Untitled Flashcards Set

What is psychosis?

• Psychosis is NOT a formal diagnosis 

• Psychosis =  a cluster of symptoms relating to disruptions in perceptions and interpretations of reality 

  • Hallucinations 

  • Delusions 

  • Disorganization

• Encompasses “positive symptoms” – ‘adding’ something unusual to the ‘typical’ experience 

• At least one positive symptom is necessary to count as psychosis, but “negative symptoms” and “cognitive symptoms” are also common 

What is schizophrenia?

• A formal categorical diagnosis of psychotic symptoms 

• Emil Kraepelin - ‘dementia praecox’ 

• Eugen Bleuler - coined the term ‘schizophrenia’ 

  • A condition characterized by disorganized thoughts and a split from reality 

  • Did not believe the disorder is a single diagnostic entity!

• Psychosis/Psychotic Disorders are an umbrella term that includes Schizophrenia 

Positive Symptom: Hallucinations 

• A sensory experience that occurs in the absence of any external stimulus

• Auditory - most common

• Visual 

• Somatic 

• Olfactory

• Gustatory  

Positive Symptom: Delusions 

• An erroneous belief that is fixed and firmly held despite clear contradictory evidence, a belief that is not held by the individual’s culture/subculture

• Some delusions can be very complex, elaborate beliefs 

• Held with a high degree of certainty and resistant to contradictory information  

• Themes:

  • Persecutory

  • Grandiose

  • Ideas of Reference

  • Erotomanic

  • Religious 

  • Somatic

  • Thought insertion/broadcast/withdrawal

Positive Symptom: Disorganization 

Thought/Speech

Disruptions in the ability to communicate clearly

• Tangentiality 

• Circumstantiality 

• Derailment 

• Illogical phrases/loosening of associations

• Word salad 

Bizarre Behavior

Behaviors/actions that are unusual or deviate from the norm

• Erratic or illogical behavior

• Dressing inappropriately (ex: for the weather)

• Catatonia (immobility, mimicry, unusual postures)

Negative Symptoms and Cognition

• Negative Symptoms: something that is ‘missing’ from the ‘typical’ experience 

  • Alogia - reduced speech 

  • Anhedonia - reduced pleasure 

  • Asociality - reduced social drive

  • Avolition - reduced motivation 

  • Blunted affect - reduced expressiveness 

• Cognitive Symptoms

  • Poor executive functioning and planning 

  • Difficulties with memory/concentration 

  • Difficulties with abstract thinking 

• Negative and cognitive symptoms are less responsive to treatment, more associated with impairment 

Psychosis in HiTOP

  Primarily conceptualized under Thought Disorder spectra

• Negative symptoms could fit under Thought Disorder or Detachment 

• Somewhat correlated with Openness on the Big Five (although this is debated)

• Mania/Bipolar Disorder might overlap with Thought Disorder 

Diagnostic Considerations

• Generally requires longitudinal data, not just one instance of psychosis 

• Diagnoses can shift over time 

• Need to rule out:

  • “Organic”/medical causes

  • Substance induced psychosis 

  • Affective psychosis or psychosis due to other mental disorders 

  • Non-pathological and cultural explanations 

Medical Causes and Substance Induced

• Lots of medical conditions can present with psychosis and should be screened for appropriately 

  • Dementia and other age-related neurological conditions

  • Brain tumors 

  • … and more!   

• Many substances can outright cause psychosis; person should be monitored to see if symptoms persist when sober

  • Hallucinogens (LSD)

  • Marijuana 

  • Ketamine and PCP

  • Can exacerbate underlying risk; convert to a more “true” psychosis 

Affective Psychosis & Other Mental Disorders

• Affective Psychosis

  • Occurs ONLY during a severe episode of depression or mania and resolves once euthymic mood returns 

  • Symptoms are often (but not necessarily) mood congruent 

  • The degree to which this is meaningfully distinct is debated

• Psychotic-like features of other disorders 

  • OCD obsessions and rituals can rise to the level of delusions

  • Flashbacks in PTSD can take on a psychotic/paranoid quality 

  • Body Dysmorphia and eating disorders can distort perception of one’s body

Non-pathological & Cultural Considerations

• Shamanism - practices to induce conversations with spirits 

• Religious cultural practices where it is expected that God routinely communicates with followers 

• Self-identified psychics with ‘unusual’ perceptual experiences 

It is important to not pathologize people who just experience the world differently (and without impairment)

Schizophrenia Spectrum Disorders

• Primary psychotic disorders (psychosis is the core feature)

  • Schizophrenia 

  • Schizophreniform

  • Brief Psychotic Disorder

  • Delusional Disorder

  • Schizoaffective Disorder 

• “Diagnosis of Exclusion” – have to rule out all other causes first 

• Boundaries between diagnoses can be blurry 

• These are not primary psychotic disorders but are relevant for understanding psychosis:

  • *Bipolar Disorder

  • Schizotypal Personality Disorder 

Schizophrenia

A. Two or more of the following, each present for a significant amount of time during a 1-month period, and at least one must be 1, 2, or 3

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

B. For a significant portion of time since the onset, level of functioning in one or more major areas is markedly below level achieved prior to onset.

