9 Psychotic Disorders and Schizophrenia

Psychotic Disorders

  • Psychosis: Loss of contact with reality.
    • Can be substance-induced, illness-related, or due to brain injury.
    • Schizophrenia is a common manifestation.
  • Schizophrenia: Psychotic disorder with deterioration in personal, social, and occupational functioning due to:
    • Unusual perceptions
    • Unusual thoughts
    • Disturbed emotions
    • Motor irregularities

Schizophrenia

  • Impacts:
    • Financial and emotional costs
    • Increased suicide risk (25% attempt, 5% die)
    • Increased risk of physical illness
    • More prevalent in lower socioeconomic status (SES) groups (Downward Drift Theory)
  • Diagnostic Checklist (for 1 month):
    • Two or more of the following symptoms:
      • Delusions
      • Hallucinations
      • Disorganized speech
      • Very irregular motor activity (including catatonia)
      • Negative symptoms
    • At least one symptom must be delusions, hallucinations, or disorganized speech.
    • Impaired functioning in life spheres.
    • Beyond 1 month: Some degree of impaired functioning for at least 5 additional months.

Schizophrenia Symptoms

  • Positive Symptoms (Additions/Excesses):
    • Hallucinations: Perceptions with the clarity and impact of true perceptions, but without external stimuli (auditory most common).
    • Delusions: False beliefs about external reality, contrary to strong evidence (paranoid delusions most common).
    • Disorganized Thinking: Disturbance to logical sequences and coherence.
    • Disorganised Behaviour: Non-goal directed behavior that leads to difficulties in daily functioning.
    • Inappropriate Affect: Situationally unsuitable emotional response.
  • Negative Symptoms (Deficits):
    • Alogia: Decreased speech.
    • Affective flattening: Lack of emotional expression.
    • Avolition: Lack of initiation of activities.
    • Social Withdrawal: Withdrawal from social environment.
  • Psychomotor Symptoms:
    • Agitation: Excessive, purposeless movements.
    • Awkward movements: Grimaces, gestures, repetitive non-functional movements.
    • Catatonia:
      • Stupor: No movement or response.
      • Rigidity: Maintaining rigid posture.
      • Posturing: Holding unusual poses.
      • Echopraxia: Mimicking others’ movements.

Course of Schizophrenia

  • Phases:
    • Prodromal: Beginning of deterioration, mild symptoms.
    • Active: Symptoms become apparent.
    • Residual: Return to prodromal-like levels.
  • Relapses: More likely during times of life stress.
  • Type I:
    • Dominated by positive symptoms.
    • Linked to biochemical irregularities.
  • Type II:
    • Dominated by negative symptoms.
    • Tied to structural irregularities.

Causes of Schizophrenia

  • Biological Views:
    • Inheritance and brain activity play key roles.
    • More common among relatives; closer relation = greater likelihood.
    • Dopamine Hypothesis: Excessive dopamine activity.
    • Challenge to Dopamine Hypothesis: Irregular activity of dopamine and other neurotransmitters.
    • Dysfunctional brain circuit (prefrontal cortex, hippocampus, amygdala, thalamus, striatum).
    • Exposure to viruses before birth.
  • Psychodynamic Views:
    • Schizophrenogenic family dynamics (cold, contradictory parenting).
  • Cognitive-Behavioral Views:
    • Operant conditioning: Lack of reinforcement for typical responses, attention to irrelevant cues.
    • Misinterpreting Sensations: Brain produces unusual stimuli; person develops additional symptoms to understand.
  • Sociocultural Views:
    • Social labeling: Features influenced by diagnosis (self-fulfilling prophecy).
    • Family dysfunction: High expressed emotion (criticism, disapproval, hostility) tied to relapse.
  • Developmental Approach:
    • Diathesis-stress Approach: Biological predisposition triggered by extreme stress.

Treatment for Schizophrenia

  • Milieu Therapy: Therapeutic community promoting activity, respect, responsibility.
  • Token Economy: Operant conditioning to change behaviors.
  • Antipsychotic Medications:
    • First Generation (Neuroleptics): Reduce positive symptoms by blocking dopamine; side effects similar to neurological conditions.
    • Second Generation (Atypical): Reduce positive and some negative symptoms by targeting dopamine and serotonin; lower side effects.
    • Effectiveness: Symptoms reduce in 70% of people; positive symptoms reduce more quickly; high relapse rates if stopped prematurely.
  • Psychological Treatments:
    • Cognitive Behavioural Therapy: Cognitive remediation (computer tasks for attention, planning, memory, problem-solving).
    • Hallucination reinterpretation and acceptance: Change view of hallucinations, education on biological causes, identify triggers, challenge inaccurate ideas.
    • Family Therapy: Addresses family issues, creates expectations, provides psychoeducation, emotional support; reduces relapse and readmissions when combined with medication.
  • Community Care/Social Therapy: Addresses social and personal difficulties, offers practical advice, problem-solving, social skills training, reduces rehospitalization.