What is Dissociation (Psychology)?

Introduction

Dissociation, as a concept that has been developed over time, is any of a wide array of experiences, ranging from a mild emotional detachment from the immediate surroundings, to a more severe disconnection from physical and emotional experiences. The major characteristic of all dissociative phenomena involves a detachment from reality, rather than a loss of reality as in psychosis.

The phenomena are diagnosable under the DSM-5 as a group of disorders as well as a symptom of other disorders through various diagnostic tools. Its cause is believed to be related to neurobiological mechanisms, trauma, anxiety, and psychoactive drugs. Research has further related it to suggestibility and hypnosis, and it is inversely related to mindfulness, which is a potential treatment.

Brief History

French philosopher and psychologist Pierre Janet (1859-1947) is considered to be the author of the concept of dissociation. Contrary to some conceptions of dissociation, Janet did not believe that dissociation was a psychological defence.

Psychological defence mechanisms belong to Sigmund Freud‘s theory of psychoanalysis, not to Janetian psychology. Janet claimed that dissociation occurred only in persons who had a constitutional weakness of mental functioning that led to hysteria when they were stressed. Although it is true that many of Janet’s case histories described traumatic experiences, he never considered dissociation to be a defence against those experiences. Quite the opposite: Janet insisted that dissociation was a mental or cognitive deficit. Accordingly, he considered trauma to be one of many stressors that could worsen the already-impaired “mental deficiency” of a hysteric, thereby generating a cascade of hysterical (in today’s language, “dissociative”) symptoms.

Although there was great interest in dissociation during the last two decades of the nineteenth century (especially in France and England), this interest rapidly waned with the coming of the new century. Even Janet largely turned his attention to other matters.

There was a sharp peak in interest in dissociation in America from 1890 to 1910, especially in Boston as reflected in the work of William James, Boris Sidis, Morton Prince, and William McDougall. Nevertheless, even in America, interest in dissociation rapidly succumbed to the surging academic interest in psychoanalysis and behaviourism.

For most of the twentieth century, there was little interest in dissociation. Despite this, a review of 76 previously published cases from the 1790s to 1942 was published in 1944, describing clinical phenomena consistent with that seen by Janet and by therapists today. In 1971, Bowers and her colleagues presented a detailed, and still quite valid, treatment article. The authors of this article included leading thinkers of their time – John G. Watkins (who developed ego-state therapy) and Zygmunt A. Piotrowski (famed for his work on the Rorschach test). Further interest in dissociation was evoked when Ernest Hilgard (1977) published his neodissociation theory in the 1970s. During the 1970s and 1980s an increasing number of clinicians and researchers wrote about dissociation, particularly multiple personality disorder.

Carl Jung described pathological manifestations of dissociation as special or extreme cases of the normal operation of the psyche. This structural dissociation, opposing tension, and hierarchy of basic attitudes and functions in normal individual consciousness is the basis of Jung’s Psychological Types. He theorised that dissociation is a natural necessity for consciousness to operate in one faculty unhampered by the demands of its opposite.

Attention to dissociation as a clinical feature has been growing in recent years as knowledge of post-traumatic stress disorder (PTSD) increased, due to interest in dissociative identity disorder (DID), and as neuroimaging research and population studies show its relevance.

Historically the psychopathological concept of dissociation has also another different root: the conceptualization of Eugen Bleuler that looks into dissociation related to schizophrenia.

Diagnosis

Refer to Dissociative disorder.

Dissociation is commonly displayed on a continuum. In mild cases, dissociation can be regarded as a coping mechanism or defence mechanism in seeking to master, minimise or tolerate stress – including boredom or conflict. At the non-pathological end of the continuum, dissociation describes common events such as daydreaming. Further along the continuum are non-pathological altered states of consciousness.

More pathological dissociation involves dissociative disorders, including dissociative fugue and depersonalisation disorder with or without alterations in personal identity or sense of self. These alterations can include: a sense that self or the world is unreal (depersonalisation and derealisation), a loss of memory (amnesia), forgetting identity or assuming a new self (fugue), and separate streams of consciousness, identity and self (dissociative identity disorder, formerly termed multiple personality disorder) and complex post-traumatic stress disorder (CPTSD). Although some dissociative disruptions involve amnesia, other dissociative events do not. Dissociative disorders are typically experienced as startling, autonomous intrusions into the person’s usual ways of responding or functioning. Due to their unexpected and largely inexplicable nature, they tend to be quite unsettling.

Dissociative disorders are sometimes triggered by trauma, but may be preceded only by stress, psychoactive substances, or no identifiable trigger at all. The ICD-10 classifies conversion disorder as a dissociative disorder. The DSM groups all dissociative disorders into a single category and recognises dissociation as a symptom of acute stress disorder, posttraumatic stress disorder (PTSD), and borderline personality disorder.

Misdiagnosis is common among people who display symptoms of dissociative disorders, with an average of seven years to receive proper diagnosis and treatment. Research is ongoing into aetiologies, symptomology, and valid and reliable diagnostic tools. In the general population, dissociative experiences that are not clinically significant are highly prevalent with 60% to 65% of the respondents indicating that they have had some dissociative experiences.

Diagnostic and Statistical Manual of Mental Disorders

Diagnoses listed under the DSM-5 are dissociative identity disorder, dissociative amnesia, depersonalisation/derealisation disorder, other specified dissociative disorder and unspecified dissociative disorder. The list of available dissociative disorders listed in the DSM-5 changed from the DSM-IV-TR, as the authors removed the diagnosis of dissociative fugue, classifying it instead as a subtype of dissociative amnesia. Furthermore, the authors recognised derealisation on the same diagnostic level of depersonalisation with the opportunity of differentiating between the two.

The DSM-IV-TR considers symptoms such as depersonalisation, derealisation and psychogenic amnesia to be core features of dissociative disorders. The DSM-5 carried these symptoms over and described symptoms as positive and negative. Positive symptoms include unwanted intrusions that alter continuity of subjective experiences, which account for the first two symptoms listed earlier with the addition of fragmentation of identity. Negative symptoms include loss of access to information and mental functions that are normally readily accessible, which describes amnesia.

Peritraumatic Dissociation

Peritraumatic dissociation is considered to be dissociation that is experienced during and immediately following a traumatic event. Research is on-going related to its development, its importance, and its relationship to trauma, dissociative disorders, and predicting the development of PTSD.

