Lecture 12: Psychotic symptoms across disorders Flashcards
Psychosis vs. Psychotic Symptoms (wat is het verschil?)
- Psychosis is a symptom (or collection of symptoms)
- Psychotic disorders are diagnoses in which psychosis / psychoses play an important part
- Psychotic symptoms are (inherently) much more common than psychotic disorders.
- Valid question whether the psychotic syndromes are ‘distinct nosological entities’ (Plain English: are they different disorders?)
psychosis =
disturbances in experience of reality or reality testing
(to avoid complex philosophical debates: the dsm classifies based on observable behaviours and reported experiences (want wat is reality dan????)
psychotic symptoms: transdiagnostics
- Delirium
- Major Depressive Disorder
- Autism Spectrum Disorders1
- Bipolar Disorders
- (Street-)drugs / withdrawal
- Side effects of medication (e.g. prednisone, Parkinson’s medication)
- Lack of sleep
- Post-partum / Estrogen withdrawal
- Dementias
- Brain tumor
dsm symptoms
- Delusions
- Hallucinations
- Grossly disorganized or abnormal motor behavior
- Disorganized thinking (speech) -> or: formal thought disorder
- Negative symptoms
wat voor spectrum heb je binnen psychosis
affective (more acute onset, better premorbid adjustment)
non-affective (more insidious onset, poorer premorbid adjustment)
what is the most commonly used diagnostic instrument for psychosis
positive and negative syndrome scale (PANSS)
- semi-structured interview/rating scale
- 30 symptoms
positive symptoms=
- delusions
- hallucinations
delusions =
fixed belies that are not amenable to change in light of conflicting evidence
ockams razor=
is de stelling dat wanneer er verschillende hypotheses zijn die een verschijnsel in gelijke mate kunnen verklaren, die hypothese gekozen moet worden die de minste aannames bevat en het kleinste aantal entiteiten veronderstelt.
delusions soorten:
most common
- persecutory
- referential (delusions of reference) -> hidden meanings that somehow relate to the individual
less common
- somatic (eg. smelling really badly)
- religious
- grandiosity
- erotomanic (celebrity in love with me -> vrouw van lldl)
- nihilistic
hallucinations=
- Hallucinations are perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions.
- Can be on any modality
- Most common: auditory (‘voices’)
- Hallucinations are normal religious/spiritual experiences in many cultures
hoevaak komen audiovisual hallucinations and imaginary friendships voor
- Audiovisual hallucinations:
- Children around 8 years old: around 9%, 76% no longer at 12/13 years old
- General population: 5% – 28%
- Imaginary friendships:
- Children 5-12 yrs. old: +/- 46%
negative symptoms soorten =
Often
- Lessened expressivity
- Avolition: reduction of self-motivated goal-oriented activities
Less common:
- Alogia: reduction in speech output
- Anhedonia: reduced enjoyment of formerly enjoyable activities
- A-sociality: reduced interest in social activities
grossly disorganized or abnormal behaviour
can be considered as ‘difficulties in getting from A to B’.
disorganization
- catatonia (heel wax-like lichaam)
mania
wat is er met catatonia
- Catatonia is not only associated with schizophrenia / psychosis / mood disorders
- May be present in children / adolescents with autistic, developmental and tic disorders
- “a treatable syndrome secondary to many etiologies that is not linked as a subtype to schizophrenia anymore”.
wat is een bias bij psychosis van veel clinicians
clinicians generally focus on positive symptoms, whilst clients regard negative and disorganization symptoms as most troubling
non-dsm 5 symptoms of psychosis
- Mania
- Depression
- Anosognosia (difficulties with clinical insight)
- Jumping – to conclusions
- Cognitive slowing down (influence of medication?)
- Disturbances in working memory
- Disturbed motor function
- Disturbed experience of the ‘self’
- Difficulties in social cognition & metacognition
waarom is anosognosia een soort van circular reasoning
als ze er wel in zouden geloven zou het geen psychosis zijn
wat voor problemen bij social cognition
reading other people, inschatten van anderen hun stemming, victimization, when you misjudge others (dus bijvoorbeeld aangevallen worden door een “vriend”). maakt ook therapeutic alliance lastig: underestimation of clients satisfaction with social functioning.
incidence, prevalence en lifetime prevalence of psychotic disorders
indidence = 15 cases yearly per 100.000 ppl
prevalence = 0.07% (but a lot of variation between studies and cultures)
life time prevalence = 0.4% (schizophrenia)
known risk factors=
- Genetic factors
- Sex (men) and age
- Prenatal and perinatal risk factors
- Birth season
- Age of the father
- Level of urbanicity
- Trauma as a child
- Migration
- Premorbid intelligence
- Cannabis use
biological components of psychosis
- dopamine:
- reward (prediction)
- motivational salience -> mental highlighter
- motor function
Antipsychotics working on D2 receptor “necessary and sufficient” for antipsychotic activity.
