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Background: Sexual abuse and bullying are associated with poor mental health in adulthood. We previously established a clear relationship between bullying and symptoms of psychosis. Similarly, we would expect sexual abuse to be linked to the emergence of psychotic symptoms, through effects on negative affect. Method: We analysed English data from the Adult Psychiatric Morbidity Surveys, carried out in 2007 (N = 5954) and 2014 (N = 5946), based on representative national samples living in private households. We used probabilistic graphical models represented by directed acyclic graphs (DAGs). We obtained measures of persecutory ideation and auditory hallucinosis from the Psychosis Screening Questionnaire, and identified affective symptoms using the Clinical Interview Schedule. We included cannabis consumption and sex as they may determine the relationship between symptoms. We constrained incoming edges to sexual abuse and bullying to respect temporality. Results: In the DAG analyses, contrary to our expectations, paranoia appeared early in the cascade of relationships, close to the abuse variables, and generally lying upstream of affective symptoms. Paranoia was consistently directly antecedent to hallucinations, but also indirectly so, via non-psychotic symptoms. Hallucinosis was also the endpoint of pathways involving non-psychotic symptoms. Conclusions: Via worry, sexual abuse and bullying appear to drive a range of affective symptoms, and in some people, these may encourage the emergence of hallucinations. The link between adverse experiences and paranoia is much more direct. These findings have implications for managing distressing outcomes. In particular, worry may be a salient target for intervention in psychosis. [ABSTRACT FROM AUTHOR]

Informal caregivers of individuals affected by psychotic disorder can play a key role in the recovery process. However, little research has been conducted on the lived experiences of carers and family members. We conducted a bottom-up (from lived experience to theory) review of first-person accounts, co-written between academics and experts by experience, to identify key experiential themes. First-person accounts of carers, relatives, and individuals with psychosis were screened and discussed in collaborative workshops involving individuals with lived experiences of psychosis, family members, and carers, representing various organizations. The lived experiences of family members and carers were characterized by experiential themes related to dealing with the unexpected news, the search for a reason behind the disorder, living with difficult and negative emotions, dealing with loss, feeling lost in fragmented healthcare systems, feeling invisible and wanting to be active partners in care, struggling to communicate with the affected person, fighting stigma and isolation, dealing with an uncertain future, and learning from one's mistakes and building resilience and hope. Our findings bring forth the voices of relatives and informal carers of people with psychosis, by highlighting some of the common themes of their lived experiences from the time of the initial diagnosis and throughout the different clinical stages of the disorder. Informal carers are key stakeholders who can play a strategic role, and their contributions in the recovery process merit recognition and active support by mental health professionals. [ABSTRACT FROM AUTHOR]

Objectives: SlowMo is the first blended digital therapy for paranoia, showing significant small‐moderate reductions in paranoia in a recent large‐scale randomized controlled trial (RCT). This study explored the subjective service‐user experience of the SlowMo therapy content and design; the experience of the blended therapy approach, including the triangle of the therapeutic alliance; and the experience of the digital aspects of the intervention. Design: Qualitative co‐produced sub‐study of an RCT. Methods: Participants were 22 adult service users with schizophrenia‐spectrum psychosis and persistent distressing paranoia, who completed at least one SlowMo therapy session and a 24‐week follow‐up, at one of 3 sites in Oxford, London, and Sussex, UK. They were interviewed by peer researchers, using a topic guide co‐produced by the Patient and Public Involvement (PPI) team. The transcribed data were analysed thematically. Multiple coding and triangulation, and lay peer researcher validation were used to reach a consensus on the final theme structure. Results: Six core themes were identified: (i) starting the SlowMo journey; (ii) the central role of the supportive therapist; (iii) slowing things down; (iv) value and learning from social connections; (v) approaches and challenges of technology; and (vi) improvements in paranoia and well‐being. Conclusions: For these service users, slowing down for a moment was helpful, and integrated into thinking over time. Learning from social connections reflected reduced isolation, and enhanced learning through videos, vignettes, and peers. The central role of the supportive therapist and the triangle of alliance between service user, therapist, and digital platform were effective in promoting positive therapeutic outcomes. [ABSTRACT FROM AUTHOR]

Background: Marginalized groups are more likely to experience problems with technology-related access, motivation, and skills. This is known as the “digital divide.” Technology-related exclusion is a potential barrier to the equitable implementation of digital health. SlowMo therapy was developed with an inclusive, human-centered design to optimize accessibility and bridge the “digital divide.” SlowMo is an effective, blended digital psychological therapy for paranoia in psychosis. Objective: This study explores the “digital divide” and mobile app engagement in the SlowMo randomized controlled trial. Methods: Digital literacy was assessed at baseline, and a multidimensional assessment of engagement (ie, adherence [via system analytics and self-report] and self-reported user experience) was conducted at 12 weeks after therapy. Engagement was investigated in relation to demographics (ie, gender, age, ethnicity, and paranoia severity). Results: Digital literacy data demonstrated that technology use and confidence were lower in Black people and older people (n=168). The engagement findings indicated that 80.7% (96/119) of therapy completers met the a priori analytics adherence criteria. However, analytics adherence did not differ by demographics. High rates of user experience were reported overall (overall score: mean 75%, SD 17.1%; n=82). No differences in user experience were found for ethnicity, age, or paranoia severity, although self-reported app use, enjoyment, and usefulness were higher in women than in men. Conclusions: This study identified technology-related inequalities related to age and ethnicity, which did not influence engagement with SlowMo, suggesting that the therapy design bridged the “digital divide.” Intervention design may moderate the influence of individual differences on engagement. We recommend the adoption of inclusive, human-centered design to reduce the impact of the “digital divide” on therapy outcomes. [ABSTRACT FROM AUTHOR]

