The lessons I learned as a psychiatrist from my transcultural work in low- and middle-income countries.

Transcultural observations offer an opportunity to study attitude to mental illness in different societies and family structures. The disparity between industrialised and lower-income societies reflects greater tolerance due to the ability of extended families to compensate for the patient's limitations.

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

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

Key Elements of a Family Intervention for Schizophrenia: A Qualitative Analysis of an RCT.

Schizophrenia is a complex biopsychosocial condition in which expressed emotion in family members is a robust predictor of relapse. Not surprisingly, family interventions are remarkably effective and thus recommended in current treatment guidelines. Their key elements seem to be common therapeutic factors, followed by education and coping skills training. However, few studies have explored these key elements and the process of the intervention itself. We conducted a qualitative and quantitative analysis of the records from a pioneering family intervention trial addressing expressed emotion, published by Leff and colleagues four decades ago. Records were analyzed into categories and data explored using descriptive statistics. This was complemented by a narrative evaluation using an inductive approach based on emotional markers and markers of change. The most used strategies in the intervention were addressing needs, followed by coping skills enhancement, advice, and emotional support. Dealing with overinvolvement and reframing were the next most frequent. Single-family home sessions seemed to augment the therapeutic work conducted in family groups. Overall the intervention seemed to promote cognitive and emotional change in the participants, and therapists were sensitive to the emotional trajectory of each subject. On the basis of our findings, we developed a longitudinal framework for better understanding the process of this treatment approach.

The most important things I have learnt in my career as a psychiatrist.

This paper is something of a patchwork, incorporating many issues that have intrigued me during 34 years of research. I have included the importance of maintaining a solid base in clinical work, alongside research activities, and being alert to the possibility of a somatic condition contributing to psychiatric symptoms. I stress the value of careful observation of patients, their response to treatments and reasons for dropping out. In addition, I have included 14 more lessons, learned from my experience of research, which I hope will be of use to those readers who aspire to become researchers.

What do We Know about Family Interventions for Psychosis at the Process Level? A Systematic Review.

The evidence regarding effectiveness of family interventions for psychosis (FIP) is strong and consistent. However, there is a gap in the research on the process of these interventions, and little is known about their active ingredients. This review aims to identify the active ingredients of FIP. We conducted a systematic literature review, focusing on qualitative research, and analyzed 22 papers in total. We found a single study comprehensively exploring the process of FIP. All other studies focused on particular aspects of process-related variables. The key elements of FIP seem to be the so-called "common therapeutic factors", followed by education about the illness and coping skills training. This review supports the value of a stepped model of intervention according to the needs of the families. However, the evidence reviewed also reveals a gap in the research findings based on the limited research available. FIP are complex, psychosocial interventions with multiple components, and more intensive, qualitative research is needed to establish linkages between process and outcome.

Confronting Auditory Hallucinations Using Virtual Reality: The Avatar Therapy.

The AVATAR therapy is a computer-based intervention which aims to reduce the frequency and severity of voices. The approach is based on computer technology which enables each patient to create an avatar of the entity (human or non-human) that they believe is talking to them. The therapist promotes a dialogue between the patient and the avatar in which the avatar progressively comes under the patient's control. Using real-time voice conversion delivery software, the therapist can modify the relationship between the patient and his/her voice. The innovation of this new intervention is discussed in the present paper as well as the advantages of using a computer based system. The subjective view of the technology from a participant's point of view is also presented.

Avatar therapy for persecutory auditory hallucinations: What is it and how does it work?

We have developed a novel therapy based on a computer program, which enables the patient to create an avatar of the entity, human or non-human, which they believe is persecuting them. The therapist encourages the patient to enter into a dialogue with their avatar, and is able to use the program to change the avatar so that it comes under the patient's control over the course of six 30-min sessions and alters from being abusive to becoming friendly and supportive. The therapy was evaluated in a randomised controlled trial with a partial crossover design. One group went straight into the therapy arm: "immediate therapy". The other continued with standard clinical care for 7 weeks then crossed over into Avatar therapy: "delayed therapy". There was a significant reduction in the frequency and intensity of the voices and in their omnipotence and malevolence. Several individuals had a dramatic response, their voices ceasing completely after a few sessions of the therapy. The average effect size of the therapy was 0.8. We discuss the possible psychological mechanisms for the success of Avatar therapy and the implications for the origins of persecutory voices.

