Schizophrenia Spectrum Disorder Diagnosis with DSM5-TR Changes

hey there everybody and welcome to  this presentation on schizophrenia   spectrum disorders in the dsm 5 tr  i'm your host dr donnelly snipes   in this brief presentation we're going to review  criteria for schizophrenia spectrum disorders   including but not limited to schizophrenia  brief psychotic disorder schizophrenia form   disorder delusional disorder and  schizotypal personality disorder how common is schizophrenia in the general  population you may not feel like you run   into it very much now you may be interacting  with people who have schizophrenia that are on   medication and it's well managed or they may be  between psychotic episodes and it's well managed   so assuming that you have never run into somebody  with schizophrenia is a faulty assumption in   general mental health practice it's not going to  be a client that you probably often see because   they're probably more frequently going  to need a higher level of care and or be   seeing a psychiatrist however if you work in  addiction facilities the prevalence of people   with schizophrenia or schizophrenia spectrum  disorders increases markedly so depending on   where you're working you may see more or less more  or fewer people with schizophrenia but what is the   prevalent in general in the general  population in the u.s brief psychotic disorder   five out of every thousand schizophrenia three  to seven out of every thousand schizophreniform   one out of every thousand schizo schizo effective  three out of one thousand and delusional disorder   two out of every thousand so if you add all  those up you're gonna get approximately 18   out of every 1 000 people or 1.8 almost 2 out  of every 100 people now there are a few more   diagnoses in this category in the dsm 5tr that  i did not go over in this presentation for the   sake of brevity so that number may increase  a little bit but what we are looking at is   a couple per hundred therefore when you go to  a festival when you go to a large store the   mall where there's hundreds of people you can  pretty much bet there are at least a few people   with schizophrenia spectrum disorders and  it's really important to recognize that   the vast majority of people with schizophrenia  either are well controlled and even if they're   not well controlled are not violent towards other  people and are not dangerous towards other people   they are much more likely to be victimized  themselves or be a danger to themselves so   i'm going to bring that up a couple of times  because the media does us a gross disservice of   highlighting the occasional person with a mental  illness that engages in violent behavior but the   vast majority of people are not violent  and it's important to destigmatize that   the vast majority of people with schizophrenia  are on medication and it's well controlled schizophrenia spectrum disorders are  defined by abnormalities in one or more   of the following five areas delusions  hallucinations disorganized thought or speech   disorganized behavior or negative symptoms so let's talk about delusions first because  that is a term that is often thrown around   in the general public and just like a lot of  other terms that are um taken out of context   and may be used very loosely in the general public  delusions in diagnosis are very much more specific   the difference between a delusion and a strongly  held belief is sometimes difficult to determine   now this is straight out of the dsm-5tr and  is based in part on the degree of conviction   with which the belief is held in spite of  contradictory evidence and there's a cultural   aspect as some beliefs may be seen as delusional  by people in one culture but not in another   delusions also do not have to be bizarre  in nature so somebody in one culture   can hold this belief very firmly and even  though there's contradictory evidence that   for that belief they also have some supportive  evidence somewhere that created that belief and   it could be that it was passed down from  their culture it could be that there's   information on both sides whatever the case may be  but if their belief if their strongly held belief   is largely culturally endorsed then it's not  a delusion it's a strongly held belief what we   are looking at in terms of diagnosing a delusion  is a strongly held belief that has contradictory   evidence and lacks cultural or religious support  and i guess religion kind of falls under culture   what types of delusions are  we talking about persecutory   these are the delusions where people think they're  being followed where somebody's out to get them   referential delusions are when somebody  believes that other people's normal behavior   is directed at them i worked with a patient one  time a couple decades ago many many years ago that   had referential delusions and believed that when  people said t-h-e when they said that word that   they were cursing at him and they were being  mean and demeaning and telling him he was a   horrible person now i'm not sure how he got  to the point where he believed that t-h-e   meant what he believed they meant but he did  and so watching television was very triggering   for him because it's really hard as you can see  how i had to carefully choose my words in this   particular segment not to use that particular  word how hard it is to go without saying it   but there can be other behaviors that people  do in the course of you know daily functioning   that a person with referential delusions may  think is targeted or directed toward them   grandiose obviously thinking that they are  all that they are the next messiah they are   um the president they are somebody that is  super duper