11. Psychotic disorders Flashcards
psychosis
symptoms in which there is misinterpretation and misapprehension of the nature of reality
disturbances of perception (hallucination)
disturbances of belief and interpretation of the environment (delusions)
disorganised speech patterns (thought disorder)
delusions
beliefs that are held with great conviction even in the face of overwhelming evidence to the contrary and are not shared by members of the patient’s own culture or subcultures
hallucinations
false perceptions
content of delusions
persecutory
referential
grandiose
erotomanic
nihilistic
somatic
discussion of delusions
bizarre?
mood congruent?
how pervasiive is the delusion?
how firmly entrenched is the delusion?
hallucinations
most common are auditory (voices arguing, commenting, running commentary, audible thoughts, thought echo)
visual (formed, unformed)
pseudohallucinations- sometimes used to indicate presence of insight
psychotic disorders
schizotypal PD
delusional disorder
brief psychotic disorder
schizophreniform disorder
schizophrenia
schizoaffective disorder
substance/medication induced psychotic disorder
psychotic disorder due to another medical condition
variations in catatonia
dual diagnosis
up to half have SUD
frequent premorbid cannabis use increases risk for developing schizophrenia
maintain or cause symptoms, lead to relapse, poor adherence to treatment
distal risk factors for psychosis onset
maternal pregnancy complications
family history of psychotic disorder
candidate genes
developmental delay
ethnic minority
quality of early rearing environment
trauma
vulnerable personality
proximal risk factors for psychosis onset
age
urbanicity
substance use
traumatic head injury
stressful life events
subtle impairments in cognition
poor functioning
cognitive, affective, and social disturbances subjectively experienced by the individual
migration
psychosis aetiology
usually emerges in late adolescence or early adulthood
psychosis typical pathway
impaired social functioning and some neurotic symptoms
exacerbation of symptoms into subthreshold psychotic symptoms
first episode psychosis
interventions- premorbid phase
Clinical stage 0, increased risk of psychosis no current symptoms
indicated prevention of FEP:
improved mental health literacy
family education
drug education
brief cognitive skills training
interventions- possible prodrome
Clinical stage 1a, mild or non specific psychosis symptoms
indicated secondary prevention of FEP:
formal mental health literacy
family psychoeducation
CBT
actively reduce substance use
interventions- possible prodrome
Clinical stage 1b, ultra high risk of psychosis
indicated secondary prevention of FEP:
psychoeducation
CBT
substance use work
omega 3 fatty acids
antidepressant agents or mood stabilisers
common signs among young people of an ‘at risk’ mental state
neurotic symptoms: anxiety, restlessness, anger, irritability
mood related symptoms: depression, anhedonia, guilt, suicidal ideas, mood swings
changes in volition: apathy, loss of drive, boredom, loss of interest, fatigue, reduced energy
cognitive changes: disturbance of attention and concentration, preoccupation, daydreaming, thought blocking, reduced abstraction
physical symptoms: somatic complaints, weight and appetite loss, sleep disturbance
attenuated or subthreshold psychotic symptoms: perceptual abnormalities, suspiciousness, change in self, others or the world
other symptoms: obsessive compulsive phenomena, dissociative phenomena, increased interpersonal sensitivity
behavioural changes: deterioration in role functioning, social withdrawal, impulsivity, odd behaviour, aggressive, disruptive behaviour
assessment- possible prodromal state/risk for first episode
interview and observation of at risk symptoms
Bonn scale for the assessment of basic symptoms
schizophrenia prediction instrument- adult version
comprehensive assessment of at risk mental states (caarms)
schizophrenia proneness instruments (children and adolescents)
benefits of early intervention
potential prevention or delay in transition to psychosis
facilitating engagement in services before too ‘out of touch’
reduction in psychosocial disability, especially vocationally
pre-existing engagement with services may increase treatment adherence in a later psychotic episode
reduction in severity of psychotic episode by early identification
Treatment- acute and early recovery
clinical phase 2, first episode of psychotic disorder
early intervention for FEP
Psychoeducation
CBT
Substance use work
SGA medication
antidepressant agents or mood stabilisers
vocational rehabilitation
Treatment- late/incomplete recovery
clinical phase 3a, incomplete remission from first episode of care
early intervention for FEP
As for stage 2, but with additional emphasis on medical and psychosocial strategies to achieve remission
Treatment- recurrence or relapse of psychotic disorder which stabilises with treatment
clinical phase 3b, late/incomplete recovery
early intervention for FEP
As for stage 3a, but with additional emphasis on relapse prevention and early warning signs strategies
Treatment- multiple relapses with objective worsening in clinical extent and illness impact
clinical phase 3c, late/incomplete recovery
early intervention for FEP
As for stage 3b but with emphasis on long term stabilisation
Treatment- severe, persistent, unremitting illness
clinical phase 4, chronicity
as for stage 3c but with emphasis on clozapine, other tertiary treatments and social participation despite ongoing disability
predictors of better outcomes at stage 2 treatment
earlier intervention
female
older age of onset
better premorbid functioning
lower severity of psychopathology, particularly negative symptoms
subjective sense of hope
absence of substance use
adherence to treatment
social and family contacts
acute stage psychosis treatment
CBT
Supportive therapy or befriending
Group program
Stage 3- critical period, psychosis
period of up to 5 years after onset of psychosis after which the level of functioning attained endures for the long term
intervention during this stage can halt deterioration and incomplete recovery
stage 3 modifiable factors
comorbidity- SUD, depression
psychological adjustment- integration recovery models
Psychosocial milieu including family relationships
severity of psychopathology- awareness of negative symptoms, insight, cognitive function
