Schizophrenia Spectrum Disorders: Symptoms, Causes, and Cultural Considerations

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Videos:
Kimberly Huber, Ph.D., on Understanding Neurodevelopmental
Disorders and Autism:
http://www.youtube.com/watch?v=p6cUARufs80
Counseling Diagnostic Assessment Vignette #33 - Symptoms of
Brief Psychotic Disorder:
http://www.youtube.com/watch?v=q58A-IM8iUs
Living With Schizophrenia:
https://www.youtube.com/watch?v=48YJMOcykvc&t=3s
Include each of the following items in your discussion post.
don't forget to cite and source!
Please put the answer under each one
a. Describe the symptoms, causes, and prognosis for a
diagnosis of schizophrenia.
b. Discuss how other psychotic disorders differ from
schizophrenia.
c. Comment on the importance of cultural awareness in the
diagnosis of schizophrenia.
Textbook:
Sue, D., Sue, D. W., Sue, D., & Sue, S. (2014). Essentials of
understanding abnormal behavior (2nd ed.). Belmont, CA:
Wadsworth Cengage Learning.
Chapter 1111-1Symptoms of Schizophrenia Spectrum Disorders
The symptoms associated with schizophrenia spectrum disorders
fall into four categories: positive symptoms, psychomotor

abnormalities, cognitive symptoms, and negative symptoms.11-
1aPositive Symptoms
Case Study
Over a month before he committed the Navy yard shooting,
Aaron Alexis called police to report that three people—two
males and a female—were following him. He explained that he
was unable to sleep because these people talked to him through
the walls, ceiling, and floors of his hotel room. He also reported
that they were using a microwave to send vibrations into his
body (Winter, 2013).
Positive symptoms associated with schizophrenia spectrum
disorders involve delusions, hallucinations, disordered thinking,
incoherent communication, and bizarre behavior. The term
“positive symptoms” refers to behaviors or experiences
associated with schizophrenia that are new to the person. These
symptoms can range in severity, and can persist or fluctuate. In
the case above, Alexis experienced two positive symptoms:
auditory hallucinations (hearing voices) and a delusion that
three people were following him, keeping him awake and
sending vibrations into his body. Many people with positive
symptoms do not understand that their symptoms are the result
of mental illness (Islam, Scarone, & Gambini, 2011).
Delusions
Many individuals with psychotic disorders experience
delusions. Delusions are false beliefs that are firmly and
consistently held despite disconfirming evidence or logic.
Individuals experiencing delusions are not able to distinguish
between their private thoughts and external reality. Lack of
insight is particularly common among individuals experiencing
delusions; in other words, they do not recognize that their
thoughts or beliefs are extremely illogical. In the following case
study, therapists confront a graduate student’s delusion that rats
were inside his head, consuming a section of his brain.
Case Study
Erin’s therapists reminded him that he was a scientist and asked

him to explain how it would be possible for rats to enter his
brain. Erin had no explanation, but he was certain that he would
soon lose functions controlled by the area of the brain that the
rats were consuming. To prevent this from happening, he
banged his head so that the “activated” neurons would
“electrocute” the rats. Realizing he was not losing his sight
even though the rats were eating his visual cortex, he
entertained two possible explanations: Either his brain had a
capacity for rapid regeneration or the remaining brain cells were
compensating for the loss (Stefanidis, 2006).
Although some individuals with delusions, like Erin, attempt to
maintain some sense of logic, most are either unaware or only
moderately aware of the illogical nature of their delusional
beliefs (Figure 11.1).
Figure 11.1Lack of Awareness of Psychotic Symptoms in
Individuals with Schizophrenia
Most individuals with schizophrenia are unaware or only
somewhat aware that they have symptoms of the disorder. The
symptoms they are most unaware of include asociality,
delusions, and restricted affect.
Source: Amador, X. (2003). Poor insight in schizophrenia:
Overview and impact on medication compliance. Retrieved from
http:// www.xavieramador.com/file/cns-specialreport- on-
insight.pdf. Used by permission of Dr. Xavier Amador.
Individuals with schizophrenia spectrum disorders experience a
variety of delusional themes:
· Delusions of grandeur. Individuals may believe they are
someone famous or powerful (from the present or the past).
· Delusions of control. Individuals may believe that other
people, animals, or objects are trying to influence or take
control of them.
· Delusions of thought broadcasting. Individuals may believe
that others can hear their thoughts.
· Delusions of persecution. Individuals may believe that others
are plotting against, mistreating, or even trying to kill them.

· Delusions of reference. Individuals may believe they are the
center of attention or that all happenings revolve around them.
· Delusions of thought withdrawal. Individuals may believe that
someone or something is removing thoughts from their mind.
Myth vs Reality
Myth
Individuals experiencing delusions or hallucinations steadfastly
accept them as reality.
Reality
The strength of hallucinations and delusions can vary
significantly among individuals with schizophrenia spectrum
disorders. Some believe in them 100 percent, whereas others are
less certain. Many people cope by testing out the reality of their
thinking. Some individuals with schizophrenia are able to
combat delusions and hallucinations through a combination of
conscious effort and medication (Saks, 2013).
A common delusion involves paranoid ideation, or
suspiciousness about the actions or motives of others as
illustrated in the following case.
Case Study
I was convinced that a foreign agency was sending people out to
get rid of me. I was so convinced because I kept receiving
messages from them via a device planted inside my brain. . . . I
decided to strike first: to kill myself so they wouldn’t have a
chance to carry out their plans and kill me. (Kean, 2011, p. 4)
Those with paranoid thinking often experience persecutory
delusions, or beliefs that others are plotting against them,
talking about them, or out to harm them in some way. Their
delusional thinking causes them to be very suspicious and
misinterpret the behavior and motives of others. The man in the
case study was so concerned about the conspiracy against him
that he decided to take his own life to prevent their plot from
succeeding. Fortunately, he received help before his delusional
thinking resulted in suicide.

Painting by Artist with Schizophrenia
The inner turmoil and private fantasies of people with
schizophrenia are often revealed in their artwork. This painting
was created by an individual with schizophrenia. What do you
think the painting symbolizes?
BSIP/Universal Images Group/Getty Images
Delusions can produce strong emotional reactions such as fear,
depression, or anger. Those with persecutory delusions may
respond to perceived threats by leaving “dangerous” situations,
avoiding areas where they might be attacked, or becoming more
vigilant. Paradoxically, these “safety” behaviors may prevent
them from encountering information that contradicts the
delusional belief.
Delusions may include plausible themes, such as being followed
or spied on, as well as bizarre beliefs, such as plots to remove
internal organs or thoughts being placed in one’s mind. The
strength of delusional beliefs and their effects on the person’s
life can vary significantly. Delusions have less impact when the
individual is able to suggest alternative explanations for the
delusion and can acknowledge that others may question the
accuracy of the belief (Islam et al., 2011).
Did You Know?
In one study, 28 percent of the participants had positive
attitudes about their psychotic symptoms, including “having a
feeling of importance and power,” and “hearing voices.” Some
participants reported discontinuing their antipsychotic
medications so their symptoms would return.
Source: Moritz et al., 2013
Capgras delusion, named after the person who first reported it,
is a rare type of delusion involving a belief in the existence of
identical doubles who replace significant others (Dulai & Kelly,
2009). The mother of one woman with Capgras delusion
explained how her daughter would phone her and ask questions
such as what she had worn as a Halloween costume at the age of
12 or who had attended a specific birthday party: “She was

testing me because she didn’t think I was her mother. . . . No
matter what question I answered, she was just sobbing” (J.
Stark, 2004). The daughter believed that an impostor in a
bodysuit had kidnapped her mother and was then pretending to
be her mother. Capgras delusion is most common with brief
forms of psychosis that develop suddenly after an emotionally
distressing event (Salvatore, 2014).
Hallucinations
Case Study
An individual describes his experience with auditory
hallucinations while hospitalized with schizophre nia:
“You’re alone,” an insidious voice told me. “You’re going to
get what’s coming to you.” . . . No one moved or looked
startled. It was just me hearing the voice. . . . I had seen others
screaming back at their voices. . . . I did not want to look mad,
like them. . . . Never admit you hear voices. . . . Never question
your diagnosis or disagree with your psychiatrist . . . or you
will never be discharged. (Gray, 2008, p. 1006)
A hallucination is a perception of a nonexistent or absent
stimuli; it may involve a single sensory modality or a
combination of modalities, including hearing (auditory
hallucination), seeing (visual hallucination), smelling (olfactory
hallucination), touching (tactile hallucination), or tasting
(gustatory hallucination). Auditory hallucinations are most
common; the voices can be malicious or benevolent or involve
both qualities (M. Hayward, Berry, & Ashton, 2011). As you
can see from the case study, some individuals with
hallucinations recognize that their perceptions are not real and
try their best to “look normal” even when the hallucinations are
occurring.
Hallucinations are particularly distressing when they involve
dominant, insulting voices. Negative hallucinations can be quite
unsettling; those who hear destructive voices often try to cope
by ignoring them or by keeping busy with other activities
(Jepson, 2013). Not all auditory hallucinations are negative,

