Schizophrenic Disorders

By Sawiji, S.Kep.Ns., MSc.*

E-mail: sawijiamani@gmail.com
Mobile Phone: 081 328 028333
DEPARTMENT OF NURSING BASIC SCIENCE
MUHAMMADIYAH GOMBONG HEALTH SCIENCE INSTITUTE1

Topics of discussion
1.
2.
3.
4.
5.
6.
7.
8.

Symptoms of Schizophrenia
Diagnostic considerations
Onset and Course
Special Topic: Culture and schizophrenia
Etiological factors
Vulnerability markers
Treatments
Will not cover
Phases of Schizophrenia
Neuropathology

What is schizophrenia?

Schizophrenia is usually thought to be :

a mental disorder or illness

which disturbs how a person
thinks, feels and behaves. And
also how it affects the person
changes over time.
3

Etiology of schizophrenia

This is an area of great debate. Many

theories have been put forward in the
past which have not been supported by
later scientific research.

It

is probable that there are a

number of different causes.
4

1.

2.

3.

Modern techniques have demonstrated that

some affected people have changes in
the structure of their brains.
There is also evidence that some of these
individuals may have been affected by
infections before they were born.
Occasionally the disorder appears to run
in families affecting many members.
5

4. Increasingly, it has been shown that some of the

chemical messengers in the brain

(particularly two called serotonin and
dopamine) are not working correctly.
5. The individuals breakdown may occur as a result
of drug or alcohol misuse, emotional
stress or difficulties in life experiences.

There is no scientific evidence to support the idea

that how parents bring up their child can cause
schizophrenia.
6

Schizophrenic Symptoms

There are three :

a.

positive symptoms
negative symptoms
disorganized symptoms

b.
c.

a. Positive (psychotic)
symptoms :
An excess or distortion of normal
functions.
Positive symptoms do not refer to
good symptoms, but to functions
that are present that should not be.
These are symptoms usually equated
with craziness
8

a.1. Hallucinations
-heightened sensory (perceptual)

experiences that are not due to external

stimuli

-Possible to experience hallucinations through

any of the 5 sensory modes

-Most common hallucination is auditory

Example: Hearing two voices carrying on a running
conversation about terrible person you are
9

a.2. Delusions
-Beliefs rigidly held although preposterous
in nature that usually involve a
misrepresentation of perceptions and
experiences
Example: Belief that you alone can end starvation
in the world
Example: Belief that squirrels are aliens sent to
earth on a reconnaissance mission

10

b. Negative symptoms
A loss or deficit in normal functions.
Negative symptoms do not refer to bad
symptoms, but to functions that are absent
that should be present.
These are aspects of behavior and social
relationships that should be there, but are
not.
11

b.1. Blunted affect

(affective flattening)
-Restriction or flattening of nonverbal
display of emotion
-Imagine if people wore masks all the time. You
could communicate with them, but you could not
read their facial emotional reactions.
Example: A persons voice may lack normal
changes in pitch and volume when describing
something exciting that happened to them.
12

b.2. Anhedonia
-An inability to experience pleasure
Example: losing pleasure in eating, or
social relationships that you would
typically find enjoyable

13

b.3. Alogia (speechlessness)

-Poverty of speech that may look like brief
replies with very little content (empty).
Example
Interviewer: Do you have any children?
Client: Yes.
Interviewer: How many children do you have?
Client: Two.
Interviewer: How old are they?
Client: Three and seven.
14

b.4. Avolition
-The lack of volition or willpower to initiate
and persist in goal-directed activities.
Example: Showing little interest in bathing,
brushing teeth and combing ones hair (i.e.,
personal hygiene)
Example: Not wanting to go to a 3pm class eventhough you have dressed for class
15

c. Disorganized symptoms
Symptoms that do not fit the characteristics
of positive or negative symptoms.
Reflect bizarre behaviors and disturbances
in thinking.

