Anusha Thakur

1. Briefly describe the ethical and legal issues of psychotherapy.

Mandatory ethics is the view of ethical practice that deals with the minimum level of
professional practice, while aspirational ethics is a higher level of ethical practice that
addresses doing what is in the best interests of clients. Additionally, positive ethics is an
approach taken by practitioners who want to do their best for clients rather than simply meet
minimum standards to stay out of trouble. Professional codes of ethics serve the following
functions (Corey, 2009):
1. Educate therapists and the general public about the responsibilities of the profession
2. Provide a basis for accountability
3. Protect clients from unethical practices
4. Provide basis for self-reflection and improvement of professional practice.
According to Corey (2009), following are the ethics that should be observed by
therapists:
1. Balancing clients’ needs before the therapist’s own : It is essential for therapists to
become aware of their own needs, areas of unfinished business, potential personal
problems, and their sources of countertransference. These factors could interfere with
effectively and ethically serving clients. As helping professionals, therapists have
responsibilities to work actively toward expanding their self-awareness and to learn to
recognize areas of prejudice and vulnerability. Being aware of personal problems and
willingness to work through them leaves less chance that they will project them onto
clients. If certain problem areas surface and old conflicts become reactivated, they
have an ethical obligation to seek personal therapy to avoid harming clients.
2. Ethical decision making: Therapists can ensure ethical decision making in the
following ways:
a. Identify the problem or dilemma. Gather information that will shed light on
the nature of the problem. This will help the therapist decide whether the
problem is mainly ethical, legal, professional, clinical, or moral.
b. Identify the potential issues. Evaluate the rights, responsibilities, and welfare
of all those who are involved in the situation.
c. Look at the relevant ethics codes for general guidance on the matter. Consider
whether the therapist’s own values and ethics are consistent with or in conflict
with the relevant guidelines.
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d. Consider the applicable laws and regulations, and determine how they may
have a bearing on an ethical dilemma.
e. Seek consultation from more than one source to obtain various perspectives on
the dilemma, and document in the client’s record what suggestions the
therapist received from this consultation.
f. Brainstorm various possible courses of action. Continue discussing options
with other professionals. Include the client in this process of considering
options for action. Again, document the nature of this discussion with the
therapist’s client.
g. Enumerate the consequences of various decisions, and reflect on the
implications of each course of action for the therapist’s client.
h. Decide on what appears to be the best possible course of action. Once the
course of action has been implemented, follow up to evaluate the outcomes
and to determine if further action is necessary. Document the reasons for the
actions the therapist took as well as your evaluation measures.
3. Right of Informed Consent: Informed consent involves the right of clients to be
informed about their therapy and to make autonomous decisions pertaining to it.
Providing clients with information they need to make informed choices tends to
promote the active cooperation of clients in their counseling plan. By educating the
clients about their rights and responsibilities, the therapist both empowers them and
builds a trusting relationship with them.
Some aspects of the informed consent process include the general goals of counseling,
the responsibilities of the counselor toward the client, the responsibilities of clients,
limitations of and exceptions to confidentiality, legal and ethical parameters that could
define the relationship, the qualifications and background of the practitioner, the fees
involved, the services the client can expect, and the approximate length of the
therapeutic process. Further areas might include the benefits of counseling, the risks
involved, and the possibility that the client’s case will be discussed with the therapist’s
colleagues or supervisors.
4. Confidentiality: Confidentiality is an ethical concept, and the duty of therapists to not
disclose information about a client. Professionals have the responsibility to define the
degree of confidentiality that can be promised. Counselors have an ethical and legal
responsibility to discuss the nature and purpose of confidentiality with their clients
early in the counseling process. In addition, clients have a right to know that their
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therapist may be discussing certain details of the relationship with a supervisor or a

