Like dreams, I think the person is always at the centre of a delusion and the other actors are either pro (grandiose delusion) or con (paranoid delusion). I have occasionally come across neutral delusions (one person turned into another person without harmful intent) but these are rare. It's usually either a wish or a fear. And the fears seem to be more prevalent. Says something about human nature - we need our fears to help us survive.

That's a great question. The interesting thing is that persecutory thoughts are more common than one would think - about 10-15%. Since those thoughts are common outside of delusions or hallucinations I've wondered about that - and I have come to understand that self-doubt, self-condemnation, self-hatred and fear are the core issues underneath these thoughts - at least for persecutory thoughts outside of delusions and hallucinations.

It is therefore quite possible that the these core issues are also at play for delusions and hallucinations.

Thoughts?

Very interesting question. One way of approaching this question is through trying to understand the emotional basis underlying their perceptions. The amygdala is the centre of emotional processing in the brain. Several studies looking at amygdala volume, function and interconnections with other brain regions (i.e. hippocampus) in patients with schizophrenia have delineated several deficits in the realm of emotional processing and recognition as well as social cognition. I think that if one can not understand or explain an emotional state (whether in themselves or someone else) then it might cause a discomforting feeling and lead to perceiving questionable realities through a negative (i.e fear or anger) based perspective.

Some research done at Oxford university some years ago pointed out that when subjects were hallucinating there was evidence of subvocalizations going on at the same time. It is very possible that underlying the individual's delusions and hallucinations are self perceived deficits the individual has difficulty admitting to resulting in projecting the source of the produced discomfort to others.

I think that persecutory and paranoid thoughts and perceptions may be a part of a adaptive or evolutionary development of mammals and humans for protecting themselves from dangerous situations

I found this very interesting research that examined how depression may contribute to the persistence of persecutory thoughts in schizophrenia (Vorontsova, Garely, & Freeman, 2013). Similar to what has already been discussed, when an individual is already feeling bad about themselves they are more likely to engage in cognitive thought patterns that are more negative. This is also discussed in the article. I have included the article and citation for your review.

Vorontsova, N., Garety, P., & Freeman, D. (2013). Cognitive factors maintaining persecutory delusions in psychosis: The contribution of depression. Journal Of Abnormal Psychology, 122(4), 1121-1131. doi:10.1037/a0034952

Sorry, still getting used to this process. Here is the article.

Mary Seeman hits the nail on the head.

Other key considerations in delusions include:

1) They are attempts to find meaning in events that are confusing or ambiguous to the person, producing heightened arousal and anxiety.

2) Once formed, the delusion actually tends to lessen the intensity of those feelings for a time, providing the suffer with an explanation and a focus, around which he or she can be vigilant and try to take protective measures.

In my clinical experience, months or more before a person develops paranoid delusions, grandiose ideas have already developed, typically as an overcompensation to feeling insignificant and powerless. Having come to believe that he is of great importance, the person secondarily concludes that he is an object of envy and malicious intent. Even when grandiose ideas or delusions have not preceded paranoia, sometimes, what I call "delusions of

beneficence" have manifested. In these, the person construes events he experiences as ambiguous or confusing as somehow having taken place for his benefit, and views others involved in these events as having had benevolent intent. It is only after having established considerable rapport with the patient that I've come to learn retrospectively of this manifestation of incipient psychosis.

Underlying almost all delusions, whether or not paranoid, the person experiences himself to be at the center of events that should not have been taken personally.

Please read current online First Person Account or upcoming publication of Schizophrenia Bulletin, where I was able to have a former deceased client's write-up on the issue accepted for publication. The tittle of the article is: "The Vacuum of the Mind: A Self-Report on the Phenomenology of Autistic, Obsessive-Compulsive, and Depressive Personality. The posthumous author, Jay D. Paul, talks about emergence, dynamics, and coping with hearing voices from his personal perspectives. The article, I believe , will be of interest to psychiatric community, as Jay Paul was a highly intelligent person, and he writes in a very erudite manner. I am extremely pleased that Schizophrenia Bulletin editorial board accepted his article for publication.

This is a pivotal question. Whether this range of problem is trauma-based and related to fears to safety/integrity; due to a feeling of uncertainty about the environment and disconnection due to extreme dissociation, or is related to an information-processing or sensory-processing/association problem - these all potentially heighten arousal. The important question is whether these beliefs and experiences are a primitive but ineffective "cognitive repair mechanism"! I think the understanding is not about what these experiences are due to but their purpose and what they achieve,

Besides what you have said above, it must happen that when high intensity stressors happen/are remembered, the body uses a great number of minerals and vitamins and other chemicals. As the body is depleted of B12, biotin, and other vitamins, the intensity of the fear increases and the brain is trying to figure out a logical reason for the flashbacks, the intense fear. I can see it through my cat before and after the bacopa and a multivitamine, and probiotics. Her fear has decreased and her crazy evil cat attitude has markedly reduced. She is now loving and trusting. I am going to add phosphatildyserine and watch its effects. Today, as the sound of saws cutting trees in the yard begun and continued for 5 hours, she began to act fearful again, hissing and retreating, ears back, etc., but never at the level she used to show before. She did fine, soon after the workers left, not an usual attitude for her.

I have little doubt that paranoid delusions are a vestigial behaviour that used to be evolutionary advantageous in ancestral tribal life - in order to maintain vigilance related to the threat from foreign tribes (war has probably been very common for all of hominid evolution). Modern schizophrenia filled the role of shaman in tribal societies (both conditions are highly heritable). For those who treat psychotic patients, try observing how often delusions are spiritual (i.e telepathic and other magic-religious themes). Also, try noticing how the majority of delusions involve out-groups (and rarely close friends or family). A more detailed explanation can be found in my book "Shamans Among Us" or my 43 minute Youtube lecture on the subject. Chapter 10 of my book contains an analysis of 26 psychotic patients with their verbatim responses (almost every psychotic response was either spiritual or paranoid).

Joseph, how are you able to differentiate between a psychotic experience and a spiritual experience, or do you think the latter don't exist? I am reminded of some research decades ago of electrodes touching different parts of the brain and the person seeing either angels or demons, so the capacity to "see" is there. When is it "real" and when is it psychotic?

Now we are getting into some of the finer points, which are admittedly more speculative. Evolutionary psychiatrist John Price says that the conviction of the deluded is evolutionarily required so that the entire tribe follows one shaman (and therefore becomes united). How this happens psychologically is anyone's guess. We psychiatrists call that various levels of insight.

Spiritual feelings permeate most people at some point in their lives ( although I am an atheist, I once experienced spiritual feelings). Actually, all of us have residual spiritual/superstitious feelings. How many of us can jokingly say my child will die tomorrow without some tinge of regret? Communication in the animal kingdom is often asymmetrical ( I.e. Bird calls, warnings). In every tribe, shamans generate spiritual content and the rest follow to varying degrees. Moreover, almost every religion began in the head of one delusional prophet. Pascal Boyer's operational definition of religion matches very nicely with Schneiderian symptoms of schizophrenic psychosis. I think it's more than a coincidence.

Very interesting question. I just wanted to point out that according to the "aberrant salience hypothesis" of psychosis, a VERY influential hypothesis, the nature of delusions should be random. But it's not the case

The temporal parietal junction or TPJ is involved in moment to moment social perception and communication – perception of dynamic gestures and person perception (especially in the auditory, visual and somatosensory domains). This region is involved in (audiovisual) speech and visual human/biological motion perception (including emotional gestures and prosody) as well as social attention, theory of mind, and self representation or embodiment. Homologous regions in non-human primates contain neurons that are not only used in the perception of multimodal social gestures (movement and person perception), but that also carry an automatic computation of agency, social prediction (summarized in several papers such as Wible, 2012). These neurons are also preferentially used to detect or perceive social threat (see Barraclough and Perrett’s work as well as Puce and Perrett, 2003). ERP (Puce) and FMRI data (Grezes et al., 2007) from human subjects and single neuron recordings in non-human primates (Perrett) show that this neural circuit is tuned to rapidly detect emotionally negative and is preferentially active during the perception of socially threating gestures. The amygdala is most often cited with regard to this function. However, amygdala damage in humans does not cause a deficit in the perception of dynamic body expressions of fear (see Atkinson et al.2007; Cristinzio et al., 2010). Hence, although the TPJ is generally used to perceive dynamic gestures, there is a neural tuning for the detection of social threat and therefore over-activation of these gesture representations might produce the feeling of being in a socially threating situation.

