narrative inquiry case study

Qualitative study design: Narrative inquiry

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Narrative inquiry

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Narrative inquiry can reveal unique perspectives and deeper understanding of a situation. Often giving voice to marginalised populations whose perspective is not often sought. 

Narrative inquiry records the experiences of an individual or small group, revealing the lived experience or particular perspective of that individual, usually primarily through interview which is then recorded and ordered into a chronological narrative. Often recorded as biography, life history or in the case of older/ancient traditional story recording - oral history.  

• Qualitative survey 
• Recordings of oral history (documents can be used as support for correlation and triangulation of information mentioned in interview.) 
• Focus groups can be used where the focus is a small group or community. 

Reveals in-depth detail of a situation or life experience.  

Can reveal historically significant issues not elsewhere recorded. 

Narrative research was considered a way to democratise the documentation and lived experience of a wider gamut of society. In the past only the rich could afford a biographer to have their life experience recorded, narrative research gave voice to marginalised people and their lived experience. 

Limitations

“The Hawthorne Effect is the tendency, particularly in social experiments, for people to modify their behaviour because they know they are being studied, and so to distort (usually unwittingly) the research findings.” SRMO  

The researcher must be heavily embedded in the topic with a broad understanding of the subject’s life experience in order to effectively and realistically represent the subject’s life experience. 

There is a lot of data to be worked through making this a time-consuming method beyond even the interview process itself. 

Subject’s will focus on their lived experience and not comment on the greater social movements at work at the time. For example, how the Global Financial Crisis affected their lives, not what caused the Global Financial Crisis. 

This research method relies heavily on the memory of the subject. Therefore, triangulation of the information is recommended such as asking the question in a different way, at a later date, looking for correlating documentation or interviewing similarly related participants. 

Example questions

• What is the lived experience of a home carer for a terminal cancer patient? 
• What is it like for parents to have their children die young? 
• What was the role of the nurse in Australian hospitals in the 1960s? 
• What is it like to live with cerebral palsy? 
• What are the difficulties of living in a wheelchair? 

Example studies

• Francis, M. (2018). A Narrative Inquiry Into the Experience of Being a Victim of Gun Violence. Journal of Trauma Nursing, 25(6), 381–388. https://doi-org.ezproxy-f.deakin.edu.au/10.1097/JTN.0000000000000406 
•  Kean, B., Oprescu, F., Gray, M., & Burkett, B. (2018). Commitment to physical activity and health: A case study of a paralympic gold medallist. Disability and Rehabilitation, 40(17), 2093-2097. doi:10.1080/09638288.2017.1323234  https://doi-org.ezproxy-f.deakin.edu.au/10.1080/09638288.2017.1323234
• Liamputtong, P. (2009). Qualitative research methods. Oxford University Press. Retrieved from http://ezproxy.deakin.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=cat00097a&AN=deakin.b2351301&site=eds-live   
• Padgett, D. (2012). Qualitative and mixed methods in public health. SAGE. Retrieved from http://ezproxy.deakin.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=cat00097a&AN=deakin.b3657335&authtype=sso&custid=deakin&site=eds-live&scope=site  
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Article Contents

Introduction, narrative, storytelling and program evaluation, the context: a community intervention trial to promote the health of recent mothers, illustrating the analytic approach: the unique insights from narrative, two examples of stories from the cdo data set, concluding remarks.

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Researching practice: the methodological case for narrative inquiry

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Therese Riley, Penelope Hawe, Researching practice: the methodological case for narrative inquiry, Health Education Research , Volume 20, Issue 2, April 2005, Pages 226–236, https://doi.org/10.1093/her/cyg122

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Research interest in the analysis of stories has increased as researchers in many disciplines endeavor to see the world through the eyes of others. We make the methodological case for narrative inquiry as a unique means to get inside the world of health promotion practice. We demonstrate how this form of inquiry may reveal what practitioners value most in and through their practice, and the indigenous theory or the cause-and-consequence thinking that governs their actions. Our examples draw on a unique data set, i.e. 2 two years' of diaries being kept by community development officers in eight communities engaged in a primary care and community development intervention to reduce postnatal depression and promote the physical health of recent mothers. Narrative inquiry examines the way a story is told by considering the positioning of the actor/storyteller, the endpoints, the supporting cast, the sequencing and the tension created by the revelation of some events, in preference to others. Narrative methods may provide special insights into the complexity of community intervention implementation over and above more familiar research methods.

When preventive intervention programs are described, they tend to focus on the technology of the intervention without informing us about how the context in which it was implemented affected the technology. We learn little about the many compromises, choice points and backroom conversations that allowed it to take the form it took. [( Trickett, 1998 ), p. 329].

The history of health promotion has been one of developing and testing increasingly sophisticated theories to inform and strengthen the effectiveness of actions taken by the front-line workers. Theories of health promotion have been developed for multiple levels of analysis (individual, group, organizational, community, etc.) ( Glanz et al. , 1990 ) and for a variety of settings (schools, workplaces, hospitals, etc.) ( Poland et al. , 2000 ). Large-scale, whole-community prevention trials have been conducted purporting to test particular state-of-the-art theories in cancer control and heart disease prevention ( Thompson et al. , 2003 ). Studies of interventions typically include process evaluations, which allow investigators to comment on the extent to which what took place actually matched what was planned ( Flora et al. , 1993 ).

What we hear less about, however, is the private contexts of practice as Trickett describes above and ways of viewing the ‘problem’ at hand other than those preconceived by the intervention's designers. Evaluators who use qualitative methods may get closer to this ( Patton, 1990 ). ‘Key informant’ interviews have become increasingly used to gain insight into the factors that have helped or hindered program development or might explain why programs appear to work in some contexts, but not in others ( Goodman et al. , 1993 ). Even so, this literature contains examples of studies where interviews held at the end of the program still have failed to give investigators confidence about what really happened and why ( Tudor-Smith et al. , 1998 ). Investigators who have engaged practitioners in interviews about the nature of their practice have also commented on how difficult it is for people, in retrospect, to articulate aspects of what they do and think ( Hawe et al. , 1998 ). Thus, many aspects of practice remain elusive.

In this paper we suggest that narrative methods may give new and deeper insights into the complexity of practice contexts. By narrative inquiry, we mean the use of personal journals by and serial interviews with fieldworkers during their implementation of a health promotion intervention. Narrative methods may also allow us to better understand the mechanisms through which health programs are transported and translated. In doing so, the natural or indigenous theory of an intervention may be revealed, i.e. the cause-and-consequence thinking of practitioners, which may or may not match the theory supposed to be tested by the intervention. We use a case study from a whole-community intervention trial to illustrate how we are using these methods. The results of the analysis are not presented here.

Narrative inquiry has a long, strong and contested tradition. There are a range of approaches to narrative inquiry, emanating from diverse disciplines such as psychology, sociology, medicine, literature and cultural studies ( Riessman, 1993 ; Mishler, 1995 ). As a result, the process of interpreting stories is now a point of scholarly investigation in itself, because there is no one unifying method ( Riessman, 1993 ; Mishler, 1995 ; Schegloff, 1997 ; Manning et al. , 1998 ). Approaches differ on the core questions of why and how stories are told. That is, the nature of the storytelling occasion and therefore the knowledge claims that can be made about the problem under investigation.