16

c.1. Disorganized speech

-Saying things that convey little, if any,

meaning. Speech presumed to reflect

underlying disorganized thinking.
Example- lettuce is a transformation of a dead cougar
(especially US = PUMA) that suffered a relapse on
the lions toe.
Interviewer: Why are you in the hospital, Jeff?
Jeff: I really dont want to be here. Ive got other things
to do. The time is right, and you know, when
opportunity knocks
17

c.2. Bizarre behaviors

-Grossly disorganized behavior or
catatonic behavior, such as unusual
body movements or inappropriate affect
such as emotional expressions that do not
match the situation
Example: Maintaining a squatting posture that is
resistant to any efforts at changing the posture
Example: Giggling while relaying some personal
tragedy
18

Schizophrenia Symptoms
Positive
symptoms

Negative
symptoms

Hallucinations Blunted

affect
Delusions

Anhedonia

Disorganized
symptoms
Disorganized
Speech
Disorganized
Behavior

Alogia
Avolition
19

Schizophrenic Disorders

Symptoms of Schizophrenia
Diagnostic considerations
Onset and Course
Special Topic: Culture and schizophrenia
Etiological factors
Vulnerability markers
Treatments
Will not cover
Phases of Schizophrenia
Neuropathology

20

2. Diagnosing Schizophrenia

Must show an impairment in social or

occupational functioning

duration of at least 6 months with

continuous disturbance, where 2 or more
positive, negative or disorganized
symptoms are present for at least 1 month
21

Excluding related disorders

Before a diagnosis of schizophrenia can

be given, disorders with similar symptoms
must be ruled out as a possibility

22

Example of Diagnostic
exclusion

For example; during month where

positive, negative or disorganized
symptoms are active those symptoms
must appear in absence of a major
depressive or manic episode
If depression and mania symptoms are
present, their duration must be brief in
relation to the duration of active and
residual schizophrenia symptoms.
23

Distinguishing Schizophrenia
from other similar disorders

Other disorders have psychotic symptoms

as their core symptoms, including:
Schizoaffective disorder
Schizophreniform disorder
Brief psychotic disorder
Delusional disorder
24

Schizoaffective vs.
Schizophrenia

For schizoaffective disorder

delusions and hallucinations must be present
for at least 2 weeks without prominent mood
symptoms.
Mood symptoms must be present for a
substantial portion of the psychotic
disturbance
For schizophrenia:
the length of time that mood symptoms are
present is brief in comparison to the duration
of psychotic disturbance
25

Schizophreniform and Brief

psychotic vs. Schizophrenia
Brief psychotic Schizophreniform Schizophrenia

1 day

1 month

6 months

26

Delusional disorder vs.

Schizophrenia

Delusional disorder is exactly as it sounds.

Non-bizarre delusions is the prominent
psychotic symptom
Other schizophrenic symptoms, such as
hallucinations, disorganized and negative
symptoms are absent in delusional
disorder
27

Schizophrenic Disorders

Symptoms of Schizophrenia
Diagnostic considerations
Onset and Course
Special Topic: Culture and schizophrenia
Etiological factors
Vulnerability markers
Treatments
Will not cover
Phases of Schizophrenia
Neuropathology

28

3. a. Onset of the disorder

Lifetime prevalence rate in general

population is 1%
men appear to have an earlier age of
onset (typically 18-25)
onset for women is typically 25-35
Likelihood of onset drops significantly
after 55
29

3.b. Course

The course for schizophrenia varies.

Not everyone with schizophrenia will
deteriorate in functioning over time

30

Chapter 13: Schizophrenic

Disorders

Symptoms of Schizophrenia
Diagnostic considerations
Onset and Course
Special Topic: Culture and schizophrenia
Etiological factors
Vulnerability markers
Treatments
Will not cover
Phases of Schizophrenia
Neuropathology

31

4. Special topic:
Is schizophrenia solely
a western disorder

Jane M. Murphy (1976)

Interested in cross-cultural comparisons
of mental illness in Western and NonWestern cultures
Wanted to examine whether severe mental
illness as defined in western culture was
present in Non-Western cultures
32

Choice of Inuit and Yorubas

Examined Inuit from Alaska and Yoruba

of Nigeria
Chose them because they were hunter
gatherer cultures (i.e., distinctly different
than the west) and had little contact with
western culture

33

Inuit sample

Lived with Inuit from 1954-1955 in a

village of 499 Inuit
Data came from one of the Inuit villagers,
life histories of a few Inuit and daily
observations

34

Yoruba sample

Lived among a Yoruba tribe during 1961

and 1963
Data was gathered from interviews with 3
native healers and a member of an
indigenous cult.

35

Examined 5 questions

Do Inuit and Yoruba exhibit behavior

similar to the symptoms we call
schizophrenia?
If so, what do these behaviors look like?
Is there a word used to label these
behaviors?
Are these symptoms different from those
exhibited by witch doctors and shamen?
If so, how are they different?
36

Behaviors similar to
Schizophrenia?

