Anxiety and depression in the Republic of Ireland during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic in Ireland resulted in a nationwide quarantine on March 27, 2020. This study represents the first assessment of rates of anxiety and depression in the general population of Ireland during the pandemic.

AIMS

Our first aim was to estimate the probable prevalence rates of generalized anxiety disorder (GAD) and depression and to identify sociodemographic risk factors associated with screening positive for GAD or depression. Our second aim was to determine if COVID-19 related anxiety was highest amongst those in society at greatest risk of morality from COVID-19.

METHOD

Self-report data were collected from a nationally representative Irish sample (N = 1041) online between March 31 and April 5; the first week of the nationwide quarantine measures. Recognized cut-off scores on the GAD-7 and PHQ-9 were used to estimate rates of GAD and depression. Correlates of screening positive for GAD or depression were assessed using logistic regression analysis.

RESULTS

GAD (20.0%), depression (22.8%) and GAD or depression (27.7%) was common. Screening positive for GAD or depression was associated with younger age, female sex, loss of income due to COVID-19, COVID-19 infection and higher perceived risk of COVID-19 infection. Citizens aged 65 and older had significantly higher levels of COVID-19 related anxiety than adults aged 18-34.

CONCLUSIONS

Initial results from this multi-wave study monitoring changes in population anxiety and depression throughout the pandemic indicate that GAD and depression were common experiences in the population during the initial phase of the COVID-19 pandemic.

Home Is Where You Hang Your Hat: Host Town Identity, But Not Hometown Identity, Protects Against Mental Health Symptoms Associated with Financial Stress

Debt and financial insecurity are associated with stress, low self-worth, and poor health. Joining and identifying with social groups (social identification) promotes better health and higher self-esteem. Here, we examined whether identifying with one's local neighborhood protected people from developing mental health symptoms associated with financial stress. We analyzed data from a general population survey (Study 1, N = 4319) and a student mental health survey (Study 2, N = 612) conducted in the North West of England. We administered measures of financial stress, self-esteem, neighborhood identity, and mental health, and conducted moderated mediation analyses to test our predictions. Study 1 (population survey) demonstrated that stronger identification with one's local neighborhood attenuated the adverse effects of financial stress on self-esteem and subsequent mental health. Study 2 (student survey) showed that strong host town identities buffered students from mental health symptoms related to financial stress. Strong hometown identities, however, showed no buffering effect. The findings suggest that one way financial stress impacts mental health is by eroding self-esteem. Identifying with one's current place of residence appears to disrupt this pathway, while identifying with one's previous place of residence does not provide the same psychological protection.

Randomised controlled trial of early detection and cognitive therapy for preventing transition to psychosis in high-risk individuals

Background

There is interest in the possibility of indicated prevention of psychosis. There is a strong case for using psychological approaches to prevent transition to psychosis in high-risk patients.

Aims

To identify individuals at high risk of transition to psychosis, and psychological characteristics relevant to the development of psychosis in this group.

Method

The design of a randomised controlled trial of cognitive therapy for the prevention of psychosis in people at high risk (meeting operational criteria of brief or attenuated psychotic symptoms, or first-degree family history with functional decline) is outlined. The first patients recruited are compared with non-patient samples on cognitive and personality factors; an interim analysis of transition rate is reported.

Results

Cases (n=31) were recruited mainly from primary care. Of the 23 high-risk patients monitored for 6–12 months, 5 (22%) made the transition to psychosis. The high-risk group scored significantly higher than non-patients on measures of schizotypy, metacognitive beliefs and dysfunctional self-schemas (sociotropy).

Conclusions

The findings validate the methods of identifying individuals at high risk of experiencing a psychotic episode. Compared with non-patient controls, the cases showed dysfunctional metacognitive beliefs and self-schemas.

Stress sensitivity in paranoia: poor-me paranoia protects against the unpleasant effects of social stress

BACKGROUND

The attributional theory of paranoia suggests that paranoid beliefs may protect individuals from low self-esteem and distress (Bentall et al. 2001). The current study tested this theory by investigating a hypothesis that paranoid beliefs in combination with low perceived deservedness of persecution (poor-me beliefs) confer protection against the distress caused by social but not activity related stress.

METHODS

Paranoid symptoms, perceived deservedness of persecution, self-esteem, mood, and stress levels of individuals diagnosed with schizophrenia spectrum disorders (N = 91) and healthy controls (N = 52) were assessed in the context of daily life using the experience sampling method.

RESULTS

Individuals holding poor-me beliefs (poor-me individuals) showed blunted sensitivity to social but not activity stress. In contrast, individuals holding paranoid beliefs in combination with high perceived deservedness of persecution (bad-me individuals) showed heightened sensitivity to social stress. No consistent differences in reactions to activity stress emerged. Although both poor-me and bad-me individuals reported low self-esteem, this disturbance was particularly characteristic of bad-me individuals.

CONCLUSIONS

The results suggest that poor-me paranoid beliefs may protect individuals against the distress associated with unpleasant social situations. The specificity of reactions to social stress is discussed in the context of wider literature. Future directions for research are suggested.

Do paranoid delusions exist on a continuum with subclinical paranoia? A multi-method taxometric study

BACKGROUND

There is widespread interest in whether psychosis exists on a continuum with healthy functioning. Previous research has implied that paranoia, a common symptom of psychosis, exists on a continuum but this has not been investigated using samples including both patients and non-patients and up-to-date taxometric methods.

