Understanding Schizophrenia and Psychosis

Psychosis and Schizophrenia

• Psychosis involves a loss of awareness of shared reality, caused by various factors like drug misuse, severe depression or neurological injury.
• Schizophrenia is a chronic mental disorder characterized by delusional beliefs and hallucinations.

Media Portrayal

• Media portrayals of psychosis/psychosis are often negative, harmful, and misleading, wrongly associating them with antisocial behaviour and splitting personality.
• Such portrayals, which are judgemental, unhelpful and damaging, contribute to stigma and social isolation.
• Media often simplifies symptoms of schizophrenia, suggesting that willpower and agency can overcome the condition leading to a focus on personal attribution.

Risk and Schizophrenia

• Shaw et al. (2020) found that 8% of homicides in England and Wales involved individuals with contact with mental health services in the past year, with less than 25% having a diagnosis of schizophrenia.
• Most common diagnoses among this group were personality disorders, or drug and alcohol misuse.
• Individuals with schizophrenia are not inherently more prone to criminal violence than the general public, yet 10% commit suicide.

Recent Events

• Individuals with diagnosed mental health conditions may not adhere to medication regularly.
• Criminal damage history, previously not viewed as an indicator for high risk in criminal charges, needs further consideration where mental health is in question.
• Responsibility in relation to the actions of an individual with a mental health condition needs careful, thoughtful consideration.

DSM V: Schizophrenia

• Defining characteristic symptoms of schizophrenia involve cognitive, behavioral and emotional dysfunction.
• The clinical syndrome is heterogeneous.
• Diagnostic criteria include delusions, hallucinations, disorganized speech/behaviour, and negative symptoms for a sustained period.
• The disorder requires exclusion of other possibilities, to include substance abuse and physical conditions.

Main features of Psychosis/Schizophrenia

• Delusional beliefs are misinterpretations of reality.
• Hallucinations can be auditory, visual, or any sensory modality.
• Avolition (loss of motivation) is a negative symptom.
• Other negative symptoms include alogia (poverty of speech), anhedonia (loss of pleasure), and flat affect.

Diagnoses of Schizophrenia/Psychosis: Symptom Groups

• Psychiatric diagnoses differentiate positive from negative symptoms, using an excess cognition vs. deficit in behaviour classification.
• Positive symptoms include delusions, hallucinations, and disorganized speech.
• Negative symptoms include avolition, alogia, anhedonia, and flat affect.

Diagnoses of Schizophrenia: Common Subtypes

• Schizophrenia prevalence: 1 in 300 worldwide or 1 in 222 adults (WHO, 2022)
• Paranoid subtype: Delusions and hallucinations, frequently persecutory in nature.
• Catatonic subtype: Characterized by apathy, withdrawal, and immobility.
• Disorganized subtype: Disorganized speech and behaviour.

ICD-10 Diagnostic Criteria

• ICD-10 criteria for schizophrenia include thought echo, insertion or withdrawal of thoughts, delusions of control, delusional perceptions, hallucinations (voices commenting, hallucinatory perception from inside the body), and persistent bizarre or inappropriate delusions.
• Other criteria include incoherent speech, catatonic behaviour and negative symptoms.

Emotional Situations

• Bereavement and stress/trauma can frequently lead to sensory or perceptual experiences which could be erroneously identified as hallucinations or delusions.
• These experiences are transient and common in the general population. Frequency and duration play a critical role in diagnosis.

Environmental Cues

• Environmental factors also affect risk in psychosis, with ambiguities and misinterpretations of sensory data.
• Instances of peripheral misinterpretations in ambiguous environments are more common, including dim lighting. Contextual information is vital for evaluation and interpretation.

Relatable Feelings

• Feelings of being watched, followed, or targeted are relatively common.
• Determining how common experiences interact with and lead to psychosis or possible delusion requires careful questioning to assess whether experiences are considered as common and valid, or if an individual feels singled out.

The Role of Religion

• Religious experiences and beliefs can sometimes be misunderstood as psychosis—or can be considered potentially at risk of misinterpretation in clinical settings.
• Factors that sometimes lead to this include guidance from a high power, engrained belief systems, and experiences interpreted as messages from a higher power, receiving divine messages, or experiencing miraculous acts.
• Diverse interpretations involving religious figures, stigmata, demonic possession, incarnation of deities and sacred visions may be culturally acceptable experiences, but need awareness of context for clinical diagnosis.

Understanding Schizophrenia

• Biological factors include genetics and neurology.
• Psycho-social factors include social determinants and stress.

Genetics of Schizophrenia

• Twin studies suggest a genetic component to schizophrenia risk.
• Monozygotic twins have a higher concordance rate (42%) than dizygotic twins (9%).
• Environmental influences also play a significant role, and may interact with genes that are implicated in the condition in causing the condition.

What Causes Schizophrenia?

• Schizophrenia is a multifactorial disorder, and genetic predisposition, along with environmental factors is implicated.
• Lifetime risk for the general population is below 1%, but reaches above 40% in monozygotic twins of affected individuals.
• Family and twin studies show that risk of diagnosis is higher for relatives of diagnosed individuals, but various genetic risk factors may be interacting with a complex interplay of environmental factors.

