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First-episode psychosis (FEP) is a major life event and can have an adverse impact on the diagnosed individual and their families. The importance of intervening early and providing optimal treatments is widely acknowledged. In comparison to patient groups, literature is scarce on identifying treatment predictors and moderators of caregiver outcomes. This study aimed to identify pre-treatment characteristics predicting and/or moderating carer outcomes, based on data from a multi-element psychosocial intervention to FEP patients and carers (GET-UP PIANO trial).
Carer demography, type of family relationship, patient contact hours, pre-treatment carer burden, patient perceptions of parental caregiving and expressed emotion (EE) were selected, a priori, as potential predictors/moderators of carer burden and emotional distress at 9 months post treatment. Outcomes were analysed separately in mixed-effects random regression models.
Analyses were performed on 260 carers. Only patient perceptions of early maternal criticism predicted reports of lower carer burden at follow-up. However, multiple imputation analysis failed to confirm this result. For treatment moderators: higher levels of carer burden at baseline yielded greater reductions in carer emotional distress at follow-up in the experimental group compared with treatment as usual (TAU). Higher levels of perceived EE moderated greater reductions in carer reports of tension in experimental group, compared with TAU, at follow-up. In younger caregivers (<51 years old), there were greater reductions in levels of worry during the baseline to follow-up period, within the experimental group compared with TAU.
The study failed to identify significant treatment predictors of FEP carer outcomes. However, our preliminary findings suggest that optimal treatment outcomes for carers at first episode might be moderated by younger carer age, and carers reporting higher baseline levels of burden, and where patients perceive higher levels of negative effect from caregivers.
Non-psychotic affective symptoms are important components of psychotic syndromes. They are frequent and are now thought to influence the emergence of paranoia and hallucinations. Evidence supporting this model of psychosis comes from recent cross-fertilising epidemiological and intervention studies. Epidemiological studies identify plausible targets for intervention but must be interpreted cautiously. Nevertheless, causal inference can be strengthened substantially using modern statistical methods.
Directed Acyclic Graphs were used in a dynamic Bayesian network approach to learn the overall dependence structure of chosen variables. DAG-based inference identifies the most likely directional links between multiple variables, thereby locating them in a putative causal cascade. We used initial and 18-month follow-up data from the 2000 British National Psychiatric Morbidity survey (N = 8580 and N = 2406).
We analysed persecutory ideation, hallucinations, a range of affective symptoms and the effects of cannabis and problematic alcohol use. Worry was central to the links between symptoms, with plausible direct effects on insomnia, depressed mood and generalised anxiety, and recent cannabis use. Worry linked the other affective phenomena with paranoia. Hallucinations were connected only to worry and persecutory ideation. General anxiety, worry, sleep problems, and persecutory ideation were strongly self-predicting. Worry and persecutory ideation were connected over the 18-month interval in an apparent feedback loop.
These results have implications for understanding dynamic processes in psychosis and for targeting psychological interventions. The reciprocal influence of worry and paranoia implies that treating either symptom is likely to ameliorate the other.
Attachment theory proposes that psychological functioning and affect regulations are influenced by the attachment we form with others. Early relationships with parents or caregivers lay the foundations for attachment styles. These styles are proposed to influence how we relate to others during our life can be modified by the relationships and events we experience in our lifespan. A secure attachment style is associated with a capacity to manage distress, comfort with autonomy and the ability to form relationships with others, whereas insecure attachment can lead to dysfunctional relationships, emotional and behaviour avoidance. Attachment theory provides a useful framework to inform our understanding of relationship difficulties in people with psychosis. This paper aims to complement recent systematic reviews by providing an overview of attachment theory, its application to psychosis, including an understanding of measurement issues and the clinical implications offered.
A narrative review was completed of the measures of attachment and parental bonding in psychosis. Its clinical implications are also discussed. The paper also explores the link between insecure attachment styles and illness course, social functioning and symptomatology. The following questions are addressed: What are the key attachment measures that have been used within the attachment and psychosis literature? What are the results of studies that have measured attachment or parental bonding in psychosis and what clinical implications can we derive from it? What are some of the key questions for future research from these findings in relation to the onset of psychosis research field?
