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When is psychosis constructive ?

When is psychosis constructive ?. Dr Mike Jackson Consultant Clinical Psychologist Betsi Cadwaladr University Health Board University of Wales, Bangor mike.jackson@wales.nhs.uk. The Clinician’s Illusion in Psychosis. Non-clinical/ Benign Psychosis. Psychotic disorders.

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When is psychosis constructive ?

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  1. When is psychosis constructive ? Dr Mike Jackson Consultant Clinical Psychologist Betsi Cadwaladr University Health Board University of Wales, Bangor mike.jackson@wales.nhs.uk

  2. The Clinician’s Illusion in Psychosis Non-clinical/ BenignPsychosis Psychotic disorders Psychotic ‘patients’ – in the system Patients who ‘engage’ Research sample Low schizotypes

  3. A methodological issue In order to understand psychotic disorder, we need to contrast with non-clinical, or ‘benign psychosis’ • Which factors lead to problems or distress in psychosis ? As well as • Which factors lead to psychosis per se ?

  4. Psychosis Continuum : Nemesis Study (van Os et al) • Epidemiological Sample • Predictive validity, 2 years later : • 8% still had ‘subclinical symptoms’, • 8% had developed psychotic disorders. • A 60-fold increase in risk of developing a psychotic disorder amongst those who reported a psychotic experience at baseline.

  5. The proneness persistence hypothesisvan Os, J., Linscott, R.J. Myin-Germeys, I. et al. (2008) A systematic review and meta-analysis of the psychosis continuum ‘Subclinical psychotic experiences are prevalent, but mostly self-limiting and of good outcome, although a small proportion go on to develop psychotic disorder’ • Poor outcome associated with: genetic risk Substance misuse Trauma history Urbanicity • What’s the story with the ‘normal’ psychosis ?

  6. Studies comparing benign psychosis with psychotic disorder • William James (1902) • Anton Boisen (1931) • Jackson, Claridge, Fulford (1995, 1997, 2001, 2010) • Day, Peters (1998) • Andrew, Gray & Snowdon (2008) • Brett, Peters, Johns (2010) • Thornton, Jackson, Linden (2011) • Herriot-Maitland, Peters, (2011)

  7. Benign Psychosis ? Exotic groups ? • Religious / Political/ ideological extremists • Alien abductees • Conspiracy theorists • Mediums ….. Infrequent but normal life experiences • Bereavement • Spiritual/ psychic experience • Extreme circumstances • Dreams ?

  8. The Hardy question Have you ever been aware of, or influenced by, a presence or a power, whether you call it God or not, which is different from your everyday self ? General population : 28.1% Psychosis self-help group : 89.1%

  9. Benign experiences ? I can cope more with death now, and know that there is something after it. I do not feel alone, as if she is with me, caring for me. I feel I have found a friend, a prop if you like. Inside my head, I can put the world to rights. I talk to my friend (whom I believe to be God) and talking things out often makes insurmountable problems seem like molehills.

  10. Snakes or Seraphs ?  It is evident that from the point of view of their psychological mechanism, the classic mysticism and these lower mysticisms spring from the same mental level, .....That region contains every kind of matter : "seraph and snake" abide there side by side." James (1902) Varieties of Religious Experience So what makes the difference ?

  11. The relationship between trauma and beliefsabout hearing voices: a study of psychiatricand non-psychiatric voice hearersAndrew, Gray and Snowden 2008 Spiritualists and mediums (n=22) vsPsychiatric voice Hearers (n=21) Measures Voice characteristics, Trauma history Mood disorder (Anxiety, depression)

  12. Andrew et al, 2008 Comparison of voice characteristics : Psychiatric voice hearers : • voices more frequent, • longer durations, • more negative content, • less control • more distress • Believed the voices to be more malevolent and omnipotent • more resistant coping.

  13. Andrew et al, 2008 Trauma Comparison • Both groups report high levels of trauma • Higher rate of CSA in diagnosed group • Higher rates of PTSD symptoms • Less resolution of trauma ?

  14. Thornton, Jackson,Linden 2011 Replication of Andrew’s findings re voice characteristics and trauma Benign group externalise more than patients, Benign group – less threat-based appraisals, and less need for control Strong contrasts in attachment : Higher rate of insecure paternal attachment in diagnosed group.

