1
|
Puckett J, Sood M, Newman-Taylor K. Does insecure attachment lead to psychosis via dissociation? A systematic review of the literature. Psychol Psychother 2024; 97:372-392. [PMID: 38358073 DOI: 10.1111/papt.12521] [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: 04/11/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024]
Abstract
PURPOSE Insecure attachment may constitute a vulnerability factor for psychosis, and dissociation may be a key mechanism in the development of auditory hallucinations specifically. While there is good evidence for the role of these processes in isolation, it is unclear whether dissociation accounts for the association between insecure attachment and psychosis. This systematic review takes a theory-driven approach to examine proposed causal relationships across the clinical and nonclinical literature. METHODS We searched five databases (PubMeD, Web of Science, PsycINFO, CINAHL and ETHOS) for published and unpublished research examining attachment, dissociation and psychosis. Two independent reviewers extracted the data and assessed the quality of all included studies. RESULTS We identified 242 potential articles and included 13 in the final review (2096 participants). We found that (1) disorganised attachment was consistently associated with dissociation and inconsistently associated with voices and paranoia, (2) dissociation was associated with voices and paranoia, and these links were stronger in clinical samples, and (3) dissociation played a role in the impact of insecure attachment on voice hearing and paranoia in clinical groups. CONCLUSIONS This is the first review to synthesise the research examining attachment, dissociation, and psychosis. The evidence is consistent with proposed causal hypotheses and raises conceptual and measurement issues, for example, the need to clarify the relative contributions of different insecure attachment styles, and utilise behavioural/observational measures to strengthen study designs. Most importantly, we need experimental and longitudinal studies to confirm causal links and targets for treatment.
Collapse
Affiliation(s)
- Joseph Puckett
- Psychology Department, University of Southampton, Southampton, UK
| | - Monica Sood
- Psychology Department, University of Southampton, Southampton, UK
| | - Katherine Newman-Taylor
- Psychology Department, University of Southampton, Southampton, UK
- Psychology Department, Southern Health NHS Foundation Trust, Southampton, UK
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Reid J, Cole C, Malik N, Bell V, Bloomfield M. The effectiveness and tolerability of trauma-focused psychotherapies for psychotic symptoms: A systematic review of trauma-focused psychotherapies. Int J Methods Psychiatr Res 2024; 33:e2005. [PMID: 38441953 PMCID: PMC10914124 DOI: 10.1002/mpr.2005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/31/2023] [Accepted: 12/05/2023] [Indexed: 03/07/2024] Open
Abstract
INTRODUCTION Psychological trauma is an established risk factor for psychosis. Trauma-focused psychotherapies (TFPT) have been suggested as a potential treatment for reducing psychotic symptoms in those who have experienced trauma. We therefore sought to investigate the effectiveness, tolerability, and acceptability of TFPT for psychotic symptoms. METHODS We conducted a systematic review of studies of any form of TFPT that measured psychotic symptoms across a broad range of diagnoses. RESULTS From 2584 papers initially identified, 17 studies (857 participants) met eligibility criteria. TFPT were found to be well tolerated, with very few adverse events. Acceptability was also high, with a mean dropout rate of 20%. CONCLUSIONS Whilst the evidence of effectiveness for TFPT in reducing psychotic symptoms is weak, we found tentative evidence in favour of exposure-based interventions. Methodologically rigorous trials investigating the efficacy of TFPT for the treatment of psychotic symptoms are needed to assess this promising intervention.
Collapse
Affiliation(s)
- Jordan Reid
- Translational Psychiatry Research GroupDivision of PsychiatryResearch Department of Mental Health NeuroscienceInstitute of Mental HealthUniversity College LondonLondonUK
| | - Charles Cole
- Department of Clinical, Educational and Health PsychologyUniversity College LondonLondonUK
| | | | - Vaughan Bell
- Department of Clinical, Educational and Health PsychologyUniversity College LondonLondonUK
| | - Michael Bloomfield
- Translational Psychiatry Research GroupDivision of PsychiatryResearch Department of Mental Health NeuroscienceInstitute of Mental HealthUniversity College LondonLondonUK
| |
Collapse
|
4
|
Newman-Taylor K, Bentall R. Cognitive behavioural therapy for psychosis: The end of the line or time for a new approach? Psychol Psychother 2024; 97:4-18. [PMID: 37804105 DOI: 10.1111/papt.12498] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE Following its introduction in the early 1990s, cognitive behavioural therapy for psychosis (CBTp) has been evaluated in a large number of clinical trials and is now established as a recommended treatment in the UK National Health Service and elsewhere in the world. Meta-analyses, however, indicate modest effects compared to treatment as usual or comparison therapies such as supportive counselling. Here, we seek to identify factors impacting the effectiveness of CBTp, and avenues for future psychotherapy research that may improve outcomes. METHOD We outline two recent umbrella reviews and discuss factors likely to impact the effectiveness of CBTp. RESULTS Modest effect sizes from meta-analyses mask heterogeneous outcomes, with some people benefiting and others possibly being harmed by therapy. Common factors such as the therapeutic alliance play an important role in determining outcomes but have been largely neglected by CBTp researchers. There is also the promise of improving outcomes by identifying and targeting the psychological mechanisms that either maintain psychotic symptoms (e.g. worry) or are causally implicated (e.g. trauma). CONCLUSIONS It is unlikely that everyone with psychosis will be equally responsive to the same therapeutic protocols. We need a new, personalised psychotherapy approach to CBTp research and practice, and can learn from research for anxiety and depression examining predictors of therapeutic response to inform treatment decisions. Precision psychological therapies informed by a combination of individual characteristics, common factors and a focus on specific mechanisms will require new research strategies and are likely to lead to improved outcomes for people with psychosis.
