There are 3 first rank symptoms:

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1

Passivity experiences. These

are: Thoughts coming into the mind from outside.

Thoughts which seem to be taken out of the mind.

Thoughts which are broadcast.

First Rank Symptoms

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2

Hallucinations: These can occur in any sensory form but they are usually auditory. Usually a voice is heard commenting on character and giving commands. Sometimes the hallucinations affect the sense of touch, when the body feels either on fire or numb, for example. The person may sometimes feel separated from the body. Friston (1995) says that schizophrenics find it difficult to connect different areas of the brain. In the brain we have an auditory feedback loop which tells us that the voice in our heads is our own. Schizophrenics don’t make this connection. They are often not aware that they are talking out loud.

First Rank Symptoms

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3

Delusions: There are 4 types: Delusions of grandeur – such as a belief that a person is Napoleon, God, Queen Victoria, etc.

Delusions of persecution – such as the CIA or FBI are after you.

Delusions of reference – objects and events have negative influences. For example, the TV sends out negative messages.

Delusions of nihilism – the destruction of everything, all is purposeless – the belief that nothing exists and that the person or individual has been dead for years and has been observing themselves from a distant place.

The Second Rank Symptoms of Schizophrenia:

     These are: Thought process disorder – we are bombarded with sensory information and most people focus on the information that is important at that time.

Schizophrenics find it hard to focus on specific bits of sensory information and so find it difficult to concentrate. This is the reason for the individual shifting from one topic to another. Sometimes the language can be completely jumbled, and in psychology, this is called a ‘word salad’. One word can lead to an association which is not connected with what was said before. Another aspect of this condition is thought blocking or stopping in the middle of a sentence.

2

nd

Rank Symptoms

    Disturbance of affect (emotions) – There are 3 types of emotional disturbance: Blunting - the emotional actions are not as acute as most other individuals.

Flattening – there appears to be no emotional tone to the voice. On occasions when most people would respond with anger or joy, a schizophrenic would respond in a monotone.

Inappropriate affect (emotion) – the wrong emotions are displayed in situations that shouldn’t elicit such a response, eg laughing at news of a death.

Second Rank Symptoms

    Psychomotor disturbances – one of the main psychomotor disturbances is catatonia – a posture is adopted which may be maintained for days. Attempting to move someone in such a state can bring on physical violence. Catatonics are also silent. Another psychomotor disturbance is stereotypy (repetitive behaviour). This is when the person makes repetitive movements, eg the movement of knitting a sweater.

2

nd

Rank Symptoms

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Lack of volition – lack of will to

do something, eg talk or participate. This is when the person does not have the will to interact with others. If the state gets very bad, the person is completely unresponsive to others.

Types of schizophrenia

1 Hebephrenic schizophrenia –  This form of schizophrenia results in severe disturbance of language which often leads to incoherence.   It is progressive and irreversible and usually starts in adolescence. They often have many delusions and/or hallucinations which generally are sexual or religious.

2 Simple schizophrenia

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Simple schizophrenia – the

onset is usually in late adolescence and the symptoms are: Withdrawal from reality.

Lack of drive.

A sharp decline in academic performance.

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3 Catatonic schizophrenia

A posture is adopted which may be maintained for days. Attempting to move someone in such a state can bring on physical violence. Catatonics are also silent. Another psychomotor disturbance is stereotypy (repetitive behaviour). This is when the person makes repetitive movements, eg the movement of knitting a sweater.

One other symptom is that catatonics can be moved into any shape, which is termed ‘waxy flexibility’. There are two main types of catatonia: Agitated catatonia – this is when they make excited and violent movements.

Mutism – this is when they are totally unresponsive but they are often aware of what you are saying. Another form is when the person does the opposite of what you ask them to do.

4 Paranoid schizophrenia

   The onset of paranoid schizophrenia is usually later than adolescence. They have delusions and hallucinations of persecution. However, their awareness is high and language and behaviour are almost the same as other peoples.

5 Atypical schizophrenia

   This category has been used for people who are not easy to classify. Some people who have very unusual thoughts or emotions are put into this category.

Others may have schizophrenic reactions which only last for a few months.

