Psychosis

Question 1

What is psychosis

Answer 1

A symptom of mental illness characterised by radical changes in personality, impaired functioning, and a distorted or non-existent sense of objective reality

Failure to organise experience (e.g., may have poor memory, or poor link between memory and reason)

Question 2

What are abnormalities that Schizophrenia and psychotic disorders are characterised by?

Answer 2

Delusions
Hallucinations
Disorganised thinking/speech
Grossly disorganised/abnormal behaviour
Negative symptoms

Question 3

What are delusions?

Answer 3

Firmly held false beliefs maintained despite strong evidence to the contrary (when evidence is offered it’s explained away)

Question 4

What are different kinds of delusions?

Answer 4

Bizarre – implausible – in one’s cultural worldview (common in sz)

Non-Bizarre – “someone watching me” is plausible but not happening

Jealousy – Partner is unfaithful

Erotomaniac – Higher status is in love with them

Grandiose – inflated worth, power, knowledge, relationship to a deity or someone famous

Being controlled – feelings, impulses, thoughts, actions, controlled by an external force – puppet

Reference – ordinary, insignificant comments, objects or events is about them / special meaning to them – Jacinda trying to send me message pack bags and go do something (fully organised leads to action VS idea of reference) VS idea of reference (person QS reality of belief it is not firmly held NOT delusion)

Persecutory – they or someone close to them is being attacked, cheated, persecuted, or conspired against (can include government and police)

Somatic – concern of serious physical illness or something wrong in body/change (male believed to be pregnant)

Thought broadcasting – thoughts broadcasted out loud so people can hear (common in SZ)

Thought insertion – thoughts not there on but inserted into their mind

Question 5

What are hallucinations?

Answer 5

perceptions that are not based in reality (sensory organ is not stimulated); can be positive (perceiving something that is not there) or negative (not perceiving something that does exist)

Question 6

What are the different types of hallucinations?

Answer 6

Auditory (usual voices from inside or external, can be any noise, music etc) – RARE TO HAVE others WITHOUT auditory,

**Auditory not psychotic on its own but following it and developing a delusional system to explain hallucination that’s the psychotic piece

Gustatory (taste, usually unpleasant, e.g., client metallic taste)

Somatic (physical experience in the body, e.g., feeling of electricity)

Olfactory (odder, burning rubber or decaying fish)

Tactile (touched, push, punched or something under the skin, electric shocks (creeping or crawling under the skin)

Visual (people, flashes of light) * distinguished from illusions, which are misperceptions of real external stimuli)

Question 7

What is disorganised thinking/speech

Answer 7

Switch from one topic to another (loose associa¬tions). Answers can be completely unrelated.

Question 8

Grossly disorganised/abnormal behaviour

Answer 8

Childlike “silliness” to unpredictable agitation.

Catatonic: decrease in reactivity to the environment:

Resistance to instructions;

Frozen: maintaining a rigid, inappropriate or bi¬zarre posture; complete lack of verbal and motor responses.

It can also include purposeless and excessive motor activity {catatonic excitement).

repeated stereotyped movements, staring, mutism, and the echoing of speech.

e.g., if move their arm up it would just stay there - some people say that person is scared stiff

Question 9

What are negative symptoms

Answer 9

Thought, feelings, behaviours normally present that are now diminished or absent:

Reductions in the expression of emo¬tions: in eye contact, speech, body gestures, facial expressions OR in motivated self-initiated purposeful activities. The individual may sit for long periods of time and show little interest in participating in work or social activities

Question 10

What is the criteria for schizophrenia?

Answer 10

Abnormalities in 2+ domains above (one of which must be 1-3) active for one month and symptoms persist for >6 months

Question 11

What is the criteria for schizphreniform?

Answer 11

Sz criteria met but >1 month less 6 months, and don’t need as much impairment

Question 12

What is schizoaffective disorder?

