What are Schizophrenia Spectrum Disorders? - Chapter 8

What is the nature of psychotic symptoms?

The first four of the five characteristics of a diagnosis of schizophrenia spectrum disorders listed in the DSM-5 are known as positive symptoms. These reflect an excess or distortion of normal functions, or extra feelings that are usually not present (e.g., delusions). The fifth characteristic represents negative symptoms, which are a loss or diminishment of normal functions (e.g., lack of emotional expression).

What are delusions?

Thoughts and beliefs that are firmly held, but yet false, are known as delusions. Delusions are usually misinterpretations of experiences or perceptions that become fixed and not likely to be changed, even when the individual is challenged with evidence of their conflicting thoughts. That delusions are often defended with logic makes clinicians suggest that delusions may result from an inability to integrate perceptual input with existing knowledge, when the rational thought processes are still intact.

There are six main types of delusion found in individuals experiencing psychosis:

1. Persecutory delusions (paranoia) are delusions in which the person believes they are being spied upon, persecuted or that they are in danger, usually due to some conspiracy
2. Grandiose delusions make the person believe that they are a person with fame or power or with exceptional abilities
3. Delusions of control are seen when individuals think their thoughts, actions or feelings are being controlled by some external force (e.g., aliens) and that these thoughts are controlled through some device controlling their brain
4. Delusions of reference result in the person believing that external events, normally seen as independent, are referring to them
5. Nihilistic delusions make the person think that either some part of the world or themselves does not exist anymore (e.g., they are dead) or that some major catastrophe will occur
6. Erotomaniac delusions are rare beliefs that a person (often of a higher social status) falls in love with them. This can result in stalking some celebrity.

What are hallucinations?

Sensory abnormalities across multiple modalities (e.g., auditory, olfactory, and visual) are known as hallucinations. Most reported hallucinations are known to be in the auditory modality. These auditory hallucinations usually manifest as voices, and can be experienced as two or more voices conversing, commands to the individual to act in certain ways, or a voice commenting on the individual's thoughts. All these voices are perceived as distinct from a person's own thoughts. Imaging techniques have shown that when an individual reports hearing these voices, there is a neural activation in the brain areas involved in the perception of sounds and speech generation. The second most common form of hallucinations are visual, which vary from simply perceiving colors and shapes that are not present to seeing specific things such as individuals who aren't there. Hallucinations can also occur in other modalities such as tactile and somatic (e.g., burning or tingling skin) or olfactory and gustatory (e.g., unusual tasting food or smells that are not present). Some individuals believe their hallucinations are real, but many also don't.

This led to the suggestion that psychotic episodes are related to a reality-monitoring deficit, meaning that it may be difficult for a sufferer to distinguish whether some belief or percept is real, and whether they created it or if someone else did.

A study where individuals had to remember words generated by themselves or by the experimenter found that individuals diagnosed with schizophrenia differed from controls in three aspects:

1. They found more items belonging to the generated list of words when they were not
2. They were more likely to say that words generated by themselves were actually generated by the experimenter
3. They reported that spoken items were presented as pictures

This suggests that those suffering from schizophrenia have a reality monitoring deficit, which results in a problem between distinguishing what actually occurred and what not, and that they have a self-monitoring deficit, meaning they have trouble distinguishing between thoughts and ideas generated by themselves and ones generated by others.

What is disorganised thinking?

Disorganised thinking is usually noticeable in the individual's speech, with some common features recognizable when a person is experiencing psychotic symptoms. Most common is derailment or loose associations, seen when the individual is jumping quickly from topic to topic during a conversation. Answers to questions may be tangential, where the response is not quite or only slightly relevant to the question. Speech can become very unstructured and even incomprehensible when 'clanging' is exhibited, where the speech is based upon sound instead of concepts (e.g., rhyming or alliteration). More examples of incomprehensible speech are neologisms (made-up words) and word salads (very disorganized sentences where phrases have no link at all). The disorganization of speech in schizophrenia spectrum disorders seems to be due to the individual's difficulty inhibiting associations between thoughts and therefore jump from idea to idea, and that they have difficulty understanding the broader context of a conversation. This leads to a sometimes very detailed speech with many words and ideas and it being grammatically correct, but it will result in little substantive content, known as poverty of content.

