Psychosis Lecture Notes PDF

Schizophrenia Spectrum and Other Psychotic Disorders Prof Lisa Phillips Outline of lecture • Introduce the different psychotic disorders described in DSM5; • Discuss the various changes in conceptualisations about psychosis over time; • Introduce some of the ongoing controversies and critical di...

Schizophrenia Spectrum and Other Psychotic Disorders Prof Lisa Phillips Outline of lecture • Introduce the different psychotic disorders described in DSM5; • Discuss the various changes in conceptualisations about psychosis over time; • Introduce some of the ongoing controversies and critical discussions in the field. • BUST SOME MYTHS!!!! Psychosis • Can refer to: • a variety of disorder or syndromes, or • a range of symptoms. • At the disorder level it refers to a group of disorders distinguished from one another in terms of: • symptom configuration (e.g., delusional disorder versus schizophrenia), • duration (e.g., schizophrenia versus schizophreniform disorder). Psychotic symptoms •Abnormalities in one or more of the following domains: •delusions, •hallucinations, •disorganized thinking (speech), •grossly disorganized or abnormal motor behavior (including catatonia), •negative symptoms Delusions  Fixed beliefs that are not amenable to change in light of conflicting evidence. ◦ ◦ ◦ ◦ ◦ ◦ Persecutory delusions: i.e., belief that one is going to be harmed, harassed, and so forth by an individual, organization, or other group; Referential delusions: i.e., belief that certain gestures, comments, environmental cues, and so forth are directed at oneself; Grandiose delusions: i.e., when an individual believes that he or she has exceptional abilities, wealth, or fame; Erotomanic delusions: i.e., when an individual believes falsely that another person is in love with him or her; Nihilistic delusions involve the conviction that a major catastrophe will occur, Somatic delusions focus on preoccupations regarding health and organ function. Bizarre vs non-bizarre  Primary vs secondary  Hallucinations • Perception-like experiences that occur without an external stimulus; • Auditory most common, but may occur in any sensory modality; • Hallucinations may be a normal part of religious experience in certain cultural contexts. Disorganised Thinking/Speech • Also referred to as Formal Thought Disorder • Is typically inferred from the individual’s speech: •Clanging - speech pattern based on phonological association rather than semantic or syntactic. •Circumstantiality/Tangentiality – Speech including unnecessary or irrelevant detail. Goal is eventually reached. •Flight of ideas - Sequence of loosely associated concepts are articulated. Sometimes rapidly changing from topic to topic. •Derailment - speech train steers off-topic to unrelated things. •Incoherence - word salad. Incomprehensible speech. •Pressure of speech - excessive spontaneous speech production and rapid rate. Difficult to interrupt. Grossly disorganised or abnormal motor behaviour May manifest itself in a variety of ways, ranging from childlike “silliness” to unpredictable agitation. • Catatonia: a marked decrease in reactivity to the environment. • Negative symptoms  Diminished emotional expression: reductions in the expression of emotions in the face, eye contact, intonation of speech (prosody), and movements of the hand, head, and face that normally give an emotional emphasis to speech.  Avolition: a decrease in motivated self-initiated purposeful activities Alogia: manifested by diminished speech output Anhedonia: decreased ability to experience pleasure from positive stimuli or a degradation in the recollection of pleasure previously experienced    Asociality: the apparent lack of interest in social interactions and may be associated with avolition, but it can also be a manifestation of limited opportunities for social interactions. Experience of psychotic symptoms in the general population Psychotic sx (hallucinations and delusions) are present—at various degrees of severity • in about 5% of the general population who are not seeking help; • in about 25% of people with (nonpsychotic) common mental disorders, such as anxiety and depression; • in around 80% of patients with psychotic disorders Linscott & van Os, 2012 Experience of psychotic symptoms in the general population •Highest prevalence in children (17%); •Moderately high prevalence in adolescence (7%); Kelleher et al, 2012 •Lowest prevalence in later adulthood (⩾ 70 years) - 3% Yates et al., 2021 Prevalence of hallucinations with age From: Yates et al., 2021 • Acceptance that hearing voices (and related experiences) are valid human experiences. • Respect for each person’s framework of understanding and beliefs about their experiences. • Create safe spaces for people to go to and share experiences, and network for deeper connection • Belief in each person’s resilience and capacity to take control of their experiences and recover • Work collaboratively and inclusively with other services to develop knowledge and use holistic approaches to recovery. • Fostering and supporting self determination and self empowerment • Based on work by Romme and Escher, 1993, 1996 Hearing Voices Network http://www.inter voiceonline.org DSM5 Schizophrenia Spectrum and other Psychotic Disorders. Brief psychotic disorder A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3): 1. 