Schizophrenia Spectrum and Other Psychotic Disorders

Overview​

• Affects about 1% of the general population and is the most debilitating and costly of all adult psychological disorders​

• Schizophrenia is the most common and most important disorder within the spectrum (includes brief psychotic disorder, schizoaffective disorder & schizophreniform​

• Begins between ages of 16-25 yrs. but signs are present long before psychotic symptoms appear​

• Is a complex disorder of brain function with a wide variation in symptoms and signs, and course of illness ​

• Costly and debilitating​

  • Long history of schizophrenia​

  • Billions of dollars spent on this disorder​

• Men peak earlier​

• Women peak late 20s​

• When diagnosed, changes prognosis​

  • Earlier: worse​

  • Later: more positive​

• Don’t know origin​

• Etiology:​

  • Schizophrenia is primarily in the brain​

  • Can see it on scans​

  • Not only genetic factors​

  • High heritability​

  • Environment​

• Risk factor:​

  • Consumption of cannabis at a younger age​

  • Environmental: Correlation between early consumption of cannabis and sometimes 5 times risk of dev ​

• Prenatal brain dev can give few hints in etiology of dev ​

• Not as prevalent as other conditions (1% or 0.3%-0.7%)​

• Serious due to duration of symptoms​

• Brief psychotic disorder​

• Schizoaffective ​

• Schizophreniform disorder​

• Symptoms can vary (varying clinical presentation)​

• Nature of disorder: continuously debated​

• A lot of public misconceptions, adding to the stigma

Stages of Schizophrenia​

• Pre-psychotic or prodromal stage:​

  • First signs and symptoms before emergence of positive symptoms​

  • Often overlooked (e.g., social withdrawal, lack of motivation, sleep disturbance, neglecting personal hygiene, unexplained functional decline)​

  • About 75% of of individuals who develop schizophrenia report a decline in school function and social withdrawal as prodromal symptoms​

  • Early identification of those at risk provides opportunity for early, preventive interventions (e.g., academic accommodations & support to prevent drop-out; skills to cope with stress associated with prodromal symptoms, etc) ​

  • No treatment: decline in performance in work, school, life​

• Active Stage​

  • Full threshold disorder (2 or more of the symptoms i.e., delusions, hallucinations, paranoia)​

  • Obvious to others​

  • First episode psychosis- first time a person experiences psychotic symptoms; acting quickly with proper treatment results in recovery and can alter the course of illness ​

• Residual​

  • Incomplete remission​, but not full functioning of the pre prodromal stage​

  • Risk for recurrence and relapse​

• Severe and persistent​

Core Symptoms of Schizophrenia​

• Positive Symptoms​

  • Delusions​

  • Hallucinations​

    • 75% report hallucination​

    • MOST ARE AUDITORY (most frequent) and are derogatory or abusive (some are benevolent)​

    • Rare cases: Voices that create running commentary of a person actions and perceptions​

    • Severe cases: visual hallucinations​

      • Indicates higher severity than auditory hallucinations​

    • Belief that you are being persecuted by the FBI (for example)​

    • Repetitive physical actions ​

    • Behavioral excess​

    • Sensory experience that doesn’t exist​

• Disorganized/Cognitive Symptoms​

  • Behaviour​: don’t connect

  • Speech: unable to hold conversation

• Negative symptoms​: stable over time​

  • Decrease in behaviour​

  • Diminished facial affect​

    • Sad story and no facial emotions​

  • Anhedonia​

  • Speak painfully slowly​

  • Physical inertia​

• Positive symptoms tend to respond more readily to medication than negative symptoms​

• Older antipsychotic: increase level of functioning by reducing the positive symptoms​

Delusions​

• Fixed, false beliefs that are held despite incontrovertible proof to the contrary​

• Can be bizarre or non-bizarre​

Bizarre delusions​

• Beliefs are completely implausible (e.g., thoughts are being broadcasted out loud) ​

Non-bizarre delusions​

• Unshakable beliefs in something that isn’t true or based on reality, but not completely unrealistic (i.e., plausible in real life, like being conspired against)​

• Usually involve mistaken perceptions or experiences

• Beliefs are idiosyncratic: can change​

• Persucaotyr: going after me​

• Grandios: has powers to do things​

• Deluison of referncw: earthquate across the world is god ​

• jelaous​

​

• Somatic: bodily functions​

• Cant counter delusions by reality testing

Hallucinations​

• 75% of people with schizophrenia experience hallucinations​

• Auditory hallucinations (usually voices) are most common​

  • May be “command hallucinations” –from the innocuous to commands to cause harm to the self or others​

• Note: Hallucinations can occur​

  • in normal individuals with brain lesions; ​

  • during bereavement; 1/3 of spouses report hallucinations of the deceased;​

  • may be a normal part of religious/mystical experiences in certain cultures​

  • in healthy people, pseudo hallucinations can be generated at will by mild sensory deprivation​

