SCHIZOPHRENIA

Prepared by:

CHARMAINE L. PINEDA, RPm

What is Schizophrenia?
■ Schizophrenia is a chronic psychotic disorder
characterized by acute episodes involving a break
with reality, as manifested by features such as:
– Delusions
– hallucinations,
– illogical thinking
– incoherent speech
– bizarre behavior.
■ Schizophrenia is believed to affect about 1% of
the adult population and typically develops in late
adolescence or early adulthood
Diagnostic Criteria
A. CHARACTERISTICS SYMPTOM. Two (or more) of the following,
each present for a significant portion of time during a 1 -
month period (or less if successfully treated). At least one of
these must be (1 ), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g., frequent derailment or
incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms
Diagnostic features
B. SOCIALOCCUPATIONAL DYSFUNCTION. For a significant portion
of the time since the onset of the disturbance, level
of functioning in one or more major areas, such as work,
interpersonal relations, or self-care, is markedly below the level
achieved prior to the onset (or when the onset is in childhood
or adolescence, there is failure to achieve expected level of
interpersonal, academic, or occupational functioning).

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 (i.e., active-phase symptoms) and may include
periods of prodromal or residual symptoms. During these
prodromal or residual periods, the signs of the
disturbance may be manifested by only negative symptoms or by
two or more symptoms listed in Criterion A present in an
attenuated form (e.g., odd beliefs, unusual perceptual
experiences).
Diagnostic Criteria

D. SCHIZOAFFECTIVE AND MOOD DISORDER

EXCLUSION. Schizoaffective disorder and depressive or bipolar
disorder with psychotic features have been ruled out because either:
1 ) no major depressive or manic episodes have occurred concurrently
with the active-phase symptoms, or
2) if mood episodes have occurred during active-phase symptoms,
they have been present for a minority of the total duration of the active
and residual periods of the illness.
Diagnostic Criteria

E. SUBSTANCE/GENERAL MEDICAL CONDITION EXCLUSION. The

disturbance is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition.
F. RELATIONSHIP TO A PERVASIVE DEVELOPMENT DISORDER. If there
is a history of autism spectrum disorder or a communication disorder
of childhood onset, the additional diagnosis of schizophrenia is made
only if prominent delusions or hallucinations, in addition to the other
required symptoms of schizophrenia, are also present for at least 1
month (or less if successfully treated).
Types of Impairments
Associated with Schizophrenia
■ Disturbed thought processes - Delusions (fixed false ideas) and thought
disorder (disorganized thinking and incoherent speech)
■ Attentional deficiencies - Difficulty attending to relevant stimuli and screening
out irrelevant stimuli
■ Perceptual disturbances - Hallucinations (sensory perceptions in the absence
of external stimulation)
■ Emotional disturbances - Flat (blunted) or inappropriate emotions
■ Other types of impairments - Confusion about personal identity, lack of
volition, excitable behavior or states of stupor, odd gestures or bizarre facial
expressions, impaired ability to relate to others, or possible catatonic behavior
or gross disturbance in motor activity and orientation
Prevalence

■ Schizophrenia affects about 1% of the U.S.

population and about 0.3% to 0.7% of the global
population.
■ Nearly 1 million people in the United States are
treated for schizophrenia each year, with about a
third of them requiring hospitalization.
■ The World Health Organization (WHO) estimates
that about 24 million people worldwide suffer from
schizophrenia.
Prevalence

