The Fear-Avoidance Model of exaggerated pain perception--II.
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Biomedical subjects
Publications and source records attributed to P D Slade.
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The present report is of the effect of variations of auditory input on hallucinatory experiences in seven schizophrenic patients. Nine experimental conditions, each of two minutes' duration were compared with a control condition. At the end of each period subjects were required to rate the duration, loudness, and clarity of hallucinations during that time. Experimental conditions varied according to the amount of structure present in the material and in its attention-commanding properties. One condition required the active monitoring of material presented and resulted in the greatest decrease in hallucinatory experiences. For the passive conditions, findings were broadly consistent with predictions, indicating that it is not stimulation per se, but rather the extent to which structure is present and attended to, that is important in determining the occurrence of hallucinatory phenomena.
As a consequence of technological advances over the last 15 years, patients suffering from terminal renal failure are now being kept alive for considerable periods of time, either by renal haemodialysis or, where appropriate and possible, by renal transplantation. The former necessarily imposes restrictions on the patients' lives which may be manifest at various levels. The basic aim of the study to be reported was to conduct an exploratory investigation of the psychological impact of dialysis on such patients, together with some of the factors that may influence their reactions to it. Using a Semantic Differential technique, 21 patients on dialysis were compared with a group of 21 healthy control subjects in terms of the personal meaning of selected concepts. Both groups were then subdivided on the basis of age, sex and, in the case of the patients, in terms of length of time on dialysis. Subgroup comparisons were then conducted. The findings suggest various hypotheses which have both theoretical and clinical implications.
The term 'schizophrenic' is used in two distinct ways: namely to describe a particular type of illness and also as a label for the person suffering from this illness. If we concentrate on the 'illness' conception of schizophrenia it readily becomes apparent that its definition and nature varies somewhat from one proponent to another. Added to this is the problem that the major conceptions of schizophrenia are based on disjunctive concepts. The basic argument of this paper is that while all clinical conceptions of schizophrenia have assumed the existence of a disease-entity syndrome, no attempt has ever been made to test its logical alternative: namely a random-symptom model. Some data will be presented which are at least compatible with this alternative and some of the theoretical implications spelt out.
1. The antidepressant action of mianserin was tested in a double-blind clinical trial lasting 6 weeks. Forty-six patients with moderate to severe degrees of depression were treated at random with mianserin or diazepam. Patients who failed to improve by week 3 were taken out of the trial. 2. Mianserin was more effective than diazepam in reducing scores on the Hamilton Rating Scale for depression. Fewer patients allocated to mianserin had to be withdrawn from the trial on account of failure to improve. Mianserin was more effective than diazepam in reducing symptoms of 'retarded depression' and as effective as diazepam in reducing symptoms of 'anxious depression'. 3. Mianserin did not cause any more side-effects than diazepam, very few side-effects being encountered with either drug. 4. The design of this trial on antidepressant drugs is commended on ethical grounds.
Previous research has suggested that patients suffering from anorexia nervosa tend to overestimate their body size, whereas normal females tend to be very accurate in this respect. This paper presents the results of further investigations of body perception amongst anorexic and normal females. The results, in contrast to earlier findings, indicate no such difference between groups. Detailed analysis of the data, however, points to the likelihood of certain differences between the present group of anorexic patients and previous groups. Moreover, it seems that body perception disturbance is not a consistent feature of anorexia nervosa and is only present amongst some patients at certain stages during their illness. On subdividing the anorexic group it was demonstrated that patients who vomit tend to overestimate their size more than do non-vomiters. It also seems likely that normal females are far from homogeneous in terms of body perception. In line with previous findings, a direct relationship was found between marked overestimation of body size and an early relapse. Evidence is also discussed which suggests that body perception disturbance is not specific to anorexia nervosa and may reflect an abnormal sensitivity about body size associated with such factors as the anticipation of an undesired change in weight, extreme concern about slimness and anxiety about putting on weight.
Two alternative explanations of the body-image abnormality in anorexia nervosa patients are outlined: namely, the 'abnormal sensitivity' and 'adaptational failure' hypotheses. Evidence relating to these 2 conflicting hypotheses was obtained from body-perception measurements carried out on groups of pregnant women. In the first study 40 pregnant women, at approximately 4 month's duration, were found to overestimate their bodily dimensions, albeit to a lesser extent than the previously tested group of anorexia nervosa patients (Slade & Russell, 1973a). When they were subdivided on the basis of a history of weight change over the previous 12 months, the 'stable weight' subgroup was found to overestimate significantly more than the 'weight gain' and 'weight loss' subgroups. In a second study 16 of the original group of pregnant women were retested at approximately 8 month's duration. Although their weight and bodily dimensions had increased on retesting, their tendency to overestimate was found to be significantly reduced. It was concluded that the phenomenon of body-image disorder is not specific to anorexia nervosa, extending not only to patients with obesity and to some normal women, but also to women during pregnancy. Moreover, the 'abnormal sensitivity' hypothesis was considered to fit these and other recently accumulated data better than the alternative 'adaptational failure' hypothesis. Some of the theoretical and clinical implications of these findings are discussed.
Previous research by the author (Slade, 1972, 1973) and others has suggested that psychological stress plays an important role in triggering off the experience of auditory hallucinations. Clearly, however, predispositional factors are involved as well. The present study is an attempt to investigate some of the psychological factors which may predispose the individual to such experiences. A battery of tests involving cognitive, personality and mental imagery variables and the verbal transformation effect was administered to two small groups of psychotic patients differing only in respect of a history of auditory hallucinations and a normal control group. The main conclusion was that the results lend direct support to the proposition of Mintz & Alpert (1972) that a combination of vivid mental imagery and poor reality-testing in the auditory modality provides the basic predisposition for the experience of auditory hallucinations.
The research findings of the writer to date on auditorily hallucinated patients are briefly summarized and an hypothetical four-factor model outlined to account for them. This general working model envisages auditory hallucinations as stemming from the interaction of psychological stress with an underlying hallucinatroy predisposition which is to a large extent genetically determined. A third factor of external stimulation is seen as exerting an inhibitory effect on the conscious experience of the hallucination. While a fourth speculative factor of a positive feedback loop is introduced to account for a number of otherwise incompatible observations. Each of the four factors in the hypothetical model is defined as precisely as is possible at present and discussed in relation to other research findings in this area and to the literature more generally. An attempt is made to spell out some of the theoretical predictions and clinical implications of the model.
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