Chapter 11
Schizophrenia
Chapter Outline
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Clinical Symptoms of Schizophrenia
History of the Concept of Schizophrenia
Etiology of Schizophrenia
Therapies for Schizophrenia
Schizophrenia
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Schizophrenia - Psychotic disorder
characterized by major disturbances in
thought, emotion, and behaviour
Disordered thinking in which ideas are
not logically related
Faulty perception and attention
Flat or inappropriate affect
Bizarre disturbances in motor activity
Prevalence
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Nationally representative sample in Finland (Perala
et al., 2007):
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lifetime prevalence of all psychotic disorders
exceeds 3%
a prevalence for schizophrenia of 0.87%.
Prevalence
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A meta-analysis of prevalence and incidence rates conducted by
Canadian researchers (see Goldner, Hsu, Waraich, & Somers,
2002) concluded that there may be real variation in
schizophrenia across geographical regions around the world:
Asian populations having the lowest prevalence rates.
symptoms such as auditory and visual hallucinations are
comparatively higher among people from African nations
(Bauer et al., 2011)
Countries such as India are known for having substantially
better recovery rates, especially among people in southern
India.
The incidence is significantly higher in males than in females
(male:female ratio = 1.4) (McGrath, 2006).
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Prevalence
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The prevalence of schizophrenia appears to be considerably
higher in Canada, relative to worldwide prevalence levels
(Dealberto, in press). Why? The two factors receiving the most
consideration are immigration rates and Canada’s high latitude.
Greater prevalence is found among people who immigrate to new
countries (perhaps reflecting greater stress exposure) and in
countries with high latitude where there is less sunlight and
reduced Vitamin D, which is a prenatal factor implicated in the
development of schizophrenia (see Kinney et al., 2009).
There is a need for carefully controlled epidemiological
investigations.
Prevalence and Comorbidity
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Prevalence in Canada: 1% of general
population
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Usually appears in late adolescence or early adulthood
Appears earlier for men than for women
Almost half are treated in the community
Almost 10% commit suicide
50% suffer from a comorbid disorder
Comorbid Conditions
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Substance abuse (37%) & Depression (40%)
Course of Schizophrenia
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Schizophrenia sometimes begins in childhood; however,
it usually appears in late adolescence or early adulthood
People with schizophrenia typically have a number of
acute episodes of their symptoms.
Between episodes, they often have less severe but still
very debilitating symptoms.
Most people with schizophrenia are treated in the
community; however, hospitalization is sometimes
necessary.
Hospitalisation
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In Canada, hospitalization rates are typically much
higher among young men relative to young women,
accounting for 19.9% of hospitalizations in general
hospitals.
Schizophrenia accounts for 30.9% of hospitalizations in
psychiatric hospitals.
Despite recent advances in treatment, many people with
schizophrenia remain chronically disabled.
This can be attributed to symptoms inherent to
schizophrenia, as well as the comorbid disorders
Remission in Schziophrenia
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According to a recent review published in the Harvard
Review of Psychiatry
Remission rates vary widely across studies
slightly more than 1 in 3 have symptom remission
(i.e., 35.6% in first-episode schizophrenia and 37.0%
in multiple episode schizophrenia) (see AlAqeel &
Margolese, 2012).
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Remission was most frequently associated with milder
initial symptoms, better premorbid functioning, earlier
treatment response, and a shorter duration of untreated
psychosis.
Comorbid Anxiety Disorder
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A meta-analysis that showed that there is a high
prevalence of comorbid anxiety disorder
The most prevalent comorbid condition was social
anxiety disorder, which was estimated as being
found in 14.9% of people with schizophrenia (see
Achim et al., 2011).
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Diagnosing Schizophrenia
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No essential symptom must be present for a
diagnosis of schizophrenia.
People with schizophrenia can differ from each
other more than do people with other disorders.
There is heterogeneity at the empirical and
conceptual levels.
Clinical Symptoms
•Positive Symptoms
•Excesses or distortions
•Disorganized speech
•Delusions
•Hallucinations
Positive Symptoms
• Define an acute episode of schizophrenia.
• Positive symptoms
• the presence of too much of a behaviour that is
not apparent in most people
• Negative symptoms
• the absence of a behaviour that should be
evident in most people.
Positive Symptoms
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Excesses or distortions
Disorganized speech (also called a thought disorder)
Problems in organizing ideas and in speaking so that a
listener can understand
Loose associations
Derailment
Delusions
Hallucinations
Disorganized speech
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“ Interviewer : Have you been nervous or tense lately?
Client : No, I got a head of lettuce.
Interviewer : You got a head of lettuce? I don ’t understand.
Client : Well, it ’s just a head of lettuce.
Interviewer : Tell me about lettuce. What do you mean?
Client : Well, . . . lettuce is a transformation of a dead cougar that suffered a relapse on the lion ’s toe. And
he swallowed the lion and something happened. The . . . see, the . . . Gloria and Tommy, they ’re two
heads and they ’re not whales. But they escaped with herds of vomit, and things like that.
Interviewer : Who are Tommy and Gloria?
Client : Uh, . . . there ’s Joe DiMaggio, Tommy Henrich, Bill Dickey, Phil Rizzuto, John Esclavera, Del
Crandell, Ted Williams, Mickey Mantle, Roy Mantle, Ray Mantle, Bob Chance Interviewer: Who are they?
Who are those people?
Client : Dead people . . . they want to be fucked . . . by this outlaw.
Interviewer : What does all that mean?
Client : Well, you see, I have to leave the hospital. I ’m supposed to have an operation on my legs, you
know. And it comes to be pretty sickly that I don ’t want to keep my legs. That ’s why I wish I could have
an operation.
Interviewer : You want to have your legs taken off?
Client : It ’s possible, you know.
Interviewer : Why would you want to do that?
Client : I didn ’t have any legs to begin with. So I would imagine that if I was a fast runner, I ’d be scared to
be a wife, because I had a splinter inside of my head of lettuce.” (Neale & Oltmanns, 1980, pp. 103–104)
Disorganized Speech
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At one time regarded as the principal clinical symptom of
schizophrenia, and they remain one of the criteria for the
diagnosis.
