Psychosis, a category or continuum? Opinions from a snowflake.

The number of people experiencing a common mental disorder (depression and anxiety) has been on a steady increase over the last few decades. Figures from the most recent adult psychiatric morbidity survey found that in 1993, 6.9% of 16 to 64 year olds showed symptoms of such disorders, with the proportion rising to 9.3% by 2014. Explanations for these numbers have often been associated with the increasing development of technology, namely the internet. This correlation will likely be unsurprising to many of us. Platforms such as Facebook or Instagram have exposed us to unprecedented social pressure, Twitter has made us addicted to unnecessary breaking news (guilty!), and the exponential amount of information available at our finger tips has meant my beloved ‘snowflake generation’ are more vigilant of potential mental health symptoms than any previous generation in history.

But rather than attribute these numbers to those who are experiencing mental health issues, it is worth recognising that the goal posts of what constitutes a mental disorder has also been shifting amongst psychiatrists, whose opinions massively impact public perception. In the mid twentieth century, mental health disorders were seen as distinct, categorical conditions. It was an era of binaries, you either had a condition or you did not. Since the mid 1980’s, there has been a significant shift away from this perspective. More and more, the strict categories of mental health conditions have been broken down and increasingly viewed as residing on a fluid continuum with ‘normal’ everyday experiences.

For many, this idea is intuitive, especially perhaps for conditions such as depression and anxiety. Whilst there are multiple paths to major depressive disorder or generalised anxiety disorder, it is not unreasonable to view them as being on the extreme end of everyday feelings of sadness, stress and fear. Where you land on the continuum of depression-Depression or anxiety-Anxiety is a question of nature vs nurture. Certainly it is dependent on your physiology: your genetic predisposition, how your brain is wired, and how well it functions. But these causes are heavily mitigated by environmental factors, such as trauma and life adversity. Furthermore, with changing circumstances can come a changing prognosis; for many people, these conditions are phasic and do not last a lifetime.

I would argue that the commonality, and thus relatability of the everyday experiences upon which depression and anxiety are built (e.g. low self-esteem or fatalist thinking), has contributed to society becoming increasingly better at understanding and compassionate towards the plight of the sufferer (although surely there is room for improvement). I would also argue that from this perspective, not all mental health conditions are created equal. Public perception of schizophrenia continues to be that of a distinct category. The characteristic symptom of psychosis, that includes both hallucinations (false perceptions) and delusions (false beliefs), are seemingly unrelatable to the masses. Witnessing someone in the throes of a psychotic episode can be intimidating and threatening to the inexperienced and an instinctual response is to keep a distance. In this day and age, schizophrenia continues to be perceived as the pinnacle of ‘madness’, a diagnosis of which would be a death wish.

But how unrelatable are the experiences of psychosis? Is it possible that hallucinations and delusions could also lie at the extreme end of what we think of as ‘normal’? The most compelling evidence to suggest this could well be the case stems from that fact that psychotic experiences are far more common than one might think. Schizophrenia affects approximately 1% of the population (Salomon et al., 2012). Of this, only 60-80% experience auditory verbal hallucinations, ‘hearing voices’ (Nayani and David, 1996). But this phenomenon is not exclusive to schizophrenia as it is commonly experienced in other psychiatric conditions, including bi-polar disorder and even depression. Recent research has also shown that between 10-15% of the general population (those without any known psychiatric condition) also experience such hallucinations (Beavan et al. 2011). This percentage changes as you move away from western societies that have been historically influenced by medical psychiatry. The first ever cross-national study on voice hearing by Nuevo and colleagues (2010) found highly variable prevalence rates across 52 different countries, with the highest instances reported in Nepal (31.4%). Further to this, the prevalence of voice hearing appears to vary across age within specific populations, with higher instances in children and adolescents compared to adults (Kelleher et al., 2012).

It is important to note that the varying figures may well be down to biases of self-report – as of yet there is no test for auditory verbal hallucinations, rather it is just a matter of subjective judgements that are susceptible to cultural influences. Consequently, similar experiences to voice hearing, such as daydreams or vivid thoughts, may be interpreted differently depending on how you have learnt to view life. Furthermore, cultural attitudes are also likely to play a considerable role. If your cultural heritage views hearing voices as a negative sign of serious ill-health, as in Western cultures, then you may well be more reluctant to admit your experiences! In contrast to this, cultures where voice hearing is more socially acceptable (e.g. perhaps interpreted as communication with one’s ancestors), the reduced stress of stigma may mean individuals find it easier to manage and cope with their experiences.

In spite of the growing evidence in favour of the continuum hypothesis emerging from the field of cultural psychiatry, there is still one limitation. At what point along the continuum do we pass from a state of health into ill-health? In my previous blog post, Psychiatrists talk truth, I talk Trump, I emphasised ‘need for care’ as the defining point at which psychiatrists intervene. Based on this, the current psychosis continuum appears to be one of risk (e.g. ranging from those with functioning lives and those who do not), as opposed to one of experience (e.g. ranging from vivid thoughts to full-blown external hallucinations). More work on how such experiences arise in the brain would help to unpack the latter, leading to a better understanding of what is actually happening – this is what I hope to address during my PhD research (not sure if 4 years is enough though).

As I draw this post to a close I find myself reflecting upon the value of the continuum hypothesis and feeling a sense of pride in how the average snowflake-millennial approaches mental health. The first benefit is how it fundamentally reduces stigma, lessening the mentality of ‘them vs us’. A report produced by the charity Time to Change illustrates that the number of people willing to live with, work with and live nearby individuals with mental health conditions is on the rise. It was the wise Mahatma Gandhi who once said ‘The true measure of any society can be found in how it treats its most vulnerable members’. The second benefit of society adopting the continuum approach is that with an increase in mental health awareness there is likely to be an increase in early intervention. As of yet, there is no cure for schizophrenia and no pill to make distressing voices go away. Growing evidence is continuing to show that early intervention is highly impactful on the long-term outcome of those at risk of schizophrenia. If improving the lives of some 650,000 people in the UK doesn’t justify a change in public perception, then consider the economic implication. In the year 2004-2005, the estimated cost of schizophrenia care was £6.7 billion. Just think of the savings that could be made!

You can mock us millennials for being too sensitive, but it seems we may not be as bad with money after all!

Image result for millennial meme

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If you are interested in reading further about the psychosis continuum vs category debate have a look at the following paper:

David, A. S. (2010, December). Why we need more debate on whether psychotic symptoms lie on a continuum with normality. Psychological Medicine. https://doi.org/10.1017/S0033291710000188

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