Appraisals, psychotic symptoms and affect in daily life, and changes during CBT
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Appraisals, psychotic symptoms and affect
in daily life, and changes during CBT
Emmanuelle PetersKing’s College London, Institute of Psychiatry
U.K.
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• Inez Myin-Germeys (University of Maastricht)
• Tineke Lataster (University of Maastricht)
• Sally Williams • Kathryn Greenwood (Sussex Trust Partnership)
• Elizabeth Kuipers • Jan Scott (Newcastle University)
• Philippa Garety
Collaborators
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BackgroundBackground
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•Symptom dimensions
What should we be measuring as outcomes of
CBT?
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DelusionsDelusionsConvictionConviction
PreoccupationPreoccupation
DistressDistressImpact on Impact on functioningfunctioning
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VoicesVoicesBeliefsBeliefs
DistressDistress
Impact on Impact on functioningfunctioning
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•Symptom dimensions
•Appraisals
What should we be measuring as outcomes of
CBT?
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A Cognitive Model of the Positive Symptoms of Psychosis (Garety et al
01; 07)
Maintaining factors• reasoning & attributions• dysfunctional schemas• emotional processes• appraisal of psychosis
Bio-psycho-social
vulnerability
Trigger Emotional changes
Basic cognitive dysfunction Anomalous experience
Positive Symptoms
Appraisal of
experience
Appraisal influenced by:• reasoning & attributional biases• dysfunctional schemas
of self & world• isolation & adverse
environments Garety
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•Symptom dimensions
•Appraisals
•On-line measurement
What should we be measuring as outcomes of
CBT?
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MethodsMethods
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10 times a day 6 consecutive days at random moments
Delespaul, 1995;
Myin-Germeys et al (2001) Arch Gen Psychiat;
Oorschot et al (2009) Psychol Assessment
1. Multiple assessments
2. Real world, no lab
3. In the moment, not retrospective
4. Evaluation of the context
The Experience Sampling Method
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ESM ESM bookletbookletPositive Positive
& & negative negative affectaffect
PsychoticPsychotic
SymptomsSymptoms
SpontaneousSpontaneous
thoughtsthoughts
AppraisalsAppraisals
SymptomSymptom
DistressDistress
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•Spontaneous thoughts (“What was I thinking just before the beep went off?) Content coded for presence of pathology
•Affect (positive & negative)
•Characteristics of key symptoms:• Hallucinations: intensity, distress, interference
• Delusions: intensity, conviction, distress, interference, preoccupation
Variables assessed in ESM booklet
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•Appraisals:• Hallucinations only: control (“my voices are out
of my control”) & power (“my voices are powerful”)
• Hallucinations and delusions: ‘decentring’ (“my problem is due to the way
my mind works”) insight (“my problem is due to an illness”)
•Activity
•Coping
Variables assessed in ESM booklet
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1. What was I thinking just before the beep went off? ................................................................................................................................................................................................
2. I feel...Not at all Moderate Very
happy 1 2 3 4 5 6 7 low 1 2 3 4 5 6 7 guilty 1 2 3 4 5 6 7• ashamed 1 2 3 4 5 6 7 in a good mood 1 2 3 4 5 6 7 anxious 1 2 3 4 5 6 7 annoyed 1 2 3 4 5 6 7 scared 1 2 3 4 5 6 7 relaxed 1 2 3 4 5 6 7
3. My first problem (hallucinations, elicited at initial interview) ...................................................................................................... is .... present 1 2 3 4 5 6 7 upsetting me 1 2 3 4 5 6 7 interfering with what I am doing 1 2 3 4 5 6 7 out of my control 1 2 3 4 5 6 7 powerful 1 2 3 4 5 6 7
4. Right now I believe this problem is to do with.... the way my mind works 1 2 3 4 5 6 7 an illness 1 2 3 4 5 6 7• due to X 1 2 3 4 5 6 7
5. My second problem. (delusions, elicited at initisl interview) .................................................................................................. is.....• present 1 2 3 4 5 6 7 I believe is true 1 2 3 4 5 6 7 upsetting me 1 2 3 4 5 6 7 interfering with what I am doing 1 2 3 4 5 6 7 going round and round 1 2 3 4 5 6 7 in my mind
6. Right now I believe this problem is to do with....• the way my mind works 1 2 3 4 5 6 7• an illness 1 2 3 4 5 6 7• due to X 1 2 3 4 5 6 7
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7. Where am I?.................................................................................................................................................................................................
