A rationale for MBT along the psychosis continuum
MARTIN DEBBANÉ, Ph.D.
Associate Professor
Faculty of Psychology and Educational Sciences,
Research Unit Co-Director, Office Médico-Pédagogique
University of Geneva
Senior Lecturer
Research Department of Clinical, Educational and Health
Psychology,
University College London
For more information, visit MENTALISATION.UNIGE.CH ...
... or write to [email protected]
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Acknowledgements
University of Geneva, CH
Deborah Badoud
Stephan Eliez
Larisa Morosan
Marie Schaer
London, UK
Anthony Bateman
Peter Fonagy
Patrick Luyten
George Salaminios
University Hospitals Lausanne,
CH
Alessandra Solida-Tozzi
Sabrina Bardy
The psychosis continuum in clinical care
Schizophrenia Spectrum and Psychotic disorders: Overview
Spectrum of disorders (DSM &
CIM):
Schizotypal (Personality) Disorder
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Schizoaffective Disorder
Substance/Medication Induced
Psychotic Disorder
Psychotic disorder due to another
medicla condition
Catatonia
Other/Unspecified
Symptomatic Triad:
Positive:
Hallucinations and
Delusions...
Negative:
Blunted affect,
Avolition...
Disorganization:
Disorganized
communication, affect,
behaviour...
Schizophrenia: How are we doing therapeutically?
Carbon & Correll, Dialogues in Clinical Neurosciences, 2014
35 to 50% of patients diagnosed with schizophrenia never SOCIALLY REMIT
Carbon & Correll, Dialogues in Clinical Neurosciences, 2014
Schizophrenia: How are we doing therapeutically?
A developmental framework to the development
of psychotic disorders
Psychotic Episode(s)
and remission
First Episode &
Relapses
Chronic Schizophrenia
Flip
Debbané, M. Schizotypy: a developmental
model. In Claridge & Mason, Routledge,
2015
Trans-theoretical developmental framework
Clinical High Risk
Period
D sub-
clinical
Continuum
Clinical
Schizotypal trait (Schizo seed)
Stressors
Key
vulnerability
window
Psychotic Episode(s)
and remission
First Episode &
Relapses
Chronic Schizophrenia
Flip
Debbané, M. Schizotypy: a developmental
model. In Claridge & Mason, Routledge,
2015
Clinical High Risk
Period
D sub-
clinical
Continuum
Clinical
Schizotypal trait (Schizo seed)
Stressors
Key
vulnerability
window
Trans-theoretical developmental framework
Rapado-Castro et al., Schizophrenia Research, 2015
Sources of distress in Clinical High-Risk (CHR) seeking treatment
Distress to APS,
Anxiety and Substance
use predictive of
transition to a
psychotic disorder
(12% transitioned 4-8
months after intake)
How do we diagnose Clinical High-Risk (CHR) ?
Evaluation of Clinical High Risk (CHR)
for Psychosis
Two main approaches in the evaluation of high risk for psychosis clinical states
« Basic Symptoms » (BS)
« Ultra High-Risk » (UHR)
1) The Ultra High Risk (UHR) Approach
McGlashan et al. 2010; SIPS, version x (restriction in age range since 2005: age 15-25 yrs.)
UHR criterion ‘Attenuated Psychotic Symptoms’ (APS) At least any 1 of the following 5 symptoms with a SIPS score of ‘3’ to ‘5’: unusual thought content / delusional ideas (P1) suspiciousness / persecutory ideas (P2) grandiosity (P3) perceptual abnormalities / hallucinations (P4) disorganized communication (P5) First occurrence or worsening within past 12 months At least weekly occurrence within past month UHR criterion ‘Brief Limited Intermittent Psychotic Symptoms’ (BLIPS) At least any 1 of the above 5 symptoms (P1-P5) with a SIPS score of ‘6’ Psychotic level of intensity, i.e., a score of ‘6’ was reached within past 3 months At least present for several minutes per day at a frequency of at least once per month UHR ‘trait-state’ criterion At least any 1 of the following risk criteria: 1st-degree biological relative with a history of psychotic disorder schizotypal personality disorder in patient a At least a 30% drop in GAF score over the last month as compared to 12 months ago.
Courtesy Frauke Schultze-Lutter
UHR: Longitudinal Follow-up
416 participants with prodrome (311
atfollow-up) aged 15-30 years
- 34.9 % convert to psychotic disorder
- Majority diagnosed during first 3 years
57% 69% / +12% 83% / + 14% 90% / + 7% 95% / + 5% 100% / + 5%
First described by Gerd HUBER (1966)
« … Basic Symptoms are subtle, subjective, sub-
clinical disturbances in drive, stress tolerance,
affect, thinking, speech, perception and motor
action, which are phenomenologically distinct from
psychotic symptoms. They can be present before,
during and after the first psychotic episode. The
term ‘basic’ refers to the idea that basic symptoms
are the first specific psychopathological expression
of the somatic disturbance underlying the
development of psychosis. »
Schultze-Lutter et al., 2012
2) Basic Symptoms Approach
Basic Symptoms
‘Cognitive-Perceptive Basic Symptoms‘ (COPER) 1 basic symptom of at least weekly frequency (SPI ≥ ‚3‘) within past 3 months and first occurrence or significant increase in frequency at least 12 months ago:
thought interference thought perseveration thought pressure thought blockages dist.of receptive speech decreased ability to discriminate
between ideas and perception, … unstable ideas of reference derealisation visual perception dist. acoustic perception dist.
'Cognitive Disturbances’ (COGDIS) ≥ 2 basic symptoms of at least weekly frequency (SPI ≥ ‚3‘) within past 3 months :
inability to divide attention thought interference thought pressure thought blockages dist. of receptive speech dist. of expressive speech dist. of abstract thinking unstable ideas of reference captivation of attention by details
of the visual field
Basic Symptoms
‘Cognitive-Perceptive Basic Symptoms‘ (COPER) 1 basic symptom of at least weekly frequency (SPI ≥ ‚3‘) within past 3 months and first occurrence or significant increase in frequency at least 12 months ago:
thought interference thought perseveration thought pressure thought blockages dist.of receptive speech decreased ability to discriminate
between ideas and perception, … unstable ideas of reference derealisation visual perception dist. acoustic perception dist.
COPER : 28% convert to a
schizophrenic disorder; the criteria
perfroms well for exclusion of risk (Schultze-Lutter et al., 2010)
Basic Symptoms
'Cognitive Disturbances’ (COGDIS) ≥ 2 basic symptoms of at least weekly frequency (SPI ≥ ‚3‘) within past 3 months :
inability to divide attention thought interference thought pressure thought blockages dist. of receptive speech dist. of expressive speech dist. of abstract thinking unstable ideas of reference captivation of attention by details
of the visual field
COGDIS « Performs better for
predicting schizophrenia » 37% convert
to schizophrenic disorder.
After 1 year: 23.9%
After 2 years: 22.4%
After 3 years: 14.9%
After > 3 years: 17.9%
COGDIS: Risk more imminent
(Schultze-Lutter et al., 2010)
Basic Symptoms
From trait... to risk... to disorder
Debbané M, Eliez S, Badoud D, Conus P, Flückiger
R, Schultze-Lutter F. (2015)Developing psychosis
and its risk states through the lens of schizotypy.
Schizophrenia Bulletin
% Cumulative conversion
rate to psychotic disorder
90 80 70 60 50 40 30 20 10
0 6 12 18 24 30 36 42 48 ...
UHR
BS
Is this the best clinicians can do?
To Recap
90 80 70 60 50 40 30 20 10
0 6 12 18 24 30 36 42 48 ...
UHR
BS
UHR + BS
% Cumulative conversion
rate to psychotic disorder
An MBT approach....
Brent & Fonagy, in press
1) Developmental
3) Posits intervening (attachement disturbance – interpersonal stress)
2) Links social-cognitive mechanisms to neurobiological dimensions
Brent & Fonagy, in press
1) Developmental
3) Posits intervening (attachement disturbance – interpersonal stress)
2) Links social-cognitive mechanisms to neurobiological dimensions
Premorbid Prodrome Psychosis Onset
Through research, developing a clearer, developmentally sensitive staging model
specifying key therapeutic targets in transition phases
Current clinical Guidelines from International Early Psychosis Association Writing Group
Distress to APS,
Anxiety and Substance
use predictive of
transition to a
psychotic disorder
(12% transitioned 4-8
months after intake)
What should early treatment
focus on?
Top 3 distress symptoms
- Social and functional difficulties
- Depressive symptoms
- Attenuated psychotic symptoms
Top 3 transition predictive symptoms
- Attenuated psychotic symptoms
- Anxiety
- Substance Use
Building a rationale around an MBT
approach for CHR
Attachement
System
Alteration of stress regulation
(HPA)
Dysregulation of meso-cortical
dopaminergic system
Alteration of interpersonal
regulation system (Oxytocine)
Brent et al., Isr J Psychiatry Relat Sci, 2014
Adolescent
Biopsychosocial
Pressure
Disturbed self experience & increased
Salience
Alteration of mentalization capacities
Brent et al., Isr J Psychiatry Relat Sci, 2014
Dysregulation of meso-cortical
dopaminergic system
Building a rationale around an MBT
approach for CHR (2)
Psychotic manifestation conceptualized as
an interruption in the experience of self-
continuity.
In schizotypal individuals (+), the mind then
attempts to re-establish
« centrality/agency » by way of « hasty »
appraisals of ambiguous percepts.
Building a rationale around an MBT
approach for CHR (2)
Indirect evidence of
mentalizing impairments
in CHR:
Theory of Mind (ToM)
Reality Monitoring
Hyper-Reflectivity
Cognitive pehnotypes associated to:
Schizotypy
Genetic risk (familial)
Clinical High-Risk states (CHR)
First Episode Psychosis (FEP)
Schizophrenia
Alterations in mentalization along the
psychosis continuum
Two key mentalization Axis in
Psychosis
Mental Activity
Targeting
Psychic Reality
Mental Activity
Targeting
External Reality
Appearance Inference
Imitative
Frontoparietal
mirroir neuron system
MPFC/ACC
Inhibition
system
Self-focused Differentiated from self
Self – Other Axis
Internal – External Axis
Simple – ajusted to level of mentalization
Targeting affect
Centered on the mind of the patient (≠ behaviour)
Staying in the present (within working memory)
Favour pre-conscious or conscious
Some technical observations
... as usual ...
• Functional analysis of schizotypal moment (attentionnel focus)
• From description to co-reconstruction (before-during-after)
• Sustain an embodied description (you are facing heavy
pretend / psychic equivalence)
• Model opacity of Mind (specifically in the face of paranoia)
• Extensively use an explicit opening of your mind / thinking
processes
• Generate alternative perspectives (cultivate « safe doubt »)
• Increase what you already do:
• Carefully monitor the level of complexity of your interventions
• Therapist’s use of self; making mind explicit, drawing on
affective experience, checking and marking own understanding
• Explicit modeling of linking therapist’s affective experience to
productions of therapist mind (mentalizing)
Some technical observations
• Sharon is a 16 year old which « meets diagnostic
criteria » for a CHR state based on Attenuated Psychotic
Symptoms (Delusions, Paranoia, Ideas of Reference)
• Has been feeling very depressed, has significantly
reduced social contact with friends (< 1h compared to >
10h a week) for the last 6 months
• Almost stopped attending school, feels uninterested, low
motivation for about 6 months.
• The period of psychological distress linked to end of
relationship with boyfriend
Short Vignette - Sharon
Interruption in self-experience
Dysregulation of Arousal
Dissociation and social withdrawal increasing
epistemic vigilence
Non-Mentalizing
Intense projections / appraisals of others’
mental states regarding self
Attempts to understand self-experience in thwarted, rigid, sometimes delusional ways
Increasing degree of psychotic phenomena penetrating
interpersonal relationships
Non
Mentalization
Cycle in
Psychosis
A tentative non-mentalizing cycle in
Psychosis
For more information, visit MENTALISATION.UNIGE.CH ...
... or write to [email protected]
SAVE THE DATE !!
... Thanks for listening ...
