Chapter 12
• Psychosis: a loss of contact with reality
• A change in your ability to perceive and respond to the
environment
• Can be substance-induced – but most due to
schizophrenia.
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Prevalence: 1% (about 2.5 million Americans)
Little variability in prevalence cross-culturally
Equal rates across men and women
More frequently found among low SES
• “downward drift” theory
• At greater risk for suicide and to be victims of crime
3
• The DSM-5 calls for a diagnosis of schizophrenia only
after symptoms of psychosis continue for six months or
more
• Individuals must also show a deterioration in their
work, social relations, and ability to care for
themselves
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• There are three kinds of symptoms of schizophrenia:
• Positive symptoms – “Pathological Excesses”
• (e.g., hallucinations)
• Negative symptoms
• (e.g., flat affect)
• Psychomotor symptoms
• (e.g., catatonic postures)
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• Positive symptoms include:
• Hallucinations – false perceptions
• Most common are auditory
• Can involve ANY of the 5 senses – olfactory, tactile, visual
• Delusions – faulty interpretations or beliefs
• Lots of kinds of delusions
https://www.youtube.com/watch?v=G
vF4-C1EuJU
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• Types of delusions
• Persecutory
• Referential
• Somatic
• Religious
• Grandiose
• Thought withdrawal
• Thought insertion
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• Disorganized Thinking and Speech:
• Loose associations (derailment):
• “Kyra serves drinks at a bar. I love candy bars. I went to Hershey, PA
when I was five years old.”
• Neologisms (made-up words):
• “butterflower”
• Perseveration
• Patients repeat their words and statements again and again
• “Let’s go to supper at the supper club, with the supper, supper”
• Clang (rhymes):
• How are you? “Well, hell, it’s well to tell”
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• Other positive symptoms include:
• Heightened perceptions
• People may feel that their senses are being flooded by sights and
sounds, making it impossible to attend to anything important
• Inappropriate affect – emotions that are unsuited to the situation
https://www.youtube.com/watch?v=n
7BEOxj81fM
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• Poverty of speech (alogia)
• Flat affect or blunted affect
poor eye contact
monotonous voice
face appears to lack emotion
• Loss of volition (avolition or apathy)
lack of initiation or follow through
• Social withdrawal
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• Catatonic stupor – stop responding to environment,
motionless and mute
• Catatonic rigidity – rigid posture, resisting movement
• Catatonic posturing – awkward positions
• Catatonic excitement – “wild waving of arms &legs”
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• Type I and Type II schizophrenia
• Type I schizophrenia is dominated by positive symptoms
• Better adjustment prior to the disorder
• Later onset of symptoms
• Greater likelihood of improvement
• Tied more closely to biochemical abnormalities in the brain
• Type II schizophrenia is dominated by negative symptoms
• Tied largely to structural abnormalities in the brain
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• Lots of proposed explanations for schizophrenia
• Biological explanations have received the most research support
• Biological theories:
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Genetic
Biochemical Abnormalities
Abnormal Brain Structure
Viral problems
• Diathesis-stress relationship
• People have a biological risk for schizophrenia (diathesis)
• Might only develop symptoms if they experience certain kinds of stress
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• There is a big genetic risk in schizophrenia
• The closer you are related to a person with the
disorder, the more likely you are to get it.
• 1% risk with no family hx
• 17% risk for dizygotic twins
• 48% risk for monozygotic twins
• (Not 100%! Stress plays a role.)
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• Genetic factors
• Genetic factors may lead to the development of schizophrenia through
two kinds of (potentially inherited) biological abnormalities:
• Biochemical abnormalities
• Abnormal brain structure
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• The Dopamine Hypothesis
• Certain neurons using dopamine fire too often, producing symptoms of
schizophrenia
• This theory was discovered accidentally
• Antipsychotic drugs (which increase dopamine) were tested as allergy pills
• They failed in that role – but they were found to increase dopamine
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• Antipsychotics/neuroleptics are
dopamine antagonists: bind to
dopamine receptors (D2), thus
preventing dopamine from binding,
and preventing neurons from firing.
• Extrapyramidal side effects: muscular
tremors, uncontrollable shaking,
similar to symptoms of Parkinson’s
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• Biochemical abnormalities
• Research since the 1960s has supported and clarified this hypothesis
• Example: patients with Parkinson’s disease develop schizophrenic
symptoms if they take too much L-dopa, a medication that raises
dopamine levels
• Example: people who take high doses of amphetamines, which
increase dopamine activity in the brain, may develop amphetamine
psychosis – a syndrome similar to schizophrenia
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Antipsychotics work . . .
