Tag: Psychosis

1:20 – On the prototypical case of schizophrenia. 

One interesting point about schizophrenia is that it can be difficult to date its onset. Although onset of flamboyant psychotic symptoms and diagnosis with schizophrenia typically occurs somewhere around the early 20s, and there is often a prior history of contact with psychological/psychiatric services and differences in behaviour and the person’s experience that occur well before diagnosis. These differences and difficulties are related to being a subject in the world. For example, even as a, say 11 or 13 year old, the person would often feel profoundly different and cut-off from others, even if they don’t display conspicuous behavioural differences. Interestingly people with schizophrenia may find it difficult to verbalise in what sense they are profoundly and fundamentally different. This feeling of a lack of naturalness in and attunement to the world is reflected in the person being perceived as peculiar or eccentric, and sometimes leads to a interest in metaphysical or philosophical issues. 

The onset of psychosis itself, is linked to an increasing sense of self-alienation. For example, the patient starts to experience their thoughts as being ‘at a distance from themselves’ and eventually as not belonging to themselves. This may lead to a sense of revelation that they are in contact with another dimension of reality that is not accessible to other people (and such a sense is often experienced by those with schizotypal traits without psychosis). Other schizophrenic symptoms such as the sense of have thoughts inserted into their head, and of one’s thoughts/actions being controlled (ie. passivity phenomena) is also related to this increasing sense of self-alienation. Delusions are also related to the growing sense of self-alienation, and are often developed while the person realises that something is happening, but doesn’t understand what is happening. 

For most patients, schizophrenia is a fluctuating condition (with or without medication). Only a minority of people deteriorate into a chronic debilitated state.  

26:15 – On psychosis and it’s relationship to schizophrenia

Psychosis is nearly impossible to define satisfactorily. People may have the auditory hallucinations characteristic of psychosis, but should not be considered psychotic if they recognise them as such and are able to function in the world. Only when such private experiences are taken to be the objective, shared world and are then acted upon is there a clear case of psychosis. And indeed, many people who are discharged as non-psychotic will continue to have unusual experiences but are able to separate their own experiences from those of the socially shared reality. 

32:10 – On psychosis in schizophrenia vs. psychosis in other conditions. 

The experience of psychosis itself is similar between its occurrence in schizophrenia and in other conditions. However, you might say that before psychosis, the experience of the person with schizophrenia is closer to the psychotic state than that of non-schizophrenic people. 

38:00 – What catalyses psychotic episodes?

Drug abuse can precipitate schizophrenia, but often there are questions about the direction of causality. Self-medication through dug abuse is common amongst people with schizophrenia. Additionally trauma, emotional deprivation (as was more common in the foster homes of past generations) or the loss of another person on whom the person is in some way dependent, is often a catalyst. 

44:30 – Is psychosis itself adaptive?

I asked this question after coming across this paper: https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00237/full

In contrast, Josef doesn’t consider there to be any real adaptiveness to psychosis itself. 

49:00 – On the marked difference in quality of life outcomes between different cultures.

Research almost 30 years ago by the WHO suggested that people in less developed countries had a better prognosis than people in more developed countries. However, such studies are extremely complicated. But the social environment is certainly important for life outcomes for those with schizophrenia. People with schizophrenia will do better in more tolerant social environment than a rigid and hostile one. So we could expect a more productivity-focused social environment to lead to worse outcomes for people with schizophrenia. 

55:00 – On the link between Autism and Schizophrenia

Josef does not think there is a link between the two conditions. This is not surprising given Josef’s emphasis on anomalous self-experiences – a recent paper has pointed to very different self-experiences in ASD and schizophrenia (https://academic.oup.com/schizophreniabulletin/article/46/1/121/5485220). He is also sceptical about the dramatic increase in prevalence of ASD in recent years, mentioning the work of Ian Hacking (for example, https://www.lrb.co.uk/the-paper/v28/n16/ian-hacking/making-up-people)

0:00 – On Josef’s background.

Josef was trained as a medical doctor at the University of Copenhagen, and then completed his internship at a hospital running important studies that showed that schizophrenia has an important genetic basis. He has worked simultaneously in clinical and research capacities throughout his career.

He arrived at his interest in phenomenology because of his interest in psychopathology. The phenomenological perspective was the most mature account of psychopathology, and was very much mainstream until DSM-3.

3:25 – Josef’s overview of what we know about schizophrenia.