important influential erotomaniac   is a delusion when somebody believes that another  person or other people are hopelessly in love with   them and they cannot be convinced that these  other people don't love them nihilistic is   interesting because nihilistic delusions involve  the belief that the person the person believes   that they've disappeared they have died they've  been annihilated in some way and then somatic   delusions these are body oriented delusions  where people may believe that maybe they have   bugs crawling under their skin or they have  particular organs that are rotting in them now the   bugs crawling under their skin that can also be  a side effect of certain substances therefore it   would be important to differentiate that delusion  from a substance and substance induced condition   or sensation but these are the the delusions  that we're typically going to be um seeing now hallucinations delusions are  thoughts that are objectively false or thoughts that have significant  contradictory evidence   hallucinations are perception-like experiences  that occur in the context of clear awareness   and the dsm is very clear that this does  not happen upon immediate awakening or   upon drifting off to sleep when we're  not when we don't have clear awareness   and it doesn't happen when under the influence  of substances but hallucinations that occur in   the context of clear awareness even without an  external stimulus and not under voluntary control one of the examples of hallucinations people  with parkinson's disease it's not uncommon   for them to have hallucinations  particularly visual hallucinations   they see things or people that aren't there  hallucinations may involve any sense but auditory   hallucinations are most common in schizophrenia  spectrum disorders it can be any sense that we   don't want to rule it out if it's not auditory  if it is a hallucination that is brought on by a   medical condition then we're going to diagnose the  medical condition um such as parkinson's disease   auditory hallucinations are perceived as distinct  from personal thoughts so the person hears these   voices that are not them thinking it's  somebody talking to them in their head disorganized speech and thinking can  involve loose associations the person   moves from one topic to another and you're like  oh how did we get from here to there and it's   not just occasionally they are all over the  place all over the map they're not loosely   associating you're talking about gardening and  all of a sudden they start talking about trains   because they're not interested in what you have  to say and they stay on trains for a while because   they just wanted to change the subject that's  not what we're talking about what we're talking   about is somebody who's just all over the map and  what they talk about and you just can't follow it   derailment is another uh form of disorganized  thinking where they will derail the conversation   tangentiality and all of these are kind of   loosely associated if you will um tangentiality  you know when somebody is tangential   they will be talking about food and then they  might may start talking about weight and then   they start talking about inflation and all of  these are tangentially related but they have   difficulty staying on one topic now in extreme  cases you may see word salad where the person is   stringing together words but they make no sense  in any language it's not like they're speaking   russian or greek or something it's just a bunch of  words that are strung together it's important to   differentiate disorganized thinking or speech from  cultural and religious phenomena such as speaking   in tongues and trance states where the person is  possessed by an external entity and these are all hallucinations and delusions are a matter of  perception are a matter of thinking and it's   important again to recognize is this something  that is supported culturally for the individual abnormal motor behavior is any goal directed  behavior leading to difficulties in performing   activities of daily living this can  include catatonia where the person just   stands there and it is completely catatonic stupor  resistance to instructions you tell them to do   something and they just don't do it  they are they seem completely unphased   and we want to differentiate that from exam for  example from oppositional defiant disorder mutism   where they will not speak  purposeless excessive motor activity   there used to be a gentleman in the town that  that i lived in before i moved to nashville who   had schizophrenia and he ran every day and  the town knew him very well he was a very   uh cheerful uh person but he ran  every day and this was part of his the running was part of his disorder  because he felt like if he didn't do it   bad things were going to happen so it became sort  of a compulsive behavior but when he was running   he was always waving at everybody and people  in town even law enforcement got to know him as   running man but again he was a very kind person  but his behaviors from a external standpoint   from an objective standpoint were relatively  purposeless and his waving while he was running   it was nice it was sweet it was congenial  but it was also excessive motor activity   so it would though that behavior might fall here  and another abnormal motor behavior can also   include repeated stereotyped movements or echoing  of speech we want to differentiate and we're   going to talk in differential diagnosis but we do  want to differentiate this from for example from   stimming that we might see in people  with autism spectrum disorders negative symptoms include diminished  emotional expression the person just doesn't   