Collapse
Affiliation(s)
- Katherine Newman-Taylor
- Psychology Department, University of Southampton, Southampton, UK
- Psychology Department, Southern Health NHS Foundation Trust, Southampton, UK
| | - Richard Bentall
- Psychology Department, University of Sheffield, Sheffield, UK
| |
Collapse
|
5
|
Smyth E, Steel C, Ellett L. The prevalence of non-affective psychosis in refugee populations: A systematic review. Schizophr Res 2023; 260:99-112. [PMID: 37634388 DOI: 10.1016/j.schres.2023.08.011] [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: 07/13/2021] [Revised: 06/27/2023] [Accepted: 08/13/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND As we face the largest refugee crisis since World War Two, research is increasingly examining the impact of forced displacement. The risk of non-affective psychosis in refugees is evidenced to be significantly greater than non-refugees, and the role of pre-, peri- and post-migratory trauma and dissociation is increasingly implicated. AIMS To determine the prevalence of non-affective psychosis in refugee populations. METHOD PRISMA guidelines were followed. Three key databases (PubMed, PsychINFO and Web of Science), Google scholar and study references were searched. The full-text of 62 studies were screened and 23 studies were eligible for inclusion. A narrative synthesis was undertaken and the Quality Assessment Tool for Quantitative Studies was used to assess methodological quality. (PROSPERO registration CRD42019152170). RESULTS The results were widely heterogeneous. The combined weighted average prevalence of non-affective psychosis in refugee populations was 0.9 %. Psychosis prevalence for individual psychotic symptoms was 28.4 %; 0.5 % for schizophrenia; 1.0 % for psychosis; 0.6 % for mixed psychotic disorders and 2.9 % for psychotic episodes. CONCLUSIONS Variations in examined populations, diagnostic and prevalence classifications, and study designs and methodologies likely contributed to heterogeneity across the data. The findings highlight a greater need to provide more specialist mental health services and trauma-focused interventions, as well as transculturally sensitive assessment and treatment to address refugee vulnerability to psychosis. Future research should examine psychosis prevalence longitudinally and in refugees-only, address methodological bias and further examine the role of trauma and dissociation in refugee psychosis prevalence.
Collapse
Affiliation(s)
- Emily Smyth
- Psychology Department, Royal Holloway, University of London, Egham Hill, Egham TW20 0EX, UK.
| | - Craig Steel
- The Oxford Institute of Clinical Psychology Training and Research, The Oxford Centre for Psychological Health, University of Oxford, Isis Education Centre, Warneford Hospital, Oxford OX3 7JX, UK.
| | - Lyn Ellett
- School of Psychology, University of Southampton, UK.
| |
Collapse
|
6
|
Rahme C, El Kadri N, Haddad C, Fekih-Romdhane F, Obeid S, Hallit S. Exploring the association between lifetime traumatic experiences and positive psychotic symptoms in a group of long-stay patients with schizophrenia: the mediating effect of depression, anxiety, and distress. BMC Psychiatry 2023; 23:29. [PMID: 36635691 PMCID: PMC9835034 DOI: 10.1186/s12888-023-04531-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/06/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Positive psychotic symptoms of schizophrenia are generally characterized by hallucinations and delusions. We propose to assess the relationship between total composite trauma and positive psychotic symptoms, along with the mediation effect of cognition, fear of COVID-19, insomnia, anxiety, distress, and depression of Lebanese patients with schizophrenia. METHODS A cross-sectional study was carried out, between June and July 2021, by deriving data from 155 long-stay in-patients diagnosed with schizophrenia. RESULTS Depression, anxiety, and distress but not cognitive impairment, insomnia, and fear of COVID-19) mediated the association between lifetime traumatic experiences and positive psychotic symptoms. Higher traumatic experiences were associated with greater depression, anxiety, and distress, indicating a significant positive total effect on positive psychotic scores. Moreover, higher depression, anxiety, and distress were significantly associated with higher positive psychotic symptoms. CONCLUSION Our results contribute to the existing knowledge by suggesting other possible intervention paths through mediating factors. Interventions that improve anxiety, depression, and distress severity may be effective in reducing positive psychotic symptoms among patients with schizophrenia having experienced lifetime trauma.
Collapse
Affiliation(s)
- Clara Rahme
- Research Department, Psychiatric Hospital of the Cross, Jal Eddib, Lebanon
| | | | - Chadia Haddad
- Research Department, Psychiatric Hospital of the Cross, Jal Eddib, Lebanon.,INSPECT-LB: National Institute of Public Health, Clinical Epidemiology and Toxicology, Beirut, Lebanon.,Modern University of Business Sciences, Damour, Lebanon
| | - Feten Fekih-Romdhane
- The Tunisian Center of Early Intervention in Psychosis, Department of psychiatry "Ibn Omrane", Razi hospital, 2010, Manouba, Tunisia.,Tunis El Manar University, Faculty of Medicine of Tunis, Tunis, Tunisia
| | - Sahar Obeid
- Social and Education Sciences Department, School of Arts and Sciences, Lebanese American University, Jbeil, Lebanon
| | - Souheil Hallit
- Research Department, Psychiatric Hospital of the Cross, Jal Eddib, Lebanon. .,School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, P.O. Box 446, Jounieh, Lebanon. .,Applied Science Research Center, Applied Science Private University, Amman, Jordan.
