SCHIZOPHRENIA

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SCHIZOPHRENIA INTRODUCTION- Schizophrenia was
called a type of mental deterioration beginning
early in life. In 1860 the Belgian psychiatrist
Benedict Moral described the case of a 13 year
old child who had formely been the most brilliant
pupil in his school, who gradually lost interest
in his studies and he talked frequently of
killing his father. He used the term Demence
precoce (mental deterioration at an early age)
to describe the condition and to distinguish it
from the old age. ORIGIN- In the latin form it
is called Dementia Praecox. It was subsequently
adopted in the late 19th century by the German
psychiatrist EMIL KRAEPELIN. He refers to a
group conditions that all seemed to have the
feature of mental deterioration beginning early
in life. In 1991 a Swiss psychiatrist Eugen
Bleuler used Schizophrenia because he thought
the condition was characterized primarily by 1.
Disorganization of thought processes. 2. Lack of
coherence between thought and emotion. 3. An
inward orientation away from reality.
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PREVALENCE AND ONSET- 1. Global prevalence rates
for schizophrenics are difficult to pin down
because of variation in the criteria in defining
cases over time and place. 2. Some believe that
it occurs at an approximately constant rate in
most if not all societies.3. Lifetime
prevalence is estimated at 0.7 percent among
persons not currently institutionalized. (Kessler
et al., 1994) 4. Allen 1997- Schizophrenia
appears both rarer and of less severe quality in
traditional, smaller scale societies than it is
in modern, well developed ones. 5. During any
given year almost 1 percent of adult U.S.
citizens, over 2 million persons meet diagnostic
criteria for schizophrenia. 6. Initial onset
occurs between the ages of 15 and 45 and median
age is mid 20s. Prevalence rate is same for men
and women early to mid 20 for male and late 20s
for females.
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7. Because of its complexity, high rate of
incidence, tendency to recur or become chronic,
it is considered the most serious and baffling
disorder. CLINICAL PICTURE OR SYMPTOMS OF
SCHIZOPHRENIA- The symptoms of schizophrenia
have been divided into 2 categories 1. Positive
syndrome- Positive syndrome are those in which
something has been added to a normal behaviour
and experience, style. 2. Negative syndrome-
Negative syndrome refer to an absence or deficit
of behaviour normally present in a
person. Although most person or patients exhibit
both positive and negative signs during the
course of their disorder.
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Positive sub syndrome
Negative sub syndrome
Hallucinations Emotional flattening
Delusions Poverty of speech
Derailment of association Asociality
Bizarre behaviour Apathy
Minimal Cognitive impairment Significant Cognitive impairment
Sudden onset Insidious onset
Variable course Chronic course
Type I
Type II
Good response to drugs Uncertain response to drugs
Limbic system abnormalities Frontal lobe abnormalities
Normal brain ventricles Enlarged brain ventricles
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?Dolphus and Colleagues(1996) suggested that
there are atleast four discriminable patterns of
schizophrenia signs- Positive Negative
Disorganized Mixed ? Disturbance of Associative
Linking- 1. It is also known as thought
disorder. This symptom is most important in
schizophrenic patients. 2. The schizophrenic
patient are not able to communicate properly
though. They follow semantic rules and syntactic
or how to form sentence rules but they are not
able to make sense. 3. This symptom is not due to
low intelligence, low education and cultural
deprivation. 4. This symptom is also known by the
names cognitive slippage, derailment or
lossening of associations or incoherence. 5.
The patient uses words in combination that sounds
communicative but the listener is not able to
understand. 6. This symptom is readily recognized
by the clinical psychologist.
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?Disturbance of Thought Content- All types of
delusions are included in this symptom. 1. One of
the delusion can be that ones thoughts and
feelings are being controlled by external
agents. 2. The private thoughts are being
broadcasted to everyone. 3. Thoughts are being
inserted in to ones brain by alien forces. 4.
Some mysterious agency has robbed one of ones
thoughts. 5. Some T.V. program have some intended
personal meaning often termed as an idea of
reference. ?Disruption of Perception- 1. The
patient is unable to sort out and process the
large amount of sensory information. 2.Everything
seems out of control such as thoughts and images,
objects are brighter, thoughts are racing in the
head, noises are louder, things are vivid and
they come like a flood from the broken dam. 3.
Approximately 50 of the patients experience this
break down during the onset of the disorder.
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4. Most of the patients also experience dramatic
perceptual phenomenon that is hallucination, most
of the auditory hallucination, though they suffer
from visual and olfactory hallucination. The most
common hallucination is a kind of running
commentary which is going on about a persons
behaviour and thoughts. ?Emotional
Dysfunction- 1. Inappropriate emotion and affect
is the common function in the schizophrenic
patient. 2. They are not able to experience joy
and pleasure. (Anhedonia) 3. They may show
emotional shallowness and blunting and some of
them totally emotionless. 4. Though they are able
to recognize what is happening intellectually but
they are not able to express as for as feelings
are concerned. 5. In acute phase, the emotion
clashes with the situation. For e.g. the person
may laugh on hearing the death of parent.
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?Confused sense of self- 1. They are confused
about their identity. 2. They may adopt a new
identity. For e.g. considering themselves Jesus
Christ or the Virgin Mary. 3. They are confused