Interplay between childhood physical abuse and familial risk in the onset of psychotic disorders.

BACKGROUND: Childhood abuse is considered one of the main environmental risk factors for the development of psychotic symptoms and disorders. However, this association could be due to genetic factors influencing exposure to such risky environments or increasing sensitivity to the detrimental impact of abuse. Therefore, using a large epidemiological case-control sample, we explored the interplay between a specific form of childhood abuse and family psychiatric history (a proxy for genetic risk) in the onset of psychosis. METHODS: Data were available on 172 first presentation psychosis cases and 246 geographically matched controls from the Aetiology and Ethnicity of Schizophrenia and Other Psychoses study. Information on childhood abuse was obtained retrospectively using the Childhood Experience of Care and Abuse Questionnaire and occurrence of psychotic and affective disorders in first degree relatives with the Family Interview for Genetic Studies. RESULTS: Parental psychosis was more common among psychosis cases than unaffected controls (adjusted OR = 5.96, 95% CI: 2.09-17.01, P = .001). Parental psychosis was also associated with physical abuse from mothers in both cases (OR = 3.64, 95% CI: 1.06-12.51, P = .040) and controls (OR = 10.93, 95% CI: 1.03-115.90, P = .047), indicative of a gene-environment correlation. Nevertheless, adjusting for parental psychosis did not measurably impact on the abuse-psychosis association (adjusted OR = 3.31, 95% CI: 1.22-8.95, P = .018). No interactions were found between familial liability and maternal physical abuse in determining psychosis caseness. CONCLUSIONS: This study found no evidence that familial risk accounts for associations between childhood physical abuse and psychotic disorder nor that it substantially increases the odds of psychosis among individuals reporting abuse.

Expressed emotion among relatives of chronic pain patients, the interaction between relatives' behaviours and patients' pain experience.

BACKGROUND: Chronic pain is a sensory and emotional experience that causes significant disturbances to a patient's life as well as to their family. Whether the family environment is affected by chronic pain and, in turn, affects the patients' pain experience has yet to be investigated. The interaction between patients and spouses has been assessed using the expressed emotion (EE) construct, a tool previously described in the field of mental health. For schizophrenia and other psychiatric illnesses, a correlation exists between family EE and patients' outcomes. AIMS: The main objective of this study was to observe the presence of EE among relatives of chronic spinal pain patients and to evaluate its correlation with their symptoms. METHODS: A prospective observational study was conducted on 54 patients and their spouses currently seen at the Chronic Pain Unit of Hospital Clinic of Barcelona. The following variables were recorded: age, gender, pain score, quality of life and EE. RESULTS: Data showed that a considerable proportion of spouses were rated as high EE. There was an association between EE and patients' quality of life, and the level of EE predicted some other variables of patients' quality of life. CONCLUSION: The EE level of spouses of chronic pain patients affects the patients' quality of life and thus the way that they experience their pain.

Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study.

BACKGROUND: One in four patients with schizophrenia responds poorly to antipsychotic medication, continuing to hear persecutory auditory hallucinations. Patients who are able to sustain a dialogue with their persecutor feel much more in control. AIMS: To develop a computerised system that enables the patient to create an avatar of their persecutor. To encourage them to engage in a dialogue with the avatar, which the therapist is able to control so that the avatar progressively yields control to the patient. METHOD: Avatar therapy was evaluated by a randomised, single blind, partial crossover trial comparing the novel therapy with treatment as usual (TAU). We used three main outcome measures: (a) the Psychotic Symptom Rating Scale (PSYRATS), hallucinations section; (b) the Omnipotence and Malevolence subscales of the Revised Beliefs About Voices Questionnaire (BAVQ-R); and (c) the Calgary Depression Scale (CDS). RESULTS: The control group showed no change over time in their scores on the three assessments, whereas the novel therapy group showed mean reductions in the total PSYRATS score (auditory hallucinations) of 8.75 (P = 0.003) and in the BAVQ-R combined score of omnipotence and malevolence of the voices of 5.88 (P = 0.004). There was no significant reduction in the CDS total score for depression. For the crossover control group, comparison of the period of TAU with the period of avatar therapy confirmed the findings of the previous analysis. The effect size of the therapy was 0.8. CONCLUSIONS: Avatar therapy represents a promising treatment for medication-resistant auditory hallucinations. Replication with a larger sample is required before roll-out to clinical settings.

