After the schizophrenia concept what

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After the schizophrenia concept -
what? Richard Bentall Professor of
Experimental Clinical Psychology, The University
of Manchester
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1 What is wrong with the schizophrenia concept?
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The origins of the concept
Emil Kraepelin (1856-1926) first described
dementia praecox
Eugen Bleuler (1857-1939) renamed the putative
illness schizophrenia
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A fundamental assumption
Kraepelin believed that diagnosis by symptoms
would be a Rosseta stone that would lead to an
understanding of aetiology
According to this viewpoint, it should be
possible to specify exactly how many psychoses
there are!
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The neoKraepelinian movement
Kraepelins assumptions about the categorical
nature of psychiatric disorders were embraced by
the authors of DSM-III (and its successors) who
described themselves as neoKraepelinians.
In her book, The broken brain (1990),
noeKraepelinian Nancy Andreasen predicted that,
in the future, psychiatric interviews would be 15
minutes long, and that psychotherapy would only
have a marginal role in the treatment of mental
illness.
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The vanishing consensus effect
Different diagnostic systems diagnose different
patients as schizophrenic (Brockington, 1990).
Recent data from van Os et al. (1999)
Diagnosis RDC DSM-III-R ICD-10 N N N
Schizophreniform disorder - 20 2.8 - Schizophren
ia 268 38.0 371 52.6 387 54.8 Schizoaffective
manic 98 13.9 13 1.8 41 5.8 Schizoaffective
bipolar 129 18.3 23 3.3 Schizoaffective
depressed 118 16.7 40 5.7 Major
depression 16 2.3 71 10.1 19 2.7 Mania 18 2.6 8
7 12.3 61 8.6 Bipolar disorder 16 2.3 66 9.4 6 0.
9 Unspecified functional psychosis 43 6.1 68 9.6 9
5 13.5 Delusional disorder - 10 1.4 18 2.6 Not
classified - - 16 2.3
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There is no clear boundary between the well and
the sick
Population surveys show that psychotic symptoms
are much more widely experienced than psychiatric
admission data suggests. Lifetime prevalence
rates for DSM-criteria symptoms

• Hallucinations 11.1 (Tein, 1991) 7.9 (van Os
  et al., 2000) 13.2 (Poulton et al., 2000)

• Delusions 12.0 (van Os et al., 2000) 12.6
  paranoia (Poulton et al., 2000)

There are many happy, functioning psychotic
people in the population!
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But other studies suggest that Kraepelin proposed
too few psychoses!
Studies using factor analysis have suggested that
there are at least three clusters of
schizophrenic symptoms (e.g. Liddle, 1987
Andreasen et al., 1995)
Cognitive disorganisation
Positive hallucinations and delusions
Negative
Interestingly, similar results have been obtained
from MD patients (Maziade et al., 1995 Toomey,
Faraone, Simpson, Tsuang, 1998).
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Prediction of treatment response

• Different illnesses should respond to different
  treatments
• Schizophrenia - antipsychotics
• Manic depression - lithium carbonate
• This does not seem to be the case. Johnstone et
  al. (1986) randomly assigned patients to pimozide
  (an antipsychotic), lithium carbonate, both or
  neither. Drug response was symptom-specific but
  not diagnosis-specific
• Delusions and hallucinations - antipsychotics
• Abnormal mood - lithium carbonate

This observation remains a cause of surprise and
debate (Tamminga Davis, 2007)
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Aetiological specificity
Psychopathology and biological studies point to
similarities between SZ and MD patients rather
than differences

• The dopamine theory should be renamed the
  dopamine hypothesis of psychosis (Carlsson, 1995)

• Identical deficits on cognitive and
  neuropsychological tests (e.g. Fleming Green,
  1995 Nelson, Saz, Strakowski, 1998
  Nuechterlein, Dawson, Ventura, Miklowitz,
  Konishi, 1991 Oltmanns, 1978 Serper, 1993)

• Gene loci that have been associated with
  schizophrenia overlap with those associated with
  other disorders (Craddock Owen, 2005 Ivleva et
  al 2008).

