What does the schizophrenic spectrum and related psychotic disorders look like? - Chapter 7 (Abnormal Psychology)

A person suffers from psychosis if he has hallucinations and delusions and can not say with certainty whether his observations are real or not. A form of psychosis that often occurs is schizophrenia. People can sometimes think very clearly and function well, but also have moments when they can no longer take care of themselves.

Schizophrenia occurs in 1 to 2 percent of people in the United States and in 0.5 to 1 percent of all people around the world. Schizophrenia is more common in men than women and is more common in colored people than in whites. About 90% of people with schizophrenia seek help. The disorder often develops in youth or young adulthood.

Symptoms of schizophrenia

Schizophrenia is a very complex disorder. A distinction is made between two categories of symptoms, the positive and the negative symptoms. The DSM-V refers to the schizophrenia spectrum, to show that there are five domains of symptoms that define psychotic disorders, and their number, severity and duration distinguish psychotic disorders from each other.

Positive symptoms

Positive symptoms, or Type I symptoms, are characterized by the presence of delusions, hallucinations, disorganized speech and thoughts and disorganized or catatonic behavior. These symptoms can also occur in other disorders, such as bipolar disorder, so that makes the diagnosis for schizophrenia difficult. It is also possible that the symptoms occur in people who actually have no problems. Think of people who hear voices and attribute this to their religion. There are also people who, due to the symptoms, have no control over reality: delusional disorder (delusions).

The rule is that if the positive symptoms only occur during a manic or depressive period, the diagnosis 'mood disorder with psychotic characteristics' is made. If the positive symptoms also occur outside the manic or depressive periods, the diagnosis is made schizophrenia.

Delusions are ideas that the patient thinks are true, while those ideas are very unlikely or even impossible. Many people sometimes have unlikely thoughts, but there are differences between these kinds of thoughts and delusions. When healthy people have unlikely thoughts, they are not completely unbelievable, while delusions are. People with delusions constantly think about it and seek evidence for their ideas, with which they try to convince others. In addition, people with delusions can not accept that their thoughts are not right.

There are four kinds of delusions:

1. A persecutory delusion is a delusion in which people think that someone they know is after them to observe and punish them.
2. In a delusion of reference people think that things are specifically aimed at them. For example, they think that the weather forecast is a secret message to them. They believe that certain things have been put in scene and that everything is a plot.
3. People with grandiose delusions think that they are a very special person with special powers.
4. Delusions of thought insertion are delusions in which people think that their thoughts are influenced by others.

Many patients have several of the above delusions at the same time. It may be that delusions are very simple, but they can also take on very complex forms.

Many of these types of delusions occur throughout the world, but the themes of delusions differ per culture. Americans think faster that the CIA is after them, while, for example, Germans think that Satan is aiming at them. A number of scientists believe that thoughts shared by healthy people in that culture should not be regarded as delusions. However, this statement is not supported in the United States.

Hallucinations are observations of a person who are not actually there. The most common hallucination is the auditory hallucination (hearing). In auditory hallucinations , for example, someone can hear music or voices. Often people hear voices that speak to or over the listener and accuse or threaten him.

Another form of hallucination that often occurs is the visual hallucination. These types of hallucinations often occur together with auditory hallucinations.

Other forms are the tactile hallucination, in which someone feels something on his body, for example worms on his skin, and the somatic hallucination, where someone feels something in his body, for example pain that feels as if someone has hit him with a laser beam.

People with schizophrenia often also suffer from formal thought disorder, also called disorganized speech and thoughts . This means that they are often very confused in thinking and speaking. Schizophrenics often have the tendency to jump from one subject to another without any logical connection between them. It seems completely logical to them. This is indicated by the terms loosening of association and derailment. In totally incoherent stories, people also speak of word salad. Sometimes they make new words (neologisms) or make sentences of words that have no substantive connection, but whose sounds are related (clangs).

People with schizophrenia often have difficulty with cognitive tasks and have serious problems with concentration. Schizophrenic men seem to have more language problems than schizophrenic women. This is probably due to the fact that language use is more distributed over the brain in women than in men. In this way, women can compensate better if there are brain damage.

Someone with schizophrenia often behaves very confused. For example, he can suddenly scream or walk back and forth all the time. In schizophrenia there is a form called catatonic excitement . Here a person suddenly behaves very wildly for no apparent reason and is also difficult to get silent. This is known as disorganized or catatonic behavior. People often show unexpected behavior and have trouble organizing daily life. They can also often repeat simple tasks.