colleague. There is a legal requirement to break confidentiality in cases involving
child abuse, abuse of the elderly, abuse of dependent adults, and danger to self or
others.
5. Focusing on Both Individual and Environmental Factors in a Multicultural Setting:
Therapists who operate from a multicultural framework have certain assumptions and
a focus that guides their practice. They view individuals in the context of the family
and the culture, and their aim is to facilitate social action that will lead to change
within the client’s community rather than merely increasing the individual’s insight.
6. Ethical Issues in Assessment and Diagnosis: Regardless of their theoretical
orientation, therapists need to engage in assessment, which is generally an ongoing
part of the therapeutic process. Assessment should not precede and dictate
intervention; rather, it is woven in and out of the therapeutic process as a pivotal
component of therapy itself. This assessment may be subject to revision as the
clinician gathers further data during therapy sessions. Some practitioners consider
assessment as a part of the process that leads to a formal diagnosis.
A danger of the diagnostic approach is the possible failure of therapists to consider
ethnic and cultural factors in certain patterns of behaviour. It is important to be aware
of unintentional bias and keep an open mind to the presence of distinctive ethnic and
cultural patterns that could influence the diagnostic process. Unless cultural variables
are considered, some clients may be subjected to erroneous diagnoses. Certain
behaviours and personality styles may be labeled neurotic or deviant simply because
they are not characteristic of the dominant culture.
Ethical dilemmas may be created when diagnosis is done strictly for insurance
purposes, which often entails arbitrarily assigning a client to a diagnostic
classification. It is a clinical, legal, and ethical obligation of therapists to screen
clients for life-threatening problems such as organic disorders, schizophrenia, bipolar
disorder, and suicidal types of depression.
It is essential to assess the whole person, which includes assessing dimensions of
mind, body, and spirit. Therapists need to take into account the biological processes as
possible underlying factors of psychological symptoms and work closely with
physicians. Clients’ values can be instrumental resources in the search for solutions to
their problems, and spiritual and religious values often illuminate client concerns.
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7. Evidence-Based Practice: Mental health practitioners must choose the best

therapeutic approach or interventions with a particular client. The central aim of
evidence-based practice (EBP) is to require psychotherapists to base their practice on
techniques that have empirical evidence to support their efficacy. Evidence-based
practice requires clinicians to be accountable to their clients and to have up-to-date
information on effective treatments. The overarching goal of EBP is to enhance the
effectiveness of client services and to improve public health and warn that mental
health professionals need to take a proactive stance to make sure this goal is kept in
focus.
8. Dual or Multiple Relationships: Dual or multiple relationships, either sexual or
nonsexual, occur when counselors assume two (or more) roles simultaneously or
sequentially with a client. This may involve assuming more than one professional role
or combining professional and nonprofessional roles. Counseling professionals must
learn how to manage multiple roles and responsibilities in an ethical way. This entails
dealing effectively with the power differential that is inherent in counseling
relationships and training relationships, balancing boundary issues, addressing
nonprofessional relationships, and striving to avoid using power in ways that might
cause harm to clients, students, or supervisees.
According to the American Psychological Association (2017), the following code of
conduct must be followed for therapy:
1. Informed Consent to Therapy: Psychologists inform clients/patients as early as is
feasible in the therapeutic relationship about the nature and anticipated course of
therapy, fees, involvement of third parties, and limits of confidentiality and provide
sufficient opportunity for the client/patient to ask questions and receive answers.
When obtaining informed consent for treatment for which generally recognized
techniques and procedures have not been established, psychologists inform their
clients/patients of the developing nature of the treatment, the potential risks involved,
alternative treatments that may be available, and the voluntary nature of their
participation. When the therapist is a trainee and the legal responsibility for the
treatment provided resides with the supervisor, the client/patient, as part of the
informed consent procedure, is informed that the therapist is in training and is being
supervised and is given the name of the supervisor.
2. Therapy Involving Couples or Families: When psychologists agree to provide services
to several persons who have a relationship, they take reasonable steps to clarify at the
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outset (1) which of the individuals are clients/patients and (2) the relationship the
psychologist will have with each person. This clarification includes the psychologist's
role and the probable uses of the services provided or the information obtained. If it
becomes apparent that psychologists may be called on to perform potentially
conflicting roles, psychologists take reasonable steps to clarify and modify, or
withdraw from, roles appropriately.
3. Group Therapy: When psychologists provide services to several persons in a group
setting, they describe at the outset the roles and responsibilities of all parties and the
limits of confidentiality.
4. Providing Therapy to Those Served by Others: In deciding whether to offer or provide
services to those already receiving mental health services elsewhere, psychologists
carefully consider the treatment issues and the potential client's/patient's welfare.
Psychologists discuss these issues with the client/patient or another legally authorized
person on behalf of the client/patient in order to minimize the risk of confusion and
conflict, consult with the other service providers when appropriate, and proceed with
caution and sensitivity to the therapeutic issues.
5. Sexual Intimacies with Current Therapy Clients/Patients: Psychologists do not engage
in sexual intimacies with current therapy clients/patients.
6. Sexual Intimacies with Relatives or Significant Others of Current Therapy
Clients/Patients: Psychologists do not engage in sexual intimacies with individuals
they know to be close relatives, guardians, or significant others of current
clients/patients. Psychologists do not terminate therapy to circumvent this standard.
7. Therapy with Former Sexual Partners: Psychologists do not accept as therapy
clients/patients persons with whom they have engaged in sexual intimacies.
8. Sexual Intimacies with Former Therapy Clients/Patients: Psychologists do not engage
in sexual intimacies with former clients/patients for at least two years after cessation
or termination of therapy. Psychologists do not engage in sexual intimacies with
former clients/patients even after a two-year interval except in the most unusual
circumstances.
9. Interruption of Therapy: When entering into employment or contractual relationships,
psychologists make reasonable efforts to provide for orderly and appropriate
resolution of responsibility for client/patient care in the event that the employment or
contractual relationship ends, with paramount consideration given to the welfare of
the client/patient.
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10. Terminating Therapy: Psychologists terminate therapy when it becomes reasonably