Measurements

Two of the most commonly used screening tools in the community are the Dissociative Experiences Scale and the Multiscale Dissociation Inventory. Meanwhile, the Structured Clinical Interview for DSM-IV – Dissociative Disorders (SCID-D) and its second iteration, the SCID-D-R, are both semi-structured interviews and are considered psychometrically strong diagnostic tools.

Other tools include the Office Mental Status Examination (OMSE), which is used clinically due to inherent subjectivity and lack of quantitative use. There is also the Dissociative Disorders Interview Schedule (DDSI), which lacks substantive clarity for differential diagnostics.

Peritraumatic dissociation is measured through the Peritraumatic Dissociative Scale.

Aetiology

Neurobiological Mechanism

Preliminary research suggests that dissociation-inducing events, drugs like ketamine, and seizures generate slow rhythmic activity (1-3 Hz) in layer 5 neurons of the posteromedial cortex in humans (retrosplenial cortex in mice). These slow oscillations disconnect other brain regions from interacting with the posteromedial cortex, which may explain the overall experience of dissociation.

Trauma

Dissociation has been described as one of a constellation of symptoms experienced by some victims of multiple forms of childhood trauma, including physical, psychological, and sexual abuse. This is supported by studies which suggest that dissociation is correlated with a history of trauma.

Dissociation appears to have a high specificity and a low sensitivity to having a self-reported history of trauma, which means that dissociation is much more common among those who are traumatised, yet at the same time there are many people who have suffered from trauma but who do not show dissociative symptoms.

Adult dissociation when combined with a history of child abuse and otherwise interpersonal violence-related PTSD has been shown to contribute to disturbances in parenting behaviour, such as exposure of young children to violent media. Such behaviour may contribute to cycles of familial violence and trauma.

Symptoms of dissociation resulting from trauma may include depersonalisation, psychological numbing, disengagement, or amnesia regarding the events of the abuse. It has been hypothesized that dissociation may provide a temporarily effective defence mechanism in cases of severe trauma; however, in the long term, dissociation is associated with decreased psychological functioning and adjustment.

Other symptoms sometimes found along with dissociation in victims of traumatic abuse (often referred to as “sequelae to abuse”) include anxiety, PTSD, low self-esteem, somatisation, depression, chronic pain, interpersonal dysfunction, substance abuse, self-harm and suicidal ideation or actions. These symptoms may lead the victim to present the symptoms as the source of the problem.

Child abuse, especially chronic abuse starting at early ages, has been related to high levels of dissociative symptoms in a clinical sample, including amnesia for abuse memories. It has also been seen that girls who suffered abuse during their childhood had higher reported dissociation scores than did boys who reported dissociation during their childhood. A non-clinical sample of adult women linked increased levels of dissociation to sexual abuse by a significantly older person prior to age 15, and dissociation has also been correlated with a history of childhood physical and sexual abuse. When sexual abuse is examined, the levels of dissociation were found to increase along with the severity of the abuse.

A 2012 review article supports the hypothesis that current or recent trauma may affect an individual’s assessment of the more distant past, changing the experience of the past and resulting in dissociative states.

Psychoactive substances

Refer to Dissociative Drug.

Psychoactive drugs can often induce a state of temporary dissociation. Substances with dissociative properties include ketamine, nitrous oxide, alcohol, tiletamine, amphetamine, dextromethorphan, MK-801, PCP, methoxetamine, salvia, muscimol, atropine, ibogaine, and minocycline.

Correlations

Hypnosis and Suggestibility

There is evidence to suggest that dissociation is correlated with hypnotic suggestibility, specifically with dissociative symptoms related to trauma. However, the relationship between dissociation and hypnotic suggestibility appears to be complex and indicates further research is necessary.

Aspects of hypnosis include absorption, dissociation, suggestibility, and willingness to receive behavioural instruction from others. Both hypnotic suggestibility and dissociation tend to be less mindful, and hypnosis is used as a treatment modality for dissociation, anxiety, chronic pain, trauma, and more. Difference between hypnosis and dissociation: one is suggested, imposed by self or other, meaning dissociation is generally more spontaneous altering of awareness.

Mindfulness and Meditation

Mindfulness and meditation have shown an inverse relationship specifically with dissociation related to re-experiencing trauma due to the lack of present awareness inherent with dissociation. The re-experiencing episodes can include anything between illusions, distortions in perceived reality, and disconnectedness from the present moment. It is believed that the nature of dissociation as an avoidance coping or defence mechanism related to trauma inhibits resolution and integration.

Mindfulness and meditation also can alter the state of awareness to the present moment; however, unlike dissociation, it is clinically used to bring greater awareness to an individual’s present state of being. It achieves this through increased abilities to self-regulate attention, emotion, and physiological arousal, maintain continuity of consciousness, and adopt an approach to the present experience that is open and curious. In practice, non-judgmental awareness has displayed a positive relationship with lower symptoms of PTSD avoidance, which can relate to greater opportunities for success with exposure therapy and lowering PTSD symptoms of hypervigilance, re-experiencing, and overgeneralization of fears.

When using mindfulness and meditation with people expressing trauma symptoms, it is crucial to be aware of potential trauma triggers, such as the focus on the breath. Often, a meditation session will begin with focused attention and move into open monitoring. With severe trauma symptoms, it may be important to start the meditation training and an individual session at the peripheral awareness, such as the limbs. Moreover, trauma survivors often report feeling numb as a protection against trauma triggers and reminders, which are often painful, making it good practice to start all trainings at the limbs as a gradual exposure to body sensations. Doing so will also increase physical attachment to the present moment and the sense of grounding, thereby increasing tolerance to trauma reminders and decreasing the need and use of dissociation.

Treatment

When receiving treatment, patients are assessed to discover their level of functioning. Some patients might be higher functioning than others. This is taken into account when creating a patient’s potential treatment targets. To start off treatment, time is dedicated to increasing a patient’s mental level and adaptive actions in order to gain a balance in both their mental and behavioural action. Once this is achieved, the next goal is to work on removing or minimising the phobia made by traumatic memories, which is causing the patient to dissociate. The final step of treatment includes helping patients work through their grief in order to move forward and be able to engage in their own lives. This is done with the use of new coping skills attained through treatment. One coping skill that can improve dissociation is mindfulness due to the introduction of staying in present awareness while observing non-judgmentally and increasing the ability to regulate emotions. Specifically in adolescents, mindfulness has been shown to reduce dissociation after practicing mindfulness for three weeks.

