Schizophrenia and Psychotic Disorders PDF

Master's Degree in Psychology, Neuroscience and Human Sciences APPLIED CLINICAL NEUROSCIENCE SCHIZOPHRENIA AND PSYCHOTIC DISORDERS Prof. Laura Fusar-Poli [email protected] CORE SYMPTOMS OF SCHIZOPHRENIA In 1908 Eugen Bleuler (1957 – 1939) coin...

Master's Degree in Psychology, Neuroscience and Human Sciences APPLIED CLINICAL NEUROSCIENCE SCHIZOPHRENIA AND PSYCHOTIC DISORDERS Prof. Laura Fusar-Poli [email protected] CORE SYMPTOMS OF SCHIZOPHRENIA In 1908 Eugen Bleuler (1957 – 1939) coined the term schizophrenia (Ancient Greek, schizo (‘split’) and phren (‘mind’) –previously dementia praecox: “Dementia Praecox or the Group of Schizophrenias”. In offering the name Schizophrenia in place of Dementia Praecox, Bleuler was arguing that the minds and psychic functions of these individuals were split in a substantial way—not only that their thinking and affect were segregated from each other. Although people often mistakenly think of schizophrenia as a ‘split personality’, Bleuler had intended the term to reflect the ‘loosening’ of thoughts and feelings which he had found to be a prominent feature of the illness. “I believe that the tearing apart (‘Zerreissung’) or splitting (‘Spaltung’) of the psychic functions is a prominent symptom of the whole group”. “I call dementia praecox ‘schizophrenia’ because (as I hope to demonstrate) the ‘splitting’ of the different psychic functions is one of its most important characteristics. CORE SYMPTOMS OF SCHIZOPHRENIA “Dementia Praecox or the Group of Schizophrenias”. fundamental (i.e., particularly characteristic of schizophrenia) vs accessory (shared with other disorders) primary (directly due to an assumed organic deficit) vs secondary (developing as a result of the primary disturbance—these included delusions and hallucinations) 4As (ALL FUNDAMENTAL SYMPTOMS) Associations (loosening of) –primary a disordered pattern of thought, inferring a cognitive deficit Affect (blunted) –secondary diminished emotional response to stimuli Autism –secondary a loss of awareness of external events, and a preoccupation with the self and one’s own thoughts Ambivalence –secondary an apparent inability to make decisions, again suggesting a deficit of the integration and processing of incident and retrieved information  FIRST RANK SYMPTOMS (SCHNEIDER, 1959) =Symptoms supposed to be specific to, and therefore pathognomic of, schizophrenia ECHO DE LA PENSÉE (=THE PATIENT’S THOUGHTS ARE HEARD AS AND, SHORTLY AFTER, THEY ARE FORMULATED) A 32-year-old housewife complained of a man’s voice, speaking in an intense whisper from a point about two feet above her head. The voice would repeat almost all the patient’s goal-directed thinking—even the most banal thoughts. The patient would think, ‘I must put the kettle on,’ and after a pause of not more than one second the voice would say, ‘I must put the kettle on.’ It would often say the opposite, ‘Don’t put the kettle on.’ THOUGHT INSERTION (=ALIEN THOUGHTS ARE INSERTED INTO THE PATIENT’S MIND BY AN EXTERNAL AGENCY) A 29-year-old housewife said, ‘I look out of the window and I think the garden looks nice and the grass looks cool, but the thoughts of Eamonn Andrews come into my mind. There are no other thoughts there, only his… He treats my mind like a screen and flashes his thoughts onto it like you flash a picture.’ THOUGHT BROADCASTING (=THE PATIENT’S THOUGHT ARE OVERHEARD BY, OR OTHERWISE ACCESSIBLE TO, OTHERS) A 21-year-old student said, ‘As I think, my thoughts leave my head on a type of mental ticker-tape. Everyone around has only to pass the tape through their mind and they know my thoughts.’ PASSIVITY OF AFFECT (=The patient’s affect is under the control of an external agency. ) A 23-year-old woman reported: ‘I cry, tears roll down my cheeks and I look unhappy, but inside I have a cold anger because they are using me in this way, and it is not me who is unhappy, but they are projecting unhappiness onto my brain. They project upon me laughter, for no reason, and you have no idea how terrible it is to laugh and look happy and know it is not you, but their emotions.’ PASSIVITY OF VOLITION (=The patient’s volition is under the control of an external agency. ) A 29-year-old shorthand typist described her actions as follows: ‘When I reach my hand for the comb it is my hand Passivity of impulse (=The patient’s impulses are under the control of an external agency). A 26-year-old engineer emptied the contents of a urine bottle over the ward dinner trolley. He said, ‘The sudden impulse came over me that I must do it. It was not my feeling, it came into me from the X-ray department, that was why I was sent there for implants yesterday. It was nothing to do with me, they wanted it done. So I picked up the bottle and poured it in. It seemed all I could do.’ Somatic passivity (=The patient’s bodily sensations are under the control of an external agency.) A 38-year-old man had jumped from a bedroom window, injuring his right knee which was very painful. He described his physical experience thus: ‘The sun-rays are directed by U.S. army satellite in an intense beam which I can feel entering the centre of my knee and then radiating outwards causing the pain.’ Delusional perception (=The patient attributes delusional significance to normal percepts). A young Irishman was at breakfast with two fellow-lodgers. He felt a sense of unease, that something frightening was going to happen. One of the lodgers pushed the salt cellar towards him (he appreciated at the time that this was an ordinary salt cellar and his friend’s intention was innocent). Almost before the salt cellar reached him he knew that he must return home ‘to greet the Pope, who is visiting Ireland to see his family and to reward them… because our Lord is going to be born again to one of the women… And because of this they [the women] are born different with their private parts back to front.’  SIMULATION OF SCHIZOPHRENIA https://www.youtube.com/watch?v=SN1GCoVzxGg SYMPTOMS OF SCHIZOPHRENIA OTHER SYMPTOMS Cognitive –dementia praecox (problems representing and maintaining goals, problems with attention, monitoring, prioritizing, memory, learning, verbal fluency, problem solving, emotion recognition) Affective symptoms Behavioural symptoms DSM-5 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 SCHIZOPHRENIA Schizophreniform disorder is similar but the duration is shorter (1 month up to 6 months) The functional impairment is usually more circumscribed than that seen with other psychotic disorders, although in some cases, the impairment may be substantial and include poor occupational functioning and social isolation. When poor psychosocial functioning is present, delusional beliefs themselves often play a significant role. A common characteristic of individuals with delusional disorder is the apparent normality of their behavior and appearance when their delusional ideas are not being discussed or acted on. DELUSIONAL THEMES MANIA DELUSIONAL THEMES MANIA DEPRESSION DEPRESSION DEPRESSION MANIA INTERVIEW https://www.youtube.com/watch?v=ZB28gfSmz1Y DIAGNOSTIC PROCESS DIFFERENTIAL DIAGNOSIS Psychiatric differential Drug-induced psychotic disorder (common), for example, amphetamines, cocaine, cannabis, alcohol, LSD, phencyclidine, glucocorticoids, L-dopa. Schizoaffective disorder. Depressive psychosis. Manic psychosis. Other psychotic disorder such as brief psychotic disorder, persistent delusional disorder, or induced delusional disorder. Puerperal psychosis. Personality disorder. DIFFERENTIAL DIAGNOSIS Organic differential Delirium. Dementia. Stroke. Temporal lobe epilepsy. Central nervous system infections such as AIDS, neurosyphilis, herpes encephalitis. Other neurological conditions such as head trauma, brain tumour, Huntington’s disease, Wilson’s disease. Endocrine disorders, especially Cushing’s syndrome. Metabolic disorders, especially vitamin B12 deficiency and porphyria. Autoimmune disorders, especially systemic lupus erythematosus (SLE). EPIDEMIOLOGY PEAK RISK 15-35 YEARS  EPIDEMIOLOGY Prevalence Figures for the lifetime prevalence of schizophrenia vary according to diagnostic criteria, but are usually quoted at around 1%. Point prevalence is about 0.4%. Sex ratio Unlike many other mental disorders such as depression and anxiety disorders, which are more common in women, schizophrenia affects men and women in more or less equal numbers. However, it tends to present earlier in men, and also to affect them more severely. Why this is so remains unclear. Age of onset Onset can be at any age, but the syndrome is rare in childhood and early adolescence and uncommon after the age of 45. Mean age of onset in males is about 28 years, and in females about 32 years. If symptoms first present in middle or old age, it is particularly important to exclude organic conditions that may masquerade as schizophrenia.  