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Schizophrenia
and Other Psychotic
Disorders
Dr Seddigh
Nature of Schizophrenia and
Psychosis: An Overview
Schizophrenia vs. Psychosis
Psychosis – Broad term (e.g., hallucinations,
delusions)
Schizophrenia – A type of psychosis
Psychosis and Schizophrenia are heterogeneous
Disturbed thought, emotion, behavior
Differential Diagnosis

Medical/surgical/
substance-induced
Psychotic d/o due to GMC
Dementias
Delirium
Medications
Substance induced
Amphetamines
Cocaine
Withdrawal states
Hallucinogens
Alcohol

Mood disorders
Bipolar disorder
Major depression with psychotic
features
Mood disorders
“Functional”
disorders
Schizophrenia
“spectrum”
disorders
P
S
Y
C
H
O
S
I
S
Substance
induced
Delirium
Dementia
Amnestic d/o
“organic”
mental
disorders
Table 13.1
Table 13.1 Early Figures in the History of Schizophrenia
Schizophrenia: The “Positive”
Symptom Cluster

The Positive Symptoms
 Active manifestations of abnormal behavior
 Distortions of normal behavior
 Delusions: The Basic Feature of Madness
 Gross misrepresentations of reality
 Include delusions of grandeur or persecution
 Hallucinations: Auditory and/or Visual
 Experience of sensory events without environmental input
 Can involve all senses but most common is auditory
Schizophrenia: The “Negative”
Symptom Cluster







The Negative Symptoms
Absence or insufficiency of normal behavior
Spectrum of Negative Symptoms
Avolition (or apathy) – Lack of initiation and
persistence
Alogia – Relative absence of speech
Anhedonia – Lack of pleasure, or indifference
Affective flattening – Little expressed emotion
Schizophrenia: The “Disorganized”
Symptom
Cluster
 The Disorganized Symptoms

Include severe and excess disruptions
 Speech, behavior, and emotion
 Nature of Disorganized Speech
 Cognitive slippage – Illogical and incoherent speech
 Tangentiality – “Going off on a tangent”
 Loose associations – Conversation in unrelated directions
 Nature of Disorganized Affect
 Inappropriate emotional behavior
 Nature of Disorganized Behavior
 Includes a variety of unusual behaviors
 Catatonia – Spectrum
 Wild agitation, waxy flexibility, immobility
Hallucinations (Positive
Symptom)

False sense perception
 Types
– Auditory – hear something that is not there,
–
–
–
–
most common hallucination
Tactile – feel something that is not there
Visual – see something that is not there, more
commonly results from substance use or brain d
Olfactory/Gustatory – smell or taste something
that is not there
Somatic – feels like something is going on

Delusions (Positive Symptom)
Fixed, false beliefs
 Types
– Bizarre – something that the person’s culture would view as
–
–
–
–
–
–
implausible
Thought insertion – thoughts are being inserted into
person’s head
Thought withdrawal – thoughts are being taken out of
person’s head
Thought broadcast – thoughts are being broadcasted
Control – person is being controlled by something or
someone else
Somatic – things happening to body
Grandiose – exaggeration of self

Disorganized Speech (Positive
Symptom)
Speech that is hard to understand or follow,
impairs communication
 Types
– Loose associations – speech goes from one place to
another, but is based on some sort of association
between two things
– Incoherence – lacks clarity, intelligibility, relevance
– Frequent derailment – gets off track, loses track of
topic
– Clang – speech goes from one place to another based
on sounds
Disorganized Speech:
Geometric
Analogy
Tangential
Normal: goal directed and linear
Q
A
Q
A
Incoherence
Q
Circumlocution
Q
A
Loosening of Associations
A
Q
A
Grossly Disorganized or Catatonic
Behavior (Positive Symptom)

Grossly Disorganized Behavior
–
–
–
–
–
–

Child-like silliness
Unpredictable or inappropriate behavior
Unpredictable agitation
Markedly disheveled appearance
Dresses in unusual manner
Clearly inappropriate sexual behavior
Catatonic Behavior
–
–
–
–
Stupor
Rigidity or posturing
Negativism (resistance to a person moving them)
Waxy flexibility or catalepsy (limbs remain in the position
they are placed)
Schizophrenia
A.
Two or more of the following, each present
for a significant portion of the time during a
1-month period**
1.
2.
3.
4.
5.
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
**Exception to the 2+ symptom requirement:
only 1 psychotic symptom required if:
Delusion is bizarre
Hallucination consists of
Subtypes of Schizophrenia










Paranoid Type
Intact cognitive skills and affect
Do not show disorganized behavior
Hallucinations and delusions – Grandeur or persecution
The best prognosis of all types of schizophrenia
Disorganized Type
Marked disruptions in speech and behavior
Flat or inappropriate affect
Hallucinations and delusions – Tend to be fragmented
Develops early, tends to be chronic, lacks remissions
Subtypes of Schizophrenia
(cont.)
 Catatonic Type










