schizophrenia chapter questions

Question 1

What is psychosis?

Answer 1

Psychosis is a state of being profoundly out of touch with reality.

Question 2

What are hallucinations?

Answer 2

Hallucinations are abnormal sensory experiences such as hearing or seeing non-existent things.

Question 3

What are delusions?

Answer 3

Delusions are fixed, false and often bizarre beliefs.

Question 4

What are the five characteristic symptoms of schizophrenia contained in the DSM-IV-TR diagnostic criteria for schizophrenia?

Answer 4

Positive/ Type I symptoms: delusions, hallucinations, disorganised speech, grossly disorganized or catatonic behaviour
Negative/ type II symptoms: negative symptoms (such as lack of emotion, speech, or motivation)

Question 5

How many of the five characteristic symptomse need to present for a diagnosis of schizophrenia?

Answer 5

Two or more of the five symptoms need to present for a diagnosis of schizophrenia.

Question 6

What are the criteria for significant social/occupational dysfunction?

Answer 6

There must be evidence of significant impairment and deterioration present over time in an individual’s ability to function in his or her social and occupational world. People with schizophrenia have significant difficulties with work, school and relationships.
For example, 60-70% of individuals with schizophrenia never marry, and those who do often report poor quality marriages and high rates of separation and divorce. Typically, the socioeconomic status of individuals with schizophrenia is below that of their family of origin and of their unaffected parents and siblings (downward drift).

Question 7

For at least how long must behavioural disturbance have been present for a diagnosis of schizophrenia?

Answer 7

Over 6 months

Question 8

What is the definition of positive symptoms?

Answer 8

Positive or Type I symptoms of schizophrenia: symptoms that represent pathological excesses, exaggerations, or distortions from normal functioning, such as delusion, hallucinations, and disorganized speech, thought or behaviour

Question 9

What is disorganized speech?

Answer 9

Disorganized speech or thought: severe disruptions in the process of speaking or thinking.

Question 10

What is grossly disorganized behaviour?

Answer 10

Grossly disorganized behaviour refers to a wide of variety of bizarre or disrupted behavioural patterns that can include dishevelment, extreme agitation uncontrollable childlike silliness, inability to perform simple activities of daily living, etc.

Question 11

How many types of delusions are there?

Answer 11

DSM-IV-TR distinguishes between bizarre and nonbizarre delusions. Bizarre delusions are those that do not relate to ordinary life experience. In contrast, the belief that one is being followed by the CIA would be considered a nonbizarre delusion
In terms of content, delusions of persecution- the idea that one is being attacked, followed, controlled and so on- are the most common. Delusion of grandeur, such as peter’s belief that he is Jesus, and delusions of reference, which involve the false assumption that external events are connected to oneself (such as the idea that a TV announcer is specifically talking to you) also occur frequently. Other common themes in delusions include guilt (delusion of sin), illness (hypochondriacal delusions), and the impending end of the world (nihilistic delusions).

Question 12

What is catatonic behaviour?

Answer 12

Catatonic behaviours are bizarre motoric behaviours. They can range from extreme immobility and unresponsiveness (known as catatonic rigidity and catatonic stupor, respectively) to extreme agitation, such as a purposeless flailing, pacing or spinning (catatonic excitement). Catatonic rigidity sometimes includes an unusual symptom known as waxy flexibility in which patients’ limbs, often held in rigid posture for hours, can be bent and reshaped as though made of wax.

Question 13

What are the negative symptoms of schizophrenia?

Answer 13

Negative or Type II symptoms of schizophrenia: symptoms that represent pathological deficits, such as flat affect, loss of motivation, and poverty of speech.
Negative symptoms of schizophrenia include:
Affective flattening情感冷淡: lack of response to emotionally relevant stimuli
Avolition/ apathy: lack of motivation, interest in normal activities
Alogia失语症: poverty of speech, minimal or absent verbal communication, lowered volume or content
Anhedonia快感缺乏症: lack of interest in enjoyable experiences

Question 14

What are the DSM-IV subtypes of schizophrenia?

