Reducing Distress from Auditory Verbal Hallucinations: A Multicenter, Parallel, Single-Blind, Randomized Controlled Feasibility Trial of Relating Therapy.

INTRODUCTION: There is a significant demand for interventions that reduce distress related to auditory verbal hallucinations (AVHs). AVH distress is associated with the way voice hearers relate with AVHs. We aimed to establish the feasibility of a randomized controlled trial to demonstrate that adding "Relating Therapy" (RT) to treatment as usual (TAU) is superior to TAU in reducing AVH distress. METHODS: We conducted a multicenter, parallel, single-blind, randomized controlled feasibility trial in five mental health centers in Germany. Participants were ≥19 years of age, had persistent and distressing AVHs, and had a diagnosis of a schizophrenia-spectrum disorder. RT was delivered over a maximum of 16 sessions within 5 months. Blind assessments were conducted at baseline and at 5 and 9 months. Feasibility outcomes were the number of patients recruited and retained, and safety and therapist adherence. The primary endpoint was the distress factor score of the AVH subscale of the Psychotic Symptoms Rating Scales at 9 months. RESULTS: Eighty-five of 177 enrolled participants were randomized into RT + TAU (n = 43) or TAU (n = 42). Feasibility was excellent with 87% retention at 9 months, 86% reaching treatment uptake criteria, 98% therapist adherence, and no unexpected serious adverse reactions. Compared to TAU, RT + TAU showed nonsignificant trends toward less AVH distress (b = -2.40, SE = 1.52, p = 0.121, 90% CI (-4.94 to 0.15) and stronger improvement on all but one of the secondary outcomes. CONCLUSION: A randomized controlled trial of RT is feasible, safe, and well accepted. Our results provide an encouraging basis to further test the efficacy of RT in a definitive multicenter trial.

A cross-national investigation of psychosis-like experiences in five European countries included in the E-CLECTIC study: Psychometric challenges in studying their measurement.

BACKGROUND: Psychotic-like experiences (PLEs) are subtle, subclinical perturbations of perceptions and thoughts and are common in the general population. Their characterisation and unidimensionality are still debated. METHODS: This study was conducted by the Electronic-halluCinations-Like Experiences Cross-culTural International Consortium (E-CLECTIC) and aimed at measuring the Community Assessment of Psychic Experiences (CAPE) factorial structure across five European countries (Belgium; Czech Republic, Germany; Greece, and Spain) and testing the adequacy of the unidimensional polytomous Rasch model of the tool via Partial Credit Model (PCM) of the CAPE to detect people with a high risk for developing psychosis. RESULTS: The sample included 1461 participants from the general population. The factorial analysis confirmed the best fit for the bifactor implementation of the three-factor model, including the positive, negative and depressive dimensions and a general factor. Moreover, the unidimensional polytomous Rasch analysis confirmed that CAPE responses reflected one underlying psychosis proneness. CONCLUSIONS: The study proved that the CAPE measures a single latent dimension of psychosis-proneness. The CAPE might help locate and estimate psychosis risk and can be used as a screening tool in primary care settings/education settings.

How does loneliness interact with positive, negative and depressive symptoms of psychosis? New insights from a longitudinal therapy process study.

Cross-sectional research suggests an association between loneliness and psychotic symptoms, but the causal direction of this association is still unclear. Even though loneliness has been proposed as a potential treatment target to improve psychotherapy for psychosis, not much is known about its role in the treatment process. In this study, we re-analyzed data from a therapy process study to investigate the temporal dynamics between loneliness and psychotic symptoms throughout therapy and to explore whether state-of-the-art CBT for psychosis (CBTp) decreases loneliness. Over the course of up to 45 weekly sessions of CBTp, 57 patients reported their feelings of loneliness and current positive, negative and depressive symptom levels at each session. Multilevel regression revealed a reduction in all symptoms over time, but no reduction in loneliness. Time-lagged multilevel regression showed that loneliness predicted subsequent negative and depressive symptoms, whereas positive symptom levels predicted subsequent loneliness. Thus, changes in loneliness seem to be both cause and consequence of psychotic symptom changes. These findings highlight the importance of loneliness as a treatment target, particularly in patients with negative symptoms and depression. Future research should address loneliness-specific interventions as an augmentation of state-of-the-art CBTp.

Predicting the onset of psychotic experiences in daily life with the use of ambulatory sensor data - A proof-of-concept study.

