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PYB306 Psychopathology > 8. Psychotic disorders > Flashcards

8. Psychotic disorders Flashcards

1
Q

Psychosis as an umbrella term

A

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

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2
Q

definition of psychosis

A

An altered sense of reality or lack of shared reality with other people

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3
Q

Psychosis as a term

A
  • A term with multiple (and evolving) definitions

* psychosis represents a spectrum of disorders with many different etiologies or origins.

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4
Q

What do people which psychosis have difficult discerning between?

A

– what’s real or not real, or

– what’s internal and self-generated versus external and other-generated.

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5
Q

DSM 5 definition of psychosis

A

it is generally restricted to the presence of active symptoms such as delusions or hallucinations.

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6
Q

Schizophrenia Spectrum & Other Psychotic Disorders

A 
Schizophrenia
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizoaffective
Disorder
Substance Induced Psychosis
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7
Q

Psychosis may also occur in…

A 
Bipolar Disorder
Major depressive disorder
obsessive compulsive disorder
Delirium
Neurocognitive disorder
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8
Q

Subthreshold psychotic
phenomena may occur
in:

A

Schizotypal personality disorder
Paranoid personality disorder
Schizoid personality disorder

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9
Q

Compared to other mental disorders schizophrenia is…

A

relatively rare, but potentially very impactful (the second leading cause of disease burden). It is commonly misunderstood and stigmatised.

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10
Q

Symptoms of schizophrenia

A

The most common symptoms of schizophrenia include changes in the way a person thinks, perceives, and relates to other people and the outside environment.

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11
Q

temporal phases

A

prodromal
Active
residual

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12
Q

Three symptom types of schizophrenia

A

Positive
negative
disorganisation of speech and behaviour

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13
Q

positive symptoms of schizophrenia

A

an excess or distortion of normal function, including hallucinations and delusions

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14
Q

Negative symptoms of schizophrenia

A

a deficiency or absence of normal function

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15
Q

Prodromal temporal phase of Schizophrenia

A

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”

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16
Q

Active temporal phase of schizophrenia

A

presence of positive symptoms and meet full criteria for illness

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17
Q

Residual temporal phase of Schizophrenia

A

similar to prodromal. Active symptoms have reduced but still impair; negative symptoms often remain

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18
Q

DSM 5 diagnostic criteria for Schizophrenia

A

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)

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19
Q

Required duration of schizophrenia for DSM-5 satisfaction

A

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

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20
Q

Schizophrenic symptoms must not be a result of…

A

– Substance use

– Medical condition

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21
Q

Exclude Schizoaffective Disorder, Depression or Bipolar with psychotic features

A

– No mood symptoms present OR

– Mood symptoms have been present only for a minority of total illness

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22
Q

Delisions

A

Delusional thoughts are rigidly held false or idiosyncratic beliefs

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23
Q

characteristics of delusions

A

– 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

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24
Q

Examples of delusion content and themes

A

• 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

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25
Q

Why are delusions difficult to identify?

A
  • 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
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26
Q

Hallucinations

A
  • 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
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27
Q

Hallucinations distinguished from illusions

A

Distinguished from illusions, in which an actual external stimulus is misperceived or misinterpreted

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28
Q

Auditory hallucinations

A

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

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29
Q

Auditory events that don’t count for Schizophrenia

A

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)

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30
Q

Negative symptoms of schizophrenia

A

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

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31
Q

Disorganised thought and speech

A 
• 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
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32
Q

Grossly disorganised behaviour

A
  1. May manifest in any form of goal-directed behaviour, leading to difficulties performing ADLs such as organising meals or maintaining hygiene.
  2. 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)
  3. May behave in unpredictable manner & demonstrate untriggered
    agitation (e.g., shouting or swearing).
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33
Q

Behavioural disorganisation/Unusual behaviours

A

• Catatonia
• “changed” (reduced & awkward) spontaneous movement
• “Inappropriate” or “incongruous” or “bizarre” behaviour. The
behaviour doesn’t fit the situation; the signals grossly conflict

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34
Q

catatonia

A

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)

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35
Q

How should the grossly disorganised behaviour criterion be applied?

A

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.

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36
Q

Neurocognitive changes

A

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

37
Q

Are neurocognitive changes required for diagnosis?

A

Not a requirement for diagnosis but significant impact on functioning and identified as an associated feature in DSM

38
Q

Emergence of neurocognitive change

A

May emerge prior to onset of active symptoms and stabilise

39
Q

neurocognitive change in Schizophrenia patients

A

20-25% of persons with Schizophrenia have neuropsychological profiles in the normal range (but may still represent a decline from premorbid)

40
Q

Abilities affected by neurocognitve change

A

Not all abilities affected – can remain highly functional in specific domains even where decline evident in others

41
Q

Lived exiperiences as a symptom of schizophrenia

A

• 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:

42
Q

violence as a symptom for schizophrenia?

