I say. They’ve put bugs in the walls of my house”) D D I • Delusions of being controlled (believing that one’s thoughts, I Thought disorder - A disturbance in thinking S , impulses, or actions are controlled by external forces, S characterized by the breakdown of logical associations such as agents of the devil) O O between thoughts. R • Delusions of grandeur (believing oneself to be Jesus or believing R D one is on a special mission, or having grand but illogical plans for D E saving the world) E R R S S

B B E Filtering out extraneous stimuli. E Attentional Deficiencies H H To read this you must screen out background noises A A and other environmental stimuli. V V I I Attention, the ability to focus on relevant stimuli and O O ignore irrelevant ones, is basic to learning and R R thinking.

D D People with schizophrenia often have difficulty filtering I I out irrelevant stimuli, making it nearly impossible for S S them to focus their attention, organize their thoughts, O O and filter out unessential information. R R D D E E R R S S

B B E A painting by a schizophrenia patient. E Eye Movement Dysfunction H H A A About one in three chronic schizophrenia patients V V shows evidence of eye movement dysfunction (Ross, I I 2000). O O R R Patients with this dysfunction (also called eye tracking dysfunction) have abnormal movements of the eyes

D D when they track a moving target across their field of I I vision. S S O O Rather than steadily tracking the target, the eyes fall R R back and then catch up in a kind of jerky movement. D D E E R R S S

3 B B E Abnormal Event-Related Potentials E Hallucinations H H Hallucinations - Perceptions occurring in the A Researchers have also studied brain wave patterns, A absence of external stimuli that become confused with V called event-related potentials, or ERPs, that occur V reality. I in response to external stimuli like sounds and flashes I O of light. O R R Hallucinations can involve any of the senses. ERPs can be broken down into various components

D that emerge at different intervals following the D Auditory hallucinations (“hearing voices”) are I presentation of a stimulus. I most common, affecting about three of four schizophrenia patients. S Schizophrenia patients also show reduced levels of S O later-occurring ERPs. O R R Tactile hallucinations (such as tingling, electrical, D These later-occurring ERPs are believed to be involved D or burning sensations). E in the process of focusing attention on a stimulus in E R order to extract meaningful information. R Somatic hallucinations (such as like snakes S S are crawling inside one’s belly).

B B E Hallucinations E Hallucinations H H Visual hallucinations (seeing things that are not Hallucinations are not unique to schizophrenia. A A there) V V I I People with major and mania sometimes Gustatory hallucinations (tasting things that are experience hallucinations. O O not present), R R Nor are hallucinations invariably a sign of Olfactory hallucinations (sensing odors that are not psychopathology. D D present) are rarer. I I They are common and socially valued in some S S cultures O O R R D D E E R R S S

B B E Emotional Disturbances E The Case of Georgiana H H Disturbances of affect or emotional response in A A schizophrenia may involve negative symptoms, such V V as a loss of normal affect or , I I which is labeled blunted affect or flat affect. O O R R Flat affect is inferred from the absence of emotional expression in the face and voice. D D I I People with schizophrenia may speak in a monotone S S and maintain an expressionless face, or “mask.” O O R R “Then it got out of hand, where I couldn’t control D D coming and going, back and forth, and in my E E body, out of my body, it was no longer under my R R control.” S S

4 B B E Other Types of Impairment E Other Types of Impairment H H A People who suffer from schizophrenia may become A Disturbances of volition are most often seen in the V confused about their personal identities—the cluster of V residual or chronic state. I attributes and characteristics that define themselves as I O individuals and give meaning and direction to their O People with schizophrenia may show highly excited or R lives. R wild behavior or may slow to a state of stupor.