- genetics
- gender: men more
- cannabis use
first antipsychotic=
Chlorpromazine (1950s) first antipsychotic
* 1960’s: first notion that these worked on dopamine
* 1970’s: First evidence that antipsychotics work on dopamine (D2) receptors
gender differences in schizophrenia
more men, women have more symptoms but tend to function better
dopamine hypothesis=
dopamine plays an important role in psychosis, like a mental highlighter -> tells you there is something very important around, and you have to focus
aberrant salience =
- elevated dopamine (striatum) leads to errors in assigning meaning/relevance: abberant salience
- innocent/unimportant stimuli are assigned significant meaning
hoe kan je delusions uitleggen volgens de dopamine hypothesis
delusions are formed to explain the disturbed meaning
hoe kan je negative symptoms uitleggen volgens dopamine hypothesis
Disturbances in dopamine system = disruption of motivational system, reward of stimuli is disrupted: negative symptoms
social risk factors for psychotic symptoms
- Growing up in an urbanized area
- Minority group position (Dose-response)
- Cannabis use
- Developmental trauma
trauma as a risk factor for psychosis
- A lot of trauma in persons with a psychotic disorder (50 – 98%)
- 80% of people experiences their psychotic episode as traumatic in itself
- Prevalence PTSD among persons with a psychotic disorder: 16%
- In 90% of cases PTSD is not noted in the patient file, but is present
social defeat hypothesis=
Feeling of social exclusion (migrants, deaf children) leads to dopamine sensitisation, which in turn leads to elevated risk of psychotic disorders
explanatory model of hallucinations
- errors in source monitoring
- perception isnt just coming from the senses (bottom-up), but also from expectations (top-down)
- mental imagery does not seem to just be more perception-like, but it is possible that the top-down factors are allocated more importance by the brain
errors in source monitoring=
“Inner speech” hypothesis: differentiation between internally and externally represented information gets disturbed. Internal is assigned as coming from external source.
Criticisms:
- Not all studies find this effect
- We know that attribution errors are made all the time (elderly, children) and more often do not lead to hallucinations
cognitive model for hallucinations
trigger (external or internal) -> intrusive thought -> increases cognitive dissonance + misattribution to an external source and experienced as an auditory hallucination -> appraisal of hallucination -> behavioural, affective responses, somatic
kijken in schrift
self-regulatory executive function model
- Positive Beliefs about worry
- Negative beliefs about controllability of thoughts and corresponding danger
- Cognitive Confidence
- Negative beliefs about thoughts in general
3 soorten recovery
- Clinical recovery = Symptom reduction
- Personal recovery = Living well in spite of symptoms
- Social / Psychosocial/ societal recovery = Ability for ‘role-fulfilment’
biases of client and therapist
client:
- insight
- self-stigma
therapist
- theoretical bias
- social stigma
-> hierdoor different narratives on mental health services, mental illness and stigma
pro’s of medication
- quick
- easy theoretical framework/evidence based
- possible large effects
- adherence is easy
cons of medication
- side effects
- loss of therpeutic alliance
- medication dependence
- possible medication carrousal (allerlei soorten uitproberen)
- long term health effects
team-based approaches =
Focus on maintaining community functioning, flexibly adjusting treatment as symptoms come and go (theoretically), adjusting the type and intensity of care depending on the needs of the client that day
team-based approaches pros
- flexibly offer variety of services
- community based
- multidisciplinary
team-based approaches cons
- neglect as usual in praktijk
- squeaky wheel gets the grease: wie het hardste schreeuwt krijgt meer aandacht
- large case loads for teams
- team functioning impacts care
- not able to offer all kinds of treatment
societal recovery interventions=
focus on rehabilitation.
very limited attention on symptoms, focus on managing symptoms enough for real-world outcomes
= tailor support so symptoms can be managed so practical, real-life outcomes can be achieved
pro’s van societal recovery intervention
- real life outcomes
- support
- relatively direct improvement of QoL
cons of societal recovery intervention
- difficult to implement
- reliance on factors outside of mental healthcare (bv employers, die hebben hier eigenlijk niks mee te maken)
- stigma
- what are the effects of failing? negatieve ervaring?
symptom oriented therapies=
reframing symptoms and challenging their underlying assumptions (for instance: voices are all-powerful) will reduce their impact on functioning / improve QoL.
bv. CBT
“John can be helped to challenge the idea that the rats can harm him”
pros of symptom-oriented psychotherapy
- short treatment
- well researched and protocolized
- can be delivered by psychologists and nurses
- transferable
cons symptom oriented psychotherapy
- limited success with limited patients amount
- not all symptoms are very amenable
- lack of insight is a big obstacle in these therapies
third generation cbt
The idea that CBT is ‘static’ is nonsense. There is constant development. We are currently in the ‘third’ generation
Integrating for instance:
- Mindfulness: From Buddhism, focus on ‘in the now’ and being in touch with emotions
- Acceptance and Commitment Therapy: Fighting inevitability is useless, rich life is possible with symptoms
- Metacognition: Thinking about your own cognitive/affective ‘machinery’
non-symptom oriented psychotherapies=
psychotic symptoms interfere with one’s ability to form a coherent, continuous mental image of oneself, others and world; developing a shared understanding will help.
bv metacognitive therapy/mentalizing -> self-reflectivity, understanding the others mind
pros of non symptom oriented psychotherapies
- non stigmatizing
- helped some patients
- long term
cons of non-symptom oriented psychotherapies
- difficult to administer and teach
- evidence based not so much
- complicated to validate the case conceptualisations
- not transferable
- long term
Metacognitive Reflection and Insight Therapy (MERIT)
Stimulating 4 domains (Self, Other, Decentration, Mastery): through eliciting narrative episodes, and asking questions at or just above the metacognitive functioning of the client
