let's talk about psychosis this is a key concept in psychiatry and it's often misunderstood so let's try to break it down as simply as possible psychosis is an abnormal mental state where someone is unable to distinguish what's real from what isn't using this definition the word psychosis is an incredibly broad term that can encompass many possible symptoms and causes including other conditions like delirium or dementia in psychiatry however the word often has a more specific meaning referring to a state of primary psychosis that is not attributable to any other medical or psychiatric condition someone in a state of primary psychosis still meets the definition of being unable to distinguish reality from unreality but they do so in a very specific way that once you learn it we'll help you to recognize cases of schizophrenia when they occur so for the rest of this lecture we're going to leave behind the broad definition of psychosis and focus exclusively on the signs and symptoms of psychosis as they are seen in cases of schizophrenia symptoms of schizophrenia are classically split into two groups positive symptoms and negative symptoms positive symptoms are those that are present in schizophrenia but absent for most people whereas negative symptoms are those that are not present in schizophrenia but are for most people positive and negative symptoms make up the five diagnostic criteria for schizophrenia in the dsm to better remember these let's use the mnemonic hdbs network this phrase stands for hallucinations delusions disorganized behavior disorganized speech and negative symptoms the mental image conjured by this phrase should be easy to link to schizophrenia as auditory hallucinations are common in this disorder these voices are incredibly clear and sound like real voices of the patient so they're very high definition however they're also not real so it's as if the patient is hearing radio waves spreading a network of fake bs let's go over each of these one by one first the h is for hallucinations hallucinations are perceptions in the absence of a stimulus while hallucinations can take many forms including seeing things that aren't there feeling things on your skin or even smelling things in schizophrenia the hallucinations are most often auditory in nature reflecting the oddness of psychosis more than just hearing voices people with schizophrenia hear voices in a consistent and recognizable way the voices typically take the form of a running commentary between several speakers often a mix of male and female voices who talk about the patient in a critical or demeaning way the voices are intermittent rather than continuous and are clearly perceived as coming from outside their head as opposed to voices inside their head these voices are not vague or nebulous instead they hear what the voices say in a clear and vivid fashion people with auditory hallucinations often experience them as distressing and will generally try to find specific reducing behaviors that can decrease the intensity of the voices like listening to the radio watching tv or talking with others patients will also generally try to hide or minimize the fact that they experience auditory hallucinations however they may at times inadvertently reveal their experience by reacting to what the voices are telling them which is described on a mental status exam as responding to internal stimuli auditory hallucinations almost never occur in the absence of other positive symptoms with delusions being reported concurrently with auditory hallucinations nearly 90 of the time and this leads us to the d of hdbs network which stands for delusions a delusion is defined as a fixed false belief fixed because they are unchangeable even when the patient is presented clear evidence to the contrary and false because they are so clearly incorrect or incompatible with reality delusions must also be clearly outside the norms of one's cultural or religious background so even if you find the beliefs of another culture or religious group to be strange if they are shared by a large group then they are not a delusion like auditory hallucinations delusions schizophrenia often come in specific and recognizable forms in particular schizophrenic delusions tend to be paranoid and persecutory in nature such as someone believing that they are the target of a vast conspiracy these delusions often involve ideas of reference where random or everyday events are connected in a way that has some great or cosmic significance for example someone watching the news on television may believe that the anchors are blinking in morse code in order to communicate a special coded message that only they can understand in addition to ideas of reference delusion schizophrenia also frequently involve belief that one's thoughts or actions are being manipulated by outside forces these delusions include thought broadcasting or the idea that once thoughts are being transmitted externally to be heard by others thought withdrawal or the idea that once thoughts are being taken out of their mind thought insertion or the idea that thoughts are being inserted into one's head by others and delusions of control or the idea that one's movements are not their own and that they're being controlled by someone else like a puppet the final category positive symptom is thought disorganization people with schizophrenia often have profound difficulty with maintaining a clear and coherent train of thought because psychiatrists cannot read minds thought disorganization must be inferred from disorganization in two other domains behavior and speech which make up the b and s of hdbs network speech tends to follow rules that are so ingrained that most people don't even realize them until they're broken for example during a conversation most people go from one topic to another based on a linear train of thought involving logical associations between words and ideas however in a state of psychosis the normal connections from one thought to the next are replaced by a loosening of associations in which topics are connected by less meaningful connections for