Psychotic Disorders

Question 1

Hallucinations

Answer 1

A perception-like experience with the clarity and impact of a true perception but without the external stimulation of the relevant sensory organ.
About 75% of schizophrenia patients report hallucinations.
Generally auditory hallucinations (eg hearing voices)
Also can be visual, olfactory, gustatory (taste), tactile and somatic (feelings located within body).

Question 2

Delusions

Answer 2

False personal beliefs that are fixed or transient, are firmly held despite what almost everyone else believes and despite clear proof that it’s not real.
Can be bizarre or non-bizarre, depending on if they are physically possible

Question 3

Paranoid delusions

Answer 3

Most commonly reported by patients.
Entail a belief that someone, or a force or agency, is seeking to harm the patient or their interested.
Try to avoid the threat by minimising contact with strangers or remaining vigilant.

Question 4

Somatic delusions

Answer 4

Entail a false belief regarding the appearance or functioning of one’s body (eg believes they have cancer).
Often highly distressing and can lead to the pursuit of multiple medical interventions.

Question 5

Grandiose delusions

Answer 5

Primarily associated with manic episodes (bipolar disorder), so psychotic symptoms are not restricted to psychotic disorders.
Include ideas that one has acquired special powers, worth, knowledge, abilities, influence, associations, achievements or even an alternate identity, often entailing power, wealth or fame.
Religious delusions - believe they are a religious figure.

Question 6

Nihilistic delusions

Answer 6

Typically associated with episodes of severe major depression.
A conviction that one is dead or that parts of one’s body or the environment have ceased to exist.

Question 7

Delusions of guilt

Answer 7

Associated with episodes of severe major depression.
Beliefs of personal responsibility and that punishment is deserved for specific events or outcomes, sometimes from catastrophic events eg earthquake or sometimes from negative events in the patients personal life eg death of someone close to them.

Question 8

Delusions of jealousy

Answer 8

Usually centred on the patients’ partner and include beliefs of infidelity.

Question 9

Erotomanic delusions

Answer 9

A false belief that the patients’ romantic feelings for another, often a person perceived by the patient to be of significant status or influence, are reciprocated by the other person.

Question 10

Disorganised thinking (formal thought disorder)

Answer 10

Refers to disturbances in the logical sequencing and coherence of thought.
Can range from subtle increases in the use of vague language to highly incoherent speech.
Positive (addition of disturbed thought process) or negative (deficits in thought processes) manifestations.

Question 11

Grossly disorganised behaviour (abnormal motor behaviour)

Answer 11

Can manifest in many ways, including ‘any form is goal-directed behaviour, leading to difficulties in performing activities of daily living’.
Includes catatonic behaviour (marked decrease in reactivity to the environment).

Question 12

Positive symptoms

Answer 12

Hallucinations, delusions, disorganised thinking, and grossly disorganised behaviours.
The addition of disturbance.

Question 13

Negative symptoms

Answer 13

Alogia, affective flattening, avolition.

Deficits in psychological processes.

Question 14

Alogia

Answer 14

Marked reduction in thoughts as reflected in decreased speech.

Question 15

Affective flattening

Answer 15

A lack of emotional expressiveness that may or many not be accompanied by a subjective loss of emotional experience.

Question 16

Avolition

Answer 16

A lack of initiation in activities.

Question 17

Diagnosis of psychotic disorders: core features

Answer 17

Psychotic symptoms persist for a least one to several weeks and cause significant interference with the person’s functioning in important domains in their life.

Question 18

Diagnosis of schizophrenia

Answer 18

Two or more symptoms present for a significant proportion of time during a one-month period:
Delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, negative symptoms.
At least one of the symptoms must be delusions, hallucinations or disorganised speech.
Must be present for at least 6 months.

Question 19

Diagnosis of psychotic disorders: associated features

Answer 19

Patients with psychotic disorder often suffer from depression.
Anxiety and trauma-related problems are common.
Substance abuse if common and can worsen symptoms.
Suicide rates are very high.
Quality of life is affected eg 40-50% of people with a psychotic disorder are unemployed.
Significantly affected by stigma Eg increased risk of violence.

