eds, schizophrenia, and other psychotic disorders

Myths about eating disorders

• People with eating disorders are thin

  • Most people with eating disorders are average or above average, anorexia is the least common of all eating disorders

• Eating disorders are a choice

  • Not a choice, mental illness

• The media (or parents) cause eating disorders

  • If this were the case, then a lot more people would have eating disorders

• Only women get eating disorders

  • The ratio is 3:1 for all ED cases combined

  • More likely and higher prevalence among women than men, but it is not impossible 

Sociocultural theory

• Cultural views of body image promote eating disorders behaviour because individuals are trying to get closer to what society values

Sociocultural factors

• Body ideals change

Affect regulation model of BE

• People engage in binging when their negative mood increases, and then the eating makes them feel better (this can be applied to other EDs)

Biological theories

• High heritability

• Strong biological component

• We don’t know exactly if there are specific genes involved, but there is research going on now

• Those studies don’t know if it’s genetics or if they run in families

Schizophrenia & other psychotic disorders

• This does not mean multiple personalities

  • A myth you hear about would be that DID

Schizophrenia criteria DSM-5

1. At least 2 of the following

1. Delusions - positive 

2. Hallucinations - positive

3. Disorganized speech - positive

4. Disorganized behaviour

5. Negative symptoms

      B. Social/occupational dysfunction

      C. Duration: continuous signs of the disturbance either more than 6 months

• When we see psychosis during mania, it is a mood disorder

• To be schizophrenic we have to see that the positive symptoms are occurring when other symptoms are happening (PTSD, anxiety)

Positive symptoms

•  Characterized by the presence of unusual perceptions, thoughts, or behaviours

• Positive refers to the fact that symptoms are salient, added symptoms

• Distortions to reality

Negative symptoms

• Characterized by losses or deficits in certain domains

• Negative refers to the absence of behaviours, feelings, experiences, etc.

Delusions

•  Ideas that an individual believes to be true, but are highly unlikely or simply impossible

• Often they are related to someone following them, government agencies 

• Can be grandiose thinking that they are Jesus/God or that God is telling them what to do

• Thought insertion: thoughts are being inserted into their mind, being taken out of their mind, and people can read their mind

1. Persecutory (paranoid): being persecuted, watched, conspired against.

2. Reference: random events are directed at oneself (the idea that the TV or radio is speaking directly to you)

3. Grandiose: great power, knowledge, talent, or a famous/powerful person.

4. Somatic: appearance or part of the body is diseased, or altered.

5. Being Controlled: thoughts, feelings, and behaviours are being imposed, and controlled by an external force.

Delusions vs. normal self-deception

• Delusions are different from thoughts we tell ourselves in at least 3 ways:

1. Bizarreness: self-deceptions have some possibility, whereas delusions are unfounded in any truth (i.e. I didn’t do well on this exam, the prof is out to get me/they want me to fail, US gov’t is out to get me even though you have no record)

2. Preoccupation: search out or make connections that fit the delusions and are preoccupied with said delusions, amount of time spent engaging in delusions (i.e. walking down the street and a cop car drove by, then it would be a part of their delusions)

3. Resistance: inability to be aware or have insight about the decisions (i.e. a thought of instructor is out to get you, cannot come up with alternate explanations)

More about delusions

•  Usually, multiple different types of delusions are woven together into a complex belief system

• The specific content of delusions differs across cultures and cohorts – what they experience differs from what they experience/culture

• Cultural relativism is important to consider when diagnosing delusions - when thinking about psychosis and these types of experiences

Hallucinations

• Unreal perceptual experiences: seeing/hearing/feeling things that aren’t there, any of the senses 

• Hallucinations in schizophrenia are bizarre and are extremely distressing and impairing

• Auditory Hallucinations:

  • Most common

  • More common in women than men

  • Voices talk to each other

  • Can be aggressive, threatening, &/or give orders

Disorganized thought and speech

• Loosening of association or derailment: tendency to go from one topic to another completely unrelated (no smooth transition)

• Word salad: incoherent speech and you would not understand what they were saying

• Neologisms: made-up words

Disorganized or catatonic behaviour

• Disorganized – unpredictable and untriggered

• Catatonic: a group of disorganized behaviours that generally reflect an extreme lack of responsiveness (i.e. not moving, agitated, can occur in response to delusions)

• This can explain:

  • Dishevelled appearances, inappropriate hygiene/clothing given the context (i.e. during summer wearing a winter coat)

  • Shouting, swearing, pacing

Negative symptoms

• 3 types are recognized as core negative symptoms:

• Antipsychotics do not help improve these symptoms

1. Affective flattening: the non-responsive, complete absence of overt emotional expression/responsiveness (i.e. blunted response to environment)

2. Alogia: reduction of speech, saying few words/not initiating speech even if asked directly (i.e. being asked a question and just responding with “yes”)

3. Avolition: lack of motivation/goal-directed activities, lot of difficulty completing tasks or engaging in behaviours

Cognitive deficits (associated features)

• Causes most distress

• Deficits in working memory, cognition, and attention may cause:

  • Difficulty suppressing unwanted, irrelevant info

  • Difficulty paying attention to relevant info (i.e. paying attention to a fly instead)

  • Overall difficulties in reasoning, communication, and problem-solving

Other features associated with schizophrenia

• Inappropriate affect: laughing at sad things, crying at happy things, not doing purposefully and there is a mismatch in recognizing situations

• Anhedonia: lack of interest in everything

• Impaired social skills: not necessarily a symptom of the disorder in the same way, but rather a result of symptoms (i.e. if someone is having a hallucination, it interferes with how they talk to people or eat at a restaurant)

Phases of schizophrenia

1. Prodromal phase - symptoms present before full criteria are met

   1. Aren’t meeting full requirements

   2. I.e. could be hearing some hallucinations, but not that often

   3. Early development of symptoms

2. Acute - active psychosis 

   1. Actively experiencing delusions, hallucinations

3. Residual phase - symptoms present after the acute phase

   1. Will not be meeting full criteria for full psychosis

   2. But maybe some residual symptoms (i.e. might still have hallucinations but not all)

Prevalence

• About 1% of lifetime prevalence worldwide

• About 300.000 Canadians

• Relatively similar rates in men and women

Prognosis and course

• Schizophrenia is debilitating:

  • Life expectancy 10 years shorter

  • High relapse (85% have residual and/or active symptoms)

  • Higher rates of infectious and circulatory diseases

  • 10-15% die by suicide

• Poor outcome: 

  • Younger age of onset

  • Delay to treatment (the longer you have symptoms without intervention = the worse it could get over time)

Gender differences

• Age of onset:

  • Between 15-45 y/o

    • Women late 20s-early 30s

    • Men around early 20s

• Course: 

  • Women tend to have a better prognosis - b/c tend to be higher-functioning

• Cognitive deficits:

  • Women show fewer cognitive deficits 

Other psychotic disorders

• Schizoaffective: a mix of schizophrenia and mood disorder symptoms, where they can have both at the same time (more of their time would be psychosis and mood symptoms within an episode, what is the context of the symptoms) 

• Schizophreniform: less than 6 months, extremely rare, meet criteria and have symptoms, but they only occur 1-6 months and do not occur after that

• Brief psychotic disorder: symptoms that last a month, tend to see a sudden onset of symptoms and more in response to a sudden stressor

• Delusional disorder: the presence of delusions and no other symptoms, but the delusions are still causing distress and impairment

Biological theories

• Genetics:

  • About 50% concordance rate of MZ twins vs 14% DZ twins

  • About a 40% likelihood of having schizophrenia if both parents have the disorder

• Brain abnormalities:

  • Enlarged ventricles

  • Reduced grey matter in the temporal (aspect of attention, speech) and frontal lobes (memory)

  • The prefrontal cortex (higher order processing), limbic system (amygdala, emotions), hippocampus (memory)

• Possible etiological factors:

  • Prenatal virus exposure

    • High rates of schizophrenia associated with flu

  • Birth complications

    • Perinatal hypoxia 

  • Neurotransmitters

    • Overactive DA in mesolimbic pathway: 

    • Underactive DA in profrontal areas

    • Potential (hypothesized) role of dopamine:

Psychosocial factors associated with psychosis

• Stress:

  • Psychotic episodes often follow periods of high stress

  • Interaction between life stress and genetic vulnerability 

• Family communication patterns:

  • “Expressed emotion”

    • Critical comments, hostility, emotional overinvolvement, lack of warmth

    • Increased risk of relapse

• Social class:

  • Strong negative association between SES and the risk of schizophrenia 

    • Sociogenic theory

    • Social drift hypothesis

Biopsychosocial model

• Vulnerability-stress model

• Combo of genetic vulnerability and stress increases an individual’s risk

Biological treatments

• Biologically treated disorder

• The first line of treatment is medications

• It is important to have a combo with social skills training, family

• Neuroleptics: revolutionized treatment of schizophrenia

  • Dopamine antagonist: dopamine is blocked

  • Reduction of positive symptoms (hallucinations, delusions, disorganized behaviour

  • Don’t appear to be great for helping with negative symptoms

• Issues:

  • 25% of people don’t respond at all

  • Don’t appear to be great for helping with negative symptoms

  • Discontinuation = 78%, as many people don’t want to take them lifelong

  • Only helps when an individual is taking them

  • Side effects: groggy, dry mouth, blurred vision, drooling, sexual dysfunction, weight gain, depression

  • Akinesia: slowed motor activity, monotonous speech, lack of facial expression

  • Parkinson’s disease: neuroleptics block dopamine; parkinson’s is thought to be caused by lack of dopamine

  • Tardive dyskinesia: irreversible, long-term side effect of neuroleptics, another motor side effect

• Atypical antipsychotics:

  • May be more effective

  • Generally bind to DA reception, but also influence other transmitters

  • Fewer neurological side effects, but still have side effects that include dizziness, nausea, sedation, weight gain, irregular heartbeat, Type II diabetes, serious diseases

  • Clozapine, olanzapine, risperidone

  • Treat positive symptoms, not negative