Evidence indicates that the speech of many people with
schizophrenia is not disorganized and that the presence
of disorganized speech does not discriminate well
between schizophrenia and other psychoses, such as
some mood disorders (Andreasen, 1979).
Delusions
•Beliefs held contrary to reality
•Persecutory delusions were found in 65% of a large, cross-national
sample (Sartorius, Shapiro, & Jablonsky, 1974).
•The person may be the unwilling recipient of bodily sensations or
thoughts imposed by an external agency.
People may believe that their thoughts are broadcast or transmitted, so
that others know what they are thinking.
People may think their thoughts are being stolen from them, suddenly
and unexpectedly, by an external force.
Some people believe that their feelings are controlled by an external
force.
Some people believe that their behaviour is controlled by an external
force.
Some people believe that impulses to behave in certain ways are
imposed on them by some external force.
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Delusions
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Delusions are found among more than half of
people with schizophrenia,
Delusions are also found among people with
other diagnoses: Notably mania and delusional
depression.
The delusions of people with schizophrenia,
however, are often more bizarre.
They are highly implausible (Junginger, Barker, &
Coe, 1992).
Hallucinations
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The most dramatic distortions of perception
Sensory experiences in the absence of any
stimulation from the environment.
They are more often auditory than visual; 74%
of one sample reported having auditory
hallucinations (Sartorius et al., 1974).
Like delusions, hallucinations can be very
frightening experiences.
Hallucinations
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Some people with schizophrenia report hearing
their own thoughts spoken by another voice.
Some people claim that they hear voices arguing.
Some people hear voices commenting on their
behaviour.
Negative Symptoms
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Behavioural deficits
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Avolition - Lack of energy
Alogia - Poverty of speech, amount of speech, poverty of
content of speech etc.
Anhedonia - Lack of interest in recreational activities,
relationships with others, and sex
Flat affect - a lack of emotional expressiveness
Asociality - Few friends, poor social skills, and little
interest in being with others
Negative Symptoms
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Attentional deficits contribute to clear reductions and
impairments in working memory.
These symptoms tend to endure beyond an acute
episode and have profound effects on people ’s lives.
The presence of many negative symptoms is a strong
predictor of a poor quality of life (e.g., occupational
impairment, few friends) two years following
hospitalization (CME Institute, 2007).
Negative Symptoms
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It is important to distinguish among negative
symptoms that are truly symptoms of schizophrenia
and those that are due to some other factor
(Carpenter, Heinrichs, & Wagman, 1988).
example, flat affect (a lack of emotional
expressiveness) can be a side effect of
antipsychotic medication.
AVOLITION
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refers to a lack of energy and a seeming absence of
interest in or an inability to persist in what are usually
routine activities.
Clients may become inattentive to grooming and personal
hygiene, with uncombed hair, dirty nails, and dishevelled
clothes.
They have difficulty persisting at work, school, or
household chores and may spend much of their time
sitting around doing nothing.
a 10-year longitudinal study showing that apathy was a
unique predictor of poorer life functioning and negative
ratings of quality of life (see Evensen et al., 2012).
ALOGIA
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A negative thought disorder, alogia can take
several forms.
In poverty of speech, the sheer amount of speech is
greatly reduced.
In poverty of content of speech, the amount of
discourse is adequate, but it conveys little
information and tends to be vague and repetitive.
ANHEDONIA
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An inability to experience pleasure is called
anhedonia.
It is manifested as a lack of interest in recreational
activities, failure to develop close relationships with
other people, and lack of interest in sex.
Clients are aware of this symptom and report that
normally pleasurable activities are not enjoyable for
them.
FLAT AFFECT
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In people with flat affect , virtually no stimulus can elicit an
emotional response.
The client may stare vacantly, the muscles of the face
flaccid, the eyes lifeless.
flat and toneless voice.
Flat affect is found in a majority of people with
schizophrenia.
The concept refers only to the outward expression of
emotion and not to the person ’s inner experience, which
may not be impoverished at all.
ASOCIALITY
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Some people with schizophrenia have severely impaired
social relationships, a characteristic referred to as
asociality.
They have few friends, poor social skills, and little interest
in being with other people.
A study of clients from the Hamilton (Ontario) Program for
Schizophrenia showed that people diagnosed with
schizophrenia have lower sociability and greater shyness
(Goldberg & Schmidt, 2001).
People with schizophrenia also reported more childhood
“social troubles.”
Other Symptoms: Catatonia
• Catatonia is defined by several motor abnormalities.
• Some clients gesture repeatedly, using peculiar and sometimes
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complex sequences of finger, hand, and arm movements that often
seem to be purposeful, odd as they may be.
An unusual increase in their overall level of activity, which might
include much excitement, wild flailing of the limbs, and great
expenditure of energy similar to that seen in mania.
Catatonic immobility:
clients adopt unusual postures and maintain them for very long periods of
time.
waxy flexibility , whereby another person can move the persons ’ limbs into
strange positions that they maintain for extended periods.
INAPPROPRIATE AFFECT
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The emotional responses of these individuals are out of
context
The client may laugh on hearing that his or her
mother just died
The client may become enraged when asked a
simple question about how a new garment fits.
These clients are likely to shift rapidly from one
emotional state to another for no discernible reason.
This symptom is quite rare, but its appearance is of
considerable diagnostic importance because it is
relatively specific to schizophrenia.
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The impact of symptoms on life
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Delusions and hallucinations may cause considerable distress,
compounded by the fact that hopes and dreams have been shattered.
Cognitive impairments and avolition make stable employment difficult,
with impoverishment and often homelessness the result.
Strange behaviour and social-skills deficits lead to loss of friends and
a solitary existence.
The strongest predictor of this social disability is chronic cognitive
impairment (Liddle, 2000).
High substance abuse rates perhaps reflect an attempt to achieve
relief from negative emotions (Blanchard et al., 1999).
Little wonder, then, that the suicide rate among people with
schizophrenia is high.
Early Descriptions of Schizophrenia
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Concept formulated by Emil Kraepelin and Eugen Bleuler
Kraepelin first presented his notion of dementia praecox
Differentiated two groups of endogenous psychoses
Manic-depressive illness
Dementia praecox
Dementia paranoides, catatonia, and hebephrenia
Kraepelin believed that they shared a common core:
an early onset (praecox) and a deteriorating course
marked by a progressive intellectual deterioration
(dementia).
