Breakdown of thought processes and deficit of typical

emotional responses.
Schizophrenia means a splitting of mental functions and NOT
a split personality.
Emil Kraeplin named it dementia praecox. Primary disturbance
said to be disruption of cognition and began in the late teens or
early adulthood.
Eugen Bleuler replaced term with the term schizophrenia.
Described the symptoms as positive or negative.
symptoms
DSM-IV :
1. One or more for much of one month [Delusions,
Hallucinations, Disorganized Speech, Grossly disorganized
behavior or catatonic behaviour, Negative symptoms: Blunted
affect (lack or decline in emotional response), alogia (lack or
decline in speech), or avolition (lack or decline in motivation)]
2. Social or occupational dysfunction
3. Continuous signs of the disturbance persist for at least 6
months, must include at least one month of symptoms (or less,
if symptoms remitted with treatment).
Positive symptoms :
-Symptoms that most individuals do not normally experience
-Reflects excess or distortion of normal functions.
-e.g. hallucinations, delusions, thought disorders and
movement disorders.
Negative symptoms :
-Symptoms that are not present or diminished in the affected
persons
-Reflects diminution or loss of normal functions
-e.g. social withdrawal, flat affect, lack of pleasure, and defects
in attention control.
Schneiders first-rank symptoms :
(a) auditory hallucination
(b) delusional perception
(c) somatic hallucination
(d) thoughts insertion, broadcasting, control or withdrawal
Slater&Roth : (a) thought disorders
(i) loose association/derailment - Ideas slip off the topic's track
on to another which is obliquely related or unrelated.
(ii) clanging - Sounds, rather than meaningful relationships,
appear to govern words or topics. Excessive rhyming, and/or
alliteration.
(iii) neologisms - New word formations. These may also
involve elisions of two words that are similar in meaning or in
sound.
(iv) tangentiality - Replying to questions in an oblique,
tangential or irrelevant manner.









Types of Schizophrenia
Paranoid Schizophrenia
-hallucinations and delusions, suicidal thoughts and behaviour,
violence, anxiety, emotional distance
-least impairment among all types
Disorganized Schizophrenia
- speech and behavior that are disorganized or difficult to
understand, and flattening or inappropriate emotions.
-may laugh at the changing color of a traffic light or at
something not closely related to what they are saying or doing.
-may disrupt normal activities, such as showering, dressing, and
preparing meals.
Catatonic Schizophrenia
-characterized by disturbances of movement.
-Catatonic Stupor remain motionless and silent for long
stretches
-Catatonic Rigidity rigid, upright posture for hours
-Catatonic Posturing assume awkward, bizarre positions for
long periods of time
-the behavior is putting these people at high risk because it
impairs their ability to take care of themselves.
Undifferentiated Schizophrenia
-characterized by some symptoms seen in all of the above types
but not enough of any one of them to define it as another
particular type of schizophrenia.
Residual Schizophrenia
-characterized by symptoms which have lessened in strength
and number.
-may continue to display negative symptoms
Models of Schizophrenia
Genetic Explanation
1.Twin studies by Gottesman and Shields (1972)
-to investigate the concordance rates of schizophrenia in twins
-Monozygotic = 42% ; Dizygotic = 9%
2. Kamin (1997) Twins that are adopted into different families
tend to be reared similarly
3. Adoption study by Heston(1966)
-47 adopted away children whose biological mothers are
schizophrenic compared to 50 adopted away children whose
biological mothers are not schizophrenic (sex-matched). 5 index
subjects developed schizophrenia and none from control group
4. Family studies by Kendler, Masterson and Davis (1985)
-Relatives of schizophrenics were 18 X more likely to be
diagnosed with schizophrenia
Biochemical Explanation
1.Excess Dopamine, a kind of neurotransmitters (problems of
regulation in norepinephrine)
2.It is found to be more concentrated in the schizophrenic
brains, especially in the limbic system
3.Dopamine Hypothesis : An excess of the neurotransmitter
dopamine causing neurons to be fire too often and transmit too
many messages/A more recent hypothesis/An excess of
dopamine receptor cells leads to more firing and excess
messages
4.Iverson (1979)Post-mortems on schizophrenics have shown
unusually high level of dopamine
5.Evidence for dopamine hypothesis :
-L-Dopa (increases levels of dopamine) can produce
schizophrenic symptoms
6. To reduce effect of dopamine : Chlorpromazine blocks
dopamine receptor sites, making the brain less sensitive to
dopamine and reducing schizophrenic symptoms
7. Criticism
-Dopamine may not be the only neurotransmitter involved.
Anti-schizophrenic drugs work by blocking serotonin receptors
rather than dopamine receptors!
-Rather than saying dopamine level is a cause of schizophrenia,
it is possible that alterations in the amount of brain dopamine
is a result of this illness!
-Not all antipsychotic drugs (e.g. Chlorpromazine) work well on
every schizophrenic patient!

