M4. Lesson 4.4: Schizophrenia and Psychotic Related Disorders

Question 1

People who have committed highly publicized mass murders may have had schizophrenia which means that majority of people with schizophrenia are dangerous. True or False.

Answer 1

False. Sadly, a few of the individuals who have committed some of the recently highly publicized mass murders may have had schizophrenia, though most people who commit such crimes do not have schizophrenia and the vast majority of people with schizophrenia are not dangerous.

Question 2

Hypothetically, if you have met people with schizophrenia, why would you have not noticed?

Answer 2

It is also likely that you have met people with schizophrenia without ever knowing it, as they may suffer in silence or stay isolated to protect themselves from the horrors they see, hear, or believe are operating in the outside world.

Question 3

What types of symptoms do psychotic disorders typically involve?

Answer 3

Psychotic disorders involve many different types of symptoms, including delusions, hallucinations, disorganized speech and behavior, abnormal motor behavior (including catatonia), and negative symptoms such anhedonia/amotivation and blunted affect/reduced speech.

Question 4

What are delusions?

Answer 4

Delusions are false beliefs that are often fixed, hard to change even when the person is presented with conflicting information, and are often culturally influenced in their content (e.g., delusions involving Jesus in Judeo-Christian cultures, delusions involving Allah in Muslim cultures). They can be terrifying for the person, who may remain convinced that they are true even when loved ones and friends present them with clear information that they cannot be true. There are many different types or themes to delusions.

Question 5

What are the different types of delusions?

Answer 5

1. Persecutory
2. Grandiose
3. Referential
4. Others

Question 6

What is the most common delusion type?

Answer 6

Persecutory

Question 7

What are persecutory delusions?

Answer 7

The most common delusions are persecutory and involve the belief that individuals or groups are trying to hurt, harm, or plot against the person in some way. These can be people that the person knows (people at work, the neighbors, family members), or more abstract groups (the FBI, the CIA, aliens, etc.).

Question 8

What are grandiose delusions?

Answer 8

Grandiose delusions are where the person believes that they have some special power or ability (e.g., I am the new Buddha, I am a rock star)

Question 9

What are referential delusions?

Answer 9

Referential delusions, where the person believes that events or objects in the environment have special meaning for them (e.g., that song on the radio is being played specifically for me)

Question 10

What are other types of delusions?

Answer 10

Other types of delusions where the person may believe that others are controlling their thoughts and actions, their thoughts are being broadcast aloud, or that others can read their mind (or they can read other people’s minds)

Question 11

What are hallucinations?

Answer 11

When you see a person on the street talking to themselves or shouting at other people, they are experiencing hallucinations. These are perceptual experiences that occur even when there is no stimulus in the outside world generating the experiences.

Question 12

In what forms can hallucinations come as?

Answer 12

They can be auditory, visual, olfactory (smell), gustatory (taste), or somatic (touch).

Question 13

What is the most common form of hallucination in psychosis for adults mostly?

Answer 13

The most common hallucinations in psychosis (at least in adults) are auditory, and can involve one or more voices talking about the person, commenting on the person’s behavior, or giving them orders.

Question 14

What is the content and voices of auditory hallucinations like?

Answer 14

The content of the hallucinations is frequently negative (“you are a loser,” “that drawing is stupid,” “you should go kill yourself”) and can be the voice of someone the person knows or a complete stranger. Sometimes the voices sound as if they are coming from outside the person’s head. Other times the voices seem to be coming from inside the person’s head, but are not experienced the same as the person’s inner thoughts or inner speech.

Question 15

What is disorganized speech?

Answer 15

Talking to someone with schizophrenia is sometimes difficult, as their speech may be difficult to follow, either because their answers do not clearly follow from your questions, or because one sentence does not logically follow from another. This is disorganized speech.

Question 16

Can disorganized speech be present in writing?

Answer 16

Yes, it can.

Question 17

What does disorganized behavior include?

Answer 17

Disorganized behavior can include odd dress, odd makeup (e.g., lipstick outlining a mouth for 1 inch), or unusual rituals (e.g., repetitive hand gestures).

Question 18

What is abnormal motor behavior?

Answer 18

Abnormal motor behavior can include catatonia, which refers to a variety of behaviors that seem to reflect a reduction in responsiveness to the external environment. This can include holding unusual postures for long periods of time, failing to respond to verbal or motor prompts from another person, or excessive and seemingly purposeless motor activity.

Question 19

What are negative symptoms?

Answer 19

Some of the most debilitating symptoms of schizophrenia are difficult for others to see. These include what people refer to as “negative symptoms” or the absence of certain things we typically expect most people to have.

Question 20

What symptoms are examples of negative ones?

Answer 20

Anhedonia or amotivation; and flat affect or reduced speech/alogia

Question 21

What is anhedonia or amotivation?

