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Psychology 2030A/B
David Vollick

Abnormal  Psychology  Chapter  13:   Schizophrenia  and  Other  Psychotic  Disorders     Introduction   • Schizophrenia  is  a  disorder  characterized  by  a  broad  spectrum  of   cognitive  and  emotional  dysfunctions  including  delusions  and   hallucinations,  disorganized  speech  and  behavior,  and  inappropriate   emotions   • This  disorder  can  disrupt  a  persons  perception,  thought,  speech,  and   movement   • Complete  recovery  is  rare   • The  majority  of  people  with  schizophrenia  in  our  country  are  unemployed   and  living  in  poverty   • Subtypes:  different  presentations  and  combinations  of  symptoms  such  as   hallucinations,  delusions,  and  disorders  of  speech,  cognition,  emotion,  and   socialization     Early  Figures  in  Diagnosing  Schizophrenia   • Kraepelin  provided  what  stands  today  as  the  most  enduring  description   and  categorization  of  schizophrenia   • Two  of  Kraepelin’s  accomplishments  are  especially  important   • First,  he  combined  several  symptoms  of  insanity  that  had  usually  been   viewed  as  reflecting  separate  and  distinct  disorders:   o Catatonia  –  alternating  immobility  and  excited  agitation   o Hebephrenia  –  silly  and  immature  emotionality   o Paranoia  –  delusions  of  grandeur  or  persecution   • Kraepelin  thought  these  symptoms  shared  similar  underlying  features   and  included  them  the  term  dementia  praecox   • In  a  second  important  contribution,  Kraepelin  distinguished  dementia   praecox  from  manic-­‐depressive  illness   • Bleuler,  a  swiss  psychiatrist  who  introduced  the  term  schizophrenia   • Bleuler’s  belief  that  underlying  all  the  unusual  behaviors  shown  by  people   with  this  disorder  was  an  associatiative  splitting  of  the  basic  functions  of   personality   • Furthermore,  Bleuler  believed  that  difficulty  keeping  a  consistent  train  of   thought,  characteristic  of  all  persons  with  this  disorder,  led  to  the  many   and  diverse  symptoms  they  displayed     Identifying  Symptoms   • Schizophrenia  is  actually  a  number  of  behaviors  or  symptoms  that  aren’t   necessarily  shared  by  all  the  people  who  are  given  this  diagnosis     Clinical  Description   • The  term  psychotic  has  been  used  to  characterize  many  unusual   behaviors,  although  in  its  strictest  sense  it  usually  involves  delusions  and   hallucinations   • Schizophrenia  is  one  of  the  disorders  that  involve  psychotic  behavior   • Media  portrayals  continue  to  frequently  depict  people  with  schizophrenia   as  violent   • The  popular  press  also  misrepresents  abnormal  psychology  to  the   detriment  of  people  who  experience  these  debilitating  disorders   • DSM  has  multiple-­‐part  process  for  determining  whether  someone  has   schizophrenia   • Mental  health  workers  typically  distinguish  between  positive  and   negative  symptoms,  also  appears  to  be  an  important  aspect  of  the   disorder   • Positive  symptoms  generally  include  the  more  active  manifestations  of   abnormal  behavior,  such  as  delusions  and  hallucinations   • Negative  symptoms  involve  deficits  in  normal  behavior  in  such  areas  as   speech  and  motivation   • Disorganized  symptoms  include  rambling  speech,  erratic  behavior,  and   inappropriate  affect   • A  diagnosis  of  schizophrenia  requires  that  two  or  more  positive,  negative,   or  disorganized  symptoms  be  present  for  at  least  one  month     Positive  Symptoms:  Delusions   • A  belief  that  would  be  seen  by  most  members  of  a  society  as  a   misinterpretation  of  reality  called  a  disorder  of  thought  content  or  a   delusion   • People  with  schizophrenia  as  believing  there  are  famous  or  important   people  is  a  delusion  of  grandeur   • Delusions  of  persecutions  are  beliefs  that  can  be  most  disturbing   • More  unusual  delusions  include  Cotard’s  syndrome,  