Unit 8, Abnormal

psychosis

refers to a loss of touch with reality characterized by symptoms such as hallucinations & delusions observed in schizophrenia

dementia praecox

term introduced by Kraeplin to describe what is currently known as schizophrenia.

• “dementia” - based on clinical observation of common pattern of cognitive & behavioural decline during onset

• “praecox” - derived from Latin, meaning “very early”

Eugen Bleuler

Swiss physician who first used the term “schizophrenia” in 1911.

• emphasized heterogeneity

• introduced distinction between “basic” (positive) & “accessory” (negative) symptoms

first-rank symptoms

outdated diagnostic criteria of schizophrenia, historically provided means of differentiating schizophrenia from other types of psychosis.

• includes: hearing voices conversing with each or commenting on what the person is doing, believing one’s own thoughts are being broadcasted to others, or believing that thoughts/behaviour are under control of outside force

• described by Kurt Schneider

• influenced modern diagnosis of schizophrenia

diagnostic criteria of schizophrenia

diagnosis in North America based on 6 criteria defined by DSM-5:

A. combination of symptoms & clinical features that define the disorder & include core symptoms must be present for >1 month: A1) delusions; A2) hallucinations; A3) disorganized speech; A4) grossly disorganized or catatonic behaviour; A5) negative symptoms

B. problems with work/social functioning in >1 area

C. continuous signs of disturbance for >6 months, with >1 month of active symptoms

D. exclusion of concurrent schizoaffective or mood disorders

E. disturbance cannot be caused by substance use or medical conditions

F. consideration of history of ASD or communication disorder in childhood

prevalence of schizophrenia-spectrum disorders

• affects ~1% of worldwide population

• ~30% of Canadians newly diagnosed between ages of 20-34, men tend to be diagnosed earlier

• similar rates across ethnicities & socioeconomic levels

schizoaffective disorder

similar to schizophrenia, but contains added element of diagnosed mood episode occurring simultaneously with symptoms of schizophrenia. co-occurring symptoms must precede/follow >2 weeks of delusions/hallucinations without mood symptoms.

• 2 subtypes based on primary mood episode: bipolar type (manic episodes) & depressive type (depressive episodes)

prevalence of schizoaffective disorder

• less common than schizophrenia

• ~0.3 in lifetime, occurs more in females

schizophreniform disorder

characterized by same diagnostic criteria as schizophrenia, but only lasts between 1-6 months.

• no requirement for decline in functioning

• diagnosis often withheld after at least 6 months, and given if symptoms improve & reoccur

• low prevalence across all socio-cultural settings

delusional disorder

characterized by experiencing delusions for >1 months and not experiencing other psychotic symptoms.

• functioning is not markedly impaired (besides impact of delusions) and behaviour is not obviously bizarre/odd

• prevalence: low, ~0.2%

brief psychotic disorder

diagnosed if positive symptoms of schizophrenia are present (A1-A4) for more than a day and remit by 1 month, with eventual return to premorbid functioning level

• symptoms persist between 1-6 months, schizophreniform disorder diagnosed; longer than 6 months, schizophrenia diagnosed

• may account for up to 9% of first-episode psychosis

substance/medication-induced psychotic disorder

diagnosed when positive symptoms of schizophrenia occur due to initiation/withdrawal from a substance.

• distinguished by symptoms being caused by substance entering/leaving the body

• development & presentation differ considerably depending on substance

• diagnosed in up to 25% of first episode psychosis

psychotic disorder due to another medical condition

characterized by prominent hallucinations/delusions caused by physiological effects of medical condition. diagnosis considered when medical condition is capable of producing psychotic symptoms (e.g., epilepsy) & symptoms cannot be explained by another mental disorder

• more common in ages older than 65

other specified/unspecified schizphrenia-spectrum and other psychotic disorder

diagnosis made in situations with insufficient info to make another diagnosis, but symptoms of psychosis present.

• applies to cases with characteristic schizophrenia/psychotic disorder symptoms are present & cause significant distress with daily functioning, but full Dx of other psychotic disorders isn’t met

positive symptoms

refers to the addition of an experience that is in excess of typical psychological functioning.

• includes hallucinations, delusions, and disorganized thinking

hallucinations

abnormal perceptual experiences that occur in absence of external stimuli. can occur in any sensory modality (hearing, seeing, smelling, tasting, or feeling). occurs in clear sensorium or (not diagnostic of psychosis) upon use of hallucinogenic substances.

• commonly experienced while falling asleep/waking up (not diagnostic of psychosis)

• positive symptom

clear sensorium

refers to a clear mental state, not clouded by substance use, fatigue, or a neurological condition.

• doesn’t necessarily indicate presence of mental health condition

hypnogogic hallucination

a type of hallucination that occurs as someone is falling asleep

• not diagnostic of psychosis

hypnopompic hallucination

a type of hallucination that occurs as someone is waking up

• not diagnostic of psychosis

auditory hallucination

a type of hallucination that ranges from hearing sounds that others cannot hear to hearing fully formed voice(s).

