Group mindfulness-based therapy for persecutory delusions: A pilot randomised controlled trial

Mindfulness for psychosis: Current evidence, unanswered questions and future directions

PURPOSE & METHOD

Mindfulness for psychosis research has grown exponentially over the last 15 years. In this paper, a brief overview of mindfulness for psychosis is provided followed by a summary of the findings from a systematic search of meta-analyses dated up to February 2023. Current issues in the field are discussed and a future research agenda is presented.

RESULTS

Ten meta-analyses published between 2013 and 2023 were identified. Reported effect sizes on reductions in psychotic symptoms ranged from small-large across reviews. Four key issues in the field are identified and discussed - (1) is mindfulness for psychosis safe? (2) is home practice essential and related to clinical outcomes? (3) what is the impact of mindfulness practice versus metacognitive insights derived from practice, on clinical outcomes? (4) do the benefits translate into routine clinical practice?

CONCLUSIONS

Mindfulness is a promising intervention that is emerging as being both safe and effective for people with psychosis. Future research focused on evaluating mechanisms of change and implementation in routine clinical practice should be prioritised.

Mindfulness-based interventions for patients with schizophrenia spectrum disorders: A systematic review of the literature

BACKGROUND

Mindfulness-based interventions (MBIs) have emerged as secular practices, including elements of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). While MBIs have been widely adopted for physical and mental illness, only a few available programs are explicitly adapted for psychosis. However, previous reviews have reported the vital heterogeneity regarding treatment program structure. Therefore, this review aims to compare the structure of different mindfulness protocols applied to patients with schizophrenia spectrum disorder (SSD).

METHODS

A systematic search was conducted up to March 2023 in PubMed, Embase and PsycInfo. Following our protocol (CRD 42023253356), we followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist.

RESULTS

We included 22 randomized controlled trials (RCTs) involving 1500 patients SSD. All programs varied in structure, session components, duration, and instructor experience. While MBSR-like programs focused on stress reactivity, MBCT-like programs addressed primary symptoms of psychosis and relapse prevention. Despite the heterogeneity of programs, some common mechanisms emerged, including attention training, emotion and stress regulation, decentering, self-compassion, and cognitive restructuring.

CONCLUSIONS

The critical heterogeneity found limits the interpretation of results. However, most recent trials present fewer risks of bias and more homogenous programs. Findings suggested potential benefits, such as reduced negative symptoms, increased well-being, and decreased hospitalization rates. For future studies, authors should align on more congruent MBIs programs for patients with SSD. Further research is needed to identify optimal mindfulness teaching approaches for patients with psychosis and investigate specific mechanisms of action, relevant processes, and optimal doses in varying settings.

Experimental studies of paranoid thinking in clinical and nonclinical populations: a systematic review and meta-analysis

Paranoia is common in clinical and nonclinical populations, consistent with continuum models of psychosis. A number of experimental studies have been conducted that attempt to induce, manipulate or measure paranoid thinking in both clinical and nonclinical populations, which is important to understand causal mechanisms and advance psychological interventions. Our aim was to conduct a systematic review and meta-analysis of experimental studies (non-sleep, non-drug paradigms) on psychometrically assessed paranoia in clinical and nonclinical populations. The review was conducted using PRISMA guidelines. Six databases (PsycINFO, PubMed, EMBASE, Web of Science, Medline and AMED) were searched for peer-reviewed experimental studies using within and between-subject designs to investigate paranoia in clinical and nonclinical populations. Effect sizes for each study were calculated using Hedge's g and were integrated using a random effect meta-analysis model. Thirty studies were included in the review (total n = 3898), which used 13 experimental paradigms to induce paranoia; 10 studies set out to explicitly induce paranoia, and 20 studies induced a range of other states. Effect sizes for individual studies ranged from 0.03 to 1.55. Meta-analysis found a significant summary effect of 0.51 [95% confidence interval 0.37-0.66, p < 0.001], indicating a medium effect of experimental paradigms on paranoia. Paranoia can be induced and investigated using a wide range of experimental paradigms, which can inform decision-making about which paradigms to use in future studies, and is consistent with cognitive, continuum and evolutionary models of paranoia.

Schizophrenia and Increased Distrust-Based Competitiveness in Interpersonal Interactions: A Serial Process Model

BACKGROUND AND HYPOTHESIS

Game theory paradigms, such as the Prisoner's Dilemma Game (PDG), have been used to study nonclinical paranoia, though research using clinical populations has been scarce. We test our novel theoretical model that schizophrenia leads to competitiveness in interpersonal interactions, and that this link is serially mediated by trait paranoia, state paranoia, and distrust.

STUDY DESIGN

In this quasi-experimental study, individuals with schizophrenia spectrum diagnoses with current persecutory delusions (n = 46) and a nonclinical control group (n = 43) played the PDG, and completed measures of trait paranoia, state paranoia, and distrust.