Audiovisual gestures (e.g. speech) are the most prominent type of multimodal representation in the TPJ. Auditory hallucinations of voices are the most prevalent symptom of schizophrenia; they are accompanied by the feeling that someone is actually there and speaking. Stimulation of the posterior lateral temporal region produces hallucinations of action scenes involving people. Visual hallucinations of people in action are the next most prominent category of hallucination. The most common delusions in schizophrenia are delusions of persecution and delusions of reference. They are characterized by the feeling of being followed, watched, or that people are secretly communicating using gestures or clothes. Hence, the prominent positive symptoms of schizophrenia revolve around the perception or feeling of an entity that is speaking, communicating, watching, following, observing or spying. Abnormal activation (due to epilepsy) or stimulation of the human TPJ produces the feeling of a presence or multiple presences (Blanke, Arzy, Brugger). Abnormal activity in the TPJ of epileptic patients was associated with persecutory delusions (Ishii et al., 2005). Hence, just as overactivation of secondary visual regions can produce hallucinations of objects, overactivation of the TPJ could produce either the frank hallucination of a human presence (voice, visual presence) or the feeling of a social presence or presences. This type of experience would most likely be accompanied by a feeling of social threat or fear (given the representational properties of neurons in the posterior superior temporal sulcus and TPJ). This framework is described in several papers (e.g. Wible, 2012) and can also be used to account for negative symptoms and passivity symptoms (delusions of control). For example, emotional gesture perception and reaction for the face and body as well as prosody perception are dependent on the TPJ. The supramarginal gyrus (part of the TPJ) may be especially important for the creation the intentions or plans for movements including emotional and prosodic reaction. Stimulation in human subjects produced the feeling of having executed a movement whereas stimulation of premotor cortex produced movement without awareness (see Desmurget et al., 2009). Hence, conscious intentions to move arise from the inferior parietal region (part of TPJ). Abnormal activity in these emotional gesture perception/reaction circuits and motor reaction circuits could result in social unreactivity or asociality as well as a lack of facial movement, eye contact, vocal inflection and facial expression and problems judging agency and ownership of acts; all symptoms of schizophrenia. Patients with TPJ damage also often present with a lack of insight (a prominent feature of schizophrenia).

(A FEW) REFERENCES

Atkinson, A.P., Heberlein, A.S., and Adolphs, R. (2007). Spared ability to recognise fear from static and moving whole-body cues following bilateral amygdala damage. Neuropsychologia 45, 2772-2782.

Cristinzio, C., N'diaye, K., Seeck, M., Vuilleumier, P., and Sander, D. (2010). Integration of gaze direction and facial expression in patients with unilateral amygdala damage. Brain 133, 248-261.

Desmurget M, Reilly KT, Richard N, Szathmari A, Mottolese C, Sirigu A. Movement intention after parietal cortex stimulation in humans. Science (New York, NY May 8 2009;324(5928):811-813.

Desmurget M, Sirigu A. A parietal-premotor network for movement intention and motor awareness. Trends Cogn Sci Oct 2009;13(10):411-419.

Grezes, J., Pichon, S., and De Gelder, B. (2007). Perceiving fear in dynamic body expressions. Neuroimage 35, 959-967.

Ishii R, Canuet L, Iwase M, et al. Right parietal activation during delusional state in episodic interictal psychosis of epilepsy: a report of two cases. Epilepsy Behav Sep 2006;9(2):367-372.

Puce, A., and Perrett, D. (2003). Electrophysiology and brain imaging of biological motion. Philos Trans R Soc Lond B Biol Sci 358, 435-445.

Article Hippocampal temporal-parietal junction interaction in the pr...

Cynthia,

Thanks for adding your anatomical/physiological perspective to this issue. You mention delusions of reference, which often are persecutory in nature, but can also manifest as grandiose ideation. In your opinion, are the subjective experiences of paranoia and grandiosity linked, ie, originate, or mediated by, the hippocampal temporal-parietal junction interaction?

I think of grandiosity as possibly an abnormality of self perception (also mediated by TPJ). The intraparietal sulcus computes salience (and is the dividing sulcus between the inferior parietal and superior parietal regions. So abnormal self representation plus increased salience could be part of the mechanism of grandiose delusions.

Mind and body in a way are two sides of a coin, so to speak. All our psychological processes and behavioral manifestations, including hallucinations and delusions, are accompanied by underlying corresponding neurological activities of the brain. Given the advance in brain functioning assessment instruments, we will always find psychological processes and activities reflected in our brain functioning for both typical or atypical behaviors. In that sense, all behavior and psychological activities, normal or atypical dysfunctions,related to what I believe the information processing system, will be reflected in our typical or atypical brain activities and functioning. The progress in behavior science will be related to therapeutic intervention at behavioral, social, and cultural level, as well as due to increased understanding how best to direct intervention at specific brain activity sites through medication or other invasive intervention. It will always be a question of value, which is one preferable, and what is consistent with personal and social values and norms for the day. One needs to pay attention to judicious use of balance between biological and psychological interventions, as both, seemingly coming from different directions, but with the same goal and end:, that is to reduce personal and social distress and optimize one' adaptive functioning. It is an exciting time for brain-behavior scientists, as correlation between behavior and brain activities are being increasingly possible to be identified, give support to a particular theoretical model or clinical intervention, recognizing that its value will always be time limited with advancement of human knowledge and change of social values of the day.

Still there is long debate in this question. However, it is an experience of interest of patient which occurs outside and is frequently a cause of distress.delusion and hallucinations are trying to make sense of their internal unusual experiences and persecutor y ideas are due to biases when an individual not able to draw conclusion and uncertainity.

I am not aware of a study that predicts the nature of delusion. There is evidence that paranoid delusions are more prevalent in Schizophrenia, but positive content delusions ocurr (which are a puzzle regarding treatment frequently).

Primary Delusional Disorders are excellent examples of the complexity of delusion. It is my opinion that your question has not an evidence-based answer yet.

Cynthia Wible: Fascinating insights into the potential neurophysiology of psychosis. I will have to reread your comments (and absorb) a few more times. Brugger's work, which you reference, has always intrigued me. Just in case you are not aware, Tabor and Hurley's 2007 paper, "Neuroimaging in Schizophrenia: Misattributions and Religious Delusions" . They suggest that the inferior parietal lobe involves attributing actions to external agents (and is preferentially activated in both schizophrenia and religious ideation). I am not well enough versed in neuropsychology to have a strong opinion, however it is fascinating how a hazy picture of the neuroanatomy of psychosis is beginning to form.

I recently submitted a write-up of a deceased client of mine, which was accepted for publication in Schizophrenia Bulletin in First Person Account section. It just came out online, and the tittle is: Vacuum of the Mind: A Self-Report on the Phenomenology of Autistic, Obsessive-Compulsive, and Depressive Comorbidity by Jay D. Paul, which I am sure you all will find very interesting reading and has relevance to the discussion topic..

The article highlights the issue that many individuals with serious mental illness (including schizophrenia) may already have all the insights that the clinicians are trying to provide to them. The challenge is to help them translate their own insights and understanding in the recovery process by helping them to modulate their emotions and self-control. We believe that a positive psychology approach of stimulating the “intact mind” (see Mind Stimulation Therapy: Cognitive Intervention for Persons with Schizophrenia, Routledge, 2013) may have potential to make impact in functional outcome, in conjunction with therapeutic environmental support that may need to involve “agitation/stress control” medication, not necessarily targeting at elimination of what may be considered as strongly entrenched behavior habits, such as hallucinations and delusions, which may have underlying neural networks supporting them following the Law of Exercise principle, rather enhancing the capacity for positive redirection from therapeutic support.

Joseph Polimeni thank you for your comments and the reference. I have a less detailed summary of these ideas (Schizophrenia as a Disorder of Social Communication) and also a new paper coming out in Schiz. Bull. with Dominic Ffytche.

Petra,

You've made a very salient point: How much of the actual content of a patient's thought life are we made aware of? Of course, there are structured and informal interviews with patients in treatment settings, but much of what we know is self-reported from the patient. However, it should also be noted that the patient is receiving services because at least some, if not most, of his/her thought content is paranoid, grandiose, or otherwise distressing to the patient.

I would raise the suggestion that perhaps it does not matter clinically if the patient has highly unusual beliefs (eg, my initial suggestion that ants may be, in fact, tiny reptiles), if paranoid ideation also manifests. Conversely, if a patient does express highly unusual ideas that in themselves are harmless, it could be an indication of faulty information processing that may also manifest as additional paranoid or persecutory content.

I think it matters as this might indicate vulnerability to relapse. However, if they are not concerned by intrusive, unusual ideas this might indicate resilience, not something we often consider.

