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Society and Psychosis
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Book description

Psychiatry is in the process of rediscovering its roots. It seemed as if the long history of interest in the impact of society on the rates and course of serious mental illness had been forgotten, overtaken by the advances of neuroscience and genetics. However, as our knowledge of physiological and genetic processes improves it becomes increasingly clear that social conditions and experiences over the life course are crucial to achieving a full understanding. Old controversies are giving way to genuinely integrated models in which social, psychological and biological factors interact over time, culminating in the onset of psychosis. This book reviews these issues from an international perspective, laying the foundations for a new understanding of the psychotic disorders, with profound implications for health policy and clinical practice. It should be read by all members of the mental health team and those responsible for service organization and management.

Reviews

'I felt it a privilege to share in the thinking of great minds in this field. The book both stands on its own as a rich compendium of the latest knowledge in the field and offers an invitation to think in new ways.'

Patricia E. Murphy - Rush University Medical Center

'… provides a much-needed counterbalance to the current biochemical zeitgeist in psychopathology research. … Each of the chapters provides a well-written overview of some of the many social factors associated with receiving psychotic diagnoses. … a refreshing alternative to traditional views of psychosis.'

Source: PsycCritiques

'… an excellent attempt to summarize the current understanding of the social aspects of schizophrenia with regard to its aetiology, course and outcome.'

Source: Psychological Medicine

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Contents

  • Acknowledgements
    pp x-x
    • By Craig Morgan, Senior Lecturer Institute of Psychiatry, King's College, London, UK, Kwame McKenzie, Professor of Psychiatry, University of Toronto, University of Central Lancashire; Senior Scientist and Clinician Centre for Addictions and Mental Health, Toronto, Canada, Paul Fearon, Senior Lecturer and Head of the Section of Epidemiology and Social Psychiatry Institute of Psychiatry King's College, London, UK
  • 1 - Introduction
    pp 1-10
    • By Craig Morgan, Section of Social and Cultural Psychiatry, Health Service and Population Research Department Box 33, Institute of Psychiatry De Crespigny Park, London, UK, Kwame McKenzie, Department of Mental Health Sciences, University College, London (Hampstead Campus), Rowland Hill Street, London, UK, Paul Fearon, Section of Epidemiology and Social Psychiatry, Department of Psychiatry and Psychological Medicine Box 63, Institute of Psychiatry De Crespigny Park, London, UK
  • View abstract

    Summary

    This introduction presents an overview of the key concepts discussed in this book, which reflects the current trends in the study of society and psychosis and contributes to developing an agenda for future research. Psychotic symptoms can occur in a range of disorders identified in the Diagnostic and Statistical Manual and the International Classification of Diseases, including schizophrenia spectrum disorders, affective disorders, a range of brief psychotic disorders and grief reactions. One of the basic tenets of the epidemiology of schizophrenia has been that the incidence is more or less uniform around the world. The causes of schizophrenia and other psychoses have been the subject of intense research efforts and frequently acrimonious debates. In contrast to the controversy that surrounds the possible role of socioenvironmental factors in the aetiology of psychosis, it is accepted that the social environment can influence the course and outcome of psychosis.
  • 2 - Climate change in psychiatry: periodic fluctuations or terminal trend?
    pp 11-22
    • By Julian Leff, Department of Psychiatry and Psychological Medicine, Box 63, Institute of Psychiatry De Crespigny Park, London, UK
  • View abstract

    Summary

    Innovations in the practice of psychiatry can influence the direction of research. One can ask whether there is a natural periodicity in the swings between biological and psychosocial research, or whether they can perceive a tendency towards inexorably increasing biologism in recent years that eventually eclipse psychosocial research. The problem of detecting such a tendency is equivalent to the arguments over climate change, except that the time period available for scrutiny is less than 100 years instead of many millennia. The number of articles in the American Journal of Psychiatry (AJP) and the British Journal of Psychiatry (BJP) assigned to psychosocial and biological categories and the proportion of psychosocial articles in each year are shown in this chapter. The discipline of social psychiatry in the UK has a long history and has maintained a high research output, despite the greater influx of funds into biological psychiatry.
  • 3 - Social science, psychiatry and psychosis
    pp 25-40
    • By Craig Morgan, Section of Social and Cultural Psychiatry Health Service and Population Research Department Box 33, Institute of Psychiatry De Crespigny Park, London, UK
  • View abstract

