Psychosis

Question 1

Psychotic-like experiences

Answer 1

Persecutory Ideation (e.g. felt as if people seem to drop hints about you or say things with a double meaning)

Bizarre Experiences (e.g. felt as if electrical devices such as computers can influence the way you think)

Perceptual Abnormalities (e.g. heard voices when you are alone, seen objects, people or animals that other people can’t see)

Question 2

What is Psychosis?

Answer 2

A constellation of symptoms particularly disturbances in:
❖ Perception (Hallucinations).
❖ Belief and interpretation of the environment (Delusions).
❖ Disorganisation of thoughts and behaviour (e.g., speech patterns, odd behaviour).
❖ Mood/feelings (e.g., decreased intensity or agitation).

Question 3

Positive Symptoms of psychosis

Answer 3

• Delusions/Unusual thinking
• Hallucinations:
• Thought Disorder

Question 4

Delusions/Unusual thinking:

Answer 4

severe reality distortions/unusual bizarre beliefs.

Question 5

Hallucinations:

Answer 5

sensory experiences felt with the full force of a perception in all modalities- auditory (most common), visual, olfactory (smell), gustatory (taste), tactile

Question 6

Thought Disorder

Answer 6

Impaired ability to put ideas together in linear and goal directed fashion; disorganised thinking (e.g. thought blocking, derailment, poverty tangentiality). Difficulties making meaning from speech.

Question 7

Negative Symptoms of psychosis-5 A’s

Answer 7

Anhedonia
Asociality
Avolition
Affective Flattening (paralanguage).
Alogia  (Poverty of speech)

Hence, can give the missed impression that they are lifeless, absent & difficult to connect

Question 8

Anhedonia

Answer 8

loss of interest in pleasurable activities or the anticipation of pleasure, not so much in the moment (e.g., socialising, recreational pursuits such as hobbies).

Question 9

Asociality

Answer 9

lack of desire to form relationships, withdrawal.

Question 10

Avolition

Answer 10

lack of motivation for goal directed behaviour (“get up and go”, “Initiative”).

Question 11

Affective Flattening

Answer 11

• reduced expression through face, body and voice (paralanguage).

Question 12

Alogia

Answer 12

(Poverty of speech) reduced verbal out poorly, difficulty elaborating.

Question 13

How do you know if neg symptoms or depression?

Answer 13

Criteria overlap, first ep psychosis is insidious (subtle and harmful), depression is sadness, negative symptoms of psychosis is neither happy nor sad

Question 14

Delusions

Answer 14

Fixed beliefs that are not amenable to change in light of conflicting evidence. Cntent may be persecutory, referential, somatic, religious, grandiose.

Question 15

When is a delusion considered bizarre?

Answer 15

if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences.

Question 16

What is the distinction between a delusion and a strongly held idea?

Answer 16

• sometimes difficult to make
• depends in part on the degree of conviction with which the belief is held despite clear contradictory evidence
• diminished or distorted sense of reality and unable to distinguish the real from unreal.

Question 17

What disorders include delusions?

Answer 17

schizophrenia, schizoaffective disorder, delusional disorder, schizophreniform disorder, brief psychotic disorder, substance induced disorder, bipolar disorder, major depressive disorder with psychotic features, dementia.

Can also be due to medical causes such as brain injury, intoxication, somatic illness

Question 18

Primary delusions

Answer 18

Primary: Various types. Autonomous, original, and incomprehensible from a psychological point of
view. They appear suddenly, the patient has a complete conviction of it. Not psychologically understandable. E.g. uncanny feeling the world is odd, false memories, self-referential ideas

Question 19

Secondary delusions

Answer 19

Delusional idea that manifests as an attempt to explain strange, senseless experiences. Psychologically understandable.
❖ Common Themes:
Persecution (central psychotic experience) , Grandiosity (special power), Control (e.g., thought insertion, thought
broadcasting), Reference (e.g., isolated or random events have special personal significance); Love (e.g., jealousy or possessiveness towards other person-erotimania), Guilt or unworthiness (more depression), Somatic (e.g., unexplained medical or perceived bodily sensation); Nihilistic (intense feelings of emptiness), Control (e.g., thought insertion, thought broadcasting), Mixed (two or more themes).