AIM

To assess the latent structure of paranoia in a diverse sample using taxometric methods.

METHOD

We obtained data from 2836 participants, including the general population as well as at-risk mental state and psychotic patients using the P-scale of the Paranoia and Deservedness Scale. Data were analysed using three taxometric procedures, MAMBAC, MAXEIG and L-MODE (Ruscio, 2016), and two sets of paranoia indicators (subscales and selected items from the P scale), including and excluding the patient groups.

RESULTS

Eleven of the twelve analyses supported a dimensional model. Using the full sample and subscales as indicators, the MAMBAC analysis was ambiguous. Overall, the findings converged on a dimensional latent structure.

CONCLUSIONS

A dimensional latent structure of paranoia implies that the processes involved in sub-clinical paranoia may be similar to those in clinical paranoia.

Effectiveness of group body psychotherapy for negative symptoms of schizophrenia: multicentre randomised controlled trial

BACKGROUND

Negative symptoms of schizophrenia have a severe impact on functional outcomes and treatment options are limited. Arts therapies are currently recommended but more evidence is required.

AIMS

To assess body psychotherapy as a treatment for negative symptoms compared with an active control (trial registration: ISRCTN84216587).

METHOD

Schizophrenia out-patients were randomised into a 20-session body psychotherapy or Pilates group. The primary outcome was negative symptoms at end of treatment. Secondary outcomes included psychopathology, functional, social and treatment satisfaction outcomes at treatment end and 6-months later.

RESULTS

In total, 275 participants were randomised. The adjusted difference in negative symptoms was 0.03 (95% CI -1.11 to 1.17), indicating no benefit from body psychotherapy. Small improvements in expressive deficits and movement disorder symptoms were detected in favour of body psychotherapy. No other outcomes were significantly different.

CONCLUSIONS

Body psychotherapy does not have a clinically relevant beneficial effect in the treatment of patients with negative symptoms of schizophrenia.

Psychological treatments for early psychosis can be beneficial or harmful, depending on the therapeutic alliance: an instrumental variable analysis

BACKGROUND

The quality of the therapeutic alliance (TA) has been invoked to explain the equal effectiveness of different psychotherapies, but prior research is correlational, and does not address the possibility that individuals who form good alliances may have good outcomes without therapy.

METHOD

We evaluated the causal effect of TA using instrumental variable (structural equation) modelling on data from a three-arm, randomized controlled trial of 308 people in an acute first or second episode of a non-affective psychosis. The trial compared cognitive behavioural therapy (CBT) over 6 weeks plus routine care (RC) v. supportive counselling (SC) plus RC v. RC alone. We examined the effect of TA, as measured by the client-rated CALPAS, on the primary trial 18-month outcome of symptom severity (PANSS), which was assessed blind to treatment allocation.

RESULTS

Both adjunctive CBT and SC improved 18-month outcomes, compared to RC. We showed that, for both psychological treatments, improving TA improves symptomatic outcome. With a good TA, attending more sessions causes a significantly better outcome on PANSS total score [effect size -2.91, 95% confidence interval (CI) -0.90 to -4.91]. With a poor TA, attending more sessions is detrimental (effect size +7.74, 95% CI +1.03 to +14.45).

CONCLUSIONS

This is the first ever demonstration that TA has a causal effect on symptomatic outcome of a psychological treatment, and that poor TA is actively detrimental. These effects may extend to other therapeutic modalities and disorders.

Insecure attachment is associated with paranoia but not hallucinations in psychotic patients: the mediating role of negative self-esteem

BACKGROUND

A growing body of research has investigated associations between insecure attachment styles and psychosis. However, despite good theoretical and epidemiological reasons for hypothesising that insecure attachment may be specifically implicated in paranoid delusions, few studies have considered the role it plays in specific symptoms.

METHOD

We examined the relationship between attachment style, paranoid beliefs and hallucinatory experiences in a sample of 176 people with a diagnosis of schizophrenia spectrum disorders and 113 healthy controls. We also investigated the possible role of negative self-esteem in mediating this association.

RESULTS

Insecure attachment predicted paranoia but not hallucinations after co-morbidity between the symptoms was controlled for. Negative self-esteem partially mediated the association between attachment anxiety and clinical paranoia, and fully mediated the relationship between attachment avoidance and clinical paranoia.

CONCLUSIONS

It may be fruitful to explore attachment representations in psychological treatments for paranoid patients. If future research confirms the importance of disrupted attachment as a risk factor for persecutory delusions, consideration might be given to how to protect vulnerable young people, for example those raised in children's homes.

Negative cognition, affect, metacognition and dimensions of paranoia in people at ultra-high risk of psychosis: a multi-level modelling analysis

BACKGROUND

Paranoia is one of the commonest symptoms of psychosis but has rarely been studied in a population at risk of developing psychosis. Based on existing theoretical models, including the proposed distinction between ‘poor me’ and ‘bad me’ paranoia, we aimed to test specific predictions about associations between negative cognition, metacognitive beliefs and negative emotions and paranoid ideation and the belief that persecution is deserved (deservedness).

