8. Psychotic disorders Flashcards
Psychosis as an umbrella term
Psychosis is an umbrella term that occurs in numerous conditions
with many different origins and aetiologies, for example:
- secondary to substance use
- During a manic episode
- schizophrenia
definition of psychosis
An altered sense of reality or lack of shared reality with other people
Psychosis as a term
- A term with multiple (and evolving) definitions
* psychosis represents a spectrum of disorders with many different etiologies or origins.
What do people which psychosis have difficult discerning between?
– what’s real or not real, or
– what’s internal and self-generated versus external and other-generated.
DSM 5 definition of psychosis
it is generally restricted to the presence of active symptoms such as delusions or hallucinations.
Schizophrenia Spectrum & Other Psychotic Disorders
Schizophrenia Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizoaffective Disorder Substance Induced Psychosis
Psychosis may also occur in…
Bipolar Disorder Major depressive disorder obsessive compulsive disorder Delirium Neurocognitive disorder
Subthreshold psychotic
phenomena may occur
in:
Schizotypal personality disorder
Paranoid personality disorder
Schizoid personality disorder
Compared to other mental disorders schizophrenia is…
relatively rare, but potentially very impactful (the second leading cause of disease burden). It is commonly misunderstood and stigmatised.
Symptoms of schizophrenia
The most common symptoms of schizophrenia include changes in the way a person thinks, perceives, and relates to other people and the outside environment.
temporal phases
prodromal
Active
residual
Three symptom types of schizophrenia
Positive
negative
disorganisation of speech and behaviour
positive symptoms of schizophrenia
an excess or distortion of normal function, including hallucinations and delusions
Negative symptoms of schizophrenia
a deficiency or absence of normal function
Prodromal temporal phase of Schizophrenia
noticeable deterioration in functioning; subthreshold
symptoms prior to onset of full symptoms
– e.g., “peculiar” behaviours, withdrawal, avolition, unusual perceptual experiences, angry outbursts, tension, restlessness
– Often noted by relatives as “personality change”
Active temporal phase of schizophrenia
presence of positive symptoms and meet full criteria for illness
Residual temporal phase of Schizophrenia
similar to prodromal. Active symptoms have reduced but still impair; negative symptoms often remain
DSM 5 diagnostic criteria for Schizophrenia
Two or more, each present for significant period of time during a 1 month
period. At least one of A1, A2 or A3.
A1. delusions* (+ve)
A2. hallucinations* (+ve)
A3. Disorganised speech (e.g., frequent derailment or incoherence)*
A4. Grossly disorganised or catatonic behaviour
A5. Negative symptoms (e.g., diminished emotional expression or avolition)
Required duration of schizophrenia for DSM-5 satisfaction
Persistence for 6 months may be prodromal or residual periods where criterion A symptoms may be in an attenuated form (odd beliefs, unusual perceptual experiences) or negative symptoms present only
Schizophrenic symptoms must not be a result of…
– Substance use
– Medical condition
Exclude Schizoaffective Disorder, Depression or Bipolar with psychotic features
– No mood symptoms present OR
– Mood symptoms have been present only for a minority of total illness
Delisions
Delusional thoughts are rigidly held false or idiosyncratic beliefs
characteristics of delusions
– Tend to be preoccupying – hard for the person not to think about
– Held to even when shown to be false, despite evidence to the contrary
– Person tends to be unable to consider that others might hold a different perspective
Examples of delusion content and themes
• Of being controlled: Feelings, impulses, thoughts, or actions are not
self-controlled, but directed by other people or an external force
• Thought broadcasting: that thoughts are being broadcast out loud
• Persecutory: A strong sense of being talked about,
• attacked, harassed, cheated, or conspired against
• Grandiose: Highly inflated sense of self-worth, power, knowledge,
identity, or special connections with a deity or famous person
• Erotomanic: belief that another person is in love with him or her, can
be a person of higher status
• Delusions of reference: the everyday actions of others are premeditated
and make special reference to the patient
• Nihilistic delusions are the belief that part of the individual or the
external world does not exist, or that the individual is dead
Why are delusions difficult to identify?
