Schizophrenia.pdf

Unit 1 Schizophrenia* Structure 1.0 Objectives 1.1 Introduction 1.2 What is Schizophrenia? 1.3 Overview on the Symptoms of Schizophrenia 1.3.1 Positive Symptoms 1.3.2 Negative Symptoms 1.3.3 Disorganised Symptoms 1.4 Types of Schizophrenia 1.5 Biological Causal Factors 1.5.1 Genetic Influences 1.5.2 Prenatal Exposure 1.5.3 Neurodevelopmental Factors 1.5.4 Neuroanatomical Factors 1.5.5 Neurochemical Factors 1.5.6 Neurocognitive Factors 1.6 Psychological and Cultural Causal Factors of Schizophrenia 1.7 Diathesis-Stress Model of Schizophrenia 1.8 Treatment for Schizophrenia 1.9 Let Us Sum Up 1.10 References 1.11 References for Figures 1.12 KeyWords 1.13 Answers to Check Your Progress 1. 14 Unit End Questions 1.15 Web Resources 1.0 OBJECTIVES After reading this unit, you will be able to, describe the clinical picture of schizophrenia; elaborate on the positive, negative and disorganised symptoms of schizophrenia; discuss the different types of schizophrenia; identify other psychotic disorders; * Dr. Itisha Nagar,Assistant Professor of Psychology, Kamla Nehru College, University of Delhi, New Delhi 15 Mental Disorders- II elaborate on the biological etiology of schizophrenia; describe the psychosocial and cultural factors affecting schizophrenia; and explain the treatment of schizophrenia. 1.1 INTRODUCTION Academic Counsellor Dr. Mahima is interacting with the learners of BAPCH programme and she is discussing about the BPCC113 course on Understanding and Dealing with Psychological Disorders. Let us look at her conversation with the learners of BAPCH. Dr. Mahima: Hello learners. Learners: Hello Maam. Dr. Mahima: So are we ready to discuss about BPCC113 course. Learners: Yes Maam. Seema (Learner): Maam I had one question. Maam this is the same course that we studied in the last semester. Why are we studying this again? Dr. Mahima: No Seema, this is not the same course. As you notice, the title of this course is similar to that of BPCC111, but if you read it clearly, the title of this course is Understanding and Dealing with Psychological Disorders. Whereas, BPCC111 was Understanding Psychological Disorders. Rahim (Learner): Then, Maam, what is the difference. Dr. Mahima (With a smile): I do like your curiosity. Well, BPCC111 was about Psychological disorders and this course that is BPCC113 is in a way a continuation of BPCC111, where we will discuss some more psychological disorders. But more importantly we will also discuss about the treatment part. John (Learner): So Maam, in treatment, do we talk about medication etc. Dr. Mahima: John, though we will learn a bit about Pharmacotherapy. All the learners need to remember that psychologists do not prescribe medication. Navjyot (Learner): In that case Maam, how do we treat the disorders. Dr. Mahima: Well, there are various psychotherapies that we will learn about in the block 2 of this course. But before that we will cover some more psychological disorders, that we were not able to cover in BPCC111. So let us start with discussion on these psychological disorders. As it must be clear from the above conversation, in BPCC113, we will not only cover some of the psychological disorders but will also focus on the treatment of the psychological disorders. Thus, the course is divided in to two blocks, block 1 and block 2. Block 1 covers the psychological disorders and block 2 will focus on the treatment part. So let us now start with discussion on an important psychological disorder, that is Schizophrenia. 16 Schizophrenia DSM and ICD: What are they? DSM: The full form of DSM is Diagnostic and Statistical Manual of Mental Disorders. It is basically a handbook that provides detailed guidelines that can be followed in order to diagnose mental disorders. Each mental disorder is categorised and criteria for their diagnosis is clearly given in this manual. It is released by American Psychiatric Association. And the latest, DSM 5, was released in 2013, before which DSM IV TR was followed. ICD: Though in the present course we have discussed the psychological disorders as per DSM, there is ICD as well that is followed for classification of disorders. ICD stands for International Statistical Classification of Diseases and Related Health problems and is maintained by WHO. The latest version of ICD, that is ICD 11 was accepted in 2019 and will come in to effect 2022 onwards. In the present course, we will follow DSM 5. 1.2 WHAT IS SCHIZOPHRENIA? Consider the following examples; A 25-year-old woman cries and tells you that she is hearing voices of people crying and abusing her. A 45-year-old woman sits silently for days and doesn’t respond to anything or anyone. She blankly stares at you if you try to strike a conversation with her. A 30-year-old man covers his laptop’s camera claiming that the aliens are recording everything that he does. He wraps the laptop in a red cloth and keeps it locked inside his cupboard. Each of the above cases may have schizophrenia, a broad spectrum of condition that affects individual’s cognitive and emotional functioning including delusions and hallucinations, disorganised speech, behaviour and inappropriate emotions. Schizophrenia is a serious condition that affects almost all aspects of daily functioning. The hallmark of the condition is a break from reality and withdrawal into their own world of delusions and hallucinations. It is characterised by disordered thinking: thoughts are not logically related, faulty perception and attention; disturbed emotions: lack of emotional expressiveness or inappropriate emotions; and disturbed behaviour: disturbances in movement, disheveled appearance, lack of self-care. People with schizophrenia may withdraw from reality into their own world of delusions and hallucinations. Given that the disorder affects so many aspects of daily functioning, schizophrenia takes a toll on the individual and his/her family. Symptoms of schizophrenia can make stable employment and interpersonal relationships a challenge often leading to homelessness in many cases. Schizophrenia is one of the most complex and severe of all mental disorders. It usually begins in adolescence and early adulthood, usually somewhat earlier in men than women. People with schizophrenia usually have acute episodes over the lifetime and less severe but still challenging symptoms between episodes. About 50 percent of people with schizophrenia also 17 Mental Disorders- II have co-morbid substance abuse. They are 12 times more likely to commit suicide than the general population. People with schizophrenia not only suffer from the condition but also from the stigma associated with the condition. They are likely to face discrimination, ridicule and in general be devalued by the society. Abandonment by family is common. In spite of advanced research in treatment of schizophrenia, complete recovery from schizophrenia is rare. The search from causes and treatment of schizophrenia is made complicated by the presence of different presentations and combinations of symptoms such as hallucinations, delusions, disorders of speech, emotion and socialisation. DSM-5 recognises schizophrenia and other related psychotic disorders under the head of schizophrenia spectrum disorder. Other related disorders include, schizoaffective disorder, schizophreniform disorder, delusional disorder and brief psychotic disorder. In this Unit, we will discuss schizophrenia and other related psychotic disorders. Box 1.1: DSM-5 Criteria for Schizophrenia Spectrum Disorders (APA,2013) A. Two or more of the following for at least a one-month (or longer) period of time, and at least one of them must be 1, 2, or 3: 1) Delusions 2) Hallucinations 3) Disorganised speech 4) Grossly disorganised or catatonic behaviour 5) Negative symptoms, such as diminished emotional expression B. Social-Occupational Dysfunction: Impairment in one of the major areas of functioning for a significant period of time since the onset of the disturbance: Work, interpersonal relations, or self-care. C. Duration: Some signs of the disorder must last for a continuous period of at least 6 months. This six-month period must include at least one month of symptoms (or less if treated) that meet criterion A (active phase symptoms) and may include periods of residual symptoms. During residual periods, only negative symptoms may be present. D. Schizoaffective and Major Mood Disorder Exclusion: Schizoaffective disorder and bipolar or depressive disorder with psychotic features have been ruled out. E. Substance/General Medical Condition Exclusion: The effects of a substance or another medical condition do not cause the disturbance. F. Relationship to Global Developmental Delay or Autism Spectrum Disorder: If there is a history of autism spectrum disorder or a communication disorder (childhood onset), the diagnosis of schizophrenia is only made if prominent delusions or hallucinations, along with other symptoms, are present for at least one month. The prevalence rate of schizophrenia is a little less than 1 percent, and is approximately 0.7 percent which means about 1 out of 140 individuals who survive until at least age of 55 will develop the disorder. ( APA, 2013). However, this is the number for those who come from families where there has never been a case of schizophrenia. Some individuals may have statistically 18 higher risk of developing the disorder than others. For instance, this may Schizophrenia include those whose parents had schizophrenia. A vast majority of cases of schizophrenia begin in late adolescence and early