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Grunfeld G, Lemonde AC, Gold I, Paquin V, Iyer SN, Lepage M, Joober R, Malla A, Shah JL. Consistency of Delusion Themes Across First and Subsequent Episodes of Psychosis. JAMA Psychiatry 2024:2821873. [PMID: 39110444 PMCID: PMC11307164 DOI: 10.1001/jamapsychiatry.2024.2040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/21/2024] [Indexed: 08/10/2024]
Abstract
Importance Despite growing interest in the phenomenology of delusions in psychosis, at present little is known about their content and evolution over time, including whether delusion themes are consistent across episodes. Objective To examine the course of delusions and thematic delusion content across relapse episodes in patients presenting to an early intervention service for psychosis. Design, Setting, and Participants This longitudinal, observational study used clinical data systematically collected from January 2003 to March 2018 from a cohort of consenting patients with affective or nonaffective first-episode psychosis, followed up naturalistically for up to 2 years in an early intervention service for psychosis in Montréal, Quebec, Canada. Data included the thematic content and severity of delusions (scores ≥3 using the Scale for the Assessment of Positive Symptoms) and associated psychotic and nonpsychotic symptoms, both across an initial episode and, in the event of remission, a potential relapse. Data were analyzed from September 2021 to February 2023. Exposure An early intervention service for psychosis, organized around intensive case management and a multidisciplinary team approach, which observed each patient for up to 2 years of care. Main Outcomes and Measures The primary outcome was positive symptom relapse and remission, including the presence and content of delusions, which was coded per the Scale for the Assessment of Positive Symptoms and accepted definitions. The main statistical measures included repeated paired-sample t tests and binary logistic regression analyses. Results Of 636 consenting patients, mean (SD) age was 23.8 (4.75) years; 191 patients were female, 444 were male, and 1 patient was nonbinary. Remission rates were high, and relapse rates were relatively low: 591 individuals had baseline delusions, of which 558 (94.4%) achieved remission. Of these 558 patients, only 182 (32.6%) had a subsequent relapse to a second or later episode of psychosis. Of the 182 patients who did relapse, however, a large proportion (115 [63.2%]) reported threshold-level delusions. Of these 115, 104 patients (90.4%) had thematic delusion content consistent with that reported during the index (first) episode. Those who relapsed with delusions had fewer delusion themes present during subsequent episodes of psychosis compared with the index episode and lower levels of other psychotic and nonpsychotic symptoms. Conclusions and Relevance Specialized early intervention services for psychosis can achieve high rates of sustained remission. However, in this study, the minority of individuals with delusions who later relapsed experienced similar delusion themes during subsequent episodes. These findings raise important considerations for the conceptualization of delusions and have clinical implications for trajectories of illness and care.
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Affiliation(s)
- Gil Grunfeld
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, Quebec, Canada
| | - Ann-Catherine Lemonde
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, Quebec, Canada
| | - Ian Gold
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
- Department of Philosophy, Faculty of Arts, McGill University, Montréal, Quebec, Canada
| | - Vincent Paquin
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, Quebec, Canada
| | - Srividya N. Iyer
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, Quebec, Canada
| | - Martin Lepage
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, Quebec, Canada
| | - Ridha Joober
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, Quebec, Canada
| | - Ashok Malla
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, Quebec, Canada
| | - Jai L. Shah
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada
- Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, Quebec, Canada
