Psychotic Disorders (Schizophrenia) ! Flashcards
What is psychosis?
Extreme impairment in several areas of functioning:
- clarity of thought.
- emotional response.
- communication.
- understanding reality.
- behaviour.
Severely interfere with normal life.
Psychotic symptoms are observed in many other conditions:
- schizophrenia, bipolar, depression, substance abuse, withdrawal.
Schizophrenia: DSMV
A. (Characteristic symptoms) Two of more of the following:
- delusions
- hallucinations
- disorganised speech
- grossly disorganised or catatonic behaviour
- negative symptoms
B. For significant proportion of time.. level of functioning markedly below pre-onset functioning.
C. Signs of disturbance must persist for at least 6 months.
D. Schizoaffective disorder and depressive/bipolar disorder with psychotic features has been ruled out.
E. … not attributable to psychological effects of a substance or other medical condition.
Positive symptoms
Delusions: firmly held (erroneous) beliefs: distorted reasoning, misinterpretation or perception.
- delusion of control
- delusion of reference
- erotomania
- grandiose delusion
- persecutory delusion
- religious delusion
Hallucinations: distortions or exaggerations of perception.
- perceiving sensations that aren’t apparent to others.
- can relate to any of the senses.
- but can also relate to other senses.
Auditory hallucinations (most common): hearing voices which may comment on patients behaviour.
Visual hallucinations: seeing things no one else can.
Negative symptoms
Affective flattening- reduction in range and intensity of emotional expression.
Alogia- poverty of speech.
Avolition- reduction or difficult with goal0directed behaviour.
Other social dysfunction impairments- reduced energy, lack of motivation, poor hygiene, problems functioning at school/work/etc, moodiness.
Disorganised symptoms
Patient’s inability to think clearly and respond appropriately.
Most commonly associated with irregular speech:
- talking in sentences that do not make sense.
- rambling loose associations.
- using nonsense words.
- speaking incoherently.
Can also be related to behaviours:
- odd movements.
- disorganised actions.
- catatonia.
Causes of schizophrenia
Several causal explanations have been suggested. Schizophrenia strongly linked to biological causes- but environmental triggers also likely to be needed. Some associated causes: - genetics. - obstetric events. - infections. - brain structure and function. - neurochemistry etc.
Genetic explanations
Schizophrenia tends to run in families- risk of schizophrenia about 10% if parent has the illness.
Gen pop. = 1%.
MZ twins = 11-14% quite low- against 1-4% DZ twins.
But 60% of pts do not have other family member with disorder- genetic predisposition does not always lead to illness.
Probable that inherited genes make a person vulnerable to schizophrenia- but environmental factors act on vulnerability to trigger illness..
Neurochemistry - dopamine
Overabundance of dopamine strongly implicated.
- dopamine aids communication between nerve cells.
- imbalance affects perception of stimuli.
- increases may relate to positive symptoms.
- certain recreational drugs increase levels (eg. cocaine).
- drugs that treat Parkinson’s increase dopamine.
- antipsychotic medications reduce dopamine and reduce positive symptoms.
Social explanations: life experiences
Risk for schiz increases with number of adverse social factors experienced in childhood (Wicks et al, 05). Some key risk factors: - birth events- eg. maternal illness. - physical or sexual abuse. - poverty. - lower social class. - social deprivation. - migration and racial discrimination. - relationships. - urbanicity.
Cognitive causes for schiz
Interaction between neurobiological, environmental, cognitive and behavioural factors (Beck & Rector 05).
- brain structure abnormalities may predispose- and environmental stressors may provide trigger.
- but cognitive interpretations guide maladaptive behaviour.
- delusions could be due to cognitive biases- such as external attributions.
- and inappropriate behaviour- such as jumping to conclusions.
- hallucinations may be result of attention biases.
Impact on psychotic disorders
European study explored personal impact (Thornicroft et al, 04).
- poorer personal outcomes: higher rates of unemployment; more likely to be single; greater use of welfare benefits.