adulthood. Although in rare cases schizophrenia may be diagnosed in children. According to Li and colleagues (2016), there is gender difference in prevalence rates of schizophrenia, that is for every 3 men diagnosed with schizophrenia only 2 women are diagnosed. Additionally, schizophrenia tends to begin earlier in men than women. In females there may be a late onset of schizophrenia, which is attributable to the protective roles played by female hormones such as estrogen. In addition to having early onset of schizophrenia, males also tend to have more severe form of schizophrenia. Looking at the history of the concept of schizophrenia, Emil Kraepelin and Eugen Bleuler, two European psychiatrists initially formulated the concept of schizophrenia. Kraepelin first identified schizophrenia in 1896 as a ‘dementia praecox’ or premature deterioration of the brain. Dementia praecox included several diagnostic subtypes dementia paranoids (delusions of grandeur or persecution), catatonia (alternating immobility and excited agitation), and hebephrenia (silly and immature emotionality) that were considered to be distinct categories before him. Kraepelin believed that they shared a common core; all of them had early onset and led to progressive deterioration of the brain. Bleuler disagreed with Kraepelin on these two major counts: (1) the disordermay not always have an early onset and (2) the disorder does not lead to progressive, inevitable deterioration of the brain. Thus, Bleuler in 1908 replaced the word dementia praecox with schizophrenia, from the Greek words ‘schizein’ (“to split”), and ‘phren’ (“mind”). The split accounts associative splitting, split from reality and withdrawal into an inner world and a splitting between the thoughts and an utter disorganisation of thought processes. Unfortunately, the concept of split in schizophrenia inspired the common misunderstanding that schizophrenia is split or multiple personality. Check Your Progress I 1) What is schizophrenia? _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 1.3 Overview on the Symptoms of Schizophrenia John Forbes Nash Jr. won the Nobel Prize in Economic Sciences in 1994, but for most of his life he balanced his mathematical genius against his struggle with schizophrenia. His life and struggles have been beautifully presented in the Oscar award winning movie, ‘A Beautiful Mind’. John Nash’s intellectual brilliance and his history with schizophrenia and both began at a young age. As a young boy, Nash was “a singular little boy, solitary and introverted”. He used to be socially aloof, was intellectually 19 Mental Disorders- II above average but performed below average. Because of his poor social skills, his parents forced him to participate in social activities although he did not enjoy them. As an adult Nash experienced auditory hallucinations and delusions. He hallucinated about a Princeton college roommate and had both persecutory delusion that he was being chased by Russian spies and delusion of grandeur that he worked for a secret service agency helping them decode secret codes. He commented that, “I started to hear something like telephone calls in my brain, from people who were opposed to my ideas”. His wife corroborates erratic behaviour with evidentiary accounts of writing on walls, elaborate narrative referring to himself with a different name, writing nonsensical postcards, and making persistent phone calls to former colleagues. He was admitted to psychiatric hospitals multiple times, and received several weeks of insulin-induced shock therapy. Rare for his condition, John Nash was in full remission for over 20 years. He and his wife met with a car accident and passed away in the year 2015. Let us now look at the various symptoms of schizophrenia. Early on symptoms of schizophrenia were divided into two categories positive and negative symptoms. Positive symptoms consist of feelings or behaviours that are usually not present; an addition or excess in normal repertoire of behaviour and experiences. Positive symptoms are characterised by bizarre and odd behaviour. Hallucinations and delusions are examples of positive symptoms. Relative to negative symptoms, positive symptoms are associated with sudden onset and acute episodes. They are associated with neurochemical changes in the brain and relatively minimal cognitive impairment compared to negative symptoms. Prognosis of people with positive symptoms is thus relatively better. Negative symptoms on the other hand refer to lack of feelings or behaviours that are usually present that is, absence/deficit of normal behaviour. They are not as dramatic as positive symptoms, but are nevertheless extremely damaging aspects of schizophrenia and are often more difficult to treat. Compared to positive symptoms, negative symptoms have insidious onset and chronic in nature. Negative symptoms include poverty of speech, flat affect, avolition, apathy, and asociality. They are associated with structural brain changes and significant cognitive impairment that are not largely affected by medications. The prognosis for schizophrenia with predominance of negative symptoms is poorer than positive symptoms. Apart from positive and negative symptoms, a third dimension, which appeared important, was added to the symptomatology of schizophrenia, disorganised symptoms. Disorganised symptoms consist of disorganised speech, affect, and behaviour. This division has been very useful in research on etiology and treatment of schizophrenia 20 Schizophrenia Positive Negative Disorganised Symptoms Symptoms Symptoms Avolition Disorganised Delusions Speech Alogia Hallucinations Disorganised Affect Anhedonia Disorganised Asosciality Behaviour Flat Affect Fig. 1.1 Symptoms of Schizophrenia 1.3.1 Positive Symptoms The positive symptoms of Schizophrenia are discussed as follows: a) Delusions: Delusion comes from the Latin word ‘ludre’, which means to play. Delusions are tricks that the mind plays on an individual. It refers to an erroneous belief that is held firmly in spite of contradictory evidences. It would be wrong to say that all people with schizophrenia have delusions, but it is present in about 90 percent of them. There are many different types of delusions, some more common (persecutory) and others less common (for example, Cotard’s syndrome, which is a relatively rare condition that may comprise of any one or a series of delusions like, having lost one’s organs, blood, or body parts and may insist that one has lost one’s soul or is dead). The different types of delusions have been discussed below. Persecutory Delusions: Persecutory delusions are fixed and irrational belief that someone is being harmed or harassed in some way, “someone is out to get me.” For instance, John Nash believed that the Russian spies were out to get him. It is present in almost 65 percent of people diagnosed with schizophrenia. Famous Hindi movie actress Parveen Babi was also diagnosed with schizophrenia. Her delusional belief made her think that other famous actors were trying to harm her and even filed a complaint against them. Control Delusions: Control delusions consist of an irrational belief that a person is being somehow controlled by an external agency (other people, government, aliens, God, etc.). Based on the manner of the control exercised, control delusions include, thought insertion, thought broadcasting, thought withdrawal, and external control. In thought insertion, a person might believe that his or her own thoughts have been placed there by an external 21 Mental Disorders- II agency. For example, “government has inserted a computer chip in my brain so that thoughts can be implanted in my mind”. In thought broadcasting,a person might believe that his or her own thoughts are being broadcast and transmitted, so others know what he or she is thinking. For example, “I don’t need to tell you about me since you can hear my thoughts well”. In thought withdrawal, a person might feel someone has robbed one’s thoughts. For example, a man continually blames his poor memory on “government agents” who he claims are able to steal his thoughts. And a person might feel his/her feelings are controlled by external force. For example, a person believes that his behaviour is being controlled by radio frequency waves emitted by cell phone towers and that a chip is put in him to control his behaviour. Grandiose Delusions: Refers to exaggerated sense of importance, power, knowledge, or identity. It also includes belief in exceptional relationship to divinity or an important person. For instance, John Nash believed he was able to decode secret codes sent by Soviet in newspapers and magazines and was employed by CIA.Taking another example, a person with schizophrenia thought her son was an avatar of God Vishnu. Somatic Delusions: Somatic delusions refer to an irrational belief that one’s physical body is affected, usually in a negative way often by an outside source. For instance, a person believes that her left leg is twisted in spite of contrary medical and family assurances. Ideas of Reference: These delusions consist of a fixed believe that everyday events have special reference to one self. For example, a TV anchor is watching the person from the TV screen. Frequent appearance of a person while walking in garden means they are being followed. When you are walking on the road, and you overhear a few people talking, then you believe that the overheard segments of conversations are about them. They may believe that magazine articles and newspapers somehow are