Understanding Schizophrenia Spectrum Disorders

Hi, I'm Dr. Tom Field and I'm here to talk to you about the schizophrenia spectrum. Psychosis is a misunderstood condition. The way the media paints it, people with psychosis are dangerous, right, or a burden to society. In fact, most people with psychosis are distressed by their symptoms, recognize their experiences as unusual, want help for their symptoms, are peaceful and not violent. and are distressed by high expressed emotion by others. From a biopsychosocial perspective, there are three factors, all three factors are important to schizophrenia, all have a role, and the biological factors have a notable role. Genetics, there's a genetic component risk factor to schizophrenia. We know that there are changes, alterations to the default mode network and frontal limbic circuitry that we'll talk about in a minute. You also see dopamine system be dysregulated and a high amount of dopamine is associated with hallucinations and also delusions. And we should also note that substance use can impact this. That hallucinogen use and stimulant use can induce psychosis, especially if at high dosages. In terms of psychology, the psychological aspect, Spiritual beliefs and practices are often held by people with schizophrenia that are outside of accepted traditions, and those things can be complicated to assess for whether or not they are indeed delusional or they're just a spiritual practice. An example of this, let's say that a person develops, let's say, a belief system quite similar to a Wiccan belief system, and that things like casting spells and such are part of that. The question is... To what extent would someone in the Wiccan tradition accept their beliefs as being within the bounds of accepted tradition? Same thing with if a person, for example, believes that, has a belief system grounded in something like Christianity, would it be, again, something that people within that Christian community would consider as within the bounds of it, within the tradition? Even though what you see in schizophrenia and psychosis is that people developed belief systems outside of that, such as, you know, I am the, you know, a major religious figure within the tradition, right? I'm the second coming of Jesus Christ is one example of that. And people within those communities would reject that, right? And reject those beliefs and spiritual practices. Same thing with Wiccanism, with Wicca, that you will sometimes work with clients who they're, you know, They say things like, well, I wanted to cast this spell on a person because they were going to harm my dog. They'll come up with these really bizarre types of stories about their belief system that, again, most people from a Wiccan tradition would reject as being part of their accepted tradition. But again, it's hard to assess for sometimes. And then you have the social aspect. You should know that psychosis and schizophrenia especially is associated with homelessness. It's a bit of a chicken or egg, right? Is it that the person has schizophrenia and they were unable to care for themselves and they became homeless? Or is it that living on the street was very, very stressful and created something like a paranoia that was adaptive within a person that then led to schizophrenia? It's hard to know sometimes. But I will note here that people with schizophrenia can be on the fringe of society, right? Rejected by society, not cared for by society. I'll also note here again that high expressed emotion level within families can be detrimental for people with schizophrenia, and that is something you want to consider intervening with if you're working with people with schizophrenia, not only finding them housing and the basic case management work, but also making sure that family members and those around them are not making their symptoms worse. In terms of default mode network deficits that I had referred to previously, Remember, the default mode network is associated with this kind of free-flowing thoughts, thoughts that aren't necessarily attached to any directional ideas. So, for example, you may just be driving home, as the example I've given to you, and your thoughts are just wandering. You're not thinking about the road ahead of you. You're not thinking about what you've just done at work. You just, you know, they're floating around. And that kind of daydreaming is not problematic inherently, but you do see in ADHD, autism. and schizophrenia, that there is an impaired ability to kind of control those wandering thoughts, right? and that the person has difficulty with attention and concentration and that um you know their their thoughts are are just hard to kind of reign in if you will okay so sometimes called the impaired frontal parietal network part of the reason why we are very interested in different forms of things like meditation and you know ways to get people to focus attention in these kinds of issues is because of this we want someone to be able to engage right more of the executive functioning part of the brain the front frontal lobes to strengthen that the problem is that can be quite complicated for someone with or adhd autism or schizophrenia mindfulness just seems out of reach for them sometimes right that it's hard for them to be able to focus in the first place and to receive the benefits of mindfulness practice we're going to cover the following disorders within the category of schizophrenia spectrum just like autism schizophrenia is seen now as a spectrum that has different kind of levels of severity we'll look at schizophrenia then schizophrenia form brief psychotic disorder schizoaffective disorder delusional disorder then we'll look at three diagnoses within cluster a personality disorders that are all within the schizophrenia spectrum first let's talk about the relationship with psychosis and mood we talked about this a little bit last week, that you will have some clients who have mood symptoms, such as depression or maybe even bipolar disorder symptoms, mania or hypomania, and they also experience psychosis. And the question is, what is the diagnosis? So let's try to differentiate this a little bit, okay? On the left-hand side is, again, least severe, right-hand side most severe. On left-hand side, short-lasting or sub-threshold psychosis, meaning it doesn't last for a particularly long amount of time, not enough to meet the criteria for schizophrenia certainly and it's sub-threshold they don't meet all of the criteria needed the following fit within this schizophrenic form grief psychotic disorder and you also see this with schizotypal personality which is persistent sub-threshold psychotic symptoms and other specified or unspecified psychosis okay next you have psychosis only during a mood disorder episode okay mood episode you major depression with psychotic features bipolar disorder with psychotic features the hallucinations they experience they those only occur during the psychotic episode sorry so during the mood episode okay and not outside of it when the mood episode resolves the psychosis resolves next we have people who experience psychosis during and outside of the mood episode okay schizoaffective disorder would be the diagnosis here they may for example have periods of depression or hypomania or mania and they have hallucinations during those episodes and also outside of it. It tends to persist. It tends to be the one persisting symptom and in that case if they have recurrent mood episodes it would be schizoaffective disorder. Psychosis without major mood symptoms would be schizophrenia okay or a delusional disorder if it meets criteria for schizophrenia. I'll note here that you can have a mood episode of schizophrenia, but it has to be fleeting and not a huge part of the clinical picture if you look at, let's say, over the course of a year or two. So you can have someone, let's say they have two years of symptoms. Maybe 22 of those months they have hallucinations, delusions, negative symptoms. Only two of those months they have mood symptoms, if that makes sense. The predominant symptoms they're struggling with are psychotic symptoms, not mood symptoms. That would be more schizophrenia, whereas... schizoaffective they're