Schizophrenia Spectrum Disorders

I. Schizophrenia: a chronic psychotic disorder characterized by disturbed behavior, thinking, emotions, and perceptions.

Acute episodes of schizophrenia are characterized by delusions, hallucinations, illogical thinking, incoherent speech, and bizarre behavior.

A. Positive Symptoms: involve a break with reality, as represented by the appearance of hallucinations and delusional thinking.

B. Negative Symptoms: affect the person’s ability to function in daily life and include such features as lack of emotions or emotional expression, loss of motivation, loss of pleasure in normally pleasant activities, social withdrawal or isolation, and limited output of speech.

C. Diagnostic Criteria

1) At least one month of two or more of the following symptoms with at least one being a, b, or c.

a) Delusionsb) Hallucinationsc) Disorganized speechd) Grossly disorganized behavior or catatonic behaviore) Negative symptoms

2) A significant drop since the onset of symptoms in level of functioning such as work, self-care, interpersonal relations or academic performance. 3) Six months of disturbance with at least 1 month of the symptoms listed in (1). Additionally, other disorders and the use of certain drugs must be ruled out that can mimic the symptoms of schizophrenia.

D. Course of Development

1) Prodromal Phase: the period of gradual deterioration involving unusual thoughts and perceptions without delusions or hallucinations.

2) Residual Phase: the phase that follows an acute phase, characterized by a return to the level of functioning of the prodromal phase.

E. Prevalence of Schizophrenia

Schizophrenia affects about 1% of the U.S. population and about 0.3% to 0.7% of the global population. 

Men are slightly more likely to develop schizophrenia, but it is essentially equally common among men and women. 

The peak age at which psychotic symptoms first appear is in the early to middle 20s for men and the late 20s for women.

II. A Review of Specific Symptoms

A. Aberrant Content of Thought

1) Delusions of Persecution

2) Delusions of Reference

3) Delusions of Being Controlled

4) Delusions of Grandeur

5) Thought Broadcasting: believing one’s thoughts are somehow transmitted to the external world so that others can overhear them.

6) Thought Insertion: believing one’s thoughts have been planted in one’s mind by an external source.

7) Thought Withdrawal: believing that thoughts have been removed from one’s mind.

B. Thought Disorder: a disturbance in thinking characterized by the breakdown of logical associations between thoughts.

1) Loose associations: derailment.

2) Neologisms: made-up words.

3) Perseveration: patients repeat their words and statements again and again.

4) Clang: rhymes.

5) Blocking: involuntary and abrupt interruption of speech or thought.

6) Poverty of Speech: speech that is slow, limited in quantity or vague.

C. Attentional Deficiencies

People with schizophrenia often have difficulty filtering out irrelevant stimuli, making it nearly impossible for them to focus their attention, organize their thoughts, and filter out unessential information.

1) Cognitive Load: one can only handle a finite number of mental exercises at one time without them interfering with each other.

D. Eye Movement Dysfunction

Many schizophrenia patients have some form of eye movement dysfunction, such as difficulty tracking a slow-moving target across their field of vision. 

Rather than steadily tracking the target, the eyes fall back and then catch up in a kind of jerky movement.

E. Hallucinations: sensory perceptions occurring in the absence of external stimuli that become confused with reality.

1) Auditory hallucinations (“hearing voices”) are most common, affecting about three out of four schizophrenia patients.

a) Command hallucinations: voices that instruct schizophrenics to perform certain acts, such as harming themselves or others.

2) Tactile hallucinations (such as tingling, electrical, or burning sensations). 3) Somatic hallucinations (such as feeling like snakes are crawling inside one’s belly).

4) Visual hallucinations (seeing things that are not there, such as other people, demons, spirits, animals, aliens, objects, etc.). 5) Gustatory hallucinations (tasting things that are not present). 6) Olfactory hallucinations (sensing odors that are not present).

F. Loss of Ego Boundaries

Schizophrenics may fail to recognize themselves as unique individuals and be unclear about how much of what they experience is part of themselves.

