Lecture 8: Psychotic Disorders: Chapter 9 Flashcards
What is a psychosis? How is it described in the DSM?
Disruption in the experience of reality
DSM doesn’t define what is psychotic, but defines psychosis in terms of symptoms
What are the 2 types of symptoms of psychosis?
- Positive: add something
- Negative: remove something
What are hallucinations? What are 3 characteristics of it?
Perception-like experiences which occur without external stimulus
- Lifelike
- Full force/impact of normal perceptions
- Can occur in all modalities
What is the most common type of hallucination?
Auditory (voices)
What percentage of children around age 8 has audiovisual hallucinations? How is this at age 12?
age 8: 9%
age 12: hallucinations don’t persist, 76% of the kids who experienced hallucinations before don’t experience it anymore
What percentage of the general population experiences audiovisual hallucinations?
5-28%
What percentage of children (5-12y) have an imaginary friend?
46%
In which age categories are the most incidences of psychotic experiences?
Highest in adolescents (5 per 100)
Lowest in older adults (1 per 100)
Fill in the percentage:
About ..% of persons who experienced psychotic experiences will report a second PE each year
30%
What are delusions? Why is this a problematic definition and what is a solution for it?
Beliefs/convictions which conflict with reality
Problematic, because it conflicts with religions or just remembering something that is wrong.
Solution: it depends on how rigid your thinking is and if it’s not part of a subculture
–> Fixed beliefs that are not amenable to change in light of conflicting evidence
Why are hallucinations not automatically a sign of an illness?
They can be culturally induced (shamans, burning bushes in bible etc.)
How can you help a kid with an imaginary friend?
Talk to the kid, because he’s probably lonely
Are conspiracy theories a delusion?
No
What debate pops up when defining delusions?
Belief vs. delusion
What are the 2 most common types of delusions?
- Persecutory
- Referential
What are the 7 types of delusions? Give an example for each
- Persecutory: they’re after me
- Referential: things that are not related to you feel related to you, what is seen on TV relates to you
- Somatic: bugs under skin
Insertion: someone implanted chip in brain - Grandiosity: thinking you win a nobel price, but actually didn’t study
- Erotomanic: celebrity is in love with me
- Nihilistic: impending catastrophe, world is going to end, can suck the soul out of people by looking in their eyes
- Control: believe external force controls feelings, e.g. phone signals controls you
Why can’t you make a distinction between bizarre and non-bizarre delusions?
It’s a very subjective judgment. It’s like asking if something is normal or abnormal
What are 2 positive symptoms of Schizophrenia?
Delusions & hallucinations
What are 5 negative symptoms of schizophrenia?
- Avolition
- Alogia
- Anhedonia
- Blunted affect
- Asociality
What are 2 disorganized symptoms of schizophrenia?
- Disorganized behavior
- Disorganized speech
A study with 200 people with schizophrenia was conducted. Which hallucinations were experienced as unpleasant and which ones were evaluated more positively?
Unpleasant: third person hallucinations
More positive: hallucinations from a known person
Which area in the brain is more active in auditory hallucinations? What is the problem in the brain in hallucinations?
Broca’s area (speech production) and Wernicke’s area (comprehension)
Problem in connections between frontal lobe (production of speech) and the temporal lobe (understanding of speech)
What are the 2 most common negative symptoms in schizophrenia?
- Reduced expressivity
- Avolition: reduced self-motivation and goal-oriented activities
What is avolition in schizophrenia? How is it compared to controls?
Reduced self-motivation and goal-oriented activities, usually in routine-activities
But equally motivated by goals that had to do with interacting with others and with avoiding criticism and more motivated by goals to reduce boredom
What is alogia? Give an example
Reduced speech production: people don’t talk much
E.g. Answer question with 1 word and not elaborating on it
What is anhedonia?
Reduced enjoyment
What is asociality?
Reduced interest in social activities. Have few freinds, poor social skills and little interest in being with others. They spend much time alone and otherwise interact superficially
What are the 2 types of pleasure experiences in anhedonia? Which type is affected in people with schizophrenia?
- Consummatory pleasure: pleasure in the moment (e.g. eating a good meal)
- Anticipatory pleasure: expected pleasure from future events (e.g. graduating)
Schizophrenia: impaired anticipatory pleasure. They can still enjoy a current moment
What is blunted affect? What are some characteristics of it?
Lack of outward expression or emotion
E.g. motionless face muscles, lifeless eyes, flat toneless voice
How can you divide the negative symptoms of schizophrenia in domains?
- Motivation and pleasure domain: emotional experience, sociality, motivation
- Expression domain: outward expression of emotion and vocalization
What is disorganized speech?
Problems in organizing ideas and in speaking so a listener can understand
What are loose associations/derailments in disorganized speech?
