L11 Distorted reality: psychotic symptoms across disorders Flashcards
What is the first article about?
Psychosis as a State of Aberrant Salience: A Framework Linking Biology, Phenomenology, and Pharmacology in Schizophrenia
The paper tries to integrate the neurobiology (brain), phenomenological experience (mind), and pharmacological aspects of psychosis in schizophrenia into a unified framework
Structure:
1. The dopanime hypothesis of psychosis
2. Dopamine as a mediator of motivational salience
3. Psychosis as a Disorder of Aberrant Salience
4. Dampening of Aberrant Salience by Antipsychotics
5. Implications of this model and its links to other models
6. Limitations of the framework
What is a broad overview of the main argument in the article?
Psychosis involves an overactive dopamine system which causes an aberrant assignment of salience to experiences, leading to delusions as the mind tries to make sense of these unusual sensations, and hallucinations as direct experiences of this misassigned importance to internal thoughts. Antipsychotics dampen this aberrant salience to alleviate symptoms.
What are the two ideas in the dopamine hypothesis?
- dopamine hypothesis of antipsychotic action
- dopamine hypothesis of psychosis
How has the dopamine hypothesis of the antipsychotic action developed and what did this lead to?
- Developed from the observation that antipsychotics increase the turnover of dopamine
- It led to the discovery of the dopamine D2 receptor - plays a central role in the action of these medications
- Neuroimaging studies using PET and SPECT have confirmed the importance of D2 receptor occupancy for antipsychotic effects
What is evidence that supports the dopamine hypothesis of psychosis?
- Psychostimulant drugs that release dopamine can induce de novo psychosis and worsen psychotic symptoms in partially remitted patients
- Early postmortem studies showed dopaminergic abnormalities (but their interpretation is complicated by drug effects)
- Most compelling evidence - neuroimaging studies demonstrating heightened dopamine synthesis, increased dopamine release in response to stimuli, and elevated synaptic dopamine levels in psychotic patients with schizophrenia
- There is lot of evidence for heightened dopaminergic transmission, likely involving presynaptic dysregulation rather than changes in the number of dopamine receptors
What is important to consider when suggesting the role of dopamine in psychosis?
- Dopaminergic abnormality is likely not exclusive or primary in schizophrenia, as other neurochemical systems are also involved
- The dopamine disturbance is likely a “state” abnormality associated with the dimension of psychosis within schizophrenia rather than a fundamental abnormality of the illness itself
- “Dopamine [is] the wind of the psychotic fire” - while dopamine plays a role, it’s not the primary underlying cause
↪ dopamine acts as an exacerbating factor, intensifying or driving the symptoms of psychosis rather than being the fundamental origin of the condition itself
What hypothesis proposes dopamine’s role in behaviour? What observations led to a development of alternative ideas?
Dopamine has been widely linked to reward and reinforcement - but it’s unclear how dopamine contributes to those:
- The anhedonia hypothesis - dopamine mediates pleasure derived from rewarding experiences
Observations leading to alternative ideas:
- dopamine is involved in aversive events
- dopamine activity precedes pleasure consummation
- dopamine changes the ‘wanting’ without necessarily changing the ‘liking’ - change in drive to obtain food and sex but not the extent of liking these
What were the alternative ideas proposed?
- Dopamine neurons are important for predicting rewarding events and coding outcome expectancies - doesn’t explain dopamine’s role in aversive events and its long-term modulatory role in behaviours
- Incentive/motivational salience hypothesis
What is the Incentive/motivational salience hypothesis
- Most plausible framework for understanding psychosis
- This hypothesis builds on earlier work on incentive motivation and the role of dopamine in motivated behaviours
- Dopamine mediates the conversion of a neural representation of an external stimulus from something neutral into something attractive or aversive
- In particular, the mesolimbic dopamine system is crucial in the “attribution of salience” where events and thoughts become attention-grabbing and drive goal-directed behaviour due to their association with reward or punishment
- In simple terms: dopamine does not create pleasure but instead assigns importance (salience) to stimuli, making certain objects, thoughts, or events stand out and drive motivation. This system helps organisms focus on rewards and threats, guiding behavior toward beneficial outcomes (e.g., food, social interaction) and away from dangers.