personally referring to them. Researchers have noted that many different forces, including sociocultural and political experiences, can shape an individual’s delusional content. Dr. B.N. Gangadhar, Professor, NIMHANS, Bangalore has noted that patients’ delusions are coloured by the current knowledge that they have. For example, in a post-world war world, John Nash’s persecution belief was that he could find secret Soviet codes in magazines and newspapers. With advancement in technology, popular delusions are no longer limited to being followed, people may believe that they are being tracked through Google and Yahoo, having search engines throwing up a person’s name to the world all the time, and being followed through phone apps that reveal one’s location. Lerner and colleagues (2006) examined two cases (A and B) in which people diagnosed with schizophrenia suffered from the delusion that internet was affecting them negatively. Case A: Was found to be wearing a saucepan on his head to protect himself from the “powers of the internet”. Case B: Believed that people on an Internet website can observe all of her actions 24 hours a day. 22 b) Hallucinations: Sometimes we may have perceptual experiences like, Schizophrenia hearing someone call our name or seeing something moving when actually it does not. However, for many people these experiences are fleeting and uncommon. We readily agree that we perhaps misperceived, our names or the movement of the object. However, in people with schizophrenia these experiences, known as hallucinations are common. Thus, hallucinations or sensory experiences in absence of any input from the environment is common. Hallucinations can affect any sensory modality but auditory hallucinations are by far the most common, occur in 75 percent cases with schizophrenia. A patient with schizophrenia with auditory hallucinations shares, “Tell me how can I do anything when all I can hear are the voices crying from inside of me. The voices are so sad they are howling, crying, wanting my help, and I can do nothing about them. I cannot stop them.” Other kind of hallucinations are visual hallucinations. For instance, in the movie A Beautiful Mind, it was shown that John Nash would see his roommate from Princeton college, who did not exist. Another person with schizophrenia who could smell poison in the food made for him was affected with olfactory hallucinations. Example of tactile hallucination includes the misperception of a person who constantly feels that ants are crawling up the arms. Finally, gustatory hallucination is the experience of a person with schizophrenia who can taste bitterness in everything they eat and drink. There are very rare cases of people with schizophrenia who enjoy their hallucinations. For instance, the hallucination of one’s dead mother can be an enjoyable experience for a man. But in most cases hallucination are frightening and annoying. Many people report that the voices they hear are abusive and derogatory, like you’re ugly and stupid.” Studies report that the voices are usually at normal conversational volume, known to the patient in real life. There are more than one voice, and often worse, when the person is alone. People may become emotionally involved with their hallucinations and would often incorporate them in their hallucinations. For instance, a person with persecutory delusions may hear “God” instructing him to hurt those around him. In such cases, a person may even act on their hallucinations and do what the voices tell them to do. Researchers suggest that people who are hallucinating others’ voices are actually listening to their own thoughts and voices, but may misinterpret them as coming from some other source. 1.3.2 Negative Symptoms The negative symptoms of schizophrenia are discussed as follows: a) Avolition: Avolition refers to a lack of motivation and seeming absence of will/ interest in the ability to persist in routine activities like self-care, work, and/or school. For example, people with schizophrenia may become inattentive to grooming and personal hygiene, may have uncombed hair, dirty nails, unbrushed teeth, and disheveled clothes. 23 Mental Disorders- II Box 1.2 Examples of Disorganised Speech Loose Associations “My cat is fat. I like monkey soup. They said who barber shipping off blade hair. Don’t let barber in house he brings evil things. Today is independence day. Flag from your house will be held. Sing song every lady will. Stop telling me to kill my sister. She is good. Supermarket is good today. I will call him he will dance on earth. Water is gone planet will also jump and dance.” Neologisms “I am here from India...and you have to have a “faucity” of all acts of “memvers” to go through for the children’s code...and it no “blutenence”...it is an “amortion” law...there is nothing to cater me....it is like their “privatilinia” Clang Associations Psychiatrist: “How are you feeling today?” Patient: “Well, hell, it’s well to tell. Who can tell me the name of my song? I don’t know but it won’t be long. It won’t be short, tall, none at all.” Tangential Speech Psychiatrist: “Do you know where you are?” Patient: “In the hospital...”(voice trails off). Psychiatrist: “Yes, go ahead continue.” Patient (after considerable silence): “The hospital is next to park I can smell.” Psychiatrist: “Smell what?” Patient: “Smell of a chocolate cake” b) Alogia: Alogia means significant reduction in the amount of speech that is, people with schizophrenia do not talk much. They may answer a question in one-two words and then may stop responding. Their comments are likely to be delayed or slow. Research has found that in alogia, people with schizophrenia may display their difficulty with formulating their thoughts and not their inadequate communication skills. c) Anhedonia: Anhedonia is a presumed loss of interest and experience of reported pleasure in activities that are typically considered pleasurable for everyone, such as food, socialisation, sexual relations, hobbies, watching TV, etc. Researchers have distinguished between consummatory pleasure or the in-the-moment pleasure (example, amount of pleasure experienced while eating good meal) and anticipatory pleasure, which refers to the expected or anticipated pleasure from a future event (for instance, anticipated pleasure of going on a trip, graduating, celebrating festivals etc.). It has been found that people with schizophrenia report loss of anticipatory pleasure and not consummatory pleasure. d) Asociality: Some people with schizophrenia have severe impairments in social relationships, for instance they have few friends, poor social skills, and very little interest in being with other people. Instead, they wish to spend much of their time alone. In case of John Nash, it was reported that he had poor social skills since childhood, and his parents would often force him to go out with friends and socialise. 24 e) Flat Affect: Flat affect is the lack of outward expression of emotion. A Schizophrenia person with this symptom may appear to be inexpressive, have a poker face, stare lifelessly at others, and the muscles of the face would lay motionless. Their voice is also flat and toneless and they may even not look at others while replying to them. This symptom has been found to effects large number of people with schizophrenia. However, it is important to point out that the concept of flat affect refers only to the outward expression of emotions and not the patient’s inner experience. Studies have found that people with schizophrenia display much less expressions facially than control group, but they reported experiencing the same amount of emotion and were even more physiologically aroused. 1.3.3 Disorganised Symptoms Disorganised symptoms of Schizophrenia are as follows: a) Disorganised Speech: Psychologists talk about two kinds of thought disturbances namely, disturbances in content and form. While presence of delusions in thinking is indicating of disturbances in the content of the thought, disorganised thinking/speech is disturbance in the thought form, also known as formal thought disorder. Disorganised speech includes problems in organising ideas and speaking so that that the listener can understand. As a symptom, disorganised speech is not only unique to schizophrenia ; it is also present in mania, depression, and dementia. To the listener, disorganised speech sounds like as if someone as put a paragraph in a blender. In disorganised speech one can make out that there are repeated references to central themes and ideas, however the thoughts are not connected. It is very difficult for the listener to make out the meaning behind the speech. This inability to communicate meaningfully is not attributed to poor intelligence, cultural deprivation or poor environment. Different forms of organised speech have been studied. Derailment or loose associations: In case of derailment the verbalizations are not connected, forgotten mid-sentence, jumbled up, or mixed in their phrasing. Loose association is also known as word salad. Neologisms: Neologisms refer to making up of new words that do not make sense to the listeners and carry a meaning only for the person with schizophrenia. Clang Associations: Clang associations are repetitions of same words over and over and so speak in a manner that the words rhyme. Alogia: Alogia is lack of speech caused by disruption of thinking processes. A patient displaying symptoms of schizophrenia will fail to respond, speak very slowly, or their answers will lack spontaneity. Tangential Speech: In tangential speech the patient with schizophrenia will respond clearly to the topic in question, stop abruptly and then talk about a completely different topic. A person with schizophrenia describes what it is like to have a disorganised speech: “My thoughts get all jumbled up. I start thinking or talking about something but I never get there. Instead, I wander off in the wrong direction and get caught up with all sorts of different things that may be connected with things I want to say but, in a way, that I cannot explain” 25 Mental Disorders- II Fig. 1.2 Various forms of Disorganised Speech b) Disorganised Affect and Behaviour:While in disorganised speech, a person with schizophrenia loses the ability to communicate by organising thoughts. In disorganised behaviour, people lose their ability to organise their behaviour to make it conform to social standards. For instance, they may get into unreasonable bouts of agitation, dress in unusual clothes, mutter to themselves, act childlike in a silly manner, speak to themselves, and hoard food or garbage. Disorganised affect similarly means difficulty in organising emotions to suit to the needs of the situation. For instance, the person may laugh at someone’s death, cry during a happy moment, or get very angry when someone asks a simple question like how are they doing? They are likely to shift from one emotion to another without any apparent reason. Because of disorganised affect and behaviour, a person may have difficulty in functioning in everyday life. The person may not be able to look after self, one’s hygiene, dress or even eat. A striking example of disorganised behaviour is catatonia or the motor dysfunctions that range from wild agitation to immobility. On one end of the catatonic spectrum, some people may become extremely agitated, pace rapidly, or move fingers in stereotyped way. On the other hand, patient with catatonia may show almost an absence of movement and speech. The person may appear to be completely unaware of the surroundings. For instance, the person may hold an unusual posture for a long period of time without any seeming discomfort. Catatonia may involve waxy flexibility. People with schizophrenia may also exhibit echolalia (repetition of other people words) or echopraxia (repetition of other’s actions). For many, it is perplexing to understand how do people with schizophrenia maintain their position for such long period of time? Researchers have found cases of schizophrenia with pain insensitivity, although the causes are unclear but brain areas with pain perception are unclear. Clinical picture of schizophrenia dominated by catatonic symptom was diagnosed as a type of schizophrenia in DSM IV. However, in DSM-5, catatonia is not a separate condition, but it is associated with many psychiatric conditions like schizophrenia, bipolar disorder, depression, and other disorders. 26 Check Your Progress II Schizophrenia 1) List the three categories of symptoms of schizophrenia. _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 1.4 TYPES OF SCHIZOPHRENIA Emil Kraepelin distinguished between three subtypes of schizophrenia: paranoid, disorganised, and catatonia, which were used till DSM IV. However, in DSM-5 the different sub-types of schizophrenia were removed because the sub-types would usually overlap and the nature of symptoms in an individual could change over time. The main types of schizophrenia as distinguished in DSM IV have been discussed below. Paranoid Schizophrenia: The clinical picture is dominated by presence of delusions and/or hallucinations. Additionally, disorganised speech, affect, catatonia or disorganised behaviour is not prominent in the clinical presentation. Usually the person is plagued with persecutory delusions that are most common, the person may become suspicious of family, friends and relatives. They may complain of being watched, poised, followed, and harassed by “enemies”. Delusion of grandeur also common wherein a patient might claim to be the world’s greatest thinker, artist, researcher who has cure for cancer, AIDS, be some prominent person. In some cases, this delusional belief of being special may provide them with some justification (in their minds) for them being persecuted. There is lack of insight and critical judgment, the individuals may display erratic behaviour and may end up being violent against the “enemies” when convinced of their delusions or in response to a “voice” in their head that asks them to commit violent acts. Relative to other sub-types of schizophrenia, people with paranoid schizophrenia function at someone higher cognitive level and the prognosis for them is generally better. Disorganised Schizophrenia: In the clinical presentation of someone with disorganised schizophrenia, the following features are prominent: disorganised speech, disorganised behaviour, flat or inappropriate affect. However, the criteria for catatonia is not met. Disorganised schizophrenia was initially called hebephrenia. Usually it has an early, insidious onset, is less common, and represents more severe disintegration of personality. The person is likely to have a history of odd or eccentric behaviour; early signs include seclusion, day-dreaming, and odd religious and philosophical issues, Gradually, the person becomes more reclusive and preoccupied with fantasies. As the illness progresses, the person may become emotionally indifferent or infantile. For instance, the speech will become unclear may include baby talk, childlike giggling or clang associations. It is common to find silly smile or unprovoked laughter. Behaviour will be bizarre with odd facial expressions, muttering to one self with sudden and inexplicable laughter or weeping. Hallucinations and delusions if present may not be 27 Mental Disorders- II coherent or organized as is seen in case of paranoid schizophrenia. Everyday activities become difficult to manage and prognosis is generally poor. Catatonic Schizophrenia: In catatonic schizophrenia, motor disturbances (rigidity, agitation, or odd mannerism) are predominant. They are likely to display waxy flexibility or maintain limb and body positions for a long duration of time and on other occasions engage in excessive activity. Mutism, word repetition (echolalia), and movement imitation (echopraxia) may be displayed. The patients may display odd mannerisms including grimacing. Fig. 1.3 Catatonic State (Source: https://www.psychiatryadvisor.com) Undifferentiated type: People would not neatly fit into any of the above three types of schizophrenia would be included under this category. Residual type: People who have had at least one episode of schizophrenia but may not any longer have major symptoms were diagnosed with residual type of schizophrenia. They may show residual or “leftover” symptoms such as unusual ideas that are not fully delusional. May show social withdrawal, flat affect, inactivity and odd thoughts. Check Your Progress III 1) List the types of schizophrenia _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 1.5 BIOLOGICAL CAUSAL FACTORS UNDERLYING SCHIZOPHRENIA In this section of the present unit, we will discuss the main biological causes of schizophrenia. 1.5.1 Genetic Influences A number of research studies coming from many different sources, family studies, twin studies, adopted children studies, and linkage and association studies have made it clear that genes are important in making a person vulnerable to schizophrenia. Heritability estimates are stable at 80 percent. 28 Overall, studies suggest that schizophrenia is polygenic in nature, that is, Schizophrenia there is no one gene responsible for schizophrenia but multiple combination of genes that produce vulnerability for schizophrenia. Family Studies: Studies have examined families who have members with schizophrenia and found that severity of parent’s disorder influences the likelihood of child developing schizophrenia. Further, it has been found that all types of schizophrenia can be seen in a family, that is, one inherits a general predisposition for schizophrenia spectrum and psychotic disorders. Rate of schizophrenia is highest in monozygotic twins that is 48 percent compared to general population where the prevalence rate is 1percent (Gottesman, 1991) Twin Studies: Studies of twins with schizophrenia conclude that if one of the identical twins has schizophrenia, then 48 percent of the times the other twin also has schizophrenia. However, in non-identical twins, the rate is 17 percent (Gottesman,1991). These studies show that genes play an important role in causing schizophrenia. If only genes played a role then the concordance rate of identical twins should have been 100 percent since they share genetic material. Whereas, if the environment only played a role then the concordance rate should have been 0 percent. Another study examines the rates of schizophrenia in off springs of discordant twins (one sibling has schizophrenia and other did not) and found the rate same (17 percent), suggesting that perhaps the well-twin is the carrier of schizophrenia genes which was never expressed, but passed on to others. The classic case study of Genain Quadruplets (born 1930) dramatically illustrates the role of genetic influences in schizophrenia (Mirsky et al. 1984). All the four sisters were diagnosed with some form of schizophrenia. However, it was found that time of onset for schizophrenia, symptoms, type of schizophrenia, course of disorder, and ultimately the outcomes differed significantly from one sister to another. This