1. Schizophrenia: Diagnosis and symptoms (p. 419) Schizophrenia is a group of disorders characterized by cognitive distortions, personality disintegration, affective disturbances, and social withdrawal. It receives a great deal of attention because it is so disabling, the prevalence rate is 1 percent (and therefore millions of people are affected), and its symptoms and causes are diverse. Age of onset is earlier for males than for females. The lifetime prevalence for schizophrenia is higher among African Americans and lower among Hispanic Americans than among the general population.
2. History of the diagnostic category and DSM-IV-TR (p. 420) Emil Kraepelin first named the disorder dementia praecox (meaning early insanity), defining it as an early occurring, incurable organic disorder involving progressive mental deterioration. Eugen Bleuler objected to this, arguing that the disorder did not necessarily occur early in life. Bleuler proposed that four As defined the disorder: autism (self-focus), associations (unconnected ideas), affect (inappropriate emotions), and ambivalence (uncertainty over actions). He also suggested that schizophrenia was caused by a combination of genetic and environmental factors with different possibilities for recovery of functioning. In early editions of the diagnostic manual, schizophrenia was broadly defined, using Bleulers four As. With the DSM-III, DSM-III-R, and DSM-IV, the definition became quite restrictive. The current category in DSM-IV-TR states that a diagnosis of schizophrenia should be given only if delusions, auditory hallucinations, or marked disturbances in thinking, affect, or speech have impaired functioning for at least six months at some point in the person's life and for at least one month currently. Organic causes and affective disorders must be ruled out.
3. The symptoms of schizophrenia (p. 421) There appear to be three types of symptoms in schizophrenia: psychoticism (hallucinations and delusions) and disorganization, which are considered positive symptoms, and flat affect and other forms of social withdrawal, which are considered negative symptoms.
   Positive symptoms: People with schizophrenia often report delusions (false beliefs) that can take many forms, such as delusions of grandeur (believing one is a famous person), thought broadcasting (others can hear the schizophrenics thoughts), or delusions of persecution. Capgrass syndrome, a rare delusion, is the belief in the existence of an identical double who may coexist with or replace the schizophrenic or significant others. Unlike other people, individuals with schizophrenia reach delusional conclusions on the basis of little information; they can, however, be trained to challenge their delusions. Hallucinations are sensory perceptions not attributable to environmental stimuli. Hallucinations are not pathognomonic (distinctive) to schizophrenia. Auditory hallucinations are most common. Some believe that auditory hallucinations may stem from subvocal speech, and are phenomena people with schizophrenia can cope with in a variety of ways. During times when symptoms are prominent, hallucinations and delusions are so strong that they are treated as real; in other situations, people with schizophrenia can ward them off.
   Schizophrenic individuals have difficulty concentrating and communicating. One symptom is called loosening of associations, or cognitive slippage. Thoughts shift from topic to topic, and communication can be vague or overly concrete. People with schizophrenia also show odd movements or postures; maintaining an unusual body position is characteristic of catatonic schizophrenia.
   Negative symptoms are associated with poor prognosis and may be associated with structural abnormalities in the brain. Some symptoms are part of the disorder itself (primary symptoms), while others are the result of medication or hospitalization (secondary symptoms). Examples of negative symptoms are anhedonia (an inability to feel pleasure) and lack of insight. Suicide risk factors include severe depression, young age, and traumatic experience. Cultural factors affect how symptoms are expressed and also affect rate of diagnosis as well as errors or bias in diagnosis.
4. Types of schizophrenia (p. 429) Paranoid schizophrenia is the most common form of schizophrenia and is characterized by delusions or hallucinations, usually involving persecution or grandiosity. It is possible to differentiate this disorder from delusional disorder because delusional disorder involves less bizarre beliefs and is free from other dysfunctional behaviors. Disorganized schizophrenia features severe regression to a childish state without delusions. Behavior and speech tend to be bizarre. Catatonic schizophrenia is divided into an excited form marked by hyperactivity and a withdrawn form in which immobility and waxy flexibility are seen. Often patients swing from one state to the other. Undifferentiated schizophrenia is a form marked by a mix of symptoms; residual schizophrenics are those people whose symptoms are in remission.