INTRODUCTION: Predictive models of psychotic symptoms could improve ecological momentary interventions by dynamically providing help when it is needed. Wearable sensors measuring autonomic arousal constitute a feasible base for predictive models since they passively collect physiological data linked to the onset of psychotic experiences. To explore this potential, we investigated whether changes in autonomic arousal predict the onset of hallucination spectrum experiences (HSE) and paranoia in individuals with an increased likelihood of experiencing psychotic symptoms. METHOD: For 24 h of ambulatory assessment, 62 participants wore electrodermal activity and heart rate sensors and were provided with an Android smartphone to answer questions about their HSE-, and paranoia-levels every 20 min. We calculated random forests to detect the onset of HSEs and paranoia. The generalizability of our models was tested using leave-one-assessment-out and leave-one-person-out cross-validation. RESULTS: Leave-one-assessment-out models that relied on physiological data and participant ID yielded balanced accuracy scores of 80 % for HSE and 66 % for paranoia. Adding baseline information about lifetime experiences of psychotic symptoms increased balanced accuracy to 82 % (HSE) and 70 % (paranoia). Leave-one-person-out models yielded lower balanced accuracy scores (51 % to 58 %). DISCUSSION: Using passively collectible variables to predict the onset of psychotic experiences is possible and prediction models improve with additional information about lifetime experiences of psychotic symptoms. Generalizing to new individuals showed poor performance, so including personal data from a recipient may be necessary for symptom prediction. Completely individualized prediction models built solely with the data of the person to be predicted might increase accuracy further.

Cross-cultural validation of the revised Green et al., paranoid thoughts scale.

BACKGROUND: With efforts increasing worldwide to understand and treat paranoia, there is a pressing need for cross-culturally valid assessments of paranoid beliefs. The recently developed Revised Green et al., Paranoid Thoughts Scale (R-GPTS) constitutes an easy to administer self-report assessment of mild ideas of reference and more severe persecutory thoughts. Moreover, it comes with clinical cut-offs for increased usability in research and clinical practice. With multiple translations of the R-GPTS already available and in use, a formal test of its measurement invariance is now needed. METHODS: Using data from a multinational cross-sectional online survey in the UK, USA, Australia, Germany, and Hong Kong (N = 2510), we performed confirmatory factory analyses on the R-GPTS and tested for measurement invariance across sites. RESULTS: We found sufficient fit for the two-factor structure (ideas of reference, persecutory thoughts) of the R-GPTS across cultures. Measurement invariance was found for the persecutory thoughts subscale, indicating that it does measure the same construct across the tested samples in the same way. For ideas of reference, we found no scalar invariance, which was traced back to (mostly higher) item intercepts in the Hong Kong sample. CONCLUSION: We found sufficient invariance for the persecutory thoughts scale, which is of substantial practical importance, as it is used for the screening of clinical paranoia. A direct comparison of the ideas of reference sum-scores between cultures, however, may lead to an over-estimation of these milder forms of paranoia in some (non-western) cultures.

Differentiating paranoia and conspiracy mentality using a network approach.

Although mostly considered distinct, conspiracy mentality and paranoia share conceptual similarities (e.g., persecutory content, resistance to disconfirming evidence). Using self-report data from a large and multinational online sample (N = 2510; from the UK, the US, Hong Kong, Germany, and Australia), we examined whether paranoia and conspiracy mentality represent distinct latent constructs in exploratory and confirmatory factor analyses. Utilising network analysis, we then explored common and unique correlates of paranoia and conspiracy mentality while accounting for their shared variance. Across sites, paranoia and conspiracy mentality presented distinct, yet weakly correlated (r = 0.26), constructs. Both were associated with past traumatic experiences, holding negative beliefs about the self and other people, sleep problems, and a tendency to worry. However, paranoia was related to increased negative affect (i.e., anxiety) and decreased social support, whereas the opposite pattern was observed for conspiracy mentality (i.e., decreased anxiety and depression, increased social support). Paranoia and conspiracy mentality are related but not the same constructs. Their similar and distinct correlates point to common and unique risk factors and underlying mechanisms.

Time-dependent effect of antipsychotic discontinuation and dose reduction on social functioning and subjective quality of life-a multilevel meta-analysis.