Petra Habets and Neil Krohn have raised the issue I've been yelling at my computer about. :) We only know about a person who is delusional if those delusions negatively affect her life, make her a danger to herself or others, make her unable to care for herself, etc. For all we know, for every one person with paranoid delusions, there are a hundred thousand with delusions that will never play a role in public (like the original poster's example about a patient convinced ants are reptiles). Perhaps some delusions are even beneficial to the person who has them (a person is convinced aliens dressed in spaghetti informed her that she would one day find the cure for cancer and would save millions and make a fortune, so she overcomes a wretchedly poor social status and horrid pre-college education to get a PhD in microbiology, and does wonderful things).

Psychologists who study delusions, or treat patients suffering from delusions, should be aware that delusions may not be the pathology. Negative delusions, dangerous, or harmful delusions, may be the pathology.

Just want to play devil's advocate for a moment - how would one formally distinguish between shared delusional disorder and religion? What I'm trying to highlight is what is in my opinion the highly subjective socially convergent bias of the DSM.

Hilda, some therapists can and do so effectively. A mother of 4, friend of mine who had planned to have more children had to have the tubes tied, this caused strong anxiety, she was from Ecuador, originally, and a devout Catholic. She began seeing blood on the walls, a woman, like a virgin covered in blood, blood on the bedspread, flames, etc. I went with her to a Colombian therapist at the University of Minnesota Hospital. He explained to me how this were projections in cultural approved ways of the anxiety, of the sadness, and of the internal conflict with her beliefs and desires that could not be fulfilled. After that one session she had no more problems and did not have to take any medication at all. As to the subjective socially convergent bias of the DSM, I have no comments.

Why do many delusions and hallucinations have paranoid or persecutory content?

The answer is very simple. This occurs because a need for security is the primary and fundamental need of human beings. Therefore any threat for safety (real or imaginable) is perceived with over vigilance, which is a basis for the idea of persecution. This idea, when fixed, easily turns into paranoid delusion of reference, influence and persecution with or without the corresponding hallucinations.

There are accounts on the internet of persons with persistent and annoying noises in their head. If, as sometimes occurs, they cannot be persuaded of the simple and obvious explanation, ie they have a latent ear disorder, it is not unreasonable for them to conclude that the CIA has implanted radios in their teeth, or that aliens are beaming messages to them.

Since writing this, I have just happened across the case of a 49y old lady whose main complaint was sudden rotatory vertigo, typical of Meniere Spectrum Disorder. "She had been subject for six months to an almost constant noise in her ears, 'like a shell-sound", or 'like being by the sea'; she could fancy it was something apart from herself'. When it occurred she felt stupid, and required to be addressed very plainly, as though 'her mind were unable to grapple a thing'".

J Russell Med Times Gaz 1880; 2:239.

Hilda,

I can probably think of some examples of my own, but what precisely were you referring to by "highly subjective socially convergent bias of the DSM."?

While I have my concerns about the either/or nature of DSM diagnosis assignment (I think symptoms tend to fall on a continuum), I do think that certain core concepts like depression, anxiety, and psychosis are generally consistent with regard to the category. There may be disagreements about particular elements and specific patients (and patients can also have more than one diagnosis), but categories of disorders are helpful with treatment decisions. Granted that psychiatry deals with descriptive states and disorders, as opposed to etiological ones (eg, pneumonia caused by a bacterium), but DSM can still be useful.

When we are dealing with delusional patients, it's important to remember what is truth. The greater clarity we have about truth, the less relativistic we are, the greater clarity we can help bring to the patient. Adult victims of child sexual abuse have a hard time, maybe because their brain has been blocked from developing certain areas. Yes,bc of fear, but also due to the inability of growing through normal childhood developmental stages and experiences. Thus, certain connections are not developed or poorly developed, and this 'underdevopment' may lead to delusions because the connections are not there or are very inmature in nature, so to speak.

General Psychopathology (1963) by the German psychiatrist and philosopher, Karl Jaspers is highly relevant to Neil Krohn's question. Among the keen insights Jasper's offers is to distinguish between the form and content of a delusional belief.

Stephen,

I'll definitely check the Jaspers book out. Thanks.

Jan,

If you have any specific works you'd recommend, please list them.

Jaspers is amazing - helped me through my Membership, but the problem of interpreting potential delusions is partly pathoplastic. Changes in society, technology and our perception of freedom (what it represents) and what is surveillance (the big brother effect, whether or not benign) can make this dividing line tricky. This can also have an effect of what we see as truth and socio-cultural norms of that particular time!

Neal,

Check out Viktor Tausk's On the Origin of the "Influencing Machine" in Schizophrenia

Sean,

Your point is spot-on regarding delusional content, but I think that the form dimension of delusions is relatively impervious to such changes.

Fair point about the form, I would accept this from the psychopathological perspective, but cultural dimensions are important in considering "abnormal" ideas and possibly the dividing line between what is accepted and what is outside the norms of that time.

Yes, indeed.

Stephen,

I loved Tausk's "Influencing Machine" article. A lot of psychoanalytic jargon, but some great insights into the genesis and expression of delusionary form and content.

Note: this article is available in full text online with a Google search.

Glad you liked it, Neil.

I'll suggest some other titles later.

Neil,

Check out these sources:

1) Stages of onset of schizophrenic psychosis.

Docherty, John P.; Van Kammen, Daniel P.; Siris, Samuel G.; Marder, Stephen R.

The American Journal of Psychiatry, Vol 135(4), Apr 1978, 420-426.

Retreat from sanity: The structure of emerging psychosis.

This helps to contextualize delusion formation in the psychotic process -- from incipient stages on.

2) Retreat from sanity: The structure of emerging psychosis.

Bowers, Malcolm B.

Oxford, England: Human Sciences Press. (1974). 245 pp.

This does the same as 1), but also helps to contextualize psychosis, and delusions as one manifestation of it, in critical developmental challenges and stresses in a person's life.

3) Operators and Things: the inner life of a schizophrenic. Barbara O'Brien, Abington Books: Cambridge.

Quite amazing 1st person account. It helps one appreciate the subjective aspect of inescapable psychotic experience, especially when hallucinations fuel and butress delusional ideas.

Steve

Stephen, thanks for the references. I am reading O'Brien and finished Docherty, et.al. I have a question, how did Jasper escape nihilism and ended accepting the conception of the purpose in life being to find truth?

Sonia, That profound philosophical question is beyond me. Perhaps you could consult the Stanford encyclopedia op Philosophy, available online.

One of the Basic Symptoms of Schizophrenie Are Ego-disturbances like thougt-broadcasting and Insertion, with other wird's lose of privacy. Delusions are 2nd Rank Symptoms, they might serve as explanation. Of you lose your Privatyacht nö Wonder your delusions are of persecutory nature!

All people are capable of paranoid. self-referential thinking and delusions of persecution IF you place them under enough stress. Stress releases cortisol, (nor)adrenaline and a bunch of other hormones and neurotransmitters responsible for the "fight, flight or freeze" response. This means the subcortical region kicks into overdrive and the frontal executive functioning areas begin to disengage. Some people are genetically more vulnerable to this sort of response, (they have a lower stress/vulnerability threshold http://sydney.edu.au/bmri/docs/stress_vulnerability_model.pdf ), and people with some mental illnesses are chronically in this state, but anyone can be pushed into it if the stressors in their physical and social environment are increased enough.

Our perceptions of the world are not necessarily, (or even often) veridical. Veridical perception is accurate, truthful, and most of all, objective. Our perceptions appear to us to be veridical, but, by and large, we all see and hear what we expect to see and hear, and fail to perceive things we find to be unexpected or counterintuitive based on our previous experience or our encultured expectations. When someone is sleep deprived, malnourished, dehydrated, intoxicated with stimulant drugs, or subjected to chronic psychological stress or chronic social defeat or disadvantage, this bias becomes worse. These factors can all change peoples’ brain chemistry and brain function, altering how they perceive the world outside their skull and also altering how they interpret what they think they are perceiving.

Methamphetamine toxicity can model paranoia and psychosis quite effectively. Delusions of persecution are quite common amongst regular meth or coke users, although vulnerability varies considerably from individual to individual;

http://www.ncbi.nlm.nih.gov/pubmed/11955469

.

http://www.nctimes.com/news/local/sdcounty/the-neuroscience-of-meth-from-pleasure-to-paranoia-drug-s/article_5fd09c7c-fc16-5161-940e-03da1e949618.html

.

When a healthy person is given 5 to 10mg of methamphetamine, they typically perform slightly better on neurocognitive tests. They will answer questions faster, get more questions right, and draw more useful analogies than when sober. The low dose of meth is increasing dopamine signalling and speeding up communication between brain cells, and also reducing fatigue so the person can concentrate for longer. (This is why the US Navy and Airforce issue dexamphetamine to combat pilots in war zones).

