According to Hollywood stereotypes, there are the clever, nerdy young people who spend most of their time sitting around thinking and reading, and then there are the jocks – the sporty, athletic lot who prefer to do as little thinking and studying as possible. This seems like a gross over-simplification and yet a new study in the Journal of Health Psychology suggests there may be a kernel of truth to it. Continue reading “Are brainy people lazy? “Need For Cognition” correlates with less physical activity”
The message from recent surveys is that it’s not just people with a diagnosis of schizophrenia who hear voices in their heads, many people considered mentally well do to. This revelation may have a welcome de-stigmatising effect in terms of how people think about some of the symptoms associated with a diagnosis of schizophrenia, but a new study published in Psychosis asks us to hang on a minute – to say that one “hears voices” can mean different things to different people. You might assume that “hears voices” means that a person has an hallucinated auditory experience just like someone is talking to them. But what about hearing an inner voice that is experienced like an out-of-control thought rather than an external voice? Or a heard voice that’s not like either a thought or an external voice? Continue reading “A lot of “Voice Hearing” isn’t an auditory experience at all”
The label “schizophrenic” is loaded with connotations. For many, its utterance provokes thoughts of madness, of violence and oddity. No wonder that clinical psychologist Lorna Howe and her colleagues found the people they interviewed – all diagnosed with the illness – had strived to avoid the label.
In all, the researchers conducted in-depth interviews lasting up to 90 minutes with seven participants diagnosed with schizophrenia. There were three men, four women (average age 44), and they’d been diagnosed between 6 and 17 years previously. They were currently under the care of an NHS community mental health team in England.
Howe’s team transcribed the interviews and looked for interconnecting themes in the participants’ testimonies – a process known as interpretative phenomenological analysis. The overall picture was of a dilemma, in which the participants needed the diagnosis to access treatment, but had feared and avoided it because of its stigma. “I was too scared to tell the doctors what my real symptoms were so they could treat me,” said Carol.
Once they’d received a diagnosis of schizophrenia, the participants described how they attempted to hide it from other people. They mentioned the media’s role in propagating the violence-schizophrenia link, and the way that mental health professionals used alternative terms, such as psychosis, as if they were conscious of the stigma associated with the s-word. “People are always afraid of saying that word to me,” said Carol. “… because it is a dirty word.”
The participants also spoke of the lack of understanding about schizophrenia, and the chasm between the perspectives of their clinicians who tended to see it as a biological illness (a “chemical imbalance”) and the perspectives of other people in their lives. “My mother … all she said was ‘I told you, it’s because you’re psychic …,” said Janet. The biological emphasis from professionals was seen as limiting hope for recovery, and the researchers said this encouraged “individuals to become passive recipients of care.”
Another theme was managing stigma. Janet said she avoids telling people about her diagnosis – “nobody likes rejection, so I just don’t put myself in that position”. Most of the participants saw themselves as “normal” despite their diagnosis. “… to have people treat me like that, you want to say, ‘Look, I’m not that bad’,” said Ben.
The final theme from the interviews was “accepting diagnosis” – the participants described how the label had given them access to treatment and an understanding of their problems. “It was like a relief in a way that at least they knew now what I already knew, that I’d got this schizophrenia,” said David. There was one exception – Janet said she accepts that she has mental health problems, but she rejects the idea that she has schizophrenia.
Howe and her colleagues pointed to some useful lessons from their interviews. Untreated schizophrenia is associated with poorer outcomes, so the results suggest more needs to be done to overcome delays in treatment caused by ill people’s fearful avoidance of a diagnosis. Clinicians’ evasion of the term schizophrenia, and their focus on biological models, may spread confusion and undermine hope. “Professionals may need to take the lead and break their ‘conspiracy of silence’ surrounding schizophrenia to allow the public and those with a diagnosis to follow,” said Howe and her colleagues.
Howe, L., Tickle, A., & Brown, I. (2014). ‘Schizophrenia is a dirty word’: service users’ experiences of receiving a diagnosis of schizophrenia. Psychiatric Bulletin, 38 (4), 154-158 DOI: 10.1192/pb.bp.113.045179 [open access]
The August issue of Psychiatric Bulletin is a themed issue on stigma in mental health
When a patient with schizophrenia hears voices in their head, is the experience shaped by the culture they live in? Tanya Luhrmann and her colleagues investigated by interviewing twenty people diagnosed with schizophrenia living in San Mateo, California; twenty in Accra, Ghana; and twenty others in Chennai India. There were similarities across cultures, including descriptions of good and bad voices, but also striking differences.
