CHAPTER 9

SCHIZOPHRENIA:
CLINICAL PICTURE, CAUSES
AND TREATMENT
Terminologies
CEBU, KATRINA
 Psychosis is a mental health problem that
causes people to perceive or interpret things
differently from those around them. This
might involve hallucinations or delusions.
Loss of contact with reality
Vs. Neurosis: has contact with reality and not
caused by organic disease.

CEBU, KATRINA
 Perception in the absence of external
stimulus that has qualities of a real
perception.
Visual, Auditory, Olfactory, Gustatory,
Tactile, Proprioceptive, Equilibrioceptive,
Nociceptive, Thermoceptive, Chronoceptive

CEBU, KATRINA
Refers to a strongly held belief despite evidence that the belief is false.
The basic characteristic of madness

CEBU, KATRINA
Bizarre Delusions:
These types of delusions are considered extremely odd, highly implausible,
and inappropriate based on the persons culture and life experiences.

Non-bizarre delusions:
These are considered delusions that theoretically are possible, but still
unlikely based on circumstances

CEBU, KATRINA
Mood-congruent delusions:
These are considered delusions that directly stem from a persons mood
(e.g. depression or mania)

Mood-neutral delusions:
A mood-neutral delusion is a false belief that isnt directly related to a
persons emotional state.

CEBU, KATRINA
Persecutory delusions
belief that one is being persecuted, spied upon or is in danger

Referential delusions
belief that independent external events are making specific
reference to a person

Grandiose delusions
belief that someone is famous or powerful
CEBU, KATRINA
Erotomanic delusions
belief that a particular person, usually a celebrity or someone especially
important, is romantically or sexually involved with or in love with him/her.

Nihilistic delusions
involves the conviction that a major catastrophe will occur

Somatic delusions
- belief that he/she has a medical condition or other physical problem or flaw.
CEBU, KATRINA
 Terminologies
Positive Symptoms
Positive symptoms are psychotic behaviors not generally seen in healthy
people. People with positive symptoms may lose touch with some
aspects of reality.

CEBU, KATRINA
 Terminologies
Negative Symptoms
Associated with disruptions to normal emotions
It describes normal aspects of the persons behavior that they no
longer have.
AVOLITION - Difficulty in beginning and sustaining goal-related activities

CEBU, KATRINA
 Terminologies

Alogia
Reduced speaking

Anhedonia
Inability to experience pleasure

CEBU, KATRINA
 Terminologies
Cognitive Symptoms
Changes in memory or other aspects of thinking

Spectrum
Range of connected conditions, sometimes also
extending to include singular symptoms or traits.

CEBU, KATRINA
SCHIZOPHRENIA
CEBU, KATRINA
 A startling disorder characterized by a broad
spectrum of cognitive and emotional
dysfunctions including delusions and
hallucinations, disorganized speech and behavior,
and inappropriate emotions.

CEBU, KATRINA
ORIGIN
CEBU, KATRINA
 The disease was first identified as a discrete
mental illness by Dr. Emile Kraepelin in 1887
and the illness itself is generally believed to
have accompanied mankind through its
history.
Dr. Kraepelin used the term "dementia
praecox" for individuals who had symptoms
that we now associate with schizophrenia.

CEBU, KATRINA
 Kraepelin believed that dementia praecox was primarily a disease of the brain, and
particularly a form of dementia.

The Swiss psychiatrist, Eugen Bleuler, coined the term, "schizophrenia" in 1911.
He was also the first to describe the symptoms as "positive" or "negative." He
changed the name to schizophrenia as it was obvious that Krapelin's name was
misleading as the illness was not a dementia (it did not always lead to mental
deterioration) and could sometimes occur late as well as early in life.

CEBU, KATRINA
 The word "schizophrenia" comes from the Greek roots schizo (split) and phrene
(mind) to describe the fragmented thinking of people with the disorder. His term
was not meant to convey the idea of split or multiple personality, a common
misunderstanding by the public.

Both Bleuler and Kraepelin subdivided schizophrenia into categories, based on

prominent symptoms and prognoses. Over the years, those working in this field
have continued to attempt to classify types of schizophrenia.

CEBU, KATRINA
SIGNS AND SYMPTOMS
CEBU, KATRINA
 Slightly more men are diagnosed with schizophrenia than Symptoms of
schizophrenia usually start at ages 16 to 30.

Categories: Positive, Negative, Cognitive, and Disorganized

CEBU, KATRINA
SIGNS AND SYMPTOMS
Positive Symptoms
Hallucinations
Delusions
Thought Disorders
Movement Disorders

CEBU, KATRINA
 SIGNS AND SYMPTOMS
NEGATIVE Symptoms
Flat Effect - reduced expression of emotions via facial expression or voice tone
Anhedonia
Apathy
Avolition
Alogia

CEBU, KATRINA
SIGNS AND SYMPTOMS
COGNITIVE Symptoms
Poor executive functioning
Trouble focusing or paying attention
Problems with working memory

CEBU, KATRINA
SIGNS AND SYMPTOMS
DISORGANIZATION Symptoms
Bizarre Behavior
Incomprehensible speech

CEBU, KATRINA
 Criteria for
schizophrenia

CAPIT, SHEKAINA
 Criteria for schizophrenia
DSM-5
A. Two (or more) of the following, each present for a significant portion of
time during a 1-month period (or less is successfully treated). At least one of
these must be (1), (2), or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms

CAPIT, SHEKAINA
 Criteria for schizophrenia
DSM-5
B. For a significant portion of the time since the onset of disturbance, level of
functioning in one or more major areas, such as work, interpersonal relations, or
self-care, is markedly below the level achieved prior to the onset

CAPIT, SHEKAINA
 Criteria for schizophrenia
DSM-5
C. Continuous signs of the disturbance persist for at least 6 months.
This 6-month period must include at least 1 month of symptoms that meet
Criterion A and may include periods of prodromal or residual symptoms.
During these prodromal or residual periods, the signs of the disturbance may be
manifested only negative symptoms or by two or more symptoms listed in
Criterion A present in an attenuated form

CAPIT, SHEKAINA
PHASES OF SCHIZOPHRENIA
Prodromal
Active
Residual

CAPIT, SHEKAINA
 PRODROMAL SCHIZOPHRENIA
Prodromal refers to the period of time from when the first change in a
person occurs until he or she develops full-blown psychosis
Cannot be recognized easily; very important
This phase can last for days or months.

