7 Psychosis Flashcards
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Psychosis and
the nature-nurture debate
- Gene-stress interaction hypothesis:
prolonged exposure to psychosocial distress (e.g., childhood traumas, life events, and discrimination) may with time contribute to sustained dysregulation of the hypothalamic-pituitary-adrenal axis leading to dopamine sensitization in mesolimbic areas and increased stress-induced striatal dopamine release; individual vulnerability to such neurochemical change is proposed to be genetically influenced - neurocognitive hypothesis of inner speech proposes that some individuals, due to neurochemical deficits in self-monitoring, may eventually experience incidents of inability to recognise inner speech as self-produced and, instead, appraise such speech as autonomous, outer voice
o An impaired self-monitoring has also been found in behavioural and neuroimaging studies among individuals with delusions - Also substance abuse more common in individuals with schizophrenia
Art 1
Psychosis and
the cognitve-beh approach
The cognitive-behavioral approach to psychosis = psychotic phenomena through the underlying cognitive, emotional, and behavioral processes, which are hypothesized to constitute psychological aftermath of distressing, often overwhelming, depriving, and traumatic experiences
- Given that similar psychosocial aetiological factors have been recognized in depression and anxiety, it does not seem surprising that epidemiological studies demonstrated a considerable incidence of mood disorders among individuals with diagnoses of paranoid schizophrenia
- Hallucinations and paranoia are accompanied by emotional distress
- Cognitive-behavioural treatment models of psychosis propose that anxiety does not arise directly from positive symptoms of psychosis but rather from an individual interpretation of those symptoms and personal meanings attached to such experiences
- Thus, the appraisal of unusual phenomena appears to play a critical role in determining whether or not an individual arrives at a paranoid interpretation of hallucinatory experiences
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Intro
- Specific causes of psychosis-type experiences remain unclear
- Range of factors that relate to psychological makeup, environment & biological background interact development of psychosis
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Gene-stress interaction hypothesis
- Prolonged exposure to psychosocial distress
- > sustained dysregulation of HPA-axis
- > dopamine sensitization is mesolimbic areas
- > stress-induced dopamine release
•Genetical individual vulnerability
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the neurocognitive hypothesis of inner speech
Neurochemical deficits in self-monitoring
-> inability to differentiate inner speech from outside speech
- Impaired self-monitoring in individuals with delusions
- Higher rates of alcohol & illicit drug misuse increase the severity of symptoms
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A cognitive-behavioral approach to psychosis
Underlying cognitive, emotional & behavioural processes
-> psychologically distressing, overwhelming, depriving & traumatic experiences
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-Epidemiological studies:
Considerable incidence of mood disorders among paranoid schizophrenics, Prevalence rate of diagnostic comorbidity 57.3% (62% of those have some form of anxiety disorder)
- Experiencing positive symptoms of psychosis (especially auditory hallucinations) as dominating & insulting
- > higher levels of psychological distress
- Higher levels of anxiety linked to hallucinations & delusions
- Positive symptoms of psychosis accompany emotional distress (also anxiety)
- Anxiety results from individual interpretation of symptoms & meaning attached to experience
- > Cognitive content of distress expresses itself in a symptom of psychosis exacerbation (worsening) of distress
- Paranoid ideation & psychoticism + high distress decrease of well-being & life satisfaction
=>Primary target of CBT-P should be emotional distress
Art 2
Psychosis Case report
This article described a case report of an elderly man with anxiety & paranoid schizophrenia who was treated with CBT-P
- Improvements in psychosocial functioning following 16 sessions of CBT-P
- > Focused on cognitive restructuring of paranoid appraisals of voiced & graded behavioural exposure to anxiety-inducing stimuli
- > More functional appraisals of psychosis-type experiences
- > Improvements in behavioural functioning
- Behavioural changes were consistent with the principles & desired goals of cognitive restructuring & graded exposure
- > Individual helped to re-evaluate validity of their problematic anxiety-inducing beliefs that trigger avoidance & inhibit functional reactions
- > Person is assisted with gradual implementation of desired behaviours -> reinforcement of more functional & reality-based appraisals of feared stimuli
-Client’s consistent collaboration & engagement, readiness for change, openness to new knowledge & motivation fundamental for successful intervention
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Treatment psychosis
- Recommendation for a combination of
- antipsychotic medicines
- psychotherapy (e.g. CBTp or family therapy)
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NICE Guidelines UK
CBTp for
- prevention of psychotic episode as well as
- after first episode, then combined with antipsychotic medication
- > Offer CBTp to all patients
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CBT for psychosis
Evidence for CBT?
- Small to medium effect sizes with regard to changes in positive symptoms and psychopathology
- Debate about effectiveness
- Anti-psychotic medication to target positive symptoms, but…
- Significant minority of patients continue to hallucinate 25-50%
- Side effects
- Compliance?
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Structure of CBTp
- Introduction to CBT models and Psychoeducation
- Working on auditory hallucinations
- Working on delusional thoughts
- Working on negative symptoms and - if applicable - co-morbid disorders
- Relapse prevention
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Therapy protocol
-Therapeutic alliance: Might be harder to establish, Be non-confrontative and supportive
- Make session structure predictable:
1. Review homework
2. Discuss topic/problem of client/patient
3. Topic of session (input from therapists)
4. Short review and new homework
-Ask:
•Degree of comfort during the session
•Feedback/barriers for interventions/homework
- Introduction
- Explain that treatment = collaboration
- Homework
- Clear structure
- Define treatment goals together
2.Working with (auditory) hallucinations
•Cognitive model for hallucinations (Morrison, 2004)
-emphasis on the role of subjective and cognitive appraisals of voices
•Aim: reduce the perceived power of voices, make sense of them, reduce distress
3.Working with delusional thoughts
• Interpretation is key
• Importance of feeling safe
• Emotional response is based in reality, even is the explanation/the belief is not
4.Working with negative symptoms • Apply different CBT techniques, e.g -Behavioural self monitoring -Activity scheduling -Behavioural activation -Social skills training
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Psychoeducation
- Vulnerability- Stress-Model
- Continuum approach
- Normalisation of symptoms
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Normalisation
- Famous/successful people hear voices
- Lifetime prevalence of auditory hallucinations in general population approx. 5% in adults and 10% in adolescents
- Sleep deprivation leads to hallucinations
- Childhood trauma: association with severity of hallucinations and delusions
