DIFFICULTIES IN DIAGNOSING PERSONALITY
PERSONALITY
DISORDERS
A person’s characteristic traits, coping styles, and ways of
interacting in the social environment emerge during childhood and
normally crystallize into established patterns by the end of
adolescence or in early childhood
Personality – refers to the set of unique traits and behaviors that
characterize the individual
Five traits that are at the center of the five-factor model of
personality
Neuroticism
Extraversion/Introversion
Openness to experience
Agreeableness/Antagonism
Conscientiousness
CLINICAL FEATURES OF PERSONALITY DISORDERS
 There are certain people who, although they do not necessarily
display obvious symptoms of most disorders, nevertheless
have certain traits that are so inflexible and maladaptive that
they are unable to function effectively meet the demands of
society
 Personality disorders – are characterized by chronic
interpersonal difficulties, problems with one’s identity or
sense of self, and an inability to function adequately in society
 In order to be diagnosed, the enduring pattern of behavior
must be
 Pervasive and inflexible
 Stable and of long duration
 Cause clinically significant distress
 Impairment in functioning manifested in two of the
following areas
o Cognition
o Affectivity
o Interpersonal functioning
o Impulse control
 Personality disorders stem largely from the gradual
development of inflexible and distorted personality and
behavioral patterns that result in persistently maladaptive
ways of perceiving, thinking about, and relating to the world
 Stressful events early in life may help set the stage
for development of inflexible and distorted
personality patterns
 The DSM-5 personality disorders are grouped into three
clusters (A,B, and C. These were derived on the basis of what
were originally thought to be important similarities of features
among the disorders within a given cluster
 There are proposals to abandon the cluster
organization since there are simply too many
overlapping features across both categories and
clusters
 Epidemiological studies – designed to establish the
prevalence of a particular disorder in a very large sample of
people living in the community; assesses the prevalence of
personality disorders
 Often used different assessment interviews
 10-12 percent of people meet criteria for at least one
personality disorder when the time period being
asked about is the person’s behavior over the last 2-
5 years
 Cluster C disorders are most common (7%)
 Cluster A (4%)
 Cluster B (3.5%-4%)
CHALLENGES IN PERSONALITY DISORDER
RESEARCH
DISORDERS
 Special caution is in order regarding the diagnosis of
personality disorders because more misdiagnoses
probably occur here than in any other category of
disorder
 Diagnostic criteria are not as sharply defined as they are
for most other diagnostic categories
 The development of semi-structured interviews and self-
report inventories for diagnosis of personality disorders,
certain aspects of diagnostic reliability has increased
substantially
 Several theorists have attempted to deal with the
problems inherent in a categorical approach by adopting
a dimensional approach
 This assumes that personality and personality
disorders is more on a continuum
 Five-factor model – the most influential model of
personality that builds on the five-factor model of normal
personality to help researchers understand the
commonalities and distinctions among the different
personality disorders by assessing how these individuals
score in the five basic personality traits. Each personality
trait also has subcomponents or facets
 Neuroticism
- Anxiety
- Angry-hostility
- Depression
- Self-consciousness
- Impulsiveness
- Vulnerability
 Extraversion
- Warmth
- Gregariousness
- Assertiveness
- Activity
- Excitement seeking
- Positive emotions
 Within the dimensional approach, normal personality
trait dimensions can be recast into corresponding
domains that represent more pathological extremes of
these dimensions
 Negative affectivity: Neuroticism
 Detachment: Extraversion
 Antagonism: Extremely low agreeableness
 Disinhibition: Extremely low conscientiousness
DIFFICULTIES IN STUDYING THE CAUSES OF
PERSONALITY DISORDERS
 Relatively little is known about the causal factors
involved in the development of most personality
disorders
 Personality disorders only began to receive
consistent attention from researchers after they
entered DSM in 1980
 There is a high comorbidity among them
 One of the problems with the diagnostic categories of
personality disorders is that the exact same observable
behaviors may be associated with different personality
disorders and yet have different meanings with each
disorder
 Researchers have more confidence in prospective studies
wherein groups of people are observed before a disorder
appears and are followed over a period of time to see
which individuals develop problems and what causal
factors have been present
 However, the vast majority of research has been
conducted on people who already have the disorders
 Infant’s temperament has been suggested to may have
predisposed them to the development of particular
personality traits and disorders
  Temperament lays foundation for the development
of the adult personality, but it is not the sole
determinant of adult personality
 For at least most disorders, the genetic contribution
appears to be mediated by the genetic contributions to the
primary trait dimensions most implicated in each
disorder rather than to the disorders themselves
 Psychodynamic theorists originally attributed great
importance in the development of character disorders to
an infant’s getting excessive versus insufficient
gratification of his or her impulses in the first few years
of life
 Genetic propensities and temperament may be important
predisposing factors for the development of particular
personality traits and disorders
 Parental influences, including emotional, physical, and
sexual abuse, may also play a big role in the development
of personality disorders
 Various kinds of social stressors, societal changes, and
cultural values have also been implicated as sociocultural
causal factors
CLUSTER A PERSONALITY DISORDERS
 People with these disorders often seem odd or eccentric, with
unusual behavior ranging from distrust and suspiciousness to
social detachment
PARANOID PERSONALITY DISORDER
 People with Paranoid personality disorder are
suspicious and distrustful of others, often reading hidden
meanings into ordinary remarks
 They tend to see themselves as blameless and blame
others for their own mistakes and failures
 They are chronically tense, constantly expecting trickery
and looking for clues to validate their expectations while
disregarding all evidence to the contrary
 Oftentimes they are preoccupied with doubts about the
loyalty of friends
 They commonly bear grudges, refuse to forgive
perceived insults and slights, and are quick to react with
anger and sometimes violent behavior
 People with paranoid personalities are not usually
psychotic
 During periods of high stress, they may experience
transient psychotic symptoms that last from a few
minutes to a few hours
 Individuals with paranoid personality disorder do
not appear to be at elevated liability for
schizophrenia
Causal factors
 Paranoid personality disorder is note very well studied,
and one reason for that is that people who are highly
suspicious and lacking in trust tend not to want to
participate in research studies
 There is evidence of modest genetic liability to paranoid
personality disorder
 This may occur through the heritability of high
levels of antagonism (low agreeableness) and
neuroticism (angry-hostility)
 Psychosocial causal factors that are suspected to play a
role
 Parental neglect
 Parental abuse
 Exposure to violent adults
 Symptoms of paranoid personality disorder also seem to
increase after traumatic brain injury and are often found
in chronic cocaine users
SCHIZOID PERSONALITY DISORDER
 Individuals with schizoid personality disorder have
difficulties forming social relationships and usually lack
much interest in doing so
 They tend not to have good friends, with the possible
exception of a close relative
 They are unable to express their feelings and is seen by
others as cold and distant
 They often lack social skills and can be classified as
loners or introverts, with solitary interests and
occupations
 People with this disorder tend not to take pleasure in
many activities including sexual activity
 They are not very emotionally reactive
 Rarely experience strong positive or negative
emotions
 Show a generally apathetic mood
 These deficits contribute to their appearing cold and
aloof
 Prevalence is more common in males than in females
 In the context of the five-factor model
 They show extremely high levels if introversion
 They are also low on openness to feelings
 Also low on achievement striving
Causal factors
 There has only been little research with schizoid
personality disorder and this may have been because of
the tendency of people with the disorder to be the type of
people who we do not expect to participate or volunteer
in a research study
 Schizoid personality traits appears to have high
heritability of around 55 percent
 There is also evidence that symptoms of schizoid
personality disorders do precede psychotic illness in
some cases
 There is also a link between schizoid personality and
autism spectrum disorders
 Theorists suggested that the severe disruption in
sociability seen in schizoid personality disorder may be
due to severe impairment in an underlying affiliative
system
 Cognitive theorists propose that individuals with schizoid
personality disorders exhibit cool and aloof behaviors
because of maladaptive underlying schemas that lead
them to view themselves as self-sufficient loners and to
view others as intrusive
SCHIZOTYPAL PERSONALITY DISORDER
 People with schizotypal personality disorder are also
excessively introverted and have pervasive social and
interpersonal deficits
 Have cognitive and perceptual distortions
 Oddities and eccentricities in their communication
and behavior
 Contact with reality is maintained but they are highly
personalized and superstitiously thinking
 They often believe they have powers and may engage in
magical rituals
 Other perceptual problems
 Odd speech
 Paranoid beliefs
 Ideas of reference – the belief that conversations of
others have special meaning or personal significance
 Many researchers conceptualize schizotypal personality
disorder as an attenuated form of schizophrenia
 Core symptoms of schizotypy form the basis of the only
proposed trait that does not map neatly onto the five
factors of normal personality
 Psychoticism
- Unusual beliefs and experiences
- Eccentricity
 - Cognitive and perceptual dysregulation
Causal factors
 There is significant research available on schizotypal
personality disorder
 Prevalence of this disorder in the general population is
about 1 percent