    Summary

    The relationship between psychiatry and the social sciences has a chequered history, with examples of both fruitful collaboration and periods of extreme animosity, the legacy of which is an ongoing ambivalence of each towards the other. Perhaps the core idea that unified the amorphous perspectives of the 'antipsychiatry' movement was that mental illness was a myth, a social construction designed to silence difference. Research in the social sciences has an important contribution to make to the understanding of how social contexts shape the course and outcome of schizophrenia and other psychoses, and how one can intervene to moderate these contexts and improve long-term outcomes. From the inception of the discipline, sociologists have been interested in the social patterning and determinants of health and illness. This body of work can be considered under two headings: structural strain theory and social stress theory.
  • 4 - Conceptualising the social world
    pp 41-57
    • By Dana March, Department of Epidemiology Mailman School of Public Health, Columbia University, Presbyterian Hospital, 722 West 168th Street, New York, NY, USA, Craig Morgan, Section of Social and Cultural Psychiatry Health Service and Population Research Department Box 33, Institute of Psychiatry De Crespigny Park, London, UK, Michaeline Bresnahan, Department of Epidemiology Mailman, School of Public Health, Columbia University, Presbyterian Hospital, 722 West 168th Street, New York, NY, USA, Ezra Susser, Department of Epidemiology Mailman School of Public Health, Columbia University, Presbyterian Hospital, 722 West 168th Street, New York, NY, USA
  • View abstract

    Summary

    Conceptualising the social world is a critical first step in attempting to understand the aetiological role of social factors. This chapter draws on ideas developed in a previous era to suggest a theoretically informed rubric for conceptualising components of the social world to make them amenable to investigation, the focus being specifically on aetiology. The ecological notion of aetiology held by Faris and Dunham and their contemporaries eventually gave way to a focus on what they termed constitutional factors. The chapter addresses the necessity of considering distinctions between processes and conditions, levels of organisation and place and time. Care must be taken to guard against two common inferential mistakes involving multiple levels of organisation. The ecological fallacy is familiar to most investigators. The equally important converse fallacy, sometimes referred to as the atomistic fallacy, is less familiar. It results from comparing individuals and inferring causation at the group level.
  • 5 - Genes and the social environment
    pp 58-74
    • By Jennifer H. Barnett, Department of Psychiatry, University of Cambridge, Box 189, Addenbrooke's Hospital, Cambridge, UK, Peter B. Jones, Department of Psychiatry, University of Cambridge, Box 189, Addenbrooke's Hospital, Cambridge, UK
  • View abstract

    Summary

    This chapter considers how genes might interact with aspects of the social environment in the genesis of psychiatric disorders. Psychiatric research has been revolutionised by molecular genetics, such as the hunt for candidate genes for schizophrenia. The search for gene-environment interactions depends crucially on the development of similarly sophisticated means of measuring environmental risk. The chapter describes evidence for such interactions from early adoption studies to recent investigations using modern molecular genetic techniques. It discusses the principal methodological issues of such research, and the need for clarification of the mechanisms of gene-environment interaction. Differences in environmental and phenotypic measures are understandable given that many gene-environment studies will necessarily be opportunistic, taking advantage of large datasets such as birth cohorts where much of the phenotypic and environmental exposure data have been collected. Finally, the chapter also considers the challenges that increasing knowledge of epigenetics will bring to the field.
  • 6 - Society, place and space
    pp 77-94
    • By Jane Boydell, Section of Epidemiology and Social Psychiatry, Department of Psychiatry and Psychological Medicine, Box 63, Institute of Psychiatry De Crespigny Park, London, UK, Kwame McKenzie, Department of Mental Health Sciences, University College, London (Hampstead Campus), Rowland Hill Street, London, UK
  • View abstract