however. One individual reported hearing positive voices: “I
thought I could hear the voice of God, and it was God who tol d
me to refer myself for mental health help . . .” (Jepson, 2013, p.
483).
Auditory hallucinations often seem very real to the individual
experiencing them and sometimes involve relationship-like
qualities (Chin, Hayward, & Drinnan, 2009). In one study
involving individuals hospitalized with acute psychosis, 61
percent of respondents reported that the voice they heard had a
distinct gender; 46 percent believed that the voice was that of a
friend, family member, or acquaintance; and 80 percent reported
having back-and-forth conversations with the voice. Most
believed the voices were independent entities. Some even
conducted “research” to test the reality of the voices. One
woman said she initially thought that the voice might be her
own but rejected it when the voice called her “Mommy,”
something she would not call herself. Another woman
explained, “They are not imaginary. They see what I do. They
tell me that I’m baking a cake. They must be there. How else
would they know what I’m doing?” (Garrett & Silva, 2003, p.
447).
Controversy
Should We Challenge Delusions and Hallucinations?
The doctor asked a patient who insisted that he was dead:
“Look. Dead men don’t bleed, right?” When the man agreed, the
doctor pricked the man’s finger, and showed him the blood. The
patient said, “What do you know, dead men do bleed after
all.” (Walkup, 1995, p. 323)
Clinicians are often unsure about whether to challenge
psychotic symptoms. Some contend that delusions and
hallucinations serve an adaptive function and that any attempt
to change them would be useless or even dangerous. The
example of the man who believed he was dead illustrates the
apparent futility of using logic with delusions. However, many
clinicians have found that some clients respond well to

challenges to their hallucinations and delusions (K. Ross,
Freeman, Dunn, & Garety, 2011).
Coltheart, Langdon, and McKay (2007) used a “gentle and
tactful offering of evidence” to successfully treat a man who
believed his wife was not his wife but was, instead, his business
partner. The man was asked to entertain the possibility that the
woman was actually his wife. The therapist pointed out that the
woman was wearing a wedding ring identical to the one he had
bought for his wife. The man said that the woman probably
bought the ring from the same shop. He was then shown the
initials engraved in the ring—those of his wife. Within 1 week,
he accepted the fact that the woman was his wife. This approach
of gently presenting contradictory information and having
clients consider alternative explanations appears to be a
successful approach to weakening delusions.
For Further Consideration
1. Should we challenge psychotic symptoms? If so, what is the
best way of doing so?
2. In what ways might hallucinations or delusions serve an
adaptive function?11-1bCognitive Symptoms
Disordered thinking, communication, and speech are common
characteristics of schizophrenia. Individuals experiencing
these cognitive symptoms may have difficulty focusing on one
topic, speak in an unintelligible manner, or reply tangentially to
questions. Loosening of associations, also referred to
as cognitive slippage, is another characteristic of disorganized
thinking. This involves a continual shifting from topic to topic
without any apparent logical or meaningful connection between
thoughts. This may occur when cognitive confusion makes it
difficult for the person to pay attention or respond to
appropriate cues during conversation (Morris, Griffiths,
LePelley, & Weickert, 2013). Disorganized communication
often involves the kind of incoherent speech or bizarre,
idiosyncratic responses seen in the following case study.
Case Study

INTERVIEWER: “You just must be an emotional person, that’s
all.”
PATIENT: “Well, not very much I mean, what if I were dead?
It’s a funeral age. Well, I . . . um. Now I had my toenails
operated on. They got infected and I wasn’t able to do it. But
they wouldn’t let me at my tools.” (P. Thomas, 1995, p. 289)
The beginning phrase in the person’s first sentence appears
appropriate to the interviewer’s comment. However, the
reference to death later in the sentence is not. Slippage appears
in the comments referring to a funeral age, having toenails
operated on, and getting tools. None of these thoughts are
related to the interviewer’s comment. They have no hierarchical
structure or organization and thus represent disorganized
thinking. People with schizophrenia may also demonstrate
difficulty with abstractions and thus respond to words or
phrases in a very concrete manner. For example, a saying such
as “a rolling stone gathers no moss” might be interpreted as
meaning no more than “moss cannot grow on a rock that is
rolling.”
Individuals with schizophrenia also show unusual thoughts
including overinclusiveness, or abnormal categorization in their
thinking. For example, when asked to sort cards with pictures of
animals, fruit, clothing, and body parts into piles of things that
go together, one man placed an ear, apple, pineapple,
pear, strawberry, lips, orange, and banana together in a category
he named “something to eat.” When asked the reason for
including the ear and lips in the “something to eat” category, he
explained that an ear allows you to hear a person asking for
fruit, and lips allow you to ask for and eat fruit (Doughty,
Lawrence, Al-Mousawi, Ashaye, & Done, 2009).
In another study, individuals with schizophrenia and healthy
controls wore a head-mounted virtual reality display that gave
them the sense of going through a neighborhood, a shopping
center, and a market. Fifty incoherencies such as a mooing dog,
an upside-down house, and a red cloud were presented during
the journey. Almost 90 percent of those with schizophrenia

failed to detect these inconsistencies. Even when the
inconsistencies were identified, about two thirds of the
participants had difficulty explaining them (Sorkin, Weinshall,
& Peled, 2008).
An Episode of Withdrawn Catatonia
The woman in the wheelchair is experiencing a form of
catatonia that involves unresponsiveness and the adoption of a
rigid body posture. Positions such as this are sometimes held for
hours, days, weeks, or even months at a time.
Grunnitus Studio/Science Source
Cognitive symptoms of schizophrenia also include problems
with attention and memory and difficulty making decisions. As
compared with healthy controls, individuals with schizophrenia
have moderately severe to severe cognitive impairment, as
evidenced by poor executive functioning—deficits in the ability
to sustain attention, to absorb and interpret information, and to
make decisions based on recently learned information
(Costafreda et al., 2011). Difficulties with social-cognitive
skills, social perspective taking, and understanding one’s own
and other’s thoughts, motivations, and emotions are also
common.
Schizophrenia: Etta
An interview with Etta, who suffers from schizophrenia.
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11-1cGrossly Disorganized or Abnormal Psychomotor Behavior
The symptoms of schizophrenia that involve motor functions
can be quite bizarre and extremely distressing to family
members, as is evident in the following case study.
Case Study
At age 20, patient A . . . was found sitting at the edge of the bed
for hours, displaying simple repetitive movements of the right
hand while simultaneously holding his left hand in a bizarre
posture and repeating “I do, I do, I do.” (Stober, 2006, pp. 38–

39)
This young man was experiencing an episode of catatonia, a
condition involving a lack of responsiveness to the
environment, peculiar body movements or postures, strange
gestures and grimaces, or a combination of these (Enterman &
van Dijk, 2011). People with excited catatonia have very
disorganized behavior and may be very agitated, hyperactive,
and lack inhibitions. Their behavior can become dangerous and
involve violent acts. In one sample of 568 individuals with
schizophrenia, 7.6 percent had experienced excited catatonia
(Kleinhaus et al., 2012).
In sharp contrast, people experiencing withdrawn catatonia are
extremely unresponsive, as was the young man in the case
study. They show prolonged periods of stupor and mutism,
despite an awareness of all that is going on around them. Some
may adopt and maintain strange postures and refuse to move or
change position. They may stand for hours at a time, perhaps
with one arm stretched out to the side. They also may lie on the
floor or sit awkwardly on a chair, staring, aware of what is
occurring but not responding or moving. If someone attempts to
change the person’s position, they may persistently resist.
Others exhibit a waxy flexibility, allowing their bodies to be
arranged in almost any position and then remaining in that
position for long periods. The extreme withdrawal associated
with a catatonic episode can be life-threatening when it results
in inadequate food intake (Aboraya, Chumber, & Altaha,
2009).1-1dNegative Symptoms
Negative symptoms of schizophrenia are associated with an
inability or decreased ability to initiate actions or speech,
express emotions, or feel pleasure (Barch, 2013). The term
“negative” is used because certain behaviors or experiences are
lost from a person’s life once schizophrenia develops. Such
symptoms include:
· avolition—an inability to initiate or persist in goal-directed
behavior;
· alogia—a lack of meaningful speech;

