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Psychosis
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Integrating subjective experiences,
psychodynamic understandings and
biological knowledge
Toronto, June 5 2008
Johan Cullberg MD PhD
Ersta Sköndal University College,
Stockholm
The ego’s ongoing
construction of the world
•Rapid changes between perceptions and
interpretations
•The ego constructs a ”Gestalt”
•This dialectics is abolished in dreaming
and (partly) in psychosis
Psychosis:
•Failure in creating a correct ”Gestalt” of the
outer world
•Regressive creating of meaning
•Inner, private world is given priority
•Meaning is more important than rationality
First Episode Psychosis - model
Recovery
1st
2nd critical period
critical period
DUP
Prodromal phase
Relapse
Treatment
Psychosis phase
Recovery phase
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Stages and subjective experiences in
psychosis:
1: Prodromal phase - days or months
• Withdrawal tendencies – social, working or
study problems
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Affective outbursts
Increased inner speed
Premonition of mental break-down
Compensatory strategies
Depression and panic attacs
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2: PSYCHOSIS PHASE:
(weeks - months)
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“Am I in the world or am I the world?”
Regressive strategies to create meaning
Hallucinations confirm delusional thinking
Thoughts and actions controlled by others
Resistance to relying in anyone/anything
from outer world (care, medication, trust
etc)
• Omnipotence and deep loneliness
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3: Late psychotic phase:
• Delusions more often questioned and less
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maintained
“Islands of normality” increasingly frequent
Depressive thoughts more prominent through
reality confrontation
Tendency to seek protection in psychosis
Cooperation with therapist deepening – who can
be trusted?
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4: Recovery phase: Remaining
psychotic symptoms or resolution
(most often within 3 months)
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Separation between inner and outer world
Psychotic “shadows” may remain
Pain, shame - relief
PTSD (traumatic memories from care)?
Denial of psychosis?
Are the bridges burned?
Life with the memory of psychosis and
awareness of one’s vulnerability
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From
Disease model (Kraepelin around 1890)
to
Vulnerability-Stress model (Zubin 1977)
or
Vulnerability-Interactional stress model
(Strauss 1983)
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Dimensions of vulnerability to psychosis
A: Genetic
B: Pre/perinatal
injuries
C: Early trauma,
Attachment problems
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1 factor- low risk
2 factors higher risk
3 factors high risk
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Three phases of Schizophrenia (Ciompi)
Biological factors
Phase 1
Psykosocial factors
Early traumatic experiences etc
Genetics, perinatal injuries
Premorbid vulnerability
Stress
Phase 2
Acute psychosis
Psyko-social factors
Phase 3
Some disability or ”chronicity”
Complete remission
or a few symptoms
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Long-term schizophrenia
• Around 1/3 of first episode psychosis patients tend to ”chronify”
• Inner world is mixing up with external world
• Deficient control of the ”expected future”
• Deficient awareness of body?
• But often: fantasy, warmth, sense of humour
• Between two fires: overstimulation and understimulation
• Neuroleptic medication 25-40% better than placebo. Risk for overmedication!
• With network and relations, job and supported living, most
patients recover
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The schizophrenic person’s personality
change – a dynamic partial explanation
• The early vulnerability also implies a
sensitization of self image – ”outsider”
• The first psychosis is a mental trauma
which further disturbs the self-image
• A partial withdrawal to the inner world
means a higher security of self
• ”Schizophrenia”
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The affective vulnerability
• A thin ”mental skin”
• Complex and highly charged inner mental
representations of good/bad
• Easily evoked symbolic connections
external/inner world
• Lowered ability to deal with separation,
frustration, falling in love, aggression
• Psychotherapy and low dose medication
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What is curative?
• Milieu
– low stimulation level, security, coherence
• Medication when needed
– lowest effective dose
• Therapeutic alliance
– respect, interest, non-intrusive warmth
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Attitudes towards the patient -according
to the Danish OPUS project:
n A long awaited guest who you want to feel
welcome and at home during a long visit.
n A collaborator, whose insights and attitudes
are decisive for the outcome.
n An individual with personal preferences
that should be taken into account in the
treatment to the greatest extent possible.
Merete Nordentoft, Bispebjerg Hospital, psykiatrisk afdeling, 2006
Antipsychotic medication – the
patient’s friend or enemy?
• ”Therapeutic window” at 1-4 mg haldol-eqv in f.e.p.
• Higher dose gives side-effects without increasing anti•
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psychotic effects
Side-effects appear soon after intake, anti-psychotic
effects after 1-5 days – slow increase of doses!
Antipsychotic effects because of more indifference which
lowers vulnerability to psychotic thoughts? (Healy,
Kapur)
High dose inhibits the dopamine systems of frontal lobes
and thus down-grades the motivational affects
Moderate dose give a chance for psychological
restructuring, high doses lower vitality
The effect is 30-50% betterjc than with no medication 17
Thresholds for antipsychotic drug effects in FEP
D2 receptor occupancy (%)
100
80
EPS threshold
Antipsychotic effect threshold
60
40
20
0
0
1
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Dose/plasma concentration
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Farde et al (1992)
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”Hearing inner voices”
• When you hear constant inner voices and know
they don’t come ”from outside” - you don’t
suffer from a psychosis but from a disorder of
perception – a minor disturbance of the brain
• Such voices rarely are helped with medication –
still many psychiatrists are tempted to continue
med which may lower your quality of life
• You need psychological support for better
dealing with the voices
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Psychological treatments and
psychosis – different models should be
encouraged in the team
• Dynamic models: Identifying relational or
developmental crisis, trauma (separation,
frustration, stress). Important in early phase –
brief and schizophreniform psychoses
• Cognitive models: Taking control over voices,
depressive thinking, investigting delusional
thinking. Important in late phases
• Educational models: How to think about
psychosis, treatments, relapses – all cases
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Coherence
and
Hope
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