‘Story’ and ‘narrative’ are words often used interchangeably, but they are analytically different. The difference relates to where the primary data ends and where the analysis of that data begins. Frank ( Frank, 2000 ) points out that people tell stories, but narratives come from the analysis of stories. Therefore, the researcher's role is to interpret the stories in order to analyze the underlying narrative that the storytellers may not be able to give voice to themselves. For example, in a narrative study of people who are unemployed, Ezzy ( Ezzy, 2000 ) explored the role that broader social forces play in how people tell stories about their job loss. He described two narratives: the heroic and tragic job loss narratives. The heroic narrative gives prominence to the role of a person's individual agency and autonomy, whereas the tragic job loss narrative is one is which the person is a victim of institutional or social forces beyond their control. These narrative structures provide insights into how people come to understand their unemployment and the type of action or inaction they take as a result.

The word ‘narrative’ is used extensively in health research. It commonly refers to the field of illness narratives, such as accounts of cancer from the patient's perspective ( Frank, 1998 ). The use of words like ‘narrative’ and ‘story’ became more popular in health promotion in the early 1990s as part of an increased emphasis on reflective practice and methods of program evaluation which gave more control to research participants. For example, Dixon argued that storytelling methods were ideally suited to community development projects because the creation of the project's meaning or public representation is placed more in the control of participants, as opposed to external researchers ( Dixon, 1995 ). Storytelling has developed as a training and practice development technique for knowledge development in health promotion ( Centre for Community Development in Health, 1993 ; Labonte et al. , 1999 ).

Thus health promotion was part of what Chamberlayne et al. ( Chamberlayne et al. , 2000 ) referred to as the ‘biographical turn’ in the social sciences. That is, they were part of the larger move towards methods that tap into the personal and social meanings that are considered to be the basis of people's actions. Incorporated within these methods are mechanisms for critical reflection which conceive the individual as the primary sense-making agent in the construction of his/her own identity ( Blumer, 1969 ; Giddens, 1984 , 1991 ; Schwandt, 1998 ). Reflective writing also became a feature within the context of professional development literature ( Schon, 1999 ), and also in education ( Orem, 2001 ), business ( Hartog, 2002 ) and medicine ( Webster, 2002 ).

In our case, narrative inquiry is providing insight into the mechanisms by which community development officers facilitate transformative change among people and organizations, as part of their role to implement a new community-level intervention. We are using narrative inquiry alongside a fleet of methods including self-completed questionnaires, interviews, observation, document analysis and network analysis of inter organizational collaboration patterns ( Hawe et al. , 2004 ).

The intervention, PRISM (Program of Resources, Information and Support for Mothers), is a coordinated and comprehensive primary care and community-based strategy to promote maternal health after childbirth. The study involved 16 local government areas in the state of Victoria, Australia and approximately 20 000 women. The rationale for the intervention and the evidence on which it is based are described by the PRISM designers ( Gunn et al. , 2003 ; Lumley et al. , 2003 ). The intervention is anchored and facilitated in each of the eight intervention communities by a full-time community development officer (CDO) working with a local steering committee for 2 years.

The diaries and interviews

The data are in the form of field diaries and in-depth interviews. Each CDO maintained a field diary over the 2 years of their employment. CDOs were invited to record in it their feelings, thoughts, frustrations, plans and hopes. Agreement to be involved in program documentation was a part of their employment contract with the PRISM research team. Nevertheless the CDOs' agreement to write diaries with the authors (the ‘EcoPRISM team’) was confidential and entirely independent of the PRISM research team. The average field diary consists of approximately 40 000 words of verbatim reflection.

The interview data comprise 34 interviews (in total) undertaken at strategic points of intervention implementation with each CDO. The interviews provided the opportunity for CDOs to talk about what they may have found tedious or difficult to write down. The interviews explored emerging themes within the data. The interviews were tape recorded and transcribed. They were undertaken both over the telephone and face-to-face.

Creating and sustaining the right research conditions for collecting this data was paramount. Unless we could create the right conditions, the CDOs may tell us only part of their story, what they think we want to hear or indeed nothing at all. These conditions encompassed:Creating these conditions in order to gather data in an ethical and principled manner required the researcher (T. R.) to position herself closely with the CDOs. CDOs spent approximately 90 min a week working on program documentation.

Flexibility in how the data were recorded. Some CDOs had electronic diaries. Some were hand written. Some were emails and others were a combination of the three. A couple of CDOs changed recording methods over time.

Adjusting recording methods to suit field conditions.

Empathy to the challenges CDOs faced in implementing the intervention and in their research relationship with us.

Participation in project dissemination. Co-authoring of papers and conference presentations about the project with CDOs.

Trust within the research relationship. By this we mean trust that we would maintain confidentiality and trust that we would represent the CDOs' story accurately.

How narrative analysis differs from thematic analysis

Thematic analysis is common in health promotion research. It involves the open coding of data, i.e. the building of a set of themes to describe the phenomenon of interest by putting ‘like with like’ ( Morse and Field, 1995 ). The researcher looks for patterns in the data, labels them and groups them accordingly ( Strauss, 1987 ). This approach to analysis can stop at the stage of simple listing of themes [e.g. ( Gordon and Turner, 2003 )]. If the development of themes is led by the researcher's a priori interests, some researchers have preferred to use the term ‘template’ analysis ( Crabtree and Miller, 1999 ). On the other hand, if the themes are derived inductively from the data itself then the thematic analysis may be considered to be more close to a grounded theory analysis [e.g. ( Kalnins et al. , 2002 )]. In practice, many researchers in health promotion conduct thematic analyses that reflect both the ideas they bring to the data set beforehand (from the research questions) as well as being open to ‘new’ themes in the data.

Narrative analysis differs from thematic analysis in two interconnected ways. First, narrative analysis focuses more directly on the dynamic ‘in process’ nature of interpretation ( Ezzy, 2002 ). That is, how the interpretations of the CDOs might change with time, with new experiences, and with new and varied social interactions. So, integration of time and context in the construction of meaning is a distinctly narrative characteristic ( Simms, 2003 ). This is something that Ricoeur calls the ‘threefold present’ in which the past and the future co-exist with the present in the mind of the narrator, through memory in the first case and expectation in the second. A thematic analysis might document different themes arising at different stages of the intervention. However, how time drives or potentially transforms the interpretation is integral to the construction of narratives. It is central to the development of narrative types ( Schutz, 1963a , b ), as we describe later.

Second, narrative analysis begins from the stand point of storyteller, or in our case CDO. From here we analyze how people, events, norms and values, organizations, and past histories and future possibilities, are made sense of and incorporated into the storyteller's interpretations and subsequent actions. That is, narrative analysis contextualizes the sense-making process by focusing on the person, rather than a set of themes. This is an important methodological distinction. In analyzing the CDO diaries we attempt to stand in the CDOs' shoes and experience events as they do. As situations, people and events change over time, our vantage point remains the same. In this way we gain unique insights into how they interpret the world. Thematic analysis, in contrast, de-contextualizes the data (e.g. by ‘cutting and pasting’ themes together) to examine the meta or broader issues. Narrative inquiry shares with discourse analysis both a concern for how broader institutional values and cultural norms are expressed in language, and the belief that language is a form of action ( Potter and Wetherell, 1987 ). However, narrative analysis adds further insights into ‘contexts of practice’ because it studies the world through the eyes of one storyteller and applies a theory of time.

Key features of narrative inquiry

Narrative inquiry attempts to understand how people think through events and what they value. We learn this through a close examination of how people talk about events and whose perspectives they draw on to make sense of such events. This may reveal itself in how and when particular events or activities are introduced, how tension is portrayed, and in how judgments are carried out (e.g. the portrayal of right and wrong).

A narrative approach looks closely at the sentences constructed by the storyteller and the information and meaning they portray. The following categories have been adapted from Young ( Young, 1984 ). Are the sentences descriptive? That is, a sentence or paragraph that sets the scene, but has no temporal role in the story. Are they consecutive ? Is there a logic to where the sentence fits into the story? Are they consequential to the story? That is, they have causal implications. If the sentences are evaluative , do they show something of the attitude of the CDO? These sentences give meaning to the story. If they are transformative , they express a change in how the storyteller evaluates something, such as an epiphany.

