Richmond Fellowship is a charity and voluntary sector provider of mental health services in England.
Established in 1959, Richmond Fellowship serves over 9000 people in England every year, and offers a range of support to people with mental health problems including supported accommodation, residential care, employment support and community based support, working with the NHS and local authorities to deliver services.
Brief History
Richmond Fellowship was founded in 1959. The aim of the service was reintegrating people with mental ill health into the community despite long periods of time in hospital.
In 1973, Princess Alexandra became a patron of Richmond Fellowship and the organisation became a registered housing association in 1976. Richmond Fellowship played a significant role in hospital re-provision during the 1980s, providing new homes in the community for people across England. At this time Richmond Fellowship expanded its services for people with mental health problems including work schemes and day centres.
In 1975 the Richmond Fellowship opened a halfway house in Morriston, New Jersey. In 1985, the organisation expanded to Hong Kong.
Throughout the 1990s, Richmond Fellowship grew and developed a widespread programme of mental health support including self contained flats, floating community support and 24-hour nursed care. It achieved Investors in People status in 1998.
Continued growth saw Richmond Fellowship adapt its mission to ‘Making Recovery Reality’ in 2006 to reassert its core values and better represent the holistic range of support it offers to people with mental health problems.
In October 2015 Richmond Fellowship joined a new national group of charities, Recovery Focus, which brought together organisations with strong individual services, innovative approaches, flexible local presence and a wide range of expertise from around England. The partnership is made up of mental health charities Richmond Fellowship, 2Care, Croftlands Trust and My Time along with substance misuse charities Aquarius and CAN.
In April 2016, Helen Edwards was appointed the new group Chair of Recovery Focus, the group which brings together a coalition of mental health and substance use charities such as Richmond Fellowship and Aquarius.
Campaigns
Richmond Fellowship is an active member of Time to Change running awareness campaigns to tackle mental health stigma. Richmond Fellowship is also a supporter of the Mental Health Crisis Care Concordat and a member of the National Suicide Prevention Alliance.
Systems-centred therapy (SCT) is a particular form of group therapy based on the Theory of Living Human Systems developed by Yvonne Agazarian.
The theory postulates that living human systems survive, develop, and transform from simple to complex through discriminating and integrating information. Corresponding to the small and rigorously defined set of concepts, SCT defines a set of methods, techniques and instruments. SCT practitioners use these with individuals, couples and groups to explore the experience of their differences and work with these to integrate them. Using the method of functional subgrouping, these living human systems increase their ability to see both sides of their issues and resolve them productively. The theory was first developed in Agazarian’s 1997 book, Systems-Centred Therapy for Groups, and grew out of her earlier work in group psychotherapy under the influence of such figures as W.R. Bion and John Bowlby through the further input of the general systems theory of Ludwig von Bertalanffy.
SCT explains how living human systems contain their energy within functional boundaries and direct it towards their goals: the primary goals of survival and development and the secondary goals of environmental mastery. In SCT training groups, all members work in functional subgroups rather than work alone. Subgroups work both sides of every issue in the group-as-a-whole. This practice strengthens both the therapeutic capacity of the training group and allows individual members to choose which side of the conflict has therapeutic salience for their own personal work.
Theory of Living Human Systems: An Introduction
SCT and consultation developed by Yvonne Agazarian is based on the Theory of Living Human Systems, a theory that can be applied to any living human system as small as one individual or a large group and couples, families, classrooms, committees, businesses or even nations. Thus the theory offers a set of ideas for thinking about how living human systems work that can be applied at any level.
The theory defines “a hierarchy of isomorphic systems that are energy-organizing, self-correcting and goal directed” – working on the assumption that psychic patterns will be repeated in the same form (isomorphy)at every nested level of interaction. Each of these constructs is then operationally defined with methods developed that test the hypothesis of the theory. In this way, it offers a comprehensive systems theory and methodology of practice that can be applied in clinical, organisational and educational settings. Most importantly, Agazarian’s theory of living human systems introduces the hypothesis that the single essential process by which living human systems survive, develop and transform is by discriminating and integrating differences.
Working with Differences
Differences are challenging for people, whether they are differences in opinions, beliefs, ideas, wishes, or feelings. Differences are challenging even when we find them inside of ourselves. Groups often respond to differences that are “too different” by ignoring the differences, avoiding the differences, trying to change or convert the differences or blaming, judging or scapegoating the differences. Groups that respond in these ways to differences can survive unchanged for a long time since anything that challenges the status quo does not become incorporated into the group or is rejected by the group.
Because of this tendency, Systems-centred therapists or consultants pay a lot of attention to communication within the system. They are particularly looking to reduce the defensive “noise” within the communication. Noise is defined as contradictions, (Simon and Agazarian), ambiguities and redundancies (Shannon and Weaver). This concept of noise was developed from work by Shannon and Weaver who formulated observations about the inverse relationship between noise and information transfer. By highlighting and reducing contradiction, ambiguities, and redundancies, i.e. “noise”, communication is more effective in transferring information and the system has a better chance of discriminating and integrating its differences.
According to the theory of living human systems, groups that are able to take in and use differences are able to not only survive but also develop and transform. This kind of development enables groups to use their differences as resources to find solutions to problems that are more comprehensive and responsive to the complexity of the problem. They are able to move with less difficulty toward their goals.