I  which  the  person   believes  a  part  of  his  body  or  her  body  has  changed  in  some  impossible   way   • Capagras  syndrome  in  which  the  person  believes  someone  he  or  she   knows  has  been  replaced  by  a  double   • Possible  explanation  for  why  delusions  persist  in  the  face  of  contradictory   information  in  that  the  new  information  in  not  properly  integrated   • Schizophrenic  patients  with  more  severe  delusions  produced  smaller   N400  brain  waves  to  target  words  that  were  inconsistent  with  the   expected  category  than  did  patient  with  less  severe  delusions   • Delusions  may  serve  a  purpose  for  people  with  schizophrenia  who  are   otherwise  quite  upset  by  the  changes  taking  place  within  themselves     Positive  Symptoms:  Hallucinations   • The  experience  of  sensory  events  without  any  input  form  the  surrounding   environment  is  called  a  hallucination   • Hallucinations  can  involve  any  of  the  senses,  although  hearing  things  that   aren’t  there,  or  auditory  hallucination,  is  the  most  common  form   experienced  by  people  with  schizophrenia   • People  tend  to  experience  hallucinations  more  frequently  when  they  are   unoccupied  or  restricted  from  sensory  input   • One  theory  of  auditory  verbal  hallucinations  states  that  people  who  are   hallucinating  are  in  fact  hearing  the  voices  of  others,  but  listening  to  their   own  voices  and  cannot  recognize  the  difference   • An  alternative  theory  is  that  auditory  verbal  hallucinations  arise  from   abnormal  activation  of  the  primary  auditory  cortex   • Found  that  auditory  verbal  hallucinations  were  associated  with  increased   metabolic  activity  in  the  left  primary  auditory  cortex  and  in  the  right   middle  temporal  gyrus   • Positive  symptoms  are  multidimensional  with  some  dimensions   responding  more  readily  than  others  to  antipsychotic  medications     Negative  Symptoms   • The  negative  symptoms  usually  indicate  the  absence  or  insufficiency  of   normal  behavior   • They  include  emotional  and  social  withdrawal,  apathy,  and  poverty  of   thought  or  speech     Negative  Symptoms:  Avolition   • Avolition  is  the  inability  to  initiate  and  persist  in  activities   • People  with  this  symptoms  show  little  interest  in  performing  even  the   most  basic  daily  functions,  including  those  associated  with  personal   hygiene   • Avolition  was  not  related  to  negative  symptoms  of  schizophrenia  other   than  emotional  withdrawal   • Avolition  was  more  highly  associated  with  poor  outcome  than  were  other   schizophrenia  symptoms  –  positive  or  negative     Negative  Symptoms:  Alogia   • Alogia  referred  to  the  relative  absence  of  speech   • A  person  with  alogia  may  respond  to  questions  with  very  brief  replies   that  have  little  content  and  may  appear  unlimited  in  the  conversation   • Such  deficiency  in  communication  is  believed  to  reflect  a  negative  thought   disorder  rather  than  inadequate  communication  skills   • Some  researchers,  for  example,  suggest  that  people  with  alogia  may  have   trouble  finding  the  right  words  to  formulate  their  thoughts   • Sometimes  alogia  takes  the  form  of  delayed  comments  or  slow  responses   to  questions     Negative  Symptoms:  Anhedonia   • Anhedonia,  is  the  presumed  lack  of  pleasure  experienced  by  some  people   with  schizophrenia   • Regardless  of  the  dependence  or  independence  from  depression,   anhedonia  is  clinically  meaningful  in  that  it  related  to  a  delay  in  seeking   treatment  for  schizophrenia     Negative  Symptoms:  Affective  Flattening   • People  with  flat  affect  do  not  show  emotions  when  you  would  normally   expect  toneless  manner,  and  seem  unaffected  by  things  going  on  around   them   • However,  although  they  do  not  react  openly  to  emotional  situations,  they   may  indeed  be  responding  