PSCY Essay

Schizophrenia Spectrum and Other Psychotic Disorders SSY 230: Lecture 14

Schizophrenia

The broad category of schizophrenia includes a set of disorders in which individuals experience distorted perception of reality and impairment in thinking, behavior, affect, and motivation.

Schizophrenia is a serious mental illness, given its potentially broad impact on an individual’s ability to live a productive and fulfilling life. Although a significant number of people with schizophrenia eventually manage to live symptom-free lives, in some ways, all must adapt their lives to the reality of the illness.

In economic terms, schizophrenia also exacts a heavy burden, with an estimated annual cost in healthcare alone of $12,000 to $20,000 per person per year in the United States, third only to heart disease and cancer.

One important symptom of schizophrenia is the presence of a delusion, a deeply entrenched false belief not consistent with the client’s intelligence or cultural background. For example, a delusion of persecution is the false belief that someone or something is out to harm you when in fact there is no basis for such a belief. More examples of delusions are described in the following slide.

Types and Examples of Delusions

Grandeur A grossly exaggerated conception of the individual’s own importance. Such delusions range from beliefs that the person has an important role in society to the belief that the person is actually Christ, Napoleon, or Hitler.

Control The feeling that one is being controlled by others, or even by machines or appliances. For example, a man may believe that his actions are being controlled by the radio, which is “forcing” him to perform certain actions against his will.

Reference The belief that the behavior of others or certain objects or events are personally referring to oneself. For example, a woman believes that a soap opera is really telling the story of her life, or a man believes that the sale items at a local food market are targeted at his own particular dietary deficiencies.

Persecution The belief that another person or persons are trying to inflict harm on the individual or on that individual’s family or social group. For example, a woman feels that an organized group of politically liberal individuals is attempting to destroy the right-wing political organization to which she belongs.

Self-blame Feelings of remorse without justification. A man holds himself responsible for a famine in Africa because of certain unkind or sinful actions that he believes he has committed.

Somatic Inappropriate concerns about one’s body, typically related to a disease. For example, without any justification, a woman believes she has brain cancer. Adding an even more bizarre note, she believes that ants have invaded her head and are eating away at her brain.

Infidelity A false belief usually associated with pathological jealousy involving the notion that one’s lover is being unfaithful. A man lashes out in violent rage at his wife, insisting that she is having an affair with the mailman because of her eagerness for the mail to arrive each day.

Thought

broadcasting

Thought

Insertion

The idea that one’s thoughts are being broadcast to others. A man believes that everyone else in the room can hear what he is thinking, or possibly that his thoughts are actually being carried over the airwaves on television or radio.

The belief that outside forces are inserting thoughts into one’s mind. For example, a woman concludes that her thoughts are not her own, but that they are being placed there to control her or upset her.

Schizophrenia

A second major symptom of schizophrenia is hallucinations, which are false perceptions not corresponding to the objective stimuli present in the environment. People may suffer from hallucinations in several sensory modalities, including vision, hearing, smell, and touch. Individuals who experience both visual and auditory hallucinations appear to have more significant deficits than those who experience hallucinations in one sensory modality, who in turn are more significantly impaired than individuals with no hallucinations.

Associated with delusions or auditory hallucinations related to a theme of persecution may be paranoia, the irrational belief or perception that others wish to cause you harm. People who experience paranoia become unable to trust others, feeling convinced that they will be mistreated or even threatened with bodily injury.

Language that is incomprehensible and incoherent is referred to as disorganized speech. The thought process underlying this type of speech reflects loosening of associations—that is, a flow of thoughts that is vague, unfocused, and illogical. The speech of individuals with schizophrenia may contain neologisms,which are words not contained in language. Unlike words that eventually may become accepted words in a particular language (such as google), these words have highly idiosyncratic meanings that are used only by the individual.

Another characteristic symptom that people with schizophrenia may show is inappropriate affect, meaning that the person’s emotional response does not match the social cues present in a situation or the content of what is being discussed. The individual may, for example, burst into laughter during a sad situation or when hearing someone express discontent or unhappiness.

Diagnostic Features of Schizophrenia

The following slides will delineate the six criteria associated with a diagnosis of schizophrenia. The symptoms in Criterion A refer to the active phase of the disorder, that is, the period during which the individual’s symptoms are most prominent. The symptoms

For an individual to be diagnosed with schizophrenia, he or she must meet all of the criteria listed in A–F.

the individual experiences during the active phase fall into two categories based on their A

nature.

.