Answer 14

Paranoid, Disorganized, Catatonic, Undifferentiated, Residual
Paranoid schizophrenia: prominent delusions or auditory hallucinations, most common
Disorganized schizophrenia: prominent disorganized speech, disorganized behaviour, and flat or inappropriate affect, most severe
Catatonic schizophrenia: prominent psychomotoric symptoms, such as rigid physical immobility, and unresponsiveness or extreme behavioural agitation, muteness, echolalia and echopraxia
Undifferentiated schizophrenia: active schizophrenic symptoms that do not fit the paranoid, disorganized, or catatonic subtypes
Residual schizophrenia: following at least one episode of schizophrenia, a state in which there are no prominent positive symptoms of schizophrenia but some negative symptoms and milder positive symptoms remain.

Question 15

List the other DSM disorders related to schizophrenia.

Answer 15

Schizoaffective Disorder, Schizophreniform Disorder, Brief Psychotic Disorder, Delusion Disorder, Shared Delusional Disorder
Schizoaffective Disorder分裂情感性障碍: DSM-IV-TR diagnosis involving symptoms of both a mood disorder and schizophrenia
Schizophreniform Disorder [医]精神分裂症样精神障碍: DSM-IV-TR diagnosis involving a psychotic episode that has all the features of schizophrenia but has not lasted for 6 months
Brief Psychotic Disorder [医]短时精神障碍: DSM-IV-TR diagnosis involving a psychotic episode that has all the features of schizophrenia but lasts less than one months.
Delusion Disorder妄想症: DSM-IV-TR diagnosis involving nonbizarre delusions lasting at least a month
Shared Delusional Disorder/ Folie A Deux 感应性精神病: DSM-IV-TR diagnosis involving delusions that develop in the context of a close relationship with a psychotic person. i.e. patients typically in LT and close relationship with a schizophrenic person.

Question 16

What percentage of the population is estimated to have schizophrenia?

Answer 16

Lifetime prevalence of schizophrenia at around 1% population worldwide (Harrap & Trower, 2001; Jablensky, 1997)

Question 17

What is the most common lifetime period for schizophrenia to start?

Answer 17

Early adulthood (Male-early 20s; Female-late 20s)

Question 18

After what age does it become less common for schizophrenia to develop?

Answer 18

60, but still possible in women

Question 19

What social factors have been identified as having a role in the development of schizophrenia?

Answer 19

Larger social and institutional forces may play a role in the development of the schizophrenia. For example, there is epidemiological evidence that rates of schizophrenia are higher in lower socioeconomic classes and among those born in urban area. These data suggest that stress associated with urban poverty could be one contributing factor in the onset of schizophrenia. Another emphasis in sociocultural work on schizophrenia concerns the potentially negative effects of social institutions, such as the medical establishment, on the symptoms and identity of those with severe mental illnesses. For example, David Rosenhan’s famous ‘pseudo-patient’ study argued that the dehumanizing conditions of the psychiatric hospitals contributed to the actual patient’ symptomatic behaviour.

Question 20

What is “downward drift”?

Answer 20

Downward drift is the decline in socioeconomic status of individuals with schizophrenia relative to their families of origin.
i.e., the socioeconomic status of individuals with schizophrenia is below that of their family of origin and of their unaffected parents and siblings.

Question 21

What does the evidence of pregnancy and birth complications add to our knowledge about the development of schizophrenia?

