City Avoidance in the Early Phase of Psychosis: A Neglected Domain of Assessment and a Potential Target for Recovery Strategies

Abstract

Background: A considerable amount of research has explored the link between living in an urban environment during childhood and the increased risk to develop psychosis. However, the urban milieu is more than a risk factor as it is also a place for socialization and enrichment. The aims of the current study were to explore, in a large sample of early psychosis (EP) patients, their pattern of use of the city, their perception when exposed to various critical stressors, and their sensitivity to diverse forms of stimuli. Methods: We sent a questionnaire (based on previous work conducted in a group of patients, including video-recorded walk-along in the city and a literature review) to 305 EP patients and to 220 medical students. Results: Response rate in patients was low (38%). City avoidance and negative perceptions towards the urban environment increased in patients after onset of psychosis. Patients’ tendency to avoid city center correlates with both problematic social interactions and stimuli perceived as unpleasant. Patients seemed less likely to enjoy urban spaces considered as relaxing, suggesting a lower capacity to benefit from positive aspects of this environment. Conclusions: The development of psychosis influences the way EP patients perceive the city and their capacity to feel at ease in the urban environment, leading to a high rate of city avoidance. Considering the possible influence of city avoidance on social relations and the recovery process, the development of strategies to help patients in this regard may have a significant effect on their recovery process.

Urban remediation: a new recovery-oriented strategy to manage urban stress after first-episode psychosis

“…The current review along with our own results, where city avoidance correlates with experience of stressful situations in the city [15], lead us to hypothesize a mediating role of the urban environment in a downward spiral of isolation and psychological distress (figure 2). Persons with early psychosis may have more difficulties to adjust their interaction with the city environment, which may lead to a self-perpetuating cycle of increasing interactions with the negative features of the urban milieu.…”

“…Through a recent survey among early psychosis patients and controls, we found that while both groups prefer parks and open spaces to crowded places, the former do so to at a lesser degree than the latter [15]. In other words, patients seem to have less capacity to draw pleasure from exposure to commonly considered 'enjoyable places' than controls, suggesting they may in turn have less capacity to derive respite from them.…”

“…In order to study the generalizability of these findings, we developed a questionnaire that we proposed to 117 early psychosis patients and 220 medical students [15]. Among various domains, the questionnaire explored frequency of city attendance as well as urban elements that are generating stress, ranging from nature of the built environment to social interactions and sensory stimulations.…”

“…However, while the quest for the identification of risk factors for psychiatric disorders has understandably led researchers to focus on the mechanisms underlying this potential causal link, various elements suggest that other aspects of the interaction between the urban environment and psychiatric patients are highly relevant topics for research as well. Among these, data showing that once psychosis has emerged, patients struggle to adapt to urban milieu, stay away from it or need to develop various strategies to adapt to it [11][12][13][14][15], suggest that city avoidance in early psychosis patients and ways to overcome it might be an important domain to explore as well.…”

Stress and the City: Living in Rural Environment has a Protective Effect on Hospital Readmission Rates in Chronic Psychiatric Disorders

“…Some aspects of urban living might also be particularly burdensome for patients with psychiatric disorders. For patients with psychosis it has been shown that they perceive the city and the urban environment as more stressful, leading to a high rate of city avoidance (55). Thus further research is needed to identify which factors related to urbanicity might contribute to the increased risk of hospital readmissions.…”