Experiencing Psychosis: Schizophrenia Spectrum Problems

Question 1

Introduction

Answer 1

Main clinical symptoms of psychosis:
lack of contact with reality, delusions, hallucinations, lack of insight, disturbances in thought and language, sensory perception, emotion regulation, and behaviour. Most common diagnosis is schizophrenia.

these symptoms can lead to:

• poor educational performance
• increasing lack of productivity
• difficulties in interpersonal relationships
• neglect of day-to-day activities
• preoccupation with a personal world to the exclusion of others.

downward drift phenomenon - those who experience these symptoms fall to the bottom of the social ladder or even become homeless because they can’t hold down a job or sustain a relationship.

Psychosis is a collective name given to an extensive range of disparate symptoms that can often leave an individual feeling frightened and confused, and the presence of different combinations of these symptoms may lead to a diagnosis of any one of a number of schizophrenia spectrum disorders (the name for separate psychotic disorders that range across a spectrum depending on severity, duration and complexity of symptoms.

the main diagnostic categories defining schizophrenia spectrum disorders in DSM-5:
schizophrenia
schizotypical personality disorder
delusional disorder
brief psychotic disorder
schizoaffective disorder

Question 2

The Nature of Psychotic Symptoms

Delusions and Hallucinations

Answer 2

DSM-5 lists 5 important characteristics for diagnosing schizophrenia spectrum disorders. The first 4 of these characteristics are traditionally known as positive symptoms (excess of normal function, delusions, hallucinations, disorganised thinking (speech), abnormal motor behaviour), because they tend to reflect an excess or distortion of normal functions, and the final category represents what are known as negative symptoms, and these reflect symptoms characteristic of a diminution or loss of normal functions.

Main types of delusion found in those experiencing psychosis:

• persecutor - the individual believes they are being persecutive, spied upon, or are in danger (usually as the result of a conspiracy of some kind)
• grandiose - the individual believes they are someone with fame or power or have exceptional abilities, wealth or fame (e.g. Jesus Christ, or a famous music star)
• delusions of control - the person believes that his or her thoughts, feelings or actions are being controlled by external forces (e.g. extraterrestrial or supernatural beings)
• delusion of reference - the individual believes that independent external events are making specific reference to him or her (e.g. believes DJ on radio talking to her)
• nihilistic delusions - the individual believes that some aspect of either the world or themselves has ceased to exist (e.g. the person may believe that they are in fact dead)
• erotomanic delusions - relatively rare psychotic delusions, where an individual has a delusional belief that a person of higher social status falls in love and makes amorous advances towards them.

Hallucinations: a sensory experience in which a person can see, hear, smell, taste or feel something that isn’t there. the most common are auditory hallucinations (external voices commanding the individual to act in certain ways, two or more voices conversing with each other, or a voice commentating on the individuals own thoughts.)
individuals diagnosed with schizophrenia have a reality-monitoring deficits - where an individual has a problem distinguishing between what actually occurred and what did not occur. As well as a self-monitoring deficit (can not distinguish between thoughts and ideas they generated themselves and thoughts or ideas that other people generated).

Question 3

The Nature of Psychotic Symptoms
Disorganised Thinking (Speech)

Answer 3

a number of common features displayed by individuals experiencing psychotic symptoms. The most common forms of disorganised speech are:
1. derailment - a disorder of speech where the individual may drift quickly from one topic to another during a conversation
OR
2. loose associations - disorganised thinking in where the individual may drift quickly from one topic to another during a conversation

Their answers to questions may be tangential rather than relevant (known as tangentiality), examples of confused speech:

3. clanging - a form of speech pattern in schizophrenia where thinking is driven by word sounds. for example, rhyming or alliteration may lead to the appearance of logical connections where none in fact exists.
4. neologisms - made up words, frequently constructed by condensing or combining several words (sniggeration, relaudation, circlingology).
5. word salads - when the language of the person experiencing a psychotic episode appears so disorganised that there seems to be no link between one phrase and the next.

