Lecture 7: Psychotic disorders

The term psychosis

This term was first used by Von Feuchtersleben in 1845. There are different terms throughout the paper written by Beck et al. which might be little bit confusing. These terms are psychosis, psychotic symptom, psychotic disorder, schizophrenia spectrum disorder, and schizophrenia. How are these related to each other? In this lecture the focus will be on psychotic symptoms and psychotic disorders.

The Continuum Model of Psychopathology describes how everyone experiences anxiety and depression from time to time and that this is normal. There is some arbitrary point where there is so much anxiety and/or depression which can be pathological. This is the same for psychotic symptoms. About 10-20% of people in the population hear voices from time to time. This is not necessarily a sign of psychopathology. These voices can say nice and reassuring things, which gets you in the ‘safe area’ of the CMP, but these voices can also say you have to do dangerous things. In psychotic disorders this model works a little bit differently. In psychotic disorders we see the whole collection of symptoms and there is not a continuum anymore.

Psychotic symptoms

Positive symptoms are when there is something extra. Examples of these are delusions, hallucinations, disorganised thought and speech, and disorganised or catatonic behaviour (muscle stiffness). Negative symptoms are when there is something missing or when something as extremely decreased.

Delusions are cognitive phenomena. These are not things we feel or perceive, it’s something we think. Delusions are not self-perceptions. Examples of delusions:

• Persecutory delusions: paranoia, usually paired with loneliness, feeling like someone is spying on them
• Delusion of reference: related to persecutory delusions, thinking that things are about them, thinking that people who are in a restaurant are laughing are laughing about you
• Grandiose delusion: thinking they are much more than they are, e.g. being convinced they are Superman or thinking they are appointed by God. It is usually to people who have lost everything, e.g. job, family, money
• Delusion of being controlled: feeling unfree to have their own actions, thoughts, and will
• Delusion of thought broadcasting: feeling like others can read or hear your thoughts
• Delusion of thought insertion: thinking that others are putting thoughts into their minds, e.g. thinking about having lunch with friends when suddenly a sexual or aggressive thought pops up in their mind, and they find that something that they would not think of
• Delusion of thought withdrawal: when it all goes blank, thinking someone else ‘stole’ their thoughts
• Delusion of guilt or sin: thinking they have sinned, feeling guilty about imagined things they’d done wrong
• Somatic delusions: can be difficult to establish, e.g. feeling like you have four arms

Primary delusions: when delusions just happen to be there and we don’t know where they come form

Secondary delusion: when there is a reason why someone has a specific delusion

Examples of bizarre delusions are when someone says they have a chip in their head and when this person would ask for brain surgery. A ‘normal’ or ‘reasonable’ delusion would be when someone thinks their neighbour is spying on them. The chances would be small, but it could be true.

When assessing delusions you have to remember to take into consideration the influence of religion, culture, and metaphysics. Some people may for example attribute the voice in their head to a holy spirit or God.

Hallucinations

Perceptual phenomena. People perceive things which are not there. The sensory modalities are auditory hallucinations, sensory hallucinations, tactile hallucinations, visual hallucinations, olfactory hallucinations (scent), and gustatory hallucinations (taste).

Examples of auditory hallucinations are nonverbal auditory hallucinations (hearing dogs barking), verbal auditory hallucinations (voices, either from inside your head or outside your head, these voices can be kind but they can also be mean and make you do dangerous things), musical hallucinations (often to females of older age having a hearing impairment or tinnitus).

Groups of visual hallucinations are simple ones (flashes of light), geometric ones (spiral forms, checkers boards), and complex ones (faces, landscapes, animals, people).

Olfactory hallucinations can be nice ones, e.g. smelling roses, but people can also smell garlic, feces, gasoline.

Gustatory hallucinations may experience strange tastes in their mouths. Tactile hallucinations examples are when someone feels like they’re being touched, e.g. feeling a hand on their shoulder. Somatic hallucinations are when someone feels like there is e.g. a snake inside their body.

Disorganised thought and speech

Illogicality: when you understand what a patient is saying but it doesn’t make any sense.

Derailment: you get a partial answer to your question, but the conversation suddenly goes into a total different direction.

Tangentiality: your question is heard and understood, but you don’t really get an answer, e.g. asking how many sibling one’s got, and they respond with ‘Oh, my siblings, they are the worst, they are like the police …’.

Incoherence: grammatical structure of sentences has disappeared.

Neologisms: newly made up words.

Clanging: repeating the sound of a word, e.g. rhyme words

Disorganised and catatonic behaviour

For a long time it was thought that catatonic behaviour was very rare, but in reality it is not. Some people are able to not rest their head on their pillow, having their chin on their chest. This is obviously damaging to your muscles and neck. Catatonic behaviour are characterised by bizarre posturing, mutism (not speaking), stupor, negativism (not wanting anything), waxy flexibility (maintaining a specific position, thinking that if they would change their position it would have bad consequences), catatonic excitement (e.g. lying on bed all day, then suddenly getting up and destroying the place), echolalia (repeating words or questions), echopraxia (repeating bodily movements).

Catatonic behaviour is usually treated with benzodiazepines.