Satisfaction with inpatient treatment for first-episode psychosis among different ethnic groups: a report from the UK AeSOP study.

BACKGROUND: There is concern about the level of satisfaction with mental healthcare among minority ethnic patients in the UK, particularly as black patients have more compulsory admissions to hospital. AIMS: To determine and compare levels of satisfaction with mental healthcare between patients from different ethnic groups in a three-centre study of first-onset psychosis. METHOD: Data were collected from 216 patients with first-episode psychosis and 101 caregivers from South London, Nottingham and Bristol, using the Acute Services Study Questionnaire (Patient and Relative Version) and measures of sociodemographic variables and insight. RESULTS: No differences were found between ethnic groups in most domains of satisfaction tested individually, including items relating to treatment by ward staff and number of domains rated as satisfactory. However, logistic regression modelling (adjusting for age, gender, social class, diagnostic category and compulsion) showed that black Caribbean patients did not believe that they were receiving the right treatment and were less satisfied with medication than white patients. Black African patients were less satisfied with non-pharmacological treatments than white patients. These findings were not explained by lack of insight or compulsory treatment. CONCLUSIONS: The study found that black patients were less satisfied with specific aspects of treatment, particularly medication, but were equally satisfied with nursing and social care. Understanding the reasons behind this may improve the acceptability of psychiatric care to black minority ethnic groups.

Assessment of posttraumatic symptoms in patients with first-episode psychosis.

Posttraumatic stress disorder is common among patients with psychotic disorders. The present study examined the internal reliability and comparability of the Impact of Event Scale (IES) in a sample of 38 patients with first-episode psychosis and 47 controls exposed to severe physical and/or sexual abuse. The IES total score and both subscales showed high internal consistency in both groups (Cronbach's alpha coefficients of approximately 0.9 or higher). Given their equivalent trauma reporting, the lack of differences in IES scores between patients and controls seems to indicate that patients are likely to report accurately and neither exaggerate nor minimize their posttraumatic symptoms. Overall, the findings suggest that the IES can be used to assess symptoms of posttraumatic stress in patients with psychotic disorders as in other populations.

Reliability and comparability of psychosis patients' retrospective reports of childhood abuse.

An increasing number of studies are demonstrating an association between childhood abuse and psychosis. However, the majority of these rely on retrospective self-reports in adulthood that may be unduly influenced by current psychopathology. We therefore set out to explore the reliability and comparability of first-presentation psychosis patients' reports of childhood abuse. Psychosis case subjects were drawn from the Aetiology and Ethnicity of Schizophrenia and Other Psychoses (ÆSOP) epidemiological study and completed the Childhood Experience of Care and Abuse Questionnaire to elicit abusive experiences that occurred prior to 16 years of age. High levels of concurrent validity were demonstrated with the Parental Bonding Instrument (antipathy: r(s)=0.350-0.737, P<.001; neglect: r(s)=0.688-0.715, P<.001), and good convergent validity was shown with clinical case notes (sexual abuse: κ=0.526, P<.001; physical abuse: κ=0.394, P<.001). Psychosis patients' reports were also reasonably stable over a 7-year period (sexual abuse: κ=0.590, P<.01; physical abuse: κ=0.634, P<.001; antipathy: κ=0.492, P<.01; neglect: κ=0.432, P<.05). Additionally, their reports of childhood abuse were not associated with current severity of psychotic symptoms (sexual abuse: U=1768.5, P=.998; physical abuse: U=2167.5, P=.815; antipathy: U=2216.5, P=.988; neglect: U=1906.0, P=.835) or depressed mood (sexual abuse: χ(2)=0.634, P=.277; physical abuse: χ(2)=0.159, P=.419; antipathy: χ(2)=0.868, P=.229; neglect: χ(2)=0.639, P=.274). These findings provide justification for the use in future studies of retrospective reports of childhood abuse obtained from individuals with psychotic disorders.