| |
Collapse
|
7
|
Patterson VC, Tibbo PG, Stewart SH, Town J, Crocker CE, Ursuliak Z, Lee S, Morrison J, Abidi S, Dempster K, Alexiadis M, Henderson N, Pencer A. A multiple baseline trial of adapted prolonged exposure psychotherapy for individuals with early phase psychosis, comorbid substance misuse, and a history of adversity: A study protocol. Front Psychol 2022; 13:1012776. [PMID: 36578677 PMCID: PMC9791093 DOI: 10.3389/fpsyg.2022.1012776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/08/2022] [Indexed: 12/14/2022] Open
Abstract
Background Adversity is prevalent among people with psychotic disorders, especially those within the first 5 years of a psychotic disorder, called early phase psychosis. Although adversity can lead to many negative outcomes (e.g., posttraumatic stress symptoms), very few treatments for adversity-related sequelae have been tested with individuals with psychotic disorders, and even fewer studies have specifically tested interventions for people in early phase psychosis. Furthermore, people who misuse substances are commonly excluded from adversity treatment trials, which is problematic given that individuals with early phase psychosis have high rates of substance misuse. For the first time, this trial will examine the outcomes of an adapted 15-session prolonged exposure protocol (i.e., PE+) to observe whether reductions in adversity-related psychopathology occurs among people with early phase psychosis and comorbid substance misuse. Methods This study will use a multiple-baseline design with randomization of participants to treatment start time. Participants will complete baseline appointments prior to therapy, engage in assessments between each of the five therapy modules, and complete a series of follow-up appointments 2 months after the completion of therapy. Primary hypothesized outcomes include clinically significant reductions in (1) negative psychotic symptoms measured using the Positive and Negative Syndrome Scale, (2) adversity-related sequelae measured using the Trauma Symptom Checklist-40, and (3) substance use frequency and overall risk score measured with the Alcohol, Smoking, and Substance Involvement Screening Test. We also anticipate that clinically significant reductions in hopelessness and experiential avoidance, measured with the Beck Hopelessness Scale and Brief Experiential Avoidance Questionnaire, the theorized mechanisms of change of PE+, will also be observed. A secondary outcome is a hypothesized improvement in functioning, measured using the Clinical Global Impression and Social and Occupational Functioning Assessment scales. Discussion The results of this treatment trial will contribute to the advancement of treatment research for individuals in early phase psychosis who have current substance misuse and a history of adversity, and the findings may provide evidence supporting the use of hopelessness and experiential avoidance as mechanisms of change for this treatment. Clinical trial registration Clinicaltrials.gov, NCT04546178; registered August 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04546178?term=NCT04546178&draw=2&rank=1.
Collapse
Affiliation(s)
- Victoria C. Patterson
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Philip G. Tibbo
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
- Mental Health and Addictions, IWK Health, Halifax, NS, Canada
| | - Sherry H. Stewart
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
| | - Joel Town
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
| | - Candice E. Crocker
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
| | - Zenovia Ursuliak
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
| | - Siranda Lee
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
| | - Jason Morrison
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
| | - Sabina Abidi
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Mental Health and Addictions, IWK Health, Halifax, NS, Canada
| | - Kara Dempster
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
| | - Maria Alexiadis
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
| | - Neal Henderson
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
| | - Alissa Pencer
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
- Mental Health and Addictions, Nova Scotia Health, Halifax, NS, Canada
- Mental Health and Addictions, IWK Health, Halifax, NS, Canada
| |
Collapse
|
8
|
Peters E, Hardy A, Dudley R, Varese F, Greenwood K, Steel C, Emsley R, Keen N, Bowe S, Swan S, Underwood R, Longden E, Byford S, Potts L, Heslin M, Grey N, Turkington D, Fowler D, Kuipers E, Morrison A. Multisite randomised controlled trial of trauma-focused cognitive behaviour therapy for psychosis to reduce post-traumatic stress symptoms in people with co-morbid post-traumatic stress disorder and psychosis, compared to treatment as usual: study protocol for the STAR (Study of Trauma And Recovery) trial. Trials 2022; 23:429. [PMID: 35606886 PMCID: PMC9125351 DOI: 10.1186/s13063-022-06215-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 03/26/2022] [Indexed: 11/18/2022] Open
Abstract
Background People with psychosis have high rates of trauma, with a post-traumatic stress disorder (PTSD) prevalence rate of approximately 15%, which exacerbates psychotic symptoms such as delusions and hallucinations. Pilot studies have shown that trauma-focused (TF) psychological therapies can be safe and effective in such individuals. This trial, the largest to date, will evaluate the clinical effectiveness of a TF therapy integrated with cognitive behaviour therapy for psychosis (TF-CBTp) on post-traumatic stress symptoms in people with psychosis. The secondary aims are to compare groups on cost-effectiveness; ascertain whether TF-CBTp impacts on a range of other meaningful outcomes; determine whether therapy effects endure; and determine acceptability of the therapy in participants and therapists. Methods Rater-blind, parallel arm, pragmatic randomised controlled trial comparing TF-CBTp + treatment as usual (TAU) to TAU only. Adults (N = 300) with distressing post-traumatic stress and psychosis symptoms from five mental health Trusts (60 per site) will be randomised to the two groups. Therapy will be manualised, lasting 9 months (m) with trained therapists. We will assess PTSD symptom severity (primary outcome); percentage who show loss of PTSD diagnosis and clinically significant change; psychosis symptoms; emotional well-being; substance use; suicidal ideation; psychological recovery; social functioning; health-related quality of life; service use, a total of four times: before randomisation; 4 m (mid-therapy); 9 m (end of therapy; primary end point); 24 m (15 m after end of therapy) post-randomisation. Four 3-monthly phone calls will be made between 9 m and 24 m assessment points, to collect service use over the previous 3 months. Therapy acceptability will be assessed through qualitative interviews with participants (N = 35) and therapists (N = 5–10). An internal pilot will ensure integrity of trial recruitment and outcome data, as well as therapy protocol safety and adherence. Data will be analysed following intention-to-treat principles using generalised linear mixed models and reported according to Consolidated Standards of Reporting Trials-Social and Psychological Interventions Statement. Discussion The proposed intervention has the potential to provide significant patient benefit in terms of reductions in distressing symptoms of post-traumatic stress, psychosis, and emotional problems; enable clinicians to implement trauma-focused therapy confidently in this population; and be cost-effective compared to TAU through reduced service use. Trial registration ISRCTN93382525 (03/08/20) Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06215-x.
