The experience of body image concerns in patients with persecutory delusions: 'People don't want to sit next to me'

Barriers to Pain Management as Perceived by Cancer and Noncancer Patients With Chronic Disease

BACKGROUND

Pain is the most common symptom experienced by both cancer and non-cancer patients. A wide variety of barriers may hinder the optimal treatment of cancer and noncancer pain that are related to the health care system, health care providers, and patients.

PURPOSE

To explore the barriers to pain management as perceived by patients with cancer and noncancer chronic diseases.

METHOD

A descriptive, cross-sectional correlational design was employed to recruit a sample of 200 patients (n = 100 patients with cancer, n= 100 patients with noncancer) from two hospitals in Jordan. Patients filled out an Arabic version of Barriers Questionnaire II (ABQ-II).

RESULTS

Harmful effects of medications were the greatest barrier to effective pain management, while fatalism had the lowest mean scores. Age was negatively correlated with physiological effects (r = -0.287, p < .01), communication (r = -0.263, p < .01), harmful effects (r = -0.284, p < .01), and the overall barrier score (r = -0.326, p < .01) among noncancer patients with chronic disease and (p > .05) for patients with cancer. Patients with cancer had higher mean scores (M = 2.12, SD = 0.78) in the fatalism subscale than those with noncancer chronic disease (M = 1.91, SD = 0.68), while patients with noncancer chronic disease had significantly higher mean scores (M = 2.78, SD = 0.78) in the communication subscale than patients with cancer (M = 2.49, SD = 0.65), (t = -2.899, p = .005).

CONCLUSION

To improve the quality of care for patients who are in pain, it is recommended to address pain management barriers as they arise.

Body image as a mediator in the relationship between psychotic experiences and later disordered eating: A 12-month longitudinal study in high school adolescents

BACKGROUND

The relationship between psychosis and disordered eating remains a challenging area of research to which little interest was paid. Using longitudinal data, we aimed to explore the hypothesis that the pathways from psychotic experiences (PEs) to disordered eating (DE) and body-mass index (BMI) are mediated by body-image disturbances.

METHODS

A prospective longitudinal study was performed. High-school students (N = 510, 61.2% females, mean age of 16.05 ± 1.01 years) were asked to complete three scheduled assessments (Baseline, 6 months, and 12 months).

RESULTS

Two body image components, that is, Overweight Preoccupation and Body Area Satisfaction, mediated the prospective association between baseline PEs and DE 12 months later. Direct effects were significant. After accounting for indirect effects through more severe body image concerns at 6 months, higher baseline PEs were significantly associated with greater DE at 12 months. Baseline PEs and 6-month body image explained a significant proportion of variance in 12-month DE. However, we did not find evidence of a direct prospective association between PEs and BMI.

CONCLUSION

This study is the first to assess the mediating role of body image between PEs and DE. Findings offer promising new avenues for early intervention to help mitigate the effects of PEs on DE in adolescents.

Body image concerns in patients with persecutory delusions

BACKGROUND

Persecutory fears build on feelings of vulnerability that arise from negative views of the self. Body image concerns have the potential to be a powerful driver of feelings of vulnerability. Body image concerns are likely raised in patients with psychosis given the frequent weight gain. We examined for the first-time body esteem - the self-evaluation of appearance - in relation to symptom and psychological correlates in patients with current persecutory delusions.

METHODS

One-hundred and fifteen patients with persecutory delusions in the context of non-affective psychosis completed assessments of body image, self-esteem, body mass index (BMI), psychiatric symptoms and well-being. Body esteem was also assessed in 200 individuals from the general population.

RESULTS

Levels of body esteem were much lower in patients with psychosis than non-clinical controls (d = 1.2, p < 0.001). In patients, body esteem was lower in women than men, and in the overweight or obese BMI categories than the normal weight range. Body image concerns were associated with higher levels of depression (r = -0.55, p < 0.001), negative self-beliefs (r = -0.52, p < 0.001), paranoia (r = -0.25, p = 0.006) and hallucinations (r = -0.21, p = 0.025). Body image concerns were associated with lower levels of psychological wellbeing (r = 0.41, p < 0.001), positive self-beliefs (r = 0.40, p < 0.001), quality of life (r = 0.23, p = 0.015) and overall health (r = 0.31, p = 0.001).

