Clinical and theoretical relevance of responses to analogues of psychotic experiences in people with psychotic experiences with and without a need-for-care: an experimental study.

BACKGROUND: Certain ways of responding to psychotic experiences (PEs) appear more commonly associated with clinical distress (e.g. avoidance) and other ways with benign or positive outcomes (e.g. reappraisal and acceptance). Past research has largely been limited to retrospective self-report. We aimed to compare clinical and non-clinical individuals on experimental analogues of anomalous experiences. METHOD: Response styles of two groups with persistent PEs (clinical n = 84; non-clinical n = 92) and a control group without PEs (n = 83) were compared following experimental analogues of thought interference (Cards Task, Telepath) and hearing voices (Virtual Acoustic Space Paradigm). RESULTS: The non-clinical group with PEs were less likely to endorse unhelpful response styles, such as passive responding or attempts to avoid, suppress, worry about or control mental experiences, compared with the clinical group on all three tasks. The clinical group were more likely to endorse unhelpful response styles compared with controls on two out of three tasks (Cards Task and Telepath). The non-clinical group performed similarly to controls on unhelpful responding across all tasks. There were no group differences for helpful response styles, such as cognitive reappraisal or mindful acceptance of experiences. CONCLUSIONS: In line with cognitive models of psychosis, the findings suggest that the way in which individuals respond to unusual experiences may be an important factor in understanding clinical distress, supporting the therapeutic rationale of targeting potentially unhelpful patterns of response.

Overgeneral autobiographical memory bias in clinical and non-clinical voice hearers.

BACKGROUND: Hearing voices can be a distressing and disabling experience for some, whilst it is a valued experience for others, so-called 'healthy voice-hearers'. Cognitive models of psychosis highlight the role of memory, appraisal and cognitive biases in determining emotional and behavioural responses to voices. A memory bias potentially associated with distressing voices is the overgeneral memory bias (OGM), namely the tendency to recall a summary of events rather than specific occasions. It may limit access to autobiographical information that could be helpful in re-appraising distressing experiences, including voices. METHODS: We investigated the possible links between OGM and distressing voices in psychosis by comparing three groups: (1) clinical voice-hearers (N = 39), (2) non-clinical voice-hearers (N = 35) and (3) controls without voices (N = 77) on a standard version of the autobiographical memory test (AMT). Clinical and non-clinical voice-hearers also completed a newly adapted version of the task, designed to assess voices-related memories (vAMT). RESULTS: As hypothesised, the clinical group displayed an OGM bias by retrieving fewer specific autobiographical memories on the AMT compared with both the non-clinical and control groups, who did not differ from each other. The clinical group also showed an OGM bias in recall of voice-related memories on the vAMT, compared with the non-clinical group. CONCLUSIONS: Clinical voice-hearers display an OGM bias when compared with non-clinical voice-hearers on both general and voices-specific recall tasks. These findings have implications for the refinement and targeting of psychological interventions for psychosis.

Interpersonal processes in paranoia: a systematic review.

Paranoid ideation is a core feature of psychosis, and models of paranoia have long proposed that it arises in the context of disturbances in the perception of the self. However, to develop targeted interventions, there is a benefit in clarifying further, which aspects of self-perception are implicated. Interpersonal sensitivity is a personality trait which has been associated with the risk of paranoid thinking in the general population. However, not all studies have found this link. We aimed to review the empirical literature assessing the association between interpersonal sensitivity and paranoia in both general population and clinical samples; and to explore if associations found differed depending on whether state or trait paranoia was assessed. The review followed PRISMA guidelines. Articles were identified through a literature search in OVID (PsychINFO, MEDLINE) and Web of Science up to December 2016. Fourteen studies with a total of 12 138 participants were included. All studies were of 'fair' or 'good' quality. A robust association was found between interpersonal sensitivity and paranoia in clinical and general population samples alike, regardless of the method of assessment of both paranoia and interpersonal sensitivity. Although this finding was more pronounced in studies of trait paranoia, it is likely that differences in study purpose, measurement, and power explain these differences. Findings from this review support the hypothesis that feelings of personal vulnerability and exaggerated socially evaluative concerns are central for both onset and maintenance of paranoid symptoms, suggesting avenues for future research in targeted interventions.