■ Men have a slightly higher risk of developing schizophrenia

than women and also tend to develop the disorder at an
earlier age.
■ The peak age at which psychotic symptoms first appear is in
the early to middle twenties for men and the late twenties for
women.
■ Women tend to have a higher level of functioning before the
onset of the disorder and to have a less severe course of
illness than men.
■ Men with schizophrenia tend to have more
cognitive impairment, greater behavioral deficits, and a
poorer response to drug therapy than do women with the
disorder.
Development & Course
■ Schizophrenia typically develops during late adolescence or early
adulthood
■ In some cases, the onset of the disorder is acute. It occurs
suddenly, within a few weeks or months. The individual may have
been well adjusted and may have shown few signs of behavioral
disturbance. Then a rapid transformation in personality and
behavior leads to an acute psychotic episode.
■ In most cases, there is a slower, more gradual decline in
functioning.
■ The period of gradual deterioration is called the prodromal phase
or prodrome. It is characterized by subtle symptoms involving
unusual thoughts or abnormal perceptions (but not outright
delusions or hallucinations), as well as waning interest in social
activities, difficulty meeting responsibilities of daily living, and
impaired cognitive functioning involving problems with memory
and attention, use of language, and ability to plan and organize
one’s activities.
Development & Course
– One of the first signs of gradual deterioration or a prodrome is often
a lack of attention to one’s appearance. The person may fail to
bathe regularly or wear the same clothes repeatedly.
– Over time, the person’s behavior becomes increasingly odd. There
are lapses in job performance or schoolwork. Speech becomes
vague and rambling. These changes in personality may be so
gradual that they raise little concern at first among friends and
family.
– The changes may be attributed to “a phase” the person is passing
through. But as behavior becomes more bizarre—such as hoarding
food, collecting garbage, or talking to oneself on the street—the
acute phase of the disorder begins. Psychotic symptoms
then develop, such as wild hallucinations, delusions, and
increasingly bizarre behavior. Following acute episodes, some
people with schizophrenia enter the residual phase, in which their
behavior returns to the level of the prodromal phase. Flagrant
psychotic behaviors are absent, but the person is still impaired by
significant cognitive, social, and emotional deficits, such as a deep
sense of apathy and difficulties in thinking or speaking clearly, and
by harboring unusual ideas, such as beliefs in telepathy or
clairvoyance.
Development & Course

■ These cognitive and social deficits can make it difficult

for schizophrenia patients to function effectively in
their social and occupational roles.
■ Although schizophrenia is a chronic disorder, as many
as one-half to two-thirds of schizophrenia patients
improve significantly over time. Full return to normal
behavior is uncommon but does occur in some cases.
Typically, patients develop a chronic pattern
characterized by occasional acute episodes and
continued cognitive, emotional, and motivational
impairment between psychotic episodes.
Risk & Prognosis Factors

■ There is currently no known cure for schizophrenia and

a full recovery from schizophrenia is unusual, with only
approximately 15% returning to previous functioning
capabilities. However, most individuals with the
condition are able to live a meaningful and satisfying
life, in the presence or absence of symptoms.
■ For most patients, the symptoms tend to change over
time and the impact they have on the life and daily
activities of each individual may vary significantly. In
general, women patients are more likely than men to
maintain improvement of symptoms.
Comorbidity

■ Rates of comorbidity with substance-related disorders are high in schizophrenia.

■ Over half of individuals with schizophrenia have tobacco use disorder and smoke
cigarettes regularly.
■ Comorbidity with anxiety disorders is increasingly recognized in schizophrenia.
■ Rates of obsessive-compulsive disorder and panic disorder are elevated in
individuals with schizophrenia compared with the general population.
■ Schizotypal or paranoid personality disorder may sometimes precede the onset of
schizophrenia.
Comorbidity

■ Life expectancy is reduced in individuals with schizophrenia because of

associated medical conditions.
■ Weight gain, diabetes, metabolic syndrome, and cardiovascular and pulmonary
disease are more common in schizophrenia than in the general population.
■ Poor engagement in health maintenance behaviors (e.g., cancer screening, exercise)
increases the risk of chronic disease, but other disorder factors, including
medications, lifestyle, cigarette smoking, and diet, may also play a role.
■ A shared vulnerability for psychosis and medical disorders may explain some of the
medical comorbidity of schizophrenia.
Suicide Risk

