Mood instability and psychosis: analyses of British national survey data

Suicidality in People With Obsessive-Compulsive Symptoms or Personality Traits

Objective: Obsessive-Compulsive Disorder (OCD) and Obsessive-Compulsive Personality Disorder (OCPD) have been reported to be associated with mood instability (MI), depression and suicide-related outcomes. We examined whether obsessive-compulsive symptoms and personality traits as well as obsessional thoughts of death, are associated with suicidal thoughts, non-suicidal self-injury and attempted suicide. Methods: We used data from 7,839 people from the 2000 British Adult Psychiatric Morbidity Survey that elicited symptoms of OCD with a computerized version of the Clinical Interview Schedule-Revised (CIS-R) and traits of OCPD with a self-completed version of the SCID-II. We created a series of logistic regression models, first entering only OCD symptoms and OCPD traits in separate models, to which depression and mood instability (MI) were added. We also examined the relation of obsessional thoughts about death with self-harm in a network analysis model that included the main symptoms of mood instability and depression. Results: OCD symptoms were associated with suicidal thoughts (OR: 1.23, 95% CI: 1.14-1.32), and suicide attempts (OR: 1.13, 95% CI: 1.04-1.24) in the fully-adjusted model. OCPD traits were associated with suicidal thoughts (OR: 1.14, 95% CI: 1.10-1.19), non-suicidal self-injury (OR: 1.14 95% CI: 1.03-1.26), and suicide attempts (OR: 1.09; 1.01-1.17). Depression and MI were both associated with all three suicide-related outcomes. In the network analysis, MI was the most prominent correlate of suicide-related outcomes, being associated with suicidal ideas (partial r = 0.15) and non-suicidal self-injury (partial r = 0.07). Limitation: This was a cross-sectional study that used a single-item measure for mood instability. Conclusions: Obsessive-compulsive symptoms and personality traits are related to suicide-related outcomes independently of depressive symptoms and mood instability. This relationship is not accounted for by obsessional thoughts of death alone.

Method of homicide and severe mental illness: A systematic review

There is limited research that has examined offense characteristics in homicides committed by individuals with mental illness and with differing psychiatric diagnoses. The aim of this systematic review is to synthesize previous findings of studies analyzing homicide behavior by mentally ill individuals, and reporting any associations between mental illness and method of homicide. We searched four databases (MedLine, PsychINFO, Web of Science and Embase), and identified 52 relevant articles for analysis. Of these 52 articles, nine reported specific information on mental illness and method of homicide. Five out of nine articles revealed an association between schizophrenia/delusional disorder and the use of sharp instruments as a method of homicide. Four out of nine studies revealed an association between mood disorders (bipolar disorder/major depression) and strangulation/asphyxiation/suffocation/drowning. Our review confirms consistency across studies reporting a significant association between close contact methods and schizophrenia/mood disorders. Also identified as possible influential factors concerning weapon choice are illness duration, victim characteristics and planning/lack of planning of the homicide. Additionally, studies revealed up to 96% of severely mentally ill offenders experienced psychiatric symptoms at the time of the homicide. Future research may examine the presence of specific psychiatric symptoms when a mentally ill offender commits a homicide and whether these may be more influential in the method of homicide used than the psychiatric diagnosis of the offender.

Untangling the complex relationships between symptoms of schizophrenia and emotion dynamics in daily life: Findings from an experience sampling pilot study

The unfolding of emotions over time (i.e., emotion dynamics) has been characterized by baseline, intraindividual variability and regulatory tendency (return time to baseline after deflection). Mounting evidence suggests that compared to healthy individuals, individuals with schizophrenia are characterized by a more negatively valenced baseline and a higher intraindividual variability. However, the regulatory tendency has not been investigated in schizophrenia so far. We hypothesize that the severity of positive symptoms is linked to increased emotional variability and that the severity of negative symptoms is associated with an increased regulatory tendency. Fifteen individuals diagnosed with schizophrenia took part in this pilot experience sampling study and reported their emotional state ten times a day. The dynamics of valence and arousal and their relationship with symptomatology were estimated with the DynAffect model. Regulatory tendency in valence and arousal was positively associated with negative symptom severity and negatively associated with positive symptom severity. However, the severity of positive symptoms was not credibly associated with the variability of valence. The study only partly corroborates findings on increased stress reactivity in schizophrenia, which might be due to the small sample size. However, results suggest that negative symptoms could stem from over-regulated emotion dynamics, which may impede goal-directed behavior.

