Module 5: Psychosis, schizophrenia, and bipolar disorders Flashcards
\What are positive symptoms?
Delusions and hallucinations
Disordered thought and speech, loose associations of ideas, disjointed concepts, trailing off sentences, confusing,
Can still speak normally, but do not pick up on somatic ques
disordered/abnormal motor behaviour - behaviours are not culturally normative
What are negative symptoms?
a decline in normal functioning - the 4 As of psychosis
Affective flattening (monotonous tone and immobile facial expressions
Anhedonia - lack of response to pleasurable events
Alogia (speech poverty, reduction in the quality or quantity of speech
Avolition (loss of drive, difficulty keeping plans)
Social withdrawal
What are the 4 A’s in psychosis negative symptoms?
- Affective flattening
- Anhedonia
- Alogia (speech poverty)
- Avolition (loss of drive/difficulty keeping plans)
What is the most common types of hallucinations in order?
“a perception like experience with the clarity and impact of a true perception but without the external stimulation of the relevant sensory organ”
- auditory
- visual
- olfactory
How common are hallucinations in the general population?
LP = 7.3% in nonclinical population, most often auditory and disappear with time, only a small percentage seek help for auditory hallucinations
Since auditory hallucinations are common in nonclinical populations, would schizophrenia be better understood with a dimensional approach?
What is the meta-cognitive theory about hallucinations?
people with schizophrenia struggle thinking about thinking,
cannot to take mental events and integrate into larger representations,
difficulty understanding mental events
What suggests a dysfunction with perception might be at play in hallucinations?
neuroimaging studies show altered activation in brain with speech sounds and production, suggesting alternates in auditory pathways in brain that may contribute to auditory hallucinations
What is the theory of misattribution from the internal forward model on hallucinations?
- when the brain goes to produce a motor action: 1) a motor command is generated to produce the movement and an efference copy, which is a prediction of the outcome of the movement
a) If the prediction of the motor is aligned with what then occurs in reality - then the two processes cancel out and perception occurs as normal
b) If there is a misalignment between the prediction and the generation of motor function - it may cause hallucinations, the perception of something seemingly external
What are delusions?
“A firmly held false belief based on something incorrect about reality despite what almost everyone else beliefs and despite usually obvious proof or evidence to the contrary”
Bizarre vs. non bizarre delusions?
Bizarre - clearly illogical based on the individuals cultural context
Non-bizarre - not necessarily illogical based on individuals cultural context
Types of delusions?
- Persecutory - paranoid delusions, individual fears harm MOST COMMON
- Referential - ideas of reference taking trivial/unimportant events and frames them of being of personal significance
Grandiose - delusions of power and superiority, wealth, fame, importance
Somatic - delusions that one’s body is grossly abnormal, diseased or infected with something toxic
Religious - religious theme and common in schizophrenia, common with cross over with delusions of grandeur, not socially acceptable
Thought alienation - belief that their thoughts have been inserted into their head (insertion) or taken away (withdrawal)
Broadcasting - belief that one’s thoughts are being broadcasted/transmitted to others
External - belief that someone else is in control of their thinking and behaviour, eg. a radio transmitter tower controlling their thoughts and actions
Misidentification - belief that people around oneself have been replaced by imposters
Schizophrenia prevalence, gender and onset?
“Un umbrella term for complex syndrome with cognitive, perceptual, behavioural, language and emotional dysfunctions”
LP = 1-2% in general population
3:2 male to women, disproportionately affecting men
Onset = Early adulthood
What is criteria A for schizophrenia?
A. Two or more of following symptoms for a significant portion of one month period, at least 1, 2 or 3
1. Delusions
2. Hallucinations
3. Disorganised speech
4. Grossly disorganised / catatonic
5. Negative symptoms (diminished emotional expression or evolution, overlap with depression)
What is criteria B and C?
B. for a significant portion of time since the onset, level of function is markedly below the level achieved prior to the onset
C. Continuous sign of disturbance persisting at least 6 months (can be diagnosed with other psychotic disorders if it hasn’t been 6 months yet)
What if patient has a history of autism in a diagnosis of schizophrenia?
Criteria F. If there is a history of autism or communication disorder of childhood onset, a diagnosis of schizophrenia can only be made if there are prominent delusions or hallucinations, as well as other schizophrenic symptoms, that have lasted at least one month
What other things do you need to rule out for a diagnosis of schizophrenia?
D. Schizoaffective disorder, depressive and bipolar disorder with psychotic features have been ruled out because:
No major depressive or manic episodes have occurred
Mood episodes that have occurred have only been there for a small about of time
E. not attributed to physiological effects of a substance or other medical condition
When do you put specifiers for schizophrenia?