- Delusional thoughts may involve a complex belief system (a bizarre, confusing story)
- Facts, and fiction may be interwoven
- The ideas may be difficult to completely disprove or falsify
- The belief system may be fragmented (& therefore hard to identify)
- The person may have some awareness and not reveal full extent of beliefs
Hallucinations
- A sensory perception that has a compelling sense of reality as a true perception, but that occurs without external stimulation of the relevant sensory organ
- Can occur in any sensory modality (auditory, visual, olfactory, taste, touch) although auditory are most common in Schizophrenia
Hallucinations distinguished from illusions
Distinguished from illusions, in which an actual external stimulus is misperceived or misinterpreted
Auditory hallucinations
May be perceived as a voice (familiar or unfamiliar) that is distinct from one’s own thoughts
• Content is variable, although often pejorative or threatening
– May issue instructions (commands)
– Tease/mock
– May be voices conversing
– voices commenting on person
• The voices are unwanted, uncontrollable, vivid, usually unpleasant, and intrusive (extremely difficult to ignore).
• Because they seem real, people may talk back (giving the appearance of talking-to-oneself)
• May be other sounds (not voices or words)
• Can give rise to delusional interpretations of events
Auditory events that don’t count for Schizophrenia
The presence of these alone would not qualify as hallucinations for Schizophrenia
– Perceiving sounds/voices when falling asleep (hypnogogic hallucinations) or on waking (hypnopompic hallucinations)
– The perception of your name being called
– Sounds that are like hallucinations (e.g. unwanted, uncontrollable), but they have an external if distal cause (ringing in one’s ears after a concert)
– A “transient” hallucinatory experience (DSM-5)
Negative symptoms of schizophrenia
A loss or diminution of responses or functions,
including
– Blunted affect - Diminished emotional expression visible in facial expression, prosody of speech
– Anhedonia
– Avolition – apathy or reduction in initiative/movement
towards goals
– Social withdrawal
– Alogia – impoverished thinking, poverty of speech,
thought blocking
Disorganised thought and speech
• Disorganised speech/thought identified through mental status exam • Formal thought disorder, for example – Derailment: person’s ideas slip off one track onto another completely unrelated or only obliquely related one – Tangentiality – Loosening of associations – Neologisms – Clanging – Perseveration
Grossly disorganised behaviour
- May manifest in any form of goal-directed behaviour, leading to difficulties performing ADLs such as organising meals or maintaining hygiene.
- May be inferred from a dishevelled appearance or inappropriate dress (e.g., wearing multiple overcoats on a hot day), or there may be instances of inappropriate sexual behaviour (e.g., public masturbation)
- May behave in unpredictable manner & demonstrate untriggered
agitation (e.g., shouting or swearing).
Behavioural disorganisation/Unusual behaviours
• Catatonia
• “changed” (reduced & awkward) spontaneous movement
• “Inappropriate” or “incongruous” or “bizarre” behaviour. The
behaviour doesn’t fit the situation; the signals grossly conflict
catatonia
reduced behaviour/reactivity despite external prompts
– Motoric immobility (catalepsy or stupor) with reduced responsiveness – seems unaware of surroundings
– Marked muscular rigidity
– Motoric excesses (repetitive, apparently purposeless movement, such as pacing, hand wringing)
How should the grossly disorganised behaviour criterion be applied?
Care should be taken not to apply this criterion too broadly:
– Must not be merely aimless, purposeless behaviour,
OR
– Due to delusion per se (e.g., organised behaviour directed by delusion), AND
– Must be not consist of a few instances of restlessness or agitated behaviour.
Neurocognitive changes
Neurocognitive impairment is often a feature of Schizophrenia:
– most prominent of these deficits are memory, attention, working
memory, problem solving, processing speed, and social cognition
– May also affect executive functions – planning, problem solving
– Reduced cognitive functioning compared with their expected level if they
had not developed the illness
– Can be 1.5 – 2 SDs on standardized tests
Are neurocognitive changes required for diagnosis?