8. I am on my own yes/no
Not at all Moderate Very much
If no, I am with people that I like 1 2 3 4 5 6 7
9. What am I doing..........................................................................................................................................................................................Not at all Moderate Very
This is pleasant -3 -2 -1 0 +1 +2 +3This is difficult -3 -2 -1 0 +1 +2 +3
10. Since the last beep, Never Some All my problems were present 1 2 3 4 5 6 7
IF PROBLEMS NOT PRESENT (score = 1), GO STRAIGHT TO END11. When my problems happened.......
• I pushed them to the back of my mind yes/no• I shouted back yes/no• I did something else yes/no• I prayed yes/no• I went to bed yes/no• I reassured myself yes/no• I thought about it differently yes/no• I isolated myself yes/no• I checked it out yes/no• I talked to someone yes/no• I just let it wash over me until it was over yes/no• I took some medication yes/no• I took some alcohol/streetdrugs yes/no• Other (please specify).....................................................................................................................................................................
Not at all Moderate Very12. The beep disturbed me 1 2 3 4 5 6 7It is now exactly: .......hrs.......min
Write down the nicest thing that has happened since the last beep:............................................................................................................................
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DesignDesign
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1. Baseline 1. Baseline (at referral stage)(at referral stage)
2. Pre-therapy2. Pre-therapy(after 3-6 months on waiting list)(after 3-6 months on waiting list)
3. Mid-therapy3. Mid-therapy(3 months into therapy)(3 months into therapy)
4. End of therapy4. End of therapy(after 6-8 months of therapy) (after 6-8 months of therapy)
5. Follow-up5. Follow-up(3 months post-therapy)(3 months post-therapy)
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Results - baselineResults - baseline
Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych MedPeters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
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Baseline N= 12Baseline N= 12(attending outpatients clinic for CBT for psychosis;(attending outpatients clinic for CBT for psychosis;
9 with hallucinations9 with hallucinations9 with delusions)9 with delusions)
Average observations Average observations per person = 44.5per person = 44.5
Total observations Total observations = 534 = 534
Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych MedPeters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
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Presence Presence of of
symptomsymptomss
Psychosis related:Psychosis related:3.6% (range: 0-18)3.6% (range: 0-18)
Anxiety & depression:Anxiety & depression:4.7% (range: 0-26)4.7% (range: 0-26)
Non-pathological:Non-pathological:73.7%73.7%
Hallucinations:Hallucinations:73% of observations73% of observations
Delusions:Delusions:67% of observations 67% of observations
Spontaneous thoughts
Key identified symptoms
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Symptom dimensions & Symptom dimensions & appraisalsappraisals
Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych MedPeters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
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Hallucinations characteristics
NB: includes only scores > 1 on “hallucinations present”
Mean (SD) (N = 9)
Standardised ß (N = 299) * = p < .001 (Multi-level linear regressions)
Potential range of scores = 2-7 1 2 3 4
1. Intensity 4.0 (1.5) 1.02. Distress 2.9 (0.7) .62
*1.0
3. Interference
2.3 (0.9) .61*
.89* 1.0
4. Control 3.0 (1.6) .89*
1.22*
.82* 1.0
5. Powerful 2.8 (1.0) .63*
.83* .72* .24*Intensity of voices, distress, interference, control and power are all related to each
other
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Delusions characteristicsMean (SD) (N = 9)
Standardised ß (N = 399) * = p < .001
Potential range of scores = 1-7 1 2 3 4
1. Intensity 3.5 (2.2) 1.02. Conviction 3.5 (2.4) .82
*1.0
3. Distress 3.2 (1.8) .57*
.19*
1.0
4. Interference 2.5 (1.8) .53*
.24*
.72*
1.0
5. Preoccupation
3.7 (1.6) .55*
.26*
.69*
. 62*
Intensity of delusions, distress, interference, & preoccupation are all related to each other, but
lower effect sizes with conviction
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Are symptom appraisals constant? Difference between two
subsequent observationsMean (SD) T-test (df) p
HALLUCINATIONS
1. Control 0.62 (.5) 3.8 (8) .003
2. Power 0.77 (.5) 4.7 (8) .001
3. Decentring 0.72 (.7) 2.9 (8) .009
4. Insight 0.52 (.8) 2.0 (8) .04
DELUSIONS
1. Conviction 0.43 (.4) 3.5 (8) .004
2. Decentring 0.34 (.4) 2.3 (8) .02
3. Insight 0.38 (.6) 2.0 (8) .04
Voice appraisals all highly variable
Delusion appraisals also variable
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Relationships between Relationships between symptoms, appraisals & symptoms, appraisals &
affectaffect
Peters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych MedPeters et al (In Press) Appraisals, psychotic symptoms & affect in daily life, Psych Med
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Dependent variables(Multi-level linear regressions)
Voice intensity ratings (ß)
Delusions intensity ratings (ß)
Psychotic thought content (ß)
1. Negative affect
.30* .68* .31*
2. Positive affect
-.19* -.38* -.46*
* = p < .001
Is affect related to symptoms?
