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Strelchuk D, Wiles N, Turner K, Derrick C, Martin D, Davies J, Zammit S. Eye-movement desensitisation and reprocessing therapy (EMDR) to prevent transition to psychosis in people with an at-risk mental state (ARMS): mixed method feasibility study. BJPsych Open 2024; 10:e105. [PMID: 38721786 PMCID: PMC11094432 DOI: 10.1192/bjo.2024.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/28/2024] [Accepted: 02/18/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Trauma plays an important role in the development of psychosis, but no studies have investigated whether a trauma-focused therapy could prevent psychosis. AIMS This study aimed to establish whether it would be feasible to conduct a multicentre randomised controlled trial (RCT) to prevent psychosis in people with an at-risk mental state (ARMS), using eye-movement desensitisation and reprocessing therapy (EMDR). METHOD This started as a mixed-method randomised study comparing EMDR to treatment as usual but, as a result of low participant recruitment, was changed to a single-arm feasibility study. The proposed primary outcome for an RCT was transition to psychosis at 12-month follow-up. Data on secondary outcomes were also collected. Qualitative interviews were conducted with patients and therapists. RESULTS Fourteen participants were recruited from the Early Intervention teams. Most people who expressed an interest in taking part attended an assessment to determine eligibility. All those eligible consented to take part. A total of 64% (7 of 11) of participants who were offered EMDR were followed up at 12 months. Of the 11 participants offered EMDR, one (11%, 95% CI: 0.2%, 48%) transitioned to psychosis. Nine patients and three therapists were interviewed. Participants who completed therapy (n = 4; mean 10.5 sessions) found EMDR helpful, but those who discontinued (n = 6; mean 5.2 sessions) said it had not benefitted them overall. Therapists said EMDR could be effective, although not for all patients. CONCLUSIONS Future studies recruiting people with an ARMS to an RCT may need to extend recruitment beyond Early Intervention teams. Although some individuals found EMDR helpful, reasons for discontinuing need to be addressed in future studies.
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Affiliation(s)
- Daniela Strelchuk
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, UK; and National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, UK; and National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, UK
| | - Katrina Turner
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, UK; and Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Catherine Derrick
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - David Martin
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, UK; and Medical Education, Avon Wiltshire Partnership NHS Mental Health Trust, Bath NHS House Combe Park, Bath, UK
| | - Jonathan Davies
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - Stan Zammit
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, UK; and MRC Centre for Neuropsychiatric Genetics and Genomics, Division of Psychological Medicine and Clinical Neuroscience, Cardiff University, UK
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Hardy A, Keen N, van den Berg D, Varese F, Longden E, Ward T, Brand RM. Trauma therapies for psychosis: A state-of-the-art review. Psychol Psychother 2024; 97:74-90. [PMID: 37795877 DOI: 10.1111/papt.12499] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/11/2023] [Accepted: 09/10/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Traumatic events, particularly childhood interpersonal victimisation, have been found to play a causal role in the occurrence of psychosis and shape the phenomenology of psychotic experiences. Higher rates of post-traumatic stress disorder (PTSD) and other trauma-related mental health problems are also found in people with psychosis diagnoses compared to the general population. It is, therefore, imperative that therapists are willing and able to address trauma and its consequences when supporting recovery from distressing psychosis. METHOD This paper will support this need by providing a state-of-the-art overview of the safety, acceptability and effects of trauma therapies for psychosis. RESULTS We will first introduce how seminal cognitive-behavioural models of psychosis shed light on the mechanisms by which trauma may give rise to psychotic experiences, including a putative role for trauma-related emotions, beliefs and episodic memories. The initial application of prolonged exposure and eye movement and desensitation and reprocessing therapy (EMDR) for treating PTSD in psychosis will be described, followed by consideration of integrative approaches. These integrative approaches aim to address the impact of trauma on both post-traumatic stress symptoms and trauma-related psychosis. Integrative approaches include EMDR for psychosis (EMDRp) and trauma-focused Cognitive-Behavioural Therapy for psychosis (tf-CBTp). Finally, emerging dialogic approaches for targeting trauma-related voice-hearing will be considered, demonstrating the potential value of adopting co-produced (Talking with Voices) and digitally augmented (AVATAR) therapies. CONCLUSION We will conclude by reflecting on current issues in the area, and implications for research and clinical practice.
