What Really Causes Violence in Psychosis?

2013-03-19

A new study investigates how anger associated with delusions — not simply being out of touch with reality — is critical in determining whether psychosis turns violent.

The research, published in JAMA Psychiatry, included 458 participants around age 31 who experienced a first episode of psychosis in East London, an inner-city neighborhood with a history of poverty and social stress, between 1996 and 2000. They were diagnosed with some sort of psychosis either through local mental-health services and hospitals or via the criminal-justice system.

Schizophrenia and schizoaffective disorder — a condition that includes the delusions and social withdrawal of schizophrenia, along with a mood conditions like depression or bipolar disorder— together accounted for more than half of the participants’ diagnoses. However, 14% suffered from psychotic depression, a condition in which delusions develop as part of a severe depression, and 10% had bipolar disorder in which a manic episode included psychotic delusions. The rest were diagnosed with a variety of less common psychotic conditions.

Nearly two-thirds of the participants were not involved in any violence at all in the year before their first psychotic episode. But 26% had committed what the authors defined as minor violent acts, including assaults that did not lead to injuries or involve weapons. Another 12% were seriously violent, engaging in crimes like injurious assaults, use of lethal weapons or sexual attacks.

The researchers, led by Dr. Jeremy Coid, a professor of psychiatry at Queen Mary University in London, interviewed participants about the content of their delusions and their emotional experiences. Anger related to delusions was strongly linked with attempting to harm others. After adjusting for other factors, 31% of the minor violence could be attributed to anger connected with delusions. In the seriously violent patients, anger accounted for 56% of the incidents. Elation, anxiety and fear were not associated with violence.

Those who engaged in violence also tended to be younger and were more than twice as likely to have taken drugs in the past year, although alcohol use did not matter. The seriously violent were far more likely to be male, but there was no difference in risk by gender for minor violence.

None of the delusions were dangerous in and of themselves. But three types, all of which involved a sense of personal threat, were linked to serious violence if they provoked anger. One delusion centered on the idea that the person was being spied on or was under surveillance by some type of threatening authority, group or person.  Another focused on the misguided belief that people with hostile intent were targeting the victim. Finally, there was the fantasy of some sort of conspiracy against the delusional person.

Any anger generated from feeling threatened under these situations could make the patients lash out. “Anger due to delusions appeared to constitute the main drive to serious violence,” the study authors write. On the other hand, a more depressive response to the threats seemed to thwart violence so that a “depressive affect had a protective effect,” according to the research.

“If patients are not angry, the delusions themselves don’t cause a problem,” Coid told the New York Times. What causes delusions to result in angry responses in some people and not in others? Researchers aren’t sure, but they believe that a better understanding of this connection, as well as a greater appreciation for how this anger response is related to the delusions of psychosis, could lead to treatments that prevent violent behavior and its potentially tragic consequences.

What to do after an affair

2013-03-18

By Ian Kerner, CNN Contributor

• Infidelity is much more complicated than our culture admits, expert says
• Couples can find their way to a deeper and more intimate bond after an affair
• You can’t heal from infidelity overnight — take time to rebuild the relationship slowly

Editor’s note: Ian Kerner, a sexuality counselor and New York Times best-selling author, writes about sex and relationships for CNN Health. Read more from him on his website, GoodInBed.

We’ve all heard the adage: “Once a cheater, always a cheater.” If your partner has been unfaithful, you’re likely getting all sorts of advice from well-meaning friends and family.

Much of that advice may involve ending your relationship. Yet it’s possible — and perhaps even beneficial — to stay in a marriage or long-term relationship when one partner cheats. That’s the idea of two new books from noted experts on the topic: a newly revised edition of the best-selling “After the Affair” by Janis Abrahms Spring and “The New Monogamy: Redefining Your Relationship After Infidelity” by Tammy Nelson.

But should you really forgive and move on after infidelity?

“Most of us are totally unprepared for what lies ahead in a relationship, and ignorant of what’s required to last the course,” Spring writes. “An affair shocks us into reality. Fortunately, it also invites us to try again.”

Adds Nelson, “Many couples instinctively know that infidelity is much more complicated than our culture sometimes admits.”

Couples can, and do, often find their way to an ultimately deeper, more intimate bond — but it can take time and effort.

“In the wake of infidelity, most betrayed partners feel surprised and caught off guard,” says marriage and family therapist James Walkup. “But even though the hurt person may have assumed they would not stay married to a straying spouse, they may realize they still love their partner and want to work on the relationship.”

