NS Psychological Disorders IV_Sz_Bahrain SD 2023-24 (1).pptx

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Psychological Disorders IV: Schizophrenia Class MED3 Bahrain Course Health Psyc...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Psychological Disorders IV: Schizophrenia Class MED3 Bahrain Course Health Psychology Code HP Lecturer Dr. Sally Doherty Date November 2021 Learning Outcomes Define schizophrenia Outline the symptoms of schizophrenia Outline theories of the aetiology of schizophrenia Schizophrenia and Other Psychotic Disorders Class of disorders marked by delusions, hallucinations, disorganised thinking, disorganised motor behaviour and negative symptoms. Prevalence estimates suggest that schizophrenia occurs in about 0.7% of the population but there is variation by ethnicity, country etc.. Psychotic features typically emerge between late teens and mid- 30’s; onset before adolescence is rare. Peak onset for males is mid-20’s and for females is late-20’s. Huge societal cost due to extreme debilitating nature of the illness. Schizophrenia and Physical Health Life expectancy is reduced in individuals with schizophrenia because of associated medical conditions. Weight gain, diabetes , metabolic syndrome, cardiovascular and pulmonary disease are more common in schizophrenia than in the general population. Poor engagement in health maintenance behaviours (e.g. cancer screening, exercise) and medications, lifestyle, cigarette smoking and diet contribute to increased risk of chronic disease in schizophrenia patients. See link below for more on mental illness and physical health https://www.youtube.com/watch?v=yGZdrpquGo0&feature=youtu.be General Symptoms of Schizophrenia and Psychotic Disorders (1) Delusions and irrational thought Delusions = false beliefs maintained even though they are clearly out of touch with reality e.g. belief that you a tiger, that private thoughts are broadcast to others etc.. (2) Distorted perception Hallucinations are sensory perceptions that occur in the absence of a real, external stimulus or are gross distortions of perceptual input… hearing voices. (3) Disorganised thinking  General Symptoms of Schizophrenia and Psychotic Disorders (4) Disorganised or abnormal motor behavior Problems in goal-directed behaviour, leading to difficulties in performing activities of daily living. Catatonic behaviour is a decrease in reactivity to the environment - may Maintain a rigid or inappropriate posture or lack verbal or motor responses. Other features may include staring, grimacing and echoing of speech. (5) Negative Symptoms 2 types especially prominent in schizophrenia: Diminished emotional expression – reductions in expression of Positive vs. negative symptoms in Schizophrenia positive symptoms: behavioral excesses or peculiarities, such as hallucinations, delusions, bizarre behavior, and wild flights of ideas; negative symptoms: behavioral deficits, such as flattened emotions, social withdrawal, apathy, impaired attention, and poverty of speech.  Schizophrenia – DSM V criteria A) 2 or more of following for significant time during 1 month period (one must be (1), (2) or (3): 1. Delusions 2. Hallucinations 3. Disorganised speech 4. Grossly disorganised or catatonic behaviour 5. Negative symptoms B) Level of functioning is impaired since onset of symptoms C) Continuous signs of disturbance for at least 6 months Note: individuals with this disorder will vary substantially on most features as it is a heterogeneous clinical syndrome Cognitive impairment in schizophrenia Broad range cognitive deficits – e.g. attention, working memory and other executive functions, semantic memory, social cognition and language Like negative symptoms in schizophrenia, cognitive impairments are stable and independent of positive symptoms. Negative symptoms and cognitive deficits are important because they strongly determine functional outcome. Cognitive impairment in schizophrenia Cognitive impairment as an endophenotype - i.e. potential marker of genetic risk for schizophrenia Epigenetics – environmental induced changes in gene expression - stress-induced epigenetic changes in germline cells can be passed onto and alter cognition in offspring – i.e. environmental risks might be relevant even before conception Uncontrolled stress and HPA axis (hypothalamic-pituitary- adrenal) associated with both cognitive dysfunction and psychiatric illness  Cognition and its disruption in psychiatric disorders Source: Millan et al, (2012). Nature Review Drug Discovery 1;11(2):141-68 Cognition and its disruption in psychiatric disorders Social cognition in schizophrenia social cognition is the processes that are used to acquire and interpret information about others Social cognition deficits in schizophrenia: - social withdrawal exacerbates negative symptoms - false attribution of harmful intentions to others aggravates paranoia and delusions - plus hinders interpretation of verbal language Social cognition deficits predict onset of psychosis in individuals at high-risk of developing schizophrenia Cognition and its disruption schizophrenia Schizophrenia as a disconnection syndrome – dorsolateral prefrontal cortex (DLPFC) functions affected. But many cortical and subcortical regions also affected with complex pattern of hypo and hyper-activation