Clinical Final 👩‍🔬 - Addiction, Psychotic Disorders, and Ethics

What did statistics Canada find in their 2018 study on hospital discharge data? 

First Nations People living on and off reserves have acute hospital care for substance-related disorders 4 to 7 times more than non-Indigenous Canadians

• alcohol was not an issue for indigenous people before the French brought brandy and the English brought rum 

Define Impulse-control disorders

Disorders in which a person acts on an irresistible, but potentially harmful impulse (Kleptomania or Pyromania)

What is the term for those using multiple mind-altering and behaviour-altering substances?

Polysubstance use

What is a substance?

A substance is any natural or synthesized product that alters perceptions, thoughts, behaviours, and emotions—- PSYCHOACTIVE EFFECTS

What are the levels of involvement with substances?

Substance Use

Substance Intoxication

Substance-related disorders: substance-use disorder + substance-induced disorder

What counts as substance use? 

Substance use is the consumption of psychoactive substances

• in MODERATE amounts 

• NOT AFFECTING LIFE socially, occupationally, or educationally 

It is NOT a disorder in the DSM-5

What constitutes substance intoxication? What are 3 elements dictating intoxication? 

The physiological effects following substance ingestion 

• impaired decision making 

• impaired motor control (speech and walking) 

• mood changes 

Intoxication depends on type of substance ingested, the quantity of substances ingested, as well as individual biological reaction to substance(s)

What constitutes substance-use disorder?

Defined by the DSM 5 as:

• how significantly substance use effects life socially, educationally, occupationally

• puts you in physically dangerous situations (while driving)

• continued use despite harms

CRITERIA: 

• at least 2 symptoms in the last year interfering with life 

• 4 to 5 for MILD and 6 + for SEVERE

P. I. S. R. symptom criteria →  direct or indirect activation of reward system in brain

What criteria does the P for Substance Use Disorder in the DSM?

PHARMACOLOGICAL CRITERIA also called PHYSIOLOGICAL DEPENDENCE:

• TOLERANCE, increasing or decreasing dosage to experience the same effects of the drug

• WITHDRAWAL, unpleasant physiological symptoms when substance is no longer being ingested

Vomiting, diarrhea, chills, fever, etc.

What criteria does the I in Substance-use disorders represent?

IMPAIRED CONTROL, also known as PSYCHOLOGICAL SYMPTOMS 

• use longer tor more than intended

• multiple unsuccessful attempts to stop or reduce 

• time devoted to a substance 

• cravings + drug-seeking behaviours

What does the S in the criteria for Substance Use Disorder represent?

SOCIAL IMPAIRMENT

• failure to fulfill major role obligations

• use despite persistent problems

• important activities given up

What does the R stand for in criteria for Substance Use Disorder?

RISKY USE

• physically dangerous use

• exacerbation of physical or psychological problems

Can yo use drugs and not become addicted to them 

Yes, contrary to popular belief, some people can use heroin, cocaine, and crack several times a year without any impact on their lives

• what we don’t know is who will become addicted and who won’t 

DEPENDENCE can be present without MISUSE

• cancer patients take morphine and go through withdrawal without misuse

How can the severity of Substance Use Disorder vary?

Route of Administration

Duration of effects

Polysubstance use

What were alcoholism and drug misuse labeled as in the early editions of the DSM?

Both alcoholism and drug abuse were labelled under SOCIOPATHIC PERSONALITY DISTURBANCES (forerunner of antisocial personality disorder)

• seen as a sign of moral weakness

Why are rates of mood disorder and substance use disorder commonly co-morbid with one another?

1. SUBSTANCE USE AND MOOD DISORDERS may cooccur by chance, simply because they are both very common

2. DRUG WITHDRAWAL CAN CAUSE SYMPTOMS OF DEPRESSION, ANXIETY + INCREASED RISK TAKING

• alcohol ingestion led to increased risk taking in gambling vs gamblers with no alcohol ingested

3. DISORDERS CAN LEAD TO SUBSTANCE ABUSE

• self medication with substances is common

When is a symptom a result of substance use and when is it not?

If a symptom seen in ______ appears within 6 weeks of withdrawal from a substance

• not considered a part of the disorder, rather an effect of withdrawal

Symptoms occurring after 6 weeks of a withdrawal may be considered for a seperate diagnosis.

What are 7 complications of substance use disorder according to slides? 

• Sedating drugs can lead to depressive disorders 

• Stimulants can lead to substance-induced psychotic disorders and anxiety disorders

• Health (needle administration) can be jeaprodized severely 

• Aggressive or violent behaviour 

• Accident-related injuries (Liam Payne)

• Suicide

• Fetal Problems 

What are the 5 clusters of drugs as defined in the textbook?

