Lecture 11; Oct 10, 2013

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Schizophrenia I

Schizophrenia
Schizophrenia is classified as a psychotic
disorder.
Psychosis (from G. psyche mind/soul and
-osis abnormal condition) means a loss of
contact with reality.
Schizophrenia aects approximately 1/100
people in North America. The annual cost of
schizophrenia in the US is estimated at
around $60 billion, due largely to the cost of
treatment and lost wages.
Schizophrenia is a common disease with
severe consequences for patients and their
loved ones, and for this reason, it is an area
that has received a lot of attention from
researchers.
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Myths about schizophrenia

1. MYTH: People who have schizophrenia are violent
and dangerous.

FACT: Individuals who are being treated for

schizophrenia are not more violent than anyone else.
For those living with untreated schizophrenia, they are
the greatest danger to themselves - the greatest risk is
self-harm or suicide.

2. MYTH: People who have schizophrenia have
multiple personalities.

FACT: Schizophrenia is not the same as multiple

personality disorder (aka dissociative identity disorder.)

3. MYTH: People who have schizophrenia see things

that arent there.

FACT: Schizophrenia is characterized mostly by

auditory hallucinations (voices, etc.,.) Visual
hallucinations are possible, but much less common.

4. MYTH: Schizophrenia is a rare condition.

FACT: Schizophrenia affects 1/100 people.

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Characteristics of schizophrenia
The symptoms experienced by people with schizophrenia can be
divided into three basic groups.
Positive symptoms are symptoms that go beyond normally
occurring experiences.
E.g. hallucinations, delusions, paranoia.

Negative symptoms are characterized by a deficit or absence in a

normal behavior.
E.g. apathy, limited thought/speech, emotional and social withdrawal.

Cognitive symptoms (also called disorganized symptoms) are

symptoms that are characterized by erratic changes in speech,
motor behavior, and emotions.
E.g. disorganized speech, inappropriate emotional reactions
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Positive symptoms
Delusions: irrational beliefs or paranoia that misrepresents reality.

Delusions of grandeur: i.e., belief that one is famous (such as Napoleon or

Jesus Christ), or important in some special way (capable of ending world
hunger, for example).
Delusions of persecution: i.e. when an individual believes that others are out
to get him/her.
Erotomanic delusions: i.e. when an individual believes that another person
(often a celebrity) is in love with him/her.

Delusions can be classified as bizarre if they are clearly implausible.

i.e. Belief that an outside force has removed the individuals internal organs
and replaced them with those from someone else

Delusions can instead be non-bizarre, if they are somewhat plausible.

i.e. Believing that the government is listening to the individuals phone calls

Delusions expressing a loss of control over mind and body are common.
i.e. Belief that outside forces are inserting thoughts into ones mind, or that
ones body is being manipulated by some outside force.

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Positive symptoms
Hallucinations: the experience
of sensory events without any
input from the surrounding
environment. Hallucinations
can involve any of the senses,
but auditory hallucinations
such as voices are the most
common.
Many hallucinations are simply
a running commentary of
whats going on.
Others can be more sinister.
Command hallucinations
involve voices giving orders.

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Negative symptoms
Apathy: the inability to get started, to perform basic
day-to-day functions.
This can lead to problems with hygiene, keeping a job,
and keeping a place to live.

Autism: refers to the tendency to keep to oneself and

lose interest in other people or the surroundings.
Note: autism here refers to a set of behaviors, not
comorbidity with autism the disorder.

Ambivalence: emotional and social withdrawal.

Anhedonia without pleasure (G.): indierence to
activities that are typically considered to be
pleasurable.
Aective flattening: the absence of visible emotions,
facial expressions, and emotional inflections in
speech.

Approximately 25% of people with schizophrenia exhibit

a flat affect it is as though they are wearing an
expressionless mask all the time.

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Negative symptoms can lead to the

neglect of basic life necessities such
as employment and housing.
As
such, homelessness is common
among people with schizophrenia.

Cognitive symptoms
Disorganized speech: people with
schizophrenia have a confusing way of talking.
They often jump about randomly from topic to
topic, or go off on illogical tangents.

Inappropriate aect: occasionally, people with

schizophrenia display emotions that are
inappropriate for the current situation.
They may laugh or cry in situations that call for
neither.

Disorganized behavior: people with

schizophrenia can show motor symptoms
ranging from wild agitation to catatonic
immobility.
Catatonic patients seem frozen in place, but may
display waxy flexibility.
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A video

http://www.youtube.com/watch?v=gGnl8dqEoPQ
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DSM-5 diagnostic criteria

Key points:
Individual must have at
least one of: delusions,
hallucinations, or
disorganized speech.
Diminished level of
function.
Long-lasting symptoms.
Not due to drugs or some
other medical condition.
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History
The condition historically known simply as
madness or lunacy likely corresponds to what
we now call schizophrenia.
Emil Kraeplin (1856-1926) was the first to
thoroughly define the symptoms of
schizophrenia, combing several elements of
insanity into one disorder.
Catatonia, hebephrenia (silly and immature
emotionality), and paranoia had previously been as
separate disorders.
He also distinguished schizophrenia from manicdepression (which we now call bipolar disorder)

Kraeplin called schizophrenia dementia praecox

premature dementia (L.) because the disorder
usually appears in late adolescence.
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Emil Kraeplin (1856-1926)

History
Eugen Bleuler (1857-1939) introduced the term
schizophrenia, replacing Kraeplins dementia
praecox.

