In this video I describe the positive symptoms of schizophrenia, including delusions, hallucinations, disorganized speech, and abnormal motor behavior, as well as negative symptoms of reduced emotional expression, anhedonia, alogia, avolition, and asociality. I also discuss diagnostic criteria, cognitive factors, neurological correlates, and the role of gender and culture in prevalence. Please note that the symptoms described in this video are not comprehensive and there are other symptoms involved in diagnosis for each of these disorders.
Video Transcript
Hi, I’m Michael Corayer and this is Psych Exam Review. In this video, we’re going to look at the category schizophrenia spectrum and other psychotic disorders in the DSM-5, with the main focus on schizophrenia. So this term schizophrenia comes from the Greek schizo for split and phren or phrenos for mind. And this is a term that was coined by the Swiss psychiatrist, Paul Eugen Bleuler. And unfortunately, it might be related to some misconceptions about what schizophrenia is. Because when people think of this splitting of the mind, they might have a tendency to think of dissociative identity disorder, formerly known as multiple personality disorder. But in the case of schizophrenia, the splitting is not referring to personalities or identities, but a splitting and a disintegration of mental functions, a separation from reality.
And so the main symptoms that we see in schizophrenia are delusions, hallucinations, disorganized speech, and abnormal motor behavior. So delusions refers to false beliefs about the world, beliefs that have little to no evidence supporting them. So they might come in the form of delusions of persecution, where the patient believes that a government agency is reading their thoughts or controlling their mind, or it could be delusions of grandeur, where they believe that they’re incredibly famous or successful or wealthy, or they have supernatural powers.
And then we have hallucinations. This refers to false perceptions. And so this could be hearing voices, or it could be seeing things that aren’t actually there.
Then we have disorganized thought and speech. And what we see is in patients with schizophrenia, it’s very difficult to follow their thinking. So they might be trying to describe something and their speech is often described as being incoherent or as being “word salad” which is a jumble of words and ideas all mixed together, and it’s incomprehensible.
And then lastly, we have abnormal motor behaviors and these often come with what’s called catatonia. And there’s a separate listing in the DSM-5 with different types of catatonia that can be seen, and I’ll talk about that in a little more detail later in this video. But generally, we see abnormal motor behaviors, often in the form of reductions in motor behavior.
Okay, we also have negative symptoms in schizophrenia. So you might recall that negative symptoms refer to behaviors that you normally see in healthy individuals, but that are missing or lacking in patients suffering from a particular disorder. And so in the case of schizophrenia, the negative symptoms that are common are blunted emotional expression, so patient no longer shows the same emotional reactivity to situations or stimuli, or they may show inappropriate reactions; they might laugh at things that aren’t humorous. We also see anhedonia. This is common in a number of mental illnesses and this refers to a lack of pleasure. And so things that the patient used to enjoy, things that used to bring them pleasure no longer do. And then we see alogia, which refers to diminished speech. So in extreme cases, this can be mutism where they don’t speak at all or it could just be reductions in their usual amount of speech. And then we see avolition, and this refers to a reduced sense of will, a reduced sense of initiating behavior. So it’s a decrease in self-initiated, purposeful activities. So the patient might do things if instructed or encouraged to do so, but on their own, they may not initiate any of these behaviors. And then lastly we see asociality, and this refers to a decrease in social activities.
So now we’ll look at the diagnostic criteria for schizophrenia. And what we see is first the patient needs to show at least 2 of the positive symptoms that I described. So go back to that list here you can see, they must have at least two of these; delusions, hallucinations, disorganized speech, and abnormal motor behavior. And one of those 2 must be from the first 3. So they have to have delusions, hallucinations, or disorganized speech in order to get the diagnosis of schizophrenia. And these symptoms must occur somewhat frequently over the course of a 1 month period. And this is to help differentiate schizophrenia from other disorders in this category. So we have something called brief psychotic disorder, which is also in this category where the symptoms only lasting for a day or a few days, rather than over an extended period of time, like over the course of a month. And there must be some evidence for a schizophrenia diagnosis of some abnormal behaviors or some of these symptoms occurring over the course of 6 months. So looking at a longer time period here for this diagnosis.
And it’s important to note that when it comes to recognizing these symptoms in patients that the patients themselves often will lack awareness or they lack insight into their condition. So you can imagine, if you are experiencing delusions, you don’t know that they’re delusions. You actually believe them, right? Or if you’re having hallucinations, you might not be aware that some of your experiences are hallucinatory. So you might need somebody else to help put that out to you. So you wouldn’t go to a psychiatrist and say, “Well, you know, I have all these false beliefs about the world” because you actually believe them. So for you they’re not necessarily going to be false beliefs. You might not recognize that maybe the CIA is not actually tracking your thoughts or reading your mind or something. You might actually believe that and so you might need some help in recognizing that you’re experiencing some of these symptoms.
Okay, next we’ll look at some cognitive aspects associated with schizophrenia. And generally, we see deficits in a few areas. We see deficits in executive function, we see deficits in memory, and also deficits in attention. And we see what I mentioned before, this idea of losing contact with reality. This is referred to as psychosis.
