Schizophrenia in the
Social Environment
Objectives
Describe schizophrenia in the context of
developmental stages
Describe how schizophrenia affects males
and females differently, as well as African
Americans
Describe the status of individuals with
schizophrenia within the macro system
Improve your overall understanding of
schizophrenia
Outline
What is schizophrenia?
–Causes, symptoms, etc.
Onset, course and prognosis
Shift in treatments (macro level
information)
Schizophrenia
What is Schizophrenia?
•Chronic, severe and disabling thought
disorder
– Break from reality (psychotic episode)
– Illogical and irrational thoughts
– Extreme emotional and social
disregulation
– NOT Dissociative Identity Disorder
Schizophrenia Demographics
• Affects about 1-2% of population (2 million)
• More frequently seen in the lower
socioeconomic classes
• More frequently seen in large cities vs. rural
• More frequently in divorced/separated families
• 10-15% may commit suicide
• Affects men and women equally
• Approximately 20% are homeless
Causes
• No known single cause
• Theoretical causes include genetics,
environmental,
and behavioral factors (drugs)
• No cure
Symptoms
• Positive Symptoms (delusions, hallucinations)
– Pathological additions to normal behavior
• Negative Symptoms (flat affect)
– Characteristics that are lacking or reduced
• Psychomotor Symptoms
– Odd gestures
– Excited Movement
– Motionless stupor
Positive Symptoms
• Delusions-beliefs contrary to
reality
– Persecution
– Reference
– Grandeur
– Control
• Disorganized
Thinking/Speech
– Loose Associations
– Word Salad
– Perseveration
• Heightened Perceptions &
Hallucinations
– Sensory Flooding
– Hallucinations
Negative Symptoms
• Poverty of Speech
• A decrease in speech or
speech content (catatonia)
• Blunted or Flat Affect
– Flat-virtually no
emotion
– Ambivalence
• Social Withdrawal
– Conflicted feelings
about many things
Psychosocial Factors
• Disturbed Family
Communication
– Expressed Emotion
•Family members
express critical or
overprotective
emotions (e.g. flat
affect, staring)
•Predictive of relapse
Onset, Course and
Prognosis
Childhood Precursors
Some children who later develop SZ show (majority have
normal childhoods):
1. Delayed developmental milestones (walking, etc)
2. More language and speech problems (predictor)
3. Poorer coordination (sports, phy ed class)
4. Poorer academic achievement
5. Poorer social functioning and fewer friends
**Statistical associations not predictors**
Source: Torrey, 2006
Surviving Schizophrenia
Onset
• 75% of those who get SZ are between the ages of 17
and 25; Unusual to get before 14 or after 30
• Childhood SZ does occur but rare
• Postpartum SZ happens but is usually eventually
diagnosed as manic depressive illness or major
depression with psychotic features
• Late-onset SZ: Age 40 or over; more females than
males and 1/3 go on to develop Alzheimer-type
dementia
Questions
Based on the article:
•What aspects of an individual's life are
affected by the development of
schizophrenia during middle
adulthood?
•How does this affect their
development, biologically,
psychologically, and socially?
Predictors of Outcome
Good vs. Worse Prognosis
• Consider “normal” prior to
SZ
• Female
• No hx or relatives with SZ
• Family hx depression or
bipolar disorder
• Sudden onset
• More positive symptoms
• Quick response to initial dose
meds
• Good illness awareness
• Family hx of SZ
• Male
• Younger the age when SZ
developed (15 vs.25)
• Slower, gradual onset
• Have more negative
symptoms (flattened affect)
• Poor illness awareness
• Poor initial response to meds
Illness awareness…
or lack thereof
Two theories on lack of insight
(1) Anosognosia
–
–
–
–
Neurological term
Limited or no awareness
Strokes or brain tumors in the right side of the brain
Frontal lobe damage
(2) Psychological defense mechanism
– Blocking
– Do not want to talk about illness episodes when better
Men and Schizophrenia
• Males earlier onset than
females
• More severe in males
• Males do not respond well to
antipsychotic meds-require
higher doses than women
(metabolic issue?)
• Higher relapse rate than
women
• More trouble with long-term
adjustment (e.g. marriage,
work, level of function) when
compared to women
African Americans and SZ
• Recent study shows African
Americans has 3 fold increase
in SZ when compared to whites
• Past studies show same
• Researchers not sure why
Long-term Prognosis
Studies that follow individuals long-term generally
show that the course of outcome is better after 30
years than after 10 years
• Illness seems to “die down” after many years
• Gets worse before it gets better
Schizophrenia and Life Expectancy
People with SZ tend to die younger
WHY?
