PsychosisPsychosis- -

Integrating subjective Integrating subjective experiences, psychodynamic experiences, psychodynamic understandings and biological understandings and biological

knowledgeknowledge

Toronto, June 5 2008Toronto, June 5 2008

Johan Cullberg MD PhDJohan Cullberg MD PhD

Ersta Sköndal University College, Ersta Sköndal University College, StockholmStockholm

The ego’s ongoing The ego’s ongoing construction of the construction of the

world world

•Rapid changes between Rapid changes between

perceptions and interpretations perceptions and interpretations

•The ego constructs a ”Gestalt”The ego constructs a ”Gestalt”

•This dialectics is abolished in This dialectics is abolished in

dreaming and (partly) in psychosisdreaming and (partly) in psychosis

Psychosis:Psychosis:

•Failure in creating a correct ”Gestalt” of Failure in creating a correct ”Gestalt” of

the outer worldthe outer world

•Regressive creating of meaningRegressive creating of meaning

•Inner, private world is given priorityInner, private world is given priority

•Meaning is more important than Meaning is more important than

rationality rationality

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First Episode Psychosis - model

1st critical period

DUP Treatment

2nd critical period

Recovery

Relapse

Prodromal phase Psychosis phase Recovery phase

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Stages and subjective Stages and subjective experiences in psychosis:experiences in psychosis: 1:1: Prodromal phase - Prodromal phase - days or monthsdays or months

• Withdrawal tendencies – social, working Withdrawal tendencies – social, working

or study problemsor study problems

• Affective outburstsAffective outbursts

• Increased inner speedIncreased inner speed

• Premonition of mental break-downPremonition of mental break-down

• Compensatory strategiesCompensatory strategies

• Depression and panic attacsDepression and panic attacs

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2: PSYCHOSIS PHASE:2: PSYCHOSIS PHASE:(weeks - months)(weeks - months)

• ““Am I Am I inin the world or the world or am Iam I the world?” the world?”

• Regressive strategies to create meaning Regressive strategies to create meaning

• Hallucinations confirm delusional thinking Hallucinations confirm delusional thinking

• Thoughts and actions controlled by othersThoughts and actions controlled by others

• Resistance to relying in anyone/anything Resistance to relying in anyone/anything from outer world (care, medication, trust from outer world (care, medication, trust etc)etc)

• Omnipotence and deep lonelinessOmnipotence and deep loneliness

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3: Late psychotic phase:3: Late psychotic phase:

• Delusions more often questioned and less Delusions more often questioned and less maintainedmaintained

• ““Islands of normality” increasingly Islands of normality” increasingly frequentfrequent

• Depressive thoughts more prominent Depressive thoughts more prominent through reality confrontation through reality confrontation

• Tendency to seek protection in psychosisTendency to seek protection in psychosis

• Cooperation with therapist deepening – Cooperation with therapist deepening – who can be trusted?who can be trusted?

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4: Recovery phase: Remaining 4: Recovery phase: Remaining psychotic symptoms or psychotic symptoms or resolution resolution (most often within 3 (most often within 3 months)months)

• Separation between inner and outer Separation between inner and outer worldworld

• Psychotic “shadows” may remainPsychotic “shadows” may remain

• Pain, shame - reliefPain, shame - relief

• PTSD (traumatic memories from care)?PTSD (traumatic memories from care)?

• Denial of psychosis? Denial of psychosis?

• Are the bridges burned?Are the bridges burned?

• Life with the memory of psychosis and Life with the memory of psychosis and awareness of one’s vulnerabilityawareness of one’s vulnerability

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From From Disease model (Kraepelin around 1890)Disease model (Kraepelin around 1890)

totoVulnerability-Stress model (Zubin 1977)Vulnerability-Stress model (Zubin 1977)

ororVulnerability-Interactional stress model Vulnerability-Interactional stress model

(Strauss 1983)(Strauss 1983)

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Dimensions of vulnerability to Dimensions of vulnerability to psychosispsychosis

B: Pre/perinatal injuries

C: Early trauma, Attachment problems

A: Genetic

1 factor- low risk2 factors higher risk3 factors high risk

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Three phases of Schizophrenia Three phases of Schizophrenia (Ciompi)(Ciompi)

Psykosocial factorsBiological factors

Early traumatic experiences etcGenetics, perinatal injuries

Premorbid vulnerability

Phase 1

Phase 2

Phase 3

Stress

Acute psychosis

Psyko-social factors

Some disability or ”chronicity”Complete remissionor a few symptoms

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Long-term schizophreniaLong-term schizophrenia• Around 1/3 of first episode psychosis patients tend to Around 1/3 of first episode psychosis patients tend to

”chronify””chronify”

• Inner world is mixing up with external worldInner world is mixing up with external world

• Deficient control of the ”expected future”Deficient control of the ”expected future”

• Deficient awareness of body?Deficient awareness of body?

• But often: fantasy, warmth, sense of humourBut often: fantasy, warmth, sense of humour

• Between two fires: overstimulation and understimulationBetween two fires: overstimulation and understimulation

• Neuroleptic medication 25-40% better than placebo. Risk Neuroleptic medication 25-40% better than placebo. Risk for over-medication!for over-medication!