In the first category are positive symptoms, exaggerations or distortions of normal thoughts, emotions, and behavior. In the table, the disturbances numbered 1 through 4 under Criterion A fit into the category of positive symptoms.

The symptoms in Criterion A-5 are negative symptoms, which relate to functioning that is below the normal level of behavior or feeling. Restricted affect refers to a narrowing of the range of outward expressions of emotions. Avolition is a lack of initiative, either not wanting to take any action or lacking the energy and will to take action. Asociality refers to a lack of interest in social relationships, including an inability to empathize and form close relationships with others.

Two (or more) of the following symptoms must be present for a significant portion of time during a 1-month period (although this can be less if the individual is successfully treated). At least one symptom must be from the first three categories. 1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly abnormal psychomotor behavior 5. Negative symptoms such as restricted affect, avolition, and asociality

Positive and Negative Symptoms

Diagnostic Features of Schizophrenia

Criterion B is consistent with other, general DSM criteria for psychological disorders, in that it stipulates that there must be significant impairment. The degree of impairment in schizophrenia, however, implies a particularly serious and far-reaching impact in the individual’s life. Criterion C, indicating the period of disturbance, is also carefully delineated to ensure that individuals receive this diagnosis only if they show a substantial duration of symptoms.

Criteria D and E refer to other disorders that should not be present in people diagnosed with schizophrenia. It is particularly important for clinicians to rule out Criterion D, schizoaffective disorder, when making their diagnosis. We will discuss this disorder in more detail later in the chapter. Similarly, in the interests of differentiating

schizophrenia from other disorders, Criterion F makes it clear that the symptoms of schizophrenia involving, for example, communication must not overlap with symptoms of an autism spectrum disorder.

B. Occupational dysfunction

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, the person fails to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration of at least 6 months

Continuous signs of the disturbance must persist for at least 6 months. During at least one of these six months, the person must show the active-phase symptoms from Criterion A (or less if the person was successfully treated). The six months may include periods during which the individual had symptoms leading up to (prodromal) or following (residual) an active phase. During these periods, the person must show only negative symptoms or two or more of the active-phase symptoms but in attenuated form.

D. No evidence of schizoaffective, depressive, or bipolar disorder

E. Symptoms are not due to substance use disorder or general 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 or hallucinations are also present for at least a month (or less if successfully treated).

Schizophrenia

Before publication of DSM-5, the diagnostic criteria for schizophrenia included five subtypes based on which symptoms were most prominent in the individual. These subtypes were labeled catatonic, disorganized, paranoid, undifferentiated, and residual. They were dropped from DSM-5, since researchers studying schizophrenia now believe they represent fine-grained distinctions not supported by empirical evidence. However, the terms may still be in use today by mental health professionals who believe they capture qualitatively important diagnostic entities.

Once a subtype of schizophrenia, a separate disorder is now known in DSM-5 as catatonia, a condition in which the individual shows marked psychomotor disturbances. These disturbances may consist of decreased, excessive, or peculiar motor activity that is not in response to what is occurring in the individual’s environment. For example, with no apparent provocation, the individual may hold odd, rigid poses for long periods of time as well as being unable to speak or move. Catatonia may be diagnosed in association with another psychological disorder, a medical condition, or a cause the clinician cannot identify.

History of Schizophrenia

Schizophrenia has a long and fascinating history. French physician Benedict Morel (1809–1873) first identified it as a disease, which he named démence precocé (brain dementia of the young). The next major point in schizophrenia’s history is associated with the German psychiatrist Emil Kraepelin (1856–1926), who used Latin to refer to the condition, which then became known as dementia praecox. At the root of its symptoms, Kraepelin believed, was one underlying and progressively degenerating disease process that caused, in his terms, the “weakening” of mental processes.

In 1911, Swiss psychologist Eugen Bleuler revised the concept of schizophrenia once again, to reflect his belief that the disorder was actually a set of diseases. He coined the term schizophrenia to signify that the underlying cause was a splitting (“schiz”) among the functions of the mind. Unlike Kraepelin, Bleuler thought it was possible for people with schizophrenia to recover from the disorder.

Reflecting the importance of Bleuler’s contributions, clinicians still refer to the fundamental features of the disorder he identified as Bleuler’s “Four A’s.” Briefly, the four A’s are:

1. Association—thought disorder, as might be evident through rambling and incoherent speech

2. Affect—disorder of the experience and expression of emotion

3. Ambivalence—inability to make or follow through on decisions

4. Autism—withdrawal from reality

Note that Bleuler did not intend for the “splitting” to be a splitting of personalities, as is often mistakenly thought (as in “split personality”). Instead, it is a discontinuity between the individual’s experience of an emotion and the way the emotion is expressed.