CAPIT, SHEKAINA
 ACTIVE SCHIZOPHRENIA
Also called as acute phase
start to have symptoms such as hallucinations, delusions, or confusing
thoughts and speech.
This phase usually lasts 4 to 8 weeks. This is when schizophrenia usually is
diagnosed.

CAPIT, SHEKAINA
 RESIDUAL SCHIZOPHRENIA
Similar to prodromal schizophrenia
Obvious psychosis has subsided but the patient may manifest negative
symptoms
The patient may continue to have erroneous or strange beliefs

CAPIT, SHEKAINA
 Criteria for schizophrenia
DSM-5
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic
features have been ruled out because either
1) no major depressive or manic episodes have occurred with the active-phase
symptoms
2) if mood episodes have concurrently occurred during active-phase
symptoms, they have been present for a minority of the total duration of the
active and residual periods of the illness.

CAPIT, SHEKAINA
 Criteria for schizophrenia
DSM-5
E. The disturbance is not attributable to the physiological effects of a substance
or another medical condition.
F. If there is a history of autism spectrum disorder or a communication
disorder of childhood onset, the additional diagnosis of schizophrenia is made
only if prominent delusions of hallucinations, in addition to the other required
symptoms of schizophrenia, are also present for at least 1 month (or less if
successfully treated).

CAPIT, SHEKAINA
 Criteria for schizophrenia
DSM-IV-TR
A. Characteristic symptoms: Two (or more) of the following, each present for a
significant portion of time during a 1-month period (or less if successfully treated): (1)
delusions (2) hallucinations (3) disorganized speech (4) grossly disorganized or catatonic
behaviour (5) negative symptoms, (Note: Only one Criterion A symptom is required if
delusions are bizarre or hallucinations consist of a voice keeping up a running
commentary on the person's behavior or thoughts, or two or more voices conversing
with each other.
B. For a significant portion of the time since the onset of the disturbance, one or more
major areas of functioning such as work, interpersonal relations, or self-care are
markedly below the level achieved prior to the onset (or when the onset is in childhood
or adolescence, failure to achieve expected level of interpersonal, academic, or
occupational achievement).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month
period must include at least 1 month of symptoms (or less if successfully treated) that
meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal
(symptomatic of the onset) or residual symptoms. During these prodromal or residual
periods, the signs of the disturbance may be manifested by only negative symptoms or
two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd
beliefs, unusual perceptual experiences).
CAPIT, SHEKAINA
D. Schizoaffective Disorder and Mood Disorder With
Psychotic Features have been ruled out because either (1)
no Major Depressive Episode, Manic Episode, or Mixed
Episode have occurred concurrently with the active-phase
symptoms; or (2) if mood episodes have occurred during
active-phase symptoms, their total duration has been brief
relative to the duration of the active and residual periods.
E. The disturbance is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication)
or a general medical condition.
F. If there is a history of Autistic Disorder or another
Pervasive Developmental Disorder, the additional
diagnosis of Schizophrenia is made only if prominent
delusions or hallucinations are also present for at least a
month
 Criteria for schizophrenia
ICD-10
A group of severe mental disorders in which a person has trouble telling the difference between
real and unreal experiences, thinking logically, having normal emotional responses to others, and
behaving normally in social situations. Symptoms include seeing, hearing, feeling things that are
not there, having false ideas about what is taking place or who one is, nonsense speech, unusual
behavior, lack of emotion, and social withdrawal.
A major psychotic disorder characterized by abnormalities in the perception or expression of
reality. It affects the cognitive and psychomotor functions. Common clinical signs and
symptoms include delusions, hallucinations, disorganized thinking, and retreat from reality.
A severe emotional disorder of psychotic depth characteristically marked by a retreat from
reality with delusion formation, hallucinations, emotional disharmony, and regressive behavior.
Class of psychoses with disturbance mainly of cognition (content and form of thought,
perception, sense of self versus external world, volition) and psychomotor function, rather than
affect.
Schizophrenia is a severe, lifelong brain disorder. People who have it may hear voices, see things
that aren't there or believe that others are reading or controlling their minds. In men, symptoms
usually start in the late teens and early 20s. They include hallucinations, or seeing things, and
delusions such as hearing voices. For women, they start in the mid-20s to early 30s. Other
symptoms include unusual thoughts or perceptions disorders of movement, difficulty speaking
and expressing emotion, and problems with attention, memory and organization
CAPIT, SHEKAINA
no one is sure what causes schizophrenia, but your genetic
makeup and brain chemistry probably play a role. Medicines
can relieve many of the symptoms, but it can take several
tries before you find the right drug. You can reduce relapses
by staying on your medicine for as long as your doctor
recommends. With treatment, many people improve enough
to lead satisfying lives.
Type 1 Excludes
brief psychotic disorder (F23 ), cyclic schizophrenia (F25.0 ),
mood [affective] disorders with psychotic symptoms (F30.2 ,
F31.2 , F31.5 , F31.64 , F32.3 , F33.3 ), schizoaffective
disorder (F25.- ), schizophrenic reaction NOS (F23 )
Type 2 Excludes
schizophrenic reaction in: alcoholism (F10.15-, F10.25-,
F10.95-), brain disease (F06.2), epilepsy (F06.2), psychoactive
drug use (F11-F19 with .15. .25, .95), schizotypal disorder
(F21)
 MAJOR CHANGES TO DIAGNOSTIC
CRITERIA FOR SCHIZOPHRENIA
Elimination of special attribution of bizarre delusions and Schneiderian first-
rank auditory hallucination (two voices talking to each other)
Only one positive symptom (hallucinations, delusions, disorganized speech)
is required

