Chapter 13: Schizophrenia and Other Psychotic Disorders

Question 1

What is schizophrenia?

Answer 1

Characterized by an array of diverse symptoms, including extreme oddities in perception, thinking, action, sense of self, and manner of relating to others. However, the hallmark of schizophrenia is a significant loss of contact with reality, referred to as psychosis.

Question 2

T or F: The risk of developing schizophrenia over the course of one’s lifetime is a little under 1 percent.

Answer 2

True. Around 0.7 percent to be exact.

*Approximately 1 out of every 140 people alive today who survive until at least age 55 will develop the disorder.

Question 3

T or F: People whose fathers were older (50 years or more) at the time of their birth have an elevated risk of developing schizophrenia when they grow up.

Answer 3

True.

Question 4

T or F: Having a parent who works as a dry cleaner is a risk factor for schizophrenia.

Answer 4

True.

Question 5

When do the vast majority of schizophrenia cases begin?

Answer 5

The vast majority of cases of schizophrenia begin in late adolescence and early adulthood (18-30), but this differs between men and women.

*In men, there is a peak in new cases of schizophrenia between ages 20 and 24. The incidence of schizophrenia in women peaks during the same age period, but the peak is less marked than it is for men. After about age 35, the number of men developing schizophrenia falls markedly, whereas the number of women developing schizophrenia does not.
There is a second rise in new cases that begins around age 40, as well as a third spike in onset that occurs when women are in their early sixties.

Question 6

Do men or women tend to have more severe cases of schizophrenia?

Answer 6

Males tend to have a more severe form of schizophrenia

*May also explain why schizophrenia is more common in males than it is in females (for every three men who develop the disorder, only two women do so [1.4:1])

Question 7

What might explain the better clinical outcome of

women with schizophrenia?

Answer 7

Female sex hormones play some protective role (I.e., when estrogen levels are low or are falling, psychotic symptoms in women with schizophrenia often get worse, signalling that estrogen may be a protective factor).

Question 8

What is a delusion (schizophrenia)?

Answer 8

A delusion is essentially an erroneous belief that is fixed

and firmly held despite clear contradictory evidence.

Question 9

T or F; Not all people who have delusions suffer from schizophrenia.

Answer 9

True. However, delusions are common in schizophrenia, occurring in more than 90 percent of patients at some time during their illness

Question 10

In schizophrenia, certain types of delusions or false beliefs are quite characteristic. What are they?

Answer 10

• Beliefs that one’s thoughts, feelings, or actions are being controlled by external agents (made feelings or impulses)
• That one’s private thoughts are being broadcast indiscriminately to others (thought broadcasting)
• That thoughts are being inserted into one’s brain by some external agency (thought insertion), or that some external agency has robbed one of one’s thoughts (thought withdrawal).
• Delusions of reference, where some neutral environmental event (such as a television program or a song on the radio) is believed to have special and personal meaning intended only for the person.
• Other strange propositions, including delusions of bodily changes (e.g., bowels do not work) or removal of organs, are also not uncommon.

Question 11

What is a hallucination (schizophrenia)?

Answer 11

A hallucination is a sensory experience that seems real to the person having it, but occurs in the absence of any external perceptual stimulus.

Question 12

T or F: Hallucinations can occur in any sensory modality (auditory, visual, olfactory, tactile, or gustatory).

Answer 12

True. However, auditory hallucinations (e.g., hearing voices) are by far the most common.

*75 percent of patients with schizophrenia

Question 13

T or F: Patients can become emotionally involved in their hallucinations, often incorporating them into their delusions.

Answer 13

True. In some cases, patients may even act on their hallucinations and do what the voices tell them to do.

Question 14

Are patients who are hallucinating really hearing

voices?

Answer 14

Neuroimaging studies that compare hallucinating patients with non-hallucinating patients suggest that patients with speech hallucinations have a reduction in brain (gray matter) volume in the left hemisphere auditory and speech perception areas. Reduced brain volume in these areas could lead to a failure to correctly identify internally generated speech, erroneously tagging it as coming from an external source.

