From the Editor
“Something as basic as grocery shopping was both frightening and overwhelming for me. I remember my mom taking me along to do grocery shopping as a form of rehabilitation… Everything seemed so difficult.”
So comments a patient on the experience of a relapse of psychosis.
Typically, we describe psychosis with lists of symptoms. But how do patients understand these experiences? In a new World Psychiatry paper, Dr. Paolo Fusar-Poli (of King’s College) and his co-authors attempt to answer this question with a “bottom-up” approach. As they explain: “To our best knowledge, there are no recent studies that have successfully adopted a bottom-up approach (i.e., from lived experience to theory), whereby individuals with the lived experience of psychosis (i.e., experts by experience) primarily select the subjective themes and then discuss them with academics to advance broader knowledge.” We discuss their paper.
In the second selection, we consider a new Quick Takes podcast. Dr. Kevin Hill (of Harvard University) reviews the cannabis literature and weighs the evidence. He notes the hazards of CBD, the lack of evidence for cannabis and sleep, and his fondness for the Chicago Bears. “There are very strong proponents for cannabis and there are people who are entirely sceptical about it. And the answers to a lot of these questions are somewhere in the middle.”
Finally, in the third selection, Dr. Robert Bell (of the University of Toronto) and his co-authors advocate for the expansion of public health care to cover psychotherapy. Dr. Bell, who is a former Deputy Minister of Health of Ontario, makes a clear case drawing on international examples. “Canadians understand that good health requires mental-health support, and co-ordinated investment in mental-health treatment would pay dividends in reducing the impact of mental-health disability on the economy.”
Selection 1: “The lived experience of psychosis: a bottom-up review co-written by experts by experience and academics”
Paolo Fusar-Poli, Andrés Estradé, Giovanni Stanghellini, et al.
World Psychiatry, 7 May 2022
Psychosis is characterized by symptoms such as hallucinations (perceptions in the absence of stimuli) and delusions (erroneous judgments held with extraordinary conviction and unparalleled subjective certainty, despite obvious proof or evidence to the contrary). The nature of these symptoms makes psychosis the most ineffable experience of mental disorder, extremely difficult for affected persons to comprehend and communicate: ‘There are things that happen to me that I have never found words for, some lost now, some which I still search desperately to explain, as if time is running out and what I see and feel will be lost to the depths of chaos forever’.
K. Jaspers often refers to the paradigm of ‘incomprehensibility’ with respect to the primary symptoms of psychosis that cannot be ‘empathically’ understood in terms of meaningful psychological connections, motivation, or prior experiences. However, psychotic disorders – especially schizophrenia – have, more than any other mental condition, inspired repeated attempts at comprehension.
In the two-hundred-year history of psychosis, numerous medical treatises and accurate psychopathological descriptions of the essential psychotic phenomena have been published. However, this top-down (i.e., from theory to lived experience) approach is somewhat limited by a narrow academic focus and language that may not allow the subjectivity of the lived experience to emerge fully.
So begins a paper by Fusar-Poli et al.
- “We established a collaborative team of individuals with the lived experience of psychosis and academics. This core writing group screened all first-person accounts published in Schizophrenia Bulletin between 1990 and 2021, and retrieved further personal narratives within and outside the medical field…”
- “The core writing group selected the lived experiences of interest, tentatively clustered them into broader experiential themes, and identified illustrative quotations. The material was stored on a cloud-based system (i.e., google drive) fully accessible to all members of the group.”
- “The initial selection of experiential themes and quotations was collegially shared and discussed in two collaborative workshops, which involved numerous individuals with the lived experience of psychosis as well as family members and carers…”
- “In a final step, the selection of experiential themes was revised and enriched by adopting a phenomenologically-informed perspective…”
The authors focus on the different stages of illness. Here, we summarize the prodrome, first episode, and chronic stages.
Several themes emerged including a feeling that something important is about to happen, heightened salience of meanings in the inner and outer world, compromised vital contact with reality, and keeping it secret.
In terms of heightened sense of meanings –
“During the prodromal phase of psychosis, individuals feel assaulted by events personally directed to them, accompanied by a strong need to unravel their obscure meaning: ‘A leaf fell and in its falling spoke: nothing was too small to act as a courier of meaning’. Seemingly innocuous everyday events assume new salient meanings. Previously irrelevant stimuli are brought to the front of the perceptual field and become highly salient. This perceptual background, until then unnoticed, now takes on a character of its own: ‘At first, this started with sudden new perspectives on problems I had been struggling with, later the world appeared in a new manner. Even the places and people most familiar to me did not look the same anymore’.”
First Episode Stage
Several themes emerged including a sense of relief and resolution associated with the onset of delusions, feeling that everything relates to oneself, a dramatic dissolution of the sense of self and devitalization, and feeling overwhelmed by chaos or noise inside the head.
In terms of feeling overwhelmed by chaos or noise inside the head –
“The disorganization of thoughts is a prominent experiential theme: ‘My head is ‘swarming’ with thoughts or ‘flooding’. I become overwhelmed by all the thinking going on inside my head. It sometimes manifests itself as incredible noise’. Words such as ‘rollercoaster’, ‘whirlwind’, ‘vertigo’ or ‘maelstrom’ are used by individuals to try to convey an experience of inner chaos and confusion, which is difficult to articulate accurately through language: ‘Being in a whirlwind is not a very good metaphor for that experience, but I have trouble finding words to describe it’.
“As one individual describes, thought disorder can be experienced as a ‘weakening of the synthetic faculty’. ‘My thoughts seemed to have lost the power to squeeze things to clear organization’. The weakening of the natural ‘core self’ that organizes the meaning and significance of events can lead to a disturbed ‘grip’ or ‘hold’ on the conceptual field.”
