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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 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 • Kathryn Greenwood (Sussex Trust Partnership) • Elizabeth Kuipers • Jan Scott (Newcastle University) • Philippa Garety
What should we be measuring as outcomes of CBT? • Symptom dimensions
Conviction Delusions Preoccupation Distress Impact on functioning
Beliefs Voices Distress Impact on functioning
What should we be measuring as outcomes of CBT? • Symptom dimensions • Appraisals
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
What should we be measuring as outcomes of CBT? • Symptom dimensions • Appraisals • On-line measurement
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
Appraisals Psychotic Symptoms ESM booklet Symptom Distress Positive & negative affect Spontaneous thoughts
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
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
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
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:............................................................................................................................
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)
Results - baseline Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
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
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
Symptom dimensions & appraisals Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
Hallucinations characteristics Intensity of voices, distress, interference, control and power are all related to each other
Delusions characteristics Intensity of delusions, distress, interference, & preoccupation are all related to each other, but lower effect sizes with conviction
Are symptom appraisals constant? Voice appraisals all highly variable Delusion appraisals also variable
Relationships between symptoms, appraisals & affect Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
Is affect related to symptoms? * = p < .001 Intensity of symptoms and psychotic thoughts are highly related to both negative and less positive affect
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
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
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
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)
Hallucinations: Intensity * * = p <.01
Hallucinations: Distress (when hallucinations present only) * * = p <.01
Hallucinations: Interference (when hallucinations present only) * * * * = p <.01
Hallucinations: Control (when hallucinations present only) * * * * = p <.01
Hallucinations: Power (when hallucinations present only) * * * * = p <.01
Hallucinations: Decentring (when hallucinations present only) * * * = p <.01
Hallucinations: Insight (when hallucinations present only) * * * * * = p <.01
Delusions: Intensity * * * * = p <.01
Delusions: Conviction (when delusions present only) * * * = p <.01
Delusions: Distress (when delusions present only) * * * * = p <.01
Delusions: Interference (when delusions present only) * * * * = p <.01
Delusions: Preoccupation (when delusions present only) * * * * = p <.01
Delusions: Insight (when delusions present only) * * = p <.01
Delusions: Decentring (when delusions present only) * * * * = p <.01