The varying impact of type, timing and frequency of exposure to childhood adversity on its association with adult psychotic disorder

BACKGROUND: Childhood adversity has been associated with onset of psychosis in adulthood but these studies have used only general definitions of this environmental risk indicator. Therefore, we sought to explore the prevalence of more specific adverse childhood experiences amongst those with and without psychotic disorders using detailed assessments in a large epidemiological case-control sample (AESOP). METHOD: Data were collected on 182 first-presentation psychosis cases and 246 geographically matched controls in two UK centres. Information relating to the timing and frequency of exposure to different types of childhood adversity (neglect, antipathy, physical and sexual abuse, local authority care, disrupted living arrangements and lack of supportive figure) was obtained using the Childhood Experience of Care and Abuse Questionnaire. RESULTS: Psychosis cases were three times more likely to report severe physical abuse from the mother that commenced prior to 12 years of age, even after adjustment for other significant forms of adversity and demographic confounders. A non-significant trend was also evident for greater prevalence of reported severe maternal antipathy amongst those with psychosis. Associations with maternal neglect and childhood sexual abuse disappeared after adjusting for maternal physical abuse and antipathy. Paternal maltreatment and other forms of adversity were not associated with psychosis nor was there evidence of a dose-response effect. CONCLUSIONS: These findings suggest that only specific adverse childhood experiences are associated with psychotic disorders and only in a minority of cases. If replicated, this greater precision will ensure that research into the mechanisms underlying the pathway from childhood adversity to psychosis is more fruitful.

Insight, grey matter and cognitive function in first-onset psychosis.

BACKGROUND: Several studies have suggested that neuropsychological and structural brain deficits are implicated in poor insight. Few insight studies however have combined neurocognitive and structural neuroanatomical measures. AIMS: Focusing on the ability to relabel psychotic symptoms as pathological, we examined insight, brain structure and neurocognition in first-onset psychosis. METHOD: Voxel-based magnetic resonance imaging data were acquired from 82 individuals with psychosis and 91 controls assessed with a brief neuropsychological test battery. Insight was measured using the Schedule for the Assessment of Insight. RESULTS: The principal analysis showed reduced general neuropsychological function was linked to poor symptom relabelling ability. A subsequent between-psychosis group analysis found those with no symptom relabelling ability had significant global and regional grey matter deficits primarily located at the posterior cingulate gyrus and right precuneus/cuneus. CONCLUSIONS: The cingulate gyrus (as part of a midline cortical system) along with right hemisphere regions may be involved in illness and symptom self-appraisal in first-onset psychosis.

Insight, grey matter and cognitive function in first-onset psychosis

BACKGROUND: Several studies have suggested that neuropsychological and structural brain deficits are implicated in poor insight. Few insight studies however have combined neurocognitive and structural neuroanatomical measures. AIMS: Focusing on the ability to relabel psychotic symptoms as pathological, we examined insight, brain structure and neurocognition in first-onset psychosis.METHOD: Voxel-based magnetic resonance imaging data were acquired from 82 individuals with psychosis and 91 controls assessed with a brief neuropsychological test battery. Insight was measured using the Schedule for the Assessment of Insight. RESULTS: The principal analysis showed reduced general neuropsychological function was linked to poor symptom relabelling ability. A subsequent between-psychosis group analysis found those with no symptom relabelling ability had significant global and regional grey matter deficits primarily located at the posterior cingulate gyrus and right precuneus/cuneus. CONCLUSIONS: The cingulate gyrus (as part of a midline cortical system) along with right hemisphere regions may be involved in illness and symptom self-appraisal in first-onset psychosis.

The culture and identity schedule a measure of cultural affiliation: acculturation, marginalization and schizophrenia.

BACKGROUND: Previous epidemiological studies have shown a high incidence of schizophrenia in African-Caribbeans in the UK, but not in Asians. AIMS: We investigated the hypothesis that cultural adherence might protect the Asians against the stress of living in a majority white culture. METHODS: The Culture and Identity Schedule (CANDID) was given to patients with a diagnosis of schizophrenia making their first contact with psychiatric services, and to a matched group of controls randomly selected from the general population. RESULTS: While the Asian patients displayed no drift away from the traditional values as espoused by their controls, the African-Caribbean patients were less traditional than their controls. CONCLUSIONS: The fact that a movement away from their traditional culture distinguishes African-Caribbean patients with a severe psychiatric illness, schizophrenia, from their mentally healthy controls strongly favours marginalization over biculturalism as an interpretation of this shift.