- The concept of motivational salience provides a bridge between brain activity and the subjective experience of psychosis
How does the dopamine mediation differs in normal circumstances and psychosis?
- Under normal circumstances, stimulus-linked dopamine release mediates the acquisition and expression of appropriate motivational saliences
- In psychosis, however, there is stimulus-independent release of dopamine, meaning that dopamine is dysregulated, causing random stimuli to feel intensely important (aberrant salience)
- Thus, dopamine in the psychotic state becomes a creator of aberrant saliences rather than a mediator of contextually relevant ones
What do patients often experience before they experience psychosis?
- Patients may experience an exaggerated release of dopamine, out of sync with the context, leading to inappropriate salience and motivational significance being assigned to stimuli
- This induces a heightened awareness, emotionality, anxiety, and a drive to make sense of the altered perceptions
- Patients report a heightened awareness of insignificant things, increased sensory keenness, and a feeling that something in the world is changing, leading to perplexity and a search for explanation
- These abberant saliences in psychosis are unique due to their persistence in the absence of sustaining stimuli so patients go days or weeks without an explanation for this hightened awarness
According to this framework how do delusions develop?
- Delusions are “top-down” cognitive explanations that individuals develop to make sense of these experiences of aberrant salience
- Reaching a delusional explanation can provide a sense of relief or “psychotic insight” and guides further thoughts and actions, driving the patient to seek confirmatory evidence (e.g. glances from strangers, headlines in newspapers)
What explains the differences in delusions in patients?
Since the delusions are constructed by the individual to make sense of the heightened experience, the content of delusions is influenced by the individual’s psychodynamic themes and cultural context
- This explains how the same neurochemical dysregulation leads to variable phenomological expression
According to this framework how do hallucinations develop?
- Hallucinations arise from a conceptually similar and more direct process: the abnormal salience of internal representations of percepts and memories (e.g. a normal background noise might suddenly feel deeply meaningful)
- This can explain the varying severity of hallucinations, from internal thoughts to external voices (aliens intercepting your brain)
- Psychotic experiences become a clinical illness when shared with others or when they significantly affect the individual’s behaviour
What may further support the development of delusions and hallucinations?
- Pre-existing abnormalities in cognitive, interpersonal, and psychosocial functioning in patients with schizophrenia
- These include biases in probabilistic reasoning, a tendency to “jump to conclusions”, altered attributional styles, differences in “theory of mind”, and abnormal levels of perceptual aberrations and magical ideation
- These factors interact with the aberrant neurochemistry to shape the diverse phenomenology of psychosis
What things remain unclear when it comes to the effects of antipsychotics?
- Although dopamine receptor blockade by antipsychotics reaches a steady state within days, the improvement in psychotic symptoms is slow and cumulative
- A common early improvement reported by patients is that their symptoms “don’t bother me as much anymore” - The core belief in the delusion or the reality of the hallucination may persist even after it stops interfering with thought and function
- Patients often dislike taking antipsychotics due to dysphoria or a “deficit-like state”.
- Antipsychotics provide symptomatic control, as symptoms typically return upon discontinuation of treatment
How do antipsychotics work?
- All antipsychotics share the common property of dampening salience by blocking the underlying aberrant dopaminergic drive
- While antipsychotics differ in their physical properties, their psychological effect of dampening salience is the final common pathway of improvement
- Antipsychotics provide a platform of attenuated salience, allowing for further psychological and cognitive resolution of symptoms
- In summary, antipsychotics, when administered to a patient who works under aberrantly salient
ideas (delusions) or aberrantly salient perceptions (hallu-cinations), block the underlying aberrant dopaminergic drive, and given the critical role of dopamine in salience, this leads to an attenuation of the salience of these ideas and perceptions
Where does the concept of dampening salience originate from?