DEPRESSANTS, substances inducing sedation and relaxation (alcohol, benzodiazepines, and barbiturates)

• most likely to cause tolerance and withdrawal

STIMULANTS, substances elating mood and increasing activity and alertness (amphetamines, cocaine, nicotine, and caffeine)

OPIOIDS, substances leading to temporary analgesia (pain reduction) and euphoria (heroin, opium, codeine, morphine)

HALLUCINOGENS, substances altering sensory perception and producing hallucinations, delusions, and paranoia (cannabis and LSD)

OTHER, inhalants (airplane glue), anabolic steroids, and other over-the-counter medications (nitrous oxide)

What consists of Alcohol Use Disorder?

Alcohol (sedative, relaxing, depressant) is the most frequently abused substance

DSM REQUIREMENTS:

1. Clinically significant impairment or distress caused by alcohol misuse of at least 2 of 11 symptoms, for a year:

• TOLERANCE + WITHDRAWAL

• psychological effects-drug-seeking, impaired control, use despite social problems, risky use, all of it!

2. MILD - 2 symptoms, MODERATE - 4 to 5 symptoms, SEVERE - 6 or more symptoms

What is the historical perspective of alcohol use disorder?

Alcohol Use Disorder has been recognized throughout history.

1800s-1900s: moral defect

1930s: prohibition in the United States 

1940s-1960s: psychodynamic model

1950s: disease model

1960s=1970s: behavioural model

2000s: integrative model

M. P. D. B. I.

What are 5 things to remember about alcohol consumption from the slides? 

• 66% consume alcohol with an 11% increase in the past decade

• 22% of men exceed low risk and 19% of women 

• 18% drink heavily

• 9% have alcohol disorder

• 3% have significant problems

What are 4 ways alcohol consumption patterns vary?

AGE - alcohol use disorder has a early onset of 11-14 years old, and those who drink earlier seem to be at higher risk for chronic and severe alcohol use disorder later

CULTURE
RELIGION

GENDER - affects onset, course, remission

What did Conrod (2013) find about alcohol consumption patterns?

Conrod and colleagues (2013) found 4 personality traits that put adolescents at greater risk of alcohol use disorder:

• anxiety sensitivity: fear of anxiety-related sensations

• sensation seeking: tendency to seek novel experiences

• impulsivity: predisposition to act upon urges without consideration

• hopelessness: tendency towards negative thinking

Brief personality coping skill interventions reduced binge drinking and other alcohol related harms

Describe the route of alcohol, once consumed in the body

1. ESOPHAGUS

2. STOMACH - small amounts are absorbed

3. SMALL INTESTINE - easy absorption into the bloodstream

4. CIRCULATORY SYSTEM + ORGANS/HEART - system distributes alcohol to every major organ in the body including heart and lungs (vaporized and exhaled)

5. LIVER - enzymes break down and metabolize alcohol into carbon dioxide and water

What are the neurotransmitter effects of alcohol?

GABA (primary inhibitory NT)

• Alcohol is a GABA agonist, downregulating the effects of regular GABA

• potentially responsible for “anti-anxiety” effects a it becomes difficult for neurons to communicate with each other

GLUTAMATE (primary excitatory NT)

• Alcohol downregulates GLUTAMATE, potentially responsible for blackouts

SEROTONIN (mood, sleep, eating)

• potentially responsible for alcohol cravings

DOPAMINE (reward system)

• possibly responsible for the pleasurable feelings of alcohol consumption

What can be produced in the body from certain doses of alcohol?

Endogenous opioids, the body’s naturally occurring analgesics (pain-killers)

What are components of alcohol withdrawal symptoms?

WITHDRAWAL DILIRIUM or DILIRIUM TREMENS

frightening body tremors and hallucinations resulting from alchol withdrawal 

Does alcohol permanently kill brain cells?