loose associations that appear to govern psychotic speech can be very detailed in terms of number of words, breadth of ideas, and grammatical correctness, but it will usually convey very little substantive content (poverty of content)

Question 4

The Nature of Psychotic Symptoms

Grossly Disorganised or Abnormal Motor Behaviour

Answer 4

Manifested in a variety of ways:

• childlike and silly: inappropriate for the persons age
• inappropriate to the context: mastrubating in public
• unpredictable/agitated: shouting/swearing in public
• difficult completing goal-directed activity: e.g. cooking
• appearance dishevelled, dress inappropriately: thick clothing in hot weather, walking in public with only underwear on

Catatonic motor behaviours - characterised by a decrease in reactivity to the environment (catatonic stupor), maintaining rigid, immobile postures (catatonic rigidity), resisting attempts to be moved (catatonic negativism), or purposeless and excessive motor activity that often consists of simply, stereotyped movements (catatonic excitement or stereotypy).

Question 5

The Nature of Psychotic Symptoms

Negative Symptoms

Answer 5

characterised by flat affect, lack of interest in social or work activities, poverty of speech and apathy:
diminished emotional expression (also described as affective flattening) - a reduction in facial expressions of emotions, lack of eye contact, poor voice intonation, and lack of head and hand movements that would normally give rise to emotional expression

affective flattening - limited range and intensity of emotional expressions; a ‘negative’ symptom of schizophrenia

abolition - inability to carry out or complete normal day to day goal-orientated activities, and this results in the individual showing little interest in social or work activities

alogia - a lack of verbal fluency in which the individual gives very brief, empty replies to questions.

anhedonia - inability to react to enjoyable or pleasurable events.

asociality - lack of interest in social interactions, perhaps brought about by a gradual withdrawal from social interactions

Question 6

The Diagnosis of Schizophrenia Spectrum Disorders

the four main schizophrenic spectrum disorder diagnostic categories in DSM-5

Answer 6

Emil Kraeplin developed the term Dementia Praecox:
early onset and progressive cognitive impairment. He believed the psychotic symptoms began in early adulthood.
In contrast, Bleular disagreed with Kraeplin and believed that the disorder did not always have an early onset and it did not inevitably progress towards dementia. in 1908, he proposed his own term - Schizophrenia from the Greek, schizen ‘to split’ and phren - ‘mind’.
Schizophrenia has a range of symptoms covering cognitive, behavioural and emotional dysfunction and impaired occupational or social functioning, as well as prodromal, active and residual phases.

DSM-5 summary of Delusional Disorder Criteria:

• one or more delusions lasting at least 1 month
• apart from the impact of the delusions, normal functioning is not markedly impaired and behaviour is not bizarre
• any manic or major depressive episodes which have occurred have been brief in relation to the delusional episode
• the disorder is not directly attributable to the use of a substance or medication and is not better explained by other mental disorder.

DSM-5 summary of Brief Psychotic Disorder Criteria:
presence of at least one of the following,
-delusions
-hallucinations
-disorganised speech
-highly disorganised and catatonic behavior
this distrubance lasts between 1 day and 1 month with eventual return to normal behaviour. this disorder is not directly attributable to the use of a substance or medication and is not better explained by other mental disorder.

DSM-5 Summary of Schizophrenia Criteria:
at least two of the following must be present for a significant period of time during a one month period,
-delusions
-hallucinations
-disorganised speech
-highly disorganised and catatonic behavior
the inability to function in one or more major areas such as work, self-care, or interpersonal relationships is markedly diminished. continuous signs of distrubance for at least 6 months. this disorder is not directly attributable to the use of a substance or medication and is not better explained by other mental disorder.

