L12: Psychotic symptoms

Question 1

what is the difference between psychosis & psychotic disorders?
which one is more common?

Answer 1

psychosis: a symptom (or collection of symptoms)
psychotic disorders: diagnoses in which psychosis/psychoses play an important part
psychotic symptoms are more common than psychotic disorders (are psychotic disorders really different disorders?)

Question 2

Define psychosis

Answer 2

formal def: disturbances in experience of reality or reality testing
DSM: classifies based on observable behaviours & reported experiences

Question 3

What are the various psychotic symptoms according to the DSM?

Answer 3

• positive symptoms: delusions & hallucinations
• negative symptoms
• grossly disorganised / catatonic behaviour
• disorganized thinking/speech
• non DSM symptoms

Question 4

What are disorganization symptoms?

Answer 4

• difficulties in getting from A to B & explaining oneself
• often these & negative symptoms are most troublesome to the patient (rather than the clinicians focus: positive symptoms)

Question 5

What are some non-DSM 5 psychotic symptoms?

Answer 5

• disturbed self experience
• cognitive biases: jumping to conclusions
• anosognosia: lack of awareness that one is ill
• disturbances in social cognition (can lead to victimization)

Question 6

What are the consequences of disturbed social cognition in psychosis?

Answer 6

• can lead to victimization (you can be burglered or attacked & wouldnt realize)
• therapeutic alliance is hard to construct

Question 7

Is catatonia transdiagnostic?

Answer 7

yes!
may also be present in autism & tic disorders

Question 8

How is psychosis diagnosed?

Answer 8

most commonly used: Positive & Negative Syndrome Scale: semi structured interview

Question 9

What can “cause” psychotic symptoms?

where can you encounter them

Answer 9

• bipolar disorders
• extreme stress
  -drugs/intoxication/withdrawal
• medication side effect
• sleep disorders & deprivation
• trauma
• brain tumours
• dementias
• post partum/estrogen withdrawal
• autism spectrum disorders
• major depressive disorders
• delirium

Question 10

What are the positive symptoms of psychosis?

Answer 10

• delusions: fixed beliefs that arent amenable to change in light of conflicting evidence
• hallucinations: perception like experiences that occur w/o external stimulus. theyre vivid & clear and can be on any modality (most common is auditory & imaginary friends in childhood). normal religious/spiritual experiences in many cultures

Question 11

What are some negative symptoms in psychosis?

common & less common

Answer 11

common:
- lessened expressivity
- avolition
less common
- alogia
- anhedonia
- a-sociality

Question 12

What is avolition?

Answer 12

reduction of self motivated goal oriented activities

Question 13

What is anhedonia?

Answer 13

reduced enjoyment of formerly enjoyable activities

Question 14

What is alogia?

Answer 14

reduction in speech output

Question 15

What are some common & uncommon delusions?

Answer 15

most common
- persecutory
- referential (think that somethings about you when its not)
less common
- somatic
- religious
- grandiosity
- erotomanic (celebrity x is in love me)
- nihilistic (world is gonna end)

Question 16

What is the prevalence?

Incidence, current prevalence, lifetime prevalence

Answer 16

incidence: 15 new cases per 100k per year
prevalence right now: 0.7% (lots of variance between studies)
lifetime prevalence: 0.4%

Question 17

What are the known risk factors (diatheses)?

Answer 17

• biological: genetic factors, dopamine hypothesis
• social: growing up in urbanized area, minority group position/migration, cannabis use, developmental trauma
• psychological: trauma (very prevalent)
• sex
• age
• prenatal & perinatal risk factors
• birth season
• age of father
• premorbid intelligence

Question 18

What is the dopamine hypothesis of psychosis?

Answer 18

• claims that dopamine play important role in psychosis (like a mental highlighter for important things)
• important part of dopamine hypothesis: Aberrant (aka atypical) Salience: elevated dopamine (striatum) leads to errors in assigning meaning/relevance (so like innocent/unimportant stimuli are assigned significant meaning)
• so delusions formed to explain disturbed meaning
• disturbances in dopamine system also dysrupts motivational sistem -> negative symptoms
• antipsychotics work on dopamine receptors

Question 19

What is the aberrant salience theory of antipsychotics?

Answer 19

idea that antipsychotics are effective cause they dampen salience: they create disinterest in surroundings
block the underlying dopaminergic drive
-> would explain the gradual response to them, as antipsychotics dont change the actual delusions/hallucinations, just the degree to which one notices them
-> also explains the return of symptoms after stopping antipsychotics: since they dont erase the symptoms, just dapen the salience

Question 20

How do antipsychotics work? what are still some mysteries about their workings?

