PSYC A232

Introduction to Abnormal Psychology

Study Guide
Unit 3

236
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236
Contents

Unit 3 Schizophrenia spectrum and other psychotic disorders

Introduction...................................................................................................................... 1
Unit 3 outline ................................................................................................................... 2
Schizophrenia spectrum and other psychotic disorders ................................................. 3
Symptoms, diagnosis and course ............................................................................ 3
Activity 3.1 ................................................................................................................ 8
Biological theories .................................................................................................... 9
Activity 3.2 .............................................................................................................. 11
Psychosocial perspectives ..................................................................................... 11
Reading 3.1 (E-Library) .......................................................................................... 13
Activity 3.3 .............................................................................................................. 13
Treatment ............................................................................................................... 14
Activity 3.4 .............................................................................................................. 17
Reading 3.2 (E-Library) .......................................................................................... 17
Self-test 3.1 ............................................................................................................ 18
Summary ...................................................................................................................... 18
References .................................................................................................................... 19
Feedback on activities and the self-test ........................................................................ 20
 Unit 3 1

Unit 3
Schizophrenia spectrum and
other psychotic disorders

Introduction
Schizophrenia spectrum and other psychotic disorders are a group of mental illnesses that can
have a profound impact on a person's life. These disorders are characterised by a range of
symptoms that can include hallucinations, delusions, disorganised thinking, and unusual
behaviours. For individuals who suffer from these disorders, everyday life can be a challenge
as they struggle to differentiate between reality and their own perceptions. The onset of these
disorders tends to occur in adolescence or early adulthood and can be chronic or episodic in
nature. The complexity of these disorders and their impact on individuals and society make
them an important area of study for researchers and mental health professionals alike.
In this unit, we will explore the causes, symptoms, diagnosis, and treatment options for
schizophrenia spectrum and other psychotic disorders, and the impact they have on
individuals and their loved ones.
In short, this unit:
• describes the symptoms, diagnosis and course of schizophrenia;
• explains schizophrenia spectrum and other psychotic disorders from biological and
psychosocial perspectives; and
• discusses the biological, psychological and social treatment of schizophrenia spectrum
and other psychotic disorders.
All the learning tasks are clearly outlined in this Study Guide, and it is highly recommended
you follow this guide in your study. In this unit, you will need to cover the following
materials:
• Unit 3 of the custom textbook, entitled ‘Schizophrenia spectrum and other psychotic
disorders’
• Two assigned readings.
2 PSYC A232 Introduction to Abnormal Psychology

Unit 3 outline
The following provides you with an outline for working through Unit 3. The page numbers
refer to the page numbers of your custom textbook. The activities and self-test are shown in
italics. The assigned readings are available in the University’s E-Library. Remember to refer
also to the Online Learning Environment (OLE) as you work through the unit.

Schizophrenia spectrum and other psychotic disorders along the continuum [p. 195]
Symptoms, diagnosis and course [p. 197]
Positive symptoms
Negative symptoms
Cognitive deficits
Diagnosis
Course
Prognosis
Activity 3.1
Other psychotic disorders
Biological theories [p. 213]
Genetic contributors to schizophrenia
Structural and functional brain abnormalities
Neurotransmitters
Activity 3.2
Psychosocial perspectives [p. 221]
Social drift, trauma, and urban living
Stress and relapse
Schizophrenia and the family
Cognitive perspectives
Cross-cultural perspectives
Reading 3.1 (E-Library)
Activity 3.3
Treatment [p. 225]
Biological treatments
Psychological and social treatments
Activity 3.4
Reading 3.2 (E-Library)
 Unit 3 3

Self-test 3.1
Summary

Schizophrenia spectrum and other

psychotic disorders
Have you ever seen the film called A Beautiful Mind? It is based on the life of mathematician
John Nash and his battle with schizophrenia. Schizophrenia is a severe mental disorder that is
often associated with considerable impairments in functioning. While schizophrenia affects
one in 300 people (0.32%) globally (World Health Organization, 2022; Saha et al., 2005), it is
frequently depicted in films and media. This might be because schizophrenia sufferers’
inability to recognise the difference between what is real and what is not is compelling and
disorienting for others to imagine. Because of this disease’s powerful symptoms,
schizophrenia is frequently associated with significant distress and impairment in almost all
important areas of life.
Schizophrenia is classified as a psychotic disorder — a group of mental illnesses
characterised by a loss of contact with reality, including symptoms such as delusions and
hallucinations. While schizophrenia is the most common of the psychotic disorders, there are
various other types of psychotic disorders, as we will discuss in this unit.

Symptoms, diagnosis and course

Please begin by turning to the following topics in your textbook to learn about schizophrenia
spectrum disorder in detail.

Textbook topics
Schizophrenia spectrum and other psychotic disorders along the continuum [p. 195]
Symptoms, diagnosis and course [p. 197]
Positive symptoms
Negative symptoms
Cognitive deficits
Diagnosis
Course
Prognosis
Other psychotic disorders

Schizophrenia is a complex neuropsychiatric disorder. Its core diagnostic symptom is

psychosis — a mental state affecting perception, cognition, and emotion during acute
episodes. Schizophrenia is referred to as a ‘spectrum’ due to the fact that the symptoms cover
five domains which can vary in number, severity, and duration. Individuals with
schizophrenia might display all or just some of the psychotic symptoms, meaning that
different cases can appear quite different from one another. Although they may experience
symptoms under these five domains, individuals with schizophrenia can at times act and
4 PSYC A232 Introduction to Abnormal Psychology

function like healthy people. Their disorganised thinking and speech, loss of touch with
reality and ability to look after themselves are present during the active phase of the illness.
Table 3.1 Five domains of symptoms that constitute schizophrenia spectrum disorders

Category Domain of symptoms

Positive 1. Delusions
symptoms
2. Hallucinations
3. Disorganised thought and speech
4. Disorganised or abnormal motor behaviour (including catatonia)
Negative 5. Restricted affect and avolition/asociality
symptoms

It is important to note that the terms positive and negative do not refer to the semantic
meanings of good/beneficial or bad/detrimental here. Instead, they can be viewed in
mathematical terms of addition (+) or subtraction (–). Positive symptoms are symptoms that
have been added — overt, atypical and disruptive symptoms, while negative symptoms are
symptoms that involve the loss of certain qualities in the person.

