appraisals, psychotic symptoms and affect in daily life, and changes during cbt

Appraisals, psychotic symptoms and affect

in daily life, and changes during CBT

Emmanuelle PetersKing’s College London, Institute of Psychiatry

U.K.

• Inez Myin-Germeys (University of Maastricht)

• Tineke Lataster (University of Maastricht)

• Sally Williams • Kathryn Greenwood (Sussex Trust Partnership)

• Elizabeth Kuipers • Jan Scott (Newcastle University)

• Philippa Garety

Collaborators

BackgroundBackground

•Symptom dimensions

What should we be measuring as outcomes of

CBT?

DelusionsDelusionsConvictionConviction

PreoccupationPreoccupation

DistressDistressImpact on Impact on functioningfunctioning

VoicesVoicesBeliefsBeliefs

DistressDistress

Impact on Impact on functioningfunctioning


•Appraisals


CBT?

A Cognitive Model of the Positive Symptoms of Psychosis (Garety et al

01; 07)

Maintaining factors• reasoning & attributions• dysfunctional schemas• emotional processes• appraisal of psychosis

Bio-psycho-social

vulnerability

Trigger Emotional changes

Basic cognitive dysfunction Anomalous experience

Positive Symptoms

Appraisal of

experience

Appraisal influenced by:• reasoning & attributional biases• dysfunctional schemas

of self & world• isolation & adverse

environments Garety


•Appraisals

•On-line measurement


CBT?

MethodsMethods

10 times a day 6 consecutive days at random moments

Delespaul, 1995;

Myin-Germeys et al (2001) Arch Gen Psychiat;

Oorschot et al (2009) Psychol Assessment

1. Multiple assessments

2. Real world, no lab

3. In the moment, not retrospective

4. Evaluation of the context

The Experience Sampling Method

ESM ESM bookletbookletPositive Positive

& & negative negative affectaffect

PsychoticPsychotic

SymptomsSymptoms

SpontaneousSpontaneous

thoughtsthoughts

AppraisalsAppraisals

SymptomSymptom

DistressDistress

•Spontaneous thoughts (“What was I thinking just before the beep went off?) Content coded for presence of pathology

•Affect (positive & negative)

•Characteristics of key symptoms:• Hallucinations: intensity, distress, interference

• Delusions: intensity, conviction, distress, interference, preoccupation

Variables assessed in ESM booklet

•Appraisals:• Hallucinations only: control (“my voices are out

of my control”) & power (“my voices are powerful”)

• Hallucinations and delusions: ‘decentring’ (“my problem is due to the way

my mind works”) insight (“my problem is due to an illness”)

•Activity

•Coping

Variables assessed in ESM booklet

1. What was I thinking just before the beep went off? ................................................................................................................................................................................................

2. I feel...Not at all Moderate Very

happy 1 2 3 4 5 6 7 low 1 2 3 4 5 6 7 guilty 1 2 3 4 5 6 7• ashamed 1 2 3 4 5 6 7 in a good mood 1 2 3 4 5 6 7 anxious 1 2 3 4 5 6 7 annoyed 1 2 3 4 5 6 7 scared 1 2 3 4 5 6 7 relaxed 1 2 3 4 5 6 7

3. My first problem (hallucinations, elicited at initial interview) ...................................................................................................... is .... present 1 2 3 4 5 6 7 upsetting me 1 2 3 4 5 6 7 interfering with what I am doing 1 2 3 4 5 6 7 out of my control 1 2 3 4 5 6 7 powerful 1 2 3 4 5 6 7

4. Right now I believe this problem is to do with.... the way my mind works 1 2 3 4 5 6 7 an illness 1 2 3 4 5 6 7• due to X 1 2 3 4 5 6 7

5. My second problem. (delusions, elicited at initisl interview) .................................................................................................. is.....• present 1 2 3 4 5 6 7 I believe is true 1 2 3 4 5 6 7 upsetting me 1 2 3 4 5 6 7 interfering with what I am doing 1 2 3 4 5 6 7 going round and round 1 2 3 4 5 6 7 in my mind

6. Right now I believe this problem is to do with....• the way my mind works 1 2 3 4 5 6 7• an illness 1 2 3 4 5 6 7• due to X 1 2 3 4 5 6 7

7. Where am I?.................................................................................................................................................................................................

8. I am on my own yes/no

Not at all Moderate Very much

If no, I am with people that I like 1 2 3 4 5 6 7

9. What am I doing..........................................................................................................................................................................................Not at all Moderate Very

This is pleasant -3 -2 -1 0 +1 +2 +3This is difficult -3 -2 -1 0 +1 +2 +3

10. Since the last beep, Never Some All my problems were present 1 2 3 4 5 6 7

IF PROBLEMS NOT PRESENT (score = 1), GO STRAIGHT TO END11. When my problems happened.......