2. 3. 4. B. C.  Delusions. Hallucinations. Disorganized speech (e.g., frequent derailment or incoherence). Grossly disorganized or catatonic behavior. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Specify if: ◦ ◦ ◦ With marked stressor(s) (brief reactive psychosis): If symptoms occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual’s culture. Without marked stressor(s): If symptoms do not occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual’s culture. With postpartum onset: If onset is during pregnancy or within 4 weeks postpartum. Delusional disorder A. The presence of one (or more) delusions with a duration of 1 month or longer. B. Criterion A for schizophrenia has never been met. C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd. D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder. Schizophreniform disorder A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): Delusions. Hallucinations. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or avolition). 1. 2. 3. B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional.” Schizophrenia A.Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or avolition). B.For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). C.Continuous signs of the disturbance persist for at least 6 months. D.The disturbance is not attributable to the physiological effects of a substance or another medical condition. Schizoaffective disorder A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness. C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness. D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Others in DSM5  Substance/medication induced psychotic disorder  Psychotic disorder due to another medical condition  Catatonia ◦ ◦ ◦ ◦ ◦ Catatonia Associated With Another Mental Disorder Catatonic Disorder Due to Another Medical Condition Unspecified Catatonia Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified Schizophrenia Spectrum and Other Psychotic Disorder Disorder Duration Criteria Symptom Criteria Schizoaffective 2+ wks of delusions/hallucinations with no mood disturbance 2+ of major sx Delusional 1 month Delusions with no positive sx Brief Psychotic 1 day – 1 month 1+ of major sx 2+ of major sx Subtypes of1-66 months Psychotic Disorders months 2+ of major sx Schizophrenia Schizophreniform Age of onset Source: Sham, MacLean, Kendler, 1994) Epidemiology  Lifetime prevalence of schizophrenia: 1-2%; delusional disorder 0.2%; schizoaffective disorder: ~0.3%  Cross-cultural, cross-country and intra country variation ◦ Higher prevalence amongst migrants, developing countries and 2-fold risk urban vs rural dwellers (McGrath, 2006)  Schizophrenia: 3:2 male :female ratio (McGrath, 2007)  Peak age of onset: late adolescence/early adulthood Associated features • Depression • Suicide (5-10% of people diagnosed with sz commit suicide: Palmer et al., 2005) • Anxiety • PTSD- trauma may be the experience of psychosis itself OR associated with treatment • Substance use problems • Poor quality of life in general- occupational, relationship, social and emotional functioning • Stigma Psychosis and violence • The risk of perpetrating violent outcomes is increased in individuals with schizophrenia spectrum disorders compared with community control individuals (Whiting et al., 2021),  Most individuals experiencing psychosis are not violent and do not display aggressive or dangerous behaviour;  The origins of violence/aggression AND psychosis are heterogenous- but factors that may increase risk of violence/aggressive behaviour by individuals with psychotic disorders include: Past history of violence*; Substance use *; Certain personality traits*; Paranoid beliefs; Social circumstances *; Being male*; Content of auditory hallucinations; Being young* *also increases chance of future violence in people without psychotic disorders Psychosis and violence  The risk of an individual with a psychotic disorder becoming a victims of violence in the community, is up to 14 times the rate of being victimized compared with being arrested as a perpetrator (Swanson et al., 2006); YET  The majority of studies focussing on violence and severe mental illness focus on perpetration of violence- not on people with SMI being victims (Choe et al., 2008); • Similarly, a study of the British news media found that stories of violence by people with schizophrenia outweighed news stories that were more sympathetic about the disorder by about 4 to 1. Historical conceptualisations of ‘schizophrenia’ Benedict Augustine Morel (1860) – ‘demence precoce’ • The first attempt at a rigorous description of what we now know as schizophrenia. • Based on