Negative symptoms

Negative symptoms, or Type-II symptoms, mean the loss of certain capacities (normal behavior).

People with schizophrenia often suffer from affective flattening, where they show much less or even no emotions. This is sometimes called blunted affect . They often speak monotonously and do not look after others.

Affective flattening can be a sign of 'anhedonia'. This is the loss of interest in everything from life. It is also possible that people do feel emotions, but can not express them.

Another negative symptom is alogia, a reduction in speech power. A person speaks less to others, and gives short and simple answers to questions. It may even be the case that someone does not say anything anymore for a number of weeks. Probably these people also have a reduction in thinking.

Avolition is the inability to complete normal daily activities. For example, someone who experiences this, tends to be really disorganized, careless and unmotivated. Taking each day with no positive emotions causing them to space out for the majority of the time..

The negative symptoms of schizophrenia are also difficult to diagnose, often even more difficult than the positive symptoms. This is mainly due to the absence of behavior instead of presence. Also, the symptoms lie on a continuum of normal to abnormal behavior, so it is difficult to determine what exactly is abnormal. Another reason is that there are other factors that can cause the negative symptoms, such as the side effects of certain medications.

People with schizophrenia can also display instead of flattened affect inappropriate affect. They do that when, for example, they suddenly start to laugh when someone tells something sad. This may be because a schizophrenic person reacts to something other than the pathetic story. It is also possible that it is because something goes wrong in the brain with processing or expressing emotions. As with mood disorders, anhedonia also occurs in schizophrenia. This also has to do with 'affective flattening'. Furthermore, people with schizophrenia have poor social skills.

Cognitive deficits

Due to schizophrenia, defects can arise in cognitive processes, such as attention and memory. People can often focus less well. Often there is an error in the working memory, so that less information is remembered and the information is often manipulated.

People can hardly focus on relevant stimuli and confuse them with their own thoughts. They can no longer find out what is real and what is not.

Diagnosis

Schizophrenia has been seen as a disease since 1800. The first name that was conceived for it was dementia praecox. This name was given because it was thought that the cause of this disorder was a premature decay, a precursor of dementia. Later the name 'schizophrenia' was given. The term schizophrenia comes from the Greek schizein that means 'shared' and 'phren' means thoughts. So shared thoughts, or split mind. This name was given, because it was thought that the bodily functions were split off from the thoughts. At the beginning of the twentieth century, everyone who had a psychosis got the label schizophrenia, but nowadays the definition is more precise. According to the DSM-V, people are diagnosed with schizophrenia if they show a two or more symptoms of schizophrenia for at least 6 months. At least one of these symptoms must be hallucinations, illusions, or disorganized speech. Of those 6 months there must be at least 1 month in which there are more and more extreme symptoms, which impede the functioning of the person. This is called the acute phase. The symptoms must interfere with daily functioning. Before people actually enter the 'schizophrenia' phase, they often have prodromal symptoms, and after an episode there are residual symptoms. These symptoms are not as bad as during an episode, but people usually behave strangely and sometimes have mild hallucinations.

In the DSM-IV there were several subtypes for schizophrenia. The DSM-V no longer has these subtypes because there was not enough evidence for the diagnostic stability, validity and usefulness of these subtypes.

Prognosis

Schizophrenia is more chronic than other disorders, 50-80% will be taken again for schizophrenia after a first admission. Life expectancy is 10 years shorter than in people without schizophrenia. 10-15% of people with schizophrenia commit suicide.

Contrary to what people often think, people with schizophrenia do not deteriorate as the disorder progresses. Most people stabilize after 5 to 10 years, and they do not need to be treated as often as they get older. This may be because after a while people have found the right medicine with a dose that works best for them. It is also possible that the person's family learns how to deal with the patient better, preventing new episodes. It is also possible that the chance of new episodes becomes smaller as a result of the aging of the brain. 20-30% of patients heal partially or completely.

It has been found that people who live in developing countries and have schizophrenia have a better prognosis than people in the West. This is probably because people in developing countries have a better social network, which means they have less stress. Stress can lead to new episodes of the disorder.