CONCLUSIONS

Patients with current persecutory delusions have low body esteem. Body image concerns are associated with poorer physical and mental health, including more severe psychotic experiences. Improving body image for patients with psychosis is a plausible target of intervention, with the potential to result in a wide range of benefits.

Improving the therapist's metacognition and capacity to intersubjectively attune with a patient with psychosis through the exploration of the therapist's developmental history: a case report

Clinical literature emphasizes how symptoms of psychosis can be efficiently targeted by psychological treatments. The most well-known approach to these symptoms is cognitive-behavioral therapy; but in the last few decades also other approaches are enriching the landscape, focusing on the dysfunctions in mentalization or metacognition, a spectrum of mental activities involving thinking about one's own and others' mental states. This huge amount of theoretical reflection and empirical research focused on the implementation of treatments does not seem to be associated with an attention to the inner world of the therapist who relates to the patient with psychosis; for example, to the impact of the therapist's developmental history on the therapeutic relationship. In this paper the authors are inspired by an intersubjective perspective, according to which although the treatment is for the patient's benefit, both the patient's and the therapist's developmental history and psychological organization are equally relevant for understanding the clinical exchange. On this basis, the authors make a "parallel" analysis of the clinical case of a young woman with symptoms of psychosis (i.e., persecutory delusions, auditory verbal hallucinations, social withdrawal) and its supervision process. They show how the therapeutic relationship can be significantly conditioned by the therapist's developmental history; and how a process of supervision focused on the exploration of the traumatic elements of this history can effectively promote the therapist's metacognitive capabilities, a functional patient-therapist intersubjective attunement, and a good clinical outcome.

Functionality appreciation is inversely associated with positive psychotic symptoms in overweight/obese patients with schizophrenia

BACKGROUND

While the relationship between negative aspects of body image and positive schizophrenia symptoms was extensively investigated and is relatively well-established, there is a dearth of literature on the relationship between positive symptoms and positive aspects of body image, such as body appreciation and functionality appreciation, in patients with schizophrenia. This study aimed to (1) compare weight stigma, body and functionality appreciation between obese/overweight and normal-weight patients with schizophrenia, and (2) explore the associations between these variables and positive psychotic symptoms in the obese/overweight group.

METHOD

A cross-sectional study was conducted in the Psychiatric Hospital of the Cross, Lebanon during September 2022 recruiting selected in-patients diagnosed with schizophrenia. Patients were classified as overweight/obese if they had a BMI > 25 (N = 76 (37.25%), aged 55.57 ± 11.30 years, 42.6% females). The Weight self‑stigma questionnaire, the Functionality Appreciation Scale, and the Body Appreciation Scale, and the Positive and Negative Syndrome Scale (PANSS) were used.

RESULTS

No significant difference was found between overweight/obese and normal-weight patients for all variables, except for weight stigma; a significantly higher weight stigma score was significantly found in overweight/obese compared to normal-weight patient. In the bivariate analysis, higher functionality appreciation was significantly associated with higher positive PANSS scores. The results of the linear regression, taking the positive PANSS score as the dependent variable, showed that higher functionality appreciation (Beta = - 0.52) and higher social support (Beta = - 0.16) were significantly associated with lower positive PANSS scores, whereas having a secondary education level compared to illiteracy (Beta = 7.00) was significantly associated with higher positive PANSS scores.

CONCLUSION

Although based on cross-sectional data, these findings preliminarily suggest that higher functionality appreciation can help reduce the severity of positive psychotic symptoms in overweight/obese schizophrenia patients, and that interventions aimed at improving functionality appreciation could be regarded beneficial therapeutic targets in the treatment of psychosis.

