This is a summary of 4.3 Severe Mental Illness in Urban Context. I added tables to summarise the main points which really helped me for the exam, I hope it helps you too! This includes a summary of the literature and some brief answers to the reading questions to help you with revision :)
• BRIEF PSYCHOTIC DISORDER:
o Prevalence = 9% of cases of first onset psychosis
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,• DELUSIONAL DISORDER:
o Prevalence = 0.2%
• SCHIZOTYPAL PERSONALITY DISORDER:
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,Reading 1: Nolen-Hoeksema – Psychopathology Chap 8 (2020):
• INTRO:
o Schizophrenia (S) = hallucinations + delusions are common
§ Beliefs & experiences out of touch with reality = psychotic
o Psychoticism -> speak incoherently + act in unpredictable manner
§ Can be put in a continuum – people meet more or less criteria for
schizophrenia
§ Family members of those with S often show problems in attention &
memory – similar abnormalities to those with S but less severe
o DSM lists S & other psychotic disorders in order of severity:
§ 1) Schizotypal PD = moderate symptoms of S – but retained reality testing
• Odd & eccentric speaking + unusual beliefs/perceptions + difficulty
relating to other people
§ 2) Delusional disorder = persistent beliefs contrary to reality
• Lack other symptoms of S + not impaired in functioning
• Delusions about things that are possible but untrue
§ 3) Brief psychotic disorder = symptoms of S for 1 month or less
§ 4) Schizophreniform = symptoms of S for 1-6 months
§ 5) Schizoaffective disorder = mixture of S & MDD or mania
§ 6) Schizophrenia (0.5-2% of general population develop it)
• à All have similarities with S but not as severe or persistent
§ Also have psychoses caused by medication/drugs or medical condition
o Psychosis = unable to tell difference between what is real or not
§ Schizophrenia -> one of the most puzzling & severe psychotic disorders
§ Varies from accurate to false view of reality + levels of functioning
§ Often develops in late teens/early adulthood
o These disorders -> high medical cost + health care use
§ In need of care when they could be contributing to society – often forever
(S tends to be chronic)
§ S = often live independently or with family + prisons + homeless shelters
• SYMPTOMS, DIAGNOSIS, AND COURSE:
o Schizophrenia = psychosis is core symptom
§ Schizophrenia spectrum -> 5 symptoms to define psychotic disorders
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, § Number; severity; duration distinguish psychotic features from each other
o Different combo of symptoms possible -> different types of S
§ Positive symptoms (delusion; hallucination; disorganized thought;
disorganized/abnormal motor behavior)
§ Negative symptoms (e.g., restricted emotional expression or affect)
§ Cognitive deficits – decline in functioning
• Positive symptoms:
o = Overt expressions of unusual perceptions, thoughts, behaviors
o Delusions -> ideas one believes are true but are v unlikely/impossible
§ = “fixed beliefs that are not amenable to change in light of conflicting evidence”
§ ≠ Self-deception (at least possible; not preoccupied with them;
acknowledge their beliefs may be wrong)
§ Look for evidence in support of their beliefs to convince others
§ Persecutory delusion – belief people are following/after you
§ Delusion of reference – belief random events/comments are directed at them
• E.g., red neckties with John Nash
§ Grandiose delusion – belief one is a special being/possesses special powers
§ Delusions of thought insertion – belief one’s thoughts are being controlled
§ à Also seen in severe depression & bipolar
§ Effect of culture on content of delusions
• UK = controlled by computer – Pakistani = controlled by black magic
• Also changes with time -> focus on Germans in WW2 in US
§ Beliefs that are part of culture’s belief system aren’t delusions
o Hallucinations -> see or hear (any sense) something that isn’t actually there
§ Mentally healthy people can also experience these sometimes
• In S = more frequent; persistent; complex; linked to delusions
• Also common in severe depression & bipolar
§ Auditory hallucinations – most common (voices, music)
• Can come from in or out of someone’s head – might talk back to them
§ Visual hallucinations (often with auditory) – see something
§ Tactile hallucinations – something out of one’s body (e.g., bugs on back)
§ Somatic hallucinations – something in one’s body (e.g., warm eating intestine)
§ Different types across cultures again
• E.g., religious visions in Puerto Ricans
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, o Disorganized thought & speech -> often referred to as formal thought disorder
§ Loose association/derailment – slip from one topic to unrelated other topic
• Common to answer Qs with unrelated answers
§ “Word salad” – when speech is totally incoherent
§ Neologism – make up words only known to them
§ Clangs – make associations between words based on sounds > content
§ !! More language deficits in M > F (F use both hemispheres of brain for it)
o Disorganized or catatonic behavior -> unpredictable agitation
§ Shouting, swearing, pacing rapidly out of nowhere
• Likely in response to hallucinations & delusions :/
§ Takes them a lot of effort to do simple tasks (e.g., get ready, brush teeth)
§ Catatonia = disorganized behavior that reflects unresponsiveness to env
• Negativism – lack of response to instructions
• Rigid/inappropriate posture
• Lack of verbal/motor responses (e.g., mute)
• Catatonic excitement – excessive motor activity for no apparent reason
Positive symptoms - Added unusual behavior/thoughts/perceptions
- Delusions (ideas thought to be true but are v unlikely/impossible) –
persecutory; reference; grandiose; thought insertion…
- Hallucinations (perceiving something that isn’t there) – auditory; visual;
tactile; somatic
- Disorganized thought & speech (more in M) – loose association/
derailment; word salad; neologism; clang
- Disorganized or catatonic behavior (unpredictable agitation) – catatonia
• Negative symptoms:
o = Loss of certain qualities of the person (restricted affect; asocial)
§ Strong neg symptoms = more linked to poor outcome > strong pos symptoms
§ Harder to treat + persistent
o Restricted affect -> severe reduction or absence in emotional expression
§ Fewer facial expressions, avoid eye contact, less gestures, flat voice tone…
§ Those with S show anhedonia + lower pleasure
• BUT proof they may experience lots of emotions that they can’t express
§ Troubles with predicting future emotional experience (L for decisions)
o Avolition/asociality -> can’t initiate/persist at common goal-directed activities
§ Physically slowed down in movement + seems unmotivated
• Poor hygiene – lack of desire to socialize
§ !! Only diagnose if they have access to friends/family but shows no interest
Negative symptoms - Loss of qualities in person (can be more severe than pos symptoms)
- Restricted affect (reduced/absent emotional expression) – does not
mean they experience less emotions!!