· asociality—minimal interest in social relationships;
· anhedonia—reduced ability to experience pleasure from
positive events; and
· diminished emotional expression—reduced display of emotion
involving facial expressions, voice intonation, or gestures in
situations in which emotional reactions are expected.
Negative symptoms are common in individuals with
schizophrenia spectrum disorders. In fact, approximately 15–25
percent of individuals diagnosed with schizophrenia display
primarily negative symptoms (D. P. Johnson et al., 2009). One
group of individuals with schizophrenia with negative
symptoms endorsed beliefs such as “I attach very little
importance to having close friends,” “If I show my feelings,
others will see my inadequacy,” and “Why bother, I’m just
going to fail” (Rector, Beck, & Stolar, 2005). These beliefs may
contribute to a lack of motivation to interact with others.
Negative symptoms are more common in men and are associated
with poor social functioning and prognosis (J. Addington &
Addington, 2009).11-2Understanding Schizophrenia
According to DSM-5, a diagnosis of schizophrenia requires the
presence of two of the following: delusions, hallucinations,
disorganized speech, gross motor disturbances, or negative
symptoms. At least one of the two indicators must be delusions,
hallucinations, or disorganized speech (see Table 11.3).
Additionally, there is deterioration from a previous level of
functioning in areas such as work, interpersonal relationships,
or self-care. The symptoms must be present most of the time for
at least 1 month, and the disturbance must persist for at least 6
months, unless the symptoms subside due to successful
treatment (APA, 2013). Because the lifetime prevalence rate of
schizophrenia in the United States is about 1 percent, it affects
millions of people (National Institute of Mental Health, 2014b).
It is popularly believed that overwhelming stress can cause a
well-adjusted and relatively normal person to experience a
psychotic breakdown and develop schizophrenia. Although
sudden onset of psychotic behaviors can occur in previously

well-functioning people, in most cases of schizophrenia, there is
evidence of impairment in premorbid functioning; that is,
individuals often show some abnormalities before the onset of
major symptoms (Kastelan et al., 2007). The typical course of
schizophrenia consists of three phases: prodromal, active, and
residual.
The prodromal phase includes the onset and buildup of
schizophrenic symptoms. Social withdrawal and isolation,
peculiar behaviors, inappropriate affect, poor communi cation
patterns, and neglect of personal grooming may become evident
during this phase. Friends and relatives often notice these
differences and consider the changes in behavior as odd or
peculiar. Often, excessive demands on the individual or other
psychosocial stressors in the prodromal phase result in the onset
of prominent psychotic symptoms, or the active phase of
schizophrenia. In this phase, the person shows full-blown
symptoms of schizophrenia, including severe disturbances in
thinking, marked deterioration in social relationships, and
restricted or markedly inappropriate affect.
Eventually, the person may enter the residual phase, in which
the symptoms are no longer prominent. In the residual phase,
the psychotic behavior and symptom severity decline.
Frequently, the individual once again demonstrates the milder
impairment seen in the prodromal phase. Although long-term
studies have shown that many people with schizophrenia can
lead productive lives, complete recovery is rare. (Figure
11.2 illustrates different courses schizophrenia may take.)
11-2aLong-Term Outcome Studies
What are the chances of recovering from or showing significant
symptom improvement after an episode of schizophrenia?
Recent developments in both psychotherapy and medication
have led to increased optimism regarding the course of the
disorder. In a 10-year follow-up study of individuals
hospitalized for schizophrenia, the majority of participants
improved over time, whereas only a minority appeared to
deteriorate (Rabinowitz, Levine, Haim, & Hafner, 2007).

What factors appear to influence recovery from schizophrenia?
Factors associated with a positive outcome include gender
(women have a better outcome), higher levels of education,
being married or having a social network of friends, and a
higher premorbid level of functioning (Irani & Siegel,
2006; Sibitz, Unger, Woppmann, Zidek, & Amering, 2011). In a
10-year follow-up study examining baseline predictors
associated with recovery, researchers found that fewer negative
symptoms, a prior history of good work performance and ability
to live independently, and lower levels of depression and
aggression were all associated with improved outcome
(Shrivastava, Shah, Johnston, Stitt, & Thakar, 2010). Peer
support, work opportunities, and reducing the stigma of
schizophrenia facilitate recovery (Warner, 2009).
Checkpoint Review
1. Describe the prodromal, active, and residual phases of
schizophrenia.
2. What factors are associated with a positive outcome in
schizophrenia?
Obstacles to Recovery
The film, The Soloist, is based on the true story of Nathaniel
Ayers (pictured on the left), a homeless musician coping with
schizophrenia. When Los Angeles Times columnist Steve Lopez
attempted to help Ayers after writing an acclaimed series of
articles about the talented musician, he ran into many of the
obstacles facing people who are homeless and mentally ill.
LHB Photo/Alamy Archives du 7e Art/Photos 12/Alamy11-
3Etiology of Schizophrenia
Case Study
A 13-year-old boy who was having behavioral and academic
problems in school was taking part in a series of family therapy
sessions. Family communication was negative in tone, with a
great deal of blaming. Near the end of one session, the boy
suddenly broke down and cried out, “I don’t want to be like

her.” He was referring to his mother, who had been receiving
treatment for schizophrenia. Her bizarre behavior frightened
him, and he was concerned that his friends would find out about
her condition. But his greatest fear was that he would inherit the
disorder. Sobbing, he turned to the therapist and asked, “Am I
going to be crazy, too?”
If you were the therapist in the case study, how would you
respond? At the end of this section on the etiology of
schizophrenia, you should be able to reach your own conclusion
about what to tell the boy.
Schizophrenia and other psychotic conditions are best
understood using a multipath model that integrates heredity
(genetic influences on brain structure and neurocognitive
functioning), psychological characteristics, cognitive processes
(e.g., faulty psychological processing of information), and
social adversities such as low social or economic status. To
develop an accurate etiological framework, all of these
dimensions must be considered, as shown in Figure 11.3.
Figure 11.3Multipath Model of Schizophrenia
The dimensions interact with one another and combine in
different ways to result in schizophrenia.
© Cengage Learning®
Although we discuss the biological, psychological, social, and
sociocultural dimensions separately, keep in mind that each
dimension interacts with the others. For example, emotional or
sexual abuse, cannabis use, and trauma are all hypothesized to
affect dopamine levels and neurocognitive functioning in those
susceptible to schizophrenia. In one sample, each of these
factors increased the risk of persistent psychotic symptoms,
especially among individuals who were exposed to all three
influences (Cougnard, Marcelis, et al., 2007).
Did You Know?
· Marijuana use increases the risk of psychosis by 40 percent.
· Being a “heavy pot user” increases the risk of psychosis by

50–200 percent.
· It is estimated that 14 percent of the cases of psychosis might
not have occurred if marijuana had not been used.
Source: T. H. M. Moore et al., 2007; Nordentoft & Hjorthoj,
2007
The interactive model of schizophrenia (see Figure 11.4)
demonstrates how an underlying biological vulnerability
combined with other risk characteristics (e.g., male sex, young
age) can result in the development of prodromal symptoms of
schizophrenia. As time progresses, psychotic features may
appear or intensify if additional environmental risk factors
(e.g., cannabis use, trauma) occur. If the environmental
exposures are chronic or severe, the risk of developing
schizophrenia further increases. We now begin the discussion of
specific risk factors associated with schizophrenia.
Figure 11.4Interactive Variables and the Onset of Clinical
Psychosis
This model shows how psychological and social factors may
interact with genetic vulnerability to result in psychosis.
Source: Dominguez, M. D. G., Saka, M. C., Lieb, R., Wittchan,
H.-U., & Van Os, J. (2010). Reprinted with permission from the
American Journal of Psychiatry, copyright © 2010 American
Psychiatric Association.11-3aBiological Dimension
Genetics and heredity play an important role in the development
of schizophrenia. Whereas past research focused on the attempt
to identify the specific gene or genes that cause schizophrenia,
most researchers agree that schizophrenia results from
interactions among a large number of different genes; single
genes appear to make only minor contributions toward the
illness (Schizophrenia Working Group of the Psychiatric
Genomics Consortium, 2015). Researchers have found that
closer blood relatives of individuals diagnosed with
schizophrenia run a greater risk of developing the disorder
(Figure 11.5). Thus, the boy described in the case study earlier

who is concerned about developing schizophrenia like his
mother has a 16 percent chance of being diagnosed with
schizophrenia, whereas his mother’s nieces or nephews have
only a 4 percent chance. (It should be noted that the risk for the
general population is about 1 percent.)
Figure 11.5Risk of Schizophrenia among Blood Relatives of
Individuals Diagnosed with Schizophrenia
This figure reflects the estimate of the lifetime risk of
developing schizophrenia— a risk that is strongly correlated
with the degree of genetic influence.
Source: Data from Gottesman (1978, 1991).
However, even among monozygotic (identical) twins, if one
twin receives the diagnosis of schizophrenia, the risk of the
second twin developing the disorder is less than 50 percent.
This is because environmental influences also play a significant
role in genetic expression of the disorder. For example, low
birth weight and other pregnancy and delivery complications are
associated with an increased risk for schizophrenia. Yet most
infants with these types of complications do not develop the
disorder. Instead, the risk is the greatest among those with
genetic susceptibility (Forsyth et al., 2013).
Endophenotypes
Genetic research strategies have moved from demonstrating that
heredity is involved in schizophrenia to attempting to identify
the genes that are responsible for the specific characteristics or
traits that are evident in this disorder. This approach involves
the identification and study of endophenotypes—measurable,
heritable traits (Braff, Freedman, Schork, & Gottesman, 2007).
Endophenotypes are hypothesized to underlie heritable illnesses
(such as schizophrenia) and thus exist in the individual before
the disorder, during it, and following remission. These
characteristics are found with higher frequency, although in
milder forms, among “non-ill” relatives of individuals with a
disorder. Researchers have identified several possible

