NYT article about peer respite care for psychosis

[Trieb]

Hi SDN! Longtime lurker here. I recently came across this article from the NYT Magazine and I'm curious what this forum thinks. It describes "peer respite" centers where patients evidently receive something akin to short-term, acute "inpatient" care from other individuals with history of mental illness. The facilities are unlocked with no MDs or psychologists involved. They take a philosophy that explicitly rejects the disease model of psychosis and accepts hallucinations as a nonpathological aspect of human experience:

The people who stay at Afiya are in dire need; many are not only in mental disarray but also homeless. Many are suicidal. There are no clinicians on staff, no security personnel, only people who know such desperation firsthand. In the living room, a homemade banner declares: "Holding multiple truths. Knowing that everyone has their own accurate view of the way things are."

For Mazel-Carlton, one of the groups’ most essential tenets is that there must be no disabusing anyone of a personal reality. Unlike on a psych ward or in many a psychiatrist’s office, unusual beliefs are not monitored, corrected, constrained.

I wasn't aware that facilities like this exist. I was also struck by the article's tone, which was strongly critical of biological psychiatry, implying that antipsychotics are mostly ineffective and laden with side effects:

Yet the evidence that the medications improve outcomes is murky. And it is countered by other studies suggesting that maintenance on the drugs may actually worsen outcomes and even cause brain atrophy, though these findings have been debated. The area is devoid of conclusive science, a failure that is a prominent part of a wider problem in biomedical psychiatry: its lack of progress in treating serious conditions, or even precisely diagnosing and comprehending them.

[...]

Present methods can do damage and undermine outcomes not only through psychotropic side effects, and not only through the power imbalances of locked wards and court-ordered outpatient care and even seemingly benign practitioner-patient relationships, but also through a singular focus on reducing symptoms, a professional mind-set that leaves people feeling that they are seen as checklists of diagnostic criteria, not as human beings.

A few questions for discussion—are any of you familiar with peer respite centers and what do you think about them? Would inpatient psychiatry stand to gain from incorporating more of the "[neuro-]diversity" framework for mental illness seemingly advocated here? Personally, I sympathize with efforts to make psychiatric admissions less coercive and traumatic, but I instinctively feel skeptical about the notion of depathologizing psychosis.

As a medical student, I'm also curious how legitimate are some of these claims re: antipsychotic medications. And, more generally, does the cultural pendulum seem to be swinging away from biological psychiatry? This feels like one of many instances of anti-psychopharm sentiment I've seen in the public discourse lately.

Doctors Gave Her Antipsychotics. She Decided to Live With Her Voices.

---

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[Stagg737]

A few questions for discussion—are any of you familiar with peer respite centers and what do you think about them?

Haven't encountered these in our areas, but did peripherally work with a therapist with schizophrenia whose patients I shared actively refused to take meds while inpatient. Seemed very counter-productive to them being able to maintain safety.

Would inpatient psychiatry stand to gain from incorporating more of the "[neuro-]diversity" framework for mental illness seemingly advocated here?

Some places might, but what patients and the public don't understand is that much of inpatient psychiatry is not aimed at resolving psychosis, but stabilizing patients so that they can be safe and perform basic ADLs. I discharge people who are still psychotic all the time. Understanding that inpatient psych (in it's current state) is not meant to "fix" or "cure" anyone is something that many individuals, including patients, don't understand. As a med student try and think about the goals of treatment in various settings, it will help you gain a better understanding of treatment choices as a whole in every field.

And, more generally, does the cultural pendulum seem to be swinging away from biological psychiatry?

I don't think so, the idea that there isn't a biological component to most psychosis is imo absurd. We just don't fully understand the complexity and nuances of these chemical interactions in the brain and their role in symptom presentations and treatments. The research possibilities and potential breakthroughs yet to be achieved in psychiatry are part of why I enjoy it so much.


ETA in regards to the following from the article: "Present methods can do damage and undermine outcomes not only through psychotropic side effects, and not only through the power imbalances of locked wards and court-ordered outpatient care and even seemingly benign practitioner-patient relationships, but also through a singular focus on reducing symptoms, a professional mind-set that leaves people feeling that they are seen as checklists of diagnostic criteria, not as human beings."

Imo, this is the difference between what psychiatrists (should) do and what patients and the public sees. They miss the forest for the trees. Yes, the small goal is symptom reduction, but the bigger picture is maintaining stability and optimizing their functioning, usually by addressing small, distressing symptoms by reducing them. If a person's hallucinations don't bother them and they can be safe and functional, then I don't try and "fix" them. Again, think about what your actual goal of treatment is, it's a great way to make sure you're not just throwing meds or other unnecessary treatments at your patients.

 

[clausewitz2]

A patient response to this piece worth watching:

My Response to Daniel Bergner's New York Times Magazine Piece on Psychotic Disorders

The story in question. So this is pretty emotional. I’m sorry for that. But I’m very tired and I need this perspective to get out there. Bergner’s piece does not contain a single piece of pushback, an interview with an antagonistic psychiatric specialist, or the perspective of a patient with a...

freddiedeboer.substack.com

I think these sorts of units can be helpful for some people who experience the symptoms we typically call psychosis. I think anyone who can work with people with psychotic disorders in a skillful way is not going to be focused on the degree of concordance between anyone's belief system and consensus reality too much. I think they also won't be primarily going through symptom checklists but then I recognize a lot of people aren't that skillful sometimes. It is upsetting sometimes to see the degree to which the system for serving people with SPMI can socialize into a very passive kind of "patienthood". I also don't work inpatient partly because I had deep reservations about what acute inpatient looks like and how it operates in the 21st century.

All that beings aid, I think this piece is part of the way in which the recovery movement sometimes goes very wrong. Some people who experience psychosis are high-functioning to begin with and are going to remain pretty high-functioning afterwards. Sometimes they win Nobel Prizes, after all. These people, who usually also have a fair endowment of social, economic, and professional resources, often become the activist core. They assume that since approaches like these are a good fit for them they are a good fit for everyone who has been given a similar diagnosis. What gets forgotten is the much lower-functioning people who maybe can't navigate life nearly as well as them and who end up falling through the cracks when we start gutting more intensive levels of support/restrictive levels of care.

 

[Candidate2017]

A few questions for discussion—are any of you familiar with peer respite centers and what do you think about them?

We've always had "respite centers". We call them parks, underpasses, encampments. Nice outdoorsy places where people can escape mean doctors and not be hounded by nurses with giant needles containing very expensive antipsychotics shilled by Big Pharma.

 

[calvnandhobbs68]

A patient response to this piece worth watching:

My Response to Daniel Bergner's New York Times Magazine Piece on Psychotic Disorders

The story in question. So this is pretty emotional. I’m sorry for that. But I’m very tired and I need this perspective to get out there. Bergner’s piece does not contain a single piece of pushback, an interview with an antagonistic psychiatric specialist, or the perspective of a patient with a...

freddiedeboer.substack.com

I think these sorts of units can be helpful for some people who experience the symptoms we typically call psychosis. I think anyone who can work with people with psychotic disorders in a skillful way is not going to be focused on the degree of concordance between anyone's belief system and consensus reality too much. I think they also won't be primarily going through symptom checklists but then I recognize a lot of people aren't that skillful sometimes. It is upsetting sometimes to see the degree to which the system for serving people with SPMI can socialize into a very passive kind of "patienthood". I also don't work inpatient partly because I had deep reservations about what acute inpatient looks like and how it operates in the 21st century.

All that beings aid, I think this piece is part of the way in which the recovery movement sometimes goes very wrong. Some people who experience psychosis are high-functioning to begin with and are going to remain pretty high-functioning afterwards. Sometimes they win Nobel Prizes, after all. These people, who usually also have a fair endowment of social, economic, and professional resources, often become the activist core. They assume that since approaches like these are a good fit for them they are a good fit for everyone who has been given a similar diagnosis. What gets forgotten is the much lower-functioning people who maybe can't navigate life nearly as well as them and who end up falling through the cracks when we start gutting more intensive levels of support/restrictive levels of care.

Yes, absolutely. This is extremely similar to the autism "neurodiversity" movement which, on the surface, seems like a good thing but when you get down to it is driven primarily by people with mild versions of what we could consider Level 1 ASD at this time. Without an appreciation for the kinds of lives people with Level 3 ASD lead and what their life would look like if all these support systems/treatments that are in place because we consider this to be a "disorder" fell away if we "de-disordered" autism.

 

[Alemo]

"Present methods can do damage and undermine outcomes not only through psychotropic side effects, and not only through the power imbalances of locked wards and court-ordered outpatient care and even seemingly benign practitioner-patient relationships, but also through a singular focus on reducing symptoms, a professional mind-set that leaves people feeling that they are seen as checklists of diagnostic criteria, not as human beings."

I mean I know it's journalism, but where to begin? Almost everything in here is completely wrong, and although indeed the ideas discussed in each of these sentences are important, they have also been discussed at length in The Literature. Not that this hit piece writer has ever delved into The Literature. Turns out doing your research isn't just watching One Flew Over the ****oo's Nest, man. C'mon bro.

Let's review:

1. I don't know how an outcome can be undermined. An expected outcome? A winning strategy can be undermined. But there's nothing to undermine if there aren't any genuine, more effective efforts to treat mental illness occurring in the first place.
2. Every medical treatment has adverse effects. Despite what the NYT writer wants to think, us evil rapacious power hungry psychiatrists still practice informed consent. It's up to the patients to choose what treatment they want.
3. [But wait, what about when it's not?] Gee, please reference the entire field of forensic psychiatry and the mirror field of legal treatment of mental illness. Only 100+ years of lawyers, physicians, and philosophers considering real world implications of all of this. Buncha' chumps. They don't really care about you, man. C'mon man. Old privileged people, man. I mean, hAvE yOu eVeR eVeN SeEn OnE FlEw OvEr tHe ****Oo'S NesT? We as a society do not have clear answers to the questions of how to deal with the chaotic behavior that mental illness can cause. I'm sure you do, NYT writer. You thought about this for a few hours...so you must...right? Right?
4. Yes there are power imbalances of locked-wards and court-ordered outpatient care. There's nothing inherently wrong with power imbalances. You know...like codified law....and democratic processes....and limits to doing whatever the **** you want when ever you want....you know....those situations you encounter every single day of your life anywhere at anytime. No one is jerking off about holding someone in the hospital for longer than they need to be. But I know, writing that most psychiatrists are people who like to listen to others and have a lot of patience and aren't sadists just....isn't interesting.
5. "Seemingly benign practitioner-patient relationships?" Is there some inherent quality about any physician-patient relationship that isn't benign? Again, I know this doesn't quite have a "stick it to the man" ring to it, but I'm not tapping into my dark side when I meet with a patient. Or let's put it this way: Not all power that can be abused is abused!
6. The "singular focus" on reducing symptoms is entirely patient driven. Sometimes those symptoms include anosognosia. Sometimes patients disagree that suicide should be wrong, or that they should be prevented from taking their own life. Guess what? A lot of psychiatrists do too. We are agents of the state exercising *parens patriae* duties. Shockingly (sarcasm may or may not be intended), the US government has a vested interest in protecting citizens. If you shoot yourself in the head, the people left behind aren't going to say "nice" because you exercised bodily autonomy. I tell all my patients that if they really want to kill themselves, they can do it. You can google. You'll be alone at some point. We are not Big Brother. We're not in it for the gotchas. At the end of the day, we are offering services that may or may not be helpful. If psychiatrists knew something extra about existential crises and the nature of the human condition, don't you think they would be sharing that little secret?
7. If anyone is treating people in psychiatry as a checklist of diagnostic criteria, they have completely utterly 100% missed every possible point of the entire exercise. Even surgeons are not grabbing people off the streets to replace their knees. But holy ****, you spend one day seeing patients in psychiatry and you'll see that diagnostic checklists are not something to build your house on. I really can't overstate how ignorant that comment was.

But hey, none of this sells newspaper. You'd have to think...read some articles....think....do some research....challenge simple conclusions....recognize nuance....think some more....ugh. Not worth it. WHY U NO SELL MORE NEWSPAPER?????

JESUS CHRIST

 

[Alemo]

We've always had "respite centers". We call them parks, underpasses, encampments. Nice outdoorsy places where people can escape mean doctors and not be hounded by nurses with giant needles containing very expensive antipsychotics shilled by Big Pharma.

I wrote a giant angry bombastic screed but this is just..... *kiss*

 

[smalltownpsych]

I don’t even know where to begin with this. People that don’t work with mental illness think they know what we should do. The bad stuff that happens to our patients is not from the people trying to help them. The only one arguing with a psychotic patient about their psychosis is someone who doesn’t know jack about working with people with psychosis. Medications are not the only solution and we know that and it isn’t us that is promoting that, it’s the political forces that pay the people that provide the necessary psychosocial rehabilitative work with this population almost nothing and ensure that the psychiatrists are relegated to a medication only role. Revolving door of brief acute inpatient care that barely stabilizes patient. Overcrowded underfunded state hospital systems. Co-occuring substance use with severe mental illness not being addressed at all other than be mixed in with the other patients and creating a toxic environment for all. Maybe we should have the reporter meet with the floridly unmedicated psychotic substance using patient and try to do a better job helping or improving the situation than us. Maybe he could meet with the patients family afterwards to deliver his brilliant plan. I guarantee that he will be quickly clamoring for medications and involuntary commitment.

 

[smalltownpsych]

Just wanted to add that a peer recovery and support model can be useful if it is well done with close professional oversight. Maybe in a dream fantasy world of some sort we could get a psychiatrist to be involved in that. There was a time when MDs would actually get to do more to treat mental illness than just the biological. It might be nice to get the people on the team who were smart enough to get into med school and resilient enough to make it through all the years of training to actually be more involved in the whole approach.

 

[splik]

. I was also struck by the article's tone, which was strongly critical of biological psychiatry, implying that antipsychotics are mostly ineffective and laden with side effects:

Biological psychiatry was in the ascendance in the 1980s and 1990s. There was a time when psychiatry was much more polarized with different camps - the biological psychiatrists, diagnostic psychiatrists, psychodynamic psychiatrists, social and community psychiatrists warring with each other claiming to hold the one true narrative to explain mental life. Today, I really think the term "biological psychiatry" is either a pejorative or a straw man. I certainly would never refer pts to anyone who called themselves a biological psychiatrist. That is just too reductionistic. I think the prevailing approach today is pluralistic, recognizing there is no one grand narrative that holds moral authority in psychiatry, and that for most patients, we should consider biological, psychological and sociocultural factors - though one of these may hold more relevance for formulating a particular individual's problems. Sadly, there are a lot of psychiatrists who do have a more narrow view of just treating psychosis with medications, but in general that is not considered the gold standard approach now and multimodal approaches supporting recovery including psychosocial interventions are considered the ideal.

I am optimistic that over the past 20 years we are coming back to exploring different approaches to extreme experiences including voice hearing etc. There was a period of time when psychotherapy was considered contraindicated in patients with psychosis. This was based on a misinterpretation of the Chestnut Lodge Studies which found psychoanalytic approaches could worsen psychosis. Recently, CBT has been studied for psychosis and if you read the manuals and talk to the originators, whether the acknowledge it or not, they owe alot to psychodynamic ways of thinking about psychosis. Interesting one of the first uses for Cognitive Therapy was in psychosis, Beck published the first paper about this in the 1950s.

The residential approaches described in the article based on the Soteria approach actually go back to the 1960s. Kingsley Hall, developed by RD Laing and co-conspirators in London was really the inspiration for these modern day programs. The most famous patient at Kingsley Hall was Mary Barnes, who along with Joseph Berke (her therapist) wrote an account of her madness and treatment. I will also note LSD was used at Kingsley Hall and now we are seeing an interest in using psychedelics once again.

In short, the history of psychiatry, like history itself, is somewhat circular. Ideas come to prominence, fade, and then rise again. That is what we are seeing here. Foucault, who wrotes some of the best histories of madness (though he never let the facts get in the way of a good story), would say that there is no best way of seeing things, only different ways, and each era has a different narrative or explanatory model for the problems of our time that they proclaim as superior but really is no superior to the last. I would tend to agree with him.

 

[smalltownpsych]

Biological psychiatry was in the ascendance in the 1980s and 1990s. There was a time when psychiatry was much more polarized with different camps - the biological psychiatrists, diagnostic psychiatrists, psychodynamic psychiatrists, social and community psychiatrists warring with each other claiming to hold the one true narrative to explain mental life. Today, I really think the term "biological psychiatry" is either a pejorative or a straw man. I certainly would never refer pts to anyone who called themselves a biological psychiatrist. That is just too reductionistic. I think the prevailing approach today is pluralistic, recognizing there is no one grand narrative that holds moral authority in psychiatry, and that for most patients, we should consider biological, psychological and sociocultural factors - though one of these may hold more relevance for formulating a particular individual's problems. Sadly, there are a lot of psychiatrists who do have a more narrow view of just treating psychosis with medications, but in general that is not considered the gold standard approach now and multimodal approaches supporting recovery including psychosocial interventions are considered the ideal.

I am optimistic that over the past 20 years we are coming back to exploring different approaches to extreme experiences including voice hearing etc. There was a period of time when psychotherapy was considered contraindicated in patients with psychosis. This was based on a misinterpretation of the Chestnut Lodge Studies which found psychoanalytic approaches could worsen psychosis. Recently, CBT has been studied for psychosis and if you read the manuals and talk to the originators, whether the acknowledge it or not, they owe alot to psychodynamic ways of thinking about psychosis. Interesting one of the first uses for Cognitive Therapy was in psychosis, Beck published the first paper about this in the 1950s.

The residential approaches described in the article based on the Soteria approach actually go back to the 1960s. Kingsley Hall, developed by RD Laing and co-conspirators in London was really the inspiration for these modern day programs. The most famous patient at Kingsley Hall was Mary Barnes, who along with Joseph Berke (her therapist) wrote an account of her madness and treatment. I will also note LSD was used at Kingsley Hall and now we are seeing an interest in using psychedelics once again.

In short, the history of psychiatry, like history itself, is somewhat circular. Ideas come to prominence, fade, and then rise again. That is what we are seeing here. Foucault, who wrotes some of the best histories of madness (though he never let the facts get in the way of a good story), would say that there is no best way of seeing things, only different ways, and each era has a different narrative or explanatory model for the problems of our time that they proclaim as superior but really is no superior to the last. I would tend to agree with him.

…and my wife says I’m a Pollyanna! lol. Actually I have seen evidence of this myself and it is good to see some of these shifts back to the useful information from the past. I partnered with an amazing psychiatrist the last few years and he had developed an integrative model of care very similar to Soteria independently because of his insights into what patients needed to thrive. The insights I learned from this experience have greatly influenced my own conceptualization of treatment of severe mental illness. A couple of quick takes were recognizing the importance of a continuum of care where exposure to real world stressors could be titrated as gradually as possible. Intensive (3 sessions per week) therapeutic support and monitoring as this titration occurred. Close family involvement in treatment. Attention to interplay between stress, symptoms, and medication. Diet and exercise and exposure to natural environment. Smaller more pedestrian and bike friendly community. Not returning to the same environment after discharge. Just a few things we paid close attention to.

 

[FlowRate]

A few questions for discussion—are any of you familiar with peer respite centers and what do you think about them? Would inpatient psychiatry stand to gain from incorporating more of the "[neuro-]diversity" framework for mental illness seemingly advocated here? Personally, I sympathize with efforts to make psychiatric admissions less coercive and traumatic, but I instinctively feel skeptical about the notion of depathologizing psychosis.

I'm trying to remember what it's called but one of the CMHC's in the Boston area operates in a more "patient driven" model with psychotic patients. I didn't interact with that CMHC much and it's been a couple of years so the name for that particular model of psychosis care is not coming to me. Maybe this will jog someone else's memory?

As others said, good psychiatric care involves collaborative treatment of our patients and informed consent. It's common to "tolerate" some degree of psychotic symptoms that are not otherwise causing distress or impairment. (Or that persist despite best efforts at multiple antipsychotic trials.) Often that means maintaining a patient's function rather than snowing them on heavily sedating meds/doses. CBT for psychosis works on teaching patients reality testing skills and other basic regulation/interpersonal functions so that the psychotic symptoms aren't so derailing.

 

[Candidate2017]

I'm finishing my draft of the DSM-P (public), for use among the lay public , including midlevels, journalists, and the personality disordered. $199.

Sad = MDD
Anxious = GAD
Mood swings = bipolar
Lack of focus = ADHD
Poor sleep = insomnia disorder
Hearing voices = schizophrenia

Due to simplifying every psychiatric disorder to one diagnostic criteria, it has achieved an interrater reliability of 110%. Unlike DSM-V or whatever Roman numeral psychiatrists are up to these days.

 

[clausewitz2]

Recently, CBT has been studied for psychosis and if you read the manuals and talk to the originators, whether the acknowledge it or not, they owe alot to psychodynamic ways of thinking about psychosis. Interesting one of the first uses for Cognitive Therapy was in psychosis, Beck published the first paper about this in the 1950s.

To chime in, I've had a number of conversations with Aaron Brinen (one of the big proponents of Beck's last re-branding of CBT for psychosis) and he has said that his general view is psychosis is essentially a defense against anxiety and thus should be approached therapeutically in very much the same was as you'd approach any anxiety disorder.

 

[Evidence Based]

I'm trying to remember what it's called but one of the CMHC's in the Boston area operates in a more "patient driven" model with psychotic patients. I didn't interact with that CMHC much and it's been a couple of years so the name for that particular model of psychosis care is not coming to me. Maybe this will jog someone else's memory?

As others said, good psychiatric care involves collaborative treatment of our patients and informed consent. It's common to "tolerate" some degree of psychotic symptoms that are not otherwise causing distress or impairment. (Or that persist despite best efforts at multiple antipsychotic trials.) Often that means maintaining a patient's function rather than snowing them on heavily sedating meds/doses. CBT for psychosis works on teaching patients reality testing skills and other basic regulation/interpersonal functions so that the psychotic symptoms aren't so derailing.

Are you thinking of Advocates in Framingham? They use the open dialogue model for their first episode psychosis program.

I'm also going to go against the dominant strain of this thread and say that I find the Hearing Voices Network model to be quite helpful with some (certainly not all) patients with psychotic disorders, and I actually think there's a decent amount of overlap between this and approaches like CBT for psychosis or open dialogue that have research support. I work in community mental health psychosis program and have plenty of "low functioning" patients with psychosis who this wouldn't be appropriate for, but I think elements of this approach (ex. psychotic experiences can have some meaning, symptom eradication is not always the goal) can be very empowering. Obviously an article like this is not going to have a lot of nuance and we can find plenty to feel threatened by, but certainly an important perspective.

 

[Alemo]

I work in community mental health psychosis program and have plenty of "low functioning" patients with psychosis who this wouldn't be appropriate for, but I think elements of this approach (ex. psychotic experiences can have some meaning, symptom eradication is not always the goal) can be very empowering. Obviously an article like this is not going to have a lot of nuance and we can find plenty to feel threatened by, but certainly an important perspective.

I hear what you're saying. I just have a hard time believing there are (many) psychiatrists who are doggedly chasing symptoms in otherwise high-functioning patients.

 

[FlowRate]

Are you thinking of Advocates in Framingham? They use the open dialogue model for their first episode psychosis program.

That exactly it, thanks!

 

[tr]

To chime in, I've had a number of conversations with Aaron Brinen (one of the big proponents of Beck's last re-branding of CBT for psychosis) and he has said that his general view is psychosis is essentially a defense against anxiety

Hm, sounds like crap. Psychosis is a disruption in incentive salience processing and sensory integration thresholding. It hasn't got anything to do with anxiety.

and thus should be approached therapeutically in very much the same was as you'd approach any anxiety disorder.

Exposure, yeah? Make them listen to even more voices? Good plan

Don't get me wrong I think CBT for psychosis is fantastic but my understanding is it focuses more on logic-based techniques, coping strategies, and behavioral activation vs exposure like you would use for anxiety/panic.

 

[clausewitz2]

Hm, sounds like crap. Psychosis is a disruption in incentive salience processing and sensory integration thresholding. It hasn't got anything to do with anxiety.

Not sure this mechanism is as well-established as all that. There is also a large body of work arguing it is a dysfunction of prediction error and surprisal a la Friston. Regardless, those mechanisms might explain some of the specific experience of psychosis (obviously most people who are anxious don't hallucinate) but when you look carefully at when and where people with psychosis tend to get substantial exacerbations of their symptoms, it looks a lot more like the situations that tend to make people anxious.

Exposure, yeah? Make them listen to even more voices? Good plan

You jest, but ACT for psychosis is absolutely a thing and puts a lot of emphasis on learning to notice voices and accept their presence without suppressing, challenging, or otherwise engaging with them. In exactly the same way you teach someone with OCD that trying to reason their way out of their intrusive thoughts is a good way to strengthen their intrusive thoughts, the goal is to make the voice-hearer regard their voices as more or less irrelevant to their life, and certainly not worth sacrificing anything important. You even help people practice noticing the voices more clearly so that their observer-self is explicitly aware that "oh, the hates-me voices is telling me I'm pedophile scum. Huh, well, cool story, brain." You also then notice all the thoughts and feelings that seem to pop up in response to that and just sort of let them unfold.

Don't get me wrong I think CBT for psychosis is fantastic but my understanding is it focuses more on logic-based techniques, coping strategies, and behavioral activation vs exposure like you would use for anxiety/panic.

Classic CBTp doesn't really get into anything very logic-based until well into the protocol. A lot of it initially is about paying attention to the positive symptoms and starting to identify patterns that suggest the person in question has some ability to influence their experience. CT-R does a very similar thing with more emphasis on also smuggling in the third-wave idea of explicitly identifying goals and values and drawing attention to the contrast between the ends that are important to the person and the ends that are served by allowing the voices and emotions they provoke make decisions for them.

This is really pretty similar in important ways to how you'd approach panic disorder. You choose to let yourself have those sensations and that dread and start to learn that it passes even if you do nothing at all, and that all avoidance buys you is a progressively smaller world. You don't do this because you like it or would actively choose to experience them but because you are tired of them making decisions for you.

 

[futureapppsy2]

Yes, absolutely. This is extremely similar to the autism "neurodiversity" movement which, on the surface, seems like a good thing but when you get down to it is driven primarily by people with mild versions of what we could consider Level 1 ASD at this time. Without an appreciation for the kinds of lives people with Level 3 ASD lead and what their life would look like if all these support systems/treatments that are in place because we consider this to be a "disorder" fell away if we "de-disordered" autism.

As someone who does a lot of rehabilitation work and has a lot of colleagues strongly wielded to the neurodiversity movement, it’s a very mixed bag, imo. On one hand, research is increasingly suggesting that autistic self-advocates were, on the whole, correct about masking leading to iatrogenic harm over time, and the philosophy that we shouldn’t make everything disabled people do about making them less disabled is much appreciated. Otoh, a lot of the differentiation between “neurodiversity” and “mental illness” just seems like internalized stigma. For example, I have a colleague who is really into neurodiversity and thus thinks his son’s autism shouldn’t be treated. But my colleague has ADHD himself and thinks that should be treated, but that ADHD is neurodiversity and not mental illness, because it makes him special and good, not like that awful mental illness, except for the functional limitations it causes that he wants treated. It just seems like a lot of words to say “I think I’m better than other people with mental illnesses, so I made up a new term.” 🤷‍♀️

 

[calvnandhobbs68]

As someone who does a lot of rehabilitation work and has a lot of colleagues strongly wielded to the neurodiversity movement, it’s a very mixed bag, imo. On one hand, research is increasingly suggesting that autistic self-advocates were, on the whole, correct about masking leading to iatrogenic harm over time, and the philosophy that we shouldn’t make everything disabled people do about making them less disabled is much appreciated. Otoh, a lot of the differentiation between “neurodiversity” and “mental illness” just seems like internalized stigma. For example, I have a colleague who is really into neurodiversity and thus thinks his son’s autism shouldn’t be treated. But my colleague has ADHD himself and thinks that should be treated, but that ADHD is neurodiversity and not mental illness, because it makes him special and good, not like that awful mental illness, except for the functional limitations it causes that he wants treated. It just seems like a lot of words to say “I think I’m better than other people with mental illnesses, so I made up a new term.” 🤷‍♀️

Right, there aren’t bad ideas there and they aren’t even really unique ideas. I mean that’s what the ADA was about, let’s adapt the environment to what people with disabilities need rather than trying to make them “less disabled”. But I agree about the point that it’s also stigmatizing against people with more severe forms of the illness and who are more disabled, like the ASD example. It’s like someone saying “My seizures are well controlled and I do just fine day to day, so you all should embrace seizure disorders as part of neurodiversity I’m not like those terrible uncontrolled epileptics” or don’t even think about the lives that people with uncontrolled epilepsy lead.

 

[mistafab]

The NYT posts anti-psychiatry articles every so often - typically vague in what they endorse but critical of the field regardless.

They want the reader to feel like heroes without actually doing anything to help these folks. +1 bonus point if they actually employ some simulacrum of psychiatric practice but think they are doing something different (this article gets that bonus point).

 

[Crayola227]

Not sure this mechanism is as well-established as all that. There is also a large body of work arguing it is a dysfunction of prediction error and surprisal a la Friston. Regardless, those mechanisms might explain some of the specific experience of psychosis (obviously most people who are anxious don't hallucinate) but when you look carefully at when and where people with psychosis tend to get substantial exacerbations of their symptoms, it looks a lot more like the situations that tend to make people anxious.




You jest, but ACT for psychosis is absolutely a thing and puts a lot of emphasis on learning to notice voices and accept their presence without suppressing, challenging, or otherwise engaging with them. In exactly the same way you teach someone with OCD that trying to reason their way out of their intrusive thoughts is a good way to strengthen their intrusive thoughts, the goal is to make the voice-hearer regard their voices as more or less irrelevant to their life, and certainly not worth sacrificing anything important. You even help people practice noticing the voices more clearly so that their observer-self is explicitly aware that "oh, the hates-me voices is telling me I'm pedophile scum. Huh, well, cool story, brain." You also then notice all the thoughts and feelings that seem to pop up in response to that and just sort of let them unfold.




Classic CBTp doesn't really get into anything very logic-based until well into the protocol. A lot of it initially is about paying attention to the positive symptoms and starting to identify patterns that suggest the person in question has some ability to influence their experience. CT-R does a very similar thing with more emphasis on also smuggling in the third-wave idea of explicitly identifying goals and values and drawing attention to the contrast between the ends that are important to the person and the ends that are served by allowing the voices and emotions they provoke make decisions for them.

This is really pretty similar in important ways to how you'd approach panic disorder. You choose to let yourself have those sensations and that dread and start to learn that it passes even if you do nothing at all, and that all avoidance buys you is a progressively smaller world. You don't do this because you like it or would actively choose to experience them but because you are tired of them making decisions for you.

I honestly don't have a ton of familiarity beyond the passing with CBT, but I am pretty familiar with the theories in ACA, the 12 Step program for adult children of alcoholics and dysfunctional families, and it just clicked in my brain that what you are describing about not "running" from feelings and just feeling them, and then not letting them make decisions for you, is EXACTLY how the process is recommended to begin by various 12 Step grouod. Literally it's how the workbook for ACA begins. I've been going on and on to people about how much it helped me personally, but I had no idea that their approach is essentially identical to some aspects of CBT.

 

[Crayola227]

Nvm that a lot of what gets people inpatient is that their behavior often at least indirectly puts other people in danger. I'm not trying to further the idea that psychotic people are violent, I'm saying that "your reality is just as accurate as anyone else's" is problematic for others if in your reality your psychosis leads to you wandering around in traffic (my favorite example because of how many times I saw it as the presentation in my 5 week psych rotation). Certainly most of the people wandering around in traffic didn't mean anyone harm, but no less did they present a very clear and immediate danger to themselves and others. You could argue I guess that these people should be allowed to die in an accident due to their "neurodiversity" but I kind of think the limit of that is where other people have to chance serious injury or death to respect it.

Trying to remember that one case, a guy who was doing well in the community off meds who ended up stabbing his wife to death because he thought she was an imposter. There are very real consequences to some of this.

Anyone who thinks living inside your own reality and **** shared reality is just like, totally not completely problematic, is ironically enough living in their own reality.

 

[futureapppsy2]

I honestly don't have a ton of familiarity beyond the passing with CBT, but I am pretty familiar with the theories in ACA, the 12 Step program for adult children of alcoholics and dysfunctional families, and it just clicked in my brain that what you are describing about not "running" from feelings and just feeling them, and then not letting them make decisions for you, is EXACTLY how the process is recommended to begin by various 12 Step grouod. Literally it's how the workbook for ACA begins. I've been going on and on to people about how much it helped me personally, but I had no idea that their approach is essentially identical to some aspects of CBT.

This is actually more in line with third-wave therapies, like Acceptance and Commitment Therapy and DBT, than traditional CBT, actually.

 

[clausewitz2]

This is actually more in line with third-wave therapies, like Acceptance and Commitment Therapy and DBT, than traditional CBT, actually.

I should have been more clear and apologize if I didn't draw that distinction well enough. That said, where do you judge EX/RP as falling in the trad CBT/third-wave spectrum? It definitely tells people to identify precisely the situations that are upsetting to them and then deliberately seek them out (in a systematic and methodical way).

 

[tr]

Not sure this mechanism is as well-established as all that. There is also a large body of work arguing it is a dysfunction of prediction error and surprisal a la Friston.

Are these not the same thing/focusing on different aspects of the same circuit dynamics? Mismatch 'surprise' signal resulting in impaired calculation of incentive salience?

Regardless, those mechanisms might explain some of the specific experience of psychosis (obviously most people who are anxious don't hallucinate) but when you look carefully at when and where people with psychosis tend to get substantial exacerbations of their symptoms, it looks a lot more like the situations that tend to make people anxious.

Stressful circumstances exacerbate psychiatric symptomatology rather nonspecifically. Even many non-psychiatric illness states (neurological, autoimmune, etc) are exacerbated by life stressors.

You jest, but ACT for psychosis is absolutely a thing and puts a lot of emphasis on learning to notice voices and accept their presence without suppressing, challenging, or otherwise engaging with them. In exactly the same way you teach someone with OCD that trying to reason their way out of their intrusive thoughts is a good way to strengthen their intrusive thoughts, the goal is to make the voice-hearer regard their voices as more or less irrelevant to their life, and certainly not worth sacrificing anything important. You even help people practice noticing the voices more clearly so that their observer-self is explicitly aware that "oh, the hates-me voices is telling me I'm pedophile scum. Huh, well, cool story, brain." You also then notice all the thoughts and feelings that seem to pop up in response to that and just sort of let them unfold.

Classic CBTp doesn't really get into anything very logic-based until well into the protocol. A lot of it initially is about paying attention to the positive symptoms and starting to identify patterns that suggest the person in question has some ability to influence their experience. CT-R does a very similar thing with more emphasis on also smuggling in the third-wave idea of explicitly identifying goals and values and drawing attention to the contrast between the ends that are important to the person and the ends that are served by allowing the voices and emotions they provoke make decisions for them.

This is really pretty similar in important ways to how you'd approach panic disorder. You choose to let yourself have those sensations and that dread and start to learn that it passes even if you do nothing at all, and that all avoidance buys you is a progressively smaller world. You don't do this because you like it or would actively choose to experience them but because you are tired of them making decisions for you.

Agreed but the above are all also supremely nonspecific and are approaches that can be helpful transdiagnostically, so don't argue strongly for some unique connection between psychosis and anxiety.

Taking an exposure-based approach to psychosis would probably involve something like creating recordings of the voices and playing them back at progressively louder or more intense volumes. That seems like a really really bad idea for a psychotic patient. Works great for phobias and generalized and social anxiety though.

 

[clausewitz2]

Are these not the same thing/focusing on different aspects of the same circuit dynamics? Mismatch 'surprise' signal resulting in impaired calculation of incentive salience?

My understanding was that the idea is more schizophrenia involves inappropriately strong gain for sensory prediction errors relative to higher-level representations. That is too say, the predictive coding scheme in psychosis overestimates the precision of sensory mismatch signals and so a system trying to minimize surprisal is going to be much faster to adjust higher level representations like belief than to potentially discount sensory inputs. Not sure how incentive saliency really fits into the predictive coding framework.

Stressful circumstances exacerbate psychiatric symptomatology rather nonspecifically. Even many non-psychiatric illness states (neurological, autoimmune, etc) are exacerbated by life stressors.

Agreed but the above are all also supremely nonspecific and are approaches that can be helpful transdiagnostically, so don't argue strongly for some unique connection between psychosis and anxiety.

Well, yes, that's sort of the point. Hearing voices qua hearing voices is not the issue for most people, it's how they respond to it and think about it that leads to difficulties. I don't think Aaron literally meant GAD and schizophrenia are the same thing, more that you get an awful lot of clinical mileage out of using similar approaches.

Taking an exposure-based approach to psychosis would probably involve something like creating recordings of the voices and playing them back at progressively louder or more intense volumes. That seems like a really really bad idea for a psychotic patient. Works great for phobias and generalized and social anxiety though.

I agree that that approach would be a bad idea. But that assumes the core fear is really just the idea of hearing voices. I think most of the time that's not really the case and that often the core fear is more like the fear of being impaired or controlled by them That is going to be tapped more by having people do increasingly complicated or difficult things while actively hearing them. Another approach would involve doing things deliberately that the voices either tell them not to do or that they know make them angry/especially abusive. You wouldn't treat someone with chronic pain therapeutically by kicking them in the shins, but you might try and get them moving (safely) in ways they feel/fear are impossible for them.

 

[tr]

My understanding was that the idea is more schizophrenia involves inappropriately strong gain for sensory prediction errors relative to higher-level representations. That is too say, the predictive coding scheme in psychosis overestimates the precision of sensory mismatch signals and so a system trying to minimize surprisal is going to be much faster to adjust higher level representations like belief than to potentially discount sensory inputs. Not sure how incentive saliency really fits into the predictive coding framework.

I think the prediction-error problem appears in both lower-level sensory information processing (e.g., Deficits in Predictive Coding Underlie Hallucinations in Schizophrenia) and higher-level reward/threat processing.

Incentive salience is coded by a mismatch prediction algorithm in the VTA. (Schultz et al., Science 275:1593)

"M1 and M2 represent two different cortical modalities whose output is assumed to arrive at the VTA in the form of a temporal derivative (surprise signal) ˙V(t), which reflects the degree to which the current sensory state differs from the previous sensory state. The high degree of convergence forces ˙V(t) to arrive at the VTA as a scalar signal. Information about reward r(t) also converges on the VTA. The VTA output is taken as a simple linear sum d(t) 5 r(t) 1 ˙V(t). The widespread output connections of the VTA make the prediction error d(t) simultaneously available to structures constructing the predictions."

•Normally active dopamine neurons make accurate predictions of rewards and threats based on available information.
•Predictive accuracy is continually monitored by a firing pattern that encodes a “mismatch” between expected and actual outcomes
•Overactive dopamine neurons predict rewards and threats everywhere, out of proportion to the available information.
•If overactive dopamine neurons impair incentive salience, blocking dopamine should help this.
•Restoring the ‘salience filter’ can’t fix established cognitions, but can reduce their importance to the patient.
•An unfortunate side effect is the eradication of normal incentive salience, resulting in the ‘indifference’ state characteristic of antipsychotic medication.
•Dopamine blockade can restore the ‘salience filter’ but can’t affect cognitional content
–CBT can help with altering cognitional content: Turner et al., Am J Psych 2014 171(5): 523 - 538
•The enhancement of the ‘salience filter’ can contribute to an undesired feeling of indifference to stimuli, and hence to discontinuation of medication

Well, yes, that's sort of the point. Hearing voices qua hearing voices is not the issue for most people, it's how they respond to it and think about it that leads to difficulties. I don't think Aaron literally meant GAD and schizophrenia are the same thing, more that you get an awful lot of clinical mileage out of using similar approaches.

I agree that that approach would be a bad idea. But that assumes the core fear is really just the idea of hearing voices. I think most of the time that's not really the case and that often the core fear is more like the fear of being impaired or controlled by them That is going to be tapped more by having people do increasingly complicated or difficult things while actively hearing them. Another approach would involve doing things deliberately that the voices either tell them not to do or that they know make them angry/especially abusive. You wouldn't treat someone with chronic pain therapeutically by kicking them in the shins, but you might try and get them moving (safely) in ways they feel/fear are impossible for them.

I mean, sure, but insofar as these approaches can be helpful across pretty much all psychiatric diagnoses as well as some nonpsychiatric ones like chronic pain, what does it really mean to cite them as evidence of a specific connection between GAD and schizophrenia? Seems arbitrary.

The positive symptoms of schizophrenia at least seem to be related to overattribution of meaning across levels of processing: overattribution of meaningful sensory information to internally generated or ambient noise (thus AH/VH), and overattribution of significance to neutral complex cognitions and perceptions (thus PI/DoR). Intentionally re-exposing the patient to experiences that are already the product of overinterpretation/overattribution risks having them attribute even more meaning to them.

For anxiety patients their fundamental mismatch prediction and correction machinery is still there, so they are capable of using experience to readjust that threat prediction more in line with the positive or neutral outcomes they would experience in the process of exposure therapy. If the threat prediction/feedback correction machinery itself is broken as in psychosis, that's not going to be possible.

 

[clausewitz2]

I think the prediction-error problem appears in both lower-level sensory information processing (e.g., Deficits in Predictive Coding Underlie Hallucinations in Schizophrenia) and higher-level reward/threat processing.

Incentive salience is coded by a mismatch prediction algorithm in the VTA. (Schultz et al., Science 275:1593)

View attachment 355017
"M1 and M2 represent two different cortical modalities whose output is assumed to arrive at the VTA in the form of a temporal derivative (surprise signal) ˙V(t), which reflects the degree to which the current sensory state differs from the previous sensory state. The high degree of convergence forces ˙V(t) to arrive at the VTA as a scalar signal. Information about reward r(t) also converges on the VTA. The VTA output is taken as a simple linear sum d(t) 5 r(t) 1 ˙V(t). The widespread output connections of the VTA make the prediction error d(t) simultaneously available to structures constructing the predictions."

View attachment 355019

•Normally active dopamine neurons make accurate predictions of rewards and threats based on available information.
•Predictive accuracy is continually monitored by a firing pattern that encodes a “mismatch” between expected and actual outcomes
•Overactive dopamine neurons predict rewards and threats everywhere, out of proportion to the available information.
•If overactive dopamine neurons impair incentive salience, blocking dopamine should help this.
•Restoring the ‘salience filter’ can’t fix established cognitions, but can reduce their importance to the patient.
•An unfortunate side effect is the eradication of normal incentive salience, resulting in the ‘indifference’ state characteristic of antipsychotic medication.
•Dopamine blockade can restore the ‘salience filter’ but can’t affect cognitional content
–CBT can help with altering cognitional content: Turner et al., Am J Psych 2014 171(5): 523 - 538
•The enhancement of the ‘salience filter’ can contribute to an undesired feeling of indifference to stimuli, and hence to discontinuation of medication



I mean, sure, but insofar as these approaches can be helpful across pretty much all psychiatric diagnoses as well as some nonpsychiatric ones like chronic pain, what does it really mean to cite them as evidence of a specific connection between GAD and schizophrenia? Seems arbitrary.

The positive symptoms of schizophrenia at least seem to be related to overattribution of meaning across levels of processing: overattribution of meaningful sensory information to internally generated or ambient noise (thus AH/VH), and overattribution of significance to neutral complex cognitions and perceptions (thus PI/DoR). Intentionally re-exposing the patient to experiences that are already the product of overinterpretation/overattribution risks having them attribute even more meaning to them.

For anxiety patients their fundamental mismatch prediction and correction machinery is still there, so they are capable of using experience to readjust that threat prediction more in line with the positive or neutral outcomes they would experience in the process of exposure therapy. If the threat prediction/feedback correction machinery itself is broken as in psychosis, that's not going to be possible.

Sorry, again, I obviously was being unclear. I don't think anyone meant GAD had some specific connection to schizophrenia above and beyond any other psychiatric disorder. More to point at the transdiagnostic piece that you are correct is not useful in explaining the etiology of the schizophrenias but is absolutely vital in understanding what to do to clinically help people dealing with psychosis outside of pharmaceutical interventions.

What does the model you describe above say about the non-trivial proportion of people with psychotic disorders who don't have obviously aberrant dopaminergic activity as measured by PET? Regardless, I think we are talking about two substantially different models of psychosis, as I don't think the mapping from the one you are describing to the one I am referring to is trivial, cf. The dysconnection hypothesis (2016)

However, I have no problem agreeing worrying about whether you are going to pay the bills or get that promotion at work to an excessive degree is importantly different from worrying about the Soviet agents trying to disintegrate you.

EDIT:
Friston apparently sees salience as a kind of rough shorthand that predictive processing models provide a more comprehensive and accurate formalism for: Psychiatry Online

 

[tr]

What does the model you describe above say about the non-trivial proportion of people with psychotic disorders who don't have obviously aberrant dopaminergic activity as measured by PET? Regardless, I think we are talking about two substantially different models of psychosis, as I don't think the mapping from the one you are describing to the one I am referring to is trivial, cf. The dysconnection hypothesis (2016)

EDIT:
Friston apparently sees salience as a kind of rough shorthand that predictive processing models provide a more comprehensive and accurate formalism for: Psychiatry Online

Sure, though I think I would frame it that the review you cite considers the alterations in incentive salience in psychosis as a particular instance of a broader impairment in feedback integration/prediction that can occur in other circuits as well (which I did mention), and focuses on mechanism on the synaptic and signaling level rather than at the circuit level. From pages 18-19:

"To recap, a neurobiological plausible implementation of perceptual inference is predictive coding – a process theory that assigns specific roles to neuronal populations, canonical microcircuits and hierarchical connections (Bastos et al., 2012, Clark, 2013b). The most promising candidate for explaining false inference in schizophrenia is the neuronal encoding of uncertainty (Averbeck et al., 2011). Psychologically, this corresponds to the salience or precision afforded to sensory evidence (Joyce et al., 2013); while physiologically it is thought to be encoded by the gain or excitability of principal (e.g., superficial pyramidal) cells. This resonates with concepts like aberrant salience (Kapur, 2003), while explicitly implicating modulatory neurotransmission in pathophysiology."

It's not that the incentive salience related circuits are the only ones in which the feedback integration/prediction system can fail. It's that the disruption in the functions subserved by these circuits underlie some of the most striking and characteristic symptoms of psychosis.

 

[Alemo]

Overactive dopamine neurons predict rewards and threats everywhere, out of proportion to the available information.

Does this have any implications for mania? Predicting rewards everywhere sounds pretty manic….

 

[tr]

Does this have any implications for mania? Predicting rewards everywhere sounds pretty manic….

I mean, dopaminergic activation will goose the reward circuit in VTA/NAcc, hence gambling and hypersexuality in Parkinson's patients overtreated with L-dopa. So this kind of behavior can be associated with upticks in dopaminergic activity in the context of a manic episode.

I don't think it's causally related to the generation of the manic state though; I think it is downstream of the original insult which seems more related to disruption of the circadian clock.

Daytime spikes in dopaminergic activity drive rapid mood-cycling in mice - Molecular Psychiatry

Disruptions in circadian rhythms and dopaminergic activity are involved in the pathophysiology of bipolar disorder, though their interaction remains unclear. Moreover, a lack of animal models that display spontaneous cycling between mood states has hindered our mechanistic understanding of mood...

www.nature.com

 

[clausewitz2]

I mean, dopaminergic activation will goose the reward circuit in VTA/NAcc, hence gambling and hypersexuality in Parkinson's patients overtreated with L-dopa. So this kind of behavior can be associated with upticks in dopaminergic activity in the context of a manic episode.

I don't think it's causally related to the generation of the manic state though; I think it is downstream of the original insult which seems more related to disruption of the circadian clock.

Daytime spikes in dopaminergic activity drive rapid mood-cycling in mice - Molecular Psychiatry

Disruptions in circadian rhythms and dopaminergic activity are involved in the pathophysiology of bipolar disorder, though their interaction remains unclear. Moreover, a lack of animal models that display spontaneous cycling between mood states has hindered our mechanistic understanding of mood...

www.nature.com

Some people have tried to reason from that dopaminergic activation to mania more directly and derive treatment implications from it. So this was a thing:

Methylphenidate in mania project (MEMAP): study protocol of an international randomised double-blind placebo-controlled study on the initial treatment of acute mania with methylphenidate - BMC Psychiatry

Background Treatment of patients with acute mania remains a considerable medical challenge since onset of action of antimanic medication is delayed for several days. Psychostimulants could have an earlier onset of action. This assumption is based on the ‘vigilance regulation model of mania’...

bmcpsychiatry.biomedcentral.com

Shockingly the study seems to have been discontinued before reaching its endpoints, who would have thought.

 

[clausewitz2]

Sure, though I think I would frame it that the review you cite considers the alterations in incentive salience in psychosis as a particular instance of a broader impairment in feedback integration/prediction that can occur in other circuits as well (which I did mention), and focuses on mechanism on the synaptic and signaling level rather than at the circuit level. From pages 18-19:

"To recap, a neurobiological plausible implementation of perceptual inference is predictive coding – a process theory that assigns specific roles to neuronal populations, canonical microcircuits and hierarchical connections (Bastos et al., 2012, Clark, 2013b). The most promising candidate for explaining false inference in schizophrenia is the neuronal encoding of uncertainty (Averbeck et al., 2011). Psychologically, this corresponds to the salience or precision afforded to sensory evidence (Joyce et al., 2013); while physiologically it is thought to be encoded by the gain or excitability of principal (e.g., superficial pyramidal) cells. This resonates with concepts like aberrant salience (Kapur, 2003), while explicitly implicating modulatory neurotransmission in pathophysiology."

It's not that the incentive salience related circuits are the only ones in which the feedback integration/prediction system can fail. It's that the disruption in the functions subserved by these circuits underlie some of the most striking and characteristic symptoms of psychosis.

That makes sense, salience as a subset of the general computational architecture they are proposing. It's always tricky, isn't it, when discussing these computational models, to suss out exactly which principles/mechanisms are being invoked as simply a formalism to make the system functional and which are being posited as psychological or cognitive mechanisms per se. Thanks for helping me straighten that out.

This is an interesting parallel with OCD, where at least one major theory of its cognitive etiology involves a lack of confidence in sensory evidence v. higher-order representations. "I can see that it's not dirty but what if it was?"

 

[Stagg737]

Threads like this are why I love this sub-forum, thanks to all who provide my non-reportable CME 😂

Are you thinking of Advocates in Framingham? They use the open dialogue model for their first episode psychosis program.

I'm also going to go against the dominant strain of this thread and say that I find the Hearing Voices Network model to be quite helpful with some (certainly not all) patients with psychotic disorders, and I actually think there's a decent amount of overlap between this and approaches like CBT for psychosis or open dialogue that have research support. I work in community mental health psychosis program and have plenty of "low functioning" patients with psychosis who this wouldn't be appropriate for, but I think elements of this approach (ex. psychotic experiences can have some meaning, symptom eradication is not always the goal) can be very empowering. Obviously an article like this is not going to have a lot of nuance and we can find plenty to feel threatened by, but certainly an important perspective.

Sure, there are plenty of higher functioning psychotic patients who would likely benefit significantly from these programs, possibly more so that antipsychotics may help in the long-term. However, I significantly doubt that those running such a program where there is no oversight from a MH professional are going to be screening out severely psychotic patients who may be more volatile and a risk to themselves or the other individuals around them. Without any kind of professional oversight, this just sounds like a program setting itself up to get shut down.