Moment-to-moment associations between negative affect, aberrant salience, and paranoia.

INTRODUCTION: There is an ongoing debate about whether negative affect are consequences or triggers of paranoid thinking. It has also been suggested that aberrant salience is central to the development of delusions. This study modelled the moment-to-moment relationships between negative affect, aberrant salience, and paranoia in acute inpatients with psychosis. METHODS: Participants with active paranoid delusions were assessed using clinical rating scales and experience sampling method (ESM) over 14 days. ESM data were analysed using time-lagged multilevel regression modelling. RESULTS: Both negative affect and aberrant salience predicted an increase in paranoia at the next time point. Conversely, the level of paranoia did not predict subsequent changes in negative affect or aberrant salience. Negative affect predicted an increase in aberrant salience at the next time point, and vice versa. CONCLUSIONS: Negative affect and aberrant salience appear to drive and exacerbate paranoia, rather than being merely the sequelae of the symptom. Our results suggest both direct and indirect (via aberrant salience) pathways from negative affect to paranoia.

Acute mental health service use by patients with severe mental illness after discharge to primary care in South London.

BACKGROUND: To return the patients to primary care is arguably the desired service outcome for community mental health teams (CMHTs). AIMS: To assess acute mental health service use (hospitalisation or Home Treatment Team) by people with severe mental illness following discharge to primary care. METHOD: Retrospective cohort study comparing receipt and duration of acute care by 98 patients in the two years following discharge to primary care from CMHT, with a cohort of 92 patients transferred to another CMHT. RESULTS: The discharged group was significantly more stable on clinical measures. Fifty-seven (58.2%) patients were re-referred after median 39 weeks, with 35 (60.3%) in crisis. The difference in acute service use between discharged patients (27.9 days/patient) and transferred patients (31.7 days/patient) was not significant. Hospitalisation in the two years prior to discharge or transfer increased the odds of re-referral (OR 3.93, 95% CI 1.44-14.55), subsequent acute service use (OR 1.02, 95% CI 1.01-1.03) and duration of input (0.45 extra days/patient, 95% CI 0.22-0.68). CONCLUSIONS: The majority of the discharged patients were re-referred to mental health services. Although these were more stable, there was no difference from the transferred group on acute service use. Further support may be required in primary care to maintain stability.

Paranoid explanations of experience: a novel experimental study.

BACKGROUND: Paranoia is a common experience in the non-clinical population. We use a novel experimental methodology to investigate paranoid ideas in individuals without a history of mental illness. AIMS: We aimed to determine whether this paradigm could elicit unfounded paranoid thoughts and whether these thoughts could be predicted by factors from a cognitive model. METHOD: Fifty-eight individuals took part and completed measures assessing trait paranoia, mood, self and other schema and attributional style. They were exposed to two experimental events: 1) an interruption to the testing session by a stooge, and 2) a recording of laughter played outside the testing room and subsequently asked about their explanations for these events. RESULTS: 15.5% (n = 9) of the sample gave a paranoid explanation for at least one of the experimental events. The remainder reported generally neutral explanations. Individuals with a paranoid explanation reported significantly higher levels of trait paranoia. Factors predictive of a paranoid interpretation were interpersonal sensitivity and attributional style. CONCLUSIONS: The results show that spontaneous paranoid explanations can be elicited in non-clinical individuals, even for quite neutral events. In line with current theories, the findings suggest that emotional processes contribute to paranoid interpretations of events, although, as a novel study with a modest sample, it requires replication.

Are there reliable and valid measures of anxiety for people with psychosis? A systematic review of psychometric properties.

