Section B

Lesson 5
Psychological Disorders and Psychotherapy
(iii) Schizophrenia
The disorders now called schizophrenia were at one time attributed to
a type of mental deterioration beginning early in life. In 1860, the
Belgian psychiatrist Benedict Morel used the term “dēmence prē
coce” to refer to mental deterioration that sets in at an early age to
distinguish it from the dementing disorders associated with old age.
The Latin form of this term - “dementia praecox” - was subsequently
adopted in the late 19th century by the German psychiatrist, Emil
Kraepelin, to refer to a group of conditions that all seemed to have the
feature of mental deterioration beginning early in life. Actually, the
term is misleading as there is no compelling evidence of progressive
brain degeneration in the natural course of the disorder.
It was Eugen Bleuler, who in 1911 introduced a more acceptable
descriptive term, “schizophrenia” (split mind) because he thought the
condition was characterized primarily by:
 disorganization of thought processes
 a lack of coherence between thought and emotion
 an inward orientation away (split off) from reality.
The splitting thus does not refer to multiple personalities, an entirely
different form of disorder. Instead in schizophrenia, there is a split
within the intellect, between the intellect and emotion, and between
the intellect and external reality.
Although schizophrenic disorders sometimes first occur during
childhood or old age, about three-fourths of all initial onsets occur
between the ages of 15 and 45, with a median age in the mid-20s.
The prevalence rates overall, appears to be about the same for males

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and females but males tend to have earlier onsets (early to mid-20s
versus late 20s for females) and many investigators believe males
develop more severe forms of this disorder. Interestingly the male-
female difference in age of onset reverses with increasing age range,
and late onset (35 and older) schizophrenia is significantly more
common among women than men.
Schizophrenia, because of its complexity, its high rate of incidence
(especially at the beginning of adult life), and its tendency to recur or
become chronic, is considered the most serious of all mental
disorders, as well as among the most baffling.
Characteristics (Clinical Picture) of Schizophrenia:
Two general symptom patterns or syndromes of schizophrenia have
been differentiated – positive-syndrome and negative syndrome.
Positive signs and symptoms are those in which something has been
added onto a normal repertoire of behaviour and experience, such as
marked emotional turmoil, motor agitation, delusional interpretation
of events, or hallucinations.
Negative signs and symptoms, by contrast, refer to an absence or
deficit of behaviours normally present in a person’s repertoire, such as
emotional expressiveness, communicative speech, or reactivity to
environmental events.
A related differentiation, with more emphasis on biological variables
and speed of onset, refers to essentially these same patterns as Type I
and Type II schizophrenia, respectively. Although most patients
exhibit both positive and negative signs during the course of their
disorders, a preponderance of negative symptoms in the clinical
picture has increasingly been shown to have relatively grave
prognostic significance. It is important to keep in mind that the
positivity /negativity distinction is not dichotomous.

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Whatever the combination or relative proportion of positive and
negative signs in particular instances, schizophrenia encompasses
many specific manifestations that vary greatly over time in an
individual’s life and from one person to another. The basic
experience in schizophrenia, however, seems to be disorganization
in perception, thought, and emotion to the extent that the affected
person is no longer able to perform customary social roles in an
adequate fashion.
Diagnostic Signs Distinguishing the Positive-Negative and Type I-
Type II Sub-syndromes in Schizophrenia:
POSITIVE SYNDROME NEGATIVE SYNDROME
Hallucinations Emotional flattening/flat effect/inappropriate
Delusions emotion
Derailment of associations/disordered Poverty of speech/alogia
thought Asociality
Bizarre behaviour/disordered behaviours Apathy - reactivity to environmental events-
Minimal cognitive impairment Avolition – lack of motivation
Marked emotional turmoil, Significant cognitive impairment
Motor agitation, Insidious onset
Sudden onset Chronic course
Variable course

Type – I
the above plus :
good response to drugs
limbic system abnormalities
normal brain ventricles
Type – II
the above plus :
uncertain response to drugs
frontal lobe abnormalities
enlarged brain ventricles

