ENCOUNTERS WITH PSYCHOSIS

This essay offers a personal account of one physician's attempt to engage with psychotic patients in an inner‐city hospital. It considers some of the obstacles to psychoanalytic work with psychotic patients, including anxiety in the psychotherapist, anxiety in the patient, institutional resistances, and paradigmatic errors. A discussion of paradigmatic errors in Western mental health care is expanded upon. Rorty's ( 1979 ) critique of objectivity and Kuhn's ( 1962 ) work on scientific paradigm shifts are discussed in an attempt to demonstrate how we might better understand psychosis as an illness and connect with patients across the entire diagnostic spectrum.     

Taxometric analysis supports a dimensional latent structure for schizotypy

The existence of a discrete class of people vulnerable to schizophrenia spectrum disorders is the most replicated finding of taxometric research. Evidence for such a “taxon” has been obtained with diverse measures of schizotypy in clinical, high-risk, and normal samples. However, recent demonstrations that skewed indicators of a latent dimension can yield a spuriously taxonic pattern of results may call some of these findings into question. Normal adults (N = 1073) completed measures of positive (perceptual aberration, magical ideation) and negative (physical and social anhedonia) components of schizotypy. Taxometric curves resembled those obtained previously, but when a simulation procedure took skew into account, dimensional models of schizotypy received stronger support than taxonic models for most schizotypy components, with findings for magical thinking inconclusive. A re-evaluation of previous taxonic conclusions regarding the latent structure of schizotypy is indicated.     

Acting on persecutory delusions: the importance of safety seeking

OBJECTIVE: Acting on delusions is a significant clinical issue. The concept of safety behaviours--actions carried out with the intention of reducing perceived threat--provides a new way of understanding acting on delusions. A study was conducted with the aim of examining the prevalence and correlates of safety behaviours related to persecutory delusions. METHOD: One hundred patients with persecutory delusions were assessed for safety behaviours, acting on delusions, anxiety, depression, and psychotic symptoms. Case note data were collected on instances of serious violence or suicide attempts. RESULTS: Ninety-six patients had used safety behaviours in the last month. Greater use of safety behaviours was associated with higher levels of distress. A history of violence or suicide attempts was associated with greater use of safety behaviours. Safety behaviours were significantly associated with acting on delusions, but not with the negative symptoms of psychosis. CONCLUSION: Safety behaviours are a common form of acting on persecutory delusions. These behaviours have the consequence that they are likely to prevent the processing of disconfirmatory evidence and will therefore contribute to delusion persistence.     

Jumping to conclusions and the continuum of delusional beliefs

The present study examined the jumping to conclusions reasoning bias across the continuum of delusional ideation by investigating individuals with active delusions, delusion prone individuals, and non-delusion prone individuals. Neutral and highly self-referent probabilistic reasoning tasks were employed. Results indicated that individuals with delusions gathered significantly less information than delusion prone and non-delusion prone participants on both the neutral and self-referent tasks, (p<.001). Individuals with delusions made less accurate decisions than the delusion prone and non-delusion prone participants on both tasks (p<.001), yet were more confident about their decisions than were delusion prone and non-delusion prone participants on the self-referent task (p=.002). Those with delusions and those who were delusion prone reported higher confidence in their performance on the self-referent task than they did the neutral task (p=.02), indicating that high self-reference impacted information processing for individuals in both of these groups. The results are discussed in relation to previous research in the area of probabilistic reasoning and delusions.     

Rephrasing the madness and creativity debate: What is the nature of the creativity construct?

This paper aims to reframe the debates about the association between creativity and mental illness. For centuries the link between the two has been debated, yet research has largely ignored the underlying nature of creativity in this context. The full understanding of the creativity construct, however, is essential to completely grasp its relationship with psychopathology. Three possible models for the creativity construct are proposed: the existence of different kinds of creativity each associated with specific types of psychopathology, creativity operating as a continuum, and creativity as a single entity. Support for each model is examined among the current literature. It is concluded that all three models are viable possibilities for the conceptualization of the creativity construct, each offering ample predictions and hypotheses for future research.     

