Psychosis - Integrating subjective experiences, psychodynamic understandings and biological knowledge

1. Psychosis- Integrating subjective experiences, psychodynamic understandings and biological knowledge Toronto, June 5 2008 Johan Cullberg MD PhD Ersta Sköndal University College, Stockholm

2. The ego’s ongoing construction of the world Rapid changes between perceptions and interpretations The ego constructs a ”Gestalt” This dialectics is abolished in dreaming and (partly) in psychosis

3. Psychosis: Failure in creating a correct ”Gestalt” of the outer world Regressive creating of meaning Inner, private world is given priority Meaning is more important than rationality

4. Recovery Relapse 2nd critical period 1st critical period Treatment DUP Prodromal phase Psychosis phase Recovery phase jc

5. Withdrawal tendencies – social, working or study problems Affective outbursts Increased inner speed Premonition of mental break-down Compensatory strategies Depression and panic attacs Stages and subjective experiences in psychosis:1:Prodromal phase - days or months jc

6. “Am I in the world or am I the world?” Regressive strategies to create meaning Hallucinations confirm delusional thinking Thoughts and actions controlled by others Resistance to relying in anyone/anything from outer world (care, medication, trust etc) Omnipotence and deep loneliness 2: PSYCHOSIS PHASE:(weeks - months) jc

7. 3: Late psychotic phase: • Delusions more often questioned and less maintained • “Islands of normality” increasingly frequent • Depressive thoughts more prominent through reality confrontation • Tendency to seek protection in psychosis • Cooperation with therapist deepening – who can be trusted? jc

8. 4: Recovery phase: Remaining psychotic symptoms or resolution (most often within 3 months) Separation between inner and outer world Psychotic “shadows” may remain Pain, shame - relief PTSD (traumatic memories from care)? Denial of psychosis? Are the bridges burned? Life with the memory of psychosis and awareness of one’s vulnerability jc

9. From Diseasemodel (Kraepelinaround 1890)toVulnerability-Stressmodel (Zubin 1977)orVulnerability-Interactional stress model (Strauss 1983) jc

10. Dimensions of vulnerability to psychosis A: Genetic 1 factor- low risk2 factors higher risk 3 factors high risk C: Early trauma, Attachment problems B: Pre/perinatal injuries jc

11. Three phases of Schizophrenia (Ciompi) jc

12. Long-term schizophrenia • Around 1/3 of first episodepsychosis patients tend to ”chronify” • Inner world is mixing up with external world • Deficientcontrol of the ”expectedfuture” • Deficientawareness of body? • Butoften: fantasy, warmth, sense of humour • Betweentwofires: overstimulation and understimulation • Neurolepticmedication 25-40% betterthan placebo. Risk for over-medication! • With network and relations, job and supportedliving, most patients recover jc

13. The schizophrenic person’s personality change – a dynamic partial explanation • The early vulnerability also implies a sensitization of self image – ”outsider” • The first psychosis is a mental trauma which further disturbs the self-image • A partial withdrawal to the inner world means a higher security of self • ”Schizophrenia” jc

14. The affective vulnerability • A thin ”mental skin” • Complex and highlycharged inner mental representations of good/bad • Easilyevokedsymbolicconnectionsexternal/inner world • Lowered ability to deal with separation, frustration, falling in love, aggression • Psychotherapy and lowdosemedication jc

15. What is curative? • Milieu – low stimulation level, security, coherence • Medicationwhenneeded – lowesteffectivedose • Therapeuticalliance– respect, interest, non-intrusivewarmth jc

16. Attitudes towards the patient -according to the Danish OPUS project: n A long awaited guest who you want to feel welcome and at home during a long visit. n A collaborator, whose insights and attitudes are decisive for the outcome. n An individual with personal preferences that should be taken into account in the treatment to the greatest extent possible. Merete Nordentoft, Bispebjerg Hospital, psykiatrisk afdeling, 2006

17. Antipsychotic medication – the patient’s friend or enemy? • ”Therapeuticwindow” at 1-4 mg haldol-eqv in f.e.p. • Higherdose gives side-effectswithoutincreasinganti-psychoticeffects • Side-effectsappearsoon after intake, anti-psychoticeffects after 1-5 days – slow increase of doses! • Antipsychoticeffectsbecause of moreindifferencewhichlowersvulnerability to psychoticthoughts? (Healy, Kapur) • High doseinhibits the dopamine systems of frontal lobes and thusdown-grades the motivationalaffects • Moderate dosegive a chance for psychologicalrestructuring, high doseslowervitality • The effect is 30-50% betterthan with no medication jc

18. Thresholds for antipsychotic drug effects in FEP D2 receptor occupancy (%) 100 80 60 40 20 0 EPS threshold Antipsychotic effect threshold 0 1 2 3 4 5 Farde et al (1992) Dose/plasma concentration jc

19. ”Hearing inner voices” • When you hearconstant inner voices and knowtheydon’t come ”from outside” - you don’tsuffer from a psychosisbut from a disorder of perception – a minor disturbance of the brain • Suchvoicesrarely are helped with medication – still manypsychiatrists are tempted to continue med whichmaylower your quality of life • You needpsychological support for betterdealing with the voices jc

20. Psychological treatments and psychosis – different models should be encouraged in the team • Dynamic models: Identifying relational or developmental crisis, trauma (separation, frustration, stress). Important in early phase – brief and schizophreniform psychoses • Cognitive models: Taking control over voices, depressive thinking, investigting delusional thinking. Important in late phases • Educational models: How to think about psychosis, treatments, relapses – all cases jc

21. Coherenceand Hope jc