1. Psychosis and schizophrenia
MADNESS
Psychosis and schizophrenia

2. PSYCHOSIS DELIRIUM DEMENTIA Schizophrenia Mania Drugs Depression
Cocaine, LSD, Cannabis, Alcohol
L-Dopa, Steroids, Anticholinergics
PSYCHOSIS
Schizoaffective Disorder
Metabolic
Puerperal psychosis
Ca2+, MG2+, Cu2+, Vit B12
Other psychotic disorders
Endocrine
Thyroid, Cushing’s, Addison’s
Infections
PERSONALITY
DISORDER
Encephalitis, syphilis,
any
Parapsychotic phenomena
DELIRIUM
DEMENTIA
Acute brain failure
Clouding of consciousness
Attention defecit
Alzheimer’s
Vascular
Parkinson’s/Lewy Body
Huntington’s
Encephalopathy,
Acquired Brain Injury,
Stroke, etc.

3. [clear consciousness & intellectual capacity usually preserved]
PSYCHOSIS
≃“off legs”
Hallucinations
Delusions
[clear consciousness & intellectual capacity usually preserved]
REALITY FAILURE
Group of pathologies which disrupt the process of perceiving and interpreting reality.
[thought disorganisation]
[various causes]
[delusions]
[abnormal attention/salience]
Psychosis usually defined as hallucinations + delusions; however bearing in mind that most of the purpose of a CNS is to accurately perceive and interpret information about the outside world, these two seemingly discrete symptoms actually describe quite an overarching and nonspecific deficit. Equivalent to medical “diagnosis” of Off Legs – ie represents a potentially large group of different disease processes which are grouped together purely because they all share an end result which looks broadly similar. Conceptualise psychosis as Reality Failure akin to Kidney/Heart/Liver failure, ie multitude of different aetiologies but roughly similar clinical picture. But more treatable than Kidney/Heart/Liver failure.
[hallucinations]
[inappropriate/blunted affect]

4. AUDITORY VERBAL HALLUCINATIONS
Thoughts/internal monologue experienced as external/ Other
Experienced by ~5% of healthy population
“an antecedent of clinical disorders when combined with negative emotional states, specific cognitive difficulties and poor coping, plus family history of psychosis, and environmental exposures such as childhood adversity.” *
* Johns LC et al, 2014: Auditory Verbal Hallucinations in Persons With and Without a Need for Care,
Schizophrenia Bulletin, Volume 40, Issue Suppl_4, Pages S255–S264, 

5. delusions
Fixed, false, unshakeable belief, out of context with cultural background
But nobody has unproblematic access to The Truth??
? Result of efforts to make sense of perplexity
“Doxastic shear-pin”: allow continued function in the face of paralysing difficulty*
What drives formation of the belief?
i.e. intense feeling of being controlled/persecuted/culpable etc.
Often persecutory
? Default to fear in the face of uncertainty
* Fineberg SK & Corlett PR The Doxastic Shear Pin: Delusions as errors of learning and memory. Cog Neuropsych. 21, 1: 73-89

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

7. Schneider’s first rank symptoms
[pathognomonic… sort of]
3 Hallucinations:
Thought Echo
AVH*: 3rd Person Arguing
AVH: Running commentary
3 Thought phenomena:
Thought withdrawal
Thought insertion
Thought broadcasting
Misc:
Passivity phenomena
Delusional Perception
*AVH = Auditory Verbal Hallucination

8. TIME FOR SOME NEUROBIOLOGY
Significant genetic component
Heritability ~80%
Prevalence ~1%
>200 genes
Genes for D2, neurodevelopment and inflammation
Excess of striatal dopamine
Especially in response to stress
Abnormal functional organisation of Default Mode Network
(stimulus-independent thought and self-reflection)

9. Causes of psychosis Genetic component Developmental adversity/abuse
Genes predisposing to SCZ must also confer significant advantage
[?? A more flexible grasp of reality]
Developmental adversity/abuse
Biased cognitive schemas
Sensitised striatal dopaminergic system
[high expressed emotion, “double-bind” family dynamic]
Life stressors
[stress-Vulnerability Model]
Relationship with recreational drugs
[~25% of psychosis]
Scz affects ~1-3% of population (regardless of time or geography as far as we can tell). Given fairly catastrophic effects of “going insane” on an individual’s survival/reproduction across almost all times/places in human history, genes must therefore confer a significant advantage to whole population ?language ?more flexible grasp of reality

10. treatment Antipsychotics Psychological therapies
Antidopaminergic (also serotonergic, anticholinergic, antihistaminergic…)
“Typical” and “Atypical”
Psychological therapies
CBT for Psychosis
Avatar therapy (just real enough to be immersive)
Sense of agency over voices

11. eliciting psychotic symptoms
Introducing the topic:
Routine questions, normalise
Start with open questions:
“How have things been for you lately?”
“Have you had any unusual or frightening experiences lately?”
“Anything which you can’t explain?”

12. Auditory hallucinations:
“ When you are alone are you ever able to hear strange sounds?”
“ Are there ever voices where you can’t see who’s speaking?”
“What do they say? Do they give you commands?”
“How real do they seem?”
“Could your mind be playing tricks on you?”
LOGICAL, CURIOUS QUESTIONS

13. Delusions (persecutory)
“How safe do you feel?”
“What are your neighbours like?”
“Is anyone listening in on you/watching you?”
LOGICAL, CURIOUS QUESTIONS
Don’t reinforce, but do react normally.

14. Summary Reality is not something we can claim unproblematic access to
(must hold central the reality of the patient)
Psychosis is a syndrome, not a unitary disease process
Don’t underestimate the social determinants of schizophrenia
Try to understand the person, and why they have become psychotic