Why is diagnosis difficult?

      The question that needs to be asked is: Can there be so many different types of schizophrenia?

This suggests that there is no single, underlying factor. If there was, we would expect all people with schizophrenia to show exactly the same set of characteristics.

This has led some researchers to question the validity of schizophrenia as a diagnosis and suggest that the term should be abandoned.

According to this view, each of the symptoms of schizophrenia should be seen as a disorder in its own right.

There are some individuals who show symptoms similar to those seen in schizophrenia but who do not exactly meet the criteria, for example, schizophreniform psychosis -

Schizophreniform disorder

 The symptoms of both disorders can include delusions , hallucinations , disorganized speech , disorganized or catatonic behavior , and social withdrawal academic functioning is required for the diagnosis of schizophrenia, in schizophreniform disorder an individual's level of functioning affected. may or may not be . While impairment in social, occupational, or

Diagnostic problems

   While the onset of schizophrenia is often gradual over a number of months or years, the onset of schizophreniform disorder can be relatively rapid.

Some psychologists believe that schizophrenia should be seen in terms of the degree to which problems are experienced, not simply the presence or absence of such problems.

For example, it has been found that people who have not been diagnosed with schizophrenia can nevertheless experience on the its main symptoms (ie hearing voices) but the have strategies to cope with them and they do not feel disabled by them.

Diagnostic problems

   It can also be difficult for clinicians to distinguish between schizophrenia and other seemingly quite separate syndromes. For example, people with temporal lobe epilepsy often show similar symptoms to those of schizophrenia.

Certain recreational drugs can cause psychotic behaviour and can be difficult to distinguish between drug-induced psychosis and schizophrenia.

Explanations of schizophrenia:

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Genetic explanations:

In the general population, 1 in a 100 people suffers from schizophrenia – 1% If one parent is schizophrenic, the chances of a child becoming schizophrenic is 1 in 5 -20% If both parents are schizophrenic, the chances go up to 1 in 2. – 50% When studies are done in genetics and genetic links, identical and non-identical twins are looked at for the purposes of research.

Identical twins have the same genetic material. When one identical twin has schizophrenia, there is a 42% chance that the other will have schizophrenia as well. When one non-identical twin has schizophrenia, there is a 9% chance of the other having schizophrenia. When identical twins are separated at birth and are therefore in different environments, the percentage is still as high. 42% This suggests a genetic influence. However, no twin study has yet shown 100 per cent concordance in monozygotic twins (identical twins). This suggests genetics cannot offer a complete explanation.

The Risks of Getting Schizophrenia

 The risks:

Source: Treatment Advocacy Centre

   After a person has been diagnosed with schizophrenia in a family, the chance for a sibling to also be diagnosed with schizophrenia is 7 to 9 percent. If a parent has schizophrenia, the chance for a child to have the disorder is 10 to 15 percent. Risks increase with multiple affected family members.

Genetic explanation continued:

    There seems to be a genetic link but the gene responsible has not been identified. There is probably not one crucial gene but lots of little genes, each of which play only a minor role. Since 2001, about 6 or these schizophrenia genes have been found. The strongest evidence is for a gene called Neuregulin. It is important to emphasize that neither Neuregulin nor any other gene make it inevitable that a person gets schizophrenia, it is just that different forms of these genes affect an individual’s risk of this happening.

Genetic explanation continued:

   Psychologists have looked at environmental factors as well. Heston (1966) looked at children who were adopted by non-schizophrenic parents but whose biological mothers were schizophrenic. 10% of these children developed schizophrenia. Klanning et al (1996) demonstrated by using the new Danish Twin Register that if one schizophrenic twin is admitted into hospital, the likelihood of the other being admitted is 28% higher than the general population.

Biochemical explanations:

    Schizophrenics have very high levels of dopamine in the brain, and dopamine receptors are 6 times greater in certain areas of the brain than is evidenced in non-schizophrenics.

Psychoactive drugs, such as cocaine and amphetamines, can produce reactions which are similar to certain types of schizophrenia, such as feelings of persecution and hallucinations. These psychoactive drugs are known to increase the production of dopamine. Phenothiazines are drugs given to schizophrenics to reduce the effects of schizophrenia. These drugs reduce the concentration of dopamine in the brain – eg Largactil. Even though there is evidence that dopamine is linked to schizophrenia, caution must be exercised when saying that it causes schizophrenia.

