Melissa Connell

Auditory verbal hallucinations in persons with and without a need for care

Auditory verbal hallucinations (AVH) are complex experiences that occur in the context of various clinical disorders. AVH also occur in individuals from the general population who have no identifiable psychiatric or neurological diagnoses. This article reviews research on AVH in nonclinical individuals and provides a cross-disciplinary view of the clinical relevance of these experiences in defining the risk of mental illness and need for care. Prevalence rates of AVH vary according to measurement tool and indicate a continuum of experience in the general population. Cross-sectional comparisons of individuals with AVH with and without need for care reveal similarities in phenomenology and some underlying mechanisms but also highlight key differences in emotional valence of AVH, appraisals, and behavioral response. Longitudinal studies suggest that AVH are an antecedent of clinical disorders when combined with negative emotional states, specific cognitive difficulties and poor coping, plus family history of psychosis, and environmental exposures such as childhood adversity. However, their predictive value for specific psychiatric disorders is not entirely clear. The theoretical and clinical implications of the reviewed findings are discussed, together with directions for future research.

Age at first tobacco use and risk of subsequent psychosis-related outcomes: A birth cohort study

Objective: Compared to the substantial body of research examining links between cannabis use and psychosis, there has been relatively little attention to the role of tobacco as a potential risk factor for psychosis. This study explored the association between age at first tobacco use and psychosis-related outcomes in a birth cohort. Method: This study is based on a large birth cohort (the Mater-University Study of Pregnancy). At approximately 21 years of age, cohort members (N = 3752) were assessed for three psychosis-related outcomes (International Classification of Diseases non-affective psychosis, the presence of any hallucination and total count of delusional-like experiences) with the Composite International Diagnostic Interview and the Peters Delusional Inventory. Associations between age at first tobacco use and psychosis-related outcomes were examined using logistic regression in a model (a) adjusted for sex and age and (b) in a second model excluding all respondents who had a history of past problematic and current cannabis use. Results: When adjusted for age and sex, those who commenced tobacco at 15 years of age or younger were significantly more likely to (a) have non-affective psychosis, (b) be in the highest quartile of total score of the Peters Delusional Inventory and (c) report hallucinations. After excluding all those with a history of a cannabis use disorder, or who were current (last month) cannabis users, a significant association between age at first tobacco use and the presence of hallucinations persisted. Conclusion: There is an association between age at first tobacco use and subsequent psychosis-related outcomes in young adults. While the findings cannot be used to deduce causality, it adds weight to the hypothesis that early tobacco use may contribute to the risk of developing psychosis-related outcomes.

Hallucinations in adolescents and risk for mental disorders and suicidal behaviour in adulthood: Prospective evidence from the MUSP birth cohort study

BACKGROUND Hallucinations, once equated with serious mental disorders, are common in adolescents. Given the high prevalence of hallucinations, it is important to determine if they are associated with adverse mental health outcomes in adulthood. This study compared the mental health outcomes of participants (aged 30-33years) in the Mater-University of Queensland Study of Pregnancy (MUSP) who reported hallucinations at (a) 14years only and (b) 14 and 21years versus cohort members without hallucinations. METHOD Participants (n=333) were aged between 30 and 33years and (a) reported hallucinations on the Youth Self-Report Questionnaire at 14 and/or the Young Adult Self-Report Questionnaire at 21years and (b) controls (n=321) who did not report hallucinations. Lifetime diagnoses of mental disorders were ascertained by the Structured Clinical Interview for DSM Disorders (DSM IV-TR) administered by clinical psychologists. Suicidal behaviour was measured by self report. RESULTS Hallucinations at 14years only were not associated with an increased risk of mental disorders in adulthood. Hallucinations reported at both 14 and 21years were associated with lifetime diagnoses of psychotic disorders (OR, 8.84; 95% CI: 1.61-48.43 and substance use disorders (OR, 2.34; 95% CI: 1.36-4.07) and also strongly associated with lifetime suicide attempts (OR, 7.11; 95% CI: 2.68-18.83). CONCLUSIONS Most adolescents who experience hallucinations do not have an increased rate of mental disorder in adulthood; however, those with hallucinations that are experienced at more than one point in time are at increased risk of suicidal behaviour and both psychotic and non-psychotic psychopathology.

Recovery from first-episode psychosis and recovering self: A qualitative study.

OBJECTIVE The objective of this study was to explore the subjective factors associated with the experience of first-episode psychosis (FEP) and the very first stages of recovery to develop our understanding of this process and improve treatment outcomes. METHOD Interpretive Phenomenological Analysis was used to explore the experiences of 20 young people who had recently experienced FEP. RESULTS Two broad superordinate themes captured essential thematic trends in the data: experiences of self-estrangement and self-consolidation. The concept of dialogical self was used to understand the effect of psychosis on self and the process of resuming familiar social positions to facilitate recovery. The concept of making meaning after traumatic events was also applied to the narratives of personal growth that participants formed. Those who reported subjective improvements in recovery were more likely to have developed a meaningful interpretation of their psychosis, strengthened relationships with others, and forged a stronger sense of self. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The experience of self-consolidation was strongly associated with the persons resumption of familiar social roles and their ability to make meaning from their experience in a way that promoted personal growth. Although these processes are known to be part of personal recovery, this study highlights their importance in the very early stages of recovery immediately after the experience of FEP.