Answer 12

An uninterrupted period of “illness” during which there is a major mood episode (dx or mania) concurrent with active Sz

Delusions or hallucinations 2+ weeks in absence of major mood episode during lifetime of illness (so know not mood dx with psychotic features)

Symptoms that meet criteria for mood episode are present for majority of “illness”

Question 13

What is brief psychotic disorder?

Answer 13

Criteria A met but for less than 1 month

Question 14

What is delusional disorder?

Answer 14

1+ delusions > 1 month

Criterion A for Sz not met (e.g., hallucinations or thought disorder not present)

Apart from impact of delusions, functioning not markedly impaired and behaviour not overtly odd or bizarre (may seem normal until they talk about delusions)

Question 15

What are non diagnostic differentials?

Answer 15

• Cultural considerations (e.g., in te ao Māori hear ancestors)
• Subcultural (e.g., religious beliefs)
• Overvalued idea (rather than delusion)
• Psychotic process (without being psychotic disorder)
• Medical causes

Question 16

What are diagnostic differentials

Answer 16

• Anxiety
  SAME: similar delusions e.g. threat is perceived, not real,
  DIFF: but in delusions very hard to prove threat isn’t real, usually bizarre
• PTSD – 94% with psychotic dx have a trauma history
  SAME: flashbacks have hallucinatory quality; hypervigilance can reach paranoid proportions.
  DIFF: traumatic event and symptom relating to reliving or reacting to the event
• ASD
  SAME: altered processing & sensory exp,
  DIFF: defi¬cits in social interaction with repetitive and restricted behaviours
• DID (auditory hallucinations/personalities)
  DIFF: nothing else?
• Substance Use Disorder (esp. brief psychosis)
  DIFF: just with substance - Laboratory tests, history of substance use, relationships between substance in¬ take and onset of the symptoms
• Mood Disorder with psychotic features
  Mood: If delusions oc¬cur exclusively during mood episodes,
  DIFF: Schizoaffective- symptoms for at least 2 weeks in the absence of a major mood episode.
• Malingering and factitious disorder
  DIFF: Evidence that the symptoms are intentionally produced – understandable gain)
• OCD/body/eating
  SAME: poor or absent insight, and the preoccupations may reach delusional proportions.
  DIFF: prominent obsessions, compul¬sions, preoccupations with appearance or body odor, hoarding, or body-focused repeti¬tive behaviours.
• Personality (paranoid, schizopryple)
  DIFF: other personality stuff
• Hypochondriac
  SAME: Somatic Hallucinations
  DIFF: nothing else? distinguished from hypochondriacal preoccupation

Question 17

Psychometrics for psychosis

Answer 17

Positive and Negative Syndrome Scales (PANS) Kay et al., 1987

Psychotic Symptom Rating scale for Schizophrenia (PSYRATS) - Haddock

Question 18

Onset age, prevalence, Māori, across cultures, gender, prognosis

Answer 18

• Onset of Sz usually late adolescence or young adulthood; earlier in M
• Lifetime prevalence ~ 1%
• Higher for Māori - 1.3% Māori men (misdiagnosis e.g., cultural phenom cannot explain this fully - may be greater stress (racism etc) and drugs may impact Māori differently)
• Similar across genders (but females function better)
• Sz higher incidence in males
• Similar prevalence across cultures
• Can get better *Stanton & Joyce found that 5year follow up, 33% did not meet criteria anymore

Question 19

Consequences

Answer 19

• Accidents – decade shorter life span
• 50% of suicide attempts
• Increased use, abuse, and dependence of a substance
• 1/3 of the homeless population
• 50% unemployed
• Cost for country
• 50% of all psychiatry beds

Question 20

Risk factors?