C. Continuous signs of the disorder present for at least 6 months. Must include at least 1 month of symptoms, including prodromal or residual symptoms

Schizophreniform

• Diagnosed when symptoms of schizophrenia are present for a significant portion of time (at least a month), but signs of disturbance are not present for the full six months required for the diagnosis of schizophrenia. 

• Must meet Criterion A symptoms for both Schizophreniform and Schizophrenia 

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

Brief Psychotic Disorder 

• The sudden onset of psychotic behavior that lasts less than 1 month followed by complete remission with possible future relapses (in DSM-5) 

• Marked by one or more of the following psychotic symptoms:

• Delusions

• Hallucinations

• Disorganized speech

• Grossly disorganized or catatonic behavior

Delusional Disorder

• One or more delusional thoughts for one month or more, that has no explanation by another physiological, substance-induced, medical condition or any other mental health condition.

• Main classifications of delusions: 

• Bizarre delusions: involve a phenomenon that is impossible and unrelated to normal life.

• Non-bizarre delusions: situations that are possible, such as being manipulated or harmed, but remain fixed false beliefs even after proven false.

Schizoaffective Disorder

1. Delusions or hallucinations for 2 or more weeks in the absence of a mood episode

2. Mood symptoms are present for the majority of the duration of the active and residual parts of the illness.

Subtypes:

• Depressive (only met criteria for depressive episodes)

• Bipolar (has had at least one manic episode) 

*you can have Schizophrenia and a comorbid mood disorder WITHOUT meeting criteria for schizoaffective 

Schizotypal Personality Disorder 

riteria

1. Pervasive pattern of social and interpersonal deficits, cognitive or perceptual distortions, or eccentricity of behavior indicated by 5 or more of the following:

   1. Ideas of reference 

   2. Odd beliefs or magical thinking 

   3. Unusual perceptual experiences 

   4. Odd thinking and speech

   5. Suspiciousness or paranoid ideation

   6. Inappropriate or constricted affect 

   7. Odd or eccentric behavior 

   8. Lack of close friends 

   9. Excessive social anxiety that does not diminish with familiarity, associated with paranoia 

2. Does not exclusively occur during the course of schizophrenia, bipolar disorder, other psychotic disorders, or autism spectrum disorders

Schizotypal Personality Disorder Cont. 

• Cluster A personality disorder but tied to non-psychotic schizophrenia spectrum illnesses

• First introduced in DSM III 

  • emerged from studying non-psychotic family members of probands 

• Course of disorder is stable (DSM-5-TR), few develop schizophrenia or other psychotic disorders 

Causes of Psychosis 

Stress-Vulnerability Model 

• AKA diathesis-stress model 

• Vulnerability: your innate likelihood for developing psychosis given biological, developmental, and personality factors

• Stress: daily life difficulties, emotional states, patterns of thought, and traumatic experiences that increase the likelihood of psychosis

Vulnerability: Genetics

• No one gene has been identified as causative 

  • Multiple genes combine their individually small risk

• Schizophrenia is highly heritable (70-80% heritability estimates)

• Heritability: the proportion of variation in a population trait that can be attributed to genetic factors

• 1% baseline risk

• ~10% risk if you have a first-degree relative w/ the disorder

• ~50% risk if your identical twin has schizophrenia 

• Bipolar disorder and schizophrenia share most of their genetic risk profile

Vulnerability: Structural & Functional Brain Abnormalities

• No one feature is diagnostic of schizophrenia/psychosis, but several findings have been somewhat consistently linked with the diagnosis

  • Larger ventricles

  • Gray matter loss after initial diagnosis

  • Thinner cortices

  • Lower brain volume

• Cognitive Impairments

  • These appear relatively early (in CHR too)

• Sensory Gating impairments

  • Filtering out irrelevant sensory information 

• Social Cognition

  • Mental processes involved in understanding and interacting with others

Dopamine Hypothesis of Schizophrenia 

• Influential theory of the mechanisms of psychosis

• Positive symptoms caused by “too much” dopamine in certain brain circuits like the mesolimbic system