  15. Nasty voices • ‘You’re scum, you should be dead’. • The wolf is at my door you bitch • They’re coming to get you, you stupid cow

  16. Thornton, Jackson,Linden 2011 Replication of Andrew’s findings re voice characteristics and trauma Benign group externalise more than patients, Benign group – less threat-based appraisals, and less need for control Strong contrasts in attachment : Higher rate of insecure paternal attachment in diagnosed group.

  17. a) Frontotemporal activation during benign hallucinations SMA VLPFC VLPFC STS STS STS STS STS

  18. Implications The ‘voice area’ is active in the absence of external auditory input, in benign and pathological AVH Activity in voice production and voice reception areas Evidence for less volitional involvement in benign AVH

  19. Problem solving psychosis ? Where plagues and mightiest woes have bred in certain families, owing to some ancient blood guiltiness, there madness has entered with holy prayers and rites, and by inspired utterances found a way of deliverance for those who are in need; and he who has a part in this gift, and is truly possessed and truly out of his mind, is by the use of purifications and mysteries made whole and exempt from evil, .... And has a release from the calamity which was afflicting him. Socrates, The Phaedrus of Plato

  20. Inspiration/ Creativity : paradigm shifting processWallas, 1926, The Art of Thought, IMPASSE INCUBATION INSIGHT VERIFICATION Theoretical/ creative block, paradox Getting away from the problem. ‘Unconscious processing’ ‘Paradigm shift’, creative breakthrough, ‘psychotic content’ Scientific testing/ critical reception in peer group

  21. Impasse-resolution in spiritual experience IMPASSE INCUBATION INSIGHT VERIFICATION Existential impasse – e.g. bereavement Denial , depression, revelation, breakthrough, fresh perspective Acceptance, resolution A NEGATIVE FEEDBACK CYCLE?

  22. A NEGATIVE FEEDBACK CYCLE ? REDUCES

  23. During a period of medical and financial crisis "Iheard words not of my choice, but like another voice within me saying my name - "Sean, none of this matters. You will always have what you need "This is the beginning of things. Have no worries because .... you are living in a timed existence now. That will pass, and this is the beginning of eternity” Benign Participant, male, 53

  24. The "voice" continued to speak for long periods "almost daily", for about nine months, "it turned me upside down in many ways. It altered my views completely ..... [I] live life now as far as I can by what I'm learning". "I think I have support and guidance, so nothing in this world can worry me"

  25. Extreme Circumstances Day 59 I have the nagging feeling that I am accompanied by someone. As I doze off, my companion assures me that he will keep watch or work on a project. Sometimes I remember conversations that have been shared, confidences, advice. I know it could not have happened, but the feeling persists. Fatigue is growing dangerous. My companion assures me I can last till April 20th Steven Callahan : Adrift

  26. Extreme Circumstances ’A voice in my head told me that this was true, cutting through the jumble in my mind with its coldly rational sound. It was as if there were two minds within me arguing the toss. The voice was clean and sharp and commanding. It was always right and I listened to it when it spoke, and acted on its decisions. The other mind rambled out a disconnected series of images and memories and hopes, which I attended to in a daydream state, as I set about obeying the orders of the voice’ (p141) Joe Simpson, Touching the Void

  27. Control Systems TheoryFletcher and Frith, 2009 • Hierarchical Cognitive system of conceptual framework • Prediction error – discrepancy between expectation and reality (cf impasse) – generates salience signal (dopamine surge in limbic system) • Promotes reconfiguration of higher order concepts to improve fit with reality • Self correcting system

  28. Impasse-resolution in psychosis ? Crisis Prodrome Psychotic experiences Delusional beliefs ISOLATION ‘FALSIFICATION’ A Positive feedback cycle ?

  29. A POSITIVE FEEDBACK CYCLE ? INCREASES

  30. Salience Dysregulation TheoryKapur, 2003 • Limbic system ‘fires and releases dopamine independent of cue and context, creating experiences of aberrant novelty and salience’. • ‘the wind of the psychotic fire’ – • thus leads the individual to incorrectly interpret their ongoing experiences as being deeply significant, • System keeps trying to correct itself – delusional formation

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