Clients' experience of case formulation in cognitive behaviour therapy for psychosis

OBJECTIVES

Case formulation (CF) is considered essential to the practice of cognitive behaviour therapy, and crucial when working with more complex problems such as psychosis. Several claims are made for the beneficial impact of CF on clients, although little empirical research has been conducted.

DESIGN

The study used content analysis methodology to assess clients' experience of the CF process in cognitive behaviour therapy for psychosis. In addition, therapists ranked seven documented benefits for them of CF.

METHOD

Thirteen clients and their respective therapists were interviewed 2-3 weeks after shared written formulation.

RESULTS

Overall, clients' reactions to CF were cognitively, behaviourally, and emotionally complex, and subject to change over time. Therapists reported that they found the CF to be most useful in increasing their understanding of their clients.

CONCLUSIONS

Formulation is a complex process for clients, and future research into CF faces methodological challenges.

Factors associated with positive outcomes in 131 patients treated with gauze-based negative pressure wound therapy

Negative Pressure Wound Therapy (NPWT) is commonly used in many surgical specialties to improve wound management and healing outcomes. This study reports the ability of gauze-based NPWT to address several treatment goals commonly defined at the onset of therapy. A prospective, multi-center, non-comparative clinical investigation was carried out using gauze-based NPWT in chronic and acute wounds. 131 patients including traumatic, post-surgical and chronic wounds were assessed. Weekly percentage reductions in wound area, depth and volume were 8.3%, 15.8% and 20.5% respectively (p < 0.001). A reduction in exudate level was observed from baseline to treatment discontinuation (p < 0.001). An increase (p = 0.007) in red granulation tissue and a decrease (p < 0.001) in non-viable tissue was observed. Baseline wound characteristics associated with slower rates of progress included chronic wound aetiologies, longer wound duration prior to NPWT and presence of diabetes as a co-morbidity. Important indicators of wounds which had improved sufficiently and no longer required NPWT included reduction in volume and exudate levels. Gauze-based NPWT can be used to address many of the treatment goals commonly defined at the onset of therapy including reduction in wound volume, management of exudate and infection status, and improvement in wound bed quality.

Reducing Clostridium difficile infection in acute care by using an improvement collaborative

PROBLEM

In 2006, despite a focus on infection control, Salford Royal had the fourth highest rate of Clostridium difficile infection in north west England.

DESIGN

Interrupted time series in five collaborative wards (intervention group) and 35 non-collaborative wards (control group).

SETTING

University teaching hospital with 850 acute beds.

KEY MEASURES FOR IMPROVEMENT

Number of cases of C difficile infection per 1000 occupied bed days.

STRATEGIES FOR CHANGE

In February 2007, a newly formed antimicrobial team led the implementation of revised guidelines in all wards and departments. From March to December 2007, five wards participated in an improvement collaborative. Since December 2007, the changes from the collaborative have been collated and implemented throughout the organisation.

EFFECTS OF CHANGE

At baseline the non-collaborative wards had 1.15 (95% CI 1.03 to 1.29) cases per 1000 occupied bed days. In August 2007 cases reduced 56% from baseline (0.51, 0.44 to 0.60), which has been maintained since that time. In the collaborative wards, there were 2.60 (2.11 to 3.17) cases per 1000 occupied bed days at baseline. A shift occurred in April 2007 representing a reduction of 73% (0.69, 0.50 to 0.91) from baseline, which has been maintained.

LESSONS LEARNT

Careful use of antimicrobial drugs is important in reducing the number of cases of C difficile infection. A collaborative learning model can enable teams to test and implement changes that can accelerate, amplify, and sustain control of C difficile.

A dynamic care pathway to coordinate the use of advanced therapy in diabetic foot ulceration

The non-coordinated use of advanced therapies is not clinically or cost effective. A care pathway for the sequential use of these interventions on complex wounds provides a more restructured approach, and helped improve patient outcomes.

Weight status and perceived body size in children

OBJECTIVE

To investigate associations between weight status and body size perception in children in the UK.