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Affiliation(s)
- Amy Hardy
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Nadine Keen
- South London and Maudsley NHS Foundation Trust, London, UK
| | - David van den Berg
- Mark van der Gaag Research Centre, Parnassia Psychiatric Institute, The Hague, The Netherlands
- Vrije University, Amsterdam, The Netherlands
| | - Filippo Varese
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Eleanor Longden
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Thomas Ward
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Rachel M Brand
- School of Health, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
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Wood HJ, Babusci C, Bendall S, Sarpal DK, Jones N. Trauma and Trauma-Informed Care in Early Intervention in Psychosis: State of Implementation and Provider Views on Challenges. Psychiatr Serv 2023; 74:1240-1246. [PMID: 37194314 DOI: 10.1176/appi.ps.20220624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Although trauma is increasingly recognized as a major risk factor for psychosis and for its link to treatment outcomes, the landscape of trauma-related practices in specialized early psychosis services in the United States and other countries remains only poorly characterized. Research documenting the perspectives of frontline providers is also lacking. The primary goals of this study were to document the state of trauma-related policy implementation in early intervention in psychosis (EIP) programs and to gather provider perspectives. METHODS This was a mixed-methods project involving an international EIP provider survey, followed by in-depth provider interviews. The survey was disseminated in Australia, Canada, Chile, the United Kingdom, and the United States. In total, 164 providers, representing 110 unique sites, completed the survey. Frequencies were calculated for responses to survey items, and open-ended responses were analyzed with a systematic content analysis. RESULTS The survey findings suggested low implementation rates for a variety of assessment and support practices related to trauma and trauma-informed care. Coding of open-ended responses revealed numerous concerns and uncertainties among providers regarding the relationship between trauma and psychosis and the state of the EIP field. CONCLUSIONS An expansion of research and service development aimed at better meeting the trauma-related needs of young people with psychosis is essential, with implications for EIP outcomes and service user and staff experiences.
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Affiliation(s)
- Helen J Wood
- Services for the Treatment of Early Psychosis, UPMC Western Psychiatric Hospital, Pittsburgh (Wood, Sarpal); School of Social Work (Babusci, Jones) and Department of Psychiatry (Sarpal), University of Pittsburgh, Pittsburgh; Centre for Youth Mental Health, University of Melbourne, and Orygen, Melbourne (Bendall)
| | - Christina Babusci
- Services for the Treatment of Early Psychosis, UPMC Western Psychiatric Hospital, Pittsburgh (Wood, Sarpal); School of Social Work (Babusci, Jones) and Department of Psychiatry (Sarpal), University of Pittsburgh, Pittsburgh; Centre for Youth Mental Health, University of Melbourne, and Orygen, Melbourne (Bendall)
| | - Sarah Bendall
- Services for the Treatment of Early Psychosis, UPMC Western Psychiatric Hospital, Pittsburgh (Wood, Sarpal); School of Social Work (Babusci, Jones) and Department of Psychiatry (Sarpal), University of Pittsburgh, Pittsburgh; Centre for Youth Mental Health, University of Melbourne, and Orygen, Melbourne (Bendall)
| | - Deepak K Sarpal
- Services for the Treatment of Early Psychosis, UPMC Western Psychiatric Hospital, Pittsburgh (Wood, Sarpal); School of Social Work (Babusci, Jones) and Department of Psychiatry (Sarpal), University of Pittsburgh, Pittsburgh; Centre for Youth Mental Health, University of Melbourne, and Orygen, Melbourne (Bendall)
| | - Nev Jones
- Services for the Treatment of Early Psychosis, UPMC Western Psychiatric Hospital, Pittsburgh (Wood, Sarpal); School of Social Work (Babusci, Jones) and Department of Psychiatry (Sarpal), University of Pittsburgh, Pittsburgh; Centre for Youth Mental Health, University of Melbourne, and Orygen, Melbourne (Bendall)
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4
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Schaug JP, Storebø OJ, Pedersen MB, Haahr UH, Simonsen E. How first-episode psychosis patients' subjective beliefs about their childhood trauma's causal effect provide support for potential schizophrenia subtypes. Schizophr Res 2023; 262:175-183. [PMID: 37992561 DOI: 10.1016/j.schres.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/04/2023] [Accepted: 11/08/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Childhood and adolescent trauma is a risk factor for developing psychosis-spectrum disorders. The current study aimed to assess how childhood trauma might predict psychosis symptomatology, and how patients' beliefs of whether trauma is the cause of psychosis might affect this association. METHODS Ninety-six first-episode psychosis patients were assessed for childhood traumatic experiences with the Brief Betrayal Trauma Survey, and for psychosis symptoms with the Positive and Negative Syndrome Scale. RESULTS Non-interpersonal trauma predicted higher positive symptoms, whereas more trauma domains experienced predicted lower negative symptoms. Almost half of the participants believed trauma to be related to psychosis, were 12 times more likely to reexperience trauma through psychosis, and had higher excitative and emotional symptoms. Non-interpersonal trauma also predicted higher positive symptoms in this group. Those who did not believe trauma to be the cause of psychosis had higher negative symptoms, and a negative dose-response was found for negative and disorganised symptoms, in which more trauma domains experienced predicted lower scores. CONCLUSIONS Results imply two traumagenic pathways to psychosis, one characterised by positive, excitative, and emotional symptoms, and one negative subtype, characterised by negative and disorganised symptoms. Clinical implications for how findings might contribute to better treatments are discussed.
