11. Psychotic disorders

Question 1

psychosis

Answer 1

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)

Question 2

delusions

Answer 2

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

Question 3

hallucinations

Answer 3

false perceptions

Question 4

content of delusions

Answer 4

persecutory
referential
grandiose
erotomanic
nihilistic
somatic

Question 5

discussion of delusions

Answer 5

bizarre?
mood congruent?
how pervasiive is the delusion?
how firmly entrenched is the delusion?

Question 6

hallucinations

Answer 6

most common are auditory (voices arguing, commenting, running commentary, audible thoughts, thought echo)
visual (formed, unformed)
pseudohallucinations- sometimes used to indicate presence of insight

Question 7

psychotic disorders

Answer 7

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

Question 8

dual diagnosis

Answer 8

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

Question 9

distal risk factors for psychosis onset

Answer 9

maternal pregnancy complications
family history of psychotic disorder
candidate genes
developmental delay
ethnic minority
quality of early rearing environment
trauma
vulnerable personality

Question 10

proximal risk factors for psychosis onset

Answer 10

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

Question 11

psychosis aetiology

Answer 11

usually emerges in late adolescence or early adulthood

Question 12

psychosis typical pathway

Answer 12

impaired social functioning and some neurotic symptoms
exacerbation of symptoms into subthreshold psychotic symptoms
first episode psychosis

Question 13

interventions- premorbid phase
Clinical stage 0, increased risk of psychosis no current symptoms

Answer 13

indicated prevention of FEP:
improved mental health literacy
family education
drug education
brief cognitive skills training

Question 14

interventions- possible prodrome
Clinical stage 1a, mild or non specific psychosis symptoms

Answer 14

indicated secondary prevention of FEP:
formal mental health literacy
family psychoeducation
CBT
actively reduce substance use

Question 15

interventions- possible prodrome
Clinical stage 1b, ultra high risk of psychosis

Answer 15

indicated secondary prevention of FEP:
psychoeducation
CBT
substance use work
omega 3 fatty acids
antidepressant agents or mood stabilisers

Question 16

common signs among young people of an ‘at risk’ mental state

Answer 16

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

Question 17

assessment- possible prodromal state/risk for first episode

Answer 17

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)

Question 18

benefits of early intervention

Answer 18

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

Question 19

Treatment- acute and early recovery
clinical phase 2, first episode of psychotic disorder

Answer 19

early intervention for FEP
Psychoeducation
CBT
Substance use work
SGA medication
antidepressant agents or mood stabilisers
vocational rehabilitation

Question 20

Treatment- late/incomplete recovery
clinical phase 3a, incomplete remission from first episode of care

Answer 20

early intervention for FEP
As for stage 2, but with additional emphasis on medical and psychosocial strategies to achieve remission

Question 21

Treatment- recurrence or relapse of psychotic disorder which stabilises with treatment
clinical phase 3b, late/incomplete recovery

Answer 21

early intervention for FEP
As for stage 3a, but with additional emphasis on relapse prevention and early warning signs strategies

Question 22

Treatment- multiple relapses with objective worsening in clinical extent and illness impact
clinical phase 3c, late/incomplete recovery

Answer 22

early intervention for FEP
As for stage 3b but with emphasis on long term stabilisation

Question 23

Treatment- severe, persistent, unremitting illness
clinical phase 4, chronicity

Answer 23

as for stage 3c but with emphasis on clozapine, other tertiary treatments and social participation despite ongoing disability

Question 24

predictors of better outcomes at stage 2 treatment

Answer 24

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

Question 25

acute stage psychosis treatment

Answer 25

CBT
Supportive therapy or befriending
Group program

Question 26

Stage 3- critical period, psychosis

Answer 26

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

Question 27

stage 3 modifiable factors

Answer 27

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

Question 28

SE parkinsonism

Answer 28

mask like face, muscle rigidity
pill rolling tremor
shuffling gait
retropulsion
diminished arm swinging

Question 29

SE dystonia

Answer 29

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

Question 30

SE akathisia

Answer 30

subjective feeling of inner restlessness with a drive to move
frequent changes of posture, inability to sit still
constant walking

Question 31

SE tardive dyskinesia

Answer 31

abnormal involuntary movements of face, tongue and lips, with chewing movements, tongue movement, puckering of lips, grimacing

Question 32

risk of relapse after first episode

Answer 32

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

Question 33

risk factors for relapse

Answer 33

cannabis use
antisocial personality
pre premorbid adjustment
non adherence to medication
cognitive flexibility
stressful life event
expressed emotions

Question 34

stage 4 treatment

Answer 34

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

Question 35

treatment of psychosis general considerations

Answer 35

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

Question 36

goals for family involvement in treatment

Answer 36

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

Question 37

high EE v low EE relapse rate

Answer 37

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

Question 38

CBT for psychosis

Answer 38

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

Question 39

working with delusions

Answer 39

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

Question 40

working with hallucinations

Answer 40

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

Question 41

treatment starting point

Answer 41

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

Question 42

socratic questioning

Answer 42

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

Question 43

useful questions in challenging beliefs about voices (socratic questioning)

Answer 43

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 _?

Question 44

testing beliefs

Answer 44

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

Question 45

increasing sense of control

Answer 45

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

Question 46

enhancing coping

Answer 46

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

Question 47

working with negative symptoms and thought disorder

Answer 47

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

Question 48

relapse prevention and recovery

Answer 48

early warning signs
triggers and stressful situations
monitoring
affect regulation
treatment adherence
reducing risk
valued living
social skills training
vocational support

Question 49

issues in treatment

Answer 49

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