Lisa - Schizophrenia Spectrum and other psychotic disorders

Question 1

The Psychoses

🚫Myth: Individuals with psychotic disorders all have the same symptoms

Answer 1

⭐️Can refer to a variety of syndromes, and psychotic symptoms or syndromes can occur in a range of disorders including being part of organic presentations (eg amphetamine psychosis, dementia, etc.)

⭐️At the disorder level, it refers to a group of disorders distinguished from one another in terms of SYMPTOM CONFIGURATION (eg delusional disorder versus schizophrenia), DURATION (eg schizophrenia vs schizophreniform disorder) and the RELATIVE PERVASIVENESS- in terms of both duration and the clinical picture- of those symptoms vs affective symptoms (eg bipolar disorder and schizoaffective disorder)

Question 2

Psychotic symptoms

Answer 2

Abnormalities in 1/+ of the following:
😥Delusions
😥Hallucinations
😥Disorganised thinking (speech)
😥Grossly disorganised or abnormal motor behaviour (including catatonia)
😥Negative symptoms

Question 3

Psychotic symptoms:

Delusions

Answer 3

⭐️Fixed beliefs that are not amenable to change in light of conflicting evidence.

1. Persecutory delusions: belief that one is going to be harmed, harassed, etc. by an individual, organisation, or other group (most common).
2. Referential delusions: belief that certain gestures, comments, environmental cues, etc. are directed at oneself.
3. Grandiose delusions: when an individual believes that he/she has exceptional abilities, wealth, or fame.
4. Erotomanic delusions: when an individual believes falsely that another person is in love with him/her.
5. Nihilistic delusions: involve the conviction that a major catastrophe will occur.
6. Somatic delusions: focus on preoccupations regarding health and organs function.

Can be characterised as:
Bizarre (eg belief that an external peep has stolen one’s organs and left no scars/wounds) vs Non-bizarre (may have more plausibility- eg belief you’re under surveillance by police)

OR

Primary (formed without preceding event/process that has led to the conviction- eg fixed belief that the police are out to get you) vs Secondary (develop as a consequence of abnormal change in memory, mood thought/perception- eg hearing voices that confirm that the police safe our to get you)

Question 4

Psychotic symptoms:

Hallucinations

Answer 4

⭐️Perception-like experiences that occur without an external stimulus.

Auditory hallucinations most common.

Interestingly, hallucinations may be a normal part of religious experience. Therefore ⭐️ to be considered a hallucination clinically, needs to occur outside the realm of peep’s cultural context.

😥Multiple voices talking about the them in 1st, 2nd and 3rd person; can be benign and benevolent/condescending/commanding.

Sometimes people aren’t distressed by hallucinations and so don’t seek treatment.⭐️Shows that the mere presence hallucinations is not sufficient to diagnose mental illness.

Question 5

Psychotic symptoms:

Disorganised thinking/speech (aka Formal Thought Disorder)

Answer 5

Is typically inferred from the individual’s speech:
😥Derailment or loss associations: jump from 1 thought to the other
😥Tangentiality: jump from 1 topic to another
😥Incoherence or “word salad”

✖️Seen also in those with brain injury/severe head injury and so is therefore not sufficient to diagnose mental illness alone

Question 6

Psychotic symptoms:

Grossly disorganised or abnormal motor behaviour

Answer 6

⭐️May manifest itself in a variety of ways, ranging from childlike “silliness” to unpredictable agitation.

Catatonia: a marked decrease in reactivity to the environment.

Question 7

Psychotic symptoms:

Negative symptoms

Answer 7

😥Diminished emotional expression: reductions in the expression of emotions in the face, eye contact, intonation of speech (prosody), and movements of the hand, head, and face that normally give an emotional emphasis to speech.

😥Avolition: a decrease in motivated self-initiated purposeful activities.

😥Alogia: manifested by diminished speech output.

😥Anhedonia: decreased ability to experience pleasure from positive stimuli or a degradation in the recollection of pleasure previously experienced.

😥Asociality: the apparent lack of interest in social interactions and may be associated with avolition, but it can also be a manifestation of limited opportunities for social interactions.

❓How do you distinguish between anhedonia for psychosis vs that for depression? Obviously important due to difference in medication administered for each.

Question 8

Continuum of psychotic symptoms in the community:
DSM-5:
Types of Psychotic Disorders

🚫Myth: You are either psychotic or not

Answer 8

1. Brief Psychotic Disorder
2. Delusional Disorder
3. Schizophreniform Disorder
4. Schizophrenia
5. Schizoaffective Disorder

Question 9

DSM-5:
Types of Psychotic Disorders:
Brief Psychotic Disorder

Answer 9

⭐️A psychotic disturbance lasting more than one day but less than a month with eventual return to premorbid level of functioning.

Question 10

DSM-5:
Types of Psychotic Disorders:
Delusional Disorder

Answer 10

⭐️At least 1 month/+ of delusions.