Positive symptoms
Let’s recap the four positive symptoms described in the textbook.
Delusions
Delusions are defined as false, unshakeable beliefs that are held with strong conviction
despite contradictory evidence (textbook, p. 241) — i.e. firm beliefs that do not align with
reality. The term comes from the Latin verb ludere, which means ‘to play’; in essence, tricks
are played on the mind. There are certain common themes among schizophrenic delusions:
persecutory, referential, somatic, religious, grandiose and more. 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 (thought broadcasting),
that thoughts are being inserted into one’s brain by some external agent (thought insertion),
and that some external agent has robbed one of one’s thoughts (thought withdrawal) (see
Table 1 on page 198 of the textbook for more). Also common are delusions of reference,
where some neutral environmental event (such as a television programme or a song on the
radio) is believed to have special and personal meaning intended only for the person. Other
strange propositions, including delusions of bodily changes (e.g. believing one’s bowels do
not work) or removal of organs, may also arise.
Paranoid delusions (also called persecutory delusions) can cause the sufferer to feel
threatened, persecuted, or mistrustful of others, leading to social isolation and difficulty in
forming relationships. On the other hand, grandiose delusions can make a person feel special
or superior to others, leading to arrogant behaviour or unrealistic expectations. In both cases,
delusions can make it difficult for the person to think logically, make sound decisions, and
communicate effectively with others.
Hallucinations
Hallucinations are defined as false or inaccurate perceptions that affect the senses and cause
people to hear, see, taste, touch or smell what others do not (textbook, p. 244). The term
comes from the Latin verb alucinari meaning to ‘wander in mind’. Hallucinations can occur
in all five senses — i.e. auditory, visual, olfactory, tactile, and gustatory hallucinations.
 Unit 3 5

• Auditory verbal hallucinations (AVHs) are the most common type of hallucination; they
are found in 70%–80% of patients with schizophrenia. A person experiencing them
hears voices, which can often be critical, insulting, or commanding, and which can lead
to the sufferer feeling frightened, confused, or overwhelmed. In imaging studies,
patients with AVHs show increased activity in Broca’s area, an area of the temporal lobe
involved in speech production. This suggests that auditory hallucinations occur when
patients misinterpret their own self-generated and verbally mediated thoughts (inner
speech or self-talk) as coming from another source.
• Visual hallucinations are the second most common type with a prevalence at 24%–72%.
These hallucinations involve seeing things that are not there. This can be highly
disturbing and can make it difficult for the person to function effectively in daily life.
Visual hallucinations are often accompanied by auditory hallucinations.
Hallucination experiences are often unpleasant and frightening. It is important to remember
that hallucinations do not occur only in schizophrenia and other psychotic disorders, but also
in depression or bipolar disorders.
Disorganised thought and speech
This domain of symptoms refers to how an affected person fails to make sense when
communicating with others, despite seeming to conform to the grammatical rules of
language. Additionally, disorganisation of speech may be displayed as the tendency to slip
from one topic to a totally unrelated one with little coherent transition. This is sometimes
called cognitive slippage, derailment, loosening of associations, or incoherence. In some
cases, completely new, made-up words (neologisms) appear in the patient’s speech.
Formal thought disorder is a term clinicians use to refer to these types of problems. These
symptoms can make it difficult for the person to communicate effectively with others, leading
to frustration and isolation.
Disorganised or catatonic behaviour
Individuals with schizophrenia may display unpredictable and untriggered agitation such as
shouting, swearing or pacing rapidly, although these behaviours may occur in response to
hallucination or delusions. Not surprisingly, these disorganised behaviours can frighten
others.
Furthermore, a schizophrenia sufferer might have impaired abilities to organise routine
aspects of daily functioning, such as work, social relations, self-care, and personal hygiene.
In other cases, grossly disorganised behaviour appears as silliness or unusual dress. These
disruptions of ‘executive’ behaviour may stem from impairment in the functioning of the
prefrontal region of the cerebral cortex involved in attention and memory.
Catatonia is an even more striking behavioural disturbance. The patient with catatonia may
show a virtual absence of all movement and speech in what is called a catatonic stupor.
As you would expect, disorganised behaviour makes it difficult for the person to maintain
relationships or hold down a job, as they struggle to follow social norms or meet expectations
in a work environment. Disorganised behaviour can also make it difficult for the person to
take care of themselves, leading to problems with cleanliness, nutrition, or medication
management.
6 PSYC A232 Introduction to Abnormal Psychology

Negative symptoms
As we saw earlier, negative symptoms reflect an absence or deficit of behaviours that are
normally present. They can be divided into two subcategories: restricted affect and avolition/
asociality.
• Restricted affect is a severe reduction in or absence of emotional expression in any
individual with schizophrenia (textbook, p. 202). They may show fewer facial
expressions, avoid eye contact, use fewer gestures to communicate with others and have
a flat tone of voice. Studies have found that schizophrenic people are likely to have
diminished ability to experience pleasure or anhedonia. Anhedonia is the loss of the
ability to experience pleasure.
• Avolition is the inability to initiate or persist in goal-directed activity. Individuals with
avolition may do very little in the day, which affects their personal hygiene and
grooming. Furthermore, they also lack the desire to interact with others, called
asociality, resulting in social isolation.

Cognitive deficits
Basic cognitive processes such as attention, memory and processing speed may be deficient
in individuals with schizophrenia. They may find it difficult to pay attention to relevant
information and suppress irrelevant information, and therefore struggle to distinguish which
thoughts in their mind are relevant to the situation and environment and what they can ignore.
Taken together, cognitive deficits can be considered as an early marker of risk for
schizophrenia as they may contribute to the development of the other positive and negative
symptoms we covered above.

Diagnosis
According to the DSM-5-TR, an individual can be diagnosed with schizophrenia when they
show two or more symptoms of psychosis, at least one of which should be delusions,
hallucinations, or disorganised speech. (The full DSM-5-TR diagnostic criteria can be found
in Table 2 on page 204 of the textbook.) These symptoms must be present for at least one
month consistently and acutely in the acute phase of the disease, or for at least six months in
a way that impairs social or occupational functioning.