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2. How to explain psychosis By studying the
actual experiences of psychiatric patients the
symptoms of psychosis rather than imaginary
syndromes.
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A paranoid continuum?

• Many psychologists have argued that psychotic
  experiences exist on a contiuum with normal
  functioning (e.g. Claridge, 1990) and have
  developed psychometric instruments to assess this
  continuum (e.g. Bentall, Claridge Slade, 1988),
• Epidemiological studies show that large numbers
  of people report delusional beliefs (12.0, van
  Os et al., 2000, Holland) or paranoia (12.6
  paranoia, Poulton et al., 2000, New Zealand)
• Freeman et al. (2005) administered a paranoia
  questionnaire to over 1000 people in a UK
  internet survey. They found evidence for a
  continuum, although extreme beliefs about threats
  of harm were only endorsed by a minority.

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Two types of paranoia?

• Trower and Chadwick (1995) argue that there are
  two types of paranoia
• Poor me paranoia (persecution underserved,
  self-esteem preserved)
• Bad me paranoia (persecution deserved,
  self-esteem low)

• However, there has been almost no research to
  examine the distinction.

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The PADS (Melo et al., in press)
Adequate reliability was found for both
dimensions. In non-patients, a clear relationship
was observed between paranoia and deservedness,
but this relationship was absent in patients. In
the patient sample, deservedness scores appeared
to be suppressed.
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Fluctuations in deservedness (Melo et al., 2006)
43 paranoid patients compared with 22 healthy
controls. Initial intention was to repeat
assessments of paranoid patients after 1 month
proved difficult. All patients completed a
deservedness analogue scale on each assessment 0
I dont deserve to be persecuted 12 I
deserve to be persecuted.
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Fluctuations in deservedness (Melo et al., 2006)
Deservedness
0 - 1
1.1 - 4
4.1 - 6
gt 6
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Time course of deservedness?
Bad me
Onset of acute episode
Deservedness
Poor me
Time
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Psychological processes that have been implicated
in paranoia

• Jumping to conclusions (e.g. Garety et al. 2001)
• Patients with delusions tend to jump to
  conclusions (make a decision about uncertain
  events) on the basis of little information
• Typically measured by the beads task
• Well replicated finding
• Seems to be associated with delusions rather
  than specifically paranoia

• Theory of mind (e.g. Corcoran Frith, 1996)
• It has been argued that paranoid patients have
  difficulty in understanding other peoples
  thoughts and feelings (they have a poor theory
  of mind)
• Assessed by false belief stories, hinting tasks
  or even appreciation of jokes
• Psychotic patients perform poorly on ToM tasks,
  but specificity to paranoia is ot proven

Attributions (Causal explanations) (e.g. Kaney
Bentall, 1989)
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Three types of attribution?
Simplifying somewhat, the attributions (causal
explanations) we construct for events can be
broken down into three main types
Internal
Totally due to me
External Personal
Totally due to another person or other people
External Situational
Totally due to the situation (circumstances or
chance)
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The original attributional model
Bentall, Kinderman Kaney (1994) proposed that a
tendency to explain negative events in terms of
external-personal causes (the actions of others)
is a dysfunctional defensive process, that leads
to paranoid beliefs.
Reduced negative thoughts about self
External (other-blaming) attributions (explanation
s) for negative events
Threat of activation of negative beliefs about
self
Increased belief that others have malevolent
intentions towards self.
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Problem 1 The relationship between self-esteem
and paranoia (Bentall et al., 2008)
Wellcome Paranoia Study Schizophrenic paranoid
(N38), remitted schizophrenic paranoid (N27),
depressed paranoid (N18), depressed
non-psychotic (N27) and control participants
(N33) (Bentall et al., in press.)
Correlations between negative self-esteem
paranoia (Fenigstein Scale) Spearman
r SZ-P .32 SZ-R .41 DEP-P .42 DEP-NP .53 Cont
rol .39
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Thewissen, Bentall, Lecomte, van Os
Myin-Germeys (2008)