STUDY RESULTS

Individuals with schizophrenia competed more in the PDG than the control group. Supporting our theoretical model, all direct effects were significant: schizophrenia was associated with higher trait paranoia (H1); trait paranoia predicted state paranoia in the PDG (H2); state paranoia in the PDG predicted distrust of the opponent in the PDG (H3); and distrust predicted competition in the PDG (H4). The hypothesized indirect effect of schizophrenia on competition in the PDG via trait paranoia, state paranoia, and distrust was supported in a serial mediation model (H5).

CONCLUSIONS

The findings make clear theoretical and methodological contributions. We provide the first evidence for a theoretical process model by which schizophrenia leads to competitiveness in interpersonal interactions via trait paranoia, state paranoia, and distrust. Game theory paradigms, and the PDG in particular, are important for advancing theory and research on paranoia as it occurs in both clinical and nonclinical populations.

The Pandemic Paranoia Scale (PPS): factor structure and measurement invariance across languages

BACKGROUND

Globally, the corona virus disease 2019 (COVID-19) pandemic has created an interpersonally threatening context within which other people have become a source of possible threat. This study reports on the development and validation of a self-report measure of pandemic paranoia; that is, heightened levels of suspicion and mistrust towards others due to the COVID-19 pandemic.

METHODS

An international consortium developed an initial set of 28 items for the Pandemic Paranoia Scale (PPS), which were completed by participants from the UK (n = 512), USA (n = 535), Germany (n = 516), Hong Kong (n = 454) and Australia (n = 502) using stratified quota sampling (for age, sex and educational attainment) through Qualtrics and translated for Germany and Hong Kong.

RESULTS

Exploratory factor analysis in the UK sample suggested a 25-item, three-factor solution (persecutory threat; paranoid conspiracy and interpersonal mistrust). Confirmatory factor analysis (CFA) on the remaining combined sample showed sufficient model fit in this independent set of data. Measurement invariance analyses suggested configural and metric invariance, but no scalar invariance across cultures/languages. A second-order factor CFA on the whole sample indicated that the three factors showed large loadings on a common second-order pandemic paranoia factor. Analyses also supported the test-retest reliability and internal and convergent validity.

CONCLUSION

The PPS offers an internationally validated and reliable method for assessing paranoia in the context of a pandemic. The PPS has the potential to enhance our understanding of the impact of the pandemic, the nature of paranoia and to assist in identifying and supporting people affected by pandemic-specific paranoia.

Self-Structure in Persecutory Delusions

There is currently limited research examining self-structure in clinical groups and no current data on the extent to which self-structure is amendable to change following psychological therapy. We address this important gap by examining self-structure in individuals with persecutory delusions using the card sort task, an established paradigm measuring key self-structure indices, including the degree to which self-structure is compartmentalized (characterized by primarily positive or negative attributes, as opposed to a mix of both), and the proportion and importance of negative attributes. In Study 1, individuals with a schizophrenia spectrum diagnosis with current persecutory delusions (clinical group, n = 27) and a healthy control group (n = 47) were compared on self-structure indices. In Study 2 (n = 27), the clinical group also completed the card sort task before and after randomization to either a 12-week mindfulness-based psychological therapy or treatment-as-usual control. In Study 1, self-structure differed significantly between the clinical and control groups. The clinical group had a greater proportion of negative attributes, assigned more importance to negative self-aspects, and had more compartmentalized self-structures compared with controls. In Study 2 there were no associations between delusion severity and self-structure. Large effect sizes for reductions in compartmentalization and proportion of negative attributes across self-aspects were found following mindfulness therapy. The findings highlight key differences in self-structure between individuals with persecutory delusions and healthy controls, and suggest that it might be possible to change self-structure following psychological therapy. These data support the central role of the self in theoretical models of paranoid thinking.

Engagement, clinical outcomes and therapeutic process in online mindfulness for psychosis groups delivered in routine care

OBJECTIVES

There is growing evidence for the benefit of mindfulness-based interventions (MBI) for people with psychosis. However, research is yet to evaluate the clinical benefit of delivering MBI groups online. We examine engagement, clinical outcomes, participant experience and therapeutic process of delivering therapy groups online in routine clinical practice.

METHODS

The study used an uncontrolled pre-post design to examine engagement, therapeutic benefits (depression, anxiety, beliefs about voices) and group process in a 12-session online mindfulness group for individuals with a schizophrenia spectrum diagnosis with current distressing voices. Qualitative data on participant experience of online group therapy were analysed using Thematic Analysis.

RESULTS

17/21 participants (81%) completed one of three consecutively run therapy groups. For completers there were significant reductions pre-post in depression, anxiety, beliefs about voices and voice-related negative affect, with medium to large effect sizes. There were individuals showing reliable and clinically significant improvements in each clinical outcome, and none showing reliable or clinically significant deterioriation. Participants' rankings of the importance of different group therapeutic factors were very similar to those observed in face-to-face mindfulness for psychosis groups. Qualitative analysis of participant feedback identified three themes: 'experience of online delivery', 'therapeutic benefits' and 'feeling connected to people in the group'.

