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The period before the formation of a persecutory delusion may provide causal insights. Patient accounts are invaluable in informing this understanding.
To inform the understanding of delusion formation, we asked patients about the occurrence of potential causal factors – identified from a cognitive model – before delusion onset.
A total of 100 patients with persecutory delusions completed a checklist about their subjective experiences in the weeks before belief onset. The checklist included items concerning worry, images, low self-esteem, poor sleep, mood dysregulation, dissociation, manic-type symptoms, aberrant salience, hallucinations, substance use and stressors. Time to reach certainty in the delusion was also assessed.
Most commonly it took patients several months to reach delusion certainty (n = 30), although other patients took a few weeks (n = 24), years (n = 21), knew instantly (n = 17) or took a few days (n = 6). The most frequent experiences occurring before delusion onset were: low self-confidence (n = 84); excessive worry (n = 80); not feeling like normal self (n = 77); difficulties concentrating (n = 77); going over problems again and again (n = 75); being very negative about the self (n = 75); images of bad things happening (n = 75); and sleep problems (n = 75). The average number of experiences occurring was high (mean 23.5, s.d. = 8.7). The experiences clustered into six main types, with patients reporting an average of 5.4 (s.d. = 1.0) different types.
Patients report numerous different experiences in the period before full persecutory delusion onset that could be contributory causal factors, consistent with a complex multifactorial view of delusion occurrence. This study, however, relied on retrospective self-report and could not determine causality.
Trauma and dissociation may be important factors contributing to the experiences of distressing voice hearing. However, there is scant mention of how to target and treat such processes when working with people with psychosis. This case study reports on an initial attempt to work with dissociation and trauma memories in a person with voices. A single case approach was used, with standardized measures used before, during and after 24 sessions of cognitive therapy, and at 6-month follow-up. In addition, session-by-session measures tracked frequency and distress associated with voices and dissociation. The participant reported significant improvements in terms of reduced frequency and distress of dissociation, and voice hearing, as well as improvement in low mood at the end of treatment. At follow-up there were enduring benefits in terms of dissociation and trauma-related experiences, as well as broad recovery but not of change in voices. This case illustrated the potential benefit of targeting dissociation and exposure to trauma memories in producing general symptom improvement and specific reductions in dissociation and voice hearing at end of treatment.
To explore the factors affecting intra-household food allocation practices to inform the development of interventions to prevent low birth weight in rural plains of Nepal.
Qualitative methodology using purposive sampling to explore the barriers and facilitating factors to improved maternal nutrition.
Rural Dhanusha District, Nepal.
We purposively sampled twenty-five young daughters-in-law from marginalised groups living in extended families and conducted semi-structured interviews with them. We also conducted one focus group discussion with men and one with female community health volunteers who were mothers-in-law.
Gender and age hierarchies were important in household decision making. The mother-in-law was responsible for ensuring that a meal was provided to productive household members. The youngest daughter-in-law usually cooked last and ate less than other family members, and showed respect for other family members by cooking only when permitted and deferring to others’ choice of food. There were limited opportunities for these women to snack between main meals. Daughters-in-law’ movement outside the household was restricted and therefore family members perceived that their nutritional need was less. Poverty affected food choice and families considered cost before nutritional value.
It is important to work with the whole household, particularly mothers-in-law, to improve maternal nutrition. We present five barriers to behaviour change: poverty; lack of knowledge about cheap nutritional food, the value of snacking, and cheap nutritional food that does not require cooking; sharing food; lack of self-confidence; and deference to household guardians. We discuss how we have targeted our interventions to develop knowledge, discuss strategies to overcome barriers, engage mothers-in-law, and build the confidence and social support networks of pregnant women.
Background: Internalized stigma is a significant difficulty for those who experience psychosis, but it has never been conceptualized using cognitive theory. Aims: The aim of this paper is to outline a cognitive model conceptualizing internalized stigma experienced by people who also experience psychosis. Method: Previous literature is reviewed, critiqued and synthesized to develop the model. It draws upon previous social cognitive models of internalized stigma and integrates cognitive behavioural theory and social mentality theory. Results: This paper identifies key cognitive, behavioural and emotional processes that contribute to the development and maintenance of internalized stigma, whilst also recognizing the central importance of cultural context in creating negative stereotypes of psychosis. Moreover, therapeutic strategies to alleviate internalized stigma are identified. A case example is explored and a formulation and brief intervention plan was developed in order to illustrate the model in practice. Conclusion: An integrative cognitive model is presented, which can be used to develop individualized case formulations, which can guide cognitive behavioural interventions targeting internalized stigma in those who experience psychosis. More research is required to examine the efficacy of such interventions. In addition, it is imperative to continue to research interventions that create change in stigma at a societal level.