about the aspect of their body, their gender and
about the boundary separating self from the
world. 4. They may suffer from cosmic and
oceanic feeling. 5. They may consider
themselves tied up with universal power such as
God, Devil etc. 6. The feelings appear to be
related to external controlled delusions. ?Disrup
ted Volition- 1. Goal directed activity is
disturbed. 2. The impairment is there in day
today functioning such as work, social relation,
self care. 3. The person is not able to perform
the standard performance which he used to
master. 4. They show disregard about personal
safety, health and hygiene. 5. This symptom can
be due to impairment in the functioning of
central region of cerebral cortex.
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?Retreat to an Inner World- 1. Relation to
external world is almost loosened. 2. Withdrawal
from reality is there. 3. No active participation
in the environment. 4. The person develops his
own illogical and fantastic ideas. 5. They
interact with the persons of their own creation,
it seems to be self directed dramas. ?Disturbed
Motor Behaviour- 1. Peculiar movement are
observed in schizophrenias. 2. This symptom is
more in catatonic schizophrenia. 3. The disturbed
motor behavior can range from hyperactivity to
marked decrease in motor activity and
movement. 4. They show rigid posture, mutism,
ritualistic, mannerism and bizarre expression.
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?Subtypes of Schizophrenia- According to DSM IV
TR 2000 and DSM IV. Five types are given 1.
Undifferentiated type 2. Paranoid type 3.
Catatonic type 4. Disorganized type 5. Residual
type ?Undifferentiated type- 1.
Undifferentiated type of schizophrenia is
something of a wastebasket category. 2. The basic
criteria of this type of schizophrenia patient
includes- delusions, hallucinations, disordered
thoughts and bizarre behaviour. 3. Most of this
picture is seen in patients who are in the
process of breaking down and becoming
schizophrenic.
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4. People in the acute, early phases of a
schizophrenic breakdown frequently exhibit
undifferentiated symptoms as do those who are in
transitional phase from one to another of the
standard subtypes. 5. In some few instances,
treatment efforts are unsuccessful and the mixed
symptoms of the early undifferentiated disorder
slide into a more chronic phase typically
developing both the more specific symptoms of
other subtypes as well as increasingly severe
negative symptoms. ?Catatonic Type- 1. The
central feature of schizophrenia, catatonic type
is related to motor signs. 2. In this type the
patient seem in the form of excited of stuporous
condition. 3. In the withdrawal reaction there is
a sudden loss of all animation and a tendency to
remain motionless for hours or even days in a
single position.
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4. According to DSM IV TR 2000 this disorder can
be characterized from following points- Motor
immobility Excessive Motor activity Extreme
negativism/mutism Peculiarities of voluntary
movement Echolalia or echo- praxia imitate the
actions of others or obey commands) 5. Most of
the psychologist study this schizophrenia under
two stages- Stupor state Excited state 6. The
clinical picture may undergo an abrupt change,
with excitement coming on suddenly, where in an
individual may talk or shout incoherently, pace
rapidly and engage in uninhibited, impulsive and
frenzied behaviour.
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7. In this state, an individual may be dangerous.
Sometimes it is difficult to distinguish them
from manic patients. They openly may indulge in
sexual activities, attempt self mutilation or
even suicide or impulsively attack or try to kill
others. 8. The facial expression is typically
vacant, and their skin appears waxy. 9. Threats
and painful stimuli have no effect and they may
have to be dressed and washed by nursing
personnel. ?Disorganized type- 1. It usually
occurs at an earlier age than most other types of
schizophrenia. 2. It represents a more severe
disintegration of the personality. 3. An affected
person has a history of oddness over
scrupulousness about trivial things and
preoccupation with obscure religious and
philosophical issues. 4. While schoolmates are
enjoying normal play and social activities, the
patient gradually becomes more seclusive and more
pre occupied by fantasies.
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5. As the disorder progresses the person becomes
emotionally indifferent and infantile. 6. There
are many common symptoms such as a silly smile
and inappropriate shallow laughter after little
or no provocation. 7. Speech becomes incoherent
and may include considerable baby talk, childish
giggling, a repetitious use of similar sounding
words and derailing of associative thoughts. 8.
The patient may invent new words. 9. Speech
becomes wholly incomprehensible. 10.
Hallucinations, particularly auditory ones, are
common. 11. In occasional cases, individual
become hostile and aggressive. 12. They may
exhibit peculiar mannerism and other bizzare
forms of behaviour. 13. These behaviour may take
the form of odd facial grimaces, talking and
gesturing to themselves, sudden inexplicable
laughter and weeping. 14. In some cases an
abnormal interest in urine and feces which they
may smear on walls and even on themselves.
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• 15. The prognosis is generally poor if a person
  develops disorganized schizophrenia.
• Paranoid type-
• Formerly about one half of all schizophrenic
  first admissions to hospitals were diagnosed as
  schizophrenia paranoid type.
• In recent years, however the prevalence of the
  paranoid type has shown a substantial decrease.
• Paranoid type schizophrenic persons show
  histories of increasing suspiciousness and of
  severe difficulties in interpersonal
  relationships.
• The symptoms picture is dominated by absurd,
  illogical and often changing delusion.
• Delusion are the most frequent and may involve
  a wide range of bizarre ideas and plots.

