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People holding persecutory beliefs have been hypothesised to show a self-serving attributional style, which functions to protect self-esteem Bentall, Corcoran, Howard, Blackwood, and Kinderman (2001). Experimental support for this has... more
People holding persecutory beliefs have been hypothesised to show a self-serving attributional style, which functions to protect self-esteem Bentall, Corcoran, Howard, Blackwood, and Kinderman (2001). Experimental support for this has been mixed. Freeman et al. (1998) suggested depressed and grandiose subgroups of those with persecutory beliefs might explain events differently. In this study, 71 participants completed measures of delusional beliefs, depression and attributional style. We hypothesised that those with persecutory beliefs would form grandiose and depressed subgroups, and that a self-serving attributional style would characterise only the grandiose subgroup. Hypotheses were partially confirmed. Clear subgroups were evident and only those with both persecutory and grandiose beliefs showed an externalising attributional style for negative events. Depression, irrespective of co-occurring persecutory beliefs, was related to a reduced self-serving bias and an externalising attributional style for positive events. On their own, persecutory beliefs were not related to any particular attributional style. Depressed and grandiose subgroups of those with persecutory beliefs might account for some of the inconsistencies in the attribution literature. Even within a single symptom group, care should be taken in both research and therapy to consider individual symptom patterns.
High expressed emotion in carers predicts relapse in psychosis, but it is not known why this is so. In our cognitive model of psychosis, we postulated that the effect is mediated through affective changes. To investigate the relationships... more
High expressed emotion in carers predicts relapse in psychosis, but it is not known why this is so. In our cognitive model of psychosis, we postulated that the effect is mediated through affective changes. To investigate the relationships between carer expressed emotion, patients' symptoms and carer characteristics during a recent relapse of psychosis. A total of 86 patients and carers were investigated in a cross-sectional design. Patients whose carers showed high expressed emotion had significantly higher levels of anxiety and depression, but not more psychotic symptoms or lower self-esteem. Linear regression showed that carers'critical comments predicted anxiety in patients. Critical comments were related to low carer self-esteem and avoidant coping strategies. Low carer self-esteem was also related to carer depression, stress and carer 'burden', and to low patient self-esteem. Our hypothesis was partially supported. Carer criticism was associated with patient anxiety, low carer self-esteem and poor carer coping strategies. Family interventions should focus on improving these after a relapse of symptoms of psychosis.
Being bullied is an aversive experience with short-term and long-term consequences, and is incorporated in biopsychosocial models of psychosis. We used the 2000 and the 2007 British Adult Psychiatric Morbidity Surveys to test the... more
Being bullied is an aversive experience with short-term and long-term consequences, and is incorporated in biopsychosocial models of psychosis. We used the 2000 and the 2007 British Adult Psychiatric Morbidity Surveys to test the hypothesis that bullying is associated with individual psychotic phenomena and with psychosis, and predicts the later emergence of persecutory ideation and hallucinations. We analysed two nationally representative surveys of individuals aged 16 years or older in Great Britain (2000) and England (2007). Respondents were presented with a card listing stressful events to identify experiences of bullying over the entire lifespan. We assessed associations with the dependent variables persecutory ideation, auditory and visual hallucinations, and diagnosis of probable psychosis. All analyses were controlled for sociodemographic confounders, intelligence quotient (IQ), and other traumas. We used data for 8580 respondents from 2000 and 7403 from 2007. Bullying was associated with presence of persecutory ideation and hallucinations, remaining so after adjustment for sociodemographic factors, IQ, other traumas, and childhood sexual abuse. Bullying was associated with a diagnosis of probable psychosis. If reported at baseline, bullying predicted emergence and maintenance of persecutory ideation and hallucinations during 18 months of follow-up in the 2000 survey. Controlling for other traumas and childhood sexual abuse did not affect the association between bullying and psychotic symptoms, but reduced the significance of the association with diagnosis of probable psychosis. Bullying was most strongly associated with the presence of concurrent persecutory ideation and hallucinations. Bullying victimisation increases the risk of individual psychotic symptoms and of a diagnosis of probable psychosis. Early detection of bullying and use of treatments oriented towards its psychological consequences might ameliorate the course of psychosis. None.
