Psychiatry as a vocation: Moral injury, COVID-19, and the phenomenology of clinical practice.

In this article, we focus on a particular kind of emotional impact of the pandemic, namely the phenomenology of the experience of moral injury in healthcare professionals. Drawing on Weber's reflections in his lecture Politics as a Vocation and data from the Experiences of Social Distancing during the COVID-19 Pandemic Survey, we analyse responses from healthcare professionals which show the experiences of burnout, sense of frustration and impotence, and how these affect clinicians' emotional state. We argue that this may relate to the ethical conflicts they experience when they are forced to make clinical decisions where there are no optimal outcomes, and how in turn that impacts on their own emotional state. We then further examine the notion of 'burnout' and the phenomenology of 'moral injury'. Our argument is that these experiences of moral injury across a range of clinicians during the pandemic may be more prevalent and long-standing in psychiatry and mental health than in other areas of healthcare, where ethically difficult decisions and resource constraints are common outside times of crisis. Hence, in these clinical arenas, moral injury and the phenomenology of emotional changes may be independent of the pandemic. The insights gained during the pandemic may provide wider insights into the challenges of developing services and training the workforce to provide appropriate mental health care.

Soundless voices, silenced selves: are auditory verbal hallucinations in schizophrenia truly perceptual?

In much contemporary psychiatric training and practice, there is a strong emphasis on the audible or perceptual quality and externality of auditory verbal hallucinations in clinical assessments. A typical question during clinical assessment is asking whether the voices that a person hears sound identical to the way the clinician's voice is heard. In this Personal View, we argue that the most important factor in auditory verbal hallucinations in schizophrenia spectrum psychoses is a loss of first-person authority, and that a perceptual quality is not required for it to be this kind of hallucination. We draw on evidence from cognitive neuroscience showing that the activation of brain networks retrieved during capture of auditory verbal hallucinations that were experienced when a patient was in a functional MRI scanner does not match activation of networks retrieved during auditory perception. We propose that, despite early writings by Esquirol and Schneider that defined auditory verbal hallucinations as beliefs in perception rather than true perception, cognitive neuroscience, psychiatric training and practice, and patients adopting clinical vocabulary have been strongly influenced by the progression of the diagnostic criteria for schizophrenia, which increasingly place emphasis on language, such as the "full force" of a true perception. We hold that this change has resulted in an unhelpful top-down influence on the field, imposing perceptual qualities on auditory verbal hallucinations, and leading to misunderstandings and inaccuracies in clinical practice and patients' self-reports, and misinterpretations in cognitive neuroscience. We encourage a revision of the definition of auditory verbal hallucinations to move away from the necessity for auditory perception, and towards beliefs in perception due to the loss of first-person authority.

Measurement of brain glutathione with magnetic Resonance spectroscopy in Schizophrenia-Spectrum disorders - A systematic review and Meta-Analysis.

Oxidative stress may contribute to declining course and poor outcomes in psychosis. However, in vivo Magnetic Resonance Spectroscopy studies yield disparate results due to clinical stage, sample demographics, neuroanatomical focus, sample size, and acquisition method variations. We investigated glutathione in brain regions from participants with psychosis, and the relation of glutathione to clinical features and spectroscopy protocols. Meta-analysis comprised 21 studies. Glutathione levels did not differ between total psychosis patients (N = 639) and controls (N = 704) in the Medial Prefrontal region (k = 21, d = -0.09, CI = -0.28 to 0.10, p = 0.37). Patients with stable schizophrenia exhibited a small but significant glutathione reduction compared to controls (k = 14, d = -0.20, CI = -0.40 to -0.00, p = 0.05). Meta-regression showed older studies had greater glutathione reductions, possibly reflecting greater accuracy related to spectroscopy advancements in more recent studies. No significant effects of methodological variables, such as voxel size or echo time were found. Reduced glutathione in patients with stable established schizophrenia may provide novel targets for precision medicine. Standardizing MRS acquisition methods in future studies may help address discrepancies in glutathione levels.

Associations between primary care recorded cannabis use and mental ill health in the UK: a population-based retrospective cohort study using UK primary care data.