Thinks that schizophrenia is not well represented by the current medical model, which emphasises chronic psychotic symptoms, such as hallucinations and delusions. This is likely due to the desire of recent DSM efforts for reliability of diagnoses. The core features of the schizophrenia spectrum, which include distortion of subjective life and disorders or expressivity, are relatively neglected perhaps because they tend to require clinical experience to reliably identify.

Schizophrenia is more than just the chronic condition identified by the DSM. One piece of evidence that suggests schizophrenia is a spectrum rather than just the severe diagnosable condition is that only a minority of patients with diagnosable schizophrenia experience a deteriorating chronic course, many experience a remitting course and a significant proportion (20-25%) of those that would qualify for a diagnosis are never treated or seek medical help at all. Then there are milder parts of the spectrum that wouldn’t qualify for a schizophrenia diagnosis, which again, do not typically seek psychiatric help. Also, there are links between vulnerability to schizophrenia and creativity.

10:30 – Contrasting the core of schizophrenia from the symptoms.

There is something qualitative about the symptoms of schizophrenia. A schizophrenic delusion or hallucination is easily distinguished by the experienced clinician from the delusions or hallucinations symptomatic of other conditions. Josef considers the nature of these symptoms to be reflective of differences in the subjective experience, which he considers the core of schizophrenia colouring the manifest symptoms. Said differently, it is not the case that the symptoms in schizophrenia are not simply occurring to a person that otherwise experiences life as a neurotypical person does. The differences occur right down to a fundamental level of the person’s subjective experience, and these differences pre-date and may give rise to the more obvious clinical symptoms.

Josef tells a story of a client of his that was surprised to learn that most people experience thoughts as their own, as opposed to existing in some sort or collective space as experienced by the client.

Therefore, to understand schizophrenia, we need to be thinking in terms that are pervasive and fundamental, rather than modular.

21:45 – On the compatibility of predictive Bayesian computation accounts and phenomenological accounts of schizophrenia.

Intuitively, Josef is attracted to such accounts.

26:10 – Are schizotypal traits adaptive?

People with schizotypal traits often don’t share the naturalness with which neurotypical people relate to the world. And if you don’t take the obvious for granted, this may facilitate a curiousity about the world and lead to greater creativity. And indeed, there is a documented link between schizophrenia (and relatives of those with schizophrenia) and creativity.

Here is a link to the study Josef mentioned on the prevalence of schizophrenia in the relatives of university scientists.

Robert Sapolsky’s lecture on schizophrenia: https://www.robertsapolskyrocks.com/schizophrenia.html

Josef’s translation of Hans Gruhle’s 1929 work, ‘The schizophrenic basic mood (self-disorder)’.

33:25 – On the disorder of self in schizophrenia.

Josef thinks that the disorders of self-experience in schizophrenia, are coming to be increasingly recognised. In fact, disorders of self-experience will be mentioned in the new ICD-11.

35:45 – On the scale that Josef published to measure anomalous self experiences: the Examination of Anomalous Self Experience.

The above link contains not only the measure itself, but also courses on the measure. There is also a self-report version, recently published the Inventory of Psychotic-Like Anomalous Self-Experiences.

36:50 – Does Josef find the research on meditation or psychedelics interesting, given his interest in alterations of self-experience?

Josef published a paper on the relation of mystical states and schizophrenia, but doesn’t follow the meditation or psychedelics fields closely.

38:20 – Why Josef is not hopeful that dimensional classification systems for psychopathology?

Clinicians say that they only need ~25 diagnostic categories, not the ~400 in DSM-5. The reliance on well defined diagnostic criteria (in the DSM and ICD) and the discarding of phenotypic/prototypic descriptions, has resulted in an unending proliferation of diagnoses. Josef is also sceptical that a dimensional approach will be adopted by clinicians – “clinicians like categories”.

Instead, Josef thinks the best solution might be to have different classification systems depending on the context/purpose.

50:15 – Alternatives for students or researcher who do not have the option of gaining direct experience with schizophrenic populations.

Josef recommends a number of books to gain insight into the phenomenology of schizophrenia, including;

Madness & Modernism by Louis Sass

The Center Cannot Hold by Elyn Saks

The Psychiatric Interview for Differential Diagnosis

52:00 – On what historical European psychiatry has to offer contemporary psychiatry.

All European psychiatry was somewhat phenomenological until the domination of psychiatry by American research, following DSM-3. But there has been a recent revival of phenomenology. For example, Oxford University Press has recently published The Oxford Handbook of Phenomenological Psychopathology and Cambridge University Press has recently published The Maudsley Reader in Phenomenological Psychiatry.