Narrative inquiry captures how people make sense of the world. This ‘thinking through’ events is presented in the recording of events, such as the extent of detail given. It is also captured in the form of internalized soliloquies ( Athens, 1994 ; Ezzy, 1998 ). These are the conversations one has with oneself or imagined others.

Narrative analysis focuses on who is mentioned in the telling of events (and who is absent) and the role they have in the telling of events. Gergen and Gergen ( Gergen and Gergen, 1984 ) refer to these people as the supporting cast of a person's narrative. As a supporting cast member, they have a purpose or reason for existing in the story. The manner in which the supporting cast are discussed in the field diaries may range from factual accounting of events, to theorizing what that supporting cast member is thinking or doing. Most importantly, who is mentioned in the field diary reveals the people or organizations that are most significant to the CDO in their practice.

Thinking about the context of the storytelling is another important feature of narrative inquiry. Frank ( Frank, 2000 ) refers to the storytelling relation . By this he means that data emerges from within the relation between the teller, the listener and the context of the telling of the story. Storytelling can be a political occasion. Narrative inquiry takes as a given that people may exclude details of events or exaggerate aspects of stories ( Ezzy, 2000 ). What is of analytical interest to the narrative researcher is why these exclusions or exaggerations exist.

On the basis of careful examination of the data, why and how the story is being told, who the supporting cast are and the nature of the storytelling occasion, one can determine the narrative's plot or what the story is about. The plot of a persons' narrative is the organizing theme ( Ezzy, 1998 ) that brings coherence to the telling of events. Events are understood according to the plot. As a result, we can see and understand how a person makes sense of the world.

Finally, the point of the story considers both the organizing theme and the form of the narrative. Form refers to the flow of the narrative over time. Common prototypes are stable, progressive and regressive narratives ( Gergen and Gergen, 1988 ). A stable narrative is one in which the person's evaluations of situations and events remains the same over the course of time. A regressive narrative is one in which these evaluations get worse with time. A progressive narrative is one in which the person's evaluations improve over time. These broad narrative forms are represented in Frye's ( Frye, 1957 ) forms of literary narrative: the tragedy, the comedy, the happy ending, the satire, the romantic saga, etc. It is the inter-relationship of the organizing theme and form that creates what is called ‘coherent directionality’ in the narrative. This means how it makes sense over time.

A complete narrative analysis takes all CDOs and all their stories. It is beyond the scope of this paper to present this in totality here. Instead, to illustrate the insights we are gaining through narrative inquiry, we present two examples of stories below. Table I outlines the narrative approach applied to these two examples. We have also demonstrated the type of themes we could derive from the same quotations if we were to undertake two kinds of thematic analysis, either guided by an a priori interest in program implementation or not. This is presented in Tables II and III .

Example of narrative analysis of two stories

Thematic analysis of two stories: example led by a priori interests

Thematic analysis of two stories: example based on text (free codes) for both stories

The cinema story

I do a lot of my best project work after hours in the supermarket. Friday evening after work was very fruitful in this way. Good conversations with three young mums interested in the project, one who inspired me weeks ago to set up classes at the swimming pool—and then I bumped into the local cinema owner. I had asked him some time ago to think about piloting a Cry Baby program at his cinema, but hadn't got back to him to check. At the bakery counter he said yes! So next week we'll get together to discuss upcoming films, a launch for the first Cry Baby session…

Catching the hairdresser

Ring Sally the hairdresser—catch her at last. She seems interested (though privately always consider that when people are hard to catch and not returning calls it suggests that they may well end up not contributing— my personal theory that, in the end, people contribute to any activity in inverse proportion to the amount of effort involved in contacting them in the first place) so send her again details of Project and [voucher] contract.

As demonstrated in Table I narrative analysis can be applied to short, very specific stories. We have applied these steps to the entire CDO data set in order to identify the main plots to each of the CDO narratives. Then, through a process of comparison between each of the narratives, a narrative typology or model of ideal types (of narratives) has been created, understood from a phenomenological point of view ( Schutz, 1963a , b ). This means comparing each of the organizing themes for similarities and differences regarding their interpretative framework. By placing each narrative theme under scrutiny, we find that some plots are very similar in nature (form and theme), while others stand out as different. In this way we hope to be able to put forward some of the defining characteristics of practice in the context we have researched, that is, experienced community development practitioners working within the context of a community intervention trial.

The assumption that we bring to this work is that a better understanding of intervention dynamics and indigenous theory may lead to fewer failed community interventions ( Thompson et al. , 2003 ). Because our PRISM trial collaborators are conducting a traditional process evaluation ( Lumley et al. , 2003 ), focused on the program elements, we will be able to determine how a different way of describing intervention unfolding sheds additional light on the ‘black box’ of the intervention. Our interpretations will also be linked to the burgeoning field of implementation analysis ( Ottoson et al. , 1987 ; Bauman, 1991 ; Bammer, 2003 ). This field argues that we need to move beyond mechanistic ways of viewing interventions [e.g. ( Flora et al. , 1993 )] to encompass new methods better suited to the complexity of the personal, organizational and community change processes that interventions purport to bring about.

A primary weakness of narrative inquiry is that it is retrospective. So the length of time required for analysis and presentation of results can be a disincentive. For this reason, fine-tuning narrative methods is a major challenge for future work. Hence, we relied on thematic analysis in order to feedback data that might be timely and important for fine-tuning the intervention in progress ( Riley et al. , 2004 ). However, the narrative analysis takes us much further into the private world of the practitioner and helps us (re)think what the intervention represents. It helps us understand the intensely personal investments being made by CDOs in the project. This is revealed in the CDO's placement of ‘self’ in the narrative. We learn about the progressive or regressive trade-offs, risks and rewards. This provides the social context to allow us to better interpret project dynamics and tensions. For example, the stakes involved when different opinions arose regarding how far PRISM could be adapted to suit local context ( Riley et al. , 2004 ).

Riger ( Riger, 1989 ) argues that some of the most important (but typically untold) stories within community interventions are about the power dynamics, i.e. what gets said publicly about the intervention and why. Our analysis thus far privileges the perspective of the CDO. However, another data set in our study, key informant interviews held in each community at the end of the intervention, will allow us to challenge or confirm these views. This includes members of the steering committees (i.e. some of the ‘supporting cast’).

Narrative analysis requires an in-depth engagement with and understanding of the participant's experience. As a result, there is a blurring of interpretive boundaries between the analyst and the research participant. Such a blurring results in two distinct criticisms of narrative analysis. One is that the analyst can play too strong an interpretative role without sufficient links back to empirical data ( Atkinson, 1997 ). The other criticism is that the analyst plays too weak an interpretive role. Atkinson ( Atkinson, 1997 ) argues that within some forms of narrative analysis there is a lack of analytical attention to social context and interaction, subsequently celebrating, rather than analyzing, the research participant's stories. Researchers are likely to be open to such criticism when unable to define and defend the interpretive framework that is being applied to interrogate the data.

