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Psychotic disorders (Schizophrenia) (Psychological model (Paranoia Ellett…
Psychotic disorders (Schizophrenia)
.
a mental disorder characterised by abnormalities in the perceptions or expressions of reality
Negative symptoms
Blunted affect
Anhedonia (lack of emotions and pleasure)
Lack of motivation
Positive symptoms
Auditory and visual hallucinations
Paranoid/ persecutory delusions
Disorganised speech and cognitions
Diagnosis
ICD: Subtypes
Paranoid
Hebephrenic (affect and thought)
Catatonic
Undifferentiated
Residual (remission of sorts, negative symptoms only)
DSM-5
categorical but aims to capture underlying structure of psychosis more clearly
A)
Characteristic symptoms
3 core symptoms, at least one of which required for diagnoses (for 1 month)
Delusions
Hallucinations
Disorganised speech
Plus other symptoms
Negative Symptoms
Disorganised thought/ Catatonia
B) Functional deficit (social or occupational)
C) 6 month duration of disruption
Use (A) for categorical assessment and also rate symptoms on scales to measure gradient of psychosis and monitor changes in condition without need to re-diagnose.
Gradients on 8 dimensions
5 from (A)
Cognition
Depression
Mania
Epidemiology
Van Os
Men = women
Age of onset: 20-32 (earlier for men)
Prenatal effects
Malnutrition
Infection
Nicotine
1% population prevalence
Heritability
Murray
: 65%: concordance with MZ twins, DZ only 12%
Social aspects; Schz described as a
"disorder of not belonging"
Matheson
Poverty
Migration
Discrimination/ Abuse
Higher in urban environments
Stigma felt post-diagnosis increases distress and psychosis:
i.e.
need to make them feel accepted in order to ease recovery/ dealing with disorder
Common comorbidity & drugs
Murray
Substance abuse frequent: self-medication
Drugs associated with onset too: cannabis, cocaine, amphetamines
Freeman
Cannabis: THC triggers paranoia in vulnerable individuals even when cognitive interventions implemented
i.e.
people still paranoid even when aware of the cause of their paranoia
Neural mechanisms
fMRI and PET scans reveal
functional differences
in brain activity. Frontal lobes, hippocampus and temporal lobes prominently different from typical activity
Medical model
Illness with yet unidentified biological cause
Serotonin and dopamine levels relevant but mechanisms unclear in Schizophrenia compared to anxiety or depression
Interested in symptoms which signal presence of disorder unlike typical experience
Psychological model
Interested in the subjective experiences, processes and symptoms of Schz individuals
A continuum model: the typical population experience Schz symptoms in everyday life but far less frequently and more mildly than those diagnosed
How to typical psychological processes lead to atypical symptoms?
Van Os
Outside of the clinical population, 12% have psychotic symptoms and experiences
Stressors such as sleep deprivation or bereavement can result in psychosis in anyone
e.g.
with hallucinations
Goldstone et al
Delusions
Peters
Significant proportion of general population endorse delusionary ideas
the
difference
is that the clinical population have higher
belief in their delusions
and
lower thought flexibility
which cause the severity of their symptoms
Paranoia
Ellett / Freeman
47% undergraduates experience it
Associated with youth, lower intellect, singledom, poverty, low social support and stress
Environment
Self-awareness, experiences of failure increase vulnerability to paranoia
Positive mood induction and self-affirmation alleviate
Stress-Vulnerability model
Garety
an integrative approach
genetic, prenatal and environmental factors cause
vulnerability
then,
stressful triggers
such as drug abuse or life events create psychotic behaviour
A biopsychosocial approach which can explain individual variability in psychosis
Biases causing individual differences
i.e.
vulnerability factors
Attribution biases
Bentall et al
Depression: maladaptive internal attributions
e.g.
"They didn't text me back because I am unlikable"
Paranoid delusions: maladaptive external attributions
e.g.
"they look familiar because they have been following me"
Nonclinical control group: situational attributions
e.g.
"they didn't text me back because they are busy with deadlines at uni"
or
"they look familiar because they go to the same uni as me and I must have seen them around before"
Reasoning biases
Huq et al
Jumping to conclusions: the Bead task
Clinically psychotic (deluded) individuals pick only 1 bead before making an assumption/ conclusion
60:40 beads red/yellow
Non-clinical population chose to draw around 3 beads, and non-delusional psychiatric participants demanded more information with an average draw of 4 beads
Cognitive model of Positive Symptoms
Garety
Biopsychosocial vulnerabilities interact with abnormal triggers
e.g.
family history + abuse
Emotional changes
e.g.
Anxiety
Cognitive dysfunction related to anomalous events
e.g.
strangers talking about me
Appraisals
e.g.
I'm being followed
Positive symptoms
e.g.
delusions
Maintaining factors: schemas, emotional and cognitive processes, reasoning and attribution biases
e.g.
isolating self
Medical model of treatment
View drug interventions as necessary, and prioritised over psychological treatments in the short term
Antipsychotics can be Typical or Atypical
Atypical are preferred as they are newer and viewed as more effective, especially in regard to
negative
symptoms, but have more side effects
e.g.
weight gain
...but both are effective in treating
positive
symptoms
Clinical significance of effects are not entirely validated/ established
Adverse side effects
Movement, sedation, constipation, low blood pressure, impotence photosensitive rashes, neuroleptic malignant syndrome (can be life threatening)
Cognitive Behavioural Therapy (CBT)
Reduces distress and increases self-care techniques and empowerment. Hence, patients are more able to manage their own symptoms
Note: management techniques not cure
Why?
Medication only partially effective for 50% psychosis patients
Positive symptoms persist for 40%
Acute episode relapses occur for 80%
Suicide 10%
Stages: "EAFIE"
Chadwick
Engangement
Assessment
Formulation
Intervention
Evaluation
(Behavioural aspects such as sleep pattern also important - diary can be kept)
(Present alternative attributions/ reasoning techniques)
(Challenge beliefs and present disconfirming evidence, whilst taking them seriously and hearing out their logic)
(Create framework of experiences and goals)
(Transparency key due to delicate and potentially paranoid state of patient)
(Understand beh+cog patterns)
(Build rapport)
ABC Model
Activating Event
Belief
Consequence
Efficacy
Moderate effectiveness
Wykes:
0.4
Fairly Robust
Effective at 12 month follow-up
In treatment of delusions, evidence is inconsistent
NICE CBTp meta-analysis
Mindfulness as an alternative therapy