Anxiety Disorders: Garety P

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.

So SH, Freeman D, Garety P. · Department of Psychology, Institute of Psychiatry, King's College, London, London, UK. · Aust N Z J Psychiatry. · Pubmed #18777232 No free full text.

Abstract: OBJECTIVE: This is the first study to investigate the relationship between the level of state anxiety and the jumping to conclusions (JTC) reasoning bias in patients with first-episode psychosis using an experimental manipulation procedure. METHOD: Thirty patients with psychotic delusions and 30 non-clinical controls, from Hong Kong, were randomized into an anxiety induction or an anxiety reduction imagery condition. Questionnaires were used to measure trait emotions, psychotic symptoms and delusional thinking at baseline. After the anxiety manipulation, participants completed two versions of an assessment of the JTC reasoning bias, the beads task. RESULTS: Both the patients and the non-clinical controls were responsive to the anxiety reduction imagery, but only the non-clinical controls responded to the anxiety induction imagery. The JTC reasoning bias was, as hypothesized, more common in patients than in controls, but was not significantly different between the anxiety manipulation conditions. Both patients and controls had higher rates of JTC than in previous studies. CONCLUSIONS: Patients with psychotic delusions have a marked JTC cognitive bias. This is the first JTC study in a Chinese sample, and the results suggest that the bias applies cross-culturally. The results indicate that state anxiety does not influence JTC. Limitations of the study include an inadequate anxiety state manipulation effect in psychotic patients using brief imagery, and unusually high rates of JTC in both patients and controls.

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.

Freeman D, Pugh K, Green C, Valmaggia L, Dunn G, Garety P. · Department of Psychology, Institute of Psychiatry, King's College London, Denmark Hill, London, UK. · J Nerv Ment Dis. · Pubmed #17984781 No free full text.

Abstract: Experimental research is increasingly important in developing the understanding of paranoid thinking. An assessment measure of persecutory ideation is necessary for such work. We report the reliability and validity of the first state measure of paranoia: The State Social Paranoia Scale. The items in the measure conform to a recent definition in which persecutory thinking has the 2 elements of feared harm and perpetrator intent. The measure was tested with 164 nonclinical participants and 21 individuals at high risk of psychosis with attenuated positive symptoms. The participants experienced a social situation presented in virtual reality and completed the new measure. The State Social Paranoia Scale was found to have excellent internal reliability, adequate test-retest reliability, clear convergent validity as assessed by both independent interviewer ratings and self-report measures, and showed divergent validity with measures of positive and neutral thinking. The measure of paranoia in a recent social situation has good psychometric properties.

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.

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.