This name change is important, because it shows

that Bleuler believed that the core problem was not
premature aging of the brain.

The word schizophrenia means split mind (G.),

and this comes from Bleulers belief in the
breaking of associative threads the destruction
of forces that connect one function to the next.
In other words, the various elements of the
individuals mind become disconnected from
each other. Thoughts no longer have any logical
connection to each other, or to reality in general.
Unfortunately, the concept of split mind has lead
to the popular but incorrect use of schizophrenia
to refer to split/multiple personalities.

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Eugen Bleuler (1857-1939)

Development
Schizophrenia is usually diagnosed in
late adolescence or early adulthood.
It strikes right as people enter the world
and begin to gain independence, it is a
cruel surprise that deprives people of the
chance of a normal life.
There is usually a lag of 1-2 years
between the first onset of symptoms
and diagnosis.

In 85% of people, full-blown

schizophrenia is preceded by a
prodromal stage a 1-2 year period
where subdued symptoms begin to
appear.
Magical thinking, minor illusions (feeling
of a presence when one is alone, etc.,),
and ideas of reference are common
prodromal symptoms.
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Mental illnesses like schizophrenia often appear

during university. The stress of moving, school,
and possible drug/alcohol abuse probably makes
it worse.

Development and prognosis

Complete remission is rare: most people (~78%) being
treated for schizophrenia go through a pattern of relapse
and recovery.
The prognosis for schizophrenia is poorer than for most
other disorders, but recovery/remission is more likely given
the following factors:
Good social adjustment prior to onset of schizophrenia.
A low proportion of negative symptoms.
A good social support system for patients.

The symptoms of schizophrenia may decrease with age, or

at least level out.
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Development and prognosis

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Illustration from Barlow & Durand, Abnormal Psychology, 6th ed. Wadsworth, 2012

Etiology - genetics
There is clear evidence for a genetic link
to schizophrenia.
This can be shown by looking at how
the relative risk of developing the illness
changes depending on whether other
people in ones family have
schizophrenia.

Monozygotic (identical) twins share

100% of their genes.

Therefore, if schizophrenia was 100%

caused by genetics, both twins would
always have schizophrenia.
In reality, the risk is only 48%.

Dizygotic (fraternal) twins only share

50% of their genes.

If schizophrenia was 100% genetic,

then youd expect 50% of fraternal
twins to have schizophrenia if the other
does.

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Illustration from Barlow & Durand, Abnormal Psychology, 6th ed. Wadsworth, 2012

Endophenotypes
Endophenotypes are subtle markers of disorder-related genes
that appear in people before overt symptoms.

People with schizophrenia have deficient smooth-pursuit eye

tracking. Their relatives also show deficiencies.
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Illustration from Barlow & Durand, Abnormal Psychology, 6th ed. Wadsworth, 2012

Endophenotypes
Pre-pulse inhibition (PPI)
happens when a startling stimulus
of some kind (a pulse) is
preceded by a warning prepulse.
In healthy people, a pre-pulse
warning reduces their startle
response. This does not happen
in people with schizophrenia, and
it is also reduced in their relatives.
Antipsychotic drugs increase PPI
in people with schizophrenia.
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People with schizophrenia have impaired pre-pulse inhibition.

This can also be used as an animal measure of schizophreniclike symptoms.

Etiology
How can it be that even if you possess
100% of your twins schizophrenic
genes, your odds of developing the
disorder are only 48%?
Genetics are somewhat like a loaded
gun. Having bad genes does not
guarantee developing the disorder, but
it certainly raises the risk.
Something else must happen during
life to trigger the illness

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Etiology perinatal factors

There is evidence that problems before
and shortly after birth (the perinatal
period) can increase the risk of
developing schizophrenia.
Fetal exposure to influenza and other
virus-like diseases may subtly damage
the fetal brain in a way that causes the
symptoms of schizophrenia later in
life.
Pregnancy and delivery complications
are also correlated with the
development of schizophrenia.
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Etiology - stress
Stress seems to be a contributing factor in the development
of schizophrenia in individuals who are susceptible.
Numerous studies have shown that diagnoses of
schizophrenia are often preceded by a stressful life event.
Anecdotal evidence seems in favor of this as well. Schizophrenia
often appears in the midst of the stressful transition to
independent living that young adults undergo.

There is also evidence that people with schizophrenia

experience stressors in a dierent way.
A study of an earthquake in California found that people with
schizophrenia were more likely to react to this stressor with low
self-esteem and avoidant coping styles (not thinking of the
problem, giving up).

Stress and genetics interact. Having a risky genetic

background may be a loaded gun, but stress may pull the
trigger.
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