Definition of psychoses
The term ‘psychosis’ is an umbrella term meaning ‘out of touch with reality’.
Can refer to a variety of clusters of symptoms.
General symptoms that can be crossovers to other illnesses
–organic presentations like dementia.
–Substance use: amphetamine psychosis, and so on.
What does psychosis refer to a a disorder level?
- symptom configuration (e.g., delusional disorder versus schizophrenia).
–Delusional beliefs that are either Non-bizarre (plausible, e.g., “I am being poisoned,” “My partner is unfaithful”) or bizarre delusion (implausible and not derived from ordinary experiences; e.g., “aliens replaced my organs with plastic”).
- duration (e.g., schizophrenia versus schizophreniform disorder)
–< or > than 6 months
relative pervasiveness in terms of both duration and the clinical picture - of psychotic symptoms versus affective symptoms (e.g., bipolar disorder and schizoaffective disorder). Which is the core?
What does schizophrenia refer specifically to?
The term ‘schizophrenia’ refers to “split mindedness” or “a mind torn asunder” (Bleuler).
- Schizophrenia it is not multiple personalities (i.e. not Dissociative Identity Disorder).
Schizophrenia involves disruption in various aspects of perceiving, thinking, feeling and behaviour. Phenomena associated with schizophrenia can be classified into two major groups of symptoms – positive symptoms and negative symptoms
- Positive symptoms– additive to normal experience.
- Negative symptoms – deficit in normal function.
Positive pschosis symptoms
Hallucinations
- A perception in the absence of environmental stimuli.
- Hallucinations occur in any sensory modality, of which auditory is the most common then visual.
- For example, “I can hear a voice that is providing a running commentary of what I am doing in the third person. It just said, ‘he is watching the lecture’.”
Delusions
- A fixed and false belief that is not amenable to change in light of conflicting evidence.
- Can be “bizarre” or “non-bizarre”.
- For example, “I believe that an interdimensional being is making me feel sad today”.
Describe Delusion types (with examples)
6
Persecutory
Belief that others are spying on or planning to harm them (e.g., “My neighbors have hidden cameras in my walls”).
Grandiose
Belief in having exceptional abilities or fame (e.g., “I am destined to cure all diseases”).
Erotomanic
Belief that someone, often of higher status, is in love with them (e.g., “The Prime Minister sends me secret love signals”).
Somatic
False belief about body function or sensation (e.g., “My intestines have been replaced with metal coils”).
Nihilistic
Belief that oneself, others, or the world does not exist (e.g., “My organs have rotted away, and I am already dead”).
Referential
Belief that ordinary events have special personal meaning (e.g., “The news anchor is speaking directly to me”).
Describe an example of Tangentiality
Q: “Have you been taking your medication?”
A: “Medication is important. I once read an article about how people use herbal remedies in India, and they have a different approach to health there. Natural methods are interesting.”
(Notice that the speech is related to the idea of medication and health but never answers the question.)
Describe a loose associations example
Q: “Have you been taking your medication?”
A: “Medication is good. Good things come to those who wait. Wait and see, they say. The sea is blue, like my mother’s eyes. Eyes are windows to the soul.”
(Notice that the ideas jump rapidly, with tenuous conceptual links.)
Negative symptoms of psychosis
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Avolition - lack of motivation to achieve goals
Alogia - includes poverty of speech (less speech than normal), poverty of content of speech (less content than normal - vague), latency of speech and thought blocking
Anhedonia (inability to experience pleasure)
Affective flattening - dulled emotional expression.
Inattention – disturbance in selective attention.
Other symptoms
Catatonia – immobility, rigidity, and unusual posturing, as well as abnormal speech (e.g., mutism, echolalia) and movement patterns.
Incongruent or inappropriate affect – Display incongruent with person’s emotion or inappropriate to context.
Bizarre behaviour – No rational basis.
List B-F DSM 5 Schizophrenia Diagnostic criteria
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. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated). (Check specifications in notion)
Analyse the biosocial case formation (image on Notion, L3)
Notion
History of psychosis
Descriptions of psychotic experiences occur throughout historical and religious texts. Explanations of psychosis in these sources are often supernatural.
Describe Benedict Augustine Morel (1860)
- Morel was the first to rigorously describe what we now understand as schizophrenia.
- His observations focused on individuals exhibiting a specific set of symptoms, marked by early onset and a deteriorating course of illness.
- He recognized the progressive nature of the disorder, which led to the term “démence précoce” (early dementia), referring to the early onset of cognitive decline.
Describe Kraepelin
(1898) refined Morel’s concept and introduced the term “dementia praecox”.
The key features of dementia praecox for Kraepelin were:
Early onset: Symptoms typically appear in late adolescence or early adulthood.
Progressive deterioration: The illness often leads to cognitive decline over time.
Symptom clusters: Focused on hallucinations, delusions, emotional dysfunction, and cognitive impairments.
Distinction from other disorders: Kraepelin differentiated schizophrenia from manic-depressive psychosis (bipolar disorder)and others based on the course and long-term outcome.
His work in “Compendium der Psychiatrie” (Compendium of Psychiatry; 1883), helped shape the classification of mental disorders and laid the groundwork for modern psychiatric diagnosis.
Paul Eugen Bleuler
(30 April 1857 – 15 July 1939)
“Dementia Praecox or the Group of Schizophrenias” (1908 - paper/1911 - book) presented a broader definition than Krapelin’s.
Disagreed with Kraepelin – based on his observation that schizophrenia does not necessarily display early onset, deteriorating course and therefore not characteristic of a dementia.
Emphasised splitting of associative processes in thought, affect and action – this seen as the core of the disorder. Four “A”s were Bleuler’s primary symptoms.
