Chapter 6 (revised)

Chapter 11: Strategic Leadership

Chapter 6Chapter 6

Schizophrenia Spectrum and Schizophrenia Spectrum and Other Psychotic DisordersOther Psychotic Disorders


Chapter outline

• Introduction• History of Schizophrenia• Prevalence and course• Clinical picture• Schizophrenia subtypes• Dangerousness• Cross-cultural and African perspectives• Aetiology• Controversial issues


Introduction

• Schizophrenia is one of the most extreme forms of mental illness:• Schizophrenia involves all areas of human

functioning.• Often disastrous impact on affected

individuals and their families.• Considered extreme because of absence of:

• known causes, • objective diagnostic criteria• specified course• effective treatments


Introduction, cont.

• Severe decline in functioning in the areas of:• appreciation of reality• social interaction• perception• thought• emotion

• Positive vs. negative symptoms• Positive (active) symptoms and negative

symptoms (decrease in normal function) both present in Schizophrenia, often in combination.


Psychosis and the psychotic disorders

• Psychosis usually describes a break in the individual’s contact with reality.

• Can take form of the experience of delusions and/or hallucinations.

• Delusion: Firmly held false belief or a notion that is not accepted by most members of the person’s culture.

• Hallucinations: Sensory experiences in the absence of environmental stimuli.


Psychosis, cont.

• DSM-5: ‘Psychosis’ indicates presence of delusions, hallucinations, disorganised speech, or disorganised or catatonic behaviour.

• Psychotic episode is typically associated with a significant disruption in functioning.

• ‘Insight’ = awareness and recognition of own illness.• Schizophrenia (and other psychotic disorders) usually

associated with ‘poor insight’ • person has little awareness that anything is

wrong with them• At start of first episode may be hard to identify

specific disorder.



The psychotic disorders

Schizophrenia: Two or more of the following:• Delusions• Hallucinations• Grossly disorganised or catatonic behaviour• Negative symptoms• Minimum of 6 months; minimum of 1 month of active

phase symptoms


Psychotic disorders, cont.

Schizophreniform Disorder: Two or more of the following:• Delusions• Hallucinations

• Grossly disorganised or catatonic behaviour• Negative symptoms• No functional decline• 1 – 6 months



Brief Psychotic Disorder: Sudden onset of at least one of following positive psychotic symptoms:• Delusions• Hallucinations• Grossly disorganised or catatonic behaviour• 1 day – 1 month



Schizoaffective Disorder: Two or more of the following:• Delusions• Hallucinations• Grossly disorganised or catatonic behaviour• Negative symptoms concurrent with Major

Depressive, Manic or Mixed Episode• Minimum of 2 weeks of same period of illness of

hallucinations or delusions with absence of mood symptoms

• Mood episode present for substantial portion of active and residual periods of illness


Psychotic disorders, cont.Delusional Disorder

• Non-bizarre delusions; absence any other active-phase Schizophrenia

• 1 month

Shared Psychotic Disorder• Delusion in person influenced by another with

long-standing delusion with similar content

Psychotic Disorder Due to General Medical Condition• Psychotic symptoms are physiological effects of

General Medical Condition



Substance-Induced Psychotic Disorder• Psychotic symptoms are physiological effects of a

drug, medications, or toxins

Psychotic Disorder Not Otherwise Specified• Psychotic presentations that do not meet criteria

for disorders specified above

DSM-5 changes quite extensive (e.g. inclusion of Schizotypal Personality Disorder)


History of Schizophrenia• John Haslam – described Schizophrenia in the early

1800s as a form of insanity.• Benedict Morel – 1860; introduced term dementia

praecox (demence = loss of mind; precoce = early, premature).

• Emil Kraepelin – Used the term dementia praecox.• Focused on subtypes of Schizophrenia (end 19th

century).• Eugen Bleuler – 1911; introduced term

‘Schizophrenia’, meaning ‘splitting of the mind’. • Martin Bleuler – emphasised psychosis as

essential feature.


History of Schizophrenia, cont.

• Adolph Meyer – Schizophrenia = result of interaction between biological predisposition and environmental stressor.

• U.S. practitioners followed Bleuler’s approach, while Europe favoured Kraepelin.

• Internationally, discrepancy arose in diagnosis of Schizophrenia (twice as many diagnoses in the US).