• Patients with positive psychotic symptoms (n79),
  individuals with an at-risk mental state for
  paranoid psychosis (n38), and control subjects
  (n38) assessed using experience sampling method
  (ESM).
• 6 day diary, 10 bleeps/day
• 4 items measuring momentary self-esteem
• Other items measuring context, significant
• experiences and attributions

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Thewissen, Bentall, Lecomte, van Os
Myin-Germeys (2008)
Paranoia was associated with average low
self-esteem, an effect that survived correction
for depression but not SE instability. Paranoia
also independently related to SE stability.
1 Multilevel linear random regression model, ß
can be interpreted identically to the regression
outcome in a unilevel linear regression model.
Since 16 patients had missing data at day level,
only 139 participants were included in the
analyses. 2 Unilevel linear regression model 3
Paranoia Scale tertile scores, T1low paranoia
T2medium paranoia T3high paranoia
plt0.05 plt.01 plt.001
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Thewissen, Bentall, Lecomte, van Os
Myin-Germeys (further unpublished analyses)
We have identified paranoid episodes using both
strict (3SD paranoia) and loose (2SD
paranoia) definitions (the results are the same).
We have then looked at 1. the intervals
preceding the onset of paranoia (compared to
epochs not preceding paranoia)
Very sharp increases in anger and decreases in
self-esteem
2. paranoid epochs compared to non-paranoid
epochs
High levels of anger, depression and anxiety, low
self-esteem.
3. The final interval before the end of a
paranoid epoch, compared to other paranoid
intervals
Sharp decreases in depression.
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Problem 2 Is the association between
attributions and paranoia replicable?

• Replications
• Candido Romney (1990) (Canada)
• Fear et al. (1996) (Wales)
• Lassar Debbelt (1998) (Germany)
• Lee Wong (1998) (South Korea)

• Partial replications
• Kristev et al. (1999) (Australia partial
  replication)
• Martin Penn (2002)
• McKay et al. (2005)

• Complete failures to replicate
• Humphries and Barrowclough (2006)

• Attributional abnormalities present in acute
  paranoid but not normal paranoids
• Jannsen et al (2006)
• McKay et al. (2005)
• Martin Penn (2001 non-patients) vs Martin
  Penn (2002 patients)

• Attributional abnormalities present only in
  poor-me or grandiose paranoids
• Melo et al. 2006
• Jolley et al (2007)

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Attributions and deservedness (Melo et al., 2006)
Low scores indicate external attributions for
negative events
p lt .001
p lt .01
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Must everyone get prizes?

• In our recent Wellcome Trust funded study we
  combined data from the following groups (Bentall
  et al. in press)
• Schizophrenia patients with paranoid delusions
• Schizophrenia patients with paranoid delusions
  in remission
• Depressed patients with paranoid delusions
• Depressed patients without paranoid delusions
• Patient with late onset (aged gt 65)
  schizophrenia-like psychosis with paranoid
  delusions
• Elderly (aged gt 65) depressed patients without
  paranoid delusions
• Healthy controls

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Must everyone get prizes?

• And modelled the relationships between measures
  of
• Paranoid beliefs
• Threat anticipation
• Attributional style (excluding internality)
• Self-esteem (positive and negative)
• Depression and anxiety
• Theory of mind (2 measures)
• Jumping to conclusions (2 measures)
• Cognitive (executive) function (short WAIS and
  digit span backwards)

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Could all of these theories be true?
Structural equation modelling revealed the
following relationships
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Could all of these theories be true?
Structural equation modelling revealed the
following relationships
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Summary of paranoia data

• There is evidence to support the role of
  multiple psychological processes in paranoia

• These can be broadly grouped into two classes
  emotional (self-esteem and attributions) and
  cognitive (executive function?)

