Stephen KellettConsultant Clinical Psychologist

IAPT Programme Director University of Sheffield

Sheffield S & HC NHS Trust

Present StudyAssessment, case description, treatment and long-

term outcome of client presenting with Paranoid Personality Disorder (PPD)

Hermeutic single case experimental design (Elliott 2002)(1) traditional outcomes measures

(2) personal questionnaire daily(3) perceptions of therapy and therapist(4) post therapy interview(5) well described case

(6) expert panel or ‘jury’ to consider the evidence for change

PPD : DSM-1V (APA, 1994) DEFINITION

suspects (without sufficient basis) that others are exploiting, harming or deceiving them

pre-occupied with trustworthinessinability to confidereads demeaning/threatening meanings into

eventsgrudgesperceives attacks on characterjealous

Present Study cont

Repetition of measures focal to PPD across phases of CAT treatment and phases within phases (ie. addition of mindfulness)

(1) reformulation/assessment phase

(2) CAT intervention

(3) follow-up

The Case

Carl (pseudonym, aged 37, signed off work)Referred by Consultant Psychiatrist opinion re. thought disorderScreened and placed on waiting listAssessed via SCID-II (Spitzer et al, 1997)

Factor Description

CHILDHOOD father morbidly jealous of mother

used as a ‘spy’

interrogated

sibling

reinforcement of schema by step-father

OCCUPATION unskilled jobs 2 years

benefit fraud investigator 13 years

DWP currently

The Case cont

RELATIONSHIPS married – disconnected & distrustful of partner

1 child – few friends

‘COPING’ drugs & alcohol

MENTAL HEALTH history of depression

schizoid

anti-depressant/anti psychotic

SYMTOMATOLOGY disconnected

untrusting

suspicious

‘The Game’

vigilance; ‘the radar’

‘safety’ behaviours

conspiracy theories

Hermeneutic SCED; what was done and when(1) Traditional Outcome Measures reported at assessment,

termination, and follow-up Beck Depression Inventory-II (BDI; Beck et al, 1994) Brief Symptom Inventory (BSI; Derogatis, 1993) Inventory of Interpersonal Problems (IIP-32; Barkham et al, 1994) Personality Structure and Questionnaire (PSQ; Pollock et al, 2001)

(2) Personal Questionnaire

Actual Wording PPD criteria/concept Frequency Scale

Item 1 “I have felt suspicious of other motives today”

DSM-IV 301.0.1

Subjects that others are exploiting, harming or deceiving others

Daily 1 ‘not at all’ to

10 ‘all the time’

Item 2 “I have been scanning my environment today”

Hypervigilance

Daily 1 ‘not at all’ to

10 ‘all the time’

Hermeneutic SCED cont

Actual Wording PPD criteria/concept Frequency Scale

Item 3 “I have been questionning the motives of others today”

301.0.2

Is preoccupied with unjustified doubts about loyalty or trustworthiness of others

Daily

1 ‘not at all’ to

10 ‘all the time’

Item 4 “I have been in a world of my own today”

Dissociation/

Disconnection

Daily 1 ‘not at all’ to

10 ‘all the time’

Item 5 “I have been looking for connections today” Conspiracy Daily 1 ‘not at all’ to

10 ‘all the time’

Item 6 “I have felt anxious today” Anxiety Daily 1 ‘not at all’ to

10 ‘all the time’

Hermeneutic SCED cont

(3) Perception of therapy and therapist

Session Impact Questionnaire (Stiles et al, 1994) 5 ‘impacts’ measured after each session (understanding, problem

solving, relationship, unwanted thoughts, hindering aspects)

(4) Post-therapy Interview

Therapy change interview (Elliott, Slatick & Urman, 2001)

Structure of intervention

co-working and sharing; reformulation letterSDR (starting to get cognitive)introduction of mindfulness techniquesintegrating RR analysis and mindfulnesshomeworkin session enactmentstermination issues

Mindfulness-based cognitive therapy (Segal, Williams & Teasdale, 2002)

Mindfulness of breathStaying presentAllowing/letting beThinking and thoughtDealing with barriers