observations of individuals displaying a set of symptoms and experiencing early onset and deteriorating course. Emil Kraepelin (1898) – ‘dementia praecox’ • A refined and more formal definition • Emphasised early onset and deteriorating course • Differentiated from manic-depressive psychosis and other psychotic illnesses based on clusters of symptoms, onset, course, and outcome. • Symptoms emphasised were hallucinations, delusions, negativism, attentional difficulties, stereotypies, and emotional dysfunction Historical conceptualisations of ‘schizophrenia’ Eugen Bleuler (1911)- ‘schizophrenia’ ◦ Conceptualised manic depression and schizophrenia lying on a continuum ◦ Not necessarily early onset and deteriorating course ◦ ‘Breaking of associative threads’ loosening of connections between thought structures seen as the core of the disorder ◦ Primary symptoms - Five ‘A’s’: Disturbances in thinking; Disturbances in affect; Ambivalence; Autism; Avolition Historical conceptualisations of ‘schizophrenia’ Kurt Schneider (1959) • first rank symptoms: ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Hearing one’s voice out loud; Hallucinatory voices talking about him or her; Hallucinations in the form of a running commentary; Somatic hallucinations produced by external agencies; Thought withdrawal; Thought insertion; Thought broadcasting; Delusional perception (ideas of reference); Made feelings, Made actions; Made impulses Historical conceptualisations of ‘schizophrenia’ • US-UK Cross-National Project (1972) and WHO Multi- Centre Collaborative Study (1974): • Varying rates of schizophrenia between countries due to lack lack of standardised criteria • Late 1970s: • development of the Feighner criteria and Research Diagnostic Criteria- precursors to the landmark and expansive DSM-III. Historical conceptualisations of ‘schizophrenia’ • 1980: DSM-III- diagnostic criteria for schizophrenia published • Narrow (neo-Kraepelinian) view • Exclusion and inclusion rules, and duration criteria. • Plus very importantly, must interfere with life domain functioning • Five subtypes: paranoid, disorganised (hebephrenia) catatonia, undifferentiated, and residual Current conceptualisations of schizophrenia and psychosis McGorry (late 1980s- present) • Over-focus on chronic samples who are only representative of very poor outcome patients and are contaminated by institutionalisation, medication side-effects, etc. • Need to prospectively study first-episode patients and prodromal patients • Diagnosis is not stable in first episode Richard Bentall (1990’s - present) • Need to study psychotic symptoms individually, not schizophrenia as a construct. From: Kahn et al., 2015 Psychosis and Genetics • Not a simple picture! • At least 100 genes involved (Schizophrenia Working Group of the Psychiatric Genomics Consortium, 2014published in Nature); • Epigenetic approach • Eg COMT gene and interaction with cannabis (Caspi et al., 2005) Biological Factors: Neurotransmitters • Dopamine hypothesis: excessive dopamine function in CNS (see figure) • Other neurotransmitters proposed to have role: norepinephrine, seratonin Biological factors: Brain structure • Enlarged ventricles (indicating potential loss of brain tissue); • Reduced grey and white matter in prefrontal cortex- - partic assoc with negative sx and poorer outcome; • Hippocampal volume in normal > UHR>FEP> chronic sz; Biological factors: Brain function Neurocognition in schizophrenia • Deficits in sustained auditory and visual attention; •Problematic initial processing of information into sensory memory. •Impaired detection of relevant stimuli that are embedded in irrelevant ‘noise’ • Problematic organisation of information in working memory. • Executive function • Language - thought disorders • Cognitive set changing (switching) • IQ deteriorated • Psychomotor speed 49 Social Cognition in schizophrenia • Emotion perception – the ability to comprehend emotional cues in a social context • Social perception – the ability to comprehend communicative cues in a social context – may not be emotional. 51 Psychological factors: Role of Family • Schizophrenogenic mother (Fromm- Reichmann, 1948): • cold, aloof, overprotective, domineering, strips child of self-esteem, stifles independence. Partic at risk if fathers passive; • DISCREDITED!!!!! (Hirsch & Leff, 1975); Psychological factors: social • Living in urban environment • Migration • Being socially excluded • Do some environments make you psychotic? Van Os – NEMESIS study- yes especially if you are a member of a minority group in high density living and more so if you use cannabis Psychological factors: social defeat hypothesis proposes that the negative experience of being excluded from the majority group increases the risk of psychosis by sensitizing the mesolimbic dopamine system and thereby to an increased risk of schizophrenia or psychosis (Selten and Cantor-Graae, 2005; Selten et al., 2016). • Supportive evidence: (i) the protective effect of high ethnic