Objectives: SlowMo therapy is a pioneering blended digital therapy for paranoia, augmenting face‐to‐face therapy with an interactive 'webapp' and a mobile app. A recent large‐scale trial demonstrated small–moderate effects on paranoia alongside improvements in self‐esteem, worry, well‐being and quality of life. This paper provides a comprehensive account of therapy personalisation within this targeted approach. Design: Case examples illustrate therapy delivery and descriptive data are presented on personalised thought content. Method: Thought content was extracted from the webapp (n = 140 participants) and coded using newly devised categories: Worries: (1) Persecutory, (2) Negative social evaluation, (3) Negative self‐concept, (4) Loss/life stresses, (5) Sensory‐perceptual experiences and (6) Health anxieties. Safer thoughts: (1) Safer alternative (specific alternatives to worries), (2) Second‐wave (generalised) coping, (3) Positive self‐concept, (4) Positive activities and (5) Third‐wave (mindfulness‐based) coping. Data on therapy fidelity are also presented. Results: Worries: 'Persecutory' (92.9% of people) and 'Negative social evaluation' (74.3%) were most common. 'General worries/ life stresses' (31.4%) and 'Negative self‐concept' (22.1%) were present in a significant minority; 'Health anxieties' (10%) and 'Sensory‐perceptual' (10%) were less common. Safer thoughts: 'Second‐wave (general) coping' (85%), 'Safer alternatives' (76.4%), 'Positive self‐concept' (65.7%) and 'Positive activities' (64.3%) were common with 'Third‐wave' (mindfulness) coping observed for 30%. Fidelity: Only three therapy withdrawals were therapy related. Session adherence was excellent (mean = 15.2/16; SD = 0.9). Behavioural work was conducted with 71% of people (119/168). Conclusion: SlowMo therapy delivers a targeted yet personalised approach. Potential mechanisms of action extend beyond reasoning. Implications for cognitive models of paranoia and causal interventionist approaches are discussed. [ABSTRACT FROM AUTHOR]

The original CHoice of Outcome In Cbt for psychosEs (CHOICE) measure was designed in collaboration with experts by experience as a patient-reported "Psychological Recovery" outcome measure for cognitive-behavioral therapy for psychosis (CBTp). A short version (CHOICE-SF) was developed to use as a brief outcome measure, with a focus on sensitivity to change, for use in future research and practice. CHOICE-SF was developed and validated using 3 separate samples, comprising 640 service users attending 1 of 2 transdiagnostic clinics for (1) CBTp or (2) therapies for voice hearing or (3) who took part in the treatment as usual arm of a trial. In the initial subsample of 69 participants, items from the original CHOICE measure with medium to large effect sizes for change pre- to post-CBTp were retained to form the CHOICE-SF. Internal consistency, construct validity, and sensitivity to change were confirmed, and the factor structure was examined in 242 participants. Specificity was confirmed by comparison with 44 participants who completed CHOICE at 2 time points but did not receive therapy. Validation of CHOICE-SF was carried out by confirming factor structure and sensitivity to change in a new sample of 354 and a subsample of 51 participants, respectively. The CHOICE-SF comprised 11 items and 1 additional personal goal item. A single-factor structure was confirmed, with high internal consistency, construct validity, and sensitivity to change. The CHOICE-SF is a brief, psychometrically robust measure to assess change following psychological therapies in research and clinical practice for people with psychosis and severe mental illness. [ABSTRACT FROM AUTHOR]

This study aimed to investigate potential ethnic differences in cognitive responses to caregiving in psychosis that might be relevant to the delivery of caregiver interventions for difficulties related to psychosis. We compared cross-sectional outcomes across early-stage caregivers who self-identified as white British (n = 37) and those who self-identified as black African or Caribbean (n = 41) using United Kingdom (UK) census ethnicity criteria. Self-report questionnaires were used to examine caregiver beliefs about psychosis, including the perceived causes, consequences, timeline, the degree of control that patients have over their difficulties, as well as their appraisals of caregiving. Caregivers from black African or Caribbean backgrounds reported a significantly shorter expected duration of illness than white British caregivers. They were also more likely to cite psychosocial causes (e.g., relationship issues), and less likely to cite biological and genetic causes, as their principal explanations for problems. However, overall differences in perceived causes of illness between ethnicities were not significant, despite the power in this sample to detect medium-sized effects. Factors associated with ethnicity may contribute to individual differences in explanatory models of illness and in experiences of caregiving. A degree of sensitivity to the range of views that people might hold about psychosis may help to engage caregivers from diverse ethnic backgrounds. [ABSTRACT FROM AUTHOR]

Paranoid thoughts are common across the psychosis continuum. It is well established that reasoning biases (conceived as an overreliance on fast thinking and lack of willingness and/or ability to engage in slow thinking) contribute to paranoia. Targeted therapies have shown promise in improving reasoning in order to reduce paranoia. Psychometrically robust and easy-to-use measures of these thinking styles will assist research and clinical practice. Existing assessments include experimental tasks that are complex to administer or self-report measures that have limitations in comprehensively assessing cognitive biases in paranoia. We have developed the first questionnaire to assess fast and slow thinking biases related to paranoid thoughts, and here report on its evaluation. In study 1, we generated, evaluated, and extracted items reflecting reasoning, and assessed their reliability and validity in a non-clinical sample (n = 209). In study 2, we replicated the factor analysis and psychometric evaluation in a clinical sample (n = 265). The resultant Fast and Slow Thinking (FaST) questionnaire consists of two 5-item scales reflecting fast and slow thinking and is therefore brief and suitable for use in both research and clinical practice. The fast thinking scale is reliable and valid. Reliability and criterion validity of the slow scale shows promise. It had limited construct validity with objective reasoning assessments in the clinical group, possibly due to impaired meta-cognitive awareness of slow thinking. We recommend the FaST questionnaire as a new tool for improving understanding of reasoning biases in paranoia and supporting targeted psychological therapies. [ABSTRACT FROM AUTHOR]