A person can communicate with a listener but has difficulty sticking to one topic
What is disorganized behavior in schizophrenia?
Different behavioral symptoms, such as agitation, unusual dressing, act in a silly manner, wander around or collect garbage
They lose ability to organize behavior and conform to community standards
What is catatonia?
A spectrum of different physical symptoms
- Repeated peculiar/complex sequences of movements, which seem purposeful. Having an unusual increas in activity, sometimes similar to mania
- Immobility: adopt unusual postures and maintain them for very long periods of time
What is anosognosia?
Reduced insight into illness
When is typically the onset of schizophrenia? When is the peak of the symptoms?
between 16 and 30 years
Peak (men): early-mid 20
Peak (women): late 20
What is the prevalence of schizophrenia and how does it relate to gender?
1%
Men slightly more often than women
What is the symptom that bothers people with schizophrenia the most? On which symptoms does treatment often focus?
Sense of shattered self and not having any friends
But treatment focuses often more on hallucinations and delusions
What are the DSM criteria for schizophrenia? (A(5) - B - C)
A. For at least one month continuously: 2 of these (at least on of 1,2,3)
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized/catatonic behavior
5. Negative symptoms
B. Significant impact functioning
C. Continued signs/impairment for 6 months
What is schizoaffective disorder?
Mixture of symptoms of schizophrenia (criterion A) and mood disorders
DSM: requires a depressive or manic episode rather than simply mood disorder symptoms
What is the main difference between schizophreniform disorder and schizophrenia?
Schizophreniform disorder lasts only 1 to 6 months.
Schizophrenia: last at least 6 months
What are 2 characteristics of brief psychotic disorder?
- Lasts from 1 day to 1 month
- Brought on by extreme stress
What are the 5 criteria of delusional disorder?
- Presence of one or more delusions within 1 month or longer
- Criterion A for schizophrenia never been met, hallucinations are not prominent and related to the delusions
- Functioning is not markedly impaired and behavior is not obviously bizarre (apart from the impact of the delusions)
- In case of manic or MD episodes, these were brief compared to delusional periods
- Disturbance not attributable to physiological effects of substance or other medical conditions
Give an example of a delusion
Being convinced that someone in your family tries to poison you
What is the main issue in diagnosing delusional disorder?
The DSM criteria ask for a judgment of if something is bizarre or not. That is very subjective
What are the 8 types of delusional disorder?
- Erotomanic
- Grandiose
- Jealous
- Persecutory
- Somatic
- Mixed
- Unspecified
- With bizarre content
What is the erotomanic type of delusional disorder?
Central theme of delusion is that another person is in love with the individual
What is the grandiose type of delusional disorder?
Central theme of delusion is the conviction of having some great, but unrecognized talent, or insight
What is the jealous type of delusional disorder?
Central theme is that is that his/her spouse is unfaithful
What is the persecutory type of delusional disorder?
Central theme is the individual belief that he/she is being conspired ageainst, followed, cheated on, poisoned etc.
What is the somatic type of delusional disorder?
Central theme of delusion involves bodily functions or sensations
What is the mixed type of delusional disorder?
No one delusional theme predominates
What is the unspecified type of delusional disorder?
Dominant delusional belief cannot be clearly determined or is not prescribed in the specific types
What is the difference between psychotic depression/psychotic bipolar and schizoaffective disorder?
Schizoaffective: hallucinations have to be present outside the mood episode
What are the 6 types of psychotic disorders, next to schizophrenia?
- Delusional disorder
- Brief psychotic disorder
- Schizophreniform disorder
- Schizoaffective disorder
- Substance/medication induced psychotic disorder
- Psychotic disorder due to another medical condition
How can you distinguish delusional disorder and mood disorders?
Delusional: symptoms of mood have to be relatively short compared to symptoms of delusional disorder
How can you distinguish delusional disorder and OCD/BDD?
If the belief of catastrophe/body experience is extremely solidified + anosoagnosia, OCD/BDD fits better than delusional disorder
What is the incidence of schizophrenia?
15 new cases per 100.000 people in a year
What is dementia praecox?
It was the way people first described schizophrenia.
Praecox = premature
How is a psychotic disorder diagnosed?
With a structured clinical interview (e.g. MINI-plus, DSM structured interview SCID)
What does the beads task measure? How does it work?
It measures if someone is jumping to conclusions
Mainly black beads jar and mainly orange beads jar have been mixed up. If the participant chooses one color, it means jumping to conclusions
How is neurocognition measured in psychotic disorders?
Digit-span test
Why is science convinced that schizophrenia has a genetic component?
Behavioral genetics studies have been well replicated
What is the heritability of schizophrenia?
0,77
What does it mean that schizophrenia is genetically heterogeneous?
Genetic influences may vary from person to person
What is the relation between schizophrenia and bipolar disorder?