EPIDEMIOLOGY Geography Generally speaking, lifetime prevalence is similar across populations and stable over time, despite the reduced reproductive fitness of affected individuals. Prevalence and severity tend to be greater in urban areas, maybe because schizophrenia sufferers drift into urban areas as a consequence of their illness or its prodromal symptoms (the drift hypothesis), or else because the stress of urban living actually plays a part in the aetiology of the syndrome (the breeder hypothesis). Migration The prevalence of schizophrenia seems to be higher in immigrants, especially second-generation Afro-Caribbean immigrants to the UK (about a 10-fold increase). This may reflect such factors as poor integration, socioeconomic deprivation, or diagnostic bias among doctors. Seasonality of births The lifetime prevalence of schizophrenia is increased by about 5-10% if born from January to April in the northern hemisphere or July to September in the southern hemisphere. This may reflect a viral contribution to aetiology. Socioeconomic status As the socioeconomic backgrounds of the fathers of schizophrenia sufferers are normally distributed, observed socioeconomic differences most probably result from social drifting. For instance, schizophrenia sufferers are much more likely to be unemployed. GENETIC RISK FACTORS A concordance rate of about 50% in monozygotic twins suggests that genetic and environmental factors are more or less equally involved in the expression of the disorder. In adoption studies, biological offspring of schizophrenic parents adopted by non-schizophrenic parents maintain their increased risk, whereas biological offspring of non-schizophrenic parents adopted by schizophrenic parents do not suffer any increased risk. ENVIRONMENTAL RISK FACTORS Obstetric complications Immigration Childhood trauma (abuse, neglect) Winter birth – Jan to April (in Northern emisphere) Bullying Urbanicity Cannabis use Social defeat: the negative experience of being excluded from the majority group CLINICAL HIGH RISK STATES (CHR)  ATTENUATED PSYCHOTIC SYNDROME (CHAPTER III DSM-5) a. At least one of the following of symptoms is present in attenuated form, with relatively intact reality testing and is of sufficient severity or frequency to warrant clinical attention: Delusions Hallucinations Disorganized speech. b. Symptom(s) must have been present at least once per week in the last 1 month c. Symptom(s) must have begun or worsened in the past year d. Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical attention Symptom(s) is not better explained by another mental disorder, including: Depressive or bipolar disorder with psychotic features and is not attributable to physiological effects of a substance or another medical condition e. Criteria for any psychotic disorder have never been met. DURATION OF UNTREATED PSYCHOSIS (DUP) Duration of Untreated Psychosis (DUP) is defined as the time from manifestation of the first psychotic symptom to initiation of adequate antipsychotic drug treatment. DUP correlates with several outcomes at 6 and 12 months: total symptoms, depression/anxiety, negative symptoms, overall functioning, positive symptoms, and social functioning. Longer DUP predicts worse outcome at 6 months in terms of total symptoms, overall functioning, positive symptoms, and quality of life. Patients with a long DUP are significantly less likely to achieve remission. Reducing DUP through earlier detection and treatment improves outcome of psychosis and schizophrenia. It is thus essential to detect individuals with a first episode of psychosis early. EVEN WITH FIRST EPISODE SERVICES Long DUP, patients have typically been ill for 1 year (it is 2 years under standard psychiatric care) at first contact Social and occupational life has already deteriorated Patients are difficult to engage and lack insight May require hospital admission Severe