Biochemical explanations continued:

    The causes are probably more complex, and there is evidence that not all schizophrenics react positively to phenothiazines. Crow et al (1982) pointed out that phenothiazines only reduce the symptoms of the Type 1 conditions, which are hallucinations and delusions. They do not reduce the ill-effects of the Type 2 symptoms, such as problems with speech, diminished drive, and loss of emotional content. This suggests that schizophrenia may have more than one cause. Dopamine appears to be linked with delusions and hallucinations, but not with the other symptoms. Genetics may play a part, in that it predisposes certain people to schizophrenia, but environmental factors may trigger a schizophrenic attack.

Neuroanatomical explanations:

   Magnetic resonance imaging (MRI) has been a tremendous breakthrough because it provides a picture of the living brain. MRI studies show quite definite structural abnormalities in the brains of many patients with schizophrenia.

Brown et al, 1986, found decreased brain weight and enlarged ventricles, which are cavities in the brain that hold cerebrospinal fluid. One of the main problems in trying to understand the causal direction is that, so far, brain imaging in relation to schizophrenia has mainly been restricted to people who have already been diagnosed. Hence, it is not clear whether structural abnormalities predispose to schizophrenia, or whether the onset of clinical symptoms cause structural damage.

Schizophrenia and Brain Tissue Loss

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Significant Loss of Brain Gray Matter:

Individuals with schizophrenia, including those who have never been treated, have a reduced volume of grey matter in the brain, especially in the temporal and frontal lobes. Recently neuroscientists have detected grey matter loss of up to 25% (in some areas). The damage started in the parietal, or outer, regions of the brain but spread to the rest of the brain over a five year period. Patients with the worst brain tissue loss also had the worst symptoms, which included hallucinations, delusions, bizarre and psychotic thoughts, hearing voices, and depression.

Early and late grey matter deficits

New drug research

    Please note that while there is significant loss of brain grey matter, this is not a reason to lose all hope.

There are reasons to believe that this grey matter loss may be reversible. Moreover, the NIMH is currently researching a drug that seems to have potential for reversing the cognitive decline that is caused by schizophrenia, and there are many drug companies also now researching in this area. It is anticipated that we will see some significant announcements related to these developments in the next few years.

Pregnancy and birth factors as explanations for schizophrenia:

      Since the late 1920s, it has been noticed that an overwhelmingly high proportion of people diagnosed with schizophrenia were born in the winter and early spring. A number of viral infections, such as measles, scarlet fever, polio, diphtheria and pneumonia, and in particular, influenza A, have been suggested as an explanation of schizophrenia. Influenza A is most prevalent in the winter and could explain the high proportion of winter births in those diagnosed with schizophrenia. It is thought that the 25 to 30 week foetus is most vulnerable because of accelerated growth in the cerebral cortex at this time. It is hypothesized that the viral infection enters the brain and gestates until it is activated by hormonal changes in puberty. Alternatively, there may be a gradual degeneration of the brain which eventually becomes so severe that symptoms of schizophrenia emerge.

Torrey et al, 1988, found that peaks in schizophrenia diagnosis have corresponded with major flu epidemics.

Diathesis-Stress explanations:

   Although it has been well established that biological factors are important in explaining the origins of schizophrenia, it is clear that environmental influences also have a part to play. The reasoning behind this theory is that certain individuals have a constitutional predisposition to the disorder, but will only go on to develop schizophrenia if they are exposed to stressful situations. Stressful events in the environment, such as major life events, traumatic experiences, or dysfunctional families, may then act as a ‘trigger’ in a high-risk individual.

Psychological explanations: The role of social and family relationships

    This theory was proposed by Bateson who suggested that schizophrenia can be created by parents imposing a ‘no win’ situation on their children. Whatever the child does, the child is wrong and whatever the child wants, they cannot have - no matter what they do to get it. Bateson proposed the ‘double bind’ hypothesis, where children are given conflicting messages from parents who express care, yet at the same time appear critical. It was thought that this led to confusion, self doubt and eventual withdrawal.

