> [!check] Objectives > - Describe symptoms associated with psychotic disorders. > - Diagnose psychotic disorders including Schizophrenia, Schizoaffective Disorder and Delusional Disorder  based on the history and clinical presentation using DSM-V criteria.  > - Review epidemiology of schizophrenia. > - Describe risk factors for developing schizophrenia. > - List prognostic factors in patients diagnosed with Schizophrenia. > - Outline the treatment of psychotic disorders. # Psychosis [[psychosis|Psychosis]] is a loss of contact with reality, in which people have trouble distinguishing between what is real and what is not. When this occurs, it is known as a psychotic episode. It involves: - changes in **thinking** - changes in **perception** - changes in **beliefs** - changes in **mood** - changes in **behavior** - lack of **insight** - this is pretty specific to psychosis #### Changes in Thinking Patients might have difficulty concentrating, following conversations, or remembering things. Thoughts might be jumbled, or not connect in a way that makes sense. Specific cognitive changes in psychotic disorders include changes in: - working memory - attention or vigilance - verbal learning and memory - visual learning and memory - reasoning and problem solving - (⭐️ - most common) ***speed of processing*** - social cognition (e.g., reading facial expressions) Psychotic patients might also experience differences in ***salience*** - which is a key attentional mechanism that facilitates learning and survival by enabling a person to focus their limited perceptual and cognitive resources on the *most pertinent subset* of available sensory data. #### Changes in Perception [[hallucinations|Hallucinations]] are false sensory perceptions that are not associated with any real external stimuli. They DO NOT arise from the sensory systems (e.g., a person can be congenitally deaf and still experience auditory hallucinations). > [!multi-column] >> [!people] Auditory Hallucinations >> - commenting (i.e., narration) >> - conversing (i.e., between 2 voices) >> - commanding (can cause harm to self or others) > >> [!inspection] Visual Hallucinations >> - shapes, shadows, lights >> - tend to be poorly formed >> >>*If they are very detailed, consider organic, pseudohallucination, or [[malingering]].* > >>[!palpation] Tactile Hallucinations >>- can occur from the "inside out" (e.g., bugs under skin) >>- can occur from the "outside in" (e.g., people are kissing my ear) > >>[!GI] Gustatory & Olfactory Hallucinations >>- tend to be foul or negative (e.g., burning rubber, garbage, rotting, etc.) #### Changes in Beliefs [[delusions|Delusions]] are fixed false beliefs that are based on incorrect inferences about external reality. They are inconsistent with the patient's intelligence and cultural background. They CANNOT be corrected by reasoning. Types of delusions include: - [[persecutory delusions]] - [[grandiose delusions]] - [[somatic delusions]] - [[religious delusions]] - [[erotomaniac delusions]] - [[delusions of infidelity]] - [[delusions of reference]] - [[thought broadcasting]] - [[thought insertion]] - [[thought withdrawal]] #### Changes in Mood Mood swings are often experienced during a psychotic episode. A person might feel unusually excited, depressed, or anxious. They might show very little emotion or less emotion to others who are around. #### Change in Behavior During a psychotic episode, many patients might act differently from how they normally do. This might be due to experiences like [[hallucinations]] and [[delusions]]. #### Lack of Insight **Insight** is the capacity to discern the true nature of a situation, which can include: - awareness of symptoms - attribution of symptoms to the disorder - awareness of specific signs and symptoms of a disorder - understanding of the social consequences of a disorder - awareness of the need for treatment A lack of insight (similar to [[anosognosia]]) is common in psychotic disorders (50-70%). It can either be complete (e.g. "there is nothing wrong with me") or partial (e.g., "it's just stress"). - patients who lack insight are less likely to adhere to treatment #### Positive vs. Negative Symptoms > [!multi-column] >> [!green] Positive Symptoms >> Mental phenomena that people normally DO NOT EXPERIENCE, such as: >> - [[delusions]] >> - [[hallucinations]] >> - [[disorganized thinking]] >> - excitement > >> [!red] Negative Symptoms >> A loss of function in different spheres of mental activity: >> - [[flattened affect]] >> - [[alogia]] (↓ spontaneous speech) >> - [[avolition]] (inability to initiate goal-directed behavior) >> - [[anergia]] (lack of energy / fatigue) >> - [[anhedonia]] (↓ pleasure) >> - [[asociality]] >> - [[inattention]] >> - [[ambivalence]] #### Epidemiology of Psychosis The lifetime risk of developing any of the [[psychotic disorders]] is ~3%. Interestingly, psychosis occurs ***worldwide at roughly the same incidence***, regardless of race, class, intelligence, culture, gender, or background. Risk factors include: - (⭐️) family history - use of cannabis and other illicit drugs (particularly in early adolescence) - brith complications - ↑ paternal age - stress (e.g., childhood trauma, refugee migration) ###### Prognosis > [!multi-column] >> [!blank] >> Recovery is less complete with each successive [[psychosis|psychotic episode]] relapse. In other words, regaining one's previous level of functioning is **more difficult with each successive episode**. It is therefore important to catch a person after their first episode, to try to keep them there so that they don't deteriorate. This is why early intervention is so important. > >> [!blank] >> ![[schizophrenia relapse prognosis.png]] # Schizophrenia ![[schizophrenia]] # Schizoaffective Disorder ![[schizoaffective disorder]] # Delusional Disorder ![[delusional disorder]] # Substance-Induced Psychosis ![[substance-induced psychotic disorder]] # Schizophreniform Disorder ![[schizophreniform disorder]] # Brief Psychotic Disorder ![[brief psychotic disorder]]