Daydreaming and grandiose delusions: development of the Qualities of Daydreaming Scale.

BACKGROUND: Daydreaming may contribute to the maintenance of grandiose delusions. Repeated, pleasant and vivid daydreams about the content of grandiose delusions may keep the ideas in mind, elaborate the details, and increase the degree of conviction in the delusion. Pleasant daydreams more generally could contribute to elevated mood, which may influence the delusion content. AIMS: We sought to develop a brief questionnaire, suitable for research and clinical practice, to assess daydreaming and test potential associations with grandiosity. METHOD: 798 patients with psychosis (375 with grandiose delusions) and 4518 non-clinical adults (1788 with high grandiosity) were recruited. Participants completed a daydreaming item pool and measures of grandiosity, time spent thinking about the grandiose belief, and grandiose belief conviction. Factor analysis was used to derive the Qualities of Daydreaming Scale (QuOD) and associations were tested using pairwise correlations and structural equation modelling. RESULTS: The questionnaire had three factors: realism, pleasantness, and frequency of daydreams. The measure was invariant across clinical and non-clinical groups. Internal consistency was good (alpha-ordinals: realism=0.86, pleasantness=0.93, frequency=0.82) as was test-retest reliability (intra-class coefficient=0.75). Daydreaming scores were higher in patients with grandiose delusions than in patients without grandiose delusions or in the non-clinical group. Daydreaming was significantly associated with grandiosity, time spent thinking about the grandiose delusion, and grandiose delusion conviction, explaining 19.1, 7.7 and 5.2% of the variance in the clinical group data, respectively. Similar associations were found in the non-clinical group. CONCLUSIONS: The process of daydreaming may be one target in psychological interventions for grandiose delusions.

Feasibility and acceptability of the "Never Events" method in the context of multi-agency child protection: findings from an exploratory study.

This report outlines an exploratory study that investigated whether the "Never Events" system - first used in healthcare contexts to identify and investigate preventable incidents that cause serious harm or death as a result of human error - could be adapted in the context of UK multi-agency child protection. Using a sequential design, two online surveys were carried out that explored practitioners' (n = 46) views about the feasibility of adopting the Never Events model and what, if any, incidents or events could be investigated plausibly using such a model. Practitioners were drawn from a purposive sample. An inter-disciplinary panel of senior practitioners - drawn from nursing, public health, social work and child mental health services- discussed the surveys' findings and the list of proposed child protection Never Events. The findings indicate that the complex, judgment-based nature of child protection contributes to difficulties creating shared understandings about what constitutes harm and the extent to which multi-agency systems can share decision-making and responsibility for the way they identify and support families. Thinking through and discussing the relative strengths and limitations of the Never Events model may nevertheless be a valuable exercise in interprofessional training and the design of highly localized review and reporting systems.

Female family carers' experiences of violent, abusive or harmful behaviour by the older person for whom they care: a case of epistemic injustice?

Family carers affected by violent, abusive or harmful behaviour by the older person for whom they care face social and epistemic challenges in developing and sharing knowledge about their experiences. These difficulties have contributed to a situation in which there is a paucity of evidence and public discourse about how we understand violence and harm instigated by people who have care needs or are 'vulnerable'. This paper reports the findings of a qualitative study that involved 12 in-depth interviews with female carers affected by violence, abuse or harm. The study was informed theoretically by Miranda Fricker's concept of epistemic injustice which was used as a framework for analysis. There were two principal findings: (1) Carers were sensitive to anticipatory stigma and loss of moral autonomy. As a result, they self-censured what they shared and, at times, were met with subtle but powerful processes of silencing. (2) Carers had limited linguistic and conceptual resources to explain the emotional and social aspects of the harm they experienced, exacerbated by implicit social norms about the 'private' and gendered nature of familial care. To conclude, we discuss the implications of these findings for sociological research and health and social care practice.

Why do patients with psychosis listen to and believe derogatory and threatening voices? 21 reasons given by patients.