clear that the client/patient no longer needs the service, is not likely to benefit, or is
being harmed by continued service. They may terminate therapy when threatened or
otherwise endangered by the client/patient or another person with whom the
client/patient has a relationship. Except where precluded by the actions of
clients/patients or third-party payors, prior to termination psychologists provide
pre-termination counseling and suggest alternative service providers as appropriate.
As per the Mental Healthcare Act (2017), mental health professionals can be held
liable under various sections. These fall into three broad categories (Hongally, Sripad,
Nadakuru, Meenakshisundaram & Jayaprakasan, 2019):
1. Registration and Record Maintenance: Clinical psychologists, mental health nurses,
and psychiatric social workers in the state, are required to register with the concerned
SMHA. Section 55 (d) says that only those whose names are published by the
authority are permitted to practice in the state. Every mental health establishment
(MHE) must fulfill minimum norms as specified by the SMHA (Section 65.4): (1)The
minimum standards of facilities and services, (2) The minimum qualifications for the
personnel engaged in such establishment, and (3) Provisions for maintenance of
records and reporting. These minimum norms will be published by the concerned
SMHA in their state rules. Currently, because the minimum norms have not been
published, the provisional registration, which is valid for 12 months, will be issued
after application and payment of the prescribed fee. This requires to be renewed
before 1 month of expiry (Section 66.10). If failed to do so, then the establishment is
liable to pay a renewal fee of ₹ 20,000 for new provisional registration.
State Mental Health Rules 2018 has mandated the following documents to be
maintained and provided on demand.
1. Basic outpatient (OP) record
2. Basic inpatient (IP) record
3. Basic psychological assessment record
4. Basic psychotherapy record.
The format in which all basic minimum records are to be maintained in all mental
health facilities can be accessed from draft rules. Whenever a patient/nominated
representative (NR) requests for information related to diagnosis/treatment, the above
documents must be released in the prescribed format.
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Section 72 says that an MHE must display information in a conspicuous area

regarding contact details, including address and telephone numbers, of the concerned
board. Furthermore, it has to provide the person with necessary forms to apply to the
board and give free access to make telephone calls to the board to apply for a review
of the admission.

2. Promoting the Rights of Persons with Mental Illness: The Act quotes a few specific
rights of patients that need to be upheld during services. All of these need to be
thoroughly understood and essentially practiced during the delivery of care. Human
rights that are given major importance include the right to access mental health care
and treatment without discrimination and good quality mental health services at
affordable prices. The facilities include acute care and OP and IP treatment. The onus
is upon the government, MHPs, and MHEs to ensure that the rights are not violated.

3. Treatment, Admission and Discharge:

a. Advance Directive: Medical officer/psychiatrist in charge must follow a valid
advance directive (AD) under Section 10. The act has also provided the
MHRB the power to review, alter, modify, or cancel AD under Section 11. The
MHP can apply to the MHRB regarding the same, which will then listen to
both parties and arrive at a decision. Under Sections 13 and 14, MHCA 2017
clearly states that MHP is not liable for unforeseen consequences of following
AD and the duty of making the AD available to the MHP lies upon
patient/NR.
b. Informed Consent: When a person is deemed to have capacity, he/she is
eligible to provide consent. In cases of incapacity, NR and AD have to be
considered for the consent for admission and various modalities of treatment.
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c. Least Restrictive Care: A person should only be detained in a mental health