example someone in a psychotic state who has asked a question may answer based on the sound of words rather than the actual meanings which is known as a clang association if you were to ask a patient with schizophrenia what do you do at the beach they may reply by saying beach that's no leech preach let me teach in this case the important part of the word its meaning is replaced by an irrelevant characteristic or its phonetic sound other ways in which thought disorganization can become apparent is when people simply make up words known as neologisms repeat what the other person said without regard to its meaning known as echolalia or say the same word repeatedly without any purpose known as perseveration in severe cases thought disorganization can go so far that the words coming out of the mouth are complete nonsense known as a word salad in addition to speech thought disorganization can manifest and disorganize behavior whereas most people behave in a way that is dictated by clear motivations disorganized behavior in schizophrenia is notable for its purposelessness people with schizophrenia may act bizarrely or unpredictably such as walking around endlessly from one corner of the room to the next repeating the same hand motions over and over or copying a movement that someone else just did other patients may become hypoactive and simply stand in front of a wall for hours upon end in some cases patients may become agitated and prone to attacking others while the behavior varies from one patient to the next the key unifying feature is its purposelessness finally the n in hdbs network stands for negative symptoms while all the symptoms we talked about so far are positive symptoms or things that are present that shouldn't be these symptoms are things that should be present but are not you can remember the main negative symptoms of schizophrenia by thinking of them as the five a's the first a is for affect while most people experience a full range of emotion people with schizophrenia often have a blunted affect with very little emotional expression affective deficits tend to be progressive and people with long-standing schizophrenia may develop a completely flat affect with no trace of emotion the second a is for ambivalence while most people are able to make dozens or even hundreds of decisions on a daily basis people with schizophrenia often have extreme difficulty in making even simple decisions which prevents most meaningful or girl-directed behavior even when asked about things that should be relatively uncontroversial like if they want a blanket on a cold night someone with schizophrenia may take several minutes to respond or not even respond at all the third a is for aelogia while most people communicate frequently with others patients with schizophrenia often struggle with speech a state known as aelogia aelogia can range from small reductions in the amount of speech to being completely mute for months or years on end the fourth a is for anhedonia while most people have a range of activities that they enjoy people with schizophrenia often experience anhedonia or the ability to feel pleasure or engage in interests anhedonia can lead to a state of a motivation where people stop trying to pursue any form of gold-directed behavior leading to an inability to hold a job or even take care of one's own basic needs like eating or bathing finally the fifth a is for asociality while most people enjoy socializing with others and consider this to be among the most meaningful parts of their lives people schizophrenia often develop severe difficulties relating to other people and instead are preoccupied with their own internal experiences they often appear completely disinterested in what is going on around them even during major life events that would normally provoke strong emotions such as birth death and marriage many patients end up withdrawing socially and living in their own world leading to isolation and loneliness all right let's take a moment to review our mnemonic as we've covered a lot so far you can use the phrase hdbs network to remember that schizophrenia involves hallucinations typically auditory delusions often paranoid or persecutory disorganized behavior disorganized speech and negative symptoms as captured in the five a's per dsm criteria two or more of these symptoms must be present for a period of at least six months to qualify for the diagnosis you can remember this by thinking of it as 2-4 six afrenia you need two symptoms for at least six months so now that we know how to diagnose schizophrenia let's take a look at the disorder across the life span including who gets it what happens once they get it and what we can do to help schizophrenia is found in about 0.5 to 1 percent of the population giving it a low base rate it is typically diagnosed in early adulthood with the age of onset being earlier in men who tend to show symptoms between 18 and 25 than it is for women who more often show symptoms between 25 and 35 for unclear reasons men are affected more frequently than women with three men diagnosed for every two women men also tend to have a more severe form of the disorder with worse outcomes overall while the symptoms of schizophrenia generally do not begin until early adulthood many people who are diagnosed with schizophrenia show signs even in childhood including odd beliefs social withdrawal physical clumsiness and poor performance in school this presyndromal state is known as a prodrome although these symptoms are common in people who go on to develop schizophrenia they are unfortunately not specific enough to allow us to predict who will go on to have this disease with only around one third of patients diagnosed as having a prodrome actually going on to have a first break where active symptoms of psychosis emerge as the other two thirds do not develop schizophrenia the risk of false positives from diagnosing and treating based only on prodromal symptoms is too high for patients who do have a first break schizophrenia often involves a lifelong pattern of acute symptomatic exacerbations on top of a progressive