Psychopathology Ch. 13 3/27

Psychosis

significant loss of contact with reality

Psychosis can be a symptom of

• manic or depressive episode w psychotic features (can be mood congruent or incongruent)

• can be drug induced e.g.,

  • hallucinations while using LSD

• can be the result of brain damage or neurological issue

  • e.g., unpleasant smell as an aura prior to a seizure

• disorders where it is a hallmark feature = “psychotic disorders”

Psychotic Disorders

• not multiple personalities

  • that is Dissociative Identity Disorder (not psychotic)

DSM Schizophrenia

• A. 2+ of the following (has to be one of first 3 *starred*), during a 1 month period:

  • Delusions*

  • Hallucinations*

  • Disorganized Speech*

  • Disorganized behavior/catatonic behavior

  • “negative” symptoms

• B. Level of functioning in work, relationships, or self-care is markedly below the level that was present prior to symptom onset

• C. Continuous sign of disturbance for 6+ months

• D. Rule out other possible causes (e.g., MDD with psychotic features, substance induced, medical issue, autism or communication disorder)

Delusions

• erroneous belief that is fixed and firmly held despite clear contradictory evidence (out of touch with reality)

• false beliefs exist on a spectrum

  • e.g., on far left (least) - thinking your friend might know what you’re thinking bc you are close, middle - thinking your friend can read your mind, far right, extreme: being convinced your thoughts are being broadcasted into your friends’ mind = thought broadcasting = crossed line to genuine delusion

• Examples

  • Made feelings or impulses:

    • thoughts or feelings being controlled by external agent

  • Thought broadcasting

    • your thoughts being broadcasted to others

  • thought insertion/withdrawal

    • thoughts being inserted/withdrawn from brain by external agent

  • Delusion of reference

    • something in environment having special meaning or being intended for your

  • Grandiose delusion

    • exaggerated, self-opinion, special abilities/powers

  • delusion of persecution

    • being persecuted by others

Hallucinations

• sensory experience that seems real but isn’t (no external perceptual stimulus)

• auditory: 75% of SZ patients

  • many voices unfriendly

  • some patients act on them

  • can become incorporated into delusions

• visual 39% of SZ patients

• olfactory, tactile, gustatory: 1-7% of SZ patients

Hypnagogic Hallucinations

hallucinations that occur while falling asleep

Disorganized Speech

• a collection of speech abnormalities that can make a person’s verbal communication difficult or impossible to comprehend (in other words: making no sense)

  • BPRS - Brief Psychiatric Rating Scale

    • mild = tangents TO extremely severe = incomprehensible

    • neologisms = made up words

disorganized behavior

• behavior that is “off” or doesn’t match the situation (e.g., silliness or unusual dress)

• disruption in goal-directed behavior (work, school etc.)

• self-neglect (e.g., no longer maintaining personal hygiene)

Catatonic Behavior

• a state of unresponsiveness, absence of movement and speech

3 types of Schizophrenic Symptoms

1. positive = added experience

2. Disorganized

3. Negative = loss of typical behavior

Negative Symptoms Schizophrenia

• a loss of typical behavior

  • shows little emotion

    • “flat affect/blunted affect”

  • avolition

    • inability to initiate or persist in goal-directed activity

    • (hardest to treat)

Cognitive Impairment

• Lower IQ

• poorer functioning on specific cognitive tasks

  • reaction time

  • attention

  • executive functioning

  • working memory

  • social/emotion tasks

  • visual processing

Other psychotic disorders DSM

• schizoaffective disorder

  • blend of schizophrenia and mood disorder

  • psychosis that is usually concurrent with either a major depressive or manic episode

  • difference between schizoaffective and depression with psychosis:

    • schizoaffective requires that psychosis sometimes occurs outside of mood episodes

• delusional disorder

  • 1+ delusions for 1+ month(s)

  • apart from impact of delusion, functioning is not markedly impaired

• schizophreniform disorder

  • same criteria as schizophrenia but shorter time frame

  • 1-6 months disturbance rather than 6+

  • 2/3 → schizophrenia after 6m

• brief psychotic disorder

  • same criteria as schizophrenia but even shorter time frame

  • 1 day - 1 month disturbance

Schizophrenia heritability

• highly heritable ~80%

  • “one of the highest”

• genome wide association studies (GWAS)

  • which genes are correlated with schizophrenia symptoms?

  • we have 20,000+ genes, each of which we correlated with schiz symptoms

  • 150,000 participants

  • result

    • 108 loci associated with SZ, 83 new regions

    • some overlap with bipolar disorder, autism, ADHD, intellectual disability genes

    • Rare alleles, copy number variations = deletions/duplications of DNA

• probably, many genese involved each contributing a small evffect- no schizo gene

  • oppositie of s

• one common gene that simpo- COMT

  • loc chrom 22

  • CHECK SLIDES

Schizophrenia Dopamine Hypothesis

• may be due to overactive dopamine system

• evidence?

  • COMT gene

  • antipsychotic meds → block dopamine receptors

  • amphetamines → excess dopamine; abuse of amphetamine ssometimes leads to psychotic state similar to schizophrenia

  • L-DOPA to treat parkinson’s → increases dopamine, psychotic symptoms as side effect

Brain Tissue Loss - Schizophrenia

• changes over 5 years of adolescents w/ and w/o schizophrenia

• fluid filled ventricles

Brain Areas Hallucination

• hallucinating, increased activity in Broca’s area (speech production) rather than Wernicke’s area (speech comprehension)!

• hallucinations could be misperceived subvocal speech

• patients with auditory hallucinations have reduced brain volume in left hemisphere auditory and speech perception areas

Schizophrenia Environmental Factors

• CHECK SLIDES

• higher risk for fetuses exposed to

  • flu

  • rubella

  • toxoplasmosis

• small risk

• bacterial infections → pro inflammatory cytokines that can impact brain development

• birth complications

  • breech delivery

  • umbilical cord around neck

• early nutritiional definciency

  • conceived duirng Dutch Hunger Winter → 2x increase risk SZ

• life as a fetus

  • separate vs shared prenatal environemnts

  • some identical (monozygotic) twins are dichorionic while others are monochorionic (shared placenta and amniotic sac)

Marijuana Schizophrenia

• maybe - cause or consequence

  • ppl w schizophrenia are CHECK SLIDES

Prevalnce and Onset Schizophrenia

• prevalence 1%

• slightly more common in males 1.4:1

  • earlier onset for males

• prodromal phase

  • prodrome: early set of symptoms that may indicate the start of disease; precursor to disease

  • could last several weeks to years

  • conversion rate 20-40%

  • CHECK SLIDES (and add the early, non-specific changes and other attenuated symptoms)

Impact of Schizophrenia

• 15-25 years after onset, 38% “recovered”/functioning well (as in can function bc of but still has symptoms)

• health risks

• CHECK SLIDES

Pharmacological Treatment

• Antipyschotics

  • 1st gen

    • haloperiodol (haldol), chlorpormazine (Thorazine)

    • dopamine antagonists (block dopamine receptors)

    • extrapyramidal sideeffect CHECK SLIDES

  • 2nd gen

    • clozapine, risperidone, olanzapine, serioqeul

    • still work on dopamine

    • fewer extrapyramidal symptoms

    • not more effective than first generation (except potentionally

    • CHECK SLIDES

Psychosocial Treatments

• family treatments

  • reduce expressed emotion bc doubles chance of relapes

    • criticism

    • hostility

    • emotional over involvement

• social skills training

  • compensate for poor interpresonal skills

• CBT for psychosis

  • challenge beliefs that aren’t useful

  • promote

  • CHECK SLIDES

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