 More males affected than females
 It has moderate heritability
 A genetic relationship to schizophrenia has also been
suspected
 The disorder appears to be part of a spectrum of liability
for schizophrenia and often occurs in some of the first-
degree relatives of people with schizophrenia
 Biological associations of schizotypal personality
disorder with schizophrenia are remarkable
 Mild impairments in cognitive functioning
 Deficits to sustain attention
 Deficits in working memory
 Deficits in their ability to inhibit attention to a
second stimulus that rapidly follows presentation of
a first stimulus
 Teenagers who have schizotypal personality disorder
have been shown to be at increased risk for developing
schizophrenia and schizophrenia-spectrum disorders in
adulthood
 Schizotypal personality disorder in adolescence has been
associated with elevated exposure to stressful life vents
CLUSTER B PERSONALITY DISORDERS
 Individuals with these disorders share a tendency to be
dramatic, emotional, and erratic
HISTRIONIC PERSONALITY DISORDER
 People with histrionic personality disorder are
characterized by excessive attention-seeking behavior
and emotionality
 They tend to feel unappreciated if they are not the center
of attention
 Their appearance and behavior are often quite theatrical
and emotional as well as sexually provocative
 They may attempt to control their partners through
seductive behavior and emotional manipulation
 They show a good deal of dependence
 Speech is often vague and impressionistic
 Usually considered self-centered, vain, and excessively
concerned about the approval of others
 They are seen as overly reactive, shallow, and insincere
 Prevalence in the general population is a little over 1
percent
 This disorder occurs more often in women than in men
 Many of the criteria for histrionic personality disorder
involve maladaptive variants of female related traits
 Overdramatization
 Vanity
 Seductiveness
 Overconcern with physical appearance
 Personality traits prominent in histrionic personality
disorder are actually more common in men than in
women
Causal factors
 Very little systematic research has been conducted on
histrionic personality disorder
 Perhaps result of the difficulty researchers have had
in differentiating it from other personality disorders
 Many do not believe it is a valid diagnosis
 Highly comorbid with
 Borderline personality disorder
 Antisocial personality disorder
 Narcissistic personality disorder
 Dependent personality disorder
 There is some evidence for a genetic link with antisocial
personality disorder
 Histrionic personality disorder may be characterized
as involving extreme versions of two common,
normal personality traits: Extraversion and
neuroticism (to some extent)
- High levels of extraversion include high levels
of
o Gregariousness
o Excitement seeking
o Positive emotions
- High levels of neuroticism involve
o Depression and self-consciousness
facets
o High on openness to fantasies
NARCISSISTIC PERSONALITY DISORDER
 People with narcissistic personality disorder show an
exaggerated sense of self-importance, a preoccupation
with being admired, and a lack of empathy for the
feelings of others
 Two subtypes of narcissism (a notion supported by
numerous studies)
 Grandiose narcissism – manifested by traits related
to grandiosity, aggression, and dominance
- Reflected in a strong tendency to overestimate
their abilities and accomplishments while
underestimating the abilities and
accomplishments of others
- Sense of entitlement is frequently a source of
astonishment to others
- Behave in stereotypical ways to gain the
acclaim and recognition they crave
- They believe that they are so special and that
only higher-status people can understand them
- They have unwillingness to forgive others for
perceived slights
- They easily take offense
 Vulnerable narcissism
- Have a very fragile and unstable sense of self-
esteem
- Arrogance and condescension is a façade for
intense shame and hypersensitivity to rejection
and criticism
- They may be completely absorbed and
preoccupied with fantasies of outstanding
achievement but at the same time experience
profound shame about their ambitions
- May avoid interpersonal relationships due to
fear of rejection or criticism
 Both subtypes are associated with high levels of
interpersonal antagonism, low altruism, and tough
mindedness
 A person with a more grandiose form of narcissism is
extremely low in certain facets of neuroticism and high
extraversion
 People with narcissistic personalities are unwilling or
unable to take the perspective of others
 If they do not receive the validation or assistance they
desire, they are inclined to by hypercritical and
retaliatory
Causal factors
 There is a great deal of theory but precious little
empirical data on the environmental and genetic factors
involved in the etiology of narcissistic personality
disorder
 Grandiose and vulnerable forms of narcissism are
associated with different causal factors
  Grandiose narcissism is associated with parental
overevaluation
 Vulnerable narcissism is more associated with childhood
abuse, neglect, or poor parenting
ANTISOCIAL PERSONALITY DISORDER
 People with antisocial personality disorder is
characterized by their tendency to persistently disregard
and violate the rights of others
 Combination of deceitful, aggressive, and antisocial
behaviors
 They have a lifelong pattern of unsocialized and
irresponsible behavior with little regard for safety
 Only individuals ages 18 or over can be diagnosed with
ASPD
 Must have shown symptoms of conduct disorder
before age 15
 After age 15, there must also be evidence of such
things as repeated unlawful behavior, deceitfulness,
impulsivity, aggressiveness, or consistent
irresponsibility in work or financial matters
 The prevalence of antisocial personality disorder in the
general population is around 2-3 percent
 More common in men than in women
 Very common in prison samples
 ASPD diagnosis place a heavy emphasis on observable
behaviors such as
 Lying
 Getting into fights
 Failing to honor financial obligations
Causal factors
 Research suggests that genes play a role in ASPD and
criminality
 There is moderate heritability for antisocial or criminal
behavior
 Many environmental factors have also been implicated in
the development of ASPD
 Low family income
 Inner-city living
 Poor supervision by parents
 Having a young mother
 Being raised in a single-parent family
 Conflict between parents
 Having a delinquent sibling
 Other non-shared environmental factors
 Delinquent peers
 Physical or sexual abuse
 Various academic or social experiences
 There is genotype-environment interaction
 MAOA (monoamine oxidase A) gene – a gene
involved in the breakdown of neurotransmitters like
norepinephrine, dopamine, and serotonin
 Individuals with low MAOA activity were more
likely to develop ASPD if they experienced early
maltreatment
Developmental perspective
 ASPD has its roots in childhood, especially for boys
 The number of antisocial behaviors exhibited in
childhood is the single best predictor of who will develop
and adult diagnosis of ASPD
 Children with an early history of oppositional defiant
disorder are more likely to develop ASPD as adults
 ADHD – attention deficit hyperactivity disorder; the
second early diagnosis that is often a precursor to adult
ASPD; characterized by restless, inattentive and
impulsive behavior, a short attentions pan, and high
distractibility
 The behavioral problems that predisposing factors create
have a cascade of pervasive effects over time
 It is very likely that problems in brain development play
a role
 Variability in MAOA gene may alter serotonin
levels during the course of development. This may
compromise the structure, function, and
connectivity of the brain as the person matures
BORDERLINE PERSONALITY DISORDER
 The term borderline personality was originally used to
refer to patients who were very challenging to deal with
and who were thought to have a condition that was on the
border between neurosis and psychosis
 Now the most well-researched form of personality
pathology
 People with BPD show a pattern of behavior
characterized by impulsivity and instability in their
interpersonal relationships, their self-image and their
moods
 It is characterized by great suffering on the part of the
patients themselves and is often misunderstood and
stigmatized by clinical professionals
 Affective instability – a central characteristic of BPD
which shows itself in unusually intense emotional
responses to environmental triggers, and a slow return to
a baseline emotional state
 Also characterized by drastic and rapid shifts from
one emotion to another
 People with BPD often have chronic feelings of
emptiness and have difficulty forming a sense of who
they really are
 They struggle to cope with a highly negative self-concept
and find it hard to tolerate being alone
 People with BPD have unstable interpersonal
relationships
 People with BPD are very fearful of abandonment
 They are very attuned to signs of rejection and quick
to perceive rejection in the behaviors of others
 They often misperceive anger when they are
presented with neutral faces
 Impulsivity – another important feature of BPD that is
characterized by rapid responding to environmental
triggers without thinking or caring about long-term
consequences
 Self-mutilation – repetitive cutting behavior; another
characteristic feature of borderline personality
 75% of people with BPD have cognitive symptoms
 Short transient episodes in which they appear to be
out of contact with reality and experience psychotic-
like symptoms
 75% of individuals receiving the diagnosis in clinical
settings are women
 Arise from gender imbalance in treatment seeking
rather than prevalence of the disorder
Comorbidity with other disorders
 BPD is rarely diagnosed alone and commonly occurs
with a variety of other disorders
 It tends to be comorbid with both internalizing disorders
as well as externalizing disorders
 BPD is most associated with Major depressive disorder
and mania as well as with panic disorder, agoraphobia,
generalized anxiety disorder, and PTSD
 Neuroimaging data indicate that BPD individuals show
different neural responses to emotional stimuli than do
individuals with chronic depression
 There is also substantial co-occurrence of BPD and other
personality disorders. There is high comorbidity with
 Schizotypal
 Narcissistic
  Dependent
 In terms of the 5-factor model, BPD is conceptualized as
involving high neuroticism, low agreeableness, low
conscientiousness, and high openness to feelings and
actions
Causal factors
 BPD runs in families
 Genes play an important role and may account for 40
percent of the variance in the disorder
 Genes confer susceptibility to certain personality
traits
 BPD is a very complicated and clinically heterogenous
disorder and may involve a very large number of genes