What about abnormal motor behaviour?

Unusual behavior present in schizophrenics can be seen in a variety of ways, such as very childlike behavior or behavior inappropriate in a specific context (e.g., masturbating in public). The behavior can be unpredictable, they may show trouble with goal-directed activities (e.g., maintaining hygiene) and the person may seem agitated (e.g., shouting). The appearance of a person can also be strange or inappropriate in specific contexts (e.g., only wearing underwear in the streets). Catatonic motor behaviors are seen in several ways:

• Catatonic stupor: a significant decrease in a person's reactivity to the environment.
• Catatonic rigidity: a rigid and immobile posture.
• Catatonic negativism: resisting any attempts to be moved.
• Catatonic excitement or stereotypy: excessive, purposeless and unnecessary motor activity consisting of stereotyped movements.

What is meant by negative symptoms?

Some negative symptoms found in schizophrenia spectrum disorders are:

• Diminished emotional expression (or affective flattening) consists of a reduction in many characteristics of emotional expression, such as eye contact, voice intonation, facial expressions related to emotions and head and hand movements related to emotions.
• Avolition is the inability to do normal daily goal-oriented activities, which may result in little interest in social activities or work.
• Alogia is the lack of verbal fluency when an individual gives only brief and empty replies to questions.
• Anhedonia is seen when individuals are unable to recall pleasurable events and show a decreased ability to experience any pleasure from normally positive stimuli.
• Asociality refers to the lack of interest in social interactions, possibly due to the withdrawal from social interactions in general.

How are Schizophrenia Spectrum Disorders diagnosed?

The DSM-5 categorizes schizophrenia spectrum disorders along a continuum of less severe to disabling, while taking into account the number, duration, and severity of symptoms. The diagnostic criteria for four of these schizophrenia spectrum disorders are explained below. It is important to note that all symptoms must not be attributable to some sort of substance or medication.

What is Delusional Disorder?

A delusional disorder is characterized by one or more delusions lasting over a month, and it has several subtypes:

• The persecutory type is the most common subtype in which the individual believes they are being cheated on, conspired against, spied on, poisoned, followed, harassed, or obstructed in the attainment of long-term goals.
• Another subtype is the erotomanic type, where the person believes another person of higher status is in love with them or making romantic advances towards them.
• The grandiose subtype is seen in individuals who believe they have some great power, insight or wealth. Grandiose beliefs often contain a religious or spiritual content.

Apart from these delusions, sufferers often behave quite normal and display no bizarre behaviour. The delusions can however be detrimental to any social or work lives, and mood problems are also common in individuals diagnosed with delusional disorder.

What is Brief Psychotic Disorder?

When an individual is suddenly (within a 2-week period) experiencing at least one of the main psychotic symptoms, one can speak of a brief psychotic disorder. These main psychotic symptoms are delusions, disorganized speech, hallucinations or abnormal psychomotor behaviour. The sudden change is likely to cause emotional turmoil or overwhelming confusion in the sufferer, and the disturbance lasts one day to a month before one return back to normal behaviour.

What is Schizophrenia?

Schizophrenia is diagnosed when the disturbance influences major life areas (such as work, social or romantic), and no single symptom is characteristic of the disorder. The disturbances last at least 5 months and are caused by at least two of the following: delusions, hallucinations, disorganized speech, highly disorganized or catatonic behaviour, or negative symptoms. Prodromal symptoms are symptoms that precede the active disturbance phase, and residual symptoms are ones that may follow the active disturbance phase, examples of which are negative symptoms or social isolation. Other symptoms seen in schizophrenics may be depressed mood, anxiety or anger, inappropriate affect (laughing at inappropriate moments), disturbed sleep patterns and low interest in eating. Individuals may also show a lack of insight into their condition and be hostile or aggressive. The latter is more common in younger male sufferers and individuals with a history of violence, substance abuse, impulsivity or non-adherence to treatment. Usually, schizophrenics are not aggressive and more likely to be the receiver of violence instead of the one that exerts it.

What is Schizoaffective Disorder?

When one also displays mood problems such as depression or mania alongside schizophrenia symptoms, a diagnosis of schizoaffective disorder is possible. The psychotic symptoms must remain for 2 weeks or more after the mood problems are (temporarily) gone. Schizoaffective disorder can seriously affect occupational functioning and may also restrict social functioning. Difficulties in caring for themselves and an increased risk of suicide is also associated with schizoaffective disorder.

