Acceptability of Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS): A novel intervention for anorexia nervosa.

OBJECTIVE: Investigate the acceptability of Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS), a novel intervention for anorexia nervosa (AN), conducted as a feasibility trial to provide an initial test of the intervention. METHODS: SPEAKS therapy lasting 9-12 months was provided to 34 people with AN or atypical AN by eight specialist eating disorder therapists trained in the model across two NHS Trusts in the UK (Kent and Sussex) during a feasibility trial. All participants were offered a post-therapy interview; sixteen patients and six therapists agreed. All patient participants were adult females. Interviews were semi-structured and asked questions around individuals' experience of SPEAKS, the acceptability of the intervention and of the research methods. Interviews were analyzed using thematic analysis. RESULTS: Key areas explored in line with research questions led to 5 overarching themes and 14 subthemes: (1) shift in treatment focus and experience, (2) balancing resources and treatment outcomes, (3) navigating the online treatment environment, (4) therapist adaptation and professional development, and (5) research processes. DISCUSSION: SPEAKS was found to be an acceptable intervention for treating AN from the perspective of patients and therapists. The findings provide strong support for delivery of a larger scale randomized control trial. Recommendations for future improvements, particularly pertaining to therapist understanding of the treatment model are detailed, alongside broader clinical implications. PUBLIC SIGNIFICANCE: We aimed to evaluate the acceptability of a new anorexia nervosa treatment called SPEAKS. Interviews were conducted with patients and therapists involved in the pilot study and responses were analyzed. Results showed that both patients and therapists found SPEAKS to be an acceptable treatment for anorexia nervosa. The study suggests that SPEAKS meets the criteria for moving forward with a larger trial to assess its effectiveness.

Specialist psychotherapy with emotion for anorexia in Kent and Sussex: An intervention development and non-randomised single arm feasibility trial.

OBJECTIVE: Anorexia nervosa (AN) is a serious eating disorder treated using psychological interventions, yet outcomes remain limited. Emotional difficulties are recognised as a treatment target. This research programme developed and evaluated feasibility of an emotion-focused therapy for adults with AN. METHODS: Phase One intervention development utilised 'intervention mapping'. Qualitative research drew on lived experience highlighting objectives for change. Empirical evidence was synthesised into hypotheses of core emotional difficulties and an associated model of change. Relevant psychotherapeutic theory-based change methods were integrated to form the Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS) intervention, guidebook and clinician training package. Phase Two tested SPEAKS in a single-arm, multisite feasibility trial across two specialist services, utilising prespecified progression criteria, and embedded process evaluation. RESULTS: SPEAKS was 9-12 months (40 sessions) of weekly individual psychotherapy, drawing on a range of psychotherapeutic modalities, predominantly Emotion Focused Therapy and Schema Therapy. Forty-six participants consented to feasibility trial participation; 42 entered the trial and 34 completed. Thirteen of 16 feasibility criteria were met at green level and three at amber, highlighting areas for improving model adherence. CONCLUSIONS: A randomised controlled trial is indicated. Therapist training and guidebook adjustments to improve model adherence are suggested.

Co-producing principles to guide health research: an illustrative case study from an eating disorder research clinic.

