Chapter 11: Psychotic Disorders

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All right, buckle up everybody because today we're taking a deep dive into a pretty complex area, uh, psychotic disorders and specifically schizophrenia.

Yeah.

We've got a ton of research and case studies to go through.

So by the end of this, you should have a much better understanding of not just the definitions, but the theories behind it, the research and what it all means in real world terms.

Yeah.

It's a really fascinating area and a lot of times it's misunderstood.

I think to really grasp this, you need to kind of shift your thinking.

Most people, when they hear psychosis, they think of that as the diagnosis, but it's actually more of a symptom.

It's like having a fever, right?

Exactly.

That's just an indication that something is wrong, but you don't know what.

Perfect analogy.

Psychosis is a sign that something's off in the brain, but it doesn't really tell us the whole story.

And so while it's a key part of schizophrenia, it can show up in other conditions as well.

So if psychosis is the symptom, what are we actually looking for then to diagnose schizophrenia?

That's where things get really interesting.

So we look for a certain cluster of symptoms and the most well -known of course are delusions, hallucinations and disorganized thinking.

Right.

But it's not just about having those experiences, it's about the content of those experiences.

So what the delusions are actually about.

What kind of hallucinations they're having.

Exactly.

Exactly.

Someone experiencing a delusion of grandeur, you know, where they believe they have these incredible powers or there's some famous figure, is going to present very differently from someone with paranoid delusions who believes they're being followed or conspired against.

Now, what about terms like,

I remember seeing this in some of the research, the terms functional and organic psychosis.

What do those mean?

Yeah, those are definitely terms that were used more in the past.

Functional implied more of a psychological root,

whereas organic pointed to a biological cause, you know, like a brain injury.

But today we've moved away from that strict distinction.

So how do we classify them now?

Well now we tend to focus more on the primary features of the illness.

So for example, is it primarily involving delusions or is it a combination of symptoms?

And so that helps us differentiate between, you know, things like delusional disorder where the main issue is persistent, non bizarre delusions versus something like schizophrenia, where you see a wider range of symptoms.

So it's a more nuanced approach than just simply functional versus organic.

Exactly.

And then within these primary psychosis, we've got diagnoses like brief psychotic disorders, schizophrenia form disorders, schizoaffective disorder.

It's quite a range of different.

It is a lot to keep track of.

But for this deep dive, let's maybe just focus on schizophrenia as our main example, because it's often considered kind of the prototype for these conditions.

Okay, that makes sense.

And it's got a fascinating history too.

I came across this term while I was reading through some of the research,

dementia precox.

Is that an older term?

It is, yeah.

It was coined by Emil Kraepelin back in the late 1800s.

And he believed that this dementia precox inevitably led to mental deterioration.

And thankfully, you know, our understanding has come a long way since then.

So no more doom and gloom outlook?

No, not at all.

I mean, while it can be, you know, chronic and certainly challenging, it doesn't always follow this kind of downward spiral.

In fact, we recognize that it typically involves three phases, the prodromal, the active, and the residual.

So what might somebody be experiencing during that prodromal phase?

So imagine it like a slow fade,

work starts to suffer,

hygiene sleeps,

sleep gets all messed up, you might even feel like you're on this strange kind of solitary mission that only you understand.

And then comes the active phase, which is, I'm assuming that's what most people think about when they think about schizophrenia.

Yeah, this is when the more prominent psychotic symptoms really take center stage.

The disorganized thinking becoming more apparent, the delusions take hold, hallucinations might start, the world can just feel incredibly overwhelming.

And then what about the residual phase?

Is that like kind of a recovery period?

It's not quite a recovery period.

The intensity of the psychotic symptoms might decrease, but there can still be some, you know, lingering effects.

Social withdrawal might continue.

You know, thinking and emotional expression can remain unusual.

Think of it like the aftermath, you know, where things are calmer, but not quite back to normal.

To illustrate these phases, we've got a case study from the research that you sent over.

The place of George A., a 19 -year -old college student, this one really kind of stood out to me.

Yeah, it's a pretty classic example.

You know, George started showing these subtle changes.

He was isolating himself, staying up late, acting kind of secretive.

He was writing these strange notes and talking about, you know, religion in a way that was very different for him.

Yeah, and his hygiene and his schoolwork went downhill.

