Category: Mental Health

What is Forensic Psychiatry?

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Introduction

Forensic psychiatry is a subspeciality of psychiatry and is related to criminology. It encompasses the interface between law and psychiatry.

According to the American Academy of Psychiatry and the Law, it is defined as “a subspecialty of psychiatry in which scientific and clinical expertise is applied in legal contexts involving civil, criminal, correctional, regulatory, or legislative matters, and in specialized clinical consultations in areas such as risk assessment or employment.”

A forensic psychiatrist provides services – such as determination of competency to stand trial – to a court of law to facilitate the adjudicative process and provide treatment, such as medications and psychotherapy, to criminals.

Court Work

Forensic psychiatrists work with courts in evaluating an individual’s competency to stand trial, defences based on mental disorders (e.g. the insanity defence), and sentencing recommendations. The two major areas of criminal evaluations in forensic psychiatry are competency to stand trial (CST) and mental state at the time of the offense (MSO).

Competency to Stand Trial

Competency to stand trial (CST) is the competency evaluation to determine that defendants have the mental capacity to understand the charges and assist their attorneys. In the United States, this is seated in the Fifth Amendment to the United States Constitution, which ensures the right to be present at one’s trial, to face one’s accusers, and to have help from an attorney. CST, sometimes referred to as adjudicative competency, serves three purposes: “preserving the dignity of the criminal process, reducing the risk of erroneous convictions, and protecting defendants’ decision-making autonomy”.

In 1960, the Supreme Court of the United States in Dusky v. United States established the standard for federal courts, ruling that “the test must be whether the defendant has sufficient present ability to consult with his attorney with a reasonable degree of rational understanding and a rational as well as factual understanding of proceedings against him.” The evaluations must assess a defendant’s ability to assist their legal counsel, meaning that they understand the legal charges against them, the implications of being a defendant, and the adversarial nature of the proceedings, including the roles played by defence counsel, prosecutors, judges, and the jury. They must be able to communicate relevant information to their attorney, and understand information provided by their attorney. Finally, they must be competent to make important decisions, such as whether or not to accept a plea agreement.

In England, Wales, Scotland, and Ireland, a similar legal concept is that of “fitness to plead”.

As an Expert Witness

Forensic psychiatrists are often called to be expert witnesses in both criminal and civil proceedings. Expert witnesses give their opinions about a specific issue. Often, the psychiatrist will have prepared a detailed report before testifying. The primary duty of the expert witness is to provide an independent opinion to the court. An expert is allowed to testify in court with respect to matters of opinion only when the matters in question are not ordinarily understandable to the finders of fact, be they judge or jury. As such, prominent leaders in the field of forensic psychiatry, from Thomas Gutheil (2009) to Robert Simon and Liza Gold (2010) and Sadoff (2011) have identified teaching as a critical dimension in the role of expert witness. The expert will be asked to form an opinion and to testify about that opinion, but in so doing will explain the basis for that opinion, which will include important concepts, approaches, and methods used in psychiatry.

Mental State Opinion

Mental state opinion (MSO) gives the court an opinion, and only an opinion, as to whether a defendant was able to understand what he/she was doing at the time of the crime. This is worded differently in many states, and has been rejected altogether in some, but in every setting, the intent to do a criminal act and the understanding of the criminal nature of the act bear on the final disposition of the case. Much of forensic psychiatry is guided by significant court rulings or laws that bear on this area which include these three standards:

  • M’Naghten rules: Excuses a defendant who, by virtue of a defect of reason or disease of the mind, does not know the nature and quality of the act, or, if he or she does, does not know that the act is indeed wrong.
  • Durham rule: Excuses a defendant whose conduct is the product of mental disorder.
  • ALI test: Excuses a defendant who, because of a mental disease or defect, lacks substantial capacity to appreciate the criminality (wrongfulness) of his or her conduct or to conform his conduct to the requirements of law.

“Not guilty by reason of insanity” (NGRI) is one potential outcome in this type of trial. Importantly, insanity is a legal and not a medical term. Often, psychiatrists may be testifying for both the defence and the prosecution.

Forensic psychiatrists are also involved in the care of prisoners, both in jails and prisons, and in the care of the mentally ill who have committed criminal acts (such as those who have been found not guilty by reason of insanity).

Risk Management

Many past offenders against other people, and suspected or potential future offenders with mental health problems or an intellectual or developmental disability, are supervised in the community by forensic psychiatric teams made up of a variety of professionals, including psychiatrists, psychologists, nurses, and care workers. These teams have dual responsibilities: to promote both the welfare of their clients and the safety of the public. The aim is not so much to predict as to prevent violence, by means of risk management.

Risk assessment and management is a growth area in the forensic field, with much Canadian academic work being done in Ontario and British Columbia. This began with the attempt to predict the likelihood of a particular kind of offense being repeated, by combining “static” indicators from personal history and offense details in actuarial instruments such as the RRASOR and Static-99, which were shown to be more accurate than unaided professional judgment. More recently, use is being made also of “dynamic” risk factors, such as attitudes, impulsivity, mental state, family and social circumstances, substance use, and the availability and acceptance of support, to make a “structured professional judgment.” The aim of this is to move away from prediction to prevention, by identifying and then managing risk factors. This may entail monitoring, treatment, rehabilitation, supervision, and victim safety planning and depends on the availability of funding and legal powers. These schemes may be based on published assessments such as the HCR-20 (which incorporates 10 Historical, 5 Clinical and 5 Risk Management factors) and the risk of sexual violence protocol from Simon Fraser University, BC.

United Kingdom

In the UK, most forensic psychiatrists work for the National Health Service, in specialist secure units caring for mentally ill offenders (as well as people whose behaviour has made them impossible to manage in other hospitals). These can be either medium secure units (of which there are many throughout the country) or high secure hospitals (also known as special hospitals), of which three are in England and one in Scotland (the State Hospital, Carstairs), the best known of which is Broadmoor Hospital. The other ‘specials’ are Ashworth hospital in Maghull, Liverpool, and Rampton hospital in Nottinghamshire. Also, a number of private-sector medium secure units sell their beds exclusively to the NHS, as not enough secure beds are available in the NHS system.

Forensic psychiatrists often also do prison inreach work, in which they go into prisons and assess and treat people suspected of having mental disorders; much of the day-to-day work of these psychiatrists comprises care of very seriously mentally ill patients, especially those suffering from schizophrenia. Some units also treat people with severe personality disorder or learning disabilities. The areas of assessment for courts are also somewhat different in Britain, because of differing mental health law. Fitness to plead and mental state at the time of the offence are indeed issues given consideration, but the mental state at the time of trial is also a major issue, and this assessment most commonly leads to the use of mental health legislation to detain people in hospitals, as opposed to their getting a prison sentence.

Learning-disabled offenders who are a continuing risk to others may be detained in learning-disability hospitals (or specialised community-based units with a similar regimen, as the hospitals have mostly been closed). This includes those who commit serious crimes of violence, including sexual violence, and fire-setting. They would be cared for by learning disability psychiatrists and registered learning disability nurses. Some psychiatrists doing this work have dual training in learning disability and forensic psychiatry or learning disability and adolescent psychiatry. Some nurses would have training in mental health, also.

Court work (medicolegal work) is generally undertaken as private work by psychiatrists (most often forensic psychiatrists), as well as forensic and clinical psychologists, who usually also work within the NHS. This work is generally funded by the Legal Services Commission (used to be called Legal Aid).

Canada

Criminal Law Framework

In Canada, certain credentialed medical practitioners may, at their discretion, make state-sanctioned investigations into and diagnosis of mental illness. Appropriate use of the DSM-IV-TR is discussed in its section entitled “Use of the DSM-IV-TR in Forensic Settings”.

Concerns have been expressed that the Canadian criminal justice system discriminates based on DSM IV diagnosis within the context of Part XX of the Criminal Code. This part sets out provisions for, among other things, court ordered attempts at “treatment” before individuals receive a trial as described in section 672.58 of the Criminal Code. Also provided for are court ordered “psychiatric assessments”. Critics have also expressed concerns that use of the DSM-IV-TR may conflict with section 2(b) of the Canadian Charter of Rights and Freedoms, which guarantees the fundamental freedom of “thought, belief, opinion, and expression”.

Confidentiality

The position of the Canadian Psychiatric Association holds, “in recent years, serious incursions have been made by governments, powerful commercial interests, law enforcement agencies, and the courts on the rights of persons to their privacy.” It goes on to state, “breaches or potential breaches of confidentiality in the context of therapy seriously jeopardize the quality of the information communicated between patient and psychiatrist and also compromise the mutual trust and confidence necessary for effective therapy to occur.”

An outline of the forensic psychiatric process as it occurs in the province of Ontario is presented in the publication The Forensic Mental Health System In Ontario: An Information Guide published by the Centre for Addiction and Mental Health in Toronto. The Guide states: “Whatever you tell a forensic psychiatrist and the other professionals assessing you is not confidential.” The Guide further states: “The forensic psychiatrist will report to the court using any available information, such as: police and hospital records, information given by your friends, family or co-workers, observations of you in the hospital.” Also according to the Guide: “You have the right to refuse to take part in some or all of the assessment. Sometimes your friends or family members will be asked for information about you. They have the right to refuse to answer questions, too.”

Of note, the emphasis in the guide is on the right to refuse participation. This may seem unusual given that a result of a verdict of “Not Criminally Responsible by reason of Mental Disorder” is often portrayed as desirable to the defence, similar to the insanity defence in the United States. A verdict of “Not Criminally Responsible” is referred to as a “defence” by the Criminal Code. However, the issue of the accused’s mental state can also be raised by the Crown or by the court itself, rather than solely by the defence counsel, differentiating it from many other legal defences.

Treatment/Assessment Conflict

In Ontario, a court-ordered inpatient forensic assessment for criminal responsibility typically involves both treatment and assessment being performed with the accused in the custody of a single multidisciplinary team over a 30- or 60-day period. Concerns have been expressed that an accused may feel compelled on ethical, medical, or legal grounds to divulge information, medical, or otherwise, to assessors in an attempt to allow for and ensure safe and appropriate treatment during that period of custody.

Some Internet references address treatment/assessment conflict as it relates to various justice systems, particularly civil litigation in other jurisdictions. The American Academy Of Psychiatry and the Law states in its ethics guidelines, “when a treatment relationship exists, such as in correctional settings, the usual physician-patient duties apply”, which may be seen as contradiction.

South Africa

In South Africa, patients are referred for observation for a period of 30 days by the courts if questions exist as to CST and MSO. Serious crimes require a panel, which may include two or more psychiatrists. Should the courts find the defendant not criminally responsible, the defendant may become a state patient and be admitted in a forensic psychiatric hospital. They are referred to receive treatment for an indefinite period, but most were back in the community after three years.