• I pushed them to the back of my mind yes/no• I shouted back yes/no• I did something else yes/no• I prayed yes/no• I went to bed yes/no• I reassured myself yes/no• I thought about it differently yes/no• I isolated myself yes/no• I checked it out yes/no• I talked to someone yes/no• I just let it wash over me until it was over yes/no• I took some medication yes/no• I took some alcohol/streetdrugs yes/no• Other (please specify).....................................................................................................................................................................

Not at all Moderate Very12. The beep disturbed me 1 2 3 4 5 6 7It is now exactly: .......hrs.......min

Write down the nicest thing that has happened since the last beep:............................................................................................................................

DesignDesign

1. Baseline 1. Baseline (at referral stage)(at referral stage)

2. Pre-therapy2. Pre-therapy(after 3-6 months on waiting list)(after 3-6 months on waiting list)

3. Mid-therapy3. Mid-therapy(3 months into therapy)(3 months into therapy)

4. End of therapy4. End of therapy(after 6-8 months of therapy) (after 6-8 months of therapy)

5. Follow-up5. Follow-up(3 months post-therapy)(3 months post-therapy)

Results - baselineResults - baseline

Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych MedPeters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med

Baseline N= 12Baseline N= 12(attending outpatients clinic for CBT for psychosis;(attending outpatients clinic for CBT for psychosis;

9 with hallucinations9 with hallucinations9 with delusions)9 with delusions)

Average observations Average observations per person = 44.5per person = 44.5

Total observations Total observations = 534 = 534


Presence Presence of of

symptomsymptomss

Psychosis related:Psychosis related:3.6% (range: 0-18)3.6% (range: 0-18)

Anxiety & depression:Anxiety & depression:4.7% (range: 0-26)4.7% (range: 0-26)

Non-pathological:Non-pathological:73.7%73.7%

Hallucinations:Hallucinations:73% of observations73% of observations

Delusions:Delusions:67% of observations 67% of observations

Spontaneous thoughts

Key identified symptoms

Symptom dimensions & Symptom dimensions & appraisalsappraisals


Hallucinations characteristics

NB: includes only scores > 1 on “hallucinations present”

Mean (SD) (N = 9)

Standardised ß (N = 299) * = p < .001 (Multi-level linear regressions)

Potential range of scores = 2-7 1 2 3 4

1. Intensity 4.0 (1.5) 1.02. Distress 2.9 (0.7) .62

*1.0

3. Interference

2.3 (0.9) .61*

.89* 1.0

4. Control 3.0 (1.6) .89*

1.22*

.82* 1.0

5. Powerful 2.8 (1.0) .63*

.83* .72* .24*Intensity of voices, distress, interference, control and power are all related to each

other

Delusions characteristicsMean (SD) (N = 9)

Standardised ß (N = 399) * = p < .001

Potential range of scores = 1-7 1 2 3 4

1. Intensity 3.5 (2.2) 1.02. Conviction 3.5 (2.4) .82

*1.0

3. Distress 3.2 (1.8) .57*

.19*

1.0

4. Interference 2.5 (1.8) .53*

.24*

.72*

1.0

5. Preoccupation

3.7 (1.6) .55*

.26*

.69*

. 62*

Intensity of delusions, distress, interference, & preoccupation are all related to each other, but

lower effect sizes with conviction

Are symptom appraisals constant? Difference between two

subsequent observationsMean (SD) T-test (df) p

HALLUCINATIONS

1. Control 0.62 (.5) 3.8 (8) .003

2. Power 0.77 (.5) 4.7 (8) .001

3. Decentring 0.72 (.7) 2.9 (8) .009

4. Insight 0.52 (.8) 2.0 (8) .04

DELUSIONS

1. Conviction 0.43 (.4) 3.5 (8) .004

2. Decentring 0.34 (.4) 2.3 (8) .02

3. Insight 0.38 (.6) 2.0 (8) .04

Voice appraisals all highly variable

Delusion appraisals also variable

Relationships between Relationships between symptoms, appraisals & symptoms, appraisals &

affectaffect


Dependent variables(Multi-level linear regressions)

Voice intensity ratings (ß)

Delusions intensity ratings (ß)

Psychotic thought content (ß)

1. Negative affect

.30* .68* .31*

2. Positive affect

-.19* -.38* -.46*

* = p < .001

Is affect related to symptoms?

Intensity of symptoms and psychotic thoughts are highly related to both negative and less

positive affect

Dependent variables(Multi-level linear regressions)

Voice intensity ratings (range 2-7) (ß)

Power appraisals (ß)

Control appraisals (ß)

1. Negative affect

.07 .22* .05

2. Symptom distress

.62* .36* .35*

Are voice appraisals related to distress?

