Schizophrenia and Psychotic Disorders I

Introduction

• “Psychosis” is a widely misunderstood term. Contrary to popular opinion, it has nothing to do with violence.

  • Psychosis describes a mental state characterised by a profound disturbance in thinking; consequently, a person has a difficult time distinguishing between most people’s reality and their own perception of the world.

  • It’s a symptom, rather than a disorder

• Psychosis is a central frame of schizophrenia, yet a person may expericne psychotic phenomena without necessarily qualifying for a diagnosis of schizophrenia.

  • Examples of mental disorders that might involve psychosis include bipolar disorder and severe forms of depression

• Schizophrenia Society of Ontario: “Schizophrenia is a disease of the brain….which involves a loss of contact with reality, making it very hard for a person to distinguish between what is real and what is not.”

• World Health Organization: “Schizophrenia is a severe mental disorder, characterised by profound disruptions in thinking, affecting language, perception, and the sense of self.”

Clinical Perspectives

• Most modern approaches break down the symptoms of schizophrenia into three broad categories

  • Positive symptoms

  • Negative symptoms

  • Symptoms relating to disorganisation

Positive (Acute) Symptoms

• Positive symptoms have two primary forms:

  • Hallucinations: these involve a person having a sensory experience that occurs without any clear stimulus.

    • The most common form of hallucinations is auditory

    • Hallucinations are not solely auditory, however, as they can involve any of the senses (sight, smell, hearing, taste, and touch)

  • Delusions: they involve a person holding beliefs that most others consider impossible or highly improbable.

    • For example, a person might imagine themselves to possess superhuman powers or believe that they are in imminent danger from foreign spies. Even when presented with evidence that their beliefs are untrue, the person usually continues to hold them

    • Thus, delusions are sometimes described as “irrational” or “false” beliefs

    • Sometimes false beliefs aren’t delusions

      • For example, many years ago, there were some people who believed that the earth was flat. They wouldn’t have been considered delusional

    • Sometimes delusional beliefs might be ‘correct’

      • Years ago a man leaked information that the Government was watching people’s computer data, phone data, etc.

      • If someone went to a therapist and said, ‘I feel like the government is watching me,’ they wouldn’t be wrong

    • What is delusional is inherently tied to social context!

Negative (Chronic) Symptoms

• Negative symptoms relate to feelings and behaviours that are typically described as deficits in “normal behaviour.”

• Unlike positive symptoms, which tend to be episodic, negative symptoms are usually understood as chronic, meaning that these feelings and behaviours might be present for years, even permanently.

• The As: Flat affect, anhedonia, asociality, avolition, etc.

• Anhedonia: involves a change in one’s subjective sense of enjoyment - activities that were once loved may no longer be pleasurable

Disorganised Symptoms

• Although psychotic symptoms are usually held up as the core feature of this disorder, some researchers argue that cognitive deficits are in fact the primary hallmark of schizophrenia.

• In general, a person’s memory, attention, and learning may all be adversely affected. Individuals diagnosed with schizophrenia might consequently struggle to participate in conventional components of modern life

  • Speech cognition, or motor behaviour

Debates and Controversies

• What exactly is schizophrenia?

  • Is it a medical disease?

  • Will we be able to identify it using fMRI or genetic testing?

  • Is it possible that it’s not a disease at all, but rather a social construction used to categorise and identify various types of strange and unusual behaviours?

• How long has schizophrenia existed? We don’t know

  • While we have early records of things that sound like hallucinations, schizophrenia is defined by much wider criteria

• It was not until the late 19th century that physicians began placing various symptoms together with the idea that they represented a distinct and coherent disease.

Prevalence Debates

• Is schizophrenia a universal brain disorder based on genetic inheritance?

  • Perhaps it would be better described as a “disease of civilization”: a consequence of industrialization, the emergence of new toxins and bacteria, or simply a response to the framework of modern, urbanised life.

• By studying the epidemiology of schizophrenia, researchers have hoped to get an answer to these sorts of questions

  • Epidemiology: the distribution of a disease across a population

Epidemiology and Prognosis

• Schizophrenia - or rather its symptoms - have been reportedly found in all cultures across the world. Typical age of onset is 15-35

  • World Health Organisation: 1% incidence of schizophrenia in almost every society across the world

    • Does this make sense?