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Rosén Rasmussen A, Handest P, Vollmer-Larsen A, Parnas J. Pseudoneurotic Symptoms in the Schizophrenia Spectrum: A Longitudinal Study of Their Relation to Psychopathology and Clinical Outcomes. Schizophr Bull 2024; 50:871-880. [PMID: 38227579 PMCID: PMC11283190 DOI: 10.1093/schbul/sbad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND AND HYPOTHESIS Nonpsychotic symptoms (depression, anxiety, obsessions, etc.) are frequent in schizophrenia-spectrum disorders and are usually conceptualized as comorbidity or transdiagnostic symptoms. However, in twentieth century foundational psychopathological literature, many nonpsychotic symptoms with specific phenomenology (here termed pseudoneurotic symptoms) were considered relatively typical of schizophrenia. In this prospective study, we investigated potential associations of pseudoneurotic symptoms with diagnostic status, functional outcome as well as psychopathological dimensions of schizophrenia. STUDY DESIGN First-admitted patients (N = 121) diagnosed with non-affective psychosis, schizotypal disorder, or other mental illness were examined at initial hospitalization and 5 years later with a comprehensive assessment of psychopathology. Informed by the literature, we constructed scales targeting pseudoneurotic symptoms and other, more general, nonpsychotic symptoms. STUDY RESULTS Pseudoneurotic symptoms aggregated in schizophrenia-spectrum groups compared to other mental illnesses and occurred at similar levels at baseline and follow-up. They longitudinally predicted poorer social and occupational functioning in schizophrenia-spectrum patients over a 5-year-period but not transition to schizophrenia-spectrum disorders from other mental illnesses. Finally, the level of pseudoneurotic symptoms correlated with disorder of basic self at both assessments and with positive and negative symptoms at follow-up. The scale targeting general nonpsychotic symptoms did not show this pattern of associations. CONCLUSIONS The study supports that a group of nonpsychotic symptoms, ie, pseudoneurotic symptoms, are associated with schizophrenia-spectrum disorders and linked with temporally stable psychopathology, particularly disorder of the basic self. Their prospective association with social and occupational functioning needs replication.
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Affiliation(s)
- Andreas Rosén Rasmussen
- Mental Health Center Amager, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Center for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Josef Parnas
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Communication, Center for Subjectivity Research, University of Copenhagen, Copenhagen, Denmark
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Palaniyappan L, Benrimoh D, Voppel A, Rocca R. Studying Psychosis Using Natural Language Generation: A Review of Emerging Opportunities. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2023; 8:994-1004. [PMID: 38441079 DOI: 10.1016/j.bpsc.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 03/07/2024]
Abstract
Disrupted language in psychotic disorders, such as schizophrenia, can manifest as false contents and formal deviations, often described as thought disorder. These features play a critical role in the social dysfunction associated with psychosis, but we continue to lack insights regarding how and why these symptoms develop. Natural language generation (NLG) is a field of computer science that focuses on generating human-like language for various applications. The theory that psychosis is related to the evolution of language in humans suggests that NLG systems that are sufficiently evolved to generate human-like language may also exhibit psychosis-like features. In this conceptual review, we propose using NLG systems that are at various stages of development as in silico tools to study linguistic features of psychosis. We argue that a program of in silico experimental research on the network architecture, function, learning rules, and training of NLG systems can help us understand better why thought disorder occurs in patients. This will allow us to gain a better understanding of the relationship between language and psychosis and potentially pave the way for new therapeutic approaches to address this vexing challenge.
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Affiliation(s)
- Lena Palaniyappan
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada; Robarts Research Institute, Western University, London, Ontario, Canada; Department of Medical Biophysics, Western University, London, Ontario, Canada.