BACKGROUND: Around two-thirds of patients with auditory hallucinations experience derogatory and threatening voices (DTVs). Understandably, when these voices are believed then common consequences can be depression, anxiety and suicidal ideation. There is a need for treatment targeted at promoting distance from such voice content. The first step in this treatment development is to understand why patients listen to and believe voices that are appraised as malevolent. AIMS: To learn from patients their reasons for listening to and believing DTVs. METHOD: Theoretical sampling was used to recruit 15 participants with non-affective psychosis from NHS services who heard daily DTVs. Data were obtained by semi-structured interviews and analysed using grounded theory. RESULTS: Six higher-order categories for why patients listen and/or believe voices were theorised. These were: (i) to understand the voices (e.g. what is their motive?); (ii) to be alert to the threat (e.g. prepared for what might happen); (iii) a normal instinct to rely on sensory information; (iv) the voices can be of people they know; (v) the DTVs use strategies (e.g. repetition) to capture attention; and (vi) patients feel so worn down it is hard to resist the voice experience (e.g. too mentally defeated to dismiss comments). In total, 21 reasons were identified, with all participants endorsing multiple reasons. CONCLUSIONS: The study generated a wide range of reasons why patients listen to and believe DTVs. Awareness of these reasons can help clinicians understand the patient experience and also identify targets in psychological intervention.

Suicidal ideation and behaviour in patients with persecutory delusions: Prevalence, symptom associations, and psychological correlates.

BACKGROUND: To determine the prevalence of suicidal ideation and behaviour - and their correlates - in patients with persecutory delusions. METHODS: 110 patients with persecutory delusions in the context of non-affective psychosis were assessed for suicidal thoughts and behaviours over the past month. Symptom and psychological assessments were also completed. RESULTS: The severity of suicidal ideation was: no suicidal ideation (n = 26, 23.6%); wish to be dead (n = 21, 19.1%); nonspecific active suicidal thoughts (n = 14, 12.7%); suicidal thoughts with methods but no intent (n = 29, 26.4%); suicidal thoughts with intent but no specific plan (n = 13, 11.8%); and suicidal intent with plan (n = 7, 6.4%). In the past month, five patients (4.5%) had made an actual, interrupted, or aborted suicide attempt. The severity of suicidal ideation was associated with higher levels of depression, paranoia, hallucinations, anger, insomnia, negative beliefs about the self and others, pessimism, worry, and delusion safety-seeking behaviours and lower levels of psychological well-being and reward responsiveness. Severity of ideation was not associated with cannabis or alcohol use, working memory, pain, or meaningful activity levels. CONCLUSIONS: Patients with persecutory delusions are typically in a severe state of psychological stress, and at risk of suicide, as indicated by very high levels of suicidal ideation. This exploratory study also identifies correlates of suicidal ideation that could be investigated in causal research designs.

Stabilising sleep for patients admitted at acute crisis to a psychiatric hospital (OWLS): an assessor-blind pilot randomised controlled trial.

BACKGROUND: When patients are admitted onto psychiatric wards, sleep problems are highly prevalent. We carried out the first trial testing a psychological sleep treatment at acute admission (Oxford Ward sLeep Solution, OWLS). METHODS: This assessor-blind parallel-group pilot trial randomised patients to receive sleep treatment at acute crisis [STAC, plus standard care (SC)], or SC alone (1 : 1). STAC included cognitive-behavioural therapy (CBT) for insomnia, sleep monitoring and light/dark exposure for circadian entrainment, delivered over 2 weeks. Assessments took place at 0, 2, 4 and 12 weeks. Feasibility outcomes assessed recruitment, retention of participants and uptake of the therapy. Primary efficacy outcomes were the Insomnia Severity Index and Warwick-Edinburgh Mental Wellbeing Scale at week 2. Analyses were intention-to-treat, estimating treatment effect with 95% confidence intervals. RESULTS: Between October 2015 and July 2016, 40 participants were recruited (from 43 assessed eligible). All participants offered STAC completed treatment (mean sessions received = 8.6, s.d. = 1.5). All participants completed the primary end point. Compared with SC, STAC led to large effect size (ES) reductions in insomnia at week 2 (adjusted mean difference -4.6, 95% CI -7.7 to -1.4, ES -0.9), a small improvement in psychological wellbeing (adjusted mean difference 3.7, 95% CI -2.8 to 10.1, ES 0.3) and patients were discharged 8.5 days earlier. One patient in the STAC group had an adverse event, unrelated to participation. CONCLUSIONS: In this challenging environment for research, the trial was feasible. Therapy uptake was high. STAC may be a highly effective treatment for sleep disturbance on wards with potential wider benefits on wellbeing and admission length.

Adapted CBT to Stabilize Sleep on Psychiatric Wards: a Transdiagnostic Treatment Approach.