Answer 21

1) The external birth environment:
Season of birth: in the northern hemisphere there is reasonably consistent evidence for a 5-8% excess of births in winter and spring of children who later develop SCH (Bradbury & Miller, 1985), similar effect have been found for spring in the Southern hemisphere (Adams & Kendell, 1999).
Place of birth: urbanisation: An increased risk of developing schizophrenia in urban compared with rural areas has been reported by many researchers. More recent data suggest that the ‘social drift’ hypothesis might not be the whole story. Reports have shown that greater risk is associated with urban birth rather than later urban living (Marcelis et al, 1999). However, there is evidence that the effects may not be restricted to SCH and can also apply to other mental illnesses.
2) The uterine environment:
Prenatal influenza: In 1988, Mednick and colleagues observed that women in the second trimester of pregnancy during the 1957 -1958 influenza pandemic were twice as likely to have given birth to individuals who were later admitted with schizophrenia. Other illnesses, both pre- and perinatally, have also been implicated. A wide range of viruses can be considered neurotropic have been associated with CNS problems including learning disability, epilepsy and psychosis. Again, there is no evidence that allow us to establish whether these are specific effects of the infection, or effects of pyrexia, medications or the maternal immune response.
Prenatal famine饥荒: famine in the population while a baby is in utero has been shown to be associated with later schizophrenia. Being in early gestation怀孕in the Netherlands during the Nazi blockade at the end of 1944 has an effect for later schizophrenia. The obvious mechanism is a relative lack of foetal胎儿的nutrition, which would also explain the increased rate of schizophrenia with short birth-spacing.
Prenatal stress: Birth cohort studies (Myhrman et al, 1996) have identified factors such as maternal stress (as measured by death of the spouse in the year after birth), the ‘unwantedness’ of the pregnancy and depression in late pregnancy as being associated with SCH.

Question 22

What is the dopamine hypothesis of schizophrenia?

Answer 22

Dopamine hypothesis: the hypothesis that excess dopamine transmission causes the psychotic symptoms of schizophrenia

Question 23

What evidence is there in support of the dopamine hypothesis?

Answer 23

There is evidence that neuroleptic drugs can affect the dopamine system (Carlsson & Lindqvist, 1963). Furthermore, L-DOPA, a dopamine precursor used to alleviate parkinsonian symptoms, can cause psychosis with overuse. Similarly, stimulant drugs such as amphetamines and cocaine will produce psychosis in overdose, partly by blocking dopamine reuptake and thereby causing excess dopamine transmission. Finally, it was discovered that many individuals with schizophrenia, particularly those with a preponderance of positive psychotic symptoms, had an excess of dopamine receptors in the brain, particularly a variety known as D2 receptors.
Also need to know the modifications of the dopamine hypothesis

Question 24

What other strands of evidence support a biological explanation of schizophrenia?

Answer 24

At proximal level, brain dysfunction, brain structure abnormalities, neuropsychological and neurophysiological abnormalities are associated with schizophrenia; at the distal level, genetic evidence suggests that a predisposition to schizophrenia is inherited.
Brain function abnormalities: Several abnormalities in brain function appear to be associated with schizophrenia. For example, studies have shown a general decrease in activity in the prefrontal cortex – a syndrome known as hypofrontality – that seems to be particularly associated with negative symptoms of schizophrenia. Studies have also suggested altered cell membrane metabolism and changes in neuron size and density in the prefrontal region of the brain. Neuroimaging and post-mortem studies have shown abnormalities in several neurotransmitter systems of people with schizophrenia, including the dopamine, glutamate, and serotonin and GABA system. +dopamine hypothesis in here.
Brain structure abnormalities: Findings on association between enlarged lateral ventricles and schizophrenic, particularly in cases with prominent negative symptoms. While the differences in ventricle size btw clients with SCH vs. control are relative small and subtle, they may indicate a loss of brain tissue in SCH, possibly due to reduced blood flow. Other neuroanatomical findings in SCH include a decrease in the size of the temporal lobe (especially in the medial temporal structures such as the hippocampus and the amygdala), and abnormalities in the frontal and parietal lobes. In particular, cell membrane degradation seen in prefrontal cortex, and decreases in the mass of neuronal cells have been found in the hippocampus and other areas. Finally, some studies have indicated abnormalities in subcortical structures such as the corpus callosum and the thalamus. Some researchers suggest that the neuroanatomical changes seen in the MRIs of schizophrenic brains suggest an abnormality in large brain ‘networks’ that connect the prefrontal cortex with the limbic system.
A variety of neuropsychological deficits cause deficits in functioning, and contribute to the development and maintenance of negative symptoms. There is evidence that Cognitive abilities such as verbal fluency, learning, memory, attention, and psychomotor skills are all reduced compared to those of control subjects, consistent with neuroanatomical research suggesting abnormalities in the frontal and temporal lobes. Interestingly, similar temporal and frontal lobe deficits were also found in close relatives of SCH patients, suggesting that such deficits may constitute a necessary but not sufficient risk factor for the disorder. SCH often showed impaired sensory gating which they often describe as ‘feeling flooded with stimulation’.
In addition, researchers have found neurophysiological differences btw SCH and control. SCH often showed abnormal visual tracking, slow reaction times and abnormal brain wave patterns. However, many of the neurophysiological signs found in SCH are also found in those with mood disorders, so they are not uniquely associated with SCH.
Genetics- see 26, 27

Question 25

What is concordance?

