Early intervention in psychosis services: A systematic review and narrative synthesis of barriers and facilitators to seeking access.

BACKGROUND: The duration of untreated psychosis (DUP) continues to be a global priority. Early intervention services were established to reduce treatment delays but have had limited impact. This systematic review examines barriers and facilitators to seeking access to these services, to identify targets for service level change. METHODS: We conducted a systematic review of relevant databases (PsychINFO, MEDLINE, CINAHL, and PsychARTICLES) using pre-defined search terms for psychosis, early intervention, and barriers and facilitators. Given the majority of qualitative studies, a thematic synthesis rather than meta-analysis was indicated. RESULTS: The search yielded 10 studies. Mental health stigma and discrimination predict DUP, compounded by structural barriers which limit the impact of early intervention services on timely access to recommended treatments. Synthesis of the qualitative studies generated three themes: knowledge, relationships, and stigma. Lack of knowledge, absence of supportive relationships (social and professional), and self-stigma constitute significant barriers to seeking access to early intervention services. CONCLUSIONS: This is the first review of the barriers and facilitators to seeking access to early intervention services. The findings highlight public health and secondary care service targets to expedite access to recommended treatments and thereby reduce the DUP.

Validity of a Revised Obsessive-Compulsive Personality Disorder (OCPD) Trait Profile and Its Relationship with Social Interaction Anxiety and Coping.

There is evidence suggesting that the conceptualization and operationalization of Obsessive-Compulsive Personality Disorder (OCPD) is not satisfactory (Watters et al., 2019). In this study, we used an online sample (N = 1008) to investigate the construct validity of the PID-5 OCPD trait measure. Regression analyses supported our hypothesis that rigid perfectionism captured the core phenomenology of OCPD whereas restricted affectivity and intimacy avoidance were not conceptually related to the OCPD construct. Based on the biosocial theory for overcontrol (Lynch, 2018), we introduced anxiousness and workaholism to the PID-5 OCPD trait profile. In establishing the validity of the revised OCPD trait profile, we investigated, for the first time, the role of social interaction anxiety and maladaptive coping in OCPD. Our revised OCPD profile showed good validity and was characterized by marked social interaction anxiety and dysfunctional coping mechanisms. The findings may lead to a new conceptualization of OCPD which prioritizes deficits in social interaction and coping. We identify areas that need to be prioritized in the evaluation of OCPD by mental health professionals and offer avenues for new clinical research in the field.

Pathways from insecure attachment to paranoia: the mediating role of emotion regulation.

BACKGROUND: Paranoia is common across the clinical and non-clinical spectrum. Cognitive behavioural therapy for psychosis currently yields modest results, warranting research into symptom-specific maintenance factors to improve outcomes. There is strong evidence of a relationship between insecure attachment and increased paranoia, but little is known about the mediating mechanisms. Emotion dysregulation is associated with both insecure attachment and paranoia, and a candidate causal mechanism. AIMS: This study aimed to determine if emotion dysregulation mediates the association between attachment and paranoia. METHOD: Sixty-two individuals with elevated paranoia were recruited from NHS services and community settings across the South of England. Mediation analyses were conducted on trait attachment, emotion regulation and paranoia variables, which were collected at one time point. RESULTS: As predicted, emotion dysregulation mediated the relationship between attachment avoidance and paranoia, and between attachment anxiety and paranoia. Emotion suppression did not mediate the relationship between attachment avoidance and paranoia, possibly due to power. Attachment avoidance correlated with deactivating emotion regulation strategies (e.g. lack of emotional awareness) and attachment anxiety correlated with hyperactivating emotion regulation strategies (e.g. impulse control difficulties). Both deactivating and hyperactivating strategies correlated with paranoia. CONCLUSION: Emotion dysregulation is not routinely targeted in cognitive behavioural therapy for psychosis. This study suggests that incorporating emotion regulation strategies in therapy may improve clinical outcomes. Experimental studies are now required to support a causal argument, and pilot intervention studies should investigate if emotion regulation skills development (aligned with attachment style) is effective in reducing non-clinical and clinical paranoia.

How does attachment style affect psychosis? A systematic review of causal mechanisms and guide to future inquiry.