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What is Amisulpride?

Introduction

Amisulpride is an antiemetic and antipsychotic medication used at lower doses intravenously to prevent and treat postoperative nausea and vomiting; and at higher doses by mouth to treat schizophrenia and acute psychotic episodes.

It is sold under the brand names Barhemsys (as an antiemetic) and Solian, Socian, Deniban and others (as an antipsychotic). It is also used to treat dysthymia.

It is usually classed with the atypical antipsychotics. Chemically it is a benzamide and like other benzamide antipsychotics, such as sulpiride, it is associated with a high risk of elevating blood levels of the lactation hormone, prolactin (thereby potentially causing the absence of the menstrual cycle, breast enlargement, even in males, breast milk secretion not related to breastfeeding, impaired fertility, impotence, breast pain, etc.), and a low risk, relative to the typical antipsychotics, of causing movement disorders.

Amisulpride is indicated for use in the US in adults for the prevention of postoperative nausea and vomiting (PONV), either alone or in combination with an antiemetic of a different class; and to treat PONV in those who have received antiemetic prophylaxis with an agent of a different class or have not received prophylaxis.

Amisulpride is believed to work by blocking, or antagonising, the dopamine D2 receptor, reducing its signalling. The effectiveness of amisulpride in treating dysthymia and the negative symptoms of schizophrenia is believed to stem from its blockade of the presynaptic dopamine D2 receptors. These presynaptic receptors regulate the release of dopamine into the synapse, so by blocking them amisulpride increases dopamine concentrations in the synapse. This increased dopamine concentration is theorised to act on dopamine D1 receptors to relieve depressive symptoms (in dysthymia) and the negative symptoms of schizophrenia.

It was introduced by Sanofi-Aventis in the 1990s. Its patent expired by 2008, and generic formulations became available. It is marketed in all English-speaking countries except for Canada. A New York City based company, LB Pharmaceuticals, has announced the ongoing development of LB-102, also known as N-methyl amisulpride, an antipsychotic specifically targeting the United States. A poster presentation at European Neuropsychopharmacology seems to suggest that this version of amisulpride, known as LB-102 displays the same binding to D2, D3 and 5HT7 that amisulpride does.

Brief History

The US Food and Drug Administration (FDA) approved amisulpride based on evidence from four clinical trials of 2323 subjects undergoing surgery or experiencing nausea and vomiting after the surgery. The trials were conducted at 80 sites in the United States, Canada and Europe.

Two trials (Trials 1 and 2) enrolled subjects scheduled to have surgery. Subjects were randomly assigned to receive either amisulpride or a placebo drug at the beginning of general anaesthesia. In Trial 1, subjects received amisulpride or placebo alone, and in Trial 2, they received amisulpride or placebo in combination with one medication approved for prevention of nausea and vomiting. Neither the subjects nor the health care providers knew which treatment was being given until after the trial was complete.

The trials counted the number of subjects who had no vomiting and did not use additional medications for nausea or vomiting in the first day (24 hours) after the surgery. The results then compared amisulpride to placebo.

The other two trials (Trials 3 and 4) enrolled subjects who were experiencing nausea and vomiting after surgery. In Trial 3, subjects did not receive any medication to prevent nausea and vomiting before surgery and in Trial 4 they received the medication, but the treatment did not work. In both trials, subjects were randomly assigned to receive either amisulpride or placebo. Neither the subjects nor the health care providers knew which treatment was being given until after the trial was complete.

The trials counted the number of subjects who had no vomiting and did not use additional medications for nausea or vomiting in the first day (24 hours) after the treatment. The trial compared amisulpride to placebo.

Medical Uses

Schizophrenia

Although according to other studies it appears to have comparable efficacy to olanzapine in the treatment of schizophrenia. Amisulpride augmentation, similarly to sulpiride augmentation, has been considered a viable treatment option (although this is based on low-quality evidence) in clozapine-resistant cases of schizophrenia. Another recent study concluded that amisulpride is an appropriate first-line treatment for the management of acute psychosis.

Postoperative Nausea and Vomiting

Amisulpride is indicated for use in the United States in adults for the prevention of postoperative nausea and vomiting (PONV), either alone or in combination with an antiemetic of a different class; and to treat PONV in those who have received antiemetic prophylaxis with an agent of a different class or have not received prophylaxis.

Contraindications

Amisulpride’s use is contraindicated in the following disease states:

  • Pheochromocytoma.
  • Concomitant prolactin-dependent tumours e.g. prolactinoma, breast cancer.
  • Movement disorders (e.g. Parkinson’s disease and dementia with Lewy bodies).
  • Lactation.
  • Children before the onset of puberty.

Neither is it recommended to use amisulpride in patients with hypersensitivities to amisulpride or the excipients found in its dosage form.

Adverse Effects

  • Very Common (≥10% incidence):
    • Extrapyramidal side effects (EPS; including dystonia, tremor, akathisia, parkinsonism).
  • Common (≥1%, <10% incidence):
    • Insomnia.
    • Hypersalivation.
    • Nausea.
    • Headache.
    • Hyperactivity.
    • Vomiting.
    • Hyperprolactinaemia (which can lead to galactorrhoea, breast enlargement and tenderness, sexual dysfunction, etc.).
    • Weight gain (produces less weight gain than chlorpromazine, clozapine, iloperidone, olanzapine, paliperidone, quetiapine, risperidone, sertindole, zotepine and more (although not statistically significantly) weight gain than haloperidol, lurasidone, ziprasidone and approximately as much weight gain as aripiprazole and asenapine).
    • Anticholinergic side effects (although it does not bind to the muscarinic acetylcholine receptors and hence these side effects are usually quite mild) such as
      • Constipation.
      • Dry mouth.
      • Disorder of accommodation.
      • Blurred vision.
  • Rare (<1% incidence):
    • Hyponatraemia.
    • Bradycardia.
    • Hypotension.
    • Palpitations.
    • Urticaria.
    • Seizures.
    • Mania.
    • Oculogyric crisis.
    • Tardive dyskinesia.
    • Blood dyscrasias such as leucopenia, neutropenia and agranulocytosis.
    • QT interval prolongation (in a recent meta-analysis of the safety and efficacy of 15 antipsychotic drugs amisulpride was found to have the 2nd highest effect size for causing QT interval prolongation).
    • Somnolence.

