please see attachment
Textbook:
Sue, D., Sue, D. W., Sue, D., & Sue, S. (2014). Essentials of understanding abnormal behavior (2nd ed.). Belmont, CA: Wadsworth Cengage Learning.
Chapter 11
11-1Symptoms of
Schizophrenia
Spectrum Disorders
The symptoms associated with schizophrenia spectrum disorders fall into four categories:
positive symptoms, psychomotor abnormalities, cognitive symptoms, and negative symptoms.
11-1aPositive Symptoms
Case Study
Over a month before he committed the Navy yard shooting, Aaron Alexis called police to report that three people—two males and a female—were following him. He explained that he was unable to sleep because these people talked to him through the walls, ceiling, and floors of his hotel room. He also reported that they were using a microwave to send vibrations into his body (Winter, 2013).
Positive symptoms
associated with schizophrenia spectrum disorders involve delusions, hallucinations, disordered thinking, incoherent communication, and bizarre behavior. The term “positive symptoms” refers to behaviors or experiences associated with schizophrenia that are new to the person. These symptoms can range in severity, and can persist or fluctuate. In the case above, Alexis experienced two positive symptoms: auditory hallucinations (hearing voices) and a delusion that three people were following him, keeping him awake and sending vibrations into his body. Many people with positive symptoms do not understand that their symptoms are the result of mental illness (Islam, Scarone, & Gambini, 2011).
Delusions
Many individuals with psychotic disorders experience delusions.
Delusions
are false beliefs that are firmly and consistently held despite disconfirming evidence or logic. Individuals experiencing delusions are not able to distinguish between their private thoughts and external reality. Lack of insight is particularly common among individuals experiencing delusions; in other words, they do not recognize that their thoughts or beliefs are extremely illogical. In the following case study, therapists confront a graduate student’s delusion that rats were inside his head, consuming a section of his brain.
Case Study
Erin’s therapists reminded him that he was a scientist and asked him to explain how it would be possible for rats to enter his brain. Erin had no explanation, but he was certain that he would soon lose functions controlled by the area of the brain that the rats were consuming. To prevent this from happening, he banged his head so that the “activated” neurons would “electrocute” the rats. Realizing he was not losing his sight even though the rats were eating his visual cortex, he entertained two possible explanations: Either his brain had a capacity for rapid regeneration or the remaining brain cells were compensating for the loss (Stefanidis, 2006).
Although some individuals with delusions, like Erin, attempt to maintain some sense of logic, most are either unaware or only moderately aware of the illogical nature of their delusional beliefs (
Figure 11.1
).
Figure 11.1Lack of Awareness of Psychotic Symptoms in Individuals with Schizophrenia
Most individuals with schizophrenia are unaware or only somewhat aware that they have symptoms of the disorder. The symptoms they are most unaware of include asociality, delusions, and restricted affect.
Source: Amador, X. (2003). Poor insight in schizophrenia: Overview and impact on medication compliance. Retrieved from http:// www.xavieramador.com/file/cns-specialreport- on-insight . Used by permission of Dr. Xavier Amador.
Individuals with schizophrenia spectrum disorders experience a variety of delusional themes:
· Delusions of grandeur. Individuals may believe they are someone famous or powerful (from the present or the past).
· Delusions of control. Individuals may believe that other people, animals, or objects are trying to influence or take control of them.
· Delusions of thought broadcasting. Individuals may believe that others can hear their thoughts.
· Delusions of persecution. Individuals may believe that others are plotting against, mistreating, or even trying to kill them.
· Delusions of reference. Individuals may believe they are the center of attention or that all happenings revolve around them.
·
Delusions of thought withdrawal. Individuals may believe that someone or something is removing thoughts from their mind.
Myth vs Reality
Myth
Individuals experiencing delusions or hallucinations steadfastly accept them as reality.
Reality
The strength of hallucinations and delusions can vary significantly among individuals with schizophrenia spectrum disorders. Some believe in them 100 percent, whereas others are less certain. Many people cope by testing out the reality of their thinking. Some individuals with schizophrenia are able to combat delusions and hallucinations through a combination of conscious effort and medication (Saks, 2013).
A common delusion involves
paranoid ideation
, or suspiciousness about the actions or motives of others as illustrated in the following case.
Case Study
I was convinced that a foreign agency was sending people out to get rid of me. I was so convinced because I kept receiving messages from them via a device planted inside my brain. . . . I decided to strike first: to kill myself so they wouldn’t have a chance to carry out their plans and kill me. (Kean, 2011, p. 4)
Those with paranoid thinking often experience
persecutory delusions
, or beliefs that others are plotting against them, talking about them, or out to harm them in some way. Their delusional thinking causes them to be very suspicious and misinterpret the behavior and motives of others. The man in the case study was so concerned about the conspiracy against him that he decided to take his own life to prevent their plot from succeeding. Fortunately, he received help before his delusional thinking resulted in suicide.
Painting by Artist with Schizophrenia
The inner turmoil and private fantasies of people with schizophrenia are often revealed in their artwork. This painting was created by an individual with schizophrenia. What do you think the painting symbolizes?
BSIP/Universal Images Group/Getty Images
Delusions can produce strong emotional reactions such as fear, depression, or anger. Those with persecutory delusions may respond to perceived threats by leaving “dangerous” situations, avoiding areas where they might be attacked, or becoming more vigilant. Paradoxically, these “safety” behaviors may prevent them from encountering information that contradicts the delusional belief.
Delusions may include plausible themes, such as being followed or spied on, as well as bizarre beliefs, such as plots to remove internal organs or thoughts being placed in one’s mind. The strength of delusional beliefs and their effects on the person’s life can vary significantly. Delusions have less impact when the individual is able to suggest alternative explanations for the delusion and can acknowledge that others may question the accuracy of the belief (Islam et al., 2011).
Did You Know?
In one study, 28 percent of the participants had positive attitudes about their psychotic symptoms, including “having a feeling of importance and power,” and “hearing voices.” Some participants reported discontinuing their antipsychotic medications so their symptoms would return.
Source: Moritz et al., 2013
Capgras delusion, named after the person who first reported it, is a rare type of delusion involving a belief in the existence of identical doubles who replace significant others (Dulai & Kelly, 2009). The mother of one woman with Capgras delusion explained how her daughter would phone her and ask questions such as what she had worn as a Halloween costume at the age of 12 or who had attended a specific birthday party: “She was testing me because she didn’t think I was her mother. . . . No matter what question I answered, she was just sobbing” (J. Stark, 2004). The daughter believed that an impostor in a bodysuit had kidnapped her mother and was then pretending to be her mother. Capgras delusion is most common with brief forms of psychosis that develop suddenly after an emotionally distressing event (Salvatore, 2014).
Hallucinations
Case Study
An individual describes his experience with auditory hallucinations while hospitalized with schizophrenia:
“You’re alone,” an insidious voice told me. “You’re going to get what’s coming to you.” . . . No one moved or looked startled. It was just me hearing the voice. . . . I had seen others screaming back at their voices. . . . I did not want to look mad, like them. . . . Never admit you hear voices. . . . Never question your diagnosis or disagree with your psychiatrist . . . or you will never be discharged. (Gray, 2008, p. 1006)
A
hallucination
is a perception of a nonexistent or absent stimuli; it may involve a single sensory modality or a combination of modalities, including hearing (auditory hallucination), seeing (visual hallucination), smelling (olfactory hallucination), touching (tactile hallucination), or tasting (gustatory hallucination). Auditory hallucinations are most common; the voices can be malicious or benevolent or involve both qualities (M. Hayward, Berry, & Ashton, 2011). As you can see from the case study, some individuals with hallucinations recognize that their perceptions are not real and try their best to “look normal” even when the hallucinations are occurring.
Hallucinations are particularly distressing when they involve dominant, insulting voices. Negative hallucinations can be quite unsettling; those who hear destructive voices often try to cope by ignoring them or by keeping busy with other activities (Jepson, 2013). Not all auditory hallucinations are negative, however. One individual reported hearing positive voices: “I thought I could hear the voice of God, and it was God who told me to refer myself for mental health help . . .” (Jepson, 2013, p. 483).
Auditory hallucinations often seem very real to the individual experiencing them and sometimes involve relationship-like qualities (Chin, Hayward, & Drinnan, 2009). In one study involving individuals hospitalized with acute psychosis, 61 percent of respondents reported that the voice they heard had a distinct gender; 46 percent believed that the voice was that of a friend, family member, or acquaintance; and 80 percent reported having back-and-forth conversations with the voice. Most believed the voices were independent entities. Some even conducted “research” to test the reality of the voices. One woman said she initially thought that the voice might be her own but rejected it when the voice called her “Mommy,” something she would not call herself. Another woman explained, “They are not imaginary. They see what I do. They tell me that I’m baking a cake. They must be there. How else would they know what I’m doing?” (Garrett & Silva, 2003, p. 447).