Collapse
Affiliation(s)
- Emmanuelle Peters
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Amy Hardy
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK. .,South London & Maudsley NHS Foundation Trust, London, UK.
| | - Robert Dudley
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,Newcastle University, London, UK
| | - Filippo Varese
- School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Kathryn Greenwood
- Research and Development, Sussex Partnership NHS Foundation Trust, Brighton, UK.,School of Psychology, University of Sussex, London, UK
| | - Craig Steel
- Oxford Centre for Psychological Health, Oxford Health NHS Foundation Trust, Oxford, UK.,Oxford Institute of Clinical Psychology Training and Research, University of Oxford, Oxford, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nadine Keen
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Samantha Bowe
- Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Swan
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Raphael Underwood
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Eleanor Longden
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Byford
- Health Service & Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Laura Potts
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Margaret Heslin
- Health Service & Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nick Grey
- Research and Development, Sussex Partnership NHS Foundation Trust, Brighton, UK.,School of Psychology, University of Sussex, London, UK
| | - Doug Turkington
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK.,Newcastle University, London, UK
| | - David Fowler
- Research and Development, Sussex Partnership NHS Foundation Trust, Brighton, UK.,School of Psychology, University of Sussex, London, UK
| | - Elizabeth Kuipers
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,South London & Maudsley NHS Foundation Trust, London, UK
| | - Anthony Morrison
- Complex Trauma and Resilience Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
9
|
Rey MGD, Martín LM, García FA, López FJC, López FR. Trauma infantil y psicosis: una revisión narrativa. CLÍNICA CONTEMPORÁNEA 2022. [DOI: 10.5093/cc2022a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
10
|
Trauma and psychosis: a qualitative study exploring the perspectives of people with psychosis on the influence of traumatic experiences on psychotic symptoms and quality of life. BMC Psychiatry 2022; 22:213. [PMID: 35331194 PMCID: PMC8944047 DOI: 10.1186/s12888-022-03808-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 02/23/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Despite experiencing high rates of trauma and trauma-related conditions, people with psychosis are seldomly asked about possible traumatic events. While there are some barriers to discussing trauma in clinical services, research has shown that disclosure is not only possible but also beneficial to both psychotic and traumatic symptoms. The current study is the first to evaluate service users' perception of the influence of trauma on the development and maintenance of their psychotic symptoms, as well as their views on how their life and mental health have been affected by traumatic events and their disclosure (or lack of). METHODS Eleven participants with experiences of psychosis and trauma took part in semi-structured interviews. RESULTS Consistently with previous literature, our participants reported high rates of interpersonal trauma, but had rarely had the opportunity to discuss any of these events. Using thematic analysis, we identified three major themes that have important implications for healthcare: factors that facilitate or hinder talking about trauma; consequences of talking or not; and relationship between trauma and psychosis. Participants generally benefited from talking about trauma and concerningly often associated the prolonged lack of opportunities to discuss traumatic events with negative feelings towards the self and with a deterioration of their mental health. Participants also recognised direct links between past traumas and the content and characteristics of their psychotic experiences. CONCLUSIONS Our findings highlight the importance, as perceived by service users, of discussing trauma and looking at psychosis through a "trauma lens". These results stress the need to systematically assess trauma history and traumatic symptoms in psychosis and might potentially help to overcome clinicians' worries about discussing trauma with service users. Our findings underscore the need to change current practice and implement trauma-informed approaches to understand clients' difficulties and provide support.
