Making Sense of Paranoia Dr Alison Brabban October

Making Sense of Paranoia Dr Alison Brabban October 2012

A Traditional View of Delusions “Empty speech acts, whose informational content refers to neither world or self. They are not symbolic expressions of anything” Berrios (1991) “Un-understandable: not reflecting a person’s personality or experiences” Jaspers 2

Moving away from the dichotomy to a truly biopsychosocial model of psychosis.

Padesky’s 5 Aspects Model (1986) ENVIRONMENT THOUGHTS MOOD / FEELINGS BIOLOGY BEHAVIOUR

Formulations Provide explanations of why the problems have arisen and what is keeping them going. Ø Are specific to the individual. Ø Bridge the gap between theory and practice. Ø “Hypotheses” which are modifiable. Ø Determine treatment approaches. Ø Predict problems that will arise. Ø Can be understood at different levels. Ø

“Patients come to psychotherapy because they are demoralized by the menacing meanings of their symptoms. The psychotherapist collaborates with the patient in formulating a plausible story that makes the meanings of the symptoms more benign and provides procedures for combating them, thereby enabling the patient to regain his morale” (Frank, 1986)

A Basic Formulation The Stress-Vulnerability Model

The Stress-Vulnerability Model (Zubin and Spring, 1977) Psychosis Stress No Psychosis Vulnerability 8

The Stress-Vulnerability Model 9

Trauma and Psychosis What’s the evidence?

Bebbington et al (2004) N = 8000 General Population Ø Those with psychotic symptoms l l Ø 3 times more likely to have been sexually abused than those with other mental health problems. 15 times more likely to have been sexually abused than those with no disorder Other experiences reported: l l Bullying Violence in Home Run away from home Placed in care as a child

Read, Goodman, Morrison, Ross and Aderhold (2005) Childhood trauma and the symptoms of schizophrenia. Females: 36 studies from 1984 -2001; total sample =2318 Males: 23 studies from 1987 -2001; total sample =1234

Dutch general population (n = 4045) free from psychotic symptoms, followed for 3 years (Janssen et al. , 2004) Controlled for: age, sex, education, discrimination, ethnicity, urbanicity, unemployment, marital status, other mental health problems, psychosis in relatives, drug use. : Ø Those abused as children 9 times more likely to develop ‘pathology level psychosis’ Ø Those suffering most severe level of abuse 48 times more likely to develop psychosis

Shevlin et al. 2008 (Schz. Bulletin) N = 8580 § People who had experienced three types of trauma (sexual abuse, bullying, violence in home etc. ) were 18 times more likely to be psychotic than non-abused people. § People who had experienced five types of trauma were 193 times more likely to be psychotic.

Early Adversity & Psychosis § 11 General Population Studies have found a link between child maltreatment and psychosis. § 8 of these looked for and found a dose response: the more severe the trauma or the higher number of traumatic experiences the greater risk of developing psychosis. 15

Varese et al (2012) Meta-Analysis 36 studies included (epidemiological, prospective, and patient controlled studies). Ø Total N = 79, 397 Ø 3 times more likely to have been exposed to childhood adversity. Ø If no childhood trauma existed – 33% of current psychotic population would not be psychotic. (160, 000 in UK) Ø 9/10 data sets that looked for a dose effect found one. Ø 16

Similarities found in brains of severely abused children and adults with a diagnosis of schizophrenia • • • Overactivity of hypothalamic-pituitaryadrenal (HPA) axis Abnormalities in neurotransmitter systems (especially dopamine) Hippocampal damage Cerebral atrophy Reversed Cerebral Asymmetry

Issues for Assessment • Need to take a full life history: lifeline. • Ask about bullying. • Ask whether person has experienced any unwanted sexual experiences that made him/her uncomfortable. • Has person been physically punished or attacked in a way that left cuts or bruises? • What were the triggers to onset of psychosis? • Consider intolerable emotions rather than trauma per se 18

“There were so many doctors and nurses and social workers in your life asking you about the same thing, mental, but not asking you why? ”

There was an assumption that I had a ‘mental illness’. Because I wasn’t saying anything about my abuse no one knew. (Lothian & Read, 2002)

I just wished they would have said What happened to you? , what happened? …But they didn’t. (Lothian & Read, 2002)

Formulating Delusions A Cognitive Formulation

Common Perceptions About Delusions Ø Associated with deficits in reasoning. Ø They are not amenable to reason. Ø They are held with absolute conviction. Ø These beliefs are qualitatively different to non-delusional beliefs. 23

Belief Acquisition Events in the World Perception Inference Belief Search for New Information 24

Internal Anomalous Experiences Ø Hallucinations Ø Feelings of significance Ø Heightened emotional experiences Ø Heightened perceptual experiences (Free floating dissociated elements? ) 25

There are two jars: A mainly orange jar containing 85 orange and 15 black beads and a mainly black jar containing 85 black and 15 orange beads Mainly Black Jar (85 black; 15 orange) Mainly Orange Jar (85 orange; 15 black)

The bead drawn is: Would you like to see anymore beads or have you decided now? BEADS PREVIOUSLY SEEN

Mean number of beads viewed before making a decision (Dudley et al. , 1997 a) n= 15 per group 33

Cognitive Biases in Patients with Delusions Use less information and more likely to jump to conclusions • More likely to look for confirmatory data • Less likely to have alternative beliefs available. • Have more victimisation experiences so person’s view of self & world tends to be biased. • Attributional Biases: External, personal for negative events (defensive? ). • 34

The Cognitive Model Behaviour Event THOUGHT Feelings Physiology 35

Cognitive Model of Delusions A B Activating Belief Event: Anomalous Experience Delusion C Consequences: Affect Behaviour Physiology 36

Formulation Early Events Schema (Core Beliefs) Conditional Schema/Beliefs Activating Event Thoughts, Feelings, Behaviour 37

Normalising Paranoia Ø Paranoia is an adaptive response Ø ‘Better safe than sorry’ Ø Makes sense and ‘not your fault’ Ø An adaptive response that has become potentially maladaptive Ø Threat sensitivity/hypervigilance leads to increased awareness of potential threats. 38

Dissociation and Anomalous Experiences Ø Are hallucinatory experiences disconnected flash-backs? Ø Dissociated Affect can be triggered by reminders of past traumas. Ø Delusional mood as a learnt, classically conditioned response (i. e. Pavlov)? 39

Priming and our Perceptions Is hearing believing?

For further Information: abrabban@btopenworld. com