Hyperprolactinaemia results from antagonism of the D2 receptors located on the lactotrophic cells found in the anterior pituitary gland. Amisulpride has a high propensity for elevating plasma prolactin levels as a result of its poor blood-brain barrier penetrability and hence the resulting greater ratio of peripheral D2 occupancy to central D2 occupancy. This means that to achieve the sufficient occupancy (~60–80%) of the central D2 receptors in order to elicit its therapeutic effects a dose must be given that is enough to saturate peripheral D2 receptors including those in the anterior pituitary.

Discontinuation

The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotics to avoid acute withdrawal syndrome or rapid relapse. Symptoms of withdrawal commonly include nausea, vomiting, and loss of appetite. Other symptoms may include restlessness, increased sweating, and trouble sleeping. Less commonly there may be a feeling of the world spinning, numbness, or muscle pains. Symptoms generally resolve after a short period of time.

There is tentative evidence that discontinuation of antipsychotics can result in psychosis. It may also result in reoccurrence of the condition that is being treated. Rarely tardive dyskinesia can occur when the medication is stopped.

Overdose

Torsades de pointes is common in overdose. Amisulpride is moderately dangerous in overdose (with the TCAs being very dangerous and the SSRIs being modestly dangerous).

Interactions

Amisulpride should not be used in conjunction with drugs that prolong the QT interval (such as citalopram, bupropion, clozapine, tricyclic antidepressants, sertindole, ziprasidone, etc.), reduce heart rate and those that can induce hypokalaemia. Likewise it is imprudent to combine antipsychotics due to the additive risk for tardive dyskinesia and neuroleptic malignant syndrome.

Pharmacology

Pharmacodynamics

Amisulpride functions primarily as a dopamine D2 and D3 receptor antagonist. It has high affinity for these receptors with dissociation constants of 3.0 and 3.5 nM, respectively. Although standard doses used to treat psychosis inhibit dopaminergic neurotransmission, low doses preferentially block inhibitory presynaptic autoreceptors. This results in a facilitation of dopamine activity, and for this reason, low-dose amisulpride has also been used to treat dysthymia.

Amisulpride and its relatives sulpiride, levosulpiride, and sultopride have been shown to bind to the high-affinity GHB receptor at concentrations that are therapeutically relevant (IC50 = 50 nM for amisulpride).

Amisulpride, sultopride and sulpiride respectively present decreasing in vitro affinities for the D2 receptor (IC50 = 27, 120 and 181 nM) and the D3 receptor (IC50 = 3.6, 4.8 and 17.5 nM).

Though it was long widely assumed that dopaminergic modulation is solely responsible for the respective antidepressant and antipsychotic properties of amisulpride, it was subsequently found that the drug also acts as a potent antagonist of the serotonin 5-HT7 receptor (Ki = 11.5 nM). Several of the other atypical antipsychotics such as risperidone and ziprasidone are potent antagonists at the 5-HT7 receptor as well, and selective antagonists of the receptor show antidepressant properties themselves. To characterise the role of the 5-HT7 receptor in the antidepressant effects of amisulpride, a study prepared 5-HT7 receptor knockout mice. The study found that in two widely used rodent models of depression, the tail suspension test, and the forced swim test, those mice did not exhibit an antidepressant response upon treatment with amisulpride. These results suggest that 5-HT7 receptor antagonism mediates the antidepressant effects of amisulpride.

Amisulpride also appears to bind with high affinity to the serotonin 5-HT2B receptor (Ki = 13 nM), where it acts as an antagonist. The clinical implications of this, if any, are unclear. In any case, there is no evidence that this action mediates any of the therapeutic effects of amisulpride.

Amisulpride shows stereoselectivity in its actions. Aramisulpride ((R)-amisulpride) has higher affinity for the 5-HT7 receptor (Ki = 47 nM vs. 1,900 nM) while esamisulpride ((S)-amisulpride) has higher affinity for the D2 receptor (4.0 nM vs. 140 nM). An 85:15 ratio of aramisulpride to esamisulpride (SEP-4199) which provides more balanced 5-HT7 and D2 receptor antagonism than racemic amisulpride (50:50 ratio of enantiomers) is under development for the treatment of bipolar depression.

Society and Culture

Brand Names

Brand names include: Amazeo, Amipride (AU), Amival, Solian (AU, IE, RU, UK, ZA), Soltus, Sulpitac (IN), Sulprix (AU), Midora (RO) and Socian (BR).

Availability

Amisulpride was not approved by the Food and Drug Administration for use in the United States until February 2020, but it is used in Europe, Israel, Mexico, India, New Zealand and Australia to treat psychosis and schizophrenia.

An IV formulation of Amisulpride was approved for the treatment of postoperative nausea and vomiting (“PONV”) in the United States in February 2020.

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What is Tangential Speech?

Introduction

Tangential speech or tangentiality is a communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation.

It tends to occur in situations where a person is experiencing high anxiety, as a manifestation of the psychosis known as schizophrenia, in dementia or in states of delirium. It is less severe than logorrhoea and may be associated with the middle stage in dementia. It is, however, more severe than circumstantial speech in which the speaker wanders, but eventually returns to the topic.

Some adults with right hemisphere brain damage may exhibit behaviour that includes tangential speech. Those who exhibit these behaviours may also have related symptoms such as seemingly inappropriate or self-centred social responses, and a deterioration in pragmatic abilities (including appropriate eye contact as well as topic maintenance).

Brief History

The earlier phenomenological description allowed for further definition on the basis of formal characteristic rather than content, producing later practice relying upon clinical assessment. The term has undergone a re-definition to refer only to a persons speech in response to a question, and to provide the definition separation from the similar symptoms loosening of association and derailment.