What is the prevalence of Schizophrenia Spectrum Disorders?

The lifetime prevalence rate of schizophrenia seems to be around 0.3 to 0.7%, and it seems to arise most in the age group of 15 to 35 years. It is one of the most disabling medical disorders with a mortality rate of up to 50% higher than normal and sufferers tend to die ten years younger on average. Also, about 10% of sufferers commit suicide. Despite improvements in treatment, about 80% of those diagnosed will suffer lifelong impairment, and about the same amount will have no job.

The prevalence seems to be about the same across the world, only the course of schizophrenia appears to be less severe in developing nations. Some important factors contributing to this may be beliefs about the origins of psychological disorders or the supporting role of family. Rates of diagnosis of schizophrenia are usually higher in some ethnic groups, which may be due to racial disparities in the treatment of mental health. Immigration or a family history of immigration seems to be an important risk factor, especially immigrants from developing countries. This may be due to experienced stress from language difficulties, poor housing, unemployment and low socio-economic status. Schizophrenia occurs as much in males as in females, but females tend to have a later onset and less hospital admissions, possibly resulting from higher levels of social role functioning prior to their illness. Delusional disorder is estimated to have a lifetime prevalence rate of 0.2%, and this is 9% for brief psychotic disorder.

What is the course of psychotic symptoms?

Development of psychotic symptoms is usually through the succession of three stages:

1. The prodromal stage
2. The active stage
3. The residual stage

What is the prodromal stage?

The majority of individuals developing psychotic symptoms show signs of symptoms during their late adolescence or early adulthood. For some the onset is quick, but for most it is a long process where normal functioning deteriorates over a period of around 5 years. This slow process of deterioration is known as the prodromal stage. The prodromal stage consists of a slow withdrawal from one’s normal life and their social interactions, and shallow and inappropriate expression of emotions and a deterioration in work, personal care or academics (research shows that even gray matter loss may occur in areas mediating social cognition).

A psychosis usually develops during late adolescence, which is a basic fact. This specific time period may be best explained with the diathesis-stress model, stating that a disorder develops out of a biological vulnerability with an environmental trigger. A majority of individuals showing symptoms of psychosis experience stressful life-events in the prior three weeks. The transition from adolescence to adulthood is known to be one of the most stressful periods in a person's life, and this may therefore be the reason why so many psychoses develop during this time period. A theory is that psychotic symptoms may appear when a person fails to cope with normal maturation, resulting in social exclusion and other psychotic symptoms.

What is the active stage?

The active stage follows the prodromal stage, and this is when the person shows unambiguous symptoms of a psychosis, which are delusions, hallucinations, disordered communication and speech, or full-blown symptoms characteristic of the disorder.

What is the residual stage?

Usually recovery is a gradual process, but symptoms can continue to show over a long period of time. When one ceases to show any prominent signs of positive symptoms, the individual has reached the residual stage. Negative symptoms may still show during the residual stage, and it has been shown that relapse is common in schizophrenia spectrum disorders. Stressful life events or returning back to a stressful environment from some sort of hospitalization is a big predictor of relapse. Not taking treatments or medication is also traceable as the cause for a relapse. Reasons for not adhering to treatments may vary from lack of insight, history of substance abuse, negative attitudes towards medication or poor therapeutic relationship.

What is the aetiology Psychotic Symptoms?

Psychosis consists of a broad range of varying symptoms, and not a single one is sufficient enough to diagnose a condition like schizophrenia. Therefore, the aetiology also varies, with explanations from different domains including the biological, psychological and sociological domain. Understanding psychosis is often attempted with the diathesis-stress perspective. This means that psychosis is thought to be explained due to partly a biological vulnerability to developing psychosis, and an environmental stressor being the decider whether or not this vulnerability will turn into a psychosis. Environmental stressors can be many things, such as dysfunctional relationships, troubled youth, educational demands and many more. Explaining psychosis is mostly done by looking at the specific features of a psychosis,

What are the biological theories of psychotic symptoms?