METHOD

We used data from 117 participants from the Early Detection and Intervention Evaluation for people at risk of psychosis (EDIE-2) trial of cognitive–behaviour therapy, comparing them with samples of psychiatric in-patients and healthy students from a previous study. Multi-level modelling was utilized to examine predictors of both paranoia and deservedness, with post-hoc planned comparisons conducted to test whether person-level predictor variables were associated differentially with paranoia or with deservedness.

RESULTS

Our sample of at-risk mental state participants was not as paranoid, but reported higher levels of ‘bad-me’ deservedness, compared with psychiatric in-patients. We found several predictors of paranoia and deservedness. Negative beliefs about self were related to deservedness but not paranoia, whereas negative beliefs about others were positively related to paranoia but negatively with deservedness. Both depression and negative metacognitive beliefs about paranoid thinking were specifically related to paranoia but not deservedness.

CONCLUSIONS

This study provides evidence for the role of negative cognition, metacognition and negative affect in the development of paranoid beliefs, which has implications for psychological interventions and our understanding of psychosis.

The effect of the environment on symptom dimensions in the first episode of psychosis: a multilevel study

BACKGROUND

The extent to which different symptom dimensions vary according to epidemiological factors associated with categorical definitions of first-episode psychosis (FEP) is unknown. We hypothesized that positive psychotic symptoms, including paranoid delusions and depressive symptoms, would be more prominent in more urban environments.

METHOD

We collected clinical and epidemiological data on 469 people with FEP (ICD-10 F10-F33) in two centres of the Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP) study: Southeast London and Nottinghamshire. We used multilevel regression models to examine neighbourhood-level and between-centre differences in five symptom dimensions (reality distortion, negative symptoms, manic symptoms, depressive symptoms and disorganization) underpinning Schedules for Clinical Assessment in Neuropsychiatry (SCAN) Item Group Checklist (IGC) symptoms. Delusions of persecution and reference, along with other individual IGC symptoms, were inspected for area-level variation.

RESULTS

Reality distortion [estimated effect size (EES) 0.15, 95% confidence interval (CI) 0.06-0.24] and depressive symptoms (EES 0.21, 95% CI 0.07-0.34) were elevated in people with FEP living in more urban Southeast London but disorganized symptomatology was lower (EES -0.06, 95% CI -0.10 to -0.02), after controlling for confounders. Delusions of persecution were not associated with increased neighbourhood population density [adjusted odds ratio (aOR) 1.01, 95% CI 0.83-1.23], although an effect was observed for delusions of reference (aOR 1.41, 95% CI 1.12-1.77). Hallucinatory symptoms showed consistent elevation in more densely populated neighbourhoods (aOR 1.32, 95% CI 1.09-1.61).

CONCLUSIONS

In people experiencing FEP, elevated levels of reality distortion and depressive symptoms were observed in more urban, densely populated neighbourhoods. No clear association was observed for paranoid delusions; hallucinations were consistently associated with increased population density. These results suggest that urban environments may affect the syndromal presentation of psychotic disorders.

Externalizing biases and hallucinations in source-monitoring, self-monitoring and signal detection studies: a meta-analytic review

BACKGROUND

Cognitive models have postulated that auditory hallucinations arise from the misattribution of internally generated cognitive events to external sources. Several experimental paradigms have been developed to assess this externalizing bias in clinical and non-clinical hallucination-prone samples, including source-monitoring, verbal self-monitoring and auditory signal detection tasks. This meta-analysis aims to synthesize the wealth of empirical findings from these experimental studies.

METHOD

A database search was carried out for reports between January 1985 and March 2012. Additional studies were retrieved by contacting authors and screening references of eligible reports. Studies were considered eligible if they compared either (i) hallucinating and non-hallucinating patients with comparable diagnoses, or (ii) non-clinical hallucination-prone and non-prone participants using source-monitoring, verbal self-monitoring or signal detection tasks, or used correlational analyses to estimate comparable effects.

RESULTS

The analysis included 15 clinical (240 hallucinating patients and 249 non-hallucinating patients) and nine non-clinical studies (171 hallucination-prone and 177 non-prone participants; 57 participants in a correlation study). Moderate-to-large summary effects were observed in both the clinical and analogue samples. Robust and significant effects were observed in source-monitoring and signal detection studies, but not in self-monitoring studies, possibly due to the small numbers of eligible studies in this subgroup. The use of emotionally valenced stimuli led to effects of similar magnitude to the use of neutral stimuli.

CONCLUSIONS

The findings suggest that externalizing biases are important cognitive underpinnings of hallucinatory experiences. Clinical interventions targeting these biases should be explored as possible treatments for clients with distressing voices.

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.

Dissociation mediates the relationship between childhood trauma and hallucination-proneness

BACKGROUND

It has been proposed that the relationship between childhood trauma and hallucinations can be explained by dissociative processes. The present study examined whether the effect of childhood trauma on hallucination-proneness is mediated by dissociative tendencies. In addition, the influence of dissociative symptoms on a cognitive process believed to underlie hallucinatory experiences (i.e. reality discrimination; the capacity to discriminate between internal and external cognitive events) was also investigated.

METHOD

Patients with schizophrenia spectrum disorders (n=45) and healthy controls (with no history of hallucinations; n=20) completed questionnaire measures of hallucination-proneness, dissociative tendencies and childhood trauma, as well as performing an auditory signal detection task.