Background: Meta-analyses indicate superiority of antipsychotic maintenance treatment over discontinuation within up to 24 months after treatment initiation for patients with schizophrenia-spectrum disorders. In terms of functional recovery, long-term trials show improved functioning after discontinuation, suggesting a time-dependent effect of antipsychotic maintenance. However, these trials were not included in previous meta-analyses. We therefore investigated whether the effect of antipsychotic maintenance treatment vs. discontinuation on social functioning and quality of life varies by trial length. Methods: The study was preregistered with PROSPERO (CRD42021248933). PubMed, PsycINFO, Web of Science, Embase and trial registers were systematically searched on 8th November 2021 and updated on 25th June, 2023 and 10th August, 2023 for studies that compared antipsychotic maintenance to discontinuation and reported data on social functioning or subjective quality of life in patients with schizophrenia-spectrum disorders. Risk of bias was assessed with the RoB 2, the ROBINS-I and the RoB-ME tools. Quality of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Findings: We included k = 35 studies (N = 5924) with follow-ups between one month and 15 years. Overall, maintenance and discontinuation did not differ on social functioning (k = 32; n = 5330; SMD = 0.204; p = 0.65; 95% CI [-0.69, 1.10]) or quality of life (k = 10; n = 943; SMD = -0.004; p = 0.97; 95% CI [-0.22, 0.21]), whilst subgroup analyses of middle- (2-5 years; k = 7; n = 1032; SMD = 0.68; 95% CI [0.06, 1.28]) and long-term follow-ups (>5 years; k = 2; n = 356; SMD = 1.04; 95% CI [0.82, 1.27]) significantly favoured discontinuation. However, the quality of evidence was rated as very low. Interpretation: Although our findings suggest a time-dependent decrease in the effect of maintenance treatment on social functioning, interpretation of these findings is limited by the serious risk of bias in middle- and long-term trials. Therefore, any conclusions regarding the long-term benefits of antipsychotic treatment or discontinuation for functional recovery are premature and more high-quality trials tailored to comparing state of the art maintenance treatment vs. discontinuation are needed. Funding: None.

The use of adaptive emotion regulation strategies in people with attenuated psychotic symptoms - Results from a two-week diary study.

BACKGROUND: Prior research has shown that negative emotion constitutes a trigger for psychosis. This effect is further amplified by using maladaptive emotion regulation strategies. In contrast, the role of adaptive emotion regulation strategies is less clear despite its potential for informing interventions and prevention efforts. In this study, we investigated whether the decreased use of adaptive emotion regulation strategies in daily life is associated with an elevated risk of psychosis. METHODS: Participants reporting a lifetime prevalence of attenuated psychotic symptoms (AS; n = 43) and comparison participants without attenuated psychotic symptoms (n = 40) completed a 14-day diary study with one daily assessment of adaptive emotion regulation (ER) strategies ranging from tolerance-based ER-strategies (e.g., understanding, constructively directing attention) to change-focused ER-strategies (e.g., modification, effective self-support). We tested for group differences in adaptive ER-strategies use with multilevel models. RESULTS: AS used multiple tolerance-based adaptive ER-strategies (acceptance, understanding, clarity, directing attention) less frequently in daily life. However, only a single change-focused adaptive ER-strategy (modification) showed consistently lower utilization rates in AS. CONCLUSION: People with an elevated risk of psychosis use various adaptive ER-strategies focusing on comprehending and accepting negative emotions less frequently. Fostering these strategies with targeted interventions could promote resilience against transitioning into psychosis.

Predictors of successful discontinuation of antipsychotics and antidepressants.

BACKGROUND: To offer support for patients who decide to discontinue antipsychotic and antidepressant medication, identifying which potentially modifiable factors correlate with discontinuation success is crucial. Here, we analyzed the predictive value of the professional support received, circumstances prior to discontinuation, a strategy of discontinuation, and use of functional and non-functional coping strategies during discontinuation on self-reported discontinuation success and on objective discontinuation. METHODS: Patients who had attempted discontinuing antipsychotics (AP) and/or antidepressants (AD) during the past 5 years (n = 316) completed an online survey including questions on subjective and objective discontinuation success, sociodemographic, clinical and medication-related factors, and scales to assess the putative predictors. RESULTS: A regression model with all significant predictors explained 20-30% of the variance in discontinuation success for AD and 30-40% for AP. After controlling for baseline sociodemographic, clinical and medication-related factors, the most consistent predictor of subjective discontinuation success was self-care behavior, in particular mindfulness, relaxation and making use of supportive relationships. Other predictors depended on the type of medication: For AD, good alliance with the prescribing physician predicted higher subjective success whereas gradual tapering per se was associated with lower subjective success and a lower chance of full discontinuation. In those tapering off AP, leaving time to adjust between dose reductions was associated with higher subjective success and fewer negative effects. CONCLUSIONS: The findings can inform evidence-based clinical guidelines and interventions aiming to support patients during discontinuation. Further studies powered to take interactions between variables into account are needed to improve the prediction of successful discontinuation.