Several themes emerged including coming to terms with and accepting the new self-world, and persisting inner chaos not visible from the outside.
In terms of coming to terms with and accepting the new self-world –
“Individuals often report feeling more optimistic about the future or believing that the worst is now behind them: ‘after more than 40 years of psychosis, I can now say, I feel better than I have ever felt in my life’. Individuals may also report feeling more satisfied with their occupational activities than before…
“As the intensity of psychotic symptoms and the associated distress frequently decrease, they can be more easily dismissed: ‘I go out among people almost every day and, although I still feel ‘stared at’ and occasionally talked about, I do not believe, even if I am psychic, that I am an agent of God’.”
A few thoughts:
2. This is a remarkable and unique paper.
3. It offers us a different look at psychosis, pulling together many first-hand experiences.
4. The authors consider other topics including the ambivalence towards medications – well captured in this comment: “It is hard realizing that I probably will have to continue taking medications for the rest of my life, but the misery without them is terrible.”
5. We can hope to read more of such papers in the future.
The full World Psychiatry paper can be found here:
Selection 2: “Cannabis: Exploring the evidence & clinical implications with Dr. Kevin Hill”
Quick Takes, May 2022
In this episode, I speak with Dr. Kevin Hill, director of the Division of Addiction Psychiatry at Beth Israel Deaconess Medical Center and an associate professor at Harvard Medical School. Dr. Hill is a prolific author on the topic of cannabis.
On the evidence for cannabis for medical purposes
“We have three cannabinoids approved in the United States, and they’re approved for a few conditions: nausea and vomiting associated with cancer and chemotherapy appetite stimulation in certain wasting conditions; and now we have cannabidiol for three seizure disorders; and also spasticity associated with multiple sclerosis…
“So there is some evidence there, but it’s not nearly as much as many people would like it to be.”
“On the whole, I think CBD is less harmful than THC. However, there are risks here. For example, we published a paper early in 2021 talking about drug-drug interactions in the Annals of Internal Medicine.
“Watkins et al. looked at one of the Epidiolex open-label studies. They were 16 patients in it and five had LFTs (liver enzymes) more than five times the upper limit of normal. These things are real. And my concern having talked to so many patients who have been interested – there are a lot of people out there using CBD with no supervision at all.”
On cannabis for sleep
“There really isn’t evidence to support the use of THC or CBD for insomnia. My take on the literature: THC functions like alcohol in terms of sleep, so it will decrease the amount of time you spend in REM sleep. I’m talking about that with my patients; it will help you get to sleep, and perhaps this is all dose related, maybe very small doses of THC… And CBD: there’s not good evidence supporting its use for sleep despite popular belief.”
On the need for science to catch up
“There are millions of people using these cannabinoids and yet the science has just not kept pace with that level of interest.”
On screening tools for cannabis use disorder
“There’s a relative of the AUDIT called the CUDIT. If you don’t have the time to really take a great history, then think about a screening tool.”
The above answers have been edited for length.
The podcast can be found here, and is just over 24 minutes long:
For the record, Dr. Hill is the first author of an American Journal of Psychiatry paper that drew from 850 papers on cannabis; it was considered in a past Reading which can be found here:
Selection 3: “It’s time for therapy to be included in Canada’s universal health care system”
Robert Bell, Anne Golden, Paul Alofs, and Lionel Robins
The Globe and Mail, 14 May 2022
The Problem: Canada does not have reliable publicly funded mental-health supports. Many people fall through the cracks trying to get help
Marion has been feeling very sad lately. She feels like her life is worthless and sometimes she can’t get out of bed in the morning. Sometimes she worries she’s going to lose her job because she has so little energy or motivation. Her state of mind is hard on her relationship as well.
She talked to her family doctor and the doctor offered her a prescription, but the medication seems to make Marion feel sleepy and even less energetic. The doctor told her that she should try counselling, but she doesn’t have private health insurance at work, and she can’t afford to pay for a psychologist or psychotherapist. Her thoughts and feelings about being useless are getting worse and she doesn’t know what to do.
So begins an essay by Bell et al.
They offer a solution: “Canada must provide publicly funded talk therapy for all who need it.”
Noting the burden of mental health problems in our society – “the Mental Health Commission of Canada has estimated that absenteeism and disability from mental illness costs the Canadian economy more than $50 billion annually” – they advocate for psychotherapy. “Publicly funded talk therapy is a crucial missing element of mental-health support in Canada. The majority of Canadians who receive counselling are currently paying for it out of pocket or through private insurance from their employer. Those who cannot afford it face years-long wait lists to access publicly funded counselling, or don’t seek it out at all.”
They highlight real world experiments:
- England. “The National Health Service began providing access to publicly funded talk therapy in 2008. In a 2019 review of this policy decision, the NHS found that about 50 per cent of patients with depression or anxiety will recover if they receive between six and 12 hours of talk therapy. This type of treatment might include CBT or another appropriate form of talk therapy, many types of which are publicly funded…”
- Australia. “Researchers confirming in a 2020 study that the country’s NewAccess public therapy program has resulted in ‘reliable recovery rates in both depression and anxiety symptoms’ for patients.”
They ultimately argue that this reform would lead to cost savings: “The cost effectiveness of talk therapy has also been demonstrated by a 2017 study published in the Psychiatric Services journal, which estimated that Canada would save $2 for every dollar spent on public funding for talk therapy, as the investment would result in a reduction in hospital admissions, fewer suicide attempts and suicides, as well as lower disability costs.”
A few thoughts:
1. This is a good essay.
2. They make a good case – in part on economic grounds. (Clinicians tend not to speak in such terms, but policymakers do.)
3. Progress has been made: there are small and growing psychotherapy experiments in Ontario and other provinces. Still, we are far behind Australia and England.
The full Globe essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.