Course
In Hong Kong, the prevalence of schizophrenia is around 1.25% (Chang et al., 2017). The
typical onset for the psychotic features of schizophrenia starts in the late teens through
mid-30s, peaking at around 40 years. When psychotic symptoms develop rapidly, it is called
acute onset. However, the disorder is characterised by different phases. Symptoms occurring
in the period before the acute phase are prodromal symptoms, and those in the period after are
called residual symptoms. The following table provides a summary.
 Unit 3 7

Table 3.2 Characteristics of the different phases of schizophrenia

Prodromal phase Acute phase Residual symptoms OR

• Very mild positive
symptoms: May include
subtle hallucinations,
delusions, or
disorganised thoughts
that are not as severe as
in the acute phase.
• Mild negative symptoms:
Social withdrawal,
reduced emotional
expression, and apathy
may begin to emerge.
• Generalised functional
decline: Individuals may
start to struggle with
daily activities, work,
school, and relationships.
• Subclinical symptoms:
Below the threshold for
clinical diagnosis but still
noticeable to the
individual or those
around them.
• Gradual progression:
The phase may last
several years, with
symptoms increasing and
functioning declining
gradually.
• Significant social
consequences:
Difficulties in social and
occupational functioning
arise, causing strain on
relationships and daily
life.
• Severe positive
symptoms:
Hallucinations,
delusions, and
disorganised thoughts
become more
pronounced and
disruptive.
• Increased negative
symptoms: Social
withdrawal, reduced
emotional expression,
apathy, and avolition
may intensify.
• Disorganised speech
and behaviour:
Individuals may exhibit
rambling, incoherent
speech and erratic,
purposeless behaviour.
• Impaired daily
functioning: Work,
school, and social life
are often significantly
impacted, as the
individual’s ability to
cope with daily tasks
deteriorates.
• Need for medical
intervention: The acute
phase typically
necessitates medical
intervention, including
antipsychotic
medication and possible
hospitalisation, to
manage and stabilise the
individual’s condition.
remission
• Diminished psychotic
symptoms:
Hallucinations,
delusions, and
disorganised thoughts
may no longer interfere
with daily functioning.
• Ongoing cognitive
impairments:
Individuals may still
experience disorganised
thinking and other
cognitive difficulties.
• Prolonged disability:
The cognitive
impairments that persist
can contribute to a
prolonged disability,
affecting various aspects
of life.
• Reduced impact on daily
function: The disorder is
considered to be in
remission when
symptoms no longer
significantly interfere
with daily activities,
work, and social life.
• Continued need for
support: Individuals in
remission may still
require ongoing support
from mental health
professionals,
medication, and other
services to maintain
stability and prevent
relapse.

The course of schizophrenia is relatively chronic with cognitive and functional impairment. It
is considered to be in remission if the symptoms no longer interfere with daily function,
although individuals might still experience disorganised thinking and cognitive impairments.
Psychotic symptoms tend to diminish as individuals age.

Prognosis
The life expectancy of individuals with schizophrenia is 10–20 years shorter than normal
individuals and they suffer from infectious and circulatory diseases at a higher rate than their
8 PSYC A232 Introduction to Abnormal Psychology

counterparts. This higher risk is due to various factors, including unhealthy lifestyle habits,
medication side effects, reduced healthcare access, immune system dysfunction, cognitive
impairments, and co-occurring conditions. These factors hinder their ability to maintain good
health and access appropriate care, leading to increased susceptibility to conditions like heart
disease, stroke, and respiratory infections.
Research has shown that gender and age factors and cultural influences play a role in the
prognosis. Although prevalence of schizophrenia is similar among men and women, here are
notable differences in the display of symptoms. Men have a higher chance of presenting an
earlier onset age, negative symptoms, lower social functioning and comorbid substance abuse
than women; meanwhile women display relatively late onset with more affective symptoms.
Women tend to have a better prognosis than men.
Culture influences the epidemiology, phenomenology, outcome and treatment of
schizophrenia. Types of delusions differ across cultures with themes relating to the
corresponding social background and cultural beliefs. Examples of culture-bound syndromes
include:
• Running amok found in Malaysia and Indonesia, in which an individual experiences an
episode of sudden and uncontrolled violent behaviour. This can be considered a
delusional episode in the context of schizophrenia (Saint Martin, 1999).
• Windigo psychosis found in indigenous communities in Canada and the United States, in
which an individual experiences a fear of becoming a cannibalistic monster or being
possessed by one. This can be considered a persecutory delusion in the context of
schizophrenia (Volkan, 2021).
Before moving on to the next part of the unit, please work through the following activity
questions to explore the influence of culture in the presentation of schizophrenia. Feedback
on this and all activities and self-tests in this unit is available at the end of this Study Guide
and in the interactive ePub version on the OLE.

Activity 3.1
1. What is a delusion? What types of delusions are most common in schizophrenia?
2. What is the connection between the culture and the delusions of a schizophrenic person?
3. Why might culture influence the presentation of delusions?
4. How might cultural factors influence the presentation of a schizophrenic Hong Kong
person’s delusions?

Other psychotic disorders

Other types of psychotic disorders discussed in the textbook are schizoaffective disorder,
schizophreniform disorder, delusional disorder, and brief psychotic disorder. In short:
• Schizoaffective disorder consists of a mix of schizophrenia and mood disorder
symptoms.
• In schizophreniform disorder, the clinical picture is like that of schizophrenia apart from
the fact that the symptoms have not lasted long enough (6 months) to qualify for a
diagnosis of schizophrenia.
 Unit 3 9

• In delusional disorder, delusions are present but the person may otherwise behave quite
normally. In other words, there is no sign of the gross disorganisation and performance
deficiencies that are associated with schizophrenia.
• Finally, brief psychotic disorder is very short-lived. It involves the sudden onset of
psychotic symptoms, disorganised speech, or catatonic behaviour. Although the person
may be quite impaired, the duration of this impairment is very brief (and too short to
allow for a diagnosis of schizophreniform disorder). The person typically returns to his
or her former level of functioning within a few days.

Biological theories
We will now turn our attention to the biological underpinnings of this complex disorder.
While the exact causes of schizophrenia are still not fully understood, numerous studies have
suggested a role for genetic factors, as well as structural and functional brain abnormalities,
and abnormalities in certain neurotransmitters. These biological theories provide a valuable
framework for understanding the mechanisms underlying schizophrenia, and may ultimately
pave the way for new and more effective treatments. In the following sections, we will
explore each of these theories in more detail.

