Schizophrenia and Psychosis

Schizophrenia is a chronic, severe, debilitating mental illness. It is one of the psychotic mental disorders and is characterized by symptoms of thought, behavior, and social problems. The thought problems associated with schizophrenia are described as psychosis, in that the person’s thinking is completely out of touch with reality at times. For example, the sufferer may hear voices or see people that are in no way present or feel like bugs are crawling on their skin when there are none. The individual with this disorder may also have disorganized speech, disorganized behavior, physically rigid or lax behavior (catatonia), significantly decreased behaviors or feelings, as well as delusions, which are ideas about themselves or others that have no basis in reality (for example, the individual might experience paranoia, in that he or she thinks others are plotting against them when they are not).

Types of Schizophrenia

There are five types of schizophrenia, each based on the kind of symptoms the person has at the time of assessment.

Paranoid schizophrenia: The individual is preoccupied with one or more delusions or many auditory hallucinations but does not have symptoms of disorganized schizophrenia.

Disorganized schizophrenia: Prominent symptoms are disorganized speech and behavior, as well as flat or inappropriate affect. The person does not have enough symptoms to be characterized as suffering from catatonic schizophrenia.

Catatonic schizophrenia: The person with this type of schizophrenia primarily has at least two of the following symptoms: difficulty moving, resistance to moving, excessive movement, abnormal movements, and/or repeating what others say or do.

Undifferentiated schizophrenia: This is characterized by episodes of two or more of the following symptoms: delusions, hallucinations, disorganized speech or behavior, catatonic behavior or negative symptoms, but the individual does not qualify for a diagnosis of paranoid, disorganized, or catatonic type of schizophrenia.

Residual schizophrenia: While the full-blown characteristic positive symptoms of schizophrenia (those that involve an excess of normal behavior, such as delusions, paranoia, or heightened sensitivity) are absent, the sufferer has a less severe form of the disorder or has only negative symptoms (symptoms characterized by a decrease in function, such as withdrawal, disinterest, and not speaking).

The causes of schizophrenia, like all mental disorders, are not completely understood or known at this time. There is no known single cause of schizophrenia.

As with most other mental disorders, schizophrenia is not directly passed from one generation to another genetically, and there is no single cause for this illness. Rather, it is the result of a complex group of genetic, psychological, and environmental factors. Genetically, schizophrenia and bipolar disorder have much in common, in that the two disorders share a number of the same risk genes. However, the fact is that both illnesses also have some genetic factors that are unique. There are some genetic commonalities with schizophrenia and epilepsy as well.

Environmentally, the risks of developing schizophrenia can even occur before birth. For example, the risk of schizophrenia is increased in individuals whose mother had one of certain infections during pregnancy. Difficult life circumstances during childhood, like the early loss of a parent, parental poverty, bullying, witnessing parental violence; being the victim of emotional, sexual, or physical abuse or of physical or emotional neglect; and insecure attachment have been associated with the development of this illness. Even factors like how well represented an ethnic group is in a neighborhood can be a risk or protective factor for developing schizophrenia. For example, some research indicates that ethnic minorities may be more at risk for developing this disorder if there are fewer members of the ethnic group to which the individual belongs in their neighborhood.

Many studies of people with schizophrenia have found abnormalities in brain structure. In some small but potentially important ways, the brains of people with schizophrenia look different than those of healthy people. For example, fluid-filled cavities at the center of the brain, called ventricles, are larger in some people with schizophrenia. The brains of people with the illness also tend to have less gray matter, and some areas of the brain may have less or more activity.

It should be emphasized that these abnormalities are quite subtle and are not characteristic of all people with schizophrenia, nor do they occur only in individuals with this illness. Microscopic studies of brain tissue after death have also shown small changes in distribution or number of brain cells in people with schizophrenia. It appears that many (but probably not all) of these changes are present before an individual becomes ill, and schizophrenia may be, in part, a disorder in development of the brain.

Positive, more overtly psychotic symptoms:

1. Beliefs that have no basis in reality (delusions)
2. Hearing, seeing, feeling, smelling, or tasting things that have no basis in reality (hallucinations)
3. Disorganized speech
4. Disorganized behaviors
5. Catatonic behaviors

Negative, potentially less overtly psychotic symptoms:

1. Affective flattening – The person’s range of emotional expression is clearly diminished; poor eye contract; reduced body language
2. Alogia – A poverty of speech, such as brief, empty replies
3. Avolition – Inability to initiate and persist in goal-directed activities (such as school or work)

Schizoaffective Disorder and Mood Disorder With Psychotic Features have been considered as alternative explanations for the symptoms and have been ruled out. The disturbance must also not be due to the direct physiological effects of use or abuse of a substance (e.g., alcohol, drugs, medications) or a general medical condition.

If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders, is a process involving interviews with scoring systems. The patient is asked to answer questions in a questionnaire, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time consuming.

To be diagnosed with personality disorders, a psychologist will look for the following criteria:

Symptoms have been present for an extended period of time, are inflexible and pervasive, and are not a result of alcohol or drugs or another psychiatric disorder. The history of symptoms can be traced back to adolescence or at least early adulthood.

The symptoms have caused and continue to cause significant distress or negative consequences in different aspects of the person’s life.

Symptoms are seen in at least two of the following areas:

  • Thoughts (ways of looking at the world, thinking about self or others, and interacting)
  • Emotions (appropriateness, intensity, and range of emotional functioning)
  • Interpersonal Functioning (relationships and interpersonal skills)
  • Impulse Control

At first, people with personality disorders usually do not seek treatment on their own. They tend to seek help once their behavior has caused severe problems in their relationships or work, or when they are diagnosed with another psychiatric problem, such as a mood or substance abuse disorder.

Although personality disorders take time to treat, there is increasing evidence that certain forms of psychotherapy help many people. In some cases, medications can be a useful addition to therapy.

There are several different forms (modalities) of treatment used for personality disorders : 

•   Individual psychotherapy has been a mainstay of treatment.
•   Family therapy, including couples therapy.
•   Group therapy for personality dysfunction is probably the second most used.
•   Psychological-education may be used as an addition.
•   Self-help groups may provide resources for personality disorders.
•   Psychiatric medications for treating symptoms of personality dysfunction or co-occurring conditions.