Something very instructive happens when we increase the dose, however. If we give the same test subjects 30 to 50mg of methamphetamine, they will answer questions much faster, but get more of their answers wrong. They will also draw many, many analogies between disparate pieces of information that any sane and sober person would see are clearly unrelated.

http://www.ihra.net/files/2010/05/02/Presentation_23rd_P3_Hart.pdf

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http://vimeo.com/5124438

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The higher dose is overstimulating the brain. When neurons "talk" to each other TOO quickly, the person begins to misinterpret stimuli, to jump to conclusions, to see connections that aren't there, and to assume things are true which aren't. They then build more and more elaborate architectures of assumption built upon assumption, and this is how delusions develop.

We are all hardwired with autonomic responses to stress. The fight-or-flight response is a response to threat. Like all mammals, our nervous systemns are programmed to detect potential threats. We are actually wired to be over responsive, because our very distant ancestors evolved in an environment where a major source of threat was getting eaten by an ambush predator. In such an environment, it's best to initially treat every rustle in the long grass as a hungry predator, (even if you are only right one in every 1000 times, because any hominids who tended to ignore a noise in the bushes would eventually be removed from the gene pool).

For modern humans the main source of stress is not getting pounced on by a tiger or lion. The main source of stress for modern humans is other humans. Being a bit suspicious of the motives of others is an adaptive advantage. However an overactive "threat detector" (one that stays "switched on") can result in delusions of persecution, paranoia, and chronic problems with social function, mood and cognition.

.

>

http://psychmed.iop.kcl.ac.uk/neuroscience-and-emotion/downloads/73.pdf

>

http://www.ncbi.nlm.nih.gov/pubmed/1837756

>

http://www.nytimes.com/2003/04/01/health/behavior-self-protection-or-delusion-the-many-varieties-of-paranoia.html?pagewanted=2

re: Tausk's "Influencing Machine";

>>

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3330285/pdf/184.pdf

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The seminal case is James Tilly Matthews;

http://en.wikipedia.org/wiki/James_Tilly_Matthews

.

http://www.theairloom.org/

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Regards,

Paul.

The evolutionary models of psychopathology may offer a comprehensive framework for approaching this interesting question. When developing his "compassion-focused therapy", Gilbert distinguishes three systems (and their underlying brain structures/mechanisms) of affect regulation, namely: the drive system, the threat detection system, and the soothing system. Gilbert clearly describes the psychopathological manifestations linked to hyperactivation/underactivation of those systems, and I think that the hyperactivation of the "detection threat system", linked with the inability/difficulty to access the soothing system, could be linked to the onset and development of certain psychotic phenomena.

re threat detection and hallucination; Just noticed this recent article;

The effect of arousal on auditory threat detection and the relationship to auditory hallucinations

Dudley et al

>

http://www.sciencedirect.com/science/article/pii/S0005791614000068

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Paul.

In my outpatient clinical work with individuals with paranoid beliefs, I've typically found them to trust me (or at least, say they did) more quickly than would seem warranted. And from what they tell me in session, it seems that they often too quickly place their trust in certain others they hope will be benevolent and caring individuals. In the psychotherapy of such individuals, I do not leave their unearned trust unaddressed, rather than considering a "positive transference," not to be interpreted. Instead, I say that though I believe myself to be worthy of their trust, they could not possibly know me well enough yet to trust me so completely. I then ask specifically about times when they've trusted others prematurely. As therapy proceeds, I wonder aloud whether their paranoid ideas might somehow be related, at least in part, to what may be a tendency to be too quickly trusting. I then conjecture whether they might have misdirected a normal need to be discerning of others' attitudes and motives into their very specific paranoid ideas.

Have others found clinical or experimental evidence of the same phenomenon?

As a general brain-based paradigm to understand paranoia, the classic Jacksonian (J.H. Jackson) "release" of more primitive brain regions when higher level areas are damaged or dysfunctional is a useful. (Jason W. Brown's microgenetic theory is also useful, but often ignored alternative.) Paul Dessaurer succinctly highlights prefrontal cortical dysfunction and amygdala over-activation in schizophrenia. They may well be related. But if my clinical observation that paranoid individuals tend to too quickly trust those individuals they hope to be benevolent is corroborated, how might it be understood from the perspectives of neurophysiology and neuropsychology?

Neurotransmitters and receptors might be a place to start?

And then there are the times where really freaky stuff happens when you are in this state... for example I stood next to a young man in a psych ward and his doodling turned into very accurate Reiki symbols. I naturally asked him if he was using Reiki on himself seeing as he knew it. His answer was that he didnt know what he was drawing but that he was reading it from me and my knowledge. When I was psychotic I diagnosed a nurse with a very rare eye disorder, I sensed it and was later proven to be right. As Paul said there is heightened perception which comes before the point of exhaustion or stimulus overload.

You must have heard people say they feel psychic, know things are going to happen before they do... I had words word pop into my mind as I was turning on the car radio for example and the very first word said was a repeat of my word. Its hard to not be paranoid when life does not happen as it always has before. When coincidence starts to happen all the time we humans freak out. Our minds are meaning making machines and when things get illogical we feel tricked, the next logical step is to find someone who is doing the tricking... In the past it was probably witches, demons, gods, elves, pixies - our culture is riddled with tricksters. Our modern mind looks for the CIA, candid camera, Truman show experiences or family with made up agendas, anything that will explain the weird experiences.

I found peace in thinking that my electromagnetic field had become conscious thus giving me another sense which I was unaccustomed to. Psychics and mediums would not find my answer unusual. Quantum physics scientists might one day explain this effect (an I fully agree with Paul on the pathway to this altered state). What I do disagree with is putting the whole lot into one basket called mental health disorders and expecting to find an answer solely in the mechanics of the physical body. We are more than the sum of our parts, how can we explain away unusual experiences when we still don't even have an explanation for the spark of life?

Because fear.

Heather Howes' comments should remind us all that that subjective experience and mind/brain process remain a mystery. We actually understand very little. We should guard against becoming "true believers" in our theories lest we fall into a delusional trap of our own, only thinly disguised as science. Clinicians with the hubris to think that they can "explain" any of it "away" with complete confidence, risk disrespecting the patient's experience and beliefs, and researchers doing the same, risk losing their ability to pose novel hypotheses and generate new means of testing them.

Nikola,

Your response is certainly concise, but could you (or others in this discussion) expand upon how fear precisely interacts with delusions and hallucinations to created paranoic or persecutory ideation? For example, a person can be fearful for any number of reasons and a) not develop a psychotic disorder and b) not develop paranoia, even if sz..

Ideas, arguments, solutions?

Margaret,

I don't think too many involved in this discussion would dispute that neurtransmitters (NT) play a role in the genesis of paranoid ideation. But how precisely were you thinking, among the myriad of possible etiologicla pathways, you would begin to identify ones that were most likely to be responsible? Were you thinking of pathways connecting witht he amygdala? If so, how might the NT mechanisms for paranoia be mapped out?

Stephen,

You have provided some outstanding examples of the form in paranoic ideation manifests (Tausk's influencing machine), your own clinical insights about how to handle paraoia and trust in the therapeutic relationship, and your caution (following Heather's comments) about the frontier of the mind/body connections, how little we really know, and where new and cutting edge hypotheses might take us in our quest for understanding.

Given all these igreat insights, in your opinion, where is the next big breakthrough likely to occur?

Neil,

By identifying persons having paranoia as a symptom, the medications that affect those symptoms, any known mechanisms of actions of those medications (might shed light on a particular neurotransmitter and its ratio relative to other important neurotransmitters involved in a "normal" profile) I have not been involved in this particular genetic research (only bacterial, a lifetime ago) so I don't know how much is known about the players, what types of diagnostic testing (for example the ability to measure the level of a particular neurotransmitter such as serotonin, dopamine, glutamate, GABA and others) however with the advent of the human genome project and data mining for similar sequence motiefs in families of neurotransmitters and receptors, isolation of those genes from neurotypical and paranoid individuals and comparison of the genetic sequences (eventually). I don't know if there is an animal model to carry out this process, but that would be a good starting place. I suppose that rats might make a good species since they have been used in many psychological studies and if there are any strains around with traits that suggest this problem. Persons with bipolar disorder who tend to be more towards the depressive state tend to be stable when subjected to an antidepressant, antipsychotic, and mood stabilizer combination. I am sure that you know all of this. I am merely following the discussion because it is one of my interests. I am certainly no authority, mainly an observer of human behavior with some molecular biology experience and a follower of this discussion.

Another avenue could be Carl Jung's writings. He had much to say on paranoia, delusions and psychosis from a psychological perspective. He went through a period like that himself, I have been told by my husband who has followed the writings of Carl Jung for approximately 25 to 30 years.

Why do many delusions and hallucinations have paranoid or persecutory content?

