WEEK 1 Flashcards
1
Q
Bryan Charnley self portraits
A
drew self portraits over the course of stopping antipsychotics. the aim was to realize when he’d gotten psychotic and go back on meds, but he lost insight and killed himself.
2
Q
common psychosis symptoms
A
- having your mind read
- hallucinations, mainly auditory but also visual, olfactory, sensory…
- inability to filter out irrelevant stimuli
- paranoia - that people are out to get you
- thought-broadcasting
- depression is common alongside psychosis
- nihilistic delusions + feelings of body decay at the extremely worrying stage
- loss of insight
3
Q
key aspects of asylums in the 1800s
A
- should provide good accommodation
- built in green areas outside cities
- provide a healthier lifestyle for patients
- allow patients to recover away from the poor living conditions of the victorian cities
4
Q
deterioration of asylum conditions
A
prior to 1845, conditions were great and patients were well looked after. however, since they were separated from their families, there was a lack of patient recovery. this led to the system being overwhelmed due to the sheer amount of numbers. conditions worsened by the turn of the 1900s. the mentally ill were segregated from the rest of society, forgotten.
5
Q
Kraepelin
A
- had the biggest effect on the classification of mental health.
- considered the existence of a disease called dementia praecox, now known as schizophrenia. he compared it to alzheimer’s, except that its onset was early in life. he also distinguished it from ‘manic depressive insanity’ which has a fluctuating course and frequent relapses but a better prognosis.
6
Q
Bleuler
A
- coined the term schizophrenia
- unlike Kraepelin, believed there existed many types of schizophrenia.
- thought it was a psychological reaction rather than an organic neurodegenerative disorder (Kraeplin)
- more optimistic about the outcome
7
Q
the four As of schizophrenia (Bleuler)
A
- autism: difficulties in social communication
- ambivalence: uncertainty
- loose associations: unusual forms of thought
- blunting or incongruity of affect: lack of incongruity in the display of emotions
8
Q
Kraeplinian view of Psychosis
A
- still used 100 years later, modified by Bleuler
- divide people with psychosis into people with dementia praecox (schizophrenia) and people with manic depression (bipolar disorder).
9
Q
Schneider’s first rank symptoms
A
- believed that Bleuler’s ideas were too complex for psychiatrists to reliably detect schizophrenia
- list of symptoms:
1) auditory hallucinations: thought echo, third-person hallucinations, running commentaries
2) thought insertion or withdrawal: thoughts that are alien to you being inserted or withdrawn thoughts
3) thought broadcasting
4) “made” acts, thoughts, or feelings via external force
5) delusional perception
10
Q
Positive symptoms
A
- the presence of abnormal phenomena:
1) delusions: fixed false idea, unshakeable, and not shared among people by the same culture
2) hallucinations: perception when there is a lack of stimulus
3) formal thought disorder: disorganized thinking
11
Q
Negative symptoms
A
- the absence of normal behavior
1) flat or blunted affect: lack of emotional response
2) cognitive difficulties
3) poverty of speech
4) loss of initiative and motivation
5) self-neglect
6) social disinhibition: embarrassing or rude behavior
12
Q
Schizophrenia rates according to age and gender
A
- peaks at 16-25, children are unlikely to develop it
- women develop it later in life. the theory is that estrogen is protective, so they are less likely to develop it during reproductive periods.
- neurodevelopmental disorders are more common in males
- schizophrenia is seen as a language disorder - the disorder of your inner language
13
Q
Phases of schizophrenia
A
premorbid phase, prodromal phase, onset/deterioration phase, stable/improving phase
14
Q
four year outcome of schizophrenia
A
- some people have one episode in their lifetime
- some have one episode every two to three years
- some have several episodes but their symptoms continue throughout
- some people have several episodes with symptoms that continue, accumulate, and get worse over time - particularly their negative symptoms.
15
Q
course/prognosis of schizophrenia
A
- 40% will have no positive upsetting symptoms at 10 years, but about half of them will still be taking meds
- 40% will have relapses and remissions
- 20% never recover, going into a chronic state called “tx-resistant”
16
Q
5 dimensions of psychosis symptoms
A
1) positive dimension: delusions + hallucinations
2) negative dimension: loss of motivation + cognitive difficulties + self-neglect
3) disorganization dimension: thought disorder + jumbled up speech
4) manic dimension
5) depressed dimension
17
Q
dimensions of psychosis and responses to treatment
A
- those in the positive dimension respond best to antipsychotics
- those in the manic dimension respond best to mood stabilizers
- those in the depressed dimension respond best to antidepressants
18
Q
continuum of psychosis
A
- in the general population, 15% experience what psychiatrists would call psychosis symptoms.
- like anxiety and depression, people experience psychosis at some point in their lives
19
Q
Tim Crowe
A
- first person to apply brain scanning to people with schizophrenia
- found that people with schizophrenia showed larger fluid-filled space in the center of the brain and less cortical volume compared to healthy comparisons
20
Q
Danny Weinberger
A
there is a developmental problem making one more vulnerable to psychosis, and not an inevitable deterioration. it is neurodevelopmental, not neurodegenerative.
21
Q
progressive brain changes in psychosis
A
- what we thought was progressive neurodegeneration because of the illness was in part due to:
1) antipsychotics
2) cannabis and other drugs
3) stress and cortisol damage
4) lack of exercise - changes in lifestyle + decreasing antipsychotic dosage can improve this
22
Q
psychosis: loci implicated
A
- DRD2 dopamine receptor gene
- glutamate genes that influence dopamine release
- neurodevelopmental genes
- genes related to infection and stress
you can now calculate your polygenic risk score
23
Q
copy number variants
A
- duplication or deletion of certain parts of your dna sequence, leading to an abnormal number
- common in schizophrenia, autism, and learning disabilities
- if you lose or duplicate a chunk of your DNA, and if these are neurodevelopmental genes, this will mess u p the development of your brain
- the same CNVs may cause schiz, autism, and learning disabilities.
