Week 5 Lecture - Psychosis (SZ)

Question 1

what is psychosis

Answer 1

Diagnostic label given to those whose experiences are outside the cultural norm

Question 2

what does psychosis include

Answer 2

○ Hallucinations: experiencing things (like hearing voices or seeing things) which others cannot verify (sensory in origin)
○ Delusions: Holding strong beliefs (e.g. there is a conspiracy against them) that others do not share (cognitive in origin)
○ Disordered thoughts: Difficulties putting coherent thoughts together and concentrating
○ A generally disturbed relationship with reality

Question 3

types of psychotic disorder

Answer 3

• Schizophrenia: hallucinations (e.g. hearing voices), delusions, lack of motivation
  
  • Bipolar Disorder: mood disorder with ‘swings’ between elation (mania) and depression
  • Schizoaffective Disorder: elements of bipolar & schizophrenia
  • Postpartum (Puerperal) Psychosis: psychotic symptoms following childbirth
  • Delusional Disorder: holding a firm belief that is not true

Question 4

what are psychotic symptoms divided into?

Answer 4

○ Positive Symptoms (experiences which are added to the ‘normal’ behavioural repertoire – hallucinations, delusions, disorganised speech)
○ Negative Symptoms (emotional withdrawal, apathy, lack of motivation, self-neglect)
○ Additional symptoms e.g. depression, suicidal thoughts, problems with memory, attention and theory of mind, etc.

Question 5

SZ epidemiology

Answer 5

• Schizophrenia is the most prevalent psychosis
  
  • Lifetime schizophrenia prevalence (as morbid risk):
    ○ 7.2/1,000 persons (0.7% of the population) (nearly always rounded up to 1% for ease)
    ○ Equal risk for men and women
    § 18-25 onset for men for first onset but 2 peaks for women at 30s and 40s
    ○ Mortality risk 2-3 time higher in people diagnosed with schizophrenia (median SMR = 2.7)
    ○ Excess mortality equivalent for men and women diagnosed with schizophrenia
  • McGrath et al (2008)

Question 6

SZ course

Answer 6

most remain on medication and live in community

Question 7

SZ outcome measures

Answer 7

symptom remission
social functioning

Question 8

symptom remission

Answer 8

e.g. not hearing voices

Question 9

social functioning

Answer 9

e.g. still hearing voices but going back to work and having good relationships

Question 10

outcomes of SZ measured in what?

Answer 10

survivors

Question 11

stats outcomes for SZ

Answer 11

• Approximately 40% of excess mortality in schizophrenia is due to suicide
  
  • Approximately 5% of people diagnosed with schizophrenia commit suicide (rate = 0.3% for those with no disorder)
  • For patients, suicide risk is associated with being male, younger, agitated, and less adherent to medication.

Question 12

what causes psychosis?

Answer 12

• Psychosis is a complex end-point with contributions from biology (e.g. genetics, biochemistry), psychology (e.g. stress, trauma) and social circumstances (e.g. inequality, racism)

Question 13

genetic causes of psychosis

Answer 13

• Genetic links strongly indicated by heritability.
  
  • The chance of developing schizophrenia is:
    ○ 1 in 100 for individuals with no relatives with schizophrenia
    ○ 1 in 10 for individuals with 1 parent with schizophrenia
    ○ 1 in 8 for individuals with 1 non-identical twin with schizophrenia
    ○ 1 in 2 for individual with 1 identical twin with schizophrenia
    But
  • No single causal genes or single ‘gene of major effects’ identified; rather, many genes appear to interact to increase vulnerability to psychotic experiences (Merikangas et al 2022).

Question 14

neurochemical causes of psychosis

Answer 14

• The dopamine hypothesis: Developed in the 1960s following the discovery of the antipsychotic (neuroleptic) drug chlorpromazine which was very effective in reducing positive psychotic symptoms.
  