Not a requirement for diagnosis but significant impact on functioning and identified as an associated feature in DSM
Emergence of neurocognitive change
May emerge prior to onset of active symptoms and stabilise
neurocognitive change in Schizophrenia patients
20-25% of persons with Schizophrenia have neuropsychological profiles in the normal range (but may still represent a decline from premorbid)
Abilities affected by neurocognitve change
Not all abilities affected – can remain highly functional in specific domains even where decline evident in others
Lived exiperiences as a symptom of schizophrenia
• Loneliness – can be isolating, hard to connect, secondary to social disengagement
• Disorientation – unable to trust own perceptions, alienated from own mind
• Frightening – experience of persecution, sense of impending threat
• Distressing content of hallucinations
• Ever-presence of hallucinations
• Loss of self-control, personal agency
• Challenges of self-determination – own perspective devalued/dismissed,
mandated tx
• Messages of “you can’t” from family, friends, health professionals
• Impacts of medication – feeling numb, slowed down, desire to sleep
• Stigma – misconceptions about schizophrenia resulting in social exclusion,
rejection and impacting on self worth
• Shame and loss – self stigma relating to diagnosis, loss of intended life
Walsh, Hochbrueckner, Corcoran & Spence (2016) The lived experience of schizophrenia:
violence as a symptom for schizophrenia?
• A common fear amongst the general public
• The vast majority of persons with schizophrenia are NOT violent
• Tend to be more frequently victimised than others in general
population
• Spontaneous and random violence is uncommon but may occur in
those with persecutory delusions in acute periods of illness
• Prediction of violence based on factors other than the psychosis
itself
– Much more common amongst those with substance misuse problems or history
of aggression/violence, antisocial personality
Reliability of diagnoses of schizophrenia
The poor reliability of some of the subtypes, suggests that dropping them was a good decision.
Prevalence of schizophrenia
- Over many studies, estimates remain at around 1% lifetime prevalence
- Has long been seen as being equally prevalent in males and females
- Current evidence suggests men are 30-40% more likely to develop Schizophrenia than women (Seeman, 2008)
Gender differences in the presentation of schizophrenia
– On average, males present with symptoms earlier than females
– Males are more likely to present with negative symptoms
– Males more often have chronic presentation
– Males often have poorer social functioning and more schizotypal traits
Course of schizophrenia
• Course is variable – approximately one quarter single active episode
and little or no subsequent impact on life functioning (~20%).
• A large proportion show a chronic course but severity is highly
variable
Effect if treatment for schizophrenia
• For most (with treatment), there is a general pattern of improvement and recovery over time
chronicity and deterioration of schizophrenia
- Chronicity and deterioration initially regarded as a core feature of schizophrenia – Kraeplin’s dementia praecox
- Prevailing view is less pessimistic
- Onset may be gradual (insidious) or sudden (acute).
- Typically, there is some period of decline in functioning (prodrome) prior to acute symptoms
onset of schizophrenia
Onset may be from adolescence to middle age but is most common in early 20s
Patient related factors of schizophrenia prognosis
– Negative symptoms are more strongly related to prognosis than are
positive symptoms
– Medications – side effects, dose
– Lifestyle factors – tobacco and substance use
required treatment for schizophrenia
Generally, long-term treatment is required, with brief periods of hospitalisation
What do chronic presnetations of schizophrenia impact on?
– Occupational functioning – Social engagement – Self cares – may need living supports – Engagement in health related behaviours- increased risk for medical illness
What are psychotic disorders other than schizophrenia?
- Brief psychotic disorder
- Schizophreniform Disorder
- Delusional disorder
- Schizoaffective disorder
- Substance induced Psychotic Disorder
- Psychosis due to a medical condition
Substances that can evoke psychotic symptoms
illicit substances and prescription
medications
– During intoxication with alcohol, cannabis, hallucinogens (MDMA), stimulants (cocaine)
– Medications including anaesthetics, analgesics, antihypertensives etc
– Toxins – e.g. paint, fuel, carbon monoxide
Some studies suggest substances account for between 7-25% of first episode psychosis
Schizophreniform Disorder
characterized by a symptomatic presentation that is equivalent to Schizophrenia EXCEPT for
• duration (ie. the disturbance lasts from 1 - 6 mo) and
• absence of a requirement that there be a decline in functioning.
