Schizophrenic Disorders
Chapter 13
Onset and Course of the Disorder
• Onset-typically occurs during
adolescence or early adulthood.
• Period of risk-for the development of the
disorder is thought to be between the
ages of 15 and 35.
• The course of schizophrenia can follow
many different patterns, but the problems
of most patients can be divided into three
phases.
Three Phases of Schizophrenic Onset
• Promodol-precedes the phase of active
schizophrenia.
• Active Phase: appearance of the
positive symptoms.
• Residual Phase
• Positive symptoms; such as hallucinations,
delusions, and disorganized speech have
improved.
• Symptoms similar to the promodal phase:
negative symptoms become more pronounced
Symptoms
• Positive symptoms- psychotic
symptoms or the presence of aberrant
behavior.
• Negative symptoms- defined as
responses that are missing from the
persons behavior .
• Disorganization - include verbal
communication problems and bizarre
behavior.
Positive Symptoms
• Hallucinations-sensory experiences that are
not caused by actual external stimuli.
• Delusional Beliefs-beliefs held with the
utmost conviction, even when presented
with contrary evidence.
– Preoccupation with the delusions to the point
that the patient finds it difficult to NOT talk
about the delusion.
– Common delusions include the belief that
thoughts are being inserted into the patient’s
head, and that other people are reading the
patient’s thoughts.
Negative Symptoms
• Blunted Affect -restriction of patients nonverbal
display of emotional responses.
• Anhedonia -inability to experience pleasure
• Social Withdrawal -early symptom that something is
wrong, appears to be both a symptom of the
disorder and a strategy that is actively employed by
some patients to deal with their other symptoms.
• Avolition-lack of will do anything. Become apathetic
and cease to work toward personal goals or to
function independently. s.
• Alogia-speech disturbance that refers to
impoverished thinking.
– Poverty of speech-don’t have anything to say
– Thought blocking-patient’s train of speech is interrupted
before a thought or idea has been completed.
Disorganized
• Disorganized Speech-tendency of the schizophrenic to say
things that don’t make sense, including irrelevant responses to
questions, expressing disconnected ideas, and using words in
peculiar ways.
– Loose association (derailment)-shifting topics too abruptly
– Tangentiality-replying to a question with an irrelevant response.
– Perseveration-persistently repeating the same word or phrase over
and over again.
• Bizarre Behavior
– Catatonia-most often refers to immobility and marked muscular
rigidity.
• Can also refer to excitement and overactivitysuch as purposeless
pacing, repetitious movements.
– Stupurous state-reduced responsiveness where the person seems
unaware of their surroundings, though completely conscious and
believed able to hear and understand everything going on around
them.
– Inappropriate affect-`lack of adaptability in emotional expression.
Diagnostic Criteria-DSM-IV
• Characteristic Symptoms: Two or more of the
following present for a significant portion of time
during a one month period:
–
–
–
–
–
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms, such as flat affect, alogia or avolition
• Social/Occupational Dysfunction: For a significant
portion of the time since the onset of the
disturbance, one or more major areas of functioning
such as work, interpersonal relations, or self-care is
markedly below the level achieved prior to the onset.
• Duration-Continuous signs of disturbance persist for
at least 6 months
Subcategories: Five Subtypes
• Catatonic-characterized by symptoms of motor
immobility or excessive and purposeless activity
• Disorganized-characterized by disorganized speech,
behavior and flat or inappropriate affect.
• Paranoid- delusions of persecution or
grandiosityfrequent auditory hallucinations
• Undifferentiated Type- display psychotic symptoms
but do not meet the criteria for a specific subtype
• Residual Type- no longer meet the criteria for active
phase, but still exhibit negative symptoms and some
forms of hallucinations, delusions, or disorganized
speechsaid to be in a partial remission.
Related Psychotic Disorders
• Schizoaffective Disorder -defined by an episode in
which the symptoms of schizophrenia partially
overlap with a major depressive episode or a manic
episode.
• Delusional Disorder –Do not meet the full
symptomatic criteria for schizophrenia, but are
preoccupied for at least one month with delusions
that are not bizarre.
• Brief Psychotic Disorder- people who exhibit
psychotic symptoms, such as delusions,
hallucinations, disorganized speech for at least 1
day but less than one month. The episode often
follows a stressful event.
Course and Outcome
• Severe progressive disorder that most often
begins in adolescence.
• Recent evidence indicates there can be
marked improvement in the patient, but the
prediction of which is difficult.
• Patient is thought to be improved in relation
to symptom severity and occupational
functioning relative to initial assessment.
• Best predictor of future social adjustment
appears to be previous social adjustment.
Epidemiology
• Lifetime risk factors for the general
population are 1%.
• Gender Differences
• Cross Cultural
Etiology
• Biological Factors -strongest evidence for etiology.
• Social Factors - The disorder appears to be
expressed in its full blown form only when
vulnerable individuals experience some type of
environmental event, which might include anything
from nutritional variables to stressful life events.
• Psychological Factors -research indicated that
family interactions and communication problems are
not primarily responsible for the initial appearance of
symptoms, however they may contribute to the
onset of the disorder in people with a genetic
predisposition, and they also influence the course of
the disorder after the symptoms have appeared.
Biological Factors
•
•
•
•
•
Genetics
Pregnancy and Birth Complications
Viral Infections
Neuropathology
Neurochemistry
Genetics
• Twin Studies-MZ =48%, DZ =17
• Linkage studies-designed to identify
the location of a specific gene that is
responsible for the disorderunable to
identify a specific gene, but has
implicated regions on a small number
of chromosomes that may contribute to
the etiology.
