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Transcultural observations offer an opportunity to study attitude to mental illness in different societies and family structures. The disparity between industrialised and lower-income societies reflects greater tolerance due to the ability of extended families to compensate for the patient's limitations.
This paper is something of a patchwork, incorporating many issues that have intrigued me during 34 years of research. I have included the importance of maintaining a solid base in clinical work, alongside research activities, and being alert to the possibility of a somatic condition contributing to psychiatric symptoms. I stress the value of careful observation of patients, their response to treatments and reasons for dropping out. In addition, I have included 14 more lessons, learned from my experience of research, which I hope will be of use to those readers who aspire to become researchers.
One in four patients with schizophrenia responds poorly to antipsychotic medication, continuing to hear persecutory auditory hallucinations. Patients who are able to sustain a dialogue with their persecutor feel much more in control.
To develop a computerised system that enables the patient to create an avatar of their persecutor. To encourage them to engage in a dialogue with the avatar, which the the rapist is able to control so that the avatar progressively yields control to the patient.
Avatar therapy was evaluated by a randomised, single blind, partial crossover trial comparing the novel therapy with treatment as usual (TAU). We used three main outcome measures: (a) the Psychotic Symptom Rating Scale (PSYRATS), hallucinations section; (b) the Omnipotence and Malevolence subscales of the Revised Beliefs About Voices Questionnaire (BAVQ-R); and (c) the Calgary Depression Scale (CDS).
The control group showed no change over time in their scores on the three assessments, whereasthe novel therapy group showed mean reductions in the total PSYRATS score (auditory hallucinations) of 8.75 (P = 0.003) and in the BAVQ-R combined score of omnipotence and malevolence of the voices of 5.88 (P = 0.004). There was no significant reduction in the CDS total score for depression. For the crossover control group, comparison of the period of TAU withthe period ofavatar therapy confirmed the findings of the previous analysis. The effect size of the therapy was 0.8.
Avatar therapy represents a promising treatment for medication-resistant auditory hallucinations. Replication with a larger sample is required before roll-out to clinical settings.
Several studies have suggested that neuropsychological and structural brain deficits are implicated in poor insight. Few insight studies however have combined neurocognitive and structural neuroanatomical measures.
Focusing on the ability to relabel psychotic symptoms as pathological, we examined insight, brain structure and neurocognition in first-onset psychosis.
Voxel-based magnetic resonance imaging data were acquired from 82 individuals with psychosis and 91 controls assessed with a brief neuropsychological test battery. Insight was measured using the Schedule for the Assessment of Insight.
The principal analysis showed reduced general neuropsychological function was linked to poor symptom relabelling ability. A subsequent between-psychosis group analysis found those with no symptom relabelling ability had significant global and regional grey matter deficits primarily located at the posterior cingulate gyrus and right precuneus/cuneus.
The cingulate gyrus (as part of a midline cortical system) along with right hemisphere regions may be involved in illness and symptom self-appraisal in first-onset psychosis.
Studies demonstrating an association between childhood trauma and psychosis in adulthood have not systematically explored gender differences.
To investigate gender differences in the prevalence of childhood sexual and physical abuse among people with psychosis in comparison with healthy controls.
The Childhood Experiences of Care and Abuse Questionnaire was completed to elicit experiences of sexual and physical abuse during childhood in first-episode psychosis cases and population-based controls.
Among women, those in the cases group were twice as likely to report either physical or sexual abuse compared with controls following adjustment for all confounders. In particular, the effect of physical abuse in women was stronger and more robust than that for sexual abuse. A similar trend was found for psychotic-like experiences in the female control group. No association was found in men.
Reports of severe childhood physical or sexual abuse were associated with psychosis in women but not in men.
It remains unclear if the excess of neurological soft signs, or of certain types of neurological soft signs, is common to all psychoses, and whether this excess is simply an epiphenomenon of the lower general cognitive ability present in psychosis.
To investigate whether an excess of neurological soft signs is independent of diagnosis (schizophrenia v. affective psychosis) and cognitive ability (IQ).
Evaluation of types of neurological soft signs in a prospective cohort of all individuals presenting with psychoses over 2 years (n=310), and in a control group from the general population (n=239).
Primary (P<0.001), motor coordination (P<0.001), and motor sequencing (P<0.001) sign scores were significantly higher in people with any psychosis than in the control group. However, only primary and motor coordination scores remained higher when individuals with psychosis and controls were matched for premorbid and current IQ.
Higher rates of primary and motor coordination signs are not associated with lower cognitive ability, and are specific to the presence of psychosis.
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.
People from Black ethnic groups (African-Caribbean and Black African) are more prone to develop psychosis in Western countries. This excess might be explained by perceptions of disadvantage.
To investigate whether the higher incidence of psychosis in Black people is mediated by perceptions of disadvantage.
A population-based incidence and case-control study of first-episode psychosis (Aetiology and Ethnicity in Schizophrenia and Other Psychoses (ÆSOP)). A total of 482 participants answered questions about perceived disadvantage.
Black ethnic groups had a higher incidence of psychosis (OR=4.7, 95% CI 3.1–7.2). After controlling for religious affiliation, social class and unemployment, the association of ethnicity with psychosis was attenuated (OR=3.0, 95% CI 1.6–5.4) by perceptions of disadvantage. Participants in the Black non-psychosis group often attributed their disadvantage to racism, whereas Black people in the psychosis group attributed it to their own situation.
Perceived disadvantage is partly associated with the excess of psychosis among Black people living in the UK. This may have implications for primary prevention.
Grey matter and other structural brain abnormalities are consistently
reported in first-onset schizophrenia, but less is known about the extent
of neuroanatomical changes in first-onset affective psychosis
To determine which brain abnormalities are specific to (a) schizophrenia
and (b) affective psychosis
We obtained dual-echo (proton density/T2-weighted) magnetic resonance
images and carried out voxel-based analysis on the images of 73 patients
with first-episode psychosis (schizophrenia n=44,
affective psychosis n=29) and 58 healthy controls
Both patients with schizophrenia and patients with affective psychosis
had enlarged lateral and third ventricle volumes. Regional cortical grey
matter reductions (including bilateral anterior cingulate gyrus, left
insula and left fusiform gyrus) were evident in affective psychosis but
not in schizophrenia, although patients with schizophrenia displayed
decreased hippocampal grey matter and increased striatal grey matter at a
more liberal statistical threshold
Both schizophrenia and affective psychosis are associated with volumetric
abnormalities at the onset of frank psychosis, with some of these evident
in common brain areas
First-episode psychosis is typically preceded by a prodrome in which
there is deterioration in global and social functioning
To examine whether the duration of the prodromal phase influences grey
and white matter volumes at the onset of psychosis
Eighty-two people were scanned using magnetic resonance imaging when they
developed a first episode of psychosis. The duration of the prodromal
phase was estimated from detailed interviews and medical records.
Voxel-based morphometry was used to assess neuroanatomical
A long prodromal phase was associated with smaller grey matter volumes in
the cingulate, frontal and left insular cortex, and with less white
matter volume bilaterally in the superior longitudinal and uncinate
fasciculi and the cingulum
The severity of volumetric abnormalities in first-episode psychosis was
greater in those with a long prodrome