Yes.

And his roommate even described him as like a quiet guy who had never dated.

Right.

So these changes were pretty noticeable.

Exactly.

And sadly, those, you know, subtle shifts eventually spiraled into full -blown psychosis.

George became convinced that he was on this special mission from God, preparing for the second coming of Christ.

He started hearing voices, believing they were God or the devil speaking to him.

He even believed he needed to die to atone for his sins.

Yeah, it really highlights the intensity of these experiences.

And his case also is a good example of another important distinction,

positive versus negative symptoms in schizophrenia.

Right.

I've heard those terms before.

Yeah.

Can you remind me what those are again?

Sure.

So think of positive symptoms as things that are added to someone's experience.

So things like hallucinations, delusions, agitation,

bizarre behavior, those are all that are present in someone with schizophrenia, but not typically present in someone without it.

So they're experiencing these things on top of reality.

Exactly.

And then negative symptoms would be more like things that are being taken away.

Exactly.

It's like losing parts of yourself.

OK.

So things like, you know, anhedunia, which is the inability to feel pleasure, apathy, flat emotions, poverty of thought, feeling empty, lacking motivation, these are all negative symptoms.

And the research that you sent over goes on to list even more.

It's a lot to process for both for somebody experiencing it, but also the people around them as well.

Absolutely.

And we can't forget about the disorganization symptoms, which really impact thinking and behavior.

And so those include things like behavioral disorganization, distractibility, difficulty following conversations,

problems following through on tasks.

So like their internal compass is just broken and it's almost impossible to navigate everyday life.

So we've got these these different clusters of symptoms.

But what actually causes this to happen in the first place?

That's the million dollar question, right?

And unfortunately, there's no single answer.

It's likely a very complex interplay of genetic,

biological and environmental factors.

So let's start with the genetic piece.

Sure.

What's the evidence there?

Well, twin and adoption studies have been really revealing.

They show us that if your identical twin has schizophrenia, you have a much higher risk of developing it compared to, you know, you had a fraternal twin.

So the genes sort of they load the gun to something else has to pull the trigger, so to speak.

Yeah, I like that analogy.

Yeah.

And that something else could be, you know, a combination of things.

And then we also see some some interesting findings when we look at at brain structure and function in people with schizophrenia.

Like what kind of findings?

Well,

brain imaging studies have shown that people with schizophrenia often have enlarged ventricles.

Ventricles remind me what those are again.

Yeah.

So those are the fluid filled spaces in the brain.

OK.

And and when they're enlarged, it suggests that, you know, the surrounding brain areas

might have shrunk.

And is that a sign of like abnormal development or is it that something is actually deteriorating?

It could be either or even a combination of both.

The current thinking is that it might reflect, you know, problems with brain development early in life.

OK.

But we also know there can be ongoing deterioration over time as well.

So so kind of a one to punch.

Yeah.

That's scary.

Is there research on ways to slow that down or stop it?

There is.

Yeah, there's some research suggesting that certain medications might actually help slow down or even stop that process of brain deterioration.

Wow.

It's a very promising area of research.

So we've talked about genes.

We talked about the structure of the brain.

What about the brain's chemistry?

Does that play a role?

Absolutely.

One of the, you know, longstanding theories is the dopamine hypothesis, which suggests that schizophrenia is linked to overactive dopamine pathways in the brain.

Dopamine.

That's the that's the feel good neurotransmitter, right?

It's involved in a lot of things, including pleasure, motivation and movement.

OK.

But in schizophrenia, it's almost like that dopamine accelerator is is stuck down.

OK.

And so it leads to this, you know, kind of sped up and chaotic brain state.

So if it were all about dopamine, though, wouldn't we be able to fix it fairly easily with medication?

Yeah, that's a great point.

And the dopamine hypothesis,

while helpful, you know, doesn't fully explain everything, especially the negative symptoms.

Right.

And so that's where the glutamate model comes in.

Glutamate.

So another brain chemical.

Yes.

Glutamate is actually the most abundant neurotransmitter in the brain.

Oh, wow.

And it's it's crucial for learning and memory.

And the glutamate model focuses on something called the NMDA receptor, which helps regulate glutamate activity.

OK.

So how does that tie into schizophrenia?