History of Schizophrenia

In the decades following Bleuler’s work, clinicians in Europe and the United States proposed further distinctions among forms of schizophrenia. One notable contributor to the debate was the German psychiatrist Kurt Schneider, who believed clinicians should diagnose schizophrenia only when an individual displays what he called first-rank symptoms (FRS). These are the symptoms that are truly key, defining features of the disorder. They include audible thoughts (voices heard arguing), the experience of outside influences on the body, the belief that others are taking thoughts out of one’s head, and diffuse or vague thoughts, delusions, and acts or behaviors seen as reflecting the influence of other people on the individual.

First-rank symptoms retain a special meaning even today. DSM-III and the ICD-10 included them as an advance on the less precise set of criteria included in earlier diagnostic manuals. However, researchers disagree on whether FRS represent valid criteria, given that using them may lead clinicians to falsely diagnose as many as nearly one in five individuals.

As debate continues on the FRS, researchers are also rethinking whether schizophrenia is best thought of as a spectrum rather than a single disease entity. The schizophrenia spectrum refers to a range of disorders that reflect a similar underlying disease process. To this end, a provisional section of the DSM-5 (Section 3) includes a set of symptom severity ratings (see the table on the following slide). Although not formal diagnostic categories, they can inform the assessment process as well as allowing clinicians to track changes in a client’s symptoms across time and over the course of treatment.

Dimensions of Psychosis Symptom Severity in Section 3 of the DSM-5

Schizophrenia

PrevalenceEstimates from the United States place the lifetime

prevalence of schizophrenia at 1 percent. Men and

women are equally likely to develop the disorder over

the course of their lifetimes, although women typically

do so later in life.

The prevalence of schizophrenia is relatively low

compared to other psychological disorders, but a

surprisingly high percentage of adults report

experiencing minor psychotic symptoms. Reviewing a

large number of studies on psychotic symptoms, one

group of researchers estimate the lifetime prevalence

as about 5 percent, and the prevalence at any one time

as about 3 percent.

Course of Schizophrenia

The course of schizophrenia, as mentioned, was once thought to be lifelong. This situation began to change during the 1970s as researchers and clinicians developed a better diagnostic system and understanding of the nature of psychotic disorders. We now know that schizophrenia may take one of several courses. Even so, compared to other psychological disorders, both course and outcome are poorer for people with schizophrenia.

Researchers who follow people with schizophrenia for extended periods of time propose a long-term framework in which 25 to 35 percent show chronic psychotic symptoms. Some people with schizophrenia can even show complete recovery for the remainder of their lives; 40 percent show significant improvement if they receive current treatment during their acute phase. However, even when they are symptom-free, these individuals may still be impaired in their functioning and adjustment. Furthermore, people with schizophrenia are two to three times more likely to die than others in their age group, leading to a reduction in life expectancy of 15 to 20 years. This higher mortality reflects, in part, the economic and social challenges these individuals face in their daily lives. The use of antipsychotic medications may improve mortality by reducing suicide rates, but alternatively may increase mortality due to negative effects on cardiovascular health.

The factors that contribute to poorer prognosis among people with schizophrenia include deficits in cognitive functioning, a longer period of time without treatment, substance abuse, a poorer course of early development, higher vulnerability to anxiety, and negative life events. In addition, overinvolvement of family members in the individual’s life, as we discuss later in the chapter, also predicts poorer outcome.

Single men seem to be at particularly high risk if they possess these additional characteristics. Men also are more likely to experience negative symptoms, to have poorer social support networks, and to have poorer functioning over time than women. Perhaps surprisingly, given better resources for treating affected individuals, the prognosis for individuals from developing (agricultural-based) countries is better than that for individuals from developed (industrial) nations.

Brief Psychotic Disorder

As the term implies, brief psychotic disorder is a diagnosis that clinicians use when an individual develops symptoms of psychosis for more than a day but less than a month. The

individual must experience one of four symptoms, which are delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

Clinicians assigning this particular diagnosis need to note the context in which individuals display the symptoms of this disorder. Has the client experienced a recent stressor,

such as a natural disaster, the loss of a close relative, or an accident? Another possibility is that a woman develops this disorder soon after giving birth. Such circumstances might

affect the clinician’s decision-making process in making a diagnosis of brief psychotic disorder.