Controversy
Should We Challenge Delusions and Hallucinations?
The doctor asked a patient who insisted that he was dead: “Look. Dead men don’t bleed, right?” When the man agreed, the doctor pricked the man’s finger, and showed him the blood. The patient said, “What do you know, dead men do bleed after all.” (Walkup, 1995, p. 323)
Clinicians are often unsure about whether to challenge psychotic symptoms. Some contend that delusions and hallucinations serve an adaptive function and that any attempt to change them would be useless or even dangerous. The example of the man who believed he was dead illustrates the apparent futility of using logic with delusions. However, many clinicians have found that some clients respond well to challenges to their hallucinations and delusions (K. Ross, Freeman, Dunn, & Garety, 2011).
Coltheart, Langdon, and McKay (2007) used a “gentle and tactful offering of evidence” to successfully treat a man who believed his wife was not his wife but was, instead, his business partner. The man was asked to entertain the possibility that the woman was actually his wife. The therapist pointed out that the woman was wearing a wedding ring identical to the one he had bought for his wife. The man said that the woman probably bought the ring from the same shop. He was then shown the initials engraved in the ring—those of his wife. Within 1 week, he accepted the fact that the woman was his wife. This approach of gently presenting contradictory information and having clients consider alternative explanations appears to be a successful approach to weakening delusions.
For Further Consideration
1. Should we challenge psychotic symptoms? If so, what is the best way of doing so?
2. In what ways might hallucinations or delusions serve an adaptive function?
11-1bCognitive Symptoms
Disordered thinking, communication, and speech are common characteristics of schizophrenia. Individuals experiencing these
cognitive symptoms
may have difficulty focusing on one topic, speak in an unintelligible manner, or reply tangentially to questions.
Loosening of associations
, also referred to as cognitive slippage, is another characteristic of disorganized thinking. This involves a continual shifting from topic to topic without any apparent logical or meaningful connection between thoughts. This may occur when cognitive confusion makes it difficult for the person to pay attention or respond to appropriate cues during conversation (Morris, Griffiths, LePelley, & Weickert, 2013). Disorganized communication often involves the kind of incoherent speech or bizarre, idiosyncratic responses seen in the following case study.
Case Study
INTERVIEWER: “You just must be an emotional person, that’s all.”
PATIENT: “Well, not very much I mean, what if I were dead? It’s a funeral age. Well, I . . . um. Now I had my toenails operated on. They got infected and I wasn’t able to do it. But they wouldn’t let me at my tools.” (P. Thomas, 1995, p. 289)
The beginning phrase in the person’s first sentence appears appropriate to the interviewer’s comment. However, the reference to death later in the sentence is not. Slippage appears in the comments referring to a funeral age, having toenails operated on, and getting tools. None of these thoughts are related to the interviewer’s comment. They have no hierarchical structure or organization and thus represent disorganized thinking. People with schizophrenia may also demonstrate difficulty with abstractions and thus respond to words or phrases in a very concrete manner. For example, a saying such as “a rolling stone gathers no moss” might be interpreted as meaning no more than “moss cannot grow on a rock that is rolling.”
Individuals with schizophrenia also show unusual thoughts including overinclusiveness, or abnormal categorization in their thinking. For example, when asked to sort cards with pictures of animals, fruit, clothing, and body parts into piles of things that go together, one man placed an ear, apple, pineapple, pear, strawberry, lips, orange, and banana together in a category he named “something to eat.” When asked the reason for including the ear and lips in the “something to eat” category, he explained that an ear allows you to hear a person asking for fruit, and lips allow you to ask for and eat fruit (Doughty, Lawrence, Al-Mousawi, Ashaye, & Done, 2009).
In another study, individuals with schizophrenia and healthy controls wore a head-mounted virtual reality display that gave them the sense of going through a neighborhood, a shopping center, and a market. Fifty incoherencies such as a mooing dog, an upside-down house, and a red cloud were presented during the journey. Almost 90 percent of those with schizophrenia failed to detect these inconsistencies. Even when the inconsistencies were identified, about two thirds of the participants had difficulty explaining them (Sorkin, Weinshall, & Peled, 2008).
An Episode of Withdrawn Catatonia
The woman in the wheelchair is experiencing a form of catatonia that involves unresponsiveness and the adoption of a rigid body posture. Positions such as this are sometimes held for hours, days, weeks, or even months at a time.
Grunnitus Studio/Science Source
Cognitive symptoms of schizophrenia also include problems with attention and memory and difficulty making decisions. As compared with healthy controls, individuals with schizophrenia have moderately severe to severe cognitive impairment, as evidenced by poor executive functioning—deficits in the ability to sustain attention, to absorb and interpret information, and to make decisions based on recently learned information (Costafreda et al., 2011). Difficulties with social-cognitive skills, social perspective taking, and understanding one’s own and other’s thoughts, motivations, and emotions are also common.
Schizophrenia: Etta
An interview with Etta, who suffers from schizophrenia.
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11-1cGrossly Disorganized or Abnormal Psychomotor Behavior
The symptoms of schizophrenia that involve motor functions can be quite bizarre and extremely distressing to family members, as is evident in the following case study.
Case Study
At age 20, patient A . . . was found sitting at the edge of the bed for hours, displaying simple repetitive movements of the right hand while simultaneously holding his left hand in a bizarre posture and repeating “I do, I do, I do.” (Stober, 2006, pp. 38–39)
This young man was experiencing an episode of
catatonia
, a condition involving a lack of responsiveness to the environment, peculiar body movements or postures, strange gestures and grimaces, or a combination of these (Enterman & van Dijk, 2011). People with excited catatonia have very disorganized behavior and may be very agitated, hyperactive, and lack inhibitions. Their behavior can become dangerous and involve violent acts. In one sample of 568 individuals with schizophrenia, 7.6 percent had experienced excited catatonia (Kleinhaus et al., 2012).
In sharp contrast, people experiencing withdrawn catatonia are extremely unresponsive, as was the young man in the case study. They show prolonged periods of stupor and mutism, despite an awareness of all that is going on around them. Some may adopt and maintain strange postures and refuse to move or change position. They may stand for hours at a time, perhaps with one arm stretched out to the side. They also may lie on the floor or sit awkwardly on a chair, staring, aware of what is occurring but not responding or moving. If someone attempts to change the person’s position, they may persistently resist. Others exhibit a waxy flexibility, allowing their bodies to be arranged in almost any position and then remaining in that position for long periods. The extreme withdrawal associated with a catatonic episode can be life-threatening when it results in inadequate food intake (Aboraya, Chumber, & Altaha, 2009).
1-1dNegative Symptoms
Negative symptoms
of schizophrenia are associated with an inability or decreased ability to initiate actions or speech, express emotions, or feel pleasure (Barch, 2013). The term “negative” is used because certain behaviors or experiences are lost from a person’s life once schizophrenia develops. Such symptoms include:
·
avolition
—an inability to initiate or persist in goal-directed behavior;
·
alogia
—a lack of meaningful speech;
·
asociality
—minimal interest in social relationships;
·
anhedonia
—reduced ability to experience pleasure from positive events; and
·
diminished emotional expression
—reduced display of emotion involving facial expressions, voice intonation, or gestures in situations in which emotional reactions are expected.
Negative symptoms are common in individuals with schizophrenia spectrum disorders. In fact, approximately 15–25 percent of individuals diagnosed with schizophrenia display primarily negative symptoms (D. P. Johnson et al., 2009). One group of individuals with schizophrenia with negative symptoms endorsed beliefs such as “I attach very little importance to having close friends,” “If I show my feelings, others will see my inadequacy,” and “Why bother, I’m just going to fail” (Rector, Beck, & Stolar, 2005). These beliefs may contribute to a lack of motivation to interact with others. Negative symptoms are more common in men and are associated with poor social functioning and prognosis (J. Addington & Addington, 2009).
11-2Understanding Schizophrenia
According to DSM-5, a diagnosis of schizophrenia requires the presence of two of the following: delusions, hallucinations, disorganized speech, gross motor disturbances, or negative symptoms. At least one of the two indicators must be delusions, hallucinations, or disorganized speech (see
Table 11.3
). Additionally, there is deterioration from a previous level of functioning in areas such as work, interpersonal relationships, or self-care. The symptoms must be present most of the time for at least 1 month, and the disturbance must persist for at least 6 months, unless the symptoms subside due to successful treatment (APA, 2013). Because the lifetime prevalence rate of schizophrenia in the United States is about 1 percent, it affects millions of people (National Institute of Mental Health, 2014b).