 It is likely that experiences as well as other
environmental factors and influences interact with genes
to determine who will develop problems at a later point
 Child maltreatment and other extreme early life
experiences have long been linked to BPD
 Some people, by virtue of their genetic predispositions,
may be highly sensitive to the effects of negative early
life experiences
 Stressful early experiences may create long term
dysregulation of the HPA axis and shape brain
development, compromising key brain circuits that
are involved in emotional regulation
CLUSTER C PERSONALITY DISORDERS
 People with these disorders often show anxiety and
fearfulness
AVOIDANT PERSONALITY DISORDER
 People with avoidant personality disorder show
extreme social inhibition and introversion, leading to
lifelong patterns of limited social relationships and
reluctance to enter into social interactions
 They do not seek out other people, but desire affection
and are often lonely and bored
 They do not enjoy their aloneness and wants contact with
other people
 Feeling inept and socially inadequate are the two most
prevalent and stable features of avoidant personality
disorder
 Individuals with this disorder also show more
generalized timidity and avoidance of many novel
situations and emotions, and show deficits in their ability
to experience pleasure as well
 It is more commonly diagnosed with women
 Its key difference with schizoid personality disorder is
that people with schizoid personality disorder has little
desire to form close relationships
Causal factors
 Some research suggests that avoidant personality may
have its origins in an innate inhibited temperament that
leaves the infant and child shy and inhibited in novel and
ambiguous situations
 The fear of being negatively evaluated, which is
prominent in avoidant personality disorder, is moderately
heritable
 The genetically and biologically based inhibited
temperament may often serve as the diatheses that leads
to avoidant personality disorder
DEPENDENT PERSONALITY DISORDER
 Individuals with dependent personality disorder who an
extreme need to be taken care of, which leads to clinging
and submissive behavior
 They also show acute fear at the possibility of separation
or sometimes of simply having to be alone because they
see themselves as inept
 They often fail to get appropriately angry with others
because of a fear of losing their support
 It is estimated that dependent personality disorder occurs
slightly under 1 percent of the population and is more
common in women than in men
 It is often comorbid with other disorders
 Mood disorders
 Eating disorders
 Somatic symptom disorders
 Anxiety disorders
 Comorbidity is also high between dependent personality
disorder and other personality disorders
 Schizoid
 Avoidant
 Borderline
 Histrionic
 In terms of the five-factor model, dependent personality
disorder is associated with high levels of neuroticism and
agreeableness
Causal factors
 It is estimated that somewhere between 30-60 percent of
the variance in dependent personality disorder symptoms
might be attributable to genetic factors
 Several other personality traits such as neuroticism and
agreeableness that are prominent in dependent
personality disorder also have genetic component
 It is possible that people with these partially
genetically based predispositions to dependence and
anxiousness may be especially prone to adverse
effects of parents who are authoritarian and
overprotective
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
 People with OCPD are characterized by an excessive
concern with orderliness and control
 Their preoccupation with maintaining mental and
interpersonal control occurs in part through careful
attention to rules, order, and schedules
 Their perfectionism is often quite dysfunctional in that it
can result in them never finishing projects
 They are seen by others as being rigid, stubborn, and cold
 People with OCPD do not have true obsessions or
compulsive rituals as is the case with OCD
 It is thought to be more common in men than in women
 The person with OCPD has difficulty in interpersonal
relationships because of excessive devotion and great
difficulty expressing emotions
Causal factors
 In the context of the five-factor theory, these individuals
are believed to have excessively high levels of
conscientiousness
 They are also high on assertiveness (a facet of
extraversion) and low compliance
 Cloninger’s biological dimensional approach
 Novelty seeking – low
 Reward dependence - low
 Harm avoidance – high
 OCPD traits show a modest genetic influence
GENERAL SOCIOCULTURAL CAUSAL FACTORS FOR
PERSONALITY DISORDERS
 The sociocultural factors that contribute to personality
disorders are not well understood
 There is less variance across cultures than within cultures
 There is some evidence that narcissistic personality disorder is
more common in western cultures
 Histrionic personality disorder might be expected to be, and
is, less common in Asian cultures
TREATMENTS AND OUTCOMES PERSONALITY
DISORDERS
 Goals in treatment may include reducing subjective distress,
changing specific dysfunctional behaviors, and changing
whole patterns of behavior or the entire structure of
personality
 Those from clusters A and B have general difficulties in
forming and maintaining good relationships, including the
therapist
 Non-completement of treatment is a particular problem in the
treatment of personality disorders
 When people have a personality disorder as well as another
disorder, they tend to do less well than comparable patients
without comorbid personality disorders
ADAPTING THERAPEUTIC TECHNIQUES TO SPECIFIC
PERSONALITY DISORDER
 Therapeutic techniques must often be modified,
 For people with severe personality disorders, therapy
may be more effective in situations where acting-out
behavior can be constrained
 Cognitive approaches are increasingly used,
 Cognitive therapy for personality disorder assumes
that the dysfunctional feelings and behaviors
associated with the personality disorders are largely
the result of schemas that tend to produce
consistently biased judgements, as well as
tendencies to make cognitive errors
 Cognitive approach techniques
- Monitoring automatic thoughts
- Challenging faulty logic
- Assigning behavioral tasks in an effort to
challenge the patient’s dysfunctional beliefs
TREATING BORDERLINE PERSONALITY DISORDER
 Psychological treatment is considered essential for BPD
 Medications are also used, although most appropriately
in a time-limited way and as an adjunct to psychological
treatment approaches
Psychosocial treatments
 Dialectical behavior therapy – developed by Masha
Linehan; a unique kind of CBT specifically adapted for
BPD
 Encourage patients to accept this negative affect
without engaging in self-destructive or other
maladaptive behaviors
 Problem-focused treatment based on clear hierarchy
of goals
- Decreasing suicidal and self-injurious behavior
- Increasing coping skills
 The therapy combines individual and group
components as well as phone coaching
 In group setting, patients learn interpersonal
effectiveness, emotion regulation, and distress
tolerance skills
 Efficacious treatment for BPD
- Patients show reductions in self-destructive and
suicidal behaviors as well as in levels of anger
 Transference focused psychotherapy – primary goal is
to strengthen the ego of these individuals, with a
particular focus on their primary primitive defense
mechanism of splitting
 Help patients see shades of gray between extremes
and integrative and negative views of themselves
and others into more nuanced views
 Expensive and time consuming
 As effective as DBT
 Mentalization – uses therapeutic relationship to help
patients develop the skills they need to accurately
understand their own feelings and emotions, as well as
the feelings and emotions of others
Biological treatments
 Drugs are often used in the treatment of BPD
 Many patients with BPD are taking multiple medications
 Antidepressant medications are widely used, although
there is no compelling evidence that they are effective
 Most appropriate only when participants have
comorbid mood disorder
TREATING OTHER PERSONALITY DISORDER
 Treatment of Clusters A and B PDs is not as promising
as some of the recent advances that have been made in
the treatment of PD
 In schizotypal PD, low doses of antipsychotic drugs may
result in modest improvements
 Antidepressants from the SSRI category may also
be useful
 Some cluster C disorders, such as dependent and
avoidant personality disorder, appears to be more
promising
 There is significant improvement in patients using a
form of short-term psychotherapy that is active and
confrontational
 Short-term inpatient treatment for Cluster C PDs is
even more effective than long-term inpatient or
outpatient therapy
 Antidepressants from the MAOI and SSRI categories
may also sometimes help in the treatment of avoidant
PD, just as they do so in closely related social phobia
PSYCHOPATHY
 This syndrome was first identified in the 19 th century when
terms such as manie sans delire (insanity without delirium) ,
moral weakness or moral insanity were used to describe it
 The most comprehensive early description of psychopathy
was made by Cleckley in the 1940s in his book The Mask of
Sanity which provided detailed case studies of people he
identified as psychopaths
 The prevalence of psychopathy is unknown
 The diagnosis of psychopathy is more focused on personality
structure
DIMENSIONS OF PSYCHOPATHY
 Psychopathy checklist-Revised – provided clinicians a
way to diagnose psychopathy on the bases of the
Cleckley criteria following a detailed interview and
careful checking of past records
 Widely used for forensic assessments
 Extensive research with this checklist has shown that
psychopathy can best be understood by considering the
following four dimensions
 Interpersonal dimension – reflects a personality
style characterized by glibness/superficial charm, a
grandiose sense of self-worth, pathological lying,
and the conning manipulation of others
 Affective dimension – reflects traits such as lack of
remorse or guilt, callousness/lack of empathy,
shallow affect, and a failure to accept responsibility
for one’s behavior
 Lifestyle dimension – reflects a need for
stimulation, a tendency to be easily bored,
impulsivity, irresponsibility, a lack of reasonable
long term goals, as well as a parasitic lifestyle
 Antisocial dimension – reflects the aspects of
psychopathy that involve poor behavior controls
 Overall, a diagnosis of psychopathy appears to be the
single best predictor of violence and recidivism
 Deficits in the prefrontal cortex as well as the amygdala
are thought to play a role in some of the behavioral and
emotional disturbances like psychopathy
CLINICAL PICTURE IN PSYCHOPATHY
  Often charming, spontaneous, and likable on first
acquaintance, psychopaths are deceitful and
manipulative, callously using others to achieve their own
ends