Diagram 1: Sequential Diagrammatic Reformulation for PPD Case

TOTALLYUNFEELING

CUT OFF&

EMPTY

CORE PAINanxiousfearful

insecurehectored

CAPTAIN PARANOIA

(though I feel complete)

INTERROGATINGI

INTERROGATED

`THE GAME`Players versus

non-playersOBSERVINGWATCHING

IMONITORED

SOCIALWITHDRAWAL

`the radar`SUSPICIOUS

IWARY

DISTRUSTFUL

find this frightening

after a while

start to feel

vulnerable

only way I know to feel safe

obsess about it

start to believe

thoughts

`peas in the bag`

try to see a pattern

need to make sense

anxiety triggeredsee threat

everywhere

when with people, always keep my distance

find it hard to `connect`

never develop `true` trust

start to see threatswithdraw into myself

mood plummets

Hard to tolerate this

feel totally exhausted

can’t ever relax

never ever stop thinking

try to make sense of confusion

need something to tie it all together

start to play

this game is real

`ha ha; I’ve seen you`

win / outwit/triumph

Key question 1

At what stage does active therapy start to work and are there any sudden gains?

Graph 1; levels of suspiciousness over the course of CAT and follow-up

0

5

10

15

20

25

30

35

40

45

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55

Weeks

To

tal

wee

kly

sco

re

Baseline CAT Follow-up

Table 1; means, (SDs) and F-values for the experimental variables

Baseline mean (SD)

Treatment mean (SD)

Follow-up mean (SD)

F-value

Suspicious 34.33 (2.08) 11.82 (7.12) 7.00 (0.00) 11.60**

Hypervigilent

23.67 (9.81) 9.61 (11.04) 7.00 (0.00) 0.06

Questioning 21.67 (16.67) 9.67 (2.76) 7.00 (0.00) 1.98

Dissociation 20.33 (14.01) 11.15 (7.15) 7.00 (0.00) 1.26

Conspiracy 19.67 (17.78) 10.48 (6.11) 7.00 (0.00) 2.49

Anxious 27.33 (11.52) 16.48 (10.30) 17.16 (9.06) 4.24** p < 0.05

** p < 0.01

What do significant F-values mean in this context?

An overall change in both the intercept (i.e. start of treatment post formulation) and the slope (regression line)

Key question 2

Is there any clinically significant change in the traditional outcome measures?

Graph 2; BDI-II score at assessment, termination and follow-up

0

5

10

15

20

25

30

35

40

1 2 3

Time points

Sco

re

Key question 3; are some sessions more impactful/helpful than others?

Significant increase in ratings of problem solving in treatment sessions (t = -2.27, P < 0.05)

No difference in understanding, relationship, unwanted thoughts or hindering aspects

Key question 4

can the client describe what changes were due to therapy and what made the difference

the change interview conducted at final follow-up session

Change interview results

“feel so much better, not be thinking all the time”

“not playing the game such a relief … I can manage my thoughts now”

5 = surprised; 1 = expectedIn therapy actions … ‘developing trust’Key changes (1) use of SDR (2) integrating

mindfulness and RRs“ I see people differently now”Managing the paranoia with somebody, very

difficult at first

Conclusions for the case

Integration the key issue

Good evidence of change and change being attributable to the therapy conducted

HSCED effective research methodology in PD populations

CAT and BPD multi-site HSCED study

Project team = Stephen Kellett, Dawn Bennett and Tony Ryle

Progress = 8 therapists over 8 sites have completed a 24 plus 4 follow-up session CAT interventions with BPD clients

Sessions sampled from each of the therapies and CCAT conducted to attain competency rating (111 CCATs completed)

MethodologyAT EACH SESSION At every 4th Session At 3 month post-

therapy

CORE-OM Dissociative Experiences Scale

Elliot Change Interview

Personal Questionnaire Personality Structure Scale

Helpful Aspects of Therapy

Measure of alliance

Audio tape of session

Need for an expert panel/jury

We are attempting to recruit a panel of professionals to consider the evidence for change in a number of cases

Professionals not aligned to CAT and sceptical about change

One day meeting

S.Kellett@sheffield.ac.uk