G. Catatonia: people with schizophrenia may become unaware of the environment and maintain a fixed or rigid posture; even bizarre, apparently strenuous positions for hours as their limbs become stiff or swollen.

III. Theoretical Perspectives

A. Genetic Factors

B. Biochemical Factors

1) The Dopamine Hypothesis: schizophrenia involves an over reactivity of dopamine transmission in the brain.

C. Viral Infections

Investigators have found that exposure to the “flu” virus in the 1st trimester of pregnancy was correlated with a sevenfold risk of schizophrenia.

1) The Neurodevelopmental Hypothesis: schizophrenia is the result of nervous system impairments that develop before or at birth.

D. Brain Abnormalities

Brain scans of schizophrenia patients show abnormalities both in the physical structures of the brain and in brain functioning.

The most prominent finding of structural abnormalities is loss of brain tissue (gray matter).

Brain scans of schizophrenia patients show abnormal functioning and loss of brain tissue in the prefrontal cortex of the brain.

Evidence also points to abnormalities in brain circuitry connecting the prefrontal cortex and lower brain structures, including parts of the limbic system involved in regulating emotions and memory.

Copyright © 2014, 2011, 2008 by Pearson Education, Inc. All rights reserved.

Loss of brain tissue in adolescents with early-onset schizophrenia. The brains of adolescents with early-onset schizophrenia (right image) show a substantial loss of gray matter. Some shrinkage of gray matter occurs normally during adolescence (left image), but the loss is more pronounced in adolescents with schizophrenia.

E. Family Factors

1) Communication Deviance (CD): a pattern of unclear, vague, disruptive, or fragmented communication that is often found among parents and family members of schizophrenia patients.  High CD parents have difficulty focusing on what their children are saying. Evidence shows that parents of schizophrenia patients tend to have higher levels of CD.

2) Expressed Emotion (EE): a pattern of responding to the schizophrenic family member in hostile, critical, and unsupportive ways. Schizophrenia patients from high EE families stand a higher risk of relapsing than those with low EE (more supportive) families.

High EE relatives typically show less empathy, tolerance, and flexibility than low EE relatives.

IV. Treatment Approaches

A. Biological Approaches

Antipsychotic drugs block dopamine receptors in the brain, which reduces dopamine activity in the brain and helps quell the more obvious symptoms such as hallucinations and delusions.

1) Tardive Dyskinesia (TD): a disorder characterized by involuntary movements of the face, mouth, neck, trunk, or extremities and caused by long-term use of antipsychotic medication.

Second generation antipsychotic drugs, referred to as atypical antipsychotics, has largely replaced the earlier generation of antipsychotics and have the advantage of carrying fewer neurological side effects and a lower risk of TD.

B. Learning-Based Therapies

1) reinforcing healthy behaviors

2) developing social skills

3) reframing or reinterpreting delusional thinking

4) developing self-care routines

5) cognitive rehabilitation training to strengthen basic cognitive skills such as attention and memory.

C. Self-Help Clubs

D. Family Intervention Programs

They provide direct support for the healthy family members. They help to prevent the negative reactions family members often have to the schizophrenic family member that can promote relapse.

V. Outlook For Recovery

A. Premorbid Adjustment

B. Precipitating Event

C. Sudden Onset

D. Age of Onset

VI. Other Schizophrenia Spectrum Disorders

A. Brief Psychotic Disorder: a psychotic disorder lasting from a day to a month that often follows exposure to a major stressor.

B. Schizophreniform Disorder: a psychotic disorder lasting less than 6 months in duration, with features that resemble schizophrenia.

C. Schizoaffective Disorder: a type of psychotic disorder in which individuals experience both severe mood disturbance and features associated with schizophrenia.

D. Delusional Disorder: applies to people who hold persistent, clearly delusional beliefs, often involving paranoid themes.

1) Erotomania: a rare delusional disorder in which the individual believes that he or she is loved by someone, usually someone famous or of high social status.