Very first behavioural studies of anti-psychotics in aminals and humans in the 1950s
- Rats who had come to associate a ringing bell with a shock would try to avoid the mere sound of the bell. However, when these rats received an antipsychotic they stopped avoiding the bell, even though they were motorically capable of doing so and still re-sponded to the shock. This led to the suggestion that antipsy-chotics induce “a forgetfulness of motive” (more recently… ‘‘impair incentive salience attributions’’)
- Early clinical observations noted a désintéressement in surroundings and a state of indifference in patients treated with these drugs
How does this view help explain why there is a slow, gradual response to the drugs?
- Despite antipsychotics blocking the dopamine system at onset, the response is slow and gradual
- By attenuating the salience of delusions and hallucinations, antipsychotics do not primarily change the content of thoughts or perceptions but make them less likely to form and more likely to extinguish
- Patients don’t immediately abandon the idea or percept rather they report that it “doesn’t bother me as much”
- This is implictly understood in the field since rating scales for psychosis often assess the degree to which symptoms preoccupy the mind and affect behaviour rather than solely focusing on the content
- Over time, the content of delusions and hallucinations may be deconstructed and recede from awareness
How can then symptom reduction be explained as a dynamic process?
Symptom resolution is a dynamic process where antipsychotics reduce salience, and the patient “works through” their symptoms towards psychological resolution, possibly involving processes of extinction, encapsulation, and belief transformation
Why does relapse occur?
- Because antipsychotics block the expression of abnormal dopaminergic transmission but do not fundamentally alter the underlying dysregulation
- When antipsychotic treatment is stopped, the endogenous dopaminergic dysregulation gets reinstated
- When in remission, the thoughts are not erased but recede to the background of consciousness and the resurgence of an abnormally heightened dopa-minergic state, whether due to drugs, stress, or endogenous dysregulation, reinvests these dormant symptoms with salience, making them clinically relevant again - often the same content as previously experienced by the patient
How could this framework lead to psychological treatment?
- Psychosis is viewed as a dynamic interaction between a bottom-up neurochemical drive and a top-down psychological process
- This suggests that specific psychotherapies for psychosis should be feasible and synergistic with pharmacotherapies
- Currently, treatment mainly focuses on biological modification without specific help for cognitive-psychological resolution
- Understanding and implementing psychological processes in therapies could enhance antipsychotic effects
- Early studies of cognitive therapies for psychosis show additional efficacy beyond drug effects
- The model suggests that an “overnight” treatment for psychosis is implausible because patients incorporate psychotic beliefs into their cognitive schemas over time
- Blocking neurochemical abnormalities quickly will not immediately dismantle these schemas - Improvement requires psychological strategies with longer timelines
What is an explanation for the unpleasant subjective effects of antipsychotics?
- effects: “neuroleptic-induced dysphoria” and decreased motivational drive
- These may be an unavoidable consequence of dampened salience, affecting both aberrant and normal motivations
- This might explain the higher incidence of substance abuse as self-medication in patients with schizophrenia
- Selectively dampening aberrant salience without affecting normal drives remains a challenge
How can this framework add to other already existing models?
- The aberrant salience hypothesis can complement other models of psychosis that focus on primary neurochemical abnormalities (e.g., mesolimbic dopamine, hypofrontality, glutamate deficit, neurodevelopmental disorder) by providing a link to symptomatic expression
- It differs from ideas focusing on deficient “filtering” of information by conceptualising salience at a cognitive-motivational level rather than a preattentive sensorimotor or electrophysiological level
What are the disclaimers/limitations of this framework?