Question 11

DSM-5:
Types of Psychotic Disorders:
Schizophreniform Disorder

Answer 11

⭐️2/+ psychotic symptoms, present for a significant portion of time during a 1-month, but no more than 6-month period.

😥Sadly, at least two-thirds will go on to develop schizophrenia/schizoaffective disorder.

Question 12

DSM-5:
Types of Psychotic Disorders:
Schizophrenia

Answer 12

⭐️Lasts at least 6 months, with at least 1 month of 2/+ of the psychotic symptoms.

⭐️Must be evident that for a significant portion of time since the onset of the disturbance, level of functioning across various domains is markedly below the level achieved prior to the onset.

Question 13

DSM-5:
Types of Psychotic Disorders:
Schizoaffective Disorder

Answer 13

⭐️The co-occurrence of the symptoms of schizophrenia and a major mood episode, in addition to at least 2-weeks of delusions or hallucinations without mood disturbance.
Mood symptoms are present for the majority of the total duration of the disorder.

Question 14

Psychotic disorders:

Associated features

Answer 14

😥Depression
😥Suicide
😥Anxiety
😥PTSD- trauma may be the experience of psychosis itself OR associated with treatment
😥Substance use problems
😥Poor quality of life in general: occupational, relationship, social and emotional functioning
😥Stigma

Question 15

Psychotic Disorders and Genetics

🚫Myth: Psychotic disorders are purely genetic disorders

Answer 15

Genetics 👨‍👩‍👧
-Family studies: risk of developing schizophrenia increases as degree of genetic relatedness increases.
-Adoption studies: higher concordance rate among adopted children who had one biological parent with disorder than adopted children with no affected biological relatives.
-Epigenetics:
Genes of interest: COMT gene- involved in the breakdown of dopamine. When paired with cannabis it may thus lead to ⬆️ risk.
Gene-environment interactions (eg maternal complications, maternal malnutrition, marijuana use)

Question 16

Psychotic disorders:
Underlying factors:
Biological

🚫Myth: Psychotic disorders are caused by a character flaw (making an individual more liable to the disorder due to being lethargic or easily confused, for example)

Answer 16

Neurotransmitters:
Dopamine hypothesis: excessive dopamine function in CNS.
Evidence:
-drugs that reduce dopamine activity have some efficacy in treating schizophrenic symptoms
-amphetamine (which causes the release of dopamine) found to produce symptoms of schizophrenia
✖️No evidence of excessively high dopamine in schizophrenic brains
❓Norepinephrine? Serotonin?

Brain structure and function:
-Enlarged ventricles
-Reduced grey and white matter in PFC
-Impaired executive functioning (eg set shifting)
Theoretical models:
-Prenatal damage: result of genetic factors/environmental influence (maternal/viral infection while pregnant, inadequate foetal nutrition)/birth trauma/complications

• Hippocampus, pituitary volume
• Olfaction: Olfactory deficits present in pre-psychotic young people

Question 17

Psychotic disorders:
Underlying factors:
Psychological

Answer 17

Role of family 👨‍👩‍👧
-Schizophrengenic mother: cold, aloof, overprotective, domineering, strips child of self-esteem, stifles independence; particularly at risk if father’s passive
✖️Discredited however

-Communication deviance model: Families of schizophrenics tend to have deviant communication patterns (expressed emotion - EE)

Social 🎉
-Living in an urban environment 
-Migration
-Being socially excluded 
⭐Environments have an increased risk of making you psychotic if you are a member of a minority group in high density living and more so if you use cannabis 

Childhood Trauma 😰
A significant proportion of people with psychotic disorders report traumatic experiences in childhood, such as sexual and physical abuse. Many studies also suggest that these experiences play a causal role in psychosis😓.

Stress 😩

• Stressful live events
• Coping mechanisms/strategies used

Cognitive
⭐️Core of model: culturally unacceptable interpretations of intrusions into awareness.
⭐️Role of APPRAISAL is central

Culturally unacceptable interpretation results from faulty knowledge of self ➡️ misattribution of thought to external source.
Response serves to increase likelihood of future intrusions:
😥Disturbance in mood (eg anxiety)
😥Physiological arousal (eg lack of sleep)
😥Behavioural change
😥Cognitive change

Question 18

Substance use and psychosis

Answer 18

Substance-induced psychosis is an example of a gene X environment interaction whereby a genetic likelihood of having psychosis may present following cannabis use.

⭐️This obviously doesn’t apply to everyone and so it must be recognised that there are many complex factors at play giving rise to the presentation of schizophrenia.

The Swedish Conscript Study compared those who had or had not used cannabis by 18 years.
⭐️Was found that those had used cannabis were more likely to develop sz than those who had not.
✖️Did not however measure various things such as continued cannabis/other drug use that may have led to drug use.
⭐️Whilst a follow up study did address this limitation, they still found a heightened risk for sz amongst those who did use cannabis. Yet, we can still conclude that there are multiple reasons as to why one may use cannabis.

