MODULE 2

Schizophrenic Disorders

"It's been a hard day; you breathe a sigh of relief as you slip under the covers and relax. You'd gotten out of bed rather early in the morning to take care of some business you had been neglecting. First you called your bank and closed both of your accounts. There's no use taking any chances that a lien might be put on your savings. Then a warm bath, the first of many this day. It's inconvenient to have to scrub all that poison dust from your body but a person as important as you can't take any chances with his health. They'll stop at nothing to do you in, of course. The visitor was proof of that. Imagine, walking right through a locked door and into your head! And what was it he told you to remember? 'You, my friendly friend, must keep your forehead free of fear for fences fill the fourth finger.' that's important. Yes, it certainly was a hard day. Just like the day before, and the day before that, and the day before that. It'll sure be good when this trial is over and the world is safe."

This person is psychotic. The symptoms it illustrates are those of schizophrenia, the most common of the psychoses. This module will deal with the symptoms of schizophrenia as well as with the different varieties of the disorder. As you read the text, try to answer the following questions.

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A psychosis is a major disorder that is usually characterized by obvious mental and emotional disruption. Since the psychotic's perceptions are distorted, his behavior is abnormal. Often psychotics are so unable to deal with the environment that hospital care is necessary.

It has been estimated that about 85 percent of all psychotics are varieties of schizophrenia. Schizophrenia occurs in people of all ages, but it open begins in late adolescence. In fact, the illness was originally known as dementia prae cox which means disorder of the mind that occurs early in life.

SYMPTOMS OF SCHIZOPHRENIA

The symptoms of schizophrenia are varied. Sometimes a schizophrenic will display many or all of them; in other cases, only a few will be present.

The most obvious symptom of schizophrenia is a disorganization of the thought processes. A schizophrenic may use words without regard for their meaning. "We must all take care to flub somewhere in our drain brains," is an example of the disorganized "word salad" typical of a schizophrenic. Less disturbed schizophrenics may have distorted ideas about themselves. They may attribute their problems to totally unrelated factors as, for example, when a slim young woman tells her therapist, after great hesitation, that her inability to relate to other people is due to her eye color.

Schizophrenia is also characterized by contradictory emotional attitudes to ward people and things. This is indicated by such statements as, "It's a real thrill to find myself among all you colorful cruel criminal doctors."

Delusions and hallucinations are frequently found with patients who are diagnosed as psychotic

Delusions and hallucinations may be present in schizophrenia. Delusions are false and unreasonable beliefs that are based on erroneous percepffons in to environment. There are many kinds of delusions. A delusion of grandeur is a belief that one is a very important person or that one possesses special powers A common delusion of grandeur is that of assuming the identity of a famous historical figure such as Napoleon or Julius Caesar. Another kind of delusion is that of persecution in which the individual has fears that he is being plotted against or tortured from within. A person who sees two men chatting on the street and runs from an imagined conspiracy against him is suffering from delusions of persecution. A common delusion of persecution is that one is the target of a worldwide secret organization whose agents are everywhere. ;1

Hallucinations are false perceptions that add something to or subtract some thing from the environment. They may take the form of seeing or hearing something that is not there, or not seeing or hearing something that is there Auditory hallucinations are more common than visual hallucinations. Voices in the head are sometimes reported. The voices are often related to the delusion ary symptoms. A schizophrenic may hear the voices of the secret agents who are out to kill him. Another may hear instructions from God and then act upon] them. Hallucinations are not to be confused with illusions. Illusions are misinterpretations of something real in the environment. A magician's tricks are illu signs. An entire audience can experience the illusions at the same time. An hallucination is a perception of something that does not exist. Hallucinations are limited to individuals, and they are not public.

The affective behavior of schizophrenics is often inappropriate. For example, they may laugh under conditions which would make others cry.

In addition to delusions and hallucinations, the schizophrenic may suffer from emotional or affective symptoms. The term affective refers to the "feeling" aspect of emotion rather than to the behavioral aspect. Inappropriate affectiv responses are feelings for which there is little or no outward cause. A sudden fit of giggling or a violent outburst in the midst of an otherwise peaceful conversation would be indicative of inappropriate affective responses. Emotionality may also be completely lacking. In this case the response pattern is called flat affect. The individual shows little or no emotionality. His face is a blank, without the usual expressiveness that talking and feeling normally produce.