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Brand RM, Bendall S, Hardy A, Rossell SL, Thomas N. Trauma-focused imaginal exposure for auditory hallucinations: A case series. Psychol Psychother 2021; 94 Suppl 2:408-425. [PMID: 32436342 PMCID: PMC8246845 DOI: 10.1111/papt.12284] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 04/21/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE There is mounting evidence that traumatic life events play a role in auditory hallucinations (AH). Theory suggests that some AH are decontextualized trauma memory intrusions. Exposure-based trauma-focused therapies that target trauma memory intrusions may therefore be a promising new treatment. We aimed to assess the feasibility and acceptability of a standard protocol trauma-focused imaginal exposure intervention for trauma-related AH and to provide initial proof of concept regarding potential effects on AH. DESIGN We conducted a single-arm case series of a six session (90 min per session) imaginal exposure intervention for trauma-related AH with assessments at baseline, post-therapy, and one-month follow-up. RESULTS Fifteen people were recruited and eligible to start the intervention. Participants reported high levels of satisfaction; however, temporary distress and symptom exacerbation were common and contributed to discontinuation. There was a large reduction in AH severity at one-month follow-up (adjusted d = 0.99), but individual response was highly variable. There were also large reductions in post-traumatic stress disorder symptoms and the intrusiveness of the trauma memory. CONCLUSIONS Imaginal exposure for trauma-related AH is generally acceptable and may have large effects on AH severity for some people. However, temporary distress and symptom exacerbation are common and can lead to discontinuation. Low referral rates and uptake also suggest feasibility issues for standalone imaginal exposure for AH. The intervention may be more feasible and acceptable in the context of a broader trauma-focused therapy. Well-powered trials are needed to determine efficacy and factors that impact on acceptability and therapy response. PRACTITIONER POINTS Some AH can be understood as trauma memory intrusions that lack temporal and spatial contextualization and are therefore experienced without autonoetic awareness. Imaginal exposure to trauma memories associated with AH may be an effective intervention for some people. Temporary distress and symptom exacerbation may be common when using standard trauma-focused imaginal exposure for AH. This can impact on the acceptability of the therapy and should be considered in future development and delivery.
Collapse
Affiliation(s)
- Rachel M. Brand
- Centre for Mental HealthSwinburne UniversityHawthornVictoriaAustralia
| | - Sarah Bendall
- Orygen: The National Centre of Excellence in Youth Mental HealthParkvilleVictoriaAustralia,The Centre for Youth Mental HealthThe University of MelbourneMelbourneVictoriaAustralia
| | - Amy Hardy
- Institute of Psychiatry, Psychology & NeuroscienceKing’s College LondonUK,South London & Maudsley NHS Foundation TrustUK
| | - Susan L. Rossell
- Centre for Mental HealthSwinburne UniversityHawthornVictoriaAustralia,PsychiatrySt Vincent's Hospital MelbourneMelbourneVictoriaAustralia
| | - Neil Thomas
- Centre for Mental HealthSwinburne UniversityHawthornVictoriaAustralia
| |
Collapse
|
14
|
Peach N, Alvarez-Jimenez M, Cropper SJ, Sun P, Halpin E, O'Connell J, Bendall S. Trauma and the content of hallucinations and post-traumatic intrusions in first-episode psychosis. Psychol Psychother 2021; 94 Suppl 2:223-241. [PMID: 32154644 DOI: 10.1111/papt.12273] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 02/15/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Increasing evidence suggests experiences of childhood trauma may be causally related to the development of hallucinations. Cognitive theories of psychosis suggest post-traumatic intrusions to be a primary mechanism in this relationship. These theories predict that the content of hallucinations will be related to traumatic experiences; however, few studies have investigated this. This study examined the relationship between childhood trauma, the content of hallucinations, and the content of post-traumatic intrusions in a sample with first-episode psychosis. METHODS Sixty-six young people aged 15-25 experiencing a first episode of psychosis were recruited from an early intervention service. Participants completed assessments of traumatic experiences, hallucination content, and post-traumatic intrusion content using a systematic coding frame. The coding frame assessed for three types of relationships between traumatic experiences, the content of hallucinations, and the content of post-traumatic intrusions: direct relationships (hallucination content exactly matching the trauma/intrusion), thematic relationships (hallucinations with the same themes as the trauma/intrusion), and no relationship (hallucination and trauma/intrusion content unrelated). RESULTS Of those people who reported trauma and hallucinations (n = 36), 22 of these (61%) experienced post-traumatic intrusions, and of these, 16 (73%) experienced hallucinations that were directly or thematically related to their post-traumatic intrusions. Twelve people experienced hallucination content directly related to their trauma, six of whom (50%) also had intrusions relating to the same traumatic event as their hallucinations. CONCLUSIONS The finding that some people experience hallucinations and post-traumatic intrusions relating to the same traumatic event supports theories proposing a continuum of memory intrusion fragmentation. These results indicate that early intervention services for young people with psychosis should provide assessment and intervention for trauma and PTSD and should consider the impact of past traumatic events on the content of current hallucinatory experience. PRACTITIONER POINTS Trauma and post-traumatic stress disorder should be assessed in those experiencing a first episode of psychosis. Interventions for trauma should be offered in early intervention for psychosis services. In a notable proportion of people, hallucination content is related to traumatic experiences. Clinical assessment and formulation of hallucinations requires consideration of how past traumatic events may be contributing to hallucinatory experience. It is important for clinicians to have an understanding of the phenomenological differences between hallucinations and post-traumatic intrusions when conducting clinical assessments with people with comorbid psychosis and PTSD.
