The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: a meta-analysis

Hallucinations as a trauma-based memory: implications for psychological interventions

The relationship between hallucinations and life events is a topic of significant clinical importance. This review discusses the extent to which auditory and visual hallucinations may be directly related to traumatic events. Evidence suggests that intrusive images occur frequently within individuals who also report hallucinatory experiences. However, there has been limited research specifically investigating the extent to which hallucinations are the re-experiencing of a traumatic event. Our current theoretical understanding of these relationships, along with methodological difficulties associated with research in this area, are considered. Recent clinical studies, which adopt interventions aimed at the symptoms of posttraumatic stress disorder in people diagnosed with a psychotic disorder, are reviewed. There is a need for the development of evidence-based interventions in this area.

Decreasing self-reported cognitive biases and increasing clinical insight through meta-cognitive training in patients with chronic schizophrenia

BACKGROUND AND OBJECTIVES

The aim of this study was to assess the impact of meta-cognitive training (MCT) on cognitive biases, symptoms, clinical insight, and general functioning among low-level functioning persons diagnosed with chronic schizophrenia who were attending a daily Community Social Support Group Program; we compared the treatment-as-usual (TAU) condition with the MCT + TAU condition.

METHODS

Forty-four patients diagnosed with chronic schizophrenia were allocated to either the MCT + treatment-as-usual condition or the treatment-as-usual (TAU) condition. Delusion and hallucination severity, cognitive biases, clinical insight, and global functioning were assessed pre- and post-treatment (clinical trial NCT02187692).

RESULTS

No significant changes were found in symptom severity as measured with the PSYRATS. Conversely, a medium to large effect size was observed for delusional ideation changes when assessed by the self-report measure (Paranoia Checklist). MCT was found to ameliorate cognitive biases as measured by the self-report scale at large effect size, however, no changes in jumping to conclusions (the Fish Task) and theory of mind deficits ("Reading the Mind in the Eyes" Test) were found in the behavioral tasks. MCT increased insight at large effect size. No changes in global functioning were found between the two conditions.

LIMITATIONS

Low intensity intervention. No follow-up assessment was provided. Only PSYRATS was assessed blind to patient allocation.

CONCLUSIONS

MCT has a beneficial effect on low-functioning chronic schizophrenic patients in ameliorating cognitive biases and increasing clinical insight.

Can we respond mindfully to distressing voices? A systematic review of evidence for engagement, acceptability, effectiveness and mechanisms of change for mindfulness-based interventions for people distressed by hearing voices

Adapted mindfulness-based interventions (MBIs) could be of benefit for people distressed by hearing voices. This paper presents a systematic review of studies exploring this possibility and we ask five questions: (1) Is trait mindfulness associated with reduced distress and disturbance in relation to hearing voices? (2) Are MBIs feasible for people distressed by hearing voices? (3) Are MBIs acceptable and safe for people distressed by hearing voices? (4) Are MBIs effective at reducing distress and disturbance in people distressed by hearing voices? (5) If effective, what are the mechanisms of change through which MBIs for distressing voices work? Fifteen studies were identified through a systematic search (n = 479). In relation to the five review questions: (1) data from cross-sectional studies showed an association between trait mindfulness and distress and disturbance in relation to hearing voices; (2) evidence from qualitative studies suggested that people distressed by hearing voices could engage meaningfully in mindfulness practice; (3) MBIs were seen as acceptable and safe; (4) there were no adequately powered RCTs allowing conclusions about effectiveness to be drawn; and (5) it was not possible to draw on robust empirical data to comment on potential mechanisms of change although findings from the qualitative studies identified three potential change processes; (i) reorientation of attention; (ii) decentring; and (iii) acceptance of voices. This review provided evidence that MBIs are engaging, acceptable, and safe. Evidence for effectiveness in reducing distress and disturbance is lacking however. We call for funding for adequately powered RCTs that will allow questions of effectiveness, maintenance of effects, mechanisms of change and moderators of outcome to be definitively addressed.