Answer 25

Concordance: In a group of twins, the percentage who both have disorder.

Question 26

What does the evidence from twin studies tell us about the role of genetics in schizophrenia?

Answer 26

Twin studies showed that the concordance rate was 17% in dizygotic (DZ) twins and 48% in monozygotic (MZ) twin (Gottesman, 1991). This provide power evidence for genetic contribution to schizophrenia, since the MZ twins shared 100% genetic similarity while DZ twins only shared 50% genetic similarity.
However, this result has two important caveats. First, subtle environmental confounds can affect twin studies, since identical twins are more likely to imitate each other and to be treated similarly than fraternal twins. Also, MZ twins sometimes uniquely share another environment- the placenta胎盘— which may be implicated in schizophrenia through prenatal illnesses or injuries. Second, twin studies clearly indicate that the genetic contribution to schizophrenia is a partial one and that environment plays an equally large role, since if genes were the complete cause of schizophrenia the concordance rate for MZ twins would be 100%, not 48%. Note that the concordance rate in Gottesman’s samples for regular siblings is 9%, substantially lower than the 17% rate DZ twins. Genetically speaking, regular siblings and DZ both share 50% of genes. But DZ twins share more in the way of environment –prenatal and postnatal –since they are born and raised together. This environmental similarity, therefore, must be responsible for their higher concordance rates.

Question 27

What have we learnt about the heritability of schizophrenia from adoption studies?

Answer 27

Adoption studies attempt to further isolate genetic factors from environmental factors. Heston’s study of adoptions from schizophrenic mothers shows of 47 adopted children born to schizophrenia mothers, 5 developed schizophrenia, and over half developed other significant type of psychopathology. By contrast, of 50 adoptees from normal mothers, none developed schizophrenia, and less than 20% developed other disorders.
Additional note
There are two main strategies in adoption studies. One is to find parents with schizophrenia who have given up children for adoption (and therefore have not raised them) and to look are concordance rates among these biologically but not environmentally related parent-child pairs. The other strategy is to find adoptee that developed schizophrenia and to look at concordance rates with their biological relatives, if they can be located.
There are some environmental confounds. Postnatal environment is shared with biological parents up until the adoption, and there could be additional environmental confounds from selective adoption placement with families similar to the biological family and from later contact with the biological family. Adoptees develop schizophrenia depends, in part, on the psychological health of their adoptive families.

Question 28

What are antipsychotics?

Answer 28

Antipsychotic medications: medications that reduce psychotic symptoms

Question 29

What are neuroleptics?

Answer 29

Neuroleptic is another name for an antipsychotic medication.

Question 30

What are “atypical’ antipsychotics?

Answer 30

Atypical or second-generation antipsychotics: Newer antipsychotic medications that target both positive and negative symptoms of schizophrenia.
Atypical antipsychotics seem to be related to their antagonistic targeting of certain serotonin and norepinephrine receptors with a smaller effect on dopamine receptors. Fewer side effects compare to traditional antipsychotics, but often cause significant weight gain.

Question 31

What are the cognitive components of schizophrenia?

Answer 31

Cognitive theorists focus on the role of Attentional processes.
For example, the positive symptoms of schizophrenia may be related to a problems of overattention in which individuals with schizophrenia are unable to screen out irrelevant stimuli (impaired sensory gating), possibly because of dopaminergic (dopamine-related) abnormalities. This overattention leads to difficulties coping with stress, and possibly further to psychotic symptoms such as delusions when clients attempt to explain their odd subjective experiences to themselves.
The negative symptoms of schizophrenia may be related to an equally problematic underattention to important stimuli, leading to withdrawal and apathy. For example, studies have shown that individual with prominent negative symptoms do not have a normal orienting response –physical changes associated with sharpened attention –to novel stimuli.
Interestingly, Attentional problems remain present in residual schizophrenia are found in the nonschizophrenic relatives of individuals with schizophrenia, suggesting that they may reflect an underlying vulnerability to the disorder

Question 32

What are the behavioural components of schizophrenia?