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6. An individuals thinking and behaviour become
centered on the themes of persecution,
grandeur. 7. In chronic cases, there is usually
less disorganization of the behaviour than in
other types of schizophrenia and less extreme
withdrawal from social interaction. 8. Paranoid
schizophrenia patients can sometimes be dangerous
if they are convinced that people are persecuting
them. 9. Paranoid patients tend to be higher on
adaptive coping and cognitive integrative
skills. 10. Paranoid patients are far from easy
to deal with because of weaving of delusions and
hallucinations into a paranoid construction. 11.
They show less bizarre behaviour and less extreme
withdrawal from the outside world than the other
types of schizophrenia and less likely to be
confined in protective environment.
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• Residual type-
• Mild indications of schizophrenia shown by
  individuals in remission following a
  schizophrenia episode. They show some signs of
  their past disorder such as odd beliefs, flat
  affect and eccentric behaviour.
• CASUAL FACTORS IN SCHIZOPHRENIA
• There are three factors which influence the
  schizophrenic patients
• Biological factors
• Psychosocial factors
• Socio-cultural factors
• Biological factors- Paul E. Meehl (1962),
  Schizophrenia, while its content is learnt is
  fundamentally a neurological disease of genetic
  origin.
• Research relating to
  biological factors implicated on genetics and on
  various biochemical, neurophysiologic and
  neuroanatomical process.