Well, researchers have found that disrupting the NMDA receptor can actually mimic a lot of the symptoms of schizophrenia, including those negative symptoms that the dopamine model doesn't fully explain.

So it's not just about too much dopamine, it's about glutamate not functioning properly as well.

Exactly.

That's that's a much more complex picture.

It is.

And then to make things even more interesting, there's also the neurodevelopmental and neurodegenerative models to consider as well.

Hold on.

Yeah.

So is schizophrenia about how the brain develops or is it about how it deteriorates?

Well, it's probably both.

OK.

The neurodevelopmental model suggests that subtle abnormalities might occur during brain development, maybe even before birth, that kind of set the stage for schizophrenia later in life.

So so like a vulnerability that's there from the beginning.

Exactly.

And then the neurodegenerative model proposes that there's ongoing deterioration in the brain over the course of the illness, which which might contribute to the progression of symptoms and cognitive decline.

So a potential developmental issue early on, right, plus potential ongoing deterioration.

Yeah.

That's that's rough.

It can be.

But even with all of that complexity, there's still hope.

You know, we've got effective treatments and the research is constantly evolving.

That's good to hear.

Well, we've covered a lot of ground already, and I feel like we're just getting started.

I know.

We'll have to pick this back up in part two.

Sounds good.

Welcome back, everybody.

I'm ready to keep going here, especially the treatment side of things.

We talked about medication in the last part, but I know that could be a tricky area.

It definitely is.

You know, antipsychotics can be really effective at managing those those positive symptoms of schizophrenia, the hallucinations and delusions.

But they're not without their downsides.

Yeah.

Side effects are a big concern, I imagine.

And it's it's a tough decision for someone to have to weigh the benefits of the symptom relief against the potential side effects.

Absolutely.

It really is a balancing act.

And it's not always an easy choice to make.

So what are some of the common side effects that folks might experience with these medications?

Well, it varies, you know, from person to person, but some of the common ones include weight gain, drowsiness, movement problems, even hormonal changes.

I can see why somebody might hesitate to take medication if they're worried about those those sorts of side effects.

It's a valid concern.

And it's why, you know, open communication between the person with schizophrenia and their doctor is so important.

Right.

It's you know, it's about finding the right medication, the right dosage to minimize those side effects, but still effectively,

you know, managing the symptoms.

So really finding that that sweet spot, the best possible balance for for each person.

Exactly.

And sometimes that means, you know, exploring alternative treatment options or adjusting the medication over time.

It's not just a one and done kind of thing.

Speaking of figuring out treatment, I noticed in the research that you sent over something called the quick reference when to refer for medication treatment.

What is that exactly?

Yeah, that's a really helpful tool for therapists and other mental health professionals.

It basically outlines a range of situations where it might be appropriate to refer someone for a medication evaluation.

So it's kind of like a guide to help professionals make informed decisions about whether or not medication is a good option.

That's a good way to put it.

Yeah, it lists things like psychosis due to another medical condition, depression with psychotic features, schizophrenia, other psychotic disorders,

drug induced states and even severe personality disorders.

Wow, that's that's quite a list.

It really shows you how how careful assessment is really crucial in figuring out the the right treatment plan.

It is.

And it's important to remember that this is, you know, this guy is just not a guide.

The decision to actually prescribe medication always comes down to the individual and their doctor working together.

Switching gears a bit here, I want to talk about something that I think is really important, but often overlooked when we're discussing mental health, and that's trauma.

Yeah, trauma is a huge factor in mental health in general, and it can it can play a particularly complex role in schizophrenia.

It's like adding another layer of difficulty to an already difficult situation.

That's a great way to to think about it.

And and actually, the research goes into, you know, post -traumatic stress disorder or PTSD to help us understand how trauma can can impact our mental well -being.

So so how did we even come to understand PTSD as a concept?

Well, the recognition of of trauma related mental health issues can be traced all the way back to World War One.

OK, you know, soldiers returning from the front lines.

We're experiencing, you know, a lot of severe anxiety, insomnia, nightmares.

Right.

And that's that's what they call shell shock.

Right.

Exactly.

Exactly.

And at first, people thought it was just this physical reaction to the constant bombardment.

Right.

But but over time, it became clear that that these these psychological wounds of war were were just as real, if not more so.

