Trauma therapies for psychosis: A state-of-the-art review

Using Virtual Reality Social Environments to Promote Outcomes' Generalization of AVATAR Therapy for Distressing Voices: A Case Study

AVATAR therapy (AT) works by facilitating a 'face-to-face' dialog between the person and a digital representation (avatar) of their persecutory voice. Although there is cumulative evidence of this way of working with voices, enhancing the therapeutic focus on improved confidence and a sense of control of the voices in social situations represents a promising way to boost the generalization of therapy gains into social contexts. This paper presents a descriptive clinical case example of AVATAR_VRSocial therapy, a new augmented version of AT incorporating immersive Virtual Reality to help the person deal better with their voices in daily situations. "Laura" is a woman who was hearing a very distressing, threatening voice. She felt anxious and distressed when anticipating hearing it and would engage in safety-seeking behaviors to prevent hearing the voice. Laura was supported to stand up to her avatar and regain power over it by using assertive responses, both in active avatar dialog and when exposed to the avatar voice in VR scenarios, which turned into reduced distress when hearing the voice in her everyday life. Laura's dialog with her avatar evolved into a more explicit exploration of the meaning and the purpose of the voice in relation to previous trauma and personal relationships. The additional work in VR appeared to facilitate exposure to social situations while hearing the distressing voice, without performing seeking-safety behaviors, and to allow for practicing strategies to reduce the voice's interference, which evolved from the dialogic sessions with the personalized avatar.

The effect of trauma-focused therapy on voice-hearing: An experience sampling study

Trauma and post-traumatic stress are involved in the aetiology and maintenance of voice-hearing. It has been proposed that trauma-focused therapy (TFT) might affect voice-hearing, but previous studies are limited and remain undecided.

OBJECTIVES

We aimed to investigate the effect of TFT on voice-hearing in people with PTSD and psychosis using experience sampling method (ESM). A secondary aim was to explore how changes in voice-hearing are related to changes in PTSD.

DESIGN

This is an adjunct longitudinal ESM study of a sub-group of participants (N = 39) from a randomised controlled trial that compared TFT to a waiting-list control group.

METHODS

Voice-hearing participants filled in 10 daily voice-hearing-related questionnaires for six consecutive days at baseline and post-treatment at pseudo-random times during the day. PTSD symptom severity was assessed at baseline and post-treatment. Multilevel linear regression was used to test the effect of TFT on voice-hearing and to analyse the relationship between changes in voice-hearing and changes in PTSD.

RESULTS

The intention-to-treat analysis showed a significant interaction effect between time and treatment condition (p < .00001) with a small effect size (dppc2 = -0.27), indicating a larger decrease in voice-hearing in the TFT group than in the waiting-list control group. Also, a significant association was observed between changes in PTSD symptoms and changes in voice-hearing (p < .00001).

CONCLUSIONS

Our findings tentatively suggest that, even when voices are not targeted directly, TFT for PTSD can alleviate distressing voices.

A temporal network analysis of complex post-traumatic stress disorder and psychosis symptoms

BACKGROUND

Symptoms of complex post-traumatic stress disorder (cPTSD) may play a role in the maintenance of psychotic symptoms. Network analyses have shown interrelationships between post-traumatic sequelae and psychosis, but the temporal dynamics of these relationships in people with psychosis and a history of trauma remain unclear. We aimed to explore, using network analysis, the temporal order of relationships between symptoms of cPTSD (i.e. core PTSD and disturbances of self-organization [DSOs]) and psychosis in the flow of daily life.

METHODS

Participants with psychosis and comorbid PTSD (N = 153) completed an experience-sampling study involving multiple daily assessments of psychosis (paranoia, voices, and visions), core PTSD (trauma-related intrusions, avoidance, hyperarousal), and DSOs (emotional dysregulation, interpersonal difficulties, negative self-concept) over six consecutive days. Multilevel vector autoregressive modeling was used to estimate three complementary networks representing different timescales.