The effects of an Audio Visual Assisted Therapy Aid for Refractory auditory hallucinations (AVATAR therapy): study protocol for a randomised controlled trial

BACKGROUND

Psychological interventions which adopt an explicitly interpersonal approach are a recent development in the treatment of distressing voices. AVATAR therapy is one such approach which creates a direct dialogue between a voice-hearer and a computerised representation of their persecutory voice (the avatar) through which the person may be supported to gain a sense of greater power and control. The main objective of the trial is to test the clinical efficacy of this therapy to reduce the frequency and severity of auditory verbal hallucinations (AVH). Secondary objectives of the study are to explore explanatory mechanisms of action and potential moderators, to carry out a qualitative evaluation of participants' experience and to conduct an economic evaluation.

METHODS/DESIGN

The AVATAR randomised clinical trial will independently randomise 142 participants to receive either 7 sessions of AVATAR therapy or supportive counselling (SC). The study population will be individuals with schizophrenia spectrum and other psychotic disorders who report hearing persistent distressing voices, for more than 12 months, which are unresponsive or only partially responsive to antipsychotic medication. The main hypotheses are that, compared to SC, AVATAR therapy will reduce the frequency and severity of AVH and will also reduce the reported omnipotence and malevolence of these voices. Assessments will occur at 0 weeks (baseline), 12 weeks (post-intervention) and 24 weeks (follow-up), and will be carried out by blinded assessors. Both interventions will be delivered in a community-based mental health centre. Therapy competence and adherence will be monitored in both groups. Statistical analysis will follow the intention-to-treat principle and data will be analysed using a mixed (random) effects model at each post treatment time point separately. A formal mediation and moderator analysis using contemporary causal inference methods will be conducted as a secondary analysis. The trial is funded by the Welcome Trust (WT).

DISCUSSION

AVATAR therapy showed promising effects in a pilot study, but the efficacy of the approach needs to be examined in a larger randomised clinical trial before wider dissemination and implementation in mental health services.

TRIAL REGISTRATION

Current Controlled Trials

ISRCTN

65314790 , registration date: 27 March 2013.

Bringing the "self" into focus: conceptualising the role of self-experience for understanding and working with distressing voices

A primary goal of cognitive behavior therapy for psychosis (CBTp) is to reduce distress and disability, not to change the positive symptoms of psychosis, such as hearing voices. Despite demonstrated associations between beliefs about voices and distress, the effects of CBTp on reducing voice distress are disappointing. Research has begun to explore the role that the psychological construct of "self" (which includes numerous facets such as self-reflection, self-schema and self-concept) might play in causing and maintaining distress and disability in voice hearers. However, attempts to clarify and integrate these different perspectives within the voice hearing literature, or to explore their clinical implications, are still in their infancy. This paper outlines how the self has been conceptualised in the psychosis and CBT literatures, followed by a review of the evidence regarding the proposed role of this construct in the etiology of and adaptation to voice hearing experiences. We go on to discuss some of the specific intervention methods that aim to target these aspects of self-experience and end by identifying key research questions in this area. Notably, we suggest that interventions specifically targeting aspects of self-experience, including self-affection, self-reflection, self-schema and self-concept, may be sufficient to reduce distress and disruption in the context of hearing voices, a suggestion that now requires further empirical investigation.

Effects of cognitive behaviour therapy for worry on persecutory delusions in patients with psychosis (WIT): a parallel, single-blind, randomised controlled trial with a mediation analysis

BACKGROUND

Worry might be a contributory causal factor in the occurrence of persecutory delusions in patients with psychotic disorders. Therefore we postulated that reducing worry with cognitive behaviour therapy (CBT) would reduce persecutory delusions.

METHODS

For our two-arm, assessor-blinded, randomised controlled trial (Worry Intervention Trial [WIT]), we recruited patients aged 18-65 years with persistent persecutory delusions but non-affective psychosis from two centres: the Oxford Health National Health Service (NHS) Foundation Trust (Oxford, UK) and the Southern Health NHS Foundation Trust (Southampton, UK). The key inclusion criteria for participants were a score of at least 3 on the Psychotic Symptoms Rating Scale (PSYRATS) denoting a current persecutory delusion; that the delusion had persisted for at least 3 months; a clinical diagnosis of schizophrenia, schizoaffective disorder, or delusional disorder; and a clinically significant level of worry. We randomly assigned (1:1) eligible patients, using a randomly permuted block procedure with variable block sizes and division by four strata, to either six sessions of worry-reduction CBT intervention done over 8 weeks added to standard care (the CBT-intervention group), or to standard care alone (the control group). The assessors were masked to patient allocations and did their assessments at week 0 (baseline), 8 weeks (end of treatment), and 24 weeks, follow-up. The primary outcomes were worry measured by the Penn State Worry Questionnaire (PSWQ) and delusions measured by the PSYRATS-delusion scale; we did the analyses in the intention-to-treat population, and also did a planned mediation analysis. This trial is registered with the ISRCTN Registry (number ISRCTN23197625) and is closed to new participants.

