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‘TRAUMA, DISSOCIATION AND PSYCHOSIS’ Kristiansand May 30- June 1, 2017

‘TRAUMA, DISSOCIATION AND PSYCHOSIS’ Kristiansand May 30- June 1, 2017. The social causes of psychosis: From heresy to certainty Professor John Read john@uel.ac.uk. The social causes of psychosis. AGENDA Some history and terminology Public’s causal beliefs, and stigma

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‘TRAUMA, DISSOCIATION AND PSYCHOSIS’ Kristiansand May 30- June 1, 2017

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  1. ‘TRAUMA, DISSOCIATION AND PSYCHOSIS’Kristiansand May 30- June 1, 2017 The social causes of psychosis: From heresy to certainty Professor John Read john@uel.ac.uk

  2. The social causes of psychosis AGENDA • Some history and terminology • Public’s causal beliefs, and stigma • The evidence-base: the social causes of mental health problems • Implications • Clinical • Primary prevention

  3. www.isps.org20th INTERNATIONAL CONGRESS Liverpool, August 2017www.isps2017uk.org Hearing Voices Networkwww.intervoiceonline.org

  4. Emil Kraepelin(1856-1926)how to ignore the social context

  5. Kraepelin and Bleuler Kraepelin (1913): the causes ‘are at the present time still wrapped in impenetrable darkness’ Bleuler (1911): ‘The pathology of schizophrenia gives us no indication as to where we should look for the causes of the disease’ …. ‘to be discovered later’ !

  6. DSM5 diagnostic criteria for ‘schizophrenia’ Two of: • Hallucinations • Delusions • Thought Disorder • Catatonia • Negative symptoms A DYSJUNCTIVE CATEGORY Scientifically meaningless

  7. Public believe mental health problems, including psychosis, are caused primarily by adverse life events, in……. South Africa China Egypt Turkey Fiji Japan Malaysia Switzerland Ethiopia Greece Bali Brazil England Ireland Germany India Australia Italy Mongolia Russia New Zealand

  8. Service users’ causal beliefs In an international study 297 of 306 ‘typical schizophrenics’ (97%) did not believe they had an illness. Dismissed as ‘lack of insight’, a ‘symptom’ of ‘schizophrenia’(Murray & Dean 2008: 285). Now called ‘Anosognosia’: “Damage to the prefrontal and parietal areas together make anosognosia especially likely. Anosognosia, or lack of awareness of illness, thus has an anatomical basis and is caused by damage to the brain by the disease process” http://www.treatmentadvocacycenter.org/about-us/our-reports-and-studies/2143

  9. UK psychiatrists’ causal beliefs • 2813 UK psychiatrists (Kingdon et al, 2004) ‘primarily social’ 0.4% ‘primarily biological’ 46.1% ‘a balance of both’ 53.5% For every British psychiatrist who thinks ‘schizophrenia’ is caused primarily by social factors there are 115 who think it is caused primarily by biological factors

  10. Relationship between bio-genetic causal beliefs and negative attitudes(Read et al. in Models of Madness 2 – 2013) • In 28 of 31 studies (90%)bio-genetic causal beliefs are related to negative attitudes. • In 24 of 26 studies (92%)psycho-social beliefs are related to positive attitudes.

  11. The evidence-base: the social causes of mental health problems

  12. No single cause of psychosisAs for other mental health problems - causes, usually in combination, include: • Genetic predisposition ?? • Brain differences (can be caused by environment) • Maternal prenatal health and stress • Birth complications • Rape and physical assault • War trauma • Heavy early cannabis use • Urban living • Ethnicity (poverty, isolation and racism) • Child abuse • Poverty • Child neglect • Early parental loss • Bullying

  13. No evidence of genetic predisposition(Hamilton, 2008, American Journal of Psychiatry) • ‘The most comprehensive genetic association study of genes previously reported to contribute to the susceptibility to schizophrenia’ found that ‘none of the polymorphisms were associated with the schizophrenia phenotype at a reasonable threshold for statistical significance’ • ‘The distribution of test statistics suggests nothing outside of what would be expected by chance’

  14. ‘Time to abandon the bio-bio-bio model of psychosis: Exploring the epigenetic and psychological mechanisms by which adverse life events lead to psychotic symptoms’JOHN READ, RICHARD BENTALL, ROAR FOSSEEpidemiologia e Psichiatria Sociale, 2009 “The failure to find robust evidence of a genetic predisposition for psychosis can be understood in terms of recently developed knowledge about how epigenetic processes turn gene transcription on and off through mechanisms that are highly influenced by the individual’s socio-environmental experiences. The implications, for research, mental health services and primary prevention, are profound.”