Both the Inuit and Yoruba had individuals

with behaviors that resembled
schizophrenia.

37

What do these behaviors

look like?
Within the Inuit these behaviors were:
talking to oneself, screaming at someone who
does not exist, believing that a child or husband
was murdered by witchcraft when nobody else
believes it,
Some of the Yoruba behaviors included:
hearing voices and trying to get other people to
see their source though none can be seen,
asking oneself questions and answering them,
picking up sticks and leaves for no purpose
except to put them in a pile
38

Was there a word used to

describe these behaviors?

Yes.
The Inuit term was Nuthkavihak
Were was the word used by the Yorubas
These behaviors were so distinct or
different from normal Inuit and Yoruba
behavior that each culture had labeled
them.
39

Are behaviors different

than those of the Shaman?

No.
Some of these behaviors such as seeing
things that others do not see and looking into
the future were attributed to shaman in the
Inuit and Yoruba village
The shaman was not referred to as Were or
Nuthkavihak
Why?
40

Shaman behavior

The shaman were seen as controlling

when they would exhibit these behaviors
Example: When the shaman is healing he is
out of his mind, but he is not crazy.

The shamans behaviors were used for a

specific purpose within these cultures

41

Volition and multiple

behaviors

Those who exhibit Were and Nuthkavihak

are different from the Shaman in two
primary ways
Shaman voluntarily hear voices or see
things. The behaviors of Were and
Nuthkavihak are involuntary.
Those with Were or Nuthkavihak exhibit
patterns or multiple behaviors. The
shaman do not exhibit multiple behaviors.
42

Overall conclusion

Murphy found that hunter gatherer cultures

with limited contact with western culture
had recognized and labeled severe mental
illness.
Her findings that both western and nonwestern cultures exhibit symptoms of
schizophrenia have been supported by
epidemiological data, such as those from
the World Health Organization.
43

Prevalence of Schizophrenia
across West and Non-West
Lifetime
morbid risk
(in percents)

England
Japan
Russia
United States
Ireland
Urban India
Rural India
Denmark

0.0% 0.1% 0.2% 0.3% 0.4% 0.5% 0.6%

Based on a narrow definition of schizophrenia

44

Schizophrenic Disorders

Symptoms of Schizophrenia
Diagnostic considerations
Onset and Course
Special Topic: Culture and schizophrenia
Etiological factors
Vulnerability markers
Treatments
Will not cover
Phases of Schizophrenia
Neuropathology

45

5. Etiological factors: a. Genes

Family and twin studies indicate a

genetic influence
pairwise concordance rates show:
MZ concordance = 48 percent
DZ concordance = 17 percent

Twin concordance rate also implicate

other factors beyond genetics
46

Etiology: b. Social Factors

Highest prevalence found in the lower

socioeconomic status
2 hypotheses about why this occurs
Hypothesis 1 is social causation:
low socioeconomic factors, such as,
stressful life events, social isolation or
poor nutrition leads to developing
Schizophrenia
47

Etiology:
Social Factors cont

Hypothesis 2 is social selection :

due to cognitive and social impairments
associated with people who develop
schizophrenia, they are less able to
progress to higher levels of education, or
keep high paying jobs, which leads them to
drift into a low socioeconomic status
48

c. Psychological factors:
Expressed Emotion (EE)

EE is a general negative or intrusive

attitude towards schizophrenic patient
High EE would be critical, hostile or
emotionally over-involved

49

Relapse rate and EE

patients who return to live with families are

more likely to relapse if at least one relative
was high in expressive emotion (EE)
52% of patients in high EE families relapsed
compared to 22% from low EE families
Relapsed defined as definite return of positive
symptoms (hallucinations or delusions) in first
9-12 months after hospital discharge

50

Relapse rate for EE and

level of contact
60
50
40

High contact
(>35 hr/wk)
Low contact
(<35 hr/wk)

30
20
10
0

High EE

Low EE

High EE families close contact

Low EE families close contact

risk of relapse
risk of relapse

51

Multiple pathways
to schizophrenia

The development of schizophrenia unfolds over

time.
Many factors play a role in someone developing
schizophrenia, as well as the course the disorder
takes
Genes, biological factors (nutrition), psychosocial
factors (adverse economic circumstances) in
combination or singularly tells a story of why
someone developed schizophrenia
52