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Affiliation(s)
- Julie Perrine Schaug
- Centre for Evidence-Based Psychiatry, Psychiatric Research Unit, Psychiatric Services Region Zealand, 4200 Slagelse, Denmark
| | - Ole Jakob Storebø
- Centre for Evidence-Based Psychiatry, Psychiatric Research Unit, Psychiatric Services Region Zealand, 4200 Slagelse, Denmark; Department of Psychology, University of Southern Denmark, Faculty of Health Sciences, 5230 Odense M, Denmark; Department of Child and Adolescent Psychiatry, Psychiatry Region Zealand, 4000 Roskilde, Denmark.
| | - Marlene Buch Pedersen
- Early Psychosis Intervention Centre, Psychiatric Services Region Zealand East, 4000 Roskilde, Denmark
| | - Ulrik Helt Haahr
- Psychiatric Research Unit, Psychiatric Services Region Zealand, 4200 Slagelse, Denmark
| | - Erik Simonsen
- Early Psychosis Intervention Centre, Psychiatric Services Region Zealand East, 4000 Roskilde, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
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5
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Janssen H, van den Berg KC, Paulik G, Newman-Taylor K, Taylor CDJ, Steel C, Keijsers GPJ, Marcelis MC. Emotional and non-emotional mental imagery and auditory verbal hallucinations (hearing voices): A systematic review of imagery assessment tools. Clin Psychol Psychother 2023. [PMID: 37905563 DOI: 10.1002/cpp.2920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 07/19/2023] [Accepted: 10/07/2023] [Indexed: 11/02/2023]
Abstract
It is unknown to what extent mental imagery and auditory verbal hallucinations (AVHs) are related. Trials evaluating this issue used both emotional and non-emotional mental imagery tools, thereby complicating outcomes comparisons. Therefore, the present study aimed to systematically review the literature on mental imagery in individuals with AVHs to (1) inventory imagery assessment tools used in this population, (2) to collect information on the relation between emotional and non-emotional mental imagery in all sensory domains and AVHs and (3) to integrate the outcomes of this systematic review in a model of different mental imagery domains and related assessment tools. We conducted a systematic literature search in the PubMed Database. After full-text screening, 17 papers were included. Findings showed that a variety of assessment methods have been used to assess various aspects of mental imagery in people with AVHs, suggesting that there is a lack of agreed theoretical conceptualization of mental imagery and AVHs. In addition, the studies confirmed as was expected that non-emotional mental imagery seemed unrelated to AVHs whereas emotional mental imagery was related to AVHs. Lastly, we proposed a model of mental imagery domains and corresponding assessment methods distinguishing between emotional and non-emotional mental imagery.
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Affiliation(s)
- Hella Janssen
- Medical Psychiatric Research Group, Geestelijke Gezondheidszorg Eindhoven (GGzE), Eindhoven, Netherlands
- Department of Psychiatry and Neuropsychology, MHeNs Maastricht University, Maastricht, Netherlands
| | - Karin C van den Berg
- Medical Psychiatric Research Group, Geestelijke Gezondheidszorg Eindhoven (GGzE), Eindhoven, Netherlands
- Department of Clinical Psychological Sciences, Maastricht University, Maastricht, Netherlands
| | - Georgie Paulik
- Perth Voices Clinic, Murdoch, Australia
- School of Psychological Science, University of Western Australia, Perth, Australia
- School of Psychology and Exercise Science, Murdoch University, Perth, Australia
| | - Katherine Newman-Taylor
- Psychology Department, University of Southampton, Southampton, UK
- Psychology Department, College Keep, Southern Health NHSF Trust, Southampton, UK
| | - Christopher D J Taylor
- Secondary Care Psychological Therapies Service, Pennine Care National Health Service (NHS) Foundation Trust, Lancashire, UK
- Division of Psychology and Mental Health, The University of Manchester, Manchester, UK
| | - Craig Steel
- Oxford Centre for Psychological Health, Oxford, UK
- Oxford Institute of Clinical Psychology Training and Research, Oxford, UK
| | - Ger P J Keijsers
- Department of Clinical Psychological Sciences, Maastricht University, Maastricht, Netherlands
- Behavioural Science Institute, Radboud University, Nijmegen, Netherlands
| | - Machteld C Marcelis
- Medical Psychiatric Research Group, Geestelijke Gezondheidszorg Eindhoven (GGzE), Eindhoven, Netherlands
- Department of Psychiatry and Neuropsychology, MHeNs Maastricht University, Maastricht, Netherlands
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6