Answer 20

(story (all concrete/no green, mother starving, born in winter, underweight, not enough oxygen when birth, move to urban, poor)

• Poverty / Lower SES
• Urban birth/ upbringing/migration
• Reduced green space
• Perinatal environment (maternal infection, maternal starvation, born too small, late winter birth).
• Obstetric complications (e.g., birth asphyxia - low oxygen)

Question 21

Biological causes

Answer 21

Genetic
- twin studies reveal predisposition is inherited, but genes not the whole story
- monozygotic 28%, dizygotic 6% (e.g., down syndrome 98, Huntington’s disease 100)
- For 90% of all people diagnosed with schizophrenia neither parent will have schizophrenia

Neurological/structural impairment
- Reduced frontal lobe activity
- Enlarged ventricles

neurochemical irregularities
- dopamine - give lots of dopamin they display psychotic symptoms and dopamine up takers is meds used for schizophrenia
- things show that this is weak or not the full picture: take long for drugs to kick in (2 weeks) when dopamine uptake is immediate
- but limitations bc antipsychotics work for psychosis due to other etiologies not just Sz
- now focus on several NT’s (more than dopamine but serotonin, Glutamate, GABA)
Consider/other

• viral infection (if mum got influenza 2nd trimester more likely chance of Sz Dx
• the season of birth – winter (less vitamin D, more likely to be sick, eat less greens?)

Question 22

Psychological causes

Answer 22

Family dysfunctional
- Family communication (disorder also disrupts communication – chicken or egg)
- Among genetically predisposed, psychosis appeared in disturbed/dysfunctional/chaotic adoptive families/environments

High expressed emotion
- families with high expressed emotions:
critical, hostile, overly emotionally involved, high contact = have higher relapse
- Environment not only plays a role in the development of schizophrenia but maintenance and relapse

Childhood trauma
- Child abuse directly leads to schizophrenia - been debated but recent evidence = people with abuse and neglect develop schizophrenia
- MODEL: trauma that hasn’t been able to make sense of it so leads to Sz symptoms hallucinations, confusion, etc. - traumatic experiences/memories become decontextualised no memory there to reason (“I’m not hallucinating having a memory of..”)
- Are paranoid delusions beliefs developed from abuse (e.g. they’re after me)? Are hallucinations dissociative events (e.g., flashbacks)?

Question 23

Social/cultural causes

Answer 23

• The inverse relationship between social class and schizophrenia (low SES causes stress)
• Hypothesis 1: environmental stress
• Hypothesis 2: social drift (psychosis = gradual downward SES)
• (Unemployment rates predict the pattern of psychosis hospitalisation)
• Green space:
• Living close to green spaces reduces the risk of developing Sz (remains after controlling SES etc) – the reason may be stress relief, pollution exposure etc - for normal people having green space allows the mind to organise which is what is missing in psychosis

Question 24

2 pathways to psychosis

Answer 24

1) Primarily endogenous (driven by biological factors - predominantly negative symptoms- will see changes in the brain level eg MRI – medication management
2) Primarily trauma induced (predominantly positive symptoms – work around trauma for treatment

Question 25

Model for schizophrenia

Answer 25

Impact of stress (stress impacted by coping skills, social support, meaningful activities) and Alochol and drug abuse/medication BOTH (stress/alcohol/meds) impact on biological vulnerability which lead to to Sz symptoms and possible hospitalisation

Question 26

Treatment

Answer 26

Psychotherapy and/or Antipsychotic medication

• If pathway 1- is primary biologically driven leading to negative symptoms - medications may be helpful first-line tx
• If pathway 2- primarily trauma driven leading to positive symptoms - may be psychotherapy work

Question 27

CBT and psychosis

Answer 27

• Early intervention (e.g., psychoeducation, relapse prevention planning, social/occupational functioning, family work, normative social relationships)
• Special care around the first episode
• Poorer prognosis with every psychotic episode (neurotoxic)
• Behavioural experiment work for delusions if not in the active episode
• bucket analogy (size of bucket, water already in bucket = vulnerability; water added = stress; holes in bucket = protective factors)

note:
- ‘Hearing voices’ group (learn to live with voices)