Today, not all committed relationships follow the traditional definition of monogamy. For example, both partners may decide together what constitutes cheating going forward — whether that means flirting with a particular friend, visiting a strip club or even having sex outside the relationship.

“I have seen a growing number (of) straight and same-sex couples thrive on the infamous ‘monogamish’ agreement,” psychotherapist Jean Malpas says. “They realize that long-term relationships might need to include the reality of attractions to other people. They carefully define trust and craft guidelines for acceptable behavior based on their level of comfort with risk and fluidity.”

Such a “monogamish” approach tends to be more common among gays, lesbians, bisexuals and transgendered people, notes sex therapist Margie Nichols.

“The issue is commonly on the table for consideration or discussion when LGBTQ partners get together, and when a transgression is purely sexual (as opposed to emotional), it may be less likely to end the relationship,” she says.

That’s not to say that monogamish couples are safe from infidelity, however.

“Just because a couple is monogamish does not mean that they will be any more forgiving of a partner who breaks the rules and violates their trust,” says social psychologist Justin Lehmiller. “Deciding whether to work things out has less to do with the gender of the partners and more to do with whether it was a good quality relationship to begin with.”

Nelson adds, “Ideally, your relationship will continue to grow and change as each of you grows and changes, and it may change position on the (monogamy) continuum throughout the years.”

You can’t heal from infidelity overnight. Instead, take time to rebuild your relationship slowly. Rather than ignoring the affair, be willing to share your pain, listen to each other and provide comfort when one partner is remembering the betrayal — all can help lessen the pain while re-creating the original bond that joined the two of you together.

“Turning your back on a damaged relationship may be the simplest or most sensible solution, one that frees you from the tyranny of hope,” Spring writes. “But it also may be a way to escape growing up, facing bitter truths about life, love and yourself, and assuming the terrible responsibility for making your relationship work.”

Some couples undoubtedly view an infidelity as the end of their relationship — and in some cases, going your separate ways may be the best decision. But for partners who are willing to recommit themselves to each other, an affair can be a turning point.

“Sometimes my clients acknowledge that coping with infidelity was the worst and yet the best thing to happen to their relationship,” Walkup says. “The distance between them has been bridged, and a deeper level of sharing and intimacy can bring joy and hope in the long run.”

Why Marriage Is Good for Your Health — Until You Get Sick

By Bonnie Rochman

It’s supposed to last through sickness and in health, but it turns out that it’s a better idea to get married because you love someone, not because you think it’s going to keep you healthy for the long haul.

That’s the message from a study published this month in the Journal of Health and Social Behavior, which contradicts previous research that extolled the health benefits of partnership. It turns out that marriage is all well and good — until a person’s health starts declining.

While studies of married and single people show that healthy unmarried people are far likelier to die than healthy married people during the 20-year research period, the numbers equal out when both married and unmarried people report poor health. “Marriage is more protective for healthy people,” says lead author Hui Zheng, an assistant professor of sociology at Ohio State University.

In the study, researchers tracked 789,000 people who participated in the National Health Interview Survey from 1986 to 2004. Participants were asked to rate their health from excellent to poor. Follow-up data allowed Zheng and Patricia Thomas, a postdoctoral fellow at the University of Texas at Austin, to determine that 24,100 participants died between 1986 and 2006.

When they reported excellent health, unmarried people in the study were on average 75% more likely to have died than married people. More specifically, separated folks were 58% more likely to die during these studies, divorced people were 62% more likely and widowed people were 93% more likely to kick the bucket compared with married people.

Marriage, then, can be a boon for a health. “It encourages people to maintain good health behaviors and have good social support and a sense of purpose in life,” says Zheng.

But while “marriage is good for health … its protective effect declines as people’s health declines,” says Zheng. Unmarried people who reported fair (as opposed to excellent, very good, good or poor) health were 40% more likely to die than similar married people in the study. That breaks down to a 39% greater risk of dying for those who were separated, a 31% higher risk for divorced people and 20% higher risk of dying for widowed people compared with those who were married.

What’s going on? Does love fade as health fades? That’s hard to document from the studies analyzed, but part of the explanation may be more prosaic. Married people are not as quick to report declining health as unmarried people are. So by the time a married person cops to having failing health, that person may already be in dire straits.

Meanwhile, a separate Danish study published this week in the International Journal of Epidemiology has found that gay men are doing pretty well with longevity: their mortality rate has dropped below that of unmarried or divorced men. Denmark boasted the world’s first legislation in 1989 recognizing same-sex partnerships.