D They may fail to recognize themselves as unique D People with schizophrenia also show significant I individuals and be unclear about how much of what I impairment in interpersonal relationships. S they experience is part of themselves. S O O R In psychodynamic terms, this phenomenon is R D sometimes referred to as loss of ego boundaries. D E E R R S S

B B E A young man diagnosed with E Subtypes of Schizophrenia H disorganized schizophrenia. H A A The DSM-IV lists three specific types of schizophrenia: V V disorganized, catatonic, and paranoid. I I People with schizophrenia who display active psychotic O O features, such as hallucinations, delusions, R R incoherent speech, or confused or disorganized behavior, but who do not meet the specifications of the D D other types, are considered to be of an undifferentiated I I type. S S O O Others who have no prominent psychotic features at the R R time of evaluation but have some residual features (for D D example, social withdrawal, peculiar behavior, blunted E E or inappropriate affect, strange beliefs or thoughts) R R would be classified as having a residual type of S S schizophrenia.

B B E Disorganized Type E Catatonic Type H H Disorganized type - The subtype of schizophrenia Catatonic type - The subtype of schizophrenia A A characterized by disorganized behavior, bizarre characterized by gross disturbances in motor activity, V V delusions, and vivid hallucinations. such as catatonic stupor. I I O O People with disorganized schizophrenia display People with catatonic schizophrenia may show unusual R R silliness and giddiness of mood, giggling and talking mannerisms or grimacing or maintain bizarre, nonsensically. apparently strenuous postures for hours, although D D their limbs become stiff or swollen. I I They often neglect their appearance and hygiene and S S lose control of their bladders and bowels. A striking but less common feature is waxy flexibility, O O which involves adopting a fixed posture into which R R they have been positioned by others. D D E E R R S S

5 B B E Paranoid Type E Type I versus Type II Schizophrenia H H Paranoid type - The subtype of schizophrenia A A Type I schizophrenia is characterized by the more characterized by hallucinations and systematized V V flagrant or positive symptoms of schizophrenia we delusions, commonly involving themes of persecution. I I describe earlier, such as hallucinations, delusions, and O O looseness of associations, as well as by an abrupt The behavior and speech of someone with paranoid R R onset, preserved intellectual ability, and a more schizophrenia does not show the marked favorable response to antipsychotic medication. disorganization typical of the disorganized type, D D nor is there a prominent display of flattened or I I Type II schizophrenia corresponds to a pattern inappropriate affect or catatonic behavior. S S consisting largely of the deficit or negative O O symptoms of schizophrenia, such as lack of emotional The delusions often involve themes of grandeur, R R expression, low or absent levels of motivation, loss of persecution, or . D D ability to experience pleasure, social withdrawal, and E E poverty of speech, as well as by a more gradual onset, R R intellectual impairment, and poorer response to S S antipsychotic drugs.

B B E A person diagnosed with E Psychodynamic Perspectives H catatonic schizophrenia. H A A Within the psychodynamic perspective, schizophrenia V V represents the overwhelming of the ego by primitive I I sexual or aggressive drives or impulses arising from the O O id. R R These impulses threaten the ego and give rise to

D D intense intrapsychic conflict. I I S S Under such a threat, the person regresses to an early O O period in the oral stage, referred to as primary R R narcissism. D D E E R R S S

B B E Paranoid Schizophrenia. E Learning Perspectives H H Although learning theory does not offer a complete A A explanation of schizophrenia, the development of some V V forms of schizophrenic behavior can be understood in I I terms of the principles of conditioning and O O observational learning. R R From this perspective, people with schizophrenia learn D D to exhibit certain bizarre behaviors when these are I I more likely to be reinforced than normal behaviors. S S O O Social-cognitive theorists suggest that modeling of R R schizophrenic behavior can occur within the mental D D hospital, where patients may begin to model E E themselves after fellow patients who act strangely R R S S

