abpsych 3: psychosis

definition of psychosis

an abnormal mental state involving significant problems with reality testing; it’s characterized by serious impairments or disruptions in the most fundamental higher brain functions- perception, cognition and cognitive processing, and emotions or effect- as manifested in behavioral phenomena, such as delusions, hallucinations, and significantly disorganized speech (APA)

positive symptoms

• delusions: an often highly personal idea or belief system, not endorsed by one’s culture or subculture, that is maintained with conviction in spite of irrationality or evidence to the contrary

• hallucinations: a false sensory perception that has a compelling sense of reality despite the absence of an external stimulus

• disorganized speech: incoherent speech

• disorganized behavior: behavior that is self-contradictory or inconsistent

negative symptoms

• blunted or flat affect: total or near absence of appropriate emotional responses to situations and events

• anhedonia: the inability to enjoy experiences or activities that normally would be pleasurable

• alogia: inability to speak because of dysfunction in the central nervous system

• avolition: failure to engage in goal-directed behavior

• asociality: declining to engage, or incapable of engaging, in social interaction

cognitive deficits

seven cognitive domains: processing speed, attention, working memory, visual learning, reasoning and problem-solving, and social cognition

social processing deficits

• interpretation of emotional expression: less accurate in the ability to label facial expressions of emotion, with particular difficulty labeling fear and sadness

• affect production: display less positive and more negative facial expressions, as well as emotional expressions that seem inconsistent with the social context (inappropriate affect)

• nonverbal synchrony: brain activity less synchronized with conversation partners in brain areas relevant to social processing

phases of schizophrenia

• prodromal: when there are early warning signs of schizophrenia such as cognitive deficits

• active: when there are active positive symptoms

• residual: positive symptoms are no longer present, and only negative symptoms or mild behavioral and cognitive disturbances remain

myths about mental illness and violence

• severely mentally ill people account for only 3-5% of violent crimes in the general population

• drug abuse is a more likely factor in violent behavior

brief psychotic disorder

presence of 1 or more symptoms for at least 1 day but less than 1 month

delusional disorder

• presence of 1 or more delusions with a duration of 1 month or longer

• criterion A for schizophrenia has never been met

schizophreniform disorder

2 or more symptoms for 1 month but less than 6 months

schizophrenia

2 or more symptoms for a significant portion of time during 1 month and persisting for at least 6 months

schizoaffective disorder

• an uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with criterion A of schizophrenia

• delusions or hallucinations for 2 weeks in the absence of a major mood episode

research domain criteria

RDoC; based on dimensions of observable behavior and neurobiological measure

the hierarchical taxonomy of psychopathology

HiTOP; includes graded dimensions of symptoms and identifies risk profiles for certain symptomatic presentations

systems of neuroscience of psychosis

SyNoPsis; includes graded dimensions of three symptom categories: language, affectivity, and motor behavior

heritability estimates for psychosis

• heritability estimates: 25-50% MZ, 10-15% DZ

• as many as 8300 genetic variants

neurotransmitter involvement

• dopamine: dopamine capacity is associated with psychotic symptom severity; dopamine agonists are associated with positive symptoms; antipsychotics that reduce dopamine activity diminish psychotic symptoms

• glutamate: blockage of receptors (NMDA) produces psychotic symptoms

• GABA: may underlie the reduced capacity for working memory in schizophrenia; blockage of receptors induces psychotic symptoms

neurobiology: neural circuits

multiple brain circuits; hyperdopaminergic function in key frontal brain regions and excessive stimulation of basal ganglia

diathesis-stress model

• diathesis

  • constitutional vulnerability

    • inherited genetic factors

    • prenatal stressors

  • neurodevelopmental alterations

    • neuromaturation

    • life stressors

• stress

  • prenatal stressors

  • life stressors

typical antipsychotics

• act by blocking activity in the dopamine systems

• high-potency neuroleptics: higher risk of extrapyramidal effects (e.g., motor abnormalities)

• low-potency neuroleptics: higher risk for seizures, antihistaminic effects (sedation, weight gain), anticholinergic effects (cognitive dulling, dry mouth, blurry vision, urinary hesitancy, constipation), and antiadrenergic effects (postural hypotension, sexual dysfunction)

atypical antipsychotics

• block dopamine neurotransmission to some extent, but also impact serotonin, glutamate, and other neurotransmitters to varying degrees

• increased risk for developing a “metabolic syndrome”

assertive community treatment

• strong research support

• intensive multidisciplinary team-based approach designed to support individual with severe mental illness

• key features: shared caseloads, frequent client contact, low client-to-staff ratios, community outreach, integration of services, 24/7 availability, individualized treatment

• primary goals: reduce hospitalization rates and assist clients in successfully integrating into community life

supportive employment

• strong research support

• vocational rehabilitation approach tailored for individuals with schizophrenia

• focuses on integrating employment and mental health services, with a priority on quickly placing individuals into community-based jobs, providing personalized job development, and offering continuous support

family psychoeducation

• strong research support

• involves family members in the treatment process, focusing on their role in supporting recovery

• patient-centered goals: reducing relapse rates, decreasing hospitalizations, and improving overall outcomes

• family-centered goals: reducing distress, improving family-patient relationships, and lessening the burden of mental illness on family members

• interventions last at least 9 months

cognitive behavioral therapy

• strong research support

• involves a collaborative therapeutic relationship, shared understanding of the problem, goal setting, and teaching the person techniques to manage their symptoms

• challenges the notion of discontinuity between psychotic and normal thinking and thus, assumes that similar cognitive mechanisms are at play with psychosis

• techniques: cognitive restructuring and behavioral experiments/reality testing

cognitive remediation

• strong research support

• interventions aim to enhance cognitive performance through repeated cognitive exercises to enhance cognitive functions such as learning and memory, processing speed, and sustained attention