density, i.e. residence in a neighbourhood where the own ethnic group is well-represented (Schofield et al., 2017); (ii) experiments with rodents that demonstrate dopamine sensitization in defeated animals (Hammels et al., 2015); (iii) a positron emission tomography (PET) study showing increased dopamine synthesis and increased stress-induced dopamine release in the striatum of individuals (healthy volunteers, clinical high-risk subjects and schizophrenia patients) with a personal or parental history of migration (Egerton et al., 2017). (iv) the pattern of findings in Israel (i.e. a modest increase in risk among first generation non-black migrants and the absence of an increase in risk among second-generation migrants) may fit with this interpretation, because the migration of Jews to a Jewish state involves a change from social exclusion to inclusion. • Psychological factors: childhood trauma • A significant proportion of people with psychotic disorders report traumatic experiences in childhood, such as sexual and physical abuse; • Numerous population based studies suggest that childhood trauma is an important risk factor for psychosis- a history of abuse was related to psychotic symptoms and/or the diagnosis of a psychotic disorder either during adolescence or adulthood (eg Lataster et al., 2006; Spauwen et al., 2006; Kelleher et al., 2008; Arseneault et al., 2011; Janssen et al., 2004; Shevlin et al., 2007; Cutajar et al., 2010; Bebbington et al., 2004, 2011; Whitfield et al., 2005); • John Read, Richard Bentall, Tony Morrison- outspoken in criticising mainstream psychiatry/psychology for ignoring role of CSA Psychological factors: childhood trauma- potential psychological mechanisms • Cross-sectional studies have demonstrated that negative perceptions of the self, anxiety, and depression partially mediated associations between trauma and psychotic symptoms- suggesting strong relationships between negative personal evaluations and low self-esteem, negative affect, and the characteristics of positive symptoms. • Lardinois et al (2011) found a significant, interaction between daily life stress and childhood trauma on both negative affect, and intensity of symptoms in patients with psychosis, suggesting that, a history of childhood trauma is associated with increased sensitivity to stress. Psychological factors: childhood trauma- potential biological mechanisms • reduced cortical thickness and dysregulated cortisol following exposure to childhood trauma – may facilitate development of psychosis • gene-environment interactions are likely to play a roleAlemany et al (2011) found that the relationship between childhood abuse and psychosis was moderated by the BDNF-Va166Met polymorphism, with Met carriers reporting more positive psychotic-like experiences when exposed to childhood abuse than did individuals carrying the Val/Val genotype. Psychological factors: Stress • Stress-vulnerability model: • Coping Psychological factors: Cognitive • Eg Morrison, Bentall, Birchwood, Garety • Core of model- culturally unacceptable interpretations of ‘intrusions into awareness’; • Role of appraisal is central; • Culturally unacceptable interpretation results from faulty knowledge of self- leads to misattribution of thought to external source; Beliefs about yourself What happened? How I make sense of it Beliefs about yourself and others What do you do when this happens? Life experience How does it make you feel? Images of being thrown into a blue van and stabbed Seeing blue vans There is a conspiracy Other people want to harm me I am vulnerable Other people are dangerous Paranoia is useful- keep on your toes Hypervigilance Thought suppression Avoidance Checking Prison sentences Assaults Childhood abuse Fear Anger Paranoia Increased tension Increased arousal? Substance use and psychosis • Substance-induced psychosis • Short-term- during intoxication or withdrawal phase • i.e. amphetamines, cocaine, hallucinogens Cannabis and psychosis: Swedish conscript study • Andreasson et al. (1987) • Those who had used cannabis by 18 years were 2.4 times more likely to develop schizophrenia than those who had not; • Comparison with those who not used cannabis by 18 years: # times cannabis used 1-10 times Relative likelihood of developing sz 1.5 times more likely 10+ times 2.3 times more likely Swedish conscript study- followup • Zammit et al. (2002) • Reported on 27-year follow-up on the original cohort; • Relationship between cannabis use and schizophrenia persisted when controlling for other factors such as other drug use, psychiatric symptoms at baseline; • Estimated that the attributable risk of cannabis use to schizophrenia was 13% Other cohort studiesrelationship with cannabis • Christchurch Health and Development Study • Daily cannabis users had rates of psychotic symptoms that were between 1.6 and 1.8 times higher (depending on factors controlled for) • Netherlands Mental Health Survey and Incidence Study • 17 times more likely to report clinically significant