Chapter 14: Schizophrenia and Other Psychotic Disorders
The disorder is characterized by an array of diverse symptoms, including
extreme oddities in perception, thinking, action, sense of self and manner of
relating to others.
The hallmark of schizophrenia is psychosis: a significant loss of contact with
The Epidemiology of Schizophrenia
Schizophrenia is about as prevalent as epilepsy.
The suffering of the person with schizophrenia is often readily apparent, as are
bizarre behaviour and unusual appearance.
Children whose fathers are older at the time of their birth have 2-3 times higher
chance of developing schizophrenia.
1 out of every 100 people living until at least age 55 will develop schizophrenia
High in western Ireland and Croatia, and low in Papua New Guinea
Vast majority of cases begin in late adolescence and early adulthood, rarely
found in children.
Begins earlier in men than in women. Average onset for men-25 women-29
Also believed men develop worse cases than women.
May be less prevalent in women because the sex hormones (estrogen) play some
Origins of the Schizophrenia Construct
First clinical description of Schizophrenia was offered in 1810 by John Haslam
First case was of James Tilly Matthews, a married man with 2 children.
Second case was of a 13 year old boy, was described as Demence Precoce –
mental deterioration at an early age.
The careful description of what we now call schizophrenia was discovered by
The clinical term Schizophrenia was developed by Eugen Bleuler. “Schizien”
meaning to split and “phren” meaning mind because he believed the condition
was characterized primarily by disorganization of thought processes, a lack of
coherence between thought nd emotion and an inward orientation away (split
off) from reality.
The Clinical Picture in Schizophrenia
Delusions Delusion: an erroneous belief that is fixed and firmly held despite clear
o Comes from Latin verb ludere, meaning “to play”
In essence, tricks are played on the mind
A disturbance in the content of thought
Common in schizophrenia, but not all people who have delusions have
Prominent among these are beliefs are:
o That one’s thoughts, feelings and actions are being controlled by external
agents (made feelings or impulses)
o That one’s private thoughts are being broadcasted indiscriminately to
others (thought broadcasting)
o Thoughts are being inserted into one’s brain by an external agent
o Or that some external agent has robbed one of one’s thoughts (thought
Also common among delusions are delusions of reference: which are when
some neutral environmental event (TV show or song on radio) is believed to
have special and personal meaning intended only for the patient.
Also common, delusions of bodily changes: organs do not work, or removal of
organs is thought to be necessary.
Hallucination: a sensory experience that occurs in the absence of any external
Can occur in any of the 5 senses.
Auditory hallucinations are the most common (hearing voices) in schizophrenic
Patients can become emotionally involved in their hallucinations, often
incorporating them into their delusions.
Patients may also act on their hallucinations and do what the voices tell them to
Voices can be of people the person actually knows, as well as the Devil.
Hallucinating patients show increased activity in Broca’s area of the Brain- an
area of the temporal lobe that is involved in speech production.
Research findings suggest that auditory hallucinations occur when patients
misinterpret their own self-generated and verbally mediated thoughts (inner
speech or self-talk) as coming from another source.
Disorganized speech is the external manifestation of a disorder in thought form.
Affected person fails to make sense, despite seeming to conform to the semantic
and syntactic rules governing verbal communication. Words and word combinations sound communicative, but the listener is left with
little or no understanding of the point the speaker is trying to make.
Sometimes make up new words – known as “neologisms”
Disorganized and Catatonic Behaviour
Goal directed behaviour most disrupted in schizophrenic patients
Impairment in daily functioning – disruption in “executive” behaviours due to
impairment in the functioning of the prefrontal region of the cerebral cortex.
Catatonia – behavioural disturbance involving a virtual absence of all movement
and speech and patient is in what is called a catatonic stupor.
Two general symptom patterns/syndromes of schizophrenia have been
o Positive syndrome schizophrenia
o Negative syndrome schizophrenia
Positive symptoms: are those that reflect an excess or distortion in a normal
repertoire of behaviour and experiences such as delusions and hallucinations.