Textbook topics
Biological theories [p. 213]
Genetic contributors to schizophrenia
Structural and functional brain abnormalities
Neurotransmitters

Genetic contributors to schizophrenia

It has long been known that disorders of the schizophrenia type tend to run in families. The
occurrence of schizophrenia among the immediate family members (i.e. parents, siblings, and
offspring) of an individual diagnosed with schizophrenia is estimated to be approximately
10%. For second-degree relatives who share only 25% of their genes with the individual, the
lifetime prevalence is closer to 3%. But of course, just because something runs in families
does not automatically mean that genetic factors are involved.
Schizophrenia concordance rates for identical twins are routinely and consistently found to be
significantly higher than those for fraternal twins or ordinary siblings. Torrey et al. (1994)
discovered that the rate of agreement between pairs of identical or monozygotic (MZ) twins
regarding schizophrenia is about 28%, while the rate for non-identical or fraternal (DZ) twins
is approximately 6%. This suggests that genes play a role but are not sufficient to fully
explain schizophrenia. Studies of discordant MZ twin pairs reveal that children of the ‘well’
twin are at significantly higher risk of developing schizophrenia.
Twin studies assume that any differences between identical and non-identical twins are due to
genes. Some studies use adoption to try to separate the effects of genes and environment on
schizophrenia. Researchers have compared the rates of schizophrenia among biological and
adoptive relatives of people with schizophrenia who were adopted as children and found that
adopted children of biological parents with schizophrenia have a higher risk of developing
the disorder.
10 PSYC A232 Introduction to Abnormal Psychology

Structural and functional brain abnormalities

Cognitive impairment is regarded as a core feature of schizophrenia. Indeed, almost all
aspects of cognition are impaired. In brain research, one of the most well-replicated findings
concerns reductions in grey matter volume (which leads to cognitive impairment, mood and
neurological disorders, physical impairment, etc.) as well as structural abnormalities in the
grey matter itself including in the medial, temporal, superior temporal and prefrontal areas.
However, possibly more important is the idea that there may be a problem with the way
activity in different brain regions is coordinated. Major brain changes take place during
adolescence as the brain matures. If problems occur, such as a head injury, during this critical
phase of development, schizophrenia may result. According to AbdelMalik et al. (2003),
individuals with schizophrenia were found to be more likely to have a history of head injury
in their childhood than their unaffected siblings. In addition, among the affected group,
individuals who had had a childhood head injury had an earlier onset of psychosis than those
without a history of head injury.

Neurotransmitters
Abnormal activity of the neurotransmitter dopamine is linked to schizophrenia, with studies
dating back to the 1960s. The drug chlorpromazine (Thorazine), which blocks dopamine
receptors, was found to help patients. Furthermore, amphetamine abuse leads to a psychosis
similar to schizophrenia, caused by a functional excess of dopamine. Dysregulated dopamine
transmission can cause an increase in attention to and significance of stimuli, known as
aberrant salience. An excess of dopamine in the brain can be caused by increased synthesis
and release, slowed metabolism, or blocked reuptake of this neurotransmitter. Prolific or
sensitive receptors can also mimic excess dopamine.
The diathesis-stress model suggests that individuals with a genetic predisposition to
schizophrenia may experience symptoms when faced with stressful events that increase
dopamine levels, such as drug use or environmental stressors. For example, a person with a
genetic predisposition may experience auditory hallucinations when exposed to stressful
stimuli that increase dopamine levels. Another example may be a person who experiences
delusions or paranoia after prolonged drug use, which in turn increase dopamine levels.
 Unit 3 11

Activity 3.2
1. Referring to the textbook discussion on pages 219–220, try to determine whether the
following statements are correct or incorrect.

Statement Correct Incorrect

a. The original dopamine theory of schizophrenia suggests ☐ ☐
that increased levels of dopamine in the brain contribute to all
symptoms of schizophrenia, globally.
b. Phenothiazines, medications used to reduce the symptoms ☐ ☐
of schizophrenia, block dopamine reuptake in the brain.
c. Atypical antipsychotics work to reduce the symptoms of ☐ ☐
schizophrenia by binding to a specific type of dopamine
receptor common in the prefrontal cortex.
d. Low dopamine activity in the prefrontal area of the brain ☐ ☐
may explain the negative symptoms of schizophrenia.
e. Serotonin and glutamate are not thought to be involved in ☐ ☐
schizophrenia.

2. According to the diathesis-stress model, what is the role of the HPA axis in
schizophrenia, and how does it relate to dopamine production?

Psychosocial perspectives
While biological theories offer important insights into the development and manifestation of
schizophrenia, psychosocial perspectives are equally important in understanding the disorder.
Research has suggested that social factors, such as living in urban areas, experiencing trauma,
and social drift, may contribute to the onset of schizophrenia. Stressful life events have also
been associated with an increased risk of relapse in individuals with schizophrenia.
Furthermore, the role of family dynamics and cognitive processes in the development and
maintenance of schizophrenia have been extensively studied. Finally, cross-cultural
perspectives provide valuable insights into the ways in which cultural factors influence the
manifestation and treatment of schizophrenia. In this section, we will explore each of these
psychosocial perspectives, and explore their implications for the diagnosis, treatment, and
management of schizophrenia. Please turn to the following sections in your custom textbook.
12 PSYC A232 Introduction to Abnormal Psychology

Textbook topics
Psychosocial perspectives [p. 221]
Social drift, trauma, and urban living
Stress and relapse
Schizophrenia and the family1
Cognitive perspectives
Cross-cultural perspectives

Social drift, trauma, and urban living

People with schizophrenia are more likely to live in poor neighbourhoods, be unemployed, or
find themselves in other chronically stressful circumstances. This correlation may be
explained by social drift theory, which suggests that cumulative exposure to environmental
risk factors in deprived and urban areas over time increases the risk of psychological
disorders, particularly for individuals with genetic predispositions. Childhood trauma, urban
living, and exposure to environmental factors like cannabis use are also potential risk factors
for developing schizophrenia. The link between urban living and psychosis is not limited to
stressful conditions but also overcrowding, which increases the risk of exposure to infectious
agents. Studies suggest that cumulative exposure to environmental risk factors predicts the
onset and persistence of psychotic symptoms.

