Alison Wearden

A critical evaluation of the use of interpretative phenomenological analysis (IPA) in health psychology

With the burgeoning use of qualitative methods in health research, criteria for judging their value become increasingly necessary. Interpretative phenomenological analysis (IPA) is a distinctive approach to conducting qualitative research being used with increasing frequency in published studies. A systematic literature review was undertaken to identify published papers in the area of health psychology employing IPA. A total of 52 articles are reviewed here in terms of the following: methods of data collection, sampling, assessing wider applicability of research and adherence to the theoretical foundations and procedures of IPA. IPA seems applicable and useful in a wide variety of research topics. The lack of attention sometimes afforded to the interpretative facet of the approach is discussed.

Attachment theory: A framework for understanding symptoms and interpersonal relationships in psychosis.

We investigated associations between adult attachment, symptoms and interpersonal functioning, including therapeutic relationships in 96 patients with psychosis. Using a prospective design, we also assessed changes in attachment in both psychiatrically unstable and stable groups. We measured attachment using the Psychosis Attachment Measure (PAM) and interpersonal problems and therapeutic relationships were assessed from both psychiatric staff and patient perspectives. Avoidant attachment was associated with positive symptoms, negative symptoms and paranoia. Attachment ratings were relatively stable over time, although changes in attachment anxiety were positively correlated with changes in symptoms. Predicted associations between high levels of attachment anxiety and avoidance and interpersonal problems were supported, and attachment avoidance was associated with difficulties in therapeutic relationships. Findings suggest that adult attachment style is a meaningful individual difference variable in people with psychosis and may be an important predictor of symptoms, interpersonal problems and difficulties in therapeutic relationships over and above severity of illness.

A comparison of salivary cortisol in chronic fatigue syndrome, community depression and healthy controls

BACKGROUND Previous studies reporting cortisol hyposecretion in chronic fatigue syndrome may have been confounded by venepuncture, fasting and hospitalisation. METHODS Morning and evening salivary cortisol were obtained on consecutive days in the first 3 days of the menstrual cycle and compared in three samples of women taking no medication and matched for age: 14 patients with chronic fatigue syndrome, 26 community cases of ICD-10 current depressive episodes and 131 healthy community controls. RESULTS The mean evening cortisol was significantly lower in the chronic fatigue syndrome patients compared to controls with depression (P = 0.02) and healthy controls (P = 0.005). Chronic fatigue syndrome patients without psychiatric disorder had significantly lower morning salivary cortisols compared to controls (P = 0.009). CONCLUSION Chronic fatigue syndrome patients display cortisol hyposecretion in saliva as well as plasma compared to patients with depression and healthy controls. LIMITATIONS Small samples of female patients with cortisol estimated at only two time points in the day. Cortisol secretion may be secondary to other neurotransmitter abnormalities or other physiological or lifestyle factors in chronic fatigue syndrome patients. CLINICAL RELEVANCE Chronic fatigue syndrome is biochemically distinct from community depression.

Adult attachment, alexithymia, symptom reporting, and health-related coping

OBJECTIVE The objective of this study was to test a hypothesised model of associations between adult attachment style and two health-related outcomes, symptom reporting and coping with health problems. Alexithymia, a construct involving a deficit in the ability to identify and describe emotions, is thought to develop as a result of childhood interactions with caregivers. We wished to determine whether alexithymia acted as a mediating variable between attachment and health outcomes. METHOD Two hundred and one female undergraduates, aged 18-34, completed questionnaire measures of attachment style, alexithymia, positive and negative affectivity, symptom reporting, and coping with health problems. RESULTS Insecure attachment (both avoidant and anxious), alexithymia, and negative affectivity were all weakly intercorrelated. However, insecure attachment was associated with alexithymia independent of its association with negative affectivity. Avoidant attachment was weakly predictive of symptom reporting and emotional preoccupation as a way of coping with health problems. Regression analyses showed that the association between avoidant attachment and these health-related outcomes was mediated by alexithymia and negative affectivity, both of which made significant independent contributions to the health outcomes. CONCLUSIONS Our results are consistent with the proposition that alexithymia develops in response to interactions with primary caregivers that also influence infant and adult attachment. Associations between adult attachment and health outcomes may be due in part to disturbances in affect regulation.

