Psychosis, insight and hearing voices

People with psychosis are said to lack insight when they have a poor awareness that they are mentally ill and don't think they need to get help. Lack of insight is associated with poorer outcomes and worse adherence to treatment while improved insight has been linked to better treatment compliance and less hostility. A team of researchers led by Guillem Lera from the Hospital de la Ribera in Valencia looked into the links between insight and auditory hallucinations in a study of 168 psychotic patients. They found that patients with persistent auditory hallucinations had significantly less insight than patients with occasional or no hallucinations. The further away the hallucinations were thought to come from the less insight people had. The patients who heard voices 'in their head' showed better insight than those who heard voices coming from outside themselves.

Lera, Guillem ... [et al] - Insight among psychotic patients with auditory hallucinations
Journal of Clinical Psychology, 67(7), 1-8

For the very paranoid everyone is a threat

Previous research has shown that even neutral social contact can trigger paranoid thinking in people with paranoia. Social contact can have a wide variety of different contexts from complete strangers to friends and family and a team of researchers led by Dina Collip from Maastricht University studied 154 people assessing their paranoia and asking them to record their feelings in everyday life. People with low and medium levels of paranoia reported higher levels of perceived social threat when they were with less familiar people, however, people with high levels of paranoia showed no difference in the level of perceived threat between familiar and unfamiliar people.

Collip, D. ... [et al] - Social world interactions: how company connects to paranoia Psychological Medicine (2011), 41: 911-921

Immigration and psychosis

Migration is an accepted risk factor for schizophrenia but the level of risk in second-generation immigrants in unclear. A team of researchers from McGill University in Canada reviewed 21 studies into psychosis among immigrants. They found that while first-generation immigrants were 2.3x as likely to develop psychosis as other people second-generation immigrants were 2.1x as likely. While there was no significant difference in risk between the generations there were wide variations in levels of psychosis between different ethnic groups and different host countries.

Bourque, F., van der Ven, E. and Malla, A. - A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants Psychological Medicine (2011), 41: 897-910

Cannabis use and psychosis

Much research has been devoted to the links between cannabis use and psychosis and a team of researchers from Maastricht University in the Netherlands has added to the evidence to suggest that there is a link. The researchers studied 1,923 people who were aged between 14 and 24 at the start of the study. They were asked about their cannabis use and assessed for psychosis symptoms at the start of the study (T1), 3.5 years later (T2) and 8.4 years later (T3). The researchers found that people who hadn't used cannabis at the start of the study but who used it between T1 and T2 had nearly twice the risk of developing psychosis symptoms by the end of the study. If they carried on using cannabis between T2 and the end of the study their risk was 2.2 times greater. By the end of the study the incidence rate of psychosis symptoms was 14% in those who had smoked cannabis compared to only 8% in those who hadn't.

Kuepper, Rebecca ... [et al] - Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study British Medical Journal doi: 10.1136/bmj.d738

Cannabis use and psychosis

The extent and nature of the link between cannabis use and psychosis is one of the most controversial areas of psychiatry. A team of researchers, led by Matthew Large from the Prince of Wales Hospital in New South Wales reviewed 83 studies into the relationship between cannabis use and the age at which people become ill with psychosis. They found that people who used cannabis became ill, on average, 2.7 years earlier than those who didn't with people who used any illegal drugs becoming ill 2 years earlier. Alcohol use was not associated with an earlier onset of psychosis.

Large, Matthew - Cannabis use and earlier onset of psychosis Archives of General Psychiatry
doi:10.1001/archgenpsychiatry.2011.5

What to do with people who fall through the gaps?

Unless people present a danger to themselves or others mental health services don't treat them until they voluntarily seek help. Psychologists now think that people might be at risk of developing psychosis for a while before they become severely ill. Developing psychosis can have a massive impact on people's lives but so can being labelled as mentally ill and the side effects of antipsychotic drugs so that intervening in the lives of people who are 'at risk' for psychosis is a vexed issue, both medically and ethically. Researchers from the Institute of Psychiatry, King's College London attempted to shed a little more light on this debate in a study of people who had been referred to mental-health services by their GP. The study found that 21.2% of people had not turned up for their appointment with mental-health services. Around half this group subsequently received a diagnosis of mental illness and over a fifth of the 'no-shows' were later given a diagnosis of psychosis with nearly 70% of them seeking help from other mental-health services. People who did go on to their appointments with mental-health services were more likely to be employed. The authors of the study argue that there is a case for mental-health services chasing up people who have been referred to them by GPs but who have not turned up for their appointments.