Research has highlighted the importance of recovery as defined by the
service user, and suggests a link to negative emotion, although little is
known about the role of negative emotion in predicting subjective
To investigate longitudinal predictors of variability in recovery scores
with a focus on the role of negative emotion.
Participants (n=110) with experience of psychosis
completed measures of psychiatric symptoms, social functioning,
subjective recovery, depression, hopelessness and self-esteem at baseline
and 6 months later. Path analysis was used to examine predictive factors
for recovery and negative emotion.
Subjective recovery scores were predicted by negative emotion, positive
self-esteem and hopelessness, and to a lesser extent by symptoms and
functioning. Current recovery score was not predicted by past recovery
score after accounting for past symptoms, current hopelessness and
current positive self-esteem.
Psychosocial factors and negative emotion appear to be the strongest
longitudinal predictors of variation in subjective recovery, rather than
In the UK almost 60% of people with a diagnosis of schizophrenia who use
mental health services say they are not involved in decisions about their
treatment. Guidelines and policy documents recommend that shared
decision-making should be implemented, yet whether it leads to greater
treatment-related empowerment for this group has not been systematically
To examine the effects of shared decision-making on indices of
treatment-related empowerment of people with psychosis.
We conducted a systematic review and meta-analysis of randomised
controlled trials (RCTs) of shared decision-making concerning current or
future treatment for psychosis (PROSPERO registration CRD42013006161).
Primary outcomes were indices of treatment-related empowerment and
objective coercion (compulsory treatment). Secondary outcomes were
treatment decision-making ability and the quality of the therapeutic
We identified 11 RCTs. Small beneficial effects of increased shared
decision-making were found on indices of treatment-related empowerment (6
RCTs; g = 0.30, 95% CI 0.09–0.51), although the effect
was smaller if trials with >25% missing data were excluded. There was
a trend towards shared decision-making for future care leading to reduced
use of compulsory treatment over 15–18 months (3 RCTs; RR = 0.59, 95% CI
0.35–1.02), with a number needed to treat of approximately 10 (95% CI
5–∞). No clear effect on treatment decision-making ability (3 RCTs) or
the quality of the therapeutic relationship (8 RCTs) was found, but data
For people with psychosis the implementation of shared treatment
decision-making appears to have small beneficial effects on indices of
treatment-related empowerment, but more direct evidence is required.
A recent editorial claimed that the 2014 National Institute for Health and Care Excellence (NICE) guideline on psychosis and schizophrenia, unlike its equivalent 2013 Scottish Intercollegiate Guidelines Network (SIGN) guideline, is biased towards psychosocial treatments and against drug treatments. In this paper we underline that the NICE and SIGN guidelines recommend similar interventions, but that the NICE guideline has more rigorous methodology. Our analysis suggests that the authors of the editorial appear to have succumbed to bias themselves.
Research suggests that the way in which cognitive therapy is delivered is an important factor in determining outcomes. We test the hypotheses in which the development of a shared problem list, use of case formulation, homework tasks and active intervention strategies will act as process variables.
Presence of these components during therapy is taken from therapist notes. The direct and indirect effect of the intervention is estimated by an instrumental variable analysis.
A significant decrease in the symptom score for case formulation (coefficient =–23, 95% CI –44 to –1.7, P = 0.036) and homework (coefficient =–0.26, 95% CI –0.51 to –0.001, P = 0.049) is found. Improvement with the inclusion of active change strategies is of borderline significance (coefficient =–0.23, 95% CI –0.47 to 0.005, P = 0.056).
There is a greater treatment effect if formulation and homework are involved in therapy. However, high correlation between components means that these may be indicators of overall treatment fidelity.
A high-frequency periodic jet, issuing immediately below the point of separation, is used to force the turbulent wake of a bluff axisymmetric body, its axis aligned with the free stream. It is shown that the base pressure may be varied more or less at will: at forcing frequencies several times that of the shear layer frequency, the time-averaged area-weighted base pressure increases by as much as 35 %. An investigation of the effects of forcing is made using random and phase-locked two-component particle image velocimetry (PIV), and modal decomposition of pressure fluctuations on the base of the model. The forcing does not target specific local or global wake instabilities: rather, the high-frequency jet creates a row of closely spaced vortex rings, immediately adjacent to which are regions of large shear on each side. These shear layers are associated with large dissipation and inhibit the entrainment of fluid. The resulting pressure recovery is proportional to the strength of the vortices and is accompanied by a broadband suppression of base pressure fluctuations associated with all modes. The optimum forcing frequency, at which amplification of the shear layer mode approaches unity gain, is roughly five times the shear layer frequency.