BACKGROUND: Almost all patients admitted at acute crisis to a psychiatric ward experience clinically significant symptoms of insomnia. Ward environments pose challenges to both sleep and the delivery of therapy. Despite this, there is no description of how to adapt cognitive behavioural therapy (CBT) for insomnia to overcome these challenges. AIMS: (i) To describe the key insomnia presentations observed in the Oxford Ward Sleep Solution (OWLS) trial and (ii) outline key adaptations aimed to increase accessibility and hence effectiveness of CBT for insomnia for a ward setting. METHODS: Trial therapists collaboratively agreed the key insomnia presentations and therapy adaptations based on their individual reflective logs used during the trial. RESULTS: Three key insomnia presentations are outlined. These are used to illustrate the application of 10 CBT for insomnia therapy adaptations. These include use of sleep monitoring watches to engage patients in treatment, stabilizing circadian rhythms, reducing the impact of night-time observations and managing discharge as a sleep challenge. CONCLUSIONS: Whilst inpatient wards bring challenges for sleep and therapy delivery, creative adaptations can increase the accessibility of evidence based CBT for insomnia techniques. This therapy has proven popular with patients.

Group-Based Worry Intervention for Persecutory Delusions: an Initial Feasibility Study.

BACKGROUND: A one-to-one cognitive behavioural therapy intervention targeting worry significantly reduces both worry and persecutory delusions (Freeman et al., 2015). AIM: To adapt this intervention for group delivery and conduct a feasibility trial within routine clinical practice. METHOD: Thirteen participants were randomized to a weekly 8-session worry intervention group (n = 7) or wait-list control (n = 6). RESULTS: All but one participant completed measures at all time points. Participants attended an average of six therapy sessions. CONCLUSIONS: Recruitment, retention and therapy uptake were feasible. Observed treatment effects were in the expected direction, but may be diluted compared with one-to-one interventions.

Working the Edge: The Emotional Experiences of Commissioning and Funding Arrangements for Service Leaders in the Sexual Violence Voluntary Sector.

The specialist voluntary sector plays a crucial role in supporting survivors of sexual violence. However, in England, short-term funding underpins the sector's financial stability. This article examines sector leaders' ways of coping, resisting and being affected by funding practices. Using the concept of edgework, we show how funding and commissioning dynamics push individuals to the edge of service sustainability, job satisfaction, and emotional well-being. We examine how these edges are "worked," for example, by circumventing and remolding the edge. We offer an original way to theorize participants, make visible the emotional toll of service precarity and offer suggestions for support.

Voluntary sector specialist service provision and commissioning for victim-survivors of sexual violence: results from two national surveys in England.

BACKGROUND: In England, voluntary sector specialist (VSS) services are central to supporting victim-survivors of sexual violence (SV). However, empirical evidence is lacking about the scope, range and effectiveness of VSS provision for SV in England. OBJECTIVES: To undertake national surveys to map SV VSS service provision and describe arrangements for funding and commissioning. DESIGN: Cross-sectional surveys. SETTING: VSS services for SV and commissioners from multiple organisations across England (January-June 2021). METHODS: Senior staff working in VSS services and commissioners from multiple organisations were surveyed electronically. Surveys explored SV service commissioning, funding and delivery, partnerships between organisations, perceived unmet need for services, and views about facilitators and challenges. Data were analysed descriptively to characterise VSS service provision for SV and commissioning across England. RESULTS: 54 responses were received from VSS providers and 34 from commissioners. Data demonstrated a complex and evolving funding and commissioning landscape in which providers typically secured funding from multiple sources, impacting consistency and scope of service provision. It was common for multiple organisations to co-commission services, demonstrating trends towards larger contracts that may disadvantage smaller specialist providers. Numerous examples of partnership working between organisations were identified, although developing partnerships was noted as challenging, particularly between VSS organisations. There was clear evidence of unmet need for services, with some groups of victim-survivors such as those from black and minority ethnic groups, often underserved by specialist services. However, there was also evidence of innovative service development and commissioning approaches to meet the needs of victim-survivors who face challenges accessing services. CONCLUSIONS: This study provides novel insights into SV service provision and commissioning in England, including unmet needs among victim-survivors.

The Difficulties of Grandiose Delusions: Harms, Challenges, and Implications for Treatment Engagement.