Answer 32

Behavioural theorists focus on the importance of learning in the development and treatment of schizophrenia. In particular, they argued that reinforcement of abnormal responses, such as receiving attention for disorganized speech, can contribute to the abnormal behaviours of schizophrenia through the principle of operant conditioning. For the most part, behaviourists emphasize the role of biological factors that may predispose someone to learn abnormal responses. For example, biological abnormalities may lead individuals with schizophrenia to respond to atypical, rather than normal, social cues, leading to social difficulties and negative symptoms such as social withdrawal

Question 33

What are the sociocultural components of schizophrenia?

Answer 33

Larger social and institutional forces may play a role in the development of the schizophrenia. For example, there is epidemiological evidence that rates of schizophrenia are higher in lower socioeconomic classes and among those born in urban area. These data suggest that stress associated with urban poverty could be one contributing factor in the onset of schizophrenia. Another emphasis in sociocultural work on schizophrenia concerns the potentially negative effects of social institutions, such as the medical establishment, on the symptoms and identity of those with severe mental illnesses. For example, David Rosenhan’s famous ‘pseudo-patient’ study argued that the dehumanizing conditions of the psychiatric hospitals contributed to the actual patient’ symptomatic behaviour.

Question 34

What are the family systems components of schizophrenia?

Answer 34

Early view: hostile family environments contributes (double-blind communications)
Contemporary view: communication deviance; expressed emotion (EE)
Early family theorists focused on the idea that overly hostile, confusing, or otherwise pathological family environments could contribute to schizophrenia. For example, one of the early theories indicates that on-going double-blind communications from parents to children could lead to cognitive confusion and emotional paralysis characteristic of schizophrenia. However, this theory has been generally viewed as overly reductionist and abandoned by current family theorists.
Contemporary family researchers focus more on specific, measurable variables related to pathological family communication in families with severe mental illnesses like schizophrenia. For example, researchers have explored different aspects of communication deviance- odd or idiosyncratic communications –within families. Many studies have also examined how individuals affected by expressed emotion (EE) –high levels of criticism and overinvolvement among family members. There is evidence that high levels of EE, which correlate with communication deviance, are present in families of individuals with schizophrenia and predict relapse in the affected family members. Furthermore, when EE levels in the family decrease, the functioning of the family member with SCH improves.

Question 35

What are the psychodynamic components of schizophrenia?

Answer 35

Freud’s theory on schizophrenia involved a profound withdrawal of emotional investment in the external world so that individual with the disorder could not form deep relationships with others, including relationships with psychotherapists. He pressured that this withdrawal occurred partly in reaction to emotional traumas very early in life and presented a fixation at an infantile stage. Freud suggested that hallucinations and other psychotic symptoms are secondary symptoms of schizophrenia related to the individual’s attempt to reconnect with the outside world, an idea that overlaps with some contemporary cognitive and sociocultural theories.
A number of later psychodynamic theorists differed from Freud in their beliefs that schizophrenia could be entirely psychological origin and effectively treated by psychodynamic psychotherapy. Fromm-Reichmann believed that schizophrenia could be caused by mothers who were alternately or simultaneously cold, overprotective and demanding. However, this theory predated biological discoveries about SCH, so now considered as misguided

Question 36

What is “Expressed Emotion”?

Answer 36

Expressed Emotion: high levels of criticism and overinvolvement among family members
Note: positively correlates to communication deviance; higher level of EE is often present in patients’ families; higher levels of EE predict relapse of discharged patients

Question 37

What are the most common types of psychological treatments for schizophrenia?

