Public Perception of Schizophrenia

1980 survey of Quebec residents: “lack of will” as main cause

2001 Survey of Quebec residents:

◦ 54% described schizophrenia as biological illness
◦ 40% considered main cause to be genetic
◦ 54% considered people with schizophrenia to be violent or dangerous
We see the shift in more accepting of schizophrenia, we still have a considerable
amount of

Studies in other regions tend to show the same trend

Schizophrenia Spectrum & Other Psychotic Disorders

•Psychosis = impaired sense of reality

• Schizophrenia
◦Splitting of the mind

• Schizophreniform Disorder

• Brief Psychotic disorder

• Delusional Disorder

• Schizoaffective Disorder

Key Features of Schizophrenia

25% have negative symptoms

Other symptoms: catatonia (increase motor behavior or complete absence of

motor behaviors)
Positive Symptom: Delusions

A false belief that is firmly held despite disconfirming evidence or logic

• Gross misrepresentations of reality

• Highly implausible

Present among > 50% of individuals with schizophrenia

Delusions often have common themes

These delusions are very terrifying
• People are after you
• People can control your thoughts and behaviors

Positive Symptom: Hallucinations

• Distortions of perceptions

• A sensory experience (such as an image, sound, smell, or taste) that seems real
but that does not exist outside of the mind
◦Hearing = auditory hallucination (most common)

◦Seeing = visual hallucination

◦Smelling = olfactory hallucination

◦Touching = tactile hallucination

◦Tasting = gustatory hallucination

Positive Symptom: Disorganized Speech

• Loose association/derailment
◦Series of ideas presented with loosely apparent or unapparent logical
 connections

• “Word salad”
◦Random words or phrases linked together in an unintelligible manner

◦there are words grouped together that have no sense

Negative Symptoms

• Flat Affect:
◦Lack of emotional expressiveness (facial expression, voice intonation, or
gestures)

◦E.g. stare vacantly, flat and toneless voice

◦Present in majority of people with schizophrenia

• Asociality:
◦Loss of interest in social relationships, few friends, poor social skills

• Anhedonia:
◦Inability to experience pleasure

• Avolition:
◦Lack of energy or will, apathy

◦E.g., lack of grooming or attention to personal hygiene that make it hard to

persist in life

◦Mostly spent their time doing nothing

• Alogia:
◦Loss of meaningful speech, poverty of speech (amount or content)

◦Conveying little information or repeating themselves

◦For example: “Why do people believe in God?”

‣ “Well, I understand also that, every man and every lady, is not just pointed
in the same direction. Some are pointed different. They go in their
different ways. The way that Jesus Christ wanted 'em to go. Myself. I am
pointed in the ways of uh, knowing right from wrong, and doing it, I can't
 do any more, or not less than that.”

Catatonia

• Marked disturbance in motor activity—either extreme excitement or immobility

• Agitation
◦Constant hyperactive motor activity

• Repetitive motor movements (“stereotypies”)

◦Gesture repeatedly- sometimes peculiar and complex movements

• Immobility
◦Hold rigid poses for hours

◦Waxy flexibility:
‣ another person can move the persons’ limbs into strange positions that
they maintain for extended periods

Inappropriate Affect

• Emotional responses that are out of context

◦Laughing in an extremely sad situation

◦Enraged when asked a benign question

◦Rapid shifts from one emotional state to another for no discernible reason

DSM-5 Criteria for Schizophrenia

J foracute

Heterogeneity

• Had subtypes of schizophrenia in past DSM versions

• DSM-5 removed subtype classifications from previous DSM due to limited
stability, reliability, and validity
◦Subtypes rarely used in practice

◦Instead, DSM-5 includes a dimensional rating of symptoms so clinicians can

consider the heterogeneity

• Heterogeneity:
◦People with schizophrenia can differ from each other more than people with
other disorders

Prevalence & Course of Schizophrenia

• Lifetime prevalence: <1%

• Men (18-25) have earlier onset than women (25-30)

• Typically have a number of acute episodes

◦Between episodes, can have less severe symptoms but still may be very
debilitating

◦About 1 in 3 have symptom remission

• 50% have a comorbid disorder:

◦commonly substance abuse, depression, anxiety

• Life expectancy that is 20 years shorter

• High mortality rate

◦Almost 10% die by suicide

◦Sense of hopelessness or by command

• Account for≈ 30% of stays in psychiatric hospitals

Myth busting: People with Schizophrenia are Violent

• Majority of individuals with schizophrenia are not aggressive

◦Hostility and aggression can be associated with schizophrenia, usually a
reaction to something vs. spontaneous or random assault

◦Aggression and risk of violence is likely to occur when mediated by substance

abuse comorbidity (Fazel et al 2009)

‣ The risk is similar to patients with substance abuse without psychosis

• More frequently victimized

◦14x the risk of being victimized vs. being the perpetrator (Brekke et al 2001)

Impact on Life
• Delusions and hallucinations can be incredibly frightening experiences

• Cognitive impairments and avolition make stable employment difficult

• Can be isolating

Etiology of Schizophrenia: Biological

• Genes

• Biochemical factors

• Brain structure and functions

Lifetime Risk of Schizophrenia (%)

The risk for the general population < 1%

As the risk XXX

Among MZ twins, if one twin

has schizophrenia, it is most
likely that the second child will
have schizophrenia

If both parents have

schizophrenia, then the child
will have a very high probability
of having schizophrenia.

Genetic Influences

• Family, twin, and adoption methods suggest genetic predisposition

◦Relatives of people with schizophrenia are at increased risk

◦MZ concordance 44.3% vs. DZ concordance 12%

◦Adoption studies:
‣ Children reared apart from mothers with schizophrenia at increased risk
at developing schizophrenia

‣ When you remove the shared environment we can be confident that the
effect is due to genes.

◦Not one gene but interaction of genes to developing schizophrenia

Biochemical Factors:

• Abnormalities in dopamine, serotonin, glutamate

• Dopamine theory:
◦schizophrenia result from excess dopamine activity in certain areas of the
brain

◦Medications that are effective in reducing symptoms reduce dopamine activity

‣ Amphetamines, a stimulant increasing dopamine level, produce symptoms
closely resemble paranoia
◦Even small doses of amphetamine can increase the severity of
symptoms in individuals diagnosed with schizophrenia

◦Increase availability of dopamine and norepinephrine

• Rather than excess levels of dopamine, newer research suggests it’s abnormal
dopamine receptor activity
◦Too many receptors or overly sensitive
receptors.

◦Under-activation -> negative symptoms

◦Over-activation -> positive symptoms

Brain Structures

• Enlarged ventricles
◦Spaces in the brain that implies a loss of brain
cells

• Decreased cortex volume

◦Significant loss of brain cells in cortex over 6
years in young people with schizophrenia

◦May influence cognitive functioning

• Decrease activity in prefrontal cortex

◦Play a role in speech, decision making

• Thoughts about how these complications can occur that develop schizophrenia:
◦Complications during delivery lead to structural changes due to lack of oxygen
reaching the brain

◦Prenatal exposure to virus

‣ More inconsistent data

‣ That the virus will impact brain development

Etiology of Schizophrenia: Psychosocial Factors

• The psychosocial factors are more so the stressors than the diathesis, the
diathesis is the schizophrenia being biological

• Psychological stress interact with biological vulnerability

◦Greater life stress = increased relapse

• Schizophrenia more common among people living in low SES

◦Sociogenic hypothesis:
‣ Stressors associated with being in a low social class may cause or
contribute to the development of schizophrenia

◦Social selection hypothesis:

‣ people with schizophrenia may drift into low SES living areas (generally
more support for this theory)

Myth busting: “Schizophrenogenic Mother”

• Parenting does not cause schizophrenia

Etiology of Schizophrenia: Psychosocial Factors

• Expressed emotion (EE) = a negative communication pattern characterized by

high levels of:
◦Criticism

◦Emotional overinvolvement, overconcern, or overprotectivenes

◦Hostility

◦low warmth

• Relapse (1st year):

◦50% (high EE families)

◦13% (low EE families)

• It is bidirectional, that expressions of delusions can be x

Etiology of Schizophrenia: Psychosocial

Factors

Exposure to abuse or early adversities

Risk of psychotic symptoms increase when exposed to

early stressors

G x E – children at risk for psychosis may be more

susceptible to early adverse experiences

Evidence-Based Treatments

Treatment is difficult because patients lack insight into their impaired condition

