Psychosis Flashcards
Psychotic-like experiences
Persecutory Ideation (e.g. felt as if people seem to drop hints about you or say things with a double meaning)
Bizarre Experiences (e.g. felt as if electrical devices such as computers can influence the way you think)
Perceptual Abnormalities (e.g. heard voices when you are alone, seen objects, people or animals that other people can’t see)
What is Psychosis?
A constellation of symptoms particularly disturbances in:
❖ Perception (Hallucinations).
❖ Belief and interpretation of the environment (Delusions).
❖ Disorganisation of thoughts and behaviour (e.g., speech patterns, odd behaviour).
❖ Mood/feelings (e.g., decreased intensity or agitation).
Positive Symptoms of psychosis
- Delusions/Unusual thinking
- Hallucinations:
- Thought Disorder
Delusions/Unusual thinking:
severe reality distortions/unusual bizarre beliefs.
Hallucinations:
sensory experiences felt with the full force of a perception in all modalities- auditory (most common), visual, olfactory (smell), gustatory (taste), tactile
Thought Disorder
Impaired ability to put ideas together in linear and goal directed fashion; disorganised thinking (e.g. thought blocking, derailment, poverty tangentiality). Difficulties making meaning from speech.
Negative Symptoms of psychosis-5 A’s
Anhedonia Asociality Avolition Affective Flattening (paralanguage). Alogia (Poverty of speech)
Hence, can give the missed impression that they are lifeless, absent & difficult to connect
Anhedonia
loss of interest in pleasurable activities or the anticipation of pleasure, not so much in the moment (e.g., socialising, recreational pursuits such as hobbies).
Asociality
lack of desire to form relationships, withdrawal.
Avolition
lack of motivation for goal directed behaviour (“get up and go”, “Initiative”).
Affective Flattening
- reduced expression through face, body and voice (paralanguage).
Alogia
(Poverty of speech) reduced verbal out poorly, difficulty elaborating.
How do you know if neg symptoms or depression?
Criteria overlap, first ep psychosis is insidious (subtle and harmful), depression is sadness, negative symptoms of psychosis is neither happy nor sad
Delusions
Fixed beliefs that are not amenable to change in light of conflicting evidence. Cntent may be persecutory, referential, somatic, religious, grandiose.
When is a delusion considered bizarre?
if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences.
What is the distinction between a delusion and a strongly held idea?
- sometimes difficult to make
- depends in part on the degree of conviction with which the belief is held despite clear contradictory evidence
- diminished or distorted sense of reality and unable to distinguish the real from unreal.
What disorders include delusions?
schizophrenia, schizoaffective disorder, delusional disorder, schizophreniform disorder, brief psychotic disorder, substance induced disorder, bipolar disorder, major depressive disorder with psychotic features, dementia.
Can also be due to medical causes such as brain injury, intoxication, somatic illness
Primary delusions
Primary: Various types. Autonomous, original, and incomprehensible from a psychological point of
view. They appear suddenly, the patient has a complete conviction of it. Not psychologically understandable. E.g. uncanny feeling the world is odd, false memories, self-referential ideas
Secondary delusions
Delusional idea that manifests as an attempt to explain strange, senseless experiences. Psychologically understandable.
❖ Common Themes:
Persecution (central psychotic experience) , Grandiosity (special power), Control (e.g., thought insertion, thought
broadcasting), Reference (e.g., isolated or random events have special personal significance); Love (e.g., jealousy or possessiveness towards other person-erotimania), Guilt or unworthiness (more depression), Somatic (e.g., unexplained medical or perceived bodily sensation); Nihilistic (intense feelings of emptiness), Control (e.g., thought insertion, thought broadcasting), Mixed (two or more themes).
Persecutory Delusions
At first episode of Psychosis, over 70% of client’s have
persecutory delusions
Two central concerns (1) Harm is going to occur (2) Others intend to do it. Maybe be other people or machines, or systems. E.g. paranoia, I’m targeted by many trying to ruin my life.
