The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: a meta-analysis

Immersive virtual reality in the treatment of auditory hallucinations: A PRISMA scoping review

BACKGROUND

A large group of psychiatric patients suffer from auditory hallucinations (AH) despite relevant treatment regimens. In mental health populations, AH tend to be verbal (AVH) and the content critical or abusive. Trials employing immersive virtual reality (VR) to treat mental health disorders are emerging.

OBJECTIVE

The aim of this scoping review is to provide an overview of clinical trials utilizing VR in the treatment of AH and to document knowledge gaps in the literature.

METHODS

PubMed, Cochrane Library, and Embase were searched for studies reporting on the use of VR to target AH.

RESULTS

16 papers were included in this PRISMA scoping review (ScR). In most studies VR therapy (VRT) was employed to ameliorate treatment resistant AVH in schizophrenia spectrum disorders. Only two studies included patients with a diagnosis of affective disorders. The VRT was carried out with the use of an avatar to represent the patient's most dominant voice.

DISCUSSION

The research field employing VR to treat AH is promising but still in its infancy. Results from larger randomized clinical trials are needed to establish substantial evidence of therapy effectiveness. Additionally, the knowledge base would benefit from more profound qualitative data exploring views of patients and therapists.

A phenomenological comparison of auditory hallucinations between borderline personality disorder and schizophrenia: A systematic review

OBJECTIVE

Borderline personality disorder (BPD) with auditory hallucinations (AHs) may inadvertently be misdiagnosed with a primary psychotic disorder, such as schizophrenia (SZ). This misidentification can lead to challenges in providing effective psychological treatment. This review therefore aims to identify the phenomenological characteristics of AHs in BPD in comparison to SZ, as well as psychological interventions that explicitly target AHs in BPD.

METHODS

A systematic review was conducted to summarise the existing evidence base regarding the phenomenological similarities and differences of AHs in BPD and SZ, along with the identification of psychological interventions for AHs in BPD.

RESULTS

Eighteen studies were eligible for inclusion. Compared to the SZ group, BPD clients were characterised by more persistent and repetitive AHs, significantly more voice-related distress and appraisals of omnipotence, and an earlier age of onset of AHs. The BPD group also reported more severe depression and anxiety, a higher incidence of childhood trauma, and more negative self-schema. Cognitive Behaviour Therapy Coping Strategy Enhancement (CBT-CSE) might be a promising intervention to reduce AH-related distress in BPD, although further studies are required to determine its effectiveness.

CONCLUSION

In order to prevent misdiagnosis of AHs in BPD, the DSM-5 may need to acknowledge the broader and more frequent occurrence of psychosis symptoms in BPD clients. Such clarification may enhance diagnostic practices and facilitate more timely access to treatment. There is also a need to develop and trial psychological interventions that explicitly target AHs in BPD.

User-Centered Development of STOP (Successful Treatment for Paranoia): Material Development and Usability Testing for a Digital Therapeutic for Paranoia

BACKGROUND

Paranoia is a highly debilitating mental health condition. One novel intervention for paranoia is cognitive bias modification for paranoia (CBM-pa). CBM-pa comes from a class of interventions that focus on manipulating interpretation bias. Here, we aimed to develop and evaluate new therapy content for CBM-pa for later use in a self-administered digital therapeutic for paranoia called STOP ("Successful Treatment of Paranoia").

OBJECTIVE

This study aimed to (1) take a user-centered approach with input from living experts, clinicians, and academics to create and evaluate paranoia-relevant item content to be used in STOP and (2) engage with living experts and the design team from a digital health care solutions company to cocreate and pilot-test the STOP mobile app prototype.

METHODS

We invited 18 people with living or lived experiences of paranoia to create text exemplars of personal, everyday emotionally ambiguous scenarios that could provoke paranoid thoughts. Researchers then adapted 240 suitable exemplars into corresponding intervention items in the format commonly used for CBM training and created 240 control items for the purpose of testing STOP. Each item included newly developed, visually enriching graphics content to increase the engagement and realism of the basic text scenarios. All items were then evaluated for their paranoia severity and readability by living experts (n=8) and clinicians (n=7) and for their item length by the research team. Items were evenly distributed into six 40-item sessions based on these evaluations. Finalized items were presented in the STOP mobile app, which was co-designed with a digital health care solutions company, living or lived experts, and the academic team; user acceptance was evaluated across 2 pilot tests involving living or lived experts.

RESULTS

All materials reached predefined acceptable thresholds on all rating criteria: paranoia severity (intervention items: ≥1; control items: ≤1, readability: ≥3, and length of the scenarios), and there was no systematic difference between the intervention and control group materials overall or between individual sessions within each group. For item graphics, we also found no systematic differences in users' ratings of complexity (P=.68), attractiveness (P=.15), and interest (P=.14) between intervention and control group materials. User acceptance testing of the mobile app found that it is easy to use and navigate, interactive, and helpful.

CONCLUSIONS

Material development for any new digital therapeutic requires an iterative and rigorous process of testing involving multiple contributing groups. Appropriate user-centered development can create user-friendly mobile health apps, which may improve face validity and have a greater chance of being engaging and acceptable to the target end users.

Worry Intervention in an Older Adult With a Persecutory Delusion: A Single Case Experimental Design

Background

This report presents the single case of Jack, a 67-year-old referred to our Older Adult Community Mental Health Team (OA CMHT) for his distressing persecutory delusion and high levels of worry. Jack also reported learning difficulties and autistic traits, although neither were formally diagnosed.

Method

Ten sessions of worry intervention taken from The Feeling Safe Programme worry module were used to reduce Jack's time spent worrying and increase his engagement in meaningful activity. Weekly face-to-face sessions were held, with Jack's brother acting as a co-therapist. Adaptations to the intervention were made based on Jack's learning preferences. An AB single case experimental design was adopted to compare Jack's scores on measures of worry, paranoia and delusional conviction, and wellbeing and daily functioning before and after intervention.

Results

Results demonstrate the worry intervention improved Jack's scores on all measures to a clinically significant degree.

Conclusions

This is the first known report of applying the worry intervention to an older adult. The results show the intervention can be of considerable benefit in terms of reducing worry and paranoia, in the context of both older age and suspected neurodiversity.

Oxytocin as a treatment for high-risk psychosis or early stages of psychosis: a mini review

Individuals at clinical high risk for psychosis (CHR-P) present as help-seeking individuals with social deficits as well as cognitive and functional impairment and have a 23-36% risk of transition to first-episode psychosis. The therapeutic role of intranasal oxytocin (ΟΤ) in psychiatric disorders has been widely studied during the last decades, concerning its effects on social behavior in humans. A literature search was conducted via Pubmed and Scopus, using the search terms "oxytocin" and "psychosis." Six studies were included in the current review. There were differences in terms of demographics, intervention type, and outcome measures. ΟΤ may affect the social cognition skills of people at prodromal and early stages of psychosis, but its effect on clinical symptoms is ambiguous. Because of the high level of heterogeneity of existing studies, more original studies are needed to examine and clarify whether OT improves high-risk and early psychosis populations.

Efficacy of Remotely Delivered Evidence-Based Psychosocial Treatments for Schizophrenia-Spectrum Disorders: A Series of Systematic Reviews and Meta-Analyses

BACKGROUND

Schizophrenia is among the most persistent and debilitating mental health conditions worldwide. The American Psychological Association (APA) has identified 10 psychosocial treatments with evidence for treating schizophrenia and these treatments are typically provided in person. However, in-person services can be challenging to access for people living in remote geographic locations. Remote treatment delivery is an important option to increase access to services; however, it is unclear whether evidence-based treatments for schizophrenia are similarly effective when delivered remotely.

STUDY DESIGN

The current study consists of a series of systematic reviews and meta-analyses examining the evidence-base for remote-delivery of each of the 10 APA evidence-based treatments for schizophrenia.

RESULTS

Of the 10 treatments examined, only cognitive remediation (CR), cognitive-behavioral therapy (CBT), and family psychoeducation had more than 2 studies examining their efficacy for remote delivery. Remote delivery of CBT produced moderate effects on symptoms (g = 0.43) and small effects on functioning (g = 0.26). Remote delivery of CR produced small-moderate effects on neurocognition (g = 0.35) and small effects on functioning (g = 0.21). There were insufficient studies of family psychoeducation with equivalent outcome measures to assess quantitatively, however, studies of remotely delivered family psychoeducation suggested that it is feasible, acceptable, and potentially effective.

CONCLUSIONS

Overall, the evidence-base for remotely delivered treatment for schizophrenia is limited. Studies to date suggest that remote adaptations may be effective; however, more rigorous trials are needed to assess efficacy and methods of remote delivery that are most effective.

