Appraising appraisals: role of belief in psychotic experiences
Authors: Angela Woods, Sam Wilkinson
Journal: The Lancet Psychiatry (2017)

There is a burgeoning interest, particularly among psychosis and hallucinations researchers, in the prevalence of so-called psychotic experiences in the general population. Individuals who are variously presented in the research literature as "non-clinical" or "healthy" or "without a need for care" provide an opportunity to explore and understand unusual experiences without the confounding factors that come with diagnosis.3Johns LC Kompus K Connell M et al.Auditory verbal hallucinations in persons with and without a need for care.Schizophr Bull. 2014; 40: S255-S264Crossref PubMed Scopus (194) Google Scholar Frequently studied in clinical terms with clinical measures, this group is neither a natural nor homogeneous cohort, but may be thought of as an artifact of the effort to investigate what leads people with apparently very similar experiences to meet or not meet criteria for diagnosis. The Unusual Experiences Inquiry (UNIQUE) study involves one of the largest samples of people with frequent unusual experiences but no need for clinical care.4Peters E Ward T Jackson M Morgan C Charalambides M McGuire P et al.Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a 'need for care'.World Psychiatry. 2016; 15: 41-52Crossref PubMed Scopus (97) Google Scholar In The Lancet Psychiatry, Emmanuelle Peters and colleagues5Peters E Ward T Jackson M Woodruff P Morgan C McGuire P Garety PA Clinical relevance of appraisals of persistent psychotic experiences in people with and without need for care: and experimental study.Lancet Psychiatry. 2017; 4: 927-936Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar report an experimental study involving 84 people with diagnosed psychotic disorders (clinical group), 92 participants from the general population with persistent psychotic experiences but without a need for care (non-clinical group), and 83 controls from the general population without persistent psychotic experiences, to investigate how they make sense of unusual experiences. They used a dual approach of a structured clinical interview in the clinical and non-clinical groups to assess participants' appraisals of their own psychotic experiences, and an experimental stage in which all participants completed three tasks that were designed to simulate transient unusual experiences similar to psychotic experiences. When asked to explain how each task worked, participants in the non-clinical group were likely to offer appraisals that were spiritual, normalising, and non-personal in nature. By contrast, those in the clinical group appraised the experiences as negative, dangerous, and personal. As the authors note, these data support the underlying logic and clinical relevance of this kind of research, showing that "the way in which psychotic experiences are interpreted, rather than merely their presence, is important to clinical status". By using novel experimental measures alongside existing clinical constructs, Peters and colleagues' study points to the clinical relevance of appraisals in understanding how and for whom psychotic experiences can be distressing. We suggest that future research could benefit from disambiguation of the nature of appraisals and further reflection on the tools and methods with which they are studied. There are at least two options for how we could think of appraisals. First, an appraisal can be understood as a belief about the origins and importance of an experience. This approach brings to prominence questions of temporality: is a belief formed as the experience is unfolding or does it happen after the fact, as a retrospective interpretation? If both are appraisals, simply of different types, what is the interplay between them? A second approach is to not to think of appraisals on the model of beliefs (ie, knowledge-based responses made to determinate experiences) at all, but rather as background states of the person that exist before the experience and contribute to determining the experience itself. This account, and what it suggests about the nature of experience more generally, is in keeping with Bayesian approaches to cognition that view every experience-generating interaction with the world as preloaded with so-called priors.6Fletcher PC Frith CD Perceiving is believing: a Bayesian approach to explaining the positive symptoms of schizophrenia.Nat Rev Neurosci. 2008; 10: 48-58Crossref PubMed Scopus (879) Google Scholar These priors would correspond to the notion of appraisal and contribute to the experience being the way that it is. Such a view is also congruent with more phenomenologically minded accounts7Ratcliffe M Feelings of being: phenomenology, psychiatry and the sense of reality. Oxford University Press, Oxford2008: 324Google Scholar that view psychosis in terms of changes in people's background modes of being in the world. In relation to psychotic experiences particularly, which of these approaches is accurate has clinical and theoretical consequences. The first, belief-based, approach suggests suitability of an intervention that targets specific interpretations of specific experiences. The second, background-state, option supports a more holistic intervention addressing the person's moods, emotions, or modes of being—ie, how they more generally relate to the world. These approaches in turn prompt us to ask new questions about the populations under investigation. Peters and colleagues5Peters E Ward T Jackson M Woodruff P Morgan C McGuire P Garety PA Clinical relevance of appraisals of persistent psychotic experiences in people with and without need for care: and experimental study.Lancet Psychiatry. 2017; 4: 927-936Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar describe their non-clinical group as being highly selective, consisting of high-functioning people who were generally members of subcultural groups that provide validation and acceptance of psychotic experiences. Although they state that the aim of the study was not to characterise a general population sample with psychotic experiences, but to compare individuals with poor and good outcomes of their psychotic experiences, the clinical relevance of their findings will depend, at least in part, on the transferability of characteristics and practices from one group to another. Research has highlighted the importance of understanding beliefs about anomalous experiences within the context of individuals' spiritual beliefs,8Luhrmann TM When God talks back: understanding the American evangelical relationship with God. Vintage Books, New York, NY2012Google Scholar, 9Powers AR Kelley MS Corlett PR Varieties of voice-hearing: psychics and the psychosis continuum.Schizophr Bull. 2017; 43: 84-98Crossref PubMed Scopus (60) Google Scholar and shown that appraisal is not simply an in-the-moment assessment, but can develop over time through socially meaningful practices of cultivation, which in turn might shape phenomenology. Comprehensive understanding of these experiences is unlikely to be reached through the methods and measures of psychiatry alone and, therefore, future studies could fruitfully engage concepts and modes of inquiry indigenous to these groups8Luhrmann TM When God talks back: understanding the American evangelical relationship with God. Vintage Books, New York, NY2012Google Scholar and to the many other disciplines engaged in the study of human experience.10Woods A Jones N Bernini M et al.Interdisciplinary approaches to the phenomenology of auditory verbal hallucinations.Schizophr Bull. 2014; 40: 246-254Crossref PubMed Scopus (53) Google Scholar Improved understanding of the relevance of spiritual context in the appraisal of psychotic experiences in non-clinical cohorts has the strong potential to enhance understanding of the importance of context in the ways individuals make sense of psychotic experiences more generally. We declare no competing interests. Clinical relevance of appraisals of persistent psychotic experiences in people with and without a need for care: an experimental studyWe provide robust evidence that the way psychotic experiences are appraised differs between individuals with and without a need for care, supporting cognitive models of psychosis. Specifically, the absence of paranoid and threatening appraisals might protect against persistent psychotic experiences becoming clinically relevant. Full-Text PDF Open Access