  • Chlorpromazine is a dopamine antagonist (i.e. it blocks dopamine-mediated neurotransmission in the brain). (very effective at reducing positive symptoms)
  • Led to the conclusion that schizophrenia was a hyperdopaminergic state (i.e. characterised by an overproduction of the neurotransmitter dopamine).

Question 15

dopamine theory of psychosis

Answer 15

• Amphetamine and cannabis use (which increase dopamine production) can cause psychotic symptoms in non-psychotic users.
  
  • Amphetamine and cannabis EXACERBATE psychotic symptoms in users diagnosed with schizophrenia
  • Patients with Parkinson’s (a condition characterised by REDUCED dopamine production) treated with the dopamine enhancing drug levodopa can experience psychotic side effects mimicking the symptoms of schizophrenia.
  • both increase dopamine in NS and can cause symptoms and exacerbate symptoms already there
  • L-dopa was used to increase dopamine in NS in PD - created psychotic symptoms in some people that were the same as in SZ

Question 16

critique of dopamine theory of psychosis

Answer 16

○ Delayed and selective impact of chlorpromazine
○ Increased dopamine transmission is not pathognomonic for (i.e. specific to) schizophrenia; those diagnosed show substantial neurochemical heterogeneity (Grunder &Cumming, 2016).
○ Research now indicates that glutamate, GABA, ACh, and serotonin (5-HT) also implicated in psychotic experiences
○ Conclusion: Neurotransmitter levels are involved in, but are not direct causes of schizophrenia symptoms

Question 17

trauma as a psychosocial cause

Answer 17

• Research evidence shows a clear link between childhood trauma and the subsequent development of psychosis (e.g. Barrigon et al, 2015; Duhig et al, 2015)
  
  • In a meta-analysis of population and case-control studies Varese et al (2012) concluded that adversity and trauma (sexual abuse, physical abuse, emotional/psychological abuse, neglect, parental death, and bullying) are strongly associated with an increased risk for psychosis.
  • Trauma at the top of the list
  • Childhood trauma significant link
  • Adversity in childhood also big link

Question 18

disadvantage as a psychosocial cause

Answer 18

• Consistent evidence for an elevated risk of psychosis in relation to:
  ○ Socioeconomic deprivation
  ○ Migration (both first and second generation migrants) in all developed countries
  ○ Racial discrimination (increased rates of psychotic disorders in ethnoracial minoritized groups, particularly people of Black ethnicities)
  Kirkbride et al (2024)
  
  • These relationships are complex and can be reciprocal.
  • For example, compromised mental health can lead to poorer achievement, lower paid employment, and consequently lower socio-economic status.
    ○ Would lead to association between SES and psychosis as a result despite the lack of a causal link
  • Both the necessity to, and the act of migrating are also socially dislocating, and stressful – factors which independently amplify psychosis risk.

Question 19

delusions as a cause -

Answer 19

Maher’s proposal is a ‘one factor’ theory – delusional thinking is characterised by only one departure from normality – the anomalous thought

Question 20

one-factor theory

Answer 20

• One factor theory of delusions supported (at the time) by:
  ○ Evidence that perception itself remains normal and unchanged in psychosis; and
  ○ The absence of conclusive evidence that psychotic patients “…show abnormalities in logical reasoning” (Maher, 1974).

Question 21

normal explanation vs anomalous experience

Answer 21

○ Normal explanation: An explanation acquired through the operation of a normal (intact) cognitive processes
○ Anomalous experience: An (intuitive) awareness that something is different, odd or peculiar.

Question 22

continuum model of psychotic experiences

Answer 22

• Many psychotic experiences exist on a continuum from good to poor mental health and are not unique to psychosis
  
  • From a survey of psychiatric symptoms in >8000 randomly sampled people Bebbington et al (2013) found that “…paranoia is so common as to be almost normal”.
  • Similarly Beavan et al’s (2011) meta-analysis found that ‘hearing voices’ when no-one was there was reported

Question 23

stress-vulnerability model

Answer 23

• Proposed by Zubin and Spring (1977) the model suggests that people are more or less vulnerable to psychosis as a result of biological, psychological and social factors
  
  • The resulting vulnerability interacts with stressors which can ‘trigger’ psychotic experiences and distress
  • The psychosocial milieu can also mitigate or exacerbate the intensity of psychotic experience
  • It follows from this model that a person may be constitutionally vulnerable to psychosis but, in the absence of sufficient stress, does not experience schizophrenia.

