The use of imagery in cognitive therapy for psychosis: A case example

There has been a long tradition of studying imagery in relation to psychotic symptoms. Recent studies have suggested that imagery may be involved in the development and maintenance of psychotic symptoms (hallucinations and delusions in particular). Following a review of this literature, including work conducted by the author and colleagues, a case study is used to illustrate the clinical applications of this work. Working with images that were associated with persecutory delusions appeared to contribute to a reduction in distress, preoccupation, and conviction in relation to these beliefs, which were assessed using a standardised measure (PSYRATS). The implications for theory, practice, and future research are considered.     

Imagery and psychotic symptoms: a preliminary investigation

Recent cognitive accounts of psychotic symptoms have suggested that processes involved in the maintenance of emotional disorders may also be implicated in the maintenance of hallucinations and delusions, and particularly emphasise the appraisals of such symptoms as important. Imaginal appraisals have been identified in emotional disorders, and many studies have reported spontaneously occurring images in patients with anxiety disorders. Such images appear to be linked to affect, beliefs and memories. This study examined the occurrence of imagery, using a semi-structured interview, in 35 patients who were experiencing hallucinations and/or delusions and receiving cognitive therapy. The majority of patients (74.3%) reported images, and most of these were recurrent and associated with affect, beliefs and memories. Common themes included images about feared catastrophes associated with paranoia, traumatic memories, and images about the perceived source or content of voices. The theoretical and clinical implications of these findings are discussed and directions for further research considered.     

Psychotic symptoms in posttraumatic stress disorder

Recent data suggest that the presence of psychotic symptoms in patients suffering from posttraumatic stress disorder (PTSD) may represent an underrecognized and unique subtype of PTSD. Among combat veterans with PTSD, 30% to 40% report auditory or visual hallucinations and/or delusions. The presence of psychotic symptoms in PTSD is associated with a more severe level of psychopathology, similar to that of chronic schizophrenia. In this review, the differential diagnosis of psychotic symptoms in PTSD is discussed, including possible comorbid schizophrenia, psychotic depression, substance-induced psychosis, and personality disorder. A recent biologic study supporting the existence of a unique subtype of PTSD with psychotic features is also addressed, as are the similarities between PTSD with psychotic features and psychotic depression disorder. Finally, data on the treatment implications of psychotic symptoms in PTSD are presented. The intriguing recent findings on psychotic symptoms in PTSD need further investigation in noncombat-related PTSD populations before findings can be generalized to all individuals with PTSD.     

Metacognitive Therapy Focused on Psychosocial Function in Psychosis

Metacognitive Insight and Reflection Therapy is a manual-based individual psychotherapy aimed at enhancing four metacognitive processes through patient’s personal narratives which may promote recovery by helping individuals suffering from schizophrenia to develop a richer and more integrated sense of self. This study is a single case analysis of the effects of a meta-cognitively oriented CBT on residual psychotic symptoms and functional targets. Outcome measures (PANNS, PDI 21, BAVQ-R, PSP, MAS-A) were collected at two different times: pre-CBT and 1-year. Results showed reductions in the distress, preoccupation and conviction associated with delusions and improvements in metacognitive abilities, social functioning, hopefulness and of the sense of self-confidence to cope with the psychotic symptoms. Adopting a metacognitive perspective during psychotherapy had several benefits: to foster the development of therapeutic alliance, to allow the patient to assess the efficacy and acknowledge the consequences of the different strategies he could use to cope with his symptoms and to question the predominance of his delusions in his life. To conclude, Metacognitive Reflection and Insight Therapy seem particularly adapted to address psychosocial issues, such as social or work functioning.     

Violent behavior in schizophrenic patients: relationship with clinical symptoms

Considerable evidence suggests that violent behavior observed in schizophrenic patients is motivated by psychotic symptomatology. The understanding of violence in schizophrenic patients requires consideration of psychiatric symptomatology. Objective: This study investigated the relationship between violent behavior and psychiatric symptomatology in schizophrenic patients. Method: One hundred and thirteen patients were recruited. Thirteen patients were excluded due to concomitant substance abuse six months prior to the assessment. Diagnoses were based on the SCID‐I. Psychotic symptom severity was assessed with the PANSS. Violent behaviors were assessed with the OAS. Results: Violent behaviors were associated with more severe psychotic symptomatology including hallucinations, delusions, excitement, poor impulse control, and thinking disturbances. Conclusions: Patients with exacerbation of psychotic symptomatology have an increased risk of violent behavior. It is necessary to determine which subtypes of hallucinations and delusions are implicated in the association of schizophrenia and violent behavior. Violent behavior in schizophrenic patients is a heterogeneous phenomenon best explained in the context of specific symptoms associated with violence and course of illness. The retrospective assessment of the variables raises methodological questions concerning the reliability of measurement of the impact of psychotic symptoms on violence. Aggr. Behav. 00:1–10, 2005. © 2005 Wiley‐Liss, Inc.     

