Attachment and social functioning in psychosis

Individuals who experience psychosis typically have diminished social networks and difficulties with social and interpersonal functioning. Therefore, factors underlying social functioning are an intensively studied topic. As attachment theory is by its very nature a theory about interpersonal relationships, it provides insight into these difficulties experienced in psychosis and helps to further develop existing models and conceptualisations of psychosis. Another factor closely related to social dysfunction is social cognition, referring to skill sets or mental processes which help an individual to understand and to accurately interpret the social world. Secure attachment bonds provide optimal conditions for the development of these skills and can be disrupted by negative interpersonal experiences, including difficulties in early attachment relationships. In this chapter, we discuss state of the art research on the link between social cognition, interpersonal difficulties and attachment style in psychosis

A systematic review of adult attachment and social anxiety

Background Attachment has been implicated in the development of social anxiety. Our aim was to synthesise the extant literature exploring the role of adult attachment in these disorders. Method Search terms relating to social anxiety and attachment were entered into MEDLINE, PsycINFO and Web of Science. Risk of bias of included studies was assessed using and adapted version of the Agency for Healthcare Research and Quality assessment tool. Eligible studies employed validated social anxiety and attachment assessments in adult clinical and analogue samples. The review included cross sectional, interventional and longitudinal research. Results Of the 30 identified studies, 28 showed a positive association between attachment insecurity and social anxiety. This association was particularly strong when considering attachment anxiety. Cognitive variables and evolutionary behaviours were identified as potential mediators, concordant with psychological theory. Limitations Due to a lack of longitudinal research, the direction of effect between attachment and social anxiety variables could not be inferred. There was substantial heterogeneity in the way that attachment was conceptualised and assessed across studies. Conclusions The literature indicates that attachment style is associated with social anxiety. Clinicians may wish to consider attachment theory when working clinically with this population. In the future, it may be useful to target the processes that mediate the relationship between attachment and social anxiety

Cognitive behavioural therapy for thought disorder in psychosis

Clinicians are often sceptical about offering cognitive behavioural therapy (CBT) to individuals experiencing thought disorder. This view may result from perceived difficulties in clients being able to learn and better understand their experiences through verbal dialogue. However, it may also partly be due to the lack of clear guidance on how to address and work with these difficulties within therapy. This paper provides recommendations for delivering CBT in individuals experiencing thought disorder. It considers how clinicians might conduct their cognitive behavioural assessment, formulation, and intervention, targeting unhelpful appraisals and behaviour, and generating insight. The aim is to better disseminate the techniques sometimes applied in clinical practice

Mood instability, mental illness and suicidal ideas : results from a household survey

Purpose: There is weak and inconsistent evidence that mood instability (MI) is associated with depression, post traumatic stress disorder (PTSD) and suicidality although the basis of this is unclear. Our objectives were first to test whether there is an association between depression and PTSD, and MI and secondly whether MI exerts an independent effect on suicidal thinking over and above that explained by common mental disorders. Methods: We used data from the Adult Psychiatric Morbidity Survey 2007 (N = 7,131). Chi-square tests were used to examine associations between depression and PTSD, and MI, followed by regression modelling to examine associations between MI and depression, and with PTSD. Multiple logistic regression analyses were used to assess the independent effect of MI on suicidal thinking, after adjustment for demographic factors and the effects of common mental disorder diagnoses. Results: There are high rates of MI in depression and PTSD and the presence of MI increases the odds of depression by 10.66 [95 % confidence interval (CI) 7.51–15.13] and PTSD by 8.69 (95 % CI 5.90–12.79), respectively, after adjusting for other factors. Mood instability independently explained suicidal thinking, multiplying the odds by nearly five (odds ratio 4.82; 95 % CI 3.39–6.85), and was individually by some way the most important single factor in explaining suicidal thoughts. Conclusions: MI is strongly associated with depression and PTSD. In people with common mental disorders MI is clinically significant as it acts as an additional factor exacerbating the risk of suicidal thinking. It is important to enquire about MI as part of clinical assessment and treatment studies are required

Antipsychotic drugs versus cognitive behavioural therapy versus a combination of both in people with psychosis:a randomised controlled pilot and feasibility study