BACKGROUND AND HYPOTHESIS: Grandiose delusions may entail difficult responsibilities and detrimental actions for patients. Recognition of these consequences by patients may provide an avenue for engagement in treatment. Furthermore, when patients carry out actions within the delusional system ("immersion behaviors") or spend considerable time thinking about their grandiose beliefs this may contribute to the persistence of the grandiosity and further harmful consequences. We, therefore, investigated grandiose-related subjective harm, immersion behaviors, and perseverative thinking. STUDY DESIGN: A cross-sectional study with 798 patients with psychosis (375 of whom had grandiose delusions) and 4518 nonclinical adults. Factor analyses using data from participants scoring highly on grandiosity were used to form 3 scales: subjective harm from exceptional experiences questionnaire; immersion behaviors questionnaire; and thinking about exceptional experiences questionnaire. Associations with grandiosity were tested using structural equation modeling. STUDY RESULTS: A total of 268 (77.9%) patients with grandiose delusions identified grandiose-related harms in the past 6 months and 199 (55.1%) wanted help. Immersion behaviors and perseverative thinking were highly prevalent, and explained 39.5% and 20.4% of the variance in grandiosity, respectively. Immersion behaviors and perseverative thinking were significantly associated with subjective harm, even when severity of grandiosity was controlled. Requests for help were associated with higher levels of subjective harm, use of immersion behaviors, and perseverative thinking but not severity of grandiosity. CONCLUSIONS: Acting on grandiose delusions, including harmful behaviors and excessive thinking about grandiose delusions, may be routes for clinicians to engage patients in treatment. This could be a starting point for targeted psychological interventions for grandiose delusions.

Testing the combination of Feeling Safe and peer counselling against formulation-based cognitive behaviour therapy to promote psychological wellbeing in people with persecutory delusions: study protocol for a randomized controlled trial (the Feeling Safe-NL Trial).

BACKGROUND: Persecutory delusions are strong threat beliefs about others' negative intentions. They can have a major impact on patients' day-to-day life. The Feeling Safe Programme is a new translational cognitive-behaviour therapy that helps patients modify threat beliefs and relearn safety by targeting key psychological causal factors. A different intervention approach, with growing international interest, is peer counselling to facilitate personal recovery. Combining these two approaches is a potential avenue to maximize patient outcomes. This combination of two different treatments will be tested as the Feeling Safe-NL Programme, which aims to promote psychological wellbeing. We will test whether Feeling Safe-NL is more effective and more cost-effective in improving mental wellbeing and reducing persecutory delusions than the current guideline intervention of formulation-based CBT for psychosis (CBTp). METHODS: A single-blind parallel-group randomized controlled trial for 190 out-patients who experience persecutory delusions and low mental wellbeing. Patients will be randomized (1:1) to Feeling Safe-NL (Feeling Safe and peer counselling) or to formulation-based CBTp, both provided over a period of 6 months. Participants in both conditions are offered the possibility to self-monitor their recovery process. Blinded assessments will be conducted at 0, 6 (post-treatment), 12, and 18 months. The primary outcome is mental wellbeing. The overall effect over time (baseline to 18-month follow-up) and the effects at each timepoint will be determined. Secondary outcomes include the severity of the persecutory delusion, general paranoid ideation, patient-chosen therapy outcomes, and activity. Service use data and quality of life data will be collected for the health-economic evaluation. DISCUSSION: The Feeling Safe-NL Trial is the first to evaluate a treatment for people with persecutory delusions, while using mental wellbeing as the primary outcome. It will also provide the first evaluation of the combination of a peer counselling intervention and a CBT-based program for recovery from persecutory delusions. TRIAL REGISTRATION: Current Controlled Trials ISRCTN25766661 (retrospectively registered 7 July 2022).

The meaning in grandiose delusions: measure development and cohort studies in clinical psychosis and non-clinical general population groups in the UK and Ireland.