express their emotions at all they're  they're very blank-faced um a lot of the time   abolition volition is voluntariness and they ha  avalation means a lack of voluntary engagement   there is no motivation they just  they don't want to get up and do   anything they're they're flat and hedonia  they have difficulty feeling pleasure and   asociality they have no desire to engage with  others one of the things and this is a little   tangential one of the things that you may see  in people with schizophrenia spectrum disorders   who are on anti antipsychotics or atypical  antipsychotics is an increase in negative symptoms   because atypical antipsychotics and antipsychotics  reduce the amount of dopamine dopamine   is responsible for energy motivation and to a  certain extent pleasure and if somebody is just   completely exhausted they feel like they're in  a fog all the time and they've got no motivation   then you're going to see some more negative  symptoms and getting medication in the right   balance for each person takes a little bit  of time it's also important to recognize   that most antipsychotic and atypical antipsychotic  medication is highly sensitive to blood plasma   levels therefore if the person gets dehydrated  they will become destabilized on their medication   generally in florida in the summer we would see a  marked increase in crisis stabilization admissions   of people with who were on  these types of medications   especially those who were homeless or  who worked outside because they would   get dehydrated their meds would get out of whack  and they would start having active phase symptoms so let's talk about schizophrenia brief  psychotic disorder and schizophrenia form   why did i put all these together  because this is your continuum here in these disorders brief psychotic disorder is the  shortest followed by schizophrenia form followed   by schizophrenia in these three disorders two  active face symptoms are present most of the time   for a month delusions hallucinations disorganized  speech disorganized behavior or catatonia   or and or negative symptoms so two or more  their level of functioning is in schizophrenia   is markedly below that achieved prior to onset now  the functioning level does not have to decrease   for brief psychotic or schizophreniform  disorder so when you get to the far   end of the spectrum you start having a  marked uh decompensation and functioning   active phase symptoms and the rest can be rest  of the time can be pro active phase symptoms   can be prodromal or residual that means a sub  threshold the person has to be exhibiting symptoms   for approximately six months for schizophrenia  one to six months for schizophrenia form and   less than one month for brief psychotic so what am  i saying here i'm saying that the person must have   active face symptoms during  for schizophrenia for example   during for for at least six months for  schizophrenia schizophrenia but they only have to   rise to the level of diagnosis if you will um for  one month but then during the other days in that   six months they have a sub threshold prodromal  or residual symptoms so they're not completely their pre-symptomatic self it's important to rule out another  psychological or medical condition or   substance there are a lot of things neurocognitive  disorders specifically that can cause   hallucinations delusions disorganized thought  disorganized speech so it's important to rule   those out bipolar disorder mood disorders those  also are things that we need to assess for roughly one-third or 32 percent of individuals  with substance-induced psychosis are later   diagnosed with schizophrenia spectrum disorders 20  and that would be 26 percent with bipolar disorder   and 44 for cannabis induced psychotic disorder so  that's really interesting that when we have a um person who experiences substance  induced psychosis they often go   on to either develop schizophrenia spectrum  disorders or bipolar disorder and by far the   most problematic substance induced psychosis is  the one that occurs as a result of cannabis use   i'm not saying anything for or against  cannabis i'm just identifying the data   that we have they have started to explore the  involvement of the endocannabinoid receptors in   the development of schizophrenia but the  information out there is still very new delusional disorder the delusions last for greater  than a month global functioning is generally   better than in people with get schizophrenia  schizophrenic form or brief psychotic disorder   one-third of people with delusional disorder  that lasts between one and three months later   receive a diagnosis of schizophrenia if the  diagnosis persists for more than six months   it often doesn't change okay  so that was really interesting   so there's a a window between three  months and six months that may be   a critical period for receiving treatment if the  person so what they're saying is if the person   has delusional disorder that lasts between one  and three months and then they have a remission   they may go on they're much more likely to go  on later and get a diagnosis of schizophrenia   however if their delusional disorder persists  for more than six months without a remission   then it often doesn't change they  often don't go on to develop what   would be considered schizophrenia so  i thought that was kind of interesting   and i'm wondering what happens you know  why is the what is this difference here a diagnosis of schizophrenia requires the  exclusion of other psychological and medical   conditions that may cause psychosis so let's talk  about some of this differential diagnosis stuff   because as usual it's not super easy and a lot of  these are not super