• most common type of hallucination experienced by individuals with schizophrenia (80%)

• voices often negative & critical

command hallucination

a type of auditory hallucination occurring when perceived voices give the individual commands to do things

visual hallucination

a type of hallucination involving seeing partially formed images & objects that may disappear upon interacting

• can be similar to visual manifestation of memory/dream

• rarely resemble actual objects in environment

• common, experienced by 23-31% of individuals with schizophrenia

tactile hallucination

a type of hallucination involving feeling sensations, such as touch, in the absence of physical input

• experienced by 9-19% of individuals with schizophrenia

gustatory hallucination

a type of hallucination involving tasting something that has no physical source

• experienced by ~6% of individuals with schizophrenia

delusions

fixed false beliefs that are unfounded & highly resistant to contradictory evidence. types based on theme & include grandiose, persecutory, somatic, and referential

• positive symptom

persecutory/paranoid delusion

a type of delusion involving the belief that one is being conspired against, spied upon, or persecuted.

• most common type of delusion, occurs in 60% of individuals with delusional disorders

grandiose delusion

a type of delusion involving the belief that one possesses special powers, abilities, or knowledge

religious delusions

a type of delusion related to grandiose delusions, involving unfounded/unrealistic beliefs regarding religious themes, and can often involve the individual taking on the role of a religious icon

somatic delusion

a type of delusion involving beliefs that one’s body is changing

referential delusion

a type of delusion involving a belief that common events, objects, or other individuals hold a personally relevant & significant meaning to the affected individual

• e.g., believing the way papers are arranged on a desk contains a special message

bizarre delusion

an overarching category of delusions involving impossible situations that cannot be derived from ordinary life experiences

• includes thought withdrawal, thought insertion, delusions of control

thought withdrawal

a type of bizarre delusion involving the belief that one’s thoughts have been removed by an outside force

thought insertion

a type of bizarre delusion involving the belief that external thoughts have been placed into one’s mind

delusion of control

a type of bizarre delusion involving the belief that one’s body/actions are being acted on/manipulated by an outside force

non-bizarre delusion

an overarching category of delusions involving circumstances that could occur in reality, but have extremely low likelihood

• e.g., being monitored by a government organization

thought disorder

refers to disorganized linguistic communication through verbal/written means.

• several types with overarching theme of difficulties understanding what the affected individual is trying to communicate

• positive symptom

loosening of associations

a type of thought disorder occurring when speech switches from topic to topic with little obvious connection between them

tangentiality

a type of thought disorder occurring when an individual’s response is completely unrelated to the topic being discussed

perseveration

a type of thought disorder involving a fixation on a specific word/idea and repeating it over & over

neologisms

a more severe type of thought disorder, refers to the use of words made up by the affected individual or the use of a real word in an irregular context

• e.g., “you can tell the time by looking at the cow”

word salad

the most severe form of thought disorder, occurs when all connections between words in a sentence are lost & speech becomes completely incoherent

negative symptoms

refers to a deficit in psychological functioning. can be broadly classified as experiential or expressive

• 5 A’s: avolition, anhedonia, asociality, alogia, and affective flattening

• observed in 25-30% of individuals with persistent schizophrenia

• associated with impaired community functioning & quality of life

experiential negative symptoms

negative symptoms involving a decrease in ability to experience enjoyment from situations & to motivate onself

• includes avolition, anhedonia, asociality

• impaired motivation considered to be one of the most debilitating symptoms of schizophrenia

avolition/apathy

an experiential negative symptom involving a lack of motivation and lack of interest in daily activities

anhedonia

an experiential negative symptom involving a diminished capacity to anticipate & experience pleasurable emotions

asociality

an experiential negative symptom involving a lack of interest in social interactions, leading to social withdrawal

expressive negative symptoms

negative symptoms involving impairments in the ability to interact with the social worlds as a result of limited speech or difficulty with nonverbal expression of emotions

• includes alogia, affective flattening

alogia

an expressive negative symptom involving poverty of speech

affective flattening

an expressive negative symptom involving a lack of emotional expressivity & diminished facial expression

disorganized behaviour

a negative symptoms referring to problems initiating and/or sustaining appropriate goal-directed behaviour

• ranges from basic self-care, to social disinhibition, to bizarre/inappropriate behaviour

abnormal motor behaviour

a negative symptom including a variety of symptoms affecting different parts of the body

• includes catatonia, waxy flexibility, posturing, odd mannerisms

• can occur as a result of schizophrenia, effects of medication, or comorbid disorders

• more uncommon, typically indicates higher severity

catatonia

an abnormal motor behaviour classified as a negative symptoms reflecting a marked decrease in reactivity to environment to the point of being completely unaware of surroundings

• can involve purposeless, repetitive behaviours

• e.g., hand clapping, going silent, maintaining rigid/inappropriate/bizarre posture

waxy flexibility

an abnormal motor behaviour classified as a negative symptoms reflecting, in which the individual maintains physical positions that other people put them in instead of returning to a normal position

odd mannerisms

an abnormal motor behaviour classified as a negative symptom, includes mimicking another person’s movements, grimacing, or staring

cognitive symptoms of schizophrenia

includes problems with attention, memory, learning, processing speech, and problem solving.

impairments in social contexts affects skills such as emotion, recognition, ability to infer thoughts & intentions, and emotional reactivity

• symptoms apparent prior to onset, can present in childhood, and remain stable in most cases