Background Informal caregiving is an integral part of the care of people with severe mental illness, but the support needs of those providing such care are not often met. Aims To determine whether interventions provided to people caring... more
Background Informal caregiving is an integral part of the care of people with severe mental illness, but the support needs of those providing such care are not often met. Aims To determine whether interventions provided to people caring for those with severe mental illness improve the experience of caring and reduce caregiver burden. Method We conducted a systematic review and meta-analyses of randomised controlled trials (RCTs) of interventions delivered by health and social care services to informal carers (i.e. family or friends who provide support to someone with severe mental illness). Results Twenty-one RCTs with 1589 carers were included in the review. There was evidence suggesting that the carers' experience of care was improved at the end of the intervention by psychoeducation (standardised mean difference -1.03, 95% CI -1.69 to -0.36) and support groups (SMD = -1.16, 95% CI -1.96 to -0.36). Psychoeducation had a benefit on psychological distress more than 6 months late...
This study examined the impact of caring on women who were primary care-givers to those with schizophrenia. From the 46 women and 21 men carers assessed for the study, women were considered primary care-givers more often than men (83% v.... more
This study examined the impact of caring on women who were primary care-givers to those with schizophrenia. From the 46 women and 21 men carers assessed for the study, women were considered primary care-givers more often than men (83% v. 57%). Higher levels of burden among women primary carers were associated with living with patients, and more hours in contact
Delusional beliefs with persecutory content are common in psychosis, but difficult to treat. Interventions targeting hypothesised causal and maintaining factors have been proposed as a way of improving therapy. The current study is a... more
Delusional beliefs with persecutory content are common in psychosis, but difficult to treat. Interventions targeting hypothesised causal and maintaining factors have been proposed as a way of improving therapy. The current study is a feasibility randomised controlled trial of the 'Thinking Well (TW)' intervention: This novel approach combines the recently developed Maudsley Review Training Programme (MRTP), with additional, focussed cognitive-behavioural therapy sessions. 31 participants with distressing persecutory delusions and schizophrenia spectrum disorders were randomised to TW or to treatment as usual in a 2:1 ratio. Participants completed outcome assessments at 0 (baseline), 1 (post-MRTP), 6 (post-TW) and 8 (follow-up) weeks. Key outcomes included belief flexibility, paranoia, and delusional conviction and distress. Participants allocated to TW completed the MRTP package and four CBT sessions with a clinical psychologist. Recruitment proved feasible. Participants rep...
Aggressive behaviour in psychosis is not uncommon. Community provision for people with psychosis has left informal caregivers to take on a greater role in their care. However, few studies have explored links between patient-initiated... more
Aggressive behaviour in psychosis is not uncommon. Community provision for people with psychosis has left informal caregivers to take on a greater role in their care. However, few studies have explored links between patient-initiated violence in mental health caregiving relationships and caregiver functioning. Our study investigated caregiver reports of aggressive acts committed by their relative with psychosis and their links to caregiver appraisals of the caregiving relationship and caregiver outcomes. Caregivers of patients with a recent relapse of psychosis, recruited to a psychological therapy trial, completed the audiotaped Camberwell Family Interview at baseline. This semi-structured interview includes questions on the quality of the relationship between caregiver and patient, and patient history of violence. Seventy-two transcripts of interviews were assessed for reports of patient-initiated violence. One-half of the caregiver sample (52.9%) reported an incident of patient-i...
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... more
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. 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. On an intention-to-treat analysis, there were significant improvements in state paranoia an...
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... more
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. Seventy-two carers completed the Maslach Burnout Inventory along with self-report measures of coping styles and illness beliefs. 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...
High expressed emotion (EE) is a robust predictor of elevated rates of relapse and readmission in schizophrenia. However, far less is known about how high EE leads to poorer patient outcomes. This study was designed to examine links... more
High expressed emotion (EE) is a robust predictor of elevated rates of relapse and readmission in schizophrenia. However, far less is known about how high EE leads to poorer patient outcomes. This study was designed to examine links between high EE (criticism), affect, and multidimensional aspects of positive symptoms in patients with psychosis. Thirty-eight individuals with nonaffective psychosis were randomly exposed to proxy high-EE or neutral speech samples and completed self-report measures of affect and psychosis symptoms. Patients reported significant increases in anxiety, anger, and distress after exposure to the proxy high-EE speech sample as well as increases in their appraisals of psychosis symptoms: voice controllability, delusional preoccupation, and conviction. These findings offer further evidence of the potential deleterious impact of a negative interpersonal environment on patient symptoms in psychosis.
