Emotional and non-emotional mental imagery and auditory verbal hallucinations (hearing voices): A systematic review of imagery assessment tools.

It is unknown to what extent mental imagery and auditory verbal hallucinations (AVHs) are related. Trials evaluating this issue used both emotional and non-emotional mental imagery tools, thereby complicating outcomes comparisons. Therefore, the present study aimed to systematically review the literature on mental imagery in individuals with AVHs to (1) inventory imagery assessment tools used in this population, (2) to collect information on the relation between emotional and non-emotional mental imagery in all sensory domains and AVHs and (3) to integrate the outcomes of this systematic review in a model of different mental imagery domains and related assessment tools. We conducted a systematic literature search in the PubMed Database. After full-text screening, 17 papers were included. Findings showed that a variety of assessment methods have been used to assess various aspects of mental imagery in people with AVHs, suggesting that there is a lack of agreed theoretical conceptualization of mental imagery and AVHs. In addition, the studies confirmed as was expected that non-emotional mental imagery seemed unrelated to AVHs whereas emotional mental imagery was related to AVHs. Lastly, we proposed a model of mental imagery domains and corresponding assessment methods distinguishing between emotional and non-emotional mental imagery.

The prevalence of non-affective psychosis in refugee populations: A systematic review.

BACKGROUND: As we face the largest refugee crisis since World War Two, research is increasingly examining the impact of forced displacement. The risk of non-affective psychosis in refugees is evidenced to be significantly greater than non-refugees, and the role of pre-, peri- and post-migratory trauma and dissociation is increasingly implicated. AIMS: To determine the prevalence of non-affective psychosis in refugee populations. METHOD: PRISMA guidelines were followed. Three key databases (PubMed, PsychINFO and Web of Science), Google scholar and study references were searched. The full-text of 62 studies were screened and 23 studies were eligible for inclusion. A narrative synthesis was undertaken and the Quality Assessment Tool for Quantitative Studies was used to assess methodological quality. (PROSPERO registration CRD42019152170). RESULTS: The results were widely heterogeneous. The combined weighted average prevalence of non-affective psychosis in refugee populations was 0.9 %. Psychosis prevalence for individual psychotic symptoms was 28.4 %; 0.5 % for schizophrenia; 1.0 % for psychosis; 0.6 % for mixed psychotic disorders and 2.9 % for psychotic episodes. CONCLUSIONS: Variations in examined populations, diagnostic and prevalence classifications, and study designs and methodologies likely contributed to heterogeneity across the data. The findings highlight a greater need to provide more specialist mental health services and trauma-focused interventions, as well as transculturally sensitive assessment and treatment to address refugee vulnerability to psychosis. Future research should examine psychosis prevalence longitudinally and in refugees-only, address methodological bias and further examine the role of trauma and dissociation in refugee psychosis prevalence.

The IBER study: a feasibility randomised controlled trial of imagery based emotion regulation for the treatment of anxiety in bipolar disorder.

BACKGROUND: Intrusive mental imagery is associated with anxiety and mood instability within bipolar disorder and therefore represents a novel treatment target. Imagery Based Emotion Regulation (IBER) is a brief structured psychological intervention developed to enable people to use the skills required to regulate the emotional impact of these images. METHODS: Participants aged 18 and over with a diagnosis of bipolar disorder and at least a mild level of anxiety were randomly assigned (1:1) to receive IBER plus treatment as usual (IBER + TAU) or treatment as usual alone (TAU). IBER was delivered in up to 12 sessions overs 16 weeks. Clinical and health economic data were collected at baseline, end of treatment and 16-weeks follow-up. Objectives were to inform the recruitment process, timeline and sample size estimate for a definitive trial and to refine trial procedures. We also explored the impact on participant outcomes of anxiety, depression, mania, and mood stability at 16-weeks and 32-weeks follow-up. RESULTS: Fifty-seven (28: IBER + TAU, 27: TAU) participants from two sites were randomised, with 50 being recruited within the first 12 months. Forty-seven (82%) participants provided outcome data at 16 and 32-weeks follow-up. Thirty-five participants engaged in daily mood monitoring at the 32-week follow-up stage. Retention in IBER treatment was high with 27 (96%) attending ≥ 7 sessions. No study participants experienced a serious adverse event. DISCUSSION: The feasibility criteria of recruitment, outcome completion, and intervention retention were broadly achieved, indicating that imagery-focused interventions for bipolar disorder are worthy of further investigation.