CAPIT, SHEKAINA
 DSM IV-TR TO DSM 5
DSM-5 raises the symptom threshold, requiring that an individual must
exhibit at least two of the specified symptoms (before, only one symptom
was needed)
The diagnostic criteria no longer identify subtypes.

CAPIT, SHEKAINA
types of schizophrenia

Barrenechea, Mikel
 types of schizophrenia
DSM-IV
Paranoid, Disorganized, Catatonic,
Undifferentiated, Residual Type
Delusions, Hallucinations, Disorganized
speech, and Behavior, Negative Symptoms.
2/5 symptoms required, unless delusions
were bizarre or hallucinations included a
running commentary of persons
thoughts/behavior
Barrenechea, Mikel
DSM 5
Removal of sub-types due to them
being unstable conditions, and having
low validity
Removal of exception due to delusions
being bizzare due to lack of
specificity and poor reliability.
Retains 2/5 symptoms needed, but at
least one has to be Delusions,
Hallucinations, or Disorganized Speech
 types of schizophrenia
REACTIVE SCHIZOPHRENIA PROCESS SCHIZOPHRENIA
(TYPE 1) (TYPE 2)

Possesses more Positive symptoms Possesses more Negative

1st Gen Antipsychotics symptoms
(Chlorpromazine, Fluphenazine, 2nd Gen Antipsychotics
Haloperidol) (Aripiprazole, Iloperidone,
Easier to relieve Clozapine)
Harder to relieve
Barrenechea, Mikel
 PARANOID SCHIZOPHRENIA

The most common type of schizophrenia, paranoid schizophrenia is a type of

schizophrenia which the patient has delusions or beliefs that people are plotting against
them or people they know. It has predominantly positive symptoms of schizophrenia,
such as auditory hallucinations and delusions, but it has a prominent absence of negative
symptoms, mainly disorganized speech and movement, and flat affect.
In order to be diagnosed with paranoid schizophrenia, or schizophrenia, paranoid type,
these symptoms need to be present for at least one to six months.
This differs from paranoid personality disorder due to how paranoid personality disorder
is more based on the situation wherein paranoid schizophrenia is perennial. It should be
noted though that long-term PPD can eventually turn into paranoid schizophrenia

Barrenechea, Mikel
 disorganized schizophrenia

A sub-type of schizophrenia, categorized by disorganized thought,

speech and behavior. While it does have the presence of
hallucinations and delusions, it is not as prominent as it is in
Paranoid Schizophrenia.
In order to be classified as disorganized schizophrenia, any sign of
catatonic schizophrenia.
It is not recognized as an actual sub-type of schizophrenia in the
DSM 5, while remaining a sub-type in the DSM-IV.
Barrenechea, Mikel
 Catatonic schizophrenia

A type of schizophrenia wherein the patient has symptoms of catatonia, such as waxy
flexibility, posturing, and negativism.
There are two other sub-types of catatonic schizophrenia, one which involves stupor,
wherein the patient goes into a motionless state and becomes unresponsive to any external
stimuli. The other one is catatonic excitement, wherein the patient is in a constant state of
purposeless agitation.
In the DSM-IV, it is listed as a sub-type of schizophrenia which has symptoms of catatonia
(rigidity, posturing, etc.) . Though in the DSM-5, catatonic schizophrenia is rarely used as
subtype mainly because it was used more as a diagnostic sub-type as opposed to an actual
sub-type of schizophrenia, as well as being present in other psychotic disorders and
psychotic mood disorders.
Barrenechea, Mikel
 Other types
Undifferentiated Schizophrenia
A type of schizophrenia wherein the
patient has enough of the symptoms to be
recognized as affected by schizophrenia,
but not enough to be properly matched
with either Paranoid, Disorganized, or
Catatonic Schizophrenia.
The symptoms can potentially subside
within a less than a month if treatment is
successful.
Barrenechea, Mikel
Residual Schizophrenia
A type of schizophrenia wherein there is an
absence of prominent delusions,
hallucinations, and grossly disorganized
behavior, but continuing evidence of
disturbance due to presence of negative
symptoms according to the DSM-IV.
It is akin to a transitional stage of
schizophrenia, wherein the patient may have
either recovered from an acute psychotic
episode to a period of full remission or vice
versa.
 Icd 10
Post-schizophrenic Depression
Post-schizophrenic depression is a sub=type of
schizophrenia found in the ICD 10 (ICDF20.4),
and is defined as a depressive episode following
the aftermath of a schizophrenic illness.
Both positive and negative symptoms are present,
but they are no longer as prominent, and should
the positive/negative symptoms subside, then a
depressive episode should be diagnosed instead
Barrenechea, Mikel
Simple-type Schizophrenia
Another type of schizophrenia present in the
ICD 10 (ICD F20.6) wherein there is a
gradual development in oddities in conduct,
ability to meet demands of society and a
decline in total performance.
There is also notable development as well of
negative symptoms without a prior onset of
any psychotic symptoms
CAUSES OF SCHIZOPHRENIA
 What causes Schizophrenia?