psychotic symptoms • Epidemiological Catchment Area (ECA) Study • daily cannabis use can double the risk of experiencing symptoms of psychosis. Cohort studies in context Schoeler et al. 2016: cannabis use and risk of relapse • • • • • Prospective cohort study followed up for at least 2 years after the onset of psychosis 220 patients who presented to psychiatric services in South London, England with first-episode psychosis change in cannabis use status (eg, from user to nonuser) and change in pattern of continued cannabis use within the first 2 years after onset are risk factors for relapse. These associations were independent of the effects of other potential confounders that vary over time, such as medication adherence and other illicit drug use. the longer the period of continued [monthly] cannabis use after onset of psychosis, the more likely a patient is to experience a relapse Cannabis use status and pattern of continued cannabis use after onset of psychosis are predictive of subsequent relapse but not vice versa Quality of Life Optimal outcome Clinical Functional ILLNESS COURSE Chronic illness, clear deterioration 23% Single episode, good recovery 8% Multiple episodes, good recovery 21% Chronic illness, little recovery 20% (Adapted from Summary report of symposium "Schizophrenia and other Psychosis (http://www.science.org.au) Multiple episodes, partial recovery 28% Relapse rates • Up to 80% of First Episode Psychosis patients will experience a psychotic relapse within 5 years of remission from the initial episode (Wiersma et al., 1998; Robinson et al., 1999); • EPPIC 7 year follow-up study (FEP): • symptomatic remission 37-59% cohort; • social/vocational recovery 31%; • ~25% both social/vocational recovery and symptom remission • Henry et al., 2010 Risk factors for relapse • Yes: Substance use, medication non-adherence, carer critical comments, poor premorbid adjustment showed a consistently positive association with relapse. • No: DUI, DUP, positive, negative, affective symptoms, age of onset, insight, gender, marital status, education and employment • Alvarez-Jiminez et al. (2012) Expressed Emotion • Brown 1950’s and 60’s noticed many relapsing patients shared common family environments- conflict, criticism, hostile, over-involved • Developed Camberwell Family Interview to assess patterns of family interaction • Relapse at 9 months and 2 years associated with: High EE • More than 35 hours face-to-face contact with high EE family • Not taking neuroleptics • Copyright  2008 McGraw-Hill Australia Pty Ltd PPTs t/a Abnormal Psychology by Elizabeth Rieger Potential Impact of relapse/chronic illness • Unemployment • Housing difficulties • Poor physical health • Side-effects of anti-psychotic medication • Premature death (Hjorthoj et al., 2017) Psychosis and hospitalisation Psychosis and treatment • Pharmacological treatment- primary approach in acute phase of illness • Best practice: low-dose approach • ‘Atypical anti-psychotics’ fewer side effects than ‘typicals’ • Soteria model (Bola & Mosher, 2003) Highly supportive care, usually medication free, living in a community • Comparable results to treatment as usual • Psychological treatments and psychosis • CBT- addressing hallucinations, delusions, negative symptoms • Substance use • Family education • Psychoeducation of patient • Relapse prevention • Occupational and social functioning Ongoing issues • No biological markers or physiological tests to diagnose schizophrenia; • Aetiology continues to be uncertain; • Ongoing debate about whether schizophrenia is a valid diagnosis. • See entire issue of Schizophrenia Research (Vol 242, 2022) Prevention Culture Westerman (2021) • Descriptions of Aboriginal people experiencing “visits” from loved ones following their passing as a normal aspect of grieving. • Can be associated with ‘being sung’- non-physical retribution for wrongdoing (payback) involving conjuring (or calling/ ceremonial singing for) spirits to inhabit the person’s psyche and for bad mental, physical, or spiritual health to result. • Often associated with little distress or agitation- cf psychosis which is often accompanied by agitation and/or distress • Visits and ‘being sung’- a separation of “self” from the “entity” –“I am being sung by, or I am being visited by” cf “I am god, I am the devil” • The content of hallucinations in the context of visits or being sung are consistently of a cultural nature – visually it may be spirits being seen or when voices are heard these will be from “cultural beings” or take on a consistently cultural form. Stigma • Schizophrenia has a long history of neglect, demonisation and concealment; • Numerous studies have demonstrated that sz is less recognised by general public than other disorders such as depression; • Myths highlighted in lecture are damaging to individuals with sz because they maintain a culture and environment that heightens risk of prejudice and discrimination- thereby limiting opportunities for recovery and increasing stress;