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Understanding Psychosis

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Richard Duffy

on 17 February 2014

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Transcript of Understanding Psychosis

At least 1 First Rank Symptom
Bizarre delusions
2 or more of:
Persistent Hallucinations
Catatonic symptoms (excitement, posturing, waxy flexibility, negativism, mutism, stupor)
Negative symptoms (apathy, paucity of speech, social withdrawl, blunted emotions)
Significant & persistent behaviour change
Thought disorder

Present for most of the time during a period of 1 month or more
Insight is not a binary concept

Levels of insight:

1. Recognition of Illness
2. Attribution of Illness
3. Awareness of treatment
4. Awareness of social consequences of illness
Psychotic symptoms may appear as a result of physical injury or disruption in the brains functioning (encephalitis, AIDS, tumor, thyrotoxicosis)

Organic psychosis usually accompanied by other difficulties, such as memory loss or confusion.

Visual hallucinations increase the likelihood that an illness is organic

MRI or CT can often confirm these diagnoses
Patients with longer duration of untreated psychosis (DUP) have a worse longer term prognosis
Much of the damage in biological and social function occurs within first 2 yrs of illness
Ireland - DETECT service – detection of first episode psychosis
Incidence 15 new cases anually per 100,000 pop.
approx. 675 new cases in Ireland anually
Males = females, Males earlier onset
Prevalence – life time risk of schizophrenia 700-1300 per 100,000
Irish Point prevalence 200–500 per 100,000
= approx. 40,500 cases

Affect blunting/flattening
Lack of drive
(related to hypofrontality in functional brain studies
? cortical cell loss)

Schizophrenic thought disorder
‘Negative’ symptoms - Often friends or family have more problems coping with these as they are often regarded as ‘bad’ behaviour.

The person might just stop going out, stop meeting up with friends, they may stay in bed all day, self care might be getting worse or they may smoke more.

‘Secondary’ features of these negative symptoms may include sleep disturbance, agitation, low mood, social isolation.
‘Positive’ symptoms - Talking to oneself or to ‘someone else’ who can’t be seen; appearing perplexed or distracted; expressing strange or bizarre beliefs about themselves, others or the world
e.g. “ I wrote all the Beatles hits”
" The TV is talking about me”

Other ways of recognizing positive symptoms is that the person may use unusual words or their conversation is hard to follow.
Some symptoms you might notice……
Positive symptoms refer to those symptoms that are ‘more than’ normal experiences

Negative symptoms refer to those symptoms or changes in behavior that are ‘less than’ a normal range of experiences
Positive & Negative Symptoms
ICD 10
B. Delusions of thought interference
thought insertion
thought broadcast
thought withdrawal
C. Delusions of control
Passivity of affect – made affect (feelings)
Passivity of volitions – made volition (will)
Passivity of impulse – made impulses
Somatic passivity
D. Delusional perception - a normal perception interpreted with delusional meaning
In the absence of organic pathology, the following are highly suggestive of schizophrenia: 11 symptoms in 4 categories

A. Auditory hallucinations
running commentary
hearing thoughts aloud - Écho de la pensée
third person - voices heard arguing - Gedankenlautwerten
Schneiderian First-Rank Symptoms
This diagnosis is made when a person has concurrent or consecutive symptoms of both a mood disorder (such as depression or mania) and psychosis.

In other words, the picture is not typical of a mood disorder or a psychosis, but displays various elements of both.
This is a severe depressive illness with psychotic symptoms mixed in, but without periods of mania or highs occurring at any point during the illness.
In BPAD, psychosis occurs in the context of mood disturbance

Psychotic symptoms, when present, tend to fit with the extreme highs and lows of the person’s mood. Mood congruency

A depressed person might hear a voice telling them to harm themselves or believe they are dead

A manic person may believe they are special and can perform amazing feats or have special role in the world
The presence of hallucinations and/or delusions without major mood symptoms is the essence of schizophrenia

Symptoms must be present for at least 1 month (ICD 10) or 6 months (DSM IV)
Main symptom- strongly belief in things that are not true.