Definition

The term refers simplistically to a thought disorder shown from speech with a lack of observance to the main subject of discourse, such that a person whilst speaking on a topic deviates from the topic. Further definition is of speech that deviates from an answer to a question that is relevant in the first instance but deviates from the relevancy to related subjects not involved in a direct answering of the question. In the context of a conversation or discussion the communication is a response that is ineffective in that the form is inappropriate for adequate understanding. The person’s speech seems to indicate that their attention to their own speech has perhaps in some way been overcome during the occurrence of cognition whilst speaking, causing the vocalised content to follow thought that is apparently without reference to the original idea or question; or the person’s speech is considered evasive in that the person has decided to provide an answer to a question that is an avoidance of a direct answer.

Other

According to the St. Louis system for the diagnosis of schizophrenia, tangentiality is significantly associated with a low IQ prior to diagnosis.

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What is Schizophrenics Anonymous?

Introduction

Schizophrenics Anonymous is a peer support group to help people who are affected by schizophrenia and related disorders including bipolar disorder, schizoaffective disorder, psychotic depression and psychosis.

Brief History

The programme was established in Detroit in 1985. The founder was Joanne Verbanic, who was diagnosed with schizophrenia in 1970. Shortly before forming SA, Verbanic publicly disclosed her diagnosis and discussed her illness on national television in an effort to challenge the stigma associated with the condition. She was a 2006 recipient of a Lilly Reintegration Award in recognition of her lifetime contributions to the mental health community, and she continued to be active as a spokesperson for persons with schizophrenia and other mental illness until her death on 07 May 2015.

By 2007, more than 150 local SA groups operated in 31 of the 50 United States, and in Australia, Brazil, Canada, Mexico, France, India and Venezuela.

Technical support for Schizophrenics Anonymous was provided by the National Schizophrenia Foundation (NSF) until 2007 when NSF ceased operations. In response to the loss of a national sponsor, a group of consumers, family members, and mental health providers came together to form a not-for-profit organisation, Schizophrenia and Related Disorders Alliance of America (SARDAA).

SARDAA promotes recovery for persons with schizophrenia and related brain disorders including bipolar disorder, schizoaffective disorder, depression with psychosis, and experience with psychosis. They envision a future in which every person with a schizophrenia-related brain disorder has the opportunity to recover from their disorders. The name Schizophrenics Anonymous was changed to Schizophrenia Alliance in 2015 and added Psychosis Support and Acceptance in 2018. They provide an online directory of SA groups, sponsor five weekly SA conference calls, and one Family and Friends conference call. At their annual conference, the group trains individuals and groups who have started or would like to start an SA group.

Although some SA groups are organised by mental health professionals, research has suggested that peer-led SA groups are more sustainable and longer lasting. Some groups are organised in psychiatric hospitals or jails and are not open to the public.

Programme Principles

The SA programme is based on the twelve-step model, but includes just six steps. The organisation describes the programme’s purpose of helping participants to learn about schizophrenia, “restore dignity and sense of purpose,” obtain “fellowship, positive support, and companionship,” improve their attitudes about their lives and their illnesses, and take “positive steps towards recovery.”

Joanne Verbanic wrote the original “Schizophrenics Anonymous” book, better known as “The Blue Book,” which describes the six steps to recovery. The steps require members to admit they need help, take responsibility for their choices and consequences, believe they have the inner strength to help themselves and others, forgive themselves and others, understand that false beliefs contribute to their problems and change those beliefs, and decide to turn their lives over to a higher power.

Research

One study about the risks of professional partnerships centres on the partnership between Schizophrenics Anonymous (SA) and the Mental Health Association of Michigan (MHAM) over a 14-year period. The study shows that the professional partnership resulted in increased access to SA Groups across Michigan and organisation expansion and development within SA. The professional influence also lead more SA Groups to be held in more traditional mental health treatment settings and led to more professional-led SA groups.

Self-help groups are more available to people who live independently. Researchers at Michigan State University studied whether SA would be successful in group homes. The results were positive: the groups had high attendance and participation and were well liked. However, staff members controlled who could lead and who could attend the meetings, and how the meetings should be run. The programs fell apart. The same obstacle occurred in SA groups started in prisons and monitored by employees.

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What is Foreclosure (Psychoanalysis)?

Introduction

Foreclosure (also known as “foreclusion”; French: forclusion) is the English translation of a term that the French psychoanalyst Jacques Lacan introduced into psychoanalysis to identify a specific psychical cause for psychosis.

Brief History

According to Élisabeth Roudinesco, the term was originally introduced into psychology ‘in 1928, when Édouard Pichon published, in Pierre Janet’s review, his article on “The Psychological Significance of Negation in French”: “…[and] borrowed the legal term forclusif to indicate facts that the speaker no longer sees as part of reality’.

According to Christophe Laudou, the term was introduced by Damourette and Pichon.

Freud vs Laforgue

The publication took part against the background of the Twenties dispute between Freud and René Laforgue over scotomisation. ‘If I am not mistaken’, Freud wrote in 1927, ‘Laforgue would say in this case that the boy “scotomises” his perception of the woman’s lack of a penis. A new technical term is justified when it describes a new fact or emphasizes it. This is not the case here’. Freud went on to suggest that if one wanted to ‘reserve the word “Verdrängung” [“repression”] for the affect, then the correct German word for the vicissitude of the idea would be “Verleugnung” [“disavowal”]’.

Lacan’s Introduction of Foreclosure

In 1938 Lacan relates the origin of psychosis to an exclusion of the father from the family structure thereby reducing this structure to a mother-child relationship. Later on, when working on the distinctions between the real, imaginary and symbolic father, he specifies that it is the absence of the symbolic father which is linked to psychosis.

Lacan uses the Freudian term, Verwerfung, which the “Standard Edition” translates as “repudiation”, as a specific defence mechanism different from repression, “Verdrängung”, in which “the ego rejects the incompatible idea together with its affect and behaves as if the idea has never occurred to the ego at all.” In 1954 basing himself on a reading of the “Wolf Man” Lacan identifies Verwerfung as the specific mechanism of psychosis where an element is rejected outside the symbolic order as if it has never existed. In 1956 in his Seminar on Psychoses he translates Verwerfung as forclusion, that is foreclosure. “Let us extract from several of Freud’s texts a term that is sufficiently articulated in them to designate in them a function of the unconscious that is distinct from the repressed. Let us take as demonstrated the essence of my Seminar on the Psychoses, namely, that this term refers to psychosis: this term is Verwerfung (foreclosure)”.