is because all identical twins do not have the similar prenatal environments. Around two-thirds of identical twins’ embryos are monochorionic, which means they share a placenta and blood supply. The remaining identical twins and all non-identical twins are dichorionic; they have separate placentas and separate foetal circulations. Studies have found that identical twins who are monochorionic are much more likely to be concordant for schizophrenia (around 60 percent) than monozygotic twins who are dichorionic (around 11 percent). Adoption Studies: It is reasonable to expect that one reason that monozygotic twins (identical twins) could have higher rate for schizophrenia because they are more likely to be raised in more similar environments than dizygotic (non-identical twins). This is because identical twins are always of the same gender. Thus, it is reasonable to assume that twin studies may overemphasize the importance of genetics in causation of schizophrenia. Adoption studies then can help in truly distinguishing between the roles of the environment and genetics. Adoption studies suggest that concordance rate is higher between biological relatives and not adoptive relations of people who go on to develop schizophrenia. Heston (1966) followed children born to mothers in state mental hospital suffering from schizophrenia. About 16.6 percent developed schizophrenia, whereas none of the 50 control children (born to mothers without schizophrenia, but given up for adoption) developed 29 Mental Disorders- II schizophrenia. Twin and adoption studies taken together implicate the role of genetics in the etiology of schizophrenia, however the environment in which children are raised in also plays a role. For instance, researchers found lower concordance rates between biological mothers with schizophrenia and their children raised in supportive homes compared to those who grew up in non-supportive households. These findings are positive as they suggest that a supportive environment can become protective for people with genetic vulnerability for schizophrenia. Fraternal twins Identical twins Fertilization Cell divides Joe Pam Sally Sue Fig. 1.4: Identical and Non-Identical Twins Fig. 1.5 : Possibility of developing schizophrenia in offspring of discordant twin set with schizophrenia (Source. https://www.genome.gov/genetics-glossary/identical-twins) Molecular Genetics: Research suggests that genetic makeup of an individual makes her/him vulnerable to schizophrenia spectrum disorders and not just schizophrenia in particular. It is also important to understand that there is no ‘one gene’ for schizophrenia, rather several genes working in combination lead to vulnerability to the schizophrenia spectrum and other psychotic disorders. Through linkage analysis, a method for finding out if schizophrenia occurs with a known DNA marker trait like colour-blindness and blood group, researchers were able to locate chromosomes: 1, 2, 3, 5, 6, 8, 10, 11, 13, 20, and 22 for their role in schizophrenia. Recent studies have been able to identify candidate genes on the chromosomes. For instance, COMT gene (Catecholamine O-Methyl Transferase) on chromosome 22 is in particular important, as it has been involved in dopamine metabolism. 30 1.5.2 Prenatal Exposure Schizophrenia Whether or not a genotype is expressed or not depends on biological and environmental triggers. Genes are triggered ‘on’ and ‘off’ because of prenatal exposures. Research suggests that in identical twins who are discordant for schizophrenia some environmental factors hits ‘on’ for genes of schizophrenia for the twin that goes on to develop schizophrenia and not for the healthy twin. Consistent with the diathesis-stress model, prenatal exposures to infections and other stressors in people with genetic vulnerability for schizophrenia may precipitate to cause schizophrenia in adulthood. Thus, genetic predisposition for schizophrenia may predispose an individual to suffer more environmental damage than would be the case with a child without any genetic predisposition. Viral infections: Viral infections have been suggested to play a key role in development of schizophrenia. In northern hemisphere, more people with schizophrenia are born between January and March than would be expected by chance suggesting the role of a seasonal infection. Risk of schizophrenia increases if the mother gets the flu in the fourth to seventh month of gestation. Other maternal infections like rubella and toxoplamosis (a parasitic infection) have also been linked to increases possibility of developing schizophrenia. It has been hypothesised that the antibodies developed in the mother’s body against the infection may cross the placenta and disrupt the neurodevelopment of the foetus. Rhesus incompatibility: Rhesus (Rh) incompatibility occurs when an Rh- negative mother carries an Rh-positive foetus. Studies have found that the rate of schizophrenia is about 2.1 percent in males who are Rh- incompatible with their mothers (Hollister et al.1986). For males who have no such incompatibility with their mothers, the rate of schizophrenia is 0.8 percent—which is near the expected prevalence rate for general population. Rh incompatibility has been linked to birth complications, which in turn may lead to brain abnormalities of the type associated with schizophrenia. Pregnancy and birth complications: The probability of patients with schizophrenia with a history of complicated pregnancy or birth complication (for example, breech delivery, prolonged labor, or the umbilical cord around the baby’s neck) is high. Although there is much to learn, but these findings do suggest that damage to the brain at critical time of development is an important precursor to schizophrenia. Early Nutritional Deficiency and Maternal Stress: It was found that children conceived at the height of famine had a two-fold increase in the development of schizophrenia later. General malnourishment is linked to abnormal brain development. Similarly, maternal stress experienced in first trimester or pregnancy and early in second trimester has also been linked to increased risk of schizophrenia. 1.5.3 Neurodevelopmental Factors According to some researches, schizophrenia may actually be a neurodevelopmental disorder that stems from brain lesions that occurs very early in development, perhaps even before birth. The brain lesions lie dormant until normal maturation shows problems in adult age. If this is the case then we should be able to see early indications of the condition before 31 Mental Disorders- II the illness sets in. Retrospective studies or trying to study the childhood of people diagnosed with schizophrenia in present provide some evidence for this. Researcher showed home videos of the childhood of people diagnosed with schizophrenia and found unusual hand movements, less positive facial emotions and more negative facial emotions. Similarly, prospective studies identified high-risk children or those high on genetic vulnerability to develop schizophrenia and found that these children were poorer than control children on measures of attention as well were rated lower on social competence. 1.5.4 Neuroanatomical Factors Brain Volume: Since schizophrenia has strong biological etiology, it has been suggested that perhaps the brain of people with schizophrenia may be anatomically different than typical others. Even though brain scans cannot be used for the purpose of diagnosis, neuroanatomical differences have been reported in brains of people with schizophrenia relative to control groups. Although it may not be found in everyone with schizophrenia, but large a number of studies have shown that compared with controls, people with schizophrenia have enlarged brain ventricles. This finding has been reported as early as 1927 when post-mortem brains of people with schizophrenia showed enlargement. This enlargement of ventricles means that either the surrounding brain areas have not developed fully or have shrunken. Studies have reported at least a 3 percent reduction in brain volume relative to controls. Reduction in brain volume has been found in people with recent onset of schizophrenia and not only those who have had chronic psychosis. This indicates that brain abnormalities may predate the illness rather than develop as a result of un-treated psychosis. It is important to note that reduction in brain volume are not progressively degenerative although some studies may show reduction in grey areas in the brain over time. Fig. 1.6: MRI scans of twins: a healthy twin and one with schizophrenia showing enlarged brain ventricles in the sibling with schizophrenia (Source: https://www.webmd.com/schizophrenia/ss/slideshow-schizophrenia-overview) Specific Brain Areas: Researches have suggested that structural problems in brain areas such as temporal lobes, amygdala, hippocampus, and thalamus are present before the onset of schizophrenia, perhaps beginning prenatally. In addition, abnormally low activity in the frontal lobe (in particular the pre- 32 frontal lobe) is shown in people with schizophrenia. Problems in the frontal Schizophrenia lobes have been implicated in the negative symptoms and attentional- cognitive deficits found in individuals with schizophrenia. There is low density of neurons in the pre-frontal cortex of the frontal lobes. Research has found that people with schizophrenia have missing “inhibitory interneurons” which regulate excitability of other neurons. Thus, brains of people with schizophrenia are unable to regulate activity in certain brain areas making them incapable of handling even normal levels of stress. The low density of neurons in different areas of the brain maybe related to the abnormal synaptic pruning in adolescence/early adulthood of people with genetic vulnerability for schizophrenia. Overall, brain dysfunction in schizophrenia is clear, but it may manifest differently at different stages of illnesses and different people. 