Paranoid Continuum of Psychotic Experiences
10 - Delusions of Persecution/Mental disorder
❖ Severe threat: e.g., people trying to cause significant physical or psychological or social harm; conspiracies
known to wider public.
❖ Moderate threat: e.g, people going out of their way to get at you.
❖ Mild threat: e.g., people trying to cause minor distress such as irritation, being monitored (e.g. cameras)
❖ Ideas of reference e.g., people talking about you, ?being watched.
❖ Social evaluative concerns e.g. fears of rejection, feelings of vulnerability, thoughts that the world is
potentially dangerous
1 - Mental health concerns/Exaggerated Self-Consciousness & Hypervigilance
How many psychotic individuals have cognitive disturbance? Which cognitive
Not included in diagnostic Criteria but ubiquitous with 80% of psychotic disorders exhibiting clinically significant impairment.
❖ Cognition: deficits/difficulties in attention, working memory, processing speed problem solving and cognitive control
❖ Social Cognition: Processing social and emotional cues or stimuli; Theory of Mind
❖ Suggestive of an organic (brain based) element to psychosis.
❖ Present prior to onset of psychosis & impact every day independent functioning (e.g. ADL’s -Activities of Daily Living)
Functional Impairments
❖ Role functioning = responsibilities and
functioning in job school home and community.
❖ Social functioning- friendship group, nature of
friendships, amount of social contact and engagement.
❖ Strongly related to severity of negative and cognitive symptoms.
❖ Psychosocial or pre-morbid functioning prior to onset can predict recovery outcomes
❖ Functional Recovery is critical in treatment
Maintaining meaningful life roles, goals and relationships in their life ( particularly frustrating to clients and families).
Insight
- Not in diagnostic criteria but is often seen clinically as a cardinal feature of psychosis
- As one concept of insight, cognitive insight was introduced in 2004 to describe the capacity of patients with psychosis to distance themselves from their psychotic experiences, reflect on them, and respond to corrective feedback. (Riggs et al 2012)
- Big challenge to engagement in services and treatment, long delays in treatment and can result in involuntary treatment.
Disturbed Experience of Self
Have you felt as if you were standing next to yourself or watched yourself like looking at someone else or as if in a movie?
• Have you felt as if your whole body or parts of your body were detached or did not belong to you?
• Have you felt unreal or like a stranger to yourself?
• Have you looked in the mirror and felt disconnected from your own image?
- Have you felt like you were in a dream or just going through the motions?
- A disturbed self-experience can be most puzzling and frightening to patients, and may lead to withdrawal from social contact.
- Subtle experiences of self-disturbance have already been found in the prodromal phase of psychosis, and they have been recognized as a risk factor for transition to psychosis in subjects at ‘ultra-high risk’ for the disorder.
peak age of onset of the first psychotic episode
in the early to mid 20’s for males and late 20’s for females (DSM-5).
Schizophrenia is the ?? leading cause of burden
Schizophrenia is the third leading cause of burden and injury in young men aged 15-24 years and the fifth in
young women the same age (Aust. Institute of Health & Welfare 2007).
First Episode Psychosis (FEP)
used within clinical and research settings can be misleading regardless of which operational definition is used.
This term is typically used to refer to individuals early in the course of a psychotic illness or treatment rather than individuals who are truly in the midst of a first ‘episode’ of illness. (Nicholas et al, 2009)
Diagnostically, a First Episode of Psychosis is often used interchangeably with Scizophreniform Disorder.
Schizophreniform Disorder
Characterized by the presence of the symptoms of schizophrenia, but it is distinguished from that condition by its shorter duration, which is at least 1 month but less than 6 months. Delusions Hallucinations Disorganised Behaviour (catatonia) Negative Symptoms
❖ There can be no manic, depressive or mixed depressive episodes during these symptoms and any mood disturbance must have been present during only a minority of this time, thereby excluding schizoaffective
disorder or bipolar disorder with psychotic features.