Maybe: evidence comes from heavy drinkers who experience blackouts, hallucinations, and seizures

ORGANIC BRAIN DISORDERS → dementia and Wernicke Korsakoff Syndrome

• DEMENTIA: loss of intellectual abilities that can be associated directly with neurotoxicity from alcohol consumption

• WERNICKE-KORSAKOFF SYNDROME: confusion, loss of muscle coordination, and unintelligeble speech due to thiamine deficiency (from alcohol largely)

Blood Alcohol Level + standardized ethanol units

Standardized ethanol unit: 0.5 oz ethanol

is found in 1 oz of hard liquor, 5 oz of wine, 0.5 pint of 5% beer

BAL = 0.06 (2 to 4 drinks) - warmth, euphoria, loss of certain motor control

BAL = 0.09 (4 to 6 drinks) - exxagerated emotion, talkative, noisy, legally drunk

BAL = 0.12 (6 to 8 drinks) - clumsiness, unsteady walking, narrowing visual field

BAL = 0.15 (8 to 10 drinks) - very drunk, lack of coordination, tunnel vision

BAL of 0.35 brings someone to a coma

What is Fetal Alcohol Syndrome? 

Fetal Alcohol Syndrome is a pattern of problems relating to the victim’s drinking levels while pregnant

• cognitive and learning difficulties

• behavioural deficits

• small eye openings, short nose, underdeveloped jaw, thin upper lip, small head + flat face 

What are the Canadian recommendations for drinking?

LOW RISK: 0 to 2 drinks a week for everyone

HEAVY DRINKING: 4 or more drinks on one occasion for women, 5 or more drinks on one occasion for men, at least once a month over a year 

What are the 4 effects of alcohol use disorder?

Acute effects

Chronic effects

Neurological effects

Social effects

What are the 4 acute effects of alcohol use disorder?

Respiratory Suppression - shallow breathing leading to CO2 in the blood

Hemmorhagic pancreatitis - bleeding into or around the pancreas

Asphyxia - oxygen deprivation leading to unconsciousness or death

Withdrawal - GABA receptors become less sensitive, glutamate activity can lead to over-excitation and cell death, in severe cases 5% develop delirium tremens and 1-5% die

• treatment: benzodiazepines and acamprosate (GABA agonist that’s less addictive and controls excitotoxicty when ethanol is withdrawn)

What are 2 types of chronic effects of alcohol use disorder? 

Gasointestinal 

Liver (Fatty liver, hepatitis, cirrhosis - scarred tissue replacing healthy tissue) 

What are the 4 neurological effects of alcohol use disorder?

Wernicke-Korsakoff Encephalopathy (thiamine defficiency)

Alcohol-induced dementia (lesions)

Peripheral neuropathy (nerve damage)

Fetal Alcohol Syndrome (growth retardation, cognitive deficits, behaviour problems, learning difficulties)

What are 4 social effects of alcohol use disorder?

Accident-related 

Legal - violent crimes, people with poorer executive function are more likely to be aggressive when intoxicated (Robert Phil)

Social 

Economic

What are the biological factors of alcoholism?

GENETICS: 

family history, adoption, and twin studies suggest that genetics play a substantial role as high as 50%

CENTRAL NERVOUS SYSTEM CIRCUITS:

James Olds found the Pleasure Pathway → DOPAMINERGIC SYSTEM in MID BRAIN through NUCLEUS ACCUMBENS to FRONTAL LOBE

• substances that inhibit GABA directly increase dopamine availability in the reward center

• 66% alcoholics (vs 33% non alcoholics) carry a DRD2 gene regulating dopamine 2 receptor

What are the 3 psychological influences of alcoholism?

1. Learning - reinforcement (positive or negative), conditioning (stimuli paired with anxiety reduction become conditioned stimuli)

2. Cognitive - alcohol expectancies (personal beliefs of what will or won’t happen when drinking)

3. Social Modeling - parents and peers, UBC Pit study

What are the socio-cultural influences of alcoholism?

1. Some religions ban alcohol or drug use

2. Some cultures expect heavy drinking on occasion

3. Media depictions of alcohol

What are opioid-related disorders?

OPIATE is the natural chemicals in the opium poppy that create narcotic effects (reducing pain—analgesic—-and inducing sleep), OPIOIDS include opium, morphine, heroin, codeine, methadone, and oxycoton. 

DSM: 

again, at least 2 symptoms for 1 year of pharmacological symptoms (withdrawal and tolerance), psychological effects (seeking behaviours + impaired control), affecting social life, risky use

What are included in the clinical picture of opioids?

13% of Canadians use opioid pain relievers (2% for non-medical reasons)

34% increase in ER emissions

OPIOID DEPENDENCE: 12 month prevalence in adults of .37% and up to 1% in young adults

• onset: late teens/early adulthood + 37% from earlier prescriptions

• course: chronic, 20-30% long term abstinence

• gender: twice as high in men than in women (where prescription opioids are more common)

• culture: higher in the indigenous community

What are 3 complications related to opioid related disorders?