Aim: Looking after someone in the early stages of psychosis can have a negative impact on caregivers, but there is little clarity about which interventions, if any, caregivers should be offered. This study investigated sleep disturbances in early psychosis caregivers and the relationship between their sleep quality and distress. Method: In all, 79 caregivers of patients with a recent first episode of psychosis completed self‐report measures including the Pittsburgh Sleep Quality Index (PSQI), the RAND 36‐item Health Survey 1.0 (SF‐36) and the Experiences of Caregiving Inventory (ECI). Results: All caregivers were living with their relatives with psychosis and had been providing support since the onset of illness (mean duration = 92.5 weeks, SD = 84.0); 60% (47/79) obtained a global PSQI score that exceeded the established cut‐off score for clinically significant sleep problems (>5). Low "sleep duration" and "sleep disturbances" contributed the most to elevated PSQI scores, with 17.7% of participants reporting regular wakening at night due to "stress" or "worries." When predicting psychological distress (SF‐36) from negative appraisals of caregiving (ECI) and poor sleep (PSQI), a significant unadjusted regression model was obtained, F(2,73) = 29.440, P = .000, R2 of.447. An estimation of the indirect effect of negative thoughts about caregiving on mental distress through poor sleep was also significant (ab = −.05, 95% CI [−.09, −.02], PM = .39). Conclusion: Caregivers of people with psychosis may have significant problems with sleep, which relates to distress and negative appraisals about caregiving. Health services need to ask caregivers directly about such issues and consider offering brief interventions to improve sleep quality. [ABSTRACT FROM AUTHOR]

Objectives: Informal caregiving relationships play an important role in facilitating recovery outcomes in psychosis. The relationship can serve as a source of positive experiences that co‐exist alongside common challenges typically associated with mental health problems. People with psychosis, when compared to the general population, are more likely to perpetrate acts of violence, a relationship that is particularly evident during the first psychosis episode. Although victims of service user violence are typically people already known to them, such as informal carers, there remains a lack of understanding about their caring experiences and needs. This study sought to address gaps in the literature by exploring the subjective accounts of informal carers supporting a relative experiencing their first episode of psychosis who has also behaved violently towards them. Design: A cross‐sectional design was employed. Methods: Individual semi‐structured interviews, which were audio recorded and later transcribed for analyses, were undertaken with a convenience sample of eight carers drawn from a specialist early psychosis service. Interview questions focused on their experiences of patient violence, the subjective impact, and coping strategies. An interpretative phenomenological approach was used to analyse the data. Results: Participants were mostly living with their relative with psychosis and were typically female, parents, and from a black and minority ethnic background. Data analyses identified seven key themes from participant interviews including the lack of predictability over when the violence occurred, being scared and fearful, keeping quiet about what happens at home and in the caregiving relationship, and staying safe. Conclusions: Reports by informal carers about experiencing violence and victimization from their relatives with psychosis are an important issue in some caregiving relationships during the first episode. Developing a more informed understanding of the specific needs of these carers and the caregiving relationship is indicated. The implications for service providers are discussed. Practitioner points: Carers were exposed to a broad range of patient violence, which included being kicked and having weapons used against them. The violence typically occurred within carers' homes, when no other people were around.Patient violence impacted negatively on carer emotional and physical functioning, which included leaving carers living in fear of their own safety and what might become of their relative.The results highlight the importance of routinely asking first‐episode carers about their experience of patient violence.The development of interventions (e.g., identification of early triggers, de‐escalation) that are able to take account of the ongoing nature and complexity of the caregiving relationship but are purposefully aimed at supporting carers to remain safe in their relationship should be explored for their impact. [ABSTRACT FROM AUTHOR]

A modest association can be found between people with a schizophrenia spectrum diagnosis (psychosis) and perpetrating acts of violence. When a person with psychosis does engage in violence, it is their informal carers, when compared to those from the general population, who are more likely to be the targets, and violence will often occur within the family home. Despite the importance of carer support for improving patient outcomes, our understanding of how carers are impacted by patient initiated violence in psychosis remains limited. This paper reviews literature documenting the effects of patient-initiated violence in psychosis on carer functioning. The review comprised searches of Medline, PsychInfo, Embase, and Web of Science databases and the hand searches of reference lists from relevant published papers. The review was limited to English language publications from inception to 11th September 2017, and where carer experiences following reports of violence from patients with psychosis were specifically recorded. Data from 20 papers using mixed methodologies were reviewed. Patient violence in psychosis was linked to poorer carer outcomes, including carer reports of burden, trauma, fear, and helplessness. There is, however, a significant need for further studies to systematically quantify the impact and correlates of patient initiated violence on psychosis caregivers, and improve prevention. [ABSTRACT FROM AUTHOR]

Modern psychiatric epidemiology researches complex interactions between multiple variables in large datasets. This creates difficulties for causal inference. We argue for the use of probabilistic models represented by directed acyclic graphs (DAGs). These capture the dependence structure of multiple variables and, used appropriately, allow more robust conclusions about the direction of causation. We analyzed British national survey data to assess putative mediators of the association between bullying victimization and persecutory ideation. We compared results using DAGs and the Karlson--Holm--Breen (KHB) logistic regression commands in STATA. We analyzed data from the 2007 English National Survey of Psychiatric Morbidity, using the equivalent 2000 survey in an instant replication. Additional details of methods and results are provided in the supplementary material. DAG analysis revealed a richer structure of relationships than could be inferred using the KHB logistic regression commands. Thus, bullying had direct effects on worry, persecutory ideation, mood instability, and drug use. Depression, sleep and anxiety lay downstream, and therefore did not mediate the link between bullying and persecutory ideation. Mediation by worry and mood instability could not be definitively ascertained. Bullying led to hallucinations indirectly, via persecutory ideation and depression. DAG analysis of the 2000 dataset suggested the technique generates stable results. While causality cannot be fully determined from cross-sectional data, DAGs indicate the relationships providing the best fit. They thereby advance investigation of the complex interactions seen in psychiatry, including the mechanisms underpinning psychiatric symptoms. It may consequently be used to optimize the choice of intervention targets. [ABSTRACT FROM AUTHOR]