- Association (disorganised thinking) – Impaired logical connections in thought, leading to disorganized speech and thought disorder.
- Affect (emotional disturbance) – Inappropriate or blunted emotional responses, often mismatched with the situation.
- Ambivalence (conflicting thoughts & feelings) – Holding contradictory beliefs, emotions, or desires at the same time, leading to indecision.
- Autism (social withdrawal & inner world preoccupation) – Detachment from reality, with focus on internal thoughts rather than external reality.
Describe Kurt Schneider
(7 January 1887 – 27 October 1967)
In 1959,proposed ‘first rank symptoms’ and made the diagnosis on cross section (deemed duration criteria not necessary) .
11 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.
Problems with Schneider’s approach:
- These symptoms are not specific to schizophrenia (not ‘pathognomonic’)
- Cross-sectional diagnosis a problem too. Consider DSM-5-TR diagnosis “brief psychotic disorder”, for example.
Describe modern diagnostic tools
Modern diagnostic tools like the DSM-III (1980) and its successor, including DSM-5-TR, emphasize narrow (Neo-Kraepelinian) view of schizophrenia.
Diagnosis is based on criteria that:
Outline signs and symptoms, duration of disturbance, and impact of functioning that is characteristic of schizophrenia.
Highlight exclusion factors.
Global lifetime prevalence of schizophrenia
1%
Psychological, social and environmental, and behavioural risk factors for psychosis
Really random examples of each one
Migration and discrimination: First-generation migrants have increased risk, while second-generation migrants face an even higher risk of developing psychosis. Migrants from developing countries or who live in areas where they experience prejudice and discrimination exhibit high risk. Social adversity is high, support can be lower.
Urbanicity: Living in urban environments during childhood or adolescence increases schizophrenia risk by approximately 2-fold, likely due to chronic social stress and reduced social cohesion.
Expressed emotion (EE): High levels of EE (hostility, criticism, over-involvement) in families are associated with increased relapse rates and symptom severity in schizophrenia.
Cannabis use: Cannabis use during adolescence is consistently linked to a higher risk of psychosis, particularly in genetically predisposed individuals.
Schizotypal personality traits: Schizotypal personality traits are significant predictors of psychosis risk, especially when combined with cognitive deficits and other vulnerabilities including exposure to stress and developmental trauma. Related to genetic vulnerability.
Genetic contributions to schizophrenia and psychosis
Genetics play an important and complex role in determining who might be at risk for schizophrenia and other psychotic disorders.
Schizophrenia is highly polygenic
- This means that many different genes—hundreds or even thousands—each play a small role in increasing the risk of schizophrenia. No single gene causes schizophrenia. Instead, it’s the combined effect of many genes working together.
Both common and rare genetic variations contribute to risk for schizophrenia.
- Common variations (in the general population) contribute just a little.
- Rare variations (e.g. ‘copy number variants’ – DNA section deletion or duplication) tend to have greater impact.
Genetic risk is increased if family history is present.
Gene-environment interactions: Stressors usually required to activate genetic vulnerability. Risk increases with age as stressors accumulate.
How do genes work to create risk for psychosis?
- Many of the genes linked to schizophrenia are involved in how brain cells communicate with each other at the synapse (the connection between two neurons).
- These genes affect brain development and how neurons are organised.
Schizophrenia shares some genetic risk factors with other conditions, like bipolar disorder or autism.
- This means that mental health conditions sometimes (often) have overlapping biogenetic roots.
- It is not surprising that psychotic symptoms occur transdiagnostically (across disorders)!
Understanding the biogenetic contributions to schizophrenia can help us:
- Identify people who might be at higher risk.
- Develop better treatments by targeting specific biological pathways.
- Reduce stigma by showing that schizophrenia is influenced by biology, not just personal choices or behavior. Although, the opposite can also be true – focusing on biogenetic explanations can increase perceptions of uncontrollability.
Structural brain abnormalities in schizophrenia
Reduced grey matter volume in schizophrenia
- Prefrontal Cortex (PFC) – Impaired decision-making, planning, and cognitive control; contributes to disorganized thinking and executive dysfunction.
- Temporal Lobes – Involved in auditory processing and memory; reductions here are linked to hallucinations (especially auditory) and memory deficits.
- Hippocampus – Critical for memory formation and reality monitoring; reduced volume is associated with disrupted memory and difficulties distinguishing reality from delusions.
- Amygdala – Regulates emotion and threat perception; volume reductions may contribute to blunted emotional responses or heightened paranoia.
- Thalamus – A key sensory relay station; reductions may lead to abnormal sensory processing and cognitive disturbances, possibly contributing to hallucinations and thought disorders.
White matter abnormalities in schizophrenia
- Disrupted connectivity between brain regions (especially between the PFC, thalamus, and hippocampus) leads to impaired communication and disorganized thinking.
- Enlarged Ventricles – Larger fluid-filled spaces suggest loss of surrounding brain tissue, a common finding in schizophrenia, often linked to cognitive deficits and more severe symptoms.
What is thought process disorder?
Tangentiality
Thoughts start off linearly, but quickly veer off into unrelated areas without returning to the original point. When interrupted, patients tend to ask what the question was in the first place.
Loose associations
There is an apparent disconnection between one thought (usually a sentence) and the next. An indication that loosening of associations is occurring is when the interviewer is unable to follow the train of thought (‘huh?’). When severe, speech becomes incomprehensible.
Describe the difference between mood and affect
Mood refers to a person’s sustained experience of emotion. (climate generally)
Affect refers to the immediate experience and expression of emotion. (more like Tassie weather, lots of changes)
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