Understanding how people with delusions arrive at false conclusions is central to the refinement of cognitive behavioural interventions. Making hasty decisions based on limited data... more
Understanding how people with delusions arrive at false conclusions is central to the refinement of cognitive behavioural interventions. Making hasty decisions based on limited data ('jumping to conclusions', JTC) is one potential causal mechanism, but reasoning errors may also result from other processes. In this study, we investigated the correlates of reasoning errors under differing task conditions in 204 participants with schizophrenia spectrum psychosis who completed three probabilistic reasoning tasks. Psychotic symptoms, affect, and IQ were also evaluated. We found that hasty decision makers were more likely to draw false conclusions, but only 37% of their reasoning errors were consistent with the limited data they had gathered. The remainder directly contradicted all the presented evidence. Reasoning errors showed task-dependent associations with IQ, affect, and psychotic symptoms. We conclude that limited data-gathering contributes to false conclusions but is not the only mechanism involved. Delusions may also be maintained by a tendency to disregard evidence. Low IQ and emotional biases may contribute to reasoning errors in more complex situations. Cognitive strategies to reduce reasoning errors should therefore extend beyond encouragement to gather more data, and incorporate interventions focused directly on these difficulties.
Caregivers make a significant and growing contribution to the social and medical care of people with long-standing disorders. The effective provision of this care is dependent on their own continuing health. To investigate the... more
Caregivers make a significant and growing contribution to the social and medical care of people with long-standing disorders. The effective provision of this care is dependent on their own continuing health. To investigate the relationship between weekly time spent caregiving and psychiatric and physical morbidity in a representative sample of the population of England. Primary outcome measures were obtained from the Adult Psychiatric Morbidity Survey 2007. Self-report measures of mental and physical health were used, along with total symptom scores for common mental disorder derived from the Clinical Interview Schedule-Revised. In total, 25% (n = 1883) of the sample identified themselves as caregivers. They had poorer mental health and higher psychiatric symptom scores than non-caregivers. There was an observable decline in mental health above 10 h per week. A twofold increase in psychiatric symptom scores in the clinical range was recorded in those providing care for more than 20 ...
Social anxiety due to rejection sensitivity (RS) exacerbates psychosis-like experiences in the general population. While reduced dorsal anterior cingulate cortex (dACC) activity during social rejection in high schizotypy has suggested... more
Social anxiety due to rejection sensitivity (RS) exacerbates psychosis-like experiences in the general population. While reduced dorsal anterior cingulate cortex (dACC) activity during social rejection in high schizotypy has suggested self-distancing from rejection, earlier stages of mental processing such as feature encoding could also contribute to psychosis-like experiences. This study aimed to determine the stage of mental processing of social rejection that relates to positive schizotypy. Forty-one healthy participants were assessed for schizotypy and RS. Event-related potential amplitudes (ERPs) were measured at frontal, temporal and parieto-occipital sites and their cortical sources (dACC, temporal pole and lingual gyrus) at early (N100) and late (P300 and late slow wave, LSW) timeframes during rejection, acceptance and neutral scenes. ERPs were compared between social interaction types. Correlations were performed between positive schizotypy (defined as the presence of perce...
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... more
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 provi...
BackgroundResponsiveness to cognitive behaviour therapy (CBT) in psychosis may have a neurological basis. This study aimed to determine whether improvement in symptoms following CBT for psychosis (CBTp) in people with schizophrenia is... more
BackgroundResponsiveness to cognitive behaviour therapy (CBT) in psychosis may have a neurological basis. This study aimed to determine whether improvement in symptoms following CBT for psychosis (CBTp) in people with schizophrenia is positively associated with pre-therapy grey matter volume in brain regions involved in cognitive processing.
For many patients with persecutory delusions, leaving home and going into crowded streets is a key clinical problem. In this study we aimed to inform treatment development by determining the psychological mechanisms whereby busy urban... more
For many patients with persecutory delusions, leaving home and going into crowded streets is a key clinical problem. In this study we aimed to inform treatment development by determining the psychological mechanisms whereby busy urban environments increase paranoia. In a randomized design with prespecified mediation analysis, we compared the effects on patients of going outside into a busy social environment with staying inside. Fifty-nine patients with current persecutory delusions, in the context of nonaffective psychosis, reporting fears when going outside were assessed on factors from a cognitive model of paranoia. They were then randomized either to enter a busy local shopping street or to complete a neutral task indoors. They were then reassessed on the measures. Compared with staying inside, the street exposure condition resulted in significant increases in paranoia, voices, anxiety, negative beliefs about the self, and negative beliefs about others. There was also a decrease...