RESULTS

Compared to both healthy and non-hallucinating clinical controls, hallucinating patients reported both significantly higher dissociative tendencies and childhood sexual abuse. Dissociation positively mediated the effect of childhood trauma on hallucination-proneness. This mediational role was particularly robust for sexual abuse over other types of trauma. Signal detection abnormalities were evident in hallucinating patients and patients with a history of hallucinations, but were not associated with pathological dissociative symptoms.

CONCLUSIONS

These results are consistent with dissociative accounts of the trauma-hallucinations link. Dissociation, however, does not affect reality discrimination. Future research should examine whether other cognitive processes associated with both dissociative states and hallucinations (e.g. deficits in cognitive inhibition) may explain the relationship between dissociation and hallucinatory experiences.

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.

Mind-mindedness and maternal responsiveness in infant-mother interactions in mothers with severe mental illness

BACKGROUND

Previous cross-diagnosis studies of interaction between mothers with severe mental illness and their babies have concluded that mothers with schizophrenia have deficits in interaction, but these studies have not included healthy controls.

METHOD

In-patients on a mother and baby unit, with diagnoses of schizophrenia (n=15), depressive mood disorders with or without psychosis (n=23), or mood disorders where mania was the predominant feature, with or without psychosis (n=12), were observed interacting with their infants on admission and discharge. Mothers' mind-mindedness and other measures of the quality of maternal and infant behaviour were coded. Findings from this sample were compared with those from healthy mothers and their infants (n=49).

RESULTS

Compared with healthy controls, on admission depressed mothers were marginally less likely to comment appropriately on their infants' mental states. Both the depressed and mania groups were more likely to touch their babies and engage in attention-seeking behaviours. Interactional behaviours of mothers in the schizophrenia group were not markedly different from healthy controls. On discharge there were fewer differences between the clinical and healthy groups, although the depressed group continued to engage in more attention-seeking and touching behaviour and the mania group continued to touch their infants more. Only mothers in the schizophrenia group showed changes in interactional behaviours between admission and discharge, talking more to their infants.

CONCLUSIONS

The findings challenge previous conclusions that mothers with schizophrenia have deficits in their interactions with their babies, and demonstrate that mothers with severe mental illness are able to respond appropriately to their infants' cues.

The role of verbal behavior in human learning: II. Developmental differences

When children in four different age ranges operated a response device, reinforcers were presented according to fixed-interval schedules ranging in value from 10 to 70 seconds. Only the behavior of the subjects in the youngest of the four groups, the preverbal infants, resembled that of other animal species. The children in age ranges 5 to 6(1/2) and 7(1/2) to 9 years exhibited either the low-rate or high-rate response patterns typical of human adults. Those who showed the low-rate pattern reported a time-based formulation of the contingencies and some of them were observed to occasionally count out the interval before responding. The performance of children aged 2(1/2) to 4 years differed from that of both infants and older children, though containing some patterning elements similar to those produced by the older and younger subjects. The predominant response pattern of the infants consisted of a pause after reinforcement followed by an accelerated rate of responding that terminated when the next reinforcer was delivered. Analysis of postreinforcement-pause duration and response rate showed that infant performance, but not that of the older children, consistently exhibited the same kinds of schedule sensitivity observed in animal behavior. The evidence supports the suggestion that the development of verbal behavior greatly alters human operant performance and may account for many of the differences found between human and animal learning.

The role of verbal behavior in human learning: III. Instructional effects in children

Lever pressing of children from three age groups (2(1/2) to 4, 5 to 6(1/2), and 7(1/2) to 9 years) could produce reinforcers according to a fixed-interval 40-s schedule: (1) Some were instructed to respond at a high rate, others at a low rate, and (2) they were subsequently taught to provide their own spoken self-instructions consonant with the earlier, experimenter-supplied instructions. All subjects who received high-rate instructions responded at a steady, high rate, which was maintained following self-instructional training. The effects of low-rate instructions were directly related to the age of the children. The two older groups produced low-rate patterns, with the oldest children responding at very low rates; effects were least noticeable in the youngest age group. Following self-instructional training, all three groups showed adult-like low-rate behavior and the oldest children showed an improved ability to estimate the interval length. The results provide further evidence of the importance of language as a determinant of human behavior.

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.

Fatigue Intervention by Nurses Evaluation--the FINE Trial. A randomised controlled trial of nurse led self-help treatment for patients in primary care with chronic fatigue syndrome: study protocol. [ISRCTN74156610]

BACKGROUND

Chronic fatigue syndrome, also known as ME (CFS/ME), is a condition characterised primarily by severe, disabling fatigue, of unknown origin, which has a poor prognosis and serious personal and economic consequences. Evidence for the effectiveness of any treatment for CFS/ME in primary care, where most patients are seen, is sparse. Recently, a brief, pragmatic treatment for CFS/ME, based on a physiological dysregulation model of the condition, was shown to be successful in improving fatigue and physical functioning in patients in secondary care. The treatment involves providing patients with a readily understandable explanation of their symptoms, from which flows the rationale for a graded rehabilitative plan, developed collaboratively with the therapist. The present trial will test the effectiveness and cost-effectiveness of pragmatic rehabilitation when delivered by specially trained general nurses in primary care. We selected a client-centred counselling intervention, called supportive listening, as a comparison treatment. Counselling has been shown to be as effective as cognitive behaviour therapy for treating fatigue in primary care, is more readily available, and controls for supportive therapist contact time. Our control condition is treatment as usual by the general practitioner (GP).

