University of Groningen
Early detection and prevention of first symptoms of psychiatric disorders in adolescence el Bouhaddani, Saliha
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10.33612/diss.99345675
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2019
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el Bouhaddani, S. (2019). Early detection and prevention of first symptoms of psychiatric disorders in adolescence. Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.99345675
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WiSdoM bEgINS IN WonDER
Socrates
7
GeneRal i••Duc•oN
INTRoduction
Many adolescents struggle with negative thoughts or find it difficult to cope with stressful situations [1]. These adolescents may be at a higher risk for developing a psychiatric disorder later in life. Seventy-five per cent of all severe psychiatric disorders, as defined by a chronic trajectory and substantially impaired functioning, develop in adolescence or early adulthood [2]. Therefore, it is important to identify those adolescents at risk for psychiatric symptoms and make them more resilient to stressful events. This thesis aims to capture the spirit of the following questions: how can adolescents at risk for persistent psychiatric symptoms be identified early? And is it possible to reduce the risk of persistent problems through an easily accessible and acceptable intervention that emphasises positive psychological development?
Adolescence is a key phase in life, marked by physical and psychological changes.
This often co-occurs with an increase of potentially stressful experiences, such as peer pressure and increased performance requirements at school [1]. These changes require self-esteem and social status [3]. An important phenomenon in this period is the need to belong to a social group [4]. How they are perceived by others can be a daily worry for adolescents. It is therefore not surprising that this challenging phase is often accompanied by increased stress, making adolescents vulnerable to developing psychosocial problems.
The term psychosocial problems refers to an extensive group of problems, including anxiety, depression and behavioural problems [5]. In the Netherlands, various large-scale longitudinal studies examining emotional and behavioural problems in general population adolescents have indicated that 16–22% of the adolescents studied, had psychosocial problems [5, 6]. In the U.S., a recent
8
national survey among 10,123 adolescents between 13 and 18 years of age reported a prevalence rate of 22.2% for psychiatric disorders [7]. Anxiety disorder was the most prevalent disorder, followed by behavioural disorder and mood disorder [7].
Subgroups of adolescents, such as ethnic minorities, may differ in their risk of developing psychosocial problems. Reported prevalence rates of psychosocial problems in ethnic minority adolescents were either similar or higher than that of their Dutch peers [8–10]. Ethnic minority youths reported more psychotic experiences and more externalising problems than native youths [9, 11, 12].
Further, studies have shown that non-Western minorities, especially Dutch- Moroccan minorities, are at higher risk for developing psychotic disorders and mental health problems in general than Dutch youths [8, 11, 13, 14].
On the other hand, ethnic minority youths reported less internalising problems than native youths [9]. As an explanation for this apparent paradox, it has been suggested that, due to their disadvantaged position in society, ethnic minorities may develop an external attribution style to protect themselves against internalising problems, which might lead to more externalising than internalising problems [15].
The importance of early identification
Early identification, defined as detecting the onset of a psychiatric disorder at an early stage, has received increased attention in recent years. The increased emphasis on early identification is mainly fuelled by epidemiological data showing that approximately 75% of psychiatric disorders develop in the first 25 years of life. Early detection fits well within a staging model, in which the development of mental disorders is seen as a longitudinal continuum consisting of several stages [16]. Fusar-Poli and colleagues [17] have argued that, often, the first symptoms of psychiatric disorders are a combination of non-specific dysregulations (insomnia, anxiety, depression) that dynamically influence each other and that, over time, develop into specific clinical disorders such as anxiety, mood and psychotic disorders. Figure 1 displays this staging model, in which psychiatric symptoms evolve from non-specific early symptoms to diagnosable syndromes of psychiatric disorders [18]. This makes early, mild and non-specific symptoms potential markers of emerging psychiatric disorders [17, 19]. However, how these early symptoms are related to the
Chapter 1 9
development of a psychiatric disorder is not well understood. For instance, in adolescence, psychosocial problems – and even psychiatric symptoms – are very common, and often transient. Examining the trajectories of symptoms provides the opportunity to identify markers for persistency of symptoms and to develop early intervention methods.