It is popularly believed that overwhelming stress can cause a well-adjusted and relatively normal person to experience a psychotic breakdown and develop schizophrenia. Although sudden onset of psychotic behaviors can occur in previously well-functioning people, in most cases of schizophrenia, there is evidence of impairment in
premorbid
functioning; that is, individuals often show some abnormalities before the onset of major symptoms (Kastelan et al., 2007). The typical course of schizophrenia consists of three phases: prodromal, active, and residual.
The prodromal phase includes the onset and buildup of schizophrenic symptoms. Social withdrawal and isolation, peculiar behaviors, inappropriate affect, poor communication patterns, and neglect of personal grooming may become evident during this phase. Friends and relatives often notice these differences and consider the changes in behavior as odd or peculiar. Often, excessive demands on the individual or other psychosocial stressors in the prodromal phase result in the onset of prominent psychotic symptoms, or the active phase of schizophrenia. In this phase, the person shows full-blown symptoms of schizophrenia, including severe disturbances in thinking, marked deterioration in social relationships, and restricted or markedly inappropriate affect.
Eventually, the person may enter the residual phase, in which the symptoms are no longer prominent. In the residual phase, the psychotic behavior and symptom severity decline. Frequently, the individual once again demonstrates the milder impairment seen in the prodromal phase. Although long-term studies have shown that many people with schizophrenia can lead productive lives, complete recovery is rare. (
Figure 11.2
illustrates different courses schizophrenia may take.)
11-2aLong-Term
Outcome
Studies
What are the chances of recovering from or showing significant symptom improvement after an episode of schizophrenia? Recent developments in both psychotherapy and medication have led to increased optimism regarding the course of the disorder. In a 10-year follow-up study of individuals hospitalized for schizophrenia, the majority of participants improved over time, whereas only a minority appeared to deteriorate (Rabinowitz, Levine, Haim, & Hafner, 2007).
What factors appear to influence recovery from schizophrenia? Factors associated with a positive outcome include gender (women have a better outcome), higher levels of education, being married or having a social network of friends, and a higher premorbid level of functioning (Irani & Siegel, 2006; Sibitz, Unger, Woppmann, Zidek, & Amering, 2011). In a 10-year follow-up study examining baseline predictors associated with recovery, researchers found that fewer negative symptoms, a prior history of good work performance and ability to live independently, and lower levels of depression and aggression were all associated with improved outcome (Shrivastava, Shah, Johnston, Stitt, & Thakar, 2010). Peer support, work opportunities, and reducing the stigma of schizophrenia facilitate recovery (Warner, 2009).
Checkpoint Review
1. Describe the prodromal, active, and residual phases of schizophrenia.
2. What factors are associated with a positive outcome in schizophrenia?
Obstacles to Recovery
The film, The Soloist, is based on the true story of Nathaniel Ayers (pictured on the left), a homeless musician coping with schizophrenia. When Los Angeles Times columnist Steve Lopez attempted to help Ayers after writing an acclaimed series of articles about the talented musician, he ran into many of the obstacles facing people who are homeless and mentally ill.
LHB Photo/Alamy Archives du 7e Art/Photos 12/Alamy
11-3Etiology of Schizophrenia
Case Study
A 13-year-old boy who was having behavioral and academic problems in school was taking part in a series of family therapy sessions. Family communication was negative in tone, with a great deal of blaming. Near the end of one session, the boy suddenly broke down and cried out, “I don’t want to be like her.” He was referring to his mother, who had been receiving treatment for schizophrenia. Her bizarre behavior frightened him, and he was concerned that his friends would find out about her condition. But his greatest fear was that he would inherit the disorder. Sobbing, he turned to the therapist and asked, “Am I going to be crazy, too?”
If you were the therapist in the case study, how would you respond? At the end of this section on the etiology of schizophrenia, you should be able to reach your own conclusion about what to tell the boy.
Schizophrenia and other psychotic conditions are best understood using a multipath model that integrates heredity (genetic influences on brain structure and neurocognitive functioning), psychological characteristics, cognitive processes (e.g., faulty psychological processing of information), and social adversities such as low social or economic status. To develop an accurate etiological framework, all of these dimensions must be considered, as shown in
Figure 11.3
.
Figure 11.3Multipath Model of Schizophrenia
The dimensions interact with one another and combine in different ways to result in schizophrenia.
© Cengage Learning®
Although we discuss the biological, psychological, social, and sociocultural dimensions separately, keep in mind that each dimension interacts with the others. For example, emotional or sexual abuse, cannabis use, and trauma are all hypothesized to affect dopamine levels and neurocognitive functioning in those susceptible to schizophrenia. In one sample, each of these factors increased the risk of persistent psychotic symptoms, especially among individuals who were exposed to all three influences (Cougnard, Marcelis, et al., 2007).
Did You Know?
· Marijuana use increases the risk of psychosis by 40 percent.
· Being a “heavy pot user” increases the risk of psychosis by 50–200 percent.
· It is estimated that 14 percent of the cases of psychosis might not have occurred if marijuana had not been used.
Source: T. H. M. Moore et al., 2007; Nordentoft & Hjorthoj, 2007
The interactive model of schizophrenia (see
Figure 11.4
) demonstrates how an underlying biological vulnerability combined with other risk characteristics (e.g., male sex, young age) can result in the development of prodromal symptoms of schizophrenia. As time progresses, psychotic features may appear or intensify if additional environmental risk factors (e.g., cannabis use, trauma) occur. If the environmental exposures are chronic or severe, the risk of developing schizophrenia further increases. We now begin the discussion of specific risk factors associated with schizophrenia.
Figure 11.4Interactive Variables and the Onset of Clinical Psychosis
This model shows how psychological and social factors may interact with genetic vulnerability to result in psychosis.
Source: Dominguez, M. D. G., Saka, M. C., Lieb, R., Wittchan, H.-U., & Van Os, J. (2010). Reprinted with permission from the American Journal of Psychiatry, copyright © 2010 American Psychiatric Association.
11-3aBiological Dimension
Genetics and heredity play an important role in the development of schizophrenia. Whereas past research focused on the attempt to identify the specific gene or genes that cause schizophrenia, most researchers agree that schizophrenia results from interactions among a large number of different genes; single genes appear to make only minor contributions toward the illness (Schizophrenia Working Group of the Psychiatric Genomics Consortium, 2015). Researchers have found that closer blood relatives of individuals diagnosed with schizophrenia run a greater risk of developing the disorder (
Figure 11.5
). Thus, the boy described in the case study earlier who is concerned about developing schizophrenia like his mother has a 16 percent chance of being diagnosed with schizophrenia, whereas his mother’s nieces or nephews have only a 4 percent chance. (It should be noted that the risk for the general population is about 1 percent.)
Figure 11.5Risk of Schizophrenia among Blood Relatives of Individuals Diagnosed with Schizophrenia
This figure reflects the estimate of the lifetime risk of developing schizophrenia— a risk that is strongly correlated with the degree of genetic influence.
Source: Data from Gottesman (1978, 1991).
However, even among monozygotic (identical) twins, if one twin receives the diagnosis of schizophrenia, the risk of the second twin developing the disorder is less than 50 percent. This is because environmental influences also play a significant role in genetic expression of the disorder. For example, low birth weight and other pregnancy and delivery complications are associated with an increased risk for schizophrenia. Yet most infants with these types of complications do not develop the disorder. Instead, the risk is the greatest among those with genetic susceptibility (Forsyth et al., 2013).
Endophenotypes
Genetic research strategies have moved from demonstrating that heredity is involved in schizophrenia to attempting to identify the genes that are responsible for the specific characteristics or traits that are evident in this disorder. This approach involves the identification and study of
endophenotypes
—measurable, heritable traits (Braff, Freedman, Schork, & Gottesman, 2007). Endophenotypes are hypothesized to underlie heritable illnesses (such as schizophrenia) and thus exist in the individual before the disorder, during it, and following remission. These characteristics are found with higher frequency, although in milder forms, among “non-ill” relatives of individuals with a disorder. Researchers have identified several possible endophenotypes that occur in those with schizophrenia and in their unaffected biological relatives. These traits include irregularities in working memory, executive function, sustained attention, and verbal memory (Chan, Di, McAlonan, & Gong, 2011; Turetsky et al., 2007).
