Mental Health: Schizophrenia, Anxiety, Depression, and Addiction

Posted on Dec 19, 2024 in Psychology and Sociology

Features of Schizophrenia

Schizophrenia is a severe brain disease with a usually deteriorating course. It is typically diagnosed between 15 and 20 years of age, usually about 5 years earlier in men than in women. It affects about 1% of the population, and its specific causes are still unknown. The risk of developing schizophrenia is directly associated with the degree of biological relationship with an affected individual.

Dementia Praecox (Kraepelin, 1856-1926)

• Great variability of symptoms
• Internal connection is only recognized by its presentation at some point in the evolution
• Weakening of the will, which impairs mental activity and the drive to work
• Loss of internal unity of the activities of intellect, emotions, and will, in themselves and between different aspects

Schizophrenia (Bleuler, 1857-1940)

Main symptoms (The 4 A’s):

• Association (thought disorder)
• Affect (emotional dissonance)
• Ambivalence
• Autism

Accessory Symptoms:

Delusions, hallucinations, impaired language and writing, somatic symptoms and syndromes, and acute catatonic states (manic states, melancholy twilight, confusional states, etc.).

First-Order Symptoms (Schneider)

• Audible thoughts
• Hearing voices that echo one another
• Hearing voices commenting on one’s actions
• Thought withdrawal and other influences on thought
• Thought broadcasting
• Delusional perception
• Feelings or actions experienced as made or influenced by others

Characteristics of Schizophrenia

1. Psychotic: Includes delusions and hallucinations
2. Disorganized: Includes language disorders, disruptive behavior, and inappropriate affect
3. Negative symptoms
4. Autism (Bleuler)
5. Acts without projection into the future (Minkowski)
6. Loss of vital contact with reality (Minkowski)
7. Lack of life purpose (Roa). Schizophrenia is organized regardless of the other, i.e., a deficit that the patient has in the links and social networks that constitute us as living beings

Disorganization of speech/language

Bizarre conduct/direction of behavior

Negative Symptoms

• Alogia/reduced speech flow
• Flattening of affect/reduced emotional expression
• Anhedonia/reduced capacity for pleasure
• Abulia/reduced will, momentum

Markers

1. Present prior to clinical symptoms and are independent of disease status.
2. Clearly more prevalent in individuals with schizophrenia.
3. Comparatively more specific for those with schizophrenia than for other diseases.
4. Also present in siblings (phenotype).

Predictors

Obstetric Complications (OC)

Direct: Cyanosis at birth, need for resuscitation, perinatal apnea.

Indirect: Low birth weight, cardiac abnormalities, nuchal cord, third-trimester bleeding, polyhydramnios, presence of meconium in the amniotic fluid, and a transverse presentation.

Vulnerability

Given by a number of factors that can be researched from before birth, in the subject or their family, indicating an increased likelihood of contracting the disease, as seen in the studies reviewed. It enables us to identify people at high risk or population groups at high risk.

This identification is relevant from an epidemiological point of view because it could allow for early intervention in these high-risk populations or maintain surveillance programs.

Prodromes

Early symptoms of schizophrenia, which would constitute a process already underway, which has been described clinically.

• Isolation
• Depersonalization
• Abnormal behavior
• Changes in self
• Decline in academic or employment performance
• Problems with speech
• Depressive symptoms

Cognitive Disorders in Schizophrenia

Severe disturbances:

• Learning
• Executive functions
• Surveillance
• Motor speed
• Verbal fluency

Moderately impaired:

• Attention
• Delayed recall
• Bender skills
• Immediate memory
• Working memory

Minor alterations:

• Perceptual abilities
• Recognition memory
• Nominal
• Minimal changes
• Recognition call for reading
• Long-term memory

Prognostic Factors for Schizophrenia

• Insidious onset
• Male gender
• Negative symptoms
• Cognitive alterations
• Substance abuse
• Although good mood symptoms have been considered a good outcome, depressive symptoms are associated with greater suicide risk

Anxiety Disorders

Definitions of Anxiety

DSM-IV-TR (2001)

Anxiety is the apprehensive anticipation of future danger or adversity, accompanied by a feeling of dysphoria or somatic symptoms of tension. The focus of anticipated danger may be internal or external.

Anguish

Anxiety is an emotion that, from that context, affects not only the psychic life of people but also has a physiological correlate.

