Psychosis

Schizophrenia

A broad spectrum of cognitive, emotional and behavioural dysfunctions.

3 classes of symptoms

1. Positive

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

     • Delusions

     • Hallucinations

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

2. Negative

3. Disorganized

Delusions

Beliefs that are gross misrepresentations of reality

• Bizarre - clearly implausible, not understandable or derived from ordinary life experiences.

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

Categories of delusions

• Guilt or sin; belief that being punished by a god (usually bizarre)

• Somatic; sensations/inside of body (bizarre or non-bizarre)

• Persecutory; (bizarre or non)

• Of reference; feeling they are important with messages sent to you (bizarre)

• Grandiose; person is especially important/special powers(bizarre or non)

• Of being controlled; being controlled by something (usually bizarre)

Hallucinations

experience of sensory events without input from surrounding environment

• Auditory (most common)

• Visual (second most common)

• Tactile (feel outside of body)

• Somatic (feel inside of body)

• Olfactory

Negative symptoms

• Absence of insufficiency of typical behaviour

  • Avolition - initiate/persist at basic activities

  • Alogia - amount of speech

  • Anhedonia - pleasure/interest

  • Affective flattening - emotional expression

  • Asociality - social relationships/skills

Disorganized symptoms

• Erratic speech, motor behaviour and emotions

  • Inappropriate affect

  • Disorganized behaviour; acting in unusual ways

  • Catatonia - motor dysfunctions that range from agitation to immobility

    • Waxy flexibility

  • Disorganized speech - tangentially, loose associations, derailment.

Schizophrenia DSM-5 criteria

• 2+ for a month (must include 1,2 or 3)

  1. Delusions

  2. Hallucinations

  3. Disorganized speech

  4. Disorganized or catatonic behaviour

  5. Negative symptoms

• Impaired functioning

• Continuous disturbance for 6 months (prodromal symptoms)

Stigma

• Schizophrenia is seen as linked to violence but:

  • It is linked to substance abuse

  • Substance abuse is linked to violence

Biological causes of schizophrenia

• Genetics - inherent 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.

• Reduced brain matter, larger ventricles.

Genain quadruplets

• All 4 identical developed schizophrenia.

• Varied severity; youngest had most severed, third born had mildest.

• Family influence; grandmother had paranoid schizophrenia, father was abusive and disturbed.

• Cognitive stability; stable or improved cognition over decades.

Psychosocial influence

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

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

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

Substance use + schizophrenia

Cannabis:

• More than 2x the risk of developing schizophrenia

• One study found young men were more than 6x more likely

  • Can dysregulate dopamine channels

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

Cigarettes:

• Prevalence of smoking

  • 80% vs 20% of general population

• Dopamine for negative symptoms

Biological treatments

• Antipsychotic (neuroleptic)

  • Compliance issues; generally antipsychotic work on pos symptoms but can increase negative symptoms.

• Transcranial magnetic stimulation

  • Exposure to magnetic fields to regulate brain regions.

  • Over frontal lobes for negative symptoms

  • Over temporal lines 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% with one episode will have another

• 38% recovery rate; slightly 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 to reduce stigma and comprehensive care for people with schizophrenia.