Emotional Abuse and Psychosis: A Recent Review of the Literature

This article evaluates the published empirical findings on childhood emotional abuse and its proposed relationship with psychotic symptoms. Research and governmental policy indicates that emotional abuse is present in all forms of abuse and neglect, suggesting it is the form of abuse most frequently linked to mental health problems. Literature searches were conducted in 3 peer-reviewed electronic databases and relevant papers were reviewed. Results suggest childhood emotional abuse is statistically related to psychosis in adulthood. This adds tentative support to the hypothesis that emotional abuse is related to psychotic experiences; in particular to hallucinations and persecutory delusions. A number of studies also provide tentative support to the dose–response effect proposed between cumulative trauma and a greater risk of positive psychotic symptoms.     

Acting on persecutory delusions: the importance of safety seeking

OBJECTIVE: Acting on delusions is a significant clinical issue. The concept of safety behaviours--actions carried out with the intention of reducing perceived threat--provides a new way of understanding acting on delusions. A study was conducted with the aim of examining the prevalence and correlates of safety behaviours related to persecutory delusions. METHOD: One hundred patients with persecutory delusions were assessed for safety behaviours, acting on delusions, anxiety, depression, and psychotic symptoms. Case note data were collected on instances of serious violence or suicide attempts. RESULTS: Ninety-six patients had used safety behaviours in the last month. Greater use of safety behaviours was associated with higher levels of distress. A history of violence or suicide attempts was associated with greater use of safety behaviours. Safety behaviours were significantly associated with acting on delusions, but not with the negative symptoms of psychosis. CONCLUSION: Safety behaviours are a common form of acting on persecutory delusions. These behaviours have the consequence that they are likely to prevent the processing of disconfirmatory evidence and will therefore contribute to delusion persistence.     

Delusions and decision-making style: use of the Need for Closure Scale

Clinicians and researchers have suggested that rapidity in belief formation, due to having a high 'need for closure' (NFC), may contribute to the acceptance of delusional explanations. The aim of the study is to determine whether NFC has such a direct link with delusions. A secondary aim is to examine if NFC is related to the delusion-associated reasoning process of 'jumping to conclusions'. One hundred and eighty-seven patients with psychosis, recruited for a treatment trial of psychological therapy (the PRP trial), completed the Need for Closure Scale (NFCS), symptom measures, and probabilistic reasoning tasks. The NFCS was considered in terms of its two dimensions: a desire for simple structure and a preference for quick, decisive answers. The individuals with psychosis reported being poor at making quick, decisive answers but required a greater need for simple structure. NFC was associated with levels of anxiety and depression. There were weak links between NFC and both positive and negative symptoms of psychosis, but these were explained by differences in affect. NFCS scores were unrelated to jumping to conclusions. Contrary to the argument that NFC is directly linked to delusions, individuals with delusions actually perceive themselves as indecisive. There was no evidence that NFC-at least as assessed by the NFCS-could be a proximal cause of delusions. Any potential effect on psychotic symptom presentation is indirect, mediated through affect. The use of the NFCS on its own in the study of psychotic symptoms cannot be recommended.     

Is Fear of Others Linked to an Uncertain Sense of Self? The Relevance of Self-Worth, Interpersonal Self-Concepts, and Dysfunctional Beliefs to Paranoia

The assumption that a low sense of self-worth can give rise to paranoid delusions is relevant from a therapeutic perspective, but research has been inconsistent. The present study sought to investigate how interpersonal self-concepts and global self-worth relate to psychotic and depressive psychopathology in persons with psychosis. Participants with psychosis (n = 83) and healthy controls (n = 33) were assessed for global self-worth, interpersonal self-concepts, and dysfunctional beliefs using the Frankfurt Self-Concept Scale and the Dysfunctional Attitude Scale. Symptoms were assessed with the Positive and Negative Syndrome Scale, the Peters et al. Delusions Inventory, the Paranoia Checklist, and the Beck Depression Inventory. We hypothesized that perceived threat to self-worth, as expressed in dysfunctional acceptance beliefs and negative interpersonal self-concepts, would be uniquely associated with persecutory delusions. In contrast, low global self-worth would be strongly associated with symptoms of depression. Multiple regression analyses were used to investigate the association between symptoms and self-concepts. As expected, low global self-worth was associated with depression, whereas the more specific perception of not being accepted by relevant others was most clearly related to psychotic symptoms. Almost half of the variance in paranoia scores was explained by negative interpersonal self-concepts and the interaction between negative interpersonal self-concepts and dysfunctional acceptance beliefs. Thus, cognitive interventions for delusions might be improved by focusing more on interpersonal self-concepts.     