Green, C. E. L. ... [et al] - Outreach and Support in South London (OASIS). Outcomes of non-attenders to a service for people at high risk of psychosis: the case for a more assertive approach to assessment Psychological Medicine (2011), 41, 243–250

Insight and psychosis

In a mental-health context insight can be defined as being aware that you have a mental-health problem; being aware that you need treatment and being aware that your symptoms are due to an illness. A team of Spanish researchers studied insight in a study of 110 patients with psychosis. They found that after two years of illness insight was poorer in people suffering from schizophrenia than in people suffering from other types of psychosis. The more severe people's psychosis the less insight they had. Being depressed when one develops psychosis; having poorer decision-making skills and a lower IQ, and going for a longer time without getting help were all associated with poorer insight as were reductions in frontal and parietal grey matter.

Parellada, Mara ... [et al] - Trait and state attributes of insight in first episodes of early-onset schizophrenia and other psychoses: a two-year longitudinal study Schizophrenia Bulletin 37 (1), 38–51, 2011

Psychosis and suicide

The long-term risk of suicide after a first episode of psychosis is unknown although most researchers think it is probably higher than the rate in the rest of the population. Researchers from the Institute of Psychiatry, King's College London studied 2,723 people in Camberwell, London; Nottingham and Dumfries and Galloway (Scotland) following them for 11 years after their first episode of psychosis. They found that although the rate of suicide was highest in the first year after becoming ill the increased risk persisted for years. Over the course of the study suicide among the participants occured nearly 12 times more than would be expected among the general population. 53 of the participants killed themselves over the course of the study, 49 more than would have been expected in a similar group of unaffected people. Even after ten years the suicide rate among the participants was four times as high as in the general population.

Dutta, Rina ... [et al] - Reassessing the long-term risk of suicide after a first episode of psychosis Archives of General Psychiatry 67(12), December 2010, 1230-1237

Charting the path from childhood delusions to mental illness

Although only around 1% of people suffer from full-blown schizophrenia or psychosis hallucinations or delusional beliefs - psychotic-like experiences (PLEs) - are more common and some psychologists think they are a risk factor for developing mental illness. One study found that 11-year-olds who reported a PLE were 16 times more likely to be diagnosed with schizophrenia when they were 26. For most people PLEs decline as they grow up but in a few people they persist, or even get worse. A team of researchers from the Institute of Psychiatry, King's College London looked into this is in a study of 409 teenagers who were studied four times at six-month intervals. They found that the teenagers whose PLEs were persistent suffered frequent victimization and higher levels of depression and anxiety. Those whose PLEs increased were more likely to smoke and use cannabis and cocaine.

Mackie, C. J., Castellanos-Ryan, N. and Conrod, P.J. - Developmental trajectories of psychotic-like

experiences across adolescence: impact of victimization and substance use Psychological Medicine (2011), 41, 47–58

Child abuse and psychosis

There is a growing recognition that having a difficult or traumatic childhood can increase the likelihood of people developing psychosis later in life but it is difficult to disentangle what types of trauma or abuse are linked to an increased risk. A team of researchers from the Institute of Psychiatry, King's College London looked into this further in a study of 428 people, 182 of whom had psychosis. The researchers asked people about difficulties and problems in their childhood and found that people with psychosis were three times more likely to report severe physical abuse by their mother before they were 12. There was also some - although not statistically significant - evidence that 'severe maternal antipathy' was linked to an increased risk of psychosis. However, paternal maltreatment and other forms of adversity were not linked to an increased risk of psychosis.

Fisher, H.L. ... [et al] - The varying impact of type, timing and frequency of exposure to childhood adversity on its association with adult psychotic disorder Psychological Medicine (2010), 40, 1967–1978

Why people do what the voices tell them to do

People who hear voices often report being given commands by them but not everyone obeys such commands. Researchers from the Adult Learning Disability Service in Prescot, Merseyside and the University of Manchester studied 49 people who were hearing voices. They classified the commands the participants had been given as benign, self-harm or harm-others. The study found that obeying their last self-harm command was associated with 'elevated voice malevolence,' worse symptoms and perceived negative consequences for non-compliance. Compliance with the last harm-others command was associated with more severe symptoms, worse perceived consequences for non-compliance and higher levels of social rank attributed to the voice.