Bridging the gap between body image and paranoia-like thoughts

A feeling of vulnerability is believed to be one of the foundations upon which paranoia is built. Factors that may increase vulnerability include negative affective states, low self-esteem and high social rejection sensitivity. Body image, which is one aspect of the overall self-esteem, has recently been shown to be associated with paranoia. However, little is known about factors underlying this association. In this online study conducted on a non-clinical sample (n = 539, 65.5% of female), self-report data assessing paranoia-like thoughts, body image, self-esteem, negative emotions, rejection sensitivity as well as various attitudes and beliefs related to body appearance were collected. The results revealed a significant serial mediation effect of negative emotions, self-esteem and rejection sensitivity in the relationship between body image and paranoia-like thoughts. Parallel mediation analysis showed an effect of social criticism as the only one of four studied groups of beliefs related to body appearance in the relationship between paranoia-like thoughts and body image. Moreover, paranoia-like thoughts were increased in people who were not satisfied with their body, both as a result of feeling too thin and overweight. To conclude, body image is an important factor related to paranoia-like thoughts, through its association with increased vulnerability and negative general self-view. The findings highlight the importance of negative emotions, low self-esteem and high rejection sensitivity, as well as the role of critical comments and lack of perceived acceptance as potential (socially-focused) mechanisms paving the way from negative body image to paranoia-like thoughts.

Intersections of paranoia and the body in the general population

Negative body image may be associated with heightened feelings of paranoia. The current study aimed to conduct multidimensional assessments of body image and psychosis facets in the general population. Respondents were 407 individuals, who provided basic sociodemographic information, and completed online questionnaires evaluating dysmorphic concerns, body consciousness, paranoia, persecutory and magical ideation and perceptual aberration. Correlation analysis and a series of regressions onto various body image facets (i.e. dysmorphic concerns, private body consciousness, public body consciousness and body competence) were conducted. Distinct patterns of significant associations were uncovered across the range of body image and psychosis facets examined. Paranoia significantly contributed to the severity of dysmorphic concerns, and magical ideation significantly contributed to private and public body consciousness, though effect sizes were modest. Our findings corroborate the relationship between paranoia and dysmorphic concerns, and tentatively suggest that challenging paranoid beliefs could be a useful strategy for managing negative body image.

The effect of medication adherence on psychosocial adjustment to body weight, image, and self-esteem in patients with schizophrenia

PURPOSE

The present study aimed to evaluate the effect of medication adherence on psychosocial adjustment to body weight, image, and self-esteem in patients with schizophrenia.

DESIGN AND METHODS

This cross-sectional and correlational study consisted of 154 patients with schizophrenia registered in a Community Mental Health Center.

FINDINGS

The patients had moderate psychosocial adjustment to body weight, image, and self-esteem, and 56.5% had poor medication adherence. There was a significant positive correlation between participants' medication adherence and psychosocial adjustment to body weight, image, and self-esteem.

PRACTICE IMPLICATIONS

Psychiatric nurses should support patients regarding medication adherence, and psychosocial adjustment to body weight, image, and self-esteem.

Relationships between paranoia and body image concern among community women

Previous research has indicated that lifetime body image concerns are associated with increased odds of paranoid ideation. In this study, we sought to replicate and extend this finding by exploring how paranoia relates to different aspects of body image concern using a comprehensive, cross-sectional design. Women without a mental health diagnosis (n = 119) completed online questionnaires assessing paranoia, shape and weight concerns, and figure ratings for how they "think" their body looks and how they "feel" in their body. Participant's "actual" figure ratings were estimated from height and weight; discrepancy scores were then calculated for "actual-think" and "actual-feel" figure ratings. Correlational analyses, and mediation models testing paranoia as a mediator between "actual-feel" and shape and weight concerns, were conducted. Paranoia was significantly correlated with increased shape and weight concerns, and with "feeling" larger. Paranoia significantly mediated paths from feeling larger to increased shape or weight concerns. There were no significant associations of paranoia with "actual-think" ratings. Limitations include that height and weight data could not be objectively confirmed, and only women were included in the study. Further research is needed to understand mechanisms by which paranoia may influence shape and weight concerns and vice versa, and how "feeling" larger may feed paranoia. Future research should investigate these relationships among clinical eating disorder groups.