    Summary

    This chapter discusses the impact of society, place and space on the incidence of psychosis. It introduces the history of social causation theory before using the well established effect of urban residence on the incidence of psychosis in general, and schizophrenia in particular, as a lens through which to consider the possibilities for, and problems with, this research field. The chapter explains the reasons why the socioenvironmental context seems to be important. Over time, society, place and space have been conceptualised in a number of different ways. The environment has been considered as a cause of illness at a population level and at an individual level, and as a vector of risk factors at an individual level. The urban environment may simply increase the possibility of individuals encountering known risk factors. It may increase the impact of known risk factors or it may produce new risk factors for an individual.
  • 7 - Childhood adversity and psychosis
    pp 95-111
    • By Helen Fisher, Department of Psychiatry and Psychological Medicine, and Social, Genetic and Developmental Psychiatry Centre Box 63 Institute of Psychiatry De Crespigny Park London UK, Tom Craig, Section of Social and Cultural Psychiatry Health Service and Population Research Department, Box 33, Institute of Psychiatry De Crespigny Park, London, UK
  • View abstract

    Summary

    This chapter focuses on childhood adversity, and reviews the most commonly researched aspects of early adversity and trauma. The concept of childhood adversity encompasses a diverse range of experiences, including sexual abuse, physical abuse, emotional or psychological abuse, neglect, bullying by peers, parental loss through separation or death, domestic violence and parental mental illness. While the nature and strength of any association between childhood adversity and psychosis needs further clarification, models have nonetheless been proposed that identify potential mechanisms through which early trauma may increase the risk of later psychosis. It makes sense for these two strands of research (epidemiology and studies of biological, psychological and social mechanisms) to proceed simultaneously. The chapter reviews some of the hypothesised models. A framework that integrates both the biological and psychological levels to model the hypothetical link between childhood adversity and psychosis could be developed by unifying two integrative theories.
  • 8 - Family environment and psychosis
    pp 112-126
    • By Pekka Tienari, Department of Psychiatry, The University of Oulu, PO Box 5000 90014, Oulu, Finland, Karl-Erik Wahlberg, Department of Psychiatry, The University of Oulu, PO Box 5000 90014, Oulu, Finland
  • View abstract

    Summary

    This chapter provides an overview of research based on family environment and schizophrenia and other psychoses. The most frequently studied intrafamilial factors are family communication and expressed emotion (EE). The chapter focuses specifically on these in assessing the evidence for the role of family environment in the aetiology and course of psychosis. Research findings appear to confirm a greater prevalence of communication disturbance in the parents of schizophrenic patients than in other parents. The communication deviance (CD) construct and scale were developed to describe the disturbed communication styles found in the families of patients diagnosed with schizophrenia. EE has been found to be a reliable psychosocial predictor of relapse in schizophrenia. Studies of the efficacy of family interventions for those with psychosis provide further relevant evidence. Earlier adoption studies have convincingly confirmed the importance of a genetic contribution to schizophrenia.
  • 9 - Adult adversity: do early environment and genotype create lasting vulnerabilities for adult social adversity in psychosis?
    pp 127-142
    • By Inez Myin-Germeys, Department of Psychiatry and Neuropsychology, Maastricht University, PO Box 616, (Location DOT10) 6200 MD, Maastricht, The Netherlands, Jim van Os, Department of Psychiatry and Neuropsychology, Maastricht University, PO Box 616, (Location DOT10) 6200 MD, Maastricht, The Netherlands
  • View abstract