Narrative inquiry encourages the analyst to consider what is in the data set and also what is not there, such as missing characters or alternative viewpoints. This makes the systematic ‘coding’ of data extremely difficult ( Rice and Ezzy, 1999 ) and affirms the importance of a guiding set of analytical principles with which to interrogate the data. Introspective reflexivity is critical in this regard ( Finlay, 2003 ). By this we mean that researchers must interrogate the dynamic created between the researcher and ‘the researched’ and devise accountability mechanisms. In this way the researchers' location and representation within the study is a key component of both data collection and analysis and we have drawn on insights from ethnography in this regard ( Michalowski, 1997 ; Reinharz, 1997 ; McCorkel and Myers, 2003 ). The challenges arising from our research context have been explored in a series of presentations and publications we have pursued with CDOs ( Riley and Hawe, 2000 , 2001 , 2002 ; Riley et al. , 2001 ; Sanders et al. , 2001 ). For an exploration of the ethical challenges we faced, see Riley et al. ( Riley et al. , 2004 ).

Our data set is unique. We know of no other large-scale intervention studies using narrative methods to understand practice contexts. CDOs told us that, overall, writing about their experience helped. It enabled their viewpoints to be articulated and better heard. We hope that by describing our narrative approach we will encourage other researchers to investigate the opportunity provided by narrative inquiry in everyday practice and in intervention study contexts.

We are indebted to the CDOs (Wendy Arney, Deborah Brown, Kay Dufty, Serena Everill, Annie Lanyon, Melanie Sanders, Leanne Skipsey, Jennifer Stone and Scilla Taylor) for their willingness to engage with us and to share their reflections on their use of diaries. The PRISM research trial team is Judith Lumley, Rhonda Small, Stephanie Brown, Lyn Watson, Wendy Dawson, Jane Gunn and Creina Mitchell. Our thanks to them for the opportunity to participate as collaborators in the trial. The EcoPRISM study is funded by the National Health and Medical Research Council, Australia. P. H. is a Senior Scholar of the Alberta Heritage Foundation for Medical Research, Canada and holds the Markin Chair in Health and Society at the University of Calgary.

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Author notes

1VicHealth Centre for the Promotion of Mental Health and Social Wellbeing, School of Population Health, University of Melbourne, Carlton, Victoria 3053, Australia (Formerly at the Centre for the Study of Mothers' and Children's Health, LaTrobe University, Bundoora, Victoria 3086, Australia), 2Department of Community Health Sciences, University of Calgary, Calgary, Alberta T2N 4N1, Canada and 3School of Public Health, LaTrobe University, Bundoora, Victoria 3086, Australia

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• Section 2: Home
• Developing the Quantitative Research Design
• Qualitative Descriptive Design
• Design and Development Research (DDR) For Instructional Design
• Qualitative Narrative Inquiry Research

What is a Qualitative Narrative Inquiry Design?

Tips for using narrative inquiry in an applied manuscript, summary of the elements of a qualitative narrative inquiry design, sampling and data collection, resource videos.

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• Case Study Design in an Applied Doctorate
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Narrative inquiry is relatively new among the qualitative research designs compared to qualitative case study, phenomenology, ethnography, and grounded theory. What distinguishes narrative inquiry is it beings with the biographical aspect of C. Wright Mills’ trilogy of ‘biography, history, and society’(O’Tolle, 2018). The primary purpose for a narrative inquiry study is participants provide the researcher with their life experiences through thick rich stories. Narrative inquiry was first used by Connelly and Calandinin as a research design to explore the perceptions and personal stories of teachers (Connelly & Clandinin, 1990). As the seminal authors, Connelly & Clandinin (1990), posited:

Although narrative inquiry has a long intellectual history both in and out of education, it is increasingly used in studies of educational experience. One theory in educational research holds that humans are storytelling organisms who, individually and socially, lead storied lives. Thus, the study of narrative is the study of the ways humans experience the world. This general concept is refined into the view that education and educational research is the construction and reconstruction of personal and social stories; learners, teachers, and researchers are storytellers and characters in their own and other's stories. In this paper we briefly survey forms of narrative inquiry in educational studies and outline certain criteria, methods, and writing forms, which we describe in terms of beginning the story, living the story, and selecting stories to construct and reconstruct narrative plots. 

Attribution: Reprint Policy for Educational Researcher: No written or oral permission is necessary to reproduce a tale, a figure, or an excerpt fewer that 500 words from this journal, or to make photocopies for classroom use. Copyright (1990) by the American Educational Research Association; reproduced with permission from the publisher. 

• Example Qualitative Narrative Inquiry Design

First, the applied doctoral manuscript narrative inquiry researcher should recognize that they are earning a practical/professional based doctorate (Doctor of Education), rather than a research doctorate such as a Ph.D. Unlike a traditional Ph.D. dissertation oral defense where the candidates focus is on theory and research, the NU School of Education applied doctoral candidate presents their finding and contributions to practice to their doctoral committee as a conceptual professional conference level presentation that centers on how their study may resolve a complex problem or issue in the profession. When working on the applied doctoral manuscript keep the focus on the professional and practical benefits that could arise from your study. If the Applied Doctoral Experience (ADE) student is unsure as to whether the topic fits within the requirements of the applied doctoral program (and their specialization, if declared) they should reach out to their research course professor or dissertation chair for guidance. This is known as alignment to the topic and program, and is critical in producing a successful manuscript. Also, most applied doctoral students doing an educational narrative inquiry study will want to use a study site to recruit their participants. For example, the study may involve teachers or college faculty that the researcher will want to interview in order to obtain their stories. Permission may be need from not only the NU Institutional Review Board (IRB), but also the study site. For example, conducting interviews on campus, procuring private school district or college email lists, obtaining archival documents, etc. 

The popularity of narrative inquiry in education is increasing as a circular and pedagogical strategy that lends itself to the practical application of research (Kim, 2016). Keep in mind that by and large practical and professional benefits that arise from a narrative inquiry study revolve around exploring the lived experiences of educators, education administrators, students, and parents or guardians. According to Dunne (2003), 

Research into teaching is best served by narrative modes of inquiry since to understand the teacher’s practice (on his or her own part or on the part of an observer) is to find an illuminating story (or stories) to tell of what they have been involved with their student” (p. 367).

• Temporality – the time of the experiences and how the experiences could influence the future;
• Sociality – cultural and personal influences of the experiences; and;
• Spatiality – the environmental surroundings during the experiences and their influence on the experiences. 

From Haydon and van der Riet (2017)

• Narrative researchers collect stories from individuals retelling of their life experiences to a particular phenomenon. 
• Narrative stories may explore personal characteristics or identities of individuals and how they view themselves in a personal or larger context.
• Chronology is often important in narrative studies, as it allows participants to recall specific places, situations, or changes within their life history.

Sampling and Sample Size

• Purposive sampling is the most often used in narrative inquiry studies. Participants must meet a form of requirement that fits the purpose, problem, and objective of the study
• There is no rule for the sample size for narrative inquiry study. For a dissertation the normal sample size is between 6-10 participants. The reason for this is sampling should be terminated when no new information is forthcoming, which is a common strategy in qualitative studies known as sampling to the point of redundancy.

Data Collection (Methodology)

• Participant and researcher collaborate through the research process to ensure the story told and the story align.
• Extensive “time in the field” (can use Zoom) is spent with participant(s) to gather stories through multiple types of information including, field notes, observations, photos, artifacts, etc.
• Field Test is strongly recommended. The purpose of a field study is to have a panel of experts in the profession of the study review the research protocol and interview questions to ensure they align to the purpose statement and research questions.
• Member Checking is recommended. The trustworthiness of results is the bedrock of high-quality qualitative research. Member checking, also known as participant or respondent validation, is a technique for exploring the credibility of results. Data or results are returned to participants to check for accuracy and resonance with their experiences. Member checking is often mentioned as one in a list of validation techniques (Birt, et al., 2016).