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Early Descriptions of Schizophrenia
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Bleuler broke with Kraepelin on two major points:
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Did not believe in early onset
Did not believe in inevitably progress toward dementia
Proposed own term — schizophrenia
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Schizophrenia come from the Greek words:
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schizein , meaning “to split”
phren, meaning “mind”
Early Descriptions of Schizophrenia
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Over the years, the number of people
diagnosed with schizophrenia has varied
considerably depending on how
schizophrenia has been conceptualized and
defined, and this has hampered attempts to
determine accurately the extent of changes
in prevalence over time.
DSM5
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Heterogeneity of schizophrenic symptoms
suggested the presence of subtypes of the disorder.
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Three types of schizophrenic disorders that were
included in DSM-IV-TR:
disorganized (hebephrenic)
Catatonic
Paranoid
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Were initially proposed by Kraepelin many years
ago.
Disorganized Schizophrenia
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Kraepelin’s hebephrenic form of schizophrenia was called
disorganized schizophrenia in DSM-IV-TR .
Speech is disorganized and difficult for a listener to follow.
Clients may speak incoherently, stringing together similarsounding words and even inventing new words, often
accompanied by silliness or laughter.
They may have flat affect or experience constant shifts of
emotion, breaking into inexplicable fits of laughter and crying.
Their behaviour is generally disorganized and not goal directed
Clients sometimes deteriorate to the point of incontinence,
voiding anywhere and at any time, and completely neglect their
appearance, never bathing or combing hair.
Catatonic Schizophrenia
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Clients typically alternate between catatonic immobility and wild
excitement, but one of these symptoms may predominate.
These clients resist instructions and suggestions and often echo
(repeat back) the speech of others.
The onset of catatonic reactions may be more sudden than the
onset of other forms of schizophrenia, although the person is
likely to have previously shown some apathy and withdrawal
from reality.
Catatonic schizophrenia is seldom seen today, perhaps
because drug therapy works effectively on these bizarre motor
processes.
Paranoid Schizophrenia
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The key to this diagnosis is the presence of prominent
delusions.
Delusions of persecution are most common
grandiose delusions: an exaggerated sense of their own
importance, power, knowledge, or identity.
delusional jealousy: the unsubstantiated belief that their
partner is unfaithful.
Vivid auditory hallucinations may accompany the
delusions.
ideas of reference: they incorporate unimportant events
within a delusional framework and read personal
significance into the trivial activities of others.
Paranoid Schizophrenia
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Individuals with paranoid schizophrenia are agitated,
argumentative, angry, and sometimes violent.
They remain emotionally responsive, although they
may be somewhat stilted, formal, and intense with
others.
They are also more alert and verbal than are people
with other types of schizophrenia.
Their language, although filled with references to
delusions, is not disorganized
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The DSM-5 work group successfully proposed discontinuing
all of the “classic” subtypes of schizophrenia and rejected
alternatives to take their place.
One major argument for discontinuing the subtypes was that
they are rarely used diagnostically, with the exception of
paranoid schizophrenia.
It is stated in the DSM-5 (APA, 2013) that the subtypes had
“...limited diagnostic stability, low reliability, and poor validity”
(p. 810).
Instead, DSM-5 includes a dimensional rating of symptoms
that enables clinicians to consider the heterogeneity in
symptom expression.
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Despite the problems with subtyping systems, there
is continuing interest in differentiating the forms of
schizophrenia.
A radically different and promising approach
focuses on schizophrenia subtypes that differ
qualitatively in terms of neurocognitive features that
involve brain abnormalities.
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Heinrichs and Awad (1993) conducted a cluster analysis that identified subtypes of schizophrenia
based on performances on a battery of neuropsychological tests that included the Wisconsin Card
Sorting Test (a test of executive functioning), the Wechsler Adult Intelligence Scale (WAIS), and
measures of motor function and verbal memory.
Five subtypes:
normative, intact cognition.
executive subtype, which was distinguished by impairment on the Wisconsin Card Sorting Test;
executive-motor subtype, which had deficits in card sorting and motor functioning
motor subtype, which had deficits only in motor functioning
dementia subtype, which had pervasive and generalized cognitive impairment.
These subtypes differed on other variables, such as duration of symptoms and extent of
hospitalization.
A subsequent study of a subset of the clients showed that most of the neurocognitive and functional
differences persisted over time, even though there were no apparent symptom differences among
the subtypes (Heinrichs, Ruttan, Zakzanis, & Case, 1997).
A continuing focus on neuropsychological differences may provide important insights into the
heterogeneity of schizophrenia.
Etiology Of Schizophrenia
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THE GENETIC DATA
The family, twin, and adoption methods employed in this
research have led researchers to conclude that a
predisposition to schizophrenia is inherited by the majority
of people who experience schizophrenia (e.g., Kendler &
Gruenberg, 1984).
When the family is viewed from a broader perspective,
90% of people who develop schizophrenia have parents
who do not have schizophrenia, and between 60 and 80%
do not have a sibling with schizophrenia.
relatives of people with schizophrenia are at increased risk,
and the risk increases as the genetic relationship between
proband and relative becomes closer.
Etiology Of Schizophrenia
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Further, the negative symptoms of
schizophrenia appear to have a stronger
genetic component (Malaspina et al.,
2000).
The relatives of people with schizophrenia
are also at increased risk for other
disorders (e.g., schizotypal personality
disorder) that are thought to be less
severe forms of schizophrenia (Kendler,
Neale, & Walsh, 1995).
Etiology Of Schizophrenia
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Concordance for identical twins (44.30%), although
greater than that for fraternal twins (12.08%), is less
than 100%.
Consistent with a genetic interpretation of these
data, concordance among MZ twins does increase
when the proband is more severely ill (Gottesman &
Shields, 1972).
Etiology Of Schizophrenia
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There is a critical problem in interpreting the results
of twin studies.
A common “deviant” environment rather than
common genetic factors could account for the
concordance rates.
