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1.  Testing the Psychopathology of Psychosis: Evidence for a General Psychosis Dimension 
Schizophrenia Bulletin  2012;39(4):884-895.
Background: Psychiatric taxonomists have sometimes argued for a unitary psychosis syndrome and sometimes for a pentagonal model, including 5 diagnostic constructs of positive symptoms, negative symptoms, cognitive disorganization, mania, and depression. This continues to be debated in preparation for impending revisions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases. We aimed to identify general and specific dimensions underlying psychopathological features of psychosis. Methods: The samples comprised 309 patients admitted to psychiatric services in the acute phase of their first or second episode of psychosis and 507 patients with enduring psychosis recruited from community mental health teams. Patients’ symptoms were assessed on the Positive and Negative Symptom Scale. Analyses compared unitary, pentagonal, and bifactor models of psychosis. Results: In both samples, a bifactor model including 1 general psychosis factor and, independently, 5 specific factors of positive symptoms, negative symptoms, disorganization, mania, and depression gave the best fit. Scores of general and specific symptom dimensions were differentially associated with phase of illness, diagnosis, social functioning, insight, and neurocognitive functioning. Conclusions: The findings provide strong evidence for a general psychosis dimension in both early and enduring psychosis. Findings further allowed for independent formation of specific symptom dimensions. This may inform the current debate about revised classification systems of psychosis.
PMCID: PMC3686436  PMID: 22258881
classification; DSM-V; dimensions; item response modeling; psychosis; schizophrenia
2.  Subjective Cognitive Complaints in Schizophrenia: Relation to Antipsychotic Medication Dose, Actual Cognitive Performance, Insight and Symptoms 
PLoS ONE  2013;8(12):e83774.
Subjective cognitive complaints are prevalent in those affected by functional psychoses and a variety of possible associated factors have been investigated. However, few studies have examined these potential factors within single studies or analyses.
Patients with a history of a schizophrenia spectrum disorder (n = 115) and a non-clinical comparison group (n = 45) completed the Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS) and the Brief Assessment of Cognition in Schizophrenia (BACS). The patient group also completed the Positive and Negative Syndromes Scale (PANSS), the Birchwood Insight Scale (IS), and the Hospital Anxiety and Depression Scale (HADS).
The BACS and SSTICS scores were associated in the non-clinical comparison group, but not in the patient group. In the patient group worse subjective cognition was associated positively with good insight, greater dysphoria and greater positive symptoms. Linear regression revealed that, once other variables had been accounted for, dysphoria (HADS anxiety and depression factor) was the only significant predictor of SSTICS scores.
Subjective cognitive impairment in patients with psychosis in the absence of formal testing should not be taken as evidence of impaired cognitive functioning. Mood should be investigated when patients present with subjective cognitive complaints.
PMCID: PMC3869800  PMID: 24376745
3.  Cognitive Styles and Psychotic Experiences in a Community Sample 
PLoS ONE  2013;8(11):e80055.
In clinical populations paranoid delusions are associated with making global, stable and external attributions for negative events. Paranoia is common in community samples but it is not known whether it is associated with a similar cognitive style. This study investigates the association between cognitive style and paranoia in a large community sample of young adults.
2694 young adults (mean age 17.8, SD 4.6) from the ALSPAC cohort provided data on psychotic experiences and cognitive style. Psychotic experiences were assessed using a semi-structured interview and cognitive style was assessed using the Cognitive Styles Questionnaire-Short Form (CSQ-SF) on the same occasion. Logistic regression was used to investigate associations between paranoia and CSQ-SF scores, both total and domain-related (global, stable, self, external). The role of concurrent self-reported depressive symptoms in the association was explored.
Paranoia was associated with Total CSQ-SF scores (adjusted OR 1.69 95% CI 1.29, 2.22), as well as global (OR 1.56 95% CI 1.17, 2.08), stable (OR 1.56 95% CI 1.17, 2.08) and self (OR 1.37 95% CI 1.05, 1.79) domains, only Total score and global domain associations remained after additional adjustment for self-reported depression. There was no association between paranoia and external cognitive style (OR 1.10 95% CI 0.83, 1.47).
Paranoid ideation in a community sample is associated with a global rather than an external cognitive style. An external cognitive style may be a characteristic of more severe paranoid beliefs. Further work is required to determine the role of depression in the association between cognitive style and paranoia.