Aims In occupational settings, burnout is a common response to chronic exposure stressors and has been frequently documented in formal caregivers (i.e. paid psychiatric staff). However, the literature is limited on reports of burnout among informal caregivers and particularly within early psychosis groups. The current study sought to investigate reports of burnout in carers of young adults treated within a specialist early psychosis service and links with key appraisals reported about the illness and coping. Methods Seventy-two carers completed the Maslach Burnout Inventory along with self-report measures of coping styles and illness beliefs. Results Seventy-eight per cent of carers reported high burnout in at least one of the three key burnout markers (i.e. emotional exhaustion, depersonalization or low personal accomplishment). Seven per cent of carers met full criteria for high burnout across all the three domains. A carer's belief about the negative consequences of the illness for themselves was a significant predictor of emotional exhaustion and depersonalization. Low personal accomplishment was linked to a carer's less optimistic beliefs about the illness timeline and fewer reports of adaptive coping. Conclusions The results provide preliminary support for the importance of asking carers in the early illness phase about their experiences of caregiving. Targeted assessment may serve as a helpful tool to identify and intervene with carers in need of additional support with stress management, use of adaptive coping strategies, and balanced recovery focused information about psychosis. [ABSTRACT FROM AUTHOR]

Objectives Few studies have investigated service user satisfaction with cognitive behavioural therapy for psychosis ( CBTp). This study explored its associations with clinical presentation and outcomes, retrospective expectations of progress, perceptions of the therapist, and demographic variables. Design and methods One hundred and sixty-five service users completed self-report questionnaires pre- and post- CBTp in relation to the constructs of interest. Regression analyses explored associations with (1) overall satisfaction with therapy and (2) perceived progress, skills, and knowledge gained. Results Ninety-six per cent of service users reported satisfaction with therapy. Higher levels of overall satisfaction with, and perceived benefit from, therapy were associated with positive therapy expectations, positive ratings of therapist's personal qualities, competence and trustworthiness, lower pre-therapy depression, and improvements in quality of life. Symptom improvements were not related to overall satisfaction with therapy; however, with the exception of voices, better clinical outcomes were associated with subjective ratings of having made more progress and gained more CBT skills and knowledge. Demographic factors were not associated with satisfaction or perceived progress. In multiple regression analyses, expectations of progress showed the strongest associations with both satisfaction and perceived benefits. Other remaining significant associations consisted of perceptions of the therapist for satisfaction, and both pre-therapy levels of, and changes in, depression for perceived benefits. Qualitative feedback emphasized the importance of the therapeutic relationship and developing new coping strategies. Conclusions The findings provide preliminary evidence that high levels of satisfaction with therapy are not contingent on good clinical outcomes and are instead associated with positive therapy expectations and perceptions of the therapist. Practitioner points Therapy expectations represent a neglected area of research and may have implications for levels of satisfaction with therapy and perceived benefit., The findings reinforce the importance of cognitive behavioural therapy for psychosis ( CBTp) therapists demonstrating that they are supportive, competent, and trustworthy., The findings suggest that positive experiences of therapy do not require changes in psychosis symptoms and are instead related to changes in quality of life., Depressive symptoms at the start of therapy may adversely influence the extent to which CBT skills and knowledge are gained and levels of perceived progress at the end of therapy., The present sample was restricted to service users who completed therapy., Satisfaction levels were high. Further research is needed to explore factors associated with dissatisfaction with therapy. [ABSTRACT FROM AUTHOR]

Objective: Posttraumatic stress symptoms (PTSS) have been identified in caregivers of people with psychosis, but their clinical correlates are less well known. This study aimed to assess PTSS in a sample of caregivers of people with psychosis and to examine the relationship between PTSS and caregiving experiences.Method: A total of 32 caregivers of people with psychosis completed self-report questionnaires and structured interviews assessing PTSS and caregiving processes, including expressed emotion, burden, and coping.Results: In all, 44% of the sample reported PTSS, which were associated with caregiver reports of burden and less adaptive (avoidant) coping. No links were observed with expressed emotion in this sample.Conclusion: Almost half of caregivers of people with psychosis reported PTSS related to their caring role, which may have implications for their caregiving experiences and coping efforts. The findings highlight the importance of assessing need in caregivers and optimizing opportunities to offer needs-led therapeutic interventions to caregivers. [ABSTRACT FROM AUTHOR]

Background In 1993, Kavanagh and colleagues outlined outcomes from a training programme designed to equip mental health practitioners to deliver evidence-based cognitive-behavioural family interventions within routine care. The authors highlighted how the training had not been able to deliver notable increases in the numbers of families being seen by the trained clinicians. There were significant issues in the translation and provision of family interventions within clinical settings, specifically difficulties with the integration of family interventions and caseload demands, and insufficient time within job plans and service settings to undertake the work. The authors posed the question: what can the matter be? Interestingly, the same question was being asked over a decade later. Objective The current article provides a narrative review of the issues on implementation of family interventions in psychosis. Results Current evidence suggests that while there exist pockets of good practice and provision for family interventions, it was a mistake to assume that care coordinators would be able to include these family interventions as part of their role, effectively to add duties without significant modification to their current roles and duties. It also seems to have been an underestimate of the skills required for delivering family work in psychosis and the ongoing requirements for high-quality supervision. Conclusion We argue for carer specialists to be involved in mental health teams, particularly early intervention teams, and for a triage system to offer families a range of evidence-based support, as well as family interventions for more complex problems and presentations. [ABSTRACT FROM AUTHOR]

