Schizophrenia and Other Psychotic Disorders

What is psychosis?

a cluster of symptoms relating to disruptions in perceptions and interprtations of reality

• such as hallucinations, delusions, disorganization

encompasses “positive symptoms” - adding something unusual to the typical experience

At least 1 positive symptom is necessary to count as psychosis, but “negative symptoms and “cognitive symptoms” are also common.

What is schizophrenia?

a formal categorical diagnosis of psychotic symptoms.

A condition characterized by disorganized thoughts and a split from reality

Eugen Bleuler coined the term

psychosis/psychotic disorders are an __________ term that includes schizophrenia

umbrella

What are hallucinations?

a sensory experience that occurs in the acsence of any external stimulus

• auditory (most common)

• visual

• somatic

• olfactory

• gustatory

What are delusions?

an erroneous belief that is fixed and firmly held despite clear contradictory evidence, a belief that is not helf by the individuals culture/subculture

key: held with a high degree of certainty and resistant to contradictory information

• themes: persecutory, grandiose, ideas of refernce, erotomanic, religious, somatic, thought insertion/broadcast/withdrawal

What are examples of positive symptoms?

disorganization of though/speech

• disruptions in the ability to communicate clearly and causes tangentialiy, circumsstantiality, derailment, illogical phrases/loosening of associations, word salad.

disorganization of behavior (bizarre behavior)

• erratic/illogical behavior

• dressing inappropriately

• catatonia (immobility, mimicry, unusual postures)

What are negative symptoms and what are some examples?

something that is ‘missing’ from the typical experience

• alogia (reduced pleasure

• anhedonia (reduced pleasure)

• asociality (reduced social drive)

• avolition (reduced motivation)

• blunted affect (reduced expressiveness)

What are some cognitive symptoms?

poor executive functioning and planning

difficulties with memory/concentration

difficulties with abstract thinking

Where does psychosis lie in the HiTOP model?

falls primarily under though disorder

ALTHOUGH, negative symptoms could fit under thought disorder or detachment

concerning the BIG 5, correlated with openness (debated)

Mania/Bipolar disorder may overlap with thought disorder

What are the diagnostic considerations for Schizophrenia Spectrum and Other Psychotic Disorders?

reauires longitudinal data (not just 1 psychotic experience)

must rule of “organic”/medical causes, substances use, affective psychosis or psychosis due to another mental disorder

non-pathological and cultural explanations

Examples of medical causes or substance use that causes psychosis?

medical conditions

• dementia, brain tumors, age-related neurlogical conditions

substance use

• hallucinogens (LSD), marjiuana, ketamine and PCP

While these may not cause a psychotic episode, they could exacerbate underlying risk and convert into a more “true” psychosis.

What is affective psychosis?

occurs ONLY during a severe episode of depression or mania and resolves once euthymic mood returns

symptoms are often mood congruent

debated with this is meaningfully distinct

What are some psychotic-like features of other mental disorders?

OCD obsessions and rituals can rise to the lvels of delsions

flashbacks in PTSD can take on a psycotic/paranoid quality

body dysmorphia and eating disorders can distort perception of one’s body

What are non-pathological and cultural considrerations related to psychotis disorders?

Shamaism

• practices to induce conversations with spirits

Religious cultural practices

• expected that God routinely communicates with followers

Seld-identifies psychics

• unusual perceptual experiences

What are the primary psychotic disorders with psychosis as the core feature?

Schizophrenia

Schizophreniform

Brief Psychotic Disorder

Delusional Disorder

Schizoaffective Disorder

What are not primary psychotic disorders but are relevant for understanding psychosis?

Bipolar Disorder

Schizotypal Personality Disorder

What is the DSM-5 criteria for schizophrenia?

A. Two or more of the following, each present for a significant amount of time during a 1-month period, and at least one must be 1, 2, or 3

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

B. For a significant portion of time since the onset, level of functioning in one or more major areas is markedly below level achieved prior to onset.