Training Standards

Some practitioners of forensic psychiatry have taken extra training in that specific area. In the United States, one-year fellowships are offered in this field to psychiatrists who have completed their general psychiatry training. Such psychiatrists may then be eligible to sit for a board certification examination in forensic psychiatry. In Britain, one is required to complete a three-year subspeciality training in forensic psychiatry, after completing one’s general psychiatry training, before receiving a Certificate of Completion of Training as a forensic psychiatrist. In some countries, general psychiatrists can practice forensic psychiatry, as well. However, other countries, such as Japan, require a specific certification from the government to do this type of work.

References

Gutheil, T.G. (2009) The Psychiatrist as Expert Witness. 2nd Ed. Washington: American Psychiatric Publishing.

Robert, S. & Gold, L. (Eds). (2010) American Psychiatric Textbook of Forensic Psychiatry. Washington: American Psychiatric Publishing.

Sadoff, R.L. (2011). Ethical Issues in Forensic Psychiatry: Minimizing Harm. New Jersey: Wiley-Blackwall.

What is the National Institute of Mental Health?

Published on by Andrew Marshall2 Comments

Introduction

The National Institute of Mental Health (NIMH) is one of 27 institutes and centres that make up the National Institutes of Health (NIH). The NIH, in turn, is an agency of the United States Department of Health and Human Services and is the primary agency of the United States government responsible for biomedical and health-related research.

NIMH is the largest research organisation in the world specialising in mental illness. The institute was first authorised by the US government in 1946, when then President Harry Truman signed into law the National Mental Health Act, although the institute was not formally established until 1949.

NIMH is a $1.5 billion enterprise, supporting research on mental health through grants to investigators at institutions and organisations throughout the United States and through its own internal (intramural) research effort. The mission of NIMH is “to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure.”

In order to fulfil this mission, NIMH “must foster innovative thinking and ensure that a full array of novel scientific perspectives are used to further discovery in the evolving science of brain, behavior, and experience. In this way, breakthroughs in science can become breakthroughs for all people with mental illnesses.”

Research Priorities

NIMH has identified four overarching strategic objectives for itself:

  • Promote discovery in the brain and behavioural sciences to fuel research on the causes of mental disorders.
  • Chart mental illness trajectories to determine when, where and how to intervene.
  • Develop new and better interventions that incorporate the diverse needs and circumstances of people with mental illnesses.
  • Strengthen the public health impact of NIMH-supported research.

Brief History

Organisational History

Throughout its history the NIMH has witnessed a number of name and organisational changes, including:

  • PHS Narcotics Division (1929-1930).
  • PHS Division of Mental Hygiene (1930-1943).
  • Mental Hygiene Division, within the PHS Bureau of Medical Services (1943-1949).
  • National Institute of Mental Health (NIMH), one of the National Institutes of Health (NIH, 1949-1967).
  • NIMH as an independent division of the PHS (1967-1968).
  • NIMH, within the Health Services and Mental Health Administration (1968-1973).
  • NIMH, within NIH (1973).
  • NIMH, within the Alcohol, Drug Abuse, and Mental Health Administration (1973-1992).
  • NIMH, within NIH (1992-present).

In 1992, when the Alcohol, Drug Abuse, and Mental Health Administration was abolished, NIMH was transferred to NIH, retaining its research functions while its treatment services were transferred to the new Substance Abuse and Mental Health Services Administration.

Functions

Mental health has traditionally been a state responsibility, but after World War II there was increased lobbying for a federal (national) initiative. Attempts to create a National Neuropsychiatric Institute failed. Robert H. Felix, then head of the Division of Mental Hygiene, orchestrated a movement to include mental health policy as an integral part of federal biomedical policy. Congressional subcommittees hearings were held and the National Mental Health Act was signed into law in 1946. This aimed to support the research, prevention and treatment of psychiatric illness, and called for the establishment of a National Advisory Mental Health Council (NAMHC) and a National Institute of Mental Health. On 15 April 1949, the NIMH was formally established, with Felix as director. Funding for the NIMH grew slowly and then, from the mid-1950s, dramatically. The institute took on a highly influential role in shaping policy, research and communicating with the public, legitimising the importance of new advances in biomedical science, psychiatric and psychological services, and community-based mental health policies.

In 1955 the Mental Health Study Act called for “an objective, thorough, nationwide analysis and re-evaluation of the human and economic problems of mental health.” The resulting Joint Commission on Mental Illness and Health prepared a report, “Action for Mental Health”, resulting in the establishment of a cabinet-level interagency committee to examine the recommendations and determine an appropriate federal response.

In 1963, Congress passed the Mental Retardation Facilities and Community Mental Health Centres Construction Act, beginning a new era in Federal support for mental health services. NIMH assumed responsibility for monitoring the Nation’s community mental health centres (CMHC) programmes.

During the mid-1960s, NIMH launched a campaign on special mental health problems. Part of this was a response to President Lyndon Johnson’s pledge to apply scientific research to social problems. The institute established centres for research on schizophrenia, child and family mental health, suicide, as well as crime and delinquency, minority group mental health problems, urban problems, and later, rape, aging, and technical assistance to victims of natural disasters.

Alcohol abuse and alcoholism did not receive full recognition as a major public health problem until the mid-1960s, when the National Centre for Prevention and Control of Alcoholism was established as part of NIMH; a research program on drug abuse was inaugurated within NIMH with the establishment of the Centre for Studies of Narcotic and Drug Abuse.

In 1967, NIMH separated from NIH and was given bureau status within PHS. However, NIMH’s intramural research program, which conducted studies in the NIH Clinical Centre and other NIH facilities, remained at NIH under an agreement for joint administration between NIH and NIMH. Secretary of Health, Education, and Welfare John W. Gardner transferred St. Elizabeth’s Hospital, the Federal Government’s only civilian psychiatric hospital, to NIMH.

In 1968, NIMH became a component of PHS’s Health Services and Mental Health Administration (HSMHA).

In 1970 the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act (P.L. 91-616) established the National Institute of Alcohol Abuse and Alcoholism within NIMH.

In 1972, the Drug Abuse Office and Treatment Act established a National Institute on Drug Abuse within NIMH.

In 1973, NIMH went through a series of organisational moves. The institute temporarily re-joined NIH on 01 July with the abolishment of HSMHA. Then, the DHEW secretary administratively established the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) – composed of the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and NIMH – as the successor organisation to HSMHA. ADAMHA was officially established in 1974.

The President’s Commission on Mental Health in 1977 reviewed the mental health needs of the nation and to make recommendations to the president as to how best meet these needs in 1978.

In 1980 The Epidemiologic Catchment Area (ECA) study, an unprecedented research effort that entailed interviews with a nationally representative sample of 20,000 Americans was launched. The field interviews and first wave analyses were completed in 1985. Data from the ECA provided a picture of rates of mental and addictive disorders and services usage.

The Mental Health Systems Act of 1980 – based on recommendations of the President’s Commission on Mental Health and designed to provide improved services for persons with mental disorders – was passed. NIMH participated in development of the National Plan for the Chronically Mentally Ill, a sweeping effort to improve services and fine-tune various Federal entitlement programs for those with severe, persistent mental disorders.

In 1987, administrative control of St. Elizabeth’s Hospital was transferred from the NIMH to the District of Columbia. NIMH retained research facilities on the grounds of the hospital. The NIMH Neuroscience Centre and the NIMH Neuropsychiatric Research Hospital, located on the grounds of St. Elizabeth’s Hospital, were dedicated in 1989.

In 1992, Congress passed the ADAMHA Reorganisation Act, abolishing ADAMHA. The research components of NIAAA, NIDA and NIMH re-joined NIH, while the services components of each institute became part of a new PHS agency, the Substance Abuse and Mental Health Services Administration (SAMHSA). The return to NIH and the loss of services functions to SAMHSA necessitated a realignment of the NIMH extramural program administrative organisation. New offices were created for research on Prevention, Special Populations, Rural Mental Health and AIDS.

In 1994 The House Appropriations Committee mandated that the director of NIH conduct a review of the role, size, and cost of all NIH intramural research programmes (IRP). NIMH and the National Advisory Mental Health Council (NAMHC) initiated a major study of the NIMH Intramural Research Programme. The planning committee recommended continued investment in the IRP and recommended specific administrative changes; many of these were implemented upon release of the committee’s final report; other changes – for example, the establishment of a major new programme on Mood and Anxiety Disorders – have been introduced in the years since.

In 1996 NIMH, with the NAMHC, initiated systematic reviews of a number of areas of its research portfolio, including the genetics of mental disorders; epidemiology and services for child and adolescent populations; prevention research; clinical treatment and services research. At the request of the National Institute for Mental Health director, the NAMH Council established programmatic groups in each of these areas. NIMH (National Institute of Mental Health) continued to implement recommendations issued by these Workgroups.

In 1997, NIMH realigned its extramural organisational structure to capitalise on new technologies and approaches to both basic and clinical science, as well as changes that had occurred in health care delivery systems, while retaining the Institute’s focus on mental illness. The new extramural organisation resulted in three research divisions: Basic and Clinical Neuroscience Research; Services and Intervention Research; and Mental Disorders, Behavioural Research and AIDS.

Between 1997 and 1999 NIMH refocused career development resources on early careers and added new mechanisms for clinical research.

In 1999 The NIMH Neuroscience Centre/Neuropsychiatric Research Hospital was relocated from St. Elizabeth’s Hospital in Washington, D.C. to the NIH Campus in Bethesda, Maryland, in response to the recommendations of the 1996 review of the NIMH (National Institute of Mental Health) Intramural Research Programme by the IRP Planning Committee.

The first White House Conference on Mental Health, held 07 June, in Washington, D.C., brought together national leaders, mental health scientific and clinical personnel, patients, and consumers to discuss needs and opportunities. The National Institute on Mental Health developed materials and helped organise the conference.

US Surgeon General David Satcher released The Surgeon General’s Call To Action To Prevent Suicide, in July, and the first Surgeon General’s Report on Mental Health, in December. NIMH, along with other federal agencies, collaborated in the preparation of both of these landmark reports.