Objectives: Schizotypy relates to rejection sensitivity (anxiety reflecting an expectancy of social exclusion) and neuroticism (excessive evaluation of negative emotions). Positive schizotypy (e.g., perceptual aberrations and odd beliefs) and negative schizotypy (e.g., social and physical anhedonia) could relate to altered attention to rejection because of neuroticism.Methods: Forty-one healthy individuals were assessed on positive and negative schizotypy and neuroticism, and event-related potentials during rejecting, accepting and neutral scenes. Participants were categorised into high, moderate and low neuroticism groups. Using temporo-spatial principal components analyses, P200 (peak latency =290 ms) and P300 amplitudes (peak latency = 390 ms) were measured, reflecting mobilisation of attention and early attention, respectively.Results: Scalp-level and cortical source analysis revealed elevated fronto-parietal N300/P300 amplitude and P200-related dorsal anterior cingulate current density during rejection than acceptance/neutral scenes. Positive schizotypy related inversely to parietal P200 amplitude during rejection. Negative schizotypy related positively to P200 middle occipital current density. Negative schizotypy related positively to parietal P300, where the association was stronger in high and moderate, than low, neuroticism groups.Conclusions: Positive and negative schizotypy relate divergently to attention to rejection. Positive schizotypy attenuates, but negative schizotypy increases rejection-related mobilisation of attention. Negative schizotypy increases early attention to rejection partly due to elevated neuroticism. [ABSTRACT FROM PUBLISHER]

Caregivers play an important role in the treatment and recovery of people with psychosis but they have different needs from service users and can experience significant distress as part of their role. Responding to caregiver needs is not readily identified as being the primary responsibility of clinical services that have limited resources. A small pilot study sought to evaluate the effect and acceptability of providing a brief, needs‐led intervention to long‐term caregivers of service users with psychosis. A two or three session, interactive and structured intervention, adapted from family work with psychosis, focused on facilitated carer access to reliable information about psychosis, goal setting and adaptive problem‐solving. Measures of affect, coping and care‐giving impact were completed at baseline and post‐intervention. Data for the first four caregivers who attended individual sessions are presented. Post‐intervention scores indicate reductions in levels of carer distress and depressive symptoms. Caregivers reported high levels of acceptability and satisfaction. Further studies are required to evaluate the impact of such interventions on a larger number and wider range of caregivers. Practitioner points: To date, it has proved difficult for clinical services to meet the needs of caregivers of service users with psychosis.The caregivers of service users with psychosis have readily identifiable needs that can be met with a brief, structured, individualized and interactive intervention.Offering a time‐limited intervention to carers who would like support with their role has benefits for both the caregivers and the service. [ABSTRACT FROM AUTHOR]

Randomised controlled trials (RCTs) have shown the efficacy of CBTp, however, few studies have considered its long-term effectiveness in routine services. This study reports the outcomes of clients seen in a psychological therapies clinic, set up following positive results obtained from an RCT (Peters et al., 2010). The aims were to evaluate the effectiveness of CBTp, using data from the service's routine assessments for consecutive referrals over a 12 years period, and assess whether gains were maintained at a 6+ months' follow-up. Of the 476 consenting referrals, all clients (N = 358) who received ≥5 therapy sessions were offered an assessment at four time points (baseline, pre-, mid-, and end of therapy) on measures assessing current psychosis symptoms, emotional problems, general well-being and life satisfaction. A sub-set (N = 113) was assessed at a median of 12 months after finishing therapy. Following the waiting list (median of 3 months) clients received individualized, formulation-based CBTp for a median number of 19 sessions from 121 therapists with a range of experience receiving regular supervision. Clients showed no meaningful change on any measure while on the waiting list (Cohen's d ⇐ 0.23). In contrast, highly significant improvements following therapy, all of which were significantly greater than changes during the waiting list, were found on all domains assessed (Cohen's d: 0.44-0.75). All gains were maintained at follow-up (Cohen's d: 0.29-0.82), with little change between end of therapy and followup (Cohen's d ⇐ 0.18). Drop-out rate from therapy was low (13%). These results demonstrate the positive and potentially enduring impact of psychological therapy on a range of meaningful outcomes for clients with psychosis. The follow-up assessments were conducted on only a sub-set, which may not generalize to the full sample. Nevertheless this study is the largest of its kind in psychosis, and has important implications for the practice of CBTp in clinical services. [ABSTRACT FROM AUTHOR]

Background: Historically, it has been difficult to demonstrate an impact of training in psychological interventions for people with psychosis on routine practice and on patient outcomes. A recent pilot evaluation suggested that postgraduate training in Cognitive Behavioural Therapy for Psychosis (CBTp) increased the delivery of competent therapy in routine services. In this study, we evaluated clinical outcomes for patients receiving therapy from therapists who successfully completed training, and their association with ratings of therapist competence and therapy content. Aims: To characterize the therapy delivered during training and to inform both a calculation of effect size for its clinical impact, and the development of competence benchmarks to ensure that training standards are sufficient to deliver clinical improvement. Method: Paired patient-reported outcome measures (PROMS) were extracted from anonymized therapy case reports, and were matched with therapy ratings for each therapist. Results: Twenty clients received a course of competent therapy, including a high frequency of active therapy techniques, from nine therapists. Pre–post effect size for change in psychotic symptoms was large (d = 1.0) and for affect, medium (d = 0.6), but improved outcomes were not associated with therapist competence or therapy content. Conclusions: Therapists trained to research trial standards of competence achieved excellent clinical outcomes. Therapy effect sizes suggest that training costs may be offset by clinical benefit. Larger, methodologically stringent evaluations of training are now required. Future research should assess the necessary and sufficient training required to achieve real-world clinical effectiveness, and the cost-effectiveness of training. [ABSTRACT FROM AUTHOR]