No one factor can fully explain why schizophrenia develops

Complex interplay between genetic and environmental factors

BAYONA, Neil Thomas

 Genetic Factors
Familial, tends to run in families
Strong association of closeness of blood relationship
to the development of schizophrenia
First-degree relatives, 10%
Second-degree relatives, 3%

BAYONA, Neil Thomas

 Genetic Factors
Twin Studies
Concordance rates with identical twins is higher than fraternal twins or ordinary sibling

Concordance rate: Monozygotic twins- 28%

Dizygotic twins- 6%
Reduction in shared genes reduces risk of Schizophrenia by nearly 80%

BAYONA, Neil Thomas

 Genetic Factors
Twin Studies
Concordance rates for identical twins are not
close to 100%
1st: Genes play a role in causing schizophrenia
2nd: Genes are not the only contributor.

Predisposition to schizophrenia may remain

unexpressed

released by unknown environmental factors

BAYONA, Neil Thomas

 Genetic Factors
Adoption Strategy

Separation of hereditary from

environmental influences

BAYONA, Neil Thomas

 Genetic Factors
Adoption Strategy
Children born from mothers who have
schizophrenia can also contract the disorder
by 16.6 percent (Heston, 1966).

Offsprings raised by mothers who were

diagnosed with schizophrenia were more
likely to be diagnosed as mentally retarded,
neurotic or psychotic.

BAYONA, Neil Thomas

 Genetic Factors
Quality of the Adoptive Family

Finnish Adoptive Family

Studies of Schizophrenia
Tienari and colleagues
Index adoptees developed more
schizophrenia and schizophrenia-related
disorders

BAYONA, Neil Thomas

 Genetic Factors
Quality of the Adoptive Family

Communication deviance
-How understandable the speech of the family
member is.
High-risk children raised by adopted families low in
communication deviance were healthier.

BAYONA, Neil Thomas

 Genetic Factors
Quality of the Adoptive Family
Genetic make up may control how sensitive we are to certain
aspects of the environment.

Also raises the possibility that certain kinds of environments

may be controlled to protect people with genetic susceptibility
to schizophrenia from ever developing the illness.

BAYONA, Neil Thomas

 Genetic Factors
Quality of the Adoptive Family
Degree of Adversity: predicted problems in
adopted children.
Children raised in dysfunctional families and
had high genetic risk for schizophrenia went on
to develop schizophrenia-related disorders

BAYONA, Neil Thomas

 Genetic Factors
Molecular Genetics
Schizophrenia is believed to be involved with many genes working
together to confer the susceptibility to illness.

May explain the degree of schizophrenia of different people

BAYONA, Neil Thomas

 Genetic Factors
Molecular Genetics
Linkage analysis: Researchers can see whether a disorder tends to co-
occur with any known DNA.
Genome- wide association methods: Used to identify susceptibility
genes.

BAYONA, Neil Thomas

 Genetic Factors
Molecular Genetics
Candidate genes:

-1,2,6,8,13,22

-Host genes that are known to aberrant in schizophrenia

BAYONA, Neil Thomas

 Genetic Factors
Molecular Genetics
Candidate gene 1: COMT (catechol-O-methyltransferase)
Located on chromosome 22
Involved in dopamine metabolism
Dopamine- implicated to be responsible in psychosis

BAYONA, Neil Thomas

 Genetic Factors
Molecular Genetics
Children with Velocardiofacial syndrome are at high-risk of
developing schizophrenia as they move through
adolescence.

BAYONA, Neil Thomas

 Genetic Factors
Molecular Genetics
Candidate gene 2: Neuroglin 1 gene, chromosome 8
Candidate gene 3: Dysbindin gene, chromosome 6
Candidate gene 4: DISCI gene, chromosome 1
Other several dopamine receptor genes

BAYONA, Neil Thomas

 Genetic Factors
Endophenotypes
Genes may have a weak effect
Only relevant in certain population subgroups

Difficulties:
Schizophrenia is genetically complex
Researchers are still not sure what phenotype they should
be looking for.

BAYONA, Neil Thomas

 Genetic Factors
Endophenotypes
- Discrete, stable, and measurable traits that are
thought to be under genetic control

-Scoring high on certain tests/measures that are

thought to reflect a predisposition to schizophrenia.

BAYONA, Neil Thomas

 Genetic Factors
PRENATAL EXPOSURES

Genotypes can be triggered by

environmental and biological triggers

BAYONA, Neil Thomas

 Genetic Factors
PRENATAL EXPOSURES: VIRAL INFECTION
Kraeplin suggested that infections in the years of development
might have a causal significance

Finnish Influenza
Elevated risks of schizophrenia in children born to mothers who
had been in their second trimester of pregnancy at the time of
the influenza epidemic
Greatest risk of schizophrenia was when the mother got the flu
in the 4th-7th month of gestation

BAYONA, Neil Thomas

 Genetic Factors
PRENATAL EXPOSURES: VIRAL INFECTION
Explanations: Mothers antibodies to the virus cross the
placenta and somehow disrupt the neurodevelopment of
the fetus

Other maternal infections related:

-Rubella (German measles)
-Toxoplasmosis (a parasitic infection)

BAYONA, Neil Thomas

 Genetic Factors
PRENATAL EXPOSURES: RHESUS INCOMPATIBILITY
Major cause of blood disease in newborns
Rh incompatibility seems to be associated with
increased risk for schizophrenia
Can cause brain abnormalities as well

BAYONA, Neil Thomas

 Genetic Factors
PRENATAL EXPOSURES: PREGNANCY AND BIRTH
COMPLICATION

Delivery was complicated in some way

Obstetric Complication
Delivery problems:
Breech Delivery
Prolonged Labor
Umbilical cord around babys neck