BACKGROUND: There is significant value in co-produced health research, however power-imbalances within research teams can pose a barrier to people with lived experience of an illness determining the direction of research in that area. This is especially true in eating disorder research, where the inclusion of co-production approaches lags other research areas. Appealing to principles or values can serve to ground collaborative working. Despite this, there has not been any prior attempt to co-produce principles to guide the work of a research group and serve as a basis for developing future projects. METHODS: The aim of this piece of work was to co-produce a set of principles to guide the conduct of research within our lived experience led research clinic, and to offer an illustrative case for the value of this as a novel co-production methodology. A lived experience panel were recruited to our eating disorder research group. Through an iterative series of workshops with the members of our research clinic (composed of a lived experience panel, clinicians, and researchers) we developed a set of principles which we agreed were important in ensuring both the direction of our research, and the way in which we wanted to work together. RESULTS: Six key principles were developed using this process. They were that research should aim to be: 1) real world-offering a clear and concrete benefit to people with eating disorders, 2) tailored-suitable for marginalised groups and people with atypical diagnoses, 3) hopeful-ensuring that hope for recovery was centred in treatment, 4) experiential-privileging the 'voice' of people with eating disorders, 5) broad-encompassing non-standard therapeutic treatments and 6) democratic-co-produced by people with lived experience of eating disorders. CONCLUSIONS: We reflect on some of the positives as well as limitations of the process, highlighting the importance of adequate funding for longer-term co-production approaches to be taken, and issues around ensuring representation of minority groups. We hope that other health research groups will see the value in co-producing principles to guide research in their own fields, and will adapt, develop, and refine this novel methodology.

It important that when researchers are trying to understand illnesses they do this together with people who have experienced them. This can be difficult, because researchers often take over­even if everyone is meant to be working as a team. We are a group of people trying to understand eating disorders and help people who have them get better. In our group there are some people that have experienced an eating disorder, health workers and researchers.We thought it might be helpful if we could start by working out what things were most important to us as a group, and then try to stick by them. We talked a lot together to come up with a list of principles.The six principles we thought were the most important were that research should make a difference to people's lives, see people as individuals, be hopeful, make sure that people have a voice, look at things that aren't traditional therapies, and always work together as equals.There are some issues with what we did; we found it hard to get a good mix of people in our group, and we were lucky in having enough money to pay people to do what we wanted to do, which is not always true. Despite this, we still hope that other teams might look at what we have done, and see if they could build on it, or change it, so it would work for them.

Does trait mindfulness mediate the relationship between borderline personality symptoms and emotion dysregulation?

BACKGROUND: Emotion dysregulation is core to many biopsychosocial models of Borderline Personality Disorder (BPD) and is often targeted as part of their associated psychological therapies. Several distinct specialist psychotherapies are thought to be effective for people diagnosed with BPD but it is unclear whether they share common change mechanisms. Some evidence suggests that Mindfulness Based Interventions improve competency in emotion regulation as well as trait mindfulness, which are both plausibly associated with good treatment outcomes. It is unclear whether the association between the severity of BPD symptoms and emotion dysregulation is mediated by trait mindfulness. Would improvement in trait mindfulness mediate an association between lower severity of BPD symptoms and fewer problems of emotion dysregulation? METHODS: One thousand and twelve participants completed online, single time-point, self-report questionnaires. RESULTS: As predicted, the severity of BPD symptoms was significantly and positively associated with emotion dysregulation with a large effect size (r = .77). Trait mindfulness mediated this relationship as the 95% confidence interval for the indirect effect did not cross zero (size of direct effect = .48 and size of indirect effect = .29 [.25, .33]. CONCLUSIONS: The relationship between the severity of BPD symptoms and emotion dysregulation was confirmed in this dataset. As hypothesised, this relationship was mediated by trait mindfulness. Process measures of emotion dysregulation and mindfulness should be included in intervention studies for people diagnosed with BPD to understand if improvements in these factors are a universal occurrence with good response to treatment. Other process measures should also be explored to identify other factors involved in the relationship between BPD symptoms and emotion dysregulation.

Enhancing member engagement in a Tier 3 personality disorder service during COVID-19: evaluation of a virtual group programme.