PURPOSE: Current models of psychosis posit a developmental and maintaining role for anxiety, supported by robust empirical evidence. Given the central role for anxiety in psychosis, valid and reliable assessment is necessary. This systematic review is the first to critically appraise measures of anxiety applied to psychosis samples. METHODS: Web of Science, MEDLINE, PsycINFO, EMBASE, and CINAHL were systematically searched for studies evaluating psychometric properties of instruments measuring anxiety in samples with non-affective psychosis diagnoses. Psychometric properties were extracted and rated according to established criteria. The COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist was used to assess the methodological quality of studies. RESULTS: Of 4,344 records identified, 11 studies were identified as eligible for inclusion, by two independent raters with high reliability. Reported psychometric properties for 17 different instruments ranged from unacceptable to excellent. The Scale of Anxiety Evaluation in Schizophrenia was assessed most extensively and demonstrated consistently good psychometric properties. The Beck Anxiety Index, Depression Anxiety Stress Scale, DSM-based Generalised Anxiety Disorder Symptoms Severity Scale, Liebowitz Social Anxiety Scale, Obsessive-Compulsive Inventory, Psychological Stress Index, Perseverative Thinking Questionnaire, and Yale-Brown Obsessive Compulsive Scale demonstrated adequate reliability and/or validity on the limited properties reported. Methodological quality was largely poor according to the requirements of the COSMIN checklist. CONCLUSIONS: The instruments listed are recommended as at least adequate for the assessment of anxiety in psychosis on the basis of these preliminary data. Further validation of existing instruments designed to measure anxiety in people with psychosis is strongly recommended. PRACTITIONER POINTS: Anxiety has a developmental and maintaining role in psychosis; therefore, we should routinely screen for symptoms of anxiety when working with people with psychosis spectrum disorders. Studies included in this review reported reliable and valid measures of anxiety for people with psychosis; however, the methodological quality of most studies was poor. We recommend the BAI, DASS, or SAES for general screening, and the DGSS, LSAS, OCI, PSI, PTQ, and Y-BOCS to assess symptoms associated with specific anxiety disorders and anxiety-related processes.

Is there an association between caregiver antipathy and psychosis? A systematic review.

PURPOSE: Existing reviews of trauma and psychosis have identified associations between childhood emotional abuse (CEA) and psychosis. However, conceptual issues relating to assessment of CEA limit the conclusions that can be drawn from the literature. The aim of this review was to identify and evaluate studies reporting an association between childhood experiences of caregiver antipathy (i.e. criticism, hostility, coldness, or rejection from a parental figure experienced prior to age 17 years) and psychosis symptoms/diagnosis. METHODS: Five databases were systematically searched for articles published until May 2020. Studies were evaluated against inclusion/exclusion criteria, and a narrative synthesis of findings was completed. Study quality was assessed by two independent raters. RESULTS: Fourteen studies comprised of 1,848 participants met inclusion criteria. Twelve of these studies found significant associations between caregiver antipathy and psychosis, and two did not. There was evidence that adults with schizophrenia-spectrum diagnoses report more severe caregiver antipathy in childhood than non-clinical controls and that caregiver antipathy severity is positively correlated with psychosis symptom severity. Most studies received weak or moderate quality ratings and all used cross-sectional or case-control designs which showed associations, rather than causal relationships, between childhood caregiver antipathy and later psychosis. CONCLUSIONS: Future research would benefit from more rigorous and valid assessment of CEA, use of multivariate methods to account for possible patterns of co-occurrence, and longitudinal study designs to make more robust causal claims. The findings may have important implications for the delivery of psychological care for people with psychosis who report adverse caregiving experiences. PRACTITIONER POINTS: People with schizophrenia-spectrum diagnoses may report more severe caregiver antipathy in childhood than non-clinical controls. Caregiver antipathy severity appears to be positively correlated with psychosis symptom severity in clinical and non-clinical populations. Clinicians should consider the possible impact of caregiver antipathy on psychosis symptoms, their content and distress maintenance. Clinicians should also recognise the potential impact of adverse caregiving experiences on therapeutic relationships, patterns of help-seeking and service engagement. Best practice in clinical services would be to adopt individual, formulation-based approaches within trauma-informed models of care.

