PSYB32H3 Chapter 11: ch.11 for PSYB32
19 Jul 2010
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Chapter 11: schizophrenia
• Psychotic disorder characterized by major disturbances in though, emotion and behavior: disordered thinking in which
areas are not logically related, faulty perception and attention, flat or inappropriate affect, and bizarre disturbances in
motor activity
• Schizophrenics withdraw from people and reality into a fantasy life of delusions and hallucinations
• Estimates of prevalence in the general population vary b/w 0.2% and 2% (dependent upon measurement instrument
• Life time prevalence is accepted to be about 1%
• Lifetime prevalence of all psychotic disorders exceed 3% with prevalence for schizo of 0.87%
• A meta-analysis of prevalence and incidence rates conducted by Canadian researchers concluded that there may be
real variation in schizo across geographical regions around the world, with Asian populations having he lowest
prevalence rates
• Incidence is significantly higher in males than in females (1:4 ratio)
• Sometimes begins in childhood, usually appears in late adolescence or early adulthood, somewhat earlier for men than
for women
• People with schizo have number of acute episodes of their symptoms
• b/w episodes they often have less severe but still very debilitating symptoms
• People can be treated in the community or hospitalization is sometimes necessary
• People who were first diagnosed while inpatients and hose residing in rural areas were more likely to require
additional inpatient services in the first year of treatment
• In Canada, Hospitalization rates are much higher in young men relative to young women
• Schizo accounts for 39% of separations from psychiatric hospitals; 10% of people with it commit suicide\many people
with it remain chronically disabled/ disability can be attributed to symptoms inherent to schizo, as well as the co
morbid disorders from which approximately 50% of those schizo suffer
Schizo and Comorbidity
• Comorbid substance abuse is a major problem for patients with schizo (according in 70% of them)
• Childhood conduct disorder problems are potent risk factors for substance use disorders in schizo
• 40% people depressed at onset; more likely to use relapse-related mental health services, o be a safety concern, to
have substance-related problems, and report poorer life satisfaction, quality of life, mental functioning, family
relationships and medication adherence (after three years of study)
• co morbid anxiety disorders are also common and can impose an additional burden on people with schizo and result in
further decline in their perceived quality of life
• co morbidity with OCD is also related o previous history of suicidal ideation and suicide attempts
• PTSD is highly prevalent and under diagnosed among military veterans with schizo
• co morbidity during developing (prodromal) phase of schizo
• Prospectively identified prodromal patients experience a wife variety of co morbid psychiatric syndromes, especially
major depressive disorder and cannabis dependence
CLINICAN SYMPTOMS OF SCHIZOPHRENIA
Positive Symptoms: comprise excesses or distortions such as disorganized speech, hallucinations and delusions; define
acute episodes of schizo; they are the presence of too much of a behaviour that is not apparent in most people
# Disorganized speech aka thought disorder: problems in organizing ideas and in speaking so that a listener understand
o Incoherence in conversations; repeated references to central idea but imagines and fragments of thought are not
connected
o Loose associations or derailment: patient may be more successful in communicating with a listener but has difficulty
sticking to one topic; they seem to drift off on a train of associations evoked by an idea from the past
o Speech of many patients is not disorganized and that the presence of disorganized speech does not discriminate well
b/w schizo and other psychoses such as mood disorders
# Delusions: beliefs help contrary to reality; patient may be unwilling recipient of bodily sensations or thoughts
imposed by an external agency; they believe that their thoughts are broadcast or transmitted so others know what they
are thinking; they think their thoughts are being stolen from them by an external force; some believe that their feelings
are controlled by an external force; some believe that their behaviour is controlled by an external force; some believe
that their impulses to behave in a certain way are imposed on them by some external force
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# Hallucinations: sensory experiences in the absence of any stimulation from the environment; more often auditory than
visual
o Some patients report heading their own thoughts spoken by another voice; some claim that they hear voices arguing
and some hear voices commenting on their behaviour
Negative symptoms are the absence of a behaviour that should be evident in most people; behaviour deficient’s; presence
of these are strong predictors of poor quality of life two years following hospitalization; associated with earlier onset brain
damage and progressive loss of cognitive skills
# Avolition aka apathy refers to lack of energy and seeming absence of interest in or an inability to persist in what are
usually routine activities
# Agolia: poverty of speech: amount of speech is reduced; poverty of content of speech: among of discourse is adequate
but it conveys little info and tends to be vague and repetitive
# Anhedonia: an inability to experience pleasure; lack of interest in recreational activities, failure to develop close
relationships with other people, and lack of interest in sex; patients are aware of this symptom and report that
normally pleasurable activities are not enjoyable to them
# Flat Affect: no stimulus can elicit an emotional response; the patient stares vacantly, muscles of the face flaccid, and
eyes lifeless; when spoken to they answer in a flat and toneless voice; concept refers only to the outward expression of
emotion and not to the patient’s inner experience which may not be impoverished at all
# Asociality: severely impaired social relationships; they do poorly on facial affect recognition and facial recognition
tasks
Catatonia: motor abnormalities; some have unusual increase in overall level of activity others have catatonic immobility
in which patients adopt unusual postures and maintain them for very long periods of time; they also have waxy flexibility
whereby another person can move the patient’s limbs into strange positions that they maintain for extended periods
Inappropriate affect: emotional responses of these people re out of context; they shift from one emotional state to another
for no discernible reason; specific to schizophrenia
History Of the concept of schizo
# Formulated by Kraepelin and Bleuer: Dementia praecox earlier term for it
# The DSM IV requires at least 6 months of disturbance for the diagnosis; this period must include at least one month of
active phase which is defined by the presence of at least two of the following: delusions, hallucinations, disorganized
speech, grossly disorganized or catatonic behaviour and negative symptoms (only one of these symptoms is required
if the delusions are bizarre or if the hallucinations consist of voices commenting or arguing)