facility if that is the least restrictive environment consistent with safe and
effective care and treatment. “Least restrictive alternative” or “least restrictive
environment” or “less restrictive option” means offering an option for
treatment or a setting for treatment which
1. Meets the person's treatment needs, and
2. Imposes the least restriction on the person's rights.
d. Determination of Mental Illness: Diagnosis must always be done based on
national/international guidelines such as the International Classification of
Diseases (ICD). It would be good practice to make an ICD diagnosis and
coding it accordingly to all patients, in the OP/IP records.
e. Assessment of Mental Capacity: Every person is considered to possess the
capacity to make decisions regarding his/her mental health care unless proved
otherwise. When he/she can understand the information that is necessary to
make a decision on the treatment or admission, can appreciate consequences
of a decision or lack of decision on the treatment, and can communicate the
decision, he/she is deemed to have the capacity. Documentation regarding the
assessment of capacity is crucial for using other provisions under the act, like
AD and NR.
f. Admission: According to Section 86 of MHCA 2017, any person who
considers himself/herself to be mentally ill can request for admission in MHE
under the section. The MHP may admit such a person if he/she feels the illness
is severe and the patient will benefit from admission. According to the act, the
presence of NR/caregiver is not mandatory during the IP course of an
independent patient.
g. Supported Admission: The MHRB must be informed within 7 days of a
supported admission (3 days in the case of a minor or woman). The admitted
person, his/her NR, or an appropriate organization may appeal this decision. If
a Section 89 admission has to continue beyond its allowed maximum duration
of 30 days and ongoing supported admission is required, this can be done
under Section 90. At this stage, the MHRB should be informed, and they must
review the admission within 21 days and either permit the admission or order
discharge of the individual. These reviews of a supported admission continue
at a maximum frequency of 180 days. Should an individual no longer fulfill
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the criteria for a supported admission, the supported admission must be

terminated.
h. Emergency Treatment: Any medical treatment, including treatment for mental
illness, may be provided by any registered medical practitioner to a person
with mental illness either at a health establishment or in the community,
subject to the informed consent of the NR, where he/she is available, and
where it is immediately necessary to prevent:
i. Death or irreversible harm to the health of the person; or
ii. The person inflicting serious harm to himself/herself or others; or
iii. The person is causing serious damage to the property belonging to
himself/herself or to others where such behavior is believed to flow
directly from the person's mental illness.
i. Discharge of Independent Patients: Any person admitted under Section 86 as
an independent patient should be immediately discharged on request. The
discharge may be delayed for 24 h to allow assessment necessary for
admission under Section 89 if the mental health professional thinks that he/she
is unable to understand the nature and purpose of the decisions and requires
substantial or very high support from the NR.
If patient has recently threatened or attempted or is threatening or attempting
to cause bodily harm to himself/herself; has recently behaved or is behaving
violently toward another person or has caused or is causing another person to
fear bodily harm from him/her; has recently shown or is showing an inability
to care for himself/herself to a degree that places the individual at risk of harm
to himself/herself, such person can be either admitted as a supported patient
under Section 89 or discharged from the establishment within 24 h or on
completion of assessments for admission as a supported patient under Section
89, whichever is earlier.
j. Prohibited procedures include:
i. Electroconvulsive therapy (ECT) without muscle relaxants and
anesthesia
ii. ECT for minors. In cases where ECT is necessary, consent by guardian
and approval by the board should be received beforehand
iii. Physical restraint
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2. Explain in detail the concept of mental health and mental illness.

The Mental Healthcare Act (2017) defines a mental illness as a substantial disorder of
thinking, mood, perception, orientation, or memory that grossly impairs judgment or ability
to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol
and drugs.
Mental health is defined by the World Health Organization as a state of wellbeing in
which every individual realises his or her own potential, can cope with the normal stresses of
life, can work productively and fruitfully and is able to make a contribution to their
community ("The Difference Between Mental Health and Mental Illness I nib", 2021).
When we have good mental health, we are resilient, can handle life’s challenges and
stresses, have meaningful relationships and make sound decisions. Mental health, like
physical health, is important at every stage of life, from childhood and adolescence through
adulthood and old age ("Mental health vs. mental illness", 2018).
Being mentally healthy is influenced by life experiences, relationships with others,
physical health and one’s environment. Just as people may experience physical problems over
the course of their lives, they may also experience emotional or mental health problems that
affect their thinking, mood and behaviors. This does not necessarily mean that a person who
is going through a difficult time and is experiencing poor mental health has a mental illness.
Feeling miserable and socially isolated are red flags that one’s mental health needs attention
("Mental health vs. mental illness", 2018).
Mental health and mental illness can be thought of as separate entities working
independently. One can have good mental health but be living with a diagnosed mental illness
that is being treated successfully, or once can have poor mental health but not have a mental
illness ("Mental health vs. mental illness", 2018).
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3. Write the etiology of schizophrenia in detail.