METHODS AND DESIGN

This study protocol describes the design of an ongoing, single-blind, pragmatic randomized controlled trial of a brief (18 week) self-help treatment, pragmatic rehabilitation, delivered by specially trained nurse-therapists in patients' homes, compared with nurse-therapist delivered supportive listening and treatment as usual by the GP. An economic evaluation, taking a societal viewpoint, is being carried out alongside the clinical trial. Three adult general nurses were trained over a six month period to deliver the two interventions. Patients aged over 18 and fulfilling the Oxford criteria for CFS are assessed at baseline, after the intervention, and again one year later. Primary outcomes are self-reported physical functioning and fatigue at one year, and will be analysed on an intention-to-treat basis. A qualitative study will examine the interventions' mechanisms of change, and also GPs' drivers and barriers towards referral.

Persecutory delusions and the determination of self-relevance: an fMRI investigation

BACKGROUND

People with persecutory delusions regard ambiguous data in the social domain as self-relevant and selectively attend to threatening information. This study aimed to characterize these social cognitive biases in functional neuroanatomical terms.

METHOD

Eight schizophrenic patients with active persecutory delusions and eight matched normal controls underwent functional magnetic resonance imaging while determining the self-relevance of ambiguous self-relevant or unambiguous other-relevant neutral and threatening statements.

RESULTS

In determining self-relevance, the deluded subjects showed a marked absence of rostral-ventral anterior cingulate activation together with increased posterior cingulate gyrus activation in comparison to the normal subjects. The influence of threat on self-relevance determination did not yield statistically significant differences between deluded and normal subjects.

CONCLUSIONS

Abnormalities of cingulate gyrus activation while determining self-relevance suggest impaired self-reflection in the persecutory deluded state. This may contribute to persecutory belief formation and maintenance.

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.

Self-responsibility and the self-serving bias: an fMRI investigation of causal attributions

We use causal attributions to infer the most likely cause of events in the social world. Internal attributions imply self-responsibility for events. The self-serving bias describes the tendency of normal subjects to attribute the causation of positive events internally ("I am responsible em leader ") and negative events externally ("Other people or situational factors are responsible em leader "). The self-serving bias has been assumed to serve a positive motivational function by enhancing self-esteem. Abnormalities of attributional style have been implicated in both depression and psychosis. We examined the neural basis of both self-responsibility and the self-serving bias using functional magnetic resonance imaging during the performance of attributional decision tasks. We found that the determination of self-responsibility recruits areas previously implicated in action simulation (bilateral premotor cortex and cerebellum), suggesting that such higher order social cognition is related to simpler internal models of goal-directed action. The dorsal striatum, previously implicated in motivated behavior, mediates the self-serving bias.

Health beliefs link to duration of untreated psychosis and attitudes to later treatment in early psychosis

BACKGROUND

Health beliefs influence health behaviours and have been shown to influence outcomes in a variety of illnesses, treatments and preventative interventions.

AIMS

We aimed to measure health beliefs in first episode psychosis with the hypotheses that their structure would resemble that in physical illness (diabetes) and would correlate with prior duration of untreated psychosis and later attitudes to treatment.

METHOD

The Multidimensional Health Locus of Control scale was used in a sample of 50 people with schizophrenia during the first episode and at 18-month follow-up, 51 diabetic controls and 51 normal controls.

RESULTS

Schizophrenia patients, both at first episode and 18 months later, had a pattern of health beliefs that was similar to those of the patients with diabetes and significantly different to the normal controls. There were significant associations between internal locus of control score and short DUP, and between external locus of control score and a positive attitude to medication as measured by the Drug Attitudes Inventory.

CONCLUSIONS

Health beliefs in first episode schizophrenia correlate with determinants of outcome.

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.

Cognitive neuropsychiatric models of persecutory delusions

OBJECTIVE

The major cognitive theories of persecutory delusion formation and maintenance are critically examined in this article.

METHOD

The authors present a comprehensive review of the literature, citing results of relevant functional neuroimaging and neural network studies.

RESULTS

People with persecutory delusions selectively attend to threatening information, jump to conclusions on the basis of insufficient information, attribute negative events to external personal causes, and have difficulty in envisaging others' intentions, motivations, or states of mind. Presence of the "reality distortion" cluster of psychotic symptoms correlates with cerebral blood flow in the left lateral prefrontal cortex, ventral striatum, superior temporal gyrus, and parahippocampal region. Social cognitive processing (selective attention to threat, attribution of causation or mental states) in normal subjects involves similar areas. Neural network models of persecutory delusions highlight the importance of disordered neuromodulation in their formation and of disordered neuroplasticity in their maintenance.

CONCLUSIONS

Further studies examining the interaction of these cognitive processes, cross-sectionally and longitudinally, at cognitive psychological, neural network, and functional neuroanatomical levels are warranted to establish a comprehensive cognitive neuropsychiatric model of the persecutory delusion.

Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome

OBJECTIVE

To assess the efficacy of an educational intervention explaining symptoms to encourage graded exercise in patients with chronic fatigue syndrome.

DESIGN

Randomised controlled trial.