• After publication of DSM-III, more restrictive view of Schizophrenia in the US.


Prevalence and course• Similar prevalence worldwide (0.5%-1.5% adult

population).


Prevalence and course, cont.

Development of psychotic episode• Prodromal phase - first appearance and escalation

of symptoms.• Active phase - distinct psychotic symptoms.• Residual phase - intensity of symptoms decreases,

functioning improves to an extent.

Course• Differs between individuals:

• Some present with relapse and remissions.• Others remain chronic.



Prevalence and course, cont.

Age of onset• Males mid 20s; females late 20s.

Factors associated with poor prognosis:• being male• early age of onset• poor insight• poor pre-morbid and inter-episode functioning• poor compliance with medication


Clinical picture

Schizophrenia• Disturbances in several major areas of functioning:

• thought, perception, motor behaviour, affect, emotion, and life functioning.

• Rare to display symptoms in all areas at once.• No essential symptom required to make the

diagnosis.• However, regarded as a psychotic disorder by

ICD-10 and DSM-5 which implies presence of:• hallucinations, delusions, disorganised behaviour

and/or speech.


Clinical picture, cont.The Positive Symptoms• Active manifestations or distortions of abnormal

behaviour.• Hallucinations (auditory and/or visual):

• experience of sensory events without environmental input

• can involve all senses• Delusions (the basic feature of ‘madness’):

• beliefs held contrary to reality• may be gross misrepresentations of reality.

• Types of delusion (Kurt Schneider, 1959): • persecution, thought broadcasting, control,

grandeur, reference and withdrawal• Most common delusions are of persecution.


Clinical picture, cont.

Positive Symptoms, cont.• Disorganised speech

• Does not conform to linguistic rules.• Unusual patterns of speech and writing

verbal communication holds little meaning for others.

• Switch rapidly between topics. • Other forms of disorganised speech include:

Loosening of associations; problems with attention; neologisms.



Positive Symptoms, cont.• Disorganised or catatonic behaviour

• Activity levels range from unusually high to unusually low.

• Agitation - rapid pacing, talking fast, arms swinging.

• Catatonia - unusual physical postures for extended periods.

• Inappropriate affect - expressed emotion is inappropriate or unrelated to expected emotions/affect.



The Negative Symptoms• Absence or insufficiency of normal behaviour

such as social interaction and display of emotions.• Associated with a poor prognosis.

• Spectrum of negative symptoms • affective flattening – little expressed emotion• avolition (or apathy) – lack of initiation and

persistence• alogia – relative absence of speech


Schizophrenia Spectrum Disorders


Schizophrenia subtypes (ICD-10)

Paranoid type• Intact cognitive skills and affect.• Do not show disorganised behaviour.• Hallucinations and delusions (persecution or

grandeur).• Best prognosis of all types of Schizophrenia.

Hebephrenic type• Marked disruptions in speech and behaviour.• Flat or inappropriate affect.• Hallucinations and delusions (fragmented content).• Develops early; tends to be chronic; lacks remissions

poor prognosis.


Schizophrenia subtypes, cont.

Catatonic type• Show unusual motor responses and odd mannerisms

(e.g., echolalia and echopraxia). • Tends to be severe and quite rare.

Undifferentiated type• ‘Catch-all’ category.• Person presents with symptoms of Schizophrenia but

fails to meet criteria for another type.


Catatonia• DSM-IV-TR listed Catatonic Schizophrenia as a subtype of Schizophrenia, and

although DSM-5 no longer lists subtypes of Schizophrenia, it recognises that catatonia is exhibited in a wide range of disorders, e.g. neurodevelopmental, psychotic, bipolar, depressive and medical conditions APA, 2013).

• In order to cater for this, the DSM-5 includes a disorder called Catatonia with Another Mental Disorder.

• The ICD-10, in contrast to the DSM-5, lists Catatonic Schizophrenia as a subtype of Schizophrenia.

• Catatonia includes a wide range of psychomotor impairments. These disturbances can range from extreme activity to complete immobility.

• Seemingly involuntary movements, echolalia, and echopraxia may be present.

• Echolalia presents as the senseless and parrot-like repetition of a phrase just uttered by another person, while echopraxia involves imitating the movements of others (American Psychiatric Association, 2013).


