Psychosis and Schizophrenia PDF

Psychosis and Schizophrenia Gina Collins and David Hunt  Media Labels – diagnoses and risk Main features of Psychosis/Schizophrenia Risk and Protective factors: Biological Overview Psychological Social...

Psychosis and Schizophrenia Gina Collins and David Hunt  Media Labels – diagnoses and risk Main features of Psychosis/Schizophrenia Risk and Protective factors: Biological Overview Psychological Social Treatments Services Biological Behavioural – CBT The “continuum of experience”  Media Portrayal Psychosis/ psychotic = anti-social Schizophrenia = Split Psychosis = loss of Personality “shared” sense of reality Schizophrenia = split Both wrong, misleading, mind, real & imagined< judgemental, unhelpful, associated with damaging additional symptoms… Misunderstanding leads to stigma, social isolation  Risk and Schizophrenia Shaw et al., 2020 found of all homicide convictions in England and Wales over an 18-month period 8 % had contact with mental health services in the year before Of these, less than 25% had diagnosis of schizophrenia – most common diagnoses » personality disorder » drug or alcohol misuse – People with schizophrenia “no more prone to criminal violence than the general public” – Whereas 10% of people with schizophrenia commit suicide  Recent events Known to mental health services – sections on several occasions. Low adherence to medication. History of criminal damage but deemed a low risk. Manslaughter conviction (diminished responsibility). Where does the responsibility lie?  Positive portayals Simplified portrayal of symptoms associated with schizophrenia. Implicit suggestion that agency and willpower alone can overcome the disorder – drawing attention to attribution. DSM V: Schizophrenia Characteristic symptoms involve a wide range of cognitive, behavioral and emotional dysfunctions. Constellation of signs and symptoms associated with impaired occupational or social functioning. Schizophrenia is a heterogeneous clinical syndrome. A. Two (or more), each present for significant period of time during 1-month period (at least one must be 1, 2, or 3) 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behaviour 5. Negative symptoms B. Markedly lower level of functioning in one or more major areas, e.g., work, relationships, self-care C. Continuous for at least six months; may include prodromal or residual symptoms D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out E. Not attributable to effects of substance or another medical condition. F. If history of ASD/communication disorder of childhood onset, diagnoses requires prominent delusions or hallucinations  Psychosis (Symptom) – Loss of awareness of socially perceived (shared) reality – Due to (Causes): Schizophrenia Drug misuse Severe depression Bipolar Neurological injury Post-partum psychosis Main features of Schizophrenia (Chronic mental disorder) Psychosis/ – Delusional beliefs A belief that can be seen as a misinterpretation of Schizophrenia reality Persecutory/grandeur/reference/misidentification/ paranoia – Hallucinations Can be any modality Auditory can be most common, including simple sounds, voices directed at the individual or commentary about others Hallucinations may be quite frightening – Withdrawal states Avolition - loss of energy and absence of interest in routine activities  Diagnoses of Schizophrenia/Psychosis: Symptom groups Psychiatric diagnoses distinguish between forms in which symptoms are generally more “Positive” or “Negative” – Positive - “excess cognition” Hearing voices Delusions Disorganised speech – Negative - “deficits in behaviour” Avolition - loss of motivation Alogia - poverty of speech Anhedonia – loss of pleasure Flat affect (outward expression but probably not actual experience)  Diagnoses of Schizophrenia: Common subtypes Prevalence: Schizophrenia affects approximately 24 million people or 1 in 300 people (0.32%) worldwide; or 1 in 222 people (0.45%) among adults (WHO, 2022) Paranoid Delusions prominent, especially persecutory, e.g., ideas of reference, that snippets of overheard conversation applies to them Hallucinations Catatonic Apathy, withdrawal states, leading into immobility but with islands of excitement & agitation. May later recall experience Hebephrenic (Disorganized) Content of speech disordered and bizarre associations Disorganized, not congruent with social cues ICD-10 Diagnostic criteria Picchioni & Murray 2007 (BMJ) BLURRING THE BOUNDARIES  Bereavement can often lead to sensory experiences. Vivid flashbacks can be similar to hallucinations. Stress and trauma can also produce similar effects: Belief systems – Emotional interpretation of ordinary events. situations These experiences are typically transient and not uncommon in the general population, though they may sometimes be mistaken for clinical symptoms. Frequency and duration plays a key part in diagnoses.  Everyday occurrences being misinterpreted (e.g., creaky pipes, ambiguous noises). Peripheral hallucinations, such as seeing fleeting shadows or figures out of the corner of the eye. Environmental cues These perceptual misinterpretations are common and tend to occur more frequently in ambiguous environments (e.g., dim lighting). Understanding the contextual information is really important.  