CONCLUSIONS

Findings in relation to therapy engagement, clinical benefits, participant experience and group process offer encouragement that online delivery of mindfulness for psychosis groups may be a useful addition to mental health services for people with distressing voices.

Home practice in mindfulness-based interventions for psychosis groups: a systematic review and qualitative study

BACKGROUND

Regular home practice is considered a core component of mindfulness groups and may be associated with better treatment outcomes. This study aimed to (1) review the existing evidence on how much home practice people do in mindfulness-based interventions for psychosis groups, and (2) explore participants' experiences of the barriers and facilitators to completing home practice in a mindfulness for psychosis group using a qualitative study.

METHODS

In study 1, we conducted a systematic review of mindfulness-based interventions for psychosis studies and extracted data on home practice rates. In study 2, we conducted semi-structured interviews with people who had completed a mindfulness for psychosis group (N = 5) as part of their routine community care, specifically focusing on experiences of home practice.

RESULTS

Out of 43 studies included in the systematic review, only 5 reported any data on amount of home practice, and none examined the relationship between completion of home practice and treatment outcomes. In the qualitative study, participants described home practice as being difficult but important. Arising themes were similar to findings from previous (non-psychosis) studies suggesting that generic challenges are common, rather than being specific to psychosis.

CONCLUSIONS

We recommend that future mindfulness-based interventions for psychosis studies record data on home practice rates, in order to investigate any association between home practice and treatment outcome. Our qualitative findings suggest home practice can be a valued part of mindfulness for psychosis group, and a normalising approach could be taken when and if participants encounter common challenges.

Are they out to get me? Individual differences in nonclinical paranoia as a function of narcissism and defensive self-protection

OBJECTIVE

Three studies tested a novel model of the narcissism-paranoia link, whereby narcissism (primarily its socially maladaptive facets) is associated with paranoia via over-use of defensive self-protection and/or under-use of self-affirmation.

METHODS

In Study 1, 245 online volunteers (87% female; M_AGE  = 20.92; 44% White-British) completed trait measures of narcissism, self-enhancement/protection strategies and paranoia. In Study 2, 116 students (82% female; M_AGE  = 20.23; 70% White-British) completed baseline measures, then reported state reactions and paranoia following two difficult and two pleasant interpersonal events after 3-10 days. In Study 3, 517 online volunteers (64% female; M_AGE  = 22.76; 77% White/Caucasian) completed baseline measures, experienced a standardized social exclusion (vs. neutral) manipulation (Cyberball), then reported state reactions and paranoia.

RESULTS

In Study 1, narcissism was associated with higher paranoia via defensiveness. In Study 2, this was replicated in difficult but not pleasant events, and was driven by the Entitlement/Exploitativeness facet of narcissism. In Study 3, narcissistic rivalry and vulnerable narcissism, but not admiration, were associated with Cyberball-related paranoia via general defensiveness and denigration of others.

CONCLUSIONS

Individuals high in narcissism-especially its socially maladaptive facets-who over-rely on defensive self-protection strategies in response to threat, are particularly vulnerable to paranoia. Findings help to understand individual differences in paranoia.

Recommendations for monitoring and reporting harm in mindfulness for psychosis research

There is increasing interest in potential harmful effects of mindfulness-based interventions. In relation to psychosis, inconsistency and shortcomings in how harm is monitored and reported are holding back our understanding. We offer eight recommendations to help build a firmer evidence base on potential harm in mindfulness for psychosis.

A randomised trial comparing a brief online delivery of mindfulness-plus-values versus values only for symptoms of depression: Does baseline severity matter?

BACKGROUND

Acceptance/mindfulness-based interventions often focus on (a) developing dispositional mindfulness and (b) pursuing personally meaningful and valued activities. Acceptance/mindfulness-based interventions can reduce depression, but little is known about the combined effects of components or the influence of baseline variables on outcomes. This study tested whether practicing a brief (10-min) mindfulness meditation over a 2-week period followed by a single values session (mindfulness+values) was more effective than values alone (values only) in reducing symptoms of depression. The study was delivered online and modules were fully self-help (i.e., no therapist contact).

METHODS

206 participants (M_age=23.4 years, SD=6.53) with elevated depression scores (DASS-depression ≥ 10) were randomised to: mindfulness+values condition or a 2-week wait period followed by the values session (i.e., values only condition). Symptoms of depression were assessed at baseline, after the 2-week mindfulness practice/wait period, and 1-week following the values session.

RESULTS

Reductions in depression and recovery rates were significantly greater following mindfulness+values than values only. Baseline severity affected outcomes: mindfulness+values was significantly more beneficial than values only for individuals with high baseline levels of depression. Outcomes did not differ for those with low levels of depression. Rates of deterioration were higher than expected for values only participants.

LIMITATIONS

Conclusions are preliminary and tentative due to no follow-up period and a small sample. Drop-out was high (50%) and findings cannot be assumed to generalise to treatment seeking or more diverse samples.

CONCLUSIONS

Tentatively, results suggest mindfulness+values can significantly reduce depression, especially for individuals with higher baseline depression.