  • Typically thought of chronic, lifelong condition, but some stabilise, some improve, and some get worse over time

  • Outcomes for those in the Global South are much better than developed countries, why?

    • Stigma? Support? Employment?

Debates on Cause

• Over the years, researchers have propounded a host of theories, many of which have been accompanied by compelling evidence

• As of yet, however, no one has managed to come up with a theory grounded in enough in enough evidence to produce scientific consensus on the matter

• Researchers have long argued that there is a genetic component to schizophrenia

  • If schizophrenia was more common among their biological family, then it would make sense to conclude that schizophrenia had a strong genetic component.

  • Another popular form of research involved comparing monozygotic twins; if both twins developed schizophrenia it would increase the likelihood that a genetic basis was involved

• In short, it is fair to say that questions related to the genetics of schizophrenia are becoming more specific and more complex. A simple answer is very unlikely.

• Some other prominent theories include the idea that schizophrenia is a result of complications during birth, advanced paternal age at time of conception, use of cannabis, maternal infections during pregnancy, irregularities in a neurotransmitter called dopamine, and inflammation

• Etiology: cause or causes

• The drift hypothesis suggests that the disproportionate number of people diagnosed with schizophrenia in lower income areas is primarily a consequence of their illness, rather than a cause of it

  • In this view, it is assumed that the experience of schizophrenia acts to propel people down the socio-economic ladder

”Refrigerator Mothers”

• A now rejected theory described the “cold” parenting style of mothers as a potential cause of Schizophrenia in the mid 20th century

• Infuriated many parents who felt “blamed” for their offspring’s problems

  • built alliances with biologically-minded psychiatry to form the National Alliance on Mental Illness (NAMI), which has demanded more access to treatment and less stigma around Schizophrenia

  • Also active in helping to popularise biological conceptions of Schizophrenia

• While biological explanations have become dominant, some psychological theories persist (e.g. experiencing abuse, bullying, etc.)

Genetic and Biological Causes

• Figures for average risk of developing Schizophrenia:

  • General population: 1%

  • Spouses of people with Schizophrenia: 2%

  • Children of one parent with Schizophrenia: 7-15%

  • Children of two parents with Schizophrenia: 27-46%

  • Monozygotic twins: 7-50%

• Genetics may play a role, but far more complex than simple genetics. Cannot “predict” Schizophrenia

  • Not wide variation in statistics

• The speculated genetic risk for developing Schizophrenia is not limited to Schizophrenia. Rather, the risk is shared for Schizophrenia, Bipolar disorder, major depressive disorder and ADHD

  • Key question: what conclusions might we draw from that one the nature of mental disorders?

Social Factors

• Some speculate that the real cause can be found in the social world. Why? The highest prevalence of schizophrenia is found in neighbourhoods with the lowest socioeconomic status

• Two theories differing theories explain this phenomenon:

  • Social Causation, and life events

    • There is some environmental factor that is prompting schizophrenia

  • Social Drift

    • It assumes that the schizophrenia is primary. Perhaps the person had it from birth

• Perhaps it’s both?

• These theories might also work hand-in-hand with others (eg. biological theories, psychological theories). It’s not as simple as biological vs. social

Stigma and Popular Representations

• Schizophrenia is a significant and often unique social experience. In most parts of the world, schizophrenia is a label that brings forward powerful assumptions - typically negative - that mark a person as different, damaged, or deranged

• These assumptions are harmful and hurtful to individual diagnosed with schizophrenia; they may decrease the likelihood that a person seeks out care and may also exacerbate the stress that sometimes precipitates psychotic episodes

Conclusion

• Schizophrenia is the subject of substantial debate and disagreement - are we talking about a disease? Several diseases? Several disorders? Should we talk about “the schizophrenias?”

• Some suggest schizophrenia “significantly misdiagnosed” in those who “really have” bipolar disorder or autism

  • Why might that be the case? What would that possibly point to?

  • Question: can we have “misdiagnosis” if a diagnosis itself is not certain and verifiable (e.g via an MRI)?

• Substantial debate over aetiology….does there need to be a single pathway?