Neutralizing Antibodies Impair the Oncolytic Efficacy of Reovirus but Permit Effective Combination with T cell-Based Immunotherapies

Reovirus type 3 Dearing (Reo), manufactured for clinical application as pelareorep, is an attractive anticancer agent under evaluation in multiple phase 2 clinical trials for the treatment of solid tumors. It elicits its anticancer efficacy by inducing both oncolysis and intratumoral T-cell influx. Because most people have been preexposed to Reo, neutralizing antibodies (NAb) are prevalent in patients with cancer and might present a barrier to effective Reo therapy. Here, we tested serum of patients with cancer and healthy controls (n = 100) and confirmed that Reo NAbs are present in >80% of individuals. To investigate the effect of NAbs on both the oncolytic and the immunostimulatory efficacy of Reo, we established an experimental mouse model with Reo preexposure. The presence of preexposure-induced NAbs reduced Reo tumor infection and prevented Reo-mediated control of tumor growth after intratumoral Reo administration. In B cell-deficient mice, the lack of NAbs provided enhanced tumor growth control after Reo monotherapy, indicating that NAbs limit the oncolytic capacity of Reo. In immunocompetent mice, intratumoral T-cell influx was not affected by the presence of preexposure-induced NAbs and consequently, combinatorial immunotherapy strategies comprising Reo and T-cell engagers or checkpoint inhibitors remained effective in these settings, also after a clinically applied regimen of multiple intravenous pelareorep administrations. Altogether, our data indicate that NAbs hamper the oncolytic efficacy of Reo, but not its immunotherapeutic capacity. Given the high prevalence of seropositivity for Reo in patients with cancer, our data strongly advocate for the application of Reo as part of T cell-based immunotherapeutic strategies.

Preclinical evaluation of the gorilla-derived HAdV-B AdV-lumc007 oncolytic adenovirus 'GoraVir' for the treatment of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive malignancy which shows unparalleled therapeutic resistance due to its genetic and cellular heterogeneity, dense stromal tissue, and immune-suppressive tumour microenvironment. Oncolytic virotherapy has emerged as a new treatment modality which uses tumour-specific viruses to eliminate cancerous cells. Non-human primate adenoviruses of the human adenovirus B (HAdV-B) species have demonstrated considerable lytic potential in human cancer cells as well as limited preexisting neutralizing immunity in humans. Previously, we have generated a new oncolytic derivative of the gorilla-derived HAdV-B AdV-lumc007 named 'GoraVir'. Here, we show that GoraVir displays oncolytic efficacy in pancreatic cancer cells and pancreatic-cancer-associated fibroblasts. Moreover, it retains its lytic potential in monoculture and co-culture spheroids. In addition, we established the ubiquitously expressed complement receptor CD46 as the main entry receptor for GoraVir. Finally, a single intratumoural dose of GoraVir was shown to delay tumour growth in a BxPC-3 xenograft model at 10 days post-treatment. Collectively, these data demonstrate that the new gorilla-derived oncolytic adenovirus is a potent oncolytic vector candidate that targets both pancreatic cancer cells and tumour-adjacent stroma.

Socs1-knockout in skin-resident CD4+ T cells in a protracted contact-allergic reaction results in an autonomous skin inflammation with features of early-stage mycosis fungoides

Recent detailed genomic analysis of mycosis fungoides (MF) identified suppressor of cytokine signaling 1 (SOCS1), an inhibitor of JAK/STAT signaling, as one of the frequently deleted tumor suppressors in MF, and one-copy deletion of SOCS1 was confirmed in early-stage MF lesions. To better understand the functional role of SOCS1 in the genesis of MF, we used a genetically engineered mouse model emulating heterozygous SOCS1 loss in skin resident CD4+ T cells. In these mice an experimentally induced contact-allergic reaction was maintained for 20 weeks. Ten weeks after discontinuing contact-allergic challenges, only the skin with locally one-copy deletion of Socs1 in CD4+ T cells still showed high numbers of CD3+/CD4+ Socs1 k.o. cells in the dermis (p ＜ 0.0001) with prevalent Stat3 activation (p ＜0.001). And in one out of 9 mice, this had progressed to far more dramatic increases, including the thickened epidermis, and with an explosive growth of Socs1 k.o. T cells in circulation; indicative of cutaneous lymphoma. Hence, we show that Socs1 mono-allelic loss in CD4+ T cells locally in protractedly inflamed skin results in autonomous skin inflammation with features of early-stage MF.

