Cognition symptoms of Schizophrenia
Cognitive impairment is the hallmark of schizophrenia. Such impairment is manifest in a number of ways. Three particularly significant groups of cognitive symptoms are impaired reality testing, thought disorder, and delusions.
Impaired Reality Testing
The schizophrenic's sense of reality is affected in a number of ways such that beliefs about the world and personal experience are often not accurate. False beliefs about self and others are common. Judgment and insight are often affected. For example, the schizophrenic often has poor insight about the scope, nature, and consequences of the condition. (Impaired reality testing is not limited to cognition. For example, schizophrenic perception may include hallucinations.)
- Thought Disorder refers to impairment in goal-directed thought, such as problem solving, speech, and reasoning. Examples include:
- Concrete thinking: This refers to reduced ability to perceive and use abstract qualities. It is most readily perceived in speech and logic. In response to the proverb, "A rolling stone gathers no moss," a concrete response might be, "It moves too fast for moss to grow." (Note that those of low intelligence tend to also be concrete, but in schizophrenia this concrete thinking can be greatly exaggerated for the level of intelligence.)
- Poverty of thought: Some schizophrenics appear almost empty of thoughts. This is reflected in speech that is slow and minimal, as if the patient can think of nothing else on the subject at hand.
- Confusion: Even simple ideas and flow of logic can be difficult for some patients. Abstract ideas are particularly confusing, largely because they do not perceive the abstract nature of ideas and words.
- Inattention/Distraction: Many patients have trouble focusing and sustaining their attention. They are readily distracted by irrelevant stimuli.
- Magical thinking: This impairment in reality testing is a failure to maintain a valid sense of "cause and effect": "If I bend my finger, the world will fall." "A force field protects me." "The way things are arranged in a shop window has a special message for me."
- Loose associations: This refers to the way words and thoughts are connected to each other. Whereas in normal thought there is a continuity of intended meaning, associational impairment in schizophrenia shows continuity that depends on a narrow focus, usually on individual words or sounds, without regard to the initial intended meaning of the thought. Thus, word associations, reflecting these decontextualized thought associations, are called "loose" because they do not follow logical content: "Flowers have pistils. They are the flower's only form of protection." Whereas some loose associations are idiosyncratic, Chapman and Chapman demonstrated that most are "excessive yielding to normal response biases." This means that the schizophrenic gives in and focuses excessively on the most obvious meaning of words, even when that meaning is wrong for the context.
- Disordered speech: Speech, depending heavily on abstraction and logic, is often greatly disrupted in schizophrenia. In mild forms this might simply result in minor misuse of words, an odd quality to the choice of words, or fabricated words. More severe problems can include confabulation (keying in on a word or phrase and "filling in" related ideas), neologisms, clang associations, ad-hoc combination of words or ideas that do not plausibly go together, and preservation of content or sounds. In the extreme, speech might present as "word salad," in which sentences might retain some syntax (e.g., nouns for subjects, followed by verbs), but the words are strung together without meaning.
- Idiosyncrasy: This refers to speech or thoughts that seem random, clearly not related to other current conversation or thought content. Such thoughts are sometimes referred to as "autistic" (without regard for reality).
False beliefs that are irrational and resist refutation. They probably arise from thought disorder. Delusions can range from plausible ideas that simply aren't true ("I am the father of Madonna's child") to patently absurd delusions (called bizarre in DSM and meaning implausible given our understanding of the world, such as "Aliens possess my body")
Types of delusions
Delusion of Persecution:
- Delusion of Reference: Unusual significance is attached to events/objects
- Delusion of Grandeur: The belief places extreme important on the individual, with goals, achievements, and worth far in excess of reality
One holds extreme beliefs that others are persecuting or controlling the person in some way (often for grandiose reasons).
Schizophrenic impairment of emotion
- - Inappropriate affect (e.g., laughing in response to a sad event)
- - Anhedonia—greatly reduced ability to experience pleasure
- - Flat affect—reduced emotional response of any kind
Behavior issues in Schizophrenia
- - Many behavioral impairments that probably reflect a neurological basis
- - Odd gait, incoordination, tremors, writhing
- - Difficulty initiating or terminating actions
- - Odd, eccentric mannerisms (bizarre grimacing; repetitive, purposeless movement, etc.)
- - Catatonic behavior—odd posturing or movement over which the schizophrenic appears to have no control
The content of auditory hallucinations is often what is termed Id based, meaning that it readily reflects id-like impulses of a sexual or aggressive nature, and the voices are often critical or demanding of the patient.
Motivation impairment of Schizophrenics
Motivational impairment is primarily experienced as apathy, lack of energy, and inability to focus efforts. It seems to underlie poor self-care (hygiene, grooming, cooking, cleaning) and lack of effort in school and work. Although not as dramatic as impairment in other domains, it is probably central to the need of most affected persons to have assistance in daily living activities.
Kraeplin first came up with term. We now refer to it as schizophrenia.
Prognosis of Schizophrenia
- For many, the course is chronic and/or deteriorating. Many others improve but retain significant symptoms. Thus, prognosis is generally regarded as poor. Here are three particular points about prognosis:
- - The paranoid subtype has better prognosis.
- - Generally, florid, positive symptoms are associated with at least periodic improvement, whereas negative symptoms are associated with lack of
- improvement over time.