Successful recruitment to a study of first-episode psychosis by clinicians: a qualitative account of outcomes and influences on process.

Abstract Background: Strategies proposed to promote recruitment of representative samples to trials and mental health research have focused on researchers external to clinical services. How clinicians approach recruitment as researchers and particularities of recruiting people with first episode of psychosis warrant investigation. Aims: To describe recruitment, by clinicians, of people with first-episode psychosis (FEP) and factors influencing process and enrolment. Methods: Observational study nested within longitudinal examination of trauma and outcomes for patients experiencing first psychotic episode. Data collected during 20 scheduled meetings of clinicians recruiting from services in Australia. Results: Timely recruitment of 60 young people demonstrates that clinicians can successfully engage patients in research. Success depends on satisfaction of organisational preconditions and clinician motivation grounded in considering the study worthwhile. Pre-selection of participants was informed by judgments about health, insight and quality of the therapeutic alliance. Patients’ decisions were influenced by family support, acceptance of diagnosis and altruism. Honoraria had variable effect. Conclusions: Clinicians are well placed to recruit when appropriately supported, and people with FEP are willing to engage in research that fits their personal circumstances. Research should examine the meaning of participation in such studies and ways participation could support recovery.

Recovery from first-episode psychosis: A dialogical perspective

This study aims to understand the process of change in self and its relationship to recovery in the first 3 months following first-episode psychosis (FEP). Because psychosis is understood as a disorder of self, theories of self are needed to consider how sense of self is affected and restored. The authors used semistructured interviews to explore the experiences of 12 young people who had been diagnosed with FEP. The interviews were conducted at two time points: during the first month following the onset of psychosis and 3 months later. The authors employed Interpretive Phenomenological Analysis to explicate interview data and explore the experience of change following FEP. Themes that emerged in the data came under two superordinate themes: loss of self and strengthening of self. Dialogical theory of self was used to interpret the findings and explore the relationship between sense of self and recovery for young people during this critical phase following FEP.

Why are psychotic experiences associated with self-injurious thoughts and behaviours? A systematic review and critical appraisal of potential confounding and mediating factors

Psychotic experiences (PEs), including hallucination- and delusion-like experiences, are robustly associated with self-injurious thoughts and behaviours (SITB) in the general population. However, it remains unclear as to why there is an association. The purpose of this systematic review was to elucidate the role of other factors that influence the association between PEs and SITB and, in doing so, highlight potential mechanisms underlying the relationship. A search of electronic international databases was undertaken, including PubMed, PsycINFO and EMBASE, and eligible studies were grouped according to seven confounder categories: sociodemographics, mental disorders, alcohol and substance use, environmental, psychological, intervention and family history/genetic factors. The systematic search strategy identified 41 publications reporting on 1 39 427 participants from 16 different countries. In the majority of studies, where adjustment for other variables occurred, the association between PEs and SITB persisted, suggesting PEs have an independent role. Common mental disorders, psychological distress and negative environmental exposures explained a substantial amount of the variance and therefore need to be considered as potential underlying mechanisms. There was high variability in the variables adjusted for in these studies, and so the question still remains as to whether the association between PEs and self-harm/suicidality can be attributed (fully or in part) to confounding and mediating factors or directly causal mechanisms. Regardless of causality, the now extensive literature reporting an association between these two clinical phenomena supports the broad usefulness of PEs as an indicator of risk for SITB.

Nineteen and Up study (19Up): understanding pathways to mental health disorders in young Australian twins

Purpose The Nineteen and Up study (19Up) assessed a range of mental health and behavioural problems and associated risk factors in a genetically informative Australian cohort of young adult twins and their non-twin siblings. As such, 19Up enables detailed investigation of genetic and environmental pathways to mental illness and substance misuse within the Brisbane Longitudinal Twin Sample (BLTS). Participants Twins and their non-twin siblings from Queensland, Australia; mostly from European ancestry. Data were collected between 2009 and 2016 on 2773 participants (age range 18–38, 57.8% female, 372 complete monozygotic pairs, 493 dizygotic pairs, 640 non-twin siblings, 403 singleton twins). Findings to date A structured clinical assessment (Composite International Diagnostic Interview) was used to collect lifetime prevalence of diagnostic statistical manual (4th edition) (DSM-IV) diagnoses of major depressive disorder, (hypo)mania, social anxiety, cannabis use disorder, alcohol use disorder, panic disorder and psychotic symptoms. Here, we further describe the comorbidities and ages of onset for these mental disorders. Notably, two-thirds of the sample reported one or more lifetime mental disorder. In addition, the 19Up study assessed general health, drug use, work activity, education level, personality, migraine/headaches, suicidal thoughts, attention deficit hyperactivity disorder (ADHD) symptomatology, sleep–wake patterns, romantic preferences, friendships, familial environment, stress, anorexia and bulimia as well as baldness, acne, asthma, endometriosis, joint flexibility and internet use. The overlap with previous waves of the BLTS means that 84% of the 19Up participants are genotyped, 36% imaged using multimodal MRI and most have been assessed for psychological symptoms at up to four time points. Furthermore, IQ is available for 57%, parental report of ADHD symptomatology for 100% and electroencephalography for 30%. Future plans The 19Up study complements a phenotypically rich, longitudinal collection of environmental and psychological risk factors. Future publications will explore hypotheses related to disease onset and development across the waves of the cohort. A follow-up study at 25+years is ongoing.