Intertumoral Differences Dictate the Outcome of TGF-β Blockade on the Efficacy of Viro-Immunotherapy

The absence of T cells in the tumor microenvironment of solid tumors is a major barrier to cancer immunotherapy efficacy. Oncolytic viruses, including reovirus type 3 Dearing (Reo), can recruit CD8⁺ T cells to the tumor and thereby enhance the efficacy of immunotherapeutic strategies that depend on high T-cell density, such as CD3-bispecific antibody (bsAb) therapy. TGF-β signaling might represent another barrier to effective Reo&CD3-bsAb therapy due to its immunoinhibitory characteristics. Here, we investigated the effect of TGF-β blockade on the antitumor efficacy of Reo&CD3-bsAb therapy in the preclinical pancreatic KPC3 and colon MC38 tumor models, where TGF-β signaling is active. TGF-β blockade impaired tumor growth in both KPC3 and MC38 tumors. Furthermore, TGF-β blockade did not affect reovirus replication in both models and significantly enhanced the Reo-induced T-cell influx in MC38 colon tumors. Reo administration decreased TGF-β signaling in MC38 tumors but instead increased TGF-β activity in KPC3 tumors, resulting in the accumulation of α-smooth muscle actin (αSMA⁺) fibroblasts. In KPC3 tumors, TGF-β blockade antagonized the antitumor effect of Reo&CD3-bsAb therapy, even though T-cell influx and activity were not impaired. Moreover, genetic loss of TGF-β signaling in CD8⁺ T cells had no effect on therapeutic responses. In contrast, TGF-β blockade significantly improved therapeutic efficacy of Reo&CD3-bsAb in mice bearing MC38 colon tumors, resulting in a 100% complete response. Further understanding of the factors that determine this intertumor dichotomy is required before TGF-β inhibition can be exploited as part of viroimmunotherapeutic combination strategies to improve their clinical benefit.

Significance

Blockade of the pleiotropic molecule TGF-β can both improve and impair the efficacy of viro-immunotherapy, depending on the tumor model. While TGF-β blockade antagonized Reo&CD3-bsAb combination therapy in the KPC3 model for pancreatic cancer, it resulted in 100% complete responses in the MC38 colon model. Understanding factors underlying this contrast is required to guide therapeutic application.

Preinduced reovirus-specific T-cell immunity enhances the anticancer efficacy of reovirus therapy

BACKGROUND

Many solid tumors do not respond to immunotherapy due to their immunologically cold tumor microenvironment (TME). We and others found that oncolytic viruses (OVs), including reovirus type 3 Dearing, can enhance the efficacy of immunotherapy by recruiting CD8⁺ T cells to the TME. A significant part of the incoming CD8⁺ T cells is directed toward reovirus itself, which may be detrimental to the efficacy of OVs. However, here we aim to exploit these incoming virus-specific T cells as anticancer effector cells.

METHODS

We performed an in-depth characterization of the reovirus-induced T-cell response in immune-competent mice bearing pancreatic KPC3 tumors. The immunodominant CD8⁺ T-cell epitope of reovirus was identified using epitope prediction algorithms and peptide arrays, and the quantity and quality of reovirus-specific T cells after reovirus administration were assessed using high-dimensional flow cytometry. A synthetic long peptide (SLP)-based vaccination strategy was designed to enhance the intratumoral frequency of reovirus-specific CD8⁺ T cells.

RESULTS

Reovirus administration did not induce tumor-specific T cells but rather induced high frequencies of reovirus-specific CD8⁺ T cells directed to the immunodominant epitope. Priming of reovirus-specific T cells required a low-frequent population of cross-presenting dendritic cells which was absent in Batf3^-/- mice. While intratumoral and intravenous reovirus administration induced equal systemic frequencies of reovirus-specific T cells, reovirus-specific T cells were highly enriched in the TME exclusively after intratumoral administration. Here, they displayed characteristics of potent effector cells with high expression of KLRG1, suggesting they may be responsive against local reovirus-infected cells. To exploit these reovirus-specific T cells as anticancer effector cells, we designed an SLP-based vaccination strategy to induce a strong T-cell response before virotherapy. These high frequencies of circulating reovirus-specific T cells were reactivated on intratumoral reovirus administration and significantly delayed tumor growth.

CONCLUSIONS

These findings provide proof of concept that OV-specific T cells, despite not being tumor-specific, can be exploited as potent effector cells for anticancer treatment when primed before virotherapy. This is an attractive strategy for low-immunogenic tumors lacking tumor-specific T cells.

Preconditioning of the tumor microenvironment with oncolytic reovirus converts CD3-bispecific antibody treatment into effective immunotherapy

Background

T-cell-engaging CD3-bispecific antibodies (CD3-bsAbs) are promising modalities for cancer immunotherapy. Although this therapy has reached clinical practice for hematological malignancies, the absence of sufficient infiltrating T cells is a major barrier for efficacy in solid tumors. In this study, we exploited oncolytic reovirus as a strategy to enhance the efficacy of CD3-bsAbs in immune-silent solid tumors.