DEPRESSION

LEGAL PROBLEMS
HEALTH (HIV/AIDS - B.C. has the highest rates in the developed world, HEPATITIS - 90% of intravenous users, SKIN ABCESSES/SCARRING

What are the mortality rates of opioid related disorders?

MORTALITY is 94% accidental with fentanyl as a large cause

• 22% mortality vs 12% for the rest of population

• average age of death 40, 33% overdose and 50% are homicide, suicide, or accident

Weed 101

THC tetrahydrocannabinol is high inducing

CBD cannabidol is anti-inflammatory and analgesic

K2/SPICE are dangerous synthetic versions of THC 

Anandamide, brain’s own THC

• 15-20% of Canadians use cannabis with 26% being young adults (more common in those with mental disorders) 

• 400 chemical compounds with limited research (case studies with open designs, single dose lab setup, using synthetic > actual plant)

Response varies by strain, means of administration, and THC dose

What is part of the clinical description of Cannabis Use Disorder? 

At least 2 symptoms for a year

• 9% develop a dependence(versus 32% for nicotine and 10-12% for alcohol)

• 4% men and 1% women are heavy users + youth are at risk

• moderate heritability from twin studies

What are the 4 repercussions of cannabis use disorder and heavy use, plus tolerance and withdrawal effects

TOLERANCE - some say they experience “reverse tolerance” feels better after repeated use

WITHDRAWAL (33% of regular users) tiredness, irritability, appetite loss, IMPAIRED CONTROL + OCCUPATIONAL AND EDUCATIONAL DISTURBANCES

and

• Decreased reactivity to dopamine + reward circuitry

• amotivational syndrome

• lung cancer, bronchitis, esophagus

• motor vehicle accidents and er visits from panic

What is the relationship between schizophrenia and marijuana use?

SCHIZOPHRENIA is found in vulnerable adolescents

• a family history of psychosis brings you to 10% risk

• marijuana doubles this risk to 20%

• mechanisms are unclear, but disrupts normal neurological development

What are the biological treatments for Substance Use Disorders? 

ANTAGONISTS

1. naloxene 

used for overdose, acting within 2 minutes and lasting 30-60 minutes - many need multiple doses and causes opioid withdrawal

2. naltrexone 

used for opioid abuse, blocking opioid receptors for pleasure and also used to decrease craving for alcohol 

3. acomprasate 

upregulates GABA to protect from withdrawal symptoms 

AGONIST SUBSTITUTIONS (providing safer drugs) 

1. methadone

opioid agonist

2. buprenorphine 

partial agonist/antagonist that is more effective than methadone + less withdrawal, can be combined with naloxene 

3. nicotine patches

AVERSIVE TREATMENTS 

1. disulifram (antabuse) for alcohol, preventing acetaldehyde breakdown and making it hell 

2. anti anxiety and depression medication

What are the psychosocial treatments for substance use disorder? 

ALCOHOL ANONYMOUS/NARCANON

• effective if continued, but 75-85% dropout rate 

RESIDENTIAL TREATMENT CENTERS

• expensive, not more effective than outpatient treatment

• beneficial for managing withdrawal symptoms and stabilization

BEHAVIOURAL + COGNITIVE TREATMENT

• learning self-control strategies and learning situation managemnet

HARM REDUCTION

• controversially controlled drinking

• safe injection sites

• relapse prevention

Explain Behavioural Addiction

BEHAVIOURAL ADDICTION is a compulsion to repeatedly engage in non-drug related behaviour despite negative consequences

• beyond substance definition of tolerance + withdrawal, as well as dopamine circuitry alteration

• gambling, sex, and provisional internet gaming

What is the clinical picture of gambling addiction?

GAMBLING ADDICTION was the first behavioural addiction to be recognized, may activate the same brain systems as pharmaceuticals

• blunted VMPFC activation, limiting risk-reward assessment

• up to 3% of the population with 1% severe cases

• chronic disorder - only 1.3% in B.C. seek treatment

What are the dysfunctional cognitive beliefs of gambling addiction? 

GAMBLER”S FALLACY believing result of an independent event is influenced by previous events

HOT HAND FALLACY believing success in an independent event will predict future successes for other events 

“NEAR"“ WINS results appearing as almost a win to motivate further gambling

ANTHROMORPHOTISM assuming control 

What is internet gaming disorder?

INTERNET GAMING DISORDER is a provisional behavioural addiction

• tolerance and withdrawal

• preoccupation or excessive use

• impairment in education or occupation + social functioning

What is hypersexual disorder and what are its nuances?

