Nadine Keen

Nightmares in Patients with Psychosis: The Relation with Sleep, Psychotic, Affective, and Cognitive Symptoms

Objective: To examine the prevalence of nightmares in people with psychosis and to describe the link between nightmares and sleep quality, psychotic, affective, and cognitive symptoms. Methods: Forty participants with psychotic symptoms completed an assessment of nightmares, sleep quality, positive symptoms of psychosis, affect, posttraumatic stress, social functioning, and working memory. Results: Among the patients, 55% reported weekly distressing nightmares. Experience of more frequent nightmares was related to poorer sleep quality and sleep efficiency. More distressing nightmares were positively associated with greater delusional severity, depression, anxiety, stress, and difficulties with working memory. Conclusions: Nightmares might be common in those with psychosis and are associated with increased day- and nighttime impairment. Future research should investigate treatments for nightmares, for people presenting with psychotic symptoms.

The use of rescripting imagery for people with psychosis who hear voices.

BACKGROUND Image rescripting can be helpful in reducing the distress associated with intrusive images or memories across a range of disorders. Existing studies using imagery rescripting with people with psychosis have not included people who hear voices. AIMS This study aimed to explore the use of image rescripting with people with psychosis who have intrusive images or memories and hear voices. METHOD This study used a one-off image rescripting session, using an A-B design with four participants with psychosis who were attending adult mental health community services. RESULTS Clinically significant reductions in distress, negative affect and reduced conviction in the beliefs associated with the imagery were reported at 1-week follow-up and maintained for three of the four participants at 1-month follow-up. CONCLUSIONS The study offers early indications that image rescripting can be used as a treatment approach for people with psychosis. Exploring visual imagery and rescripting visual memories where appropriate may be a useful extension of cognitive behavioural therapy for psychosis (CBTp).

Posttraumatic stress symptoms (PTSS) in caregivers of people with psychosis and associations with caregiving experiences.

ABSTRACT Objective: Posttraumatic stress symptoms (PTSS) have been identified in caregivers of people with psychosis, but their clinical correlates are less well known. This study aimed to assess PTSS in a sample of caregivers of people with psychosis and to examine the relationship between PTSS and caregiving experiences. Method: A total of 32 caregivers of people with psychosis completed self-report questionnaires and structured interviews assessing PTSS and caregiving processes, including expressed emotion, burden, and coping. Results: In all, 44% of the sample reported PTSS, which were associated with caregiver reports of burden and less adaptive (avoidant) coping. No links were observed with expressed emotion in this sample. Conclusion: Almost half of caregivers of people with psychosis reported PTSS related to their caring role, which may have implications for their caregiving experiences and coping efforts. The findings highlight the importance of assessing need in caregivers and optimizing opportunities to offer needs-led therapeutic interventions to caregivers.

The long-term effectiveness of cognitive behavior therapy for psychosis within a routine psychological therapies service

Randomised controlled trials (RCTs) have shown the efficacy of CBTp, however, few studies have considered its long-term effectiveness in routine services. This study reports the outcomes of clients seen in a psychological therapies clinic, set up following positive results obtained from an RCT (Peters et al., 2010). The aims were to evaluate the effectiveness of CBTp, using data from the service’s routine assessments for consecutive referrals over a 12 years period, and assess whether gains were maintained at a 6+ months’ follow-up. Of the 476 consenting referrals, all clients (N = 358) who received ≥5 therapy sessions were offered an assessment at four time points (baseline, pre-, mid-, and end of therapy) on measures assessing current psychosis symptoms, emotional problems, general well-being and life satisfaction. A sub-set (N = 113) was assessed at a median of 12 months after finishing therapy. Following the waiting list (median of 3 months) clients received individualized, formulation-based CBTp for a median number of 19 sessions from 121 therapists with a range of experience receiving regular supervision. Clients showed no meaningful change on any measure while on the waiting list (Cohen’s d <= 0.23). In contrast, highly significant improvements following therapy, all of which were significantly greater than changes during the waiting list, were found on all domains assessed (Cohen’s d: 0.44–0.75). All gains were maintained at follow-up (Cohen’s d: 0.29–0.82), with little change between end of therapy and follow-up (Cohen’s d <= 0.18). Drop-out rate from therapy was low (13%). These results demonstrate the positive and potentially enduring impact of psychological therapy on a range of meaningful outcomes for clients with psychosis. The follow-up assessments were conducted on only a sub-set, which may not generalize to the full sample. Nevertheless this study is the largest of its kind in psychosis, and has important implications for the practice of CBTp in clinical services.

Psychological interventions for post-traumatic stress symptoms in psychosis: A systematic review of outcomes

Individuals with severe mental health problems, such as psychosis, are consistently shown to have experienced high levels of past traumatic events. They are also at an increased risk of further traumatisation through victimization events such as crime and assault. The experience of psychosis itself and psychiatric hospitalization have also been recognized to be sufficiently traumatic to lead to the development of post-traumatic stress (PTS) symptoms. Rates of post-traumatic stress disorder (PTSD) are elevated in people with psychosis compared to the general population. The current guidance for the treatment of PTSD is informed by an evidence base predominately limited to populations without co-morbid psychiatric disorders. The systematic review therefore sought to present the current available literature on the use of psychological treatments targeting PTS symptoms in a population with a primary diagnosis of a psychotic disorder. The review aimed to investigate the effect of these interventions on PTS symptoms and also the effect on secondary domains such as psychotic symptoms, affect and functioning. Fifteen studies were identified reporting on cognitive behavior therapy, prolonged exposure, eye movement desensitisation and reprocessing and written emotional disclosure. The review provides preliminary support for the safe use of trauma-focused psychological interventions in groups of people with severe mental health problems. Overall, the interventions were found to be effective in reducing PTS symptoms. Results were mixed with regard to secondary effects on additional domains. Further research including studies employing sufficiently powered methodologically rigorous designs is indicated.