The most commonly used measures of attachment in psychosis research are reviewed. Self-report questionnaires and semi-structured interviews have mainly been used to examine attachment styles in adult samples and in recent years comprise a measure specifically developed for a psychosis group. The review suggests that insecure attachment styles are common in psychosis samples. Key relationships were observed between insecure, avoidant and anxious attachment styles and psychosis development, expression and long-term outcome.
Attachment theory can provide a useful framework to facilitate our understanding of interpersonal difficulties in psychosis that may predate its onset and impact on observed variability in outcomes, including treatment engagement. Greater attention should be given to the assessment of attachment needs and to the development of interventions that seek to compensate for these difficulties. However, further investigations are required on specifying the exact mechanisms by which specific attachment styles impact on the development of psychosis and its course.
A common precursor to ice shelf disintegration, most notably that of Larsen B Ice Shelf, is unusually intense or prolonged surface melt and the presence of surface standing water. However, there has been little research into detailed patterns of melt on ice shelves or the nature of summer melt ponds. We investigated surface melt on Larsen C Ice Shelf at high resolution using Envisat advanced synthetic aperture radar (ASAR) data and explored melt ponds in a range of satellite images. The improved spatial resolution of SAR over alternative approaches revealed anomalously long melt duration in western inlets. Meteorological modelling explained this pattern by föhn winds which were common in this region. Melt ponds are difficult to detect using optical imagery because cloud-free conditions are rare in this region and ponds quickly freeze over, but can be monitored using SAR in all weather conditions. Melt ponds up to tens of kilometres in length were common in Cabinet Inlet, where melt duration was most prolonged. The pattern of melt explains the previously observed distribution of ice shelf densification, which in parts had reached levels that preceded the collapse of Larsen B Ice Shelf, suggesting a potential role for föhn winds in promoting unstable conditions on ice shelves.
For people with psychosis, contact with informal caregivers is an important source of social support, associated with recovery, and with better outcomes following individual cognitive therapy (CBTp). In this study, we tested whether increased flexibility in delusional thinking, an established predictor of positive outcome following CBTp, was a possible mechanism underlying this effect.
219 participants with delusions (mean age 38 years; 71% male; 75% White) were grouped according to the presence of a caregiver (37% with a caregiver) and caregiver level of expressed emotion (High/Low EE, 64% Low). Delusional belief flexibility was compared between groups, controlling for interpersonal functioning, severity of psychotic symptoms, and other hypothesised outcome predictors.
Participants with caregivers were nearly three times more likely than those without to show flexibility (OR = 2.7, 95% CI 1.5 to 5.0, p = 0.001), and five times more likely if the caregiving relationship was Low EE (OR = 5.0, 95% CI 2.0–13.0, p = 0.001). ORs remained consistent irrespective of controlling for interpersonal functioning and other predictors of outcome.
This is the first evidence that having supportive caregiving relationships is associated with a specific cognitive attribute in people with psychosis, suggesting a potential cognitive mechanism by which outcomes following CBTp, and perhaps more generally, are improved by social support.
Psychotic phenomena appear to form a continuum with normal experience and beliefs, and may build on common emotional interpersonal concerns.
We tested predictions that paranoid ideation is exponentially distributed and hierarchically arranged in the general population, and that persecutory ideas build on more common cognitions of mistrust, interpersonal sensitivity and ideas of reference.
Items were chosen from the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) questionnaire and the Psychosis Screening Questionnaire in the second British National Survey of Psychiatric Morbidity (n = 8580), to test a putative hierarchy of paranoid development using confirmatory factor analysis, latent class analysis and factor mixture modelling analysis.
Different types of paranoid ideation ranged in frequency from less than 2% to nearly 30%. Total scores on these items followed an almost perfect exponential distribution (r = 0.99). Our four a priori first-order factors were corroborated (interpersonal sensitivity; mistrust;ideas of reference; ideas of persecution). These mapped onto four classes of individual respondents:a rare, severe, persecutory class with high endorsement of all item factors, including persecutory ideation; a quasi-normal class with infrequent endorsement of interpersonal sensitivity, mistrust and ideas of reference, and no ideas of persecution; and two intermediate classes, characterised respectively by relatively high endorsement of items relating to mistrust and to ideas of reference.
The paranoia continuum has implications for the aetiology, mechanisms and treatment of psychotic disorders, while confirming the lack of a clear distinction from normal experiences and processes.
