7. Psychosis

Question 1

Mental disorders vary in their:

Answer 1

– Manifestations
– Severity
– Duration
– Prognosis

Question 2

What is phychosis?

Answer 2

Any disorder so severe that a victim loses contact with reality

Question 3

Examples of psychosis?

Answer 3

– Schizophrenia
– Bipolar disorder (previously known as manic- depressive illness)
– Dissociative identity disorder (split-personality)
– Schizoaffective disorders
– Persistent delusional disorders

Question 4

Naming of schizophrenia?

Answer 4

– Schizo - ‘split’
– Phrene – ‘mind’

I.e. the thought fragmentation NOT split personality. That is a different disorder

Question 5

Epidemiology of schizophrenia?

Answer 5

• 1% of the world population
• Diagnosis usually quite late: – menearly20’s
– womenlate20’s

Question 6

Outcomes for patients with schizophrenia

Answer 6

• 20% who have a first episode recover
• 80% will suffer either another acute episodes
or a more chronic condition

• 10% of schizophrenics successfully commit suicide

Question 7

Symptoms of schizophrenia?

Either positive or negative

Answer 7

Positive:
– Pervasive thought disturbance
– Delusions
– Hallucinations
– Emotional disorder
– Behavioural disruption

Negative: (so deficits..)
– Difficulty in ignoring irrelevant stimuli (external or internal). Disorganised throught
– Cognitive deficits
– Withdrawal from personal contact

Symptoms can be episodic and between psychotic episodes there is a lack of insight, making treatment adherence challenging

Question 8

In the cognitive deficits found in schizophrenia patients, what abilities are impaired?

Answer 8

– Sustained attention
– Planning
– Verbal and visuo-spatial working memory 
– Language skills
– Explicit learning and memory 
– Perceptual / motor processing

Question 9

Early signs/predictors for people who could develop schizophrenia and how it encourages disease progression?

Answer 9

Few early friends –> Delusional social interpretation
(leads to little opportunity for social reality testing. Misconceptions of social situations not addressing so leads to an individual who cannot distinguish between reality and fantasy)

Social reality testing= Testing our interpretation of a social situation with another person’s.

Question 10

Difference between delusions and hallucination?

Answer 10

Hallucination is from internal stimuli i.e. no external source

Delusion is an idiosyncratic belief that is contradicted by reality and rational argument

Question 11

What are the characteristics of the delusions of schizophrenia?

Answer 11

• Ideas of reference and changes in salience. e.g. New’s broadcast is actually targeted specifically at them
  2. Delusional system: Often stemmed from the above. Giving weight to something that is actually meaningless

Question 12

Main hallucinations of schizophrenia?

Answer 12

Auditory

Note not always voices but also noises

Question 13

What is the progression of abnormal emotions in schizophrenia?

Answer 13

Starts of emotional reactivity

leads to a anhedonia (lack of emotions) and inappropriate emotions

Question 14

Describe the 2 categories of behavioural disruption in schizophrenia?

Answer 14

1. Catatonic
   Extreme!
   Freezing in position for a v prolonged period (catatonic part), followed by period of freed movement.
   Also presents are repeated stereotypical movements for prolonged time period
2. Disorganised
   Thoughts behind movement/speech are disorganised so the actions/speech are also disorganised.

Question 15

Is schizophrenia a unitary disorder?

What are the subtypes?

Answer 15

Subtypes in previous literature include:
• Catatonic
• Disorganised (Hebephrenic) • Paranoid
• Simple (fewer positive symptoms and severe negative)
• Undifferentiated
• Residual (both pos and neg present)

Recently, advances now see disorder in domains, gradients and dimensions in DSM-5

Question 16

Causes of schizophrenia:

Genetics?

Answer 16

– Genetics

By twin studies, there is a heightened risk if twin is affected.

Question 17

Causes of schizophrenia:

– Physiological?

Answer 17

First theory was Dopamine hypothesis: i.e. overstimulations of the dopamine system. Treated with classical antipsychotics, which only successfully treated positive symptoms

Second theory is Dopamine-serotonin interaction hypothesis:
Developed the atypical antipsychotics

Role of Ach, Glut and GABA??

Question 18

Causes of schizophrenia:

– Anatomical?

Answer 18

Reduction is global volume.
Changes due to disease or drugs, thought to do disease.

Esp in those who develop disease after foetal hypoxia episode

Atrophy location @ cortico-striatal-thalamo-cortical loop involved in stimuli detection and processing

Question 19

Causes of schizophrenia:

– Psychosocial?

Answer 19

• Social class: lower
• Minority position
• Urban environment
• Family environment
• Cannabis use? Potentially self-medicating

Question 20

Treatment of schizophrenia, options?

Answer 20

• Early intervention tend to result in better long-term outcomes **

• Drug therapies
– Classical antipsychotics
– Atypical antipsychotics

Psychological interventions:
– Family intervention
– Cognitive Behaviour Therapy (challenging behaviour and delusions thought process)
– (Social-skills training)

Question 21

Issues of treatment side effects in schizophrenia?

Answer 21

• Side effects = Severe (cardiac arrhythmia, weight gain, movement abnormalities) Potential impair drug adherence

Question 22

In early intervention and assessment of potentially schizophrenic patients, what is looked at?

NICE guidelines

Answer 22

– Psychiatric
– Medical
– Physical
– Psychological
– Developmental
– Social
– Occupational and educational 
– QOL
– Economic

Question 23

NICE guideline recommendation after first psychotic episode?

Answer 23

Oral antipsychotic medication in conjunction with psychological intervention (family intervention and individual CBT)

Question 24

NICE guideline recommendations for continuing treatment and care?

Answer 24

– Offer CBT to assist in promoting recovery (particularly if persistent symptoms or in remission)
– Offer family intervention
– Consider offering depot or long-acting antipsychotic medication if the patient would prefer it after an acute episode or to avoid covert non-adherence as a clinical priority
– Monitor physical health regularly, particularly in relation to potential side effects of medication, but also overall physical health.

Question 25

Dependence proportions of schizophrenic patients?

Answer 25

– Independent (30%)

– Relatively dependent (50%) – Highly dependent (20%)

Question 26

Wee schizophrenia assessed in domains, gradients and dimensions in DSM-5 of the symptoms. What are they?

Answer 26

Negative symptoms:

• Impaired cognition
• Depression
• Mania

Abnormal psychomotor behaviour:

• Delusion
• Hallucination
• Disorganised speech

Scored 1-4 depending on symptoms.