Neurostructures
How do genes produce a vulnerability to schizophrenia? Clues to the ways that genes might increase susceptibility to developing schizophrenia have involved the identification of structural and neurochemical differences between individuals with and without schizophrenia. Individuals with schizophrenia have decreased volume in the cortex and other areas of the brain (Haijma et al., 2013), as well as ventricular enlargement (enlarged spaces in the brain). Ventricular enlargement may be an early indication of an increased susceptibility to schizophrenia (Ettinger et al., 2012).
How might decreased cortex volume and enlarged ventricles predispose someone to develop schizophrenia? These structural characteristics may result in atypical or weak connectivity between the various brain regions, leading to reductions in integrative functioning in the brain and impaired cognitive processing (Salgado-Pineda et al., 2007). Thus, ineffective communication between different brain regions may lead to the cognitive symptoms (e.g., disorganized speech and impairment in memory, decision making, and problem solving), negative symptoms (e.g., lack of drive or initiative), and positive symptoms (e.g., delusions and hallucinations) that are found in schizophrenia.
Biochemical Influences
Abnormalities in certain neurotransmitters (chemicals that allow brain cells to communicate with one another) including dopamine, serotonin, GABA, and glutamate have also been linked to schizophrenia (Benes, 2009; de la Fuente-Sandoval et al., 2013). Particular attention is given to the neurotransmitter dopamine (Howes, Kambeitz, et al., 2012). According to the
dopamine hypothesis
, schizophrenia may result from excess dopamine activity in certain areas of the brain. Support for the dopamine hypothesis has come from research with three types of drugs: phenothiazines, L-dopa, and amphetamines.
· Phenothiazines are conventional antipsychotic drugs that decrease the severity of disordered thinking, decrease social withdrawal, alleviate hallucinations, and improve the mood of individuals with schizophrenia. Phenothiazines reduce dopamine activity in the brain by blocking dopamine receptor sites.
· L-dopa is used to treat symptoms of Parkinson’s disease, such as muscle and limb rigidity and tremors. L-dopa increases levels of dopamine; schizophrenic-like side effects often occur in individuals with Parkinson’s disease who take this medication. (In contrast, the phenothiazines, which reduce dopamine activity, can produce side effects that resemble Parkinson’s disease.)
· Amphetamines are stimulants that increase the availability of dopamine and norepinephrine (another neurotransmitter) in the brain. When individuals not diagnosed with schizophrenia use amphetamines, they sometimes show symptoms very much like those of acute paranoid schizophrenia. Also, even small doses of amphetamine can increase the severity of symptoms in individuals diagnosed with schizophrenia.
Did You Know?
Agitation and psychotic symptoms associated with the use of “bath salts” has dramatically increased emergency room visits and hospitalizations. Street names for these synthetic hallucinogenic and stimulant substances include meow, miaow, drone, bubbles, plant food, spice E, and M-cat.
Source: Kolli, Sharma, Amani, Bestha, & Chaturvedi, 2013
Thus, one group of drugs that blocks dopamine reception has the effect of reducing the severity of schizophrenic symptoms, whereas two drugs that increase dopamine availability either produce or worsen these symptoms. Such evidence suggests that excess dopamine may be responsible for schizophrenic symptoms. The evidence is not clear-cut, however. Phenothiazines are not effective in treating many cases of schizophrenia, and newer antipsychotics work mainly by blocking serotonin receptors rather than dopamine receptors (Canas, 2005).
The use of cocaine, amphetamines, alcohol, and especially cannabis appears to increase the chances of developing a psychotic disorder (Callaghan et al., 2012). Methamphetamine use may result in a fivefold increase in the likelihood of psychotic symptoms during intoxication (McKetin, Lubman, Baker, Dawe, & Ali, 2013). When distressing psychotic symptoms such as delusions or hallucinations develop during substance use or intoxication, a diagnosis of substance/medication-induced psychotic disorder may be appropriate (APA, 2013).
The effects of cannabis occurs in a dose-dependent manner—the higher the intake of cannabis, the greater the likelihood of psychotic symptoms (Davis, Compton, Wang, Levin, & Blanco, 2013). Use of high potency forms of cannabis also increases the risk of psychosis (Di Forte et al., 2015). Adolescents who use cannabis are more likely to report prodromal symptoms (e.g., “Something strange is taking place in me,” “I feel that I am being followed,” or “I am being influenced in a special way”; Miettunen et al., 2008). Among cannabis users who develop schizophrenia, the onset of psychosis is nearly 3 years earlier in comparison to nonusers (Large, Sharma, Compton, Slade, & Nielssen, 2011).
Several possible interpretations may explain the relationship between cannabis use and psychosis (Foti, Kotov, Guey, & Bromet, 2010):
1. the increased risk of developing psychosis may be due to cannabis use itself;
2. individuals with a predisposition for psychosis may also be predisposed to use cannabis;
3.
individuals with prodromal symptoms or psychotic-type experiences may use cannabis to self-medicate for these symptoms; or
4. cannabis may influence dopamine levels or increase vulnerability through interactions with environmental stressors associated with cannabis use (e.g., family conflict or poor school or work performance).
Although the prevalence of schizophrenia is roughly equal between men and women, the age of onset is earlier in males than in females (Segarra et al., 2012). The gender ratio shifts by the mid-40s and 50s, when the percentage of women receiving the diagnosis exceeds that of men. This trend is especially pronounced in the mid-60s and later (Thorup, Waltoft, Pedersen, Mortensen, & Nordentoft, 2007). Researchers have hypothesized that the later age of onset found in women is due to the protective effects of estrogen, which diminish after menopause (E. Hayes, Gavrilidis, & Kulkarni, 2012).
Rate of Gray Matter Loss in Teenagers with Schizophrenia
Male and female adolescents with schizophrenia show progressive loss of gray matter in the parietal, frontal, and temporal areas of the brain that is much greater than that found in adolescents without schizophrenia.
Reprinted with permission of Dr. Paul Thompson, UCLA Laboratory of Neuro Imaging
Because the
concordance rate
—the likelihood that both members of a twin pair show the same characteristic— is less than 50 percent when one identical twin has schizophrenia, physical, psychological, or social influences that are not shared between the twins must also play a role. Conditions influencing prenatal or postnatal neurodevelopment that have been associated with schizophrenia include prenatal infections, obstetric complications, and head trauma (Cannon, Clarke, & Cotter, 2014; Mittal, Ellman, & Cannon, 2008).
Although a variety of biological influences appear to increase susceptibility to schizophrenia, specific psychological, social, and sociocultural variables can also influence development of schizophrenia. We now examine these influences as possible contributors to the disorder.
11-3bPsychological Dimension
Individuals who develop schizophrenia have certain cognitive attributes, dysfunctional beliefs, and interpersonal functioning that may predispose them to the development of psychotic symptoms. For example, deficits in empathy (understanding the feelings of others) and a tendency to focus only on one’s own thoughts and feelings appear to compromise social interactions (Harvey, Zaki, Lee, Ochsner, & Green, 2013). This problem is also apparent during nonverbal communication; individuals with schizophrenia tend to gesture less when speaking and nod less frequently when listening compared to individuals without the disorder. Such a communication pattern may interfere with the development of interpersonal rapport and emotional connection (Lavelle, Healey, & McCabe, 2013).
Did You Know?
Characteristics that sharply increase the likelihood of developing schizophrenia include:
1. genetic risk;
2. recent deterioration in functioning, especially social withdrawal;
3. increasing frequency of unusual thoughts;
4. high levels of suspiciousness and paranoia;
5. social impairment; and
6. substance abuse.
Source: Cannon et al., 2008
These communication problems and the lack of insight that frequently occurs with schizophrenia may result, in part, from an inability to recognize that others have emotions, beliefs, and desires that may be different from one’s own. Thus, individuals with schizophrenia may operate based on their own perspectives without understanding that others have their own viewpoint. As you might imagine, this could create major difficulties in communication and interpersonal interactions.
Early cognitive deficits are also associated with schizophrenia. Low cognitive test scores in childhood and adolescence predicted the presence of psychotic-like experiences and clinically significant psychotic symptoms in middle age; the low scores may represent early evidence of abnormalities in neural development (Barnett et al., 2012). Additionally, in a group of young men, a decline in verbal ability between ages 13 and 18 was associated with an increased risk of developing a psychotic disorder (MacCabe et al., 2013). These cognitive decrements may be an indication of brain abnormalities that result in less “cognitive reserve” and reduced opportunity for the brain to bounce back from neurological insult (Barnett et al., 2012).