BACKGROUND: Drop-out rates from evidence-based interventions for people with a diagnosis of personality disorder (PD) are high. The COVID-19 pandemic has likely exacerbated barriers to engagement with the introduction of virtual working. Virtual therapy has a good evidence-base for Axis I disorders, but limited research for Axis II disorders. AIMS: To investigate facilitators and barriers to engagement in a Tier 3 PD service virtual group programme. METHOD: A virtual group programme was developed in collaboration with service members, and analysed members' attendance rates over a 5-month period pre- and post-COVID-19. Thematic analysis of semi-structured telephone interviews with 38 members is reported, describing their experience of the virtual group programme. RESULTS: Attendance rates were significantly higher pre-COVID (72%) than post-COVID (50%). Thematic analysis highlighted key barriers to attendance were: practical issues, low motivation, challenges of working in a group online and feeling triggered at home. Main promoters of engagement were: feeling valued, continued sense of connection and maintaining focus on recovery. DISCUSSION: The results suggest that the pandemic has exacerbated relational and practical barriers to engagement in a Tier 3 PD service. Ways of enhancing engagement are discussed, as well as preliminary recommendation for services offering virtual therapy to people with a diagnosis of PD.

Seeing Through the Façade of Anorexia: A Grounded Theory of Emotional Change Processes Associated With Recovery From Anorexia Nervosa.

Objectives: Difficulties in managing emotions have been implicated in the development and maintenance of anorexia nervosa (AN), and psychological treatment models seek to address this in putative targets of change. Yet the field of psychotherapy remains unclear and insufficiently evidenced about the process of change and how this is actually achieved, including in what steps and in what order within clinical treatment. This qualitative study sought to develop theory about the process of emotional change during recovery from anorexia. Methods: Semi-structured interviews were carried out with nine women currently engaged in psychological treatment for anorexia. Interviews included questions pertaining to participants' experience of anorexia, emotions, and emotion management. A constructivist version of grounded theory was employed. Results: The analysis produced 10 major categories, comprising over 60 focused codes. Categories were clustered together into three super categories, reflecting 3 distinct but interrelated phases of participants' journeys toward recovery. The phases were: (1) Coping in a world of uncertainty, (2) Seeing through the façade of anorexia, and (3) Recovery and growth. Whilst movement toward later positions often appeared to be contingent on earlier ones, the analysis suggests that this was not an entirely linear process and that participants moved between positions as they grappled with the process of change. Participants came to view behaviors associated with anorexia as emotion-management strategies that were not working and as a façade. As they moved toward recovery and growth, they became less confined by their need for safety, and to see emotions as meaningful and valuable. Becoming more connected to emotional experience and expression, coincided with positive shifts in their intra and interpersonal relationships. Conclusion: These findings support the recent shift toward emotion-focused models of anorexia. They also highlight an important focus in supporting individuals with AN to connect with, and be guided by, emotional experiences in their relationships with themselves and the world around them. This new grounded theory offers a putative process of change that could be utilized to guide intervention development.

SPEAKS study: study protocol of a multisite feasibility trial of the Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS) intervention for outpatients with anorexia nervosa or otherwise specified feeding and eating disorders, anorexia nervosa type.

INTRODUCTION: Anorexia nervosa (AN) is a severe mental health condition associated with high mortality rates and significantly impaired quality of life. National guidelines outline psychotherapeutic interventions as treatments of choice for adults with AN, but outcomes are limited and therapy drop-out high, resulting in calls for new innovative treatments. The Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS) research programme sought to develop the SPEAKS intervention avoiding some difficulties inherent in development of earlier interventions, such unclear hypotheses about change processes. SPEAKS focuses on a core hypothesised maintaining factor (emotional experience) with clear proposed model of change. The current feasibility trial aims to provide an initial test of SPEAKS and inform design of a full randomised controlled trial protocol. METHODS AND ANALYSIS: This study employs a multisite, single-arm, within-group, mixed-methods design. Up to 60 participants (36 therapy completers) meeting inclusion criteria will be offered the SPEAKS intervention instead of treatment-as-usual (TAU). SPEAKS is a weekly psychotherapy lasting nine to 12 months, provided by trained and experienced eating disorders therapists. All other clinical input remains inline with TAU. Acceptability will be assessed using VAS scales and end of therapy interview. Reach and recruitment, such as recruitment yield, will be monitored. To support sample size estimation and economic estimation, data pertaining to eating disorder-related symptoms will be recorded every 3 months, alongside service usage and intervention-specific measures. Videoed therapy sessions will inform model adherence. Additional analyses coding videoed therapy will test SPEAKS change process hypotheses. ETHICS AND DISSEMINATION: Ethical approval has been granted by London-Bromley Research Ethics Committee (NHS Rec Reference: 19/LO/1530). Data will be disseminated via high-impact, peer-reviewed journals (Open Access preferred), conferences, service user and charity networks (eg, UK charity BEAT) and through a free open conference hosted by National Health Service Trusts and Higher Education Institutions. TRIAL REGISTRATION NUMBER: ISRCTN11778891. TRIAL STATUS: Recruitment began on 12 December 2019 and ends on 28 February 2021. All data will be collected and the trial ended by 28 February 2022. PROTOCOL VERSION: SPEAKS protocol V.3.0 (30 August 2020). Changes were made to the original protocol due to the COVID-19 pandemic. A further set of changes were made to incorporate the measures of change processes, resulting in this being the third version of the protocol.

