Salience and psychosis

Dr. Shitij Kapur is a psychiatrist-neuroscientist at the University of Toronto. He is articulate and creative. Among a number of contributions to a better understanding of psychosis, he has recently proposed a model of psychosis that focuses on the concept of ‘salience’.

Salience, in this model, is defined as a determination, by the brain, as to the relevance, to the person (organism), of any mental experience. Some mental experiences are significant, others are not. The latter can be ignored.

Experiences that are salient, on the other hand, are added to our conceptual framework, our understanding of the world, our beliefs about what is happening.

The heart of Kapur’s model is the idea that psychosis arises from a relative inability of the brain to determine salience. The brain can’t tell the differences between relevant and irrelevant information. There are obvious implications of this inability on the resulting conceptual frameworks, our belief systems.

Let’s look at a simple example. Walking down the street I notice a man sitting in a car, smoking a cigarette. A moment later a woman walks past the car, stops and answers a call on her cell phone. I think nothing of it; no salience to me.

But suppose I couldn’t tell if those two events were salient or not and I assumed, therefore, that they might be. This could start me off a train of thought and speculation. To begin, if these experiences are salient, there must be some reason, related to me, that the man is in the car as I walk by. Was he there to watch me? Was it the man in the car who called the woman? If so, are they working together to spy on me? As you can see, I am well on my way to paranoid delusional system, a belief system that is based on fundamentally flawed ‘evidence’; evidence that is flawed because I am unable to determine salience.

It is interesting that Kapur’s model proposes that psychotic experiences, delusion beliefs in this case, are actually formed in exactly the same way as non-psychotic beliefs. The only difference is that delusions incorporate experiences (information) that are not actually relevant (salient).

One clinical implication is that the person who has formed the delusional belief is as sure that it is true as they are about any non-psychotic belief they hold. Why shouldn’t they be; the belief was formed through the same process.

Psychosis as an extreme state

‘The mind of a person who is psychotic works exactly the same way as the mind of anyone else. The difference is a matter of intensity and duration’.

This assertion, paraphrased from an unpublished presentation in 1985 by Dr. Antonio Wood, a psychiatrist and Buddhist practitioner, points to what I would suggests is a key concept: psychosis does not involve a fundamental change in the way mind operates. Instead, psychosis represents an intensification and extension of experiences that are common to all human beings.

Dr. Wood’s logic begins by pointing out the basic sanity of mind, a state of ‘basic healthiness’ that is, from a Buddhist point of view, the inherent state of mind. Insanity, then, is any departure from basic sanity.

On a moment-to-moment basis all of us (who take the time to notice) frequently and repeatedly lose track of basic sanity, of being present, and drift off into thoughts and emotions of the past or the future. Dr. Wood terms those moments in which we are not fully present as ‘temporary insanity’.

While ‘temporary insanity’ comes and goes, more intensive and long lasting loss of basic sanity occurs in relation to particular areas of our life. These are the life situations and issues that ‘push our buttons’. Our neuroses, the habitual patterns that we experience in these situations, involve a disconnection from what is actually happening around us. Dr. Wood calls this ‘permanent partial insanity’.

Finally, Dr. Wood describes clinical psychosis as ‘extreme neurosis’. In psychosis the loss of connection with basic sanity is more frequent and pervasive. How frequent and how pervasive will differ for each individual.

So, from this point of view, people who experience psychosis are not aliens from another mental planet. They are ordinary human beings who are experiencing an extreme version of what we all experience every moment of every day.

Note: My apologies to Dr. Wood. I have taken his unpublished ideas and presented them in a way that makes sense, and seems helpful, to me (without consulting him). He is certainly not responsible for my misunderstandings.

How is psychosis a problem?

Steve, a university student, begins smelling an intense obnoxious odor emanating from his own body. Despite frequent showers and application of deodorants, the smell persists. Embarrassed, he stops going to classes and is forced to drop out of school.

Marion works in a flower shop to support herself while taking art school classes. She has recently received a raise in pay but over hears, on repeated occasions, her supervisor telling other employees that she is going to be fired. Confused and upset, Marion has difficult sleeping and begins to call in sick to work.

Barry, a young businessman, hears God saying “you can not be harmed, I will protect you”. Not sure if he can believe what God has said, Barry drives his car off a highway at high speed. The car rolls over three times and sustains serious damage. Barry is not hurt.

James becomes convinced over a period of nearly a year that a terrorist organization is stalking him. One day on the street he hears a passerby say “it’s time to grab him”. Convinced that the terrorist are about to abduct and torture him he decides to take control of his fate. He goes to a nearby bridge and jumps. Landing on rocks below, James is paralyzed from the waist down.

Shelia believes that her thoughts cause major world events. On the morning of September 11, 2001 she turns on the TV. Seeing the collapse of the twin towers she is overwhelmed with guilt. Going to the garage, Shelia finds a rope and hangs herself from a rafter.

Note: These five vignettes are based on actual experiences but have been somewhat altered to protect confidentiality.

Constructing Reality

In psychiatry, psychosis is defined as a loss of contact with reality. Perhaps the most obvious interpretation of this definition would be that there is some kind of objective reality ‘out there’ that most of us (‘normal’ people) are in contact with. However, in this post-modern world it is probably no surprise if I suggest that, instead of there being an objective reality, each of us constructs our own experience of what is ‘real’.

The view that there is no objective reality is strongly supported by the neurosciences and what we could call the contemplative sciences, the latter representing the concepts and methods that have arisen during the 2500 year history of introspective observation and scholarly debates by practitioners of Buddhist (and related) meditation.

The neurosciences, using experimental and clinical observations, have demonstrated that perceptual experiences (seeing, hearing, etc) are constructed. Unlike a camera that reproduces a scene, the sensory systems of the brain sample information about the world around us, code it in neural activity, carry out analysis of key features and then construct (and project) a perceptual experience. What we hear, see and feel is a constructed simulation.

In regard to our belief systems, the cognitive neurosciences have explored how we put together concepts and information to create conceptual frameworks that we call our beliefs. From the point of view of contemplative sciences all concepts, indeed all experiences of the phenomenal world, are insubstantial and have no ‘reality’; no independent essence.

Going further, the contemplative sciences have concluded that all mental experiences are created by mind. Our moment-to-moment mental experiences are viewed as being dominated by “primitive beliefs about reality” and are described as being like a dream that we have while awake.

Given these conclusion from western and eastern traditions, perhaps it would be helpful to define psychosis not as a loss of contact with reality, but as an alteration in the way the experience of reality is constructed.

What this blog is about.

This blog is about psychosis and particularly psychosis as it is experienced by young people. From a psychiatric point of view the term psychosis refers to “a loss of contact with reality”. In psychiatric practice psychosis manifests in one, or all, of three ways; as hallucinations (‘false’ perceptions), as delusions (‘false’ beliefs) and as disorganization.

My interest in psychosis in young people stems most directly from the ten years (1996-2005) when I was Clinical Nurse Specialist and Coordinator of the Nova Scotia Early Psychosis Program. During that time I had the privilege of getting to know hundreds of young people who were experiencing psychosis, and their parents.

As I tried to help these young people and their families understand what they were experiencing and how to deal with it, I found myself drawing upon two sources of information from my own background, the neurosciences and the study and practice of Buddhism.

In this blog I will try to bring together information from those two sources (and any others I can find) with the practicalities of clinical care and recovery to accomplish two objectives. The first is to open a door into the complex world of psychosis in young people. The second is to use the concept of psychosis as a focal point for exploring the nature of human mental experience.