PMCID: PMC3828222  PMID: 24244608
4.  Do Specific Early-Life Adversities Lead to Specific Symptoms of Psychosis? A Study from the 2007 The Adult Psychiatric Morbidity Survey 
Schizophrenia Bulletin  2012;38(4):734-740.
Previous studies have reported associations between childhood adversities, eg, loss of a parent, being raised in institutional care, sexual and other kinds of abuse by adults and bullying by peers, and psychosis in adulthood. However, the mechanisms by which these adversities lead to psychotic experiences are poorly understood. From models of the psychological processes involved in positive symptoms, it was predicted that childhood sexual abuse would be specifically associated with auditory hallucinations in adulthood, and that disruption of early attachment relations and more chronic forms of victimization such as bullying would be specifically associated with paranoid ideation. We therefore examined the associations between sexual trauma, physical abuse, bullying, and being brought up in institutional or local authority care and reports of auditory hallucinations and paranoid beliefs in the 2007 Adult Psychiatric Morbidity Survey. All simple associations between childhood adversities and the two symptom types were significant. Childhood rape was associated only with hallucinations (OR 8.9, CI = 1.86–42.44) once co-occurring paranoia was controlled for. Being brought up in institutional care (OR = 11.08, CI = 3.26–37.62) was specifically associated with paranoia once comorbid hallucinations had been controlled for. For each symptom, dose-response relationships were observed between the number of childhood traumas and the risk of the symptom. The specific associations observed are consistent with current psychological theories about the origins of hallucinations and paranoia. Further research is required to study the psychological and biological mediators of these associations.
PMCID: PMC3406525  PMID: 22496540
paranoia; hallucinations; childhood sexual abuse; victimization; disrupted attachment
5.  Cost-effectiveness of supported self-management for CFS/ME patients in primary care 
BMC Family Practice  2013;14:12.
Nurse led self-help treatments for people with chronic fatigue syndrome/myalgic encephalitis (CFS/ME) have been shown to be effective in reducing fatigue but their cost-effectiveness is unknown.
Cost-effectiveness analysis conducted alongside a single blind randomised controlled trial comparing pragmatic rehabilitation (PR) and supportive listening (SL) delivered by primary care nurses, and treatment as usual (TAU) delivered by the general practitioner (GP) in North West England. A within trial analysis was conducted comparing the costs and quality adjusted life years (QALYs) measured within the time frame of the trial. 296 patients aged 18 and over with CFS/ME diagnosed using the Oxford criteria were included in the cost-effectiveness analysis.
Treatment as usual is less expensive and leads to better patient outcomes compared with Supportive Listening. Treatment as usual is also less expensive than Pragmatic Rehabilitation. PR was effective at reducing fatigue in the short term, but the impact of the intervention on QALYs was uncertain. However, based on the results of this trial, PR is unlikely to be cost-effective in this patient population.
This analysis does not support the introduction of SL. Any benefits generated by PR are unlikely to be of sufficient magnitude to warrant recommending PR for this patient group on cost-effectiveness grounds alone. However, dissatisfaction with current treatment options means simply continuing with ‘treatment as usual’ in primary care is unlikely to be acceptable to patients and practitioners.
Trial registration
The trial registration number is IRCTN74156610
PMCID: PMC3556109  PMID: 23327355
Cost-effectiveness; Primary care; CFS/ME; Self-management; Supportive listening; Pragmatic rehabilitation
6.  Better Than I Thought: Positive Evaluation Bias in Hypomania 
PLoS ONE  2012;7(10):e47754.
Mania is characterised by increased impulsivity and risk-taking, and psychological accounts argue that these features may be due to hypersensitivity to reward. The neurobiological mechanisms remain poorly understood. Here we examine reinforcement learning and sensitivity to both reward and punishment outcomes in hypomania-prone individuals not receiving pharmacotherapy.
We recorded EEG from 45 healthy individuals split into three groups by low, intermediate and high self-reported hypomanic traits. Participants played a computerised card game in which they learned the reward contingencies of three cues. Neural responses to monetary gain and loss were measured using the feedback-related negativity (FRN), a component implicated in motivational outcome evaluation and reinforcement learning.
As predicted, rewards elicited a smaller FRN in the hypomania-prone group relative to the low hypomania group, indicative of greater reward responsiveness. The hypomania-prone group also showed smaller FRN to losses, indicating diminished response to negative feedback.
