MADNESS PSYCHOSIS AND SCHIZOPHRENIA Schizophrenia Drugs Cocaine LSD

MADNESS PSYCHOSIS AND SCHIZOPHRENIA

Schizophrenia Drugs • Cocaine, LSD, Cannabis, Alcohol • L-Dopa, Steroids, Anticholinergics Metabolic • Ca 2+, MG 2+, Cu 2+, PSYCHOSIS Vit B 12 Mania Depression Schizoaffective Disorder Puerperal psychosis Other psychotic disorders Endocrine • Thyroid, Cushing’s, Addison’s Infections • Encephalitis, syphilis, any DELIRIUM Acute brain failure • Clouding of consciousness • Attention defecit PERSONALITY DISORDER • Parapsychotic phenomena DEMENTIA Encephalopathy, Acquired Brain Injury, Stroke, etc. • • Alzheimer’s Vascular Parkinson’s/Lewy Body Huntington’s

≃“off legs” PSYCHOSIS [clear consc iousness & in tellectual capacity usu ally preserv ed] • Hallucinations • Delusions REALITY FAILURE Group of pathologies which disrupt the process of perceiving and interpreting reality. [various causes] [thought disorganisation] [abnormal attention/salience] [h ] s n o i t a allucin [delus ions] [inappropriate/blunted affect]

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 S 255– S 264, https: //doi. org/10. 1093/schbul/sbu 005

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 * Fineberg SK & Corlett PR. 2016. The Doxastic Shear Pin: Delusions as errors of learning and memory. Cog Neuropsych. 21, 1: 73 -89

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

SCHNEIDER’S FIRST RANK [pathognomonic… sort of] SYMPTOMS 3 Hallucinations: Misc: • Thought Echo • Passivity phenomena • AVH*: 3 rd Person Arguing • Delusional Perception • AVH: Running commentary 3 Thought phenomena: • Thought withdrawal • Thought insertion • Thought broadcasting *AVH = Auditory Verbal Hallucination

TIME FOR SOME NEUROBIOLOGY • Significant genetic component – Heritability ~80% – Prevalence ~1% – >200 genes – Genes for D 2, 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)

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]

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

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? ”

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

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.

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