Delusional disorder Catatonia Schizoaffective disorder
DSM5 (APA, 2013) for schizophrenia
Paranoid, disorganized, catatonic, undifferentiated, and residual sub-types removed Two Criterion A symptoms are required for diagnosis of schizophrenia. Requirement for a person to now have at least one of three “positive” symptoms of schizophrenia: Hallucinations Delusions Disorganized speech The APA believes this helps increase the reliability of a schizophrenia diagnosis.
ICD 10 (WHO, 1994)
The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time
Mental condition where somebody is unable to distinguish between reality and their imagination. Presents in schizophrenia, bipolar disorder Drug- or alcohol-induced
Psychosis vs. Psychopath
Psychosis - an acute condition that, if treated, can often lead to a full recovery. Psychopath - someone who has an incurable anti-social personality disorder, lack the capacity for empathy, behave in a manipulative fashion and often have a total disregard for the consequences of their actions.
Hallucinations and Delusions
Hallucinations False perception of something that is not really there; sight, sound, touch, smell, taste (Excludes dreams and illusions) Delusions Unshakeable belief, conviction; outside normal cultural and personal experience
Auditory hallucinations - major diagnostic symptom of schizophrenia. - Romme and Escher (1989) - 1:25 people may hear voices, but not be mentally ill. - 70% of people who hear voices, identify a traumatic event that triggered the voices. Positive or negative interpretation. - - Johns (2001) - continuity of psychotic experiences in general populations
An unshakable belief in something that is implausible, bizarre or obviously untrue. Two common types: Paranoid delusion will often believe that an individual or organisation is making plans to hurt or kill them, leads to unusual behaviour. Delusions of grandeur believe that they have some imaginary power, or authority.
Confusion of thought
People with psychosis often have disturbed, confused and disrupted patterns of thought. Signs of this include: speech may be rapid and constant, the content of speech appears random; switch from one topic to another in mid-sentence, and train of thought may suddenly stop, resulting in an abrupt pause in conversation or activity.
Lack of insight
People who are experiencing a psychotic episode often totally unaware that their behaviour is in any way strange that the delusions or hallucinations could be imaginary. May be capable of recognising delusional or bizarre behaviour in others, but lack the self-awareness to recognise it themselves. Often complain that all of their fellow patients are mentally ill while they are perfectly normal.
Genes scattered; all but 8 chromosomes have been implicated Indicates a polygenetic vulnerability to schizophrenia Genetic factors Family, twin and adoption methods indicate genetic predisposition and transmission Diathesis-stress model
Ventricles enlarged (not specific to schizophrenia) Impaired neuropsychological performance Loss of grey matter during adolescence Possible causes: Viral infection e.g. influenza and neonates Pregnancy and delivery complications Substance abuse e.g. cannabis
Excessive quantity of dopamine
Theory revised: Excess numbers of dopamine receptors or oversensitive dopamine receptors Dopamine abnormalities mainly related to positive symptoms Dopamine theory doesn’t completely explain disorder Antipsychotics block dopamine rapidly but symptom relief takes several weeks To be effective, antipsychotics must reduce dopamine activity to below normal levels Other neurotransmitters involved: Serotonin GABA Glutamate
Psychosocial factors. Adoptees with parents with high communication deviance showed elevated thought disorder. Pregnancy and delivery complications Pre-eclampsia leading to foetal hypoxia Low birth weight Viral infections in neonate (Tsuang, 2001)
NICE Clinical Guideline (CG82)
Schizophrenia guideline updated March, 2009 Psychological interventions CBT during acute phase or later; 16+ sessions Family intervention for those in close contact with families, during acute phase or later Arts therapies for negative symptoms NB social skills training not recommended Pharmacological interventions Oral anti-psychotics If first 2 unhelpful consider clozapine Depot injections
Key stages of CBT include 1) Developing a therapeutic alliance based on the patient’s perspective, 2) Developing alternative explanations of schizophrenia symptoms, 3) Reducing the impact of positive and negative symptoms 4) 4) Offering alternatives to the medical model to address medication adherence (Turkington, 2006)
Enhancements to CBT Treatment for Psychosis
Virtual reality with paranoia (Freeman, 2008) Advantages include the fact that paranoid thoughts cannot be based in reality and that the person cannot respond to a live human trigger Can be used to identify causal roles 3 treatment purposes; Exposure to persecutory fears Develop coping strategies Educational function
Family intervention should: (NICE, 2009)
include the person with schizophrenia if practical be carried out for between 3 months and 1 year include at least 10 planned sessions take account of the whole family's preference for either single-family intervention or multi-family group intervention take account of the relationship between the main carer and the person with schizophrenia have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work. Family intervention may be particularly useful for families of people with schizophrenia who have: recently relapsed or are at risk of relapse persisting symptoms.
