• Auditory hallucinations
1. Voices heard arguing or giving instructions [2nd person]2. Voices heard commenting on one’s actions [running commentary, usually describing the patient in the 3rd person]• Somatic/thought passivity experiences [delusions of control / of being controlled]• Thought echo [thoughts being heard aloud]• Thought withdrawal• Thought insertion [thoughts are ascribed to other people who are intruding into the patient’s mind]• Thought broadcasting [also called thought diffusion]• Delusional perception [linking a normal sensory perception to a bizarre conclusion, e.g. seeing an aeroplane means the patient is the president]
The delusion often involves their being influenced by a ‘diabolical machine’, just outside the technical understanding of the victim, that influences them from afar. It was typically believed to be operated by a group of people who were persecuting the individual, whom Tausk suggested were "to the best of my knowledge, almost exclusively of the male sex" and the persecutors, "predominantly physicians by whom the patient has been treated".
But there’s something about psychosis that’s intrinsically fascinating, at least to me. I read all those books and many others, and once I got my head above water, I mused some about the questions Sandra raised. I say "some" because the cases that made it to Grady weren’t subtle – they were psychotic with a capital "P". But later, in the clinics and mental health centers where I followed people who came of their own accord not under extreme duress, I struggled with those same questions. I must add that it was a very different time – actually a better time in my view. It was a time when psychiatrists, psychologists, social workers, nurses, etc. were judged [to borrow a metaphor] not by the color of their degree, but by the quality of their skill in helping our patients. And the model was biopsychosocial. The divisions of labor and the strictly biomedical role of the psychiatrist wasn’t so much a part of things. About that time, I took on a patient I’ve described here [1. from n equals one…, 2. from n equals one…, 3. from n equals one…]. I’ve seen psychotic patients throughout my career, but this is the patient I followed from right after residency until I retired, and a lot of what I think is based on that case. I make no apology for that. Not many people have that kind of opportunity.
She became adept at identifying things that "triggered" her discomfort. She had numerous flirtations with psychosis. So for a time, we met erratically – when she felt "it" happening. Her way of describing the danger signal was "special meanings." She meant that when she felt like something happening was a communication meant uniquely for her. Those things always went back to either emotional ambiguity or confusing abstract meanings – always.
But back to the homogeneity of Schizophrenia. Although the cases that fit Bleuler’s classical description of Schizophrenia feel like a unitary syndrome to me, one my patient fit to a tee, I take Dr. Steingard’s point. It’s what I "think" or "feel", not what I "know", and those cases are only a subset of patients labeled Schizophrenic. I find her observations in her practice intriguing. Is the psychosis we’ve called Schizophrenia or some sub-set of it biological? I think probably so, but again, it’s a "think" or a "feel", not a "know". So point made and taken. But there’s one thing I do know for sure. Psychosis is not an "antipsychotic deficiency." While I never did think that, I have appreciated Robert Whitaker’s perspective on the light use of medication for acute symptoms and then backing off. That’s what I actually did with the case I’m talking about as best I could. I never could get her totally medication free for long. If I were seeing her now, I would’ve tried maintenance anxiolytics rather than a low dose neuroleptic. My intuition is that would’ve worked. I just didn’t know that then. I’d much rather that we had worried about dependency than dyskinesia.
Parenthetically, there’s something that hasn’t gotten its fair share of press. Drs. Taylor and Fink have successfully peeled Catatonia out of the Schizophrenia spectrum in the DSM-5 and described its treatment in detail. While it’s a rare syndrome and only a piece of the puzzle, theirs is a fine accomplishment. Something else to throw into the parentheses, historian Ned Shorter has a blog post up on the very topic of the non-unity of Schizophrenia in Psychology Today – Breaking Up “Schizophrenia”: Following science will soon lead to other ways of describing chronic psychosis. And finally about those antipsychotics, even Dr. Clinical Neuroscience, NIMH Director Tom Insel, made a stab at listening to the music recently [Director’s Blog: Antipsychotics: Taking the Long View, NIMH Director Rethinks Standard Psychiatric Treatment for Schizophrenia].
Thanks again for this interesting and enriching experience.
Insel’s recognition of the heterogeneity of schizophrenia and the RA1SE project is very good news—- Each model integrates medication, psychosocial therapies, family involvement, rehabilitation services, and supported employment, all aimed at promoting symptom reduction and improving life functioning.
Also good news, the project was bolstered by funds from the American Recovery and Reinvestment Act of 2009. The Affordable Care Act focuses on evidence-based care and could be a prime motivator for better research and better assessments of research, which Insel’s blog also addresses with a project called DORA (Declaration on Research Assessment).
The Journal Impact Factor is frequently used as the primary parameter with which to compare the scientific output of individuals and institutions. The Journal Impact Factor, as calculated by Thomson Reuters, was originally created as a tool to help librarians identify journals to purchase, not as a measure of the scientific quality of research in an article. With that in mind, it is critical to understand that the Journal Impact Factor has a number of well-documented deficiencies as a tool for research assessment.
http://am.ascb.org/dora/
Around 2010 I read an article in Harper’s magazine about exploration of prodromal symptoms of people who had been diagnosed with schizophrenia; which, at the time, meant that they had already had a psychotic episode. The article describes pretty much what Dr. Nardo describes with his patient here. I thought it looked very promising.
But, when I began to see “prodromal” extended to people who had not yet had a psychotic episode, I felt like the usefulness of the term and the purpose of it was ruined. Perhaps the direction that Insel and RA1SE is taking will nip the drive to arrest psychosis in people who have not yet experienced it in the bud. It’s not like there aren’t enough people who are and have been psychotic to focus their attention on.
Wiley-
There have been many initiaves aimed towards early intervention for people with psychosis. Some have targted those who do not yet meet the critieria for psychosis. Others like RAISE (I am a part of that study), work with people who do meet criteria for at least Schizophreniform Disorder. This was part of the controversy with the new DSM. There were those who wanted to include a new category of High risk psychosis or attentuated psychosis (there are a couple of different terms used). There were those who thought this might encourage and broaden the use of neuroleptics. Patrick McGorry who is one of the leading researchers in this area has backed away from promoting the early use of neuroleptics. He wrote the editorial that accompanied the Wunderink study which is the study that Insel is talking about when he states that perhaps not everyone should be on these drugs long term.
Here is a link to a blog I wrote about this:
http://www.madinamerica.com/2013/10/wunderink-matters/
Wunderink is a very important study.
After reading your article here, I did a search with trauma AND psychosis AND dissociation. On the first page of results there were four that I had already read in my search for more information about studies about trauma related psychosis and a category— PTSD. Combat veterans and immigrants who had been tortured in their country of origin were the subjects of the studies. In one of the articles I hadn’t read, one was a book review of Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology.
There is a joke in the abstract that I would love to have explained to me, but it clearly does represent an academic vanity that exists in every field, but one that is the lion’s share of psychiatric hypotheses as dogma.
It is intriguing to read the stories of many of the leading names of that time and how certain individuals, despite their valuable contributions towards understanding psychosis, were less influential. One such example is Pierre Janet, who published notable work on hallucinations and delusions. Carl Jung, on his return to Vienna after visiting Janet in Paris, commented that Janet only had a ‘primitive’ knowledge of schizophrenia. In reaction to this, Freud commented to Jung, ‘You can imagine that I would have been very sorry if your Vienna complex had been obliged to share the available cathexis with a Paris complex.’
I don’t get it, but it appears to be an example of how in academia personalities play too much a part in what is accepted and what is promoted.
PTSD-P