  15. Poverty • 30 years ago the relationship between ‘schizophrenia’ and poverty described as ‘one of the most consistent findings in the field of psychiatric epidemiology’ (Eaton, 1980). • Deprived children are four times more likely to develop ‘non-schizophrenic psychotic illness’ but eight times more likely to grow-up to be ‘schizophrenic’ (Harrison, Gunnell, Glazebrook, Page, & Kwiecinski, 2001). Even among children with no family history of psychosis the deprived children were seven times more likely to develop ‘schizophrenia’,

  16. Relative povertyWilkinson & Pickett ‘The Spirit Level’ (2009)

  17. Users of mental health services who were abused as children: • higher severity of disturbance • earlier first admissions • longer and more frequent hospitalisations, • longer in seclusion • more medication (and less likely to be helped by medication) • more likely to self-mutilate • more likely to kill themselves

  18. Prevalence of child abuse in psychiatric inpatients ‘Models of Madness’ chapter 16 Average child abuse rates from review of 40 inpatient studies • Female inpatients: Sexual abuse: 50% Physical abuse: 48% Either sexual or physical: 69% • Male inpatients: Sexual abuse: 28% Physical abuse: 51% Either sexual or physical: 60%

  19. Other types of childhood maltreatment Averages from six studies of people diagnosed ‘schizophrenic’ Emotional Abuse ….. 47% Emotional Neglect … 51% Physical Neglect …… 41% (Read et al., 2008, Clinical Schizophrenia)

  20. Parental loss 390 people with a first episode of psychosis, compared to a control group 2.4 times more likely to have been separated from one or both parents before age 16 12.3 times more likely to have had their mother die (Morgan et al., 2007)

  21. Shevlin et al. 2007 Schizophrenia BulletinUK, n = 8580 People who had experienced three types of trauma (sexual abuse, physical abuse etc.) were 18 times more likely to be psychotic than non-abused people People who had experienced five types of trauma were 193 times more likely to be psychotic

  22. ‘Child Maltreatment and Psychosis: A Return to a Genuinely Integrated Bio-Psycho-Social Model’J Read, et al., 2008, Clinical Schizophrenia • Ten out of eleven recent generalpopulation studies found, after controlling for other factors (including family history of psychosis), that child maltreatment is significantly related to psychosis. • Eight of these studies tested for, and found, a dose-response. • This paper advocates a return to the original stress-vulnerability model proposed by Zubin and Spring in 1977, in which heightened vulnerability to stress is not necessarily genetically inherited, but can be acquired via adverse life events.

  23. Meta-analysis of childhood adversity and psychosis studies VARESE F, SMEETS F, DRUKKER M, LIEVERSE R, LATASTER T, VIECHTBAUER W, READ J, VAN OS J, BENTALL R. Schizophrenia Bulletin (2012) • Analysed the most rigorous 41 studies …. • People who had suffered childhood adversity were 2.8 times more likely to develop psychosis than those who had not (p < .001 level). • Nine of the ten studies that tested for a dose-response found it.

  24. Meta-analysis of childhood adversity and psychosis studies

  25. Meta-analysis of childhood adversity and psychosis studies odds ratios for each type of adversity: number of studies • sexual abuse 2.4 20 • physical abuse 2.9 13 • emotional abuse 3.4 6 • neglect 2.9 7 • bullying 2.4 6 • parental death 1.7 8

  26. Theories about HOW child abuse/neglect leads to psychosis • COGNITIVE(R. Bentall, A. Morrison) • PSYCHODYNAMIC(B. Karon, A. Silver, H. Sullivan) • DISSOCIATION(A. Moskowitz, C. Ross, E. Longden) • ATTACHMENT(A. Gumley, K. Berry) chapters 16-18 Models of Madness • TRAUMAGENIC NEURODEVELOPMENTAL MODEL (J. Read, R. Fosse)

  27. What causes brain differences?

  28. The TraumagenicNeurodevlopmental Model

  29. Evidence that schizophrenia is a brain disease • Overactivity of hypothalamic-pituitary-adrenal (HPA) axis • Abnormalities in neurotransmitter systems (especially dopamine) • Hippocampal damage • Cerebral atrophy • Reversed Cerebral Asymmetry