Question 20

Persecutory Delusions

Answer 20

At first episode of Psychosis, over 70% of client’s have
persecutory delusions
Two central concerns (1) Harm is going to occur (2) Others intend to do it. Maybe be other people or machines, or systems. E.g. paranoia, I’m targeted by many trying to ruin my life.

Question 21

Paranoid Continuum of Psychotic Experiences

Answer 21

10 - Delusions of Persecution/Mental disorder
❖ Severe threat: e.g., people trying to cause significant physical or psychological or social harm; conspiracies
known to wider public.
❖ Moderate threat: e.g, people going out of their way to get at you.
❖ Mild threat: e.g., people trying to cause minor distress such as irritation, being monitored (e.g. cameras)
❖ Ideas of reference e.g., people talking about you, ?being watched.
❖ Social evaluative concerns e.g. fears of rejection, feelings of vulnerability, thoughts that the world is
potentially dangerous
1 - Mental health concerns/Exaggerated Self-Consciousness & Hypervigilance

Question 22

How many psychotic individuals have cognitive disturbance? Which cognitive

Answer 22

Not included in diagnostic Criteria but ubiquitous with 80% of psychotic disorders exhibiting clinically significant impairment.
❖ Cognition: deficits/difficulties in attention, working memory, processing speed problem solving and cognitive control
❖ Social Cognition: Processing social and emotional cues or stimuli; Theory of Mind
❖ Suggestive of an organic (brain based) element to psychosis.
❖ Present prior to onset of psychosis & impact every day independent functioning (e.g. ADL’s -Activities of Daily Living)

Question 23

Functional Impairments

Answer 23

❖ Role functioning = responsibilities and
functioning in job school home and community.
❖ Social functioning- friendship group, nature of
friendships, amount of social contact and engagement.
❖ Strongly related to severity of negative and cognitive symptoms.
❖ Psychosocial or pre-morbid functioning prior to onset can predict recovery outcomes
❖ Functional Recovery is critical in treatment

Maintaining meaningful life roles, goals and relationships in their life ( particularly frustrating to clients and families).

Question 24

Insight

Answer 24

• Not in diagnostic criteria but is often seen clinically as a cardinal feature of psychosis
• As one concept of insight, cognitive insight was introduced in 2004 to describe the capacity of patients with psychosis to distance themselves from their psychotic experiences, reflect on them, and respond to corrective feedback. (Riggs et al 2012)
• Big challenge to engagement in services and treatment, long delays in treatment and can result in involuntary treatment.

Question 25

Disturbed Experience of Self

Answer 25

Have you felt as if you were standing next to yourself or watched yourself like looking at someone else or as if in a movie? • Have you felt as if your whole body or parts of your body were detached or did not belong to you? • Have you felt unreal or like a stranger to yourself? • Have you looked in the mirror and felt disconnected from your own image? - Have you felt like you were in a dream or just going through the motions? * A disturbed self-experience can be most puzzling and frightening to patients, and may lead to withdrawal from social contact. * Subtle experiences of self-disturbance have already been found in the prodromal phase of psychosis, and they have been recognized as a risk factor for transition to psychosis in subjects at ‘ultra-high risk’ for the disorder.

Question 26

peak age of onset of the first psychotic episode

Answer 26

in the early to mid 20’s for males and late 20’s for females (DSM-5).

Question 27

Schizophrenia is the ?? leading cause of burden

Answer 27

Schizophrenia is the third leading cause of burden and injury in young men aged 15-24 years and the fifth in young women the same age (Aust. Institute of Health & Welfare 2007).

Question 28

First Episode Psychosis (FEP)

Answer 28

used within clinical and research settings can be misleading regardless of which operational definition is used. This term is typically used to refer to individuals early in the course of a psychotic illness or treatment rather than individuals who are truly in the midst of a first ‘episode’ of illness. (Nicholas et al, 2009) Diagnostically, a First Episode of Psychosis is often used interchangeably with Scizophreniform Disorder.