Brain Changes Associated with Schizophrenia
In these PET scans of the frontal cortex, the adult brain on the left (healthy subject) shows high levels of metabolic activity whereas the one on the right (subject of the same age with schizophrenia) shows reduced lower metabolic activity. Such findings help explain the cognitive difficulties experienced by individuals with schizophrenia.
ISM/Photo take
Certain personal cognitive processes involving misattributions or negative attitudes can lead to or maintain psychotic symptoms such as delusions. For example, negative symptoms such as limited motivation and
restricted affect
, may be due to individuals’ beliefs that they are worthless and that their condition is hopeless (Beck, Grant, Huh, Perivoliotis, & Chang, 2013). The combination of low expectancy for pleasure and success combined with low motivation may maintain negative symptoms. In fact, some researchers believe that an individual’s interpretation of events may be the primary cause of the distress and disability associated with schizophrenia (Garety, Bebbington, Fowler, Freeman, & Kuipers, 2007). In other words, pessimistic interpretations may produce and maintain negative symptoms.
Table 11.1
presents patterns of thinking that may be associated with negative symptoms.
Table 11.1
Negative Expectancy Appraisals Associated with Negative Symptoms
|
Negative Symptom |
Low Self-Efficacy (Success) |
Low Satisfaction (Pleasure) |
Low Acceptance |
Low Available Resources |
|
Restricted affect |
If I show my feelings, others will see my inadequacy. |
I don’t feel the way I used to. |
My face appears stiff and contorted to others. |
I don’t have the ability to express my feelings. |
|
Alogia |
I’m not going to find the right words to express myself. |
I take so long to get my point across that it’s boring. |
I’m going to sound weird, stupid, or strange. |
It takes too much effort to talk. |
|
Avolition |
Why bother, I’m just going to fail. |
It’s more trouble than it’s worth. |
It’s best not to get involved. |
It takes too much effort to try. |
Source: Rector, Beck, & Stolar (2005), p. 254.
11-3cSocial Dimension
The role of social relationships in the development of schizophrenia has been extensively studied. In fact, not long ago, dysfunctional family patterns, rather than biology, were considered the primary cause of schizophrenia (Walker & Tessner, 2008). Although research has failed to substantiate the hypothesis that family dysfunction is a major cause of schizophrenia, blaming families for schizophrenia still occurs today. One parent whose son was hospitalized for psychosis heard a nurse say, “Well, no wonder he’s ill—look at the state of his mother.” The staff member apparently failed to understand that the mother’s state of mind was the result of weeks of stress attempting to help her adult son cope with his psychotic symptoms prior to his hospitalization (Wainwright, Glentworth, Haddock, Bentley, & Lobban, 2014, p. 8). It is quite probable, however, that among individuals with a biological predisposition, the social environment does increase risk of schizophrenia. We will consider social factors that are associated with increased vulnerability to schizophrenia.
Certain social stressors appear to influence the appearance of psychotic symptoms. In a longitudinal study focused on 2,232 twins, those who experienced maltreatment by an adult or bullying by peers had a higher risk of psychotic symptoms at age 12 (see
Figure 11.6
); the risk was magnified among those exposed to both bullying and maltreatment. In contrast, being in a traumatic accident was associated with only a slightly increased risk of psychotic symptoms (Arseneault et al., 2011). Similarly, another study found a dose-dependent relationship between the severity of bullying and the risk for psychotic experiences in school-age adolescents—the more severe the bullying, the greater the risk of schizophrenia. The study reported another finding that has important implications for prevention programs—the psychotic symptoms in affected youth often decreased or subsided if the bullying stopped (Kelleher et al., 2013).
Figure 11.6Risk of Psychotic Symptoms at Age 11 Associated with Cumulative Childhood Trauma
Youth exposed to both bullying and childhood maltreatment demonstrate a significantly increased risk of developing psychotic symptoms.
Source: Arseneault et al. (2011). Reprinted with permission from the American Journal of Psychiatry, copyright © 2011 American Psychiatric Association.
Relationships within the home can also influence the development of schizophrenia. Individuals with psychosis were 3 times more likely to report severe physical abuse from mothers before 12 years of age than were individuals without psychosis (H. L. Fisher et al., 2010). In contrast, among adolescents with symptoms that appeared to put them “at imminent risk” for the onset of psychosis, positive remarks and warmth expressed by caregivers were associated with decreases in negative and disorganized symptoms and improvement in social functioning (M. P. O’Brien et al., 2006). Children at higher biological risk for schizophrenia may be more sensitive to the effects of both adverse and healthy child-rearing patterns (Aas et al., 2012).
Expressed emotion (EE)
, a negative communication pattern found among some relatives of individuals with schizophrenia, has been associated with higher relapse rates in individuals diagnosed with schizophrenia (Breitborde, Lopez, & Nuechterlein, 2009). EE is determined by a variety of factors, including critical comments made by relatives; statements of dislike or resentment directed toward the individual with schizophrenia by family members; and statements reflecting emotional overinvolvement, overconcern, or overprotectiveness with respect to the family member with schizophrenia. Although high EE has been associated with an increased risk of relapse, there are different interpretations for this finding (see
Figure 11.7
).
· A high EE environment is stressful and may lead directly to relapse in the family member who has schizophrenia (Cutting & Docherty, 2000).
· An individual who is more severely ill has a greater chance of relapse and may cause more negative or high EE communication patterns in relatives.
·
The effects of EE and illness are bidirectional: Odd behaviors or symptoms of schizophrenia may increase the likelihood that family members criticize, overprotect, or react to the symptoms with frustration, which in turn produces increases in psychotic symptoms (Rosenfarb, Goldstein, et al., 1995).
Figure 11.7Possible Relationships between High Rates of Expressed Emotion and Relapse Rates in Patients with Schizophrenia
This figure shows several ways in which expressed emotions and relapse rates can be related.
© Cengage Learning®
The EE construct appears to have less meaning for different cultural groups. It is possible that this occurs because cultural factors may influence whether family members view the symptoms as burdensome. For example, family criticism scores were not associated with relapse for Mexican Americans with schizophrenia (Rosenfarb, Bellack, & Aziz, 2006). Among a sample of African Americans and European Americans with schizophrenia, high levels of critical and intrusive behavior by family members (high EE) were associated with better outcomes for African American clients over a 2-year period, whereas European American clients had better outcomes with low levels of EE. Within some African American families, seemingly negative family communication may, in fact, reflect caring and concern (Rosenfarb, Bellack, et al., 2006). Lopez, Hipke, and associates (2004) concluded that cultural groups may interpret family communication processes such as emotional overprotection or overinvolvement differently. In fact, therapists who focus on reducing critical and intrusive communication patterns in some culturally diverse families may inadvertently increase family stress.
11-4Treatment of Schizophrenia
Through the years, schizophrenia has been treated by a variety of means, including performing a
prefrontal lobotomy
—a surgical procedure in which the frontal lobes are disconnected from the remainder of the brain. Today schizophrenia is often treated with antipsychotic medications, along with some type of psychosocial therapy. In recent years, the research and clinical perspective on people with schizophrenia has shifted from a focus on illness and deficit to one of recovery and promotion of health, competencies, independence, and self-determination (Bellack, 2006; Lysaker & Roe, 2012). This change of focus is affecting therapists’ views regarding clients, families, and their own role in the treatment process. We first discuss medication in the treatment of schizophrenia, and then the psychological and social therapies.
11-4aAntipsychotic Medications
Many consider the 1955 introduction of Thorazine, the first antipsychotic drug, to be the beginning of a new era in treating schizophrenia. For the first time, a medication was available that sufficiently relaxed even those most severely affected by schizophrenia and helped organize their thoughts to the point that straitjackets were no longer needed for physical restraint. The
first-generation antipsychotics
(also called conventional or typical antipsychotics) are still viewed as effective treatments for schizophrenia, although their use has been largely supplanted by the newer
atypical antipsychotics
, medications with somewhat different chemical properties compared to the earlier drugs. Although medications have improved the lives of many with schizophrenia, they do not cure the disorder. Conventional antipsychotic medications (such as chlorpromazine/Thorazine or haloperidol/Haldol) have dopaminergic receptor–blocking capabilities (i.e., they reduce dopamine levels), a factor that led to the dopamine hypothesis of schizophrenia.
Did You Know?
In a randomized, double-blind study, adolescents at risk for developing psychosis were given either omega-3 fatty acids (fish oil) or a placebo for 3 months and then followed for a year. In the placebo group, 14 percent developed psychosis compared to only 2 percent in the fish oil group. Could prevention be this easy? Researchers in the United States and Canada are currently examining this possibility.