1.5.5 Neurochemical Factors Dopamine Hypothesis: Schizophrenia is a result of excessive dopamine in the brain. A number of observations have led to the dopamine hypothesis. (1) chropromazine, a drug used to treat schizophrenia was linked to its ability to block dopamine receptors, (2) anti-psychotic drugs like chloropromazine can produce negative side-effects similar to Parkinson’s disease (a disease caused by deficient dopamine),(3) dopamine agonist (L-dopa) used to treat disorders like Parkinson’s disease gives rise to psychotic states similar to schizophrenia, (4) abuse of amphetamines increases dopamine in the brain and leads to a form of psychosis that is, paranoia and auditory hallucinations in typical people who abuse the drug and can worsen symptoms in people with schizophrenia. Overall studies have found that dopamine antagonists reduce symptoms of schizophrenia and dopamine agonists increase symptoms of schizophrenia. Evidence suggests that people with schizophrenia are not producing excessive dopamine, but in fact have increased number of dopamine receptors. Post-mortem of people with schizophrenia have found show that there are more D2 receptors in brains. The relationship between dopamine and schizophrenia is not that direct. A significant number of people with schizophrenia have not been helped by anti-psychotic medicines that block dopamine receptors. Moreover, anti-psychotic medications are not very effective for negative symptoms making one question if dopamine hypothesis accounts for only positive symptoms. Thus, dopamine is involved in symptoms of schizophrenia but the relationship is more complicated than previously conceived. Glutamate Hypothesis: Glutamate is excitatory neurotransmitter and its receptors are called NMDA receptors. Ketamine and PCP, NMDA antagonists are recreational drugs that result in psychotic symptoms. It has been hypothesised that they work by either leading to deficits in glutamate or blocking NMDA receptors. Deficits of glutamate are also found in post- mortem brains of patients with schizophrenia. Thus, currently new drugs for schizophrenia have been designed to activate glutamate receptors. The dopamine receptors have been found to inhibit the release of glutamate. Overall, it has been proposed that overactive dopaminergic system can lead to deficits in glutamate leading to under activity of NMDA rectors. 33 Mental Disorders- II 1.5.6 Neurocognitive Factors People with schizophrenia perform poorer than control individuals on number of neuropsychological tasks; they have been found to have slower reaction time, poor sustained attention, and poor working memory. For instance, performance is poor for people with schizophrenia in sustained attention tasks like Continuous Performance Task,wherein participants are required 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 (for example, “press when you see the number 9”). A large proportion of people with schizophrenia also show eye-tracking dysfunction. In smooth pursuit of eye movement tasks that involve tracking of a moving target such as a pendulum, not only do people with schizophrenia show difficulties but at least 50 percent of the first-degree relatives of people with schizophrenia also exhibit problems in eye-tracking. This suggests that disturbances in eye-tracking have a genetic basis. However, the strongest finding in the area of neurocognition and schizophrenia has been reported throughthe use of a psychophysiological measure called P50. In this measure when two clicks are heard in close succession (50 milliseconds), the brain produces a positive electrical response to each click. In typical participants, the response to second click is less marked than first click which is equal in schizophrenia. The implication of this finding is that while a typical brain dampens responses to repeated sensory events, the brain of a person with schizophrenia is unable to. As is the case in eye-tracking tasks, first-degree family members of patients with schizophrenia are also more likely than controls to have problems with P50 suppression. Check Your Progress IV 1) What is rhesus incompatibility? _______________________________________________________ _______________________________________________________ _______________________________________________________ 1.6 PSYCHOSOCIAL AND CULTURAL CAUSAL FACTORS OF SCHIZOPHRENIA One of the earliest (mis)understanding regarding the causality of schizophrenia was the belief that cold and aloof behaviour of parents, in particular mothers leads to schizophrenia. This was extremely distressing for the families, who were not only faced with the caregiving of an individual with extremely challenging illness, but they also suffered all the more because the blame of the illness was directed towards them by mental health professionals. Today, however, many popular theories of decades ago for example the double-bind hypothesis of schizophrenia by Gregory Bateson have not stood the test of time. According to Bateson, schizophrenia was a result of being presented with ideas, feelings, and demands that were mutually incompatible (for instance, asking one’s son for finding a job and then scolding them for finding a job and neglecting other responsibilities). Such contradictory and disorganised messages over a period of time led to disorganised thinking seen in schizophrenia. However, later it was found that disorganised communication was not the cause but result of having 34 to interact with someone who is severely ill and disorganised. However, Schizophrenia this does not mean that family environments play no role in the etiology of schizophrenia. Interpersonal Relationships: Highly emotional family environments can prove to be stressful for people with schizophrenia leading to higher rates of relapse than in families with supportive family relationships. Brown (1958) studied the concept of Expressed Emotion in context of schizophrenia; it includes (1) emotional over-involvement (2) hostility (3) excessive criticism of ex-patient by family members. It was found that patients with schizophrenia living with families high on expressed emotion, faced more relapses than those living with families low on expressed emotion. Research found that relapse was highest in individuals whose family members who believed that the symptoms are under voluntary control of the patient. Table 1.1: Examples of communication in families showing high and low on Expressed High Expressed Emotion Low Expressed Emotion I always tell her “why don’t you I know it’s better for him to be on his pick up a book, listen to music or own and get away from me and try something that would keep your to do things his own way. mind off it” I just tend to let it go because I know She is deliberately quiet and pas- that when she wants to speak, she sive because she knows that if she will speak. behaves like this then no one will ask her to help in housework. Urban Living: The researchers have 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 as adults than were children who had spent their childhoods in more rural settings (Pederson & Mortensen, 2001). Urban living is associated with stressful living and high paced lifestyle, which may trigger schizophrenia in biologically vulnerable individuals. Immigration: Urban living and its link with increased risk for schizophrenia implicate the role of stress and social adversity in schizophrenia’s etiology. In support, it has been observed that first generation (that is, those born in another country) had 2.7 times the risk of developing schizophrenia; this risk becomes 4.5 times for second-generation immigrants (that is, those with one or both parents having been born abroad). Many hypotheses have been discussed in this regard, but the most accepted one is that immigrants are likely to face increased adjustment issues due to experiences of discrimination. Consistent with the explanation, individuals with darker skin have been found to have much higher risk of developing schizophrenia. Cannabis Abuse: Relative to general population people with schizophrenia are likely to smoke cannabis twice as much. Heavy cannabis use in young individuals make them 6 times more likely to develop schizophrenia at the age of 27 years. (Zamamit, Allebeck, Andreasson, Lundberg, & Lewis, 2002) However, it is questionable whether people in early symptoms of psychosis are more likely to abuse cannabis, that is relationship between cannabis use and schizophrenia is correlational and not causal. Studies have found that cannabis use is predictive of psychotic symptoms; cannabis use 35 Mental Disorders- II in fact may trigger or bring forward the onset of psychosis. Additionally, cannabis is a hallucinogen that leads to increased production of dopamine in the brain. It is important to note that scientists have found that cannabis use does not trigger schizophrenia in all individuals but in those that may carry a genetic vulnerability to schizophrenia. Check Your Progress V 1) What is expressed emotion? _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 1.7 DIATHESIS-STRESS MODEL OF SCHIZOPHRENIA Overall, there is no simple answer to ‘what’ causes schizophrenia; the etiology of the disorder is complex. The etiology of schizophrenia can be summarised well through the diathesis-stress model. According to the Diathesis- stress model of schizophrenia, biological factors (genetic predisposition to develop schizophrenia) undoubtedly play a role in the etiology of schizophrenia however; genetic predispositions can be shaped by environmental factors such as prenatal exposures, infections, and stressors that occur during critical periods of brain development. Favourable pre-natal environment and healthy family environment can prevent the expression of schizophrenic genes in biologically vulnerable individuals. For a person who develops schizophrenia, predisposing genetic factors combine in additive and interactive ways with multiple environmental risk factors. Some of these environmental factors that operate prenatally, peri- natally, and also post-natally have been identified while some still remain unknown. The important factor is that there is abnormal development of brain pathways, which can be caused by multiple reasons but all leading to the same end result, schizophrenia. Genetic Influences + Prenatal and perinatal environmental stressors= Brain Developmental Maturational Processes & Stress Psychosis Fig. 1.8 : Diathesis-Stress Model of Schizophrenia 36 Schizophrenia Box 1. 