Wednesday, 12 November 2014

To boldly go….(where Anglophone psychiatrists rarely have been before)

I went to the EASE conference in Copenhagen for 3 days.
(EASE =Evaluation of Anomalous Self-Experience)
It was the best psychiatry conference I’ve ever been to.

The purpose of an EASE interview is to enquire about a whole range of unusual experiences called disorders of the self (or self-disorders) that were described initially in patients with schizophrenia (or dementia praecox) by German psychiatrists nearly 100 years ago that have been largely lost to Anglophone psychiatry .

The EASE was devised by Prof Parnas and collaborators such as Lennart Jansson, Paul Moller,  Peter Handest, Jorgen Thalbitzer, Dan Zahavi.

It’s based from a philosophical and phenomenological viewpoint. It uses terms like ipseity, hyper-reflectivity that I don’t trust myself to explain properly.

I strongly advise going to the website (which is in the process of being refreshed as of 12/11/14) with better descriptions and links to reading materials.

So what was so great?
·         Whole new world of patient experiences that were closed to me
·         The tradition of (European)  continental psychiatry
·         The implications of self-disorders clinically

Well it was refreshing and eye-opening to me to discover a whole world of unusual experiences that I was dimly aware of at best and unaware of usually. The correlation is of course that I didn’t ask my patients about these experiences. These experiences include feeling detached from the flow of time, from their own thoughts and bodies, from merging with external objects, from feeling an absence of their core being and more. 

The EASE interview (which usually takes place over several sessions and can be quite lengthy) helps you to ask about these experiences and categorise them. Prof Parnas strongly discourages a structured interview approach (he calls it “an atrocity”). He also cautions that “humility is essential” when categorising these existential experiences and for psychiatrists to avoid becoming “biological idiots”.

Germans wrote the great songs of psychiatry from the late 19th to early-mid 20th century. There are the German Psychiatry “Beatles” of Kraepelin, Kurt Schneider, Jaspers and Bleuler.
To modern Anglophone psychiatry, Bleuler was the Ringo Starr of this quartet.  In US-UK-Down Under eyes Kraepelin split the psychosis based on course, Schneider using First Rank Symptoms (used as the basis of “core schizophrenia”), Jaspers defined psychopathological terms and Bleuler just came up with the name “schizophrenia”. The reason for this is that Bleuler’s concept of schizophrenia (which included a lot of unusual experiences assessed in EASE) was overly expanded in the US to include a lot of cases of depression and personality disorders. This problem was highlighted in the US-UK diagnostic study and explained the very high rates of schizophrenia in the US particularly New York. The yanks then decided to standardise on the British version believing it to represent Schneider’s concept of schizophrenia. The Brits however had made an error of their own, they had too narrow a concept of Schneider. Kurt Schneider himself had described unusual experiences similar to Bleuler on a spectrum with First Rank Symptoms at the extreme end of the spectrum. This error was compounded by DSM treating First Rank Symptoms as delusions (e.g. of thought broadcasting) not as experiences.
Denmark for obvious geographic reasons is still influenced by the original German concepts untainted by Anglophone misconceptions. To me, it was fantastic to hear our Danish hosts switch fluently from perfect English to German and Danish in describing psychopathology.  There is still this strong tradition of Continental psychiatry paying close attention to the source materials.
 Bleuler stated that the delusions and hallucinations were secondary symptoms to the primary disturbances in autism, affect, associations and ambivalence. A lot of these disturbances are measured in the EASE scale which leads me into the third point, the clinical implications.
My viewpoint on the classification of psychosis has changed with experience and research. Initially I viewed schizophrenia and bipolar disorder as very separate illnesses. Over the past 10 years I’ve changed my conception of psychosis to a spectrum (like a rainbow) with schizophrenia and bipolar disorder as different colours on this spectrum at nearly opposite ends (like violet and red on a rainbow) – see my first blogpost “Utility without Validity”.
I may be at a tipping point of a change back to viewing them as more separate than before. This is because disorders of self are far commoner in schizophrenia than in bipolar disorder (see the papers on the EASE website, one paper said disorders of self were 9 times commoner in schizophrenia compared to bipolar disorder). There are similar amounts of disorders of self in schizophrenia and schizotypal disorder. This indicates that schizotypal disorder and schizophrenia lie on a spectrum.
A gradient of severity of disorders in self seems to exist
1.       Schizophrenia and schizotypal disorder
2.       Bipolar disorder/ other psychosis
3.       Other mental disorders
4.       No mental disorder
This would seem useful in identifying and separating schizophrenia from other mental disorders, the differentiation from schizotypal disorder being one of degree of positive and negative symptoms present. There was no relationship between self-disorder scale scores and borderline personality disorder symptom scores.
There were other clinical implications. One of them was that in a sample of patients thought to be at high risk of developing psychosis, it was the presence of disorders of self that predicted transition to psychosis best. The transition rates to psychosis in this at risk group is dropping to perhaps 20—25% in 2 years. If this finding is replicated this improves our ability to predict transition and avoid unnecessary treatment.

Disorders of self are not merely straight forward neuropsychological impairments by another name and didn’t correlate with neuropsychology scores.
For me the biggest implication is that if these disorders of self are the fundamental disorder of schizophrenia, the soil from which the other symptoms grow out of?
If so, what effect do antipsychotics have on this? I suspect they may dampen but not remove them. EASE assessments are done when the patients aren’t floridly psychotic yet they still seem to describe these problems as active. So current antipsychotics may do a good job on delusions and hallucinations (a far better job than e.g. CBT for psychosis or CBTp) but not on these disorders of self.
Further research would also be needed on how disorders of self effect prognosis and risk. In the meantime I am going to be using EASE interviews on a range of patients, some with schizophrenia, some with psychosis but unlikely to be schizophrenia and other patients without a psychosis.
There no CBT models of these type of problems and no apparent CBT interventions for them (indeed in the COMPARE CBTp trial high scores on the “disorganisation” item are an exclusion criteria from the trial and many disorders of the self do seem linked to hebephrenic type pictures and hence high scores on the “disorganisation” item).  
You could argue an existential problem like disorders of the self should respond to psychodynamic therapy but early experience of this in schizophrenia was discouraging. It has been modified recently to reduce paranoia induced by the therapy and perhaps this might be an avenue of approach. My hunch is these experiences are so dislocating that it might be a bit too hard for “the couch”.
So disorders of self could revolutionise how we conceive of schizophrenia but could also pose a massive challenge in how to address and help them.

May we live in interesting times…

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