There’s been a lovely synchronicity of publishing across journals this month – with both British Journal of Psychiatry and Schizophrenia Bulletin publishing articles on a topic of great interest to me – mood instability.
Mood instability is a common presenting feature of many people referred for psychiatric assessment – in community mental health team assessments up to 80% of those presenting may complain of a degree of mood instability (Gilbert, 2005) [Wiley pay wall]. My own most recent experience in prison clinics would also support a high prevalence.
Traditionally psychiatry has divided clinical presentations into psychotic and neurotic symptom clusters. This classical division is now somewhat tenuous however – there is substantial evidence of psychotic symptoms being present in, so called, neurotic presentations (Kelleher 2014 – recent editorial review [PDF, Open Access]).
Marwaha et al – Schizophrenia Bulletin
Marwaha and colleagues [PDF, open access] present a study in Schizophrenia Bulletin this month in which they use British National Survey data to assess the relationship between mood instability and psychotic symptoms. They also look to explore mood instability as a mediator between reported childhood sexual abuse and later onset of psychotic symptoms.
Briefly their methods were as follows:
- Assess rates of possible psychotic symptoms – paranoid ideation or auditory hallucinations
- Assess for presence of mood instability (answer to question – “do you have a lot of sudden mood changes?”.
- Test for:
- Mood instability correlating with psychotic symptoms
- Mood instability correlating with maintenance of psychotic symptoms
- Mood instability as mediating influence between reported childhood sexual abuse and psychotic symptoms
- Test for confounding factors – sociodemographic status, co-morbid mood symptoms, PTSD symptoms
- Mood instability correlated with the presence of probable psychosis:
- Odds ratio 7.51 (95% CI 4.1-13.8), 1.99 (1.1-3.7) after adjusting in 2000 cohort
- Odds ratio 21.43 (95% CI 9.7 – 41.2) 8.11 (2.8 – 23.5) after adjusting in 2007 cohort
- The presence of mood instability significantly correlated with maintenance of paranoid ideation, but there was only a trend correlation with maintenance of auditory hallucinations.
- Using mood instability as a possible mediator between childhood sexual abuse and later psychosis saw a significant mediation effect accounting for approximately 1/3 of the variation.
Discussion and limitations
Building on epidemiological data the study is obviously limited in its application to the phenomenological experience of mood instability and later psychosis. Correlation does not necessarily imply causation – but, as the authors note, the findings indicate that further research is needed to explore the nature of the relationship – in particular phenomenological work.
The link between mood instability, psychosis and the possible mediating effects in relation to childhood sexual abuse link well with traumagenic models of psychosis (Read et al 2014 [PDF, Open Access]). This model seeks to link the correlation between early life trauma and subsequent psychotic experiences to neuroimaging evidence and disruption of the hypothalamic-pituitary (stress response) axis.
Experiences of mood instability do, in my opinion, provide a plausible link to these lines of thinking and I think this is an area of research that has been neglected, possibly because of long-standing beliefs as to the nature of the psychosis-neurosis divide.
Bilderbeck et al 2014
The Marwaha et al study raises some interesting questions and highlights the importance of good clinical exploration of mood experience, and the role of possible trauma in the development of psychotic symptoms.
Serendipitously in this month’s BJP we have a paper from a group of Oxford based researchers looking at the experience of service users referred to secondary care for assessment of mood instability symptoms [Abstract, RCPsych UK Paywall] (Bilderbeck, A. C., Saunders, K. E. A., Price, J., & Goodwin, G. M. (2014). Psychiatric assessment of mood instability: qualitative study of patient experience. The British Journal of Psychiatry, 204(3), 234–239. doi:10.1192/bjp.bp.113.128348).
The authors use qualitative methods to explore the experience of assessment in secondary care. They looked to understand what service users were seeking in the experience as well as their feelings after assessment. Their significant themes are summarised here:
- Wanting an explanation and help
- The participants explained that an overall goal for them was to receive some form of explanation, and help, for their experiences. Their attitudes towards diagnosis varied – some were particularly concerned about possibly being diagnosed with Bipolar affective disorder, others felt that the diagnosis was secondary to some form of explanation. For some participants receiving a diagnosis was inadequate, not being felt to adequately cover the nature of their experiences.
- Wanting consistent and continuous care
- The participants described wanting to experience a degree of continuity in the support they were offered. Some were disturbed by seeing different clinicians at each assessment.
- Struggling to communicate and be understood
- The participants described their difficulty in communicating with the assessing clinicians. Some described feeling pressured during the assessment. Influences from early life traumatic experience were described as significant to the participants, however it was not always felt to be easy to communicate these issues.
- Wanting to feel involved and informed
- The participants wished to be involved in the assessment and care planning process, unfortunately this was not a universally positive experience. Some participants also highlighted issues around stigma in relation to psychiatric diagnosis, again unfortunately not all participants felt this was adequately addressed and found themselves having to find information for themselves.
- Wanting to be acknowledged, but often feeling dismissed and discredited
- Participants described wanting to feel acknowledged, empathised with and cared for during the assessment process. Unfortunately this was not a universal experience with some participants describing feeling that assessments were dismissive, limited by time pressures, overly formal / impersonal and frustrating. The nature of diagnosis, particularly personality disorder, was also questioned – with some participants finding explanations to lack utility or meaning.
In my experience mood instability is a common presentation to the mental health services that is associated with a great deal of distress. Accompanied by intense emotional feelings during consultation it can also be difficult for assessing clinicians to sufficiently contain their client’s distress.
Recent research seems to highlight however the significance of emotional instability, with traditional diagnostic boundaries being eroded and questioned.
The prevalence of previous childhood trauma, combined with the possible mediating influence of mood instability, also highlights the need for a sensitive handling of clinical assessment.
Sadly these factors do not always appear adequately addressed and some service users may still be left distressed and discontent with their mental health service contact.
Mental health services need to focus on these issues – people present to us in crisis and in need of compassion and support. Greater research understanding of links between phenomenological experience will obviously be of benefit, but likely ultimately to be of limited benefit if we struggle to meet distress with appropriate compassion.