| | - David Benrimoh
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada; Department of Psychiatry, Stanford University, Palo Alto, California
| | - Alban Voppel
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montreal, Quebec, Canada; Department of Psychiatry, University of Groningen, Groningen, the Netherlands
| | - Roberta Rocca
- Interacting Minds Centre, Department of Culture, Cognition and Computation, Aarhus University, Aarhus, Denmark
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Messas G, Stanghellini G, Fulford KWM(B. Phenomenology yesterday, today, and tomorrow: a proposed phenomenological response to the double challenges of contemporary recovery-oriented person-centered mental health care. Front Psychol 2023; 14:1240095. [PMID: 37809297 PMCID: PMC10551134 DOI: 10.3389/fpsyg.2023.1240095] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/22/2023] [Indexed: 10/10/2023] Open
Abstract
This paper argues that a dialectical synthesis of phenomenology's traditional twin roles in psychiatry (one science-centered, the other individual-centered) is needed to support the recovery-oriented practice that is at the heart of contemporary person-centered mental health care. The paper is in two main sections. Section I illustrates the different ways in which phenomenology's two roles have played out over three significant periods of the history of phenomenology in 20th century psychiatry: with the introduction of phenomenology in Karl Jaspers' General Psychopathology in 1913; with the development a few years later of structural phenomenological psychopathology; and in the period of post-War humanism. Section II is concerned with the role of phenomenology in contemporary mental health. There has been a turn to phenomenology in the current period, we argue, in response to what amounts to an uncoupling of academic psychiatry from front-line clinical care. Corresponding with the two roles of phenomenology, this uncoupling has both scientific aspects and clinical aspects. The latter, we suggest, is most fully expressed in a new model of "recovery," defined, not by the values of professionals as experts-by-training, but by the values of patients and carers as experts-by-experience, specifically, by what is important to the quality of life of the individual concerned in the situation in question. We illustrate the importance of recovery, so defined, and the challenges raised by it for both the evidence-base and the values-base of clinical decision-making, with brief clinical vignettes. It is to these challenges we argue, that phenomenology through a synthesis of its twin roles is uniquely equipped to respond. Noting, however, the many barriers to such a synthesis, we argue that in the current state of development of the field, it is by way of a dialectical synthesis of phenomenology's roles that we should proceed. From such a dialectic, a genuine synthesis of roles may ultimately emerge. We conclude with a note on the wider significance of these developments, arguing that contrary to 20th century stereotypes, they show psychiatry to be leading the way for healthcare as a whole, in developing the resources for 21st century person-centered clinical care.
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Affiliation(s)
- Guilherme Messas
- Department of Mental Health, Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, Brazil
- The Collaborating Centre for Values-Based Practice, St Catherine’s College, Oxford, United Kingdom
| | - Giovanni Stanghellini
- Department of Health Sciences, University of Florence, Florence, Italy
- ‘D. Portales’ University, Santiago, Chile
| | - K. W. M. (Bill) Fulford
- The Collaborating Centre for Values-Based Practice, St Catherine’s College, Oxford, United Kingdom
- St Catherine’s College, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
- Medical School, University of Warwick, Coventry, United Kingdom
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Yager J, Kay J. Purpose in Life: Addressing Transdiagnostic Psychopathologies Concerning Patients' Sense of Purpose. J Nerv Ment Dis 2023; 211:411-418. [PMID: 37094572 DOI: 10.1097/nmd.0000000000001657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
ABSTRACT Having a purpose in life is strongly associated with well-being and quality of life. Some individuals develop their sense of purpose early in life and can sustain lifelong ideals. In contrast, we identify four transdiagnostic syndromes where purpose in life is impaired: 1) deficiencies in generating purpose; 2) loss of purpose due to traumatic events such as catastrophic illnesses or bereavements; 3) conflicts due to crossed purposes; and 4) maladaptive purposes, such as life-limiting single-minded goals, dominating others, or exacting revenge. Several psychotherapies associated with positive and existential psychologies help patients construct, reconstruct, or retain a sense of purpose. However, given the strong links between a sense of purpose and beneficial health and mental health outcomes, the authors suggest that many patients in psychiatric treatment including psychotherapies will benefit from attention to these issues. This article reviews approaches for assessing and addressing purpose in life in psychiatric treatment, to enhance patients' healthy sense of purpose where this characteristic is impaired.