DSM-5 Summary of Schizoaffective Disorder Criteria:

• a continuous period of illness during which there is a major mood episode (major depressive or manic)
• delusions or hallucinations for 2 or more weeks without the occurrence of a major mood episode
• symptoms for a major mood episode are present for the majority of the duration of the illness
• this disorder is not directly attributable to the use of a substance or medication and is not better explained by other mental disorder.

why have formal diagnostic criteria in psychiatry and clinical psychology?
there is no simple test for schizophrenia. e.g. blood test or brain scan.
the agreement of diagnosis across cultures and clinicians were very different (DSM and ICD greatly improved the reliability of diagnosis)
controversy on schizophrenia as a single disorder

Question 7

The Prevalence of Schizophrenia Spectrum Disorders

Answer 7

the lifetime prevalence rate for a diagnosis of schizophrenia is between 0.5 and 0.7 per cent (around 24 million people worldwide mostly aged 15-35 years old), and is similar across different countries and cultures. Mortality rate is 50% higher than normal. significant lifelong impairment

rates of diagnosis of schizophrenia do tend to be higher in some ethnic groups (e.g. people in African-Carribean origin in the UK), and in immigrant populations generally

DSM-5 estimates for the lifetime prevalence rate for delusional disorder is around 0.2 per cent, and psychotic disorder at 9 per cent of cases of first-onset psychosis.

Question 8

The Course of Psychotic Symptoms

Answer 8

psychotic symptoms usually develop through a well-defined succession of stages:

1. the prodomal stage
2. the active stage
3. the residual stage

The Prodromal Stage:
the slow deterioration from normal functioning to the delusional and dysfunctional thinking characteristics of many forms of schizophrenia, normally taking place over an average of 5 years. (slow withdrawal from normal life and social interactions, shallow and inappropriate emotions, lack of personal care/work/school performance, grey matter loss) psychotic symptoms initially develops during late adolescence or early adulthood. psychotic symptoms caused by underlying inherited biological vulnerability, which frequently manifests as specific symptoms if the individual has a certain critical and stressful life experiences. Strong evidence for stress-diathesis explanation.

The Active Stage:
the stage in which an individual begins to show unambiguous symptoms of psychosis, including delusions, hallucinations, disordered speech and communication, and a range of full-blown symptoms.

Residual Stage:
the stage of psychosis when the individual ceases to show prominent signs of positive symptoms (such as delusions, hallucinations, or disordered speech). However, may still exhibit negative symptoms (unamiguous symptoms of psychosis). relapse is common.

relapse following recovery from an acute psychotic episode can be traced to either:

• stressful events or return to a stressful family environment after a period of hospitalisation or care
• non-adherence to medication (why? poor insight, negative attitudes to medication, history of non-adherence, substance abuse, inadequate discharge or aftercare planning, poorer therapeutic relationships between patient and service providers.)

Question 9

The Aetiology of Psychotic Symptoms

Answer 9

what is the diathesis-stress perspective that is used to explain the aetiology of psychotic symptoms?

it is the perspective that psychopathology is caused by a combination of a genetically inherited biological diathesis (a biological predisposition) and environmental stress. Therefore you may not develop any symptoms unless you experience certain forms of life stressors.

life stressors:

• early rearing factors
• dysfunctional relationships with family
• inability to cope with stresses of normal adolescent development
• educational/work demands

Question 10

The Aetiology of Psychotic Symptoms
Biological Theories
what causes schizophrenia?: Genetic Factors

Answer 10

Concordance studies, twin studies and adoption studies are used to determine the extent of genetic factors in psychosis, give examples of these types of methods:

concordance studies shows the probability with which a family member or relative will also develop the disorder. It depends on how closely related they are and how much genetic material the two share in common. The studies suggest that an individual who has a first-degree relative diagnosed with schizophrenia is 10 times more likely to develop psychotic symptoms than someone who has no first-degree relatives diagnosed with schizophrenia. concordance studies suggest inherited component to schizophrenia.

Greater concordance in the diagnosis of schizophrenia in MZ than DZ twins. Studies of the offspring of twins suggest psychotic symptoms are inherited even when the parent shows no symptoms (Gottesman & Bertelsen, 1989). the concordance rate for MZ twins is 44 per cent but falls to 12 per cent in DZ twins.

Adoption studies show that adopted children show psychotic symptoms similar to their biological and not their adopted mother (Heston, 1966).