Since the appointment of Thomas R. Insel as Director of NIMH in 2002, the institute has undergone organisational changes to better target mental health research needs (the expansion from three extramural divisions to five divisions, with the two new divisions focusing on adult and child translational research). NIMH also weathered several years of controversy due to conflict of interest and ethics violations by some of its intramural investigators. This situation cast light on an area that affected all of NIH, and resulted in more stringent rules about conflict of interest for all of NIH. Recently, Congressional interest turned to ethics and conflict of interest concerns with external investigators who receive NIMH or other NIH support. Current federal law has responsibility for managing and monitoring conflict of interests for external investigators with their home institutions/organisations. NIH responded to these new concerns by initiating a formal process for seeking public input and advice that will likely result in a change to the rules for monitoring and managing conflict of interest concerns for externally supported investigators. Finally, the past decade has also been marked by exciting scientific breakthroughs and efforts in mental illness research, as new genetic advances and bioimaging methodologies have increased understanding of mental illnesses. Two notable consequences of these advances are the Institute’s collaboration with the Department of Army to launch the Study To Assess Risk and Resilience in Service Members (STARRS), a Framingham-like effort scheduled to last until 2014 and the Research Domain Criteria (RDoC) effort, which seeks to define basic dimensions of functioning (such as fear circuitry or working memory) to be studied across multiple levels of analysis, from genes to neural circuits to behaviours, cutting across disorders as traditionally defined.

A collection of interviews with directors and individuals significant in the foundation and early history of the institute conducted by Dr. Eli A. Rubenstein between 1975 and 1978 is held at the National Library of Medicine in Bethesda, Maryland.

Noted Researchers

In 1970, Julius Axelrod, a NIMH researcher, won the Nobel Prize in Physiology or Medicine for research into the chemistry of nerve transmission for “discoveries concerning the humoral transmitters in the nerve terminals and the mechanisms for their storage, release and inactivation.” He found an enzyme that terminated the action of the nerve transmitter, noradrenaline in the synapse and which also served as a critical target of many antidepressant drugs.

In 1960s-70s John B. Calhoun, ethologist and behavioural researcher studied the population density and its effects on behaviour in the NIMH facility in Maryland. Later his work become renowned after several publications, including article in Scientific American and a widely known “Universe 25” story predicting anti-utopian future based on rodent experiments in overpopulated environment.

In 1984, Norman E. Rosenthal, a psychiatrist and NIMH researcher, pioneered seasonal affective disorder, coined the term SAD, and began studying the use of light therapy as a treatment. He received the Anna Monika Foundation Award for his research on seasonal depression.

Louis Sokoloff, a NIMH researcher, received the Albert Łasker award in Clinical Medical Research for developing a new method of measuring brain function that contributed to basic understanding and diagnosis of brain diseases. Roger Sperry, a NIMH research grantee, received the Nobel Prize in Medicine or Physiology for discoveries regarding the functional specialisation of the cerebral hemispheres, or the “left” and “right” brain.

Eric Kandel and Paul Greengard, each of whom have received NIMH support for more than three decades, shared the Nobel Prize in Physiology or Medicine with Sweden’s Arvid Carlsson. Kandel received the prize for his elucidating research on the functional modification of synapses in the brain. Initially using the sea slug as an experimental model but later working with mice, he established that the formation of memories is a consequence of short and long-term changes in the biochemistry of nerve cells Greengard was recognised for his discovery that dopamine and a number of other transmitters can alter the functional state of neuronal proteins, and also that such changes could be reversed by subsequent environmental signals.

Nancy Andreasen, a psychiatrist and long-time NIMH grantee, won the National Medal of Science for her groundbreaking work in schizophrenia and for joining behavioural science with neuroscience and neuroimaging. The Presidential Award is one of the nation’s highest awards in science.

Aaron Beck, a psychiatrist, received the 2006 Albert Lasker Award for Clinical Medical Research. Often called “America’s Nobels”, the Laskers are the nation’s most distinguished honour for outstanding contributions to basic and clinical medical research. Beck developed cognitive therapy – a form of psychotherapy – which transformed the understanding and treatment of many psychiatric conditions, including depression, suicidal behaviour, generalised anxiety, panic attacks and eating disorders.

In 2010, Mortimer Mishkin was awarded the National Medal of Science. Mishkin is chief of the NIMH’s Section on Cognitive Neuroscience, and acting chief of its Laboratory of Neuropsychology. He is the first NIMH intramural scientist to receive the medal. Due in part to work spearheaded by Mishkin, science now understands much about the pathways for vision, hearing and touch, and about how those processing streams connect with brain structures important for memory.

What is the Eating Attitudes Test?

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Introduction

The Eating Attitudes Test (EAT, EAT-26), created by David Garner, is a widely used 26-item, standardised self-reported questionnaire of symptoms and concerns characteristic of eating disorders.

Background

The EAT is useful in assessing “eating disorder risk” in high school, college and other special risk samples such as athletes. EAT has been extremely effective in screening for anorexia nervosa in many populations.

The EAT-26 can be used in non-clinical as well as clinical settings not specifically focused on eating disorders. It can be administered in group or individual settings by mental health professionals, school counsellors, coaches, camp counsellors, and others with interest in gathering information to determine if an individual should be referred to a specialist for evaluation for an eating disorder. It is ideally suited for school settings, athletic programs, fitness centres, infertility clinics, paediatric practices, general practice settings, and outpatient psychiatric departments.

Scale and Referral Index

The EAT-26 uses a six-point scale based on how often the individual engages in specific behaviours. The questions may be answered:

  • Always.
  • Usually.
  • Often.
  • Sometimes.
  • Rarely.
  • Never.

Completing the EAT-26 yields a “referral index” based on three criteria:

  1. The total score based on the answers to the EAT-26 questions;
  2. Answers to the behavioural questions related to eating symptoms and weight loss; and
  3. The individual’s body mass index (BMI) calculated from their height and weight.

Generally, a referral is recommended if a respondent scores “positively” or meets the “cut off” scores or threshold on one or more criteria.

Permission to use the EAT-40 or EAT-26 can be obtained from David Garner through the EAT-26 website. Instructions, scoring, and interpretive information can be obtained from the EAT-26 website at no charge. Completion of the EAT-26 with anonymous feedback on the EAT-26 website is possible.

Brief History

The EAT was developed in response to a National Institute of Mental Health consensus panel that recognized a need for screening large populations to increase early identification of anorexia related symptoms. Additionally, the NIMH wanted a measure that could be used to examine the social and cultural factors involved in the development and maintenance of eating disorders. The original version of the EAT was published in 1979, with 40 items each rated on a 6-point Likert scale. In 1982, Garner and colleagues modified the original version to create an abbreviated 26-item test. The items were reduced after a factor analysis on the original 40-item data set revealed 26 independent items. Since then, the EAT has been translated into many different languages and has gained widespread international as a tool to screen for eating disorders. Both the original paper and the subsequent 1982 publication are 3rd and 4th on the list of the 10 most cited articles in the history of the journal Psychological Medicine, a prominent peer-reviewed journal in the fields of psychology and psychiatry.

The EAT-26 is recommended as the first step in a two-stage screening process. Accordingly, individuals who score higher than a 20 should be referred to a qualified professional to determine if they meet the diagnostic criteria for an eating disorder. The EAT-26 is not designed to make a diagnosis of an eating disorder and should not be used in place of a professional diagnosis or consultation. The EAT should only be used as a screener for general eating disorders, as research has not shown it to be a valid instrument in making specific diagnoses.

Limitations

The EAT suffers from the same problems as other self-report inventories, in that scores can be easily exaggerated or minimised by the person completing them. Like all questionnaires, the way the instrument is administered can have an effect on the final score. If a patient is asked to fill out the form in front of other people in a clinical environment, for instance, social expectations have been shown to elicit a different response compared to administration via a postal survey.

As the EAT was originally developed to screen subjects at high risk for anorexia nervosa (AN), it remains controversial whether its present items and scoring cut-off are well-suited to diagnosing other eating disorders. Although the EAT can adequately diagnose undifferentiated eating disorders in clinical settings, it may not fare well in settings unequipped to address major eating disorders.

While the EAT-26 has demonstrated good internal consistency, its test-retest reliability remains uncertain. The stability of an EAT-26 score has been demonstrated to be moderate over two years, but vulnerable to fluctuations over four years. This may be due to changes in an individual’s eating behaviours and attitudes over time naturally or in response to receiving eating disorder treatment.

Another area of debate is the cut-off score of 20 first proposed by David Garner and colleagues to diagnose anorexia nervosa. High false-positive rates and low predictive power for screening for AN and bulimia nervosa (BN) in non-clinical settings have been reported. Use of the EAT-26 as a screening tool could also result in high false-negative rates in individuals with binge eating disorder (BED) or eating disorders not otherwise specified (EDNOS). Such rates may be due to changes over time in the DSM and ICD criteria for eating disorders from which the items in the EAT are based. Another explanation may be the EAT’s inability to distinguish subthreshold forms of abnormal eating behaviour from clinical eating disorders. Lowering the cut-off score to 11 has been demonstrated to improve sensibility and sensitivity rates in individuals with BN, BED, and EDNOS and presents a promising solution to the aforementioned issue.

What is Cognitive Neuropsychiatry?

Published on by Andrew Marshall2 Comments

Introduction

Cognitive neuropsychiatry is a growing multidisciplinary field arising out of cognitive psychology and neuropsychiatry that aims to understand mental illness and psychopathology in terms of models of normal psychological function.

Background

A concern with the neural substrates of impaired cognitive mechanisms links cognitive neuropsychiatry to the basic neuroscience. Alternatively, CNP provides a way of uncovering normal psychological processes by studying the effects of their change or impairment.

The term “cognitive neuropsychiatry” was coined by Prof Hadyn Ellis (Cardiff University ) in a paper “The cognitive neuropsychiatric origins of the Capgras delusion”, presented at the International Symposium on the Neuropsychology of Schizophrenia, Institute of Psychiatry, London (Coltheart, 2007).

Although clinically useful, current syndrome classifications (e.g. DSM-IV; ICD-10) have no empirical basis as models of normal cognitive processes. No neuropsychological accounts of how the brain ‘works’ would ever be complete without a cognitive level of analysis. CNP moves beyond diagnosis and classification to offer a cognitive explanation for established psychiatric behaviours, regardless of whether the symptoms are due to recognised brain pathology or to dysfunction in brain areas or networks without structural lesions.

CNP has been influential, not least because of its early success in explaining some previously bizarre psychiatric delusions, most notably the Capgras delusion, Fregoli delusion and other delusional misidentification syndromes. The Capgras delusion is “explained as the interruption in the covert route to face recognition, namely affective responses to familiar stimuli, localised in the dorsal route of vision from striate cortex to limbic system. According to standard molecular hypotheses, acute delusions are the result of a dysregulated activity of some neuromodulators.”