Narrative Data Collection Essentials

• Restorying is the process of gathering stories, analyzing themes for key elements (e.g., time, place, plot, and environment) and then rewriting the stories to place them within a chronological sequence (Ollerenshaw & Creswell, 2002).
• Narrative thinking is critical in a narrative inquiry study. According to Kim (2016), the premise of narrative thinking comprises of three components, the storyteller’s narrative schema, his or her prior knowledge and experience, and cognitive strategies-yields a story that facilitates an understanding of the others and oneself in relation to others.

Instrumentation

• In qualitative research the researcher is the primary instrument.
• In-depth, semi-structured interviews are the norm. Because of the rigor that is required for a narrative inquiry study, it is recommended that two interviews with the same participant be conducted. The primary interview and a follow-up interview to address any additional questions that may arise from the interview transcriptions and/or member checking.

Birt, L., Scott, S., Cavers, D., Campbell, C., & Walter, F. (2016). Member checking: A tool to enhance trustworthiness or merely a nod to validation? Qualitative Health Research, 26 (13), 1802-1811. http://dx.doi.org./10.1177/1049732316654870

Cline, J. M. (2020). Collaborative learning for students with learning disabilities in inclusive classrooms: A qualitative narrative inquiry study (Order No. 28263106). Available from ProQuest Dissertations & Theses Global. (2503473076). 

Connelly, F. M., & Clandinin, D. J. (1990). Stories of Experience and Narrative Inquiry. Educational Researcher, 19 (5), 2–14. https://doi.org/10.1080/03323315.2018.1465839

Dunne, J. (2003). Arguing for teaching as a practice: A reply to Alasdair Macintyre. Journal of Philosophy of Education . https://doi.org/10.1111/1467-9752.00331 

Haydon, G., & der Riet, P. van. (2017). Narrative inquiry: A relational research methodology suitable to explore narratives of health and illness. Nordic Journal of Nursing Research , 37(2), 85–89. https://doi.org/10.1177/2057158516675217

Kim, J. H. (2016). Understanding Narrative Inquiry: The crafting and analysis of stories as research. Sage Publications. 

Kim J. H. (2017). Jeong-Hee Kim discusses narrative methods [Video]. SAGE Research Methods Video https://www-doi-org.proxy1.ncu.edu/10.4135/9781473985179

O’ Toole, J. (2018). Institutional storytelling and personal narratives: reflecting on the value of narrative inquiry. Institutional Educational Studies, 37 (2), 175-189. https://doi.org/10.1080/03323315.2018.1465839

Ollerenshaw, J. A., & Creswell, J. W. (2002). Narrative research: A comparison of two restorying data analysis approaches. Qualitative Inquiry, 8 (3), 329–347. 

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A Narrative Review of the Pathophysiology and Treatment of Methamphetamine-Associated Psychosis

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• Peter Stacy 1 , 2 ,
• Jenna Frantz 1 ,
• Genevieve Miller 1 , 2 ,
• Brian Merrill 1 &
• Danielle Gainer 1  

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The evaluation and management of methamphetamine-associated psychosis (MAP) is an area of study with a paucity of large-scale, longitudinal data. Methamphetamine use has soared in popularity worldwide in the past decade, leading to a surge in individuals experiencing its neurotoxic effects. Current evidence suggests that methamphetamine causes neurodegeneration and psychosis through VMAT2 inhibition which raises dopamine and GABA levels in the brain’s dopaminergic pathways, leading to oxidative stress and inflammation. Differentiating MAP from primary psychotic disorders is challenging; high rates of persistent psychosis leading to a diagnosis of primary psychotic disorder and an absence of an etiologic differentiation amongst the DSM-5 diagnostic criteria further complicate the diagnostic process. Once a diagnosis of methamphetamine-associated psychosis is made, benzodiazepines have been shown to provide temporary relief; in addition, depending on the severity and impact of psychotic symptoms, antipsychotics may be indicated both short and long terms for ongoing symptom management. Robust data for these treatments is limited and primarily draws on animal studies or case reports. Further research is needed to codify MAP treatment standards of care.

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The methamphetamine-associated psychosis spectrum: a clinically focused review, current understanding of methamphetamine-associated dopaminergic neurodegeneration and psychotoxic behaviors.

Chronic Methamphetamine and Psychosis Pathways

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Stimulant use, including methamphetamine, 3,4-methyl enedioxy-methamphetamine (MDMA), and cocaine, constitutes a growing prevalence worldwide. These highly potent substances have numerous negative biopsychosocial impacts including homelessness, intravenous drug use, cardiovascular morbidity, drug-seeking sex work, and long-term psychiatric symptoms (Barr et al., 2006 ). Methamphetamine use, after rising steadily in the 1990s and declining in the early 2000s, has risen to all-time highs (Substance Abuse and Mental Health Services Administration (SAMHSA), 2023 ). Use patterns, availability, and health consequence are a function of the type and abundance of methamphetamine available, largely produced via a phenyl-2-proponone (P2P) method. Given the relative ease with which the precursor P2P can be obtained, methamphetamine is produced on a widespread industrial scale, which results in ubiquitous availability at historically low prices. Moreover, P2P methamphetamine, compared to alternatives prepared from ephedrine or pseudoephedrine, seems to pose unique health risks, including worse neurotoxicity and psychosis (Courtney & Ray, 2014 ). Most recent epidemiological data indicate that in 2021, over 2.5 million people in the USA reported methamphetamine use that year, with over 16 million people reporting a lifetime history (SAMSHA 2023 ). Despite these statistics, only about 17.8% of individuals in drug treatment programs in the USA are enrolled for the treatment of stimulant use (Ronsley et al., 2020 ).

Current modes of treatment for stimulant use disorder are varied, encompassing social and pharmacological methods, with the most robust evidence-based treatment endorsing contingency management for reduction in psychostimulant use (Ronsley et al., 2020 ). Pharmacotherapy options have been explored for treating methamphetamine use disorder including opioid antagonists (Jayaram-Lindström et al., 2008 ), anticonvulsants (Elkashef et al., 2012 ), psychostimulants (Konstenius et al., 2014 ), and antidepressants (Naji et al., 2022 ), but the results have provided insufficient evidence of significant benefit (Chan et al., 2019 ). Despite the availability of research studying methamphetamine use disorder, research specifically related to methamphetamine-associated psychosis (MAP) and evidence-based treatments are lacking. Studies conducted in Japan show that psychosis is a common effect of methamphetamine use with up to 21% of users experiencing psychosis that persists more than 6 months after discontinuing use, and 49% experienced psychotic relapse over the course of 15–20 months (Barr et al., 2006 ). Studies have reported that approximately 15–23% of recreational methamphetamine users experience MAP (McKetin et al., 2006 , 2010 ), and up to 60% of people with methamphetamine use disorder (previously known as dependence) experience psychosis (Smith et al., 2009 ; Sulaiman et al., 2014 ).

Pharmacotherapy is often employed in MAP treatment (Chiang et al., 2019 ; Fluyau et al., 2019 ), but evidence regarding specific medications, dosage, and treatment duration is limited. Therefore, the present review aims to provide updated, clinically focused information on the differentiation between methamphetamine-associated psychosis and primary psychotic disorders, along with the proposed neurobiological effects of MAP and evidence-based treatment.

The authors conducted electronic searches, using PubMed, Google Scholar, and PsycINFO. Search parameters included all English-language articles published up to April 2023. Search terms included “methamphetamine” (or “amphetamine”) in conjunction with terms such as “psychosis,” “substance induced,” “treatment,” “stimulant induced,” “persistent,” and “neurobiology.” Among search results with relevant titles, abstracts were reviewed. Full-text articles were retrieved for further investigation as determined by authors. All relevant randomized controlled trials, retrospective cohort studies, and review articles were included. References in retrieved articles were reviewed for additional relevant articles. Manuscripts that were not subject to peer-review as well as literature published in languages other than English were excluded.

