Psychosis and Schizophrenia

Psychosis Experiences

  • Psychosis experiences exist on a spectrum:
    • Fleeting psychosis experiences.
    • Extended episodes with multiple psychosis experiences.
    • Psychosis disorders.
  • As severity increases, the number of people experiencing it decreases.

Normative vs. Nonclinical Psychosis

  • Normative experiences: Individuals typically do not experience any psychosis experiences.
  • Nonclinical psychosis: Experiencing some psychosis experiences without significant impairment to functioning; often short-term and fleeting.
  • Attenuated psychotic symptoms: Functional impairment associated with psychosis, but not meeting the full criteria for a disorder.
  • Clinical levels of symptoms: Meeting criteria for a psychosis disorder.

Symptoms of Psychosis

  • Three main categories:
    • Hallucinations
    • Delusions
    • Disorganized speech
  • Symptoms highly associated with psychosis but not enough to qualify on their own:
    • Disorganized behavior
    • Negative symptoms
    • Difficulty with attention, learning, and memory
  • Experiencing one of the top three symptoms suggests a psychosis experience.
  • Experiencing only the bottom symptoms might indicate something else.

Symptom Groupings

  • Positive Symptoms
    • Hallucinations and delusions.
    • Experiences that are not part of the person’s baseline.
    • Hallucinations: New sensory experiences (visual or auditory).
    • Delusions: New thoughts, concerns, or beliefs.
    • Adding something new
  • Disorganized Symptoms
    • Disorganized speech
    • Disorganized behavior
    • Difficulty making sense of things
    • Speech is unclear or jumbled
    • Behavior doesn't match the situation
  • Negative Symptoms
    • Taking away things that should be there.
    • Examples: avolition (lack of motivation), difficulty producing speech, difficulty initiating activities.
  • Cognitive Symptoms
    • Difficulties with attention, learning, and memory.
    • Fall into the cognitive domain.
    • Commonly referred to as cognitive symptoms of disorders like schizophrenia.

Hallucinations

  • Sensory experiences or perceptions in the absence of external stimuli.
    • Smelling flowers when no flowers are present.
  • Experiences are perceived as separate from the self.
    • The person believes the hallucination is real and coming from an external source.
    • Example: Hearing a voice and believing it's coming from outside.
  • Different from illusions, which are misinterpretations of actual stimuli.
    • Example: Seeing a shape in the street and thinking it’s a monster.
  • Can involve more than one sensory domain (multimodal hallucinations).
    • Example: Seeing a dog that's barking (both auditory and visual).
  • Types of hallucinations:
    • Visual
    • Auditory
    • Smells
    • Taste
    • Tactile (feeling something)

Auditory Hallucinations

  • Most common type.
  • Often verbal, involves hearing voices or commands.
  • Can involve multiple voices or whispers.
  • Command hallucinations: Voices commanding the person to do something.
  • MRI scans show activation in Broca's area (speech production region) during auditory hallucinations, indicating it's processed like a real voice.

Visual Hallucinations

  • Range from seeing full-fledged figures to shadows or shapes.
  • Can be clear and fully formed or vague.
  • Can be fleeting.

Olfactory Hallucinations

  • Involve smelling odors, often unpleasant ones.
  • Can lead to concerns about personal hygiene.

Tactile Hallucinations

  • Involve feeling sensations on the skin.
  • Examples: feeling bugs crawling, sensations inside the body, electricity shooting through the body.

Paranormal Concerns

  • If the person says that they saw the ghost, the ghost is talking to them, the ghost is touching them.
  • That they're interacting with them, would this count as a hallucination?
  • Yes. So if the person is saying that they are like, they saw the ghost, the ghost is talking to them, the ghost is touching them, other people in their community and their maybe their home or family are like, there is no ghost. Like, I was there. There is no ghost. And but the person is convinced that they're then, yes, that they could meet criteria for any of these.