Functional Subgrouping
In systems-centred therapy, members are taught to manage differences and resolve conflicts by a technique called functional subgrouping. Rather than individual members working alone, functional subgrouping requires that all members of a system that are similar work together to deeply explore their similarity. When that subgroup finishes its exploration, the subgroup holding a difference begins its work, exploring their similarities with one another. Inevitably, as the members of a subgroup talk with each other, they discover differences (i.e. differences within the apparently similar) within their subgroup and also, find similarities with the other subgroup (similarities in the apparently different). By using functional subgrouping, the whole group has a better chance of integrating its differences rather than rejecting differences. When a group can make use of its differences it becomes more complex and interesting akin to the way music is enriched by harmonies or interwoven themes. The group moves from the survival of the status quo to development and transformation.
SCT clients learn through experience. By exploring one’s experience rather than explaining it, members learn to tell the difference between comprehensive understanding (words first, experience second) and apprehensive understanding (experience first, words second). Clients learn to restore the connection between their comprehensive, thinking self and their emotional, intuitive self. Learning this skill leads to “containing” the energy and gaining the knowledge that frustrations and conflicts arouse, rather than discharging, binding or constricting it in defensive symptoms. Energy in SCT is understood as the ability of the group or individual to work towards its goals.
Working with Perspectives
Another important part of the theory of living human systems is that groups function more effectively when there is the capacity to shift perspective from the perspective of the individual to the perspective of the whole group. Being able to shift perspective from seeing things from the perspective of a person in a group (or couple or family or business, etc.) to the perspective of a member of the group creates a climate of mutual work toward a common goal. Individuals who are able to make the shift from the perspective of an individual to the perspective of a member or systems-centred perspective are less likely to take personally the inevitable challenges that arise as a human system moves toward its goal. When we take things less personally, we are less likely to get bogged down in frustration, hurt feelings and unproductive arguments. When we understand ourselves in the context of the systems that we belong to and co-create – our families, schools, businesses, labour unions, political parties, churches, sports clubs – we not only participate in their tasks, we are also involved in their development: establishing the distribution of authority and the degree of trust that help these systems survive and grow. Doing this, we contribute to the system balance between innovation and continuity, and at the same time strike a balance between our own desire to learn and our want for security.
Phases of Development
The systems-centred methods which developed from the theory of living human systems offers a map of predictable phases for the development of human systems. In the first phase of development, a system comes to terms with the issues of giving and taking authority and with the authority that resides in the members. Successful management of this phase leads to cooperation between members and between members and leaders. Unsuccessful management of this phase results in members behaving defiantly or compliantly which inevitably undermines the group’s development.
In the second phase, called the intimacy phase, the group wrestles with the challenges of closeness and distance from fellow members. This is the phase of team building for workgroups and the phase in which the issues related to separation and individuation are explored in therapy groups. As the group works in this phase it explores the pull to becoming enchanted with itself or becoming disenchanted and falling into despair with no energy to do its work. Successful management of this phase allows members to gain greater access and intimacy with themselves and also to work together with others in a climate of tested and mutual trust.
In the third phase of development, the group has the opportunity to develop a greater access to its emotional and rational intelligence and develops the capacity to use that information effectively in the service of the group’s goals. The group works more efficiently as it is more able to accept the reality of the role each member plays in the group, and stays more connected to the goal of the group and the reality of the environment in which the group is working.
Successfully managing the challenges of these phases of development means that the system is capable of developing an effective distribution of authority, establishing a climate of trust, and developing the capacity for system adaptation and learning. Wheelan (2005) has shown that work groups that are more developed in their phases have increased productivity.
As Psychotherapy
The theory of living human systems has been applied to psychotherapy as well as to business, organisational and educational consultation. In its application to psychotherapy, a unique aspect of this theory is that it is equally applicable to both individual and couples psychotherapy and to group psychotherapy. SCT posits that much of a person’s suffering is related to viewing oneself only from the perspective of the individual self, a person-centred view. By developing a capacity to see oneself from the perspective of the system one is a part of, a systems-centred perspective, the psychotherapy client is able to more consciously influence their own development and the development of the systems they are a part of.
A SCT therapist uses the phases of development described in the theory of living human systems to systemically train a client to recognise states of mind that interfere with reaching the client’s goal. These interfering states of mind are referred to as defences. Two of the most common defences that bring people to psychotherapy are anxiety and depression; these are addressed in the first phase of treatment. Clients are taught how to recognise and reduce these defences so that they are freed to traverse life less painfully and more smoothly. SCT work is a partnership in which the therapist governs the structure of the therapy and clients make a series of manageable choices at different “forks in the road”. Each fork is a choice a person makes between familiar defences and experiencing the emotion, conflict or impulses that triggered the defence. The systems-centred therapist teaches the client to systematically weaken the defence, such as anxiety or tension, in a structured sequence that matches the client’s ability to choose. As each defence is undone, the client can choose to take the fork in the road away from the symptoms generated by their defensive responses, and towards discovering the conflicts, between their emotions or impulses and the fears of their emotions or impulses, that were being defended against. As SCT psychotherapy proceeds, the client acquires skills that increase their ability to undo their own defences. Through this process, clients regain their ability to use their common sense, (and existential humour!) to manage the every day conflicts between themselves and reality. Clear outcome criteria for each step are in the sequence of defence modification locates the client in the SCT treatment plan. Because each defence modification addresses a specific symptom, therapy can be delivered either continuously or chunked into modules. SCT can therefore be applied to the goals of both short-term and long-term therapy.