❖ Symptoms cannot be due to the effects of substance (drug of abuse or medication) or a nuerologiocal
disorder
Comorbidity in First Episode of Psychosis (FEP)
As many as 80-90% of people with FEP fulfils the criteria for at least one co-morbid psychiatric disorder including major depression, Anxiety Disorders (including social phobia and post traumatic stress disorder) and obsessive compulsive disorder,
Relapse risk factors
non-adherence to medication, substance use, poor pre-morbid adjustment, ‘critical comments’ from family and supports
A young person may experience a number of Early Warning Signs 1-4 weeks preceding a relapse. Important to avoid being unrealistic.
Kraepelian view of schizophrenia
relentless dementing illness associated with inevitable
deterioration- “Dementia Praecox”, believing that these patients suffered from an early form of dementing illness.
❖ Held the belief that biological and genetic disorders
cause psychiatric illness.
Eugen Bleuler view of schizophrenia
not all schizophrenic patients eventually become demented and that the prognosis of the disease is not uniformly grim, as Kraepelin suggested.
❖ Advocated for the discharge of some schizophrenic patients from the hospital rather than a lifelong commitment, which was common practice in the 1800s.
❖ Was an early proponent of what has come to be known as the biopsychosocial model in psychiatry.
duration of untreated psychosis (DUP)
longer DUP is associated with worse functional outcomes in addition to persistent symptoms, poorer quality of life and lower treatment response
❖ Early intervention as a service model evolved in
the mid 1980s
Mean duration of untreated psychosis (DUP) of 1-2 years
significant association between DUP and homicide (longer duration, more likely homicide risk)
Help Seeking Delays
- No Knowledge of psychosis
- Difficulty differentiating from ‘normal’ adolescent issues
- Paranoia and mistrust
- Negative Symptoms
- Stigma
- Insight and engagement with services
Health Service Delays
- Not recognising Symptoms at First Contact
- Delays to Assessment
- Delays to referral
- Delays within mental health services
- Not recognising importance of prompt treatment
Critical period in psychosis
❖ About 80% of people experience their first episode of psychosis between the ages of 16 and 30.
Clinical deterioration and subsequent psycho-social impacts are most marked within the first 3-5 years after an acute episode of psychosis, and then plateau after this time
Aetiology
❖ Biological (e.g., genetic, physiological, biochemistry) and may be present from birth
❖ Psychological (e.g., young person’s upringing, emotional experiences and interactions with other people).
❖ Social Factors (e.g., young person’s present life situation and sociocultural background
Stress-Vulnerability Model
Generally accepted that psychosis results from impact of stress and other risk factors upon biological predisposition. ‘stress vulnerability’ interaction
❖ The greater the person’s vulnerability, the
less stress is required to trigger an episode
of psychosis.
Straw that broke the camels back/buckets overflowing analogies used here. e.g. relationship breakup causes psychosis after build up of other stressors e.g. exams.
Distal: Feotal and early life risk factors for psychosis
❖ Maternal complications/perinatal trauma, especially foetal hypoxia
❖ Family history
❖ Candidate genes
❖ Developmental delay
❖ Season of Birth (late winter early spring)
❖ Ethnic Minority
Early Life
❖ Quality of early rearing environment
❖ Trauma (abuse & neglect)
❖ Vulnerable Personality (e.g schizoid personality)
Proximal Risk Factors (closer in time to episode)
Age ❖ Urbanicity ❖ Substance Use, especially cannabis use ❖ Traumatic Head Injury ❖ Stressful life events ❖ Poor functioning ❖ Subtle impairments in cognition ❖ Cognitive, affective and social disturbances subjectively experienced by the individual (‘basic symptoms’), ❖ Migration
Following a first episode young people may have different symptom trajectories:
- No further episodes (50%)
- At least one further relapse(50%)
- Multiple relapses (35%)
- Severe, persistent and unremitting (15%)
Clinical Staging Model
Prodromal phase, acute phase, recovery phase
Assumes that treatments are offered earlier in the course of an illness have the potential to be safer, more effective and affordable than those offered later in the course of the illness.
