Schizophrenia Spectrum Disorder Diagnosis with DSM5-TR Changes

Hey there, everybody, and welcome to this presentation on schizophrenia spectrum disorders in the DSM 5TR. I'm your host, Dr. Donnellice Snipes. In this brief presentation, we're going to review criteria for schizophrenia spectrum disorders, including, but not limited to schizophrenia, brief psychotic disorder, schizophreniform 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 prevalence in general in the general population in the US brief psychotic disorder 5 out of every thousand, schizophrenia, 3 to 7 out of every thousand, schizophreniform, 1 out of every thousand, schizoaffective, 3 out of 1000, and delusional disorder 2 out of every thousand. So if you add all those up, you're going to get approximately 18 out of every 1,000 people, or 1.8, almost two out of every 100 people. Now, there are a few more diagnoses in this category in the DSM5TR 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 taken out of context and maybe 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 5 TR. 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 the. 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 the 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 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, substance induced condition or sensation. But these are the, the delusions that we're typically going to be 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, so 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, 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 form of disorganized thinking where they will derail the conversation. Tangentiality. And all of these are kind of loosely associated, if you will. 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 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 unfazed. And we want to differentiate that, 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 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 cheerful 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 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, 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 very blank faced a lot of the time. Volition is voluntariness and they have avolition means a lack of voluntary engagement. There is no motivation. They don't want to get up and do anything. They're flat anhedonia, 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 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 admission of people 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 schizophreniform. Why did I put all these together? Because this is your continuum here. In these disorders, brief psychotic disorder is the shortest, followed by schizophreniform, followed by schizophrenia. In these three disorders, two active phase symptoms are present most of the time for a delusions, hallucinations disorganized speech, disorganized behavior, or catatonia, or, and or negative symptoms. So two or more. Their level of functioning 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 decompensation in functioning active phase symptoms. And the rest can be rest of the time can be active phase symptoms can be prodromal or residual. That means sub threshold. The person has to be exhibiting symptoms for approximately six months for schizophrenia, one to six months for schizophreniform, and less than one month for brief psychotic. So what am I saying here? Saying that the person must have active phase symptoms during, for schizophrenia, for example, during, for at least six months for schizophrenia, but they only have to rise to the level of diagnosis, if you will, 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 1/3 or 32% of individuals with substance induced psychosis are later diagnosed with schizophrenia spectrum disorders. And that would be 26% with bipolar disorder and 44% for cannabis induced psychotic disorder. So that's really interesting that when we have a 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 schizophrenia, schizophreniform 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 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. Those 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 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. And it lasts at least two weeks 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 Steve. Schizo means 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, the person may present with symptoms of delusional disorder or hallucinations. However, it would would be diagnosed as major neurocognitive disorder with behavioral disturbance. It is important if you have somebody presenting with, with symptoms that seem like schizophrenia or schizophrenia spectrum disorders, especially if the onset was very rapid, that they be evaluated for a major neurocognitive disorder. Early onset dementia, early onset Alzheimer's, something like that. 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, 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 did the symptoms start, what causes them? Is there a possibility of an autism spectrum disorder? And communication disorder of childhood onset could explain 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 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 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 millions, 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 pattern 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 presentations. 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 scheme, 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 as blue. And they may have difficulty understanding that other people see something different, just like a lot of us have 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 the symptoms may be egosyntonic. 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 impairments in motor coordination as well as sensory impairments. A lot of people with schizophrenia have sensory gating 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 light, sound, smells, textures may be almost imperceptible to them or maybe ultra intense to them. When to a person without schizophrenia, 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 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 represents a huge change for the individual as well as for the family. Cognitively, 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 are 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 phase symptoms as well as their anhedonia, avolition, a sociality. It doesn't mean that they cannot work. A lot of times people with schizophrenia 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, 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 with 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. That can make it more difficult. They 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, 5 to 6% of people with schizophrenia spectrum disorders die by suicide. However, 20% attempt suicide and it's important to recognize that that's one in five people with schizophrenia will attempt suicide. That's a lot. 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 act at 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 neurochemicals 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 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 axis 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 schizospectrum disorders. Additionally, recently, glutamate and glutamine levels have been reported to be increased in individuals at familial risk of 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, 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 socioeconomic status. They didn't say urban. Those with a low socioeconomic status in an urban environment, 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. 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 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, 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, that's 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 dysregulated. Understanding of schizophrenia has advanced significantly and is now exploring vitamin D deficiency in the mother which 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 neuroinflammation. 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, and prevent or reduce stress related inflammation in the mother, 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.