Methods

The mutant p53 and K-ras induced murine pancreatic cancer model KPC3 resembles human pancreatic ductal adenocarcinomas with a desmoplastic tumor microenvironment, low T-cell density and resistance to immunotherapy. Immune-competent KPC3 tumor-bearing mice were intratumorally injected with reovirus type 3 Dearing strain and the reovirus-induced changes in the tumor microenvironment and spleen were analyzed over time by NanoString analysis, quantitative RT-PCR and multicolor flow cytometry. The efficacy of reovirus in combination with systemically injected CD3-bsAbs was evaluated in immune-competent mice with established KPC3 or B16.F10 tumors, and in the close-to-patient human epidermal growth factor receptor 2 (HER2)⁺ breast cancer model BT474 engrafted in immunocompromised mice with human T cells as effector cells.

Results

Replication-competent reovirus induced an early interferon signature, followed by a strong influx of natural killer cells and CD8⁺ T cells, at the cost of FoxP3⁺ Tregs. Viral replication declined after 7 days and was associated with a systemic activation of lymphocytes and the emergence of intratumoral reovirus-specific CD8⁺ T cells. Although tumor-infiltrating T cells were mostly reovirus-specific and not tumor-specific, they served as non-exhausted effector cells for the subsequently systemically administered CD3-bsAbs. Combination treatment of reovirus and CD3-bsAbs led to the regression of large, established KPC3, B16.F10 and BT474 tumors. Reovirus as a preconditioning regimen performed significantly better than simultaneous or early administration of CD3-bsAbs. This combination treatment induced regressions of distant lesions that were not injected with reovirus, and systemic administration of both reovirus and CD3-bsAbs also led to tumor control. This suggests that this therapy might also be effective for metastatic disease.

Conclusions

Oncolytic reovirus administration represents an effective strategy to induce a local interferon response and strong T-cell influx, thereby sensitizing the tumor microenvironment for subsequent CD3-bsAb therapy. This combination therapy warrants further investigation in patients with non-inflamed solid tumors.

Dendritic cell vaccination and CD40-agonist combination therapy licenses T cell-dependent antitumor immunity in a pancreatic carcinoma murine model

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is notoriously resistant to treatment including checkpoint-blockade immunotherapy. We hypothesized that a bimodal treatment approach consisting of dendritic cell (DC) vaccination to prime tumor-specific T cells, and a strategy to reprogram the desmoplastic tumor microenvironment (TME) would be needed to break tolerance to these pancreatic cancers. As a proof-of-concept, we investigated the efficacy of combined DC vaccination with CD40-agonistic antibodies in a poorly immunogenic murine model of PDAC. Based on the rationale that mesothelioma and pancreatic cancer share a number of tumor associated antigens, the DCs were loaded with either pancreatic or mesothelioma tumor lysates.

METHODS

Immune-competent mice with subcutaneously or orthotopically growing KrasG12D/+;Trp53R172H/+;Pdx-1-Cre (KPC) PDAC tumors were vaccinated with syngeneic bone marrow-derived DCs loaded with either pancreatic cancer (KPC) or mesothelioma (AE17) lysate and consequently treated with FGK45 (CD40 agonist). Tumor progression was monitored and immune responses in TME and lymphoid organs were analyzed using multicolor flow cytometry and NanoString analyzes.

RESULTS

Mesothelioma-lysate loaded DCs generated cross-reactive tumor-antigen-specific T-cell responses to pancreatic cancer and induced delayed tumor outgrowth when provided as prophylactic vaccine. In established disease, combination with stimulating CD40 antibody was necessary to improve survival, while anti-CD40 alone was ineffective. Extensive analysis of the TME showed that anti-CD40 monotherapy did improve CD8 +T cell infiltration, but these essential effector cells displayed hallmarks of exhaustion, including PD-1, TIM-3 and NKG2A. Combination therapy induced a strong change in tumor transcriptome and mitigated the expression of inhibitory markers on CD8 +T cells.

CONCLUSION

These results demonstrate the potency of DC therapy in combination with CD40-stimulation for the treatment of pancreatic cancer and provide directions for near future clinical trials.

Mental Health Europe's “beyond the bio-medical paradigm task force” issues on ICD-10

Introduction

Recent developments in psychiatric diagnosis risk downgrading psychological and social aspects of personal recovery and marginalise the individual needs and aspirations of people, considered in their local context. The publication of the fifth edition of the Diagnostic and Statistical Manual for Mental Health Disorders (DSM-5) by the American Psychiatric Association (APA) prompted MHE to establish the Beyond the Biomedical Paradigm Task Force (BBPtf) to investigate, debate and report on these issues.