The role of family relations:

    Another view was proposed by Lidz (1973). He suggests that schizophrenics often come from families in which parents experience constant discord. Sometimes both parents have severe problems and sometimes one parent appears to be emotionally demanding and distressed. Erica Fromm observed that many schizophrenics have mothers who are domineering, neglecting, guilt producing and cold.

The role of family relations continued:

   In the past 50 years, there has been some interest in the idea that disturbed patterns of communication within families might be a factor in the development of schizophrenia. The term ‘schizophrenogenic families’ was used to describe families with high emotional tension, with many secrets, close alliances and conspiracies.

The criticism of this approach is that many people from these types of background do not become schizophrenic.

The Psychodynamic explanation

         This is basically an idea that Freud proposed. The first stage of development is the oral phase, when the infant’s main pleasure comes from sucking. At this stage the child is completely egocentric. The baby believes that the mother and itself are one. At this stage the id is totally dominant. The id is all the drives we have. Infants demand the satisfaction of their drives.

Psychodynamic theory suggests that in the case of schizophrenia the person regresses to the oral stage of development. The ego (the person we wish to show the world we are) is overwhelmed by the id or the demands of the id. The superego (all the things authority figures tell you you should and shouldn’t be) is overwhelmed by the id’s drives and feels unbearable guilt. During the oral stage, the infant is egocentric and believes in its complete self importance. When people regress to the oral stage, they suffer from delusions of self-importance and fantasies become confused with realities, which leads to hallucinations. The main criticism of this model is that schizophrenic behaviour does not resemble infantile behaviour.

Behavioural explanations:

      The behaviourists believe that all behaviour occurs because of reinforcements. They argue that schizophrenic behaviour becomes pronounced because it is a reinforced form of attention. Attempts have been made to change behaviour through conditioning. The main criticisms are: Very little evidence exists to suggest that conditioning changes schizophrenic behaviour.

How do they start behaving in this way without models to copy?

Cognitive explanations:

     Many schizophrenics have problems with language and thought processing. Maher (1968) proposed the idea that schizophrenics cannot concentrate on more than one or two aspects of sensory information. The cognitive psychologists argue that schizophrenics are bombarded with sensory information and explain catatonic behaviour as the individual ‘shutting down’ because they cannot take any more sensory bombardment.

As people with schizophrenia are subjected to sensory overload and do not know which aspects of a situation to attend to and which to ignore, it means that superficial incidents might be seen as highly relevant and significant. For example, a conversation at the next table in a restaurant might be interpreted as being personally relevant. In other words, the person may think the conversation is about them personally.

Cognitive explanations continued:

     Apart from attentional deficits, schizophrenics have abnormalities of memory, which becomes apparent when trying to problem solve or do similar tasks. They appear to forget what they have been taught and approach a similar but new task as if they have never encountered anything like it before. These difficulties are associated with abnormal functioning of the frontal lobes.

The main criticisms of the cognitive explanations are that they do not really explain the causes of schizophrenia. They merely propose that schizophrenia is an illness associated with a breakdown in the ability to concentrate on one or a few things at one time.

Current psychological thinking:

    By the mid-1970s, psychologists had become more interested in the part the family might play in the course, rather than the cause of schizophrenia. Vaughn and Leff, 1976, observed that patients with schizophrenia who returned to homes where a high level of emotion was expressed, (high EE) such as hostility, criticism, over-involvement and over-concern, showed a greater tendency to relapse than those returning to homes where emotional ups and downs and negativity were low (low EE).

It was found that the relapse rate increased to 92% in high EE homes with increased contact coupled with no medication.

Twenty years on, EE has now become a well established ‘maintenance’ model of schizophrenia.

Conclusions:

  Adoption studies show that the family in which a child is brought up in makes little, if any, difference to that child’s risk of developing schizophrenia. Evidence clearly demonstrates a biological link. On the other hand, psychological factors undoubtedly influence the course of the illness; that is, the chances of a patient with schizophrenia relapsing and becoming ill again are affected by how the people around them behave.