Catatonia• In the case of excessive motor activity (or ‘excited catatonia’), the activity or

excitement appears to be aimless and not influenced by the context.

• People with this subtype may talk and shout incoherently and move constantly.

• They sleep little, and possible risks include physical exhaustion and harm to self or others (American Psychiatric Association, 2013).

• In the case of motoric immobility, the person with catatonic symptoms may adopt a strange or bizarre posture.

• In some instances, negativism (maintenance of a rigid posture and resistance to being moved) may be present.

• Catalepsy or waxy flexibility occurs when a person remains in any physical position that they are put into by someone else.

• While in this state, the immobile person may not eat or pay any attention to their excretory functions (American Psychiatric Association, 2013).


Other Schizophrenia Spectrum and Psychotic Disorders

• Schizotypal Personality Disorder: Although this is a personality disorder (See Chapter 12), the DSM-5 notes it in this category as it considers it to be part of the schizophrenia spectrum disorders (APA, 2013).

• Delusional Disorder: The essential feature of this disorder is the presence of one (or more) delusions that persists for at least a month (APA, 2013).

• Brief Psychotic Disorder: The essential features of this disorder are that it involves the sudden onset of positive symptoms of psychosis (i.e. delusions, hallucinations or disorganized speech), or abnormal psychomotor behaviour (such as catatonia) (APA, 2013). The psychosis develops suddenly, i.e. within 2 weeks, without a prodromal phase, and a person with this disorder usually recovers fully (APA, 2013).


Other Schizophrenia Spectrum and Psychotic Disorders

• Schizophreniform Disorder: The symptoms of this disorder are identical to those of Schizophrenia, with the main difference between the two disorders being the duration of the two disorders (APA, 2013). This disorder follows the same pattern as that of schizophrenia, i.e. prodromal, acute and residual phases, which typically lasts for 1 – 6 months (but does not exceed 6 months) (APA, 2013).

• Schizoaffective Disorder: This disorder can best be understood as an overlap between Schizophrenia and a Mood Disorder. Although this disorder requires that the person displays symptoms of schizophrenia, the symptoms of a major mood episode (depressive or bipolar) must be present for the majority of the total duration of the disorder (APA, 2013).


Dangerousness and mortality risk

• Media portrays those suffering from Schizophrenia as prone to violence and more dangerous than the general population.

• These portrayals are not always accurate.• Paranoid Schizophrenia:

• More risk of violence, due to unpredictable and rapid behaviour (usually in reaction to delusions or perceived threats).

• Able to plan and execute attacks, while Disorganised type would be unable to do so.


Dangerousness & mortality risk, cont.

• Rates for medical illness and mortality in significantly higher in schizophrenic patients.

• Both natural and unnatural causes:• 28% of increased mortality risk is for suicide.• 12% for accidents.• 40% with diagnosis attempt suicide. • +/- 10% of individuals diagnosed with

Schizophrenia complete suicide within the first ten years of their diagnosis.

• Protect by effective treatment.


Dangerousness & mortality risk, cont.

• Schizophrenia: Elevated risk for medical illness.• May be modifiable as mostly due to lifestyle

factors:• hypertension; smoking; raised glucose levels;

physical inactivity...• High rates of cigarette smoking increased risk

for cardiovascular disease.• Also higher rates of infection with HIV and

infectious hepatitis.


Cross-cultural & African perspectives, cont.

• Clinical presentation complicated by substance abuse.

• Tension between Western & traditional views because Schizophrenic symptoms similar to:• ukuthwasa (ancestral calling)• amafufunyana (spirit possession)

• Cost of anti-psychotics this treatment beyond reach of low-income populations in SA.


AetiologySchizophrenia is a complex condition characterised

by multiple interacting causes – biological, psychological and social.

Biological factors Genetics (family and twin studies)• Inherited tendency for Schizophrenia.• Do not inherit specific forms of Schizophrenia.• Risk increases with genetic relatedness. • Problem with family studies is no control for

environmental influences.


Aetiology, cont.Biological factors, cont.Twin studies• Monozygotic twins – 48% risk for Schizophrenia.• Fraternal (dizygotic) twins – risk drops to 17%.• Adoption studies – risk for Schizophrenia remains

high where biological parent has Schizophrenia.• Stronger genetic effect for negative symptoms.• Risk for offspring of non-symptomatic twin is 17%

(same as for offspring from affected twin).