Our findings indicate that proneness to hypomania is associated with both reward hypersensitivity and discounting of punishment. This positive evaluation bias may be driven by aberrant reinforcement learning signals, which fail to update future expectations. This provides a possible neural mechanism explaining risk-taking and impaired reinforcement learning in BD. Further research will be needed to explore the potential value of the FRN as a biological vulnerability marker for mania and pathological risk-taking.
PMCID: PMC3474792  PMID: 23082210
7.  Assessing negative cognitive style: Development and validation of a Short-Form version of the Cognitive Style Questionnaire 
The Cognitive Style Questionnaire (CSQ) is a frequently employed measure of negative cognitive style, associated with vulnerability to anxiety and depression. However, the CSQ's length can limit its utility in research. We describe the development of a Short-Form version of the CSQ. After evaluation and modification of two pilot versions, the 8-item CSQ Short Form (CSQ-SF) was administered to a convenience sample of adults (N = 278). The CSQ-SF was found to have satisfactory internal reliability and test-retest reliability. It also exhibited construct validity by demonstrating predicted correlations with measures of depression and anxiety. Results suggest that the CSQ-SF is suitable for administration via the Internet.
PMCID: PMC3289144  PMID: 22389545
Cognitive style; Depression; Anxiety
8.  Assessing negative cognitive style: Development and validation of a Short-Form version of the Cognitive Style Questionnaire 
► We developed a Short-Form version of the Cognitive Style Questionnaire (CSQ). ► The CSQ Short Form (CSQ-SF) demonstrated satisfactory internal reliability. ► Test–retest reliability was also satisfactory. ► Scores demonstrated predicted correlations with measures of depression and anxiety. ► The CSQ-SF may be a useful research tool in assessing vulnerability to depression.
The Cognitive Style Questionnaire (CSQ) is a frequently employed measure of negative cognitive style, associated with vulnerability to anxiety and depression. However, the CSQ’s length can limit its utility in research. We describe the development of a Short-Form version of the CSQ. After evaluation and modification of two pilot versions, the 8-item CSQ Short Form (CSQ-SF) was administered to a convenience sample of adults (N = 278). The CSQ-SF was found to have satisfactory internal reliability and test–retest reliability. It also exhibited construct validity by demonstrating predicted correlations with measures of depression and anxiety. Results suggest that the CSQ-SF is suitable for administration via the Internet.
PMCID: PMC3289144  PMID: 22389545
Cognitive style; Depression; Anxiety
9.  Childhood Adversities Increase the Risk of Psychosis: A Meta-analysis of Patient-Control, Prospective- and Cross-sectional Cohort Studies 
Schizophrenia Bulletin  2012;38(4):661-671.
Evidence suggests that adverse experiences in childhood are associated with psychosis. To examine the association between childhood adversity and trauma (sexual abuse, physical abuse, emotional/psychological abuse, neglect, parental death, and bullying) and psychosis outcome, MEDLINE, EMBASE, PsychINFO, and Web of Science were searched from January 1980 through November 2011. We included prospective cohort studies, large-scale cross-sectional studies investigating the association between childhood adversity and psychotic symptoms or illness, case-control studies comparing the prevalence of adverse events between psychotic patients and controls using dichotomous or continuous measures, and case-control studies comparing the prevalence of psychotic symptoms between exposed and nonexposed subjects using dichotomous or continuous measures of adversity and psychosis. The analysis included 18 case-control studies (n = 2048 psychotic patients and 1856 nonpsychiatric controls), 10 prospective and quasi-prospective studies (n = 41 803) and 8 population-based cross-sectional studies (n = 35 546). There were significant associations between adversity and psychosis across all research designs, with an overall effect of OR = 2.78 (95% CI = 2.34–3.31). The integration of the case-control studies indicated that patients with psychosis were 2.72 times more likely to have been exposed to childhood adversity than controls (95% CI = 1.90–3.88). The association between childhood adversity and psychosis was also significant in population-based cross-sectional studies (OR = 2.99 [95% CI = 2.12–4.20]) as well as in prospective and quasi-prospective studies (OR = 2.75 [95% CI = 2.17–3.47]). The estimated population attributable risk was 33% (16%–47%). These findings indicate that childhood adversity is strongly associated with increased risk for psychosis.
PMCID: PMC3406538  PMID: 22461484
psychosis; adversity; trauma; meta-analysis; abuse; neglect
10.  Nurse led, home based self help treatment for patients in primary care with chronic fatigue syndrome: randomised controlled trial 
Objective To evaluate the effectiveness of home delivered pragmatic rehabilitation—a programme of gradually increasing activity designed collaboratively by the patient and the therapist—and supportive listening—an approach based on non-directive counselling—for patients in primary care with chronic fatigue syndrome/myalgic encephalomyelitis or encephalitis (CFS/ME).