By common environment we mean not only similar
child-rearing practices, but also a more similar
intrauterine environment, for MZ twins are more
likely than DZ twins to share a single blood supply.
Etiology Of Schizophrenia
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ADOPTION STUDIES
The study of children whose mothers had schizophrenia
but who were reared from early infancy by nonschizophrenic adoptive parents has provided moreconclusive information on the role of genes in
schizophrenia by eliminating the possible effects of a
deviant environment.
Children reared without contact with their so-called
pathogenic mothers were still more likely to become
schizophrenic than were the control participants.
A similar study was conducted in Denmark (Kety et al.,
1975, 1994) and it produced similar results.
Etiology: Adoption Study
Etiology: Molecular Genetics
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Not likely transmitted by a single gene
Now using “endophenotypic strategy”
Endophenotypes – characteristics that reflect actions of
genes predisposing individual to a disorder, even in the
absence of diagnosable pathology (Turetsky et al., 2007,p. 69)
Assumed to be determined by fewer genes than the more
complex schizophrenia phenotype
Some examples:
Serotonin type 2A receptor (5—HT2a) gene
Dopamine D3 receptor gene
Chromosomal regions on chromosomes 6, 8, 13, and 22,
Microdeletion on chromosome 22ql1
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Etiology: Molecular Genetics
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One of the most remarkable new findings emerging
from genome-wide analyses is that five major
psychiatric disorders including schizophrenia may
all stem from several specific genetic variations that
apply to all five disorders (Cross-Disorder Group of
the Psychiatric Genomics Consortium, in press).
Etiology: Molecular Genetics
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The Cross-Disorder Group is a large international team
led by Jordan Smoller.
They have focused on five disorders that appear to share
a common genetic vulnerability: schizophrenia, major
depressive disorder, bipolar disorder, autism spectrum
disorder, and attention deficit hyperactivity disorder.
Initial work indicates that these disorders involve singlenucleotide polymorphisms in regions on chromosomes
3p21 and 10q24, and in two calcium subunits:
CACNA1C and CANB2.
Etiology: Molecular Genetics
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Intriguing new results have emerged from research on
people without a family history of schizophrenia who
nevertheless developed schizophrenia (who are referred to
as “sporadic cases”) and these studies have illustrated the
neural complexity involved in schizophrenia.
It has been found in these investigations that schizophrenia
seems to reflect relatively rare protein-altering gene
mutations that have implicated up to 40 genes, including a
disruption in DCGR2 (Xu et al., 2011, 2012). This is a gene
found in the 22q11.2 microdeletion region known for
vulnerability to schizophrenia (see Rodriguez-Murillo et al.,
2012).
Many of these gene mutations may have taken place in
early development.
Etiology: Molecular Genetics
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Another important development identified by
researchers from the Salk Institute in California is
that the cells of people with schizophrenia had
fewer synapses; that is, their neurons make fewer
connections than do healthy nerve cells (Brennand
et al., 2011).
The Genain Quadruplets
Dopamine Theory
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Schizophrenia thought to be related to excess
activity of dopamine
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Drugs effective in treating schizophrenia  dopamine
activity
Also produce side effects similar to Parkinson’s
disease which is caused in part by  dopamine
Other clues provided by amphetamine psychosis
Closely resembles paranoid schizophrenia and can
exacerbate symptoms of schizophrenia
Amphetamines cause release of norepinephrine
and dopamine
Dopamine thought to be the culprit of the
symptoms
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Dopamine Theory
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Researchers, at first, assumed that schizophrenia was
caused by an excess of dopamine.
But as other studies progressed, this assumption did not
gain support.
the major metabolite of dopamine, homovanillic acid
(HVA), was not found in greater amounts in people with
schizophrenia (Bowers, 1974).
Such data, plus improved technologies for studying
neurochemical variables in humans, have led researchers
to propose excess or oversensitive dopamine receptors,
rather than a high level of dopamine, as factors in
schizophrenia.
Dopamine Theory
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Some post-mortem studies of brains of schizophrenic
people, as well as PET scans of schizophrenic people,
have revealed that dopamine receptors are greater in
number or are hyper-sensitive in some people with
schizophrenia (e.g., Goldsmith, Shapiro, & Joyce,
1997).
Having too many dopamine receptors would be
functionally akin to having too much dopamine.
Dopamine Theory
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Excess dopamine receptors may not be responsible
for all the symptoms of schizophrenia; in fact, they
appear to be related mainly to positive symptoms.
Amphetamines worsen positive symptoms and
lessen negative ones.
Antipsychotics lessen positive symptoms, but their
effect on negative symptoms is less clear; some
studies show no benefit (e.g., Haracz, 1982), while
others show a reduction in negative symptoms (e.g.,
van Kammen, Hommer, & Malas, 1987).
Dopamine Theory
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EVALUATION OF THE DOPAMINE THEORY
Despite the positive evidence, the dopamine theory does
not appear to be a complete theory of schizophrenia.
For example, it takes several weeks for antipsychotics to
gradually lessen positive symptoms, although they begin
blocking dopamine receptors rapidly (Davis, 1978).
This disjunction between the behavioural and
pharmacological effects of antipsychotics is difficult to
understand within the context of the theory.
Dopamine Theory
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OTHER NEUROTRANSMITTERS
Newer drugs used in treating schizophrenia implicate
neurotransmitters such as serotonin in the disorder.
Dopamine neurons generally modulate the activity of other
neural systems; for example, in the prefrontal cortex, they
regulate GABA neurons.
Similarly, serotonin neurons regulate dopamine neurons in the
mesolimbic pathway. Thus, dopamine may be only one piece in
a much more complicated puzzle.
Glutamate, a transmitter that is widespread in the human brain,
may also play a role (Carlsson et al., 1999).
Low levels of glutamate have been found in cerebrospinal fluid of
people with schizophrenia (Faustman et al., 1999), and postmortem studies have revealed low levels of the enzyme needed
to produce glutamate (Tsai et al., 1995).
Brain Structure and Function
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Enlarged Ventricles
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Enlarged ventricles which implies a loss of subcortical brain cells
consistent findings indicate structural problems in the
hippocampus, the basal ganglia, and in the prefrontal and
temporal cortex (e.g., Dwork, 1997).