1. Disturbance of associative linking: Often referred to as formal

thought disorder, associative disturbance is usually considered a
prime indicator of a schizophrenia disorder. Basically, an affected
person fails to make sense, despite seeming to conform to the
semantic and syntactic rules governing verbal communication. The
failure is not attributable to low intelligence poor education or cultural
deprivation. Disturbance of associative linking is also referred to as
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“cognitive slippage”, “derailment” or “loosening” of associations or
“incoherence”. The patient is usually seen to use words in
combinations that sound communicative, but the listener can
understand little or nothing of what point he or she is trying to make.
2. Disturbance of thought content: Disturbances in the content of
thought typically involve certain standard types of delusions or false
beliefs. Prominent among these are:
 beliefs that one’s thoughts, feelings or actions are being
controlled by external agents;
 that one’s private thoughts are being broadcast indiscriminately
to others;
 that thoughts are being inserted into one’s brain by alien forces;
 that some mysterious agent has robbed one of one’s thoughts;
or
 that some neutral environmental event (such as a television
program or a billboard) has an intended personal meaning, often
termed as an “idea of reference”.
3. Disruption of perception: The patient seems unable to sort out
and process the great mass of sensory information to which all of us
are constantly exposed. As a result, stimuli overwhelm the meagre
resources the person has for information processing.
The schizophrenic patient is:
 unable to screen out distractions
 unable to discriminate between relevant and irrelevant stimuli
 highly sensitive to stimuli of all kinds – from both internal and
external sources
 unable to integrate his perceptions into a meaningful pattern
Other even more dramatic perceptual phenomena include
hallucinations – false perceptions, such as voices that only the
schizophrenic person can hear. Hallucinations in the schizophrenias

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are most often auditory, although they can also be visual and even
olfactory. The typical hallucination is one in which a voice (voices)
keeps up a running commentary on the person’s behaviour and
thoughts.
4. Emotional Dysfunction: The schizophrenic syndromes are often
said to include an element of clearly inappropriate emotion, or affect.
In the more severe or chronic cases, the picture is usually one of
apparent anhedonia (inability to experience joy or pleasure) and
emotional shallowness or “blunting” (lack of intensity or clear
definition). The person may appear virtually emotionless, so that even
the most compelling and dramatic events produce at most an
intellectual recognition of what is happening. We must be cautious in
interpreting this sign, however, because evidence suggests that the
deficit is only one of expressiveness, not of feeling per se. In other
instances, particularly in acute phases, the person may show strong
affect, but the emotion clashes with the situation or with the content
of his or her thoughts. For eg., the person may respond to news of a
parent’s death with gleeful hilarity.
5. Confused Sense of Self: Schizophrenic persons may feel confused
about their identity to the point of loss of a subjective sense of self.
Delusional assumption of a new identity, including a unique one such
as Jesus Christ or the Virgin Mary, is not uncommon. In other
instances the person may be perplexed about aspects of his or her own
body, including its gender, or may be uncertain about the boundaries
separating the self from the rest of the world.
6. Disrupted Volition: Goal-directed activity is almost universally
disrupted in schizophrenic individuals. The impairment always occurs
in the areas of routine daily functioning, such as work, social relations
and self-care, such that observers note that the person is not himself or
herself any more. The picture is one of deterioration from a previously
mastered standard of performance in everyday affairs. For e.g., the