BAYONA, Neil Thomas

 Genetic Factors
PRENATAL EXPOSURES: EARLY NUTRITIONAL
DEFICIENCY

Malnourishment of mothers
Lack of specific nutrients such as
folate and iron
*still unknown to researchers

BAYONA, Neil Thomas

 Genetic Factors
PRENATAL EXPOSURES: MATERNAL STRESS

Stressful events during the first

trimester or early in the second
trimester
Increase in stress hormones passing
through the placenta

BAYONA, Neil Thomas

RISK AND CAUSAL FACTORS
OF SCHIZOPHRENIA
GENES & ENVIRONMENT

Monozygotic twins who shared a

placenta are much more likely to develop
schizophrenia than monozygotic twins
that did not share their placenta

BAYONA, Neil Thomas

 RISK AND CAUSAL FACTORS
OF SCHIZOPHRENIA
GENES & ENVIRONMENT
Diathesis-Stress Model:
Being at genetic risk does not seem to make people more susceptible to
environmental triggers.

BAYONA, Neil Thomas

 RISK AND CAUSAL FACTORS
OF SCHIZOPHRENIA
GENES & ENVIRONMENT

People who had a parent with schizophrenia and who had birth
complications later showed brain abnormalities in adulthood
People conceived from parents with schizophrenia tend to have
it worst
.

BAYONA, Neil Thomas

 Neurodevelopmental Perspective
Preschizophrenia children showed more motor abnormalities

Consistent findings from high-risk research:

More deviant
Adolescents: lower ratings in social competence

BAYONA, Neil Thomas

 Neurodevelopmental Perspective
As the brain matures, problems in the same neural
circuits manifest themselves in psychotic symptoms

PRODROMAL- very early, signs of schizophrenia

BAYONA, Neil Thomas

Structural and Functional Brain Abnormalities

Positron emission tomography (PET)

Magnetic Resonance imaging (MRI)

BAYONA, Neil Thomas

 Neurocognition
Experience problems in neurocognitive functioning
Cognitive difficulties can be seen from the start of
the illness
Cognitive deficits:
Reaction time
Continuous Performance Task

BAYONA, Neil Thomas

 Neurocognition
Problem with Working memory
Less prefrontal brain activity
Eye-tracking dysfunction
Problems with the active functional allocation of
attentional resources

BAYONA, Neil Thomas

 Neurocognition
P50
Strongest finding in the area of neurocognition and
schizophrenia
Brain produces a positive electrical response to each click
Normal subjects: second click is less marked
Patients with schizophrenia: response to second slick is
as strong as the first one.

BAYONA, Neil Thomas

 Neurocognition
Problems with active functional allocation of
attentional resources
Attentional dysfunctions could be indicators
of biological susceptibility to at least some
forms of schizophrenia

BAYONA, Neil Thomas

 Loss of Brain Volume
Enlarged brain ventricles
Indicator of a reduction in
the amount of tissue brain
Seen in genetically high risk
individuals
Gray matter declined
significantly over time in the
patients
Neuroprogessive disorder

BAYONA, Neil Thomas

 Affected brain areas
Reductions in the volume in the frontal and temporal lobes
Reduction in the volume of:
Amygdala
Hippocampus
Thalamus
 White matter problems
Nerve fibres are covered in myelin sheath
Disruption of white matter
Problems in how well the cells of the nervous system can function
Temporal areas: predict later social functioning
Reduction of the Corpus Callosum

BAYONA, Neil Thomas

 Brain Functioning
Hypofrontality and Hyperactivation in frontal brain
Frontal lobe dysfunction: negative symptom
Problem with the way activity in different brain regions gets coordinated
Performance of task would suffer

BAYONA, Neil Thomas

 Cytoarchitecture
Overall organization of cells in the brain

Genetic Vulnerabilities + Prenatal Results= disruption of the migration of

neurons in the brain

Abnormalities in the distribution of cells:

Cortex and Hippocampus

BAYONA, Neil Thomas

 Cytoarchitecture
Missing neurons: Inhibitory interneurons
Regulating excitability of other neurons
Burst of excitatory neurons

BAYONA, Neil Thomas

Brain development in adolescence
Neuronal redundancy
Fail to occur in a normal way
Excitatory synapse decrease
Inhibitory synapse increase

BAYONA, Neil Thomas

 Patients with schizophrenia had smaller brain volume than their co-
twins.
Well co-twins has smaller brains than healthy control twins.

BAYONA, Neil Thomas

 History of fetal oxygen deprivation
Genes can create an enhances susceptibility to potentially aversive
environmental events
Functional circuits

BAYONA, Neil Thomas

 Neurochemistry
Chemical Imbalance
notion that alterations in brain chemistry may be associated
with abnormal mental states
Dopamine Hypothesis
attributing symptoms of schizophrenia (like psychoses) to a
disturbed and hyperactive dopaminergic signal transduction.

BAYONA, Neil Thomas

 Neurochemistry
Dopamine Hypothesis
1. Pharmacological action of chlorpromazine
therapeutic benefits are linked to ability to
block dopamine receptors
2. Amphetamines produce an excess of
dopamine
led to auditory hallucinations and paranoia
excess in dopamine results in a psychotic
state similar to schizophrenia
3. increase of dopamine

BAYONA, Neil Thomas

How does dopamine induce psychosis?
Aberrant Salience
dysregulation of dopamine transmission results In
heightened sensory awareness

BAYONA, Neil Thomas

How does a functional excess of dopamine come about?