RESULTS

Our between-subjects network suggested that, on average over the testing period, most cPTSD symptoms related to at least one positive psychotic symptom. Many average relationships persist in the contemporaneous network, indicating symptoms of cPTSD and psychosis co-occur, especially paranoia with hyperarousal and negative self-concept. The temporal network suggested that paranoia reciprocally predicted, and was predicted by, hyperarousal, negative self-concept, and emotional dysregulation from moment to moment. cPTSD did not directly relate to voices in the temporal network.

CONCLUSIONS

cPTSD and positive psychosis symptoms mutually maintain each other in trauma-exposed people with psychosis via the maintenance of current threat, consistent with cognitive models of PTSD. Current threat, therefore, represents a valuable treatment target in phased-based trauma-focused psychosis interventions.

Co-designing a low-intensity psychological therapy for fear of recurrence in psychosis using translational learning from fear of recurrence in oncology: protocol for intervention development for future testing in a feasibility study

INTRODUCTION

Fear of recurrence is a transdiagnostic problem experienced by people with psychosis, which is associated with anxiety, depression and risk of future relapse events. Despite this, there is a lack of available psychological interventions for fear of recurrence, and psychological therapies for schizophrenia are often poorly implemented in general. However, low-intensity psychological therapy is available for people who experience fear of recurrence in the context of cancer, which means there is an opportunity to learn what has worked in a well-implemented psychological therapy to see if any learning can be adapted for schizophrenia care. This article describes the design, methods and expected data collection of development, acceptab i lity, feasibility, a n d preliminary outcome signals for a copro d uced low-intensity psycholo g ical intervention targeting fear o f relapse in people with schizophrenia (INDIGO), which aims to develop an acceptable psychological intervention for fear of recurrence.

METHODS AND ANALYSIS

INDIGO will use a mixed-methods approach to co-design and deliver a model and treatment pathway for a psychological intervention for people diagnosed with schizophrenia who experience fear of recurrence. The study will consist of four stages. First, in-depth interviews with mental health staff and people diagnosed with schizophrenia (with a further social network mapping task for patient participants only) to develop the intervention. Second, in-depth interviews with people who have accessed the Glasgow Fear of Recurrence service and oncology staff will be conducted to inform further development of the intervention. Third, co-design workshops will be held with people diagnosed with schizophrenia and mental health staff to co-design intervention content and the treatment pathway. Finally, people diagnosed with schizophrenia will be presented with an intervention prototype and invited to complete 'think-aloud' interviews to gather further feedback so adaptations can be implemented.

ETHICS AND DISSEMINATION

The INDIGO study received ethical approval from East Midlands-Nottingham 2 Research Ethics Committee (24/EM/0124). The study received independent peer review prior to funding. This co-design study is expected to lead to a future feasibility study and, if indicated, a randomised controlled trial.

Trauma and social pathways to psychosis: Examining the role of attachment, social rank and dissociation in a clinical sample

OBJECTIVES

The trauma and social pathways model of psychosis proposes interactions between trauma, attachment, social rank and dissociation in pathways to psychosis, though this model has yet to be empirically investigated. The primary aim of this study was to examine the overall predictive value of the trauma and social pathways model using regression analysis. A secondary aim was to delineate hypothesized pathways between trauma and positive symptoms of psychosis using serial mediation analysis.

METHOD

This was a cross-sectional study of people attending mental health services for a psychosis-related diagnosis (N = 71). Measures of trauma, positive symptoms of psychosis, attachment, social comparison and dissociation were completed.

RESULTS

A model of recurrent trauma, insecure attachment, social rank and dissociation predicted 23.2% of the variance in positive symptoms of psychosis. Recurrent trauma, attachment and dissociation contributed significantly to the model, while social rank did not. Further, serial mediation analysis indicated that the sequence of disorganized attachment and dissociation fully mediated the relationship between recurrent trauma and positive symptoms.