Using Directed Acyclic Graphs in Epidemiological Research in Psychosis: An Analysis of the Role of Bullying in Psychosis

Modern psychiatric epidemiology researches complex interactions between multiple variables in large datasets. This creates difficulties for causal inference. We argue for the use of probabilistic models represented by directed acyclic graphs (DAGs). These capture the dependence structure of multiple variables and, used appropriately, allow more robust conclusions about the direction of causation. We analyzed British national survey data to assess putative mediators of the association between bullying victimization and persecutory ideation. We compared results using DAGs and the Karlson-Holm-Breen (KHB) logistic regression commands in STATA. We analyzed data from the 2007 English National Survey of Psychiatric Morbidity, using the equivalent 2000 survey in an instant replication. Additional details of methods and results are provided in the supplementary material. DAG analysis revealed a richer structure of relationships than could be inferred using the KHB logistic regression commands. Thus, bullying had direct effects on worry, persecutory ideation, mood instability, and drug use. Depression, sleep and anxiety lay downstream, and therefore did not mediate the link between bullying and persecutory ideation. Mediation by worry and mood instability could not be definitively ascertained. Bullying led to hallucinations indirectly, via persecutory ideation and depression. DAG analysis of the 2000 dataset suggested the technique generates stable results. While causality cannot be fully determined from cross-sectional data, DAGs indicate the relationships providing the best fit. They thereby advance investigation of the complex interactions seen in psychiatry, including the mechanisms underpinning psychiatric symptoms. It may consequently be used to optimize the choice of intervention targets.

Borderline intellectual functioning and psychosis: Adult Psychiatric Morbidity Survey evidence

Borderline intellectual functioning (BIF) is associated with several neuropsychological deficits. We used national data to establish the prevalence of psychosis and psychotic symptoms, and the role of potential mediators. The BIF group were more than twice as likely to have probable psychosis (adjusted odds ratio (OR)=2.3, 95% CI 1.4-4.0) and to report hallucinations (adjusted OR = 2.9, 95% CI 1.9-4.4) but not persecutory ideation. Salient mediators were depressive symptoms and the cumulative total of life events. Our findings suggest mechanisms other than drug use that are contributing to the strong relationship between BIF and severe mental illness and that may be amenable to treatment.

The association between childhood adversities and subsequent first onset of psychotic experiences: a cross-national analysis of 23 998 respondents from 17 countries

BACKGROUND

Although there is robust evidence linking childhood adversities (CAs) and an increased risk for psychotic experiences (PEs), little is known about whether these associations vary across the life-course and whether mental disorders that emerge prior to PEs explain these associations.

METHOD

We assessed CAs, PEs and DSM-IV mental disorders in 23 998 adults in the WHO World Mental Health Surveys. Discrete-time survival analysis was used to investigate the associations between CAs and PEs, and the influence of mental disorders on these associations using multivariate logistic models.

RESULTS

Exposure to CAs was common, and those who experienced any CAs had increased odds of later PEs [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.9-2.6]. CAs reflecting maladaptive family functioning (MFF), including abuse, neglect, and parent maladjustment, exhibited the strongest associations with PE onset in all life-course stages. Sexual abuse exhibited a strong association with PE onset during childhood (OR 8.5, 95% CI 3.6-20.2), whereas Other CA types were associated with PE onset in adolescence. Associations of other CAs with PEs disappeared in adolescence after adjustment for prior-onset mental disorders. The population attributable risk proportion (PARP) for PEs associated with all CAs was 31% (24% for MFF).

CONCLUSIONS

Exposure to CAs is associated with PE onset throughout the life-course, although sexual abuse is most strongly associated with childhood-onset PEs. The presence of mental disorders prior to the onset of PEs does not fully explain these associations. The large PARPs suggest that preventing CAs could lead to a meaningful reduction in PEs in the population.

Transdiagnostic Extension of Delusions: Schizophrenia and Beyond

Delusion is central to the conceptualization, definition, and identification of schizophrenia. However, in current classifications, the presence of delusions is neither necessary nor sufficient for the diagnosis of schizophrenia, nor is it sufficient to exclude the diagnosis of some other psychiatric conditions. Partly as a consequence of these classification rules, it is possible for delusions to exist transdiagnostically. In this article, we evaluate the extent to which this happens, and in what ways the characteristics of delusions vary according to diagnostic context. We were able to examine their presence and form in delusional disorder, affective disorder, obsessive-compulsive disorder, borderline personality disorder, and dementia, in all of which they have an appreciable presence. There is some evidence that the mechanisms of delusion formation are, at least to an extent, shared across these disorders. This transdiagnostic extension of delusions is an argument for targeting them therapeutically in their own right. However there is a dearth of research to enable the rational transdiagnostic deployment of either pharmacological or psychological treatments.

Depression and Schizophrenia: Cause, Consequence, or Trans-diagnostic Issue?

The presence of depression in schizophrenia has been a challenge to the Kraepelinian dichotomy, with various attempts to save the fundamental distinction including evoking and refining diagnoses such as schizoaffective disorder. But the tectonic plates are shifting. Here we put forward a summary of recent evidence regarding the prevalence, importance, possible aetiological pathways and treatment challenges that recognizing depression in schizophrenia bring. Taken together we propose that depression is more than comorbidity and that increased effective therapeutic attention to mood symptoms will be needed to improve outcomes and to support prevention.