Connecting neurosis and psychosis: the direct influence of emotion on delusions and hallucinations

Diagnostic classification systems contain a core divide between neurosis and psychosis, leading to their separate study and treatment. The basis for the separation of the disorders is outlined and reassessed. It is argued that the empirical evidence does not support such a sharp distinction between neurosis and psychosis. The frequent occurrence of emotional disorder prior to and accompanying psychosis indicates that neurosis contributes to the development of the positive symptoms of psychosis. Psychological theories and experimental evidence concerning the influence of emotion on the content and form of delusions and hallucinations are therefore reviewed. It is argued that in many cases delusions are a direct representation of emotional concerns, and that emotion contributes to delusion formation and maintenance. The content of hallucinations less often directly expresses the emotional concerns of the individual, but emotion can trigger and contribute to the maintenance of hallucinatory phenomena, although how this occurs is not well understood. It is concluded that study needs to be made of the interaction between psychotic and neurotic processes in the development of delusions and hallucinations, and that neurotic and psychotic disorders may have common maintenance processes.     

Psychometric evaluation of the Dutch Persecutory Ideation Questionnaire (PIQ) and its relation to aggression

Patients with schizophrenia and a violent past more often have persecutory delusions than other types of delusions. The main aim of the present study was to examine the relation between persecutory ideation and self-reported aggression in a community based and clinical population. A second aim was to evaluate the psychometric properties of the Dutch version of the Persecutory Ideation Questionnaire (PIQ; McKay, Langdon, & Coltheart, 2006). From the general population, 269 persons were included as well as 79 inpatients from different psychiatric facilities. In the community based sample, the PIQ appeared to be a reliable and valid instrument to measure persecutory ideation. Evaluation of the PIQ in a sample with patients with a psychotic disorder showed that the PIQ had good criterion validity. In addition, results showed that persecutory ideation was significantly related to self-reported aggression in the community based, and in the clinical sample. Moreover, in the community based sample, this association was higher than that between positive psychopathological experiences in general and aggression in the community based sample. In sum, persecutory ideation can be measured reliably with the PIQ, and there seems a robust relation between persecutory ideation in particular and aggression in both clinical and community based samples.     

The relationship between cognitive inhibition and psychotic symptoms

Cognitive models of schizophrenia have highlighted deficits of inhibitory attentional processes as central to the disorder. This has been investigated using "negative priming" (S. P. Tipper, 1985), with schizophrenia patients showing a reduction of negative priming in a number of studies. This study attempted to replicate these findings, but studied psychotic symptoms rather than the broad diagnostic category of schizophrenia. Psychotic individuals exhibiting positive symptoms were compared with asymptomatic psychiatric patients and with a normal control group. As predicted, the symptomatic group failed to show the usual negative priming effect, which was present in the asymptomatic and normal groups. A modest but significant correlation was found between negative priming and delusions. Neither diagnosis, nor affective or negative symptoms, nor chronicity, nor medication, was related to negative priming. These data replicate previous findings that positive symptoms are related to a reduction in cognitive inhibition, although considerable variability was observed among the psychotic patients.     

Effects of cultural themes in psychotic symptoms on the diagnosis of schizophrenia in African Americans

Cultural themes focusing on race-related issues and religiosity were identified via content analysis in the delusions and hallucinations of a sample of 118 African American psychiatric patients. The purpose of the study was to determine whether cultural themes in psychotic symptoms influence the diagnosis from different sources (i.e., chart, SCID, and best estimate) of schizophrenia for Black patients. It was hypothesized that the best estimate diagnoses of cultural experts would diagnose schizophrenia in African Americans more frequently when they exhibit race-related themes in their psychotic symptoms. It was also hypothesized that diagnosis of the paranoid subtype would yield a stronger difference among the sources than the broader category of schizophrenia. The results did not support the hypotheses. Implications for understanding the relationship between culture and psychosis among African Americans are discussed.     

