Lecture 11 - Psychosis Flashcards
Define psychosis
- umbrella term
- variety of syndromes + symptoms
- at disorder level: group of disorders distinguished by configuration, duration, relative pervasiveness
What are the 5 key psychotic symptoms?
- delusions
- hallucinations
- grossly disorganised or abnormal motor behaviour (incl. catatonia)
- disorganised thought (speech)
- negative sx
What are delusions? What are the 2 specifiers? What are the 6 types?
- fixed beliefs, not amenable to chance in light of conflicting evidence
- bizarre v. non-bizarre
- primary v. secondary
- PERSECUTORY: one is going to be harmed/harassed
- REFERENTIAL: certain gestures/comments/environmental cues are directed at oneself
- GRANDIOSE: exception abilities, wealth, fame
- EROTOMANIC: falsely believe others are in love with them
- NIHILISTIC: major catastrophe will occur
- SOMATIC: preoccupations regarding health + organ function
What are hallucinations?
- perception-like experiences that occur without an external stimulus
- auditory most common (but can be any sense)
- hallucinations may be a normal part of religious experience in certain cultural contexts
- hearing voices network > normalising it in everyday life
Explain disorganised thought/speech
- aka formal thought disorder
typically inferred from individual’s speech:
- derailment or loose associations
- tangentiality
- incoherence or ‘word salad’
Explain disorganised or abnormal motor behaviour
- manifest in a no. of ways (range from childlike silliness to unpredictable agitation)
- catatonia: marked decrease in reactivity to the environment
Explain the negative symptoms of psychosis
- DIMINISHED EMOTIONAL EXPRESSION: in face, eye contact, intonation of speech (prosody) + movements in hand, head and face that typically give emotional emphasis
- AVOLITION: decreased motivation for self-initiated, purposeful activities
- ALOGIA: diminished speech output
- ANHEDONIA: decrease ability to experience pleasure
- ASOCIALITY: lack interest in social interactions (may be associated with avolition, can also manifest limited opps for social interaction)
What is delusional disorder?
- 1+ delusions
- > 1 mth
- specifiers: erotomantic, grandiose, jealous, persecutory, somatic, mixed, unspecified
What is brief psychotic disorder? What are the specifiers?
- 1+ of delusions, hallucinations, disorganised speech, grossly disorganised behaviour
- 1 day to 1 month, eventual full return to premorbid level of functioning
- specifiers: without/with marked stressor, postpartum onset, catatonia
What is schizophreniform disorder? What are the specifiers?
- 2+ of delusions, hallucinations, disorganised speech, grossly disorganised behaviour, -ve sx
- 1-6mths
- specifiers: with/without good prognostic features; catatonia
What is schizophrenia?
- 2+ of delusions, hallucinations, disorganised speech, grossly disorganised behaviour, -ve sx
- 6+ mths (1+mth of active sx)
What is schizoaffective disorder?
- major mood episode (depression or mania) co-occurs with schizophrenia A criteria
- delusions/hallucinations for >2wks without mood (but majority of time mood episode present)
What are the other DSM-5 psychotic disorders?
- substance/medication induced psychotic disorder
- psychotic disorder due to another medical condition
CATATONIA
- catatonia associated w another mental dx
- catatonia dx due to another medical condition
- unspecified catatonia
- other specified scz spectrum and other psychotic dx
- unspecified scz spectrum and other psychotic dx
Explain the psychosis symptom severity ratings
- scales for dimensional assessment of primary psychosis sx
- captures variation in severity of sx which may help treatment planning, prognostic decision-making and research
- for: hallucinations, delusions, -ve sx (facial expressibility, prosody, gestures, self-initiated behaviour)
- scale:
- 0: not present
- 1: equivocal (severity/duration not sufficient to be considered psychosis)
- 2: mild (little pressure to act upon H/D or not very bothered by H/D; mild -ve sx)
- 3: moderate (some pressure to act upon H/D or somewhat bothered by H/D; mod -ve sx)
- 4: severe (severe pressure to act upon H/D or very bothered by H/D; severe -ve sx)
What are the associated features of psychotic disorders?
- depression
- suicide (5-10% complete)
- anxiety
- PTSD (trauma may be experience of psychosis itself; may be associated with treatment - police, restraint, hospital etc.)
- substance use
- poor QOL (occupational, rship, social, emotional functioning)
- stigma
What is the prev, gender split and onset of psychotic disorders?