(after diagnosis, beyond the length of a year) - to describe level of severity
What is first vs. multiple episode?
Number of instances of psychotic symptoms experienced
First episode (acute, partial or full remission) OR
Multiple episode (acute, partial or full remission)
What is acute, partial or full remission?
Acute = Any time period in which the symptom criteria are fulfilled
Partial = after episode, when criteria are only partially fulfilled (getting better)
Full = after episode, when criteria are not fulfilled /no symptoms are present (feel completely fine / symptom free)
What are the 4 types of specifiers to further categorise schizophrenia?
Continuous = symptoms fulling diagnostic criteria remain for the majority of the illness course, periods of subthreshold are brief
Unspecified = covers individuals that don’t cover within first or multiple categories
Catatonia = marked by psychomotor disturbances that cause described motor engagement and activity
Severity specifier - rated by a quantitative assessment of primary psychosis symptoms to not present to present and severe
What are the 5 stages to describe the course of schizophrenia?
- Premorbid - show signs of risk factors, eg. social withdrawal, trouble with peers
- Prodromal - functioning declines, mood symptoms, deterioration of social or school skills, some early psychotic features
- Acute - full blown symptoms
- Early recovery - symptoms improve, accompanied by anxiety and/or depression
- Late recovery - reintegrate into society, improve symptoms, 80-90% have a relapse which can be exacerbated by drug use, peer conflict, and not compliance with treatment - can cause relapse cycles
What factors influence good outcomes for schizophrenia?
- female
- late and acute onset
- positive symptoms
- good social support
- good overall functioning
What factors influence bad outcomes for schizophrenia?
- male
- early and gradual onset
- negative symptoms
- poor social support
- lower overall functioning / autistic
- trauma and family history
What are the 4 types of “Schizophrenia disorders in the DSM from least to worse severity?
The number of letters also happens to correspond with the increase in severity
- schizoid PD - Introverted and voluntary withdrawal from social interactions, eccentric thoughts and beliefs
- Schizotypal PD = Schizoid + magical thinking and odd behaviour
- schizophrenia = Schizotypal + psychosis
- Schizoaffective = Schizophrenia + mood disorder eg. depression, mania, bipolar
Before a diagnosis after 6 months, what are the other forms of schizophrenia?
1 day - 30 days = brief psychotic disorder
30 days-6 months = schizophreniform disorder, lasting at least 1 month
> 6 months schizophrenia
What are 2 less common psychotic disorders?
Delusion disorder = experience delusions for at least one month, but have few to no negative symptoms and less impairment
Shared psychotic disorder (folie a deux) = delusions from one person manifest in another, ie. one person with psychotic disorder convinces someone else of another delusion, incredibly rare
The balance between the biopsychosocial model for each disorder differs - what is it for schizophrenia?
Schizophrenia seems to have a higher rate of biological causes compared to psycho and social
most influential = genetics - found heritability rate of 81% for schizophrenia and psychosis
What are the 2 main findings of brain structure in schizophrenia patients?
- Reductions in neural volume of hippocampus, amygdala and thalamus
Reductions in the nucleus accumbens, intracranial space, left precentral cyprus and caudal middle frontal gyrus
Increased in sizes of the ventricles
What is the dopamine hypothesis in schizophrenia?
- Comes from a discovery from antipsychotic drugs, chlorpromazine
- Chlorpromazine blocks dopamine receptors in neurons by binding to postsynaptic receptors instead of dopamine - preventing dopaminergic transmission
Since chlorpromazine is a treatment for schizophrenia that blocks dopamine, researchers hypothesise that dopamine was responsible for the symptoms of schizophrenia
What’s the evidence for the dopamine hypothesis?
Most dopaminergic neurons begin at the centre of the brain (in the ventral tegmental area and substantia nigra)
Neuroimaging shows schizophrenia patients have higher amount and activity of dopaminergic pathways
especially in the mesocortical pathway that go to the frontal cortex
Treatment of external L-Dopa in parkinson’s disease is also linked with psychosis
Vise versa = Dopamine antagonists chlorpromazine can result in movement problems like in Parkinson’s disease
Amphetamines that increase dopamine production can also result in psychosis
What are 3 limitations of the dopamine hypothesis?
- Chlorpromazine is sedative immediately, but antipsychotic effects take days/weeks but dopamine transmission is really fast?
- Chlorpromazine only works with the positive symptoms of schizophrenia
- Dopamine antagonists do not always work and dont’ ‘cure’ someone of schizophrenia
What is the one psychological aetiology for schizophrenia?