■ Approximately 5%-6% of individuals with schizophrenia die by

suicide, about 20% attempt suicide on one or more
occasions, and many more have significant suicidal
ideation.
■ Suicidal behavior is sometimes in response to command
hallucinations to harm oneself or others.
■ Suicide risk remains high over the whole lifespan for males
and females, although it may be especially high for younger
males with comorbid substance use.
■ Other risk factors include having depressive symptoms or
feelings of hopelessness and being unemployed, and the risk
is higher, also, in the period after a psychotic episode or
hospital discharge.
Suicide Risk

■ Approximately 5%-6% of individuals with schizophrenia die by

suicide, about 20% attempt suicide on one or more
occasions, and many more have significant suicidal
ideation.
■ Suicidal behavior is sometimes in response to command
hallucinations to harm oneself or others.
■ Suicide risk remains high over the whole lifespan for males
and females, although it may be especially high for younger
males with comorbid substance use.
■ Other risk factors include having depressive symptoms or
feelings of hopelessness and being unemployed, and the risk
is higher, also, in the period after a psychotic episode or
hospital discharge.
Treatment Options

■ Schizophrenia requires lifelong treatment, even when

symptoms have subsided. Treatment with medications
and psychosocial therapy can help manage the
condition. In some cases, hospitalization may be
needed.
Treatment Options
■ Medications
■ Second-generation antipsychotics
■ First-generation antipsychotics
■ Psychosocial interventions
– Individual therapy
– Social skills training
– Family therapy
– Vocational rehabilitation and supported
employment.
■ Hospitalization
■ Electroconvulsive therapy
Treatment Options
■ Learning-Based Therapies
Although few behavior therapists believe that
faulty learning causes schizophrenia, learning-based
interventions have proved to be effective in modifying
schizophrenic behavior and in helping people with the
disorder develop behaviors that can help them adjust
more effectively to living in the community. Therapy
methods include the following:
1. Selective reinforcement of behavior
2. Token economy
3. Social skills training
Treatment Options

■ Family Intervention Programs

Family conflicts and negative family interactions can heap
stress on family members with schizophrenia, increasing
the risk of recurrent episodes.
Researchers and clinicians have worked with families of
people with schizophrenia to help them cope with the
burdens of care and to assist them in developing more
cooperative, less confrontational ways of relating to
others.
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SCHIZOAFFECTIVE
DISORDER
What is Schizoaffective
Disorder?
■ It is sometimes referred to as a “mixed bag” of
symptoms because it includes psychotic behaviors
associated with schizophrenia (e.g., hallucinations
and delusions) occurring at the same time as a
major mood disorder (major depressive episode or
manic episode).
■ At some point in the course of the disorder, however,
delusions or hallucinations must have occurred for a
period of at least two weeks without the presence of
a major mood disorder (so as to distinguish the
disorder from a mood disorder with psychotic
features).
Diagnostic Criteria

A. An uninterrupted period of illness during which

there is a major mood episode (major depressive or
manic) concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include
Criterion A1 : Depressed mood.
B. Delusions or hallucinations for 2 or more weeks
in the absence of a major mood episode (depressive
or manic) during the lifetime duration of the illness
Diagnostic Criteria

C. Symptoms that meet criteria for a major

mood episode are present for the majority
of the total duration of the active and
residual portions of the illness.
D. The disturbance is not attributable to the
effects of a substance or another medical
condition.
Prevalence

■ Schizoaffective disorder appears to be about one-

third as common as schizophrenia. Lifetime
prevalence of schizoaffective disorder is estimated
to be 0.3%.
■ The incidence of schizoaffective disorder is higher in
females than in males, mainly due to an increased
incidence of the depressive type among females.
Development & Course
■ The typical age at onset of schizoaffective disorder is early
adulthood, although onset can occur anywhere from
adolescence to late in life.
■ A significant number of individuals diagnosed with another
psychotic illness initially will receive the diagnosis
schizoaffective disorder later when the pattern of mood
episodes has become more apparent.
■ With the current diagnostic Criterion C, it is expected that
the diagnosis for some individuals will convert from
schizoaffective disorder to another disorder as mood
symptoms become less prominent.
■ The prognosis for schizoaffective disorder is somewhat
better than the prognosis for schizophrenia but worse than
the prognosis for mood disorders.
Development & Course
■ Schizoaffective disorder may occur in a variety of temporal patterns.