Adult mental health service engagement with patients who are parents: Evidence from 15 English mental health trusts.

OBJECTIVES: Ascertaining whether mental health service users have children is a clinical requirement in UK health services, and acknowledgement of a patient's parenting role is necessary to enable engagement with their parenting experience and to facilitate support, both of which are associated with improved outcomes for the parent-child dyad. The current study sought to investigate the practice of mental health practitioners working in UK adult mental health services with regard to the following: Ascertaining whether patients have children; engagement with the parenting role of patients; engagement with the construct of 'think patient as parent'. METHODS: Self-report online/paper survey of 1105 multi-disciplinary adult mental health practitioners working in 15 mental health trusts in England. RESULTS: A quarter of adult mental health practitioners did not routinely ascertain whether patients had dependent children. Less than half of practitioners engaged with the parenting experience or the potential impact of parental mental health on children. CONCLUSIONS: The parenting role of patients is not routinely captured by large numbers of practitioners working in adult mental health settings. This is despite it being a mandatory requirement and an integral component of the systematic care of the adult, and preventative care for the offspring. Failure to engage with patients who are parents is a missed opportunity with profound downstream public health implications. The practice deficits identified in this study should be viewed in terms of broader structural failures to address the intergenerational transmission of poor mental health. PRACTITIONER POINTS: Some parents who have mental health difficulties may struggle to provide appropriate and effective care to their children. The parenting role can also exacerbate mental health difficulties. Identification of dependent children is a mandatory component of adult mental health clinical practice and is necessary to understand a parent's support needs. A quarter of adult mental health practitioners are failing to do so. A missed opportunity to engage with the support needs of the parent-child dyad.

The Maudsley Anorexia Nervosa Treatment for Adults (MANTRA): a feasibility case series of an integrated group based approach.

BACKGROUND: Individuals with Anorexia Nervosa (AN) typically struggle in social and emotional contexts. An Integrated Group Based approach for the delivery of MANTRA - The Maudsley Anorexia Nervosa Treatment for Adults - extends current NICE recommended therapy by augmenting treatment with opportunities for experiential practice in a group context. A feasibility case series, delivered across three NHS community services is presented. METHODS: The design was a case series of four Integrated Group MANTRA treatments delivered across three NHS sites (N = 29). Feasibility data of: retention, acceptability and effectiveness; alongside the qualitative capture of participant experiences of treatment is presented. RESULTS: Primary outcomes suggest treatment acceptability. Participants committed to treatment with only 2 dropouts. There was significant change with medium effect sizes for eating disorder cognitions and symptoms (as measured by the global score on EDEQ) and BMI. Core themes emerging from qualitative analysis captured the value of the relational aspect of the treatment, the incorporation of experiential methods, and the opportunity to draw on the support of the group members to reduce shame and stigma. CONCLUSIONS: An Integrated Group based MANTRA approach is a feasible and effective alternative intervention for community Eating Disorder services.