inside   • The  flat  affect  in  schizophrenia  may  represent  difficulty  expressing   emotion,  not  a  lack  of  feeling   • The  negative  emotions  experienced  were  less  intense  in  the  patients  with   flat  affect     Sociality     • The  severe  deficits  in  social  relationships,  such  as  having  few  friendships,   little  interest  in  socializing,  and  poor  social  skills  shown  by  some  people   with  schizophrenia  are  referred  to  coactively  as  asociality   • Suggested  that  patients  who  have  poor  social  or  interpersonal  functioning   before  the  development  of  their  psychosis  also  have  greater  levels  of   negative  symptoms  and  greater  social  impairment  at  the  time  of  their   admission  to  a  schizophrenia  treatment  program   • The  best  predictor  of  asociality  in  people  with  schizophrenia  is  chronic   cognitive  impairment,  suggesting  that  difficulties  in  processing   information  may  contribute  significantly  to  the  social  skills  deficits  and   other  social  difficulties  displayed  by  many  patients     Disorganized  Symptoms:  Disorganized  Speech   • People  with  schizophrenia  often  lack  insight,  awareness  that  they   problem   • In  addition  “associative  splitting”  and  “cognitive  slippage”   • DSM  uses  the  term  disorganized  speech  to  describe  such  communication   problems   • Tangentiality  –  that  is  ongoing  off  on  tangent  instead  of  answering  a   specific  question   • Abruptly  changed  the  topic  of  conversation  to  unrelated  areas,  a  behavior   that  has  been  called  loose  association  or  derailment     Disorganized  Symptoms:  Inappropriate  Affect  and  Disorganized  Behavior   • Occasionally,  people  with  schizophrenia  display  inappropriate  affect,   laughing  or  crying  at  improper  times   • People  with  schizophrenia  engage  in  several  other  “active”  behaviors  that   are  usually  viewed  as  unusual   • Catatonia  is  one  of  the  most  curious  symptoms  in  some  individuals  with   schizophrenia;  it  involved  motor  dysfunctions  that  range  from  wild   agitation  to  immobility   • Catatonic  immobility  is  a  manifestation  that  can  also  involve  waxy   flexibility,  or  the  tendency  to  keep  their  bodies  and  limbs  in  the  position   they  are  put  in  by  someone  else     Schizophrenia  Subtypes   • Three  divisions  have  persisted:  paranoid,  disorganized,  and  catatonic   • Research  supports  dividing  schizophrenia  into  these  categories,  because   differenced  among  them  are  identifiable     Schizophrenia  Subtypes:  Paranoid  Type   • People  with  the  paranoid  type  of  schizophrenia  stand  out  because  of  their   delusions  or  hallucinations;  at  the  same  time,  their  cognitive  skills  and   affect  are  relatively  intact   • They  generally  do  not  have  disorganized  speech  or  flat  affect,  and  they   typically  have  a  better  prognosis  than  people  with  other  forms  of   schizophrenia   • The  delusions  and  hallucinations  usually  have  a  theme,  such  as  grandeur   or  persecution   • The  DSM  criteria  for  inclusion  in  this  subtype  specify  preoccupation  wit   one  or  more  delusions  or  frequent  auditory  hallucinations  but  without  a   marked  display  of  disorganized  speech,  disorganized  or  catatonic   behavior,  or  flat  or  inappropriate  affect     Schizophrenia  Subtypes:  Disorganized  Type   • People  with  the  disorganized  type  of  schizophrenia  show  marked   disruption  in  their  speech  and  behavior;  they  also  show  flat  or   inappropriate  affect,  such  as  laughing  in  a  silly  way  at  the  wrong  times   • They  also  seem  unusually  self-­‐absorbed  and  may  spend  considerable   amounts  of  time  looking  at  themselves  in  the  mirror   • H  tend  not  to  be  organized  around  a  central  theme,  as  in  paranoid  type   but  as  more  fragmented   • Tend  to  show  signs  of  difficulty  early,  and  their  problems  are  often   chronic,  lacking  the  remissions  that  characterize  