Stress and relapse

Stressful circumstances alone may not cause schizophrenia, but they may trigger new
episodes in people with the disorder. Higher levels of stress shortly before the onset of a new
episode have been identified by researchers. Such stressful events may be especially
important among adults who experienced adverse events in childhood. Immigration is a
major stressor linked to an increased risk for episodes in schizophrenia and other psychotic
disorders.
On the other hand, recent research suggests that exposure to pet dogs during infancy and
early childhood may be associated with a significantly decreased risk of developing
schizophrenia. Exposure to a pet may alter immune activation and lower the risk of immune
disorders and stress response, as well as altering gut flora. In the latter case, the changes in
the gut-brain axis may in turn modify the risk of schizophrenia.

Schizophrenia and the family

In the past, psychodynamic theories blamed schizophrenia on overprotective and rejecting
mothers, but these theories were not proven by science. However, research shows that
families high in expressed emotion can negatively influence clinical conditions. Expressed
emotion is a measurement of family environment that takes into account how a family
member talks about their loved one with schizophrenia during a private interview with a
researcher. It assesses three main elements:

1. Please note that there is an editorial error on page 224 of the textbook. In the first column of the page, a paragraph beginning with
the sentence ‘The link between high levels of family expressed emotion …’ is repeated. You can skip the subsequent paragraph
beginning with the same sentence and continue reading at ‘High levels of emotional expression …’ (2nd column of the page).
 Unit 3 13

• Criticism: negative comments and attitudes towards the patient

• Hostility: angry or resentful feelings
• Emotional overinvolvement (EOI): an excessive amount of attention or involvement in
the patient’s life.
Multiple studies worldwide have demonstrated that expressed emotion predicts relapse in
individuals with schizophrenia, regardless of cultural differences in emotional expression. It
is therefore a critical factor in a psychosocial understanding of schizophrenia. High levels of
expressed emotion are associated with more relapses, whereas low levels are linked with
better outcomes. This highlights the importance of family support in the management of
schizophrenia, and the potential benefits of interventions to reduce expressed emotion.
Family interventions to reduce expressed emotion tend to reduce the relapse rate in family
members with schizophrenia.
You have just covered the psychosocial perspectives of schizophrenia; be sure that you
have also read the sections on cognitive and cross-cultural perspectives in your textbook
(pp. 224–225). Next, please read the following review article. It aims to systematically
investigate a territory-wide dataset in Hong Kong using a longitudinal approach for the risk
of self-harm among seven types of psychiatric disorders: depression, alcohol misuse or
dependence, personality disorders, bipolar disorders, anxiety disorders, schizophrenia, and
substance misuse or dependence.

Reading 3.1 (E-Library)

Chai, Y., Luo, H., Wong, G. H. Y., Tang, J. Y. M., Lam, T. C., Wong, I. C. K., & Yip,
P. S. F. (2020). Risk of self-harm after the diagnosis of psychiatric disorders in Hong
Kong, 2000–10: A nested case-control study. The Lancet Psychiatry, 7(2), 135–147.
This article is available in the University’s E-Library → E-Reserve.

The article discusses the prevalence of suicide among individuals with schizophrenia and the
need for effective interventions to reduce suicide risk in this population. The authors note that
while the effectiveness of related treatments and interventions should be considered in future
research, information on interventions and treatments given to patients in their dataset was
unavailable. However, they cite a study conducted in Hong Kong that found adolescents with
schizophrenia who received early intervention had a significantly lower risk of suicide
compared to those who received standard general psychiatric care. Overall, the article
highlights the importance of addressing suicide risk among individuals with schizophrenia
and the need for further research on effective prevention strategies.

Activity 3.3
1. Esther lives with her parents. She frequently has relapses into schizophrenia. What is the
relationship between the concept of expressed emotion and relapse of schizophrenia
symptoms? Given that Esther has frequent relapses, what behaviours might a therapist
expect her parents to typically demonstrate? Please illustrate in your own words.
2. In what ways might culture impact expressed emotion?
3. Can you think of some possible limitations of using expressed emotion as a measure of
family interaction in schizophrenia?
14 PSYC A232 Introduction to Abnormal Psychology

Treatment
Treatments for schizophrenia involve pharmacological approaches to reduce psychotic
symptoms and prevent relapse, and psychological and social treatments to help individuals
cope with the consequences of the disorder and assist them in integrating into the community.
Please now read the following topics to find out more.

Textbook topics
Treatment [p. 225]
Biological treatments
Psychological and social treatments

Biological treatments
Your textbook discusses two classes of antipsychotic drugs used in the treatment of
schizophrenia and other psychotic disorders: first-generation antipsychotics (typical) and
second-generation antipsychotics (atypical). First-generation antipsychotics, introduced in
the 1950s, primarily target dopamine receptors and are more effective in treating positive
symptoms. Second-generation antipsychotics, which emerged later, act on multiple
neurotransmitters and are more effective in addressing both positive and negative symptoms.
While second-generation antipsychotics are generally considered safer and more effective,
both classes have side effects, and ongoing research seeks to determine the best treatment
options for individual patients.
 Unit 3 15

Table 3.3 A comparison of first- and second-generation antipsychotics

Category First-generation antipsychotics Second-generation antipsychotics

(typical)
Drug Chlorpromazine (Thorazine),
names Trifluoperazine (Stelazine),
(brand Thioridazine (Mellaril),
names in Fluphenazine (Prolixin),
brackets) Perphenazine (Trilafon)
How they Primarily block dopamine receptors,
work / reducing dopamine action in the
Features brain
Common Grogginess, dry mouth, blurred
side vision, drooling, sexual dysfunction,
effects weight changes, constipation,
menstrual irregularities, depression,
inability to move, Parkinson’s-like
symptoms, tardive dyskinesia
Remarks More effective in treating positive
symptoms; significant side effects;
maintenance doses often do not
restore full functioning
(atypical)
Clozapine (Clozaril),
Risperidone (Risperdal),
Olanzapine (Zyprexa),
Quetiapine (Seroquel),
Ziprasidone (Geodon, Zeldox)
Act on multiple neurotransmitters
including dopamine and serotonin;
more effective in treating both
positive and negative symptoms
Dizziness, nausea, sedation, seizures,
drooling, weight gain, increased heart
rate, low white blood cell count,
sexual dysfunction, low blood
pressure, gastrointestinal problems,
vision problems, problems with
concentration
Safer and more effective for many
patients; still have side effects; best
treatment options still being
researched; lower mortality rates in
patients with schizophrenia