Answer 20

block neurotransmitter receptors (especially dopamine)
mysteries:
- dopamine receptors reach steady state within days, but the improvemetn of psychosis is very slow
- subjective improvement: one of first improvements noted by clients is that delusions/hallucinations dont interfere as much, but the core belief in the truth of them persists
- they only provide symptomatic control cause when antipsychotics are stopped, symptoms usually return

Question 21

What is the dev of psychosis like?

Answer 21

endogenous psychosis (psychosis w an internal cause) evolves slowly, often through series of states

Question 22

What is the relationship between drugs & psychosis?

Answer 22

drugs (dopamine releasers) usually dont cause psychosis in single exposure
but patients whove had psychosis in past, taking drugs can cause return/worsening of symptoms

Question 23

What is the anhedonia hypothesis of dopamine?

Answer 23

idea that dopamine is a neurochemical mediator of ‘life’s pleasures’ aroused by naturally rewarding experiences (food, sex, drugs) and by neutral stimuli that become associated with them. thus (lack of) dopamine plays role in anhedonia

Question 24

What are some counter arguments against the anhedonia hypothesis of dopamine?

Answer 24

• dopamine is involved in rewarding events, but also in aversive ones
• pre-consummation: the firing of dopamine neurons & dopamine release precede the consummation of pleasure & are seen regardless of eventual consummation
• blockers: dopamine blockers (like antipsychotics) change the drive to obtain rewards, even w/o apparent change in pleasure associated w them, they changed “wanting” without changing “liking”

Question 25

What is the motivational salience hypothesis?

Answer 25

idea that dopamine mediates the translation of the neural representation of a stimulus from a neutral bit of information into an attractive or aversive entity. mesolimbic dopamine system is seen as critical for attribution of salience: it determines what grabs our attention.

Question 26

What is the Self-Regulatory Executive Function Model?

Answer 26

psych model for maintenance of symptoms have - positive beliefs about worry - negative beliefs about controllability of thoughts & corresponding danger - cognitive confidence - negative beliefs about thoughts

Question 27

What are the 3 levels of recovery in treatment?

Answer 27

1. clinical recovery: symptom reduction 2. personal recovery: living well in spite of symptoms 3. social/psychosocial/societal recovery: ability for "role-fulfilment"

Question 28

How does the biological framework see psychotic symptoms? What are this framework's pros and cons?

Answer 28

these symptoms are a result of erroneous brain function -> classify these as psychotic symptoms -> meds pros: - quick treatment/effects - easy theoretical frameowkr/evidence base - possibly very large effects - adherence is relatively easy cons - side effects - loss of therapeutic alliance - medication dependence - possible mediacation caroussel (have to try many different meds) - long term health effects

Question 29

How does the team-based approach see psychotic symptoms? What are this framework's pros and cons?

Answer 29

flexibly adjusting type & intensity of care depending on the needs of the client will assist day-to-day functioning by using teams consisting of different type of mental health care practicioners pros: - flexibly offers variety of services - community based - multidisciplinary - adjusting treatment as symptoms come and go - focus on maintaining community functioning cons: - large case loads for teams, so not full attention - team functioning impacts care - not able to offer all kinds of treatment (like EMDR, group training)

Question 30

How do the societal recovery interventions see psychotic symptoms (treatment)? what are its pros & cons?

Answer 30

vocational rehabilition. tailor support so symptoms can be managd so practical, real life outcomes can be achieved pros: - real life outcomes - linked outcomes - relatively direct improvement of quality of life & self esteem cons: - difficult to implement - reliance on factors outside mental healthcare (employers) - stigma - bad effects of "failing"

Question 31

How do the psychological symptom oritened therapies (like CBT) see psychotic symptom treatment? what are its pros and cons?

Answer 31

excplicity label symptoms as "psychotic", then reframe symtpoms & challenge underlying assumptions so that impact on functioning will be reduced & general QoLis improved pros: - short treatment - well researched & protocolozed - can be delivered by psychologists, but also nurses - transferable between professionals cons - limited success w limited nr of patients - not all symptoms are "very susecptible aka amenable" - lack of insight on big obstacle

Question 32

How do the non symptom oritened therapies see psychotic symptom treatment? what are its pros and cons?