going to have more mood symptoms they're either going to have them as much if not more than you know more often than not they'll be in a mood kind of state you know a mood disorder state such as depression or mania or hypomania. Okay now that we've learned about the spectrum let's take a look at schizophrenia. Schizophrenia requires two or more symptoms of the five listed for at least one month. Okay, you need to meet them for a month with six months of prodromal or residual symptoms. What prodromal means is that they have symptoms that maybe didn't meet all of the criteria, but definitely were symptoms of schizophrenia that were kind of leading up to. Okay, and then residual meaning they have some symptoms that persist afterwards. And these don't have to be one of the five symptoms, the prodromal or residual. It can be things like odd. beliefs or unusual perceptual experiences that you see in things like schizotypal personality and we'll explore that diagnosis later. Okay, but you need to have either pronormal or residual symptoms here. Okay, and then the five symptoms are delusions, hallucinations, disorganized speech. Disorganized speech meaning it's difficult for them to put words together. It's unclear when they speak. Grossly disorganized or catatonic behavior. Catatonic behavior, of course, is staring into space for long periods of time without, you know, any... real active thought happening. If you interrupt someone from a catatonic state, they'll say, I don't remember what I was thinking about. And then negative symptoms that include flat affect and abolition. There's a marked decline in functioning and mood disorders have been ruled out. Maybe actually just for a second, I should describe what negative symptoms are. The way to think about this is delusions and hallucinations are called positive symptoms. Those are symptoms that most people don't have. Those are additional perceptual experiences that most people don't have. So, for example, most people don't hear voices or see visions. Negative symptoms are the absence of experiences that most people have. Flat affect, not having a full, rich emotional life. Abolition, lack of motivation to accomplish most tasks. A person may do very, very little throughout the day. It's not that they're lazy. They just don't have motivation. They have abolition. And the specifiers are first or multiple episodes, currently an active episode or partial or full remission, continuous, ongoing, and with catatonia. Okay, you also have sub-threshold schizophrenia diagnoses here, kind of like PTSD and acute stress disorder. Schizophreniform, these are the same symptoms as schizophrenia, but they only last one to six months. Okay. Did I say for at least one month duration? Yes, with six months of prodromal. Okay, got it. So they do not have the six months of prodromal symptoms. The specifiers are with good prognostic features and without good prognostic features. Then you have brief psychotic disorder. And this is similar to schizophreniform, but symptoms last for one month and do not include negative symptoms such as flat affect and avolition. That's important because the negative symptoms are actually a major warning sign that they're... that this is going to be a long-term deal and it's going to be a progressive problem over time i say that because and you may or may not know this about schizophrenia in general the positive symptoms of hallucinations and delusions those actually improve over time okay but what tends to happen is the negative symptoms those tend to uh to worsen over time and so a person's hallucinations and delusions may not be as severe but there over time they may have less and less motivation to do things they may have a flatter and flatter affect those types of things and things to just be aware of okay and in general when you have negative symptoms you have a worse uh you know uh a a worsen prognosis okay then you have with and without mark stressor and uh with postpartum onset the stressor is important because here's stress again remember cortisol it's back baby And cortisol can cause a person to have psychosis if it's an exceedingly high amount of stress. And postpartum onset, you can have a postpartum or peripartum related psychosis. That again is brief, but when it's there, it's often frightening for the person to experience. So we've talked about this term good prognostic features. What does this mean? Well, I already mentioned negative symptoms. Let's talk about the other stuff. Onset of symptoms within four weeks of behavior change, meaning you don't have this slow burning prodromal pattern of a person slowly manifesting these symptoms. It feels pretty acute. The faster it comes, hopefully the faster it goes, right? Confusion, that can be good because the person is like, well, what's happening with me? What's going on versus a person who sees it as more egocentronic? Mood-related psychosis, because again... the psychosis will hopefully resolve when the mood symptom resolves mood episode results good pre-existing occupational and social functioning if the person has been working a job right they've been able to you know demonstrate um good friendships they've been in dating relationships it tells you that they're probably you know pretty likely hopefully to recover from this versus someone who they they've been on this kind of prodromal course for a while they don't really have a strong social support system they tend to be more loners or isolated That's not good because it tells you that probably they're at higher risk. And then, of course, the negative symptoms, absence of affect, a flat or blunted affect. If they have an absence of flat or blunted affect, that is a good sign, right, that those negative symptoms are a warning sign. When you are conducting an intake interview or a subsequent session and you're trying to get a sense for psychosis, it's interesting. There are some signs that have been shown. very obvious with psychosis. I will also say before I start to read some of these to you that you'll work with other clients who do not have really obvious presentations of psychosis because it can be very internal to them. You can have people, for example, during early psychosis or in mood episodes who experience psychosis who see hallucinations, let's say, and they don't want to tell anyone else and you would never know, right? You will also meet clients who experience the following and this is usually more of a marker of schizophrenia more severe problems neologisms so just making up words that don't exist they're just new words that are made up often and are referred to often contamination this is uh it's actually a term from the raw shark i got strained in the raw shark one time and uh what contamination means is you're adding these different concepts together that really don't fit together so as an example saying um You know, I had this vision just now that you were wearing a crab hat. You'd be like, what do you mean, crab hat? You know, it was a hat made of crabs. That doesn't exist, right? Those two ideas don't actually exist together in reality. Disorganization, disorganized speech can be difficult to understand them. And then at the extreme end, that would be word salad. where it all just sounds like a big mess and you can't really piece apart what the person's actually trying to communicate and incoherence. Loose associations, that they seem to kind of jump around from topic to topic. Preoccupied and ruminations, those can occur if the person's experiencing hallucinations, right, and they sense they are what's called responding to internal stimuli. Distracted and catatonia. Catatonia can be of course, a major sign of schizophrenia, but can be sometimes hard to differentiate from dissociative symptoms in PTSD, such as this kind of zoning out that people do sometimes. Emotional, you might see agitation or flat affect. Behavioral, a person may be anxious, guided or suspicious and may experience abolition. Anxiety is actually quite common. You'll see as we read some of the others, particularly schizotypal personality, that social anxiety can often occur. physiological, you know, it's not as pronounced. A person does not tend to be that agitated, that can