- lifetime prev: 1-2% schizophrenia, 0.2% delusions, 0.3% schizoaffective
- higher in migrants, developing countries, urban
- SCZ gender split 3:2 M:F
- onset: peak late adolescence/early adulthood (women, also peak at menopause)
What are the stages of the illness course of psychotic disorders? (6)
premorbid prodrome acute early recovery late recovery relapse
Explain the premorbid phase
- assessed retrospectively
- social functioning deficits
- premorbid adjustment scale
- home movies study > poorer motor skills, more motor abnormalities
- better premorbid hx: older age of onset, late age at first hospitalisation, later first neuroleptic use
Explain the prodromal phase
- retrospective
- average: 2 years
- non-specific changes followed by specific
- can resolve! 65% don’t do on to develop psychosis
Explain the acute phase
- emergence of persistent +ve and -ve sx
- duration untreated psychosis (DUP): longer DUP = longer time for treatment response
- DUP influenced by health professionals + lacking help-seeking/resources + stigma
Explain the early and late recovery phases
EARLY
- few few mths post starting treatment
- sig. of episode/illness may be considered
- integration: into sense of self, accomodate illness > better outcome!
- sealing-over: lack insight/integration > poorer outcomes
LATER
- resume work/study
- social reconnection
- up to 80% FEP have relapse within 5yrs
- 7yr follow up FEP: sx remission 37-50%; social/vocational recovery 31%; both 25%
What are the risk factors for relapse? What does relapse not depend on?
RISK
- substance use
- medication non-adherence (due to stigma, dampening of motivational drives)
- carer critical comments
- poor premorbid adjustment
- expressed emotion: families (conflict, criticism, hostile, over-involved)
DOESN’T MATTER
- age of onset, gender, education, employment, marital status
- insight, DUI, DUP
- +ve/-ve/affective sx
What is the impact of relapse/chronic illness?
- unemployment
- housing difficulties
- poor physical health
- side-effects of anti-psychotics
- neglect children
Explain the history of SCZ
KRAEPELIN: dementia praecox
- deteriorating course, early onset
- diff from manic depression (worse prognosis)
- sx: hallucinations, delusions, negativism, attn. diffs, stereotypes, emo dysregulation
BLEULER: manic depression + SCZ on continuum
- not necessarily early onset/deteriorating
- sx: disturbed thought + affect, ambivalence, autism, avolition
SCNEIDER: first rank sx
- hallucinations (somatic, voices of self/other)
- thought withdrawal/insertion/broadcasting
- delusional perception (ideas of reference)
- made feelings/actions/impulses
1970s: varying rates, no standard criteria. Criteria made.
1980: DSM-III
- narrow (neo-Kraepelin) view
- inclusion, exclusion, duration
- impaired functioning
- 5 subtypes: paranoid, disorganised, catatonia, undifferentiated, residual
CURRENT
- over-focus on chronic samples > representative of very poor outcomes + contaminated by institutions, med side-effects etc.
- need to look more at FEP and prodrome
- must study psychotic sx not SCZ as a construct
Explain the aetiological models of psychosis
STRESS-VULNERABILTY
- diff predispositions, need diff levels of environmental factors to push us over
GENETICS
- adoption studies, GxE interactions
- risk increases as degree of genetic relatedness increases
NEUROTRANSMITTERS
- DA hypothesis > excessive
- drugs that reduce DA help; amphetamines release DA can can cause sx
- BUT not high DA in scz patients > maybe overly sensitive receptors? maybe only associated with +ve sx?
- also NE and 5HT
BRAIN STRUCTURE + FUNCTION
- enlarged ventricles
- smaller PFC + hippocampus
- lower IQ and WM + worse exec functioning
FAMILY
- discredited: schizophrenogenic mother (cold, overprotective, domineering, aloof etc)
- communication deviance model: deviant communication patterns in fam (incoherent, confused, vague, incomplete verbal exchanges)
SOCIAL
- urban environment
- migration (minority group)
- social exclusion
- cannabis
CHILDHOOD TRAUMA
- sexual/physical abuse > often ignored in literature, but some suggest it may play a causal role
Explain the cog model of psychosis
- culturally unacceptable interpretations of intrusions into awareness
- role of appraisal is central!!
- interpretations result from fault sense of self/others > misattribute thought to external source
- response increases likelihood of future intrusions: mood disturbance, physiological arousal, behavioural change, cognitive change
What are the 2 tasks in UHR research?
1: accurate identification of young people at risk of psychosis
- fam hx, attenuated sx, BLIPS
- 6mths: 28% transitioned to scz; 37% at 12mths
- if no transition > high comorbidity + dev other dx
2: develop preventative interventions
- aim: reduce transition rates + reduce impact on functioning/delay psychosis
- psych interventions + omega-3 over anti-psychotics