Cognitive bias modification for paranoia (CBM-pa): a randomised controlled feasibility study in patients with distressing paranoid beliefs

BACKGROUND

Cognitive Bias Modification for paranoia (CBM-pa) is a novel, theory-driven psychological intervention targeting the biased interpretation of emotional ambiguity associated with paranoia. Study objectives were (i) test the intervention's feasibility, (ii) provide effect size estimates, (iii) assess dose-response and (iv) select primary outcomes for future trials.

METHODS

In a double-blind randomised controlled trial, sixty-three outpatients with clinically significant paranoia were randomised to either CBM-pa or an active control (text reading) between April 2016 and September 2017. Patients received one 40 min session per week for 6 weeks. Assessments were given at baseline, after each interim session, post-treatment, and at 1- and 3-months post-treatment.

RESULTS

A total of 122 patients were screened and 63 were randomised. The recruitment rate was 51.2%, with few dropouts (four out of 63) and follow-up rates were 90.5% (1-month) and 93.7% (3-months). Each session took 30-40 min to complete. There was no statistical evidence of harmful effects of the intervention. Preliminary data were consistent with efficacy of CBM-pa over text-reading control: patients randomised to the intervention, compared to control patients, reported reduced interpretation bias (d = -0.48 to -0.76), improved symptoms of paranoia (d = -0.19 to -0.38), and lower depressed and anxious mood (d = -0.03 to -0.29). The intervention effect was evident after the third session.

CONCLUSIONS

CBM-pa is feasible for patients with paranoia. A fully powered randomised control trial is warranted.

Developing a mechanism-based therapy for acute psychiatric inpatients with psychotic symptoms: an Intervention Mapping approach

Background

Treatment guidelines for psychosis recommend offering psychotherapy already in the acute illness phase. However, there is a lack of available interventions adapted to the specific needs and key change mechanisms of inpatients experiencing severe symptoms and crisis. In this article we outline the scientific development process of a needs-oriented and mechanism-based group intervention for acute psychiatric inpatients with psychosis (MEBASp).

Methods

To guide our intervention design, we used Intervention Mapping (IM), a six-step framework for developing evidence-based health interventions that consisted of an extensive literature review, an in-depth problem definition and needs analysis, the modeling of change mechanisms and outcomes and the production of an intervention prototype.

Results

Our low-threshold modularized group intervention consists of nine stand-alone sessions (two per week) within three modules and targets different aspects of metacognitive and social change mechanisms. Module I and II aim to reduce acute symptoms by fostering cognitive insight, Module III focuses on reducing distress via cognitive defusion. Therapy contents are adapted from existing metacognitive treatments such as the Metacognitive Training and presented in a destigmatizing, simply understandable and experience-oriented way.

Conclusion

MEBASp is currently evaluated in a single-arm feasibility trial. Using a systematic and rigorous development methodology and providing a detailed description of the development steps demonstrated to be invaluable in improving the intervention's scientific foundation, validity, and replicability for similar research.

The cognitive-phenomenological assessment of delusions and hallucinations at the early intervention in psychosis service stage: The results of a quality improvement project

AIM

Clinical assessments are vital for gaining an understanding of a patients' presenting problem. A priority for Early Intervention in Psychosis Service staff is understanding and supporting their patients' experiences of hallucinations and/or delusions. We aimed to identify what cognitive-phenomenology dimensions of hallucinations and delusions EIPS staff were assessing with their patients.

METHODS

We developed a brief checklist of cognitive-phenomenological dimensions of hallucinations and delusions called the Lived Experience Symptom Survey (LESS) based on relevant literature. As part of a Quality Improvement Project, we reviewed the health records of a sub-sample of EIPS patients using the LESS identifying whether each dimension was present or absent.

RESULTS

We found that all patients had been asked about the content of their hallucinations and/or delusions, and the majority had been asked about the valence of this content. Despite patients having experienced psychosis for almost 2 years on average, less than half of patients were asked about the potential or actual harm associated with these symptoms. All other cognitive-phenomenological dimensions were assessed inconsistently.

CONCLUSIONS

The assessment of hallucination and delusions in our EIPS was inconsistent and incomprehensive. These findings require replication in other EIPS' but may point to a need for guidelines and training around how to conduct a thorough assessment of hallucinations and delusions for current and future EIPS staff. Improved assessment of these symptoms will aid the development of risk assessments and treatment plans.

Sequential mixed method evaluation of the acceptability, feasibility, and appropriateness of cognitive behavioral therapy for psychosis stepped care

Background

Cognitive Behavioral Therapy for psychosis (CBTp) is recommended by national treatment guidelines yet remains widely inaccessible in the U.S. A stepped care model, favored and feasible for other scarce interventions, may improve access to CBTp.

Methods

We employed an exploratory sequential mixed method design inclusive of two distinct phases to quantitatively evaluate the acceptability, feasibility, and appropriateness of CBTp Stepped Care (CBTp-SC) among practitioners who were trained in low-intensity CBTp (Step 1), Group-Administered CBTp (Step 2), and Formulation-based CBTp (Step 3). In Phase 1, we queried respondents using the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and the Feasibility of Intervention Measure to ascertain perceptions of these leading indicators of implementation success. In Phase 2, we conducted focus groups with CBTp-SC-trained practitioners (n = 10) and administrators (n = 2) from 2 of the 4 Phase 1 study sites to evaluate the theoretical assumptions of stepped care and to better understand key barriers and facilitators.

Results

Forty-six practitioners trained in all three levels of CBTp-SC completed the online survey in Phase 1. All participants were employed by a community mental health agency currently sustaining CBTp-SC. Respondents endorsed high levels of acceptability, feasibility, and appropriateness for the CBTp-SC model. We found evidence to suggest that licensed practitioners and Step 3 practitioners perceived formulation-based CBTp as more appropriate for their clients. In Phase 2, six themes emerged which affirmed the utility of the model for stakeholders, supported stepped care theoretical assumptions, and revealed key areas for improvement.

Conclusions

Early adopters of CBTp-SC in the U.S. perceive it to be acceptable, feasible, and appropriate in community mental health care settings. Practitioners and administrators identified training and implementation barriers, including the importance of organizational readiness, a CBTp coordinator role, and a desire to adapt the intervention. These early findings will facilitate iterative refinement of the stepped care model for U.S. public behavioral health agencies. Additional research is needed to explore perceptions and clinical outcomes among CBTp service users.

The CHALLENGE trial: the effects of a virtual reality-assisted exposure therapy for persistent auditory hallucinations versus supportive counselling in people with psychosis: study protocol for a randomised clinical trial

Background

Many patients suffering from schizophrenia spectrum disorders continue having distressing auditory hallucinations in spite of treatment with antipsychotic medication. The aim of this trial is to examine the effect of a targeted virtual reality therapy for persistent auditory hallucinations in individuals with psychosis. The trial explores whether this type of therapy can decrease the severity, frequency and distress of auditory hallucinations and, additionally, whether it can reduce clinical symptoms and enhance daily functioning in individuals with psychosis.

Methods

The study is a randomised, assessor-blinded parallel-group superiority clinical trial, allocating a total of 266 patients to either the experimental intervention or supportive counselling. The participants will be randomised to either (1) seven sessions of virtual reality therapy or (2) seven sessions of supportive counselling to be delivered within the first 12 weeks after inclusion in the study. All participants will be assessed at baseline and 12 and 24 weeks post-baseline. Independent assessors blinded to the treatment allocation will evaluate the outcome. The primary outcome is the level of auditory hallucinations measured with the Psychotic Symptoms Rating Scales (PSYRATS-AH) total score at the cessation of treatment at 12 weeks. Secondary outcomes are frequency of auditory hallucinations, the distress caused by auditory hallucinations, perceived voice power, patient acceptance of voices, patients’ ability to respond to voices in an assertive way and social and daily function.

Discussion

Promising evidence of the efficacy of this immersive virtual reality-based therapy for auditory hallucinations exist, but evidence needs to be established in a large, methodological rigorous trial. If the therapy proves to be beneficial in reducing the severity of refractory auditory hallucinations, a large group of patients with schizophrenia and related disorders could be the target group of this short-term psychotherapeutic intervention.

Crisis-focused Cognitive Behavioural Therapy for psychosis (CBTp) in acute mental health inpatient settings (the CRISIS study): protocol for a pilot randomised controlled trial

Background

Cognitive Behavioural Therapy for psychosis (CBTp) has an established evidence base and is recommended by clinical guidelines to be offered during the acute phases of psychosis. However, few research studies have examined the efficacy of CBTp interventions specifically adapted for the acute mental health inpatient context with most research trials being conducted with white European community populations.