Genetic-environment interactions:
•Inherited components to schizophrenia were an important predictor of symptoms in adopted children only when there were communication problems within the adopted family (Wahlberg et al., 2004). (i.e. stressful enivornment or life events)
•Supports a diathesis-stress explanation of schizophrenia

Question 11

The Aetiology of Psychotic Symptoms
Biological Theories
Molecular Genetics

Answer 11

What is inherited in schizophrenia?

Genetic linkage analyses have helped to identify some of the specific genes through which the risk for psychosis might be transmitted. blood samples are collected in order to study the inheritance patterns within families that have members diagnosed with schizophrenia.
Genes associated with the development of psychotic symptoms have been located on a number of different chromosomes (Kendler et al., 2000). Genetic predisposition for schizophrenia is not transmitted through a single gene.
It works by comparing the inheritance of characteristics for gene location is well known with the inheritance of psychotic symptoms, then it can be reasonably concluded that the gene controlling psychotic symptoms is probably found on the same chromosome as the gene controlling eye colour, and is probably genetically linked to that ‘marker’ characteristic in some way.

Genome-wide association studies (GWAS) allow researchers to identify rare mutations in genes that might give rise to psychotic symptoms.

Question 12

The Aetiology of Psychotic Symptoms
Biological Theories
Brain Neurotransmitters

Answer 12

Bio-Chemical Factors:

what is the dopamine hypothesis and how did the role of dopamine in psychosis come to be discovered?

• it argues that psychotic symptoms are related to excess activity of the neurotransmitter dopamine.
• drugs that alleviate psychotic symptoms block the brain’s dopamine receptor site (e.g. phenothiazines).
• amphetamine psychosis resembles psychosis and is related to excess dopamine
• MRI scans and post-mortem studies suggest sufferers exhibit more dopamine receptors in the brain (Seeman & Kupar, 2001)

there are two important dopamine pathways in the brain: the mesolimbic pathway and the mesocortical pathway may be impaired during psychosis (schizophrenia).
the higher dose of drug, the more psychotic symptoms diminish.
antipsychotics attach to the receptors of neurons that use dopamine, and they prevent dopamine from attaching and therefore prevents the activation of neuron B.

problems with Dopamine (DA) theory?

• DA blockade is successful within hours of taking antipsychotic medication, but symptoms may take several days or even weeks to begin to abate.
• a number of patients fail to obtain the benefit from treatment even after many months
• also newer atypical antipsychotics are effective in reducing psychotic symptoms but are not so clearly affecting the DA system.

Question 13

The Aetiology of Psychotic Symptoms
Biological Theories
the neuroscience of schizophrenia

Answer 13

what abnormalities can be found in the brains of individuals diagnosed with schizophrenia, and which brain areas are most affected by these abnormalities?

• psychotic symptoms are associated with brain abnormalities, including smaller brain size and enlarged ventricles (the areas in the brain containing cerebrospinal fluid).
• schizophrenia is specifically associated with reduced volumes of cortical grey matter in the prefrontal cortex with affects executive functioning, decision making and working memory
• brain imaging studies have also shown abnormalities in the frontal lobes and temporal lobes including limbic structures, the basal ganglia and the cerebellum.
• abnormal brain development may pre-date birth

Brain abnormalities & psychotic symptoms
•Underactivity in the frontal lobes associated with memory and attention problems and the negative symptoms of schizophrenia
•Abnormalities in the temporal lobes-limbic system associated with positive symptoms (McCarley et al., 2002)
•Abnormalities in basal ganglia associated with problems in executive functioning (Stratta et al., 1997)
•Abnormalities in the cerebellum associated with deficits in verbal ability (Levitt et al., 1999)

can you describe the evidence supporting the view that brain abnormalities in individuals diagnosed with schizophrenia may result from abnormal prenatal development?