Often noted in males
Structural problems
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reduction in cortical grey matter in both the temporal and frontal
regions (Goldstein et al., 1999) and reduced volume in basal
ganglia (e.g., the caudate nucleus) and limbic structures
Correlated with impaired performance on neuropsychological
tests, poor adjustment prior to the onset of the disorder, and poor
response to drug treatment (e.g., Andreasen et al., 1982).
Brain Structure and Function
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Prefrontal cortex
Known to play a role in behaviours such as speech,
decision-making, and willed action all of which are
disrupted in schizophrenia
MRI studies have shown reductions in grey matter in the
prefrontal cortex
clients with schizophrenia have shown low metabolic rates in
the prefrontal cortex
Clients with schizophrenia showed less prefrontal activation
(prominent dysfunction) in specific areas relative to
comparison participants
The frontal hypoactivation is less pronounced in the nonschizophrenic twin of discordant MZ pairs, again suggesting
that this brain dysfunction may not have a genetic origin
(Torrey et al., 1994).
Congenital And Developmental
Considerations
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A possible interpretation of these brain abnormalities
is that they are the consequence of damage during
gestation or birth.
The presence at birth or in infancy of
“craniofacial/midline anomalies and/or early
functional impairments that commonly occur as a
symptom of CNS [central nervous system] anomaly”
were associated with a doubling of the risk for
schizophrenia spectrum disorder (a group or array of
disorders related to and including schizophrenia)
Congenital And Developmental
Considerations
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Many studies have shown high rates of delivery
complications when babies were born to women with
schizophrenia; such complications could have led to a
reduced supply of oxygen to the brain, resulting in damage
(e.g., Verdoux et al., 1997).
These obstetrical complications do not raise the risk of
schizophrenia in everyone who experiences them; rather,
the risk is increased in those who experience complications
and have a genetic predisposition (Cannon & Mednick,
1993).
Congenital And Developmental
Considerations
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Although the data are not entirely consistent, another possibility is that
a virus invades the brain and damages it during fetal development
(e.g., Mednick, Huttonen, & Machon, 1994).
In 1957, Helsinki, Finland, experienced an epidemic of influenza.
Researchers examined rates of schizophrenia among adults who had
likely been exposed during their mothers ’ pregnancies.
People who had been exposed to the virus during the second trimester
of pregnancy had much higher rates than those who had been exposed
in either of the other trimesters or among non-exposed control adults.
Brown et al. (2004) reported that serologically documented influenza
exposure during early to mid-gestation was associated with a threefold
increase of schizophrenia, and that first trimester exposure conferred a
sevenfold increased risk.
Congenital And Developmental
Considerations
•
•
The relevance of prenatal exposure was shown by
new data qualifying past links between low birth
weight and the subsequent development of
schizophrenia by showing that low birth weight is
only a risk factor when it is combined with prenatal
exposure to influenza or hypoxia (Fineberg et al., in
press).
Childhood infection of the central nervous system
doubles the risk of adult schizophrenia (Khandaker
et al., 2012).
Contemporary Research
•
research has moved away from trying to find some
highly specific “lesion” and is examining neural
systems and the way different areas of the brain
interact with one another.
Psychological Stress And Schizophrenia
•
•
Data show that, as with other disorders, increases in
life stress increase the likelihood of a relapse (e.g.,
Hirsch et al., 1996).
Clients who take part in a stress-management
program are less likely to be readmitted to the
hospital in the year following treatment, especially if
they had attended treatment sessions regularly
(Norman et al., 2002).
Other Etiologies
•
•
Psychological Stress
•
 in life stress  the likelihood of a relapse
Social class and Schizophrenia
•
 rates of schizophrenia found in central city areas
inhabited by people in the  socio-economic class
•
•
The relation between social class and schizophrenia does
not show a continuous progression of higher rates of
schizophrenia as the social class becomes lower.
Sociogenic hypothesis - stressors associated with
being in a low social class may cause or contribute
to the development of schizophrenia
Other Etiologies
• The stressors encountered by those in the lowest social class
could be biological
• Eg. Children of mothers whose nutrition during pregnancy was poor are
at increased risk for schizophrenia (Susser et al., 1996).
• Social-selection theory
•
During the course of their developing psychosis, people with schizophrenia may
drift into the poverty-ridden areas of the city.
•
The growing cognitive and motivational problems besetting these individuals may
so impair their earning capabilities that they cannot afford to live elsewhere.
•
Or, they may choose to move to areas where little social pressure will be brought to
bear on them and they can escape intense social relationships.
Family and Schizophrenia
•
•
•
•
Schizophrenic mother
Described the supposedly cold and dominant, conflict-inducing
parent who was said to produce schizophrenia in her off spring
(Fromm-Reichmann, 1948).
These mothers were characterized as rejecting, overprotective,
self-sacrificing, impervious to the feelings of others, rigid and
moralistic about sex, and fearful of intimacy—a very destructive
view since it basically blamed the mother (or other family
members) for a severe psychiatric disorder in a child.
Controlled studies evaluating the theory have not yielded
supporting data.
Family and Schizophrenia
•
•
•
Some findings do suggest that the faulty communications
of parents play a role in the etiology of schizophrenia.
For example, in a longitudinal study of adolescents with
behaviour problems, a family communication pattern
characterized by hostility and poor communication
predicted the later onset of schizophrenia or
schizophrenia-related disorders (Norton, 1982).
However, it does not appear that communication deviance
is a specific etiological factor for schizophrenia, since
parents of manic clients are equally high on this variable
(Miklowitz, 1985).
Relapse and the role of the family
•
•
•
•
Expressed emotion (EE) critical comments made about
the client and for expressions of hostility toward or
emotional over-involvement with him or her:
those revealing a great deal of expressed emotion, called
high-EE families, and those revealing little, called low-EE
families.
At the end of the follow-up period, 10% of the clients
returning to low-EE homes had relapsed.
In marked contrast, 58% of the clients returning to highEE homes had gone back to the hospital!
Relapse and the role of the family
•
•
It has also been found that negative symptoms of
schizophrenia are the ones most likely to elicit
critical comments (King, 2000) and that relatives
who make the most critical comments tend to
view the clients as being able to control their
symptoms (e.g., Provencher & Fincham, 2000).