Criticism
Irvin D. Yalom has seen the formation of subgroups as a negative indicator in the context of group therapy.
Role suction is a term introduced in the United States by Fritz Redl in the mid-20th century to describe the power of a social group to allocate roles to its members.
W.R. Bion’s group dynamics further explored the ways whereby the group (unconsciously) allocates particular functions to particular individuals in order to have its covert emotional needs met; and the process has recently been highlighted anew within the systems-centred therapy of Yvonne Agazarian.
Among regularly occurring group roles are those of the scapegoat for the group’s troubles; the joker; the peacemaker; the critic/spokesperson for group standards; the idol, or upholder of the group ideal; and the identified patient. In mixed gender groups, women may be disproportionately pressured by role suction into playing a nurturing/peacemaker role.
The ease whereby people pick out those who play complementary games, and the psychological splitting of good and bad help fuel such role differentiation.
Behind role suction, such forces as projective identification and countertransference have been singled out as operating at an unconscious level in the group.
Role lock – confirming mutual suction into complementary roles, such as victim and abuser – is ensured by the intermeshing of projective identifications.
Wider Systems
The British anti-psychiatrists explored the theme of group suction in connection with role attribution in the family nexus, as well as with the allocations of roles in the wider social system, David Cooper suggesting that ‘there are always good or bad, loved or hated ‘mothers’ and ‘fathers’, older or younger ‘brothers’ and ‘sisters’…in any institutional structure”.
A wider variety of roles can however be found in organisational life, the person-in-role acting as a container for the (unconscious) group forces.
Role of the Therapist
Bion has described his experience as a group therapist when he “feels he is being manipulated so as to be playing a part, no matter how difficult to recognise, in somebody else’s phantasy…a temporary loss of insight, a sense of experiencing strong feelings, and at the same time a belief that their existence is quite adequately justified by the objective situation”. Bion’s work has also been used to illustrate the part played by role suction in the selection of group leaders – dependent groups favouring narcissistic leaders, the fight/flight group paranoids.
R.D. Laing considered that a central part of the therapist’s job was “not to allow himself to collude with the patients in adopting a position in their phantasy-system: and, alternatively, not to use the patients to embody any phantasy of their own” – to resist role suction. Later therapists however have explored how a measure of adaptation to patients’ role suction – a degree of role responsiveness – can be a useful element in the therapeutic use of the countertransference.
Criticism
From the point of view of systems-centred therapy, the debate relates to the interface between a personal system and the psycho-dynamics of social systems themselves.
Debate has arisen about how far the group imposes roles, and how far the individual’s own personality goes to meet the group halfway. Earl Hopper has used the term personification to challenge Redl’s concept, suggesting instead that group roles reflect the underlying personality of the individual involved. However, Kibel objects that in many cases the roles imposed are in fact ego-dystonic; with others pointing to how personal tendencies combine with group expectations with varying degrees of fit.
1924 – Anna Elisabeth (Lise) Østergaard, Danish psychologist and politician (d. 1996).
Lise Ostergaard
Anna Elisabeth “Lise” Østergaard (18 November 1924 to 19 March 1996) was a Danish psychologist and a politician in the social-democratic party.
Under Anker Jørgensen’s leadership, she was Minister without Portfolio (1977-1980) and Minister of Culture (February 1980 to September 1982). As a psychologist, she was head of psychology in Copenhagen’s Rigshospitalet (1958) as well as the first woman to become professor of clinical psychology at Copenhagen University (1963), a position she resumed after her political career ended in the mid-1980s.
Biography
Born on 18 November 1924 in Odense, Østergarrd was the daughter of Alfred Østergaard (1890-1962) and his wife Martha Kirstine Nielsen (1885–1944). She spent her first 12 years in Odense before moving with her parents to Gentofte. Although she encountered difficulties at school, she finally embarked on psychology studies at Copenhagen University. On leaving home against her father’s wishes, she paid her own way by working as a doctor’s secretary.
Psychology
After graduating in 1947, Østergaard worked as a psychologist in Norrtulls sjukhus, a children’s hospital in Stockholm. In 1949, she returned to Denmark, first spending a year in Dronning Louises Børnehospital (Queen Louise’s Children’s Hospital) before moving to the newly established children’s psychology clinic at Copenhagen University where she remained until 1954. She then entered the Rigshospitalet’s psychology department where she was appointed head psychologist in 1958, expanding her experience in clinical psychology. As a result, from 1955 to 1960 she headed a course in clinical psychology for the Dansk Psychologforening (Danish Psychologists Association) while teaching as the first woman psychologist at the university. She also took up assignments as a guest lecturer in Lund, Sweden, and Bergen, Norway.
Published in 1961, her Den psykologiske testmetode og dens relation til klinisk psykiatri (The Psychological Test Method and its Relationship to Clinical Psychiatry) raised considerable interest among psychiatrists. While working at Rigshospitalet, Østergaard treated a number of schizophrenic patients. In 1962, this led to her En psykologisk analyse af de formelle schizofrene tankeforstyrrelser (A Psychological Analysis of Formal Schizophrenic Thought Disorders), paving the way for research on the borderline between psychology and psychiatry in collaboration with the National Institute of Mental Health in the United States.