Barrowcliff, Alastair L. and Haddock, Gillian - Factors affecting compliance and resistance to auditory command hallucinations: perceptions of a clinical population Journal of Mental Health, 2010; 1–11, iFirst article

Child sex abuse and schizophrenia risk

Being sexually abused as a child is a risk factor for psychosis and schizophrenia. Researchers from Monash University in Australia studied 7,697 people, 2,759 of whom had - according to police and medical records - been sexuall abused as children. They found that over a 30-year period people who had suffered child abuse had double the rate of psychosis (2.8% vs 1.4%) and nearly treble the rate of schizophrenia (1.9% vs 0.7%). Those who had suffered penetration of an orifice by another person or an object were at an even greater risk of psychosis and schizophrenia - 3.4% and 2.4% respectively.

Psychosis and socialising - investigating the connection

Psychosis symptoms are often preceded by a withdrawal from social relationships and a decline in social function. Researchers from Denmark set out to investigate this further in a study of 398 people. 11 of them had some symptoms of psychosis, 12 were defined as 'prodromal' - i.e. about to develop psychosis, 12 met the diagnostic criteria for psychosis and the remainder were an unaffected control group. The researchers used a questionnaire to measure people's interpersonal problems and found that there was an increase in them as their symptoms got worse. The research adds to other studies suggesting that addressing these problems in getting on with other people could be a useful way of helping people at risk of developing psychosis.

Mondrup, Lise and Rosenbaum, Bent - Interpersonal problems in the prodromal state of schizophrenia: an exploratory study Psychosis October 2010, 2(3), 238-247

Social difficulties and psychosis

People who go on to develop psychosis often have difficulties in getting on with other people. But are these problems a risk factor for developing the condition? A new study (lead author Eva Velthorst from the University of Amsterdam) looked at 245 people who had sought help for their psychological problems and who were thought to be at risk of developing psychosis. The participants were followed for 18 months to see which of them developed psychosis and their problems in getting on with other people were assessed with a questionnaire at the start of the study. The participants who went on to develop psychosis had significantly greater difficulties in making new friends, maintaining friendships, dealing with people they did not know and joining community activities. Using statistical analysis the researchers found that difficulties in getting on with other people significantly predicted whether people developed psychosis.

Velthorst, Eva ... [et al] - Disability in people clinically at high risk of psychosis British Journal of Psychiatry October 2010, 197(4), 278-284

Childhood trauma, cannabis use and psychosis

Although it is still a controversial topic some research has shown that using cannabis in adolescence is associated with an increased risk of developing psychosis. At the same time suffering childhood trauma is associated both with an increased risk of substance misuse and of developing psychosis. A team of Irish researchers tried to get to the bottom of the links between childhood trauma, substance abuse and psychosis in a study of 211 children aged between 12 and 15. They were asked about childhood trauma, cannabis use and any mental-health problems they might be having. The researchers found that both childhood trauma and cannabis use were significantly associated with an increased risk of developing psychosis symptoms. However, the presence of both childhood trauma and early cannabis use significantly increased the risk for psychotic symptoms beyond the risk posed by either factor alone.

Harley, M. ... [et al] - Cannabis use and childhood trauma interact additively to increase the risk of psychotic symptoms in adolescence Psychological Medicine, October 2010, 40(10), 1627-1634

Antidepressants for psychosis

As well as suffering from delusions and hallucinations people with schizophrenia often experience so-called negative symptoms such as flat mood, lack of interest in being sociable and an inability to experience pleasure, as well as many cognitive problems. Psychiatrists often prescribe antidepressants for these symptoms but there are reports of negative effects as well as positive ones. Researchers from the University of Wolverhampton reviewed 23 studies into the use of antidepressants for people with psychosis. They found a moderate positive effect from the antidepressants and significant responses for the drugs fluoxetine, trazodone and ritanserin.