■ The following is a typical pattern:

– An individual may have pronounced auditory hallucinations and
persecutory delusions for 2 months before the onset of a prominent
major depressive episode.
– The psychotic symptoms and the full major depressive episode are
then present for 3 months. Then, the individual recovers completely
from the major depressive episode, but the psychotic symptoms
persist for another month before they too disappear.
– During this period of illness, the individual's symptoms concurrently
met criteria for a major depressive episode and Criterion A for
schizophrenia, and during this same period of illness, auditory
hallucinations and delusions were present both before and after the
depressive phase.
– The total period of illness lasted for about 6 months, with psychotic
symptoms alone present during the initial 2 months, both depressive
and psychotic symptoms present during the next 3 months, and
psychotic symptoms alone present during the last month.
– In this instance, the duration of the depressive episode was not brief
relative to the total duration of the psychotic disturbance, and thus
the presentation qualifies for a diagnosis of schizoaffective disorder.
Development & Course
■ The expression of psychotic symptoms across the lifespan is
variable. Depressive or manic symptoms can occur before
the onset of psychosis, during acute psychotic
episodes, during residual periods, and after cessation of
psychosis.
■ This pattern is not necessarily indicative of schizoaffective
disorder, since it is the co-occurrence of psychotic and mood
symptoms that is diagnostic.
■ For an individual with symptoms that clearly meet the criteria
for schizoaffective disorder but who on further follow- up only
presents with residual psychotic symptoms (such as
subthreshold psychosis and/or prominent negative
symptoms), the diagnosis may be changed to
schizophrenia, as the total proportion of psychotic illness
compared with mood symptoms becomes more prominent.
■ Schizoaffective disorder, bipolar type, may be more common
in young adults, whereas schizoaffective disorder, depressive
type, may be more common in older adults.
Risk and Prognosis
Factors
■ Genetic and physiological. Among individuals
with schizophrenia, there may be an increased
risk for schizoaffective disorder in first-degree
relatives. The risk for schizoaffective disorder
may be increased among individuals who have
a first-degree relative with schizophrenia,
bipolar disorder, or schizoaffective disorder.
Comorbidity
■ Many individuals diagnosed with schizoaffective
disorder are also diagnosed with other mental
disorders, especially substance use disorders and
anxiety disorders.
■ Similarly, the incidence of medical conditions is
increased above base rate for the general
population and leads to decreased life expectancy.
Suicide Risk

■ The lifetime risk of suicide for schizophrenia and schizoaffective disorder is 5%,
and the presence of depressive symptoms is correlated with a higher risk for
suicide.
■ There is evidence that suicide rates are higher in North American populations
than in European, Eastern European, South American, and Indian populations
of individuals with schizophrenia or schizoaffective disorder.
Treatment Options
■ People with schizoaffective disorder generally respond
best to a combination of medications, psychotherapy
and life skills training.
■ Treatment varies, depending on the type and severity
of symptoms and whether the disorder is the
depressive or bipolar type. In some cases,
hospitalization may be needed. Long-term treatment
can help to manage the symptoms
■ Medications
– Antipsychotics.
– Mood-stabilizing medications
– Antidepressants
Treatment Options
■ Psychotherapy
– Individual Therapy
– Group or Family Therapy
■ Life skills training
– Social skills training
– Vocational rehabilitation and supported employment
■ Hospitalization
■ Electroconvulsive therapy
 ■ Abnormal Psychology in a Changine World
9th edition by Nevid, Rathus, and Greene
■ DSM V

References: ■
■
www.webmd.com
www.mayoclinic.org
■ www.nimh.nih.gov/health/topics/
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