cut and dry now schizophrenia   schizophreniform and brief psychotic disorder are  relatively easy to differentiate from each other   because they are very different in terms of  duration in schizophrenia hallucinations or   delusions in the absence of a major mood episode  if the person has a major mood episode and the   only time they have hallucinations or delusions  is when they're in that major mood episode   whether it's major depression or mania then  it's not schizophrenia though those solutions   hallucinations and delusions are related to  the mood disorder if however the hallucinations   or delusions occur and there is not  concurrently a major mood episode   then we're looking at schizophrenia or or  something else in people with schizophrenia   the delusions often show greater disorganization  greater pervasiveness and greater preoccupation   so the person it influences more areas of  their life it is more prevalent throughout   their life and they are more preoccupied  with that particular thought or delusion   schizophreniform disorder requires the criteria  for schizophrenia be met with a duration of at   least one but less than six months and does  not require that decline in functioning   the person can have those symptoms and can  be able to manage them to a certain extent   so it doesn't negatively impact their  functioning but the symptoms are still   there and brief psychotic disorder lasts  more than one day but less than a month delusional disorder is characterized by at least  one month of delusions but no other psychotic   symptoms no hallucinations no disorganized  thinking no disorganized behavior no negative   symptoms any mood disorder episodes are relatively  brief in comparison to the delusional disorder   schizoaffective disorder  requires a mood episode to occur   concurrently with the active phase symptoms  of schizophrenia remember the active phase   symptoms we're talking about those five  criteria um and it lasts at least two weeks   unless unless hallucinations or delusions  prior to or after the mood episode resolves schizoid personality disorder does not  involve active phase psychotic symptoms   the person is detached from social relationships  and has a restricted range of emotional expression   when i was going through diagnosis back in  the day there was a my diagnosis professor   did not really highlight the fact and i think he  did us a disservice he did not highlight the fact   that schizo break it doesn't necessarily  mean break with reality so schizoid   personality disorder does not involve those  hallucinations or delusions or disorganization   it involves a break from social relationships  and a restricted range of emotional expression   schizotypal symptoms are persistent and there has  not been a full episode of active schizophrenia in major neurocognitive disorders uh the person  may present with symptoms of delusional disorder   or hallucinations however it wouldn't would  be diagnosed as major neurocognitive disorder   with behavioral disturbance it is important  if you have somebody presenting with   a with symptoms that seem like schizophrenia  or schizophrenia spectrum disorders especially   if the onset was very rapid um that they'd be  evaluated for a major neurocognitive disorder   early onset dementia early onset alzheimer's   something like that and if that is the case then  those things need to be addressed with their   medical doctor in order to slow the progression  as much as possible and maintain their quality   of life so there is a lot of overlap between  major neurocognitive disorders and schizophrenia   and the difference is the causation in many cases  but and the treatment is very very different   substance or medication induced psychotic disorder  may be indistinguishable from delusional disorder   with the exception of the chronological  relationship of use to the onset and remission so this is kind of interesting too substance  or medication-induced psychotic disorder   is caused the only time they're having these  symptoms is when they are either actively   using or in the detox period from the use of  the substance and the farther away they get   from the substance the fewer their symptoms  are the less intense their symptoms are   that would indicate that it was caused  by the substance or medication however uh   hallucinogen persisting perception disorder  is a condition that occurs in people who have   used hallucinogens particularly lsd but any  hallucinogen and they may have hallucinations   years after the use of that substance we need  to make sure that we're assessing for that if   the person presents with hallucinations so yes  substance induced is generally you can identify   due to the symptoms based on the proximity  to when they used the substance however if   it was a hallucinogen that's got its whole other  whole different diagnosis depression and bipolar   disorder we can differentiate if delusions occur  exclusively during mood episodes the diagnosis is   made for major depressive or bipolar disorder with  psychotic features and i already talked about that   if when the mood episode resolves  the psychotic features also resolve   then it is the mood disorder with psychotic  features not schizophrenia autism spectrum   disorders and communication disorders of childhood  onset are also important to rule out when we are making a diagnosis now people  with autism spectrum disorder   aren't typically going to have  hallucinations or delusions   but they may have the repetitive behavior  they may have the catatonia they may have   some of the other symptoms and remember it  only requires two out of the five in order to meet the criteria for schizophrenia so you  want to really effectively