Collapse
Affiliation(s)
- Natalie Peach
- School of Psychological Sciences, The University of Melbourne, Vic., Australia
| | - Mario Alvarez-Jimenez
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Vic., Australia.,The Centre for Youth Mental Health, The University of Melbourne, Vic., Australia
| | - Simon J Cropper
- School of Psychological Sciences, The University of Melbourne, Vic., Australia
| | - Pamela Sun
- School of Psychological Sciences, Monash University, Melbourne, Vic., Australia
| | - Emma Halpin
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Vic., Australia.,The Centre for Youth Mental Health, The University of Melbourne, Vic., Australia
| | - Jessica O'Connell
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Vic., Australia.,The Centre for Youth Mental Health, The University of Melbourne, Vic., Australia
| | - Sarah Bendall
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Vic., Australia.,The Centre for Youth Mental Health, The University of Melbourne, Vic., Australia
| |
Collapse
|
15
|
Brand RM, Hardy A, Bendall S, Thomas N. A tale of two outcomes: Remission and exacerbation in the use of trauma‐focused imaginal exposure for trauma‐related voice‐hearing. Key learnings to guide future practice. CLIN PSYCHOL-UK 2021. [DOI: 10.1111/cp.12202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Rachel M. Brand
- Centre for Mental Health, Swinburne University, Hawthorn, Victoria, Australia,
| | - Amy Hardy
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK,
- South London & Maudsley NHS Foundation Trust, London, UK,
| | - Sarah Bendall
- Orygen: The National Centre of Excellence in Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia,
| | - Neil Thomas
- Centre for Mental Health, Swinburne University, Hawthorn, Victoria, Australia,
| |
Collapse
|
16
|
Liu J, Mahendran R, Chong SA, Subramaniam M. Elucidating the Impact of Childhood, Adulthood, and Cumulative Lifetime Trauma Exposure on Psychiatric Symptoms in Early Schizophrenia Spectrum Disorders. J Trauma Stress 2021; 34:137-148. [PMID: 33096583 DOI: 10.1002/jts.22607] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/18/2020] [Accepted: 08/31/2020] [Indexed: 12/30/2022]
Abstract
Cumulative lifetime trauma has a profound impact on the development of schizophrenia spectrum disorders. However, few studies have determined participants' most distressing (i.e., "worst") life event in childhood or adulthood or examined whether this event contributes to poorer clinical outcomes. The present study aimed to (a) determine the associations between the worst life event and demographic/clinical variables and (b) examine the associations between the worst life event and psychiatric symptoms (i.e., positive, negative, depressive, and anxiety symptoms). Participants (N = 150) were outpatients newly diagnosed with schizophrenia spectrum disorders who were assessed for lifetime trauma exposure, positive and negative symptoms of schizophrenia, and symptoms of depression and anxiety. Multinomial logistic regression analysis was conducted to examine the associations between demographic and clinical variables and worst life events (none, childhood, or adulthood). Multiple linear regression analyses were performed to examine the associations between worst life events and psychiatric symptoms. More participants reported that their worst life event occurred during adulthood (31.1%) than childhood (21.3%). Adulthood trauma was associated with male gender, older age, non-Chinese ethnicity, and psychiatric comorbidities; childhood trauma was associated with a family history of depression/anxiety. Adulthood trauma was significantly associated with more severe positive psychotic symptoms, f2 = 0.19, whereas childhood and adulthood trauma exposure were both significantly associated with more severe depressive and anxiety symptoms, f2 s = 0.19 and 0.25, respectively. Our findings underscore the importance of conducting assessments for worst life events and the associated risk factors to develop meaningful formulations and appropriate trauma-focused treatment plans.
Collapse
Affiliation(s)
- Jianlin Liu
- Research Division, Institute of Mental Health, Singapore.,Department of Psychological Medicine, National University of Singapore, Singapore
| | - Rathi Mahendran
- Department of Psychological Medicine, National University of Singapore, Singapore.,Academic Development Department, Duke-National University of Singapore Medical School, Singapore
| | - Siow Ann Chong
- Research Division, Institute of Mental Health, Singapore
| | | |
Collapse
|
17
|
Alameda L, Rodriguez V, Carr E, Aas M, Trotta G, Marino P, Vorontsova N, Herane-Vives A, Gadelrab R, Spinazzola E, Di Forti M, Morgan C, Murray RM. A systematic review on mediators between adversity and psychosis: potential targets for treatment. Psychol Med 2020; 50:1966-1976. [PMID: 32744193 DOI: 10.1017/s0033291720002421] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Various psychological and biological pathways have been proposed as mediators between childhood adversity (CA) and psychosis. A systematic review of the evidence in this domain is needed. Our aim is to systematically review the evidence on psychological and biological mediators between CA and psychosis across the psychosis spectrum. This review followed PRISMA guidelines. Articles published between 1979 and July 2019 were identified through a literature search in OVID (PsychINFO, Medline and Embase) and Cochrane Libraries. The evidence by each analysis and each study is presented by group of mediator categories found. The percentage of total effect mediated was calculated. Forty-eight studies were included, 21 in clinical samples and 27 in the general population (GP) with a total of 82 352 subjects from GP and 3189 from clinical studies. The quality of studies was judged as 'fair'. Our results showed (i) solid evidence of mediation between CA and psychosis by negative cognitive schemas about the self, the world and others (NS); by dissociation and other post-traumatic stress disorder symptoms; and through an affective pathway in GP but not in subjects with disorder; (iii) lack of studies exploring biological mediators. We found evidence suggesting that various overlapping and not competing pathways involving post-traumatic and mood symptoms, as well as negative cognitions contribute partially to the link between CA and psychosis. Experiences of CA, along with relevant mediators should be routinely assessed in patients with psychosis. Evidence testing efficacy of interventions targeting such mediators through cognitive behavioural approaches and/or pharmacological means is needed in future.