endophenotypes that occur in those with schizophrenia and in
their unaffected biological relatives. These traits include
irregularities in working memory, executive function, sustained
attention, and verbal memory (Chan, Di, McAlonan, & Gong,
2011; Turetsky et al., 2007).
Neurostructures
How do genes produce a vulnerability to schizophrenia? Clues
to the ways that genes might increase susceptibility to
developing schizophrenia have involved the identification of
structural and neurochemical differences between individuals
with and without schizophrenia. Individuals with schizophrenia
have decreased volume in the cortex and other areas of the brain
(Haijma et al., 2013), as well as ventricular enlargement
(enlarged spaces in the brain). Ventricular enlargement may be
an early indication of an increased susceptibility to
schizophrenia (Ettinger et al., 2012).
How might decreased cortex volume and enlarged ventricles
predispose someone to develop schizophrenia? These structural
characteristics may result in atypical or weak connectivity
between the various brain regions, leading to reductions in
integrative functioning in the brain and impaired cognitive
processing (Salgado-Pineda et al., 2007). Thus, ineffective
communication between different brain regions may lead to the
cognitive symptoms (e.g., disorganized speech and impairment
in memory, decision making, and problem solving), negative
symptoms (e.g., lack of drive or initiative), and positive
symptoms (e.g., delusions and hallucinations) that are found in
schizophrenia.
Biochemical Influences
Abnormalities in certain neurotransmitters (chemicals that allow
brain cells to communicate with one another) including
dopamine, serotonin, GABA, and glutamate have also been
linked to schizophrenia (Benes, 2009; de la Fuente-Sandoval et
al., 2013). Particular attention is given to the neurotransmitter

dopamine (Howes, Kambeitz, et al., 2012). According to
the dopamine hypothesis, schizophrenia may result from excess
dopamine activity in certain areas of the brain. Support for the
dopamine hypothesis has come from research with three types
of drugs: phenothiazines, L-dopa, and amphetamines.
· Phenothiazines are conventional antipsychotic drugs that
decrease the severity of disordered thinking, decrease social
withdrawal, alleviate hallucinations, and improve the mood of
individuals with schizophrenia. Phenothiazines reduce dopamine
activity in the brain by blocking dopamine receptor sites.
· L-dopa is used to treat symptoms of Parkinson’s disease, such
as muscle and limb rigidity and tremors. L-dopa increases levels
of dopamine; schizophrenic-like side effects often occur in
individuals with Parkinson’s disease who take this medication.
(In contrast, the phenothiazines, which reduce dopamine
activity, can produce side effects that resemble Parkinson’s
disease.)
· Amphetamines are stimulants that increase the availability of
dopamine and norepinephrine (another neurotransmitter) in the
brain. When individuals not diagnosed with schizophrenia use
amphetamines, they sometimes show symptoms very much like
those of acute paranoid schizophrenia. Also, even small doses
of amphetamine can increase the severity of symptoms in
individuals diagnosed with schizophrenia.
Did You Know?
Agitation and psychotic symptoms associated with the use of
“bath salts” has dramatically increased emergency room visits
and hospitalizations. Street names for these synthetic
hallucinogenic and stimulant substances include meow, miaow,
drone, bubbles, plant food, spice E, and M-cat.
Source: Kolli, Sharma, Amani, Bestha, & Chaturvedi, 2013
Thus, one group of drugs that blocks dopamine reception has
the effect of reducing the severity of schizophrenic symptoms,
whereas two drugs that increase dopamine availability either
produce or worsen these symptoms. Such evidence suggests that
excess dopamine may be responsible for schizophrenic

symptoms. The evidence is not clear-cut, however.
Phenothiazines are not effective in treating many cases of
schizophrenia, and newer antipsychotics work mainly by
blocking serotonin receptors rather than dopamine receptors
(Canas, 2005).
The use of cocaine, amphetamines, alcohol, and especially
cannabis appears to increase the chances of developing a
psychotic disorder (Callaghan et al., 2012). Methamphetamine
use may result in a fivefold increase in the likelihood of
psychotic symptoms during intoxication (McKetin, Lubman,
Baker, Dawe, & Ali, 2013). When distressing psychotic
symptoms such as delusions or hallucinations develop during
substance use or intoxication, a diagnosis of
substance/medication-induced psychotic disorder may be
appropriate (APA, 2013).
The effects of cannabis occurs in a dose-dependent manner—the
higher the intake of cannabis, the greater the likelihood of
psychotic symptoms (Davis, Compton, Wang, Levin, & Blanco,
2013). Use of high potency forms of cannabis also increases the
risk of psychosis (Di Forte et al., 2015). Adolescents who use
cannabis are more likely to report prodromal symptoms (e.g.,
“Something strange is taking place in me,” “I feel that I am
being followed,” or “I am being influenced in a special
way”; Miettunen et al., 2008). Among cannabis users who
develop schizophrenia, the onset of psychosis is nearly 3 years
earlier in comparison to nonusers (Large, Sharma, Compton,
Slade, & Nielssen, 2011).
Several possible interpretations may explain the relationship
between cannabis use and psychosis (Foti, Kotov, Guey, &
Bromet, 2010):
1. the increased risk of developing psychosis may be due to
cannabis use itself;
2. individuals with a predisposition for psychosis may also be
predisposed to use cannabis;
3. individuals with prodromal symptoms or psychotic-type
experiences may use cannabis to self-medicate for these

symptoms; or
4. cannabis may influence dopamine levels or increase
vulnerability through interactions with environmental stressors
associated with cannabis use (e.g., family conflict or poor
school or work performance).
Although the prevalence of schizophrenia is roughly equal
between men and women, the age of onset is earlier in males
than in females (Segarra et al., 2012). The gender ratio shifts by
the mid-40s and 50s, when the percentage of women receiving
the diagnosis exceeds that of men. This trend is especially
pronounced in the mid-60s and later (Thorup, Waltoft,
Pedersen, Mortensen, & Nordentoft, 2007). Researchers have
hypothesized that the later age of onset found in women is due
to the protective effects of estrogen, which diminish after
menopause (E. Hayes, Gavrilidis, & Kulkarni, 2012).
Rate of Gray Matter Loss in Teenagers with Schizophrenia
Male and female adolescents with schizophrenia show
progressive loss of gray matter in the parietal, frontal, and
temporal areas of the brain that is much greater than that found
in adolescents without schizophrenia.
Reprinted with permission of Dr. Paul Thompson, UCLA
Laboratory of Neuro Imaging
Because the concordance rate—the likelihood that both
members of a twin pair show the same characteristic— is less
than 50 percent when one identical twin has schizophrenia,
physical, psychological, or social influences that are not shared
between the twins must also play a role. Conditions influencing
prenatal or postnatal neurodevelopment that have been
associated with schizophrenia include prenatal infections,
obstetric complications, and head trauma (Cannon, Clarke, &
Cotter, 2014; Mittal, Ellman, & Cannon, 2008).
Although a variety of biological influences appear to increase
susceptibility to schizophrenia, specific psychological, social,
and sociocultural variables can also influence development of
schizophrenia. We now examine these influences as possible

contributors to the disorder.11-3bPsychological Dimension
Individuals who develop schizophrenia have certain cognitive
attributes, dysfunctional beliefs, and interpersonal functioning
that may predispose them to the development of psychotic
symptoms. For example, deficits in empathy (understanding the
feelings of others) and a tendency to focus only on one’s own
thoughts and feelings appear to compromise social interactions
(Harvey, Zaki, Lee, Ochsner, & Green, 2013). This problem is
also apparent during nonverbal communication; individuals with
schizophrenia tend to gesture less when speaking and nod less
frequently when listening compared to individuals without the
disorder. Such a communication pattern may interfere with the
development of interpersonal rapport and emotional connection
(Lavelle, Healey, & McCabe, 2013).
Did You Know?
Characteristics that sharply increase the likelihood of
developing schizophrenia include:
1. genetic risk;
2. recent deterioration in functioning, especially social
withdrawal;
3. increasing frequency of unusual thoughts;
4. high levels of suspiciousness and paranoia;
5. social impairment; and
6. substance abuse.
Source: Cannon et al., 2008
These communication problems and the lack of insight that
frequently occurs with schizophrenia may result, in part, from
an inability to recognize that others have emotions, beliefs, and
desires that may be different from one’s own. Thus, individuals
with schizophrenia may operate based on their own perspectives
without understanding that others have their own viewpoint. As
you might imagine, this could create major difficulties in
communication and interpersonal interactions.
Early cognitive deficits are also associated with schizophrenia.
Low cognitive test scores in childhood and adolescence
predicted the presence of psychotic-like experiences and