•Debate over what causes these structural and functional differences
•Two key environmental risk factors identified:
ØBirth complications
ØMaternal infection - Influenza

evidence suggests that schizophrenia may be associated with birth complications and eternal infections during pregnancy. psychodynamic theories of psychosis have claimed that it is:

1) due to regression to a state of primary narcissism, or
2) develops because of a ‘schizophrenogenic mother’ who fosters psychotic symptoms in her offspring (psychodynamic theories).

Question 14

The Aetiology of Psychotic Symptoms
Psychological Theories
psychodynamic and behavioural theories

Answer 14

What are the main features of psychodynamic explanations of psychosis?
Freud believed that psychosis is caused by regression to a previous ego state which gives rise to a preoccupation with the self - this is known as regression to a state of primary narcissism.

Fromm-Reichmann (1948) developed the concept of a ‘schizophrenogenic mother’ - a cold, rejecting, distant and dominating mother who causes schizophrenia.

very little evidence supporting psychodynamic theories of psychosis.

In the 1950s-60s, explanations were related to dysfunctional family dynamics and championed by such contemporary psychodynamic theorists as Gregory Bateson and R.D. Laing.

BEHAVIOURAL THEORIES

psychotic behaviours may be rewarded through operant conditioning (Ullman & Krashner, 1975)

supported by the fact that extinction studies can be used to eliminate inappropriate psychotic behaviours

however, while this account might explain the maintenance of symptoms it is unlikely to explain their acquisition.

Question 15

The Aetiology of Psychotic Symptoms
Psychological Theories
Attentional theories

Answer 15

can you describe some of the attentional deficits that are characteristic of psychosis and explain how they might contribute to the clinical symptoms?

• difficult to attend to normal social cues and involve themselves in normal social interactions. instead their attention becomes attracted to irrelevant cues, such as an insect on the floor, an unimportant word in a conversation, a background noise, and so forth. attention to irrelevant cues such as these makes their behaviour look increasingly bizarre, and as a result it gets more and more attention, which acts as a reinforcer to strengthen such behaviours.
• inappropriate behaviours can be eliminated and acceptable social and self-care behaviours developed using operant reinforcement procedures does suggest that at least some of the unusual behaviours emitted by individuals diagnosed with schizophrenia may be under the control of contingencies of reinforcement.
• around 50 per cent of individuals diagnosed with schizophrenia show abnormalities in their attentional processes suggesting an inability to attend to and process relevant stimuli

Question 16

The Aetiology of Psychotic Symptoms
psychological theories:
cognitive theories

Answer 16

a number of cognitive biases have been implicated in the development of some psychotic symptoms, what are these biases and how might they contribute to factors such as delusional thinking?

delusional disorders is often associated with cognitive biases in attention, attribution, reasoning (threat anticipation model), and interpretation (information processing).
delusional disorders are associated with a reasoning bias called ‘jumping to conclusions’ where the individual infers meaning on the basis of very little evidence.
there is evidence that individuals diagnosed with schizophrenia may not be able to understand the mental states of others (a ‘theory of mind’
(TOM) deficit), and this may be a factor in the development of delusions - especially delusions of persecution.

TOM deficits may be important in the development of delusional beliefs (Frith, 1997)
•TOM deficits are a stable marker for schizophrenia across time
•TOM deficits identified in the prodromal stage
•Indicative of global cognitive dysfunction

Delusions: a consequence of dysfunctional perception?

• Maher (1974) suggested that delusions might relate to perceptual abnormalities (including vivid and intense sensory experiences), some evidence to support this. In particular, irrational beliefs may be induced in the people from the general population under certain conditions (e.g. paranoia in people with undetected hearing loss). Maher suggests that reasoning ability is unaffected by psychotic individuals. Perceptual abnormalities may play a role in the development of some delusions, but does not provide a complete account.
• some of these sensations are experienced as hallucinations
• individuals seek to explain these experiences (using normal cognitive appraisal mechanisms)
• delusions are maintained in the same way as any strong belief

Bias in reasoning: Probabilistic reasoning studies:
•An alternative account of delusions is that these unusual beliefs arise from biases in judgement and reasoning (Garety & Hemsley, 1994).
•In particular it was proposed that individuals who experience delusions may be exhibit biases involving
–“Jumping to conclusions”
–“Overconfidence in conclusions”