Twin Studies (Cardno et al., 2002)

• This research studied twins to investigate shared genetic risks for psychotic symptoms.
• Findings indicated genetic correlations between schizophrenia, schizoaffective, and manic disorders.
• Suggests that genetic factors play a role in the occurrence of these conditions, but that other factors are also contributing to their development.

Biological - Dopamine

• Chemical imbalances, possibly including genetic risk/injury/drugs, may trigger psychosis, including Parkinson's which involves low levels of dopamine activity.
• Symptoms can be lessened by psychotropic meds due to excess activity.

Biological Factors and Schizophrenia

• Pre-natal or childhood brain development disruptions are associated with a higher risk of developing schizophrenia.
• Perinatal complications are shown to have a five-fold impact when examining genetic influences related to schizophrenia.

Drugs

• Estimates of preventing cases of first-onset psychosis if cannabis use were prevented range from 8% - 24% in different countries.

Psychological Stress

• Stressful life events, such as bereavement, job loss, and significant transitions, can trigger symptoms or contribute to the onset/relapse of psychosis.
• Family environment where expressed emotion scores are high increase risk of relapse.

Social Stress: Racism

• Societal stress, such as racism, creates a different risk than that of other environmental variables, potentially leading to an increased rate of psychosis, and requires further investigation to identify if other factors are at play that other factors may not be considered sufficiently in the case of racial bias.

Polygenic Risk Score (Agerbo et al., 2015)

• The study established a relation between various factors, including a polygenic risk score, parental socioeconomic status, family history of psychiatric disorders in the increased risk of developing schizophrenia.
• Implications include better predictions of risk and possibilities for improved prevention tactics

Neurodevelopmental Considerations

• Neurodevelopmental issues and adverse experiences during brain development can also be influential factors.
• Societal factors, like poor housing, and high rates of overcrowding, or exposure to high noise pollution, environmental unpredictability and lack of opportunity are linked to an increased risk of psychosis.
• Adverse experiences and drug use cause deviance in behaviour leading to isolation and potential for social adversity, further reinforcing a potential circle of negative experience.

Medical and Psychological Models

• Genetic influences are likely distributed, but may also be influenced by other factors such as viral infections or environmental issues.
• Social disadvantage, and particular familial or environmental experiences are commonly implicated.

Psychosis Interventions

• Interventions addressing psychosis symptoms might include family interventions, psychoeducation and CBT.
• Evidence suggests these interventions reduce relapse risk in diagnosed patients.

Psychiatric Services

• Traditional care approaches were frequently centered in institutions or based on pharmaceutical intervention alone, overlooking more holistic issues relevant to mental health care.
• An evaluation of traditional intervention approaches revealed that they were largely ineffective and damaging.
• Modern approaches include the development of psychosocial interventions that include family therapy, social support groups and individualised care approaches tailored to the needs of each individual patient.

Anti-psychotic Medication

• First-generation antipsychotics and second-generation antipsychotics include differing side-effects and clinical benefits.
• Considerations of side effects and appropriate dosage requires careful monitoring to maintain health balance, and avoid potentially serious side-effects that may be side effects of the treatment, though not necessarily a primary symptom of the diagnosis.

Chlorpromazine

• First antipsychotic medication involved sedative induced calmness as a primary feature.
• Subsequent considerations revealed potential side-effects, including sedation, weight gain, and movement disorders, that need careful management, and potential additional diagnosis in extreme cases.

Psychological Interventions

• Family interventions, psychoeducation, and CBT effectively reduce relapse risk in schizophrenia and should be considered a part of any intervention program.
• Development of comprehensive treatments requires further research efforts that also include group and multielement interventions to evaluate efficacy.

NICE Guidelines (2014)

• NICE guidelines provide a structured approach to early and long-term psychosis diagnoses, and suggest methods for intervention.

Changing Interactions

• Family members should attempt to have normal conversations, remain calm (avoid shouting, criticizing, etc.), avoid standing closely, and encourage open discussions with the individual.

Symptoms on a Continuum

• A continuum of experience for psychosis exists across a range of individuals, where symptoms vary between groups of patients.
• Some individuals have successfully managed symptoms resulting from voice-type hallucinations, and differences between groups, including different types of voice, and the amount of command-style voices, suggest the necessity for further research, and also highlight the need to develop supportive measures for families and individuals coping with specific elements of their diagnosis.

Cognitive Therapy

• Cognitive therapy emphasizes self-monitoring of medication use, recognizing symptoms' signs, and seeking support from professionals.
• An investigation into the content of the beliefs and origins of voices (including paranoia or particular religious interpretations), and adjusting or modifying the strength of fixed beliefs, are all crucial methods.
• Checking evidence and managing/answering voices is also an important part of this method.

Cognitive Therapy for Schizophrenia

• This research focused on the efficacy of cognitive therapy for people with schizophrenia who are not using antipsychotics.
• Results indicated that cognitive therapy reduced psychiatric symptoms.
• A larger-scale study to validate these findings is considered necessary.

Conclusions

• Schizophrenia has several contributing factors, and understanding the experience is key.
• Comprehensive and targeted support is needed.
• Further studies should evaluate efficacy and safety.