Anxiety: Psychic aspects that result in unrest

Anguish: Somatic aspects: Sweating, tachycardia, somatic phenomena

These symptoms occur with:

• Fear not applicable
• Fear of nothing (Except the fear in phobias)

Fear: These symptoms occur associated with an object – Fear of something

Anxiety is Pathological When

• It is disproportionate to the event that causes it
• It persists after the danger has disappeared
• It appears unreasonably
• It interferes with the normal functioning of the individual

Classification of Anxiety Disorders According to DSM-IV

Anxiety Disorders:

• Panic disorder without agoraphobia
• Panic disorder with agoraphobia
• Agoraphobia without a history of panic disorder
• Specific Phobia
• Social Phobia or Social Anxiety Disorder
• Obsessive-Compulsive Disorder
• Post-Traumatic Stress Disorder (PTSD)
• Acute Stress Disorder
• Generalized Anxiety Disorder (GAD)
• Anxiety Disorder due to a medical condition
• Substance-induced anxiety disorder
• Anxiety disorder not otherwise specified

Generalized Anxiety Disorder (GAD)

A persistent state of anxiety and worry for 6 months, which significantly affects job performance, social relationships, or other areas.

Differential Diagnosis of Anxiety and Depression

Common symptoms:

1. Irritability
2. Decreased concentration
3. Appetite alterations (anorexia or hyperphagia)
4. Weight alterations (loss or gain)
5. Sleep alterations
6. Physical symptoms

Differential Diagnosis

Depression

Mood:

• Sad and burdened
• Linked with temporality
• Centered in the past
• Pessimistic about the future
• Predominance of despair and discouragement
• (In agitated depression: restless, irritable, and tense)

Psychomotor activity:

• Slow movements
• Posture and expression of depression (rarely agitated)
• Slow and poor language

Interest:

• Decreased overall interest
• Loss of the ability to experience pleasure (anhedonia)

Insomnia:

• Irregular sleep
• Early awakening
• (In bipolar disorder, there may be hypersomnia)

Characteristic Symptoms:

• Suicidal ideation
• Chronic-recurrent pain without a specified organic basis

Anxiety

Mood:

• Focusing on the future, scared and excited
• With a new fear of panic attacks or facing the phobic object or situation

Psychomotor activity:

• Rarely slowed
• Usually dominated by hypervigilance

Interest:

• Interest is maintained, even sexuality

Insomnia:

• Difficulty falling asleep

Characteristic Symptoms:

• Depersonalization (feeling of bodily change, afraid to lose control)
• Derealization (feeling that the environment has become strange or unreal)

Generalized Anxiety Disorder (GAD)

Definition: Generalized anxiety disorder is chronic worry and anxiety, exaggerated in relation to everyday life. We all worry at times, but people with GAD are never able to relax and generally expect the worst. Often the concern is not directed at anything in particular. Instead, each day causes stress and tension.

They worry excessively about family, work, money, and health. The concern is such that it interferes with their ability to live life.

Anxiety can advance to the point of worrying about worry.

• Excessive anxiety and worry, most of the day for at least 6 months about various events or activities.
• The individual has difficulty controlling their worry.
• The anxiety and worry are associated with three (or more) of the following six symptoms:

1. Restlessness or impatience
2. Fatigue
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance

Risk Factors of Generalized Anxiety Disorder

• Family member with an anxiety disorder
• Long-term exposure to abuse, poverty, or violence
• Low self-esteem
• Poor coping capacity
• Female sex

Panic Attack

They correspond to intense physical symptoms:

1. Cardiac alterations: palpitations, arrhythmia, tachycardia, angina.
2. Respiratory alterations: dyspnea or asthma.
3. Sweating (night sweats).
4. Tremors and shivering.
5. Insatiable hunger.
6. Diarrhea.
7. Vertigo.
8. Congestion (vasomotor neurasthenia)
9. Paresthesias but with anguish.

Stress

Physiological and psychological processes that develop when there is an excess of perceived environmental demands on an individual, and they fail to satisfy them.

Acute Stress Disorder

Acute Stress Disorder is a temporary phenomenon, important and serious, often found in a person without an apparent mental disorder in response to an exceptionally stressful situation, and it usually resolves within hours or days.

• Anxiety
• Dissociative symptoms
  • Feeling of numbness
  • Detachment or absence of the reality that surrounds
  • Feeling of being detached from the body
  • Derealization
  • Depersonalization
  • Dissociative Amnesia
• Symptoms arise within the month following the episode
• The traumatic event is experienced on a recurring basis.
• Avoidance of stimuli that may arouse recollections of trauma
• The symptoms cause clinically significant distress, interfere with the individual’s activity, and affect their ability to carry out essential tasks
• The disturbance lasts at least two days and does not extend beyond 4 weeks after the traumatic event.
• Other reasons must be ruled out: substance use, presence of physical or mental illness, such as a brief psychotic disorder
• Decreased emotional reactivity (difficulty or inability to feel pleasure in activities that were once rewarding)
• Difficulty sleeping, irritability, poor concentration, hypervigilance, startle response, motor restlessness.
• Desperation and despair (bordering on depression).
• Sometimes feelings of guilt for having escaped unscathed, where others died, or for failing to provide enough help to others.
• Often seen as responsible for what happened.
• May be halfway to developing Post-Traumatic Stress Disorder.