Aims

The aim of this study is to conduct a pilot randomised controlled trial (RCT), which incorporates the examination of feasibility markers, of a crisis-focused CBTp intervention adapted for an ethnically diverse acute mental health inpatient population, in preparation for a large-scale randomised controlled trial. The study will examine the feasibility of undertaking the trial, the acceptability and safety of the intervention and the suitability of chosen outcome measures. This will inform the planning of a future, fully powered RCT.

Methods

A single-site, parallel-group, pilot RCT will be conducted examining the intervention. Drawing on principles of coproduction, the intervention has been adapted in partnership with key stakeholders: service users with lived experience of psychosis and of inpatient care (including those from ethnic minority backgrounds), carers, multi-disciplinary inpatient clinicians and researchers. Sixty participants with experience of psychosis and in current receipt of acute mental health inpatient care will be recruited. Participants will be randomly allocated to either the crisis-focused CBTp intervention or treatment as usual (TAU).

Discussion

Findings of this pilot RCT will indicate whether a larger multi-site RCT is needed to investigate the efficacy of the intervention. If the initial results demonstrate that this trial is feasible and the intervention is acceptable, it will provide evidence that a full-scale effectiveness trial may be warranted.

Trial registration

This trial has been prospectively registered on the ISRCTN registry (ISRCTN59055607) on the 18th of February 2021.

Changes in positive and negative voice content in cognitive-behavioural therapy for distressing voices

OBJECTIVE

People who experience distressing voices frequently report negative (e.g. abusive or threatening) voice content and this is a key driver of distress. There has also been recognition that positive (e.g. reassuring, or guiding) voice content contributes to better outcomes. Despite this, voice content has been neglected as a standalone outcome in evaluations of psychological therapies for distressing voices. We aimed to examine whether a modular cognitive-behavioural therapy (CBT) intervention for voices led to changes in negative and positive voice content.

DESIGN/METHODS

In a naturalistic, uncontrolled pre- and post- service evaluation study, 32 clients at an outpatient psychology service for distressing voices received eight sessions of CBT for distressing voices and completed self-report measures of negative and positive voice content at pre-, mid- and post- therapy.

RESULTS

There was no significant change in positive voice content. There was no significant change in negative voice content from pre- to post-therapy; however, there was a significant change in negative voice content between mid and post-treatment in which the cognitive therapy component was delivered. The CBT treatment was also associated with significant changes in routinely reported outcomes of voice-related distress and voice severity.

CONCLUSIONS

The cognitive component of CBT for distressing voices may be associated with changes in negative, but not positive, voice content. There may be benefit to enhancing these effects by developing treatments targeting specific processes involved in negative and positive voice content and further exploring efficacy in well-powered, controlled trials with more comprehensive measures of voice content.

Measuring the longitudinal course of voice hearing under psychological interventions: A systematic review

Trials of psychological interventions targeting distressing voices have used a range of variables to measure outcomes. This has complicated attempts to compare outcomes across trials and to evaluate the effectiveness of these interventions. Therefore, this review aimed to identify the variables that have been used to measure the longitudinal course and impact of voice hearing under these interventions and to evaluate how these variables change over time. Inclusion and exclusion criteria were applied, resulting in a total of 66 articles. Of these, 60 studies (28 RCTs, 23 uncontrolled, 9 non-randomised) were published in peer-reviewed journals, whilst 6 were recently completed or currently ongoing. The findings of this review suggest that a range of variables that are not directly relevant to psychological interventions have been used (e.g., depression, characteristics of voice hearing experience), whilst those directly impacted by psychological interventions (e.g., voice-related distress), broader concepts of outcome (e.g., functioning) and specific associated processes (e.g., self-schema) have received less attention. Findings also showed that the majority of variables demonstrated improvements, but effect sizes varied considerably across trials. This may be attributed to methodological differences such as statistical power, blinding, control groups and different methods of measurement. Our review highlights the importance of determining a set of outcomes that are directly targeted and should change under psychological interventions. Recommendations include the use of voice-related distress as a primary outcome. This can ultimately facilitate comparisons across studies and inform the development of psychological interventions.

A systematic review of relational-based therapies for the treatment of auditory hallucinations in patients with psychotic disorders

BACKGROUND

Auditory hallucinations in patients with psychotic disorders may be very distressing. Unfortunately, a large proportion of individuals are resistant to pharmacological interventions and the gold-standard cognitive-behavioral therapy for psychosis offers at best modest effects. To improve therapeutic outcomes, several therapies have been created to establish a relationship between voice-hearers and their voices. With increasing literature, we conducted a systematic review of dialogical therapies and examined the evidence behind their efficacy.

METHODS

A systematic search was performed in PubMed, PsycINFO, Web of Science, and Google Scholar. Articles were included if they discussed the effects of dialogical interventions for patients with psychotic disorders.

RESULTS

A total of 17 studies were included within this systematic review. Cumulative evidence from various therapies has shown that entering in a dialog with voices is beneficial to patients, even those who are resistant to current pharmacological treatments. Heightened benefits have been mainly observed with Relating Therapy and Avatar Therapy/Virtual Reality assisted Therapy, with evidence generally of moderate quality. Both these interventions have shown large to very large effects on voices and voice-related distress as well as moderate to large magnitude improvements on affective symptoms. Though, cognitive-behavioral therapy for command hallucinations and making sense of voices noted no improvements on voices.

CONCLUSIONS

Literature on relational-based interventions with a strong emphasis on the relational aspects of voice hearing has shown positive effects. Results suggest that these dialogical therapies might surpass the efficacy of current gold-standard approaches.

A narrative review of psychological theories of post-traumatic stress disorder, voice hearing, and other psychotic symptoms

BACKGROUND

Most voice hearers report childhood trauma. Many voice hearers report comorbid post-traumatic stress symptoms and that the content of their voices (auditory verbal hallucinations) is directly (voices repeat phrases spoken by perpetrators) or indirectly (voice content and trauma is thematically similar) related to their trauma. The factors that maintain trauma-related voices are unknown, and there is limited research in this area. This study aimed to identify potential maintaining factors of trauma-related voices by reviewing models of post-traumatic stress disorder (PTSD) and positive symptoms of psychosis.

METHOD

Models of PTSD and positive symptoms were reviewed to identify potential factors that are unique and common to both sets of symptoms.

RESULTS

We reviewed 10 models of PTSD, 4 models of positive symptoms, and 2 trauma-informed models of voice hearing. One model provided a theoretical explanation of different types of trauma-related voices. Twenty-one factors were extracted from 16 theoretical models. No existing model incorporated all these factors.

DISCUSSION

Existing PTSD and positive symptom models present a range of common and unique factors. There may be value in extending existing integrative models to include a broader range of potential factors that could explain different pathways to, and expressions of, trauma-related voices. A future research agenda is presented to investigate how such an extension could lead to more complete individualized case formulations and targeted treatments.

Spatial and chronic differences in neural activity in medicated and unmedicated schizophrenia patients

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The medicated schizophrenia group yielded concordant activity among three right lateralized frontal clusters and a left lateralized parietal cluster.

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The unmedicated schizophrenia group yielded concordant activity among right lateralized frontal-parietal regions.

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A neural compensatory mechanism in schizophrenia.

A major caveat with investigations on schizophrenic patients is the difficulty to control for medication usage across samples as disease-related neural differences may be confounded by medication usage. Following a thorough literature search (632 records identified), we included 37 studies with a total of 740 medicated schizophrenia patients and 367 unmedicated schizophrenia patients. Here, we perform several meta-analyses to assess the neurofunctional differences between medicated and unmedicated schizophrenic patients across fMRI studies to determine systematic regions associated with medication usage. Several clusters identified by the meta-analysis on the medicated group include three right lateralized frontal clusters and a left lateralized parietal cluster, whereas the unmedicated group yielded concordant activity among right lateralized frontal-parietal regions. We further explored the prevalence of activity within these regions across illness duration and task type. These findings suggest a neural compensatory mechanism across these regions both spatially and chronically, offering new insight into the spatial and temporal dynamic neural differences among medicated and unmedicated schizophrenia patients.

'Like jumping off a ledge into the water': A qualitative study of trauma-focussed imaginal exposure for hearing voices

OBJECTIVE

There is growing evidence of a link between the experience of hearing voices and past traumatic events, and trauma-focussed psychological interventions are being applied to hearing voices as an emerging treatment direction. To inform the ongoing development and implementation of this application, there is a need to understand clients' therapy experiences.

DESIGN

Qualitative study exploring the experience of people who received an intervention for voices linked to a previous traumatic event.