    Summary

    This chapter presents an overview of evidence concerning adult adversity and risk of psychosis. It discusses the two possible ways of approaching the question of how the adult environment interacts with the individual to increase the risk of psychosis. One mechanism through which environmental exposures might impact on the risk for psychosis is sensitisation. The chapter presents evidence to suggest that behavioural sensitisation may be one mechanism linking the experience of previous larger stresses, such as significant life events or childhood trauma, and psychosis. Another mechanism that is important in understanding the effect of adult adversities on the risk of psychosis is gene-environment interaction. The chapter provides some direct and indirect evidence for mechanisms of gene-environment interaction in psychosis. A more direct way to study gene-environment interaction is to investigate whether certain functional polymorphisms are related to the ways individuals respond to the environment.
  • 10 - Migration, ethnicity and psychosis
    pp 143-160
    • By Kwame McKenzie, Centre for Addictions and Mental Health, University of Toronto, 455 Spadina Av. Toronto, Canada, Paul Fearon, Section of Epidemiology and Social Psychiatry, Department of Psychological Medicine and Psychiatry, Box 63, Institute of Psychiatry, De Crespigny Park, London, UK, Gerard Hutchinson, Psychiatry Unit Department of Clinical Medical Sciences, University of the West Indies, Mount Hope, Champs Fleurs, Trinidad
  • View abstract

    Summary

    This chapter reviews the literature reporting differences in the incidence of psychosis between migrant and ethnic groups, and discusses methodological issues. Race, culture and ethnicity are three related but distinct concepts. The use of racial categories has largely disappeared from scientific research and been replaced by the use of ethnicity. The chapter builds a model of how migration, culture and ethnicity affect rates of incident psychosis by using the best-researched group, people of African and Caribbean origin in the UK. Social factors are important in the genesis of psychotic disorders. The three most cited possible social reasons for increased rates of psychosis in migrant groups are socioeconomic factors, racism and the urban environment. A sociodevelopmental model would suggest that ongoing negative social experiences, acting on a template of social deprivation and urbanicity, cause changes in social adjustment which predispose to further negative social experiences and which ultimately result in psychosis.
  • 11 - Social factors as a basis for treatment
    pp 163-178
    • By Richard Warner, Department of Psychiatry, University of Colorado at Boulder, 233 UCB Boulder, CO, USA
  • View abstract

    Summary

    Social factors can affect the course and outcome of mental illness. Programmes that attempt to ameliorate the effect of such social problems as unemployment, poverty, homelessness, incarceration and isolation have proven effective in improving outcome, quality of life and social inclusion for people with serious mental illness. Transitional employment programmes (TEPs), developed in the 1970s, were the precursors of supported employment. A refinement of the supported employment model has been named individual placement and support (IPS). Norwegians with mental illness report that poverty, unemployment and substandard living conditions are among their greatest obstacles to recovery. Housing cooperatives could become a viable response to the homelessness of people with mental illness and, simultaneously, improve their economic situation and quality of life. The psychosocial clubhouse seeks to address both the problems of social isolation and powerlessness of people with mental illness.
  • 12 - Public attitudes, stigma and discrimination against people with mental illness
    pp 179-197
    • By Graham Thornicroft, Health Service and Population Research Department, Box 29, Institute of Psychiatry De Crespigny Park, London, UK, Aliya Kassam, Health Service and Population Research Department, Box 29, Institute of Psychiatry De Crespigny Park, London, UK
  • View abstract

    Summary

    This chapter focuses on people who have diagnoses of mental illnesses. The stigma concept has been used extensively for some particular physical conditions. The focus on the core concept of stigma has also separated the field of mental illness from the mainstream of disability-related policy and, in particular, the stigma idea has offered policymakers and politicians few recommendations for action. 'Stigma' can be seen as an overarching term that contains three important elements: problems of knowledge (ignorance); problems of attitudes (prejudice); and problems of behaviour (discrimination). Most of the published work on mental health and stigma consists of attitude surveys, but very few have been repeated over time to see if attitudes are becoming more or less favourable. A series of common beliefs about mental illnesses have developed, which are firmly held but not based firmly on evidence. These are often described by experts as 'myths'.
  • 13 - Outcomes elsewhere: course of psychosis in ‘other cultures’
    pp 198-216
    • By Kim Hopper, Nathan Klein Institute for Psychiatric Research and Mailman School of Public Health, Colombia University, 722 West 168th Street, Sociomedical Sciences #928, New York, NY, USA
  • View abstract