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Affiliation(s)
- Joel Yager
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, Colorado
| | - Jerald Kay
- Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio
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Stephensen H, Urfer-Parnas A, Parnas J. Double bookkeeping in schizophrenia spectrum disorder: an empirical-phenomenological study. Eur Arch Psychiatry Clin Neurosci 2023:10.1007/s00406-023-01609-7. [PMID: 37084145 DOI: 10.1007/s00406-023-01609-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 04/04/2023] [Indexed: 04/22/2023]
Abstract
Double bookkeeping is a term introduced by Eugen Bleuler to describe a fundamental feature of schizophrenia where psychotic reality can exist side by side with shared reality even when these realities seem mutually exclusive. Despite increasing theoretical interest in this phenomenon over the recent years, there are no empirical studies addressing this issue. We have, therefore, conducted a phenomenologically descriptive qualitative study of 25 patients with schizophrenia in which we addressed the following issues: (1) Experience of double reality; (2) Emergence and development of two realities; (3) Truth quality of psychotic or private reality; (4) Insight into illness; (5) Communication of psychotic experiences. The most important result was that most patients felt to be in contact with another dimension of reality. Hallucinatory and delusional experience pertained to this different reality, which patients most frequently kept separated from the shared reality. This other dimension was considered by the patients as being more profound and real. The pre-psychotic and psychotic experiences were difficult to verbalize and typically described as totally different than ordinary experience. Double reality was persistent across remissions. None of the patients considered their condition as an illness analogous to a somatic disorder. Most patients described a vague sense of duality preceding the crystallization of double bookkeeping. This emergence of doubleness was associated with a fundamental alienation from oneself, the world, and others stretching back to childhood or early adolescence. We discuss the results with a special emphasis on the concept of psychosis, clinical interview, treatment, and pathogenetic research.
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Affiliation(s)
- Helene Stephensen
- Center for Subjectivity Research, University of Copenhagen, Karen Blixens Plads 8, 2300, Copenhagen S, Denmark.
- Mental Health Centre Glostrup, University Hospital of Copenhagen, 2605, Brøndby, Denmark.
| | - Annick Urfer-Parnas
- Mental Health Centre Amager, University Hospital of Copenhagen, 1610, Copenhagen V, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen N, Denmark
| | - Josef Parnas
- Center for Subjectivity Research, University of Copenhagen, Karen Blixens Plads 8, 2300, Copenhagen S, Denmark
- Mental Health Centre Glostrup, University Hospital of Copenhagen, 2605, Brøndby, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, 2200, Copenhagen N, Denmark
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Hofmann J, Hubacher Haerle P, Maatz A. What’s the Linguistic Meaning of Delusional Utterances? Speech Act Theory as a Tool for Understanding Delusions. PHILOSOPHICAL PSYCHOLOGY 2023. [DOI: 10.1080/09515089.2023.2174424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Julian Hofmann
- Department of Philosophy, Zürichbergstrasse 43, University of Zurich, Zurich, Switzerland
- Department of Psychiatry, Psychotherapy and Psychosomatics, Centre for Social Psychiatry, Militärstrasse 8, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland
| | - Pablo Hubacher Haerle
- Faculty of Philosophy, Sidgwick Avenue, University of Cambridge, Cambridge, United Kingdom
| | - Anke Maatz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Centre for Social Psychiatry, Militärstrasse 8, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland
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8
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Grunfeld G, Lemonde AC, Gold I, Iyer SN, Malla A, Lepage M, Joober R, Boksa P, Shah JL. "The more things change…"? Stability of delusional themes across 12 years of presentations to an early intervention service for psychosis. Soc Psychiatry Psychiatr Epidemiol 2023; 58:35-41. [PMID: 35907013 DOI: 10.1007/s00127-022-02324-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 06/20/2022] [Indexed: 01/20/2023]
Abstract
PURPOSE While the prevalence of delusional themes appears to be consistent across geographic contexts, little is known about the relative prevalence of such themes within a given setting over periods of time. We therefore investigated delusional themes across 12 years of presentation to a catchment-based early intervention service for first episode psychosis (FEP). METHODS Systematically collected data from 500 patients at an early intervention service for FEP were analyzed. Four cohorts of 3 years each, from 2006 to 2017, were used to compare the frequency of delusion themes across cohorts. We also integrated into the analysis baseline sociodemographic factors such as gender, age, and highest level of education and clinical factors such as anxiety, depression, suicidality, hallucinations, and primary diagnosis (affective or non-affective psychosis). RESULTS Sex and education level were stable across cohorts, while patient age varied (p = 0.047). Clinical anxiety, depression, and suicidality at entry were also stable. Across cohorts, the proportion of patients with affective versus non-affective diagnosis differed (p = 0.050), with no differences in global rating of delusion severity or theme prevalence except for delusions of guilt or sin (p = 0.001). This single theme difference was not correlated with age or diagnosis. CONCLUSION Our study suggests relatively stable prevalence of delusion themes across cohorts of individuals experiencing FEP. This demonstrates the potential utility of studying thematic content both for understanding delusions in clinical populations and in research. Future explorations of the relationships between delusion themes and across individual patient episodes should be conducted.