METHOD

Ten participants experiencing voices with some connection to a previous traumatic event participated in individual semi-structured interviews following six sessions of imaginal exposure, an exposure-based trauma-focussed intervention. Participant responses were analysed using thematic analysis.

RESULTS

Participants reported a range of benefits from the intervention, including improved mental health, reduction of distressing voice-hearing experiences, and increased clarity of the traumatic event. The therapy was perceived as distinctly different to previous therapy experiences, and participants noted that therapy could be intense and challenging, yet helpful later. Participants also reported that outside circumstances impacted on their progress in therapy and their voice-hearing experience.

CONCLUSIONS

The findings suggest that exposure-based trauma-focussed therapies may be beneficial for people who hear trauma-related voices. However, this intervention can be intense and clinicians and consumers need to consider the timing of delivery, and pay attention to internal and external resources that can increase participants' sense of safety.

PRACTITIONER POINTS

Imaginal exposure may be an effective intervention for people who hear voices that they perceive to be associated with a past traumatic event. Positive changes associated with the intervention may be highly variable between individuals, and encompass changes in sense of self, changes to internal states, and changes to voice-hearing experience. Imaginal exposure interventions may involve some temporary discomfort and symptom exacerbation, which may affect the acceptability of the intervention. This needs to be considered in both future research and clinical delivery.

Negative content in auditory verbal hallucinations: a natural language processing approach

INTRODUCTION

Negative content of auditory verbal hallucinations (AVH) is a strong predictor of distress and impairment. This paper quantifies emotional voice-content in order to explore both subjective (i.e. perceived) and objectively (i.e. linguistic sentiment) measured negativity and investigates associations with distress.

METHODS

Clinical and non-clinical participants with frequent AVH (n = 40) repeated and recorded their AVH verbatim directly upon hearing. The AVH were analyzed for emotional valence using Pattern, a rule-based sentiment analyzer for Dutch. The AVH of the clinical individuals were compared to those of non-clinical voice-hearers on emotional valence and associated with experienced distress.

RESULTS

The mean objective valence of AVH in patients was significantly more negative than those of non-clinical voice-hearers. In the clinical individuals a larger proportion of the voice-utterances was negative (34.7% versus 18.4%) in objective valence. The linguistic valence of the AVH showed a significant, strong association with the perceived negativity, amount of distress and disruption of life, but not with the intensity of distress.

CONCLUSIONS

Our results indicate that AVH of patients have a more negative linguistic content than those of non-clinical voice-hearers, which is associated with the experienced distress. Thus, patients not only perceive their voices as more negative, objective analyses confirm this.

Pathways from insecure attachment to paranoia: the mediating role of emotion regulation

Background:

Paranoia is common across the clinical and non-clinical spectrum. Cognitive behavioural therapy for psychosis currently yields modest results, warranting research into symptom-specific maintenance factors to improve outcomes. There is strong evidence of a relationship between insecure attachment and increased paranoia, but little is known about the mediating mechanisms. Emotion dysregulation is associated with both insecure attachment and paranoia, and a candidate causal mechanism.

Aims:

This study aimed to determine if emotion dysregulation mediates the association between attachment and paranoia.

Method:

Sixty-two individuals with elevated paranoia were recruited from NHS services and community settings across the South of England. Mediation analyses were conducted on trait attachment, emotion regulation and paranoia variables, which were collected at one time point.

Results:

As predicted, emotion dysregulation mediated the relationship between attachment avoidance and paranoia, and between attachment anxiety and paranoia. Emotion suppression did not mediate the relationship between attachment avoidance and paranoia, possibly due to power. Attachment avoidance correlated with deactivating emotion regulation strategies (e.g. lack of emotional awareness) and attachment anxiety correlated with hyperactivating emotion regulation strategies (e.g. impulse control difficulties). Both deactivating and hyperactivating strategies correlated with paranoia.

Conclusion:

Emotion dysregulation is not routinely targeted in cognitive behavioural therapy for psychosis. This study suggests that incorporating emotion regulation strategies in therapy may improve clinical outcomes. Experimental studies are now required to support a causal argument, and pilot intervention studies should investigate if emotion regulation skills development (aligned with attachment style) is effective in reducing non-clinical and clinical paranoia.

Feasibility and efficacy of an acceptance and mindfulness-based group intervention for young people with early psychosis (Feel-Good group)

BACKGROUND

Over the last decade, researchers have sought for alternative interventions that have better treatment effects than Cognitive Behavioral Therapy (CBT) when treating psychotic symptoms. Mindfulness-based interventions have been a proposed alternative to CBT, yet research regarding its feasibility, acceptance and effectiveness is lacking when treating individuals with early psychosis in inpatient settings.

OBJECTIVE

Before conducting a large-scale randomized-controlled trial (RCT), this pilot study evaluated the feasibility and the potential efficacy of a mindfulness-based inpatient group intervention that targets emotion regulation in patients with early psychosis, and thus indirectly improving psychotic symptoms.

METHODS

A pre-post study was performed. Thirty-six patients with early psychosis treated at the specialized inpatient treatment "Frühinterventions- und Therapiezentrum; FRITZ" (early intervention and therapy center) received eight group therapy sessions. Assessments were performed at baseline, after 8 weeks post treatment and at follow-up after 16 weeks.

RESULTS

Rates of patients who participated in the study suggests that a mindfulness-based group therapy is highly accepted and feasible for patients with early psychosis being treated in an inpatient ward. Friedman analyses revealed significant changes in the primary outcomes of emotional goal attainment (Goal 1: W = 0.79; Goal 2: W = 0.71) and psychotic symptoms (PANSS-T: W = 0.74). Significant, albeit small, effect sizes were found in patients' self-perception of emotion regulation skills (ERSQ: W = 0.23).

DISCUSSION

We found favorable findings regarding the feasibility and acceptance of the Feel-Good mindfulness-based intervention. Results of the study provide a basis for an estimation of an adequate sample size for a fully powered RCT that needs to be conducted to test whether Feel-Good is effective in the inpatient treatment of psychotic symptoms for individuals with early psychosis.

CLINICAL TRIAL REGISTRATION

[https://clinicaltrials.gov/ct2/show/NCT04592042], identifier [NCT04592042].

[Causes of visual hallucinations in Parkinson's disease]

BACKGROUND

Visual hallucinations (VH) have mainly been considered as late symptoms of Parkinson's disease (PD); however, minor forms of VH also occur in early stages of the disease. Initially dopaminergic overstimulation was discussed as the cause and later on VH have been considered as an early red flag of dementia in PD.

OBJECTIVE

The present study analyzed whether the pathophysiological concept of VH has been enlarged in recent years.

MATERIAL AND METHODS

Clinical, pharmacological, neuropathological as well as functional magnetic resonance imaging studies dealing with VH were reviewed. A systematic classification in monomodal and multimodal models of VH is proposed. The applicability to various forms of VH and various triggering situations is critically examined.

RESULTS

Reduction of the visual information input, erroneous visual processing, attention deficits, and dysfunctional connectivity between various cerebral networks have been shown. There is partial overlapping with the Lhermitte syndrome and the Charles Bonnet syndrome. No model is able to fully explain all VH variants. Not all VH have the same pathogenesis and the same poor prognosis.

CONCLUSION

The chain of causes underlying VH is complex and can vary from patient to patient. So far the therapeutic applications are largely unexplored; however, there is preliminary evidence that beside adjustment of the medication, improvement of visual acuity, active involvement of the partner, and possibly, individually adaptable coping strategies could be successfully implemented.

Effectiveness of Cognitive Behavioural Therapy for Suicide in Schizophrenia: A Systematic Review

Background:

Suicide is probably one of the worst potential complications for people with schizophrenia. Even though the use of antipsychotic medication is essential in reducing suicidal behaviour, the use of psychological treatments seems to be in the same way necessary. Cognitive Behavioural Therapy (CBT) is an evidence-based form of psychotherapy that is constantly trying to synchronise with the latest recommendations from the research. The goal of the present work is to systematically review the scientific evidence from published studies testing the effectiveness of CBT designed to deal with suicide in patients with schizophrenia.

Methods:

We searched using multiple terms related to suicide prevention based on CBT in schizophrenia. Two databases (Medline and SCOPUS) were scrutinised for the electronic search and different reference lists from previous reviews were also hand checked.

Results:

We identified 5 randomised and controlled trials of CBT that included suicide-related cognitions or behaviours as a primary outcome measure. CBT focusing on suicidal cognitions and behaviours was found to be effective in reducing suicidal ideation. As the number of studies fulfilling the inclusion criteria is small and the assessment of outcomes is heterogeneous, we did not perform a meta-analysis and we present results in a narrative way.