Background: Increasing access to evidence-based talking therapies for people with psychosis is a national health priority. We have piloted a new, "low intensity" (LI) CBT intervention specifically designed to be delivered by frontline mental health staff, following brief training, and with ongoing supervision and support. A pilot feasibility study has demonstrated significant improvement in service user outcomes. This study is a qualitative analysis of the experiences of the staff and service users taking part in the evaluation. Aims: To evaluate the acceptability of the training protocol and the therapy, and to examine the factors promoting and restraining implementation. Method: All trained staff and service users completed a semistructured interview that was transcribed and subjected to thematic analysis. Results: Service users spoke about learning new skills and achieving their goals. Staff spoke about being able to use a brief, structured intervention to achieve positive outcomes for their clients. Both groups felt that longer, more sophisticated interventions were required to address more complex problems. The positive clinical outcomes motivated therapists to continue using the approach, despite organizational barriers. Conclusions: For both trained staff and service users, taking part in the study was a positive experience. Staff members' perceived skill development and positive reaction to seeing their clients improve should help to promote implementation. Work is needed to clarify whether and how more complex difficulties should be addressed by frontline staff. [ABSTRACT FROM AUTHOR]

Background: Given the evidence that reasoning biases contribute to delusional persistence and change, several research groups have made systematic efforts to modify them. The current experiment tested the hypothesis that targeting reasoning biases would result in change in delusions. Methods: One hundred and one participants with current delusions and schizophrenia spectrum psychosis were randomly allocated to a brief computerized reasoning training intervention or to a control condition involving computer-based activities of similar duration. The primary hypotheses tested were that the reasoning training intervention, would improve (1) data gathering and belief flexibility and (2) delusional thinking, specifically paranoia. We then tested whether the changes in paranoia were mediated by changes in data gathering and flexibility, and whether working memory and negative symptoms moderated any intervention effects. Results: On an intention-to-treat analysis, there were significant improvements in state paranoia and reasoning in the experimental compared with the control condition. There was evidence that changes in reasoning mediated changes in paranoia, although this effect fell just outside the conventional level of significance after adjustment for baseline confounders. Working memory and negative symptoms significantly moderated the effects of the intervention on reasoning. Conclusion: The study demonstrated the effectiveness of a brief reasoning intervention in improving both reasoning processes and paranoia. It thereby provides proof-of-concept evidence that reasoning is a promising intermediary target in interventions to ameliorate delusions, and thus supports the value of developing this approach as a longer therapeutic intervention. [ABSTRACT FROM PUBLISHER]

Previous research has indicated that nightmares might be a common problem for people with psychotic symptoms. Furthermore, more distressing nightmares have been associated with higher levels of delusional severity, depression, anxiety, stress and working memory. However no known research has investigated the use of nightmare treatments in those with symptoms of psychosis. This study aimed to assess the acceptability and feasibility of using imagery rehearsal (IR) therapy as a treatment of nightmares for those presenting with co-morbid psychotic symptoms. Six participants presenting with frequent distressing nightmares and psychotic symptoms were recruited. Five participants attended 4–6 sessions of IR. Measures of nightmares, sleep quality, psychotic and affective symptoms were completed at baseline and immediately following the intervention. It was feasible to adapt IR for those experiencing psychotic symptoms. Descriptive improvements were noted on measures of nightmare-related distress, vividness and intensity. Positive post-session feedback endorsed the acceptability of IR. Nightmare frequency did not reduce following IR; however, participants described a change in emotional response. IR was an acceptable and feasible intervention for this small sample. A larger study powered to detect group changes, with an additional control is warranted to test the efficacy of the intervention for those with psychosis. [ABSTRACT FROM AUTHOR]

Aim This study explored the relationship between individuals with early psychosis and first-degree relatives who were carers, to see whether negative and distressing experiences of the patient-carer relationship were associated with social cognition difficulties in both groups. Method The study had a cross-sectional correlational design. A total of 33 patients with early psychosis (within 3 years of first psychotic episode) and 24 first-degree relative carers (all parents) completed measures of mood, expressed emotion and negative experiences of caregiving. Social cognition measures of theory of mind and emotion recognition were also collected. Results Patient perceptions of carer criticism were related to increased anxiety and depression. Carer negative experiences of caregiving were related to higher levels of expressed emotion, anxiety and depression. Both patients and carers showed impaired performance on social cognition tasks. However, patient social cognition was not related to perceptions of carer criticism or symptoms. Carer social cognition was not related to expressed emotion or carer burden. Conclusion Even in the early stages of psychosis, both patients and carers were reporting negative experiences of the caregiving relationship. These were related to higher levels of anxiety and depression. Social cognition difficulties were found in both early psychosis patients and first-degree relatives, but did not relate to caregiving relationships. The findings underscore the importance of providing targeted family interventions to individuals with early psychosis and their carers that address appraisals of the relationship and low mood. [ABSTRACT FROM AUTHOR]

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Background Cognitive models propose that cognitive and emotional processes, in the context of anomalies of experience, lead to and maintain delusions. No large-scale studies have investigated whether persecutory and grandiose delusions reflect differing contributions of reasoning and affective processes. This is complicated by their frequent cooccurrence in schizophrenia. We hypothesized that persecutory and grandiose subtypes would differ significantly in their associations with psychological processes. Methods Participants were the 301 patients from the Psychological Prevention of Relapse in Psychosis Trial (ISRCTN83557988). Persecutory delusions were present in 192 participants, and grandiose delusions were present in 97, while 58 were rated as having delusions both of persecution and grandiosity. Measures of emotional and reasoning processes, at baseline only, were employed. Results A bivariate response model was used. Negative self-evaluations and depression and anxiety predicted a significantly increased chance of persecutory delusions whereas grandiose delusions were predicted by less negative self-evaluations and lower anxiety and depression, along with higher positive self and positive other evaluations. Reasoning biases were common in the whole group and in categorically defined subgroups with only persecutory delusions and only grandiose delusions; however, jumping to conclusions, and belief flexibility were significantly different in the 2 groups, the grandiose group having a higher likelihood of showing a reasoning bias than the persecutory group. Conclusion The significant differences in the processes associated with these 2 delusion subtypes have implications for etiology and for the development of targeted treatment strategies. [ABSTRACT FROM PUBLISHER]

