Week 11: Psychotic disorders Flashcards
What do people with psychotic disorders struggle with?
Thinking clearly, making good judgements, responding emotionally, communicating, understanding reality and behaving appropriately
What are the different types of psychotic disorders?
Schizophrenia Schizoaffective disorder Schizophreniform disorder Brief psychotic disorder Delusional disorder
Schizophrenia is characterized by….
Major disturbances in thought (disordered thinking with illogical ideas), emotion (lack of expression, inappropriate emotions) and behaviour (disturbances in movement and behaviour)
Schizophrenia and suicide?
Those with schizophrenia have increased risk of suicide and death
What is the prevalence of schizophrenia?
1%
Gender differences in schizophrenia?
Men slightly more than women
- men are also diagnosed at an earlier age than women
When is the typical onset of schizophrenia?
Late adolescence or early adulthood
What are the symptoms of schizophrenia? and how many need to be present for diagnosis?
Delusions
Hallucinations
Disorganised speech
Disorganised motor behaviour (catatonia)
Negative symptoms (diminished motivation or emotional expression)
Two or more, with at least one of the first 3
How long do the symptoms have to persist to be diagnosed as schizophrenia?
At least 6 months
What does it mean to have a positive symptom?
To have gained things you didnt have before
What does it mean to have negative symptoms?
To have lost things you had in the past
What are the positive emotions in schizophrenia?
Delusions and hallucinations
What are the negative symptoms of schizophrenia?
Avolition (lack of interest)
Alogia (lack of speech)
Anhedonia (no more pleasure in pleasurable activities)
Blunted affect (lowered emotional expression)
Asociality (little or no desire to socialize with others- inability to form close personal realtionships)
What are the disorganized symptoms of schizophrenia
disorganised speech and behaviour
What are delusions?
They are firmly held beliefs that are contrary to reality
Often resistant to disconfirming evidence
What are persecutory delusions?
the affected persons believe they are being persecuted, despite a lack of evidence. Specifically, they have been defined as containing two central elements: The individual thinks that harm is occurring, or is going to occur.
What are thought insertion delusions?
experiencing one’s own thoughts as someone else’s
What are thought broadcasting delusions?
Delusion that one’s thought is projected and perceived by others.
What are outside control delusions?
delusion that one’s thoughts, feelings, and actions are not one’s own but are being imposed by someone else or some other external force.
What are gradiose delusions?
A delusion of grandeur is a false or unusual belief about one’s greatness
What are ideas of reference delusions?
Thoughts that things that have happened in the real world are somehow weirdly connected to the individual
What are hallucinations?
Sensory experiences in the absence of sensory stimulation
What are the different types of halluncinations?
Auditory
Visual
Hearing voices
What is the most common types of hallucination?
Auditory
Why do people hear voices?
Increased levels of activity in brocas area during hallucinations
What are the two categories of negative schizophrenia symptoms?
Experience - motivation, emotional experience, sociality
Expression - expression of emotion, vocalizations
Disorganised speech in schizophrenia?
Incoherence: inability to organise ideas Loose associations (derailment): rambles, difficulty staying on track
Disorganised behaviour in schizophrenia?
Odd or peculiar behaviour
(silliness, agitation, unusual dress)
E.g. wearing several heavy coats in summer
What are some of the movement symptoms of schizophrenia?
Catatonia
Catatonic immobility
Waxy flexibility
What is catatonia?
Motor abnormalities
Repetitive complex gestures
Excitable, wild flailing of the limbs
What is catatonic immobility?
Maintaining unusual posture for long periods of time
Eg. standing on one leg
What is waxy flexibility?
Limbs can be manipulated and posed by another person
What causes the positive symptoms of schizophrenia?
Thought to be caused by excess dopamine in the mesolimbic pathway
How do we improve positive symptoms?
Theoretically, decreasing dopamine in the mesolimbic pathway would be therapeutic
- Antipsychotics are dopamine blockers
What causes the negative symptoms of schizophrenia?
Shortage of dopamine in the mesocortical pathway - can increase to improve
What is the role of the mesolimbic system?
Regulation of emotional behaviour and motivation
What is the role of the mesocortical pathway?
Cognition and executive function
What are the dopamine levels like in a normal brain?
They are at normal levels and in balance - therefore there are no schizophrenic symptoms experienced
Summarise dopamine levels in a schizophrenic brain?
Mesolimbic - increased dopamine = +symptoms
Mesocortical - decreased dopamine = - symptoms
Explain the conundrum of treating schizophrenia?
Treating with a dopamine agonist can successfully treat their positive symptoms by reducing dopamine in the mesolimbic system
BUT
also reduces more in the mesocortical pathway meaning the negative and cognitive symptoms are not treated and in some cases can be made worse
Why were dopamine agonists historically considered to be a good treatment for schizophrenia?