Cognitive Explanation
1.Frith (1992) explained that schizophrenics are cognitively
impaired in that they are unable to distinguish between actions
brought about by external forces and generated internally due
to functional disconnection between frontal areas (action) and
posterior areas (perception).Proved his idea by detecting
changes in cerebral blood flow in the brains of schizophrenics
during cognitive task using PET scan
2.Schizophrenia is explained in terms of diathesis-stress.
Stressors may be biological (prenatal viral infection),
psychosocial (living condition) or psychological (traumatic
experiences).The more stressors accumulate, the greater the
risk of a person developing schizophrenia!
3.Neuroanatomical Abnormalities: There are structural
abnormalities in the brain of schizophrenics (e.g. Enlargement
of lateral ventricles, reduced brain volume)
4.Functional Abnormalities : PET scan shows abnormal
activation patterns in many brain regions
5.Neurocognitive deficits : Schizophrenics are generally
impaired in cognitive tasks (e.g. general intellectual ability,
verbal memory)

Biochemical Treaments
Anti-psychotic drugs
Chlorpromazine (Thorazine)
-Treat symptoms of schizophrenia, mania(in people who have
bipolar disease) by blocking dopamine receptor site
-To control nausea and vomiting
-Side effects : drowsiness, blank facial expression, restlessness,
agitation, nervousness, increased appetite, weight gain
Haloperidol (Haldol)
-Treat symptoms of schizophrenia, acute psychotic states and
delirium (acutely disturbed state of mind)
-Treat symptoms of Tourette disorder (involuntary muscle
contraction near the mouth)
-Side effects : dizziness, fast heartbeat, tremor, seizure,
convulsion, flu, sweating, fever
2. Atypical Antipsychotic drugs
Clozapine
-Treat psychotic symptoms, hallucinations, and breaks with
reality
-Sometimes cause agranulocytosis (loss of white blood cells)
-Expensive!
Risperidone and Olanzapine
-Change the activity of natural substances in the brain
-Treat symptoms of schizophrenia, mania
-Side effects (risperidone) : Drowsiness, dizziness, restlessness,
weight gain, increased appetite
-Side effects ( olanzapine) : Anxiety, agitation, depression,
difficulty in walking
3. ECT
-may "jumpstart the brain", helping boost neurotransmission
-extremely rare for patients with schizophrenia to be offered
ECT but might help people who have a concurrent mood
disorder, or who are unresponsive to antipsychotic drugs
-Strength : -significantly reduced positive and negative
symptoms; there is a potential for improvement even in
patients with chronic schizophrenia unresponsive to most
typical and atypical antipsychotic drugs
-Weakness : -confusion and memory loss upon awakening;
persistent memory loss; perceive the treatment as terrifying
and shameful; use of anaesthesia can be risky for people with
pre-existing conditions; seizures may be dangerous for people
with pre-existing heart or nervous system conditions; some feel
that their personalities have changed
Behavioural Treatment
Token Economy
-operant conditioning (positive reinforcement)
- tokens (called conditioned reinforcers) given to a person
after they have behaved in a certain way that deserves credit
can be traded in for desired back-up reinforcers
Clinical Application by Paul and Lentz (1977)
28 chronic schizophrenic patients randomly assigned to 3
groups: typical hospitalization, milieu therapy and token
economy
Milieu Therapy
- Focus on community structure & cohesion
- Group decision making
- Crisis resolution
- Problem solving
- Group pressure for change
- tokens in return for maintaining their personal hygiene,
attending therapy sessions, keeping their living space clean,
and engaging in social interaction
- more diverse range of back-up reinforcers to their
patients(candy, clothing, cigarettes, additional furniture for
patients rooms, radio and TV use, and sleeping late)
-Results: (i) Token economy group was the most effective
resulting in more discharges
(ii) 98% of token economy group were discharged compared to
75% in the milieu therapy group and only 45% in the control
group

