Anxiety Disorders: Fowler D

Garety PA, Bebbington P, Fowler D, Freeman D, Kuipers E. · Department of Psychology, Institute of Psychiatry, King's College London, London, UK. · Psychol Med. · Pubmed #17335638 No free full text.

Abstract: BACKGROUND: Cognitive models of the positive symptoms of psychosis specify the cognitive, social and emotional processes hypothesized to contribute to their occurrence and persistence, and propose that vulnerable individuals make characteristic appraisals that result in specific positive symptoms. METHOD: We describe cognitive models of positive psychotic symptoms and use this as the basis of discussing recent relevant empirical investigations and reviews that integrate cognitive approaches into neurobiological frameworks. RESULTS: Evidence increasingly supports a number of the hypotheses proposed by cognitive models. These are that: psychosis is on a continuum; specific cognitive processes are risk factors for the transition from subclinical experiences to clinical disorder; social adversity and trauma are associated with psychosis and with negative emotional processes; and these emotional processes contribute to the occurrence and persistence of psychotic symptoms. There is also evidence that reasoning biases contribute to the occurrence of delusions. CONCLUSIONS: The benefits of incorporating cognitive processes into neurobiological research include more sophisticated, bidirectional and interactive causal models, the amplification of phenotypes in neurobiological investigations by including emotional processes, and the adoption of more specific clinical phenotypes. For example, there is potential value in studying gene x environment x cognition/emotion interactions. Cognitive models and their derived phenotypes constitute the missing link in the chain between genetic or acquired biological vulnerability, the social environment and the expression of individual positive symptoms.

Kuipers E, Garety P, Fowler D, Freeman D, Dunn G, Bebbington P. · King's College London, Institute of Psychiatry, Department of Psychology, PO Box 77, London SE5 8AF, UK. · Schizophr Bull. · Pubmed #16885206 links to  free full text

Abstract: Psychosis used to be thought of as essentially a biological condition unamenable to psychological interventions. However, more recent research has shown that positive symptoms such as delusions and hallucinations are on a continuum with normality and therefore might also be susceptible to adaptations of the cognitive behavioral therapies found useful for anxiety and depression. In the context of a model of cognitive, emotional, and social processes in psychosis, the latest evidence for the putative psychological mechanisms that elicit and maintain symptoms is reviewed. There is now good support for emotional processes in psychosis, for the role of cognitive processes including reasoning biases, for the central role of appraisal, and for the effects of the social environment, including stress and trauma. We have also used virtual environments to test our hypotheses. These developments have improved our understanding of symptom dimensions such as distress and conviction and also provide a rationale for interventions, which have some evidence of efficacy. Therapeutic approaches are described as follows: a collaborative therapeutic relationship, managing dysphoria, helping service users reappraise their beliefs to reduce distress, working on negative schemas, managing and reducing stressful environments if possible, compensating for reasoning biases by using disconfirmation strategies, and considering the full range of evidence in order to reduce high conviction. Theoretical ideas supported by experimental evidence can inform the development of cognitive behavior therapy for persistent positive symptoms of psychosis.

Freeman D, Pugh K, Antley A, Slater M, Bebbington P, Gittins M, Dunn G, Kuipers E, Fowler D, Garety P. · Department of Psychology, Institute of Psychiatry, King's College London, London, UK. · Br J Psychiatry. · Pubmed #18378984 links to  free full text