symptoms Impaired cognitive function TREATMENT OF FIRST EPISODE PSYCHOSIS ANTIPSYCHOTICS SIDE EFFECTS ACUTE DYSTONIA: https://www.youtube.com/watch?v=2krwEbm5hBo RABBIT SYNDROME: https://www.youtube.com/watch?v=G0UORTWJsKo DEPOT PREPARATIONS = LONG-ACTING INJECTION ANTIPSYCHOTICS PROGNOSTIC FACTORS GOOD PROGNOSIS BAD PROGNOSIS RULE OF THIRDS:. According to this rule one third of patients will have just a single psychotic episode during their lifetime; another third will experience different psychotic episodes that will recede without causing much deterioration and they will preserve psychosocial functioning the final third will present psychotic symptoms continually, as well as suffering notable deterioration and functional incapacity.  THE DIFFICULTY WITH DIAGNOSING SCHIZOPHRENIA The majority of medical disorders are defined by their aetiology or pathology, and so are relatively easy to define and recognize. For instance, if someone is suspected of having malaria, a blood sample can be taken and examined under a microscope for malarial parasites; and if someone appears to have suffered a stroke, a brain scan can be taken to look for evidence of arterial obstruction. In contrast, mental disorders such as schizophrenia cannot (as yet?) be defined according to their aetiology or pathology, but only according to their manifestations or symptoms. This means that they are more difficult to describe and diagnose, and more open to misunderstanding and misuse. If a person is suspected of having schizophrenia, there are no laboratory or physical tests that can objectively confirm the diagnosis. Instead, the psychiatrist is left to base his diagnosis on nothing but the person’s symptoms, without the support of any tests. If the symptoms tally with the diagnostic criteria for schizophrenia, the psychiatrist is justified in making a diagnosis of schizophrenia. The problem here is one of circularity: the concept of schizophrenia is defined according to the symptoms of schizophrenia, which in turn are defined according to the concept of schizophrenia. Thus, it is impossible to be sure that ‘schizophrenia’ maps into any real or distinct disease entity. Given the ‘menu of symptoms’ approach to diagnosis, it is even possible for two people with no symptoms in common to receive the same label of schizophrenia. Perhaps for this reason, a diagnosis of schizophrenia is a poor predictor of either the severity of the condition or its likely outcome or prognosis. What’s more, psychotic symptoms may form an inadequate basis for diagnosing schizophrenia. Delusions and hallucinations occur in a number of different disorders and states, and therefore represent relatively non-specific indicators of mental disorder. Most of the disability associated with schizophrenia is related to chronic cognitive and negative symptoms, not acute, albeit more florid, positive symptoms. Diagnosing schizophrenia on the basis of psychosis may be akin to diagnosing pneumonia on the basis of nothing more than a fever. Both clinical practice and research into the causes of mental disorders suggest that many of the concepts delineated in classifications of mental disorders, including schizophrenia, depression, and bipolar disorder, do not in fact map onto any real or distinct entities, as Kraepelin led us to believe, but instead lie at different extremes of a single spectrum of mental disorders or states. Even assuming that the concept of schizophrenia is valid, the symptoms and clinical manifestations that define it are open to interpretation. Recent studies have found that, in reaching a diagnosis of schizophrenia, the rate of agreement between any two independent assessors, that is, the inter-rater reliability, is 65 per cent at most. So the concept of schizophrenia is lacking not only in validity, but also in reliability. That this is so is a consequence of the empirical challenges of investigating the brain, but also, and above all, of the conceptual challenges of understanding the structure and content of human experience. TOOLS PANSS (psychosis, clinician-rated) CAPE (psychotic-like experiences, self-rated) SIS-R (schizotypy, clinician-rated) CAARMS (clinical high-risk states, clinician-rated) SIPS (clinical high-risk states, clinician-rated)