clinically significant psychotic symptoms in middle age; the
low scores may represent early evidence of abnormalities in
neural development (Barnett et al., 2012). Additionally, in a
group of young men, a decline in verbal ability between ages 13
and 18 was associated with an increased risk of developing a
psychotic disorder (MacCabe et al., 2013). These cognitive
decrements may be an indication of brain abnormalities that
result in less “cognitive reserve” and reduced opportunity for
the brain to bounce back from neurological insult (Barnett et
al., 2012).
Brain Changes Associated with Schizophrenia
In these PET scans of the frontal cortex, the adult brain on the
left (healthy subject) shows high levels of metabolic activity
whereas the one on the right (subject of the same age with
schizophrenia) shows reduced lower metabolic activity. Such
findings help explain the cognitive difficulties experienced by
individuals with schizophrenia.
ISM/Photo take
Certain personal cognitive processes involving misattributions
or negative attitudes can lead to or maintain psychotic
symptoms such as delusions. For example, negative symptoms
such as limited motivation and restricted affect, may be due to
individuals’ beliefs that they are worthless and that their
condition is hopeless (Beck, Grant, Huh, Perivoliotis, & Chang,
2013). The combination of low expectancy for pleasure and
success combined with low motivation may maintain negative
symptoms. In fact, some researchers believe that an individual’s
interpretation of events may be the primary cause of the distress
and disability associated with schizophrenia (Garety,
Bebbington, Fowler, Freeman, & Kuipers, 2007). In other
words, pessimistic interpretations may produce and maintain
negative symptoms. Table 11.1 presents patterns of thinking
that may be associated with negative symptoms.
Table 11.1

Negative Expectancy Appraisals Associated with Negative
Symptoms
Negative Symptom
Low Self-Efficacy (Success)
Low Satisfaction (Pleasure)
Low Acceptance
Low Available Resources
Restricted affect
If I show my feelings, others will see my inadequacy.
I don’t feel the way I used to.
My face appears stiff and contorted to others.
I don’t have the ability to express my feelings.
Alogia
I’m not going to find the right words to express myself.
I take so long to get my point across that it’s boring.
I’m going to sound weird, stupid, or strange.
It takes too much effort to talk.
Avolition
Why bother, I’m just going to fail.
It’s more trouble than it’s worth.
It’s best not to get involved.
It takes too much effort to try.
Source: Rector, Beck, & Stolar (2005), p. 254.11-3cSocial
Dimension
The role of social relationships in the development of
schizophrenia has been extensively studied. In fact, not long
ago, dysfunctional family patterns, rather than biology, were
considered the primary cause of schizophrenia (Walker &
Tessner, 2008). Although research has failed to substantiate the
hypothesis that family dysfunction is a major cause of
schizophrenia, blaming families for schizophrenia still occurs
today. One parent whose son was hospitalized for psychosis
heard a nurse say, “Well, no wonder he’s ill—look at the state
of his mother.” The staff member apparently failed to
understand that the mother’s state of mind was the result of

weeks of stress attempting to help her adult son cope with his
psychotic symptoms prior to his hospitalization (Wainwright,
Glentworth, Haddock, Bentley, & Lobban, 2014, p. 8). It is
quite probable, however, that among individuals with a
biological predisposition, the social environment does increase
risk of schizophrenia. We will consider social factors that are
associated with increased vulnerability to schizophrenia.
Certain social stressors appear to influence the appearance of
psychotic symptoms. In a longitudinal study focused on 2,232
twins, those who experienced maltreatment by an adult or
bullying by peers had a higher risk of psychotic symptoms at
age 12 (see Figure 11.6); the risk was magnified among those
exposed to both bullying and maltreatment. In contrast, being in
a traumatic accident was associated with only a slightly
increased risk of psychotic symptoms (Arseneault et al., 2011).
Similarly, another study found a dose-dependent relationship
between the severity of bullying and the risk for psychotic
experiences in school-age adolescents—the more severe the
bullying, the greater the risk of schizophrenia. The study
reported another finding that has important implications for
prevention programs—the psychotic symptoms in affected youth
often decreased or subsided if the bullying stopped (Kelleher et
al., 2013).
Figure 11.6Risk of Psychotic Symptoms at Age 11 Associated
with Cumulative Childhood Trauma
Youth exposed to both bullying and childhood maltreatment
demonstrate a significantly increased risk of developing
psychotic symptoms.
Source: Arseneault et al. (2011). Reprinted with permission
from the American Journal of Psychiatry, copyright © 2011
American Psychiatric Association.
Relationships within the home can also influence the
development of schizophrenia. Individuals with psychosis were
3 times more likely to report severe physical abuse from
mothers before 12 years of age than were individuals without

psychosis (H. L. Fisher et al., 2010). In contrast, among
adolescents with symptoms that appeared to put them “at
imminent risk” for the onset of psychosis, positive remarks and
warmth expressed by caregivers were associated with decreases
in negative and disorganized symptoms and improvement in
social functioning (M. P. O’Brien et al., 2006). Children at
higher biological risk for schizophrenia may be more sensitive
to the effects of both adverse and healthy child-rearing patterns
(Aas et al., 2012).
Expressed emotion (EE), a negative communication pattern
found among some relatives of individuals with schizophrenia,
has been associated with higher relapse rates in individuals
diagnosed with schizophrenia (Breitborde, Lopez, &
Nuechterlein, 2009). EE is determined by a variety of factors,
including critical comments made by relatives; statements of
dislike or resentment directed toward the individual with
schizophrenia by family members; and statements reflecting
emotional overinvolvement, overconcern, or overprotectiveness
with respect to the family member with schizophrenia. Although
high EE has been associated with an increased risk of relapse,
there are different interpretations for this finding (see Figure
11.7).
· A high EE environment is stressful and may lead directly to
relapse in the family member who has schizophrenia (Cutting &
Docherty, 2000).
· An individual who is more severely ill has a greater chance of
relapse and may cause more negative or high EE communication
patterns in relatives.
· The effects of EE and illness are bidirectional: Odd behaviors
or symptoms of schizophrenia may increase the likelihood that
family members criticize, overprotect, or react to the symptoms
with frustration, which in turn produces increases in psychotic
symptoms (Rosenfarb, Goldstein, et al., 1995).
Figure 11.7Possible Relationships between High Rates of
Expressed Emotion and Relapse Rates in Patients with
Schizophrenia

This figure shows several ways in which expressed emotions
and relapse rates can be related.
© Cengage Learning®
The EE construct appears to have less meaning for different
cultural groups. It is possible that this occurs because cultural
factors may influence whether family members view the
symptoms as burdensome. For example, family criticism scores
were not associated with relapse for Mexican Americans with
schizophrenia (Rosenfarb, Bellack, & Aziz, 2006). Among a
sample of African Americans and European Americans with
schizophrenia, high levels of critical and intrusive behavior by
family members (high EE) were associated with better outcomes
for African American clients over a 2-year period, whereas
European American clients had better outcomes with low levels
of EE. Within some African American families, seemingly
negative family communication may, in fact, reflect caring and
concern (Rosenfarb, Bellack, et al., 2006). Lopez, Hipke, and
associates (2004) concluded that cultural groups may interpret
family communication processes such as emotional
overprotection or overinvolvement differently. In fact,
therapists who focus on reducing critical and intrusive
communication patterns in some culturally diverse families may
inadvertently increase family stress.11-4Treatment of
Schizophrenia
Through the years, schizophrenia has been treated by a variety
of means, including performing a prefrontal lobotomy—a
surgical procedure in which the frontal lobes are disconnected
from the remainder of the brain. Today schizophrenia is often
treated with antipsychotic medications, along with some type of
psychosocial therapy. In recent years, the research and clinical
perspective on people with schizophrenia has shifted from a
focus on illness and deficit to one of recovery and promotion of
health, competencies, independence, and self-determination
(Bellack, 2006; Lysaker & Roe, 2012). This change of focus is
affecting therapists’ views regarding clients, families, and their