They managed the obvious treatments - looked like they worked
What treatment is better than a dopamine agonist for schizophrenia? why?
Atypical D2 partial agonist antipsychotics (eg. aripiprazole)- they bind to the receptors but only activates it partially slightly depressing and slightly increasing dopamine system
- normalizing the activity of both systems
The glutamate hypothesis of schizophrenia?
‘Go’ neurotransmitter
Much research implicating glutamate NMDA receptors in schizophrenia
NMDA receptors can cause psychotic symptoms in humans
Some glutamatergic drugs have shown promise in treating schizophrenia
What is the most prominent structural change in schizophrenia
Ventricular enlargement
What does ventricular enlargement cause?
Poorer performance on cognitive tests, poor premorbid adjustment, poor response to treatment
What does TRS stand for?
Treatment-resistant schizophrenia
What is Treatment-resistant schizophrenia? how does it differ from normal schizophrenia?
A form of schizophrenia that does not respond to any antipsychotic treatment - may represent a distinct pathophysiological entity (maybe a different disorder)
more grey matter volume and reduction in lobes of the brain - reduced connectivity in certain key brain regions and decreased dopaminergic synapses
What does normal cortical development involve? when does it occur?
Proliferation, migration of cells, dendritic circuit absorption and myelination
First 2 occur mostly during prenatal life and the latter two during first 2 post natal decades
How does pruning and myelin deposition potentially contribute to schizophrenia?
Psychosis nearly always emerges while the prefrontal cortex is still developing - may involve excessive pruning of excitatory pathways - leading to an excitatory-inhibitory imbalance in the prefrontal cortex
Amphetamines and schizophrenia?
Can increase levels of dopamine in the brain and increases psychotic symptoms (stimulant induced psychosis)
GABA and schizophrenia?
Reduced synthesis and reuptake of GABA has been demonstrated in the prefrontal cortex in patients with schizophrenia
Acetylcholine and schizophrenia?
Decreased levels of cholinergic receptors are observed in the hippocampus, thalamus, and striatum
Serotonin and schizophrenia?
Prefrontal 5HT receptors have been linked to the pathogenesis of schizophrenia
Activation of 5HT receptors induced a schizophrenia-like state in humans
Disruption of one neurotransmitter system in schizophrenia leads to….
Compensatory mechanisms by other systems
What immune system activation is present in schizophrenia?
- Elevated cytokines and microglial activation
- Neuroinflammation is linked to the risk of psychosis and related disorders
The gut microbiome is what and what is it increasingly being linked to…
Normal flora of the gut is made up of several species of viruses and fungi
Schizophrenia, depression and bipolar
The guts microbiome and schizophrenia?
- Increased number of microbiome species
- Greater lactic acid bacteria
- Differences in metabolic pathways controlling glutamate and B12 transport (increased)
- Decreased carbs and lips metabolism
The gut and the brain are connected via the…
Vagas nerve
What other factors are linked to the development of schizophrenia?
Prenatal exposure to viral infections
Poor prenatal nutrition
Adverse obstetric events - difficulties during birth
Cannabis smoking during adolescence - increases chance of psychosis by 3x
Is there a genetic risk of schizophrenia?
Yes there is
- risk greater if you have affected relatives
- twin studies support
What genes have a role to play in schizophrenia?
Dopamine receptor D2 gene
Genes encoding proteins involved in glutamatergic neurotransmission and several calcium voltage channel proteins
Genes expressed in tissues with immunity roles
What is the concordance rate in monozygotic twins?
33%
What is the concordance rate in non-identical twins?
7%
What is interesting about twins and their risk of schizophrenia?
Early age onset of schizophrenia in one twin was a risk for the other developing it later on
Suggesting that early-onset schizophrenia may have a stronger genetic component of risk than other subtypes
What is schizoaffective disorder?
People have symptoms of both schizophrenia and a mood disorder (depression or bipolar)
What is the prevalence of schizoaffective disorder? why might this not be a true reflection of those with it?
0.03%
Because it is a combination of the 2, it may be misdiagnosed as one or the other.
This makes it hard to know how many people actually have it
Any gender differences in schizoaffective disorder?
Equal in men and women - no
Are treatments effective in schizoaffective disorder?
They can help to manage it but relapses are common
People with schizoaffective disorder typically have…
substance abuse disorders as well
What are the two different types of schizoaffective disorder?
Bipolar type: Includes episodes of mania and sometimes major depression
Depressive type: includes only major depressive episodes
Symptoms of schizoaffective disorder?
Delusions Depression Hallucinations lack of personal care Mania or sudden jumps in energy or happiness Risky behaviour Problems with speech and communication
Causes of schizoaffective disorder?