Conclusion:

Research on CBT focused on suicide prevention in patients with schizophrenia is promising but current evidence is notoriously insufficient. Although those therapies seemed to be efficacious in the prevention of suicide, scarcity of randomised clinical trials specifically focusing on suicide is probably the most important issue to be faced. Given the current evidence, clinicians should be familiar with CBT techniques focusing on suicidal cognitions. However, suicide prevention and treatment in those with schizophrenia is complex, and many other factors such as possible earlier use of clozapine, optimizing adherence to medication, and other psychosocial aspects should be addressed. Combination of different strategies appears to be mandatory.

Cognitive Behavioral Therapy in Treatment of Schizophrenia

Schizophrenia is a heterogeneous disorder that affects behavioral, affective, and cognitive domains and consists of positive and negative psychotic symptoms. Antipsychotic therapy is the first-line treatment for schizophrenia. However, treatment adherence levels are low. Even if there is good treatment compliance, residual symptoms and treatment resistance can be seen. As a result, recent schizophrenia treatment guidelines suggest Cognitive Behavioral Therapy (CBT) as adjunctive to antipsychotic therapy. CBT is known effective, especially on positive symptoms. This paper aims to review CBT practices and their effectiveness in schizophrenia.

Virtual reality cognitive-behavioural therapy versus cognitive-behavioural therapy for paranoid delusions: a study protocol for a single-blind multi-Centre randomised controlled superiority trial

BACKGROUND

Seventy per cent of patients with psychotic disorders has paranoid delusions. Paranoid delusions are associated with significant distress, hospital admission and social isolation. Cognitive-behavioural therapy for psychosis (CBTp) is the primary psychological treatment, but the median effect size is only small to medium. Virtual reality (VR) has a great potential to improve the effectiveness of CBTp. In a previous study, we found that VR based CBT (VRcbt) for paranoid delusions is superior to waiting list. As a next step, a direct comparison with CBTp is needed. The present study aims to investigate whether VRcbt is more effective and cost-effective than regular CBTp in treating paranoid delusions and improving daily life social functioning of patients with psychotic disorders.

METHODS

A total of 106 patients with DSM-5 diagnosis of psychotic disorder and at least moderate level of paranoid ideations will be recruited for this multicentre randomized controlled trial (RCT). Patients will be randomized to either VRcbt or standard CBTp for paranoid delusions. VRcbt consists of maximum 16 sessions in virtual social situations that trigger paranoid ideations and distress, delivered in an 8-12 week time frame. Standard CBTp also consists of maximum 16 sessions including exposure and behavioural experiments, delivered in an 8-12 week time frame. The two groups will be compared at baseline, post-treatment and six months follow-up. Primary outcome is the level of paranoid ideations in daily life social situations, measured with ecological momentary assessments (EMA) at semi-random moments ten times a day during seven days, before and after treatment. Every session, participants and therapists will rate the level of paranoid ideation and global clinical impression.

DISCUSSION

Comparison of VRcbt and CBTp will provide information about the relative (cost-) effectiveness of VRcbt for this population. VRcbt may become a preferred psychological treatment for paranoid delusions and social anxiety in patients with psychotic disorder.

TRIAL REGISTRATION

Netherlands Trial Register, NL7758. Registered on 23 May 2019.

Managing unusual sensory experiences: A feasibility trial in an At Risk Mental States for psychosis group

OBJECTIVES

To conduct a feasibility study on a new, tablet-delivered treatment for unusual sensory experiences in service-users with an At Risk Mental States for psychosis.

DESIGN

A mixed method design was employed, using content analysis to investigate whether service-users and therapists found the new treatment acceptable and helpful. We also collected data on the impact of treatment, but without a control group could not make any claims about effectiveness.

METHODS

Eligible participants were contacted before starting treatment and offered the chance to participate. Assessments were conducted before and after the treatment, which typically was completed in 4-6 sessions by an accredited CBT therapist. A structured interview was used to collect qualitative feedback.

RESULTS

Qualitative feedback suggested that the treatment was acceptable to service-users and therapists, and the progression criteria were met for recruitment, retention, and adherence to treatment.

CONCLUSIONS

The new treatment targeting subtypes of auditory and visual hallucinations was acceptable to service-users and the benefits of addressing psychological mechanisms thought to contribute to hallucinations was supported by qualitative feedback.

PRACTITIONER POINTS

A novel treatment has been developed for unusual sensory experiences based on subtyping voices and using technology to help explain psychological mechanisms that may be linked to hallucinations. The treatment was acceptable to service users and therapists in At Risk Mental States for psychosis services with qualitative feedback supporting the approach. The treatment may be particularly useful in preventing the progressions of psychosis as people who have not developed fixed ideas about the origin of the experiences may be more open to alternative explanations.

Systematic review and meta-analysis of therapeutic alliance, engagement, and outcome in psychological therapies for psychosis

AIM

The moderate association between therapeutic alliance (TA) and psychological therapy outcome is well established. Historically, the field has not focused on people with a severe mental illness. This is the first review to conduct a meta-analysis of associations between TA and therapeutic engagement as well as outcome in psychological therapy for psychosis.

ELIGIBILITY CRITERIA

Eligible studies conducted a quantitative investigation of the relationship between TA during a psychological therapy and outcome at a subsequent time-point.

METHOD

A systematic review examined the relationship between TA and engagement as well as outcome measures within psychological therapy for psychosis. Correlational meta-analyses using an aggregate random effects model were conducted.

RESULTS

Twenty-four studies were eligible for inclusion (n = 1,656) of which 13 were included in the meta-analyses. Client- and therapist-rated TA were associated with engagement in therapy (r_{client (c)}  = 0.36, p = .003; r_{therapist (t)}  = 0.40, p = .0053). TA was also associated with reduction in global (r_c  = 0.29, p = .0005; r_t  = 0.24, p = .0015) and psychotic symptoms (r_c  = 0.17, p = .0115; r_t  = 0.30, p = .0003). The systematic review identified no evidence or limited evidence for a relationship between TA during therapy and depression, substance use, physical health behaviours, global as well as social functioning, overall mental health recovery, and self-esteem at follow-up. Although number of studies was small, TA was related to a reduced risk of subsequent hospitalization in 40% of analyses (across two studies) and improved cognitive outcome in 50% of analyses (across three studies).

CONCLUSIONS

The observed TA-therapy engagement and TA-outcome associations were broadly consistent with those identified across non-psychotic diagnostic groups. Well-powered studies are needed to investigate the relationship between TA and process as well as outcome in psychological therapy for psychosis specifically.

PRACTITIONER POINTS

This is the first review to conduct a meta-analytic synthesis of the association between therapeutic alliance (TA) and both engagement and change in outcome in psychological therapies for psychosis. TA (as rated by therapist and client) was associated with the extent of therapeutic engagement as well as reduction in global mental health symptoms and psychotic symptoms. The significant associations between TA and engagement as well as change in outcome identified in the current review are broadly consistent with those observed across non-psychotic diagnostic groups. We consider factors that could impact upon the dynamic and potentially interdependent relationships between TA and therapeutic techniques, including attachment security and severity of paranoid ideation.

Comparison of a theoretically driven cognitive therapy (the Feeling Safe Programme) with befriending for the treatment of persistent persecutory delusions: a parallel, single-blind, randomised controlled trial

BACKGROUND

There is a large clinical need for improved treatments for patients with persecutory delusions. We aimed to test whether a new theoretically driven cognitive therapy (the Feeling Safe Programme) would lead to large reductions in persecutory delusions, above non-specific effects of therapy. We also aimed to test treatment effect mechanisms.

METHODS

We did a parallel, single-blind, randomised controlled trial to test the Feeling Safe Programme against befriending with the same therapists for patients with persistent persecutory delusions in the context of non-affective psychosis diagnoses. Usual care continued throughout the duration of the trial. The trial took place in community mental health services in three UK National Health Service trusts. Participants were included if they were 16 years or older, had persecutory delusions (as defined by Freeman and Garety) for at least 3 months and held with at least 60% conviction, and had a primary diagnosis of non-affective psychosis from the referring clinical team. Patients were randomly assigned to either the Feeling Safe Programme or the befriending programme, using a permuted blocks algorithm with randomly varying block size, stratified by therapist. Trial assessors were masked to group allocation. If an allocation was unmasked then the unmasked assessor was replaced with a new masked assessor. Outcomes were assessed at 0 months, 6 months (primary endpoint), and 12 months. The primary outcome was persecutory delusion conviction, assessed within the Psychotic Symptoms Rating Scale (PSYRATS; rated 0-100%). Outcome analyses were done in the intention-to-treat population. Each intervention was provided individually over 6 months. This trial is registered with the ISRCTN registry, ISRCTN18705064.