Working with Psychosis

This is the first of four papers about working with psychosis in a newly established post of psycho-analytic psychotherapist in an acute psychiatric unit in Australia. In this paper the author gives an account of some early impressions and experiences with staff and patients, particularly connected with an unacknowledged grief in the aftermath of psychosis. The author next discusses some of the psycho-analytic theory about psychosis which he found containing and helped make some sense of his experiences. He then introduces a case study of an exploratory psycho-analytic psychotherapy with a 40-year-old man suffering from a bi-polar disorder. The beginning of the therapy is described when this man revealed feelings of grief and despair about his illness. Being able to face and bear these feelings enabled him to begin to mourn what was irretrievably lost because of his illness and to contemplate what might still be possible. The author describes some of the early themes and one session in detail, and discusses how fluctuations in contact with the client reflect his retreat to a pathological organization in the mind. This psychic retreat was dominated by a psychotic process, and the retreat offered refuge from a dread of fragmentation and the pain of mourning and loss.     

The entropic tongue: Disorganization of natural language under LSD

Serotonergic psychedelics have been suggested to mirror certain aspects of psychosis, and, more generally, elicit a state of consciousness underpinned by increased entropy of on-going neural activity. We investigated the hypothesis that language produced under the effects of lysergic acid diethylamide (LSD) should exhibit increased entropy and reduced semantic coherence. Computational analysis of interviews conducted at two different time points after 75 μg of intravenous LSD verified this prediction. Non-semantic analysis of speech organization revealed increased verbosity and a reduced lexicon, changes that are more similar to those observed during manic psychoses than in schizophrenia, which was confirmed by direct comparison with reference samples. Importantly, features related to language organization allowed machine learning classifiers to identify speech under LSD with accuracy comparable to that obtained by examining semantic content. These results constitute a quantitative and objective characterization of disorganized natural speech as a landmark feature of the psychedelic state.     

Disintegration: A reconceptualization of psychosis proneness as a personality trait separate from the Big Five

A nine-facet hierarchical taxonomy of “Disintegration”, a trait-like disposition that causes variations in psychotic-like behavior, is proposed, along with the scales to assess it. Strong correlations were demonstrated in students (n = 466) between lower-level dimensions, independent of the assessment method. Disintegration lay beyond the Five-Factor Model (FFM) space. This finding was replicated across informant types (self, mother, and father), samples (students and a national representative sample, n = 1001), and units of analyses (facets and items). The most frequent approach to preserve the FFM taxonomy of both normal and non-normal personality variants – mapping psychotic-like phenomena onto the Openness domain – found little support in our data. Disintegration was normally distributed in the general population.     

Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale?

Schizophrenia is a severe and disabling disorder with considerable psychological, social and economic costs. Over the last 15 years there has been a significant development in the use of cognitive behaviour therapy for psychosis (CBTp) in the treatment of schizophrenia, with 20 randomised controlled trials having been published. The majority of this work has been with alleviating medication resistant symptoms in chronic patients, but preliminary work has also been carried out with speeding recovery in acute schizophrenia and in relapse prevention and early intervention. A review of these studies indicates modest effect sizes, with the strongest evidence available for chronic patients. There is evidence that the effect size of the trials is significantly and negatively correlated to their methodological quality. We conclude cautiously that overall there is good evidence for the efficacy and effectiveness of CBTp in the treatment of schizophrenia.     

Dialectical Displacement and Redeployment of Attachments in the Kenotic Mode of Conversion: The Leaving Behind of Anton Boisen in Psychosis

This paper introduces a kenotic theory of conversion that builds from simple attachment to childhood experience of peak states to encompass dialectical stages of development: Priming, Decentering, Reflection, Encounter, Denucleation, Emplacement and Discipline. Thereafter, the dialectical mode gives rise to the mature phase of conversion—the continuing integration of the religious worldview through Metamorphosis and Embassy. The conversion theory is illustrated by an interpretation of a dialectical set of experiences of Anton Boisen. I interpret Anton Boisen’s conversion from a 19th Century Christianity that was wedded to religious and racial manifest destiny to that of a reborn Christian living with the 20th Century’s experience of evangelical and evolutionary universalism. Boisen’s clinical desolations (“psychosis”) and adoption of vocation (“change of allegiance”) suggest his conversion counterposed the instinctual with the higher order ideals he struggled to embody—a dialectical negation of his younger static and triumphalist Christian cultural identity that developed into a more integrated, expansive, and inclusive view of the human family and deepening allegiance to the ordinary, underserved, and growing population of the mentally suffering.