FINDINGS

From Nov 1, 2011, to Sept 9, 2013, we recruited 150 eligible participants and randomly assigned 73 to the CBT intervention group, and 77 to the control group. 143 patients (95%) provided primary outcome follow-up data. Compared with standard care alone, at 8 weeks the CBT intervention significantly reduced worry (mean difference 6·35 [SE 1·56] PSWQ units, 95% CI 3·30-9·40; p<0·001) and persecutory delusions (2·08 [SE 0·73] PSYRATS units, 95% CI 0·64-3·51; p=0·005). The reductions were maintained to 24 weeks follow-up. The mediation analysis suggested that the change in worry accounted for 66% of the change in delusion. No patients died or were admitted to secure units during our study. Six suicide attempts (two in the CBT intervention group, and four in the control group) and two serious violent incidents (one in each group) were noted, but no adverse events were deemed related to the treatments or the assessments.

INTERPRETATION

To our knowledge, this is the first large trial focused on persecutory delusions. We have shown that long-standing delusions were significantly reduced by a brief intervention targeted on worry, although the limitations for our study include no determination of the key elements within the intervention. Our results suggest that worry might cause paranoia, and that worry intervention techniques might be a beneficial addition to the standard treatment of psychosis.

FUNDING

Efficacy and Mechanism Evaluation programme, which is a UK Medical Research Council and National Institute of Health Research partnership.

Cognitive-behaviour therapy and schizophrenia

People who experience debilitating psychotic symptoms that affect their everyday life are often, but not always, given a diagnosis of schizophrenia. Although the first line of treatment is medication, many people experience a suboptimal response and after the acute symptoms resolve they can continue to experience both hallucinations and delusions. These are generally termed residual symptoms and are the phenomena that cognitive-behavioural therapy for psychosis (CBTp) was originally devised to target. The success of CBTp in randomised controlled trials from the early 90s and evidence of cost-effectiveness has meant that many healthcare services across the world include CBTp in their treatment armamentaria. For instance, in the UK the National Institute for Health and Care Excellence guidance says that all individuals who have a diagnosis of schizophrenia should be given the option of a course of CBTp. Recently, however, the treatment effects have been re-examined, the targets widened and the premise that CBTp should be solely an adjunct to medication has been questioned. This article will describe and probe some of these changes and reflect on the development of psychological treatments for psychosis.

An early Phase II randomised controlled trial testing the effect on persecutory delusions of using CBT to reduce negative cognitions about the self: the potential benefits of enhancing self confidence

BACKGROUND

Research has shown that paranoia may directly build on negative ideas about the self. Feeling inferior can lead to ideas of vulnerability. The clinical prediction is that decreasing negative self cognitions will reduce paranoia.

METHOD

Thirty patients with persistent persecutory delusions were randomised to receive brief CBT in addition to standard care or to standard care (ISRCTN06118265). The six session intervention was designed to decrease negative, and increase positive, self cognitions. Assessments at baseline, 8 weeks (posttreatment) and 12 weeks were carried out by a rater blind to allocation. The primary outcomes were posttreatment scores for negative self beliefs and paranoia. Secondary outcomes were psychological well-being, positive beliefs about the self, persecutory delusions, social comparison, self-esteem, anxiety, and depression.

RESULTS

Trial recruitment and retention were feasible and the intervention highly acceptable to the patients. All patients provided follow-up data. Posttreatment there was a small reduction in negative self beliefs (Cohen's d=0.24) and a moderate reduction in paranoia (d=0.59), but these were not statistically significant. There were statistically significant improvements in psychological well-being (d=1.16), positive beliefs about the self (d=1.00), negative social comparison (d=0.88), self-esteem (d=0.62), and depression (d=0.68). No improvements were maintained. No adverse events were associated with the intervention.

CONCLUSIONS

The intervention produced short-term gains consistent with the prediction that improving cognitions about the self will reduce persecutory delusions. The improvement in psychological well-being is important in its own right. We recommend that the different elements of the intervention are tested separately and that the treatment is lengthened.