Psychological and social treatments

While drugs can help control the positive symptoms of schizophrenia, many individuals still
experience negative symptoms such as apathy and social problems. Psychological
interventions can help individuals increase social skills and reduce isolation and stress, which
can reduce the risk of relapse. When antipsychotic drugs fail to be effective, this is due in part
to people discontinuing the drugs due to side effects or not feeling they need them. So
psychological interventions can also help people understand their disorder and the need to
remain on medication, and cope with side effects. Many individuals with schizophrenia
struggle with basic needs such as housing and medical care, and mental health professionals
can support them in addressing these needs.
Behavioural, cognitive, and social treatments
Experts recommend a comprehensive approach to treating schizophrenia that addresses the
behavioural, cognitive, and social deficits of each individual. Cognitive impairments in
particular are a critical target for treatment.
• Cognitive treatments aim to help individuals change attitudes towards their illness and
participate in society.
• Behavioural treatments use operant conditioning and modelling to teach social skills.
• Social interventions involve increasing contact with supportive others through self-help
support groups.
16 PSYC A232 Introduction to Abnormal Psychology

While these treatments can improve functioning, the effects can be small in the long term,
and current research aims to improve and tailor them to individuals and their symptoms.
Family therapy
Family-oriented therapies can be effective in reducing the risk and frequency of relapse for
people with schizophrenia. These therapies combine basic education on schizophrenia with
training for family members in coping with their loved one’s difficult behaviours and the
impact of the disorder on family life. Family members learn communication and problem-
solving skills to reduce conflict and stress, as well as specific behavioural techniques for
encouraging appropriate behaviour. Psychoeducation is an effective tool that can decrease
relapse rates by 50 to 60 per cent. Multifamily psychoeducational therapy may be especially
effective in increasing mutual support among a group of families and reducing feelings of
isolation and stigma. Family-based therapies can also increase patients’ adherence to taking
antipsychotic medication and improve social functioning and quality of life. Culturally
sensitive interventions are critical, and therapists must take into account the culture of their
clients in designing interventions.
Assertive Community Treatment
People with schizophrenia require significant support and care for their diverse needs, and
Assertive Community Treatment (ACT) is an evidence-based approach that provides
comprehensive services 24/7 to meet those needs. ACT programmes rely on medical
professionals, social workers, and psychologists to provide intensive treatment, support, and
rehabilitation, and have been shown to improve functioning in those with schizophrenia and
reduce hospitalisation risk. Other outpatient care models similar to ACT have also shown
generally similar positive effects.
A community programme named EASY was launched in Hong Kong in 2001 (Tang et al.,
2010). The programme aims to promote knowledge about psychosis and encourage timely
help-seeking behaviours among affected individuals. The programme also collaborates with
other networks and organisations to enhance rehabilitation services. This programme has
shown significant effect in reducing hospital stays and improving occupational functioning,
highlighting the importance of early intervention.
Stigma
Despite growing public awareness about mental health issues, people with serious mental
disorders like schizophrenia still face substantial stigma. Studies have shown that the general
public typically perceive individuals with psychological disorders as dangerous and
unpredictable. This biased perception results in people with mental illness often being
subjected to discrimination in social situations and among friends and family. This constant
exposure to stigma negatively affects quality of life and adherence to treatment, among other
detrimental effects. Mental illness stigma is a cross-diagnostic and cross-cultural
phenomenon. It is a major barrier to well-being for those with mental illness, affecting almost
every area of their lives. It is important to remember that those with psychological disorders
are aware of the social stigma and negative stereotypes, which further increases their anxiety
and psychological distress.
 Unit 3 17

Activity 3.4
Suggest a promising new treatment for schizophrenia by consulting academic datasets online
or in the University’s E-Library. Briefly outline the treatment you identified, and explain its
benefits.
You might like to start your search by searching for schizophrenia at
https://www.cochranelibrary.com/

In this section of the unit, you have covered various treatments for schizophrenia. Please now
read the following article which will give you a neurodevelopmental perspective on
schizophrenia. (As a reminder, neurodevelopmental refers to the study of the biological and
environmental factors that influence the lifespan development and function of the nervous
system.) This article aims to explore schizophrenia from various ‘new’ models: (1) mapping
the pathophysiology of schizophrenia by recognising that this is a neurodevelopmental
disorder which involves alternations in brain circuits; (2) the hypothesis for four stages of
schizophrenia, from risk to prodrome to psychosis to chronic disability; and (3) the possible
predictions for schizophrenia in 2030.

Reading 3.2 (E-Library)

Insel, T. R. (2010). Rethinking schizophrenia. Nature, 468, 187–193.
This article is available in the University’s E-Library → E-Reserve.

This article extends our understanding of schizophrenia treatment beyond the typical
pharmacological approach by viewing and rethinking schizophrenia as a neurodevelopmental
disorder. To do this, the author has categorised the stages of schizophrenia from a lifespan
perspective, providing a global picture of the disorder. This allows us to look at the disease
from the angle of preventive strategies, such as by reducing cognitive deficits by combining
somatic (i.e. related to the physical body), psychosocial and cognitive treatments, adopting
integration of care, and minimising stigma.
Table 3.4 Four stages of schizophrenia from a neurodevelopmental perspective

Stage I Stage II Stage III Stage IV

Features Genetic vulnerability Cognitive, Abnormal thought Loss of function
Environmental behavioural and and behaviour Medical
exposure social deficits Relapsing-remitting complications
Help-seeking course Incarceration
Diagnosis Genetic sequence SIPS Clinical interview Clinical interview
Family history Cognitive assessment Loss of insight Loss of function
Imaging
Disability None/mild cognitive Change in school and Acute loss of Chronic disability
deficit social function function Unemployment
Acute family distress Homelessness
Invervention Unknown Cognitive training? Medication Medication
Polyunsaturated fatty Psychosocial Psychosocial
acids? interventions interventions
Family support? Rehabilitation
services

Stage I, pre-symptomatic risk; stage II, pre-psychotic prodrome; stage III, acute psychosis; stage IV, chronic illness.

Source: Insel, 2010, p. 190

18 PSYC A232 Introduction to Abnormal Psychology

You have almost come to the end of Unit 3. Please attempt the following self-test to evaluate
your grasp of some of the ideas and approaches you have covered in this unit.

