Psychotic Disorders

Psychotic Disorders

Psychosis - • presence of delusions and prominent hallucinations • without insight • positive symptoms (delusions, hallucinations, • disorganized speech and behavior) • mental impairment that “grossly interferes with the • capacity to meet ordinary demands of life” • DSM II • gross impairment of reality testing

Psychotic Disorders Delusional Disorder Brief Psychotic Disorder Shared Psychotic Disorder Schizophrenia Schizophreniform Disorder Schizoaffective Disorder

Schizophrenia

Background of Schizophrenia • 'dementia praecox' first described by Emil Kraepelin (1896) He distinguished it from manic depression He designated subtypes He believed SCZ was an early-onset neuro-degenerative disease • schizophrenia named by Eugene Bleuler (1908) He did not believe SCZ was a degenerative disease “breaking of associative threads”

Schizophrenia • Schizophrenia is a psychotic disorder involving disturbance • of thought, emotion, perception, attention, and behavior • The lifetime prevalence of schizophrenia is about 1% • Substance abuse is a co-morbid condition in 50% of • schizophrenia patients • Rate of suicide is high (~ 15%)

Schizophrenia is the most dreaded diagnosis of all mental disorders Course • Appears to be a developmental disorder that is present at birth • but does not become active until adolescence or later • age of onset for men = early 20’s, women = late 20’s • usually 5-10 years of deterioration, then stable • may be improvement after 6th decade • long-term follow-up studies show outcome may be better than • previously thought • Vermont Longitudinal Study: after 32 years, 62% recovered • or showed only mild impairment

Diagnostic Criteria for Schizophrenia A) Active-phase symptoms Must have two (or more) of the following for a significant portion of one-month period: • delusions • hallucinations • disorganized speech • grossly disorganized or catatonic behavior • negative symptoms positive symptoms B) Impairment Work, interpersonal relations, or self-care must be markedly below normal functioning level during achieved prior to onset C) Duration Signs of disturbance persist for at least 6 months (includes prodromal phase, negative symptoms, positive symptoms in attenuated form

Delusions Definition: a false belief based on incorrect inference about external reality, firmly held in spite of evidence to the contrary Bizarre vs Nonbizarre Bizarre - clearly implausible, not understandable, and not derived from ordinary life experiences Nonbizarre - involve situations that occur in real life

Delusions Definition: a false belief based on incorrect inference about external reality, firmly held in spite of evidence to the contrary Bizarre vs Nonbizarre Bizarre - clearly implausible, not understandable, and not derived from ordinary life experiences Nonbizarre - involve situations that occur in real life Dimensions of Delusional Belief (Chadwick & Lowe, 1990) • conviction • perspective (insight) • preoccupation • anxiety

Types of Delusions • thought insertion/thought extraction • delusions of control • delusions of reference • delusional misidentification syndromes • delusions of persecution • grandiose delusions • erotomania • delusions of jealousy • somatic delusions

Hallucinations Definition: a sensory perception that has the compelling sense of reality without external stimulation of the relevant sensory organ The individual may or may not realize that the percept is hallucinatory in nature.

Hallucinations Auditory • most common type in schizophrenia • may involve two or more voices arguing • running commentary of one’s actions and thoughts • constant criticism • most dangerous: gives instructions that must be obeyed Visual • often involve distortions of body or environment rather than • appearance of things that are not there Tactile • may accompany somatic delusions • example: insects crawling under skin Olfactory • most common: one is emitting a foul odor

Hallucinations Not Tied to Psychotic Disorders 25% of healthy population reports at least one 30 – 70% of college students report at least one (Stip & Letourneau, 2009) • conviction • perspective (insight) • preoccupation • anxiety

Disorganized Speech Formal Thought Disorder (Andreasen, 1979) • Poverty of speech • Poverty of content of speech (alogia, poverty of thought) • Pressure of speech • Distractible speech • Derailment (loose associations, flight of ideas) • Incoherence (word salad) • Clanging • Neologisms (making up new words) • Perseveration

Disorganized Behavior • childlike silliness • difficulties performing daily activities (meals, hygiene) • bizarre dressing • inappropriate or unpredictable actions • inappropriate sexual behavior (e.g. public masturbation) • public voiding • unpredictable or untriggered agitation (shouting/swearing) • inappropriate affect (laughing, crying)