Probabilistic reasoning and delusions:
•It was predicted that people with delusions would make judgements more rapidly and would be more confident in their judgements than would non-delusional people (Garety & Hemsley, 1994)

Probabilistic Reasoning:
•Participants shown the two containers and are informed of the ratios(85%:15% red vs green and vice versa) and then the containers are removed
•Either container is equally likely to be chosen. You have to determine if container A or B has been chosen. Beads are drawn (and replaced) one after another.
•Indicate when you have decided which container has been chosen
Moritz et al (2005) B J Clin Psych, 44, 193-207)

Probabilistic Reasoning (results):
•In general population people tend to be conservative requiring more attempts than would be expected. Many studies have reported that Jumping to conclusions (JTC) associated with unusual beliefs irrespective of diagnosis.
•JTC is NOT correlated with the number and severity of delusional beliefs.
•JTC is more prominent with emotionally salient material.

factors contributing to cognitive biases:
•Anomalous experiences (such as hallucinations)
•Anxiety, depression & worry
•Biases to seek confirmatory evidence
•Social factors (such as isolation and trauma)

Conclusion
•Delusional participants => bias towards early acceptance or early rejection of hypotheses
•This tendency may contribute to erroneous inferences and thus to delusion formation
•However, no evidence that these individuals have a deficit in their ability to reason probabilistically or fail to test hypotheses
•Therefore conclude: Data-gathering bias not general reasoning deficit

Question 17

The Aetiology of Psychotic Symptoms
sociocultural theories:
social factors

Answer 17

what is a sociocultural theory of psychosis? can you describe and evaluate the significance of at least two sociocultural accounts of psychosis?

identifies social, cultural or familial factors that generate stressors that could precipitate psychotic symptoms.

the sociogenic hypothesis claims that individuals in low socio-economic classes experience significantly more life stressors than those in higher socioeconomic classes, and this is more likely to contribute to the increased prevalence of the diagnosis of schizophrenia in low socio-economic groups.
study conducted in Denmark showing that factors associated with low socioeconomic status may be risk factors for psychosis (include unemployment, low educational attainment, lower wealth status, low income, parental unemployment, parental lower income)
criticisms - little evidence that socioeconomic class increases the risk of psychotic symptoms, also individuals with schizophrenia have indicated being of  a low socioeconomic status, they are as likely to have parents from higher socioeconomic status as from a low one.

another explanation for schizophrenic individuals to have a low socioeconomic status is that the intellectual, behavioural, and motivational problems afflicting them causes a downward drift into unemployment, poverty and lower socioeconomic classes. this is known as the socio-selection theory which claims that individuals displaying psychotic symptoms will drift into lifestyles where there is less social pressure to achieve.

one final sociocultural view of schizophrenia is known as social labelling, in which it is argued that the development and maintenance of psychotic symptoms is influenced by the diagnosis itself.

Question 18

Sociocultural Theories

familial/social factors

Answer 18

what is double-blind hypothesis and how does it try to explain the development of psychotic symptoms?

theory advocating that psychotic symptoms are the result of an individual being subjected within the family to contradictory messages from loved ones
(a family member saying their okay but their face looks sad).

this hypothesis has identified a construct called communication deviance (CD) in families, which is related to the development of psychotic symptoms. CD is a general term used to describe communications that would be difficult for an ordinary listener to follow and leave them puzzled and unable to share a focus of attention with the speaker.

Examples of communication deviance
•Abandoned or abruptly ceased remarks or sentences
•Inconsistent references to events or situations
•Using words or phrases oddly or wrongly
•Use of peculiar logic

Communication deviance & psychotic symptoms
•CD is a stable characteristic of families with offspring who develop psychotic symptoms (Wahlberg et al., 2001)
•CD is a risk factor for psychotic symptoms independently of any biological or inherited predisposition (Wahlberg et al., 2004)

Expressed emotion (EE): A qualitative measure of the ‘amount’ of emotion displayed, typically in the family setting, usually by a family or caretakers.