Objectives

Mental Health Europe (MHE) – along with others both within and outside mainstream psychiatry – has noted with concern the increasing dominance of a biological approach to mental health problems. We see a risk of diagnoses being misused when they become part of a complex managerial health system responding mainly to the economic and issues of safety or social control. This kind of misuse could breach the principles of the UN CRPD. MHE welcomes the role of the WHO in coordinating internationally appropriate classification systems. However, we want to ensure that systems based on biomedical, economic and managerial issues are balanced with systems based on knowledge of personal experiences, life stories and direct relationships, which have proven outcomes and which respect human rights and dignity.

Aims

This workshop will explore the complex philosophical issues associated with psychiatric diagnosis and, in particular, the ICD-10 revision process.

Disclosure of interest

I am President of the British Psychological Society and a member of both Mental Health Europe's “Beyond the Bio-Medical Paradigm Task Force” and the Council for Evidence Based Psychiatry. I am currently in receipt of funding from the National Institute for Health Research (NIHR) and the Economic and Social Research Council (ESRC), and I have previously received funding from a variety of sources.

The others authors have not supplied their declaration of competing interest.

Effect of targeting CD40 for DC vaccination in pancreatic adenocarcinoma

e15783

Background: Although immunotherapy yields striking results in various malignancies, results in pancreatic cancer have been disappointing. Both a highly immunosuppressive tumor microenvironment and a dense desmoplastic stroma have been found to prohibit proper T-cell infiltration in these tumors, thereby preventing immunotherapy efficacy. We hypothesize that a rational and translational multistep approach is needed to sensitize pancreatic cancer to immunotherapy. In an aggressive murine pancreatic ductal adenocarcinoma model, we assessed the effectiveness of dendritic cell (DC) vaccination in combination with αCD40 treatment, as these treatments are known to induce effector T cells and degrade stroma, respectively. Methods: Immune competent C57BL/6 mice were inoculated subcutaneously with pancreatic tumor cells (KPC3). Mice with established tumors were vaccinated with tumor-loaded monocyte derived DCs and consequently treated with αCD40 agonistic antibodies. Tumor sizes were monitored over time. Immune responses were determined by flow cytometry of cells in peripheral blood, spleen and tumor. NanoString Technologies were applied on tumor samples. Results: A significant delay in tumor growth was found in the combination therapy arm compared to untreated mice and mice treated with DCs or αCD40 alone. Monotherapy had no effect on tumor growth. Survival of mice treated with the combination therapy was also improved compared to untreated mice or mice treated with monotherapy (P < 0.001). Interim blood analysis showed significant increases in frequencies of activated and proliferating T cells in treated animals and those cells also displayed an effector memory phenotype. This was more pronounced for CD4 T cells in mice treated with DCs while αCD40 therapy induced a confined response in CD8 T cells. Increased frequencies of tumor infiltrating lymphocytes were found in all treated mice compared to untreated mice. mRNA expression analysis indicated less exhausted phenotype of intratumoral lymphoid cells in mice treated with DCs and αCD40 compared to monotherapy DCs or αCD40. Conclusions: These results demonstrate the potency of this novel form of combination immunotherapy and reveals a mechanistic insight into the requirements of effective immunotherapy in pancreatic cancer.

Stigma: a linguistic analysis of the UK red-top tabloids press’ representation of schizophrenia

Aims:

Media representations of mental health problems may influence readers’ understanding of, and attitude towards, people who have received psychiatric diagnoses. Negative beliefs and attitudes may then lead to discriminatory behaviour, which is understood as stigma. This study explored the language used in popular national newspapers when writing about schizophrenia and considered how this may have contributed to the processes of stigmatisation towards people with this diagnosis.

Methods:

Using corpus linguistic methods, a sample of newspaper articles over a 24-month period that mentioned the word ‘schizophrenia’ was compared with a similar sample of articles about diabetes. This enabled a theory-driven exploration of linguistic characteristics to explore stigmatising messages, while supported by statistical tests (log-likelihood) to compare the data sets and identify words with a high relative frequency.

Results:

Analysis of the ‘schizophrenia’ data set identified that overtly stigmatising language (e.g. ‘schizo’) was relatively infrequent, but that there was frequent use of linguistic signatures of violence. Articles frequently used graphic language referring to acts of violence, descriptions of violent acts, implements used in violence, identity labels and exemplars of well-known individuals who had committed violent acts. The word ‘schizophrenic’ was used with a high frequency ( n = 108) and most commonly to name individuals who had committed acts of violence.

