Schizophrenia Spectrum and

UNIT 5 SCHIZOPHRENIA SPECTRUM AND Other Psychotic Disorders

OTHER PSYCHOTIC DISORDERS*

Structure
5.0 Introduction
5.1 History of Concept of Schizophrenia and Psychosis
5.2 Overview on the Symptoms of Schizophrenia
5.3 Positive Symptoms
5.3.1 Delusions
5.3.2 Hallucinations
5.4 Negative Symptoms
5.5 Disorganized Symptoms
5.5.1 Disorganized Speech
5.5.2 Disorganized Affect and Behaviour
5.6 Types of Schizophrenia
5.7 Other Psychotic Disorders
5.7.1 Schizophreniform Disorder
5.7.2 Schizoaffective Disorder
5.7.3 Delusional Disorder
5.7.4 Brief Psychotic Disorder
5.8 Statistics
5.9 Biological Causal Factors
5.9.1 Genetic Influences
5.9.2 Prenatal Exposure
5.9.3 Neurodevelopmental Factors
5.9.4 Neuroanatomical Factors
5.9.5 Neurochemical Factors
5.9.6 Neurocognitive Factors
5.10 Psychological and Cultural Causal Factors
5.11 Diathesis-Stress Model of Schizophrenia
5.12 Treatment for Schizophrenia
5.12.1 Biological Treatment
5.12.2 Psychosocial Treatment
5.13 Summary
5.14 Key Words
5.15 Review Questions
5.16 References and Further Reading

* Dr. Itisha Nagar,Assistant Professor of Psychology, Kamala Nehru College, University of

Delhi, New Delhi 141
Mood Disorders, Psychotic 5.17 References for Images
Disorders, Somatic Symptoms
and Eating Disorders 5.18 Web Resources
Learning Objectives
After reading this Unit, you will be able to:
Describe the clinical picture of schizophrenia;
Elaborate on the positive, negative and disorganized symptoms of
schizophrenia;
Discuss the different types of schizophrenia;
Identify other psychotic disorders;
Elaborate on the biological etiology of schizophrenia;
Describe the psychosocial and cultural factors affecting schizophrenia; and
Explain the treatment of schizophrenia.

5.0 INTRODUCTION
Consider the following examples;

‘A 25-year-old woman cries

and tells you that she is hearing
‘A middle-aged homeless voices of people crying and
man walks on the road abusing her’
alone; his clothes are in
tatters; he seems to be
talking to himself ‘A 45-year-old woman sits
claiming that the silently for days and doesn’t
Government of India is respond to anything or anyone.
spying on him.’ 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, disorganized speech, behavior 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 behavior: 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
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individual and his/her family. Symptoms of schizophrenia can make stable Schizophrenia Spectrum and
Other Psychotic Disorders
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,
affecting nearly 1 percent of the general population. 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 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 socialization. DSM-5 recognizes 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 [Link] this Unit, we will
discuss schizophrenia and other related psychotic disorders. Let us start by taking
a look at the history of the concept of schizophrenia.

Fig. 5.1: Schizophrenia

Source: [Link]

5.1 HISTORY OF THE CONCEPT OF

SCHIZOPHRENIA AND PSYCHOSIS
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 disorder
143
Mood Disorders, Psychotic may not always have an early onset and (2) the disorder does not lead to
Disorders, Somatic Symptoms
and Eating Disorders
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 disorganization of thought processes. Unfortunately, the
concept of split in schizophrenia inspired the common misunderstanding that
schizophrenia is split or multiple personality.

5.2 OVERVIEW ON THE 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 behavior.
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 i.e. 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,disorganized
symptoms. Disorganized symptoms consist of disorganized speech, affect, and
behavior. This division has been very useful in research on etiology and treatment
of schizophrenia.

Box 5.1: 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) Disorganized speech
4) Grossly disorganized or catatonic behavior
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.
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 Schizophrenia Spectrum and
C. Duration: Some signs of the disorder must last for a continuous period Other Psychotic Disorders
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.
H. 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.

Box 5.2: Case Study: 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 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 behavior 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
committed 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.

5.3 POSITIVE SYMPTOMS

5.3.1 Delusions
Delusion comes from the Latin verb 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 145
Mood Disorders, Psychotic them. There are many different types of delusions, some more common
Disorders, Somatic Symptoms
and Eating Disorders (persecutory) and others less common (e.g. 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 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 been 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 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
[Link] 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 over hear 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.