Delusions are often circumscribed (restricted to one area or a limited number of areas)

Delusions are non bizarre and are unlikely but possible

No other evidence of psychosis (hallucinations, problems with language) but this does not stop this condition from being distressing & disruptive to the person and those around them

Five types - Erotomanic, Grandiose, Somatic, Persecutory, Jealous
Drug and alcohol use, intoxication or withdrawal can cause psychotic symptoms.

With intoxication these symptoms will rapidly resolve and disappear once the effects of the substance wears off.

Sometimes the symptoms last longer although they appear to have clearly begun with substance use (eg alcoholic hallucinosis)

May also occur with prescribed medications
Psychotic symptoms may arise suddenly in response to a major stress in the person’s life.

These stressors may include a death in the family, a sudden change in life circumstances or a particularly traumatic personal event (mugging, being sent to prison).

Symptoms may initially be severe but the person makes a full recovery in a few days.
Deferential Diagnosis
Psychosis is a symptom not an illness

Everybody’s experience is different and
unique to them

Attaching a specific name or label to a psychotic illness is not always useful initially

Diagnosis is usually attempted, depending on the duration and type of symptoms displayed

Diagnosis in first-onset psychosis is difficult
Making a Diagnosis
Poor Quality of Life

Increased burden to family and carers

High rate of depression, anxiety and substance abuse

High rate of suicidality – 15 - 38%

High prevalence of cardiovascular and respiratory illness.

Delayed diagnosis leads to
Lack of insight
Behavior can drastically change: extreme activity or lethargy, may laugh inappropriately or become angry for no apparent reason.

These changes can be explained by the symptoms previously described. A person believing they are in danger or that they have a special role will behave a certain way
Changed behavior
and functioning
In a psychotic episode, how someone is feeling may change suddenly for no apparent reason.

A person may feel ‘strange’ or cut off from the world, with everything, they may feel profoundly uncomfortable - delusional mood

Mood swings are common

A person may be less able to express their emotion - flattened or blunted mood
Everyday thoughts become confused or not linked correctly

Sentences do not make sense

May have difficulty concentrating, following a conversation or remembering

Thoughts appear to be speeded up or slowed down
Confused Thinking
Misperceptions or distortions of perceptions of external stimuli (real objects )

More fleeting than hallucinations

Occur when level of consciousness is reduced (e.g. delerium) or when attention is focused elsewhere
Lacks one or all of requirements for the definition of an hallucination:

A sensory experience that does not seem to the patient to represent external reality being located in the mind rather than in external space.
The sensory experience appears to originate in the external world but it appears unreal
A false perception which is perceived as occurring as part of ones internal experience and not as part of the external world.
Auditory – 2nd or 3rd person
Hallucinations - types

The subjective experience of an hallucination is that of experiencing a normal perception in that modality of sensation

A true hallucination will be perceived as:

In external space
Distinct from imagined images
Outside conscious control
Having relative permanence
In psychosis, a person may hear, see, smell, taste or feel something that is not actually there.

Perceptions which arise in the absence of any external stimulus (Esquirol, 1833).

They may hear voices when there is no one else around and there is nothing else to explain them
They may see things that other people can’t see.

How do you ask about that?
An isolated, acceptable and comprehensible idea pursued beyond the bounds of reason
Demonstrably false but held with virtual but not unshakeable conviction
May pre-occupy and dominate a persons life and affect their actions
Content is usually understandable when persons background is known
Theme tends to be culturally common
Over-valued idea
Also known as delusions of control or delusions of bodily passivity

The delusional belief that one is no longer in sole control of their body, that one is being forced by some external agent