- It does not aim to address complex ontological issues related to the mind-body problem
- It is a pathophysiological hypothesis, explaining how psychotic symptoms arise given neurochemical abnormalities, not an etiological hypothesis explaining why schizophrenia occurs
- It primarily addresses the psychotic symptoms of schizophrenia, not the more enduring deficit and cognitive abnormalities. It may have more relevance for understanding psychosis in other illnesses like manic psychosis
- Schizophrenia is more complex than just abnormal dopamine, involving other neurodevelopmental, cognitive, and interpersonal factors
- While focusing on dopamine, the article acknowledges that other neurotransmitters likely collaborate in the production of psychosis. However, current knowledge about the dopamine system allows for a more integrated brain-to-mind framework
What is the second article about?
The Special Challenges of Psychotherapy with
Persons with Psychosis: Intersubjective
Metacognitive Model of Agreement and Shared
Meaning
- It looks at psychotherapy with people who experience psychosis
- It presents challenges in establishing agreement and shared understanding between client and the therapist
- Differing narratives, varying levels of insight, and potential stigma act as significant barriers to a strong therapeutic alliance
- Intersubjective metacognitive model is proposed - it emphasises the role of metacognition and empathy which can be used to navigate these obstacles
- Through a case example, the paper illustrates how attending to the experiential elements and fostering mutual exploration can lead to improved therapeutic outcomes
What is the fundamental aspect of the therapeutic alliance?
- Agreement between client and the therapist on the goals and process of psychotherapy = goal consensus
↪ Often referred to as a pan-theoretical ingredient - Research suggests that in early psychosis, the effectiveness of psychotherapy (whether beneficial or harmful) depends on the therapeutic alliance
↪ low alliance was harmful with regard to patients’ symptomatology when individuals attended more therapy session
What does goal consensus include as defined by the paper?
- agreement on goals
- the therapist’s explanation of the nature of therapy and the client’s understanding of it
- the extent of goals discussion and specification
- the client’s commitment to the goals and congruence on the origin of the problem and on the responsibility of solving it
What is the model in the article based on? What does this lead to?
- It’s based on the assumption that the formation of shared treatment goals in psychotherapy is fundamentally an injersubjective process
- Hence, psychotherapy is not simply a cognitive alignment of abstract understandings but rather it develops through a shared process where the therapist and client explore and seek shared meaning
Picture 1
What is intersubjectivity?
- It involves sharing or appreciating what is occurring within the minds of two persons and the mutual understanding of each others’ subjective experience
- It acts as the basis for relatedness and as a precondition for the development of self-reflection and the emergence of the narratization of experience
What are the three possible barriers according to the intersubjective framework? What challenges to the development of agreement do these barriers lead to?
- the client and therapist may not share similar understanding of the context within their dialogue is happening = differing narratives
- the lack of joint understanding between the client and therapist about what is mental health and what is mental illness or the lack of mental health = differing levels of client insight and therapist theoretical perspectives
- the belief that the client may not be an equal party who can in fact make meaning of his or her challenges in any phase of the illness = stigma on the part of the therapist and self-stigma on the part of the client
What challenge does the first barrier of differing narratives lead to?
→ the need to overcome differences in the personal narratives of the client and therapist with regard to their roles in the mental health system and the role of the mental health system itself
How does the challenge of the differing narratives the role of the mental health system present?
- Clients may have negative experiences and perceptions of the mental health system, feeling oppressed or demeaned and viewing it as a threat to their well-being - some may identify as “psychiatric survivors”
- Legitimate fears about confidentiality, stigma, and practical implications like employment may be present
- On the other hand, therapists often view the mental health system as benevolent and offering essential assistance to persons in need
What does the first challenge lead to?
It can lead to a fundamental misunderstanding of roles from the outset, where clients may perceive goal setting as an opportunity to be controlled by the system and the therapist, while therapists assume that any developed goal is simply offering a path to wellness
What challenge does the second barrier of the client’s insight lead to?