Are effort-based decision-making tasks worth the effort?-A study on the associations between effort-based decision-making tasks and self-report measures.

OBJECTIVES: Amotivation is a common symptom in various mental disorders, including psychotic or depressive disorders. Effort-based decision-making (EBDM)-tasks quantifying amotivation at a behavioral level have been on the rise. Task performance has been shown to differentiate patient groups from healthy controls. However, findings on indicators of construct validity, such as the correlations between different tasks and between tasks and self-reported/observer-rated amotivation in clinical and healthy samples have been inconclusive. METHODS: In a representative community sample (N = 90), we tested the construct validity of the Deck Choice Task, the Expenditure for Rewards Task and the Balloon Task. We calculated correlations between the EBDM-tasks and between the EBDM-tasks and self-reported amotivation, apathy, anticipatory pleasure, and BIS/BAS. RESULTS: Correlations between tasks were low to moderate (0.198 ≤ r ≤ 0.358), with the Balloon Task showing the largest correlations with the other tasks, but no significant correlations between any EBDM-task and the self-report measures. CONCLUSION: Although different EBDM-tasks are conceptualized to measure the same construct, a large part of what each task measures could not be accounted for by the other tasks. Moreover, the tasks did not appear to substantially capture what was measured in established self-report instruments for amotivation in our sample, which could be interpreted as questioning the construct validity of EBDM-tasks.

Pandemic paranoia in the general population: international prevalence and sociodemographic profile.

BACKGROUND: The term 'pandemic paranoia' has been coined to refer to heightened levels of mistrust and suspicion towards other people specifically due to the COVID-19 pandemic. In this study, we examine the international prevalence of pandemic paranoia in the general population and its associated sociodemographic profile. METHODS: A representative international sample of general population adults (N = 2510) from five sites (USA N = 535, Germany N = 516, UK N = 512, Australia N = 502 and Hong Kong N = 445) were recruited using stratified quota sampling (for age, sex, educational attainment) and completed the Pandemic Paranoia Scale (PPS). RESULTS: The overall prevalence rate of pandemic paranoia was 19%, and was highest in Australia and lowest in Germany. On the subscales of the PPS, prevalence was 11% for persecutory threat, 29% for paranoid conspiracy and 37% for interpersonal mistrust. Site and general paranoia significantly predicted pandemic paranoia. Sociodemographic variables (lower age, higher population size and income, being male, employed and no migrant status) explained additional variance and significantly improved prediction of pandemic paranoia. CONCLUSIONS: Pandemic paranoia was relatively common in a representative sample of the general population across five international sites. Sociodemographic variables explained a small but significant amount of the variance in pandemic paranoia.

Low goal-directed behavior in negative symptoms is explained by goal setting - Results of a diary study.

BACKGROUND AND OBJECTIVES: Engaging in goal-directed activities is a core difficulty of people with negative symptoms in schizophrenia. A previously developed goal pursuit model of negative symptoms (Schlier et al. 2017) postulates that negative symptom severity correlates with a tendency to set more avoidance- than approach-oriented goals. This shift in goal orientation correlates with low levels of goal expectancy, goal importance, and goal commitment. We explored whether these alterations translate into reduced goal-directed behavior (i.e., reduced goal striving and goal attainment). METHODS: We conducted a one-week diary-study in a population sample (N=91). Participants were assessed for subclinical negative symptoms at baseline. Next, they set a daily goal and completed an online survey measuring goal orientation, goal characteristics, goal pursuit, and goal attainment once per day for one week. RESULTS: Multilevel regression analyses and structural equation models showed that negative symptoms correlated with a tendency to set less approach-oriented goals with reduced goal expectancy and goal commitment. Goal orientation, expectancy, and commitment mediated the association between negative symptoms and reduced goal pursuit and attainment. LIMITATIONS: We used a community sample, thus our results need to be replicated in a clinical sample of people with motivational negative symptoms. CONCLUSIONS: Our results support the hypothesis that dysfunctional goal pursuit processes explain why negative symptoms lead to reduced goal-directed behavior. Interventions focusing on goal setting and goal expectations could be promising in improving goal-directed behavior in people with negative symptoms.

Taking a machine learning approach to optimize prediction of vaccine hesitancy in high income countries.