Post-Traumatic Stress Disorder

• The disorder arises as a delayed or protracted response
• There might be some personality traits (asthenic and compulsive) that predispose to it
• Events of unusual or threatening nature are the same ones that cause discomfort in most people.

Panic

• Sudden episodes of intense fear
• New, surprising, distinctive, boundary experience
• Traumatic psychological experience, the worst of my life
• Loss of control: common denominator
• Maximum intensity in minutes
• Distinguishing residual symptoms of the crisis
• Intense physical symptoms
• They are associated with a fear of impending doom

Depressive Syndrome

The loss of the object and desire for it. All our patients who report being depressed refer to several events that have meant personal loss. So this is the language of depression, alluding to traumatic moments or not, and different types of grief, depending on the modes of being of each person. They do not refer to the biochemical substrate that may involve the mental state, i.e., they do not tell us that their neurotransmitter system, serotonin or noradrenergic, is diminished, but they inform us of the intense grief or despair that arises from a loss or a traumatic separation, expected or not, in the subject’s vital moment.

The nuclear-affective axis is vital and profound sadness that surrounds the subject, affecting all areas of intra- and interpersonal relationships.

Bleichmar (2003) proposes four main pathways into depression:

• Traumatic events of reality
• Intergenerational transmission
• Previous narcissistic disorders
• The attack directed at the representation of an object of great cathexis

Symptoms of Depression

• Affects of hopeless sadness
• Impairment of self-image
• Past laden with guilt
• Future of loneliness, condemnation, and punishment
• Physical and mental fatigue
• Body devitalization

It affects five broad areas:

1. Affectivity: sadness, anxiety, irritability, anhedonia, etc.
2. Thought: marked by a slow, negative tone and content, suicidal ideation, suicide attempts, suicide.
3. Behavior: aggression, self-destructive behavior.
4. Biological rhythms: difficulty sleeping, nightmares, decreased sex drive, loss of appetite and weight loss, anorexia, bulimia.
5. Somatic disorders: headaches, amenorrhea, dry mouth, constipation, palpitations.

Major Depressive Disorder

A period of at least 2 weeks in which there is depressed mood or loss of interest or pleasure in most activities.

Also experiencing at least four symptoms that include:

• Change in appetite or weight.
• Altered sleep.
• Alteration in psychomotor activity.
• Lack of energy.
• Feelings of worthlessness or guilt.
• Difficulty thinking, concentrating, or making decisions.
• Recurrent thoughts of death or suicidal ideation, suicide plans, or attempts.
• May or may not have psychotic productivity
• There is an experience of breaking the basic continuity of personality
• Symptoms have greater intensity in the morning
• Prevalence of early awakening

Bipolar Disorder I

(One or more manic or mixed episodes, accompanied by major depressive episodes)

Bipolar Disorder II

(One or more major depressive episodes accompanied by at least one hypomanic episode)

Cyclothymic Disorder

(At least 2 years with numerous periods of hypomanic symptoms and depressive symptoms that do not meet the criteria for a manic or depressive episode)

Dysthymic Disorder

• Chronically depressed mood that is present most of the day, for at least two years.
• Presence of two or more of the following symptoms:
  • Loss or increased appetite
  • Insomnia or hypersomnia
  • Lack of energy or fatigue
  • Low self-esteem
  • Difficulty concentrating or making decisions
  • Feelings of hopelessness
• There have been no major depressive episodes, manic, mixed, or hypomanic episodes.

Manic Episode

Abnormally and persistently elevated, expansive, or irritable mood for at least 1 week.

• Persistently elevated, expansive, or irritable mood.
• Inflated self-esteem.
• Decreased need for sleep.
• Talkativeness.
• Flight of ideas.
• Distractibility.
• Increased activity.

Mixed Episode

Characterized by a period of at least 1 week in which nearly every day criteria are met both for a Manic Episode and for a major depressive episode.

Hypomanic Episode

Defined as a specified period in which there is an abnormal and persistently elevated, expansive, or irritable mood lasting at least 4 days.

Addiction

Addiction is a behavior, a way to bond, a trace of a pathology of adaptation.

