Lecture 19: Psychosis Flashcards
1
Q
Psychosis
A
- A serious mental illness characterised by defective or lost contact with reality often with hallucinations or delusions
- A neurological disorder, believed to be caused by a biochemical imbalance in brain (schizophrenia)
2
Q
DSM5
A
- Schizophrenia spectrum & other psychotic disorders = they are defined by abnormalities in one or more of the following 5 domains -> delusions, hallucinations, disorganised thinking, disorganised motor behaviour, & negative symptoms
3
Q
British Psychological Study Definition
A
- Hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse etc.
- Calling them symptoms of mental illness, psychosis…is only one way of thinking about them, with positives & negatives
- The problems we think of as ‘psychosis’ can be understood & treated in same way as other psychological problems
4
Q
What is psychosis (NZEIPS)?
A
- Range of unusual experiences that a person may have
- Can affect how a person thinks, feels & experiences world
- Result in directly telling what is real from not & can be distressing
- Potential to disrupt person’s ability to maintain life responsibilities
5
Q
Symptoms vs. Disorder
A
- Symptoms present in general pop. = 13.2-17.5%
- Psychotic ‘disorder’ related to severity = distress & impairment in functioning
- Spectrum, on a continuum
- Romme & Escher = voices not a sign of illness
= reaction to life events
= many voice hearers do not have mental illness & function well
= people seek help due to overwhelming distress
= voices have meaning relevant to experiences of voice hearer - Psychosis is not a diagnosis, but symptoms can be a feature of PTSD, schizo etc…
6
Q
Schizophrenia
A
- Syndrome rather than disease
- Psychosis present for at least 6/12mnths
- Issues with validity & reliability
- Stigma & clinical pessimism
- Heterogenous disorder with variety of causes & outcomes
- Still poorly understood
7
Q
Phenomenology (+ve)
A
Positive symptoms = those that psychosis adds
- Delusions = false beliefs that persist in spite of evidence to contrary
- Hallucinations = experiencing things that others are not experiencing
- Thought insertion = person experiences thoughts are put into mind by external source
- Thought withdrawal = person experiences thoughts being removed by external source
- Thought broadcast = experiences thoughts as being spoken aloud or heard by others
8
Q
Phenomenology (-ve)
A
Negative symptoms = those which psychosis inhibits
- Avolition & loss of drive = content with doing little
- Poverty of thought control = minimal conversation, generativity
- Thought disorder = difficulty concentrating
- Asociality = isolative, lack of reciprocity
- Flattened emotional experience
- Harder to work with
- Overlap with depression, medication effects…
9
Q
Hallucinations
A
- Auditory = voices most common & distressing
= feel real, heard in external space
= different forms -> commentating, ancestors, pleasant supportive - Visual = more associated with drugs, trauma…
- Other modalities = tactile, olfactory…
10
Q
Delusions
A
- Fixed false beliefs = that persist in spite of evidence to contrary
- Common themes e.g. paranoia, religiose, kapgras…
- Influenced by culture
- Can include beliefs about other psychotic experiences = voice is the devil’s etc.
11
Q
Experience of psychosis
A
- Varies from person to person and over time
- Often confusing
- May not be aware that their experiences are not objectively shared by other
- Distressing
- Debilitating
- Lonely (feeling cut off)
- Despair & loss of hope
- Stigmatising
- Preoccupying
- Loss of sense of self
- treatment (+/-)
12
Q
Can be a positive experience…
A
- Positive if perhaps unrealistic ideas e.g. religiouse delusions
- Comfort from voices = company, positive messages
- Indirect info about emotions or concerns
- Creativity
- Entertainment (e.g. trippy experiences)
- Posttraumatic growth
13
Q
Risks associated with psychosis
A
- Disability = UK: 88% unemployment rate
- Risks of chronicity = loss of productivity, health burden
- Other health related issues = 3x more likely to die
= smoking (2x higher)
= homelessness - Suicide = up to 10% with chronic psychosis complete suicide
= highest risk time around 1st contact
= around diagnosis
= higher for men than women compared to general population
14
Q
Stages of psychosis
A
- Premorbid phase
- Prodrome or At Risk Mental States (ARMS) = precedes onset
- BLIPS & APS
- First episode of psychosis
- Recovery
- Relapse
- Further recovery etc.