Lacan and Psychosis

The problem Lacan sought to address with the twin tools of foreclosure and the signifier was that of the difference between psychosis and neurosis, as manifested in and indicated by language usage. It was common analytic ground that “when psychotics speak they always have some meanings that are too fixed, and some that are far too loose, they have a different relation to language, and a different way of speaking from neurotics.” Freud, following Bleuler and Jung had pointed to ‘a number of changes in speech…in schizophrenics…words are subjected to the same process as that which makes the dream’. Lacan used foreclosure to explain why.

When Lacan first uses the Freudian concept of Verwerfung (repudiation) in his search for a specific mechanism for psychosis, it is not clear what is repudiated (castration, speech). It is in 1957 in his article “On a question preliminary to any possible treatment of psychosis” that he advances the notion that it is the Name-of-the-Father (a fundamental signifier) that is the object of foreclosure. In this way Lacan combines two of his main themes on the causality of psychosis: the absence of the father and the concept of Verwerfung. This ideas remains central to Lacan’s thinking on psychosis throughout the rest of his work.

Lacan considered the father to play a vital role in breaking the initial mother/child duality and introducing the child to the wider world of culture, language, institutions and social reality – the Symbolic world – the father being “the human being who stands for the law and order that the mother plants in the life of the child…widens the child’s view of the world.” The result in normal development is “proper separation from the mother, as marked out by the Names-of-the-father.” Thus Lacan postulates the existence of a paternal function (the “Name of the Father” or “primordial signifier”) which allows the realm of the Symbolic to be bound to the realms of the Imaginary and the Real. This function prevents the developing child from being engulfed by its mother and allows him/her to emerge as a separate entity in his/her own right. It is a symbol of parental authority (a general symbol that represents the power of father of the Oedipus complex) that brings the child into the realm of the Symbolic by forcing him/her to act and to verbalise as an adult. As a result, the three realms are integrated in a way that is conducive to the creation of meaning and successful communication by means of what Lacan calls a Borromean knot.

When the Name-of-the-Father is foreclosed for a particular subject, it leaves a hole in the Symbolic order which can never be filled. The subject can then be said to have a psychotic structure, even if he shows none of the classical signs of psychosis. When the foreclosed Name-of-the-Father re-appears in the Real, the subject is unable to assimilate it and the result of this collision between the subject and the inassimilable signifier of the Name-of-the-father is the entry into psychosis proper characterized by the onset of hallucinations and/or delusions. In other words, when the paternal function is “foreclosed” from the Symbolic order, the realm of the Symbolic is insufficiently bound to the realm of the Imaginary and failures in meaning may occur (the Borromean knot becomes undone and the three realms completely disconnected), with “a disorder caused at the most personal juncture between the subject and his sense of being alive.” Psychosis is experienced after some environmental sign in the form of a signifier which the individual cannot assimilate is triggered, and this entails that “the Name-of-the-Father, is foreclosed, verworfen, is called into symbolic opposition to the subject.” The fabric of the individual’s reality is ripped apart and no meaningful Symbolic sense can be made of experience. “Absence of transcendence of the Oedipus places the subject under the regime of foreclosure or non-distinction between the symbolic and the real’; and psychotic delusions or hallucinations are the consequent result of the individual’s striving to account for what he/she experiences.

What is Unipolar Mania?

Introduction

Unipolar mania is an unrecognised mental illness characterised by episodes of mania and normal mood, with the absence of depressive symptoms.

Refer to Bipolar Disorder.

Background

The concept has its origins as far back as the year 1889, when the German psychiatrist Emil Kraepelin first used the term of “periodic mania” to refer to people with recurrent manic episodes and no depression. One year later, Carl Wernicke proposed that mania and depression should be viewed as separate disorders. As the time went on, unipolar mania became an invalid diagnosis due to its variations across different patients. Currently patients with symptoms of mania, even in the absence of any depressive symptoms, would get the bipolar 1 diagnosis.

Symptoms

Symptoms of unipolar mania are similar to those of bipolar mania. They can include:

  • Elevated self-esteem or grandiosity.
  • Increased motivation or psychomotor agitation.
  • Decreased need for sleep.
  • Unusually talkative.
  • Difficulty maintaining attention.
  • Racing thoughts.
  • Excessive involvement in activities with a high likelihood of painful consequences.(e.g. extravagant shopping, improbable commercial schemes, hypersexuality).

The episode generally have a stronger tendency to present with psychosis or/and need psychiatric assistance.

What is Bipolar I Disorder?

Introduction

Bipolar I disorder (BD-I; pronounced “type one bipolar disorder”) is a type of bipolar spectrum disorder characterised by the occurrence of at least one manic episode, with or without mixed or psychotic features.

Most people also, at other times, have one or more depressive episodes, and all experience a hypomanic stage before progressing to full mania.

It is a type of bipolar disorder, and conforms to the classic concept of manic-depressive illness, which can include psychosis during mood episodes.

Refer to Bipolar II Disorder and Mixed Affective State.

Bipolar mood shifts.

Diagnosis

The essential feature of bipolar I disorder is a clinical course characterised by the occurrence of one or more manic episodes or mixed episodes. Often, individuals have had one or more major depressive episodes. One episode of mania is sufficient to make the diagnosis of bipolar disorder; the person may or may not have a history of major depressive disorder. Episodes of substance-induced mood disorder due to the direct effects of a medication, or other somatic treatments for depression, drug abuse, or toxin exposure, or of mood disorder due to a general medical condition need to be excluded before a diagnosis of bipolar I disorder can be made. Bipolar I disorder requires confirmation of only 1 full manic episode for diagnosis, but may be associated with hypomanic and depressive episodes as well. Diagnosis for bipolar II disorder does not include a full manic episode; instead, it requires the occurrence of both a hypomanic episode and a major depressive episode. Serious aggression has been reported to occur in one of every ten first-major episode BD-I patients with psychotic features, its prevalence in this group being particularly high in association with a recent suicide attempt, alcohol-abuse, learning disability, or manic polarity in the first episode.

Bipolar I disorder (and bipolar II disorder) is often comorbid with other disorders including PTSD, substance use disorders and a variety of mood disorders. Up to 40% of people with bipolar disorder also present with PTSD, with higher rates occurring in women and individuals with bipolar I disorder. In addition, the episodes must not be better accounted for by schizoaffective disorder or superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or a psychotic disorder not otherwise specified.

