Effective elements of cognitive behaviour therapy for psychosis: results of a novel type of subgroup analysis based on principal stratification

Background. Meta-analyses show that cognitive behaviour therapy for psychosis (CBT-P) improves distressing positive symptoms. However, it is a complex intervention involving a range of techniques. No previous study has assessed the delivery of the different elements of treatment and their effect on outcome. Our aim was to assess the differential effect of type of treatment delivered on the effectiveness of CBT-P, using novel statistical methodology. Method. The Psychological Prevention of Relapse in Psychosis (PRP) trial was a multi-centre randomized controlled trial (RCT) that compared CBT-P with treatment as usual (TAU). Therapy was manualized, and detailed evaluations of therapy delivery and client engagement were made. Follow-up assessments were made at 12 and 24 months. In a planned analysis, we applied principal stratification (involving structural equation modelling with finite mixtures) to estimate intention-to-treat (ITT) effects for subgroups of participants, defined by qualitative and quantitative differences in receipt of therapy, while maintaining the constraints of randomization. Results. Consistent delivery of full therapy, including specific cognitive and behavioural techniques, was associated with clinically and statistically significant increases in months in remission, and decreases in psychotic and affective symptoms. Delivery of partial therapy involving engagement and assessment was not effective. Conclusions. Our analyses suggest that CBT-P is of significant benefit on multiple outcomes to patients able to engage in the full range of therapy procedures. The novel statistical methods illustrated in this report have general application to the evaluation of heterogeneity in the effects of treatment.

Prefrontal cortical-ventral striatal interactions involved in affective modulation of attentional performance: implications for corticostriatal circuit function

Anatomically segregated systems linking the frontal cortex and the striatum are involved in various aspects of cognitive, affective, and motor processing. In this study, we examined the effects of combined unilateral lesions of the medial prefrontal cortex (mPFC) and the core subregion of the nucleus accumbens (AcbC) in opposite hemispheres (disconnection) on a continuous performance, visual attention test [five-choice serial reaction-time task (5CSRTT)]. The disconnection lesion produced a set of specific changes in performance of the 5CSRTT, resembling changes that followed bilateral AcbC lesions while, in addition, comprising a subset of the behavioral changes after bilateral mPFC lesions previously reported using the same task. Specifically, both mPFC/AcbC disconnection and bilateral AcbC lesions markedly affected aspects of response control related to affective feedback, as indexed by perseverative responding in the 5CSRTT. These effects were comparable, although not identical, to those in animals with either bilateral AcbC or mPFC/AcbC disconnection lesions. The mPFC/AcbC disconnection resulted in a behavioral profile largely distinct from that produced by disconnection of a similar circuit described previously, between the mPFC and the dorsomedial striatum, which were shown to form a functional network underlying aspects of visual attention and attention to action. This distinction provides an insight into the functional specialization of corticostriatal circuits in similar behavioral contexts.

Cross-modal preference acquisition: evaluative conditioning of pictures by affective olfactory and auditory cues

In this research, a cross-model paradigm was chosen to test the hypothesis that affective olfactory and auditory cues paired with neutral visual stimuli bearing no resemblance or logical connection to the affective cues can evoke preference shifts in those stimuli. Neutral visual stimuli of abstract paintings were presented simultaneously with liked and disliked odours and sounds, with neutral-neutral pairings serving as controls. The results confirm previous findings that the affective evaluation of previously neutral visual stimuli shifts in the direction of contingently presented affective auditory stimuli. In addition, this research shows the presence of conditioning with affective odours having no logical connection with the pictures.

The influence of affective statements on performance on implicit and explicit memory tasks

Consumers are often exposed to brand names presented concurrently with information such as brand claims and warnings, prior to making product choices. As implicit memory has been implicated in the consumer choice process, two experiments were conducted to assess the influence of additional information, namely simple positive and negative statements, on implicit and explicit memory tasks. In Experiment 1, the mere presence of additional statements at study significantly reduced performance on a two-alternatives forced recognition task. However, the same manipulation had no effect on implicit preference judgement task performance. The valence of the accompanying information had no effect on either task. In Experiment 2, using modified implicit and explicit choice tasks, performance on the former was unaffected by statement valence, whereas the latter task was. Hence, positive priming was obtained for brand names previously shown with negative information. The results of the experiments are discussed in relation to both implicit memory and consumer choice.