Treating your worst nightmare: a case-series of imagery rehearsal therapy for nightmares in individuals experiencing psychotic symptoms

Previous research has indicated that nightmares might be a common problem for people with psychotic symptoms. Furthermore, more distressing nightmares have been associated with higher levels of delusional severity, depression, anxiety, stress and working memory. However no known research has investigated the use of nightmare treatments in those with symptoms of psychosis. This study aimed to assess the acceptability and feasibility of using imagery rehearsal (IR) therapy as a treatment of nightmares for those presenting with co-morbid psychotic symptoms. Six participants presenting with frequent distressing nightmares and psychotic symptoms were recruited. Five participants attended 4–6 sessions of IR. Measures of nightmares, sleep quality, psychotic and affective symptoms were completed at baseline and immediately following the intervention. It was feasible to adapt IR for those experiencing psychotic symptoms. Descriptive improvements were noted on measures of nightmare-related distress, vividness and intensity. Positive post-session feedback endorsed the acceptability of IR. Nightmare frequency did not reduce following IR; however, participants described a change in emotional response. IR was an acceptable and feasible intervention for this small sample. A larger study powered to detect group changes, with an additional control is warranted to test the efficacy of the intervention for those with psychosis.

The role of shame in people with a diagnosis of schizophrenia

OBJECTIVES To examine the role of shame and its relationship to depression in schizophrenia. It was predicted that individuals with a diagnosis of schizophrenia would exhibit higher levels of shame due to the stigma associated with their diagnosis, independently of depression levels, compared with psychiatric and medical control groups. DESIGN Cross-sectional design with three groups: individuals with a diagnosis of (1) schizophrenia, (2) depression, and (3) rheumatoid arthritis. METHODS Sixty individuals participated in the study (20 per group). Groups were compared on questionnaires assessing external shame, trait shame and guilt, and depression. RESULTS The pattern of group differences depended on the type of shame measure used. Both the schizophrenia and depression groups exhibited higher levels of external shame, or seeing others as shaming, than the medical group. For individuals with schizophrenia, seeing others as shaming was associated with higher levels of depression, a relationship not found in either control group. They also showed lower levels of trait guilt and shame (at trend level), compared with both control groups. No difference was found between the groups on depression, suggesting that the observed differences were not attributable to differences in levels of depression. CONCLUSIONS The findings highlight the importance of shame in schizophrenia, especially the link between seeing other people as shaming and depression, which was unique to this group. These results suggest that stigma associated with a diagnosis of mental illness, and schizophrenia in particular, has negative emotional consequences that may impede recovery, and should be addressed by psychological and social interventions. PRACTITIONER POINTS Clinical implications Individuals with a diagnosis of mental illness (schizophrenia or depression) are more likely to experience others as shaming than those diagnosed with a physical illness, irrespective of current levels of depression and proneness to shame. There is a specific association between external shame and depression in individuals diagnosed with schizophrenia, suggesting the need for interventions levelled both at the individuals illness appraisals, and at social stigma relating to schizophrenia. Limitations of the study The participant numbers were low in each group. The three groups could not be matched on all variables. No additional internalized-stigma measure was used.

Integrated Trauma-Focused Cognitive-Behavioural Therapy for Post-traumatic Stress and Psychotic Symptoms: A Case-Series Study Using Imaginal Reprocessing Strategies

Despite high rates of trauma in individuals with psychotic symptoms, post-traumatic stress symptoms are frequently overlooked in clinical practice. There is also reluctance to treat post-traumatic symptoms in case the therapeutic procedure of reprocessing the trauma exacerbates psychotic symptoms. Recent evidence demonstrates that it is safe to use reprocessing strategies in this population. However, most published studies have been based on treating post-traumatic symptoms in isolation from psychotic symptoms. The aims of the current case series were to assess the acceptability, feasibility, and preliminary effectiveness of integrating cognitive-behavioural approaches for post-traumatic stress and psychotic symptoms into a single protocol. Nine participants reporting distressing psychotic and post-traumatic symptoms were recruited from a specialist psychological therapies service for psychosis. Clients were assessed at five time points (baseline, pre, mid, end of therapy, and at 6+ months of follow-up) by an independent assessor on measures of current symptoms of psychosis, post-traumatic stress, emotional problems, and well-being. Therapy was formulation based and individualised, depending on presenting symptoms and trauma type. It consisted of five broad, flexible phases, and included imaginal reprocessing strategies (reliving and/or rescripting). The intervention was well received, with positive post-therapy feedback and satisfaction ratings. Unusually for this population, no-one dropped out of therapy. Post therapy, all but one (88% of participants) achieved a reliable improvement compared to pre-therapy on at least one outcome measure: post-traumatic symptoms (63%), voices (25%), delusions (50%), depression (50%), anxiety (36%), and well-being (40%). Follow-up assessments were completed by 78% (n = 7) of whom 86% (n = 6) maintained at least one reliable improvement. Rates of improvements following therapy (average of 44% across measures post therapy; 32% at follow-up) were over twice those found during the waiting list period (19%). No participant indicated a reliable worsening of any symptoms during or after therapy. The study shows that an integrative therapy incorporating reprocessing strategies was an acceptable and feasible intervention for this small sample, with promising effectiveness. A randomised controlled trial is warranted to test the efficacy of the intervention for this population.