Women generally have a better course of the disorder than men. Women need to be admitted less often, and usually have milder negative symptoms. Women can also adapt better in their social world when they are not psychotic. The reason that the disorder for women is usually less severe than for men is probably that women lose their social network less. It is also possible that the drug for schizophrenia affects the regulation of dopamine and that women are more protected there than men. In addition, women often have a better history than men: they often have a diploma, are married and have children, and have good social skills. This may also be because women often develop schizophrenia later than men.

Other psychotic disorders

The DSM-V also contains other mental disorders that have similarities with schizophrenia.

A schizoaffective disorder is a mix of schizophrenia and a mood disorder. People often have spontaneous symptoms of schizophrenia and mood swings (manic and depressed). Some people think that the disorder exists because clinicians can not decide which disorder is involved: schizophrenia or a mood disorder.

In Schizophreniform disorder , people have symptoms of schizophrenia, no schizoaffective disorder or mood disorder and symptoms do not come from drugs, drugs or alcohol. They only need these symptoms for 1 to 6 months to get the diagnosis. The majority (about 2/3) of people with schizophreniform disorder eventually receive a diagnosis of schizophrenia or schizoaffective disorder.

Brief psychotic disorder: sudden symptoms of schizophrenia lasting only 1 day to 1 month. The symptoms often come from a stressful situation such as an accident. Some women also have it after the birth of their child.

Delusional disorder: these people have delusions for at least a month, which relate to things that can happen in life (being chased). They have no trouble with functioning. It is more common in women than in men.

People with schizotypal personality disorder have a lifelong pattern of significant disruptions in their self-concept, the way they interact with others and their thinking and behavior. They have no clear and independent view of themselves and can have difficulty setting realistic or clear goals. Their emotional expression can be limited, or peculiar. They think and behave in weird ways, even though they still have a grip on reality. Sometimes they develop schizophrenia.

Biological theories

Research has been conducted into schizophrenia through family studies, twin studies and adoption studies. It appears that genes have an influence on getting schizophrenia. For example, this conclusion can be drawn from the finding from a family study, that the greater the genetic similarity between two people, the greater the chance that if one has schizophrenia, the other will get it. The fact that a child of two schizophrenic parents has a great chance of becoming schizophrenic can also say something about the environment in which the child grows up. Therefore, adoption studies were carried out, which showed that children of a schizophrenic mother who grew up in another family were much more likely to develop schizophrenia than adopted children without schizophrenic parents. This is a strong argument for the role of genes in the development of schizophrenia.

From twin studies found that genetic factors may play a greater role in schizophrenia severe than in mild schizophrenia. It appears that genes play a role in this disorder, but it is still unclear which genes play a role in their development.

One of the biggest difficulties is that schizophrenia is not a single, but a group of disorders together, making finding specific genes involved is difficult. It may even be that the different types of schizophrenia all have different genetic backgrounds. It could also be that some forms of schizophrenia are not genetically transmitted. The last problem is that if someone has a genetic predisposition to schizophrenia, it does not have to be that he also gets schizophrenia.

There are deviations in the brains found in people with schizophrenia. Very often they appear to have enlarged ventricles. Ventricles are spaces in the brain that are filled with fluid. If these are larger, there is less room for the brain. The enlarged ventricles indicate the death of the brain tissue. People with enlarged ventricles are often less social, emotional and show less 'good' behavior. They also often have more serious symptoms and respond less well to medication.

The most consistent finding is that people with schizophrenia have a large reduction of grey matter in the cortex, especially in the medial, temporal, superior temporal, and frontal areas. There is also abnormal activity in the prefrontal cortex and in the temporal cortex. Certain parts of the brain are often smaller in people with schizophrenia. Especially with the prefrontal cortex it has been found that it is often smaller and shows less activity. The prefrontal cortex is important in language, expressing emotions, plans and social interactions. He is connected to both the limbic system, which is involved in emotions and cognitions, and the basal ganglia, which are involved in motor skills.

The prefrontal cortex is particularly developed in adolescence, which is probably the reason that adolescents develop schizophrenia in particular.

Research has shown that in people who show the negative symptoms of schizophrenia (such as poor motivation or weak social skills), the prefrontal cortex is indeed often less active. In the case of people who mainly show the positive symptoms (hallucinations or delusions), this is found less.

People with schizophrenia also appear to show abnormalities in both the structure and activity of the hippocampus. The hippocampus plays an important role in the long-term memory.