Expressed emotion & psychotic symptoms
•Many individuals with psychotic symptoms are living in family environments where communications are hostile and critical
•EE is a robust predictor of relapse (Kavanagh, 1992)
•High EE families tend to have an attributional style that blames the sufferer for his/her condition (Weisman et al., 2000)
•Interventions to moderate EE in a family can have beneficial effects on symptoms (Hogarty et al., 1986)

Expressed Emotion
•Focus on family environment and risk of relapse
•Audiotaping family dynamics
•Number of critical comments per hour are recorded (greater or less than 6)
•Total face to face contact time (greater or less than 35 hours per week)

Question 19

The Treatment of Psychosis

Biological Treatments

Answer 19

traditionally custodial care and hospitalisation were the main forms of intervention.

1) custodial care - form of hospitalisation or restraint for individuals with psychopathologies whose behaviour is thought of as disruptive or harmful
2) hospitalisation - to admit someone to a hospital for treatment

Electroconvulsive therapy (ECT) and psychosurgery were common forms of treatment for psychosis prior to the development of antipsychotic drugs.

what are antipsychotic drugs, how are they thought to deal with the psychotic symptoms, and how are they categorised?

they are the first line of intervention for psychotic symptoms, the main classes of drugs used for treating psychotic symptoms are known as antipsychotics or neuroleptics (because some of these drugs produce undesired motor behaviour effects
(Tardive Dyskinesia) similar to the symptoms of neurological diseases such as Parkinson’s disease).
Antipsychotic drugs are split into two broad groups:
- first generation antipsychotic drugs (drugs developed over the past 50 years such as tardive dyskinesia)
- and second generation (drugs developed in recent years)

FIRST GENERATION
reduced the positive symptoms of schizophrenia (such as hallucinations, and disordered thought and communication). they block excessive dopamine activity in the brain

criticisms with antipsychotic drugs:

• not a cure for psychosis, suppress rather than eliminate, as a result patients are dependent on medication
• these drugs have undesirable side effects (tiredness, lack of motivation, dry mouth, blurred vision, constipation, impotence, dizziness)
• 20 to 50 per cent of users will develop disorders of motor movement such as tardive dyskinesia.
• antipsychotic-induced weight gain (AIWG) an important concern in the management of patients treated for psychosis. In addition to weight gain, antipsychotics are also known to impair glucose metabolism, increase cholesterol and triglyceride levels and cause arterial hypertension, leading to metabolic syndrome. The metabolic syndrome will increase the risk of diabetes mellitus by five times and cardiovascular illness by two times over the next 5–10 years.

SECOND GENERATION

5 benefits over traditional antipsychotics PG 272
2 doubts on the benefits. PG272

they are thought out to be successful for treating the positive symptoms of schizophrenia, and are thought to be effective because they reduce levels of dopamine activity in the brain.

Question 20

The Treatment of Psychosis
Psychological Therapies
Social Skills Training

Answer 20

what are the important characteristics of social skills training for individuals diagnosed with schizophrenia?

• social skills training can be useful to help psychosis sufferers with the social skills they need to deal with day to day social situations.
• Consists of role-playing, modelling and positive reinforcement
• Skills learnt include conversational skills, appropriate physical gestures, eye contact and positive appropriate facial expressions (Smith et al., 1996)
• Promotes better social skills, independent living and lower rates of re-hospitalization (Hogarty, 2002)

Question 21

The Treatment of Psychosis
Psychological Therapies
CBTp

Answer 21

What is CBTp and how is it used to treat individuals diagnosed with schizophrenia? with what particular types of symptoms is it most effective?