 Unencumbered by feelings for others, they are free to be
social predators, taking what they want and doing what
they please, sometimes for not better reason than because
they are bored
Inadequate conscience development
 Psychopaths appear unable to understand and accept
ethical values except on a verbal level
 Their conscience development is severely retarded or
non-existent, and they behave as though social
regulations and laws do not apply to them
Irresponsible and impulsive behavior
 Psychopaths learn to take rather than earn what
they want
 They often break the law impulsively and without
regard for the consequences
 Many studies have shown that antisocial
personalities and some psychopaths have high rates
of alcohol abuse and dependence and other
substance abuse/dependence disorders
 Elevated rates if suicide attempts and completed
suicides are also only associated with these
dimensions and not with the interpersonal-affective
dimensions
Ability to impress and exploit others
 Some psychopaths are superficially charming and
likeable, with a disarming manner that easily wins
them new friends
 They seem to have good insight into other people’s
needs and weaknesses and they are highly adept at
exploiting them
CAUSAL FACTORS IN PSYCHOPATHY
 The causes of psychopathy are complex and
involve many factors
Genetic influences
 Several studies have now demonstrated that
psychopathy and some of its important features
also show considerable heritability
Low-fear and impaired fear conditioning
 Research indicates that psychopaths who are high
on the dimensions of the first factor and who are
egocentric, callous, and exploitative have low trait
anxiety and show poor conditioning of fear
 Psychopaths are deficient in the conditioning of at
least subjective and certain physiological
components of fer
More general emotional factors
 Psychopaths appear to have more general
emotional deficits than simple deficits in the
conditioning of anxiety
 Individuals with psychopathy show less activity in
the amygdala not only during fear conditioning but
also when viewing sad or frightened faces
Early parental loss, Parental rejection and
inconsistency
 Slow conscience development and high levels of
both reactive and instrumental aggression are
influenced by the damaging effects of parental
rejection, abuse, and neglect, accompanied by
inconsistent discipline
DEVELOPMENTAL PERSPECTIVE IN
PSYCHOPATHY
 There are at least two different dimensions of
children’s difficult temperament that seem to lead
to different developmental outcomes
 Some children have great difficult learning to
regulate their emotions and show high levels
of emotional reactivity, including aggressive
and antisocial behaviors when responding to
stressful demands and negative emotions like
frustration and anger
 Other children may have few problems
regulating negative emotions, instead showing
fearlessness and low anxiety as well as
callous/unemotional traits and reduced
amygdala activation
Sociocultural causal factors
 Psychopaths have existed throughout history and
are found in all SE groups, races, ethnicities, and
cultures
 Kunlangeta – used to refer to people with
psychopathic traits by Native Alaskans
 One of the primary symptoms where cultural
variations occur is the frequency of aggressive and
violent behavior
 Socialization forces may have an enormous impact
on the expression of aggressive impulses
 Cultures can be classified according to how
individualistic or collectivist they are
 It is somewhat expected for individualistic
cultures to be more likely to promote some of
the behavioral characteristics that may lead to
psychopathy when brought to extremes
TREATMENTS AND OUTCOMES IN
PSYCHOPATHIC PERSONALITY
 Psychopaths experience little personal distress and
do not believe they need treatment
 Few studies have found that treatments that work
for other criminal offenders can actually be harmful
for psychopaths in that rates of reoffending
increase rather than decrease
 Biological treatments for antisocial and
psychopathic personalities have not been
systematically studied, partly because there is little
evidence that such approaches have any substantial
impact
 Cognitive-behavior treatments have been thought
to offer the greatest promise of more effective
treatment. Common targets of these interventions
include
 Increasing self-control, self-critical thinking,
and social perspective thinking
 Increasing victim awareness
 Teaching anger management
 Changing antisocial attitudes
 Curing drug addiction

SCHIZOPHRENIA AND
OTHER PSYCHOTIC
DISORDERS
Schizophrenia is a severe disorder that is often associated with considerable
impairments in functioning
SCHIZOPHRENIA
 Schizophrenia – a disorder characterized by an array of diverse
symptoms including extreme oddities in perception, thinking, action,
sense of self, and manner of relating to others
 Psychosis – The hallmark of the disorder which refers to a significant
loss of contact with reality
ORIGINS OF THE SCHIZOPHRENIA CONSTRUCT
 John Haslam – described the case of a patient who appears to
have suffered from a variety of symptoms including ones that
are typical of schizophrenia (delusions)
 Benedict Morel – described the case of a 13 year old boy who
had formerly been the most brilliant pupil in his school but who
gradually lost interest in his studies, became increasingly
withdrawn and lethargic, reclusive and quiet; and appeared to
have forgotten everything he had learned
 Demence proce – term used to describe the case; refers to
mental deterioration at an early age
 Emil Kraepelin – known for his careful description of
schizophrenia way back then.
 Dementia praecox – refers to a group of conditions that
all seemed to feature mental deterioration beginning early
in life
 Described patients with the aforementioned description as
someone who
- Becomes suspicious of people around oneself
- Sees poison in food
- Is pursued by the police
- Feels one’s own body is being influenced
- Thinks that he is going to be shot
- Thinks that neighbors are jeering at him
 Eugene Bleuler – gave the term Schizophrenia (sxizo = to split
or to crack; phren = mind)
 he believed that the condition was characterized primarily
by
- Disorganization of thought processes
- Lack of coherence between thought and emotion
- Inward orientation away from reality
 There is a split within the intellect, between the intellect
and emotion, and between intellect and the external reality
EPIDEMIOLOGY
 The risk of developing schizophrenia over the course of one’s
lifetime is a little under 1 percent
 Some people have a statistically higher risk of developing the
disorder
 There are groups of people who seem to have an especially high
risk of developing schizophrenia
 People whose fathers were older at the time of their birth
 Having a parent who works as a dry cleaner
 First and second generation immigrants from the black
Caribbean and black African countries who live in
majority white communities
 The characteristic age of onset of schizophrenia differs in men
and women
 In men, there is a peak in new cases of schizophrenia
between ages 20 and 24
 Incidence in women peaks during the same age period, but
is less marked compared to men
 Development of the disorder falls for men after about age
35
 Development of the disorder does not fall for women,
however.
 Males also tend to have more severe forms of schizophrenia
 Gender-related differences in illness severity may also explain
why schizophrenia is more common in males than it is in
females
 Female sex hormones may play some protective role
 When estrogen levels are low or are falling, psychotic
symptoms in women with schizophrenia often get worse
CLINICAL PICTURE
DELUSIONS
 Delusions – essentially an erroneous belief that is fixed and
firmly held despite clear contradictory evidence
 Latin verb Ludere = to play
 People with delusions believe things that others who share their
social, religious, and cultural backgrounds do not believe
 It involves a disturbance in the content of thought
 It is common in schizophrenia, occurring in more than 90
percent of patients at some point during their illness
 Prominent beliefs
 Made feelings or impulses – belief that one’s thoughts,
feelings or actions are being controlled by external agents
 Thought broadcasting – belief that their thoughts are being
broadcast indiscriminately to others
 Thought insertion – belief that thoughts are being inserted
into one’s brain by some external agency
 Thought withdrawal – belief that some external agency has
robbed on of one’s thoughts
 Delusions are not elaborated beliefs. They become elaborated
into a complex delusional system
HALLUCINATIONS
 Hallucination – a sensory experience that seems real to the
person having it, but occurs in the absence of any external
perceptual stimulus
 Latin verb Hallucinere or Allucinere = to wander in mind
or idle talk
 Auditory hallucinations are the most common to occur, as it can
occur as well in any sensory modality
 Hallucinations often have relevance for the patient at some
affective, conceptual, or behavioral level
 Patients can become emotionally involved in their
hallucinations, often incorporating them into their delusions
 People who consider themselves to be socially inferior tend to
perceive the voices they hear as being more powerful than they
are and to behave accordingly
 Hallucinated voices were often those of people known to the
patient in real life
 Some unfamiliar voices or the voices of God or the Devil
can also be heard
 Neuroimaging studies suggest that patients with speech
hallucinations have a reduction in gray matter volume in the left
hemisphere auditory and speech perception areas
 Neuroimaging studies reveal that hallucinating patients show
increased activity in Broca’s area
DISORGANIZED SPEECH
 Disorganized speech is the external manifestation of a disorder
in thought form
 An affected person fails to make sense, despite seeming to using
language in a conventional way and following the semantic and
syntactic rules governing verbal communication
 Words and word combinations sound communicative, but the
listener is left with little to no understanding of the point the
speaker is trying to make
 Neologisms – new words; completely made up words that
appear in the patient’s speech
 Formal thought disorder – refers to problems in the way that
disorganized thought is expressed in disorganized speech
DISORGANIZED BEHAVIOR
 Goal directed activity is almost universally disrupted in
schizophrenia
 Impairment occurs in areas of routine daily functioning, such as
work, social relations, and self-care, to the extent that observers
note that the person is not himself anymore
 Many researchers attribute the disruptions of executive behavior
to impairment in the functioning of the prefrontal region of the
cerebral cortex
 Catatonia – condition wherein patient may show a virtual
absence of all movement and speech and be in what is called a
catatonic state.
