A preliminary investigation of schematic beliefs and unusual experiences in children

Looking for the good in times of adversity: Examining the interplay of temperament and social schemas in shaping resilience in youth

AIM

Resilience is a broad and dynamic concept that can be seen as being constituted by the combination of internal factors, for example, temperament profiles, and external factors, for example, social support. This paper aimed to identify temperament profiles in help-seeking youth exposed to adverse childhood experiences, and to investigate whether temperament (putative internal protective factor) interacts with social schemas (as proxy for the putative external protective factor social support) such that their combination is associated with (a) reduced mental health problems and (b) attenuated decrease in positive affect following daily life stressors.

METHODS

Self-report questionnaires were used to measure temperament, social schemas and mental health problems. The experience sampling method was used to assess stress and positive affect (i.e., stress-sensitivity as a potential daily life resilience mechanism). Temperament profiles were identified by latent profile analysis and regression analyses were used to examine (interaction) effects.

RESULTS

In 138 subjects, three temperament profiles were identified, that is, a moderate, volatile and persevering profile, of which the latter was negatively associated with mental health problems. Neither mental health problems nor stress sensitivity were found to be affected by the interaction between temperament and social schemas. However, positive social schemas were found to be independently associated with reduced mental health problems (b = -4.41; p = <.001) and reduced stress sensitivity (b = .10, p = .044).

CONCLUSIONS

Findings are relevant for both practice and research, and contribute to improving our understanding of putative protective factor in the development of mental ill-health, thereby further unravelling the construct of resilience.

What's the impact of voice-hearing experiences on the social relating of young people: A comparison between help-seeking young people who did and did not hear voices

Limited research has explored the specific impact of voice-hearing experiences upon the social relating of adolescents. This study examined the associations of voice-hearing in youth with social relating, and putative explanatory factors. An observational, cross-sectional design using a clinical comparison group was employed to examine historical and concurrent associations with voice-hearing. Thirty-four young people (age 14-18 years) with voice-hearing experiences and 34 young people who did not hear voices were recruited from NHS mental health services. Participants completed measures about social relating and potential explanatory factors. Analyses of covariance were used to examine between-group differences. Voice-hearers scored higher on negative schematic beliefs (self-beliefs, partial η2 = .163, p = .001; other-beliefs, partial η2 = .152, p =. 002) and depressive and anxiety symptoms (partial η2 = .23 and partial η2 = .24, p-s <. 001 respectively). The two groups did not differ significantly on childhood trauma levels (partial η2 = .02, p = .273), however, the voice-hearing group scored lower on premorbid adjustment (partial η2 = .19, p < .001). Hearing voices in help-seeking youth could be an indicator for social relating issues and holding negative schematic beliefs, and may be an indicator for of increased psychopathological complexity. Although poorer premorbid adjustment might indicate an early vulnerability to social relating difficulties, voice-hearing might be an aggravating factor and one that requires treatment.

Psychosocial predictors of distressing unusual experiences in adolescence: Testing the fit of an adult cognitive model of psychosis

BACKGROUND

For adults with psychosis, international guidelines recommend individual and family based cognitive behavioural therapy interventions. Recommendations are extended to children and adolescents, based on adult research. It is also recommended that psychological interventions are offered for childhood presentations of psychotic-like or Unusual Experiences (UE), in the absence of a formal diagnosis, when these are Distressing (UEDs). Cognitive models underpinning these interventions require testing in adolescent populations, to further refine therapies. We address this need, by testing for the first time, the application of the adult cognitive model of psychosis to adolescent UEDs.

METHODS

We used baseline data from the Coping with Unusual ExperienceS (CUES+) randomised controlled trial for 122 clinically referred adolescents (12-18 years) with self-reported UEDs. Known psychological mechanisms of adult cognitive models of psychosis; negative life events, affect (anxiety and depression), reasoning (jumping to conclusions bias), and schemas were investigated using multiple linear regression models, alongside variables particularly associated with the development and severity of adolescent UEDs and UE type (dissociation, externalising/behavioural problems, managing emotions).

RESULTS

The psychological mechanisms of adult cognitive models of psychosis explained 89% of the total variance of adolescent UED severity, F (10, 106) = 99.34, p < .0005, r² = 0.89, with schemas as the principal significant contributor. Variance explained 40 - 72% across each of the UE types (paranoia, hallucinations, delusions, paranormal thinking and grandiosity).

