Chapter 5

Schizophrenia

Description of the Disorder

• Characterized by broad daily impairments– Social functioning– Difficulties caring for oneself

• Burdensome for caregivers– Those with insufficient care often end up in jail or

homeless • Positive and negative symptoms• Cognitive impairments • Mood difficulties

Clinical Picture cont.

• Positive symptoms (e.g., hallucinations or delusions)– Tend to fluctuate in presence/severity

• Negative symptoms (e.g., blunted affect, anhedonia, or psychomotor retardation)– Tend to be more stable and less responsive to

certain types of medication• Cognitive impairments (e.g., planning)

Clinical Picture cont.

• Co-occuring mood disturbance or anxiety is common – Depression

• Associated with poor outcomes

– Anxiety• Contributes to formation and maintenance of delusions

• Suicide– As many as 10% with schizophrenia die from suicide

• Substance use problems• Lack of insight ( denial of illness)• Refusal to comply with treatment

Clinical Picture cont.

• Higher rates of violence?– Most individuals with the disorder are not violent

or aggressive toward others; far more likely to be victims of crimes

– Often report some type of victimization– Sexual assault or physical abuse frequently

reported frequently

Diagnostic Considerations

• Positive and negative symptoms last at least 6 months. • Social dysfunction• Does not occur exclusively during a mood disturbance• Medical examination

– Rule out drugs that may mimic psychotic symptoms– Rule out brain insults (e.g., tumors)

• Family history• Comorbid disorders

– SUDs (most common)– Mood disorders

Diagnostic Considerations cont.

• Differential diagnosis– Schizoaffective disorder • Meet criteria for a mood episode• Also exhibit symptoms of schizophrenia during a period

without mood episode• Mood episode must be present for a substantial period of

the illness

– Delusional disorder• Delusions: Specify type and if bizarre• No other symptoms of schizophrenia aside from tactile or

olfactory hallucinations

Epidemiology

• About 2.2 million people have schizophrenia in the United States, 51 million worldwide– Annual incidence ranges from 8 to 40 per 100,000

• 0.7% lifetime risk for developing schizophrenia• Prevalence is stable across cultures– Some evidence that the disorder is more common

in urban areas of industrialized countries• Onset most likely occurs in early adulthood• Some evidence for association with low SES

Assessment

• Psychological assessment– Measures for severity of positive and negative

symptoms• PANNS, BPR, and PSYRATS

– Assessing cognition in individuals with schizophrenia• NIMH-MATRICS

– Social skills

Assessment cont.

• Family assessment– Expressed emotion• Important stressor that may increase the chance of

relapse and rehospitalization

– Family burden• Family interventions may have a significant impact on

reducing relapse rates

Assessment cont.

• Biological assessment– Rule out organic factors (e.g., tumor, stroke, or

substance abuse)– fMRI and other imaging techniques show

structural changes in the brain

Etiological Considerations

• Behavioral genetics– Higher rate of schizophrenia among offspring of

individuals with schizophrenia than in the general population• 50% chance of developing schizophrenia if both parents

have schizophrenia, 13% if one parent

– Concordance rate in monozygotic twins is between 25% and 50%, compared to 6% to 15% for dizygotic twins

Etiological Considerations cont.

• Behavioral genetics– Because rate is not 100%, even among

monozygotic twins, it is likely that there is a gene–environment interaction• Expressed emotion in the family• Familial burden

Etiological Considerations cont.

• Neuroanatomy and neurobiology– Dopamine hypothesis: Overabundance of

dopamine in certain limbic areas of the brain may be responsible for positive symptoms, while a lack of dopamine in cortical areas may be responsible for negative symptoms

– Role of serotonin, glutamate, and GABA– Enlarged ventricles and decreased brain volume

and blood flow to cortical areas

Etiological Considerations cont.

• Learning and modeling– Role of operant conditioning in delusions and

hallucinations• More relevant for maintenance of the disorder than

etiology

• Life events– Stress-vulnerability model

Etiological Considerations cont.

• Cognitive influences– Cognitive deficits are a common and persistent

feature of the disorder• Interfere with a person’s ability to interact effectively

with others, perform basic daily activities, or sustain attention

– Impairment in social cognition– Attributional style

Etiological Considerations

• Sex– Women have milder overall course and later onset– Men are more likely to receive treatment

• Cultural/ethnic considerations– Individuals with schizophrenia are perceived differently

in less-industrialized countries• Course is more benign in these countries

– Hispanic families tend to be more accepting and less blaming of persons with schizophrenia

– Stigma exists in Westernized countries

Course and Prognosis

• Onset usually occurs between 16 and 25 years of age– Onset in childhood is rare; more common but still

rare is onset in late adulthood– Prodromal periods prior to the emergence of the

disorder are common• Include disruptions in sleep, anxiety, depression, and

aggression/irritability, among others

• Onset may be gradual or acute

Course and Prognosis cont.

• Typically a long-term illness– Considerable variability exists in course and

outcome across individuals; however, degrees of the disorder are typically present throughout most of life.

• Better prognosis – Earlier antipsychotic medications initiation– Sex (women)– Interplay of biological factors, treatment, substance

use, and social support