OBJECTIVES. High negative expressed emotion by family members towards schizophrenia patients increases the risk of subsequent relapse. The study aimed to determine whether individuals with high schizotypy (HS) and low schizotypy (LS)... more
OBJECTIVES. High negative expressed emotion by family members towards schizophrenia patients increases the risk of subsequent relapse. The study aimed to determine whether individuals with high schizotypy (HS) and low schizotypy (LS) would differ in activation of brain areas involved in cognitive control when listening to relative criticism. METHODS. Twelve HS and 12 LS individuals listened to relative's critical, positive and neutral comments about them while undergoing functional MRI. Activation maps in the two groups during the comments were compared using SPM5. RESULTS. The left superior frontal and middle frontal gyri and bilateral posterior cingulate cortex were activated during criticism, compared to neutral comments, across all participants. While there were no group differences in brain activity for criticism versus neutral comments, the HS group, who had lower current mood relative to the LS group, activated to a lesser extent the thalamus, insula, putamen and brain stem during positive, compared to neutral, comments. CONCLUSIONS. Listening to relative criticism in healthy individuals engages brain areas for cognitive control of negative emotion and self-referential processing. However, HS individuals may have an attenuated ability to respond to rewarding aspects of positive comments due to their lower current mood.
Continuity of care is a central objective of community psychiatric services, but there is no consensus about its measurement. We developed measures of continuity of care suitable for routine use, and measured continuity and individual... more
Continuity of care is a central objective of community psychiatric services, but there is no consensus about its measurement. We developed measures of continuity of care suitable for routine use, and measured continuity and individual patient outcome over a period in which community services were developing. One hundred patients with severe mental illness receiving continuing care from two sectorised services were sampled and interviewed. Data were collected concerning their care over 20 months prior to interview. After 20 months prospective follow-up, they were re-interviewed. Continuity was defined as: perceived accessibility of services and knowledge about them, the number of keyworkers in a defined period of time, and the proportion of time out of contact with services. Continuity of care improved significantly on all measures over the period of the study. Individual patient outcome also improved, but in multiple regression models including clinical and demographic variables, measures of continuity were not significant predictors of outcome. Continuity was similar for white and non-white patients. Simple measures of continuity are useful in evaluating changes in the process of care, but they are not straightforwardly related to individual outcome.
Despite an acknowledgement of the impact of serious mental disorders on informal caregivers, we still know little about how to best help them. The aim of the study was to evaluate the effectiveness of a two-phased carers'... more
Despite an acknowledgement of the impact of serious mental disorders on informal caregivers, we still know little about how to best help them. The aim of the study was to evaluate the effectiveness of a two-phased carers' intervention comprising family sessions followed by relatives' groups. This intervention was designed to be of 'intermediate' intensity, that is,one lying between brief educational programmes and long-term family psychoeducational treatments. An exploratory randomised controlled trial was conducted comparing the experimental support programme with 'standard' care. All carers of patients with a psychotic disorder from a defined population were approached. Outcome measures were based on a 'stress-appraisal-coping' model of caregiving. Despite concerted attempts to engage carers, only 42% participated in the study. The carers' programme did not offer any significant advantage on any of the outcome measures: psychological morbidity, negative appraisal, coping or social support. The severity of caregiving difficulties decreased over the study period for the group as a whole. There is still uncertainty about the most effective interventions for carers. Meeting 'needs' may not improve caregiver distress.
