Psychosis

Overview of Schizophrenia

• Broad spectrum of cognitive, emotional, and behavioural dysfunctions

• Different classes of symptoms

  • Positive

  • Negative

  • Disorganized

• Individual can experience positive, negative, and/or disorganized symptoms

Symptoms of Schizophrenia

• Positive symptoms:

• Negative symptoms:

• Disorganized Symptoms

Negative Symptoms

• Absence of insufficiency of typical behaviour

  • Avolition - initiate/persist at basic activities

  • Alogia - amount of speech

    • Person can speak its just that they’re not speaking while having an episode

  • Anhedonia - pleasure/interest

  • Affective flattening - emotional expression

  • Asociality - social relationships/skills

Positive Symptoms

• Active manifestations of abnormal behaviour, or an excess of distortion of normal behaviour

  • Delusions

  • Hallucinations

  • One or both experienced by 50-70% of people with the disorder

Disorganized Symptoms

• Erratic speech, motor behaviour, and emotions

  • Inappropriate affect

  • Disorganized behaviour - acting in usual ways, unusual dress

  • Catatonia - motor dysfunctions that range from agitation to immobility

    • Waxy flexibility

  • Disorganized speech - tangentiaty, loose associations, derailment

Delusions

• Beliefs that are gross misrepresentations of reality

• Various types

  • Bizarre - clearly implausible, not understandable, not derived from ordinary life experiences (eg. all organs removed by aliens)

  • Non-bizarre - involve situations that can conceivably occur in real life but aren’t happening (eg. being followed by FBI)

Types of Delusions

• Of guilt or sin (usually bizarre)

• Somatic - sensations or beliefs of things that are happening in one’s body that are not actually happening (bizarre or non)

• Persecutory - that people are out to get you and/or are following you (bizarre or non)

• Of reference - when someone things that they’re being talked to or paid attention to by other people (usually bizarre)

• Grandiose - that they are more important than the people around them (bizarre or non)

• Of being controlled - mafia example (usually bizarre)

Hallucinations

• Experience of sensory events without input from surrounding environment

  • Auditory (most common)

  • Visual (second most common)

  • tactile

  • Somatic

  • Olfactory

Schizophrenia DSM-5 Criteria

• a) 2 or more of the following, each present for a significant portion of time during a 1 month period

  • Delusions

  • Hallucinations

  • Disorganized speech

  • Disorganized or catatonic behaviour

  • Negative symptoms

  • MUST INCLUDE FIRST, SECOND, OR THIRD

• b) Impaired functioning

• c) Continuous disturbance for 6 months (prodromal symptoms)

• When a person is about to enter a schizophrenic episode there can be a precursor for a certain period of time before going into full blown psychosis

  • They have those active impairing symptoms for a month but there are indicators of psychosis for 6 months

Schizophrenia and Violence

• people who are in a psychotic episode are more likely to use substances to the point where they engage in violence

• The violence is not driven by the psychosis but is caused by the substance use

• Psychosis alone does not lead to violence

• Substances make the symptoms of psychosis worse

Causes of Schizophrenia

• Biological

• Psychosocial

• Substance use

Biological Influences

• Genetics

  • Inherit a tendency for psychosis, not a specific schizophrenic disorder

  • Close genetic relatives of people with schizophrenic disorders are at increased risk for schizophrenia

  • Risk in monozygotic twins is 48%

  • Risk drops to 17% for fraternal (dizygotic) twins

  • Risk decreases with increasing genetic difference - the closer you are the higher the risk factor

• Viral Infection

  • Prenatal exposure increases risk

  • Maternal flu infection in the second trimester can triple risk

  • Other infections (eg. rubella, toxoplasmosis, and cytomegalovirus) have also been implicated

  • Immune system activation and neuroinflammation affecting fetal brain development

  • Low relative risk of developing schizophrenia in the world

Structural differences in the brain between schizophrenic and normal

• Schizophrenic

  • Reduced brain matter that is causing larger ventricles

  • less volume to the brain

  • structural differences to the brain

• normal

  • Increased brain matter so the ventricles were smaller

Psychosocial Influences

• Stress - may activate underlying vulnerability and/or increase risk of relapse

• Family interactions - “expressed emotion” associated with relapse

• Social drift - People in urban areas have higher rates of schizophrenia

  • The sociogenic hypothesis - stressors having low income contribute to onset of schizophrenia

  • The social-selection theory - those with the disorder move to impoverished areas of city due to lack of resources or to access social services

Substance Use

• Cannabis

  • findings from research studies

    • Cannabis use more than DOUBLES risk of developing schizophrenia

    • One study found that young men were more than 6x more likely to develop schizophrenia from heavy use

  • Can dysregulate dopamine channels

  • Directionality of relationship?

  • Other vulnerabilities interact - genetic predisposition, stage of brain development

• Cigatettes

  • Prevalence of smoking

    • 80% of people who smoke have schizophrenia vs 20% of general population have schizophrenia

  • Dopamine from nicotine lessens negative symptoms

Treatment and Outcomes

• biological interventions

• Psychosocial interventions

• Prognosis and outcomes

Biological Treatments

• Medication

  • Antipsychotic (neuroleptic) medication

  • Compliance issues

    • increased negative side effects

    • Tardive dyskinesia - unusual movement around the mouth or teeth

• Transcranial magnetic stimulation

  • Exposure to magnetic fields that up and down regulate brain regions

  • Over frontal lobes for negative side effects

  • Over temporal lobes for hallucinations

Psychosocial Treatments

• Early intervention programs

  • Coping skills, stress management, medication compliance, psychoeducation

• Social skills training

  • Social judgements, taking turns talking, role plays

• Community care and vocational programs

• Cognitive-behavioural therapy - reality testing, behaviour activation, recognizing triggers

Prognosis and Outcomes

• 50-80% of people who have one episode will have another

  • Not constantly experiencing hallucinations or delusions, typically lasts for a 1 month time frame and then will come back again at a later point in their life

• 38% recovery rate - significantly reduced symptoms and restoration of function. Linked with early intervention and social support

• Life expectancy shortened 10 years - social determinants of health

  • smoking/substance use

  • less access to healthcare

  • unemployment

  • social isolation

  • lack of housing

• Need for reduced stigma and comprehensive care for people with schizophrenia to improve outcomes