FINDINGS

From Feb 8, 2016, to July 26, 2019, 130 patients with persecutory delusions (78 [60%] men; 52 [40%] women, mean age 42 years [SD 12·1, range 17-71]; 86% White, 9% Black, 2% Indian; 2·3% Pakistani; 2% other) were recruited. 64 patients were randomly allocated to the Feeling Safe Programme and 66 patients to befriending. Compared with befriending, the Feeling Safe Programme led to significant end of treatment reductions in delusional conviction (-10·69 [95% CI -19·75 to -1·63], p=0·021, Cohen's d=-0·86) and delusion severity (PSYRATS, -2·94 [-4·58 to -1·31], p<0·0001, Cohen's d=-1·20). More adverse events occurred in the befriending group (68 unrelated adverse events reported in 20 [30%] participants) compared with the Feeling Safe group (53 unrelated adverse events reported in 16 [25%] participants).

INTERPRETATION

The Feeling Safe Programme led to a significant reduction in persistent persecutory delusions compared with befriending. To our knowledge, these are the largest treatment effects seen for patients with persistent delusions. The principal limitation of our trial was the relatively small sample size when comparing two active treatments, meaning less precision in effect size estimates and lower power to detect moderate treatment differences in secondary outcomes. Further research could be done to determine whether greater effects could be possible by reducing the hypothesised delusion maintenance mechanisms further. The Feeling Safe Programme could become the recommended psychological treatment in clinical services for persecutory delusions.

FUNDING

NIHR Research Professorship and NIHR Oxford Health Biomedical Research Centre.

Effects of SlowMo, a Blended Digital Therapy Targeting Reasoning, on Paranoia Among People With Psychosis: A Randomized Clinical Trial

IMPORTANCE

Persistent paranoia is common among patients with psychosis. Cognitive-behavioral therapy for psychosis can be effective. However, challenges in engagement and effectiveness remain.

OBJECTIVE

To investigate the effects on paranoia and mechanisms of action of SlowMo, a digitally supported reasoning intervention, plus usual care compared with usual care only.

DESIGN, SETTING, AND PARTICIPANTS

This parallel-arm, assessor-blinded, randomized clinical trial recruited participants at UK community health services from May 1, 2017, to May 14, 2019. Eligible participants consisted of a referral sample with schizophrenia-spectrum psychosis and distressing, persistent (≥3 months) paranoia.

INTERVENTIONS

Individuals were randomized 1:1 to SlowMo, consisting of 8 digitally supported face-to-face sessions and a mobile app, plus usual care (n = 181) and usual care only (n = 181).

MAIN OUTCOMES AND MEASURES

The primary outcome was paranoia, measured by the Green et al Paranoid Thoughts Scale (GPTS) total score at 24 weeks. Secondary outcomes included GPTS total score at 12 weeks and GPTS Part A (reference) and Part B (persecutory) scores, the Psychotic Symptom Rating Scales (PSYRATS Delusion subscale), reasoning (belief flexibility, possibility of being mistaken [Maudsley Assessment of Delusions, rated 0%-100%]), and jumping to conclusions (Beads Task).

RESULTS

A total of 361 participants were included in intention-to-treat analysis, of whom 252 (69.8%) were male and 249 (69.0%) were White; the mean (SD) age was 42.6 (11.6) years. At 24 weeks, 332 participants (92.0%) provided primary outcome data. Of 181 participants in the SlowMo group, 145 (80.1%) completed therapy. SlowMo plus usual care was not associated with greater reductions than usual care in GPTS total score at 24 weeks (Cohen d, 0.20; 95% CI, -0.02 to 0.40; P = .06). There were significant effects on secondary paranoia outcomes at 12 weeks, including GPTS total score (Cohen d, 0.30; 95% CI, 0.09-0.51; P = .005), Part A score (Cohen d, 0.22; 95% CI, 0.06-0.39; P = .009), and Part B score (Cohen d, 0.32; 95% CI, 0.08-0.56; P = .009), and at 24 weeks, including Part B score (Cohen d, 0.25; 95% CI, 0.01-0.49; P = .04) but not Part A score (Cohen d, 0.12; 95% CI, -0.05 to 0.28; P = .18). Improvements were observed in an observer-rated measure of persecutory delusions (PSYRATS delusion) at 12 weeks (Cohen d, 0.47; 95% CI, 0.17-0.78; P = .002) and 24 weeks (Cohen d, 0.50; 95% CI, 0.20-0.80; P = .001) and belief flexibility at 12 weeks (Cohen d, 0.29; 95% CI, 0.09-0.49; P = .004) and 24 weeks (Cohen d, 0.28; 95% CI, 0.08-0.49; P = .005). There were no significant effects on jumping to conclusions. Improved belief flexibility and worry mediated paranoia change (range mediated, 36%-56%).

CONCLUSIONS AND RELEVANCE

SlowMo did not demonstrate significant improvements in the primary measure of paranoia at 24 weeks; however, a beneficial effect of SlowMo on paranoia was indicated by the results on the primary measure at an earlier point and on observer-rated paranoia and self-reported persecution at 12 and 24 weeks. Further work to optimize SlowMo's effects is warranted.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN 32448671.

Efficacy and durability of cognitive behavior therapy in managing hallucination in patients with schizophrenia

BACKGROUND

The cognitive behavior therapy (CBT) approach to psychosis is a relatively recent development and focuses directly on the core psychotic symptoms of hallucinations and delusions.

AIM

The aim of this study is to assess the efficacy of cognitive behavior therapy in managing hallucination in patients with schizophrenia and to evaluate the generalizability and durability of the therapeutic gains.

MATERIALS AND METHODS

In this confirmatory pre-post assessment study, based on the purposive sampling technique, a sample consisting of 40 (20 for experimental and the other 20 for control group) patients having schizophrenia with core symptoms of hallucination and delusions under treatment as usual were selected and matched on the sociodemographic and clinical variables. For the clinical variables, the Psychotic Symptom Rating Scale and Scale for the Assessment of Positive Symptoms were used. After baseline assessment, the cognitive behavioral program was tailored on the experimental group and patients of both the group were reassessed after the completion of treatment. Follow-up data to see the durability of program were taken from all the patients of experimental and control groups.

RESULTS

Cognitive behavior therapy was found to be effective for the treatment of auditory hallucination in schizophrenia. The therapeutic gains in all study variables were found to be maintained or further improving at follow-up which proves that cognitive behavior therapy is durable.

CONCLUSION

Cognitive behavior therapy in conjunction with pharmacotherapy was found to be more effective in improving clinical symptoms of schizophrenia and global functioning compared to pharmacotherapy alone.

Increasing access to brief Coping Strategy Enhancement for distressing voices: a service valuation exploring a possible role for briefly-trained therapists

Hearing voices is a distressing and trans-diagnostic experience. Cognitive behavioural therapy (CBT) is an effective psychological treatment for distressing voices, but is offered to only a minority of patients. Limited resources are a barrier to accessing CBT. Evaluations of brief forms of CBT for voices have offered encouraging findings, but the ability of briefly-trained therapists to deliver these brief therapies has yet to be explored. We evaluated the outcomes of a brief form of CBT (Coping Strategy Enhancement, CSE) for voices when delivered by highly-trained and briefly-trained therapists. This was a service evaluation comparing pre–post outcomes in patients who had completed brief CSE over four sessions, within NHS Mental Health Services, delivered by highly-trained and briefly-trained therapists. The primary outcome was the negative impact scale of the Hamilton Program for Schizophrenia Voices Questionnaire. Data were available from 92 patients who completed a course of brief CSE – nearly half of whom received therapy from a briefly-trained therapist. Modest benefits across the sample were consistent with previous evaluations and did not seem to be influenced by the training of the therapist. This service evaluation offers further evidence that brief CSE can begin a therapeutic conversation about distressing voices within routine clinical practice. The usefulness of this initial conversation does not seem to be reliant upon the extent of therapist training, suggesting that briefly-trained therapists may play a role in increasing access to these conversations for patients distressed by hearing voices.

Key learning aims

(1)

RELATE-a randomised controlled feasibility trial of a Relating Therapy module for distressing auditory verbal hallucinations: a study protocol

INTRODUCTION

Auditory verbal hallucinations (AVHs) are associated with distress and reduced functioning. Research suggests that distress is associated with the voice hearer's responding to AVH in a passive and subordinate manner. A novel approach focuses on relating to AVH and teaches assertive responses to AVH using experiential role-plays. A small pilot study found a large effect of this approach on AVH distress but an independent multicentre study is required to ascertain effectiveness across different settings. We aim to estimate the expected effect for a subsequent trial to demonstrate that adding a module of Relating Therapy (RT) to treatment as usual (TAU) is superior to TAU alone in reducing AVH distress. We also test the feasibility of patient recruitment, therapist training, and therapy monitoring in different psychological and psychiatric outpatient facilities in Germany.