In 1963, Østergaard became the first female professor of psychology at Copenhagen University. After heading the Studenterrådgivningsklinikken (Student Advisory Clinic, 1964-1968), she established the Institut for Klinisk Psykologi (Clinical Psychology Institute) in 1968. From 1970 to 1973, she was a member of Denmark’s Unesco committee and from 1973 a member of Akademiet for de Tekniske Videnskaber (The Danish Academy of Technical Sciences).
It is taken either by mouth or by injection into a muscle. The injectable version is long-acting and lasts for about two weeks.
Common side effects include movement problems, sleepiness, dizziness, trouble seeing, constipation, and increased weight. Serious side effects may include the potentially permanent movement disorder tardive dyskinesia, as well as neuroleptic malignant syndrome, an increased risk of suicide, and high blood sugar levels. In older people with psychosis as a result of dementia, it may increase the risk of dying. It is unknown if it is safe for use in pregnancy. Its mechanism of action is not entirely clear, but is believed to be related to its action as a dopamine and serotonin antagonist.
Study of risperidone began in the late 1980s and it was approved for sale in the United States in 1993. It is on the World Health Organisation’s List of Essential Medicines. It is available as a generic medication. In 2018, it was the 159th most commonly prescribed medication in the United States, with more than 3 million prescriptions.
Medical Uses
Risperidone is mainly used for the treatment of schizophrenia, bipolar disorder, and irritability associated with autism.
Schizophrenia
Risperidone is effective in treating psychogenic polydipsia and the acute exacerbations of schizophrenia.
Studies evaluating the utility of risperidone by mouth for maintenance therapy have reached varying conclusions. A 2012 systematic review concluded that evidence is strong that risperidone is more effective than all first-generation antipsychotics other than haloperidol, but that evidence directly supporting its superiority to placebo is equivocal. A 2011 review concluded that risperidone is more effective in relapse prevention than other first- and second-generation antipsychotics with the exception of olanzapine and clozapine. A 2016 Cochrane review suggests that risperidone reduces the overall symptoms of schizophrenia, but firm conclusions are difficult to make due to very low-quality evidence. Data and information are scarce, poorly reported, and probably biased in favour of risperidone, with about half of the included trials developed by drug companies. The article raises concerns regarding the serious side effects of risperidone, such as parkinsonism.
Long-acting injectable formulations of antipsychotic drugs provide improved compliance with therapy and reduce relapse rates relative to oral formulations. The efficacy of risperidone long-acting injection appears to be similar to that of long acting injectable forms of first generation antipsychotics.
Bipolar Disorder
Second-generation antipsychotics, including risperidone, are effective in the treatment of manic symptoms in acute manic or mixed exacerbations of bipolar disorder. In children and adolescents, risperidone may be more effective than lithium or divalproex, but has more metabolic side effects. As maintenance therapy, long-acting injectable risperidone is effective for the prevention of manic episodes but not depressive episodes. The long-acting injectable form of risperidone may be advantageous over long acting first generation antipsychotics, as it is better tolerated (fewer extrapyramidal effects) and because long acting injectable formulations of first generation antipsychotics may increase the risk of depression.
Autism
Compared to placebo, risperidone treatment reduces certain problematic behaviours in autistic children, including aggression toward others, self-injury, challenging behaviour, and rapid mood changes. The evidence for its efficacy appears to be greater than that for alternative pharmacological treatments. Weight gain is an important adverse effect. Some authors recommend limiting the use of risperidone and aripiprazole to those with the most challenging behavioural disturbances in order to minimise the risk of drug-induced adverse effects. Evidence for the efficacy of risperidone in autistic adolescents and young adults is less persuasive.
Other Uses
Risperidone has shown promise in treating therapy-resistant obsessive-compulsive disorder, when serotonin reuptake inhibitors are not sufficient.
While antipsychotic medications such as risperidone have a slight benefit in people with dementia, they have been linked to higher incidences of death and stroke. Because of this increased risk of death, treatment of dementia-related psychosis with risperidone is not US Drug and Food Administration (FDA) approved.
Forms
Available forms of risperidone include tablet, oral dissolving tablet, oral solution, and powder and solvent for suspension for injection.
Adverse Effects
Common side effects include movement problems, sleepiness, dizziness, trouble seeing, constipation, and increased weight. About 9 to 20% of people gained more than 7% of the baseline weight depending on the dose. Serious side effects may include the potentially permanent movement disorder tardive dyskinesia, as well as neuroleptic malignant syndrome, an increased risk of suicide, and high blood sugar levels. In older people with psychosis as a result of dementia, it may increase the risk of dying.
While atypical antipsychotics appear to have a lower rate of movement problems as compared to typical antipsychotics, risperidone has a high risk of movement problems among the atypicals. Atypical antipsychotics however are associated with a greater amount of weight gain.
Drug Interactions
Carbamazepine and other enzyme inducers may reduce plasma levels of risperidone.
If a person is taking both carbamazepine and risperidone, the dose of risperidone will likely need to be increased.
The new dose should not be more than twice the patient’s original dose.
CYP2D6 inhibitors, such as SSRI medications, may increase plasma levels of risperidone and those medications.
Since risperidone can cause hypotension, its use should be monitored closely when a patient is also taking antihypertensive medicines to avoid severe low blood pressure.
