Schizophrenia

&
Psychotic Disorders

Schizophrenia

What is Schizophrenia?
A psychotic disorder - a disconnect from reality.

Schizo(greek) = division or split.

Phrenia (Greek/Latin) = mind.
Profound disruption in cognition, emotion and/or behavior.
Hallucinations and/or delusions.

Schizophrenia is not
multiple Personality (a dissociative disorder).
Schizoid personality disorder or schizotypal personality disorders.

Severity level may vary.

A thought disorder characterized by
disorganized thinking
disorganized speech, unreal perceptions and sense of self.

Schizophrenia throughout history:

From exorcisms to Freud to CBT
Early view : the problem is possession by evil spirits.
Exorcism, incarceration, blood-letting.

Emile Kraepelin (1800s) coined the term dementia

praecox.
Persons with schizophrenia were referred to be demented.

Eugene Blueler (1911) coined the term schizophrenia.

Sigmund Freud developed first models of psychosis.
Harry Stack Sullivan used an objects relations approach to
show that symptoms could be reduced with psychotherapy.
George Brown & John Birley (1968) proposed that
environmental factors (i.e. family, etc.) influenced the
course of schizophrenia.
Aaron Beck (1952) described a case of the use of CBT to
treat persecutory delusions.

Other Psychotic Disorders

Schizoaffective: Schizophrenia with depression, mania or
mixed.
Schizophreniform: Schizophrenia symptoms for at least
1 month but less than 6 months.
Major Depressive Disorder with Psychotic Features.
Bipolar I Disorder with Psychotic Features (psychotic
features may be present during manic episodes).

Brief Psychotic Reaction: Psychotic symptoms for at

least 1 day , less that 6 mos.
Delusional Disorders: Delusions w/out signs of
schizophrenia: Grandiose, Persecutory, Erotomanic, Jealous, Somatic.
Shared Psychotic Disorder (Folie a deux): A delusion
shared by two persons.
Psychotic Disorder due to medical condition
Drug Induced Psychosis (e.g. LSD, acute cocaine
intoxication)

Schizophrenia & disorganized thinking

Disorganized thinking is a hallmark of schizophrenia.
It is not cognitive distortions or errors in thinking.

Disorganized thinking (cognitive impairment) evident by:

Inability to distinguish reality from fantasy.
Delusions Fixed false beliefs that are taken as truths.
Most common delusions: grandeur, reference

Hallucinations False perceptions that are accepted as real.

Auditory, visual, tactile, olfactory, gustatory

Impaired reality testing.

Impaired thinking that is:
Tangential:
Loosely connected to preceding and following thoughts.
Circumstantial: Circular speech with rambling disorganized details.
Flight of ideas: Continuous rapid speech jumping from disconnected
idea to idea.
Loose associations: One thought does not logically relate to another.

Symptomatology:
Positive & Negative Symptoms
Positive symptoms (better prognosis)
Appear to reflect an excess or distortion of normal
functions.
Hallucinations (i.e. bizarre distorted perceptions).
Delusions (i.e. bizarre thinking).
Bizarre behavior (e.g. manner of clothing , appearance).

Symptoms of Schizophrenia (cont.)

Negative symptoms (poorer prognosis)
Appear to reflect a diminution or loss of normal
functions:
Flat or blunted affect
Avolition/apathy (poor grooming, unable to hold job,
seeming disinterested in life activities, etc.)
Alogia (poverty of speech & content); word salad,
echolalia (imitation of sounds)
Anhedonia (profound loss of interest in pleasure, sexual
activity, closeness, relationships)

Cultural & Religious Considerations of

Symptoms of Schizophrenia:
Stigma associated with schizophrenia.
Misconception: Persons with schizophrenia are dangerous and
violent.
Fact: Less than 10% of violent crime in society is committed by
persons with schizophrenia (Walsh, Buchanan & Fahy, 2002).
The relationship between schizophrenia and violence is mediated
by alcohol/drug use and the risk is similar for substance abusing
individuals without psychosis (Fazel, Gautam, Geddes, & Grann, 2009).

Mental illness misused as a form of oppression.

Historically oppressive regimes have used the label of mental
illness against those who do not conform to their objectives and
who are then confined to mental health sanatoriums (i.e. prisons).

Cultural & Religious Considerations of

Symptoms of Schizophrenia (cont.):
Symptoms must be considered against the backdrop
of the persons culture and religion.
Historical accounts of visions, messages,
visitations, dreams religious beliefs or psychotic
delusions?
Why is schizophrenia diagnosed more frequently
among African-Americans, Latinos, and the poor?
Is delusional content culturally determined?

What causes schizophrenia?