Do antipsychotics improve reasoning biases? A review.

OBJECTIVE: To explore how reasoning biases in schizophrenic patients respond to treatment. Patients with schizophrenia, especially those with delusions, show not only cognitive deficits but also "reasoning biases," namely, "jumping to conclusions," reduced belief flexibility, an externalizing attributional style, and an impaired "theory of mind." METHODS: This is a systematic review of 17 longitudinal and cross-sectional studies. RESULTS: "Jumping to conclusions" and reduced "belief flexibility" are most closely related to the severity of delusions, whereas "theory of mind" is better related to negative symptoms and "attributional style" to overall psychopathology. Antipsychotic treatment leads to an improvement in belief flexibility and theory of mind, with the suggestion that "belief flexibility" may be mediating the treatment response. On the other hand, the "jumping to conclusions" bias is likely a stable "trait" factor, which does not change with treatment, although it may moderate the outcome of response. The findings above are offered with the caveat that most of the available studies are small, often uncontrolled, few are longitudinal, that the measurement of some of the reasoning measures varies across studies, and that their relationship to the more established "cognitive" deficits remains unclear. CONCLUSIONS: The fact that these reasoning biases could be moderators and mediators of treatment outcome provides a greater impetus to study them systematically.

Cost-effectiveness of an early intervention service for people with psychosis.

BACKGROUND: There is concern that delaying treatment for psychosis may have a negative impact on its long-term course. A number of countries have developed early intervention teams but there is limited evidence regarding their cost-effectiveness. AIMS: To compare the costs and cost-effectiveness of an early intervention service in London with standard care. METHOD: Individuals in their first episode of psychosis (or those who had previously discontinued treatment) were recruited to the study. Clinical variables and costs were measured at baseline and then at 6- and 18-month follow-up. Information on quality of life and vocational outcomes were combined with costs to assess cost-effectiveness. RESULTS: A total of 144 people were randomised. Total mean costs were 11,685 pounds sterling in the early intervention group and 14,062 pounds sterling in the standard care group, with the difference not being significant (95% CI -8128 pounds sterling to 3326 pounds sterling). When costs were combined with improved vocational and quality of life outcomes it was shown that early intervention would have a very high likelihood of being cost-effective. CONCLUSIONS: Early intervention did not increase costs and was highly likely to be cost-effective when compared with standard care.

Effect of early intervention on 5-year outcome in non-affective psychosis.

BACKGROUND: Early specialised care may improve short-term outcome in first-episode non-affective psychosis, but it is unclear if these benefits endure. AIMS: To assess the long-term effect of early intervention in psychosis. METHOD: Individuals with first-episode psychosis were randomised to specialised care or care as usual (trial number: ISRCTN73679874). Outcome after 5 years was assessed by case-note review. RESULTS: There were no significant differences in the admission rate (coefficient 0.096, 95% CI -0.550 to 0.742, P = 0.770) or the mean number of bed days (coefficient 6.344, 95% CI -46 to 58.7, P = 0.810). CONCLUSIONS: These findings that specialist intervention did not markedly improved outcome at 5 years accord with those from a larger OPUS study. The sample size of this study was small and these results should be generalised with caution. More research is needed.

Attributional biases in paranoia: the development and validation of the Achievement and Relationships Attributions Task (ARAT).

INTRODUCTION: Attributional biases, in particular a tendency to blame other people for negative events, have been reported among people with persecutory delusions and in people in the general population with subclinical paranoia. However, existing attribution measures have some shortcomings. The present study therefore describes the development and validation of a new attribution measure: the Achievement and Relationships Attributions Task (ARAT). The ARAT assesses attributional style in a range of everyday life situations related to achievement and interpersonal events, and provides a context for attributions. Each scenario has three possible causes embedded within it: internal, personal-external, and situational-external. METHODS: Three hundred and fifteen healthy volunteers completed the ARAT and measures of paranoia and depression. RESULTS: A tendency to blame other people rather than themselves was associated with high trait paranoia and multidimensional aspects of paranoid beliefs. Depression was associated with a decreased tendency to internalise success. CONCLUSIONS: The ARAT is a valid measure of attributional style in relation to paranoid ideation in a nonclinical population and has good interrater reliability.