Risperidone and its metabolite paliperidone are reduced in efficacy by P-glycoprotein inducers such as St John’s wort.
Discontinuation
The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotic treatment to avoid acute withdrawal syndrome or rapid relapse. Some have argued the additional somatic and psychiatric symptoms associated with dopaminergic super-sensitivity, including dyskinesia and acute psychosis, are common features of withdrawal in individuals treated with neuroleptics. This has led some to suggest the withdrawal process might itself be schizomimetic, producing schizophrenia-like symptoms even in previously healthy patients, indicating a possible pharmacological origin of mental illness in a yet unknown percentage of patients currently and previously treated with antipsychotics. This question is unresolved, and remains a highly controversial issue among professionals in the medical and mental health communities, as well as the public.
Dementia
Older people with dementia-related psychosis are at a higher risk of death if they take risperidone compared to those who do not. Most deaths are related to heart problems or infections.
Pharmacology
Pharmacodynamics
Risperidone has been classified as a “qualitatively atypical” antipsychotic agent with a relatively low incidence of extrapyramidal side effects (when given at low doses) that has more pronounced serotonin antagonism than dopamine antagonism. Risperidone contains the functional groups of benzisoxazole and piperidine as part of its molecular structure. Although not a butyrophenone, it was developed with the structures of benperidol and ketanserin as a basis. It has actions at several 5-HT (serotonin) receptor subtypes. These are 5-HT2C, linked to weight gain, 5-HT2A, linked to its antipsychotic action and relief of some of the extrapyramidal side effects experienced with the typical neuroleptics.[46]
It was recently found that D-amino acid oxidase, the enzyme that catalyses the breakdown of D-amino acids (e.g. D-alanine and D-serine – the neurotransmitters) is inhibited by risperidone.
Risperidone acts on the following receptors:
Receptors
Description
Dopamine
This drug is an antagonist of the D1 (D1, and D5) as well as the D2 family (D2, D3 and D4) receptors, with 70-fold selectivity for the D2 family. This drug has “tight binding” properties, which means it has a long half-life and like other antipsychotics, risperidone blocks the mesolimbic pathway, the prefrontal cortex limbic pathway, and the tuberoinfundibular pathway in the central nervous system. Risperidone may induce extrapyramidal side effects, akathisia and tremors, associated with diminished dopaminergic activity in the striatum. It can also cause sexual side effects, galactorrhoea, infertility, gynecomastia and, with chronic use reduced bone mineral density leading to breaks, all of which are associated with increased prolactin secretion.
Serotonin
Its action at these receptors may be responsible for its lower extrapyramidal side effect liability (via the 5-HT2A/2C receptors) and improved negative symptom control compared to typical antipsychotics such as haloperidol for instance. Its antagonistic actions at the 5-HT2C receptor may account, in part, for its weight gain liability.
Alpha α1 Adrenergic
This action accounts for its orthostatic hypotensive effects and perhaps some of the sedating effects of risperidone.
Alpha α2 Adrenergic
Perhaps greater positive, negative, affective and cognitive symptom control.
Histamine H1
Effects on these receptors account for its sedation and reduction in vigilance. This may also lead to drowsiness and weight gain.
Voltage-Gated Sodium Channels
Because it accumulates in synaptic vesicles, Risperidone inhibits voltage-gated sodium channels at clinically used concentrations. Though this medication possesses similar effects to other typical and atypical antipsychotics, it does not possess an affinity for the muscarinic acetylcholine receptors. In many respects, this medication can be useful as an “acetylcholine release-promoter” similar to gastrointestinal drugs such as metoclopramide and cisapride.
Pharmacokinetics
Risperidone undergoes hepatic metabolism and renal excretion. Lower doses are recommended for patients with severe liver and kidney disease. The active metabolite of risperidone, paliperidone, is also used as an antipsychotic.
Society and Culture
Regulatory Status
Risperidone was approved by the FDA in 1993 for the treatment of schizophrenia. In 2003, the FDA approved risperidone for the short-term treatment of the mixed and manic states associated with bipolar disorder. In 2006, the FDA approved risperidone for the treatment of irritability in autistic children and adolescents. The FDA’s decision was based in part on a study of autistic people with severe and enduring problems of violent meltdowns, aggression, and self-injury; risperidone is not recommended for autistic people with mild aggression and explosive behaviour without an enduring pattern. On 22 August 2007, risperidone was approved as the only drug agent available for treatment of schizophrenia in youths, ages 13-17; it was also approved that same day for treatment of bipolar disorder in youths and children, ages 10-17, joining lithium.
Availability
Janssen’s patent on risperidone expired on 29 December 2003, opening the market for cheaper generic versions from other companies, and Janssen’s exclusive marketing rights expired on 29 June 2004 (the result of a paediatric extension). It is available under many brand names worldwide.
Risperidone is available as a tablet, an oral solution, and an ampule, which is a depot injection.
Lawsuits
On 11 April 2012, Johnson & Johnson (J&J) and its subsidiary Janssen Pharmaceuticals Inc. were fined $1.2 billion by Judge Timothy Davis Fox of the Sixth Division of the Sixth Judicial Circuit of the US state of Arkansas. The jury found the companies had downplayed multiple risks associated with risperidone (Risperdal). The verdict was later reversed by the Arkansas State Supreme court.