It is my observation that delusions and hallucinations stem from a fight/flight response that has been frozen by ambiguity. It is driven by mistrust, leading to paranoia, leading to delusions and hallucinations. There is always a grain of truth in the perceptions. A person who is paranoid believes that everything anyone says or does, or any distorted perception is potentially threatening as the paranoia builds (eventually the delusions and hallucinations that are perceived come from threats created by fears that are part of the structure of the personal psyche). A double meaning is seen in anything that he/she perceives. This causes the fight/flight response to run amock. Somehow the person caught in this unresolvable loop tries to make sense of this information that is stuck in time. It does not compute. The mistrust and paranoia drive the process and lead to the triggering of delusions and hallucinations unique to the personal content of the person's psyche and centering around the final incident that triggered the psychosis as well as the personal nightmares that the individual has. The culmination is a network of neurons making any and all connections to experiences that would bolster the paranoid thoughts and conjure the "demons" the person lives in fear of. No one has mentioned the religious themes running through paranoid/psychotic experiences. Those psychic structures may date back at least thousands of years, maybe longer to fears going along with the possibility of becoming a religious sacrifice and the mixed emotions that must have come with that responsibility. They may belong to the collective unconscious rather than the personal unconscious as Jung would say. Disclaimer: this is all speculation on the observer's part. No scientific evidence involved.

"for example I stood next to a young man in a psych ward and his doodling turned into very accurate Reiki symbols. I naturally asked him if he was using Reiki on himself seeing as he knew it. His answer was that he didnt know what he was drawing but that he was reading it from me and my knowledge"

Hi Heather,

Schizophrenics draw a symbol of wholeness, a mandala, when in a psychotic state. Carl Jung noted it and talked about it in patients he observed. Here is a link with some condensed information concerning some of the observations about this universal symbol relating to psychosis as viewed by Carl Jung and others:

http://jungianschizophrenia.blogspot.com/2009/01/jungs-experience-of-schizophrenia.html

This may be similar to your Reiki symbol encounter, that is a universal symbol in the collective unconscious.

This is a little off the beaten path, but I thought that I would mention it.

I just stumbled along a book called "The Imprinted Brain, How Genes Set the Balance Between Autism and Psychosis", by Christopher Badcock. It has a comment commending the book by Dr. Crespi, winner of T. Dobzhansky Prize and E. O. Wilson Award, Evolutionary Biology:

"Deeply Scholarly yet Absorbing narrative, "The Imprinted Brain" will change the way we view the human brain and its functions, evolution, and disordering in mental illness. Badcock has drawn evolutionary biology together with genetics, psychology, psychiatry, and neuroscience to demonstrate, for the first time, how genomic conflicts play a central role in how the human brain works, and how the brain becomes dysregulated in social-brain disorders including autism and schizophrenia."

I suffered a concussion in December and have been overdoing the reading and thinking. Unfortunately I am going to have to take a break before I read this book. I thought some of you might find it interesting, perhaps.

Neil,

I agree with Joelle, Nikola, and Margaret that fear is central and fundamental to delusional interpretation of experience. And as Margaret points out, ambiguity is also an important factor. When ambiguity, and or the unexpected is added to extreme fear, the conditions are especially ripe. Demonstrated deficits in even the earliest phases in sensory processing in individuals with schizophrenia, and event-related potential (erp) mismatch negativity (MMN) to "odd-ball" or unexpected stimuli, generated by the temporal lobes and amygdalae in such individuals, as well as in normal subjects under fear-inducing conditions demonstrate the importance of fear. And then, there are also functional neuroimaging studies, demonstrating heightened amagdylae activity, combined with reduced pre-frontal cortical function in schizophrenia, which point to excessive fear, combined with a reduced ability to make sense of it. But even before the application of advanced neuro-technologies to the problem, deficient pre-frontal functioning was demonstrated in such patients on the Wisconsin Card Sort test, showing that these individuals are impaired in their ability to make sense of an unpredictable rule changes.

In my view, the treatment of individuals with delusions needs to multiple dimensions:

1) Biologically, neural activity subserving excessive and inappropriate fear need to be dialed down with medication. Better anti-psychotic medication with less or no risk of Tardive Dyskinesia is urgently needed. When Margaret Mchenney fully recovers, I hope that she'll find her colleagues at Lilly to making progress on this with medications targeting novel mechanisms of action.

2) Psychologically,

a) Cognitive-Behavior Therapy (CBT) has demonstrated its usefulness in treating non-psychotic disorders of fear (such as in extreme social anxiety), with the paradigm of Exposure and Response Prevention, in which feeling the individual is encouraged to feel the fear, and in learning to tolerate it, reduce it, and to not respond by avoiding the fear-inducing situation. If this this approach hasn't been applied to fear underlying delusions (DOES ANYONE KNOW WHETHER IT HAS BEEN?) it might be useful.

b) Psychodynamic psychotherapy can help delusional individuals to find non-delusional alternatives to explain the underlying fears as not just a manifestation of aberrantly functioning neurobiology (and not as Heather cautions, "explain away"). It is crucial to help individuals with paranoid delusions find personally-relevant meanings to construct a non-delusional (and also non-grandiose) personal narrative for understanding their fears. In my experience, this is crucial for the person to be able to surrender their delusional narrative, but it is personally painful emotionally. It takes time, persistence and commitment on the part of both the patient and the therapist. Utilizing CBT techniques within the context of such a therapy can be very useful.

A final thought for now, it can not be over-emphasized that those persons experiencing fears driving their delusional narrative, experience such fears as truly existential.

Stephen,

I don't want to mislead you in any way. This is not my area of expertise, merely an area of interest. My training is in microbiology, molecular biology, microbial genetics (Streptomyces spp.) I happen to know some families with some individual histories of this type. I have observed this phenomenon over the years in several generations of several of these families and had the privilege of interviewing some of the individuals who had observed family members' struggles, or actual persons wrestling with these struggles.

"with the paradigm of Exposure and Response Prevention, in which feeling the individual is encouraged to feel the fear, and in learning to tolerate it, reduce it, and to not respond by avoiding the fear-inducing situation. If this this approach hasn't been applied to fear underlying delusions (DOES ANYONE KNOW WHETHER IT HAS BEEN?) it might be useful."

I have seen this approach with some success in committed individuals. Medication must be used in conjunction with therapy, and there must be strict compliance.

"It takes time, persistence and commitment on the part of both the patient and the therapist. Utilizing CBT techniques within the context of such a therapy can be very useful."

Absolutely.

"it can not be over-emphasized that those persons experiencing fears driving their delusional narrative, experience such fears as truly existential."

I totally concur.

"Better anti-psychotic medication with less or no risk of Tardive Dyskinesia is urgently needed"

Atypical anti-psychotics seem to be a good answer although some are problematic. The use of a particular medication involves trial and error, and the choice is based on experience of the individual using the drug and its unique effect on that person, as well as professional input. Dr. and patient must work as a team to maximize success.

"it is my observation that delusions and hallucinations stem from a fight/flight response that has been frozen by ambiguity. It is driven by mistrust, leading to paranoia, leading to delusions and hallucinations. There is always a grain of truth in the perceptions"

I forgot to add another player that leads to delusions and hallucinations, that is anxiety.

So, it is driven by mistrust and anxiety, leading to paranoia, leading to psychosis (delusions and hallucinations).

Stephen,

" a) Cognitive-Behavior Therapy (CBT) has demonstrated its usefulness in treating non-psychotic disorders of fear (such as in extreme social anxiety), with the paradigm of Exposure and Response Prevention, in which feeling the individual is encouraged to feel the fear, and in learning to tolerate it, reduce it, and to not respond by avoiding the fear-inducing situation. If this this approach hasn't been applied to fear underlying delusions (DOES ANYONE KNOW WHETHER IT HAS BEEN?) it might be useful"

I found three resources that may answer your question while I was searching for a different reference:

"CBT for Psychosis: A symptom based approach (The International Society for Psychological and Social Approaches...) by Roger Hagen, Douglas Turkington, Torkil Berge, and Rolf W. Gra(^)ve (Dec 2010)

"Staying Well after Psychosis: a Cognitive Interpersonal Approach to Recovery and Relapse Prevention" by Andrew Gumely and Matthias Schwannauer

"A Casebook of Cognitive Therapy for Psychosis" by Anthony P. Morrison

Stephen,

Per your post of 5/12/14, I'd like to add some clinical validation of the points you made about the role of the ambiguity and unexpected quality of stimuli in the genesis of paranoid ideation. Some years ago I was having a session with a patient in a state hospital (this patient was on Clozapine, so being treated for positive symptoms of sz). While I was speaking, there came a scraping/screeching noise from the floor above that I immediately recognized as someone dragging a heavy desk with metal feet across the floor. My patient became very alarmed, though, by this ambiguous and unexpected stimulus and was so fearful that he insisted we leave the building immediately. When I explained to him what I knew the sound to be, he remained very fearful and insisted that the hospital was being "invaded" by someone or something with hostile intent. We had to end the session so that he could exit the building where he believed he would no longer be in danger.