Fast and slow thinking in distressing delusions: A review of the literature and implications for targeted therapy.

The recent literature on reasoning biases in psychosis and delusions is reviewed. The state-of-the-art knowledge from systematic reviews and meta-analyses on the evidence for jumping to conclusions is briefly summarised, before a fuller discussion of the more recent empirical literature on belief flexibility as applied to delusions. The methodology and evidence in relation to studies of belief flexibility and the Bias Against Disconfirmatory Evidence (BADE) across the delusional continuum will be critically appraised, and implications drawn for improving cognitive therapy. It will be proposed that dual process models of reasoning, which Kahneman (Kahneman, 2011) popularised as 'fast and slow thinking', provide a useful theoretical framework for integrating further research and informing clinical practice. The emergence of therapies which specifically target fast and slow thinking in people with distressing delusions will be described.

The psychological effect of an urban environment on individuals with persecutory delusions: the Camberwell walk study.

BACKGROUND: Epidemiological studies have found that individuals who live in urban areas are at increased risk of developing psychosis. However it is unknown whether exposure to urban environments exacerbates psychotic symptoms in people who have a diagnosed psychotic disorder. The aim of the study was to examine the psychological and clinical effects of exposure to one specific deprived urban environment on individuals with persecutory delusions. It was predicted that the urban environment would affect emotional and reasoning processes highlighted in a cognitive model of persecutory delusions and would increase paranoia. METHOD: Thirty patients with persecutory delusions were randomised to exposure to a deprived urban environment or to a brief mindfulness relaxation task. After exposure, assessments of symptoms, reasoning, and affective processes were taken. Thirty matched non-clinical participants also completed the study measures to enable interpretation of the test scores. RESULTS: In individuals with persecutory delusions, exposure to the urban environment, rather than participation in a mindfulness task, increased levels of anxiety, negative beliefs about others and jumping to conclusions. It also increased paranoia. The individuals with persecutory delusions scored significantly differently from the non-clinical group on all measures. CONCLUSIONS: For individuals with psychosis, spending time in an urban environment makes them think more negatively about other people and increases anxiety and the jumping to conclusions reasoning bias. Their paranoia is also increased. A number of processes hypothesised in cognitive models to lead to paranoid thoughts are exacerbated by a deprived urban environment. Further research is needed to clarify which aspects of urban environments cause the negative effects. Methodological challenges in the research area are raised.

A large-scale validation study of the Medication Adherence Rating Scale (MARS).

Adherence to medication is an important predictor of illness course and outcome in psychosis. The Medication Adherence Rating Scale (MARS) is a ten-item self-report measure of medication adherence in psychosis [Thompson, K., Kulkarni, J., Sergejew, A.A., 2000. Reliability and validity of a new Medication Adherence Rating Scale (MARS) for the psychoses. Schizophrenia Research. 42. 241-247]. Although initial results suggested that the scale has good reliability and validity, the development sample was small. The current study aimed to establish the psychometric properties of the MARS in a sample over four times larger. The scale was administered to 277 individuals with psychosis, along with measures of insight and psychopathology. Medication adherence was independently rated by each individual's keyworker. Results showed the internal consistency of the MARS to be lower than in the original sample, though adequate. MARS total score correlated weakly with keyworker-rated adherence, hence concurrent validity of the scale appeared only moderate to weak. The three factor structure of the MARS was replicated. Examination of the factor scores suggested that the factor 1 total score, which corresponds to the Medication Adherence Questionnaire [Morisky,D.E., Green,L.W. and Levine,D.M., 1986. Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care. 24, 67-74] may be a preferable measure of medication adherence behaviour to the total scale score.

Jumping to conclusions and persecutory delusions.

