Interventions To Improve Mental Health & Wellbeing - Psychosis

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Non-Affective Psychosis

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- Not related to emotions or mood (unlike bipolar and psychotic depression)
- e.g. schizophrenia or delusion disorder

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Bleuler (1911)

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- Coined term 'schizophrenia'
- Observed not just in old people (praecox) and not always severe mental deterioration
- Biological cause, but hallucinations psychological reaction

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Schneider (1959)

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- 11 first-rank symptoms of schizophrenia
- i.e. hallunications, delusions, passivity of experience

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Bentall (2003)

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- Argues for abandoning psychiatric diagnoses
- Advocates approaches aimed at understanding behaviours or specific symptoms
- Psychiatric diagnoses describes behaviours but doesn't indicate cause

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Continuum Hypothesis

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- No qualitative difference between 'mentally ill' and 'healthy'
- Instead, psychotic symptoms on a spectrum of normal individual variation
- 1 in 5 reported hallucinations and delusions (van Os et al. 2000)

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Zubin and Spring (1977)

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- Model of interaction between vulnerability and stressful events
- Stress x Vulnerability = Likelihood of psychosis
- Vulnerability inherited AND environmental
- Everyone can experience psychosis given enough stress

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Grandiose Delusions

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- Inflated worth, power, knowledge, identity or special relationship to a deity of famous person

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Delusions of Reference

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- Belief that events, objects or people in immediate environment have a particular or unusual significance

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Three Defining Characteristics of Delusions

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- Certainty: held with extraordinary convinction
- Incorrigibility: impervious to other experiences and compelling counter-argument
- Falsity: their content being impossible

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Garety and Hemsley (1994)

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- Definition of delusions:
- Continuum
- Multi-dimensional (e.g. conviction, preoccupation, distress, impact)
- Potentially responsive rather than fixed
- Psychological understandable
- Involve rational and normal psychological processes

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Second-Person Hallucination

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- Imagined person talking directly to you, giving instructions

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Third-Person Hallucination

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- Imagined person talking about you

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Passivity Experiences

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- Alteration in how sense of self experienced
- Centered on persons thoughts, intentions, will, actions and emotions
- e.g. thought insertion, thought broadcast, thought block, thought echo
- Lead to delusional beliefs

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Frith's (1992) Model

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- Passivity experience reflects abnormal experience where person not aware of sense of effort or prior intention involved in deliberate act

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Dopamine Hypothesis

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- Derived from drawing connections between schizophrenia, amphetamine psychosis and Parkinson's disease
- Amphetamine psychosis similar to paranoid psychosis, same drugs used to treat
- Psychosis patients have increased dopamine receptors

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Neuroleptics

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- Drugs used to treat schizophrenia
- Blocks brains receptors for dopamine
- Typical: chlorpromazine, haloperidol
- Atypical: risperidone, clozapine

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Expressed Emotion (EE)

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- Relatives who: make a lot of critical comments, show hostility or have marked over involvement (doing everything for someone)
- Has an impact on physiological arousal
- Increases probability of relapse following an episode
- Brown et al. (1972), Vaughn et al. (1976), Butzlaff & Hooley (1998)

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Social Isolation Theory

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- Higher psychosis in urban areas because of less family and friend connections in the city

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Social Drift Hypothesis

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- Higher psychosis in lower socio-economic status because symptoms of psychosis negatively impact individuals life

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Psychotic Symptom Rating Scales (PSYRATS)

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- Semi-structured interview assessing dimensions of hallucinations and delusions
- Haddock et al. (1999)

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Measures of Psychosis Symptoms

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- Paranoia Scale
- Beliefs About Voices Questionnaire-Revised
- SANS and PANSS subscales
- Social Functioning Scale

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Psychiatric Interviews

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- Present State Examination
- Brief Psychiatric Rating Scale
- Scales for Assessment of Positive Symptoms (also negative version)
- Positive and Negative Syndrome Scale (PANSS)
- Krawiecka Scale (Manchester/KGV scale)

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Neuroleptics Side Effects

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- Sedation
- Depression/loss of motivation
- Weight gain
- Sexual dysfunction
- Hormonal imbalances
- Cognitive problems
- Parkinsons symptoms (extrapyramidal)
- Tardive Dyskinesia: irreversible sucking, lip smacking, tongue movements - like fly-catching
- Agranulocytosis: clozapine induced, toxic, can cause death

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Family Interventions

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- Involve:
- Psychoeducation
- Goal setting/problem solving
- Improving communication
- Cognitive reappraisals
- Decreasing guilt and anger
- Maintaining realistic expectations

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Cognitive Behavioural Family Intervention

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1) Assessment and individualised formulation of presenting problems
2) Individualised education about psychosis
3) Stress management and coping
4) Goal planning with family for patient change

- Barrowclough and Tarrier (1992)

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Common Coping Problems

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- Overestimating patients ability to improve functioning or control delusions
- Overestimating rate of improvement or anticipating complete cure
- Unrealistic expectation for patients behaviour, unsuccesful coercion, criticisms
- Overestimating own ability to control illness
- Unrealistic expectations of own influence on patients illness
- Differences in how family understands illness = inconsistent approach

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Pilling et al. (2002)
Pharoah et al. (2010)
Lobban et al. (2013)

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- Meta-analytic/systematic reviews of studies
- Family intervention as an adjunct to routine care decreases frequency of relapse and rehospitalisation
- Improvement in family outcomes

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Social Skills Training

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- Attempt to improve interpersonal deficits
- Evidence for efficacy mixed
- Variations in form and length of interventions, difficult to draw conclusions
- Best when structured educational methods; social reinforcement, modelling and role play
- More US than UK

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Cognitive Remediation

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- Attempt to improve independence and quality of life
- Evidence for efficacy mixed
- Errorless learning, scaffolding and verbalising instructions
- Improves specific deficits but no generalisation
- More US than UK

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Formulation

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- A 'picture' or 'story' bringing together information to explain how problems are developed and maintained
- Developed in collaboration with patient
- Therapist may not share all aspects of their own understanding, avoids distressing patient or resistance
- Past experiences explaining delusions

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CBT for Psychosis

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- Examine evidence for/against beliefs, considering advantages/disadvantages of belief, behavioural 'experiments' to test beliefs
- At least 16 sessions
- Therapist normalises symptoms
- Therapist needs to take more responsibility for session (apologies) than when depression/anxiety
- Meta-analytic reviews provide support (Wykes et al. 2008)

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Schizophrenia Commission 2012

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- November 2011 'Rethink Mental Illness'
- Independent Commission of 14 experts reviewing how to improve outcomes for psychosis patients
- Formal evidence from 80 experts, visited mental health services and reviewed literature
- Not a good review, not enough CBT, too much medication