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Affiliation(s)
- Gil Grunfeld
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada.,Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, QC, Canada
| | - Ann-Catherine Lemonde
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada.,Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, QC, Canada
| | - Ian Gold
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada.,Department of Philosophy, Faculty of Arts, McGill University, Montréal, QC, Canada
| | - Srividya N Iyer
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada.,Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, QC, Canada
| | - Ashok Malla
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada.,Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, QC, Canada
| | - Martin Lepage
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada.,Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, QC, Canada
| | - Ridha Joober
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada.,Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, QC, Canada
| | - Patricia Boksa
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada
| | - Jai L Shah
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montréal, QC, Canada. .,Prevention and Early Intervention Program for Psychosis, Douglas Mental Health University Institute, Montréal, QC, Canada.
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Stanghellini G, Aragona M, Gilardi L, Ritunnano R. The person’s position-taking in the shaping of schizophrenic phenomena. PHILOSOPHICAL PSYCHOLOGY 2022. [DOI: 10.1080/09515089.2022.2144192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Giovanni Stanghellini
- Department of Health Sciences, University of Florence, Florence, Italy
- “Diego Portales” University, Santiago, Chile
| | | | | | - Rosa Ritunnano
- Institute for Mental Health, University of Birmingham, Birmingham, UK
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10
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Subjective experience and meaning of delusions in psychosis: a systematic review and qualitative evidence synthesis. Lancet Psychiatry 2022; 9:458-476. [PMID: 35523211 DOI: 10.1016/s2215-0366(22)00104-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/07/2022] [Accepted: 03/16/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delusions are a common transdiagnostic feature of psychotic disorders, and their treatment remains suboptimal. Despite the pressing need to better understand the nature, meaning, and course of these symptoms, research into the lived experience of delusional phenomena in psychosis is scarce. Thus, we aimed to explore the lived experience and subjective apprehension of delusions in help-seeking individuals with psychosis, regardless of diagnosis and thematic content of the delusion. METHODS In our systematic review and qualitative evidence synthesis, we searched MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science for qualitative studies published in English from database inception, with the last search on Sept 9, 2021. Grey literature search and hand-searching of relevant journals were also done. Studies were eligible if they provided an analysis of lived experience of delusions or predelusional phenomena presented from the perspective of individuals (age 14-65 years) who had developed a clinical high-risk stage of psychosis, or a diagnosable affective or non-affective psychotic disorder (as clinically defined, self-reported, or assessed within the primary study). Studies with only a subset of relevant participants were eligible only if data for the population of interest were reported separately. Studies that did not discriminate between the experience of delusion and other positive symptoms (eg, hallucinations) were included only if data for delusions were reported separately or could be extracted. First-person accounts (and author interpretations) discussing changes in the sense of self, lived world, and meaning in relation to delusions were extracted and synthesised using a novel thematic synthesis approach informed by a critical realist stance and a phenomenological theoretical framework. Analytic themes were developed into a new overarching framework for understanding the emergence of delusional phenomena. The study was registered with PROSPERO, CRD42020222104. FINDINGS Of the 3265 records screened, 2115 were identified after duplicate removal. Of these, 1982 were excluded after title and abstract screening and 106 after full-text eligibility assessment. Of the 27 studies entering quality assessment, 24 eligible studies were included in the qualitative evidence synthesis, representing the perspectives of 373 help-seeking individuals with lived experience of delusions in the