PSY208F

SCHIZOPHRENIA LECTURE NOTES

1. INTRODUCTION

• Schizophrenia: a debilitating chronic psychotic illness

- onset usually in late adolescence / early adulthood
- tends to be a lifelong disorder
- patients need continual care services

• Occurs all over the world in similar proportions (1-2% of the population)

• Varies with class, gender, culture

2. PRESENTATION

Two classes of symptoms: positive symptoms and negative symptoms

Positive Symptoms:
- characterised by the presence of unusual perceptions, thoughts or behaviours
- these symptoms can occur in other disorders (eg: mood disorders)

a) DELUSIONS

= false belief, based on incorrect inferences about external reality, not consistent with
patient’s intelligence and background.

They are implausible

Patient is typically preoccupied by them
Patients are resitant to contradictory arguments or facts proving their delusions wrong

Common types:

1. Paranoid delusions: - Most common.

- Belief of being watched or tormented by people they
know or authorities.
- eg. A Beautiful Mind – Prof. Nash contacted the FBI
about conspiracies to take over the world

2. Grandiose delusions: - belief that one is a special person or entity or has special
powers.
3. Delusions of reference: - believe that random events or comments are directed at
them
- eg: television broadcast is refering to them, or news
announcer is talking to him/her.

4. Delusions of control: - belief that one’s thoughts are being controlled by outside
forces – thought insertion or thought extraction

5. Somatic delusions: - false belief involving functioning of the body

b) HALLUCINATIONS

= false sensory perceptions which are not based on real external stimuli
- are either recurrent or persistent and experienced in a state of full wakefulness or
alertness

- types:

1. Auditory - eg hearing voices, music, etc.

- most common
- may be threatening (commanding self-harm)

2. Visual - Seeing something that is not there eg: a person or small animal
- often accompanies auditory hallucinations

3. Tactile - perception that something is happening to the outside of the body

- eg: bugs are crawling over body (often with cocaine psychosis)

4. Somatic - perception that something is happening inside one’s body

- eg: worms eating one’s intestines

5. Olfactory - perception of a smell

- usually indicates an organic condition eg: temporal lobe epilepsy
c) FORMAL THOUGHT DISORDER

= disorganisation in thoughts and speech

1. Poverty of content – thought that gives little information because of vagueness, empty
repititions or obscure phrases.

2. Lossening of associations / derailment - gradual or sudden deviation in train of

thought. Slip from one topic to another,
unrelated topic.

3. Tangentiality - inability to have goal-directed associations of thought; speaker

never gets to desired point to desired goal /

4. Perseveration - persisting response to a previous stimulus after a new stimulus

has been presented.

5. Word salad - incoherent mixture of words and phrases

d) DISORGANISED BEHAVIOUR
- displays of unpredictable agitation
- disheeveled and dirty
- socially inappropriate behaviour. Eg. Public masturbation
- Catatonic behaviour – extreme lack of responsiveness to the outside world.

Negative symptoms:
- represent losses or deficits in certain domains
- they involve the absence of behaviours rather than the presence of
behaviours

a) Affective flattening = absence or near absence of any signs of affective expression;

voice monotonous, face immobile.

Inappropriate affect = disharmony between the emotional feeling tone and the idea,
thought, or speech accompanying it eg: laughing at sad things

b) Avolition = an inability to persist at common, goal-directed activities; person has great

trouble completing tasks, is unmotivated and disorganised; may withdraw socially and sit
all day doing nothing.

c) Alogia = reduction in speaking; person may not initiate speech with others; may gief
brief answers to questions.
3. DIAGNOSIS

Disorder Description
Brief psychotic disorder Symptoms present for at least 1 day,
but less than 1 month
Schizophreniform disorder Symptoms lasting more than 1
month, but less than 6 months
Schizophrenia At least 6 months of some
symptoms; 1 month of acute
symptoms of positive and negative
symptoms
Schizoaffective disorder Symptoms of schizophrenia + mood
symptoms; at least 2 weeks of
ONLY schizophrenia symptoms
Delusional disorder Only non-bizarre delusions for at
least 1 month
Substance-induced psychotic Hallucinations or delusions caused
disorder by a substance (eg LSD)

Schizophrenia: Diagnostic Criteria:

A. Characteristic symptoms: Two (or more) of the following, each present for a
significant portion of time during a 1-month period:
1. delusions
2. hallucinations
3. disorganized speech (e.g., frequent derailment or incoherence)
4. grossly disorganized or catatonic behavior
5. negative symptoms, i.e., affective flattening, alogia, or avolition
B. Social/occupational dysfunction: For a significant portion of the time since the
onset of the disturbance, one or more major areas of functioning such as work,
interpersonal relations, or self-care are markedly below the level achieved prior to
the onset.