Being physically assaulted is known to increase the risk of the occurrence of post-traumatic stress disorder (PTSD) symptoms but it may also skew judgements about the intentions of other people. The objectives of the study were to assess paranoia and PTSD after an assault and to test whether theory-derived cognitive factors predicted the persistence of these problems.
At 4 weeks after hospital attendance due to an assault, 106 people were assessed on multiple symptom measures (including virtual reality) and cognitive factors from models of paranoia and PTSD. The symptom measures were repeated 3 and 6 months later.
Factor analysis indicated that paranoia and PTSD were distinct experiences, though positively correlated. At 4 weeks, 33% of participants met diagnostic criteria for PTSD, falling to 16% at follow-up. Of the group at the first assessment, 80% reported that since the assault they were excessively fearful of other people, which over time fell to 66%. Almost all the cognitive factors (including information-processing style during the trauma, mental defeat, qualities of unwanted memories, self-blame, negative thoughts about self, worry, safety behaviours, anomalous internal experiences and cognitive inflexibility) predicted later paranoia and PTSD, but there was little evidence of differential prediction.
Paranoia after an assault may be common and distinguishable from PTSD but predicted by a strikingly similar range of factors.
There is evidence that patients with schizophrenia benefit from standard cognitive behaviour therapy (CBT) only if active techniques are used (‘full therapy’). By contrast, attending sessions but not proceeding beyond engagement and assessment strategies (‘partial therapy’), or simply not attending sessions (‘no therapy’), is not associated with better outcomes. The factors leading to full therapy are unknown. We hypothesized that patients' initial ideas about the nature and extent of their problems would predict use of CBT. A match between patients' views of their problems and the principles underlying treatment would lead to better outcomes.
Ninety-two patients with a recent relapse of psychosis completed the Illness Perception Questionnaire (IPQ) before receiving CBT. We examined whether their illness perceptions predicted the take-up of therapy.
Patients who did not attend sessions believed their problems would not last as long as those who attended them. Those who attended sessions but did not proceed to full therapy had a lower sense of control over their problems and a more biological view of their causes. Patients who took up full therapy were more likely to attribute the cause of their problems to their personality and state of mind. The take-up of therapy was predicted neither by levels of psychiatric symptoms nor by insight.
People with psychosis who have psychologically orientated views of their problems, including the potential to gain control over them, may be more likely to engage fully and do well with standard CBT for psychosis, irrespective of the severity of their problems.
Previous studies have suggested that beliefs about voices mediate the relationship between actual voice experience and behavioural and affective response.
We investigated beliefs about voice power (omnipotence), voice intent (malevolence/benevolence) and emotional and behavioural response (resistance/engagement) using the Beliefs About Voices Questionnaire – Revised (BAVQ-R) in 46 voice hearers. Distress was assessed using a wide range of measures: voice-related distress, depression, anxiety, self-esteem and suicidal ideation. Voice topography was assessed using measures of voice severity, frequency and intensity. We predicted that beliefs about voices would show a stronger association with distress than voice topography.
Omnipotence had the strongest associations with all measures of distress included in the study whereas malevolence was related to resistance, and benevolence to engagement. As predicted, voice severity, frequency and intensity were not related to distress once beliefs were accounted for.
These results concur with previous findings that beliefs about voice power are key determinants of distress in voice hearers, and should be targeted specifically in psychological interventions.
Meta-analyses show that cognitive behaviour therapy for psychosis (CBT-P) improves distressing positive symptoms. However, it is a complex intervention involving a range of techniques. No previous study has assessed the delivery of the different elements of treatment and their effect on outcome. Our aim was to assess the differential effect of type of treatment delivered on the effectiveness of CBT-P, using novel statistical methodology.
The Psychological Prevention of Relapse in Psychosis (PRP) trial was a multi-centre randomized controlled trial (RCT) that compared CBT-P with treatment as usual (TAU). Therapy was manualized, and detailed evaluations of therapy delivery and client engagement were made. Follow-up assessments were made at 12 and 24 months. In a planned analysis, we applied principal stratification (involving structural equation modelling with finite mixtures) to estimate intention-to-treat (ITT) effects for subgroups of participants, defined by qualitative and quantitative differences in receipt of therapy, while maintaining the constraints of randomization.
Consistent delivery of full therapy, including specific cognitive and behavioural techniques, was associated with clinically and statistically significant increases in months in remission, and decreases in psychotic and affective symptoms. Delivery of partial therapy involving engagement and assessment was not effective.