Self-test 3.1
1. What is Assertive Community Treatment (ACT), and how can it help individuals with
schizophrenia?
2. What are the negative effects of stigma and discrimination on individuals with
schizophrenia?

Summary
This unit provided an overview of schizophrenia, a severe mental illness that affects around
1% of the population locally. Typically, onset occurs in late adolescence or early adulthood,
and men experience symptoms earlier than women. Symptoms can include hallucinations,
delusions, disorganised speech and behaviour, and negative symptoms such as flat affect and
social withdrawal. Women generally have a better long-term outcome than men, while men’s
symptoms may be more severe.
Schizophrenia is a complex disorder with various possible causes, including genetic factors,
prenatal exposure to viruses, pregnancy and birth complications, early nutritional
deficiencies, maternal stress, and head injury. Brain abnormalities have been found in many
patients with schizophrenia, including enlarged ventricles, reduced volume of the thalamus,
and abnormalities in temporal lobe areas such as the hippocampus and amygdala. The
neurotransmitters dopamine and glutamate are also important in the development of
schizophrenia, with research suggesting that individuals with the disorder may produce and
release too much dopamine into the synapse.
Treatment for schizophrenia usually involves long-term medication and psychosocial
interventions such as social skills training, cognitive remediation training, cognitive-
behaviour therapy, case management, and family therapy. Antipsychotic medications, such as
first- or second-generation antipsychotics, are commonly used, with second-generation
medications causing fewer motor side effects. However, some evidence suggests that
antipsychotic medications may be linked to brain tissue loss.
The interplay between genetic and environmental factors underscores the importance of a
multifaceted approach to treatment that addresses both biological and psychosocial factors.
Patients with schizophrenia are more likely to relapse if their relatives are high in expressed
emotion (EE), and high-EE environments may trigger biological changes that cause
dysregulations in the dopamine system and lead to a return of symptoms.
Despite the challenges associated with schizophrenia, with proper treatment, many patients
can show improvement in symptoms and functioning. Assertive Community Treatment
(ACT) is an evidence-based intervention that provides comprehensive, community-based
support for individuals with schizophrenia. Therefore, it is crucial to have a comprehensive
treatment approach that addresses the biological and psychosocial aspects of this disorder to
improve outcomes for those with schizophrenia. 　
 Unit 3 19

References
AbdelMalik, P., Husted, J., Chow, E. W., & Bassett, A. S. (2003). Childhood head injury and

expression of schizophrenia in multiply affected families. Archives of General Psychiatry,

60(3), 231–236.

Chang, W. C., Wong, C. S. M., Chen, E. Y. H., Lam, L. C. W., Chan, W. C., Ng, R. M. K.,

Hung, S. F., Cheung, E. F. C., Sham, P. C., Chiu, H. F. K., Lam, M., Lee, E. H. M.,

Chiang, T. P., Chan, L. K., Lau, G. K. W., Lee, A. T. C., Leung, G. T. Y., Leung, J. S. Y.,

Lau, J. T. F., ... Bebbington, P. (2017). Lifetime prevalence and correlates of

schizophrenia-spectrum, affective, and other non-affective psychotic disorders in the

Chinese adult population. Schizophrenia Bulletin, 43(6), 1280–1290.

Gold, C., Heldal, T. O., Dahle, T., & Wigram, T. (2005). Music therapy for schizophrenia or

schizophrenia‐like illnesses. Cochrane Database of Systematic Reviews, (2), CD004025.

Gorczynski, P., & Faulkner, G. (2010). Exercise therapy for schizophrenia. Cochrane

Database of Systematic Reviews, (5), CD004412.

Insel, T. R. (2010). Rethinking schizophrenia. Nature, 468, 187–193.

Saha, S., Chant, D., Welham, J., & McGrath, J. (2005). A systematic review of the prevalence

of schizophrenia. PLoS Medicine, 2(5), e141.

Saint Martin, M. L. (1999). Running amok: A modern perspective on a culture-bound

syndrome. Primary Care Companion to the Journal of Clinical Psychiatry, 1(3), 66–70.

Tang, J. Y. M., Wong, G. H. Y., Hui, C. L. M., Lam, M. M. L., Chiu, C. P. Y., Chan, S. K. W.,

Chung, D. W. S., Tso, S., Chan, K. P. M., Yip, K. C., Hung, S. F., & Chen, E. Y. H.

(2010). Early intervention for psychosis in Hong Kong — the EASY programme. Early

Intervention in Psychiatry, 4(3), 214–219.

Torrey, E. F., Webster, M., Knable, M., & Johnston, N. (1994). The familial transmission of

schizophrenia: Archaic and modern views. In C. N. Stefanis, N. E. Laskos, & A.

Rabavilas (Eds.), Psychiatry: A world perspective (Vol. 3, pp. 89–101). Elsevier.

Volkan, K. (2021). Schizophrenia, culture, and culture-bound syndromes. Psychological

Research and Applications, 3, 1–13.

20 PSYC A232 Introduction to Abnormal Psychology

World Health Organization. (2022, January 10). Schizophrenia. Fact sheets.