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person may no longer maintain minimal standards of personal
hygiene, or may evidence a profound disregard of personal safety and
health.
7. Retreat to an Inner World: Ties to the external world are almost
by definition loosened in the schizophrenic disorders. In extreme
instances, the withdrawal from reality seems deliberate and involves
active disengagement from the environment. This rejection of the
external world may be accompanied by the elaboration of an inner
world in which the person develops illogical and fantastic ideas,
including the creation of strange beings who interact with the person
in various self-directed dramas.
8. Disturbed Motor Behaviour: Various peculiarities of movement
are sometimes observed in the schizophrenias. This is the chief and
defining characteristic of catatonic schizophrenia. These motor
disturbances range from an excited sort of hyperactivity to a marked
decrease in all movement or an apparent clumsiness. Also included
here are various forms of rigid posturing, mutism, ritualistic
mannerisms, and bizarre grimacing.
Types (subtypes) of Schizophrenia:
Recent editions of the DSM have listed five subtypes of
schizophrenias based on the differing clinical pictures long thought to
be variants of a common theme of disorder. They are: the
undifferentiated type, paranoid type, catatonic type; disorganized type
and residual type. The undifferentiated and paranoid types are most
common.
1. Disorganized Type: Usually occurs at an early age than most other
types of schizophrenia and represents a more severe disintegration of
the personality. It is relatively uncommon. It was earlier referred to as
hebephrenic schizophrenia.
Typically, an affected person has

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  a history of oddness;
 over-scrupulousness about trivial things;
 preoccupations with obscure religious and philosophical issues;
 frequently, broods over the dire results of masturbation or minor
infractions of social conventions;
 while schoolmates are enjoying normal play and social
activities, this person gradually becomes more seclusive and
more preoccupied with fantasies.
As the disorder progresses,
 the person becomes emotionally indifferent and infantile;
 a silly smile and inappropriate, shallow laughter after little or no
provocation are common symptoms. If asked the reason for his
or her laughter, the patient may state that he or she does not
know or may volunteer some wholly irrelevant and
unsatisfactory explanation;
 speech becomes incoherent and may include considerable baby
talk, childish giggling, a repetitious use of similar-sounding
words, and a derailing of associated thoughts that may give a
pun like quality to speech;
 the patient may invent new words (neologisms);
 in some cases, speech becomes wholly incomprehensible.
Hallucinations, particularly auditory ones are common. The voices
heard by these patients may accuse them of immoral practices, “pour
filth” into their minds and call them vile names.
Delusions are usually of a sexual, religious, hypochondriacal, or
persecutory nature.
In occasional cases, individuals become hostile and aggressive. They
may exhibit peculiar mannerisms and other bizarre forms of
behaviour. These behaviours may take the form of:
 odd facial grimaces;

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  talking and gesturing to themselves;
 sudden, inexplicable laughter and weeping;
 in some cases, an abnormal interest in urine and faeces, which
they may smear on walls even on themselves;
 obscene behaviour and the absence of any modesty or sense of
shame are characteristic;
 although they may exhibit outbursts of anger and temper
tantrums in connection with fantasies, they are indifferent to
real-life situations, no matter how horrifying or gruesome they
may be.
2. Catatonic Type: The central feature is pronounced motor signs
either of an excited or a stuporous type. Catatonic reactions often
make their appearance with dramatic suddenness, but usually the
patient has shown a background of eccentric behaviour, often
accompanied by some degree of withdrawal from reality.
When under an excited state, patients exhibit excessive and
sometimes violent motor activity. On the other hand, a withdrawn
state, is marked by generalized inhibition manifested by stupor,
mutism, negativism or waxy flexibility. Many catatonics alternate
between periods of extreme withdrawal and extreme excitement, but
in most cases one reaction or the other is predominant.
In the withdrawal reaction, there is a loss of all animation and a
tendency to remain motionless in a rigid, stereotyped position – mute
and staring into space. The same position may be maintained for
hours or even days, and the hands and feet may become blue and
swollen because of the immobility. A patient may feel that he has to
hold his hand out flat because the forces of “good” and “evil” are
waging a “war” on his hand and if he moves it he may tilt the
precarious balance in favour of the forces of evil.
Some of these patients are highly suggestible and will automatically
obey commands or imitate the actions of others (echopraxia) or mimic