BACKGROUND: Cannabis use is a global public health issue associated with increased risks of developing mental health disorders, especially in young people. We aimed to investigate the relationships between cannabis exposure and risks of receiving mental illness diagnoses or treatment as outcomes. METHODS: A population based, retrospective, open cohort study using patients recorded in 'IQVIA medical research data', a UK primary care database. Read codes were used to confirm patients with recorded exposure to cannabis use who were matched up to two unexposed patients. We examined the risk of developing three categories of mental ill health: depression, anxiety or serious mental illness (SMI). RESULTS: At study entry, the exposed cohort had an increased likelihood of having experienced mental ill health [odds ratio (OR) 4.13; 95% confidence interval (CI) 3.99-4.27] and mental ill health-related prescription (OR 2.95; 95% CI 2.86-3.05) compared to the unexposed group. During the study period we found that exposure to cannabis was associated with an increased risk of developing any mental disorder [adjusted hazard ratio (aHR) 2.73; 95% CI 2.59-2.88], also noted when examining by subtype of disorder: anxiety (aHR 2.46; 95% CI 2.29-2.64), depression (aHR 2.34; 95% CI 2.20-2.49) and SMI (aHR 6.41; 95% CI 5.42-7.57). These results remained robust in sensitivity analyses. CONCLUSION: These findings point to the potential need for a public health approach to the management of people misusing cannabis. However, there is a gross under-recording of cannabis use in GP records, as seen by the prevalence of recorded cannabis exposure substantially lower than self-reported survey records.

Co-occurring psychotic and eating disorders in England: findings from the 2014 Adult Psychiatric Morbidity Survey.

BACKGROUND: Psychotic disorders and eating disorders are complex mental illnesses associated with increased mortality and functional impairment. This study aimed to investigate the co-occurrence and relationships between eating disorders and psychotic disorders and assess the mediation effect of mood instability. METHODS: This study used data from the Adult Psychiatric Morbidity Survey (APMS) 2014, a general population-based survey in England. Participants (total N = 7546, female N = 4488, male N = 3058, mean age = 52.3 years) were categorised based on psychotic disorder status into the groups of probable psychosis, diagnosed psychosis, and healthy controls without psychosis. The dependent variable of this study was the presence or absence of an eating disorder, with mood instability as the mediator. Logistic regression and mediation analyses were conducted to assess the relationships between these variables. RESULTS: Both probable and diagnosed psychoses were significantly related to the presence of an eating disorder, and mood instability was found to be a mediating variable with moderate effect. CONCLUSION: The present study demonstrates a significant relationship between eating disorders and psychotic disorders in the English general population, indicating higher levels of co-occurrence between these two groups of disorders than when compared with healthy controls. The findings also suggest the relationship between eating and psychotic disorders is mediated, to an extent, by the presence of mood instability traits. Future research could extend the present study's findings through assessing whether specific eating disorders are more significantly related to psychotic disorders than others.

Eating disorders as well as psychotic disorders pose a significant risk to those diagnosed, with anorexia nervosa having the highest mortality rate among all mental disorders. The two groups of disorders are shown to be related as those with psychotic disorders are more likely to also be diagnosed with an eating disorder. Further, the relationship between eating and psychotic disorders could be due to trait mood instability. Mood instability is defined as the rapid switching between moods that those affected cannot control easily and has been found in individuals who are diagnosed with either an eating or a psychotic disorder. This leads to the question whether mood instability is involved in the relationship between psychotic and eating disorders. As individuals with both eating and psychotic disorders experience high levels of distress and treatment is challenging, it is important to understand the nature of the relationship between these two disorders.This study used data collected from a population-based survey in England to examine whether psychotic disorders were related to eating disorders, and whether mood instability was implicated in the relationship. The study found that psychotic and eating disorders were significantly related, and mood instability had a moderate effect on the relationship.

The phenomenology of auditory verbal hallucinations in schizophrenia and the challenge from pseudohallucinations.

