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Psychosis and schizophrenia

MADNESS. Psychosis and schizophrenia. Schizophrenia. Mania. Drugs. Depression. Cocaine, LSD, Cannabis, Alcohol L-Dopa, Steroids, Anticholinergics. Schizoaffective Disorder. Metabolic. Puerperal psychosis. Ca 2+ , MG 2+ , Cu 2+ , Vit B12. Other psychotic disorders. Endocrine.

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Psychosis and schizophrenia

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  1. MADNESS Psychosis and schizophrenia

  2. Schizophrenia Mania Drugs Depression • Cocaine, LSD, Cannabis, Alcohol • L-Dopa, Steroids, Anticholinergics Schizoaffective Disorder Metabolic Puerperal psychosis • Ca2+, MG2+, Cu2+, Vit B12 Other psychotic disorders Endocrine • Thyroid, Cushing’s, Addison’s PSYCHOSIS Infections PERSONALITY DISORDER • Encephalitis, syphilis, any • Parapsychoticphenomena DELIRIUM DEMENTIA Acute brain failure • Clouding of consciousness • Attention defecit • Alzheimer’s • Vascular • Parkinson’s/Lewy Body • Huntington’s Encephalopathy, Acquired Brain Injury, Stroke, etc.

  3. PSYCHOSIS ≃“off legs” • Hallucinations • Delusions [clear consciousness & intellectual capacity usually preserved] REALITY FAILURE Group of pathologies which disrupt the process of perceiving and interpreting reality. [thought disorganisation] [various causes] [delusions] [abnormal attention/salience] [hallucinations] [inappropriate/blunted affect]

  4. AUDITORY VERBAL HALLUCINATIONS • Thoughts/internal monologue experienced as external/ Other • Experienced by ~5% of healthy population • “an antecedent of clinical disorders when combined with negative emotional states, specific cognitive difficulties and poor coping, plus family history of psychosis, and environmental exposures such as childhood adversity.” * * Johns LC et al, 2014: Auditory Verbal Hallucinations in Persons With and Without a Need for Care, Schizophrenia Bulletin, Volume 40, Issue Suppl_4, Pages S255–S264, https://doi.org/10.1093/schbul/sbu005

  5. delusions • Fixed, false, unshakeable belief, out of context with cultural background • But nobody has unproblematic access to The Truth?? • ? Result of efforts to make sense of perplexity • “Doxastic shear-pin”: allow continued function in the face of paralysing difficulty* • What drives formation of the belief? • i.e. intense feeling of being controlled/persecuted/culpable etc. • Often persecutory • ? Default to fear in the face of uncertainty * FinebergSK & Corlett PR. 2016. The Doxastic Shear Pin: Delusions as errors of learning and memory. Cog Neuropsych. 21, 1: 73-89

  6. schizophrenia “NEGATIVE SYMPTOMS” • Anhedonia • Apathy • Social withdrawal • Blunted mood “POSITIVE SYMPTOMS” • Hallucinations • Delusions - Persecutory/Grandiose - Delusional perceptions - Delusions of control - Thought delusions “DISORGANISED SYMPTOMS” • Thought disorder • Disorganised speech/behaviour • Inappropriate affect

  7. Schneider’s first rank symptoms [pathognomonic… sort of] Misc: • Passivity phenomena • Delusional Perception *AVH = Auditory Verbal Hallucination 3 Hallucinations: • Thought Echo • AVH*: 3rd Person Arguing • AVH: Running commentary 3 Thought phenomena: • Thought withdrawal • Thought insertion • Thought broadcasting

  8. TIME FOR SOME NEUROBIOLOGY • Significant genetic component • Heritability ~80% • Prevalence ~1% • >200 genes • Genes for D2, neurodevelopment and inflammation • Excess of striatal dopamine • Especially in response to stress • Abnormal functional organisation of Default Mode Network • (stimulus-independent thought and self-reflection)

  9. Causes of psychosis Genetic component • Genes predisposing to SCZ must also confer significant advantage [?? A more flexible grasp of reality] Developmental adversity/abuse • Biased cognitive schemas • Sensitised striatal dopaminergic system [high expressed emotion, “double-bind” family dynamic] Life stressors [stress-Vulnerability Model] Relationship with recreational drugs [~25% of psychosis]

  10. treatment • Antipsychotics • Antidopaminergic(also serotonergic, anticholinergic, antihistaminergic…) • “Typical” and “Atypical” • Psychological therapies • CBT for Psychosis • Avatar therapy (just real enough to be immersive) • Sense of agency over voices

  11. eliciting psychotic symptoms Introducing the topic: Routine questions, normalise Start with open questions: • “How have things been for you lately?” • “Have you had any unusual or frightening experiences lately?” • “Anything which you can’t explain?”

  12. Auditory hallucinations: • “ When you are alone are you ever able to hear strange sounds?” • “ Are there ever voices where you can’t see who’s speaking?” • “What do they say? Do they give you commands?” • “How real do they seem?” • “Could your mind be playing tricks on you?” LOGICAL, CURIOUS QUESTIONS

  13. Delusions (persecutory) • “How safe do you feel?” • “What are your neighbours like?” • “Is anyone listening in on you/watching you?” LOGICAL, CURIOUS QUESTIONS Don’t reinforce, but do react normally.

  14. Summary • Reality is not something we can claim unproblematic access to (must hold central the reality of the patient) • Psychosis is a syndrome, not a unitary disease process • Don’t underestimate the social determinants of schizophrenia • Try to understand the person, and why they have become psychotic

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