4 Other Psychotic Disorders Apart from schizophrenia, there are other types of psychotic disorders also. They are elaborated in this section. Schizophreniform Disorder: Schizophreniform disorder is a schizophrenia spectrum disorder used to classify those individuals who experience symptoms of schizophrenia for a brief period of time in life and can usually function more or less normally after the episode. The symptoms usually disappear as a result of successful treatment, but often the reasons are not very clear. According to the DSM-5 criteria, the psychotic symptoms should last for at least a month but lesser than 6 months. The individual has good social and occupational functioning before the onset of the condition. Professionals consider schizophreniform disorder as a provisional diagnosis until follow-up reveals a more specific diagnosis. This is because, when an individual has new-onset psychosis, the course of the illness is often uncertain. When the psychosis lasts lesser than a month the diagnosis received is of brief psychotic disorder. However, majority of cases may later be diagnosed with schizophrenia, schizoaffective disorder, or affective disorder. DSM-5 Diagnostic Criteria for schizophrenifrom Disorder A. Two (or more) of the following, each present for a significant portion of time during a 1 - month period (or less if successfully treated): 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms, i.e., affective flattening, alogia, or avolition B. An episode of the disorder lasts at least 1 month but less than 6 months. C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features has been ruled out. D. The disturbance is not attributable to the physiological effects of a substance (e.g. durg of abuse, a medication) or another medical condition. Schizoaffective disorder: This is a condition in which people experience both schizophrenia symptoms and mood disorder symptoms. The prognosis of this condition is poor that is, people tend to face significant difficulties in life for a number of years. In this condition, an individual experiences DSM-5 Criteria for Schizoaffective Disorder (APA, 2013) An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. 37 Mental Disorders- II Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. The disturbance is not due to the direct physiological effects of a substance (for example, , a drug of abuse, a medication) or a general medical condition. Specify whether: Bipolar Type: Applies if manic episode is part of the presentation. Depressive Type: Applies only when major depressive episodes are part of presentation. Delusional Disorder: Delusional disorder is a psychotic disorder in which an individual has rigid and persistent belief that does not correspond to the reality. Delusional disorder is different from schizophrenia in that it does not share any other feature with schizophrenia except the presence of delusions. Their speech and behaviour do not show the gross disorganization and deterioration that is usually present in people with schizophrenia. Delusions can be persecutory in nature (for example, a persistent belief that someone is trying to poison them), erotomonia (for example, a persistent belief that a person usually of higher status like an actor or sportsperson is in love with them), jealous type (for example, an individual may believe that their spouse/partner has an affair in spite of contradictory evidence), somatic type (for example, a person may believe that she/he is infested with insects) or mixed type. The delusions found in schizophrenia are differentiated from those found in a delusional disorder. In schizophrenia the delusions may be extremely bizarre and odd (for example, someone is controlling one’s thoughts and broadcasting it to the entire world) whereas in delusional disorder the delusional beliefs are somewhat believable but are not true (for example, the belief that one’s spouse/partner is having an affair). DSM-5 Criteria for Delusional Disorder (APA, 2013) A. The presence of one (or more) delusions with a duration of 1 month or longer. B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (for example, the sensation of being infested with insects associated with delusions of infestation). C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behaviour is not obviously bizarre or odd. D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive- compulsive disorder. 38 Schizophrenia Brief Psychotic Disorder: As the name suggests, brief psychotic disorder is the sudden onset of psychotic symptoms, disorganised speech or behaviour. The episode lasts for very few days, not enough to warrant a diagnosis of schizophrenia. The person usually returns to former level of functioning, and may never have an episode ever again. The episodes may be triggered by extreme stressful circumstances. DSM-5 Criteria for Brief Psychotic Disorder (APA, 2013) A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3): 1) Delusions. 2) Hallucinations. 3) Disorganized speech (e.g., frequent derailment or incoherence). 4) Grossly disorganized or catatonic behavior. Note:Do not include a symptom if it is a culturally sanctioned response. B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Check Your Progress VI 1) What is diathesis- stress model of schizophrenia? _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 1.8 TREATMENT FOR SCHIZOPHRENIA Prior to 1950s, treatment was very limited. The treatment options available in the present era are different from 1950s when antipsychotics were introduced. Let us see some of the treatment options available. Biological Treatment: It has been long known that schizophrenia requires some form of biological treatment. Before the discovery of anti-psychotic medicines, Insulin Coma Therapy was used in which insulin was injected to reduce blood sugar levels and cause coma in patients. At the time, the insulin coma therapy was found to be useful however it could lead to serious illnesses and/or death. During the time, psychosurgery and prefrontal lobotomy were also used and in the late 1930 Electroconvulsive Therapy (ECT) was employed for the treatment of schizophrenia. ECT did not prove to be very effective for people with schizophrenia. 39 Mental Disorders- II Neuroleptics or anti-psychotic medicines were developed in 1950s, which provided real hope for people with schizophrenia. These medications would help reduce positive symptoms like delusions and hallucinations, however their effect for negative symptoms like social withdrawal was marginal. Neuroleptics are dopamine antagonists; they interfere with the dopamine neurotransmitter system in the brain. Some neuroleptics also affect other systems such as the serotonergic and glutamate system. In general, each drug is effective with some people and not with others. Clinicians and patients often must go through a trial-and- error process to find the medication that works best, and some individuals may not benefit significantly from any of them. Traditional anti-psychotic medicines like chrolopromazine, reduces the positive symptoms of schizophrenia within 6 weeks by reducing the availability of dopamine. They are also associated with severe side effects like tardive dyskinesia (a movement abnormality with Parkinsonian symptoms). Atypical anti-psychotic medications like clozapine and resperidone are likely to treat both positive and negative symptoms. Some of the side effects associated with them are weight gain, diabetes, and fatal reduction in white blood cells. Psychosocial Treatment: Historically, it was believed that psychotherapy could help patients to gain insight into the psychosocial problems that caused schizophrenia. However, it is clear now that therapeutic interventions cannot cure schizophrenia. Psychosocial interventions are used to help individuals with schizophrenia and their families manage the illness and prevent relapses. Psychologists have developed programs using behavioural techniques to teach social skills, self-care, and vocational skills to patients with schizophrenia admitted in hospitals. These skills helped the patients to live more independently post-discharge from the hospitals. To enhance