occur I guess, but it's not as common. Let's talk about schizoaffective disorder next, since we've talked about schizophrenia now. We'll move into the way in which this can intersect with mood. This is marked by concurrent major mood episode, major depression or mania, with two of the five key symptoms of schizophrenia. okay delusions or hallucinations for two weeks outside of the major mood episode occur the mood episode lasts for the duration of the psychotic symptoms okay and if not you would diagnose schizophrenia so as I mentioned before more often than not they're having especially if this the psychotic symptoms persisting like perpetually they would be having there would be in a depressed episode more often than not or a manic episode more or not, and is less severe compared to schizophrenia. There's less occupational impairment, typically with schizoaffective disorder. There are two subtypes, bipolar and depressive type. Delusional disorder. Next. This is when a person meets only the criteria for delusions, not hallucinations, and they do not meet any of the other criteria for schizophrenia. They only have delusions, not negative symptoms, things like that. They have at least one delusion for a duration of at least one month. Functioning is not impaired. Behavior is not bizarre or odd. And the mood episodes are brief relative to delusional periods. Subtypes are as follows. Erotomanic, that means that a person imagines other people are in love with them. Grandiose, which is that a person imagines that they're on, you know, have, you know. exceedingly amazing capabilities. right that other people maybe haven't seen yet and they have great ideas that people just need to understand buy into and jealous that could be thinking that your partner is cheating on you without any evidence due cause to suspect it persecutory this is one of the most well known there are cameras set up in my house the police or the fbi are watching me the cameras are feeding back information about me. Somatic, there's a ghost in my chest. These can be quite bizarre delusions. And then you have mixed and unspecified. I'll note here that with these different delusions, the most important thing to understand here is that the person believes these things no matter the evidence. And they are deeply held beliefs that the person won't question. Or they may even be able to say. Well, I know that you don't believe this, or maybe I should believe this, but I do believe it. The person can't entertain the idea that it's not true. So what I'll mention to you about delusional disorder here that's important to take in is that it wouldn't be a shared delusion. It's not something typically that would be shared by other people. In fact, the other people around them are probably very disturbed by these delusions because it can lead to things like stalker behavior, right? Or it can lead to... you know a person becoming uh you know quite um isolative such as persecutory delusions and so they it is kind of disturbing to other people when these occur and so you know you would usually be hearing from other people around this person that you know they have this delusional problem and they probably need some help okay we're going to talk next about cluster c personality disorders cluster c sorry cluster a Where's my head at? These are personality disorders that are considered more schizophrenia spectrum now. Paranoid personality, schizoid and schizotypal personality. Let's begin with paranoid personality. This is a pervasive distrust and suspiciousness of the malevolent motives of others without evidence. Feels a little bit delusional, but it's really only about the mistrust in others. and it's a mistrust about everyone globally. The person suspects exploitation, harm, and deceit. They're preoccupied with doubts about trustworthiness and loyalty of friends or associations. They're reluctant to confide in others out of fear information will be used against them. And therapy is quite a challenge for someone, as you might imagine. They're always on guard and thinking that you may use information against them. In fact, even in therapy, I have seen... that a person making an inert kind of reflection of content could be misconstrued. So a person may say, oh, so you feel that your mother was pretty harsh to you this past week. And the person may respond with, what did you mean by that? Why did you pick that out? You know, the person with paranoid personality is always questioning your motives. They may read hidden meanings into benign remarks or events, just as I just mentioned. They may bear persistent grudges and be unforgiving. They may also perceive character attacks, even if no one means that, and react quickly in an angry fashion or counterattacking, and be suspicious of the fidelity of their partner. So in general, someone with paranoid personality is quite difficult to live with, as you might imagine. Most of the time they do not have long-standing relationships. They tend to be quite isolative because they don't trust other people. Schizoid personality. This is an extension of reactive attachment in childhood, which we haven't explored yet. It's this idea that a person doesn't really have a relational frame for attachment relationships. They don't really care about other people around them for relational purposes. A person with schizoid personality has a detachment from social relationships and restricted emotional expression in interpersonal settings. The reason for their restricted emotional expression It will be further explored when we talk about reactive attachment and under activation in the temporal lobes. What I'll say here is that you can kind of imagine a person living in the cabin in the woods by themselves. They don't want to see anyone. They don't want to talk to anyone. They're perfectly happy. And they don't have what's interesting. They don't have any interests, really. They always select solitary activities. They're apathetic to close relationships. They lack close friends. They have non-existent sexual interest. But they're also anhedonic. You know, they don't have things they love, but they enjoy. They just... tend to be kind of flat in the way they approach life. They seem indifferent to praise or criticism, doesn't just doesn't really bother them, and they're emotionally detached, cold with a flat affect. As you might imagine, someone like this is not going to initiate therapy on their own accord. If they are in therapy, they will despise it. It'll be a chore to them. So annoying, right, because they don't really care about the other person and what they think. I will add here that I have worked with people with schizoid personality on inpatient units They hate being there. They stay in their room. They don't come out until they're discharged. I will also add, I once worked with a late adolescent who had this and had a perfect job, which was they were a movie projectionist. They would go into the movie theater. They would hit the projector and just watch movies and had to interact with no one and loved it. That was a perfect job for them. Okay, schizotypal personality disorder. This one's an interesting one. It's a bit confusing to describe. It's not schizophrenia. And it's kind of like, to capture this, I want you to imagine, again, Theodore Milan's ideas about the kind of spectrum of personality. He talked about how people can trend eccentric, but this would be like extreme eccentricism, right? That is... above and beyond what would be in the bounds of accepted behavior. And I'll give you a clinical example in a minute of what I mean by this. I once was in, I think it was taken in Seattle, this is a photo in Seattle, I asked the person if I could take a photo of them, walking down the street in a Sasquatch outfit. Now, that is slightly odd behavior, but in the Northwest it's kind of the going thing, right? But I think you're looking more for dress and behavior that would be really off-putting to others. Like you look at this picture and it's kind of endearing, right? The person has clearly put a lot of effort into this task for a job. Whereas other people, their dress is kind of strange, odd. You know, you're not quite sure what to think of it. A