Summary Background Little evidence is available for head-to-head comparisons of psychosocial interventions and pharmacological interventions in psychosis. We aimed to establish whether a randomised controlled trial of cognitive behavioural therapy (CBT) versus antipsychotic drugs versus a combination of both would be feasible in people with psychosis. Methods We did a single-site, single-blind pilot randomised controlled trial in people with psychosis who used services in National Health Service trusts across Greater Manchester, UK. Eligible participants were aged 16 years or older; met ICD-10 criteria for schizophrenia, schizoaffective disorder, or delusional disorder, or met the entry criteria for an early intervention for psychosis service; were in contact with mental health services, under the care of a consultant psychiatrist; scored at least 4 on delusions or hallucinations items, or at least 5 on suspiciousness, persecution, or grandiosity items on the Positive and Negative Syndrome Scale (PANSS); had capacity to consent; and were help-seeking. Participants were assigned (1:1:1) to antipsychotics, CBT, or antipsychotics plus CBT. Randomisation was done via a secure web-based randomisation system (Sealed Envelope), with randomised permuted blocks of 4 and 6, stratified by gender and first episode status. CBT incorporated up to 26 sessions over 6 months plus up to four booster sessions. Choice and dose of antipsychotic were at the discretion of the treating consultant. Participants were followed up for 1 year. The primary outcome was feasibility (ie, data about recruitment, retention, and acceptability), and the primary efficacy outcome was the PANSS total score (assessed at baseline, 6, 12, 24, and 52 weeks). Non-neurological side-effects were assessed systemically with the Antipsychotic Non-neurological Side Effects Rating Scale. Primary analyses were done by intention to treat; safety analyses were done on an as-treated basis. The study was prospectively registered with ISRCTN, number ISRCTN06022197. Findings Of 138 patients referred to the study, 75 were recruited and randomly assigned—26 to CBT, 24 to antipsychotics, and 25 to antipsychotics plus CBT. Attrition was low, and retention high, with only four withdrawals across all groups. 40 (78%) of 51 participants allocated to CBT attended six or more sessions. Of the 49 participants randomised to antipsychotics, 11 (22%) were not prescribed a regular antipsychotic. Median duration of total antipsychotic treatment was 44·5 weeks (IQR 26–51). PANSS total score was significantly reduced in the combined intervention group compared with the CBT group (–5·65 [95% CI −10·37 to −0·93]; p=0·019). PANSS total scores did not differ significantly between the combined group and the antipsychotics group (–4·52 [95% CI −9·30 to 0·26]; p=0·064) or between the antipsychotics and CBT groups (–1·13 [95% CI −5·81 to 3·55]; p=0·637). Significantly fewer side-effects, as measured with the Antipsychotic Non-neurological Side Effects Rating Scale, were noted in the CBT group than in the antipsychotics (3·22 [95% CI 0·58 to 5·87]; p=0·017) or antipsychotics plus CBT (3·99 [95% CI 1·36 to 6·64]; p=0·003) groups. Only one serious adverse event was thought to be related to the trial (an overdose of three paracetamol tablets in the CBT group). Interpretation A head-to-head clinical trial of CBT versus antipsychotics versus the combination of the two is feasible and safe in people with first-episode psychosis

Self-esteem is associated with premorbid adjustment and positive psychotic symptoms in early psychosis

<p>Abstract</p> <p>Background</p> <p>Low levels of self-esteem have been implicated as both a cause and a consequence of severe mental disorders. The main aims of the study were to examine whether premorbid adjustment has an impact on the subject's self-esteem, and whether lowered self-esteem contributes to the development of delusions and hallucinations.</p> <p>Method</p> <p>A total of 113 patients from the Thematically Organized Psychosis research study (TOP) were included at first treatment. The Positive and Negative Syndrome Scale (PANSS) was used to assess present symptoms. Premorbid adjustment was measured with the Premorbid Adjustment Scale (PAS) and self-esteem by the Rosenberg Self-Esteem Scale (RSES).</p> <p>Results</p> <p>Premorbid social adjustment was significantly related to lower self-esteem and explained a significant proportion of the variance in self-esteem. Self-esteem was significantly associated with the levels of persecutory delusions and hallucinations experienced by the patient and explained a significant proportion of the variance even after adjusting for premorbid functioning and depression.</p> <p>Conclusion</p> <p>There are reasons to suspect that premorbid functioning is an important aspect in the development of self- esteem, and, furthermore, that self-esteem is associated with the development of delusions and hallucinations.</p

Emotional and symptomatic reactivity to stress in individuals at ultra-high risk of developing psychosis

Background The stress–vulnerability model of psychosis continues to be influential. The aim of this study was to compare emotional and symptomatic responses to stress in individuals at ultra-high risk (UHR) of developing psychosis, in age- and gender-matched healthy controls, and in patients with non-affective psychosis. Method A total of 27 UHR, 27 psychotic and 27 healthy individuals completed the experience sampling method, an ambulant diary technique, where they were required to fill in self-assessment questions about their emotions, symptoms and perceived stress at semi-random times of the day for 6 days. Quesionnaire and interview assessments were also completed. Results Multilevel regression analyses showed that individuals at UHR of developing psychosis reported greater negative emotions in response to stress than the healthy individuals. Against the initial hypotheses, the UHR individuals also experienced greater emotional reactivity to stress when compared with the patient group. No significant differences were observed between the patients and the non-clinical sample. Stress measures significantly predicted the intensity of psychotic symptoms in UHR individuals and patients, but the extent of this did not significantly differ between the groups. Conclusions Individuals at UHR of developing psychosis may be particularly sensitive to everyday stressors. This effect may diminish after transition to psychosis is made and in periods of stability. Subtle increases in psychotic phenomena occur in response to stressful events across the continuum of psychosis