CONCLUSIONS

Findings suggest that the psychological components of adult cognitive models of psychosis, particularly schemas, are also implicated in adolescent UEDs.

Narrative identity in the psychosis spectrum: A systematic review and developmental model

Individuals with schizophrenia-spectrum disorders face profound challenges as they attempt to maintain identity through the course of illness. Narrative identity-the study of internalized, evolving life stories-provides a rich theoretical and empirical perspective on these challenges. Based on evidence from a systematic review of narrative identity in the psychosis spectrum (30 studies, combined N = 3859), we argue that the narrative identities of individuals with schizophrenia-spectrum disorders are distinguished by three features: disjointed structure, a focus on suffering, and detached narration. Psychotic disorders typically begin to emerge during adolescence and emerging adulthood, which are formative developmental stages for narrative identity, so it is particularly informative to understand identity disturbances from a developmental perspective. We propose a developmental model in which a focus on suffering emerges in childhood; disjointed structure emerges in middle and late adolescence; and detached narration emerges before or around the time of a first psychotic episode. Further research with imminent risk and early course psychosis populations would be needed to test these predictions. The disrupted life stories of individuals on the psychosis spectrum provide multiple rich avenues for further research to understand narrative self-disturbances.

Understanding the role of self in auditory verbal hallucinations using a self-discrepancy paradigm

OBJECTIVE

Negative auditory verbal hallucination (AVH) content is a major predictor of distress and typically occurs more frequently than positive or neutral content. Recent research has found that negative views of self are associated with the negative content of AVHs. However, research investigating the role of self in AVH content is in its infancy and warrants further study.

DESIGN

The current study examined correspondence between negative voice content and internalized representations of self, using a self-discrepancy paradigm incorporating multiple domains of self (ideal, ought, and feared). It also considered the impact of depression and anxiety.

METHOD

An adapted self-discrepancy questionnaire was administered to a transdiagnostic clinical sample of 86 current voice-hearers. Participants rated how similar they believed themselves to be (actual self), and how similar their voices would say they are (voice self), to their ideal, ought, and feared self-concepts.

RESULTS

Voice content was related to how the person viewed themselves in relation to their ideal, ought, and feared self-concepts. Additionally, voices reflected negative feared self-concepts, particularly in people with anxiety.

CONCLUSIONS

These findings provide further insight into the phenomenon of hearing voices and have the potential to change the way we approach formulation and treatment of AVHs. In particular, treatment approaches that reduce discrepancies between how one views themselves and their positive and negative self-concepts, or alter the relationship one has with their self-concepts and negative voices, have the potential to reduce the impact of distressing voices.

PRACTITIONER POINTS

Voice experiences can be meaningfully related to how the person views themselves in relation to concepts of their ideal, ought, and feared selves Negative voice content might be understood as reflecting discrepancies from these self-representations, which may have a self-regulatory function in relation to goal-directed behaviour. Identifying how voice content relates to self could be useful in not only challenging the extent of perceived self-discrepancies, but also considering how to enact valued parts of self.

Hallucinations in Children and Adolescents: An Updated Review and Practical Recommendations for Clinicians

Hallucinations in children and adolescents are now known to occur on a continuum from healthy to psychopathology-related phenomena. Although hallucinations in young populations are mostly transient, they can cause substantial distress. Despite hallucinations being widely investigated, research so far has had limited implications for clinical practice. The present article has 3 main aims: (1) to review research findings since 2014 (when the last major review of the area was published); (2) to present assessment tools validated to measure hallucinations in children and adolescents; and (3) to discuss therapeutic strategies and clinical issues. We conclude by presenting a tailored care model for clinicians and outline future challenges for research.

In and out of schizophrenia: Activation and deactivation of the negative and positive schemas

Theorists, clinicians, and investigators have attempted to find a common source for the negative and positive symptoms of schizophrenia. We propose that a unified theory, based on a common cognitive structure not only has explanatory value, but can serve as a framework for a psychotherapeutic intervention. Specifically, we propose that the cognitive triad - the negative view of the self, others, and the future - is the source of the content for the negative and positive symptoms. We report literature supporting the relationship between each facet of the negative triad and each of the key symptoms: expressive negative symptoms, delusions, and verbal hallucinations. We conclude that the literature supports the validity of the cognitive model of negative and positive symptoms. The cognitive model furthers the understanding of the positive and negative symptoms of schizophrenia, and we describe how this provides a framework for a psychotherapeutic intervention.