person with schizotypal personality experiences acute discomfort in close relationships. They don't feel comfortable getting close to others. They're quite anxious. They want to have relationships, but they feel anxious and uncomfortable. They have perceptual and cognitive distortions, not usually hallucinations, but things like they may have ideas of reference. They may perceive things differently than other people. For example, the TV was sending me a message, that kind of thing. They can have eccentric behavior that includes ideas of reference, as I just mentioned. odd ideas or magical thinking right if i touch this thing then something else happens in the universe right unusual perceptual experiences odd thinking and speech paranoia flat affect lack of close friends and social anxiety so here's a clinical example i once worked with a young man on an inpatient unit and in general in an inpatient unit particularly with people who are younger they tend to bond very quickly to each other because they often haven't found people who kind of have struggled the way they have right through childhood and adolescence. And so it's pretty typical for a person to be roundly welcomed in an inpatient unit. If they're, you know, kind of in their, I would say, late teens, early 20s. However, this person was rejected by peers very quickly upon their entry into the unit. And the reason for that is they were in a group therapy session. in which a member was talking about the death of their dog and how sad that was to them, how much of a loss that was to them, to which the person with schizotypal personality responded, you know, actually, I think that's a... I'm really glad that happened. I cast a spell on your dog just a couple of nights ago. I was thinking about them, and I'm really glad that they died, because I think that'll be better for you. It won't be as much as, you know... that dog is going to do amazing things in the spiritual world. And as you might imagine, like, the person in the group was absolutely disturbed by this, you know, very upset by what the person said, who had lost their dog. And the person with schizotypal personality had no idea why. You know, in fact, the whole group kind of rallied behind the person who'd lost the dog and was, like, disgusted, really, with the person who had said that with schizotypal personality. After the group, I talked with them and I said, are you aware of how people responded to you there? And their sense was, well, yeah, but I don't get it. Why were they so upset with what I said? And so you can tell here that, again, the person is... behaves in an odd way that pushes people away it's not just your kind of northwest eccentric right it's more of a person who is indeed disturbing to others when they when they act and they have these kind of magical beliefs around you know i cast a spell those kinds of things that aren't grounded in reality right i mean the person had met the the client with excuse the terrible personality had not met the group member who'd lost their dog two days ago so there's no way they could have cast a spell on them, right? That's magical thinking. And so, you know, those are the types of things you're looking for with schizotypal personality. Again, it's hard to put your finger on, but it definitely comes across as a very odd eccentric presentation that is off-putting to others. We should also mention here life expectancy concerns with psychotic issues. 20% of individuals with schizophrenia attempt suicide and 5 to 6% die by suicide. And part of the reason for that is, of course, that depression can accompany it, as well as, you know, it's not pleasant to have to live with hallucinations, right? And to feel like you have difficulty with kind of organizing your life, right, of taking care of yourself. And also, of course, homelessness is another major factor here. About 80% are addicted to tobacco. It's a very high percentage. There's all kinds of theories as to why that is. But it also, of course, creates... potential life expectancy issues with things like lung cancer. The course is considered a chronic progressive illness. I've mentioned this before, but positive symptoms decrease over time because dopamine declines with age and negative symptoms increase. Be careful about olfactory hallucinations, by the way. When a client mentions olfactory hallucinations, that means things they are smelling. That can be potentially a sign of a brain tumor. So just kind of know that if a client says I'm smelling smoke, for example, then you probably want to get them neurologically evaluated. So what do we do to prevent schizophrenia and psychosis? Social connection during adolescence makes a big difference. We don't want people to be isolated. Social situations provide easy means to test out false assumptions that could become delusional. Connect with others emotionally and reduce social anxiety. So. Facilitating that, encouraging that is important. Note that psychotic symptoms do increase with isolation. We may also want to focus on family-focused therapy, reducing negative emotional displays particularly, which can be distressing. Reducing stress and fostering coping, as well as substance use prevention. In terms of case management, it's important that we consider referrals and coordinations with psychiatrists, nurse practitioners in their medication treatment, and look at medication adherence. Family involvement, of course, is another part of case management because often people with schizophrenia, specifically if they're younger, are cared for by family members. They live with family, and so making sure that the family understands how best to kind of intervene and help is useful. They may also themselves need help. They may feel burnout as caregivers. Supported employment and housing is very important so that a person is able to work a job and be independent. We also might provide psychoeducation on personal hygiene, medication adherence, the impact of substance use, relapse prevention, and a list of support people. In terms of treatment planning, we want more structured therapies here. Unstructured therapies like psychodynamic are not going to be the key here. A person needs something more structured because often their thoughts are quite scrambled. It's hard for them to think coherently. They may need inpatient service level. In cases where there's cognitive dulling, it's hard for them to concentrate and focus. Cognitive remediation therapy may be indicated. CBT is often used for coping with hallucinations and delusional beliefs. You can play things like the evidence game. Can you tell me the evidence for that? And if we don't have evidence, then we're only going to believe things that we have evidence for. Kind of introducing that as an idea. I once worked with a client with schizophrenia who would ask frequently, are you mad at me? Are you mad at me? And I would say, is there any evidence that I'm mad at you? And they would say, no, I guess not. So the evidence game helps. Behavioral activation, negative symptoms. So in other words, we want the person to get out of bed, to get active, get out there, do even things like volunteering, even if they're not capable of working a job. Because that helps, right, with self-esteem. It helps them to get out and about rather than to have this abolition, which will get worse over time, especially if they don't exercise. the muscle of forcing themselves, you know what I mean, to be active and out there in the world. So in summary, psychosis is associated with mood symptoms. When it exists outside of mood symptoms, the prognosis is worse. There are two major symptom clusters, positive symptoms marked by hallucinations and delusions, and negative symptoms, abolition, loss of motivation, catatonia, flat affect. Medication and medication adherence are often important treatment considerations. The goal for many clients is independence and coping. In other words, especially if you have schizophrenia, it's unlikely that's going to remit. The goal is independence and coping. Reducing heightened emotional displays within the person's environment can be helpful. And social involvement is a useful preventative measure. And that wraps this video lecture.