Neurotoxicity of Methamphetamine

Once metabolized, methamphetamine increases dopamine levels in the central nervous system through the inhibition of dopamine transporters (DAT) and the vesicular monoamine transporter (VMAT2) (Chiang et al., 2019 ). VMAT2 inhibition causes an increased concentration of dopamine in the three dopaminergic pathways: nigrostriatal, which is primarily involved in behaviors associated with reward or predicted stimuli; mesolimbic, which aids in processing rewards and translating reward-associated emotions into action; and mesocortical, which is thought to primarily affect cognitive function (Hsieh et al., 2014 ). Without the activity of the dopamine and VMAT2 transporters, dopamine is also released from the ventral tegmental area and travels to the nucleus accumbens and pre-frontal cortex of the mesolimbic dopaminergic pathway, where it increases to neurotoxic levels (Jan et al., 2012 ). Eventually, the dopaminergic receptor density and function adjust to chronically heightened dopamine signaling (Chiang et al., 2019 ; Hsieh et al., 2014 ). Activation of dopamine in the three pathways causes increased release of gamma-aminobutyric acid (GABA) from the substantia nigra pars reticulata of the brain, and subsequent disinhibition of glutamate release within the cortex (Chiang et al., 2019 ; Hsieh et al., 2014 ). An increase in glutamate reinforces this process, allowing the cycle to perpetuate for over 24 h after methamphetamine use (Hsieh et al., 2014 ). The dysregulation in dopaminergic and GABA signaling in the cortex is one of the mechanisms believed to trigger the disorganized thought process and hallucinations associated with MAP through the damage of cortical interneurons (Chiang et al., 2019 ; Hsieh et al., 2014 ).

In addition to the relationship between neurotransmitter dysregulation and psychotic symptoms, inflammation and oxidative stress in the brain are also theorized to exacerbate MAP. As an individual uses methamphetamine, the blood brain barrier is compromised by a methamphetamine-induced influx of pro-inflammatory cytokines and a decrease of pro-inflammatory cytokines, which are cytotoxic to the neurons (Licinio et al., 1993 ; Papageorgiou et al., 2019 ; Srisurapanont et al., 2021 ; X. Yang et al., 2020a , b ). High levels of inflammatory cytokines have been correlated with more severe psychosis and cognitive dysfunction in patients with MAP (X. Yang et al., 2020a , b ). The inflammatory cytokine, IL-2, can provoke dopamine release (Lapchak, 1992 ), and therefore may contribute to the dopamine excess that causes psychotic symptoms (Licinio et al., 1993 ), as well as triggering an overproduction of reactive oxygen species, thereby becoming neurotoxic and causing apoptosis of neurons involved in dopaminergic signaling (Chiang et al., 2019 ; Jan et al., 2012 ). This increased oxidative burden occurs via methamphetamine-induced morphologic changes in mitochondria and DNA strand breaks (Paulus & Stewart, 2020 ).

While methamphetamine leads to microscopic degeneration, it also can cause gross changes in the brain. Studies have indicated that those who have experienced MAP, compared to methamphetamine users who have not experienced psychosis, have less cortical thickness in areas of the brain where substance use dysregulation is theorized to occur (Srisurapanont et al., 2021 ).

Risk Factors

Individuals with MAP were 5 times more likely to have a family history of schizophrenia compared to methamphetamine users without psychosis (Seeman, 2005 ), suggesting a relationship between the hereditary factors for schizophrenia and MAP. Multiple genetic variations commonly found in individuals with schizophrenia have also been found significantly more frequently in patients with MAP compared to healthy controls (Kishimoto et al., 2008 ) and compared to methamphetamine users without psychosis (Breen et al., 2016 ). In addition to possible genetic predisposition for MAP, shared risk factors between substance abuse and mental illness, such as environmental exposures, neurological mechanisms, impulsivity, and social pressures, may play a role in development of MAP (Kuitunen-Paul et al., 2020 ). For example, childhood trauma may be a risk factor for psychosis among methamphetamine users; individuals that reported three or more adverse childhood events (ACEs) had 4.5 times higher odds of a lifetime psychosis compared to methamphetamine users without reported ACEs (Ding et al., 2014 ). It has been reported that regular methamphetamine users were 11 times more likely to experience psychosis than the general population (Lappin & Sara, 2019 ), and the risk of MAP is higher among methamphetamine users with earlier age of initiation of methamphetamine use, larger doses of methamphetamine, longer duration of drug use, or more frequent methamphetamine use (Cumming et al., 2020 ; Jones et al., 2020 ; M. Yang et al., 2020a , b ). Additionally, Yang and colleagues found that there is a positive correlation between methamphetamine use duration and MAP duration (M. Yang et al., 2020a , b ).

Definitions

Acute methamphetamine-associated psychosis.

Acute methamphetamine-associated psychosis can be diagnosed when the psychotic symptoms emerge during or within 1 month of usage of the drug, commonly showing signs of irritability, anxiety, psychosis, and mood disturbances with the prominent psychotic symptoms being auditory and tactile hallucinations, ideas of reference, and paranoid delusions (Zweben et al., 2004 ; M. Yang et al., 2020a , b ). In a study conducted by Fasihpour et al. ( 2013 ), in an inpatient setting, the predominant symptoms were persecutory delusions (82%), auditory hallucinations (70.3%), reference delusions (57.7%), visual hallucination (44.1%), grandiosity delusions (39.6%), infidelity delusions (26.1%), bizarre delusions (7.2%), thought broadcasting (6.3%), passivity feelings (4.5%), thought withdrawals (3.6%), tactile hallucinations (1.8%), thought insertions (1.8%), olfactory hallucinations (0.9%), and nihilistic delusions (0.9%). (Fasihpour et al., 2013 ).

Chronic Methamphetamine-Associated Psychosis

Methamphetamine-associated psychosis was initially believed to follow a transient course, with symptoms fading with time since last use, but approximately 16–25% of methamphetamine users experience chronic MAP that lasts 1 month or more beyond achieving abstinence (Fiorentini et al., 2021 ; Iwanami et al., 1994 ; McKetin et al., 2016 ; Su et al., 2018 ; Voce et al., 2019a , b ), and one study reported patients that experienced symptoms similar to schizophrenia after 8 to 12 years of abstinence (Teraoka, 1967 ). Chronic MAP manifests with chronic symptoms including ideas of reference, delusions, and hallucinations (Akiyama et al., 2011 ; M. Yang et al., 2020a , b ). These findings suggest that methamphetamine-associated psychosis is not always limited to a transient or acute course and can instead persist chronically in a significant portion of patients.

Schizophrenia as a Comparison

Due to the overlap in symptoms, schizophrenia should be included in the differential of MAP. These similarities can be seen in the diagnostic criteria for schizophrenia, found in the DSM-5-TR, replicated in Table  1 (American Psychiatric Association, 2022 ). Looking at the pathophysiology of schizophrenia, it is clear why this is the case. Dopamine and glutamate are the leading neurotransmitters implicated in schizophrenia (Jauhar et al., 2022 ). Increased dopamine synthesis has been frequently replicated in studies looking at patients with schizophrenia, which correlates with the symptoms seen in patients with MAP. Another hypothesis is glutamate deficiency, illustrated in recreational phencyclidine (an anesthetic drug) use which blocks the glutamatergic postsynaptic receptor N-methyl-D-aspartate (NMDA) and is known to cause lengthy periods of intense psychosis (Jauhar et al., 2022 ).