Additionally, the study of cognitive neuropsychiatry has shown to intersect with the study of philosophy. This intersection revolves around a reconsideration of the mind-body relationship and the contemplation of moral issues that can arise by fields such as neuropsychopathology. For example, it has been under consideration whether or not Parkinson’s patients should be held morally accountable for their physical actions. This discussion and study has taken place due to the discovery that under certain circumstances, Parkinson’s patients can initiate and control their own movement. Examples such as this are cause for difficult judgement calls, i.e. “about who is mad and who is bad” (Stein 1999). Cognitive neuropsychiatry has also explored the difference between implicit and explicit cognition, especially in catatonic patients. For more information on the bridge between neuropsychiatry and philosophy see (e.g. Stein, 1999).

References

Coltheart, M. (2007) The 33rd Sir Frederick Bartlett Lecture Cognitive Neuropsychiatry and Delusional Belief. Quarterly Journal of Experimental Psychology. https://doi.org/10.1080/17470210701338071.

Stein, D. (1999) Philosophy, Psychiatry, & Psychology 6.3, pp.217-221. https://www.researchgate.net/publication/236774712_Philosophy_and_Cognitive_Neuropsychiatry.

What is Delusional Misidentification Syndrome?

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Introduction

Delusional misidentification syndrome is an umbrella term, introduced by Christodoulou (in his book The Delusional Misidentification Syndromes, Karger, Basel, 1986) for a group of delusional disorders that occur in the context of mental and neurological illness.

Refer to Cognitive Neuropsychiatry.

Background

They all involve a belief that the identity of a person, object, or place has somehow changed or has been altered. As these delusions typically only concern one particular topic, they also fall under the category called monothematic delusions.

This psychopathological syndrome is usually considered to include four main variants:

  • The Capgras delusion is the belief that (usually) a close relative or spouse has been replaced by an identical-looking impostor.
  • The Fregoli delusion is the belief that various people the believer meets are actually the same person in disguise.
  • Intermetamorphosis is the belief that an individual has the ability to take the form of another person in both external appearance and internal personality.
  • Subjective doubles, described by Christodoulou in 1978 (American Journal of Psychiatry 135, 249, 1978), is the belief that there is a doppelgänger or double of themselves carrying out independent actions.

However, similar delusional beliefs, often singularly or more rarely reported, are sometimes also considered to be part of the delusional misidentification syndrome. For example:

  • Mirrored-self misidentification is the belief that one’s reflection in a mirror is some other person.
  • Reduplicative paramnesia is the belief that a familiar person, place, object, or body part has been duplicated. For example, a person may believe that they are in fact not in the hospital to which they were admitted, but an identical-looking hospital in a different part of the country, despite this being obviously false.
  • The Cotard delusion is a rare disorder in which people hold a delusional belief that they are dead (either figuratively or literally), do not exist, are putrefying, or have lost their blood or internal organs.
    • In rare instances, it can include delusions of immortality.
  • Syndrome of delusional companions is the belief that objects (such as soft toys) are sentient beings.
  • Clonal pluralisation of the self, where a person believes there are multiple copies themselves, identical both physically and psychologically but physically separate and distinct.

There is considerable evidence that disorders such as the Capgras or Fregoli syndromes are associated with disorders of face perception and recognition. However, it has been suggested that all misidentification problems exist on a continuum of anomalies of familiarity, from déjà vu at one end to the formation of delusional beliefs at the other.

What is the Centre for Epidemiologic Studies Depression Scale?

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Introduction

The Centre for Epidemiologic Studies Depression Scale (CES-D) is a brief self-report questionnaire developed in 1977 by Laurie Radloff to measure depressive symptoms severity in the general population.

The CES-D consists of 20 questions that asks about various symptoms of depression as they have occurred in the past week, and the majority of the items focus on the affective component of depression. Although initially designed for use in general population surveys, CES-D now serves as a screening instrument in primary care clinics and in research.

A revision, the CESD-R was produced in 2004.

Centre for Epidemiologic Studies Depression Scale for Children

The Centre for Epidemiologic Studies Depression Scale for Children (CES-DC) is a modified version of the Centre for Epidemiologic Studies Depression Scale. This measure assesses both depressive symptoms as well as symptom improvement in a wide range of children and adolescents, ages 6-17. The CES-DC was first developed to measure the incidence and prevalence of depression among children and adolescents in large-scale epidemiological research. Several research studies have found the CES-DC to be a reliable and valid measure of depressive symptoms in children.

Question Breakdown and Scoring

The CES-DC is an inventory of 20 self-report items regarding depressive symptoms, taking about 5 minutes to complete. Each item asks how often a symptom has occurred within the last week. Response choices are assigned point values, which are summed together to determine a total measure score. Response choices for each item and their corresponding point values are as follows:

  • 0 points: “Not at all”.
  • 1 point: “A little”.
  • 2 points: “Some”.
  • 3 points: “A lot”.

Items 4, 8, 12 and 16 are phrased to reflect positive affect and behaviour, and therefore are scored in opposite order as follows:

  • 0 points: “A lot”.
  • 1 point: “Some”.
  • 2 points: “A little”.
  • 3 points: “Not at all”.

Interpretation

Scores on the CES-DC range from 0 to 60, in which higher scores suggest a greater presence of depressive symptoms. A score of 15 or higher is interpreted to indicate a risk for depression. However, screening for depression is a complex process and scoring a 15 or higher on the CES-DC should be followed by further evaluation.

Limitations

A study evaluating the CES-DC found that the scores do not necessarily match up to a DSM diagnosis, and while it is a good psychometric tool for adolescents, reliability and validity is poor when applied to children.

What is Behavioural Neuroscience?

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Introduction

Behavioural neuroscience, also known as biological psychology, biopsychology, or psychobiology, is the application of the principles of biology to the study of physiological, genetic, and developmental mechanisms of behaviour in humans and other animals.

Brief History

Behavioural neuroscience as a scientific discipline emerged from a variety of scientific and philosophical traditions in the 18th and 19th centuries. In philosophy, people like René Descartes proposed physical models to explain animal as well as human behaviour. Descartes suggested that the pineal gland, a midline unpaired structure in the brain of many organisms, was the point of contact between mind and body. Descartes also elaborated on a theory in which the pneumatics of bodily fluids could explain reflexes and other motor behaviour. This theory was inspired by moving statues in a garden in Paris. Electrical stimulation and lesions can also show the affect of motor behaviour of humans. They can record the electrical activity of actions, hormones, chemicals and effects drugs have in the body system all which affect ones daily behaviour.

Other philosophers also helped give birth to psychology. One of the earliest textbooks in the new field, The Principles of Psychology by William James, argues that the scientific study of psychology should be grounded in an understanding of biology.

The emergence of psychology and behavioural neuroscience as legitimate sciences can be traced from the emergence of physiology from anatomy, particularly neuroanatomy. Physiologists conducted experiments on living organisms, a practice that was distrusted by the dominant anatomists of the 18th and 19th centuries. The influential work of Claude Bernard, Charles Bell, and William Harvey helped to convince the scientific community that reliable data could be obtained from living subjects.

Even before the 18th and 19th century, behavioural neuroscience was beginning to take form as far back as 1700 B.C. The question that seems to continually arise is: what is the connection between the mind and body? The debate is formally referred to as the mind-body problem. There are two major schools of thought that attempt to resolve the mind–body problem; monism and dualism. Plato and Aristotle are two of several philosophers who participated in this debate. Plato believed that the brain was where all mental thought and processes happened. In contrast, Aristotle believed the brain served the purpose of cooling down the emotions derived from the heart. The mind-body problem was a stepping stone toward attempting to understand the connection between the mind and body.

Another debate arose about localisation of function or functional specialisation versus equipotentiality which played a significant role in the development in behavioural neuroscience. As a result of localisation of function research, many famous people found within psychology have come to various different conclusions. Wilder Penfield was able to develop a map of the cerebral cortex through studying epileptic patients along with Rassmussen. Research on localisation of function has led behavioural neuroscientists to a better understanding of which parts of the brain control behaviour. This is best exemplified through the case study of Phineas Gage.

The term “psychobiology” has been used in a variety of contexts, emphasizing the importance of biology, which is the discipline that studies organic, neural and cellular modifications in behaviour, plasticity in neuroscience, and biological diseases in all aspects, in addition, biology focuses and analyses behaviour and all the subjects it is concerned about, from a scientific point of view. In this context, psychology helps as a complementary, but important discipline in the neurobiological sciences. The role of psychology in this questions is that of a social tool that backs up the main or strongest biological science. The term “psychobiology” was first used in its modern sense by Knight Dunlap in his book An Outline of Psychobiology (1914). Dunlap also was the founder and editor-in-chief of the journal Psychobiology. In the announcement of that journal, Dunlap writes that the journal will publish research “…bearing on the interconnection of mental and physiological functions”, which describes the field of behavioural neuroscience even in its modern sense.

Relationship to Other Fields of Psychology and Biology

In many cases, humans may serve as experimental subjects in behavioural neuroscience experiments; however, a great deal of the experimental literature in behavioural neuroscience comes from the study of non-human species, most frequently rats, mice, and monkeys. As a result, a critical assumption in behavioural neuroscience is that organisms share biological and behavioural similarities, enough to permit extrapolations across species. This allies behavioural neuroscience closely with comparative psychology, evolutionary psychology, evolutionary biology, and neurobiology. Behavioural neuroscience also has paradigmatic and methodological similarities to neuropsychology, which relies heavily on the study of the behaviour of humans with nervous system dysfunction (i.e. a non-experimentally based biological manipulation).

Synonyms for behavioural neuroscience include biopsychology, biological psychology, and psychobiology. Physiological psychology is a subfield of behavioural neuroscience, with an appropriately narrower definition.

Research Methods

The distinguishing characteristic of a behavioural neuroscience experiment is that either the independent variable of the experiment is biological, or some dependent variable is biological. In other words, the nervous system of the organism under study is permanently or temporarily altered, or some aspect of the nervous system is measured (usually to be related to a behavioural variable).