and are distressed by high expressed emotion by others. From a biopsychosocial perspective, there are three factors, all three factors are important to schizophrenia, all have a role, and the biological factors have a notable role. Genetics, there's a genetic component risk factor to schizophrenia.

We know that there are changes, alterations to the default mode network and frontal limbic circuitry that we'll talk about in a minute. You also see dopamine system be dysregulated and a high amount of dopamine is associated with hallucinations and also delusions. And we should also note that substance use can impact this. That hallucinogen use and stimulant use can induce psychosis, especially if at high dosages. In terms of psychology, the psychological aspect, Spiritual beliefs and practices are often held by people with schizophrenia that are outside of accepted traditions, and those things can be complicated to assess for whether or not they are indeed delusional or they're just a spiritual practice.

An example of this, let's say that a person develops, let's say, a belief system quite similar to a Wiccan belief system, and that things like casting spells and such are part of that. The question is... To what extent would someone in the Wiccan tradition accept their beliefs as being within the bounds of accepted tradition? Same thing with if a person, for example, believes that, has a belief system grounded in something like Christianity, would it be, again, something that people within that Christian community would consider as within the bounds of it, within the tradition? Even though what you see in schizophrenia and psychosis is that people developed belief systems outside of that, such as, you know, I am the, you know, a major religious figure within the tradition, right?

I'm the second coming of Jesus Christ is one example of that. And people within those communities would reject that, right? And reject those beliefs and spiritual practices.

Same thing with Wiccanism, with Wicca, that you will sometimes work with clients who they're, you know, They say things like, well, I wanted to cast this spell on a person because they were going to harm my dog. They'll come up with these really bizarre types of stories about their belief system that, again, most people from a Wiccan tradition would reject as being part of their accepted tradition. But again, it's hard to assess for sometimes. And then you have the social aspect. You should know that psychosis and schizophrenia especially is associated with homelessness.

It's a bit of a chicken or egg, right? Is it that the person has schizophrenia and they were unable to care for themselves and they became homeless? Or is it that living on the street was very, very stressful and created something like a paranoia that was adaptive within a person that then led to schizophrenia?

It's hard to know sometimes. But I will note here that people with schizophrenia can be on the fringe of society, right? Rejected by society, not cared for by society.

I'll also note here again that high expressed emotion level within families can be detrimental for people with schizophrenia, and that is something you want to consider intervening with if you're working with people with schizophrenia, not only finding them housing and the basic case management work, but also making sure that family members and those around them are not making their symptoms worse. In terms of default mode network deficits that I had referred to previously, Remember, the default mode network is associated with this kind of free-flowing thoughts, thoughts that aren't necessarily attached to any directional ideas. So, for example, you may just be driving home, as the example I've given to you, and your thoughts are just wandering. You're not thinking about the road ahead of you. You're not thinking about what you've just done at work.

You just, you know, they're floating around. And that kind of daydreaming is not problematic inherently, but you do see in ADHD, autism. and schizophrenia, that there is an impaired ability to kind of control those wandering thoughts, right?

and that the person has difficulty with attention and concentration and that um you know their their thoughts are are just hard to kind of reign in if you will okay so sometimes called the impaired frontal parietal network part of the reason why we are very interested in different forms of things like meditation and you know ways to get people to focus attention in these kinds of issues is because of this we want someone to be able to engage right more of the executive functioning part of the brain the front frontal lobes to strengthen that the problem is that can be quite complicated for someone with or adhd autism or schizophrenia mindfulness just seems out of reach for them sometimes right that it's hard for them to be able to focus in the first place and to receive the benefits of mindfulness practice we're going to cover the following disorders within the category of schizophrenia spectrum just like autism schizophrenia is seen now as a spectrum that has different kind of levels of severity we'll look at schizophrenia then schizophrenia form brief psychotic disorder schizoaffective disorder delusional disorder then we'll look at three diagnoses within cluster a personality disorders that are all within the schizophrenia spectrum first let's talk about the relationship with psychosis and mood we talked about this a little bit last week, that you will have some clients who have mood symptoms, such as depression or maybe even bipolar disorder symptoms, mania or hypomania, and they also experience psychosis. And the question is, what is the diagnosis? So let's try to differentiate this a little bit, okay? On the left-hand side is, again, least severe, right-hand side most severe. On left-hand side, short-lasting or sub-threshold psychosis, meaning it doesn't last for a particularly long amount of time, not enough to meet the criteria for schizophrenia certainly and it's sub-threshold they don't meet all of the criteria needed the following fit within this schizophrenic form grief psychotic disorder and you also see this with schizotypal personality which is persistent sub-threshold psychotic symptoms and other specified or unspecified psychosis okay next you have psychosis only during a mood disorder episode okay mood episode you major depression with psychotic features bipolar disorder with psychotic features the hallucinations they experience they those only occur during the psychotic episode sorry so during the mood episode okay and not outside of it when the mood episode resolves the psychosis resolves next we have people who experience psychosis during and outside of the mood episode okay schizoaffective disorder would be the diagnosis here they may for example have periods of depression or hypomania or mania and they have hallucinations during those episodes and also outside of it.

It tends to persist. It tends to be the one persisting symptom and in that case if they have recurrent mood episodes it would be schizoaffective disorder. Psychosis without major mood symptoms would be schizophrenia okay or a delusional disorder if it meets criteria for schizophrenia.

I'll note here that you can have a mood episode of schizophrenia, but it has to be fleeting and not a huge part of the clinical picture if you look at, let's say, over the course of a year or two. So you can have someone, let's say they have two years of symptoms. Maybe 22 of those months they have hallucinations, delusions, negative symptoms. Only two of those months they have mood symptoms, if that makes sense.

The predominant symptoms they're struggling with are psychotic symptoms, not mood symptoms. That would be more schizophrenia, whereas... schizoaffective they're going to have more mood symptoms they're either going to have them as much if not more than you know more often than not they'll be in a mood kind of state you know a mood disorder state such as depression or mania or hypomania.

Okay now that we've learned about the spectrum let's take a look at schizophrenia. Schizophrenia requires two or more symptoms of the five listed for at least one month. Okay, you need to meet them for a month with six months of prodromal or residual symptoms.

