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 mentalisation@unige.ch

SAVE THE DATE !!

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 mentalisation@unige.ch

SAVE THE DATE !!

... Thanks for listening ...

martin.debbane@unige.ch

m.debbane@ucl.ac.uk