In August 2012, Johnson & Johnson agreed to pay $181 million to 36 US states in order to settle claims that it had promoted risperidone and paliperidone for off-label uses including for dementia, anger management, and anxiety.
In November 2013, J&J was fined $2.2 billion for illegally marketing risperidone for use in people with dementia.
In 2015, Steven Brill posted a 15-part investigative journalism piece on J&J in The Huffington Post, called “America’s most admired lawbreaker”, which was focused on J&J’s marketing of risperidone.
J&J has faced numerous civil lawsuits on behalf of children who were prescribed risperidone who grew breasts (a condition called gynecomastia); as of July 2016 there were about 1,500 cases in Pennsylvania state court in Philadelphia, and there had been a February 2015 verdict against J&J with $2.5 million awarded to a man from Alabama, a $1.75M verdict against J&J that November, and in 2016 a $70 million verdict against J&J. In October, 2019, a jury awarded a Pennsylvania man $8 billion in a verdict against J&J.
Names
Brand names include Risperdal, Risperdal Consta, Risperdal M-Tab, Risperdal Quicklets, and Risperlet.
Psychogenic disease (or psychogenic illness) is a name given to physical illnesses that are believed to arise from emotional or mental stressors, or from psychological or psychiatric disorders.
Background
It is most commonly applied to illnesses where a physical abnormality or other biomarker has not yet been identified. In the absence of such biological evidence of an underlying disease process, it is often assumed that the illness must have a psychological cause, even if the patient shows no indications of being under stress or of having a psychological or psychiatric disorder. Examples of diseases that are believed by many to be psychogenic include psychogenic seizures, psychogenic polydipsia, psychogenic tremor, and psychogenic pain.
There are problems with the assumption that all medically unexplained illness must have a psychological cause. It always remains possible that genetic, biochemical, electrophysiological, or other abnormalities may be present which we do not have the technology or background to identify.
The term psychogenic disease is often used in a similar way to psychosomatic disease. However, the term psychogenic usually implies that psychological factors played a key causal role in the development of the illness. The term psychosomatic is often used in a broader way to describe illnesses with a known medical cause where psychological factors may nonetheless play a role (e.g. asthma can be exacerbated by anxiety).
In psychology, emotional detachment, also known as emotional blunting, has two meanings:
One is the inability to connect to others on an emotional level; and
The other is as a positive means of coping with anxiety.
This coping strategy, also known as emotion focused-coping, is used by avoiding certain situations that might trigger anxiety. It refers to the evasion of emotional connections. Emotional detachment may be a temporary reaction to a stressful situation, or a chronic condition such as depersonalisation-derealisation disorder. It may also be caused by certain antidepressants. Emotional blunting as reduced affect display is one of the negative symptoms of schizophrenia.
Signs and Symptoms
Emotional detachment may not be as outwardly obvious as other psychiatric symptoms. Patients diagnosed with emotional detachment have reduced ability to express emotion, to empathise with others or to form powerful emotional connections. Patients are also at an increased risk for many anxiety and stress disorders. This can lead to difficulties in creating and maintaining personal relationships. The person may move elsewhere in their mind and appear preoccupied or “not entirely present”, or they may seem fully present but exhibit purely intellectual behaviour when emotional behaviour would be appropriate. They may have a hard time being a loving family member, or they may avoid activities, places, and people associated with past traumas. Their dissociation can lead to lack of attention and, hence, to memory problems and in extreme cases, amnesia. In some cases, they present an extreme difficulty in giving or receiving empathy which can be related to the spectrum of narcissistic personality disorder.
In children (ages 4-12 were studied), traits of aggression and antisocial behaviours were found to be correlated with emotional detachment. Researchers determined that these could be early signs of emotional detachment, suggesting parents and clinicians to evaluate children with these traits for a higher behavioural problem in order to avoid bigger problems (such as emotional detachment) in the future.
Causes
Emotional detachment and/or emotional blunting have multiple causes, as the cause can vary from person to person. Emotional detachment or emotional blunting often arises due to adverse childhood experiences, or to psychological trauma in adulthood.
Emotional blunting is often caused by antidepressants in particular selective serotonin reuptake inhibitors (SSRIs) used in major depressive disorder, and often as an add-on treatment in other psychiatric disorders.
Behavioural Mechanism
Emotional detachment is a behaviour which allows a person to react calmly to highly emotional circumstances. Emotional detachment in this sense is a decision to avoid engaging emotional connections, rather than an inability or difficulty in doing so, typically for personal, social, or other reasons. In this sense it can allow people to maintain boundaries, psychic integrity and avoid undesired impact by or upon others, related to emotional demands. As such it is a deliberate mental attitude which avoids engaging the emotions of others.
This detachment does not necessarily mean avoiding empathy; rather, it allows the person to rationally choose whether or not to be overwhelmed or manipulated by such feelings. Examples where this is used in a positive sense might include emotional boundary management, where a person avoids emotional levels of engagement related to people who are in some way emotionally overly demanding, such as difficult co-workers or relatives, or is adopted to aid the person in helping others.
Emotional detachment can also be “emotional numbing”, “emotional blunting”, i.e., dissociation, depersonalisation or in its chronic form depersonalisation disorder. This type of emotional numbing or blunting is a disconnection from emotion, it is frequently used as a coping survival skill during traumatic childhood events such as abuse or severe neglect. Over time and with much use, this can become second nature when dealing with day to day stressors.