Abstract: BACKGROUND: Judging whether we can trust other people is central to social interaction, despite being error-prone. A fear of others can be instilled by the contemporary political and social climate. Unfounded mistrust is called paranoia, and in severe forms is a central symptom of schizophrenia. AIMS: To demonstrate that individuals without severe mental illness in the general population experience unfounded paranoid thoughts, and to determine factors predictive of paranoia using the first laboratory method of capturing the experience. METHOD: Two hundred members of the general public were comprehensively assessed, and then entered a virtual reality train ride populated by neutral characters. Ordinal logistic regressions (controlling for age, gender, ethnicity, education, intellectual functioning, socio-economic status, train use, playing of computer games) were used to determine predictors of paranoia. RESULTS: The majority agreed that the characters were neutral, or even thought they were friendly. However, a substantial minority reported paranoid concerns. Paranoia was strongly predicted by anxiety, worry, perceptual anomalies and cognitive inflexibility. CONCLUSIONS: This is the most unambiguous demonstration of paranoid ideation in the general public so far. Paranoia can be understood in terms of cognitive factors. The use of virtual reality should lead to rapid advances in the understanding of paranoia.

Valmaggia LR, Freeman D, Green C, Garety P, Swapp D, Antley A, Prescott C, Fowler D, Kuipers E, Bebbington P, Slater M, Broome M, McGuire PK. · Department of Psychological Medicine, PO 67, Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, UK. · Br J Psychiatry Suppl. · Pubmed #18055940 No free full text.

Abstract: BACKGROUND: Virtual reality provides a means of studying paranoid thinking in controlled laboratory conditions. However, this method has not been used with a clinical group. AIMS: To establish the feasibility and safety of using virtual reality methodology in people with an at-risk mental state and to investigate the applicability of a cognitive model of paranoia to this group. METHOD: Twenty-one participants with an at-risk mental state were assessed before and after entering a virtual reality environment depicting the inside of an underground train. RESULTS: Virtual reality did not raise levels of distress at the time of testing or cause adverse experiences over the subsequent week. Individuals attributed mental states to virtual reality characters including hostile intent. Persecutory ideation in virtual reality was predicted by higher levels of trait paranoia, anxiety, stress, immersion in virtual reality, perseveration and interpersonal sensitivity. CONCLUSIONS: Virtual reality is an acceptable experimental technique for use with individuals with at-risk mental states. Paranoia in virtual reality was understandable in terms of the cognitive model of persecutory delusions.

Gracie A, Freeman D, Green S, Garety PA, Kuipers E, Hardy A, Ray K, Dunn G, Bebbington P, Fowler D. · King's College London, Department of Psychology, Institute of Psychiatry, London, UK. · Acta Psychiatr Scand. · Pubmed #17803758 No free full text.

Abstract: OBJECTIVE: The current study investigated the relationship between trauma and predisposition to hallucinations and to paranoia in a non-clinical sample. METHOD: A total of 228 students completed online measures of trauma, post traumatic stress disorder (PTSD), schematic beliefs, perceptual anomalies, and predisposition to hallucinations and paranoia. RESULTS: Associations were found between negative schematic beliefs, PTSD and predisposition to both paranoia and hallucinations. PTSD reexperiencing-symptoms were most strongly associated with a predisposition to hallucinations. Negative beliefs about self and others were most strongly associated with a predisposition to paranoia. CONCLUSION: The results provide support for the prediction that there may be two routes between trauma and predisposition to psychosis. Clear support was found for a link between trauma and psychosis mediated by negative beliefs about self and others. There may also be a direct association between re-experiencing symptoms and hallucinations.

Steel C, Garety PA, Freeman D, Craig E, Kuipers E, Bebbington P, Fowler D, Dunn G. · Department of Psychology, Institute of Psychiatry, Kings College London, De Crespigny Park, London, UK. · Int J Methods Psychiatr Res. · Pubmed #17623388 No free full text.

Abstract: 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.

Kuipers E, Watson P, Onwumere J, Bebbington P, Dunn G, Weinman J, Fowler D, Freeman D, Hardy A, Garety P. · Department of Psychology, King's College London, Institute of Psychiatry, Box PO77, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK. · Soc Psychiatry Psychiatr Epidemiol. · Pubmed #17370044 No free full text.

