lecture 10- Psychotic disorders ( schizophrenia) Flashcards
what is psychosis
Extreme impairment in several areas of functioning o Clarity of thought o Emotional response o Communication o Understanding reality o Behaviour * Severely interfere with normal life * Psychotic symptoms are observed in many other conditions o Schizophrenia (and subtypes) o Bipolar disorder o Severe depression o Alcohol and drug abuse o Withdrawal from alcohol/recreational drugs
name some aspects of schizophrenia on the DSM
A. (Characteristic symptoms) Two or more of following … at least one must be 1, 2 or 3:
o Delusions
o Hallucinations
o Disorganised speech
o Grossly disorganised or catatonic behaviour
o Negative symptoms
* B. For significant proportion of time … level of functioning … markedly below pre-onset functioning
* C. Signs of disturbance must persist for at least 6 months (with some variations according to profile)
* D. Schizoaffective disorder and depressive/bipolar disorder with psychotic features has been ruled out
* E. …is not attributable to psychological effects of a substance or another medical condition
name the positive symptoms of schiz
delusions
hallucinations
explain some aspects of delusions - a positive symptom
Firmly held (erroneous) beliefs o Distorted reasoning o Misinterpretation of perception * Delusion of control * Delusion of reference * Erotomania * Grandiose delusion * Persecutory delusion * Religious delusion
explain the different types of hallucinations- a positive syptom
Distortions or exaggerations of perception
o Perceiving sensations that are not apparent to others
* But are vivid, substantial, and real to the patient
o Can relate to any of the senses
* Most commonly auditory
* Followed by visual
o But can also relate to other senses
* Olfactory – smell
* Taste
* Tactile/body sensations
* Auditory hallucinations (most commonly)
o Hearing voices that no-one else can hear
* May be heard as conversations between other people
* Or may be directed at the patient
o Voices may comment on patient’s behaviour
* Often menacing or intimidating
* Voices may even ‘issue commands’ or warn of danger
* Visual hallucinations
o Seeing things that no-one else can see
* May be distinct, such as people or objects
* Or may be vague perceptions of colour and sha
name and explain negative symptoms of hallucinations
Affective flattening
o Reduction in range and intensity of emotional expression
* Alogia
o Poverty of speech
* Avolition
o Reduction or difficulty with goal-directed behaviour
* Other social dysfunction impairments
o Reduced energy
o Lack of motivation
o Poor hygiene
o Problems functioning at school, work, or other activities
o Moodiness (including severe mood swings)
describe disorganised speech
Patient’s inability to think clearly and respond appropriately
* Most commonly associated with irregular speech
o Talking in sentences that do not make sense
o Rambling loose associations
o Using nonsense words
o Speaking incoherently
* Can also be related to behaviours
o Odd movements
o Disorganised actions
o Catatonia
list some causes of schizophrenia
veral causal explanations have been suggested
o Schizophrenia is strongly linked to biological causes
* But, environmental triggers are also likely to be needed
o Some of the most strongly associated causes:
* Genetics
* Obstetric events
* Infections
* Brain structure and function
* Neurochemistry
* Substance misuse/withdrawal – as discussed earlier
* Social explanations and life experiences
* Cognition
explain some genetic explanations for schiz
Schizophrenia tends to (somewhat) run in families
o Risk of schizophrenia about 10% if parent has the illness
* General population risk is 1%
o Risk in monozygotic twins is 11-14% (quite low)
* Against 1-4% in dizygotic twins
* BUT 60% of pts do not have any other family member with psychotic disorder
o AND genetic predisposition does not always lead to illness
* Probable that inherited genes make a person vulnerable to schizophrenia
o But environmental factors act on vulnerability to trigger illness
describe some social explanations of schi
Risk for schizophrenia increases with number of adverse social factors experienced in childhood (Wicks et al 2005) * Some key social risk factors (e.g. see Mueser & McGurk, 2004; Jarvis, 2007) o Birth events (maternal illness, etc) o Physical or sexual abuse in childhood o Poverty o Lower social class o Social deprivation o Migration and racial discrimination o Relationships o Urbanicity
explain some cognitive causes of schi
Interaction between neurobiological, environmental, cognitive, and behavioural factors (Beck & Rector 2005; Kuipers et al 2006)
o Brain structure abnormalities may predispose illness
* And environmental stressors may provide trigger
o But cognitive interpretations guide maladaptive behaviour
o Delusions could be due to cognitive biases
* Such as negative external attributions
o And inappropriate behaviour
* Such as jumping to conclusions
o Hallucinations may be result of attention biases
describe (Thornicroft et al 2004) study on the social impacts of schiz
European study explored personal impact (Thornicroft et al 2004) o Poorer personal outcomes * Higher rates of unemployment * More likely to be single * Greater use of welfare benefits o Poorer quality of life * Anxiety/depression * Alcohol/substance abuse * Poor social life * Health factors (side effects of medication etc) * Poor personal care and hygiene * Labelling and stigma * Social deprivation
explain how schiz affects functional impairment
While social deprivation might be potential cause
o It is also a consequence
* Schizophrenic people often live in poor urban areas
o But did that cause the illness?