In trying to make sense of the extensive phenomenological variation of first-personal reports on auditory verbal hallucinations, the concept of pseudohallucination is originally introduced to designate any hallucinatory-like phenomena not exhibiting some of the paradigmatic features of "genuine" hallucinations. After its introduction, Karl Jaspers locates the notion of pseudohallucinations into the auditory domain, appealing to a distinction between hallucinatory voices heard within the subjective inner space (pseudohallucination) and voices heard in the outer external space (real hallucinations) with differences in their sensory richness. Jaspers' characterization of the term has been the target of a number of phenomenological, conceptual and empirically-based criticisms. From this latter point of view, it has been claimed that the concept cannot capture distinct phenomena at the neurobiological level. Over the last years, the notion of pseudohallucination seems to be falling into disuse as no major diagnostic system seems to refer to it. In this paper, we propose that even if the concept of pseudohallucination is not helpful to differentiate distinct phenomena at the neurobiological level, the inner/outer distinction highlighted by Jaspers' characterization of the term still remains an open explanatory challenge for dominant theories about the neurocognitive origin of auditory verbal hallucinations. We call this, "the challenge from pseudohallucinations". After exploring this issue in detail, we propose some phenomenological, conceptual, and empirical paths for future research that might help to build up a more contextualized and dynamic view of auditory verbal hallucinatory phenomena.

'An experience of meaning': A 20-year prospective analysis of delusional realities in schizophrenia and affective psychoses.

Delusions are transdiagnostic and heterogeneous phenomena with varying degrees of intensity, stability, and dimensional attributes where the boundaries between everyday beliefs and delusional beliefs can be experienced as clearly demarcated, fuzzy, or indistinguishable. This highlights the difficulty in defining delusional realities. All individuals in the current study were evaluated at index and at least one of six subsequential follow-ups over 20 years in the Chicago Longitudinal Study. We assessed 16 distinct delusions categorized as thought or thematic delusions. We also examined the probability of recurrence and the relationships between delusions and hallucinations, depression, anxiety, and negative symptoms. The sample consisted of 262 individuals with schizophrenia vs. affective psychosis. Thought delusions were significantly different between groups at all follow-up evaluations except the 20-year timepoint. Thematic delusions were more common than thought delusions and show a significant decreasing pattern. In general, delusional content varied over time. Referential, persecutory, and thought dissemination delusions show the highest probability of recurrence. Hallucinations were the strongest indicator for thought, thematic, and overall delusions. The formation and maintenance of delusions were conceptualized as a multimodal construct consisting of sensory, perceptual, emotional, social, and somatic embodiment of an "experience of meanings". Given the significant associations between delusions and hallucinations, future work incorporating participatory research is needed to better define and align subjective and objective perspectives. Our research also points to the need for future clinical interventions that specifically evaluate and target the coexistence and entanglement of delusions and hallucinations.

Subjective experience and meaning of delusions in psychosis: a systematic review and qualitative evidence synthesis.

BACKGROUND: Delusions are a common transdiagnostic feature of psychotic disorders, and their treatment remains suboptimal. Despite the pressing need to better understand the nature, meaning, and course of these symptoms, research into the lived experience of delusional phenomena in psychosis is scarce. Thus, we aimed to explore the lived experience and subjective apprehension of delusions in help-seeking individuals with psychosis, regardless of diagnosis and thematic content of the delusion. METHODS: In our systematic review and qualitative evidence synthesis, we searched MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science for qualitative studies published in English from database inception, with the last search on Sept 9, 2021. Grey literature search and hand-searching of relevant journals were also done. Studies were eligible if they provided an analysis of lived experience of delusions or predelusional phenomena presented from the perspective of individuals (age 14-65 years) who had developed a clinical high-risk stage of psychosis, or a diagnosable affective or non-affective psychotic disorder (as clinically defined, self-reported, or assessed within the primary study). Studies with only a subset of relevant participants were eligible only if data for the population of interest were reported separately. Studies that did not discriminate between the experience of delusion and other positive symptoms (eg, hallucinations) were included only if data for delusions were reported separately or could be extracted. First-person accounts (and author interpretations) discussing changes in the sense of self, lived world, and meaning in relation to delusions were extracted and synthesised using a novel thematic synthesis approach informed by a critical realist stance and a phenomenological theoretical framework. Analytic themes were developed into a new overarching framework for understanding the emergence of delusional phenomena. The study was registered with PROSPERO, CRD42020222104. FINDINGS: Of the 3265 records screened, 2115 were identified after duplicate removal. Of these, 1982 were excluded after title and abstract screening and 106 after full-text eligibility assessment. Of the 27 studies entering quality assessment, 24 eligible studies were included in the qualitative evidence synthesis, representing the perspectives of 373 help-seeking individuals with lived experience of delusions in the context of psychosis. Gender was reported as male (n=210), female (n=110), transgender (n=1), or not reported (n=52). Only 13 studies reported ethnicity, with White being predominant. The age of most participants ranged from 15 to 65 years. We found no eligible studies investigating subclinical or predelusional experiences in at-risk mental state populations through qualitative methods. Most studies were undertaken in western, educated, industrialised, rich, and democratic (WEIRD) societies, and most included participants had received or self-reported a diagnosis within the schizophrenia spectrum. Studies differed in relation to whether they focused on one kind or theme of delusion or delusional phenomena more generally as a unified category. Three superordinate themes relating to experiential changes and meanings in delusion were identified: (1) a radical rearrangement of the lived world dominated by intense emotions; (2) doubting, losing, and finding oneself again within delusional realities; and (3) searching for meaning, belonging, and coherence beyond mere dysfunction. Based on the review findings and thematic synthesis, we propose the Emergence Model of Delusion to advance understanding of delusional phenomena in psychosis. INTERPRETATION: Delusions are best understood as strongly individualised and inherently complex phenomena emerging from a dynamic interplay between interdependent subpersonal, personal, interpersonal, and sociocultural processes. Integrative approaches to research on delusion, which consider their potential adaptiveness and favour explanatory pluralism, might be advantageous. Effective clinical care for individuals with psychosis might need adapting to match more closely, and take account of, the subjective experience and meaning of delusions as they are lived through, which might also help redress power imbalances and enduring epistemic injustices in mental health. FUNDING: Priestley Scholars, Wellcome Trust.