Schizophreniform Disorder

People receive a diagnosis of schizophreniform disorder if they experience symptoms of schizophrenia for a period of 1 to 6 months. If symptoms persisted for longer than 6 months, the clinician conducts an evaluation to determine whether a diagnosis of schizophrenia is appropriate. Those clients who show a rapid development of symptoms (within a span of 4 weeks), seem confused or perplexed while in the peak of the episode, and have otherwise good social and personal functioning prior to the episode have a better chance of not developing schizophrenia. They are also likely to have a good prognosis if they do not show the negative symptoms of apathy, withdrawal, and asociality.

Schizoaffective Disorder

In schizoaffective disorder, individuals with depressive or bipolar disorder also experience delusions and/or hallucinations. However, the diagnosis can be made only if, during a 2-week period, clients have psychotic but not mood disorder symptoms. For most of the duration of their illness, they must have a major mood episode (depressive or manic) as well as symptoms of schizophrenia. In other words, they must have both a mood episode and a psychotic disorder, and at least 2 weeks during which delusions and/or hallucinations are the only symptoms they show.

Schizophrenia vs. Schizophreniform vs. Schizoaffective

Delusional Disorders

People with delusional disorders have delusions that have lasted for at least 1 month as their only symptom. Furthermore, they must have no other symptoms of schizophrenia and must never have met the criteria for schizophrenia. In fact, these individuals can function very well and do not seem odd to others except when they talk about their particular delusion. Based on which delusional theme is prominent, clinicians diagnose these individuals with one of five major types of disorder, or with mixed or unspecified types that include people who have no one prominent delusion:

● People with the erotomanic type of delusional disorder falsely believe that another person is in love with them. The target of their delusion is usually a person of higher status than they are. For example, a woman may be certain that a famous singer is in love with her and that he communicates secret love messages to her in his songs.

● The conviction that they possess special and extremely favorable personal qualities and abilities characterizes people who have the grandiose type of delusional disorder. A man may believe that he is the Messiah waiting for a sign from heaven to begin his active ministry.

● In the jealous type of delusional disorder, individuals are certain their romantic partner is unfaithful to them. They may even construct a plan to entrap their partner to prove his or her infidelity.

● People with the persecutory type of delusional disorder believe that someone close to them is treating them in a malevolent manner. They may, for example, become convinced that their neighbors are deliberately poisoning their water.

● People with the somatic type of delusional disorder believe they have a medical condition causing an abnormal bodily reaction that does not actually exist.

Activity prompt:

Select two types of delusions from slide 3, and one from slide 17. Provide examples of these delusion types one may see in a client/patient with schizophrenia or a delusional disorder.

Shared Psychotic Disorder

The DSM-IV listed shared psychotic disorder as a separate diagnosis for use when one or more people develop a delusional system as a result of a close relationship with a psychotic person who is delusional. This case is more familiarly referred to as folie à deux (folly of two) when two people are involved. Occasionally, three or more people or the members of an entire family are affected.

Shared psychotic disorder now appears in the DSM-5 in the section on other specified schizophrenia spectrum and other psychotic disorders, as “delusional symptoms in partner of individual with delusional disorder”. Although rare, shared psychotic disorder is occasionally found in forensic cases, both criminal and civil.

Theories and Treatment of Schizophrenia

Schizophrenia reflects a complex interplay of biological, psychological, and sociocultural forces. As a result, researchers are well aware of the need to approach the disorder from an interactive perspective.

A key concept in understanding schizophrenia’s causes is vulnerability, the idea that individuals have a biologically determined predisposition to developing schizophrenia but that the disorder develops only when certain environmental conditions are in place. As we look at each of the contributions to a vulnerability model, keep in mind that no single theory contains the entire explanation.

Biological Theories

Biological explanations of schizophrenia have their origins in the writings of Emil Kraepelin, who thought of schizophrenia as a disease caused by degenerative processes in the brain. Nineteenth-century technology was not up to the kind of research needed to identify those abnormalities. Contemporary neuroimaging methods are providing scientists with key data that is just now making such investigations possible.