Concordance studies have shown that psychotic symptoms have an inherited predisposition. Developing schizophrenia when a family member has a schizophrenia diagnosis, depends on how closely they are related to each other. Because family members not only share some genes but also share environments (which can be a stressful one), one can also develop schizophrenia due to that environment and not due to their genes. Therefore, research on monozygotic and dizygotic twins has been done, which has shown that heritability is about 80% for schizophrenia, making it the most heritable psychiatric disorder.

Of course, there are problems with twin studies, some of them being that MZ twins are always the same sex, that MZ twins might be treated differently than DZ twins because MZ twins look identical, and that MZ twins have shared prenatal influences due to their shared placenta, which is not the case for DZ twins. These problems are tackled by studying the offspring of monozygotic twins, which has shown that the number of children (of MZ twins) developing psychotic symptoms are approximately the same (16.8% with parent diagnosed vs. 17.4% with parent not diagnosed), irrespective of whether their parent is diagnosed with schizophrenia or not.

Another method of looking at the genetic role played in the development of schizophrenia, is to use adoption studies. These focus on the fact that children do share genetic material with their parents but are raised in a different environment. A study found that 16.6% of children adopted from their schizophrenic mother showed symptoms of psychosis, while the control group (consisting of children adopted from non-schizophrenic mothers) showed no symptoms. Studies also showed that the adopted environment also played an important role, where adopted children of mothers diagnosed with schizophrenia were more likely to develop it themselves if their adopted environment had dysfunctional communication patterns, thus more evidence for the diathesis-stress model.

Finding which specific genes are responsible for conditions, characteristics or other qualities are done with molecular genetics. Genetic linkage analysis is one of the main methods and works by looking at an individual's characteristic of which a gene location is known (e.g., eye colour) and comparing it to the inheritance of various psychotic symptoms. So, if some characteristic follows the same pattern within a family as some psychotic symptom, it can be reasonably assumed that the genes controlling both are probably on the same chromosome. Another technique is genome-wide association studies (GWAS) finds rare mutations, which could possibly give rise to psychotic symptoms. Mutations resulting in 'copy number variations' (CNVs), which refers to an abnormal deletion or duplication in one's DNA,

Although these techniques can be extremely useful, it must be remembered that some genes are responsible for really specific functioning which is indeed related to schizophrenia, but which is also often seen in many other disorders (e.g., deficits in executive functioning). Many people suffering from a schizophrenia spectrum disorder don't share the underlying genetic factors, yet still share their symptoms, showing once again the heterogeneity of schizophrenia disorders. Also, some of the studies linking genes to schizophrenia have been did not be replicated.

It is known that communication in the brain is largely done by neurotransmitters, therefore cognition and behavior are very dependent on them working efficiently. Therefore, researchers think that many problems seen in schizophrenia could be caused by a malfunction in the workings of brain neurotransmitters. A very known and prominent biochemical theory of schizophrenia is the dopamine hypothesis, which argues that symptoms of schizophrenia are associated with an excess of activity of the neurotransmitter dopamine. Arguments for this hypothesis are:

• Drugs that alleviate (positive) symptoms of psychosis (e.g., antipsychotics like phenothiazines) act by blocking dopamine receptor sites in the brain, thus reducing dopamine activity.
• Amphetamine psychosis, excessive use of amphetamines leading to symptoms characteristic of psychosis, was found to be caused by amphetamines raising dopamine activity in the brain, thus further proving that excess dopamine can lead to psychosis-related symptoms.
• Brain imaging indicates that excessive levels of dopamine is released from areas such as the basal ganglia in those diagnosed with schizophrenia.
• Higher levels of dopamine and more receptor sites for dopamine (especially in the limbic area) are found in deceased individuals diagnosed with schizophrenia.

Two dopamine pathways in the brain especially important in schizophrenia spectrum disorders appear to have different roles when it comes to the role they play in the generation of symptoms.

First there is the mesolimbic pathway, starting in the ventral tegmental area and projects to the hypothalamus, amygdala, hippocampus, and nuclear accumbens. This pathway is known to have an excess amount of dopamine receptors in those diagnosed with schizophrenia. This excess of dopamine receptors is responsible for the positive symptoms, and thus often alleviated with medication blocking these receptors. The second pathway, the mesocortical pathway, also starts in the ventral tegmental area, but projects to the prefrontal cortex, and it appears that dopamine neurons may actually be underactive in the prefrontal cortex. This may be the cause for the negative symptoms, since the prefrontal cortex is known to play a role in many of the behavior associated with negative symptoms (motivation, planned behavior etc.).