Negative Symptoms Avolition - Inability to initiate or persist in goal-directed activities Alogia - • Refers to a reduction in the amount or content of speech Flat Affect - Emotions appear to be absent Anhedonia - Inability to experience pleasure Asociality (social isolation) Refers to a severe impairment in social relationships

Subtypes of Schizophrenia • paranoid type • disorganized type • catatonic type • undifferentiated type

Paranoid Type • delusions and hallucination is prominent feature • least severe disturbance of the subtypes • later age of onset • better prognosis • delusions are usually organized around a coherent theme • hallucinations related to content of delusional theme • delusions may predispose to suicide; • when combined with anger may predispose to violence

Disorganized Type (hebrephrenic) • disorganized behavior, disorganized thought, • flat or inappropriate affect • fragmentary delusions not organized around a theme • earlier age of onset • more continuous course (without significant remissions) • poorer premorbid functioning • difficulty or inability to care for self

Catatonic Behavior Posturing - individual assumes a posture as if “frozen” Waxy flexibility - limbs may be moved and posed by another Negativism - physical resistance to being moved and resistance to all instructions Echolalia - parroting the words of another Echopraxia - mimicking the gestures of another

Catatonic Type Clinical picture is dominated by at least two: motoric immobility, excessive purposeless motor activity, extreme negativism, posturing, waxy flexibility, echolalia, echopraxia • rarely diagnosed today • may be misdiagnosed encephalitis lethargica (sleeping sickness) • potential risk for malnutrition, exhaustion, self-inflicted injury • during periods of excessive motor activity, individual may need • constant supervision to avoid injuring self or others Undifferentiated Type • patient meets criteria for diagnosis of schizophrenia but does • not meet criteria for paranoid, catatonic, or disorganized type

Gender Differences • Females • later age of onset • more positive symptoms • more paranoid subtype • better response to drugs • better outcome • Males • earlier onset • poorer premorbid adjustment • lower educational achievement • more negative symptoms • more cognitive impairment • worse outcome

Etiology - Diathesis 1. Genetic Predisposition • Family studies • Twin studies • Adoption studies • High Risk studies • Molecular genetics

The Role of Genetics in Schizophrenia { { { {

Molecular Genetics schizophrenia is polygenetic COMT = catechol-O-methyltransferase DISC1 = disrupted in schizophrenia 1 NRG1 = neuroregulin 1 DTNBP1 = dysbindin 5HT2A = serotonin transporter gene

Other Possible Diatheses (sporadic schizophrenia) • 2. Obstetric Complications 3. Flu Hypothesis 4. Winter Birth Hypothesis More brain abnormalities (increased ventricles, reduced gray matter) in sporadic than in family diathesis. (Cannon et al., 1993)

Cannabis and schizophrenia. A longitudinal study of Swedish conscripts, Lancet, 1987)

toxoplasmosis virus Brown et al (2005) Am J Psychiatry (162) 2.62 greater risk

Etiology - Stress People at risk for SCZ appear to be more vulnerable to stress • recent stressful event • stressful family environment • accumulation of stressful life events

Protective Factors • family history of mood disorder • rather than schizophrenia • good premorbid adjustment • acute onset • higher IQ • late age of onset • precipitating events • absence of brain abnormalities • married • paranoid subtype • predominantly positive symptoms • minimal comorbidity

Risk Factors for Relapse • substance abuse • urban setting • lower IQ • industrialized nation • low SES • high family Expressed Emotion*

Psychodynamic Theory of Schizophrenia Schizophrenogenic Mother: Cold, dominant, rejecting mother caused SCZ (Fromm-Reichmann, 1948) The “Double Bind” Mother sends “mixed messages” to child (e.g., tells child she loves him while pushing him away) (Bateson, 1959) This theory has been discredited

Expressed Emotion (EE) Certain negative attitudes expressed toward the mentally ill person by family members with whom the ill person lives Criticism (disapproval) Hostility (animosity) Emotional overinvolvement (intrusiveness) Patients living with families high in EE were 3.7 times more likely to relapse than patients with low EE families (Kavanagh, 1992)

Question of the Week: The issue of individual civil rights for the seriously mentally ill is a major controversy today. Do you feel that schizophrenic patients should ever be institutionalized against their will? If you answer yes, under what conditions should the decision be made and who should have the authority to make this decision? Recommended Movie of the Week: A Beautiful Mind starring Russell Crowe (note that in real life John Nash’s hallucinations were auditory - not visual as portrayed in the movie. This change was probably made for cinematic purposes.)

Psychotic Disorders