Making Sense of Paranoia

Making Sense of ParanoiaMaking Sense of Paranoia

Dr Alison BrabbanDr Alison Brabban

October 2012October 2012

A Traditional View of DelusionsA Traditional View of Delusions

““Empty speech acts, whose informational content Empty speech acts, whose informational content refers to neither world or self. They are not refers to neither world or self. They are not symbolic expressions of anythingsymbolic expressions of anything””

Berrios (1991)Berrios (1991)

““Un-understandable: not reflecting a personUn-understandable: not reflecting a person’’s s personality or experiencespersonality or experiences””

JaspersJaspers

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Moving away from the Moving away from the dichotomy to a truly bio-dichotomy to a truly bio-psychosocial model of psychosocial model of

psychosis.psychosis.

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PadeskyPadesky’’s 5 Aspects Models 5 Aspects Model (1986)(1986)

ENVIRONMENT

THOUGHTS

BIOLOGY MOOD / FEELINGS

BEHAVIOUR

FormulationsFormulations

Provide explanations of why the problems Provide explanations of why the problems have arisen and what is keeping them going.have arisen and what is keeping them going.

Are specific to the individual.Are specific to the individual. Bridge the gap between theory and practice.Bridge the gap between theory and practice. ““HypothesesHypotheses”” which are modifiable. which are modifiable. Determine treatment approaches.Determine treatment approaches. Predict problems that will arise.Predict problems that will arise. Can be understood at different levels.Can be understood at different levels.

“Patients come to psychotherapy because they are demoralized by the

menacing meanings of their symptoms. The psychotherapist collaborates with the patient in

formulating a plausible story that makes the meanings of the

symptoms more benign and provides procedures for combating them, thereby enabling the patient to

regain his morale”

(Frank, 1986)

A Basic FormulationA Basic Formulation

The Stress-Vulnerability ModelThe Stress-Vulnerability Model

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The Stress-Vulnerability ModelThe Stress-Vulnerability Model(Zubin and Spring, 1977)(Zubin and Spring, 1977)

Vulnerability

StressNo Psychosis

Psychosis

The Stress-Vulnerability ModelThe Stress-Vulnerability Model

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Trauma and PsychosisTrauma and Psychosis

WhatWhat’’s the evidence?s the evidence?

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Bebbington et al (2004)Bebbington et al (2004)N = 8000 General PopulationN = 8000 General Population

Those with psychotic symptoms Those with psychotic symptoms 3 times more likely to have been sexually abused 3 times more likely to have been sexually abused

than those with other mental health problems.than those with other mental health problems. 15 times more likely to have been sexually abused 15 times more likely to have been sexually abused

than those with no disorderthan those with no disorder

Other experiences reported:Other experiences reported: BullyingBullying Violence in HomeViolence in Home Run away from homeRun away from home Placed in care as a childPlaced in care as a child

Read, Goodman, Morrison, Ross and Aderhold (2005) Read, Goodman, Morrison, Ross and Aderhold (2005) Childhood trauma and the symptoms of schizophrenia.Childhood trauma and the symptoms of schizophrenia.

Females: 36 studies from 1984-2001; total sample =2318 Males: 23 studies from 1987-2001; total sample =1234

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53

61

20

50 49

69

36

0

10

20

30

40

50

60

70

80

CSA CPA EITHER BOTH

Pro

po

rtio

n e

xp

eri

en

ce

d

Type of abuse

Males

Females

Dutch general population (n = 4045) free from Dutch general population (n = 4045) free from psychotic symptoms, followed for 3 yearspsychotic symptoms, followed for 3 years

(Janssen et al., 2004) (Janssen et al., 2004)

Controlled for: age, sex, education, discrimination, ethnicity, urbanicity, unemployment, marital status, other mental health problems, psychosis in relatives, drug use.:

Those abused as children 9 times more likely to develop ‘pathology level psychosis’

Those suffering most severe level of abuse 48 times more likely to develop psychosis

Shevlin et al. 2008 (Schz. Bulletin)Shevlin et al. 2008 (Schz. Bulletin)N = 8580N = 8580

People who had experienced three types of People who had experienced three types of trauma trauma (sexual abuse, bullying, violence in home etc.) (sexual abuse, bullying, violence in home etc.) were were 18 times more likely to be psychotic than 18 times more likely to be psychotic than non-abused people.non-abused people.