Psychotic experiences and suicide attempt risk in common mental disorders and borderline personality disorder

OBJECTIVE

Recent research has demonstrated a strong relationship between psychotic experiences and suicidal behaviour. No research to date, however, has investigated the role of borderline personality disorder (BPD) in this relationship, despite the fact that BPD is highly comorbid with common mental disorders and is associated with both recurrent suicidal behaviour and psychotic experiences. This paper examined the relationship between psychotic experiences and suicide attempts, including interrelationships with BPD and common mental disorders.

METHOD

We used the 2007 Adult Psychiatric Morbidity Study, a stratified, multistage probability sample of households in England, which recruited a nationally representative sample aged 16 years and older. Participants were assessed for common mental disorders, BPD (clinical and subclinical), suicidal behaviour, and psychotic experiences.

RESULTS

Approximately 4% of the total sample (n = 323) reported psychotic experiences. Psychotic experiences were associated with increased odds of suicide attempts in individuals with BPD (OR = 2.23, 95% CI = 1.03-4.85), individuals with a common mental disorder (OR = 2.47, 95% CI = 1.37-4.43), individuals without a common mental disorder (OR = 3.99, 95% CI = 2.47-6.43), and individuals with neither a common mental disorder nor BPD (OR = 3.20, 95% CI = 1.71-5.98).

CONCLUSION

Psychotic experiences are associated with high odds of suicidal behaviour in individuals with and without psychopathology. This relationship is not explained by clinical or subclinical BPD.

Hallucinations in borderline personality disorder and common mental disorders

Hallucinations are classically associated with psychotic disorders. Recent research, however, has highlighted that hallucinations frequently occur outside of the context of psychosis. Despite this, to our knowledge, there has been no epidemiological research to compare the prevalence of hallucinations across common mental disorders with the prevalence in borderline personality disorder (BPD). Using data from the Adult Psychiatric Morbidity Survey (n = 7403), we investigated the prevalence of hallucinations in individuals with a range of mental disorders and BPD. Hallucinations were prevalent in all disorders (range 11-24%). Hallucinations were no more prevalent in individuals with BPD (13.7%) than in individuals with a (non-psychotic) mental disorder (12.6%) (χ² = 0.03, P = 0.92).

Mood instability and impulsivity as trait predictors of suicidal thoughts

OBJECTIVES

Impulsivity, the tendency to act quickly without adequate planning or concern for consequences, is a commonly cited risk factor for suicidal thoughts and behaviour. There are many definitions of impulsivity and how it relates to suicidality is not well understood. Mood instability, which describes frequent fluctuations of mood over time, is a concept related to impulsivity that may help explain this relationship. The purpose of this study was to determine whether impulsivity could predict suicidal thoughts after controlling for mood instability.

METHODS

This study utilized longitudinal data from the 2000 Adult Psychiatric Morbidity Survey (N = 2,406). There was a time interval of 18 months between the two waves of the study. Trait impulsivity and mood instability were measured with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders. Logistic regression analyses were used to evaluate baseline impulsivity and mood instability as predictors of future suicidal thoughts.

RESULTS

Impulsivity significantly predicted the presence of suicidal thoughts, but this effect became non-significant with mood instability included in the same model.

CONCLUSIONS

Impulsivity may be a redundant concept when predicting future suicidal thoughts if mood instability is considered. The significance is that research and therapy focusing on mood instability along with impulsivity may be useful in treating the suicidal patient.

PRACTITIONER POINTS

Mood instability and impulsivity both predict future suicidal thoughts. Impulsivity does not predict suicidal thoughts after controlling for mood instability. Assessing and treating mood instability could be important aspects of suicide prevention and risk management.

Greater variation in affect is associated with lower fasting plasma glucose

Background

Depression and bipolar illness are associated with a 2–3 fold increase in the prevalence of diabetes. However, it is unknown whether variation in mood affects glucose metabolism. The aim of this study was to assess whether changes in affect were related to fasting plasma glucose and glycated haemoglobin.

Methods

379 men and 441 women who took part in the 2003 Health Survey for England and had valid data for GHQ12 and fasting blood glucose were included. Mood variability was assessed by the General Health Questionnaire 12 (GHQ12). Fasting plasma glucose and glycated haemoglobin (HbA_1c) were measured by standard laboratory methodology and their relationship to variability assessed using linear regression.

Results

There was a significant inverse relationship between fasting blood glucose, but not HbA_1c, and variability score (R² = 0.327, p = 0.02) after adjusting for sociodemographic factors, anthropometric measurements, lifestyle, and use of medication.

Conclusion

This study has shown an inverse association between changes in affect and fasting plasma glucose. This unexpected finding suggests that the association between affect and glucose is more complex than previously thought. Fasting blood glucose may reflect the operation of homeostatic mechanisms that are disturbed in certain mental states and are associated, therefore, with altered risk of diabetes and related metabolic conditions. This may have implications for the management of those with such conditions and with mental disorders.