Insomnia
Worry
Anxiety
Avoidance
Panic
Low mood Guilt Slowed thought
Anergia
Worry
Avolition
Salience
Hallucinations
Delusions
Anxiety Syndrome
Mood Syndrome
Psychosis Syndrome Stage of
nonspecific mental syndrome
Stage of specific mental syndrome Early intervention
FIGURE 1. Staging model of early psychiatric symptoms (based on Van Os, 2013 [18])
10
Prevention and early treatment
Prevention can be defined on three different levels [20]. First of all, universal prevention focuses on promoting the health of an entire group, regardless of the risk for a disease. Second, selective prevention targets people who have an increased risk of developing a certain disorder. Third, indicated prevention aims to prevent certain symptoms of a disorder from worsening. Meta-analytic studies have shown that selective and indicated prevention can be effective for depression, anxiety and behavioural problems [21–23]. However, the effects are often small (e.g. Hedges' g around 0.20 [24]). These interventions often focus on one or two specific psychiatric disorders, while recent studies have shown that psychiatric symptoms in adolescence co-occur and often cannot be linked to a specific psychiatric disorder [12, 18, 25, 26].
A transdiagnostic approach, based on the assumption that common mechanisms explain various symptoms, is therefore required to prevent these unspecific symptoms from developing into full-blown disorders and to stimulate resilience. In order to address processes that play a role in the onset or maintenance of multiple psychiatric symptoms, intervention tools should be flexible [27, 28]. In addition, in order to strengthen resilience to a variety of symptoms, the focus should be on positive psychological development rather than on psychopathology [29, 30]. Mechanisms that potentially meet these criteria are empowerment and cognitive biases.
Currently, few interventions address multiple early symptoms. It is common in the field of youth mental health to focus on specific psychiatric symptoms, such as anxiety or depressed mood. However, symptoms of depression can, for example, develop into an anxiety disorder [31] and psychotic experiences can precede non-psychotic disorders such as depression [32]. The treatment of early symptoms must therefore be more general, development-oriented and strongly focused on risk and protective factors instead of symptoms [33].
Empowerment
Empowerment is an important general protective factor and helpful in strengthening resilience. Empowerment can be defined as a process by which people gain greater control over their lives, participate in decision-making and develop critical awareness of their environment [34]. It is associated with enhanced positive psychological development. There are various models that describe empowerment. Zimmerman’s model of psychological empowerment describes empowerment as a developmental phenomenon that includes three key components. The intrapsychic component refers to a person’s internal sense
Chapter 1 11
FIGURE 2. Adolescent empowerment cycle (based on Chinman and Linney, 1998 [35])
of control. The interactional component addresses how people relate to their environment, and the behavioural component refers to taking actions that are self-motivated. These three key components are similar to the developmental tasks that characterise adolescence [34].
Another model frequently used to explain empowerment is the adolescent empowerment cycle ([35]; figure 2). This model implies that adolescents develop a stable, positive identity and enhanced self-esteem by experimenting with different roles and taking part in positive activities. This model states that empowerment can lead to better self-efficacy, which is related to an increased ability to seize opportunities and to change situations.
Many theories on adolescent development and problem behaviour include similar concepts, which implies that the empowerment process is of great importance to positive development in adolescence [35]. Studies have indicated that enhancing youth empowerment is a promising strategy to promote healthy development and self-esteem [36–39].
Identity Crisis Formation Role lessness
Social Bonding Development
Nature of activities in which to participate
Participation in activities Receive positive reinforcement
Need to experiment with different roles;
need for stable identity
Bond to positive institutions
Developmental gains:
• Positive identity development
• Positive role choice
• Enhanced self-efficacy/self-esteem
12
Cognitive biases
Cognitive biases are argued to be a general risk factor for the emergence and persistence of psychiatric problems [36, 37]. Various theories have underlined the role of cognition in emotional problems [38]. Beck’s cognitive theory is one of the most substantial and valid ones. This theory claims that cognitive processes play a definite role in the maintenance and development of psychiatric problems. People’s basic beliefs, referred to as ‘schemas’ [36], form a fundamental concept in the theory. Schemas are organised representations of experiences that are stored in memory and that serve as a mental filter, guiding the selection, interpretation and recall of information [39]. Beck affirms that people have the tendency to process their thoughts in a manner consistent with their common standpoint. Each individual possesses schemas about him-/herself, others and the world. These schemas differ as a result of life experiences and events. For example, a person who has suffered a negative experience such as maltreatment is more likely to develop negative schemas, thereby increasing the risk of that individual developing a mental health disorder [39]. It is assumed that schemas lead to different cognitive distortions, such as an attention bias.
Negative attention bias refers to the phenomenon whereby some people selectively shift their attention towards and linger on negative stimuli [40].