Question 15

What is disorganized speech?

Answer 15

Disorganized speech, on the other hand, is the external manifestation of a disorder in thought form. Basically, an affected person fails to make sense, despite seeming to using language in a conventional way and following the semantic and syntactic rules governing verbal communication.

Question 16

T or F: Goal-directed activity is almost universally disrupted in schizophrenia.

Answer 16

True. Many researchers attribute these disruptions of “executive” behaviour to impairment in the functioning of the prefrontal region of the cerebral cortex.

Question 17

What is catatonia?

Question 18

There are two general symptom patterns of schizophrenia. What are they?

Answer 18

Referred to as positive-and negative-syndrome schizophrenia.

Positive symptoms are those that reflect an excess or distortion in a normal repertoire of behaviour and experience, such as delusions and hallucinations. Disorganized thinking (as revealed by disorganized speech) is also thought of in this way.

Negative symptoms, by contrast, reflect an absence or deficit of behaviours that are normally present.

Question 19

Regarding the negative symptom pattern of schizophrenia, it is thought that the negative symptoms fall into two broad domains. What are they?

Answer 19

One domain involves reduced expressive behaviour—either in voice, facial expression, gestures or speech. This may show itself in the form of blunted affect or flat affect or in alogia, which means very little speech.

The other domain concerns reductions in motivation or in the experience of pleasure. The inability to initiate or persist in goal-directed activity is called avolition. Diminished ability to experience pleasure is called anhedonia.

Question 20

What does the presence of persistent negative symptoms in schizophrenia demonstrate for future outcomes?

Answer 20

The presence of negative symptoms in the clinical picture is not a good sign for the patient’s future outcome. Even though patients with negative symptoms may seem emotionally unexpressive, how they appear and how they are feeling are two different things.

Question 21

T or F: Most patients with schizophrenia have positive symptom and negative symptom patterns?

Answer 21

True.

Question 22

T or F: There is a great deal of heterogeneity in the presentation of schizophrenia.

Answer 22

True. Patients with this disorder often look quite different clinically.

Question 23

T or F: The subtypes of schizophrenia (paranoid, disorganized, catatonic) are no longer used in DSM-5.

Answer 23

True. Research using the sub-typing approach did not yield major insights into the etiology or treatment of the disorder.

Question 24

What is schizoaffective disorder?

Answer 24

Conceptually something of a hybrid, in that it is used to describe people who have features of schizophrenia and severe mood disorder.

Question 25

The reliability of schizoaffective disorder has tended to be quite poor, and clinicians often do not agree about who meets the criteria for the diagnosis. What has the DSM-5 done to improve reliability?

Answer 25

DSM-5 specifies that mood symptoms have to meet criteria for a full major mood episode and also have to be present for more than 50 percent of the total duration of the illness.

Question 26

T or F: Long-term outcomes (10yrs) are better for those with schizoaffective disorder than those with schizophrenia.

Answer 26

True.

Question 27

What is schizophreniform disorder?

Answer 27

Category reserved for schizophrenia-like psychoses that last at least a month but do not last for 6 months and so do not warrant a diagnosis of schizophrenia

Question 28

What is delusional disorder?

Answer 28

Like those with schizophrenia, these individuals old beliefs that are considered false and absurd by those around them. Unlike individuals with schizophrenia, however, people given the diagnosis of delusional disorder may otherwise behave quite normally.

Question 29

What is erotomania?

Answer 29

A subtype of delusional disorder. The theme of the delusion involves great love for a person, usually of higher status.

Question 30

What is brief psychotic disorder?

Answer 30

Involves the sudden onset of psychotic symptoms or disorganized speech or catatonic behaviour. The episode usually lasts only a matter of days (too short to warrant a diagnosis of schizophreniform disorder)

Question 31

T or F: Brief psychotic disorder is often triggered by stress.

Answer 31

True.

Question 32

T or F: Brief psychotic disorder often lasts a few days so a diagnosis of schizophreniform cannot be diagnosed.

