Prelim 3- Schizophrenia and Psychosis Pt.1

Psychosis

• trouble distinguishing what is real and what is not real

• develop beliefs that are not real or perceive things that are not real

• symptoms can occur in a variety of different disorders and medical conditions 

• psychotic disorders/schizophrenia spectrum disorders

psychotic disorders (schizophrenia spectrum disorders)

diagnosed by examining symptoms across 5 different domains

1. delusions 

• intense, intractable beliefs that do not waver even with evidence that conflicts or disconfirms them 

• content varies 

• persecutory, referential, grandiose, erotomanic, somatic

persecutory 

being harassed by an individual, group, or organization

referential

gestures, comments, environmental cues are directed towards oneself

grandiose

belief in having exceptional abilities, fame, or wealth

erotomanic 

false belief that another person is in love with you

somatic

related ti health or organ function

Bizarre

• delusions are clearly implausible, do not derive from ordinary life circumstances, and are not easily understood by same culture peers

center on loss of control of body or mind

Nonbizarre

delusions are plausible

hallucinations 

• vivid, clear, perceptual like experiences that occur without an external stimulus 

• not under voluntary control 

• auditory most common

• can be tactile, visual, olfactory 

What % hears voice at some point and who hears a recurrent voice?

10-25%, 1%

where do auditory hallucinations occur?

• perception is that the voice is inside the head, not transmitted through the ears

• fMRI studies confirm that different neural regions are activated during auditory hallucinations than during hearing auditory stimuli

disorganized speech and thought

• loose associations or frequent switching from topic to topic

• tangentiality

• incoherence

• mildly disorganized speech is common

  • must be severe enough to impair effective communication

tangentiality

providing unrelated responses to conversational prompts

incoherence

• “word salad”

• words in string are disconnected from each other

grossly disorganized or abnormal motor behavior

• silliness, agitation, mutism or lack of verbal response, staring, echoing, grimacing

• catatonia

catatonia

decrease in reactivity to environment, sometimes to the point of stupor or lack of motion

positive symptoms 

• hallucinations and delusions

• their presence occurs in addition to more typical, expected perceptions and experiences 

negative symptoms

• marked by the absence or diminishing of what we would expect to see in someone

• flat affect

• avolition

• anhedonia

• asociality

flat affect

diminished emotional expression

avolition

decrease in self-motivated activities 

anhedonia

lack of interest or pleasure

asociality

social withdrawal or disinterest in social activities

disorganized symptoms 

• describes illogical speech, erratic behavior and effect that does not match situation

Schizophrenia Spectrum and Other Psychotic Disorders

• differentiated by number and duration of symptoms

• brief psychotic disorder

• schizophreniform disorder

• schizophrenia

brief psychotic disorder

at last 1 symptom must be 1,2,3

1. delusions

2. hallucinations

3. disorganized speech

4. grossly disorganized or catatonic behavior

• duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning

• specify if with: peripartum onset, marked stressor

Schizophreniform Disorder 

• 2 ore more for significant portion of time 1-6 months, at least one must be1,2,3

1. delusions

2. hallucinations

3. disorganized speech (frequent derailment or incoherence)

4. grossly disorganized or catatonic behavior

5. negative symptoms. 

• when diagnosis must be made without waiting for recovery, should be qualified as “provisional”

• schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out either 

  • no major depressive or manic episodes have occurred concurrently with the active-phase symptoms

  • if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness

Schizophrenia

• 2 more more for significant portion of time at least 1 month, at least one must be1,2,3

1. delusions

2. hallucinations

3. disorganized speech (frequent derailment or incoherence)

4. grossly disorganized or catatonic behavior

5. negative symptoms. 