Treatments for Anorexia Nervosa (AN) are somewhat effective, but there is room for improvement. A core struggle for individuals with Anorexia Nervosa is managing emotions especially in a social context. One of the leading treatments for AN - MANTRA ­ was adapted to be delivered in a group to provide opportunities for individuals to practice experiencing and managing emotions amongst others. We hoped that being in a group could help tackle the shame and isolation that many people with AN endure. Patients seemed to find value in this approach and there are early signs that it may support people on their journey of recovery from Anorexia Nervosa.

The revised Green et al., Paranoid Thoughts Scale (R-GPTS): psychometric properties, severity ranges, and clinical cut-offs.

BACKGROUND: The Green et al., Paranoid Thoughts Scale (GPTS) - comprising two 16-item scales assessing ideas of reference (Part A) and ideas of persecution (Part B) - was developed over a decade ago. Our aim was to conduct the first large-scale psychometric evaluation. METHODS: In total, 10 551 individuals provided GPTS data. Four hundred and twenty-two patients with psychosis and 805 non-clinical individuals completed GPTS Parts A and B. An additional 1743 patients with psychosis and 7581 non-clinical individuals completed GPTS Part B. Factor analysis, item response theory, and receiver operating characteristic analyses were conducted. RESULTS: The original two-factor structure of the GPTS had an inadequate model fit: Part A did not form a unidimensional scale and multiple items were locally dependant. A Revised-GPTS (R-GPTS) was formed, comprising eight-item ideas of reference and 10-item ideas of persecution subscales, which had an excellent model fit. All items in the new Reference (a = 2.09-3.67) and Persecution (a = 2.37-4.38) scales were strongly discriminative of shifts in paranoia and had high reliability across the spectrum of severity (a > 0.90). The R-GPTS score ranges are: average (Reference: 0-9; Persecution: 0-4); elevated (Reference: 10-15; Persecution: 5-10); moderately severe (Reference: 16-20; Persecution:11-17); severe (Reference: 21-24; Persecution: 18-27); and very severe (Reference: 25+; Persecution: 28+). Recommended cut-offs on the persecution scale are 11 to discriminate clinical levels of persecutory ideation and 18 for a likely persecutory delusion. CONCLUSIONS: The psychometric evaluation indicated a need to improve the GPTS. The R-GPTS is a more precise measure, has excellent psychometric properties, and is recommended for future studies of paranoia.

The Parenting Experience of Those With Borderline Personality Disorder Traits: Practitioner and Parent Perspectives.

BACKGROUND: Borderline Personality Disorder (BPD) is associated with challenges around emotional intensity and interpersonal difficulties. The children of parents with BPD are at risk of poorer outcomes in terms of their own mental health, educational outcomes and wellbeing. The challenges of being a parent can also exacerbate the symptoms of those with BPD traits. There is a pressing need to understand the experience of these parents and to determine what support would be appropriate and useful. AIM: To explore and compare the experiences and support needs of parents with BPD traits with the experiences and understanding of practitioners who work with them. METHODS: Interviews with 12 parents with BPD traits and 21 practitioners with experience of working with individuals with BPD. The two strands of interviews were analyzed independently using a thematic framework approach, after which the superordinate and subordinate themes were subject to comparison. RESULTS: Parents with BPD traits represent themselves as experiencing considerable challenges in their role as a parent. These included the impact of emotional intensity, social isolation and lack of a positive parenting models to draw upon. Practitioners demonstrated a strong degree of shared understanding into these difficulties. Both groups highlighted a lack of appropriate support for these parents. CONCLUSION: This research highlights the clinical need for parenting-focused support for individuals with BPD traits. Preliminary suggestions for format and content are given.

The Dunn Worry Questionnaire and the Paranoia Worries Questionnaire: new assessments of worry.