Prevalence and assessment of self-disorders in the schizophrenia spectrum: a systematic review and meta-analysis.

Self-disorders have been proposed as the "clinical core" of the schizophrenia spectrum. This has been explored in recent studies using self-disorder assessment tools. However, there are few systematic discussions of their quality and utility. Therefore, a literature search was performed on Medline, Embase, PsychINFO, PubMed and the Web of Science. Studies using these assessment tools to explore self-disorders within schizophrenia spectrum disorders (SSDs) were included. A meta-analysis was performed on the outcomes of total self-disorder score and odds ratios of self-disorders, using Comprehensive Meta-Analysis software. Weighted pooled effect sizes in Hedge's g were calculated using a random-effects model. 15 studies were included, giving a sample of 810 participants on the schizophrenia spectrum. Self-disorders showed a greater aggregation within schizophrenia spectrum groups compared to non-schizophrenia spectrum groups, as measured with the Bonn Scale for the Assessment of Basic Symptoms (Hedge's g = 0.774, p < 0.01) and Examination of Anomalous Self-Experiences (Hedge's g = 1.604, p < 0.01). Also, self-disorders had a greater likelihood of occurring within SSDs (odds ratio = 5.435, p < 0.01). These findings help to validate self-disorders as a core clinical feature of the broad schizophrenia spectrum.

The effectiveness of gaming interventions for depression and anxiety in young people: systematic review and meta-analysis.

BACKGROUND: Recent research has investigated the use of serious games as a form of therapeutic intervention for depression and anxiety in young people. AIMS: To conduct a systematic review and meta-analysis into the effectiveness of gaming interventions for treating either depression or anxiety in individuals aged 12-25 years. METHOD: An electronic search was conducted on the 30 March 2020, using PsycINFO, ISI Web of Science Core Collection, Medline and EMBASE databases. Standardised effect sizes (Hedge's g) were calculated for between-participant comparisons between experimental (therapeutic intervention) and control conditions, and within-participant comparisons between pre- and post-intervention time points for repeated measures designs. RESULTS: Twelve studies (seven randomised controlled trials (RCTs) and five non-randomised studies) were included. For RCTs, there was a statistically significant and robust effect (g = -0.54, 95% CI -1.00 to -0.08) favouring the therapeutic intervention when treating youth depression. For non-RCTs, using a repeated measures design, the overall effect was also strong (g = -0.75, 95% CI -1.64 to 0.14) favouring therapeutic intervention, but this was not statistically significant. Interestingly, we found no statistically significant effect for treating youth anxiety. CONCLUSIONS: There is preliminary evidence to suggest that gaming interventions are an effective treatment for youth depression, but not anxiety. Further research is warranted to establish the utility, acceptability and effectiveness of gaming interventions in treating mental health problems in young people.