The effect of these delusions, hallucinations, and distorted affective responses is that the schizophrenic is prevented from responding to the world as it really is. Each of these symptoms may, then, be thought of as part of a larger withdrawal pattern. There are two types or patterns of withdrawal that keep a schizophrenic from responding appropriately to the environment. These are autism and regression.

Schizophrenics often withdraw into fantasy life. This withdrawal produces a state called autism, in which communication with others is impaired. The schizophrenic's speech and thought relate to a private, unshared world rather than to the public world common to most of us. In the absence of shared ideas, speech may seem incoherent and distorted.

The pattern of withdrawal called regression involves childish behavior. Habits of personal cleanliness may be forgotten. Speech, too, may become childish, slurred, and illogical. Bedwetting is sometimes a problem. Emotional responses may also reflect childish attitudes.

VARIETIES OF SCHIZOPHRENIA

We will begin by describing undifferentiated schizophrenia.

John is an 1 8-year-old college freshman who lives at home with his parents. John spends most of his time in his room looking at old comic books. He has not been to school for over three weeks. He does not speak to the rest of the family and neglects his appearance. His face usually wears a blank expression. John is a simple schizophrenic.

Undifferentiated schizophrenia is usually characterized by both autistic and regressive withdrawal with gradual deterioration. The undifferentiated schizophrenic often hides himself away, like John, in a fantasy world. He is not often emotionally aroused and usually exhibits the state of emotional inexpressiveness called flat affect. The inability to perform social functions appropriately, called social unresponsiveness, is also a characteristic of undifferentiated schizophrenia. The undifferentiated schizophrenic rarely has hallucinations.

The following is a short case history of a disorganized schizophrenic:
Patricia was always a bright student in elementary and high school. As she approached the last part of her senior year in high school, her performance dropped suddenly. When questioned about this, Patricia would go into a wild giggling fit saying that only girls had to take schoolwork so seriously. She began to stay away from school, hiding alone at home playing with toy automobiles. Finally, she announced that she herself was made of steel and was turning into an automobile.

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The disorganized schizophrenic generally exhibits childlike behavior (hebe = youth, phren= mind). As in undifferentiated schizophrenia, regression is a common symptom. The individual may also have somatic (bodily) delusions. There may be claims that the brain is turning to stone, or that all of the internal organs are rotting away. Inappropriate affect, as in fits of laughter in response to an unhappy event, is also characteristic of disorganized schizophrenia. A fourth symptom of disorganized schizophrenia, emotional lability, is related to inappropriate affect. Emotional lability is characterized by rapid shifts of uncontrolled emotional expression. The patient may have sudden fits of laughter that immediately break off and turn to uncontrollable sobbing only to be followed by a shift to a violent display of rage.

Catatonic schizophrenia is frequently characterized by complete withdrawal

There are of catatonic schizophrenia. In one the individual is stuporous and inactive for long periods. He seems completely oblivious to outside stimuli. He may not even respond when a pin pricks his flesh. Affective responses are flat, showing no emotionality Mr. M always worked very hard to support his wife and two small daughters. Then, he began getting quite upset about the pressures of his lob. Early one morning, his wife awoke to find Mr. M sitting quietly on the edge of the bed. He would not respond to any of her questions and seemed to be unaware of her presence. No amount of prodding could move him or even get him to change his position. After two days of this behavior, Mr. M was hospitalized. Mr. M is a catatonic schizophrenic.

The second form of catatonic schizophrenia is characterized by dangerous hyperactivity and excitement. Violent and sudden outbursts of anger are common in this form. Often, the patient has to be restrained from doing damage to persons or property. There are cases where both forms of catatonic schizophrenia are present in the same patient. He might stand rigid for hours and then suddenly burst into a violent rage.

The fourth category we will study is paranoid schizophrenia. Mr. K was admitted to the hospital in a state of great distress. He told the doctors that his neighborhood gas station was really a Martian space ship sent to Earth to kidnap him. He was valuable to the Martians, he said, because only he knew the secret of Earth's weak defenses. Mr. K knew all of this because when he was at home he heard the gas station attendants whispering to one another about the kidnapping plans. He was very frightened and had to be put under sedation.