A

• 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

43
Q

Reliability of diagnoses of schizophrenia

A

The poor reliability of some of the subtypes, suggests that dropping them was a good decision.

44
Q

Prevalence of schizophrenia

A
  • 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)
45
Q

Gender differences in the presentation of schizophrenia

A

– 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

46
Q

Course of schizophrenia

A

• 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

47
Q

Effect if treatment for schizophrenia

A

• For most (with treatment), there is a general pattern of improvement and recovery over time

48
Q

chronicity and deterioration of schizophrenia

A
  • 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
49
Q

onset of schizophrenia

A

Onset may be from adolescence to middle age but is most common in early 20s

50
Q

Patient related factors of schizophrenia prognosis

A

– Negative symptoms are more strongly related to prognosis than are
positive symptoms
– Medications – side effects, dose
– Lifestyle factors – tobacco and substance use

51
Q

required treatment for schizophrenia

A

Generally, long-term treatment is required, with brief periods of hospitalisation

52
Q

What do chronic presnetations of schizophrenia impact on?

A 
– Occupational functioning
– Social engagement
– Self cares – may need living supports
– Engagement in health related behaviours- increased risk for medical
illness
53
Q

What are psychotic disorders other than schizophrenia?

A
  • Brief psychotic disorder
  • Schizophreniform Disorder
  • Delusional disorder
  • Schizoaffective disorder
  • Substance induced Psychotic Disorder
  • Psychosis due to a medical condition
54
Q

Substances that can evoke psychotic symptoms

A

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

55
Q

Schizophreniform Disorder

A

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.

56
Q

Schizoaffective Disorder

A

– 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

57
Q

Aetiology of Schizophrenia

A

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.

58
Q

Perinatal factors of schizophrenia

A

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

59
Q

maternal malnutrition and schizophrenia

A

– 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

60
Q

Possible biological factors of schizophrenia

A

Genes
viral infections
neuroanatomical and neurochemical hypotheses

61
Q

Genes as a biological factor of Schizophrenia

A

(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)

62
Q

Viral infections as a possible biological factor of schizophrenia

A

People who develop schizophrenia are somewhat more likely than other people to have been born during the winter when viral infections are more prominent.

63
Q

Neuropathology and schizophrenia

A

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

64
Q

What has PET indicated in schizophrenia?

A

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

65
Q

Dopamine hypothesis of schizophrenia

A

– Proposed that symptoms of schizophrenia are a result of excessive levels of dopaminergic activity
– Antipsychotics block one type of dopamine receptor

66
Q

Disadvantages of antipsychotic medications for treating schizophrenia

A

• not all patients respond to antipsychotic
medications
• Antipsychotics take time to be effective despite
blocking receptors immediately

67
Q

Cannabis as treatment for Schizophrenia

A

• 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

68
Q

Social class as a factor of schizophrenia

A

Social Class – inverse relationship with SCZ
– Highest prevalence in low SES areas
– Social causation
– Social selection hypothesis

69
Q

social causation of schizophrenia

A

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.

70
Q

Social selection hypothesis

A

BUT it is possible that those who develop schizophrenia end up in lower social classes as a result of the illness

71
Q

Migration as a factor of schizophrenia

A

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.

72
Q

Express emotion as a factor of schizophrenia

A

– 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

73
Q

Environmental factors that affect schizophrenia

A
  • 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
74
Q

Expressed emotion in western cultures

A

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

75
Q

Why is schizophrenia less severe in developing countries

A
  • 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
76
Q

Challenges of identifying causes

A

• 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?

77
Q

Primary treatment of schizophrenia

A

medication (neuroleptics/antipsychotic medications)

78
Q

first generation antipsychotic medications

A

good effect, motor side effects

79
Q

advantages of Secondary generation antipsychotic medications

A

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

80
Q

What is the effect of antipsychotic medications

A

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

81
Q

Cognitive therapy as a treatment for schizophrenia

A

Cognitive therapy with delusions and hallucinations

– Testing beliefs/accuracy of perception

82
Q

Cognitive remediation as a treatment for schizophrenia

A

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

83
Q

Psychosocial Rehabilitation (community case management) as treatment for schiz

A

– 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

84
Q

family oriented aftercare as a treatment for Schiz

A

– Educational component
– Establish realistic expectations
– Communication patterns

85
Q

Social skills training as a treatment for schiz

A

– role playing, modelling & social reinforcement for appropriate behaviour
– To improve social & occupational functioning

86
Q

Collaborative recovery model as treatment for schiz

A
  • 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
87
Q

How does the collaborative recovery model enhance quality of life?

A

– promoting day-to-day function
– Improving physical and mental wellbeing
– Securing and sustaining a home
– Increasing social connectedness
– Engaging with educational and vocational opportunities

88
Q

What caution needs to be taken with regards to language in treatment?

A

• 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

PYB306 Psychopathology (13 decks)

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