Collapse
Affiliation(s)
- Luis Alameda
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Service of General Psychiatry, Treatment and Early Intervention in Psychosis Program, Lausanne University Hospital (CHUV), CH-1008Lausanne, Switzerland
- Department of Psychiatry, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Spain
- Instituto de Investigacion Sanitaria de Sevilla, IBiS, Spain
| | - Victoria Rodriguez
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ewan Carr
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Monica Aas
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Giulia Trotta
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Paolo Marino
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Natasha Vorontsova
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Andrés Herane-Vives
- Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Departamento de Clínicas, Facultad de Medicina, Universidad Católica del Norte, Coquimbo, Chile
| | - Romayne Gadelrab
- Department of Psychological Medicine, Centre for Affective Disorders, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Edoardo Spinazzola
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Marta Di Forti
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Craig Morgan
- ESRC Centre for Society and Mental Health, King's College London, UK
| | - Robin M Murray
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
18
|
Wake S, Wormwood J, Satpute AB. The influence of fear on risk taking: a meta-analysis. Cogn Emot 2020; 34:1143-1159. [PMID: 32116122 PMCID: PMC7423744 DOI: 10.1080/02699931.2020.1731428] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 01/20/2020] [Accepted: 02/10/2020] [Indexed: 12/21/2022]
Abstract
A common finding in the study of emotion and decision making is the tendency for fear and anxiety to decrease risk taking. The current meta-analysis summarises the strength and variability of this effect in the extant empirical literature. Our analysis of 136 effect sizes, derived from 68 independent samples and 9,544 participants, included studies that experimentally manipulated fear or measured naturally varying levels of fear or anxiety in both clinical and non-clinical samples, and studies measuring risky decision making and risk estimation. A multilevel random effects model estimated a small to moderate average effect size (r = 0.22), such that fear was related to decreased risky decision making and increased risk estimation. There was also high heterogeneity in the effect sizes. Moderator analyses showed that effect sizes were greater when risk tasks used tangible (e.g. monetary) outcomes and when studies used clinically anxious participants. However, there also remained considerable variability in effect sizes, the sources of which remain unknown. We posit several potential factors that may contribute to observed variability in this effect for future study, including factors concerning both the nature of fear experience and the risk taking context.
Collapse
Affiliation(s)
- Sean Wake
- Department of Psychology, Northeastern University, Boston, MA, USA
| | - Jolie Wormwood
- Department of Psychology, University of New Hampshire, Durham, NH, USA
| | - Ajay B. Satpute
- Department of Psychology, Northeastern University, Boston, MA, USA
| |
Collapse
|
19
|
‘Felt security’ as a means of facilitating imagery rescripting in psychosis: a clinical protocol and illustrative case study. COGNITIVE BEHAVIOUR THERAPIST 2020. [DOI: 10.1017/s1754470x20000288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
People with psychosis do not have routine access to trauma-focused cognitive behavioural therapy (CBT) interventions such as imagery rescripting (IR), partly due to clinical caution. This case study describes the use of a simple imagery task designed to engender ‘felt security’, as a means of facilitating IR with a woman struggling with distressing memory intrusions, linked to her voices and paranoia. We assessed the impact of the felt security task, which was used before IR to enable Kip to engage in reprocessing of her trauma memories, and again after IR so that she would leave sessions feeling safe. The brief imagery task was effective in improving felt security before IR sessions. Felt security then reduced during IR, when distressing material was recalled and reprocessed, and increased again when the task was repeated. It is not yet clear whether trauma-focused interventions such as IR need to be routinely adapted for people with psychosis. In the event that individuals express concerns about IR, if the person’s formulation indicates that high levels of arousal may trigger an exacerbation of voices, paranoia or risk, or where clinicians are otherwise concerned about interventions likely to increase emotional arousal in the short term, the felt security task may facilitate safe and effective reprocessing of trauma memories. This in turn may increase access to trauma-focused CBT for people with psychosis.
Key learning aims
(1)
To understand that people with psychosis need access to trauma-focused CBT.
(2)
To be familiar with a simple attachment-based imagery task designed to foster ‘felt security’.
(3)
To learn that this task may facilitate imagery rescripting in people with psychosis.
Collapse
|
20
|
Vallath S, Ravikanth L, Regeer B, Borba PC, Henderson DC, Scholte WF. Traumatic loss and psychosis - reconceptualising the role of trauma in psychosis. Eur J Psychotraumatol 2020; 11:1725322. [PMID: 32341762 PMCID: PMC7170325 DOI: 10.1080/20008198.2020.1725322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 01/10/2020] [Accepted: 01/14/2020] [Indexed: 02/05/2023] Open
Abstract
Literature suggests that the occurrence of psychological trauma (PT) from various negative life experiences beyond events mentioned in the DSM-criterion A, receives little to no attention when comorbid with psychosis. In fact, despite research indicating the intricate interplay between PT and psychosis, and the need for trauma-focused interventions (TFI), there continue to be mixed views on whether treating PT would worsen psychosis, with many practitioners hesitating to initiate treatment for this reason. This study, therefore, aimed to understand patient perspectives on the role of PT in psychosis and related treatment options. A qualitative exploratory approach was adopted using in-depth interviews with individuals experiencing psychosis. The Global Assessment of Functioning (GAF) scale was administered on a predetermined maximum variation sample resulting in two groups of participants- those with moderate-mild disability (GAF 54-80; n = 10) and those experiencing moderate-severe disability (GAF 41-57; n = 10). With the former group, a semi-structured interview schedule was used, while with the latter, owing to multiple symptoms and difficulty in cognitive processing, a structured interview schedule was used. Results from interpretative phenomenological analysis (IPA) indicated that traumatic loss was central to experienced PT, but received no attention; this often contributed to the psychotic experience and/or depression, through maintenance factors such as cognitive distortions and attenuated affective responses. Further, the experience of loss seems to be more consequential to trauma-related symptoms than the event itself. Participants opined strongly the need for TFI and the role of it in promoting recovery from psychosis.