A randomised controlled trial of cognitive behaviour therapy for psychosis in a routine clinical service

Objective: To evaluate CBTp delivered by non-expert therapists, using CBT relevant measures. Methods: Participants (N=74) were randomised into immediate therapy or waiting list control groups. The therapy group was offered six months of therapy and followed up three months later. The waiting list group received therapy after waiting nine months (becoming the delayed therapy group). Results: Depression improved in the combined therapy group at both the end of therapy and follow-up. Other significant effects were found in only one of the two therapy groups (positive symptoms; cognitive flexibility; uncontrollability of thoughts) or one of the two timepoints (end of therapy: PANSS general symptoms, anxiety, suicidal ideation, social functioning, resistance to voices; follow-up: power beliefs about voices, negative symptoms). There was no difference in costs between the groups. Conclusions: The only robust improvement was in depression. Nevertheless, there were further encouraging but modest improvements in both emotional and cognitive variables, in addition to psychotic symptoms.

The multidimensional measurement of the positive symptoms of psychosis

The measures most frequently used to assess psychotic symptoms fail to reflect important dimensions. The Psychotic Symptom Rating Scale (PSYRATS) aims to capture the multidimensional nature of auditory hallucinations and delusions. Individuals (N = 276) who had recently relapsed with positive symptoms completed the auditory hallucinations and delusions PSYRATS scales. These scores were compared with the relevant items from the SAPS and PANSS, and with measures of current mood. Total scores and distribution of items of the PSYRATS scales are presented and correlated with other measures. Positive symptom items from the SAPS and PANSS reflected the more objective aspects of PSYRATS ratings of auditory hallucinations and delusions (frequency and conviction) but were relatively poor at measuring distress. A major strength of the PSYRATS scales is the specific measurement of the distress dimension of symptoms, which is a key target of psychological intervention. It is advised that the PSYRATS should not be used as a total score alone, whilst further research is needed to clarify the best use of potential subscales. Copyright (c) 2007 John Wiley & Sons, Ltd.

Cognitive behaviour therapy for psychosis: current evidence and future directions

The past decade has seen considerable growth in the evidence base of cognitive behavioural therapy for psychosis. Consistent reports of moderate effect sizes have led to such interventions being recommended as part of routine clinical practice. Most of this evidence is based on a generic form of CBT for psychosis applied to a heterogeneous group. An increase in the effectiveness of cognitive behavioural interventions may require new protocols. Such therapeutic developments should be based on the theoretical understanding of the psychological processes associated with specific forms of psychotic presentation. The current evidence base of CBT for psychosis is reviewed, and barriers that have held back the development of this research are discussed.

Affective prosody in children with Williams syndrome

The aim of the current study was to investigate expressive affect in children with Williams syndrome ( WS) in comparison to typically developing children in an experimental task and in spontaneous speech. Fourteen children with WS, 14 typically developing children matched to the WS group for receptive language ( LA) and 15 typically developing children matched to the WS groups for chronological age ( CA) were recruited. Affect was investigated using an experimental Output Affect task from the Profiling Elements of Prosodic Systems-Child version ( PEPS-C) battery, and by measuring pitch range and vowel durations from a spontaneous speech task. The children were also rated for level of emotional involvement by phonetically naive listeners. The WS group performed similarly to the LA and CA groups on the Output Affect task. With regard to vowel durations, the WS group was no different from the LA group; however both the WS and the LA groups were found to use significantly longer vowels than the CA group. The WS group differed significantly from both control groups on their range of pitch range and was perceived as being significantly more emotionally involved than the two control groups.