- Posttraumatic growth
15
Q
ARMS/Procedure
A
- Insidious and gradual changes
- Huber’s Basic Symptoms = sensitivity to stress, flattening emotions, reduced drive
- Attenuated Psychotic Symptoms (APS) = magical thinking, suspiciousness, illusions
- Brief Limited Intermittent Psychotic Symptoms (BLIPS) = hearing name called
- Drop off in functioning
- ARMS does not always transition to psychosis
- Often only identified in hindsight to psychosis
16
Q
Acute phase
A
- Often first becomes apprent to others
- Characterised by florid symptoms
- Marked distress, confusion
- Often self medication increases
- Profound impact on functioning
- Hard to help = low recognition/insight
17
Q
Recovery
A
- Many people make a good recovery
- Recovery can be complicated for some
- Many experience relapse
- Symptom resolution vs. functional recovery
- Psychosis is a significant life event = impact on sense of self, stigma…
18
Q
Treatment (medication)
A
- Anti-psychotics often remain first choice
- Most report moderate improvement
- High variability in effects between people (trial & error)
- Efficacy vs. tolerability, risks vs. benefits
- Takes time to work
- Not well tolerated by some
- Side effects can be significant e.g. weight gain, sedation
- High discontinuation rates
- Sometimes given involuntarily
- Long-term effects not well understood
- May shorten L.E for some
- Treatment not cure
- ‘Dampening down’ effect not targeted treatment
19
Q
Treatment (psychological approaches)
A
- CBT most studied and evidence for = recommended for ARMS
- Third wave therapies
- Most clinicians use integrated approach
- Narrative approaches, cultural approaches
- Hearing Voices Network, Open Dialogue
- Focus on engagement + rapport
- Less evidence for psychodynamics approaches
20
Q
CBT
A
- Aims to alleviate distress
- Change the distressing beliefs about symptoms like voices
- Normalising approach
- Collaborative Empiricism = client as expert of their own experiences
= behavioural experiments
21
Q
ACT
A
- Seeks to help people to relate different to their distressing experiences
- Voices as life events
- Acceptance of distress as transient & normal
- Increased capacity to cope with distress
- Reduced fusion with unhelpful ideas
- Committed action informed by values rather than psychotic symptoms
- Self-compassion
22
Q
Targets for therapy
A
- Beliefs about experiences
- Normalisation
- Relating to unwanted experiences
- Re-authoring
- Trauma
- Directly with voices & delusions
- Substance use (MI)
- Other comorbidities
23
Q
Early intervention for Psychosis
A
- Biggest dev. in psychiatry in last 20 years
= optimistic & client-centred approach
= practical & pragmatic, family involvement
= rise of psychosocial treatments, esp. psychological
= consumer movement unhappy with institutionalisation & clinical pessimism - Focus on proactive engagement, risk management, secondary prevention
24
Q
Aims of Early Intervention
A
- Improve access to early treatment
- Reduce delays to treatment
- Promote meaningful engagement
- Intensive input during critical period
- Reduce risks e.g. suicide
- Secondary prevention
- Promote functional recovery
- Reduces distress & stigma
25
Q
How does EI do this?
A
- Engagement first
- Optimistic & normalising approach
- Youth-friendly culture
- Client-centred & flexible
- Holistic & integrated MDT
- Practical approach, ‘whatever it takes’
- Well resourced & mobile teams
- Psychological perspective
- Proactive approach to referrals
26
Q
Effectiveness of EI
A
- Suicide risk is halved
- > 50% secure a job
- Reduced relapse
- Promotes more complete recovery
- Reduced rates of admission to inpatient units
- Better treatment of comorbidities
- Much more user friendly
- Cost effective = but more expensive upfront costs (staffing)
27
Q
Who gets psychosis?
A
- First episode = young people
- Prevalence of 3% over lifetime
- Similar rates across cultures & countries
- Increased rates in urban areas
- Minority groups experience higher rates
28
Q
Causes of psychosis
A
- Mechanisms not well understood
- Trauma & social deprivation
- Genetics play a role but often oversimplified
- Often multiple factors
- Risk & vulnerability
- Stress & vulnerability model
29
Q
Stress & vulnerability
A
- All people are vulnerable to psychosis
- Psychosis can be caused by stress from life events or internal experiences
- Some people’s vulnerabilities are lower than others
- And some people’s stressors are higher
- When stress outstrips coping…psychosis can happen
30
Q
Trauma & psychosis
A
- Strong association
- Previously denied (focus on bio-bio-bio model)
- Content of psychotic symptoms often congruent with traumatic experience
- People with childhood trauma are 9x more likely to experience psychosis
- Higher rates in refugee population
- Dose effect
- Makes sense, psychosis as a defense
31
Q
Maori & psychosis
A
- Different indigenous conceptualisations of experiences that we may label psychosis = common everyday experiences (common to hear voices)
= whakapapa/tupuna
= matakite/gift
= maori illness
= trauma
= substance use (haurangi) - Effects of intergeneration trauma, colonisation as risk factors
32
Q
Drugs & psychosis
A
- Many substances can cause psychotic symptoms
- Intoxication vs. drug induced
- Marijuana is not benign
- THC use prior to age 15 greatest risk
- Heavy use prior to 19 (10.3% increased risk)
- Epigenetics: nature via nurture (genes switched on by adversity/drugs)