Etiology of Schizophrenia (Sadock, Sadock & Ruiz, 2015)
Psychoanalytical Theories
Sigmund Freud postulated that schizophrenia resulted from developmental fixations
early in life. These fixations produce defects in ego development, and he postulated that such
defects contributed to the symptoms of schizophrenia. Ego disintegration in schizophrenia
represents a return to the time when the ego was not yet developed or had just begun to be
established. Because the ego affects the interpretation of reality and the control of inner
drives, such as sex and aggression, these ego functions are impaired. Thus, intrapsychic
conflict arising from the early fixations and the ego defect, which may have resulted from
poor early object relations, fuel the psychotic symptoms. Psychoanalytic theory also
postulates that the various symptoms of schizophrenia have symbolic meaning for individual
patients. For example, fantasies of the world coming to an end may indicate a perception that
a person’s internal world has broken down. Feelings of inferiority are replaced by delusions
of grandeur and omnipotence. Hallucinations may be substitutes for a patient’s inability to
deal with objective reality and may represent inner wishes or fears. Delusions, similar to
hallucinations, are regressive, restitutive attempts to create a new reality or to express hidden
fears or impulses
Psychodynamic Approaches
1. Margaret Mahler: There are distortions in the reciprocal relationship between the
infant and the mother. The child is unable to separate from, and progress beyond, the
closeness and complete dependence that characterize the mother–child relationship in
the oral phase of development. As a result, the person’s identity never becomes
secure.
2. Paul Federn: The defect in ego functions permits intense hostility and aggression to
distort the mother–infant relationship, which leads to eventual personality
disorganization and vulnerability to stress. The onset of symptoms during adolescence
occurs when teenagers need a strong ego to function independently, to separate from
the parents, to identify tasks, to control increased internal drives, and to cope with
intense external stimulation.
3. Harry Stack Sullivan: The patient’s massive anxiety creates a sense of unrelatedness
that is transformed into parataxic distortions, which are usually, but not always,
persecutory. To Sullivan, schizophrenia is an adaptive method used to avoid panic,
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terror, and disintegration of the sense of self. The source of pathological anxiety
results from cumulative experiential traumas during development.
Regardless of the theoretical model, all psychodynamic approaches are founded on
the premise that psychotic symptoms have meaning in schizophrenia. Patients, for example,
may become grandiose after an injury to their self-esteem. Similarly, all theories recognize
that human relatedness may be terrifying for persons with schizophrenia. Although research
on the efficacy of psychotherapy with schizophrenia shows mixed results, concerned persons
who offer compassion and a sanctuary in the confusing world of schizophrenia must be a
cornerstone of any overall treatment plan. Long-term follow-up studies show that some
patients who bury psychotic episodes probably do not benefit from exploratory
psychotherapy, but those who are able to integrate the psychotic experience into their lives
may benefit from some insight-oriented approaches. There is renewed interest in the use of
long-term individual psychotherapy in the treatment of schizophrenia, especially when
combined with medication.
Learning Theories
According to learning theorists, children who later have schizophrenia learn irrational
reactions and ways of thinking by imitating parents who have their own significant emotional
problems. In learning theory, the poor interpersonal relationships of persons with
schizophrenia develop because of poor models for learning during childhood.
Family Dynamics
1. Double Bind: The double-bind concept was formulated by Gregory Bateson and
Donald Jackson to describe a hypothetical family in which children receive
conflicting parental messages about their behavior, attitudes, and feelings. In
Bateson’s hypothesis, children withdraw into a psychotic state to escape the
unsolvable confusion of the double bind. The theory has value only as a descriptive
pattern, not as a causal explanation of schizophrenia.
2. Schisms & Skewed Families: Theodore Lidz described two abnormal patterns of
family behavior. In one family type, with a prominent schism between the parents,
one parent is overly close to a child of the opposite gender. In the other family type, a
skewed relationship between a child and one parent involves a power struggle
between the parents and the resulting dominance of one parent. These dynamics stress
the tenuous adaptive capacity of the person with schizophrenia.
3. Pseudomutual and Pseudohostile Families: As described by Lyman Wynne, some
families suppress emotional expression by consistently using pseudo-mutual or
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pseudo-hostile verbal communication. In such families, a unique verbal