social skills of the individuals, mental health professionals have tried to teach basic conversation, assertiveness, and relationship building to people with schizophrenia. Other efforts include psychoeducation of family members who are taught about schizophrenia and its treatment, relieved of the myth that they caused the disorder, and practical facts about neuroleptics and their side effects. They are also taught about developing more healthy relationship with the patients by reducing harsh criticisms and undue expectations. Studies indicate that individual social skills training, family intervention, and vocational rehabilitation may be helpful additions to biological treatment for schizophrenia. They help in reducing relapses, improve skills deficits, and increase compliance with drug treatments. Check Your Progress VII 1) Explain neuroleptics. _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 40 Schizophrenia 1.9 LET US SUM UP Now that we have come to the end of this unit, let us list all the major points that we have already learnt. Schizophrenia is one of the most complex and severe of all mental disorders, affecting nearly 1 percent of the general population. Schizophrenia is characterized by disordered thinking: thoughts are not logically related, faulty perception and attention, disturbed emotions: lack of emotional expressiveness or inappropriate emotions, and disturbed behaviour: disturbances in movement, disheveled appearance, lack of self-care. Positive symptoms are characterised by bizarre and odd behaviour. Hallucinations and delusions are examples of positive symptoms. They are associated with neurochemical changes in the brain and relatively minimal cognitive impairment compared to negative symptoms. Prognosis of people with positive symptoms is thus relatively better. Negative symptoms such as poverty of speech, flat affect, avolition, apathy, and asocility are not as dramatic as positive symptoms, but are often more difficult to treat. They are associated with structural brain changes and significant cognitive impairment that are not largely affected by medications. A third dimension is disorganised symptoms were added to the symptomatology of schizophrenia, disorganised symptoms. Disorganised symptoms consist of disorganised speech, affect, and behaviour. Although there are no divisions of schizophrenia according to DSM-5, DSM-IV-TR classified schizophrenia into five types. Paranoid type of schizophrenia has prominent delusions or hallucinations with relatively intact cognitive skills. People with the disorganised type of schizophrenia tend to show marked disruption in their speech and behaviour; they also show flat or inappropriate affect. People with the catatonic type of schizophrenia have unusual motor responses, such as remaining in fixed positions (waxy flexibility), or excessive activity. In addition, they display odd mannerisms with their bodies and faces, including grimacing. People who do not fit neatly into these subtypes are classified as having an undifferentiated type of schizophrenia. Some people who have had at least one episode of schizophrenia but who no longer have major symptoms are diagnosed as having the residual type of schizophrenia. According to the diathesis-stress model, biological factors (genetic predisposition to develop schizophrenia) undoubtedly play a role in the etiology of schizophrenia however; genetic predispositions are shaped by environmental factors such as prenatal exposures, infections, and stressors that occur during critical periods of brain development. Neuroleptics or anti-psychotic medicines were developed in 1950s, which provided real hope for people with schizophrenia. These medications would help reduce positive symptoms like delusions and hallucinations, however their effect for negative symptoms like social withdrawal was marginal. Psychosocial interventions are used to help individuals with schizophrenia and their families manage the illness and prevent relapses. Apart from schizophrenia, there are four other psychotic disorders. Schizophreniform disorder classifies those individuals who experience 41 Mental Disorders- II symptoms of schizophrenia for a brief period of time in life and can usually function more or less normally after the episode. Schizoaffective disorder is a condition in which people experience both schizophrenia symptoms and mood disorder symptoms. Delusional disorder is different from schizophrenia in that it does not share any other feature with schizophrenia except the presence of delusions. Brief psychotic is the sudden onset of psychotic symptoms, disorganizes speech or behaviour. The episode lasts for very few days, not enough to warrant a diagnosis of schizophrenia. 1.10 REFERENCES Barlow, D.H. & Durand, M.V. (2015). Abnormal Psychology (7th Edition). New Delhi: Cengage Learning India Edition. Bennett, P. (2011). Abnormal and Clinical Psychology: An Introductory Textbook. New Delhi: Tata McGraw-Hill Education (UK). Bhati, M.T. (2013). Defining psychosis: The evolution of DSM-5 schizophrenia spectrum disorders. Current Psychiatry Reports, 15(11), 409. Mineka, S., Hooley, J.M., &Butcher, J.N., (2017). Abnormal Psychology (16th Edition). New York: Pearson Publications. 1.11 REFERENCES FOR IMAGES Schizophrenia. Retrieved 10th August 2019, from https://www.shutterstock. com/search/schizophrenia Catatonia. Retrieved 14thAugust 2019, from hhttps://www.psychiatryadvisor. com/home/schizophrenia-advisor/the-many-misconceptions-of-catatonia- treatment-is-often-successful-with-the-right-knowledge/ Identical and Non-Identical Twins. Retrieved 19th August 2019 from https:/ /www.genome.gov/genetics-glossary/identical-twins MRI Scans of healthy twin and with schizophrenia twin, retrieved 18th August 2019, from https://www.webmd.com/schizophrenia/ss/slideshow- schizophrenia-overview 1.12 KEY WORDS Positive Symptoms: Consist of feelings or behaviours that are usually not present; an addition or excess in normal repertoire of behaviour and experiences. Hallucinations and delusions are examples of positive symptoms in schizophrenia. Negative Symptoms: Refer to lack of feelings or behaviours that are usually present that is, absence/deficit of normal behaviour for example in schizophrenia they include poverty of speech, flat affect, avolition, apathy, and asocility. Catatonia: A striking example of disorganised behaviour is catatonia or the motor dysfunctions that range from wild agitation to immobility. Diathesis-stress model: Many mental disorders including schizophrenia develop when some kind of stressor operates on a diathesis that is, predisposition toward developing a disorder is termed a diathesis (biological, psychological, or sociocultural causal factors). 42 Schizophrenia 1.13 ANSWERS TO CHECK YOUR PROGRESS Check Your Progress I What is schizophrenia? Schizophrenia can be explained as a broad spectrum of condition that affects individual’s cognitive and emotional functioning including delusions and hallucinations, disorganised speech, behaviour and inappropriate emotions. Check Your Progress II 1) List the three categories of symptoms of schizophrenia. The three categories of symptoms of schizophrenia are: Positive symptoms Negative symptoms Disorganised symptoms Check Your Progress III 1) List the types of schizophrenia The various types of schizophrenia are: Paranoid Schizophrenia Disorganised Schizophrenia Catatonic Schizophrenia Undifferentiated type Residual type Check Your Progress IV 1) What is rhesus incompatibility? Rhesus (Rh) incompatibility occurs when an Rh- negative mother carries an Rh-positive foetus. Check Your Progress V 1) What is expressed emotion? Expressed Emotion in context of schizophrenia; it includes (1) emotional over-involvement (2) hostility (3) excessive criticism of ex-patient by family members. Check Your Progress VI 1) What is diathesis- stress model of schizophrenia? According to the diathesis- stress model of schizophrenia, biological factors (genetic predisposition to develop schizophrenia) undoubtedly play a role in the etiology of schizophrenia however; genetic predispositions can be shaped by environmental factors such as prenatal exposures, infections, and stressors that occur during critical periods of brain development. Check Your Progress VII 1) Explain neuroleptics. Neuroleptics are dopamine antagonists; they interfere with the dopamine neurotransmitter system in the brain. 43 Mental Disorders- II 1.14 UNIT END QUESTIONS 1. Explain schizophrenia 2. Describe the positive and negative symptoms of schizophrenia 3. Describe the biological causal factors of schizophrenia 4. Explain the psychosocial and cultural causal factors of schizophrenia. 5. Discuss the treatment of schizophrenia, 1.15 WEB RESOURCES For a brief account on history of the concept of schizophrenia, visit - https://www.psychologytoday.com/intl/blog/hide-and-seek/201209/ brief-history-schizophrenia For a documentary on the life of Dr. John Nash, - https://www.youtube.com/watch?v=4QNM497zjSA To read the short story Toba Tek Singh that gives a description of different cases of schizophrenia. - http://www.sacw.net/partition/tobateksingh.html To get more information on Genain Quadruplets, visit -https://www.webmd.com/schizophrenia/news/20001020/four- sisters- with-schizophrenia-four-decades-of-scrutiny#1 To get more information on latest research in schizophrenia. -https://www.newscientist.com/article/2085432-the-foundations-of- schizophrenia-may-be-laid-down-in-the-womb/ 44

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