5. Psychotic disorders once considered schizophrenia, and other psychotic disorders (p. 431) In DSM-IV-TR, the term schizophrenia is reserved for psychotic episodes lasting six months or more. Brief psychotic disorder is diagnosed when symptoms have lasted less than one month; the disorder in which symptoms last between one and six months is called schizophreniform disorder. DSM-IV-TR recommends these disorders be provisional. About two-thirds of those diagnosed with schizophreniform disorder will later be diagnosed with schizophrenia or schizoaffective disorder. Other psychotic disorders include shared psychotic disorder, in which a person who has a close relationship with a delusional person accepts those beliefs, and schizoaffective disorder, a combination of mood disorder and psychotic symptoms that last at least two weeks.
6. The course of schizophrenia (p. 433) Most people with schizophrenia show poor premorbid personality before the onset of the disorder. The typical course of schizophrenia consists of three phases. The prodromal phase includes social withdrawal and peculiar speech or actions. In the active phase, symptoms are in full evidence, and by the residual phase, symptoms are no longer prominent. International studies show that return to work and reduction in symptoms is more common in developing countries than in the United States, the former Soviet Union, or Western Europe. This may be due to misdiagnosis rather than true recovery.
   It is unclear what the long-term outcome of schizophrenia tends to be. Because diagnosis requires that symptoms be present for at least six months, it makes sense that someone with a diagnosis of schizophrenia has a more severe condition than someone who recovered sooner; thus schizophrenia is defined as a chronic condition. However, in one long-term study, 26 percent of the patients had complete remission, and about 50 percent had partial remission of symptoms. Differences in outcome may be due to criteria used to define schizophrenia. Most individuals with schizophrenia recover enough to lead relatively productive lives.
7. Etiology of schizophrenia (p. 434) The causes of schizophrenia may involve genetic, physiological, psychological, and environmental factors. Therapies include neuroleptics (antipsychotic medication) and psychotherapy, but relapse rates remain too high. Researchers disagree on the impact of social and genetic factors in the cause and development of this disorder.
8. Heredity and schizophrenia (p. 435) The highest probability of selecting a schizophrenic from the general population would be reached by finding an individual with an identical twin who has the disorder. Problems in interpreting genetic studies and studies involving blood relatives. Genetic studies are limited by the variety of subtypes of the disorder, as well as by sampling and definitional problems.
   We might assume that the closer the blood relationship between a person and a diagnosed schizophrenic, the higher the probability of the disorder in that person. However, relatedness and risk are not always linked because of problems in defining schizophrenia, in reliably diagnosing individuals, and in biased selection and analysis. Furthermore, such studies confound genetics and environment. The child of a person with schizophrenia has a 12- to 13-percent chance of developing; the risk in the general population is about 1 percent.
   Twin studies and adoption studies. Since their genes are identical, we would assume that there would be stronger concordance rates among MZ twins than among DZ twins (who share about 50 percent of their genes) if schizophrenia is genetically transmitted. Concordance rates are usually two to four times higher in MZ twins than in DZ twins, but method problems, including definitions along the schizophrenia spectrum, account for a wide range in these findings. Clearly, there is a genetic influence in this disorder.
   Adoption studies screen out the effects of family environment. Heston (1966) found that five or forty-seven at-risk children (adoptees having schizophrenic birth mothers) later became schizophrenics themselves, but none of the control adoptees did. However, many at-risk children also became creative, successful adults. Other adoption studies also support the idea that heredity plays a major role in the transmission of schizophrenia. Kety et al. (1994) found that, among adoptees who developed schizophrenia, the disorder tended to exist in the relatives of the biological parents but not those of the adoptive parents.
   Studies of high-risk populations. High-risk studies are developmental comparisons between children with schizophrenic parents and those with nonschizophrenic parents. Results of Mednick et al.s research show that children who became sick had mothers with more severe schizophrenic symptoms, who had experienced complications giving birth. They were also more disruptive as children and had a slower autonomic recovery rate. Israeli prospective studies indicate that schizophrenia has only developed among high-risk children. Social withdrawal was the characteristic most related to risk of developing the disorder. However, none of the high-risk children receiving adequate parenting developed schizophrenia or a schizophrenia-like disorder. The most striking finding is the relative absence of severe psychopathology in most of the subjects. Although high-risk population studies are a promising line of research, they have no control groups with other forms of psychopathology, generalizations may be difficult, and relevant variables and appropriate definitions of disorder may be missing.