communication develops, and when a child leaves home and must relate to other
persons, problems may arise. The child’s verbal communication may be
incomprehensible to outsiders.
4. Expressed Emotion: Parents or other caregivers may behave with overt criticism,
hostility, and overinvolvement toward a person with schizophrenia. Many studies
have indicated that in families with high levels of expressed emotion, the relapse rate
for schizophrenia is high. The assessment of expressed emotion involves analyzing
both what is said and the manner in which it is said.
Genetic Factors
There is a genetic contribution to some, perhaps all, forms of schizophrenia, and a
high proportion of the variance in liability to schizophrenia is due to additive genetic effects.
In the case of monozygotic twins who have identical genetic endowment, there is an
approximately 50 percent concordance rate for schizophrenia. This rate is four to five times
the concordance rate in dizygotic twins or the rate of occurrence found in other first-degree
relatives.
Biochemical Factors
1. Dopamine Hypothesis: Schizophrenia is postulated to be resulting from too much
dopaminergic activity. The theory evolved from two observations. First, the efficacy
and the potency of many antipsychotic drugs (i.e., the dopamine receptor antagonists
[DRAs]) are correlated with their ability to act as antagonists of the dopamine type 2
(D2) receptor. Second, drugs that increase dopaminergic activity, notably cocaine and
amphetamine, are psychotomimetic. Excessive dopamine release in patients with
schizophrenia has been linked to the severity of positive psychotic symptoms.
Positron emission tomography studies of dopamine receptors document an increase in
D2 receptors in the caudate nucleus of drug-free patients with schizophrenia. There
have also been reports of increased dopamine concentration in the amygdala,
decreased density of the dopamine transporter, and increased numbers of dopamine
type 4 receptors in the entorhinal cortex.
2. Serotonin: Current hypotheses posit serotonin excess as a cause of both positive and
negative symptoms in schizophrenia. The robust serotonin antagonist activity of
clozapine and other second-generation antipsychotics coupled with the effectiveness
of clozapine to decrease positive symptoms in chronic patients has contributed to the
validity of this proposition.
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3. Norepinephrine: Anhedonia—the impaired capacity for emotional gratification and

the decreased ability to experience pleasure—has long been noted to be a prominent
feature of schizophrenia. A selective neuronal degeneration within the norepinephrine
reward neural system could account for this aspect of schizophrenic symptomatology.
However, biochemical and pharmacological data bearing on this proposal are
inconclusive.
4. GABA: The inhibitory amino acid neurotransmitter γ-aminobutyric acid (GABA) has
been implicated in the pathophysiology of schizophrenia based on the finding that
some patients with schizophrenia have a loss of GABAergic neurons in the
hippocampus. GABA has a regulatory effect on dopamine activity, and the loss of
inhibitory GABAergic neurons could lead to the hyperactivity of dopaminergic
neurons.
5. Neuropeptides: Neuropeptides, such as substance P and neurotensin, are localized
with the catecholamine and indoleamine neurotransmitters and influence the action of
these neurotransmitters. Alteration in neuropeptide mechanisms could facilitate,
inhibit, or otherwise alter the pattern of firing these neuronal systems.
6. Glutamate: Glutamate has been implicated because ingestion of phencyclidine, a
glutamate antagonist, produces an acute syndrome similar to schizophrenia. The
hypotheses proposed about glutamate include those of hyperactivity, hypoactivity, and
glutamate-induced neurotoxicity.
7. Acetylcholine & Nicotine: Postmortem studies in schizophrenia have demonstrated
decreased muscarinic and nicotinic receptors in the caudate-putamen, hippocampus,
and selected regions of the prefrontal cortex. These receptors play a role in the
regulation of neurotransmitter systems involved in cognition, which is impaired in
schizophrenia.
Neuropathology
1. Cerebral ventricles: Computed tomography (CT) scans of patients with schizophrenia
have consistently shown lateral and third ventricular enlargement and some reduction
in cortical volume. Reduced volumes of cortical gray matter have been demonstrated
during the earliest stages of the disease. Several investigators have attempted to
determine whether the abnormalities detected by CT are progressive or static. Some
studies have concluded that the lesions observed on CT scan are present at the onset
of the illness and do not progress. Other studies, however, have concluded that the
pathological process visualized on CT scan continues to progress during the illness.
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Thus, whether an active pathological process is continuing to evolve in schizophrenia