BACKGROUND: The content of grandiose delusions-inaccurate beliefs that one has special powers, wealth, mission, or identity-is likely to be highly meaningful. The meaning, for example providing a sense of purpose, could prove to be a key factor in the delusion taking hold. We aimed to empirically define and develop measures of the experience of meaning in grandiose delusions and the sources of this meaning, and to test whether severity of grandiosity in clinical and non-clinical populations is associated with level of meaning. METHODS: We did a cross-sectional self-report questionnaire study in two cohorts: non-clinical participants aged 18 years and older, with UK or Irish nationality or residence; and patients with affective or non-affective psychosis diagnoses, aged 16 years and older, and accessing secondary care mental health services in 39 National Health Service providers in England and Wales. Participants with high grandiosity completed two large item pools: one assessing the experience of meaning in grandiose delusions (Grandiosity Meaning Measure [termed gram]) and one assessing the sources of meaning (Grandiosity Meaning Measure-Sources [termed grams]). The Grandiosity Meaning Measure and Grandiosity Meaning Measure-Sources were developed using exploratory factor analysis and confirmatory factor analysis. Structural equation modelling was used to test the associations of meaning with the severity of grandiosity. The primary outcome measure for grandiosity was the Specific Psychotic Experiences Questionnaire (grandiosity subscale) and associations were tested with the Grandiosity Meaning Measure and the Grandiosity Meaning Measure-Sources. FINDINGS: From Aug 30, 2019, to Nov 21, 2020, 13 323 non-clinical participants were enrolled. 2821 (21%) were men and 10 134 (76%) were women, 11 974 (90%) were White, and the mean age was 39·5 years (SD 18·6 [range 18-93]). From March 22, 2021, to March 3, 2022, 798 patients with psychosis were enrolled. 475 (60%) were men and 313 (39%) were women, 614 (77%) were White, and the mean age was 43·4 years (SD 13·8 [range 16-81]). The experience of meaning in relation to grandiose delusions had three components: coherence, purpose, and significance. The sources of meaning had seven components: positive social perceptions, spirituality, overcoming adversity, confidence in self among others, greater good, supporting loved ones, and happiness. The measurement of meaning was invariant across clinical and non-clinical populations. In the clinical population, each person typically endorsed multiple meanings and sources of meaning for the grandiose delusion. Meaning in grandiose delusions was strongly associated with severity of grandiosity, explaining 53·5% of variance, and with grandiose delusion conviction explaining 27·4% of variance. Grandiosity was especially associated with sense of purpose, and grandiose delusion conviction with coherence. Similar findings were found for the non-clinical population. INTERPRETATION: Meaning is inherently tied to grandiose delusions. This study provides a framework for research and clinical practice to understand the different types of meaning of grandiosity. The framework is likely to have clinical use in psychological therapy to help guide patients to find sources of equivalent meaning from other areas of their lives and thereby reduce the extent to which the grandiose delusion is needed. FUNDING: Health Education England and National Institute for Health and Care Research.

The "Neglected" Relationship Between Child Maltreatment and Oral Health? An International Scoping Review of Research.

Globally, the oral health needs of children who have, or are suspected of having, experienced abuse or neglect has become a focus of concern. It is thus valuable and timely to map the contemporary nature of the research landscape in this expanding field. This review reports the findings of a scoping review of the international empirical literature. The aim was to explore the relationship between child maltreatment and oral health and how this complex issue is addressed in contemporary dental, health, and social work practice. The review identified 68 papers, analysis of which identified three themes: (1) There is a relationship between poor oral health and child maltreatment that is well evidenced but conceptually underdeveloped. (2) There are discrepancies between the knowledge of members of the dental team about child maltreatment and their confidence and aptitude to identify and report child protection concerns. (3) There are areas of local-level policy and practice development that seek to improve working relationships between dentists and health and social work practitioners; however, there is widespread evidence that the oral health needs of this group of vulnerable children are not consistently met. To orientate critical discussion and planning for future research and practice, we present the Patterns, Advances, Gaps, Evidence for practice and Research recommendations (PAGER) framework. The review's findings are likely to be of interest to researchers, practitioners, and policy makers working across dentistry, health and social work.

Understanding, treating, and renaming grandiose delusions: A qualitative study.