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van den Berg D, Tolmeijer E, Jongeneel A, Staring ABP, Palstra E, van der Gaag M, Hardy A. Voice phenomenology as a mirror of the past. Psychol Med 2023; 53:2954-2962. [PMID: 34991770 PMCID: PMC10235665 DOI: 10.1017/s0033291721004955] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 11/08/2021] [Accepted: 11/11/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Post-traumatic mechanisms are theorised to contribute to voice-hearing in people with psychosis and a history of trauma. Phenomenological links between trauma and voices support this hypothesis, as they suggest post-traumatic processes contribute to the content of, and relationships with, voices. However, research has included small samples and lacked theory-based comprehensive assessments. METHOD In people with distressing voices (n = 73) who experienced trauma prior to voice-hearing, trauma-voice links were assessed both independently and dependently (descriptions were presented and rated separately and together, respectively) by both participants and researchers. A structured coding frame assessed four types of independent links (i.e. victimisation type, physiological-behavioural, emotional, and cognitive response themes including negative self-beliefs) and three types of dependent links: relational (similar interaction with/response to, voice and trauma); content (voice and trauma content are exactly the same); and identity (voice identity is the same as perpetrator). RESULTS Independent links were prevalent in participants (51-58%) and low to moderately present in researcher ratings (8-41%) for significant themes. Identification of negative self-beliefs in trauma was associated with a significantly higher likelihood of negative self-beliefs in voices [participants odds ratio (OR) 9.8; researchers OR 4.9]. Participants and researchers also reported many dependent links (80%, 66%, respectively), most frequently relational links (75%, 64%), followed by content (60%, 25%) and identity links (51%, 22%). CONCLUSION Trauma appears to be a strong shaping force for voice content and its psychological impact. The most common trauma-voice links involved the experience of cognitive-affective psychological threat, embodied in relational experiences. Trauma-induced mechanisms may be important intervention targets.
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Affiliation(s)
- David van den Berg
- Department of Clinical Psychology, VU University and Amsterdam Public Health Research, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Department of Psychosis Research, Parnassia Psychiatric Institute, Zoutkeetsingel 40, 2512 HN The Hague, The Netherlands
| | - Eva Tolmeijer
- Department of Clinical Psychology, VU University and Amsterdam Public Health Research, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Department of Psychosis Research, Parnassia Psychiatric Institute, Zoutkeetsingel 40, 2512 HN The Hague, The Netherlands
| | - Alyssa Jongeneel
- Department of Clinical Psychology, VU University and Amsterdam Public Health Research, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Department of Psychosis Research, Parnassia Psychiatric Institute, Zoutkeetsingel 40, 2512 HN The Hague, The Netherlands
| | - Anton B. P. Staring
- ABC Department for First Episode Psychosis, Altrecht Psychiatric Institute, ABC straat 8, 3512 PX Utrecht, The Netherlands
| | - Eline Palstra
- Department of Clinical Psychology, VU University and Amsterdam Public Health Research, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Department of Psychosis Research, Parnassia Psychiatric Institute, Zoutkeetsingel 40, 2512 HN The Hague, The Netherlands
| | - Mark van der Gaag
- Department of Clinical Psychology, VU University and Amsterdam Public Health Research, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
- Department of Psychosis Research, Parnassia Psychiatric Institute, Zoutkeetsingel 40, 2512 HN The Hague, The Netherlands
| | - Amy Hardy
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK
- South London & Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent BR3 3BX, UK
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7
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Burger SR, Hardy A, van der Linden T, van Zelst C, de Bont PAJ, van der Vleugel B, Staring ABP, de Roos C, de Jongh A, Marcelis M, van Minnen A, van der Gaag M, van den Berg DPG. The bumpy road of trauma-focused treatment: Posttraumatic stress disorder symptom exacerbation in people with psychosis. J Trauma Stress 2023; 36:299-309. [PMID: 36719408 DOI: 10.1002/jts.22907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/29/2022] [Accepted: 11/29/2022] [Indexed: 02/01/2023]
Abstract
Concern for symptom exacerbation and treatment drop-out is an important barrier to the implementation of trauma-focused therapy (TFT), especially in people with a psychotic disorder. This study, which was part of a multicenter randomized controlled trial, investigated posttraumatic stress disorder (PTSD) symptom exacerbation during eye movement desensitization reprocessing (EMDR) therapy and prolonged exposure (PE) in a sample of 99 participants with PTSD and psychosis. Symptom exacerbations during the first four sessions (early exacerbation) and between-session exacerbations over the course of therapy were monitored using the PTSD Symptom Scale-Self Report. Analyses of covariance and chi-square tests were conducted to investigate exacerbation rates and their associations with treatment response and drop-out. Both early exacerbation and between-session exacerbation were relatively common (32.3% and 46.5%, respectively) but were unrelated to poor treatment response or an increased likelihood of treatment drop-out. Both clinicians and patients need to be aware that symptom exacerbation during TFT is common and not related to poor outcomes. Symptom exacerbation can be part of the therapeutic process, should be acknowledged and guided, and should not be a barrier to the implementation of TFT in people with psychosis.