Answer 32

main hypothesis: psychotic symptoms interfere w/ one's ability to form a coherent, continuous mental image of oneself, others, and world; dev a shared understanding will help pros: - non stigmatizing - def helped some patients - long term cons - difficult to administer/teach - evidence base fragmented/shaky - complicated to validate case conceptualizations - barely transferable between therapists - (extremely) long term

Question 33

What are 3 challenges to psychotherapy agreement & alliance with psychotic ppl?

Answer 33

1. differing ideas on the role of the mental health system 2. differing ideas about mental illness 3. stigmatizing beliefs held by the client & therapist

Question 34

How do a therapist' &,client (w psychosis) views on the mental health system & their roles in it differ?

Answer 34

client: can have negative attitidues towards the system cus it sees them as helpless/dependent, concerns about confidentiality, social implications like stigma & practical implications of being a mental health service user so might interpret certain things as the system trying to control/silence them therapist: might see the field as fundamentally benevolent so might interpret things as being great treatments etc -> can lead to misunderstanding

Question 35

How do a therapist' and clients (w psychosis) views differ on mental illness/health & the problems the client has?

Answer 35

clients: many may be unaware/deny that they have a mental illness -> denial of a need for treatment etc; general lack of insight makes it hard to talk about certain topics (like their delusions, hallucinations etc) therapist: theoretical perspective on where psychosis comes from etc

Question 36

How is therapeutic alliance & agreement threatened by stigma? | definition & implications

Answer 36

both may involve the belief that the client isnt an equal party that can make meaning of their challenges in the illness -> lead to their withdrawal or submission stigma: beliefs present in the speech & behaviour that casts persons w mental illness as fundamentally different & less valued than other ppl (including belief that theyre dangerous, fragile, incompetent, or incapable of understanding the demands of adult life) self stigma on clients side therapists stigma -> results in them leading a lot of decisions, general lack of joint meaning making

Question 37

Why is agreement in therapeutic alliance with someone w psychosis difficult?

Answer 37

agreement construction is an intersubjective process: its about the mutual understanding & communication of 2 peoples subjective experience which due to the 3 challenges is hard

Question 38

How can we form a therapeutic alliance & agreement with someone w psychosis? | aka how can we overcome the 3 challenges

Answer 38

2 things can serve as framework - metacognition: understanding the mental state of self & others - empathy: sharing another's affective state --> both involve active effort to think & experience about self, the other, and the dialogue empathy should lead to self reflection & other integrative repersentations through metacognition -> engage in exploration together

Question 39

How can metacognition improve therapeutic aliance & agreement w someone w psychosis? | definition & how does it help

Answer 39

def: being aware of and reflecting one's thoughts, emotions, and experiences. requires ability to shift between ones perspective & the perspectives of others differences in understanding may arise between clients therapist. - therapist should focus on exploring shared experiences rather than debating labels/diagnoses - collaboartive dialogue can help client understand themselves better - therapist must remain open minded, aware of biases, and willing to understand clients perspective

Question 40

How can empathy improve therapeutic alliance & agreement w someone w psychosis?

Answer 40

- higher therapist empathy improves therapeutic alliance

Question 41

How, specifically, can metacognition & empathy improve differing ideas on the mental health system?

Answer 41

if client has negative views on the system: metacognitvie-empathic exploration: elements of experience have to be addressed & mutually considered, as well as how these go together if therapist has positive view on system: be aware of your own theoretical baises & be continuously open to understanding the unique experience of others

Question 42

How, specifically, can empathy & metacognition, address differing views on mental illness?

Answer 42

if lack of insight on client side: emphasizing creating coherent narrative & synthesizing elements of experience into rich presentation of self if therapist' view on mental illness doesnt match clients: be aware of the clash & be aempathetic to the reject of the insight label by the client

Question 43

How, specifically, can empathy & metacognition address stigma?

Answer 43

therapist awareness & empathic attention to self stigma of client, & address their own stigma

Question 44

What methods do psychotherapists use to address psychosis (using only talking)?

Answer 44

- Psychodynamic therapy: derived from earlier psychoanalytic techniques, focus on childhood experiences & the way the psychosis unconsciously serves a useful function for the patient. but long procedure & not a lot of evidence - CBT: shorter procedure that takes patients through series of guided steps to explore alternative explanations of what theyre experiencing both aim to take the psychotic symptoms seriously & to talk about them (but this lack of drugs may only be appropriate for some cases)