own role in the treatment process. We first discuss medication
in the treatment of schizophrenia, and then the psychological
and social therapies.11-4aAntipsychotic Medications
Many consider the 1955 introduction of Thorazine, the first
antipsychotic drug, to be the beginning of a new era in treating
schizophrenia. For the first time, a medication was available
that sufficiently relaxed even those most severely affected by
schizophrenia and helped organize their thoughts to the point
that straitjackets were no longer needed for physical restraint.
The first-generation antipsychotics (also
called conventional or typical antipsychotics) are still viewed as
effective treatments for schizophrenia, although their use has
been largely supplanted by the newer atypical antipsychotics,
medications with somewhat different chemical properties
compared to the earlier drugs. Although medications have
improved the lives of many with schizophrenia, they do not cure
the disorder. Conventional antipsychotic medications (such as
chlorpromazine/Thorazine or haloperidol/Haldol) have
dopaminergic receptor–blocking capabilities (i.e., they reduce
dopamine levels), a factor that led to the dopamine hypothesis
of schizophrenia.
Did You Know?
In a randomized, double-blind study, adolescents at risk for
developing psychosis were given either omega-3 fatty acids
(fish oil) or a placebo for 3 months and then followed for a
year. In the placebo group, 14 percent developed psychosis
compared to only 2 percent in the fish oil group. Could
prevention be this easy? Researchers in the United States and
Canada are currently examining this possibility.
Source: Amminger et al., 2010; Brooks, 2012
The newer atypical antipsychotics (such as
risperidone/Risperdal, olanzapine/ Zyprexa,
quetiapine/Seroquel, aripiprazole/Abilify, and
lurasidone/Latuda) act on both dopamine and serotonin
receptors. These newer medications are purportedly less likely
to produce side effects such as the rigidity, persistent muscle

spasms, tremors, and restlessness that occur with the older
antipsychotics (Bobo, 2013). However, some researchers have
identified troublesome side effects with these newer
antipsychotic medications (Foley & Morley, 2011). In addition,
a review of studies published between 1974 and 2012 comparing
conventional and atypical antipsychotics found a lack of
evidence that the latter offer an advantage in treating
schizophrenia (Hartling et al., 2012).
Continuum
Video Project
© Cengage Learning®Andre:Schizophrenia
“I believe that other people are pathological liars, and I’m not.
So why should I even have to listen to them?”
Access the Continuum Video Project in MindTap
at www.cengagebrain.com
Conventional and atypical antipsychotics can effectively reduce
the severity of the positive symptoms of schizophrenia, such as
hallucinations, delusions, bizarre speech, and disordered
thought. In one study, over 75 percent of those taking atypical
antipsychotics felt that the medication helped them manage
their symptoms and prevent hospitalization (Jenkins et al.,
2005). Most of these medications, however, offer little relief
from negative symptoms such as social withdrawal, apathy, and
impaired personal hygiene (M. F. Green, 2007). Moreover, a
“relatively large group” of people with schizophrenia do not
benefit at all from antipsychotic medication. Additionally, from
one half to three quarters of patients discontinue use of
antipsychotics for the following reasons (Moritz et al., 2013):
· Too many side effects (80 percent)
· Belief that they do not need antipsychotics (58 percent)
· Mistrust of the physician or therapist (31 percent)
· Rejection of medication in general (28 percent)
· Friends or relatives advised them not to take the medication
(20 percent)

Many individuals treated with antipsychotic medications
develop extrapyramidal symptoms, which
include parkinsonism (muscle tremors, shakiness, and
immobility), dystonia (slow and continued involuntary
movements of the limbs and tongue), akathisia (motor
restlessness), and neuroleptic malignant syndrome (muscle
rigidity and autonomic instability, which can be fatal if
untreated). Other symptoms may involve the loss of facial
expression, shuffling gait, tremors of the hand, rigidity of the
body, and poor balance. Although many symptoms are
reversible once medication is stopped, some symptoms (e.g.,
involuntary movements) can be permanent (Abouzaid et al.,
2014). Antipsychotic medications are also associated with
increased risk of metabolic syndrome, a condition associated
with obesity, diabetes, high cholesterol, and hypertension
(Bener, Al-Hamaq, & Dafeeah, 2014).
Controversy
The Marketing of Atypical Antipsychotic Medications
The woman in the Abilify ad says, “I’m taking an antidepressant
but I think I need more help.” According to the ad, two out of
three individuals taking an antidepressant alone continue to
experience symptoms of depression. The ad goes on to suggest
that Abilify can be helpful when combined with current
antidepressant medications. Abilify is an atypical antipsychotic,
but that fact is not mentioned (Westberg, 2010).
Surprisingly, atypical antipsychotics are the top- selling class of
medications in the United States, accounting for $18.2 billion in
sales based on 3.1 million U.S. prescriptions in 2011 (Friedman,
2012), including more than $1 billion in annual sales for
quetiapine (Seroquel), aripiprazole (Abilify), olanzapine
(Zyprexa), and risperidone (Risperdal) (G. C. Alexander,
Gallagher, Mascola, Moloney, & Stafford, 2011). These
profitable drugs are heavily promoted by the pharmaceutical
companies, with resultant increases in the number of people
taking both antidepressants and antipsychotics. However, many

of these combinations are of “unproven efficacy” (Mojtabai &
Olfson, 2010). Antipsychotics are increasingly prescribed for a
range of mental disorders, including attentional, conduct, and
anxiety disorders, although they have never been evaluated or
approved for use with these disorders (Zito, Burcu, Ibe, Safer,
& Magder, 2013).
The increased use of atypical antipsychotic medications is of
particular concern due to their association with troublesome
side effects. After only 12 weeks on Abilify, Risperdal,
Seroquel, or Zyprexa, children were found to gain up to 19 lb
(Correll et al., 2010). In a 5-year study of atypical
antipsychotics in middle-aged and older individuals with
schizophrenia, 29.7 percent had serious adverse physical effects
that were probably or possibly due to the medication. Increases
in cholesterol levels and weight gain can occur in individuals
taking atypical antipsychotic medications for as little as 3
months (Foley & Morley, 2011). The U.S. Food and Drug
Administration (2011) has warned that infants born to mothers
taking antipsychotic medications during the third trimester of
pregnancy are at high risk of having abnormal muscle tone,
tremors, sleepiness, severe difficulty breathing, and difficulty
sucking.
Should regulations be in place to protect consumers from the
increasing off-label use of antipsychotic medications? Should
advertisements promoting atypical antipsychotic medications
identify them as such? Should physicians and psychiatrists be
required to inform patients when antipsychotics have not been
approved for the treatment of their specific condition?11-
4bCognitive-Behavioral Therapy
Major advances have been made in the use of cognitive and
behavioral strategies in treating the symptoms of schizophrenia;
this is particularly important for those who do not respond to
medication. Therapists teach coping skills that allow clients to
manage their positive and negative symptoms, as well as the
cognitive challenges associated with schizophrenia (Hansen,
Kingdon, & Turkington, 2006). An 18-month follow-up of 216

individuals with persisting psychotic symptoms found that those
receiving cognitive-behavioral therapy had 183 days of normal
functioning, compared to 106 days for those who received
treatment as usual consisting of pharmacotherapy and contact
with a psychiatric nurse (van der Gaag, Stant, Wolters, Burkens,
& Wiersma, 2011).
The following case study provides an example of symptoms of
schizophrenia that might be effectively addressed with
cognitive-behavioral treatment strategies.
Case Study
A young African American woman with auditory hallucinations,
paranoid delusions, delusions of reference, a history of
childhood verbal and physical abuse, and adult sexual assault
felt extremely hopeless about her prospects for developing
social ties. She believed that her “persecutors” had informed
others of her socially undesirable activities. . . . She often
loudly screamed at the voices she was hearing. . . . When she
did leave her home, she often covered her head with a black
kerchief and wore dark sunglasses, partly in an effort to
disguise herself from her persecutors. (Cather, 2005, p. 260)
Cognitive-behavioral treatment to address concerns such as
these often includes the following steps (Cather, 2005; Sivec &
Montesano, 2013):
· Engagement. The therapist explains the therapy and works to
foster a safe and collaborative method of looking at causes of
distress, drawing out the client’s understanding of stressors and
ways of coping.
· Assessment. Clients are encouraged to discuss their fears and
anxieties; the therapist shares information about how symptoms
are formed and maintained. In the preceding case study, the
therapist helped the woman make sense of her persecutory
delusions. It was explained that victims of abuse often
internalize beliefs that they are responsible for the abuse, and
that her view that she was “bad” led to expectations of negative
reactions from others and the need to disguise herself.
· Identification of negative beliefs. The therapist explains to the

client the link between personal beliefs and emotional distress,
and the ways that beliefs such as “Nobody will like me if I tell
them about my voices” can be disputed and changed to “I can’t
demand that everyone like me. Some people will and some
won’t” (Hansen et al., 2006, p. 50). This reinterpretation often
leads to less sadness and isolation.
· Normalization. The therapist works with the client to
normalize and decatastrophize the psychotic experiences.
Information that many people can have unusual experiences may
reduce a client’s sense of isolation.
· Collaborative analysis of symptoms. Once a strong therapeutic
alliance has been established, the therapist begins critical
discussions of the client’s symptoms, such as “If voices come
from your head, why can’t others hear them?” Evidence for and
against the maladaptive beliefs is discussed, combined with
information about how beliefs are maintained through cognitive
distortions.
· Development of alternative explanations. The therapist helps
the client develop alternatives to previous maladaptive
assumptions, using the client’s ideas whenever possible.
Family Communication and Education
Therapy that includes the family members of individuals with
schizophrenia reduces relapse rates and is more effective than
drug treatment alone.
iStockphoto.com/JodiJacobson
More recently, instead of trying to eliminate or combat
hallucinations, therapists teach clients to accept them in a
nonjudgmental manner. In mindfulness training, clients learn to
let go of angry or fearful responses to psychotic symptoms;
instead, they are taught to let the psychotic symptoms come into
consciousness without reacting (e.g., just noticing and accepting
the voices or thoughts rather than believing them or acting on
them). This process enhances feelings of self-control and
significantly reduces negative emotions (Shawyer et al., 2012).
This approach was used with men who had heard malevolent