Sleep Paralysis

  • Different in the sense that the curse that's more of a consciousness issue where you're sort of able to like, your your brain is sort of semi awake, but here, the person is fully conscious and actively engaging, you know, in the process.

Multimodal Hallucinations

  • Involves multiple combinations of different groups of hallucinations.
  • Add in a difference in sensory system, they activate it, then it's multimodal.
  • With the hallucinations, it's a positive symptom, it must be an added thing.

Delusions

  • Strong, highly held beliefs or unusual thoughts that are inaccurate.
  • Persist even when presented with conflicting evidence.
  • Lead to a mental misrepresentation of reality.
  • The person interprets the world through the lens of their fixed belief.
  • Beliefs are outside the norm of the person’s culture.
  • Can lead to distress and functional impairment in social relationships and ability to work.
  • Bizarre delusions: Could not occur in real life.
  • Non-bizarre delusions: Unrealistic but not impossible.

Common Types of Delusions

  • Delusions of reference: External signals have special meaning for the person.
    • Believing songs on the radio are played just for them or commercials are sending special messages.
  • Persecutory delusions: Others are trying to harm the person.
    • Believing they are being followed, poisoned, or wronged.
  • Grandiose delusions: The person is particularly skilled, important, or has special powers.
    • Believing they are a special spy or have godlike powers.
  • Somatic delusions: Something is wrong with the body.
    • Believing they have a serious disease or parasitic infestation.
  • Religious delusions: Religious themes or content.
    • Believing they are a saint or a god.
  • Erotomanic delusions: Someone, usually of higher status, is in love with the person.
    • Believing they have a secret relationship with a celebrity.
  • Jealous delusions: The person believes their partner is unfaithful, contrary to any evidence.
  • Guilt delusions: The person believes they’ve done something horribly wrong and should be punished.
  • Thought-related delusions:
    • Thought withdrawal: Thoughts are being taken out of their head.
    • Thought insertion: Something else is inserting thoughts into their head.
    • Thought control: Some external force can control what they’re thinking.
    • Thought broadcasting: Other people can hear their thoughts.

Disorganized Speech

  • Confusing or abnormal speech, failure to make sense.
  • Words are clear, but the way they are strung together doesn't make sense.
  • Conforms to rules of language in terms of noun and verb combinations.
  • Reflects a disorganized or confused thought process.

Manifestations of Disorganized Speech

  • Derailment or loosening of associations: Difficulty maintaining focus on one topic, flight of ideas.
    • Example: Shifting from talking about a marathon to ancient Greece and democracy.
  • Tangentiality: Trying to answer a question but answering in an unrelated manner.
  • Incoherence (word salad): Words and phrases are strung together nonsensically.
    • Words are just dumped into a salad and then mix around and sort of come out in all kinds of different ways, and it's the person who's trying to listen really cannot follow.
  • Neologisms: Creation of new words.
    • Example: Using the word "wally loop" without knowing what it means.

Disorganized Behavior

  • Disorganized affect: Inappropriate emotional behaviors or responses.
    • Laughing or crying at odd times.
  • Inappropriate, unproductive, or unusual behavior.
    • Lack of bathing, wearing inappropriate clothing.
  • Bizarre grimacing: Making unusual face or body movements.
  • Mimicking movements of others.
  • Pacing, walking in circles, making loud noises.
  • Confronting others without a logical reason.
  • Catatonia: A severe form of disorganized behavior with markedly reduced motor activity.
    • Rigid postures, staring, mutism, lack of motor response, or stupor.

Common Catatonic Behaviors

  • Rigidity or stupor lasting for hours or days.
  • Performing strange, repetitive movements.
  • Sitting or staying in uncomfortable positions.
  • Erratic or extreme movements.
  • Echolalia: Repetition of words or phrases.

Negative Symptoms

  • Things that should be there but aren't, causing impairment.
  • Characterized by the reduction or absence in the five A’s:
    • Avolition: Lack of motivation (apathy).
    • Alogia: Reduced speech outputs.
    • Anhedonia: Lack of pleasure or interest in activities.
    • Asociality: Social withdrawal (not due to anxiety).
    • Affective flattening: Muted expressions of emotions, both positive and negative.