Research indicates that both interpretations of
the operation of EE—the causal and the
reactive—may be correct (Rosenfarb et al.,
1994).
Relapse and the role of the family
•
Researchers focused their attention on a polymorphism
of the neuregulin 1 gene because this gene is implicated
in risk for psychosis and it also influences prefrontal
cortical activation. They found that schizophrenic clients
with the genetic polymorphism displayed more unusual
thoughts in the conflict situation and not the control
condition. Thus, being in an unsupportive environment
may interact with a genetic diathesis.
Developmental / High-Risk Studies
•
•
•
•
Children who later developed schizophrenia had lower IQs
than did members of various control groups (e.g., Lane &
Albee, 1965).
Teachers described pre-schizophrenic boys as
disagreeable in childhood and pre-schizophrenic girls as
passive (e.g., Watt, 1974).
Both men and women were described as delinquent and
withdrawn in childhood (Berry, 1967).
Pre-schizophrenic children showed poorer motor skills and
more expressions of negative aff ect.
Developmental / High-Risk Studies
•
•
•
•
•
•
High-risk children: their mothers have chronic schizophrenia
Low-risk children: mothers do not have schizophrenia
Comparing high-risk and low-risk participants as adults - 15 of the 207
high-risk participants developed schizophrenia as compared to 0 out of
104 for the low-risk
Negative-symptom schizophrenia was preceded by a history of
pregnancy and birth complications and by a failure to show electrodermal
responses to simple stimuli.
Positive-symptom schizophrenia was preceded by a history of family
instability, such as separation from parents and placement in foster
homes or institutions.
Attentional dysfunction, low IQ, poor concentration, poor verbal ability,
poor motor coordination were also found
Developmental / High-Risk Studies
•
A cross-sectional and longitudinal MRI comparison
determined that participants who developed a
psychotic disorder, relative to those who did not,
had reduced grey matter volumes, suggesting that
lower grey matter volume predates the onset of
psychotic disorders, including schizophrenia (also
see Lui et al., 2009).
Developmental / High-Risk Studies
•
•
Traditional hospital care does little to effect
meaningful, enduring changes in the majority of
mentally disordered people
Studies designed specifically to follow clients with
schizophrenia after discharge from a hospital show
generally poor outcomes (Robinson et al., 1999).
Developmental / High-Risk Studies
•
•
•
A major problem with any kind of treatment for
schizophrenia is that many clients lack insight into their
impaired condition and refuse any treatment (Amador et
al., 1994).
As they don ’t believe they have a disorder, they don ’t
see the need for professional intervention, particularly
when it includes hospitalization or drugs.
This is especially true of those with paranoid
schizophrenia, who may regard any therapy as a
threatening intrusion by hostile outside forces.
Developmental / High-Risk Studies
•
•
•
•
The American Psychiatric Association (2004) treatment
guidelines for schizophrenia recommend a multi-point
treatment course that consists of several strategies known to
improve functional outcome:
Selection and application of antipsychotic medication to control
acute psychotic symptoms, including strategies for maintaining
adherence
Identification and treatment of comorbid disorders, including
substance use and depressive disorders
Use of psychosocial treatment approaches with demonstrated
effectiveness in improving symptoms and ability to function
socially and vocationally
Developmental / High-Risk Studies
•
•
•
In the early 1930s, the practice of inducing a coma with
large dosages of insulin was introduced by Sakel (1938),
who claimed that up to three quarters of the schizophrenics
he treated showed significant improvement.
Later findings were less encouraging, and insulin-coma
therapy—which presented serious risks to health, including
irreversible coma and death—was gradually abandoned.
ECT was also used after its development in 1938 by Cerletti
and Bini; it, too, proved to be only minimally effective.
Prefrontal Lobotomy
•
•
•
•
•
•
Prefrontal Lobotomy - A surgical procedure that destroys the tracts
connecting the frontal lobes to lower centres of the brain.
Initial reports claimed high rates of success (Moñiz, 1936), and for 20
years thereafter, thousands of people—not only those diagnosed with
schizophrenia— underwent variations of psychosurgery.
A related procedure known as a leucotomy is a more circumscribed
and specific procedure than a lobotomy.
The lobotomy procedure was used especially for those whose
behaviour was violent.
Many clients did indeed quiet down after undergoing a lobotomy and
could even be discharged from hospitals.
During the 1950s, however, this intervention fell into disrepute. After
surgery, many clients became dull and listless and suffered serious
losses in their cognitive capacities (e.g., becoming unable to carry on a
coherent conversation with another person).
First-generation (conventional)
antipsychotic drugs
•
•
•
•
Although the antipsychotics reduce some of the positive
symptoms of schizophrenia, they are not a cure.
about 30 to 50% of people with schizophrenia do not
respond favourably to conventional antipsychotics,
although some of these clients may respond to some of
the newer antipsychotic drugs (e.g., clozapine).
there has been success in treating psychosis
effective treatments for cognitive aspects and negative
symptoms are “unmet therapeutic challenges” (p. 1168).
First-generation (conventional)
antipsychotic drugs
•
•
•
•
Commonly reported side effects of antipsychotics include dizziness, blurred
vision, restlessness, and sexual dysfunction.
•
•
•
•
•
•
•
•
extrapyramidal side effects:
dysfunctions of the nerve tracts that descend from the brain to spinal motor neurons.
resemble the symptoms of Parkinson ’s disease.
People taking antipsychotics often develop :
tremors of the fingers,
a shuffling gait,
drooling.
dystonia, a state of muscular rigidity
dyskinesia, an abnormal motion of voluntary and involuntary muscles, producing
chewing movements, as well as other movements of the lips, fingers, and legs
Akathisia - an inability to remain still; people pace constantly and fidget.
These perturbing symptoms can be treated by drugs used with people who have
Parkinson ’s disease.
First-generation (conventional)
antipsychotic drugs
•
tardive dyskinesia
•
the mouth muscles involuntarily make sucking, lip-smacking, and chinwagging motions.
•
In more severe cases, the whole body can be subject to involuntary motor
movements.