Abstract: BACKGROUND: Illness perception, a measure of illness representations developed from physical medicine, has recently been applied to psychosis. We investigated how illness perceptions relate to affect and expressed emotion (EE) in carer-patient dyads, particularly if their perceptions differed. METHOD: We interviewed 82 carer-patient dyads, after a relapse of psychosis. Carers were assessed for illness perceptions, distress, self-esteem and EE; patients for illness perceptions, depression, anxiety and self-esteem, in a cross sectional study. RESULTS: Carers were more pessimistic than patients about illness persistence and consequences, and carers with low mood were particularly pessimistic about persistence and controllability. Discrepant views about illness consequences were related to greater anxiety, depression, and lower self-esteem in patients, while discrepant views on controllability were associated with greater distress, depression, and lower self-esteem in carers. Illness perceptions did not relate directly to EE. CONCLUSIONS: In this sample, meta-cognitive carer representations of illness in psychosis are related to negative affective reactions in carers, but not to EE. Resolving discrepant illness perceptions between carers and patients might provide a way of improving family reactions to the health threat of psychosis.

Fialko L, Freeman D, Bebbington PE, Kuipers E, Garety PA, Dunn G, Fowler D. · Department of Psychology, Institute of Psychiatry, King's College London, University of London, London, UK. · Acta Psychiatr Scand. · Pubmed #16889588 No free full text.

Abstract: OBJECTIVE: To examine the clinically important phenomenon of suicidal ideation in psychosis in relation to affective processes and the multidimensional nature of hallucinations and delusions. METHOD: In a cross-sectional study of 290 individuals with psychosis, the associations between level of suicidal ideation, affective processes, positive symptoms, clinical and demographic variables were examined. RESULTS: Forty-one per cent of participants expressed current suicidal ideation. Suicidal ideation was associated with depressed mood, anxiety, low self-esteem, negative illness perceptions, negative evaluative beliefs about the self and others and daily alcohol consumption. Frequency of auditory hallucinations and preoccupation with delusions were not associated with suicidal ideation; however, positive symptom distress did relate to suicidal thoughts. CONCLUSION: Affective dysfunction, including distress in response to hallucinations and delusions, was a key factor associated with suicidal ideation in individuals with psychotic relapse. Suicidal ideation in psychosis appears to be an understandable, mood-driven process, rather than being of irrational or 'psychotic' origin.

Watson PW, Garety PA, Weinman J, Dunn G, Bebbington PE, Fowler D, Freeman D, Kuipers E. · King's College London, Department of Psychology, Institute of Psychiatry, London, UK. · Psychol Med. · Pubmed #16563207 No free full text.

Abstract: BACKGROUND: Assessing illness perceptions has been useful in a range of medical disorders. This study of people with a recent relapse of their psychosis examines the relationship between illness perception, their emotional responses and their attitudes to medication. METHOD: One hundred patients diagnosed with a non-affective psychotic disorder were assessed within 3 months of relapse. Measures included insight, self-reported illness perceptions, medication adherence, depression, self-esteem and anxiety. RESULTS: Illness perceptions about psychosis explained 46, 36 and 34% of the variance in depression, anxiety and self-esteem respectively. However, self-reported medication adherence was more strongly associated with a measure of insight. CONCLUSIONS: Negative illness perceptions in psychosis are clearly related to depression, anxiety and self-esteem. These in turn have been linked to symptom maintenance and recurrence. Clinical interventions that foster appraisals of recovery rather than of chronicity and severity may therefore improve emotional well-being in people with psychosis. It might be better to address adherence to medication through direct attempts at helping them understand their need for treatment.

Freeman D, Garety PA, Kuipers E, Fowler D, Bebbington PE, Dunn G. · Department of Psychology, Institute of Psychiatry, King's College London, P.O. Box 77, University of London, Denmark Hill, London SE5 8AF, UK. · Behav Res Ther. · Pubmed #16530161 No free full text.

Abstract: 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.