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 Schizophrenia Spectrum and
Box. 5.3: Examples of Different Types of Delusions Other Psychotic Disorders

“A Muslim lunatic from Chaniot had suddenly announced his name was
Mohamed Ali that he was Quaid-e-Azam Mohamed Ali Jinnah. This had led
a Sikh inmate to declare himself Master Tara Singh, the leader of the Sikhs.
Apprehending serious communal trouble, the authorities declared them
dangerous, and shut them up in separate cells. One inmate had got so badly
caught up in this India-Pakistan-Pakistan-India rigmarole that one day, while
sweeping the floor, he dropped everything, climbed the nearest tree and
installed himself on a branch, from which vantage point he spoke for two
hours on the delicate problem of India and Pakistan. The guards asked him
to get down; instead he went a branch higher, and when threatened with
punishment, declared: ‘I wish to live neither in India nor in Pakistan. I wish
to live in this tree.’ When he was finally persuaded to come down, he began
embracing his Sikh and Hindu friends, tears running down his cheeks, fully
convinced that they were about to leave him and go to India.”
-An excerpt from the short story Toba Tek Singh by Sadat Hasan Manto

Box 5.4: Delusions and their Relation with Social-Cultural and

Political Experiences
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.
Researchers, Lerner and colleagues (2006) examined two cases 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.

5.3.2 Hallucinations
Sometimes we may have perceptual experiences like, 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 147
Mood Disorders, Psychotic voices crying from inside of me. The voices are so sad they are howling, crying,
Disorders, Somatic Symptoms
and Eating Disorders
wanting my help, and I can do nothing about them. I cannot stop them.” Other
kind of hallucinations are visual [Link] 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.

Positive Symptoms Negative Symptoms Disorganized

Symptoms

Disorganized
Delusions Avolition
Speech

Hallucinations Disorganized
Alogia
Affect

Disordermized
Anhedonia
Behavior /
Catatonia

Asociality

Flat Affect

Fig. 5.2: Symptoms of Schizophrenia

148
 Schizophrenia Spectrum and
Check Your Progress 1 Other Psychotic Disorders
1) Define Schizophrenia.
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2) Distinguish between positive and negative symptoms of schizophrenia.
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3) What are persecutory delusions?
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4) How are hallucinations different from illusions?
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5.4 NEGATIVE SYMPTOMS

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.

Alogia: Alogia means significant reduction in the amount of speech i.e. 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.

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, socialization, 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.

149
Mood Disorders, Psychotic Asociality: Some people with schizophrenia have severe impairments in social
Disorders, Somatic Symptoms
and Eating Disorders
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 socialize.
Flat Affect: Flat affect is the lack of outward expression of emotion. A 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.

5.5 DISORGANIZED SYMPTOMS

5.5.1 Disorganized 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, disorganized thinking/speech is
disturbance in the thought form, also known as formal thought disorder.
Disorganized speech includes problems in organizing ideas and speaking so that
that the listener can understand. As a symptom, disorganized speech is not only
unique to schizophrenia ; it is also present in mania, depression, and dementia.
To the listener, disorganized speech sounds like as if someone as put a paragraph
in a blender. In disorganized 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 organized 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.
150
A person with schizophrenia describes what it is like to have a disorganized Schizophrenia Spectrum and
Other Psychotic Disorders
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”

Box 5.5: Examples of Disorganized 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 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”

Clang
Associations

Neologisms Alogia

Forms of
Disorganized Tangential
Derailment
Speech Speech

Fig. 5.3: Different forms of disorganized speech 151

Mood Disorders, Psychotic
Disorders, Somatic Symptoms
5.5.2 Disorganized Affect and Behaviour
and Eating Disorders
While in disorganized speech, a person with schizophrenia loses the ability to
communicate by organizing thoughts. In disorganized behavior, people lose their
ability to organize their behavior 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. Disorganized affect similarly means difficulty in
organizing emotions to suit to the needs of 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 disorganized affect and behavior, 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 disorganized behavior 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; a person can move the patient’s limbs into positions that the
patient will maintain for a long period of time. 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.

