Chapter 13
Schizophrenia Spectrum and
Other Psychotic Disorders
Chapter Overview
This chapter outlines the primary features of schizophrenia and related psychotic disorders.Positive, negative, and disorganized symptoms as well as the historic subtypes of schizophrenia are described.Related problems include schizophreniform, schizoaffective, delusional, and brief psychotic disorders.Etiological factors, relapse, and treatment are discussed, as are the significant changes in this category of diagnoses that has occurred in the switch to DSM-5.
Chapter Outline
PERSPECTIVES ON SCHIZOPHRENIA
Early Figures in Diagnosing Schizophrenia
Identifying Symptoms
CLINICAL DESCRIPTION, SYMPTOMS, AND SUBTYPES
Positive Symptoms
Negative Symptoms
Disorganized Symptoms
Historic Schizophrenia Subtypes
Other Psychotic Disorders
PREVALENCE AND CAUSES OF SCHIZOPHRENIA
Statistics
Development
Cultural Factors
Genetic Influences
Neurobiological Influences
Psychological and Social Influences
TREATMENT OF SCHIZOPHRENIA
Biological Interventions
Psychosocial Interventions
Treatment across Cultures
Prevention
Detailed Outline
Perspectives on Schizophrenia
Schizophrenia is a complex syndrome that has been recognized for many years. Perhaps the earliest and best description of this disorder was published in 1809by John Haslam in his book Observations on Madness and Melancholy.
A number of historic figures during the 19th and early 20th century contributed to the evolving definitions and possible causes of this spectrum of disorders.
Clinical Description, Symptoms, and Subtypes
Schizophrenia is characterized by a broad spectrum of cognitive and emotional dysfunctions that include delusions and hallucinations, disorganized speech and behavior, and inappropriate emotions.
The symptoms of schizophrenia can be divided into positive, negative, and disorganized. Positive symptoms are active manifestations of abnormal behavior, or an excess or distortion of normal behavior, and include delusions and hallucinations. Negative symptoms involve deficits in normal behavior on such dimensions as affect, speech, and motivation. Disorganized symptoms include rambling speech, erratic behavior, and inappropriate affect.
Discussion Point:
From your perspective, which of the symptoms types of schizophrenia would be most distressing or debilitating?
Psychotic behaviors, such as hallucinations and delusions, characterize several other disorders; these include schizophreniform disorder (which includes people who experience the symptoms of schizophrenia for less than 6 months); schizoaffective disorder (which includes people who have symptoms of schizophrenia and who exhibit the characteristics of mood disorders, such as depression and bipolar affective disorder); delusional disorder (which includes people with a persistent belief that is contrary to reality, in the absence of the other characteristics of schizophrenia); and brief psychotic disorder (which includes people with one or more positive symptoms, such as delusions, hallucinations, or disorganized speech or behavior over the course of less than a month).
A proposed new disorder – attenuated psychosis syndrome – which includes one or more of the symptoms of schizophrenia such as hallucinations or delusions, but the individual is aware that these are unusual experiences and not typical for healthy persons. This is included in the Appendix of DSM-5 as a disorder in need of further study.
Prevalence and Causes of Schizophrenia
A number of causative factors have been implicated for schizophrenia, including genetic influences, neurotransmitter imbalances, structural damage to the brain caused by a prenatal viral infection or birth injury, and psychological stressors.
Discussion Point:
What are some possible explanations for gender differences in the onset of schizophrenia?How might gender influence the prognosis of someone with this disorder?
Relapse appears to be triggered by hostile and critical family environments characterized by high expressed emotion.
Discussion Point:
With the contribution of endophenotype research to the understanding of schizophrenia, how might the diagnosis and classification of this disorder change?How is treatment likely to be affected?
Treatment of Schizophrenia
Successful treatment for people with schizophrenia rarely includes complete recovery. The quality of life for these individuals can be meaningfully affected, however, by combining antipsychotic medications with psychosocial approaches, employment support, and community-based and family interventions.
