Unravelling psychosis: Psychosocial epidemiology, mechanism and meaning.

This paper reviews a revolution in our understanding of psychosis over the last 20 years. To a major extent, this has resulted from a process of cross-fertilization between psychosocial epidemiology and cognitive behavior therapy for psychosis (CBT-p). This encouraged complementary strategies for the acquisition and analysis of data. These include the use of a range of dependent variables related to psychosis, and the exploitation of data from cross-sectional and longitudinal epidemiological surveys, virtual reality experiments, experience sampling methodology, and treatment trials. The key element is to investigate social and psychological measures in relation to each other. This research has confirmed the role of the external social world in the development and persistence of psychotic disorder. In addition, several psychological drivers of psychotic experiences have been identified. There is now persuasive evidence that the influence of social factors in psychosis is significantly mediated by non-psychotic symptoms, particularly mood symptoms and other attributes of affect such as insomnia. Psychotic symptoms are also driven by reasoning biases such as jumping to conclusions and belief inflexibility, though little is known about social influences on such biases. It is now clear that there are many routes to psychosis and that it takes many forms. Treatment of all kinds should take account of this: the dependence of CBT-p on a detailed initial formulation in terms of psychological processes and social influences is an example of the required flexibility. Individual mediators are now being targeted in specific forms of CBT-p, with good effect. This in turn corroborates the hypothesized role of non-psychotic symptoms in mediation, and attests to the power of the approaches described

The need for psychiatric treatment in the general population: the Camberwell Needs for Care Survey

Background, This paper presents the first results of a two-stage psychiatric population survey, which uses a new method of directly evaluating needs for specific psychiatric treatment and the extent to which they have been met.Method, The sample was drawn at random from the population of an area of inner south London with high levels of deprivation. Seven hundred and sixty subjects aged 18-65 completed the GHQ-28. All those scoring > 5 and half of the rest were invited to take part in the second stage, comprising measures of mental state (SCAN), social role performance (SRPS), life events and difficulties (LEDS) and a Treatment Inventory. This information was used to rate the community version of the Needs for Care Assessment (NFCAS-C).Results, In all, 408 subjects were interviewed in the second stage. The weighted 1 month prevalence of hierarchically ordered ICD-10 psychiatric disorders was 9.8 %, the 1 year prevalence 12.3 %. The equivalent prevalences for depressive episode were 3.1 % and 5.3 % respectively, while those for anxiety states were both 2.8 %. At interview nearly 10% of the population were identified as having a need for the treatment of a psychiatric condition. This rose to 10.4 % if the whole of the preceding year was assessed. Less than half of all potentially meetable needs were met. There was only partial overlap between diagnosis and an adjudged need for treatment.Conclusion. A majority of people with mental health problems do not have proper treatment; given more resources and greater public and medical awareness, most could be treated by family doctors

A commentary on Kendler (2014)

Kendler argues for the reality of psychiatric diagnostic classes in terms of two realist theories of truth, coherence and correspondence. I would advocate an alternative interpretation of the truth status of diagnostic classifications that leads to different conclusions. This is based firstly on Karl Popper's ideas on the growth of knowledge, whereby hypotheses developed from theoretical conjectures are deliberately subjected to attempts at refutation (we refine our always provisional views of what is true by increasing our knowledge of what is false). My second source of argument is John Wing's view that diseases are theoretical constructs on which disease theories may be based and tested. Such theories relate variously to aetiology, pathology, treatment, course and outcome. Rejecting a disease theory does not force rejection of the disease construct it seeks to qualify. We adhere to disease constructs more strongly than to the disease theories based on them. However, if it becomes apparent that the information obtained by testing disease theories is incoherent, we may eventually jettison particular disease constructs, as has happened regularly in the history of medicine. The disease constructs used in psychiatry may be approaching this point

Treatment of male sexual deviation by use of a vibrator: Case report

A new technique of enhancement of heterosexual responsiveness is described. This uses a classical conditioning paradigm with heterosexual photographic material as the CS and erections elicited by a vibrator as the UCS. A 44-year-old fetishist was treated in this manner. His response to treatment was favorable and details of change are presented. The timing of physiological and diary measure changes is in line with an explanation in terms of the treatment procedure. However, attitude changes began before treatment commenced

Emotional dysfunction in schizophrenia spectrum psychosis: the role of illness perceptions

Background. Assessing illness perceptions has been useful in a range of medical disorders. This study of people with a recent relapse of their psychosis examines the relationship between illness perception, their emotional responses and their attitudes to medication.Method. One hundred patients diagnosed with a non-affective psychotic disorder were assessed within 3 months of relapse. Measures included insight, self-reported. illness perceptions, medication adherence, depression, self-esteem and anxiety.Results. Illness perceptions about psychosis explained 46, 36 and 34% of the variance in depression, anxiety and self-esteem respectively. However, self-reported medication adherence was more strongly associated with a measure of insight.Conclusions. Negative illness perceptions in psychosis are clearly related to depression, anxiety and self-esteem. These in turn have been linked to symptom maintenance and recurrence. Clinical interventions that foster appraisals of recovery rather than of chronicity and severity may therefore improve emotional well-being in people with psychosis. It might be better to address adherence to medication through direct attempts at helping them understand their need for treatment

Prevalence of psychosis in black ethnic minorities in Britain: analysis based on three national surveys

Purpose A considerable excess of psychosis in black ethnic minorities is apparent from clinical studies, in Britain, as in other developed economies with white majority populations. This excess is not so marked in population surveys. Equitable health service provision should be informed by the best estimates of the excess. We used national survey data to establish the difference in the prevalence of psychosis between black ethnic groups and the white majority in the British general population. Methods Analysis of the combined datasets (N = 26,091) from the British national mental health surveys of 1993, 2000 and 2007. Cases of psychosis were determined either by the use of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), or from a combination of screening items. We controlled for sex, age, social class, unemployment, design features and other putative confounders, using a Disease Risk Score. Results People from black ethnic minorities had an excess prevalence rate of psychosis compared with the white majority population. The OR, weighted for study design and response rate, was 2.72 (95 % CI 1.3–5.6, p = 0.002). This was marginally increased after controlling for potential confounders (OR = 2.90, 95 % CI 1.4–6.2, p = 0.006). Conclusions The excess of psychosis in black ethnic minority groups was similar to that in two previous British community surveys, and less than that based on clinical studies. Even so it confirms a considerable need for increased mental health service resources in areas with high proportions of black ethnic minority inhabitants

Transdiagnostic Extension of Delusions: Schizophrenia and Beyond

Delusion is central to the conceptualization, definition, and identification of schizophrenia. However, in current classifications, the presence of delusions is neither necessary nor sufficient for the diagnosis of schizophrenia, nor is it sufficient to exclude the diagnosis of some other psychiatric conditions. Partly as a consequence of these classification rules, it is possible for delusions to exist transdiagnostically. In this article, we evaluate the extent to which this happens, and in what ways the characteristics of delusions vary according to diagnostic context. We were able to examine their presence and form in delusional disorder, affective disorder, obsessive-compulsive disorder, borderline personality disorder, and dementia, in all of which they have an appreciable presence. There is some evidence that the mechanisms of delusion formation are, at least to an extent, shared across these disorders. This transdiagnostic extension of delusions is an argument for targeting them therapeutically in their own right. However there is a dearth of research to enable the rational transdiagnostic deployment of either pharmacological or psychological treatments