One of the earliest discoveries to emerge as a result of developments in neuroimaging methods was that individuals with schizophrenia have enlarged ventricles, the structures in the brain holding cerebrospinal fluid. This condition was accompanied by cortical atrophy, a wasting away of brain tissue, and is found primarily in two areas: the frontal and temporal lobes. Deterioration of the frontal lobes results in a diminished ability to plan as well as to exert control over intrusive thoughts and unwanted behaviors. Loss of tissue in the temporal lobes interferes with the processing of auditory information. Altered activity in the frontal and temporal lobes of the brain in turn seems related both to negative symptoms and cognitive deficits. Decreased activity in the frontal lobe also has been shown to be linked to poorer social functioning, reflecting the lack of inhibitory control that this area of the brain ordinarily provides in mature adults.

This figure compares fMRI scans averaged across the brains of people with schizophrenia with those of

normal controls on one type of social task in which participants tried to infer the intentions of fictional

characters depicted in comic strips. As shown, participants with schizophrenia had decreased activation of

areas of the frontal and temporal lobes involved in social judgments.

This reduced ability of the brain regions to communicate with each other seems particularly to affect working

memory and the ability to control cognitive operations, by reducing links between the thalamus and the

frontal lobe of the cortex. It may also add to further changes in the frontal and temporal lobes.

Biological Theories

As important as they may be, structural changes alone cannot entirely explain what happens to the brain to increase the individual’s vulnerability to developing schizophrenia.

Instead, researchers believe that additional clues to schizophrenia’s causes exist in the neurotransmitters responsible for communicating information in the nervous system. An early candidate for such altered neurotransmitter functioning is dopamine. Alterations in dopamine receptors mean that they do not bind properly when dopamine is released from presynaptic neurons. Such alterations, in turn, lead to excess amounts of dopamine in the brain that contribute to schizophrenia’s effects on cognition and goal-directed behavior.

Gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter, also appears to play a role in schizophrenia due to changes the disorder may produce in the N-methyl-D-aspartate (NMDA) receptors. Evidence supporting this idea is based on the fact that the drug ketamine reduces the activity of NMDA receptors. Studies using animal models suggest that dysfunctions in these receptors could contribute to abnormal neural oscillations (brain waves), which in turn could lead to difficulties in both sensory integration and cognition.

Biological Theories

Research on patterns of family inheritance supports the idea that schizophrenia is, at least in part, a genetically caused disorder, with heritability estimates known to range from 60 to 70 percent. Having established this high heritability, researchers have since moved on to try to locate the specific genes involved and to understand the factors that increase the genetically vulnerable person’s chances of actually developing the disorder. Particularly intriguing is the continued evidence connecting cognitive functioning to schizophrenia, with large-scale studies suggesting the overlap of multiple genes in both areas.

The search for genetic abnormalities in schizophrenia is made considerably more complicated by the fact that, over recent decades, researchers have identified abnormalities among at least 19 possible genes dispersed over as many as 10 chromosomes. Some of the functions served by these genes rely on the actions of dopamine and GABA, but other candidates include serotonin and glutamate. Researchers are also searching for abnormalities in the genetics of immune functioning among individuals with schizophrenia. Such abnormalities might predate the apparent onset of the illness, reflecting neurodevelopmental changes much earlier in life.

Indeed, according to the neurodevelopmental hypothesis, schizophrenia is a disorder of development that arises during adolescence or early adulthood due to alterations in the genetic control of brain maturation. The genetic vulnerability some individuals inherit becomes evident if they are exposed to certain risks during early brain development. These risks can occur during the prenatal period in the form of viral infections, malnutrition, or exposure to toxins. Thus, schizophrenia may reflect not only abnormal genetic inheritance but also deficits associated with epigenetic processes. As their illness progresses over time, individuals may show continued deleterious changes through a process of neuroprogression, in which the effects of schizophrenia interact with brain changes caused by normal aging.

Somewhat related to the neurodevelopmental hypothesis is the idea that cognitive deficits of people with schizophrenia reflect a loss of neuroplasticity, adaptive changes in the brain in response to experience. According to this view, people with schizophrenia form too many associations when attempting to learn and remember new material, in contrast to the normal way people trim out or prune information they do not need to retain. The cognitive functioning of individuals with schizophrenia suffers because they essentially remember “too much,” including information they never actually encountered, perhaps leading to the characteristic psychological symptoms of delusions and hallucinations.

Biological Treatments

The primary biological treatment for schizophrenia is antipsychotic medication, or neuroleptics. Psychiatrists prescribe two categories of neuroleptics: the so-called typical or first-generation antipsychotics, and the atypical or second-generation antipsychotics. Chlorpromazine (Thorazine) and haloperidol (Haldol) are two of the typical antipsychotic medications. They seem to reduce symptoms primarily by acting on the dopamine receptor system in areas of the brain associated with delusions, hallucinations, and other positive symptoms.