METHODS AND ANALYSIS

We will recruit 75 patients diagnosed with a schizophrenia spectrum disorder and persistent distressing AVH across four sites. Patients will be randomised to receive either 16 sessions of RT plus TAU or TAU alone within a 5-month period. Randomisation will be stratified by sites. Single-blind assessments will take place at baseline, at 5 months (T1) and at 9 months (T2). The primary outcome is the distress factor score of the AVH subscale of the Psychotic Symptoms Rating Scale at T2 adjusted for the baseline value. Secondary outcomes are change in depressive symptoms, quality of life, time spent in structured activities as well as negative relating to voices and to other people.

ETHICS AND DISSEMINATION

The trial has received ethical approval from the German Psychological Society Ethics Committee. The trial results will be disseminated through conference presentations, peer-reviewed publications and social media.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04578314).

A Randomised Comparison of Values and Goals, Versus Goals Only and Control, for High Nonclinical Paranoia

Background

Paranoia is common in the general population. Focusing on values and enhancing value-based acts may attenuate it. This study compared three brief (30-min, self-directed) online conditions: focusing on values and value-based goal setting (n = 30), goal setting only (n = 32) and non-values/goals control (n = 32) in a high paranoia sample.

Methods

Participants were randomly assigned to condition. State paranoia (primary outcome) and positive and negative self-views following a difficult interpersonal experience (secondary outcome) were assessed at baseline and two-weeks.

Results

Intention-to-treat: state paranoia was significantly lower following the values condition as compared to non-values/goals control (ηp2 = .148) and goals only (ηp2 = .072). Only the former comparison was significant. Per-protocol: groups did not significantly differ (p = .077). Within-group effect sizes: values and value-based goal setting (intention-to-treat d = .82, per-protocol d = .78), goals only (intention-to-treat d = .41, per-protocol d = .42) non-values/goals control (intention-to-treat d = .25, per-protocol d = .24). Positive self-views increased in all conditions. The increase was largest for the values condition, but not significantly so.

Limitations

Reliance on self-report, brief follow-up, predominantly White female sample.

Conclusions

The values condition was most effective at reducing non-clinical paranoia. The values condition appeared to increase positive self-views more so than comparison groups, but the sample was small and the difference was non-significant.

Relating behaviours and therapeutic actions during AVATAR therapy dialogue: An observational study

OBJECTIVES

AVATAR therapy is a novel relational approach to working with distressing voices by engaging individuals in direct dialogue with a digital representation of their persecutory voice (the avatar). Critical to this approach is the avatar transition from abusive to conciliatory during the course of therapy. To date, no observational study has examined the moment-to-moment dialogical exchanges of this innovative therapy. We aim to (1) map relating behaviours between participants and their created avatars and (2) examine therapeutic actions delivered within AVATAR dialogue.

METHOD

Twenty-five of the fifty-three AVATAR therapy completers were randomly selected from a randomized controlled trial (Craig et al. The Lancet Psychiatry, 5, 2018 and 31). Seventy-five audio recordings of active dialogue from sessions 1 and 4 and the last session were transcribed and analysed using a newly developed coding frame. Inter-rater reliability was good to excellent.

RESULTS

Fine-grained analysis of 4,642 observations revealed nuanced communication around relational power and therapeutic activity. Early assertiveness work, reinforced by the therapist, focussed on increasing power and distancing. Participants' submissive behaviours reduced during therapy, but the shift was gradual. Once the transition to a more conciliatory tone took place, the dialogue primarily involved direct communication between participant and avatar, focussing on sense of self and developmental and relational understanding of voices.

CONCLUSIONS

AVATAR therapy supports voice-hearers in becoming more assertive towards a digital representation of their abusive voice. Direct dialogue with carefully characterized avatars aims to build the voice-hearers' positive sense of self, supporting the person to make sense of their experiences.

PRACTITIONER POINTS

AVATAR therapy enables voice-hearers to engage in face-to-face dialogue with a digital representation ('avatar') of their persecutory voice. Fine-grained analyses showed how relating behaviours and therapeutic actions evolve during active AVATAR therapy dialogue. Carefully characterized avatars and direct therapist input help voice-hearers become more assertive over the avatar, enhance positive sense of self, and support individuals to make sense of their experiences.

Trauma-focused imaginal exposure for auditory hallucinations: A case series

OBJECTIVE

There is mounting evidence that traumatic life events play a role in auditory hallucinations (AH). Theory suggests that some AH are decontextualized trauma memory intrusions. Exposure-based trauma-focused therapies that target trauma memory intrusions may therefore be a promising new treatment. We aimed to assess the feasibility and acceptability of a standard protocol trauma-focused imaginal exposure intervention for trauma-related AH and to provide initial proof of concept regarding potential effects on AH.

DESIGN

We conducted a single-arm case series of a six session (90 min per session) imaginal exposure intervention for trauma-related AH with assessments at baseline, post-therapy, and one-month follow-up.

RESULTS

Fifteen people were recruited and eligible to start the intervention. Participants reported high levels of satisfaction; however, temporary distress and symptom exacerbation were common and contributed to discontinuation. There was a large reduction in AH severity at one-month follow-up (adjusted d = 0.99), but individual response was highly variable. There were also large reductions in post-traumatic stress disorder symptoms and the intrusiveness of the trauma memory.

CONCLUSIONS

Imaginal exposure for trauma-related AH is generally acceptable and may have large effects on AH severity for some people. However, temporary distress and symptom exacerbation are common and can lead to discontinuation. Low referral rates and uptake also suggest feasibility issues for standalone imaginal exposure for AH. The intervention may be more feasible and acceptable in the context of a broader trauma-focused therapy. Well-powered trials are needed to determine efficacy and factors that impact on acceptability and therapy response.

PRACTITIONER POINTS

Some AH can be understood as trauma memory intrusions that lack temporal and spatial contextualization and are therefore experienced without autonoetic awareness. Imaginal exposure to trauma memories associated with AH may be an effective intervention for some people. Temporary distress and symptom exacerbation may be common when using standard trauma-focused imaginal exposure for AH. This can impact on the acceptability of the therapy and should be considered in future development and delivery.

Moment-to-moment dynamics between auditory verbal hallucinations and negative affect and the role of beliefs about voices

BACKGROUND

Negative affect (NA) has been suggested to be both an antecedent and a consequence of auditory verbal hallucinations (AVH). Furthermore, negative appraisals of voices have been theorized to contribute to the maintenance of AVH. Using the experience sampling method (ESM), this study examined the bi-directional relationship between NA and AVH, and the moderating effect of negative beliefs about voices.

METHODS

Forty-seven patients diagnosed with schizophrenia spectrum disorders with frequent AVH completed a clinical interview, followed by ESM for 10 times a day over 6 days on an electronic device. Time-lagged analyses were conducted using multilevel regression modeling. Beliefs about voices were assessed at baseline.

RESULTS

A total of 1654 data points were obtained. NA predicted an increase in AVH in the subsequent moment, and AVH predicted an increase in NA in the subsequent moment. Baseline beliefs about voices as malevolent and omnipotent significantly strengthened the association between NA and AVH within the same moment. In addition, the belief of omnipotence was associated with more hallucinatory experiences in the moment following NA. However, beliefs about voices were not associated directly with momentary levels of NA or AVH.

CONCLUSIONS

Experiences of NA and AVH drove each other, forming a feedback loop that maintained the voices. The associations between NA and AVH, either within the same moment or across moments, were exacerbated by negative beliefs about voices. Our results suggest that affect-improving interventions may stop the feedback loop and reduce AVH frequency.