Disabling or Decreasing Neural Function

  • Lesions: A classic method in which a brain-region of interest is naturally or intentionally destroyed to observe any resulting changes such as degraded or enhanced performance on some behavioural measure. Lesions can be placed with relatively high accuracy “Thanks to a variety of brain ‘atlases’ which provide a map of brain regions in 3-dimensional “stereotactic coordinates.
    • Surgical lesions: Neural tissue is destroyed by removing it surgically.
    • Electrolytic lesions: Neural tissue is destroyed through the application of electrical shock trauma.
    • Chemical lesions: Neural tissue is destroyed by the infusion of a neurotoxin.
    • Temporary lesions: Neural tissue is temporarily disabled by cooling or by the use of anaesthetics such as tetrodotoxin.
  • Transcranial magnetic stimulation: A new technique usually used with human subjects in which a magnetic coil applied to the scalp causes unsystematic electrical activity in nearby cortical neurons which can be experimentally analysed as a functional lesion.
  • Synthetic ligand injection: A receptor activated solely by a synthetic ligand (RASSL) or Designer Receptor Exclusively Activated by Designer Drugs (DREADD), permits spatial and temporal control of G protein signalling in vivo. These systems utilise G protein-coupled receptors (GPCR) engineered to respond exclusively to synthetic small molecules ligands, like clozapine N-oxide (CNO), and not to their natural ligand(s). RASSL’s represent a GPCR-based chemogenetic tool. These synthetic ligands upon activation can decrease neural function by G-protein activation. This can with Potassium attenuating neural activity.
  • Psychopharmacological manipulations: A chemical receptor antagonist induces neural activity by interfering with neurotransmission. Antagonists can be delivered systemically (such as by intravenous injection) or locally (intracerebrally) during a surgical procedure into the ventricles or into specific brain structures. For example, NMDA antagonist AP5 has been shown to inhibit the initiation of long term potentiation of excitatory synaptic transmission (in rodent fear conditioning) which is believed to be a vital mechanism in learning and memory.
  • Optogenetic inhibition: A light activated inhibitory protein is expressed in cells of interest. Powerful millisecond timescale neuronal inhibition is instigated upon stimulation by the appropriate frequency of light delivered via fibre optics or implanted LEDs in the case of vertebrates, or via external illumination for small, sufficiently translucent invertebrates. Bacterial Halorhodopsins or Proton pumps are the two classes of proteins used for inhibitory optogenetics, achieving inhibition by increasing cytoplasmic levels of halides (Cl−) or decreasing the cytoplasmic concentration of protons, respectively.

Enhancing Neural Function

  • Electrical stimulation: A classic method in which neural activity is enhanced by application of a small electric current (too small to cause significant cell death).
  • Psychopharmacological manipulations: A chemical receptor agonist facilitates neural activity by enhancing or replacing endogenous neurotransmitters. Agonists can be delivered systemically (such as by intravenous injection) or locally (intracerebrally) during a surgical procedure.
  • Synthetic Ligand Injection: Likewise, Gq-DREADDs can be used to modulate cellular function by innervation of brain regions such as Hippocampus. This innervation results in the amplification of γ-rhythms, which increases motor activity.
  • Transcranial magnetic stimulation: In some cases (for example, studies of motor cortex), this technique can be analysed as having a stimulatory effect (rather than as a functional lesion).
  • Optogenetic excitation: A light activated excitatory protein is expressed in select cells. Channelrhodopsin-2 (ChR2), a light activated cation channel, was the first bacterial opsin shown to excite neurons in response to light, though a number of new excitatory optogenetic tools have now been generated by improving and imparting novel properties to ChR2

Measuring Neural Activity

  • Optical techniques: Optical methods for recording neuronal activity rely on methods that modify the optical properties of neurons in response to the cellular events associated with action potentials or neurotransmitter release.
    • Voltage sensitive dyes (VSDs) were among the earliest method for optically detecting neuronal activity. VSDs commonly changed their fluorescent properties in response to a voltage change across the neuron’s membrane, rendering membrane sub-threshold and supra-threshold (action potentials) electrical activity detectable. Genetically encoded voltage sensitive fluorescent proteins have also been developed.
    • Calcium imaging relies on dyes or genetically encoded proteins that fluoresce upon binding to the calcium that is transiently present during an action potential.
    • Synapto-pHluorin is a technique that relies on a fusion protein that combines a synaptic vesicle membrane protein and a pH sensitive fluorescent protein. Upon synaptic vesicle release, the chimeric protein is exposed to the higher pH of the synaptic cleft, causing a measurable change in fluorescence.
  • Single-unit recording: A method whereby an electrode is introduced into the brain of a living animal to detect electrical activity that is generated by the neurons adjacent to the electrode tip. Normally this is performed with sedated animals but sometimes it is performed on awake animals engaged in a behavioural event, such as a thirsty rat whisking a particular sandpaper grade previously paired with water in order to measure the corresponding patterns of neuronal firing at the decision point.
  • Multielectrode recording: The use of a bundle of fine electrodes to record the simultaneous activity of up to hundreds of neurons.
  • fMRI: Functional magnetic resonance imaging, a technique most frequently applied on human subjects, in which changes in cerebral blood flow can be detected in an MRI apparatus and are taken to indicate relative activity of larger scale brain regions (i.e., on the order of hundreds of thousands of neurons).
  • PET: Positron Emission Tomography detects particles called photons using a 3-D nuclear medicine examination. These particles are emitted by injections of radioisotopes such as fluorine. PET imaging reveal the pathological processes which predict anatomic changes making it important for detecting, diagnosing and characterising many pathologies.
  • Electroencephalography: Or EEG; and the derivative technique of event-related potentials, in which scalp electrodes monitor the average activity of neurons in the cortex (again, used most frequently with human subjects). This technique uses different types of electrodes for recording systems such as needle electrodes and saline-based electrodes. EEG allows for the investigation of mental disorders, sleep disorders and physiology. It can monitor brain development and cognitive engagement.
  • Functional neuroanatomy: A more complex counterpart of phrenology. The expression of some anatomical marker is taken to reflect neural activity. For example, the expression of immediate early genes is thought to be caused by vigorous neural activity. Likewise, the injection of 2-deoxyglucose prior to some behavioural task can be followed by anatomical localisation of that chemical; it is taken up by neurons that are electrically active.
  • MEG: Magnetoencephalography shows the functioning of the human brain through the measurement of electromagnetic activity. Measuring the magnetic fields created by the electric current flowing within the neurons identifies brain activity associated with various human functions in real time, with millimetre spatial accuracy. Clinicians can noninvasively obtain data to help them assess neurological disorders and plan surgical treatments.

Genetic Techniques

  • QTL mapping: The influence of a gene in some behaviour can be statistically inferred by studying inbred strains of some species, most commonly mice. The recent sequencing of the genome of many species, most notably mice, has facilitated this technique.
  • Selective breeding: Organisms, often mice, may be bred selectively among inbred strains to create a recombinant congenic strain. This might be done to isolate an experimentally interesting stretch of DNA derived from one strain on the background genome of another strain to allow stronger inferences about the role of that stretch of DNA.
  • Genetic engineering: The genome may also be experimentally-manipulated; for example, knockout mice can be engineered to lack a particular gene, or a gene may be expressed in a strain which does not normally do so (the ‘transgenic’). Advanced techniques may also permit the expression or suppression of a gene to occur by injection of some regulating chemical.

Other Research Methods

Computational models, i.e. using a computer to formulate real-world problems to develop solutions. Although this method is often focused in computer science, it has begun to move towards other areas of study. For example, psychology is one of these areas. Computational models allow researchers in psychology to enhance their understanding of the functions and developments in nervous systems. Examples of methods include the modelling of neurons, networks and brain systems and theoretical analysis. Computational methods have a wide variety of roles including clarifying experiments, hypothesis testing and generating new insights. These techniques play an increasing role in the advancement of biological psychology.

Limitations and Advantages

Different manipulations have advantages and limitations. Neural tissue destroyed as a primary consequence of a surgery, electric shock or neurotoxin can confound the results so that the physical trauma masks changes in the fundamental neurophysiological processes of interest. For example, when using an electrolytic probe to create a purposeful lesion in a distinct region of the rat brain, surrounding tissue can be affected: so, a change in behaviour exhibited by the experimental group post-surgery is to some degree a result of damage to surrounding neural tissue, rather than by a lesion of a distinct brain region. Most genetic manipulation techniques are also considered permanent. Temporary lesions can be achieved with advanced in genetic manipulations, for example, certain genes can now be switched on and off with diet. Pharmacological manipulations also allow blocking of certain neurotransmitters temporarily as the function returns to its previous state after the drug has been metabolised.

Topic Areas

In general, behavioural neuroscientists study similar themes and issues as academic psychologists, though limited by the need to use nonhuman animals. As a result, the bulk of literature in behavioural neuroscience deals with mental processes and behaviours that are shared across different animal models such as:

  • Sensation and perception.
  • Motivated behaviour (hunger, thirst, sex).
  • Control of movement.
  • Learning and memory.
  • Sleep and biological rhythms.
  • Emotion.

However, with increasing technical sophistication and with the development of more precise non-invasive methods that can be applied to human subjects, behavioural neuroscientists are beginning to contribute to other classical topic areas of psychology, philosophy, and linguistics, such as:

  • Language.
  • Reasoning and decision making.
  • Consciousness.

Behavioural neuroscience has also had a strong history of contributing to the understanding of medical disorders, including those that fall under the purview of clinical psychology and biological psychopathology (also known as abnormal psychology). Although animal models do not exist for all mental illnesses, the field has contributed important therapeutic data on a variety of conditions, including:

  • Parkinson’s disease, a degenerative disorder of the central nervous system that often impairs the sufferer’s motor skills and speech.
  • Huntington’s disease, a rare inherited neurological disorder whose most obvious symptoms are abnormal body movements and a lack of coordination. It also affects a number of mental abilities and some aspects of personality.
  • Alzheimer’s disease, a neurodegenerative disease that, in its most common form, is found in people over the age of 65 and is characterised by progressive cognitive deterioration, together with declining activities of daily living and by neuropsychiatric symptoms or behavioural changes.
  • Clinical depression, a common psychiatric disorder, characterised by a persistent lowering of mood, loss of interest in usual activities and diminished ability to experience pleasure.
  • Schizophrenia, a psychiatric diagnosis that describes a mental illness characterised by impairments in the perception or expression of reality, most commonly manifesting as auditory hallucinations, paranoid or bizarre delusions or disorganised speech and thinking in the context of significant social or occupational dysfunction.
  • Autism, a brain development disorder that impairs social interaction and communication, and causes restricted and repetitive behaviour, all starting before a child is three years old.
  • Anxiety, a physiological state characterised by cognitive, somatic, emotional, and behavioural components. These components combine to create the feelings that are typically recognised as fear, apprehension, or worry.
  • Drug abuse, including alcoholism.

What is Affect (Psychology)?

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Introduction

Affect, in psychology, refers to the underlying experience of feeling, emotion or mood.

Dimensions of Affect

Affective states are psycho-physiological constructs – meaning, largely, concepts that connect mental and physical processes. According to most current views, they vary along three principal dimensions: valence, arousal, and motivational intensity.