Schizoaffective Disorder
– Describes an episode only
– a disturbance in which a mood episode & the active-phase symptoms of Schizophrenia occur together
– and were preceded, or are followed, by at least 2 weeks of delusions or hallucinations without prominent mood symptoms
– If mood and psychotic symptoms co-occur for entire duration of episode, then the dx is mood disorder with psychotic features
Aetiology of Schizophrenia
not known.
[There may not be a single cause]
The primary theory is biological, and many factors are implicated.
• The primary treatments are pharmacological.
• Social and psychological explanations for schizophrenia have been proposed, but they have not given rise to front-line treatments.
Perinatal factors of schizophrenia
Thought to account for a small proportion of incidence of
Schizophrenia
• Hypoxia
• Maternal infection
• Birth injuries
• Maternal malnutrition
However, the vast majority of persons with these risk factors DO NOT go on to develop Schizophrenia
maternal malnutrition and schizophrenia
– severe malnutrition in early months of pregnancy leads to an increased risk of schizophrenia for the offspring
– Disruption to development of the fetal nervous system
Possible biological factors of schizophrenia
Genes
viral infections
neuroanatomical and neurochemical hypotheses
Genes as a biological factor of Schizophrenia
(a degree of heritability suggested by twin and family studies)
– The average concordance rate for MZ twins is 48%, whereas the comparable figure for DZ twins is 17%.
– 2003 meta-analytic review suggests heritability of 80% (Sullivan, Kendler & Neale, 2003)
Viral infections as a possible biological factor of schizophrenia
People who develop schizophrenia are somewhat more likely than other people to have been born during the winter when viral infections are more prominent.
Neuropathology and schizophrenia
Structural brain imaging studies indicate that a number of brain areas, and connections among areas, are involved in schizophrenia.
– A decrease in total volume of brain tissue
– Mildly to moderately enlarged lateral ventricles
What has PET indicated in schizophrenia?
Use of positron emission tomography (PET) technique indicates dysfunction in various neural circuits in some regions of prefrontal cortex, regions of temporal lobes
– Smaller hippocampus
– Smaller amygdala
– Reduced frontal lobe activity
Dopamine hypothesis of schizophrenia
– Proposed that symptoms of schizophrenia are a result of excessive levels of dopaminergic activity
– Antipsychotics block one type of dopamine receptor
Disadvantages of antipsychotic medications for treating schizophrenia
• not all patients respond to antipsychotic
medications
• Antipsychotics take time to be effective despite
blocking receptors immediately
Cannabis as treatment for Schizophrenia
• Some RCTs have shown that exposure to dronabinol, found in cannabis, can induce psychotic states
• People with a pre-existing liability to psychosis are more susceptible
• Other studies suggest a strong link but causality is difficult to argue
• Meta-analysis (Marconi et al 2016)
– Dose-response relationship
– Higher risk in those predisposed
– Age of use and cumulative use may be a factor
• Has become a focus in prevention/public health models
Social class as a factor of schizophrenia
Social Class – inverse relationship with SCZ
– Highest prevalence in low SES areas
– Social causation
– Social selection hypothesis
social causation of schizophrenia
Harmful events associated with membership in the lowest social classes, such as stress, social isolation, and poor nutrition, play a causal role in the development of the disorder.
Social selection hypothesis
BUT it is possible that those who develop schizophrenia end up in lower social classes as a result of the illness
Migration as a factor of schizophrenia
Higher rates of schizophrenia have been found repeatedly among people who have migrated to a new country (Cantor-Graae & Selton, 2005).
– social adversity increases risk for schizophrenia.
