Meta-Analysis of Caregiver-Directed Psychosocial Interventions for Schizophrenia.

With the recent movement toward a personal-recovery paradigm to treat schizophrenia, the locus of mental health care delivery has shifted toward community-based care. Family caregivers comprise a substantial component of that community, and are often providing care for longer periods, but often have no formal training or support. Caregiver-directed psychosocial interventions (CDPI) have been developed to train and assist caregivers in their efforts to maximize the odds of treatment success for those in their care. This meta-analysis compared CDPI versus treatment as usual (TAU) on outcomes such as hospitalization, relapse, non-compliance, and "other outcomes" (emergency services utilization, suicide attempt, and death). A systematic literature search (2005-2015) was conducted to identify randomized controlled trials of outpatient administered CDPI versus TAU to treat adult patients recovering from schizophrenia. Relative risks (RR) with 95% confidence intervals derived via random effects meta-analysis were calculated to compare CDPI versus TAU on the aforementioned outcomes. Eighteen of the 693 citations were retained for analysis. Overall RR for CDPI versus TAU suggested improved outcomes associated with CDPI: hospitalization [0.62 (0.46, 0.84) p < 0.00001], relapse [0.58 (0.47, 0.73) p < 0.00001] and other outcomes [0.70 (0.19, 2.57) p = 0.59]. CDPI was associated with significantly better compliance with medication and clinical activities combined [0.38 (0.19, 0.74) p = 0.005]. Medication compliance alone favored CDPI but was non-significant. Compliance with clinical activities alone favored CDPI significantly [0.22 (0.11, 0.47) p < 0.00001]. CDPI is associated with reductions in hospitalization, relapse, and treatment non-compliance.

Auditory hallucinations: a comparison of beliefs about voices in individuals with schizophrenia and borderline personality disorder.

OBJECTIVE: Individuals with borderline personality disorder (BPD) may experience distressing auditory hallucinations, phenomenologically similar to those seen in psychosis. However, access to effective intervention is limited. The cognitive model of auditory hallucinations highlights the role of appraisals in maintaining distress. Cognitive behavioural therapy (CBT) that targets such beliefs has shown efficacy in psychosis. This study examined appraisals about voices in individuals with psychosis and those with BPD to establish whether CBT for voices might have clinical utility for those with BPD. METHODS: Participants included 45 patients with distressing auditory hallucinations, recruited from the National Health Service. All participants received a structured clinical diagnostic interview and the Beliefs about Voices Questionnaire. Ten participants met criteria for BPD (22%), 23 met criteria for a diagnosis of schizophrenia (51%) and 12 met criteria for both disorders (27%). RESULTS: Multivariate analyses confirmed that there were no group differences in beliefs about the malevolence or omnipotence of voices, or in behavioural resistance or engagement. Those with BPD and those with both diagnoses reported significantly greater emotional resistance than those with schizophrenia. Those with schizophrenia reported significantly greater emotional engagement with their voices. CONCLUSION: Auditory hallucinations in psychosis and BPD do not differ in their phenomenology or cognitive responses (beliefs about the power and malevolence of their dominant voice). The main differential appears to be the affective response. CBT that focuses on appraisals and the relationship with voices may be helpful for distressing auditory hallucinations in individuals with BPD as well as psychosis.

Childhood maltreatment and internalized shame in adults with a diagnosis of bipolar disorder.

UNLABELLED: Relatively little is understood regarding the aetiology of bipolar disorder (BD) other than for the influence of a large genetic component on the development of the disorder and the impact of stressful life events on changes in current mood. However, amongst a range of psychiatric diagnoses, research consistently demonstrates a higher frequency of reports of childhood abuse and neglect compared with individuals in the general population. In addition, those who report experiences of childhood maltreatment also report high levels of internalized shame in adulthood, although there is little research demonstrating this association amongst clinical populations. An adult sample of 35 participants with a diagnosis of BD and a control group of 35 participants with no psychiatric diagnoses completed measures of childhood abuse and neglect, and internalized shame. Participants in the BD group reported a significantly greater frequency of high levels of childhood trauma compared with participants in the control group, with the reported frequency of childhood emotional abuse and neglect being particularly high. Levels of current internalized shame were also significantly higher amongst participants in the BD group. Significant correlations were observed between current internalized shame and reports of childhood emotional abuse and neglect. Clinical implications of the study's findings are discussed, and limitations of the methodology are considered. KEY PRACTITIONER MESSAGE: The frequency of reports of childhood trauma would appear to be higher amongst adults with a diagnosis of BD compared with individuals with no psychiatric diagnoses. Levels of internalized shame in adulthood are also likely to be higher than those in the general population, although the current literature does not shed light on the relationship between childhood abuse and neglect, mood-related behaviour, and shame. Experiences of childhood abuse and neglect, particularly childhood emotional abuse and emotional neglect, are likely to be frequently reported by clients with a diagnosis of BD. Clinicians should therefore explicitly consider these experiences in their assessment, formulation and intervention with clients with a diagnosis of BD.

