Chapter 11: Schizophrenia
If you are unable to tell the difference between what is real and what is unreal, you are
suffering from psychosis.
One of the most common psychotic disorders is schizophrenia, which consists of unreal
or disorganized thoughts and perceptions as well as verbal, cognitive, and behavioural
In Canada, 0.5% - 2.0% of the population has been diagnosed with a schizophrenia-
o Schizophrenia, schizoaffective disorder, delusional disorder…
Nearly half (41%) are in jails, prisons, homeless shelters, hospitals, nursing homes, etc.
Incidences of schizophrenia tend to be higher among immigrants than native-born
Schizophrenia may be more common in men, although gender differences vary among
studies and with the criteria used to diagnose schizophrenia.
o Women with schizophrenia tend to have better premorbid histories than men.
o More likely to graduate high school or university, to have married with children,
and to have developed good social skills.
o Onset for women is later (late 20s, early 30s) than it is for men (late teens, early
o Women show fewer cognitive deficits than men, particularly in verbal processing.
Reasons for gender differences may be due to estrogen, which regulates dopamine, which
is a component of schizophrenia.
o May also be due to the pace of prenatal brain development; it is hormonally
regulated, so slower for males.
Symptoms, Diagnosis, and Prognosis of Schizophrenia…
o Two categories of symptoms:
Positive (type I symptoms) are the presence of unusual perceptions,
thoughts, or behaviours. These symptoms represent very salient
Include delusions, hallucinations, disorganized thought and speech,
and disorganized or catatonic behaviour.
Can occur in other disorders as well, particularly in depression and
Many people with schizophrenia are also depressed or show mood
If psychotic symptoms appear during periods of clear mania or
depression, it is mood disorder with psychotic features.
If psychotic symptoms appear in the absence of depression or
mania, or if the mania or depression doesn’t meet the criteria for a
mood disorder, it is schizophrenia or schizoaffective disorder.
Delusions are ideas that an individual believes are true but are highly
unlikely and often simply impossible. People often hold beliefs that are likely to be wrong, such as
winning the lottery, but those are called self-deceptions.
Self-deceptions are not completely implausible; delusions often
Self-deceptions may be thought of occasionally; delusions are all
People with self-deceptions often acknowledge they’re wrong;
people with delusions are extremely resistant to counter-
A persecutory delusion is heard about the most; it’s the belief that
they are being watched or tormented by people they know (e.g.
professors, agencies, etc.).
A delusion of reference is the belief that random events or
comments by others are directed at them (e.g. the local news
anchor is reporting on their movements, etc.).
A grandiose delusion is the belief that one is a special person or
being or possesses special powers. May believe they are the most
intelligent, insightful and creative person on the earth, etc.
A delusion of thought insertion is the belief that one’s thoughts
are being controlled by outside forces.
Delusions can be simple and transient, but are often complex and
The different kinds of delusions can occur at the same time.
Content of delusions may differ across cultures.
White people may fear prosecution from the government, while
Caribbean people may think people are trying to kill them with
In Japan = delusions of slander and that someone knows something
horrible about them.
German and Austrian people = fear that they’ve committed a sin.
A belief being odd doesn’t make it a delusion unless it is odd
within the culture.
Hallucinations are unreal perceptual experiences.
Sometimes unreal experiences happen to people, however, they are
usually during times of stress, when they’re tired, or under the
An auditory hallucination is the most common type of
hallucination (e.g. hearing voices, music, etc.), and is more
common in women than men. Often times they hear voices
accusing them of evil deeds or threatening them. Voices may also
tell them to harm themselves.
A visual hallucination is often accompanied by an auditory
Hallucinations can also involve any sensory modality; tactile
hallucinations = perception that something is happening to the outside of one’s body (e.g. bugs crawling up the back), and
somatic hallucinations = perception that something is happening
inside one’s body (e.g. worms are eating one’s intestines).
Content of hallucinations varies by culture.
Disorganized thinking of people with schizophrenia is referred to as
formal thought disorder.