Characteristics of Drug Addiction

• Tendency to increase doses to achieve the same effect
• Psychological and/or physical dependence
• Suspension causes a withdrawal syndrome
• Adverse effects affect the individual and their environment

Alcoholism

Regular presence of alcohol dependence, manifested by an inability to abstain from drinking alcohol and to stop once it has been consumed.

Types of Alcohol Drinkers

Normothymic: They drink because they feel more confident and lively, more fluent in words, they experience themselves as more social and more fully as people. They experience well-being that they do not have without the drug.

Tedium-phobic: Experience of being entertained, of feeling comfortable with life without the usual tedium of routine daily tasks. Time slips by quickly, joyfully. The space of the bar is welcoming. Problems seem unimportant, and the conversation is entertaining.

Impulsive-symptomatic: Drink in order to alleviate painful symptoms caused by another underlying psychiatric illness.

Mode of Intake of Alcoholic Patients

Inability to abstain: An individual cannot go more than several hours without consuming a certain amount of alcohol. If they do not, they experience psychic and physical manifestations, called Deprivation Syndrome.

Inability to stop: Once they start drinking, they cannot stop until they have reached drunkenness.

Alcohol Dependence

• Tolerance: The need for increasing amounts of alcohol consumption to achieve the desired effect.
• Withdrawal Syndrome
• Without meaning to, the subject takes larger amounts or over a longer period of time.
• Threatens and states that they will stop drinking alcohol
• Spends a lot of time related to alcohol (getting it, consuming it, and recovering from its effects)
• Their activities revolve around alcohol (they will abandon or reduce other activities)
• They leave family activities or hobbies.
• They admit that their problem is serious.

Normal Drinker

• Is 16 years of age or older
• If female, is not pregnant or breastfeeding
• Eats a balanced, normocaloric diet and has a normal nutritional status
• Drinks alcoholic beverages approved by health authorities
• Does not present pathological intoxication
• Drinks alcohol without negative consequences for themselves or others. Does not have problems with the law because of this.
• Drinks alcohol without disrupting their marital relationship, family life, or job performance
• Does not rely on alcohol to rejoice, disinhibit, or communicate
• Does not have pathologies that are aggravated or outweighed by alcohol
• If they drink, they do not get drunk

Problem Drinker

Any person who violates one or more of the 10 points of a normal drinker

If the problem drinker is part of a group: Problem drinkers or alcoholics

DSM

Divides alcohol-related disorders into two broad groups:

• Alcohol use disorders (abuse and dependence)
• Alcohol-induced disorders (intoxication, withdrawal, delirium, psychotic disorder, mood disorder, anxiety disorder, sexual disorder, sleep disorder, dementia, persistent)

Acute Alcohol Intoxication or Drunkenness

• Must have signs and symptoms consistent with the effect of alcohol, used recently.
• Must have disturbed behavior in at least one of the following features:
  1. Disinhibition, argumentative attitude, aggressiveness, mood lability, impaired attention, altered judgment, etc.
  2. Unsteady gait, difficulty standing, nystagmus, decreased level of consciousness, facial flushing, conjunctival injection.
  3. If alcohol intoxication is severe, there may be hypotension, hypothermia, and depression of reflexes.

Pathological Intoxication

1. Occurs with a small amount of alcohol
2. Verbal and/or physical aggression, unusual in the person
3. Appears within minutes of having consumed alcohol.
4. Mental confusion, hallucinations, delusional interpretations of the situation, heightened emotions, subsequent amnesia.

Alcohol Withdrawal Syndrome

1. One of the most characteristic syndromes of alcohol abuse.
2. When alcohol is consumed again, the symptoms of the syndrome disappear, and the emergence of a new intoxication is reinforced.
3. Appears within the first few hours of suspended intake.
4. Can be mild, moderate, or severe in intensity. For the severity of symptoms, it is important to consider:
   • Time of alcohol intake
   • Magnitude and rate of intake
   • General condition of the patient.

Mild Deprivation Syndrome

1. Appears within 6 to 48 hours of suspended intake. Lasts 1 to 4 days.
2. Symptoms and signs: irritability, restlessness, anxiety, fear, hyperarousal to stimuli, distractibility, excessive sweating, systolic hypertension, tachycardia, congestive facies, conjunctival injection, insomnia, nightmares, anorexia.

Moderate Deprivation Syndrome

1. Usually appears between 24 and 72 hours and lasts from 3 to 7 days.
2. Signs are increased
3. Psychomotor agitation, gastrointestinal symptoms (nausea, vomiting, diarrhea, or others) are added.

Severe Deprivation Syndrome

1. Usually appears between 24 and 72 hours
2. Can last between 2 and 10 days
3. Symptoms are more severe than previously described
4. Seizures and/or psychotic symptoms are added. Delirium Tremens.