C. Duration: Continuous signs of the disturbance persist for at least 6 months. This
6-month period must include at least 1 month of symptoms (or less if successfully
treated) that meet Criterion A.

The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition.

Types of Schizophrenia:
a) Paranoid schizophrenia:
- most common
- prominent delusions and hallucinations that involve themes of persecution and
grandiosity eg. Conspiracy plots against them
- do not show grossly disorganized speech or behaviour
- very resistant to arguments against their delusions
- typically tense, suspicious, guarded, sometimes hostile or aggressive (violence
and suicide)
- onset usually at a later age than the other types
- better prognosis than the other types – better cognitive and social functioning

b) Disorganized schizophrenia:
- regression to primitive, disinhibited and unorganized behaviour
- Patients are usually active, but in an aimless, disorganised way.
- pronounced thought disorder
- personal appearance dilapidated, innapropriate emotional responses eg.
uncontrollable, inappropriate laughter
- typically early onset; often unresponsive to treatment; poor prognosis.

c) Catatonic schizophrenia:
- Rare
- marked disturbance in motor functioning – stupor, rigidity, alternating
excitement
- stereotypies and mannerisms eg. Grimacing, rocking, hand-flapping
- mutism is common
- echolalia (repitition of words just spoken) or echopraxia (repetitive imitation of
movements)

d) Undifferentiated schizophrenia:
- patients are clearly schizophrenic, but cannot be fitted into one of the above
types.

e) Residual schizophrenia:
- continuing presence of schizophrenic disturbance in the absence of a complete
set of active symptoms or of sufficient symptoms to meet the criteria
- eg. flat affect, social withdrawal, eccentric behaviour, illogical thinking, mild
loosening of associations.
- no prominent delusions or hallucinations

PROGNOSIS:
- more chronic and debilitating than other disorders
- 50-80% of hospitalized patients will be rehospitalized with another episode

4. EFFECTS OF GENDER, CLASS AND CULTURE:

Gender:

• Equal numbers of men and women, but women become ill later, and recover
better. The later the age of onset, the better the prognosis. Peak ages of onset for
men are 15 to 25 years, for women they are 25 to 35 years.
• Women hospitalized less often and for briefer periods of time.
• Women’s social skills are less impaired when not psychotic. Show milder
negative symptoms
• Men may be seen as more of a threat to community; more likely to be
incarcerated.

Class:

• Schizophrenia has been described in all socio-economic status groups

• Class affects access to treatment and diagnostic pattern
• Urbanisation and poverty may cause stress which may induce schizophrenia
• Some evidence that schizophrenics from poorer backgrounds will be homeless, or
imprisoned

Culture:

• Culture affects community response, content of delusions, hallucinations, patterns

of recovery
• People in developing countries have a better prognosis – there tends to me more
broader and closer family networks around the person with schizophrenia,
providing more people to care for the patient
• Culture-bound psychosis and its implications for diagnosis

Much conflict around understanding CBS’s in South Africa -

• Amafufunyana:
A set of symptoms, includes hysteria, violence, aggression, weeping, ‘frenzy’.
Earlier studies describes it as a form of spirit possession or hysteria occuring among
Zulu and Xhosa-speakers.
In later studies the term is used in different ways by different informants – emerges
less as a discrete diagnostic entity with attached symptoms than as a construction or
explanatory model which patients use to make sense of their experience.
Is an intersubjective state, socially sanctioned and constructed, with ritual paths to
healing.

• Ukuthwasa:
The calling to become a healer.
The state of emotional turmoil a person goes through on the path to becoming a
traditional healer. However, not all people who go through Ukuthwasa becomes a
healer.
 Can look like serious mental disorder (mood disorder or schizophrenia or delusional
disorder) – dreams, depressive sypmtoms, anxiety.
Is distressing, causes disorganization of social behaviour

Both Amamfufunyana and Ukuthwasa do not have one single meaning, the
meanings shift in different circumstances and should always be explored in the
clinical setting.

