Schizophrenia

1. Schizophrenia Madiha Anas Institute of Psychology Beaconhouse National University

2. Definition • characterized in general by fundamental and characteristic • distortions of thinking and perception, and affects • that are inappropriate or blunted.

3. Schizophrenia • Schizophrenia is defined by • a group of characteristic positive and negative symptoms • deterioration in social, occupational, or interpersonal relationships

4. History • Emil Kraepelin: • This illness develops relatively early in life, and its course is likely deteriorating and chronic; • deterioration reminded one of dementia (“Dementia praecox”) • Eugen Bleuler: • He renamed Kraepelin’s dementia praecox as schizophrenia (1911); he recognized the cognitive impairment in this illness, which he named as a “splitting“ of mind. • (schiz-, or “divide”, and phren, or “mind”)

5. Typical stages of schizophrenia • prodromal phase • functioning deteriorates gradually for years before any clearly psychotic symptoms appear • become withdrawn and socially isolated • cease to care about their appearance or hygiene, forgetting to bathe • emotions seem shallow and inappropriate • active phase • begins showing prominent psychotic symptoms • hallucinations, delusions, disorganized speech, and severe withdrawal. • residual phase • Blunted or flat affect is especially common in this period. • unusual perceptual experiences and odd ideas, claiming, for example, to be able to tell the future or to have other special powers • In some cases, the residual phase ends with a return to perfectly normal functioning, or complete remission.

6. Schizophrenia • Disorders of Language and Thought • Loosening of Association • Disorders of Perception • Disorders of Motor Behavior

7. Delusions • firmly held beliefs that have no basis in reality. • Most schizophrenics do not seem to realize that other people find their delusional beliefs implausible. • 1) Delusion of persecution • one is being plotted against spied upon threatened or otherwise mistreated, particularly by conspiracy. • 2) Delusions of control (influence) • other people force or perhaps extraterrestrial beings are controlling ones thoughts, feelings, and actions • Thoughts of broad casting • The belief that one’s thoughts are being broadcast to the outside world, so that everyone can hear them. • Thoughts insertion • The belief that other people are inserting thoughts, especially obscene thoughts, into one’s head • Thoughts withdrawal • The belief that other people are removing thoughts from one’s head

8. Delusions (cont) • 3) Delusions of reference • The belief that one is being referred to by things or events that , in fact, have nothing to do with one. • For example, schizophrenics may think that their lives are being depicted on television or in news stories. • 4) Delusions of grandeur • The belief that one is an extremely famous and powerful person. • Such delusions may crystallize into stable delusional identity, with the person claiming, for example, that he or she is president. • 5) Delusions of sin and guilt • The belief that one has committed “the unpardonable sin” or has inflicted great harm on others. • Schizophrenic may claim that they have killed their children. • 6) Hypochondriacal delusions • The unfounded belief that one is suffering from hideous physical disease. • 7) Nihilistic delusions • The belief that one or others or the whole world has ceased to exist. • The patient may claim, that he or she is a spirit returned from the dead.

9. LOOSENING OF ASSOCIATIONS • Ideas jump from one track to another, with the result that the person wanders further away from the topic. • When the problem is severe, speech may become completely incoherent. • The mental process involved in this confusion is not exactly known but it is likely that the problem lies in the mind’s way of dealing with associations. • In normal people they edit their speech before the conversation, selecting the most important and ignoring the irrelevant. • In the schizophrenic mind this process seems to breakdown, so that the speaker follows his or her own private train of associations, without editing for relevance. • This does not mean that schizophrenics cannot give straight answer to a direct question. They can make very common primary associations to a given stimulus about as easily as normal. It is the secondary associations in which they have difficulty. • For example, in a study two colored disks were presented to the schizophrenics who were quite dissimilar and were asked to tell what the difference is. They told that one is red and the other one is purple but when two shades of a color were presented to them they could not differentiate them and began reeling off associations.