In San Mateo the interviewees talked about their condition as a brain disease, they used psychiatric diagnostic terms to describe themselves, and their experiences were almost overwhelmingly negative. Fourteen described hearing voices that told them to hurt others or themselves. Eight people didn’t know the identity of their voices and few described having a personal relationship with their voices.
By contrast, in Chennai, the interviewees frequently spoke of their relationships with their voices – that is, they heard the voices of relatives or friends, giving them advice or scolding them. These patients rarely used diagnostic terms, and rarely talked of voices instructing them to commit violence. Instead, distress, when it occurred, usually arose from their voices talking about sex. Nine interviewees described voices that were significantly good – in terms of being playful or entertaining.
In Accra, yet another picture emerged. Most of the interviewees here mentioned hearing God. This isn’t simply a case of this sample being more religious – the interview groups in all three locations were predominantly religious. Half the interviewees in Accra reported that their voice hearing was mostly or entirely positive. Others frequently emphasised the positive. Use of diagnostic labels was rare, as were incitements to violence by voices.
Luhrmann and her team said their most striking finding was that the experiences of voice hearing in the two non-Western samples were less harsh and more “relational” – that is, patients perceived their voices as other people, who could not be controlled. The researchers believe this difference is likely due to Western cultures emphasising independence and individuality – in which case heard voices are experienced as a violation – whereas African and Asian cultures emphasise how each person’s mind is interwoven with others. “We believe that these social expectations about minds and persons may shape the voice-hearing experience of those with serious psychotic disorder,” the researchers said.
These results need to be replicated with larger samples matched more precisely for illness severity, and with more tightly controlled measures (the current study was deliberately qualitative and exploratory). If replicated, the findings would imply the experience of hearing voices in schizophrenia is to some extent malleable, which could have exciting therapeutic implications. Indeed, it’s notable that the outcomes for patients with schizophrenia outside the West, especially in India, are known to be more positive – perhaps because of the way patients relate to their voices. “The harsh violent voices so common in the West may not be an inevitable feature of schizophrenia,” the researchers said.
Luhrmann, T., Padmavati, R., Tharoor, H., & Osei, A. (2014). Differences in voice-hearing experiences of people with psychosis in the USA, India and Ghana: interview-based study The British Journal of Psychiatry DOI: 10.1192/bjp.bp.113.139048
Traditionally, when a person says they can hear voices that don’t exist in external reality (not to be confused with inner speaking), psychiatry has treated this as a sign of mental illness. However, it’s become clear in recent years that many people hear hallucinated voices without it causing them distress. To improve our understanding of how voice-hearing becomes problematic it’s clear we need to understand more about the different ways that people experience hearing voices.
Now Lucy Holt and Anna Tickle have published a “meta-ethnographic synthesis” of what we know so far about the varieties of people’s voice-hearing experiences. The researchers trawled the peer-reviewed literature using key-word searches to find studies of adequate quality that involved asking adults to describe their voice-hearing experiences first-hand. This process uncovered seven papers, published between 2003 and 2011, involving the first-hand accounts of 139 people aged 19 to 84 (52 per cent were women).
Holt and Tickle analysed the papers looking for recurring themes in people’s descriptions of their voice-hearing. The results are fascinating and some insights potentially useful for clinicians. The first theme is that most people gave the voices they heard an identity – often they named them, or they attributed a gender to them. Some people heard voices that belonged to real people encountered in the past, other voices were seen as belonging to God or a spiritual force.
Another important theme was the amount of power that people perceived their heard voices as having, and, related to that, how much power they felt they had over them. There was a continuum such that some people felt completely powerless over their heard voices, while others felt they could take them over. Intriguingly this appeared to be related to the explanations people gave for their heard voices. Those who subscribed to a biomedical account, believing that their voices were caused by a chemical imbalance in the brain, tended to feel less in control of their voices. The perceived power of voices was also linked to the voices’ identity, particularly if they were attributed to an authoritarian figure.
People also spoke of the strategies that their voices used to maintain power, such as criticising the person and exploiting his or her weaknesses. Other participants described strategies they used to regain control of their voices, such as using distraction or, opposite to that, deliberately engaging with the voices.
The way that heard voices affected people’s relationships was another theme. People described how hearing voices made it difficult to lead an ordinary life. Heard voices could interfere with social relationships, for example by making critical comments about friends or family. But voices could also play a beneficial role by reducing loneliness. “I have not got many friends … so the only thing I can stay very close to are the voices and I do stay very close to them,” said one person.