In addition to being highly sedating, causing a person to feel fatigued and listless, the typical antipsychotics also have serious undesirable consequences. These include extrapyramidal symptoms (EPS), which are motor disorders like rigid muscles, tremors, shuffling movement, restlessness, and muscle spasms affecting posture. After several years, people being treated with the typical antipsychotics can also develop tardive dyskinesia, another motor disorder, which consists of involuntary movements of the mouth, arms, and trunk of the body.

The distressing side effects and failure of typical antipsychotics to treat negative symptoms of schizophrenia led psychiatric researchers several decades ago to embark on a search for alternatives that would both be more effective and have fewer motor symptoms. These are the medications we now refer to as atypical antipsychotics. Such medications operate against both serotonin and dopamine neurotransmitters and hence are also called serotonin-dopamine antagonists.

Biological Treatments

Despite hopes that the atypical antipsychotic medications would result in fewer side effects, one of the first, clozapine (Clozaril), soon turned out to have potentially lethal side effects by leading to agranulocytosis, a condition that affects the functioning of the white blood cells. Now, patients receive the atypical medications only under very controlled conditions, and only when other medications do not work. Instead, clinicians can prescribe one of a number of safer atypical antipsychotics, including risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel).

Unfortunately, even medications in the newer group of atypical antipsychotics are not without potentially serious side effects. They can cause metabolic disturbances, particularly weight gain, increases in blood cholesterol, and greater insulin resistance, placing clients at greater risk of diabetes and cardiovascular disease.

Because of the many complexities in the biological treatment of individuals with schizophrenia, researchers and clinicians increasingly recognize the need to take the individual’s medical and psychiatric profile into account. For treatment-resistant clients, clozapine is the only approach that has empirical support. In other instances, clinicians may attempt to find either a combination of antipsychotics or a combination of antipsychotics and other classes of medications. The next question is how long to maintain a client on medications, balancing the value of continued treatment against the risk of relapse and possible health hazards that occur with their use over time.

Psychological Theories

Although evidence continues to accumulate regarding the role of genetics in schizophrenia, researchers nevertheless believe that psychological theories can provide important insights. Those who continue to explore the cognitive functions affected by schizophrenia are increasingly seeing these as potentially fundamental to understanding the disorder’s central features.

The cognitive correlates of schizophrenia, as shown by the summary of neuropsychological

performance in the below figure, range from general intellectual ability to deficits in

attention, declarative memory (long-term recall of information), and processing speed.

Overall, estimates of the number of people with schizophrenia who are cognitively impaired

vary from 55 to 70 or 80 percent.

Keep in mind, however, that factors extraneous to the disease can also cause these

abnormalities. Such factors include age, educational background, use of medication, and

severity or length of illness. If they are not controlled for, the cognitive impairment thought

to be associated with schizophrenia may be due to these extraneous factors and not to the

disorder itself.

Schizophrenia and Marijuana Use

People who use cannabis (marijuana) also show an elevated risk of developing schizophrenia.

Although researchers were long aware of the cannabis-schizophrenia link, they believed that people with schizophrenia used the drug to alleviate their symptoms.

Long-term follow-up studies show instead, however, that people develop the disorder after continued use of cannabis.

The relationship is specific to extent of marijuana use, with people who are heavier marijuana users prior to being diagnosed with schizophrenia placing themselves at higher risk of developing it.

Psychological Theories

One significant psychological area studied in people with schizophrenia is social cognition, meaning the ability to accurately read the emotions of others. A deficit in social cognition is particularly problematic when individuals with schizophrenia are given the task of recognizing negative emotions such as fear, anger, and disgust, though they are better at identifying mild happiness in the facial expressions of others. Not surprisingly, the nonverbal communicative abilities of people with schizophrenia also appear to be impaired.

These impairments in cognitive functioning can set up a vicious cycle that leads to a worsening of the individual’s situation. Problems in memory, planning, and processing speed, for example, interfere with the ability to hold mentally challenging jobs. The limitations people with schizophrenia have in social cognition and communication make it particularly difficult for them to work in people-oriented jobs. Unable to maintain consistent employment, they can slip into poverty, which further stresses their ability to lead a productive life. Living in high-poverty areas in turn places them at risk for engaging in substance abuse, which can contribute to the symptoms they experience as a result of their disorder.