BACKGROUND: The cognitive process of worry, which keeps negative thoughts in mind and elaborates the content, contributes to the occurrence of many mental health disorders. Our principal aim was to develop a straightforward measure of general problematic worry suitable for research and clinical treatment. Our secondary aim was to develop a measure of problematic worry specifically concerning paranoid fears. METHODS: An item pool concerning worry in the past month was evaluated in 250 non-clinical individuals and 50 patients with psychosis in a worry treatment trial. Exploratory factor analysis and item response theory (IRT) informed the selection of scale items. IRT analyses were repeated with the scales administered to 273 non-clinical individuals, 79 patients with psychosis and 93 patients with social anxiety disorder. Other clinical measures were administered to assess concurrent validity. Test-retest reliability was assessed with 75 participants. Sensitivity to change was assessed with 43 patients with psychosis. RESULTS: A 10-item general worry scale (Dunn Worry Questionnaire; DWQ) and a five-item paranoia worry scale (Paranoia Worries Questionnaire; PWQ) were developed. All items were highly discriminative (DWQ a = 1.98-5.03; PWQ a = 4.10-10.7), indicating small increases in latent worry lead to a high probability of item endorsement. The DWQ was highly informative across a wide range of the worry distribution, whilst the PWQ had greatest precision at clinical levels of paranoia worry. The scales demonstrated excellent internal reliability, test-retest reliability, concurrent validity and sensitivity to change. CONCLUSIONS: The new measures of general problematic worry and worry about paranoid fears have excellent psychometric properties.

Anorexia Nervosa and a Lost Emotional Self: A Psychological Formulation of the Development, Maintenance, and Treatment of Anorexia Nervosa.

In this paper, we argue that Anorexia Nervosa (AN) can be explained as arising from a 'lost sense of emotional self.' We begin by briefly reviewing evidence accumulated to date supporting the consensus that a complex range of genetic, biological, psychological, and socio-environmental risk and maintenance factors contribute to the development and maintenance of AN. We consider how current interventions seek to tackle these factors in psychotherapy and potential limitations. We then propose our theory that many risk and maintenance factors may be unified by an underpinning explanation of emotional processing difficulties leading to a lost sense of 'emotional self.' Further, we discuss how, once established, AN becomes 'self-perpetuating' and the 'lost sense of emotional self' relentlessly deepens. We outline these arguments in detail, drawing on empirical and neuroscientific data, before discussing the implications of this model for understanding AN and informing clinical intervention. We argue that experiential models of therapy (e.g., emotion-focused therapy; schema therapy) be employed to achieve emergence and integration of an 'emotional self' which can be flexibly and adaptively used to direct an individual's needs and relationships. Furthermore, we assert that this should be a primary goal of therapy for adults with established AN.

Preventing family transmission of anxiety: Feasibility RCT of a brief intervention for parents.

OBJECTIVES: Children of anxious parents are at high risk of anxiety disorders themselves. The evidence suggests that this is due to environmental rather than genetic factors. However, we currently do little to reduce this risk of transmission. There is evidence that supporting parenting in those with mental health difficulties can ameliorate this risk. Therefore, the objective of this study was to test the feasibility of a new one-session, group-based, preventive parenting intervention for parents with anxiety disorders. DESIGN: Feasibility Randomized Controlled Trial. METHODS: A total of 100 parents with anxiety disorders, recruited from adult mental health services in England (and child aged 3-9 years), were randomized to receive the new intervention (a 1-day, group workshop), or to treatment as usual. Children's anxiety disorder and anxiety symptoms were assessed to 12 months by outcome assessors who were blind to group allocation. Exploratory analyses were conducted on an intention to treat basis, as far as possible. RESULTS: A total of 51 participants were randomized to the intervention condition and 49 to the control condition (82% and 80% followed to 12 months, respectively). The attendance rate was 59%, and the intervention was highly acceptable to parents who received it. The RCT was feasible, and 12-month follow-up attrition rates were low. Children whose parents were in the control condition were 16.5% more likely to have an anxiety disorder at follow-up than those in the intervention group. No adverse events were reported. CONCLUSIONS: An inexpensive, light-touch, psycho-educational intervention may be useful in breaking the intergenerational cycle of transmission of anxiety disorders. A substantive trial is warranted. PRACTITIONER POINTS: Anxiety disorders run in families, but we currently do little to help anxious parents to raise confident children. A brief group workshop was highly acceptable to such parents and was very inexpensive to run. Children of parents who took part in the brief intervention were 16.5% less likely to have an anxiety disorder, 1 year later, than children whose parents were in the control group. This was a feasibility study, and while it showed that both the intervention and the research were feasible, the study needs replicating with a much larger sample. Many parents faced barriers to attending the workshop, and future efforts should focus on widening accessibility. We were unable to obtain sufficient self-report data from children, so the outcomes are based on parent report only.