Excess of dopamine in synapse

slow down of metabolization of dopamine
blocking of neuronal reuptake
Sensitivity of receptors
the effects of normal amounts of dopamine would be multiplied

BAYONA, Neil Thomas

Measures of Dopamine
Measure dopamine in the brains of deceased
patients
Schizophrenia patients produce more dopamine
No strong evidence to support this
Metabolite
product that remains after a drug is metabolized
by the body
Homovanillic acid (HVA)
Collected in cerebrospinal fluid
negative results

BAYONA, Neil Thomas

Other neurotransmitters
Glutamate hypothesis of schizophrenia
excitatory neurotransmitter
Angel Dust or PCP
Known to block glutamate receptors
PCP induces symptoms that are very similar to
schizophrenia
PCP exacerbates symptoms in schizophrenic patients

BAYONA, Neil Thomas

Other neurotransmitters
Ketamine
a synthetic compound used as an anesthetic and
analgesic drug and also (illicitly) as a hallucinogen.
exacerbates hallucinations, delusions and thought
disorder
age determines whether ketamine causes psychosis
blocks glutamate receptors

BAYONA, Neil Thomas

 Glutamate vs. dopamine
Dopamine inhibits release of glutamate
overactive dopaminergic system results in excessive suppression of glutamate
resulting to inactivity of NMDA receptors
inactivity results in schizophrenia-like symptoms and brain damage

BAYONA, Neil Thomas

PSYCHOSOCIAL AND CULTURE FACTORS
BUAC, MIIKO
 Family and schizophrenia
Do bad families cause schizophrenia?
Parents were routinely assumed to have cause their
childrens disorders, to the extent that blame was
directed to them by mental health professionals.
Schizophrenogenic mother- mothers were singled out and
their cold and aloof behavior was the root cause of
schizophrenia.
Double bind hypothesis
symptoms of schizophrenia are a
manifestation of contradictory
patterns of interaction in the
family.

Bateson's Etiologic Hypothesis

disorganized thinking in family
would reflect in the offspring.

These ideas lack empirical evidence

Buac, Kevin Miko M.

 Family communication
problems could be the result of
trying to communicate with
someone who is severely ill
and disorganized.

Communication deviance

Buac, Kevin Miko M.

 Amorphous and fragmented communication may
reflect genetic susceptibility to schizophrenia

Finnish Adoptive Study

adverse family environments and
communication deviance have little
pathological consequences if the exposed child
has no genetic risk for schizophrenia
a possible genetic vulnerability has
interacted with the adoptive rearing
environment.
 Families and Relapse
Highly emotional family environments might be
stressful to patients

A major contributors to relapse in psychological

disorders such as schizophrenia, alcoholism, and
learning disabilities is expressed emotion.

Expressed Emotion (EE)

measure of the family environment that is based on
how a family member speaks about the patient during
a private interview with a researcher this interview is
known as the Camberwell Family Interview.
Expressed Emotion (EE) cont.
It is the critical, hostile, and emotionally over-
involved attitude that relatives have toward a family
member with a disorder.

Elements: criticism, hostility, and emotional over

involvement (EOI).
High expressed emotion involves more criticism,
hostility, and emotional over-involvement than low
expressed emotion.

Predicts relapse in patients with schizophrenia

lower EE levels, the lower the relapse rates
 How can EE trigger relapse?
Schizophrenic patients are sensitive to stress
environmental stress is thought to interact with
preexisting biological vulnerabilities to increase
the probability of relapse
Cortisol triggers dopamine activity
glucocorticoid secretion enhances glutamate
release

Intrusive and controlling behaviors also predict

schizophrenia
 Urban Living
urban environment increases
a person's risk of developing
schizophrenia

There is a positive correlation

between living conditions and
lower rates of schizophrenia.

Buac, Kevin Miko M.

 The connection between these factors is unclear,
but higher rates of schizophrenia in urban areas
may be due to environmental toxins, social
context that , and viruses including prenatal
infections.

The larger the town of birth, the greater the risk

of schizophrenia.

Place of birth along with rural or urban living are

factors in the development of schizophrenia
 Living outside a city before age the age of 15 may
reduce your chances of getting schizophrenia.

For those who live in an urban area, try to

maintain an active social network, healthy diet,
and a low-stress lifestyle (all of which are
protective factors).

If the risk factor of urban living could be remove

schizophrenia cases could decrease by about 30%
 Immigration
The stress and hardship along with the period of
adjustment faced by immigrants immigrating to a
new country could be contributing to an increased
risk of psychosis among certain communities.

Recent immigrants have much higher risks of

developing schizophrenia compared to people who
are native to the country of immigration

Immigrants are more likely to receive this diagnosis

because of cultural misunderstandings.
 Immigrants with darker skin have a much higher
risk of developing schizophrenia compared to
immigrants with lighter skin.

Why?
Experiences of discrimination results in paranoid and
suspicious outlook, thus setting the stage for the
development of schizophrenia.

People who are genetically predisposed to develop

schizophrenia are more likely to move to other
countries.

The stress that results from social disadvantage and

social defeat may have an effect in dopamine
activity.
 Cannabis Abuse
Schizophrenic people are more likely to smoke
cannabis in .
Using cannabis during adolescence greatly increases
the risk of developing schizophrenia at a later stage of
life.
 Cannabis Abuse
People who carry a certain form of the COMT
gene have an increased risk for developing
psychotic symptoms in adulthood if they used
cannabis during adolescence, however it has
no adverse influence on those who have a
different form of the gene.

Cannabis use might trigger onset of psychosis.