C. Continuous signs of the disorder present for at least 6 months. Must include at least 1 month of symptoms, including prodromal or residual symptoms

What is schizophreniform?

Diagnosed when symptoms of schizophrenia are present for a significant portion of time (at least a month), but signs of disturbance are not present for the full six months required for the diagnosis of schizophrenia. 

Must meet Criterion A symptoms for both Schizophreniform and Schizophrenia 

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

What is brief psychotic disorder?

The sudden onset of psychotic behavior that lasts less than 1 month followed by complete remission with possible future relapses (in DSM-5) 

Marked by one or more of the following psychotic symptoms:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

What is delusional disorder?

One or more delusional thoughts for one month or more, that has no explanation by another physiological, substance-induced, medical condition or any other mental health condition.

Main classifications of delusions: 

• Bizarre delusions and Non-bizarre delusions

What are bizarre delusions?

involve a phenomenon that is impossible and unrelated to normal life.

What are non-bizarre delusions?

situations that are possible, such as being manipulated or harmed, but remain fixed false beliefs even after proven false.

What is schizoaffective disorder?

Uninterrupted period of illness where there is a major mood episode concurrent with criterion A of schizophrenia.

Delusions or hallucinations for 2 or more weeks in the absence of a mood episode

Mood symptoms are present for the majority of the duration of the active and residual parts of the illness.

Disturbance is not attributable to substances or other medical conditions and is not better explained by another mental disorder

Subtypes

• Depressive (only met criteria for depressive episodes)

• Bipolar (had had at least 1 manic episode)

Can you have Schizophrenia and a comorbid mood disorder WITHOUT meeting criteria for schizoaffective ?

Yes!

What is schizotypal personality disorder criteria?

A. Pervasive pattern of social and interpersonal deficits, cognitive or perceptual distortions, or eccentricity of behavior indicated by 5 or more of the following:

1. Ideas of reference 

2. Odd beliefs or magical thinking 

3. Unusual perceptual experiences 

4. Odd thinking and speech

5. Suspiciousness or paranoid ideation

6. Inappropriate or constricted affect 

7. Odd or eccentric behavior 

8. Lack of close friends 

9. Excessive social anxiety that does not diminish with familiarity, associated with paranoia 

B. Does not exclusively occur during the course of schizophrenia, bipolar disorder, other psychotic disorders, or autism spectrum disorders

What cluster of personality disorders is schizotypal personality disorder tied to?

Cluster A personality disorder but tied to non-psychotic schizophrenia spectrum illnesses

What are the assessmentsof schizotypy?

SPQ (schizotypal personality questionnaire) and SIS (structured interview for schizotypy)

What is the SPQ (schizotypal personality questionnaire) assessment?

Long and Brief forms 

3 factors

• Cognitive-Perceptual

• Disorganized

• Interpersonal 

“ I often hear a voice speaking my thoughts aloud” (T/F)

What is the SIS (structured interview for Schizotypy) assessment?

Most detailed/prominent

Symptoms rated for frequency, duration, level of conviction

“How often have you had the experience of hearing your name called but realizing that it must have been your Imagination?

Would you say often, sometimes, rarely, or never?

What are the causes for psychosis?

Stress

Genetics

Structural and Functional Brain Abnormalities

Explain the vulnerability of genetics to led to psychosis.

schizophrenia is highly heritable (70-80%)

• 1% baseline risk

• 10% risk if -degree relative has schizophrenia

• 50% risk if identical twin has schizophrenia

ALTHOUGH, no 1 gene had been identified as causative (multiple genes combine their individually small risks)

What disorders share the most genetic risk profile?

bipolar disorder and schizophrenia

What are some structural & functional brain abnormalities that lead to vulnerability to schizophrenia?