  • Post-mortem studies found an excess of D2 receptors in certain regions and by the efficacy of antipsychotics 

• However, other brain regions show “too little” dopamine activity

  • ex: mesocortical system, which is linked with negative symptoms

• Glutamate is also implicated 

• Vastly oversimplified 

Stress: Modifiable Risk

• For people with high vulnerability/already diagnosed:

  • Psychotic symptoms are worsened by daily stress

• For people with moderate vulnerability/high risk of developing a psychotic disorder:

  • First psychotic episode often preceded by a stressor (breakup, finals season)

• For people with a low vulnerability:

  • Stressors like lack of sleep or sensory deprivation can induce psychosis

  • Intense emotional experiences (like bereavement) can trigger psychosis 

Treatments 

For Psychosis First Generation Antipsychotic Medications

• Antipsychotic medications are dopamine antagonists 

• First generation, or “typical” antipsychotics helped some symptoms of schizophrenia 

  • Ex: Chlorpromazine or Haldol 

• Typicals can help reduce hallucinations, delusions, and disorganized speech

  • But they do little to improve cognitive deficits or negative symptoms and can be associated with distressing motor side effects. 

• Extrapyramidal symptoms (EPS) such as acute dystonia and tardive dyskinesia are some of the more prominent side effects to keep in mind within this drug class. 

• Other side effects include fatigue and weight gain

Second Generation Antipsychotic Medications

• The newer generation of antipsychotics is referred to as atypical antipsychotics. 

• Not necessarily more helpful for schizophrenia but have a different side effect profile: fewer motor side effects, higher risk of diabetes, metabolic side effects

• Similar mechanism of action, though bind less tightly to D2 receptors and may have some effect on serotonin as well 

• Risperdal, abilify, Olanzapine, Clozapine 

• Clozapine was originally for treatment resistant patients but now widely used 

Antipsychotic Medication Efficacy

• Frontline treatment; best associated with preventing relapse 

• “Rule of Thirds” 

  • 1/3 see very significant reduction in positive symptoms

  • 1/3 see some improvement, but positive symptoms persist

  • 1/3 see very little to no improvement 

• Special case of Clozaril/clozapine 

  • The first of the second generation antipsychotics 

  • Risk of it dangerously reducing white blood cell count (agranulocytosis), need regular blood monitoring 

  • Generally used only after “failing” 2 other antipsychotics, but some argue it should be more widely prescribed 

• Antipsychotic polypharmacy generally contraindicated 

  • Excluding clozapine and possibly olanzapine, little evidence for difference in efficacy between antipsychotics; decisions often made instead based on side effect tolerability

  • Little evidence that taking more than one at once is more effective

  • Unfortunately, clinical practice doesn’t always reflect this 

Cognitive Behavioral Therapy for psychosis (CBTp)

• Included in international treatment guidelines for psychosis, though very few providers are in the US are trained in it

• Numerous randomized control trials and meta-analyses support CBTp’s efficacy in reducing symptoms and improving quality of life 

• Provides clients with education around psychosis, helps them make sense of their symptoms, and gives them skills to manage them

• Therapist takes a stance of collaborative curiosity, without confronting or colluding with psychotic ideas 

• De-emphasizes objective truth; instead focuses on whether a belief or experience is “useful” to a client in pursuing their goals

CBTp Intervention Examples

• For hallucinations…

  • Distraction techniques (for example, listening to music)

  • Stress management skills to reduce voice frequency

  • Making voices “prove” that they have the special knowledge or power they claim

• For delusions…

  • “even if this is true, how can we still get you to…”

  • Building skills around considering alternative hypotheses 

• For negative symptoms…

  • Behavioral activation/activity scheduling 

  • Psychoeducation around the difference between anticipatory/experienced pleasure

Family Treatments

• Psychoeducation – provide factual, recovery-oriented information

  • By professionals, i.e., manualized Multi-Family Groups

  • By other families, i.e., NAMI Groups

• Psychotherapy for families 

  • May reduce “expressed emotion” (anxiety, criticism, and over-involvement), which increases symptoms 

  • Treat secondary stressors (trauma, marital strife, adjustment) related to a schizophrenia diagnosis 

• Psychosis-specific treatments

  • Family work embedded in Coordinated Specialty Care programs

  • CBTp skills for families, i.e., Psychosis REACH 

Other Recovery-Oriented Treatments

• Cognitive Remediation

  • Training to improve cognitive symptoms

  • Skills to compensate for deficits

• Supported Employment

  • Individualized placement and support for vocational goals

  • On the job coaching and support

• Social Skills Training 

• Peer Support 

  • Meeting with someone with lived experiences of psychosis 

  • Often embedded within a care setting