Call for Research: Ethnography, Psychosis and At-Risk Groups

An article this week in Nature highlights new issues surrounding the intersections of psychosis, clinical risk, and adolescence. Psychosis is now thought to lie along a “continuum” in the population from “at-risk” groups who have “psychotic-like experiences” (PLEs) (e.g., hallucinations and delusions that are transient or do not disrupt social functioning) (Meehl 1962; Polanczyk, Moffitt et al. 2010) to people who experience a full-blown “first-episode psychosis” (FEP) who may then go on to develop multiple-episode “psychotic disorders” like schizophrenia (Kelleher and Cannon 2010). Recent estimates find that 5-8% of the general population experience PLEs or “subclinical” psychotic symptoms and may be at-risk for FEP (Yung and McGorry 1996; Norman, Scholten et al. 2005; Van Os, Linscott et al. 2009), but this does not mean that all people with PLEs will develop FEP or schizophrenia. In fact, a recent study of an “ultra high-risk” group with PLEs and cognitive deficits over 18 months had only 19% of participants transition to psychosis (Ruhrmann, Schultze-Lutter et al. 2010).

Great debate (Dobbs 2010) has arisen over when and how to treat people with PLEs in order to try and prevent FEPs with some arguing that treatment before the development of FEP is good, “evidence-based care” (Bosanac, Patton et al. ; Frances 2009; McGorry, Nelson et al. 2009; McGorry, Johanessen et al. 2010). Preventive care is promoted because the duration of untreated psychosis may predict, for some, the social, psychological and biological impact of FEP (Keshavan, Haas et al. 2003; Iyer, Boekestyn et al. 2008). Others argue that the duration of untreated psychosis does not prevent future psychotic episodes (Norman and Malla 2001), and prescribing antipsychotics to people “falsely identified” and “medicalized” (Conrad 2007) as pre-psychotic who will never go on to develop FEP exposes people who may never become ill, particularly teenagers, to the known risks of taking “antipsychotic” medications (e.g., a shortened life span, stigma, debilitating side effects, and difficulties securing health insurance (Bosanac, Patton et al. ; Corcoran, Malaspina et al. 2005; Frances 2009)). These issues deserve careful consideration as western society struggles to determine what constitutes “evidence-based treatment” for psychoses and where the boundary between people who may or may not need clinical treatment along the psychosis continuum lies.

The primacy of “objective” scientific descriptions have yet to produce an overall understanding of the ways people develop disordered reactions to mental distress, and the ways we might best help them mitigate that distress (Castillo 2006; Frazzetto and Gross 2007; Abbott 2008; Abbott 2008, and this week’s article in Nature). Alternatively, anthropological and sociological literature at times elicits the ways people develop rituals, beliefs, relationships and practices both inside and outside of clinical settings that seem to help them adapt and flourish in spite of mental distress (Hahn and Kleinman 1983; Dow 1986; Fischer 2007; Larsen and Larsen 2007; Rose 2007; Luhrmann 2008; Biehl and Locke 2010). Anthropological research on whether or not at-risk people who present in clinics go on to develop first-episode psychosis could contribute to longstanding debates about the relevance of phenomenological heuristics for understanding and addressing psychiatric disorder (Corin 1990; Estroff 2004; Larsen 2004; Biehl 2005; Jenkins, Strauss et al. 2005; Luhrmann 2010) and the overall importance of “subjective” evidence in “evidence-based” medicine (Greenhalgh 1999; Hunink and Glasziou 2001). This research may also produce hypotheses about the possible ways that clinical (e.g., enrollment in first-episode psychosis treatment programs) and complementary approaches meant to help people cope with PLEs may or may not prevent full-blown psychosis. Such hypotheses may inform current debates about whether or not people who experience PLEs (e.g., as an “at risk” or “high risk” group) should be “medicalized” (Conrad 2007) and classified in the DSM-V or ICD-11 (expected revisions of the two current diagnostic manuals for psychiatrists) and “preventively” treated with antipsychotic medication (Bosanac, Patton et al. ; Kihlstrom 2002; Banzato 2004; Middleton 2008; Frances 2009; McGorry, Johanessen et al. 2010).

Abbott, A. (2008). “Model Behaviour.” Nature 450: 6-7.
Abbott, A. (2008). “The Brains of the Family.” Nature 454: 154-7.
Banzato, C. (2004). “Classification in psychiatry: The move towards ICD-11 and DSM-V.” Current Opinion in Psychiatry 17(6): 497.
Biehl, J. and P. Locke (2010). “Deleuze and the Anthropology of Becoming.” Current Anthropology 51(3): 317 – 351.
Biehl, J. G. (2005). Vita: Life in a zone of social abandonment. London, University of California Press.
Bosanac, P., G. Patton, et al. “Early intervention in psychotic disorders: faith before facts?” Psychological Medicine 40(03): 353-358.
Castillo, R. J. (2006). “Recovery from Transient Psychosis.” Psychiatric Times 23(14).
Conrad, P. (2007). The medicalization of society, Johns Hopkins University Press.
Corcoran, C., D. Malaspina, et al. (2005). “Prodromal interventions for schizophrenia vulnerability: the risks of being.” Schizophrenia Research 73(2-3): 173-184.
Corin, E. (1990). “Facts and Meaning in Psychiatry. An Anthropological Approach to the Lifeworld of Schizophrenics.” Culture, Medicine, and Psychiatry 14: 153 – 188.
Dobbs, D. (2010). “The Making of a Troubled Mind.” Nature 468: 154-156.
Dow, J. (1986). “Universal aspects of symbolic healing: a theoretical synthesis.” American Anthropologist 88(1): 56-69.
Estroff, S. E. (2004). Subject/Subjectivities in Dispute: The Poetics, Politics, and Performance of First-person Narratives of People with Schizophrenia. Schizophrenia, Culture, and Subjectivity: The Edge of Experience. J. H. Jenkins and R. J. Barrett. Cambridge, Cambridge University Press. 11: 282 – 302.
Fischer, M. M. J. (2007). To live with what would otherside be unendurable: return(s) to subjectivities. Subjectivity: Ethnographic Investigations. J. Biehl, B. Good and A. Kleinman. Berkeley, University of California Press.
Frances, A. (2009). “Whither DSM-V?” The British Journal of Psychiatry 195(5): 391.
Frazzetto, G. and C. Gross (2007). “Beyond Susceptibility.” European Molecular Biology Organization Reports 8(Special Issue July): S3-S6.
Greenhalgh, T. (1999). “Narrative based medicine in an evidence based world.” BMJ318(7179): 323.
Hahn, R. and A. Kleinman (1983). “Belief as pathogen, belief as medicine:” Voodoo death” and the” placebo phenomenon” in anthropological perspective.” Medical Anthropology Quarterly 14(4): 3-19.
Hunink, M. and P. Glasziou (2001). Decision making in health and medicine: integrating evidence and values, Cambridge Univ Pr.
Iyer, S., L. Boekestyn, et al. (2008). “Signs and symptoms in the pre-psychotic phase: description and implications for diagnostic trajectories.” Psychological Medicine38(08): 1147-1156.
Jenkins, J. H., M. E. Strauss, et al. (2005). “Subjective experience of recovery from Schizophrenia-related disorders and atypical antipsychotics.” International Journal of Social Psychiatry 51(3): 211 – 227.
Kelleher, I. and M. Cannon (2010). “Psychotic-like experiences in the general population: characterizing a high-risk group for psychosis.” Psychological Medicine: 1-6.
Keshavan, M., G. Haas, et al. (2003). “Prolonged untreated illness duration from prodromal onset predicts outcome in first episode psychoses.” Schizophrenia Bulletin 29(4): 757.
Kihlstrom, J. F. (2002). To Honor Kraepelin . . . From Symptom to Pathology in the Diagnosis of Mental Illness. Rethinking the DSM. L. E. Beutler and M. L. Malik. Washington, DC, American Psychological Association.
Larsen, J. A. (2004). “Finding meaning in first episode psychosis: experience, agency, and the cultural repertoire.” Medical Anthropology Quarterly 18(4): 447 – 471.
Larsen, J. A. and J. A. Larsen (2007). “Symbolic healing of early psychosis: psychoeducation and sociocultural processes of recovery.” Culture, Medicine & Psychiatry 31(3): 283-306.
Luhrmann, T. (2008). “”The Street Will Drive You Crazy”: Why homeless psychotic women in the institutional circuit in the United States say no to offers of help.” American Journal of Psychiatry 165(1): 15-20.
Luhrmann, T. (2010). What Counts as Data. Emotions in the Field: the Psychology and Anthropology of Fieldwork Experience. J. Davies and D. Spencer. Palo Alto, CA, Stanford University Press: 212 – 238.
McGorry, P., J. Johanessen, et al. (2010). “Early intervention in psychosis: keeping faith with evidence-based health care.” Psychological Medicine 40(03): 399-404.
McGorry, P., B. Nelson, et al. (2009). “Intervention in individuals at ultra-high risk for psychosis: a review and future directions.” The Journal of clinical psychiatry 70(9): 1206-1212.
Meehl, P. (1962). “Schizotaxia, schizotypy, schizophrenia.” American Psychologist 17: 827-838.
Middleton, H. (2008). “Whither DSM and ICD, Chapter V?” Mental Health Review Journal13(4): 4-15.
Norman, R. and A. Malla (2001). “Duration of untreated psychosis: a critical examination of the concept and its importance.” Psychological Medicine 31(03): 381-400.
Norman, R., D. Scholten, et al. (2005). “Early signs in schizophrenia spectrum disorders.” The Journal of nervous and mental disease 193(1): 17.
Polanczyk, G., T. Moffitt, et al. (2010). “Etiological and clinical features of childhood psychotic symptoms: results from a birth cohort.” Archives of General Psychiatry67(4): 328.
Rose, N. (2007). The politics of life itself: biomedicine, power, and subjectivity in the twenty-first century, Princeton University Press.
Ruhrmann, S., F. Schultze-Lutter, et al. (2010). “Prediction of psychosis in adolescents and young adults at high risk: results from the prospective European prediction of psychosis study.” Archives of General Psychiatry 67(3): 241.
Van Os, J., R. Linscott, et al. (2009). “A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder.” Psychological Medicine 39(02): 179-195.
Yung, A. and P. McGorry (1996). “The prodromal phase of first-episode psychosis: past and current conceptualizations.” Schizophrenia Bulletin 22(2): 353.