Some things that don't completely fit the dopamine hypothesis, are the fact that antipsychotic drugs usually start working after six weeks, even though they are known to block dopamine receptors just hours after intake. Also, many new effective antipsychotics only have minimal effects on the brain's dopamine levels and focus more on other neurotransmitters. It is also known that other neurotransmitters that play a role in psychosis symptoms are serotonin, glutamate and GABA, which makes sense since these neurotransmitters all interact and influence others (e.g., dopamine release in the mesolimbic pathway is regulated by serotonin).

Individuals with psychotic symptoms appear to have a structurally different brain when compared to healthy controls. These differences are there when psychotic symptoms first start, thus it is not necessarily a result of the symptoms. The differences also continue to develop over the person's lifetime. Some important structural differences are:

• Enlarged ventricles
• Reduced gray matter in the prefrontal cortex
• Functional and structural abnormalities in the temporal cortex and the structures surrounding it, such as reduced volume in the hippocampus, basal ganglia and limbic structures

Enlarged ventricles result in an overall reduction of cortical gray matter. This enlargement of the ventricles seems to continue over time with chronic schizophrenia, and it is also clear when psychotic symptoms first start showing. The reduced gray matter in the prefrontal cortex is associated with the negative symptoms in schizophrenia, as the prefrontal cortex is important in many executive behaviours such as planning, motivation, planned behaviour, problem-solving and memory. Impairments in these fields are seen in sufferers, and sufferers exhibiting the negative symptoms show less metabolic rates in the prefrontal cortex. Recent research shows that deficits in prefrontal functioning may not only be due to less neurons, but due to disrupted connections between the synapses in pathways of other neurotransmitters.

Abnormalities in the temporal cortex, limbic structures, basal ganglia and the cerebellum are all seen in sufferers from schizophrenia and are most associated with the positive symptoms. Reduced volume in the temporal cortex and hippocampus have also been associated with the symptoms seen in sufferers, and hippocampal function and the role it plays in memory and pattern completion are both associated with those functions' disruption in schizophrenia. These structural differences seen in those diagnosed with schizophrenia suggest that different symptoms, positive or negative, may be relatable to different deficits in brain areas.

The cause of these brain abnormalities is not quite clear, but the prenatal period of an individual's life seems to be contributing to abnormalities in the brain. Brain damage occurring after the third trimester is usually self-repaired, yet this does not seem to be the case for schizophrenia sufferers, therefore brain damage must have occurred prior to the third trimester in schizophrenia. Birth complications and infections during pregnancy are also sometimes seen to increase the risk of developing psychotic symptoms.

What are the psychological theories of psychotic symptoms?

Recently the interest in psychological models of schizophrenia has increased, and this is especially true for the cognitive models viewing symptoms as a result of cognitive biases in attention, interpretation and reasoning.

According to Freud, a psychosis is a result of a regression to an earlier ego state resulting in a preoccupation with the self, known as a regression to a state of primary narcissism. It is thought to be caused by cold, distant and un-nurturing parents, and this regression gives rise to loss of contact with reality and attempts to re-establish contact would lead to hallucinations and delusions. Because of the focus on dysfunctional families in the causes of schizophrenia, the concept schizophrenogenic mother was developed. This is a cold, rejecting, dominating and distant mother causing schizophrenia (according to Fromm-Reichmann). Empirical evidence for these psychodynamic explanations is slim, such as the little evidence that mothers of sufferers actually display these characteristics.

Learning theories focuses on explaining some of the bizarre symptoms of schizophrenia, like Krasner focused on operant condition, as he said that because sufferers often find it difficult to focus on normal social interactions, they start focusing on the unusual and irrelevant cues in their surroundings. This is noticed by others, so the behaviour gets attention and so the behavior gets reinforced, and finally the behavior is strengthened. Another behavioral theory arguing that unusual behavior could be learned, is the fact that extinction can occur when an individual diagnosed with schizophrenia experiences a decrease in attention or reward when displaying the behaviour.