evaluate when do   the symptoms start what causes them is there a  possibility of an autism spectrum disorder and   communication disorder of childhood onset could  explain um disorganized speech as well as mutism associated features inappropriate affect  is very common in people with schizophrenia   they may act feel happy when nobody else is  they have great difficulty reading other people   dysphoric mood well if they are on  antipsychotics their dopamine levels   may be low so that may contribute  they are often in an environment   in which people don't share their same reality so  they may feel very isolated and misunderstood you   can see a lot of reasons why somebody might have  a dysphoric mood in in schizophrenia hostility and   aggression and i mentioned this earlier but it's  worth stating again yes people with schizophrenia   who especially who are in active phase  may get very frustrated when other people dismiss what they're saying they're saying the  sky is green and everybody else is saying no   it's not you know the sky is blue just trust us  on this the person doesn't feel supported doesn't   feel understood and that's a scary place to be  in people with schizophrenia they actually are   seeing a green sky in their reality it is green so  they can get very frustrated the majority of the   time that hostility and aggression they may get  irritable um and they may throw a little bit of a   temper tantrum but that hostility and aggression  is often self-directed very rarely do they   act out against other people and you can go to  pubmed you can google the data on the prevalence   of violence in people with schizophrenia and  you will find it's very very very very low   the other thing that i can liken it to is  plane crashes what do we see on the news   we see on the news the one time the plane crashes  we don't hear about the 22 000 other flights that   went out that day that went just fine we hear  about the one person with a mental illness that may have done something wrong  and we didn't hear about the   yes millions of others out there  with mental illnesses that are often victimized themselves or at the  very least you wouldn't know they've   got a mental illness or they're non-violent  it's really important to evaluate the facts   and not use that availability bias people with  schizophrenia often have disturbed circadian   rhythm patterns and that is really important  to recognize a lot of people with schizophrenia   may sleep during the day and be awake all night  long their circadian rhythms are messed up and a   sleep specialist may be able to help reset their  circadian patterns so they're more in a line   disturbed circadian rhythms can be problematic for  the person because at two in the morning there is   less support for the person because there are  fewer people awake who have good intentions and there can be more isolation more loneliness  there's just a lot of reasons that being awake   at night can be problematic not to mention the  fact that if they live in a household with people   that have normal circadian rhythms they may be  being disruptive to the rest of the household   anxiety and phobias are very common in people with  schizophrenia spectrum disorders we want to make   sure that we assess and accurately address anxiety  and phobias stress is going to tend to trigger   more symptoms or increase the severity of  people's presentation so we need to do what   we can to reduce stress memory deficits and slower  processing speed are also very common in people   with schizophrenia we need to recognize that and  provide reasonable accommodations whether it be at   work at home whatever they may benefit from having  lists you know to-do lists schedules that are   easily seeable and available so they  remember what they're supposed to do   and in group or at work whether they're  in full-time work or supported employment   recognizing that they've got a slower  processing speed so giving them a minute   if you give them an instruction or if you  ask them a question giving them a minute   to process what you've said and come up with  the answer in order to avoid making them feel attacked condescended to we want to empower  them we want to help them recognize that we   want to hear what they have to say they may have  difficulty taking other people's perspectives   they call this theory of mind but a lot of people  with schizophrenia have difficulty with empathy   and seeing other people's perspectives like i said  they may see the sky as green other people even   everybody else around them sees the sky is blue  and they may have difficulty understanding that   other people see something different just like a  lot of us have under difficulty understanding that   they see something different so you know i think  we all may need to take a little lesson from that   they may sometimes uh the symptoms may be ego  syntonic that means they don't recognize that   their behavior is abnormal a lot of people with  schizophrenia recognize that their behavior is not   the same as other people but some people  don't there may be apparent impairments   in motor coordination as well as sensory  impairments a lot of people schizophrenia have   sensory gaiting issues they can get overwhelmed  very easily because their brain has difficulty   deciding what's important to let in and what's not  very similar to what happens in people with adhd   they also may have sensory integration  issues where lights sound smells   textures may be almost imperceptible to  them or may be ultra intense to them when   to a person without schizophrenia  it's it's very middle of the road   we want to recognize this because a lot of times  people with schizophrenia are being traumatized   