    Summary

    Upbeat descant to the descending bass-line of progressive deterioration in the West, the course of schizophrenia in 'other cultures' has long claimed pride of place among the curiosities of cross-cultural psychiatry, a stature neither wholly earned nor unanimously subscribed to. The rumour of recovery from schizophrenia in other cultures made innocent rounds in early ethnographic circles only to be roundly discredited in clinical corridors. The World Health Organization (WHO) studies draw implicitly on the well aged convention of culture as a local model for living, circulating as 'institutionalised canonicity' and embodied as native bent and propensity. Less obviously in play in the epidemiological record, it is everywhere apparent in that literature's shadow self, what the author calls the discursive tradition of cross-cultural psychiatry. The discursive school is still a cottage industry, bearing little of the institutional support or clinical imprimatur that underwrites cross-cultural epidemiology.
  • 14 - Theories of cognition, emotion and the social world: missing links in psychosis
    pp 219-237
    • By Paul Bebbington, Department of Mental Health Sciences, University College, London (Bloomsbury Campus), Wolfson Building 48, Riding House Street, London, UK, David Fowler, School of Medicine, Health Policy and Practice University of East Anglia, Norwich, UK, Philippa Garety, Department of Psychology Box 77 Institute of Psychiatry De Crespigny Park, London, UK, Daniel Freeman, Department of Psychology Box 77 Institute of Psychiatry De Crespigny Park, London, UK, Elizabeth Kuipers, Department of Psychology Box 77 Institute of Psychiatry De Crespigny Park, London, UK
  • View abstract

    Summary

    This chapter argues that important contributions have been made by linking cognition, emotion and the social world with the emergence and maintenance of psychotic experiences. It discusses some of the consequences of the formulation of the concept of schizophrenia. Modern cognitive models of psychosis start by postulating continuities between psychosis and normal experience. There has been a prima facie assumption about aetiological theories in psychosis, a reductionist position placing genetic explanations at the beginning of the aetiological process. The study of single psychotic symptoms, or single types of symptom, is assisted by a clear account of the symptoms themselves. The association of stressful life events with relapse into positive symptoms is well established. The detailed study of the relationship between trauma and psychosis is in its early days, but the investigation of the emotional and cognitive processes common to trauma responses and to psychosis in the view carries considerable promise.
  • 15 - Society and psychosis: future directions and implications
    pp 238-251
    • By Craig Morgan, Section of Social and Cultural Psychiatry Health Service and Population Research, Department Box 33, Institute of Psychiatry De Crespigny Park, London, UK, Kwame McKenzie, Centre for Addictions and Mental Health University of Toronto, 455 Spadina Av. Toronto, Canada, Paul Fearon, Section of Epidemiology and Social Psychiatry, Department of Psychological Medicine and Psychiatry, Box 63, Institute of Psychiatry De Crespigny Park, London, UK
  • View abstract

    Summary

    This concluding chapter provides an overview and summary of the research presented in the book Society and Psychosis, to suggest directions and challenges for future research and to discuss the implications of this research. In attempting to understand the links between society and psychosis, there is a need to develop conceptual tools that allow the complexities of the social world to be studied. The framework for investigating the impact of society on psychosis provides a means of synthesising information and knowledge, and generating testable hypotheses for future research. The tentative models outlined in the book indicate genuinely integrated theories of psychosis aetiology, in which the epidemiological evidence that psychosis is associated with forms of social adversity is linked through known biological and psychological mechanisms to the development of symptoms. Irrespective of whether social factors are causally related to psychosis, many of those who present to services have significant social needs.

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