Relatable feelings Feelings of being watched, followed, or targeted are fairly common. Key question: How far does this go beyond this feeling? For example: – I was walking in a quiet park, and I felt an unease that someone was walking in my direction. – I was walking in a quiet park, and I felt an unease that someone was walking in my direction. They were wearing the same type of jacket that the last five people have worn and had a similar hand gesture which I think might be code… Persecution can be common and valid. Key question: Has anyone else noticed that you are being singled out? These experiences may not reach the level of a delusion, but most certainly can cause a lot of distress. The role of religion What is a hallucination or delusion? – Being guided by a high power? – Deeply engrained in a belief system. Experiences such as feeling guided by a higher power, receiving messages from a divine source, or witnessing miraculous signs can be deeply personal and are often tied to religious or spiritual belief systems. Many religions accept what others might consider at psychotic-like symptoms. In certain contexts, such experiences are culturally or religiously accepted and are not seen as delusions, but they may be interpreted differently in clinical settings. – Various interactions with angels/god/spirits. – Stigmata – receiving the wounds of Christ. – Demonic possession and exorcism. – Incarnation of a deity (Hinduism). – Achieving nirvana through enlightenment (Buddhism). – Sacred visions in indigenous cultures. Culturally shaped boundaries – what is normal/abnormal). Cultural context plays a key role. What do you think are some of the questions we might ask to understand if a psychotic-like symptom might reach the diagnostic criteria of psychosis? Tip: Think about what questions you might ask to better understand that experience.  Biological factors (genetics/biochemistry/ neurology) Understanding Schizophrenia Psycho-social factors (social determinants/systemic factors, sources of stress)  Genetics Genetic Twin studies, Gottesmann & Shields (1972) Monozygotic twins 42%; Dizygotic 9% Negative symptoms more genetically linked than positive – Could it be explained by same social environment? – Still much variance due to other factors Adoptee studies, Heston (1966) Greater risk for schizophrenia in those with diagnosed schizophrenic birth mothers – even though raised in another family/environment Could it be that genetic risk is for a range of related disorders that share common neuro-chemical underpinnings? Picchioni & Murray 2007 (BMJ) A Twin Study of Genetic Relationships Between Psychotic Symptoms by Cardno, et al. (2002) Investigated twins – with one defined schizophrenic, schizoaffective, or manic syndromes for shared genetic risk factors. METHOD: Seventy-seven monozygotic and 89 same-sex dizygotic twin pairs RESULTS: significant genetic correlations between all three syndromes. There was evidence of both common and syndrome-specific genetic contributions CONCLUSIONS: If diagnostic hierarchies are relaxed, there is a degree of overlap in the genes contributing to RDC (RESEARCH DIAGNOSTIC CRITERIA) schizophrenic, schizoaffective, and manic syndromes. Biological - Dopamine Biochemical – Symptoms may be triggered by chemical “imbalances” – POSSIBLY DUE TO GENETIC RISK /INJURY / /DRUGS…OR COMBINATION e.g. Parkinson’s - problem of control/initiation – related to area in brain with low levels of dopamine activity – side effects of dopamine treatment can be development of hallucinations Schizophrenia excess dopamine activity Symptoms lessen in response to psychotropic meds  Biological Studies show people can be more likely to experience schizophrenia if their brain development was disrupted during pregnancy or early childhood Ursini et al (2018) demonstrated that the risk for schizophrenia explained by polygenic risk scores was 5 times greater in those who had experienced perinatal complications, indicating an interaction between genetic and obstetric risk factors. Furthermore, in those who did not experience any obstetric complications, the risk score did not differentiate patients and control participants. Drugs “Estimates of the proportion of cases of first onset of psychosis which could be prevented if no one smoked cannabis have ranged from 8% to 24% in different countries.” Murray et al, 2017 McCutcheon, Marques & Howes, 2020  Psychological Stress Social factors Likelihood of schizophrenia highest in low socio- economic group – poor housing, low income, overcrowding or homelessness – environmental hazards, e.g. noise pollution – stresses, uncertainty – lack of opportunities Nb: stress more common when person has less control over decisions/processes governing their life Stressful life events – Bereavement – Job loss – Ending a relationship or divorce – significant transitions Education, work etc. to provide for buffers for stress  Psychological Stress Family Environment and Onset: Not a sufficient condition for onset of psychosis. May act as a trigger for relapse. Expressed Emotion (EE): "Expressed emotion is largely reactive to deterioration manifested by the young person developing a psychotic disorder, rather than a trait of family members." (McFarlane & Cook, 2007) Family expressed emotion often increases prior to the onset of psychosis. Studies on EE and schizophrenia maintenance: Example: Making critical comments (e.g., "See, she’s always like that"). 10% of individuals in low EE environments relapsed. Social Stress: Racism Review by Institute of Psychiatry, London (British Neuropsychiatry Conference 1999) Rate of 5% for young black men in South London analyses of biochemical markers/gene studies/use of drugs – not elevated risk – so WHAT gives increased risk? invited reviewer from US confirmed diagnoses, I.e. not false-positives, and confirmed factor…racism in society Picchioni & Murray 2007 (BMJ) Neurodevelopmental considerations (Murray et al., 2017) Neurodevelopmental and adverse social/drug risk factors interact during development. Subtle neural abnormalities lead to cognitive and social deficits, contributing to isolation and later negative symptoms. Deviance increases, leading to drug abuse or life events causing dysregulated dopamine release and aberrant salience. Social adversity biases cognitive interpretations, creating a cycle of stress, dopamine dysregulation, and psychotic interpretation.  Genetic risk, probably normally distributed… – but see POLY GENETIC RISK …..(PRECISON MEDICINE??) Risk from viral infection, e.g. in-utero…MAYBE Risk from