* Or did the illness cause a drift towards social deprivation?
o Social causation hypothesis (Hollingshead & Redlich 1958)
* Those in lower classes suffer greater levels of stress
* More likely to trigger predisposition
o Social drift hypothesis (Wender et al 1973)
* Those with schizophrenia cannot gain employment
* “Drift down” to the lower classes
explain the social cognition impairment of chiz
Social cues (verbal and non-verbal) involve perception:
o Processing others’ emotional facial expression
o Recognition of familiar social situations
* Theory of mind (ToM)
o Recognition of others’ intentions and thoughts
* Depends on interpreting non-verbal social cues
o Schizophrenia pts impaired in ToM (Brüne 2005)
* Often measured using ‘faux pas’ recognition tests
* Schizophrenia also associated with other cognitive dysfunctions (Rodriguez-Sanchez et al 2008)
o Information processing (esp. abstract)
o Executive function and problem-solving
o Speed of processing
explain the burden of schizophrenia
Burden
* Schizophrenic pts represent sig burden to society (Awad & Voruganti 2008)
o On caregivers – family & friends
o Economic costs
o Hospitalisation
o Psychosocial support
o State benefits
o Lost production
* But most research focuses on family burden
o Emotional, psychological, physical and economic impact
o Distress, shame, embarrassment, guilt, self-blame
Family (and/or friends) burden
* Burden of care often focuses on two constructs
o Objective burden
* Effects on the household
* Taking care of daily tasks
* Family dynamics
* Loss of social activities
* Effect on leisure time and/or career
* Finances
o Subjective burden
* Caregivers’ perceptions of that burden
* How they cope with objective burden
* Recent research focuses on determining factors
* Schizophrenia and family burden (Gutiérrez-Maldonado et al 2005)
o Burden of caring for schizophrenic person associated with:
* Reduced quality of life
* Sig impact health and functioning of caregivers
o Higher levels objective and subjective burden ð
* High expressed emotion ð
* Increases risk of schizophrenia relapse in patient
o Distress and dissatisfaction from burden:
* Perceived losses in carer’s life
* Lost opportunities because of caring for patient
* Stigma concerning schizophrenia
* Financial problem`
explain how schizophrenia affects your physical health
- Cardiovascular illness ð 20% of deaths in schizophrenia pts (Newman & Bland 1991)
- Outcomes may be related to two factors:
o Long-term treatment with antipsychotics (see later)
o Patient lifestyle - Lifestyle factors that may contribute to physical illness
o Increased cigarette and alcohol use
o Poor diet (high fat/low fibre)
o Lack of exercise
o As many as 90% schizophrenia pts dependent on nicotine
o Up to 70% abuse alcohol/drugs (Vieweg & Levenson 1995
how does schiz affect your death rates
Schizophrenia pts associated with greater mortality
o Shortened life expectancy – up to 20% (Ryan & Thakore 2002)
* Risk factor for suicide 20x greater than general population
* Major risk in psychotic pts (see Hawton et al 2005 for review)
o 4–10% schizophrenia pts kill themselves (Palmer et al 2005)
* General population rates: 17-20 per 100k for men
* 5-6 per 100k for women
* Suicide ideation and attempted suicide common
o More than 50% pts show sig ideation at some stage of illness (Barrowclough et al 2004)
what are the sucide rates of people with schiz
- Major risk in psychotic pts (see Hawton et al 2005 for review)
o 4–10% schizophrenia pts kill themselves (Palmer et al 2005) - General population rates: 17-20 per 100k for men
- 5-6 per 100k for women
- Suicide ideation and attempted suicide common
o More than 50% pts show sig ideation at some stage of illness (Barrowclough et al 2004)
explain the medication treatments for schiiz
Antipsychotic medication
o Do not cure schizophrenia
o Help relieve most troubling symptoms
* Delusions, hallucinations, disorganised thought
* Original (typical) antipsychotics:
o Haloperidol, chlorpromazine, fluphenazine, thiothixene, etc
o Replaced because of serious side effects (see later)
* Newer (atypical) medications:
o Risperidone, olanzapine, clozapine, quetiapine, aripiprazole
explain the major issues with medical treatments for schiz
Extrapyramidal symptoms (EPS)
o Repetitive, involuntary muscle movements
* Dyskinesias - movement disorders
o Tongue movements, lip smacking, eye blinking, moving arms/legs
o Akathisia - extreme form of restlessness
o Complete inability to sit still, urge to be moving constantly
* Dystonias - muscle tension disorders
o Very strong muscle contractions
o Unusual twisting of parts of body – esp. neck
* ‘Tardive’ symptoms may occur with long term treatment