 Patient may hold an unusual posture for an extended
period of time without any seeming discomfort
POSITIVE AND NEGATIVE SYMPTOMS
  Positive symptoms – reflect and excess or distortion in a
normal repertoire of behavior and experience, such as delusions
and hallucinations
 Negative symptoms – reflect an absence or deficit of behaviors
that are normally present
 Alogia – a negative symptom characterized by very little
speech production
 Avolition – a negative symptom characterized by the
inability to initiate or persist in goal-directed activity
 Anhedonia – refers to diminished ability to experience
pleasure
 Even though patients with schizophrenia may sometimes appear
emotionally unexpressive, they are nonetheless experiencing
plenty of emotion
SCHIZOPHRENIA SUBTYPES
 Paranoid schizophrenia – clinical picture is dominated by
absurd and illogical beliefs that are often highly elaborated and
organized into a coherent but delusional framework
 Disorganized schizophrenia – characterized by disorganized
speech, disorganized behavior, and flat or inappropriate affect
 Catatonic schizophrenia – involves pronounced motor signs
that reflect great excitement or stupor
OTHER PSYCHOTIC DISORDERS
SCHIZOAFFECTIVE DISORDER
 Schizoaffective disorder – used to describe people who have
features of schizophrenia and severe mood disorder
 The person has psychotic symptoms that meet criteria for
schizophrenia, and also marked changes in mood for a
substantial amount of time
 Can be unipolar or bipolar in type
 Mood symptoms have to meet criteria for a full major
episode and also have to be present for more than 50
percent of the total duration of the illness
 Prognosis for patients diagnosed with schizoaffective disorder is
somewhere between that of patients with schizophrenia and that
of patients with mood disorders
SCHIZOPHRENIFORM DISORDER
 Schizophreniform disorder – category reserved for
schizophrenia-like psychoses that last at least a month but do not
last for 6 months and so do not warrant a diagnosis for
schizophrenia
 The possibility of an early and lasting remission after a first
psychotic breakdown causes the prognosis for the disorder to be
better than that for established forms of schizophrenia
DELUSIONAL DISORDER
 Delusional disorder – patients diagnosed with this disorder
hold beliefs that are considered false and absurd by those around
them
 People given the diagnosis may behave quite normally
 Behavior does not show the gross disorganization and
performance deficiencies characteristic of schizophrenia, and
general behavioral deterioration is rarely observed in this
disorder even when it proves chronic
 Erotomania – the theme of the delusion involves great
love for a person, usually of higher status
BRIEF PSYCHOTIC DISORDER
 Brief psychotic disorder – involves the sudden onset of
psychotic symptoms or disorganized speech or catatonic
behavior
 The episode usually lasts only a matter of days, after which the
person returns to his or her former level of functioning and may
never have another episode again
 It is often triggered by stress
GENETIC AND BIOLOGICAL FACTORS
GENETIC FACTORS
 It has long been known that disorders of the schizophrenia type
are familial and tend to run in families
 Index cases – refers to the diagnosed group of people who
provide the starting point for inquiry; they are also called
probands
 The interpretation of familial concordance patterns is never
completely straightforward, in part due to the strong relationship
between the sharing of genes and the sharing of the
environments in which those genes express themselves
TWIN STUDIES
 Schizophrenia concordance rates for identical twins are
routinely and consistently found to be significantly higher than
those for fraternal twins or ordinary siblings
 Keep in mind that being a twin does no increase one’s risk for
developing schizophrenia
 Overall wise concordance rate is 28% for monozygotic (MZ)
twins and 6% for dizygotic twins (DZ)
 Genes undoubtedly play a role in causing schizophrenia, but
genes themselves are not the whole story.
 The environment also plays a role in the development of
the disorder
 Age-corrected incidence rate – (17.4 for schizophrenia) far
exceeds normal expectancy, was not significantly different from
that for offspring of the twins with schizophrenia in discordant
pairs or from that for offspring of DZ with schizophrenia
ADOPTION STUDIES
 Twin studies have the tendency to overestimate the importance
of genetic factors because some similarities between MZ twins
that actually occur for nongenetic reasons will be attributed to
genetic factors
 Several studies have attempted to overcome the shortcomings of
the twin method by using adoption method in order to achieve
a separation of hereditary from environmental influences
 Concordance rates for schizophrenia are compared for the
biological and adoptive relatives of people who have been
adopted out of their biological families at an early age and
have subsequently developed schizophrenia
 An alternative to this approach involves locating adult patients
with schizophrenia who were adopted early in life and then
looking at rates of schizophrenia in their biological and adoptive
relatives
QUALITY OF THE ADOPTIVE FAMILY
 Finnish adoptive family study of schizophrenia – followed up
the adopted-away children of all women in Finland who were
hospitalized for schizophrenia,
 The functioning of the children was compared with the
functioning of a control sample of adoptees whose
biological mothers were psychiatrically healthy
 It tells us the interaction between genes and environment
 Communication deviance – a measure of how understandable
and easy to follow the speech of a family member is
 Research findings indicate a strong interaction between genetic
vulnerability and an unfavorable family environment in the
causal pathway leading to schizophrenia
 The Finnish adoptive family study has provided strong
confirmation of the diathesis-stress model as it applies to the
origins of schizophrenia
MOLECULAR GENETICS
 Higher rates of schizotypal personality disorder are also found in
the relatives of patients with schizophrenia. This supports the
idea of the schizophrenia spectrum and suggests that a genetic
liability to schizophrenia sometimes manifests itself in a form of
pathology that is like schizophrenia, but not exactly
schizophrenia itself
 The current thinking is that schizophrenia probably involves
many genes working together to confer susceptibility
 Candidate genes – genes that are involved in processes that are
believed to be aberrant in schizophrenia
 Catechol-O-methyltransferase (located on chromosome
22)
 Neuregulin 1 (located on chromosome 8)
 Dysbindin (located on chromosome 6)
 DISC1 (located on chromosome 1)
 Velocardiofacial syndrome – involves a deletion of genetic
material on chromosome 22 which manifests a high risk for
developing schizophrenia on children as they move through
adolescence
 Candidate gene studies often fail to replicate in another study
 Genome-wide association study – the entire genome is studied
 Researchers can identify single nucleotide polymorphisms
which are sequences of DNA that are more frequently
found in people with the disorder than without it
  This approach may help us detect genes that have very
small effects but that might contribute to susceptibility for
schizophrenia
 Schizophrenia working group of the Psychiatric Genomics
consortium – combines all GWAS data from all available
schizophrenia samples into one single analysis of more than
150,000 people
 They provide further evidence that a large number of
alleles are involved in creating genetic susceptibility for
schizophrenia
 Many of the genes that are implicated are involved in the
processes that have long been thought to be important for
understanding schizophrenia
 GWAS Approaches are also telling us that some of the risk
alleles that are being implicated in schizophrenia are implicated
in bipolar disorder
 Far from being distinct disorders, schizophrenia and
bipolar disorder have a lot of overlap
 Rare alleles also may play an important role to increase a
person’s risk of schizophrenia
 These alleles may result from mutations that compromise
brain functioning in a negative way
 Copy-number variations – deletions and duplications of
DNA that is also implicated in autism, ADHD, and
intellectual disability
 Schizophrenia may be one for of neurodevelopmental disorder
with genetic links to autism, ADHD, and intellectual disability
ENDOPHENOTYPES
 Schizophrenia appears to be very complex genetically and
another impediment is that researchers are still not sure what
phenotype they should be looking for
 Endophenotypes – refers to the discrete, stable, and measurable
traits that are thought to be under genetic control
 Researchers are interested in people who score high on certain
interests or measures that are thought to reflect a predisposition
to schizophrenia
 Subjects who score high on a self-report measure of
schizotypal traits involving perceptual aberrations and
magical ideation
 Other endophenotypic risks for schizophrenia
- Abnormal performance on measures of cognitive
functioning
 Because many endophenotypes are not specific to schizophrenia,
studying such traits may shed light on basic processes that have
gone wrong in other disorders as well
PRENATAL EXPOSURES
 Whether or not a genotype is expressed depends on biological
and environmental triggers
 A range of environmental factors, including things such as
maternal exposure to stress, are capable of influencing patterns
of gene expression in the developing offspring
Viral infection
 In 1919 Kraepelin suggested that infections in the years of
development might have a causal significance for schizophrenia
 In 1957 there was a major epidemic of influenza in Finland.
Studying the residents of Helsinki, Mednick and colleagues
(1988) found elevated rates of schizophrenia in children born to
mothers who had been in their second trimester of pregnancy at
the time of the influenza epidemic.
 The first study to definitely test the maternal influenza–
schizophrenia link was not done until 2004. Brown and
colleagues (2004) analyzed specimens of maternal serum (serum
is the clear liquid that separates out from coagulated blood).
