PSYCHOSIS & SCHIZOPHRENIA

What is psychosis?

Psychosis can be defined: (Strahl, 2005)

Psychiatrically as:

• a gross impairment in reality testing
• a loss of contact with reality
• an inability to distinguish what is real from what is not real
• a loss of ego boundaries

Legally as:

• “Insane” when the person who committed the crime could not distinguish between right and wrong at the time the crime was committed
• Non Compos mentis (not of sound mind, memory or understanding)

In lay terms (at times pejoratively) as

• crazy, mad, lunatic, “psycho”, maniac

In DSM-IV-TR by the presence of:

• delusions, any prominent hallucinations, disorganized behavior, or catatonic behavior

What is the historical perspective on psychosis and schizophrenia?

Schizophrenia, in the various terms that have been used to describe it (madness, insanity, dementia praecox, unreason), has been around, perhaps, since the beginning of mankind.

However, it was not until the late 1800s that it was first actively studied. Changes in fundamental diagnostic concepts and their impact on both clinical work and research can be traced back well into the 19th century with, for example, Maudsley’s (1867) description of childhood “insanity” and Kraepelin’s description of dementia praecox (Kraepelin, 1919).

In 1980, Psychosis and Schizophrenia gained a renewed interest with the major changes in classification introduced by the DSM-III.

In 2007, the child and adolescent first-episode psychotic study, CAFEPS(Castro-Fornieles et al, 2007), became the largest early-onset first-episode psychosis sample ever studied and the one with the shortest duration of symptoms and psychopharmacological treatment.

What is schizophrenia?

The causes of schizophrenia are multifactorial, ranging from idiopathic formulations, through biological correlates (genetic factors, monoamine hypothesis, neurodevelopmental abnormalities, environmental stressors), to mostly discounted hypotheses such as psychosocial, double-bind and expressed emotion (EE) theories.

What is the diagnostic criteria of schizophrenia?

1. >= 2 symptoms <= month or less if treated:
   delusions, hallucinations, disorganized speech (incoherence) and behavior, negative symptoms (diminished emotional expression) OR 1 bizarre delusion OR running commentary OR >= 2 voices in conversation
2. Function (failure to achieve expected interpersonal
   or academic achievement in children and adolescents, or significant decline in work, interpersonal or self-care functioning in adults)
3. 6 month duration (continuous)
4. Mood symptoms, if present, are brief relative to other symptoms
5. Not secondary to substance or medical condition
6. If PDD, need hallucinations or delusions

is psychosis synonymous with schizophrenia?

• Do not assume that psychosis is synonymous with schizophrenia (Strahl, 2005; Volkmar, 1996)
• Psychotic symptoms also develop as a consequence of:
• a general medical condition (frontal lobe injury, thyroid disease, etc.)
• substance abuse (alcohol, hallucinogens, heroin, inhalants, psychostimulants)
• prescription drugs (steroids, stimulants)
• poisoning (anticholinergics, carbon monoxide, heavy metals)
• mood disorder with psychotic features (MDD, Bipolar I and II, Dysthymia)
• OCD (obsessive-compulsive disorder) – although OCD does not typically feature psychotic symptoms, the bizarre presentation can appear as psychotic
• personality disorders (paranoid, schizoid, and schizotypal personality disorders)
• PTSD (uncategorized trauma or failure of the mechanism of agentivity, Jeannerod), dissociative disorders
• multidimensional impairment (brief psychotic symptoms, poor affect regulation, difficulty with attention and impulse control)
• childhood-onset schizophrenia (spectrum)

how does childhood-onset schizophrenia differ from adult-onset schizophrenia?

• Compared with adult-onset schizophrenia, childhood-onset schizophrenia:
• is harder to treat, has worse prognosis and less robust responses to antipsychotic medications (more so in children)
• has higher rate of schizophrenia spectrum disorder reported in the families of childhood-onset schizophrenia probands (33% vs 10-20% in adult-onset schizophrenia probands)
• has more chromosomal abnormalities
• has characteristic progressive reduction in the volume of gray matter during adolescence

what are the similarities between schizotypy and childhood-onset schizophrenia?

It is similar to schizophrenia “prodrome” or clinical high risk state

• Schizotypy – concept coined by Gordon Claridge, after examining unusual experiences in the general population and the clustering of symptoms in diagnosed schizophrenia; can be broken down into 4 factors:
  1. unusual experiences (hallucinations, magical or superstitious beliefs)
  2. cognitive disorganization (derailed thoughts)
  3. introverted anhedonia (introverted, emotionally flat and asocial behavior)
  4. impulsive nonconformity (unstable mood with regard to rules)
• In the UCLA Follow-Up Study, Asarnow (2005) assessed 12 children with Schizotypal personality disorder (also referred as schizotypy) and 18 children with schizophrenia 1 to 7 years following initial project intake.
• Schizophrenia sample is comorbid with ADHD, CD/ODD, and Depression
• 17% deteriorate; 28% with good outcome at 3 follow-up years
• Outcomes for Schizotypy sample at 3 follow-up years: Schizophrenia or Schizoaffective disorder (25%), schizotypy (50%), bipolar (10%) and other (10%) disorders

what is the treatment of child-hood-onset schizophrenia?

Clozapine is superior to both (double-blind randomized controlled trial):

1. Haloperidol (Kumra et al., 1996); 6 weeks; N = 21 Clozapine led to greater improvement in symptoms, but was associated with neutropenia and seizures.
2. Olanzapine (Shaw et al., 2006); 8 weeks; N = 25 Clozapine led to greater improvement in symptoms, in particular negative symptoms, but was associated with lipid abnormalities and seizures.

what is the treatment of adolescent-onset schizophrenia?

• More similar to adult-onset schizophrenia than childhood-onset schizophrenia
• Olanzapine is superior to placebo (Kryzhanovskaya et al., 2005)
• Risperidone (Haas et al., 2009)
• Aripiprazole (Findling et al., 2008)
• TEOSS study (Olanzapine, risperidone and molindone)
• Ages 8-19 (childhood and adolescent-onset)

what do the individual, family or friends usually notice before the first psychotic episode, or in the so-called schizophrenia prodrome?

• Social isolation and anxiety
• Deterioration in role function (school)
• Attenuated or brief psychotic symptoms (illusions, overvalued ideas, suspiciousness)
• Nonspecific symptoms (anxiety, depression, irritability, apathy, withdrawal, lack of initiative and sleep disturbances)
• Estimated length of prodrome = 4 years
• Prodromal patients have a 30-40% risk of developing psychosis in ~ 2 years

what are the treatment interventions to try to prevent the first episode of psychosis?

• Antipsychotics may have some efficacy in preventing psychosis onset but are associated with side effects (olanzapine: weight gain; aripiprazole: akathisia; risperidone: prolactin increases)
• Psychological treatments (CBT) are well-tolerated but may only be effective for the duration of administration
• Neuroprotective strategies (omega fatty acids) are promising but require replication