In schizophrenic patients using cannabis elicits
heightened symptoms
 Cannabis Abuse
Cannabis then has a major role in schizophrenia;
THC a psychoactive component in cannabis exerts
its effects by binding to cannabinoid receptors in the
endocannabinoid system.
The endocannabinoid system, which is involved in
neurotransmission and regulate functions such as
sleep, cognition, emotion it is also involved in
reward processing.
THC, increases synthesis of dopamine, therefore
cannabis exacerbates symptoms in patients who
already have schizophrenia.
Cannabis may actually accelerate the progressive
brain changes that accompany schizophrenia
 Nicotine Abuse
90 percent of schizophrenic patients
may be dependent on nicotine

A specific polymorphism in a nicotine

receptor has been linked to a genetic
risk for schizophrenia (CHRNA5 Allele)

May decrease positive symptoms

(hallucination)
Diathesis-Stress Model
Biological factors play a role in etiology of
schizophrenia
Schizophrenia is a genetically influenced, not
genetically determined
Genetic predispositions can be shaped by
environmental factors:
Prenatal exposures
Infections
Stressors
 Diathesis-Stress Model
Predisposing genetic factors must have
combined in additive and interactive ways in
multiple environmental risk factors
How we are born and how we live makes a
major contribution
Schizophrenia may be the uniquely
human price we pay as a species for
the complexity of brain.
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 or
another medical condition.

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Brief Psychotic Disorder: at least 1 day to less than 1 month
Schizophreniform Disorder: >1 month to <6 months

Mood Disorder w/ Psychotic Features: loss of interest and pleasure

Schizophreniform Disorder: Alogia, avoloition and blunted affect

A complete physical examination is always indicated with the

presentation of a psychotic illness

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 Clinical Information
A disorder characterized by the presence of one or more nonbizarre delusions that persist for at least 1 month; the
delusion(s) are not due to schizophrenia or a mood disorder, and do not impair psychosocial functioning apart from the
ramifications of the delusion(s).
A kind of psychotic disorder
A mental disorder in which a person has an extreme fear and distrust of others. A paranoid person may have delusions
that people are trying to harm him or her.
Chronic mental disorders in which there has been an insidious development of a permanent and unshakeable delusional
system (persecutory delusions or delusions of jealousy), accompanied by preservation of clear and orderly thinking.
Emotional responses and behavior are consistent with the delusional state.
Disorder with presentation of a facade of coldness with characteristic pervasive mistrust and suspiciousness of others.
Gradual development of an elaborate and complex delusional system, usually involving persecutory or grandiose
delusions with few other signs of personality or thought disturbance.
Mild paranoia in nonpsychotic persons.
Psychotic behavior accompanied by persecutory or grandiose delusions with few other signs of personality or thought
disturbance

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5. Somatic Type
delusions that the person has some
physical defect or general medical
condition

BERNARDO, PHILIP
6. Mixed Type
delusions characteristic of more
than one of the above types but
no one theme predominates

BERNARDO, PHILIP
7. Unspecified Type
delusions that cannot be clearly determined or
characterized in any of the categories in the
specific types
Such as:
Cotard Syndrome
Capgras Syndrome
Fregoli Syndrome

BERNARDO, PHILIP
a. Cotard Syndrome aka Walking Corpse Syndrome
- delusion that they are dead, do not exist, or have
lost their vital organs
b. Capgras syndrome
- belief that a person, usually someone closely
related, has been replaced by an imposter
c. Fregoli Syndrome
- belief that different people are in fact the same
person

BERNARDO, PHILIP
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 Specific Symptoms of Shared Psychotic Disorder
A delusion develops in an individual in the context of a
close relationship with another person(s), who has an
already-established delusion.
The delusion is similar in content to that of the person who
already has the established delusion.
The disturbance is not better accounted for by another
Psychotic Disorder (e.g., Schizophrenia) or a Mood
Disorder With Psychotic Features and is not due to the
direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.

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 Prevalence of substance/medication-induced psychotic disorder
in the general population is unknown.
Substance/medication-induced psychotic disorder is reported in
7% to 25% of individuals with a first episode of psychosis in
different settings

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BERNARDO, PHILIP
 High doses of opium
High doses of insulin
Lobotomy or Prefrontal Leucotomy
- the removal of the frontal portion of the
brain
Electroconvulsive Therapy (ECT)
- a procedure, done under general anesthesia, in
which small electric currents are passed
through the brain, intentionally triggering a brief
seizure
- cause changes in brain chemistry that can
quickly reverse symptoms of certain mental
illnesses
 ANTIPSYCHOTIC NEUROLEPTICS MEDICATION
- FIRST GENERATION ANTIPSYCHOTIC MEDICATION CONVENTIONAL
OR TYPICAL
- SECOND GENERATION ANTIPSYCHOTIC MEDICATION ATYPICAL
 THE DOPAMINE ANTAGONIST
Include: haloperidol, trifluoperazine, fluphenazine,
perphenazine, chlorpromazine, thioridazine
- High potency: haloperidol, trifluoperazine,
fluphenazine
Medium potency: perphenazine
Low potency: chlorpromazine, thioridazine
MoA: high affinity antagonist for dopamine (D2)
receptor.
Indications: schizophrenia positive symptoms, brief
psychotic disorder, schizophreniform, and schizoaffective
disorder.
 Anticholinergic effects-
Blurred vision, constipation, dry mouth, urinary retention
Antihistamine effect -
Sedation
Anti alpha1 effect-
postural hypotension
Extrapyramidal Symptoms-
Motor disorder involving rigid muscles, tremors, shuffling
movements, restlessness, and muscle spasms affecting their
posture.