Insomnia and hallucinations in the general population: Findings from the 2000 and 2007 British Psychiatric Morbidity Surveys

Insomnia is common in people experiencing psychosis. It has been identified as a contributory cause of paranoia, but any causal relationship with hallucinations has yet to be established. We tested the hypotheses that insomnia i) has a cross-sectional association with hallucinations ii) predicts new inceptions of hallucinations and iii) that these associations remain after controlling for depression, anxiety, and paranoia. Data from the second (2000, N=8580) and third (2007, N=7403) British Psychiatric Morbidity Surveys were used to assess cross-sectional associations between insomnia and hallucinations. The 2000 dataset included an 18 month follow up of a subsample (N=2406) used to test whether insomnia predicted new inceptions of hallucinations. Insomnia was associated with hallucinations in both cross-sectional datasets. Mild sleep problems were associated with 2-3 times greater odds of reporting hallucinations, whilst chronic insomnia was associated with four times greater odds. Insomnia was also associated with increased odds of hallucinations occurring de novo over the next 18 months. These associations remained significant, although with smaller odds ratios, after controlling for depression, anxiety and paranoia. This is the first longitudinal evidence that insomnia is associated with the development of hallucinatory experiences. Effective treatment of insomnia may lessen the occurrence of hallucinations.

Persecutory delusions: a cognitive perspective on understanding and treatment

A spectrum of severity of paranoia (unfounded thoughts that others are deliberately intending to cause harm) exists within the general population. This is unsurprising: deciding whether to trust or mistrust is a vital aspect of human cognition, but accurate judgment of others' intentions is challenging. The severest form of paranoia is persecutory delusions, when the ideas are held with strong conviction. This paper presents a distillation of a cognitive approach that is being translated into treatment for this major psychiatric problem. Persecutory delusions are viewed as threat beliefs, developed in the context of genetic and environmental risk, and maintained by several psychological processes including excessive worry, low self-confidence, intolerance of anxious affect and other internal anomalous experiences, reasoning biases, and the use of safety-seeking strategies. The clinical implication is that safety has to be relearned, by entering feared situations after reduction of the influence of the maintenance factors. An exciting area of development will be a clinical intervention science of how best to enhance learning of safety to counteract paranoia.

Psychological Mechanisms Mediating Effects Between Trauma and Psychotic Symptoms: The Role of Affect Regulation, Intrusive Trauma Memory, Beliefs, and Depression

Evidence suggests a causal role for trauma in psychosis, particularly for childhood victimization. However, the establishment of underlying trauma-related mechanisms would strengthen the causal argument. In a sample of people with relapsing psychosis (n = 228), we tested hypothesized mechanisms specifically related to impaired affect regulation, intrusive trauma memory, beliefs, and depression. The majority of participants (74.1%) reported victimization trauma, and a fifth (21.5%) met symptomatic criteria for Posttraumatic Stress Disorder. We found a specific link between childhood sexual abuse and auditory hallucinations (adjusted OR = 2.21, SE = 0.74, P = .018). This relationship was mediated by posttraumatic avoidance and numbing (OR = 1.48, SE = 0.19, P = .038) and hyperarousal (OR = 1.44, SE = 0.18, P = .045), but not intrusive trauma memory, negative beliefs or depression. In contrast, childhood emotional abuse was specifically associated with delusions, both persecutory (adjusted OR = 2.21, SE = 0.68, P = .009) and referential (adjusted OR = 2.43, SE = 0.74, P = .004). The link with persecutory delusions was mediated by negative-other beliefs (OR = 1.36, SE = 0.14, P = .024), but not posttraumatic stress symptoms, negative-self beliefs, or depression. There was no evidence of mediation for referential delusions. No relationships were identified between childhood physical abuse and psychosis. The findings underline the role of cognitive-affective processes in the relationship between trauma and symptoms, and the importance of assessing and treating victimization and its psychological consequences in people with psychosis.

Fronto-Limbic Brain Dysfunction during the Regulation of Emotion in Schizophrenia

Schizophrenia is characterized by significant and widespread impairments in the regulation of emotion. Evidence is only recently emerging regarding the neural basis of these emotion regulation impairments, and few studies have focused on the regulation of emotion during effortful cognitive processing. To examine the neural correlates of deficits in effortful emotion regulation, schizophrenia outpatients (N = 20) and age- and gender-matched healthy volunteers (N = 20) completed an emotional faces n-back task to assess the voluntary attentional control subprocess of emotion regulation during functional magnetic resonance imaging. Behavioral measures of emotional intelligence and emotion perception were administered to examine brain-behavior relationships with emotion processing outcomes. Results indicated that patients with schizophrenia demonstrated significantly greater activation in the bilateral striatum, ventromedial prefrontal, and right orbitofrontal cortices during the effortful regulation of positive emotional stimuli, and reduced activity in these same regions when regulating negative emotional information. The opposite pattern of results was observed in healthy individuals. Greater fronto-striatal response to positive emotional distractors was significantly associated with deficits in facial emotion recognition. These findings indicate that abnormalities in striatal and prefrontal cortical systems may be related to deficits in the effortful emotion regulatory process of attentional control in schizophrenia, and may significantly contribute to emotion processing deficits in the disorder.

