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BACKGROUND: Cognitive behavioural therapy (CBT) has been implemented in bipolar (BP) disorder with varying degrees of success. The link between CBT for BP disorder and underlying theory is not clear. There have been attempts to identify a unique style of dysfunctional thinking in BP disorder analogous to that in unipolar (UP) disorder but this has suffered from a dearth of prospective studies controlling for mood and phase of illness. In this prospective study, we have examined whether dysfunctional thinking and the (dys)regulation of traumatic memories are trait vulnerability factors in BP versus UP mood disorders. METHOD: BP-1 and UP groups were followed-up from acute episode to recovery, and compared with a healthy control group. Measures of dysfunctional thinking and linked personality dimensions were taken, together with measures assessing autobiographical memory retrieval (AMT). The presence and control of intrusive memories of traumatic events in BP and UP disorder were assessed. RESULTS: Controlling for mood symptoms and phase of illness, the BP (but not the UP) group was largely indistinguishable from controls on dysfunctional thinking. Intrusive memories of traumatic events were present in 45% of the BP and 48% of the UP groups; and those without intrusions were more overgeneral on the AMT in all phases of illness. CONCLUSION: These findings are in line with the 'affect regulation' hypothesis for UP disorder and deliberate self-harm. This may help in understanding the mode of action of CBT in BP disorder and to further improve the therapy, primarily through the promotion of affective regulation, which is one component of the complex CBT intervention for BP disorder. [ABSTRACT FROM AUTHOR]

Background. Auditory hallucinations in psychosis often contain critical evaluations of the voice-hearer (for example, attacks on self-worth). A voice-hearer's experience with their dominant voice is a mirror of their social relationships in general, with experiences of feeling low in rank to both voices and others being associated with depression. However, the direction of the relationship between psychosis, depression and feeling subordinate is unclear.Method. Covariance structural equation modelling was used with data from 125 participants diagnosed with schizophrenia to compare three 'causal' models: (1) that depression leads to the appraisal of low social rank, voice power and distress; (2) that psychotic illness leads to voice activity (frequency, audibility), which in turn leads to depression and the appraisal of voices' power; (3) our hypothesized model, that perceptions of social rank and social power lead to the appraisal of voice power, distress and depression.Results. Findings supported model 3, suggesting that the appraisal of social power and rank are primary organizing schema underlying the appraisal of voice power, and the distress of voices.Conclusions. Voices can be seen to operate like external social relationships. Voice content and experience can mirror a person's social sense of being powerless and controlled by others. These findings suggest important new targets for intervention with cognitive and social therapy. [ABSTRACT FROM AUTHOR]

Background: Acting on harmful command hallucinations is a major clinical concern. Our COMMAND CBT trial approximately halved the rate of harmful compliance (OR = 0.45, 95% CI 0.23-0.88, p = 0.021). The focus of the therapy was a single mechanism, the power dimension of voice appraisal, was also significantly reduced. We hypothesised that voice power differential (between voice and voice hearer) was the mediator of the treatment effect., Methods: The trial sample (n = 197) was used. A logistic regression model predicting 18-month compliance was used to identify predictors, and an exploratory principal component analysis (PCA) of baseline variables used as potential predictors (confounders) in their own right. Stata's paramed command used to obtain estimates of the direct, indirect and total effects of treatment., Results: Voice omnipotence was the best predictor although the PCA identified a highly predictive cognitive-affective dimension comprising: voices' power, childhood trauma, depression and self-harm. In the mediation analysis, the indirect effect of treatment was fully explained by its effect on the hypothesised mediator: voice power differential., Conclusion: Voice power and treatment allocation were the best predictors of harmful compliance up to 18 months; post-treatment, voice power differential measured at nine months was the mediator of the effect of treatment on compliance at 18 months.

Background: A preliminary report by the authors suggested that the range of affect generated by voices (anger, fear, elation) was linked not to the form, content or topography of voice activity, but to the beliefs patients held about them, in particular their supposed power and authority. We argued that this conformed to a cognitive model; that is, voice beliefs represent an attempt to understand the experience of voices, and cannot be understood by reference to the form/content of voices alone. This study puts this cognitive model to empirical test., Methods: Sixty-two voice hearers conforming to ICD-10 schizophrenia or schizoaffective diagnoses were interviewed and completed standardized measures of voice activity; beliefs about voices and supporting evidence, coping behaviour; affect and depression., Results: Beliefs about the power and meaning of voices showed a close relationship with coping behaviour and affect (malevolent voices were associated with fear and anger and were resisted; benevolent voices were associated with positive effect and were engaged) and accounted for the high rate of depression in the sample (53%). Measures of voice form and topography did not show any link with behaviour or affect and in only one-quarter of cases did neutral observers rate voice beliefs as 'following directly' from voice content., Conclusion: The study found support for our cognitive model and therapeutic approach. Factors governing the genesis of these key beliefs remain unknown. A number of hypotheses are discussed, which centre around the possibility that voice beliefs develop as part of an adaptive process to the experience of voices, and are underpinned by core beliefs about the individuals self-worth and interpersonal schemata.

An analysis of the coping styles adopted by relatives of schizophrenic patients has been identified by many reviewers as essential to an understanding of the complex interactions between patient and caregiver and to the origins of relatives' expressed emotion (EE). This study reports a taxonomy of coping behaviour derived from interviews with relatives of schizophrenic patients. It was found that relatives adopted broad styles of coping across all areas of patients' behaviour change. Relationships were uncovered between the styles and (a) relatives perceived control, burden and stress, (b) patients' social functioning, severity of behavioural disturbance and progress of the illness. It is suggested that advising relatives of changes in their coping styles in the course of family intervention must be tempered by an understanding of their origins in patients' behaviour. Further research is recommended to identify the coping styles associated with the high EE/low EE research classification.

Recognition of prodromal symptoms of schizophrenia offers the potential of early intervention to avert relapse and re-hospitalization (Carpenter & Heinrichs, 1983). The present study investigated how a strategy to detect prodromal signs might be effectively applied in the clinical setting. A standard monitoring system was developed involving completion of a new early signs scale (ESS) measuring changes in key symptoms phenomenologically (self-report) and behaviourally (observer report). The ESS was subject to rigorous psychometric evaluation and tested in a prospective pilot investigation. The ESS reliably identified early signs and predicted relapse with an overall accuracy of 79%. Several different patterns of relapse were identified. Observer reports compensated for loss of insight in some patients. In two cases where early signs indices were detected, prompt increases in medication appeared to arrest relapse and avert readmission. The ESS offers itself as a reliable, valid and administratively feasible measure and demonstrates considerable potential as a cost-effective procedure for secondary prevention.