Multiple pathways to
schizophrenia
Schizophrenia
Hints of
psychosis

combined
liability

adolescence

young adult

Time

middle age

53

Multiple pathways
to top ten tennis ranking
Tennis top ten
Next 90
players

combined
potential

adolescence

young adult

Time

middle age

54

Schizophrenic Disorders

Symptoms of Schizophrenia
Diagnostic considerations
Onset and Course
Special Topic: Culture and schizophrenia
Etiological factors
Vulnerability markers
Treatments
Will not cover
Phases of Schizophrenia
Neuropathology

55

6. Characteristics of
Vulnerability Markers

Marker must distinguish those with

schizophrenia from other groups
Marker must be a stable characteristic
over time
Marker more common among 1st degree
relatives than general population
Marker should predict future episodes of
schizophrenia among those who have the
marker, but have not experienced a
psychotic episode
56

Why search for vulnerability

markers

Important to know who is at risk

(vulnerable) for developing psychosis.
Provides clues to the cause of
schizophrenia

57

Eye-Tracking Dysfunction

Difficulty with smooth-pursuit eye

movement
particularly when tracking the motion of a
pendulum or similar oscillating stimulus

Individuals with schizophrenia typically

exhibit rapid eye movement

target

non Scz subject

Scz subject
58

Is Eye-Tracking Dysfunction a
Vulnerability Marker for
Schizophrenia?

Marker must distinguish those with

schizophrenia from other groups
Only 8% of general population show eyetracking dysfunction compared to a
substantial portion of people w/ schizophrenia

Marker must be a stable characteristic

over time
Evidence to support eye-tracking dysfunction
as a stable trait of schizophrenia
59

Is Eye-Tracking a
Vulnerability Marker (cont)

Marker more common among 1st degree

relatives than general population
half of 1st degree relatives show similar eyetracking impairments

Marker should predict future episodes of

schizophrenia among those who have the
marker, but have not experienced a
psychotic episode
no markers found to do this yet

60

Schizophrenic Disorders

Symptoms of Schizophrenia
Diagnostic considerations
Onset and Course
Special Topic: Culture and schizophrenia
Etiological factors
Vulnerability markers
Treatments
Will not cover
Phases of Schizophrenia
Neuropathology

61

7. Treatment considerations

Although decreasing severity of symptoms in

schizophrenia is important it is not the only
treatment consideration
Being able to integrate that patient back into
the community through symptom/medicine
management skills, daily living skills, and
social skills needs to also be considered
As suggested by research on EE, teaching
families how to cope with schizophrenia will
lessen the likelihood of adverse outcomes 62

Treatment:
1) antipsychotic medication

Also known as neuroleptics because they

induce side effects that resemble the
motor symptoms of Parkinsons Disease
motor side effects include extrapyramidal
symptoms (EPS) such as muscular rigidity,
tremors, and peculiar involuntary postures
tardive dyskinesia (TD) is another side effect
that includes abnormal involuntary movements
of the mouth and face and spasmodic
movements of limbs and trunk of body
63

Symptom improvement
40
35
30
25
20

% with symptom
improvement

15
10
5
0

no improvement

partial
improvement

1/4 of the patients who use neuroleptics show no

improvement and 30%-40% show limited
improvement

64

Relapse rates
70
60
50

discontinue meds

40

continue meds

30

proper med dosage &

use

20
10
0

1yr

2nd yr

65%-70% relapse 1st year with discontinuation of meds

vs. 40% if continue to use meds. At 2yr interval even in
65
the best case scenario half will still relapse

Treatment:
2) atypical antipsychotics

Unlike neuroleptics, atypical

antipsychotics do not produce the
motor symptoms associated with EPS
May not be associated with an increased
risk of developing the syndrome TD
Clozapine and Resperidone are two of
the most widely used
66

Treatment:
3) Psychosocial

Interested in long-term strategies to improve

aspects of patients life other than the reduction
of psychotic symptoms
Some psychosocial treatments aim to improve
family coping skills and reduce relapse.
1) Eliminating unrealistic expectations for the patient
2) Improving communication and problem-solving
skills of family members
67

Treatment: Psychosocial

Other psychosocial treatments such as

social skills training and assertive
community treatment address social and
occupational functioning

68