HYPERSEXUAL DISORDER is a sexual promiscuity and behaviours in response to distress

• 1-2 hours a day of excessive masturbation, pornography dependence, or cyber sex

• at risk for STDs, unwanted pregnancy, and relationship disturbances

Definition does not signify how much is too much, and there is no information about heritability and developmental causes - what is “normal” and what is excessive

What is Schizophrenia?

SCHIZOPHRENIA is a cluster of symptoms on a large spectrum, involving disturbances in:

• thought (delusions)

• perceptions (hallucinations)

• speech, emotion, and behaviours

• full recovery is rare, though present in 1 of 100 people

Is it one disorder or many? There is heterogeneity of a spectrum!

What is psychosis? What 4 disorders is it involved with?

PSYCHOSIS is a term to characterize many symptoms of unusual, realty-distorting behaviour, but mostly:

HALLUCINATIONS sensory phenomena without external input

DELUSIONS disorder of thought and belief content

PSYCHOTIC SYMPTOMS are in

BIPOLAR DISORDER
SCHIZOPHRENIC SPECTRUM DISORDER

SEVERE MAJOR DEPRESSIVE DISORDER

SOME PERSONALITY DISORDERS

What is schizosphrenia spectrum disorder in DSM? What are the 7 things to remember?

SCHIZOPHRENIA SPECTRUM DISORDER is a collection of disorders, all commonly marked by distorted reality, falling under:

• SEVERITY of symptoms

• DURATION of symptoms

• PROGNOSIS

Constitutes of:

Attenuated psychosis syndrome

Schizotypal Personality disorder

Delusional disorder

Brief Psychotic episode

Schizophreniform disorder

Schizophrenia (most common)

Schizoaffective disorder

What are the misconceptions of schizophrenia?

• People that are previously violent are more likely to be violent + dangerous than those with schizophrenia

• Bleuler thought of Schizophrenia to be due to a split personality, confused with DID

What did Kraeplin and Bleuler contribute to the discussion of schizophrenia?

What is the criterion for Schizophrenia diagnosis?

CLUSTER A (2)

• Postive and/or negative symptoms

• Florid symptoms present at least 1 month and persisting for 6 months (in the absence of medication)

• at least one must be hallucinations, dellusions, or disorganized speech

CLUSTER B

• social and occupational impairment

CLUSTER C

• continous signs of disturbance for over 6 months

What are the positive symptoms of schizophrenia?

POSITIVE SYMPTOMS refer to symptoms grounded in distorted reality:

• hallucinations, sensory events without external stimuli: auditory (most common), visual, olfactory, gustatory

• delusions, disordered thoughts and beliefs not shared by others, commonly: prosecution, reference, influence, Cotard’s syndrome, Capgras Syndrome, Grandiose

What are Cotard's and Capgras syndrome?

COTARD’S SYNDROME is a postiive symptom of schizophrennia as part of delusions

• belief that one is dead, dying, or non-existent

CAPGRAS SYNDROME is a postiive symptom of schizophrenia as part of delusions 

• belief that a familiar has been replaced by an identical imposter 

What are the disorganized symptoms of Schizophrenia?

THE DISORGANIZED SYMPTOMS of schizophrenia include:

DISORGANIZED SPEECH

• derailment, loose associations

• tangential thinking - going off topic

• incoherence - “word salad”

• neologisms

• clang associations

GROSSLY DISORGANIZED/CATATONIC BEHAVIOUR

• impaired grooming

• inapropriate sexual behaviour

• unpredictable agitation or aggression

• odd mannerisms

• catatonic motor behaviours

What are the negative symptoms of Schizophrenia?

NEGATIVE SYMPTOMS of schizophrenia include:

AVOLITION inability to initiate and persist in activities, associated with poor outcomes

ALOGIA impoverished or absence of speech

ANHEDONIA indifference to pleasant activities
ASOCIALITY lack of interest in social interactions
AFFECT FLATTENING diminished emotional expression

What is the clinical picture (onset, prevalence, and course) of schizophrenia? 

ONSET

• normally preceded by a prodromal period (1-2 years), but can occur abruptly 

residual period occurs with only negative symptoms or attenuated positive symptoms 

PREVALENCE

• around 1%

• men (onset earlier) > women (onset later, with more favourable outcomes) 

• more common in developed countries (more common in indigenous and african-canadians) 

COURSE

• 1 episode (-22%) has favourable outcomes

• 35% have exacerbations or remission

• 8-12% have chronic course

• 35% have progressive worsening 

Overall a reduced life expectancy is present for those with schizophrenia (10-15 years) because of suicide, cardiovascular disease, substance abuse, diabetes, etc. 