The treatment of PTSD in refugees and asylum seekers using imagery rescripting within an NHS setting.

BACKGROUND: Refugees and asylum seekers present with high levels of post-traumatic stress disorder (PTSD), whilst little research has been conducted to assess the effectiveness or acceptability of psychological interventions for this group. Imagery rescripting is effective in reducing distressing intrusive memories within a range of conditions. The current study evaluates this approach for the treatment of PTSD in refugees and asylum seekers within a UK NHS service. AIMS: To evaluate the clinical outcomes of using imagery rescripting for the treatment of PTSD in UK-based refugees and asylum seekers. METHOD: Ten adult service-users from an NHS specialist service with a primary diagnosis of PTSD were recruited as part of routine service delivery. A multiple baseline design was used with participants randomly allocated to a baseline varying from 5 to 9 weeks. A baseline wait-period was followed by up to five sessions of psychoeducation and treatment preparation, in turn followed by up to 10 sessions of imagery rescripting. The Post-traumatic Symptom Scale (PSS) and Physical Health Questionnaire-9 (PHQ-9) were collected every week during baseline, at end of treatment and weekly for 5 weeks after treatment, and again at 12-week follow-up. Data were analysed with mixed regression. RESULTS: Results indicate a significant improvement both in PTSD symptoms and mood, and that this was attributable to the imagery rescripting phase of the intervention, and not the passage of time or non-specific therapy factors. CONCLUSIONS: Evidence indicates imagery rescripting to be a safe and effective treatment choice for PTSD in refugees and asylum seekers.

Cost-Effectiveness of Positive Memory Training (PoMeT) for the Treatment of Depression in Schizophrenia.

The Positive Memory Training (PoMeT) trial demonstrated reduced depression symptoms at 3 months for schizophrenia, but its longer-term outcome and cost impacts remain unknown. This study is a within-trial cost-utility analysis with quality-adjusted life years (QALYs) as outcome based on health-related quality of life (HRQoL) measurement and secondary outcome analyses of capability well-being. The incremental cost-effectiveness of PoMeT was compared to Treatment As Usual only (TAU) over 9 months from the 'health and social' care and 'societal' perspectives. Uncertainty was explored using bootstrapping and sensitivity analyses for cost outliers and outcome methods. HRQoL improvement was observed for both PoMeT and TAU at 3 months, but reached statistical significance and was sustained only for TAU. There was no change in capability well-being and no significant group difference in QALYs gained over 9 months. Mean intervention cost was GBP 823. Compared to TAU, PoMeT had significantly higher mental health care costs (+GBP 1251, 95% CI GBP 185 to GBP 2316) during the trial, but 'health and social care' and 'societal' cost differences were non-significant. Compared to the before-trial period, psychiatric medication costs increased significantly in both groups. The probability of PoMeT being cost-effective in the given format over 9 months was <30% and decreased further in sensitivity analyses.. Generalizability remains limited since the before-after cost analysis revealed additional treatment effects also in the TAU group that likely diminished the incremental impacts and cost-effectiveness of PoMeT. It is not clear whether an active post-intervention follow-up could result in sustained longer-term effects and improved cost-effectiveness.

A systematic review and narrative synthesis of mental imagery tasks in people with an intellectual disability: Implications for psychological therapies.

Mental imagery is recognised for its role in both psychological distress and wellbeing, with mental imagery techniques increasingly being incorporated into psychological interventions. In this systematic review and narrative synthesis (PROSPERO 2021: CRD42021240930), we identify and evaluate the evidence base for the phenomenon and phenomenology of mental imagery in people with intellectual disabilities, to ascertain the applicability of such interventions for this population. Electronic searches of nine databases and grey literature identified relevant publications. Two reviewers independently assessed titles and abstracts of retrieved records (n = 8609) and full-text articles (n = 101) against eligibility criteria. Data were extracted and quality appraised. Forty-onepapers met our eligibility criteria. The quality and designs were variable. Mental imagery was facilitated through ensuring participants understood tasks, providing opportunity to rehearse tasks (including using concrete prompts) and using scaffolding to help participants elaborate their responses. People with intellectual disabilities can engage with mental imagery, with appropriate adaptations, although the associated phenomenology has not been thoroughly investigated. Mental imagery interventions may be useful for people with intellectual disabilities with appropriate modifications.