Discussion:

The study suggests that while the press has largely avoided the use of words that press guidance has steered them away from (e.g. ‘schizo’ and ‘psycho’), they still use a range of graphic language to present people with a diagnosis of schizophrenia as frighteningly ‘other’ and as prone to violence. This repetition of negative stereotypical messages may well contribute to the processes of stigmatisation many people who experience psychosis have to contend with.

Arming oncolytic reovirus with GM-CSF gene to enhance immunity

Oncolytic reovirus administration has been well tolerated by cancer patients in clinical trials. However, its anti-cancer efficacy as a monotherapy remains to be augmented. We and others have previously demonstrated the feasibility of producing replication-competent reoviruses expressing a heterologous transgene. Here, we describe the production of recombinant reoviruses expressing murine (mm) or human (hs) GM-CSF (rS1-mmGMCSF and rS1-hsGMCSF, respectively). The viruses could be propagated up to 10 passages while deletion mutants occurred only occasionally. In infected cell cultures, the secretion of GM-CSF protein (up to 481 ng/10⁶ cells per day) was demonstrated by ELISA. The secreted mmGM-CSF protein was functional in cell culture, as demonstrated by the capacity to stimulate the survival and proliferation of the GM-CSF-dependent dendritic cell (DC) line D1, and by its ability to generate DCs from murine bone marrow cells. Importantly, in a murine model of pancreatic cancer we found a systemic increase in DC and T-cell activation upon intratumoral administration of rS1-mmGMCSF. These data demonstrate that reoviruses expressing functional GM-CSF can be generated and have the potential to enhance anti-tumor immune responses. The GM-CSF reoviruses represent a promising new agent for use in oncolytic virotherapy strategies.

Symptom-specific self-referential cognitive processes in bipolar disorder: a longitudinal analysis

BACKGROUND

Although depression and mania are often assumed to be polar opposites, studies have shown that, in patients with bipolar disorder, they are weakly positively correlated and vary somewhat independently over time. Thus, when investigating relationships between specific psychological processes and specific symptoms (mania and depression), co-morbidity between the symptoms and changes over time must be taken into account. Method A total of 253 bipolar disorder patients were assessed every 24 weeks for 18 months using the Hamilton Rating Scale for Depression (HAMD), the Bech-Rafaelsen Mania Assessment Scale (MAS), the Rosenberg Self-Esteem Questionnaire (RSEQ), the Dysfunctional Attitudes Scale (DAS), the Internal, Personal and Situational Attributions Questionnaire (IPSAQ) and the Personal Qualities Questionnaire (PQQ). We calculated multilevel models using the xtreg module of Stata 9.1, with psychological and clinical measures nested within each participant.

RESULTS

Mania and depression were weakly, yet significantly, associated; each was related to distinct psychological processes. Cross-sectionally, self-esteem showed the most robust associations with depression and mania: depression was associated with low positive and high negative self-esteem, and mania with high positive self-esteem. Depression was significantly associated with most of the other self-referential measures, whereas mania was weakly associated only with the externalizing bias of the IPSAQ and the achievement scale of the DAS. Prospectively, low self-esteem predicted future depression.

CONCLUSIONS

The associations between different self-referential thinking processes and different phases of bipolar disorder, and the presence of the negative self-concept in both depression and mania, have implications for therapeutic management, and also for future directions of research.

Depressive and manic symptoms are not opposite poles in bipolar disorder

OBJECTIVE

This study of 236 individuals with bipolar disorders employed longitudinal analyses to determine whether the symptoms of mania and depression can be understood as one dimension (with depression and mania as opposites) or two relatively independent dimensions.

METHOD

Weekly severity ratings of manic and depression were assessed using the Longitudinal Interval Follow-up Evaluation-II for 72 weeks. The within-subjects correlation of manic and depressive severity was examined using random effects regression.

RESULTS

Contrary to the one-dimension model, mania and depression symptoms were not negatively related. Indeed, the correlations of mania with depressive symptoms were quite small.

CONCLUSION

The data suggest that depressive and manic symptoms are not opposite poles. Rather depressive and manic symptoms appear to fluctuate relatively independently within bipolar disorder.

Enhanced relapse prevention for bipolar disorder by community mental health teams: cluster feasibility randomised trial

BACKGROUND

Relapse prevention for bipolar disorder increases time to relapse but is not available in routine practice.

AIMS

To determine the feasibility and effectiveness of training community mental health teams (CMHTs) to deliver enhanced relapse prevention.