What is SCHIZOTYPAL PERSONALITY DISORDER? 

SCHIZOTYPAL personality disorder is a relatively stable condition marked by pervasive social and interpersonal deficits (5 of the following):

• ideas of reference

• odd beliefs or magical thinking

• unusual perceptual experiences

• suspiscousness or paranoid ideation

• odd thinking or speech

• inappropriate affect

• excessive social anxiety that does not diminish with familiarity

• odd, ecentric, or peculiar behaviour

• lack of close friends other than relatives

9 total deficits

What is Delusional Disorder?

DELUSIONAL DISORDER is the presence of one or more delusions, more circumscribed than other spectrum disorders:

EROTOMANIC

GRANDIOSE
JEALOUSY

PERSECUTORY

SOMATIC

very rare (.2%)

What is Brief Psychotic Disorder?

BRIEF PSYCHOTIC DISORDER are the postive symptoms of psychosis: delusions, hallucinations, disorganized speech, grossly disorganized behaviour

for less than 1 month with a tendency to remit on its own (good outcomes)

prevalence of .9% of psychotic disorders

What is Schizophreniform Disorder?

SCHIZOPHRENIFORM DISORDER are positive and negative symptoms of psychosis for a duration of 1 to 6 months

• if presumed with good lifestlye, may resume with normal life

In 0.2% of population

What is Schizoaffective Disorder? 

SCHIZOAFFECTIVE DISORDER is a mood disorder as well as schizophrenia 

prevalent in 0.3% 

What are the genetic contributions (family, twin, and adoption studies) to Schizophrenia disorder? 

Genes are responsible for making some individuals vulnerable to schizophrenia

FAMILY STUDIES

• 48% identical twin with schizophrenia

• 46% for two parents with schizophrenia

• 9% sibling with schizophrenia

• 6% one parent with schizophrenia

• 5% one grandparent with schizophrenia

• 1% of the general population 

TWIN STUDIES (Gottessman et al.)

• 48% concordance rate for MZ twins (100% genes and environment)

• 17% concordance rate for DZ twins (50% genes and 100% environment)

How heritable, 40% 60% 80%? Higher rates includes “probable psychosis” 

ADOPTION STUDIES

• 22% for a child with a schizophrenic mother

• 1% for a child of a non-schizophrenic mother

What is a genetic trait associated with schizophrenia? 

A genetic marker for schizophrenia is smooth-pursuit eye movement 

What are the 2 theorized biochemical contributions to schizophrenia?

1. DOPAMINE CIRCUIT DYSFUNCTION

a two factor theory, that dopamine is deficient in the D1 receptor sites of the FRONTAL AREAS and dopamine is excessive in the D2 receptor sites of the striatal areas

2. GLUTAMATE DYSFUNCTION

due to GABA dysfunction or excessive dopamine, an underactivity at NMDA receptors, too much NMDA results in too little glutamate, operates through NMDA receptors

• PCP and “special K” createa schizophrenic-like symptoms

What is the 2 Factor theory of Dopamine dysfunction in relation to schizophrenia?

1. DOPAMINE CIRCUIT DYSFUNCTION

a two factor theory, that dopamine is deficient in the D1 receptor sites of the FRONTAL AREAS and dopamine is excessive in the D2 receptor sites of the striatal areas

• treatment is dopamine antagonists (which already are antipsychotic drugs)

• drugs produce negative side effects similar to parkinson’s disease

• L-DOPA (dopamine agonist) can produce psychotic symptoms in some people

• amphetamine activates dopamine and makes psychotic symptoms worse

CONTRASTING EVIDENCE:

• dopamine agonists are not universally effective

• CLOZAPINE, a weak dopamine antagoist is still effective 

• there is discontinuity between dopamine blockage and symptom change

• less helpful in reducing negative symptoms

What are the structural and functional brain abnormalties realted to schizophrenia?

PET and fMRI: hypofrontality (reduced blood flow to FC)

MRI studies: enlarged ventricles

Reduction in grey matter

Low synaptic density in schizophrenic brains

• there are cause and effect issues, but changes can be seen after first psychotic episode

• changes are not specific to schizophrenia, also seen in major depression

What is the contemporary model of schizophrenia? What 4 elements support this model?

NEURODEVELOPMENTAL MODEL suggests that early deficits in cortical development manifests as schizophrenia in later life during stressful late adolescent periods

• smaller head circumference at birth

• slower to reach developmental milestones

• higher rates of left-handedness

• congenital minor physical and craniofacial abnormalities

Evidence comes from high-risk studies looking at birth complications (obstetric complications, premature births, hypoxia)

What did Kallman discover for schizophrenia? 