Attentional abnormalities are commonly found in schizophrenia, such as under-attention (inability to focus on relevant aspects of the environment) or over-attention (attending to irrelevant aspects too much). The orienting response, a normal attentional process consisting of physiological changes when presented with a novel or prominent stimulus, shows abnormalities in 50% of cases of schizophrenia. These deficits have been shown to be correlated with negative symptoms such as blunted effect and withdrawal. Over-attention in schizophrenia is when a person attends to many cues in their environment and they are unable to filter these out, which leads to sufferers being very distractible, and therefore scoring lower on cognitive tests when distractions are present. They score higher on tests where being easily distracted leads to better performance, like with the negative priming test. The over-attendance to distractions correlates highly with positive symptoms.

Paranoid schizophrenia occurs over 50% of the time with cases of schizophrenia, and this sub-type of schizophrenia which is noted by delusions of persecution is therefore of great interest. These thoughts of persecution may be explained by the fact that sufferers are 20 times more likely to have experienced some threatening or confrontational event, therefore they might be more wary of these events. Cognitive biases may also be responsible for paranoid delusions, and the four types are explained below.

Evidence shows that individuals experiencing paranoia delusions show attentional biases towards cues with emotional meaning or cues that are paranoia relevant. Then again, research shows that sufferers of delusions of persecution are slower to recognize angry faces than controls and fixate less on salient features of the face. This might be a defense mechanism the person has developed, where an avoidance strategy makes the person avoid allocating attention to threatening stimuli.

People with delusional beliefs appear to have a bias towards attributing negative life events they experience to external causes. A study found that when experiencing paranoid delusions, individuals attributed negative events to stable and global reasons, yet they did attribute positive events internally and negative events externally (the latter seems to only count when there is a perceived threat to the self).

A reasoning biases commonly seen in persons with delusional disorders is that of jumping to conclusions. Individuals make a decision about some event based on less evidence than normally, which leads to an early acceptance and belief of paranoid thoughts, resulting in delusional symptoms. The threat-anticipation model of paranoid and persecutory delusions attempts to answer how these reasoning biases are caused. The model argues that there are four factors important in contributing to the formation of persecutory thoughts:

1. Anomalous experiences (e.g., hallucinations) which lack an obvious explanation
2. Depression, anxiety and worry causing a bias towards thinking and interpreting events
3. Reasoning biases causing the individual to find confirming evidence instead of questioning these anomalous experiences
4. Social factors which could add to feelings of threat, fear, anxiety and suspicion

Hearing voices are not necessarily a psychotic symptom, but the interpretation of these auditory hallucinations depends on whether or not the voices are negative or not. Diagnosed individuals perceive voices as more dominating, distressing and uncontrollable when compared to healthy individuals hearing them, and this distress is what characterizes voices as a symptom of psychosis. A theory as to how these voices are interpreted is that they start as an overstimulation of the auditory neural networks, and the failures in detecting signals lead a person to believe the voices are real, meaningful and not generated by themselves. The deficits in working memory and executive functioning common in schizophrenia may also cause the person to be unable to suppress the voices or use logic with top-down reasoning to suppress them, causing more distress.

Inferring the beliefs, intentions and attitudes of others is known as the theory of mind. A deficit in TOM is characteristic in autism, but it appears to possibly also play a role in schizophrenia, as a study found that individuals suffering from persecutory delusions found it harder to inter the mental state of a character in a joke. An inability to infer other people's intentions may lead to suspicious thoughts and fear that others may be hiding their intentions. TOM deficits are seen across schizophrenia spectrum disorders and can be detected at various stages of the development of a disorder, as well as in the prodromal stage.

What are the sociocultural theories of psychotic symptoms?

Higher rates of schizophrenia diagnosis are usually found in the lower socio-economic class, resulting in two sociocultural theories of schizophrenia. The sociogenic hypothesis states that individuals in a lower socio-economic class are more likely to experience more life stressors such as financial problems, unemployment, poor educational levels etc. These stressors can then evoke a psychosis in those people vulnerable for one. However, studies have found that people diagnosed with schizophrenia are just as likely to have parents of high socio-economic status compared to having parents of low socio-economic status, despite the fact that the diagnosed person is more likely to be of low socio-economic status economic status themselves.