Answer 32

True. These individuals will return to normal functioning and may never have another episode again.

Question 33

T or F: As with the mood disorders, schizophrenia concordance rates for identical twins are routinely and consistently found to be significantly higher than those for fraternal twins or ordinary siblings.

Answer 33

True. The concordance rate is 28 percent.

*If schizophrenia were exclusively a genetic disorder,
the concordance rate for identical twins would, of course, be 100 percent.

Question 34

T or F: Because MZ twins have identical genes, children of a “well” twin will have an elevated risk of schizophrenia even if their parent did not suffer from the disorder.

Answer 34

True. A predisposition to schizophrenia may remain “unexpressed” unless “released” by unknown environmental factors.

Question 35

T or F: Even if children are at genetic high risk for schizophrenia they are less likely to develop the disorder if they are raised in a healthy family environment

Answer 35

True (evidence of a genotype–environment interaction in schizophrenia).

*strong confirmation of the diathesis–stress model as it applies to the origins of schizophrenia.

Question 36

Why are researchers interested in the gene, catechol-O-methyltransferase (COMT)?

Answer 36

This gene is located on chromosome 22 and is involved in dopamine metabolism. Children who have a genetic syndrome (called velocardiofacial syndrome) that involves a deletion of genetic material on chromosome 22 are at high risk for developing schizophrenia as they move through adolescence.

Question 37

What are the genes that have been implicated in schizophrenia?

Answer 37

Catechol-O-methyltransferase (COMT), neuregulin 1 gene, dysbindin gene, DISC1 gene, as well as several dopamine receptor genes. *These candidate genes are involved in various neurobiological processes that are thought to have gone awry in schizophrenia.

Question 38

Why is the genome-wide association study (GWAS) relevant for understanding schizophrenia?

Answer 38

Unlike other genetic approaches where only a few genetic regions are tested, in a GWAS the entire genome is investigated. Study participants provide a sample of DNA and then millions of genetic variants are explored and compared across two groups (group of interest and control group).

Question 39

T or F: Some of the risk alleles that are being implicated in schizophrenia are implicated in bipolar disorder

Answer 39

True. The two disorders are far from being distinct disorders (which is the impression one gets from reading the DSM), schizophrenia and bipolar disorder (at least at the genetic level) have a lot of overlap.

Question 40

What are endophenotypes? Why are researchers focusing on endophenotypes regarding schizophrenia?

Answer 40

Discrete, stable, and measurable traits that are thought to be under genetic control.

By studying different endophenotypes, researchers hope to get closer to specific genes that might be important in
schizophrenia (magical thinking, perceptual aberration).

Question 41

T or F: Factors that jeopardize the baby’s development during the critical periods may increase the baby’s chance of developing schizophrenia.

Answer 41

True. This includes malnutrition, stress, a complicated pregnancy, viral infection, and blood incompatibility (rh).

Question 42

T or F: Schizophrenia is a disorder in which the development of the brain is disturbed very early on.

Answer 42

True. Risk for schizophrenia may start with the presence of certain genes that, if turned on, have the potential to disrupt the normal development of the nervous system. Exposure to environ-mental insults in the prenatal period may turn on these genes or may create problems in other ways, independently of genotype. Nonetheless, problems may not be apparent until other trigger-ing events take place or until the normal maturation of the brain reveals them.

Question 43

T or F: Early motor abnormalities might be an especially strong predictor of later schizophrenia.

Answer 43

True. This has been found multiple times using various research methods. To add, adolescents at high risk for schizophrenia showed more movement abnormalities (e.g., facial tics, blinking, tongue thrusts) than either nonclinical controls or adolescents with personality or behavioural problems.

Question 44

What does prodromal mean?

Answer 44

It means, very early.

A new generation of high-risk studies is focusing on young people who are at clinical (as opposed to genetic) high risk. By focusing on those who are already showing some prodromal signs of schizophrenia, researchers are hoping to improve their ability to detect, and also perhaps intervene with, people who appear to be on a pathway to developing the disorder.

Question 45

What is attenuated psychosis syndrome?