Metacognition and persecutory delusions: tests of a metacognitive model in a clinical population and comparisons with non-patients.

BACKGROUND. A metacognitive approach to the conceptualization of paranoia as a strategy for managing interpersonal threat has gained some support in studies of non-clinical populations. This study reports a clinical validation of the Beliefs about Paranoia Scale (BaPS), a self-report measure to assess metacognitive beliefs about paranoia. We aimed to replicate the factor structure of a brief version of the measure and test the specific hypotheses that positive beliefs about paranoia would predict levels of suspiciousness, and that negative beliefs about paranoia would predict problematic persecutory delusions. METHOD. A total of 122 patients meeting criteria for a diagnosis of a schizophrenia spectrum disorder completed the questionnaire assessing beliefs about paranoia. In addition, 61 of the participants were administered the Structured Clinical Interview for DSM-IV, and 60 were administered the Positive and Negative Syndromes of Schizophrenia Scale. One hundred and seventy-eight non-patients were also recruited (an undergraduate sample). RESULTS. Principal components factor analysis showed that the three-factor solution was replicated (comprising negative beliefs about paranoia, paranoia as a survival strategy, and normalizing beliefs). This measure showed good internal consistency (alphas ranged from .85 to .91). Correlational analyses revealed that positive beliefs about paranoia were positively associated with levels of suspiciousness, and independent t tests showed that negative beliefs about paranoia were significantly higher in patients with a diagnosis of schizophrenia meeting criteria for persecutory delusions in comparison to those without. Analyses of covariance showed that patients scored higher than non-patients on both positive and negative beliefs, but logistic regression did not demonstrate that co-occurrence of these beliefs predicted patient status. CONCLUSIONS. Three of our four hypotheses were confirmed, suggesting that a metacognitive approach to the conceptualization of paranoia as a strategy for managing interpersonal threat may have some utility for understanding clinical paranoia. Such a model is described and the clinical implications of the findings are also discussed.

Schizophrenia and borderline personality disorder: similarities and differences in the experience of auditory hallucinations, paranoia, and childhood trauma.

This study investigated similarities and differences in the experience of auditory hallucinations, paranoia, and childhood trauma in schizophrenia and borderline personality disorder (BPD). Patients with clinical diagnoses of schizophrenia or BPD were interviewed using the Structured Clinical Interviews for DSM-IV. Axes 1 and 2 and auditory hallucinations, paranoia, and childhood trauma were assessed. A total of 111 patients participated; 59 met criteria for schizophrenia, 33 for BPD, and 19 for both. The groups were similar in their experiences of voices, including the perceived location of them, but they differed in frequency of paranoid delusions. Those with a diagnosis of BPD, including those with schizophrenia comorbidity, reported more childhood trauma, especially emotional abuse. BPD and schizophrenia frequently coexist, and this comorbidity has implications for diagnostic classification and treatment. Levels of reported childhood trauma are especially high in those with a BPD diagnosis, whether they have schizophrenia or not, and this requires assessment and appropriate management.

Mindfulness groups for early psychosis: a qualitative study.

OBJECTIVES: The aim of the study was to explore experiences of practising mindfulness in participants within an early intervention for psychosis (EIP) service. DESIGN: A qualitative research methodology was used - that of grounded theory. This was chosen as it enabled examination of clients' experiences of mindfulness practice. METHODS: The experience of mindfulness among nine people within an EIP service who had been practising mindfulness for at least 20 weeks was investigated. Semi-structured interviews exploring how mindfulness practice related to psychosis and day-to-day life were recorded verbatim, transcribed, and analysed. RESULTS: Four main categories emerged: being able to use mindfulness, making sense of mindfulness and coping, relating to people differently, and increased self-understanding and acceptance. CONCLUSIONS: All participants reported subjective benefits and challenges of mindfulness practice, and gave insights into processes of change. These preliminary data suggest mindfulness can be of use to individuals experiencing their first episode of psychosis.