Chapter 11: Schizophrenia
• Schizophrenia is a psychotic disorder characterized by major
disturbances in thoughts, emotions, and behaviour: disordered
thinking in which ideas are not logically related, faulty perception
and attention, flat or inappropriate affect, and bizarre
disturbances in motor activity.
• Hospitalization rates are typically much higher among young
men relative to young women. About 10% of people with
schizophrenia commit suicide.
• Despite recent advances in treatment, many people with
schizophrenia remain chronically disabled. The disability can be
attributed to symptoms inherent to schizophrenia, as well as the
comorbid disorders from which approximately 50% of those with
Schizophrenia and Comorbidity
• Comorbid personality disorders (e.g. avoidant, paranoid,
dependent, and antisocial) are common and have implications
for the course and clinical management of schizophrenia, that
treatment should include evaluation of co-occurring substance
use disorders (especially alcohol and cannabis abuse or
dependence) and that attention to associated mood (especially
Major Depression Disorder) and anxiety syndromes (particularly
social phobia) may be important for “optimal” outcomes.
• Comorbid substance abuse is a major problem for people with
• Comorbidity with OCD is also related to a previous history of
suicidal ideation and suicide attempts.
Clinical Symptoms of Schizophrenia
• The symptoms of people with schizophrenia involve disturbances
in several major areas: thought, perception, and attention; motor
behaviour; affect or emotion; and life functioning.
• No essential symptom must be present for a diagnosis of
schizophrenia. Thus, people with schizophrenia can differ from
each other more than do people with other disorders.
• Positive symptoms comprise excess or distortions, such as
disorganized speech, hallucinations, and delusions. They are
what define, for the most part, an acute episode of schizophrenia. Positive symptoms are the presence of too much
of a behaviour that is not apparent in most people. While the
negative symptoms are the absence of a behaviour that should
be evident in most people.
• Also known as formal thought disorder, disorganized speech
refers to problems in organizing ideas and in speaking so that a
listener can understand.
• Speech may also be disordered by what are called loose
associations, or derailment. In these cases, the person may be
more successful in communicating with a listener but has
difficulty sticking to one topic.
• Disturbances in speech were at one time regarded as the
principal clinical symptoms of schizophrenia, and they remain
one of the criteria for the diagnosis.
• Delusions, beliefs held contrary to reality, are common positive
symptoms of schizophrenia.
• The following descriptions of these delusions are draw from
- The person may be the unwilling recipient of bodily sensations
of thoughts imposed by an external agency.
- People may believe that their thoughts are broadcast or
transmitted, so that others know what they are thinking.
- People may think their thoughts are being stolen from them,
suddenly and unexpectedly, by an external force.
- Some people believe that their feelings are controlled by an
- Some people believe that their behaviour is controlled by an
- Some people believe that impulses to behave in certain ways
are imposed on them by some external force.
Hallucinations and Other Disorders of Perception
• The most dramatic distortion of perception are hallucinations,
sensory experiences in the absence of any stimulation from the
• Some people with schizophrenia report hearing their own
thoughts spoken by another voice.
• Some people claim that they hear voices arguing.
• Some people hear voices commenting on their behaviour. Negative Symptoms
• The negative symptoms of schizophrenia consist of behavioural
deficits, such as avolition, alogia, anhedonia, flat affect, and
• There is also some evidence that negative symptoms are
associated with earlier onset of brain damage (e.g. enlarged
ventricles) and progressive loss of cognitive skills.
• Apathy or avolition refers to a lack of energy and a seeming
absence of interest in or an inability to persist in what are usually
• A negative thought disorder, alogia can takes several forms. In
poverty of speech, the sheer amount of speech is greatly
reduced. In poverty of content of speech, the amount of
discourse is adequate, but it conveys little information and tends
to be vague and repetitive.
• An inability to experience pleasure is called anhedonia. It is
manifested as a lack of interest in recreational activities, failure
to develop close relationships with other people, and lack of
interest in sex. Clients are aware of this symptoms are report
that normally pleasurable activities are not enjoyable for them.
• In people with flat affect, virtually no stimulus can elicit an
emotional response. The client may stare vacantly, the muscles
of the face flaccid, the eyes lifeless. When spoken to, the client
answers in a flat and toneless voice.
• Some people with schizophrenia have severely impaired social
relationships, a characteristic referred to as asociality. They have
few friends, poor social skills, and little interest in being with
other people. Catatonia
• Catatonia is defined by several motor abnormalities.
• At the other end of the spectrum is catatonic immobility: clients
adopt unusual postures and maintain them for very long periods
• Catatonic people may also have waxy flexibility, whereby
another person can move the person’s limbs into strange
positions that they maintain for extended periods.