CONCLUSIONS

Results provide preliminary support for the trauma and social pathways model of psychosis, specifically as it relates to recurrent trauma, insecure attachment and dissociation. Results did not support the social rank component of this model, however. These findings provide clear targets for the development of next-wave psychological interventions that focus on trauma-related variables in psychosis. Future studies should replicate these findings with a larger clinical sample, and consider a measure of shame to further elucidate social processes in pathways to psychosis.

Feasibility of trauma-focused cognitive behavioural therapy for patients with PTSD and psychosis

Studies have shown a high prevalence of trauma and PTSD among patients with severe mental illness, but relatively few studies have examined the outcomes of PTSD treatment for this patient group. The aim of this case-series was to assess the feasibility of a Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) intervention for PTSD in people with psychosis. The study examined the possibilities and obstacles when treating this population within clinical settings. Patients were selected from four community mental health centers and were screened for traumatic experiences and symptoms of PTSD. A small group of eligible participants (n=7) received manualized TF-CBT adapted for patients with psychosis. Experienced therapists received training and supervision in the intervention. Symptoms of PTSD and psychosis were assessed at baseline and post-treatment along with quality of life, level of functioning, alliance, life events, engagement, suicidal ideation and adverse events. Treatment fidelity and the different combinations of treatment modules were monitored in regard to implementation. Three cases were selected as illustrative of the different treatment courses when implementing the TF-CBT intervention within this population. Detailed case descriptions were based on quantitative ratings and the therapists' experiences with the therapy. Results from the case series highlighted issues regarding toleration of treatment, large variation in psychopathology and the task of matching treatment needs with appropriate therapeutic techniques. The complexity of the patient group may affect treatment and clinical research studies. Lessons learned from this case series can contribute to the future development implementation and evaluation of trauma treatment for patients with psychosis.

Hallucinations across sensory domains in people with post-traumatic stress disorder and psychosis

Auditory hallucinations are common in people with histories of adversity, possibly indicating a causal relationship. However, hallucinations occur in multiple sensory modalities and the relationship between trauma and hallucinations in other sensory domains is less explored. We examined the occurrence of hallucinatory experiences in different sensory modalities in people with psychosis who also met criteria for Post-Traumatic Stress Disorder (n = 67). Particular attention was paid to the number of modalities reported and whether the experiences were linked to the person's adversity. This linkage was explored in two ways. First, it was predicted that those people reporting more trauma experiences and symptoms of PTSD would report a greater number of hallucination modalities. Second, we examined if there was content or thematic linkage between the trauma and the hallucinatory experiences. There were high levels of reported auditory (89.6 %), visual (58.2 %) and tactile (46.3 %) hallucinations. Hallucinations in two or more modalities were the norm (71.6 % of the participants). The number of hallucination modalities was moderately associated with a greater number of past traumas and PTSD symptoms. There was a high degree of content and thematic linkage between the trauma and the hallucinations. The linkage between trauma and auditory hallucinations extends to other sensory domains.

The association of adverse childhood experiences with long-term outcomes of psychosis: a 21-year prospective cohort study after a first episode of psychosis

BACKGROUND

Evidence suggests a possible relationship between exposure to childhood adversity (CA) and functional impairment in psychosis. However, the impact of CA on long-term outcomes of psychotic disorders remains poorly understood.

METHODS

Two hundred and forty-three patients were assessed at their first episode of psychosis for CA and re-assessed after a mean of 21 years of follow-up for several outcome domains, including symptoms, functioning, quality of life, cognitive performance, neurological dysfunction, and comorbidity. The unique predictive ability of CA exposure for outcomes was examined using linear regression analysis controlling for relevant confounders, including socioeconomic status, family risk of schizophrenia, and obstetric complications.