Emotional detachment may allow acts of extreme cruelty and abuse, supported by the decision to not connect empathically with the person concerned. Social ostracism, such as shunning and parental alienation, are other examples where decisions to shut out a person creates a psychological trauma for the shunned party.
Reduced affect display, sometimes referred to as emotional blunting, is a condition of reduced emotional reactivity in an individual.
It manifests as a failure to express feelings (affect display) either verbally or nonverbally, especially when talking about issues that would normally be expected to engage the emotions. Expressive gestures are rare and there is little animation in facial expression or vocal inflection. Reduced affect can be symptomatic of autism, schizophrenia, depression, posttraumatic stress disorder, depersonalisation disorder, schizoid personality disorder or brain damage. It may also be a side effect of certain medications (e.g. antipsychotics and antidepressants).
Reduced affect should be distinguished from apathy and anhedonia, which explicitly refer to a lack of emotion, whereas reduced affect is a lack of emotional expression (affect display) regardless of whether emotion (underlying affect) is actually reduced or not.
Types
Constricted Affect
A restricted or constricted affect is a reduction in an individual’s expressive range and the intensity of emotional responses.
Blunted and Flat Affect
Blunted affect is a lack of affect more severe than restricted or constricted affect, but less severe than flat or flattened affect. “The difference between flat and blunted affect is in degree. A person with flat affect has no or nearly no emotional expression. He or she may not react at all to circumstances that usually evoke strong emotions in others. A person with blunted affect, on the other hand, has a significantly reduced intensity in emotional expression”.
Shallow Affect
Shallow affect has equivalent meaning to blunted affect. Factor 1 of the Psychopathy Checklist identifies shallow affect as a common attribute of psychopathy.
Brain Structures
Individuals with schizophrenia with blunted affect show different regional brain activity in fMRI scans when presented with emotional stimuli compared to individuals with schizophrenia without blunted affect. Individuals with schizophrenia without blunted affect show activation in the following brain areas when shown emotionally negative pictures: midbrain, pons, anterior cingulate cortex, insula, ventrolateral orbitofrontal cortex, anterior temporal pole, amygdala, medial prefrontal cortex, and extrastriate visual cortex. Individuals with schizophrenia with blunted affect show activation in the following brain regions when shown emotionally negative pictures: midbrain, pons, anterior temporal pole, and extrastriate visual cortex.
Limbic Structures
Individuals with schizophrenia with flat affect show decreased activation in the limbic system when viewing emotional stimuli. In individuals with schizophrenia with blunted affect neural processes begin in the occipitotemporal region of the brain and go through the ventral visual pathway and the limbic structures until they reach the inferior frontal areas. Damage to the amygdala of adult rhesus macaques early in life can permanently alter affective processing. Lesioning the amygdala causes blunted affect responses to both positive and negative stimuli. This effect is irreversible in the rhesus macaques; neonatal damage produces the same effect as damage that occurs later in life. The macaques’ brain cannot compensate for early amygdala damage even though significant neuronal growth may occur. There is some evidence that blunted affect symptoms in schizophrenia patients are not a result of just amygdala responsiveness, but a result of the amygdala not being integrated with other areas of the brain associated with emotional processing, particularly in amygdala-prefrontal cortex coupling. Damage in the limbic region prevents the amygdala from correctly interpreting emotional stimuli in individuals with schizophrenia by compromising the link between the amygdala and other brain regions associated with emotion.
Brainstem
Parts of the brainstem are responsible for passive emotional coping strategies that are characterized by disengagement or withdrawal from the external environment (quiescence, immobility, hyporeactivity), similar to what is seen in blunted affect. Individuals with schizophrenia with blunted affect show activation of the brainstem during fMRI scans, particularly the right medulla and the left pons, when shown “sad” film excerpts. The bilateral midbrain is also activated in individuals with schizophrenia diagnosed with blunted affect. Activation of the midbrain is thought to be related to autonomic responses associated with perceptual processing of emotional stimuli. This region usually becomes activated in diverse emotional states. When the connectivity between the midbrain and the medial prefrontal cortex is compromised in individuals with schizophrenia with blunted affect an absence of emotional reaction to external stimuli results.
Prefrontal Cortex
Individuals with schizophrenia, as well as patients being successfully reconditioned with quetiapine for blunted affect, show activation of the prefrontal cortex (PFC). Failure to activate the PFC is possibly involved in impaired emotional processing in individuals with schizophrenia with blunted affect. The mesial PFC is activated in aver individuals in response to external emotional stimuli. This structure possibly receives information from the limbic structures to regulate emotional experiences and behaviour. Individuals being reconditioned with quetiapine, who show reduced symptoms, show activation in other areas of the PFC as well, including the right medial prefrontal gyrus and the left orbitofrontal gyrus.
Anterior Cingulate Cortex
A positive correlation has been found between activation of the anterior cingulate cortex and the reported magnitude of sad feelings evoked by viewing sad film excerpts. The rostral subdivision of this region is possibly involved in detecting emotional signals. This region is different in individuals with schizophrenia with blunted affect.
Diagnoses
Schizophrenia
Patients with schizophrenia have long been recognized as showing “flat or inappropriate affect, with splitting of feelings from events … feelings seem flat instead of being in contact with what is going on”. One study of flat affect in schizophrenia found that “flat affect was more common in men, and was associated with worse current quality of life” as well as having “an adverse effect on course of illness”.
