Psychotic Disorders - E-Book

Comorbidity Detection Promotes Improved Diagnosis And Treatment

André Barciela Veras, Jeffrey P. Kahn

• Publisher: Saunders
• Year: 2020
• Print ISBN: 9780323683098
• eBook ISBN: 9780323683104
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

A counterintuitive and novel approach to the long-sought goal of subtyping schizophrenia and other psychotic disorders emerges from ongoing research.? Five psychosis associated anxiety and depressive subtypes each help define five corresponding psychosis diagnoses, their fixed false beliefs, and most importantly, their treatments.

These anxiety and depressive comorbidities have long been long overlooked as an understandable hodgepodge of distressing symptoms caused by the pain of psychosis.? But these five comorbidities usually precede onset of the psychosis, and their treatment can significantly improve outcome. So, maybe, the causation is the other way around: maybe they are among the underlying contributors to schizophrenia and other psychotic disorders.

The chapter authors expertly detail the data supporting this innovative approach.? They provide fictional case studies, DSM-5 diagnostic criteria, specific interviewing approaches for the five comorbidities in psychosis patients, and improved treatment options.? Other chapters explore psychoses related to substance use, medical illness and medical treatment, as well as other factors that contribute to psychotic disorders.

This first-of-its-kind reference is a valuable clinical, educational, research and training resource for psychiatrists, psychologists, nurses, social workers, neurologists and anyone interested in the care and treatment of someone with a psychotic disorder.

• Reflects current research, diagnosis, and treatment options for:
  
  

• • Schizophrenia with Voices and Panic Anxiety
    
    

  • Obsessive-Compulsive Schizophrenia and Obsessive-Compulsive Disorder
    
    

  • Persecutory Delusional Disorder and Social Anxiety
    
    

  • Delusional Depression and Melancholic Depression
    
    

  • Bipolar I Disorder and Atypical Depression
    
    

  • Substance Use Psychoses
    
    

  • Medical Illness and Iatrogenic Psychoses
    
    

• Covers treatment options and outcomes with medication and psychotherapy.?
  
  

• Includes sample patient interview approaches and/or biological tests for each diagnosis.
  
  

• Highlights symptoms, quasi-psychotic symptoms and secondary signs of the comorbidities when alone, and when in conjunction with psychosis.
  
  

• Reviews diagnosis-specific significance and contributory roles of neurotransmitters, hypofrontality, psychological trauma, and genetics.
  
  

Chapter 1: Introduction: Diagnosing Comorbidity Trees in the Forest of Psychosis

Carolina Gomes Carrilho; André Barciela Veras; Jeffrey Paul Kahn

Abstract

Despite so many false starts over the years, there are currently several well-recognized and distinct subtypes of psychosis. These subtypes allow differential determination of clinical course, prognosis, and especially of optimal treatment. Part of what allowed this progress was attention to the psychiatric and medical comorbidities of psychosis. From delusional depression to medical illness, there is strong evidence for the value of treating those comorbidities as well. This volume offers an overview of psychoses and their comorbidities and also looks at more recently accumulating research, clinical experience, and conceptual frameworks. Although not all comorbidities serve to define a psychosis subtype, some of those more recently studied may be associated with proposed additions to psychotic diagnoses. All comorbidities have significant potential value for improving treatment, outcome, and psychopathologic understanding. Converging concepts from data analytic studies and from evolutionary theory suggest that there may be five core functional psychoses, as well as others due to substance use and to medical illness and treatment.

Keywords

Psychosis; Comorbidities; Differential diagnosis; Transdiagnostic; Evolutionary theory; Ultra-high risk; Psychopathology

Definition of Functional Psychosis

Primeval social instincts helped safeguard both ancient human groups and modern animal groups of all kinds, but we humans also have an evolutionary advantage when it comes to consciousness. That ability to think about thinking has helped us evaluate environmental and interpersonal situations, readapt, reorganize environments, and inform our social interactions and other needs. So, conscious reason has allowed humans to adapt and prosper beyond the reach of other species. Our consciousness instinct is responsible for moderating our primeval social instincts.¹ However, a decrease of that rational consciousness can allow the reemergence of instinctual perceptions and beliefs, leading to heightened prominence of social instincts and to frightening concerns.

With consciousness, we humans can overcome biological social instincts, and we can better rely on reasoning to achieve better outcomes in both challenging and promising situations. Consciousness and self-awareness are adaptive traits that can improve human life when focused on ourselves and especially when focused on others. However, when consciousness decreases and social instincts emerge, we have a loss of contact with reality and with normal social functioning. When extreme, these unmoderated socially instinctive beliefs can be called “psychosis,” as in the overused but paradigmatically termed “schizophrenia.”

Eugene Bleuler (1857–1939) described “The Group of Schizophrenias” with a presumed biological cause. Considering how our inner unconscious holds much of our social instinct, it is remarkable that Bleuler, in coining the term “schizophrenia” in 1908, understood it as an illness where the brain splits apart between a conscious mind (think conscious reason) and an inner unconscious (think social instinct), so that the inner unconscious then dominates. Although primeval social instincts are adaptive to a point even today, when they are too dominant, they can contribute to psychotic experiences.¹

Psychosis is a clinical category with various symptoms, and diagnosis is possible only through psychotic clinical manifestations, rather than through laboratory, genetic, and neuroimaging investigation.² According to the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), psychotic features are defined by such alterations as delusions, hallucinations, disorganized thinking or speech, disorganized or abnormal motor behavior, and negative symptoms.³