People with schizophrenia also have reductions and abnormalities in the white matter, especially in areas associated with working memory. These abnormalities are already present before people develop the disorder, which is likely to be early signs of the disorder. The abnormalities in the white matter cause problems with the cooperation of different brain areas.

Several causes are possible for the abnormalities in people with schizophrenia.

Serious problems at birth are more common among these people. Especially if the child does not get oxygen during childbirth (perinatal hypoxia), this may increase the risk of schizophrenia.

It has also been shown that when mothers were infected with during their pregnancy influenza virus, the child was later more likely to develop schizophrenia.

It is thought that schizophrenia can also be caused by problems with the neurotransmitter dopamine. The original theory explains that there is too much dopamine in the brain, especially in the frontal lobe and in the limbic system. There is a number of indications for this. Medications that reduce the effect of dopamine (phenothiazines) also reduce the symptoms of schizophrenia. Medications that improve the action of dopamine (amphetamines) stimulate psychotic symptoms. Autopsy and PET scans show that schizophrenics have more dopamine receptors and higher dopamine levels than other people.

Nowadays this theory is found too simple. Many people do not respond to drugs that reduce dopamine. People who are helped by these drugs only show a reduction in positive symptoms, not in negative ones.

Because of these criticisms, the old theory has been replaced by a newer one. The new theory suggests that there is a dopamine surplus in the mesolimbic system, which causes the positive symptoms. Atypical antipsychotics can help reduce symptoms by binding D4 (dopamine) receptors in the mesolimbic system and thus block the action of dopamine.

In addition to the surplus in the mesolimbic system, there is a dopamine shortage in the prefrontal cortex. This deficiency creates the negative symptoms of schizophrenia. This is a good explanation for the fact that the old drugs do the positive, but not the negative symptoms remedy.

Another theory states that the positive symptoms result from a dopamine surplus in the limbic system, but that the negative symptoms are the result of abnormalities in the brain structure of the prefrontal cortex.

Finally, research shows that the neurotransmitters serotonin, glutamate and GABA probably also play a role in schizophrenia.

Psychosocial perspectives

Despite the fact that people now think that schizophrenia is largely biologically determined, there have always been psychological theories about it.

People with schizophrenia tend to live more often in places that generate high levels of stress, for example, in neighbourhoods that borderline poverty. Research suggests a statement through social selection. This means that people who are schizophrenic end up in lower social classes because, for example, they can hardly get a job. Other studies show that schizophrenics are born relatively more often in a large city than in a village. This is probably not due to the stress of a big city, but because people from a city are more susceptible to viruses, causing a pregnant woman to be infected more quickly. As a result, the child has a greater chance of schizophrenia. Stressful conditions are therefore not the cause of schizophrenia, but they can start a new psychotic episode.

The environment that is most studied is the family. An early theory about the influence of family is about the so-called double binds. These are ties that a child has with a parent (especially the mother) whereby the child always receives information that is in conflict with each other (according to Freud). For example, it may be that a child is stroked by the mother, while she is also berating the child. When children often get mixed messages like this, they learn that they can not trust their own feelings and perceptions, so that they get distorted images of themselves and the world. This can contribute to schizophrenia.

This theory is not supported by research, but studies of communication patterns have discovered striking things in families with a member who is schizophrenic. In this type of families, communication is often unclear and vague, and there are often misunderstandings. It could be that children who are already susceptible to schizophrenia from their genes, are in this way even more likely to develop this disorder.

A lot of research has been done within families into what expressed emotion is called. Families who score high on this scale are very much involved with the schizophrenic family member, and they show that they sacrifice themselves, while at the same time being very critical and hostile to the schizophrenic person. Schizophrenics with a family that scores high on expressed emotion are more likely to fall back into psychosis than schizophrenics with a family that has a low level of expressed emotion.

Critics of this theory say that the hostile attitude might just be a cause of the patient's condition. Because although people are usually forgiving of the positive symptoms, they are often not forgiving of the negative symptoms, because they often have the idea that the patient can do something about it. Another explanation is that people who have a high expressed emotion are themselves susceptible to a psychological disorder. It could therefore be that people in that kind of families have a greater genetic load for a disorder, which means that they also fall back faster.