Parental separation and parental mental health in childhood and tinnitus and hyperacusis disability in adulthood: a retrospective exploratory analysis

OBJECTIVES

To explore the relationships between parental separation and parental mental health in childhood with tinnitus and hyperacusis disability in adulthood.

DESIGN

Retrospective cross-sectional.

STUDY SAMPLE

The data for consecutive patients who attended a tinnitus and hyperacusis clinic in the UK over a six months period were included (n = 184).

RESULTS

14.7% of patients reported that while they were growing up, their parents were separated or divorced. There were no significant differences in Tinnitus Handicap Inventory (THI) and Hyperacusis Questionnaire (HQ) between patients with and without history of parental separation. About 40.2% reported history of mental health disorders in their parents. The scores on THI and HQ were worse in the group that reported mental health disorders in their parents (p < .01). Parental mental health illness did not significantly relate to THI, however, it was significantly related to the risk of hyperacusis (odds ratio [OR], after adjusting for age and gender: 2.05, p = .026). The adjusted OR for a subgroup of patients with a diagnosis of hyperacusis was 6.7 (p = .011), indicating a stronger relationship for this subgroup.

CONCLUSIONS

Among patients seeking help for their tinnitus and hyperacusis, poor parental mental health was associated with increased hyperacusis disability.

In the eye of the beholder: Perceptions of neighborhood adversity and psychotic experiences in adolescence

Adolescent psychotic experiences increase risk for schizophrenia and other severe psychopathology in adulthood. Converging evidence implicates urban and adverse neighborhood conditions in the etiology of adolescent psychotic experiences, but the role of young people's personal perceptions of disorder (i.e., physical and social signs of threat) in their neighborhood is unknown. This was examined using data from the Environmental Risk Longitudinal Twin Study, a nationally representative birth cohort of 2,232 British twins. Participants were interviewed at age 18 about psychotic phenomena and perceptions of disorder in the neighborhood. Multilevel, longitudinal, and genetically sensitive analyses investigated the association between perceptions of neighborhood disorder and adolescent psychotic experiences. Adolescents who perceived higher levels of neighborhood disorder were significantly more likely to have psychotic experiences, even after accounting for objectively/independently measured levels of crime and disorder, neighborhood- and family-level socioeconomic status, family psychiatric history, adolescent substance and mood problems, and childhood psychotic symptoms: odds ratio = 1.62, 95% confidence interval [1.27, 2.05], p < .001. The phenotypic overlap between adolescent psychotic experiences and perceptions of neighborhood disorder was explained by overlapping common environmental influences, rC = .88, 95% confidence interval [0.26, 1.00]. Findings suggest that early psychological interventions to prevent adolescent psychotic experiences should explore the role of young people's (potentially modifiable) perceptions of threatening neighborhood conditions.

Childhood unusual experiences in community Child and Adolescent Mental Health Services in South East London: Prevalence and impact

BACKGROUND

Distressing 'psychotic-like' or unusual experiences (UEDs) signify increased mental health risk in the general population, including greater likelihood and severity of co-occurring non-psychotic mental health problems, and, from fourteen years of age, increased risk of a future psychotic illness. Healthcare guidelines for under eighteens recommend psychological intervention for UEDs, to reduce current distress and adverse functional impact, and, potentially, future mental health risk. Children tend not to report UEDs unless directly asked, indicating a need for routine screening. We report on the feasibility of a routine screening methodology, and screening outcomes, in Child and Adolescent Mental Health Services (CAMHS) in South East London, United Kingdom.

METHOD

Four general community CAMHS teams were invited to screen, by adding a nine-item self-report UED measure to their routine assessment battery. Screening data were collected over 18months from 02/2015 to 07/2016.

RESULTS

All but one team agreed to screen. Each team saw around 300 accepted referrals during the audit period (total: 900); 768 of these (85%) were successfully screened; of those screened, 68% (n=524) self-reported UEs, 60% (n=461) with associated distress/adverse functional impact. Screening was acceptable to clinicians, children and families.

CONCLUSIONS

Assessing UEDs routinely in CAMHS is feasible, and suggests that around two thirds of assessed referrals could potentially benefit from interventions targeting UEDs. Additional training may be required for the CAMHS workforce to address this need.