Kuipers E, Bebbington P, Dunn G, Fowler D, Freeman D, Watson P, Hardy A, Garety P. · Department of Psychology, PO Box 77, Institute of Psychiatry, King's College London, London SE5 8AF, UK. · Br J Psychiatry. · Pubmed #16449706 links to  free full text

Abstract: BACKGROUND: High expressed emotion in carers predicts relapse in psychosis, but it is not known why this is so. In our cognitive model of psychosis, we postulated that the effect is mediated through affective changes. AIMS: To investigate the relationships between carer expressed emotion, patients' symptoms and carer characteristics during a recent relapse of psychosis. METHOD: A total of 86 patients and carers were investigated in a cross-sectional design. RESULTS: Patients whose carers showed high expressed emotion had significantly higher levels of anxiety and depression, but not more psychotic symptoms or lower self-esteem. Linear regression showed that carers'critical comments predicted anxiety in patients. Critical comments were related to low carer self-esteem and avoidant coping strategies. Low carer self-esteem was also related to carer depression, stress and carer 'burden', and to low patient self-esteem. CONCLUSIONS: Our hypothesis was partially supported. Carer criticism was associated with patient anxiety, low carer self-esteem and poor carer coping strategies. Family interventions should focus on improving these after a relapse of symptoms of psychosis.

Freeman D, Garety P, Kuipers E, Colbert S, Jolley S, Fowler D, Dunn G, Bebbington P. · Department of Psychology, Institute of Psychiatry, King's College London, University of London, PO Box 77, Denmark Hill, London, SE5 8AF, UK. · Behav Res Ther. · Pubmed #16226221 No free full text.

Abstract: 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.

Hardy A, Fowler D, Freeman D, Smith B, Steel C, Evans J, Garety P, Kuipers E, Bebbington P, Dunn G. · Institute of Psychiatry, Kings College London, London, United Kingdom. · J Nerv Ment Dis. · Pubmed #16082293 No free full text.

Abstract: Recent research indicates that there may be phenomenological, symptom, and diagnostic associations between trauma and hallucinations. However, the nature of the relationship is poorly understood from a psychological perspective. We report a theoretically informed phenomenological study. From descriptions of reported traumas and hallucinations, we assessed the rates of four types of hypothesized association between traumas and hallucinations (direct, indirect, stress, and none) in 75 participants with nonaffective psychosis. In a subgroup who had experienced trauma (N = 40), 12.5% had hallucinations with similar themes and content to their traumas, 45% had hallucinations in which the themes were the same but not the content, and 42.5% had no identifiable associations between their hallucinations and previously experienced trauma. Traumas rated as intrusive were significantly associated with hallucinations rated as intrusive, although intrusive hallucinations were not associated with traumas in general. The traumas most likely to be associated with hallucinations were sexual abuse and bullying.

Freeman D, Garety PA, Bebbington P, Slater M, Kuipers E, Fowler D, Green C, Jordan J, Ray K, Dunn G. · Department of Psychology, Institute of Psychiatry, King's College London, London, United Kingdom. · J Nerv Ment Dis. · Pubmed #15870614 No free full text.

Abstract: A cognitive model of persecutory delusions is used to predict the occurrence of nonclinical paranoid thoughts in a virtual reality environment. Scorers across the range of paranoia entered a virtual reality scene populated by five computer characters programmed to behave neutrally (N = 30). Many appraisals of the computer characters were positive or neutral. However, there were also persecutory thoughts about the characters. Providing evidence of the validity of the experimental method, persecutory ideation was predicted by higher trait paranoia and a greater sense of presence in the environment. The psychological variables from the cognitive model that predicted persecutory ideation were anxiety, timidity, and hallucinatory predisposition. Further, hallucinatory predisposition distinguished the prediction of paranoid thoughts from social anxiety in virtual reality. It is concluded that nonclinical paranoid thoughts are most closely associated with emotional disturbances and anomalous experiences. Extreme reasoning bias may particularly contribute to the development of clinical phenomena.