. . . but have serious and disabling side effects
• Used to be given antipsychotics like thorazine.
• Now, new atypical antipsychotics
• Clozapine, risperidone, olanzapine…
• More effective (85% vs. 65%)
• Few extrapyramidal effects
• No tardive dyskinesia effects.
• But, 1% risk of agranulocytosis (drop in white
blood cells) -- need frequent blood tests
• Abnormal brain structures have been found:
• Enlarged ventricles
• Smaller temporal/frontal lobes
• Smaller amounts of grey matter
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• Correlational research:
• More people who were born in the winter have schizophrenia
• Possible increased exposure to viruses?
• More direct research:
• Mothers of those with schizophrenia more likely to have had the flu
• Antibodies for certain viruses more commonly found in those with
schizophrenia.
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• Research on biology of this disorder is strong, many abandoned
psychological views
• Two main psychological theories of schizophrenia:
• Psychodynamic
• Cognitive
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• The psychodynamic explanation
• Freud believed that schizophrenia develops from two processes:
• Regression to a pre-ego stage (due to cold, un-nurturing parents)
• Efforts to re-establish ego control
• Frieda Fromm-Reichmann theorized the schizophrenogenic mothers theory
• Proposed that mothers of people with schizophrenia were cold,
domineering, and uninterested in their children’s needs
• These theories are not supported by research.
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• The cognitive view
• Cognitive theorists agree that biological factors produce symptoms
• They argue: some symptoms develop because of faulty interpretation
• Example: a man experiences auditory hallucinations and approaches
his friends for help; they deny the reality of his sensations; he
concludes that they are trying to hide the truth from him; he begins to
reject all feedback and starts feeling persecuted
• There is little direct research support for this view
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• 3 main sociocultural influences
• Multicultural factors
• Prevalence higher in some minority groups – is it because of SES?
• Social labeling
• Rosenhan’s “pseudo-patient” study
• Family dysfunction
• Parents higher in “expressed emotion” – more critical, overly involved
• Higher “expressed emotion” – 4x greater chance of relapse!
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• For much of human history, people with schizophrenia
were considered beyond help and without hope
• Though schizophrenia is still hard to treat, the
discovery of antipsychotic drugs has enabled
people with the disorder to think clearly and profit
from psychotherapies
• A historical perspective of treatment allows the best
understanding of the nature, problems, and promise of
modern approaches
• For more than half of the 20th
century, people with
schizophrenia were considered
insane and were
institutionalized in public mental
hospitals
• Because patients failed to
respond to traditional
therapies, the primary goals of
the hospitals were to restrain
them and give them food,
shelter, and clothing
• In the 1950s, clinicians developed two institutional
approaches that brought some hope to chronic patients:
• Milieu therapy
• Based on humanistic principles
• Token economies
• Based on behavioral principles
• These approaches particularly helped improve the
personal care and self-image of patients, problem areas
that were worsened by institutionalization
• Milieu therapy
• The guiding principle is that institutions can help patients make
clinical progress by creating a social climate (“milieu”) that
promotes productive activity, self-respect, and individual
responsibility
• Milieu programs have been set up in institutions throughout the
Western world with moderate success
• Research has shown that patients with schizophrenia in milieu programs
often leave the hospital at higher rates than patients receiving custodial
care
• The token economy
• Based on operant conditioning principles, token economies are used
in institutions to change the behavior of patients with schizophrenia
• Patients are rewarded when they behave in socially acceptable
ways and are not rewarded when they behave unacceptably
• Immediate rewards are tokens that can later be exchanged for food,
cigarettes, privileges, and other desirable objects
• Acceptable behaviors likely to be targeted include care for oneself and
one’s possessions, going to a work program, and showing self-control
• The token economy
• Researchers have found that token economies
help change psychotic and related behavior
• However, questions have been raised about
such programs:
• Are such programs ethical and legal? Aren’t all
humans entitled to basic rights, some of which are
compromised in a strict token economy system?