o More permanent movement/muscle disorders
explain the use of antipsychotics for treating schiz
Atypical antipsychotics
* Mostly without EPS side effects
o Although risperidone still quite high with larger doses
o Important to consider this with vulnerable pts
o e.g. elderly, pts with Parkinson’s disease
* Commonly used in psychiatric community
* Neurotransmitter activity varies between drugs
o But most commonly reduce dopamine availability
* While EPS reduced
o Still risk for tardive dyskinesia
o Particularly after long-term use
explain the effectiveness of antipsychotics
Several studies confirm atypical APs superior to original drugs
o And better EPS profile (see Serretti et al 2004 for overview)
* Original antipsychotics focused on positive symptoms
o Some atypical APs treat positive and negative symptoms
o May be due to dual role of dopamine and serotonin action
* Several studies confirm greater efficacy
o Particularly at higher doses
o Better treatment of negative symptoms
o Reduced suicidal thought
o Greater benefits in treatment-resistant conditions
explain the side effects of using antipsychotics to treat schiz
Sedation quite common
o But better tolerated over time
* Weight gain can be a particular problem
o Especially clozapine and olanzapine
o Potentially serious – consider consequences
* Can lead to poorer QoL profiles
* May affect treatment adherence
* Can cause obesity
o Some novel APs may cause diabetes
o Overweight schizophrenic pts need particular attention
* Other side effects:
o Dry mouth, dizziness, hypotension, tachycardia…
* See Tandon (2002) for overview of side effects
explain how rehab can be used to treat schizophrenia
Psychosocial therapies
* In most cases, antipsychotic treatment is essential
* However, a number of additional therapies can be used
o Help with behavioural, psychological, social, and occupational problems
* Pts can learn to control their symptoms
* Identify early warning signs of relapse
* Develop a relapse prevention plan
Rehabilitation
* Help pts function independently in community
o Learning social skills
o Employment training
* Combined therapies generally better
* 30 Turkish schizophrenia pts examined (Yildiz et al 2004)
o 15 underwent psychosocial training skills training
o 15 had ‘treatment as usual’ (TAS)
* Medication plus treatment discussion with pts and family
o Intervention group showed sig improvement
* Positive and negative symptoms, QoL, social functioning, global functioning
o TAS group showed no improvements
explain how psycho education can treat schiz
Education about mental illness for patients and their families
o Diagnoses, delusions and hallucinations
* Impact on behaviour, thought and emotion
o Potential causes
o Treatments
* Particular focus on benefits, side effects, adherence
o Prognoses
o Discuss role family can play helping pt get/stay well
* How this can impact on family burden
o Help families improve communication skills
* Efficacy of psychoeducation (PE)
o Good outcomes for family burden
* 52 PE vs. 56 controls
* Post-treatment ‘family burden’ sig better for PE group
* Near-sig difference for financial burden
* No between-group diff at baseline
o Patient outcomes
* Follow-up study – 7 years post-treatment
* 24 PE vs. 24 treatment as usual (TAS)
* Re-hospitalisation rate: PE 54% vs. 88% TAS
* No hospital days: PE 75 vs. 225 TAS
o See Bauml et al (2007) for overview
explain the use of behavioural therapies for treating schiz
o Focus changing patterns of learning
- Social skills
- Cause and effect
- Learning from experience
- Stress management
- Assertiveness
- Problem solving
- But most therapies also include cognitive processes
explain the use of cognitive therapies for treating schiz
cognitive therapies (see Beck & Renton, 2005)
o Unlike depression, not easy to ‘change’ patterns of thought in schizophrenia
* Produced by biological abnormalities
o More successful techniques help adapt thought
* Take information from environment
* Adapt ‘misinterpretations’ to cope with own ‘reality’
* But better if combined with behavioural techniques
explain the use of CBT therapies for treating schiz
CBT (see Turkington et al 2008)
o Often been dismissed in schizophrenia
* But good evidence success
* No side effects
* CBT for schizophrenia
o Typical procedure
* Aim is to enhance cognitive function
* Pt expresses thoughts about experiences
* Discuss symptom causation and maintenance
* Do NOT challenge beliefs – work with them
* Pt taught to understand processes in their complex lives
* ABC method used:
* Activating event – Beliefs – Consequence
* Pt discusses their perception of ABC – especially B to C
* Therapist discusses rationality
* Collaborative critical analysis ð develop alternative explanations