Fig. 5.4: Catatonic State

Source: [Link]
152
 Schizophrenia Spectrum and
Check Your Progress 2 Other Psychotic Disorders
1) What are neologisms?
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2) Define catatonia. Is it a condition only unique to schizophrenia?
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3) Explain clang associations.
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4) Describe disorganized behavior.
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5.6 TYPES OF SCHIZOPHRENIA

Emil Kraepelin distinguished between three subtypes of schizophrenia: paranoid,
disorganized, 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, disorganized speech, affect,
catatonia or disorganized behavior 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
behavior 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. 153
Mood Disorders, Psychotic Disorganized Schizophrenia: In the clinical presentation of someone with
Disorders, Somatic Symptoms
and Eating Disorders
disorganized schizophrenia, the following features are prominent: disorganized
speech, disorganized behavior, flat or inappropriate [Link], the criteria
for catatonia is not met. Disorganized 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 behavior; 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 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.

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.

5.7 OTHER PSYCHOTIC DISORDERS

Apart from schizophrenia, there are other types of psychotic disorders also. They
are elaborated in this section.

5.7.1 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.
154
 Schizophrenia Spectrum and
Box 5.6: DSM-5 Criteria for Schizophreniform Disorder Other Psychotic Disorders
(APA, 2013)
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. drug of abuse, a medication) or another medical
condition.

5.7.2 Schizoaffective Disorder

Schizoaffective disorder is a condition in which people experience both
schizophrenia symptoms and mood disorder symptoms. The prognosis of this
condition is poor i.e. people tend to face significant difficulties in life for a number
of years. In this condition, an individual experiences both psychotic symptoms
(delusions and hallucinations) and mood symptoms (depression or mania).
However, it is challenging for a professional to determine whether a person with
schizophrenia is experiencing mood difficulties or does the person primarily
have a mood disorder with psychotic features. For a schizoaffective disorder, the
psychotic features are present for at least 2 or more weeks in the absence of a
major mood episode (depression or mania). This condition is further divided
into bipolar type (when manic symptoms are part of presentation) or depressive
type (when depressive symptoms are prominent in absence of manic symptoms).
Box 5.7: DSM-5 Criteria for Schizoaffective Disorder
(APA, 2013)
A. 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.
B. During the same period of illness, there have been delusions or
hallucinations for at least 2 weeks in the absence of prominent mood
symptoms.
C. 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.
D. The disturbance is not due to the direct physiological effects of a
substance (e.g., 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.
155
Mood Disorders, Psychotic
Disorders, Somatic Symptoms
5.7.3 Delusional Disorder
and Eating Disorders
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 (e.g. a
persistent belief that someone is trying to poison them), erotomonia (e.g. a
persistent belief that a person usually of higher status like an actor or sportsperson
is in love with them), jealous type (e.g. an individual may believe that their
spouse/partner has an affair in spite of contradictory evidence), somatic type
(e.g. 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 maybe extremely bizarre and
odd (e.g. 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 (e.g. the belief that one’s spouse/partner is having an
affair).

Box 5.8: 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 (e.g., 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 behavior 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.

5.7.4 Brief Psychotic Disorder

As the name suggests, brief psychotic disorder is the sudden onset of psychotic
symptoms, disorganized speech or behavior. 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.
Box 5.9: 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.
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 Schizophrenia Spectrum and
3) Disorganized speech (e.g., frequent derailment or incoherence). Other Psychotic Disorders
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 3

1) Define paranoid schizophrenia.
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2) How is brief psychotic disorder different from schizophrenia?
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3) List symptoms of brief psychotic disorder.
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5.8 STATISTICS
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 higher risk of
developing the disorder than others. For instance, this may 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. 157
Mood Disorders, Psychotic
Disorders, Somatic Symptoms 5.9 BIOLOGICAL CAUSAL FACTORS
and Eating Disorders
UNDERLYING SCHIZOPHRENIA
In this section, we discuss the main biological causes of schizophrenia.

5.9.1 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. Overall, studies
suggest that schizophrenia is polygenic in nature, i.e. 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, i.e. 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 fetal 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
158
genetics in causation of schizophrenia. Adoption studies then can help in truly Schizophrenia Spectrum and
Other Psychotic Disorders
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 [Link] 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.

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.

