Week 4

Question 1

Compared to other mental disorders schizophrenia is

Answer 1

Rare but impactful: Can be chronic; <50% “recovered” at 15–25 yrs (high lifetime burden, early onset).

Misunderstood & stigmatised.

History & nosology: Long-recognised; now seen as a spectrum (DSM-5). Proposal for attenuated psychosis disorder (APD) not adopted.

Research focus: Heavily studied; ongoing hunt for biomarkers and links with neuroscience.

Question 2

What is psychosis?

Answer 2

• A term with multiple (and evolving) definitions
• A general (blanket) term; a central feature of
  schizophrenia and related disorders
• A split from reality/ loss of contact with reality/ not
  being able to discern between
• what’s real or not real, or
• what’s internal and self-generated versus external and other-generated

Question 3

What is schitzophrenia?

Answer 3

The most common symptoms of schizophrenia include changes in the way a person thinks, perceives, and relates to other people and the outside environment.

Question 4

What are the three symptom types of schizophrenia?

Answer 4

• positive symptoms
• negative symptoms
• disorganisation

Question 5

What are the three distinct phases of schizophrenia?

Answer 5

Prodromal

Active

Residual

Question 6

What is the Prodromal phase?

Answer 6

Noticeable deterioration in functioning
- may be described by others as “personality change”

presentation is may involve “odd” / “bizarre” behaviour that “deviates” from typical, unusual perceptual experiences,

angry outbursts,

tension,

restlessness,

social isolation/withdrawal

Question 7

What is the active phase?

Answer 7

full blown illness/the diagnostic criteria are met

Question 8

What is the residual phase?

Answer 8

similar to prodromal. [active symptoms have reduced but still impair; “negative” symptoms usually remain]
Relapses can also occur – “active episodes” Critical focus: What might these phases mean for the ‘treatment’ of schizophrenia?

Question 9

What are the active phase symptoms?

Answer 9

A1. delusions*
A2. hallucinations*
A3. disorganised speech (e.g., frequent derailment or
incoherence)*
A4. grossly disorganised or catatonic behaviour
A5. negative symptoms (e.g., diminished emotional
expression/reduced expressive behaviour or avolition)

Question 10

How/when can schotzophrenia be diagnosed?

Answer 10

• The diagnosis requires 2 of the 5 active phase symptoms, and one of those two symptoms must be delusions, hallucinations or disorganised speech
• must be present for a significant portion of time during a one-month period
• symptoms across the 3 phases have been for 6 months or longer

Question 11

What are Auditory hallucinations in schtophrenia?

Answer 11

*Heard as distinct voices, familiar or not
*Often critical, threatening, or commanding
*Can be voices commenting or conversing
*Unwanted, vivid, intrusive, hard to ignore
* May cause person to talk back (appears like self-talking)

Question 12

What are Auditory ‘events’ that don’t count for Schizophrenia

Answer 12

• Perceiving sounds/voices when falling asleep
  (hypnogogic hallucinations) or on waking waking (hypnopompic hallucinations)
• A sensation of your name being called
• Sounds that are like hallucinations (e.g. unwanted, uncontrollable), but they have an external if distal cause (ringing in one’s ears after a concert)
• A “transient” hallucinatory experience (DSM-5)

Question 13

What are delusions?

Answer 13

Delusional thoughts are clearly false (“preposterous”) beliefs or idiosyncratic beliefs

Question 14

what is the difference between hallucinations and delusions?

Answer 14

Hallucinations is False perceptions — experiencing something that isn’t actually there

Delusions are false beliefs - held firmly despite clear evidence to the contrary.

Question 15

What are some common delusion themes?

Answer 15

Of being controlled:
Feelings, impulses, thoughts, or actions are not self-controlled, but directed by other people or an external force

Of persecution:
A strong sense of being attached, harassed, cheated, or conspired against

Of grandeur:
Highly inflated sense of self- worth, power, knowledge, identity, or special connections with a deity or famous perso

Question 16

Delusions sound easy to identify, but may not be
because

Answer 16

• Delusional thoughts may involve a complex belief system (a bizarre, confusing story)
• Facts, and fiction may be interwoven
• The ideas may be difficult to completely disprove or falsify
• The belief system may be fragmented (& therefore hard to identify)

Question 17

What is disorganised speech?

Answer 17

• Speaking in a disorganised way (it doesn’t make sense)
• Disorganised (disordered) speech = disordered thought (or “formal thought disorder” [DSM-5])
• Speech patterns are clinically significant; impaired verbal communication is not due to factors such as poor / low formal education or other speech/ language or communication issues etc

Question 18

4 types of disorganised speech

Answer 18

1. Very fragmented speech, not following language conventions for complete sentences (known as word salad)
   Follows language conventions
2. Answers are not related to the questions [aka tangentiality], rambling speech
3. Sentences don’t follow; there is no “train of thought” conversation keeps getting derailed by new [unrelated] thoughts [aka derailment or loose associations]
4. Although correct, speech doesn’t convey much, or
   there is very little of it (this is interpreted as “alogia”)

Question 19

Speech characteristics that might indicate alogia

Answer 19

• conveys little info because it is over-concrete, over-
  abstract, repetitive, or stereotyped (“poverty of content”).
• The replies are extremely brief (“poverty of speech”)

Question 20

What’s the difference between disordered speech in Schizophrenia and alogia?