What prodromal means is that they have symptoms that maybe didn't meet all of the criteria, but definitely were symptoms of schizophrenia that were kind of leading up to. Okay, and then residual meaning they have some symptoms that persist afterwards. And these don't have to be one of the five symptoms, the prodromal or residual.

It can be things like odd. beliefs or unusual perceptual experiences that you see in things like schizotypal personality and we'll explore that diagnosis later. Okay, but you need to have either pronormal or residual symptoms here.

Okay, and then the five symptoms are delusions, hallucinations, disorganized speech. Disorganized speech meaning it's difficult for them to put words together. It's unclear when they speak. Grossly disorganized or catatonic behavior. Catatonic behavior, of course, is staring into space for long periods of time without, you know, any...

real active thought happening. If you interrupt someone from a catatonic state, they'll say, I don't remember what I was thinking about. And then negative symptoms that include flat affect and abolition.

There's a marked decline in functioning and mood disorders have been ruled out. Maybe actually just for a second, I should describe what negative symptoms are. The way to think about this is delusions and hallucinations are called positive symptoms. Those are symptoms that most people don't have.

Those are additional perceptual experiences that most people don't have. So, for example, most people don't hear voices or see visions. Negative symptoms are the absence of experiences that most people have. Flat affect, not having a full, rich emotional life. Abolition, lack of motivation to accomplish most tasks.

A person may do very, very little throughout the day. It's not that they're lazy. They just don't have motivation.

They have abolition. And the specifiers are first or multiple episodes, currently an active episode or partial or full remission, continuous, ongoing, and with catatonia. Okay, you also have sub-threshold schizophrenia diagnoses here, kind of like PTSD and acute stress disorder.

Schizophreniform, these are the same symptoms as schizophrenia, but they only last one to six months. Okay. Did I say for at least one month duration?

Yes, with six months of prodromal. Okay, got it. So they do not have the six months of prodromal symptoms. The specifiers are with good prognostic features and without good prognostic features. Then you have brief psychotic disorder.

And this is similar to schizophreniform, but symptoms last for one month and do not include negative symptoms such as flat affect and avolition. That's important because the negative symptoms are actually a major warning sign that they're... that this is going to be a long-term deal and it's going to be a progressive problem over time i say that because and you may or may not know this about schizophrenia in general the positive symptoms of hallucinations and delusions those actually improve over time okay but what tends to happen is the negative symptoms those tend to uh to worsen over time and so a person's hallucinations and delusions may not be as severe but there over time they may have less and less motivation to do things they may have a flatter and flatter affect those types of things and things to just be aware of okay and in general when you have negative symptoms you have a worse uh you know uh a a worsen prognosis okay then you have with and without mark stressor and uh with postpartum onset the stressor is important because here's stress again remember cortisol it's back baby And cortisol can cause a person to have psychosis if it's an exceedingly high amount of stress. And postpartum onset, you can have a postpartum or peripartum related psychosis. That again is brief, but when it's there, it's often frightening for the person to experience.

So we've talked about this term good prognostic features. What does this mean? Well, I already mentioned negative symptoms. Let's talk about the other stuff.

Onset of symptoms within four weeks of behavior change, meaning you don't have this slow burning prodromal pattern of a person slowly manifesting these symptoms. It feels pretty acute. The faster it comes, hopefully the faster it goes, right?

Confusion, that can be good because the person is like, well, what's happening with me? What's going on versus a person who sees it as more egocentronic? Mood-related psychosis, because again...

the psychosis will hopefully resolve when the mood symptom resolves mood episode results good pre-existing occupational and social functioning if the person has been working a job right they've been able to you know demonstrate um good friendships they've been in dating relationships it tells you that they're probably you know pretty likely hopefully to recover from this versus someone who they they've been on this kind of prodromal course for a while they don't really have a strong social support system they tend to be more loners or isolated That's not good because it tells you that probably they're at higher risk. And then, of course, the negative symptoms, absence of affect, a flat or blunted affect. If they have an absence of flat or blunted affect, that is a good sign, right, that those negative symptoms are a warning sign. When you are conducting an intake interview or a subsequent session and you're trying to get a sense for psychosis, it's interesting. There are some signs that have been shown.

very obvious with psychosis. I will also say before I start to read some of these to you that you'll work with other clients who do not have really obvious presentations of psychosis because it can be very internal to them. You can have people, for example, during early psychosis or in mood episodes who experience psychosis who see hallucinations, let's say, and they don't want to tell anyone else and you would never know, right? You will also meet clients who experience the following and this is usually more of a marker of schizophrenia more severe problems neologisms so just making up words that don't exist they're just new words that are made up often and are referred to often contamination this is uh it's actually a term from the raw shark i got strained in the raw shark one time and uh what contamination means is you're adding these different concepts together that really don't fit together so as an example saying um You know, I had this vision just now that you were wearing a crab hat. You'd be like, what do you mean, crab hat?

You know, it was a hat made of crabs. That doesn't exist, right? Those two ideas don't actually exist together in reality.

Disorganization, disorganized speech can be difficult to understand them. And then at the extreme end, that would be word salad. where it all just sounds like a big mess and you can't really piece apart what the person's actually trying to communicate and incoherence.

Loose associations, that they seem to kind of jump around from topic to topic. Preoccupied and ruminations, those can occur if the person's experiencing hallucinations, right, and they sense they are what's called responding to internal stimuli. Distracted and catatonia.

Catatonia can be of course, a major sign of schizophrenia, but can be sometimes hard to differentiate from dissociative symptoms in PTSD, such as this kind of zoning out that people do sometimes. Emotional, you might see agitation or flat affect. Behavioral, a person may be anxious, guided or suspicious and may experience abolition. Anxiety is actually quite common.

You'll see as we read some of the others, particularly schizotypal personality, that social anxiety can often occur. physiological, you know, it's not as pronounced. A person does not tend to be that agitated, that can occur I guess, but it's not as common. Let's talk about schizoaffective disorder next, since we've talked about schizophrenia now. We'll move into the way in which this can intersect with mood.