- Many clients with psychosis exhibit a lack of awareness or denial of having a mental illness = poor insight
- This is not just an educational deficit but a different way of understanding life events
- This lack of insight can lead to limited material upon which the client feels meaning can be based - meaning that clients may not see symptoms or consequences of illness as starting points for shared meaning, unlike therapists who believe that symptoms or consequences of illness are natural places around which they could make meaning and start to form goals
- Poor insight is associated with a poor therapeutic alliance and disagreement on various aspects of the client’s life
What is offered as an alternative to understanding client’s insight?
Concept of narrative insight, which views insight as a story individuals tell about their illness, potentially differing from the formal medical model
What challenge does the second barrier of the therapist’s theoretical perspective lead to?
- Therapists have diverse theoretical models of psychosis, emphasizing different underlying factors
- neurobiological factors - excessive synaptic prun-ing, loss of brain issues and release of neurotoxic amino acids
- socio-political factors - trauma, poverty
- psychological factors - attachment style and interpersonal sensitivity
- These perspectives might not be readily understood by clients even with considerable eduction
Third barrier - stigmatizing beliefs held by the client and therapist
What does stigma refer to?
Stigma in society portrays individuals with mental illness as different and less valued, including beliefs of being dangerous, fragile, incompetent, or incapable of understanding the demands of adult life
What challenge does therapist’s stigmatizing beliefs lead to?
- Therapist stigma can lead to them “taking charge,” deciding for clients, and not engaging in joint meaning-making (e.g. insisting on medication without reasoning)
- It can also lead to discouraging clients from taking risks (e.g. forming a romantic attachment) for fear that they will only be disappointed and unable to cope with disappointment
What challenge does client’s self-stigmatizing beliefs lead to?
- Clients are vulnerable to internalizing stigma (self-stigma), leading them to believe they are incapable of directing their lives, resulting in passivity, demoralization, or reliance on others for guidance
- Self-stigma is prevalent in psychosis and linked to negative outcomes like depression, hopelessness, and low self-esteem
- If a client with self-stigma does not seek to make meaning, intersubjective agreement becomes impossible
What are the two possible paths for resolutions of the barriers to agreement and shared meaning?
- Metacognition
- Empathy
What is metacognition?
- Originally from the field of education (thinking about one’s own thinking), it has broadened to include awareness and consideration of mental experiences and the synthesis of these into an integrated sense of self and others
- It involves both discrete (awareness of specific thoughts/emotions) and synthetic (integration into a larger sense of self/others) acts that inform each others
- Not purely cognitive but includes embodied experience and is an ongoing, evolving process - our larger sense of ourselves and others changes as things change around us
- It requires the ability to shift between one’s own and others’ perspectives
How does metacognition differ from other related factors?
- Metacognition is related to social cognition and mentalizing
- Social cognition - processes involved in how persons form ideas about social exchanges
- Mentalizing - focuses on how people form their own mental states
- metacognition emphasizes the integration of experiences and the complexity of understanding rather than just the correct detection of discrete thoughts or feelings
How is metacognition in clinical population?
Individuals with psychosis often experience metacognitive deficits, struggling to form complex representations of self and others and to use that knowledge to respond to ongoing psychological and social challenges
How can clients and therapists reach an agreement via metacognition?
- A path to agreement involves therapists and clients starting with a mutual exploration of jointly perceived experiential elements rather than focusing on final conclusions
- For example, instead of debating the label of mental illness, discussing specific memories, feelings, and perspectives can lead to agreed-upon treatment goals
- This idea echoes the concept of narrative insight - communicating a coherent narrative which doesn’t necessary agree with the medical model of psychosis, may actually involve efficacious metacognitive abilities
What does metacognition require of the therapist to reach an agreement with the client?
- Elements of experience have to be addressed and mutually considered
- Requires awarness of the difference between being able to perceive elements of events from the ability to synthesize (e.g. client who doesn’t think they’re ill, is not making an error or thinking wrong - they are just not bringing together info in the same manner as the therapist)
- This requires therapists to be aware of their own theoretical biases and remain open to understanding the client’s unique experiences
How can empathy aid in reaching shared agreement?