• Some people with schizophrenia have inappropriate affect. The
emotional response of these individuals are out of context; for
example, the client may laugh on hearing that his or her mother
just died or become enraged when asked a simple question
about how a new garment fits.
History of The Concept of Schizophrenia
• The concept of schizophrenia was formulated by two European
psychiatrists, Emil Kraepelin and Eugen Bleuler. Kraepelin first
presented his notion of dementia praecox the early term for
schizophrenia in 1898.
• Dementia praecox included several diagnostic concepts –
dementia paranoids, catatonia, and hebephrenia – that had been
regarded as distinct entities by clinicians in previous decades.
• The “dementia” in dementia praecox is not the same as the
dementias we discuss in the chapter on aging, defined principally
by severe memory impairments.
The Historical Prevalence of Schizophrenia
• The concept of schizophrenia was further broadened by three
additional diagnostic practices:
1. U.S clinicians tended to diagnose schizophrenia whenever
delusions or hallucinations were present. Because these
symptoms, particularly delusions, occur also in mood disorders,
many people with a DSM-II diagnosis of schizophrenia may
actually have had a mood disorder.
2. People whom we would now diagnose as having a personality
disorder were diagnosed as having schizophrenia according to DSM-II criteria.
3. People with an acute onset of schizophrenic symptoms and a
rapid recovery were diagnosed as having schizophrenia.
The DSM-IV-TR Diagnosis
• DSM-IV-TR requires at least six months of disturbance for the
diagnosis. The six-month period must include at least one month
of the active phase, which is defined by the presence of at least
two of the following: delusions, hallucinations, disorganize
speech, grossly disorganized catatonic behaviour, and negative
• A person with delusional disorder is troubled by persistent
persecutory delusions or by delusional jealousy, which is the
unfounded conviction that a spouse or lover is unfaithful. There
are also delusions of being followed, somatic delusions (believing
that some internal organ is malfunctioning) and delusions of
erotomania (believing that one is loved by some other person,
usually a complete stranger with a higher social status.
DSM-Proposal For Psychotic Risk Syndrome and Symptom Dimensions
• Psychosis risk syndrome: Syndrome proposed by DSM-5 work
group to identify young people at risk of developing
schizophrenia or other psychoses.
• Kraepelin’s hebephrenic form of schizophrenia is called
disorganized schizophrenia in DSM-IV-TR. Speech is disorganized
and difficult for a listener to follow.
• The most obvious symptoms of catatonic schizophrenia are the
catatonic symptoms described earlier. Clients typically alternate
between catatonic immobility and wild excitement, but one of
these symptoms may predominate. These clients resist
instructions and suggestions and often echo (repeat back) the
speech of others.
• The diagnosis paranoid schizophrenia is assigned to a substantial
number of recently admitted clients to psychiatric hospitals. The
key to this diagnosis is the presence of prominent delusions. Delusions of persecution are most common, but clients may
experience grandiose delusion, in which they have an
exaggerated sense of their own importance, power, knowledge,
or identity. Some clients are plagued by delusional jealousy, the
unsubstantiated belied that their partner is unfaithful.
• Clients with paranoid schizophrenia often develop ideas of
reference; they incorporate unimportant events within a
delusional framework and read personal significance into the
trivial activities of others.
Evaluation of the Subtypes
• Undifferentiated schizophrenia applies to people who meet
the diagnostic criteria of schizophrenia but not the criteria for
any of the three subtypes. The diagnosis of residual
schizophrenia is used when the client no longer meets the full
criteria for schizophrenia but still shows some signs of the
Etiology of Schizophrenia
• The negative symptoms of schizophrenia appear to have a
stronger genetic component.
• Children reread without contact with their so-called
pathogenic mothers were still more likely o become
schizophrenic than were the control participants.
• It does not appear that the genetic predisposition to
schizophrenia is transmitted by a single gene; several multi-
or polygenic models remain viable.
• The hunt for schizophrenia-related gens has proven more
difficult than expected for several reasons, including:
1. Lack of preciseness in defining the boundaries of the clinical
2. Absence of biological tests that confirm diagnostic
3. Clinical heterogeneity and the complex nature of schizophrenia. • Endophenotypes are characteristics that reflect the actions of
genes predisposing an individual to a disorder, even in the
absence of diagnosable pathology.
• The theory that schizophrenia is related to excess activity of
dopamine is based principally on the knowledge that drugs
effective in treating schizophrenia reduce dopamine activity.
• The dopamine receptors that are blocked by first-generation or
conventional antipsychotics are called D2 receptors.
• Further indirect support for the dopamine theory comes from the
literature on amphetamine psychosis. Amphetamines can
produce a state that closely resembles paranoid schizophrenia.