 Results showed that influenza exposure during the first
trimester of pregnancy was associated with a sevenfold
increased risk of schizophrenia or schizophrenia spectrum
disorders in the offspring
 Other maternal infections that occur during pregnancy that have
also been linked to increased risk for the later development of
schizophrenia include:
 Rubella (German measles)
 Toxoplasmosis (common parasitic infection)
 A possibility is that the mother’s antibodies to the virus cross the
placenta and somehow disturb brain development in the fetus
 Another possibility is that influenza causes an increase in the
production of inflammatory cytokines that cause
neurodevelopmental damage
 Influenza could also have a direct and damaging effect on the
developing brain
RHESUS INCOMPATIBILITY
 Rhesus incompatibility occurs when an Rh-negative mother
carries an Rh-positive fetus
 This incompatibility is a major cause of blood disease in
newborns
 The incompatibility also seems to be associated with increased
risk for schizophrenia
 One possibility is that it increases risk through the mechanisms
that involves oxygen deprivation or hypoxia
 Research also suggests that incompatibility between the blood of
the mother and the blood of the fetus may increase the risk of
brain abnormalities of the type known to be associated with
schizophrenia
PREGNANCY AND BIRTH COMPLICATIONS
 Patients with schizophrenia are much more likely to have been
born following a pregnancy or delivery that was complicated in
some way
 Many delivery problems affect the oxygen supply of the
newborn
 Research points toward damage to the brain at a critical
time of development
EARLY NUTRITIONAL DEFICIENCY
 In October 1944, a Nazi blockade resulted in a famine that
affected people living in Amsterdam and other cities in the west
of the country.
 Fertility levels fell and the birth rate dropped precipitously
 Some children were born during this time
 Those who were conceived at the height of the famine had
a two-fold increase in their risk of later developing
schizophrenia
MATERNAL STRESS
 If a mother experiences an extremely stressful event later in her
first trimester of pregnancy or early in the second trimester, the
risk of schizophrenia in her child is increase
 It is currently thought that the increase in stress hormones that
pass to the fetus via the placenta might have negative effects on
the developing brain
SYNTEHSIS OF ENVIRONMENT AND GENES
 The current thinking is that genetic risk for schizophrenia
emerges in one of two ways
 From large numbers of common genes whose individual
contributions of each gene is likely very small, but set the
stage for the development of the illness when all the
genetic variants interact
 From genetic mutations that could be highly specific to
certain people or to certain families
 These genetic events might involve microdeletions or problems
in the DNA sequence itself
 It is also possible that the focus on MZ concordance rates has
caused us to overestimate the heritability of schizophrenia
 Some MZ and all DZ twins do not have equally similar
prenatal developments
 Monochorionic – they share the same placenta
 Dichorionic – they have separate placentas and separate
fetal circulations
 The higher concordance rate for schizophrenia in MZ than in DZ
twins might therefore be a consequence, at least in part, of the
greater potential for monochorionic MZ twins to share
infections
 The concordance figure for dichorionic MZ twins is very
similar to that generally reported for DZ twins
 Monochorionic MZ twins may therefore have inflated
concordance rates in schizophrenia, which may have
caused is to overattribute to genetic what might more
accurately be attributed to environmental influences
 Consistent to the diathesis-stress perspective, being at genetic
risk does seem to make people more susceptible to
environmental insults
 A genetic liability to schizophrenia may predispose an
individual to suffer more damage from environmental insults
than would be the case in absence of the genetic predisposition
NEURODEVELOPMENTAL PERSPECTIVE
  Current thinking is that schizophrenia is a disorder in which the
development of the brain is disturbed very early on
 Risk for the disorder may start with the presence of certain
genes that have the potential to disrupt the normal development
of the nervous system
 The stage for schizophrenia, in the form of abnormal brain
development, may be set very early in life
 Some of the genes that have been implicated in schizophrenia
are known to play a role in the brain development and neural
connections
 Major histocompatibility complex – a region of the
genome that has been linked to schizophrenia that contains
genes that are involved in immune functioning
 it is possible that genetic vulnerability to schizophrenia
could be explained by greater genetic vulnerability to
infection
 it is also possible that infection could affect gene
expression and lead to changes in brain development that
primes the brain for the later onset of schizophrenia
 an ingenious series of studies reported by Walker and colleagues
illustrates the association between early developmental
deviation and schizophrenia risk
 Pre-schizophrenia children showed more motor
abnormalities including unusual hand movements than
their healthy siblings
 Pre-schizophrenia children showed less positive facial
emotion and more negative facial emotion
 These early problems do tell us that subtle abnormalities can be
found in children who are vulnerable to the disorder
 Aside from Walker’s research design which avoided the
problem of retrospective bias, another way to explore childhood
indicators without the problem of retrospective bias is to use a
prospective research design
 Another approach is to follow children who are known to be at
high risk for schizophrenia by virtue of their having been born to
a parent with the disorder
 One of the most consistent findings from high-risk research is
that children with a genetic risk for schizophrenia are more
deviant than control children on research tasks that measure
attention
 Adolescents at high risk for schizophrenia tend to show more
movement abnormalities than either nonclinical controls or
adolescents with personality or behavioral problems
 Movement abnormalities become more marked with time
 Movement abnormalities also became more strongly
correlated with psychotic symptoms as the children got
older
 A new generation of high-risk studies is focusing on young
people who are at clinical high risk
 Prodromal – refers to very early signs of schizophrenia
 Attenuated psychosis syndrome – one of the most
frequently reported difficulties that involves being
perplexed by reality
- There are some reports that people tend to lose
control over the content of their thoughts or having
ideas of being regarded in a negative way by others
- Suspiciousness of friends or acquaintances
- Hearing sounds such as buzzing, hissing, knocking,
or footsteps
- Symptoms are all below the level of full-blown
psychotic symptoms with regard to their severity
STRUCTURAL AND FUNCTIONAL ABNORMALITIES
 New approaches brought by technological developments are revealing
abnormalities in the structure and function of the brain as well as in
neurotransmitter activity in people with schizophrenia
NEUROCOGNITION
 Cognitive impairment is regarded as a core feature of
schizophrenia
 People with the disorder perform much worse than healthy
controls on a broad range of neuropsychological tests
 Not all patients show impairments in all areas
 Some perform within normal range of functioning
- These patients, however, show significant declines
from their earlier levels of cognitive functioning
 Cognitive impairments appear early, even in childhood wherein
young people with a clinically high risk for developing
psychosis perform less well than healthy controls on certain
neurocognitive tests
 Although people with lower IQs may be more susceptible to
developing schizophrenia, it is nonetheless the case that nay
preexisting cognitive impairments become more prominent and
extensive as the illness progresses
 The cognitive impairments we see in patients experiencing
their first episodes of illness are more severe and more
wide ranging than the cognitive impairments found in
people in the early phases
 Researchers think that a sharp decline in cognitive ability
and OQ occurs during the period of transition from the
premorbid period into full-blown illness
 Continuous performance test – a test containing tasks that
requires the subject to attend to a series of letters or numbers
and then to detect an intermittently presented target stimulus that
appears on the screen along with the letters or numbers
 54-86 percent of people with schizophrenia show eye-tracking
dysfunction
 It has been suggested that disturbances in eye tracking
have a genetic basis and that eye tracking may represent a
viable endophenotype for genetic studies
 Sensory gating - describes neurological processes of filtering
out redundant or unnecessary stimuli in the brain from all
possible environmental stimuli. Also referred to as gating or
filtering, sensory gating prevents an overload of irrelevant
information in the higher cortical centers of the brain.