Question 29

Schizophreniform Disorder

Answer 29

``` Characterized by the presence of the symptoms of schizophrenia, but it is distinguished from that condition by its shorter duration, which is at least 1 month but less than 6 months. Delusions Hallucinations Disorganised Behaviour (catatonia) Negative Symptoms ``` ❖ There can be no manic, depressive or mixed depressive episodes during these symptoms and any mood disturbance must have been present during only a minority of this time, thereby excluding schizoaffective disorder or bipolar disorder with psychotic features. ❖ Symptoms cannot be due to the effects of substance (drug of abuse or medication) or a nuerologiocal disorder

Question 30

Comorbidity in First Episode of Psychosis (FEP)

Answer 30

As many as 80-90% of people with FEP fulfils the criteria for at least one co-morbid psychiatric disorder including major depression, Anxiety Disorders (including social phobia and post traumatic stress disorder) and obsessive compulsive disorder,

Question 31

Relapse risk factors

Answer 31

non-adherence to medication, substance use, poor pre-morbid adjustment, ‘critical comments’ from family and supports A young person may experience a number of Early Warning Signs 1-4 weeks preceding a relapse. Important to avoid being unrealistic.

Question 32

Kraepelian view of schizophrenia

Answer 32

relentless dementing illness associated with inevitable deterioration- “Dementia Praecox”, believing that these patients suffered from an early form of dementing illness. ❖ Held the belief that biological and genetic disorders cause psychiatric illness.

Question 33

Eugen Bleuler view of schizophrenia

Answer 33

not all schizophrenic patients eventually become demented and that the prognosis of the disease is not uniformly grim, as Kraepelin suggested. ❖ Advocated for the discharge of some schizophrenic patients from the hospital rather than a lifelong commitment, which was common practice in the 1800s. ❖ Was an early proponent of what has come to be known as the biopsychosocial model in psychiatry.

Question 34

duration of untreated psychosis (DUP)

Answer 34

longer DUP is associated with worse functional outcomes in addition to persistent symptoms, poorer quality of life and lower treatment response ❖ Early intervention as a service model evolved in the mid 1980s Mean duration of untreated psychosis (DUP) of 1-2 years significant association between DUP and homicide (longer duration, more likely homicide risk)

Question 35

Help Seeking Delays

Answer 35

* No Knowledge of psychosis * Difficulty differentiating from ‘normal’ adolescent issues * Paranoia and mistrust * Negative Symptoms * Stigma * Insight and engagement with services

Question 36

Health Service Delays

Answer 36

* Not recognising Symptoms at First Contact * Delays to Assessment * Delays to referral * Delays within mental health services * Not recognising importance of prompt treatment

Question 37

Critical period in psychosis

Answer 37

❖ About 80% of people experience their first episode of psychosis between the ages of 16 and 30. Clinical deterioration and subsequent psycho-social impacts are most marked within the first 3-5 years after an acute episode of psychosis, and then plateau after this time

Question 38

Aetiology

Answer 38

❖ Biological (e.g., genetic, physiological, biochemistry) and may be present from birth ❖ Psychological (e.g., young person’s upringing, emotional experiences and interactions with other people). ❖ Social Factors (e.g., young person’s present life situation and sociocultural background

Question 39

Stress-Vulnerability Model

Answer 39

Generally accepted that psychosis results from impact of stress and other risk factors upon biological predisposition. ‘stress vulnerability’ interaction ❖ The greater the person’s vulnerability, the less stress is required to trigger an episode of psychosis. Straw that broke the camels back/buckets overflowing analogies used here. e.g. relationship breakup causes psychosis after build up of other stressors e.g. exams.

Question 40

Distal: Feotal and early life risk factors for psychosis

Answer 40

❖ Maternal complications/perinatal trauma, especially foetal hypoxia ❖ Family history ❖ Candidate genes ❖ Developmental delay ❖ Season of Birth (late winter early spring) ❖ Ethnic Minority Early Life ❖ Quality of early rearing environment ❖ Trauma (abuse & neglect) ❖ Vulnerable Personality (e.g schizoid personality)

Question 41

Proximal Risk Factors (closer in time to episode)

Answer 41

``` Age ❖ Urbanicity ❖ Substance Use, especially cannabis use ❖ Traumatic Head Injury ❖ Stressful life events ❖ Poor functioning ❖ Subtle impairments in cognition ❖ Cognitive, affective and social disturbances subjectively experienced by the individual (‘basic symptoms’), ❖ Migration ```

Question 42

Following a first episode young people may have different symptom trajectories:

Answer 42

- No further episodes (50%) - At least one further relapse(50%) - Multiple relapses (35%) - Severe, persistent and unremitting (15%)

Question 43

Clinical Staging Model

Answer 43

Prodromal phase, acute phase, recovery phase Assumes that treatments are offered earlier in the course of an illness have the potential to be safer, more effective and affordable than those offered later in the course of the illness. More clinical utility- matching of the timing and intensity of interventions. Prodrome can only be identified retrospectively!