Why Family Interventions?
Double-bind theory (Bateson et al., 1956) Communication deviance (Wahlberg et al., 2001) Odd use of language Inconsistency Incomplete Illogical Expressed emotion (EE) (Brown et al., 1958; Leff & Vaughn, 1985) Criticism Hostility Emotional over-involvement
Why focus on EE?
Risk of those diagnosed with schizophrenia relapsing after returning to high EE environment after inpatient treatment is 3-4 fold, compared to those in low EE environments (Kavanagh, 1992) Staff may have similar attitudes (Kuipers, 2006) Burden on carers What types of burden can you identify? High EE correlates with high subjective burden (Raune et al., 2004, cited in Kuipers, 2006)
Camberwell Family Interview (CFI) (Vaughn & Leff, 1976) Semi-structured Done individually with each relative Takes 4 hours per person Good predictor of relapse Family Questionnaire (Wiedemann et al., 2002) Briefer assessment of level of EE
What Causes High EE?
Harrison et al. (1998) proposed that 3 variables might be associated with higher levels of criticism among caregivers: Patients’ greater proportion of negative symptoms (as opposed to positive symptoms) Caregiver’s low level of knowledge of the illness Caregiver’s tendency to attribute negative symptoms to the patient (internal causal attributions) rather than to the illness (external causal attributions). Support gained for lower 2 hypotheses
Common Characteristics of Effective Family Intervention Programmes in Schizophrenia
Show concern, sympathy, and empathy to all family members who are coping with mental illness Provide information about the illness Avoid blaming the family or pathologizing their efforts to cope Foster the development of all family members Enhance adherence to medication and decrease substance abuse and stress Provide treatment that is flexible and tailored to the individual needs of families Encourage family members to develop social supports outside their family network Instil hope for the future Take a long-term perspective Strengthen communication and problem-solving
Two Types of Family Intervention
Applied Family Management Also includes behavioural training Coping skills Problem solving Communication skills (Davey, 2008) Supportive Family Management Focus on social support & reassurance
A number of family intervention manuals have been published e.g. Falloon et al. (1993) Barrowclough & Tarrier (1992) Kuipers et al. (2002)
FI Outcome Research
Sellwood et al. (2007) demonstrated that a manualised FI reduced relapse at 12 mths, and that this advantage was maintained at 5 yrs, when compared to treatment as usual. However number of re-admissions was not significantly different and no significant difference to time spent in hospital. Benefit related to relapses occurring in the community
Comparing CBT and FI
‘Generic CBT for psychosis is not indicated for routine relapse prevention in people recovering from a recent relapse of psychosis and should currently be reserved for those with distressing medication-unresponsive positive symptoms. Any CBT targeted at this acute population requires development. The lack of effect of family intervention on relapse may be attributable to the low overall relapse rate in those with carers.’ (Garety et al., 2008)
Drug side effects.
Side effects of typical antipsychotics include: drowsiness, shaking, trembling, muscle twitches, and spasms. Side effects of both typical and atypical antipsychotics include: weight gain, blurred vision, constipation, lack of sex drive, and dry mouth.