Tardive dyskinesia- motor disorder that consists of

involuntary movements of the mouth, arms, face and truck of
the body.
 Neuroleptic malignant syndrome (NMS)
a rare, but life-threatening, idiosyncratic reaction to
neuroleptic medications that is characterized by fever,
muscular rigidity, altered mental status, and autonomic
dysfunction.
 THE SEROTONIN-DOPAMINE ANTAGONISTS (SDAs)

aripiprazole, asenapine, clozapine, olanzapine, quetiapine, iloperidone,

lurasidone, paliperidone, risperidone, ziprasidone

MoA: weaker D2 antagonist and serotonin (5-HT2a) agonist

Indications: positive and negative symptoms of schizophrenia

SIDE EFFECTS:
Delay cardiac conduction
Less anticholinergic and EPS effects
Metabolic (weight gain, diabetes, high lipid)
 Is indicated for diagnostic purposes, for stabilization of medications, for
patients safety because of suicidal or homicidal ideation, and for grossly
disorganized or inappropriate behavior, including the inability to take care of
basic needs such as food, clothing, and shelter.
- A VARIETY OF METHODS TO INCREASE SOCIAL ABILLITES, SELF-
SUFFICIENCY, PRACTICAL SKILLS, AND INTERPERSONAL COMMUNICATION

- THE GOAL IS TO ENABLE PERSONS WHO ARE SEVERELY ILL TO DEVELOP

SOCIAL AND VOCATIONAL SKILL FOR INDEPENDENT LIVING
 SOCIAL SKILSS TRAINING
FAMILY-ORIENTED THERAPIES
CASE MANAGEMENT
ASSERTIVE COMMUNITY TREATMENT
GROUP THERAPY
COGNITIVE BEHAVORIAL THERAPY
INDIVIDUAL PSYCHOTHERAPY
PERSONAL THERAPY
DIALECTICAL BEHAVIOR THERAPY
VOCATIONAL THERAPY
ART THERAPY
 SOCIAL SKILSS TRAINING
-To improve functional outcomes of patients with schizophrenia
-Design to help patients acquire the skills they need to function
better to their day-to-day basis.
FAMILY-ORIENTED THERAPIES
-Assisting family members, including educating them about the
disorder and its management, helping them reduce stress and tension in
their home
CASE MANAGEMENT
-It involves case manager who ensures that their efforts are
coordinated and tat the patient keeps appointments and complies with the
treatment plan.
ASSERTIVE COMMUNITY TREATMENT
-A specialized and more intensive form of case management.
-Treatment approach involving multiple systems of interventions,
medication, psychological services, and social services; Cases are managed
through a multidisciplinary teams to ensure that discharged patients dont
get overlooked.
 GROUP THERAPY
-Focuses on real-life plans, problems and relationships
-Groups may be behaviorally oriented, psychodynamically oriented or
supportive.
COGNITIVE REMEDIATION
-To treat neurocognitive deficits of schizophrenia
-It helps improve patients attention, memory, executive functioning
skills and social functioning skills.
COGNITIVE BEHAVORIAL THERAPY
-It combines cognitive therapy and behavioral therapy
-To improve cognitive distortions, reduce distractibility, and correct
errors on judgment.
 PERSONAL THERAPY
-To enhance personal and social adjustment and to forestall relapse
-Social skills, relaxation exercises, and exploration of individual
vulnerability to stress.
DIALECTICAL BEHAVIOR THERAPY
-Combines cognitive and behavioral theories in both individual or group
settings.
-It improves interpersonal skills in the presence of an active and
emphatic therapist
VOCATIONAL THERAPY
-Help patients regain old skills or develop new ones.
-Sheltered work shops, job clubs, and part-time or transitional
employment programs
ART THERAPY
-Helps patients communicate with others and share their inner, often
frighteningworld with others.
 TREATMENT FOR
SCHIZOPHRENIFORM
HOSPITALIZTION
The psychotic symptoms can usually be treated by a 3 to 6 month course
of antipsychotic drugs (e.g., risperidone.)
PSYCHOTHERAPY
to help patients integrate the psychotic experience into their
understanding of their own minds and lives.
ELECTROCINVULSIVE THERAPY (ECT)-
-may be indicated for some patients, especially those with catatonic or
depressed features.
 TREATMENT FOR
SCHIZOAFFECTIVE DISORDER
MOOD STABILIZERS
Selective serotonin reuptake inhibitors (e.g., flouzetine and sertraline)
FAMILY THERAPT, SOCIAL SKILSS TRAINING, AND COGNITIVE
REHABILITATION
 TREATMENT FOR DELUSIONAL
DISORDER
Treatment and interventions often focused on managing the morbidity of
the disorder by reducing the impact of the delusion on the patients life.
Patients are given an antipsychotic drugs intramuscularly.
INDIVIDUAL THERAPY is more effective than group therapy
 TREATMENT FOR SHARED
PSYCHIATRIC DISORDER
The patient must be separated
- If hospitalization is indicated, they should be placed on different units
and have no contact.
TREATMENT FOR BRIEF PSYCHOTIC
DISORDER
HOSPITALIZATION
- A patient who is acutely psychotic needs a brief hospitalization for
evaluation and protection.
PSYCHOTHERAPY
THE TWO CLASSES OF DRUGS TO BE CONSIDERED:
-antipsychotic drugs
-Bezodiazapines
 References
http://reference.medscape.com/drugs/antipsychotics-1st-generation
https://en.wikipedia.org/wiki/Schizophrenia
https://www.dnalc.org/view/899-DSM-IV-Criteria-for-Schizophrenia.html
http://www.psyweb.com/mdisord/SchizoDis/undtype.jsp
http://www.psyweb.com/mdisord/SchizoDis/redtype.jsp
https://en.wikipedia.org/wiki/Post-schizophrenic_depression
http://apps.who.int/classifications/apps/icd/icd10online2004/fr-
icd.htm?gf20.htm
http://ccpweb.wustl.edu/pdfs/2013barchcatatonia.pdf
http://www.amhc.org/1418-dsm-5/article/51960-the-new-dsm-5-schizophrenia-
spectrum-and-other-psychotic-disorders