Affective instability, childhood trauma and major affective disorders

BACKGROUND

Affective instability (AI), childhood trauma, and mental illness are linked, but evidence in affective disorders is limited, despite both AI and childhood trauma being associated with poorer outcomes. Aims were to compare AI levels in bipolar disorder I (BPI) and II (BPII), and major depressive disorder recurrent (MDDR), and to examine the association of AI and childhood trauma within each diagnostic group.

METHODS

AI, measured using the Affective Lability Scale (ALS), was compared between people with DSM-IV BPI (n=923), BPII (n=363) and MDDR (n=207) accounting for confounders and current mood. Regression modelling was used to examine the association between AI and childhood traumas in each diagnostic group.

RESULTS

ALS scores in descending order were BPII, BPI, MDDR, and differences between groups were significant (p<0.05). Within the BPI group any childhood abuse (p=0.021), childhood physical abuse (p=0.003) and the death of a close friend in childhood (p=0.002) were significantly associated with higher ALS score but no association was found between childhood trauma and AI in BPII and MDDR.

LIMITATIONS

The ALS is a self-report scale and is subject to retrospective recall bias.

CONCLUSIONS

AI is an important dimension in bipolar disorder independent of current mood state. There is a strong link between childhood traumatic events and AI levels in BPI and this may be one way in which exposure and disorder are linked. Clinical interventions targeting AI in people who have suffered significant childhood trauma could potentially change the clinical course of bipolar disorder.

Mood instability: significance, definition and measurement

Mood instability is common, and an important feature of several psychiatric disorders. We discuss the definition and measurement of mood instability, and review its prevalence, characteristics, neurobiological correlates and clinical implications. We suggest that mood instability has underappreciated transdiagnostic potential as an investigational and therapeutic target.

Adult attention deficit hyperactivity symptoms and psychosis: Epidemiological evidence from a population survey in England

Despite both having some shared features, evidence linking psychosis and adult attention deficit hyperactivity disorder (ADHD) is sparse and inconsistent. Hypotheses tested were (1) adult ADHD symptoms are associated with auditory hallucinations, paranoid ideation and psychosis (2) links between ADHD symptoms and psychosis are mediated by prescribed ADHD medications, use of illicit drugs, and dysphoric mood. The Adult Psychiatric Morbidity Survey 2007 (N=7403) provided data for regression and multiple mediation analyses. ADHD symptoms were coded from the ADHD Self-Report Scale (ASRS). Higher ASRS total score was significantly associated with psychosis, paranoid ideation and auditory hallucinations despite controlling for socio-demographic variables, verbal IQ, autism spectrum disorder traits, childhood conduct problems, hypomanic and dysphoric mood. An ASRS score indicating probable ADHD diagnosis was also significantly associated with psychosis. The link between higher ADHD symptoms and psychosis, paranoia and auditory hallucinations was significantly mediated by dysphoric mood, but not by use of amphetamine, cocaine or cannabis. In conclusion, higher levels of adult ADHD symptoms and psychosis are linked and dysphoric mood may form part of the mechanism. Our analyses contradict the traditional clinical view that the main explanation for people with ADHD symptoms developing psychosis is illicit drugs.

Motive-oriented therapeutic relationship building for patients diagnosed with schizophrenia

Treatment options for patients with schizophrenia demand further improvement. One way to achieve this improvement is the translation of findings from basic research into new specific interventions. Beyond that, addressing the therapy relationship has the potential to enhance both pharmacological and non-pharmacological treatments. This paper introduces motive-oriented therapeutic relationship (MOTR) building for schizophrenia. MOTR enables therapists to proactively adapt to their patient’s needs and to prevent problematic behaviors. For example, a patient might consider medication as helpful in principle, but the rejection of medication might be one of his few remaining means for his acceptable motive to stay autonomous despite hospitalization. A therapist who is motive-oriented proactively offers many degrees of freedom to this patient in order to satisfy his need for autonomy and to weaken the motivational basis for not taking medication. MOTR makes use of findings from basic and psychotherapy research and is generic in this respect, but at the same time guides therapeutic action precisely and flexibly in a patient oriented way.

The dimensional structure of cycling mood disorders

This study examines whether mood disorders differ fundamentally in terms of phase duration. Most clinically significant mood disorders are recurrent and cyclical. The phase duration of these cycles is part of the diagnostic criteria. Specifically, we determined whether a dimensional or taxonic latent structure better captures cycling mood disorders. 319 patients recruited from 5 psychiatrists and a psychoeducational program completed three questionnaires assessing aspects of mood cycling. These were the Affective Lability Scale-Short Form (ALS-SF), Mood Disorders Questionnaire (MDQ), and the Eysenck Neuroticism scale. Patient scores on these instruments were submitted to three taxometric procedures (MAMBAC, MAXEIG, and L-Mode). Comparison curve fit indices (CCFIs) were calculated to distinguish taxonic versus dimensional latent structure. In addition, graphs were produced for each procedure and compared with those of categorical or dimensional prototypes. The CCFIs of the three procedures ranged from 0.25 to 0.27, consistent with dimensional structure. The graphs closely resembled dimensional prototypes. Mood instability and other types of cycling moods probably conform to a dimensional latent structure. Patients with disorders featuring mood cycling might benefit from common treatments.