SETTING

Chronic fatigue clinic and infectious diseases outpatient clinic.

SUBJECTS

148 consecutively referred patients fulfilling Oxford criteria for chronic fatigue syndrome.

INTERVENTIONS

Patients randomised to the control group received standardised medical care. Patients randomised to intervention received two individual treatment sessions and two telephone follow up calls, supported by a comprehensive educational pack, describing the role of disrupted physiological regulation in fatigue symptoms and encouraging home based graded exercise. The minimum intervention group had no further treatment, but the telephone intervention group received an additional seven follow up calls and the maximum intervention group an additional seven face to face sessions over four months.

MAIN OUTCOME MEASURE

A score of >/=25 or an increase of >/=10 on the SF-36 physical functioning subscale (range 10 to 30) 12 months after randomisation.

RESULTS

21 patients dropped out, mainly from the intervention groups. Intention to treat analysis showed 79 (69%) of patients in the intervention groups achieved a satisfactory outcome in physical functioning compared with two (6%) of controls, who received standardised medical care (P<0.0001). Similar improvements were observed in fatigue, sleep, disability, and mood. No significant differences were found between the three intervention groups.

CONCLUSIONS

Treatment incorporating evidence based physiological explanations for symptoms was effective in encouraging self managed graded exercise. This resulted in substantial improvement compared with standardised medical care.

An fMRI study of stimulus equivalence

In order to study brain activation during the formation of equivalence relations, 12 subjects underwent fMRI during matching-to-sample (MTS) tests of (1) previously trained arbitrary relationships between iconic stimuli and the untrained, emergent relations of (2) symmetry, (3) transitivity, and (4) symmetry with transitivity, plus a test of verbal fluency (VF). Brain activation was similar in all MTS tasks and in the VF task. In particular, both types of task activated dorsolateral prefrontal cortex (DLPFC) and posterior parietal cortex bilaterally. However VF, but not the MTS tasks, activated Broca's area. In three of the four MTS tasks, behavioural accuracy was significantly correlated with left lateralisation of DLPFC activity. Brain activation patterns during equivalence thus resembled those involved in semantic processing underlying language, without involving regions concerned with the simple sub-vocal articulation of stimulus names.

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.

Imaging attentional and attributional bias: an fMRI approach to the paranoid delusion

BACKGROUND

The pathophysiology of auditory hallucinations and delusions of control has been elucidated using functional imaging. Despite their clinical importance, there have been few similar attempts to investigate paranoid delusions. We have examined two components of social cognition (attentional and attributional biases) that contribute to the formation and maintenance of paranoid delusions, using functional magnetic resonance imaging (fMRI).

METHOD

Normal subjects performed tasks requiring attentional and attributional judgements. We investigated the neural response particularly associated with attention to threatening material relevant to self and with the 'self-serving' attributional bias.

RESULTS

The determination of relevance to self of verbal statements of differing emotional valence involved left ventrolateral prefrontal cortex (left inferior frontal gyrus, BA 47), right caudate and right cingulate gyrus (BA 24). Attention to threatening material relevant to self differentially activated a more dorsal region of the left inferior frontal gyrus (BA 44). Internal attributions of events, where the self was viewed as an active intentional agent, involved left precentral gyrus (BA 6) and left middle temporal gyrus (BA 39). Attribution of events in a non 'self-serving' manner required activation of the left precentral gyrus (BA 6).

CONCLUSIONS

Anomalous activity or connectivity within these defined regions may account for the attentional or attributional biases subserving paranoid delusion formation. This provides a simple model for paranoid delusion formation that can be tested in patients.

Social cognition and the manic defense: attributions, selective attention, and self-schema in bipolar affective disorder

Manic patients, depressed bipolar patients, and normal controls were compared on measures of social cognition. Manic patients showed a normal self-serving bias on the Attributional Style Questionnaire, but depressed patients attributed negative events more than positive events to self. On an implicit test of attributional style, both patient groups attributed negative events more than positive events to self. Both patient groups showed slowed color naming for depression-related but not euphoria-related words. Manic patients, like normal controls, endorsed mainly positive words as true of self but, like the depressed patients, recalled mainly negative words. Findings from the implicit tests indicate a common form of psychological organization in manic and depressed patients, whereas the contrasts between the scores on the implicit and explicit measures are consistent with the hypothesis of a manic defense.

Social cognition and the manic defense: attributions, selective attention, and self-schema in bipolar affective disorder

Manic patients, depressed bipolar patients, and normal controls were compared on measures of social cognition. Manic patients showed a normal self-serving bias on the Attributional Style Questionnaire, but depressed patients attributed negative events more than positive events to self. On an implicit test of attributional style, both patient groups attributed negative events more than positive events to self. Both patient groups showed slowed color naming for depression-related but not euphoria-related words. Manic patients, like normal controls, endorsed mainly positive words as true of self but, like the depressed patients, recalled mainly negative words. Findings from the implicit tests indicate a common form of psychological organization in manic and depressed patients, whereas the contrasts between the scores on the implicit and explicit measures are consistent with the hypothesis of a manic defense.

Persecutory delusions and autobiographical memory

OBJECTIVES

It was hypothesized that people with persecutory delusions, such as depressed people, would experience difficulty when attempting to generate specific autobiographical memories.