• With network and relations, job and supported living, most With network and relations, job and supported living, most patients recoverpatients recover

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The schizophrenic person’s The schizophrenic person’s personality change – a dynamic personality change – a dynamic partialpartial explanation explanation

• The early vulnerability also implies a The early vulnerability also implies a sensitization of self image – ”outsider”sensitization of self image – ”outsider”

• The first psychosis is a mental trauma The first psychosis is a mental trauma which further disturbs the self-imagewhich further disturbs the self-image

• A partial withdrawal to the inner world A partial withdrawal to the inner world means a higher security of selfmeans a higher security of self

• ””Schizophrenia” Schizophrenia”

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The affective vulnerabilityThe affective vulnerability

• A thin ”mental skin” A thin ”mental skin” • Complex and highly charged inner Complex and highly charged inner

mental representations of good/badmental representations of good/bad• Easily evoked symbolic connections Easily evoked symbolic connections

external/inner world external/inner world • Lowered ability to deal with separation, Lowered ability to deal with separation,

frustration, falling in love, aggressionfrustration, falling in love, aggression• Psychotherapy and low dose medicationPsychotherapy and low dose medication

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What is curative?What is curative?

• MilieuMilieu – low stimulation level, security, coherence – low stimulation level, security, coherence

• Medication when neededMedication when needed – lowest effective dose – lowest effective dose

• Therapeutic allianceTherapeutic alliance – respect, interest, non-intrusive warmth– respect, interest, non-intrusive warmth

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Attitudes towards the patient -Attitudes towards the patient -according to the Danish OPUS according to the Danish OPUS

project:project:

  

A long awaited guest who you want to A long awaited guest who you want to feel welcome and at home during a feel welcome and at home during a long visit. long visit.

A collaborator, whose insights and A collaborator, whose insights and attitudes are decisive for the outcome. attitudes are decisive for the outcome.

An individual with personal An individual with personal preferences that should be taken into preferences that should be taken into account in the treatment to the account in the treatment to the greatest extent possible.greatest extent possible.

Merete Nordentoft, Bispebjerg Hospital, psykiatrisk afdeling, 2006

Antipsychotic medication – the Antipsychotic medication – the patient’s friend or enemy?patient’s friend or enemy?• ””Therapeutic window” at 1-4 mg haldol-eqv in f.e.p.Therapeutic window” at 1-4 mg haldol-eqv in f.e.p.• Higher dose gives side-effects without increasing Higher dose gives side-effects without increasing

anti-psychotic effectsanti-psychotic effects• Side-effects appear soon after intake, anti-psychotic Side-effects appear soon after intake, anti-psychotic

effects after 1-5 days – slow increase of doses!effects after 1-5 days – slow increase of doses!• Antipsychotic effects because of more indifference Antipsychotic effects because of more indifference

which lowers vulnerability to psychotic thoughts? which lowers vulnerability to psychotic thoughts? (Healy, Kapur)(Healy, Kapur)

• High dose inhibits the dopamine systems of frontal High dose inhibits the dopamine systems of frontal lobes and thus down-grades the motivational affectslobes and thus down-grades the motivational affects

• Moderate dose give a chance for psychological Moderate dose give a chance for psychological restructuring, high doses lower vitalityrestructuring, high doses lower vitality

• The effect is 30-50% betterThe effect is 30-50% better than with no medicationthan with no medication

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Thresholds for antipsychotic drug effects in FEPThresholds for antipsychotic drug effects in FEP

100

80

60

40

20

0

D2 receptor occupancy (%)

0 1 2 3 4 5

Dose/plasma concentration

EPS threshold

Antipsychotic effect threshold

Farde et al (1992)Farde et al (1992)

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””Hearing inner voices”Hearing inner voices”• When you hear constant inner voices and know When you hear constant inner voices and know

they don’t come ”from outside” - you don’t suffer they don’t come ”from outside” - you don’t suffer from a psychosis but from a disorder of perception from a psychosis but from a disorder of perception – a minor disturbance of the brain– a minor disturbance of the brain

• Such voices rarely are helped with medication – still Such voices rarely are helped with medication – still many psychiatrists are tempted to continue med many psychiatrists are tempted to continue med which may lower your quality of lifewhich may lower your quality of life

• You need psychological support for better dealing You need psychological support for better dealing with the voiceswith the voices

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Psychological treatments and Psychological treatments and psychosis – different models psychosis – different models

should be encouraged in the teamshould be encouraged in the team • Dynamic models: Identifying relational or Dynamic models: Identifying relational or

developmental crisis, trauma (separation, developmental crisis, trauma (separation, frustration, stress). Important in early phase – frustration, stress). Important in early phase – brief and schizophreniform psychosesbrief and schizophreniform psychoses

• Cognitive models: Taking control over voices, Cognitive models: Taking control over voices, depressive thinking, investigting delusional depressive thinking, investigting delusional thinking. Important in late phasesthinking. Important in late phases

• Educational models: How to think about Educational models: How to think about psychosis, treatments, relapses – all casespsychosis, treatments, relapses – all cases

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Coherence Coherence

andand

Hope Hope

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