Marked differences in core beliefs about self and others, between sociotropy and autonomy: personality vulnerabilities in the cognitive model of depression

OBJECTIVE

The cognitive model of depression posits two distinctive personality vulnerabilities termed sociotropy and autonomy, each of which is composed of a cluster of maladaptive self-schemas. It is postulated that negative core beliefs about self underlie maladaptive self-schemas as a whole, whereas those about others may be implicated in the autonomous self-schemas. Therefore, the present study examined the relations of sociotropy and autonomy with core beliefs about self and others.

METHODS

The sample of this study consisted of 321 healthy Japanese volunteers. Sociotropy and autonomy were evaluated by the corresponding subscales of the Sociotropy-Autonomy Scale. Core beliefs about self and others were assessed by the negative-self, positive-self, negative-other and positive-other subscales of the Brief Core Schema Scales.

RESULTS

In the forced multiple regression analysis, sociotropy scores were correlated with negative-self scores (β = 0.389, P < 0.001). Meanwhile, autonomy scores were correlated with positive-self scores (β = 0.199, P < 0.01) and negative-other scores (β = 0.191, P < 0.01).

CONCLUSION

The present study suggests marked differences in core beliefs about self and others between sociotropy and autonomy, further contrasting the two personality vulnerabilities to depression.

Coping with Unusual ExperienceS for 12-18 year olds (CUES+): a transdiagnostic randomised controlled trial of the effectiveness of cognitive therapy in reducing distress associated with unusual experiences in adolescent mental health services: study protocol for a randomised controlled trial

BACKGROUND

Childhood 'unusual experiences' (such as hearing voices that others cannot, or suspicions of being followed) are common, but can become more distressing during adolescence, especially for young people in contact with Child and Adolescent Mental Health Services (CAMHS). Unusual experiences that are distressing or have adverse life impact (UEDs) are associated with a range of current and future emotional, behavioural and mental health difficulties. Recommendations for psychological intervention are based on evidence from adult studies, with some support from small, pilot, child-specific evaluations. Research is needed to ensure that the recommendations suit children as well as adults. The CUES+ study (Coping with Unusual ExperienceS for 12-18 year olds) aims to find out whether cognitive behaviour therapy for UEDs (CBT-UED) is a helpful and cost-effective addition to usual community care for 12-18 year olds presenting to United Kingdom National Health Service Child and Adolescent Mental Health Services in four London boroughs.

METHODS

The CUES+ study is a randomised controlled trial comparing CBT-UED plus routine care to routine care alone. CBT-UED comprises up to 16 sessions, including up to 12 individual and up to four family support meetings, each lasting around 45-60 min, delivered weekly. The primary outcome is emotional distress. Secondary outcomes are change in UEDs, risk events (self-harm, attendance at emergency services, other adverse events) and health economic outcomes. Participants will be randomised in a 1:1 ratio after baseline assessment. Randomisation will be stratified by borough and by severity of mental health presentation: 'severe' (an identified psychotic or bipolar disorder) or any 'other' condition. Outcomes will be assessed by a trained assessor blind to treatment condition at 0, 16 and 24 weeks. Recruitment began in February, 2015 and is ongoing until the end of March, 2017.

DISCUSSION

The CUES+ study will contribute to the currently limited child-specific evidence base for psychological interventions for UEDs occurring in the context of psychosis or any other mental health presentation.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials, ID: ISRCTN21802136 . Prospectively registered on 12 January 2015. Protocol V3 31 August 2015 with screening amended.

Cognitive, affective, and social factors maintaining paranoia in adolescents with mental health problems: A longitudinal study

Paranoia may be a significant concern during adolescence, but there has been little research on excessive mistrust in young people. In this longitudinal study we set out to test the predictive ability of a number of cognitive, affective, and social factors in the early development of paranoia in a clinical adolescent population. Thirty four help-seeking adolescents, aged 11-16 years, reporting paranoid thoughts and attending mental health services were recruited. Self-report and interview assessments of paranoia were conducted at baseline. Measures relating to a cognitive model of persecutory delusions were completed. Paranoia was reassessed after three months with thirty three participants. Significant predictors of paranoia persistence were anxiety, depression, worry, negative self-beliefs, perceptual anomalies, insomnia, affective reactivity, bullying, and cyber victimization. No effect was found for reasoning bias or negative perceptions of academic ability, social competence, and physical appearance. In conclusion, many of the maintenance factors implicated in adult paranoia are likely to prove important in the early development of paranoia in young people. Further experimental and treatment studies are now needed to examine the causal role of these factors in the occurrence of paranoia in adolescents.