•
affects about 10 to 20% of clients treated with antipsychotics for a long
period of time and it is not responsive to any known treatment (Sweet et
al., 1995).
•
•
•
•
•
neuroleptic malignant syndrome
occurs in about 1% of cases.
The condition can sometimes be fatal
severe muscular rigidity develops accompanied by fever.
The heart races, blood pressure increases, and the client may lapse into a
coma.
First-generation (conventional)
antipsychotic drugs
•
•
About half the people who take antipsychotics quit
after one year and up to three quarters quit after
two years (e.g., Lieberman et al., 2005).
The most common reason given for noncompliance was drug side effects (Schizophrenia
Society of Canada, 2002).
First-generation (conventional)
antipsychotic drugs
•
•
•
Clients who respond positively to antipsychotics are
kept on maintenance doses of the drug, just enough to
continue the therapeutic effect.
Conventional antipsychotics keep positive symptoms
from returning, they have little effect on negative
symptoms such as flat affect.
Antipsychotics have significantly reduced long-term
institutionalization, but they have also initiated the
revolving-door pattern of admission, discharge, and
readmission seen in some clients.
Second-generation (atypical) antipsychotics
•
•
In the decades following the introduction of antipsychotic
drugs, there was little apparent interest in developing new
drugs to treat schizophrenia.
This situation changed markedly following the introduction
of clozapine (Clozaril), which appeared to produce
therapeutic gains in people with schizophrenia who do not
respond well to traditional antipsychotics (e.g., Buchanan et
al., 1998) and appeared to produce greater therapeutic
gains than traditional antipsychotics (e.g., Rosenheck et al.,
1999).
atypical antipsychotics
•
•
•
•
The key feature of atypical antipsychotics
Relative to antipsychotics in general, is that at effective dose
levels, the atypical antipsychotics are less likely to cause side
effects.
Because side effects such as tardive dyskinesia can prove fatal for
some people, Meltzer (2013) strongly favours atypical
antipsychotics and their reduced likelihood of morbidity and
mortality.
Although the precise biochemical mechanism of the therapeutic
effects of clozapine is not fully known, we do know that it has a
major impact on serotonergic neurotransmitters and 5HT receptors
(see Meltzer, 2013).
Olanzapine (Zyprexa) and Risperidone (Risperdal)
•
•
•
Both produce fewer motor side effects than
traditional antipsychotics
They appear to be as effective as traditional
antipsychotics in reducing symptoms (e.g., Wirshing
et al., 1999), perhaps even better (Sanger et al.,
1999).
Risperidone may lead to reduced use of health
services because it was associated with a lower
length of first hospitalization and less use of
inpatient beds (Malla, Norman, Scholten, Zirul, &
Kotteda, 2001).
Psychological Treatments
•
•
Psychological treatments for schizophrenia typically come
in two forms: psychosocial treatments and cognitive
behavioural interventions.
psychosocial strategies can play an important role in
increasing the effectiveness of medication treatment and
decreasing the relapse rate (CME Institute, 2007).
Psychological Treatments
•
Freud believed that people with schizophrenia were
incapable of establishing the close interpersonal
relationship essential for analysis.
Social Skills Training
•
•
•
•
Designed to teach people with schizophrenia behaviours that can help
them succeed in a wide variety of interpersonal situations
Theoretical basis came from Robert Liberman and his associates
(see Liberman, DeRisi, & Mueser, 1989; Liberman et al., 1987).
This model and therapeutic approach focuses on three key elements:
receiving skills (i.e., social cognition), processing skills, and
behavioural responses in social interaction.
A meta-analysis of RCT investigations concluded that this approach
yields significant improvements across a variety of indicators,
including skill acquisition, social interaction, and appropriate personal
assertiveness in social situations (Kurtz & Mueser, 2008).
Family Therapy And Reducing Expressed
Emotion
•Many people with schizophrenia who are discharged from psychiatric hospitals
go home to their families.
•Family interventions differ in length, setting, and specific techniques
•These therapies have several features in common beyond the overall purpose
of calming things down for the client by calming things down for the family:
• They educate clients and families about the biological vulnerability that
predisposes people to schizophrenia, cognitive problems inherent to
schizophrenia, the symptoms of the disorder, and signs of impending
relapse.
• They provide information about and advice on monitoring the effects of
antipsychotic medication.
• They encourage family members to blame neither themselves nor the
client for the disorder and for the difficulties all are having in coping with
it.
Family Therapy And Reducing Expressed
Emotion
• They help improve communication and problemsolving skills within the family.
• They encourage clients and their families to expand
their social contacts, especially their support networks.
• They instill a degree of hope that things can improve,
including the hope that the client may not have to
return to the hospital.
Family Therapy And Reducing Expressed
Emotion
•
Compared with medication only, family therapy plus
medication typically lowers relapse over periods of
one to two years, a finding particularly evident in
studies in which the treatment lasted for at least
nine months (e.g., Kopelowicz & Liberman, 1998).
Cognitive-Behavioural Therapy
•
•
•
It used to be assumed that it was futile to try to alter
the cognitive distortions of people with
schizophrenia
Beck and Rector (2005) concluded that people with
schizophrenia can benefit from cognitive techniques
designed to address their delusions and
hallucinations.
CBT can facilitate motivation and engagement in
social and vocational activities.
Cognitive-Behavioural Therapy
•
•
•
•
Dysfunctional attitudes predict reduced life functioning in
people with schizophrenia (Horan et al., 2010) and they
have even been linked with the internalization of stigma
(Park, Bennett, Couture, & Blanchard, 2013).
defeatist beliefs:
An example of a defeatist belief is “If you cannot do
something well, there is little point in doing it at all.”
Defeatist beliefs distinguish a group of people with
schizophrenia with a particularly troubling form of negative
symptoms called “the deficit syndrome” (see Beck, Grant,
Huh, Perivoliotis, & Chang, 2013).
Cognitive-Behavioural Therapy
•
•
•
According to Birchwood and Meaden (2013), a hallucination
in which the person believes that they are being
commanded to do something (i.e., command hallucinations)
is the symptom that is the most distressing, high risk, and
treatment resistant of all symptoms of schizophrenia.
How has CBT fared as a way of treating schizophrenia?