Diathesis stress model = predisposition changes over time + life stress +/- resources can act together to influence whether an individual develops a disorder
Cup analogy of stress - cups are filled with ‘stressors’ (predisposition) and overflow when the capacity to cope is overexerted
What 4 Social/environmental factors increase risk for schizophrenia?
- Virus infection risk = children born in winter/spring have higher risk of developing schizophrenia,
- perinatal/obstetric complications = drugs, lack of oxygen or viruses
- Emotional, sexual physical abuse or neglect
- Cannabis use - people who use cannabis were 3.9x more likely to be at risk of developing psychosis
What are the cultural differences and prevalences of schizophrenia?
- Higher rates of schizophrenia in western, rich, educated, industrialised and democratic countries
- Americans had more violent/hateful voices while african/indian had more positive voices
What 4 types of treatment do we need in schizophrenia?
- Early intervention
- Protective factors = to promote support network and coping skills -
- Antipsychotics = typical and atypical (hard to get trust of the schizophrenia patient as the most common type of delusion is persecutory, where they believe they are being harmed by others)
- Therapy = CBT + family interventions to support individual and prevent relapse
What is bipolar?
- abnormal moods and exaggerated mood swings characterised by extremely high (manic episodes) and low/depressive moods
Each individual has varying rates of manic and depressive episodes
1% of the population that will need to be hospitalised from an episode
Equal gender ratio
Onset: early-late 20s
What are the symptoms of mania?
- Feelings of euphoria
- Grandiose plans and beliefs
- irritability often from people not understanding their rapid flow of ideas
- jumbled or unintelligible to others
- decreased need for sleep due to their constant flow of ideas
- Poor judgement / irrational and impulsive decision making
- Increased sex drive
What is hypomania?
Hypomania = moderate levels of mania (person is in contact with reality, doesn’t require hospitalisation BUT (very easy to move from hypomania to mania)
CRITERIA A for bipolar?
At least one week of abnormally and persistently elevated, expansive or irritable mood - present most of the day, almost every day
CRITERIA B for bipolar?
3 or more of the following symptoms
- Inflated self-esteem/feelings of grandiosity
- Decreased need for sleep
- More talkative than usual
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
- Excessive involvement in activities that have a high potential for painful consequences RISKY BEHAVIOUR
How to tell whether mania or hypomania
- look at severity of symptoms
- does it require hospitalisation? / risk to themselves or others? = MANIA
- Is there a presence of psychotic features? = MANIA
Difference between bipolar I and bipolar II?
Bipolar I
- Criteria met for at least one manic episode.
- May or may not have been preceded by and be followed by a hypomanic or major depressive episode.
Bipolar II
A. Criteria have been met for at least one HYPOMANIA episode and at least one major depressive episode.
B. There has NEVER been a manic episode.
What are the depressive symptoms in bipolar?
- Persistent sad or hopeless mood
- Anhedonia
- Lowered motivation to eat, perform normal tasks
- poor/disrupted sleep
- Feelings of worthlessness and hopelessness
- Decreased libido
- Poor concentration and difficulty in decision making and everyday tasks
- Suicidal thoughts/ideation and attempts
What is mixed episodes in bipolar?
= experience of both manic and depressive symptoms every day and switching rapidly between feelings of hopelessness to euphoria, delusions to irritability, etc.
What is rapid cycling in bipolar?
The experience of 4+ major episodes of hypomania, mania, depression in a year
- alternating between extreme mood states and normal mood (sometimes not in between normal mood states)
What is the diagnostic criteria for cyclothymia?
- At least two years with hypomanic symptoms that do not meet criteria for a hypomanic episode
- During the period, the hypomanic and depressive periods have been PRESENT FOR AT LEAST HALF THE TIME and the individual has not been without the symptoms for more than months at a time
What is the general consensus about bipolar disorders origin?
It is generally believed that an interaction of factors come together to cause the onset of bipolar disorders, as hypothesised in the stress vulnerability model
genetics, biology, environment, protective and risk factors combine together to influence the likelihood of developing bipolar and the risk of relapse
What is genetic and biological findings on bipolar?
- Higher risk in first-degree relatives
Children of bipolar parents have 8%,
Children of bipolar parents have 12% of getting depression without mania
Higher rates of heritability in monozygotic vs dizygotic twins
- Suggested neurochemical imbalances and functionality in brain could lead to rapidly switching moods
What Socio Environmental stressors may increase risk of bipolar?
Factors that increase stress/irritability
- family conflict, divorce, grief,
- positive events like getting married and having children can increase risk of bipolar, especially if they have genetic/bio vulnerability
Bipolar is also influenced by how well the individual copes with their environmental stressors and how many risk and protective factors they have in their life