- CNVs are rare but dramatically increase your liability (possibly 10x more likely to develop schizophrenia)
24
Q
continuum of neurodevelopmental disorders
A
impairments form learning disabilities to autism through to schizophrenia
25
2 genetic contributors to schizophrenia
1) polygenes (96-97%)
2) copy number variants (3-4%)
26
schizophrenia and the dopamine system
- associated to an increase in dopamine synthesis in the striatum
- since we can't do much about the release of dopamine, antipsychotics block dopamine receptors to calm a patient down
- the higher the dopamine levels in the striatum the more likely you will develop psychosis. as you develop it, dopamine levels continue to increase.
- more dopamine = increased likelihood of you attributing salient importance to insignificant things in the environment.
- dopamine abnormality arises in the prodrome
27
drugs and psychosis
- using too many amphetamines/metamphetamines can increase the risk of psychosis
- people who use cannabis may be twice as likely to develop psychosis. this is especially significant during early developmental stages (using by 15 years of age, 4.5 times more likely). higher potency cannabis (skunk) increase your chances way more than lower potency cannabis (hashish).
- synthetic cannabinoids (spice or k2) increase your chance of becoming psychosis in a number of days. this is an epidemic in the UK as its easy to smuggle and not detectible by routine tests.
28
developmental cascade to psychosis: pathways
1) developmental route: polygenes, CNVs, obstetric complications, childhood difficulties
2) drug abuse
3) dopamine dysregulation
29
incidence rates: cities
- living in a big city increases your likelihood of developing psychosis
- urban cities in the north have a higher prevalence of psychosis for some reason
30
migration and schizophrenia
- risk ratio of 1 for british whites, 2.5 non-british whites, 1.4 south-asian, 5.8 african, 9.1 african-carribean
- this is due to the social position these ethnicities find themselves in when migrating
- incidence is higher in those who migrated from developing countries or from countries with a majority black population.
- particularly high incidence in visible minorities.
31
stress and dopamine release
- drug-naive schiz patients release more DA under stress, followed by high-risk patients compared to controls
32
childhood experiences and dopamine release
- individuals who were abused as children are more likely to release more dopamine while under stress
- individuals who had more than 2 family arrangements are also more vulnerable to stress
33
clinical approach to acute psychosis
- antipsychotics (dopamine blockers)
- remove the stress: change the environment + CBT
- needs to be a combo of pharmacology, social changes, and CBT
34
urbanicity and schizophrenia
urbanicity = population density
- throughout the course of childhood, the incidence of schiz is higher the higher the population density
- for the highest density rate in a capital city, incidence of schiz is twice as high than in the most rural areas.
- dose-response type effect: the higher the pop density the higher the risk
- moving out of urban areas reduces incidence, and moving into urban areas increases incidence
35
incidence by migration generation
- incidence rates between first-generation and second-generation migrants is quite similar, in fact it is somewhat elevated in second-generation migrants. this means that the higher incidence rates have nothing to do with migration itself, but maybe living as a minority in a majority population
36
social risk factors
1) neighborhood or area-level
- population density
- ethnic density
- deprivation
- social fragmentation
crime
2) individual-level experience
- indicators of risk: childhood (separation), adulthood (isolation)
- direct measures of experience: childhood (abuse, bullying), adulthood (discrimination, life events)
37
fragmented areas
= characterised by high level of geographical and social mobility, crime, proportion of migrant groups, living in single person households or rented accommodation
- as levels of fragmentation increase, so does the risk of admission for schizophrenia. this effect persisted even after adjusting for deprivation, so living in impoverished and deprived areas is not the key factor. the key factor is living in disjointed and fragmented environments.
38
ethnic density and risk ratio of schizophrenia
as the levels of ethnic density decline, the risk ratio of schizophrenia increases. so the risk of schizophrenia is higher in areas where people are more marginalized and more isolated. living in areas with more social support and integration might protect against schizophrenia.
39
childhood adversity
- rented apartment, low SES, single parent households, unemployment, receiving welfare benefits, parental death, neglect, emotional abuse, physical abuse, sexual abuse, bullying.
- risk of psychosis increases in relation to each of the indicators
- cumulative effect is linear
- being exposed to various types of childhood adversity is associated with later risk of psychosis but also other mental disorders so specificity is questioned
40
childhood trauma: specificity and severity
- out of all factors, bullying and maltreatment were most associated with later psychosis development, but not with accidents.
- these seem to be elements with intent to harm
- the combined effect of maltreatment + bullying is higher than each alone.
- in a sexual abuse study, all individuals who had experienced it during childhood had an increased likelihood of developing psychosis. but when separated in terms of severity (no penetration vs. penetration), the increased risk was only for the most severe level.
- so severity + specificity are important to consider
41
life events and psychotic experiences
- relevant experiences included: a serious accident, witnessed violence, being hurt with a weapon, attacked.
- events that involve intention to harm had the strongest effect on likelihood of psychotic experiences.
- there's a linear association - the more events you experience, the higher your risk.
42
discrimination and psychosis
- linear trend: the higher the level of discrimination felt, the higher the risk of psychotic disorder
- the greatest increase in odds of psychotic disorder is for those who experienced physical racial harassment over verbal harassment.
43