People who had a parent admitted for schizophrenia and one parent admitted for bipolar disorder, had a higher incidence of schizophrenia than people who had just one parent admitted for schizophrenia
So there might be some shared genetic vulnerability between schizophrenia and bipolar disorder
What is a familial high-risk study? What are the results concerning schizophrenia?
Study begins with one/two parents with schizophrenia and follows their children longitudinally to identify how many develop schizophrenia and which childhood factors may predict the disorder’s onset
Results: having a parent with schizophrenia is associated with greater risk of developing schizophrenia & other disorders as well
What is a critical problem in interpreting results of twin studies and family studies?
Common shared and nonshared environmental factors rather than genetic factors could account for some portion of increased risk of the disorder
What are 3 types of behavior genetics research?
- Family studies
- Twin studies
- Adoption studies
Why are adoption studies useful in genetics research on schizophrenia?
Such studies eliminate the possible effects of being reared in an environment where a parent has schizophrenia
What is the difference in symptoms in schizophrenia between men/women?
Women have a little more symptoms, but thay remain better social functioning
What is the foundation of positive symptoms?
Dopamine issues (not for negative symptoms)
What is a socialcultural risk factor for developing schizophrenia? (4)
- Being a migrant
- Urbanicity
- Trauma
- Poverty
What are 2 key methodological requirements of genome wide association studies?
- Very large sample sizes
- Replication and rigorous statistical tests
What are the 3 main points we can conclude from genome wide association studies (GWAS)?
- Observed mutations are rare
- Only some people with these rare mutations have schizophrenia
- These mutations aren’t specific to schizophrenia
What are common brain abnormalities in schizophrenia? (3)
- Enlargement ventricles
- Dysfunction PFC and temporal cortex and surrounding brain regions
- Connections between brain regions
What are the findings in MRI studies of the PFC in schizophrenia? What is a confound in this study?
Reduction in gray matter and overall volume, but not the number of neurons in this areas
Confound = antipsychotic medications may contribute to some of this loss
When does the decline of the PFC in people with schizophrenia start?
Before disorder onset to when people are in their late 30s
How can you explain reduced volume of gray matter in PFC, but no reduction of the number of neurons?
Dendritic spines might be lost
These are small projections of dendrites where nerve impulses are received. Loss of these spines means that communication is disrupted
What is the dysconnection syndrome?
Loss of dendritic spines, resulting in neuronal communication issues. A result might be disorganized speech and behavior
Which parts of the temporal lobe reduce in size in schizophrenia?
Basal ganglia, hippocampus, amygdala
What is the role of the HPA axis in schizophrenia?
- HPA axis likely contributes to the reductions in hippocampal volume
So people with schizophrenia are more reactive to stress than people without it. - HPA axis may trigger excess release of dopamine, resulting in more positive symptoms of schizophrenia
What is the dopamine hypothesis of schizophrenia? What is it based on?
Excess activity of dopamine
Based on drugs effective in treating schizophrenia reduce dopamine activity
What are some side effects of antipsychotic drugs in schizophrenia? How does it work?
Symptoms like parkinson’s disease
Parkinson’s is caused by low levels of dopamine, antipsychotics block dopamine receptors, resulting in excessive motor activity
What is the role of glutamate in schizophrenia?
Lower levels of glutamate in people with schizophrenia. It can induce both positive and negative symptoms when decreased activity of glutamate’s NMDA receptors
Cognitive deficits and disorganization may be connected to NMDA deficits
What is the main difference in connectivity between people with schizophrenia and healthy controls? (2)
- Less connectivity white matter in frontal and temporal cortex
- Less connectivity brain networks (frontoparietal and default-mode networks)
What is the connection between genetic vulnerability and connectivity in schizophrenia?
Diminished connectivity might be a part of the genetic vulnerability for schizophrenia
What did an rTMS study on brain connectivity in schizophrenia show?
Interventions that increase connectivity may reduce negative symptoms
What does a greater striatum connectivity to other brain regions predict?
Greater reduction in symptoms early in the course of a hospital stay in a person with schizophrenia
What 2 models are the shared foundation of most models of the etiology of psychotic disorders?
- Diathesis-stress model
- Biopsychosocial model
What is the social defeat hypothesis?
Sense of social exclusion (migrants, deaf children) leads to dopamine sensitization –> increased risk of psychotic disorders
What are 2 risk factors for schizophrenia around birth?
- Maternal infections during pregnancy
- Birth complications (reduced oxygen to brain)
Why does schizophrenia begin in adolescence, when there might be complications already there at birth? Give 2 explanations
- PFC matures late, so the behavior might not show until this development peaks
- Symptoms in adolescence could reflect loss of synapses due to excessive pruning
What is the association between cannabis use and schizophrenia? Give 3 aspects
- It worsens the symptoms
- Risk of developing symptoms is greater among those who used it
- Only among those who are genetically vulnerable to schizophrenia
Explain the relation between poverty and schizophrenia
People with schizophrenia drift into poor neighborhoods as a consequence of the illness
What percentage of schizophrenics have experienced trauma during their lives?