5. CAUSES OF SCHIZOPHRENIA (We really don’t know)

Biological Theories:

The cause of schizophrenia is largely unknown, but biological factors are seen to play a
primary role in the development of schizophrenia

a) Genetic:
• Family, twin and adoption studies have all provided evidence that genes are
involved in the transmission of schizophrenia
• Children with one first degree relative (eg nontwin sibling) with schizophrenia:
9% risk
• Children with both parents schizophrenic: 46% risk
• Children with one parent with schizophrenia: 13% risk
• Adoption studies support the role of genetic factors.
• Concordance dizygotic twins: 14%
• Concordance monozygotic twins: 46%
• Even when a person carries a genetic risk, many other biological and
environmental factors may influence whether or how the individual manifests the
disorder

b) Brain abnormalities:
• Caused by prenatal difficulties and birth complications – lead to abnormal
development of the brain
• Enlarged ventricles: ventricles are fluid-filled spaces in the brain. Enlarged
ventricles suggest atrophy or deterioration of brain tissue.
• Frontal cortex smaller in schizophrenia patients; shows less activity in some
patients with schizophrenia. The frontal cortex is important in language, planning
and executing tasks or ideas, motivation, social behaviour.

c) Neurotransmitters:
• Dopamine Hypothesis:
Dopamine is a neurotransmitter in the brain – involved in the body’s motor
activity; it acts as an inhibiter, it also controls the flow of information from the
frontal cortex to other parts of the brain’ involved in pleasure and motivation.
 Initially the hypothesis was that schizophrenia is related to too much
dopaminergic activity in parts of the brain, including the frontal lobe. Found that
drugs that reduce levels of dopamine reduce symptoms of schizophrenia, but
develop motor movement disorders similar to Parkinson’s disease. Drugs that
increase dopamine activity (eg amphetamines) increase psychotic symptoms. PET
scans also found higher levels of dopamine in patients with schizophrenia.

Newer theories suggest a combination of hypo- and hyper- dopaminergic activity

in various sectors of the brain – high activity in the mesolimbic system (cognition
and emotions), and low activity in the frontal cortex (attention, motivation and
behaviour).

• Seratonergic activity currently being researched

Psychosocial theories:

• Expressed Emotion:
- Families high in expressed emotion are over-involved with each other; over-
protective of the disturbed family member; voice a self-sacrificing attitude, while
being critical, hostile, and resentful of the disturbed family member.
- Individuals with schizophrenia in families with high EE are more likely to suffer
relapses

• Stress may increase vulnerability, but this is difficult to demonstrate. Stressful life
events may precipitate onset/relapse. Research shows that stressful life events
occur shortly before the onset of a new episode.

Other Factors:

• Epidemics of influenza seem to affect rates in women 6-7 months pregnant

• Urban living increases risk – stress from overcrowding, poverty

• Winter births increase risk

6. TREATMENT OF SCHIZOPHRENIA

Comprehenisve treatments are the norm, involving medication, social support and family
interventions. For some, long-term hospitalization.

Medication:
• First line of treatment.
• Neuroleptic drugs – (antipsychotic medication)
- eg. Chlorpromazine, Haloperidol.
- Reduces Dopamine action by blocking the dopamine receptors.
- Calms agitation; reduces hallucinations and delusions
 - About 25% of people with schizophrenia do not respond to the
neuroleptics.
- more effective in treating the positive symptoms than the negative
symptoms.
- Drugs must be taken all the time to avoid relapse. Readmissions into
hospital most often because of poor drug compliance (revolving door)
- Side effects – grogginess, dry mouth, blurred vision, drooling, sexual
dysfunction, weight change, constipation, menstral disturbances,
parkinson’s symptoms (tremors).
- NB side effect: tardive dyskinesia = irreversible neurological disorder
involves involuntary movements of the face, mouth or jaw (eg. repeated
lip-smacking, puffing out cheeks).

• Atypical drugs –
- more effective than neuroleptics
- eg: Clozapine; Resperidone
- Stabilizes dopamine levels; acts on serotonin
- Less neurological side effects – no tardive dyskinesia
- some side effects – diziness, nausea, sedation, weight gain, salivation

Many patients who can control their positive symptoms with medication, still experience
many negative symptoms – lack of motivation, planning ability, social interaction.

Social interventions:
• Shelter and subsistence – many patients have trouble finding and holding down
jobs, finding enough money
• Support groups

Education:
• Symptoms and relapse
• social skills training

Family Therapy:
• Expressed Emotion training.
• Monitoring medication, side effects and symptoms
• Family therapy combined with medication more effective in reducing relapses
than medication only.