- poorer quality of life: anxiety/depression; alcohol/substance abuse; poor social life; labelling and stigma etc.
Functional impairment
While social deprivation may be potential cause it is also a consequence.
Schizophrenic people often live in poor urban areas- but did this cause illness or did the illness cause the drift to these areas?
- Social causation hypothesis- (Hollingshead & Redlich, 58)- those in lower classes sugger greater stress; more likely to trigger predisposition.
- Social drift hypothese (Wender et al, 73)- those with schiz cannot gain employment; “drift down” to lower class.
Social cognition impairment
Social cues (Verbal and non verbal) involve perception:
- processing others’ emotional facial expression.
- recognition of familiar social situations.
Theory of mind:
- recognition of other’s intentions and thoughts- depends on interpreting non verbal cues.
- schizophrenia pts impaires in ToM (Brune, 05).
Schiz also associated with other cognitive dysfunctions (Rodriguez-Sanchez et al, 08):
- information processing.
- executive functioning.
- speed of processing.
Insight
Considerable problem in schizophrenia (Mintz et al, 03).
50-80% schiz pts do not believe they are ill.
- some may acknowledge experience of symptoms, but say these are due to outside forces.
- only take meds because pressured to.
Burden
Schiz pts represent sig burden to society (Awad & Vorguganti, 08):
- on caregivers.
- economic costs.
- hospitalisation.
- state benefits.
- psychological support etc.
But most research focuses on family burden:
- emotional, psychological, physical and economic impact.
- distress, shame, embarrassment, guilt, self-blame.
Family/friends burden
Focuses on two constructs. Objective burden: - effects on the household. - taking care of daily tasks. - family dynamics. - loss of social activities. - effect on leisure time and/or career. - finances. Subjective burden: - caregivers' perceptions of that burden. - how they cope with objective burden. - recent research focuses on determining factors.
Burden
Schizophrenia and family burden (Gutierrez-Maldonado et al, 05).
- burden of caring for schiz person associated with: reduced quality of life; sig impact health and functioning of caregivers.
- higher levels objective and subjective burden- high expressed emotion (increases risk of relapse.
- distress and dissatisfaction from burden: perceived losses in carer’s life; lost opportunities because of caring for patient; stigma concerning schiz; financial problems.
Physical health outcomes
Cardiovascular illness- 20% of deaths in schizophrenia pts (Newman & Bland 1991).
Outcomes may be related to two factors:
- long term treatment with antipsychotics.
- patient lifestyle.
Lifestyle factors that may contribute to physical illness:
- increased cigarette and alcohol use.
- poor diet.
- lack of exercise.
- as many as 90% schizophrenia pts dependent on nicotine.
- up to 70% abuse alcohol/drugs (Vieweg & Levenson 95).
Suicide and mortality
Schiz pts associated with greater mortality: shortened life expectancy - up to 20% (Ryan & Thakore, 02).
Risk factor for suicide 20X greater than general population.
Major risk in psychotic pts:
- 4-10% schiz pts kill themselves (Palmer et al, 05): general population rates: 17-20 per 100k for men, 5-6 per 100k for women.
Suicide ideation and attempted suicide common: more than 50& pts show sig ideation at some stage of illness (Barrowclough et al, 04).
Treatments and therapies
Medications:
- original antipsychotics now largely replaces.
- newer drugs used.
Psychosocial therapy:
- rehabilitation.
- psychoeducation.
- individual psychotherapy- behavioural, cognitive, CBT.
Medications
Antipsychotic medication:
- do not cure schiz.
- help relieve most troubling symptoms- delusions, hallucinations, disorganised thought.
Original (typical) antipsychotics:
- haloperidol, chlorpromazine etc- replaced because of serious side effects.
Newer (atypical) medications:
- risperidone, clozapine etc.
Major problems with original antipsychotics
Extrapyramidal symptoms (EPS):
- repetitive, involuntary muscle movements.