# Remaining time in the 6 months can be either prodormal (b4 the active phase) or a residual (after the active phase)!
the problems in these two phases include social withdrawal, impaired role functioning, blunted or inappropriate affect,
lack o initiative, vague and circumstantial speech, impairment in hygiene and grooming, odd beliefs or magical
thinking and unusual perceptual experience
# Symptoms of schizophreniform disorder are the same as those of schizo but last only from one to six months
# Brief psychotic disorder lasts from one day to one month and is often brought on by extreme stress
# Delusional disorder: person is trouble by persistent persecutory delusions or by delusional jealousy which is the
unfounded conviction that a spouse or a lover is unfaithful; there are delusions of being followed, somatic delusions,
erotomania delusions (believing that one is loved by some famous stranger)
# Person with delusional disorder does not have disorganized speech or hallucinations and their delusions are less
bizarre; runs in the family
# Patients in developing countries have more acute onset and more favourable course than those in industrialized
countries
CATEGORIES OF SCHIZOPRENIA IN DSM-IV-TR
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Disorganized (Hebephrenic)
# Speech is disorganized and difficult for listener to follow; they speak incoherently, stringing together similar-
sounding words and even inventing new words, often accompanied by silliness or laughter; they have flat affect or
experience constant shifts of emotion, breaking into inexplicable fits of laughter and crying
# Behaviour is disorganized and not goal directed
# They deteriorate to point of incontinence, voiding anywhere and at any time and complete neglect appearance, never
bath/brush their teeth or comb their hair
Catatonic Schizophrenia:
# Patients alternate b/w catatonic immobility and wild excitement but one of these symptoms may predominate
# They resist instructions and suggestions and often echo the speech of others
# Onset may be more sudden then any other form of schizo, although the person is likely to have previously shown
some apathy and withdrawal from reality
Paranoid
# Presence of prominent delusions; delusions of persecution are most common, but patients experience grandiose
delusions in which they have exaggerated sense of their own importance, power, knowledge or identity
# Delusional jealousy: unsubstantial belief that their sexual partner is unfaithful
# Vivid auditory hallucinations may accompany the delusions
# Ideas of reference: they incorporate unimportant events within a delusional framework and read personal significance
into the trivial activities of others
# They are agitated, argumentative, angry and sometimes violent
# Remain emotionally responsive, although they may somewhat stilted, formal and intense with others
# More verbal and alert than patients with other types of schizo
# Language is not disorganized
Evaluation of subtypes:
# undifferentiated schizo applies to patients who meet diagnostic criteria for schizo but not criteria for any of the three
subtypes
# residual schizo is used when patient no longer meets the full criteria for schizo but still shows some signs of the
illness
# executive subtype: impairment in Wisconsin card sorting test
# executive motor subtype: had deficit in card sorting and motor functioning
# motor subtype: deficits only in motor functioning
# dementia subtype: pervasive and generalized cognitive impairment
o these subset differs on other variables such as length of illness and extent of hospitalization
o most of neurocognitive and functional differences persisted over time and even though there were no apparent
symptom differences among the subtypes
o continuing focus of neuropsychological differences in the future research may provide some important insights into
heterogeneity of schizo
# Heinrichs identified explanations of why there is a link between schizo and cognition
o illness-related brain disturbance that could have a pervasive influence on brain systems that are active in information
processing
o cognitive deficits reflect genetically determined constraints
o influence of chronic stress and distress on cognition in people prone to schizophrenia
ETIOLOGY OF SCHIZOPHRENIA
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