9. Physiological factors in schizophrenia (p. 441) After previous dead ends, the idea that a chemical imbalance exists in schizophrenics shows promise. The effects of phenothiazine drugs, L-dopa, and amphetamines support the dopamine hypothesis, which suggests that dopamine activity in certain areas of the brain is excessive in people with schizophrenia. However, some patients do not respond to phenothiazines or L-dopa in ways predicted by this biochemical theory. This could be due to there being varieties of schizophrenia. Other drugs, such as Clozapine, implicate the neurotransmitter serotonin.
   Research supports the view that, especially in schizophrenics who show such negative symptoms as flat affect, there are neurological abnormalities, including cerebral atrophy and low cerebral glucose metabolism in the frontal lobes. These differences are seen in identical twins who are discordant for the disorder. People with schizophrenia show poorer sustained attention and eye movement coordination than nonschizophrenics, differences that are considered cognitive markers. However, even stable neurological abnormalities are not specific to schizophrenia and may be seen in normal controls, and some treatment effects run counter to prediction. Heinrichs points out many contradictions in the disorder and suggests that schizophrenia is a heterogeneous illness that paradoxically resists subdivision.
10. Environmental factors in schizophrenia (p. 445) Lacking any definitive genetic or biological basis for schizophrenia, researchers also look at environmental causes, including infections or disruptions of normal brain development during fetal and perinatal periods. Environmental factors act as stressors and thereby help produce psychopathology. Stress may induce hallucinations and trigger relapse.
    Family influences are an important source of stress. Environmental factors act as stressors and thereby help produce psychopathology. Stress may induce hallucinations and trigger relapse. The family is an important source of stress. Psychodynamic theory focused on the personality of the schizophrenic mother, whereas family systems theory stresses the double-bind theory of communication patterns. Research on family influence has been hampered both by observations after the child has been diagnosed and by the lack of control groups.
    Expressed emotion (EE)highly critical, hostile, and overinvolved parentingis related to increased relapse among schizophrenics, especially those who have stopped taking medication. However, as with other environmental factors, it is not clear whether these problems are the effect of schizophrenia or its cause; neither does EE appear to be pathognomonic for the disorder.
    Schizophrenia is more common in the lower social classes than in the upper ones. Theories attribute this to the stress of poverty (breeder hypothesis) or downward drift theory (the loss in income occurring because the disorder makes earning a good living difficult). Research evidence can support both positions. Symptoms of schizophrenia in various countries studied appear to reflect cultural beliefs specific to the culture.
11. The treatment of schizophrenia (p. 450)Antipsychotic medication (neuroleptics)is the principal means of treating schizophrenia today. A new drug, Clozapine, may be effective in cases not previously helped by neuroleptics. Although effective in many cases, medications can produce neurological conditions, including tardive dyskinesia, a disorder of involuntary movements for which there is no cure. Other side effects have led to legal action to provide patients with the right to refuse such medical treatment. Clinicians often misinterpret or ignore the symptoms of drug side effects. The need for maintenance dosages for schizophrenics is currently in question.
    Psychosocial therapy is now often paired with drug treatment. Patients reported deriving most help from practical advice therapists give; they value the therapists friendship. In inpatient settings, milieu therapy and social learning treatment have been shown to be more effective than the traditional treatment. Milieu therapy allows patients to take more responsibility for decision-making. Cognitive-behavioral approaches have been useful in reducing delusions and hallucinations, and improving social skills.
    Intervention to reduce expressed emotion in families has also proven useful in reducing relapse rates. Families are given information about the disorder and taught ways to alter communication patterns. Schizophrenic patients can also be taught to respond to their parents emotions more appropriately. Combining various treatments gives hope for even more successful therapy for schizophrenia in the future.