It is unknown whether a 'jumping to conclusions' (JTC) data-gathering bias is apparent in specific delusion sub-types. A group with persecutory delusions is compared with a sample of non-clinical controls on a probabilistic reasoning task. Results suggest JTC is apparent in individuals with the persecutory sub-type of delusions.

Data-Gathering, Belief Flexibility, and Reasoning Across the Psychosis Continuum.

Background: There is evidence for a group of nonclinical individuals with full-blown, persistent psychotic experiences (PEs) but no need-for-care: they are of particular importance in identifying risk and protective factors for clinical psychosis. The aim of this study was to investigate whether reasoning biases are related to PEs or need-for-care. Method: Two groups with persistent PEs (clinical; n = 74; nonclinical; n = 92) and a control group without PEs (n = 83) were compared on jumping-to-conclusions (JTC) and belief flexibility. A randomly selected subset of interviews (n = 104) was analyzed to examine differences in experiential and rational reasoning. Results: As predicted JTC was more common in the clinical than the other 2 groups. Unexpectedly no group differences were observed between clinical and nonclinical groups on measures of belief flexibility. However, the clinical group was less likely to employ rational reasoning, while the nonclinical group was more likely to use experiential reasoning plus a combination of both types of reasoning processes, compared to the other 2 groups. Conclusions: Reasoning biases differ in groups with PEs with and without need-for-care. JTC is associated with need-for-care rather than with PEs. The ability to invoke rational reasoning processes, together with an absence of JTC, may protect against pathological outcomes of persistent PEs. However, marked use of experiential reasoning is associated with the occurrence of PEs in both clinical and nonclinical groups. Implications for theory development, intervention and further research are discussed.

AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial.

BACKGROUND: A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition. METHODS: We did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20-29) or affective disorder (F30-39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS-AH). Analysis was by intention-to-treat with linear mixed models. The trial was prospectively registered with the ISRCTN registry, number 65314790. FINDINGS: Between Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy (n=75) or supportive counselling (n=75). 124 (83%) met the primary outcome. The reduction in PSYRATS-AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling (mean difference -3·82 [SE 1·47], 95% CI -6·70 to -0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy. INTERPRETATION: To our knowledge, this is the first powered, randomised controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations. FUNDING: Wellcome Trust.

Training the Frontline Workforce to Deliver Evidence-Based Therapy to People With Psychosis: Challenges in the GOALS Study.

Improving access to psychotherapies in psychosis requires workforce expansion in resource-challenged systems. The GOALS feasibility randomized controlled trial assessed training and implementation of an evidence-based intervention by frontline workers, targeting recovery goals. Training uptake and therapy fidelity were good. Case managers with crisis management responsibilities were less likely than clinical assistants to deliver therapy. Participants receiving "sufficient therapy" achieved goals, but therapy was usually provided by clinical assistants. This is consistent with implementation science principles, that training must be combined with supportive organizational structures, such as by focusing on roles that already include therapy delivery or developing stronger organizational supports for case managers.

The multidimensional measurement of the positive symptoms of psychosis.

The measures most frequently used to assess psychotic symptoms fail to reflect important dimensions. The Psychotic Symptom Rating Scale (PSYRATS) aims to capture the multidimensional nature of auditory hallucinations and delusions. Individuals (N = 276) who had recently relapsed with positive symptoms completed the auditory hallucinations and delusions PSYRATS scales. These scores were compared with the relevant items from the SAPS and PANSS, and with measures of current mood. Total scores and distribution of items of the PSYRATS scales are presented and correlated with other measures. Positive symptom items from the SAPS and PANSS reflected the more objective aspects of PSYRATS ratings of auditory hallucinations and delusions (frequency and conviction) but were relatively poor at measuring distress. A major strength of the PSYRATS scales is the specific measurement of the distress dimension of symptoms, which is a key target of psychological intervention. It is advised that the PSYRATS should not be used as a total score alone, whilst further research is needed to clarify the best use of potential subscales.