An alternative explanation therefore is that individuals' low socio-economic status is a result of their disorder, instead of it being the cause of their disorder. This occurs due to the downward drift sufferers experience when symptoms lead them into unemployment, exclusion from social situations and poverty. Drifting to a lower socio-economic status because one's disorder is known as the social-selection theory, where there are more schizophrenia-diagnosed individuals in the lower socio-economic group because of their disorder. A final social factor in schizophrenia is that sufferers are often treated differently when they are labeled with a disorder, and that they may also see and treat themselves differently because of this label.

Poor communication between parents and children is often also seen as a risk factor, and it is argued that a psychosis could develop when communication is ambiguous and double binds the child. The double-bind hypothesis states that a parent may show a loving display of affection at one moment, and then reject it because it may be seen as a weakness. This leaves the child confused and in a conflicted situation, which could end up in a withdrawal from social interaction. Communication deviance (CD) is a construct describing forms of communications that are difficult to follow and often leaving a person puzzled. It includes abandoned or ceased sentences, inconsistent references to situations, using phrases wrongly and the use of strange logic. CD has shown to be a predictor of developing psychotic symptoms in children, independent of biological predispositions. The construct expressed emotion (EE) is also strongly linked to the development and relapse of psychotic symptoms. EE consists of a family environment which is hostile and critical and where family members are intolerant of the patient's problems. Family members who display these kinds of behaviors are also often seen to have the attributional style where they blame the sufferer for their own problems.

How can psychosis be treated?

With the right tools, many people suffering from psychotic symptoms can cope with their daily struggles and live close to a normal life. However, many sufferers are unable to achieve this, and continue to have problems for very long. Relapse is very likely, as it has been found that around 81% of people who recovered from their first episode will relapse within five years. Relapse is very dependent on whether or not the sufferer adheres to treatment. Discontinuing medication increases the risk for a relapse by close to five times, and dependence on illegal drugs is also a big risk factor for potential relapse.

What are biologically based treatments of psychotic symptoms?

Electroconvulsive therapy, which consists of passing an electric current through the head for a very short duration, used to be a common form of treatment and is only used today when other treatments don't work and if the psychotic symptoms are comorbid with depression. A prefrontal lobotomy involves separating the pathways between the lower brain areas and the frontal lobes. It was used to make disruptive and violent patients calmer and easier to treat. Because of its high fatality rate (up to 6%) and the fact that it affected the patient's intellectual and emotional responsiveness a lot, it became questioned in the 1950s and later discontinued.

Neuroleptics or antipsychotics are one of the most effective forms of treatment, and especially for treating positive symptoms. There are two types of antipsychotics, first and second generation, referring to when they were developed.

First-generation antipsychotic drugs were originally antihistamine, but it was noticed that they also calmed people. The use of them on patients with severe psychological disorders showed that the psychotic symptoms dropped in these patients, so shortly after they were widely adopted in treating schizophrenia, alleviating positive symptoms. The first problem with these antipsychotics is that they don't cure the problem but merely treat it, so lifelong medication is necessary. The second problem is that these antipsychotics also have unwanted side effects. One is tardive dyskinesia, a motor movement disorder developed by 20 to 25% of people taking the medication, and it is characterized by symptoms of Parkinson's disease like limb tremors or involuntary tics, which is explained by the lowering of dopamine activity.

Second-generation antipsychotic drugs (or atypical drugs) were developed more recently, and were thought to have the following benefits over the first-generation antipsychotics:

• They target more specific dopamine and serotonin receptors, so the effect is more precise
• Lower risk of relapse compared to the first-generation antipsychotics
• Fewer serious side effects like motor problems
• Takers of these newer medications are more likely to continue treatment
• The newer, atypical antipsychotics also help reducing negative symptoms

Recent research has cast a doubt on these assumptions, as second-generation drugs tend to have some of their own side effects (e.g., affected immune functioning) and the side effects resembling Parkinson's are sometimes also seen in atypical drugs. Studies have also found no significant differences in effectiveness when they compared the first to the second-generation drugs, and the second generation produced just as many unwanted side-effects as the first generation.

What are psychologically based therapies of psychotic symptoms?