6 B B The familial risk of schizophrenia. E Genetic Factors E H H Generally speaking, the A The closer the genetic relationship between A more closely one is related to people who V schizophrenia patients and their family members, the V greater the likelihood (or concordance rate) that the have developed I I schizophrenia, the O relatives will also have schizophrenia. O greater the risk of R R developing Overall, first-degree relatives of people with schizophrenia for oneself. D schizophrenia (parents, children, or siblings) have D Monozygotic (MZ) I about a tenfold greater risk of developing I schizophrenia than do members of the general twins, whose genetic S S heritages are identical, O population. O are much more likely R R than dizygotic (DZ) twins, whose genes D The fact that families share common environments as D well as common genes requires that we dig deeper to overlap by 50%, to be E E concordant for R examine the genetic underpinnings of schizophrenia. R schizophrenia. S S

B B E Biochemical Factors E Brain Abnormalities H H A Contemporary biological investigations of A We have compelling evidence of both structural V schizophrenia have focused on the role of the V changes (loss of brain tissue) and functional I neurotransmitter dopamine. I disturbance (abnormalities of functioning) in the O O brains of schizophrenia patients. R The leading biochemical model of schizophrenia, the R dopamine hypothesis, posits that schizophrenia However, we have yet to discover any one source of

D involves an overreactivity of dopamine transmission in D pathology in the brain that is specific to schizophrenia I the brain. I or present in all cases of schizophrenia. S S O Increasing evidence supports the view that O The most prominent finding of structural changes is R schizophrenia involves an irregularity in dopamine R the loss of brain tissue (gray matter) of about 5% on D transmission in the brain D the average in schizophrenia patients as compared to E E normal controls. R R S S

B Loss of brain tissue in adolescents with B Structural changes in the brain of a E E H early-onset schizophrenia. H person with schizophrenia as compared A A with that of a normal subject. V V I I O O R R

D D I I S S O O R R D D E E R R S S

7 B PET scans of people with schizophrenia B E E Family Theories versus normals. H H An early, but since discredited theory, focused on the A A role of the schizophrenogenic mother (Fromm- V V Reichmann, 1948, 1950). I I O O In what some feminists view as historic psychiatric R R sexism, the schizophrenogenic mother was described as cold, aloof, overprotective, and D D domineering. I I She was characterized as stripping her children of self- S S esteem, stifling their independence, and forcing them O O into dependency on her. R R D D Children reared by such mothers were believed to be at E E special risk for developing schizophrenia if their fathers R R were passive and failed to counteract the mother’s S S pathogenic influences.

B B E Communication Deviance E Expressed H H Communication deviance (CD) is a pattern of Another form of disturbed family communication, A A unclear, vague, disruptive, or fragmented expressed emotion (EE), is a pattern of responding V V communication that is often found among parents and to the schizophrenic family member in hostile, critical, I I family members of schizophrenia patients. and unsupportive ways. O O R R CD is speech that is hard to follow and from which it is Schizophrenia patients from high EE families stand a difficult to extract any shared meaning. higher risk of relapsing than those with low EE (more D D supportive) families. I I High CD parents often have difficulty focusing on what S S their children are saying. High EE relatives typically show less , O O tolerance, and flexibility than low EE relatives. R R D D E E R R S S

B Relapse rates of people with B E E Family Factors in Schizophrenia: H schizophrenia in high and low EE families. H Causes or Sources of Stress? A A No evidence supports the belief that family factors, V V such as negative family interactions, lead to I I schizophrenia in children who do not have a genetic O O vulnerability. R R Rather, a genetic vulnerability to schizophrenia D D renders individuals more susceptible to troubled I I family and social relationships. S S Within the diathesis–stress model, disturbed O O patterns of family interaction and communication R R represent sources of life stress that increase the risks D D of developing schizophrenia among people with a E E genetic predisposition for the disorder R R S S

8 B B From genes to vulnerabilty. E Endophenotypes E H H A Endophenotypes - Measurable processes or A V mechanisms not apparent to the naked eye, which are V I the means by which an organism’s genetic code comes I O to affect its observable characteristics or phenotypes. O R Investigators are investigating a number of possible R endophenotypes in schizophrenia, including D disturbances in brain circuitry, deficits in working D I memory and cognitive abilities, and abnormalities of I S neurotransmitter functioning. S O O R To better understand how schizophrenia develops, we R D need to dig under the surface to see how genes affect D E underlying processes, and how these processes in turn E R contribute to the development of the disorder. R S S