And I’d like to describe one type of catatonia here, and this is not the only type. As I said, there’s other listings in the DSM, including things like mutism, that would fall under catatonia, abnormal motor behavior. And one thing we see is locking the body into unusual postures. This is one common type of catatonia that we see in patients with schizophrenia. And then within this, they might hold sort of strange body postures, and then within this there’s different ways this can occur. So in some cases, they become very rigid, and they’ll resist moving. So if a nurse or other staff member attempts to move the patient, they’ll resist that movement in this catatonic state. Or they may show what’s called waxy flexibility. And this refers to the case where they allow themselves to be moved, but they won’t self initiate. They won’t move on their own accord. If you ask them, why don’t you move your hand this way? That looks very uncomfortable. And they won’t do so. But if you were to move it for them, they would show this waxy flexibility where they allow themselves to be repositioned.
We are see some brain differences in patients with schizophrenia compared to healthy individuals. We see a number of these in different types of brain scans. We can see differences in cellular architecture, so in the connectivity of the white matter and particularly the frontal and temporal lobes, we see differences here. We see changes in the ventricles, where the ventricles are these fluid-filled chambers in the center of the brain. And they show enlargement in patients with schizophrenia, although not all patients show this enlargement. And we also see reductions in gray matter volume. And so this is a sort of shrinking of the gray matter on the cortex.
And it’s important to note that all these differences are not diagnostic. So these are not used to confirm diagnosis of schizophrenia. And there can be patients with schizophrenia who don’t show some of these symptoms. We don’t necessarily, or I shouldn’t use the word symptoms. They don’t show these differences, right? So there could be patients suffering from symptoms of schizophrenia that would warrant a diagnosis, and they may not show enlarged ventricles, or they may not yet show certain differences in their brain architecture. And so we aren’t totally sure, what exactly is the cause, whether these differences in the brain are the cause of certain symptoms, or if they’re a consequence of suffering from the disorder, or, in some cases, they may also be related to the fact people getting treatment, perhaps other treatment, is causing changes in the brain.
Ok, so the prevalence for schizophrenia is estimated about .3 to .7% in the DSM-5. And this is quite low, it’s a fairly rare disorder. And we see variation in the sex ratio. In some cases, suggesting that males are more likely to be diagnosed with schizophrenia than females. But part of this relates to the interpretation of symptoms, and males are more likely to show the negative symptoms of schizophrenia rather than the positive symptoms. And so what this means is you might think about different expression of the same disorder. We might wonder whether there are differences between males and females in the expression, or if there’s underlying differences in the disorder, whether there’s variations of different types of schizophrenia, and a particular variation is more or less common in males or females. We can also think about how relates to expectations or how to express certain types of behavior.
And this brings us to the role of culture, in thinking about the expression of symptoms, something we talked about in previous videos. But we might wonder about certain religious practices and how those might play a role in how we determine whether something is a symptom of mental illness or not. So we have, of course, many religious stories involving hearing the voice, or the voices of God, or gods. And we might think about how people would interpret that as being part of a religious context or as part of an indication of a mental illness. Or we can also talk about this for delusions of supernatural powers, or even delusions about persecution. So for instance, sort of a stereotyped symptom of schizophrenia that might see movies is a delusion of persecution by the government, right? That the CIA is tracking my thoughts or the FBI is monitoring me. And of course, that’s culturally specific. We wouldn’t see that same version of persecution or beliefs about persecution in other cultures where they wouldn’t have those types of government agencies that potentially have the ability to be doing those things. But maybe we would see other types of persecution related more to spirits or gods or some other culturally informed view of how the world works.
Next we have idea that schizophrenia is comorbid with substance use disorders. So we might wonder whether this is a cause or consequence. So if we see this overlap, we might wonder, perhaps substance abuse is related to causing some of these symptoms that the person is suffering from, or it could be the case that suffering from schizophrenia is causing to be more likely to seek out certain substances. And one way we might see this is in the fact that about 50% of patients who suffer from schizophrenia use tobacco. And we might wonder if this is a type of self medication, whether there’s something about tobacco use and its influence on neurotransmitter levels like acetylcholine and dopamine, and whether this has something to do with reducing or minimizing some of the symptoms that the patient is suffering from.
And it’s also been suggested that schizophrenia might be viewed as a neurodevelopmental disorder. The idea here is that there’s changes or there’s influence during development of the brain, but the symptoms don’t express themselves until later. So the onset of schizophrenia typically occurs in late teens to about age 30 with the most common age of onset being in early 20s. This is true for both males and females although females are more likely to show onset a bit later. But we might wonder whether this has to do with something that’s occurred earlier in development, and it doesn’t express itself until a bit later in life.
And we also have an important point here to note, which is that there’s a common conception that people suffering from schizophrenia are likely to be violent or aggressive. And this is generally not the case. They’re rarely violent or aggressive, and they’re more likely to be the victims of abuse, or victims of violence, rather than the perpetrators. And when it comes to inflicting harm, they’re more likely to inflict harm on themselves, rather than other people. So this is related to the idea that schizophrenia comes with an elevated risk of suicide. And so approximately 20% of patients diagnosed with schizophrenia will attempt suicide at least once. This is often related to some hallucinations, and about 5 to 6% of those patients will successfully complete their suicide. Okay, so I hope you found this helpful. If so, please like the video and subscribe to the channel for more. Thanks for watching.