DESIGN

20 deluded participants, 20 depressed patients and 20 normal controls were compared on an autobiographical memory test.

METHODS

Participants attempted to recall memories to positive and negative cue words. Independent raters classified responses as specific, general, imaginary or unscorable. Over-general memories were further classified as extended or categorical.

RESULTS

Deluded participants recalled significantly more general (especially categorical) memories and fewer specific memories than the normal control subjects. Depressed participants showed little evidence of over-general memories, although they showed faster recall latencies to negative than to positive cues.

CONCLUSIONS

People with paranoid delusions show information processing features similar to those previously reported in people with depression. The possible contribution of adverse experiences to over-general autobiographical recall is discussed.

Opiate withdrawal outcome: the predictive ability of admission measures from the family assessment device (F.A.D.)

The Family Assessment Device (F.A.D.) was administered to a sample of 57 opiate misusers at admission for inpatient detoxification. Logistic regression analyses showed that the odds of a premature discharge against medical advice from the Unit were increased by progressively poorer ratings of family functioning in the areas of problem solving and roles, while progressively poorer ratings of functioning in the areas of communication and behavioral control were associated with decreasing odds of a premature discharge. It was concluded that further research was required to better understand and utilize the potentially supportive role of families in this phase of treatment.

The meaning and management of neuroleptic medication: a study of patients with a diagnosis of schizophrenia

The meaning of medication and the way in which people use medicines has been the focus of a number of studies in recent years. However, there has been little attention directed to the meaning and management of neuroleptic medication by people who have received a diagnosis of schizophrenia. This topic is highly relevant to policy because of the central role given to neuroleptics in contemporary mental health and community care services. Using data from in-depth interviews with people with a diagnosis of schizophrenia we explore patients reasons for taking neuroleptics and the ways in which patients self-regulate their medication. The data suggest that the main utility of taking neuroleptic medication is to control specific symptoms and to gain personal control over managing symptoms. The costs of taking medication were side-effects which at times equalised or outweighed the positive gains of the neuroleptic medication. Patient accounts suggest that everyday medication practices are to a significant degree related to a policy context which stresses the need to survey and control the behaviour of people living in the community and the wider meaning and symbolic significance that schizophrenia has for patients in their everyday lives. For this reason, self regulatory action in this group of patients tends to be less evident and the threat of external social control greater than patients taking medication for other chronic conditions. The findings suggest the need to develop a collaborative patient-centred model of medication management for patients diagnosed with schizophrenia.

A comparison of the long-term effectiveness of distraction and focusing in the treatment of auditory hallucinations

Cognitive-behavioural interventions for patients experiencing neuroleptic resistant auditory hallucinations have fallen into two main categories: those which encourage distraction as a coping strategy, and those which encourage patients to focus on or expose themselves to their hallucinations. A 20-session distraction treatment was compared with an equal length focusing treatment for 19 patients who were experiencing chronic auditory hallucinations. Patients were followed-up for approximately 2 years. No differences were observed between the groups for outcome on symptom severity overall, although the focusers showed a greater belief that their voices were their own thoughts at the final follow-up point. When the two groups were combined, there was a significant reduction in the frequency of hallucinations and the disruption to life caused by them during treatment, although this was not maintained at follow-up. During treatment, there was a significant increase in self-esteem for focusers but a significant decrease for distracters. At 2-year follow-up, both focusers and distracters showed a reduction in self-esteem in comparison to the end of therapy. The results show no overwhelming advantage of one treatment over the other and confirm previous observations of the difficulty of treating hallucinations with cognitive-behaviour therapy (CBT). However, there was some indication that CBT influenced some important clinical variables and further investigation is warranted.

Social reasoning in individuals with persecutory delusions: the effects of additional information on attributions for the observed behaviour of others

The extent to which individuals suffering from persecutory delusions, as compared to matched controls, were prepared to change their attributional judgments following additional information, was investigated. Participants were required to decide whether the actor or target individual had caused an action before and after information, which was either high or low in terms of distinctiveness, consistency and consensus. There were no differences between the three participant groups which all made decisions, and changed their decisions, in the directions predicted by attribution theory.

Two predictions about paranoid ideation: deluded, depressed and normal participants' subjective frequency and consensus judgments for positive, neutral and negative events

Two groups of patients suffering from persecutory delusions, one consisting of patients also suffering from depression and a non-depressed group, together with clinically depressed and normal controls matched with the deluded patients for age and intelligence, were asked to rate the frequency with which selected positive, negative and neutral events had happened to themselves and to an average other person in the past, and the frequency with which these events were likely to happen to themselves and to an average other person in the future. Results were similar for both past and expected future events. Non-depressed-deluded, depressed-deluded and depressed patients rated negative events as occurring relatively more frequently in comparison to the normal controls. Depressed participants rated positive events as occurring more frequently to others, whereas the normal participants rated negative events as occurring more often to others. Correlational analyses indicated that depression scores were associated with low estimates of the frequency with which positive events happen to self and high estimates of the frequency with which negative events happen to self. Magical ideation scores, an index of psychosis, were associated with high estimates of the frequency of negative events for both self and others. These findings are interpreted in the context of previous evidence on cognitive biases in deluded patients.