patients is still uncertain.
2. Reduced symmetry: There is a reduced symmetry in several brain areas in
schizophrenia, including the temporal, frontal, and occipital lobes. This reduced
symmetry is believed by some investigators to originate during fetal life and to be
indicative of a disruption in brain lateralization during neurodevelopment.
3. Limbic System: Because of its role in controlling emotions, the limbic system has
been hypothesized to be involved in the pathophysiology of schizophrenia. Studies of
postmortem brain samples from schizophrenia patients have shown a decrease in the
size of the region, including the amygdala, the hippocampus, and the
parahippocampal gyrus. This neuropathological finding agrees with the observation
made by magnetic resonance imaging studies of patients with schizophrenia. The
hippocampus is not only smaller in size in schizophrenia but is also functionally
abnormal as indicated by disturbances in glutamate transmission. Disorganization of
the neurons within the hippocampus has also been seen in brain tissue sections of
schizophrenia patients compared with healthy control participants without
schizophrenia.
4. Prefrontal Cortex: There is considerable evidence from postmortem brain studies that
supports anatomical abnormalities in the prefrontal cortex in schizophrenia.
Functional deficits in the prefrontal brain imaging region have also been
demonstrated. It has long been noted that several symptoms of schizophrenia mimic
those found in persons with prefrontal lobotomies or frontal lobe syndromes.
5. Thalamus: Some studies of the thalamus show evidence of volume shrinkage or
neuronal loss, in particular subnuclei. The medial dorsal nucleus of the thalamus,
which has reciprocal connections with the prefrontal cortex, has been reported to
contain a reduced number of neurons. The total number of neurons, oligodendrocytes,
and astrocytes is reduced by 30 to 45 percent in schizophrenia patients. This putative
finding does not appear to be due to the effects of antipsychotic drugs because the
volume of the thalamus is similar in size between patients with schizophrenia treated
chronically with medication and neuroleptic-naive subjects.
6. Basal Ganglia and Cerebellum: The basal ganglia and cerebellum have been of
theoretical interest in schizophrenia for at least two reasons. First, many patients with
schizophrenia show odd movements, even in the absence of medication-induced
movement disorders (e.g., tardive dyskinesia). The odd movements can include an
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awkward gait, facial grimacing, and stereotypies. Because the basal ganglia and
cerebellum are involved in the control of movement, disease in these areas is
implicated in the pathophysiology of schizophrenia. Second, the movement disorders
involving the basal ganglia (e.g., Huntington’s disease, Parkinson’s disease) are the
ones most commonly associated with psychosis. Neuropathological studies of the
basal ganglia have produced variable and inconclusive reports about cell loss or the
reduction of volume of the globus pallidus and the substantia nigra. Studies have also
shown an increase in the number of D2 receptors in the caudate, the putamen, and the
nucleus accumbens.
Neural Circuits
Recent studies view schizophrenia as a disorder of brain neural circuits. For example,
as mentioned previously, the basal ganglia and cerebellum are reciprocally connected to the
frontal lobes, and the abnormalities in frontal lobe function seen in some brain imaging
studies may be due to disease in either area rather than in the frontal lobes themselves. It is
also hypothesized that an early developmental lesion of the dopaminergic tracts to the
prefrontal cortex results in the disturbance of prefrontal and limbic system function and leads
to the positive and negative symptoms and cognitive impairments observed in patients with
schizophrenia.
Of particular interest in the context of neural circuit hypotheses linking the prefrontal
cortex and limbic system are studies demonstrating a relationship between hippocampal
morphological abnormalities and disturbances in prefrontal cortex metabolism or function
(or both). Data from functional and structural imaging studies in humans suggest that
whereas dysfunction of the anterior cingulate basal ganglia thalamocortical circuit
underlies the production of positive psychotic symptoms, dysfunction of the dorsolateral
prefrontal circuit underlies the production of primary, enduring, negative or de􀏧cit
symptoms. There is a neural basis for cognitive functions that is impaired in patients with
schizophrenia. The observation of the relationship among impaired working memory
performance, disrupted prefrontal neuronal integrity, altered prefrontal, cingulate, and
inferior parietal cortex, and altered hippocampal blood 􀏩ow provides strong support for
disruption of the normal working memory neural circuit in patients with schizophrenia.
The involvement of this circuit, at least for auditory hallucinations, has been documented in
a number of functional imaging studies that contrast hallucinating and non hallucinating
patients.
Brain Metabolism
 17