B B E Biological Approaches E Sociocultural Factors in H H Tardive dyskinesia (TD) - A disorder characterized by Treatment A involuntary movements of the face, mouth, neck, trunk, or A V V extremities and caused by long-term use of antipsychotic Ethnicity may also play a role in the family’s I medication. I O O involvement in treatment. Antipsychotic medication helped control the more flagrant R R behavior patterns of schizophrenia and reduced the need for In a study of 26 Asian Americans and 26 non-Hispanic long-term hospitalization when taken on a maintenance or White Americans with schizophrenia, family members D continuing basis after an acute episode. D I I of the Asian American patients were more frequently S Yet for many patients with chronic schizophrenia, entering a S involved in the treatment program. O hospital is like going through a revolving door: they are O repeatedly admitted and discharged. For example, family members were more likely to R R accompany the Asian American patients to their D Many are simply discharged to the streets once they are D medication evaluation sessions. E stabilized on medication and receive little if any follow-up E R care. R S S

B B Learning-Based Therapies E Psychodynamic Therapy E H H Therapy methods include the following: A Freud did not believe that traditional psychoanalysis A V was well suited to the treatment of schizophrenia. V 1. Selective reinforcement of behavior, such as I I providing attention for appropriate behavior and O The withdrawal into a fantasy world that typifies O extinguishing bizarre verbalizations through R schizophrenia prevents the individual with R withdrawal of attention. schizophrenia from forming a meaningful relationship 2. Token economy, in which individuals on inpatient with the psychoanalyst. D D units are rewarded for appropriate behavior with I I tokens, such as plastic chips, that can be exchanged for The techniques of classical psychoanalysis, Freud S S tangible reinforcers such as desirable goods or wrote, must “be replaced by others; and we do not O O privileges. R know yet whether we shall succeed in finding a R D substitute”. D 3. Social skills training, in which clients are taught E E conversational skills and other appropriate social R R behaviors through coaching, modeling, behavior S S rehearsal, and feedback.

9 B B E Psychosocial Rehabilitation E Family Intervention Programs H H People with schizophrenia typically have difficulties A A Family conflicts and negative family interactions can functioning in social and occupational roles and V V heap stress on family members with schizophrenia, performing work that depends upon basic cognitive I I increasing the risk of recurrent episodes. O abilities involving attention and memory. O R R Researchers and clinicians have worked with families of These problems limit their ability to adjust to people with schizophrenia to help them cope with the community life, even in the absence of overt psychotic D D burdens of care and assist them in developing more behavior. I I cooperative, less-confrontational ways of relating to S S others. O Recently, promising results were reported for cognitive O rehabilitation training to help schizophrenia patients R R In sum, no single treatment approach meets all the strengthen such basic cognitive skills as attention and D D needs of people with schizophrenia. E memory. E R R S S

B B E Other Forms Of Psychosis E Other Forms Of Psychosis H H A Brief psychotic disorder - A psychotic disorder A Erotomania - A delusional disorder characterized by V lasting from a day to a month that often follows V the belief that one is loved by someone of high social I exposure to a major stressor. I status. O O R Schizophreniform disorder - A psychotic disorder R Schizoaffective disorder - A type of psychotic lasting less than 6 months in duration, with features disorder in which individuals experience both severe

D that resemble schizophrenia. D mood disturbance and features associated with I I schizophrenia. S Delusional disorder - A type of psychosis S O characterized by persistent delusions, often of a O R paranoid nature, that do not have the bizarre quality of R D the type found in paranoid schizophrenia. D E E R R S S

B B E Biological Approaches E H H A A V V I I O O R R QUESTIONS? D D I I S S O O R R D D E E R R S S

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