Finding order within the disorder: a case study exploring the meaningfulness of delusions.

Can delusions, in the context of psychosis, enhance a person's sense of meaningfulness? The case described here suggests that, in some circumstances, they can. This prompts further questions into the complexities of delusion as a lived phenomenon, with important implications for the clinical encounter. While assumptions of meaninglessness are often associated with concepts of 'disorder', 'harm' and 'dysfunction', we suggest that meaning can nonetheless be found within what is commonly taken to be incomprehensible or even meaningless. A phenomenological and value-based approach appears indispensable for clinicians facing the seemingly paradoxical coexistence of harmfulness and meaningfulness.

Thinking about hallucinations: why philosophy matters.

Introduction: Hallucinations research is increasingly incorporating philosophy or the work of philosophically trained individuals. We present three different ways in which this is successfully implemented to the enhancement of knowledge and understanding of hallucinations and related phenomena.Method: We review contributions from phenomenology, philosophy of cognitive science, and philosophy of science and psychiatry.Results: We demonstrate that these areas of philosophy make significant contributions to hallucinations research. Phenomenology gives us a sophisticated and critical understanding of the lived experience of hallucinations. Philosophy of cognitive science enables big-picture theorising and synthesis of ideas, as well as a critical engagement with new paradigms. Philosophy of science and psychiatry raises valuable and theoretically informed questions about diagnosis and categorisation.Conclusions: These contributions reflect both the methodological variety within philosophy and its relevance to the hallucinations researcher.

Anxiety disorders across middle childhood and early adolescence in a UK population-based cohort.

Background: Patterns of development and underlying factors explaining anxiety disorders in children and adolescents are under-researched, despite their high prevalence, impact and associations with other mental disorders. We aimed to a] understand the pattern and persistence of specific anxiety disorders; b] examine differing trajectories of symptoms of specific anxiety disorders and; c] examine socio-demographic and health-related predictors of persistent anxiety disorder-specific symptoms, across middle childhood to early adolescence. Methods: The current study used data from 8122 participants in the Avon Longitudinal Study of Parents and Children birth cohort. The Development and Wellbeing Assessment questionnaire was administered to parents to capture child and adolescent anxiety total scores and DAWBA-derived diagnoses. Separation anxiety, specific phobia, social anxiety, acute stress reaction, and generalized anxiety at 8, 10 and 13 years were selected. Further, we included the following socio-demographic and health-related predictors: sex, birth weight, sleep difficulties at 3.5 years, ethnicity, family adversity, maternal age at birth, maternal postnatal anxiety, maternal postnatal depression, maternal bonding, maternal socio-economic status and maternal education. Results: Different anxiety disorders presented different prevalence and patterns of development over time. Further, latent class growth analyses yielded a trajectory characterized by individuals with persistent high levels of anxiety across childhood and adolescence; for specific phobia (high = 5.8%; moderate = 20.5%; low = 73.6%), social anxiety (high = 3.4%; moderate = 12.1%; low = 84.5%), acute stress reaction (high = 1.9%; low = 98.1%) and generalized anxiety (high = 5.4%; moderate = 21.7%; low = 72.9%). Finally, the risk factors associated with each of the persistent high levels of anxiety disorders were child sleeping difficulties and postnatal maternal depression and anxiety. Conclusions: Our findings show that a small group of children and young adolescents continue to suffer from frequent and severe anxiety. When considering treatment strategies for anxiety disorders in this group, children's sleep difficulties and postnatal maternal depression and anxiety need to be assessed as these may predict a more prolonged and severe course of illness.

Exploring multimodal hallucinations and disturbances in the basic and bodily self: A cross-sectional study in a non-clinical sample.