Meaningful Ways of Understanding and Measuring Change for People with Borderline Personality Disorder: A Thematic Analysis.

BACKGROUND: The effective treatment of Borderline Personality Disorder (BPD) presents healthcare providers with a significant challenge. The evidence base remains limited partially due to a lack of professional consensus and service user involvement regarding ways of measuring change. As a result, the limited evidence that is available draws on such a wide range of outcome measures, that comparison across treatment types is hindered, maintaining a lack of clarity regarding the clinical needs of this group. AIMS: This investigation aimed to follow the National Institute of Clinical Excellence (NICE, 2009) research recommendations by asking service users about meaningful change within their recovery. This forms a starting point for the future development of a tailored outcome measure. METHOD: Fifteen service users with a diagnosis of BPD participated in three focus groups across two specialist Personality Disorder services. The focus groups were analysed using Thematic Analysis. RESULTS: Two superordinate themes were synthesized from the data: (1) recovery to what?: 'How do you rewrite who you are?'; and (2) conditions for change. Each superordinate theme further consisted of three subordinate themes which elucidated the over-arching themes. CONCLUSION: This investigation highlights the complex nature of measuring change in people who have received a BPD diagnosis. Further research is needed to develop meaningful ways of measuring change according to the needs and priorities of people with BPD.

Worry processes in patients with persecutory delusions.

OBJECTIVES: Worry may be common in patients with paranoia and a contributory causal factor in the occurrence of the delusions. A number of psychological mechanisms have been linked to the occurrence of worry in emotional disorders but these are yet to be investigated in psychosis. The primary aim of the study was to test the links between five main worry mechanisms - perseverative thinking, catastrophizing, stop rules, metacognitive beliefs, and intolerance of uncertainty - and the cognitive style of worry in patients with persecutory delusions. METHOD: One hundred and fifty patients with persecutory delusions completed assessments of paranoia, worry, and worry mechanisms. RESULTS: Worry in patients with psychosis was associated with the following: a perseverative thinking style, an 'as many as can' stop rule, a range of metacognitive beliefs (cognitive confidence, worry as uncontrollable and the need to control thoughts), and intolerance of uncertainty. Higher levels of worry were associated with higher levels of paranoia. There was also evidence that intolerance of uncertainty and the metacognitive belief concerning the need to control thoughts were independently associated with paranoia. CONCLUSIONS: Worry in patients with persecutory delusions may well be understood by similar underlying mechanisms as worry in emotional disorders. This supports the use of interventions targeting worry, suitably modified, for patients with psychosis. PRACTITIONER POINTS: Worry is a significant concern for patients with paranoia Worry in paranoia is likely to be caused by similar mechanisms as worry in emotional disorders The results support the recent trial findings that standard techniques for treating worry in anxiety, suitably modified, are applicable for patients with paranoia LIMITATIONS: The findings are limited by the self-report nature of measures and by the study design which precludes any assumptions about the direction of causality between the psychological mechanisms and worry.

Treating Sleep Problems in Patients with Schizophrenia.

