Psychology Chapter on Schizophrenia and Delusions

Schizophrenia and Psychotic Disorders

• Schizophrenia is a mental disorder characterized by "splitting" of psychic functions.
• Eugen Bleuler coined the term schizophrenia in 1911.
• Bleuler believed that a "loosening" of thoughts and feelings is a primary symptom.
• Core symptoms are divided into fundamental and accessory.
• Fundamental symptoms are specific to schizophrenia; accessory symptoms are shared with other disorders.
• Fundamental symptoms are also divided into primary and secondary.
• Primary symptoms arise from an organic deficit.
• Secondary symptoms develop from a primary disturbance.
• Primary symptoms include delusions and hallucinations.
• 4 key fundamental symptoms (4As) include: associations (loosening of thought), affect (blunted), autism (loss of awareness), and ambivalence (inability to make decisions).

Core Symptoms of Schizophrenia

• Schneider (1959) identified first-rank symptoms (symptoms specific to schizophrenia).
• These symptoms often involve auditory hallucinations.
• Delusions of control (e.g., thoughts are inserted into or removed from one's mind by an external agency).
• Delusions of passivity: affect, volition, and impulses (the belief that one's feelings, will, or impulses are controlled by external forces).

4As (All Fundamental Symptoms)

• Associations (loosening of thought): a disordered pattern.
• Affect (blunted): diminished emotional response to stimuli.
• Autism: a loss of awareness of external events, with preoccupation with self and one's own thoughts.
• Ambivalence: an inability to make decisions.

DSM-5 Categorization of Psychotic Disorders

• Schizophrenia
• Schizophreniform Disorder
• Schizoaffective Disorder
• Delusional Disorder
• Brief psychotic Disorder
• Substance/Medication-Induced Psychotic Disorder
• Psychotic Disorder Due to Another Medical Condition
• Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
• Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

Schizophreniform Disorder

• Similar to schizophrenia, but the duration is shorter (1 month to 6 months).

Schizoaffective Disorder

• Presence of a major mood episode (depressive or manic) concurrent with schizophrenia criteria.
• Distinguishing characteristic is that symptoms of delusions or hallucinations are present for at least 2 weeks without a major mood episode.

Brief Psychotic Disorder

• Symptoms present for at least one day but less than one month.
• Full return to premorbid functioning.

Delusional Disorder

• Presence of one or more delusions of a duration of one month or longer.
• Criterion A (for schizophrenia) is never met.

Delusional Themes

• Delusions of persecution
• Delusions of control
• Delusions of reference
• Delusions of misidentification
• Delusions of grandeur
• Religious delusions
• Nihilistic delusions
• Somatic delusions
• Delusions of jealousy
• Delusions of love

Epidemiology

• Lifetime prevalence varies depending on diagnostic criteria.
• Point prevalence is about 0.4%.
• Peak risk is 15-35 years.
• Prevalence similar across populations and relatively stable over time.
• Higher prevalence seen in immigrants.

Genetic Risk Factors

• Concordance rate in monozygotic twins is approximately 50%, indicating a strong genetic component.
• Genetic and environmental factors equally contribute to the expression of the disorder.

Environmental Risk Factors

• Obstetric complications
• Immigration
• Childhood trauma (abuse/neglect)
• Winter birth (January-April in Northern hemisphere)
• Urban living
• Bullying
• Cannabis use

Social Defeat

• Negative experience of being excluded from the majority group.

Clinical High-Risk States (CHR)

• States preceding psychosis.
• Includes basic symptoms (perceptual and cognitive): COPERS (cognitive-perceptual basic symptoms), and COGDIS (cognitive disturbances).
• UHR (ultra-high risk) criteria:
• Attenuated positive symptoms (APS)
• Brief limited intermittent psychotic symptoms (BLIPS).
• Genetic risk/functional decline (GRFD).

Attenuated Psychotic Syndrome (DSM-5)

• One or more psychotic symptoms present in an attenuated form.

Duration of Untreated Psychosis (DUP)

• Time from first psychotic symptom to adequate antipsychotic treatment initiation.
• Longer DUP correlates negatively with treatment outcomes leading to more severe illness.

Treatment of First Episode Psychosis

• Agreed choice of antipsychotic with patient/carer.
• Titrate to minimum effective dose and follow up.
• Reassess over 2-3 weeks and adjust to response/tolerability
• Effective = continue at the dose
• Not effective = change to another medication and repeat the titration process

Antipsychotic Side Effects

• Metabolic side effects
• Movement side effects (EPS)
• Cardiac side effects
• Anticholinergic side effects
• Prolactin-related sexual dysfunction
• Sedation

Depot preparations (long-acting injections)

• Pros: better bioavailability, less potential misuse, and ensures regular contact with healthcare.
• Cons: variable absorption, potential for adverse effects, and potential for poor compliance.

Prognostic Factors

• Good prognosis: acute onset, late onset, no precipitating factors, female sex, no family history.
• Bad prognosis: insidious onset, early onset, negative symptoms, negative symptoms, male sex, family history.

Difficulty with Diagnosing Schizophrenia

• Symptoms are not always objective (no physical test for diagnosis).
• Defining schizophrenia based on symptoms; symptoms vary amongst patients.
• The classification could not accurately reflect a true disease or distinct disease entity.

Tools

• PANSS (Positive And Negative Syndrome Scale): for psychosis, clinician-rated, used across cultures for consistency.
• CAPE: (Clinician-rated, self-rated): for psychotic-like experiences.
• SIS-R (Schizotypal Personality Questionnaire): for schizotypy, clinician-rated.
• CAARMS (Clinical High-Risk Assessment for Psychosis): clinician-rated; for (CHR) states;
• SIPS (Short Intermittent Psychotic Symptoms): for CHR states; clinician-rated.