Summary of genetic research • Risk increases with genetic relatedness.• Risk is transmitted independently of diagnosis.• Strong genetic component does not explain

everything.


Aetiology, cont.Biological factors, cont.Brain structure• Abnormal neurological findings in Schizophrenia.• Found through post-mortem analysis, brain-imaging

techniques, and cognitive markers.• Structural abnormalities in the brain:

• enlarged ventricles and reduced tissue volume• prefrontal and hippocampal cell abnormalities• smaller medial temporal lobe structures

• Also functional abnormalities:• hypofrontality = less active frontal lobes• prefrontal cortex, temporal cortex, and subcortical

structures


Aetiology, cont.Biological factors, cont.Biochemical factors - The Dopamine Hypothesis• Drugs that increase dopamine (agonists) result in

schizophrenic-like behaviour.• Examples: Amphetamines; L-Dopa (for

Parkinson’s disease)• Drugs that decrease dopamine (antagonists) reduce

Schizophrenic-like behaviour.• Example: Phenothiazine

• Dopamine-serotonin relationship also studied.• Critique: Dopamine hypothesis is problematic and

overly simplistic.• Current theories emphasise many neurotransmitters.


Aetiology, cont.

Biological factors, cont.Neurodevelopmental factors• Increased risk for Schizophrenia from:

• antenatal exposure to influenza virus during 2nd trimester of pregnancy

• other early neurological insults (birth complications).

• Summary: Neurodevelopmental risk is result of:• accumulation of adverse events during pre-and

perinatal periods together with …• presence of behavioural and cognitive

symptoms during childhood.


Aetiology, cont.Psychological factors: IndividualStudies of high risk children• Pregnancy and delivery complications predict

negative symptoms.• Family instability predicts positive symptoms.• Other predictors identified: Attentional dysfunction;

low IQ scores; poor concentration; poor verbal ability; and poor motor abilities.

Psychological stress• Precipitates onset and relapse of Schizophrenia.• Stress involving close personal relationships is

NB precipitating factor.


Aetiology, cont.Psychological factors: Individual, cont.Faulty learning• Child conditioned into believing the world is an

unfriendly and threatening place. • Faulty learning result of:

• disturbed social interaction• observing inappropriate behaviour in role models• try to meet inappropriate parenting expectations

• Results in:• faulty assumptions about reality• difficulty with sense of self and self-worth• emotional immaturity• lack of effective coping skills


Aetiology, cont.

Psychological factors: Individual, cont.Expressed emotion (EE)• Associated with development/maintenance of

Schizophrenia.• EE = communication pattern expressing criticism,

hostility, and over-involvement. • High EE found in families with high relapse rates.• Works bi-directionally: Critical comments

unusual thoughts more critical comments.


Aetiology, cont.

Psychological factors: Individual, cont.Expressed emotion (EE), cont.• Problem with high EE theory: High EE also exists

in families with depression, Bipolar Disorder and eating disorders.

• High EE more common in Western families but same Schizophrenia incidence (1%) across cultures.

• EE theory more useful for prevention of relapse (rather than for aetiology) of Schizophrenia?


Aetiology, cont.Psychological factors: Family influences• Schizophrenogenic mother = a cold, rejecting,

dominating mother who hinders childhood ego development. • Lack of validating data idea no longer used.

• Family systems approach: Double-bind communication (mixed messages - verbal and non-verbal).• Approach helped show that causality of pathology

has interpersonal aspects (not just intrapersonal). • Mutual causality = reciprocal cause and effect

(interpersonal causes of the pathology continuously loop).


Aetiology, cont.

Psychological factors: Family influences, cont.

• Marital schism = parents constantly undermine each other.

• Marital skew = family maintains stability by accepting destructive and domineering behaviour of one or more family members as normal.


Aetiology, cont.

Psychological factors: Individual, cont.Cannabis use• Appears to be an independent risk factor for

Schizophrenia. • Thought to interact with genetic and

environmental risk factors to cause psychotic illness.

• Increased public awareness of this risk may play a preventative role for psychotic illness.


Aetiology, cont.Psychological factors: Family influences• Families with Schizophrenic member often have

problematic emotional transactions, boundaries, communication styles:• Pseudo-mutuality: Family role structure

characterised by rigidity and conflict, while mask of understanding maintained.