Answer 21

Anhedonia or amotivation reflect a lack of apparent interest in or drive to engage in social or recreational activities. These symptoms can manifest as a great amount of time spent in physical immobility. Importantly, anhedonia and amotivation do not seem to reflect a lack of enjoyment in pleasurable activities or events (Cohen & Minor, 2010; Kring & Moran, 2008; Llerena, Strauss, & Cohen, 2012) but rather a reduced drive or ability to take the steps necessary to obtain the potentially positive outcomes.

Question 22

What is flat affect and reduced speech?

Answer 22

Flat affect and reduced speech (alogia) reflect a lack of showing emotions through facial expressions, gestures, and speech intonation, as well as a reduced amount of speech and increased pause frequency and duration.

Question 23

Why are psychosis symptoms difficult to understand?

Answer 23

In many ways, the types of symptoms associated with psychosis are the most difficult for us to understand, as they may seem far outside the range of our normal experiences. Unlike depression or anxiety, many of us may not have had experiences that we think of as on the same continuum as psychosis.

Question 24

What are psychotic symptoms on the same contiuum with?

Answer 24

Just like many of the other forms of psychopathology, the types of psychotic symptoms that characterize disorders like schizophrenia are on a continuum with “normal” mental experiences.

Question 25

What are the studies that reflect psychotic symptoms being on the same contiuum with “normal” mental experiences?

Answer 25

For example, work by Jim van Os in the Netherlands has shown that a surprisingly large percentage of the general population (10%+) experience psychotic-like symptoms, though many fewer have multiple experiences and most will not continue to experience these symptoms in the long run (Verdoux & van Os, 2002).

Similarly, work in a general population of adolescents and young adults in Kenya has also shown that a relatively high percentage of individuals experience one or more psychotic-like experiences (~19%) at some point in their lives (Mamah et al., 2012; Ndetei et al., 2012), though again most will not go on to develop a full-blown psychotic disorder.

Question 26

There is only one type of a psychotic disorder which is schizophrenia. True or False.

Answer 26

False. Schizophrenia is the primary disorder that comes to mind when we discuss “psychotic” disorders (see Table 1 fordiagnostic criteria), though there are a number of other disorders that share one or more features with schizophrenia.

Question 27

Most research has focused on psychosis. True or False.

Answer 27

False. Most research has focused on schizophrenia.

Question 28

Is there a schizophrenia gene?

Answer 28

There is none.

It is clear that there are important genetic contributions to the likelihood that someone will develop schizophrenia, with consistent evidence from family, twin, and adoption studies. (Sullivan, Kendler, & Neale, 2003). However, there is no “schizophrenia gene” and it is likely that the genetic risk for schizophrenia reflects the summation of many different genes that each contribute something to the likelihood of developing psychosis

Question 29

Schizophrenia is a heterogeneous disorder. What does this imply?

Answer 29

Schizophrenia is a very heterogeneous disorder, which means that two different people with “schizophrenia” may each have very different symptoms (e.g., one has hallucinations and delusions, the other has disorganized speech and negative symptoms). This makes it even more challenging to identify specific genes associated with risk for psychosis.

Question 30

What are the other mental health conditions that studies have suggested to be associated with schizophrenia?

Answer 30

Importantly, many studies also now suggest that at least some of the genes potentially associated with schizophrenia are also associated with other mental health conditions, including bipolar disorder, depression, and autism

Question 31

What are examples of environmental factors that are associated with an increased risk of developing schizophrenia?

Answer 31

There are also a number of environmental factors that are associated with an increased risk of developing schizophrenia.

1. Problems during pregnancy;
2. Complications that occur at the time of birth;
3. Children born to older fathers
4. Using cannabis (especially if you have other risk factors;
5. Kids who grow up in urban settings
6. Some minority ethnic groups

Question 32

What are the problems during pregnancy that are associated with schizophrenia?

Answer 32

Problems during pregnancy such as increased stress, infection, malnutrition, and/or diabetes have been associated with increased risk of schizophrenia

Question 33

What are the complications that occur at the time of birth associated with schizophrenia?

Answer 33

Complications that occur at the time of birth and which cause hypoxia (lack of oxygen) are also associated with an increased risk for developing schizophrenia

Question 34

Why are kids in urban settings and in minority ethnic groups able to possibly develop schizophrenia?

Answer 34

These factors may reflect higher social and environmental stress in these settings

Question 35

Can the environmental risk factors mentioned be useful in a clinical setting?

Answer 35

Unfortunately, none of these risk factors is specific enough to be particularly useful in a clinical setting, and most people with these “risk” factors do not develop schizophrenia.

Question 36

If environmental risk factors can’t be used in a clinical setting, what is their purpose?

Answer 36

Together they are beginning to give us clues as the neurodevelopmental factors that may lead someone to be at an increased risk for developing this disease.

Question 37

What has been an important research area on risk for psychosis?