Express emotion as a factor of schizophrenia
– High EE characterized by criticism, hostility excessive involvement, highly emotional responses (e.g. very high anxiety/concern) from a family member
– Tone of voice communicating irritability, judgment, anger, blaming towards patient
Environmental factors that affect schizophrenia
- The family environment has a significant impact on the course (as opposed to the etiology) of schizophrenia
- Persons who live in environments with high expressed emotion are more likely to relapse
- Warmth and positive regard in the family are protective
Expressed emotion in western cultures
High EE more common in Western cultures
– Has been used to explain why the long term course of Schizophrenia seems to be less severe in developing countries
Why is schizophrenia less severe in developing countries
- Better social support from extended families
- Less social pressure to achieve occupationally
- Lower stress in rural environments and small villages
- Less stigma toward mental illness
Challenges of identifying causes
• Are the differences “clinically evident” / is there an associated “functional” difference in presentation?
• What came first: Was the brain changed before or by the schizophrenia, or by an as yet unidentified third factor.
• Is this difference due to the disorder, or other “confounding” [difficult to control factors], such as medication, institutionalisation, disrupted
schooling/relationships?.
• Is the difference characteristic of (specific to) “schizophrenia” or are
the differences seen in other forms of pathology?
Primary treatment of schizophrenia
medication (neuroleptics/antipsychotic medications)
first generation antipsychotic medications
good effect, motor side effects
advantages of Secondary generation antipsychotic medications
good effect, metabolic side effects
• Earlier treatment for first episode
• Earlier and better participation in psychosocial
rehabilitation programs
• Higher compliance, less relapse/rehospitalization
• Higher level of reintegration, better quality of life
What is the effect of antipsychotic medications
Beneficial to reduce severity of psychotic symptoms and delay relapse.
– Often takes 2-3 weeks to see benefit
– Usually reduce (but don’t eliminate) positive symptoms
– negative symptoms often remain
– Usage may depend on stage of illness - Acute phase versus maintenance medication (see Leucht et al., 2012)
– A substantial minority of patients, perhaps 25%, do not improve on classical antipsychotic drugs (Conley & Kelly, 2001).
– Another 30-40% are partial responders – condition improves, but not full remission
Cognitive therapy as a treatment for schizophrenia
Cognitive therapy with delusions and hallucinations
– Testing beliefs/accuracy of perception
Cognitive remediation as a treatment for schizophrenia
targeting cognitive deficits in
concentration, processing speech, learning and memory
– Computer based practice – games designed to
improve cognitive skills
– Some good evidence
– questions about generalisability to daily living also
raised
Psychosocial Rehabilitation (community case management) as treatment for schiz
– Educational component about disorder
– Help to set realistic expectations
– Improve coping skills of families (including communication)
– Engagement in social/community activities – employment, social groups
– Support to manage ADLs
family oriented aftercare as a treatment for Schiz
– Educational component
– Establish realistic expectations
– Communication patterns
Social skills training as a treatment for schiz
– role playing, modelling & social reinforcement for appropriate behaviour
– To improve social & occupational functioning
Collaborative recovery model as treatment for schiz
- a person-centred coaching approach to assist people in their recovery journey
- Focus beyond symptomatic treatment
- Underpinned by values of empowerment, personal choice, strengths, community
- Enhance quality of life
How does the collaborative recovery model enhance quality of life?
– promoting day-to-day function
– Improving physical and mental wellbeing
– Securing and sustaining a home
– Increasing social connectedness
– Engaging with educational and vocational opportunities
What caution needs to be taken with regards to language in treatment?
• If you want to care for something, you call it a flower, if you want to kill it, you call it a weed…Don Coyhis
• Some language conveys blame, stigma and hopelessness
• Some language forgets about the person
• Lots of recommendations exist to reduce stigma in documentation and communication
• For example:
– Rather than “case”, use person, consumer, client/patient
– Person first language – “person with Schizophrenia”, or “person
diagnosed with schizophrenia” rather than “schizophrenic”
– “Has not taken medication as prescribed” rather than “noncompliant