functional deterioration this means that social and occupational functioning are often significantly impaired even when there are no active symptoms of psychosis this is in stark contrast to mood disorders where patients generally experience symptoms in episodes with function often being preserved the rest of the time once the first break has occurred the chance of future symptom recurrence is very high with around 90 percent of people having another exacerbation in their lifetime consistent with the idea that schizophrenia is not an episodic disorder psychotic symptoms do not have a built-in expiration date in the same way that manic or depressive episodes do studies have found that without treatment symptoms of psychosis can continue unabated for years at a time people schizophrenia often lead difficult lives less than 20 of people schizophrenia are able to find employment leaving them dependent upon others for support people with schizophrenia are also more than 10 times as likely to be incarcerated or homeless than the average person these patients also tend to live 10 or even 20 years less than their peers likely due the effects of homelessness a lack of interest in medical care and a higher chance of developing medical illnesses some of this gap in life expectancy may be attributed to suicide as well with the diagnosis of schizophrenia being found in about 15 of all suicides when suicide does occur it tends to happen in an early stage of the illness when someone's insight is preserved enough that they know that they're unwell and that they will likely not be able to live the life that they would have wanted so in light of all this news about poor outcomes what can we do to help treatment of schizophrenia generally consists of medications and psychotherapy like bipolar disorder the standard of care almost always involves medications as psychotherapy alone is not considered sufficient for treating schizophrenia in most cases medications used to treat schizophrenia are known as antipsychotics most antipsychotics work by blocking a neurotransmitter known as dopamine with treatment psychotic symptoms can be reduced in a matter of days or weeks while antipsychotics are effective at rapidly reducing the positive symptoms of schizophrenia like delusions and hallucinations they are much less effective at treating negative symptoms because of this antipsychotics are much better at improving symptomatic outcomes than functional ones hospitalization may be required for severe symptoms in schizophrenia many states allow for involuntary detainment of individuals who are gravely disabled to the extent that they are unable to provide for their own food clothing and shelter psychotherapy can be a very helpful add-on treatment for schizophrenia a specific form of therapy known as cbt for psychosis has been developed to help patients take more control of their symptoms such as teaching them to recognize when an idea is a delusion or when something they hear is a hallucination and not a real voice and that's schizophrenia in a nutshell before we wrap up let's talk about a few related disorders we talked earlier about the fact that 2 4 6 afrenia cannot be diagnosed until a patient has had symptoms for 6 months however patients may still come to clinical attention for psychosis before that time frame so what diagnosis can we give in those cases psychotic symptoms lasting less than a month can be diagnosed as brief psychotic disorder while those lasting between one and six months can be diagnosed with schizophrenia form disorder the distinction between brief psychotic disorder schizophrenia form disorder and schizophrenia appears to have prognostic value as only a third of patients with brief psychotic disorder will progress to having full-blown schizophrenia while only two-thirds of patients with schizophrenia form disorder will do the same so while the six-month cut-off is ultimately arbitrary it underscores the point that the duration of psychosis matters when it comes to prognosis with a longer period predicting a worse outcome another related disorder is delusional disorder this is a condition in which people develop delusions that are similar to those found in schizophrenia but unlike in schizophrenia all the other signs of symptoms like auditory hallucinations disorganized thoughts and negative symptoms are absent in addition the life course of people with delusional disorder does not mirror those of schizophrenia as these people are often employed married and lacking in other features suggestive of mental disorder on interview they are often coherent sensible and reasonable until they begin talking about their particular delusions if all the other parts of schizophrenia are missing then why is delusional disorder a disorder at all for people with this disorder their belief in these delusions is firm enough that it can cause significant problems in their lives even in the absence of other symptoms for example if your spouse of 30 years suddenly started believing that they had been abducted by aliens working for the cia and refused to stop talking about it and may begin to strain the marriage not to mention their ability to hold a job or maintain other friendships medication treatments for delusional disorder are not very effective with very limited benefit from antipsychotics psychotherapy like cbt can help patients to lessen the social and occupational dysfunction resulting from these delusions by teaching them situations in which it is or is not appropriate to talk about them even if the therapy doesn't necessarily remove the delusions themselves and with that we're going to bring this video to a close if you're interested in learning more about schizophrenia check out some of the other videos on my channel my memorable psychopharmacology series dives into antipsychotics in more detail and there's also a more descriptive video that goes over what it's like to have schizophrenia from the patient's perspective if you're interested in learning more you can also read my book memorable psychiatry which is available on amazon until next time bye for now