The British Psychological Society recently produced a document entitled #UnderstandingPsychosis, which outlined views on definitions, aetiology, treatment and suggestions for improving services for people with psychosis and schizophrenia.
The first edition of this report was covered in a Mental Elf blog in 2014 (Understanding Psychosis and Schizophrenia: a critique by Laws, Langford and Huda), which focused on the sections on medication, CBT and the medical model (Understanding Psychosis and Schizophrenia, 2014).
In this blog we focus on revised sections, pertaining to definitions, aetiology and treatment (Cooke, 2017).
This is a narrative review, with evidence cited.
The report has been co-authored by a group of 25 people, which includes service users with lived experience of psychotic experiences, as well as influential senior psychologists. [Above paragraph added: 6/11/17].
Psychosis is defined by hearing voices, paranoia, differences in thinking, problems concentrating and difficulty completing activities (they eschew the term “negative symptoms”).
Causes are limited to social deprivation (inequality) and life events (racism, discrimination and childhood trauma).
The authors state:
Experiencing multiple childhood traumas appears to give approximately the same risk of developing psychosis as smoking does for developing lung cancer.
They cite a study where items on a screening questionnaire correlated with recall of adverse events, with an odds ratio of 11 (Bentall et al., 2012).
They state half of people who experience psychosis will experience problems only once, and recover completely, quoting a review which cites 9 studies.
There is a section on treatment, including psychosocial interventions and medication, and concluding chapters covering implementation and thoughts regarding service provision.
The main conclusions drawn are that conventional concepts of psychosis are flawed, with inadequate provision of psychological therapies for people with what is termed “psychosis”, services needing to change.
Strengths and limitations
This document aims to cover a wide remit, which is laudable.
It involves people who feel their needs are not addressed by conventional services. It emphasises choice and collaborative decision-making. It highlights what, a number of years ago, psychiatrists may have ignored regarding social environment, aetiology and outcome of psychosis. (The need to align with biology may have been a reaction to previous dominance of psychoanalysis). Aspects of the section on medication regarding collaboration and use of high dose antipsychotics are conventional.
In defining psychosis widely, it becomes difficult to comment on current practice. The authors state the prevalence of hearing voices is 10%, a recent WHO study finding this nearer 5% (McGrath et al., 2015), the authors acknowledge that what is picked up on screening questionnaires for psychotic experiences do not readily overlap with what a diagnostic interview for schizophrenia picks up (Kendler et al., 1996; Ochoa et al., 2008). In other words, they are defining a population of people with “psychosis” who do not meet conventional criteria, and appear to have over-estimated the prevalence.
The authors ignore symptoms conventionally viewed as psychotic symptoms, including bizarre delusions (Cermolacce, Sass and Parnas, 2010), flattened affect, movement disorder (seen before the advent of antipsychotics), thought disorder (which linguists have linked to speech problems seen in Neurology (McKenna and Oh, 2005)), ipseity disturbance (breakdown of ego boundaries and passivity) and cognitive impairment, which can be seen before illness onset. Symptoms given weight in the document, auditory hallucinations and suspiciousness are seen in 11.6% and 25.2% of people with diagnosed schizophrenia respectively, two years after acute exacerbation (and about 50% in acute illness), which would hardly make them pathognomonic of diagnosed schizophrenia (WHO, 1979). Murray and van Os have made the astute observation that: “the boundaries between normal mentation, common mental disorder and schizophrenia become blurred, if positive psychotic symptoms are used as a distinguisher” (van Os and Murray, 2013).
Crucially, symptoms omitted are seen in people with the highest level of impairment, who would fulfil criteria for treatment-resistant psychotic illness; the people for whom secondary services were originally set up for. One of the paradoxes in modern mental health services, is that there is under-allocation of resource to those suffering from the most disabling psychiatric syndromes, such as negative syndrome schizophrenia, and a shift of resource to the detection and probable over-treatment of relatively mild psychological issues (de Leon, 2014).
Criticism is made of the reliability of diagnoses, though the literature cited does not present peer-reviewed scientific literature.
There is no mention of bipolar psychosis, which has differences in aetiology, natural history and treatment response to non-affective psychoses. It also has a high degree of reliability (Tolin et al., 2016) . By ignoring this, and lumping “psychosis” together, they ignore the increased relapse rate in this, as well as greater number of hospitalisations (Chang et al., 2016).
The authors are apparently describing people not seen by mental health services; a point they acknowledge.
It is therefore unclear how they can comment on care provided to people within current services; a different population to what they define.