The psychological journey of weight gain in psychosis

BACKGROUND

Rapid weight gain is common with antipsychotic medication. Lost confidence, low mood and medication non-adherence often follow. Yet, the dynamic interactions between the physical and psychological consequences of weight gain, and implications for intervention, are unknown.

OBJECTIVES

We examined first-person accounts of weight gain to identify preferences for weight change interventions.

DESIGN

A qualitative design was used to explore patients' experiences of weight change in the context of psychosis.

METHOD

Semi-structured interviews, analysed using grounded theory, were conducted with 10 patients with psychosis. Sample validation was conducted with peer researchers with lived experience of psychosis.

RESULTS

Patients described that initially the extent and speed of weight gain was overshadowed by psychotic experiences and their treatment. This led to a shocking realisation of weight gain. The psychological impact of weight gain, most strikingly on the self-concept, was profound. Loss of self-worth and changed appearance amplified a sense of vulnerability. There were further consequences on mood, activity and psychotic experiences, such as voices commenting on appearance, that were additional obstacles in the challenging process of weight loss. Sedative effects of medication also contributed. Unsuccessful weight loss left little hope and few preferences for interventions. Early information about common weight gain trajectories and working with experts-by-experience were valued. Rebuilding self-confidence, efficacy and worth may be a necessary first step.

CONCLUSIONS

The journey of weight gain in patients with psychosis is characterised by loss of self-worth, agency and hope. There are multiple stages in the journey, each with different psychological reactions, that may need different treatment responses.

Subjective experience and meaning of delusions in psychosis: a systematic review and qualitative evidence synthesis

BACKGROUND

Delusions are a common transdiagnostic feature of psychotic disorders, and their treatment remains suboptimal. Despite the pressing need to better understand the nature, meaning, and course of these symptoms, research into the lived experience of delusional phenomena in psychosis is scarce. Thus, we aimed to explore the lived experience and subjective apprehension of delusions in help-seeking individuals with psychosis, regardless of diagnosis and thematic content of the delusion.

METHODS

In our systematic review and qualitative evidence synthesis, we searched MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science for qualitative studies published in English from database inception, with the last search on Sept 9, 2021. Grey literature search and hand-searching of relevant journals were also done. Studies were eligible if they provided an analysis of lived experience of delusions or predelusional phenomena presented from the perspective of individuals (age 14-65 years) who had developed a clinical high-risk stage of psychosis, or a diagnosable affective or non-affective psychotic disorder (as clinically defined, self-reported, or assessed within the primary study). Studies with only a subset of relevant participants were eligible only if data for the population of interest were reported separately. Studies that did not discriminate between the experience of delusion and other positive symptoms (eg, hallucinations) were included only if data for delusions were reported separately or could be extracted. First-person accounts (and author interpretations) discussing changes in the sense of self, lived world, and meaning in relation to delusions were extracted and synthesised using a novel thematic synthesis approach informed by a critical realist stance and a phenomenological theoretical framework. Analytic themes were developed into a new overarching framework for understanding the emergence of delusional phenomena. The study was registered with PROSPERO, CRD42020222104.