Negative symptoms: reflect an absence or deficit of behaviours that are
o Flat or blunted emotional expressiveness
o Alogia (very little speech)
o Avolition (unable to act in goal directed behaviour)
Most patients exhibit both symptoms, a preponderance of negative symptoms in
the clinical picture is not a good sign for the patient’s future outcome.
Both can co-occur
Subtypes of Schizophrenia
o Preoccupation with delusions or frequent auditory hallucinations
o No evidence of marked disorganized speech, disorganized or catatonic
behaviour, flat or inappropriate affect.
o Increasing suspiciousness and severe difficulties in interpersonal
o Become emotionally indifferent and infantile and may display odd facial
grimaces, talk and gesture to themselves and break into a sudden,
inexplicable laughter and weeping.
o Disorganized speech
o Disorganized behaviour
o Flat or inappropriate affect
o No evidence of catatonic schizophrenia Catatonic Type
o Pronounced motor signs, either of an excited or a stuporous type.
o Highly suggestible and will automatically obey commands or imitate the
actions of others (echopraxia) or mimic their phrases (echolalia)
o The clinical picture is dominated by at least 2 of the following:
Immobile body or stupor
Excessive motor activity that is purposeless and unrelated to
Extreme negativism (resistance to being moved, or o follow
instructions) or mutism
Assumption of bizarre posture, or stereotypes movements or
o Symptoms of schizophrenia that do not meet criteria for the Paranoid,
Disorganized, or Catatonic types
o Wastebasket category
o Suffered at least one episode of schizophrenia but do not show any
prominent positive symptoms.
o Continued evidence of schizophrenia, or mild psychotic symptoms.
Other Psychotic Disorders
o At some time there is either a major depressive episode, a manic episode,
or a mixed episode ha co-occurs with symptoms of schizophrenia
(delusions, hallucinations, and disorganized speech/ behaviour, negative
o During the illness, there must be a period of at least two weeks where
delusions and hallucinations have been present without mood symptoms.
o The mood symptoms are present for a substantial proportion of the total
o Symptoms of schizophrenia
o An episode of the disorder (including the prodromal, active, and residual
phases) that lasts at least one month but less than 6 months
o Non-bizarre delusions (situations that could occur in real life) that last for
at least one month.
o No evidence of full-blown schizophrenia
o Apart from the delusion, the person’s functioning is not markedly
impaired; neither is behaviour obviously odd or bizarre.
Brief Psychotic Disorder
o Presence of one of the following: Delusions, hallucinations, disorganized speech/behaviours or
o The episode lasts for at least 1 day but less than 1 month, with an eventful
full return to normal functioning.
o A diagnosis of mood disorder with psychotic features; schizoaffective
disorder or schizophrenia is ruled out.
Shared Psychotic Disorder (folie à deux)
o A delusion develops in the context of a close relationship with another
person who already has an established delusion.
o The delusion is similar in content to that of the person who already has
the established delusion.
o Other psychotic disorders are ruled out.
What Causes Schizophrenia?
Found that there was a strong association between closeness of blood
relationship and risk for developing the disorder.
Higher concordance rates for schizophrenia among identical, or monozygotic
Reduction in shared genes reduces the risk of schizophrenia by nearly 80%.
The disease is not an exclusively genetic disorder
Two conclusions from twin studies:
o Genes play a role in causing schizophrenia
o Genes themselves are not the whole story
In the adoption studies, concordance rates for schizophrenia are compared for
the biological and the adoptive relatives of persons who have been adopted out
of their biological families at an early age (preferably at birth) and have
subsequently developed schizophrenia.
o If concordance rate is greater among the patients’ biological than among
adoptive relatives, a hereditary influence is strongly suggested; the
reverse pattern would argue for environmental causation.
Findings from these studies indicate a strong interaction between genetic
vulnerability and an unfavourable family environment in the causal pathway
leading to schizophrenia.