 Many patients with schizophrenia respond almost as
strongly to the second redundant information as to the first
(P50 suppression)
 The weight of the evidence suggests that patients with
schizophrenia have problems with both basic and higher-level
cognitive processing
SOCIAL COGNITION
 Social cognition is concerned how we recognize, think about,
and respond to social information including the emotions and
intentions of others
 People with schizophrenia show significant impairments in
social cognition
 Failure to detect subtle social hints
 Difficulty recognizing emotion in faces and emotion being
conveyed in speech
 Less able to recognize when people has made a social error
 Although social cognition and nonsocial neurocognition are
related, they are largely distinct constructs which help to explain
how well patients are able to function in the real world
 When it comes to predicting social skills or quality of life
social cognitive abilities seem to play a greater role then
neurocognitive skills
LOSS OF BRAIN VOLUME
 Ventricles – fluid-filled spaces that lie deep within the brain
 Patients with schizophrenia have enlarged brain ventricles,
with males possibly being more affected than females
 Enlargement of ventricles, however, is also characteristic
of patients with Alzheimer’s disease, Huntington’s disease,
and chronic alcohol problems
 Enlargement of ventricles is an indicator of. Reduction in the
mount of brain tissue
 Enlarged ventricles imply that the brain areas that border the
ventricles have somehow shrink of decreased in volume
 Even patients with a recent onset of schizophrenia have lower
overall brain volumes than controls
 Findings suggest that some brain abnormalities likely predate
the illness rather than develop as a result of untreated psychosis
or as a consequence of taking neuroleptic medications
 Changes in brain volume has been suggested to play a causal
role in the onset of symptoms
 The brain changes that characterize people in the early stages of
the illness progressively get worse with time
 Studies of more chronically ill patients suggest that decreases in
brain tissue and increases in the size of the brain ventricles are
not limited to the early phases of this illness
 Progressive brain deterioration continues for many years
 Brain changes can also be found in MZ twins where one
has schizophrenia and the other does not
 Research findings suggest that in addition to being a
neurodevelopmental disorder, schizophrenia is also a
neuroprogressive disorder characterized by a loss of brain tissue
over time
AFFECTED BRAIN AREAS
 There is evidence of reductions in the volume of regions in the
frontal and temporal lobes—brain areas which is critical in:
 Memory
 Decision making
 Processing of auditory information
 There is also a reduction in the volume of medial temporal areas
such as the amygdala
 The hippocampus and the thalamus is also affected
 Clearly, brain structure is abnormal in schizophrenia, but the
nature of the abnormality may be linked to the stage of the
illness, use of medications, or other factors that we still need to
identify
WHITE MATTER PROBLEMS
 Evidence is growing that schizophrenia also involves problems
with white matter
 Myelin sheath – acts as an insulator and increases the
speed an efficiency of conduction between nerve cells
 Studies of patients with schizophrenia show that they have
reductions in white matter volume as well as structural
abnormalities in the white matter itself
 These can be found on first episode patients and in people
at genetic high risk for the disorder
 This suggests that they are not a result of the disease of the
effects of treatment
 Dysconnectivity – the fundamental mental problem which
refers to the abnormal integration between distinct brain regions
 At the clinical level, white matter abnormalities have been
shown to be correlated with cognitive impairments
 White matter changes in the temporal areas of the brain
also predict later social functioning
 Children of people with schizophrenia have a reduction in
the volume of the corpus callosum (tract of white matter
fibers that connects the two hemispheres)
BRAIN FUNCTIONING
 Studies of brain functioning tell us what is going on in the
working brain, either when it is engaged in a task or at rest
 Hypofrontality refers to the abnormally low frontal lobe
activation
 Patients show Hypofrontality when they are involved in
mentally challenging tasks (e.g. Wisconsin Card Sorting
test) or other tests generally thought to require substantial
frontal lobe involvement
 In other patients, hyperactivation in frontal areas is found
which suggests that they are having to work harder to be
successful on the task
 Frontal lobe dysfunction is believed to account for some of the
negative symptoms of schizophrenia and perhaps to be involved
in some attentional-cognitive deficits
 There may be a problem in the way activity in different brain
regions get coordinated
 There is activation in an network of brain areas that comprise
the default mode network
 Brain is on standby basically
 When actively engaged in a task, activity in this network is
suppressed in favor of activity in brain areas that are
relevant to the task at hand
 People with schizophrenia may have had a hard time
suppressing this network
CYTOARCHITECTURE
 If some cells fail to arrive their final destinations and
compromise the overall organization of the brain, the
cytoarchitecture will be affected greatly
 Using complex three-dimensional counting techniques,
researchers have reported an increase in neuronal density in
some areas of the brains of patients with schizophrenia
 Patients with schizophrenia are missing inhibitory neurons
(GABA Interneurons) which are responsible for regulating the
excitability of other neurons
 Absence of this type of neurons may mean that outbursts
of activity by excitatory neurons in the brain go unchecked
BRAIN DEVELOPMENT IN ADOLESCENCE
 We all have an excess of synapses well into our late teens. But
normal processes that occur during adolescence prune these
synapses, thereby decreasing neuronal redundancy
 There is also a marked decrease in gray matter and increase in
white matter volume of the hippocampus and the amygdala
 The number of excitatory synapses decreases and the number of
inhibitory synapses increases
 We can think of schizophrenia as a disorder characterized by
abnormal maturation of the brain and its networks
 People who have had a hospital contact for a head injury have a
65 percent increase in later risk for schizophrenia, which appears
to be independent of having a family history if psychiatric
illness
 The risk increases to 85% if the injury occurs between
ages of 11-15
SYNTHESIS
 The brain is compromised in schizophrenia, although the
compromise is often very subtle
 Some of the brain abnormalities that are found are likely to be
genetic in origin and others may reflect environmental insults
 Baaré and colleagues proposed that genetic risk for
schizophrenia may be associated with reduced brain
development early in life
 They also hypothesized that patients who develop
schizophrenia suffer additional brain abnormalities that are
not genetic in origin.
 In people at genetic risk for schizophrenia, a history of fetal
oxygen deprivation has been shown to be associated with brain
abnormalities in later life
 Even when both members of a twin pair have identical genes, if
only one of them experiences the environmental insult, only one
twin might be pushed across the threshold into illness while the
co-twin remains healthy
 It is unlikely that schizophrenia is the result of any one problem
in any specific region of the brain
 Functional circuits – regions that are linked to other
regions by a network of interconnections
 If there is a problem at any point in the circuit, the circuit
will not function properly
NEUROCHEMISTRY
 The idea that serious mental disorders are due to chemical
imbalances in the brain is now commonplace
 Dopamine hypothesis – derived from three important
observations
 Pharmacological action of the drug chlorpromazine. It was
used in the treatment of schizophrenia in 1952 and is
helpful to patients. It has the ability to block dopamine
receptors
 In the late 1950s and early 1960s, researchers began to see
that abuse of amphetamines led in some cases to a form of
psychosis that involved paranoia and auditory
hallucinations
 There are clinical studies that actually treated patients by
giving them drugs that increase the availability of
dopamine in the brain
- Parkinson’s disease – caused by low levels of
dopamine in a specific brain area and is treated with
a drug called L-DOPA
 Activity in the dopamine system may play a role in determining
how much salience we give to internal and external stimuli
 Dysregulated dopamine transmission may actually make us pay
more attention to and give more significance to stimuli that are
not especially relevant or important (Aberrant salience)
 If dopamine creates aberrant salience, the person will struggle to
make sense of everyday experiences that were previously in the
background but that now have become inappropriately important
and worthy of attention
 How a functional excess of dopamine comes about:
 Too much dopamine in the synapse which can be brought
by overproduction of the neurotransmitter
 Releasing more dopamine in the synapse
 Slowing down of the rate at which dopamine is
metabolized or broken down once it is in the synapse
 Ways in which functional excess of dopamine could be
mimicked
 If receptors that dopamine acts on are especially dense and
prolific or of they are especially sensitive, the effects of a
normal amount of dopamine released into the synapse
would be multiplied
 Learning about dopamine in brains of people with schizophrenia
 Measuring dopamine in the brains of deceased patients
 Study dopamine indirectly by measuring its major
metabolite
  Homovanillic acid – major metabolite of dopamine which is
best collected in cerebrospinal fluid
 The biggest abnormality in dopamine functioning occurs
presynaptically
 Subtypes of dopamine receptors
 D1
 D2 – most relevant clinically and is most researched on; it
is increased in patients with schizophrenia
 D3 – it is increased in patients with schizophrenia
 D4
 D5
 Glutamate – an excitatory neurotransmitter that is widespread
in the brain
 PCP or angel dust is known to block glutamate receptors
 PCP induces positive and negative symptoms that are very
similar to those of schizophrenia
 Ketamine – an anesthetic that produces positive and negative
symptoms like that of schizophrenia. It exacerbates
hallucinations, delusions, and thought disorder.
 Can be administered to children and animals
 It is suggested that age and brain maturity determines
whether ketamine produces psychosis
 It also blocks glutamate receptors as PCP
 The glutamate hypothesis of schizophrenia is now attracting a
lot of research attention and is also prompting the development
of new experimental drugs that might provide additional ways to
treat schizophrenia
PSYCHOSOCIAL AND CULTURAL FACTORS
DO BAD FAMILIES CAUSE SCHIZOPHRENIA?
 Schizophrenic mother – behavior was cold and aloof and is
thought to be the root cause of schizophrenia
 Theories that were popular many decades ago, like the idea that
the disorder was caused by destructive parental interaction, have
foundered for lack of empirical support
 Double-bind hypothesis – an idea that has not stood the test of
time which states that a double bind occurs when the parent
presents the child with ideas, feelings, and demands that are
mutually incompatible
 However, keep In mind that disturbances and conflict in
families that include an individual with schizophrenia may
well be caused by having a person with psychosis in the
family
- Family communication problems could be the result
of trying to communicate with someone who is
severely ill and disorganized
 Amorphous and fragmented communications brought by
communication deviance may actually reflect genetic
susceptibility to schizophrenia on the part of the relative
FAMILIES AND RELAPSE
 Schizophrenia is often a chronic disorder and its symptoms may
be especially severe at times
 Patients who returned home to live with parent or with a spouse
were at higher risk of relapse than patients who left the hospital
to live alone or with siblings
 Highly emotional environments might be stressful to
patients
 Expressed emotion – is a measure of the family environment
that is based on how a family member speaks about the patient
during a private interview with a researcher
1. Criticism – reflects the dislike or disapproval of the patient
2. Hostility – extreme form of criticism that indicates a
dislike or rejection of the patient as a person
3. Emotional overinvolvement – reflects a dramatic or
overconcerned attitude on the part of the family member
toward the patient’s illness
 It is shown to predict relapse in patients with
schizophrenia
 Expressed emotion also predicts relapse even when
potentially important patient variables are controlled
statistically
 EE levels in families are inversely related with patient’s
relapse rates
 There is a great deal of evidence that patients with
schizophrenia are highly sensitive to stress.
