L4 - SCZ AND OTHER PSYCHOTIC DISORDERS

Question 1

Name some psychotic symptoms?

Answer 1

DDHGN

Delusions - inability to question thought content
Hallucinations
Disorganised thinking (speech)
Grossly Disorganised or Abnormal Motor behaviour (catatonia)
Negative symptoms

Question 2

What are delusions?

Answer 2

They are fixed beliefs that are not amenable to change in light of conflicting evidence.

Question 3

Name some types of delusions.

Answer 3

6 - PREGNS

Persecutory delusions - belief that one is going to be harmed or harassed, by an individual, organization or other group (most common)

Referential delusions - belief that certain gestures comments, environmental cues are directed at themselves (hidden messages)

Grandiose delusions - that an individual has exceptional abilities, wealth or fame.

Erotomanic Delusions - false beliefs that someone is in love with him/her. Doesn’t believe it even when person says no.

Nihillistic Delusions - belief that a major catastrophe will occur

Somatic Delusions - Preoccupations regarding health and organ function.

Question 4

What are two features that a delusion can be?

Answer 4

Bizarre or non-bizarre

• bizarre if its clearly implausible
• non-bizarre = may have happened but extremely unlikely

and

Primary or Secondary

• primary = formed without prior change in mood or perception
• secondary = thoughts developed as a consequence of some abnormality of mood/memory/perception

Question 5

What is a Hallucination?

Answer 5

A perception-like experience that occurs without an external stimulus.

Most commonly auditory, but can happen with any sensory modality

Question 6

What are some features of disorganised thinking/speech?

Answer 6

derailment or loose associations

tangentiality - not answering question properly/providing irrelevent info

incoherence (“Word salad”)

Question 7

Describe what grossly disorganised or abnormal motor behaviour is.

Answer 7

Can manifest in numerous ways.
childlike “silliness” or unpredictable agitation

CATATONIA - marked decrease in reactivity to the environment. (not common)

Question 8

What are negative symptoms?

Answer 8

Thoughts, feelings, or behaviours normally present that are absent or diminished in a person with a mental disorder.

• Diminished emotional expression - intonation of speech, movements of hand head and face
• Avolition - decrease in motivated self-initated purposeful activites
• Alogia - diminished speech output
• Anhedonia - decreased ability to feel pleasure
• Asociality - lack of interest in social interactions

These symptoms are harder to combat that positive symptoms.

Question 9

What is Brief Psychotic Disorder?

Answer 9

A. presence of at least 1: delusions, hallucinations, disoganised speech, grossly disorganised or catatonic behaviour

B. episode lasts at least 1 day and less than 1 month

C. disturbance not better explained by MDD or Bipolar, or due to another med condition of subs use

Question 10

What is delusional disorder?

Answer 10

A. presence of at least 1 delusion with duration of 1 month or more.

B. Never had 2 or more sz symptoms for a month

C. Functioning is not markedly impaired, and behaviour is not bizarre.

D. only brief manic or depressive episodes

E. disturbance not attributed to anything else..

Question 11

Describe Shizophreniform Disorder.

Answer 11

A. 2 or more psychotic symptoms for 1 month, or less if treated.
B. Episode of the disorder lasts at least 1 month but less than 6 months.

Question 12

Describe Schizophrenia.

Answer 12

A. 2 or more psychotic symptoms for 1 month or less if treated.
B. level of functioning in one or more major areas is markedly below level achieved prior to onset/expected level.
C. continuous disturbance for at least 6 months
D. not attributable to anything else.

Question 13

Describe schizoaffective disorder.

Answer 13

A. uninterrupted period of illness during which there is a major mood episode (Major depressive or manic)
B. delusions or hallucinations for 2 or more weeks in absence of mood episode.
C. symptoms that meet criteria for major mood episode are present for majority of total active and residual portions of illness.
D. not attributable to anything else.

• no overlap of mood and schizo episodes, they happen seperately

Question 14

Age of onset for schizophrenia?

Answer 14

average:
male - 18
female - 25

same prevalence rates across genders

Question 15

Associated features with SZ?

Answer 15

Depression
suicide
anxiety
PTSD - trauma from experience of psychosis or its treatment
Substance use problems 
poor quality of life
stigma

Question 16

Are people with psychotic disorders violent?

Answer 16

No, they tend to withdraw from others.

Factors that predict violence are the same as in the general population - male, past history of violence, certain personality trains, substance abuse, etc.

They are more likely to be victimised.

Question 17

What is the link between psychosis and genetics?

Answer 17

• heritability seen
• Epigenetics - COMT gene and interaction with cannabis.
  involved in the breakdown of dopamine. Some enzymes promote a slower breakdown of dopamine than others - risk of developing psychosis is increased with specific form of COMT gene.

Question 18

Are psychotic disorders caused by a character flaw?

Answer 18

No personality traits are linked to schizo or psychotic disorders.

Question 19

What is the dopamine hypothesis?

Answer 19

This suggests that excessive dopamine functioning in the CNS is associated with psychotic symptoms.

To support this, it’s been found that:

• Drugs that reduce dopamine activity have some efficacy in treating sx of sz.
• Amphetamine, which causes the release of dopamine, produces symptoms of sz.

However, no evidence of high levels of dopamine has been found in brains of people with sz

so. .. OVERLY SENSITIVE DOPAMINE RECEPTORS?
or. . ASSOCIATED WITH POSITIVE SX ONLY?