Dealing with feeling: Specific emotion regulation skills predict responses to stress in psychosis

Elevated negative affect is an established link between minor stressors and psychotic symptoms. Less clear is why people with psychosis fail to regulate distressing emotions effectively. This study tests whether subjective, psychophysiological and symptomatic responses to stress can be predicted by specific emotion regulation (ER) difficulties. Participants with psychotic disorders (n=35) and healthy controls (n=28) were assessed for ER-skills at baseline. They were then exposed to a noise versus no stressor on different days, during which self-reported stress responses, state paranoia and skin conductance levels (SCL) were assessed. Participants with psychosis showed a stronger increase in self-reported stress and SCL in response to the stressor than healthy controls. Stronger increases in self-reported stress were predicted by a reduced ability to be aware of and tolerate distressing emotions, whereas increases in SCL were predicted by a reduced ability to be aware of, tolerate, accept and modify them. Although paranoid symptoms were not significantly affected by the stressors, individual variation in paranoid responses was also predicted by a reduced ability to be aware of and tolerate emotions. Differences in stress responses in the samples were no longer significant after controlling for ER skills. Thus, interventions that improve ER-skills could reduce stress-sensitivity in psychosis.

Bullying victimisation and risk of psychotic phenomena: analyses of British national survey data

BACKGROUND

Being bullied is an aversive experience with short-term and long-term consequences, and is incorporated in biopsychosocial models of psychosis. We used the 2000 and the 2007 British Adult Psychiatric Morbidity Surveys to test the hypothesis that bullying is associated with individual psychotic phenomena and with psychosis, and predicts the later emergence of persecutory ideation and hallucinations.

METHODS

We analysed two nationally representative surveys of individuals aged 16 years or older in Great Britain (2000) and England (2007). Respondents were presented with a card listing stressful events to identify experiences of bullying over the entire lifespan. We assessed associations with the dependent variables persecutory ideation, auditory and visual hallucinations, and diagnosis of probable psychosis. All analyses were controlled for sociodemographic confounders, intelligence quotient (IQ), and other traumas.

FINDINGS

We used data for 8580 respondents from 2000 and 7403 from 2007. Bullying was associated with presence of persecutory ideation and hallucinations, remaining so after adjustment for sociodemographic factors, IQ, other traumas, and childhood sexual abuse. Bullying was associated with a diagnosis of probable psychosis. If reported at baseline, bullying predicted emergence and maintenance of persecutory ideation and hallucinations during 18 months of follow-up in the 2000 survey. Controlling for other traumas and childhood sexual abuse did not affect the association between bullying and psychotic symptoms, but reduced the significance of the association with diagnosis of probable psychosis. Bullying was most strongly associated with the presence of concurrent persecutory ideation and hallucinations.

INTERPRETATION

Bullying victimisation increases the risk of individual psychotic symptoms and of a diagnosis of probable psychosis. Early detection of bullying and use of treatments oriented towards its psychological consequences might ameliorate the course of psychosis.

FUNDING

None.

Prevalence of psychosis in black ethnic minorities in Britain: analysis based on three national surveys

PURPOSE

A considerable excess of psychosis in black ethnic minorities is apparent from clinical studies, in Britain, as in other developed economies with white majority populations. This excess is not so marked in population surveys. Equitable health service provision should be informed by the best estimates of the excess. We used national survey data to establish the difference in the prevalence of psychosis between black ethnic groups and the white majority in the British general population.

METHODS

Analysis of the combined datasets (N = 26,091) from the British national mental health surveys of 1993, 2000 and 2007. Cases of psychosis were determined either by the use of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), or from a combination of screening items. We controlled for sex, age, social class, unemployment, design features and other putative confounders, using a Disease Risk Score.

RESULTS

People from black ethnic minorities had an excess prevalence rate of psychosis compared with the white majority population. The OR, weighted for study design and response rate, was 2.72 (95 % CI 1.3-5.6, p = 0.002). This was marginally increased after controlling for potential confounders (OR = 2.90, 95 % CI 1.4-6.2, p = 0.006).

CONCLUSIONS

The excess of psychosis in black ethnic minority groups was similar to that in two previous British community surveys, and less than that based on clinical studies. Even so it confirms a considerable need for increased mental health service resources in areas with high proportions of black ethnic minority inhabitants.