Medical Assessment

Regular medical assessments are performed to rule-out secondary causes of mania and depression. These tests include complete blood count, glucose, serum chemistry/electrolyte panel, thyroid function test, liver function test, renal function test, urinalysis, vitamin B12 and folate levels, HIV screening, syphilis screening, and pregnancy test, and when clinically indicated, an electrocardiogram (ECG), an electroencephalogram (EEG), a computed tomography (CT scan), and/or a magnetic resonance imagining (MRI) may be ordered. Drug screening includes recreational drugs, particularly synthetic cannabinoids, and exposure to toxins.

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV-TR)

Dx Code #DisorderDescription
296.0xBipolar ISingle manic episode
296.40Bipolar IMost recent episode hypomanic
296.4xBipolar IMost recent episode manic
296.5xBipolar IMost recent episode depressed
296.6xBipolar IMost recent episode mixed
296.7Bipolar IMost recent episode unspecified

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)

In May 2013, American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). There are several proposed revisions to occur in the diagnostic criteria of Bipolar I Disorder and its subtypes. For Bipolar I Disorder 296.40 (most recent episode hypomanic) and 296.4x (most recent episode manic), the proposed revision includes the following specifiers: with psychotic features, with mixed features, with catatonic features, with rapid cycling, with anxiety (mild to severe), with suicide risk severity, with seasonal pattern, and with postpartum onset. Bipolar I Disorder 296.5x (most recent episode depressed) will include all of the above specifiers plus the following: with melancholic features and with atypical features. The categories for specifiers will be removed in DSM-5 and criterion A will add or there are at least 3 symptoms of major depression of which one of the symptoms is depressed mood or anhedonia. For Bipolar I Disorder 296.7 (most recent episode unspecified), the listed specifiers will be removed.

The criteria for manic and hypomanic episodes in criteria A & B will be edited. Criterion A will include “and present most of the day, nearly every day”, and criterion B will include “and represent a noticeable change from usual behaviour”. These criteria as defined in the DSM-IV-TR have created confusion for clinicians and need to be more clearly defined.

There have also been proposed revisions to criterion B of the diagnostic criteria for a Hypomanic Episode, which is used to diagnose For Bipolar I Disorder 296.40, Most Recent Episode Hypomanic. Criterion B lists “inflated self-esteem, flight of ideas, distractibility, and decreased need for sleep” as symptoms of a Hypomanic Episode. This has been confusing in the field of child psychiatry because these symptoms closely overlap with symptoms of attention deficit hyperactivity disorder (ADHD).

Note that many of the above changes are still under active consideration and are not definite. For more information regarding proposed revisions to the DSM-5, please visit their website at dsm5.org.

ICD-10

  • F31 Bipolar Affective Disorder.
  • F31.6 Bipolar Affective Disorder, Current Episode Mixed.
  • F30 Manic Episode.
  • F30.0 Hypomania.
  • F30.1 Mania Without Psychotic Symptoms.
  • F30.2 Mania With Psychotic Symptoms.
  • F32 Depressive Episode.
  • F32.0 Mild Depressive Episode.
  • F32.1 Moderate Depressive Episode.
  • F32.2 Severe Depressive Episode Without Psychotic Symptoms.
  • F32.3 Severe Depressive Episode With Psychotic Symptoms.

Treatment

Medication

Mood stabilisers are often used as part of the treatment process.

  • Lithium is the mainstay in the management of bipolar disorder but it has a narrow therapeutic range and typically requires monitoring.
  • Anticonvulsants, such as valproate, carbamazepine, or lamotrigine.
  • Atypical antipsychotics, such as quetiapine, risperidone, olanzapine, or aripiprazole.
  • Electroconvulsive therapy, a psychiatric treatment in which seizures are electrically induced in anesthetised patients for therapeutic effect.

Antidepressant-induced mania occurs in 20-40% of people with bipolar disorder. Mood stabilisers, especially lithium, may protect against this effect, but some research contradicts this.

A frequent problem in these individuals is nonadherence to pharmacological treatment; long-acting injectable antipsychotics may contribute to solving this issue in some patients.

A review of validated treatment guidelines for bipolar disorder by international bodies was published in 2020.

Education

Psychosocial interventions can be used for managing acute depressive episodes and for maintenance treatment to aid in relapse prevention. This includes psycho education, cognitive behavioural therapy (CBT), family-focused therapy (FFT), interpersonal and social-rhythm therapy (IPSRT), and peer support.

Information on the condition, importance of regular sleep patterns, routines and eating habits and the importance of compliance with medication as prescribed. Behaviour modification through counselling can have positive influence to help reduce the effects of risky behaviour during the manic phase. Additionally, the lifetime prevalence for bipolar I disorder is estimated to be 1%.

Mnemophrenia (2019)

Introduction

Mnemophrenia is a futuristic drama about a new psychosis that arises from advanced virtual reality technology, which causes people to be unable to distinguish between real and artificial memories.

Outline

The film explores how society is affected by and how it adapts to deal with Mnemophrenia, a growing new psychosis and the still advancing technology. We see the story unfold over time, through the eyes of three generations of the same family who are all affected and involved in different ways. The story explores how attitudes to Mnemophrenia would differ from person to person and across generations, going from resistance and fear, through acceptance and eventually even using it to our benefit, pushing humanity towards a new evolutionary step.

Cast

  • Freya Berry … Jeanette Harper.
  • Robin King … Nicholas Morgan.
  • Tim Seyfert … Douglas.
  • Tallulah Sheffield … Robyin.
  • Jamie Laird … Will Hall.
  • Robert Milton Wallace … Charlie.
  • Dominic O’Flynn … Michael Murphy.
  • Angela Peters … Keri Taylor.
  • Anna Brook … Nina.
  • Michael Buckster … Richard.
  • Gary Cargill … Jim.
  • Steve Hope Wynne … David Quinn.
  • Lisa Caruccio Came … Anna Lyons.
  • Cally Lawrence … Tessa Fox.
  • John Morton … Self.