PURPOSE: The link between attachment and psychosis is now well established, but less is known about the causal mechanisms underlying this relationship. This systematic review synthesises the studies that examine mediating mechanisms in the attachment and psychosis relationship, in both clinical and non-clinical samples. METHOD: We conducted a database search (PsychINFO, MEDLINE, Web of Science) to identify all eligible studies irrespective of publication status, the language of article or article date. We assessed methodological quality and completed a narrative synthesis given the heterogeneity of studies to date. RESULTS: We identified 17 papers, comprising 3,672 participants. The relationship between attachment and psychosis is mediated by four variables or groups of variables. There is good evidence for the causal role of affective factors (affective dysregulation and affective disturbances) and cognitive factors (e.g., self-beliefs and self-esteem and beliefs about symptoms). Affective factors differed by attachment style. Tentative evidence was found for the role of duration of untreated psychosis and baseline negative symptoms. CONCLUSIONS: Cognitive and affective factors mediate the relationship between attachment style and psychosis. Whilst cognitive factors are routinely targeted in recommended psychological interventions for psychosis, affective factors and attachment style are less commonly considered. Psychological therapies may be improved by calibrating cognitive and affective interventions by attachment style, which should be subjected to experimental and then field studies to assess the impact on clinical and recovery outcomes. PRACTITIONER POINTS: The relationship between attachment and psychosis is now well established, and studies have started to examine mediating mechanisms. Affective and cognitive factors mediate the attachment-psychosis relationship. Affective factors differ by attachment style. There is limited evidence for the duration of untreated psychosis and negative psychotic symptoms as mediating mechanisms, and research replication is needed. Cognitive factors are routinely targeted in recommended psychological therapies for psychosis, but affective factors and attachment style are less commonly considered. Research should be conducted into the effectiveness of psychological therapies which calibrate cognitive and affective interventions, according to attachment style.

Targeting affect leads to reduced paranoia in people with psychosis: a single case series.

BACKGROUND: Current psychological interventions for psychosis focus primarily on cognitive and behavioural management of delusions and hallucinations, with modest outcomes. Emotions are not usually targeted directly, despite evidence that people with psychosis have difficulty identifying, accepting and modifying affective states. AIMS: This study assessed the impact of emotion regulation skills practice on affect and paranoia in seven people who met criteria for a diagnosis of schizophrenia or schizoaffective disorder. METHOD: The study utilised a single case ABA design and measured emotion regulation skills, affect and paranoia over baseline, intervention and withdrawal of intervention phases. We predicted that eight sessions of skills rehearsal would lead to improved emotion regulation, reduced negative affect, increased positive affect, and reduced paranoia. RESULTS: Most participants were able to learn to regulate their emotions, and reported reduced negative affect and paranoia. There was no clear pattern of change for positive affect. CONCLUSIONS: These findings suggest that emotion can be targeted in psychosis, and is associated with reduced paranoia. Emotion regulation may constitute a key treatment target in cognitive behavioural therapy for psychosis.

Impact of attachment imagery on paranoia and mood: evidence from two single case studies.

BACKGROUND: Cognitive behavioural therapy (CBT) for psychosis currently yields modest outcomes and must be improved. Attachment imagery may be an effective means of reducing severity of paranoid beliefs and associated affect. Experimental studies have demonstrated these effects in non-clinical groups. The impact in clinical populations remains untested. AIMS: This study assessed the impact of a brief attachment imagery task on paranoia and mood, in two people with a diagnosis of schizophrenia. METHOD: Two single case studies are presented. Both participants were working age adults with persecutory delusions. The study utilised an A-B-A design. Participants were recruited for a 6-week period, with a 2- and 3-week baseline respectively, 1-week intervention phase, and follow-up phase matched to duration of baseline. Trait paranoia and attachment were measured at the start of the baseline. State paranoia and affect were measured daily over the 6-week period. RESULTS: For both participants, the baseline phase was characterised by high and variable levels of paranoia, which reduced during the intervention phase, with a return to baseline scores at follow-up. We found a similar pattern for negative affect, and the reverse pattern for positive affect. CONCLUSIONS: Attachment imagery may function as an effective emotion regulation strategy for people with psychosis. Continued use is likely to be needed to maintain gains. This brief task could prove valuable to people needing skills to manage paranoia and mood, and give clinicians confidence that people can manage short-term distress in CBT for psychosis, for example when addressing past trauma.

What is the Lived Experience of Being Discharged From a Psychiatric Inpatient Stay?

Psychiatric patients encounter many difficulties post-discharge reflected by quantitative data such as high suicide rates within the first 3 months. However, little is known about why discharge is so difficult. This article aimed to understand the lived experience of being discharged from a psychiatric unit. Eight participants were interviewed to explore their experiences of discharge. Interpretative phenomenological analysis was used to analyse data. Four superordinate themes emerged: leaving hospital; the outside world; the journey to health; and self-identity/beliefs. Clinical implications and suggestions for further research are discussed.