Answer 45

Characterized by mild psychotic symptoms that are not severe enough to meet clinical criteria for another full-blown psychotic disorder. People with this syndrome are thought to be at risk for later psychosis.

Question 46

T or F: Cognitive impairment is regarded as a core feature of schizophrenia.

Answer 46

True. Almost all aspects of cognition (involving attention, language, and memory) are impaired.

Question 47

T or F: Those with schizophrenia have trouble with eye-tracking.

Answer 47

True. To add to this, 50% of the first-degree relatives of patients with schizophrenia also show eye-tracking problems even though they do not have schizophrenia themselves. This demonstrates a genetic basis.

Question 48

Explain how people with schizophrenia show problems with a process called sensory gating.

Answer 48

When two clicks are heard in close succession, the brain (receiving the auditory signal) produces a positive electrical response to each click. This response is called P50 because it occurs 50 milliseconds after the click. In normal subjects, the response to the second click is less marked than the response to the first click because the normal brain dampens, or “gates,” responses to repeated sensory events. If this didn’t happen, habituation (innate response to a stimulus decreases after repeated exposure) to a stimulus would never occur. Many patients with schizophrenia, in contrast, respond almost as strongly to the second click as to the first. This is referred to as “poor P50 suppression.”

Question 49

Explain the findings regarding brain ventricles and schizophrenia.

Answer 49

Compared with controls, patients with schizophrenia have enlarged brain ventricles (fluid filled spaces that lie deep within the brain), with males possibly being more affected than females. Enlarged brain ventricles are important because they are an indicator of a reduction in the amount of brain tissue. The brain normally occupies fully the rigid enclosure of the skull. Enlarged ventricles therefore imply that the brain areas that border the ventricles have somehow shrunk or decreased in volume, the ventricular space becoming larger as a result.

*patients with schizophrenia show about a 3 percent reduction in whole brain volume relative to that in controls

Question 50

T or F: The volume of gray matter (which is made up of nerve cells) declined significantly over time in the patients with schizophrenia but not in the controls (medication).

Answer 50

True. There was almost a 3 percent decrease in the volume of gray matter in the patients in the 1-year period between the first and the second scans.

*It has also been found that patients with schizophrenia had an increase in gray matter volume in multiple brain areas. **One thing that was different about the patients in this study was that they had not yet been treated with medications.

Question 51

Is schizophrenia a neurodevelopmental disorder or a neuroprogressive disorder?

Answer 51

Both.

Question 52

What brain areas are implicated in schizophrenia?

Answer 52

There is evidence of reductions in the volume of regions in the frontal and temporal lobes. These brain areas play critical roles in memory, decision making, and in the process-ing of auditory information.

There is a reduction in the volume of such medial temporal areas as the amygdala, which is involved in emotion; the hippocampus, which plays a key role in memory; and the thalamus, which is a relay center that receives almost all sensory input

Question 53

T or F: Patients with schizophrenia show reductions in white matter volume as well as structural abnormalities in the white matter itself

Answer 53

True. These abnormalities can be found in first-episode patients and also in people at genetic high risk for the disorder.

*suggests that they are not a result of the disease itself or the effects of treatment.

Question 54

What is the default mode network and how what abnormalities may be present when a patient has schizophrenia?

Answer 54

Thought of as the brain on standby. Then, when we are actively engaged in a task, activity in this network of brain areas has to be suppressed in favour of activity in brain areas that are relevant to the task at hand.

It is now being thought that individuals with schizophrenia have trouble disengaging from the default mode, and therefore, performance on tasks suffer.

Question 55

What is the brain’s cytoarchitecture?

Answer 55

The overall organization of cells in the brain.

Question 56

T or F: Patients with schizophrenia are missing particular types of neurons known as “inhibitory interneurons”

Answer 56

True. These are called GABA interneurons and they are responsible for regulating the excitability of other neurons. (Essentially they tell other neurons to calm down.) Their absence may mean that bursts of activity by excitatory neurons in the brain go unchecked. Again, research suggests that the brains of patients with schizophrenia may be less able to regulate or dampen down overactivity in certain key neural circuits

Question 57

T or F: In people at genetic risk for schizophrenia (but not in those without genetic risk), a his-tory of fetal oxygen deprivation has been shown to be associated with brain abnormalities in later life.