• Hampers development of emotional maturity in children.

• Pseudo-hostility: Overt conflict with rigid underlying coalitions.

• Resist change in family dynamics; exhibit communication deviance (avoid solutions).


Aetiology, cont.

Psychological factors: Family influences, cont.

• R.D. Laing: Schizophrenia is sane response to insane context.

• Response to mystification (parents distort child’s experiences child develops split betw. false and real selves).

• Family systems model criticised:• lack of control groups;• focus on family interactions only after diagnosis.


Aetiology, cont.

Socio-cultural factorsThe effects of social class• Schizophrenia most prevalent among people in

poorest sections of cities or employed in lowest status occupations.

• Sociogenic hypothesis:• environmental stressors (e.g. disrespect in

workplace, lack education)• biological stressors (e.g. low nutrition during

pregnancy)


Aetiology, cont.

Socio-cultural factors, cont.Social class, cont. • Social-selection theory (downward drift theory) -

people diagnosed with Schizophrenia migrate to poorest areas due to their decreased functioning.

• Research: Downward drift occurs across generations.

• More evidence for downward drift theory than sociogenic hypothesis but both implicated in causality.


Aetiology, cont.Socio-cultural factors, cont.The effects of migrant status• Research: Elevated risk for first generation adult

immigrants. • Psychosocial variables involved:

• socio-economic disadvantage• exposure to racism and discrimination• migrant family and community responses to

psychiatric disorders• Environmental causes = interaction of risk factors:

• exposure to novel viruses• abnormal immunological responses• obstetric complications• differential foetal survival


Aetiology, cont. An Integrative Aetiology of Schizophrenia• Predisposing, precipitating and maintaining factors

• Predisposing factors (biological vulnerability): Genetics; brain structure (including biochemical aspects)

• Precipitating factors (intra-personal or interpersonal triggers): Psychological stress; faulty learning; impact of the family system; cannabis use

• Maintaining factors (intra-personal or interpersonal): Family dynamics; presence of high expressed emotion in family; cannabis use; socio-cultural factors (social class; migrant status)


Controversial issues

One diagnosis or many?• ICD & DSM system criteria less useful for research

and treatment.• Complex diagnosis – more appropriate to refer to

the ‘Schizophrenias’ (cf. Bleuler)?• Lack of clear diagnostic markers of biological

dysfunction cannot diagnose Schizophrenia in purely medical terms.

• Schizophrenia can also be diagnosed as a cluster of behaviours which result from a number of possible causes (equifinality).


Controversial issues, cont.Positive vs Negative Schizophrenia• Problems with characterising Schizophrenia in

terms of positive and negative symptoms:• Tends to describe Schizophrenia as either

positive or negative, when symptoms are mixed in most cases.

• Differences in positive and negative patients not supported by consistent longitudinal studies.

• Some research: Positive and negative symptoms represent dimensions rather than subtypes of Schizophrenia.


Controversial issues, cont.

Type I vs Type II Schizophrenia• Crow (1980): Two types of Schizophrenia:

• Type I and II: Different in terms of pathophysiologies rather than their aetiologies.



‘Normality’ and ‘abnormality’• Anti-Psychiatry Movement contests the existence

of mental illness.• Diagnosing and diagnostic criteria influenced by

social values, morals, and political considerations.• Psychiatry is a form of social control.• Disagree with analogy between medical and

mental disorders (psych disorders have subjective criteria) .

• Rosenhan study questions reliability of psychological diagnoses.



Labelling• Tendency to view label given to a person “as a

description of the person as a whole, rather than merely a description of behaviour” (Jordaan, 2009, p. 193).

• Expectations about how person should act means that labelling becomes a self-fulfilling prophecy.

• Seen by self and others as the disorder.



De-institutionalisation• Legislation/policy that restricts:

• number of psychiatric hospital beds (patients) in an institution

• length of stay• Consequences in the US: Many people with

mental illness became homeless (NB those with Schizophrenia).

• Includes many who are unpredictable and may cause harm to themselves and others.


Conclusion

• Schizophrenia has significant impact on person, their family, and society as a whole.

• Significant emotional and financial costs.• Nosology still unclear (e.g. overlaps betw.

diagnostic categories).• Aetiology, course, and most effective treatment

also still unclear.

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Chapter 6 (revised)

Education