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Affiliation(s)
- Simone R Burger
- Department of Clinical Psychology, VU University and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.,Department of Psychosis research and Innovation, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Amy Hardy
- Institute of Psychiatry, Psychology, and Neuroscience; King's College London, London, United Kingdom.,South London & Maudsley NHS Foundation Trust, London, United Kingdom
| | - Tineke van der Linden
- Department of Clinical Psychology, VU University and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.,Department of Research and Innovation, GGzE Mental Health Institute, Eindhoven, the Netherlands
| | - Catherine van Zelst
- Department of Psychosis research and Innovation, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Paul A J de Bont
- GGZ Oost-Brabant Mental Health Institute, Boekel, the Netherlands
| | | | | | - Carlijn de Roos
- Academic Centre for Child and Adolescent Psychiatry Levvel, Amsterdam University Medical Centre (location AMC), The Netherlands
| | - Ad de Jongh
- Behavourial Science Institute, Radboud Universiteit Nijmegen, the Netherlands.,PSYTREC Mental Health Institute, Bilthoven, the Netherlands
| | - Machteld Marcelis
- Department of Research and Innovation, GGzE Mental Health Institute, Eindhoven, the Netherlands.,Departement of Psychiatry and Neuropsychology, Maastricht University, the Netherlands
| | - Agnes van Minnen
- Behavourial Science Institute, Radboud Universiteit Nijmegen, the Netherlands.,PSYTREC Mental Health Institute, Bilthoven, the Netherlands
| | - Mark van der Gaag
- Department of Clinical Psychology, VU University and Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.,Department of Psychosis research and Innovation, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - David P G van den Berg
- Department of Psychosis research and Innovation, Parnassia Psychiatric Institute, The Hague, The Netherlands.,Academic Centre for Dentistry Amsterdam, University of Amsterdam and VU University Amsterdam, Department of Behavioural Sciences, Amsterdam, the Netherlands
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8
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Zarubin VC, Gupta T, Mittal VA. History of trauma is a critical treatment target for individuals at clinical high-risk for psychosis. Front Psychiatry 2023; 13:1102464. [PMID: 36683986 PMCID: PMC9846262 DOI: 10.3389/fpsyt.2022.1102464] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 12/12/2022] [Indexed: 01/05/2023] Open
Abstract
People meeting criteria for a clinical high-risk (CHR) for psychosis syndrome frequently represent a heterogeneous, help-seeking, and dynamic population. Among the numerous symptoms and risk factors for psychosis, exposure to trauma stands out as both highly prevalent and poorly understood. Indeed, while up to 80% of individuals meeting criteria for a CHR syndrome report trauma histories, there is currently limited research dedicated to this specific area. This is particularly problematic as trauma is tied to risk for conversion, leads to a range of clinical issues, and contributes to disability and poor quality of life. Fortunately, recent research in the general population has led to a significant evolution in the way trauma is assessed and understood, and further, some studies have indicated that targeted trauma interventions in formal psychotic disorders are highly effective. However, direct adoption is challenging as the CHR syndrome holds a number of unique concerns (e.g., clinical heterogeneity, developmental trauma), and characteristically, involves a developing pediatric or young adult population that also comes with specific considerations (e.g., living with caregivers, transitionary period in roles). In this "perspective" we frame the issues around understanding trauma in CHR individuals, discuss viable treatments and unique considerations, and provide suggestions for future steps in developing and incorporating trauma-focused interventions in this population.