Freeman D, Dunn G, Garety PA, Bebbington P, Slater M, Kuipers E, Fowler D, Green C, Jordan J, Ray K. · Department of Psychology, Institute of Psychiatry, King's College London, London, United Kingdom. · J Nerv Ment Dis. · Pubmed #15870613 No free full text.

Abstract: Paranoia is a complex phenomenon that is likely to arise from a number of factors. In a recent cognitive model of persecutory delusions, three key factors are highlighted: anomalous experiences, emotion, and reasoning. In the first of two linked studies, we report a questionnaire survey of nonclinical paranoia designed to assess the theoretical model. A nonclinical population (N = 327) completed measures of paranoia, anomalous experiences (hallucinatory predisposition, perceptual anomalies), emotion (depression, anxiety, self-focus, stress, interpersonal sensitivity), and reasoning (need for closure). Paranoia was best explained by separation anxiety, depression, fragile inner self, hallucinatory experiences, discomfort with ambiguity, stress, self-focus, perceptual anomalies, and anxiety. The findings are consistent with the central predictions within the model of paranoia.

Harrison CL, Fowler D. · Department of Clinical Psychology, Older People's Mental Services, The Bungalow, Peterborough, United Kingdom. · J Nerv Ment Dis. · Pubmed #15505518 No free full text.

Abstract: Psychological research on negative symptoms in schizophrenia is scarce. The aim of this study was to explore the relationship between negative symptoms and trauma in individuals recovering from a psychotic illness. Specifically, the aim was to examine the association between negative symptoms and traumatic reactions to psychosis and to hospitalization. We were also interested in the association between traumatic reactions and autobiographical memory. The design was a cross-sectional investigation of 38 people recovering from functional psychotic illness. Hypotheses were examined using correlations between measures of negative symptoms, posttraumatic avoidance, and specificity of autobiographical retrieval. Negative symptoms were found to be significantly associated with avoidance of traumatic memories related to psychosis and hospitalization and with a lack of specificity in autobiographical recall. Further analysis showed that avoidance related to psychosis and low specificity in recall were significant predictors of negative symptoms. These data suggest that people who avoid traumatic memories of psychosis and hospitalization have more negative symptoms and retrieve fewer specific autobiographical memories. The possibility that negative symptoms may be reactive is explored, along with the implications for our theoretical and clinical understanding. The methodological limitations of the study and ideas for future research are discussed.

Freeman D, Slater M, Bebbington PE, Garety PA, Kuipers E, Fowler D, Met A, Read CM, Jordan J, Vinayagamoorthy V. · Department of Psychology, Institute of Psychiatry, King's College London, Denmark Hill, London, UK. · J Nerv Ment Dis. · Pubmed #12972853 No free full text.

Abstract: The use of virtual reality permits individuals' reactions to standard controlled environments to be studied. It may therefore provide a means for understanding the interpretations of experience relevant to clinical disorders. The use of this technology for understanding persecutory ideation has not been investigated. A pilot study was undertaken to examine whether individuals have persecutory thoughts about virtual reality characters under controlled conditions and if there are factors that predict the occurrence of such thoughts.Twenty-four nonclinical participants entered a neutral virtual environment that contained computer-generated people. The participants completed dimensional assessments of items related to psychiatric symptoms and their thoughts about the virtual characters.Positive views about the virtual characters were common. However, a number of participants had ideas of reference and ideas of persecution about the virtual characters. Individuals who had persecutory thoughts about the virtual characters had significantly higher levels of interpersonal sensitivity and anxiety.The study provides direct evidence that individuals attribute mental states to virtual reality characters. Important for the study of clinical phenomena, some individuals have thoughts of a persecutory nature about virtual characters. Additionally, the findings indicate that feelings of interpersonal vulnerability and anxiety may directly contribute to the development of persecutory ideation in response to essentially neutral contexts. Virtual reality may prove to be a valuable methodology for developing an understanding of persecutory ideation.