High levels of both burnout and job satisfaction have been found in recent studies of mental health professionals. A qualitative methodology was used in a related study to explore reasons for these findings and to investigate... more
High levels of both burnout and job satisfaction have been found in recent studies of mental health professionals. A qualitative methodology was used in a related study to explore reasons for these findings and to investigate staff's accounts of their strategies for coping with their work, and their views of support provided for them and how their jobs might be made less stressful and still more satisfying. A semi-structured schedule was used to interview a purposive sample of 30 mental health staff drawn from three South London geographical sectors, selected to include junior and senior members of each profession in both hospital and community settings. Interviews were transcribed and analysed using QSR NUD.IST software. Informal contacts with colleagues were the most frequently mentioned way of coping with the difficult and demanding aspects of work in both hospital and community settings, closely followed by time management techniques. The main formal sources of support described by staff were individual supervision and staff support groups. Accounts of the former were generally positive, but there was great variation in opinions about whether support groups are useful. Almost all the interviewees believed that their jobs could be improved by further training. For community mental health staff the main training gaps were the development of skills in various forms of clinical intervention, whilst ward staff identified the need for further skills in diffusing potentially confrontational and aggressive situations.
This study examines whether the adoption of a more community based model in an inner city psychiatry service is accompanied by increasing "burnout", deteriorating mental health and decreasing job satisfaction amongst... more
This study examines whether the adoption of a more community based model in an inner city psychiatry service is accompanied by increasing "burnout", deteriorating mental health and decreasing job satisfaction amongst staff. Questionnaires were sent annually for 3 consecutive years to all mental health staff working in three adult mental health sectors in inner London. Main outcome measures were the 12-item General Health Questionnaire, Maslach Burn-out Inventory and a general job satisfaction measure. There was no significant change over time in the outcome measures, once confounding by job and demographic variables was examined. Being based in the community was associated with higher GHQ-12 scores (P = 0.02) when compared to in-patient staff over the 3 years. These results suggested that working in the community may be more stressful than working in in-patient services. However, there was no evidence to suggest that levels of stress are increasing over time, either in community-based or hospital-based staff.
High levels of burnout and poor psychological well-being, but also relatively high levels of job satisfaction, have been found among mental health staff, especially those based in community settings. In order to investigate the basis of... more
High levels of burnout and poor psychological well-being, but also relatively high levels of job satisfaction, have been found among mental health staff, especially those based in community settings. In order to investigate the basis of these findings, a qualitative interview study was carried out, exploring mental health staff's views of their work and of its effects on them. A semi-structured interview was administered to a purposive sample of 30 professionals, including junior and senior members of each profession in both hospital and community settings. Interviews were transcribed verbatim and analysed using QSR NUD.IST software. For most professionals, contact with colleagues was one of the major rewards of the job. There was surprisingly little evidence of conflict or difficulties defining roles between disciplines, except for the social workers, for whom difficulty in defining roles in relation to other professions was a major preoccupation. Reported stresses differed between community and hospital staff. Community staff tended to find their contacts with patients highly rewarding, but also to feel burdened by a strong and uncomfortable sense of being constantly responsible for their clients' well-being and actions. Ward staff, on the other hand, identified as central difficulties in their job lack of autonomy, responsibility and scope for developing an independent therapeutic role. They felt demoralised by revolving door' patients and by violence and the need to restrain patients.
This study investigated the relationship between patient-rated unmet needs and subjective quality of life using routine outcome data. 265 mental health service patients from South Verona were assessed using the Camberwell Assessment of... more
This study investigated the relationship between patient-rated unmet needs and subjective quality of life using routine outcome data. 265 mental health service patients from South Verona were assessed using the Camberwell Assessment of Need, the Lancashire Quality of Life Profile, and other standardised assessments of symptoms, disability, function and service satisfaction. At 1-year follow-up, 166 patients were still in contact, of whom 121 patients (73%) were re-assessed. Higher baseline quality of life was associated with being male, a diagnosis of psychosis, higher disability, higher satisfaction with care, fewer staff-rated or patient-rated unmet needs, and fewer patient-rated met needs (accounting for 40% of the variance). Specifically, fewer baseline patient-rated unmet needs were cross-sectionally associated with a higher quality of life (B = -0.08, 95% CI -0.12 to -0.04). Apart from its baseline value, the only baseline predictor of follow-up QoL was patient-rated unmet need (B = -0.08, 95% CI -0.21 to -0.09), accounting for 58% of the variance in follow-up quality of life. Graphical chain modelling confirmed this association. The association between high numbers of unmet needs and low subjective quality of life appears increasingly robust across several studies. Future research will need to investigate whether changes in needs precede changes in quality of life. This study provides further evidence that a policy of actively assessing and addressing patient-rated unmet needs may lead to improved quality of life.

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