Treatment typically involves antipsychotic drugs that are usually administered with a variety of psychosocial treatments, with the goal of reducing relapse and improving skills in deficits and compliance in taking the medications. The effectiveness of treatment is limited, because schizophrenia is typically a chronic disorder.
Key Terms
schizophrenia, 477delusional disorder, 486
catatonia, 478shared psychotic disorder
hebephrenia, 478 (folie a deux), 487
paranoia, 478substance-induced psychotic
dementia praecox, 478 disorder, 488
associative splitting, 478psychotic disorder associated
psychotic behavior, 480 with another medical
positive symptoms, 480 condition, 488
delusion, 480brief psychotic disorder, 488
hallucination, 482attenuated psychosis
negative symptoms, 483 syndrome, 488
avolition, 483schizotypal personality
alogia, 483 disorder, 488
anhedonia, 483prodromal stage, 490
flat affect, 484schizophrenogenic mother,
disorganized speech, 484 498
inappropriate affect, 484double bind communication,
catatonic immobility, 485 498
schizophreniform disorder,expressed emotion (EE), 498
486token economy, 502
shizoaffective disorder, 486
Ideas for Instruction
1.Activity: Name that Symptom! To test students’ understanding of the different symptoms of schizophrenia, divide the class into several teams.Prepare clinical examples of the various symptom categories.Take turns reading an example to each team, which then has a chance to determine the symptom being described.If the first team does not get the answer correct, then the next team can try.Examples of the clinical symptoms include the following:
- Disorder of thought content or delusion.The flicker of candles communicates secret messages about me to aliens.
- Delusion of grandeur.I am Queen of Eastern Europe.
- Delusion of persecution.The CIA is tracking me and planning on assassinating me in my sleep.
- Auditory hallucination.Voices tell me to jump out of windows.
- Visual hallucination.I can see large spiders crawling up my walls.
- Olfactory hallucination.I smell my family’s pets around me.
- Tactile hallucination.I feel little bugs crawling under my skin.
- Tangentiality.Oh, you want to know where I was, well, my brother called me to come over and he works on cars at a shop in town that has money problems.
- Loose association.I went to the store, but the violin was fixed so I could return to church and pray.
- Waxy flexibility and catatonic immobility.(Demonstrate).
- Alogia.(Ask a student to question you and then respond in monosyllables).
These represent one example per symptom, but you can provide additionalexamples.Keep score so you can determine the team that wins the most points.
You may want to reward the winning team with extra credit points to get students invested in learning the material.
2.Video Activity: Schizophrenia. Show the film segment from Abnormal Psychology Inside/Outthat presents an interview with a patient named Edna, who displays disordered thoughts and delusions. This segment nicely demonstrates positive and negative symptoms, disorganized thoughts, and delusions associated with schizophrenia. During the interview, Edna also displays extrapyramidal symptoms.Ask your students to try and identify and classify the symptoms she displays during the interview and to attempt to diagnose her type of schizophrenia.
3.Schizophrenia.The word schizophrenia is so widely misused that you should spend some time differentiating schizophrenia from multiple personality disorder by developing a lecture on this topic. A short history of terminology, from Kraepelin’s dementia praecox to Bleuler’s schizophrenia, would be useful… A listing of Bleuler’s four As (what he considered to be the fundamental symptoms of the schizophrenic spectrum disorders) helps dispel the idea that schizophrenics are anything like the three faces of Eve. The four As are association (thought disorder), affect (inappropriate or blunted), ambivalence (indecisive in carrying out daily activities), and autism (withdrawal into self).
Supplementary Reading Material
Additional Readings:
Andreasen, N. C., & Flaum, M. (1991). Schizophrenia: The characteristic symptoms. Schizophrenia Bulletin, 17,27-48.
Birchwood, M. J. (1989). Schizophrenia: An integrated approach to research and treatment.New York: New York University Press.
Brown, M. J., & Roberts, D. P. (2000). Growing up with a schizophrenic mother. Jefferson, NC: McFarland.