  • Valence is the subjective spectrum of positive-to-negative evaluation of an experience an individual may have had.
    • Emotional valence refers to the emotion’s consequences, emotion-eliciting circumstances, or subjective feelings or attitudes.
  • Arousal is objectively measurable as activation of the sympathetic nervous system, but can also be assessed subjectively via self-report.
  • Motivational intensity refers to the impulsion to act; the strength of an urge to move toward or away from a stimulus and whether or not to interact with said stimulus.
    • Simply moving is not considered approach (or avoidance) motivation.

It is important to note that arousal is different from motivational intensity. While arousal is a construct that is closely related to motivational intensity, they differ in that motivation necessarily implies action while arousal does not.

Affect Display

Affect is sometimes used to mean affect display, which is a facial, vocal, or gestural behaviour that serves as an indicator of affect.

Effects

In psychology, affect brings about an organism’s interaction with stimuli.

Affect can influence cognitive scope (the breadth of cognitive processes). Initially, it was thought that positive affects broadened whereas negative affects narrowed cognitive scope. However, evidence now suggests that affects high in motivational intensity narrow cognitive scope whereas affects low in motivational intensity broaden it. The construct of cognitive scope has proven valuable in cognitive psychology.

Affect Tolerance

According to a research article about affect tolerance written by psychiatrist Jerome Sashin (1985), “Affect tolerance can be defined as the ability to respond to a stimulus which would ordinarily be expected to evoke affects by the subjective experiencing of feelings.” Essentially it refers to one’s ability to react to emotions and feelings. One who is low in affect tolerance would show little to no reaction to emotion and feeling of any kind. This is closely related to alexithymia.

“Alexithymia is a subclinical phenomenon involving a lack of emotional awareness or, more specifically, difficulty in identifying and describing feelings and in distinguishing feelings from the bodily sensations of emotional arousal” (Glimcher & Fehr, 2014). At its core, alexithymia is an inability for an individual to recognise what emotions they are feeling – as well as an inability to describe them. According to Dalya Samur and colleagues (2013) people with alexithymia have been shown to have correlations with increased suicide rates, mental discomfort, and deaths.

Affect tolerance factors, including anxiety sensitivity, intolerance of uncertainty, and emotional distress tolerance, may be helped by mindfulness. Mindfulness refers to the practice of being hyper aware of one’s own feelings, thoughts, sensations, and the stimulus of the environment around you – not in an anxiety-inducing way, but in a gentle and pleasant way. Mindfulness has been shown to produce increased subjective well-being, reduced psychological symptoms and emotional reactivity, and improved behavioural regulation.

Relationship to Behaviour and Cognition

The affective domain represents one of the three divisions described in modern psychology: the other two being the behavioural, and the cognitive. Classically, these divisions have also been referred to as the “ABC’s of psychology”. However, in certain views, the cognitive may be considered as a part of the affective, or the affective as a part of the cognitive; it is important to note that “cognitive and affective states … [are] merely analytic categories.”

Instinctive and Cognitive Factors in Causation of Affect

Affect can mean an instinctual reaction to stimulation that occurs before the typical cognitive processes considered necessary for the formation of a more complex emotion. Robert B. Zajonc (1980) asserts this reaction to stimuli is primary for human beings and that it is the dominant reaction for non-human organisms. Zajonc suggests that affective reactions can occur without extensive perceptual and cognitive encoding and be made sooner and with greater confidence than cognitive judgments.

Many theorists, such as Lazarus (1982) consider affect to be post-cognitive: elicited only after a certain amount of cognitive processing of information has been accomplished. In this view, such affective reactions as liking, disliking, evaluation, or the experience of pleasure or displeasure each result from a different prior cognitive process that makes a variety of content discriminations and identifies features, examines them to find value, and weighs them according to their contributions (Brewin, 1989). Some scholars, such as Lerner and Keltner (2000) argue that affect can be both pre- and post-cognitive: initial emotional responses produce thoughts, which produce affect. In a further iteration, some scholars argue that affect is necessary for enabling more rational modes of cognition (Damasio, 2006).

A divergence from a narrow reinforcement model of emotion allows other perspectives about how affect influences emotional development. Thus, temperament, cognitive development, socialisation patterns, and the idiosyncrasies of one’s family or subculture might interact in nonlinear ways. For example, the temperament of a highly reactive/low self-soothing infant may “disproportionately” affect the process of emotion regulation in the early months of life (Griffiths, 1997).

Some other social sciences, such as geography or anthropology, have adopted the concept of affect during the last decade. In French psychoanalysis a major contribution to the field of affect comes from André Green (1973). The focus on affect has largely derived from the work of Deleuze and brought emotional and visceral concerns into such conventional discourses as those on geopolitics, urban life and material culture. Affect has also challenged methodologies of the social sciences by emphasizing somatic power over the idea of a removed objectivity and therefore has strong ties with the contemporary non-representational theory.

Brief History

A number of experiments have been conducted in the study of social and psychological affective preferences (i.e., what people like or dislike). Specific research has been done on preferences, attitudes, impression formation, and decision making. This research contrasts findings with recognition memory (old-new judgements), allowing researchers to demonstrate reliable distinctions between the two. Affect-based judgements and cognitive processes have been examined with noted differences indicated, and some argue affect and cognition are under the control of separate and partially independent systems that can influence each other in a variety of ways (Zajonc, 1980). Both affect and cognition may constitute independent sources of effects within systems of information processing. Others suggest emotion is a result of an anticipated, experienced, or imagined outcome of an adaptational transaction between organism and environment, therefore cognitive appraisal processes are keys to the development and expression of an emotion (Lazarus, 1982).

Psychometric Measurement

Affect has been found across cultures to comprise both positive and negative dimensions. The most commonly used measure in scholarly research is the Positive and Negative Affect Schedule (PANAS) (Watson, Clark & Tellegen, 1988). The PANAS is a lexical measure developed in a North American setting and consisting of 20 single-word items, for instance excited, alert, determined for positive affect, and upset, guilty, and jittery for negative affect. However, some of the PANAS items have been found either to be redundant or to have ambiguous meanings to English speakers from non-North American cultures. As a result, an internationally reliable short-form, the I-PANAS-SF, has been developed and validated comprising two 5-item scales with internal reliability, cross-sample and cross-cultural factorial invariance, temporal stability, convergent and criterion-related validities.

Mroczek and Kolarz (1998) have also developed another set of scales to measure positive and negative affect. Each of the scales has 6 items. The scales have shown evidence of acceptable validity and reliability across cultures.

Non-Conscious Affect and Perception

In relation to perception, a type of non-conscious affect may be separate from the cognitive processing of environmental stimuli. A monohierarchy of perception, affect and cognition considers the roles of arousal, attention tendencies, affective primacy (Zajonc, 1980), evolutionary constraints (Shepard, 1984; 1994), and covert perception (Weiskrantz, 1997) within the sensing and processing of preferences and discriminations. Emotions are complex chains of events triggered by certain stimuli. There is no way to completely describe an emotion by knowing only some of its components. Verbal reports of feelings are often inaccurate because people may not know exactly what they feel, or they may feel several different emotions at the same time. There are also situations that arise in which individuals attempt to hide their feelings, and there are some who believe that public and private events seldom coincide exactly, and that words for feelings are generally more ambiguous than are words for objects or events. Therefore, non-conscious emotions need to be measured by measures circumventing self-report such as the Implicit Positive and Negative Affect Test (IPANAT; Quirin, Kazén & Kuhl, 2009).

Affective responses, on the other hand, are more basic and may be less problematic in terms of assessment. Brewin has proposed two experiential processes that frame non-cognitive relations between various affective experiences: those that are prewired dispositions (i.e. non-conscious processes), able to “select from the total stimulus array those stimuli that are causally relevant, using such criteria as perceptual salience, spatiotemporal cues, and predictive value in relation to data stored in memory” (Brewin, 1989, p.381), and those that are automatic (i.e. subconscious processes), characterised as “rapid, relatively inflexible and difficult to modify… (requiring) minimal attention to occur and… (capable of being) activated without intention or awareness” (Brewin1989 p.381). But a note should be considered on the differences between affect and emotion.

Arousal

Arousal is a basic physiological response to the presentation of stimuli. When this occurs, a non-conscious affective process takes the form of two control mechanisms: one mobilising and the other immobilising. Within the human brain, the amygdala regulates an instinctual reaction initiating this arousal process, either freezing the individual or accelerating mobilisation.

The arousal response is illustrated in studies focused on reward systems that control food-seeking behaviour (Balleine, 2005). Researchers have focused on learning processes and modulatory processes that are present while encoding and retrieving goal values. When an organism seeks food, the anticipation of reward based on environmental events becomes another influence on food seeking that is separate from the reward of food itself. Therefore, earning the reward and anticipating the reward are separate processes and both create an excitatory influence of reward-related cues. Both processes are dissociated at the level of the amygdala, and are functionally integrated within larger neural systems.

Motivational intensity and Cognitive Scope

Measuring Cognitive Scope

Cognitive scope can be measured by tasks involving attention, perception, categorisation and memory. Some studies use a flanker attention task to figure out whether cognitive scope is broadened or narrowed. For example:

  • Using the letters “H” and “N” participants need to identify as quickly as possible the middle letter of 5 when all the letters are the same (e.g. “HHHHH”); and
  • When the middle letter is different from the flanking letters (e.g. “HHNHH”).

Broadened cognitive scope would be indicated if reaction times differed greatly from when all the letters were the same compared to when the middle letter is different. Other studies use a Navon attention task to measure difference in cognitive scope. A large letter is composed of smaller letters, in most cases smaller “L”‘s or “F”‘s that make up the shape of the letter “T” or “H” or vice versa. Broadened cognitive scope would be suggested by a faster reaction to name the larger letter, whereas narrowed cognitive scope would be suggested by a faster reaction to name the smaller letters within the larger letter. A source-monitoring paradigm can also be used to measure how much contextual information is perceived: for instance, participants are tasked to watch a screen which serially displays words to be memorised for 3 seconds each, and also have to remember whether the word appeared on the left or the right half of the screen. The words were also encased in a coloured box, but the participants did not know that they would eventually be asked what colour box the word appeared in.

Main Research Findings

Motivation intensity refers to the strength of urge to move toward or away from a particular stimulus.

