psychotic disorders

schizophrenia

• need to last for at least 6 months

• comprising 2 or more of the following:

  • delusions, hallucinations, disorganized speech, grossly disorganized behavior, negative symptoms

  • at least one must be 1, 2, or 3

  • each present for a significant portion of time during a 1 month period (or less if successfully treated)

• level of functioning in 1+ major domains (work, relationships, or self-care) is markedly impaired

• in the active phase, must have impairment in functioning and 2 or more of the previous symptoms

• during the prodromal and residual phases, may have only negative symptoms, or other symptoms in less severity

positive symptoms

added to a person’s behavior, something that the average person does not have

• delusions, hallucinations

negative symptoms

behaviors that are absent in people with schizophrenia

• anhedonia, blunted/flat affect, alogia, avolition, asociality

disorganized symptoms

prevents people from thinking clearly and responding appropriately

• disorganized speech, disorganized behavior, catatonic behavior

delusions

false, firmly held beliefs that are not amenable to change despite conflicting evidence (positive symptom)

• may be “bizarre” (impossible) or “non-bizarre” (plausible, but without evidence)

• persecutory, religious, being controlled, thought insertion, thought withdrawal

hallucinations

perception-like experiences that occur without an external stimulus (positive symptom)

• can occur in any of the 5 senses

• visual, auditory, olfactory, gustatory, tactile/somatic

avolition

decrease in motivated, purposeful activities

• negative symptoms

blunted/flat affect

reduction in expression of emotions

• negative symptoms

anhedonia

decreased ability to experience pleasure

• negative symptoms

alogia

diminished speech output

• negative symptoms

asociality

lack of interest in social interactions

• negative symptoms

disorganized symptoms: speech

saying that convey little, if any, meaning

• going off on tangent, difficult to follow what someone is saying

derailment/loose associations

switching from one topic to another

tangentiality

answers are either vaguely related or completely unrelated

• key part: they don’t answer the question

circumstantiality

there is a flow, but there are so many irrelevant details added that it is very difficult to follow

word salad

speech is incomprehensible

• Pots dog small is tabled.

neologisms

words that only have meaning to that individual

cognitive slippage

illogical and incoherent speech

disorganized symptoms: behavior

ranges from childlike “silliness” to unpredictable agitation

• behavior is inappropriate to the context

• can include catatonia: decrease in reactivity to the environment

  • negativism: resistance to instructions

  • mutism and stupor: lack of motor and verbal responses

  • catatonic excitement: excessive motor activity without a given cause

differential diagnosis

ruling out disorders with similar symptoms

• brief psychotic disorder

• schizophreniform disorder

• schizoaffective disorder

• mood disorders with psychotic features

brief psychotic disorder

1+ symptoms, must include at least 1, 2, or 3

1) delusions

2) hallucinations

3) disorganized speech

4) grossly disorganized or catatonic behavior

• no negative symptoms

• lasts between 1 day - 1 month 

• good prognosis for recovery

schizophreniform disorder

2+ of following, at least one must 1, 2, or 3

1) delusions

2) hallucinations

3) disorganized speech

4) grossly disorganized or catatonic behavior

5) negative symptoms 

• must occur for 1-6 months

  • if recovery hasn’t been made, it is a provisional diagnosis (suggests it is likely a person has a disorder, but cannot give a full diagnosis because need more info)

schizoaffective disorder

presence of a major mood episode (manic or depressive)

2+ schizophrenia symptoms for at least 1 month, must include at least 1, 2, or 3

1) delusions

2) hallucinations

3) disorganized speech

4) grossly disorganized or catatonic behavior

5) negative symptoms

• at least 2 weeks of positive psychotic symptoms without mood symptoms

mood disorders with psychotic features

presence of a major mood episode (manic or depressive)

psychotic symptoms only occur during mood episodes

• usually during mania, but possible during depression too

• can be mood-congruent or mood-incongruent

  • mood-incongruency has a poorer prognosis

etiology

• prenatal: genetic, maternal exposure to virus

• birth-related complications: complications during delivery

• during development: brain abnormalities

• during childhood/adolescence: SES, family factors

etiology: genetics

adoption and twin studies indicate a genetic influence

• MZ concordance = 48% (environment plays a role)

