Tuesday, 7 July 2015

Childhood Trauma and Mental Illness

Rachel Upthegrove
This post is by Rachel Upthegrove, a Senior Clinical Lecturer in Psychiatry at the University of Birmingham. 

Childhood trauma is a risk factor for mental illness. This apparently simple statement, with such face validity hardly bears investigation does it? Of course traumatic events will increase the risk of mental distress and disorder - this is stating the obvious. However not all individuals with mental disorder have a history of trauma, or indeed childhood trauma, and certainly not all individuals who experience childhood trauma develop a mental illness.

Childhood trauma has been in focus as an environmental risk factor for psychosis, with some authors proposing a causal role with significant lack of recognition and underreporting of childhood trauma in those who treat patients with psychosis. Mechanisms proposed include a process of hypervigilance leading to persecutory ideation and enhanced 'threat to self' networks. However, often studies have looked at small clinical samples or alternatively adopted a large population based approach measuring self-reporting psychotic-like experiences (assessed for example by being asked to rate: 'People are trying to upset me' and 'People communicate about me in subtle way'). This is open to challenge - these measures may be very sensitive but are not necessary specific.

Many children throughout the world experience childhood adversity, and this unfortunate fact has been with human society throughout time and across cultures. Children remain subject to physical neglect, disease, illness, want, hardship, and exploitation. The challenge therefore may be to explain why indeed more children do not go one to develop psychosis, rather than any other type of mental disorder or no disorder at all. In order to begin this exploration we need to stop and think about what we mean by childhood trauma, and what is meant by psychosis.

The Bipolar Disorder Research Network is one of the world's largest studies of Bipolar Disorder, run by the Mood Disorders Research Group based at Cardiff University and the University of Birmingham. We aim to investigate how genetic and environmental factors interact to increase susceptibility to Bipolar Disorder. Patients with Bipolar disorder, also known as manic depression, have severe episodes of mood disturbance that are sustained, intense, and interfere with an individual’s ability to function. The prevalence of Bipolar Disorder is around 1% of the population, roughly evenly spread across the world.

For some people with Bipolar Disorder, mood episodes are accompanied by psychotic symptoms such as delusions and hallucinations. As part of the BDRN’s program of research, we investigated the association between childhood events and psychosis, and in particular looking at symptoms driven by dysregulation of mood or with a persecutory content using data from 2019 participants who had completed an extensive 1:1 structured clinical interview and case note review. Childhood events were coded as thirteen different categories of event including death, separation or divorce of a parent, exclusion from school, and childhood abuse (further grouped into emotional, physical, or sexual abuse) (Upthegrove et al 2015).

Unlike some previous studies with our large sample and detailed interviews, we found 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. However significant associations were found between childhood abuse and auditory and visual hallucinations, strongest between child sexual abuse and mood congruent or abusive voices. These relationships remained significant even after controlling for lifetime-ever cannabis misuse.

Our results offer both a confirmation and challenge to the argument for childhood trauma being seen as risk (or indeed causal) factor for psychosis. Child sexual abuse has a significant association with hallucinations. One prominent theory of hallucinations is that they arise from aberrant memory activation and internal monitoring. This model postulates a failure of inhibition of recall and unintended memory activation, with the resulting intrusive memories arising 'out of context' and with a perception of 'otherness' to these events. The equivocation between inner and outer events is seen as a defensive manoeuvre to avoid reliving the traumatic experience itself or acknowledging it as having happened. Hippocampal hyper-activation is also apparent during hallucinations, supporting the idea of voices as traumatic aberrant memory or an intrusive, dissociative experience. However, our results also suggest that that the pathways leading to psychotic symptoms differ and are complex, with delusions and non-hallucinatory symptoms being influenced less by childhood or early environmental experience.

Thursday, 2 July 2015

How the Light Gets in 2015

In today's post Rachel Gunn reports from How the Light Gets in Festival 2015.

How the Light Gets in is a philosophy and music festival which takes place annually at Hay-on-Wye. This May was the seventh festival with over 650 philosophy, comedy and music events over a 9 day period.

On the 24th May I attended a workshop run by Richard Bentall about hallucinations – in particular
Richard Bentall
AVHs (auditory verbal hallucinations) also known as ‘voice hearing’. In this workshop Bentall gave us a ‘whistle stop tour’ of the research and literature on ‘voice hearing’. He drew on his own research and the research of others on signal detection analysis (eg: Bentall & Slade, 1985; Badcock et. al.,2013), the research of Chris Frith and others (eg Frith, 1987; Ford & Mathalon, 2005) on the neuroscience behind the experience and on research from Marius Romme who has investigated aspects such as history, background and onset (including childhood trauma) to understand how ‘voice hearing’ might be conceptualised (Romme et. al., 2009).

There are a significant number of people in the population who experience ‘voices’ who do not consider themselves to be ill and do not seek psychiatric help (ibid). Secondary symptoms, such as stress relating to the experience of mis-attribution of one’s own internal voice to external others can be ameliorated by conceptualising the experience in ways that are meaningful to the person experiencing the phenomenon. Marius Romme is not in the business of ‘curing’ those who experience voice hearing. He is more interested in understanding the meaning that the experience holds for those facing the phenomenon. Bentall referred to the oft-cited example (Romme, 1993) of a voice hearer who read The Origin of Consciousness in the Breakdown of the Bicameral Mind by Julian Jaynes – a book that argues that consciousness as we now understand it is a recent phenomenon (Jaynes, 1976). The ‘voice hearer’ saw that there was hope for her predicament - perhaps she had the pre-conscious mind of an ancient Greek person and this was why her mind seemed to be in dialogue with gods or others. This gave her some relief regarding the tension and stress associated with the experience and changed the way she (and her psychiatrist, Romme) conceptualised voice hearing. Bentall's presentation was followed by a lively discussion with a diverse audience about the nature of hallucination.