Initial comparative research indicated that CBT plus
enriched treatment as usual is as effective as treatment as
usual alone, and that CBT seems to be particularly effective
at reducing negative symptoms of schizophrenia (Rector,
Seeman, & Segal, 2003).
Cognitive-Behavioural Therapy
•
•
•
Meta-analytic reviews (e.g., Zimmerman et al., 2005)
support the efficacy of individualized CBT for people with
persistent positive psychotic symptoms. Several
qualifications of this fi nding are needed.
First, the efficacy of a group format is less clear-cut.
Second, a comprehensive meta-analysis of approximately
30 RCT efficacy trials (Wykes, Steel, Everitt, & Tarrier,
2008) concluded that CBT plus usual treatment, relative to
usual treatment alone, demonstrates significant effects on
depression, anxiety, symptoms (both positive and negative),
and social functioning but not relapse rates.
Cognitive-Behavioural Therapy
•
Third, a recent meta-analytic comparison confirmed
once again that CBT was effective.
•
•
Supportive therapies were also effective and there
was no significant difference between CBT and
supportive therapy (Newton-Howes & Wood, in
press).
Fourth, most of the CBT studies have been conducted
in the United Kingdom and official organizations there
have given stronger endorsements of CBT than has the
American Psychiatric Association.
Cognitive-Behavioural Therapy
•
•
•
Finally, what about the generalizability of CBT to the
“real world?” Is it just as effective?
As noted by Jan Scott (2008) in an editorial in the British
Journal of Psychiatry, generalizability may be a
problem; Scott pointed to a study that found limited
effectiveness.
Indeed, the authors of this study concluded that it may
be best with generic CBT for psychosis to reserve it for
clients with medication-unresponsive positive symptoms
(see Garety et al., 2008).
Treatment Focus On Basic
Cognitive Functions
•
•
•
•
It is well established that people diagnosed with schizophrenia, as a
group, have deficits in virtually all facets of cognitive functioning and
show performance deficits on a range of simple and complex tasks
(see CME Institute, 2007; Heinrichs, 2005; Walker et al., 2004).
Moreover, these deficits are apparent in first-episode, nonmedicated clients, so deficits are not a by-product of receiving
treatment.
There is an attempt to improve these functions and thereby produce
a favourable effect on behaviour.
Attempts to normalize fundamental cognitive functions such as attention and
memory, which are known to be deficient in many people with schizophrenia and
are associated with poor social adaptation and other deficits in functional ability
(see CME Institute, 2007).
Cognitive Enhancement Therapy
•
•
•
•
Developed by Hogarty and his colleagues (Hogarty et al.,
2004), was evaluated in a two-year RCT of clients who were
also taking medication.
The approach was compared with an enriched supportive
therapy that included educational and supportive aspects of
personal therapy. The CETspecific focus is on computer-based
training in attention, memory, and problem solving, as well as
social-cognitive skills (such as initiating conversations).
CET proved successful in improving cognition and processing
speed and there was evidence to suggest that it also had a
positive effect on functional outcomes.
A subsequent two-year RCT investigation provided further
evidence of the effectiveness of CET, including evidence that it
protected against grey matter loss in the brain.
Scaffolding
•
•
•
Scaffolded instruction is a concept derived from a proposal
that everyone has a zone of current development and that
the complexity of tasks must be tailored to account for
individuals’ current skill level and level of potential
development.
The scaffolding model requires instructors to select tasks
that reflect the clients ’ current capabilities so that
eventually they are able to solve problems for themselves.
The ultimate goal is to develop general problem-solving
skills and processes that clients can generalize to new
situations.
•
•
A meta-analysis of 26 RCTs (McGurk et al., 2007)
concluded that cognitive remediation in
schizophrenia produces moderate improvements in
cognitive performance.
Further, when combined with psychiatric
rehabilitation, it also improves psychosocial
functioning.
Case Management/Assertive Community
Treatment
•
•
•
Initially, case managers were basically brokers of services.
The major innovation was the recognition that case managers
often needed to provide direct clinical services and that
services might best be delivered by a team.
The Assertive Community Treatment model (ACT; Stein &
Test, 1980; Stein & Santos, 1998) and the Intensive Case
Management model (ICM; Surles et al., 1992) both entail a
multidisciplinary team that provides community services
ranging from medication, treatment for substance abuse, help
in dealing with the kind of stressors clients face regularly (such
as managing money), psychotherapy, vocational training, and
assistance in obtaining housing and employment.
Case Management/Assertive Community
Treatment
•
•
Indications are that more intensive treatment is
more effective than less intensive methods in
reducing time spent in the hospital, improving
housing stability, and ameliorating symptoms
(Tibbo et al., 2001).
However, more intensive case management has
not shown positive effects on other domains, such
as time spent in jail or social functioning.
The Homeless Mentally Ill
•
•
Though a relatively small proportion of homeless
people in the United States are mentally ill, many
people with schizophrenia are among those without
residences.
In Canada, the situation is much different—the
mentally ill make up a large proportion of the
homeless.
The Homeless Mentally Ill
•
•
•
Patterson, Somers, and Moniruzzaman (2012) found that
persistent homelessness was associated with male gender,
a younger age when first homeless, past month alcohol use,
and daily illicit drug use.
Prolonged homelessness (i.e., having at least one single
time of being homeless for a year or more) was associated
with current substance dependence and a tendency to have
two or more mental disorders as determined by assessment
interviews.
Canada has a number of national initiatives underway to
address homelessness in general and homelessness and
mental health problems in particular.
Employment and Housing
•
•
•
•
•
Most people with schizophrenia have a desire to work and
being employed is linked with several benefits, including fewer
symptoms of mental illness, higher self-esteem, and a greater
sense of purpose (Mueser et al., 2013).
Applicants with a history of serious mental illness have a
difficult time obtaining regular employment.
How much leeway employers are willing to give former mental
health clients whose thinking, emotions, and behaviour are
usually unconventional to some degree.
Twenty or 30 years after first developing symptoms of
schizophrenia, about half of people with schizophrenia are able
to look after themselves and participate meaningfully in society
at large.
There is a chronic shortage of subsidized housing for
psychiatric clients in most places in Canada.
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•
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