Singh, Surendra P., Singh, Vidhi and Chan, Kelvin - Efficacy of antidepressants in treating the negative symptoms of chronic schizophrenia: meta-analysis British Journal of Psychiatry September 2010, 197(3), 174-179

Race, psychosis and brain scanners

Compared to the White population the incidence of psychosis among people from the African-Caribbean community living in the U.K. has been estimated as from anything between two and 18 times higher. The reasons for this are not completely clear but some people have suggested that it reflects institutional racism on the part of mental health services who are more likely to diagnose Black people as suffering from psychosis. A team of researchers from the Institute of Psychiatry, King's College London studied 143 people. Half were suffering from their first episode of psychosis and half were healthy controls; within the two groups half were White and half Black. The researchers thought that the Black people diagnosed with psychosis would have less brain abnormalities associated with the condition reflecting the fact that at least some of their diagnoses were due to institutional racism. In fact there were no differences in brain structure between the Afro-Caribbean patients and the White ones and the Afro-Caribbean patients showed a greater loss of grey matter overall than the White ones; showing, that in this sample at least, genuine changes to brain structure may have been behind the diagnoses of the Black patients not just institutional racism. Other conclusions one could draw from this study include: (i) psychosis is a complex social and cultural phenomenon not easily reduced to questions of brain structure (ii) the changes to brain structure observed are the consequences not the causes of psychosis (iii) Afro-Caribbean people aremore vulnerable to psychosis but this is due to poverty, racism, prejudice and, for immigrants at least, isolation and culture shock (iv) Afro-Caribbean people are more vulnerable to psychosis for other reasons. Whatever the theories it will be a long, tortuous and controversial process before the higher rates of psychosis among Black people are properly explained.

Morgan, K.D. ... [et al] - Differing patterns of brain structural abnormalities between black and white patients with their first episode of psychosis Psychological Medicine July 2010, 40(7), 1137-1147

Self-esteem and psychosis

Recently researchers have been looking as much at the depression and lack of motivation (negative symptoms) associated with schizophrenia as at the delusions and hallucinations (positive symptoms) that are usually associated with it. One factor that may contribute to, or be influenced by, depression and lethargy is low self-esteem. Some researchers think that paranoia actually protects against low self-esteem - 'it's not my fault everyone is conspiring against me' - while others argue that people's self-esteem falls as their symptoms get worse. A team of German researchers studied this issue in a sample of 102 people, 58 of whom had schizophrenia. The people with schizophrenia were much more likely to suffer from low self-esteem. Being depressed at the start of the study and taking more antipsychotic drugs were both associated with lower self-esteem after 4 weeks. Drugs might make people's self-esteem worse because of their chemical effects in the brain or because they lead people to develop unpleasant and undignified side effects such as weight gain and drooling. Paranoid ideas were found not to be related to self-esteem although there was a modest link between grandiose delusions and higher self-esteem.

Moritz, Steffen ... [et al] - Course and determinants of self-esteem in people diagnosed with schizophrenia during psychiatric treatment Psychosis June 2010, 2(2), 144-153

Optimism and psychosis

Some researchers think that people with a severe mental illness - such as schizophrenia - who are optimistic are more likely to find means to redefine themselves, to accept their condition, to overcome stigmatising beliefs and to actively function in the community. Others think that optimism means that people are 'in denial' about their illness and that it is not necessarily a good thing. But what makes some people with a severe mental illness more optimistic than others? Researchers from the University of Montreal looked at information from two studies. One was of 150 patients with early psychosis and the second was of 143 people with severe mental illness engaged in a vocational rehabilitation service. They found that in the first sample increased optimism could be explained by higher self-esteem, a higher capacity for leisure activities, low depression and less belief that one's problems constituted an illness. In the second study high self-esteem, low depression and high levels of social support were associated with increased optimism.

Lecomte, Tania, Corbiere, Marc and Theroux, Laurence - Correlates and predictors of optimism in individuals with early psychosis or severe mental illness Psychosis June 2010, 2(2), 122-133

Duration of psychosis and negative symptoms

Early interventions for people with psychosis is increasingly recognised as important. Psychologists call the time between people first developing symptoms of psychosis and the start of their treatment duration of untreated psychosis (DUP). The evidence about the links between longer DUP and the negative symptoms of psychosis - flat emotions, poverty of speech, inability to experience pleasure, lack of desire to form relationships and lack of motivation - is inconsistent so a team of researchers from Helsinki University studied 41 people going through their first episode of psychosis. The study found that a longer DUP was associated with more negative symptoms.

Grano, Niklas ... [et al] - Duration of untreated psychosis is associated with more negative schizophrenia symptoms after acute treatment for first-episode psychosis Clinical Psychologist March 2010, 14(1), 10-13