Psychotic symptoms can result in inappropriate behaviors towards friends and family, which can make daily life even harder for sufferers. Social skills training focuses on teaching the appropriate skills one needs in basic social interactions, therefore hopefully reducing the risk of social withdrawal. The training consists of role-playing, modeling and teaching one how to respond in specific social situations. Teaching these skills and other skills such as physical gestures, eye contact, facial expressions etc. have been shown to positively affect many things, such as overall communication skills, coping strategies, finding work, reaching out for help when they need it, finding accommodation and a general decrease in psychopathology. Supported employment is a program which helps individuals find work fit for their abilities and goals,

Cognitive therapies were thought of as inappropriate for treating psychosis, because of the lack of insight patients have and the thought that psychosis was largely due to biological and not psychological causes. This is not true today, and it is thought that cognitive behavioral therapy is effective in challenging many psychotic symptoms, so cognitive behavior therapy for psychosis (CBTp) was developed. The negative bias that many patients hold towards their hallucinations (e.g., they are dangerous and negative), can make the person indulge in safety behaviors such as shouting at the voices or drinking alcohol. CBTp can help challenge these negative biases, help identify a non-psychotic meaning for their symptoms and reduce negative symptoms one experiences by challenging their low expectations they hold about themselves. CBTp also helps with the adjustment when an individual returns to the 'normal' world after hospitalization and help maintain the use of medications. CBTp can be extended to also include helping paranoid delusional individuals challenge their attributions concerning their delusions, which is done in reattribution therapy. Individuals' paranoid beliefs are challenged by the therapist simply by asking them if their belief logically makes sense, which is often sufficient. If necessary, a 'reality test' can also be conducted, where the therapist actually tests the belief that the patient may hold.

After being discharged from some kind of hospitalization, one can receive personal therapy. Personal therapy is focused on teaching the skills needed with daily life after discharge. These skills include how to identify and deal with signs of relapse, acquiring relaxation techniques, identifying inappropriate behavioral and emotional responses and learning better ones, identifying inappropriate thinking biases and cognitions and how to deal with them, and learning to deal with criticism and negative feedback from others and themselves.

Because symptoms of schizophrenia affect cognitive deficits such as attention, memory and executive functioning, cognitive remediation training (CRT) or cognitive enhancement therapy (CET) are used to improve these cognitive skills, which may speed up progress in other treatments and improvement in social skills.

What are family interventions?

As mentioned before, families can play a big role in how an individual handles psychotic symptom. Expressed emotion (EE) and communication deviance (CD) can play a big role in whether or not a patient gets their life back on track. Family psychoeducation focuses on teaching the family of a sufferer the nature of- and how to deal with- schizophrenia or other psychotic symptoms. A method used to help the family learn about everything related to psychotic symptoms (e.g., recognizing relapse or helping with medication) is supportive family management, which consists of counseling sessions with families sharing their experiences and thus also building social support. Applied family management is a more intensive version of supportive family management, where families are actively taught how to help the afflicted family member.

What is community care?

Before the US' Community Mental Health Act of 1963, many mental health sufferers were detained in hospitals. After the act passed, many countries followed, and now mental health sufferers usually have the right to receive many services that help with their affliction. Some of these cares are outpatient therapy, preventative care, aftercare and emergency care. Assertive community treatment is a service developed out of this change in the care of the mentally ill. Assertive community treatment assists people with medication regimens, guidance with decisions, help with vocational training and offering psychotherapy. Assertive outreach is a form of care for individuals who have not yet experienced any effect with other mental health services. Assertive outreach is focused on helping individuals with severe mental problems, and some of the main goals are to increase social life, prevent relapse, find accommodation and help with medication adherence. Staff of assertive outreach meets the individual regularly over a long period and therefore hopefully builds a solid bound with the individual. Community care helps in many domains, but it is often hard to resource and coordinate.

Studies have found that sufferers from schizophrenia are much more likely to be victim of murder for many reasons, some of which are that they are more likely to live in a more dangerous part of town or they might provoke hostility because of their symptoms. Sufferers from mental illnesses are also more often seen as dangerous and violent in media. Some studies support this, and some studies contradict it, and it is still not safe to say which is true, since many variables have to be accounted for. However, one study did indicate that 99.97% of all sufferers from schizophrenia won't exhibit any serious form of violence in any given year. Substance abuse does seem to occur much more in those suffering from schizophrenia, so it is a challenge for community care to tackle this problem.