Chapman, L. J., & Chapman, J. P. (1980). Scales for rating psychotic and psychoticlike experiences as continua. Schizophrenia Bulletin, 6,476-489.
Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company.Chapter 7, Schizophrenia.
Cromwell, R. L., & Snyder, C. R. (Eds.) (1993). Schizophrenia: Origins, processes, treatment, and outcome.New York: Oxford University Press.
Farber, S. (Ed.) (1993). Madness, heresy, and the rumor of angels: The revolt against the mental health system.Chicago: Open Court.
Fowles, D. C. (1992). Schizophrenia: Diathesisstress revisited. Annual Review of Psychology, 43, 303-336.
Gray, J. A., Feldon, J., Rawlins, J. N. P., Hemsley, D. R., & Smith, A. D. (1991). The neuropsychology of schizophrenia. Behavioral and Brain Sciences, 14,1-84.
Green, M. F. (2001). Schizophrenia revealed: From neurons to social interactions. New York: W. W. Norton.
Hatfield, A. B., & Lefley, H. P. (1993). Surviving mental illness: Stress, coping and adaptation. New York: Guildford.
Heinrichs, R. W. (2001). In search of madness: Schizophrenia and neuroscience. New York: Oxford University Press.
Johnstone, E. C., Humphreys, M. S., Lang, F. H., Lawrie, S. M., & Sandler, R. (1999). Schizophrenia: Concepts and clinical management. New York: Cambridge University Press.
Leudar, I., & Thomas, P. (2000). Voices of reason, voices of insanity: Studies of verbal hallucinations. Florence, KY: Taylor and Francis/Routledge.
Lidz, T. (1985). Schizophrenia and the family.New York: International Universities Press.
Malone, J. A. (1992). Schizophrenia: Handbook for clinical care.Thorofare, NJ: SLACK Inc.
Nicholson, I. R., & Neufeld, R. W. J. (1993). Classification of the schizophrenias according to symptomatology: A twofactor model. Journal of Abnormal Psychology, 102,259-270.
Robbins, M. (1993). Experiences of schizophrenia: An integration of the personal, scientific, and therapeutic. New York: Guilford Press.
Sattler, D., Shabatay, V., & Kramer, G. (1998). Abnormal psychology in context: Voices and perspectives. Boston, MA: Houghton Mifflin Company.Chapter 7, Schizophrenia.
Schiller, L., & Bennett, A. (1996). The quiet room: A journey out of the torment of madness.New York:Harper.
Straube, E. R., & Hahlweg, K. (Eds.) (1990). Schizophrenia: Concepts, vulnerability, and intervention.New York: Springer-Verlag.
Torrey, E. F. (1995). Surviving schizophrenia: A manual for families, consumers, and providers.New York:Harper.
Warner, R. (2000). The environment of schizophrenia: Innovations in practice, policy and communications. Philadelphia, PA: Brunner-Routledge.
Weiden, P. J., Diamond, R. J., Scheifler, P. L., Flynn, L., Diamond, R. I., & Ross, R. (Eds.) (1999). Breakthroughs in antipsychotic medications: A guide for consumers, families, and clinicians.New York: W.W. Norton.
Suggested Videos
A beautiful mind. This film presents the life of John Nash, a Nobel Prize winning mathematician, and his experience with schizophrenia.(Instructors may wish to emphasize that the movie takes great license with the actual life story of Dr. Nash. The depiction of hallucinations, delusions, and the difficulty a person with schizophrenia may have distinguishing reality from fantasy is nonetheless very valuable as a teaching tool)
Abnormal Psychology Inside/Out. (Available through your Cengage Learning representative).Presents the case of a patient named Edna, who displays disordered thoughts and delusions. This segment demonstrates positive and negative symptoms, disorganized thoughts, and delusions associated with schizophrenia. During the interview, Edna also displays extrapyramidal symptoms. (15 min)
Antipsychotic agents. (Insight Media). Examining the medications used to alleviate psychotic symptoms, this video features reenactments that illustrate positive and negative symptoms as well as such features as cognitive dysfunction and dysphonic mood. It presents commonly prescribed agents used in the treatment of acute psychotic symptoms; addresses precautions, side effects, and drug interactions; and includes interviews in which professionals and patients discuss the impact of antipsychotic agents on patients with psychotic symptoms. (23 min)
Birdy. This film depicts a catatonic inpatient in a military hospital who is also a Vietnam veteran.