Comparison Between Acute Methamphetamine Psychosis and Primary Psychotic Disorder

The diagnosis of acute methamphetamine-associated psychosis can usually be differentiated from a primary psychotic disorder based on DSM 5-TR criteria replicated in Table  2 . Additionally, researchers have observed differences in the symptoms and severity of symptoms across both conditions. Close observation and comparison of symptoms across both conditions revealed the predominance of persecutory delusions, auditory and visual hallucinations, odd speech, and delusions of reference in methamphetamine-associated psychosis relative to primary psychotic disorder (Chen et al., 2003 ). Shelly et al. reported that those with acute amphetamine psychosis showed higher frequency of auditory hallucinations (48.5%) in comparison to schizophrenia (20.3%), whereas thought broadcasting was less prevalent in the MAP group (24%) compared to the schizophrenia group (Shelly et al., 2016 ). Several studies have also shown the predominance of thought disorder (characterized by the loosening of associations and disorganized speech) in schizophrenia and have established the presence of thought disorder as a salient and defining feature of schizophrenia, as these symptoms are rarely ever seen in methamphetamine-associated psychosis (Angrist et al., 1974 ; BELL, 1965 ; Yui et al., 2000 ). Studies have also reported differences in the severity of negative symptoms as a differentiating factor between schizophrenia and MAP, with some studies demonstrating fewer negative symptoms in patients with MAP compared to those with SSD (Hajebi et al., 2018 ; M. Yang et al., 2020a , b ). Hajebi et al. compared the severity of the symptoms and found that those with non-affective psychosis presented with severe negative symptoms relative to those with acute methamphetamine psychosis and that those in the non- affective psychosis group continued to maintain increased severity of negative symptoms after discharge (Hajebi et al., 2018 ). However, the literature on this subject has been discordant; Srisurapanont et al. found no significant difference in symptom severity for positive or negative symptoms between the schizophrenia and MAP groups (Srisurapanont et al., 2011 ), highlighting a need for further research to compare these two disorders.

The trials that compared the differences in the cognitive symptoms between methamphetamine-associated psychosis and schizophrenia reported that both methamphetamine-associated psychosis and schizophrenia had similar cognitive symptoms profile (Chen et al., 2015 ; Jacobs et al., 2008 ), although Ezzatpanah et al. have also reported that visual attention deficits were more pronounced in schizophrenia compared to acute methamphetamine psychosis (Ezzatpanah et al., 2014 ). These findings led to the conclusion that certain brain areas (e.g., parietal cortex) were affected more in schizophrenia compared to acute methamphetamine psychosis (Wearne & Cornish, 2018 ).

Comparison Between Chronic Methamphetamine-Associated Psychosis and Primary Psychotic Disorder

The diagnosis of chronic methamphetamine-associated psychosis is complicated by various factors, such as the previously stated overlap in symptoms with schizophrenia spectrum disorder, relapse in methamphetamine use, and possible cessation of psychiatric medication (Hajebi et al., 2018 ). Studies conducted on patients with chronic psychosis have shown that the symptom profile of chronic methamphetamine psychosis overlaps with that of schizophrenia (Medhus et al., 2013 ; Srisurapanont et al., 2011 ). However, a 2016 study by Wang et al. found subtle differences in the symptom presentation which can be used to distinguish chronic methamphetamine psychosis from schizophrenia (L. J. Wang et al., 2016 ). This study compared 53 patients with chronic methamphetamine psychosis and 53 patients with schizophrenia and found that participants in the MAP group experienced higher proportions of visual hallucinations (30.2%) and somatic hallucinations (20.8%) than patients in the schizophrenia group (11.3% and 3.8%, respectively), while conceptual disorganization was more pronounced in schizophrenia group compared to chronic methamphetamine psychosis group (L. J. Wang et al., 2016 ). The patients in the schizophrenia group had a higher educational attainment than in the chronic methamphetamine psychosis group, suggesting that the differences in conceptual disorganization were not attributed to education level. It has also been found that schizophrenia was associated with greater frequency and severity of negative symptoms compared to chronic methamphetamine psychosis (M. Yang et al., 2020a , b ). In addition to differences in symptom presentation between chronic MAP and SSD, one study also reported that treatment response to antipsychotic medication differs between patients with schizophrenia and chronic MAP, and thus could be one way to distinguish between these two diseases (Sekiguchi et al., 2021 ). In this study, patients with chronic MAP required fewer antipsychotic medications at lower chlorpromazine equivalent doses to manage their symptoms, as well as a shorter hospital stay, when compared to the SSD group (Sekiguchi et al., 2021 ). Studies differentiating chronic methamphetamine psychosis from acute methamphetamine psychosis reported that non-auditory hallucination occurred with greater frequency in chronic methamphetamine psychosis compared to acute methamphetamine psychosis (Iwanami et al., 1994 ). It has also been reported that the negative symptoms occurred with greater severity in patients with schizophrenia compared to those with acute and chronic methamphetamine psychosis, but the negative symptoms demonstrated by the chronic methamphetamine psychosis group were significantly greater than those in the acute methamphetamine group (Chen et al., 2003 ). Additionally, Voce and colleagues found that negative symptoms associated with MAP were more frequently found in patients who used methamphetamine in combination with other illicit substances compared to those without polysubstance use (Voce et al., 2019a , b ). Methamphetamine can also cause toxic injury to the brain, and while trials have shown that MAP and schizophrenia have similar symptom profiles, some biological changes seen in methamphetamine psychosis may vary from those seen in schizophrenia (Yamamuro et al., 2015 ). Yamamuro et al. used functional near-infrared spectroscopy (NIRS) to monitor the brain blood oxygenation levels while performing verbal fluency tasks (VFT) in patients with methamphetamine psychosis and schizophrenia and found that oxyhemoglobin concentration changes in the prefrontal cortex (channels 8, 9, and 12) during VFT were significantly larger in patients with methamphetamine psychosis than they were in patients with schizophrenia (Yamamuro et al., 2015 ). However, despite these findings, many studies have found biological similarities between schizophrenia and MAP regarding genes (Breen et al., 2016 ; Kishimoto et al., 2008 ), brain structure volumes (Farnia et al., 2020 ), and cytokine aberrations (Dahan et al., 2018 ; Goldsmith et al., 2016 ; X. Yang et al., 2020a , b ). When studied in a South-African population, however, no such genetic relationship was found; Asadi et al. found that polygenic risk scores for schizophrenia were not correlated with MAP nor any brain measures (Asadi et al., 2021 ), suggesting that further genetic studies in diverse populations are warranted. These findings suggest that the pathophysiology of schizophrenia and methamphetamine-associated psychosis share similar characteristics, but additional research may be useful to further explore pathophysiologic differences between the two diseases.

Treatment of Acute Map

Methamphetamine-associated psychotic symptoms can pose challenges to treatment providers, particularly if symptoms are acute and complex in nature or if agitation is involved. Furthermore, because the clinical presentation can overlap significantly with a primary psychotic disorder, securing an accurate diagnosis can prove challenging. However, obtaining the correct diagnosis can have treatment implications and can be important for discharge planning. For example, a patient with a primary psychotic disorder may benefit from case management services, while a patient with MAP may benefit from substance use disorder treatment to minimize future use of methamphetamines.

A careful history of the patient should also include the quantity, duration, and method of methamphetamine use as these factors are associated with MAP (Arunogiri et al., 2018 ; R et al., 2013 ). Studies suggest that binge use of methamphetamines is associated with psychotic symptoms (Glasner-Edwards & Mooney 2014 ; Lineberry & Bostwick, 2006 ). In addition, the onset of psychotic symptoms is associated with the duration and timing of methamphetamine use (Bramness et al., 2012 ).