feel uncomfortable the world is painful for  them because of these sensory differences   they found doing fmris and other tests that the  brain architecture in people with schizophrenia   is different certain areas are bigger certain  areas are smaller and ultimately there's a reduced   brain volume another interesting article i found  indicated that psychotic features tend to worsen   in people with schizophrenia when estrogen  levels drop now this is also a gender related   issue people who are biologically female when  they go through perimenopause and menopause   their estrogen levels drop and we  also see an exacerbation of symptoms   however i wonder and i didn't find any  research on it but i wonder in people who   are transitioning if they are transitioning to   male and reducing their estrogen how that affects  things and if they are transitioning if they have   schizophrenia and are transitioning to female if  that improves their symptoms i don't know i'm just   curious because they have found a direct  correlation between estrogen levels and symptoms functional impairment people with  schizophrenia are at a much higher risk of   developing diabetes and cardiovascular disease  people with schizophrenia actually smoke   more than people in the general population and we  can go on a whole diatribe about that but it is   important to recognize that food choices weight  management diabetes blood sugar management and   health management for cardiovascular disease  are important secondary treatment goals   for people with schizophrenia affective people  with schizophrenia often struggle with anxiety   depression anger as i said it think  about if you were in this person's shoes   and nobody else seemed to understand what you were  going through you seemed like you were in your own   universe and nobody else could see it how scary  that might be if you were constantly being told   that your perceptions were wrong and unsupported  how scary that might be how angry you might be   either at not being understood or at the  fact that you've got to deal with this and   you're different from other people there is a  grieving process that people go through when   they get their diagnosis of schizophrenia  that uh and the family also goes through   when they have a loved one that's diagnosed  with schizophrenia oftentimes the first   episode of schizophrenia doesn't  happen until the mid to late 20s   so the person may have been you know asymptomatic  up until college or even right after college   so that it represents a huge change for the  individual as well as for the family cognitively   you know schizophrenia is largely a disorder  of cognition and so people with schizophrenia   have difficulty organizing their thoughts they  also have difficulty with memory and attention   and providing supportive aids can be very  helpful here to empower the person don't   ask them to remember a bunch of stuff write  it down don't give them complex directions   one thing at a time and ideally write it down  attention keep things small if you're doing group   therapy with somebody who has schizophrenia don't  do an hour and a half group that that's ridiculous   keep it to maybe 20 minutes 30 minutes at  a time recognizing that they're going to   retain a whole lot more if they if they're able to  do it in brief chunks and eliminate distractions   don't be having a group out on on a park  bench when there's people around and traffic   and squirrels and birds and everything else that  is may distract them remember they have sensory   gating issues so it may be difficult for them to  block out those things and focus environmentally   people with schizophrenia often have employment  difficulties because of their active face symptoms   as well as their um anhedonia abolition  asociality it doesn't mean that they cannot work   a lot of times people with schizophrenia are  benefit greatly from part-time work volunteer work   or supported employment however it's important  to find the right fit where they're going to feel   welcomed and where the supervisors understand how  to respond in the event that the person starts   to decompensate and the word decompensate  can be really scary for a lot of people um   but helping educate employers about what  schizophrenia is and if the person starts having   hallucinations or delusions you know what works  best for this person when this starts to happen   you know it doesn't have to be a crisis just like  if somebody had diabetes what works best for this   person if all of a sudden they become hypoglycemic  or start going into diabetic coma you know   yes their condition is changing but  what's the best way to respond very very   practical and relationally people schizophrenia  often struggle with a lack of social support   isolation and social cognition deficits  as i talked about earlier a lot of times   they have difficulty reading people and  understanding reading emotions reading space   proper interpersonal space etc they can make it  more difficult they all often have a difficult   time with empathy and perspective taking it's not  that they don't want to it's just that they can't in terms of suicidality five to six percent of  people with schizophrenia spectrum disorders   die by suicide however 20 attempt and  it's important to recognize that that   that's that's one in five people with  schizophrenia will attempt suicide   that that that's a lot that you can  just put that into perspective causes   now this is kind of interesting to look at because the data has changed over the  past 20 years initially the belief was that   schizophrenia and psychotic disorders were caused  by dopamine imbalance all currently licensed   antipsychotic drugs block