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• Genetic influences- Many psychologist have
  proved from their studies that heredity factors
  play an important role in the development of
  schizophrenia. Some experimenters have studied
  the level of schizophrenia in the individuals
  which are grown by schizophrenic parents. It has
  been seen that in comparison to non-schizophrenic
  parents children, the chance of schizophrenia is
  found more in schizophrenic parents children
  (Reider, 1973). The chance of schizophrenia is
  more in the children of those whose both parents
  are suffered from schizophrenia rather than whose
  only one parent suffers (Kringlen, 1978). The
  evidence includes a strong correlation between
  closeness of blood relationship, chances will be
  more to become schizophrenic. As the genetic
  research itself teaches us individual
  environments have a powerful effect in
  determining outcomes with respect to
  schizophrenia. It is clear from all the studies
  that for the schizophrenia, predisposition is
  transmitted genetically. But the conclusion of
  this study can not be used to solve the problem
  of heredity vs environment because schizophrenic
  patients not only receive defective genes from
  their parents but also receive defective mal
  adaptive environment which foster schizophrenia.

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• Twin studies- It is known that identical twins
  MZs have same genetic endowment due to splitting
  in single fertilized ovum. In USA it is found
  that in the 175 sets of twins. MZs has high
  concordance rate for schizophrenia in comparison
  to DZs (Kallmam, 1946). Gottesman et al 1987
  found after the deep study on genetic factors
  that the concordance rate for MZs is 44.30 and
  for DZs it is 12.08. Now here question arise if
  genetic transmission is whole explanation for
  schizophrenia then why has MZs twins did not have
  concordance rate to be 100. Here we have to
  accept the significance of environment too.
  (Torrey et al 1994)
• Adoption studies- Many of the psychologists
  studied such children who were separated in their
  very early age from their schizophrenic parents
  also develop the traits similar to schizophrenic
  later on in their life and they tend to develop
  many other mental problems such as they are more
  likely to become mentally retarded neurotic and
  psychopathic. Some times this is also because
  they have poorly functioning adoptive parents.

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• Bio Chemical Factors- In schizophrenia one of
  the important chemical imbalance found to be is
  dopamine. It is believed that schizophrenia is
  the product of an excess of dopamine activity at
  certain synaptic sites. It has also been found
  that dopamine blocking drugs have been proved
  useful in the treatment of schizophrenia. The
  latest researches emphasize that it is not
  dopamine but there are many other bio chemical
  processes which are involved in the disorder
  called schizophrenia but we are not sure of them
  till now.
• Neuro Physiological factors- Imbalance of
  various neuro physiological process such as
  inappropriate automatic arousal is found to be
  strongly linked with schizophrenia. Disordered
  physiology would disrupt normal attention and
  information processing capabilities and will in
  turn become the under lying factor for cognitive
  and perceptual distortion in schizophrenia. Many
  psychologist have found out that many of the
  schizophrenic experience deficit cognitive
  functioning, attentional deficits, reflects hyper
  activity, poor perceptual motor coordination and
  this indicates role of neuro physiological
  factors in schizophrenia.

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• Neuro Anatomical factors- Research on the
  structural properties of brain was possible only
  after the development of computer dependent
  technologies such as CAT (Computerized Axial
  Tomography), PET (Positron Emission Tomography),
  MRI (Magnetic Resonance Imaging).
• Much evidence now
  indicates that in the minority of schizophrenics
  who are showing chronic and negative symptoms
  show abnormal enlargement of the brain
  ventricles- The hollow areas filled with cerebral
  spinal fluid lying deep with in the core.
  (Pearlson et al 1989, Raz 1993, Stevens 1997).
  Several other studies show enlarged fissures(
  narrow and long crackling and splitting or
  separation of parts) in the surface of cerebral
  cotex are responsible for this disorder. (Cannon
  and Marco 1994). Low birth weight and fetal
  damage from some unknown agent seem to be
  responsible for this disorder. Gur and Pearlson
  1993 concluded on the basis of review of neuro
  imaging studies in schizophrenia that they are
  primarily three brain region which are involved
  in integrated function and has an important role
  to play in the development of this disorder.
• The frontal
• The temporal limbic
• The interior limbic system such as basal
  ganglia