and powerful voices for more than 30 years. Their attempts to
stop the voices or to distract themselves were ineffective. After
undergoing mindfulness training, the men were less distressed
with the voices and more confident in their ability to live with
them (K. N. Taylor, Harper, & Chadwick, 2009). Similarly,
malevolent and persecuting voices became less disturbing when
individuals with schizophrenia learned to access positive
emotions such as warmth and contentment during psychotic
episodes (Mayhew & Gilbert, 2008).
Artwork to Demonstrate Creative Talents
Paintings and sculptures by William Scott, diagnosed with
schizophrenia and an autism spectrum disorder, are sold around
the world at cutting-edge art galleries. Scott is pictured here
with a self-portrait.
AP Images/Paul Sakuma11-4cInterventions Focusing on Family
Communication and Education
A serious mental illness such as schizophrenia can have a
powerful effect on family members, who may feel stigmatized
or responsible for the disorder. As one woman stated, “All
family members are affected by a loved one’s mental illness.
The entire family system needs to be addressed” (Stalberg,
Ekerwald, & Hultman, 2004).
Siblings without the disorder may display a variety of emotional
reactions to the mental illness experienced by their sibling—
love (“She’s really kind and loves me so very much it’s never
been a problem.”); loss (“Somehow I’ve lost my sister the way
she was before and I think I won’t get her back.”); anger (“Yes,
it’s hell. . . . She’s incredibly mean to our mother and she sure
as hell doesn’t deserve that.”); guilt and shame (“Yes, you can
think about how he got ill and I didn’t.”); and fear (“You worry
a lot about getting it yourself.”) (Stalberg, Ekerwald, &
Hultman, 2004, p. 450).
More than half of those recovering from a psychotic episode
return to live with their families, and new psychological
interventions address this fact. Family intervention programs

have not only reduced relapse rates but have also lowered the
cost of care. They have been beneficial for families with and
without negative communication patterns. Most programs
include the following components (Glynn et al., 2006):
· normalizing the family experience;
· demonstrating concern, empathy, and sympathy to all family
members;
· educating family members about schizophrenia;
· avoiding blaming the family or pathologizing their coping
efforts;
· identifying the strengths and competencies of the client and
family members;
· developing skills in solving problems and managing stress;
· teaching family members to cope with the symptoms of mental
illness and its repercussions on the family; and
· strengthening the communication skills of all family members.
Family approaches and social skills training are much more
effective in preventing relapse than drug treatment alone (Xia,
Merinder, & Belgamwar, 2011). Combining cognitive-
behavioral strategies, medication, family counseling, and social
skills training seems to produce the most positive results (Penn
et al., 2004). In fact, research suggests that “optimism about
outcome from schizophrenia is justified” and that “a substantial
proportion of people with the illness will recover completely
and many more will regain good social functioning” (R. Warner,
2009, p. 374).11-5Other Schizophrenia Spectrum Disorders
Disorders on the schizophrenia spectrum include some or all of
the symptoms we discussed at the beginning of this chapter. The
spectrum includes disorders that differ from schizophrenia in a
variety of ways, including the specific symptoms involved, the
duration of symptoms, or the presence of additional symptoms.
Additional disorders on the schizophrenia spectrum include
delusional disorder, brief psychotic disorder, schizophreniform
disorder, and schizoaffective disorder (see Table 11.3).
Table 11.3

Schizophrenia Spectrum and Other Psychotic Disorders
Disorders Chart
Disorder
Symptoms
Prevalence
Gender Differences
Age of Onset
Schizophrenia
Two or more psychotic symptoms of which at least one must be
delusions, hallucinations, or disorganized speech; impaired life
functioning
· About 1% of the population
· About equal
· 18–24 for men
· 24–35 for women
Brief psychotic disorder
One or more psychotic symptoms, of which at least one must be
delusions, hallucinations, or disorganized speech for at least 1
day but less than 1 month
· Up to 9% of new cases of psychosis
· Much higher in developing countries
· Twice as common in women
3. Can occur at any age
4. Most common in 30s
Schizophreniform disorder
Two or more psychotic symptoms, of which at least one must be
delusions, hallucinations, or disorganized speech for at least 1
month but less than 6 months
· Much lower rate than schizophrenia
· Higher in developing countries
3. About equal
· 18–24 for men
· 24–35 for women
Delusional disorder
One or more delusions for at least 1 month
· Rare: from 0.03%–0.18%

5. About equal
7. More prevalent in older adults
Schizoaffective disorder
Episode of mania or major depression concurrent with
delusions, hallucinations, or disorganized speech; psychotic
symptoms persist after the mood episode ends
1. About 0.32%
1. More females
1. Usually early adulthood
Source: APA (2013); Bhalla (2013); Brannon & Bienenfeld
(2012); Memon (2013).11-5aDelusional Disorder
Case Study
A man is convinced that his body gives off an unpleasant odor
and that if anyone opens a window, sneezes, or frowns, it is
because of his smell. He is suspicious when people whisper to
one another or when people on his bus get off quickly. He
believes this is evidence that his body has a terrible smell
(Begum & McKenna, 2011).
Delusional disorder is characterized by persistent delusions that
are not accompanied by other unusual or odd behaviors—other
than those related to the delusional theme (Chopra &
Bienenfeld, 2011). According to DSM-5, the delusions must
persist for at least 1 month (APA, 2013). Delusional disorder is
distinct from the other psychotic disorders due to the absence of
additional disturbances in thoughts or perceptions, beyond
occasional hallucinations that may be associated with the
delusion (e.g., sensations of insects crawling on the skin within
the context of a delusion that one’s home is infested with
insects).
This disorder is rarely diagnosed (the prevalence is 0.03–0.18
percent); however, it is believed that many with the disorder do
not perceive they have a problem and therefore do not seek
assistance. People with delusional disorder generally behave
normally when they are not discussing or reacting to their
delusional ideas. Common themes involved in delusional

disorders include the following (Chopra & Bienenfeld, 2011):
· Erotomania—the belief that someone is in love with the
individual; this delusion typically has a romantic rather than
sexual focus.
· Grandiosity—the conviction that one has great, unrecognized
talent, special abilities, or a relationship with an important
person or deity.
· Jealousy—the conviction that one’s spouse or partner is being
unfaithful.
· Persecution—the belief that one is being conspired or plotted
against.
· Somatic complaints—convictions of having body odor, being
malformed, or being infested by insects or parasites.
Women are more likely to develop erotomanic delusions,
whereas men tend to have paranoid delusions involving
persecution (Chopra & Khan, 2009).
A decreased ability to obtain corrective feedback, combined
with preexisting personality traits of suspiciousness, may
increase a person’s susceptibility to developing delusional
beliefs. For example, hearing impairment in early adolescence
is associated with an increased risk of developing delusions
(van der Werf et al., 2011). There is a significant genetic
relationship between delusional disorder and schizophrenia; a
small proportion of those with the disorder eventually develop
schizophrenia (APA, 2013). Delusional disorder can be treated
with antipsychotic medications or cognitive-behavioral therapy
(Chopra & Khan, 2009).11-5bBrief Psychotic Disorder
Case Study
Eve was a 20-year-old student studying forensic medicine when
she first experienced a chaotic world of delusions. She believed
that her body was decaying, deteriorating, and rotting away. She
feared seeing her reflection in mirrors, worried that it would
show that her skin was falling apart revealing a rotted monster.
She pasted paper over windows and smashed the mirror in the
bathroom. She splashed perfume over everything to hide the
stench of her rotting body. She stayed in constant motion