• DZ concordance = 17%

• risk of developing schizophrenia is higher if related to someone with schizophrenia

• if one twin has schizophrenia, both have equal chance of their children having schizophrenia

neurotransmitters

Dopamine: low numbers of dopamine receptors in frontal lobes

• increased production of dopamine (possibly to compensate for reduced receptors)

dopamine hypothesis

an overproduction of dopamine or an increase in sensitivity of dopamine receptors is responsible for schizophrenia

cognitive deficits

• deficits in attention

  • difficulties in sustaining and focusing attention

• deficits in working memory

  • long before a diagnosis of schizophrenia

• deficits in executive functioning

  • difficulties in planning, problem solving, abstract thinking

expressed emotions (EE)

family members negative, critical, and hostile attitudes/behaviors

• emotional over-involvement and intrusiveness of family

• risk of relapse related to EE

• “don’t go crazy again, you know how much it hurts me”

socioeconomic status (SES)

highest prevalence of schizophrenia found in those with lower SES

• Hypothesis 1: Social Causation

  • negative factors related to low SES lead to development of illness

• Hypothesis 2: Social Selection

  • cognitive/social impairments associated with the illness lead individuals to drift to a lower SES

epidemiology

Lifetime Prevalence: 0.3-0.7%

• age of onset of psychotic symptoms: late teens to mid 30s

• onset prior to adolescence is rare

• earlier age at onset predicts significantly poorer prognosis (because schizophrenia interrupts important social and cognitive developmental stage)

• likelihood of onset drops after age 55

• men and women are equally likely to be affected

gender differences in epidemiology

Age Onset: men = 18-25, women = 26-45

• men: more negative symptoms; chronic

• women: more hallucinations, paranoia; episodic

• men tend to have a poorer response to treatment than women

schizophrenia prognosis

what is the course of the disorder

• 1/3 improve, 1/3 remains the same, 1/3 become chronic/severely disabled

• top 5 causes of disability in developed countries

• most debilitating of mental illnesses

• 11% of homeless individuals have schizophrenia and 6% are in jail

suicide stats

10-15% die by suicide

• less aware and the impact —> less likely to seek help

• pronounced positive symptoms increases risk

• sometimes occurs in response to command hallucinations 

  • voices telling someone to kill themselves

violence stats

• rarely engage in violent behavior

• comorbid substance abuse, more likely to engage in risk behavior

• much more likely to be a victim of violence

race & ethnicity stats

Black and Latino Americans are twice as likely to be diagnosed with schizophrenia

• this is likely due to a racial/clinician bias and risk factors such as racism and trauma

older antipsychotics

only targets dopamine receptors

• side effects resemble Parkinson’s Disease

  • tremors, motor rigidity, involuntary movements of mouth and face, spasmodic body movements/tardive dyskinesia

• 25% relapse rate

newer antipsychotics

target multiple neurotransmitters (dopamine, serotonin, norepinephrine)

• side effects include weight gain

• less motor problems —> more likely to continue medication

• atypical antipsychotics

• relapse rate is lower if stay on medication

psychosocial treatment

focus on long-term strategies to improve aspects of patient’s life other than the reduction of psychotic symptoms

• improving social competence, housing stability, employment

• types of treatment include:

  • family therapy (better understand dynamics between family members and address negative interactions)

  • social skills training

  • vocational rehabilitation (find and maintain a job)

  • assertive community treatment

assertive community treatment

a comprehensive team works together to meet the needs of the client

• psychiatrists, nurses, social workers, vocational counselors, recreational counselors

• staff to client ratio is high, staff is available 24/7, and contact with clients is frequent

• good outcomes

CBT for psychosis

Goals: decrease conviction of delusional beliefs, promote more effective coping strategies, reduce distress

• teaches skills to challenge and modify beliefs (experimental reality testing)

• Effectiveness: superior to control condition in clinical studies, significantly decreases positive symptoms, continued improvement at 6-month follow-up