BACKGROUND: Grandiose delusions are arguably the most neglected psychotic experience in research. OBJECTIVES: We aimed to discover from patients: whether grandiose delusions have harmful consequences; the psychological mechanisms that maintain them; and what help patients may want from clinical services. DESIGN: A qualitative interview design was used to explore patients' experiences of grandiose delusions. METHOD: Fifteen patients with past or present experiences of grandiose delusions who were attending psychiatric services were interviewed. Thematic analysis and grounded theory were used to analyse the data. RESULTS: Participants reported physical, sexual, social, occupational, and emotional harms from grandiose delusions. All patients described the grandiose belief as highly meaningful: it provided a sense of purpose, belonging, or self-identity, or it made sense of unusual or difficult events. The meaning from the belief was not synonymous with extreme superiority or arrogance. The meaning obtained appeared to be a key driver of the persistence of the beliefs. Other maintenance factors were subjectively anomalous experiences (e.g., voices), symptoms of mania, fantasy elaboration, reasoning biases, and immersive behaviours. Participants described insufficient opportunities to talk about their grandiose beliefs and related experiences and were generally positive about the possibility of a psychological therapy. CONCLUSIONS: We conclude that grandiosity is a psychologically rich experience, with a number of maintenance factors that may be amenable to a targeted psychological intervention. Importantly, the term 'grandiose delusion' is an imprecise description of the experience; we suggest 'delusions of exceptionality' may be a credible alternative. PRACTITIONER POINTS: Harm from grandiose delusions can occur across multiple domains (including physical, sexual, social, occupational, and emotional) and practitioners should assess accordingly. However, grandiose delusions are experienced by patients as highly meaningful: they provide a sense of purpose, belonging, or self-identity, or make sense of unusual or difficult events. Possible psychological maintenance mechanisms that could be a target for intervention include the meaning of the belief, anomalous experiences, mania, fantasy elaboration, reasoning biases, and immersive behaviours. Patients are keen to have the opportunity to access talking therapies for this experience. Taking extra time to talk at times of distress, 'going the extra mile', and listening carefully can help to facilitate trust.

Comparison of a theoretically driven cognitive therapy (the Feeling Safe Programme) with befriending for the treatment of persistent persecutory delusions: a parallel, single-blind, randomised controlled trial.

BACKGROUND: There is a large clinical need for improved treatments for patients with persecutory delusions. We aimed to test whether a new theoretically driven cognitive therapy (the Feeling Safe Programme) would lead to large reductions in persecutory delusions, above non-specific effects of therapy. We also aimed to test treatment effect mechanisms. METHODS: We did a parallel, single-blind, randomised controlled trial to test the Feeling Safe Programme against befriending with the same therapists for patients with persistent persecutory delusions in the context of non-affective psychosis diagnoses. Usual care continued throughout the duration of the trial. The trial took place in community mental health services in three UK National Health Service trusts. Participants were included if they were 16 years or older, had persecutory delusions (as defined by Freeman and Garety) for at least 3 months and held with at least 60% conviction, and had a primary diagnosis of non-affective psychosis from the referring clinical team. Patients were randomly assigned to either the Feeling Safe Programme or the befriending programme, using a permuted blocks algorithm with randomly varying block size, stratified by therapist. Trial assessors were masked to group allocation. If an allocation was unmasked then the unmasked assessor was replaced with a new masked assessor. Outcomes were assessed at 0 months, 6 months (primary endpoint), and 12 months. The primary outcome was persecutory delusion conviction, assessed within the Psychotic Symptoms Rating Scale (PSYRATS; rated 0-100%). Outcome analyses were done in the intention-to-treat population. Each intervention was provided individually over 6 months. This trial is registered with the ISRCTN registry, ISRCTN18705064. FINDINGS: From Feb 8, 2016, to July 26, 2019, 130 patients with persecutory delusions (78 [60%] men; 52 [40%] women, mean age 42 years [SD 12·1, range 17-71]; 86% White, 9% Black, 2% Indian; 2·3% Pakistani; 2% other) were recruited. 64 patients were randomly allocated to the Feeling Safe Programme and 66 patients to befriending. Compared with befriending, the Feeling Safe Programme led to significant end of treatment reductions in delusional conviction (-10·69 [95% CI -19·75 to -1·63], p=0·021, Cohen's d=-0·86) and delusion severity (PSYRATS, -2·94 [-4·58 to -1·31], p<0·0001, Cohen's d=-1·20). More adverse events occurred in the befriending group (68 unrelated adverse events reported in 20 [30%] participants) compared with the Feeling Safe group (53 unrelated adverse events reported in 16 [25%] participants). INTERPRETATION: The Feeling Safe Programme led to a significant reduction in persistent persecutory delusions compared with befriending. To our knowledge, these are the largest treatment effects seen for patients with persistent delusions. The principal limitation of our trial was the relatively small sample size when comparing two active treatments, meaning less precision in effect size estimates and lower power to detect moderate treatment differences in secondary outcomes. Further research could be done to determine whether greater effects could be possible by reducing the hypothesised delusion maintenance mechanisms further. The Feeling Safe Programme could become the recommended psychological treatment in clinical services for persecutory delusions. FUNDING: NIHR Research Professorship and NIHR Oxford Health Biomedical Research Centre.