Source: Amminger et al., 2010; Brooks, 2012
The newer atypical antipsychotics (such as risperidone/Risperdal, olanzapine/ Zyprexa, quetiapine/Seroquel, aripiprazole/Abilify, and lurasidone/Latuda) act on both dopamine and serotonin receptors. These newer medications are purportedly less likely to produce side effects such as the rigidity, persistent muscle spasms, tremors, and restlessness that occur with the older antipsychotics (Bobo, 2013). However, some researchers have identified troublesome side effects with these newer antipsychotic medications (Foley & Morley, 2011). In addition, a review of studies published between 1974 and 2012 comparing conventional and atypical antipsychotics found a lack of evidence that the latter offer an advantage in treating schizophrenia (Hartling et al., 2012).
Continuum
Video Project
© Cengage Learning®Andre:
Schizophrenia
“I believe that other people are pathological liars, and I’m not. So why should I even have to listen to them?”
Access the Continuum Video Project in MindTap at www.cengagebrain.com
Conventional and atypical antipsychotics can effectively reduce the severity of the positive symptoms of schizophrenia, such as hallucinations, delusions, bizarre speech, and disordered thought. In one study, over 75 percent of those taking atypical antipsychotics felt that the medication helped them manage their symptoms and prevent hospitalization (Jenkins et al., 2005). Most of these medications, however, offer little relief from negative symptoms such as social withdrawal, apathy, and impaired personal hygiene (M. F. Green, 2007). Moreover, a “relatively large group” of people with schizophrenia do not benefit at all from antipsychotic medication. Additionally, from one half to three quarters of patients discontinue use of antipsychotics for the following reasons (Moritz et al., 2013):
· Too many side effects (80 percent)
· Belief that they do not need antipsychotics (58 percent)
· Mistrust of the physician or therapist (31 percent)
· Rejection of medication in general (28 percent)
· Friends or relatives advised them not to take the medication (20 percent)
Many individuals treated with antipsychotic medications develop
extrapyramidal symptoms
, which include parkinsonism (muscle tremors, shakiness, and immobility), dystonia (slow and continued involuntary movements of the limbs and tongue), akathisia (motor restlessness), and neuroleptic malignant syndrome (muscle rigidity and autonomic instability, which can be fatal if untreated). Other symptoms may involve the loss of facial expression, shuffling gait, tremors of the hand, rigidity of the body, and poor balance. Although many symptoms are reversible once medication is stopped, some symptoms (e.g., involuntary movements) can be permanent (Abouzaid et al., 2014). Antipsychotic medications are also associated with increased risk of
metabolic syndrome
, a condition associated with obesity, diabetes, high cholesterol, and hypertension (Bener, Al-Hamaq, & Dafeeah, 2014).
Controversy
The Marketing of Atypical Antipsychotic Medications
The woman in the Abilify ad says, “I’m taking an antidepressant but I think I need more help.” According to the ad, two out of three individuals taking an antidepressant alone continue to experience symptoms of depression. The ad goes on to suggest that Abilify can be helpful when combined with current antidepressant medications. Abilify is an atypical antipsychotic, but that fact is not mentioned (Westberg, 2010).
Surprisingly, atypical antipsychotics are the top- selling class of medications in the United States, accounting for $18.2 billion in sales based on 3.1 million U.S. prescriptions in 2011 (Friedman, 2012), including more than $1 billion in annual sales for quetiapine (Seroquel), aripiprazole (Abilify), olanzapine (Zyprexa), and risperidone (Risperdal) (G. C. Alexander, Gallagher, Mascola, Moloney, & Stafford, 2011). These profitable drugs are heavily promoted by the pharmaceutical companies, with resultant increases in the number of people taking both antidepressants and antipsychotics. However, many of these combinations are of “unproven efficacy” (Mojtabai & Olfson, 2010). Antipsychotics are increasingly prescribed for a range of mental disorders, including attentional, conduct, and anxiety disorders, although they have never been evaluated or approved for use with these disorders (Zito, Burcu, Ibe, Safer, & Magder, 2013).
The increased use of atypical antipsychotic medications is of particular concern due to their association with troublesome side effects. After only 12 weeks on Abilify, Risperdal, Seroquel, or Zyprexa, children were found to gain up to 19 lb (Correll et al., 2010). In a 5-year study of atypical antipsychotics in middle-aged and older individuals with schizophrenia, 29.7 percent had serious adverse physical effects that were probably or possibly due to the medication. Increases in cholesterol levels and weight gain can occur in individuals taking atypical antipsychotic medications for as little as 3 months (Foley & Morley, 2011). The U.S. Food and Drug Administration (2011) has warned that infants born to mothers taking antipsychotic medications during the third trimester of pregnancy are at high risk of having abnormal muscle tone, tremors, sleepiness, severe difficulty breathing, and difficulty sucking.
Should regulations be in place to protect consumers from the increasing off-label use of antipsychotic medications? Should advertisements promoting atypical antipsychotic medications identify them as such? Should physicians and psychiatrists be required to inform patients when antipsychotics have not been approved for the treatment of their specific condition?
11-4bCognitive-Behavioral Therapy
Major advances have been made in the use of cognitive and behavioral strategies in treating the symptoms of schizophrenia; this is particularly important for those who do not respond to medication. Therapists teach coping skills that allow clients to manage their positive and negative symptoms, as well as the cognitive challenges associated with schizophrenia (Hansen, Kingdon, & Turkington, 2006). An 18-month follow-up of 216 individuals with persisting psychotic symptoms found that those receiving cognitive-behavioral therapy had 183 days of normal functioning, compared to 106 days for those who received treatment as usual consisting of pharmacotherapy and contact with a psychiatric nurse (van der Gaag, Stant, Wolters, Burkens, & Wiersma, 2011).
The following case study provides an example of symptoms of schizophrenia that might be effectively addressed with cognitive-behavioral treatment strategies.
Case Study
A young African American woman with auditory hallucinations, paranoid delusions, delusions of reference, a history of childhood verbal and physical abuse, and adult sexual assault felt extremely hopeless about her prospects for developing social ties. She believed that her “persecutors” had informed others of her socially undesirable activities. . . . She often loudly screamed at the voices she was hearing. . . . When she did leave her home, she often covered her head with a black kerchief and wore dark sunglasses, partly in an effort to disguise herself from her persecutors. (Cather, 2005, p. 260)
Cognitive-behavioral treatment to address concerns such as these often includes the following steps (Cather, 2005; Sivec & Montesano, 2013):
· Engagement. The therapist explains the therapy and works to foster a safe and collaborative method of looking at causes of distress, drawing out the client’s understanding of stressors and ways of coping.
· Assessment. Clients are encouraged to discuss their fears and anxieties; the therapist shares information about how symptoms are formed and maintained. In the preceding case study, the therapist helped the woman make sense of her persecutory delusions. It was explained that victims of abuse often internalize beliefs that they are responsible for the abuse, and that her view that she was “bad” led to expectations of negative reactions from others and the need to disguise herself.
· Identification of negative beliefs. The therapist explains to the client the link between personal beliefs and emotional distress, and the ways that beliefs such as “Nobody will like me if I tell them about my voices” can be disputed and changed to “I can’t demand that everyone like me. Some people will and some won’t” (Hansen et al., 2006, p. 50). This reinterpretation often leads to less sadness and isolation.
· Normalization. The therapist works with the client to normalize and decatastrophize the psychotic experiences. Information that many people can have unusual experiences may reduce a client’s sense of isolation.
· Collaborative analysis of symptoms. Once a strong therapeutic alliance has been established, the therapist begins critical discussions of the client’s symptoms, such as “If voices come from your head, why can’t others hear them?” Evidence for and against the maladaptive beliefs is discussed, combined with information about how beliefs are maintained through cognitive distortions.
· Development of alternative explanations. The therapist helps the client develop alternatives to previous maladaptive assumptions, using the client’s ideas whenever possible.
Family Communication and Education
Therapy that includes the family members of individuals with schizophrenia reduces relapse rates and is more effective than drug treatment alone.
iStockphoto.com/JodiJacobson
More recently, instead of trying to eliminate or combat hallucinations, therapists teach clients to accept them in a nonjudgmental manner. In mindfulness training, clients learn to let go of angry or fearful responses to psychotic symptoms; instead, they are taught to let the psychotic symptoms come into consciousness without reacting (e.g., just noticing and accepting the voices or thoughts rather than believing them or acting on them). This process enhances feelings of self-control and significantly reduces negative emotions (Shawyer et al., 2012).
