Schizophrenia Lecture

Chapter 12
• Psychosis: a loss of contact with reality
• A change in your ability to perceive and respond to the
• Can be substance-induced – but most due to
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
• The DSM-5 calls for a diagnosis of schizophrenia only
after symptoms of psychosis continue for six months or
• Individuals must also show a deterioration in their
work, social relations, and ability to care for
• 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)
• 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
• Types of delusions
• Persecutory
• Referential
• Somatic
• Religious
• Grandiose
• Thought withdrawal
• Thought insertion
• 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”
• 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
• 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
• 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”
• 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
• Lots of proposed explanations for schizophrenia
• Biological explanations have received the most research support
• Biological theories:
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
• 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.)
• Genetic factors
• Genetic factors may lead to the development of schizophrenia through
two kinds of (potentially inherited) biological abnormalities:
• Biochemical abnormalities
• Abnormal brain structure
• The Dopamine Hypothesis
• Certain neurons using dopamine fire too often, producing symptoms of
• 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
• 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
• 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
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
• 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
• Research on biology of this disorder is strong, many abandoned
psychological views
• Two main psychological theories of schizophrenia:
• Psychodynamic
• Cognitive
• 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.
• 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
• 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!
• 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
• 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
• 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
• 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
• 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 developed in recent years are known as “atypical”
• 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
• 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
• 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
• 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
• 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
• Approximately one-third
of the homeless people in
America have a severe
mental disorder, commonly
• Today community care is a major feature of treatment for
people recovering from schizophrenia in countries around the
• 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