The good news doesn’t extend to married lesbians, however; their mortality rates rose, primarily because of suicide and cancer, according to the same research. Researchers aren’t sure why marriage didn’t have the same beneficial effects on lesbians’ health as it had on men’s health.

The complicated results confirm one thing that’s clear about marriage — it is indeed complicated, especially when it comes to the ways that these perfect unions can impact health and longevity.

Rashness & Rumination: New Understanding About the Roots of Depression

Two studies explore some of the developmental roots of depression in childhood and adolescence.

In the first study, published in the journal Clinical Psychological Science, researchers focused on depressive rumination, or the relentless focus on what has gone wrong or will go wrong, coupled with an inability to see a solution to these overwhelming problems. It’s no surprise that rumination has a strong connection to depression— in fact, studies show that some talk therapies can actually make depression worse by compelling people to focus on problems and their origins, rather than guiding them toward positive solutions on what to do about them.

To better understand what role rumination might play in seeding depression to begin with, however, the researchers, led by Mollie Moore at the University of Wisconsin-Madison studied 756 young adolescent twins, aged 12 to 14. They compared identical twins, who share the same genes, to fraternal twins, who are no more genetically alike than other siblings, using questionnaires designed to tease out whether the teens tended to brood over their problems and their insolubility or whether they thoughtfully reflected on them with an eye toward finding possible solutions. What psychologists have labeled “moody pondering” or brooding is more likely to be associated with depression, while reflection may actually be helpful as a coping mechanism for emotional or challenging experiences. The authors also looked at whether the teens were able to distract themselves from their problems, noting that “individuals who have a greater tendency to ruminate and a lesser tendency to distract are at the greatest risk for experiencing depressive symptoms.”

They found that while much of brooding is influenced by environmental influences such as parenting and peers, virtually all of the connection between whether that brooding is associated with depression may be driven by genes.  Someone who inherits a tendency to brood, in other words, also seems to inherit a tendency to become depressed.

“I appreciated the authors’ distinction between brooding and distraction and their finding that the two played opposite roles,” says Gregory Smith, professor of psychology at the University of Kentucky in Lexington, who was not associated with the research, “At the core, they found that although brooding is not highly heritable, genetic influences appear to contribute to the relationship between brooding and depression.”

That doesn’t mean that people who brood are necessarily at higher risk of depression. Because the research only looked at the twins at one point in time, the authors note that “it remains unclear from our results alone whether brooding is a risk factor for depression or is merely associated with depressed mood concurrently.”  Since rumination can be re-directed and managed through cognitive behavioral therapy or other interventions, figuring out whether the tendency to brood can trigger depression could lead to early and effective treatments, which might actually prevent depression by stopping ruminating before it becomes engrained in brain circuitry.

Smith, who is also investigating some of the potential root causes of depression, reports in his study, published in Psychological Science, on an interesting connection between depression and people’s tendency to act without thinking when faced with strong emotion, known among psychologists as “urgency.” Although this behavior seems unrelated to depression, he and his colleagues found a surprising link.

“In numerous longitudinal studies, [urgency] has been shown to predict subsequent involvement in a range of rash, ill-advised behaviors, including problem drinking, pathological gambling, smoking, risky sex, drug use, binge eating, and others,” he says.

And what’s driving these behaviors is an impulse to act without considering the consequences. “It might be [more] useful to understand impulsivity more broadly: as the tendency to respond to an immediate urge or need, without due consideration of one’s ongoing, long-term interests and health,” Smith says.

That can lead to not acting when it’s necessary, as well as actively making poor choices. “Sometimes inaction can meet an immediate need at the expense of an ongoing goal pursuit,” he says. “For example, one might be very nervous about asking one’s boss for a promotion and raise. Inaction [not asking] would alleviate the immediate nervousness, but at the expense of one’s longer-term interests.”

In the study, Smith and his colleagues studied over 1,900 fifth graders as they made the transition from elementary school into sixth grade middle school.  After controlling for factors like gender and early onset of puberty that could also affect depression, they found that fifth grade urgency was one of the best predictors of being depressed in sixth grade:  the only greater predictor was already having been depressed in fifth grade.

And this prediction held up even after the authors controlled for early involvement with smoking, drinking or binge eating:  addictive behaviors that might themselves lead to depression because of their negative consequences.  Instead, the findings suggest that impulsivity in the face of emotion — leading to either action or inaction — increases risk for both addictive disorders and depression.