other  forms  of  the   disorder     Schizophrenia  Subtypes:  Catatonic  Type   • In  addition  to  the  unusual  motor  responses  of  remaining  in  fixed   positions,  engaging  in  excessive  activity,  and  being  oppositional  by   remaining  rigid,  individual  with  catatonic  type  of  schizophrenia   sometimes  display  odd  mannerisms  with  their  bodies  and  faces,  including   grimacing   • They  often  repeat  or  mimic  the  words  of  others  (scholoalia)  or  the   movements  of  others  (echopraxia)   • This  cluster  of  behaviors  is  relatively  rare       Schizophrenia  Subtypes:  Undifferentiated  Type   • People  who  of  not  fit  neatly  into  these  subtypes  are  classified  as  having  an   undifferentiated  type  of  schizophrenia;  they  include  people  who  have  the   major  symptoms  of  schizophrenia  but  who  do  not  meet  the  criteria  for   paranoid,  disorganized,  or  catatonic  types     Schizophrenia  Subtypes:  Residual  Type   • People  who  have  had  at  least  one  episode  of  schizophrenia  but  who  no   longer  manifest  major  symptoms  are  diagnosed  as  having  the  residual   type  of  schizophrenia   • Residual  symptoms  can  include  social  withdrawal,  bizarre  thought,   inactivity,  and  flat  affect   • Research  suggests  that  the  paranoid  subtype  may  have  a  stronger  familial   link  than  other  and  that  these  people  may  function  better  before  and  after   episodes  of  schizophrenia  than  people  diagnosed  with  other  subtypes   • Crow  suggested  that  schizophrenia  can  be  dichotomized  into  two  types   based  on  a  variety  of  characteristics,  including  symptoms,  response  to   medication,  outcomes,  and  the  presence  or  absence  of  intellectual   impairment   • Type  I  is  associated  with  the  positive  symptoms  of  hallucinations  and   delusions,  a  good  response  to  medicayopm,  am  optimistic  prognosis,  and   the  absence  of  intellectual  impairment   • Type  II  includes  people  with  the  negative  symptoms  of  flat  affect  and   poverty  of  speech  (alogia),  who  show  a  poor  response  to  medication,  and   intellectual  impairments     Other  Psychotic  Disorders:  Schizophrenia  Disorder   • Some  people  experience  the  symptoms  of  schizophrenia  for  a  few  months   only;  they  can  usually  resume  normal  lives   • The  label  schizophreniform  disorder  classifies  these  symptoms   • The  DSM  diagnostic  criteria  for  schizophreniiform  disorder  include  onset   of  psychotic  symptoms  within  four  weeks  of  the  first  noticeable  change  in   unusual  behavior,  confusion  at  the  height  of  the  psychotic  episode,  good   premorbid  social  and  occupational  functioning,  an  the  absence  of  blunted   or  flat  affect     Other  Psychotic  Disorders:  Schizoaffective  Disorder   • Schizoaffective  disorder  individuals  tend  not  to  get  better  on  their  won   and  are  likely  to  continue  experiencing  major  life  difficulties  for  many   years  DSM  criteria  for  schizoaffective  disorder  require  that  in  addition  to   the  presence  of  a  mood  disorder  there  have  been  delusions  or   hallucinations  fro  a  least  two  weeks  in  the  absence  of  prominent  mood   symptoms     Other  Psychotic  Disorders:  Delusional  Disorder   • The  major  feature  of  delusional  disorder  is  a  persistent  belief  that  is   contrary  to  reality,  in  the  absence  of  other  characteristic  of  schizophrenia   • Individuals  tend  not  to  have  flat  affect,  anhedonia,  or  other  negative   symptoms  of  schizophrenia   • However,  they  may  become  socially  isolated  because  they  are  suspicious   of  others   • The  delusions  are  often  long-­‐standing,  sometimes  persisting  several  years   • DSM  recognizes  the  following  delusional  subtypes:  erotomanic,  grandiose,   jealous,  persecutory,  and  somatic   • An  erotomanic  delusion  is  the  mistaken  belief  someone  has  that  a  height-­‐ status  and  unsuspecting  person  is  in  love  with  him  r  her   • This  