This is marked by concurrent major mood episode, major depression or mania, with two of the five key symptoms of schizophrenia. okay delusions or hallucinations for two weeks outside of the major mood episode occur the mood episode lasts for the duration of the psychotic symptoms okay and if not you would diagnose schizophrenia so as I mentioned before more often than not they're having especially if this the psychotic symptoms persisting like perpetually they would be having there would be in a depressed episode more often than not or a manic episode more or not, and is less severe compared to schizophrenia. There's less occupational impairment, typically with schizoaffective disorder.

There are two subtypes, bipolar and depressive type. Delusional disorder. Next.

This is when a person meets only the criteria for delusions, not hallucinations, and they do not meet any of the other criteria for schizophrenia. They only have delusions, not negative symptoms, things like that. They have at least one delusion for a duration of at least one month.

Functioning is not impaired. Behavior is not bizarre or odd. And the mood episodes are brief relative to delusional periods.

Subtypes are as follows. Erotomanic, that means that a person imagines other people are in love with them. Grandiose, which is that a person imagines that they're on, you know, have, you know. exceedingly amazing capabilities. right that other people maybe haven't seen yet and they have great ideas that people just need to understand buy into and jealous that could be thinking that your partner is cheating on you without any evidence due cause to suspect it persecutory this is one of the most well known there are cameras set up in my house the police or the fbi are watching me the cameras are feeding back information about me.

Somatic, there's a ghost in my chest. These can be quite bizarre delusions. And then you have mixed and unspecified. I'll note here that with these different delusions, the most important thing to understand here is that the person believes these things no matter the evidence. And they are deeply held beliefs that the person won't question.

Or they may even be able to say. Well, I know that you don't believe this, or maybe I should believe this, but I do believe it. The person can't entertain the idea that it's not true.

So what I'll mention to you about delusional disorder here that's important to take in is that it wouldn't be a shared delusion. It's not something typically that would be shared by other people. In fact, the other people around them are probably very disturbed by these delusions because it can lead to things like stalker behavior, right? Or it can lead to...

you know a person becoming uh you know quite um isolative such as persecutory delusions and so they it is kind of disturbing to other people when these occur and so you know you would usually be hearing from other people around this person that you know they have this delusional problem and they probably need some help okay we're going to talk next about cluster c personality disorders cluster c sorry cluster a Where's my head at? These are personality disorders that are considered more schizophrenia spectrum now. Paranoid personality, schizoid and schizotypal personality. Let's begin with paranoid personality. This is a pervasive distrust and suspiciousness of the malevolent motives of others without evidence.

Feels a little bit delusional, but it's really only about the mistrust in others. and it's a mistrust about everyone globally. The person suspects exploitation, harm, and deceit. They're preoccupied with doubts about trustworthiness and loyalty of friends or associations.

They're reluctant to confide in others out of fear information will be used against them. And therapy is quite a challenge for someone, as you might imagine. They're always on guard and thinking that you may use information against them. In fact, even in therapy, I have seen... that a person making an inert kind of reflection of content could be misconstrued.

So a person may say, oh, so you feel that your mother was pretty harsh to you this past week. And the person may respond with, what did you mean by that? Why did you pick that out?

You know, the person with paranoid personality is always questioning your motives. They may read hidden meanings into benign remarks or events, just as I just mentioned. They may bear persistent grudges and be unforgiving.

They may also perceive character attacks, even if no one means that, and react quickly in an angry fashion or counterattacking, and be suspicious of the fidelity of their partner. So in general, someone with paranoid personality is quite difficult to live with, as you might imagine. Most of the time they do not have long-standing relationships.

They tend to be quite isolative because they don't trust other people. Schizoid personality. This is an extension of reactive attachment in childhood, which we haven't explored yet.

It's this idea that a person doesn't really have a relational frame for attachment relationships. They don't really care about other people around them for relational purposes. A person with schizoid personality has a detachment from social relationships and restricted emotional expression in interpersonal settings. The reason for their restricted emotional expression It will be further explored when we talk about reactive attachment and under activation in the temporal lobes.

What I'll say here is that you can kind of imagine a person living in the cabin in the woods by themselves. They don't want to see anyone. They don't want to talk to anyone. They're perfectly happy.

And they don't have what's interesting. They don't have any interests, really. They always select solitary activities. They're apathetic to close relationships. They lack close friends.

They have non-existent sexual interest. But they're also anhedonic. You know, they don't have things they love, but they enjoy. They just...

tend to be kind of flat in the way they approach life. They seem indifferent to praise or criticism, doesn't just doesn't really bother them, and they're emotionally detached, cold with a flat affect. As you might imagine, someone like this is not going to initiate therapy on their own accord. If they are in therapy, they will despise it.

It'll be a chore to them. So annoying, right, because they don't really care about the other person and what they think. I will add here that I have worked with people with schizoid personality on inpatient units They hate being there.

They stay in their room. They don't come out until they're discharged. I will also add, I once worked with a late adolescent who had this and had a perfect job, which was they were a movie projectionist.

They would go into the movie theater. They would hit the projector and just watch movies and had to interact with no one and loved it. That was a perfect job for them. Okay, schizotypal personality disorder.

This one's an interesting one. It's a bit confusing to describe. It's not schizophrenia.

And it's kind of like, to capture this, I want you to imagine, again, Theodore Milan's ideas about the kind of spectrum of personality. He talked about how people can trend eccentric, but this would be like extreme eccentricism, right? That is... above and beyond what would be in the bounds of accepted behavior. And I'll give you a clinical example in a minute of what I mean by this.

I once was in, I think it was taken in Seattle, this is a photo in Seattle, I asked the person if I could take a photo of them, walking down the street in a Sasquatch outfit. Now, that is slightly odd behavior, but in the Northwest it's kind of the going thing, right? But I think you're looking more for dress and behavior that would be really off-putting to others.

Like you look at this picture and it's kind of endearing, right? The person has clearly put a lot of effort into this task for a job. Whereas other people, their dress is kind of strange, odd.

You know, you're not quite sure what to think of it. A person with schizotypal personality experiences acute discomfort in close relationships. They don't feel comfortable getting close to others. They're quite anxious. They want to have relationships, but they feel anxious and uncomfortable.