Structural Impairments

• Larger ventricles

• Gray matter loss after initial diagnosis

• Thinner cortices

• Lower brain volume

Cognitive Impairments

• These appear relatively early (in CHR too)

Sensory Gating impairments

• Filtering out irrelevant sensory information

Social Cognition

• Mental processes involved in understanding and interacting with others

What is the dopamine hypothesis of schizophrenia?

theory of the mechanisms of psychosis

• Positive symptoms caused by “too much” dopamine in certain brain circuits like the mesolimbic system

  • Post-mortem studies found an excess of D2 receptors in certain regions and by the efficacy of antipsychotics 

• However, other brain regions show “too little” dopamine activity

  • ex: mesocortical system, which is linked with negative symptoms

VASTLY oversimplified

Examples of people with moderate vulnerability/high risk of developing a psychotic disorder?

1st psychotic episode preceded by a stressor (breakup, final season)

Examples of people with a low vulnerability of stress inducing schizophrenia?

lack of sleep, sensory deprivation, intense emotional experiences (like bereavement) can trigget psychosis

What are 1st generation medication treatments against psychosis?

antipsychotic medications (dopamine antagonists)

• (typical antipsychotics): Chlorpromazine or Haldol, reduces hallucinations, delusions, and disorganized speech but does little to improve cognitive deficits or negative symptoms.

• Extrapyramidal symptoms (EPS) such as acute dystonia and tardive dyskinesia are some of the more prominent side effects to keep in mind within this drug class.

  Other side effects include fatigue and weight gain

What are 2nd generation medication treatments against psychosis?

newer generation of antipsychotics (atypical antipsychotics)

• Not necessarily more helpful for schizophrenia than 1st generation medications but have a different side effect profile: fewer motor side effects, higher risk of diabetes, metabolic side effects

• Risperdal, abilify, Olanzapine, Clozapine

  • Clozapine was originally for treatment resistant patients but now widely used

“Rule of Thirds” concerning antipsychotic medication efficacy

1/3 see very significant reduction in positive symptoms

1/3 see some improvement, but positive symptoms persist

1/3 see very little to no improvement

What is the special case of Clozaril/clozapine is relation to antipsychotic medication efficacy?

The first of the second generation antipsychotics

Risk of it dangerously reducing white blood cell count (agranulocytosis), need regular blood monitoring

Generally used only after “failing” 2 other antipsychotics, but some argue it should be more widely prescribed

What is the reality for antipsychotic efficacy and what are decisions based more on?

Excluding clozapine and possibly olanzapine, little evidence for difference in efficacy between antipsychotics; decisions often made instead based on side effect tolerability

Little evidence that taking more than one at once is more effective

What is cognitive behavioral therapy for psychosis (CBTp)?

De-emphasizes objective truth; instead focuses on whether a belief or experience is “useful” to a client in pursuing their goals without confronting or colluding with psychotic ideas.

Although, few providers in US are trained in this method, this type of therapy is backed by data in symptom reduction and improving quality of life.

Examples of CBTp interventions

• For hallucinations…

  • Distraction techniques (for example, listening to music)

  • Stress management skills to reduce voice frequency

  • Making voices “prove” that they have the special knowledge or power they claim

• For delusions…

  • “even if this is true, how can we still get you to…”

  • Building skills around considering alternative hypotheses 

• For negative symptoms…

  • Behavioral activation/activity scheduling 

  • Psychoeducation around the difference between anticipatory/experienced pleasure

What are family treatments for psychosis?

• Psychoeducation – provide factual, recovery-oriented information

  • By professionals, i.e., manualized Multi-Family Groups

  • By other families, i.e., NAMI Groups

• Psychotherapy for families 

  • May reduce “expressed emotion” (anxiety, criticism, and over-involvement), which increases symptoms 

  • Treat secondary stressors (trauma, marital strife, adjustment) related to a schizophrenia diagnosis 

• Psychosis-specific treatments

  • Family work embedded in Coordinated Specialty Care programs

  • CBTp skills for families, i.e., Psychosis REACH 

T/F? People with psychotic disorders are less susceptible to visual illusions?

TRUE