And our understanding of those acute stress reactions was really advanced by the work of Eric Lindemann.

Lindemann, wasn't he the one who studied the aftermath of the horrible nightclub fire in Boston, the Coconut Grove fire?

That's the one.

Yeah.

In 1942, there was this devastating fire at the Coconut Grove nightclub.

Hundreds of people were killed or injured.

And, you know, Lindemann and his team, they they provided crisis counseling to the survivors and really saw firsthand how profoundly this trauma affected them.

It must have been horrific.

It was.

And he started to identify, you know, these common patterns of of emotional response to the trauma, things like intense emotional swings, intrusive thoughts and memories, nightmares,

even psychosomatic symptoms.

So he was one of the first to really recognize that trauma could have these, you know, these lasting mental and emotional consequences.

He really was a pioneer in the field.

And then building on his work and others, a psychiatrist named Marty Horowitz published this groundbreaking book in 1976 called Stress Response Syndrome.

And what was so important about that book?

Well, Horowitz proposed this this comprehensive model for understanding how how humans typically respond emotionally to to stressful events.

OK.

And and not just these, you know, catastrophic events like war or fires, but a whole range of of difficult experiences.

So like the death of a loved one or even surviving an assault.

Exactly.

Exactly.

And he and he argued that, you know, no matter what the specific stressful event was, there were, you know, these common phases of response that most people go through.

And that would that would help explain why, like the symptoms of PTSD could be so so varied and sometimes delayed.

Right.

Precisely.

You know, this stress response syndrome really gave us, you know, a framework for understanding those those complex and often delayed reactions to trauma.

But but I knew what you're thinking.

Yeah.

How does this all connect back to schizophrenia?

Well, while while PTSD and schizophrenia are definitely, you know, distinct diagnoses, right, there's growing recognition that trauma can actually play a role in the the development and the course of schizophrenia.

So you're saying that experiencing trauma could actually make somebody more vulnerable to developing schizophrenia?

That's one possibility.

You know, research has shown that people with schizophrenia tend to have higher rates of trauma exposure compared to the general population.

And it's not just about the trauma itself, right.

It's about how people cope with it.

That's right.

You know, trauma can can have a significant impact on on brain development, on how we regulate stress, on the the coping mechanisms we develop.

And all of these things can can interact with, you know, the underlying vulnerabilities that might be associated with schizophrenia.

It's kind of like a perfect storm of of factors coming together.

Yeah.

And the impact of trauma, you know, it can it can show up in different ways.

OK.

For some people with schizophrenia, you know, it might it might make their existing symptoms worse, harder to manage.

So the symptoms become more intense or more frequent.

Exactly.

And for others, you know, it might trigger new symptoms entirely.

Or contribute to relapses.

It's it's like the trauma kind of, you know, throws off the balance that they've they've achieved in managing their schizophrenia.

So it's crucial for for anyone working with somebody with schizophrenia to to be aware of of any any history of trauma.

Absolutely.

And that's where trauma informed care comes in.

Right.

It's it's about, you know, creating a safe environment for someone to to talk about those experiences and get the appropriate support.

It's about treating the whole person, not just the diagnosis.

Couldn't have said it better myself.

We've we've covered a lot in this in this episode from the nuances of, you know, schizophrenia symptoms to to the complexities of treatment.

Yeah.

And the role of trauma.

It's been a real deep dive.

It really has.

But before we move on to the final part, I wanted to touch on something you mentioned earlier about

how our understanding of schizophrenia is is always evolving.

Yeah, that's that's such a critical point.

You know, what we know today might be, you know, completely different tomorrow.

New research is always emerging.

So this is a this is a dynamic field, then it's not we don't have all the answers.

Not at all.

And that highlights how important it is to stay up to date, you know, on the on the latest developments in in schizophrenia research and treatment.

And for for those living with schizophrenia, it it means that there's there's always hope for for new treatments and new interventions down the road.

It's a journey.

It's not a destination.

Well said.

Ready to wrap up with part three?

Absolutely.

All right.

Welcome back to the final part of our deep dive on schizophrenia.

We've we've gone through the systems, the causes, the treatments.

But I think it's important to just kind of step back for a moment and remember the human side of all of this.

Yeah, that's so important.

It's it's very easy to, you know, get lost in the science and statistics.