Multisite randomised controlled trial of trauma-focused cognitive behaviour therapy for psychosis to reduce post-traumatic stress symptoms in people with co-morbid post-traumatic stress disorder and psychosis, compared to treatment as usual: study protocol for the STAR (Study of Trauma And Recovery) trial.

BACKGROUND: People with psychosis have high rates of trauma, with a post-traumatic stress disorder (PTSD) prevalence rate of approximately 15%, which exacerbates psychotic symptoms such as delusions and hallucinations. Pilot studies have shown that trauma-focused (TF) psychological therapies can be safe and effective in such individuals. This trial, the largest to date, will evaluate the clinical effectiveness of a TF therapy integrated with cognitive behaviour therapy for psychosis (TF-CBTp) on post-traumatic stress symptoms in people with psychosis. The secondary aims are to compare groups on cost-effectiveness; ascertain whether TF-CBTp impacts on a range of other meaningful outcomes; determine whether therapy effects endure; and determine acceptability of the therapy in participants and therapists. METHODS: Rater-blind, parallel arm, pragmatic randomised controlled trial comparing TF-CBTp + treatment as usual (TAU) to TAU only. Adults (N = 300) with distressing post-traumatic stress and psychosis symptoms from five mental health Trusts (60 per site) will be randomised to the two groups. Therapy will be manualised, lasting 9 months (m) with trained therapists. We will assess PTSD symptom severity (primary outcome); percentage who show loss of PTSD diagnosis and clinically significant change; psychosis symptoms; emotional well-being; substance use; suicidal ideation; psychological recovery; social functioning; health-related quality of life; service use, a total of four times: before randomisation; 4 m (mid-therapy); 9 m (end of therapy; primary end point); 24 m (15 m after end of therapy) post-randomisation. Four 3-monthly phone calls will be made between 9 m and 24 m assessment points, to collect service use over the previous 3 months. Therapy acceptability will be assessed through qualitative interviews with participants (N = 35) and therapists (N = 5-10). An internal pilot will ensure integrity of trial recruitment and outcome data, as well as therapy protocol safety and adherence. Data will be analysed following intention-to-treat principles using generalised linear mixed models and reported according to Consolidated Standards of Reporting Trials-Social and Psychological Interventions Statement. DISCUSSION: The proposed intervention has the potential to provide significant patient benefit in terms of reductions in distressing symptoms of post-traumatic stress, psychosis, and emotional problems; enable clinicians to implement trauma-focused therapy confidently in this population; and be cost-effective compared to TAU through reduced service use. TRIAL REGISTRATION: ISRCTN93382525 (03/08/20).

A network analysis of post-traumatic stress and psychosis symptoms.

BACKGROUND: Understanding the interplay between trauma-related psychological mechanisms and psychotic symptoms may improve the effectiveness of interventions for post-traumatic stress reactions in psychosis. Network theory assumes that mental health problems persist not because of a common latent variable, but from dynamic feedback loops between symptoms, thereby addressing the heterogeneous and overlapping nature of traumagenic and psychotic diagnoses. This is a proof-of-concept study examining interactions between post-traumatic stress symptoms, which were hypothesized to reflect trauma-related psychological mechanisms, and auditory hallucinations and delusions. METHOD: Baseline data from two randomised controlled trials (N = 216) of trauma-focused therapy in people with post-traumatic stress symptoms (87.5% met diagnostic criteria for PTSD) and psychotic disorder were analysed. Reexperiencing, hyperarousal, avoidance, trauma-related beliefs, auditory hallucinations and delusional beliefs were used to estimate a Gaussian graphical model along with expected node influence and predictability (proportion of explained variance). RESULTS: Trauma-related beliefs had the largest direct influence on the network and, together with hypervigilance, were implicated in the shortest paths from flashbacks to delusions and auditory hallucinations. CONCLUSIONS: These findings are in contrast to previous research suggesting a central role for re-experiencing, emotional numbing and interpersonal avoidance in psychosis. Trauma-related beliefs were the psychological mechanism most associated with psychotic symptoms, although not all relevant mechanisms were measured. This work demonstrates that investigating multiple putative mediators may clarify which processes are most relevant to trauma-related psychosis. Further research should use network modelling to investigate how the spectrum of traumatic stress reactions play a role in psychotic symptoms.