  30. Effects of childhood trauma on the developing brain • Overactivity of hypothalamic-pituitary-adrenal (HPA) axis • Abnormalities in neurotransmitter systems (especially dopamine) • Hippocampal damage • Cerebral atrophy • Reversed Cerebral Asymmetry

  31. ‘The traumagenic neurodevelopmental model of psychosis revisited’ READ, J., FOSSE, R., MOSKOWITZ, A., PERRY, B. (2014). Neuropsychiatry, 4, 65-79. ‘125 studies have provided indirect support for, or direct confirmation of, the model since 2001’

  32. UK’s most prominent psychiatrist-researcher changes his mind “In the last 2 decades, it has become obvious that child abuse, urbanization, migration, and adverse life events con-tribute to the etiology of schizophrenia and other psychoses. This has been a big shift for me! My preconceptions had made me blind to the influence of the social environment.” Professor Robin Murray – Institute of Psychiatry Murray, R. M., (2016). Mistakes I have made in my research career. Schizophrenia Bulletin. doi:10.1093/schbul/sbw165

  33. Implications • Political/primary prevention • Clinical

  34. Implications for primary prevention The 2012 psychosis meta-analysis calculated that the ‘estimated population attributable risk’ was 33%. So if the six childhood adversities reviewed were eliminated the number of people with psychosis would be reduced by a third! (Varese, Smeets et al. 2012).

  35. Implications for treatment • Give people an opportunity to talk about their understanding of their problems • Drugs are not enough • Be guided by ethical principle of informed choice of treatment modality • NICE Guidelines (UK – 2009): Medical and psychological treatments equally important for psychosis

  36. Cochrane review of Risperidone(Rattehalli, Jayaram, & Smith, 2010). • “Risperidone appears to have a marginal benefit in terms of clinical improvement compared with placebo in the first few weeks of treatment but the margin may not be clinically meaningful. • Global effects suggests that there is no clear difference between risperidone and placebo • Risperidone causes many adverse effects and, these effects are important and common. • People with schizophrenia or their advocates may want to lobby regulatory authorities to insist on better studies being available before wide release of a compound with the subsequent beguiling advertising.”

  37. Drug company influence • Research Funding • Scientific journals • Educational/training institutes • Training for doctors • Drug licensing bodies • Lobbying governments • More recently, the internet…..

  38. The pharmaceutical industry and the internet(Read, J. 2008, Social Science & Medicine) • The top 50 ‘schizophrenia’ websites • 58% of the websites received funding from drug companies. • Drug company funded websites were significantly more likely to….. • espouse bio-genetic rather than psycho-social causal explanations, • emphasise medication rather than psycho-social treatments, • portray ‘schizophrenia’ as a ‘debilitating’, ‘devastating’ and ‘long-term illness’

  39. Dr Steven Sharfstein President, American Psychiatric Association (2005)“If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility as a profession is compromised. As we address these Big Pharma issues, we must examine the fact that as a profession, we have allowed the bio-psycho-social model to become the bio-bio-bio model”

  40. Professor Mike ShooterPresident of the Royal College of Psychiatrists (UK) - 2005 “I cannot be the only person to be sickened by the sight of parties of psychiatrists standing at the airport desk with so many gifts with them that they might as well have the name of the drug company tattooed across their foreheads”

  41. Are mental health services asking about child abuse/neglect? • Very few studies ! • Ireland 2015 (Rossiter et al.) ActualIn File Sexual abuse 25% 8% (25%) Physical abuse 28% 20%(71%) Emotional abuse 40% 24% (60%) Physical neglect 48% 5% (10%) Emotional neglect 62% 13% (21%)

  42. Focus of assessment with ANY client, including those experiencing psychosis ‘WHAT’S TROUBLlNG YOU?’ ‘WHAT DO YOU THINK MIGHT HAVE CAUSED THAT?’ ‘WHAT DO YOU NEED?

  43. Service Users’ views about asking about trauma: Survey of NZ service users.Lothian J, Read J (2002) “There was an assumption that I had a mental illness and because I wasn’t saying anything about my abuse nobody knew” “There was so many doctors and nurses and social workers in your life asking you about the same thing, mental, mental, mental, but not asking you why” “I just wish they would have said ‘What happened to you?’ ‘What happened ?’ But they didn’t.”

  44. www.isps.org20th INTERNATIONAL CONGRESS Liverpool -- August 2017www.isps2017uk.org Hearing Voices Networkwww.intervoiceonline.org

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