Hard to ask about

Passivity of affect - to feel emotions
Passivity of impulse - to desire to do things
Passivity of volition - to perform actions
Somatic passivity - to experience bodily sensations
Passivity phenomena
Types of delusions
An abnormal belief held with absolute certainty
Requiring no external proof
May be held in the face of contradictory evidence.
Has personal significance
Excluding cultural and religious beliefs
of psychosis

Term psychosis has a number of different meanings

In popular use it can be a synonym for “severe mental disorder”

Used as a qualifier to distinguish this group of disorders from the “neurotic disorders”
What is Psychosis?
Dr. Richard Duffy, MRCPsych
Special lecturer, Psychiatry
Provides a rapid comprehensive assessment service for individuals who may be experiencing a first episode of psychosis.

Dedicated team of health care workers based in Blackrock .

Covers South Dublin and N. Wicklow area.

Funded by the HSE and the Hospitaller Order of St. John of God.

An effective Irish model of early intervention for people with first episode psychosis informed by developments in evidence based healthcare.
In a study by Ciompi in 1976, 228 patients with a diagnosis of schizophrenia were followed up over 37 years.
Complete remission 27%
Minor residual symptoms remained 22%
Intermediate course – symptoms arose episodically 24%
Severe – continued to be symptomatic 22%
Unstable / uncertain or were not classified 9%
Changed sense
of reality
Understanding Psychosis
History of
1860- Morel - Demence precoce
1863- Kahlbaum - Katatonie
1871- Hecker - Hebephrenie
1896- Krapelin - grouped catonia, hebephrenia and deterioating paranoid psychosis under dementia praecox
1911- Bluer - Schizophrenia, this included negative symptoms. His writings were influenced by Freud
1959- Schneider - First rank symptoms
1973- WHO - Finds diagnostic uncertainties
Psychosis is qualitatively different to normal experience (eg hallucinations/delusions)

In ‘psychosis’ there is a loss of contact with reality
“Neurosis” means exaggerated or quantitatively abnormal responses (eg exaggerated anxiety, exaggerated grief)
An inability to distinguish subjective experience from external reality

"Psychotic epsiode"
F00: Organic mental disorders (eg. dementia)
F10: Psychoactive substance usage
F20: Psychotic disorders (Schizophrenia)
F30: Affective Disorders (depression/bipolar disorder)
F40: Neurotic disorders (anxiety related)
F50: Behavioural syndromes associated with physiological disturbances (eating disorders)
F60: Behavioural syndromes not associated with physiological disturbances (personality disorders)
F70: Mental Retardation
F80: Disorders of psychological development
F90: Behavioural and Emotional problems usually developed in childhood.
It is this last point that distinguishes a psychotic depression from a bi-polar illness
"secondary to sleep deprivation."
He had to be locked out of the cockpit and restrained after he started ranting about religion and terrorists

Symptoms and length of illness vary between patients

Contrary to popular belief, many people with schizophrenia can lead full lives, many make a full and sustained recovery

Effects the ability to initiate and organise self-directed mental activity.

Consists of disturbances in thought, perception, mood and volition

Not split personality disorder
Delusional Jealousy
Three types
Affective – combination of heightened emotion and misperception
e.g. walking across a lonely park at night seeing a tree moving in the wind as an attacker
Completion – rely on brains tendency to fill in presumed missing parts of an abject to produce a meaningfull perception – basis of optical illusions
Both of these resolve on closer attention
Pareidolic – meaningful perceptions produced when experiencing a poorly defined stimulus
e.g. seeing faces in a fire or in clouds
Normal thinking
Organic Psychosis
Bipolar affective
Brief Reactive
Normal perception
The Dr Phil example
Perceptual distortions
Men with mental disorders live 20 years less and women 15 years less, than the general population. (Wahlbeck, 2011)
Thought retardation or poverty
Circumstantial thinking
Knights move thinking
Flight of ideas
Emotionally unstable personality disorder
Also known as borderline personality disorder
On the border between neurotic and psychotic disorder.
May experience psychotic or pseudo psychotic symptoms in times of stress
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