Positive memory training for the treatment of depression in schizophrenia: A randomised controlled trial.

BACKGROUND: Around half of people diagnosed with schizophrenia suffer from co-morbid depression, yet there are no evidence-based psychological treatments to target this presentation. METHOD: Participants were aged 18-65 years old, had a clinical diagnosis of schizophrenia or schizoaffective disorder and at least a mild level of depression. Participants were randomly assigned (1:1) to receive PoMeT or treatment as usual. PoMeT was delivered in up to 12 individual sessions within 3 months. We stratified randomisation by site and by severity of depression using randomised-permuted blocks. Assessments were carried out at baseline, 3-month, 6-month and 9-month by assessors who were blind to treatment allocation. The primary outcome was reduction in the symptoms of depression at 3-month, 6-month and 9-month as measured by the BDI-II. Analysis was by intention-to-treat with linear mixed-effects models. The trial was registered with the ISRCTN registry number 99485756. RESULTS: One hundred participants were randomly assigned to either PoMeT (n = 49) or treatment as usual (n = 51). The reduction in BDI-II total score at 3 months was significantly greater for PoMeT than for treatment as usual (mean difference = 4.33, SE = 2.00, 95% CI 0.38 to 8.23; p = 0.03). DISCUSSION: To our knowledge this is, to date, the largest powered randomised controlled trial focused on the psychological treatment of depression in people diagnosed with schizophrenia. Results indicate that a brief targeted intervention can reduce the symptoms of depression in the group. The main limitation of the study is the lack of an active control group which may contribute to an inflated treatment effect.

The IBER study: study protocol for a feasibility randomised controlled trial of Imagery Based Emotion Regulation for the treatment of anxiety in bipolar disorder.

BACKGROUND: Anxiety is highly prevalent in people diagnosed with bipolar disorder (BD), and can persist between acute episodes of mania and depression. Recent studies indicate that people with BD are prone to experiencing frequent, intrusive and emotional mental images which further fuel their levels of anxiety and mood instability. These intrusive emotional mental images represent a specific target for treatment for this disorder with the potential to reduce anxiety and improve mood stability. A new brief structured psychological intervention for BD called Imagery Based Emotion Regulation (IBER) has been developed, which translates experimental work in the area of imagery and emotion into a skills training programme to improve the regulation of intrusive and distressing emotional mental images in BD. A feasibility trial is required in order to assess whether a full randomised controlled trial is indicated in order to evaluate this approach. METHODS: The design is a two-arm feasibility randomised controlled trial (RCT), with 1:1 randomisation stratified by trial site and minimised on medication status and anxiety severity. Participants are 60 individuals diagnosed with bipolar disorder and experiencing at least a mild level of anxiety. Sites are defined by the geographical boundaries of two National Health Service (NHS) Trusts, with recruitment from NHS teams, GP surgeries and self-referral. The intervention is up to 12 sessions of Imagery Based Emotion Regulation within 16 weeks. The comparator is NHS standard care. The primary aim is to assess the feasibility of conducting a powered multi-site RCT to evaluate effectiveness. Measures of anxiety, depression, mania, mood stability and health care use will be conducted at baseline, end of treatment and at 16-week follow-up. DISCUSSION: This is the first feasibility trial of an imagery-based intervention for the treatment of anxiety in bipolar disorder. If the trial proves feasible, a large multi-site trial will be required. TRIAL REGISTRATION: ISRCTN16321795. Registered on October 16, 2018. 10.1186/ISRCTN16321795.

Imagery rescripting for the treatment of trauma in voice hearers: a case series.