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Mr. K shows many of the symptoms of paranoid schizophrenia. He has both delusions of grandeur and persecution along with auditory hallucinations. An. other characteristic of paranoid schizophrenia described in Mr. K's case history, is ideas of reference Ideas of reference are false beliefs that people are referring to the patient. Such references usually involve a plot or a conspiracy against the patient.

The chart below summarizes the four varieties of schizophrenia and their characteristic symptoms.
Variety Symptoms
Simple

disorganized

Catatonic


Paranoid

All varieties

Regression, social unresponsiveness, dulling of affect

Regression, somatic delusions, inappropriate affect, emo- tional lability

a. StuporousÄmaintaining rigid posture for long periods, flat affect
b. HyperactiveÄviolent outbursts of potentially danger- ous activity

Delusions of grandeur and persecution, hallucinations, ideas of reference

Autism
Disorganized speech and thought


MODULE 2
PROGRESS CHECK 1

Now test yourself without looking back.

1. Define psychosis.___________________________________________________________________

2. Match.

1 ) Delusion_______________

2) Hallucination________________
a. A misinterpretation of something real in the environment
b. A false belief about the world
c. A perception that adds to or subtracts from the environment

3. Someone who believes that his family is plotting to kill him by putting broken glass in his room may be suffering from:

a. disorganized schizophrenia.
b. paranoid schizophrenia.
c. undifferentiated schizophrenia
d. catatonic schizophrenia.

4. Match.

1) Ideas of reference______________

2) Somatic delusion_______________

a. Mr. B claims he is a robot and is frightened of water for fear he will rust.
b. Ellen is sure that everyone at the party is watching her.
c. Mrs. Q stands rigidly for hours.

5. Match.
1 ) Regression________________

2) Autism_____________

a. Hallucinations
b. Primitive or childish behavior
c. Violent excitement
d. Withdrawal to fantasy life

6. Regression, autism, dulling of affect and social unresponsiveness are four common symptoms of:

a. disorganized schizophrenia.
b. paranoid schizophrenia
c. undifferentiated schizophrenia.
d. catatonic schizophrenia

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7. disorganized schizophrenia is characterized by

a. unmoving physical position.
b. emotional lability.
c. delusions of persecution.
d. delusions of somatic nature.

8. Carey began to display a dulling of emotion. She preferred to stay away from other people and she
became increasingly childlike. Carey may be suffering from:

a. disorganized schizophrenia.
b. paranoid schizophrenia.
c. undifferentiated schizophrenia.
d. catatonic schizophrenia.

9. Match.

1 ) undifferentiated schizophrenia_______________

2) disorganized schizophrenia_________________

3) Catatonic schizophrenia______________

4) Paranoid schizophrenia_______________

a. Autism
b. Regression
c. Delusions of persecution
d. Hallucinations
e. Disorganized speech and thought
f. Stupor
9. Somatic delusions



8 OR MORE CORRECT PAGE 19
FEWER THAN 8 CORRECT PAGE 13


ANSWER KEY PAGE 49


MODULE 2
EXERCISES



A psychosis is a major disorder that is characterized by obvious
mental and emotional disruption. Which of these describes a
person who is psychotic?

a. Mr. A becomes nervous when he thinks about his
savings account balance. He calls the bank every
day to confirm his figures.

b. Mr. 8 says he is an orange. He crouches in a corner
all day, terrified that someone may see him.
____________________________________________3

The most common psychosis is______________________________________1


Many schizophrenics experience auditory hallucinations, hearing things (generally voices) that nobody else hears (a perception which adds to the environment), or not hearing a particular voice (a perception which subtracts from the environment).

Hallucinations are:

a. actual changes in perception.
b. erroneous opinions without perceptual changes.


A delusion is not a disorder of perception. A delusion is a disorder of thought in which the person believes something that is untrue and unreasonable.

Match.

1 ) Delusion____________

2) Hallucination_______________

a. Mr. W thinks that his wife is slowly poisoning him.

b. Mrs. X believes that she is the Czar's daughter, and demands a pension from the U.S.S.R.

c. Mr. Y hears voices whispering about him everywhere he goes.
d. Mr. Z sees snakes climbing all over the walls and floor.

Which of these illustrates a delusions

a. A man believes that he is God's chosen prophet

b. A man believes that FBI agents are following him and are going to frame him.
_________________________________
One of the most dramatic schizophrenic disturbances is the disorganization of thought processes.