Answer 57

True.

*An excellent example of how genes can create an enhanced susceptibility to potentially aversive environmental events

Question 58

The most well-studied neurotransmitter implicated in

schizophrenia is….

Answer 58

Dopamine.

Question 59

What is the dopamine hypothesis (three observations)?

Answer 59

Derived from three important observations.

1. The first was the pharmacological action of the drug chlorpromazine (Thorazine). It was learned that the therapeutic benefits of chlorpromazine were linked to its ability to block dopamine receptors.
2. In the late 1950s and early 1960s, researchers began to see that abuse of amphetamines led, in some cases, to a form of psychosis that involved paranoia and auditory hallucinations. Amphetamines are drugs that produce a functional excess of dopamine (i.e., the brain acts as if there is too much dopa-mine in the system). There was thus clinical evidence that a drug that gave rise to a functional excess of dopamine also gave rise to a psychotic state that looked a lot like schizophrenia.
3. Indirect evidence linking dopamine to schizophrenia came from clinical studies that actually treated patients by giving them drugs that increase the availability of dopamine in the brain.

Question 60

Out of the five subtypes of dopamine (D1-D5) which is the most clinically relevant for schizophrenia? What do we know about it?

Answer 60

D2. The most current findings tell us that the biggest abnormality in dopamine functioning occurs presynaptically. In other words, too much dopamine (about 14 percent more) is being synthesized and released into the synapse.

Question 61

Glutamate is an _______ neurotransmitter that is

widespread in the brain.

Answer 61

excitatory.

Question 62

Why is glutamate significant for research in schizophrenia?

Answer 62

Researchers are now exploring concentrations of glutamate in the postmortem brains of patients with schizophrenia and finding lower levels of glutamate in both the prefrontal cortex and the hippocampus compared with the levels in control subjects. Recent results from a meta-analysis further suggest that glutamate levels are also low in the brains of living patients who have schizophrenia.

Question 63

T or F: Patients with schizophrenia who returned home to live with parents or with a spouse were at higher risk of relapse than patients who left the hospital to live alone or with siblings.

Answer 63

True.

Question 64

What is expressed emotion (EE)?

Answer 64

Expressed emotion is a measure of the family environment that is based on how a family member speaks about the patient during a private interview with a researcher.

Question 65

Why is expressed emotion (EE) important?

Answer 65

Expressed emotion is important because it has been

repeatedly shown to predict relapse in patients with schizophrenia.

Question 66

What are the three elements of expressed emotion (EE) and which one is the most important to consider?

Answer 66

EE has three main elements: criticism, hostility, and emotional overinvolvement (EOI). The most important of these is criticism, which reflects dislike or disapproval of the patient.

Question 67

T or F: There is a great deal of evidence that patients with schizophrenia are highly sensitive to stress.

Answer 67

Consistent with the diathesis–stress model, environmental stress is thought to interact with preexisting biological vulnerabilities to increase the probability of relapse

*two of the major neurotransmitters implicated in schizophrenia (dopamine and glutamate) are affected by cortisol, which is released when we are stressed.

Question 68

What is a potential reason that high expressed emotion (EE) is linked to relapse?

Answer 68

High expressed emotion in a family may be stressful for the patient, and as previously noted, there is a great deal of evidence that patients with schizophrenia are highly sensitive to stress. This may be because two of the major neurotransmitters implicated in schizophrenia (dopamine and glutamate) are affected by cortisol. Therefore, high EE leads to the release of cortisol which can trigger relapse.

Question 69

T or F: Being raised in an urban environment seems to increase a person’s risk of developing schizophrenia.

Answer 69

True.

Question 70

T or F: Immigration has been found to be a risk factor for developing schizophrenia.

Answer 70

True. People who leave their native land to live in another country have almost three times the risk of developing schizophrenia compared to people who remain living in their home country.