Cognitive Behaviour Therapy for Psychosis:
helps to address any abnormal attributional processes and information processing and reasoning biases that may give rise to delusional thinking

use CBTp in a variety of ways:

• to help the sufferer challenge their delusional beliefs
• to develop non-psychotic meaning for symptoms such as hearing voices
• to reduce negative symptoms by challenging low expectations
• helping them to adjust to the realities of the outside world after dehospitalisation
• helping with medication compliance, CBT can also be extended to psychotic symptoms in the form of reattribution therapy

success of CBTp:
reduced hallucinations and delusions
decreased positive and negative symptoms
lifting mood and improving life functioning

critisicms:
does not appear to be significantly better than other forms of therapy for treating psychosis

Question 22

The Treatment of Psychosis
Psychological Therapies
Personal Therapy, CRT and CET

Answer 22

Reattribution therapy
Challenges dysfunctional and delusional beliefs. Attempts to generate alternative explanations for delusional (e.g. paranoid) beliefs. Usually provides ‘reality’ tests for clients to test out the reality of their beliefs (e.g. Chadwick & Lowe, 1994)

personal therapy:
a broad based cognitive behaviour programme that is designed to help individuals with the skills needed to adapt to day-to-day living after discharge from hospital.
Focused on day to day living skills:
ØIdentifying signs of relapse
ØRelaxation techniques
ØIdentifying inappropriate emotional and behavioural responses
ØIdentifying inappropriate cognitions
ØDealing with negative feedback from others
PG274 for more info…

cognitive remediation training (CRT):
A treatment programme for clients designed to develop and improve basic cognitive skills and social functioning generally.

cognitive enhancement therapy (CET):
a form of intervention that addresses deficits in both social cognition (the ability to act wisely in social situations) and neurocognition (basic abilities in cognitive functioning, such as memory and attention)

Question 23

The Treatment of Psychosis
Psychological Therapies
Family Interventions

Answer 23

can you describe a typical family-based intervention for psychosis and the factors that such interventions are designed to address?

family interventions (as well as most interventions) are designed to educate the family about the nature and symptoms of psychosis and how to cope with the difficulties that arise from living with someone with a diagnosis.

supportive family management - a method of counselling in which group discussions are held where families share their experiences which can help to provide reassurance and a network of social support

Elements of supportive family management:
•Families learn about diagnosis, prevalence and aetiology of symptoms
•Learn about antipsychotic medication and helping the sufferer comply with the medication regime
•Taught to recognize the signs of relapse
•Learn social skills to help solve family problems
•Learn to share experiences and avoid blaming

applied family management - an intensive form of family intervention which goes beyond education and support to include active behavioural training elements

Question 24

The Treatment of Psychosis
Psychological Therapies
Community Care

Answer 24

what are the different types of community care programmes provided for individuals diagnosed with schizophrenia, and is there any evidence for their effectiveness in controlling psychotic symptoms?

assertive community treatment and assertive outreach are forms of community care that help the individual recovering from psychotic symptoms with their medication regimes, psychotherapy, decision making, residential supervision and vocational training.

aims and characteristics of both programmes PG277

Question 25

Schizophrenia and Physical Health

Answer 25

in schizophrenia, life expentancy is reduced by 20years, primarily due to cardiovascular disease (CVD)

physical activity modifies CVD risk factors, but physical activity levels are low in this patient group.

we urgently need evidence based interventions that increase physical activity to improve health and reduce mortality.

Question 26

Early intervention services

Answer 26

• The sooner psychotic symptoms are identified and treated, the better the outcome.
• In the UK resources have been put into the establishment of early intervention services –multi-disciplinary teams to provide intensive case management to at-risk individuals.
• Aim is to reduce the duration of untreated psychosis to less than 3 months.

Are early intervention services effective?

“The evidence is clear that outcomes for patients in EI services are better than for standard care within CMHTs. This is hardly surprising given that staff in EI services have lower caseloads, have better access to psychological and social support and treatment, and can work more intensively with their patients and families. However, there is limited evidence in the UK that EI services have any impact on longer-term outcomes for patients with psychosis, and concerns that these patients do not maintain the benefits of EI when discharged from EI services to standard care.”

Neale, A., & Kinnair, D. (2017). Early intervention in psychosis services. British Journal of General Practice, 67(661), 370–371.
http://doi.org/10.3399/bjgp17X692069