Question 20

Prevalence of psychotic disorders

Answer 20

Lifetime prevalence of schizophrenia is 1-2%.
Slightly higher in men.
Peak period of onset is late adolescence and early adulthood.
Increased prevalence rate among migrants, people living in developed nations.

Question 21

The course of psychotic disorders

Answer 21

Premorbid phase: presence of risk factors prior to the onset of any symptoms.
Prodromal phase: preliminary period of decline in mental state and functioning prior to onset.
Acute phase: active positive and negative symptoms.
Early recovery phase: associated with depression and anxiety.
Later recovery phase: challenges with reintegrating into social, recreations and vocational pursuits.

Question 22

Aetiology of psychosis: genetic basis

Answer 22

Strong genetic component.

Question 23

Aetiology of psychotic fielders: gene-environment interactions

Answer 23

May develop when specific genes are activated through exposure to certain environments.
Focused on environmental exposure during developmental phases.
Foetal development (eg maternal infection)
Early childhood (eg trauma)
Middle childhood and adolescence (eg illicit substances)
Stress may increase risk for psychosis.

Question 24

Aetiology of psychotic disorders: neurotransmitters and brain structure

Answer 24

Abnormalities in certain neurotransmitters.

Numerous abnormalities in brain structure - enlarged ventricles which in diverse loss of brain tissue.

Question 25

Aetiology of psychotic disorders: psychosocial (social factors)

Answer 25

Residing in an urban environment, abuse, migration, social exclusion, racial discrimination.

Question 26

Aetiology of psychotic disorders: psychosocial (cognitive factors)

Answer 26

Early adverse experiences (eg trauma) can lead to dysfunctional cognitions, which trigger psychotic symptoms. Interpreting intrusive thoughts in a distressing manner can increase likelihood of future instructions.

Question 27

Triggering factors for psychotic disorders

Answer 27

Biological processes eg substance abuse. Psychosocial events eg stressful life events. Combination of the two.

Question 28

Symptom-specific aetiological factors: hallucinations

Answer 28

Auditory hallucination include a dysfunction in verbal self-monitoring. Patients mistake their own internal thoughts as voices in their head. Can occur due to cognitive dysfunctions and early childhood trauma/stress.

Question 29

Symptom-specific aetiological factors: delusions

Answer 29

Make cognitive errors (eg jumping to conclusions) Tendency to blame others for negative events, makes patient more suspicious of others. Memory may also play a role - more likely to have false memories (memories of things that never actually happened).

Question 30

Symptom-specific aetiological factors: thought disorder

Answer 30

Problems in the storage of information which leads to disorganised speech. Emotional distress may contribute to disrupted thought processes.

Question 31

Treatment of psychotic disorders: prodromal phase interventions

Answer 31

Emphasises early detection of those at risk, and intensive intervention to prevent progression to a more severe and enduring disturbance. Good evidence for the use of anti-psychotics in combination with CBT. CBT alone can reduce transition to psychosis in high-risk individuals. Involves challenging intrusive thoughts.

Question 32

Treatment: acute phase interventions

Answer 32

Need 24hr access to treatment at home from mobile teams, or hospitalisation. Psychoeducation critical to engage patient and family. Pharmacological approaches: anti psychotic medications, benzodiazepines (minor tranquillisers). Address co-morbidities eg substance abuse, depression, anxiety. Psychosocial approaches target social and occupational functioning once the most severe symptoms begin to improve.

Question 33

Interventions to prevent relapse

Answer 33

Relapse rates are high, especially if medication is stopped by patient. Psychological support for both individual and family is important. Social skills training. CBT: cognitive model of relapse helps patients have a sense of control over their symptoms (fear of relapse itself is a stressor). Group-based interventions to encourage social support and reintegration into society. Family interventions to reduce high expressed emotions (overprotective of individual but also critical and hostile) have been found to reduce relapse.

Question 34

Interventions of enduring psychosis

Answer 34

Alternative antipsychotic medications. | Addition of CBT to pharmacotherapy.

Question 35

Limitations of current treatment approaches

Answer 35

Poor access to mental health services (large proportion incarcerated). CBT and family interventions can be hard to access. Development of improved treatments needs to incorporate cultural values and perspectives eg Indigenous Australians. More research on effective interventions for comorbid disorders eg substance abuse and depression. Stigma.