Question 71

T or F: Cannabis use might trigger or bring forward the onset of psychosis

Answer 71

True. This could be because one of the active ingredients of cannabis (called THC) increases dopamine in several areas of the brain

Question 72

How is schizophrenia a genetically influenced, not a genetically determined, disorder?

Answer 72

Favourable environments may reduce the chance that a genetic predisposition will result in schizophrenia.

Question 73

Outline the diathesis-stress model applied to schizophrenia.

Answer 73

Genetic factors and acquired constitutional factors (such as prenatal events and birth complications) combine to result in brain vulnerability. Normal maturational processes, combined with stress factors (family stress, cannabis use, urban living, immigration, etc.), may push the vulnerable person across the threshold and into schizophrenia.

Question 74

T or F: despite many advances in treatment during the past 50 to 60 years, a “cure” for schizophrenia has not materialized.

Answer 74

True.

*With the help of therapy and medications, patients can function quite well.

Question 75

What do the antipsychotics used to treat those with schizophrenia all have in common?

Answer 75

The common property that they all share is their ability to block dopamine D2 receptors in the brain

Question 76

What are neuroleptics?

Answer 76

They are first-generation antipsychotics that are called that so that they can be distinguished from a new class of antipsychotics that was developed much more recently.

*revolutionized the treatment of schizophrenia when they were introduced in the 1950s

Question 77

Do first-generation antipsychotics work best for positive or negative symptoms of schizophrenia? At what cost?

Answer 77

Positive symptoms of schizophrenia.

Common side effects of these medications include drowsiness, dry mouth, and weight gain. Many patients on these antipsychotics also experience what are known as extrapyramidal side effects (EPS). These are involuntary movement abnormalities (muscle spasms, rigidity, shaking) that resemble Parkinson’s disease.

Question 78

What is tardive dyskinesia?

Answer 78

Some patients who have been treated with neuroleptics for long periods of time may also develop marked involuntary movements of the lips and tongue (and sometimes the hands and neck).

*females being especially susceptible

Question 79

What is neuroleptic malignant syndrome?

Answer 79

A toxic reaction to first-generation antipsychotic medication. This condition is characterized by high fever and extreme muscle rigidity, and if left untreated it can be fatal.

Question 80

Why are second-generation antipsychotics distinguished from first-generation antipsychotics?

Answer 80

They cause fewer extrapyramidal symptoms than the earlier antipsychotic medications

Question 81

T or F: Clozapine, a second generation antipsychotic, seems to be the only drug (between the two generations) that shows more efficacy in treatment of those with schizophrenia.

Answer 81

True. Otherwise, there appears to be no differences.

Question 82

Why is family therapy valuable for the treatment of schizophrenia?

Answer 82

The idea was to reduce relapse in schizophrenia by changing those aspects of the patient–relative relationship that were regarded as central to the expressed emotion (EE) construct.

Treatment is based around enhancing communication, psychoeducation, and coping/problem-solving skills.

In general, the results of research studies in this area have shown that patients do better clinically and relapse rates are lower when families receive family treatment

Question 83

How effective is social-skills training for those who have schizophrenia?

Answer 83

Although the results of some early studies were mixed,
the most recent research findings look more positive. Their improvements seem to be maintained over time, and are less likely to relapse and need hospital treatment

*Patients learn these skills, get corrective feedback, practice their new skills using role-playing, and then use what they have learned in natural settings.

Question 84

What is cognitive remediation training?

Answer 84

Using practice and other compensatory techniques, researchers are trying to help patients improve some of their neurocognitive deficits (e.g., problems with verbal memory, vigilance, and performance on card-sorting tasks).

Cognitive remediation training does seem to help patients improve their attention, memory, and executive functioning skills.

Question 85

What are the two types of individual therapy that are now being used for schizophrenia?

Answer 85

Personal therapy is a non-psychodynamic approach that equips patients with a broad range of coping techniques and skills.

Educating patients about the illness and its treatment
(this approach is called psychoeducation) is also helpful