BACKGROUND: High rates of trauma and post-traumatic stress disorder (PTSD) are reported in people who hear voices (auditory hallucinations). A recent meta-analysis of trauma interventions in psychosis showed only small improvements in PSTD symptoms and voices. Imagery Rescripting (ImRs) may be a therapy that is more effective in this population because it generalizes over memories, which is ideal in this population with typically repeated traumas. AIMS: The primary aims of this study were to investigate whether ImR reduces (1) PTSD symptoms, and (2) voice frequency and distress in voice hearers. METHOD: We used a single arm open trial study, case-series design. Twelve voice hearers with previous traumas that were thematically related to their voices participated. Brief weekly assessments (administered in sessions 1-8, post-intervention, and at 3-month follow-up) and longer measures (administered pre-, mid- and post-intervention) were administered. Mixed regression analysis was used to analyse the results. RESULTS: There was one treatment drop-out. Results of the weekly measure showed significant linear reductions over time in all three primary variables - voice distress, voice frequency, and trauma intrusions - all with large effect sizes. These effects were maintained (and continued to improve for trauma intrusions) at 3-month follow-up. On the full assessment tools, all measures showed improvement over time, with five outcomes showing significant time effects: trauma, voice frequency, voice distress, voice malevolence and stress. CONCLUSIONS: The findings of the current study suggest that ImRs for PTSD symptoms is generally well tolerated and can be therapeutically beneficial among individuals who hear voices.

The PCL as a brief screen for posttraumatic stress disorder within schizophrenia.

OBJECTIVES: To assess the utility of using the posttraumatic checklist (PCL) as a screening measure for identifying posttraumatic stress disorder (PTSD) in individuals diagnosed with a psychotic disorder. METHODS: The PCL was administered to 165 participants as part of a clinical trial. Those scoring 44 or above on the PCL underwent further assessment using the clinician administered PTSD scale (CAPS). RESULTS: Overall 18.2% of the sample exhibited a diagnostic level of PTSD symptoms, as indicated by the CAPS assessment. Only 29.7% of those who scored above the PCL threshold were diagnostic of PTSD. CONCLUSIONS: The use of PCL for identifying PTSD within this population is not recommended.

Process analysis of trauma-focused cognitive behavioural therapy for individuals with schizophrenia.

OBJECTIVE: Therapeutic alliance, modality, and ability to engage with the process of therapy have been the main focus of research into what makes psychotherapy successful. Individuals with complex trauma histories or schizophrenia are suggested to be more difficult to engage and may be less likely to benefit from therapy. This study aimed to track the in-session 'process' of working alliance and emotional processing of trauma memories for individuals with schizophrenia. DESIGN: The study utilized session recordings from the treatment arm of an open randomized clinical trial investigating trauma-focused cognitive behavioural therapy (TF-CBT) for individuals with schizophrenia (N = 26). METHOD: Observer measures of working alliance, emotional processing, and affect arousal were rated at early and late phases of therapy. Correlation analysis was undertaken for process measures. Temporal analysis of expressed emotions was also reported. RESULTS: Working alliance was established and maintained throughout the therapy; however, agreement on goals reduced at the late phase. The participants appeared to be able to engage in emotional processing, but not to the required level for successful cognitive restructuring. CONCLUSION: This study undertook novel exploration of process variables not usually explored in CBT. It is also the first study of process for TF-CBT with individuals with schizophrenia. This complex clinical sample showed no difficulty in engagement; however, they may not be able to fully undertake the cognitive-emotional demands of this type of therapy. Clinical and research implications and potential limitations of these methods are considered. PRACTITIONER POINTS: This sample showed no difficulties engaging with TF-CBT and forming a working alliance. However, the participants may not have achieved a level of active involvement required for successful cognitive restructuring of trauma memories. This discrepancy may relate to the mediating role of both working alliance and cognitive-emotional processing. The results underscore the importance of therapists understanding the relationship between alliance and other process factors which may be implicit in facilitating change.

Cognitive Emotion Regulation as a Mediator between Posttraumatic Stress Symptoms and Hypomanic Personality within a Non-Clinical Population.

BACKGROUND: There is a high prevalence of traumatic life events within individuals diagnosed with bipolar disorder. However, currently there is limited theoretical understanding of this relationship. AIMS: To explore whether non-clinical symptoms of posttraumatic stress have a direct effect on the non-clinical symptoms of bipolar disorder, or whether this relationship is mediated by cognitive emotion regulation strategies. METHOD: A cross-sectional design within non-clinical participants completing an online survey including the Impact of Events Scale, Cognitive Emotion Regulation Questionnaire and the Hypomanic Personality Scale. RESULTS: Posttraumatic stress symptoms were associated with hypomanic personality. Intrusive memories contributed a small but significant proportion of the variance between these two measures. Rumination of negative emotions mediated the relationship between posttraumatic stress and hypomanic personality. CONCLUSIONS: The relationship between traumatic events and an increased prevalence of bipolar disorder remains poorly understood. Further research should explore rumination as a potential target for treatment within those suffering from both posttraumatic stress and bipolar disorder.