Question 24

stress vulnerability model lays flat

Answer 24

homeostatic balance

Question 25

stress vulnerability model lays to right

Answer 25

increased wellbeing

Question 26

stress vulnerability model lays to left

Answer 26

more ill health

Question 27

problems with psychiatric diagnosis

Answer 27

• In organic disease diagnosis provides an EXPLANATION for why we experience the symptoms we report.
  
  • In psychiatry, on the other hand, diagnoses are substantially DESCRIPTIONS of the symptoms reported which offer no explanation.
  • Problems “…stem from applying physical disease models and medical classification to the realms of thoughts, feelings and behaviours.” (BPS, 2017) [i.e. the problem regarding behaviour exclusively as a ‘symptom’]

Question 28

formualtion

Answer 28

Formulation can be defined as the process of co- constructing a hypothesis or “best guess” about the origins of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them.” (Johnstone, 2018)
- “Formulations often take the form of written summaries or diagrams, developed by a process of collaboration between the professional and the service user. (BPS, 2017)”

Question 29

formulation and psychosis

Answer 29

• Formulation is a process of collaborative ‘meaning making’
  
  • The sense that someone makes of their experience is influenced by many factors, including culture, past experiences, and the response of people around them.
  • How someone interprets psychotic experiences will affect how distressed (or not) they feel about them.
  • In managing psychotic experiences it is not the symptoms that are the target for treatment, it is the distress associated with the symptoms

Question 30

psychological formulations for psychosis

Answer 30

• Summarise a client’s core problems
  
  • Show how a client’s difficulties may interact – informed by psychological theories and principles
  • Suggest (on the basis of psychological theory) why the client has developed these difficulties at this time and in these situations
  • Lead to a plan of intervention – based on the psychological processes and principles already identified
  • Are open to revisions and reformulations

Question 31

what can help psychosis?

Answer 31

• A range of interventions can help individuals experiencing psychological distress which is understood as ‘psychosis’
  
  • The benefit from any given intervention is likely to depend on the sense the client has made of their experiences
  • Some interventions help directly with ‘symptoms’, others address the impact of psychotic experiences
  • Psychological interventions recommended by NICE & the BPS are ‘Evidence Based’

Question 32

what basic needs need to be addressed in psychosis?

Answer 32

• Does the individual have somewhere safe to live?
  
  • Are they facing discrimination?
  • Are they ostracised/isolated in their community?
  • Do they have a job? [NICE (2014) recommends that services should offer people tailored help with finding and keeping good employment]

Question 33

CBTp

Answer 33

• Garety et al (2001) A cognitive model of positive symptoms of psychosis
  • If you can modify the negative appraisals you can modify distress
  • Collaborative alliance which aims to find out:
    ○ What’s up? – getting the details of the individual’s experiences (e.g. paranoia, voices)
    ○ Why me? – thinking about longer term risk factors / difficulties that may have influenced the current presenting issues (e.g. bullying / trauma)
    ○ Why now? – recent stressful triggers
    ○ Why still? – factors that keep the individual stuck with problematic behaviours, thoughts or feelings
    ○ What helps? – factors that protect the individual from feeling worse and developing helpful coping strategies

Question 34

family interventions/meetings

Answer 34

• Should be offered to “…all families of people with psychosis or schizophrenia who live with or are in close contact with the service user” and should
  ○ include the person with psychosis or schizophrenia if practical
  ○ be carried out for between 3 months and 1 year of referral
  ○ include at least 10 planned sessions
  ○ can be either a single-family or multi-family group intervention
  ○ have a specific supportive, educational or treatment function