The relation of sleep difficulties to fatigue, mood and disability in chronic fatigue syndrome

The relationship of sleep complaints to mood, fatigue, disability, and lifestyle was examined in 69 chronic fatigue syndrome (CFS) patients without psychiatric disorder, 58 CFS patients with psychiatric disorder, 38 psychiatric out-patients with chronic depressive disorders, and 45 healthy controls. The groups were matched for age and gender. There were few differences between the prevalence or nature of sleep complaints of CFS patients with or without current DSM-IIIR depression, anxiety or somatization disorder. CFS patients reported significantly more naps and waking by pain, a similar prevalence of difficulties in maintaining sleep, and significantly less difficulty getting off to sleep compared to depressed patients. Sleep continuity complaints preceded fatigue in only 20% of CFS patients, but there was a strong association between relapse and sleep disturbance. Certain types of sleep disorder were associated with increased disability or fatigue in CFS patients. Disrupted sleep appears to complicate the course of CFS. For the most part, sleep complaints are either attributable to the lifestyle of CFS patients or seem inherent to the underlying condition of CFS. They are generally unrelated to depression or anxiety in CFS.

Nurse led, home based self help treatment for patients in primary care with chronic fatigue syndrome: randomised controlled trial

Objective To evaluate the effectiveness of home delivered pragmatic rehabilitation—a programme of gradually increasing activity designed collaboratively by the patient and the therapist—and supportive listening—an approach based on non-directive counselling—for patients in primary care with chronic fatigue syndrome/myalgic encephalomyelitis or encephalitis (CFS/ME). Design Single blind, randomised, controlled trial. Setting 186 general practices across the north west of England between February 2005 and May 2007. Participants 296 patients aged 18 or over with CFS/ME (median illness duration seven years) diagnosed using the Oxford criteria. Interventions Participants were randomly allocated to pragmatic rehabilitation, supportive listening, or general practitioner treatment as usual. Both therapies were delivered at home in 10 sessions over 18 weeks by one of three adult specialty general nurses who had received four months’ training, including supervised practice, in each of the interventions. GP treatment as usual was unconstrained except that patients were not to be referred for systematic psychological therapies during the treatment period. Main outcome measures The primary clinical outcomes were fatigue and physical functioning at the end of treatment (20 weeks) and 70 weeks from recruitment compared with GP treatment as usual. Lower fatigue scores and higher physical functioning scores denote better outcomes. Results A total of 257 (87%) of the 296 patients who entered the trial were assessed at 70 weeks, the primary outcome point. Analysis was on an intention to treat basis, with robust treatment effects estimated after adjustment for missing data using probability weights. Immediately after treatment (at 20 weeks), patients allocated to pragmatic rehabilitation (n=95) had significantly improved fatigue (effect estimate -1.18, 95% confidence interval -2.18 to -0.18; P=0.021) but not physical functioning (-0.18, 95% CI -5.88 to +5.52; P=0.950) compared with patients allocated to treatment as usual (n=100). At one year after finishing treatment (70 weeks), there were no statistically significant differences in fatigue or physical functioning between patients allocated to pragmatic rehabilitation and those on treatment as usual (-1.00, 95% CI -2.10 to +0.11; P=0.076 and +2.57, 95% CI 3.90 to +9.03; P=0.435). At 20 weeks, patients allocated to supportive listening (n=101) had poorer physical functioning than those allocated to treatment as usual (-7.54, 95% CI -12.76 to -2.33; P=0.005) and no difference in fatigue. At 70 weeks, patients allocated to supportive listening did not differ significantly from those allocated to treatment as usual on either primary outcome. Conclusions For patients with CFS/ME in primary care, pragmatic rehabilitation delivered by trained nurse therapists improves fatigue in the short term compared with unconstrained GP treatment as usual, but the effect is small and not statistically significant at one year follow-up. Supportive listening delivered by trained nurse therapists is not an effective treatment for CFS/ME. Trial registration International Standard Randomised Controlled Trial Number IRCTN74156610.

