Topic: Schizophrenia
Course: Clinical psychology PSX_002
Student: Elena Gerovska 440 959
Teacher: PhDr. Pavel Humpolíček
March, 2015
What is schizophrenia?
• Schizophrenia is a syndrome of unknown etiology characterized by disturbances
in cognition, emotion, perception, thinking, and behavior.
• The expression of these manifestations varies across patients and over time, but
the effect of the illness is always severe and is usually long-lasting.
• The disorder is usually chronic, with a course encompassing a prodromal phase,
an active phase, and a residual phase.
Epidemiology
• Schizophrenia affects just less than 1 percent of the world’s population (Kaplan &
Sadock, 2005).
• If schizophrenia spectrum disorder are included in the prevalence estimates, then
the number of affected individuals increases to approximately 5 percent (Kaplan
& Sadock, 2005).
Etiology
• The etiology and pathogenesis of schizophrenia is not known yet.
• It is accepted generally, that in the case of schizophrenia we are dealing with “the
group of schizophrenias” which origins is multi-factorial with participation of
internal (genetic, inborn and biochemical) and external (trauma, infection of
CNS, stress) factors.
• The stress diathesis model is most often used, which states that the person in
whom schizophrenia develops has a specific biological vulnerability, or diathesis,
that is triggered by stress and leads to schizophrenic symptoms.
• Stressors may be genetic, biological, and psychosocial or environmental.
Genetic – Both single-gene and polygenic theories have been proposed.
Although neither theory has been definitely substantiated, the polygenic theory
appears to be more consistent with the presentation of schizophrenia.
o Consanguinity – Incidence in families is higher than in the general
population, and monozygotic twins concordance is greater than dizygotic.
o Adoption studies
a) The prevalence of schizophrenia is greater in the biological parents of
schizophrenic adoptees than in adoptive parents.
b) Monozygotic twins reared apart have the same concordance rate as
twins reared together.
c) Rates of schizophrenia are not increased in children born to unaffected
parents but raised by a schizophrenic parent.
Biological
o Dopamine hypothesis – Schizophrenic symptoms may result from increased
limbic dopamine activities (positive symptoms) and decreased frontal dopamine
activity (negative symptoms).
o Norepinephrine hypothesis – Increased norepinephrine levels in schizophrenia
lead to increased sensitization to sensory input.
o GABA hypothesis – Decreased GABA activity results in increased dopamine
activity.
o Serotonin hypothesis – Serotonin metabolism apparently is abnormal in some
chronically schizophrenic patients, with both hyperserotoninemia and
hyposerotoninemia being reported. Specifically, antagonism at the serotonin 5HT2
receptor has been emphasized as an important in reducing psychotic
symptoms and the development of movement disorders related to D2
antagonism. Research on mood disorders has implicated serotonin activity in
suicidal and impulsive behavior, which schizophrenic patients can also exibit.
o Glutamate hypothesis – Hypofunction of the glutamate N-methyl-D-aspartate
(NMDA)-type receptor is theorized to cause both positive and negative symptoms
of schizophrenia based on the observed psychotogenic effects of the NMDA
antagonists phencyclidine and ketamine (Ketalar), in addition to the observed
therapeutic effects of the NMDA antagonists glycine and D-cycloserine.
o Neurodevelopmental theories – There is evidence of abnormal neuronal
migration during the second trimester of fetal development. Abnormal neuronal
functioning may lead to the emergence of symptoms during adolescence.
Psychosocial and environmental
o Family factors
o Gestational and birth complications
o Exposure to influenza epidemics or maternal starvation during pregnancy
o Rhesus (Rh) factor incompatibility etc.
Diagnosis and symptoms
• Schizophrenia is a disorder whose diagnosis is based on observation and
description of the patient.
• Abnormalities are often present on most components of the mental status
examination.
• There are no pathognomonic signs or symptoms.
• General functioning
o Overall functioning – Level of functioning declines or fails to achieve the
expected level
o Thought content – Abnormal (e.g., delusions, poverty of content)
o Form of thought – Illogical (e.g., incoherence, neologisms, echolalia)
o Affect – Abnormal (e.g., flat, silly, labile, inappropriate)
o Sense of self – Impaired (e.g., loss of ego boundaries, gender confusion,
inability to distinguish internal from external reality)
o Volition – Altered (e.g., inadequate drive or motivation and marked
ambivalence)
o Interpersonal functioning – Impaired (e.g., social withdrawal and emotional
detachment, aggressiveness, sexual inappropriateness)
o Psychomotor behavior – Abnormal or changed (e.g., agitation versus
withdrawal, grimacing, posturing, rituals, catatonia)
o Cognition – Impaired (e.g., inattention, impaired information processing)
• Key features
o Delusions - Fixed beliefs that are not amenable to change in light of conflicting
evidence.