Understanding factors driving vaccine hesitancy is crucial to vaccination success. We surveyed adults (N = 2510) from February to March 2021 across five sites (Australia = 502, Germany = 516, Hong Kong = 445, UK = 512, USA = 535) using a cross-sectional design and stratified quota sampling for age, sex, and education. We assessed willingness to take a vaccine and a comprehensive set of putative predictors. Predictive power was analysed with a machine learning algorithm. Only 57.4% of the participants indicated that they would definitely or probably get vaccinated. A parsimonious machine learning model could identify vaccine hesitancy with high accuracy (i.e. 82% sensitivity and 79-82% specificity) using 12 variables only. The most relevant predictors were vaccination conspiracy beliefs, various paranoid concerns related to the pandemic, a general conspiracy mentality, COVID anxiety, high perceived risk of infection, low perceived social rank, lower age, lower income, and higher population density. Campaigns seeking to increase vaccine uptake need to take mistrust as the main driver of vaccine hesitancy into account.

RELATE-a randomised controlled feasibility trial of a Relating Therapy module for distressing auditory verbal hallucinations: a study protocol.

INTRODUCTION: Auditory verbal hallucinations (AVHs) are associated with distress and reduced functioning. Research suggests that distress is associated with the voice hearer's responding to AVH in a passive and subordinate manner. A novel approach focuses on relating to AVH and teaches assertive responses to AVH using experiential role-plays. A small pilot study found a large effect of this approach on AVH distress but an independent multicentre study is required to ascertain effectiveness across different settings. We aim to estimate the expected effect for a subsequent trial to demonstrate that adding a module of Relating Therapy (RT) to treatment as usual (TAU) is superior to TAU alone in reducing AVH distress. We also test the feasibility of patient recruitment, therapist training, and therapy monitoring in different psychological and psychiatric outpatient facilities in Germany. METHODS AND ANALYSIS: We will recruit 75 patients diagnosed with a schizophrenia spectrum disorder and persistent distressing AVH across four sites. Patients will be randomised to receive either 16 sessions of RT plus TAU or TAU alone within a 5-month period. Randomisation will be stratified by sites. Single-blind assessments will take place at baseline, at 5 months (T1) and at 9 months (T2). The primary outcome is the distress factor score of the AVH subscale of the Psychotic Symptoms Rating Scale at T2 adjusted for the baseline value. Secondary outcomes are change in depressive symptoms, quality of life, time spent in structured activities as well as negative relating to voices and to other people. ETHICS AND DISSEMINATION: The trial has received ethical approval from the German Psychological Society Ethics Committee. The trial results will be disseminated through conference presentations, peer-reviewed publications and social media. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT04578314).

A rating scale to inform successful discontinuation of antipsychotics and antidepressants.

Practitioners lack guidance on how to support discontinuation of psychotropic medication. An understanding of what constitutes discontinuation success that encompasses the patients' perspective could advance knowledge in this clinically relevant area. Here, we report the development and validation of a scale to assess subjective discontinuation success. Participants who attempted discontinuing antidepressants and/or antipsychotics during the past 5 years (n = 396) completed a questionnaire on subjective discontinuation success (Discontinuation Success Scale, DSS) developed in consultation with people with lived experience of discontinuation. Construct validity was tested by exploratory and confirmatory factor analysis. Criterion validity was tested by assessing DSS-scores' associations with objective success (i.e., full cessation, reduced dose) in combination with scoring above a predefined criterion on the Well-Being Index. Factor analyses yielded a three-dimensional scale reflecting subjective discontinuation success, positive effects, and negative effects of discontinuation. A 24-item DSS demonstrated sufficient model fit for the participants discontinuing antidepressants or antipsychotics, respectively. Significant associations with objective success and well-being were found. Participants who had achieved full cessation and scored high on well-being reached the highest DSS scores. The DSS is a viable tool for future research aimed at identifying predictors of discontinuation success in order to inform recommendations related to discontinuation.

Service User Experiences of Integrating a Mobile Solution (IMPACHS) Into Clinical Treatment for Psychosis.