Intensity of symptoms and psychotic thoughts are highly related to both negative and less
positive affect
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Dependent variables(Multi-level linear regressions)
Voice intensity ratings (range 2-7) (ß)
Power appraisals (ß)
Control appraisals (ß)
1. Negative affect
.07 .22* .05
2. Symptom distress
.62* .36* .35*
Are voice appraisals related to distress?
* = p < .001
Power appraisals are the only variable related to negative affect;
Power, control and intensity all related to symptom distress
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Dependent variables
Negative affect (ß)
Distress (ß)
Interference (ß)
Preoccupation (ß)
HALLUCINATIONS
* p <.001
1. Decentring -.12 -.21 -.30* /
2. Insight .12 .11 .14 /
DELUSIONS
1. Decentring -.29* -.32* -.44* -.45*
2. Insight .009 .01 -.03 .07
Is insight related to distress?
Decentring appraisals for delusions are related to less distress/negative affect/preoccupation and disruption to functioning, and to less interference for hallucinations. Insight is not related to distress or functioning for either
symptom
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Conclusions - baselineConclusions - baseline
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1)Despite psychotic symptoms being present a majority of the time, people are not engulfed by their symptoms
2)Intensity and presence of psychosis-related thoughts lead to more distress, less positive affect, and interference with functioning
3)Delusional conviction is potentially a separate dimension, and is not stable; nor are appraisals about symptoms (control & power of voices; ‘decentring’ & insight)
4)Power appraisals are a central factor related to negative affect
5)‘Decentring’ from your delusions is related to less distress and disruption to functioning; in contrast, traditional insight does not influence distress
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Results – longitudinal dataResults – longitudinal data
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N= 12N= 12(7 provided data on at least 2 time points;(7 provided data on at least 2 time points;
6 with hallucinations; 7 with delusions6 with hallucinations; 7 with delusions5 provided data at each time point)5 provided data at each time point)
Average observations Average observations per person = 106per person = 106
Total observations Total observations = 1273 = 1273
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HallucinationsHallucinations
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Hallucinations: Intensity
*
* = p <.01
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Hallucinations: Distress (when hallucinations present only)
*
* = p <.01
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Hallucinations: Interference (when hallucinations present only)
*
* = p <.01
**
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Hallucinations: Control (when hallucinations present only)
*
* = p <.01
**
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Hallucinations: Power (when hallucinations present only)
*
* = p <.01
**
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Hallucinations: Decentring (when hallucinations present only)
*
* = p <.01
*
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Hallucinations: Insight (when hallucinations present only)
*
* = p <.01
**
*
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DelusionsDelusions
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Delusions: Intensity
***
* = p <.01
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Delusions: Conviction (when delusions present only)
*
*
* = p <.01
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Delusions: Distress (when delusions present only)
*
*
*
* = p <.01
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Delusions: Interference (when delusions present only)
*
*
*
* = p <.01
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Delusions: Preoccupation (when delusions present only)
***
* = p <.01
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Delusions: Insight (when delusions present only)
*
* = p <.01
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Delusions: Decentring (when delusions present only)
*
* = p <.01
**
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AffectAffect
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Negative affect
*
* = p <.01
*
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-2
-1.5
-1
-0.5
0
0.5
1
Pre-therapy Mid-therapy End of therapy Follow-up
Effect sizes (compared to baseline)
Positive affect
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Conclusions – longitudinal Conclusions – longitudinal datadata
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1)For hallucinations, significant changes were demonstrated from mid-therapy, and maintained at follow-up, in:
• Interference
• Controllability
• Insight
• (power beliefs)
• (decentring)2)Changes in intensity of voices and voice-
related distress not as robust
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4)For delusions, significant changes were demonstrated from mid-therapy, which were maintained at follow-up, in:
• Intensity
• Distress
• Interference
• Preoccupation 5)Changes in conviction and insight not as
robust, decentring got worse (?)6)Negative affect, but not positive affect, was
affected by therapy
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Future researchFuture research
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1)ESM is powerful methodology to demonstrate subtle changes in people’s daily lives
2)Ecological validity ++3)Intensive methodology – not easily
transferred to the clinic?4)Good for looking at relationships amongst
different variables5)Good for looking at timeline of changes6)Good for looking at causal mechanisms
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THE END