10. Loosening of Associations (cont). • Poverty of content • Through the loosening of the associations the schizophrenic language may convey very little. Though the person may use many words, all grammatically correct, he or she communicates poorly. • Neologisms • In the schizophrenic speech the words and phrases they use are not even found in the most comprehensive dictionary. • These usages, called neologisms (new words) also involve the use of common words in a new way. • Example • “I am here from a foreign university…. And you have to have a plausity of all acts of amendment to go through for childrens code…..and it is no mental disturbance or putenence ..it is an amorition law …… there is nothing to disturb me…it is like their privatilinia…and the children have this accentuative law so they don’t go into the mortite law of church”.

11. Loosening of Associations (cont). • Clanging • Another oddity sometimes found in the speech of schizophrenics is clanging, the pairing of words that have no relation to one another beyond the fact that they rhyme or sound alike. • Example • “Well, hell its well to tell, so hot you know it runs on a cot.” • Word salad • Sometimes the schizophrenic language seems to show a complete breakdown of the associational process, so it becomes impossible for the listener to trace any links between successive words and phrases. • Example • “Its all over for a squab true tary and there aint no music, there aint no nothing besides my mother and my father who stand alone upon the island of Capri where there is no ice, there is no nothing but changers, changers, changers. That comes like in first and last names, so that thing does. Well, it’s my suitcase sir. I’ve got to travel all the time to keep my energy alive”.

12. DISORDERS OF PERCEPTION • Many schizophrenic patients report changes in perception, including • visual illusions • disturbingly acute hearing • inability to focus attention • difficulty in identifying people • and difficulty in understanding what other people are saying.

13. DISORDERS OF PERCEPTION(cont). • Break down of selective attention • Normal people exercise selective attention without thinking about it. That is they decide what they want to focus on in the environment and then concentrate on that. However schizophrenics are unable to engage in this normal selection process.

14. DISORDERS OF PERCEPTION(cont). • Hallucinations • Perceptions occurring in the absence of any appropriate external. • Auditory hallucination • They are the most common hallucinations, occurring in 70 percent of schizophrenic patients. Certain types of auditory hallucinations are especially characteristics of schizophrenia. Hearing two or more voices conversing with one another or of hearing voices that keep a running commentary on the patients thoughts or behavior. • Visual hallucinations • They see some thing in the environment which actually is not present. Some schizophrenics recognize that their hallucinations are not real that the voices are only in their heads. The more psychotic, are convinced that their hallucinations are perceptions of real events. • Olfactory and gustatory hallucination • Hallucination of taste and smell are infrequent. • Tactile hallucination • Tactile hallucination is not of much diagnostic significance. The sensation of insects moving under the skin occurs in people who abuse cocaine and occasionally among schizophrenics.

15. DISORDERS OF MOTOR BEHAVIOR • certain repetitive motor behaviors, such as the head rubbing, dress smacking, and paper tearing are clearly abnormal. • show high levels of motor activity, running about, thrashing their arms, upsetting furniture and generally expending a good deal of energy. • Schizophrenics may lapse into • catatonic stupor • remaining mute and immobile for days on end • catatonic rigidity • maintaining a rigid, upright posture for hours and resisting efforts to be moved • waxy flexibility • indefinitely maintaining postures into which they have been placed by someone else. • catatonic excitement • a different form of catatonia, move excitedly, sometimes with wild waving of arms and legs.

16. Positive and Negative Symptoms

17. DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA • characteristic symptoms: two (or more) of the following, each present for a significant portion of time during a 1 month period of (or less if successfully treated): • delusions • hallucination • disorganized speech (e.g., frequent derailment or incoherence) • grossly disorganized or catatonic behavior • negative symptoms, i.e., affective flattening, alogia, or avolition • social/occupational dysfunction: for a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self care are markedly below the level achieved prior to the onset

18. NEXT CLASS

19. Sub-Types of Schizophrenia • Disorganized Schizophrenia • Catatonic Schizophrenia • Paranoid Schizophrenia

20. Disorganized schizophrenia • best fits with the popular stereotype of a “crazy” person. • Three symptoms are especially characteristic of disorganized schizophrenia. • incoherence of speech; • Neologisms • clang associations • word salad. • mood disturbance. • flat affect; • others act silly, giggle, make faces, and so on. • disorganized behavior • lack of goal orientation, • a refusal to bathe or dress. • They may also experience hallucinations and delusions.