The study also reported a “dissociation between reported experience of emotion and its display” – supporting the suggestion made elsewhere that “blunted affect, including flattened facial expressiveness and lack of vocal inflection … often disguises an individual’s true feelings.” Thus, feelings may merely be unexpressed, rather than totally lacking. On the other hand, “a lack of emotions which is due not to mere repression but to a real loss of contact with the objective world gives the observer a specific impression of ‘queerness’ … the remainders of emotions or the substitutes for emotions usually refer to rage and aggressiveness”. In the most extreme cases, there is a complete “dissociation from affective states”.
Another study found that when speaking, individuals with schizophrenia with flat affect demonstrate less inflection than normal controls and appear to be less fluent. Normal subjects appear to express themselves using more complex syntax, whereas flat affect subjects speak with fewer words, and fewer words per sentence. Flat affect individuals’ use of context-appropriate words in both sad and happy narratives are similar to that of controls. It is very likely that flat affect is a result of deficits in motor expression as opposed to emotional processing. The moods of display are compromised, but subjective, autonomic, and contextual aspects of emotion are left intact.
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) was previously known to cause negative feelings, such as depressed mood, re-experiencing and hyperarousal. However, recently, psychologists have started to focus their attention on the blunted affects and also the decrease in feeling and expressing positive emotions in PTSD patients. Blunted affect, or emotional numbness, is considered one of the consequences of PTSD because it causes a diminished interest in activities that produce pleasure (anhedonia) and produces feelings of detachment from others, restricted emotional expression and a reduced tendency to express emotions behaviourally. Blunted affect is often seen in veterans as a consequence of the psychological stressful experiences that caused PTSD. Blunted affect is a response to PTSD, it is considered one of the central symptoms in post-traumatic stress disorders and it is often seen in veterans who served in combat zones. In PTSD, blunted affect can be considered a psychological response to PTSD as a way to combat overwhelming anxiety that the patients feel. In blunted affect, there are abnormalities in circuits that also include the prefrontal cortex.
Assessment
In making assessments of mood and affect the clinician is cautioned that “it is important to keep in mind that demonstrative expression can be influenced by cultural differences, medication, or situational factors”; while the layperson is warned to beware of applying the criterion lightly to “friends, otherwise [he or she] is likely to make false judgments, in view of the prevalence of schizoid and cyclothymic personalities in our ‘normal’ population, and our [US] tendency to psychological hypochondriasis”.
R.D. Laing in particular stressed that “such ‘clinical’ categories as schizoid, autistic, ‘impoverished’ affect … all presuppose that there are reliable, valid impersonal criteria for making attributions about the other person’s relation to [his or her] actions. There are no such reliable or valid criteria”.
Differential Diagnosis
Blunted affect is very similar to anhedonia, which is the decrease or cessation of all feelings of pleasure (which thus affects enjoyment, happiness, fun, interest, and satisfaction). In the case of anhedonia, emotions relating to pleasure will not be expressed as much or at all because they are literally not experienced or are decreased. Both blunted affect and anhedonia are considered negative symptoms of schizophrenia, meaning that they are indicative of a lack of something. There are some other negative symptoms of schizophrenia which include avolition, alogia and catatonic behaviour.
Closely related is alexithymia – a condition describing people who “lack words for their feelings. They seem to lack feelings altogether, although this may actually be because of their inability to express emotion rather than from an absence of emotion altogether”. Alexithymic patients however can provide clues via assessment presentation which may be indicative of emotional arousal.
“If the amygdala is severed from the rest of the brain, the result is a striking inability to gauge the emotional significance of events; this condition is sometimes called ‘affective blindness'”. In some cases, blunted affect can fade, but there is no conclusive evidence of why this can occur.
1896 – Lev Vygotsky, Belarusian-Russian psychologist and philosopher (d. 1934).
People (Deaths)
2014 – Patrick Suppes, American psychologist and philosopher (b. 1922).
Lev Vygotsky
Lev Semyonovich Vygotsky (17 November 1896 to 11 June 1934) was a Soviet psychologist, known for his work on psychological development in children. He published on a diverse range of subjects, and from multiple views as his perspective changed over the years. Among his students was Alexander Luria and Kharkiv school of psychology.
He is known for his concept of the zone of proximal development (ZPD): the distance between what a student (apprentice, new employee, etc.) can do on their own, and what they can accomplish with the support of someone more knowledgeable about the activity. Vygotsky saw the ZPD as a measure of skills that are in the process of maturing, as supplement to measures of development that only look at a learner’s independent ability.
Also influential are his works on the relationship between language and thought, the development of language, and a general theory of development through actions and relationships in a socio-cultural environment.
Vygotsky is the subject of great scholarly dispute. There is a group of scholars who see parts of Vygotsky’s current legacy as distortions and who are going back to Vygotsky’s manuscripts in an attempt to make Vygotsky’s legacy more true to his actual ideas.
Patrick Suppes
Patrick Colonel Suppes (17 March 1922 to 17 November 2014) was an American philosopher who made significant contributions to philosophy of science, the theory of measurement, the foundations of quantum mechanics, decision theory, psychology and educational technology. He was the Lucie Stern Professor of Philosophy Emeritus at Stanford University and until January 2010 was the Director of the Education Programme for Gifted Youth also at Stanford.
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