- Perception of the therapist as empathetic predicts a high therapeutic alliance
- Empathy involves both conceptual perspective-taking and emotional stimulation and regulation
How do empathy and metacognition differ?
- Metacognition and empathy are related, both requiring active effort to think and experience about self, other, and their dialogue
- Empathy focuses more on ongoing experience, while metacognition focuses on evolving representations
- Empathy involves sharing the other’s affective state, while metacognition involves understanding the other’s mental states
- Empathy can occur implicitly (emotional contagion, e.g. someone else’s tears) or explicitly (more complex forms of empathy), but all expressions involve experiencing, unlike the understanding in metacognition
How does empathy and metacognition develop in relation to each other?
- Empathy seems to develop before metacognitive capacities
- Empathy can pave the way for greater metacognitive activities of integration and synthesis of representations → empathy allows for experiencing that leads to confirmation and sharing of emotional states and processes, and these create the possibilities for internal representation of the self and the other to emerge
- However, empathy alone may not lead to integrated representations if metacognitive deficits exist or the therapist lacks awareness
- Conversely, metacognition can occur without empathy, focusing on cognitive understanding while neglecting emotional aspects
- The least desirable scenario is a lack of both empathy and metacognition due to factors like therapist stigma and client lack of insight, resulting in a low sense of alliance
How should empathy and metacognition be used to reach a shared agreement?
- Therapists should strive for a scenario where an empathic stance leads to self and other integrative representations through metacognition
- This involves the therapist being open, curious, and aware of potential biases
- The path of empathy, followed by reflection, invites the client to explore together with the therapist, i.e. engaging together in a process of knowing
- When both are motivated to this exploration, with the giving up illusion that one holds the truth, only then true sharing can occur
Case of Nathan part 1
Article page 8
- The initial conversation highlights differing narratives about medication and its impact on Nathan’s spiritual development. The therapist seems to prioritise medication adherence based on a medical model, while Nathan values his spiritual growth and feels the medication hinders his concentration
- The therapist initially appears unaware of the tension and the different perspectives, defending her professional stance
Case of Nathan part 2
Article page 8 down + page 9
- Later, the therapist becomes aware of the opposing stances and uses her own subjectivity to create a space for shared meaning
- Nathan expresses his fear of the therapist’s disapproval of his decisions regarding medication
- The therapist acknowledges Nathan’s anger and frustration while also expressing her own anxiety
- The conversation shifts to a joint exploration of the implications of stopping medication, moving away from a right/wrong dichotomy
- Ultimately, a compromise is reached where Nathan agrees to try a reduced dose, and both agree to monitor the effects on his work and symptoms
What does the case demonstrate?
The case demonstrates how the therapist’s growing awareness (metacognition) of her own biases and Nathan’s perspective, coupled with empathy for his wishes, allowed for a shared narrative to emerge, considering both the benefits and drawbacks of medication
What are additional considerations that play a role in therapeutic relationship?
- Age, gender, and culture are important additional considerations
↪ Adolescence presents unique challenges related to identity development and self-stigma
↪ Cultural sensitivity is crucial in understanding the meaning of illness and symptoms
↪ Family environment and gender can also play a role
Summary of the article
- Goal consensus is vital for successful psychotherapy, including with individuals with psychosis
- The presented model views the therapeutic alliance as a continually constructed shared narrative within an intersubjective space
- The three main barriers (differing narratives, insight/theoretical perspective mismatches, and stigma) can be resolved through metacognition, empathy, and intersubjectivity
- Therapists working with psychosis need to be aware of these potential barriers and create a space for exploration through empathy and reflection
- The model highlights challenges rooted in the therapist or client’s thoughts and feelings expressed in the intersubjective space
Overview of article CBT in the prevention of psychosis and other severe mental disorders in patients with an at risk mental state: A review and proposed next steps
Discusses the application and effectiveness of CBT for individuals identified as being at an ‘At Risk Mental State’ (ARMS) for developing psychosis
What is the problem of untreated psychosis and what development did this lead to?
