Schizophrenia

Schizophrenia Paul Bleuler

Different from other disorders in that

there is no essential feature.
schism or split, + mind
(schizen = split, phren = mind).
In 1908, Bleuler emphasized the
breaking of associative threads.
He observed that there was not always
early onset or deteriorating course.

DSM-5 diagnostic criteria

At least two characteristic symptoms:

+Delusions *
+Hallucinations *
+Disorganized speech
+Grossly disorganized or catatonic behavior
- Negative symptoms
* Only one symptom required if it is bizarre
delusions or continually commenting or conversing
auditory hallucinations

Symptoms are classified as

Postive or Negative

Positive symptoms involve distorted or

excessive mental activity
Delusions, hallucinations, altered emotions,
erratic behaviors
Positive symptoms occur during acute episodes

Negative symptoms involve behavioral and

mental deficits
Flattened emotions, social withdrawal
Negative symptoms are chronic (long-term) and
may not respond well to drug treatment

Positive Symptoms keep them

clear

Hallucinations are perceptions without

sensations
Delusions are mistaken beliefs that are
maintained despite contrary evidence

Paranoid: others are talking about the person

Persecution: others are out to get the person

Negative symptoms

Behavioral deficits:
Avolition
Lack of energy or interest in routine activities

Alogia
Poverty of speech
Poverty of speech content

Anhedonia
Inability to experience pleasure

Flattened affect
Monotone; less facial expression of emotion

The syndrome duration

Total duration must be at least 6 months

Prodrome
Prodrome Active
Active Phase
Phase
Prodrome
Prodrome
ProProdrome
drome

Residual
Residual Phase
Phase

Active
Active Phase
Phase Residual
Residual Phase
Phase
Active
Active Phase
Phase

Residual
Residual Phase
Phase

The active phase must last at least 1 month

Stages of Schizophrenia

Prodrome - when the first change in a person

occurs until they develop full-blown psychosis.
Acute - characterized by hallucinations, paranoid
delusions, and extremely disorganized speech and
behaviors
Residual - resembles schizophrenia prodrome as
obvious psychosis has subsided, but the patient
may exhibit negative symptoms like social
withdrawal, flat affect and uncharacteristically low
energy levels

Faces of schizophrenia

Paranoia, disorganized, and/or catatonic

Paranoid looks like

Preoccupied with one or more delusions, or
Frequent auditory hallucinations
Speech, behavior, and affect may or may not
be prominently impaired

Faces of schizophrenia

Behavior and speech are disorganized

Clang associations (words that rhyme) and
neologisms (made up words)
Complete neglect of appearance
Word salad
confused or unintelligible mixture of seemingly random
words and phrases

Flat or rapidly changing inappropriate emotion

Catatonia

Used to be part of the schizophrenia diagnosis

the DSM 5 has now given it its own category
At least two of
Motor immobility:
Catalepsy - refers to an immobile stance that can be held for
hours (like a statue)
Waxy flexibility
Stupor

Purposeless excess movement

Extreme negativism: motiveless resistance, rigidity,
mutism
Strange movements: posturing, stereotyped movements,
grimacing
Echolalia (repeat the words said to them) or echopraxia
(repeating a movement)

What causes it?

Genetics?
Excessive amounts of dopamine?
Enlarged ventricles in the brain?
Abnormal pattern of connections
between cortical cells?
Family relationships?
Birth difficulties?

Etiology of Schizophrenia

In addition to genetic predisposition,

experiences such has prenatal trauma,
infection, and stress may all be
susceptibility factors

Thus, individuals inherit a predisposition

for schizophrenia which may or may not
be activated by experience

Etiologies of schizophrenia

The etiology may be complex, due to

Broad set of symptoms
Positive and negative symptoms

Genetic factors in etiology

1% of general population
10% in first-degree relatives of
schizophrenics
45% in identical twins of schizophrenics

Etiological factors

Inherited susceptibility or several genes

are involved
Retrospective strangeness in childhood
behavior
A stress trigger is implicated.

Schizophrenia
Relationship between Positive and Negative Symptoms:
Role of the Prefrontal Cortex

The evidence indicates that schizophrenia is

associated with abnormalities in many parts of the
brain, especially the prefrontal cortex.

Weinberger (1988) first suggested that the negative

symptoms of schizophrenia are caused primarily by
hypofrontality (decreased activity of the frontal lobes)

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What are the genes?

Dopamine hyperactivity is found in

schizophrenia, but the genes for the five types
of DA receptors found so far are not linked to
schizophrenia (Coon et al., 1993)

Environmental factors in etiology

The negative symptoms may be due to

brain damage.

Some people with no family history of

schizophrenia or any related disorder
develop schizophrenia.

Prenatal damage factors:

Epidemiology

Incidence of schizophrenia increases

with:
season of birth: late winter/early spring
viral epidemics in second trimester (Tsuang,
2000)
population density and latitude
malnutrition or refeeding after thiamine
deficiency (cf. Korsakoffs syndrome)
prenatal stress: WW II widows offspring

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Brain abnormality

Magnetic Resonance Imaging (MRI)

MRI evidence suggest loss of gray matter in

temporal lobe
MRI show NO degenerative brain changes
thus suggesting the loss of gray matter is
developmental
MRI studies support the viral infection
hypothesis & errors of neural organisation.

Positron Emission Tomography (PET)

Observe live brain structure & function

Enlarged ventricles
Poor activation of frontal lobe during
cognitive tasks
People with schizophrenia do less well on
cognitive tasks.
Enlarged ventricles detectable even before
onset of schizophrenia

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And still more evidence

Higher incidence of schizophrenia in people

who experienced birth complications:
Oxygen deprivation, drugs, infections, endocrine
disorders

A variant dopamine hypothesis

Disorganized speech

aka formal thought disorder

incoherence
loose associations
derailment/distractibility
perseveration

Disorganized speech 1

Takes less place. Cat didnt know what

Mouse did and Mouse didnt know what Cat
did Cat represented more on the suspicious
side than the mouse. Dumbo was a good
guy. He saw what the cat did, put himself
with the cat so people wouldnt look at them
as comedians. Cat and Dumbo are one and
alike, but Cat didnt know what Dumbo did
and neither did the mouse.

Disorganized speech 2

Everyone should have a good laugh.

Dont cry over it. Dont tell anyone -they will tell someone. Appreciate it
without criticism. A word like milk
shouldnt be mentioned.

Disorganized speech 3

So to beseech you as full as for it.

Exactly or as kings. Shutters shut and
open so do queens. Shutters shut and
shutters and so shutters shut and shutters
and so and so shutters and so shutters
shut and so shutters shut and shutters
and. So and so shutters shut and so and
also. And also and so and so and also.

Disorganized speech credits

Disorganized speech 1 and 2 are from

a person with schizophrenia, quoted in
Zimbardos Instructors manual for
Psychology and Life.
Disorganized speech 3 is from a poem
by Gertrude Stein.