They have perceptual and cognitive distortions, not usually hallucinations, but things like they may have ideas of reference. They may perceive things differently than other people. For example, the TV was sending me a message, that kind of thing.

They can have eccentric behavior that includes ideas of reference, as I just mentioned. odd ideas or magical thinking right if i touch this thing then something else happens in the universe right unusual perceptual experiences odd thinking and speech paranoia flat affect lack of close friends and social anxiety so here's a clinical example i once worked with a young man on an inpatient unit and in general in an inpatient unit particularly with people who are younger they tend to bond very quickly to each other because they often haven't found people who kind of have struggled the way they have right through childhood and adolescence. And so it's pretty typical for a person to be roundly welcomed in an inpatient unit.

If they're, you know, kind of in their, I would say, late teens, early 20s. However, this person was rejected by peers very quickly upon their entry into the unit. And the reason for that is they were in a group therapy session. in which a member was talking about the death of their dog and how sad that was to them, how much of a loss that was to them, to which the person with schizotypal personality responded, you know, actually, I think that's a... I'm really glad that happened.

I cast a spell on your dog just a couple of nights ago. I was thinking about them, and I'm really glad that they died, because I think that'll be better for you. It won't be as much as, you know...

that dog is going to do amazing things in the spiritual world. And as you might imagine, like, the person in the group was absolutely disturbed by this, you know, very upset by what the person said, who had lost their dog. And the person with schizotypal personality had no idea why. You know, in fact, the whole group kind of rallied behind the person who'd lost the dog and was, like, disgusted, really, with the person who had said that with schizotypal personality. After the group, I talked with them and I said, are you aware of how people responded to you there?

And their sense was, well, yeah, but I don't get it. Why were they so upset with what I said? And so you can tell here that, again, the person is... behaves in an odd way that pushes people away it's not just your kind of northwest eccentric right it's more of a person who is indeed disturbing to others when they when they act and they have these kind of magical beliefs around you know i cast a spell those kinds of things that aren't grounded in reality right i mean the person had met the the client with excuse the terrible personality had not met the group member who'd lost their dog two days ago so there's no way they could have cast a spell on them, right?

That's magical thinking. And so, you know, those are the types of things you're looking for with schizotypal personality. Again, it's hard to put your finger on, but it definitely comes across as a very odd eccentric presentation that is off-putting to others. We should also mention here life expectancy concerns with psychotic issues.

20% of individuals with schizophrenia attempt suicide and 5 to 6% die by suicide. And part of the reason for that is, of course, that depression can accompany it, as well as, you know, it's not pleasant to have to live with hallucinations, right? And to feel like you have difficulty with kind of organizing your life, right, of taking care of yourself.

And also, of course, homelessness is another major factor here. About 80% are addicted to tobacco. It's a very high percentage. There's all kinds of theories as to why that is. But it also, of course, creates...

potential life expectancy issues with things like lung cancer. The course is considered a chronic progressive illness. I've mentioned this before, but positive symptoms decrease over time because dopamine declines with age and negative symptoms increase.

Be careful about olfactory hallucinations, by the way. When a client mentions olfactory hallucinations, that means things they are smelling. That can be potentially a sign of a brain tumor.

So just kind of know that if a client says I'm smelling smoke, for example, then you probably want to get them neurologically evaluated. So what do we do to prevent schizophrenia and psychosis? Social connection during adolescence makes a big difference.

We don't want people to be isolated. Social situations provide easy means to test out false assumptions that could become delusional. Connect with others emotionally and reduce social anxiety. So. Facilitating that, encouraging that is important.

Note that psychotic symptoms do increase with isolation. We may also want to focus on family-focused therapy, reducing negative emotional displays particularly, which can be distressing. Reducing stress and fostering coping, as well as substance use prevention.

In terms of case management, it's important that we consider referrals and coordinations with psychiatrists, nurse practitioners in their medication treatment, and look at medication adherence. Family involvement, of course, is another part of case management because often people with schizophrenia, specifically if they're younger, are cared for by family members. They live with family, and so making sure that the family understands how best to kind of intervene and help is useful.

They may also themselves need help. They may feel burnout as caregivers. Supported employment and housing is very important so that a person is able to work a job and be independent.

We also might provide psychoeducation on personal hygiene, medication adherence, the impact of substance use, relapse prevention, and a list of support people. In terms of treatment planning, we want more structured therapies here. Unstructured therapies like psychodynamic are not going to be the key here. A person needs something more structured because often their thoughts are quite scrambled.

It's hard for them to think coherently. They may need inpatient service level. In cases where there's cognitive dulling, it's hard for them to concentrate and focus.

Cognitive remediation therapy may be indicated. CBT is often used for coping with hallucinations and delusional beliefs. You can play things like the evidence game. Can you tell me the evidence for that?

And if we don't have evidence, then we're only going to believe things that we have evidence for. Kind of introducing that as an idea. I once worked with a client with schizophrenia who would ask frequently, are you mad at me? Are you mad at me? And I would say, is there any evidence that I'm mad at you?

And they would say, no, I guess not. So the evidence game helps. Behavioral activation, negative symptoms.

So in other words, we want the person to get out of bed, to get active, get out there, do even things like volunteering, even if they're not capable of working a job. Because that helps, right, with self-esteem. It helps them to get out and about rather than to have this abolition, which will get worse over time, especially if they don't exercise.

the muscle of forcing themselves, you know what I mean, to be active and out there in the world. So in summary, psychosis is associated with mood symptoms. When it exists outside of mood symptoms, the prognosis is worse.

There are two major symptom clusters, positive symptoms marked by hallucinations and delusions, and negative symptoms, abolition, loss of motivation, catatonia, flat affect. Medication and medication adherence are often important treatment considerations. The goal for many clients is independence and coping. In other words, especially if you have schizophrenia, it's unlikely that's going to remit. The goal is independence and coping.

Reducing heightened emotional displays within the person's environment can be helpful. And social involvement is a useful preventative measure. And that wraps this video lecture.

Transcript for:Understanding Schizophrenia Spectrum Disorders

Transcript for:
Understanding Schizophrenia Spectrum Disorders