Opiate withdrawal outcome: the predictive ability of admission measures of motivation, self-efficacy, and lifestyle stability

The ability of two models to predict the outcome of inpatient detoxification was tested. The first model related to motivation and self-efficacy for undergoing the withdrawal, and was found to be weakly predictive of premature discharges. The second model related to the stability of subjects' lifestyles prior to admission, and strongly predicted whether or not subjects would still be in receipt of withdrawal medication at the time of their discharge. It was concluded that further research was required as to the relative usefulness of cognitive/affective versus behavioral indicators of motivation for withdrawal.

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.

Probabilistic reasoning in deluded, depressed and normal subjects: effects of task difficulty and meaningful versus non-meaningful material

BACKGROUND

Research indicates that deluded patients 'jump to conclusions' on probabilistic reasoning tasks. Two experiments were carried out with patients suffering from persecutory delusions and depressed and normal controls in order to determine whether this response bias is affected by task difficulty and the meaningfulness of the materials.

METHODS

Tasks were variants of those employed by Huq et al. (1988) and Garety et al. (1991). In Experiment 1, subjects judged which of two bags a sequence of coloured beads had been taken from. Difficulty was manipulated by varying the ratios of coloured beads in the bags. In experiment 2, a neutral condition required judgements about coloured beads drawn whereas, in meaningful conditions, subjects had to judge whether personality characteristics described one of two individuals.

RESULTS

In Experiment 1, estimates of certainty varied with task difficulty, and there was no evidence of 'jumping to conclusions' in the deluded group. In Experiment 2, all groups reached an initial level of certainty and reduced their estimates of certainty following disconfirmatory evidence more quickly in the meaningful conditions. Both clinical groups expressed higher certainty levels in early trials, and a greater magnitude of reduction in certainty following disconfirmatory information. These group differences were more evident in the meaningful conditions than in the neutral conditions.

CONCLUSIONS

Probabilistic reasoning is affected by task difficulty and meaningfulness of materials in both deluded and depressed subjects. Observed reasoning abnormalities were not specific to the deluded group.

Social cognition in schizophrenia

The study of social cognition in schizophrenia may augment the understanding of clinical and behavioral manifestations of the disorder. In this article, the authors describe social cognition and differentiate it from nonsocial cognition. They garner evidence to support the role of social cognition in schizophrenia: Nonsocial information-processing models are limited to explain social dysfunction in schizophrenia, measures of social cognition may contribute greater variance to social functioning than measures of nonsocial cognition, task performance on nonsocial-cognitive measures may not parallel performance on social-cognitive tasks, and symptomatology may be best understood within a social-cognitive framework. They describe the potential implications of a social-cognitive model of schizophrenia for the etiology and development of the disorder.

Abnormalities of self-representation and persecutory delusions: a test of a cognitive model of paranoia

Patients suffering from persecutory delusions exhibit information processing and social reasoning biases that have been hypothesized to have a self-protective function. In a test of this hypothesis, patients suffering from persecutory delusions who were also depressed and non-depressed deluded subjects were compared with depressed and normal controls on two indirect assessments of self-schemata: the Dysfunctional Attitudes Scale (DAS) and incidental recall of negative and positive trait words that had previously been judged to be self-descriptive or not self-descriptive. Both the depressed subjects and the deluded subjects, whether or not they were depressed, scored highly on the DAS. Like normals, both depressed and non-depressed deluded subjects endorsed more positive than negative trait words as true of themselves whereas the depressed subjects endorsed as many negative as positive trait works. Like the depressed subjects, both groups of deluded subjects recalled as many of the negative words they had endorsed as positive words, whereas the normals remembered more positive words. No such bias was observed in subjects' recall of unendorsed words. The DAS results are interpreted as clearly consistent with a defensive model of persecutory delusions whereas the incidental recall data were equivocally so.

At the centre of a science of psychopathology? Characteristics and limitations of cognitive research

In this brief paper I will suggest that the cognitive approach has four characteristics which must place it at the centre of any complete science of psychopathology: (1) it leads to testable hypotheses about abnormal mental states; (2) it establishes a link between normal psychology and abnormal mental processes, and therefore obviates the need to dichotomise behaviour into the normal and the abnormal; (3) it has the potential to make apparently bizarre and irrational behaviour understandable; and (4) it is neutral with regard to the relative contributions that biology and the environment make to the aetiology of psychiatric disorders. I also identify three limitations of contemporary cognitive models of psychiatric disorders: (1) an over-reliance on conventional methods of psychiatric classification; (2) an underemphasis on social aspects of cognition; and (3) a failure to integrate findings obtained from different models. Once these limitations are overcome, cognitive research is likely to lead to a revolution in our understanding of abnormal behaviour.

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.

Schizophrenic patients' experiences of neuroleptic medication: a Q-methodological investigation

Q-methodology was used to explore the experiences of 50 medicated schizophrenic patients. Four main factors were identified. Participants loading on the first factor agreed with statements suggesting an uncomplaining attitude towards their medication and also with statements indicating a dependent attitude towards the medical profession. Those loading on the second factor endorsed statements indicative of a sceptical attitude towards medication, together with a concern for personal autonomy. Participants loading on the third factor had apparently made a balanced appraisal of the advantages and disadvantages of their medication, whereas those who loaded positively on the final factor reported positive benefits of medication but a sceptical attitude towards medical advice. The study highlights the complexity of psychiatric patients' attitudes to treatment.