- - A simple way to think about prognosis is the rule of thirds: about one third never get better, about one third improve but have continued problems, and about one third get better (although many retain residual symptoms).
Process vs. Reactive (focus on onset): "Process" refers to gradual but unrelenting, whereas "reactive" refers to more sudden and more likely as a response to negative outside events.
Good Premorbid vs. Poor Premorbid (focus on prior adjustment): "Good premorbid" reflects good adjustment and developmental progress prior to the onset of illness; "poor premorbid" is the opposite.
Chronic vs. Acute (focus on course): Those with "chronic" forms tend to have long-term presence of symptoms, without much change; "acute" persons tend to have bursts of severity, with significant improvement in between.
Paranoid vs. Nonparanoid (focus on manifestation): Although "paranoid" implies the presence of paranoia, this subtype typically includes those with florid symptoms, especially active and elaborate delusions (which are often paranoid, grandiose, or unusually detailed).
Positive versus negative symptoms
The most popular current approach to subtyping focuses on symptoms, placing them into two groups, positive and negative. Positive symptoms are those that are "added on" to normal functioning, such as hallucinations, delusions, thought disorder, and agitation. Negative symptoms reflect abilities that are "subtracted from" normal functioning, such as apathy, confusion, anhedonia, flat affect, poverty of speech, and attentional impairment.
Emphasizes differentiating on the major presenting symptoms:
- Paranoid: Positive symptoms (especially delusion) without negative
- Disorganized: Disorganized speech and behavior with affect disturbance
- Catatonic: Catatonia, extreme negativism or mutism, echolalia
- Undifferentiated: Not meeting criteria of other subtypes
- Residual: No gross symptoms but not well
Biological models of Schizophrenia
Has a lot to do with genetics, but not 100%.
- Birth trauma: A disproportionate number of patients had birth difficulties.
- Viral hypothesis: One model is that a subtle virus, probably affecting the fetus in utero, leads to schizophrenia, perhaps through abnormal brain development. There does appear to be some correlation of incidence with flu epidemics during gestation.
- Season of birth: There is a modest, but well documented, difference such that a disproportionate number of schizophrenics were born in late winter to early spring. This may support the viral hypothesis, in that such fetuses could be at a critical stage of neural development during flu season.
- Abnormal structural development in embryonic brains: Very recent studies of children of schizophrenics have shown abnormal neural-cell development very early in the embryo stage, before the neural tissue forms into a brain and spinal cord. This needs further research.
- Dopamine hypothesis: This hypothesis is that schizophrenia arises from problems at dopamine-receptor sites within the brain. The drugs most effective in alleviating schizophrenic symptoms do indeed block dopamine receptor sites. However, there are some problems with the hypothesis.
Meehl's Diathesis-Stressor Model of Schizophrenia
In the 1950s, Paul Meehl was the leading figure pushing for acceptance of the genetic evidence as a necessary condition for development of schizophrenia. He proposed a model of schizophrenic development that fits much of what we now know about genetic disorders, and helps account for the known rates of concordance in family studies. It has been regarded as the first of the true diathesis-stressor models of psychopathology. He proposed three stages:
- 1. The required genetic defect results in a neural defect, which he called schizotaxia.
- 2. Those with the neural defect learn in atypical ways, creating a personality/thinking pattern called schizotypy. Thus, all schizotaxic individuals became schizotypic. This personality was characterized by a number of traits, four of which Meehl considered "core traits" (meaning all schizotypic individuals would have them):
- - Cognitive slippage
- - Anhedonia
- - Interpersonal aversiveness
- - Ambivalence
- 3. Stressors, if strong enough, lead to the decompensation, which he called schizophrenia. Thus, not all schizotypic individuals develop schizophrenia, although all of them have atypical personality.
A particular pattern of bad mothering causes schizophrenia (not true).
Deficiency in the amount or content of speech, a disturbance often seen in people with schizophrenia.
Disorder of movement involving immobility or excited agitation.
Also known as loose associations. Deficits in logical continuity of speech with abrupt movement between ideas.
Type of schizophrenia featuring disrupted speech and behavior, disjointed delusions and hallucinations and flat or silly affect.
Expressed emotion (EE)
The hostility, criticism and overinvolvement demonstrated by some families toward a family member with a psychological disorder. Can often cause the person to relapse.
Serious side effects of neuroleptic medications resemblim the motor difficulties of Parkinsons.
Apparently emotionless demeanor (including toneless speech and vacant gaze) when a reaction would be expected
Naturally occurring cavities in the brain filled with CSF. Some schizophrenics have enlarged ventricles.
Major antipsychotic medications, dopamine antagonists, that dimish delusions, hallucinations, and aggressive behavior in psychotic patients but that may cause serious side effects.
Group of severe psychological disorders. Schizophrenia is a psychosis disorder.
Psychotic disorder featuring symptoms of both schizophrenia and major mood disorder.
Psychotic disorder involving the symptoms of schizophrenia but lasting less than 6 months.
Smooth pursuit eye movement
- Also called eye-tracking; the ability to follow moving targets visually. Deficits in the skill can be caused by a single gene whose location is known. This problem is associated with schizophrenia and, thus, may serve as a genetic marker for this disorder.
Sometimes irreversible side effect of long term neuroleptic medication involving involuntary motor movements especially in the face and tongue.
Category for individuals who meet the criteria for schizophrenia but not for any one of the defined subtypes.