METHOD

In a cluster randomised controlled trial, CMHT workers were allocated to receive 12 h training in enhanced relapse prevention to offer to people with bipolar disorder or to continue giving treatment as usual. The primary outcome was time to relapse and the secondary outcome was functioning.

RESULTS

Twenty-three CMHTs and 96 service users took part. Compared with treatment as usual, enhanced relapse prevention increased median time to the next bipolar episode by 8.5 weeks (hazard ratio 0.79, 95% CI 0.45-1.38). Social and occupational functioning improved with the intervention (regression coefficient 0.68, 95% CI 0.05-1.32). The clustering effect was negligible but imprecise (intracluster correlation coefficient 0.0001, 95% CI 0.0000-0.5142).

CONCLUSIONS

Training care coordinators to offer enhanced relapse prevention for bipolar disorder may be a feasible effective treatment. Large-scale cluster trials are needed.

A transdiagnostic investigation of 'theory of mind' and 'jumping to conclusions' in patients with persecutory delusions

BACKGROUND

A tendency to make hasty decisions on probabilistic reasoning tasks and a difficulty attributing mental states to others are key cognitive features of persecutory delusions (PDs) in the context of schizophrenia. This study examines whether these same psychological anomalies characterize PDs when they present in the context of psychotic depression.

METHOD

Performance on measures of probabilistic reasoning and theory of mind (ToM) was examined in five subgroups differing in diagnostic category and current illness status.

RESULTS

The tendency to draw hasty decisions in probabilistic settings and poor ToM tested using story format feature in PDs irrespective of diagnosis. Furthermore, performance on the ToM story task correlated with the degree of distress caused by and preoccupation with the current PDs in the currently deluded groups. By contrast, performance on the non-verbal ToM task appears to be more sensitive to diagnosis, as patients with schizophrenia spectrum disorders perform worse on this task than those with depression irrespective of the presence of PDs.

CONCLUSIONS

The psychological anomalies associated with PDs examined here are transdiagnostic but different measures of ToM may be more or less sensitive to indices of severity of the PDs, diagnosis and trait- or state-related cognitive effects.

The evolution of insight, paranoia and depression during early schizophrenia

BACKGROUND

How insight, paranoia and depression evolve in relation to each other during and after the first episode of schizophrenia is poorly understood but of clinical importance.

METHOD

Serial assessments over 18 months were made using multiple instruments in a consecutive sample of 257 patients with first episode DSM-IV non-affective psychosis. Repeated measures of paranoia, insight, depression and self-esteem were analysed using structural equation modelling, to examine the direction of relationships over time after controlling for confounds.

RESULTS

Depression was predicted directly by greater insight, particularly at baseline, and by greater paranoia at every stage of follow-up. Neither relationship was mediated by self-esteem, although there was a weak association of lower self-esteem with greater depression and better insight. Paranoia was not strongly associated with insight. Duration of untreated psychosis and substance use at baseline predicted depression at 18 months.

CONCLUSIONS

In first-episode psychosis, good insight predicts depression. Subsequently, paranoia is the strongest predictor. Neither effect is mediated by low self-esteem. Effective treatment of positive symptoms is important in preventing and treating low mood in early schizophrenia.

Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: acute-phase outcomes

BACKGROUND

Cognitive-behavioural therapy (CBT) improves persistent psychotic symptoms.

AIMS

To test the effectiveness of added CBT in accelerating remission from acute psychotic symptoms in early schizophrenia.

METHOD

A 5-week CBT programme plus routine care was compared with supportive counselling plus routine care and routine care alone in a multi-centre trial randomising 315 people with DSM-IV schizophrenia and related disorders in their first (83%) or second acute admission. Outcome assessments were blinded.

RESULTS

Linear regression over 70 days showed predicted trends towards faster improvement in the CBT group. Uncorrected univariate comparisons showed significant benefits at 4 but not 6 weeks for CBT v. routine care alone on Positive and Negative Syndrome Scale total and positive sub-scale scores and delusion score and benefits v. supportive counselling for auditory hallucinations score.

CONCLUSIONS

CBT shows transient advantages over routine care alone or supportive counselling in speeding remission from acute symptoms in early schizophrenia.

Persecutory delusions: a review and theoretical integration

Persecutory (paranoid) delusions are a frequently observed clinical phenomenon. In recent years, an increasing volume of research has attempted to explain these types of beliefs in terms of psychological mechanisms. Theories have emphasized early experience, perceptual abnormalities, motivational factors, and information-processing deficits. In this article we review relevant findings, including our own studies of the role of causal attributions and theory of mind deficits. We propose a new integrative model that builds on this work. The core of the model is an account of the way that causal attributions influence self-representations, which in turn influence future attributions: the attribution--self-representation cycle. We argue that biases in this cycle cause negative events to be attributed to external agents and hence contribute to the building of a paranoid world view. These abnormalities are amenable to investigation by functional neuroimaging, and recent studies have implicated specific areas of neuroactivation. However, these findings do not necessarily suggest that paranoid delusions are entirely biological in origin, and there is evidence that adverse early experience may play a role in determining the development of a cognitive vulnerability to paranoid thinking.