context of psychosis. Gender was reported as male (n=210), female (n=110), transgender (n=1), or not reported (n=52). Only 13 studies reported ethnicity, with White being predominant. The age of most participants ranged from 15 to 65 years. We found no eligible studies investigating subclinical or predelusional experiences in at-risk mental state populations through qualitative methods. Most studies were undertaken in western, educated, industrialised, rich, and democratic (WEIRD) societies, and most included participants had received or self-reported a diagnosis within the schizophrenia spectrum. Studies differed in relation to whether they focused on one kind or theme of delusion or delusional phenomena more generally as a unified category. Three superordinate themes relating to experiential changes and meanings in delusion were identified: (1) a radical rearrangement of the lived world dominated by intense emotions; (2) doubting, losing, and finding oneself again within delusional realities; and (3) searching for meaning, belonging, and coherence beyond mere dysfunction. Based on the review findings and thematic synthesis, we propose the Emergence Model of Delusion to advance understanding of delusional phenomena in psychosis. INTERPRETATION Delusions are best understood as strongly individualised and inherently complex phenomena emerging from a dynamic interplay between interdependent subpersonal, personal, interpersonal, and sociocultural processes. Integrative approaches to research on delusion, which consider their potential adaptiveness and favour explanatory pluralism, might be advantageous. Effective clinical care for individuals with psychosis might need adapting to match more closely, and take account of, the subjective experience and meaning of delusions as they are lived through, which might also help redress power imbalances and enduring epistemic injustices in mental health. FUNDING Priestley Scholars, Wellcome Trust.
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Fusar‐Poli P, Estradé A, Stanghellini G, Venables J, Onwumere J, Messas G, Gilardi L, Nelson B, Patel V, Bonoldi I, Aragona M, Cabrera A, Rico J, Hoque A, Otaiku J, Hunter N, Tamelini MG, Maschião LF, Puchivailo MC, Piedade VL, Kéri P, Kpodo L, Sunkel C, Bao J, Shiers D, Kuipers E, Arango C, Maj M. The lived experience of psychosis: a bottom-up review co-written by experts by experience and academics. World Psychiatry 2022; 21:168-188. [PMID: 35524616 PMCID: PMC9077608 DOI: 10.1002/wps.20959] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Psychosis is the most ineffable experience of mental disorder. We provide here the first co-written bottom-up review of the lived experience of psychosis, whereby experts by experience primarily selected the subjective themes, that were subsequently enriched by phenomenologically-informed perspectives. First-person accounts within and outside the medical field were screened and discussed in collaborative workshops involving numerous individuals with lived experience of psychosis as well as family members and carers, representing a global network of organizations. The material was complemented by semantic analyses and shared across all collaborators in a cloud-based system. The early phases of psychosis (i.e., premorbid and prodromal stages) were found to be characterized by core existential themes including loss of common sense, perplexity and lack of immersion in the world with compromised vital contact with reality, heightened salience and a feeling that something important is about to happen, perturbation of the sense of self, and need to hide the tumultuous inner experiences. The first episode stage was found to be denoted by some transitory relief associated with the onset of delusions, intense self-referentiality and permeated self-world boundaries, tumultuous internal noise, and dissolution of the sense of self with social withdrawal. Core lived experiences of the later stages (i.e., relapsing and chronic) involved grieving personal losses, feeling split, and struggling to accept the constant inner chaos, the new self, the diagnosis and an uncertain future. The experience of receiving psychiatric treatments, such as inpatient and outpatient care, social interventions, psychological treatments and medications, included both positive and negative aspects, and was determined by the hope of achieving recovery, understood as an enduring journey of reconstructing the sense of personhood and re-establishing the lost bonds with others towards meaningful goals. These findings can inform clinical practice, research and education. Psychosis is one of the most painful and upsetting existential experiences, so dizzyingly alien to our usual patterns of life and so unspeakably enigmatic and human.