Answer 37

Family intervention; Cognitive remediation/ rehabilitation
Family intervention aim to reduce communication deviance and expressed emotion. It includes educating relative of SCH patients to improve communication; increase awareness of factors that can trigger relapse, such as negative expressed emotion and stress; teaching coping strategies. Researches on family intervention have been shown to reduce communication deviance and expressed emotion, and to lower the risk of relapse of SCH symptoms in previously diagnosed clients.
Cognitive rehabilitation techniques are used to address problems with attention, focus and verbal fluency. There are two types: 1) Remediation improves cognitive function through new learning or relearning. 2) Compensatory strategies minimise deficits and maximise other domains through supportive environment

Question 38

How successful are the treatments for schizophrenia?

Answer 38

We do not yet have a comprehensive understanding of the Etiology of schizophrenia, or even whether schizophrenia is a single disorder. The treatments for SCH, though better than ever, are far from cures. And among other formidable obstacles to research on schizophrenia, most research subjects with the disorder have been medicated and/or hospitalized, adding confounding variables to the search for the essence and causes of SCH.
Biological interventions include using antipsychotic medication. Traditional antipsychotics (e.g., chlorpromazine, haloperidol) can reduce positive symptoms but had little effect on negative symptoms. Nevertheless, it was not effective for up to 40% and had a wide range of side effects, for example, shuffling gait, tremor, muscular problems, tardive dyskinesia. Compliance rates were also low. Atypical antipsychotics include were serotonin and norepinephrine receptor antagonists such as Clozapine, Olanzapine, and Risperidone. They are more successful in reducing positive symptoms and had better compliance rates and fewer severe side-effects but they cause significant weight gain which might lead to serious health problems.
Cognitively oriented interventions have been shown to be effective in both the treatment and prevention of some schizophrenic symptoms. For example, combine cognitive-behavioural interventions have shown some success reducing the severity of delusions in a number of research studies.
Behavioural intervention on schizophrenia has focused treatment interventions rather than explanations, for example, reinforcement-based techniques (using operant-conditioning principle) are used to alternate behaviour. In token economies (which are often used in hospital or other institutional setting), clients who engage in desired behaviours earn coinlike tokens that can be exchanged for privileges such as watching TV or having extra snacks. Such systems can effectively promote behaviour change in schizophrenia. Social skills training, which educates clients about appropriate interpersonal behaviour, has been shown to improve clients’ social and interpersonal functioning, although there is some debate about the extent of these improvements.
The sociocultural perspective has made important contributions to the treatment of schizophrenia, in terms of both hospital and outpatient care. In inpatient aspects, Milieu treatment is used and clients can take active responsibility for decisions about the management of their environment and therapy programs. In recent years, as hospital stays have been drastically shortened by economic pressures, the need for quality outpatient services has become especially great. There are more outpatient treatment options, including partial or day hospitalization programs and halfway houses for the seriously mental ill. The most important factor in effective community care for schizophrenia appears to be the coordination of services. A program called assertive community treatment (ACT), which offers frequent and coordinated contact with clients by a team of professionals, have been shown to decrease relapses, rehospitalizations, police involvement, and the need for emergency medical care. Although ACT is expensive due to the number of professionals involved, such programs have also been shown to be cost effective compared to the alternatives. For example, a recent Australian study showed that an ACT program was able to reduce the number of hospitalizations in the target population by 43%, resulting in savings of almost $14,000 per client per year.
Family interventions have been shown to reduce communication deviance and expressed emotion, and to lower the risk of relapse of schizophrenic symptoms in previously diagnosed clients. These, in turn, reduce the number of rehospitalizations for clients with schizophrenia.
Psychotherapy can be a crucial adjunct to medication since the effects of medication are typically limited in scope, and the combination of the two has been shown to improve personal adjustment, prevent relapse, and increase ongoing treatment compliance. Individuals with schizophrenia have wishes, fears, hopes, and conflicts that can be helpfully addressed in a caring therapeutic relationship.
Based on the principle of multiple causality, personal therapy was developed for schizophrenia. It combines cognitive, behavioural, psychodynamic and humanistic principles as an adjunct to appropriate pharmacological treatment and focuses on helping clients with schizophrenia to solve the practical problems of daily life. It has been shown to produce general improvement and to prevent relapses in clients with schizophrenia.