* = p < .001

Power appraisals are the only variable related to negative affect;

Power, control and intensity all related to symptom distress

Dependent variables

Negative affect (ß)

Distress (ß)

Interference (ß)

Preoccupation (ß)

HALLUCINATIONS

* p <.001

1. Decentring -.12 -.21 -.30* /

2. Insight .12 .11 .14 /

DELUSIONS

1. Decentring -.29* -.32* -.44* -.45*

2. Insight .009 .01 -.03 .07

Is insight related to distress?

Decentring appraisals for delusions are related to less distress/negative affect/preoccupation and disruption to functioning, and to less interference for hallucinations. Insight is not related to distress or functioning for either

symptom

Conclusions - baselineConclusions - baseline

1)Despite psychotic symptoms being present a majority of the time, people are not engulfed by their symptoms

2)Intensity and presence of psychosis-related thoughts lead to more distress, less positive affect, and interference with functioning

3)Delusional conviction is potentially a separate dimension, and is not stable; nor are appraisals about symptoms (control & power of voices; ‘decentring’ & insight)

4)Power appraisals are a central factor related to negative affect

5)‘Decentring’ from your delusions is related to less distress and disruption to functioning; in contrast, traditional insight does not influence distress

Results – longitudinal dataResults – longitudinal data

N= 12N= 12(7 provided data on at least 2 time points;(7 provided data on at least 2 time points;

6 with hallucinations; 7 with delusions6 with hallucinations; 7 with delusions5 provided data at each time point)5 provided data at each time point)

Average observations Average observations per person = 106per person = 106

Total observations Total observations = 1273 = 1273

HallucinationsHallucinations

-2

-1.5

-1

-0.5

0

0.5

1

Pre-therapy Mid-therapy End of therapy Follow-up

Effect sizes (compared to baseline)

Hallucinations: Intensity

*

* = p <.01

-2

-1.5

-1

-0.5

0

0.5

1



Hallucinations: Distress (when hallucinations present only)

*

* = p <.01

-2

-1.5

-1

-0.5

0

0.5

1



Hallucinations: Interference (when hallucinations present only)

*

* = p <.01

**

-2

-1.5

-1

-0.5

0

0.5

1



Hallucinations: Control (when hallucinations present only)

*

* = p <.01

**

-2

-1.5

-1

-0.5

0

0.5

1



Hallucinations: Power (when hallucinations present only)

*

* = p <.01

**

-2

-1.5

-1

-0.5

0

0.5

1



Hallucinations: Decentring (when hallucinations present only)

*

* = p <.01

*

-2

-1.5

-1

-0.5

0

0.5

1



Hallucinations: Insight (when hallucinations present only)

*

* = p <.01

**

*

DelusionsDelusions

-2

-1.5

-1

-0.5

0

0.5

1



Delusions: Intensity

***

* = p <.01

-2

-1.5

-1

-0.5

0

0.5

1



Delusions: Conviction (when delusions present only)

*

*

* = p <.01

-2

-1.5

-1

-0.5

0

0.5

1



Delusions: Distress (when delusions present only)

*

*

*

* = p <.01

-2

-1.5

-1

-0.5

0

0.5

1



Delusions: Interference (when delusions present only)

*

*

*

* = p <.01

-2

-1.5

-1

-0.5

0

0.5

1



Delusions: Preoccupation (when delusions present only)

***

* = p <.01

-2

-1.5

-1

-0.5

0

0.5

1



Delusions: Insight (when delusions present only)

*

* = p <.01

-2

-1.5

-1

-0.5

0

0.5

1



Delusions: Decentring (when delusions present only)

*

* = p <.01

**

AffectAffect

-2

-1.5

-1

-0.5

0

0.5

1



Negative affect

*

* = p <.01

*

-2

-1.5

-1

-0.5

0

0.5

1



Positive affect

Conclusions – longitudinal Conclusions – longitudinal datadata

1)For hallucinations, significant changes were demonstrated from mid-therapy, and maintained at follow-up, in:

• Interference

• Controllability

• Insight

• (power beliefs)

• (decentring)2)Changes in intensity of voices and voice-

related distress not as robust

4)For delusions, significant changes were demonstrated from mid-therapy, which were maintained at follow-up, in:

• Intensity

• Distress

• Interference

• Preoccupation 5)Changes in conviction and insight not as

robust, decentring got worse (?)6)Negative affect, but not positive affect, was

affected by therapy

Future researchFuture research

1)ESM is powerful methodology to demonstrate subtle changes in people’s daily lives

2)Ecological validity ++3)Intensive methodology – not easily

transferred to the clinic?4)Good for looking at relationships amongst

different variables5)Good for looking at timeline of changes6)Good for looking at causal mechanisms

THE END

appraisals, psychotic symptoms and affect in daily life, and changes during cbt

Documents

problem hallucinations

outcomes of cbt

mind worksinsight

myingermeys et

psychotic symptoms

esm booklet appraisals

control power

initial interview