Unravelling psychosis: psychosocial epidemiology, mechanism, and meaning

This paper reviews a revolution in our understanding of psychosis over the last 20 years. To a major extent, this has resulted from a process of cross-fertilization between psychosocial epidemiology and cognitive behavior therapy for psychosis (CBT-p). This encouraged complementary strategies for the acquisition and analysis of data. These include the use of a range of dependent variables related to psychosis, and the exploitation of data from cross-sectional and longitudinal epidemiological surveys, virtual reality experiments, experience sampling methodology, and treatment trials. The key element is to investigate social and psychological measures in relation to each other. This research has confirmed the role of the external social world in the development and persistence of psychotic disorder. In addition, several psychological drivers of psychotic experiences have been identified. There is now persuasive evidence that the influence of social factors in psychosis is significantly mediated by non-psychotic symptoms, particularly mood symptoms and other attributes of affect such as insomnia. Psychotic symptoms are also driven by reasoning biases such as jumping to conclusions and belief inflexibility, though little is known about social influences on such biases. It is now clear that there are many routes to psychosis and that it takes many forms. Treatment of all kinds should take account of this: the dependence of CBT-p on a detailed initial formulation in terms of psychological processes and social influences is an example of the required flexibility. Individual mediators are now being targeted in specific forms of CBT-p, with good effect. This in turn corroborates the hypothesized role of non-psychotic symptoms in mediation, and attests to the power of the approaches described.

Mood instability as a precursor to depressive illness: A prospective and mediational analysis

OBJECTIVE

Mood instability levels are high in depression, but temporal precedence and potential mechanisms are unknown. Hypotheses tested were as follows: (1) mood instability is associated with depression cross-sectionally, (2) mood instability predicts new onset and maintenance of depression prospectively and (3) the mood instability and depression link are mediated by sleep problems, alcohol abuse and life events.

METHOD

Data from the National Psychiatric Morbidity Survey 2000 at baseline (N = 8580) and 18-month follow-up (N = 2413) were used. Regression modeling controlling for socio-demographic factors, anxiety and hypomanic mood was conducted. Multiple mediational analyses were used to test our conceptual path model.

RESULTS

Mood instability was associated with depression cross-sectionally (odds ratio: 5.28; 95% confidence interval: [3.67, 7.59]; p < 0.001) and predicted depression inception (odds ratio: 2.43; 95% confidence interval: [1.03-5.76]; p = 0.042) after controlling for important confounders. Mood instability did not predict maintenance of depression. Sleep difficulties and severe problems with close friends and family significantly mediated the link between mood instability and new onset depression (23.05% and 6.19% of the link, respectively). Alcohol abuse and divorce were not important mediators in the model.

CONCLUSION

Mood instability is a precursor of a depressive episode, predicting its onset. Difficulties in sleep are a significant part of the pathway. Interventions targeting mood instability and sleep problems have the potential to reduce the risk of depression.

Mood instability is a common feature of mental health disorders and is associated with poor clinical outcomes

OBJECTIVES

Mood instability is a clinically important phenomenon but has received relatively little research attention. The objective of this study was to assess the impact of mood instability on clinical outcomes in a large sample of people receiving secondary mental healthcare.

DESIGN

Observational study using an anonymised electronic health record case register.

SETTING

South London and Maudsley NHS Trust (SLaM), a large provider of inpatient and community mental healthcare in the UK.

PARTICIPANTS

27,704 adults presenting to SLaM between April 2006 and March 2013 with a psychotic, affective or personality disorder.

EXPOSURE

The presence of mood instability within 1 month of presentation, identified using natural language processing (NLP).

MAIN OUTCOME MEASURES

The number of days spent in hospital, frequency of hospital admission, compulsory hospital admission and prescription of antipsychotics or non-antipsychotic mood stabilisers over a 5-year follow-up period.

RESULTS

Mood instability was documented in 12.1% of people presenting to mental healthcare services. It was most frequently documented in people with bipolar disorder (22.6%), but was common in people with personality disorder (17.8%) and schizophrenia (15.5%). It was associated with a greater number of days spent in hospital (β coefficient 18.5, 95% CI 12.1 to 24.8), greater frequency of hospitalisation (incidence rate ratio 1.95, 1.75 to 2.17), greater likelihood of compulsory admission (OR 2.73, 2.34 to 3.19) and an increased likelihood of prescription of antipsychotics (2.03, 1.75 to 2.35) or non-antipsychotic mood stabilisers (2.07, 1.77 to 2.41).

CONCLUSIONS

Mood instability occurs in a wide range of mental disorders and is not limited to affective disorders. It is generally associated with relatively poor clinical outcomes. These findings suggest that clinicians should screen for mood instability across all common mental health disorders. The data also suggest that targeted interventions for mood instability may be useful in patients who do not have a formal affective disorder.