FINDINGS

Of the 3265 records screened, 2115 were identified after duplicate removal. Of these, 1982 were excluded after title and abstract screening and 106 after full-text eligibility assessment. Of the 27 studies entering quality assessment, 24 eligible studies were included in the qualitative evidence synthesis, representing the perspectives of 373 help-seeking individuals with lived experience of delusions in the context of psychosis. Gender was reported as male (n=210), female (n=110), transgender (n=1), or not reported (n=52). Only 13 studies reported ethnicity, with White being predominant. The age of most participants ranged from 15 to 65 years. We found no eligible studies investigating subclinical or predelusional experiences in at-risk mental state populations through qualitative methods. Most studies were undertaken in western, educated, industrialised, rich, and democratic (WEIRD) societies, and most included participants had received or self-reported a diagnosis within the schizophrenia spectrum. Studies differed in relation to whether they focused on one kind or theme of delusion or delusional phenomena more generally as a unified category. Three superordinate themes relating to experiential changes and meanings in delusion were identified: (1) a radical rearrangement of the lived world dominated by intense emotions; (2) doubting, losing, and finding oneself again within delusional realities; and (3) searching for meaning, belonging, and coherence beyond mere dysfunction. Based on the review findings and thematic synthesis, we propose the Emergence Model of Delusion to advance understanding of delusional phenomena in psychosis.

INTERPRETATION

Delusions are best understood as strongly individualised and inherently complex phenomena emerging from a dynamic interplay between interdependent subpersonal, personal, interpersonal, and sociocultural processes. Integrative approaches to research on delusion, which consider their potential adaptiveness and favour explanatory pluralism, might be advantageous. Effective clinical care for individuals with psychosis might need adapting to match more closely, and take account of, the subjective experience and meaning of delusions as they are lived through, which might also help redress power imbalances and enduring epistemic injustices in mental health.

FUNDING

Priestley Scholars, Wellcome Trust.

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.

Schizophrenia Psychosis in Women

A first step towards personalized medicine is to consider whether, for some disorders, the safest and most effective treatment of women needs to differ from standard guideline recommendations developed on the basis of clinical trials conducted, for the most part, in men. A second step is to consider how women’s reproductive stages—pre-pubertal years, menstrual phases, pregnancy trimesters, lactation and postpartum periods, menopausal and postmenopausal/aging status—affect the optimal choice of treatment. This review focuses on these two steps in the treatment of psychosis, specifically schizophrenia. It discusses genetics, precursors and symptoms of schizophrenia, reproductive and associated ethical issues, antipsychotic drug response and adverse effects, substance abuse, victimization and perpetration of violence, and issues of immigration and of co-morbidity. The conclusions, while often based on clinical experience and theoretical considerations rather than strictly on the evidence of randomized controlled trials, are that clinical recommendations need to consider clinical and role differences that exist between men and women and make appropriate correction for age and reproductive status.

The comments of voices on the appearance of patients with psychosis: 'the voices tell me that I am ugly'

BACKGROUND

There are high rates of obesity and low self-esteem in patients with psychosis. The occurrence of negative voice content directly about appearance is therefore plausible. Derogatory comments about appearance are likely to be distressing, increase depression and contribute to social withdrawal.

AIMS

To systematically assess the occurrence of voice content regarding appearance and identify correlates.

METHOD

Sixty patients experiencing verbal auditory hallucinations at least once a week in the context of non-affective psychosis completed a measure assessing positive and negative voice content about appearance. They also completed assessments about body image, self-esteem, psychiatric symptoms and well-being.

RESULTS

Fifty-five (91.7%) participants reported hearing voices comment on their appearance. A total of 54 (90%) patients reported negative voice content about their appearance with 30 (50%) patients experienced negative appearance comments on a daily basis. The most common negative comment was 'the voices tell me that I am ugly' (n = 48, 80%). There were 39 (65%) patients who reported positive voice content on appearance. The most frequent positive comment was 'I look as nice as other people' (n = 26, 43.3%). Negative voice content about appearance was associated with body image concerns, paranoia, voice hearing severity, depression, worry, negative self-beliefs and safety-seeking behaviours. Positive appearance voice content was associated with greater body esteem and well-being and lower levels of depression and insomnia.

CONCLUSIONS

Voice content about appearance is very common for patients seen in clinical services. Negative voice content may reflect - and subsequently reinforce - negative beliefs about one's appearance, low self-esteem, worry and paranoia.

DECLARATION OF INTEREST

None.