At the risk of sounding flip, it sounds like whatever dose of clozapine he was taking was insufficient, or he hadn't been taking the medication long enough. Though delusions often persist despite optimal antipsychotic medication dose and adequate duration, this man's startle reaction and extreme fear in response to the unexpected and ambiguous set of stimuli you describe, and your inability to reassure him rationally, all point to his medication been sub-optimal at that point. I hope that he improved.

Stephen,

I am a bit puzzled by your response. Are you suggesting that all patients on antipsychotic medication (even a therapeutic dose) would not have the same underlying biochemical or functional dynamic that would cause paranoid ideation to manifest? I have worked in two state hospitals and two VA hospitals where patients on medications manifested paranoid ideation. It would certainly be very nice if patients all responded perfectly to medications, but as I'm sure you know there is no magic pill that will totally eliminate the positive symptoms of sz.

Neil,

"I am a bit puzzled by your response. Are you suggesting that all patients on antipsychotic medication (even a therapeutic dose) would not have the same underlying biochemical or functional dynamic that would cause paranoid ideation to manifest?"

I tend to agree with Stephen about the possibility that the medication dose could be under-dosed or the patient may not have been taking the medication long enough to reach a steady state of equilibrium to achieve therapeutic level, or the medication simply was not compatible with the patients unique genetic makeup. The medications regulate the underlying biochemical or functional dynamic that causes the paranoia and hallucinations to manifest. I have some knowledge concerning pharmacology from some courses that I have taken at Purdue University, as well as my background working for a pharmaceutical company and having a PhD chemist for a husband, who has a good deal of pharmacological knowledge, at my disposal. I know that each person has a unique reaction to a medication and some medications work for an individual more effectively or less effectively if at all. It takes years of trial and error to hit upon the right cocktail of medication for a person with a chemical imbalance because it is a complex process and requires much trial and error. The patient and his/her psychiatrist must have an excellent rapport. The persons that I am familiar with who I have talked with extensively about their illness are quite stable (except the one who is not compliant). Five altogether I know their history in detail. Of the five three of them are very compliant with their medications, one is usually compliant but likes to live on the edge because he/she enjoys mania, one is not at all compliant because he/she enjoys mania .They have all (but one) found the right balance after years of honing the cocktails, and once stable have taken the medications for several to many years. Three are bipolar with paranoid ideation and hallucinations, leading to psychosis when untreated. One is schizoaffective with the same symptoms. One is manic but has not experienced psychosis yet (not complient). During the time period that optimization of medications there was much instability. During times of extreme stress there is instability as well, however, most try to minimize that type of situation from occurring

Margaret,

I don't wish to imply that the new generation antipsychotics have not been very helpful in stabilizing many patients who formerly would have required hospitalization. However, as you probably know, psychotic patients, like most every other phenomenon on earth, fall into a normal distribution. In these days of reduced funding for state mental health facilities, it is often the most acute and chronic patients who end up spending significant amounts of time at state hospitals. So I believe that the patient I mentioned was difficult to treat, ie, he did not respond well to various trials of medications. Granted, he MAY have been underdosed or enough time had not transpired for the medication regimen to reach full effectiveness, but my illustration is still valid because it shows the nature of paranoid ideation when not fully treated. Who knows but that this patient would have been ten times worse in his symptoms had he not been taking Clozapine.

Neil,

"I believe that the patient I mentioned was difficult to treat, ie, he did not respond well to various trials of medications. Granted, he MAY have been underdosed or enough time had not transpired for the medication regimen to reach full effectiveness, but my illustration is still valid because it shows the nature of paranoid ideation when not fully treated"

Thank-you for increasing my awareness of new settings in the context of mental health. I am afraid that I am a bit naive since I don't work in this particular field. I now understand the message that I answered earlier. Sometimes I don't read between the lines well, and I am most familiar with the information that I have gathered through observation or asking questions. I really appreciate your explanation.

Great conversation folks. Thanks and props to Neil for consistently posting such excellent questions on RG.

re Psychotropic meds-

We must also acknowledge that while atypical anti-psychotics can be very effective in reducing the incidence or severity of the acute positive symptoms of schizophrenia, they do not reduce the incidence or severity of the chronic negative symptoms, and in a significant proportion of patients these medications can actually increase the severity of negative symptoms.

This appears to be one of the main reasons that many patients out in the community are "treatment resistant" and non-compliant with their medication regime.

We don't have any good pharmacological agents for treating the negative symptoms of schizophrenia, but most patients smoke tobacco, (85% of them, at least where I work) and/or cannabis, and a significant minority will take stimulants such as methamphetamine or cocaine, at least in part as an attempt at self-medication.

Even patients who have good insight into the fact that these drugs aggravate positive symptoms and make an acute episode of psychosis far more likely may continue to take these drugs as a way of temporarily escaping the endless day-to-day grind of negative symptoms.

re CBT;

If someone is constantly in a state of fear or anxiety, then CBT and teaching effective coping skills for life stressors is an excellent adjunct to pharmacological treatments that can make an enormous difference. In some cases when these issues are effectively addressed medication is no longer necessary.

However there are life circumstances in which anyone would feel frightened, depressed, or anxious much of the time.

The most severely problematic patients with psychotic disorders tend to spend much of their time in just such circumstances. Many chronically unwell people are also chronically unemployed, homeless or living in shelters or hostels, and have little or no real psychosocial supports in the community. Most lead lives you or I would find under-stimulating and boring, but many are periodically exposed to highly stressful situations that we would find confronting, frightening, or anxiety provoking. A significant proportion have experienced periods of incarceration and many come from backgrounds of trauma and disadvantage.

Getting people into stable suitable accommodation, linking them with good psychosocial supports in the community, and helping them find something engaging and rewarding to do with their time can dramatically reduce the incidence of both positive and negative symptoms. This approach to mental health is called "Social psychiatry";

http://en.wikipedia.org/wiki/Social_psychiatry

.

https://www.researchgate.net/journal/0020-7640_International_Journal_of_Social_Psychiatry .

.

Unfortunately "Bio-psychiatry" dominates public health responses to mental illness. This means that, in treating schizophrenia, psychiatry tends to focus exclusively on medications that repress acute psychotic symptoms, and to neglect the social determinants of mental health or illness.

Don't misunderstand me- psychotropic meds are definitely extremely useful for the vast majority of people suffering severe and persistent psychotic disorders, and they revolutionized our approach to mental illness (although I agree with Margaret- it would be nice to have some effective anti-psychotics that didn't cause a host of adverse side effects).

But we really shouldn't be surprised when we force people into hospital for short periods of time, heavily medicate them, and then dump them back into the environment that helped to provoke their problems, that most will relapse in their mental state.

This is largely a product of funding priorities- it is much cheaper and easier to coerce someone to attend a clinic once every few weeks for a depot injection than to engage them with a clinical psychologist for long term treatment, or to address the issues of social exclusion and disadvantage.

http://www.cartoonstock.com/newscartoons/cartoonists/for/lowres/health-beauty-psychotic-psychos-psychiatry-cocktail-angry_patient-forn436l.jpg

I have a suggestion for therapy that I call re-directive energy resource therapy. I don't know if this technique is part of another therapy, it may be. It probably is so pardon my ignorance. I have noticed that redirecting the, passive energy used in a dysfunctional or counterproductive ways such as (smoking, binge drinking, ruminating, excessive mindless television viewing, anxiety, etc) can be countered by replacing the behavior with positive active pursuits (such as exercising, reading, crossword puzzles, puzzles in general, reading, crafts, artistic pursuits, etc) that are particularly engaging for the person in their own way. The key is to establish rituals or routines and activities that redirect negative energies into positive energies and to establish some sort of schedule ideally with or but if necessary without some amount of flexibility. Rituals and routines have a calming effect that helps to give life meaning. I know that this sort of exercise has helped me erase much of the negative energy that I have been concerned with. I learned it by modeling from my husband who is always busy with something he enjoys and who has a positive outlook on life. The process must be conscious and intentional. Traditional therapy would be essential too in accelerating this process forward. It may be that some of the negative energy is too compelling for the individual to handle, in this case I recommend concurrent medication treatment. Again, I apologize for my ignorance if this approach is already in practice.

"I have a suggestion for therapy that I call re-directive energy resource therapy. I don't know if this technique is part of another therapy"

Isn't this what they used to try do in the old Victorian asylums? I was looking through some old asylum journals recently, and noted that they gave scorecards for the cricket matches of the asylum team. Even in my day, I remember visiting my parents and finding that players were needed to play against the local asylum, which had once housed Rudolf Hess. Unfortunately, I only lasted 3 balls against the asylum fast bowler!