• Goal: help individual function in the community

• APA treatment guidelines:

◦Antipsychotic medications for acute psychotic symptoms
‣ First line of treatment

◦Address comorbid disorders

◦Psychosocial treatments to improve symptoms and functioning

‣ Emphasizing how the individual XX
‣ Focusing on the functional outcomes of the individual

Antipsychotic Medications (Neuroleptics)

• 1st generation:
◦conventional antipsychotics (e.g., phenothiazine, chlorpromazine)

◦Block dopamine receptors in brain

◦Reduce positive symptoms

◦Less effect on negative symptoms

◦Significant side effects:

‣ Extrapyramidal symptoms
• Look like Symptoms of parkinson’s

• restlessness, involuntary movements, and muscular tension produced

by antipsychotic medications

‣ Tardive dyskinesia
• Chronic side effects

• involuntary and rhythmic movements of the tongue; chewing, lip

smacking, and other facial movements; and jerking movements of the
 limbs

• Affect 10-20%

◦Burden of side effects contribute to high nonadherence

‣ 50% stopped after 1 year

◦30-50% do not respond favorably to 1st generation antipsychotic meds

• 2nd generation: atypical antipsychotics (e.g., clozapine, risperidone)

◦first choice

◦Impact broader range of receptors (e.g., dopamine and serotonin)

◦Because they work on a large number of neurotransmitter receptors, they

respond greater to therapeutic benefits than 1st generation antipsychotics

◦Especially for people who did not respond well to 1st generation antipsychotics

◦Fewer side effects, lower likelihood of morbidity and mortality

◦Once the acute symptoms subside, individuals will be put on a maintenance

dose and will remain on that dose for the remainder of their life.

Psychological Treatments

Additional stress can increase the rate of relapse

• Social Skills Training

◦Focuses in increasing appropriate self-care behaviors (including medication
management), communication skills, and job skills

◦Learning how to break down tasks to make them less overwhelming

◦Social skills training was found to increase optimism, improved social

relationships Xxxxx

• CBT
◦Learn coping skills that allow clients to manage positive and negative
symptoms

◦XXXXX

◦Reduce symptom intensity, relapse, and social difficulties

◦Help manage cognitive challenges associated with schizophrenia (e.g.,

defeatist beliefs)

◦Help increase motivation and engagement in social and vocational activities

 ◦Address comorbidities
‣ Like negative appraisals

◦Defeatist beliefs
‣ XXXX
‣ CBT helps them develop more adaptive beliefs

◦Effective for negative symptoms

◦Tends to be in the smaller range for schizophrenia than other psychiatric

disorders

• Family communication & education

◦Educating family members about schizophrenia
‣ Families can impact the recovery and functioning on the schizophrenic
family member

◦Advice on monitoring effects of antipsychotic medications

◦Teaching family members to cope with symptoms and its repercussions on

the family

◦Developing skills in solving problems and managing stress

◦Strengthening communication skills of all family members

◦Goal is to reduce expressed emotions, which increases rates of relapse

◦Reduces relapse rates

◦2022 meta analysis of 90 randomized control trials:

‣ Significantly reduced relapse rates 1 year later compared to treatment

• Cognitive remediation/ cognitive enhancement therapy

◦Improve cognitive deficits associated with schizophrenia

‣ E.g. training in attention, memory, problem-solving

◦Addresses training against deficits such as cognitive deficits such as grey

matter brain loss and Less activation of prefrontal cortex

◦Meta-analysis of 26 RCTs:
‣ Cognitive training can moderately improve cognitive performance (e.g.,
processing speed)

◦Cognitive enhancement protected against grey matter loss in the brain

• Assertive Community Treatment (ACT)

◦Goal: help integrate individual into community
‣ not being hospitalized
◦Type on intense case management treatment

◦Multidisciplinary team provide community services (e.g., medication,

treatment for substance abuse, psychotherapy, vocational training,
assistance with housing/employment)
‣ Team available 24/7

‣ To have high frequency contact between he individual and the team

◦Research found ACT help with stable housing, reduce homelessness and
hospitalizations, and reduce symptoms

◦More appropriate for individuals with highest risk for hospitalization