Background: Over half of children in the general population report unusual or “psychotic-like” experiences (PLEs). The development of a later at-risk mental state is associated with persistent, distressing, PLEs, which are appraised negatively and hard to cope with. We have designed a novel, manualized, cognitive behavioural intervention for children aged 9 to 14 years, which aims to reduce emotional problems, improve coping and resilience, and help children manage PLEs, before an identifiable psychosis risk develops. We report on the feasibility, acceptability and clinical impact of the intervention. Method: Four children who reported PLEs and emotional problems in a community survey completed the intervention, and gave detailed feedback. Clinical outcomes were assessed before, during, and after therapy. Results: Emotional problems, PLE frequency, and PLE impact all decreased during the intervention. Child and therapist satisfaction with the treatment was high. Conclusions: It is feasible, acceptable and helpful to offer psychological interventions to children who report emotional distress and PLEs, prior to the emergence of clear risk factors. Our intervention has the potential to increase resilience to the development of future mental health problems. A larger, randomized controlled evaluation is underway. [ABSTRACT FROM AUTHOR]

Objective: Despite a large evidence base indicating that cognitive skills programs can reduce reoffending in individuals without mental illness, there have been no randomized controlled trials (RCTs) to determine their effectiveness in mentally disordered offenders (MDOs). In the first RCT of a cognitive skills program for MDOs, we aimed to investigate whether participation in the Reasoning and Rehabilitation (R&R) program reduced violence and antisocial behavior in this population. Method: Eighty-four male inpatients with a psychotic disorder and a history of violence were recruited from medium secure forensic hospitals. Participants were randomized to receive the R&R program, consisting of 36 two-hour sessions, or treatment as usual (TAU). Incidents of violence and antisocial behavior (verbal aggression, substance use, and leave violations) were assessed during treatment and at 12-months posttreatment. Results: Relative to the TAU group, incident rates of verbal aggression and leave violations during the treatment period were significantly lower in the R&R group; the effect on verbal aggression was maintained at 12-months posttreatment. Half of those randomized to receive R&R did not complete treatment; post hoc analyses were therefore conducted to compare treatment responses in program completers and noncompleters. After controlling for psychopathic traits, incidents of violence, verbal aggression, and leave violations during treatment were significantly lower in program completers, and there were significant effects of program completion on verbal aggression and substance use at 12-months posttreatment. Conclusions: R&R leads to a reduction in incidents of antisocial behavior in MDO populations, with potentially greater impact on those who complete treatment. [ABSTRACT FROM AUTHOR]

Previous small-sample studies have shown altered frontotemporal activity in schizophrenia patients with auditory hallucinations and impaired monitoring of self-generated speech. We examined a large cohort of patients with schizophrenia (n = 63) and a representative group of healthy controls (n = 20) to disentangle performance, illness, and symptom-related effects in functional magnetic resonance imaging–detected brain abnormalities during monitoring of self- and externally generated speech in schizophrenia. Our results revealed activation of the thalamus (medial geniculate nucleus, MGN) and frontotemporal regions with accurate monitoring across all participants. Less activation of the thalamus (MGN, pulvinar) and superior-middle temporal and inferior frontal gyri occurred in poorly performing patients (1 standard deviation below controls’ mean; n = 36), relative to the combined group of controls and well-performing patients. In patients, (1) greater deactivation of the ventral striatum and hypothalamus to own voice, combined with nonsignificant activation of the same regions to others’ voice, associated positively with negative symptoms (blunted affect, emotional withdrawal, poor rapport, passive social avoidance) regardless of performance and (2) exaggerated activation of the right superior-middle temporal gyrus during undistorted, relative to distorted, feedback associated with both positive symptoms (hallucinations, persecution) and poor performance. A further thalamic abnormality characterized schizophrenia patients regardless of performance and symptoms. We conclude that hypoactivation of a neural network comprised of the thalamus and frontotemporal regions underlies impaired speech monitoring in schizophrenia. Positive symptoms and poor monitoring share a common activation abnormality in the right superior temporal gyrus during processing of degraded speech. Altered striatal and hypothalamic modulation to own and others’ voice characterizes emotionally withdrawn and socially avoidant patients. [ABSTRACT FROM PUBLISHER]

Abstract: The distressing symptoms of psychosis, delusions, and hallucinations used to be thought of as unsuitable for psychological therapies. Recent research on the continuities between normal experiences and those found in psychosis has led to the development of a wider range of psychological therapies, adapted from approaches for anxiety and depression, to the more complex presentations found in psychosis. These can include overlaps with anxiety disorders, depression, obsessive–compulsive disorders, trauma, and personality disorders. Many people also have co-morbid substance misuse. In addition, there are issues relating to stigma, social exclusion, and barriers to recovery. Thinking about these overlaps has led to more creative therapeutic approaches with a developing evidence base. Of these, family interventions for psychosis and cognitive behavioural therapy for psychosis have some evidence for efficacy, and are recommended by National Institute for Health and Clinical Excellence guidelines for schizophrenia in combination with antipsychotic medication (being updated in 2008–2009). Problems remain regarding improving effectiveness, implementation, and increasing access across the National Health Service to psychological therapies for those with these more severe conditions. [Copyright &y& Elsevier]

Objective: Informal caregivers play a central role in patient care, and caregiving can provide positive and negative experiences. Negative caregiving experiences are associated with distress. This study investigates associations between caregiving appraisals in psychosis, distress, and 3 key illness beliefs (consequences, cure-control, and timeline), and whether illness beliefs makes a contribution to the relation between negative caregiving appraisal and distress.Method: We employed a cross-sectional study design. Caregivers (n = 146), including Early Psychosis Services caregivers (n = 60), completed self-report measures of the impact of care and illness beliefs.Results: Negative caregiving appraisals and distress were strongly associated. Caregivers appraised caregiving negatively and reported greater distress when they perceived the illness as having severe consequences for themselves and the patient, and when they perceived it as a long-term illness. In contrast, they appraised caregiving positively when they perceived that both they and the patient could exert some control over the illness. Illness beliefs did not account for the strong relation between negative caregiving appraisals and distress. Caregivers of patients with longer illness histories reported higher levels of positive caregiving appraisals.Conclusion: Caregivers' cognitive representation of psychosis may play an important role in positive and negative appraisals about caregiving, even at an early stage of the illness. Implications for interventions with early psychosis caregivers are discussed. [ABSTRACT FROM AUTHOR]