This approach was used with men who had heard malevolent and powerful voices for more than 30 years. Their attempts to stop the voices or to distract themselves were ineffective. After undergoing mindfulness training, the men were less distressed with the voices and more confident in their ability to live with them (K. N. Taylor, Harper, & Chadwick, 2009). Similarly, malevolent and persecuting voices became less disturbing when individuals with schizophrenia learned to access positive emotions such as warmth and contentment during psychotic episodes (Mayhew & Gilbert, 2008).
Artwork to Demonstrate Creative Talents
Paintings and sculptures by William Scott, diagnosed with schizophrenia and an autism spectrum disorder, are sold around the world at cutting-edge art galleries. Scott is pictured here with a self-portrait.
AP Images/Paul Sakuma
11-4cInterventions Focusing on Family Communication and Education
A serious mental illness such as schizophrenia can have a powerful effect on family members, who may feel stigmatized or responsible for the disorder. As one woman stated, “All family members are affected by a loved one’s mental illness. The entire family system needs to be addressed” (Stalberg, Ekerwald, & Hultman, 2004).
Siblings without the disorder may display a variety of emotional reactions to the mental illness experienced by their sibling—love (“She’s really kind and loves me so very much it’s never been a problem.”); loss (“Somehow I’ve lost my sister the way she was before and I think I won’t get her back.”); anger (“Yes, it’s hell. . . . She’s incredibly mean to our mother and she sure as hell doesn’t deserve that.”); guilt and shame (“Yes, you can think about how he got ill and I didn’t.”); and fear (“You worry a lot about getting it yourself.”) (Stalberg, Ekerwald, & Hultman, 2004, p. 450).
More than half of those recovering from a psychotic episode return to live with their families, and new psychological interventions address this fact. Family intervention programs have not only reduced relapse rates but have also lowered the cost of care. They have been beneficial for families with and without negative communication patterns. Most programs include the following components (Glynn et al., 2006):
· normalizing the family experience;
· demonstrating concern, empathy, and sympathy to all family members;
· educating family members about schizophrenia;
· avoiding blaming the family or pathologizing their coping efforts;
· identifying the strengths and competencies of the client and family members;
· developing skills in solving problems and managing stress;
· teaching family members to cope with the symptoms of mental illness and its repercussions on the family; and
· strengthening the communication skills of all family members.
Family approaches and social skills training are much more effective in preventing relapse than drug treatment alone (Xia, Merinder, & Belgamwar, 2011). Combining cognitive-behavioral strategies, medication, family counseling, and social skills training seems to produce the most positive results (Penn et al., 2004). In fact, research suggests that “optimism about outcome from schizophrenia is justified” and that “a substantial proportion of people with the illness will recover completely and many more will regain good social functioning” (R. Warner, 2009, p. 374).
11-5Other Schizophrenia Spectrum Disorders
Disorders on the schizophrenia spectrum include some or all of the symptoms we discussed at the beginning of this chapter. The spectrum includes disorders that differ from schizophrenia in a variety of ways, including the specific symptoms involved, the duration of symptoms, or the presence of additional symptoms. Additional disorders on the schizophrenia spectrum include delusional disorder, brief psychotic disorder, schizophreniform disorder, and schizoaffective disorder (see
Table 11.3).
Table 11.3
Schizophrenia Spectrum and Other Psychotic Disorders
Disorders Chart
Disorder
Symptoms
Prevalence
Gender Differences
Age of Onset
Two or more psychotic symptoms of which at least one must be delusions, hallucinations, or disorganized speech; impaired life functioning
· About 1% of the population
· About equal
· 18–24 for men
· 24–35 for women
Brief psychotic disorder
One or more psychotic symptoms, of which at least one must be delusions, hallucinations, or disorganized speech for at least 1 day but less than 1 month
· Up to 9% of new cases of psychosis
· Much higher in developing countries
· Twice as common in women
3. Can occur at any age
4. Most common in 30s
Schizophreniform disorder
Two or more psychotic symptoms, of which at least one must be delusions, hallucinations, or disorganized speech for at least 1 month but less than 6 months
· Much lower rate than schizophrenia
· Higher in developing countries
3. About equal
· 18–24 for men
· 24–35 for women
Delusional disorder
One or more delusions for at least 1 month
· Rare: from 0.03%–0.18%
5. About equal
7. More prevalent in older adults
Schizoaffective disorder
Episode of mania or major depression concurrent with delusions, hallucinations, or disorganized speech; psychotic symptoms persist after the mood episode ends
1. About 0.32%
1. More females
1. Usually early adulthood
Source: APA (2013); Bhalla (2013); Brannon & Bienenfeld (2012); Memon (2013).
11-5aDelusional Disorder
Case Study
A man is convinced that his body gives off an unpleasant odor and that if anyone opens a window, sneezes, or frowns, it is because of his smell. He is suspicious when people whisper to one another or when people on his bus get off quickly. He believes this is evidence that his body has a terrible smell (Begum & McKenna, 2011).
is characterized by persistent delusions that are not accompanied by other unusual or odd behaviors—other than those related to the delusional theme (Chopra & Bienenfeld, 2011). According to DSM-5, the delusions must persist for at least 1 month (APA, 2013). Delusional disorder is distinct from the other psychotic disorders due to the absence of additional disturbances in thoughts or perceptions, beyond occasional hallucinations that may be associated with the delusion (e.g., sensations of insects crawling on the skin within the context of a delusion that one’s home is infested with insects).
This disorder is rarely diagnosed (the prevalence is 0.03–0.18 percent); however, it is believed that many with the disorder do not perceive they have a problem and therefore do not seek assistance. People with delusional disorder generally behave normally when they are not discussing or reacting to their delusional ideas. Common themes involved in delusional disorders include the following (Chopra & Bienenfeld, 2011):
· Erotomania—the belief that someone is in love with the individual; this delusion typically has a romantic rather than sexual focus.
· Grandiosity—the conviction that one has great, unrecognized talent, special abilities, or a relationship with an important person or deity.
· Jealousy—the conviction that one’s spouse or partner is being unfaithful.
· Persecution—the belief that one is being conspired or plotted against.
· Somatic complaints—convictions of having body odor, being malformed, or being infested by insects or parasites.
Women are more likely to develop erotomanic delusions, whereas men tend to have paranoid delusions involving persecution (Chopra & Khan, 2009).
A decreased ability to obtain corrective feedback, combined with preexisting personality traits of suspiciousness, may increase a person’s susceptibility to developing delusional beliefs. For example, hearing impairment in early adolescence is associated with an increased risk of developing delusions (van der Werf et al., 2011). There is a significant genetic relationship between delusional disorder and schizophrenia; a small proportion of those with the disorder eventually develop schizophrenia (APA, 2013). Delusional disorder can be treated with antipsychotic medications or cognitive-behavioral therapy (Chopra & Khan, 2009).
11-5bBrief Psychotic Disorder
Case Study
Eve was a 20-year-old student studying forensic medicine when she first experienced a chaotic world of delusions. She believed that her body was decaying, deteriorating, and rotting away. She feared seeing her reflection in mirrors, worried that it would show that her skin was falling apart revealing a rotted monster. She pasted paper over windows and smashed the mirror in the bathroom. She splashed perfume over everything to hide the stench of her rotting body. She stayed in constant motion because she believed that remaining still would cause her body to deteriorate more quickly. At some point all she could do was scream.
Eve received a diagnosis of brief psychotic disorder and the psychiatrist prescribed an antipsychotic medication, an antidepressant, and a sleeping aid. Within two and one-half weeks, her symptoms had subsided and she moved back in with her family (Purse, 2013).
Critical Thinking
Morgellons Disease: Delusional Parasitosis or Physical Disease?
More than 10 years ago, “Mary Leitao plucked a fiber that looked like a dandelion fluff from a sore under her two-year-old son’s lips. . . . Sometimes the fibers were white, and sometimes they were black, red, or blue” (Devita-Raeburn, 2007). Leitao was frustrated by the inability of physicians to diagnose her son’s skin condition. In fact, many of the professionals she consulted indicated that they could find no evidence of disease or infection. Frustrated by the medical establishment, Leitao put a description of the condition on a Web site in 2001, calling it Morgellons disease after a 17th-century French medical study involving children with similar symptoms (Mason, 2006).
The Web site has since compiled 11,000 worldwide reports of the condition among adults and children. Sufferers report granules and fiber-like threads emerging from the skin at the site of itching; sensations of crawling, stinging, or biting; and rashes and skin lesions that do not heal (M. Paquette, 2007). Some describe the fibers as “inorganic but alive” and report that the fibers pull back from a lit match (Browne, 2011). Symptoms of vision changes, joint pain, fatigue, mental confusion, and short-term memory difficulties have been reported in connection with Morgellons disease (Centers for Disease Control and Prevention, 2011).