Question 44

Attenuated Psychosis Syndrome

Answer 44

DSM-V Attenuated Psychosis (condition for “further study”). The proposed diagnostic criteria for APS in DSM - 5: • At least one of the following of symptoms is present in attenuated form, with relatively intact reality testing and is of sufficient severity or frequency to warrant clinical attention: •Delusions •Hallucinations •Disorganized speech. •Symptom(s) must have been present at least once per week in the last 1 month •Symptom(s) must have begun or worsened in the past year •Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical attention Symptom(s) is not better explained by another mental disorder,

Question 45

Identifying those truely experiencing Prodrome? | Ultra-High Risk (UHR)

Answer 45

Moderate but sub-threshold symptoms, with moderate neurocognitive changes and functional decline to caseness or chronic poor functioning (≥ 30% drop in SOFAS in previous 12 months OR < 50 for previous 12 months). • People UHR of psychosis are associated with an approximately 30% risk of developing psychosis in the following two years, 400 times greater risk than normal people, three- to four-fold higher risk than people with a family history alone STATE (using CAARMS): BLIPS (full threshold psychotic symptoms for less than a week); Attenuated Psychotic symptoms (APS). • TRAIT: Schizotypal personality disorder or first degree relative with psychosis • One of the above in addition to all of the following: Age 15-25, Help-Seeking, plus ≥ (30% drop in SOFAS in previous 12 months OR < 50 for previous 12 months) or longstanding low functioning.

Question 46

Debates around ultra high risk

Answer 46

* Strong debate regarding “false positive” cases, since most UHR subjects will not finally develop psychosis. * Transition rates to psychosis highly variable (?30%) and have been declining over the years, leading to fierce criticism over the validity of the UHR/ APS state and legitimacy of its treatment. * Ethical issues of stigmatizing through unnecessary diagnosing and antipsychotics’ prescribing are matters of serious questioning clinical heterogeneity and high comorbidity are further implications of the UHR state.

Question 47

Domains of Assessment

Answer 47

❖ Clinical & Personal History ❖ MSE: Relevant to all MSE domains! In particular Insight & Judement. Insight includes whether the person recognises that hey have an illness, that the illness is a mental disorder, and that treatment is required. ❖ Biological Assessment: Although only 3% of FEP has an organic origin, the initial assessment is the most appropriate time for laboratory tests ❖ Cognitive Assessment: deficits pre-date onset, are present at first episode and alter little thereafter ❖ Assessment of co-morbid disorders: substance use ❖ Assessment of other psychiatric disorders ❖ Risk Assessment

Question 48

Risk Assessment- Risk to Self

Answer 48

20% of people with FEP report deliberate self harm or a suicide attempt prior to presentation for treatment. 50-65% will have experienced recent thoughts of suicide • Small number of people commit suicide in response to command hallucinations. Risk Assessment Needs to be systematic and routine and involve multiple risk domains & both Dynamic Factors: risk to self and other, substance use, adherence to treatment and Static Factors such, mental health and personal history (e.g family history of mental illness), significant medical co morbidities, metabolic risk, legal (including involuntary treatment status).

Question 49

first-line treatment for psychotic disorders

Answer 49

Pharmacotherapy “Start Low, go slow" particularly low-dose antipsychotic medication, may be effective in preventing or delaying transition to psychosis in the short-term when combined with CBT Allow an antipsychotic drug-free assessment phase (whilst you may assess for biological explanations for the presenting pictures; ?delirium, drug induced psychosis etc May add benzodiazepine at this stage to manage agitation/aggression, anxiety or sleep disturbance Medication is not as effective in preventing the onset of a psychotic disorder and may in fact, place individuals at risk of transitioning to psychotic disorder

Question 50

Psychological Treatments

Answer 50

CBT considered to have the most extensive evidence base. ACT shows early promise in treating psychotic disorders effectively. ACT maps well onto contemporary recovery principles.