- Avolition/asociality (physically slowed down; low desire to socialize)
• Cognitive deficits:
o Deficits in attention, memory, processing speed
o Poor working memory (hold info to manipulate it) ->hard to pay attention to
relevant info + suppress irrelevant info
§ May contribute to pos & neg symptoms
o -> Impact on daily functioning L (work, social relationships)
o This is also seen in immediate relatives of those with S even if they don’t have S
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, § Also common to see this prior development of S + don’t get better with
treatment -> early marker
Cognitive deficits - Deficits in attention; memory; processing speed
- Impact on daily functioning (work; social relationships) L
- Also seen in immediate relatives + prior full development of S
+ stays after S (don’t go with treatment)
• Diagnosis:
o Schizophrenia recognized as a psych disorder since early 1800s
§ Originally believed to be a premature deterioration of brain/dementia
§ Seen as progressive; irreversible; chronic
o Schizein (split) + phren (mind) => split mind (≠ split personalities)
§ Break in association between thoughts, language, memory, problem solving
§ Inability to maintain a train of thoughts
o DSM-5 = S -> 2+/5 symptoms of psychosis (at least 1 hallucination, delusion,
disorganized speech)
§ Symptoms present for at least 1 month (severe) + some symptoms for at
least 6 months (impairment in social/occupational functioning)
§ Need to specify if with catatonia
§ Prodromal symptoms (before acute phase) + residual (after)
• Withdrawn/uninterested in others here – “gradually slipping away”
• Beliefs that are unusual but not delusional
§ Chronic residual symptoms + relapse in acute episodes
o ≠ Autism -> S = delusions/hallucinations must be present
§ Social deficits in ASD begin v early in life (≠ S)
o Big neg impact on their lives -> longitudinal study: 40% employed/school
§ 37% recovered
§ Lower levels of education + less success in holding jobs L
o Neg symptoms less responsive to meds than pos
§ (Easier to get rid of hallucinations > restricted affect)
o DSM-IV = used to have subtypes of S (e.g., paranoid schizophrenia) – low evidence
Diagnosis - 2+/5 psychosis (hallucination, delusion, disorganized speech,
disorganized behavior, neg symptoms) for 1 month | At least 1,2, or 3
- Impairment for 6 months | Neg effect on career & social life L
- Prodromal & residual symptoms | Chronic residual + episodic acute
• Prognosis:
o S = one of the most severe & debilitating disorders
§ 50-80% of those hospitalized for one episode will come back at one point
in their life
§ Life expectancy is 10-20 years shorter
§ Higher rates of infectious and circulatory diseases
§ 5-10% of people with schizophrenia commit suicide
• Highest rate in 1st psychotic episode or recently diagnosed
o Many stabilize (≠ degression) in functioning J
§ 41% had at 1+ period of complete recovery for at least 1 year
o Gender & age factors -> F tend to do better (more periods of recovery; less hospitalization;
milder neg symptoms; better social adjustment; fewer cog deficits)
§ Onset in F is more in late 20s/early 30s + estrogen may help regulation of
dopamine – show less brain abnormalities (≠ M)
§ Functioning improves with age in both M & F (maybe find right treatment,
brain aging helps somehow, reduced dopamine levels…)
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, o Sociocultural factors -> developing S in developed countries is
more debilitating than developing it in developing countries
§ Better social environment helps (no one person is
solely responsible for the care of someone with S)
Prognosis - Many end up hospitalized multiple times + shorter life expectancy
(10-20 years) + commit suicide + develop/catch diseases
- Many also stabilize in functioning > degression
- F tend to do better + functioning improved with age
- More debilitating to have S in developed countries
• Other psychotic disorders:
o These fall on continuum of severity
§ S = worst long-term outcome
§ Schizophrenia > schizoaffective > schizophreniform…
o Schizoaffective = mix of schizophrenia & mood disorder (psychotic + mood
symptoms) – mainly mood symptoms
§ At least 2 weeks of hallucination or delusion without mood symptoms
o Schizophreniform = meet criteria A, D, and E for S but only for 1-6 months
§ Functional impairments not necessary
§ Good (quick onset, good prior functioning, confusion but not blunted
affect) vs not prognosis