Genetics
Brain chemistry and structure: problems in circuits that moderate mood and thinking
Environment: viral infections or highly stressful situations could play a part
Drug use: mind altering drugs
Diagnosis of schizoaffective disorder involves…
Periods of uninterrupted illness
An episode of depression or mania
Symptoms of schizophrenia
At least 2 psychotic periods, each lasting 2 weeks - at least one needs to happen without depressive or mani symptoms
Treatment of schizoaffective disorder?
Medication - antipsychotics (atypical) or antidepressants
Psychotherapy - help learn about their illness, set goals and manage everyday life
Skills training
Hospitalisation
Electroconvulsive therapy (for those that dont respond to medications or psychotherapy)
What is schizophreniform disorder?
Type of psychotic illness with symptoms similar to schizophrenia - lasting less than 6 months
What if schizophreniform disorder lasts longer than 6 months?
Would be considered schizophrenia instead
Symptoms of schizophreniform disorder?
Similar to schizophrenia - delusions - halluncinations - disorganised speech - odd or strange behaviour - lack of enegry - poor hygiene and grooming habits withdrawal from friends, family and social life
Causes of schizophreniform disorder?
Unknown
Genetics
Brain structure and function: disturbances in brain circuits that mediate thinking and perception
Environment: poor relationships or very stressful events
How common is schizophreniform disorder?
1 in 1000 develop it during their lifetime (18-24 yrs in men, 24-35 yrs in women)
Treatment for schizophreniform disorder?
Medication (antipsychotic drugs) and psychotherapy (recognize and learn more about the illness)
Family therapy
May need to be hospitalised if a risk
Early diagnosis and treatment are important
How many people with schizophreniform disorder don’t recover and go on to develop schizophrenia?
2/3
What is brief psychotic disorder?
A sudden, short period of psychotic behaviour often in response to a very stressful event
Recovery is quick - often under a month
What are the three types of brief psychotic disorder?
Brief psychotic disorder with obvious stressor: shortly after trauma (eg. death of loved one) - reaction to a very disturbing event
Brief psychotic disorder without obvious stressor: there is no apparent stressor that causes it
Brief psychotic disorder with postpartum onset: Only in women, within 4 weeks of having a baby
Causes of brief psychotic disorder?
Could have a genetic link
Another theory suggests that poor coping skills could trigger the disorder as a defence against or an escape from a frightening or stressful situation
People with antisocial personality disorder or paranoid personality disorder are more likely to get it
Any gender differences in brief psychotic disorder?
Typically happens more in women than in men
At what age does a brief psychotic disorder normally occur?
when people are in their 20s or 30s
Medication for brief psychotic disorder?
Antipsychotics, just like schizophrenia
What is delusional disorder?
Key symptom is having a disorder involving a real-life situation that could be true but isn’t
How long does the delusion last in delusional disorder?
For at least one month
Delusions come in many forms but they all have one thing in common. What is it?
The people affected by them can’t be convinced that something they believe isn’t true
What are the diagnoses criteria for delusional disorder?
Non-bizarre delusions
Absence of obviously odd behaviour
Absence of hallucinations
No memory loss, medical issues or drug use is responsible for the delusions
ANy mood disorders do not last as long as the delusion
What affects what kind of delusion people have?
Their personality, culture and family background
What are the common types of delusions in delusional disorder?
Persecution (someone trying to hurt you)
Infidelity (unusual jealousy or possessiveness towards another person)
Love (obsessive love that takes over thoughts or an idea someone famous is in love with you)
Religion
Guilt or worthlessness (common with people in depression)
Grandiose
Negation or nihilistic (feelings of emptiness)
Somatic (thinking they have a medical issue)
Mixed (delusions with two or more themes)
What is paraphrenia?
Symptoms similar to schizophrenia
Starts in late life
Organized system of paranoid delusions with or without hallucinations
Without deterioration of intellect or personality
What is shared psychotic disorder?
Occurs when one person is in a relationship has a delusion and the other person in the relationship adopts it too
Rare
Apart from this, thoughts and behaviour are normal
What is substance-induced psychotic disorder?
Caused by the use of or withdrawal from drugs
Drugs that depress the nervous system and stimulants affect your brain activity so what seems real to you doesn’t match the world
Usually goes away when you stop taking the drug
Medical conditions leading to psychotic behaviour?
Different medical conditions can give rise to psychotic symptoms
Post-ictal psychosis?
Happens in some people with epilepsy who have had a number of seizures in a row
Antipsychotic drugs can stop symptoms and may help prevent future episodes
Myxedematous psychosis?
May occur when the thyroid gland doesnt work
May have delusions, hallucinations and changes your sense of smell and taste
Taking thyroid hormones can help to balance your glands activity and end the psychosis
Female hormone shifts and psychosis?
May induce psychosis symptoms.
‘menstrual psychosis’ - may be confused about what is real, hallucinate and believe things that arent true
Out of balance hormones during the cycle can affect thinking and moods
Can use CBT and antipsychotic drugs