Show unusual motor responses and odd mannerisms
Examples include echolalia and echopraxia
Tends to be severe and quite rare
Undifferentiated Type
Wastebasket category
Major symptoms of schizophrenia
Fail to meet criteria for another type
Residual Type
One past episode of schizophrenia
Continue to display less extreme residual symptoms
Schizophrenia: Some Facts
and Statistics

Onset and Prevalence of Schizophrenia worldwide
 About 0.2% to 1.5% (or about 1% population)
 Often develops in early adulthood
 Can emerge at any time
 Schizophrenia Is Generally Chronic
 Most suffer with moderate-to-severe lifetime impairment
 Life expectancy is slightly less than average
 Schizophrenia Affects Males and Females About Equally
 Females tend to have a better long-term prognosis
 Onset differs between males and females
 Schizophrenia has a Strong Genetic Component
Causes of Schizophrenia:
Findings From Genetic Research

Family Studies
 Inherit a tendency for schizophrenia
 Do not inherit specific forms of schizophrenia
 Risk increases with genetic relatedness
 Twin Studies
 Monozygotic twins – Risk for schizophrenia is 48%
 Fraternal (dizygotic) twins – Risk drops to 17%
 Adoption Studies -- Risk for schizophrenia remains high
 Cases where a biological parent has schizophrenia
 Summary of Genetic Research
 Risk for schizophrenia increases with genetic relatedness
 Risk is transmitted independently of diagnosis
 Strong genetic component does not explain everything

Search for Genetic and
Behavioral Markers of
Schizophrenia
Genetic Markers: Linkage and Association
Studies
– Search for genetic markers is still inconclusive
– Schizophrenia is likely to involve multiple
genes

Behavioral Markers: Smooth-Pursuit Eye
Movement
– The procedure – Eye-tracking a moving object
– Tracking deficits – Schizophrenics and their
relatives
Causes of Schizophrenia:
Neurotransmitter Influences

The Dopamine Hypothesis
 Drugs that increase dopamine (agonists)
Result in schizophrenic-like behavior
 Drugs that decrease dopamine (antagonists)
Reduce schizophrenic-like behavior
Examples – Neuroleptics decrease dopamine, L-Dopa for Parkinson’s
disease increases dopamine
Dopamine hypothesis is problematic and overly simplistic
Current theories – Emphasize many neurotransmitters
Causes of Schizophrenia:
Other Neurobiological Influences



Structural and Functional Abnormalities in the Brain
– Enlarged ventricles and reduced tissue volume
– Hypofrontality – Less active frontal lobes
 A major dopamine pathway
Viral Infections During Mid-Prenatal Development
– Findings are inconclusive
Conclusions About Neurobiology and Schizophrenia
– Schizophrenia – Diffuse neurobiological dysregulation
– Structural and functional brain abnormalities
 Not unique to schizophrenia
Ventricular enlargement in
monozygotic twin with
schizophrenia
Barondes, 1993
Causes of Schizophrenia:
Psychological and Social
Influences



The Role of Stress
– May activate underlying vulnerability
– May also increase risk of relapse
Family Interactions
– Families – Show ineffective communication patterns
– High expressed emotion – Associated with relapse
The Role of Psychological Factors
– Exert only a minimal effect in producing schizophrenia
Cultural Differences
Figure 13.8 Cultural differences in expressed emotion (EE).
Medical Treatment of
Schizophrenia






Historical Precursors
Development of Antipsychotic (Neuroleptic) Medications
Often the first line treatment for schizophrenia
Began in the 1950s
Most reduce or eliminate positive symptoms
Acute and permanent side effects are common
 Extrapyramidal and Parkinson-like side effects
 Tardive dyskinesia
 Compliance with medication is often a problem
Psychosocial Treatment of
Schizophrenia

Historical Precursors
 Psychosocial Approaches: Overview and Goals
 Behavioral (i.e., token economies) on inpatient units
 Community care programs
 Social and living skills training
 Behavioral family therapy
 Vocational rehabilitation
 Psychosocial Approaches
– A necessary part of medication therapy
Summary of Schizophrenia
and Psychotic Disorders




Schizophrenia – Spectrum of Dysfunctions
– Affecting cognitive, emotional, and behavioral domains
– Positive, negative, and disorganized symptom clusters
DSM-IV and DSM-IV-TR
– Five subtypes of schizophrenia
– Includes other disorders with psychotic features
Several Bio-Psycho-Social Variables are Involved
Successful Treatment Rarely Includes Complete Recovery
Exploring Schizophrenia
Exploring Schizophrenia
(cont.)
GOOD
LUCK