While the connections between either ruminative negative thoughts or impulsive behaviors and depression might seem obvious, such finer-grained understanding of how these tendencies may contribute to depression could lead to better ways of preventing an array of behavior problems.

Why Married People Are Smug and Singles So Carefree

2013-03-07

By Maia Szalavitz

If you’re single, you can’t seem to get away from the couple who won’t stop cooing and talking about how great it is to be in a relationship and how relieved they are to be spared from the horrors of dating.  And if you’re married, you can’t stop hearing from singles about how marriage is a hellish trap and their own commitment-free life is a blissful expression of their independence.

It may not make the annoying nature of your self-satisfied friends any easier to take but a new study may explain why people in relationships are so convinced that partners are the way to go, while those who are single adamantly refuse to accept the joys of being part of a pair.  People who see their relationship status as unlikely to change are prone to idealize it— while those who are open to other possibilities don’t feel the need to boost themselves by disparaging the status of others.  Understanding the psychology of this process can help explain a lot of otherwise mystifying behavior among both singles and couples.

The study, which will be published in Psychological Science, is based on the theory of “cognitive dissonance,” a phenomenon first described in the 1950s. If you are deeply committed to a belief and have acted in ways that you think are irreversible as a result, it’s often easier to change your other beliefs and actions than it is to question the original idea.

“Cognitive dissonance happens when we’ve made a choice and we’re not 100% satisfied with it or it goes against something we believe,” says Kristin Laurin, assistant professor of organizational behavior at Stanford University, the lead author of the study,  “We feel uncomfortable, so what we do is adapt our attitudes so now the choice fits better with the attitude.”

The term was first coined by psychologist Leon Festinger, who studied members of an apocalyptic cult. After they had quit their jobs, cut ties with outside friends and family and sold their belongings, the predicted catastrophic flood failed to arrive. The leader gave them a lame explanation that it had been their faith that saved the world.  But while some members did quit, many others became even more fervent, in a desperate attempt to justify their already-made decisions to dedicate their lives to the cult.

Festinger and his colleagues and students soon found that a similar reaction occurs in many cases where people have paid a high price for something that fails to deliver fully.  In fact, these studies find that the more people pay for something, the more likely they are to see it as having been worth it.  Whether it’s wine or a car or even a fraternity initiation, the more you pay in cash or emotional pain, the better you tend to feel about what you’ve gotten. (This is part of why hazing is so hard to eradicate:  it does increase loyalty).

Laurin and her colleagues suspected that a similar thought process might take place when people consider their relationship status.  If you believe you are likely to stay single, it can be easier to look on the bright side, rather than constantly spending time envying people in pairs.  Similarly, if you think your relationship is going to last, it’s not a great idea to focus on the upside of being unpartnered.

Researchers tested these ideas in several experiments, one of which was conducted on Valentine’s Day two years ago. In that study, 113 college students were offered chocolates for answering survey questions about their current relationship status and whether they felt it was likely to last.

Then, they read a description of a student of the same gender, who was either single or in a relationship and were asked to write a few paragraphs about how they thought that person would spend Valentine’s evening. They also quantified how happy and fulfilled the person would be and were asked if they thought the student in the example would have a better evening if they had the opposite relational status to the one described.

As predicted, participants who saw their relational status as unlikely to change made more positive judgments about those who shared that status and were more negative about those who didn’t.

“The more the coupled people felt that their relationship was going to last, the more they wrote happy stories about relationships and sad, unhappy stories about being single,” Laurin says, “And conversely the more single people thought that they would be single for a long time, the more they wrote happy stories about single and sad, unhappy stories about relationships.”

These preferences may help explain why single people tend to find that their friends drop them when they couple up — and why couples who break up often find themselves excluded by their married friends. “I think that definitely contributes to the divide you see,” says Laurin.

However, the research did not find that couples were more likely to idealize their status than singles were — even when similar experiments were done with older adults, amongst whom being single is more stigmatized than it is in college.

“That was one of most surprising things we found,” Laurin says,  “We thought that since there’s a prevailing cultural ideology that people should be in relationships, [it] might be harder for single people to say ‘Yeah, it’s totally awesome [being single],’ but we actually found exact same size effect across both groups.”

Other experiments explored whether cuing people to think about their relational status as more or less changeable would reduce the effect (it did) and whether being more satisfied as a single or coupled person would account for the idealization of one’s own status (it didn’t).

So whether or not you have someone to come home to on Valentine’s Day — take heart.  Those smug married people or carefree singles don’t actually have it better— they just want to convince themselves that they do.