Neil,

Individuals with same diagnosis (e.g., and perhaps especially Schizophrenia) may well have disparate neurochemical and neurofunctional pathology, which may account for the substantial number of patients who are relatively resistant to the set of medications currently available. However, I was not alluding to this in my answer to your response to my earlier post. Rather, I was commenting on the patients extreme startle and fearful alarm response, impervious to your gentle attempt at reasoned reassurance.

Relevant to your original question, it is striking that delusions (both both paranoid and grandiose) often persist when the patient is no longer acutely psychotic is a striking fact. I invite participants discussing this question to comment on it.

Paul, your comments about individuals with negative symptoms, which often also persist after an acute episode are most germane. Having treated a number of the same individuals with schizophrenia for up to 20 years, I find that their delusions never completely vanished. Regarding several such folks, their delusions coexist with negative symptoms, and it seems to me that when delusions are grandiose, these reinforce the negative symptoms: Literally and figuratively, nothing really needs to be done.

Stephen,

I will make a couple of comments on your observation that patients who are no longer acutely psychotic continue to experience paranoid delusions. Firstly, I wonder - perhaps my superficial knowledge in this area is showing - if continued delusions are not a function of long-term structural damage to the brain (eg, amygdala, entire limbic system and its connections to the prefrontal cortex). In other words, could acute psychotic episodes put stress on the entire brain and precipitate damage to the neural physical and biochemical infrastructure? This damage, in turn, never allows the patient to return to baseline, and thus with each acute psychotic episode he/she deteriorates a little further, allowing the paranoid delusions to retain a foothold and continue to manifest.

Secondly, I refer back to my original question about why it is LESS common for patients to form delusions relating to non-personal information alone (eg, ants are really very small reptiles) and instead much MORE common that the delusional content relates to something relevant to the patient's life (eg, ants are an alien race preparing to overrun the earth, and thus will become a threat not only to the entire human race, but to the patient personally). Patients with psychotic disorders continue to be just as interested in their personal welfare and destiny as any human is. Therefore, the process whereby they attempt to make sense of the internal and external stimuli they experience continues in the same manner as they have used since the onset of the disorder: they misinterpret perceptions in their environment as a threat to their continued safety and existence.

What do you think?

"I was commenting on the patients extreme startle and fearful alarm response"

I understand how paranoia can arise from a fear response, but am unsure about the relevance of a startle response. If this acute onset is necessary, then it must involve reflexes at the brainstem or lower down, thus undercutting cognitive theories of paranoia. Are not ambiguous or strange stimuli, misinterpretation and fear sufficient for paranoia to develop?

Anthony,

Concerning "I have a suggestion for therapy that I call re-directive energy resource therapy. I don't know if this technique is part of another therapy"

Not all persons that experience psychosis are schizophrenic some examples are: bipolar persons, or schizoaffective persons (or maybe even hypo-mentalistic persons, opps!, that is the other end of the spectrum so, probably not) Some may be less resistant to various types of therapy other than medication.

"Isn't this what they used to try do in the old Victorian asylums?"

Well, It works for me, and by some standards there are persons that consider me a bit hyper-mentalistic.

Stephan,

Some of these comments go over my head because I am such an amateur in this subject. I need to understand this comment:

"their delusions coexist with negative symptoms, and it seems to me that when delusions are grandiose, these reinforce the negative symptoms: Literally and figuratively, nothing really needs to be done."

Are you saying that their delusions and negative symptoms cancel each other out, at least externally to the observer? I don't have the type of experience that you have and so do not have a feel for what you are expressing. Could you elaborate please. I need baby steps on this comment. And Anthony, please keep your sentiments to yourself if you can contain them. You seem to be frustrated by my lack of knowledge in the areas that you are well schooled. Patience is a virtue.

Margaret,

Just a few examples of negative symptoms that are very common in sz patients: anhedonia, avolition, poverty of speech, and flat affect. These negative symptoms often persist in this group of patients even after psychotropic medications have greatly reduced positive symptoms like hallucinations, delusions, and disorganized thinking.

An interesting question and discussion that I would like now to join!

The content of psychotic experiences has been an essential issue for me, I am a forensic psychiatrist and researcher: in the formulation and rehabilitation of risk of violence, giving expert testimony on issues of motivations for actions, why this person develops this symptom is central to that analysis. Persecutory and grandiose symptoms [delusions and hallucinations] are the ones that have an association with violence so are central to my work. [for instance papers on the psychotherapy of treatment resistant psychosis and motivation in my publications [eg: https://www.researchgate.net/publication/8992961_Can_recovery-focused_multimodal_psychotherapy_facilitate_symptom_and_function_improvement_in_people_with_treatment-resistant_psychotic_illness_A_comparison_study?ev=prf_pub ]

But why is it that psychotic experiences are so commonly of this sort, as Neil stated in his response 2 above? I would add to persecutory and grandiose, religiose or spiritual delusions. In other words, many psychotic experiences come out of disordered function in the brain areas that relate to interpersonal perception, personal relevance and personal/spiritual/transcendent meaning in the world. I am not an evolutionary psychologist/neuroscientist but I suspect the risk of psychosis is a product of the evolutionary explosion of the fore-brain and its connections in the last 2-3 million years; and the very particular highly sophisticated human processes of social relationships and meaning that have developed. I would greatly appreciate someone more knowledgeable than I adding this perspective to the discussion.

My final comment is that whilst research is seeking evidence of brain changes with psychosis, we can also repair the damage caused by the experience of psychosis using interventions in the interpersonal space. Psychosis disrupts and distorts one's sense of self, and sense of others [and can thus contribute to persisting suspiciousness]. This is an intrapsychic and interpersonal disruption that needs repair at the interpersonal levels, not simply an understanding of 'underlying' neuropathology and biological intervention.

Article Can Recovery-Focused Multimodal Psychotherapy Facilitate Sym...

Alexander,

Thanks for joining the discussion.

In your final section on repairing brain damage in individuals who have experienced psychosis, are you suggesting that damage can be repaired through psychotherapy and/or positive interpersonal interactions? For example, we know from postmortems that sz patients often have enlarged ventricles, demonstrating necrosis of brain tissue. How do you see this kind of damage being repaired?

I don't know. There are likely many paths to a psychotic illness, some through antecedent structural damage that is likely to persist regardless of what we do [eg birth trauma factors, intra-uterine viral illness in the mother etc]. Some may be genetic predisposition may contribute in ways less obviously structural; there is heterogeneity here.

We also know about the high degree of brain plasticity. Are people chronically under-stimulated through anti-psychotic medication [messy drugs that do what they need to do but also cause significant side effects], social and psychological withdrawal as a result of our interventions or failure to intervene? Might that too contribute to brain structural losses / negative symptoms?

We found in the paper I inserted the link to above that for the most treatment resistant patients on maximal medications in a good quality psychiatric rehabilitation facility that adding inter-personally based psychotherapy improved wellness and function. If that was sustained, presumably such change may be biologically measurable in the future. Whilst there is much talk of early intervention in psychosis, we are also rather keen on late intervention! People seemed available for possible improvement.

The danger for us conceptually at this stage of our understandings is in being linear: presuming all biology is 'underlying' and all psychological or social experience is simply a manifestation of the biology. We need to remain open to the 'causation' running in more than one direction.

Neil,

There is a small body of research on progressive brain damage in individuals at high risk for psychotic illness -- preceding their 1st psychotic break, and progressing further over time (ala Kraepelin's concept of Dementia Praecox). I am unsure whether number of acute episodes or exacerbations contributes to that progression, but the idea that early psychological, social, and pharmacological treatment could be neuroprotective has been raised. And the idea that pharmacologic intervention may be the cause of at least some of the progressive brain damage is a countervailing notion.

From a psychological perspective, yet one more acute episode revivifies the emotional states that led to the delusion in the 1st place, along with those delusional explanations.

As to your original question, I'm not able to add anything further to what has been said earlier at this time.

Anthony,

I do not think that exaggerated startle is necessary either, but that fear and ambiguity is.

Margaret,

Discussions such as these should be open to all. The most radical questions have have often been asked by individuals zones liminal to particular problems and issues, by people like you.

Let me give an example to illustrate my statement: "their delusions coexist with negative symptoms, and it seems to me that when delusions are grandiose, these reinforce the negative symptoms: Literally and figuratively, nothing really needs to be done."

A patient who believes that he will eventually be recognized as a deity, and bestowed commensurate powers, may not be inclined to do more than the basics for himself, as he awaits that day when all his wishes will be fulfilled.