Psychological Treatments

For many years, the most common psychological interventions for people with schizophrenia were behavioral treatments intended to lower the frequency of maladaptive behaviors that interfere with social adjustment and functioning. These interventions typically employed the token economy method of contingency management in which institutionalized individuals received rewards for acting in socially appropriate ways. The expectation was that, over time, the new behaviors would become habitual and the person would not depend on reinforcement in order to engage in that behavior. However, the token economy as a form of intervention is no longer practical, given that most individuals with schizophrenia receive treatment in the community. In addition, there is little data on its effectiveness, and with clinicians focusing on evidence-based treatment, the profession cannot justify its use.

More promising is cognitive-behavioral therapy, an approach most effective when administered as an adjunct to pharmacological treatments. Clinicians using cognitive-behavioral therapy for psychosis (CBTp) do not try to change clients’ delusions or eliminate their hallucinations but instead try to reduce their distress and preoccupation with these symptoms. In addition, they attempt to teach their clients coping skills to improve their ability to live independently. They might assign their clients the homework of keeping a diary of their experiences of hearing voices or making a “reality check” of their delusional beliefs.

Researchers are also developing interventions to help address the cognitive deficits of individuals with schizophrenia, particularly those who suffer from primarily negative symptoms. Like those who seek physical fitness training, people with schizophrenia can receive individualized training, in this case cognitive training, that builds on their current level of functioning to restore or enhance their performance. Cognitive training is guided by findings from neuroscience showing that people with schizophrenia have deficits in memory and sensory processing.

Sociocultural Theories

In some of the earliest formulations of the causes of schizophrenia, psychological theorists proposed that disturbed patterns of communication in a child’s family environment could precipitate the development of the disorder. Clinicians thought these disturbances in family relationships (deviant patterns of communication and inappropriate ways that parents interacted with their children) led to the development of defective emotional responsiveness and cognitive distortions fundamental to the psychological symptoms of schizophrenia.

Contemporary researchers have approached the issue of the extent to which family communications contribute to the disorder by trying to predict outcome or recovery in adults hospitalized for schizophrenia. Instead of regarding a disturbed family as the cause of schizophrenia, they view it as a potential source of stress in the environment of the person trying to recover from a schizophrenic episode. The stress family members create is called expressed emotion (EE) and includes interactions with the individual that reflect criticism, hostile feelings, and emotional overinvolvement or overconcern.

Supporting the concept of EE as a source of stress, researchers find that people living in families high in EE are more likely to suffer a relapse, particularly if they are exposed to high levels of criticism. When in treatment, these individuals may also develop less trust in their therapists. EE may also affect the way that people with schizophrenia process social information. Researchers found higher activation in brain regions involved in self-reflection and sensitivity to social situations when exposing schizophrenic patients to speech that was high in EE compared to neutral speech.

It goes without saying that research on EE could never employ an experimental design, and this has been a criticism of the research. Even EE critics, however, recognize that the presence of an individual with schizophrenia creates stress within the family, even if the individual is not living at home. The client’s disorder can affect parents, siblings, and even grandparents, particularly when the symptoms first begin to emerge in the early adult years.

Sociocultural Theories

Moving beyond the family environment, researchers have also studied broader social factors, such as social class and income, in relationship to schizophrenia. In perhaps the first epidemiological study of mental illness in the United States, Hollingshead and Redlich observed that schizophrenia was far more prevalent in the lowest socioeconomic classes.

A number of researchers have since replicated the finding that more individuals with schizophrenia live in the poorer sections of urban areas. One possible interpretation of this finding is that people with schizophrenia experience downward drift, meaning that their disorder drives them into poverty, which interferes with their ability to work and earn a living. The other possibility is that the stress of living in isolation and poverty in urban areas contributes to the risk of developing schizophrenia.

People born in a country other than the one in which they are currently living (those who have migrant status) also have higher rates of schizophrenia. The individuals most at risk for schizophrenia are those who migrate to lower-status jobs and urban areas, where they are more likely to suffer from exposure to environmental pollutants, stress, and overcrowding. However, as the number of ethnic minorities in a neighborhood increases, the rates of schizophrenia become lower, suggesting that these individuals benefit from less exposure to discrimination and more opportunities for social support in their immediate environments.

Sociocultural Theories

Other sociocultural risk factors for schizophrenia, or at least for symptoms of psychosis, include adversity suffered in childhood, such as parental loss or separation, abuse, and bullying. In adulthood, individuals more vulnerable to first or subsequent episodes of psychosis include people who have experienced severely stressful life events, including being a victim of assault. Individuals with high genetic risk who are exposed to environmental stressors are more likely than others who experience mild psychotic symptoms to develop a full-blown disorder.