NA and 5-HT also said to have a role

Question 20

Effects of sz on brain structure?

Answer 20

Englarged ventricles
reduced grey and white matter in prefrontal cortex

-found progressive change (UHR, FEP, Chronic) in hippocampus, pituitary volume and more.
-sz due to prenatal damage? result of genetic factors/enviro influence (maternal viral infection while pregnant, inadequate nutrition).
- Neurodevelopmental model - silent damage emerges in prefrontal cortex as the latter develops in adolescence.
- ‘TWO HIT’ model - one early hit, and another one in adolescence –> 1st hit exposed during early neurodevelopmental stages. creates vulnerability. second hit in later life, exposes symptoms.
- Olfaction - olfactory deficts are seen in pre-psychotic, FEB and chronic patients. olfactory brain reigons linked with regions believed to be associated with sz.
deficits might be risk factor

Question 21

Role of Family in SZ?

Answer 21

Psychological factor.

• Schizophrenogenic Mother - cold, aloof, overprotective, domineering, strips child of self esteem and independence.
  Has been discredited.
• COMMUNICATION DEVIANCE MODEL - Families of sz tend to have deviant communication patterns.

Question 22

Social Factors in SZ?

Answer 22

Psychological factor.

Risk factors are - living in urban enviro, migraine and being socially excluded.

Maybe a link to minority status in high density living, especially with use of cannabis.

Question 23

Childhood Trauma and SZ?

Answer 23

Psychological Factor.

sig portion of people w/ psychotic disorder report traumatic experiences in childhood. May play a causal role in psychosis.

Question 24

Stress and SZ?

Answer 24

high risk patients who developed psychosis had increased pituitary volumes, indicating higher levels of stress hormones.

Question 25

Cognitive model for SZ?

Answer 25

Morrison, Bentall, Birchwood, Garety.

We all have intrusive thoughts, but we can dismiss them.

Person at risk won’t dismiss. Sees thought as problematic, important and undismissable.
Heightened awareness of future intrusions
—> -ve appraisals, trying to make thoughts go away.

Culturally unacceptable interpretations of intrusions into awareness results from faulty knowledge of self. leads to misattribution of thought to external source.

Question 26

Substance use and Psychosis

Answer 26

Andreasson et al. (1987) - those who used cannabis by 18 years were 2.4 times more likely to develop sz compared to those who had not

Zammit et al. (2002) - at 27 year follow up, it was estimated that the rish of cannibis use to sz was 13% when other factors such as other drug use or psychiatric symptoms were controlled.

Question 27

what is the self-medication hypothesis?

Answer 27

Suggests that individuals with psychosis use cannabis to control symptoms or to improve mood.
- some people w/ psychosis say that cannabis relieves their symptoms, but often at the cost of an increase in other symptoms

• studies show increase in positive symptoms following use however…

Question 28

What is the illness course of a psychotic disorder?

Answer 28

Premorbid
Prodrome/Ultra High Risk Group - resolves in some people
Acute phase
Early Recovery
(Relapse will go back to acute)
Late Recovery

Question 29

What are some features of the premorbid phase?

Answer 29

Mostly assessed retrospectively

• presence of risk factors discussed.
• social func deficits identified by teacher
• poorer motor skills and higher level of neuromotor abnormalities

Question 30

Features of the prodromal phase?

Answer 30

• average 2 yr duration - highly variable
• identified based on having close relative with psychosis, and own experience of subtle indicative signs and symptoms.
• specific and non specific (to psychotic conditions) changes.
  specific eg: fleeting auditory hallucination
  non specific eg: depressed mood

Question 31

Features of the acute phase?

Answer 31

• Acute psychotic episodes
• young people often suffer prolonged periods of acute psychosis before actually being diagnosed or treated..
• longer DUP = longer time for treatment response.

Question 32

Features of Early Recovery Phase?

Answer 32

• this is the first few months post initiation of treatment
• significance of episode/illness may be considered
• integration/sealing-over
• problems with depression and social anxiety may emerge for the first time as the person begins to reflect on their diagnosis and its significance for their future.

Question 33

Features of the Late Recovery Phase?

Answer 33

• resumption of education/work
• social/recreational re-connecting
• relapse occurs here in 80-90% of cases

Question 34

Risk factors of relapse?

Answer 34

• Substance use, medication non adherence, carer-critical comments, poor premorbid adjustment.

not risk factors:
-DUI, DUP, positive and negative affective symptoms, age of onset, gender, marital status, education and employment.

Question 35

What is Expressed Emotion (EE)?

Answer 35

Family interaction style, where members are over protective, self sacrificing towards person with problem.. while also expressing high hostility and criticism.

This contributes to relapse, but not first onset.

Question 36

What are some impacts of relapse/chronic illness?

Answer 36

Unemployment
Housing difficulties
poor physical health
side effects of anti-psychotics
neglect children

Question 37

Psychosis and treatment?

Answer 37

Medication - in acute phase

low-dose approach is best

psych - CBT, psychoeducation for both family and patient

Question 38

What are some ways stigma negatively affects SZ?

Answer 38

• limit a person’s capacity and how they think of themselves
• stigma can be internalised, leading to feelings of shame and low self-esteem
• lead to avoidance of services and delayed treatment!