(9-29-10)
It’s not as one supposes that things are Sean Gaffney & Seamus Cashman, Ed.s (1974, p. 29).
Proverbs & Sayings of Ireland. New York: MJF Books
Inquiries regarding psychosis:
- Have you ever had any problems with confusion? With being really mixed up about things? What was happening to you then?
- Have you ever had the experience of hearing voices or seeing things other people couldn’t hear or see? What was happening to you then? What was that like? Did you think the voices were real? What do you think about this now? Did your doctor think these were hallucinations?
- Have you ever noticed or thought that television shows or things on the Internet were connected to you in some special way? What was that about? What do you think now?
- Have you ever had any other kind of really unusual or unexplainable experience? Tell me about it.
- Have you ever been hospitalized on a psychiatric unit or psychiatric hospital? What was going on then? What kind of problems lead to your being hospitalized? Do you know what your doctor’s diagnosis was?
Qualifying questions:
- Were you drinking or using drugs when that happened? Were the any medical problems occurring at that time?
- What was going on in your life when you experienced that?
Background questions:
- What medications are you taking now? What medications have you taken in the past?
- Has anyone else in your family had problems like these? Has anyone in your family been treated by a psychiatrist? What kind of problems were they having? What medications were they taking?
General Considerations:
- A respectful and frank approach tends to elicit the greatest cooperation and productive response.
- It is common currently for clients who have been hospitalized for psychiatric reasons to report that they were treated for, “depression.” This is a more socially respectable reason for mental health treatment than most other diagnoses. It is also, sometimes, a convenient rationalization given to the client by their therapist, irregardless of what other problems may have been occurring. Questioning will be necessary to determine if this “depression” is the same as your concept of depression. Furthermore, a depression that required inpatient treatment may have had psychotic features.
Schizophrenia
Differential diagnosis:
- presence of psychotic symptoms: delusions, hallucinations, or disorganized speech and thought
- “The most important clue in distinguishing schizophrenia from a mood disorder or a psychosis that is caused by substances or a medical condition is: Between psychotic episodes, schizophrenics do not completely recover from the psychosis; with these other conditions, patients usually do.” (Maxmen & Ward, 1995, pp 187-188)
- Zimmerman correctly points out that: “DSM-IV does not indicate how short the mood syndrome must be to be considered ‘brief’. I will not diagnose schizophrenia if a full mood syndrome has been present during more than 10-20% of the active phase of the illness.” (Zimmerman, 1994, pp. 22-23)
- Fauman (1994) recommends the following decision path for psychosis:
- “1. Could the patient’s symptoms be produced by drugs or a nonpsychiatric medical illness?” (p 150)
- occurrence before or persistence after suggest independent etiology
- “2. Does the patient currently meet Criterion A (characteristic symptoms) of the common criteria set for Schizophrenia?” (p. 150)
- excludes Schizophrenia, Residual Type; Delusional Disorder; and Psychotic Disorder NOS
- “3. Have the patient’s symptoms lasted less than 6 months?” (p. 151)
- excludes Schizophrenia diagnoses
- “4. Does the patient have a major depressive episode (including depressed mood) or manic episode concurrent with symptoms that meet Criterion A of the common criteria set for Schizophrenia?” (p. 151)
- If not: excludes Schizoaffective Disorder
- “5. Does the patient have significant disorganized speech and behavior?” (p. 151)
- excludes Schizophrenia, Paranoid Type
- if affect flat or inappropriate: likely diagnosis is Schizophrenia, Disorganized Type
- if without flat or inappropriate affect: likely diagnosis is Schizophrenia, Undifferentiated
- “6. Does the patient have unusual or peculiar motor activity?” (p. 151)
- likely diagnosis is Schizophrenia, Catatonic Type
- “7. Does the patient have prominent hallucinations that he or she realizes are not real?” (p. 152)
- intact reality testing likely diagnosis; Psychotic Disorder Due to a General Medical Condition or Substance-Induced Psychotic Disorder
- “8. Does the patient have bizarre delusions?” (p. 152)
- excludes Delusional Disorder
- most likely diagnosis: Schizophrenia, Paranoid Type
Complications:
Maxmen gives suicide as the chief complication of schizophrenia: “About 10% of schizophrenics eventually commit suicide; about 20% attempt it. Of those who’ve already made an attempt, half will eventually kill themselves. In general, schizophrenics do not commit suicide during a psychosis, but rather in its immediate aftermath; 30% of outpatient suicides occur within three months of hospital discharge, while 50% occur within six months of discharge.” (Maxmen & Ward, 1995, p. 181)
Etiology:
A great deal of literature suggests structural and functional pathology of the prefrontal cortex in schizophrenia. Hypofrontality, especially in dorsolateral prefrontal cortex (DLPFC), has been suggested as an etiological factor. Despite the attractiveness of simple theories, recent finding on working memory suggest: “the nature of DLPFC dysfunction in patients with schizophrenia is less straightforward than has been generally appreciated.” (Snellenberg, Torres, Thornton, 2000, p. 503). and “characterizing functional pathology in higher cortical regions as either too much or too little may be overly simplistic.” (ibid., p. 503).
- Sensory Gating deficit in schizophrenia
- “Inadequate inhibition of redundant sensory information, measured as a deficit in auditory sensory gating, is thought to underlie reports of sensory overload and attentional dysfunction in patients with schizophrenia” (Thoma et al., 2003). Thoma and colleagues present evidence that left hemisphere dysfunction is strongly related to the sensory gating deficit in schizophrenia.
- Genetics of schizophrenia
- The Finnish Adoptive Family Study of schizophrenia seeks to disentangle genetic and environmental influences. Tienari et al. (2003) interpret data on 190 adoptees at broadly defined high risk for schizophrenia spectrum disorders, including 137 at narrowly defined high risk (mother with DSM-III-R schizophrenia); comparison group 192 low-risk adoptees. Stronger findings for spectrum than narrowly defined risk, and schizotypal personality disorder also found significantly more in high than low risk adoptees. They conclude that, “the genetic liability for schizophrenia-related illness . . . is broadly dispersed.” Argue that studies should consider not only narrow defined, typical schizophrenia, but also schizotypal and schizoid personality disorders and nonschizophrenic, nonaffective psychoses.
- A microdeletion on chromosome 22q11.2 includes schizophrenia in its phenotype, as well as congenital dysmorphic features, developmental structural brain abnormalities, and cognitive dysfunction; 25% or more of individuals with 22qDS develop schizophrenia. A 22qDS subtype of schizophrenia may be present in up to 1 in 50 patients diagnosed with schizophrenia. The deletion usually as a spontaneous (de novo) mutation, without a family history of psychosis. (Basset et al., 2003).
- The Dysbindin-1 gene (DTNBP1 dystrobrevin–binding protein 1) on chromosome 6 may be a susceptibility gene for schizophrenia of “small to moderate effect” and accounting for “a modest” proportion of total genetic risk (Kendler, 2004).
- Schizophrenia and tobacco use
- Lyon (1999) concluded that smoking improved processing of auditory stimuli (sensory gating) by patients with schizophrenia and may lessen negative symptoms through increasing dopamine in the nucleus accumbens and the prefrontal and frontal areas of the brain. Patients who smoke metabolize antipsychotic medications faster than nonsmokers.
- Childhood Onset Schizophrenia