Collapse
Affiliation(s)
- S. Vallath
- Department of Psychology, The Banyan, Chennai, India
- The Banyan Academy of Leadership in Mental Health (BALM), Centre for Social Action and Research, Kanchipuram, India
- Faculty of Science, Athena Institute for Research on Innovation and Communication in the Health & Life Sciences, Vrije Universiteit, Amsterdam, Netherlands
| | - L. Ravikanth
- The Banyan Academy of Leadership in Mental Health (BALM), Centre for Social Action and Research, Kanchipuram, India
| | - B. Regeer
- Faculty of Science, Athena Institute for Research on Innovation and Communication in the Health & Life Sciences, Vrije Universiteit, Amsterdam, Netherlands
| | - P. C. Borba
- Department of Psychiatry, Boston School of Medicine, MA, USA
| | - D. C. Henderson
- Department of Psychiatry, Boston School of Medicine, MA, USA
| | - W. F. Scholte
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- ARQ National Psychotrauma Centre, Diemen, Netherlands
| |
Collapse
|
21
|
Imagery rescripting in non-clinical paranoia: a pilot study of the impact on key cognitive and affective processes. Behav Cogn Psychother 2019; 48:54-66. [DOI: 10.1017/s1352465819000419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractBackground:Paranoia is often accompanied by distressing intrusions associated with traumatic memories, yet one of the best-evidenced interventions, imagery rescripting (IR), is not routinely offered. This is likely to be due to poor understanding of the effects of IR on postulated mechanisms of change as well as the absence of a robust evidence base.Aims:This study aimed to establish proof of principle that IR impacts key cognitive-affective processes associated with distressing intrusions – memory characteristics and self-representations – and level of paranoia.Method:We used a within-subject repeated measures design to examine the effect of single-session IR on memory characteristics (level of intrusions, vividness, distress, encapsulated belief strength, emotion intensity and frequency), self-representation variables, affect and paranoia. Fifteen participants were seen once before and once after the IR session, to gather baseline and follow-up data.Results:As predicted, participants reported reductions in memory characteristics, improved self-esteem and positive affect, and reduced negative affect and paranoia, with large effect sizes. These effects were maintained at follow-up.Conclusions:While a within-subject design is useful for initial exploration of novel interventions, controlled studies are needed to determine causality. This is the first study to examine mechanisms of IR in paranoia. A controlled trial is now warranted.
Collapse
|
22
|
Imagery rescripting for the treatment of trauma in voice hearers: a case series. Behav Cogn Psychother 2019; 47:709-725. [DOI: 10.1017/s1352465819000237] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AbstractBackground: High rates of trauma and post-traumatic stress disorder (PTSD) are reported in people who hear voices (auditory hallucinations). A recent meta-analysis of trauma interventions in psychosis showed only small improvements in PSTD symptoms and voices. Imagery Rescripting (ImRs) may be a therapy that is more effective in this population because it generalizes over memories, which is ideal in this population with typically repeated traumas.Aims: The primary aims of this study were to investigate whether ImR reduces (1) PTSD symptoms, and (2) voice frequency and distress in voice hearers.Method: We used a single arm open trial study, case-series design. Twelve voice hearers with previous traumas that were thematically related to their voices participated. Brief weekly assessments (administered in sessions 1–8, post-intervention, and at 3-month follow-up) and longer measures (administered pre-, mid- and post-intervention) were administered. Mixed regression analysis was used to analyse the results.Results: There was one treatment drop-out. Results of the weekly measure showed significant linear reductions over time in all three primary variables – voice distress, voice frequency, and trauma intrusions – all with large effect sizes. These effects were maintained (and continued to improve for trauma intrusions) at 3-month follow-up. On the full assessment tools, all measures showed improvement over time, with five outcomes showing significant time effects: trauma, voice frequency, voice distress, voice malevolence and stress.Conclusions: The findings of the current study suggest that ImRs for PTSD symptoms is generally well tolerated and can be therapeutically beneficial among individuals who hear voices.
Collapse
|
23
|
Cognitive behavioural therapy for psychosis targeting trauma, voices and dissociation: a case report. COGNITIVE BEHAVIOUR THERAPIST 2019. [DOI: 10.1017/s1754470x19000035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractTrauma and dissociation may be important factors contributing to the experiences of distressing voice hearing. However, there is scant mention of how to target and treat such processes when working with people with psychosis. This case study reports on an initial attempt to work with dissociation and trauma memories in a person with voices. A single case approach was used, with standardized measures used before, during and after 24 sessions of cognitive therapy, and at 6-month follow-up. In addition, session-by-session measures tracked frequency and distress associated with voices and dissociation. The participant reported significant improvements in terms of reduced frequency and distress of dissociation, and voice hearing, as well as improvement in low mood at the end of treatment. At follow-up there were enduring benefits in terms of dissociation and trauma-related experiences, as well as broad recovery but not of change in voices. This case illustrated the potential benefit of targeting dissociation and exposure to trauma memories in producing general symptom improvement and specific reductions in dissociation and voice hearing at end of treatment.
Collapse
|