Alexander,

Fascinating and important research you've been doing. I seem to recall reading a book (title?), which described a study that found religious and spiritual experiences in a psychotic break correlated with better outcome. I would expect that religious and spiritual experiences, and delusions of that ilk probably have different implications, psychologically and biologically, and practically, in terms of outcome. Do you know?

Stephan,

"Relevant to your original question, it is striking that delusions (both both paranoid and grandiose) often persist when the patient is no longer acutely psychotic is a striking fact",

and in a different conversation and set of circumstances if I understand correctly:

"Regarding several such folks, their delusions coexist with negative symptoms, and it seems to me that when delusions are grandiose, these reinforce the negative symptoms: Literally and figuratively, nothing really needs to be done."

I had a hunch, and have for a while that perhaps there was a connection between Aspergers and psychosis, not really schizophrenia per say, but the psychosis I am more observant of.

In "The Imprinted Brain, How Genes Set the Balance Between Autism and Psychosis", by Christopher Badcock,

"Mental functions such as inhibition, self-control, and self-awareness are known to be mediated by the front part of the brain: specifically, the pre-frontal cortex...the right pre-frontal cortex was more active than normal in divergent thinking in people with milder schizophrenic tendencies. Delusions could be seen as extreme divergences in thinking, and so it is perhaps significant that brain-scanning studies point to an association between distortion of reality and hyper-activity of the medial pre-frontal cortex in patients with schizophrenia and similar disorders...a new computational model suggests that a neurological system critical to the activity of the pre-frontal cortex ( the GABA, or gamma-aminobutyric one) is dysfunctional in psychotics thanks to moving into the so-called H---or hyperactive mode...the same explanation appears to work for substance -induced psychosis and for epilectics who have schizophrenia-like symptoms."

The author of the book goes on to suggest that one of the consequences of the brain abnormality in schizophrenia would be hyper-excitability of this part of the cortex, just as one might expect if hyper-mentalism was the fundamental pathology in psychosis. And he cites Tanaka, S. (2008). "Dysfunctional GABAergic inhibition in the prefrontal cortex leading to "psychotic" hyperactivation." BMC Neuroscience 9: 41.

In another reference to six cases diagnosed in 1926 as various types of "schizoid personality disorder", some described as "autistic" by its author and bearing striking similarities to the type of high functioning autism now associated with Asperger. The author cited Sass, L. A. (1992) "Madness and Modernism". New York, Basic Books. Thomson A. (2001). Personal Communication.

I googled "1926 schizoid personality disorder, and high on the hits was this reference:

Schizoid Personality in Childhood and Asperger Syndrome, Chapter 10 [in "Asperger Syndrome, edited by Ami Klin (PhD), Fred R. Volkmar(MD) Sara S. Sparrow (PhD)] by Sula Wolff: "as we shall see, our schizoid young people were, as a group, much less impaired socially impaired in both childhood and adult life, than groups of patients described more recently as having Asperger Syndrome (AS), (Wing, 1981, 1992; Tantum, 1986, 1991)...The results of two records surveys follow, exploring the association of schizoid personality in childhood with psychiatric morbidity, including schizophrenia, in later life...The chapter ends with speculations about the genetic causes of the syndrome, in particular a possible link between schizoid personality traits and childhood autism on the one hand, schizophrenia on the other."

Maybe in some patients showing psychotic features there are no ties to autism as your first comment suggests.

Maybe in some patients there are both autistic features and psychotic features as your second comment may suggest.

In regards to my second comment just above this paragraph, if autism and schizophrenia are on a continuum, would it make sense that some of the less impaired members that complimented each other (who were opposites on the spectrum, for example someone a bit naive and mildly hypervigilant marrying someone with savant skills, yet at the same time somewhat obsessive/compulsive) marry and parent some % children having exceptionally mild traits on either continuum; some % of children having traits of moderate severity in one, the other, or both ends of each continuum; some % children with more severe traits on each continuum at one, the other, or both ends; some children having no traits being especially remarkable expressed at all on the spectrum of either traits, etc., especially taking recombination into account?

"Are not ambiguous or strange stimuli, misinterpretation and fear sufficient for paranoia to develop?"

Are humans not startled by strange or ambiguous stimuli?

As I happen to have Mental Diseases by H J Berkley (1900) open in front of me, I will give a relevant extract from his section on Chronic Progressive Paranoia:

"The hallucinatory voices, central in their origin, are rarely evolved in completed form in the beginning of the disorder. At first simple noises, like the whir or click of machinery, are heard, the low murmuring of voices in the distance, the patter of falling water. The patient is annoyed by their presence, and very often seeks an explanation for them in some electrical or supernatural cause. Little by little the sounds resolve themselves into distinct voices, and ordinary acoustic stimuli are sufficient to elicit them. The voices pursue the subject continually; in the roar of the street or in the stillness of the night equally they are heard. They follow him wherever he goes, distubing his sleep by their constant presence. After they have become fixed, acoustic stimuli are no longer necessary for evoking them, the disturbance being central. In the vast majority of these cases the voices are inimical; they threaten the person, they tell him that he is a miserable, dirty creature, a sexual pervert; they slander him in every manner, or excite him to stab himself, or to commit suicide in some other way. ..The patient is persecuted to a degree that renders life well-nigh intolerable, and death is sometimes sought as a means of relief from the torture...These hallucinations are more frequently unilateral than bilateral, and are referred to one or the other ear."

Any patient with noises in the ear, especially if unilateral, has ear disease, and if none is apparent, the doctor (or specialised audiologist) has not looked hard enough. If patients have something that draws their attention to their ear (pain, deafness, etc), then they will realise they have tinnitus and that their ear is playing up. If not, then it seems perfectly reasonable to me that they will think someone has planted devices in their head or is persecuting them. This interpretation is surely the mark of an intact brain, not a diseased one.

Hi all, it is really interesting seeing theory expressed by professionals. I am wondering if there is a body of theory expressed by people who have lived experience? As one who has been psychotic 7 times (once postpartum then over 4 years while going through early menopause, hidden dental infection and I have Pyroluria) I can only describe the experience as tripping. Rather than diminished senses the senses feel expanded, this brings with it sensory information which is unusual as its not normally available to the settled and comfortable human being. This then leads to information overload and eventually exhaustion. And yes it is hard to view the world and oneself in quite the same way again even when fully over the event.

Again not unlike tripping on any strong psychoactive substance.... Compare the experience with people who take drugs during spiritual awakening practices in South America for example (I have not tried any drugs but have spoken to many who have). This is where my question about the natural form of the chemical/neurotransmitter Dimethyltryptamine (DMT) comes in. We hear lots of talk about biochemistry and various neurotransmitters and their pathways yet DMT is always left out of the conversation. We all make DMT, even grass has DMT and its a banned substance when made for the purpose of tripping but what happens when we make too much within our own bodies? Why does this question get ignored?

In regards to autism we know that they often have to deal with constant information overload and are very sensitive to both visual and auditory stimulus. Why does this have to be seen as a disorder? If it were treated as a gift then perhaps some of the fear and social exclusion would diminish. The same for psychosis, it is well established that people in some cultures are treated as temporary spiritual sages during a break and that their long term wellness is far better than when treated as divergent, diseased and disturbed. Fear is a two way pathway and most often applied by the one with the most authority to the one who is already afraid.

Hi Stephen, re Religiosity spiritual beliefs and practices, and psychotic disorders, the evidence is a bit mixed.

It would seem that incorporating a patients beliefs in to treatment for mental illness and/or substance use problems can be a potentially useful approach BUT only if it is culturally appropriate for the individual, and if they want or welcome such an approach. If it is included without the individual's involvement in treatment planning, and particularly if it's a one-size-fits-all approach and the treatment involves the therapist trying to impose their own beliefs, then it is potentially very harmful, will make the development of a true therapeutic relationship between you and the person difficult if not impossible, and will potentially cause many people to drop out of treatment. If treatment is coerced (eg court-mandated), it is even more important that the treatment offered is not only religious or spiritually based. http://www.quickanddirtytips.com/business-career/legal/does-mandatory-aa-violate-constitution .

If the person has a serious and persistent mental illness, then these issues need to be approached with great caution.

>>

http://www.ncbi.nlm.nih.gov/pubmed/15340880 .

Regards, Paul.

"As one who has been psychotic ... I can only describe the experience as tripping. Rather than diminished senses the senses feel expanded"

Thank you for this observation. I am having extreme difficulty trying to persuade professionals that auditory hallucinations in those with ear disorders are due to auditory overload rather than underload (auditory deprivation). Just because someone is deaf does not mean that their auditory input is reduced. Anyone with tinnitus, audiosensitivity or recruitment can attest to increased and distressing perceptual experiences.