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their phrases (echolalia). Ordinarily, patients in a catatonic stupor
stubbornly resist any effort to change their position and may become
mute;
 resist all attempts at feeding;
 refuse to comply with even the slightest request;
 pay no attention to bowel or bladder control and may drool;
 facial expression is typically vacant;
 their skin appears waxy;
 threats and painful stimuli have no effect;
 may have to be dressed and washed by nursing personnel.
Catatonic patients may pass suddenly from states of extreme stupor to
great excitement, during which time they seem to be under great
“pressure of activity” and may become violent;
 may talk or shout excitedly and incoherently;
 pace rapidly back and forth;
 openly indulge in sexual activities like masturbation;
 attempt self mutilation or even suicide;
 or impulsively attack and try to kill others;
The suddenness and extreme frenzy of these attacks make such
patients dangerous to both themselves and others.
Some clinicians interpret a catatonic patient’s immobility as a way of
coping with his or her reduced filtering ability and increased
vulnerability to stimulation. It seems to provide a feeling of some
control over external sources of stimulation, though not necessarily
over inner ones.
3. Paranoid type: Formerly, about one-half of all schizophrenics’
first admissions to hospitals were diagnosed as schizophrenia,
paranoid type. In recent years, however the prevalence of the paranoid
type has shown a substantial decrease. The reasons for these changes
are uncertain but may relate to the promptness with which newly

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diagnosed schizophrenic patients are put on antipsychotic medication
that suppresses “positive” symptoms such as paranoid delusions.
Frequently, paranoid-type-schizophrenic persons show histories of
increasing suspiciousness and of severe difficulties in interpersonal
relationships.
The clinical picture is dominated by absurd, illogical and often
changing delusions;
 persecutory delusions are the most frequent and may involve a
wide range of bizarre ideas and plots;
 an individual may become highly suspicious of relatives or
associates and may complain of being watched, followed,
poisoned, talked about, or influenced by various tormenting
devices rigged up by “enemies”;
 themes of grandeur are also common in paranoid type delusions.
They may claim to be the world’s greatest economist or
philosopher, or some prominent person of the past, or even God;
 delusions are frequently accompanied by vivid auditory, visual
and other hallucinations.
Patients may hear singing, or God speaking, or the voices of their
enemies, or they may see angels or feel damaging rays piercing their
bodies at various points.
An individuals’ thinking behaviour become centred on the themes of
persecution, grandeur, or both in a pathological “paranoid”
construction” that for all its distortion of reality, provides a sense of
identity and importance perhaps not otherwise attainable for the
person. There thus tends to be a higher level of adaptive coping and of
cognitive integrative skills in a paranoid type schizophrenic person
than in other schizophrenic individuals.
The weaving of delusions and hallucinations into a paranoid
construction results in a loss of critical judgements and in erratic,

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unpredictable behaviour. In response to a command from a “voice”,
such a person may commit violent acts. Thus, paranoid schizophrenic
patients can sometimes be dangerous, as when they attack people they
are convinced have been persecuting them. Somewhat paradoxically,
such problems are exacerbated by the fact that such people show less
bizarre behaviour and less extreme withdrawal from the outside world
than individuals with other types of schizophrenia; as a consequence,
they are less likely to be confined in protective environments.
The formal sub typing has not proved very productive clinically as
patients frequently and apparently spontaneously change in subtype
over time.
[*** extra information – not in syllabus

Causes of Schizophrenia:
Genetic Factors Schizophrenia, like several other psychological
disorders, tends to run in families. The closer the family tie between
two individuals, the higher the likelihood that if one develops
schizophrenia, the other will show this disorder too (e.g., Gottesman,
1993). Schizophrenia does not appear to be traceable to a single gene,
however; on the contrary, research findings suggest that many genes
and many environmental factors operate together to produce a
tendency toward this disorder.
Other evidence for the role of genetic factors in schizophrenia is
provided by adoption studies. For instance, in one large-scale study
conducted in Finland (Tiernari, 1991), 144 children born to
schizophrenic mothers and adopted shortly after birth were compared
with adopted children born to non-schizophrenic mothers. Results
indicated that fully 9 percent of those with schizophrenic mothers
showed this mental disorder; in contrast, fewer than I percent of those
born to non-schizophrenic mothers were diagnosed as schizophrenic.