Eg The Self-Medication Hypothesis: suggests that individuals with psychosis use cannabis to control symptoms or to improve mood. 😥
-Some do report that is relieves their symptoms (depression, negative symptoms) but often at the cost of an increase in other symptoms (particularly positive symptoms eg hallucinations, delusions) . 😥

Question 19

Illness course

🚫Myth: Psychotic disorders develop quickly

Answer 19

⭐️Actually tend to occur over an extended period of time; in early stages of psychosis, it is difficult to be sure that it is psychosis (eg how can you distinguish between socially withdrawn behaviour characteristic of adolescence from that of sz?)

1. Premorbid phase
   -Social-functioning deficits
   -Display poorer motor skills and higher level of neuromotor abnormalities than healthy siblings during childhood
   ✖️Obviously not clear enough to use as a marker though
2. Prodromal phase
   - 2-year duration
   - Non-specific change in functioning/experience
3. Acute phase
   ⭐️Delay in Untreated Psychosis (DUP): longer DUP - longer time for recovery.
4. Early Recovery
   - 1st few months post start of treatment
   - Significance of episode/illness may be considered
   - Integration/sealing-over
5. Late Recovery
   - Resumption of education, work
   - Social/recreational re-connecting

Question 20

Relapse and Risk Factors for Relapse

Answer 20

😥Up to 80% of patients will experience a psychotic relapse within 5 years remission from the initial episode.

🚫Risk factors for relapse:
😥Substance use
😥Medication non-adherence
😥Carer critical comments
😥Poor premorbid adjustment showed a consistently positive association with relapse
😥Expressed Emotion: between 50s and 60s many relapsing patients shared common family environments- conflict, criticism, hostile, over-involved

NOT risk factors for relapse:

• DUI
• DUP
• Positive, negative, affective symptoms
• Age of onset
• Insight
• Gender
• Marital status
• Education
• Employment

Impact of relapse/chronic illness:
😥Unemployment
😥Housing difficulties
😥Poor physical health
😥Side-effects of antipsychotic medication
😥Neglect of children

Question 21

Psychosis and treatment

🚫Myth: Psychotic disorders are untreatable and all sufferers need to be hospitalised

Answer 21

⭐️Low-dose pharmacological treatment is the primary and best approach in acute phase of illness

Soteria model:
⭐️Highly supportive care, usually medication free, living in a community (REINTEGRATION)
✔️Comparable results to treatment as usual

Question 22

Psychotic disorders:

✖️Current issues and debate

Answer 22

1. No biological markers or psychological tests to diagnose schizophrenia
2. Aetiology continues to be uncertain
3. No clear evidence that the concept of schizophrenia is a valid construct
4. Continuum vs categorical models
   Bentall: psychotic experiences occur on a continuum within the population ranging from normal to clinically significant
5. Emphasis of hallucinations and delusions in diagnostic criteria increases reliability of diagnoses at the cost of validity.
   - Argued that current diagnostic criteria ignore fundamental cognitive impairments that vary significantly between individuals
   - Others suggest that delusions, hallucinations and thought disorder may be a common ‘end state’ in a variety of disorders, including sz
6. Accurate identification and treatment in prodromal phase
7. What is the meaning of positive symptoms of the person’s self- ie their self-evaluation? Is the content important or irrelevant? What purpose do they serve?
8. STIGMA 😥
   😥Sz has a long history or neglect, demonisation and concealment
   😥Sz is less recognised by general public than other disorders like depressions
   😥Myths highlighted are damaged to individuals with sz because they maintain a culture and environment that heightens the risk of prejudice and discrimination- thereby limiting opportunities for recovery and increasing stress.
   😥Stigma can also be internalised (self-stigma) that can lead to feelings of low self-esteem and shame leading to avoidance of services and delayed treatment.

Question 23

🚫Myths

Answer 23

1. 🚫Individuals with psychotic disorder all have the same symptoms.
2. 🚫You are either psychotic or not.
3. 🚫People with psychotic disorders are dangerous, unpredictable and out of control.
4. 🚫The psychoses are purely genetic disorders.
5. 🚫Psychotic disorders are caused by a character flaw.
6. 🚫Psychotic disorders develop quickly.
7. 🚫People with psychotic disorders cannot lead productive lives.
8. 🚫Psychotic disorders are untreatable and all sufferers need to be hospitalised.
9. 🚫Psychologists do not have a role in the treatment of psychotic disorders.

Question 24

Psychosis and violence:

🚫Myth: People with psychotic disorders are dangerous, unpredictable and out of control.

Answer 24

Whilst the vast majority of people experiencing psychosis withdraw from others when they become unwell, and most individuals are NOT violence and DO NOT display aggressive/or dangerous behaviour, there are some factors that may increase risk of violence/aggressive behaviour by individuals with psychotic disorders but are not limited to people with psychotic disorders, including:

• Past history of violence
• Certain personality traits
• Social circumstances
• Content of auditory hallucinations
• Substance use
• Paranoid beliefs
• Being male
• Being young