One of the most common forms of disorganization is a tendency to
slip from one topic to a seemingly unrelated topic with little
coherent transition, often referred to as loosening of associations,
A Person with schizophrenia may answer questions with comments
that are barely related to the question.
o At times it is so disorganized and incoherent it is referred to
as a word salad.
Neologisms = make up words that only mean
something to them.
Clangs = make associations based on the sounds of
words, rather than the content of the word.
May perservate; stay on the same word or
People with schizophrenia have difficulty in a wide range of
o Deficits in smooth pursuit eye movement (AKA eye
tracking); keep head still and track a moving object.
o This suggests deficits in fundamental attention processes.
o May not have anything to do with schizophrenia; study
found that people were impaired no matter how severe their
People with schizophrenia often show deficits in working
o Hold information in memory and manipulate it.
o Results in them being unable to suppress unwanted or
irrelevant information or to pay attention to relevant
o Basically, find it hard to identify their thoughts, and ignore
stimuli that are not relevant to what they are thinking.
o Also impairs retrieval and learning new information.
These deficits may contribute to issues in reasoning,
communication and problem solving.
Men tend to show more severe deficits in language compared to
o Argued that language is controlled more bilaterally in
women than men.
o Therefore, women can compensate.
Disorganized and Catatonic Behaviour
May display unpredictable and apparently untriggered agitation. o Suddenly shouting and swearing, etc.
o May engage in socially inappropriate behaviour, such as
masturbating in public.
Many are disheveled and dirty.
o E.g. too many clothes on a hot day, too few on a cold day.
Often have trouble with daily routines.
o E.g. bathing, brushing teeth, etc.
Catatonia = disorganized behaviour that reflect an extreme lack of
responsiveness to the outside world.
o Catatonic excitement = person becomes wildly agitated
for no apparent reason and is difficult to subdue.
May articulate delusions or hallucinations, and be
Negative (type II symptoms) represent losses or deficits in certain domains.
They involve the absence of behaviours rather than the presence of
o Severe reductions in, or even complete absence of,
o AKA blunted affect.
o People often speak in a monotone voice, no emotional
responses, and may not make eye contact with others.
o It is a lack of overt emotional expression.
Study showed that areas of the brain still lit up, they
just can’t express it.
o Poverty of speech. Reduction in speaking.
o May give brief, empty replies.
o Could be due to a lack of motivation.
o Inability to persist in common, goal-directed activities.
o Disorganized and careless.
o May sit around and do nothing; may become socially
Negative symptoms of schizophrenia may be difficult to diagnose,
o They involve an absence of behaviours, rather than the
presence of them, making them more difficult to detect.
o They lie on a continuum between normal and abnormal,
rather than being clearly bizarre.
o Things other than schizophrenia, such as mood disorders or
a side-effect of medication can cause them.
o Other symptoms
Such as laughing at sad things or crying at happy things. This could happen because they’re thinking about and responding
too other things outside the environment.
Could also happen because pathways between stimuli and proper
responses aren’t working properly.
A loss of interest in everything in life.
Lose the ability to experience emotion.
Impaired Social Skills
E.g. difficulty holding relationships, holding a job, etc.
May be due to negative symptoms, rather than the positive
People with a lot of negative symptoms have:
o Lower educational achievements
o Less success in holding jobs
o Poorer prognosis
Negative symptoms are less responsive to medication.
o Has been recognized since the early nineteenth century.
o Emil Kraepelin = most comprehensive and accurate description of schizophrenia.
First labeled dementia praecox because he believed it to be a premature
deterioration of the brain.
Viewed it as progressive, irreversible and chronic.
Definition was a narrow one.
o Eugen Bleuler disagreed with Kraepelin that it developed at a younger age.
He named it “schizo” = split and “phrenia” = mind.
Believed that it was a splitting of mental associations, thoughts, and
emotions, NOT a splitting of personalities (like DID).
Broader view of the disorder.
o In early twentieth century, US took Bleuler’s version; Europe stayed with
o In 1980, the DSM took a more narrow definition of schizophrenia.