Cognitive Symptoms

  • Not psychosis symptoms but common in people with psychosis symptoms.
  • Difficulties across cognitive domains:
    • Attention: Difficulty initiating and sustaining attention.
    • Working memory: Difficulties with working memory and mental manipulation of information.
    • Learning and memory: Difficulty with retention and recall.
    • Speed of processing: Generally slowed down.
    • Executive functioning: Impairments in reasoning, problem-solving, and decision-making.
  • Often result in difficulties going to school, holding down a job.
  • These symptoms are often rated as the most difficult by those experiencing psychosis.

Psychosis vs. Psychotic Disorders

  • Psychotic experiences can occur in other disorders (PTSD, bipolar disorder, depression) and in people without any disorders.
  • Psychotic episodes are when these experiences increase in frequency, severity, and impairment, or are very distressing.
  • Psychotic disorder is when you have a psychotic episode that is impairing or distressing, and you can’t find any other condition to explain it.
    • Ruling out substance use, physical illness, or other alternative explanations.
  • Psychosis spectrum disorders are considered schizophrenia spectrum disorders, where schizophrenia is the hallmark disorder.

Statistics on Psychosis

  • Lifetime prevalence of psychosis: about 3%
  • About 10% of the general population will endorse psychotic experiences.
  • Of those who experience psychotic experiences, about 30% will go on to develop a psychotic disorder.
  • High risk for suicide and suicide concerns associated with psychosis.
  • Suicide completion rate among those with a psychotic disorder: 12-15%
  • About 75% of those with psychotic level symptoms will make a suicide attempt in their lifetime.

Schizophrenia

  • To diagnose schizophrenia, need at least two of the following symptoms present for at least a month:
    • Delusions
    • Hallucinations
    • Disorganized speech
    • Grossly disorganized or catatonic behavior
    • Negative symptoms
  • At least one must be delusions, hallucinations, or disorganized speech.
  • Functional impairments with some sort of obvious or market shift from previous functioning.
  • Diagnosis generally not given for at least six months.

Factors of Schizophrenia

  • Symptoms may come and go.
  • Onset typically occurs in early adulthood (18-25), but symptoms can emerge at any time.
  • Roughly the same amount of males and females will experience schizophrenia.
  • Females seem to have somewhat better long-term prognosis.
  • Prevalence rate is about 1% across countries and cultures.
  • Treatment and perception of symptoms vary across cultures.
  • Content of delusions is culturally influenced.
  • Disparities in diagnosis exist, with ethnic minorities more likely to receive this diagnosis in the US.

Sex Differences

  • Prevalence rates are the same.
  • Symptoms shift in content according to culture.
  • Most common time in which schizophrenia symptoms kind of onset is this sort of late adolescence, early twenties time period, but can also develop, you know, symptoms even, you know, later midlife.
  • Somewhat higher likelihood of males developing or presenting with schizophrenia symptoms earlier than than in women.

Prodromal Phase

  • Diaphysis stress model where the individual may have preexisting biological vulnerabilities or psychological vulnerabilities to development of that disorder, in the case of the stress, that's more likely that converts to symptoms and then future disorder.
  • 1-2 year period where the person is not really having full psychosis symptoms.
  • Characterized by unusual symptoms and difficulties.
  • Often identified in retrospect, looking back, after full psychosis symptoms.
  • Feeling like something is not quite right.
  • May report jumbled thoughts or confusion.
  • Fear for no apparent reason or feeling like their brain is playing tricks.
  • Intermittently hearing, seeing, or feeling things that others don’t, but not to the level of hallucination at this point, it just the sense of being off.
  • Declining interest in people, activities, or self-care.
  • Difficulty concentrating.
  • Prodromal early warning signs and an active of acute phase and then residual phase.
  • Know symptoms really seem to be high in the first