DESIGN

Cross-sectional survey.

SETTING

School-based sample in the UK.

PARTICIPANTS

399 children (205 boys, 194 girls) aged 7-9 years.

MAIN OUTCOME MEASURES

Perceived body size was assessed using a visual method (Children's Body Image Scale, matching to images representing body mass indexes (BMI) from 3rd to 97th percentiles) and verbal descriptors from "too thin" to "too fat". BMI (converted to BMI SD scores using UK data) was assessed and demographic information was recorded.

RESULTS

Modest associations between actual and perceived body size were found with visual (r = 0.43, p<0.001) and verbal (r = 0.41, p<0.001) methods, but there was a consistent response bias towards underestimation. Using visual matching, most children (45%) underestimated their body size, with significantly greater underestimation (p<0.001) at higher BMI. A gender-by-weight group interaction (p = 0.001) showed that at lower weights girls were more accurate than boys, but at higher weights girls were less accurate. Using the verbal scale, the majority of children reported their body size as "just right" in all weight groups (52-73%), with no sex differences.

CONCLUSIONS

Children can estimate their body size using visual or verbal methods with some accuracy, but show greater underestimation at higher weights, especially in girls. These findings suggest that underestimation is more widespread than has been assumed, which has implications for health education among school-aged children.

An interview with Paul Chadwick

As a podiatrist wound care formed only a small part of my undergraduate training (I qualified in 1990). Theory as it existed at the time was taught but practical experience was minimal and restricted to post-operative dressings and for the lucky ones maybe a foot ulcer on clinical placement. My first exposure to diabetic foot ulceration came about 3 months after qualification when I was asked to cover sickness at the local hospital. It was very nearly my last I was thrown in single-handed and not prepared in terms of experience and knowledge. Unsurprisingly, I stayed away from wounds for about 3 years. When in a new role, as part of my personal development I asked to shadow the foot ulcer clinic at the Royal Hallamshire in Sheffield. From this I developed a keen interest and applied for a job in Salford where I continue to work which had a strong wound component. This has grown and now forms the majority of my clinical work.

Responding mindfully to distressing psychosis: A grounded theory analysis

This study investigates the psychological process involved when people with current distressing psychosis learned to respond mindfully to unpleasant psychotic sensations (voices, thoughts, and images). Sixteen participants were interviewed on completion of a mindfulness group program. Grounded theory methodology was used to generate a theory of the core psychological process using a systematically applied set of methods linking analysis with data collection. The theory inducted describes the experience of relating differently to psychosis through a three-stage process: centering in awareness of psychosis; allowing voices, thoughts, and images to come and go without reacting or struggle; and reclaiming power through acceptance of psychosis and the self. The conceptual and clinical applications of the theory and its limits are discussed.

Responding mindfully to unpleasant thoughts and images: reliability and validity of the Southampton mindfulness questionnaire (SMQ)

OBJECTIVE

To assess the reliability and validity of the Southampton mindfulness questionnaire (SMQ), a 16-item measure of mindful awareness of distressing thoughts and images.

METHODS

A total of 256 people participated, comprising a non-clinical community sample of 134 (83 meditators and 51 non-meditators) and a clinical sample of 122 people with a current distressing psychosis. To assess concurrent validity, non-clinical participants and half clinical participants (total 197 participants) completed the mindful attention awareness scale (MAAS). Predicted links were assessed with affect, and 59 patients completed a validated measure to assess link between mindfulness and intensity of 'delusional' experience.

RESULTS

The scale has a single factor structure, was internally reliable, significantly correlated with the MAAS, showed expected associations with affect, and distinguished among meditators, non-meditators and people with psychosis.

CONCLUSIONS

The data support use of the SMQ in clinical practice and research to assess mindful responding to distressing thoughts and images.

