Schizophrenia Spectrum & Other Psychotic Disorders

Psychotic Disorders Due to Other Causes

• Psychosis can result from:
  • Substance use (e.g., alcohol, ketamine, phencyclidine).
  • Some medications (e.g., dopamine agonists, anti-histamines, cortisone).
  • Some medical conditions (e.g., HIV infection, neurosyphilis, hypothyroidism).
• DSM-5-TR includes:
  • Substance/medication-induced psychotic disorder.
  • Psychotic disorder associated with another medical condition.
• Knowing these causes is important for treatment.

Prognosis of Schizophrenia

• Poorer prognosis than most other disorders.
• 85% of people with schizophrenia go through a prodromal stage:
  • Period before the onset of serious symptoms.
  • Characterized by less severe, but unusual behavior.
• Once treated, some patients may improve.
• However, most patients will experience several episodes and relapses.
• Shorter life-expectancy:
  • Increased risk for suicide.
  • Increased risk for accidents.
  • Self-care may be poorer.

Causes of Schizophrenia: Psychological and Social Influences

• Stress
  • May activate underlying vulnerability (gene-environment interactions).
  • Psychosocial stressors (e.g., poverty, homelessness) influence the onset and development.
  • Stressors in early life may also play a role.
  • May also increase risk of relapse & negative outcomes.
• Family Interactions
  • Unsupported theories:
    • Schizophrenogenic mother (cold, dominant, rejecting nature of mother).
    • Double bind communication (parent communicates conflicting messages).
    • These theories are no longer supported and caused undeserved destruction & guilt
• Families and Relapse
  • A particular emotional communication style (expressed emotion (EE)) is associated with relapse:
    • High levels of criticism, hostility and over-involvement.
    • Families with high expressed emotions view the symptoms of schizophrenia as controllable

Cultural Factors in Diagnosis and Treatment of Schizophrenia

• Schizophrenia is universal, affects all racial and cultural groups
• Presentation of symptoms may differ across cultures
  • Somatic symptoms (e.g., headaches, dizziness, palpitations) more prevalent in African communities
• Course & outcome of schizophrenia differ across cultures
• However, the diagnosis can be controversial
  • Psychotic behaviors not always pathologized (e.g., cultural reaction to grief)
  • Symptoms may be interpreted as amafufunyana (spiritual calling)
• Clinicians should be aware of their own biases and explore patients’ cultural perspectives to prevent misdiagnosis

Treatment of Schizophrenia

• Historical treatments were generally ineffective and often barbaric.
• Today, treatment includes biological & psychosocial interventions.
• The Mental Health Care Act of 2002 in SA promotes deinstitutionalization
  • Long periods of admission are the exception to the rule
• Unfortunately, frequent admissions still occur due to
  • Severe positive symptoms
  • Substance use
  • Pre-mature discharge
  • Non-compliance with treatment
• Severe burden for the health care system

Psychosocial Interventions

• Used in collaboration with biological interventions
• Focus on increasing medication compliance & helping patients function within their communities
• Psychodynamic therapy does not appear to be effective
• Behavioral approaches:
  • Token economies: reward adaptive behavior (esp. inpatient settings)
  • Daily activity scheduling
  • Include social and living skills training
• Cognitive remediation
  • Focuses on improving cognitive abilities (e.g., attention, executive functioning, memory)

Behavioral Family Therapy

• Educate families regarding the condition and its treatment
• Address communication & problem-solving skills to reduce stress and tension
• Provide social support

Assertive Community Treatment Programmes

• Shift from hospital treatment to community rehabilitation
• Multi-disciplinary approach (e.g., psychiatrists, psychologists, nurses, social workers, OTs)
• Focus on illness management
• Provide psychoeducation on symptoms & medication

Cultural Relevance in Treatment

• Treatment may differ across cultures
• In SA, people often first seek help from traditional healers
  • Focuses on external causes of symptoms (e.g., angered ancestors, family)
  • Obtains guidance from ancestors & performs cleansing rituals
• In order to be effective, treatments should be culturally relevant

Hallucination Example

• Question: Nathan hears a voice telling him that people are out to get him and that he should hide in the bathroom. Identify the type of hallucination Nathan is experiencing and briefly describe what a hallucination is (3 marks).
• Answer:
  • Identify the type of hallucination: auditory hallucination (1 mark)
  • Briefly describe what a hallucination is: A hallucination is a psychotic symptom of perceptual disturbance (1 mark) in which patients hear, see or sense things that is not actually present (1 mark)S