More clinical utility- matching of the timing and intensity of interventions.
Prodrome can only be identified retrospectively!
Attenuated Psychosis Syndrome
DSM-V Attenuated Psychosis (condition for “further study”). The proposed diagnostic criteria for APS in DSM - 5: • At least one of the following of symptoms is present in attenuated form, with relatively intact reality testing and is of sufficient severity or frequency to warrant clinical attention:
•Delusions
•Hallucinations
•Disorganized speech.
•Symptom(s) must have been present at least once per week in the last 1 month
•Symptom(s) must have begun or worsened in the past year
•Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical attention
Symptom(s) is not better explained by another mental disorder,
Identifying those truely experiencing Prodrome?
Ultra-High Risk (UHR)
Moderate but sub-threshold symptoms, with moderate neurocognitive changes and functional decline to caseness or chronic poor functioning (≥ 30% drop in SOFAS in previous 12 months OR < 50 for previous 12 months).
• People UHR of psychosis are associated with an approximately 30% risk of developing psychosis in the following two years, 400 times greater risk than normal people, three- to four-fold higher risk than people with a family history alone
STATE (using CAARMS): BLIPS (full threshold psychotic symptoms for less than a week); Attenuated Psychotic symptoms (APS).
• TRAIT: Schizotypal personality disorder or first degree relative with psychosis
• One of the above in addition to all of the following: Age 15-25, Help-Seeking, plus ≥ (30% drop in SOFAS in previous 12 months OR < 50 for previous 12 months) or longstanding low functioning.
Debates around ultra high risk
- Strong debate regarding “false positive” cases, since most UHR subjects will not finally develop psychosis.
- Transition rates to psychosis highly variable (?30%) and have been declining over the years, leading to fierce criticism over the validity of the UHR/ APS state and legitimacy of its treatment.
- Ethical issues of stigmatizing through unnecessary diagnosing and antipsychotics’ prescribing are matters of serious questioning clinical heterogeneity and high comorbidity are further implications of the UHR state.
Domains of Assessment
❖ Clinical & Personal History
❖ MSE: Relevant to all MSE domains! In particular Insight & Judement. Insight includes whether the person recognises that hey have an illness, that the illness is a mental disorder, and that treatment is required.
❖ Biological Assessment: Although only 3% of FEP has an organic origin, the initial assessment is the most appropriate time for laboratory tests
❖ Cognitive Assessment: deficits pre-date onset, are present at first episode and alter little thereafter
❖ Assessment of co-morbid disorders: substance use
❖ Assessment of other psychiatric disorders
❖ Risk Assessment
Risk Assessment- Risk to Self
20% of people with FEP report deliberate self harm or a suicide attempt prior to presentation for treatment. 50-65% will have experienced recent thoughts of suicide
• Small number of people commit suicide in response to command hallucinations.
Risk Assessment
Needs to be systematic and routine and involve multiple risk domains & both Dynamic Factors: risk to self and other, substance use, adherence to treatment and Static Factors such, mental health and personal history (e.g family history of mental illness), significant medical co morbidities, metabolic risk, legal (including involuntary treatment status).
first-line treatment for psychotic disorders
Pharmacotherapy “Start Low, go slow”
particularly low-dose antipsychotic medication, may be effective in preventing or delaying transition to psychosis in the short-term when combined with CBT
Allow an antipsychotic drug-free assessment phase (whilst you may assess for biological explanations for the
presenting pictures; ?delirium, drug induced psychosis etc
May add benzodiazepine at this stage to manage agitation/aggression, anxiety or sleep disturbance
Medication is not as effective in preventing the onset of a psychotic disorder and may in fact, place individuals at risk of transitioning to psychotic disorder
Psychological Treatments
CBT considered to have the most extensive evidence base.
ACT shows early promise in treating psychotic disorders effectively. ACT maps well onto contemporary recovery principles.