Cognitive performance and complaints of cognitive impairment in chronic fatigue syndrome (CFS)

Patients with chronic fatigue syndrome (CFS) complain that they have difficulties with concentration and memory but studies to date have not found consistent objective evidence of performance deficits. Two groups of CFS patients, depressed and non-depressed, and healthy controls, were asked about concentration problems in general and specifically when reading. CFS subjects were more likely than controls to report that they had concentration problems when reading, that they needed to re-read text and that they failed to take in what they were reading. Subjects then performed a task in which their reading behaviour and text recall was measured. While all CFS subjects complained of general cognitive failures and of difficulties with reading, only depressed CFS subjects recalled significantly less of the text than controls. Severity of complaints about reading problems was not related to amount of text recalled, but was related to severity of depressed mood. However, subjects were able to evaluate accurately their ability to remember the text immediately after reading it and before being tested for recall. Additionally, subjects performed a paired-associate learning task on which no significant differences between the subject groups was found. It is concluded that deficits in cognitive functioning in CFS patients are more likely to be found on naturalistic than on laboratory tasks.

Attachment styles, earlier interpersonal relationships and schizotypy in a non-clinical sample.

OBJECTIVES This paper investigates associations between adult attachment style, relationships with significant others during childhood, traumatic life-events and schizotypy. DESIGN Relationships between attachment and hypothesized correlates were investigated in a cross-sectional design using an analogue sample. The reliability of the attachment and trauma measures was investigated using a test-retest design. METHODS Three hundred and four students completed the self-report version of the Psychosis Attachment Measure (PAM), maternal and paternal versions of the Parental Bonding Instrument, the Attachment History Questionnaire, a measure of trauma and the Oxford-Liverpool Inventory of Feelings and Experiences scale through an internet website. RESULTS As predicted, there were statistically significant associations between insecure attachment in adult relationships and experiences of negative interpersonal events. Both earlier interpersonal experiences and adult attachment style predicted schizotypy, and adult attachment style emerged as an independent predictor of positive schizotypal characteristics. CONCLUSIONS The findings support associations between adult attachment style and previous interpersonal experiences and between adult attachment and schizotypy. The PAM is a reliable and valid instrument that can be used to explore attachment styles in analogue samples and associations between attachment styles and psychotic symptoms in clinical samples.

The role of depression in pain, psychophysiological syndromes and medically unexplained symptoms associated with chronic fatigue syndrome

BACKGROUND The association between depression and pain, function, medically unexplained symptoms and psychophysiological syndromes such as irritable bowel syndrome has not been explored before in chronic fatigue syndrome. METHODS Cross-sectional controlled study of the current prevalence of psychophysiological syndromes, pain, function and lifetime prevalence of medically unexplained symptoms in 77 out-patients with chronic fatigue syndrome (CFS) without DSM-III-R depression, 42 CFS out-patients with DSM-III-R depression and 26 out-patient with primary DSM-III-R depression. RESULTS Both CFS groups differed significantly from the primary depression group but not each other in the prevalence of tension headaches (P < 0.001), reporting of widespread bodily pain (P < 0.001) and the number of lifetime medically unexplained symptoms (P < 0.001). The three groups did not significantly differ in the prevalence of irritable bowel syndrome or fibromyalgia. CFS patients with depression were more impaired in social function than other CFS patients. CONCLUSION Depression is not associated with the reporting of pain, psychophysiological syndromes and medically unexplained symptoms in CFS patients. Depression is associated with decreased social function in CFS patients. LIMITATIONS Study depended on recall of symptoms, not confirmed by medical records and current investigations. Patients with depression were taking antidepressants. CLINICAL RELEVANCE Treating depression in chronic fatigue syndrome is unlikely to diminish reporting of pain and medically unexplained symptoms but may improve social function.

Adult attachment styles and psychosis: an investigation of associations between general attachment styles and attachment relationships with specific others

BackgroundIf attachment theory is to help inform our understanding of relationship difficulties in people with psychosis, it is first important to understand the composition of attachment networks in this group and how attachment style measured with reference to relationships in general actually relates to attachment in relationships with specific others.MethodWe examined attachment networks and associations between general attachment style and attachment in relationships with parents and psychiatric staff in a sample of 58 patients with psychosis. We assessed attachment dimensions of anxiety and avoidance using the Psychosis Attachment Measure (PAM) and an adapted version of the instrument asking about relationships with specific others.ResultsPatients reported a median of two attachment relationships. Both attachment anxiety and avoidance measured with reference to close relationships in general were positively correlated with attachment in key worker and parental relationships, although levels of attachment anxiety and avoidance did vary across relationships.ConclusionFuture research should determine factors influencing variations in attachment working models in samples of people with psychosis, as it may be possible to help individuals with insecure attachment styles develop more positive relationships with others.