Subtypes of paranoia in a nonclinical sample

INTRODUCTION

Previous research has proposed that there may be subtypes of paranoia with different patterns of performance on symptom and clinical measures. However, there has been little empirical examination of whether distinct subtypes actually exist. Recent research has suggested that paranoia can be found in normal individuals and exists on a continuum. Thus, it is possible that evidence for subtypes of paranoia can be derived from nonclinical samples.

METHODS

From a total of 723 participants, we identified 114 college students who showed elevated levels of paranoia as determined by two measures of paranoid ideation. The remaining sample of 609 persons served as the nonparanoid control group. All participants completed measures of depression, self-esteem, and social anxiety. Scores from the high subclinical group was subjected to cluster analysis to derive homogeneous subtypes. Participants also completed a measure of attributional style, the IPSAQ, which was used to validate the subtypes and was not used in the cluster analysis.

RESULTS

Based on the cluster analysis, three subtypes were derived. Each subtype showed a different pattern of scores on measures of depression, self-esteem, and anxiety. There were also additional differences on the externalising and personalising bias scores from the IPSAQ between the subtypes.

CONCLUSIONS

We conclude that there is preliminary evidence for the presence of subtypes among nonclinical samples and discuss the patterns of performance in relation to previous research on subtypes of paranoia. The implications of these subtypes for the study of paranoia are discussed.

A pilot randomized control trial investigating the effect of mindfulness practice on pain tolerance, psychological well-being, and physiological activity

OBJECTIVE

To investigate the effect of mindfulness training on pain tolerance, psychological well-being, physiological activity, and the acquisition of mindfulness skills.

METHODS

Forty-two asymptomatic University students participated in a randomized, single-blind, active control pilot study. Participants in the experimental condition were offered six (1-h) mindfulness sessions; control participants were offered two (1-h) Guided Visual Imagery sessions. Both groups were provided with practice CDs and encouraged to practice daily. Pre-post pain tolerance (cold pressor test), mood, blood pressure, pulse, and mindfulness skills were obtained.

RESULTS

Pain tolerance significantly increased in the mindfulness condition only. There was a strong trend indicating that mindfulness skills increased in the mindfulness condition, but this was not related to improved pain tolerance. Diastolic blood pressure significantly decreased in both conditions.

CONCLUSION

Mindfulness training did increase pain tolerance, but this was not related to the acquisition of mindfulness skills.

An investigation of the effects of TETRA RF fields on intracellular calcium in neurones and cardiac myocytes

PURPOSE

This study aimed to determine whether Terrestrial Trunked Radio (TETRA) fields can affect intracellular calcium signalling in excitable cells.

MATERIALS AND METHODS

Intracellular calcium concentration ([Ca(2 +) ](i)) was measured in cultured rat cerebellar granule cells and cardiac myocytes during exposure to TETRA fields (380.8875 MHz pulse modulated at 17.6 Hz, 25% duty cycle). [Ca(2 +) ](i) was measured as fura-PE3, fluo-3 or fluo-4 fluorescence by digital image analysis.

RESULTS

Granule cells exposed at specific absorption rates (SARs) of 5, 10, 20, 50 or 400 mW x kg(-1) showed no significant changes in resting [Ca(2 +) ](i). Increases in [Ca(2 +) ](i) in response to potassium-induced depolarization were significantly different from sham controls in TETRA-exposed cells, but the majority of the difference was attributable to initial biological variation between cell cultures. No difference was found between fura-PE3 (UV excitation) and fluo-3 (visible light excitation) measurements in these cells. Exposure to TETRA (50 or 400 mW x kg(-1)) had no significant effect on either the rate or amplitude of spontaneous Ca(2 +) transients in cardiac myocytes. The cells showed normal responses to salbutamol (50 microM) and acetylcholine (10 microM).

CONCLUSIONS

Overall, these results showed no evidence of any consistent or biologically relevant effect of TETRA fields on [Ca(2 + )](i) in granule cells and cardiac myocytes at any of the SAR tested.