Recognizing that the causes of schizophrenia are multifaceted and develop over

time, Stilo and Murray proposed a developmental cascade hypothesis that

integrates genetic vulnerabilities, damage occurring in the prenatal and early

childhood periods, adversity, and drug abuse as ultimately leading to changes in

dopamine expressed in psychosis. In the figure to the right, the specific genes

affected by schizophrenia are shown as developmental genes, or those that play a

role in brain development, and as neurotransmitter genes, which play a more

direct role in neural activity.

Sociocultural Treatments

The coordination of services is especially important in programs geared toward helping people with schizophrenia. One approach to integrating various services is assertive community treatment (ACT), in which an interprofessional team representing psychiatry, psychology, nursing, and social work reaches out to clients in their homes and workplaces.

ACT’s focus is on engendering empowerment and self-determination in its “consumers,” the term such teams use to refer to their clients. Typically, a team of about a dozen professionals work together to help approximately 100 consumers with issues such as complying with medical recommendations, managing their finances, obtaining adequate health care, and dealing with crises when they arise. This approach brings care to the clients, rather than waiting for them to come to a facility for help, a journey that may be too overwhelming for seriously impaired people. Although approaches such as ACT are expensive, the benefits are impressive. Researchers have conducted dozens of studies on the effectiveness of ACT and have concluded that it has had significant positive impact in reducing hospitalizations, stabilizing housing in the community, and lowering overall treatment costs.

As effective as it can be, critics charge that ACT is not provided in a manner consistent with its goal of empowering consumers and instead is coercive and paternalistic. To address this charge, ACT researchers are investigating the possibility of combining ACT with another program, called illness management and recovery (IMR). In IMR, consumers receive training in effective ways to manage their illnesses and pursue their goals for recovery. Resting on the principle of self-determination, IMR assumes consumers should be given the resources they need to make informed choices. The program uses peers and clinicians to deliver structured, curriculum-based interventions. Although an initial investigation of ACT-IMR revealed that the providers experienced a number of difficulties in implementing the program, it appeared to reduce hospitalization rates.

Schizophrenia: The Biopsychosocial Perspective

Definitions and diagnostic approaches to schizophrenia are undergoing significant revisions, but throughout the past decade, researchers have gained a great deal of understanding about its many possible causes. Perhaps most exciting is the evolution of an integrated approach to theories that focus on underlying brain mechanisms as expressed in cognitive deficits. Treatment is moving beyond the provision of medication to greater use of evidence-based psychological interventions. Finally, researchers appear to be gaining greater appreciation of the role of sociocultural influences. Together, these advances are increasing the chances that

individuals with these disorders will receive integrated care, maximizing their chances of recovery.

Clinicians, also, increasingly understand schizophrenia from a life-span perspective. The needs and concerns of individuals with this disorder vary over the years of adulthood, and many recover. Thus, researchers and mental health practitioners are recognizing that part of their job is to provide ways to help people with long-term schizophrenia adapt to changes in both the aging process and the evolution of the disease. The idea that schizophrenia is a neurodevelopmental disorder highlights this important new focus and provides a basis for interventions that take into account individual changes over time.

Sources

Image 1: Text, page 148

Image 2: https://www.verywellmind.com/positive-symptoms-in-schizophrenia-2953124

Image 3: https://www.verywellmind.com/negative-symptoms-in-schizophrenia-2953123

Image 4: Text, page 148

Image 5: Text, page 151

Image 6:

https://www.google.com/search?q=schizophrenia+graphic&client=safari&rls=en&source=lnms&tbm=isch&sa=X&ved=2ahUKEwin85WZhLLpAhV OTt8KHX0wBR4Q_AUoAXoECAsQAw&biw=1289&bih=716&dpr=2#imgrc=VSy8PmWKnUkQ0M

Image 7: Text, page 158

Image 8: Text, page 161

Image 9: https://saynopetodope.org.nz/young-people/

Image 10: Text, page 165

Image 11: https://www.verywellmind.com/schizophrenia-what-you-need-to-know-4156588

Video 1: https://www.youtube.com/watch?v=JmiARS9TIj8

Video 2: https://www.youtube.com/watch?v=K2sc_ck5BZU

Text: Whitbourne, Susan Krauss. Abnormal Psychology: Clinical Perspectives on Psychological Disorders. McGraw-Hill Higher Education.