Dark side of the moon. (Fanlight Productions).This film documents the struggles and successes of three formerly homeless men with mental illnesses. (25 min)
Deficits of mind and brain. (Available through your Cengage Learning representative).The second module begins with an overview of schizophrenia.Also provided are diagnostic criteria and examples of patients in therapy (showing thought insertion, thought withdrawal, and paranoid delusions). In the second portion of this module, four patients suffering from schizophrenia are presented. The third portion of this module uses the Wisconsin Card Sorting Task to demonstrate how lesion location has different effects on task completion.The fourth portion introduces PET imaging techniques for isolating patterns in cerebral processing across brain structures, the fifth describes cognitive deficits, and the sixth covers cognitive neuroscience and schizophrenia. The last portion covers genetics and schizophrenia.
First break. (Fanlight Productions). This film documents the impact of the “first break” of mental illness in three young people in their teens and early twenties, as well as the effects on their families. (51 min)
I never promised you a rose garden.The patient depicted in this film has command hallucinations that tell her to kill herself.The film provides a sympathetic portrayal of psychiatry and treatment.
One flew over the cuckoo’s nest.This classic film stars Jack Nicholson as a patient in a psychiatric hospital.The film depicts life on an inpatient ward, including controversial treatments such as ECT and frontal lobotomies.
Repulsion.This is an intense film about sexual repression and psychotic decompensation, providing good examples of hallucinations.
Rosenhan’s Experiment: Being Sane in Insane Places. (Insight Media). In 1973, psychologist David Rosenhan conducted a study in which eight mentally healthy pseudo-patients entered psychiatric institutions in order to test the validity of psychiatric diagnosis. The pseudo-patients mimicked symptoms of either schizophrenia or bipolar disorder to get admitted and then quickly stopped these behaviors once inside the hospital. This DVD looks at the methodological strengths and weaknesses of this classic study, reviews its findings, and considers its relevance today. (19 min)
The snake pit.This is one of the first films to document the treatment of patients in mental hospitals.
To Define True Madness: Concepts of Schizophrenia. (Insight Media). Exploring historical ideas of mental illness in different cultures, this program shows how early theories of mental illness based on spirit or divine possession gave way to secular, scientific views. It considers the sense of self and the idea of losing one’s mind, questioning if this defines a society’s ideas of personhood. (59 min)
OnlineResources
Mental Health Net Schizophrenia
This page provides an outstanding starting point for up-to-date information about the diagnosis, etiology, and treatment of schizophrenia, including numerous links to patient and scholarly websites.
National Alliance of the Mentally Ill
This site is a useful resource for information related to the treatment of severe mental illness, including legal issues and national health policy guidelines.
NIMH Schizophrenia: Questions and Answers
This is a site containing questions and answers regarding schizophrenia provided by the National Institute of Health.
Psych Central -- Schizophrenia
Site with lots of information about schizophrenia and available treatment options.
Schizophrenia.Com Home Page
Provides links to other webpages devoted to schizophrenia.This is a good starting place for finding information on schizophrenia on the Internet.
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WARNING SIGNS OF
SCHIZOPHRENIA
Hearing or seeing something that isn’t there
A constant feeling of being watched
Peculiar or nonsensical way of speaking or writing
Strange body positioning
Feeling indifferent to very important situations
Deterioration of academic or work performance
A change in personal hygiene and appearance
A change in personality
Increasing withdrawal from social situations
Irrational, angry, or fearful response to loved ones
Inability to sleep or concentrate
Inappropriate or bizarre behavior
Increased withdrawal from social situations
Extreme preoccupation with religion or the occult
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