Psychological processes mediating the association between developmental trauma and specific psychotic symptoms in adults: a systematic review and meta-analysis.

Experiencing psychological trauma during childhood and/or adolescence is associated with an increased risk of psychosis in adulthood. However, we lack a clear knowledge of how developmental trauma induces vulnerability to psychotic symptoms. Understanding the psychological processes involved in this association is crucial to the development of preventive interventions and improved treatments. We sought to systematically review the literature and combine findings using meta-analytic techniques to establish the potential roles of psychological processes in the associations between developmental trauma and specific psychotic experiences (i.e., hallucinations, delusions and paranoia). Twenty-two studies met our inclusion criteria. We found mediating roles of dissociation, emotional dysregulation and post-traumatic stress disorder (PTSD) symptoms (avoidance, numbing and hyperarousal) between developmental trauma and hallucinations. There was also evidence of a mediating role of negative schemata, i.e. mental constructs of meanings, between developmental trauma and delusions as well as paranoia. Many studies to date have been of poor quality, and the field is limited by mostly cross-sectional research. Our findings suggest that there may be distinct psy-chological pathways from developmental trauma to psychotic phenomena in adulthood. Clinicians should carefully ask people with psychosis about their history of developmental trauma, and screen patients with such a history for dissociation, emotional dysregulation and PTSD symptoms. Well conducted research with prospective designs, including neurocognitive assessment, is required in order to fully understand the biopsychosocial mechanisms underlying the association between developmental trauma and psychosis.

Sleep and schizophrenia: From epiphenomenon to treatable causal target.

BACKGROUND: Sleep disturbance is a common clinical issue for patients with psychosis. It has been identified as a putative causal factor in the onset and persistence of psychotic experiences (paranoia and hallucinations). Hence sleep disruption may be a potential treatment target to prevent the onset of psychosis and reduce persistent psychotic experiences. The aim of this review is to describe developments in understanding the nature, causal role, and treatment of sleep disruption in psychosis. METHOD: A systematic literature search was conducted to identify studies, published in the last five years, investigating subjective sleep disruption and psychotic experiences. RESULTS: Fifty-eight papers were identified: 37 clinical and 21 non-clinical studies. The studies were correlational (n = 38; 20 clinical, 18 non-clinical), treatment (n = 7; 1 non-clinical), qualitative accounts (n = 6 clinical), prevalence estimates (n = 5 clinical), and experimental tests (n = 2 non-clinical). Insomnia (50%) and nightmare disorder (48%) are the most prevalent sleep problems found in patients. Sleep disruption predicts the onset and persistence of psychotic experiences such as paranoia and hallucinations, with negative affect identified as a partial mediator of this relationship. Patients recognise the detrimental effects of disrupted sleep and are keen for treatment. All psychological intervention studies reported large effect size improvements in sleep and there may be modest resultant improvements in psychotic experiences. CONCLUSIONS: Sleep disruption is a treatable clinical problem in patients with psychosis. It is important to treat in its own right but may also lessen psychotic experiences. Research is required on how this knowledge can be implemented in clinical services.

When Older People Are Violent or Abusive Toward Their Family Caregiver: A Review of Mixed-Methods Research.

What happens when family caregivers experience violence and abuse from the older person for whom they care? Although this issue has received little global attention, it is relevant to researchers, practitioners, and policy makers working across the intersecting fields of older age care and medicine, adult protection and safeguarding, and domestic and intimate partner violence. To date, these fields have generated diverse explanations of violence and abuse in older age illness and how best to respond to it. This article reports the findings of a systematic literature review of 18 quantitative, qualitative, and mixed-methods studies that investigated violent and abusive behavior by older people toward their family caregivers. The review identified three central themes in the literature: (1) There are inconsistent definitions and measurements used in research about harmful, violent, and abusive behavior toward family caregivers. (2) Violent and abusive behavior toward caregivers is a sensitive and hidden topic that poses practical and methodological challenges for researchers. (3) There is some evidence to suggest that people who were violent and abusive in their earlier life-or who had a poor relationship with their family member in the past-are more likely to continue to experience violence and abusive behavior in later life. There were two central ways in which violence and abuse were conceptualized and investigated: as a "symptom of illness" or as an "act of abuse" and we present a visual map of the relationship between these two conceptualizations drawn from our analysis of the literature. We conclude by discussing the implications of the findings and recommend future directions for practice, research, and policy to support affected families.