A group of psychotics in a mental hospital were asked to define car. Which showed disordered thought?

a. One patient said, 46A car is a vehicle by which and in the tub for what my mother said bed."
b. Another said, "A car is something you drive."

c. A third said, "A car is a vehicle with a motor."
______________________________________________________8

ANSWERS

1 schizophrenia
2 a, b
3 b
4 a
6 1) a, b
2) c, d

8 a

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Schizophrenics often have contradictory emotional attitudes
toward people and things.

This ambivalence is demonstrated by:

a. Mr. K, who says to his psychiatrist, "I wish to come
to an understanding of the pleasant colorful hateful
hospital which I love with all my heart."

b. Mrs. L, who was heard to say, "l sure love money. In
fact, I hate my lack of it."

A schizophrenic may have flattened or he may have inappropriate affective responses.

Flat affect Äresponses that are dull or without emotion

inappropriate affectemotional responses that occur at unexpected times

Mrs. K giggles when she is told that her only child is dead. She thus
shows______________________________________

affect.

b. Mrs. L cries and screams when she is told that her bed sheets need changing. This is an example of_________________________ affect.

c. Mrs. M sits quietly with a blank face when told that her house has burned down. Her affect may be considered_____________________________________

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The schizophrenic symptoms that are common in most cases seen to cut the patient off from his environment. Delusions and hallucinahons keep him from seeing the world around him as others see it, and distorted thoughts and feelings keep him from responding to his environment in an adaptive way. Two patterns of withdrawal from the environment that may occur in schizophrenia are regression and autism. A patient who regresses may become childlike. Autistic patients, however, withdraw into a private fantasy life. Both kinds of withdrawal may be accompanied by hallucinations.

Match.

1 ) Autism _____

2) Regression_____ a. Mr. C was formerly a college professor. Now he reads comic books and giggles.

b. Mr. D wets his bed at night and cries for the nurse.

c. Mr. E dreams of riches and fame. The dream is so rewarding that he does not bother to work.

____________________________________________1

Some schizophrenics have somatic delusions, that is, delusions concerning their bodies. They may feel that their heart is becoming a mechanical pump, their legs are carrots, or their eyes are fuming into flashlights.
Which of these describes a somatic delusion?
a. Mr. B reports that there is a plot to poison him.
b. Miss C tells her psychiatrist that she is sure she has a rare, fatal disease, but her doctors won't tell her.
c. Mrs. D reports that she hears voices and that they will not leave her alone.

________________________________________________________1

Some schizophrenia is characterized by emotional lability, that is, rapid shifts of uncontrolled emotional expression. Which of these describes a case of emotional lability?
a. Giggling that becomes uncontrolled laughter.
b. A fit of laughter that suddenly changes to uncontrolled sobbing.
c. A fit of laughter that suddenly turns into violent rage.

ANSWERS

1 b
2 a
3 1) C2) a b
4 a, c

5 1) b, c
2) a
6 a. inappropriate
b. inappropriate
c. flat
7 b c

8 c

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Some cases of schizophrenia are characterized by ideas of reference. The person is sure that others are talking about him or plotting against him when they are simply engaged in conversation. Which of these illustrates ideas of reference?
a. Mrs. W. believes that people are shooting darts at her.
b. Mr. X thinks that his thoughts are being tuned in on the intercom.
c. Mr. Y thinks that his brain is turning into wood.
Variety Symptoms
undifferentiated

disorganized

Catatonic


Paranoid

All varieties

Regression, social unresponsiveness, dull- ing of affect

Regression, somatic delusions, inappropriate affect, emotional lability

a. Stupor--maintaining rigid posture for long periods, flat affect
b. Hyperactivity--violent outbursts of po- tentially dangerous activity

Delusions of grandeur and persecution, hal- lucinations, ideas of reference

Autism
Disorganized speech and thought

The chart above shows the basic symptoms of the major types of schizophrenia. Use the chart to identify the type of schizophrenia described in each of the following cases.

Miss Y lives with her aged parents. She spends most of her time in her room gazing at old photo albums. She rarely speaks to other members of the family and neglects her appearance; she frequently doesn't change her clothes for several days at a time. Her facial expression is usually blank.