The reliability and quality of cognitive case formulation

Limited research on the reliability of cognitive case formulation suggests cognitive therapists can agree about clients' presenting problems but show poor agreement about the inferential aspects of formulation. There has been no research examining the quality of practitioners' case formulations. This study assessed whether participants with different levels of experience could produce reliable cognitive formulations using a systematic cognitive therapy case formulation method: the J. Beck Case Conceptualization Diagram. As part of continuing education workshops on cognitive case formulation, 115 mental health practitioners were given the same case description and asked to provide case formulations. Inter-rater agreement and agreement with a "benchmark" formulation provided by J. Beck were measured. The results showed that participants were able to agree with each other and with the benchmark on most descriptive aspects of the formulation but rates of agreement decreased for aspects of the formulation requiring greater levels of theory-driven inference. Based on definitions and measurements of the quality of cognitive formulations derived in this study, the quality of formulations ranged from very poor to good, with only 44% rated as being at least good enough. Both reliability and quality of case formulations were associated with levels of clinical experience and accreditation status. Implications for training and supervision are discussed.

Assessing the acceptability and feasibility of the MEND Programme in a small group of obese 7-11-year-old children

BACKGROUND AND AIMS

An uncontrolled, pilot study to evaluate feasibility and acceptability of a new community based childhood obesity treatment programme.

METHODS

The mind, exercise, nutrition and diet (MEND) programme was held at a sports centre, twice-weekly, for 3 months. The programme consists of behaviour modification, physical activity and nutrition education. The primary outcome measure was waist circumference. Secondary outcomes were body mass index (BMI), cardiovascular fitness (heart rate, blood pressure and number of steps in 2 min), self-esteem and body composition. BMI of parents was also measured. See http://www.mendprogramme.org.

RESULTS

Eleven obese children (7-11 years) and their families were recruited. Mean attendance was 78% (range 63-88%) with one drop out. Waist circumference, cardiovascular fitness and self-esteem were all significantly improved at 3 months and continued to improve at 6 months. BMI was significantly improved at 3 months but lost significance by 6 months. Deuterium studies showed a beneficial trend but were not significant. Of the 17 parents measured, seven were obese (BMI >/= 30) and eight overweight (BMI >/= 25).

CONCLUSIONS

Although limited by the small number of participants and no control group, the MEND programme was acceptable to families and produced significant improvements in a range of risk factors associated with obesity that persisted over 3 months.

The person in recovery from acute and severe psychosis: the role of dependency, self-criticism, and efficacy

The role of 3 personality dimensions (i.e., dependency, self-criticism, and efficacy) in recovery from an acute and severe psychosis was examined. Conceptualizing psychosis as involving difficulties in establishing psychological boundaries, the authors hypothesized that dependency has a greater disruptive effect on recovery than self-criticism. Results of a reanalysis of longitudinal data (N = 76) of people with schizophrenia spectrum disorders during recovery from acute psychosis were consistent with this hypothesis: Dependency predicted depressive and negative symptoms, and, under low efficacy, perceived loss of independence and insight into the presence of the illness. These findings elucidate the central role of interpersonal relatedness as a foundation for self-definition in recovery from psychosis.

Cognitive-behavioural therapy for schizophrenia: filling the therapeutic vacuum

When does a therapeutic intervention become an accepted part of standard clinical practice? Is it when there is sufficient research evidence? But what constitutes ‘sufficient’? What about available resources and acceptability to patients? Do we have to wait until the National Institute for Clinical Excellence pronounces? A convincing evidence base for family work in schizophrenia (Kuipers, 2000) has existed for many years but has been poorly implemented (Anderson & Adams, 1996). Will cognitive-behavioural therapy (CBT) for psychosis suffer the same fate? Which professional group will champion such an implementation? The evidence for other psychological treatments is less robust. Psychoeducation may prolong time to relapse and improve insight but at the cost of increasing suicidal ideation (Carroll et al, 1998). Personal therapy (Hogarty et al, 1997) may be of value but is contra-indicated for patients who are living alone in the community. Psychodynamic approaches are advocated (Mace & Margison, 1997) but most psychiatrists do not support their use in practice, owing to lack of evidence of efficacy.