Yet another theme related to whether people saw a distinction between their own thoughts and the voices they heard. Most people recognised a clear difference between the two, perceiving heard voices as “coming from outside the self but manifested inside the body”. One exception to this was a study conducted in a psychiatric setting. Here most of the participants endorsed a biomedical explanation for their voices, and they saw their heard voices and own thoughts as one.
Holt and Tickle said their review contained useful insights for therapists, most of all by showing that “‘voice hearing’ is clearly not a homogenous experience.” The findings also suggest ways that therapists might help their clients who hear voices, for example by boosting their feelings of self-worth. Therapists could also benefit by realising that heard voices sometimes have an adaptive function.
Unfortunately, the quality of the studies identified in this review was disappointing. Many failed to provide quotes from participants; others failed to acknowledge the influence of the researcher’s own interpretative stance on the results. “It is evident that the quality of research investigating the first person perspective of hearing voices warrants improvements,” Holt and Tickle said.
Holt L and Tickle A (2013). Exploring the experience of hearing voices from a first person perspective: A meta-ethnographic synthesis. Psychology and psychotherapy PMID: 24227763
The same voices, heard differently?
A new approach to help those who hear voices
Hearing music that isn’t there
The science of how we talk to ourselves in our heads
A Community of One: Social Cognition and Auditory Verbal Hallucinations
Unusual, psychotic-like symptoms, such as hearing voices, are not as rare among the general population as you might think. For example, it’s estimated that ten per cent of us hear voices that aren’t there, with only a small minority of hearers likely to ever receive a clinical diagnosis. According to a new study, this means that the factors that cause psychotic-like symptoms are likely different from those that lead to a diagnosis of pathological psychosis. Charles Heriot-Maitland and his colleagues argue that this distinction has been missed by the majority of past studies that hunted the causes of psychosis by focusing only on patients, neglecting those who live happily with their psychotic-like experiences.
To make a start rectifying this situation, Heriot-Maitland’s team interviewed six patients with psychosis (recruited via psychosis teams in SE England) and six “healthy” non-patients, who reported similar unusual experiences (recruited via UK networks involved with spiritual or psychic phenomena). Across both groups, these experiences included: receiving visions from God, hearing voices, and feeling that their body had been taken over. Based on their symptoms alone, you couldn’t tell which group a participant belonged to – clinical or non-clinical. The researchers asked all the participants open-ended questions about the circumstances that led to the onset of their unusual experiences, how they felt about them, and how their friends, relatives and other people had responded.
Using a qualitative method called Interpretative Phenomenological Analysis, the researchers looked for emerging themes in the participants’ answers. Both similarities and differences emerged. In both groups, their unusual psychotic experiences had started after a period of negative emotion, most often accompanied by feelings of isolation and deep contemplation about the meaning of life. However, the groups differed in how they responded to and perceived their odd experiences. Members of the non-clinical group had been more aware of non-medical interpretations of their symptoms; they viewed them as transient and desirable; and people close to them shared this non-pathologising perspective. By contrast, the patients encountered invalidating, medical interpretations of their experiences and were themselves less able to accept their experiences and to incorporate them into their personal and social worlds.
From a theoretical point of view, Heriot-Maitland and his colleagues said there was a need for a more precise approach to the study of psychosis, which distinguishes risk factors for psychotic experiences from risk factors for actual clinical vulnerability. “It would seem that the more out-of-the-ordinary experiences are associated with clinical psychosis, the less chance people have of recognising their desirability, transiency, and psychological benefits, and the more chance they have of detrimental clinical consequences.”
The researchers added that this has important clinical implications: “psychotic experiences should be normalised,” they said, “and people with psychosis should be helped to re-connect the meaning of their out-of-the-ordinary experiences with the genuine emotional and existential concerns that preceded them.” They also acknowledged that more studies, including quantitative investigations, are needed to build on this initial work.
Heriot-Maitland, C., Knight, M., and Peters, E. (2011). A qualitative comparison of psychotic-like phenomena in clinical and non-clinical populations. British Journal of Clinical Psychology DOI: 10.1111/j.2044-8260.2011.02011.x
Further reading: The British Psychological Society’s response to the planned changes to the DSM – psychiatry’s diagnostic code. In its response the BPS airs its concerns about the over-medicalisation of people’s experiences.
Traditionally, psychiatrists saw the paranoia exhibited by patients with schizophrenia as qualitatively different from the feelings of mistrust and suspicion expressed by ‘healthy’ people. Today that view is changing. New research, much of it by psychologists, is demonstrating that clinical paranoia is on a continuum with the experiences of the general public (see earlier). Much of this has involved use of questionnaires or interviews to gauge rates of paranoid feeling in non-clinical samples. Better than this, though, would be observing people’s actual paranoid interpretations unfolding in response to real events. Catherine Green and her team think they’ve found a way.