Trivia

  • The word ‘mnemophrenia’ was coined especially for the film.
    • It is a portmanteau of the words ‘mneme’ and ‘schizophrenia’.
    • In the film ‘Mnemophrenia’ the word is defined as: ‘A condition or a state characterised by the coexistence of real and artificial memories, which affects the subject’s sense of identity.’
  • The director, Eirini Konstantinidou, used improvisation in order to build the characters and the shooting script for the whole film.
    • She believes that the realistic dialogue and performances that are achieved through improvisation contribute to the intended blurring of the distinction between reality and fiction.
    • Part 1 needed to be made first and edited in order for the actors of the following period (part 2) to watch it and build their characters’ experiences from what they have watched; according to the premise of the film these video recordings become part of their memories and identity.
    • That is the process that the actors of part 3 had to go through as well.
    • This technique allows for an organic development of the characters and dialogue, which is a result of the creative collaboration between the actors and herself.

Production & Filming Details

  • Director(s):
    • Eirini Konstantinidou.
  • Producer(s):
    • Robin King … assistant producer.
    • Eirini Konstantinidou … producer.
  • Writer(s):
    • Eirini Konstantinidou … (writer).
    • Robin King … (co-writer).
    • Eirini Konstantinidou … (original story).
    • Gary Cargill … (additional material).
    • Cally Lawrence … (additional material).
    • Robert Milton Wallace … (additional material).
    • Freya Berry … (additional material).
    • Michael Buckster … (additional material).
    • Tallulah Sheffield … (additional material).
    • Tim Seyfert … (additional material).
    • Angela Peters … (additional material).
    • Anna Brook … (additional material).
    • Dominic O’Flynn … (additional material).
    • Jamie Laird … (additional material).
    • Lisa Came … (additional material).
  • Music:
    • Corey Zack.
  • Cinematography:
    • Mirko Beutler … (part one: “The Beginning”).
    • Petros Nousias … (part three: “Homo Mnemonicus”).
    • Richard Thomas … (part two: “Total Cinema”).
  • Editor(s):
    • Giorgio Galli.
  • Production:
    • EK Productions.
    • Quoxel.
  • Distributor(s):
    • Indie Rights (2019) (World-wide) (all media).
  • Release Date: 11 February 2019 (US, Boston Science Fiction Film Festival).
  • Running Time: 78 minutes.
  • Rating: Unknown.
  • Country: US.
  • Language: English.

What is Metacognitive Training?

Introduction

Metacognitive training, (MCT), is an approach for treating the symptoms of psychosis in schizophrenia, especially delusions, which has been adapted for other disorders such as depression, obsessive-compulsive disorder and borderline personality disorder over the years (see below and external links for free download).

It was developed by Steffen Moritz and Todd Woodward. The intervention is based on the theoretical principles of cognitive behavioural therapy (CBT), but focuses in particular on problematic thinking styles (cognitive biases) that are associated with the development and maintenance of positive symptoms, e.g. overconfidence in errors and jumping to conclusions. Metacognitive training exists as a group training (MCT) and as an individualized intervention (MCT+).

Refer to Metacognitive Therapy.

Background

Metacognition can be defined as “thinking about thinking”. Over the course of the training, cognitive biases subserving positive symptoms are identified and corrected. The current empirical evidence assumes a connection between certain cognitive biases, such as jumping to conclusions, and the development and maintenance of psychosis. Accordingly, correcting these problematic/unhelpful thinking styles should lead to a reduction of symptoms.

Intervention

In eight training units (modules) and two additional modules, examples of “cognitive traps”, which can promote the development and maintenance of the positive symptoms of schizophrenia, are presented to patients in a playful way. Patients are instructed to critically reflect on their thought patterns, which may contribute to problematic behaviours, and to implement the contents of the training in everyday life. MCT deals with the following problematic styles of thinking: monocausal attributions, jumping to conclusions, inflexibility, problems in social cognition, overconfidence for memory errors and depressive thought patterns. The additional modules deal with stigma and low self-esteem. Individualised metacognitive training (MCT+) targets the same symptoms and cognitive biases as the group training, but is more flexible in that it allows discussion of individualised topics. The treatment materials for the group training can be obtained free of charge in over 30 languages from the website.

Efficacy

A recent meta-analysis found significant improvements for positive symptoms and delusions, as well as the acceptance of the training. These findings have been replicated in 2018 and 2019. An older meta-analysis based on a smaller number of studies found a small effect, which reached significance when newer studies were considered. Individual studies provide evidence for the long-term effectiveness of the approach beyond the immediate treatment period. MCT is recommended as an evidence-based treatment by the Royal Australian and New Zealand College of Psychiatrists as well as the German Association for Psychiatry, Psychotherapy and Psychosomatics.

Adaptations to other Disorders

Since its introduction, MCT has been adapted to other mental disorders. Empirical studies have been carried out for borderline personality disorder, obsessive-compulsive disorder (self-help approach), depression, bipolar disorders, and problem gambling.

Links (External)

Book: Delusions and Delusion Disorder

Book Title:

Delusions and Delusional Disorder: The Power to Heal Someone from Mental Disorder.

Mental Health – Psychosis Symptoms and What To Do.

Author(s): Jon Carson.

Year: 2021.

Edition: First (1st).

Publisher: Independently Published.

Type(s): Paperback and Kindle.

Synopsis:

Delusional disorder, recently called paranoid disorder, is a kind of genuine mental illness called a psychotic disorder. Individuals who have it can’t determine what’s genuine based on what is envisioned. Delusions are the fundamental manifestation of delusional disorder. They are relentless convictions in something that is not correct or dependent on the real world.

Individuals with the delusional disorder frequently can proceed to mingle and work regularly, aside from the subject of their dream, and by and large, do not carry on in a clearly odd or strange way.

The study material provides summarised various answers to the questions that are likely to be the in minds of readers. This covers:

  • Vivid introduction delusional disorder.
  • Various types of delusion.
  • What are the indications of delusional disorder?
  • What are the causes and dangerous elements of delusional disorder?
  • Could pressure cause delusions?
  • How is a delusional disorder diagnosed?
  • Treatment of delusional disorder treated.
  • What are the intricacies of delusion disorder?
  • What’s the standpoint for individuals with the delusional disorder?
  • Can the delusional disorder be forestalled?
  • Supportive activities when somebody who has a psychological sickness is encountering hallucinations, delusions, or paranoia.