Theory of mind, causal attribution and paranoia in Asperger syndrome

Theory of mind (ToM) deficits are central to autistic spectrum disorders, including Asperger syndrome. Research in psychotic disorders has developed a cognitive model of paranoid delusions involving abnormal causal attributions for negative events. Possible aetiologies of these include deficits in social reasoning, specifically ToM. The present study investigated this attributional model of paranoia in Asperger syndrome. Participants diagnosed with Asperger syndrome scored significantly higher on a measure of paranoia and lower on a measure of ToM, compared with the control group. They did not differ in self-concept and causal attributions, contrary to the attributional model of paranoia. A regression analysis highlighted private self-consciousness as the only predictor of paranoia. The theoretical and clinical implications of these findings are discussed.

Self-discrepancies and causal attributions: studies of hypothesized relationships

The self-concept and causal attributions are both centrally implicated in psychological disorders including depression and paranoia. In two investigations of the dynamic relationships between causal attributions and self-representations, non-patient participants completed questionnaires derived from Higgins' (1987) Self-Discrepancy Theory before and after completing a measure of causal attribution. In Study 1, consistent with cognitive models of depression, external attributions for negative events were associated with reductions in self-actual:self-ideal discrepancies. Study 2 revealed significantly different effects on self-discrepancies of three types of causal attributions. Internal attributions led to increased self-actual:self-ideal discrepancies as well as increased discrepancies between self-perceptions and the believed views of others about the self (self-actual:other-actual discrepancies). External situational attributions led to no changes in either self-actual:self-ideal or self-actual:other-actual discrepancies. External personal attributions led to no changes in self-actual:self-ideal discrepancies but increased self-actual:other-actual discrepancies. These findings point to the value of distinguishing between different kinds of external attributions. They show that self-representations and causal attributions are closely coupled cognitive domains. The results also suggest that paranoid ideation might be specifically associated with external-personal attributions for negative events.

A comparison of patients' and prescribers' beliefs about neuroleptic side-effects: prevalence, distress and causation

Neuroleptic side-effects adversely affect clinical outcome in schizophrenic patients. Clinicians therefore require an understanding of the impact of such side-effects. This study compared psychiatrists' estimates of the prevalence of neuroleptic side-effects and associated distress with schizophrenic patients' reports of side-effects and distress. Psychiatrists were asked to estimate the likelihood of informing patients about side-effects. Psychiatrists' estimates of prevalence but not of distress correlated significantly with patients' reports. Psychiatrists' avowed decisions to inform patients about side-effects were significantly correlated with their estimates of prevalence and distress, but not with patients' reported levels of distress. Patients were unlikely to attribute side-effects to neuroleptic medication. These results indicate that patients and psychiatrists share similar views about the prevalence and implications of neuroleptic side-effects. However, psychiatrists' apparent lack of understanding of which side-effects are most likely to cause distress to patients may adversely affect the therapeutic alliance between prescribers and consumers.

Causal attributions in paranoia and depression: internal, personal, and situational attributions for negative events

Causal attributions for positive and negative hypothetical social events made by paranoid patients, depressed patients, and nonpatient participants were examined via a novel measure of causal locus, the Internal, Personal and Situational Attributions Questionnaire. Depressed patients tended to attribute negative social events to internal (self-blaming) causes. Nonpatient participants and patients with delusions of persecution tended to avoid such self-blame. However, whereas nonpatient participants tended to choose situational or circumstantial external attributions, paranoid patients tended to choose external attributions that located blame in other individuals. These findings support R. P. Bentall, P. Kinderman, and S. Kaney's (1994) defensive attributional model of persecutory delusions, suggest some modifications to that model, and have implications for the understanding of the relationship between causal attributions and social and self-perception.

Causal attributions in paranoia and depression: internal, personal, and situational attributions for negative events

Causal attributions for positive and negative hypothetical social events made by paranoid patients, depressed patients, and nonpatient participants were examined via a novel measure of causal locus, the Internal, Personal and Situational Attributions Questionnaire. Depressed patients tended to attribute negative social events to internal (self-blaming) causes. Nonpatient participants and patients with delusions of persecution tended to avoid such self-blame. However, whereas nonpatient participants tended to choose situational or circumstantial external attributions, paranoid patients tended to choose external attributions that located blame in other individuals. These findings support R. P. Bentall, P. Kinderman, and S. Kaney's (1994) defensive attributional model of persecutory delusions, suggest some modifications to that model, and have implications for the understanding of the relationship between causal attributions and social and self-perception.