Answer 20

In Schizophrenia, disordered speech is interpreted as
evidence of disordered thought. Ie Thoughts do not form or
connect properly. Alogia is interpreted as an
impoverishment in thinking

Question 21

What are unusual behaviours?

Answer 21

• Catatonia: A state of reduced movement, speech, and reactivity, even when something happens around the person that would normally get a response.
• Motoric immobility (marked lack of movement)

catalepsy - fixed position for a long time

stupor - almost no movement/speech

• Motoric excesses (repetitive, apparently purposeless movement, such as pacing, hand wringing)
• “changed” (reduced & awkward) spontaneous movement
• “Inappropriate” or “incongruous” behaviour that doesn’t fit the situation

Question 22

Caveats in recognising unusual behaviour

Answer 22

• Must not be merely aimless, purposeless behaviour,
• Must not be Due to delusion per se (e.g., organised behaviour directed by delusion)
• Must be not consist of a few instances of restlessness or agitated behaviour

Question 23

What are negative symptoms?

Answer 23

• May be more subtle and stable through the illness profile (compared to positive symptoms), yet more difficult to
  recognise/distinguish from other conditions
• Appearance of diminished emotional expression/blunted affect [does not necessarily indicate diminished “feeling”]
• volition (no motivation/drive) and alogia (impoverished thinking)

Question 24

What are the other psychotic disorders

Answer 24

• Delusional disorder
• Brief psychotic disorder
• Schizoaffective disorder

Question 25

How is Schitozphrenia different in the DSM-4 compared to the DSM-5

Answer 25

- it made it harder to get the diagnosis (raised the symptom threshold) -> now requires two level A criteria instead of 1 - The subtypes have been removed; these proved difficult to reliably distinguish (but in some cases, old subtypes, like catatonia, can be specifiers). - Attenuated psychosis syndrome (APS) – was proposed and rejected – partially – it is included as “condition for further research”. There was a significant debate about this decision

Question 26

What is the cause of schizophrenia?

Answer 26

The cause of schizophrenia is unknown and likely multifactorial. Biological factors are the main focus; treatment is primarily pharmacological. Social and psychological theories exist but are not used in current treatments. More common in males. There are sex differences in symptoms and course.

Question 27

How is genes understood as a possible cause of schitophrenia?

Answer 27

* Genetic hypothesis for schizophrenia, stronger than other psychopathologies * Interaction effects: Genetic risk is increased in certain environments [e.g., genetic risk + unfavourable family environment - consistent with the diathesis-stress model). * Pinpointing genetic risk through molecular genetics shows links regions implicated in other neurodevelopmental conditions. * The challenge of the schizophrenias [changing the endophynotype?] Genetics: strong hereditary component; higher risk in first-degree relatives and identical twins.

Question 28

How are specific population groups understood as a possible cause of schitophrenia?

Answer 28

* Risk is increased if there is a history of * Pregnancy &/or birth complications * Prenatal environment [Maternal viral infection, or immune system compromise, or dietary deficiency or stress; such factors are thought to impact neurodevelopment?)

Question 29

How are Neuroanatomical and neurochemical hypotheses understood as a possible cause of schitophrenia?

Answer 29

*Multiple structural and function anomalies investigated [e.g., brain volume reduction, reduced/altered white matter, regional changes, abnormal cytoarchitecture], extending to functional (cognitive) endpoints. * Dopamine, glutamate (and their respective hypotheses for schizophrenia) however, the challange is that the presence of an abnormal marker does not imply a cause

Question 30

How are psychosocial and cultural aspects understood as a possible cause of schitophrenia?

Answer 30

* Family environment (e.g., “deviant communications”, the double-bind, high expressed emotion [criticism, hostility, emotional overinvolvement]) * Urban living, migration (?via social disadvantage / deviant /harmful “social” communications” [discrimination] or biological processes from these “stressors”) * Substance (cannabis) use – early cannabis exposure increases risk

Question 31

What is the most likely cause of schizophrenia?

Answer 31

The diathesis-stress model is a promising explanatory model it recognises a role for biological and genetic vulnerabilities (diathesis) and environmental or psychosocial factors (stress). In essence - brain vulnerability - from biological factors [e.g., genes] may transition to schizophrenia only in some cases. ie it will depend on developmental/ maturational processes and/or the added experience of psychosocial/environmental “stress” [e.g., family environment, social disadvantage]

Question 32

What are Some suggested care strategies, when someone experiences delusions

Answer 32

- Validate any part of the delusion that is real - do not say what the person is thinking is wrong - do not expect that rational thinking will have an effect on the persons delusions - dont take the persons accusations personally

Question 33

What is schizophrenias primary treatment?

Answer 33

medication (first and second generation antipsychotic medications, primary mechanism = D2 receptor block) Usage may depend on stage Regarded as effective for psychotic symptoms & delaying relapse. However: * There can be adverse side effects * Compliance may be poor * Tolerance may develop

Question 34

What are other treatment options?

Answer 34

Since relapse rates seem to be worse for people whose families are high in expressed emotion, family-based therapies may be useful Exercise may support brain health. Psychosocial therapies, like social skills training, are useful for patients stabilized on medication. Supportive approaches are preferred over psychoanalytic ones. CBT may help with emotional distress, though its overall effectiveness is debated.