Design Single blind, randomised, controlled trial.
Setting 186 general practices across the north west of England between February 2005 and May 2007.
Participants 296 patients aged 18 or over with CFS/ME (median illness duration seven years) diagnosed using the Oxford criteria.
Interventions Participants were randomly allocated to pragmatic rehabilitation, supportive listening, or general practitioner treatment as usual. Both therapies were delivered at home in 10 sessions over 18 weeks by one of three adult specialty general nurses who had received four months’ training, including supervised practice, in each of the interventions. GP treatment as usual was unconstrained except that patients were not to be referred for systematic psychological therapies during the treatment period.
Main outcome measures The primary clinical outcomes were fatigue and physical functioning at the end of treatment (20 weeks) and 70 weeks from recruitment compared with GP treatment as usual. Lower fatigue scores and higher physical functioning scores denote better outcomes.
Results A total of 257 (87%) of the 296 patients who entered the trial were assessed at 70 weeks, the primary outcome point. Analysis was on an intention to treat basis, with robust treatment effects estimated after adjustment for missing data using probability weights. Immediately after treatment (at 20 weeks), patients allocated to pragmatic rehabilitation (n=95) had significantly improved fatigue (effect estimate -1.18, 95% confidence interval -2.18 to -0.18; P=0.021) but not physical functioning (-0.18, 95% CI -5.88 to +5.52; P=0.950) compared with patients allocated to treatment as usual (n=100). At one year after finishing treatment (70 weeks), there were no statistically significant differences in fatigue or physical functioning between patients allocated to pragmatic rehabilitation and those on treatment as usual (-1.00, 95% CI -2.10 to +0.11; P=0.076 and +2.57, 95% CI 3.90 to +9.03; P=0.435). At 20 weeks, patients allocated to supportive listening (n=101) had poorer physical functioning than those allocated to treatment as usual (-7.54, 95% CI -12.76 to -2.33; P=0.005) and no difference in fatigue. At 70 weeks, patients allocated to supportive listening did not differ significantly from those allocated to treatment as usual on either primary outcome.
Conclusions For patients with CFS/ME in primary care, pragmatic rehabilitation delivered by trained nurse therapists improves fatigue in the short term compared with unconstrained GP treatment as usual, but the effect is small and not statistically significant at one year follow-up. Supportive listening delivered by trained nurse therapists is not an effective treatment for CFS/ME.
Trial registration International Standard Randomised Controlled Trial Number IRCTN74156610.
PMCID: PMC2859122  PMID: 20418251
11.  Social Predictors of Psychotic Experiences: Specificity and Psychological Mechanisms 
Schizophrenia Bulletin  2008;34(6):1012-1020.
It has become widely accepted that the psychotic disorders are endpoints of atypical developmental trajectories indexed by abnormal emotional and cognitive development early in life. However, the role of environmental factors in determining these trajectories has received relatively little attention. In this article, we argue that (1) the influence of environment on psychosis can best be understood if we focus on specific types of psychotic experiences such as hallucinations and delusions, (2) these symptoms are the products of specific cognitive biases and deficits, and (3) the development of these particular patterns of cognitive functioning is influenced by specific kinds of environmental adversity. This approach is at variance with more conventional approaches because it suggests that each type of experience, rather than being the manifestation of a common underlying illness process, is a product of a specific set of causal variables. Importantly, these variables include environmental determinants, although not to the exclusion of endogenous factors such as neurodevelopmental impairment or genetic vulnerability. We discuss the implications of this approach for neurobiological and genetic research into psychosis, as well as clinical practice.
PMCID: PMC2632492  PMID: 18703667
hallucinations; delusions; trauma; victimization; sexual abuse
12.  Three-Year Follow-up of a Randomized Controlled Trial of Cognitive Therapy for the Prevention of Psychosis in People at Ultrahigh Risk 
Schizophrenia Bulletin  2006;33(3):682-687.
