Schizophrenia
History of Schizophrenia
Diagnosis

Emil Kraepelin (1856-1926): dementia praecox
 Eugen Bleuler (1857-1939): schizophrenia
 The Broadened U.S. Concept
– Increased frequency of diagnosis
– Process-reactive dimension

Other U.S. diagnostic practices
– Diagnose schizophrenia whenever delusions or
hallucinations were present
– Patients having a personality disorder were also
diagnosed as schizophrenic
DSM-IV Diagnosis
 Schizophrenia
– Symptoms > 6 months
 Schizophreniform
disorder
– Symptoms 1 month - 6 months
 Brief
psychotic disorder
– Symptoms 1 day - 1 month
Prevalence of
Schizophrenia
 1-2%
of U.S. population
 2 million diagnosed in U.S.
 Primary diagnosis in 40% state/county
hospital admissions
 Low SES 3-8x higher prevalence
Prevalence of
Schizophrenia
 Median
age at diagnosis = mid-20’s
 Men = Women prevalence
– Men earlier diagnosis
Worse premorbid history
 Worse prognosis

Prognosis of Schizophrenia
 10%
continuous hospitalization
 < 30% recovery = symptom-free for 5
years
 60% continued problems in
living/episodic periods
Schizophrenia

Characteristic Symptoms: Two or more of the
following, each present for a significant portion of time
during a 1-month period (or less if successfully
treated):
– delusions
– hallucinations
– disorganized speech (e.g., frequent derailment or
incoherence)
– grossly disorganized or catatonic behavior
– negative symptoms, i.e., affective flattening, alogia, or
avolition

Social/occupational dysfunction
 Continuous signs for 6 months, at least 1 month of
symptoms
The DSM-IV Diagnosis

DSM narrowed the range of individuals who
could be diagnosed with schizophrenia in two
ways:
 Explicit and detailed criteria
 Excluding other disorders
–
–
–
–
Schizoaffective disorder
Schizophreniform disorder
Brief psychotic disorder
Delusional disorder
Course of Schizophrenia
 Prodromal
phase
 Active phase
 Residual phase
Symptom Distinction
 Positive
symptoms
– Deviant behaviors present
 Negative
symptoms
– Normal behaviors absent
– Poor premorbid history
– Poorer prognosis
– Spouses less satisfied
Positive Symptoms of
Schizophrenia
 Disorganized
Speech (thought disorder):
problems in the organization of ideas and in
speaking so that a listener can understand
 Delusions: Beliefs contrary to reality, firmly
held in spite of evidence to the contrary
(themes: control, grandeur, persecution)
 Hallucinations: sensory experiences in the
absence of any stimulation from the
environment
Negative Symptoms of
Schizophrenia

Avolition: or apathy; a lack of energy and a
seeming absence of interest in routine activities
 Alogia: a negative thought disorder:
– poverty of speech
– poverty of content

Anhedonia: inability to experience pleasure
 Flat or Blunted Affect: virtually no stimulus can
elicit an emotional response
 Asociality: severe impairments in social
relationships
Subtypes of Schizophrenia
 Paranoid
– Delusions/Hallucinations have single theme =
Persecution/Grandiosity
– No thought disorder
– Better prognosis

Subtypes of Schizophrenia
 Catatonic
– Hallmark = motor behavior
Catatonic stupor
 Catatonic excitement

Subtypes of Schizophrenia
 Disorganized
(Hebephrenic)
– Grossly disorganized cognition, affect,
behavior
– Poor prognosis
Subtypes of Schizophrenia
 Undifferentiated
– Does not meet criteria for other subtypes
Diagnosis in First Episode
(Lieberman et al., 1992)

1% Catatonic
 3% Disorganized
 19% Paranoid
 54% Undifferentiated
Etiology of Schizophrenia
Summary of Family and Twin
Studies
Relation to
Proband
Spouse
Grandchildren
Nieces/nephews
Children
Siblings
DZ twins
MZ twins
Percentage
Schizophrenic
1.00
2.84
2.65
9.35
7.30
12.08
44.30
Biochemical Factors in
Schizophrenia

Problems with biochemical research
 Dopamine Activity
– Effects of phenothiazines
– Amphetamine psychosis

Problems with Dopamine Hypothesis
– HVA not found in greater amounts in
schizophrenics
– Phenothiazines rapidly block dopamine receptors,
but effect on symptoms is slow
– Excess or oversensitive dopamine receptors
The Brain and
Schizophrenia

Autopsy studies indicate structural problems in
the limbic areas and the prefrontal cortex
 CT scan and MRI studies reveal enlarged
ventricles, suggesting deterioration or atrophy
of brain tissue.
 PET scans suggest atrophy in the prefrontal
areas.
The Brain and
Schizophrenia

Evidence supports the hypothesis that a
viral infection occurring during the mid
trimester of fetal development may cause
this brain damage
 It has been suggested that this early brain
injury remains silent until the prefrontal
cortex matures, typically in adolescence.
Psychological Stress and
Schizophrenia

Social Class - the highest rates of
schizophrenia are found in central city areas
inhabited by people in having the lowest SES
– Sociogenic hypothesis
– Social-selection theory

Family and Schizophrenia
– Schizophrenogenic mother
– Expressed emotion
– High Risk Studies
Treatment of Schizophrenia
Treatments for
Schizophrenia

Insulin coma, prefrontal lobotomy, and ECT
no longer used.
 Neuroleptics - anti-psychotic medications
which are the most effective treatment for
the positive symptoms of schizophrenia.
 Family Therapy - aimed at reducing the
expressed emotion which predicts relapse
 Behavioral Therapy - social skills training
has been found to improve social adjustment
Treatment Today
 Outpatient
and Inpatient Treatment
– 80-90% hospital discharge rate
– 40-50% readmission rate = revolving door
 $33
billion direct/indirect costs
 2.5% of total health care expenditures
Predictors of Good
Outcome
 Good
premorbid adjustment
 Acute onset
 Notable stressful life events
 Positive family environment
 More positive than negative symptoms
 More affective (vs. flat) symptoms
Medication
 Atypical
neuroleptics
– Clozaril, Risperdal
– Block 65% dopamine receptors, but more
selective to frontal and temporal nerve
tracts
– Also increase serotonin
Effectiveness of
Medications
 Effective for positive symptoms
– Atypical also effective for negative
symptoms
 Decrease
time in hospital
 Decrease relapse
– 19% vs. 55% placebo
 10-15%
patients not helped by medication
Side Effects of Medications
 Autonomic
effects
– Dry mouth
– Drowsiness
– Blurred vision
Side Effects of Medications
 Extrapyramidal
Effects
– Tardive Dyskinesia - face, mouth, jaw
movement
15% long-term regimens
 some not reversible
 can affect respiration