Environmental stress is thought to interact with preexisting
biological vulnerabilities to increase the probability of
relapse
 Cortisol (a glucocorticoid that is released when we are
stressed) affects the two of the major neurotransmitters
implicated in schizophrenia
- if patients are stressed by what their relatives do, this
could increase cortisol levels, affect important
neurotransmitter systems, and may even lead to a
return of symptoms
 Researchers are now using functional neuroimaging techniques
to learn more directly how EE affects the brain
 Hearing criticism or being exposed to emotionally
overinvolved comments leads to different patterns of brain
activity in people who are vulnerable to psychopathology
compared to healthy controls
URBAN LIVING
 Being raised in an urban environment seems to increase a
person’s risk of developing schizophrenia
 it has been found that children who had spent the first 15 years
of their lives living in an urban environment were 2.75 times
more likely to develop schizophrenia in adulthood (Mortensen,
2001)
IMMIGRATION
 It has been suggested that stress or social adversity might be
important factors to consider with respect to this disorder
 Immigrants have much higher risks of developing schizophrenia
than do people who are native to the country of immigration
 First generation immigrants have 2.7 times the risk of
developing schizophrenia
 Second generation immigrants have a relative risk that was even
higher at 4.5
 It is possible that immigrants are more likely to receive the
diagnosis die to cultural misunderstandings
 Another hypothesis is that people who are genetically
predisposed to develop schizophrenia are more likely to move to
live in another country
 Furthermore, experiences of being discriminated against could
lead some immigrants to develop a paranoid and suspicious
outlook in the world, which could set the stage for the
development of the disorder
 Another possibility suggested by animal studies is that the stress
that results from social disadvantage and social deficit may have
an effect on dopamine release or dopamine activity in key neural
circuits
CANNABIS USE AND ABUSE
 People with schizophrenia are twice as likely as people in the
general population to smoke cannabis
 A number of studies have now replicated the same link and have
highlighted early cannabis use as being particularly problematic
 Research findings suggest that using cannabis during
adolescence more than doubles a person’s risk of
developing schizophrenia at a later stage of life
 A metanalysis involving 8167 patients with psychosis has
shown that those who used cannabis had an earlier onset of
their symptoms compared to non-users
- This could be because one of the active ingredients
of Cannabis (Tetrahydrocannabinol; THC) increases
dopamine in several areas of the brain
 Having a family history of schizophrenia may make people
more sensitive to the psychosis-inducing effects of cannabis
 People carrying a particular form of the COMT gene were
at increased risk for developing psychotic symptoms in
adulthood if they used cannabis during adolescence
 There is some evidence that cannabis may actually accelerate
the progressive brain changes that seem to go along with
schizophrenia
A DIATHESIS-STRESS MODEL FOR SCHIZOPHRENIA
 Schizophrenia is a genetically influenced, not a genetically
determined, disorder
 There is not simple answer to the question of what causes
schizophrenia as the etiology of the disorder is complex and
complicated
 Predisposing genetic factors may have combined in additive and
interactive ways with multiple environmental risk factors
 How we are born and how we live make major
contributions
TREATMENTS AND OUTCOMES
 Before the 1950s the prognosis for schizophrenia was bleak and
treatment options were very limited
 Dramatic improvement came in the 1950s when antipsychotics was
introduced
CLINICAL OUTCOME
 Studies of clinical outcome shot that 15-25 years after
developing schizophrenia, around 38% of patients have a
generally favorable outcome and can be thought of as being
recovered
 Around a third of patients show continued signs of illness,
usually with prominent negative symptoms
 Patients who live in less industrialized countries tend to do
better overall than patients who live in more industrialized
nations
 this may be because of levels of EE are much lower in
countries such as India than in the united states
MORTALITY
 the health risks of having schizophrenia cannot be understated
 It is a disorder that reduces life expectancy
 Men with schizophrenia tend to die 14.6 earlier than would be
expected based on national norms
 Women with schizoaffective disorder has a lifespan reduction of
17.5 years
 Factors implicated in early death include
 Long term use of antipsychotic medications
 Obesity
 Smoking
 Poor diet
 Use of illicit drugs
 Lack of physical activity
PHARMACOLOGICAL APPROACHES
FIRST-GENERATION ANTIPSYCHOTICS
 These are medications are among the first to be used to treat
psychotic disorders
 Also referred to as neuroleptics
 These medications revolutionized the treatment of schizophrenia
when they were introduced in the 1950s and can be regarded as
one of the major medical advances of the 20th century
 There is overwhelming evidence that antipsychotic medications
help patients
 Large numbers of clinical trials have demonstrated the efficacy
and effectiveness of these drugs
 The earlier that patients receive these medications, the better
they tend to do over the longer term
 These medications are believed to work by interfering with
dopamine transmission at the D2 receptors
 They work best for positive symptoms of schizophrenia
 Common side effects include
 Drowsiness
 Dry moth
 Weight gain
 Extrapyramidal effects – involuntary movement abnormalities
that resemble Parkinson’s disease
- Muscle spasms
- Rigidity
- shaking
 African Americans and other ethnic minorities appear to
be at increased risk of this side effect
 Controlled by taking other medications
 Tardive dyskinesia – developed by patients with long term
treatment of neuroleptics; involves marked involuntary
movements of the lips and tongue
 Neuroleptic malignant syndrome – a very rare case where
there is a toxic reaction to the medication
SECOND-GENERATION ANTIPSYCHOTICS
 Began to appear in the 1980s
 Clozapine was the first of this generation to be used clinically
 Introduced in the united states
 Other examples
 Risperidone (Risperdal)
 Olanzapine (Zyprexa)
 Quetiapine (Seroquel)
 Ziprasidone (Geodon)
 Aripiprazole (Abilify)
 Lurasidone (Latuda)
 They are called second-generation antipsychotics because they
case fewer Extrapyramidal symptoms than the earlier
medications such as Thorazine and Haldol
 They are less likely to cause movement problems
 Side effects include:
 Drowsiness
 Considerable weight gain
 Diabetes
 Life-threatening drop in white blood cells
(agranulocytosis)
OTHER APPROACHES
 The fact that women with schizophrenia tend to do better than
men has prompted some researchers to explore the potentially
beneficial role of estrogen in the treatment of the disorder
 In a study of 102 young women, women who had worn a
genuine estrogen-containing patch reported significantly fewer
overall symptoms at the end of the 1-month study compared to
the placebo group
PATIENT’S PERSPECTIVE
 Not all patients benefit from antipsychotic medications and
many who do show clinical improvement will still have
problems functioning without a great deal of additional help
 Side effects can sound trivial to someone on the outside can be
so bad for patients that they refuse to take their medications,
even when those medications give them relief from their
hallucinations and delusions
 Research using PET shows that increased blockade of D2
dopamine receptors is associated with patients reporting more
negative subjective experiences such as feeling tired and
depressed even when other side effects are absent
PSYCHOSOCIAL APPROACHES
FAMILY THERAPY
 The idea was to reduce relapse in schizophrenia by changing
those aspects of the patient-relative relationship that were
regarded as central to the EE construct
 This generally involves working with patients and their families
to educate them about schizophrenia, to help them improve their
coping and problem-solving skills, and to enhance
communication skills
 Despite being effective across cultures, it is not a routine
element in the accepted standard of care for patients with
schizophrenia
CASE MANAGEMENT
 Case managers – are people who help patients find the services
they need in order to function in the community
 They act as a broker, referring the patient to the people
who will provide the needed service
 Assertive community treatment programs are specialized and
more intensive form of case management
 These are cost effective because they reduce the time that
patients spend in the hospital
 They also enhance the stability of patient’s housing
arrangements
 These approaches seem to be beneficial for patients who
are already high utilizers of psychiatric and community
services
SOCIAL-SKILLS TRAINING
 Patients with schizophrenia often have trouble forming
relationships, finding and keeping a job, or living independently
 Functional outcome or clinical outcome – is concerned with
how well patients do in their everyday lives
 Social skills training helps improve the functional outcome of
patients with schizophrenia
 Designed to help patients acquire the skills they need to
function better on a day-to-day basis
- Employment skills
- Relationship skills
- Self-care skills
- Skills in managing medications or symptoms
- Conversational skills
o Learning to make eye contact
o Speaking at a normal and moderate
volume
o Taking one’s turn in a conversation
  Patients who receive this treatment are less likely to
relapse and need hospital treatment
 Social cognitive skills training – designed to improve the
deficits in social cognition
 Findings suggest that these interventions do provide
benefits to patients and help them function better in the
community

COGNITIVE REMDIATION
 Using practice and other compensatory techniques, researchers
are trying to help patients improve some of their neurocognitive
deficits
 The hope is that these improvements will translate into better
overall functioning
 Cognitive remediation does seem to help patients improve their
attention, memory, and executive functioning skills
 It may work best when they are added to other existing
rehabilitation strategies

COGNITIVE BEHAVIORAL THERAPY

 The goal of these treatments for patients with schizophrenia is to
decrease the intensity of positive symptoms, reduce relapse, and
decrease social disability
 Therapist and patient work together and explore the subjective
nature of the patient’s delusions and hallucinations
 Current data suggests that it is not very helpful for negative
symptoms

INDIVIDUAL TREATMENT
 Before 1960 the optimal treatment for patients with
schizophrenia was psychoanalytically oriented based on a
Freudian type of approach
 Research began to suggest that in some cases, psychodynamic
treatments made patients worse
 Individual treatment now takes a different form
 Personal therapy – a non-psychodynamic approach that equips
patients with a broad range of coping techniques and skills
 It is staged and comprises different components that are
administered at different points in the patient’s recovery