delusional  belief  often  motivates  the  patient  to  engage  in  an   unrelenting  pursuit  of  the  victim  in  attempts  to  communicate  with  him  or   her   • The  grandiose  type  of  delusion  involves  believing  in  one’s  inflated  worth,   power,  knowledge,  identity,  or  special  relationship  to  a  deity  or  famous   person   • A  person  with  the  jealous  type  of  delusion  involved  the  person  believing   that  he  or  she  is  being  malevolently  treated  in  some  way   • The  somatic  type  of  delusion,  the  person  feels  afflicted  by  a  physical   defect  or  general  medical  condition   • These  delusions  differ  from  the  more  bizarre  types  often  found  in  people   with  schizophrenia  because  in  delusional  disorder  the  imagined  events   could  be  happening  but  aren’t  in  schizophrenia,  however,  the  imagined   events  aren’t  possible   • Delusional  disorder  seems  to  be  relatively  rare   • The  onset  of  delusional  disorder  is  relatively  late  between  40-­‐49   • However,  because  many  people  with  this  disorder  can  lead  relatively   normal  lives,  they  may  not  seek  treatment  until  their  symptoms  become   most  disruptive   • Seems  to  afflict  more  females   • The  characteristics  of  suspiciousness,  jealousy,  and  secretiveness  may   occur  ore  often  among  relatives  of  people  with  delusional  disorder  than   among  the  population  at  large,  suggesting  some  aspect  of  this  disorder   may  be  inherited     Other  Psychotic  Disorders:  Brief  Psychotic  Disorder   • Brief  psychotic  disorder,  which  is  characterized  by  the  presence  f  one  or   more  positive  symptoms  such  as  delusions,  hallucinations,  or   disorganized  speech  or  behaviour  lasting  one  month  or  less   • Brief  psychotic  disorder  is  often  precipitated  by  extremely  stressful   situations     Other  Psychotic  Disorders:  Shared  Psychotic  Disorder  (Folie  a  Deux)   • Shared  psychotic  disorder  (folie  a  deux),  the  condition  in  which  an   individual  develops  delusions  simply  as  a  result  of  a  close  relationship   with  a  delusional  individual   • Suggested  that  shared  psychotic  disorder  occurs  in  pre-­‐disposed   individuals  who  become  socially  isolated  with  a  psychotic  person     Other  Psychotic  Disorders:  Schizotypal  Personality  Disorder   • Characteristics  are  similar  to  those  experienced  by  people  with   schizophrenia,  but  less  severe   • Evidence  also  suggests  that  schizophrenia  and  schizotypal  personality   disorder  may  be  genetically  related  as  part  of  a  “schizophrenia  spectrum”     Statistics   • Schizophrenia  is  generally  chronic,  and  most  people  with  the  disorder   have  a  very  difficult  time  functioning  in  society   • They  tend  not  to  establish  or  maintain  significant  relationships,  and   therefore  many  people  with  schizophrenia  never  marry  or  have  children   • The  delusions  of  people  with  schizophrenia  are  likely  to  be  outside  the   realm  of  possibility   • Finally,  even  when  individuals  with  schizophrenia  improve  with   treatment,  they  are  likely  to  experience  difficulties  throughout  their  lives   • Roughly  equivalent  for  men  and  women   • 0.2-­‐1.5%  in  the  general  population   • Life  expectancy  is  slightly  less  than  average,  partly  because  of  higher  rate   of  suicide  and  accidents  among  people  with  schizophrenia  but  also   because  of  higher  rates  of  obesity.  