The measures most frequently used to assess psychotic symptoms fail to reflect important dimensions. The Psychotic Symptom Rating Scale (PSYRATS) aims to capture the multidimensional nature of auditory hallucinations and delusions. Individuals (N = 276) who had recently relapsed with positive symptoms completed the auditory hallucinations and delusions PSYRATS scales. These scores were compared with the relevant items from the SAPS and PANSS, and with measures of current mood. Total scores and distribution of items of the PSYRATS scales are presented and correlated with other measures. Positive symptom items from the SAPS and PANSS reflected the more objective aspects of PSYRATS ratings of auditory hallucinations and delusions (frequency and conviction) but were relatively poor at measuring distress. A major strength of the PSYRATS scales is the specific measurement of the distress dimension of symptoms, which is a key target of psychological intervention. It is advised that the PSYRATS should not be used as a total score alone, whilst further research is needed to clarify the best use of potential subscales. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The NICE Schizophrenia 2009 guidelines recommend family interventions for service users with an illness onset before 60 years. This study investigated the provision of family interventions in psychosis (FIp), irrespective of illness onset age, across two community mental health teams for older adults. Explanations from care coordinators about offering FIp were also examined. Service users diagnosed with schizophrenia spectrum disorders comprised approximately 10% of the team’s caseload, of which 40% were reported as having a carer. None of the identified service users with carers had been offered FIp. Service user symptoms and engagement difficulties were identified by care coordinators as the main reasons for why they were not considered suitable for FIp. The findings highlight a potential unmet clinical need for a subgroup of carers of older adults with psychosis. [ABSTRACT FROM AUTHOR]

Abstract: Psychological treatment for psychosis used to be thought of as likely to make things worse. However, within the last 15 years, cognitive-behavioural therapy (CBT) and family intervention have both been found efficacious for psychosis. The evidence is best for longer treatment (more than 6 months) for persistent symptoms and this is now recommended by the NICE guidelines for schizophrenia (2003). Psychological research on the continuum from normality to the experience of psychosis, single symptom research, and the existence of high levels of clinical comorbidities, such as anxiety and depression, have all helped CBT for psychosis to develop. Difficulties that remain include access to such treatments, and the fact that we still need to test out our hypotheses of how and why such treatments might contribute to change. [Copyright &y& Elsevier]

Gaudiano's review (this issue) raises fundamental issues about the process of evaluating a new psychological therapy for psychosis. Psychosis has previously been seen as intractable and psychological interventions as likely to make things worse. As a result, studies are faced not only with the normal difficulties of demonstrating methodological rigor but also with extra ones such as professional disbelief. Further, there are almost no equivalent, evidence-based psychological therapies to compare it with; focusing on "key" interventions is unlikely to be productive in such a complex disorder, and even if found useful there is the future problem of training and supervising sufficient practitioners to provide it. Developing models, devising and testing hypotheses and incorporating user views are advocated. [ABSTRACT FROM AUTHOR]

The Psychotic Symptom Rating Scales (PSYRATS) is an instrument designed to quantify the severity of delusions and hallucinations and is typically used in research studies and clinical settings focusing on people with psychosis and schizophrenia. It is comprised of the auditory hallucinations (AHS) and delusions subscales (DS), but these subscales do not necessarily reflect the psychological constructs causing intercorrelation between clusters of scale items. Identification of these constructs is important in some clinical and research contexts because item clustering may be caused by underlying etiological processes of interest. Previous attempts to identify these constructs have produced conflicting results. In this study, we compiled PSYRATS data from 12 sites in 7 countries, comprising 711 participants for AHS and 520 for DS. We compared previously proposed and novel models of underlying constructs using structural equation modeling. For the AHS, a novel 4-dimensional model provided the best fit, with latent variables labeled Distress (negative content, distress, and control), Frequency (frequency, duration, and disruption), Attribution (location and origin of voices), and Loudness (loudness item only). For the DS, a 2-dimensional solution was confirmed, with latent variables labeled Distress (amount/intensity) and Frequency (preoccupation, conviction, and disruption). The within-AHS and within-DS dimension intercorrelations were higher than those between subscales, with the exception of the AHS and DS Distress dimensions, which produced a correlation that approached the range of the within-scale correlations. Recommendations are provided for integrating these underlying constructs into research and clinical applications of the PSYRATS. [ABSTRACT FROM PUBLISHER]

Abstract: Background: Cognitive behavioural therapy for psychosis (CBTp) is recommended for people with schizophrenia, but routine delivery remains limited. Obstacles to increasing access include inadequate training, organisational support and supervision, resulting in low levels of staff competence and confidence. This study is a preliminary evaluation of a CBTp training programme, designed to overcome these obstacles and to increase routine delivery of competent CBTp. Method: Training outcomes for a pilot group and for the first three cohorts to complete training were analysed to identify predictors of successful completion and of therapy delivery after training. Results: Objective competence was attained by 37 students (out of 58), who delivered therapy to over 160 service users. Successful completion was associated with previous CBT therapy experience. Delivery after one year was associated with working in a therapy rather than a care co-ordination role. Conclusions: The programme succeeded in training therapists to deliver competent therapy. Our results suggest that preliminary training in CBT for other disorders may improve success rates in CBTp. Despite extensive service liaison, delivery remained problematic for care co-ordinators without role change and provision of dedicated time. The findings should inform future implementation strategies. [Copyright &y& Elsevier]