What could cause this disorder? Many dermatologists, physicians, and psychiatrists believe that Morgellons disease results from self-inflicted injury or is a somatic type of delusional disorder such as delusional parasitosis, a condition in which individuals maintain a delusional belief that they are afflicted with living organisms or other pathogens (Freudenmann & Lepping, 2009). Stephen Stone, past president of the American Academy of Dermatology, does not believe Morgellons is a real disease. He argues that the Internet community is allowing individuals with somatic delusions to band together (Marris, 2006). Some physicians, however, believe there is an underlying physical disorder, citing those with Morgellons symptoms who test positive for Lyme disease or whose symptoms are alleviated with antibacterial or antiparasitic medications (Savely, Leitao, & Stricker, 2006).
Because of the controversy and the increasing number of complaints, the Centers for Disease Control and Prevention (CDC) initiated an investigation of Morgellons, including psychological testing, environmental analysis, examination of skin biopsies, and laboratory study of fibers or threads obtained from people with the condition (CDC, 2011). Researchers concluded that no medical condition or infection could explain the reported symptoms and that the skin lesions were probably produced by scratching. Fibers found at the site of skin inflammation were cotton or nylon, not organisms. Psychological tests revealed that individuals studied were more likely to be depressed and attentive to physical symptoms than the general population, but that they were not delusional (Pearson et al., 2012). Some researchers believe that “the rapid rise of Morgellons could not have occurred without the internet . . . which can spread information—without regard for accuracy or usefulness” (Freudenreich, Kontos, Tranulis, & Cather, 2010, p. 456).
For Further Consideration
· Are Internet Web sites on diseases such as Morgellons creating disorders among vulnerable individuals, or do they provide comfort for those with an actual disease?
· How might a psychologist or a physician determine if an individual reporting symptoms of Morgellons was suffering from a somatic delusion?
A DSM-5 diagnosis of
brief psychotic disorder
requires the presence of one or more psychotic symptoms, including at least one symptom involving delusions, hallucinations, or disorganized speech, that continue for at least 1 day but last less than 1 month. The symptoms sometimes occur during pregnancy or within 4 weeks of childbirth (APA, 2013). Because of the abrupt and distressing nature of the disorder, prevention of self-harm through hospitalization and use of antipsychotic drugs is sometimes necessary (Memon, 2013).
A significant stressor often precedes the onset of symptoms, although in some cases a precipitating event is not apparent. Eve experienced a number of stressors before her psychotic episode. She had just lost her best friend to an accident, was struggling with academic demands, was working two jobs, had moved into a new apartment, was dealing with the divorce of her parents, and had just broken up with her boyfriend.
Brief psychotic disorder accounts for up to 9 percent of individuals who seek help for first-time psychotic symptoms and is twice as common in women (APA, 2013). In contrast to schizophrenia and other psychotic disorders, there is often a full return to normal functioning after the episode. When the psychotic symptoms persist, a different diagnosis from the schizophrenia spectrum may be appropriate.
11-5cSchizophreniform Disorder
According to the DSM-5, a diagnosis of
schizophreniform disorder
requires the presence of two or more of the following symptoms: delusions, hallucinations, disorganized speech, gross motor disturbances, or negative symptoms. At least one of these symptoms must involve delusions, hallucinations, or disorganized speech. This condition lasts between 1 and 6 months (APA, 2013).
Schizophreniform disorder occurs equally in men and women and shares some of the anatomical and neural deficits found in schizophrenia (Bhalla & Ahmed, 2011). Like schizophrenia, the onset peaks between the ages of 18–24 in men and 24–35 in women. Positive prognostic signs for schizophreniform disorder include an abrupt onset of symptoms, good premorbid functioning, and the absence of negative symptoms. As with schizophrenia, there is a significant risk from suicide, especially when the disorder is accompanied by depression (Bhalla, 2013). One third of individuals with this diagnosis recover within 6 months, and the other two thirds eventually receive a diagnosis of schizophrenia or schizoaffective disorder (APA, 2013) (see other similarities and differences between brief psychotic disorder, schizophreniform disorder, and schizophrenia in
Table 11.4
).
Table 11.4
Comparison of Brief Psychotic Disorder, Schizophreniform Disorder, and Schizophrenia
|
Brief Psychotic Disorder |
Schizophreniform Disorder |
Schizophrenia | |
|
Duration |
Less than 1 month |
Less than 6 months |
6 months or more |
|
Psychosocial stressor |
Likely present |
Usually present |
May or may not be present |
|
Onset of symptoms |
Abrupt onset of psychotic symptoms |
Often abrupt psychotic symptoms |
Gradual onset of psychotic symptoms |
| Outcome |
Return to premorbid functioning |
Possible return to premorbid functioning |
Occasional return to premorbid functioning |
|
Risk factors |
More common in females |
Some increased risk of schizophrenia among family members |
Higher prevalence of schizophrenia among family members |
Source: APA (2013); Bhalla & Ahmed (2011); Memon (2013).
11-5dSchizoaffective Disorder
Case Study
By her last year of college, Beth Baxter, M.D., an honors student and class president, knew there was something wrong with her brain; during the previous 4 years, she had routinely slept only 4 hours a night. . . . She fought suicidal urges and had made several half-hearted suicide attempts. In her second year of medical school, she became convinced that the songs being played on the radio were carrying messages to her. . . . She left for an imagined meeting with friends, following “messages” she heard on the radio. Found wandering a day later, she was picked up by police on the side of a highway. So began Dr. Baxter’s first hospitalization when she was diagnosed as having bipolar disorder. She managed to return and graduate from medical school, hiring a tutor to talk through all of her class notes.
After her residency, Dr. Baxter became increasingly depressed and suicidal; she tried to slash her neck and was hospitalized for a year. Due to the extent of her psychotic symptoms, her diagnosis was changed to schizoaffective disorder. She gradually began to recover, encouraged by a hospital psychiatrist who gave her hope for a full recovery. The psychiatrist was correct in her optimism. Dr. Baxter is now a psychiatrist herself, with a successful private practice. She understands the importance of taking her medications regularly to control her symptoms (Solovitch, 2014).
is diagnosed when someone demonstrates psychotic symptoms that meet the diagnostic criteria for schizophrenia combined with symptoms of a major depressive or manic episode that continue for the majority of the time the schizophrenic symptoms are present. Additionally, according to DSM-5, the psychotic features must continue for at least 2 weeks after symptoms of the manic or depressed episode have subsided. Thus, schizoaffective disorder has features of both schizophrenia and a depressive or bipolar disorder (Brannon, 2013). If a person experiences manic episodes, the clinician specifies that the client has the bipolar subtype of schizoaffective disorder rather than the depressive subtype. Diagnosis is difficult because many people with depressive or bipolar disorders experience hallucinations or delusions during a manic or depressive episode. However, individuals with mood disorders do not have psychotic symptoms in the absence of a major mood episode (APA, 2013).
Schizoaffective disorder is relatively rare, occurring in only 0.32 percent of the population, and is more prevalent in women (Brannon & Bienenfeld, 2012). Younger individuals with this disorder tend to have the bipolar subtype whereas older adults are more likely to have the depressive subtype. As with schizophrenia, the age of onset is later for women than men. In a twin study, schizoaffective disorder and schizophrenia showed substantial familial overlap (Cardno & Owen, 2014). Similar biochemical and brain structure abnormalities have been found in individuals with schizoaffective disorder and schizophrenia (Radonic et al., 2011). Prognosis with schizoaffective disorder, including degree of social disability, is better than that seen with schizophrenia but somewhat worse than prognosis for bipolar or depressive disorders (Brannon, 2013). Treatment includes antipsychotic medication combined with mood stabilizers and individual and group psychotherapies.
Need to be at least 250 words; APA format; see chapter 11 textbook content attachment
Use textbook and 2 other scholarly sources. Assignment will be submitted for plagiarism
Videos:
Kimberly Huber, Ph.D., on Understanding Neurodevelopmental Disorders and Autism:
Counseling Diagnostic Assessment Vignette #33 – Symptoms of Brief Psychotic Disorder:
Living With Schizophrenia:
Include each of the following items in your discussion post. don’t forget to cite and source!
Please put the answer under each one
a. Describe the symptoms, causes, and prognosis for a diagnosis of schizophrenia.
b. Discuss how other psychotic disorders differ from schizophrenia.
c. Comment on the importance of cultural awareness in the diagnosis of schizophrenia.
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