The researchers had 58 healthy participants sit in a room with a male experimenter and write about their journey to the lab that day (ostensibly as part of research into people’s ‘understanding of the causes of events’). Next, a male colleague knocked on the door and asked the experimenter if he could come outside for a moment. After the experimenter exited, the sound of male laughter was played for 35 seconds on speakers in the corridor.
What would you think if an experimenter left the room to talk to a colleague and then you heard laughter outside? Asked to explain these events, two of the participants thought the experimenter’s departure had something to do with them; five of them thought the laughter was about them; and two participants thought both events were somehow connected to themselves. ‘They laughed at something they read in my questionnaires,’ one participant said. In all, 15.5 per cent of the healthy sample showed evidence of mild paranoia – what’s known as ‘an idea of reference’ in which they misattributed self-relevance to the events. None of the participants showed more severe persecutory paranoia, and in fact 28 participants failed to notice the laughter.
‘The current study illustrates that paranoid explanations for events can be elicited and assessed in a real life situation,’ Green and her colleagues said. Questionnaires completed before and after the main part of the study showed that those participants who came up with more paranoid explanations also tended to score higher on ‘trait’ paranoia. However, they scored no higher on a measure of social avoidance and distress, which suggests their paranoid explanations were not merely a consequence of social anxiety. They did however score higher on interpersonal sensitivity and negative self-regard.
‘The current data suggest that some of the processes considered central to clinical paranoia … may also be operating at the milder end of the spectrum,’ the researchers concluded, ‘but the data raise questions as to what processes might be responsible for transition across the spectrum from ideas of reference to persecutory ideation.’
Green CE, Freeman D, Kuipers E, Bebbington P, Fowler D, Dunn G, and Garety PA (2011). Paranoid explanations of experience: a novel experimental study. Behavioural and cognitive psychotherapy, 39 (1), 21-34 PMID: 20846468
Further reading: Is paranoia increasing? Free Psychologist magazine article.
It’s the hallucinations and delusions associated with schizophrenia that typically attract discussion and research. However, patients with a diagnosis of schizophrenia also exhibit deficits in memory and perception and, importantly, the severity of these is predictive of quality of life, social functioning and autonomy. How can these cognitive deficits be helped? Researchers have found some success with computer-based training but patient motivation can be problem. Now a team of researchers led by Hiroko Mochizuki-Kawai at the delightfully named National Institute of Floricultural Science in Japan have tested out the benefits of floral arranging. ‘The use of natural materials may reduce tension and anxiety’ they predicted.
Ten patients (six men) with a diagnosis of schizophrenia or schizoaffective disorder agreed to undertake four one-hour sessions of flower arranging, supported by staff, over two weeks. The arranging involved following simple written instructions, holding them in memory one at a time, and placing flowers and leaves into the correct slots in an absorbent sponge. Two patients failed to attend; average attendance for the remainder was 3.1 sessions.
Before the intervention, the flower arranging patients’ performance on the ‘block-tapping’ measure of non-verbal working memory was the same as that displayed by ten controls. After two weeks’ flower arranging, however, the flower patients’ performance had improved and was now superior to the controls. The block tapping task involves observing blocks being touched one at a time and then reproducing that same order from memory. On another test, which involved copying a complex figure from memory, the flower arranging patients were again no better than controls at the study outset but were superior to controls after the two weeks of training (although this was because the controls had deteriorated at the task rather than because the flower arrangers had improved).
This was only a pilot study and it has obvious short-comings including the small sample sizes, the lack of any comparison intervention for the control group, and no way of measuring the impact of cognitive gains on quality of life. However, the researchers were upbeat in their conclusion: ‘We believe that the findings of the present study may contribute to the improvement of cognitive rehabilitation in schizophrenic patients’.
Mochizuki-Kawai, H., Yamakawa, Y., Mochizuki, S., Anzai, S., & Arai, M. (2010). Structured floral arrangement programme for improving visuospatial working memory in schizophrenia. Neuropsychological Rehabilitation, 20 (4), 624-636 DOI: 10.1080/09602011003715141
People don’t need to be treated as a stereotype for harm to occur; their mere belief that they could be viewed in a stereotyped fashion is enough – a phenomenon known as ‘stereotype threat’. For example, women reminded of the stereotype that men are better at maths tend to perform more poorly in a subsequent maths task, even if they are actually treated fairly. Now Julie Henry and colleagues have extended this line of research to the domain of mental health. They’ve found that patients with a schizophrenia diagnosis function less well socially, when they think that the person they’re chatting with knows their diagnosis.