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 Brain Dysfunction- Additional evidence suggests that several types
of brain dysfunctions occur in persons with schizophrenia. For
instance, some findings indicate that some ventricles (fluid-filled
spaces within the brain) are larger in schizophrenics than in other
persons, and this increased size may produce abnormalities in the
cerebral cortex (e.g., Weinberger, 1994). In fact, the decreased brain
volume resulting from enlarged ventricles has been found, in research
using magnetic resonance imaging, to be related to increased
hallucinations and reduced emotion among schizophrenics (e.g., Gur
& Pearlson, 1993; Klausner et al., 1992).
Schizophrenics also show reduced activity in the frontal lobes
relative to other persons during tasks involving memory or abstract
thought Pearlson, 1993). Together, these findings suggest that
schizophrenia is related to cognitive deficits and types of
abnormalities in brain functioning.
A new and especially fascinating theory concerning the causes of
schizophrenia relates the onset of this disorder to a natural "pruning"
of neural circuits in the brain that seems to occur as individuals leave
adolescence and become adults. This removal of unessential circuits
seems to help the brain function more efficiently, it provides
important benefits. According to the prodromal pruning theory,
however, this process goes astray in some persons, whose brains
"prune" too aggressively. The result is that crucial neural links are
eliminated. thus making such persons susceptible to the disordered
thought processes and behaviors that are key symptoms of
schizophrenia.
(The term prodromal refers to the earliest stage of schizophrenia, a
time when major symptoms are not present or are only beginning to
appear.) This theory is very new, but some findings offer support for
it, so it is certain to receive increased attention from researchers in the
years ahead.

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Biochemical Factors Several findings point to the possibility that
disturbances in the functioning of certain neurotransmitters may, play
a role in schizophrenia. For instance, consider these facts:
(1) Drugs that increase dopamine activity in the brain tend to
intensify schizophrenic symptoms
(2) Drugs that block the action of dopamine in the brain are effective
in reducing many symptoms of schizophrenia, especially positive
symptoms
Together, these and other findings point to the possibility that
excessive activity in the dopamine system may lead to positive
symptoms of schizophrenia and that deficits in dopamine activity may
lead to negative symptoms. Although this suggestion is intriguing,
additional findings are not entirely consistent with it; for instance,
direct comparisons of dopamine levels in schizophrenic patients and
other persons do not always reveal the expected differences. As a
result, it seems clear that dopamine is not the crucial biochemical
factor in schizophrenia. Rather, growing evidence suggests that many
neurotransmitters, and perhaps other chemicals in the brain as well
(e.g., glutamate), play roles in its occurrence. This is why the newest
drugs used in the treatment of schizophrenia target not one
neurotransmitter or chemical, but many.
Psychological Factors -The fact that schizophrenia seems to run in
families raises the possibility that some families create social
environments that place their children at risk for this disorder.
Research on relapses among schizophrenic patients—recurrences of
the disorder after periods of relative normality provides clues to what
are such environments like.It appears that patients are more likely to
suffer relapses when their families adopt certain patterns of
expressing emotion. Specifically, patients are more likely to suffer
relapses when their families engage in harsh criticism ("You are
nothing but trouble!"), express hostility toward them ("I'm sick and

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tired of taking care Of you!"), and show too much concern with their
problems ("I'm trying so hard to help you!"). The relapse rate in
families showing this pattern over the course of a year is fully 48
percent, while in families that do not show this pattern it is only about
20 percent (Kavanagh, 1992)
Harsh criticism induces emotional turmoil in those who receive it—
and this, in turn may serve as one source of stress that pushes
vulnerable persons closer to the brink of this serious mental disorder.
Hence such a family environment may also play a role in the onset of
schizophrenia.

Treatment:
1. Antipsychotic drugs
2. Family therapy
3. Individual therapy/personal therapy - post discharge from
hospital, focusing on the learning of coping skills to manage one’s
emotions and stressors.
4. Patients need to be provided social skills training to enable them
to survive in society. Continuous follow up and monitoring
required to ensure the success of the treatment approach. ***]

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