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• Neuro development issues- Fetuses and new borns
  having early insults according to developmental
  view are at the higher risk for misconnected
  circuits during cell reorganization and thus more
  vulnerable to develop schizophrenia. Maternal
  influenza in the second month of the pregnancy is
  associated with impaired fetal growth enhanced
  obstetrical complication and later developing
  schizophrenia. In one of the later studies by
  Takei and colleagues 1997 identifies that the
  critical period in catching infection is 5 month
  of pregnancy. Here, the risk of influenza
  exposure is critically associated with enlarged
  ventricles and sulci among the group of 83
  schizophrenia patient as compared to control
  group.
• 1. Psycho social factors in Schizophrenia-
• Damaging Parent-Child and family interaction-
  These studies focus on following factors
• i. Schizophrenogenic parents
• ii. Destructive parental interaction
• iii. Faulty communication.

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i) Some of variables which play an important role
in developing schizophrenia are parents
hostility, deliberate rejection or gross parental
inaptitude (absurd,silly). Many professional have
blamed parents for their angry and insensitive
behaviour towards their children one of the
indirect cause of schizophrenia. But nothing can
be said conclusively regarding these factors.

Many psychologist have also reported and
studies have shown a high evidences of emotional
conflicts in the family from which schizophrenic
persons emerge. ii) Destructive Parental
interaction- one of the other factors which can
be responsible for this disorder is the state of
severe chronic discord in which continuation of
the marriage is constantly threatened. Some of
the family show that the family members entered
into the collusion in which the seriously
disturbed behaviour of one or the other parent
was redefined as normal and justified by
rationalization. This particular type of
situation also found to be closely associated
with this disorder.
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iii) Faulty communication- Gregory Bateson 1959,
1960 was first to emphasize the conflicting and
confusing nature of communication among members
of families experiencing a schizophrenic outcome.
He used the term double bind communication to
describe one such pattern. In this pattern the
parent presents to the child ideas, feelings,
demands that are mutually in compatible. For e.g.
the mother may be verbally loving and accepting
but emotionally anxious and rejecting or she may
complain about her sons lack of affection but
freezes up or punish him when he approaches her
affectionately. In such situations mother
effectively prohibits comment on such behaviour
and father is too ineffective to intervene.
Two another style of
thinking and communication in the family are
strongly linked to the thought disorder of
schizophrenia they are amorphous and fragmented.
The amorphous pattern is characterized by the
failure in differentiation and fragmented
thinking involves greater differentiation but
lowered integration.
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iv) The role of excessive life stress and
expressed emotions- A marked increase in the
severity in the life stress has been found during
the ten week period prior to a persons
schizophrenic break down. Problems are related to
difficulties in intimate personal relationship
such as break up. Relapse of schizophrenia is
also related with stress and negative
communication called expression emotion (EE). Two
component appear to be critical of EE is
emotional over involvement with the patient and
excessive criticism of the patient. EE may be
especially intense where family members have the
view that symptoms are under voluntary control of
the patient (Weisman et al 1993) ? Socio
Cultural factors- 1.Prevelence rates for
schizophrenia appear to vary a lot throughout the
world. 2.Variation in occurrence of the disorder
in the various socio groups and geographical
regions is quiet evident but no biological
explanation for this variation is identified.
(Kirch, 1993)
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3. Systematic differences in the content and form
of schizophrenia between cultures and even sub
cultures have been noticed. For e.g. among the
aborigines of west Malesia, Kinzie and Bolten
found the positive syndrome type more in lower
socio-economic group rather than in the higher
socio-economic class. Affected individual often
drift downward on the socio economic ladder
because this disorder prevents them from finding
jobs or developing human relationships that might
otherwise provide economic stability. (Gottesman,
1991) Treatment and outcome Before the
1950s the prognosis for schizophrenia was
extremely unfavourable and even hopeless. Only
those patients who were diagnosed schizophrenic
and could afford expense of private
hospitalization got some treatment only because
they belonged to wealthy family but otherwise.
The therapies were inadequate most of the times
and the patients were simply left to adjust to an
institution and was expected never to leave.
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?Anti Psychotic Medication- (Drug therapy) 1.
For most schizophrenic patient, the outlook today
is not nearly so bleak as it was before 1950s. 2.
Improvement came with dramatic introduction of
anti psychotic drugs which are also known major
tranquilizers. 3. With the advent of these drugs
patients indeed becomes tranquil but the
changes were very abrupt and it was difficult to
find the extent of effect these drug had. 4.
These drugs transformed the environment of mental
hospitals by eliminating the threat of wild,
dangerous and violent behaviours of the
patients. 5. A schizophrenic person who enters a
mental hospital today has an 80-90 chance to
being discharged within a matter of weeks or at
most month. Unfortunately the rate of readmission
is high and almost 10 patient show resistance to
drug. 6. Many patients experience repeated
discharges and readmissions showing revolving
door and pattern.
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7. The hope of reliable cure for schizophrenia
has not materialized nor can it be seen anywhere
on the horizon and we must keep in our mind that
anti psychotic medicine are not a cure for the
schizophrenic because they are not able to
develop the social recovery of the
patient. ?Psycho social approaches- 1. Mental
health professional have realized the serious
limitation of an exclusively pharmacological
approach to the treatment of schizophrenia. 2.
There are several programs of self help for
patients who are in the hospital or who have
moved from the hospitals to their real life
situations. 3. Token economy as a social
economy program has proved helpful in social
learning programs. (Paul and Lentz,1977)
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• 4. Individual psycho therapy by highly
  experienced therapists and anti psychotic
  medication has proved helpful in treating
  schizophrenia. (Karon and Vandenbos,1981)
• 5. Perhaps the most notable indication of a
  changing view on the treatment of schizophrenia
  is the content of recently published American
  Psychiatric Associations (1997) Practice guide
  line for the treatment of patients with
  schizophrenia.
• this document
  contains comprehensive recommendation on managing
  the patients in various phases. It also
  recommends the importance of psycho social
  interventions. It also mentions those problems
  that are unresponsive to anti psychotic drugs. It
  also states some of the therapies which are to be
  used in combination with medication such as-
• Family therapy- Although this therapy is not
  new in the treatment of schizophrenia but there
  is a renewed emphasis on its importance and its
  role related to expressed emotion (EE) factor.
  Family therapy would appear to be an excellent
• i) Medium for identifying instances of EE
  and for teaching family members