§ Majority eventually develop schizophrenia or schizoaffective disorder
o Brief psychotic disorder = sudden onset of delusions, hallucinations, disorganized
speech/behavior – but only for 1 day to 1 month
§ Sometimes caused by major stressor (e.g., giving birth 1/10,000)
§ High relapse but commonly good outcomes
o Delusional disorder = delusions for at least 1 month – but not other symptoms
§ Just behaviors that follow delusions | Rare (prevalence of 0.2%) | more in
F > M | later onset than other disorders (40-49 years)
o Schizotypal PD = odd self-concept + ways of relating to others + thinking/behavior
§ Trouble setting realistic/clear goals | Restricted emotional expressions
§ Suspicious of others -> social isolation
§ Distorted perception | Deficits in WM, learning, recall…
§ Similar genetic traits to S -> some develop it
§ Falls below psychotic disorder threshold – DSM still sees it as part of S spectrum
• BIOLOGICAL THEORIES:
o Some evidence for genetic transmission
§ Possible structural & functional abnormalities in brain
§ Common birth complication or exposure to prenatal virus
§ Neurotransmitters (dopamine in excess)
• Genetic contributors to schizophrenia:
o No single genetic abnormality (different genes responsible for different symptoms
of the disorder?)
o Family studies -> greatest risk in children from 2 S parents + in monozygotic twins
§ Lower genetic similarity = lower risk
§ 1st degree relative sharing 50% of genes has 10% chance of developing it
§ (General population = 1-2%) – doesn’t mean it always happens though
§ Also higher risk of developing bipolar L
o Adoption studies -> nature vs nurture (may be a role of the environment)
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, § Exposure to illogical thought, mood swings, chaotic behavior
§ Negative symptoms can also impair child-care
§ Still found sig impact of genetics (10% risk in biological S in adoptees)
• Adoptees -> 10% of mom with S + 1% of mom without developed S
o Twin studies -> 46% in monozygotic (identical) + 14% in dizygotic (fraternal)
§ Carrying risk of S doesn’t mean they will develop it (can show different types)
§ DNA can be modified by different environmental conditions?
Genetics - Higher risk of S in 1st degree relatives (10%) also higher risk of bipolar
- Exposure to env with psychosis leads to higher risk (but genes > env)
- Different genetics lead to dif symptoms
• Structural and functional brain abnormalities:
o Major structural & functional deficits in brains of those with S
§ Some see S as neurodevelopmental disorder
o Reduction in grey matter + small/inactive PFC (develops a lot in ado)
§ Hippocampus (LTM) unusual activity to encode/retrieve memories :/
• Seen in 1st degree relatives
§ Reduced white matter (early signs of S > consequences)
• Impairs ability of different brain areas to work together
§ Enlarged ventricles (more severe symptoms)
o Damage to developing brain -> higher risk of S
§ Birth complication = prenatal & birth difficulties more common in S
• Perinatal hypoxia (oxygen) v common in S (30%)
§ Prenatal viral exposure = higher risk if mother exposed to viral infections
when pregnant (2nd trimester – development of CNS)
• S more likely to be born in spring months
• Cause system is more active
Structural & - Change in grey & white matter + PFC + hippocampus
functional - Damage to developing brain (birth complication; viral exp) link to S
• Neurotransmitters:
o Dopamine = too much (in PFC, limbic system) of it leads to S symptoms (og theory)
§ Drugs that lower dopamine help reduce S symptoms
§ Drugs that increase dopamine increase pos symptoms
§ More dopamine seen in people with S
§ !!! Too simple – not the only factors + mainly effect on pos symptoms
o 1) Excess dopamine in mesolimbic pathway (processing salience & reward)
§ Atypical antipsychotics -> bind to specific dopamine receptor
o 2) Low dopamine in PFC (attention, motivation, organization of behavior)
§ Link to neg symptoms of S
o Serotonin (regulate dopamine in mesolimbic) -> interaction between them is key
§ Lower GABA can explain hallucinations & delusions (e.g., ket)
Neurotransmitters - High dopamine in mesolimbic pathway (salience & reward) + low in PFC
(neg symptoms)
- Serotonin helps regulate dopamine (meds can target this) + low GABA
can explain hallucination & delusions
• PSYCHOSOCIAL PERSPECTIVES:
o Social factors can influence its onset, course, and outcome
• Social drift & urban birth:
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