But we can't forget that, you know, schizophrenia affects real people each with their own unique experiences and challenges.

Recognizing the person behind the diagnosis.

Exactly, exactly.

And that means approaching this this topic with compassion and understanding and empathy.

Now, before we wrap up completely, I wanted to touch on something else I saw in the research here, something called the quick reference when to refer for medication treatment.

What what's that all about?

So that's that's a handy tool for mental health professionals to to kind of help them figure out when it might be appropriate to refer someone for a medication evaluation.

It lists, you know, various events or symptoms that might warrant consideration for for medication as part of the treatment plan.

So it's like a checklist for professionals to make sure they're considering all the bases when they're they're recommending treatment.

That's a good way to think about it.

Yeah, it covers a pretty broad range of situation from psychosis.

That's that's cause I and a medical condition to depression with psychotic features, schizophrenia, other psychotic disorders, drug induced states,

severe personality disorders and even manic episodes.

It's a pretty comprehensive list.

It just underscores how important a thorough assessment is to to make sure that somebody is getting the the most appropriate help.

Absolutely.

And while this guide is a is a really valuable resource,

it's it's important to remember that that it's just a starting point.

Right.

You know, the the decision to prescribe medication is is always made on a case by case basis, taking into account, you know, the individual's needs and their doctor's clinical judgment.

So it's it's not a one size fits all approach by any means.

Not at all.

Mental health treatment is is highly individualized and and health care providers need to consider each person's unique, you know, circumstances and preferences.

I want to shift gears just a bit here and talk about something that I think is is often overlooked in discussions about mental illness just in general.

And that's that's the role of hope.

Yeah.

Hope is so essential.

It's the belief that things can get better, that that recovery is possible and that, you know, a fulfilling life is is within reach.

And it's it's not just wishful thinking.

Right.

There's actual evidence that hope plays a role in the recovery process.

Absolutely.

You know, studies have shown that that people with schizophrenia who have a strong sense of hope tend to have, you know, better outcomes.

Oh, wow.

You know, they they may have, you know, improved social functioning,

reduced symptoms and an overall better quality of life.

So it's not just about managing the the illness.

It's also about believing in in a brighter future.

I couldn't agree more.

And that hope can come from many sources, you know,

supportive relationships, meaningful activities,

personal growth and even, you know, advancements in treatment.

It's about finding those glimmers of light even in the midst of darkness.

That's a beautiful way to put it.

And I think one of the most powerful sources of hope is is seeing other people who've lived with schizophrenia

achieve recovery and go on to lead fulfilling lives.

There's something so inspiring about stories of of resilience and triumph over over adversity.

Absolutely.

You know, it's it's it's so crucial to share those stories,

to challenge the stigma surrounding schizophrenia and to show that that recovery is not only possible, it happens.

Well, as we as we wrap up this deep dive, I think it's important to just highlight a few key takeaways about about schizophrenia.

First and foremost, while it is a complex and multifaceted condition,

it's it's not a life sentence.

Right.

With with the right treatment, support and and a commitment to ongoing care,

people with schizophrenia can can live

you know, meaningful and productive lives.

And we can't forget that schizophrenia affects individuals, each with their their own unique story.

Absolutely.

You know, compassion, understanding, empathy are so important.

Absolutely.

And lastly, hope is a powerful force in the recovery process.

We need to foster hope both for individuals with schizophrenia and their and their loved ones.

Love that.

And if there's one final thought that I want to leave our listeners with, it's this if psychosis can be thought of as a warming light, a signal that something's wrong.

What does that tell us about the importance of of early intervention and mental health awareness?

That's a that's a powerful question to ponder.

You know, early intervention and mental health awareness are are so vital in addressing, you know, mental health challenges, including schizophrenia.

Before they become, you know, more severe and debilitating.

It's about recognizing the signs, seeking help early.

Yes.

And creating a culture where mental health is is valued and supported.

It's about remembering that mental health is just as important as physical health.

On that note, we'll we'll wrap up this exploration of schizophrenia.

I encourage you to continue learning about this complex and often misunderstood condition.

Remember, knowledge is power, especially when it comes to mental health.

Thank you for for joining us on this deep dive.

Yeah.

Keep asking questions, keep learning and keep that spark of hope alive.