- Despite innovations in treating schizophrenia, the prognosis remains poor, and a long duration of untreated psychosis (DUP) is associated with worse outcomes
- The concept of a critical period for intervention in the first five years of psychosis was introduced, leading to early intervention services
- Within these services, some individuals were identified with attenuated psychotic symptoms who didn’t meet the criteria for a psychotic disorder - this profile was named ‘At Risk Mental State’ (ARMS), also known as Ultra-High Risk (UHR)
What signifies the need for preventative interventions in the ARMS population?
The ARMS population showed high rates of transition into psychosis and this made the ARMS profile a new target for indicated prevention of psychosis and the prevention of accompanying intensive treatment trajectories
What three subgroups does ARMS profile include?
- those with attenuated psychotic symptoms
- a small familial risk group with a first-degree relative with a psychotic disorder
- a small group with brief limited intermittent psychotic symptoms (BLIPS)
How do these subgroups differ on risk of transition to psychosis and declined fucntioning?
- All ARMS subgroups are also characterised by social decline in recent months
- Individuals identified as ARMS are in need and should receive clinical care due to current symptoms and impaired function
- The risk of transition to psychosis at 48 months varies between subgroups, being highest in the BLIPS group (38%), followed by the attenuated symptoms group (24%), and lowest in the familial risk group (8%)
Is ARMS a disorder? How is ARMS profile related to other psychological disorders?
- No because there are many routes to psychosis, and ARMS is a heterogeneous risk profile, not a disorder
- However, ARMS patients are found across various DSM classifications, particularly in mood and anxiety disorders, substance abuse, and personality disorder
- Additionally, trauma experience is very common in ARMS, associated with multi-morbidity
Why should ARMS profile be treated?
- Treating heterogeneous risk profiles can be beneficial, as demonstrated by the reduction in coronary heart disease through early interventions
- There are several differences between ARMS and first-episode psychosis which make it more likely for such intervention to be effective and beneficial
What are these differences between ARMS and First-episode psychosis (FEP)?
- A key difference between ARMS and first-episode psychosis (FEP) is that ARMS patients, while seeking help often for depression or anxiety, fear an impending mental breakdown, whereas psychotic patients generally do not seek help for their psychosis as they perceive their experiences as reality
- ARMS patients retain awareness and insight that something is wrong and are open to multiple explanations for their experiences, unlike psychotic patients who have delusional certainty
- This difference in certainty makes ARMS patients more receptive to psychoeducation and therapy
- The risk of transition to psychosis in ARMS is time-limited, with no more transitions after 10 or more years of follow-up, unlike the lifetime risk of relapse in psychotic disorders
What are the possible preventative interventions for ARMS? Are they effective?
- Several studies have investigated interventions to prevent the transition to psychosis in ARMS patients, including antipsychotic medication, CBT, polyunsaturated fatty acids (PUFAs), and integrated therapy
- Meta-analyses have shown that CBT is effective in reducing the transition to psychosis
- Antipsychotic medication showed similar efficacy but had issues with side-effects and low tolerance
- PUFAs did not show a significant effect in a large study
Based on this evidence, what is a recommended intervention?
Based on this evidence, European guidelines recommend the detection of ARMS subjects and CBT as a first-line treatment to prevent psychosis
What is the neurocognitive model of psychosis?
- It suggests that aberrant salience and biased appraisal processes play a role
- Increased striatal dopamine release is associated with aberrant salience, causing trivial stimuli to become the centre of attention and prompting appraisal
How does the neurocognitive model tie with ARMS patients and what role does CBT play?
- Aberrant salience in ARMS patients can progress to psychotic symptoms
- The appraisal process elicited by aberrant salience is a key mechanism in developing delusions
- Emotional appraisal and the development of secondary delusional beliefs are linked to clinical outcomes
- CBT aims to target appraisal processes accompanying perceptual aberrations and suspiciousness to normalise extraordinary experiences and prevent delusion formation and avoidance behaviours
What are the cognitive biases in ARMS patients and how can CBT address them?