Answer 37

An important research area on risk for psychosis has been work with individuals who may be at “clinical high risk”..

Question 38

Who are individuals who may be at “clinical high risk”?

Answer 38

These are individuals who are showing attenuated (milder) symptoms of psychosis that have developed recently and who are experiencing some distress or disability associated with these symptoms.

Question 39

When people at “clinical high risk” are followed over time, what can be observed?

Answer 39

When people with these types of symptoms are followed over time, about 35% of them develop a psychotic disorder, most frequently schizophrenia.

Question 40

What category of diagnosis was added to identify “clinical high risk” individuals?

Answer 40

In order to identify these individuals, a new category of diagnosis, called “Attenuated Psychotic Syndrome,” was added to Section III (the section for disorders in need of further study) of the DSM-5

Question 41

Why did the “Attenuated Psychotic Syndrome” create a controversy?

Answer 41

However, adding this diagnostic category to the DSM-5 created a good deal of controversy (Batstra & Frances, 2012; Fusar-Poli & Yung, 2012). Many scientists and clinicians have been worried that including “risk” states in the DSM-5 would create mental disorders where none exist, that these individuals are often already seeking treatment for other problems, and that it is not clear that we have good treatments to stop these individuals from developing to psychosis.

Question 42

What are the counterarguments that have been said against the controversy of the new category (Attenuated Psychotic Syndrome)?

Answer 42

However, the counterarguments have been that there is evidence that individuals with high-risk symptoms develop psychosis at a much higher rate than individuals with other types of psychiatric symptoms, and that the inclusion of Attenuated Psychotic Syndrome in Section III will spur important research that might have clinical benefits. Further, there is some evidence that non- invasive treatments such as omega-3 fatty acids and intensive family intervention may help reduce the development of full-blown psychosis (Preti & Cella, 2010) in people who have high-risk symptoms.

Question 43

What is a highly active area of research about schizophrenia?

Answer 43

The currently available treatments for schizophrenia leave much to be desired, and the search for more effective treatments for both the psychotic symptoms of schizophrenia (e.g., hallucinations and delusions) as well as cognitive deficits and negative symptoms is a highly active area of research.

Question 44

What are treatments for antipsychotic medications?

Answer 44

1. Use of antipsychotic medications
2. Cognitive remediation, particularly CET (Cognitive Enhancement Theory)

Question 45

What are the two primary types of antipsychotic medications?

Answer 45

1. Typical
2. Atypical

Question 46

What is a typical antipsychotic medication?

Answer 46

The fact that “typical” antipsychotics helped some symptoms of schizophrenia was discovered serendipitously more than 60 years ago (Carpenter & Davis, 2012; Lopez-Munoz et al., 2005). These are drugs that all share a common feature of being a strong block of the D2 type dopamine receptor.

Question 47

What is the downside of typical antipsychotic medications?

Answer 47

Although these drugs can help reduce hallucinations, delusions, and disorganized speech, they do little to improve cognitive deficits or negative symptoms and can be associated with distressing motor side effects.

Question 48

What are atypical antipsychotic medications?

Answer 48

The newer generation of antipsychotics is referred to as “atypical” antipsychotics. These drugs have more mixed mechanisms of action in terms of the receptor types that they influence, though most of them also influence D2 receptors. These newer antipsychotics are not necessarily more helpful for schizophrenia but have fewer motor side effects.

Question 49

What are the downsides of the atypical antipsychotic medications?

Answer 49

However, many of the atypical antipsychotics are associated with side effects referred to as the “metabolic syndrome,” which includes weight gain and increased risk for cardiovascular illness, Type-2 diabetes, and mortality (Lieberman et al., 2005).

Question 50

What has been evidenced to also contribute to functional impairment in schizophrenia?

Answer 50

The evidence that cognitive deficits also contribute to functional impairment in schizophrenia has led to an increased search for treatments that might enhance cognitive function in schizophrenia. Unfortunately, as of yet, there are no pharmacological treatments that work consistently to improve cognition in schizophrenia, though many new types of drugs are currently under exploration.

Question 51

What psychological intervention can help cognitive deficit in schizophrenia?

Answer 51

There is a type of psychological intervention, referred to as cognitive remediation, which has shown some evidence of helping cognition and function in schizophrenia. In particular, a version of this treatment called Cognitive Enhancement Therapy (CET) has been shown to improve cognition, functional outcome, social cognition, and to protect against gray matter loss (Eack et al., 2009; Eack, Greenwald, Hogarty, & Keshavan, 2010; Eack et al., 2010; Eack, Pogue-Geile, Greenwald, Hogarty, & Keshavan, 2010; Hogarty, Greenwald, & Eack, 2006) in young individuals with schizophrenia. The development of new treatments such as Cognitive Enhancement Therapy provides some hope that we will be able to develop new and better approaches to improving the lives of individuals with this serious mental health condition and potentially even prevent it some day.