• Are such programs truly effective? For example,
patients may change overt behaviors but not
underlying psychotic beliefs
• While milieu therapy and token economies helped improve
treatment outcomes, it was the discovery of antipsychotic drugs
in the 1950s that revolutionized treatment for those with
schizophrenia
• It was discovered that one group of antihistamines,
phenothiazines, could be used to calm patients about to
undergo surgery
• Psychiatrists tested one of the drugs, chlorpromazine, on six patients with
psychosis and observed a sharp reduction in their symptoms
• Antipsychotic drugs developed throughout the 1960s, 1970s,
and 1980s are now referred to as “conventional” antipsychotic
drugs
• Drugs developed in recent years are known as “atypical”
antipsychotics
• Research has repeatedly shown that antipsychotic drugs
reduce schizophrenia symptoms in the majority of patients
• In direct comparisons, drugs appear to be more effective than any
other approach used alone
• In most cases, the drugs produce the maximum level of
improvement within the first six months of treatment
• Symptoms may return if patients stop taking the drugs too soon
• Antipsychotic drugs, particularly the conventional ones,
reduce the positive symptoms of schizophrenia
more completely, or at least more quickly, than the
negative symptoms
• Although the use of such drugs is now widely
accepted, patients often dislike the powerful effects of
the drugs, and some refuse to take them
• The most common unwanted effects produce
Parkinsonian symptoms, reactions that closely resemble
the features of the neurological disorder Parkinson’s
disease, including:
• Muscle tremor and rigidity
• Dystonia (bizarre movements of the face, neck, tongue, and back)
• Akathisia (great restlessness, agitation, and discomfort in the limbs)
• A more difficult side effect of conventional antipsychotic
drugs appears up to one year after starting the
medication
• This reaction, called tardive dyskinesia, involves involuntary
movements, usually of the mouth, lips, tongue, legs, or body
• It affects more than 10% of those taking the drugs
• It can be IRREVERSIBLE!
• Since learning of the unwanted side effects of conventional
antipsychotic drugs, clinicians have become more careful in their
prescription practices:
• They try to prescribe the lowest effective dose
• They gradually reduce or stop medication weeks or months after the
patient begins functioning normally
• Recently, new drugs have been developed
• Called “atypical” because their biological operation
differs from that of conventional antipsychotics
• They appear more effective than conventional drugs,
especially for negative symptoms
• They cause few extrapyramidal side effects
(i.e., movement disorders)
• Examples: Clozaril, Risperdal,
Zyprexa, Seroquel, Geodon,
and Abilify
• Before the discovery of antipsychotic drugs, psychotherapy was
not an option for people with schizophrenia
• Most were simply too far removed from reality to profit from
psychotherapy
• Today, psychotherapy can be very helpful when used in
combination with medication
• The most helpful forms of psychotherapy include insight therapy and two
broader sociocultural therapies: family therapy and social therapy
• These approaches are often combined
• Insight therapy
• A variety of insight therapies have been used to treat schizophrenia
• Studies suggest that the orientation of the therapist is less important than
their experience with schizophrenia
• In addition, the most successful therapists are those who take an active
role, set limits, express opinions, and challenge the patients’ statements
• Family therapy
• About 25% of persons recovering from
schizophrenia live with family members
• This creates significant family stress
• Those who live with relatives who display high
levels of expressed emotion are at greater risk
for relapse than those who live with more
positive or supportive families
• Family therapy attempts to address such issues,
create more realistic expectations, and provide
psychoeducation about the disorder
• The community approach is the broadest approach for
the treatment of schizophrenia
• In 1963, Congress passed the Community Mental Health Act,
which said that patients should be able to receive care within
their own communities, rather than being transported to
institutions far from home
• This led to massive deinstitutionalization of patients with schizophrenia
• Unfortunately, community care was (and is) inadequate for their care
• The result is a “revolving door” syndrome
• People recovering from
schizophrenia and other severe
disorders need medication,
psychotherapy, help in handling
daily pressures and responsibilities,
guidance in making decisions,
training in social skills, residential
supervision, and vocational
counseling
• This combination of services
sometimes is called assertive
community treatment
• There is no doubt that effective community programs
can help people with schizophrenia recover
• However, fewer than half of all people who need them
receive appropriate community mental health services
• In any given year, 40% to 60% of all people with
schizophrenia receive no treatment at all
• Two factors are primarily responsible:
• Poor coordination of services
• Shortage of services
• When community treatment fails, many people with
schizophrenia receive no treatment at all
• Some return to their families and receive medication and perhaps
emotional and financial support, but little else in the way of treatment
• Finally, a great number
of people with
schizophrenia become
homeless
• Approximately one-third
of the homeless people in
America have a severe
mental disorder, commonly
schizophrenia
• Today community care is a major feature of treatment for
people recovering from schizophrenia in countries around the
world
• Both in the U.S. and abroad, varied and well-coordinated
community treatment is seen as an important part of the solution
to the problem of schizophrenia