• Suicide (12x times higher than gen pop)
• Diseases (diabetes type II, heart disease, etc)
• Unhealthy lifestyles (smoking)
• Inadequate medical care and lack of access
• Homelessness
Schizophrenia & Violence
• Violence is NOT a
symptom
• Risk Factors
– History of violence
– Substance abuse
– Off medication and
actively psychotic
-Lack of illness insight
Most violent crimes are
not committed by persons
with schizophrenia, and
most persons with
schizophrenia do not
commit violent crimes.
-NIMH
SZ Treatment
– Cognitive
techniques
– Behavioral strategies
– Family & Group
therapy
*Often combined
with medication
SZ can be very difficult to treat
•Nearly half of those diagnosed do not know
that they are sick
•Co-occurring disorders
•Medication side effects
•Laws and Insurance Companies**
•Lack of social and familial support
•Stigma and discrimination
•SZ Difficult to understand
SZ and Macro Systems
Question
Psychiatric hospitals across the country are
down-sizing and closing…Less help and fewer
beds…No observable decrease in the # of
people needing help…
Does anyone know where many of these
individuals who are still in need of help
are winding up?
Big Shift
Mental health system to the…
Current Conditions
• By the end of 2006, there were 2.3 million
confined individuals.
• 16 to 37.5% of those individuals are diagnosed
with an SMI (bipolar, SZ, SZA)
• 2 to 4 times higher than found in the general
public
• HRW estimates 200,000 to 400,000 SMI
Not a New Problem
•19th century
•Dorothea Dix
•Hospitals remained the primary
treatment of SMI for next 150 years
Trend of Incarcerating SMI
•Began to notice increase in the number of
SMI being jailed beginning in the 1970’s
– Teplin and Colleagues and Cook County,
Illinois
•Failure of the mental health system
Possible causes of incarceration of those
with SMI
• Deinstitutionalization beginning in 1950’s
• Lack of community mental health centers and
services-did not want to treat SMI
• Lack of housing
– Led to Homelessness (1/3 have SMI)
• Social welfare policies (Medicare/Medicaid)
Possible Causes…continued
• Changes in drug laws
• Strict inpatient laws
• Inability to recognize illness
– 50% of people with schizophrenia and bipolar
disorder do not recognize they are ill
• Penrose's theory
Mental Health Courts and Federal Laws
• Congress saw increasing levels of SMI as a
problem
• 2000 America’s Law Enforcement and Mental
Health Project Act (ALEMHP) (S.1865), P.L.
106-515. President Clinton
• 2004 Mentally Ill Offender Treatment and
Crime Reduction Act of 2004 (MIOTCRA) P.L.
108-414. President Bush
What is a Mental Health Court?
• Similar to drug courts
• Forensic courts that manage the cases of those
with mental illness charged with committing
misdemeanors and/or felony crimes.
• Approximately 130 in operation-growing
• Based on “therapeutic jurisprudence”
• Problem: Treatment after crime committed
NAMI Mental Health in
Pennsylvania Report Card
• NAMI D+ (Nationally D+)
– Infrastructure: C– Information: D– Access: D– Services: C– Recovery Supports: C-
Mental Health and Pittsburgh
• State inmate re-entry program in Allegheny
County (MHC program)
– 2001: 3rd largest mental health facility in PA
– 20-25% inmates mentally ill
• RAND study
– 1st study to examine cost of program
– Cost effectiveness took effect after 2 years
– Received more mental health services and
spent fewer days in jail (criminal court)
Mental Health Laws and SZ in Pittsburgh
Most restrictive laws in
the nation
Troy Hill Jr.
Consequences of Strict Laws
• Fatally attacked one brother and hurt another
• Diagnosed as having paranoid SZ
• Tried to seek help but was turned away
Powerful Letter
“I have made thousands of
mistakes in my life, but my
worst mistake, the one I
lament almost daily, [was]
working … to pass the state's
Mental Health Procedures
Act”
-Bill Shane-Former PA
Legislator Thursday Sept 13,
2007 Pittsburgh Post Gazette
Summary
• Most people who develop SZ do so at late
adolescence/early adulthood
• Schizophrenia is still a very misunderstood
disease
• Many people with SZ do not receive or accept
treatment
• Many are now involved in the criminal justice
system
Questions or
Comments?