Although psychosis includes a spectrum of several disorders, schizophrenia is only approximately 30% of the psychotic spectrum. Even so, it has been 10 times more researched than the other 70% of psychotic disorders. In clinical practice and public awareness, the term “schizophrenia” has been used to epitomize the nature of all psychosis types, even those with brief psychotic episodes, and those considered at ultra-high risk (UHR) for schizophrenia. And because schizophrenia is a chronic and progressive disorder, many professionals prefer to substitute diagnoses that suggest a better clinical outcome. Indeed, when psychotic patients do recover substantially, they are usually considered ineligible for the chronic diagnosis called schizophrenia.⁴

In the early editions of the Diagnostic and Statistical Manual of Mental Disorders, psychosis was defined more by the presence of functional limitations than by the role of symptoms in those limitations. Nowadays, schizophrenia diagnosis is made solely based on the presence of hallucinations and/or delusions without insight (i.e., by impairment of reality testing). However, there are other psychotic symptoms also commonly found in nonpsychotic patients that seem to affect severity, intensity, and the co-occurrence of hallucinations and delusions. These can include disorganized thinking, neologism, thought blocking, other disturbances of thought, and negative symptoms. It is also common for adolescents with psychosis to present anxiety, mood changes, and social withdrawal before the onset of the first psychotic episode, which can further explain the relation between nonpsychotic affective symptoms with thought disturbances and the more severe psychotic symptoms.^5,6

Alongside psychotic symptoms, patients frequently have other psychiatric comorbidities. Missed diagnoses, and misdiagnoses are also common, despite the seeming homogeneity of psychotic disorders.⁶ The core diagnoses in nonpsychotic patients are also the most common comorbidities in schizophrenia: melancholic major depression, atypical major depression, obsessive-compulsive disorder, panic disorder, and social anxiety. In addition, these comorbidities can worsen prognosis and increase symptom severity; therefore adequate diagnosis and treatment of comorbidities can ameliorate positive and negative psychotic symptoms.⁷

A History of Psychosis Differential Diagnosis

Psychosis derives from the Greek word “psykhe” (mind) and “osis” (diseased state), which means mental disorder. The term “psychosis” was used to explain interactions between physical and mental processes. A German pathologist and neurologist named Nikolaus Friedreich (1825–1882) thought of psychosis as a combination of physical brain anomality and mental vulnerability, with a predominantly organic neurologic basis. Therefore psychosis was used to explain “insanity” and “mental illness.”⁸

Emil Kraepelin (1856–1926) explained how different diseases had similar processes and would produce similar symptoms, pathologic anatomy, and common etiology. People believed each disorder had its own etiology, pathologic anatomy, and symptoms, but Kraepelin believed many disorders had similar symptoms and biological foundations that would follow different courses as illness progressed. He then grouped illnesses such as catatonia, hebephrenia, and dementia paranoides into one condition called “dementia praecox,” with the idea that this illness was present in young people and had symptoms such as inappropriate emotions, stereotyped behavior, distraction or confusion, hallucinations, irrational beliefs or delusions, and a deterioration of mental functions.⁸

Besides dementia praecox, Kraepelin also differentiated dementia praecox from manic depressive illnesses and paranoia, the last two with better prognoses. Manic depressive illnesses were mood disorders, whereas paranoia had symptoms of delusional belief with less severity than in dementia praecox. Inspired in part by Kraepelin’s work, Bleuler then coined the term “schizophrenia,” believing dementia praecox did not adequately define psychosis. His notion of schizophrenia was a pathologic splitting apart of the emotional and rational consciousness parts of psychic functioning. Catatonia, which was once apart from dementia praecox classification by Kraepelin, was then included within schizophrenia.⁸ A psychiatrist named Jacob Kasanin (1897–1946) coined the term “schizoaffective disorder,” to reflect symptoms of schizophrenia, mood disorders such as mania and depression, and hallucinations, but with fewer symptoms of passivity.⁸

Just as depressive symptoms can vary in number and severity, there are patients with only a few psychosis-related symptoms but not enough to diagnose a psychotic disorder. A psychosis continuum supposition would encompass the range of psychosis symptom variety and severity in the general population. This range includes the overt psychoses, as well as many people with minor symptoms that can include hallucinations, delusions, and ideas of reference. For example, benign hypnogogic hallucinations typically include a voice calling someone’s name as they fall off to sleep. Because psychosis has several symptom dimensions that overlap with affective and nonaffective disorders, it could be thought of as both an illness continuum and also a heterogeneous disorder.⁹

DSM’s diagnostic criteria for schizophrenia are clinically relevant and useful; however, it does not provide essential information about the nature, etiology, biology, social aspects, risk factors, and structure of schizophrenia. Many professionals have debated the construct validity of schizophrenia, in view of psychotic-like experiences in many other psychotic and nonpsychotic disorders, and even in the normal population.¹⁰

Current Psychosis Differential Diagnostic Theories

Dopamine-blocking antipsychotic medication treatment has ...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Contributors
• Foreword
• Preface
• Acknowledgments
• Chapter 1: Introduction: Diagnosing Comorbidity Trees in the Forest of Psychosis
• Chapter 2: Psychotogenesis
• Chapter 3: Obsessive-Compulsive Schizophrenia and Obsessive-Compulsive Disorder
• Chapter 4: Paranoid Schizophrenia With Voices and Panic Anxiety
• Chapter 5: Persecutory Delusional Disorder and Social Anxiety
• Chapter 6: Delusional Depression and Melancholia
• Chapter 7: Bipolar I Mania and Atypical Depression
• Chapter 8: Substance Use Psychosis
• Chapter 9: Psychoses Due to Medical Illness or Iatrogenesis
• Index