Innovative technological solutions are increasingly being introduced into psychotherapy. Understanding service user perspectives is a key aspect in adapting this technology to treatment. This study investigated service users' personal experience of the utility, challenges, and rewards of using an mHealth solution in cognitive behavioral therapy for psychosis (CBTp). People participating in an early intervention program for psychosis (n = 16) utilized the mHealth solution for up to 6 months. Semi-structured qualitative interviews were conducted to capture participant experiences, and quantitative data were collected on psychopathology, usage, and quality of the solution. The solution was widely accepted and utilized in treatment. Four dominant themes were constructed from the interviews: (a) Accessibility and supporting recall, (b) Promotion of dialogue with the therapist, (c) Encouraging reflection, and (d) Factors that affected engagement with the solution. The mHealth solution was perceived as facilitating psychotherapeutic processes and supported underlying CBTp treatment principles.

Relating between the voice and voice-hearer: Validation of a revised version of the Voice And You.

Advancements in CBT for distressing voices have led to the development of understandings and the treatment of voice hearing within relational frameworks. In this study, we aim to validate and revise the Voice And You (VAY), one of the first measures that was developed to assess distressing relationships with voices. Data was pooled from 5 sources (n = 192) including the VAY and an interview-based assessment of voice-hearing. The VAY was subjected to confirmatory factor analysis and revised based on item loadings. Criterion validity was assessed by correlating the VAY with measures of voice-related distress and other voice characteristics from the Psychotic Symptom Rating Scales (PSYRATS) interview. For the original VAY, we found sufficient model fit for the voice-to-hearer relating factors (voice dominance and intrusiveness), but not for the hearer-to-voice relating factors (hearer dependence and distance). A revised version showed sufficient overall model-fit while retaining the level of criterion validity of the original scale. Thus, we derived a revised, valid, and parsimonious 14 item VAY (VAY-R) that provides a feasible tool to assess the interrelating between hearer and voice. Nevertheless, hearer-to-voice relating needs a more differentiated assessment of hearer relating styles that includes the possibility of actively engaging with the voice.

"I just don't look forward to anything". How anticipatory pleasure and negative beliefs contribute to goal-directed activity in patients with negative symptoms of psychosis.

Anticipatory pleasure refers to a state of positive affect in anticipation of future events that has been found to motivate goal-directed behavior. Previous research has indicated that patients with negative symptoms of psychosis show reduced goal-directed behavior because 'demotivating beliefs' impede anticipatory pleasure. This study aims to link demotivating beliefs and anticipatory pleasure to patients' motivation in everyday life. Using the Experience Sampling Method, we examined the motivational process of goal-directed activity in the daily lives of 35 patients with negative symptoms and 36 healthy controls. We tested whether the mechanism underlying goal-directed behavior differs between patients and healthy controls and whether demotivating beliefs interfere with goal-directed behavior by impeding anticipatory pleasure. Multilevel analyses revealed that anticipatory pleasure mediated the association between goal-intentions and goal-directed activity in both groups (indirect effects: 24-30%). In the patient group, however, the association between social goal-intentions and anticipatory pleasure was weaker (b = -0.09, SE = 0.05, p ≤ .01, [-0.17;-0.04]) than in the controls, but this was not found for goal-intentions related self-care or recreational activites. Also, demotivating beliefs were more pronounced in the patient sample. (F(1,70) = 72.11, p ≤ .001) and moderated the effect of goal-intentions on anticipatory pleasure for social activities in the whole sample (b = -0.12, SE = 0.05, p ≤ .01, [-0.20;-0.08]). Our results support the assumption that a set of demotivating beliefs prevents patients with negative symptoms from looking forward to social activities and thus provide a possible psychological explanation for the social withdrawal of patients with negative symptoms.

Construction and validation of the Approve questionnaires - Measures of relating to voices and other people.

BACKGROUND: The effectiveness of psychological treatments for auditory hallucinations ('voices') needs to be enhanced. Some forms of novel treatment are working within relational frameworks to support patients to relate assertively to distressing voices. Yet, no measure of assertive relating to voices is available to assess the extent to which this skill is developed during therapy. This study aimed to assess the factor structure and validity of two new questionnaires: a measure of relating to voices and a measure of social relating. METHODS: The relating measures were developed in consultation with members of the international research community and validated in a large sample (N = 402) of voice hearing patients within the UK. The measures were subjected to factor analysis and compared to measures of voice hearing, mental health and well-being to evaluate construct, convergent, discriminant, and criterion validity. RESULTS: Factor analysis confirmed a three-dimensional set of items that measure assertive and non-assertive (passive and aggressive) relating. This resulted in the validation of the 'Approve' questionnaires - two 15-item measures of relating to voices and other people. CONCLUSION: The Approve questionnaires can be used to assess a patient's suitability for relationally-based psychological therapies for distressing voices and the extent to which assertive relating skills are developed during the therapy.