S137. DO HALLUCINATIONS PREDICT THE TRANSITION FROM SUICIDAL THOUGHTS TO ATTEMPTS? RESULTS FROM AN AUSTRALIAN LONGITUDINAL COHORT STUDY

Abstract Background Although suicidal ideation is a well-documented risk factor for suicidal behaviour, the majority of those with suicidal thoughts do not go on to make an attempt. Therefore, it is important to improve prediction of which individuals are more likely to act on their suicidal thoughts, as highlighted in Klonsky and May’s (2015) ideation-to-action framework. Auditory hallucinations (AH) and psychological distress (PD) are strongly associated with both suicidal thoughts and behaviour, but their role in the ideation-to-attempt transition has not been investigated in a longitudinal dataset. Methods Participants were from an Australian longitudinal cohort of 1793 adolescents (12–17 years). Suicidal thoughts and behaviours were measured using the Self-Harm Behaviour Questionnaire. The Diagnostic Interview Schedule for Children was used to assess AH. PD was categorised using the General Health Questionnaire (GHQ) clinical cut-off. Those reporting suicidal ideation were stratified into four groups: (i) Those who did not have PD or AH (reference group), (ii) AH only, (iii) PD only, and (iv) PD and AH. Using logistic regression, we examined associations between baseline suicidal ideation, and incident suicide attempts during the 12-month follow-up, stratified by the four comparison groups. All analyses were adjusted for age and sex. Results AH were strongly and independently associated with baseline suicidal ideation (OR=3.84; 95%CI=2.46–6.02) and suicide attempts in the following 12 months (OR=3.21; 95%CI=1.18–8.76). Among adolescents with baseline suicidal ideation (n=235; 13.1%), 14 or 6.0% attempted suicide at follow-up. Those with AH only were not at significantly increased risk of transition from suicidal thoughts to attempts (OR=2.97; 95%CI=0.26–34.59). Similarly, adolescents with PD only did not have a significant increase in transition from ideation to attempts (OR=4.48; 95%CI=0.91–22.14). Adolescents who had both PD and AH had an eight-fold increased risk (OR=8.42; 95%CI=1.46–48.67) of acting on their suicidal thoughts. Discussion Adolescents with both PD and AH had the greatest likelihood of acting on their suicidal thoughts. AH alone did not significantly predict the transition from suicidal thoughts to attempts despite high odds ratios, possibly due to the low prevalence of suicide attempts among ideators and consequently limited statistical power. Future studies examining for negative and distressing content of hallucinations may assist in explaining their role in the ideation-to-attempt transition. Screening adolescents who are distressed and have hallucinations may assist with predicting those at greatest risk of future suicide attempts.

Prevalence and correlates of psychotic experiences in a nationally representative sample of Australian adolescents

Objective: Despite growing literature on psychotic experiences, no nationally representative study has reported on the prevalence of both hallucinatory experiences and delusional experiences in Australian adolescents. Also, while many studies have examined the association between psychotic experiences and certain demographic and clinical correlates, there are more variables of interest to be investigated, including disordered eating behaviour and hours of sleep. The aims of this study were to examine (1) the prevalence of hallucinatory experiences and delusional experiences in Australian adolescents, and (2) the associations between different types of psychotic experiences with a broad range of demographic, clinical, and psychosocial variables. Methods: A random sample of Australian adolescents aged 14- to 17-year-olds were recruited in 2013–2014 as part of the Young Minds Matter Survey. Participants completed self-report questions regarding five different psychotic experience types (auditory and visual hallucinatory experiences, and thoughts read, special messages, spied upon) experienced in the past 12 months. Using logistic regression analyses, we investigated associations between psychotic experiences and demographic, clinical, and psychosocial factors. Results: The 12-month prevalence ranged from 3.3% (95% confidence interval = [2.6, 4.3]) for special messages to 14.0% (95% confidence interval = [12.3, 15.8]) for auditory hallucinatory experiences. At the bivariate level, each psychotic experience subtype was associated with increased likelihood of major depression, being bullied, psychological distress, low self-esteem, mental health service use and insufficient sleep (<8 hours per night). Multivariate analyses revealed both auditory and visual hallucinatory experiences were associated with an increased likelihood of four of these variables (depression, being bullied, service use, insufficient sleep), whereas associations with delusional experiences were inconsistent. Conclusion: Hallucinatory and delusional experiences are common in Australian adolescents. Hallucinatory experiences, rather than delusional experiences, may be more clinically relevant in this demographic. When psychotic experiences are endorsed by adolescents, further assessment is indicated so as to ascertain more detail on the phenomenology of the experiences to better understand their clinical relevance.