Despite evidence for the effectiveness of structured psychological
therapies for bipolar disorder no psychological interventions have been
specifically designed to enhance personal recovery for individuals with
recent-onset bipolar disorder.
A pilot study to assess the feasibility and effectiveness of a new
intervention, recovery-focused cognitive–behavioural therapy (CBT),
designed in collaboration with individuals with recent-onset bipolar
disorder intended to improve clinical and personal recovery outcomes.
A single, blind randomised controlled trial compared treatment as usual
(TAU) with recovery-focused CBT plus TAU (n = 67).
Recruitment and follow-up rates within 10% of pre-planned targets to
12-month follow-up were achieved. An average of 14.15 h (s.d. = 4.21) of
recovery-focused CBT were attended out of a potential maximum of 18 h.
Compared with TAU, recovery-focused CBT significantly improved personal
recovery up to 12-month follow-up (Bipolar Recovery Questionnaire mean
score 310.87, 95% CI 75.00–546.74 (s.e. = 120.34), P =
0.010, d=0.62) and increased time to any mood relapse
during up to 15 months follow-up (χ2 = 7.64,
P<0.006, estimated hazard ratio (HR) = 0.38, 95%
CI 0.18–0.78). Groups did not differ with respect to medication
Recovery-focused CBT seems promising with respect to feasibility and
potential clinical effectiveness. Clinical- and cost-effectiveness now
need to be reliably estimated in a definitive trial.
Eradication of introduced species is often necessary to conserve native biota on islands. Seven wild turkeys Meleagris gallopavo were introduced to Santa Cruz Island, California, in 1975 and the population began to irrupt in the early 2000s. Turkeys posed a variety of threats to native species, including that they could replace the previously eradicated population of feral pigs Sus scrofa as a prey subsidy for golden eagles Aquila chrysaetos, which through incidental predation had driven three subspecies of island fox Urocyon littoralis to near extinction. We implemented a four-phase programme to eradicate the turkey population, based on general principles for eradication efforts. For example, we focused on preventing individual turkeys from becoming aware of our methods, which increased the likelihood we would be able to detect and dispatch all of the birds. Leveraging the tendency of turkeys to aggregate during winter, we used baited drop nets, precision shooting, and monitoring of surgically sterilized, radio-telemetered ‘Judas turkeys’ to eliminate the population. We estimate the population comprised 310 individuals when the project began in 2006 and that the last bird died in December 2012. Methods used in this project could be applied to other alien bird eradication programmes, of which there are few examples in the scientific literature.
Background: Individual Cognitive Behaviour Therapy for psychosis (CBTp) is the first line recommended psychological intervention for adults diagnosed with schizophrenia. However, little is yet known about service users’ subjective experiences of CBTp. Aims: This study aimed to conduct a systematic review of qualitative literature to examine service user perspective of CBTp. Method: A thematic synthesis of qualitative studies examining service users’ experiences of CBTp was conducted. A total of six studies were included in the analysis. Results: Three superordinate themes were identified: therapeutic alliance; facilitating change; and challenges of applying CBTp. Conclusion: Overall, CBTp is a helpful and acceptable therapeutic approach to service users. Developing a collaborative therapeutic relationship is essential. The applications of CBTp can be problematic and the therapist and client need to work together to overcome these difficulties.
No study systematically has investigated the supportive care needs of general head and neck cancer patients using validated measures. These needs include physical and daily living needs, health system and information needs, patient care and support needs, psychological needs, and sexuality needs. Identifying the unmet needs of head and neck cancer patients is a necessary first step to improving the care we provide to patients seen in our head and neck oncology clinics. It is recommended as the first step in intervention development in the Pan-Canadian Clinical Practice Guideline of the Canadian Partnership Against Cancer (see Howell, 2009). This study aimed to identify: (1) met and unmet supportive care needs of head and neck cancer patients, and (2) variability in needs according to demographics, disease variables, level of distress, and quality-of-life domains.