Anger and fear affective states, induced via film clips, conferred more selective attention on a flanker task compared to controls as indicated by reaction times that were not very different, even when the flanking letters were different from the middle target letter. Both anger and fear have high motivational intensity because propulsion to act would be high in the face of an angry or fearful stimulus, like a screaming person or coiled snake. Affects high in motivational intensity, thus, narrow cognitive scope making people able to focus more on target information. After seeing a sad picture, participants were faster to identify the larger letter in a Navon attention task, suggesting more global or broadened cognitive scope. The sad emotion is thought to sometimes have low motivational intensity. But, after seeing a disgusting picture, participants were faster to identify the component letters, indicative of a localised more narrow cognitive scope. Disgust has high motivational intensity. Affects high in motivational intensity, thus, narrow cognitive scope making people able to focus more on central information. whereas affects low in motivational intensity broadened cognitive scope allowing for faster global interpretation. The changes in cognitive scope associated with different affective states is evolutionarily adaptive because high motivational intensity affects elicited by stimuli that require movement and action should be focused on, in a phenomenon known as goal-directed behaviour. For example, in early times seeing a lion (fearful stimulus) probably elicited a negative but high motivational affective state (fear) in which the human being was propelled to run away. In this case the goal would be to avoid getting killed.

Moving beyond just negative affective states, researchers wanted to test whether or not the negative or positive affective states varied between high and low motivational intensity. To evaluate this theory, Harmon-Jones and Gable (2009) created an experiment using appetitive picture priming and the Navon task, which would allow them to measure the attentional scope with the detection of the Navon letters. The Navon task included a neutral affect comparison condition. Typically, neutral states cause broadened attention with a neutral stimulus. They predicted that a broad attentional scope could cause a faster detection of global (large) letters, whereas a narrow attentional scope could cause a faster detection of local (small) letters. The evidence proved that the appetitive stimuli produced a narrowed attentional scope. The experimenters further increased the narrowed attentional scope in appetitive stimuli by telling participants they would be allowed to consume the desserts shown in the pictures. The results revealed that their hypothesis was correct in that the broad attentional scope led to quicker detection of global letters and the narrowed attentional scope led to quicker detection of local letters.

Bradley and colleagues (2001) wanted to further examine the emotional reactions in picture priming. Instead of using an appetitive stimulus they used stimulus sets from the International Affective Picture System (IAPS). The image set includes various unpleasant pictures such as snakes, insects, attack scenes, accidents, illness, and loss. They predicted that the unpleasant picture would stimulate a defensive motivational intensity response, which would produce strong emotional arousal such as skin gland responses and cardiac deceleration. Participants rated the pictures based on valence, arousal and dominance on the Self-Assessment Manikin (SAM) rating scale. The findings were consistent with the hypothesis and proved that emotion is organised motivationally by the intensity of activation in appetitive or defensive systems.

Prior to research in 2013, Harmon-Jones and Gable (2009) performed an experiment to examine whether neural activation related with approach-motivation intensity (left frontal-central activity) would trigger the effect of appetitive stimuli on narrowed attention. They also tested whether individual dissimilarities in approach motivation are associated with attentional narrowing. In order to test the hypothesis, the researchers used the same Navon task with appetitive and neutral pictures in addition to having the participants indicate how long since they had last eaten in minutes. To examine the neural activation, the researchers used an electroencephalography and recorded eye movements in order to detect what regions of the brain were being used during approach motivation. The results supported the hypothesis suggesting that the left frontal-central hemisphere is relative for approach-motivational processes and narrowed attentional scope. Some psychologists were concerned that the individuals who were hungry had an increase in the left frontal-central due to frustration. This statement was proved false because the research shows that the dessert pictures increase positive affect even in the hungry individuals. The findings revealed that narrowed cognitive scope has the ability to assist us in goal accomplishment.

Clinical Applications

Later on, researchers connected motivational intensity to clinical applications and found that alcohol-related pictures caused narrowed attention for persons who had a strong motivation to consume alcohol. The researchers tested the participants by exposing them to alcohol and neutral pictures. After the picture was displayed on a screen, the participants finished a test evaluating attentional focus. The findings proved that exposure to alcohol-related pictures led to a narrowing of attentional focus to individuals who were motivated to use alcohol. However, exposure to neutral pictures did not correlate with alcohol-related motivation to manipulate attentional focus. The Alcohol Myopia Theory (AMT) states that alcohol consumption reduces the amount of information available in memory, which also narrows attention so only the most proximal items or striking sources are encompassed in attentional scope. This narrowed attention leads intoxicated persons to make more extreme decisions than they would when sober. Researchers provided evidence that substance-related stimuli capture the attention of individuals when they have high and intense motivation to consume the substance. Motivational intensity and cue-induced narrowing of attention has a unique role in shaping people’s initial decision to consume alcohol. In 2013, psychologists from the University of Missouri investigated the connection between sport achievement orientation and alcohol outcomes. They asked varsity athletes to complete a Sport Orientation Questionnaire which measured their sport-related achievement orientation on three scales – competitiveness, win orientation, and goal orientation (Weaver et al., 2013). The participants also completed assessments of alcohol use and alcohol-related problems. The results revealed that the goal orientation of the athletes were significantly associated with alcohol use but not alcohol-related problems.

In terms of psychopathological implications and applications, college students showing depressive symptoms were better at retrieving seemingly “nonrelevant” contextual information from a source monitoring paradigm task. Namely, the students with depressive symptoms were better at identifying the colour of the box the word was in compared to non-depressed students. Sadness (low motivational intensity) is usually associated with depression, so the more broad focus on contextual information of sadder students supports that affects high in motivational intensity narrow cognitive scope whereas affects low in motivational intensity broaden cognitive scope.

The motivational intensity theory states that the difficulty of a task combined with the importance of success determine the energy invested by an individual. The theory has three main layers.

  • The innermost layer says human behaviour is guided by the desire to conserve as much energy as possible. Individuals aim to avoid wasting energy so they invest only the energy that is required to complete the task.
  • The middle layer focuses on the difficulty of tasks combined with the importance of success and how this affects energy conservation. It focuses on energy investment in situations of clear and unclear task difficulty.
  • The last layer looks at predictions for energy invested by a person when they have several possible options to choose at different task difficulties.

The person is free to choose among several possible options of task difficulty. The motivational intensity theory offers a logical and consistent framework for research. Researchers can predict a person’s actions by assuming effort refers to the energy investment. The motivational intensity theory is used to show how changes in goal attractiveness and energy investment correlate.

Mood

Refer to Mood (Psychology).

Mood, like emotion, is an affective state. However, an emotion tends to have a clear focus (i.e. its cause is self-evident), while mood tends to be more unfocused and diffuse. Mood, according to Batson, Shaw and Oleson (1992), involves tone and intensity and a structured set of beliefs about general expectations of a future experience of pleasure or pain, or of positive or negative affect in the future. Unlike instant reactions that produce affect or emotion, and that change with expectations of future pleasure or pain, moods, being diffuse and unfocused and thus harder to cope with, can last for days, weeks, months or even years (Schucman & Thetford, 1975). Moods are hypothetical constructs depicting an individual’s emotional state. Researchers typically infer the existence of moods from a variety of behavioural referents (Blechman, 1990). Habitual negative affect and negative mood is characteristic of high neuroticism.

Positive affect and negative affect (PANAS) represent independent domains of emotion in the general population, and positive affect is strongly linked to social interaction. Positive and negative daily events show independent relationships to subjective well-being, and positive affect is strongly linked to social activity. Recent research suggests that high functional support is related to higher levels of positive affect. In his work on negative affect arousal and white noise, Seidner (1991) found support for the existence of a negative affect arousal mechanism regarding the devaluation of speakers from other ethnic origins. The exact process through which social support is linked to positive affect remains unclear. The process could derive from predictable, regularised social interaction, from leisure activities where the focus is on relaxation and positive mood, or from the enjoyment of shared activities. The techniques used to shift a negative mood to a positive one are called mood repair strategies.

Social Interaction

Affect display is a critical facet of interpersonal communication. Evolutionary psychologists have advanced the hypothesis that hominids have evolved with sophisticated capability of reading affect displays.

Emotions are portrayed as dynamic processes that mediate the individual’s relation to a continually changing social environment. In other words, emotions are considered to be processes of establishing, maintaining, or disrupting the relation between the organism and the environment on matters of significance to the person.

Most social and psychological phenomena occur as the result of repeated interactions between multiple individuals over time. These interactions should be seen as a multi-agent system – a system that contains multiple agents interacting with each other and/or with their environments over time. The outcomes of individual agents’ behaviours are interdependent: Each agent’s ability to achieve its goals depends on not only what it does but also what other agents do.

Emotions are one of the main sources for the interaction. Emotions of an individual influence the emotions, thoughts and behaviours of others; others’ reactions can then influence their future interactions with the individual expressing the original emotion, as well as that individual’s future emotions and behaviours. Emotion operates in cycles that can involve multiple people in a process of reciprocal influence.

Affect, emotion, or feeling is displayed to others through facial expressions, hand gestures, posture, voice characteristics, and other physical manifestation. These affect displays vary between and within cultures and are displayed in various forms ranging from the most discrete of facial expressions to the most dramatic and prolific gestures.

Observers are sensitive to agents’ emotions, and are capable of recognising the messages these emotions convey. They react to and draw inferences from an agent’s emotions. The emotion an agent displays may not be an authentic reflection of his or her actual state (refer to Emotional Labour).

Agents’ emotions can have effects on four broad sets of factors:

  • Emotions of other persons.
  • Inferences of other persons.
  • Behaviours of other persons.
  • Interactions and relationships between the agent and other persons.

Emotion may affect not only the person at whom it was directed, but also third parties who observe an agent’s emotion. Moreover, emotions can affect larger social entities such as a group or a team. Emotions are a kind of message and therefore can influence the emotions, attributions and ensuing behaviours of others, potentially evoking a feedback process to the original agent.

Agents’ feelings evoke feelings in others by two suggested distinct mechanisms:

  • Emotion contagion:
    • People tend to automatically and unconsciously mimic non-verbal expressions.
    • Mimicking occurs also in interactions involving textual exchanges alone.
  • Emotion interpretation:
    • An individual may perceive an agent as feeling a particular emotion and react with complementary or situationally appropriate emotions of their own.
    • The feelings of the others diverge from and in some way complement the feelings of the original agent.

People may not only react emotionally, but may also draw inferences about emotive agents such as the social status or power of an emotive agent, his competence and his credibility. For example, an agent presumed to be angry may also be presumed to have high power.

References

Balliene, B.W. (2005) Dietary Influences on Obesity: Environment, Behavior and Biology. Physiology & Behaviour. 86(5), pp.717-730.

Batson, C.D., Shaw, L.L. & Oleson, K.C. (1992). Differentiating Affect, Mood and Emotion: Toward Functionally based Conceptual Distinctions. Emotion. Newbury Park, CA: Sage.