Does Symptom Type Moderate the Relationship Between Insight and Outcome in Cognitive Behavioral Therapy for Psychosis? A Preliminary Investigation

Insight has emerged as a potential predictor variable in cognitive behavioral therapy for psychosis (CBTp). However, previous research has produced mixed results. The present study aimed to clarify whether symptom type is a moderating variable. A group of psychotic patients (n = 44) were assessed through pre- and post-treatment in a CBTp specialty track in a partial hospital-based program in the USA. The Insight Scale was used to measure insight, and psychotic symptomatology was assessed using the Mini-International Neuropsychiatric Interview and the Behavior and Symptom Identification Scale. Patients showed a significant decrease in psychotic symptom scores over the course of treatment [t(43) = 3.59, p < .001, Cohen's d = .64]. Furthermore, illness awareness was specifically associated with a decrease in psychotic symptoms for patients who endorsed visual hallucinations (r = ? .68, p < .01), auditory hallucinations (r = ? .49, p = .01), and/or ideas of reference (r = ? .66, p < .01). Insight did not confer additional benefit for patients with paranoid delusions, mind reading, or thought insertion symptoms. These results are discussed in relation to treatment implications within the current US health care delivery system.     

Treating PTSD in Patients With Psychosis: A Within-Group Controlled Feasibility Study Examining the Efficacy and Safety of Evidence-Based PE and EMDR Protocols

The present study uses a within-group controlled design to examine the efficacy and safety of two psychological approaches to posttraumatic stress disorder (PTSD) in 10 patients with a concurrent psychotic disorder. Patients were randomly assigned either to prolonged exposure (PE; N = 5) or eye movement desensitization and reprocessing (EMDR; N = 5). Before, during, and after treatment, a total of 20 weekly assessments of PTSD symptoms, hallucinations, and delusions were carried out. Twelve weekly assessments of adverse events took place during the treatment phase. PTSD diagnosis, level of social functioning, psychosis-prone thinking, and general psychopathology were assessed pretreatment, posttreatment, and at three-month follow-up. Throughout the treatment, adverse events were monitored at each session. An intention-to-treat analysis of the 10 patients starting treatment showed that the PTSD treatment protocols of PE and EMDR significantly reduced PTSD symptom severity; PE and EMDR were equally effective and safe. Eight of the 10 patients completed the full intervention period. Seven of the 10 patients (70%) no longer met the diagnostic criteria for PTSD at follow-up. No serious adverse events occurred, nor did patients show any worsening of hallucinations, delusions, psychosis proneness, general psychopathology, or social functioning. The results of this feasibility trial suggest that PTSD patients with comorbid psychotic disorders benefit from trauma-focused treatment approaches such as PE and EMDR.     

Delusional disorder and delusions: is there a risk of violence in social interactions about the core symptom?

Delusional disorders are rare, but psychoses with prominent and persistent delusions are less so. A small but significant association between psychosis and violence is often mediated by delusions in such illnesses. Traditionally, delusions have been viewed as “incorrigible”, but there is evidence that they change over time. During development of a scale for measuring delusions, it was found that people who acted violently on their “most important” delusion were more likely to have modified that belief after a mild form of challenge to it. When cognitive–behaviour therapy (CBT) is used for schizophrenia, attempts to modify psychotic symptoms are generally included. Could studies of CBT provide further information about possible risks of social interactions about delusions? In the UK, 2000 people with schizophrenia have been in randomized controlled trials of CBT with a goal of symptom modification. These studies were examined for evidence of violence during the treatment. There was none. Given the period prevalence of violence among people with psychosis, this is surprising. In these studies, however, both challenge to delusions and change in them was minimal and in the context of a safe clinical relationship. Challenge to delusions may, however, occur in a variety of social situations. There are no systematic data on lay challenge to them, but it seems likely that some in the sufferer's social circle will do so vigorously. Relatives, friends, and acquaintances are the people most vulnerable to the most serious violence by someone with psychosis. Study of how people interact in these circumstances and whether their interactions are relevant to modification of delusions would be worthwhile. Could those close to a sufferer learn skills for responding to such pathological beliefs that could be protective against violence, perhaps derived from the principles of CBT?. Copyright © 2006 John Wiley & Sons, Ltd.     

Psychotic manifestations in a patient with mental retardation and a 6.2 megabase deletion at the distal short arm of chromosome 12

Genetic factors are known to contribute to the development of schizophrenia and related psychoses. Cytogenetic abnormalities have been occasionally found in patients with psychotic disorders and, thus, have helped identify candidate gene contributors for these conditions. The individual described here first presented with mental retardation and anxiety disorder in his mid-childhood. In his early 20s, the patient started exhibiting various psychotic manifestations, including delusions and hallucinations. His psychotic symptoms were difficult to control with psychotropic medications. The family history was negative for psychiatric disorders. This patient was found to have a 6.2 megabase deletion of the terminal portion of the short arm of chromosome 12 that was characterized using fluorescence in situ hybridization and microarray comparative genomic hybridization analysis. The maternal chromosomes were normal, but the paternal chromosomes could not be tested. To-date such a chromosomal abnormality has not been described in association with schizophrenia/psychosis. This case suggests that psychosis-associated gene(s) may be located in the terminal region of the short arm of chromosome 12.