People who had experienced five types of People who had experienced five types of trauma were 193 times more likely to be trauma were 193 times more likely to be psychotic.psychotic.

Early Adversity & PsychosisEarly Adversity & Psychosis

11 General Population Studies have found 11 General Population Studies have found a link between child maltreatment and a link between child maltreatment and psychosis.psychosis.

8 of these looked for and found a dose 8 of these looked for and found a dose response: the more severe the trauma or response: the more severe the trauma or the higher number of traumatic experiences the higher number of traumatic experiences the greater risk of developing psychosis.the greater risk of developing psychosis.

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Varese et al (2012) Meta-AnalysisVarese et al (2012) Meta-Analysis

36 studies included (epidemiological, 36 studies included (epidemiological, prospective, and patient controlled studies).prospective, and patient controlled studies).

Total N = 79,397Total N = 79,397 3 times more likely to have been exposed to 3 times more likely to have been exposed to

childhoodchildhood adversity. adversity. If no childhood trauma existed – 33% of current If no childhood trauma existed – 33% of current

psychotic population would not be psychotic. psychotic population would not be psychotic. (160,000 in UK)(160,000 in UK)

9/10 data sets that looked for a dose effect 9/10 data sets that looked for a dose effect found one.found one.

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Similarities found in brains of severely abused Similarities found in brains of severely abused children and adults with a diagnosis of children and adults with a diagnosis of

schizophreniaschizophrenia

• Overactivity of hypothalamic-pituitary-Overactivity of hypothalamic-pituitary-adrenal (HPA) axis adrenal (HPA) axis

• Abnormalities in neurotransmitter systems Abnormalities in neurotransmitter systems (especially dopamine)(especially dopamine)

• Hippocampal damageHippocampal damage• Cerebral atrophyCerebral atrophy• Reversed Cerebral AsymmetryReversed Cerebral Asymmetry

Issues for AssessmentIssues for Assessment• Need to take a full life history: lifeline.Need to take a full life history: lifeline.

• Ask about bullying.Ask about bullying.

• Ask whether person has experienced any unwanted Ask whether person has experienced any unwanted sexual experiences that made him/her uncomfortable.sexual experiences that made him/her uncomfortable.

• Has person been physically punished or attacked in a Has person been physically punished or attacked in a way that left cuts or bruises?way that left cuts or bruises?

• What were the triggers to onset of psychosis?What were the triggers to onset of psychosis?

• Consider intolerable emotions rather than trauma per Consider intolerable emotions rather than trauma per sese

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““There were so many doctors and There were so many doctors and nurses and social workers in your life nurses and social workers in your life

asking you about the same thing, asking you about the same thing, mental, mental, mental, but not mental, mental, mental, but not

asking you why?asking you why?””

There was an assumption that I There was an assumption that I had a had a ‘‘mental illnessmental illness’’. .

Because I wasn Because I wasn’’t saying t saying anything about my abuse no one anything about my abuse no one

knew.knew.

(Lothian & Read, 2002)(Lothian & Read, 2002)

I just wished they would have I just wished they would have said What happened to you?, said What happened to you?, what happened? …But they what happened? …But they

didndidn’’t.t.

(Lothian & Read, 2002)(Lothian & Read, 2002)

Formulating DelusionsFormulating Delusions

A Cognitive FormulationA Cognitive Formulation

Common Perceptions About Common Perceptions About DelusionsDelusions

Associated with deficits in reasoning.Associated with deficits in reasoning.

They are not amenable to reason.They are not amenable to reason.

They are held with absolute conviction.They are held with absolute conviction.

These beliefs are qualitatively different to These beliefs are qualitatively different to non-delusional beliefs.non-delusional beliefs.