Hallucinations as a trauma-based memory: implications for psychological interventions.

The relationship between hallucinations and life events is a topic of significant clinical importance. This review discusses the extent to which auditory and visual hallucinations may be directly related to traumatic events. Evidence suggests that intrusive images occur frequently within individuals who also report hallucinatory experiences. However, there has been limited research specifically investigating the extent to which hallucinations are the re-experiencing of a traumatic event. Our current theoretical understanding of these relationships, along with methodological difficulties associated with research in this area, are considered. Recent clinical studies, which adopt interventions aimed at the symptoms of posttraumatic stress disorder in people diagnosed with a psychotic disorder, are reviewed. There is a need for the development of evidence-based interventions in this area.

A randomised controlled trial of positive memory training for the treatment of depression within schizophrenia.

BACKGROUND: Depression is highly prevalent within individuals diagnosed with schizophrenia, and is associated with an increased risk of suicide. There are no current evidence based treatments for low mood within this group. The specific targeting of co-morbid conditions within complex mental health problems lends itself to the development of short-term structured interventions which are relatively easy to disseminate within health services. A brief cognitive intervention based on a competitive memory theory of depression, is being evaluated in terms of its effectiveness in reducing depression within this group. METHODS/DESIGN: This is a single blind, intention-to-treat, multi-site, randomized controlled trial comparing Positive Memory Training plus Treatment as Usual with Treatment as Usual alone. Participants will be recruited from two NHS Trusts in Southern England. In order to be eligible, participants must have a DSM-V diagnosis of schizophrenia or schizo-affective disorder and exhibit at least a mild level of depression. Following baseline assessment eligible participants will be randomly allocated to either the Positive Memory Training plus Treatment as Usual group or the Treatment as Usual group. Outcome will be assessed at the end of treatment (3-months) and at 6-month and 9-month post randomization by assessors blind to group allocation. The primary outcome will be levels of depression and secondary outcomes will be severity of psychotic symptoms and cost-effectiveness. Semi-structured interviews will be conducted with all participants who are allocated to the treatment group so as to explore the acceptability of the intervention. DISCUSSION: Cognitive behaviour therapy is recommended for individuals diagnosed with schizophrenia. However, the number of sessions and length of training required to deliver this intervention has caused a limit in availability. The current trial will evaluate a short-term structured protocol which targets a co-morbid condition often considered of primary importance by service users. If successful the intervention will be an important addition to current initiatives aimed at increasing access to psychological therapies for people diagnosed with severe mental health problems. TRIAL REGISTRATION: Current Controlled Trials. ISRCTN99485756 . Registered 13 March 2014.

Autobiographical memory distributions for negative self-images: memories are organised around negative as well as positive aspects of identity.

The relationship between developmental experiences, and an individual's emerging beliefs about themselves and the world, is central to many forms of psychotherapy. People suffering from a variety of mental health problems have been shown to use negative memories when defining the self; however, little is known about how these negative memories might be organised and relate to negative self-images. In two online studies with middle-aged (N = 18; study 1) and young (N = 56; study 2) adults, we found that participants' negative self-images (e.g., I am a failure) were associated with sets of autobiographical memories that formed clustered distributions around times of self-formation, in much the same pattern as for positive self-images (e.g., I am talented). This novel result shows that highly organised sets of salient memories may be responsible for perpetuating negative beliefs about the self. Implications for therapy are discussed.

Examining vulnerability to involuntary memories in schizophrenia comorbid with post-traumatic stress disorder.

The current study explored whether individuals diagnosed with schizophrenia and a high level of PTSD symptoms experience more frequent neutral intrusive memories than individuals diagnosed with schizophrenia with low level PTSD symptoms. Results supported a vulnerability to neutral intrusive memories within the comorbid group, which did not seem to be related to psychotic symptom severity. It is possible that a subgroup of psychotic individuals processes information in a manner that make them susceptible to frequent intrusive memories, characteristic of a PTSD presentation. A longitudinal study is required to specify the development of this vulnerability so as to inform future interventions.