Blechman, E.A. (1990). Moods, Affect, and Emotions. Hillsdale, New Jersey: Lawrence Erlbaum Associates: Hillsdale.

Bradley, M.M., Codispoti, M., Cuthbert, B.N. & Lang, P.J. (2001) Emotion and motivation I: Defensive and appetitive reactions in picture processing. Emotion. 1(3), pp.276-298. doi:10.1037/1528-3542.1.3.276.

Brewin, C.R. (1989) Cognitive Change Processes in Psychotherapy. Psychological Review. 96(45), pp.379-394. doi:10.1037/0033-295x.96.3.379.

Damasio, A. (2006) Descartes’ Error: Emotion, Reason, and the Human Brain. London: Vintage (Part of the Random House Group).

Glimcher, P.W. & Fehr, E (Eds.) (2014) Chapter 27 – Understanding Others: Brain Mechanisms of Theory of Mind and Empathy. Neuroeconomics (Second Edition). Academic Press. pp.513-532. https://doi.org/10.1016/B978-0-12-416008-8.00027-9.

Green, A. (Author), Sheridan, A. (Trans) & Spillius, E.B. (General Editor) (1999) The Fabric of Affect in the Psychoanalytic Discourse. The New Library of Psychoanalysis 37. London: Routledge.

Griffiths, P.E. (1997) What Emotions Really Are: The Problem of Psychological Categories. Chicago: The University of Chicago Press.

Harmon-Jones, E. & Gable, P.A. (2009) Neural Activity Underlying the Effect of Approach-Motivated Positive Affect on Narrowed Attention. Psychological Science. 20(4), pp.406-409. doi:10.1111/j.1467-9280.2009.02302.x.

Lazarus, R.S. (1982) Thoughts on the Relations between Emotions and Cognition. American Physiologist. 37 (10), pp.1019-1024.

Lerner, J.S. & Keltner, D. (2000) Beyond valence: Toward a model of emotion-specific influences on judgement and choice. Cognition and Emotion. 14(4), pp.473-493. doi:10.1080/026999300402763.

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Quirin, M., Kazén, M. & Kuhl, J. (2009) When nonsense sounds happy or helpless: The Implicit Positive and Negative Affect Test (IPANAT). Journal of Personality and Social Psychology. 97(3), pp.500-516. doi:10.1037/a001606

Samur, D., Tops, M., Schlinkert, C., Quirin, M., Cuijpers, P. & Koole, S.L. (2013) Four decades of research on alexithymia: moving toward clinical applications. Frontiers in Psychology. 4, pp.861. https://dx.doi.org/10.3389%2Ffpsyg.2013.00861.

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What are Hallucinations in Psychosis?

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Introduction

Visual hallucinations in psychosis are hallucinations accompanied by delusions, which are abnormal beliefs that are endorsed by patients as real, that persist in spite of evidence to the contrary, and that are not part of a patient’s culture or subculture.

Presentation

Visual hallucinations in psychoses are reported to have physical properties similar to real perceptions. They are often life-sized, detailed, and solid, and are projected into the external world. They typically appear anchored in external space, just beyond the reach of individuals, or further away. They can have three-dimensional shapes, with depth and shadows, and distinct edges. They can be colourful or in black and white and can be static or have movement.

Simple versus Complex

Visual hallucinations may be simple, or non-formed visual hallucinations, or complex, or formed visual hallucinations.

Simple visual hallucinations are also referred to as non-formed or elementary visual hallucinations. They can take the form of multicoloured lights, colours, geometric shapes, indiscrete objects. Simple visual hallucinations without structure are known as phosphenes and those with geometric structure are known as photopsias. These hallucinations are caused by irritation to the primary visual cortex (Brodmann’s area 17).

Complex visual hallucinations are also referred to as formed visual hallucinations. They tend to be clear, lifelike images or scenes, such as faces of animals or people. Sometimes, hallucinations are ‘Lilliputian’, i.e. patients experience visual hallucinations where there are miniature people, often undertaking unusual actions. Lilliputian hallucinations may be accompanied by wonder, rather than terror.

Content

The frequency of hallucinations varies widely from rare to frequent, as does duration (seconds to minutes). The content of hallucinations varies as well. Complex (formed) visual hallucinations are more common than Simple (non-formed) visual hallucinations. In contrast to hallucinations experienced in organic conditions, hallucinations experienced as symptoms of psychoses tend to be more frightening. An example of this would be hallucinations that have imagery of bugs, dogs, snakes, distorted faces. Visual hallucinations may also be present in those with Parkinson’s, where visions of dead individuals can be present. In psychoses, this is relatively rare, although visions of God, angels, the devil, saints, and fairies are common. Individuals often report being surprised when hallucinations occur and are generally helpless to change or stop them. In general, individuals believe that visions are experienced only by themselves.

Causes

Two neurotransmitters are particularly important in visual hallucinations – serotonin and acetylcholine. They are concentrated in the visual thalamic nuclei and visual cortex.

The similarity of visual hallucinations that stem from diverse conditions suggest a common pathway for visual hallucinations. Three pathophysiologic mechanisms are thought to explain this.

The first mechanism has to do with cortical centres responsible for visual processing. Irritation of visual association cortices (Brodmann’s areas 18 and 19) cause complex visual hallucinations.

The second mechanism is deafferentation, the interruption or destruction of the afferent connections of nerve cells, of the visual system, caused by lesions, leading to the removal of normal inhibitory processes on cortical input to visual association areas, leading to complex hallucinations as a release phenomenon.

The third mechanism has to do with the reticular activating system, which plays a role in the maintenance of arousal. Lesions in the brain stem can cause visual hallucinations. Visual hallucinations are frequent in those with certain sleep disorders, occurring more often when drowsy. This suggests that the reticular activating system plays a part in visual hallucinations, although the precise mechanism has still not fully been established.

Prevalence

Hallucinations in those with psychoses are often experienced in colour, and most often are multi-modal, consisting of visual and auditory components. They frequently accompany paranoia or other thought disorders, and tend to occur during the daytime and are associated with episodes of excess excitability. The DSM-V lists visual hallucinations as a primary diagnostic criterion for several psychotic disorders, including schizophrenia and schizoaffective disorder.

The lifetime prevalence of all psychotic disorders is 3.48% and that of the different diagnostic groups are as follows:

  • 0.87% for schizophrenia.
  • 0.32% for schizoaffective disorder.
  • 0.07% for schizophreniform disorder.
  • 0.18% for delusional disorder.
  • 0.24% for bipolar I disorder.
  • 0.35% for major depressive disorder with psychotic features.
  • 0.42% for substance-induced psychotic disorders.
  • 0.21% for psychotic disorders due to a general medical condition.

Visual hallucinations can occur as a symptom of the above psychotic disorders in 24% to 72% of patients at some point in the course of their illness. Not all individuals who experience hallucinations have a psychotic disorder. Many physical and psychiatric disorders can manifest with hallucinations, and some individuals may have more than one disorder that could cause different types of hallucinations.

What is a Therapeutic Relationship?

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Introduction

The therapeutic relationship refers to the relationship between a healthcare professional and a client or patient. It is the means by which a therapist and a client hope to engage with each other and effect beneficial change in the client.

In psychoanalysis the therapeutic relationship has been theorised to consist of three parts: the working alliance, transference/countertransference, and the real relationship. Evidence on each component’s unique contribution to the outcome has been gathered, as well as evidence on the interaction between components. In contrast to a social relationship, the focus of the therapeutic relationship is on the client’s needs and goals.

Therapeutic/Working Alliance

The therapeutic alliance, or the working alliance may be defined as the joining of a client’s reasonable side with a therapist’s working or analysing side. Bordin (1979) conceptualised the working alliance as consisting of three parts: tasks, goals and bond. Tasks are what the therapist and client agree need to be done to reach the client’s goals. Goals are what the client hopes to gain from therapy, based on their presenting concerns. The bond forms from trust and confidence that the tasks will bring the client closer to their goals.

Research on the working alliance suggests that it is a strong predictor of psychotherapy or counselling client outcome. Also, the way in which the working alliance unfolds has been found to be related to client outcomes. Generally, an alliance that experiences a rupture that is repaired is related to better outcomes than an alliance with no ruptures, or an alliance with a rupture that is not repaired. Also, in successful cases of brief therapy, the working alliance has been found to follow a high-low-high pattern over the course of the therapy. Therapeutic alliance has been found to be effective in treating adolescents suffering from PTSD, with the strongest alliances were associated with the greatest improvement in PTSD symptoms. Regardless of other treatment procedures, studies have shown that the degree to which traumatised adolescents feel a connection with their therapist greatly affects how well they do during treatment.

Necessary and Sufficient Conditions

In the Humanistic approach, Carl Rogers identified a number of necessary and sufficient conditions that are required for therapeutic change to take place. These include the three core conditions: congruence, unconditional positive regard, and empathy. Rogers (1957; 1959) stated that there are six necessary and sufficient conditions required for therapeutic change:

  1. Therapist–client psychological contact: a relationship between client and therapist must exist, and it must be a relationship in which each person’s perception of the other is important.
  2. Client incongruence: that incongruence exists between the client’s experience and awareness.
  3. Therapist congruence, or genuineness: the therapist is congruent within the therapeutic relationship. The therapist is deeply involved, they are not ‘acting’ and they can draw on their own experiences (self-disclosure) to facilitate the relationship.
  4. Therapist unconditional positive regard: the therapist accepts the client unconditionally, without judgment, disapproval or approval. This facilitates increased self-regard in the client, as they can begin to become aware of experiences in which their view of self-worth was distorted or denied.
  5. Therapist empathic understanding: the therapist experiences an empathic understanding of the client’s internal frame of reference. Accurate empathy on the part of the therapist helps the client believe the therapist’s unconditional regard for them.
  6. Client perception: that the client perceives, to at least a minimal degree, the therapist’s unconditional positive regard and empathic understanding.

Transference and Counter-Transference

The concept of therapeutic relationship was described by Freud (1912) as “friendly affectionate feeling” in the form of a positive transference. However, transferences, or more correctly here, the therapist’s ‘counter-transferences’ can also be negative. Today transference (from the client) and counter-transference (from the therapist), is understood as subconsciously associating a person in the present, with a person from a past relationship. For example, you meet a new client who reminds you of a former lover. This would be a counter-transference, in that the therapist is responding to the client with thoughts and feelings attached to a person in a past relationship. Ideally, the therapeutic relationship will start with a positive transference for the therapy to have a good chance of effecting positive therapeutic change.

Operationalisation and Measurement

Several scales have been developed to assess the patient-professional relationship in therapy, including:

Reference

Bordin, E.S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice. 16(3), pp.252-260.