Increased activation may be effort to compensate for insufficient performance. Bipolar disorder Similar to schizophrenia but less severe – BPD shares genetic risk factors with schizophrenia Response inhibition difficulties in particular Course of Schizophrenia Three broad groups: (1) Treated successfully (2) Partial recovery with relapses (3) Chronic illness – often long term hospitalisation required 5% patients die by suicide and 20% attempt suicide on one or more occasions. Increased mortality from other illnesses esp. cardiovascular Etiology of Schizophrenia Do not yet know causes of schizophrenia Not due to a single cause Neurodevelopmental hypothesis of schizophrenia: prevailing theory - schizophrenia as disorder of faulty brain development Risk Factors for Schizophrenia Family history of schizophrenia Social – urban birth - migrant status - low social class Pre/perinatal - obstetric complications - winter birth - maternal influenza - maternal malnutrition - rhesus incompatibility Postnatal - early childhood CNS infection - epilepsy - learning disability - delayed milestones - poor childhood peer relationships - early cannabis use - life events (precipitate onset)  Etiology of Schizophrenia Genetic Component Birth and other environmental factors  Geneti cs Heritability of schizophrenia estimated to be ~64% Abnormalities on several chromosomes e.g. 5, 8, 11, 13, 22 Genetic findings inconclusive; no single gene involved. Most individuals with schizophrenia have no family history of psychosis. Liability is conferred by a spectrum of risk alleles, common and rare, with each allele contributing only a small fraction to the total population variance. Risk alleles identified are also associated with other mental disorders incl. bipolar disorder, depression and autism spectrum Genetic factors in schizophrenia Birth and other environmental factors Season of birth effect - people with schizophrenia more likely to have been born in 1st three months of year; suggests birth/time in utero relevant to schizophrenia ~20% of people with schizophrenia have had some sort birth complication Includes prenatal exposure to influenza, maternal anaemia, malnutrition, preeclampsia, asphyxia and fetal distress. Evidence cannabis is likely to have causative role in some cases of schizophrenia Rates of schizophrenia higher in urban areas and among migrant groups. Brain abnormalities in schizophrenia Smaller cortex overall, less grey matter than white, enlarged ventricles, smaller thalamus, temporal lobes (esp. hippocampal regions) and prefrontal cortex Not effect of medication – similar (but milder) findings in unaffected fist degree relative of patients. Relatives in these studies do not have the illness but may have genes susceptible to schizophrenia Brain abnormalities in schizophrenia Brain Chemistry and Schizophrenia Dopamine – overactivity of dopamine neurotransmitter system strongly implicated in schizophrenia. Some evidence overactivity of dopamine in one region (e.g. temporal lobes) occurs in combination with underactivity of dopamine in another region (e.g. frontal lobes). Evidence anti-psychotics block dopamine receptors but how exactly they work not known. Other neurotransmitter systems implicated are: cholinergic, glutamatergic, noradrenergic and serotonin. Evidence for neurodevelopmental hypothesis of schizophrenia Post-mortem changes of mal-developed cells and brain structures Brain imaging findings at time of diagnosis Gene abnormalities – especially among those the code for brain development Obstetric complications Season of birth effect - well replicated finding that there is excess of births of people with schizophrenia in first 3 months of the year Prenatal infections, malnutrition and prenatal anaemia and prenatal vitamin D deficiency all associated with schizophrenia Presence of minor anomalies among people with schizophrenia that indicate brain maldevelopment. Neurodevelopmental theories of schizophrenia  Treatment Antipsychotics work best on positive symptoms but have little impact on negative or cognitive symptoms Problematic because negative and cognitive symptoms more disabling in the long-term (limit functional outcome and capacity to work) Anti-psychotics have significant side-effects, e.g. sedation, obesity Medication alone ineffective; patients need counselling, support, family involvement, care advice and job skills training Prognosis is favourable in 20% schizophrenia patients and a small number recover completely. Most patients will have  Psychological Treatments Cognitive Behavioural Therapy (CBT) has been modified with some success in treating schizophrenia patients Social Skills training is effective in boosting patients community engagement and reducing relapse. Family Therapy – strong evidence giving support and psychoeducation to family members can reduced relapse. Cognitive Remediation – some evidence cognition in schizophrenia patients can be enhanced through computerised training modules (generalisation to everyday life problematic) Reading van Os J, Kapur S(2009). Schizophrenia. Lancet 374: 635-45. Please see this link for a summary of schizophrenia in DSM V. https://www.psychiatry.org/patients-families/schizophrenia/what-is- schizophrenia See the following Ted talk by Elyn Saks https://www.youtube.com/watch?v=f6CILJA110Y