Fig. 5.5: Identical and Non-Identical Twins

Source. [Link]
159
Mood Disorders, Psychotic
Disorders, Somatic Symptoms
and Eating Disorders
Schizophrenia
Discordant Twins

Schizophrenia Twin Well-Twin

Possibility of Possibility of
developing developing
schizophrenia (17 schizophrenia (17
percent) percent)

Fig. 5.6: Possibility of developing schizophrenia in offspring of discordant twin set with
schizophrenia

5.9.2 Prenatal Exposure

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
hypothesized that the antibodies developed in the mother’s body against the
infection may cross the placenta and disrupt the neurodevelopment of the fetus.
Rhesus Incompatibility: Rhesus (Rh) incompatibility occurs when an Rh-
negative mother carries an Rh-positive fetus. 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
160 associated with schizophrenia.
Pregnancy and Birth Complications: The probability of patients with Schizophrenia Spectrum and
Other Psychotic Disorders
schizophrenia with a history of complicated pregnancy or birth complication
(e.g., 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.

5.9.3 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 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.

Fig. 5.7: Home videos of children who went on to develop schizophrenia showing motor
movement abnormality
Source: Walker, E. F. (1994). Developmentally moderated expressions of the neuropathology
underlying schizophrenia. Schizophrenia bulletin, 20(3), 453-480.

161
Mood Disorders, Psychotic
Disorders, Somatic Symptoms
5.9.4 Neuroanatomical Factors
and Eating Disorders
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 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. 5.8: MRI scans of twins: a healthy twin and one with schizophrenia showing
enlarged brain ventricles in the sibling with schizophrenia
Source: [Link]

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-frontal
lobe) is shown in people with schizophrenia. Problems in the frontal 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.
162
5.9.5 Neurochemical Factors Schizophrenia Spectrum and
Other Psychotic Disorders

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 disorder (a disorder 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 i.e. 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 [Link] 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 hypothesized
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.

5.9.6 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 (e.g. “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 through
163
Mood Disorders, Psychotic the use of a psychophysiological measure called P50. In this measure when two
Disorders, Somatic Symptoms
and Eating Disorders
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 4

1) How do twin studies help understand etiology of schizophrenia?
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2) Is schizophrenia a neurodevelopmental disorder?
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3) On what neurocognitive skills do people with schizophrenia perform
poorer than typical control individuals?
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4) What is the dopamine hypothesis of schizophrenia?
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5.10 PSYCHOSOCIAL AND CULTURAL CAUSAL

FACTORS
One of the earliest (mis)understanding regarding the causality of schizophrenia
was the belief that cold and aloof behavior 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
164
and then scolding them for finding a job and neglecting other responsibilities). Schizophrenia Spectrum and
Other Psychotic Disorders
Such contradictory and disorganized messages over a period of time led to
disorganized thinking seen in schizophrenia. However, later it was found that
disorganized communication was not the cause but result of having to interact
with someone who is severely ill and disorganized. However, 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.

High Expressed Emotion Low Expressed Emotion

I always tell her “why don’t you I know it’s better for him to be on
pick up a book, listen to music or his own and get away from me and
something that would keep your try to do things his own way.
mind off it”
I just tend to let it go because I
She is deliberately quiet and pas- know that when she wants to
sive because she knows that if she speak, she will speak.
behaves like this then no one will
ask her to help in housework.

Fig. 5.9: Examples of communication in families showing high and low on Expressed
Emotion

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 (i.e., those born in another
country) had 2.7 times the risk of developing schizophrenia; this risk becomes
4.5 times for second-generation immigrants (i.e., 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 165
Mood Disorders, Psychotic makes them 6 times more likely to develop schizophrenia at the age of 27 years.
Disorders, Somatic Symptoms
and Eating Disorders
(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 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.

5.11 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 summarized
well through the diathesis-stress model. According to the model, 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 Vulnerability

Developmental
Maturational
Processes &
Stress

Psychosis

Fig. 5.10: Diathesis-Stress Model of Schizophrenia

166
 Schizophrenia Spectrum and
Check Your Progress 5 Other Psychotic Disorders
1) What is Expressed Emotion? How is it related to relapse in people
with schizophrenia?
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2) Explain diathesis-stress model of schizophrenia.
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5.12 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.

5.12.1 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 1930s.
Electroconvulsive Therapy (ECT) was employed for treatment of schizophrenia.
ECT did not prove to be very effective for people with schizophrenia.

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.

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Mood Disorders, Psychotic
Disorders, Somatic Symptoms
5.12.2 Psychosocial Treatment
and Eating Disorders
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.

5.13 SUMMARY
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 behavior:
disturbances in movement, disheveled appearance, lack of self-care.

Positive symptoms are characterised by bizarre and odd behavior.

