CHAPTER 4 SCHIZOPHRENIA AND THE PSYCHOSES

1. CHAPTER 4SCHIZOPHRENIA AND THE PSYCHOSES

2. AIMS AND OBJECTIVES Provide a definition of psychosis and psychotic conditions Describe problems associated with these disorders Review information regarding prevalence, age of onset, and course Discuss key findings regarding aetiology Outline treatment approaches for various stages

3. PSYCHOTIC DISORDERS Positive symptoms – hallucinations, delusions, thought disorder, and movement disturbances Negative symptoms – deficits including avolition (loss of motivation), flattening of affect (decreased expression of emotion), and alogia (lack of unprompted speech) Narrow definition of psychosis requires only positive symptoms, whereas broad definitions include disorganized behaviour and negative symptoms

4. PSYCHOTIC DISORDERS Hallucinations are false perceptions Experienced by 75% of patients with schizophrenia Generally auditory, consisting of a voice speaking Can occur in other sensory modalities, including visual, olfactory, and tactile Delusions are false beliefs Paranoid delusion –belief that someone is seeking to harm the patient Other types of delusions include: delusions of reference, somatic delusions, grandiose delusions, nihilistic delusions, and erotomanic delusions Delusions can be categorised as bizarre or non-bizarre Primary delusions (“out of the blue”) versus secondary delusions (secondary to an abnormal change in memory, mood or perception

5. PSYCHOTIC DISORDERS Thought disorder Disturbances in logical sequencing and coherence of thought Positive thought disorder: includes circumstantiality, tangentiality, “clang” associations, and neologisms Negative thought disorder: reflected in poverty of speech Disorganised behaviour Grossly disorganized or catatonic behaviour DSM-IV catatonic subtype of schizophrenia is associated with earlier age of onset and worse functioning. Requires 2 of these 5 symptoms: Immobility (e.g., waxy flexibility) Excessive, purposeless motor activity Excessive negativism or rigid posturing in response to requests to move Peculiarities of voluntary movement (e.g., unusual postures) Echolalia (imitation of speech) or echopraxia (imitation of movements)

6. PSYCHOTIC DISORDERS Negative symptoms Deficits in the expression of speech, emotion, and spontaneous behaviour, including: alogia (reduction in thoughts/speech) flattened affect (lack of emotional expressiveness) avolition (lack of initiation in activities) Negative symptoms may be difficult to distinguish from effects of medicine and symptoms of depression

7. PSYCHOTIC DISORDERS Diagnoses Schizophrenia is diagnosed when 2 or more of these symptoms: Delusions Hallucinations Disorganised speech Grossly disorganised or catatonic behaviour Negative symptoms Functioning must be well below level prior to onset Continuous signs must be present for at least 6 months Other psychotic disorders include: schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, and shared psychotic disorder

8. PSYCHOTIC DISORDERS Associated features Depression – high rates of suicide Anxiety – comorbid anxiety disorders are common Substance abuse – high rates of use/abuse, which exacerbates symptoms and may even trigger psychosis Quality of life – affects broader functioning, e.g., 40-50% unemployed Stigma – myths such as violence, intellectual disability, or “split personality”

9. PSYCHOTIC DISORDERS Historical/current conceptualisations Emil Kraeplin identified dementia praecox- “senility of the young” Term schizophrenia coined by Eugen Bleuler (“split mind”) Schneider argued for “first rank” symptoms Symptoms specific to schizophrenia, e.g., bizarre delusions Recent findings suggest that psychotic experiences are normally distributed across population Some argue that the diagnosis of schizophrenia should be abandoned due to stigma (e.g., Read et al., 2006)

10. PSYCHOTIC DISORDERS Epidemiology Lifetime prevalence of schizophrenia = 1-2% Peak onset = late adolescence/early adulthood Course of psychotic disorders Prodromal phase – preliminary period of change prior to onset Acute phase – persistent positive and negative symptoms Early recovery phase – problems with depression and anxiety may emerge Late recovery phase – continued challenges with reintegration, high unemployment High Expressed Emotion (EE) – conflictual interpersonal relationships, well-established predictor of psychotic relapse Enduring psychosis – severe, persisting forms associated with earlier and more gradual onset of symptoms, leads to chronic problems in living

11. PSYCHOTIC DISORDERS Aetiology Stress Vulnerability Model (Zubin & Sprin, 1977) – psychotic episode occurs when a triggering event interacts with an underlying vulnerability Biological Vulnerability Factors Strong genetic component Risk increases with degree of genetic relatedness Adoption studies also provide strong support Abnormalities in neurotransmitters: dopamine, neurepinephrine, serotonin Abnormalities in brain structure: enlarged ventricles, smaller hippocampal volume

12. PSYCHOTIC DISORDERS Aetiology Psychosocial Vulnerability Factors Social Factors Risk increases with early stressors, ( e.g., urban environment, migration, social exclusion, childhood abuse) Cognitive Factors Psychosis is culturally unacceptable interpretations of “intrusions into awareness” (Morrison, 2001) The way intrusions are defined is central to the development of psychosis Interpreting intrusions in distressing manner increases likelihood of future intrusions Triggering Factors Biological processes (illicit substances) Stressful life events Interaction (e.g, hormonal disturbances induced by stress)

13. PSYCHOTIC DISORDERS Aetiology Symptom-specific aetiological factors Hallucinations Dysfunction in Auditory Imagery/Refined Auditory Imagery Theory - hallucinating individuals experience deficits in auditory imagery and mistake vivid auditory imagery for actual sound – little empirical support Dysfunction in verbal self-monitoring (Seal et al., 2004) Delusions Individuals with delusions tend to “jump to conclusions” (Garety et al., 2005) Individuals prone to delusions tend to blame other people for negative events Thought disorder Problems in storage of information Emotional distress may contribute to disrupted thought processes

14. PSYCHOTIC DISORDERS Treatment Prodromal phase interventions Identifying individuals at-risk and offering intensive interventions CBT plus medication or CBT alone Acute phase interventions Emphasis on timely intervention for first-episode psychosis Psychological support and basic psychoeducation are critical Pharamacological approaches (antipsychotic medication) at low doses to avoid side-effects, such as tardive dyskinesia Psychosocial approaches target social and occupational functioning

15. PSYCHOTIC DISORDERS Treatment Interventions to prevent relapse High rate of relapse (40 - 65% at 1 year post-hospitalisation) Effective relapse prevention program include both individual interventions and family approaches Interventions for enduring psychosis Alternative antipsychotic medications Adding psychosocial interventions to pharmacotherapy The Consumer Recovery Model Focuses on importance of civil rights and patient choice Principles of hope, personal responsibility, empowerment, community Significant gaps in delivery of mental health services for psychosis

16. SUMMARY Psychotic Disorders Positive and Negative Symptoms Diagnostic Criteria Historic and Current Conceptualisations Prevalence, Onset, and Course Aetiology Biological Psychosocial Triggering Factors Treatment Prodromal Phase Acute Phase Relapse Prevention Enduring Psychosis Consumer Recovery Model