Critical periods for the neurodevelopmental processes of externalizing and internalizing

Research on neurobiological development is providing insight into the nature and mechanisms of human neural plasticity. These mechanisms appear to support two different forms of developmental learning. One form of learning could be described as externalizing, in which neural representations are highly responsive to environmental influences, as the child typically operates under a mode of hedonic approach. A second form of learning supports internalizing, in which motive control separates attention and self-regulation from the immediate influences of the context, particularly when the child faces conditions of avoidance and threat. The dorsal cortical networks of externalizing are organized around dorsal limbic (cingulate, septal, lateral hypothalamic, hippocampal, and ventral striatal) circuits. In contrast, the ventral cortical networks of internalizing are organized around ventral limbic (anterior temporal and orbital cortex, extended amygdala, dorsal striatal, and mediodorsal thalamic) circuits. These dual divisions of the limbic system in turn self-regulate their arousal levels through different brain stem and forebrain neuromodulator projection systems, with dorsal corticolimbic networks regulated strongly by locus coeruleus norepinephrine and brain stem raphe nucleus serotonin projection systems, and ventral corticolimbic networks regulated by ventral tegmental dopamine and forebrain acetylcholine projections. Because the arousal control systems appear to regulate specific properties of neural plasticity in development, an analysis of these systems explains differences between externalizing and internalizing at multiple levels of neural and psychological self-regulation. In neuroscience, the concept of critical periods has been applied to times when experience is essential for the maturation of sensory systems. In a more general neuropsychological analysis, certain periods of the child's development require successful self-regulation through the differential capacities for externalizing and internalizing.

Adverse childhood events and psychosis in bipolar affective disorder

BACKGROUND

There has been increasing interest in the association between childhood trauma and psychosis. Proposals for potential mechanisms involved include affective dysregulation and cognitive appraisals of threat.

AIMS

To establish if, within bipolar disorder, childhood events show a significant association with psychosis, and in particular with symptoms driven by dysregulation of mood or with a persecutory content.

METHOD

Data on lifetime-ever presence of psychotic symptoms were determined by detailed structured interview with case-note review (n = 2019). Childhood events were recorded using a self-report questionnaire and case-note information.

RESULTS

There was no relationship between childhood events, or childhood abuse, and psychosis per se. Childhood events were not associated with an increased risk of persecutory or other delusions. Significant associations were found between childhood abuse and auditory hallucinations, strongest between sexual abuse and mood congruent or abusive voices. These relationships remain significant even after controlling for lifetime-ever cannabis misuse.

CONCLUSIONS

Within affective disorder, the relationship between childhood events and psychosis appears to be relatively symptom-specific. It is possible that the pathways leading to psychotic symptoms differ, with delusions and non-hallucinatory symptoms being influenced less by childhood or early environmental experience.

Mood as a mediator of the link between child sexual abuse and psychosis

The significance of affective changes in psychosis is increasingly acknowledged, as is the role of early traumatic events. In a previous paper, using data from the English Adult Psychiatric Morbidity Survey 2007 (APMS2007), strong associations between child sexual abuse (CSA) and psychosis were demonstrated, with some evidence of mediation by affect. In the current paper, we subjected the same dataset to formal tests of mediation. For CSA involving sexual intercourse, 38.5% of the link was mediated, 30.0% by depression and 8.5% by anxiety. For all forms of contact abuse, 38.2% was mediated, 29.1% by depression and 9.1% by anxiety.

The impact of social deprivation on paranoia, hallucinations, mania and depression: the role of discrimination social support, stress and trust

The negative implications of living in a socially unequal society are now well documented. However, there is poor understanding of the pathways from specific environmental risk to symptoms. Here we examine the associations between social deprivation, depression, and psychotic symptoms using the 2007 Adult Psychiatric Morbidity Survey, a cross-sectional dataset including 7,353 individuals. In addition we looked at the mediating role of stress, discrimination, trust and lack of social support. We found that the participants' neighbourhood index of multiple deprivation (IMD) significantly predicted psychosis and depression. On inspection of specific psychotic symptoms, IMD predicted paranoia, but not hallucinations or hypomania. Stress and trust partially mediated the relationship between IMD and paranoid ideation. Stress, trust and a lack of social support fully mediated the relationship between IMD and depression. Future research should focus on the role deprivation and social inequalities plays in specific manifestations of psychopathology and investigate mechanisms to explain those associations that occur. Targeting the mediating mechanisms through appropriate psychological intervention may go some way to dampen the negative consequences of living in an unjust society; ameliorating economic injustice may improve population mental health.

Advances in understanding and treating persecutory delusions: a review

PURPOSE

Persecutory delusions are a central psychotic experience, at the severe end of a paranoia spectrum in the general population. The aim of the review is to provide an introduction to the understanding of persecutory delusions, highlight key putative causal factors that have the potential to be translated into efficacious treatment, and indicate future research directions.

METHODS

A narrative literature review was undertaken to highlight the main recent areas of empirical study concerning non-clinical and clinical paranoia.

RESULTS

Six main proximal causal factors are identified: a worry thinking style, negative beliefs about the self, interpersonal sensitivity, sleep disturbance, anomalous internal experience, and reasoning biases. Each has plausible mechanistic links to the occurrence of paranoia. These causal factors may be influenced by a number of social circumstances, including adverse events, illicit drug use, and urban environments.

CONCLUSIONS

There have been numerous replicated empirical findings leading to a significant advance in the understanding of persecutory delusions, now beginning to be translated into cognitive treatments. The first trials specifically focussed on patients who have persecutory delusions in the context of psychotic diagnoses are occurring. Initial evidence of efficacy is very promising.