The review stating 50% of people have recovery at follow-up is not a systematic review. A more recent systematic review suggested that only 13% of people with a diagnosis of schizophrenia met the criteria for recovery (Jääskeläinen et al., 2013). Long-term follow-up of people presenting with first episode psychosis show significant heterogeneity in symptomatic and functional outcome: a multi-centre UK first-episode study showing, in geographically defined populations, that 50% were in symptomatic remission at 10 years (a number of whom were taking antipsychotics), though only 15% fulfilled criteria for functional recovery (Revier et al., 2015).
The authors ignore aetiological factors, including head injury, cannabis, and psychoses caused by general medical conditions, e.g. epilepsy, and autoimmune conditions. Missing an organic cause of psychosis constitutes a serious clinical error. The evidence for discrimination is based on a preliminary report, and findings of delusional-like ideas in 7 people, with perceived discrimination, using the CIDI, which has poor psychometric properties compared to diagnostic interview (Jauhar and Lawrie, 2011).
It is mathematically impossible to explain how the factors they give could contribute to the prevalence they mention; the odds ratio for childhood trauma is between 2-4 in most meta-analyses (Morgan and Gayer‐Anderson, 2016) (with methodological limitations). The odds ratio for smoking and lung cancer varies depending on smoking status and cell type, anywhere up to around 100 (Pesch et al., 2012) and evidence they put for a similar association is based on items from a screening questionnaire that measures phenomena that are not related to what people conventionally call psychosis. Even then, the odds ratio of 11 does not sit well with odds given for current smokers and lung cancer.
Put simply, not everyone who experiences psychosis (however defined) has these risk factors, and not everyone who has these risk factors develops psychosis.
In the section on psychological therapies they state:
On average, people gain around as much benefit from CBT as they do from taking psychiatric medication.
The authors cite various meta-analyses, but the effect sizes given are not comparable to those for psychotropic medication, especially when considering effects of blinding, even taking into account criticisms regarding included studies (Jauhar et al., 2014), see below.
No comment is made on relapse, the best-conducted study showing no benefit (Garety et al., 2008), which contrasts to evidence for antipsychotics (see below).
The section on medication has factual errors.
They state meta-analyses: “suggested that many people experience only slight benefits and only about 20 percent experience a significant improvement or prevention of reoccurrence”. The citation was not available, though the paper we assume they are referring to has caveats to this proclamation, and the article also reports reasonable effect sizes for functioning and quality of life (Leucht et al., 2017). This refers primarily to people with longer-term illness with acute exacerbation, as opposed to first-episode illness. In reference to the statement above, the effect size is still more than twice that for CBT for overall symptoms in blinded trials, and five times that for positive symptoms (Jauhar et al., 2014).
Regarding the 20% figure regarding relapse, meta-analysis by the same authors indicating 27% versus 64% of people had a relapse at one year after medication discontinuation, a relative risk of 0.4 (Leucht et al., 2012).
The authors are selective in quoting two observational studies which suggest improved outcome where medication was either stopped naturalistically (Harrow and Jobe, 2013) or decreased (Wunderink et al., 2013), whilst ignoring in this context an observational study showing poorer outcome in never treated people with schizophrenia followed up after 14 years (Ran et al., 2015), and a national register study showing longer life expectancy for people with schizophrenia taking antipsychotics (Tiihonen et al., 2009). They do not mention in citing the Wunderink study that at 18 months relapse rates were doubled in the discontinuation group, and only 20% of people actually discontinued medication at 18 months (Wunderink et al., 2007). Furthermore, in the study they cite, people in the discontinuation group were still taking an efficacious, albeit lower dose of antipsychotic than the other group (Wunderink et al., 2013).
Implications for practice
This document gives theoretical views on what constitutes psychosis and what a group of influential senior psychologists and service users who have had psychotic experiences think would be helpful for people who experience the phenomena they define. The principles for care of people with psychosis emphasise collaborative and informed decision-making. [Above paragraph edited: 6/11/17].
However, given the definitions used, selective citing of evidence regarding aetiology and treatment, it is unclear how (or why) this guidance should be implemented within current services. It ignores a significant number of people currently seen in secondary services, and by selectively citing literature that corroborates their views, and making errors throughout, it is difficult to know how the conclusions drawn are justified, on the basis of evidence.
Conflicts of interest
Cooke A. (Editor) (2017) Understanding Psychosis and Schizophrenia: Why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality, and what can help: Revised version (PDF). A report by the British Psychological Society Division of Clinical Psychology.
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