Obtaining a history of other psychiatric symptoms also remains important. Irritability, anxiety, and mood changes can also occur with methamphetamine use (Zweben et al., 2004 ). Providers should observe for negative symptoms during a mental status exam, including signs of apathy (through blunted affect), avolition (lack of goal directed activity), alogia (decreased verbal spontaneity), and anhedonia (loss of pleasure). If available, laboratory workup can be considered including urine drug screen to assess for substance use, complete blood count, and metabolic panel to assess for infection, anemia, hypothyroidism or folate deficiency, and liver function tests to look for potential alcohol or IV drug use (Hepatitis C). Collateral history should be gathered to corroborate findings and establish a longitudinal view of the patient’s symptoms to better decide on appropriate diagnosis, treatment, and prognosis.

As there are few studies regarding treatment of MAP, treatment recommendations for clinicians are generally based upon case reports, animal studies, and the transference of knowledge in the treatment for acutely agitated patients. Benzodiazepines are effective in reducing the acute symptoms of MAP (Grigg et al., 2018 ; Richards et al., 2015 ) but are associated with sedation, tolerance, and respiratory depression, and may not be appropriate for long-term use (Johnson & Streltzer, 2013 ). In a randomized clinical trial in China, 120 patients with acute MAP symptoms were treated with either paliperidone extended release (ER) or risperidone; patients from both groups experienced statistically significant improvements in Positive and Negative Syndrome Scale (PANSS) total score following the treatment course, without statistically significant differences in efficacy between the two medications, and adverse effects were significantly reduced in the paliperidone ER group (G. Wang et al., 2020 ). Verachai and colleagues conducted a double-blind randomized controlled trial comparing the efficacy of quetiapine to haloperidol and found that quetiapine was as effective for the treatment of MAP as haloperidol, with comparable side effects (Verachai et al., 2014 ). These findings are similar to a study done by Leelahanaj in 2005, which compared olanzapine to haloperidol in efficacy (Leelahanaj et al., 2005 ). Both olanzapine and haloperidol were efficacious in the treatment of MAP, but olanzapine had lower frequency and severity of extrapyramidal symptoms. Zarrabi et al. evaluated the clinical course and treatment of 152 inpatient admissions and found that risperidone and olanzapine were used most frequently and that recovery from psychotic symptoms in 31.6% of the inpatients took more than 1 month (Zarrabi et al., 2016 ). These authors suggested that both risperidone and olanzapine are helpful with MAP symptoms but also help to restore weight and appetite, reduced by methamphetamine use. Another study conducted by Farnia and colleagues compared aripiprazole and risperidone and found that both were effective for patients with MAP (Farnia et al., 2016 ). These authors found that risperidone had the greater efficacy in reducing positive psychotic symptoms, but aripiprazole had a greater efficacy in reducing negative symptoms (Ashok et al., 2017 ; Lee et al., 2009 ; Volkow et al., 2001 ). Decreased D2 receptor availability has been associated with increased impulsivity (Lee et al., 2009 ) and pleasure (Volkow et al., 1999 ) from drug use in humans. In animal trials, rats with decreased D2 receptors demonstrate increased impulsivity and drug-seeking behavior (Dalley et al., 2007 ). These findings suggest that D2 receptor antagonists could exacerbate drug craving for methamphetamine. Since antipsychotic medications have an antagonistic effect on the D2 receptor, it is important to bear in mind the importance of administering the lowest effective dose of antipsychotic medication in patients with MAP to avoid exacerbating methamphetamine craving and use. Furthermore, paliperidone has demonstrated a faster dissociation rate from human-cloned D2 receptors in tissue culture compared to risperidone, chlorpromazine, haloperidol, and olanzapine (Seeman, 2005 ); in addition to decreased risk of extrapyramidal side effects, it could be postulated that medications with faster dissociation rate from D2 receptors may also minimize drug craving induced by D2 receptor antagonism; however, the evidence to support this claim is scarce thus far. Additionally, treating patients with MAP with the lowest effective dose is also of the utmost importance because of their increased risk of some adverse effects when treated with antipsychotic medications. Compared to patients with schizophrenia without methamphetamine use, patients with methamphetamine use disorder had 4 times higher odds of experiencing extrapyramidal side effects when receiving antipsychotic medication (Temmingh et al., 2020 ).

Regarding treatment compliance among patients with MAP, Asadi et al. found that patients with higher PANSS score had higher rates of noncompliance. Nonetheless, patients’ attitudes regarding treatment became more favorable over time (Asadi et al., 2021 ), which may increase treatment compliance.

Treatment of Chronic Map

The management of MAP, particularly treatment of refractory and persistent symptoms even after a period of abstinence, also remains ill-defined. Clinical guidelines lack an abundance of randomized controlled trials (Grigg et al., 2018 ). No antipsychotic is currently defined as superior to others in efficacy of reducing chronic methamphetamine-associated psychotic symptoms. Two recent systematic reviews conducted by Chiang et al. and Fluyau et al. in 2019 indicate that antipsychotics were effective for MAP (Chiang et al., 2019 ; Fluyau et al., 2019 ). Srisurapanont and colleagues conducted a systematic review and meta-analysis, and this data suggests that olanzapine and quetiapine are possibly superior to aripiprazole and risperidone in the treatment for MAP (Srisurapanont et al., 2021 ). However, the authors caution that these data should be interpreted with an abundance of caution due to the low quality of the trials and an overall paucity of evidence (Srisurapanont et al., 2021 ). Patients with MAP resistant to antipsychotics have also been described as responsive to clozapine treatment in case reports (Seddigh et al., 2014 ).

While antipsychotic medications may have limited efficacy in MAP, alternative treatments may be necessary for clinicians to consider. Case reports (Grelotti et al., 2010 ) and animal studies (YL et al., 2012 ) suggest that electroconvulsive therapy (ECT) may be beneficial in improving psychotic symptoms. However, an Iranian pilot study conducted on ten patients with chronic methamphetamine-associated psychotic symptoms found no difference in Brief Psychiatric Rating Scale scores in patients treated with ECT compared to those maintained on olanzapine (Ziaaddini et al., 2015 ). However, this study had a small sample size with only five patients in each group; larger longitudinal trials determining efficacy of ECT for MAP are needed.

Minocycline has also been studied recently for its efficacy in treating MAP. A small trial of five participants with treatment-resistant methamphetamine psychosis found that 200 mg minocycline once daily improved both positive and negative symptoms and neurocognitive function, such as auditory working memory, within 2 months (Alavi et al., 2021 ).

Long-term treatment of individuals with MAP should be tailored to the ongoing needs of patients as well as individuals’ risks for side effects. Management of MAP should also attend to reduction and, ideally, abstinence from methamphetamines to reduce a return or worsening of psychotic symptoms. Comprehensive treatment should be provided to address other co-occurring psychiatric symptoms as well as psychosocial interventions to bolster relapse prevention skills.

This article summarizes the current understanding of methamphetamine-associated psychosis, which is a significant and potentially long-lasting effect of increasing stimulant use worldwide. Its neurobiology, comparison to schizophrenia and other primary psychoses, and clinical and pharmacological treatment strategies summarize an adequate starting point for management; however, there is room for improvement in current standard of care. While some studies show promising results, additional longitudinal studies are needed to bolster evidence and provide more concrete data to inform clinical decision making. New pharmacological treatments and testing to differentiate between acute, chronic, and primary psychosis in people with MAP should be investigated to provide clinicians with additional tools in diagnosis and treatment.

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Stacy, P., Frantz, J., Miller, G. et al. A Narrative Review of the Pathophysiology and Treatment of Methamphetamine-Associated Psychosis. Int J Ment Health Addiction (2024). https://doi.org/10.1007/s11469-024-01323-y

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