Pregnancy and Birth Complications
• People with schizophrenia are more likely
than the general population to have been
exposed to various problems during their
mother’s pregnancy and to have suffered
birth injuries.
• Birth complications
• Severe malnutrition during the early months
of pregnancy leads to an increased risk of
schizophrenia among the offspring.
Viral Infections
• People who develop schizophrenia are
somewhat more likely than other people to
have been born during the winter months,
making their mothers more likely to develop
viral infections during their pregnancies
which are more prevalent during the winter.
• Exposure to infection presumably interferes
with brain development in the fetus.
Neuropathology
– Decrease in total volume of brain tissue among schizophrenic
patients.
– Mildly to Moderately enlarged ventricles at the expense of other
brain regions.
– Decreases size of the hippocampus, parahippocampus, amygdale,
and the thalamus, all of which are parts of the limbic system, and
play a crucial role in the regulation of emotion as well as the
integration of cognition and emotion.
– Reversal in asymmetry with regard to size in the planum
temporale….usually larger in the left hemisphere than the right in
men, in schizophrenics it is reversed.
– PET scans An fMRi indicate dysfunction in several neural circuits
as this type of imaging is conducted while the patient is
conducting specific tasks. Results indicate dysfunction in various
neural circuits including regions of the prefrontal cortex, and
temporal lobes.
– Conclusions from imaging studies indicate that the neural network
connecting the limbic areas with the frontal cortex may be
fundamentally disordered in schizophrenia, but the dysfunction
seems to be associated with an over-all severity of the disorder
rather than etiology of a subgroup of patients.
Neurochemistry
• Dopamine Hypothesis
• Multiple Neurotransmitters
Dopamine Hypothesis
• Original tenet of this hypothesis was that the disorder was
caused by excess levels of Dopaminergic activities, which
could be supported by the excessive number of D2 receptors
found in the brains of schizophrenic patients on autopsy
• Increased D2 receptors could lead to elevated sensitivity to DA.
• Antipsychotic drugs improve the symptoms of many
schizophrenic patients.
• Mechanism of action in the antipsychotic drugs is blockage of
the DA post-synaptic receptors leading to an increase in
release at the pre-synaptic neuron.
• The neuro-chemical model focusing solely on DA failed to
explain several aspects of the disorder.
– Treatment with antipsychotic drugs produces an increase in D2
receptors.
– Some patients do not respond positively to typical antipsychotic
drugs.
Multiple Neurotransmitters
• Evidence exists that other Neurotransmitters may
be involved that involve complex interactions with
DA pathways.
• Serotonin-Relief of symptoms via the atypical
antipsychotic drugs, which produce a strong
blockade of serotonin drugs and a very weak
blockade of the D2 receptor.
• Glutamate (excitatory) and GABA (inhibitory)
involvement due to their interaction with DA
pathways that connect the temporal lobe
structures with the prefrontal and limbic cortexes.
Social Factors
• Social Causation Hypothesis
• Social Selection Hypothesis
Psychological Factors
• Expressed Emotion-in either form of
hostility and too little support or over
protectiveness, significantly contributes to
patient relapse following hospital
discharge.
• Expressed Emotion is a reciprocal process
• Some patients relapse in spite of an
understanding family environment.
Criteria for Vulnerability Markers
– Must distinguish between those who already have
schizophrenia and those who do not
– Markers should be stable characteristic over time
– Proposed measure should identify more people
among the biological relatives of schizophrenic
patients than among people in the general
population.
– Should be able to predict the future development
of schizophrenia among those who have not yet
experienced a psychotic episode.
– Reliable vulnerability markers have not yet been
identified, but are being actively pursued.
Possible Vulnerability Markers
• Attention and Cognition Deficits in a
Continuous Performance Task in
schizophrenic patients and unaffected first
degree relatives.
• Eye Tracking Dysfunction
Treatment
Multi-faceted approach includes
medication, family therapy, and skills
training. However, medication is the
primary treatment for the disorder.
 Medication
Psychosocial Treatment
Medication
– Typical Antipsychotic Drugs- strong affinity for DA receptor sites. Positive
symptoms such hallucinations, respond better to the typical Antipsychotic
drugs than the negative symptoms such as alogia or blunted affect.
• High rate of non-responders-25%
• Several motor side effects (extra-pyramidal side effects )—include muscular rigidity,
tremors, restless agitation, strange involuntary movements and inability to initiate
motor movements.
• Tardive Dyskinesia-syndrome of abnormal involuntary movements of the mouth and
face, such as tongue protrusion and lip smacking, as well as spastic movements of the
limbs and trunk. This condition frequently occurs with long term use of typical
antipsychotics. Can be irreversible in some patients.
• Best known-thorazine
– Atypical Antipsychotic Drugs-strong affinity for serotonin with weak affinity for
DA.
• Are effective for both positive and negative symptoms.
• Much less likely to produce motor side effects.
• Main side effects are severe weight gain and obesity which has been known to lead to
diabetes.
• Best known-risperdal, Zyprexa
Maintenance Medication
– Relapse rate during the first year after hospital discharge is 65-70% if patients discontinue
medication.
– Continued medication at a reduced rate after they recover from psychotic episodes can reduce
this rate to 40%
Psychosocial Treatment
•
•
•
•
Family oriented aftercare
Social Skills Training
Assertive Community Treatment
Institutional Programs