Our analyses suggest that CBT-P is of significant benefit on multiple outcomes to patients able to engage in the full range of therapy procedures. The novel statistical methods illustrated in this report have general application to the evaluation of heterogeneity in the effects of treatment.
Psychological models of psychosis were examined using Experience Sampling Methods (ESM) to explore relationships between dimensions and appraisals of key symptoms and affect.
Individuals were signalled to complete ESM booklets 10 times per day for six consecutive days; 534 data points were obtained from 12 out-patients with psychosis.
Although only 3.6% of spontaneous thoughts were psychosis related, these predicted more negative and less positive affect. Delusions and hallucinations, when present, were rated at a moderate level of intensity, and intensity was associated with distress, interference and preoccupation. Symptom dimensions were related to each other, with weaker associations with delusional conviction, which, it is hypothesized, may represent a separate factor. Conviction and appraisals relating to insight and decentring (‘my problems are something to do with the way my mind works’) were highly variable. Decentring appraisals of delusions, but not insight, were associated with less distress. Appraisals about the power of voices were strong predictors of negative affect and symptom distress.
This study demonstrates that ESM is a useful methodology to capture ‘online’ variability in psychotic phenomenology and provides evidence supporting cognitive models, which posit that psychotic symptoms are multi-dimensional phenomena, shaped by appraisals that, in turn, predict their emotional and behavioural sequelae.
Cognitive skills programmes have been associated with improvements on psychometric measures and reductions in antisocial behaviour in mentally disordered offenders (MDOs). However, to date there have been no randomized controlled trials (RCTs) of such programmes with this population. In the first RCT of a cognitive skills programme with MDOs we aimed to determine if participation in the Reasoning and Rehabilitation (R&R) programme was associated with improvements in social–cognitive skills and thinking styles.
A total of 84 men with a primary diagnosis of psychotic disorder and a history of violence were recruited from medium-secure forensic units and allocated to receive R&R (n=44) or treatment as usual (TAU; n=40). At baseline and post-treatment interviews, participants completed questionnaires to assess social problem-solving, criminal attitudes, anger experience, blame externalizing and perspective-taking. Researchers were not blind to group status.
The R&R group demonstrated significant improvements on measures of social problem-solving relative to the TAU group, some of which were maintained at 12 months post-treatment. Only half of those allocated to receive R&R completed the full programme. In post-hoc analyses programme completers showed improvements in social problem-solving at the end of treatment and changes in criminal attitudes at 12 months post-treatment.
Among male MDOs, R&R participation was associated with improvements in social–cognitive skills, some of which were maintained for up to 12 months post-treatment. Our finding that programme completers do better may reflect pre-treatment patient characteristics. This study establishes that multi-site RCTs can be conducted in medium-secure forensic units.
The first episode of psychosis frequently occurs during adolescence and early adulthood, and is associated with high levels of trauma, affective disturbance and suicide. The social networks of service users often decrease significantly following the first onset, although many will remain in close contact with some family members particularly during the early phases. However, the negative impact of psychosis on families and their relationship with the identified service user are well documented. Family intervention is a recommended and evidence-based treatment in later psychosis. In this paper, we review the literature on family interventions in early psychosis in the context of new evidence for its efficacy and its routine incorporation in early intervention services for psychosis.
Background: Paranoia is a common experience in the non-clinical population. We use a novel experimental methodology to investigate paranoid ideas in individuals without a history of mental illness. Aims: We aimed to determine whether this paradigm could elicit unfounded paranoid thoughts and whether these thoughts could be predicted by factors from a cognitive model. Method: Fifty-eight individuals took part and completed measures assessing trait paranoia, mood, self and other schema and attributional style. They were exposed to two experimental events: 1) an interruption to the testing session by a stooge, and 2) a recording of laughter played outside the testing room and subsequently asked about their explanations for these events. Results: 15.5% (n = 9) of the sample gave a paranoid explanation for at least one of the experimental events. The remainder reported generally neutral explanations. Individuals with a paranoid explanation reported significantly higher levels of trait paranoia. Factors predictive of a paranoid interpretation were interpersonal sensitivity and attributional style. Conclusions: The results show that spontaneous paranoid explanations can be elicited in non-clinical individuals, even for quite neutral events. In line with current theories, the findings suggest that emotional processes contribute to paranoid interpretations of events, although, as a novel study with a modest sample, it requires replication.