Kallman showed that the severity of the parent’s disorder influenced the likelihood of the child having schizophrenia as well. 

• you inherit a general schizophrenia vulnerability, which then can manifest either as the same one your parent has or a different one

What are theories attributing to the neurodevelopmental model? 

PHYSICAL STRESS

• 1st semester maternal starvation (Dutch Hunger winter of 1945)

• Prenatal viral exposure during second trimester (Helsinki Influenza 1957) 

MICRO-GLIA + IMMUNE CELLS 

• function to remove damaged cells + promote cell death

• increase activation in regions important for executive functions 

• regulated by dopamine and GABA

There may be excessive neuronal pruning in key areas at critical adolescent periods, stressed during adolescence

Explain how neurodevelopmental factors lead to schizophrenia in men and women

What is the Multiple Hit Model of schizophrenia?

There may be a MULTIPLE HIT MODEL of genes, nutrition, virus + toxins, birth injury, and stressors that make up schizophrenia development

• brain development from conception to early adulthood (neuron formation, migration, and synaptic pruning)

• anatomical and functional disruption in neural connectivity and communication → COGNITIVE DYSMETRIA

• difficulties in processing high-level cognitive processes (attention, memory, language, emotion)

All contributing to HALLUCINATIONS, DELUSIONS, DISORGANIZED SPEECH + GROSSLY DISORGANIZED BEHAVIOUR

What are the 3 theories of recurrence for schizophrenia?

1. Stressful life events

2. Family processes

• Brown (1959) found higher risk of relapse for those living in a high-criticism family dynamic

3. Expressed Emotion

• Hooley (1985) found that emotional climate of a family is a significant indicator for relapse

• but not across cultures!!!!!!!!!!!!!!!!!!!

What was the first generation of antipsychotics for biological schizophrenia treatment?

FIRST GENERATION OF ANTIPSYCHOTIC MEDICATION focused on positive symptoms with multiple side-effects

• AKINESIA - impaired movement

• TARDIVE DYSKINESIA

It was more so about managment, not cure with a 30-50% non respondance rate

What was the second generation of antipsychotics for biological schizophrenia treatment?

SECOND GENERATION OF ANTIPSYCHOTIC MEDICATION reduced negative symptoms more than first generation

• fewer bad side effects, though still possible - diabetes, weight gain, immune dysfunction (1%), and seizures

• fewer suicides and reduced relapse rates

CLOZAPINE, OLANZAPINE, RESPERIDONE

What are the current medications for those with schizophrenia?

CHOLINERGIC SYSTEM AGONISTS

increasing acetylcholine (memory, attention, arousal), aiding neural transmission

• little research

What are the 3 psycho-social treatments for schizophrenia?

• Token economy programs (rewarding tokens for desired behaviours)

• Skill training

• Behavioural family treatment to reduce expressed emotion

PSYCHOLOGICAL TREATMENTS can reduce relapse rates but not always - drugs with support or education is the best, skill training + family treatment are about equal (slightly over half as productive as drugs + education/support)

What is included in the cognitive therapy for schizophrenia? 

COGNITIVE THERAPY acts to reframe positive symptoms

• identify possible triggers

• identify anxiety-provoking beliefs (delusions) 

• gently provide alternative explanations

.5 to 1% of those with SD have a reduction in symptoms 

Relationship with patient is critical and treatment effect sizes as well

What is the current conclusion about schizophrenia treatment? 

There is no cure, rather symptom management with first-line treatment as medication despite multiple side-effects 

• heterogeneity between patients makes research very difficult  

What are civil commitment laws? What do they balance? What do they require?

Each province and territory has respective civil commitment laws: legal proceedings that determine if a person who has not broken the law, but has a mental disorder, may be hospitalized, even involuntarily

• CIVIL COMMITMENT LAWS balance individual rights + fairness with the protection of society from the government… parens patriae and police power

Most provinces allow commitment if: 

• individuals have a mental disorder

• the individual is a threat to themselves or others (mandatory)

• they are in need of treatment 

CIVIL COMMITMENT REQUIRES:

• 2 medical opinions, except in emergencies (1 doctor in 48 hours and 2 doctors in 1 month)

How do British Columbia and Ontario differ in civil commitment? 