Participants were recruited from the otolaryngology–head and neck surgery clinics of two university teaching hospitals. Self-administered questionnaires included sociodemographic and medical questions, as well as validated measures such as the Supportive Care Needs Survey–Short Form (SCNS-SF34), the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Cancer Therapy–General (FACT-G) and Head and Neck Module (FACT-H&N) (quality of life measures).
One hundred and twenty-seven patients participated in the survey. 68% of them experienced unmet needs, and 25% revealed a clinically significant distress level on the HADS. The highest unmet needs were psychological (7 of top 10 needs). A multiple linear regression indicated a higher level of overall unmet needs when patients were divorced, had a high level of anxiety (HADS subscale), were in poor physical condition, or had a diminished emotional quality of life (FACT-G subscales).
Significance of results:
The results of this study highlight the overwhelming presence of unmet psychological needs in head and neck cancer patients and underline the importance of implementing interventions to address these areas perceived by patients as important. In line with hospital resource allocation and cost-effectiveness, one may also contemplate screening patients for high levels of anxiety, as well as target patients who are divorced and present low levels of physical well-being, as these patients may have more overall needs to be met.
Background: Research suggests that core schemas are important in both the development and maintenance of psychosis. Aims: The aim of the study was to investigate and compare core schemas in four groups along the continuum of psychosis and examine the relationships between schemas and positive psychotic symptomatology. Method: A measure of core schemas was distributed to 20 individuals experiencing first-episode psychosis (FEP), 113 individuals with “at risk mental states” (ARMS), 28 participants forming a help-seeking clinical group (HSC), and 30 non-help-seeking individuals who endorse some psychotic-like experiences (NH). Results: The clinical groups scored significantly higher than the NH group for negative beliefs about self and about others. No significant effects of group on positive beliefs about others were found. For positive beliefs about the self, the NH group scored significantly higher than the clinical groups. Furthermore, negative beliefs about self and others were related to positive psychotic symptomatology and to distress related to those experiences. Conclusions: Negative evaluations of the self and others appear to be characteristic of the appraisals of people seeking help for psychosis and psychosis-like experiences. The results support the literature that suggests that self-esteem should be a target for intervention. Future research would benefit from including comparison groups of people experiencing chronic psychosis and people who do not have any psychotic-like experiences.
Internalised stigma in young people meeting criteria for at-risk mental states (ARMS) has been highlighted as an important issue, and it has been suggested that provision of cognitive therapy may increase such stigma.
To investigate the effects of cognitive therapy on internalised stigma using a secondary analysis of data from the EDIE-2 trial.
Participants meeting criteria for ARMS were recruited as part of a multisite randomised controlled trial of cognitive therapy for prevention and amelioration of psychosis. Participants were assessed at baseline and at 6, 12, 18 and 24 months using measures of psychotic experiences, symptoms and internalised stigma.
Negative appraisals of experiences were significantly reduced in the group assigned to cognitive therapy (estimated difference at 12 months was −1.36 (95% Cl −2.69 to −0.02), P = 0.047). There was no difference in social acceptability of experiences (estimated difference at 12 months was 0.46, 95% Cl −0.05 to 0.98, P = 0.079).
These findings suggest that, rather than increasing internalised stigma, cognitive therapy decreases negative appraisals of unusual experiences in young people at risk of psychosis; as such, it is a non-stigmatising intervention for this population.
Background: More effective psychological treatments for psychosis are required. Case series data and pilot trials suggest metacognitive therapy (MCT) is a promising treatment for anxiety and depression. Other research has found negative metacognitive beliefs and thought-control strategies may be involved in the development and maintenance of hallucinations and delusions. The potential of MCT in treating psychosis has yet to be investigated. Aims: Our aim was to find out whether a short number of MCT sessions would be associated with clinically significant and sustained improvements in delusions, hallucinations, anxiety, depression and subjective recovery in patients with treatment-resistant long-standing psychosis. Method: Three consecutively referred patients, each with a diagnosis of paranoid schizophrenia and continuing symptoms, completed a series of multiple baseline assessments. Each then received between 11 and 13 sessions of MCT and completed regular assessments of progress, during therapy, post-therapy and at 3-month follow-up. Results: Two out of 3 participants achieved clinically significant reductions across a range of symptom-based outcomes at end-of-therapy. Improvement was sustained at 3-month follow-up for one participant. Conclusions: Our study demonstrates the feasibility of using MCT with people with medication-resistant psychosis. MCT was acceptable to the participants and associated with meaningful change. Some modifications may be required for this population, after which a controlled trial may be warranted.