• Comon​

• Can occur in anyone (bereavement)​

• Pseduohallucination: due to a certain circumstance (sleep deprivation)​

• Can have other senses of hallucination (taste, feeling​

• Tend to be vivid (described with high realism)​

Disorganized Thinking

• Typically inferred from the person’s speech​

  • Includes ​

    • Derailment or loose associations ​

    • Tangentiality ​

    • Incoherence (aka “Word salad”)​- words jumbled together

  • Less severe disorganized thinking or speech may occur during the “prodromal” and residual periods of schizophrenia​

• Though and speech that don’t make sense, jumbled speeach and speech incoherent​

• Seen in prodromal stage, not sever enough to raise red flag​

• Before hallucination and delusion

Disorganized Behaviour​

• Childlike silliness​

• Smiling, laughing or talking to oneself​

• Disheveled, poor hygiene​

• Difficulty engaging in goal-directed behaviours and performing activities of daily living​

• Unpredictable and untriggered agitation​

• Catatonic symptoms; e.g.​

  • Maintaining rigid, inappropriate or bizarre postures​

  • Mutism ​

  • Stupor​

Negative Symptoms

• Asociality: decreased interest in forming close relationships with others or reduced social activity​

  • decreased interaction

• Avolition: apathy; diminished motivation and difficulty in initiating and persisting in routine activities​

  • No motivation (not doing anything used ot be in everyday life)​

• Anhedonia: reduced experience of pleasure​

  • No joy

• Blunted affect: lack of outward expression of emotion (also called flat or restricted affect)​

  • No emotions shown​

• Alogia: significant reduction in the amount of speech​

  • Lack of speech​

  • No interest in speaking​

• Speak very little, slow talking, not respond, few spontaneous movement​

• Need some level of prior history (baseline compared to now)

Other Clinical Features​

• Often comorbid with substance use disorders; about 50% have a lifetime hx of SUD; ​

  • Predicts worse course of illness ​

  • Lack of insight (unaware that they are unwell)​

• Poor compliance with medication​

  • Problems with paranoia and mistrust may contribute to non-compliance​

  • 50%-70% of people who discontinue their medication relapse within 1 yr.​

• Rarely a standalone disorder​

• Brain disease​

• Anxiety and depression (45-50%)​

• Anxiety is precursor to psychosis and persecutory delusion​

• Comorbid present: worse prognosis​

Are people with schizophrenia dangerous?​

• Rates of violence relatively higher in people with schizophrenia vs the general population​

• Majority are not violent and people with schizophrenia are more likely to be victims of violence and violent crimes ​

• When violence does occurs, it is associated with​

  • substance abuse or combination of substance abuse and medication non-compliance​

  • comorbid antisocial personality disorder or psychopathy​

Etiology & Maintaining Factors​

• Genetic factors (at least in some cases)​

• Brain and neurotransmitter dysfunction- dopamine & serotonin​

  • Brain abnormalities​

  • Brain connectivity​

• Cannabis can cause psychosis by increasing a person’s existing vulnerability to psychosis​

• Exposure to trauma and acute and chronic life stress (e.g., lack of social support, bereavement, discrimination) can trigger psychotic episodes in those who are predisposed​

• High levels of EE by family strong predictor of relapse and rehospitalization​

• High level of genetic heratbility comp to other genetic markers​

  • Runs in the family​

  • Both (50%), 1 parent (13%) ​

• Greater the severity, the greater the gentic risk​

• Not 100% genetic (environment is a high risk factor for dev of schizophrenia)​

• Dopamine main suspect of schizophrenia​

  • Important in intercommunication of neurons, sub cortex and cortical brain region​

  • Drug induced psychosis​

  • Gaba​

• Connectivity in different areas of the brain is impacted​​

• Exposure to trauma and acute and chronic life stress (familial e.g., lack of social support, bereavement, discrimination) can trigger psychotic episodes in those who are predisposed​

Expressed Emotions

• Yelling, crying, screaming​

• Amplification of emotional ​

• Strong predictor of relapse and rehospitalization​

Interventions for Schizophrenia & Other Psychotic disorders ​

• Psychosocial treatment used as an adjunct to antipsychotic medication ​

• Treatment usually delivered in inpatient/day hospital or community mental health centers (team approach) ​

• Psychoeducation and family education important​

• Social and vocational training important for recovery​

• Secure, safe housing and financial support priority for those with severe persistent illness​

• Evidence for CBT & supportive therapy as adjunctive psychological interventions​

• Important to address comorbid conditions, especially substance use, which significantly increases risk for relapse of psychotic symptoms and chronicity of illness​

• First line treatment is medication​

• CBT: social skill training, try and identify behavioural intervention (never challenge delusion)​

• ACT: acceptance and commitment therapy​

  • Recognize symptoms​

  • Not engage​

  • Reduces hospitalization, homelessness​

• stages​

  • Acute phase: psychotic symptoms, find right treatment​

  • Stabilize: adhere to treatment​

  • Maintenance: functional​

Antipsychotic Medications​

• Neuroleptics​

  • Block dopamine activity​: positive symptoms reduce​

  • Extrapyramidal effects​

    • Part of dyskinesia​

      • Lose intentional movement of their limbs​

• Atypical antipsychotic medication​

  • Fewer side effects​

  • First line of treatment​

  • Perhaps more effective in managing negative symptoms and as effective for the treatment of positive symptoms​

  • Work on dopamine and serotonin and glutamate​