The bodily self is key to emotional embodiment, which is important for social functioning and emotion regulation. There is a paucity of research systematically assessing how basic and bodily self-disturbances relate to multimodal hallucinations. This study hypothesised that participants with greater hallucination-proneness would report greater degrees of basic and bodily self-disturbance and would demonstrate more ambiguous and less discrete mapping of emotional embodiment. Stage one screened non-clinical participants' degree of hallucination-proneness. Stage two participants completed seven further questionnaires. Hierarchical linear regression modelled the influence of hallucination-proneness and covariates on measures of basic and bodily self-disturbance and sensed presence. Stage two participants also completed a computerised body mapping task (EmBODY) which assessed emotional embodiment. Topographical maps were generated to compare patterns of embodiment between high and low hallucination-proneness groups. 55 respondents participated in stage two, with 18 participants from the high or low hallucination-proneness groups completing EmBODY. In the hierarchical regression analyses, the addition of a measure of hallucination proneness in the final step only increased predictive power where the dependent variable assessed sensed presence (p = 0.035 and p = 0.009, respectively). The EmBODY data revealed that participants with low hallucination-proneness consistently reported more bodily activation across 14 emotional states, whereas the high hallucination-proneness group reported more deactivation. In conclusion, hallucination-proneness was most strongly associated with sensed presence experiences. Patterns of embodiment appeared similar between the two groups, despite consistent differences in activation and deactivation. These findings are exploratory and need to be confirmed in a larger sample.

Self-harm, suicidal ideation, and the positive symptoms of psychosis: Cross-sectional and prospective data from a national household survey.

BACKGROUND: Schizophrenia is associated with premature mortality, partly through increased suicide rates. AIMS: To examine (1) if persecutory ideas, auditory hallucinations, and probable cases of psychosis are associated with suicidal thoughts or attempts cross-sectionally and prospectively, and (2) if such links are mediated by specific affective factors (depression, impulsivity, mood instability). METHOD: We analysed the 2000, 2007, and 2014 British Adult Psychiatric Morbidity Surveys (APMS) separately. Measures of psychosis provided independent variables for multi-stage logistic regressions, with suicidal thoughts and attempts as dependent variables. We also conducted analyses to assess mediation by affective variables, and longitudinal analyses on a subset of the 2000 dataset. RESULTS: In every dataset, persecutory ideas, auditory hallucinations and probable psychosis were associated cross-sectionally with lifetime suicidal attempts and thoughts, even after controlling for confounders, with a single exception (persecutory ideation and suicide attempts were unconnected in APMS 2014). Cross-sectional associations between auditory hallucinations and suicidal phenomena were moderated by persecutory ideation. In the 2000 follow-up, initial persecutory ideas were associated with later suicidal thoughts (O.R. 1.77, p < 0.05); there were no other longitudinal associations. In the 2007 and 2014 datasets, mood instability mediated the effects of psychotic phenomena on suicidality more strongly than impulsivity; depression was also an important mediator. There were appreciable direct effects of positive symptoms on suicidal thoughts and behaviour. CONCLUSIONS: Improving psychotic symptoms and ameliorating co-morbid distress may in itself be effective in reducing suicidal risk in schizophrenia. Given their potential mediating role, mood instability and depression may also be targets for intervention.

The Sensory and Perceptual Scaffolding of Absorption, Inner Speech, and Self in Psychosis.

This study examines the interconnectedness between absorption, inner speech, self, and psychopathology. Absorption involves an intense focus and immersion in mental imagery, sensory/perceptual stimuli, or vivid imagination that involves decreased self-awareness and alterations in consciousness. In psychosis, the dissolution and permeability in the demarcation between self and one's sensory experiences and perceptions, and also between self-other and/or inter-object boundaries alter one's sense of self. Thus, as the individual integrates these changes new "meaning making" or understanding evolves as part of an ongoing inner dialogue and dialogue with others. This study consisted of 117 participants: 81 participants with psychosis and 36 controls. We first conducted a bivariate correlation to elucidate the relationship between absorption and inner speech. We next conducted hierarchical multiple regressions to examine the effect of absorption and inner speech to predict psychopathology. Lastly, we conducted a network analysis and applied extended Bayesian Information Criterion to select the best model. We showed that in both the control and psychosis group dialogic and emotional/motivational types of inner speech were strongly associated with absorption subscales, apart from the aesthetic subscale in the control group which was not significant, while in psychosis, condensed inner speech was uniquely associated with increased imaginative involvement. In psychosis, we also demonstrated that altered consciousness, dialogic, and emotional/motivational inner speech all predicted positive symptoms. In terms of network associations, imaginative involvement was the most central, influential, and most highly predictive node in the model from which all other nodes related to inner speech and psychopathology are connected. This study shows a strong interrelatedness between absorption, inner speech and psychosis thus identifying potentially fertile ground for future research and directions, particularly in the exploration into the underlying construct of imaginative involvement in psychotic symptoms.