We do not know
No convincing evidence to explain underlying
causes of schizophrenia.
Researchers believe that it s a neuro-developmental
disorder originating from a genetic or in-utero insult
(e.g. disease, infection, accident, etc.)
What we know is:
Prevalence in general USA population = 1.1% or 2.5 million
adults aged 18 or older (NIMH, 2009).
Prevalence worldwide = .5% to 1%
Runs in families
Concordance rates =
50% in identical twins
10% in brothers/sisters
12% if one parent has the illness
40% if both parents have the illness

Seems to affect dopamine production/receptors.

The Dopamine Hypothesis

Too much dopamine contributes to the symptoms
of schizophrenia.
Problems in the reuptake of dopamine.
Leaving too much dopamine in the synapses.
Most medications used to treat schizophrenia are
labeled as dopamine antagonists

Schizophrenia in children
Rarely diagnosed in pre-pubertal children
(although cases have been reported).
In adolescents = 1-2 per 1,000
Factors affecting the course & prognosis of
schizophrenia in children are:
Pre-schizophrenia level of functioning
Age of onset (worst prognosis if age < 10)
Presence of developmental delays, learning disorders,
ADHD, conduct disorder

Overall the prognosis for children with

schizophrenia seems to be poorer than for adults.

Onset and Gender Factors

Onset occurs earlier in men (late teen to mid-20s)

than in women (mid 20s to mid-30s).
Early onset results in more severe negative
symptoms, and less favorable prognosis.
No significant differences relative to prevalence
by gender.

Socio-economic & Culture

Schizophrenia is found across all cultures and
socioeconomic status (SES)
International prevalence rates range from .5% to 1%.

Yet, it is more prevalent in:

Large urban areas (cities) than in rural areas
Lower socioeconomic levels

Why? Consider this:

People with schizophrenia drift towards low SES areas of
cities where social services are more available than in
rural/suburban areas.
The stress of low SES may contribute as a precipitating
factor of schizophrenia.

Types of Schizophrenia
Paranoid
Delusions (persecution or grandeur)
Auditory hallucinations
Less negative symptoms

Disorganized (previously known as Hebephrenia)

Profound disorganization & desintegration of the
personality:

Profoundly disorganized thinking.

Erratic speech (word salad).
Childish or grossly inappropriate behavior.
Flat or inappropriate affect.
Neglect of self-care (i.e. hygiene, nutrition, medical attention,
etc.).

Types of Schizophrenia (cont.)

Catatonic
Waxy rigidity

Bizarre posture or movements

Stupor or excessive motor activity
Echolalia (imitation of sounds)
Echopraxia (imitation of movements)

Undifferentiated
Does not meet criteria for any of the previous types

Residual
No positive symptoms. Some negative ones may still be
present.

Prognosis

(Sadock & Sadock, 2008).

20%-30% recover to a normal life (i.e. mild

symptoms) with medication.
20%-30% continue to experience moderate
symptoms despite medications.
40%-60% remain significantly impaired.
Predictors of a good prognosis:
Late and/or acute onset
Good support network (socioeconomic, family, etc.)
Good premorbid history
(social/employment/relationship/sexual)
Predominance of positive symptoms

Anti-Psychotic Medications
(Neuroleptics)
Older

Thorazine
Stelazine
Prolixin
Haldol

Newer

Zyprexa
Risperdol
Seroquel
Abilify
Geodon
Clozaril

Cogentin: is often used

to treat the tremors and
muscle stiffness associated
with some antipsychotic
drugs.

Common side-effects:
Restlessness.
Parkinsons-like symptoms: tremors, muscle stiffness.
Tardive dyskenesia (lip smacking, tongue protrusion, rolling of the tongue,
rapid eye blinking, involuntary jerky movements).
Weight gain.
Increased blood sugar, irregular heartbeat.

Schizophrenia How it feels

Treatment: An Integrated Approach

Pharmacotherapy is necessary

Neuroleptics (i.e. anti-psychotic medication)

Dopamine & Serotonin antagonists

Poor medication compliance is a significant barrier to progress.
25% - 50% continue to experience substantial problems while on
meds.

Social & behavioral skills training.

Case management.

Assertive community treatment (ACT)

For the more severe, chronic or dual-diagnosed cases.

Family education.

About the illness and how to relate to the client/what to expect.

Poor family attitude towards the client is a risk factor for relapse.

Cognitive-behavioral therapy.

Group and/or individual therapy

CBT treatment of Schizophrenia

First used in 1952 (Beck) to treat paranoid delusions.

Mandated treatment for all patients with schizophrenia (UK).
CBT may be used to:
Build social skills.
Reduce catastrophic interpretation of symptoms and stigma
attached to schizophrenia.

Dickerson (2004) conducted a meta-analytical review of CBT

and schizophrenia including 17 studies & 1,495 participants.
Results suggest that CBT:
Helps in reframing idiosyncratic interpretations of delusions.
Reduces distress & disability around auditory hallucinations.
Corrects dysfunctional attitudes that promote emotional and social
withdrawal (negative symptoms).
May be an effective adjunctive treatment for some patients with
schizophrenia, but results vary considerably among studies and
treatment populations.