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Affiliation(s)
- Paolo Fusar‐Poli
- Early Psychosis: Interventions and Clinical‐detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK,OASIS serviceSouth London and Maudsley NHS Foundation TrustLondonUK,Department of Brain and Behavioral SciencesUniversity of PaviaPaviaItaly,National Institute for Health Research, Maudsley Biomedical Research CentreSouth London and MaudsleyLondonUK
| | - Andrés Estradé
- Early Psychosis: Interventions and Clinical‐detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
| | - Giovanni Stanghellini
- Department of Psychological, Territorial and Health Sciences“G. d'Annunzio” UniversityChietiItaly,Center for Studies on Phenomenology and Psychiatry, Medical Faculty“D. Portales” UniversitySantiagoChile
| | - Jemma Venables
- Early Psychosis: Interventions and Clinical‐detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK,South London and Maudsley NHS Foundation TrustLondonUK
| | - Juliana Onwumere
- National Institute for Health Research, Maudsley Biomedical Research CentreSouth London and MaudsleyLondonUK,Department of Psychology, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK,Bethlem Royal HospitalSouth London and Maudsley NHS Foundation TrustBeckenhamUK
| | - Guilherme Messas
- Mental Health DepartmentSanta Casa de São Paulo School of Medical SciencesSão PauloBrazil
| | | | - Barnaby Nelson
- OrygenParkvilleVICAustralia,Centre for Youth Mental HealthUniversity of MelbourneMelbourneVICAustralia
| | - Vikram Patel
- Department of Global Health and Social MedicineHarvard Medical SchoolBostonMAUSA,Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMAUSA
| | - Ilaria Bonoldi
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
| | | | - Ana Cabrera
- Asociación Española de Apoyo en PsicosisMadridSpain
| | - Joseba Rico
- Asociación Española de Apoyo en PsicosisMadridSpain
| | - Arif Hoque
- Young Person's Mental Health Advisory Group (YPMHAG)King's College LondonLondonUK
| | - Jummy Otaiku
- Young Person's Mental Health Advisory Group (YPMHAG)King's College LondonLondonUK
| | - Nicholas Hunter
- NHS South London and Maudsley (SLaM) Recovery CollegeLondonUK
| | | | - Luca F. Maschião
- Mental Health DepartmentSanta Casa de São Paulo School of Medical SciencesSão PauloBrazil
| | - Mariana Cardoso Puchivailo
- Mental Health DepartmentSanta Casa de São Paulo School of Medical SciencesSão PauloBrazil,Department of PsychologyFAE University CenterCuritibaBrazil
| | - Valter L. Piedade
- Mental Health DepartmentSanta Casa de São Paulo School of Medical SciencesSão PauloBrazil
| | - Péter Kéri
- Global Alliance of Mental Illness Advocacy Networks‐Europe (GAMIAN‐Europe)BrusselsBelgium
| | - Lily Kpodo
- South London and Maudsley NHS Foundation TrustLondonUK
| | | | - Jianan Bao
- OASIS serviceSouth London and Maudsley NHS Foundation TrustLondonUK,Department of Forensic and Neurodevelopment Sciences, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
| | - David Shiers
- Psychosis Research UnitGreater Manchester Mental Health TrustManchesterUK,Division of Psychology and Mental HealthUniversity of ManchesterManchesterUK,School of MedicineKeele UniversityStaffordshireUK
| | - Elizabeth Kuipers
- National Institute for Health Research, Maudsley Biomedical Research CentreSouth London and MaudsleyLondonUK,Department of Psychology, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK,Bethlem Royal HospitalSouth London and Maudsley NHS Foundation TrustBeckenhamUK
| | - Celso Arango
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental HealthHospital General Universitario Gregorio Marañón School of Medicine, IiSGM, CIBERSAM, Complutense University of MadridMadridSpain
| | - Mario Maj
- Department of PsychiatryUniversity of Campania “L. Vanvitelli”NaplesItaly
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