Smoking,  angina,  and  respiratory   problems  among  those  with  schizophrenia   • For  men,  the  likelihood  of  onset  diminishes  with  age   • The  onset  for  women  is  lower  than  for  men  until  age  36,  when  the  relative   risk  for  onset  switches,  with  more  women  than  men  being  affected  later   in  life   • Women  appear  to  have  more  favorable  outcomes  than  men     Development   • Research  suggests  that  children  who  later  develop  schizophrenia  show   some  abnormal  signs  before  they  display  the  characteristics  symptoms   • Their  emotional  reactions  may  be  abnormal,  with  less  positive  and  more   negative  affect  than  their  unaffected  siblings   • It  may  be  that  brain  damage  very  early  in  the  developmental  period   causes  later  schizophrenia   • The  damage  may  lie  dormant  until  later  in  development  when  the  signs  of   schizophrenia  first  appear   • Some  research  finds  that  people  with  schizophrenia  who  demonstrate   early  signs  of  abnormality  at  birth  and  during  early  childhood  tend  to  fare   better  than  people  who  do  not   • One  interpretation  of  these  results  is  that  the  earlier  the  damage  occurs,   the  more  time  the  brain  has  to  compensate  for  it,  which  results  in  milder   symptoms   • Older  adults  tended  to  display  fewer  of  the  positive  symptoms,  such  as   delusions  and  hallucinations,  and  more  negative  symptoms,  such  as   speech  and  cognitive  difficulties   • A  great  many  people  who  improve  after  an  episode  of  schizophrenia  later   experience  the  symptoms  again     Cultural  Factors   • Many  people  in  extremely  diverse  cultures  have  the  symptoms  of   schizophrenia,  which  supports  the  notion  that  it  is  a  reality  for  many   people  worldwide   • Schizophrenia  is  thus  universal,  affecting  all  racial  and  cultural  groups   studied   • The  course  and  outcome  of  schizophrenia  vary  from  culture  to  culture   • One  prospective  study  of  schizophrenia  among  different  ethnic  groups  in   London  found  that  although  the  outcomes  of  schizophrenia  appear   similar  across  various  ethnic  groups   • Blacks  were  more  likely  to  be  detained  against  their  will,  brought  to  the   hospital  by  police,  and  given  emergency  injections   • The  differing  rated  of  schizophrenia,  therefore,  may  be  due  to   misdiagnosis  rather  than  to  any  real  cultural  distinctions   • Minority  ethnicity  to  be  associated  with  an  increased  risk  for  psychiatric   hospitalization     Genetic  Influences   • Genes  are  responsible  for  making  some  individuals  vulnerable  to   schizophrenia     Family  Studies   • Kallmann  showed  that  the  severity  of  the  parent’s  disorder  influenced  the   likelihood  of  the  child’s  having  schizophrenia:  The  more  severe  the   parent’s  schizophrenia,  the  more  likely  the  children  were  to  develop  it   also   • Another  observation  was  important:  All  forms  of  schizophrenia  were  seen   within  the  families   • You  may  inherit  a  general  predisposition  for  schizophrenia  that  manifests   in  the  same  form  or  a  different  one  from  that  of  your  parent   • There  appears  to  be  some  familial  risk  for  a  spectrum  of  psychotic   disorders  related  to  schizophrenia   • The  risk  of  having  schizophrenia  varies  according  to  how  many  genes  an   individual  shares  with  someone  who  has  the  disorder     Twin  Studies   • If  the  environment  is  solely  responsible  for  schizophrenia,  we  would   expect  little  difference  between  identical  and  fraternal  twins  with  regard   to  this  disorder   • If  only  genetic  factors  are  relevant,  both  identical  twins  would  always   have  schizophrenia  and  the  fraternal  twins  would  both  have  it  about  50%   of  the  time   • Research  from  twin  studies  indicates  that  the  truth  is  somewhere  in  the   middle   • Even  siblings  who  are  very  close  in  every  aspect  of  their  lives  can  still   have  considerably  different  experiences  physically  and  socially  as  they   grow  up,  which  may  result  in  vastly  different  outcomes     Adoption  Studies   • Something  other  than  living  in  the  home  of  a  person  with  schizophrenia   must  account  for  this  disorder     The  Offspring  of  Twins   • Twin  and  adoption  studies  strongly  suggest  a  genetic  component  for   schizophrenia   • Data  clearly  indicate  that  you  ca
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