- Appraisal processes in ARMS patients are often biased by cognitive biases such as jumping to conclusions (JTC), selective attention to threat, and an externalising and personalising bias
- CBT can address these biases through techniques like weighing alternative explanations, selective attention exercises, and behavioural experiments
- Patients are encouraged to discuss their experiences with others, stay socially active, and test negative appraisals
What other issues do ARMS patients report and how can CBT help with these?
- Many ARMS patients also experience depression, low self-esteem, and negative schemata, often linked to childhood trauma, bullying, and social isolation
- CBT for ARMS may integrate the treatment of PTSD and depression
- Cannabis use is generally discouraged due to its tendency to amplify psychotic symptoms
What are results from different trials about ARMS
- Several RCTs have been conducted, with many using the French and Morrison approach, which is formulation-driven, problem-oriented, time-limited, and educational, using collaborative empiricism
- Adaptations of this approach have included Motivational Interviewing for substance misuse (Newcastle study) and psychoeducation on dopamine sensitisation and cognitive biases (Dutch EDIE-NL)
- The Melbourne trial used a modular, educational approach focusing on stress management, depression, coping strategies, and other comorbidities
- !Meta-analyses have consistently shown that CBT reduces the risk of transition to psychosis!
- While detection and prevention are feasible, the effects of CBT on social functioning have been disappointing
What are the results of detection of ARMS patient studies?
- The EDIE-NL project found that screening the general help-seeking population detected more ARMS patients, particularly females, compared to referral
- Screened populations also had higher transition rates
- Waiting for referral leads to low detection rates, suggesting that early intervention services should implement screening in help-seeking populations using tools like the PQ-16
What is the conclusion of effectiveness of using CBT with ARMS profile?
- CBT for ARMS is successful in postponing and preventing the transition to psychosis, with effects lasting at least 48 months. Implementing screening and early treatment is cost-saving
- CBT for ARMS is likely more effective and less costly than routine care, with significant long-term cost savings and a potential reduction in the prevalence of psychotic disorders
What are the ten WHO criteria for implementing routine screening?
The screening and prevention of psychosis in ARMS patients now fulfills all ten criteria:
1. The ARMS profile indicates an important health problem, because 36% will develop psychosis in three years
2. CBT is effective in reducing the transition rate
3. a screener, diagnostic interview and treatment protocol are at hand
4. ARMS is a latent stage of psychotic disorder
5. the CAARMS and the SIPS are the state of the art structured interviews to diagnose the ARMS
6. the PQ-16 is a 2-minute screen that can be applied to the gen-eral (help-seeking) population
7. transition to psychosis results in poor prognosis and disablement
8. there is evidence and consensus on the definition of ARMS
9. the prevention is cost-saving
10. screening is already beginning to be implemented in routinemental health care in the Netherlands
What are future research suggestions?
- Future research needs to broaden the scope beyond just preventing transition to psychosis, as many non-transitioned individuals still experience poor functioning, depression, and anxiety
- Combining evidence-based treatment for co-occurring disorders with CBT for ARMS shows promising results
- Profiling within risk groups allows for personalised treatment
- Childhood trauma significantly impacts social functioning in ARMS patients, independent of transition to psychosis, highlighting the need to address trauma and PTSD
- Other suggested psychosocial components include social skills training and family involvement
Learning objectives
- Describe the clinical features of psychotic symptoms across disorders, and in psychotic disorders in particular.
- Argue for and against classification of symptoms as ‘psychotic’ using case examples.
- Describe the role of genetic and environmental factors in the aetiology of psychotic disorders [paraphrasing], also in light of the prevalence of these disorders in families/ populations.
- Describe the role that psychosocial interventions can play in the treatment of psychotic symptoms, including their strengths, limitations and obstacles to effective treatment]