21. Catatonic schizophrenia • marked disturbance in motor behavior • catatonic stupor • waxy flexibility • Catatonic rigidity • Catatonic excitement • When excited, patients may injure themselves or others • when stuporous, they must be prevented from starving. • Though catatonic immobility suggests passivity, it may in fact be quite active. To hold for hours the bizarre postures that catatonic often assume requires an extraordinary expenditure of energy.

22. Paranoid schizophrenia • delusions and hallucinations of a relatively consistent nature • often related to the themes of persecution and grandeur. • Auditory hallucinations are the common ones which also then support the delusions. • more “normal” than other schizophrenics. • They perform well on cognitive tests (Strauss,1993). • are more likely to be married, have a later onset, and show better long term outcomes than do the other kinds of schizophrenics.

23. PREVALENCE • About 1.5% of the population is suffering from this ailment in Pakistan. Schizophrenia occurs in both male and female with same frequency and the onset usually occurs between the ages of 15-40 years. • All the above mentioned data is based on the studies conducted only on the patients reported to hospitals and clinics.

24. Biochemical research: the dopamine hypothesis • dopamine hypothesis • schizophrenia is associated with excess activity in the parts of the brain that use dopamine as a neurotransmitter

25. Some Prenatal risk factors • Maternal infections and Flu during pregnancy are associated • Use of Painkillers (e.g. Aspirin) during Pregnancy linked to 500% higher risk of Schizophrenia • Maternal stress during pregnancy is associated with a higher risk of schizophrenia for the children • Low Birth Weight Infants May Have Increased Risk for Schizophrenia • Season of Birth - Mother's Low Sunlight Exposure/Lack of Vitamin D is associated with higher risk of schizophrenia in child • Older Age of Father increases risk of Schizophrenia • X-ray Radiation During Pregnancy (from medical X-rays, Intercontinental Flights, etc.) may increase risk of schizophrenia for child

26. THE PSYCHODYNAMIC VIEW • According to Sigmund Freud the development of schizophrenia involves two part psychological process • regression to a pre ego stage • restitute efforts to reestablish ego control • schizophrenia stems from a basic conflict between a persons self gratifying impulses and the demands of the real world. • regression leads to self indulgent symptoms such as neologism, loose associations, and delusions of grandeur. • Freud also believed that upon regressing to a pre ego stage these people start trying to reestablish ego control and contact with reality. • Their restitutive efforts give rise to yet other schizophrenic symptoms for example auditory hallucinations.

27. THE BEHAVIORAL VIEW • operant conditioning explains schizophrenia (Liberman, 1982; Ullmann & Krasner, 1975). • They propose that most people are taught by their environment to attend to social cues for example, to other people’s smiles, frowns, and comments. • When they respond to these stimuli in a socially acceptable way, they are better able to satisfy their emotional needs and to achieve their goals. • Some people, however, do not receive such reinforcement. • Unusual circumstances may prevent their encountering social cues in their environment, or important figures in their lives may be socially inadequate and unable to provide proper reinforcements. • Either way, these people stop attending to social cues and focus instead on other, often irrelevant cues, the brightness of light in a room, a bird flying above, or the sound of a word rather than its meaning. • As they attend more and more to such inappropriate signals, their responses become increasingly bizarre.

28. PSYCHOLOGICAL STRESS AND SCHIZOPHRENIA • Psychological stress plays a key role by interacting with a biological vulnerability to produce this illness. Two stressors that have played an important part in schizophrenia research are social class and the family. • Social class and schizophrenia • The prevalence of schizophrenia is highest among people in the lowest social class. • The correlation between social class and schizophrenia are consistent, but they are difficult to interpret in causal term.

29. The family and schizophrenia • family relationships especially those between a mother and child, are crucial in the development of schizophrenia. • Schizophrenogenic mother • was coined for mothers who were characterized as • rejecting, • overprotective, • self sacrificing, • impervious to the feelings of others, • rigid and moralistic about sex • fearful of intimacy. • Double bind communication; • some parents repeatedly communicate pairs of messages that are mutually contradictory, thus placing the children in double bind situations: the children cannot avoid displeasing their parents; nothing they do is right. Children who are repeatedly caught in such contradictions may react by developing schizophrenic symptoms.