BRITISH COLUMBIA: having a mental illness (disease of mind), need for psychiatric treatment 

• care, supervision, or control are necessary to protect the person and others

• or to prevent substantial mental or physical deterioration 

B.C. uses a broad definition that require more judgement from the court and mental health professionals (better for patients’ interest)

ONTARIO: requiring that an individual’s mental illness will result in serious bodily harm or imminent and serious physical impairment

Ontario uses a stricter definition, prognosis will be worse for lost treatment time + legal issues are worse because of criminal offences 

What are parens patriae and police power?

PARENS PATRIAE and POLICE POWER are two dictators of civil comitment

PARENS PATRIAE (state as parent) is used when citizens are unable to act in their best interest

• government can exert parens patriae to protect people from hurting themselves

POLICE POWER is used when there is a need to protect the public

• government can create laws and regulations to protect the public

What are specific processes to CIVIL COMMITMENT in B.C.?

In B.C.:

patients must be given oral or written notice of their individual rights

a family member must be notified

commitment can be appealed (3 person review board + patient has the right to a lawyer)

What are challenges of defining mental illness in law?

MENTAL ILLNESS as a legal concept, implies the cause of the disorder to be found in a medical disease model

• In Canada: disease of the mind

• terms like “insanity, mental illness, and mental disorder” are legal terms not psychiatric terms

Saskatchewan uses a PRACTICAL DEFINITION: disordered thoughts, perceptions, and thoughts vs. simply a disease

What are the distinctions between CIVIL COMMITMENT, CRIMINAL COMMITMENT, and the CHARTER OF RIGHTS? 

CHARTER OF RIGHTS AND FREEDOMS: provisions that allow for people to be removed from society if they act in a way infringing on the rights of others

• based on English common law + Napoleonic code in civil statutes 

CRIMINAL COMMITMENT (federal): for determination of competency to stand trial or after a verdict of NCRMD
CIVIL COMMITMENT (province-based): procedure where mentally ill people who have not broken the law can be deprived of liberty and incararcerated in a mental hospital

What are the processes of criminal commitment? 

CRIMINAL COMMITMENT is used when someone who has broken the law may also have a mental illness

• consists of 2 legal decisions: competency to stand trial + if they are Not Criminally Responsible on Account of Mental Disorder (NCRMD) 

How does CRIMINAL COMMITMENT determine if someone is competent to stand trial + what are possible outcomes?

Based on TRIAL IN ABSTENTIA - being mentally and physically present for trial

• focus is on individual’s state of mind at the time of the trial based on 3 criteria

FITNESS INTERVIEW TEST-R

1. Does the person understand the nature and purpose of legal proceeding?

2. Does the person understand the likely/possible consequences of proceedings?

3. Can the person communicate with their lawyer?

OUTCOMES FOR THOSE NOT FIT

• conditional discharge

• detained in a hospital

• order compulsory treatment

What are community treatment orders in mental health law? What is the rationale behind it?

COMMUNITY TREATMENT ORDERS stipulate that the person may be released into the community as long as they seek and adhere to treatment

RATIONALE: those with mental disorders may be unable to seek treatment, with deficits in insight

CONTROVERSIAL

What is NCRAMD? What are its criteria? 

Not Criminally Responsible by Reason of Mental Disorder (NCRMD) is based on the principle of mens rea (criminal intent) 

• actus rea is involuntary action

Rather, the focus is on a person’s state of mind at the time of the crime based on 3 criteria: 

suffers from a mental disorder rendering the person incapable of: 

• appreciating the nature of one’s behaviour 

• appreciating one’s behaviour is wrong

“Mental illness” here is under judicial terms defined differently in legal terms and non congruent with a DSM diagnosis 

• expert opioin is weighed as well as judge’s opinion 

What are the controversies and realities of NCMDAR defence?

NCRMD states that a person can have a mental illness and still be criminally responsible for a crime

• the disorder must be seen to directly impact the criminal action

LAY PUBLIC thinks that NCDMD is a way for guilty people to get off, but it is not used commonly

• fewer than 1 in 100 defendants in felony cases file insanity pleas

• and within this only 29% result in acquittal

• those found NCRMD spend more time in a psychiatric institution than they would have spent in prison

In Canada most with NCRMD suffered from psychotic disorders such as that of schizophrenia

What are 3 things to remember about violence and mental illness? 

Danger prediction is central to CIVIL COMMITMENT LAW 

1. Among those incarcerated, inmates with serious mental disorders (schizophrenia) are less likely to reoffend a new violent crime following release, than inmates without mental illness. 

2. 3% of violent acts are mental illness related and a critical factor is COMORBID SUBSTANCE ABUSE

3. Mental health professionals are bad at judging danger, clinical interviews and specialized training have helped