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Affiliation(s)
- Vanessa C. Zarubin
- Department of Psychology, Northwestern University, Evanston, IL, United States
- Institute for Innovations in Developmental Sciences (DevSci), Northwestern University, Chicago, IL, United States
| | - Tina Gupta
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Vijay A. Mittal
- Department of Psychology, Northwestern University, Evanston, IL, United States
- Institute for Innovations in Developmental Sciences (DevSci), Northwestern University, Chicago, IL, United States
- Department of Psychiatry, Northwestern University, Chicago, IL, United States
- Medical Social Sciences, Northwestern University, Chicago, IL, United States
- Institute for Policy Research (IPR), Northwestern University, Chicago, IL, United States
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9
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Echoes of shame: a comparison of the characteristics and psychological sequelae of recalled shame experiences across the voice hearing continuum. Behav Cogn Psychother 2023; 51:61-73. [PMID: 36285429 DOI: 10.1017/s1352465822000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Voice hearing occurs across a number of psychiatric diagnoses and appears to be present on a continuum within the general population. Previous research has highlighted the potential role of past experiences of shame in proneness to voice hearing in the general population. AIMS This study aimed to extend this past research and compare people with distressing voices, people with voices but no distress, and a non-voice hearing control group, on various dimensions of shame and shame memory characteristics. METHOD In a cross-sectional, online study 39 distressed voice hearers, 31 non-distressed voice hearers and 50 non-voice hearers undertook a shame memory priming task in which they were prompted to recall a memory of a shaming experience from their past. They then completed questionnaires assessing the characteristics of the recalled shame event and the psychological sequalae of this event (i.e. intrusions, hyperarousal, avoidance, the centrality of shame memories, external shame, and self-criticism). RESULTS The majority of recalled shame memories involved experiences such as interpersonal criticism or experiences of being devalued. Univariate analyses found no significant differences between the three groups with regard to the shame events that were recalled, but the distressed voice hearer group reported significantly more hyperarousal, intrusions, self-criticism, and external shame in relation to their experience. CONCLUSIONS The findings suggest that voice hearers recall similar types of shame experiences to non-voice hearers, but that problematic psychological sequelae of these shame experiences (in the form of intrusive memories, hyperarousal, external shame, and self-criticism) may specifically contribute to distressing voice hearing.
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10
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Brand RM, Badcock JC, Paulik G. Changes in positive and negative voice content in cognitive-behavioural therapy for distressing voices. Psychol Psychother 2022; 95:807-819. [PMID: 35523677 PMCID: PMC9542164 DOI: 10.1111/papt.12399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/19/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE People who experience distressing voices frequently report negative (e.g. abusive or threatening) voice content and this is a key driver of distress. There has also been recognition that positive (e.g. reassuring, or guiding) voice content contributes to better outcomes. Despite this, voice content has been neglected as a standalone outcome in evaluations of psychological therapies for distressing voices. We aimed to examine whether a modular cognitive-behavioural therapy (CBT) intervention for voices led to changes in negative and positive voice content. DESIGN/METHODS In a naturalistic, uncontrolled pre- and post- service evaluation study, 32 clients at an outpatient psychology service for distressing voices received eight sessions of CBT for distressing voices and completed self-report measures of negative and positive voice content at pre-, mid- and post- therapy. RESULTS There was no significant change in positive voice content. There was no significant change in negative voice content from pre- to post-therapy; however, there was a significant change in negative voice content between mid and post-treatment in which the cognitive therapy component was delivered. The CBT treatment was also associated with significant changes in routinely reported outcomes of voice-related distress and voice severity. CONCLUSIONS The cognitive component of CBT for distressing voices may be associated with changes in negative, but not positive, voice content. There may be benefit to enhancing these effects by developing treatments targeting specific processes involved in negative and positive voice content and further exploring efficacy in well-powered, controlled trials with more comprehensive measures of voice content.
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Affiliation(s)
- Rachel M. Brand
- School of Health and Behavioural SciencesUniversity of the Sunshine CoastSippy DownsQueenslandAustralia
| | - Johanna C. Badcock
- Perth Voices ClinicMurdochWestern AustraliaAustralia,School of Psychological ScienceUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Georgie Paulik
- Perth Voices ClinicMurdochWestern AustraliaAustralia,School of Psychological ScienceUniversity of Western AustraliaPerthWestern AustraliaAustralia,Discipline of PsychologyMurdoch UniversityMurdochWestern AustraliaAustralia
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Feary N, Brand R, Williams A, Thomas N. 'Like jumping off a ledge into the water': A qualitative study of trauma-focussed imaginal exposure for hearing voices. Psychol Psychother 2022; 95:277-294. [PMID: 34799984 PMCID: PMC9298761 DOI: 10.1111/papt.12372] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/06/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE There is growing evidence of a link between the experience of hearing voices and past traumatic events, and trauma-focussed psychological interventions are being applied to hearing voices as an emerging treatment direction. To inform the ongoing development and implementation of this application, there is a need to understand clients' therapy experiences. DESIGN Qualitative study exploring the experience of people who received an intervention for voices linked to a previous traumatic event. METHOD Ten participants experiencing voices with some connection to a previous traumatic event participated in individual semi-structured interviews following six sessions of imaginal exposure, an exposure-based trauma-focussed intervention. Participant responses were analysed using thematic analysis. RESULTS Participants reported a range of benefits from the intervention, including improved mental health, reduction of distressing voice-hearing experiences, and increased clarity of the traumatic event. The therapy was perceived as distinctly different to previous therapy experiences, and participants noted that therapy could be intense and challenging, yet helpful later. Participants also reported that outside circumstances impacted on their progress in therapy and their voice-hearing experience. CONCLUSIONS The findings suggest that exposure-based trauma-focussed therapies may be beneficial for people who hear trauma-related voices. However, this intervention can be intense and clinicians and consumers need to consider the timing of delivery, and pay attention to internal and external resources that can increase participants' sense of safety. PRACTITIONER POINTS Imaginal exposure may be an effective intervention for people who hear voices that they perceive to be associated with a past traumatic event. Positive changes associated with the intervention may be highly variable between individuals, and encompass changes in sense of self, changes to internal states, and changes to voice-hearing experience. Imaginal exposure interventions may involve some temporary discomfort and symptom exacerbation, which may affect the acceptability of the intervention. This needs to be considered in both future research and clinical delivery.