treatment adherence
rehabilitation
management of side effects including cognitive adjustment
SE parkinsonism
mask like face, muscle rigidity
pill rolling tremor
shuffling gait
retropulsion
diminished arm swinging
SE dystonia
acute: involuntary sustained spasm of muscles, notably head and neck (facial grimacing, protrusion of tongue)
chronic: sustained involuntary spasm of skeletal muscles, resulting in abnormal posture
SE akathisia
subjective feeling of inner restlessness with a drive to move
frequent changes of posture, inability to sit still
constant walking
SE tardive dyskinesia
abnormal involuntary movements of face, tongue and lips, with chewing movements, tongue movement, puckering of lips, grimacing
risk of relapse after first episode
90% achieve full or partial remission within 12 MO treatment commencement
relapse within 5 Y common
each relapse increases risk of persistence in symptoms (particularly negative) as well as negative outcomes associated with episodes
risk factors for relapse
cannabis use
antisocial personality
pre premorbid adjustment
non adherence to medication
cognitive flexibility
stressful life event
expressed emotions
stage 4 treatment
even in presence of ongoing disability, health and good life quality can emerge
targets: psychosocial supports, social isolation, unemployment, supports for carers to foster positive relationships, ongoing relapse prevention strategies
treatment of psychosis general considerations
psychological interventions may need to take into account effects of cognitive deficits
substance use should be a focus
comprehensive risk assessment
dont ignore axis 1 diagnoses
sexual risk and sexual dysfunction
goals for family involvement in treatment
prevent family burnout and avoid abandonment of patients in long term
decrease isolation of families because of the stigma of MI
provide realistic assessment of the illness and prognosis, give hope that good life is possible
teach families how to supervise medication and adherence gently, without power struggles
teach skills on how to avoid and handle crises without being patronising, acknowledge the strengths that families have shown
Help reconnect patients with family members if this is desired
reduce relapse rates by reducing stressful interactions among family members
high EE v low EE relapse rate
clients in high EE families have more than double the relapse rate of those in low EE families
high EE characterised by: frequent criticism, hostility, over-involvement
CBT for psychosis
26 sessions of CBT over 6 MO can sig reduce likelihood of transition to FEP
Four phases:
- engagement and development of the alliance
- education and normalisation of psychotic symptoms
- working with beliefs and thoughts related to understanding of symptoms - building alternative explanations and coping strategies
- relapse prevention and recovery
normalisation, psychoeducation, working with delusions
working with delusions
identifying precipitating and maintaining factors
modifying distressing appraisals of symptoms and generating alternative explanations
- avoid direct confrontation of the delusion
- use of behavioural experiments to gather evidence
- working with underlying schemas
- working with peripheral rather than central delusions to begin
working with hallucinations
collaborative exploration of beliefs regarding origin and nature of the hallucination
monitoring diaries
reattribution of causes
generation of possible coping strategies (acceptance, distraction, etc.)
undermining power of command hallucination , promoting self control and power
engagement strategies: address the client’s concerns, anticipate that the voices may make adverse comments about therapy, engagement is ongoing, use client’s language and worldview, acknowledge feelings associated with symptoms
treatment starting point
start with beliefs about the power of the voice, often less anxiety provoking
if belief in the power of the voice is reduced, this lowers distress and also provides evidence to be used in challenging other aspects of the hallucination
socratic questioning
therapist asks a series of questions to illicit information that may cause the client to doubt his or her beliefs about the voices
aim is to raise doubts
useful questions in challenging beliefs about voices (socratic questioning)
what do they say will happen if you dont comply?
do you always comply?
what do you think would happen if they didn’t comply?
what makes them the boss of you?
have you ever done anything sneaky to challenge them?
how did you come to believe that they could harm you, know everything about you?
how sure/convinced are you that?
What makes you so sure that?
are there times you have had doubts that?
What does _ think?
What doesn’t make sense to you about _?
testing beliefs
experiment that tests the validity of the power of the voice
always have an alternative possibility
tests must be: precise and realistic, incorporate an agreed and foolproof way of knowing when the test is complete and what the outcome was, provide a way to support one of two beliefs
increasing sense of control
voices render hearers helpless because they are seemingly beyond control
to increase control, clients can be taught to activate and stop their voices
activation cues are found in assessment
concurrent vocalisation is used to stop voices
enhancing coping
does the client have a way of coping with the voice and how effective do they find it
are there times when this strategy fails them?
are there ways to enhance or enrich positive coping strategies
working with negative symptoms and thought disorder
dysfunctional negativistic beliefs contribute to the avoidance of constructive activity seen in individuals with schizophrenia
- low expectancies for pleasure
- low expectations for success at social and non social tasks
- low expectations for social acceptance
- defeatist beliefs regarding performance
behavioural methods to break cycles
relapse prevention and recovery
early warning signs
triggers and stressful situations
monitoring
affect regulation
treatment adherence
reducing risk
valued living
social skills training
vocational support
issues in treatment
under resourced and understaffed
emphasis on case management rather than clinical treatment
MDTs but sometimes without specialist training
home based acute seen as more appropriate than hospital