50-98%
80% of patients experience psychotic episodes as traumatic too
What is the percentage of comorbidity with schizophrenia and PTSD?
16%
But: 90% of case files don’t mention PTSD, though it is present
What are 4 behavioral characteristics seen in children that are predictive of later onset of schizophrenia?
- Less social responsiveness
E.g. deaf/deprived children - Poorer motor skills
- More expression of negative symptoms
- Lower IQ, stable across childhood
Which family relationship is crucial in the development of schizophrenia? What evidence supports it? What is an issue with it?
Mother-son
This was not supported eventually, but the negative impact of incorrect blame on all the family members was huge
There is not much evidence for the role of family in causing schizophrenia
What does Morrison’s cognitive model explain?
The maintenance of auditory hallucinations
What is the main pharmacological treatment? What is a negative side of it?
Antipsychotics
–> awful side effects, especially motor skills (Extrapyramidal side effects = Parkinsonism)
What 3 characteristics are part of the construct expressed emotion (EE) in family bonds?
- Critical comments
- Hostility
- Emotional overinvolvement
What is the difference between high expressed emotion (EE) and low expressed emotion (EE) in schizophrenia?
People with schizophrenia returning to high EE: 58% relapsed
People with schizophrenia returning to low EE: 10% relapsed
So the home environment a schizophrenic returns to can influence how soon they relapse
What is a clinical high-risk study?
Type of prospective study where people are identified with early signs of schizophrenia (mild hallucinations, delusions, disorganization) that cause impairment
What is the difference between dystonia, dyskinesia and akasthesia as a side effect of antipsychotics?
Dystonia = muscular rigidity
Dyskinesia = abnormal motion of voluntary and involuntary muscles
Akasthesia = inability to remain still
What is tardive dyskinesia?
Mouth muscles involuntarily make sucking, lip-smacking motions
What are extrapyramidal signs of antipsychotics?
Parkinson like side effects
What is the difference between first and second generation antipsychotic drugs?
First = first discovered, not very effective, only for reduction positive symptoms, a lot of side effects
Second = later developed drugs, but not effective either, different unpleasant side effects
What is the most common side effect of second generation antipsychotics?
Weight gain, leading to other serious health problems
What is tapering?
Reducing medications
With tapering (42% relapse)
Why where psychological interventions for schizophrenia never really an option before?
Psychotic disorders were onece an exclusion criterion for psychotherapy
How can social skills training help people with schizophrenia? What are 3 consequences?
Teach how to successfully manage a wide variety of interpersonal situations
Consequences:
1. Fewer relapses
2. Better social functioning
3. Higher quality of life
What are 6 common features in family therapies?
- Education about schizophrenia
- Info about antipsychotics
- Reducing blaming and avoiding blaming
- Communication and problem-solving skills
- Social network expansion, more support networks
- Encourage hope
What is CBTp?
Cognitive behavior therapy specified for people with psychosis
How can CBTp reduce negative symptoms?
Challenging belief structures tied to low expectations of succes (avolition) and low expectation for pleasure (anticipatory pleausure deficit anhedonia)
What is CBSST?
Cognitive-behavioral social skills training
Reduces symptoms and improves functioning. It’s a group therapy and lasts quite long (6-9 months).
What is the NAVIGATE treatment? What is some evidence on it?
For young people early in the course of schizophrenia. It involves medication, family psychoeducation, individual therapy and help with employment and education
It seems more effective than standard care
What is the link between duration of untreated psychosis and severity?
The longer people are left untreated, the worse the outcome is for patients
What is vocational rehabilitation?
Residential treatment where residents learn marketable skills that help them secure employment and increase their chances of functioning well in the community
What is McGorry’s staging model?
It describes schizophrenia in stages, where every stage has an increased duration and severity.
All treatment is intended to avoid progression to the next stage
What are the 3 stages of the staging model?
- Prodromal phase, at-risk mental stage
- First episode
- Multiple episodes with stable phases/remission
What is stage 1 of the staging model (prodromal phase)? Name 4 aspects
- Subclinical positive symptoms, presence of negative symptoms
- Functional deterioration
- Mood swings
- Indications of cognitive problems
What is stage 2 of the staging model (first episode)? Give 3 aspects
- Positive symptoms
- Not substantially different from chronic phase
- Worsening cognitive problems
What is stage 3 of the staging model (multiple episodes)? Give 3 aspects
This is different for everyone
1. Incomplete remission of first episode
2. New episodes with reduced recovery
3. More relapse, further reduction in functioning
What is the chance that someone with schizophrenia will become symptom free?
20%