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Affiliation(s)
- Natalie Feary
- Centre for Mental HealthSwinburne University of TechnologyMelbourneVictoriaAustralia
| | - Rachel Brand
- Centre for Mental HealthSwinburne University of TechnologyMelbourneVictoriaAustralia
| | - Anne Williams
- Department of Nursing and Allied HealthSwinburne University of TechnologyMelbourneVictoriaAustralia
| | - Neil Thomas
- Centre for Mental HealthSwinburne University of TechnologyMelbourneVictoriaAustralia,Alfred HospitalMelbourneVictoriaAustralia
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12
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Kamitsis I, Harms L, Bendall S. The subjective effect of antipsychotic medication on trauma-related thoughts, emotions, and physical symptoms: A qualitative study with people who have experienced childhood trauma and psychosis. Psychol Psychother 2022; 95:256-276. [PMID: 34617384 DOI: 10.1111/papt.12367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 09/06/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Among people with psychosis, those with a history of childhood trauma are likely to experience trauma-related symptoms, such as trauma memory intrusions. Irrespective of whether these individuals continue to remember and re-experience trauma, their treatment very often includes alleviating psychotic symptoms through the use of antipsychotic medication. Antipsychotics, while primarily used to treat psychotic symptoms, can influence non-psychotic symptoms and alter how people think and feel. We thus aimed to explore how people with childhood trauma and psychosis experience the effects that antipsychotics have on their (1) thoughts, images, and memories, (2) emotions, and (3) physical responses, related to their childhood trauma. DESIGN A qualitative phenomenological research design using semi-structured interviews was implemented. METHODS Data were analysed using interpretative phenomenological analysis. RESULTS Nineteen participants were interviewed. Two super-ordinate themes were conceptualized. Many participants spoke about the impact of antipsychotics on trauma-related experiences (Theme 1). Some indicated that antipsychotics alleviated the intensity and frequency of trauma-related thoughts, emotions, and physical symptoms. A few others reported that their trauma-related flashbacks, thoughts, and physical symptoms intensified while taking antipsychotics. Participants spoke about the role of antipsychotics in confronting and processing trauma (Theme 2). A few participants reported that by suppressing trauma-related thoughts and emotions antipsychotics prevented them from confronting their trauma. CONCLUSIONS The effects of antipsychotics can be subjectively experienced as beneficial or detrimental depending on how they influence trauma-related thoughts, emotions, and physical responses. Intervention studies are needed to determine how people with childhood trauma and psychosis respond to antipsychotic drugs. PRACTITIONER POINTS Antipsychotics may alter the way in which people with childhood trauma and psychosis remember and re-experience trauma. These alterations can be beneficial or detrimental, and thus play a role in whether people consider their medication helpful. By suppressing trauma-related thoughts and emotions, antipsychotics can prevent people from confronting their trauma. This may be considered beneficial to some, but other people may need or want to confront their trauma to heal. The effectiveness of trauma-focused psychological therapies may be influenced by the emotional, cognitive, and physiological effects of antipsychotic medications. The ability of antipsychotics to suppress people's trauma memories may contribute to post-traumatic avoidance. People with post-traumatic stress symptoms and psychosis should be provided with psycho-education about post-traumatic avoidance and its role in the maintenance of post-traumatic stress disorder.