Must show symptoms for at least six months.
During six months, there must be:
At least one month of acute symptoms, during which two or more
broad symptoms occur enough to impair functioning.
o Prodromal symptoms = present before people go into the acute (active) phase.
o Residual symptoms = present after they come out of the acute (active) phase.
o During these phases, people may experience beliefs that are delusional but not
o May have strange perceptual experiences.
o May speak oddly, but remain coherent.
o Negative symptoms are especially prominent during these phases.
o During prodominal phase, family members may feel individual is “slipping
o Schizoaffective disorder = mix of schizophrenia and mood disorders. With evidence that schizophrenic symptoms are present when the mood
disorder is absent.
Must also experience both at once.
E.g. major depression and hallucinations.
o Difference between schizoaffective disorder and mood disorder with psychotic
features is that schizoaffective disorder has hallucinations and delusions without
mood symptoms for at least two weeks.
o Diagnosis of schizoaffective disorder is a controversial one.
o Type I schizophrenia = positive symptoms are much more prominent than
o Type II schizophrenia = negative symptoms are much more prominent than
o Five subtypes of schizophrenia
People have prominent delusions and hallucinations that involve
themes of persecution and grandiosity.
Many do not show grossly disorganized speech or behaviour.
May be lucid and articulate, with elaborate stories of how people
are after them.
People are highly resistant to any arguments against their
Combination of persecutory and grandiose delusions can lead
people with this type of schizophrenia to be suicidal or violent
Prognosis for paranoid schizophrenia is better than it is for other
types of schizophrenia.
o More likely to be able to hold down a job and show better
social and cognitive functioning.
Onset tends to occur later in life; episodes of psychosis are often
triggered by stress.
In general, considered to be a milder form of schizophrenia.
Do not have well-formed delusions or hallucinations. Instead,
thoughts and behaviours are severely disorganized.
People may speak in word salads.
Prone to odd, stereotyped behaviours such as frequent grimacing
and flapping their hands.
In severe cases, may not bathe, dress, or eat if left by themselves.
Emotional experiences and expressions of people are also quite
Early onset and continuous. Unresponsive to treatment. People
are most disabled by this type of schizophrenia.
Rare, so not very well researched. Show a variety of motor behaviours and ways of speaking that
suggest they’re completely unresponsive to the environment.
Diagnosis requires two of the following:
o Catatonic stupor.
o Catatonic excitement.
o Maintenance of rigid posture or complete mutism for long
o Odd mannerisms (e.g. hand flapping).
o Echolalia = senseless repetition of words spoken by others
or echopraxia = repetitive imitation of another person.
Undifferentiated and Residual Schizophrenia
Undifferentiated schizophrenia = symptoms that meet the criteria
for schizophrenia, but do not meet the criteria for paranoid,
catatonic, or disorganized schizophrenia.
o Relatively early onset, chronic, and difficult to treat.
Residual schizophrenia = At least one acute episode of acute
positive schizophrenia, but do not currently have any symptoms.
o Continue to have signs, but never develop it.
o Schizophrenia is more chronic and debilitating than other mental disorders.
o 50-80% of people hospitalized once for schizophrenia will be hospitalized again.
o Life expectancy is 10 years younger.
o People suffer from infectious and circulatory diseases at a higher rate than those
o As many as 10-15% commit suicide.
o Age and Gender Factors
Women who develop the disorder have a more favourable course than
men who develop it.
Women hospitalized less, and for briefer periods.
Women have milder negative symptoms between periods of acute positive
Women have better social adjustment when they are not psychotic.
Possibly due to the fact that women develop schizophrenia at a
Functioning seems to improve with age.
Maybe because they find treatments or have family to support
Aging of the brain may not promote new episodes.
Maybe also due to a reduction in dopamine in the brain.
o Sociocultural factors
Tends to have a more benign course in developing countries (in contrast to
Less severe in places like Nigeria, Colombia, etc; over places like the US
In developing countries, it may facilitate adaptation and recovery better. In developing countries, individuals seem to have broader, closer networks