One-year randomized trial comparing virtual reality-assisted therapy to cognitive-behavioral therapy for patients with treatment-resistant schizophrenia

The gold-standard cognitive-behavioral therapy (CBT) for psychosis offers at best modest effects. With advances in technology, virtual reality (VR) therapies for auditory verbal hallucinations (AVH), such as AVATAR therapy (AT) and VR-assisted therapy (VRT), are amid a new wave of relational approaches that may heighten effects. Prior trials have shown greater effects of these therapies on AVH up to a 24-week follow-up. However, no trial has compared them to a recommended active treatment with a 1-year follow-up. We performed a pilot randomized comparative trial evaluating the short- and long-term efficacy of VRT over CBT for patients with treatment-resistant schizophrenia. Patients were randomized to VRT (n = 37) or CBT (n = 37). Clinical assessments were administered before and after each intervention and at follow-up periods up to 12 months. Between and within-group changes in psychiatric symptoms were assessed using linear mixed-effects models. Short-term findings showed that both interventions produced significant improvements in AVH severity and depressive symptoms. Although results did not show a statistically significant superiority of VRT over CBT for AVH, VRT did achieve larger effects particularly on overall AVH (d = 1.080 for VRT and d = 0.555 for CBT). Furthermore, results suggested a superiority of VRT over CBT on affective symptoms. VRT also showed significant results on persecutory beliefs and quality of life. Effects were maintained up to the 1-year follow-up. VRT highlights the future of patient-tailored approaches that may show benefits over generic CBT for voices. A fully powered single-blind randomized controlled trial comparing VRT to CBT is underway.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

The Staff Views About Assessing Voices Questionnaire: Piloting a Novel Socratic Method of Evaluating and Training Multidisciplinary Staff's Cognitive Assessment of Patients' Distressing Voices

Cognitive features of auditory hallucinations (voices) have important clinical significance and their assessment is vital for cognitive behavior therapy to be more widely deployed by multidisciplinary staff. Using a new Socratic instrument-The Staff Views About Assessing Voices Questionnaire (SVAVQ)-we surveyed a community inpatient rehabilitation multidisciplinary workforce's (N = 50) assessment and attitude toward asking cognitive questions about patients' voices. We found that there were many clinically important gaps in what staff asked about in relation to cognitive features of voices. We identified a range of beliefs the staff hold that may prevent assessment of voice cognitive features. However, after attending the Socratic SVAVQ interview, 84% of staff said they planned to ask patients more questions about cognitive features of patients' voices. Research could now test if other psychosis services neglect the assessment of important cognitive features of patients' voices and if staff Socratic questioning improves their cognitive assessments.

Inhibitory Top-Down Control Deficits in Schizophrenia With Auditory Verbal Hallucinations: A Go/NoGo Task

Objective: Auditory verbal hallucinations (AVH), with unclear mechanisms, cause extreme distresses to schizophrenia patients. Deficits of inhibitory top-down control may be linked to AVH. Therefore, in this study, we focused on inhibitory top-down control in schizophrenia patients with AVH. Method: The present study recruited 40 schizophrenia patients, including 20 AVH patients and 20 non-AVH patients, and 23 healthy controls. We employed event-related potentials to investigate the N2 and P3 amplitude and latency differences among these participants during a Go/NoGo task. Results: Relative to healthy controls, the two patient groups observed longer reaction time (RT) and reduced accuracy. The two patient groups had smaller NoGo P3 amplitude than the healthy controls, and the AVH patients showed smaller NoGo P3 amplitude than the non-AVH patients. In all the groups, the parietal area showed smaller NoGo P3 than frontal and central areas. However, no significant difference was found in N2 and Go P3 amplitude between the three groups. Conclusions: AVH patients might have worse inhibitory top-down control, which might be involved in the occurrence of AVH. Hopefully, our results could enhance understanding of the pathology of AVH.

Psychosocial interventions in schizophrenia: Focus on guidelines

BACKGROUND

Schizophrenia is a lifelong condition with acute exacerbations and varying degrees of functional disability. Acute and long-term treatments are based on antipsychotic drugs, even if some domains of personal and social functioning are not addressed by psychopharmacotherapy. In fact, psychosocial interventions show a positive impact on patient's functioning and clinical outcome. In addition, psychosocial interventions are significantly associated with a lower number of relapses and hospitalizations in schizophrenia.

METHODS

An analytical review of the International Guidelines on Psychosocial Interventions in Schizophrenia has been performed; we included the National Institute for Health and Care Excellence (NICE) guidelines, the Scottish Intercollegiate Guidelines Network (SIGN) guidelines, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) guidelines, the Schizophrenia Patient Outcomes Research Team (PORT) guidelines and the American Psychiatric Association (APA) guidelines.

RESULTS

The international guidelines recommend psychosocial interventions as supportive treatments alongside pharmaceutical or psychotherapeutic ones.

CONCLUSION

More research studies need to be conducted and included in the updated version of the international guidelines to confirm the effectiveness of psychosocial interventions in the long-term outcome of schizophrenia.

Targeting affect leads to reduced paranoia in people with psychosis: a single case series

BACKGROUND

Current psychological interventions for psychosis focus primarily on cognitive and behavioural management of delusions and hallucinations, with modest outcomes. Emotions are not usually targeted directly, despite evidence that people with psychosis have difficulty identifying, accepting and modifying affective states.

AIMS

This study assessed the impact of emotion regulation skills practice on affect and paranoia in seven people who met criteria for a diagnosis of schizophrenia or schizoaffective disorder.

METHOD

The study utilised a single case ABA design and measured emotion regulation skills, affect and paranoia over baseline, intervention and withdrawal of intervention phases. We predicted that eight sessions of skills rehearsal would lead to improved emotion regulation, reduced negative affect, increased positive affect, and reduced paranoia.

RESULTS

Most participants were able to learn to regulate their emotions, and reported reduced negative affect and paranoia. There was no clear pattern of change for positive affect.

CONCLUSIONS

These findings suggest that emotion can be targeted in psychosis, and is associated with reduced paranoia. Emotion regulation may constitute a key treatment target in cognitive behavioural therapy for psychosis.

A qualitative study exploring how Practitioners within Early Intervention in Psychosis Services engage with Service Users' experiences of voice hearing?

WHAT IS KNOWN ON THE SUBJECT?: The experience of hearing distressing voices is commonly reported by service users with a diagnosis of first-episode psychosis, but their access to formal conversations about voices in the form of psychological therapies can be limited. Service users within Early Intervention in Psychosis (EIP) services can benefit from informal opportunities to talk about their voice hearing experiences. However, they can be reluctant to engage with these conversations. Little is known about the experiences of EIP practitioners as they try to engage service users in conversations about their voices. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: Despite EIP Services specializing in the treatment of the symptoms of psychosis such as voice hearing, practitioners can still be reluctant to initiate and continue informal conversations about voices. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: EIP practitioners may benefit from the introduction of interview guides and brief interventions to assist them with the initiation and continuation of conversations about voices. ABSTRACT: Introduction Hearing voices is a common and distressing symptom of first-episode psychosis. Formal and informal conversations about voices are helpful, but service users within Early Intervention in Psychosis (EIP) Services can be reluctant to discuss their voice hearing experiences. There is currently no literature that explores the experiences of EIP practitioners as they try to facilitate conversations about distressing voices. Aim/Question A qualitative methodology was used to investigate how EIP practitioners work with service users who hear voices. Ten practitioners were interviewed, and interviews were analysed using template analysis. Results Two themes that offer novel insights are presented: "starting a conversation about voices" and "continuing the conversation about voices." Discussion Starting and continuing a conversation about voices was considered important but not all practitioners were confident in this respect. The initiation and continuation of these conversations may need to be systematically supported. Implications for practice To support the initiation of informal conversations, a standardized interview guide for voice hearing could be introduced and systematically utilized. The continuation of these conversations could be supported by practitioners being given the opportunity to receive training in and the opportunity to deliver brief symptom-specific therapies for distressing voices.

Exploring the Benefits of Virtual Reality-Assisted Therapy Following Cognitive-Behavioral Therapy for Auditory Hallucinations in Patients with Treatment-Resistant Schizophrenia: A Proof of Concept

BACKGROUND

Combining cognitive behavioral therapy (CBT) for psychosis with another psychosocial intervention comprising virtual reality (VR)-assisted therapy (VRT) may improve targeted outcomes in treatment-resistant schizophrenia patients.

METHODS

Ten participants having followed CBT were part of our comparative clinical trial comparing VRT to CBT and were selected at the end of the study as they desired to continue to achieve improvements with VRT (CBT + VRT). Clinical assessments were administered before/after treatments and at follow-ups. Changes in outcomes were examined using linear mixed-effects models. To gain a more in depth understanding on CBT + VRT, therapists' notes, and open interviews on a sub-group of patients were qualitatively analyzed.

RESULTS

Findings showed that the sequence of both interventions was appreciated by all patients. Several significant improvements were found throughout time points on auditory verbal hallucinations, beliefs about voices, depressive symptoms, symptoms of schizophrenia and quality of life. Although most of these improvements were in similar range to those observed in our comparative trial, effects of CBT + VRT on depressive symptoms and symptoms of schizophrenia were larger than those found for either intervention alone.

CONCLUSION

This proof of concept is the first to merge gold-standard CBT with VRT for treatment refractory voices and to suggest a certain synergistic effect.