Toward earlier identification and preventative intervention in schizophrenia: evidence from the London Child Health and Development Study

PURPOSE

The London Child Health and Development Study (CHADS) is a prospective, longitudinal investigation of children, sampled from the general community aged 9-11 years and assessed biennially, who present premorbid risk markers for schizophrenia. The study aims to characterise developmental trajectories of psychological, cognitive, and biological functioning in at-risk children and identify potential targets for early preventative intervention. This review summarises CHADS findings, discusses these in the context of recent theory regarding aetiology and prevention of schizophrenia, and highlights challenges to be addressed with future research.

METHODS

We review (1) epidemiological information on the prevalence and correlates of developmental antecedents of schizophrenia in the general child population, (2) evidence of psychosocial, cognitive, and biological dysfunctions in at-risk children presenting multiple antecedents of schizophrenia and at-risk children with a family history of schizophrenia, and (3) related findings from an associated sample of help-seeking children receiving intervention.

RESULTS

Community-based screening of 9-11-year olds identified ~9 % with a triad of antecedents of schizophrenia [including psychotic-like experiences (PLEs)] who are putatively at-risk of psychosis; these children reported greater exposure and responsivity to stressors, impairments in general intelligence and specific cognitive functions, brain structure and function abnormalities, and neuromotor dysfunction. Preliminary evidence suggests distressing PLEs are a viable target for cognitive-behavioural intervention in at-risk children.

CONCLUSIONS

Intervention in early, premorbid phases of illness might alleviate current difficulties and avert future schizophrenia using benign treatments. The CHADS programme has identified several markers that may index early pathophysiology and constitute potential targets for preventative intervention.

Variation in psychosocial influences according to the dimensions and content of children's unusual experiences: potential routes for the development of targeted interventions

The psychosocial processes implicated in the development and maintenance of psychosis differ according to both the dimensional attributes (conviction, frequency, associated distress, adverse life impact) and the content or type (e.g. grandiosity, hallucinations, paranoia) of the psychotic symptoms experienced. This has informed the development of 'targeted' cognitive behavioural therapy for psychosis (CBTp): interventions focusing on specific psychological processes in the context of particular symptom presentations. In adults, larger effect sizes for change in primary outcomes are typically reported in trials of targeted interventions, compared to those for trials of generic CBTp approaches with multiple therapeutic foci. We set out to test the theoretical basis for developing targeted CBTp interventions for young people with distressing psychotic-like, or unusual, experiences (UEs). We investigated variations in the psychosocial processes previously associated with self-reported UE severity (reasoning, negative life events, emotional problems) according to UE dimensional attributes and content/type (using an established five-factor model) in a clinically referred sample of 72 young people aged 8-14 years. Regression analyses revealed associations of conviction and grandiosity with reasoning; of frequency, and hallucinations and paranoia, with negative life events; and of distress/adverse life impact, and paranoia and hallucinations, with emotional problems. We conclude that psychological targets for intervention differ according to particular characteristics of childhood UEs in much the same way as for psychotic symptoms in adults. The development of targeted interventions is therefore indicated, and tailoring therapy according to presentation should further improve clinical outcomes for these young people.

Understanding the relationship between schematic beliefs, bullying, and unusual experiences in 8-14 year olds

BACKGROUND

Cognitive models of adult psychosis propose that negative schematic beliefs (NSBs) mediate the established association between victimisation and psychotic symptoms. In childhood, unusual, or psychotic-like, experiences are associated with bullying (a common form of victimisation) and NSBs. This study tests the mediating role of NSBs in the relationship between bullying and distressing unusual experiences (UEDs) in childhood.

METHOD

Ninety-four 8-14 year olds referred to community Child and Adolescent Mental Health Services completed self-report assessments of UEDs, bullying, and NSBs about the self (NS) and others (NO).

RESULTS

Both NS and NO were associated with bullying (NS: r=.40, P<.001; NO: r=.33, P=.002), and with UEDs (NS: r=.51, P<.001; NO: r=.43, P<.001). Both NS and NO significantly mediated the relationship between bullying and UEDs (NS: z=3.15, P=.002; NO: z=2.35, P=.019).

CONCLUSIONS

Children's NSBs may mediate the adverse psychological impact of victimisation, and are appropriate treatment targets for young people with UEDs. Early educational intervention to reduce negative appraisals of the self and others may increase resilience to future adverse experiences and reduce later mental health risk.