There have been recent advances in the ability to identify people at high risk of developing psychosis. This has led to interest in the possibility of preventing the development of psychosis. A randomized controlled trial compared cognitive therapy (CT) over 6 months with monthly monitoring in 58 patients meeting criteria for ultrahigh risk of developing a first episode of psychosis. Participants were followed up over a 3-year period. Logistic regression demonstrated that CT significantly reduced likelihood of being prescribed antipsychotic medication over a 3-year period, but it did not affect transition to psychosis defined using the Positive and Negative Syndrome Scale (PANSS) or probable Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis. However, exploratory analyses revealed that CT significantly reduced the likelihood of making progression to psychosis as defined on the PANSS over 3 years after controlling for baseline cognitive factors. Follow-up rate at 3 years was 47%. There appear to be enduring benefits of CT over the long term, suggesting that it is an efficacious intervention for people at high risk of developing psychosis.
PMCID: PMC2526150  PMID: 16973786
cognitive therapy; psychosis; prevention; early intervention
13.  Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome 
BMJ : British Medical Journal  2001;322(7283):387.
To assess the efficacy of an educational intervention explaining symptoms to encourage graded exercise in patients with chronic fatigue syndrome.
Randomised controlled trial.
Chronic fatigue clinic and infectious diseases outpatient clinic.
148 consecutively referred patients fulfilling Oxford criteria for chronic fatigue syndrome.
Patients randomised to the control group received standardised medical care. Patients randomised to intervention received two individual treatment sessions and two telephone follow up calls, supported by a comprehensive educational pack, describing the role of disrupted physiological regulation in fatigue symptoms and encouraging home based graded exercise. The minimum intervention group had no further treatment, but the telephone intervention group received an additional seven follow up calls and the maximum intervention group an additional seven face to face sessions over four months.
Main outcome measure
A score of ⩾25 or an increase of ⩾10 on the SF-36 physical functioning subscale (range 10 to 30) 12 months after randomisation.
21 patients dropped out, mainly from the intervention groups. Intention to treat analysis showed 79 (69%) of patients in the intervention groups achieved a satisfactory outcome in physical functioning compared with two (6%) of controls, who received standardised medical care (P<0.0001). Similar improvements were observed in fatigue, sleep, disability, and mood. No significant differences were found between the three intervention groups.
Treatment incorporating evidence based physiological explanations for symptoms was effective in encouraging self managed graded exercise. This resulted in substantial improvement compared with standardised medical care.
PMCID: PMC26565  PMID: 11179154
14.  Learning names may help to make the right connections 
PMCID: PMC1350079  PMID: 16812786
15.  Early detection and intervention evaluation for people at risk of psychosis: multisite randomised controlled trial 
Objective To determine whether cognitive therapy is effective in preventing the worsening of emerging psychotic symptoms experienced by help seeking young people deemed to be at risk for serious conditions such as schizophrenia.
Design Multisite single blind randomised controlled trial.
Setting Diverse services at five UK sites.
Participants 288 participants aged 14-35 years (mean 20.74, SD 4.34 years) at high risk of psychosis: 144 were assigned to cognitive therapy plus monitoring of mental state and 144 to monitoring of mental state only. Participants were followed-up for a minimum of 12 months and a maximum of 24 months.
Intervention Cognitive therapy (up to 26 (mean 9.1) sessions over six months) plus monitoring of mental state compared with monitoring of mental state only.
Main outcome measures Primary outcome was scores on the comprehensive assessment of at risk mental states (CAARMS), which provides a dichotomous transition to psychosis score and ordinal scores for severity of psychotic symptoms and distress. Secondary outcomes included emotional dysfunction and quality of life.
Results Transition to psychosis based on intention to treat was analysed using discrete time survival models. Overall, the prevalence of transition was lower than expected (23/288; 8%), with no significant difference between the two groups (proportional odds ratio 0.73, 95% confidence interval 0.32 to 1.68). Changes in severity of symptoms and distress, as well as secondary outcomes, were analysed using random effects regression (analysis of covariance) adjusted for site and baseline symptoms. Distress from psychotic symptoms did not differ (estimated difference at 12 months −3.00, 95% confidence interval −6.95 to 0.94) but their severity was significantly reduced in the group assigned to cognitive therapy (estimated between group effect size at 12 months −3.67, −6.71 to −0.64, P=0.018).
Conclusions Cognitive therapy plus monitoring did not significantly reduce transition to psychosis or symptom related distress but reduced the severity of psychotic symptoms in young people at high risk. Most participants in both groups improved over time. The results have important implications for the at risk mental state concept.
Trial registration Current Controlled Trials ISRCTN56283883.
PMCID: PMC3320714  PMID: 22491790

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