Thirty people diagnosed with schizophrenia or schizoaffective disorder spent a few minutes chatting on their own to one research assistant and then they did the same with another assistant an hour later. There were a few points of deception: first, the participants were led to believe that the assistants were participants from another study. Also, most importantly, before one of the conversations began, they were told that the assistant knew about their diagnosis of schizophrenia; before the other, they were told the assistant did not know. They were also told, truthfully, that both the people they were to chat with did not themselves have a diagnosis of schizophrenia.
In reality, the research assistants didn’t know whether each participant had a diagnosis of schizophrenia or not. This was achieved by having them chat to the participants diagnosed with schizophrenia plus a number of control participants. Crucially, they weren’t told in advance who was who.
After each conversation, the research assistants rated the social behaviour of the person they’d just chatted with. The participants in turn rated the behaviour of the assistant they’d just chatted with and they said how they felt the conversation had gone.
The key finding is that the social functioning of the participants with schizophrenia seemed to deteriorate when they thought their conversational partner knew their diagnosis (even though they didn’t). Specifically, when they thought their diagnosis had been disclosed, the participants were rated by the research assistants as being more impaired at initiating conversations and at switching topics appropriately, and the assistants also found these conversations less comfortable.
Henry’s team can’t be sure, but they think these apparent deficits emerged because the participants’ concern about how they would be judged, in light of their diagnosis having been disclosed, interfered with their ability to converse in a more effective manner.
A further twist was that the participants with schizophrenia seemed unaware of these effects – they reported finding the conversations, in which they thought their diagnosis was known, just as comfortable and successful as when they thought their diagnosis had been kept hidden. This contrasts with non-clinical research on stereotype threat, in which people seem to be aware of the effects on their performance.
The results provide food for thought regarding when and how mental health diagnoses should be disclosed. The researchers said their findings suggest ‘that one of the defining qualities of [schizophrenia] – social skill impairment – is not caused solely by the disorder per se, but rather, also derives from feelings of being stereotyped.’
Henry, J., Hippel, C., & Shapiro, L. (2010). Stereotype threat contributes to social difficulties in people with schizophrenia. British Journal of Clinical Psychology, 49 (1), 31-41 DOI: 10.1348/014466509X421963
There’s no doubt the discovery of anti-psychotic drugs was a breakthrough. Previously people with schizophrenia could expect hospital confinement and little in the way of actual treatment. Today’s anti-psychotics are safer than the early versions, but they still have serious side-effects and because their prescription for psychosis is so routine, there’s a danger that some people, who might otherwise recover with psychological help only, are taking them unnecessarily.
This is a difficult area to study because any research that denies patients the drugs they need will rightly raise alarm bells. John Bola and colleagues scoured the literature looking for studies where drug treatments for schizophrenia were delayed for a set period of time, in conditions where patients received plentiful psychological and social support. They found five such studies involving 261 participants with schizophrenia, many of whom were not given anti-psychotic medication immediately. Their outcomes were compared between one and three years’ later with patients who were treated with drugs straight away.
These studies included the Rappaport Agnews State Hospital Project (pdf), the Soteria project and Soteria Bern Project (pdf), the Finnish API Project and the Cullberg Parachute Project. Across all these studies, the psychosocial treatments varied, but in general patients were provided with a community-based therapeutic milieu with ample social support, a relaxing environment, and with family therapy often also included.
Among the patients for whom drug treatment was delayed, about one-third actually ended up recovering without needing to take medication at all, and longer-term, their outcomes tended to be superior to those patients who were treated with drugs immediately.
Bola’s team said these findings show that in a residential care context (where medication can be prescribed swiftly if needed) it is possible to research drug-free approaches to schizophrenia in a safe and ethical way. And they added that that the findings point to a sub-type of schizophrenia that is associated with spontaneous recovery, in contrast to the trend for deterioration shown by the majority of patients.
“The above cited studies at least highlight the fact that no disadvantages and several advantages have been noted with no or a low-dose anti-psychotic medication in combination with psychosocial interventions for first episode schizophrenia spectrum patients,” the researchers said.
Previously on the Research Digest: “Caring for psychotic patients with maximum kindness and minimum medication“.
JR Bola, K. Lehtinen, J Cullberg, L Ciompi (2009). Psychosocial treatment, antipsychotic postponement, and low-dose medication strategies in first-episode psychosis: A review of the literature. Psychosis, 1 (1), 4-18
Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.