Evidence is accumulating that child sexual abuse (CSA) is associated with many psychiatric disorders in adulthood. This paper uses the detailed information available from the 2007 Adult Psychiatric Morbidity Survey of England (APMS 2007) to quantify links between CSA and a range of psychiatric conditions.
The prevalence of psychiatric disorder was established in a random sample of the English household population (n=7403), which also provided sociodemographic and experiential information.
We analyzed six types of common mental disorder, alcohol abuse and drug abuse, and people who screened positively for post-traumatic stress disorder (PTSD) and eating disorders. All were strongly and highly significantly associated with CSA, particularly if non-consensual sexual intercourse was involved, for which odds ratios (ORs) ranged from 3.7 to 12.1. These disorders were also related to adult sexual abuse (ASA), although the likelihood of reverse causality is then increased. Revictimization in adulthood was common, and increased the association of CSA with disorder. For several disorders, the relative odds were higher in females but formal tests for moderation by gender were significant only for common mental disorders and only in relation to non-consensual sexual intercourse. The population attributable fraction (PAF) was higher in females in all cases.
The detailed and high-quality data in APMS 2007 provided important confirmation both of the strength of association of CSA with psychiatric disorder and of its relative non-specificity. Our results have major implications at the public health level and the individual level, in particular the need for better recognition and treatment of the sequelae of CSA.
This paper reports the psychometric properties of a CBT for psychosis adherence scale, the Revised Cognitive Therapy for Psychosis Adherence Scale (R-CTPAS). The scale's factor structure, inter-rater reliability and concurrent validity were analysed in a sample of 67 audiotaped sessions of CBT for psychosis. The concurrent validity of the scale was examined through comparison with the Cognitive Therapy Scale (CTS, Young and Beck, 1980). Principal components analysis of the trial data suggested three factors: “engagement/assessment work”, “relapse prevention work” and “formulation/schema work”. Satisfactory levels of inter-rater reliability were established between rater dyads. Moderate correlations with the CTS provided an indication of concurrent validity. The R-CTPAS is concluded to be a reliable and useful instrument that can assess adherence to CBT for psychosis using the Fowler, Garety and Kuipers (1995) therapy model.
Paranoia is increasingly being studied in clinical and non-clinical populations. However there is no multi-dimensional measure of persecutory ideas developed for use across the general population-psychopathology continuum. This paper reports the development of such a questionnaire: the ‘Green et al. Paranoid Thought Scales’. The aim was to devise a tool to assess ideas of persecution and social reference in a simple self-report format, guided by a current definition of persecutory ideation, and incorporating assessment of conviction, preoccupation and distress.
A total of 353 individuals without a history of mental illness, and 50 individuals with current persecutory delusions completed a pool of paranoid items and additional measures to assess validity. Items were devised from a recent definition of persecutory delusions, current assessments of paranoia, the authors' clinical experience, and incorporated dimensions of conviction, preoccupation and distress. Test–retest reliability in the non-clinical group was assessed at 2 weeks follow-up, and clinical change in the deluded group at 6 months follow-up.
Two 16-item scales were extracted, assessing ideas of social reference and persecution. Good internal consistency and validity was established for both scales and their dimensions. The scales were sensitive to clinical change. A hierarchical relationship between social reference and persecution was found. The data provide further evidence for a continuum of paranoid ideas between deluded and healthy individuals.
A reliable and valid tool for assessing paranoid thoughts is presented. It will provide an effective way for researchers to ensure consistency in research and for clinicians to assess change with treatment.
Insight in psychosis has previously been associated with both depression and cognitive ability. Some studies have found a curvilinear relationship between insight and cognitive ability but the roles of self-esteem and depression have not been taken into account.
To investigate the relationships between insight and IQ, depression, and self-esteem.
Correlations between self-reported and observer-rated insight, and measures of IQ, depression and self-esteem were examined in 67 people with psychosis.
Better self-reported insight was associated with higher IQ and poorer self-esteem, but not depression. There was some evidence for a curvilinear relationship between IQ and self-reported insight, specifically the ‘awareness of illness' dimension, which survived correction for symptom variables.
The relationship between insight and IQ might reflect both the basis of insight in intellectual ability and the influence of a psychological mechanism that preserves self-esteem.