Family interventions in psychosis: a scale to measure therapist adherence

The efficacy of family interventions in psychosis is well documented. UK and USA schizophrenia treatment guidelines advocate the practice of family interventions within routine clinical services. However, less attention has been paid to the study of treatment fidelity and the tools used in its assessment. This study reports the inter-rater reliability of a new scale: Family Intervention in Psychosis-Adherence Scale (FIPAS). This measure is designed to assess therapist adherence to the Kuipers et al. (2002) family intervention in psychosis treatment manual. Reliability ratings were based on a sample of thirteen audiotapes drawn from a randomized controlled trial of family intervention. The results indicated that the majority of items of the FIPAS had acceptable levels of inter-rater reliability. The findings are discussed in terms of their implications for the training and monitoring of the effectiveness of practitioners for family interventions in psychosis.

Neural response to emotional prosody in schizophrenia and in bipolar affective disorder

Background Evidence suggests a reversal of the normal left-lateralised response to speech in schizophrenia. Aims To test the brain's response to emotional prosody in schizophrenia and bipolar disorder. Method BOLD contrast functional magnetic resonance imaging of subjects while they passively listened or attended to sentences that differed in emotional prosody Results Patients with schizophrenia exhibited normal right-lateralisation of the passive response to 'pure' emotional prosody and relative left-lateralisation of the response to unfiltered emotional prosody When attending to emotional prosody, patients with schizophrenia activated the left insula more than healthy controls. When listening passively, patients with bipolar disorder demonstrated less activation of the bilateral superior temporal gyri in response to pure emotional prosody, and greater activation of the left superior temporal gyrus in response to unfiltered emotional prosody In both passive experiments, the patient groups activated different lateral temporal lobe regions. Conclusions Patients with schizophrenia and bipolar disorder may display some left-lateralisation of the normal right-lateralised temporal lobe response to emotional prosody. Declaration of interest R.M. received a studentship from Neuraxis,, and funding from the Neuroscience and Psychiatry Unit, University of Manchester.

Right hemisphere language functions and schizophrenia: the forgotten hemisphere?

This review highlights the importance of right hemisphere language functions for successful social communication and advances the hypothesis that the core deficit in psychosis is a failure of segregation of right from left hemisphere functions. Lesion studies of stroke patients and dichotic listening and functional imaging studies of healthy people have shown that some language functions are mediated by the right hemisphere rather than the left. These functions include discourse planning/comprehension, understanding humour, sarcasm, metaphors and indirect requests, and the generation/comprehension of emotional prosody. Behavioural evidence indicates that patients with typical schizophrenic illnesses perform poorly on tests of these functions, and aspects of these functions are disturbed in schizo-affective and affective psychoses. The higher order language functions mediated by the right hemisphere are essential to an accurate understanding of someone's communicative intent, and the deficits displayed by patients with schizophrenia may make a significant contribution to their social interaction deficits. We outline a bi-hemispheric theory of the neural basis of language that emphasizes the role of the sapiens-specific cerebral torque in determining the four-chambered nature of the human brain in relation to the origins of language and the symptoms of schizophrenia. Future studies of abnormal lateralization of left hemisphere language functions need to take account of the consequences of a failure of lateralization of language functions to the right as well as the left hemisphere.

Affective disorder in the parents of a clinic sample of children with anxiety disorders

Background: Family history studies in adults reveal strong familiality for the anxiety disorders with some specificity. The aim of the current study was to establish whether there was an elevated rate of anxiety disorders in the parents of children with anxiety disorders, and whether there was intergenerational specificity in the form of disorder. Methods: The mental state of a clinic sample of 85 children with anxiety disorder and their parents was systematically assessed, together with a comparison sample of 45 children with no current disorder and their parents. Results: Compared to the rate of anxiety disorder amongst parents of comparison children, the rate of current anxiety disorder in mothers of anxious children was significantly raised, as was the lifetime rate of anxiety disorder for both mothers and fathers. The mothers of children with generalised anxiety disorder, social phobia, specific phobia and separation anxiety disorder all had raised lifetime rates of the corresponding disorder, but also raised rates of others disorders. Limitations: Only 60% of the fathers of the anxious children were assessed. Conclusions: Strong familiality of anxiety disorders was confirmed, especially between child and maternal anxiety disorder. All child anxiety disorders were associated with several forms of anxiety disorder in the mother. Some specificity in the form of anxiety disorder in the child and the mother was apparent for social phobia and separation anxiety disorder. The findings have implications for the management of child anxiety. (c) 2006 Elsevier B.V. All rights reserved.