_____________________________________ 6

Joe was walking down the street when he began screaming and crying. All of a sudden he stopped, picked up a flower, and began giggling.

________________________________________1

A rancher who lives alone sometmes goes to town to buy groceries, but only says enough to indicate what he wants. He usually turns away with no reply when neighbors greet him. He gives the impression of being so preoccupied with his thoughts that he is not aware that other people are around him. Psychiatric examination reveals that he habitually wets the bed. _________________________________________ 7

Mr. K has been standing in a rigid position for days. He has to be tube-fed._____________________________________2

Suddenly he becomes abusive and begins breaking fumiture, dashing aimlessly about. He may continue this until exhausted or until forcibly subdued. Which form of catatonia was manifest in this behavior?

____________________________________________8

May was always an obedient and good girl when she was little. During adolescence she began to have violent temper tantrums over very minor frustrations. She began spending all of her time playing with dolls. One day she said that she was made of porcelain and was really a doll.

_______________________________________4

Mr. L believes that his thoughts are controlled by a secret society. He thinks that this is part of a plot to stop him from doing his work. He often hears voices telling him what to do. When asked why there is a plot against him, he replies: "This is the voice of power speaking through L's mind. All men know when life swells ineffable miasmas of filth and hunger. So far erosion leaks in the light of infinity."

ANSWERS

1 disorganized schizophrenia
2 catatonic schizophrenia
3 b
4 disorganized schizophrenia
5 paranoid schizophrenia
6 undifferentiated schizophrenia
7 undifferentiated schizophrenia
8 hyperactivity


Now try these without looking at the chart.

Ned has always been responsive, interested, and happy. Now he has fits of anger followed by uncontrolled laughter. He reports that his hands are turning to stone.

________________________________________4

Mrs. B is behaving in a childish manner. Bed wetting has become a problem and she has become increasingly unresponsive.

_________________________________ 2

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Mr. B knows that there is a South American plot to take over the government of the United States. He knows that his room is bugged and his phone is being tapped. People whisper about him as he walks by.

_________________________________________________1

Miss A has been sitting in the same position for two days. Her eyes have not changed focus from a blank spot on the wall.

______________________________________________3 2 undifferentiated schizophrenia

NOW TAKE PROGRESS CHECK 2

15

1 paranoid schizophrenia

3 catatonic schizophrenia

4 disorganized schizophreni


MODULE 2
PROGRESS CHECK 2

1. Which of the following describes an individual who may be suffering from paranoid schizophrenia?
a. Mrs. K believes that her stomach is rotting away.
b. Mr. L believes that the communists will send agents to kidnap him and take him to China.
c. Mr. M looks at a Norman Rockwell painting and thinks it is a photograph.
d. Miss J wakes up suddenly in the night and thinks she sees an intruder behind her bedroom door. In reality what she sees is only a dress hanging on a hook.

2. Psychosis is a mental disorder characterized by:
a. mild mental and emotional disruption.
b. extreme emotional disruption, but normal mental function.
c. mild mental disruption.
d. extreme mental and emotional disruption.

3. The most common form of psychosis is__________________________________________

4. A patient sits rigidly in a chair. The doctor lifts the patient's arm above his head and then releases it. The arm remains in the same elevated position for a long time. The patient is probably a:
a. undifferentiated schizophrenic.
b. disorganized schizophrenic.
c. paranoid schizophrenic.
d. catatonic schizophrenic.

5. Martha no longer associates with any of her friends. Instead she escapes into a fantasy world of her own. She has almost no emotional response to events. Martha is suffering from:
a. undifferentiated schizophrenia.
b. disorganized schizophrenia.
c. paranoid schizophrenia.
d. catatonic schizophrenia.

6. Miss J sits by herself, often mumbling and gesticulating. Her speech is incoherent and full of words having meanings for her alone. Voices tell her that she is damned for eternity and that demons are pursuing her.

Miss J is a______________________________________________ schizophrenic.

7. Chuck shows extreme variation in emotion. He is also certain that his tongue is becoming a mass of jelly.

Chuck is probably suffering from ______________________________________________________

ANSWER KEY PAGE 49

6 OR MORE CORRECT PAGE 19
FEWER THAN 6 CORRECT INSTRUCTOR CONFERENCE

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