Attention bias is considered an important mechanism in experimental treatments. Studies have shown that negative attention bias decreases after treatment and that this reduction moderates the post-treatment decrease of psychiatric symptoms (e.g. [41]). These interventions are based on the hypothesis that psychiatric symptoms are often adversely affected by negative attention biases (biases towards negative stimuli). There are several theories about the nature of attention bias. According to Mathews and Mackintosh’s model [42], negative attention bias is the result of an evaluation system in the brain that increases the activation of threat-related aspects of an event. Beck and Clark [36] presume that negative attention bias results from a starting threat that activates the processing of threat-related material. This results in the activation of cognitive, physiological and behavioural anxiety responses [43]. These two approaches share the assumption that anxious people are characterised by a higher threat evaluation, even when the true threat is mild or ambiguous [43]. A recent study by Troller-Renfree and colleagues [44] showed that an attention bias towards positive or neutral stimuli was associated with less emotional problems and better coping mechanisms amongst children with a history of psychosocial deprivation.
Attention bias modification (ABM) procedures have been designed to train
Chapter 1 13
attention away from negative information towards positive information, with the aim of reducing symptoms [45–47]. ABM has been examined in both adult and adolescent samples. Several metanalytic studies have shown medium effect sizes for ABM as a treatment for anxiety in children and adolescents [48].
This study
The study presented in this thesis aims, in order to identify potential markers of risk for psychiatric disorders and to develop an intervention for selective prevention, to investigate the early detection of psychiatric symptoms in adolescents. Psychiatric symptoms are defined in a broad way, including both psychosocial problems (emotional and behavioural problems) and psychotic experiences. Psychotic experiences refer to subthreshold symptoms such as subthreshold delusions and subthreshold hallucinations that may be of a mildly distressing nature but that do not lead to direct help-seeking [49].
The thesis reports on data from a general population multi-ethnic sample of adolescents (see Figure 3). Adolescents from 12 secondary schools were screened for psychiatric symptoms and contextual risk factors. Given the instability of symptoms in adolescence, and in order to select at-risk youths, we used a two-stage screening with a follow-up at 12 months. A total of 1,841 adolescents and their mentors filled out screening questionnaires at the baseline point and at least 12 months later. This enabled us to identify adolescents eligible for an indicated preventive intervention and to detect markers of persistent psychosocial problems. Adolescents who reported high levels of psychiatric symptoms at both screening assessments were eligible for an intervention that was developed for this study. Over the course of eight weeks, the adolescents who agreed to participate underwent a group intervention at school. The programme consisted of weekly sessions of 90 minutes each. The intervention contained elements of empowerment and ABM and was developed to be suitable for a broad range of adolescents. We included both verbal and non-verbal training methods. In addition, we included scenarios and examples of difficult situations adolescents might encounter in our multicultural society. This made it easier for those with a non-Western, migrant background to identify with elements of the intervention. Before implementing the intervention, a panel of adolescents and professionals advised us on the content of the intervention. We also carried out a pilot study before implementing the intervention at schools.
The first part of each group session contained empowerment elements and was carried out by two trainers. This part focused on resilience, identity
14
and problem-solving skills through the use of role-playing and pencil-and- paper exercises. The second part consisted of training based on ABM. The ABM component comprised a visual search face-detection task. In this task, participants were confronted with 16 facial expressions, denoting either a positive emotion (happiness) or a negative emotion (anger, fear or sadness).
The participants had to find the single face associated with a positive emotion amongst the faces showing negative emotions. In this way, possible attention biases were adjusted. The available set of faces (the NIHM set by Egger et al.
[50]) consisted mostly of adolescents with a Western background. In order to adapt the task to a broad range of adolescents, we created a new set of pictures of ethnic minority youths. This set consisted of pictures of adolescents aged 11 to 17 years of various non-Western ethnic backgrounds. All participants filled out questionnaires before and after the intervention and at the follow-up six months later. We used this data to examine the effectiveness of the intervention.
Outline of the thesis
In Chapter 2 we discuss the associations between low peer status and psychotic experiences and psychosocial problems. In Chapter 3 we describe the prevalence of attention bias for negative emotions in an adolescent population.
In Chapter 4 we examine the prevalence of psychotic experiences and the association between psychotic experiences, ethnic identity and perceived discrimination. In Chapter 5 we examine markers for persistent psychosocial problems. In Chapter 6 we examine the effectiveness of a transdiagnostic intervention targeting the general underlying mechanisms of psychiatric symptoms. Chapter 7 contains a summary of the study, a general discussion and recommendations for future research.
T0 T1 T2 T3
Baseline
screening Second
screening Posttreatment
screening Follow-up
• 12 months • 1-2 month(s) 3 months • 6 months •
Se c on IN on
FIGURE 3. Flowchart of the study
Chapter 1 15
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