https://www.who.int/news-room/fact-sheets/detail/

schizophrenia#:~:text=Schizophrenia%20affects%20approximately%2024%20million,as

%20many%20other%20mental%20disorders 　

Feedback on activities and the self-test

Activity 3.1
1. A delusion is a thought, a cognition, with no basis in reality. Common delusions involve
believing that one’s actions or thoughts are being controlled by some external force, that
one’s thoughts are being broadcast, and that thoughts are being inserted into one’s mind.
These delusions are all consistent with the disorganised thoughts commonly seen in
schizophrenia.
2. Delusions can be culturally specific. The content of the delusion may be based on
sociocultural or religious factors. For example, your textbook (p. 208) describes how
researchers found that the delusions of British people with schizophrenia related to
being controlled by televisions, radios and computers, while Pakistani people reported
being controlled by black magic. Japanese people’s delusions involved being slandered
by others, while religious Germans and Austrians believed they had committed a sin.
3. Cultural factors can shape the types of delusions that individuals with schizophrenia
experience in different ways. You may have mentioned one or more of the following:
• Individuals from different cultures may have different beliefs about the causes of
mental illness, which can influence the content of the delusions.
• Cultural beliefs about the supernatural or spiritual world may influence the content
of delusions which are related to religious or supernatural themes.
• Finally, cultural factors may also influence the way in which delusions are expressed
or communicated, such as through language or cultural metaphors.
It is important for clinicians to take these cultural factors into account when assessing
and treating individuals with schizophrenia.
4. You might have different suggestions for this question. Hong Kong’s unique blend of
Eastern and Western cultures, as well as its status as a high-tech metropolis could
influence the content of delusions experienced by sufferers in the city. You might
suggest that individuals may experience delusions related to Chinese traditional beliefs,
such as possession by ghosts or spirits, while others may experience delusions related to
Western religious (e.g. Christian) themes. Themes associated with modern technologies,
AI and so on might also feature.
You might also mention in your answer that cultural factors can also influence the way
in which delusions are expressed or communicated in Hong Kong. For example,
Cantonese, the dominant language in Hong Kong, may have idiomatic expressions or
cultural metaphors that are used to describe or explain delusions. These expressions may
be difficult for non-locals to understand, and it is important for clinicians to be aware of
these cultural differences in order to effectively assess and treat individuals with
schizophrenia in Hong Kong.
 Unit 3 21

Activity 3.2
1. a. Incorrect. The original dopamine theory suggests that increased dopamine levels are
associated with the positive symptoms of schizophrenia, e.g. delusions and
hallucinations.
b. Correct
c. Incorrect. Atypical antipsychotics bind to a specific type of dopamine receptor
common in the mesolimbic system.
d. Correct
e. Incorrect. These neurotransmitters are also believed to be involved in schizophrenia.
Serotonin may interact with dopamine in important ways in this disorder; and
glutamate deficiencies may contribute to cognitive and emotional symptoms.
2. Recall that the diathesis-stress model suggests that an existing vulnerability, when
triggered by a stressor, may result in a psychological disorder. In the case of
schizophrenia, sensitivity to stress may increase an individual’s vulnerability to
developing schizophrenia. You know that the HPA axis is activated in response to stress,
and this contributes to dopamine release. You have learnt that increased amounts of
dopamine are believed to be a key factor in schizophrenia.

Activity 3.3
1. Expressed emotion (EE) is characterised by family members’ attitudes of criticism,
hostility, and emotional overinvolvement (EOI) in relation to the schizophrenia patient.
EE is a reliable predictor of relapse even when potentially important patient variables
are controlled statistically. When families lower their EE (often with clinical
intervention), patients’ relapse rates decline.
A therapist might expect to see high expressed emotion in Esther’s parents. The parents
might make highly critical or resentful remarks towards Esther and her illness, as if
Esther had some control over it. Dramatic, excessive concern towards Esther may also
be shown, emphasising the parents’ self-sacrifices (EOI).
2. As you will have read in the textbook, there is evidence to suggest that expressed
emotion (EE) may be influenced by cultural factors, such as family structure, social
norms, and values. For instance, in collectivistic cultures, family members may exhibit
higher levels of emotional involvement and expressiveness compared to individualistic
cultures. However, despite these differences, research has consistently shown that high
levels of EE are associated with increased risk of relapse in patients with schizophrenia,
regardless of cultural context. Therefore, while cultural variations in the manifestation
and interpretation of EE may exist, the fundamental importance of EE as a predictor of
clinical outcomes appears to be universal.
3. While EE is a widely used and validated measure of family interaction in schizophrenia,
there are some limitations to its use. You might have thought of some critiques related to
the points below:
• EE is based on self-report measures, which may be subject to biases and social
desirability effects.
• EE is a static measure of family interaction that does not account for changes over
time or context-dependent variations.
22 PSYC A232 Introduction to Abnormal Psychology

• EE focuses on negative aspects of family interaction, such as criticism and hostility,

and may not capture positive aspects of support and emotional warmth.
• EE is a construct that may not fully capture the complexity and heterogeneity of
family dynamics in schizophrenia, and may not be generalisable to other mental
health conditions or cultural contexts.

Activity 3.4
Your responses to this activity will depend on the direction you took in your research. The
following are some possible ideas:
• The integration of exercise (Gorczynski & Faulkner, 2010) as a treatment therapy for
patients with schizophrenia appears to help improve brain health, thereby reducing
positive and negative symptoms. Exercise improves cognition and overall functioning,
reduces inflammation, and stimulates the growth of new neurons in the hippocampus.
For more information, see: https://www.cochranelibrary.com/cdsr/doi/10.1002/1465185
8.CD004412.pub2/pdf/full
• Music therapy may be a useful adjunct to standard care for people with schizophrenia or
schizophrenia-like illnesses (Gold et al., 2005). Research results suggest that music
therapy can improve global state, negative symptoms, and social functioning in people
with schizophrenia or schizophrenia-like illnesses, compared to standard care alone.
However, there is limited evidence on the effects of music therapy on positive
symptoms, cognitive functioning, and quality of life.
For more information, see: https://www.cochranelibrary.com/cdsr/doi/10.1002/1465185
8.CD004025.pub2/pdf/full

Self-test 3.1
1. Assertive Community Treatment (ACT) is an evidence-based approach to the treatment
of individuals with severe and persistent mental illness, like schizophrenia. It is a
community-based framework that provides intensive treatment, support, and
rehabilitation to individuals with schizophrenia. The programme provides
comprehensive services 24 hours a day, relying on the expertise of medical
professionals, social workers, and psychologists to meet the variety of patients’ needs.
ACT programmes provide monitoring and adjustment of medications, occupational
training, assistance in receiving financial resources, social skills training, emotional
support, and sometimes basic housing to individuals with schizophrenia. Studies have
shown that ACT programmes produce improvements in illness severity with low
disengagement and hospitalisation rates, and can be cost-effective.
2. The negative effects of stigma and discrimination on individuals with schizophrenia
include lower quality of life, decreased likelihood to seek professional help,
discontinuing treatment, and higher treatment dropout rates. Stigmatising attitudes and
behaviours can lead to increased symptom severity and decreased treatment seeking,
adherence, and engagement. People with schizophrenia may anticipate discrimination
and stigma, which can increase psychological distress and worry about being avoided,
denied work, or perceived by others as weak or dangerous. Stigma can also result in
social isolation and decreased opportunities for social interaction, education, and
employment, all of which can impact the individual’s quality of life.