Variety of themes
Persecutory – belief that one is going to be harmed, harassed, and so forth by an
individual, organization, or other group.
Referential – belief that certain gestures, comments, environmental cues, and so
forth are directed at oneself.
Grandiose – when an individual believes that he or she has exceptional abilities,
wealth, or fame.
Erotomanic – when an individual believes falsely that another person is in love
with him or her.
Nihilistic – conviction that a major catastrophe will occur.
Somatic – preoccupation with health and organ function.
Thought withdrawal – belief that one’s thoughts have been “removed” by some
outside force.
Thought insertion – belief that alien thoughts have been put into one’s mind
Delusions of control – belief that one’s body or actions are being acted on or
manipulated by some outside force.
o Halucinations - Perception-like experiences that occur without an external
stimulus. They may occur in any sensory modality, but auditory hallucinations
are the most common in schizophrenia and related disorders.
o Disorganized thinking - Typically inferred from the individual’s speech.
The symptom must be severe enough to substantially impair effective
communication.
Less severe disorganized thinking or speech may occur during the prodromal and
residual periods of schizophrenia.
Manifestations:
Derailment or loose associations – when the individual switches from one topic
to another
Tangentiality – answers to questions may be obliquely related or completely
unrelated
Incoherence or “word salad” – the speech may be so severely disorganized that
it’s nearly incomprehensible and resembles aphasia in its linguistic disorganization.
o Grossly disorganized or abnormal behavior - Varies from childlike
silliness to unpredictable agitation.
Problems may be noted in any form of goal-directed behavior.
Catatonic behavior is a marked decrease in reactivity to the environment.
Negativism – resistance to instructions
Mutism – lack of verbal responses
Stupor – lack of motor responses
Catatonic excitement – purposeless and excessive motor activity without obvious
cause
Stereotyped movements
Staring
Grimacing
o Negative symptoms
Diminished emotional expression – includes reductions in the expression of
emotions in the face, eye contact, intonation of speech, and movements of the
hand, head, and face that normally give an emotional emphasis to speech.
Avolition – decrease in motivated self-initiated purposeful activities.
Alogia – diminished speech output
Anhedonia – decreased ability to experience pleasure from positive stimuli or a
degradation in the recollection of pleasure previously experienced.
Asociality – apparent lack of interest in social interactions.
Types of schizophrenia
• Paranoid
• Disorganized schizophrenia / Hebephrenia
• Catatonic
• Undifferentiated
• Residual
• Simple
• Other subtypes
Prognosis
In terms of overall prognosis, some investigators have described a loose rule of
thirds: approximately one third of patients lead somewhat normal lives, one third
continue to experience significant symptoms but can function within society, and the
remaining one-third are markedly impaired and require frequent hospitalization.
Approximately 10% of this final third of patients require long-term institutionalization.
Treatment
• Pharmacologic treatment
• Electro-convulsive therapy
• Psychosocial treatment
Used literature:
• Diagnostic and statistical manual of mental disorders: DSM-5. (c2013). (5th ed.,
xliv, 947 p.) Washington, D.C.: American Psychiatric Publishing.
• ICD-10 Version:2015. (n.d.). Retrieved March 14, 2015, from
http://apps.who.int/classifications/icd10/browse/2015/en#/F20-F29
• Raboch, J., & Pavlovský, P. (2004). Basic psychopathological terms and
psychiatric diagnoses. (1. vyd., 203 s.) Praha: Karolinum.
• Sadock, B., & Sadock, V. (c2005). Kaplan & Sadock's comprehensive textbook of
psychiatry. (8th ed., xlviii, 2054 s.) Philadelphia: Lippincott Williams & Wilkins.
• Sadock, B., & Sadock, V. (c2009). Kaplan & Sadock's concise textbook of child
and adolescent psychiatry. (1st ed.) Philadelphia: Lippincott, Williams &
Wilkins.
• Sadock, B., & Sadock, V. (c2010). Kaplan & Sadock's pocket handbook of clinical
psychiatry. (5th ed., p. 566). Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins.