Managing Stigma Effectively: What Social Psychology and Social Neuroscience Can Teach Us (2015)

As I mentioned earlier, I’ve internalised a lot of things that impede my recovery and add to the continuing burden of my illness. It’s good to see an article addressing stigma:

Managing Stigma Effectively: What Social Psychology and Social Neuroscience Can Teach Us

Psychiatric education is confronted with three barriers to managing stigma associated with mental health treatment. First, there are limited evidence-based practices for stigma reduction, and interventions to deal with stigma against mental health care providers are especially lacking. Second, there is a scarcity of training models for mental health professionals on how to reduce stigma in clinical services. Third, there is a lack of conceptual models for neuroscience approaches to stigma reduction, which are a requirement for high-tier competency in the ACGME Milestones for Psychiatry. The George Washington University (GWU) psychiatry residency program has developed an eight-week course on managing stigma that is based on social psychology and social neuroscience research. The course draws upon social neuroscience research demonstrating that stigma is a normal function of normal brains resulting from evolutionary processes in human group behavior. Based on these processes, stigma can be categorized according to different threats that include peril stigma, disruption stigma, empathy fatigue, moral stigma, and courtesy stigma. Grounded in social neuroscience mechanisms, residents are taught to develop interventions to manage stigma. Case examples illustrate application to common clinical challenges: (1) helping patients anticipate and manage stigma encountered in the family, community, or workplace; (2) ameliorating internalized stigma among patients; (3) conducting effective treatment from a stigmatized position due to prejudice from medical colleagues or patients’ family members; and (4) facilitating patient treatment plans when stigma precludes engagement with mental health professionals. This curriculum addresses the need for educating trainees to manage stigma in clinical settings. Future studies are needed to evaluate changes in clinical practices and patient outcomes as a result of social neuroscience-based training on managing stigma.

Particularly interesting is the following passage:

“The most difficult of all stigmatizing processes to counter is perhaps internalized stigma. Internalized stigma results when stigma of whatever specific type becomes a lens for self-perception that is judgmental, contemptuous, and dismissive. Patients feel disgust for their identity as psychiatrically ill. Compassion for self is difficult to muster. Loss of self-esteem, a sense of alienation, social withdrawal, and self-hatred are common sequelae.

During categorical social cognition, the sociobiological systems stream information about the social world through the rostral anterior cingulate gyrus where it can be compared to a model of expectable reality that has been constructed by the prefrontal cortex from memory retrieval. Detecting a mark of stigma in a person’s environment appears to generate conflict between incoming sociobiological information and an expectable reality. When the anterior cingulate gyrus detects this conflict, a need for additional control is signaled to the prefrontal cortex. The dorsolateral and ventrolateral prefrontal cortices then resolve the conflict by exercising top-down modulation over subcortical systems that constitute the pain matrix, including the amygdala (fear), insula (disgust), and ventral anterior cingulate gyrus (suffering). Activation of the pain matrix produces proximate motivation for avoiding or extruding the bearer of the stigmatizing mark. The flow of mirror neuron information is then suppressed, and person-to-person social cognition fails to activate. Empathy for the stigmatized person is suspended. The stigmatized person is then behaviorally extruded and oppressed, for which the stigmatizer typically feels no guilt.

Different types of stigma can recruit different brain circuits and signaling pathways. Moral stigma, for examples, activates circuitry of ventromedial prefrontal cortex that is essential for generating social disgust. Patients with damage to the ventromedial prefrontal cortex lose their aversion to intimate contact with strangers, social deviants, or those bearing misfortunes, such as the poor or homeless, whereas their moral disgust remained intact for those who violated the dignity of others, as with unfairness, cheating, or betrayal.”

One can imagine the intrapsychic conflicts and corresponding neurobiological chaos that internalised stigma could lead to… Could that play a role in auditory verbal hallucinations?

Therapeutic strategies are detailed:

“Role plays are used to practice psychotherapeutic strategies for recovery from internalized stigma by discovering aspects of oneself that are unsullied, intact, and worthy, while mobilizing defiance of the stigmatizing inner gaze. In manageable steps, patients practice steps of recovery”

For a view on the importance of social aspects in the recovery process, this talk is worth a watch.

Positive disintegration – a path to the resolution of ‘psychosis’?

“Without passing through very difficult experiences and even something like psychoneurosis and neurosis we cannot understand human beings and we cannot realize our multidimensional and multilevel development toward higher and higher levels.”

Positive disintegration – a path to the resolution of ‘psychosis’?

“Suffering, aloneness, self-doubt, sadness, inner conflict; these are our feelings that we have not learned to live with, that we have failed to appreciate, that we reject as destructive and completely negative, but in fact they are symptoms of an expanding consciousness. Dr. Kazimierz Dabrowski has spent 45 years piecing together the complete picture of the growth of the human psyche from primitive integration at birth; the person with potential for development will experience growth as a loosening of the stable psychic structure accompanied by symptoms of psychoneuroses. Reality becomes multileveled, the choices between higher and lower realms of behavior occupy our thought and mark us as human. Dabrowski called this process positive disintegration, he declares that psychoneurosis is not an illness and he insists that development does not come through psychotherapy but that psychotherapy is automatic when the person is conscious of his development. To Dabrowski, real therapy is autopsychotherapy; it is the self being aware of the self through a long inner investigation; a mapping of the inner environment. There are no techniques to eliminate symptoms because the symptoms constitute the very psychic richness from which grow an increasing awareness of body, mind, humanity and cosmos… Without intense and painful introspection and reflection, development is unlikely. Psychoneurotic symptoms should be embraced and transformed into anxieties about human problems of an ever higher order. If psychoneuroses continue to be classified as mental illness, then perhaps it is a sickness better than health.” [1]

“Unless we change our thinking… our understanding of psychogenic emotional and psychosomatic disorders and their therapy  will  remain  superficial,  unsatisfactory, and incomplete. Psychiatry and psychology will be unable to genuinely comprehend the nature and origin of spirituality and appreciate the important role that it plays in the human psyche and in the universal scheme of things. These revisions are therefore essential for understanding the ritual, spiritual, and religious history of humanity,  shamanism, rites of passage, the ancient mysteries of death and rebirth, and the great religions of the world. Without these radical changes in our thinking, potentially healing and heuristically invaluable experiences (“spiritual emergencies”) will be misdiagnosed as psychotic and treated by suppressive medication.” [2]

The phases of recovery from psychosis are detailed here

The Seasons of Wellbeing as an Evolutionary Map for Transpersonal Medicine (2015)

The Seasons of Wellbeing as an Evolutionary Map for Transpersonal Medicine (2015)

The four Seasons of Wellbeing (Discover, Transform, Awaken, and Integrate) refer to distinct rhythms, periods, and factors that influence the accessibility of an individual’s resources during the journey of life. Each season is explicitly and implicitly related to an individual’s experience, focus, and capacity for self-organizational states. Each can be used to understand, organize, and foster behavior change, positive growth, transformation, and human development. A genealogy of the seasons is described, emphasizing the empirical and theoretical foundations of Reorganizational Healing and its roots in models such as Grof ’s Systems of Condensed Experiences (or COEX Systems) and Wilber’s Integral Theory and Pre/Trans Fallacy. In the context of transpersonal medicine, the seasons offer a framework through which various levels and states associated with an individual’s growth can be mapped and utilized for personal evolution. In this context, seasons are applicable for practitioners and clients who have used transpersonal states to avoid painful emotions or difficult actions. The seasons can guide transpersonal medical clients on a path towards transpersonal being and integration of various states leading to a higher organizational baseline. As a practical tool, the seasons have pertinence in the development of “transpersonal vigilance,” a term defined in this article. The seasons offer resources to practitioners to support clients toward transpersonal being, in a reorganizationally informed or reorganizational way.

“Discover, the first season, is the place in which we start by default. In Discover, we want to learn, uncover or find some important and vital information. This season involves developing an understanding of the body’s movement, its energy flow and how it allows the flow of breath. We learn how we have controlled these factors with posture and tension to numb our experience and protect ourselves from pain and suffering.

We fully enter the second season, Transform, when we develop the strength and courage to begin doing something about the situations we were protecting ourselves against. We are motivated to take action to move away from what we don’t like and towards a goal or something compelling that we do want. Because we know how we have sustained pain in Discover, our efforts in Transform are successful at moving us towards our goal.

Awaken is the season in which we experience ourselves as souls. We experience connection, love and gratitude. It is the third season and its true experience really comes when we have no attachment to past traumas and no need to prove ourselves. We have no more sense of ourselves as people, roles, jobs or accomplishments. Our purpose is connection, service and growth.

The fourth season, Integrate, is experienced once we have a good understanding of how life works in each of the three prior seasons. At that point we become able to consciously combine the gifts of two seasons to uncover the learning, create the outcome or deepen the level of service we are called to experience.” [1]

four seasons 1 four seasons 2

table 2

four seasons 3

Attenuating antipsychotic-induced weight gain and metabolic side effects

Pharmacological strategies to counteract antipsychotic-induced weight gain and metabolic adverse effects in schizophrenia: a systematic review and meta-analysis.

  • Metformin was the most extensively studied drug in regard to body weight, the mean difference amounting to -3.17 kg (95% CI: -4.44 to -1.90 kg) compared to placebo.
  • Topiramate, sibutramine, aripiprazole, and reboxetine were also more effective than placebo.
  • Metformin and rosiglitazone improved insulin resistance, while aripiprazole, metformin, and sibutramine decreased blood lipids.

 “…literature supports the use of concomitant metformin as first choice among pharmacological interventions to counteract antipsychotic-induced weight gain and other metabolic adversities in schizophrenia.”

  • “Metformin could be considered an adjunctive therapy with clozapine to prevent metabolic syndrome in schizophrenic patients”

Metformin for weight loss in schizophrenia: safe but not a panacea.

On the contrary, a recent systematic review and meta-analysis of agents for reducing olanzapine and clozapine-induced weight gain in schizophrenia concluded: “topiramate and aripiprazole are more efficacious than other medications in regard to weight reduction and less burden of critical adverse effects as well as being beneficial for clinical improvement.”

In clozapine treated patients:

“Aripiprazole, fluvoxamine, metformin, and topiramate appear to be beneficial; however, available data are limited to between one and three randomized controlled trials per intervention. Orlistat shows beneficial effects, but in males only. Behavioral and nutritional interventions also show modest effects on decreasing clozapine-associated weight gain, although only a small number of such studies exist.” [1]

Use of melatonin is a promising strategy:

“Our results show that melatonin is effective in attenuating SGAs’ adverse metabolic effects, particularly in bipolar disorder. The clinical findings allow us to propose that SGAs may disturb a centrally mediated metabolic balance that causes adverse metabolic effects and that nightly administration of melatonin helps to restore. Melatonin could become a safe and cost-effective therapeutic option to attenuate or prevent SGA metabolic effects.” [2]

“…in patients treated with olanzapine, short-term melatonin treatment attenuates weight gain, abdominal obesity, and hypertriglyceridemia. It might also provide additional benefit for treatment of psychosis.” [3]

Melatonin is appropriate to consider for any patient who will be started on a psychotropic drug that is potentially associated with weight gain or other adverse metabolic effects [link]

Functional foods as potential therapeutic options for metabolic syndrome.

Obesity as part of metabolic syndrome is a major lifestyle disorder throughout the world. Current drug treatments for obesity produce small and usually unsustainable decreases in body weight with the risk of major adverse effects. Surgery has been the only treatment producing successful long-term weight loss. As a different but complementary approach, lifestyle modification including the use of functional foods could produce a reliable decrease in obesity with decreased comorbidities. Functional foods may include fruits such as berries, vegetables, fibre-enriched grains and beverages such as tea and coffee. Although health improvements continue to be reported for these functional foods in rodent studies, further evidence showing the translation of these results into humans is required. Thus, the concept that these fruits and vegetables will act as functional foods in humans to reduce obesity and thereby improve health remains intuitive and possible rather than proven.

High dose green tea extract is promising [link]

Saffron aqueous extract (SAE) appears to be potentially beneficial: [link]

Alpha-lipoic acid (ALA), a potent antioxidant may be helpful in reducing weight for patients taking antipsychotics:

“ALA was well tolerated and was particularly effective for individuals taking strongly antihistaminic antipsychotics” [5, 6]

Berberine shows promise in animal models [7]

Vitamin D deficiency exacerbates atypical antipsychotic-induced metabolic side effects in rats [8] and vitamin D supplementation may be promising in the prevention and treatment of metabolic disorders caused by antipsychotic medications.

Dehydroepiandrosterone (DHEA) supplementation “results in stabilization of BMI, waist circumference and fasting glycaemia values in schizophrenic patients treated with olanzapine” [8]

It has recently shown that the microbiota plays a critical role in olanzapine-induced weight gain in rats (Davey et al., 2013 and Davey et al., 2012) which has been confirmed in germ-free mice study (Morgan et al., 2014) [9].

Figure 1
Managing cardiovascular disease risk in patients treated with antipsychotics: a multidisciplinary approach.

My weight loss journey started with the addition of 10mg aripiprazole per day to clozapine (300mg) and venlafaxine (375mg). Aripiprazole augmentation of clozapine has been demonstrated to have beneficial effects on weight [10].

In addition, morning and lunch meals were replaced with a 30g high protein/no carbohydrate meal (Whey Protein Isolate, mixed in water)

I increased my daily exercise to 1 x 45min brisk walk in the morning and a 20min walk later in the day.

I managed to lose ~25kg and have reached a healthy BMI

A systematic review found:

“Psychiatric symptoms were significantly reduced by interventions using around 90 min of moderate-to-vigorous exercise per week (standardized mean difference: 0.72, 95% confidence interval -1.14 to -0.29). This amount of exercise was also reported to significantly improve functioning, co-morbid disorders and neurocognition.” [11]

To conclude:

“The management of weight gain and obesity in patients with schizophrenia centers on behavioural interventions using caloric intake reduction, dietary restructuring, and moderate-intensity physical activity. The decision to switch antipsychotics to lower-liability medications should be individualized, and metformin may be considered for adjunctive therapy, given its favorable risk-benefit profile.” [12]