Strengths :
-task requirements to receive tokens can be gradually increased
and new back-up reinforcers of greater value can be introduced
-effective in producing a variety of behaviour changes at least in
the setting in which the tokens are given.
Weaknesses :
-tokens are not generally available in real-world settings, so the
token-modified behaviour may not persist after the token
economy is ended.
-if the reinforcement is always the same, satiation occurs, and
the behaviour decreases in frequency.
-only focus on the observable aspects of schizophrenia, fails to
address the underlying causes of schizophrenia
-Exercises authoritarian control and dehumanises and
brainwashes people.
CBT
-based on the view that people with mental disorders have
irrational and unrealistic ways of thinking.
-goal of CBT is to change faulty belief systems.
-treatments include stress management, personal therapy and
belief modification.
-used in conjunction with anti-psychotic drugs. Whilst the drugs
are exerting their effect, the client is taught to recognise signs
of relapse, such as social withdrawal, and then given coping
strategies which enable them to the skills that they have
acquired in an effective way.
-Socratic questioning (seeks to get the other person to answer
their own questions by making them think and drawing out the
answer from them) is used
Clinical Application by Sensky et al. (2000)
-compared the role of CBT and befriending for drug resistant
schizophrenia
-CBT involved attaining a collaborative understanding of the
development of symptoms and working towards reducing
distress and disability
-although both groups showed improvements immediately
after treatment, only the CBT group continued to improve after
the treatment ended
-delusions were elucidated by guided discovery and graded
homework tasks (using Socratic questioning).
-for grandiose delusions, linked underlying beliefs were
identified using inference chaining
-for auditory hallucinations, collaborative critical analysis of
beliefs about the origin and nature of the voice(s) was followed
by the use of voice diaries, reattribution of the cause of the
voices, and generation of possible coping strategies.
Strengths :
-especially effective when combined with the anti-psychotic
drugs
-CBT can be effective in preventing relapse after a
schizophrenic episode. Often, stressors can cause a relapse, and
CBT can be effective in these cases because it helps a person (a)
recognise the stressors and (b) recognise that their reaction to
them is inappropriate.
Weaknesses :
-does not seem appropriate for people with chronic
schizophrenia, antipsychotic drugs would appear to be more
appropriate
-appropriate only for those who are capable of gaining insight
into their problem, and that it was therefore futile trying to
change the cognitive distortions of schizophrenics
Evaluative Issues
-There are no clinical tests for schizophrenia. Clinicians have to
rely on the patient/their family to diagnose based on
retrospective information given by patients whose ability to
recall information could be impaired by the disorder. Also,
some patients may simply be exaggerating their feelings or
lying.
Whilst the ICD10 and the DSMIV are similar, different
emphasis on the symptoms. The ICD10 also lists 2 types of
schizophrenia that are not listed in DSMIV (simple and post
schizophrenic depression). As a result, people may or may not
be diagnosed as schizophrenic depending on which
classification system is used.
The accuracy of diagnosis often depends on the skill of the
healthcare professional. It cannot be ignored that their
diagnosis may be influenced by their own opinions and biases,
and that they may simply label someone as schizophrenic
without knowing the extent of their disorder. Also, many
healthcare professionals working in the NHS have limited time
and resources. Clinicians may only admit the most serious cases
for treatment in order to economise the resources of their
institution
Schizophrenia is often used as a broad label for a variety of
symptoms. Many individuals do not fit exactly into one of the
subtypes of the disorder, and so clinicians often diagnose a
number of separate disorders.
The diagnosis criteria for schizophrenia is so strict that
those who show schizophrenic behaviour but do not exactly
meet the criteria are not diagnosed as schizophrenic, and are
often given a lesser diagnosis such as schizoid personality
disorder.
Schizophrenia overlaps with disorders such as bipolar, and
bipolar sufferers can also experience hallucinations and
delusions. This makes it difficult to distinguish between
disorders. Also, in order to validly diagnose schizophrenia,
surely it should have its own distinct set of symptoms?