Studies using magnetic resonance spectroscopy, a technique that measures the

concentration of specific molecules in the brain, found that patients with schizophrenia had
lower levels of phosphomonoester and inorganic phosphate and higher levels of
phosphodiester than a control group. Furthermore, concentrations of N-acetyl aspartate, a
marker of neurons, were lower in the hippocampus and frontal lobes of patients with
schizophrenia.
Applied Electrophysiology
Electroencephalographic studies indicate that many schizophrenia patients have
abnormal records, increased sensitivity to activation procedures, decreased alpha activity,
increased theta and delta activity, possibly more epileptiform activity than usual, and possibly
more left-sided abnormalities than usual. Schizophrenia patients also exhibit an inability to
filter out irrelevant sounds and are extremely sensitive to background noise. The flooding of
sound that results makes concentration difficult and may be a factor in the production of
auditory hallucinations. This sound sensitivity may be associated with a genetic defect.
Schizophrenia-like psychosis have been reported to occur more frequently than
expected in patients with complex partial seizures, especially seizures involving the temporal
lobes. Factors associated with the development of psychosis in these patients include a
left-sided seizure focus, medial temporal location of the lesion, and an early onset of seizures.
The first-rank symptoms described by Schneider may be similar to symptoms of patients with
complex partial epilepsy and may reflect the presence of a temporal lobe disorder when seen
in patients with schizophrenia.
Eye Movement Dysfunction
The inability to follow a moving visual target accurately is the defining basis for the
disorders of smooth visual pursuit and disinhibition of saccadic eye movements seen in
patients with schizophrenia. Eye movement dysfunction may be a trait marker for
schizophrenia; it is independent of drug treatment and clinical state and is also seen in first
degree relatives of probands with schizophrenia. Various studies have reported abnormal eye
movements in 50 to 85 percent of patients with schizophrenia compared with about 25
percent in psychiatric patients without schizophrenia and fewer than 10 percent in non
psychiatrically ill control participants.
Psychoneuroimmunology
Several immunological abnormalities have been associated with patients who have
schizophrenia. The abnormalities include decreased T-cell interleukin-2 production, reduced
number and responsiveness of peripheral lymphocytes, abnormal cellular and humoral
 18

reactivity to neurons, and the presence of brain-directed antibodies. Most carefully conducted
investigations that have searched for evidence of neurotoxic viral infections in schizophrenia
have had negative results, although epidemiological data show a high incidence of
schizophrenia after prenatal exposure to influenza during several epidemics of the disease.
Other data supporting a viral hypothesis are an increased number of physical anomalies at
birth, an increased rate of pregnancy and birth complications, seasonality of birth consistent
with viral infection, geographical clusters of adult cases, and seasonality of hospitalizations.
Psychoneuroendocrinology
Many reports describe neuroendocrine differences between groups of patients with
schizophrenia and groups of control subjects. For example, results of the dexamethasone
suppression test have been reported to be abnormal in various subgroups of patients with
schizophrenia, although the practical or predictive value of the test in schizophrenia has been
questioned. One carefully done report, however, has correlated persistent nonsuppression on
the dexamethasone-suppression test in schizophrenia with a poor long term outcome.
Some data suggest decreased concentrations of luteinizing hormone or
follicle-stimulating hormone, perhaps correlated with age of onset and length of illness. Two
additional reported abnormalities may be correlated with the presence of negative symptoms:
a blunted release of prolactin and growth hormone on gonadotropin-releasing hormone or
thyrotropin-releasing hormone stimulation and a blunted release of growth hormone on
apomorphine stimulation.
Rhesus-Incompatibility
Hollister, Laing, and Mednick (1996) have shown that the rate of schizophrenia is
about 2.1 percent in males who are Rh-incompatible with their mothers. For males who have
no such incompatibility with their mothers, the rate of schizophrenia is 0.8 percent very near
the expected base rate found in the general population. One possibility is that the mechanism
involves oxygen deprivation, or hypoxia. This suggestion is supported by studies that have
linked the risk for schizophrenia to birth complications. Recent research also suggests that
incompatibility between the blood of the mother and the blood of the fetus may increase the
risk of brain abnormalities of the type known to be associated with schizophrenia.
Pregnancy and Birth Complications
Patients with schizophrenia are much more likely to have been born following a
pregnancy or delivery that was complicated in some way. Although the type of obstetric
complication varies, many delivery problems (for example, breech delivery, prolonged labor,
 19

or the umbilical cord around the baby’s neck) affect the oxygen supply of the newborn. The
research again points toward damage to the brain at a critical time of development.
Maternal Stress
If a mother experiences an extremely stressful event late in her first trimester of
pregnancy or early in the second trimester the risk of schizophrenia in her child is increased.
For example, in a large population study conducted in Denmark, the death of a close relative
during the first trimester was associated with a 67 percent increase in the risk of
schizophrenia in the child. Currently, it is thought that the increase in stress hormones that
pass to the fetus via the placenta might have negative effects on the developing brain,
although the mechanisms through which maternal stress increases risk for schizophrenia are
not yet well understood.
 20

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