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Affiliation(s)
- Ilias Kamitsis
- Orygen, Parkville, Victoria, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Victoria, Australia
| | - Louise Harms
- Department of Social Work, The University of Melbourne, Victoria, Australia
| | - Sarah Bendall
- Orygen, Parkville, Victoria, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Victoria, Australia
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13
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Hardy A, Good S, Dix J, Longden E. "It hurt but it helped": A mixed methods audit of the implementation of trauma- focused cognitive-behavioral therapy for psychosis. Front Psychiatry 2022; 13:946615. [PMID: 36311513 PMCID: PMC9606605 DOI: 10.3389/fpsyt.2022.946615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/16/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Emerging evidence supports the safety, acceptability, and efficacy of trauma therapies for people experiencing post-traumatic stress and psychosis, despite common concerns about iatrogenic harm when processing trauma memories for this population. However, to date there have been no mixed-method studies examining whether trauma-focused therapy can be implemented in routine care. This study reports an audit of a post-traumatic stress in psychosis clinic based in an inner-city trust in the U.K. National Health Service. MATERIALS AND METHODS People under the care of psychosis community mental health teams with a significant history of past trauma were referred to the clinic by their multidisciplinary clinicians. Referral outcomes were recorded, including the proportion of people for whom trauma-focused cognitive-behavior therapy for psychosis was indicated. Post-traumatic stress symptoms were assessed pre- and post-therapy for clinically significant change on the Post-traumatic Stress Checklist (version 4) and Post-traumatic Stress Checklist (version 5). A subgroup of service users was also interviewed about their experience of therapy, with transcripts analyzed using inductive thematic analysis. RESULTS Seventy one service-users were referred to the clinic between 2014 and 2018, of which 51 (71.8%) attended an assessment. Of these, 20 (39.2%) were identified as having clinically significant PTSD symptoms with re-experiencing and were offered trauma-focused cognitive-behavior therapy for psychosis. Sixteen (80%) accepted and completed therapy, with no dropouts, and received a mean of 17.54 sessions (SD = 17.60, range = 12-91). There were no serious adverse events related to therapy. Clinically significant change was observed in 68.8% (n = 11) of the therapy group and post-therapy six people (37.5%) no longer met the threshold for clinically significant PTSD. Six service users completed an interview about their therapy experiences with findings organized within four main themes and associated subthemes: (1) Perseverance, (2) Establishing safety, (3) The challenges of therapy, and (4) Rebuilding one's life after trauma. CONCLUSION Trauma-focused cognitive-behavior therapy for psychosis can be safe, acceptable, and effective when implemented in routine care. Lived experience perspectives highlight the emotional demands of therapy and long-term impact of trauma, thus underscoring the necessity of sufficient support and continuity of care both during and after therapy.
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Affiliation(s)
- Amy Hardy
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Sophie Good
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Jayde Dix
- North East London NHS Foundation Trust, London, United Kingdom
| | - Eleanor Longden
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom.,Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom.,Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
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14
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Bortolon C, Brand RM, Altman R, Matos M. Beyond trauma: the contribution of characteristics of shame memories, shame, and self-criticism to voice-hearing proneness. CURRENT PSYCHOLOGY 2021. [DOI: 10.1007/s12144-021-01438-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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15
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Brand RM, Bendall S, Hardy A, Rossell SL, Meyer D, Thomas N. Moment-to-moment associations between posttraumatic stress symptoms and auditory hallucinations in the flow of daily life. Psychiatry Res 2020; 285:112838. [PMID: 32044599 DOI: 10.1016/j.psychres.2020.112838] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 11/23/2022]
Abstract
Traumatic events are associated with increased risk of auditory hallucinations (AHs) and posttraumatic stress symptoms have been implicated in this relationship. We aimed to explore the moment-to-moment relationship between posttraumatic stress symptoms and AHs in daily-life. Twenty-eight people with persistent AHs and a history of traumatic events completed six-days of ecological momentary assessment. We assessed AHs, trauma memory intrusions, avoidance, and hyperarousal at ten time points each day. Multi-level modelling showed that the severity of trauma memory intrusions (but not avoidance or hyperarousal) within the preceding hour was associated with the occurrence of AHs. This relationship was significantly stronger for people with a direct link between the content of their AHs and trauma history. In time-lagged analyses, main effects of trauma memory intrusions, avoidance, and hyperarousal on AHs were not significant. Trauma memory intrusions have momentary associations with AHs and this relationship is stronger and more enduring for those with a direct link between their AH and the trauma. Our findings are in keeping with the proposal that intrusive trauma memories are associated with the occurrence of (some) AHs.
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Affiliation(s)
- Rachel M Brand
- Centre for Mental Health, Swinburne University, PO Box 218, Hawthorn, VIC 3122, Australia.
| | - Sarah Bendall
- Orygen: The National Centre of Excellence in Youth Mental Health, 35 Poplar Road, Parkville, VIC 3052, Australia; The Centre for Youth Mental Health, The University of Melbourne, VIC 3010, Australia
| | - Amy Hardy
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK; South London & Maudsley NHS Foundation Trust, UK
| | - Susan L Rossell
- Centre for Mental Health, Swinburne University, PO Box 218, Hawthorn, VIC 3122, Australia; Psychiatry, St Vincent's Hospital Melbourne, Australia
| | - Denny Meyer
- Centre for Mental Health, Swinburne University, PO Box 218, Hawthorn, VIC 3122, Australia
| | - Neil Thomas
- Centre for Mental Health, Swinburne University, PO Box 218, Hawthorn, VIC 3122, Australia
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