The behaviourists and cognitive psychologists have not had much to say about schizophrenia. Some behaviourists have tried to explain schizophrenia using operant conditioning. According to them, schizophrenic people have not learned to deal with their social environment, so they pay too much attention to irrelevant stimuli. This theory has never been properly tested, but behaviourist techniques that teach schizophrenic people social skills do have an effect. Few cognitive psychologists have been involved with schizophrenia. It is assumed that schizophrenia has a biological basis. Cognitive psychologists suggest that the delusions are developed to give the strange sensations that someone has meaning.

People with schizophrenia often have fundamental difficulties with attention, inhibition and entry of rules of communication that ensure that they 'conserve' their limited cognitive tools. They often use certain schemes, sometimes called prejudices, to easily understand information.

Positive symptoms are often caused by hypersensitivity. Negative symptoms are due to the expectation that social interactions are hostile.

A therapist helps the patient to identify situations and to deal with stressful situations.

Treatments for schizophrenia

Scientists have tried many things to 'cure' schizophrenics. Examples of this are confining the patient, brain surgery, injecting insulin to cause a coma and ECT. These things all proved ineffective.

The drug chlorpromazine (a phenothiazine) was the first medicine that really worked against schizophrenia. It works by blocking the dopamine receptors, reducing the effect of dopamine. Another type of antipsychotic medication is neuroleptics. These drugs do not work for everyone, about 25 percent do not respond. The drugs work well to reduce the positive symptoms but much less well on the negative symptoms.

There is usually a big relapse when the medication is stopped. It is also very dangerous to continue taking this medicine for a long time, because there are very serious side effects, such as akinesia (slow motor skills, slow speaking), akathisia (not being able to sit still) and tardive dyskinesia (involuntary movements of the tongue). , from the jaw or face). Tardive dyskinesia occurs in 20 percent of people who have been using chlorpromazine for a long time, and often does not go away. To limit the side effects, people are often put on a maintenance dose. This is a dose that is just enough to cope with the positive symptoms, yet has as few side effects as possible.

Other side effects include dry mouth, poor vision and weight gain. Some people even develop symptoms of Parkinson's disease, such as stiffness and shaking.

Nowadays there are also atypical antipsychotics. These drugs seem to be more effective than the older drugs. An example is clozapine. This drug works on the dopamine receptor D3. Many people who did not respond to the old drugs respond to this drug, and it seems that this drug also reduces the negative symptoms.

Tardive dyskinesia does not occur with the use of this drug, but there are other side effects such as dizziness, palpitations and agranulocytosis. This is a very dangerous condition that affects 1 to 2 percent of people who use this medication. There is then a shortage of granulocytes and this can be fatal.

Another effective drug is risperidone. This drug also affects serotonin receptors and is as effective as clozapine, but works faster.

Psychological interventions are mainly used in combination with drug therapies. They are mainly aimed at teaching people social skills and getting them out of their isolation. Most experts believe that a broad intervention is needed that resolves behavioral, cognitive and social problems in a way that is adapted to the patient.

Cognitive interventions try to change the views that patients have about their illness, so that they will seek help sooner and they will participate more with society. They also learn to understand the disorder through cognitive interventions.

Behavioral techniques are used to teach people techniques to continue in daily life. This is often done by operant conditioning, with positive and negative reinforcers.

Social interventions are aimed at helping people out of their isolation.

Because people with schizophrenia benefit a lot from a caring and supportive family, it is important that the family of the patient learn to deal with the disorder. Therapies that are successful in this area combine providing information about the disorder with the training of family members in order to deal properly with the impact the disorder has on them. This family therapy, combined with medication, is more effective than therapy with medication alone. These interventions must take into account the culture within a family.

Sometimes people no longer have family that can take care of them. Assertive community treatment programs provide services for those with schizophrenia. The people who do this work have a medical background, they are social workers and psychologists who visit people with schizophrenia every week. They ensure that the chance of a relapse is smaller and the chance of a recording is smaller. The patients are prepared for daily life, looking for a job, etc.

Schizophrenia is seen and treated differently in other cultures than in Western culture. There are four ways in which this happens:

1. According to the structural model , there are connections between, for example, the body, emotions, society and culture. Healing then works by restoring the connections between these elements.
2. According to the social support model , the symptoms are the result of poor relationships between people. One tries to heal someone by solving those problems.
3. The persuasive model tries to heal people through rituals.
4. The clinical model is about the belief that the patient has in the healer, which heals the patient.