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• ii) How to control and avoid it. (Tarrier and
  Barrowclough, 1990)
• Individual Psycho Therapy- One-on-one
  individual psycho therapy of schizophrenia has a
  rich history but had not been given its due
  importance. This treatment is very effective in
• i) Enhancing social adjustment.
• ii) Social role performance of the discharged
  patients.
• iii) It also helps in learning coping skills
  for managing emotions and stressful events. It is
  similar to cognitive behaviour therapy and it is
  an important component in all the treatment
  package for schizophrenia.
• Social skills training and community treatment-
  Training in useful skills
• i) Is a useful procedure for overcoming
  embarrassment, ineptitude, awkwardness and
  attentional clue lessness displayed in social
  situations by many schizophrenics.
• ii) This technique also help them in learning
  how to use different resources.
• iii) Also, how to get their lives organized.

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Community based follow up are required in making
the patients learn how to manage their life
problems such programs are known as Assertive
Community Treatment (ACT) and Intensive Case
Management (ICM) such programs have to ensure
that discharged patient do not get overlooked and
lost in the real life settings. The more
intensive the services, the larger the effect in
clinical improvement and social functioning of
the patient. (Brekke et al, 1997).

Finally the need is to coordinate. Anti
psychotic medication with other non medical
services. When done well, the patient benefits
substantially (Klerman et al, 1994 Kopelowicz,
1997).
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