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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 Peters King ’ s College London, Institute of Psychiatry U.K. Collaborators. Inez Myin-Germeys (University of Maastricht) Tineke Lataster (University of Maastricht) Sally Williams

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Appraisals, psychotic symptoms and affect in daily life, and changes during CBT

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  1. Appraisals, psychotic symptoms and affect in daily life, and changes during CBT Emmanuelle Peters King’s College London, Institute of Psychiatry U.K.

  2. Collaborators • 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

  3. Background

  4. What should we be measuring as outcomes of CBT? • Symptom dimensions

  5. Conviction Delusions Preoccupation Distress Impact on functioning

  6. Beliefs Voices Distress Impact on functioning

  7. What should we be measuring as outcomes of CBT? • Symptom dimensions • Appraisals

  8. Bio-psycho-social vulnerability Emotional changes Trigger Basic cognitive dysfunction Anomalous experience Appraisal of experience Positive Symptoms • Appraisal influenced by: • reasoning & attributional • biases • dysfunctional schemas of self & world • isolation & adverse • environments • Maintaining factors • reasoning & attributions • dysfunctional schemas • emotional processes • appraisal of psychosis A Cognitive Model of the Positive Symptoms of Psychosis(Garety et al 01; 07) Garety

  9. What should we be measuring as outcomes of CBT? • Symptom dimensions • Appraisals • On-line measurement

  10. Methods

  11. The Experience Sampling Method • 10 times a day • 6 consecutive days • at random moments • Multiple assessments • Real world, no lab • In the moment, not retrospective • Evaluation of the context Delespaul, 1995; Myin-Germeys et al (2001) Arch Gen Psychiat; Oorschot et al (2009) Psychol Assessment

  12. Appraisals Psychotic Symptoms ESM booklet Symptom Distress Positive & negative affect Spontaneous thoughts

  13. Variables assessed in ESM booklet • 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

  14. 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

  15. 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

  16. 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 +3 • This 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 END • 11. 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 Very • 12. The beep disturbed me 1 2 3 4 5 6 7 • It is now exactly: .......hrs.......min • Write down the nicest thing that has happened since the last beep:............................................................................................................................

  17. Design

  18. 1. Baseline (at referral stage) 2. Pre-therapy (after 3-6 months on waiting list) 3. Mid-therapy (3 months into therapy) 4. End of therapy (after 6-8 months of therapy) 5. Follow-up (3 months post-therapy)

  19. Results - baseline Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med

  20. Average observations per person = 44.5 Total observations = 534 Baseline N= 12 (attending outpatients clinic for CBT for psychosis; 9 with hallucinations 9 with delusions) Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med

  21. Psychosis related: 3.6% (range: 0-18) Anxiety & depression: 4.7% (range: 0-26) Non-pathological: 73.7% Hallucinations: 73% of observations Delusions: 67% of observations Spontaneous thoughts Presence of symptoms Key identified symptoms

  22. Symptom dimensions & appraisals Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med

  23. Hallucinations characteristics Intensity of voices, distress, interference, control and power are all related to each other

  24. Delusions characteristics Intensity of delusions, distress, interference, & preoccupation are all related to each other, but lower effect sizes with conviction

  25. Are symptom appraisals constant? Voice appraisals all highly variable Delusion appraisals also variable

  26. Relationships between symptoms, appraisals & affect Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med

  27. Is affect related to symptoms? * = p < .001 Intensity of symptoms and psychotic thoughts are highly related to both negative and less positive affect

  28. 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

  29. 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

  30. Conclusions - baseline

  31. Despite psychotic symptoms being present a majority of the time, people are not engulfed by their symptoms • Intensity and presence of psychosis-related thoughts lead to more distress, less positive affect, and interference with functioning • Delusional conviction is potentially a separate dimension, and is not stable; nor are appraisals about symptoms (control & power of voices; ‘decentring’ & insight) • Power appraisals are a central factor related to negative affect • ‘Decentring’ from your delusions is related to less distress and disruption to functioning; in contrast, traditional insight does not influence distress

  32. Results – longitudinal data

  33. Average observations per person = 106 Total observations = 1273 N= 12 (7 provided data on at least 2 time points; 6 with hallucinations; 7 with delusions 5 provided data at each time point)

  34. Hallucinations

  35. Hallucinations: Intensity * * = p <.01

  36. Hallucinations: Distress (when hallucinations present only) * * = p <.01

  37. Hallucinations: Interference (when hallucinations present only) * * * * = p <.01

  38. Hallucinations: Control (when hallucinations present only) * * * * = p <.01

  39. Hallucinations: Power (when hallucinations present only) * * * * = p <.01

  40. Hallucinations: Decentring (when hallucinations present only) * * * = p <.01

  41. Hallucinations: Insight (when hallucinations present only) * * * * * = p <.01

  42. Delusions

  43. Delusions: Intensity * * * * = p <.01

  44. Delusions: Conviction (when delusions present only) * * * = p <.01

  45. Delusions: Distress (when delusions present only) * * * * = p <.01

  46. Delusions: Interference (when delusions present only) * * * * = p <.01

  47. Delusions: Preoccupation (when delusions present only) * * * * = p <.01

  48. Delusions: Insight (when delusions present only) * * = p <.01

  49. Delusions: Decentring (when delusions present only) * * * * = p <.01

  50. Affect

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