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 disorganized symptoms were added to the

symptomatology of schizophrenia, disorganized symptoms. Disorganized
symptoms consist of disorganized speech, affect, and behavior.

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 disorganized type of schizophrenia tend to
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 show marked disruption in their speech and behavior; they also show flat or Schizophrenia Spectrum and
Other Psychotic Disorders
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.

Apart from schizophrenia, there are four other psychotic disorders.

Schizophreniform disorder classifies 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. 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 behavior. The episode lasts
for very few days, not enough to warrant a diagnosis 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.

5.14 KEY WORDS

Schizophrenia Spectrum Disorders: A group of disorders, the hallmark of which
is a significant loss of contact with reality called psychosis.

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 i.e. absence/deficit of normal behavior for example in schizophrenia they
include poverty of speech, flat affect, avolition, apathy, and asocility.

Catatonia: A striking example of disorganized behavior is catatonia or the motor

dysfunctions that range from wild agitation to immobility.

Expressed Emotion: Refers to emotional over-involvement, excessive hostility

and criticism of a patient with schizophrenia by family members.

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Mood Disorders, Psychotic Diathesis-stress Model: Many mental disorders including schizophrenia develop
Disorders, Somatic Symptoms
and Eating Disorders
when some kind of stressor operates on a diathesis i.e. predisposition toward
developing a disorder is termed a diathesis (biological, psychological, or
sociocultural causal factors).

Neuroleptics: Anti-psychotic medicines that help reduce positive symptoms like

delusions and hallucinations. Neuroleptics are dopamine antagonists; they
interfere with the dopamine neurotransmitter system in the brain.

5.15 REVIEW QUESTIONS

1) Dementia praecox was a disease first identified by.
a) Freud
b) Kraepelin
c) Bleuler
d) Watson
2) In Schizophrenia, psychotic symptoms such as hallucinations delusions are
called ________.
3) Misinterpretation of perceptions or experiences in schizophrenia are known
as_______.
4) In schizophrenia when an individual believes they are in danger, this is
referred to as ______________.
5) The most common type of hallucinations in people with schizophrenia
are______ hallucinations.
6) Paranoid schizophrenia is a sub-type of schizophrenia characterised by:
a) The presence of disorganised behaviour and flat or inappropriate affect.
b) The presence of delusions or auditory hallucinations.
c) The severe disturbances of motor behaviour.
d) A lack of prominent positive symptoms with evidence of on-going
negative symptoms.
7) The biochemical theory of schizophrenia known as the Dopamine Hypothesis
refers to:
a) Insufficient Dopamine activity.
b) Contaminated Dopamine.
c) Excess Dopamine activity.
d) Allergic sensitivity to Dopamine.
8) Describe the symptoms and types of schizophrenia.
9) Discuss the biological causes of schizophrenia.
10) Describe other forms of other psychotic diosrders.
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 Schizophrenia Spectrum and
5.16 REFERENCES AND FURTHER READING Other Psychotic Disorders

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.

5.17 REFERENCES FOR IMAGES

Schizophrenia. Retrieved 10th August 2019, from [Link]
com/search/schizophrenia
Catatonia. Retrieved 14th August 2019, from h[Link]
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:/
/[Link]/genetics-glossary/identical-twins
Home videos of children who went on to develop schizophrenia showing
motor movement abnormality, Retrieved 18th August 2019, from http://
[Link]/viewdoc/download?doi=10.1.1.1021.2074
&rep=rep1&type=pdf
MRI Scans of healthy twin and with schizophrenia twin, retrieved 18th August
2019, from [Link]
schizophrenia-overview

5.18 WEB RESOURCES

For a brief account on history of the concept of schizophrenia, visit
- [Link]
brief-history-schizophrenia
For a documentary on the life of Dr. John Nash,
- [Link]
To read the short story Toba Tek Singh that gives a description of different
cases of schizophrenia.
- [Link]
To get more information on Genain Quadruplets, visit
- [Link]
with-schizophrenia-four-decades-of-scrutiny#1

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Mood Disorders, Psychotic To get more information on latest research in schizophrenia.
Disorders, Somatic Symptoms
and Eating Disorders - [Link]
schizophrenia-may-be-laid-down-in-the-womb/

Answer for Fill in the Blanks (1-7)

(1) Kraepelin, (2) Positive Symptoms (3) Hallucinations(4) Delusions of

Persecution (5)Auditory, (6) The presence of delusions or auditory hallucinations,
(7) Excess Dopamine activity

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