Negative symptoms

• Restricted affect
• Anhedonia: not enjoying anything
• Avolition: there’s nothing they want
• Social withdrawal
• Social isolation

Psychotic disorders

• Brief psychotic disorder
• Schizophreniform disorder
• Schizophrenia
• Schizoaffective disorder
• Delusional disorder
• Schizotypal (personality) disorder
• Substance/medication-induced psychotic disorder
• Psychotic disorder due to another medical condition
• Catatonia

Time criterion is very important when diagnosing. If the symptoms last for less than one month and doesn’t use any medication or have any symptoms anymore after one month, you could speak of a Brief Psychotic Disorder. When it lasts from 1-6 months you could speak of a Schizophreniform Disorder. If it is over 6 months you could speak of Schizophrenia. 

• A Criteria for schizophrenia, two or more of the following (among which at least one of the first three):
  • Delusions
  • Hallucinations
  • Formal thought disorders
    
    • Catatonia
    • Negative symptoms
• B criterion for schizophrenia: social and/or occupational dysfunctioning
• C criterion for schizophrenia: duration of 6 months or more, with at least one month of active-phase symptoms
• D criterion: no mood disorder
• E criterion: not due to a somatic condition
• F criterion: cave autism spectrum disorder

Phases of schizophrenia spectrum disorder

1. Prodromal phase: a bit of strange behaviour, e.g. looking through phone books all day
2. Active phase: displaying psychotic symptoms
3. Residual phase: after treatment, symptoms could appear

What is schizophrenia and what are the risk factors?

According to Bleuler, who first introduced the term of schizophrenia, it was a split of the psychic functioning. Kraeplin used the term ‘dementia praecox’, for those who were hearing voices and all the other symptoms discussed above. He thought people could not recover. He thought schizophrenia was a sign of going down on the evolutionary ladder.

Different groups of those who suffer from psychotic episodes:

Group 1: one episode only, no impairment (22%)
Group 2: several episodes with no or minimal impairment (35%)
Group 3: impairment after the first episode with subsequent exacerbation and no return to normality (8%)
Group 4: impairment increasing with each of several episodes and no return to normality (35%)

The life expectancy in schizophrenia is about 20 years less than average. People with psychosis may try to commit suicide. However, it is ‘only’ 5%, but this is still 5 times higher than in the general population. Another reason for a lower life expectancy is a unhealthy lifestyle: staying in bed all day, drinking alcohol, eating junk food, and the use of medication.

Men start psychotic disorders at younger ages, and genetic play a big role in the development of psychotic disorders and symptoms. The chances of developing psychotic symptoms or a disorder in identical twins is 48%. Gene-environment interaction plays a big role.

Neurodevelopmental factors which add up to the chances of developing psychotic symptoms later on in life are intrauterine infections, malnutrition during pregnancy, birth complications, and drug toxicity during pregnancy.

Environmental risk factors for schizophrenia are trauma, urbanisation, migration, social defeat (when you cannot meet the expectations you had set for yourself), certain types of medication (e.g. Prozac), illicit substances (e.g. drugs).

Neurotransmitters like dopamine, serotonine, GABA and glutamate play a role too.

Treatment

• Antipsychotics
  • First generation: introduced during 1950s, has proven to be very successful, patients were able to go back home and function more or less independently. Side effects can be movement disorders,=
  • Second generation: hardly induce, they are less potent, induces metabolic syndrome (obese, insulin resistance, high blood pressure)
• Adjuvant medication
  
  • Antidepressants
  • Mood stabilisers
  • Anticholinergics: treating side effects of first generation antipsychotics
  • Benzodiazepines: reducing anxiety, helping people to rest better, however they are addictive
• Clozapine: there are rare, but dangerous side effects (e.g. reduction in white blood cells)
• Depot medication
• Electroconvulsive treatment
• Transcranial Magnetic Stimulation
• Cognitive-behavioural therapy
• Psychosocial interventions
  
  • Psychoeducation
  • Family therapy
  • Sheltered living
  • Supported employment
  • Assertive community treatment

What topics are discussed which aren't discussed in the literature?

Beck, Himelstein, & Grant (2019)
How the cognitive triad is supposedly the source of the content for the negative and positive symptoms. The negative triad is defined as the negative view of the self, others, and the future. The cognitive model furthers the understanding of the positive and negative symptoms of schizophrenia and the literature describes how it provides a framework for a psychotherapeutic intervention. 

How has this topic developed over the past few years?

The DSM has made some changes in the transition from DSM IV to DSM V. For example, the criteria for certain mood disorders have been adjusted, added or removed from the DSM V. Always consult the DSM V for the latest criteria. 

What comments are made with regard to the exam?

The exam for April 2020 has been cancelled.

What questions are being asked which could be asked on the exam? What is the answer? 

A patient with a history of schizophrenia is brought to the emergency department. The patient is agitated and demonstrates generalized muscle rigidity. Temperature, heart rate, and respiratory rate are elevated. These assessment findings are consistent with which of the following adverse effects of antipsychotic medications?
A. Tardive dyskinesia
B. Neuroleptic malignant syndrome
C. Parkinsonism 
D. Serotonin syndrome 

A patient diagnosed with schizophrenia states, "I am Buddha!". Which type of psychotic symptom is the patient demonstrating? 
A. Delusion of grandeur
B. Delusion of persecution 
C. Magical thinking 
D. Religiosity 

A patient is diagnosed with schizoid personality disorder. When interviewing the patient, the healthcare provider would most likely observe which of the following behaviors?
A. Disregard for violating the rights of others
B. Distrust or suspiciousness of others' motives
C. Detachment from social relationships
D. Excessive attention seeking 

B - A - C

NOTE: due to the COVID 19 virus lecture 7 and lecture 8 will not be part of the exam material. The literature linked to these lectures will still be discussed during the exam.