• level of functioning in one or more major areas, such as work, interpersonal relations, or self, care is markedly below the level achieved prior to the onset (or when the onset is in the childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning)

• cont. signs if the disturbance persist for at least 6 months

Differences of time frames between brief psychotic, schizophrenia form, and schizophrenia

• brief psychotic: 1 symptom for less than one month

• schizophrenia form: 2 symptoms, lasting between 1-6 months

• schizophrenia: 2 symptoms, lasting more than 6 months + declines in functioning

Delusional disorder

• presence of one ore more delusions with a duration of more than 1 month

• no disorganized speech

• functioning is not impaired and behavior is not unusual

Schizoaffective disorder 

• psychotic disorder with symptoms of both schizophrenia and major mood disorder 

• show delusions and hallucinations for st least 2 weeks not during mood disruptions 

• show major mood disruptions for the majority of the time as they experience psychosis 

Facts about Schizophrenia

• full recovery from schizophrenia is rare; once the disorder develops, people tend to have symptoms for the rest of their lives

• remission defined by symptoms no longer impairing daily life and functioning

• 50-80% of people who are hospitalized for severe symptoms of schizophrenia will be re-hospitalized at some point during their lives

• equal prevalence across men and women, although men tend to develop the disorder at younger ages

• estimated global prevalence of about 1%

indictators of Schizophrenia

• signs are evident

• mild motor problems, physical abnormalities or neurological “soft sigs” and mild social problems even in childhood

• these are often non-specific and appear in many different types of neurological conditions

Schizophrenia prodrome 

• 1-2 years prior to the onset of schizophrenia 

• positive symptom early indicators: magical thinking (liking believing in having special abilities or telepathy) or feeling like someone else is present when they are not

• negative symptom early indicators: social isolation, anhedonia

• although there have been significant intervention efforts— ranging from medications to therapy to fish oil— with schizophrenia prodrome, none of them have been able to avert schizophrenia onset 

Genetics and Schizophrenia

• we know now all forms of psychopathology are heritable, to some degree

• as with others disorders, schizophrenia is polygenic

• schizophrenia was of the first disorders to be clearly show to be heritable

polygenic

• meaning there is no one “schizophrenia gene” but related to many, many different gene variants

correlation with genetics 

• higher among biologically related individuals 

antecedents of schizophrenia

• prenatal exposure to viruses, infections, birth complications (involving with loss of O2 at birth)

• childhood stress, adversity, poverty, homelessness, immigration

Cannabis affects on adolescent brain

• temporarily induces hallucinations

  • elevated rates of later diagnoses of schizophrenia

• 4-fold increase in likelihood of a diagnosis of schizophrenia

• associated with thinning of cerebral cortex that does not rebound or recover

• high genetic risk = avoid cannabis

Dopamine Hypothesis of Schizophrenia

• 4 main pathways that transmit dopamine:

  • mesolimbic, mesocortical, nigrostriatal, tuberoinfundibular

• hallucinations and delusions are correlated with excessive dopamine activity in the mesolimbic pathway

• negative symptoms seem to result from less dopamine in the mesocortical pathway

Antipsychotic medications

• first line

• older/typical antipsychotics block dopamine, in order to reduce positive symptoms

• lessening of dopamine can result in harsh side effects as dopamine is depleted in other pathways

• dopamine reduction in nigrostriatal pathway often led to Parkinson’s like symptoms

• tardive dyskinesia

• dopamine reduction in tuberinfundibular pathway can involve weight gain, lactation, sexual dysfunction

tardive dyskinesia

• involuntary lip smacking, grimacing, tongue thrusting

Atypical Antipsychotics

• work on both dopamine and serotonin

• do not have parkinson’s like side effects and greatly reduced tardive dyskinesia

• other side effects: primarily cardiometabolic (obesity, high BP, diabetes), increased stroke and heart disease risk

• people on antipsychotics report greatly reduced quality of like

How Well Do Antipsychotics Work?

• 45% experience remission of symptoms in 18 months after starting treatment

• 12% maintained remission for 6 months 

• tend to be much better at reducing positive symptoms than improving negative ones