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Belief AcquisitionBelief Acquisition

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Events in the WorldEvents in the World

Perception 

PerceptionInferenceInference BeliefBelief

Search for New InformationSearch for New Information

Internal Anomalous ExperiencesInternal Anomalous Experiences

HallucinationsHallucinations

Feelings of significanceFeelings of significance

Heightened emotional experiencesHeightened emotional experiences

Heightened perceptual experiencesHeightened perceptual experiences

(Free floating dissociated elements?)(Free floating dissociated elements?)

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There are two jars: A mainly orange jar containing 85 There are two jars: A mainly orange jar containing 85 orange and 15 black beads and a mainly black jar containing orange and 15 black beads and a mainly black jar containing

85 black and 15 orange beads85 black and 15 orange beads

Mainly Black Jar(85 black; 15 orange)

Mainly Orange Jar(85 orange; 15 black)

The bead drawn is:

BEADS PREVIOUSLY SEEN

Would you like to see anymore beads or have you decided now?

BEADS PREVIOUSLY SEEN

Would you like to see anymore beads or have you decided now?

The bead drawn is:

BEADS PREVIOUSLY SEEN

Would you like to see anymore beads or have you decided now?

The bead drawn is:

BEADS PREVIOUSLY SEEN

Would you like to see anymore beads or have you decided now?

The bead drawn is:

BEADS PREVIOUSLY SEEN

Would you like to see anymore beads or have you decided now?

The bead drawn is:

BEADS PREVIOUSLY SEEN

Would you like to see anymore beads or have you decided now?

The bead drawn is:

Mean number of beads viewed before making Mean number of beads viewed before making a decision a decision (Dudley et al., 1997a) n= 15 per group(Dudley et al., 1997a) n= 15 per group

0

1

2

3

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5

6

7

8

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85:15 ratio 60:40 ratio

DelusionsDepressionControls

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Cognitive Biases in Patients with Cognitive Biases in Patients with DelusionsDelusions

• Use less information and more likely to jump to Use less information and more likely to jump to conclusionsconclusions

• More likely to look for confirmatory dataMore likely to look for confirmatory data

• Less likely to have alternative beliefs available.Less likely to have alternative beliefs available.

• Have more victimisation experiences so Have more victimisation experiences so personperson’’s view of self & world tends to be biased.s view of self & world tends to be biased.

• Attributional Biases: External, personal for Attributional Biases: External, personal for negative events (defensive?).negative events (defensive?).

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The Cognitive ModelThe Cognitive Model

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EventEventEventEvent THOUGHTTHOUGHTTHOUGHTTHOUGHT FeelingsFeelingsFeelingsFeelings

BehaviourBehaviourBehaviourBehaviour

PhysiologyPhysiologyPhysiologyPhysiology

Cognitive Model of DelusionsCognitive Model of Delusions

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A B C

ActivatingEvent:

Anomalous Anomalous ExperienceExperience

Belief

DelusionDelusion

Consequences:AffectBehaviourPhysiology

FormulationFormulation

Early Events

Schema (Core Beliefs)

Conditional Schema/Beliefs

Activating Event

Thoughts, Feelings, Behaviour

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Normalising ParanoiaNormalising Paranoia

Paranoia is an adaptive responseParanoia is an adaptive response ‘‘Better safe than sorryBetter safe than sorry’’ Makes sense and Makes sense and ‘‘not your faultnot your fault’’ An adaptive response that has become An adaptive response that has become

potentially maladaptivepotentially maladaptive Threat sensitivity/hypervigilance leads to Threat sensitivity/hypervigilance leads to

increased awareness of potential threats.increased awareness of potential threats.

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Dissociation and Anomalous Dissociation and Anomalous ExperiencesExperiences

Are hallucinatory experiences Are hallucinatory experiences disconnected flash-backs?disconnected flash-backs?

Dissociated Affect can be triggered by Dissociated Affect can be triggered by reminders of past traumas.reminders of past traumas.

Delusional mood as a learnt, classically Delusional mood as a learnt, classically conditioned response (i.e. Pavlov)?conditioned response (i.e. Pavlov)?

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Priming and our Priming and our PerceptionsPerceptions

Is hearing believing?Is hearing believing?

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For further Information:For further Information:

abrabban@btopenworld.comabrabban@btopenworld.com