RESULTS

There were 54% of the patients with a documented history of CA at mild or higher levels. CA experiences were more prevalent and severe in schizophrenia than in other psychotic disorders (p < 0.001). Large to very large effect sizes were observed for CA predicting most role functioning variables and negative symptoms (ΔR2 between 0.105 and 0.181). Moderate effect sizes were observed for positive symptoms, personal functioning, impaired social cognition, impaired immediate verbal learning, poor global cognition, internalized stigma, poor personal recovery, and drug abuse severity (ΔR2 between 0.040 and 0.066). A dose-response relationship was observed between levels of CA and severity of outcome domains.

CONCLUSION

Our results suggest a strong and widespread link between early adversity exposure and outcomes of psychotic disorders. Awareness of the serious long-term consequences of CA should encourage better identification of those at risk and the development of effective interventions.

Childhood trauma and treatment resistance in first-episode psychosis: Investigating the role of premorbid adjustment and duration of untreated psychosis

BACKGROUND

Early identification of treatment non-response in first-episode psychosis (FEP) is essential to outcome. Despite indications that exposure to childhood trauma (CT) can have adverse effects on illness severity, its impact on treatment non-response and the interplay with other pre-treatment characteristics is sparsely investigated. We use a lack of clinical recovery as an early indicator of treatment resistance to investigate the relationship between CT and treatment resistance status at one-year follow-up and the potential mediation of this effect by other pre-treatment characteristics.

METHODS

This prospective one-year follow-up study involved 141 participants recruited in their first year of treatment for a schizophrenia-spectrum disorder. We investigated clinical status, childhood trauma (CT), premorbid adjustment (PA), and duration of untreated psychosis (DUP) at baseline and clinical status at one-year follow-up. Ordinal regression analyses were conducted to investigate how PA and DUP affected the relationship between CT and one-year outcome in FEP.

RESULTS

45 % of the FEP sample reported moderate to severe CT, with significantly higher levels of CT in the early treatment resistant group compared to participants with full or partial early recovery. Ordinal regression analysis showed that CT was a significant predictor of being in a more severe outcome group (OR = 4.59). There was a partial mediation effect of PA and a full mediation effect of DUP on the effect of CT on outcome group membership.

DISCUSSION

Our findings indicate that reducing treatment delays may mitigate the adverse effects of CT on clinical outcomes and support the inclusion of broad trauma assessment in FEP services.

How Does Individual Psychotherapy Promote Recovery for Persons with Psychosis? A Systematic Review of Qualitative Studies to Understand the Patient's Experience

Psychotherapy for individuals with psychosis is an effective treatment that promotes recovery in various ways. While there is strong quantitative evidence across modalities, less is known from the patient's perspective. There are many varied forms of psychotherapy, and gaining the patient's perspective can improve understanding of salient elements of psychotherapy and increase engagement, ultimately improving recovery rates. The purpose of this review is to identify and integrate data from published studies of patient perspectives of psychotherapy for psychosis to understand essential elements across approaches, differences between approaches, and how psychotherapy impacts recovery. We aimed to understand further: what are the perceptions about individual psychotherapy from the perspective of individuals with psychosis? The current study was a systematic review using PRISMA guidelines of studies that included qualitative interviews with persons with experiences of psychosis who participated in psychotherapy. All three authors participated in the literature search using Pubmed, APA PsycInfo, and Psychiatry Online. We identified N = 33 studies. Studies included cognitive therapies, acceptance and mindfulness approaches, trauma therapies, metacognitive therapy, and music therapy. All studies reported participants' perceived benefit with the therapeutic relationship as especially salient. Participants described diverse aspects of objective (e.g., symptoms, functioning) and subjective (e.g., self-experience or quality of life) recovery improvements, with perceived mechanisms of change, and with music therapy having some unique benefits. Participants also reported challenges and suggestions for improvement. Study findings highlight the salient aspects of psychotherapy identified by patients that may help therapists to individualize and improve approaches to psychotherapy when working with individuals experiencing psychosis. Overall, findings support the potential for integrative psychotherapy approaches for maximal treatment personalization.