Self-discrepancies and persecutory delusions: evidence for a model of paranoid ideation

The self-discrepancies of paranoid patients, depressed patients, and nonpatients were examined using a modified version of Higgins's Selves Questionnaire (E. T. Higgins, 1987). Nonpatients showed high consistencies between all domains of the self-concept, whereas depressed patients showed marked self-discrepancies. Paranoid patients alone displayed a high degree of consistency between self-perceptions and self-guides together with discrepancies between self-perceptions and the believed perceptions of parents about the self. Paranoid patients also believed that their parents had more negative views of them than did other participants. These findings are consistent with R. P. Bentall, P. Kinderman, and S. Kaney's (1994) model, which assumes that persecutory delusions are a product of attributional processes serving to maintain a positive explicit self-concept.

Self-discrepancies and persecutory delusions: evidence for a model of paranoid ideation

The self-discrepancies of paranoid patients, depressed patients, and nonpatients were examined using a modified version of Higgins's Selves Questionnaire (E. T. Higgins, 1987). Nonpatients showed high consistencies between all domains of the self-concept, whereas depressed patients showed marked self-discrepancies. Paranoid patients alone displayed a high degree of consistency between self-perceptions and self-guides together with discrepancies between self-perceptions and the believed perceptions of parents about the self. Paranoid patients also believed that their parents had more negative views of them than did other participants. These findings are consistent with R. P. Bentall, P. Kinderman, and S. Kaney's (1994) model, which assumes that persecutory delusions are a product of attributional processes serving to maintain a positive explicit self-concept.

Clinical communication skills teaching: the role of cognitive schemata

Although the inclusion of the teaching of clinical communication skills is common in the training of health professionals, few published papers exist which either describe the theoretical basis of such teaching or provide comprehensive assessment procedures. This paper highlights the contributions of behavioural analysis and, centrally, the development of cognitive scripts or schemata to the understanding of the teaching of clinical communication skills. A model for a course designed explicitly to develop such scripts is described and the implications of such an understanding are discussed.

The self, attributional processes and abnormal beliefs: towards a model of persecutory delusions

In this paper we review a series of recent investigations into cognitive abnormalities associated with persecutory delusions. Studies indicate that persecutory delusions are associated with abnormal attention to threat-related stimuli, an explanatory bias towards attributing negative outcomes to external causes and biases in information processing relating to the self-concept. We propose an integrative model to account for these findings in which it is hypothesized that, in deluded patients, activation of self/ideal discrepancies by threat-related information triggers defensive explanatory biases, which have the function of reducing the self/ideal discrepancies but result in persecutory ideation. We conclude by discussing the implications of this model for the cognitive-behavioural treatment of paranoid delusions.

Attentional bias, persecutory delusions and the self-concept

Recent studies of cognitive processes associated with persecutory delusions suggest that such delusions are associated with abnormalities in the processing of information relevant to the self. Attention to positive and negative trait words was studied in subjects suffering from persecutory delusions, matched subjects with depressed mood and normal controls using an emotional Stroop task. Subjects were required to name the ink colours of: (i) meaningless strings of Os, (ii) low self-esteem personal adjectives, (iii) high self-esteem adjectives and (iv) neutral adjectives. subjects were also asked to rate the degree to which they endorsed as self-descriptive these and other personally descriptive adjectives. The subjects with persecutory delusions demonstrated a significantly higher rate of endorsement for positive adjectives than negative adjectives, but showed a marked degree of interference when colour-naming both positive and negative words. The relevance of these findings to a model of persecutory delusions involving the self-concept is discussed.

Paranoia and the defensive attributional style: deluded and depressed patients' attributions about their own attributions

A data set of Attributional Style Questionnaire responses collected by Kaney & Bentall (1989) from persecutory deluded, normal and depressed subjects was added to a similar data set collected by the first author. The attributions made for hypothetical positive and negative events by the combined pool of subjects were then blind rated for internality by five independent judges. Whereas the internality ratings made by the subjects for their own attributions showed evidence of an exaggerated self-serving bias in the case of the deluded subjects, and an absence of such a bias in the case of the depressed subjects, the independent ratings showed no such group differences. These findings suggest that the differences in internality for positive and negative events observed on the ASQ between deluded, normal and depressed subjects may not reflect differences in the types of causal statements made by these subjects but differences in their attributions about their attributions. The relevance of this observation for attribution theory in general and attributional accounts of psychopathology in particular are discussed.