Tuesday, 30 June 2015

Sense of Agency and Delusions of Alien Control

Glenn Carruthers
This is the fifth and final post in a series of posts on the papers published in an issue of Avant on Delusions. Here Glenn Carruthers summarises his paper 'Difficulties for Extending Wegner and Colleagues' Model of the Sense of Agency to Deficits in Delusions of Alien Control'.

One of Christopher Frith's (e.g. 1992) ideas that has really taken hold is that part of the problem in delusions of alien control is a deficit in the sense of agency. Given that the sense of agency is the feeling that one controls one's actions we can see how a deficit in this feeling could lead to people saying things like:

When I reach my hand for the comb it is my hand and arm which move, and my fingers pick up the pen, but I don’t control them… I sit there watching them move, and they are quite independent, what they do is nothing to do with me… I am just a puppet who is manipulated by cosmic strings. When the strings are pulled my body moves and I cannot prevent it. (Mellor 1970: 18)

Perhaps part of the reason such patients think someone is controlling them is that they do not have this normal sense of agency. To investigate this further we would like to know how the sense of agency is elicited and why it is deficient in these cases. There have been a bunch of hypotheses developed to explain this. Here I will focus on one which was developed by Daniel Wegner and his collaborators (Wegner et al 2004; Wegner and Wheatley 1999).

Wegner and colleagues' hypothesised that the sense of agency is elicited when a subject (unconsciously) infers that one or other of their mental states (e.g. an intention) caused their action. This is called the inference to apparent mental state causation and it occurs automatically when three principles are met:

Priority: The mental state occurs at an appropriate time prior to the action.

Consistency: The mental state is consistent with the action (e.g. the intention specifies the action that actually occurred).

Exclusivity: The mental state is the only plausible cause of the action.

Monday, 29 June 2015

All that glitters...

Emily T. Troscianko
This week Emily T. Troscianko, Knowledge Exchange Fellow at the Oxford Research Centre in the Humanities, and member of the Medieval and Modern Languages Faculty at the University of Oxford, writes about anorexia for our series of accounts by experts-by-experience. Emily also contributes to Psychology Today with a blog called A Hunger Artist.


If there’s any mental illness that offers the sufferer an illusion of having it all, it’s anorexia. The twin towers of that disingenuous promise are thinness and control, bedfellows familiar from pop psychology and the diet industry. No other mental illness gets under observers’ skins (incomprehension, fear, anger, envy) quite like anorexia, and that’s because none other is quite so physical. And it’s in the interplay between the mental and the physical that the hollowness of anorexia’s illusions gets exposed.

In the early days, the heady ‘hunger high’ gets you hooked, the admiring comments about your weight loss keep you hooked, and very soon starvation has kicked in, and then all its profound psychological effects, and all the tenacious feedback loops between the physical and the psychological, make it extremely hard to get unhooked. Take hunger, for example – a powerful nexus of some of the central paradoxes of anorexia. It’s extremely rare for anorexia to involve a consistent absence of hunger. In the vast majority of cases, hunger is an achingly constant companion, and the moments of endorphin-fuelled exhilaration grow rapidly rarer.

Hunger is the thing to be denied – to yourself and to other people (no thanks, I’ve already eaten). Hunger is why you starve yourself – what higher proof of control than shutting your ears to that screaming bodily need, day after day? But hunger always risks stopping you starving yourself – the closer you get to total control, the closer you get to its opposite, in this case bingeing. Hunger is why eating is the most important thing in your day, to be controlled to perfection and indulged in with ecstasy. Hunger distracts you from other pain, and is the ultimate distraction from anything more meaningful. And because so often denied and debarred, and because of the stomach shrinkage and digestive lethargy that come from denying it often enough, hunger deserts you and nausea attacks at the critical moments when you really want to try, and try to want, to eat: on your brother’s birthday, in exam season, when you embark on recovery.

Thursday, 25 June 2015

Valuing Health Conference

University College London
On 4th June I attended some talks at the Valuing Health Conference at University College London, where the themes of Dan Hausman’s book, Valuing Health (Oxford University Press, 2015) were discussed. The event was organised by Jo Wolff and James Wilson. The intended audience was philosophers, economists, and also healthcare policy makers.

The conference started with a brief overview of the arguments in the book, presented by Dan Hausman (University of Wisconsin). There are two basic problems the book was meant to address: (1) we need to be able to compare health improvements brought by different policies; (2) we need to know what to do with the information (e.g., maximise health). Thus, the book provides answers to the following questions: How do we assign values to health states? How do we assess policies on the basis of those values? What role should people play in assigning values to policies? The discussion raises further questions about the relationship between health and wellbeing (the notion of wellbeing is clarified in chapter 6 of the book, and the distinction between wellbeing and the value of health is examined in chapter 10).

Valuing Health
by Daniel Hausman