Dyskinesias- movement disorder.
- tongue movements, lip smacking, eye blinking etc.
- akathisia - extreme form of restlessness (urge to move constantly).
Dystonias- muscle tension disorders:
- very strong muscle contractions.
- unusual twisting of parts of body.
‘Tardive’ symptoms may occur ith long term treatment:
- more permanent movement/muscle disorders.
Atypical antipsychotics
Mostly without EPS side effects: although risperidone still quite high with larger doses- important to consider this with vulnerable pts.
Commonly used in psychiatric community.
Neurotransmitter activity varies between drugs- but most commonly reduce dopamine availability.
While EPS reduces- still risk for tardive dyskinesia particularly after long term use.
Effectiveness
Several studies confirm atypical APs superior to original drugs- and better EPS profile.
Original antipsychotics focused on positive symptoms- some atypical APs treat positive and negative symptoms- may be due to dual role of dopamine and serotonin action.
Several studies confirm greater efficacy:
- particularly at higher doses.
- better treatment of negative symptoms.
- reduced suicidal thought.
- greater benefits in treatment-resistant conditions.
Atypical APs side effects
Sedation quite common- better tolerated over time.
Weight gain can be a particular problem- potentially serious.; some APs may cause diabetes; overweight schizophrenics need particular attention.
Other side effects: dry mouth, dizziness, hypotension etc.
Psychosocial therapies
In most cases, antipsychotic treatment is essential.
However a number of additional therapies used- help with behavioural, psychological social and occupational problems.
- pts can learn to control symptoms.
- identify early warning signs of relapse.
- develop relapse prevention plan.
Rehabilitation
Helps pts function independently in community:
- learning social skills.
- employment training- combined therapies generally better.
30 Turkish schiz pts examined (Yildiz et al, 04): 15 underwent psychosocial training skills training; 15 had treatment as usual (TAS- meds plus discussion with pts and family).
- intervention group showed sig. improvement- positive and negative symptoms, QoL, social functioning etc.
- TAS group showed no improvements.
Psychoeducation
Education about mental illness for pts and their families:
- diagnoses, delusions and hallucinations- impact on behaviour, thought and emotion.
- potential causes.
- treatments- particular focus on benefits, side effects, adherence.
- prognoses.
- discuss role family can play helping.
- help families improve communication skills.
Efficacy of psychoeducation
Good outcomes for family burden: 52 PE vs. 56 controls.
- post treatment ‘family burden’ sig better for PE group.
- near sig difference for financial burden.
- no between group diff at baseline.
Patient outcomes: follow up study 7 years post treatment- 24 PE vs 24 TAS.
- re hospitalisation rate: PE 54% vs 88% TAS.
- no hospital days: PE 75 vs 225 TAS.
Individual psychotherapy
Some psychotherapy methods may not be suitable- insight therapies, psychodynamics etc.
But focused therapies do work- behavioural, cognitive, CBT.
Behavioural therapies- focus changing patterns of leaning:
- social skills.
- cause and effect.
- leaning from experience.
- stress management.
- assertiveness.
- problem solving.
But most therapies also include cognitive processes.
Individual psychotherapy
Cognitive therapies (Beck & Renton, 05):
- unlike depression, not easy to change patterns of thought- produced by biological abnormalities.
- more successful techniques help adapt thought- take information from environment; adapt ‘misinterpretations’ to cope with own ‘reality’. But better if combined with behavioural techniques.
CBT (Turkington et al, 08):
- often been dismissed in schizoprenia- but good evidence success; no side effects.
CBT for schizophrenia
Typical procedure:
- aim is to enhance cognitive function.
- pt expresses thoughts about experiences.
- discuss symptoms causation and maintenance.
- do not challenge beliefs- work with them.
- pts taught to understand processes in their complex lives.
ABC method used: activating event- beliefs- consequence.
Pt discusses their perception of ABC- especially B to C- therapist discusses rationality.
- collaborative critical analysis– develop alternative explanations.