BACKGROUND: Sleep disturbance is increasingly recognized as a major problem for patients with schizophrenia but it is rarely the direct focus of treatment. The main recommended treatment for insomnia is cognitive behavioural therapy, which we have been evaluating for patients with current delusions and hallucinations in the context of non-affective psychosis. AIMS: In this article we describe the lessons we have learned about clinical presentations of sleep problems in schizophrenia and the adaptations to intervention that we recommend for patients with current delusions and hallucinations. METHOD: Twelve factors that may particularly contribute to sleep problems in schizophrenia are identified. These include delusions and hallucinations interfering with sleep, attempts to use sleep as an escape from voices, circadian rhythm disruption, insufficient daytime activity, and fear of the bed, based upon past adverse experiences. Specific adaptations for psychological treatment related to each factor are described. CONCLUSIONS: Our experience is that patients want help to improve their sleep; sleep problems in schizophrenia should be treated with evidence-based interventions, and that the interventions may have the added benefit of lessening the psychotic experiences. A treatment technique hierarchy is proposed for ease of translation to clinical practice.

The Perseverative Thinking Questionnaire in Patients with Persecutory Delusions.

BACKGROUND: Ruminative negative thinking has typically been considered as a factor maintaining common emotional disorders and has recently been shown to maintain persecutory delusions in psychosis. The Perseverative Thinking Questionnaire (PTQ) (Ehring et al., 2011) is a transdiagnostic measure of ruminative negative thinking that shows promise as a "content-free" measure of ruminative negative thinking. AIMS: The PTQ has not previously been studied in a psychosis patient group. In this study we report for the first time on the psychometric properties of Ehring et al.'s PTQ in such a group. METHOD: The PTQ was completed by 142 patients with current persecutory delusions and 273 non-clinical participants. Participants also completed measures of worry and paranoia. A confirmatory factor analysis was performed on the clinical group's PTQ responses to assess the factor structure of the measure. Differences between groups were used to assess criterion reliability. RESULTS: A three lower-order factor structure of the PTQ (core characteristics of ruminative negative thinking, perceived unproductiveness, and capturing mental capacity) was replicated in the clinical sample. Patients with persecutory delusions were shown to experience significantly higher levels of ruminative negative thinking on the PTQ than the general population sample. The PTQ demonstrated high internal reliability. CONCLUSIONS: This study did not include test-retest data, and did not compare the PTQ against a measure of depressive rumination but, nevertheless, lends support for the validity of the PTQ as a measure of negative ruminative thinking in patients with psychosis.

The patient experience of sleep problems and their treatment in the context of current delusions and hallucinations.

OBJECTIVES: There is increasing recognition that sleep problems are common in patients with psychosis, that they exacerbate delusions and hallucinations and should be a treatment target. The aim of this study was to gain a patient perspective on the nature of sleep problems in psychosis and experience of treatment. DESIGN: A qualitative, semi-structured interview-based study to explore patient accounts of sleep problems and associated psychological treatment. METHODS: Ten patients with recent delusions and hallucinations, who had experienced sleep problems and received psychological treatment during a clinical trial (the Better Sleep Trial), were interviewed. Responses were analysed using interpretative phenomenological analysis. RESULTS: Patients reported experiencing problems of getting to sleep, staying asleep, too much sleep, nightmares, and erratic sleep patterns. These sleep problems caused emotional distress, fatigue, and reduction in daytime activities. Worry and psychotic experiences disturbed sleep, while consequent tiredness meant that patients coped poorly with voices and persecutory fears. Treatment for sleep problems was viewed very positively and considered to have wide-ranging impacts. CONCLUSIONS: Sleep disturbance is a major problem for patients with psychosis, which should be treated more often in services using evidence-based interventions. PRACTITIONER POINTS: Psychological interventions for sleep problems are valued by patients with psychosis. Patients with current distressing psychotic experiences report wide-ranging benefits from a brief psychological intervention for sleep problems.