dopamine 2 receptors and  acted other receptors in the brain including the   other dopamine receptors serotonin glutamate  histamine norepinephrine and acetylcholine   so we can't say just from this medication because  it acts on the d2 receptors that necessarily d2   is the be-all-end-all chemical and actually  we found out that it's not they're actually   looking more at glutamate now which is really  interesting remember in your stress response   system your hpa axis when that is kicked off  your body dumps cortisol adrenaline glutamate and   other neural chemicals to help you fight or  flee glutamate is your main stress chemical   if you will excitatory neurochemical and  it's most prevalent when you're under stress   so it makes leads us to some other thoughts hpa  axis dysfunction your stress response system   dysfunction in that system leads to alterations  in the gut microbiome when you're stressed your   brain tells the vagus nerve we've got to prepare  to fight or flee so you need to mount a different   response in the gut so the microbiome changes and  different neurotransmitters are given priority   and when that hpa axis alters the gut  microbiome it increases inflammatory cytokines   and when that hpa access is chronically activated  then we start to see systemic inflammation   alterations in the gut microbiome as well as  systemic inflammation have been implicated in   the development of schizo spectrum disorders  additionally recently glutamate and glutamine   levels have been reported to be increased in  individuals at familial risk for schizophrenia   so people with a family history of schizophrenia  often tend to have higher glutamate or glutamine   levels which may support that intergenerational  trauma hypothesis but didn't find a whole lot of   research on that however trauma addiction social  isolation genetics maternal vitamin d deficiency   immigration and an urban environment are also all  associated as risk factors for the development   of schizophrenia now what's similar in  a lot of these things trauma addiction   so social isolation maternal vitamin d deficiency  immigration and urban environment so everything   but genetics tend to have a physical  or emotional stress component to them that's interesting they didn't say low socio  economic status they didn't say urban those   with a low low socioeconomic status in an urban  environment they it's associated with an urban   environment in general regardless of socioeconomic  status therefore we've got to ask what's different   about the urban environment lights different  um different stressors constant noise   i don't know and they don't know at  least i didn't find any articles on   exactly what factors they thought caused the  urban environment to be um at higher risk or a   risk factor for schizophrenia but i thought  these were interesting now what can we do   we know that a lot of people with schizophrenia  are born and they have a genetic predisposition   just because you've got a predisposition doesn't  mean it's going to develop however if you have   this predisposition and then you hit all these  other risk factors then the stars kind of align   so as clinicians and social service workers and  prevention workers we need to work to prevent   and mitigate trauma addiction social isolation um  nutritional deficiencies and anything that might   contribute to additional stress or we may want  to ease the impact of stress i don't know how   to really say that for people who are immigrating  as a huge stressor and people who live in an urban   environment we need to ask what is contributing  to stress we don't want those glutamate levels   to stay high in people's brains we don't  want them to become emotionally disregulated understanding of schizophrenia  has advanced significantly   and is now an ex exploring  vitamin d deficiency in the mother   which could may be implicated in causing some  of those neurological changes in the fetus   stress and trauma-induced alterations in the  gut microbiota that result in systemic including   neural inflammation diagnosis of schizospectrum  disorders requires active phase symptoms   delusional disorder symptoms persist for more  than a month but no other symptoms of psychosis   are present it's just the delusions and only  the delusions schizophrenia spectrum disorders   have a marked impact on the quality of life of  people with the disorder as well as on their   family and community a person with schizophrenia  doesn't live in isolation doesn't live in a bubble   they are probably going to be either living some  people with schizophrenia are able to manage it   and live fully independently others may need to be  in supported housing still others may have to live   continue to live at home it will  impact their ability in some cases to   hold full-time jobs you know  there are a lot of implications   of schizophrenia for not only the individual  but the community prevention strategies need to   aim to address maternal nutrition and prevent or  reduce stress-related inflammation in the mother   the the birth parent during pregnancy as well  as in the child all the way through the adult   you know just because somebody is an infant or a  toddler doesn't mean they don't experience stress   and resultant inflammation so there are a lot  of avenues that we can pursue to help mitigate some of the things that are risk factors for  schizophrenia however we still have a long   way to go before we understand exactly what  causes it and are able to develop a better   treatment and prevention strategy

Channel: Doc Snipes

Views: 50,469

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Id: qXP8e-9tgkA

Length: 53min 28sec (3208 seconds)

Published: Wed May 25 2022