1. Social Defeat and Psychosis Examining the Need for Connection Dr Kirsty Agar-Jacomb Principal Psychologist Adult Mental Health Services, WDHB kirsty.agar@waitematadhb.govt.nz

2. Overview ➢ What is Social Defeat? ➢ Social Defeat and Psychosis ➢ Epigenetics ➢ Social Psychological Survival ➢ Inequality ➢ What can we do?

3. “You think I'll weep No, I'll not weep I have full cause of weeping, but this heart Shall break into a hundred thousand flaws Or ere I'll weep. O fool! I shall go mad“ (William Shakespeare; King Lear)

4. What is Social Defeat? The negative experience of being excluded from the majority group + The interpretation of this situation as defeating Feeling of outsider status and reduced value

5. Social Defeat and Psychosis Migration and abuse -> Social Defeat -> Psychosis Social Defeat was the common denominator of 5 major risk factors of psychosis ➢ urban upbringing ➢ migration ➢ childhood trauma ➢ low intelligence, ➢ drug use (Contor-Graae & Selten, 2005; Selten et al. 2013)

6. van Nierop et al. (2013) Childhood trauma leads to social defeat, which in turn leads to psychotic experiences in the general population, with mediation by affective dysregulation SOCIAL DEFEAT AFFECTIVE DYSREGULATION CHILDHOOD TRAUMA PSYCHOTIC EXPERIENCES Direct Effect: 19.6% Indirect Effect: 30.7% Indirect Effect: 49.7%

7. van Nierop (2013) Effects of childhood trauma on the development of psychotic disorder is mediated by social defeat SOCIAL DEFEAT CHILDHOOD TRAUMA PSYCHOTIC DISORDER Direct Effect: 13.4% Indirect Effect: 86.6%

8. Epigenetics ➢ Modifications to the genetic material that influence the way genes function without changing the DNA sequence. ➢ Early life experiences effect when, how, and to what degree different genes are actually activated. “Nature dancing with nurture over time”

9. Epigenetics High levels or prolonged exposure to stress is toxic and leads to alterations in regulation of stress- mediating systems (and many other effects) Changes in brain structure and function e.g. amygdala, hippocampus, prefrontal cortex which then affects learning, memory and executive functioning. … more stress-sensitive, more anxiety, less top-down control of emotions (affect dysregulation) and memory etc. etc.

11. Social Psychological Survival ➢ The brain is an extremely complicated survival machine. ➢ Social psychological survival is what is at stake in psychosis and other mental distress. ➢ Tasks with social evaluative threat are the most stressful ➢ Social defeat is toxic

12. Income Inequality ➢ Low social status has a “determining effect on health”. ➢ Income inequality is directly linked to differences in social status. (Verhaeghe, 2014) ➢ Psychosocial effects of inequality (Wilkinson & Pickett, 2009) ○Valued or devalued ○More superiority and inferiority ○More status competition and consumerism ○More status anxiety ○More worry about how we are seen and judged ○More social evaluation anxiety (threats to self esteem, social status, fear of negative evaluation)

13. What can we do? ➢ Societal ○Address income inequality ○Keep working to address stigma ○Celebrate diversity ○Greater integration of brain, mind and culture ➢ Interpersonal ○Authentic compassionate relationships ○Social inclusion opportunities ○Trauma histories ○Share stories ➢ Individual ○Redefine success and failure ○Self compassion ○Spirituality

14. References ➢ Cantor-Graae & Selten (2005). Schizophrenia and migration: A meta- analysis and review. American Journal of Psychiatry, 162, 12-24. ➢ de Botton, A. (2009). A kinder, gentler, philosophy of success. TED Global ➢ Dickerson. T., & Kemeny, M. (2004). Acute stressors and cortisol responses: A theoretical integration and synthesis of laboratory research. Psychiatric Bulletin, 130, 355-391. ➢ Holzel, B., Carmody, J., Evans, K., Hoge, E., Dusek, J., Morgan, L., Pitman, R., & Lazar, A. (2010). SCAN, 5, 11-17 ➢ Selten, J., van de Ven, E., Rutten, B., & Cantor-Graae, E. (2013). The social defeat hypothesis of schizophrenia: An update. Schizophrenia Bulletin, 39, 1180-1186. ➢ Shonkoff, J., & Garner, A. (2012), The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129, 232-246.

15. ➢ van Nierop, M., van Os, J., Gunther, N., van Zelst, C., de Graaf, R., ten Have, M., van Dorsselaer, S., Bak, M., Myin-Germeys, I., & van Winkel, R. (2013). Does social defeat mediate the association between childhood trauma nd psychosis? Evidence from the NEMESIS-2 study. Acta Psychiatrica Scandinavica, 1-10. ➢ Verhaeghe, P. (2014). What About Me? The Struggle For Identity in a Market-Based Society. Scribe Publications ➢ Wilkinson, R. & Pickett, K. (2009). The Spirit Level: Why More Equal Societies Almost ALways Do Better. Allen Lane