• Emotional factors seem to be more important

• BUT the idea of a paranoid defence seems to
  still have some mileage with respect to poor-me
  delusions in acutely ill patients

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4. Some biological speculations
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The conditioned avoidance paradigm
The animal is placed in a shuttle box, in which
it can receive a warning signal and an electric
shock.
Note that learning continues (decreased response
latencies) long after 100 avoidance is achieved.
Escape
Aversive S
Warning S
Warning S
Avoidance R
No aversive S
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How does CAR relate to paranoia?
Moutoussis, Dayan, Williams and Bentall (2007)
have noted three ways in which CAR may be
relevant to human paranoia
1. Threat perception is abnormal in paranoia
more than would be expected by the effect of the
availability heuristic (Kaney et al. 1997
Corcoran et al. 2006 Bentall et al., 2008). Can
we model this effect as oversensitivity of the
dopamine system?
2. Paranoid patients engage heavily in safety
(avoidance) behaviours, and this may help to
maintain their expectation of threat (Morrison,
1998 Freeman et al. 2001).
3. If we accept that beliefs have affective
consequences, we can see the outlines of a
theoretical model explaining when people
sometimes prefer illogical beliefs over reality
based ones.
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How does CAR relate to paranoia?
Could attributional responses seen in poor-me
paranoia be construed as covert avoidance
responses?
Aversive emotional state
Negative thought
Negative thought
External attribution
No aversive emotional state
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The CAR and dopamine
Drugs which block d-2 receptors in the striatum
have a powerful therapeutic effect on patients
who experience persecutory delusions.
Dopamine-blocking drugs abolish the conditioned
avoidance response (CAR) in animals (Beninger et
al., 1980 Smith et al. 2005), but not escape
responding suggests a role for dopamine in
threat perception. Hence, the CAR has long been
used as initial screen for antipsychotic drug
action.
Animal studies show that repeated exposure to
social defeat in animals leads to sensitization
of the dopamine system (Selten, 2005). (This is
consistent with Read et al.s 2001 traumagenic
account of psychosis.)
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Paranoia as the end point of a developmental
pathway
Psychological description
Insecure attachment
Threat anticipation
Paranoia
Abnormal cognitive style
Victimisation/ powerlessness
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Paranoia as the end point of a developmental
pathway
Biological description
Insecure attachment
Threat anticipation
Paranoia
Abnormal dopamine
Victimisation/ powerlessness
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Other complaints
Recent research suggests

• Auditory hallucinations result from a failure of
  source monitoring, so that inner speech is
  misattributed to an alien source

• Incoherent speech occurs when individuals are
  highly emotionally aroused, leading to working
  memory deficits that present the speaker from
  taking into account the needs of the listener.

• Manic episodes are caused by oversensitivity of
  the reward system, and are provoked by goal
  attainment life events and/or dysfunctional
  efforts to avoid depression.

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5. Conclusions
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Conclusions and implications

• An approach to psychiatry based on an analysis of
  patients complaints is much more scientific than
  the Kraepelinian approach, which has failed to
  explain madness or help patients despite the
  expenditure of many millions of s and s

• Once we have explained each of the psychotic
  symptoms in turn, there will be no
  schizophrenia or bipolar disorder left over -
• We dont need a replacement diagnosis, or a new
  name like dopamine-disregulation disorder

• A complaints-based approach is also much more
  humane.

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Conclusions and implications
The treatment implication of a complaint-based
approach have yet to be fully explored. However

• A simple list of a patients complaints is much
  more clinically informative than a diagnosis.

• A complaints-based approach encourages clinicians
  to treat people as rationale agents, and to
  listen to their stories.

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Conclusions and implications
The treatment implication of a complaint-based
approach have yet to be fully explored. However

• Identification of the mechanisms underlying
  complaints may lead to a more rational (targeted)
  approach to drug therapy.

• However, it is also possible that new
  psychological therapies will be developed, that
  target the same mechanisms. Conventional CBT
  interventions have little impact on the
  mechanisms involved in paranoia (Brakolias et al,
  2008). Acceptance and Commitment Therapy (ACT)
  shows some promise (Bach Hayes, 2002).

• For many patients liberation may be better than
  cure!

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Thats all folks!