because she believed that remaining still would cause her body
to deteriorate more quickly. At some point all she could do was
scream.
Eve received a diagnosis of brief psychotic disorder and the
psychiatrist prescribed an antipsychotic medication, an
antidepressant, and a sleeping aid. Within two and one-half
weeks, her symptoms had subsided and she moved back in with
her family (Purse, 2013).
Critical Thinking
Morgellons Disease: Delusional Parasitosis or Physical Disease?
More than 10 years ago, “Mary Leitao plucked a fiber that
looked like a dandelion fluff from a sore under her two-year-old
son’s lips. . . . Sometimes the fibers were white, and sometimes
they were black, red, or blue” (Devita-Raeburn, 2007). Leitao
was frustrated by the inability of physicians to diagnose her
son’s skin condition. In fact, many of the professionals she
consulted indicated that they could find no evidence of disease
or infection. Frustrated by the medical establishment, Leitao put
a description of the condition on a Web site in 2001, calling it
Morgellons disease after a 17th-century French medical study
involving children with similar symptoms (Mason, 2006).
The Web site has since compiled 11,000 worldwide reports of
the condition among adults and children. Sufferers report
granules and fiber-like threads emerging from the skin at the
site of itching; sensations of crawling, stinging, or biting; and
rashes and skin lesions that do not heal (M. Paquette, 2007).
Some describe the fibers as “inorganic but alive” and report that
the fibers pull back from a lit match (Browne, 2011). Symptoms
of vision changes, joint pain, fatigue, mental confusion, and
short-term memory difficulties have been reported in connection
with Morgellons disease (Centers for Disease Control and
Prevention, 2011).
What could cause this disorder? Many dermatologists,
physicians, and psychiatrists believe that Morgellons disease
results from self-inflicted injury or is a somatic type of

delusional disorder such as delusional parasitosis, a condition in
which individuals maintain a delusional belief that they are
afflicted with living organisms or other pathogens
(Freudenmann & Lepping, 2009). Stephen Stone, past president
of the American Academy of Dermatology, does not believe
Morgellons is a real disease. He argues that the Internet
community is allowing individuals with somatic delusions to
band together (Marris, 2006). Some physicians, however,
believe there is an underlying physical disorder, citing those
with Morgellons symptoms who test positive for Lyme disease
or whose symptoms are alleviated with antibacterial or
antiparasitic medications (Savely, Leitao, & Stricker, 2006).
Because of the controversy and the increasing number of
complaints, the Centers for Disease Control and Prevention
(CDC) initiated an investigation of Morgellons, including
psychological testing, environmental analysis, examination of
skin biopsies, and laboratory study of fibers or threads obtained
from people with the condition (CDC, 2011). Researchers
concluded that no medical condition or infection could explain
the reported symptoms and that the skin lesions were probably
produced by scratching. Fibers found at the site of skin
inflammation were cotton or nylon, not organisms.
Psychological tests revealed that individuals studied were more
likely to be depressed and attentive to physical symptoms than
the general population, but that they were not delusional
(Pearson et al., 2012). Some researchers believe that “the rapid
rise of Morgellons could not have occurred without the internet
. . . which can spread information—without regard for accuracy
or usefulness” (Freudenreich, Kontos, Tranulis, & Cather, 2010,
p. 456).
For Further Consideration
· Are Internet Web sites on diseases such as Morgellons
creating disorders among vulnerable individuals, or do they
provide comfort for those with an actual disease?
· How might a psychologist or a physician determine if an

individual reporting symptoms of Morgellons was suffering
from a somatic delusion?
A DSM-5 diagnosis of brief psychotic disorder requires the
presence of one or more psychotic symptoms, including at least
one symptom involving delusions, hallucinations, or
disorganized speech, that continue for at least 1 day but last less
than 1 month. The symptoms sometimes occur during pregnancy
or within 4 weeks of childbirth (APA, 2013). Because of the
abrupt and distressing nature of the disorder, prevention of self-
harm through hospitalization and use of antipsychotic drugs is
sometimes necessary (Memon, 2013).
A significant stressor often precedes the onset of symptoms,
although in some cases a precipitating event is not apparent.
Eve experienced a number of stressors before her psychotic
episode. She had just lost her best friend to an accident, was
struggling with academic demands, was working two jobs, had
moved into a new apartment, was dealing with the divorce of
her parents, and had just broken up with her boyfriend.
Brief psychotic disorder accounts for up to 9 percent of
individuals who seek help for first-time psychotic symptoms
and is twice as common in women (APA, 2013). In contrast to
schizophrenia and other psychotic disorders, there is often a full
return to normal functioning after the episode. When the
psychotic symptoms persist, a different diagnosis from the
schizophrenia spectrum may be appropriate.11-
5cSchizophreniform Disorder
According to the DSM-5, a diagnosis of schizophreniform
disorder requires the presence of two or more of the following
symptoms: delusions, hallucinations, disorganized speech, gross
motor disturbances, or negative symptoms. At least one of these
symptoms must involve delusions, hallucinations, or
disorganized speech. This condition lasts between 1 and 6
months (APA, 2013).
Schizophreniform disorder occurs equally in men and women
and shares some of the anatomical and neural deficits found in
schizophrenia (Bhalla & Ahmed, 2011). Like schizophrenia, the

onset peaks between the ages of 18–24 in men and 24–35 in
women. Positive prognostic signs for schizophreniform disorder
include an abrupt onset of symptoms, good premorbid
functioning, and the absence of negative symptoms. As with
schizophrenia, there is a significant risk from suicide,
especially when the disorder is accompanied by depression
(Bhalla, 2013). One third of individuals with this diagnosis
recover within 6 months, and the other two thirds eventually
receive a diagnosis of schizophrenia or schizoaffective disorder
(APA, 2013) (see other similarities and differences between
brief psychotic disorder, schizophreniform disorder, and
schizophrenia in Table 11.4).
Table 11.4
Comparison of Brief Psychotic Disorder, Schizophreniform
Disorder, and Schizophrenia
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Duration
Less than 1 month
Less than 6 months
6 months or more
Psychosocial stressor
Likely present
Usually present
May or may not be present
Onset of symptoms
Abrupt onset of psychotic symptoms
Often abrupt psychotic symptoms
Gradual onset of psychotic symptoms
Outcome
Return to premorbid functioning
Possible return to premorbid functioning
Occasional return to premorbid functioning

Risk factors
More common in females
Some increased risk of schizophrenia among family members
Higher prevalence of schizophrenia among family members
Source: APA (2013); Bhalla & Ahmed (2011); Memon
(2013).11-5dSchizoaffective Disorder
Case Study
By her last year of college, Beth Baxter, M.D., an honors
student and class president, knew there was something wrong
with her brain; during the previous 4 years, she had routinely
slept only 4 hours a night. . . . She fought suicidal urges and
had made several half-hearted suicide attempts. In her second
year of medical school, she became convinced that the songs
being played on the radio were carrying messages to her. . . .
She left for an imagined meeting with friends, following
“messages” she heard on the radio. Found wandering a day
later, she was picked up by police on the side of a highway. So
began Dr. Baxter’s first hospitalization when she was diagnosed
as having bipolar disorder. She managed to return and graduate
from medical school, hiring a tutor to talk through all of her
class notes.
After her residency, Dr. Baxter became increasingly depressed
and suicidal; she tried to slash her neck and was hospitalized
for a year. Due to the extent of her psychotic symptoms, her
diagnosis was changed to schizoaffective disorder. She
gradually began to recover, encouraged by a hospital
psychiatrist who gave her hope for a full recovery. The
psychiatrist was correct in her optimism. Dr. Baxter is now a
psychiatrist herself, with a successful private practice. She
understands the importance of taking her medications regularly
to control her symptoms (Solovitch, 2014).
Schizoaffective disorder is diagnosed when someone
demonstrates psychotic symptoms that meet the diagnostic
criteria for schizophrenia combined with symptoms of a major
depressive or manic episode that continue for the majority of
the time the schizophrenic symptoms are present. Additionally,

according to DSM-5, the psychotic features must continue for at
least 2 weeks after symptoms of the manic or depressed episode
have subsided. Thus, schizoaffective disorder has features of
both schizophrenia and a depressive or bipolar disorder
(Brannon, 2013). If a person experiences manic episodes, the
clinician specifies that the client has the bipolar subtype of
schizoaffective disorder rather than the depressive subtype.
Diagnosis is difficult because many people with depressive or
bipolar disorders experience hallucinations or delusions duri ng
a manic or depressive episode. However, individuals with mood
disorders do not have psychotic symptoms in the absence of a
major mood episode (APA, 2013).
Schizoaffective disorder is relatively rare, occurring in only
0.32 percent of the population, and is more prevalent in women
(Brannon & Bienenfeld, 2012). Younger individuals with this
disorder tend to have the bipolar subtype whereas older adults
are more likely to have the depressive subtype. As with
schizophrenia, the age of onset is later for women than men. In
a twin study, schizoaffective disorder and schizophrenia showed
substantial familial overlap (Cardno & Owen, 2014). Similar
biochemical and brain structure abnormalities have been found
in individuals with schizoaffective disorder and schizophrenia
(Radonic et al., 2011). Prognosis with schizoaffective disorder,
including degree of social disability, is better than that seen
with schizophrenia but somewhat worse than prognosis for
bipolar or depressive disorders (Brannon, 2013). Treatment
includes antipsychotic medication combined with mood
stabilizers and individual and group psychotherapies.

Schizophrenia Spectrum Disorders: Symptoms, Causes, and Cultural Considerations

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